Modic changes as seen on MRI are associated with nonspecific chronic lower back pain and disability.

BACKGROUND: Estimating the contribution of endplate oedema known as Modic changes to lower back pain (LBP) has been the subject of multiple observational studies and reviews, some of which conclude that the evidence for an association of Modic change with LBP is uncertain while others demonstrate a clear link. The clinical trials demonstrating the benefit of basivertebral nerve ablation, a therapeutic intervention, in a tightly defined homogenous patient group with chronic LBP and Modic changes type 1 or type 2, provides further evidence for the contribution of Modic changes to LBP and shows that in these subjects, nerve ablation substantially reduces pain and disability. These interventional studies provide direct evidence that Modic changes can be associated with lower back pain and disability. This review set out to explore why the literature to date has been conflicting. METHODS: A narrative, forensic, non-systematic literature review of selected articles to investigate why the published literature investigating the association between Modic imaging changes and chronic low back pain is inconsistent. RESULTS: This review found that previous systematic reviews and meta-analyses included both heterogeneous study designs and diverse patient syndromes resulting in an inconsistent association between Modic changes and nonspecific chronic lower back pain. Re-analysis of literature data focussing on more homogenous patient populations provides clearer evidence that Modic changes are associated with nonspecific chronic lower back pain and that type 1 Modic changes are more painful than type 2. CONCLUSIONS: Studies using tightly defined homogenous patient groups may provide the best test for association between MRI-findings and pain and disability. Clinical benefit of basivertebral nerve ablation observed in randomised controlled trials further supports the association between type 1 and type 2 Modic changes with pain and disability.

Alternating lumbar lateral shift: a case report.

BACKGROUND: A lumbar lateral shift (LLS) is a common clinical observation in patients with low back pain (LBP), and a shift contralateral to the side of pain is the most common presentation. An LLS that can rapidly alternate sides presents several treatment difficulties and has rarely been described. The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS. CASE DESCRIPTION: A 39-year-old male with a 7-week history of LBP and previous lower extremity radicular pain was referred to physical therapy. An alternating LLS was present. OUTCOMES: The patient was treated for six visits over 37 days. Treatment included modified self-correction of the LLS, motor control and trunk muscle endurance training, and development of an activity management program. The patient's LLS resolved, his worst pain improved from 3/10 to 0/10, and the Oswestry Disability Index improved from 26% to 4% disability. The patient reported maintenance of improvement at 6-month follow-up. DISCUSSION: The current approach produced a positive outcome in a patient with an alternating LLS. The current understanding of mechanisms and optimal treatment of an alternating LLS is limited. LEVEL OF EVIDENCE: 4.

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews.

BACKGROUND: Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization. METHODS: A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR. RESULTS: Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making. CONCLUSIONS: This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain.

BACKGROUND: The diagnosis of subacromial pathology is limited by the poor accuracy of clinical tests for specific pathologies. The aim of this study was to estimate the diagnostic accuracy of clinical examination and imaging features for identifying subacromial pain (SAP) defined by a positive response to diagnostic injection, and to evaluate the influence of imaging findings on the clinical diagnosis of SAP. METHODS AND FINDINGS: In a prospective, diagnostic accuracy design, 208 consecutive patients presenting to their primary healthcare practitioner for the first time with a new episode of shoulder pain were recruited. All participants underwent a standardized clinical examination, shoulder x-ray series and diagnostic ultrasound scan. Results were compared with the response to a diagnostic block of xylocaineTM injected into the SAB under ultrasound guidance using ≥80% post-injection reduction in pain intensity as the positive anaesthetic response (PAR) criterion. Diagnostic accuracy statistics were calculated for combinations of clinical and imaging variables demonstrating the highest likelihood of a PAR. A PAR was reported by 34% of participants. In participants with no loss of passive external rotation, combinations of three clinical variables (anterior shoulder pain, strain injury, absence of symptoms at end-range external rotation (in abduction)) demonstrated 100% specificity for a PAR when all three were positive (LR+ infinity; 95%CI 2.9, infinity). A full-thickness supraspinatus tear on ultrasound increased the likelihood of a PAR irrespective of age (specificity 98% (95%CI 94, 100); LR+ 6.2; 95% CI 1.5, 25.7)). Imaging did not improve the ability to rule-out a PAR. CONCLUSION: Combinations of clinical examination findings and a full-thickness supraspinatus tear on ultrasound scan can help confirm, but not exclude, the presence of subacromial pain. Other imaging findings were of limited value for diagnosing SAP.

