relation physical exam findings to function in lumbar deg dysfunction

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2005; 85:120-133.PHYS THER.Ziaei and Maura D IversenMark A Lyle, Sarah Manes, Michael McGuinness, SarahConditionsFunction in Patients With Degenerative LumbarSelf-Reported Symptom Severity and PhysicalRelationship of Physical Examination Findings and

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Relationship of Physical Examination

Findings and Self-Reported Symptom

Severity and Physical Function inPatients With Degenerative Lumbar

Conditions

APTA is a sponsor of theDecade, an international,multidisciplinary initiativeto improve health-relatedquality of life for people withmusculoskeletal disorders.

Background and Purpose. Limited data are available to assist clinicians in clinicaldecision making. The purpose of this study was to examine the relationships ofsymptom provocation during physical examination (PE) procedures and self-report of symptom severity and function in patients with degenerative lumbarconditions. Subjects. Twenty-four men and 50 women with chronic low back pain(CLBP) (6 months duration) were recruited from a university hospital (medianage64.2 years, X66.8, SD12.4, range55.797.8). Methods. Demographicinformation, medical history, PE findings, and data from 2 self-report measures ofsymptom severity and function (Lumbar Spinal Stenosis [LSS] questionnaire andMedical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) werecollected. Results. Patients had moderate symptoms of degenerative lumbarconditions (mean LSS symptom score2.67, SD0.71) and reported somedifficulties with low back function (mean LSS function score1.99, SD0.61).The most frequent physical examination findings were a positive quadrant test(70%), followed by lower-extremity muscle weakness (64%), abnormal reflexes(62%), and active lumbar extension (61%). Patients who were symptomaticduring the quadrant test, patients who had pain with lateral flexion, and patients

who had lower-extremity weakness had higher self-reported LSS symptom severity(t3.06, P.003; t2.96, P.004; and t3.2, P.002, respectively). Painwith lumbar extension was moderately correlated with LSS symptom severity(Spearman rho.31, P.007). No lumbar PE procedure was associated withdecreased condition-specific function. The quadrant test was the strongestpredictor of symptom severity (.54, r2.21, P.0009). Discussion and Conclu-sion. The association between PE findings and self-reported symptom severity inthis sample is consistent with the pathoanatomy of degenerative spinal conditionsand indicates that movement that narrows the foraminal space contributes tosymptom severity. The quadrant test distinguished those subjects with clinicallymeaningful low back symptom severity but was not predictive of impairedfunction. This study illustrates the potential benefit of identifying clinical PE

measures that are reflective of condition severity and back-specific function inpatients with similar clinical syndromes. [Lyle MA, Manes S, McGuinness M, et al.Relationship of physical examination findings and self-reported symptom severityand physical function in patients with degenerative lumbar conditions. Phys Ther.2005;85:120133.]

Key Words: Condition severity, Low back pain, Physical examination, Symptoms.

Mark A Lyle, Sarah Manes, Michael McGuinness, Sarah Ziaei, Maura D Iversen

120 Physical Therapy . Volume 85 . Number 2 . February 2005

Resea

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Report

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Chronic low back pain (CLBP) affects at least20% of people older than age 65 years eachyear.1 Back pain in older adults is generallythought to arise from degenerative processes,

which are ubiquitous in this population and increase with age.2,3 The aging spine is often described withpathoanatomical terms such as spondylosis, vertebral

osteophytosis/osteoarthritis, spinal stenosis, and diskdisease. The degenerative process is multifactorial,4 andthe source of pain is often unclear because of weakassociations between imaging studies and clinical pre-sentation.2,3,5,6 The apparent discrepancy among pathol-ogy, symptoms, and function complicates patient care.

Physical therapists use physical examination (PE) proce-dures routinely when making clinical decisions. Yet,limited data are available to guide the clinical decision-making process.7 Clinicians rely on inductive reasoning,intuition, and evidence to formulate clinical decisions.The goal during any examination is to collect and

evaluate data in terms of signs and symptoms that tendto fit a pattern.8 Classification systems were developedbased on this rationale with the hope of enhancingpatient care and identifying homogeneous groups.7,9 Byidentifying subgroups with similar PE findings, clinicalresearchers can determine which patients are likely tobenefit most from a particular intervention. Flynn et al10

applied this paradigm to identify PE variables that pre-dict which individuals are likely to benefit (reportedreduced low back symptoms) from spinal manipulation.For the PE to be more clinically useful and to guideclinical decisions, we must better understand the rela-

tionship between PE findings and the patients symptomseverity and function.

Symptom severity and function can be ascertained fromself-report questionnaires and medical history. Yet, theuse of self-report measures in the clinic is limited.11

Identifying the best clinical measures that are associated with a patients condition severity and function willfacilitate the clinical decision-making process. For exam-ple, if therapists know which PE procedures are associ-

ated with worse severity or function, they may appropri-ately adjust the prognosis and intervention plan. Waddell and Mains statement in 1984 remains a con-temporary issue with regard to PE procedures: atpresent, there is no satisfactory or accepted method forassessing the severity of low back disorders.12(p204)

Physical examination and evaluation procedures havebeen studied extensively in people with low back pain(LBP).1219 Impairment-based PE procedures haveyielded weak and conflicting associations between con-dition severity and functional capabilities in people withacute LBP13,14 and CLBP.12,1519 Methodological issues

may largely explain these poor associations. For exam-ple, the inclusion of people with varying age ranges andclinical symptoms increases the heterogeneity of thesample and may explain the weak associations betweenPE procedures and self-reported symptom and function.The use of poorly defined clinical measures and refer-ence standards and poor interexaminer reliability alsomakes interpretation of the literature difficult. Further-more, biobehavioral factors (ie, cognitive-perceptual,environmental, and psychophysiological) are thought tostrongly affect the clinical presentation of people withCLBP.20 A better understanding of the relationship

between PE procedures and low back symptom severityand function may enhance clinical decision making andmay improve patient care.

