The Study:Clinical examination findings as prognostic factors in low back pain: a systematic review of the literature
- A clinical examination is commonly done on patients.
- However, making "a pathoanatomic diagnosis" is usually not possible in the average low back pain patient.
- The authors felt that perhaps the clinical examination might be more helpful in determining the prognosis for the case.
- They tried to find an association between clinical tests used in cases of "acute, recurrent or chronic low back pain and short- and long-term outcome".
- It was a review of the literature and was directed at adult patients.
- "There is evidence from confirmatory studies for an association between centralization and non-organic signs and outcome."
- "...consistent evidence of non-organic signs being predictive of long-term poor outcome of return to work."
- But as regards the prognostic value of the other tests, there was either no evidence at all, or a lack of good quality evidence in terms of their predictive value.
- Included among the other tests looked at were palpation, range of motion, and straight leg raise.
Bottom line is that it's often pretty difficult to make a prognosis based on most clinical tests, but there is some evidence for the predictive value of non-organic signs and centralization . The authors took pains to note that “clinical tests are designed and used for other purposes, and a poor association with prognosis does not discredit the test as being diagnostic or otherwise informative for clinical management. Clinical tests may still have potential as treatment effect modifiers or as part of comprehensive predictive models.”
Reviewer's Comments: Now for my take. Even though the authors of the article found evidence of non-organic signs and centralization being predictive of outcomes, this evidence is not as clear cut as I would like. I suggest keeping in mind that making a prognosis is difficult at best. No single test can predict outcomes accurately. Ultimately we must still use our own best clinical judgment based on our own experience with similar cases.
Reviewer:Roger Coleman DC
Editor’s Comments: In case you don’t remember much about “non organic signs
(I didn’t) here’s the quick review.Five types of nonorganic findings were classified by Waddell et al in 1980: 1) Tenderness, 2) pain, or reduction of pain free range of motion, upon distraction, 3) regional weakness or sensory disturbance, 4) “over reaction” such as pulling away, grimacing, etc., 5) expressed pain upon “simulated” spinal motions which don’t actually stress the spine. Presence of three or more types of non organic signs, although not necessarily associated with malingering, may still indicate the presence of psychosocial factors which will need to be dealt with in managing the patient. Psychosocial factors may be one possible explanation for the association between non-organic signs and poor therapeutic outcomes.
Editor: Mark R. Payne DC
Reference: Hartvigsen L, Kongsted A, Hestbaek L. Clinical examination findings as prognostic factors in low back pain: a systematic review of the literature. Chiropr Man Therap. 2015;23:13
Link to Abstract: http://www.ncbi.nlm.nih.gov/pubmed/25802737