Is punctate palmoplantar keratoderma type 1 associated with malignancy? A systematic review of the literature.

BACKGROUND: An association between punctate palmoplantar keratoderma type 1 (PPPK1) and malignancy has been proposed for decades. Some authors suggest that individuals with PPPK1 should undergo screening for various types of malignancies while others caution that an association is not well-established. In this systematic review, we summarized and evaluated the current evidence for a possible association between PPPK1 and malignancy. METHODS: The review was conducted along PRISMA guidelines. The search used Embase, MEDLINE, Scopus, and the Human Gene Mutation Database up to March 2022. All studies reporting on individuals with the diagnosis of PPPK1 with or without history of malignancy were included. Two authors screened for eligible studies, extracted predefined data, and performed a quality assessment. RESULTS: Of 773 studies identified, 45 were included. Most studies were reports on single families (24 of 45 studies) or multiple families (10 of 45 studies). The number of index cases with PPPK1 across all included studies was 280, and when family members reported with PPPK1 were added, a total of 817 individuals were identified. Overall, 23 studies reported on individuals with PPPK1 with a history of malignancy, whereas 22 studies reported on individuals with PPPK1 without a history of malignancy. Although the extracted data were not considered to be of sufficient quality to synthesize and answer our research question, the review did not confirm an association between PPPK1 and malignancy. CONCLUSION: This review shows that there is a lack of well-designed studies on this topic to conclude whether individuals with PPPK1 have an increased risk of malignancy. Based on the present literature, however, we could not confirm an association between PPPK1 and malignancy and find it highly questionable if patients with PPPK1 should be offered surveillance for malignancies.

Do number of days with low back pain and patterns of episodes of pain have similar outcomes in a biopsychosocial prediction model?

PURPOSES: We used two different methods to classify low back pain (LBP) in the general population (1) to assess the overlapping of individuals within the different subgroups in those two classifications, (2) to explore if the associations between LBP and some selected bio-psychosocial factors are similar, regardless which of the two classifications is used. METHOD: During 1 year, 49- or 50-year-old people from the Danish general population were sent fortnightly automated text messages (SMS-Track) asking them if they had any LBP in the past fortnight. Responses for the whole year were then classified into two different ways: (1) In relation to the number of days with LBP in the preceding year (0, 1-30, and >30), (2) In relation to the frequency and duration of episodes of LBP (more or less never pain, episodic, and more or less constant pain). Some bio-psychosocial factors, collected with a questionnaire at baseline 9 years earlier, were entered into regression models to investigate their associations with the subgroups of the two classifications of LBP and the results compared. RESULTS: The percentage of agreement between categories of the two classification systems was above 68 % (Kappa 0.7). Despite the large overlap of persons in the two classification groups, the patterns of associations with the two types of LBP definitions were different in the two classification groups. However, none of the estimates were significantly different when the variables were compared across the two classifications. CONCLUSION: Different classification systems of LBP are capable of bringing forth different findings. This may help explain the lack of consistency between studies on risk factors of LBP.

Back injuries in a cohort of schoolchildren aged 6-12: A 2.5-year prospective study.

The aims of this prospective school cohort study were to describe the epidemiology of diagnosed back pain in childhood, classified as either nontraumatic or traumatic back injury, and to estimate the association with physical activity in different settings. Over 2.5 years, 1240 children aged 6-12 years were surveyed weekly using mobile text messages to ask about the presence or absence of back pain. Pain was clinically diagnosed and injuries were classified using the International Classification of Diseases version 10. Physical activity data were obtained from text messages and accelerometers. Of the 315 back injuries diagnosed, 186 injuries were nontraumatic and 129 were traumatic. The incidence rate ratio was 1.5 for a nontraumatic back injury compared with a traumatic injury. The overall estimated back injury incidence rate was 0.20 per 1000 physical activity units (95% confidence interval 0.18-0.23). The back injury incidence rates were higher for sports when exposure per 1000 physical activity units was taken into consideration and especially children horse-riding had a 40 times higher risk of sustaining a traumatic back injury compared to the risk during non-organized leisure time physical activity. However, the reasonably low injury incidence rates support the recommendations of children continuously being physically active.

Financial compensation and vocational recovery: a prospective study of secondary care neck and back patients.

