July 20, 2013
In the previous post I discussed ruling out cervical spine fractures with using the highly sensitive test – the Canadian C-Spine Rule. As all PT’s know, the next step is differential diagnosis to ensure we are managing musculoskeletal conditions. Once we are certain the patient is PT-appropriate, I want to ensure I grasp the patient’s “SINSS” to glean more on our evaluation. For those who aren’t familiar: “SINSS” is a Maitlandconcept of assessing the severity, irritability, nature, stage of the patient’s condition, and symptom behavior. As we see in the current literature, imaging doesn’t give us diagnostic criteria for us to develop hypotheses about the cervical spine pain. Boden et. al showed that 14% of asymptomatic patients have disc bulging and Sivola et. al showed 73% of patients with no history of neck pain had disc degeneration. An even more startling finding is that 87% of asymptomatic patients having disc protrusion.8 An EMG has better sensitivity in terms of ruling out cervical radiculopathy of 50-71%, but is costly and relatively invasive when compared to a physical exam.13 Really, this leaves us with a lack of gold standard to diagnose cervical spine pain, thus leaving us with a concise physical exam to base our treatments off of.
In today’s post, I am going to skip over tests that most orthopedic physical therapists complete and focus on areas that every therapist should fit into a patient exam due to their excellent and quick diagnostic criteria. I utilize the bulk of my testing to gain information for four reasons: to rule out adverse pathology, to format a running diagnosis, draft an idea of prognosis, and to postulate their current classification.
Before a patient enters my office, I administer a few forms to assess their history from a thorough intake form and an outcome measure. We have less literature in the cervical spine for fear avoidance behaviors, although one may be able to generalize their importance with neck pain. Some preliminary studies show that it is a useful tool to predict patients who will develop prolonged disability with neck pain.14 Reliability of FABQ in cervical spine was reported as .85, but unfortunately we have not evaluated its MDIC.9 An interesting article in 2010, performed by Calley et al, showed poor correlation between therapist perceived patient fear avoidance patterns, when compared to self reported FABQ for patients with low back pain.7 Trust me, I have said the same thing you are thinking: I absolutely can tell who is a walking bag of yellow flags with poor coping mechanisms, well – this article begs to differ, so now I administer the measurement.
So let’s start with the first essential piece to an evaluation: a neurological screen. Here, I obtain my motor, reflex and somatosensory information. I assess: DTR’s, light touch, hoffman’s reflex, along with my myotomal screen. This would be added information into my “ruling out adverse pathology” container. Hoffman’s reflex maintains a specificity of .78, which is a moderately supportive test for ruling in possible UMN sign with a positive test.3 Light touch testing will give me feedback of hyperparesthesia, or hypoparesthesia in any dermatomal pattern, which will add information to my upper quarter screen. Lastly, the myotomal screen may give me added information for general muscle tone, but mostly utilized for sensitive purposes to assess nerve root compression.
While in the seated position two tests that glean us quite a bit of information are Spurlings, and Sharp-Purser testing. Both have high diagnostic power. Sharp Purser test has a +LR of 17.3, making this an excellent choice for clinical assessment of upper cervical spine instability.4 Followed by Spurlings test which has a moderate specific rate when utilized alone (.88) but when utilized with distraction test, UNLT median nerve testing, and AROM assessment where patient has <60 degrees of cervical rotation increases is specificity to .99 which is nearly flawless at ruling in cervical radiculopathy.6 Now, I am gaining information to format my hypothesis of what classification to place this patient for the time being and to hypothesize their pain generator.
But, we need more tests than these two for diagnostic criteria, right? Yes. Mobility in the spine is an essential piece to hypothesis development. A colleague asked me this last week if I assess accessory motion in supine or prone. So, of course, I looked into its reliability in each position. Inter-rater reliability in accessory motion in the lumbar spine was poor in prone and obviously not tested in other positions. I was unable to find evidence of our reliability of assessment of mobility of a specific segment in the cervical spine, nonetheless to compare positioning. We do seem to be better at finding painful segments, with a +LR of 3.9 when correlating to neck pain.9
The last two tests that were briefly mentioned earlier as cluster tests to rule in cervical radiculopathy are the cervical distraction test and upper limb tension testing (ULTT) or upper limb neurodymamic testing (ULNT). Cervical distraction testing is a reliable test, and part of the four pronged testing for ruling in cervical radiculopathy.12 It is simple to perform, and often relieving for patients. One personal caveat of this test is to play with hand positioning, this test was validated with one hand on the chin with 14 pounds of pressure, but if a patient has discomfort to this handling, switch to accommodate to patient need. ULNT is a common measurement we take in clinic to assess neural tension’s contribution to patient’s symptoms or to rule in radiculopathy. The test actually has moderately strong specificity making it a valuable test for both purposes.
