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Management of a patient with lumbar segmental instability using a clinical predictor rule.

ABSTRACT: The diagnosis of low back pain is a common and costly condition in primary healthcare, which is often grouped into a homogeneous category. It has been suggested that the population of patients with low back pain are not a homogenous group and that they should be classified into subgroups. One subgroup identified in the literature is patients thought to have lumbar segmental instability. The patient in this case report is a 59-year-old female who presented with the four predictors of success demonstrated by Hicks et al. for implementing a lumbar stabilization program for a patient with lumbar segmental instability. With conservative treatment utilizing a lumbar stabilization program, the patient was able to regain strength, lumbar stability, and demonstrate functional improvement evidenced by an improvement in her Oswestry score. It is recommended that knowledge of current literature including clinical predictor rules can help to improve clinical decision making along with treatment of patients.

SUBMITTER: Ribaudo A

PROVIDER: S-EPMC3772173 | biostudies-other | 2013 Oct

REPOSITORIES: biostudies-other

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Management of a patient with lumbar segmental instability using a clinical predictor rule.

Ribaudo Anna A

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20130814 3

The diagnosis of low back pain is a common and costly condition in primary healthcare, which is often grouped into a homogeneous category. It has been suggested that the population of patients with low back pain are not a homogenous group and that they should be classified into subgroups. One subgroup identified in the literature is patients thought to have lumbar segmental instability. The patient in this case report is a 59-year-old female who presented with the four predictors of success demo ...[more]

PMID: 24426882

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Project description:BackgroundMusculoskeletal physiotherapists routinely assess lumbar segmental motion during the clinical examination of a patient with low back pain. The validity of manual assessment of segmental motion has not, however, been adequately investigated.MethodsIn this prospective, multi-centre, pragmatic, diagnostic validity study, 138 consecutive patients with recurrent or chronic low back pain (R/CLBP) were recruited. Physiotherapists with post-graduate training in manual therapy performed passive accessory intervertebral motion tests (PAIVMs) and passive physiological intervertebral motion tests (PPIVMs). Consenting patients were referred for flexion-extension radiographs. Sagittal angular rotation and sagittal translation of each lumbar spinal motion segment was measured from these radiographs, and compared to a reference range derived from a study of 30 asymptomatic volunteers. Motion beyond two standard deviations from the reference mean was considered diagnostic of rotational lumbar segmental instability (LSI) and translational LSI. Accuracy and validity of the clinical assessments were expressed using sensitivity, specificity, and likelihood ratio statistics with 95% confidence intervals (CI).ResultsOnly translation LSI was found to be significantly associated with R/CLBP (p < 0.05). PAIVMs were specific for the diagnosis of translation LSI (specificity 89%, CI 83-93%), but showed poor sensitivity (29%, CI 14-50%). A positive test results in a likelihood ratio (LR+) of 2.52 (95% CI 1.15-5.53). Flexion PPIVMs were highly specific for the diagnosis of translation LSI (specificity 99.5%; CI 97-100%), but showed very poor sensitivity (5%; CI 1-22%). Likelihood ratio statistics for flexion PPIVMs were not statistically significant. Extension PPIVMs performed better than flexion PPIVMs, with slightly higher sensitivity (16%; CI 6-38%) resulting in a likelihood ratio for a positive test of 7.1 (95% CI 1.7 to 29.2) for translation LSI.ConclusionThis study provides the first evidence reporting the concurrent validity of manual tests for the detection of abnormal sagittal planar motion. PAIVMs and PPIVMs are highly specific, but not sensitive, for the detection of translation LSI. Likelihood ratios resulting from positive test results were only moderate. This research indicates that manual clinical examination procedures have moderate validity for detecting segmental motion abnormality.

Dataset Information

Management of a patient with lumbar segmental instability using a clinical predictor rule.

Publications

Management of a patient with lumbar segmental instability using a clinical predictor rule.

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