11.  The total number of clinical diagnostic tests that was in JOSPT 2011 systematic review (subscription required) looking at structural lumbar segmental instability.

Courtesy JOSPT (subscription required)

Quite a few!  Seems to be getting up there with clinical tests of meniscal tears.  With this many, which are appropriate and have the highest clinical utility?  As you can see from the table below, most have high specificity but low sensitivity.  Meaning, a positive test will be more indicative of structural lumbar instability but a negative test will not help very much in ruling-out this hypothesis.  In general, these are not a good screening tool.

However, the authors did find that the PLE had the highest combined sensitivity and specificity, as well as the highest positive likelihood ratio (8.8…which interprets to a moderate but usually important change).  You can read a past post on this test from me here.  I wanted to bring it back up because I would like to know if anyone is using this test in clinical practice?  I know I don’t.  

I typically go with aberrant motions (such as a painful catch, Gower’s sign, reversal of lumbopelvic rhythm, etc.) and even prone instability test.  The bad thing, the +LR for these are 1.9 and 1.4 respectively; or denoted as very small and rarely important if you interpret clinically. 

Courtesy JOSPT (subscription required)

I like to think I stay on top of things and evidenced-informed; but in this case, I may be still stuck in the stone age.  

I would like to hear about what anyone else uses to aid in this clinical diagnosis and why?

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2 comments

  1. I am PT with a grade II spondylothesis, confirmed by recent flex/ext radiograph, although I knew for several years. I feel as though the clinical tests are helpful, in particular, the prone instability test. I have been battling classic spondy symptoms for several years and have had patients referred with a dx of spondy that I do not agree with (in that I do not feel their symptoms are related to the spondy perhaps confirmed by imaging). I think when evaluating, the subjective portion of the eval is critical and whether it correlates to the positive clinical test? Do they have a strong flex bias, do they have pain with static sitting/standing that is relieved by change of position/walking/movement? If so then I believe the diagnosis is solid.

    1. JT,
      Thanks for your feedback. I highly agree with your statement of the subjective exam is key, and you need to use reasoning to make sure the clinical tests match up. My patient caseload (much older) usually doesn’t come in with spondy instability but I agree with the prone instability test. I normally do a modified version of it just with the patient prone and if pain over SP, I would get them to contract the core and if not painful afterwards, it is usually positive in my mind.
      Thanks for reading!
      Harrison

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