Background
Methods
Literature search
Study selection
Data extraction and quality assessment
Data synthesis and analysis
Item
| |||
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1. | Was the spectrum of patients representative of the patients who will receive the test in practice? | Y | U |
2. | Were selection criteria clearly described? | Y | N |
3. | Is the reference standard likely to correctly classify the target condition? | Y | Y |
4. | Is the time period between reference standard and index test short enough to the reasonably sure that the target condition did not change between the two tests? | Y | U |
5. | Did the whole sample or a random selection of the sample, receive verification using a reference standard of diagnosis? | Y | Y |
6. | Did patients receive the same reference standard regardless of the index result? | Y | Y |
7. | Was the reference standard independent of the index (i.e. The index test did not form part of the reference standard)? | Y | Y |
8. | Was the execution of the index described in sufficient detail to permit replication of the test? | Y | Y |
9. | Was the execution of the reference standard described in sufficient detail to permit its replication? | Y | U |
10. | Were the index test results interpreted without knowledge of the result of the reference standard? | Y | Y |
11. | Were the reference standard results interpreted without knowledge of the results of the index test? | Y | Y |
12. | Were the same clinical data available when test results were interpreted as would be available when the test is used in practice? | Y | Y |
13. | Were uninterpretable/intermediate test results reported? | Y | Y |
14. | Were withdrawals from the study explained? | Y | Y |
Item
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1. | Was the test evaluated in a sample of subjects who were representative of those to whom the authors intended the results to be applied? | Y | Y | Y | Y | Y |
2. | Was the test performed by raters who were representative of those to whom the authors intended the results to be applied? | Y | U | Y | Y | Y |
3. | Were raters blinded to the findings of the other raters during the study? | Y | Y | Y | Y | Y |
4. | Were raters blinded to their own prior findings of the test under evaluation? |
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
5. | Were raters blinded to the results of the accepted reference standard or disease status for the target disorder (or variable) being evaluated? |
N/A
| Y |
N/A
|
N/A
| U |
6. | Were raters blinded to clinical information that was not intended to be provided as part of the testing procedures or study design? | U | U | Y | N | N |
7. | Were raters blinded to additional cues that were not part of the test? | U | U | U | U | U |
8. | Was the order of examination varied? | N | Y | Y | Y | N |
9. | Was the stability (or theoretical stability) of the variable being measured taken into account when determining the suitability of the time-interval between repeated measures? | (PIT) N | (AMP) Y | N | N | N |
10. | Was the test applied correctly and interpreted appropriately? | Y | Y | Y | N | Y |
11. | Were appropriate statistical measures of agreement used? | Y | Y | Y | N | U |
Results
Quality scores
Diagnostic accuracy of the tests
Article
|
Clinical tests, scores
|
Inclusion (I) and exclusion (E) criteria
|
Population
|
Reference standard and positive criteria
|
Rater/s
|
---|---|---|---|---|---|
Fritz et al. [24] |
-
Aberrant Movement Pattern (Painful arc on flexion, painful arc on return, instability catch, Gower sign, reverse lumbopelvic rhythm). Positive test: at least 1 of the 5 signs was present.
| I: LBP with or without referred pain on the lower extremities, < 60 yrs | N.49 | Dynamic X-ray: the patient stands at the edge of a tall stool with feet flat on the floor and arms folded across the chest. The patient is instructed to flex forward as far as possible for the flexion X-Ray. For the extension X-ray, the patient stands with arms folded, and is asked to extend as far as possible. | 1 Physical Therapist |
-
Prone instability test
Positive test: pain provoked during the first part of the test decreases when the test is repeated with the legs off the floor.
| E: contraindications to radiographic assessment (e.g., current pregnancy), previous lumbar fusion surgery, inability (e.g., pain or muscle spasm) to actively flex and extend the spine adequately to permit an assessment of segmental motion |
- Age: 39.2 ± 11.3 yrs | Criteria for instability: sagittal plane translation greater than 4.5 mm or greater than 15% of the vertebral body width, or sagittal plane rotation greater than 15° at L1/L2, L2/L3, L3/L4 levels, greater than 20° at L4/L5, or greater than 25° at L5/S1. | ||
-
Posterior Shear Test
Positive test: familiar symptoms are provoked.
