International Journal of Mechanical Diagnosis and Therapy

Transkript

1 International Journal of Mechanical Diagnosis and Therapy 26 Branches Worldwide Americas Region Argentina Brazil Canada United States Asia/Pacific Region Australia Japan New Zealand Nigeria Saudi Arabia European Region Austria Benelux/Netherlands Croatia Czech Republic Denmark Finland France Germany Hellas/Cyprus Hungary Italy Norway Poland Slovenia Sweden Switzerland United Kingdom 2006 Volume 1, No. 1 Danish version The McKenzie Institute International Center for Postgraduate Study in Mechanical Diagnosis and Therapy

2 On the Cover: The Bronze Lady: The McKenzie Institute International Extension Award, awarded to an individual/ or individuals for outstanding contribution to education or research in the field of Mechanical Diagnosis and Therapy. Since 2001, the award has been publicly awarded in conjunction with our MII Conferences. Visit our website for a list of past recipients:

3 International Journal of Mechanical Diagnosis and Therapy Editor Allan Besselink, PT, Dip. MDT Editorial Review Board Helen Clare, PT, PhD, Dip. MDT Stuart Horton, PT, Dip. MDT Sinikka Kilpikoski, PT, Dip. MDT Stephen May, PT, Dip. MDT Julie Shepherd, PT, Dip. MDT Mark Werneke, PT, Dip. MDT Contributors Ann Carlton, PT Production The McKenzie Institute USA Nancy Morden, Executive Asst. McKenzie Institut Danmark Ansvarshavende redaktør Camilla Nymand, PT, Dip. MDT Formand Uffe Lindstrøm, Dip. MDT Næstformand Martin Melbye, Dip. MDT Sekretær Anne Juul Sørensen, Dip. MDT Kasserer Eva Hauge, Dip.MDT Bestyrelsesmedlemmer Merethe Fehrend, Cert.MDT Charlotte Krog, Dip.MDT Suppleanter Troels Balskilde, Dip.MDT Michael Rømer, Cert.MDT Webmaster Jesper Rasmussen 2006 The McKenzie Institute 2006 The McKenzie Institute

4 I n d h o l d Volume 1, Nr. 1 Marts 2006 Artikler International Journal of Mechanical Diagnosis and Therapy Editorial Review Board Helen Clare, PT, PhD, Dip. MDT clare.ha@bigpond.com Stuart Horton, PT, Dip. MDT stuart.horton@otago.ac.nz Sinikka Kilpikoski, PT, Dip. MDT sinikka.kilpikoski@kolumbus.fi Stephen May, PT, Dip. MDT s.may@shu.ac.uk Julie Shepherd, PT, Dip. MDT julie.shepherd@glos.nhs.uk Mark Werneke, PT, Dip. MDT mwerneke@centrastate.com Contributors Ann Carlton, PT acarlton@san.rr.com Production The McKenzie Institute USA Nancy Morden, Executive Asst. nancy@mckenziemdt.org & McKenzie Institut Danmark 8 Non-specific low back pain are we any nearer a structural diagnosis? Stephen May, PT, Dip. MDT 18 Low back care Advice is plentiful but is it worth taking? Richard Rosedale, Reg. PT, MCPA 20 Getting your back back to work: pain relief where to start? Timothy J. Caruso, PT, MBA, MS, Cert. MDT and David J. Pleva, PT, MA, Dip. MDT 30 A personal journey on the MDT path Eva Novakova, PT, Cert. MDT 34 Variance in manual treatment of nonspecific low back pain between Orthomanual Physicians, Manual Therapists, and Chiropractors Elise A. van de Veen, MSc, Henrica C.W. de Vet, PhD, Jan J.M. Pool, Wouter Schuller, MD, Annemarie de Zoete, DC, and Lex M. Bouter, PhD 59 Mekanisk Inkonklusiv Behandling og Rehabilitering (artikel 3/3) Camilla Nymand, Dip. MDT & Martin Melbye, Dip.MDT 67 Klassifikation af skulderpatienter ad modum McKenzie, et intertester reliabilitetsstudie Camilla F. Lauridsen, Helene Olsen, Line Martley Jensen & Mette Brøndum Spalter 3 Mission, Policies and Editorial Calendar 4 Nyt fra formanden Uffe Lindstrøm, Dip. MDT 5 Et kig indenfor, redaktionen Camilla Nymand, Dip. MDT 43 Clinical Viewpoint Clinical Reasoning: Stuart Horton, Dip Phty, DMPhty. Dip. MDT 47 Case Reports 1. Aidan Sylvester, BSc Physio, PG Dip Phty. MDT 2. Chris Littlewood, BHSc(Hons), MSc, Dip. MDT 54 Literature Reviews Reviewed by Stephen May, PT, Dip. MDT 58 Diploma Dialogue McKenzie Institut Danmark 6 Generel info fra McKenzie Institut Danmark 2006 The McKenzie Institute 7 Credential Update / Tillykke med bestået Credential Evaluering 69 Kursusoversigt / 10. Internationale McKenzie Konference New Zealand 2007 Volume 1, No. 1 March 2006 IJMDT 2

5 Mission Statements & Submission Guidelines International Journal of Mechanical Diagnosis and Therapy The McKenzie Institute International Headquarters: 1 Alexander Road Raumati Beach, Kapiti Coast, New Zealand Postal Address: PO Box 2026 Raumati Beach 6450 New Zealand Telephone: Facsimile: mckinst@xtra.co.nz International Center for Postgraduate Study The worldwide mission of The McKenzie Institute International is to further the philosophies for spinal disorders developed by Robin A. McKenzie of Raumati Beach, New Zealand. The philosophies and treatments are know internationally as the McKenzie Method of Mechanical Diagnosis and Therapy. The mission will be achieved by: Educating health care providers in the principles and practical application of Mechanical Diagnosis and Therapy, as developed by Robin Anthony McKenzie. By research and study of spinal disorders and back care treatment generally, and in particular in reference to the McKenzie Method. To promote and support research that will advance the knowledge, skill and treatment of mechanical disorders of the spine. To make known to the medical profession and other related parties, the concept and the benefits of the McKenzie Method of Mechanical Diagnosis and Therapy. IJMDT Mission: The International Journal of Mechanical Diagnosis and Therapy (IJMDT) is a collaborative effort of the worldwide branches of The McKenzie Institute Institute (MII) emphasizing scientific study, clinical relevance and education related to Mechanical Diagnosis and Therapy (MDT). Editorial Calendar Submission deadline*: January 15 May 15 September 15 Mail date: March 15 July 15 November 15 *unless the date of publication is important to the nature of the material, we welcome submissions throughout the year. General Policies The MII IJMDT seeks original material of clinical, educational or professional relevance by physical therapists and members of all related health professions. Once the submission is accepted, the material becomes the property of MII and cannot be reproduced elsewhere without permission from the Chief Editor. We reserve the right to edit for style and content and/or cut articles to fit our space requirements. Significant modifications will be discussed with the author. The author will be notified by mail or of the status of the submission. The views and opinions in the IJMDT are those of the authors and not necessarily of MII. Submission Guidelines* Articles preferred by or mailed on disk in MS-Word (.doc) format using 10pt Arial font. PDF files are also acceptable. Hard copy submissions should be typed, double-spaced on standard letter-size paper with 1 inch margins on all sides and each page numbered. A title page must be included and the name of the author(s). Degrees, professional titles and current position should be included, along with an address and daytime telephone and fax numbers where the author(s) can be reached. All statements based on published findings or data should be referenced appropriately. *Please visit our website for examples of reference styles, additional details and the most up-to-date submission guidelines as the publication advances in the future: Submit via to: Allan Besselink, Chief Editor smartsport@aol.com Nancy Morden, Executive Asst nancy@mckenziemdt.org Or mail disk or hard copy to: Ms. Nancy Morden, Executive Asst The McKenzie Institute USA 126 N. Salina Street, 4th Floor Syracuse, New York IJMDT is published annually March, July and November by The McKenzie Institute USA. All rights reserved. Contents are not to be reproduced or reprinted without permission of publisher. info@mckenziemdt.org or fax request to (315) Volume 1, No. 1 March 2006 IJMDT 3