MA Lyle, PT, MSPT, S Manes, PT, DPT, M McGuinness, PT, DPT, and S Ziaei, PT, DPT, were students in the Department of Physical Therapy,

Simmons College, Boston, Mass, at the time of this study.

MD Iversen, PT, SD, MPH, is Professor, Graduate Programs in Physical Therapy, MGH Institute of Health Professions, and Instructor in Medicine,

RBB Arthritis Research Center, Department of Medicine, Division of Rheumatology, Immunology & Allergy, Section of Clinical Sciences, Brigham

and Womens Hospital, Harvard Medical School, Boston, Mass. Address all correspondence to Dr Iversen at Graduate Programs in Physical

Therapy, MGH Institute of Health Professions, 36 First Ave, Boston, MA 02129 (USA) ([email protected]).

All authors provided concept/research design and data analysis. Mr Lyle and Dr Iversen provided writing and data analysis. Dr Iversen provided

project management, fund procurement, subjects, facilities/equipment, and institutional liaisons.

This study was approved by the institutional review boards of Brigham and Womens Hospital and Simmons College.

Partial funding for this study was provided by a Farnsworth Postdoctoral Fellowship Grant from the Medical Foundation to

Dr Iversen, a New Investigator Award from the National Arthritis Foundation to Dr Iversen, and a Research Award from the

Foundation for Physical Therapy to Dr Iversen.

The results of this study were presented at the Annual Scientific Meeting of the American College of Rheumatology; October 26, 2002; New

Orleans, La.

This article was received August 14, 2003, and was accepted August 8, 2004.

Physical Therapy . Volume 85 . Number 2 . February 2005 Lyle et al . 121by guest on January 27, 2012http://ptjournal.apta.org/Downloaded from
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The current investigation examined older adults withchronic lumbar back pain believed to arise from degen-erative processes. The purpose of this study was toexamine the relationships between select PE proceduresand the patients self-reported symptom severity andfunction using a condition-specific and a generic healthmeasure. We hypothesized that PE procedures that

reduced the opening of the intervertebral foramen andwere related to common clinical presentation (eg, mus-cle weakness of the lower extremity) would be stronglyassociated with self-reports of low back symptom severityand function.

MethodWe used a cross-sectional design and conducted a sec-ondary analysis of data from 2 clinical trials, a prospec-tive randomized controlled trial (RCT) aimed at deter-mining the effects of a 12-week submaximal bicycleprogram on CLBP (RCT under review) and the pilottrial of endurance training in patients with degenerative

lumbar conditions.21 The rights of human subjects wereprotected. Participants were recruited from a spinecenter affiliated with a large tertiary care hospital. Wemailed letters to each patients physician seeking thephysicians permission to enroll the patient, to providemedical clearance, and to gather data on the physiciansclinical impression of the patients low back condition.This letter outlined the inclusion and exclusion criteria.To enroll a somewhat homogeneous sample of patientswith CLBP due to degenerative changes in the spine,patients were enrolled if they had LBP of6 monthsduration, were 55 years of age or older, and reported

that their LBP, buttock pain, or lower-extremity pain wasmade worse with lumbar extension. Patients were eligi-ble only if the spine center physicians felt that theirsymptoms were degenerative. These inclusion criteriaare identical to those used by Stucki et al22 in thedevelopment of the Lumbar Spinal Stenosis (LSS) ques-tionnaire. We confirmed the physicians clinical impres-sions on a subset of subjects (70%) for whom radio-graphs were available. Radiographs were not requiredfor entry into the study but were used to support clinicalimpressions of the diagnosis. The physicians clinicalimpressions were reported using 5 symptom-based diag-

nostic categories. Table 1 presents the physicians clini-cal impressions and the radiologists radiographicimpressions.

Once referred by the spine center physician, eligiblepatients were contacted by telephone and screened forenrollment in the clinical trial. Patients were askedwhether walking increased their pain or bending back-ward increased their back symptoms and whether theywere currently receiving physical therapy for their lowback pain or had an epidural injection in the last 6months. Patients were not enrolled if they had back

surgery in the last year; had back pain secondary tovertebral compression fracture, cancer, or infection; hadan epidural steroid injection within the last 6 months(identified via medical record review, physician, andself-report); were currently receiving physical therapy(identified via medical record review, physician report,and patient report on telephone screen); were unable tocomplete questionnaires because of language or cogni-tive difficulties (identified by physician report andthrough telephone screen); had medical problems thatlimited their function more than their back pain (via

physician and self-report); or reported increased LBP,buttock pain, or lower-extremity pain with lumbar flex-ion (via patient report). We did not invite patients whoself-reported increased pain with lumbar flexion,because the intervention for the primary clinical trialinvolved stationary bicycling.

Those patients who met the eligibility criteria attendedthe clinic visit. A research assistant discussed the studyand answered any questions for the participants. Theparticipants signed an informed consent statement,completed the self-report questionnaires, and provideddemographic data. On the same day, one author (MDI), who was unaware of the responses on the self-reportforms, performed the PE.

Sixty patients from the RCT and 14 patients from thepilot study satisfied the inclusion criteria. Their medianage was 64.2 years (X66.8, SD12.4, range55.797.8). Most of the participants were female (68%).Sixty-two subjects (84%) were Caucasian, 8 were African American (11%), 3 were Hispanic (4%), and 1 wasArabic (1%). Fifty-nine percent of the participants hadan education exceeding the 12th-grade level. Patientdemographic data are presented in Table 2.