Shoulder pain in primary care--part 2: predictors of clinical outcome to 12 months.

OBJECTIVE: Identify predictor variables and models for clinical outcomes for primary care shoulder pain patients to 12 months follow-up. DESIGN: A non-randomized audit with measures of pain and disability at 3 weeks, 3, 6 and 12 months. PATIENTS: Of 208 patients, 161 agreed to participate with 96.9, 98.1, 87.0 and 83.9% follow-up at 3 weeks, 3, 6 and 12 months respectively. Treatment consisted of exercise and manual therapy-based physiotherapy and corticosteroid injection under specified selection criteria. METHODS: Potentially useful baseline variables were evaluated in univariate logistic regressions with the dependent variables determined by SPADI Questionnaire at 3 weeks, 3, 6 and 12 months. Variables associated (p-value ≤ 0.2) were retained for potential inclusion within multiple logistic regression analyses. RESULTS: Pain not improved by rest, intermittent pain, lower pain intensity with physical tests and absence of subacromial bursa pathology on ultrasound at the 3-week follow-up, constant pain and lower pain intensity with physical tests are predictors of excellent outcomes at the 3-month follow- up. Worse baseline pain and disability, no history of asthma, pain better with rest, better physical functioning, greater fear avoidance, male gender, no history of pain in the opposite shoulder, pain referred below the elbow, sleep disturbed by pain, smaller waist circumference, lower pain intensity with physical tests are factors predictive of excellent outcomes at the 12-month follow-up. Only higher pain intensity with physical tests was associated with a poor clinical outcome. CONCLUSION: Predictive models for clinical outcomes in primary-care patients with shoulder pain were achieved for excellent clinical outcomes, successfully classifying 70-90% of cases.

Do patients undergoing physical testing report pain intensity reliably?

OBJECTIVE: To determine the reliability of patient reports of pain intensity during the application of physical tests. METHODS: A single examiner required participants to use the numeric pain rating scale (NPRS) to report the intensity of pain provoked during physical testing of the hip. Standardized versions of 14 physical tests were used on 18 people with hip pain. Tests were repeated at 1 hour and 2-7 days later. Within- and between-session reliability of reports of pain intensity was calculated using intraclass correlation coefficients (ICCs) and Lin's concordance correlation coefficients (CCCs). Standard errors of measurement (SEMs) were calculated. RESULTS: ICC/CCC values for within-session reports of pain intensity ranged from 0.34 (95% confidence interval [95% CI] -0.08, 0.66) to 0.88 (95% CI 0.73, 0.95). Patients demonstrated "substantial" or "almost perfect" reliability in reporting pain intensity with 9 of 14 tests and "moderate" reliability with 3 tests. Two tests were unreliable (ICC 0.35 and 0.34). ICC/CCC values for between-session reports of pain intensity ranged from -0.05 (95% CI -0.42, 0.34) to 0.84 (95% CI 0.44, 0.95). Patients demonstrated substantial or almost perfect reliability in reporting pain intensity with 11 of 14 tests. Two tests were unreliable (ICC 0.26 and -0.05). The average SEM value of 0.9 points on the NPRS was the same for both within- and between-session testing (range 0.6-1.6). CONCLUSION: Patient reports of the intensity of pain provoked by physical tests are sufficiently reliable to be clinically useful. However, the SEM of 0.9 points should be considered when precise calculations of changes in pain intensity are important.

Shoulder pain patients in primary care--part 1: Clinical outcomes over 12 months following standardized diagnostic workup, corticosteroid injections, and community-based care.