Again, all patients require a thorough screen, especially as self referrals and direct access are becoming more common. Once in the office, best utilization of your and the patient’s time is required. The test must be useful to rule in a condition and drive your treatment. What does an evaluation say about prognosis though? A few areas help me drive prognostic factors, obviously duration of symptoms and our SINS rule, but maybe the strongest predictor: psychosocial factors. Coping mechanisms, avoidance behaviors or underlying depression will play a large role in our treatment. Physical therapists have the optimal position to have these conversations as we have more time with each patient and assisting them in pain management. It should be a topic we discuss with patients openly, unfortunately, I think it is commonly missed. With each patient I thoroughly discuss their barriers to our prognosis, and if I think either of the above barriers are present I address them appropriately. This is an opportunity to utilize our network of health care professionals, and an opening to discuss how to modulate experienced pain and change pain beliefs. With these items in mind, a proper prognosis can be achieved.10,11
Wrapping up today’s discussion, finding the right test for each evaluation should take into account the evidence, but also patient and therapist comfort and modifying testing based on the patient’s SINS and therapist discretion, this way a patient can move successfully toward healing.
1) Côté P, van der Velde G, Cassidy JD, et al. (2008) The burden and determinants of neck pain in workers. Results of the Bone and Joint 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine 33(Suppl):S60–S74.
2) Koury, M. J., & Scarpelli, E. (1994). A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Physical therapy, 74(6), 548–60. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pubmed/8197241
3) John A Glaser, MD, Joel K Curé, MD, et al. Cervical Spinal Cord Compression and Hoffman’s Sign. 2001. Iowa Orthopedic Journal. 21:48-52
4) Uitvlugt G, Indebaum S. Clinical Assessment of Atlantoaxial Instability Using the Sharp-Purser Test. Arthritis Rheum. 1988; 31: 918-922.
5) Hogg-Johnson, S., van der Velde, G., Carroll, L. J., Holm, L. W., Cassidy, J. D., Guzman, J., … Peloso, P. (2009). The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics, 32(2 Suppl), S46–60. doi:10.1016/j.jmpt.2008.11.010
6) Wainner er al. Reliability and Diagnostic Accuracy of Clinical Examination and Patient Self-Reported Measures For Cervical Radiculopathy. Spine. 2003; 28: 52-62.
7) Calley, D. Q., Jackson, S., Collins, H., & George, S. Z. (2010). Identifying patient fear-avoidance beliefs by physical therapists managing patients with low back pain. The Journal of orthopaedic and sports physical therapy,40(12), 774–83. doi:10.2519/jospt.2010.3381
8) Boden SD, McCowin PR, Davis DO, et al: Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990 Sep; 72(8): 1178- 84 Cleland et al.
9) Interrater reliability of the history and physical examination in patients with mechanical neck pain. Arch Phys Med Rehabil. 2006;87:1388-1395.
10) Steven Z. George, Rogelio A. Coronado, and Dennis L. Hart. Depressive Symptoms, Anatomical Region, and Clinical Outcomes for Patients Seeking Outpatient Physical Therapy for Musculoskeletal Pain. Physical Therapy. 2011. 91(3) 358-372.
11) O’Sullivan, P. (2005). Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual therapy, 10(4), 242–55. doi:10.1016/j.math.2005.07.001
12) Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. “Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.” Spine. 2003 Jan 1. Web. 08/18/2012.
13) Rubinstein, S. M., Pool, J. J. M., van Tulder, M. W., Riphagen, I. I., & de Vet, H. C. W. (2007). A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 16(3), 307–19. doi:10.1007/s00586-006-0225-6
14) Landers MR, Creger RV, Baker CV, Stutelberg KS. THe use of Fear-Avoidance Beliefs and Nonorganic Signs in Predicting Prolonged Disability in Patients with neck pain. Manual Therapy. 2008. 13:239-48.