Table 1.Spine Physicians Clinical Impressions and Radiologists RadiographicImpressions of Patient Condition

N %

Spine physicians clinical impressions (n74)a

Central low back pain 40 54Central low back pain with radiation 17 23

Central low back pain with neural deficits 4 5Neurogenic claudication due to lumbar spinal

stenosis16 22

Sciatica due to herniated nucleus pulposus 2 2.7

Radiologists impressions (n52 radiographs)a

Normal 1 2Degenerative disk disease 30 58Lumbar spinal stenosis 26 50Herniated nucleus pulposus 15 29Scoliosis 9 17Facet hyperostosis/osteoarthritis 14 27

a More than one category could be selected.

122 . Lyle et al Physical Therapy . Volume 85 . Number 2 . February 2005



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Self-report MeasuresThe primary constructs in the study were patientssymptom severity and functional status. We used a

condition-specific measurethe LSS questionnaire22and a generic measurethe Medical Outcomes Study36-Item Short-Form Health Survey (SF-36) question-naire23to assess patients self-reported clinical symp-tom severity and function. The LSS questionnaire wasdeveloped specifically for use with patients with degen-erative lumbar spinal stenosis. The psychometric prop-erties of the scale were tested on patients aged 50 yearsand older who had LBP, buttock pain, or lower-extremity pain that was typically exacerbated with lum-bar extension and evidence of degenerative lesions ofthe facets, disks, or ligamentum flavum on imaging

studies.22

The LSS questionnaire has subscales that represent anindividuals back-specific symptom severity and physicalfunction. The symptom severity scale ranges from 1 to 5,and the function scale ranges from 1 to 4, with higherscores reflective of increasing severity or decreasingfunction. The LSS symptom severity scale contains 7impairment-based questions concerning common clini-cal symptoms such as the degree of lower-extremity pain,numbness or tingling in the legs or feet, and lower-extremity weakness.22 The symptom severity scale uses aLikert classification with 5 categories (1none,2mild, 3moderate, 4severe, and 5verysevere) and yields data with established construct valid-ity when compared with the overall Sickness ImpactProfile (SIP), including the 3 dimensions of the SIP, anda visual analog scale in patients with degenerative spinalconditions (r.37, P.01, confidence interval[CI]0.24 0.49 and r.52, P.01, CI0.410.62).24

Test-retest reliability of data obtained for individual testitems, assessed using Pearson correlations, ranged from.60 to .91.22 The physical function scale has 6 questionsthat address activities such as walking distance, ability towalk for pleasure, and ability to walk to and from the

bedroom and bathroom, and it uses aLikert classification with 4 categories(1yes, comfortably; 2yes, butsometimes with pain; 3yes, butalways with pain; and 4no). Walk-ing distance was described as ability towalk over 3.2 km (2 mi), over 2 blocks

but less than 3.2 km, over 15.24 m(50 ft) but less than 2 blocks, and lessthan 15.24 m. In a previous study,22 theinternal consistency and the test-retestreliability of the function scale after 14days were (alpha.82 and Pearsonr.71.94, respectively). The develop-ers of the scale established construct validity through comparison with theglobal and physical function dimension

of the SIP (r.43, P.01, CI0.380.59 and r.49,P.01, CI0.380.59).24 The score for each subscale iscalculated as an unweighted mean of the items within

each subscale.22

The SF-36 is a generic measure constructed to surveyhealth status in clinical practice and research.23,25,26 Weused the bodily pain and physical function subscales.The SF-36 raw questionnaire data are scaled from 0 to100, with lower scores reflective of worse bodily pain anddecreased function. The 2-item pain scale is a well-validated tool used to demonstrate an individuals globalperception of pain.23 The physical function scale is a10-item scale that addresses general activities of dailyliving. The SF-36 physical function and pain subscales

have been used in patients with LBP.23,25,26

These self-report measures have proved useful in deter-mining outcomes and are sensitive to clinicalchange.2229 To determine clinically meaningful changein symptoms and function following an intervention, thedevelopers of the LSS questionnaire used a cutpoint of2.5 on the LSS satisfaction scale (2somewhat satis-fied, 3somewhat dissatisfied).22,24We used the samerationale to differentiate subjects believed to have clini-cally meaningful symptom severity and decreased func-tion. A symptom severity score of 2.5 or greater (out of a

5-point scale) or between none or mild and moderateor severe was the cutpoint used to describe individualsfelt to have clinically meaningful symptom severity.Clinically meaningful decreased physical function was opera-tionally defined as 2.0 or greater (out of a 4-point scale).

Physical ExaminationOne physical therapist (MDI), who was unaware of theself-reported questionnaire data and physician diagno-sis, performed the PE. The examiner is an experiencedclinician and researcher with 16 years of experience. Sheused lumbar symptom provocation tests, manual muscle

Table 2.Demographic Characteristics of Patients With Chronic Low Back Pain (n74)

Variable N (%) X SD Median Range

Age (y) 66.8 12.4 64.2 55.797.8

No. of medications 1.4 1.2 1 15

SexFemale 50 (68)

RaceCaucasian 62 (84)African-American 8 (11)Hispanic 3 (4)Arabic 1 (1)

Education (12 y) 30 (41)



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testing (MMT), and sensory testing. All symptom provo-cation tests were categorized as positive or negative.Specifically, active extension in standing with a30-second hold, a test used to reproduce back symp-toms30; active lumbar flexion and lateral flexion instanding, the quadrant test (ie, extension, side bendingleft, and rotation left)31; the straight-leg-raising test31;and the Lasegue test,31 a neural tension test, werecompleted. A test was considered positive if the patientreported pain or signs of neural compression such astingling, numbness, or weakness. Pain with active exten-sion in standing was further described by ranking theresponse using the following scale: 0no back pain orpain extending no farther than the knee, 1painextending beyond the knee. The test descriptions andinterpretations of positive results are shown in Table 3.