OBJECTIVE: Measure changes in pain and disability of primary care shoulder pain patients over a 12-month period. DESIGN: A non-randomized audit with repeated measures of pain and disability at 3 weeks, 3, 6 and 12 months. PATIENTS: Of 208 patients, 161 agreed to participate with 96.9%, 98.1%, 86.3%, 83.9% follow-up at 3 weeks, at 3, 6 and 12 months, respectively. Mean age was 44 years, mean symptom duration 3.6 months. METHODS: PATIENTS were treated with protocol driven corticosteroid injection and community based care. Primary outcome measure was the Shoulder Pain and Disability index (SPADI) questionnaire. Based on the SPADI and minimal clinically important difference (MCID), outcomes were categorized into: total recovery, 90% or more improved, better, unchanged and worse. RESULTS: There was significant reduction of pain and disability at 3 weeks (p < 0.001), no change at the 3- and 6-month follow-up and a significant reduction at the 12-month follow-up (p < 0.001). Excellent outcomes were achieved by 32.9% and 45.3%, and a poor clinical outcome resulted for 32.8% and 14.9% at the 3- and 12-month follow-up, respectively. CONCLUSION: Though there was significant improvement at the 3-week and 12-month follow-up, 45% achieved an excellent outcome and a 16.7% of patients were the same or worse than baseline at 12 months.

Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain.

BACKGROUND: Despite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort. METHODS: Consecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (XylocaineTM) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O'Brien's test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests. RESULTS: Twenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84). CONCLUSIONS: In this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort.

Diagnostic accuracy of clinical examination features for identifying large rotator cuff tears in primary health care.

OBJECTIVES: Rotator cuff tears are a common and disabling complaint. The early diagnosis of medium and large size rotator cuff tears can enhance the prognosis of the patient. The aim of this study was to identify clinical features with the strongest ability to accurately predict the presence of a medium, large or multitendon (MLM) rotator cuff tear in a primary care cohort. METHODS: Participants were consecutively recruited from primary health care practices (n = 203). All participants underwent a standardized history and physical examination, followed by a standardized X-ray series and diagnostic ultrasound scan. Clinical features associated with the presence of a MLM rotator cuff tear were identified (P<0.200), a logistic multiple regression model was derived for identifying a MLM rotator cuff tear and thereafter diagnostic accuracy was calculated. RESULTS: A MLM rotator cuff tear was identified in 24 participants (11.8%). Constant pain and a painful arc in abduction were the strongest predictors of a MLM tear (adjusted odds ratio 3.04 and 13.97 respectively). Combinations of ten history and physical examination variables demonstrated highest levels of sensitivity when five or fewer were positive [100%, 95% confidence interval (CI): 0.86-1.00; negative likelihood ratio: 0.00, 95% CI: 0.00-0.28], and highest specificity when eight or more were positive (0.91, 95% CI: 0.86-0.95; positive likelihood ratio 4.66, 95% CI: 2.34-8.74). DISCUSSION: Combinations of patient history and physical examination findings were able to accurately detect the presence of a MLM rotator cuff tear. These findings may aid the primary care clinician in more efficient and accurate identification of rotator cuff tears that may require further investigation or orthopedic consultation.

Clinical predictors of a positive response to guided diagnostic block into the subacromial bursa.

OBJECTIVE: To compare the accuracy of combinations of clinical examination findings for predicting a positive response to injection of local anaesthetic into the subacromial bursa. DESIGN: Prospective, cohort, diagnostic validity design. SUBJECTS: Consecutive patients with shoulder pain recruited from primary care physiotherapy and general medical practices. METHODS: All subjects underwent a standardised clinical examination (index test) followed by a diagnostic injection of xylocaineTM into the subacromial bursa (reference standard test) performed under ultrasound guidance. Clinical examination variables associated with a positive anaesthetic response (≥ 80% post-injection reduction in pain intensity) were identified (p < 0.20) and diagnostic accuracy was calculated. RESULTS: Of the 196 subjects who received a subacromial bursa injection, 66 subjects (34%) reported a positive anaesthetic response. Strain injury (adjusted odds ratio (AOR) 2.3), anterior shoulder pain (AOR 2.3) and absence of pain with external rotation at 90º abduction (AOR 3.9) were the strongest clinical predictors of positive anaesthetic response. Clinical prediction model variables demonstrated 100% specificity (3 positive tests) but low sensitivity (maximum 40%) for a positive anaesthetic response. Combinations of 9 other clinical variables also demonstrated 100% specificity (7 or more positive tests), and improved sensitivity (95 to 100%) for a PAR compared with clinical prediction model variables when less than two findings were present. CONCLUSION: Combinations of these clinical tests may assist the clinician to differentiate subacromial pain from other shoulder conditions and guide selection of targeted pain management interventions. Additional diagnostic tests may be required when clinical criteria are not satisfied.