|
- Duration of symptoms (median days) 78 |
Instability diagnosis: 2 segments with either rotational or translational instability OR 1 segment with both translational and rotational instability
| |||
- Distribution of symptoms: back/buttock only 63.3%, symptoms distal to the knee 30.6% | |||||
- Previous history of LBP: 83.7% | |||||
- LBP episodes becoming more frequent: 30.6% | |||||
Kasai et al. [25] |
-
Passive lumbar extension test: The subject was in the prone position; both lower extremities the were elevated concurrently to a height of about 30 cm from the bed while maintaining the knees extended and gently pulling the legs. Positive test when the subject complained of strong pain in the lumbar region (“low back pain”, “very heavy feeling on the low back”, “feeling as if the low back was coming off”) during elevation of both lower legs, and such pain disappeared when they returned to the initial position. In contrast, when the subject complained of an abonrmal sensation (mild numbness or prickling sensation) the test was negative. | I: lumbar degenerative diseases | N. 122 subjects with lumbar degenerative diseases: 89 lumbar spinal canal stenosis; 21 lumbar spondylolisthesis; 12 lumbar degenerative scoliosis. | Dynamic x-ray: flexion-extension films of the lumbar spine, lateral vision. | n°3 Orthopedics |
E: / |
- 39 ± 8.8 yrs; | 3 criteria to asses radiological instability: angular motion > 20°; transactional motion > 5 mm; cutoff value of - 5° for the intervertebral endplate angle on the flexion film. | n°2 for testing PLE test (who had 12 and 15 yrs of clinical experience) | ||
- mean illenss duration 11.2 months; |
Radiograph instability: positive for 1 o more of the 3 criteria.
| n°1 for testing Instability catch sign (with 20 yrs of clinical experience). | |||
-
Instability catch sign: The subject was asked to bend his body forward as much as possible and then return to the erect position; subject who was not able to return to erect position because of sudden low back pain was judged positive to the test. |
- Complain of pain: 70.5% lumbago, 60.7% intermittent claudicatio, 42.6% neurological symptoms in the lower legs |
For RX evaluation:
| |||
n°2 Orthopedics who had 8 and 14 yrs of clinical experience.
|
Test
|
2x2 table
|
Sensitivity
|
Specificity
|
PPV
|
NPV
|
+LR (95% CI)
|
-LR (95% CI)
| |
---|---|---|---|---|---|---|---|---|
TP
|
FP
| |||||||
FN
|
TN
| |||||||
PIT [23] | 20 | 9 | 71.4 | 57.1 | 69.0 | 60.0 | 1.67 | 0.50 |
8 | 12 | (0.97-2.88) | (0.97-2.88) | |||||
PLE [24] | 32 | 8 | 84.2 | 90.5 | 80.0 | 92.7 | 8.84 | 0.18 |
6 | 76 | (4.51-17.34) | (0.08-0.37) | |||||
AMP [23] | 5 | 1 | 17.9 | 95.2 | 83.3 | 46.5 | 3.75 | 0.86 |
23 | 20 | (0.47-29.75) | (0.71-1.05) | |||||
ICS [24] | 10 | 12 | 26.3 | 85.7 | 45.5 | 72.0 | 1.84 | 0.86 |
28 | 72 | (0.87-3.89) | (0.87-1.06) | |||||
PCS [24] | 14 | 23 | 36.8 | 72.6 | 37.8 | 71.8 | 1.35 | 0.87 |
24 | 61 | (0.78-2.32) | (0.66-1.15) | |||||
AS [24] | 7 | 10 | 18.4 | 88.1 | 41.2 | 70.5 | 1.55 | 0.93 |
31 | 74 | (0.64-3.76) | (0.78-1.1) | |||||
PST [23] | 16 | 11 | 50.0 | 47.6 | 59.3 | 36.5 | 0.96 | 1.05 |
16 | 10 | (0.56-1.63) | (0.60-1.85) |
Reliability of the tests
Article
|
Clinical test and scores
|
Inclusion (I) and exclusion (E) criteria
|
Population
|
Reliability
|
Rater/s
|
---|---|---|---|---|---|
Hicks et al. [23] |
- Painful arc in flexion
| I: current complaints of LBP. | N 63 | Inter-rater reliability. | N. 4 |
- Painful arc on return
| E: symptoms referred below the knee, LBP which may be attributed to current pregnancy, fractures in acute phase, tumor, infection, previous lumbar surgical fusion. | 20-66 yrs | For each pair of raters, the first rater performs all clinical examination measures on each subject; the second rater, who is blinded to the results of the first evaluation, then performs the same examination procedures, after a minimum of 15- minutes. | PT1: PT and chiropractor with 3 yrs of experience as a chiropractor and 2 yrs as an OMT | |
- Instability catch
| - Age 36.0 ± 10.3 | PT2: PT with 6 yrs of experience in orthopedic setting | |||
- Gower sign (“thigh climbing”)
| - Gender: 38♀, 25♂ | PT3: OMT with 8 yrs of experience | |||