6 Nyt fra formanden Velkommen til denne første udgave af International Journal of MDT Med udgivelsen af den første udgave tager vi et stort skridt fremad med hensyn til en endnu mere målrettet og omfangsrig kommunikation om MDT og relaterede emner. IJMDT vil sikre at langt flere, som beskæftiger sig med muskuloskeletale problemer, meget hurtigere får centrale informationer om MDT og relaterede emner. Informationerne vil, med bidrag fra hele verden, blive alsidige og den videnskabelige kvalitet høj og væsentligt. Samtidig bevarer vi enhver mulighed for at bibeholde lokale nyheder og lokalt stof. Vor tilknytning til McKenzie Institute International har mange fordele, herunder ikke mindst når det massiv vidensdeling. Fra andre muskuloskeletale tilgange tales der for tiden en del om i hvor stor udstrækning man tilhører et koncept eller om man foretager konceptuelle valg og om man er konceptuel afhængig. Det er vel en overvejelse værd at fundere lidt over om MDT et koncept og om vi er konceptuelle afhængige? Det korte svar på begge spørgsmål er NEJ. MDT er en dynamisk undersøgelses- og behandlingsstrategi, som hviler på et fagligt rationale. Det er dynamisk fordi det kontinuerligt bliver udviklet og tilpasset i forhold til hvad videnskabelige undersøgelser viser. Indgangsvinklen til hvorledes vi som klinikere vælger at håndtere vore patienter kan være forskellige, men lukkede koncepter og dogmatiske holdninger til hvorledes vi hver især håndterer muskuloskeletale problemer ser ikke ud til at have det store potentiale. Derimod vil dynamiske undersøgelses og behandlingstrategier som MDT, der hviler på et fagligt rationale, på sigt - tror jeg vise sig at bidrage til en bedre forståelse af og dermed en mere effektiv håndtering af de muskuloskeletale problemer. Et fælles træk - for de skabende områder indenfor det muskuloskeletale felt i dag og i tiden der kommer - er at de arbejder med subgruppering af de muskuloskeletale problemer. Evidens begrebet er centralt for de som arbejder med muskuloskeletale problemer. Udfører vi med MDT evidensbaseret praksis? Det korts svar er JA. MDT er beskrevet at fysioterapeuten Robin McKenzie. Med fokus på patienternes symptomatiske og mekaniske respons på belastningstrategier, samlede McKenzie data ind fra sine patienter over en periode på 20 år. Med udgangspunkt i den indsamlede data beskrev han sine undersøgelsesog behandlingsstrategier - MDT. Dele af disse strategier er gennem de sidste ca. 15 år afprøvet i videnskabelige forsøg verden over. Alle dele af MDT er ikke belyst endnu, men meget mere er undervejs. I sin fokus og bestræbelse på at benytte sig af evidensbaseret behandling, må man som kliniker ikke overse, at der i evidensbaseret praksis indgår tre elementer. Nemlig en intervention, der tager sit udgangspunkt i de bedste tilgængelige forskningsresultater sammenholdt med klinikerens egen erfaring og patientens ønsker. De bedste hilsener som altid! Uffe Lindstrøm, Dip MDT Formand IMDT Volume 1, No. 1 March 2006 IJMDT 4

7 Et kig indenfor Kære Læsere Større og mere omfangsrigt, en betydelig øget kvalitet og en stor mulighed for at give Jer et input fra hele verden dét er formatet af International Journal of MDT. McKenzie Institut International udvikler sig: flere og flere lande indtegnet på verdenskortet, til stadighed flere der sigter efter at øge deres kompetenceniveau indenfor MDT og årlige internationale og amerikanske konferencer med en bred vifte af interessant klinisk stof og opdateringer på nuværende viden. Danmark er på verdenskortet med et relativt stort antal credential terapeuter, og muligheden for at tage den kliniske del af diplomuddannelsen i Danmark er nu også en realitet. Derfor er det meget glædeligt at vores ansigt udadtil, nyhedsbladet bliver konverteret til en International Journal dét projekt glæder jeg mig over at være en del af. Der er mange ting at glæde sig over. Dét dagligt at møde patienter præsentere sig med adskillge typer af muskuloskeletale problemer som håndteres efter MDT s principper, er en stadig kilde til begejstring og entusiasme. Og lige i kølvandet kommer uundgåeligt en taknemmelighed over at have mødt nogle ekseptionelle mennesker, der har formået at give denne viden og dette buskab videre på en inspirerende og gribende måde. Jeg husker min mentor, Mark Miller, sige: Du vil opleve det øjeblik, hvor du pludselig fanger ideen og mærker flow giv mig et kald når det sker, derfra begynder det først at blive rigtigt sjovt. Det er altid en udsøgt fornøjelse, suppleret med nogen udfordring, at diskutere hvad MDT egentligt er for noget. Det er ikke usædvanligt at McKenzie hos nogle er forbundet med de her bagoverbøjnings-stræk-øvelserfor-lænderyggen. Heller ikke ret mærkeligt, når man tænker over det. Extension er ikke noget dårligt valg af strategi hvis man kun måtte vælge én ting. Knap halvdelen af kronikerne og 2/3 af de akutte og subakutte har en retningspræference, af disse vil lidt mere end 80% have ekstension som den gavnlige retning. Dertil kan man lægge pænt mange af de mekanisk inkonklusive og overvejende psykosociale problemstillinger der uden tvivl vil respondere favorabelt på at bevæge sig - også når valget falder på extension. Så man er faktisk pænt godt kørende med bare extension i rygsækken. Og så er der også nogle der allerede hár gennemskuet at McKenzie umuligt kun kan dreje sig om én enkelt øvelse, for det kan man da ikke holde 5 kurser + en diplomuddannelse + skrive artikler og designe avancerede studier om -igen og igen i flere og flere år. Rigtigt. Og så er det smart at have en god basis at tale ud fra. Det har vi i tiltagende grad. Mange aspekter af MDT i flere veldesignede studier giver en god basis og hjælp i diskussionerne. Et godt kendskab til konceptet giver viden om dets styrker og de udfordringer og forhindringer man støder på i designet af gode kvantitative studier der belyser konceptet såvel fra dets diagnostiske, som fra dets behandlende og forebyggende potientiale. At MDT er mere end lumbal extension er en smal sag at bevise bring blot en nakkepatient på banen! De fleste med blot et basalt kendskab til MDT vil kaste sig over det uden et sekunds tøven. Og er den helt gal, kan der altid trækkes kaniner op af hatten med en ekstremitetspatient her skal man næsten være uheldig for ikke at finde enten et derangement eller en dysfunktion, og det vil de fleste kaste sig over indenfor maksimalt 2 sekunders tøven. Oplevelsen af hvad MDT er, kommer for alvor til sin ret når principperne anvendes på ekstremitetsproblemer uanset problemets oprindelse og strukturelle baggrund. Der er ikke behov for hokus-pokus, raketvidenskab eller uopnåelige palpatoriske evner, og det gør slet ikke så meget at være lidt fummelfingret, bare man kan ligge trykket geografisk rigtigt når situationen kræver lidt ekstra pres. Logisk tænkning, fornuftig klinisk ræsonnering og evner til at uddanne patienterne i deres problem er gode redskaber at fylde i værktøjskassen. Med et kig på denne værktøjskasse, og sammenholdt med budskabet i såvel MTV rapporten og de europæiske guidelines, synes MDT at befinde sig et fornuftigt sted. Det tror jeg i høj grad kan betragtes som et lyspunkt. Ikke blot kan det bekræfte den enkelte kliniker i at være på rette spor, men i endnu højere grad være et stort potientiale for at udvikle tættere samarbejdsrelationer med vores lægelige kollegaer uden tvivl til stor gavn og fornøjelse for alle. Jeg håber I får glæde af denne første udgave og jeg ønsker Jer alle en rigtig god start på foråret. Camilla Nymand, Dip. MDT Ansvarshavende redaktør McKenzie Institut Danmark Volume 1, No. 1 March 2006 IJMDT 5