OBJECTIVES: Financial compensation has been shown to be a negative prognostic factor for pain and disability in patients with neck or low back pain. It is unclear whether this association is causal and to what extent it hampers return to work. The objective of this study was to assess the direct influence of a financial compensation process on the ability to remain in regular employment in patients with suspected disc herniation. METHODS: A prospective cohort study with a register-based follow-up at 1, 3, and 5 years after baseline was carried out at two multidisciplinary, non-surgical spine clinics in two public hospitals in Denmark. The study population comprised consecutive patients in regular employment with neck pain radiating to the arm or low back pain radiating to the leg. The exposure variable was any type of claim for financial compensation for the actual low back/leg or neck/arm pain. The outcome measure was receiving income compensation benefits. This information was obtained through national registers. Follow-up points were 1, 3, and 5 years after inclusion. RESULTS: The study included 1243 low back pain patients and 202 neck pain patients. The odds ratio, adjusted for relevant confounders, of receiving income compensation benefits in case of baseline financial claim was approximately 2 for low back/leg pain patients and about 4 for neck/arm pain patients at 1, 3, and 5 years. CONCLUSIONS: In employed patients, a claim for financial compensation for low back or neck pain with radiating pain was found to be independently associated with receipt of income compensation benefits after 1, 3, and 5 years.

High-level physical activity in childhood seems to protect against low back pain in early adolescence.

BACKGROUND: The evidence on the impact of physical activity on back pain in children and adolescents has been contradicting. It has also been shown that the physical activity cannot accurately be estimated in children using questionnaires. PURPOSE: The aim of this study was to establish if physical activity in childhood had any impact on back pain reporting in early adolescence (3 years later), using an objective instrumental measurement of physical activity. STUDY DESIGN: Prospective cohort study. PATIENT SAMPLE: Representative random sample of Danish children from the city of Odense sampled at age 9 years and followed-up at age 12 years. OUTCOME MEASURES: The 1-month period prevalence of back pain (neck pain, mid back pain, and low back pain) was established using a structured interview. METHODS: Physical activity was assessed with the MTI-accelerometer. The accelerometer provides a minute-by-minute measure of the physical activity performed. An overall measure of physical activity and time spent in high activity were studied in relation to back pain using logistic regression. The analyses were performed on the total sample and then stratified on back pain (yes/no) at baseline. RESULTS: High physical activity (HPA) levels seem to protect against future low back pain and appear to actually "treat" and reduce the odds of future mid back pain. When comparing the least active children to the most active children, the least active had a multivariate odds ratio of 3.3 of getting low back pain and 2.7 of getting mid back pain 3 years later. When stratified on back pain at baseline, this effect on mid back pain was especially noticeable in children who had had mid back pain already at baseline, with an odds ratio of 7.2. CONCLUSIONS: HPA in childhood seems to protect against low back pain and mid back pain in early adolescence. Larger prospective studies with repetitive follow-ups and preferably intervention studies should be performed, to see if these findings can be reproduced.

No evidence for presence of bacteria in modic type I changes.

BACKGROUND: Recent studies suggest an association between sciatica and Propionibacterium acnes. "Modic type I changes" in the vertebrae are closely associated with sciatica and lower back pain, and recent studies have questioned the ability of conventional magnetic resonance imaging (MRI) to differentiate between degenerative Modic type I changes and vertebral abnormalities caused by infection. PURPOSE: To test whether bacteria could be cultured from biopsies of Modic type I changes. MATERIAL AND METHODS: Twenty-four consecutive patients with Modic type I changes in lumbar vertebrae had a biopsy taken from the affected vertebra by a strict aseptic procedure. The biopsy was split into two specimens, which were inoculated into thioglycolate agar tubes in the surgical theatre and transported to the microbiology laboratory. In the laboratory, one specimen was streaked onto plates and analyzed for anaerobic and aerobic culture. The other tube was left unopened and incubated directly. Plates and tubes were incubated for 2 weeks and observed for visible growth. RESULTS: None of the biopsies yielded growth of anaerobic bacteria. In one patient, both biopsies yielded growth of Staphylococcus epidermidis, and in another patient coagulase-negative staphylococci were isolated from one biopsy. Both patients received oral antibiotics without convincing effect on symptoms. CONCLUSION: Our results showed no evidence of bacteria in vertebrae with Modic type I changes. The isolation of staphylococci from two patients probably represented contamination.

Poor outcome in patients with spine-related leg or arm pain who are involved in compensation claims: a prospective study of patients in the secondary care sector.

