December 2003

Ortho/neuro folly

by Dr. Christopher Kent

In a previous column, [1] I discussed the lack of scientific support for many common orthopedic tests used in chiropractic practice. As Walsh wrote, [2] "The use of orthopedic tests has been an integral part of the physical examination for a long time. They have remained a part of the examination more by virtue of common use than on the basis of any scientific demonstration of their validity and clinical significance. To make a judgment on the clinical worth of a test, its validity, reliability, sensitivity and specificity should ideally be known. Unfortunately, for most, if not all, orthopedic tests, these measures have not been determined."

Regretfully, little has changed. Recent publications cast serious doubt on the validity and clinical utility of orthopedic and neurological examination procedures.

In a paper addressing the reliability of clinical tests in the assessment of patients with neck and shoulder problems, Bertilson et al [3] reported on a study where two examiners independently assessed 100 patients with 66 clinical tests divided into 9 categories. Half the patients were examined with, and half without knowledge of the patient's history. The categories of tests included cervical ROM, shoulder tests, tenderness, hypotony, sensitivity to pain, strength, reflexes, nerve stretch, and neck compression/traction.

The authors concluded, "Reliability of clinical tests was poor or fair in several categories, and did not alter with history. Only a bimanual palpation test reached good kappa values...Some common tests may not be reliable." In short, the only test that yielded good kappa values was palpation for tenderness.

Things aren't any better with low back exams. Michel et al [4] noted that studies of back pain patients demonstrated weak agreement between history and physical examination. LeClaire et al [5] found that even with experienced clinicians, diagnostic accuracy was less than chance when history and exam were evaluated on simulators of back pain.

In a recent issue of The Back Letter, [6] it was noted that most experts questioned the need for a straight‑leg raising test as part of the clinical examination. Bogduk, for example, stated, [7] "Straight‑leg raising has no validity even if the patient has radicular pain." Rebain et al wrote, "There remains no standard passive straight leg raising procedure, no consensus on the interpretation of results, and little recognition that a negative passive straight leg raising test outcome may be of greater value than a positive one." Rheumatologist Hadler agrees [6] that "[Straight‑leg raising] is ancillary information which is difficult to interpret and drives no clinical decision in the first couple of months."

Regarding neurological examination, Deyo opined, [6] "In reality, though, if the patient has no neurological symptoms, including sciatica, in the history, the yield of this is close to zero."

It is time for our colleges, state boards, national board, and guideline developers to acknowledge the shortcomings of the ortho/neuro exam. Scientific support for such procedures in traditional medical diagnosis has been brought into question. The value of such tests in chiropractic analysis of vertebral subluxation ranges from dubious to non‑existent.

References

1. http://www.worldchiropracticalliance.org/tcj/1998/aug/aug1998kent.htm

2. Walsh MJ: "Evaluation of orthopedic testing of the low back for nonspecific lower back pain." JMPT 1998;21(4):232.

3. Bertilson BC, Grunnesjo M, Strender LE: "Reliability of clinical tests in the assessment of patients with neck/shoulder problems‑impact of history." Spine 2003;28:2222.

4. Michel A, Kohlmann T, Rapse H: "The association between clinical findings on physical examination and self‑reported severity in back pain. Results of a population‑based study." Spine 1997;22:296.

5. Leclaire R, Esdaile JM, Jequier, et al: "Diagnostic accuracy of technologies used in low back assessment. Thermography, triaxial dynamometry, spinoscopy, and clinical examination." Spine 1996;21:1325.

6. "The search for serious disease: what is the best strategy?" The Back Letter 2003;18(9):102.

7. Rebain R, Baxter GD, McDonough S, et al: "A systematic review of the passive straight leg raising test as a diagnostic aid for low back pain." Spine 2002;27:E388.

(Dr. Christopher Kent, president of the Council on Chiropractic Practice, is a 1973 graduate of Palmer College of Chiropractic. The WCA's "Chiropractic Researcher of the Year" in 1994, and recipient of that honor from the ICA in 1991, he was also named ICA "Chiropractor of the Year" in 1998. He is director of research and a co‑founder of Chiropractic Leadership Alliance. With Dr. Patrick Gentempo, Jr., Dr. Kent produces a monthly audio series, "On Purpose," covering current events in science, politics and philosophy of vital interest to the practicing chiropractor. For subscription information call 800/892‑6463.)