8 Generel info fra McKenzie Institut Danmark International Journal of Mechanical Diagnosis and Therapy NYT FRA SEKRETÆREN Kursusaktivitet I 2006 afholdes vores kurser fortrinsvis på Rygcentret, Hans Knudsens Plads i København og på fysioterapeutskolen i Århus. Der er dog enkelte afstikkere, som kan ses enten på sidste side i dette blad eller på hjemmesiden under kurser. Både refresherdagen og credentialevaluering afholdes fortsat både i København og i Århus. Har du eller din arbejdsplads brug for et kursus er du/i velkomne til at ringe eller skrive til IMDT. Venteliste Hvis du har været på venteliste til et af vore kurser, skal du være opmærksom på, at du ikke automatisk overføres til næste kursus. Derimod skal du henvende dig til kursussekrtær Eva Hauge Rasmussen og vælge det kursussted, der passer dig bedst. Adresseændring og registrering Vi får i IMDT en del breve retur og nogle medlemmer modtager ikke bladet som forventet. For at undgå dette bedes du meddele adresseændring til IMDT via hjemmesiden Referat fra bestyrelsesmøder Fra 2. okt er det muligt at læse referat fra betyrelsens møder på hjemmesiden Medlemskontingent & Told & Skat Husk at indberette CPR nummer hvis du ønsker medlemskontingent opgivet til told og skat ECTS POINT En del medlemmer har henvendt sig til IMDT vedrørende ECTS points for vores kurser. ECTS point er imidlertid ikke en standard, som gælder for alle uddannelser. Der skelnes f.eks. mellem ECTS for diplom niveau, bachelor niveau eller master niveau. Uddannelser, som er underlagt en bekendtgørelse fra et ministerium, har således en fastlagt ECTS point skala som f.eks. fysioterapeutuddannelsen, mens alle efteruddannelses kurser selv fastsætter niveauet for ECTS point. ECTS point for MDT kurserne fastsættes derfor af IMDT selv ud fra kriterier om timeantal, forberedelsesgrad, supervison, studiebelastning, undervisernes uddannelsesniveau o.s.v. Ved en eventuel ansøgning til en anden uddannelsesinstitution er det denne, der afgør, om ECTS points givet for kurser i MDT er relevante til netop aktuelle uddannelse. IMDT samarbejder med DFFMT (Danske fysioterapeuters forum for muskuloskeletal terapi) i udarbejdelsen af et passende niveau for fastsættelse af ECTS point for kurser. Der vil være løbende information på vores hjemmeside når der er nyt. Eventuelle spørgsmål kan henvendes til undertegnede. Anne Juul Sørensen Sekretær i IMDT Info@mckenzie.dk Husk at tilmelde dig nyhedsmail på THE EVIDENCE MOUNTS Ønsker du et uforglemmeligt input og samtidig både en faglig og personlig oplevelse så ligger muligheden der under den 10. internationale McKenzie Konference i Queenstown New Zealand marts Der er mulighed for at søge McKenzie Institut Danmark om støtte på 5000 kr. til 4 ansøgere til dækning af rejseudgifter/konferenceudgifter. Credentialterapeuter har fortrinsret. Send en motiverende ansøgning til McKenzie Institut Danmark (info@mckenzie.dk) inden 15. november th International Conference in Mechanical Diagnosis and Therapy Honorary Chairman: Robin McKenzie, CNZM, OBE, FCSP (HON), FNZSP (HON), DIP MDT Key Note Speakers: Nikolai Bogduk, Peter Croft, Richard Deyo, Paul Hodges, Susan Mercer, Barry Vernon-Roberts Conference Venue: / Queenstown, New Zealand: Bookmark our Conference page for more info: Volume 1, No. 1 March 2006 IJMDT 6

9 Credential Update Udviklingsmuligheder for credential terapeuter International Journal of Mechanical Diagnosis and Therapy Credential Update med Grant Watson, Dip.MDT, Dip.MT, Int. Faculty & Charlotte Krog, Dip. MDT Rygcenteret, Hans Knudsens Plads, København En workshop for Credential terapeuter som ønsker udvikling. Workshoppen giver en blanding mellem teori og praksis og vil udfordre dig I forhold til klinisk ræsonnering og problemløsning. Workshoppen finder sted 7. Juni for Credential terapeuter MED Part E og 8. juni for Credentialterapeuter UDEN part E. Kursusafgift 950 kr. For medlemmer og 1300 for ikke medlemme. Betalingen opkræves, når du har modtaget bekræftelse på deltagelse. Ved afbud senere end 1. maj opkræves et administratinsgebyr på kr Tilmelding via hjemmesiden: eller via til kursus@mckenzie.dk Tidligere på året besluttede bestyrelsen at ændre rammerne for Credentialforum. Vi har aldrig været i tvivl om at der er et behov og ønske om kursus- og udviklingsmuligheder for de af vores medlemmer som har taget credentialprøven. I løbet af efterår og vinter har vi været i dialog med McKenzie Institute International samt branches i andre lande, for at blive inspireret til alternativer til det hedengangne Credentialforum. Resultatet er blevet, at vi kører to eksklusive kurser, som vi kalder Credential Update. Der bliver et kursus, som henvender sig til de credentialterapeuter, der har gennemført ekstremitetskurset (Part E) og et andet kursus for dem, som udelukkende har credentialniveau. Tillykke! Bestået Credential Evaluering 5. November 2005 Anners Bilbenberg, Viborg Karen Elisabeth Christensen, Hørning Jannie Degn Andernsen, Hvide Sande Jannick Idas Johansen, Odense SV. Tina Junge, Odense SV Brian Knørr Skov, Aalborg Lasse Lindgren Holmstrøm, Vodskov Rikke Linding Christensen, Ulfborg Sanne Mortensen, Århus Karsten Møller, Holstebro Michael Seiger Kristiansen, Hedensted Jesper Skov, Århus Lise Skovbo Almind, Ry Marie Louise Stitz Hansen, Hovedgaard Mette Stubkjær, Ringkjøbing Berit Sønderby Kortbek, Vissenbjerg Finn Zachariasen, Sønderborg Maria Duminski Björkman, Gilleleje Anne Gøtzsche, Ringsted Jackie Lolk Rasmussen, Svendborg May-Britt Lund, Aalborg Henrik Bjarke Madsen, Odense Jesper Ottosen, Lyngby Morten Graversen, Holstebro Volume 1, No. 1 March 2006 IJMDT 7

