Table 3 Evidence table for low risk of bias studies assessing the reliability of manual palpation tests in patients with low back pain

 Alyazedi et al. 2015 [19]

USA

Inter-rater reliability

(n = 40)

Recurrent LBP or chronic LBP (≥ 3 months), 21–71 yrs. old.

Prone instability test was done in two parts: 1) relaxation phase: the subject was lying prone on the examination table with feet on the floor. The examiner performed PA mobility testing to identify painful lumbar segments with the subject’s muscles relaxed. 2) co-contraction phase: the subjects then raises their feet off the floor. If pain identified in the relaxation phase subsides at the co-contraction phase the test is considered positive.

PA glide test: Subjects were lying prone and examiners performs PA glide on the lumbar spinous processes. Lack of segmental hypomobility, is considered a positive test.

Examiners: two physical therapists who were certified as Orthopaedic Clinical Specialists

Time between inter-rater assessments was at least 15 min

Inter-rater reliability

Prone instability test for pain (relaxation phase);

k (95% CI)

k = 0.41 (0.18, 0.63)

Prone instability test for pain (co-contraction phase);

k (95% CI)

k = 0.71 (0.45, 0.98)

PA glide test for hypomobility; k (95% CI)

k = − 0.02 (− 0.22, 0.18)

 Downey et al., 2003 [21]

Australia

Inter-rater reliability

(n = 60)

[n = 20/pair]

Non-specific LBP < 7 weeks duration, > 18 yrs. old.

Palpation for the spinal level contributing most to the patients’ LBP symptoms (abnormal end-feel, abnormal quality of resistance to motion, and reproduction of pain, local or referred); patient prone, posterior to anterior pressure applied to spinal process and verbal communication between examiner and patient about reproduction of pain.

Examiners: three pairs of manipulative physiotherapists with 7–15 yrs. experience and ≥ 3 yrs. experience after postgraduate qualifications in manipulative physiotherapy.

Time between inter-rater assessments unknown.

Inter-rater reliability

Palpation to locate the spinal level; k (95% CI):

Overall: k = 0.37 (0.20, 0.54)

Pair 1: k = 0.54 (0.26, 0.82)

Pair 2: k = 0.45 (0.18, 0.72)

Pair 3: k = 0.23 (0.00, 0.46)

Palpation to name the spinal level; k (95% CI lower band):

Overall: k = 0.09 (0.00, 0.18)

Pair 1: k = 0.41 (0.12, 0.70)

Pair 2: k = 0.10 (0.00, 0.20)

Pair 3: k = − 0.13 (0.00, 0.26)

 Hicks et al., 2003 [23]

USA

Inter-rater reliability

(n = 63)

[pair 1 n = 20, pair 2 n = 28, pair 3 n = 15]

Low back pain without radiation of pain past the knee, symptom duration unknown, 20 to 66 yrs. old.

Prone instability test: The subject lies prone on the examination table with their feet on the floor. The examiner performs passive intervertebral motion testing for pain. The subject then lifts their feet off the floor. A positive test is when pain provoked during the first part of the test disappears when the legs are lifted up.

Passive intervertebral motion testing: with the subject lying prone the examiner applied PA pressure with their hypothenar eminence on each lumbar spinous process. Segmental mobility is judged as normal mobility, hypomobility (more motion than normally expected) and hypermobility (less motion than normally expected). Pain provocation is judged as manual pressure producing pain or not producing pain.

Examiners were 4 physical therapists with a least 2 yrs. experience. Examiners were placed in 3 separate pairs.