- Reversal of lumbopelvic rhythm
| - Previous LBP episodes, 51/63. | PT4: PT with 4 yrs of experience on orthopedic environment. | |||
-
Aberrant Movement Pattern: positive if at least one of the five previously cited signs is present. |
3 pair of raters: PT1 + PT2, PT2 + PT3, PT1 + PT4
| ||||
-
Prone Instability Test:
Positive test: pain provoked during the first part of the test disappears when the test is repeated with the legs off the floor.
| |||||
Fritz et al. [24] |
-
Aberrant Movement Pattern: Painful arc on flexion; Painful arc on return; Instability catch; Gower sign (“thigh climbing”); Reverse lumbopelvic rhythm. Positive test when at least 1 of the previous 5 signs was present.
| I: complaint of LBP with or without radiation into the lower extremities, < 60 yrs | N. 38 patients taken by a sample of 49 patients with these characteristics: | Inter-rater reliability. | N. 2 physical therapists |
-
Prone Instability Test:
Positive test when pain provoked during the first part of the test decreases when the test is repeated with the legs off the floor.
| E: contraindications to radiographic assessment (e.g., current pregnancy), previous lumbar fusion surgery, inability (e.g. pain or muscle spasm) to actively flex and extend the spine adequately to permit an assessment of segmental motion. | - Age: 39.2 ± 11.3 yrs; | The second rater repeats the assessment 5 minutes after the first rater’s assessment | ||
-
Posterior Shear Test:
Positive test if familiar symptoms are provoked.
| - Duration of symptoms (median days) 78; | ||||
- Distribution of symptoms: back/buttock only 63.3%, symptoms distal to the knee 30.6%; | |||||
- Previous history of LBP: 83.7% | |||||
- LBP episodes becoming more frequent: 30.6% | |||||
Schneider et al. [27] |
-
Prone instability test:
Positive test when pain provoked during the first part of the test disappears when the test is repeated with the legs off the floor.
| I: History of LBP, age between 18 and 65 years, ability to tolerate lying prone | N. 39 volunteer patients with history of LBP and undergoing chiropractic treatment at the time of their enrollment in the study | Inter-rater reliability. | N. 2 experienced doctors of chiropractic (25 and 10 years of clinical experience, respectively). |
E: History of prior lumbar surgery, stenosis, scoliosis greater than 20°, unstable spondylolisthesis, positive nerve root tension or radiculopathy, any red flags suggestive of spinal pathology. | |||||
Ravenna et al. [26] |
-
Prone Instability Test with additional guidelines:
| I: chronic or recurrent LBP; age 18 to 60 years; current symptoms of LBP, but not acute phase. | - N. 30 | ● Inter-rater reliability for PIT examined under 2 conditions: | N. 2 examiners: |
→ A trunk stabilizing belt is placed around the subject and the table at shoulder level, | E: BMI > 30 kg/m2, disk herniation, symptoms referred below the knee, lower extremity weakness or loss of reflexes, history of spinal surgery or fracture, spinal deformity, systemic inflammatory condition, neurologic disease or other serious medical conditions. LBP attributable to pregnancy or a primary hip problem. | - Age 36.1 ± 11.8 yrs |
● PIT test with additional guidelines | Second-year physical therapy student | |
→ A stool may be placed under the subject’s feet if the feet do not comfortably reach the floor. | - Men: 56.7% |
● PIT test without additional guidelines. | Licensed physical therapist with 2 years of clinical experience in outpatient orthopedic physical therapy | ||
- Diagnosis: degenerative disk disease 16.6%, disk problem 10%, LBP 73.4% | |||||
- Previous LBP episodes: 83.0% | |||||
- Current VAS (0–10): 2.8 ± 1.6 | |||||
Positive and negative criteria:
| |||||
● Positive level if the subject reports a decrease of pain with the second P/A, lifting the legs in the second part of the test
| |||||
● Negative test if the subject reports superficial bone-on-bone pressure;
| |||||
● Negative test if the subject reports an increase in symptoms lifting the legs during the second part of the test;
| |||||
● Negative level if the subject reports an increase or same with the second P/A, compared with the first.