10 Non-specific low back pain are we any nearer a structural diagnosis? Stephen May, PT, Dip. MDT Introduction The diagnostic triage is a well accepted classification of back pain (CSAG 1994, Waddell 2004). This distinguishes serious spinal pathology (< 2%), nerve root pathology (5-10%), and non-specific or mechanical back pain (>90%). Because patho-anatomical or structural diagnoses of low back pain by clinical examination have lacked validity and assessment tools have lacked reliability non-specific or mechanical back pain has been the preferred nomenclature for several decades (Spitzer et al. 1987, CSAG 1994). However it has been argued by some that a structural diagnosis can be established in non-specific back pain in over 60% of patients using double articular anaesthetic blocks or discography (Bogduk et al. 1996). Injections must be performed under fluoroscopic control to ensure accurate placement. Double blocks are necessary as single blocks are associated with a rate of false positive responses (Manchikanki et al. 2004). The equivalent control in discography is concordant pain produced at one segmental level, with no pain at an adjacent level (Laslett et al. 2005a). Such diagnostic injections have been termed reference or criterion standards (Laslett et al. 2005a). Such studies provide the theoretical framework for understanding the prevalence of different structural diagnoses in mechanical back pain; however their specialist and intrusive nature makes them unacceptable or unavailable for the majority of patients with back pain. The use of a clinical examination to determine a pathoanatomical diagnosis has in the past proved ineffective, but some new studies have attempted to locate more useful clinical tools to determine a structural diagnosis. The article will briefly review previous clinical studies relating to non specific low back pain, then more recent ones, some of which are described in detail at the end. The article will look at the diagnosis of discogenic back pain, but will not include the specific diagnosis of nerve root pathology associated with disc herniation or spinal stenosis. Thus the aim of the review is to examine the value of the clinical examination to make specific structural diagnoses in patients with non-specific low back pain as determined by reference standards. The review will summarise the value of clinical findings under the following headings: discogenic pain sacroiliac joint pain zygapophyseal joint pain prevalence of different entities Review of some recent studies Discogenic pain This section will discuss primary discogenic back pain, and does not include consideration of nerve root pain caused by disc herniation. The criterion standard for discogenic pain is discography that provokes concordant pain at one level, with an adjacent level being pain free; this is sometimes followed by anaesthetic injection at the painful level to confirm the diagnosis, and axial CT scan to gain an image of the pathological disc. Discography remains controversial with its proponents claiming it to be the only valid and reliable method to detect primary discogenic pain, and its detractors claiming it to have poor specificity and be of limited clinical value (Laslett et al. 2005a, Manchikanti et al. 2001). One study found no clinical features, from history or physical examination that correlated with discogenic pain (Schwarzer et al. 1995d). However a mechanical evaluation, noting centralisation or peripheralisation, was found to correlate with discography findings (Donelsen et al. 1997). Of the 31 patients who demonstrated centralisation 74% had a positive discography, 91% showed a competent annular wall. Of the 16 patients who demonstrated peripheralisation 69% had a positive discography, with 54% showing a competent annular wall. Of the 16 patients demonstrating no change in pain only 12.5% had a positive discography. The data from this study has been re-calculated to provide sensitivity, specificity, and positive likelihood ratio estimates for discogenic pain as follows (Bogduk and Lord 1997): centralisation 92%, 64%, 2.5 peripheralisation 69%, 64%, signs combined 92%, 52%, 2.0 Patients with discogenic pain have been found to be more likely to have pain at or above L5, obstruction to movement, change in movement loss, and centralisation/ peripheralisation (Young and Aprill 2000). Significant association between discogenic pain and pain when rising from sitting and centralisation have been noted (Young et al. 2003). Centralisation had low sensitivity (47%), but high specificity (100%) for predicting discogenic pain. The most recent study (Laslett et al. 2005a) reported similar results; with sensitivity of centralization to predict discogenic pain being poor (37%), but specificity good (90%) and extremely good in patients without severe distress or disability (100%). This study is described in detail later. These latter studies would suggest that centralisation by itself is of limited value in identifying all patients with discogenic pain; many patients with discogenic pain will not demonstrate centralisation at initial assessment. As the specificity is very Volume 1, No. 1 March 2006 IJMDT 8

11 Non-specific low back pain are we any nearer a structural diagnosis? good the mnemonic SpPin (Sackett et al. 1997) is relevant: with high Specificity, Positive test, rules in the diagnosis: thus when centralisation does occur discogenic pain is the likely cause of pain. However Donelson et al. (1997) reported good sensitivity, but weak specificity; and it is unclear why the conclusions are so different though this may be related to different samples or slightly different definitions of centralisation. If sensitivity is very good the mnemonic SnNout (Sackett et al. 1997) is relevant: with high Sensitivity, Negative test, rules out the diagnosis - thus when no centralisation discogenic pain is unlikely. Centralisation/peripheralisation appear to be strongly correlated with discogenic pain, but from the evidence to date it is unclear if this correlation can be used to rule in or rule out the diagnosis. Sensitivity and specificity have a seesaw relationship with each other, as one goes up the other comes down; further research is needed to determine if it is sensitivity or specificity that is most stable. Sacroiliac joint (SIJ) problems. The reference standard for establishing SIJ pain is fluroscopically guided, contrast enhanced intraarticular anaesthetic blocks (Laslett et al. 2005c). However as in zygapophyseal joint injections there is a false-positive rate to single joint injections, estimated for SIJ injections to be between 8% and 20% (Laslett et al. 2005c). The literature on the reliability and validity of SIJ clinical diagnostic tests was summarised in two systematic reviews (van der Wurff et al. 2000a, 2000b). Regarding reliability, SIJ tests that used palpation and attempted to detect movement abnormalities were consistently found to have poor levels of reliability; whereas SIJ tests that were based on pain provocation of the patient s concordant symptoms were found to have moderate levels of reliability, though not consistently (van der Wurff et al. 2000a). For reliable pain provocation tests see Laslett and Williams (1994), and Kokmeyer et al. (2002). In terms of validity, compared with a SIJ injection no provoking or relieving movements or positions have been found that were unique or especially common to SIJ pain, either in the history or the physical examination (van der Wurff et al 2000b); and pain provocation tests were not validated against criterion standards (Dreyfuss et al. 1996, Scwarzer et al. 1995, Maigne et al. 1996, Slipman et al. 1998). Although the most common pain pattern is over the buttock and posterior thigh, pain patterns were found to be highly variable (Slipman et al. 2000). In a review entitled Using published evidence to guide the examination of the sacroiliac joint region Freburger and Riddle (2001) summarised the literature at that point in time. They noted that movement at the joint was too small to detect, and that there was no evidence to support the use of symmetry or movement tests, whereas some pain provocation tests may be useful, as well as certain descriptions of the pain pattern - namely absence of pain in the lumbar region, pain below L5, pain around the posterior superior iliac spine, and pain in the groin area (Freburger and Riddle 2001). They also noted the general lack of validity for clinical examination in detecting SIJ problems as verified by intra-articular injections. There was some concern about injections as gold standards ; with possible, but unknown rate of false positives and the possibility of leakage of anaesthetic. The use of multiple tests has been shown to be more reliable than single tests (Kokmeyer et al. 2002, Cibulka and Koldehoff 1999, Laslett et al. 2003, Young et al. 2003), and false positive SIJ tests are common in populations without confirmed SIJ pathology (Laslett 1997). Thus the diagnostic accuracy of the clinical examination is enhanced if lumbar spine patients are first excluded - detected using a mechanical evaluation, noting centralisation or peripheralisation; following which three positive pain provocation tests are used to determine SIJ problems (Laslett et al. 2003). Sensitivity is 91%, specificity 87%, and the positive likelihood ratio improves from 4.2 to 7.0 with the exclusion of lumbar spine patients. In a study in which 81 patients with chronic back pain were given a number of injections to determine a structural pathology; findings on clinical examination were correlated with different criterion standards (Young et al. 2003). Positive SIJ injections were associated negatively with mid-line pain and pain above L5, and positively with unilateral pain, pain produced or aggravated when rising from sitting, and three or more positive pain provocation tests. The latter was very strongly correlated (P <0.001), with an odds ratio of 28.0 (Young et al. 2003). In another study (Young and Aprill 2000), findings in patients with SIJ and zygapophyseal joint (ZJ) pain were similar with lack of both obstruction to movement initially and change in movement loss following repeated movements, and lack of centralisation/ peripheralisation. Patients with SIJ pain were likely to have no pain at or above L5, and likely to have pain on rising from sitting and three or more positive pain provocation SIJ tests when compared with ZJ patients. In the study described later (Laslett Volume 1, No. 1 March 2006 IJMDT 9

