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The validity of manual examination in assessing patients with neck pain

PainSci » bibliography » King et al 2007
Tags: diagnosis, neck, manual therapy, head/neck, spine, treatment

PainSci notes on King 2007:

King et al were very critical of the reliability of tests for the source of neck pain. “Manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination,” they wrote. They compared physiotherapist diagnoses of 173 people to much more reliable testing done by “blocking” — anesthetizing — the joint. What they found was that physical therapists were good at identifying facet joints that really were hurting — which is great, good for them — but they were also rather prone to diagnosing facet joint pain even when there was none. In other words, they were over-diagnosing, telling practically everyone that they had facet joint pain, which was correct in some cases, but wrong in many others.

The authors concluded that manual examination for facet joint pain “lacks validity.” Ouch.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

BACKGROUND CONTEXT: Although manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination, that conviction is based on only one study. That study claimed that manual examination of the neck had 100% sensitivity and 100% specificity for diagnosing painful zygapophyseal joints. However, the study indicated that its results should be reproduced before they could be generalized.

PURPOSE: The present study was undertaken to answer the call for replication studies. The objective was to determine the sensitivity, specificity, and likelihood ratio of manual examination for the diagnosis of cervical zygapophyseal joint pain.

STUDY DESIGN: The study was conducted in a private practice located in a rural town. The practice specialized in musculoskeletal pain problems.

PATIENT SAMPLE: The study sample was 173 patients with neck pain in whom cervical zygapophyseal joint pain was suspected on clinical examination, and who were willing to undergo controlled diagnostic blocks of the suspected joint or joints.

OUTCOME MEASURES: The validity of manual diagnosis was determined by calculating its sensitivity, specificity, and positive likelihood ratio.

METHODS: Patients who exhibited the putatively diagnostic physical signs of cervical zygapophyseal joint pain were referred to a radiologist who performed controlled, diagnostic blocks of the suspected joint, and other joints if indicated. The results of the blocks constituted the criterion standard, against which the clinical diagnosis was compared, by creating contingency tables.

RESULTS: Manual examination had a high sensitivity for cervical zygapophyseal joint pain, at the segmental levels commonly symptomatic, but its specificity was poor. Likelihood ratios barely greater than 1.0 indicated that manual examination lacked validity. Although the results obtained were less favorable than those of the previous study, paradoxically they were statistically not different.

CONCLUSIONS: The present study found manual examination of the cervical spine to lack validity for the diagnosis of cervical zygapophyseal joint pain. It refutes the conclusion of the one previous study. The paradoxical lack of statistical difference between the two studies is accounted for by the small sample size of the previous study.

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