OBJECTIVE: To investigate whether poor outcome after spinal pain episodes is linked with the claim process and, if so, whether this link is independent of other potential risk factors of chronic pain and disability in patients with spine-related leg or arm pain. METHODS: A 1-year prospective outcome study with internal control groups in two Danish secondary care, public, multidisciplinary, non-surgical spine clinics. Patients with low back pain (LBP) radiating to the leg (n = 1243) or with neck and arm pain thought to emanate from the neck (n = 202) were referred to the clinics by their general practitioners. Rheumatologists, physiotherapists, and nurses examined, treated, and informed the patients based on cognitive principles. Follow-up data were collected with a postal questionnaire. Claim, defined as seeking some sort of financial compensation or filing any sort of financial claim, such as workers' compensation, was the main independent variable. Potential confounders examined were: age, sex, social class, smoking, duration and severity of pain and disability. The main outcome measures were: global assessment (main outcome variable), pain, disability, and intake of analgesics. RESULTS: Financial claims were registered by 31% of patients. After adjustment for covariates, the odds ratio for claim and no improvement was calculated to be 4.2 (95% CI 2.8-6.2) for the LBP/leg patients and 17.4 (95% CI 5.1-60.1) for the neck/arm patients. CONCLUSION: A claim for financial compensation is strongly and independently linked with a poor prognosis for Danish patients with pain radiating from the low-back or neck.

Are smooth pursuit eye movements altered in chronic whiplash-associated disorders? A cross-sectional study.

OBJECTIVE: To evaluate whether smooth pursuit eye movements differed between patients with long-lasting whiplash-associated disorders and controls when using a purely computerized method for the eye movement analysis. DESIGN: Cross-sectional study comparing patients with whiplash-associated disorders and controls who had not been exposed to head or neck trauma and had no notable neck complaints. METHODS: Smooth pursuit eye movements were registered while the subjects were seated with and without rotated cervical spine. SUBJECTS: Thirty-four patients with whiplash-associated disorders with symptoms more than six months after a car collision and 60 controls. RESULTS: Smooth pursuit eye movements were almost identical in patients with chronic whiplash-associated disorders and controls, both when the neck was rotated and in the neutral position. CONCLUSION: Disturbed smooth pursuit eye movements do not appear to be a distinct feature in patients with chronic whiplash-associated disorders. This is in contrast to results of previous studies and may be due to the fact that analyses were performed in a computerized and objective manner. Other possible reasons for the discrepancy to previous studies are discussed.

Is active participation in specific sport activities linked with back pain?

A cross-sectional survey of 439 children/adolescents aged 12-13, living in Odense, Denmark, in the year 2001. To investigate (1) if there is any difference in back pain reporting among those practising specific sports as compared with non-performers and (2) if there is an association between specific kinds of sports and self-reported back problems. Back pain is a common complaint in young people and physical inactivity is generally thought to contribute to this. However, some specific sport activities may be detrimental or beneficial to the spine. Information was collected through a semi-structured interview, a physical examination, and a questionnaire. Associations for back pain, low back pain, mid back pain and neck pain in the preceding month were investigated in relation to specific sports. Associations were controlled for body mass index, puberty stage and sex. There was no association between back problems and the practising of sports in general. However, some sports were either positively or negatively associated with back pain. Taking into account the relatively small subgroups and multiple testing, some sports seem to be potentially harmful or beneficial. These sports should be investigated in proper longitudinal study designs, in relation to their effects on back problems in the young.

Psychosocial factors at work in relation to low back pain and consequences of low back pain; a systematic, critical review of prospective cohort studies.

Relevant studies of low back pain (LBP) published between 1990 and 2002 were systematically retrieved via electronic databases and checking of reference lists. Forty papers fulfilled the inclusion criteria; 10 were of high quality. A wide variety of instruments had been used for collection of data on work related psychosocial factors, many of which had not undergone any form of validation. Moderate evidence was found for no association between LBP and perception of work, organisational aspects of work, and social support at work. There was insufficient evidence for a positive association between stress at work and LBP. No conclusions could be drawn regarding perception of work and consequences of LBP. There was strong evidence for no association between organisational aspects of work and moderate evidence for no association between social support at work and stress at work and consequences of LBP.

Ambiguous relation between physical workload and low back pain: a twin control study.