12 Non-specific low back pain are we any nearer a structural diagnosis? et al. 2005c) multiple pain provocation tests have been directly compared with criterion standard tests. This study evaluated the collective value of different tests and found three or more positive pain provocation tests to have a sensitivity of 94%, specificity of 78%, and positive likelihood ratio of 4.3. The authors (Laslett et al. 2005c) suggest the following diagnostic algorithm is used: no centralisation/ peripheralisation / directional preference during mechanical evaluation pain in buttock area distraction / thigh thrust tests applied if positive assume SIJ if negative apply compression / sacral thrust tests if two positive tests assume SIJ if all tests negative rule out SIJ. In conclusion, it does seem SIJ problems are open to diagnosis using clinical examination, but only if a staged differential diagnostic process is used involving mechanical evaluation and pain provocation SIJ tests. Demonstration of centralisation, peripheralisation or directional preference denotes a lumbar spine problem, and discounts the need to examine for SIJ pathology it should be noted that this may not occur at the initial assessment, but subsequently (Werneke and Hart 2003). In the absence of a positive symptomatic or mechanical response to end-range repeated lumbar movements, and in the presence of unilateral pain over the buttock pain provocation SIJ tests should be used in the order outlined above. When three of these tests produce concordant pain a SIJ problem is likely; when all tests are negative a SIJ problem can be ruled out. Zygapophyseal pain The criterion standard for identifying zygapophyseal joint (ZJ) pain needs are controlled comparative local anaesthetic blocks, as single blocks are associated with at least 27% false positive response in the lumbar spine (Manchikanti et al. 2004). Earlier studies failed to link any clinical features of history or physical examination with ZJ problems (Schwarzer et al. 1994a, 1994b, 1994c); and specifically ruled out certain features that had been suggested might be diagnostic (Fairbank et al. 1981, Helbig and Lee 1988). More recently Revel et al. (1992, 1998) proposed a set of clinical criteria that might be relevant (5 of 7 were necessary): age > 65 years pain relieved in supine lying absence of pain aggravated by coughing absence of pain aggravated by flexion absence of pain aggravated by return from flexion absence of pain aggravated by extension absence of pain aggravated by extension-rotation. However, more recent work has found there to be a lack of correlation between these clinical features and criterion standards (Manchikanti et al. 2000, Laslett et al. 2004). Sensitivity of Revel s criteria was shown to be low (13% to17%), though specificity was higher (84% to 93%). Similarly low sensitivity was shown in the study detailed later (Laslett et al. 2005b). However centralisation was never found and lack of pain on rising from sitting was significantly associated with patients with positive ZJ pain (Young et al. 2003). In another study (Young and Aprill 2000), findings in patients with SIJ and ZJ pain were similar with lack of both obstruction to movement and change in movement loss following repeated movements, and lack of centralisation/peripheralisation. Patients with ZJ pain were likely to have pain at or above L5, and unlikely to have pain on rising from sitting, or three or more positive pain provocation SIJ tests compared to SIJ patients. At this point in time, compared to criterion standards, it does not seem possible to identify ZJ pain using clinical criteria with any accuracy. It appears most likely to be a diagnosis by exclusion rather than one by positive identification. Patients with centralisation/ peripheralisation or directional preference have discogenic pain; those without, but with 3 or more positive pain provocation SIJ tests have SIJ pain; others may have ZJ pain. Prevalence of different entities According to reference or criterion standard the estimated prevalence of discogenic pain is about 39%, the prevalence of zygapophyseal joint pain is about 15%, and the prevalence of sacroiliac joint pain is about 12% (Bogduk et al. 1996). Estimates obviously vary but discogenic pain is usually the pathoanatomical structure that appears to be the principal pain generator. In 92 patients, 36 patients (39%) had a positive discography at least at one level, eight (9%) had a positive response to a double anaesthetic block at the ZJ, and only three responded to both (Schwarzer et al. 1994d, 1995d). In 216 patients who received 137 structural diagnoses, as well as additional classifications of illness behaviour and indeterminate, pathoanatomical diagnosis by reference standard was as follows (Laslett et al. 2005b): discogenic pain 70 (51%), nerve root pain 32 (23%), ZJ pain 14 (10%), spinal stenosis 10 (7%), hip pain 6 Volume 1, No. 1 March 2006 IJMDT 10

13 Non-specific low back pain are we any nearer a structural diagnosis? (4%), and SIJ pain (4%). In 120 patients who were put through an algorithm-type diagnostic process, which meant that not all patients had all structures tested, the following diagnoses were made with precision diagnostic blocks (Manchikanti et al. 2001): ZJ pain 40%, discogenic pain 26%, and SIJ pain 2%. Discogenic pain by itself has been found in 57% of 63 patients (Donelson et al. 1997), and 75% of 144 patients, and such patients were more likely to have distal leg symptoms than non-discal pain (Ohnmeiss et al. 1997). Estimates of lumbar zygapophyseal joint pain have varied from 31% of 397 patients (95% CI, 27% to 36%) (Manchikanti et al. 2004), to 40% (95% CI, 27% to 53%) of 57 patients (Schwarzer et al. 1995). Prevalence decreases if a stricter definition is applied, such as total abolition of pain, to 12% (Schwarzer et al. 1995). Estimates of the prevalence of SIJ pain have varied from 13% of 100 consecutive patients (Schwarzer et al. 1995a), to 53% of 85 patients selected with suspicion of SIJ involvement (Dreyfuss et al. 1996). However, both these studies used only single anaesthetic blocks, which have been associated with a 53% false positive response Maigne et al. 1996). In a sample of 54 patients selected on suspicion of SIJ involvement, 18% responded to two injections (Maigne et al. 1996). The wide range of possible prevalence rates should be noted, and that possible biases exist that weaken the validity of these estimates chiefly relating to the patients involved in these studies and the nature of the reference or criterion standard. Most pain populations examined in these studies are very chronic, often with high levels of disability, and all were seen in tertiary care; obviously it is only this type of population who are likely to be offered the invasive interventions. For instance, some patients had a mean duration of pain exceeding eight years, and 50% had a traumatic onset (Manchikanti et al. 2004), whilst others had a mean Roland Morris score of 18.5/23, worst pain intensity of 88/100, traumatic onset 73%, and 29% had previous lumbar surgery (Laslett et al. 2005b). This means that generalisability may be questionable to other populations, such as in primary care or pain of shorter durations. Secondarily is the question of whether double articular anaesthetic blocks and discography are absolutely valid as gold standards in making a structural diagnosis. Theoretically, these interventions might register false negatives under certain circumstances. For instance, discogenic pain that emanates from a lesion of the outer annulus fibrosus that is not connected to the inner nucleus where the needles are placed, or SIJ pain that is related to extra-articular ligaments rather than intra-articular contents where the needle is placed. In contrast, theoretically there maybe instances when false positives are registered; for instance, if there is leakage of anaesthetic beyond the joint space or in the presence of abnormal pain behaviour. Review of some recent studies Laslett M, Oberg B, Aprill CN, McDonald B (2005a). Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal Objective A previous study has suggested that the phenomenon of centralization is an indicator of discogenic pain. The aim of the study was to estimate the diagnostic accuracy of centralization for disc pain using discography as the reference standard. Furthermore, to determine the influence that patients distress and disability might have on the diagnostic process. Design A prospective, blinded, concurrent reference standard-validated study design. Setting Specialist private radiology spinal diagnostic clinic Louisiana, USA. Patients Consenting consecutive patients with chronic LBP referred for further investigations between May 2001 and October 2002 when the physiotherapist was present, which was in blocks of 4 to 8 weeks. Patients were excluded if they had a normal MRI, severe degeneration associated with spondylolisthesis, contraindications for discography, unwillingness to cooperate, fear avoidance, or excessive incapacity. 118 patients were initially included, 11 were excluded for technical discography reasons, and a further 38 failed to undergo or complete a physical examination; so the final study population numbered 69 (58.5%) who underwent both discography and a full mechanical evaluation. However, the physical therapist partially or fully examined and offered an opinion on 83 patients. Patients who had had previous spinal surgery were included and most patients had failed previous conservative treatment. Those who failed to undergo a full physical examination had significantly higher pain scores, greater disability, higher depression scores, and more surgery. For all patients mean values were as follows: age 43, duration of back pain over three years; Volume 1, No. 1 March 2006 IJMDT 11

