ReviewMeasurement of range of movement in the lumbar spine—what methods are valid? A systematic review
Introduction
The diagnosis of low back pain remains controversial and uncertain [1]. The terms non-specific or mechanical low back pain have been commonly used for over a decade, describing a heterogeneous population of patients without specific pathology [2], [3]. Clinicians involved in the management of low back pain utilise physical examination to inform management and treatment. The physical examination of patients with low back pain consists of many components [4]. Range of movement is a key component of most physical examination processes [5] facilitating the assessment of spinal function, response to therapeutic input [6], determining work restrictions, functional capacity or even permanent impairment [7].
Various methods of quantification of range of movement have been advocated [8], [9]. These measures vary in complexity and include observation, tape measurement, goniometry (electrical, electromagnetic and mechanical), inclinometry (electrical and mechanical), flexible curve lineals and roentgenographic analysis [6], [8], [10], [11], [12], [13].
Roentgenographic or radiographic analysis is the recognised ‘gold standard’ for determining range of movement, but this is an expensive procedure with risk of exposure to radiation [8], [14]. Thus the costs and risks associated with roentgenographic analysis prevent its use in routine clinical practice. The preference is for quick, simple, inexpensive and minimally invasive diagnostic tests [15]. ‘Low-tech’ methods are favoured in routine clinical practice; for example, observation, tape measurement, mechanical goniometry, mechanical inclinometry and flexible curve lineals.
An electronic search of AMED (1985–2006), CINAHL (1982–2006), Embase (1974–2006), OVID Medline (1966–2006) and The Cochrane Database of Systematic Reviews failed to identify any systematic reviews that evaluated the validity of procedures used to determine the range of movement of the lumbar spine. There is a need to identify valid tests used during clinical examination [16] and thus there is a need for such a systematic review.
The objective of this systematic review is to examine whether low-tech procedures used in routine clinical practice to determine the range of movement of the lumbar spine are of acceptable validity in comparison to the ‘gold’ standard of measurement.
Section snippets
Criteria for considering studies for the review
Table 1 lists the selection criteria, and further details are provided below.
Types of studies
For practical reasons, this review considers only English language studies that are designed to evaluate the validity of low-tech procedures used to determine the range of movement of the lumbar spine.
Types of participants
Studies that involved adult human subjects (>18 years) with non-specific low back pain were included. Low back pain is defined as pain localised below the lowest ribs and above the inferior gluteal folds [17].
Results
Following preliminary analysis via assessment of study titles, keywords and abstracts, a total of 86 studies were identified for full text analysis; 82 studies were excluded (Fig. 1). Reasons for exclusion were as follows: not in English language (1); incorrect study type—most commonly did not evaluate validity and measurement or were only descriptive in nature (48); not adult low back pain population (26); utilised high-tech procedures or failed to include gold/reference standard comparison
Discussion
Range of movement is commonly measured during routine clinical practice to assess spinal function and degree of impairment, as well as determining the response to therapeutic input. A range of low-tech procedures are used. Despite this, there is a lack of scientific evidence confirming the validity of these procedures against radiographic ‘gold standard’ measurements.
Despite identification of a wide range of potential studies, only four studies were included in this systematic review. A
Limitations
This review considered only English language studies, introducing the possibility of language bias. Although this limitation is common in systematic reviews it should be considered when interpreting the results. However, it should be noted that only one non-English language study was identified during the process and thus this limitation may only be minor. The second limitation of only one author selecting studies introduces the possibility of further selection bias. Again it is felt that this
Conclusions
In this systematic review, it was found that there is limited evidence that the DI method for measuring total lumbar range of movement is valid in comparison to the gold standard. This conclusion is drawn from only one relevant study of low methodological quality and so convincing conclusions cannot be made. There is conflicting evidence when considering the DI method for measuring lumbar flexion range of movement. There is limited evidence that the DI method for measuring lumbar extension
Acknowledgement
Conflict of interest: None.
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