‘Clinical Tests to Diagnose Lumbar Segmental Instability’ by Alqarni & colleagues in recent JOSPT puts the title in perspective. As much as we want to be able to claim, and diagnose structural lumbar spine instability…well, we can’t; or better yet, we shouldn’t.
I find it troubling to know that we continue to label people with instability with poor to actual horrible clinical tests. We all knew this deep inside, but now a systematic review is out. Don’t kill the messenger.
This is unfortunate. Instability is a catch-all phrase used by healthcare workers who have more than a 6-week certification behind their name and work in a local YMCA. But, you can also overhear it in laymen and laywomen’s conversations after they conduct a 10-minute google search on back pain or pick up a new issue of Men’s Health. Now that what we say (as musculoskeletal specialists) is not validated, by any means, is going to shut down physical therapyhood as we know it!
Well, this first review will not but at least I hope it reaches your desk. It gives a good review on end-range flexion-extension radiographs as the referenced standard for now for LSI (however, digital video fluoroscopy is coming along) so if a patient is really a candidate in your handbook for instability, then you will know where to go to next if your TrA tucking doesn’t work. It was also nice to know that passive lumbar extension test had the highest +LR (8.8), sensitivity (84%) and specificity (90%) showing an effective clinical test for diagnosing if you were to choose one (even though one test and apparent limitations). See below for test and here for the article.
This study may give a knock out punch to your favorite and 10-yr old instability tests and you know they work but its pretty high evidence, level 2a. Yes, there are other ways we can go about finding instability even though in all reality, we don’t know. We can always go back to a Delphi study, Hicks 2005 CPR for stabilization program, or even other clinical assessment tools. But, I feel this one hit the nail on the head with this in the conclusion:
“This systematic review found that the majority of clinical tests routinely employed to diagnose structural LSI demonstrated only limited ability to do so”
So, other than ruining your spring picnic, I think this review puts a few things into perspective.
- First, one single test or even a few tests will not give us the diagnosis to an acceptable level (at least for now).
- Second, there are multiple ways per above that you can put together as a larger picture in order to educate your patients (and students so the torch will be passed on correctly).
- Third, clinical diagnostics and practice is not pure science but involves reasoning, judgment and by all means experience.
- Finally, diagnosing lumbar spine instability as a misguided and even ambiguously defined term is hard enough. Lets give ourselves a break!