Time between inter-rater assessments was at least 15 min

Inter-rater reliability

Prone instability test; k (95% CI):

k = 0.87 (0.80, 0.94)

Pair 1 (n = 20): k = 1.0 (1.0–1.0)

Pair 2 (n = 28): k = 0.81 (0.80–0.94)

Passive intervertebral motion tests; k (95% CI):

Segmental mobility (dichotomous):

Hypermobility k = 0.30 (0.13, 0.47)

Hypomobility k = 0.18 (0.05–0.32)

Segmental mobility (hypo/normal/hyper):

L1 k = 0.26 (− 0.01, 0.53)

L2 k = 0.17 (− 0.13, 0.47)

L3 k = − 0.02 (− 0.25, 0.28)

L4 k = 0.11 (− 0.26, 0.35)

L5 k = 0.18 (− 0.03, 0.49)

Pain provocation (positive/negative):

L1 k = 0.36 (0.12, 0.59)

L2 k = 0.45 (0.26, 0.63)

L3 k = 0.30 (0.12, 0.47)

L4 k = 0.25 (0.11, 0.40)

L5 k = 0.55 (0.43, 0.67)

Ravenna et al., 2011 [25]

USA

Inter-rater reliability

(n = 30)

Chronic and recurrent LBP, 18 to 60 yrs. Old.

Prone Instability Test: patient prone with legs over the edge and feet resting comfortably on the floor. The examiner palpates for pain. The patient then raises their legs off the floor and examiner palpates again for pain. A positive test is when pain provoked during the first part of the test disappears or decrease when the legs are lifted up.

Examiners were a second-year Doctor of Physical Therapy student and a licensed physical therapist with two years clinical experience.

Time between inter-rater assessments was 20 min.

Prone Instability Test; k (95% CI), PABAK (95% CI)

0.10 (− 0.27, 0.47), 0.27 (− 0.08, 0.61)

Schneider et al., 2008 [26]

USA

Inter-rater reliability (n = 39)

Low back pain, symptom duration unknown, 18–65 yrs. old.

Palpation for lumbar segmental mobility, pain provocation and prone instability: patient prone with 1) Prone mobility testing: posterior to anterior joint springing palpation by examiners of SIJs, all lumbar spinous processes and all lumbar facet joints bilaterally; normal or restricted mobility was noted;

2) prone pain provocation testing: patient notifies pain or discomfort provoked while repeating prone mobility test; 3) prone instability test: patient prone with legs over the edge and feet resting comfortably on the floor. The examiner palpates for pain. The patient then raises their legs off the floor and examiner palpates again for pain. A positive test is when pain provoked during the first part of the test disappears when the legs are lifted up.

Examiners: two doctors of chiropractic with 25 and 10 years of clinical experience.

All the examinations performed in one day.

Prone Mobility Testing; k (95%CI); PABAK

Left L4–5, and L5-S1 facet mobility: k = − 0.17 (− 0.41,.06); PABAK = 0.08

Right L4–5, and L5-S1 facet mobility: k = − 0.12 (− 0.41,0.18); PABAK = − 0.09

Spinous L4–5 and S1 mobility: k = − 0.05 (− 0.36,0.27); PABAK = 0.11

Left L1–4 facet mobility: k = 0.17 (− 0.14,0.48); PABAK = 0.44

Right L1–4 facet mobility: k = − 0.01 (− 0.33,0.30); PABAK = 0.44

Spinous L1–4 mobility: k = 0.02 (− 0.27,0.32) PABAK = 0.07

Sacroiliac mobility L: k = − 0.11 (− 0.21,-0.01); PABAK = 0.54

Sacroiliac mobility R: k = − 0.10 (− 0.18,-0.02); PABAK = 0.64

Prone Pain Provocation Testing; k (95%CI): PABAK

Left L4–5, and L5-S1 pain: k = 0.73 (0.51,0.95); PABAK = 0.74

Right L4–5, and L5-S1 pain: k = 0.52 (0.25,0.79); PABAK = 0.54

Spinous L4–5 and L5-S1 pain: k = 0.57 (0.32,0.83); PABAK = 0.58

Left L1–4 pain: k = 0.46 (0.17,0.75); PABAK = 0.48

Right L1–4 pain: k = 0.38 (0.06,0.69); PABAK = 0.54

Spinous L1–4 pain: k = 0.21 (− 0.10,0.53); PABAK = 0.34

Right Sacroiliac pain: k = 0.14 (− 0.19,0.47); PABAK = 0.38

Left Sacroiliac pain: k = 0.33 (0.0,0.66); PABAK = 0.54

Prone Instability Test; k (95%CI). PABAK

Test 1: k = 0.54 (0.27,0.81); PABAK = 0.58

Test 2: k = 0.46 (0.15,0.77); PABAK = 0.58

Weiner et al., 2006 [29]

USA

Inter-rater reliability (n = 30)

Chronic LBP, ≥3 months duration, ≥60 yrs. old.

