A New Approach to the Low-Back Physical Examination

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Abstract
A rationale for a new approach to the low-back physical examination was developed. A set of 21 tests, 17 assessing organic and four assessing nonorganic signs, were organized into an examination according to specified criteria, and the reliability of the patient-reported an examiner-observed measures within the examination assessed. Primary outcome measures included patient reports of their pain location, aggravation and examiner-observed pain behaviors resulting from the maneuvers. Two pain behavior composites, conceptualized as outcome measures, were developed, one based on the 17 organic tests and one based on the four nonorganic tests. Design: The reliability of the physical examination was assessed using a short-term test-retest paradigm. Three raters, two experienced orthopaedic surgeons and an RN with no previous experience in administering physical examinations were trained in the examination methods. Patients were assigned to one of three rater pairs and examined twice within a single day. During each examination both raters evaluated each patient; however, rater role as examiner or observer was reversed across examination. Results: Forty-two patients were examined. Average times of 13.9 and 11.6 minutes were required to complete examinations 1 and 2, respectively. In addition, the time required to complete the examination decreased as the examiners became more familiar with the procedure, suggesting that an experienced examiner would usually be able to complete the examination in approximately 10 minutes. Within-examination reliabilities for the patient-reported measures (pain location and aggravation) were universally high, as expected, since these ratings required the rater only to correctly hear and code patients responses. Reliabilities for the rater-observed reliabilities (range of motion, degrees raised, most tender area, and pain behaviors) also were considered quite good. Consistency in evaluation was observed in physican-physican and physician-nurse rater pairings, even though the clinical nurse was previously inexperienced in performing a physical examination. Reliability estimates for the organic and nonorganic pain behavior composites were acceptable for both examinations (ranging from 0.84 to 0.90). Across-examination or test-retest reliabilities for patient-reported pain location average 99 for the organic, and 97 for the nonorganic tests. Pain aggravation test-retest reliability indices averaged 53 for the organic and 73 for the nonorganic tests. Test-retest reliability for the rater-observed organic and nonorganic pain behavior scores averaged 70 for the organic and 86 for the nonorganic tests. The reliability for the organic and nonorganic pain behavior composites were 0.78 and 0.82, respectively. Thus patients'' reports of pain location were quite stable across examinations but reports of pain aggravation were generally less consistent across time than were rater observed pain behaviors. Conclusions: A comprehensive physical examination that can be quickly administered and requires no expensive equipment has been developed that results in reliable assessment of patient''s self-report and examiner-observed patient pain behaviors. No apparent drop-off in the quality of information provided was observed when the examination was performed by a nurse naive to performing physical examinations prior to being trained in this protocol. Although preliminary in nature, reliability evidence for the organic and nonorganic pain behavior composites suggest that the physical examination produces useful examiner-based outcome measures to supplement or complement traditional patient self-report measures of outcome.

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