Because reproducibility is vital for clinical utility, it isimportant to note that measurements of pain with trunkmotion (ie, lumbar flexion, extension, lateral flexion)and pain with straight leg raising (the straight-leg-raisingtest) have satisfactory reliability between raters (kap-pa.40.80).32 Strender et al,33 in a study using 2physical therapist raters who had worked together formany years, also concluded that measurements of pain with trunk motion (kappa.51.76) and pain withstraight leg raising (kappa.83) have acceptable reli-ability; agreement between raters for the quadrant testwas 94%.

Response to vibration, pinprick, reflexes, and MMT(ie, iliopsoas, quadriceps femoris, hamstring, peroneal,extensor hallucis longus, gastrocnemius-soleus, and tib-ialis anterior muscles) was assessed to illustrate impair-ments suggestive of neural compression. A 128-Hz tun-ing fork was used to determine participants vibrationsense at the medial malleolus (L4), the lateral malleolus(L5), and the lateral head of the fifth metatarsal (S1). Vibration was categorized as normal, diminished, orabsent. Participants response to pinprick was deter-mined as normal, diminished, or absent at the medialmalleolus (L4), the lateral malleolus (S1), and the webspace between the first and second rays (L5).34 Patellartendon and Achilles tendon reflexes were rated asnormal, hypertonic, or hypotonic. Manual muscle test-ing (break test) was performed as outlined by Hislop andMontgomery.35 Manual muscle test scores for the lower

extremity were dichotomized into grades of less than orequal to 4 versus a grade of 5. Individuals with lower-extremity weakness in this study had a MMT grade of lessthan or equal to 4. The reliability of MMT scores isimproved when clearer delineations are used. The agree-ment (kappa) between 2 orthopedic surgeons in 50patients with LBP was .65 to 1.00 for MMT, .23 to .39 forreflexes, and .68 for numbness.32

We included other PE measures to rule out or determinethe possible contribution of adjacent joints. The hipscreens included the following: the amount of hip

Table 3.Physical Examination of Measures and Criteria for a Positive Resulta

Test/Measure Method Positive Result

Quadrant test (left/right) Patient actively moves into SBL, Ext, and RL andinto SBR, Ext, and RR as far as tolerated. Theexaminer guides the patient in this motion and

provides overpressure if no pain is reportedwith their active movement. The position isheld for 3 s.

Patient reports pain or numbness ortingling in the area of the back or lowerextremities.

Lumbar extension Patient actively extends as far as tolerated withthe examiner providing support for balance.The position is held for 30 s.

Patient reports pain or numbness ortingling: location of symptoms weredocumented as back, buttocks, thigh,calf, and foot and ankle.

Lateral flexion (right and left) Patient actively side bends as far as tolerated. Patient reports pain in the area of theback or lower extremities.

Lumbar flexion Patient actively forward bends as far astolerated.

Patient reports pain in the area of theback or lower extremities.

Straight-leg-raising test Patient is positioned supine. The examinerpassively flexes the extended lower extremityof the patient as much as tolerated.

Patient reports pain distal to the knee.Pain must be reported with 70 of hipflexion.

Lasegue test Patient is positioned supine. The examinerpassively flexes the extended lower extremityof the patient as tolerated. The patient isinstructed to flex the neck as tolerated.

Patient reports pain below the knee,which increases with neck flexion anddecreases as head returns to neutral.

a SBRside bending right, SBLside bending left, Extlumbar extension, RRrotation right, RLrotation left.




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medial (internal) rotation by visual estimate (10 or10) and notation of pain with hip medial rotation,36

the Faber test31 with notation of whether pain wasreproduced in the hip or sacroiliac region, and tender-ness to palpation at the greater trochanter.31 Report ofpain with hip medial rotation and decreased hip medialrange of motion is associated with osteoarthritis of the

hip.36

The Faber test places stress on both the hip andsacroiliac joints, and thus a report of pain in either areasuggests hip or sacroiliac pathology, respectively.31 Ten-derness to palpation in the area of the greater trochan-ter is suggestive of trochanteric bursitis.31,37 Althoughthe reliability and validity of data for the Faber test38 andtrochanteric tenderness can be questioned, we includedthese tests for their potential discriminative value and fortheir potential relationship to the reference standards.

Individuals who experienced discomfort with lumbarflexion during the PE were not excluded from the study. An individual who reported pain with lumbar flexion

also must have reported pain with the quadrant test orpain with sustained lumbar extension. Although individ-uals with degenerative low back conditions are generallymore extension sensitive, lumbar flexion also may repro-duce pain, and we feel the relationship is important toinvestigate.

Other MeasuresSeveral questionnaires were included to account forpotential confounding. The Cumulative Illness RatingScale (CIRS),39 which is a chart-based measure, and theCharlson comorbidity index,40 which is a self-report to

measure medical comorbidities, were used to measuremedical comorbidity. The CIRS rates the degree ofpathology and impairments in each of 12 major organgroups, as well as psychiatric behavioral categories,39 andis considered a valid measure of health status.41 Theprimary investigator (MDI) collected these data onsubjects from the medical record. A standardized comor-bidity value was calculated by taking individual scores onthe respective comorbidity scales, subtracting these val-ues from the mean, and dividing this value by thestandard deviation of the scores. A musculoskeletalchecklist was completed. Patients were asked to indicate

whether they had pain in the lower extremity or diffi-culty walking due to conditions of the lower extremity.The Mental Health Index (MHI-5) subscale of the SF-36was used to quantify mental health status as CLBP has apsychological dimension. The MHI-5 has been reportedto yield reliable and valid data.23 Patients were allowed tocontinue their prescribed medications. We collecteddata on medication used (pain medications, sedatives,muscle relaxants, anticonvulsants, or antidepressants)because these drugs may alter the perception of pain orsymptoms during the PE and may affect responses onself-report measures of symptoms and function. Medica-

tion usage was abstracted retrospectively from patientsmedical records using a standardized form.