AIMS: To examine the association between self reported physical workload and low back pain (LBP) in younger twins. To investigate whether genetic factors interact with physical workload in relation to LBP. METHODS: A twin control study was performed within a population based twin register using 1910 complete monozygotic (MZ) and same sexed dizygotic (DZ) twin pairs aged 25-42 and discordant for LBP. LBP in the affected twins was divided into two groups: "LBP for 30 days during the past year". Physical workload was divided into four categories: "sitting", "sitting/walking", "light physical", and "heavy physical". Data were analysed in a matched design using conditional logistic regression. MZ and DZ twins were analysed separately and together in order to determine possible genetic influences in relation to physical workload and LBP. RESULTS: Statistically significant graded relations were found for increasing workload and LBP of longer duration but not for LBP of shorter duration (

Back pain reporting pattern in a Danish population-based sample of children and adolescents.

STUDY DESIGN: A cross-sectional survey of 806 pupils in Odense, Denmark was performed. This survey included children and adolescents ages 8 to 10 and 14 to 16 years obtained through two-stage cluster sampling from schools stratified according to school type, location, and socioeconomic character of the uptake area. OBJECTIVES: To establish the 1-month prevalence of neck, middle back, and low back pain and the consequences this disorder may have in relation to age and gender. SUMMARY OF BACKGROUND DATA: The differences in definitions of back pain and the variety of age groups included in previous studies make it difficult to draw clear conclusions about the onset of pain for various spinal regions in the young. METHODS: Information on back pain within the preceding month, obtained through a standardized interview of 481 children and 325 adolescents, was categorized according to area of pain, age, and gender. The consequences of back pain also were studied. RESULTS: The 1-month prevalence of back pain was 39%. Thoracic pain is most common in childhood, whereas thoracic pain and lumbar pain are equally common in adolescence. Neck pain and pain in more than one area of the spine are rare in both age groups. No gender differences were found. Of those who had back pain, 38% also reported some type of consequence, usually either visits to a medical physician or diminished physical activities. CONCLUSIONS: For clinical and research purposes, neck pain, middle back pain, and low back pain in childhood should be regarded as three specific entities. In future research the data for different age groups should be reported separately.

The association between physical workload and low back pain clouded by the "healthy worker" effect: population-based cross-sectional and 5-year prospective questionnaire study.

STUDY DESIGN: A population-based cross-sectional and 5-year prospective questionnaire study. OBJECTIVE: To investigate self-reported physical workload as a risk factor for low back pain. SUMMARY OF BACKGROUND DATA: Both physical and psychosocial workplace factors are considered risk factors for low back pain. However, today no consensus has been reached regarding the exact role of these factors in the genesis of low back pain. METHODS: Questionnaire data were collected at baseline for 1397 (and after 5 years for 1163) men and women aged 31--50 years at baseline. Low back pain ("any low back pain within the past year," "low back pain < or = 30 days in total during the past year," "low back pain > 30 days in total during the past year") was analyzed in relation to physical workload (sedentary, light physical, and heavy physical work) using logistic regression and controlling for age, gender, and social group. The proportions of workers changing between the workload groups over the 5-year period were analyzed in relation to low back pain status. RESULTS: At baseline no statistically significant differences in low back pain outcomes were found for workers exposed to sedentary, light physical, or heavy physical work. This was true for all age, gender, and social groups. At follow-up there was a statistically significant dose-response association between any low back pain and longstanding low back pain within the past year and increasing physical workload at baseline also after controlling for age, gender, and social group. Subjects with heavy physical workload at baseline changed statistically significantly more often to sedentary work if they experienced low back pain for more than 30 days out of the past year. CONCLUSIONS: Having a sedentary job might have a protective or neutral effect in relation to low back pain, whereas having a heavy physical job constitutes a significant risk factor. Because of migration between exposure groups (the "healthy-worker" effect), longitudinal studies are necessary for investigating the associations between physical workload and low back pain.

Recovery pattern of patients treated with chiropractic spinal manipulative therapy for long-lasting or recurrent low back pain.