| |||||
Rabin et al. [12] |
-
Aberrant Movement Pattern. Painful arc on flexion; Painful arc on return; Instability catch; Gower sign (“thigh climbing”); Reverse lumbopelvic rhythm. Positive test when at least one of the cited five signs is present.
| I: age between 18 and 60 years, main complaint of LBP and/or related leg symptoms (i.e., pain, paresthesia) | N. 30 consecutive patients with LBP of any duration, with or without associated leg symptoms. | Interrater reliability | N. 4 raters physical therapists, with experience ranging from 13 to 25 yrs. |
-
Prone Instability Test:
Positive when pain elicited during the first part of the test is relieved or abolished during the second part.
| E: pregnancy; history suggesting a non-mechanical origin of symptoms (e.g., malignancy, inflammatory conditions), LBP due to a fracture, osteoporosis, regular use of corticosteroids, rheumatoid arthritis, presence of 2 or more signs suggesting lumbar nerve root compression. |
- Age: 33.5 ± 8.0 yrs | AMP was assessed by the two raters simultaneously; PIT and PLE are assessed by the two raters separately (second assessment 5 minutes after the first one). | One rater with postprofessional master’s degree (contributes to rating all subjects). | |
-
Passive Lumbar Extension Test:
Positive if LBP is elicited.
|
- Gender: 15♀, 15♂ | Other raters with bachelor degree in physical therapy contribute to rating in 23, 4, and 3 subjects, respectively. | |||
- Duration of symptoms: 164.4 ± 321.8 days | |||||
- Previous LBP episodes: 20 subjects |
Article
|
Test
|
Reliability
|
Results
|
---|---|---|---|
Hicks et al. [23] | Aberrant Movement Pattern | Inter-rater reliability | k = 0.60 (95% CI: 0.44; 0.73) |
Prone Instability Test | k = 0.87 (95% CI: 0.80; 0.94) | ||
Fritz et al. [24] | Aberrant Movement Pattern | Inter-rater reliability | k = −0.07 (95% CI: −0.45; 0.31) |
Prone Instability Test | k = 0.69 (95% CI: 0.59; 0.79) | ||
Posterior Shear Test | k = 0.27 (95% CI: 0.14; 0.41) | ||
Schneider et al. [27] | Prone Instability Test | Inter-rater reliability | k = 0.46 (95% CI: 0.15, 0.77) |
k weighed = 0.58 | |||
Ravenna et al. [26] | Prone Instability Test with additional guidelines | Inter-rater reliability | (With*) k = 0.10 (95% IC: −0.27; 0.47) |
k weighed = 0.27 (95% IC: −0.08; 0.61) | |||
(Without*) k = 0.04 (95% IC: −0.34; 0.42) | |||
k weighed = 0.47 (95% IC: 0.15; 0.78) | |||
Rabin et al. [12] | Aberrant Movement Pattern | Inter-rater reliability | k = 0.64 (95% IC 0.32; 0.90) |
Prone Instability Test | k = 0.67 (95% IC 0.29; 1.00) | ||
Passive Lumbar Extension test | k = 0.76 (95% IC 0.46; 1.00) | ||
Active Straight Leg Raising | k = 0.53 (95% IC 0.2; 0.84) |