Palpation of the SI joints and lumbar spinous processes to identify pain: 1) SI joints: patient standing on floor with shoes removed, examiner standing behind patient exerts firm pressure over sacroiliac joint, palpation of right joint with right thumb while standing to left side of patient; 2) lumbar spinous processes: examiner behind patient, firmly palpate spinous processes L1–L5 using dominant thumb

The examiners underwent training in the protocol with an expert physical therapists to refine and standardize the physical examination procedures

Time between intra-rater assessments < 5 min

SI palpation; k (95% CI not reported)

k = 0.59

Lumbar spinous palpation

k = 0.47

 Arab et al., 2009 [20]

Iran

Intra-rater and inter-rater reliability (n = 25)

LBP around posterior superior iliac spine and buttock, symptom duration unknown, 20–65 yrs. old.

Standing flexion test: The subject is standing and the examiner palpates the movement of PSIS as the subject bends forward.

Sitting flexion test: The subject is sitting and the examiner palpates the movement of PSIS as the subject bends forward.

Gillett test: The subject is standing with the examiner palpating the movement of PSIS as the subject raises that knee toward their chest.

Examiner: two physiotherapists with 1 year experience.

Time between intra-rater assessments: 15 min.

Inter-rater reliability; k (95% CI). PABAK

Standing flexion test

R- k = 0.51 (0.08–0.95); PABAK = 0.68

L- k = 0.55 (0.2–0.9); PABAK = 0.60

Sitting flexion test

R- k = 0.75 (0.42–1.08); PABAK = 0.84

L- k = 0.64 (0.32–0.96); PABAK = 0.68

Gillet test

R- k = 0.41 (0.03–0.87); PABAK = 0.60

L- k = 0.34 (− 0.06–0.7); PABAK = 0.44

Intra-rater reliability; k (95% CI). PABAK

Standing flexion test

Rater 1: R- k = 0.68 (0.35–1.01); PABAK = 0.76

Rater 1: L- k = 0.61 (0.27–0.96); PABAK = 0.68

Rater 2: R- k = 0.60 (0.18–1.02); PABAK = 0.76

Rater 2: L- k = 0.51 (0.08–0.95); PABAK = 0.68

Sitting flexion test

Rater 1: k = 0.73 (0.45–1.01); PABAK = 0.76

Rater 1: k = 0.65 (0.34–0.96); PABAK = 0.68

Rater 2: k = 0.65 (0.29–1.02); PABAK = 0.76

Rater 2: k = 0.56 (0.21–0.90); PABAK = 0.60

Gillett test

Rater 1: k = 0.42 (− 0.01–0.87); PABAK = 0.60

Rater 1: k = 0.49 (0.09–0.89); PABAK = 0.60

Rater 2: k = 0.25 (− 0.20–0.77); PABAK = 0.52

Rater 2: k = 0.23 (− 0.02–0.67); PABAK = 0.36

Tong et al., 2006 [27]

USA

Inter-rater reliability (n = 24)

LBP, symptom duration unknown, 32 to 81 yrs. old.

Seated flexion test: the evaluator palpates the cephalad movement at PSISs. As the subject bends forward, the evaluator’s thumbs follow the motion of the PSIS cephalad

Standing stork test: the evaluator’s thumb palpates the unilateral movement of left PSIS, and the other thumb palpates the midline of the sacrum. The subject then flexes the left hip and knee to a minimum of 90 degrees. The same is repeated on the right PSIS with the subject flexing the right hip.

Standing flexion test: the evaluator palpates the movement of unilateral PSIS. As the subject bends forward to touch the floor, the evaluator’s thumbs follow the PSIS cephalad. The test is repeated on each side.