Comparison of a novel direct measure of rapid pain intensity change to traditional serial 100 mm VAS measurement of pain intensity.

OBJECTIVES: Key diagnostic decisions often turn on measurement of change in pain intensity after diagnostic anesthetic blocks. This study aimed to introduce a new direct measure pain intensity change and compare it with percent change as calculated from the traditional preprocedure and postprocedure pain visual analog scales. METHODS: Shoulder pain patients enrolled in a diagnostic accuracy study comparing clinical variables with image-guided local anesthetic injections were assessed with both the traditional preprocedure and postprocedure visual analog scales and the new direct method. Percent change in pain intensity was calculated with both instruments and were compared using statistical methods. The percentage pain reduction used to classify patients as responders was 80%. RESULTS: Patients received anesthetic injections to targeted shoulder structures (N=146, 331 procedures). For data above the 80% pain reduction criterion, Lin Concordance statistic ranged from 0.22 to 0.55. Bland and Altman analyses revealed positive bias and the amount of reported pain reduction was higher with the traditional method. For data above the 80% pain reduction criterion, the bias was higher and ranged from 4.8% to 12.6%. CONCLUSIONS: The 2 methods are not interchangeable. The new method measures the pain intensity change dimension directly, whereas the traditional method estimates change indirectly by calculation. Face validity is better served by adopting the new method for decisions regarding whether a patient is a "responder" or "nonresponder" to diagnostic blocks. The traditional method should be retained for estimation of pain intensity preprocedure and the duration of pain relief postprocedure.

Discussion paper: what happened to the 'bio' in the bio-psycho-social model of low back pain?

PURPOSE: Over 20 years ago the term non-specific low back pain became popular to convey the limitations of our knowledge of the pathological source of most people's low back pain. Knowledge of underlying pathology has advanced little since then, despite limited improvements in outcomes for patients with low back pain. METHODS: This paper discusses potential misunderstandings related to diagnostic studies in the field of low back pain and argues that future diagnostic studies should include and investigate pathological sources of low back pain. RESULTS: Six potential misunderstandings are discussed. (1) Until diagnosis is shown to improve outcomes it is not worth investigating; (2) without a gold standard it is not possible to investigate diagnosis of low back pain; (3) the presence of pathology in some people without low back pain means it is not important; (4) dismissal of the ability to diagnose low back pain in clinical guidelines is supported by the same level of evidence as recommendations for therapy; (5) suggesting use of a diagnostic test in research is misinterpreted as endorsing its use in current clinical practice; (6) we seem to have forgotten the 'bio' in biopsychosocial low back pain. CONCLUSIONS: We believe the misunderstandings presented in this paper partly explain the lack of investigation into pathology as an important component of the low back pain experience. A better understanding of the biological component of low back pain in relation, and in addition, to psychosocial factors is important for a more rational approach to management of low back pain.

A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks.

BACKGROUND: The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). METHODS: Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. RESULTS: In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05). CONCLUSIONS: Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.

Interexaminer reliability of orthopaedic special tests used in the assessment of shoulder pain.

Orthopaedic special tests (OST) are commonly used in the assessment of the painful shoulder to assist to rule-in or rule-out specific pathology. A small number of tests with high levels of diagnostic accuracy have been identified but interexaminer reliability data is variable or lacking. The aim of this study was to determine the interexaminer reliability of a group of OST with demonstrated diagnostic accuracy at primary care level. Forty consecutive subjects with shoulder pain were recruited. Six tests were performed by two examiners (physiotherapists) on the same day. Tests included the active compression test, Hawkins-Kennedy test, drop-arm test, crank test, Kim test and belly-press test. 'Fair' reliability (kappa 0.36-0.38) was observed for the active compression test (labral pathology), Hawkins-Kennedy test and crank test. Prevalence of positive agreements was low for the active compression test (acromioclavicular joint), drop-arm test, Kim test and belly-press test. Prevalence and bias adjusted kappa (PABAK) values indicated 'substantial' reliability (0.65-0.78) for these tests. The active compression test (acromioclavicular joint), belly-press tests (observation and weakness), Kim test and drop-arm test demonstrate acceptable levels of interexaminer reliability in a group of patients with sub-acute and chronic shoulder conditions.