OBJECTIVE: To investigate the recovery pattern in chiropractic patients being treated for long-lasting or recurrent low back pain; in particular, to identify the minimum number of required treatments and the minimum number of days from the beginning of treatment to the occurrence of improvement. DESIGN: Prospective, uncontrolled multicenter study. SETTING: Private practice. PARTICIPANTS: Each of 19 selected Norwegian chiropractors provided 10 consecutive patients; each of the latter fulfilled a set of criteria (low back pain, a present episode longer than 2 weeks in duration, a total of more than 4 weeks of low back pain in the preceding year, no chiropractic treatment during the preceding 6 months, and suitability for manipulation). Response Rate: Data were collected on 164 patients (86% of the optimal study sample), 6 of whom were excluded. This left 158 patients for the analyses. MAIN OUTCOME MEASURES: Information on low back pain status was collected on each visit (maximum, 12 visits) through use of both a 10-point numeric pain rating scale and a global improvement scale (for the question "Do you feel that you have improved since you began receiving chiropractic treatment?," 5 answers were possible, ranging from "Yes, definite improvement" to "No, I am worse now than when the treatment started"). With respect to the numeric pain rating scale, "improvement" was defined as the point at which the score reached 2 for the first time or, if the initial score was 2, the point at which the score reached 1 for the first time. With respect to the global improvement scale, "improvement" was defined as the point at which the patient first answered "Yes, definite improvement." RESULTS: Approximately 50% of patients reported that they had "improved" at the 4th visit and within 2 weeks. After this time, fewer new cases of "improvement" occurred for every visit or day since the first treatment. At the 12th visit (earlier if treatment was concluded before the 12th visit), approximately 75% of the patients reported that "improvement" had occurred. CONCLUSION: There is a large group of chiropractic patients with relatively long-lasting or recurrent low back pain who report "improvement" early in the course of treatment.

Prognostic values of physical examination findings in patients with chronic low back pain treated conservatively: a systematic literature review.

BACKGROUND: Most patients undergo physical examination. However, low back pain can only rarely be clearly diagnosed as having an irrefutable pathoanatomic cause on the basis of the classical battery of noninvasive physical examination procedures. However, physical examination findings are also used to predict the prognosis of treatment of chronic low back pain. A systematic review of the clinical literature is needed for an understanding of findings in this area. OBJECTIVES: To establish whether various physical examination procedures can be used to predict treatment outcome in the conservative (noninvasive) treatment of chronic low back pain. DATA SOURCES: From 910 titles published between 1986 and 1998, 10 original research reports were selected. These were obtained by means of a computerized MEDLINE search through use of various combinations of the key words low back pain, treatment, physical findings, predictors, prognosis, prognostic factors, prognostic indicators, and predictors and outcome(s); manual search strategies were also used. DATA SYNTHESIS: Articles that fitted the objectives of this review were retained and systematically reviewed for the prognostic value of the relevant tests/observations. In addition, results were studied in relation to type of outcome variable and type of treatment. RESULTS: The most commonly investigated tests were lumbar range-of-motion tests, which were found to have a clear-cut significant predictive value in 3 of 9 studies. Further analyses in relation to definition of outcome (back-to-work or reduction of symptoms) were not possible because study results were usually not clearly reported for each definition and because therapies were multimodal rather than distinctly well defined. CONCLUSIONS: This area has not been fully investigated. Therefore, there is no satisfactory answer to the question of whether some physical examination tests have a prognostic value in the conservative treatment of chronic low back pain.

Is sitting-while-at-work associated with low back pain? A systematic, critical literature review.

OBJECTIVES: To present a critical review and evaluate recent reports investigating sitting-while-at-work as a risk factor for low back pain (LBP). METHODS: The Medline, Embase and OSH-ROM databases were searched for articles dealing with sitting at work in relation to low back pain for the years 1985-97. The studies were divided into those dealing with sitting-while-working and those dealing with sedentary occupations. Each article was systematically abstracted for core items. The quality of each article was determined based on the representativeness of the study sample, the definition of LBP, and the statistical analysis. RESULTS: Thirty-five reports were identified, 14 dealing with sitting-while-working and 21 with sedentary occupations. Eight studies were found to have a representative sample, a clear definition of LBP and a clear statistical analysis. Regardless of quality, all but one of the studies failed to find a positive association between sitting-while-working and LBP. High quality studies found a marginally negative association for sitting compared to diverse workplace exposures, e.g. standing, driving, lifting bending, and compared to diverse occupations. One low quality study associated sitting in a poor posture with LBP. CONCLUSIONS: The extensive recent epidemiological literature does not support the popular opinion that sitting-while-at-work is associated with LBP.

Whole-body vibration and low back pain: a systematic, critical review of the epidemiological literature 1992-1999.