Data AnalysisAnalyses were performed with the SAS statistical pack-age.*,42 We used a 3-step approach in the analyses. Instep 1, descriptive statistics were used to illustrate the

samples characteristics. In step 2, our goal was todetermine the relationship of exploratory variables. Weused ttests and Spearman correlation tests, as appropri-ate, to determine relationships between the PE measuresand the condition-specific and generic scales.43,44 Thecritical alpha level was .005 to adjust for multiple test-ing.43,44

In step 3, stepwise and hierarchical multivariate linearregression models were used to determine the uniquecontribution of each explanatory factor to the varianceof low back symptom severity and function as measuredby the condition-specific and generic self-reported out-

come measures. The stepwise modeling approach wasconfirmed with forward- and backward-selection proce-dures, with a P value of .10 necessary for entry orremoval from the model. Only PE variables that wehypothesized would affect self-report of symptoms andfunction were used in the modeling (these includedquadrant test, pain with lateral flexion, pain with exten-sion, muscle weakness, decreased sensation, trochanterictenderness, Faber test for hip pain, and pain with lumbarflexion). The PE items were entered into the model as agroup. Then only significant PE variables were retainedas demographic features such as age, sex, mental health

(ie, SF-36 MHI-5), medication use, level of education(ie, high-school or less versus advanced degree as edu-cation is a proxy for access to medical care), andcomorbidity, defined as the standardized comorbidity value, were considered in the model and entered as agroup.45

ResultsThe patients mean LSS symptom severity and functionscores were 2.67 (SD0.71) and 1.99 (SD0.61), respec-tively. The patients mean SF-36 bodily pain and physicalfunction scores were 43.7 (SD20.7) and 55.8

(SD

24.6), respectively. These scores indicate that oursample had moderate impairment. Normative data on acomparable sample of 481 adults (mean age60.4 years) with LBP and a cardiovascular comorbidity were 59.3and 66.3.23

The frequencies of positive findings for the PE measuresare displayed in Table 4. The quadrant test was the mostcommon test that reproduced the patients symptoms.Lower-extremity weakness, abnormal reflexes, and symp-

* SAS Institute Inc, PO Box 8000, Cary, NC 27511.



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toms with sustained lumbar extension followed, respec-tively, being positive in greater than 61% of the sample.

Power calculations were based on differences of 0.5point for the symptom severity scale and LSS functionscale, indicating a 10% difference. In longitudinal anal-ysis, this value was estimated to be clinically meaningful,whereas in cross-sectional analysis, such as this study, aclinically meaningful value may be as low as 0.3.22 Withalpha set at .005, a stringent level, to adjust for multipletesting in this exploratory analysis and using a mean

difference of 0.5 (on the LSS scale) and a standarddeviation of 0.6, we had 84% power to detect a differ-ence. Similarly, the clinically relevant change for theSF-36 bodily pain and physical function subscales of 10points identified by Ware et al23was used to detect powerfor the SF-36 subscales. With the alpha set at .005 andusing a mean difference of 10 points and a standarddeviation of 19, we had 60% power to detect a 10-pointdifference between groups.

Table 5 illustrates the mean self-reported symptom sever-ity and function for individuals with and without radiat-ing pain during prolonged lumbar extension (opera-tionally defined as symptoms either above or below theknee). Patients with more distal symptoms had increasedLSS symptom severity and function scores than those with localized pain.

Comparison of PE Procedures and the Condition-SpecificQuestionnaireWe estimated a single PE measures influence on theself-reported LSS and SF-36 outcome scores using a ttestcomparing group means (positive and negative PEresults) (Tab. 6). Three of the 10 PE measures showedbetween-group differences for the LSS symptom severity

score. Patients who reported symptoms during the quad-rant test had higher self-reported LSS symptom severityscores compared with those who did not report symp-toms during the quadrant test (t3.06, P.003). Thisrelationship also was observed in those who reportedsymptoms with lateral flexion (t2.96, P.004) and inthose who demonstrated lower-extremity weakness

(t

3.2, P

.002). Examination of the between-groupmeans revealed relative differences in LSS symptomseverity scores for these 3 groups of 0.58, 0.47, and 0.53,respectively. The mean LSS symptom severity scores ofpatients who reported symptoms during the quadrant,test or lateral flexion, and those with lower-extremityweakness were greater than 2.5, and those with negativefindings were less than 2.5. Pain with lumbar extensionwas moderately correlated with the LSS symptom severityscore (Spearman r.31, P.007).

One PE procedure had a between-group difference forLSS function (Tab. 7). Individuals who had pain with hip

medial rotation had decreased LSS functional statuscompared with those without hip symptoms (t2.96,P.004). Patients with a positive PE finding, on average,had mean back-specific LSS function scores thatexceeded 2.0, whereas the average mean back-specificLSS function scores of patients with negative PE findingswere less than 2.0.

Comparison of PE Procedures and the SF-36One PE procedure was found to have between-groupdifferences for the SF-36 bodily pain subscale and thephysical function subscale (Tabs. 8 and 9). Individuals

who demonstrated lower-extremity weakness had greaterbodily pain compared with those without lower-extremity weakness (t2.91, P.005). Patients whoreported pain with hip medial rotation had decreasedself-reported physical function (t3.84, P.0003).