14 Non-specific low back pain are we any nearer a structural diagnosis? time off work two years; pain VAS (best / worst) 59% (33% / 88%); Roland-Morris disability questionnaire score 19/24; previous surgery 30%; distressed (DRAM) 56%. Intervention Highly skilled and experienced radiologist and physical therapists undertook the different interventions and were blinded to each others findings. The reference standard was discography, with positive discography defined as follows: concordant pain response with injection of one disc, with no pain invoked at an adjacent disc. Physical examination included a mechanical evaluation, noting symptomatic response to repeated movements, as well as nerve function, SIJ and non-organic pain behaviour tests. Centralization was defined as the abolishment or significant reduction of most distal pain; peripheralization as the production or substantial worsening of distal symptoms that could not be subsequently decreased or centralized. Once a clear symptom response was generated this portion of the physical examination was terminated. Main outcome measures Prevalence of test results; concordance between reference standard and full or partial mechanical evaluation; and affect of distress and disability using sensitivity, specificity, and likelihood ratios for positive and negative tests (plus 95% confidence intervals). Distress was measured using DRAM, disability by Roland-Morris disability questionnaire. Main results The prevalence of positive discography was 75%; the prevalence of centralisation was 32%. Following a full mechanical evaluation centralization had a likelihood ratio of 6.9 in predicting discogenic pain. Sensitivity of centralization to predict discogenic pain was poor (37%), but specificity was reasonably good (90%) and extremely good in patients without severe distress or disability (100%). The number of true (centralization & positive discography) and false (centralization & negative discography) positive centralization responses; true (non-centralization & negative discography) and false (non-centralization & positive discography) negative centralization results; sensitivity (centralization // positive discography); specificity (non-centralization // negative discography); and Likelihood Ratios are listed in Table 1. Conclusions The ability of centralization to predict discogenic pain, as predicted by positive discography was calculated. Positive correlation between centralization and discogenic pain (sensitivity) was weak (35% to 46%). Positive correlation between non-centralization and nondiscogenic pain (specificity) was strong (80% to 100%). Comments In this group of patients centralization was not a good predictor of disc pain; many patients with discogenic pain did not demonstrate centralization. However, when centralisation does occur, especially in the absence of distress or high levels of disability, discogenic pain is highly likely. Several features may have deleteriously affected the diagnostic accuracy of the clinical examination. The patients were very chronic, disabled, distressed, with long term sick leave and about a third had had lumbar surgery. Only 6% of patients were DRAM normal and only 10% had no or minimal disability. All these features may have obscured the mechanical responses, and patient s intolerance led to premature termination of the clinical examination on a large number of occasions. Furthermore, mechanical evaluation was conducted on only a single occasion, whereas in a more normal LBP population 60% of those who initially were noncentralisers centralised on a subse- Table 1. Prevalence and diagnostic performance of centralization compared to reference standard of discography Outcome N All N=83 Full MD 69 DRAM neg 38 DRAM pos 31 RMDQ < RMDQ > True / false pos (N) 23 / 2 21 / 1 11 / 0 10 / 1 9 / 0 12 / 1 True / false neg (N) 20 /38 16 / 31 8 / 19 8 /12 10 /17 6 / 14 Sensitivity 37% 40% 37% 45% 35% 46% Specificity 90% 94% 100% 89% 100% 80% LR incalculable 4.1 incalculable 3.2 LR incalculable 0.6 incalculable 0.6 Full MD=mechanical evaluation; DRAM=distress risk assessment method: neg= normal or at risk, pos= depressed or somatic ; RMDQ= Roland Morris Disability Questionnaire; LR=likelihood ratios. Incalculable as zero in a cell. Volume 1, No. 1 March 2006 IJMDT 12

15 Non-specific low back pain are we any nearer a structural diagnosis? quent occasion (Werneke and Hart 2003). The low prevalence rate of centralisation in this study (32%), compared to other chronic low back pain populations (52%) (Aina et al. 2004) should be noted. It is important to note the effects of distress as measured by DRAM and disability on the accuracy of the mechanical evaluation. With high disability sensitivity fell from 100% to 80%, whereas with positive DRAM compared to negative it fell from 100% to 89%. Donelson et al (1997) found a sensitivity of 92% and specificity of 64% for centralisation to predict discogenic pain; in contrast, this study found a high specificity and weak sensitivity. The authors suggest this is due to the nature of the patient sample, and the slightly different definitions of centralisation used. Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B (2005b). Agreement between diagnosis reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskeletal Disorders 6:28 Available at: Background/Objective The tissue origin of low back pain (LBP) can be identified frequently using advanced imagery and discography, zygapophyseal (ZJ) or sacro-iliac joint (SIJ) provocation or anaesthetic blocks (reference standards). These methods are invasive, require specialist clinicians, and are not commonly available. Clinical examination in contrast is non-invasive and commonly available, but to date single clinical tests have proven to lack validity when compared to injections. However in clinical practice single tests are rarely used to classify or diagnose. The objective of the study was to compare multiple clinical tests with reference standards to quantify their diagnostic acumen. Design A prospective blinded validity design was used. Results from the clinical examination undertaken by a physiotherapist were compared to reference standards. Physiotherapist and radiologist were blind to each others results. Setting Specialist private radiology spinal diagnostic clinic Louisiana, USA. Clinical Diagnosis discogenic (IVD) ZJ pain SIJ pain nerve root (NR) spinal stenosis (SS) hip pain instability illness behavior (IB) other Patients Consenting consecutive patients with chronic LBP between May 2001 and October 2002 when the physiotherapist was present, which was in blocks of 4 to 8 weeks patients were seen at the clinic in the period, 296 when the physiotherapist was present; 78 were excluded most commonly because of lack of consent (53), no pain on day (10) and time constraints (9); so that 216 patients were included. Details of 216 patients: mean age 44; mean duration of LBP about Criteria centralisation / peripheralisation / directional preference in response to repeated movements; OR midline pain (1) absence of (1) above + Revel s criteria (see main article) absence of (1) above + 3 positive pain provocation tests (PPT) (2) referred pain provoked by nerve tension tests neurogenic claudication relieved by sitting / flexion passive hip test provoke concordant pain more readily than 1 or 2 above lack of specific criteria patient s behavior / responses to question / examination suggested psychosocial distress other uncommon causes of pain indeterminate (none) no conclusion could be reached three years; mean time off work over two years; mean pain intensity today/best/worst 58 / 33 / 88; mean Roland-Morris 18.5 / 23; DRAM scores 12% normal, 37% at risk, 44% depressed, 6.5% somatic. Intervention The clinical examination was undertaken by two very experienced physiotherapists over minutes immediately after the reference standard diagnostic tests. Clinical examination proceeded through these stages: The reference standards used in the structural diagnosis by the very experienced radiologist mostly employed provocation or anaesthetic block injections under fluoroscopic guidance. Spinal stenosis and other used CT or MRI imaging; instability used paradoxical motion of flexion/extension radiographs; illness behaviour, as above was based on clinical opinion; and indeterminate was as above. Not all reference standard diagnostic procedures were carried out with all patients Volume 1, No. 1 March 2006 IJMDT 13