Sacral base position: the subject is sitting, the evaluator palpates the sacral base with the subject’s trunk forward flexed and backward flexed. A positive test is when one side of the sacrum is more anterior or posterior when compared to the other side of the sacrum on the spine motions.

Examiners: four physicians.

Time between inter-rater assessments unknown.

k (95% CI not reported); p value

Seated flexion test: k = 0.06; p = 0.68

Standing stork test: k = 0.27; p = 0.07

Standing flexion test: k = 0.14; p = 0.37

Sacral base position: flexion k = 0.37; p = 0.002

extension k = 0.05; p = 0.74

 Hebert et al., 2015 [22]

USA

Inter-rater reliability

(n = 32)

Low back pain with ≥20/100 on modified ODI, median duration of symptoms = 205 days, 18 to 60 yrs. old.

Multifidus lift test: to identify lumbar multifidus contraction; participants prone and contralateral arm lifted with/without a hand weight while multifidus muscle palpated immediately lateral and adjacent to the interspinous space of  L4–L5 and L5–S1.

Examiners: > 10 yrs. clinical experience and approximately 5 yrs. research experience.

Time between intra-rater assessments unknown.

Inter-rater reliability; k (95% CI)

L4–L5 no weight: k = 0.75 (0.52,0.97)

L4–L5 weight: k = .0.79 (0.57, 1.00)

L5-S1 no weight: k = 0.81 (0.62, 1.00)

L5-S1 weight: k = 0.80 (0.59, 1.00)

 Jensen et al., 2013 [24]

Denmark

Intrarater and inter-rater reliability (n = 43)

LBP with or without radiculopathy, variable duration of symptoms, 16–60 yrs. old.

Palpation of gluteal tender points: patient seated, tender points tested from right to left with 4 kg digital pressure on upper outer quadrants of buttocks.

Examiners: two consultants in rheumatology and rehabilitation.

20 min between inter-rater assessments and 7 days between intra-rater assessments.

Intra-rater reliability (95% CI not reported)

Rater A: R k = 0.78; L k = 0.69

Rater B: R k = 0.79; L k = 059.

Inter-rater reliability

Day 1: R k = 0.68; L k = 0.53

Day 2: R k = 0.51; L k = 0.50

 Walsh et al., 2009 [28]

Ireland

Inter-rater reliability (n = 45)

Unilateral low-back related leg pain, mean duration of symptoms = 5.6 months, 18–70 yrs. old.

Palpation of sciatic nerve: With the patient lying prone they are asked if there is any pain or discomfort when the examiner applies gentle pressure at the sciatic nerve bilaterally at the midway point of a line from ischial tuberosity to the greater trochanter of the femur.

Examiner: two physiotherapists (eleven yrs. experience with a Masters in Manipulative Therapy and three months clinical experience, respectively).

Inter-rater reliability sciatic palpation: k (95% CI)

k = 0.80 (0.39–0.94)

 Weiner et al., 2006 [29]

USA

Inter-rater reliability (n = 30)

Chronic LBP, ≥3 months duration, ≥60 yrs. old.

Palpation of the lumbar paraspinal muscles, and piriformis muscles to identify pain:; 1) paralumbar muscles: patient standing on floor with shoes removed, examiner stands behind to left side of patient and braces patient in front with left arm; palpate full extent of right paravertebral musculature with right thumb. Exert approximately 4 kgf. Repeated on the other side

2) piriformis: patient supine flexes right hip and knee, keeping sole of foot on table. Cross bent leg over opposite leg and again place sole on table and exert mild medially directed pressure on lateral aspect of knee to put piriformis in stretch. Exert firm pressure (4 kg) over middle extent of piriformis. Repeated on the other side.

The examiners underwent training in the protocol with an expert physical therapists to refine and standardize the physical examination procedures

Time between intra-rater assessments < 5 min

Lumbar paraspinal palpation k (95% CI not reported)

k = 0.34

Piriformis palpation

k = 0.66