How to evaluate physical performance tests based on their reliability, validity, and practicality.
How to administer quantifiable tests of physical impairment that relate to spinal disorders.
previously supposed.34 The use of the “nonspecific” label has been interpreted to mean that the majority of patients are a homogeneous group who share a uniform clinical picture and prognosis. However, what it more likely indicates is that we are not very good at subclassifying a heterogeneous group into discrete groups requiring individualized care.35,36 Current attempts at providing better care for LBP patients have emphasized improving our ability to diagnose or classify patients into meaningful subgroups (see Chapter 9).37,38,39,40,41,42,43,44,45,46,47
Table 10.1 Key Features of Functional/Performance Tests Utility
is the automatic leap to psychology. It assumes that all organic factors have been considered, when in reality the clinician’s appreciation of the complexity of such factors is often severely limited.”56 Newton and Waddell said, “There is no convincing evidence that isokinetic or any other iso-measure has greater clinical utility in the patient with low back pain than either clinical evaluation of physical impairment, isometric strength, simple isoinertial lifting or psychophysical testing.”51
Fritz and George reported that a Physical Impairment Index performed on acute patients (<3 weeks duration) was predictive of outcome 4 weeks later.38
The tests were found to be reliable and responsive to change (although less responsive than the Oswestry Disability Index)
Flexion range of motion (ROM; single inclinometer at T12/L1)
Extension ROM (single inclinometer at T12/L1)
Lateral flexion ROM (average of each side—single inclinometer at T9-T12)
Straight leg raise (SLR) ROM (average of each side—inclinometer at superior tibial crest with the knee held in extension)
Spinal tenderness (any superficial or deep tenderness is noted)
Bilateral active SLR (raised 6 inches up and held for 5 seconds)
Active sit-up (knees flexed 90 degrees and feet held flat by the examiner. Patient sits up until fingers touch the knees and holds for 5 seconds)
Enthoven et al reported that functional tests are not predictive of 12-month outcome if performed in the early acute phase.129
However, if performed at the 4-week mark they are significant predictors of future pain and disability.
The best predictors were thoracolumbar ROM, isometric trunk extensor endurance, and finger tip to floor distance.
Plateau of treatment progress
Discrepancy between subjective and objective findings
Difficulty in returning the patient to gainful employment
Vocational planning or medical-legal case settlement
Standardized inclinometer placement and make sure the pendulum of the gravity type swings freely
Stiffening up the examination table (plywood with Velcro bands)
Table 10.2 Mobility Tests
Ankle dorsiflexion mobility/gastrocnemius and soleus length
Knee flexion mobility/quadriceps length (Nachlas test)
Hip flexion mobility/hamstring length (Straight leg raise test)
Hip extension mobility (modified Thomas test/psoas-rectus femoris length)
Hip rotation mobility (internal and external)
Lumbar spine mobility
Cervical spine mobility
Identify bony anatomical landmarks (mark on skin)
The examination bench height was standardized for each visit
Patient stands upright, feet parallel, and knees straight
The electronic inclinometer is positioned above the lateral malleolus and “zeroed” in
upright standing position, or a mechanical inclinometer is “zeroed” just below the tibial tuberosity.
The patient leans forward, placing the hands on a wall.
The tested leg is moved backward until a lunge position is assumed and the heel begins to lift from the floor; the front knee will be in a flexed position.
The subject pushes the heel down or slides slightly forward until the heel is flat on the floor; when maximum ankle dorsiflexion is achieved, the angle is recorded.
The normative data reveals 22.5 degrees
Intra-assay CV 2.2%
Patient stands upright, feet parallel, and knees straight
The knee is flexed and the ankle is dorsiflexed to a maximum angle maintaining heel-to-floor contact.
Alternatively, the patient may stand on the nontested leg and place the tested foot on a bench and the ankle is dorsiflexed to a maximum angle maintaining heel-to-bench contact.
The inclinometer position is the same as the first test (see Fig. 10.1).
The normative data reveals 24.9 degrees. (Note: please refer to the following section regarding updated procedure and normative data figures.)
Intra-assay CV 2.2%
to determine the reliability of the methods as well as offered new normative data for each method.109,110 This study used a weight-bearing modified lunge test where the knee is flexed, thus eliminating the gastrocnemius and thereby assessing primarily the soleus muscle. The three methods included the use of a standard goniometer, a digital inclinometer versus a tape measure using the distance-to-wall method. Here, the barefooted subject faces a wall while maintaining balance by placing two fingers of each hand on the wall. The great toe is initially placed 10 cm away from the wall with the knee flexed and lined up with the second toe in a weight-bearing lunge position. The evaluator moves the testing foot either closer to or farther from the wall depending on when the heel rises up off the floor. The measurement is taken when the knee just touches the wall and heel simultaneously stays down on the ground at the maximum angle of ankle dorsiflexion.
tension of the quadriceps femoris muscle and/or the articulation of the knee joint (Fig. 10.3).
The patient is prone on table.
The inclinometer is positioned at the posterior aspect of the mid-calf and zeroed (alternate position is on anterior shin after being zeroed to bottom of table or desk)
The pelvis is stabilized.
Patient’s knee is passively flexed (approximate heel to buttock).
The angle is measured at point just before lumbar spine begins to extend or hip raises up.
The normal angle equals 147.9 degrees
SD of 1.6
Intra-assay CV (%) 0.5%
The patient lies supine on a firm table and the inclinometer is placed just superior to the patellae (or alternatively on mid-tibia or strapped to lower leg with Velcro) and then zeroed.
The patient’s calf is placed in the crook of the doctor’s elbow or rests in the doctor’s hand.
The patient’s hip is flexed without permitting any knee flexion to occur.
The angle is recorded just before pelvic movement or knee flexion.
Normal ROM is 70 to 90 degrees (use 80 degrees as the mean for patient comparison).
The patient perches at the end of bench in a manner where the ischial tuberosities are supported on the end of the table’s edge.
The knee and hip are flexed and the knee is drawn up tight to the chest to eliminate lumbar lordosis and the patient is lowered to a supine position maintaining the knee-to-chest position.
The inclinometer is zeroed to the horizontal of the table top.
The leg being tested is allowed to extend toward the floor and hang freely fully relaxed.
The knee should be brought to the chest to fully remove the slack and flatten the lumbar lordosis firmly to the table.
Place the inclinometer on the anterior thigh just below the anterior superior iliac spine (ASIS). Record the angle when tested leg is fully relaxed, hip extended, and the lumbar lordosis is removed.
The normative data is 6.5 degrees
Intra-assay CV 0.7%
Interassay CV 1.2%113
Patient lies supine with the knees straight on the bench
Place the inclinometer 5 cm above the patella on the lateral thigh and set to zero.
The leg being tested is passively flexed to 90 degrees using the initial inclinometer 0 degrees reading and the inclinometer reset to zero.
The rest of the test is the same as the last three steps described previously.
The normative data is 83.5 degrees
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