16 Non-specific low back pain are we any nearer a structural diagnosis? Main outcome measures Exact agreement was when clinical examination agreed with reference standard entirely, including multiple diagnoses. Clinical agreement was when the clinical examination was included within the reference standard multiple diagnoses. Main results The radiologist came to a single diagnostic conclusion in 144 cases (66%), two in 72 cases (34%), and three in 2 cases. The physiotherapist reached a single diagnosis in 163 cases (76%) and two conclusions in 53 cases (Table 2). Exact agreement (95% confidence interval) was 32% (26%, 38%); clinical agreement was 51% (45%, 58%). Regarding only structural pathologies agreement was 57% (48%, 64%); kappa statistic was 0.31 (0.18, 0.44). Conclusions Reference standards identify a structural source of pain in many patients. Clinical examination agrees with the reference standard more often than chance. Comments According to the reference standard the most common structural diagnosis was discogenic pain (50% of all structural diagnoses, excluding IB and indeterminate). Of the rest of the 205 structural diagnoses 18% were nerve root, 12% ZJ, 7% spinal stenosis, other and hip were both less than 5%, and 3% SIJ. Twentytwo patients (10%) received two patho-anatomical diagnoses. However additionally, illness behaviour was recorded in 79 patients and indeterminate conclusion was made in 84 cases. Thus about 44% of patients fell into one of these categories. The authors conclude that the diagnosis made by the physiotherapist s clinical examination was better than expected by chance when compared to the reference standard; however agreement was generally weak with low kappa values and sensitivity. Identification of hip and discogenic pain was most accurate with sensitivity about 55%, which increased to 83% and 74% when IB and indeterminate was excluded. Clinical identification of other structural pathologies was generally much weaker. The population in which these examinations occurred was extremely chronic, disabled, and distressed; nearly a third had had lumbar spinal surgery. This has several implications; this was not a normal LBP population and there is a problem with generalisability. Furthermore the nature of the sample may have helped cause the high prevalence of patients diagnosed with illness behaviour or indeterminate, which in turn probably affected the ability of the reference standard to reach a single conclusion and the accuracy of the clinical examination. Table 2. Reference standard / physiotherapy diagnoses Reference standard IVD ZJ SIJ NR Hip SS Other IB None Totals IVD P H Y S I O T H E R A P Y ZJ SIJ NR Hip SS Other IB None Totals * Bolded numbers are counts of agreement; for abbreviations see bullet points on previous page; *total N = total number of multiple diagnoses Volume 1, No. 1 March 2006 IJMDT 14

17 Non-specific low back pain are we any nearer a structural diagnosis? Laslett M, Aprill CN, McDonald B, Young SB (2005c). Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual Therapy Background / Objective Earlier studies of single pain provocation tests have shown these to lack validity against reference standard diagnostic tests. Clinically it is common to use multiple tests to confirm a diagnosis. The objective was to determine the diagnostic accuracy of single and various combinations of multiple SIJ pain provocation tests against SIJ anaesthetic injections. Design A prospective blinded validity design was used. Results from the clinical examination undertaken by a physiotherapist were compared to reference standards. Physiotherapist and radiologist were blind to each others results; both were highly experienced. Setting Specialist private radiology spinal diagnostic clinic Louisiana, USA. Patients Patients were not consecutive. Inclusion criteria: buttock pain +/- other pain; exclusion criteria: lack of consent, midline / symmetrical pain; clear signs of NR pathology; too frail. 62 agreed to participate and were examined by physiotherapist and radiologist; exclusions were unable to tolerate the exam (3), pain free (2), or had a technical failure of / or no injection (9); leaving 48 patients. Mean age was 42 years; mean symptom duration 32 months; mean off work 18 months; mean Roland-Morris score 76%. Intervention Positive reference standard, using fluoroscopically guided injection, was provocation of familiar pain followed by 80% or more pain relief, followed by a confirmatory anaesthetic block combined with corticosteroid. Positive physical examination was pain provocation tests that produced or exacerbated concordant pain. The following pain provocation SIJ tests were used: distraction (1), compression (2), rightsided thigh thrust (3), right (4) and left-sided (5) Gaenslen s, and sacral thrust (6) numbers relate to Table 3 below. Main outcome measures Prevalence of test results; and concordance between reference standard and physical examination procedures using sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative tests (plus 95% confidence intervals). Main results 16 / 48 (33%) had positive reference standard tests. Positive physical exam tests ranged from 31% to 50%; false positive tests were common (range 19% to 31%); 11 patients (34%) with negative reference standards had two or more positive exam tests. Results for individual tests are in Table 3 the thigh thrust is the most sensitive and the distraction test the most specific. When tests were combined the optimum combination was 3 or more positive tests with a sensitivity of 94%, specificity of 78%, and likelihood ratios of With 1 / 2 or more positive tests sensitivity remained high, but specificity decreased to 44% / 66%. With 4 / 5 positive tests specificity increased, but sensitivity decreased to 60% / 27%. The best combination of tests was distraction, thigh thrust, compression and sacral thrust; with Gaenslen s adding little to accuracy. Table 3: Prevalence, sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and likelihood ratios (LR) for individual SIJ provocation tests Test results* Outcome RS Prevalence 33% 32% 44% 50% 37% 31% 37.5% Sensitivity 60% 69% 88% 53% 50% 63% Specificity 81% 69% 69% 71% 77% 75% PPV NPV LR LR *RS = reference standard, numbers refer to physical exam tests in intervention section above Volume 1, No. 1 March 2006 IJMDT 15

18 Non-specific low back pain are we any nearer a structural diagnosis? Conclusions Combination of SIJ pain provocation tests improve diagnostic acumen for SIJ problems over single tests with most accuracy being gained with 3 or more positive pain provocation tests. When all six tests do not provoke familiar pain the SIJ can be discounted as a source of back pain. Comments The results of this study contrast with earlier studies that failed to demonstrate diagnostic accuracy of history or physical examination items (Dreyfuss et al. 1996, Scwarzer et al. 1995, Maigne et al. 1996, Slipman et al. 1998) and a systematic review (van der Wurff et al. 2000). The authors suggest the greater accuracy found in this study may relate to the greater force applied by physiotherapists when using the tests. Patients involved in the study were not consecutive and were exceedingly chronic, disabled and with a long duration of sick leave consequently the results are not generalisable. However the authors maintain, from anecdotal clinical experience, that in a more normal clinical population the assessment process is more straightforward and the results if anything understate the diagnostic accuracy of multiple tests. The patient population used also means that prevalence of SIJ pain in the back pain population cannot be inferred from the data. The criterion validity, gold standard or reference standard for SIJ pathology was provocation of familiar pain, plus appropriate timed relief of 80% or more, with relief from a confirmatory anaesthetic block that also contained corticosteroid. As false positive responses do occur with single anaesthetic blocks of SIJ joints (Schwarzer et al 1995, Maigne et al 1996) the additional use of corticosteroid is a minor confounder in the reference standard. Furthermore intra-articular injections are only likely to identify intraarticular pathology, but not periarticular pathology, such as to ligaments. As the pain generating mechanism of SIJ pathology is not understood the relevance of this is unknown. References Aina A, May S, Clare H (2004). The centralization phenomenon of spinal symptoms a systematic review. Man Ther Bogduk N, Derby R, Aprill C, Lord S, Schwarzer A (1996). Precision diagnosis of spinal pain. In: Pain 1996 An Updated Review. Ed. Campbell JN. IASP, Seattle. Bogduk N, Lord S (1997). A prospective study of centralization of lumbar and referred pain: a predictor of symptomatic disc and annular competence: commentary. Pain Med J Club Cibulka MT, Koldehoff R (1999). Clinical usefulness of a cluster of sacroiliac tests in patients with and without low back pain. JOSPT CSAG (1994). Clinical Standards Advisory Group: Back Pain. HMSO, London. Donelson R, Aprill C, Medcalf R, Grant W (1997). A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine Dreyfuss P, Dreyer S, Griffin J, Hoffman J, Walsh N (1994). Positive sacroiliac screening tests in asymptomatic adults. Spine Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N (1996). The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine Fairbank JCT, Park WM, McCall IW, O Brien JP (1981). Apophyseal injection of local anesthetic as a diagnostic aid in primary lowback pain syndromes. Spine Freburger JK, Riddle DL (2001). Using published evidence to guide the examination of the sacroiliac joint region. Physical Therapy Helbig T, Lee CK (1988). The lumbar facet syndrome. Spine Kokmeyer DJ, van der Wurff P, Aufdemkampe G, Fickenscher TCM (2002). The reliability of multitest regimens with sacroiliac pain provocation tests. J Manip Physiol Ther Laslett M, Williams M (1994). The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine Laslett M (1997). Pain provocation sacroiliac joint tests: reliability and prevalence. IN Movement, Stability & Low Back Pain. The essential role of the pelvis. Eds Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, Churchill Livingstone, New York. Laslett M, Young SB, Aprill CN, McDonald B (2003). Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocations tests. Aus J Physio Laslett M, Oberg B, Aprill CN, McDonald B (2004). Zygapophysial joint blocks in chronic low back pain: a test of Revel s model as a screening test. BMC Musculoskeletal Dis /5/43 Laslett M, Oberg B, Aprill CN, McDonald B (2005a). Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B (2005b). Agreement between diagnosis reached by clinical examination and available reference standards: a prospective study of 216 patients with lumbopelvic pain. BMC Musculoskeletal Disorders 6:28.: Laslett M, Aprill CN, McDonald B, Young SB (2005c). Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual Therapy Maigne J-Y, Aivalikilis A, Pfefer F (1996). Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine Manchikanti L, Pampati V, Fellows B, Baha AG (2000). The inability of the clinical picture to characterise pain from facet joints. Pain Physician Manchikanti L, Singh V, Pampati V et al (2001). Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD (2004). Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskeletal Disorders 6: Volume 1, No. 1 March 2006 IJMDT 16