OBJECTIVES: A previous extensive review of the literature including that from the middle of 1992 concluded that whole-body vibrations may contribute to low back pain, but that the exposure-response relationship had not been clarified. We reviewed the literature of the past 7 years to find out: (i) whether there is evidence in the recent epidemiological literature for a causal association between whole-body vibrations and low back pain, and (ii) if there is evidence in the recent literature for a dose-response relationship between whole-body vibrations and low back pain. METHODS: All relevant epidemiological articles which were obtained through a search in the databases MEDLINE, OSH-ROM and TOXLINE, and through personal communication, were reviewed independently by the two authors, using a checklist. RESULTS: Twenty-four original articles concerning the association between whole-body vibrations and the lower back were retained for use. The quality of the papers was mostly low, but improved with time. Only seven articles passed our predetermined quality criteria. Of the seven reports, one showed increased frequency of lumbar prolapse in occupational drivers, and six showed low back pain to be more frequent in whole-body vibration-exposed groups. Only two out of the four articles reporting on dose, showed a dose-response association. CONCLUSIONS: Despite the lack of definite evidence, we found sufficient reasons for the reduction of whole-body vibration-exposure to the lowest possible level. If new knowledge is to be produced, good prospective studies with repeated measurements of exposure, analyses of work postures, and clear definitions and subgroupings of low back pain are needed. Other research in this field should be given up, and the resources used for more important issues, as the size of the problem of whole body vibration is probably on the decrease because of the technical prophylactic developments that are already in progress.

Alcohol and low-back pain: a systematic literature review.

BACKGROUND: The role of lifestyle factors is an important issue in the prevention and treatment of disease. Although certain lifestyle factors in relation to low-back pain have evoked much interest, interest has not focused on alcohol consumption. An appraisal of the epidemiologic literature seems warranted. OBJECTIVES: To establish if there is evidence in the literature for a causal link between alcohol consumption and low-back pain. DATA SOURCES: Nine original research reports published between 1987 and 1995 were obtained through a MEDLINE search for the years 1992 to 1998, with various combinations of the terms "alcohol," "substance abuse," "life-style, " "risk factor," "epidemiology" and "low back pain." An additional manual search was made of relevant bibliographies without limitation for year of publication. DATA SYNTHESIS: A systematic review was made of the epidemiologic literature to uncover any evidence for a causal relation between alcohol consumption and low-back pain. RESULTS: None of the studies reported a positive link between alcohol consumption and low-back pain, and no positive gradient was found in studies that included an analysis of the dose-response. None of the studies was prospective in design. CONCLUSIONS: Alcohol consumption does not seem to be associated with low-back pain, but well-designed specific alcohol/low-back pain-centered studies are lacking.

Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review.

OBJECTIVE: To systematically review the peer-reviewed literature about the reliability and validity of chiropractic tests used to determine the need for spinal manipulative therapy of the lumbo-pelvic spine, taking into account the quality of the studies. DATA SOURCES: The CHIROLARS database was searched for the years 1976 to 1995 with the following index terms: "chiropractic tests," "chiropractic adjusting technique," "motion palpation," "movement palpation," "leg length," "applied kinesiology," and "sacrooccipital technique." In addition, a manual search was performed at the libraries of the Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark, and the Anglo-European College of Chiropractic, Bournemouth, United Kingdom. STUDY SELECTION: Studies pertaining to intraexaminer reliability, interexaminer reliability, and/or validity of chiropractic evaluation of the lumbo-pelvic spine were included. DATA EXTRACTION: Data quality were assessed independently by the two reviewers, with a quality score based on predefined methodologic criteria. Results of the studies were then evaluated in relation to quality. DATA SYNTHESIS: None of the tests studied had been sufficiently evaluated in relation to reliability and validity. Only tests for palpation for pain had consistently acceptable results. Motion palpation of the lumbar spine might be valid but showed poor reliability, whereas motion palpation of the sacroiliac joints seemed to be slightly reliable but was not shown to be valid. Measures of leg-length inequality seemed to correlate with radiographic measurements but consensus on method and interpretation is lacking. For the sacrooccipital technique, some evidence favors the validity of the arm-fossa test but the rest of the test regimen remains poorly documented. Documentation of applied kinesiology was not available. Palpation for muscle tension, palpation for misalignment, and visual inspection were either undocumented, unreliable, or not valid. CONCLUSION: The detection of the manipulative lesion in the lumbo-pelvic spine depends on valid and reliable tests. Because such tests have not been established, the presence of the manipulative lesion remains hypothetical. Great effort is needed to develop, establish, and enforce valid and reliable test procedures.