Reliability of a new hand-held dynamometer in measuring shoulder range of motion and strength.

Acceptable reliability is a prerequisite for inclusion of physical examination tests in clinical examinations of the painful shoulder. The aim of this study was to establish the intraexaminer and interexaminer reliability of measures of shoulder range of motion (ROM) and muscle force using a new hand-held dynamometer with the ability to standardize overpressure force during passive ROM tests. Forty consecutive subjects with shoulder pain were recruited, and tests were performed by two physiotherapists. Tests included active ROM elevation, passive ROM glenohumeral abduction and external rotation and resisted abduction and external rotation. All tests demonstrated high levels of intraexaminer reliability (ICC 0.85-0.99; LOA 6-24° and 1.1-7.0 kg). Highest levels of interexaminer reliability reliability were observed for measures of active ROM flexion (ICC 0.88-0.95; LOA 14-22°). Passive ROM tests demonstrated 'moderate - substantial' interexaminer reliability (ICC 0.45-0.62; LOA 25-34°). The ICCs for resisted tests ranged from 0.68 to 0.84, and LOA ranged from 3.2 to 8.5 kg. Active ROM flexion demonstrated high levels of both intra- and interexaminer reliability. Measures of passive ROM and peak isometric force demonstrated acceptable levels of intraexaminer reliability.

Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain.

BACKGROUND: Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative treatment, but in carefully selected patients, surgical discectomy may provide faster relief of symptoms. Primary care clinicians use patient history and physical examination to evaluate the likelihood of disc herniation and select patients for further imaging and possible surgery. OBJECTIVES: (1) To assess the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica;(2) To assess the influence of sources of heterogeneity on diagnostic performance. SEARCH STRATEGY: We searched electronic databases for primary studies: PubMed (includes MEDLINE), EMBASE, and CINAHL, and (systematic) reviews: PubMed and Medion (all from earliest until 30 April 2008), and checked references of retrieved articles. SELECTION CRITERIA: We considered studies if they compared the results of tests performed during physical examination on patients with back pain with those of diagnostic imaging (MRI, CT, myelography) or findings at surgery. DATA COLLECTION AND ANALYSIS: Two review authors assessed the quality of each publication with the QUADAS tool, and extracted details on patient and study design characteristics, index tests and reference standard, and the diagnostic two-by-two table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for all aspects of physical examination. Pooled estimates of sensitivity and specificity were computed for subsets of studies showing sufficient clinical and statistical homogeneity. MAIN RESULTS: We included 16 cohort studies (median N = 126, range 71 to 2504) and three case control studies (38 to100 cases). Only one study was carried out in a primary care population. When used in isolation, diagnostic performance of most physical tests (scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits) was poor. Some tests (forward flexion, hyper-extension test, and slump test) performed slightly better, but the number of studies was small. In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings.Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35).Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations. AUTHORS' CONCLUSIONS: When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.

Manual correction of an acute lumbar lateral shift: maintenance of correction and rehabilitation: a case report with video.

The acute onset lumbar lateral shift, otherwise known as a list or acute scoliosis, is a common clinical observation associated with low back pain. In general orthopaedics, the presence of a lateral shift is associated with a poor prognosis; however, a manual correction method devised by McKenzie is claimed to produce rapid reversal of the deformity and reduction in pain. This single-case report presents the details of the McKenzie Mechanical Diagnosis and Treatment (MDT) management of a major right-sided lateral shift, which includes the manual correction technique, self-correction and management, prophylaxis, pain ablation, and rehabilitation to a high level of athletic function, with long-term follow-up at 9 months. The lateral shift is widely accepted as being associated with disc pathology, but the exact mechanism of shift production remains speculative. hypotheses include muscle spasm, avoidance of irritation of a spinal nerve, and space-occupying or space-deficient disc mechanics. The hypotheses used to explain the lateral shift phenomena are discussed. (Case report is supplemented by video stream, available at jmmtonline.com/).

Evidence-based diagnosis and treatment of the painful sacroiliac joint.

Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain. This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. Three or more positive pain provocation SIJ tests have sensitivity and specificity of 91% and 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.