19 Non-specific low back pain are we any nearer a structural diagnosis? Ohnmeiss DD, Vanharanta H, Ekholm J (1997). Degree of disc disruption and lower extremity pain. Spine Revel ME, Listrat VM, Chevalier XJ et al (1992). Facet joint block for low back pain: identifying predictors of a good response. Arch Phys Med Rehabil Revel M, Poiraudeau S, Auleley GR et al (1998). Capacity of the clinical picture to characterize low back pain relieved by facet joint injection. Proposed criteria to identify patients with painful facet joints. Spine Sackett DL, Richardson WS, Rosenberg W, Haynes RB (1997). Evidence-based Medicine. How to Practice & Teach EBM. Churchill Livingstone, New York. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1994a). The falsepositive rate of uncontrolled diagnostic blocks of the lumbar zygapophyseal joints. Pain Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1994b). Clinical features of patients with pain stemming from the lumbar zygapophyseal joints. Is the lumbar facet syndrome a clinical entity? Spine Schwarzer AC, Derby R, Aprill CN, Fortin J, Kine G, Bogduk N (1994c). Pain from the lumbar zygapophyseal joints: a test of two models. J Spinal Dis Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1994d). The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine Schwarzer AC, Aprill CN, Bogduk N (1995a). The sacroiliac joint in chronic low back pain. Spine Schwarzer AC, Wang S, Bogduk N, McNaught P, Laurent R (1995b). Prevalence and clinical features of lumbar zygapophyseal joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1995d). The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E (1998). The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Arch Phys Med Rehabil Slipman CW, Jackson HB, Lipetz JS, Chan KT, Lenrow D, Vresilovic EJ (2000). Sacroiliac joint pain referral zones. Arch Phys Med Rehabil Spitzer WO, LeBlanc FE, Dupuis M et al (1987). Scientific approach to the activity assessment and management of activityrelated spinal disorders. Spine 12.7.S1-S55. Van der Wurff P, Hagmeijer RHM, Meyne W (2000a). Clinical tests of the sacroiliac joint. A systematic methodological review. Part 1: reliability. Manual Therapy Van der Wurff P, Meyne W, Hagmeijer RHM (2000b). Clinical tests of the sacroiliac joint. A systematic methodological review. Part 2: validity. Manual Therapy Waddell G (2004). The Back Pain Revolution (2nd Edition). Churchill Livingstone, Edinburgh. Werneke M, Hart DL (2003). Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomic pain patterns. Spine Young S, Aprill C (2000). Characteristics of a mechanical assessment for chronic facet joint pain. J Manual Manip Ther Young S, Aprill C, Laslett M (2003). Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine Journal If its good enough for royalty... Volume 1, No. 1 March 2006 IJMDT 17

20 Low Back Care: Advice is plentiful, but is it worth taking? Richard Rosedale, Reg. PT, MCPA International Journal of Mechanical Diagnosis and Therapy Back pain is a significant health problem in western society and a major cause of disability; in fact it is the most frequent cause of work related disability in those younger than 45 years old. 1 As a result, much research has been conducted attempting to provide some answers to the challenges of prevention, treatment and reducing recurrences. As yet there are few definitive answers but enough good information to allow the establishment of evidence-based guidelines in many countries and by many institutions throughout the world. The message promoted by these guidelines is fairly consistent and provides some simple advice for those with back pain and those trying to prevent occurrences. The following would be a fairly representative sample of the information: Back pain is common and rarely due to serious disease Most people recover quickly Many will have recurrent episodes It is best to stay active and at work Regular exercise is helpful Passive treatment modalities (e.g. ultrasound) are not recommended One of the goals of these guidelines is to reduce anxiety and concern regarding back pain and its consequences. Certainly, when these guidelines are adhered to, individuals tend to experience a better recovery from an episode of low back pain. 2 However, these guidelines may not be that accessible to the general public, the advice can be fairly general in nature and some people are looking for more specific help. Many people may turn to other sources of accessible information: articles in magazines and newspapers, many Internet sites and dozens of books are available on the topic, many claiming to offer people solutions to the problem of back pain. But how much of this is useful, based on current evidence, and how much is outdated or misleading? The Internet is one of the sources that people are turning to in increasing numbers, however the information people can access may have dubious value. In a recent study it was found that most web sites on back pain provided poor quality information, some of which was seriously misleading. 3 In another article, 74 websites were reviewed; only 9 were ranked as being high quality. It was noted that most web sites available for back pain information could be classified as advertising and it would be difficult for people to get useful information. 4 Although there appear to be no thorough reviews, the same might be said for the books, magazine and newspaper articles on back pain available to the public. Not needing the scrutiny of peer review, authors are potentially able to make many unsubstantiated claims and give advice which may not be consistent with current knowledge. Consumers certainly need to be wary and discriminating with the information to which they may be exposed. A prudent first step is to check that any claims made are substantiated with a reference. This reference should state the source of the evidence on which the claim is based. If the source is a peerreviewed scientific journal, the information is likely to be more credible. If the advice being given has not been supported by evidence then this should also be stated. Everyone is of course at liberty to give opinions, provided it is stated as such and does not give the reader the impression that it has been validated. Advice leading consumers to purchase expensive products or services should be viewed with the greatest of caution, especially if backed only with personal endorsements or testimonials (these should not be considered as evidence ). If this advice is also inconsistent with some of the general guidelines outlined above, there would be even more reason for concern. For instance, the recommendation of a totally passive form of treatment, one encouraging dependency on a provider, is very suspect. An emphasis on self-care and giving the back pain sufferer the responsibility in the management of their problem would be much more inline with current evidence. Low back pain is now known to be a recurrent and persisting problem that can be present on and off throughout alifetime. 5 With this in mind it is logical that people should be instructed in strategies that will help them not only to manage their present symptoms but also to know what to do with future episodes and how to attempt to prevent those recurrences. People need advice that will keep them independent from healthcare providers, not dependent upon them. This can also make a difference to the individual on another level: It is now well established that many of the most influential factors that contribute to the transition of pain from being acute to becoming prolonged and chronic are more psychosocial than physical in nature. People s coping mechanisms, their attitudes, their fears and beliefs can all make a significant difference to how well or poorly they do when they have back pain. 6 Empowering people, giving them the responsibility to control their episode of pain and disability, can po- Volume 1, No. 1 March 2006 IJMDT 18