Regression Analysis: Condition-Specific LSSQuestionnaireThe quadrant test, trochanteric tenderness, and level ofeducation contributed to the variance of self-reportedsymptom severity on the LSS questionnaire (Fig. 1). Thequadrant test explained the greatest proportion of vari-

ance (21%). The

coefficient represents the estimate ofthe change in the dependent variable (ie, LSS symptomseverity scale) given a positive examination finding. The coefficients for the quadrant test, trochanteric tender-ness, and level of education were 0.54 (P.0009), 0.68(P.002), and 0.61 (P.005), respectively. Thus, indi-viduals who had a positive quadrant test are expected toscore a half of a point higher on the LSS symptomseverity scale. The change score of 0.61, on the con-trary, represents the positive influence of having aneducation beyond the high school level.

Table 4.Frequency of Positive Physical Examination Findings (n74)

Variable N %

Quadrant testa 42 70Lower-extremity weaknessb 44 64Abnormal reflexes 46 62Pain with lumbar extension 45 61

Abnormal vibration sense 43 58Pain with lateral flexion 40 54Abnormal pinprick 37 50Faber test (positive) for hip painc 21 30Pain with lumbar flexion 18 24Hip pain with medial rotationd 15 22Trochanteric tendernesse 13 18Straight-leg-raising test 12 16Lasegue test 11 15

a n60, quadrant test was performed in randomized controlled trial only.b n69.c n71.d n68 (not completed on patients with total hip replacement).e n73.




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Trochanteric tenderness and level of education com-bined to explain 28% of the variance in the LSS functionscore, with coefficients of 0.60 (P.007) and 0.57

(P.004), respectively (Fig. 2). The presence of trochan-teric tenderness was associated with decreased function,whereas an education beyond the 12th grade was asso-ciated with improved function.

Regression Analysis: Generic Health SF-36 QuestionnaireNo PE measure contributed to the variance of bodilypain as measured by the SF-36 (Fig. 3). Educationbeyond the high school level was associated with adecreased SF-36 bodily pain score (P.001), and beingfemale was associated with an increased bodily painscore (P.005). Pain with extension, trochanteric ten-

derness, and level of education combined to explain29% of the variance in the SF-36 physical function score(Fig. 4). Trochanteric tenderness was associated with alarge decrease in the physical function score (19.6,P.01). Education beyond the high school levelimproved the physical function score (18.5, P.01),and pain reported with extension decreased the physicalfunction score (P.004).

Discussion We used an observational design to investigate therelationship between commonly used PE procedures

and self-reported symptom severity and function inindividuals with degenerative lumbar conditions. Thefindings illustrate the complex relationship of spinal PEprocedures and self-reported condition severity andfunction. Previous work aimed at clarifying the useful-ness of PE procedures in circumstances other thandiagnosis has been unenlightening. McGregor et al14

studied the impact of self-reported and clinical factorson flexion and extension range of motion and ascentand descent speed and concluded that their data werevaried and difficult to interpret. Michel et al13 found thatrotation, fingertip-to-floor distance, and lateral flexion

range of motion correlated best withself-reported severity in people withnonspecific LBP. We found that thequadrant test distinguished betweensubjects with clinically important back-specific LSS symptom severity. Pain with lateral flexion and extension,

lower-extremity weakness, and trochan-teric tenderness were associated with worse LSS symptom severity scores.However, none of the PE measuresused in this study were discriminativeof clinically important LSS physicalfunction. Pain with lumbar extension was associated with decreased SF-36physical function scores in regressionanalyses. Our results suggest that

impairment-based symptom provocation procedures aremore reflective of the condition severity domain thanthe functional domain.

Considering variables other than back-specific provoca-tion tests proved important in this study. Hip impair-ment was present in 22% of the sample. Yet 2 hip PEmeasures contributed to the variance in function andsymptom severity. Pain with hip medial rotation wasassociated with worse LSS and SF-36 function scores, andpain with trochanteric tenderness was predictive ofworse LSS severity scores, worse LSS function scores, andworse SF-36 physical function scores. These findings maybe explained by the LSS questionnaires focus on tasksthat require ambulation. In addition, individuals with

education beyond high school reported less LSS symp-tom severity and greater function on the LSS question-naire, suggesting a potential socioeconomic or psycho-social influence. These findings illustrate theimportance of examining a patient globally; an individ-uals symptom severity and functional status may beinfluenced equally by comorbid musculoskeletal condi-tions and psychosocial factors.

The frequency of positive PE findings in this cohort wasexpected and supports the notion that tests of facet andforaminal compression are more symptom provoking

than tests of neural tension and hip or sacroiliac pathol-ogy in patients with degenerative LBP. The quadranttest, active extension, and lateral flexion all compromisethe foraminal opening and central canal.31,46,47 In con-trast, lumbar flexion enlarges the foraminal space andcentral canal.46,47 Because the pathoanatomy of degen-erative spinal conditions typically narrows the forameneither centrally or laterally,48 PE measures that furtherlessen the foramen (ie, quadrant test) are expected to bemore provocative than tests that enlarge the foraminalspace (ie, lumbar flexion). In addition to lumbar flexionwidening the foraminal space, decreased load is borne

Table 5.Mean Self-Reported Lumbar Spinal Stenosis Symptom Severity and Function Scores inPatients Who Reported Symptoms Proximal or Distal to the Knee With Sustained Extension(n74)

Self-ReportMeasure

Mean Score After 30 s of SustainedExtension

P

No Pain Reported

Distal to the Knee(n52)

Pain Reported

Distal to the Knee(n22)

LSS symptom severity 2.55 2.96 .04LSS physical function 1.91 2.18 .08SF-36a bodily pain 44.5 41.7 .60SF-36 physical function 60.0 46.0 .02

a SF-36Medical Outcomes Study 36-Item Short-Form Health Survey.



