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Table 4 Evidence table for low risk of bias studies assessing the validity of manual palpation tests in patient with low back pain

From: Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review

Authors

Year

Country

Designa

Sample size (n)

Population

Index test

Gold/Reference Standard

Validity

Static Joint Palpation (n = 182)

 Koppenhaver et al., 2014 [31]

USA

Phase II

(n = 51)

LBP with modified ODI ≥20/100, median duration of symptoms = 184 days, 18–60 yrs. old.

Palpation of spinal stiffness: the spinous processes of

L1-L5 palpated with the subject lying prone. The participant was asked to relax as a posterior to anterior (PA) force was applied.

Examiner: 1 clinician with 8 yrs. experience

Spinal stiffness was quantified using a mechanized indentation device.

Criterion validity (95%CI)

Spec: 0.45 (0.28–0.62)

Sens: 0.38 (0.21–0.59)

+LR: 0.69 (0.37–1.31)

-LR: 1.38 (0.82–2.33)

 Weiner et al., 2006 [29]

USA

Phase I

(n = 131)

Chronic LBP, mean symptom duration = 158.4 months, ≥60 yrs. old. (n = 111)

Healthy controls: pain-free individuals (n = 20)

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, repeated on the other side; 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 therapist to refine and standardize the physical examination procedures.

N/A

Difference between groups: Positive palpation n(%), (p value)

SI palpation

70 (59), p < 0.001

Lumbar spinous palpation

59 (53.2), p < 0.001

Motion Joint Palpation (n = 50)

 Soleimanifar et al., 2017 [32]

Iran

Phase II

(n = 50)

Lumbopelvic pain of unspecified duration,20–65 yrs. old.

Gillet test: the subjects stands while the examiner sits behind the patient and palpates each of the patient’s PSIS, one at a time, with one thumb on the inferior aspect of the PSIS while palpating the sacrum with the other thumb. The subject stands on one leg while pulling the opposite leg up toward the chest. A positive test is if the PSIS on the side of the knee flexion does not move or moves posterior-inferiorly only minimally or even paradoxically moves superiorly

Standing flexion test: the subject stands while the examiner sits behind the patient and palpates both of the patient’s |PSIS on their inferior margins. The subject bends forward. A positive result in a standing flexion test indicates limited movement of the ilium on the sacrum.

Sitting flexion test: the subject sits while the examiner sits behind the patient and palpates both of the patient’s |PSIS on their inferior margins. The subject bends forward. A positive result indicates limited movement of the sacrum on the ilium.

Examiner: one physical Therapist

Thigh thrust test: with the subject lying supine the examiner flexes the hip joint to 90 degree of flexion and slight adduction with the knee flexed. The examiner with one hand cups the

sacrum and wraps the other arm and hand around the flexed knee applying axial pressure. A test is positive when pain is provoked over the posterior aspect of the symptomatic SI joint.

Faber test: The patient lies supine on the table. The examiner brings the ipsilateral hip into flexion, abduction and external rotation. The foot is rested on unaffected knee. A positive test is when buttock or groin pain below L5 is reproduced

Resisted abduction test: The subject supine with the leg fully extended as well as being abducted to 30°. The examiner holds the ankle and pushes medially while the subject pushes laterally. The test is positive when familiar pain is produced over the SIJ below L5.

Gillet Test: No validity statistics reported

Standing flexion test: No validity statistics reported

Sitting flexion test: No validity statistics reported

Static Soft Tissue Palpation (n = 545)

 Adelmanesh et al., 2016 [30]

Canada

Phase III

(n = 337)

LBP with or without radiculopathy of any duration, > 18 yrs. old.

Palpation of the superior-lateral quadrant of the gluteal muscle to identify GTrP representing the combination of tenderness, taut band and pain: With the patient prone the gluteal muscle was compressed with a flat thumb or index finger against the underlying tissue or bone.

Examiner: 1 physician with 7 yrs. experience.

Multidisciplinary panel of experts based on examination of clinical evaluations, MRI, and if needed, electrodiagnostic testing.

Examiner: 1) clinical evaluation by 1 clinician with 12 yrs. experience; 2) MRI by 1 experienced neuroradiologist and 1 physiatrist; 3) electrodiagnostic testing by a physiatrist with 15 yrs. experience.

Spec (95% CI):

91.4% (86.8–96)

Sens (95% CI):

74.1% (67.7–80.3)

+LR 8.62

-LR 0.28

PPV (95% CI): 91.9% (87.6–96.3)

NPV (95% CI): 72.7% (66.1–79.3)

ROC curve (95% CI): 0.827 (0.781–0.874)

 Hebert et al., 2015 [22]

USA

Phase II

(n = 32)

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

Multifidis 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.

Examiner: 2 examiners with > 10 yrs. clinical experience and approximately 5 yrs. research experience.

Lumbar multifidus muscle thickness measures at the L4–L5 and L5–S1 spinal levels, at rest and submaximal contraction during contralateral arm lift using brightness-mode real-time ultrasound imaging.

Examiner: 1 clinician with 5 years ultrasound experience.

Changes in lumbar multifidus thickness at L4-L5 (r biserial correlation coefficient); p value.

Examiner 1

L4–L5 no weight r 0.59; p = 0.010

L4–L5 weight r 0.71; p = 0.003

L5–S1 no weight r 0.73; p = 0.002

L5–S1 weight r 0.62; p = 0.008

Examiner 2

L4–L5 no weight r 0.71; p = 0.002

L4–L5 weight r 0.69; p = 0.005

L5–S1 no weight r 0.69; p = 0.003

L5–S1 weight r 0.63; p = 0.009

Changes in lumbar multifidus thickness at L5-S1 (r biserial correlation coefficient); p value.

Examiner 1

L4–L5 no weight r 0.29; p = 0.201

L4–L5 weight r 0.44; p = 0.063

L5–S1 no weight r 0.47; p = 0.040

L5–S1 weight r 0.39; p = 0.097

Examiner 2

L4–L5 no weight r 0.45; p = 0.053

L4–L5 weight r 0.24; p = 0.0341

L5–S1 no weight r 0.44; p = 0.056

L5–S1 weight r 0.17; p = 0.472

 Walsh et al., 2009 [28]

Ireland

Phase II

(n = 45)

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

Palpation of sciatic nerve: patient prone lying is asked for any pain or discomfort when 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).

Straight leg raise (SLR) and slump tests conducted by one physiotherapist with one year experience.

Criterion Validity (reference tests: SLR and slump tests) (95% CI)

Spec 0.60 (0.46–0.74)

Sens 0.85 (0.75–0.95)

PPV 0.63 (0.49–0.77)

NPV 0.83 (0.72–0.94)

+LR 2.25

-LR 0.25

 Weiner et al., 2006 [29]

USA

Phase I

(n = 131)

Chronic LBP, mean symptom duration = 158.4 months, ≥60 yrs. old. (n = 111)

Healthy controls: pain-free individuals (n = 20)

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: 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,

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

N/A

Difference between groups: Positive palpation n(%), p value

Lumbar paraspinal palpation

60(50), p < 0.001

Piriformis palpation

57(51.4), p < 0.001

  1. GTrP Gluteal trigger point, LBP Low back pain, +LR Positive likelihood ration, −LR Negative likelihood ration, N/A Not Applicable, NPV Negative predictive value, ODI Oswestry Disability Index, PPT Pressure pain threshold, PPV Positive predictive value, Sens Sensitivity, SI Sacroiliac, Spec Specificity, yrs. years
  2. a: Design refers to Phase I-IV questions as described by Sackett & Haynes (2002). 2002;324(7336):539–41