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Palpating a tender spinal segment suggests that something’s wrong, most likely intersegmental joint dysfunction. But tenderness doesn’t necessarily indicate that a joint is hypomobile. Hypermobile joints also demonstrate palpatory tenderness. The management of hypo- vs. hyper-mobility is divergent, so how can we quickly differentiate?
Lumbar instability is a frequently overlooked cause of LBP. (1,2) Estimates suggest that spinal segmental instability is responsible for between 13-33% of all LBP. (3,4) Not surprisingly, instability is synonymous with diagnoses like spondylolisthesis. However, a new study found that instability was present in more than half (57%) of all discogenic LBP cases. (8)
This blog and video highlight up-to-date research that helps define the most sensitive and specific tests for detecting clinical instability- and the top exercises for solving these otherwise challenging cases.
Identifying Lumbar Spinal Instability
Lumbar instability can be sub-classified into two groups:
- Radiological lumbar instability– sagittal translation greater than 4.5 mm or more than 15% of the vertebral body. (5)
- Clinical lumbar instability– “a decrease in the capacity of the spinal stabilizing system to maintain the spinal neutral zone within physiological limits so that there is no neurological deficit, major deformity, or incapacitating pain.” (6,7)
Clinical lumbar instability can be challenging to identify; however, a new study from Musculoskeletal Science and Practice (6) has highlighted a cluster of four useful tests:
- Apprehension Sign
- Instability Catch Sign
- Painful Catch Sign
- Prone Instability Test
Check out this quick video demonstration of these four tests and how to apply them in daily clinical practice.
The authors of the Musculoskeletal Science and Practice study defined the reliability of each test (6):
- The Apprehension Sign “showed the highest specificity (92.60%) and the second highest positive likelihood ratio (LR+ = 2.35) but a very low sensitivity of 17.40%.”
- The Painful Catch Sign “was the most accurate test overall, having the second highest sensitivity (72.80%), the highest LR+ (2.38), and the lowest negative likelihood ratio (LR- = 0.39).”
- The Prone Instability Test “was the most sensitive test, with the highest LR- (0.39).”
Not surprisingly, the authors found that a cluster is more useful than any one test in isolation:
“The cluster of three of four positive tests was the most accurate cluster of tests overall, with the highest LR+ (5.76) 6 and the second highest specificity (91.70%) but the second lowest sensitivity (47.80%) and LR- (0.57). The cluster of two of four clinical tests showed the second highest sensitivity (89.10%), LR+ (2.41), and LR- (0.17).”
Management of Lumbar Spinal Instability
Clinically defining segmental hypermobility vs. hypomobility is not a simple positive/ negative answer, but rather a spectrum of possibilities.
Orthopedic assessment can help identify where a symptomatic segment resides on that spectrum. Patients with significant signs of instability will not likely appreciate HVLA of the hypermobile segment(s). Conversely, less stable segments typically welcome functional rehabilitation exercise. In 2005, Hicks et al. found that 83% of patients with signs of instability (including two of the tests mentioned above) improved after implementing an 8-week stabilization program. (3)
When in Doubt- Promote Stout
The bottom line is that any sign of instability justifies rehabilitation. The potential benefits are high, and the risks are low. (When was the last time you detected a problematic excessively stable core?) With that in mind, here are our top recommendations for enhancing core instability.
Here’s what those exercises look like in a ChiroUp Condition Report (generated & delivered in 21 seconds!).
With ChiroUp, you can practice more confidently knowing that you have the most up-to-date clinical knowledge at your fingertips. ChiroUp subscribers can:
- Automatically deliver the most appropriate home advice and exercises to your patients by prescribing a customized condition report.
- Review any of the spinal instability evaluations and exercises from your clinical skills library.
- Reference the updated protocol for spinal segmental instability in ChiroUp’s condition reference library.
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ChiroUp makes it easier than ever to stay up-to-date on 100+ conditions and send your patients customized reports in the matter of seconds. Get started today with our FREE 14-day trial!
- Denteneer L, Stassijns G, De Hertogh W, Truijen S, Van Daele U. Inter-and intrarater reliability of clinical tests associated with functional lumbar segmental instability and motor control impairment in patients with low back pain: a systematic review. Archives of physical medicine and rehabilitation. 2017 Jan 1;98(1):151-64. Link
- Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination to predict radiographic instability of the lumbar spine. European spine journal. 2005 Oct 1;14(8):743-50. Link
- Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Archives of physical medicine and rehabilitation. 2005 Sep 1;86(9):1753-62. Link
- Puntumetakul R, Yodchaisarn W, Emasithi A, Keawduangdee P, Chatchawan U, Yamauchi J. Prevalence and individual risk factors associated with clinical lumbar instability in rice farmers with low back pain. Patient preference and adherence. 2015;9:1. Link
- White AA, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: JB Lippincott; 1990.
- Areeudomwong P, Jirarattanaphochai K, Ruanjai T, Buttagat V. Clinical utility of a cluster of tests as a diagnostic support tool for clinical lumbar instability. Musculoskeletal Science and Practice. 2020 Jul 24:102224. Link
- Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of spinal disorders. 1992 Dec 1;5:390-. Link
- Takahashi M, Iwamoto K, Kuzuyama M, Inami H, Matsumoto Y, Ueda S, Miyauchi Y. Incidence of spinal instability among patients with discogenic low back pain with different backgrounds. Journal of Physical Therapy Science. 2021;33(8):601-5. Link
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