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Table 6.Lumbar Spinal Stenosis Symptom Severity Score Group Means for Positive and Negative Physical Examination (PE) Measures

Variable

LSS Symptom Severity Score

t P

Positive PE Measure Negative PE Measure

X SD X SD

Quadrant test 2.84 0.67 2.26 0.67

3.06 .003

a

(n42) (n18)

Pain with lateral flexion 2.89 0.73 2.42 0.60 2.96 .004a

(n34) (n40)

Pain with lumbar flexion 2.80 0.68 2.63 0.72 0.87 .39(n18) (n56)

Straight-leg-raising test 3.04 0.66 2.60 0.70 2.03 .046(n12) (n62)

Lasegue test 2.94 0.72 2.63 0.70 1.33 .188(n11) (n63)

Hip medial rotation 3.06 0.68 2.63 0.68 2.16 .03(n15) (n53)

Faber test for hip pain 2.94 0.81 2.58 0.64 1.99 .05

(n21) (n50)

Trochanteric tenderness 3.09 0.62 2.58 0.70 2.41 .019(n13) (n60)

Lower-extremity weakness 2.89 0.73 2.36 0.51 3.20 .001a

(n44) (n25)

a Significant at P.001.

Table 7.Lumbar Spinal Stenosis Physical Function Score Group Means for Positive and Negative Physical Examination (PE) Measures

Variable

LSS Physical Function Score

t PPositive PE Measure Negative PE Measure X SD X SD

Quadrant test 2.07 0.67 1.81 0.41 1.53 .13(n42) (n18)

Pain with lateral flexion 2.11 0.67 1.85 0.5 1.89 .06(n40) (n34)

Pain with lumbar flexion 2.06 0.59 1.97 0.61 0.53 .59(n18) (n56)

Straight-leg-raising test 2.13 0.52 1.96 0.62 0.90 .37(n12) (n62)

Lasegue test 2.11 0.44 1.97 0.44 0.71 .48(n11) (n63)

Hip medial rotation 2.41 0.61 1.91 0.58 2.96 .004a

(n15) (n52)

Faber test for hip pain 2.04 0.59 1.99 0.62 0.37 .71(n21) (n50)

Trochanteric tenderness 2.25 0.59 1.92 0.59 1.82 .07(n13) (n60)

Lower-extremity weakness 2.08 0.65 1.82 0.54 1.76 .08(n44) (n25)





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Table 8.Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) Bodily Pain Subscale Score Group Means for Positive and Negative PhysicalExamination (PE) Measures

Variable

SF-36 Bodily Pain Subscale Score

t P


X SD X SD

Quadrant test 40.4 21 51.6 20 1.87 .067(n42) (n18)

Pain with lateral flexion 39.8 20 48.2 21 1.77 .08(n40) (n34)

Pain with lumbar flexion 38.1 13 45.5 22 1.33 .08(n18) (n56)

Straight-leg-raising test 35.5 16.2 45.2 21 1.50 .14(n12) (n62)

Lasegue test 37.9 18.5 44.7 21 1.00 .32(n11) (n63)

Hip medial rotation 32.1 12.2 45.0 21.5 2.99 .004a

(n15) (n53)

Faber test for hip pain 34.2 19.7 46.5 19.5 2.41 .02(n21) (n50)

Trochanteric tenderness 37.7 15 45.2 21 1.17 .24(n13) (n60)

Lower-extremity weakness 38.9 20.1 53.6 20.5 2.91 .005a

(n44) (n25)


Table 9.Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) Physical Function Subscale Score Group Means for Positive and NegativePhysical Examination (PE) Measures

Variable

SF-36 Physical Function Subscale Score

t P


X SD X SD

Quadrant test 52 27 63.5 18 1.67 .10(n42) (n18)

Pain with lateral flexion 50.9 27 61.7 20 1.92 .059(n40) (n34)

Pain with lumbar flexion 46.5 25 58.8 24 1.88 .06(n18) (n56)

Straight-leg-raising test 45.2 26 57.9 24 1.66 .101(n12) (n62)

Lasegue test 50.2 26 56.8 24 0.82 .41(n11) (n63)

Hip medial rotation 34.8 22 60.2 23 3.84 .0003a

(n15) (n53)

Faber test for hip pain 49.3 27 58.4 23 1.43 .16(n21) (n50)

Trochanteric tenderness 45.2 25 58.8 24 1.85 .068(n13) (n60)

Lower-extremity weakness 51.0 26 64.3 22 2.19 .03(n44) (n25)




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by the posterior elements, namely the facet joints, whichare highly innervated and are a potential source ofsymptoms. Symptoms reported with movement alsocould represent a diskogenic etiology4951 and may

explain why some individuals reported discomfort withactive lumbar flexion. The straight-leg-raising test andthe Lasegue test place tension on the sciatic nerve31 andare not typically positive in degenerative spinal condi-tions.34,52 Impairments suggestive of neural compression(ie, abnormal reflexes, pinprick, vibration, and weak-ness) have been reported in this population,30,34,48,52 andour data revealed similar findings. Signs of neural com-pression cannot be attributed solely to pathology of thelumbar spine, however, because sensory and force defi-cits are generally more prevalent in elderly people.53

Self-report measures such as the LSS and SF-36 question-naires are useful adjuncts to clinical practice and may bemore responsive than commonly used physical examina-tion procedures to detect clinical improvement in peo-ple with LBP.54 Because of the currently limited use ofself-report measures in clinical practice (secondary totime, coding, and so on),11 the use of PE procedures toreflect symptom severity and function might be moreeasily incorporated into daily practice. Physical examina-tion procedures are widely used to discriminate betweendiagnoses.

Understanding the relationship of PE procedures andself-reported severity and function has the potential toimprove clinical decision making. The results of ourstudy illustrate that PE procedures may be useful todiscriminate among different levels of severity within agroup of people over 55 years of age with CLBP due todegenerative changes. For example, a positive quadranttest was associated with clinically meaningful increasedsymptom severity. In addition, individuals with moredistal symptoms had greater average LSS and SF-36function scores (Tab. 5). These results are consistentwith those of Loisel et al,55 who found that people withdistal radiating pain were more likely to have decreased

Figure 1.Relative contribution of physical examination measures to Lumbar SpinalStenosis questionnaire symptom severity score. The pie chart representsthe variance (percentage) of the contributory variables. Other repre-sents the variance that was unaccounted for.

Figure 2.Relative contribution of physical examination measures to Lumbar SpinalStenosis questionnaire physical function score. The pie chart represents

the variance (percentage) of the contributory variables. Other repre-sents the variance that was unaccounted for.

Figure 3.Relative contribution of physical examination measures to MedicalOutcomes Study 36-Item Short-Form Health Survey (SF-36) bodily painsubscale score. The pie chart represents the variance (percentage) of thecontributory variables. Other represents the variance that wasunaccounted for.

Figure 4.Relative contribution of physical examination measures to MedicalOutcomes Study 36-Item Short-Form Health Survey (SF-36) physicalfunction subscale score. The pie chart represents the variance (percent-age) of the contributory variables. Other represents the variance thatwas unaccounted for.




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functional status and increased pain level and were lesslikely to return to work at 1-year follow-up. We believethat identifying people with clinically meaningfulsymptom severity and function may indicate a worseprognosis.

Limitations

The study has several limitations. We attempted toassemble a homogeneous cohort of subjects based onphysicians clinical impressions of disease status andsymptoms. We used radiographs on a subset of subjects(70%), when available, to confirm the physicians clini-cal impressions. However, radiographs were not avail-able on all subjects, so the potential exists for misclassi-fication. Our sample was recruited from a large tertiarycare institution and, therefore, may have more severepain impairments compared with patients from otherfacilities, potentially limiting the generalizability of thestudy results. Nonetheless, the SF-36 scores in our sam-ple do not exceed normative data on a comparable

sample with similar comorbidities and age.23 The entrycriteria required that patients self-report pain with lum-bar extension. Therefore, the prevalence of pain withextension in this cohort is high by definition. Thedegree to which the sample may be generalized is notclear, because the prevalence of pain with extension in anonselected cohort of older patients with back pain isunknown. The LSS questionnaire contains general phys-ical function items that attribute functional performance(eg, walking) and symptoms (eg, tingling in legs) to backpain. Given that patients were selected based on reportof pain with walking or extension and the disease-

specific questionnaire measures symptoms with func-tional activities performed in standing, it is likely that wemay have found stronger relationships between certainPE tests and self-reported back function and symptoms.A fair proportion of patients who reported back painwith walking, however, did not have positive provocationtests. Finally, to be conservative, we used a Bonferronicorrection to adjust for multiple testing.

Using these stringent criteria, we had 84% power todetect clinically meaningful differences in LSS-specificscales and 60% power to detect clinically meaningful

differences in generic function (SF-36). Because a clini-cally meaningful difference for the LSS symptom severityscale and LSS function scale is 0.5 point22 and a clinicallymeaningful change for the SF-36 bodily pain and phys-ical function subscales is 10 points,23 some differences inself-reported outcomes exceeded our criteria for clini-cally meaningful change but did not meet the criteria weestablished for statistical significance in the study(P.005), indicating low power or that our alpha level was overly conservative. We suggest interpreting theseitems with caution. We provide the reader with effect

sizes and P values so that the reader can independentlyinterpret the weight of the evidence.

The study is strengthened by the use of well-validatedand reliable generic and condition-specific self-reportmeasures (the LSS and SF-36 questionnaires, respec-tively) and the use of strict inclusion criteria to gather a

relatively homogeneous sample with respect to symptompresentation. The examiner performing the PE mea-sures was unaware of the self-report data and diagnosis.Although we do not report on the reliability of the tester,an effort was made to thoroughly define the PE proce-dures and interpretation of each finding. We feel this isvery important and encourage clinicians to standardizetheir procedures and interpretation of positive findingsto facilitate communication and clarity.

ConclusionTo our knowledge, this is the first study comparingcondition-specific and generic measures of condition

severity and function with the PE findings in a sample ofolder adults with degenerative spinal conditions. In thisstudy, the associations between the impairment-basedmovement patterns and self-reported symptom severityare consistent with the pathoanatomy of degenerativespinal conditions. The quadrant test distinguished thosepatients with clinically meaningful symptom severity, asdid lateral flexion and lower-extremity weakness. Painwith hip medial rotation, trochanteric tenderness, andlevel of education were additional variables that influ-enced symptom severity and function. We feel that PEprocedures may be clinically useful in people with

chronic conditions when used in models that are predic-tive of symptom severity and function. The PE measuresused in this study were not discriminative of function,and future studies may benefit from including a clinicalmeasure that may better reflect the functiondomain.5661 Further investigation in this area is war-ranted to determine if these findings can be applied toguide intervention and prognosis.

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2005; 85:120-133.PHYS THER.Ziaei and Maura D IversenMark A Lyle, Sarah Manes, Michael McGuinness, SarahConditionsFunction in Patients With Degenerative LumbarSelf-Reported Symptom Severity and PhysicalRelationship of Physical Examination Findings and

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