This opinion piece argues for more comprehensive screening of a spinal region in patients with an apparent peripheral problem. Contemporary physiotherapy screening appears insufficient to confidently exclude the spine as either a primary symptom-driver or significant contributor in peripheral pain states. This argument applies to the patient with atraumatic peripheral nociceptive pain, regardless of symptom duration. It does not include the patient cohort with either acute, traumatic pain or central dysfunctional pain.
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Physical examination of a patient should be as specific and sensitive as possible. A screening test demonstrating high sensitivity assists in ruling out selected diagnoses or impairments (Grimes and Schultz, 2002). A screening test for either a peripheral joint or spinal region is a range of motion (ROM) test that moves the joint to its limits, stretching the associated soft tissues in an attempt to reproduce symptoms. Should such fail to produce any significant finding, a joint is considered to be ‘cleared’ (Maitland, 2001; Mosby, 2009). During the physical examination of a patient, Australian physiotherapists are encouraged to consider the joint or region both proximal and distal to the site of pain as being a possible contributor to, or driver of, a patient’s symptoms. For example, in the case of elbow pain, there is an expectation that the wrist, shoulder and cervicothoracic spine would be screened. Whilst our current approach to clearing a peripheral joint appears justifiable, screening a spinal region in the same manner needs to be questioned.
A spinal region is not a single joint and should not be assessed as such. It should not be viewed as a homogenous unit but as a series of separate, yet linked, individual segments (Mercer and Bogduk, 2001). Consider the cervical spine, comprising eight motion segments which all contribute to total neck movement. Total neck ROM may be as much as 30-degrees less than the summation of segmental ROM (Van Mameren et al, 1990). Thus, a motion segment has movement which, under normal conditions, is not utilised. However, if restriction of a segment should occur for whatever reason, this reservoir of redundant movement is called upon, with resultant adjacent level compensation. The end-result is that functional spinal range is maintained despite subclinical movement dysfunction being present (Van Mameren et al, 1990).
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The concept of spinal motion segment movement redundancy suggests that screening a spinal region utilising the same principles as for a peripheral joint is flawed. Thus, examination beyond what is currently accepted as best practice may be warranted. I propose that, in addition to active ROM with overpressure, passive physiological (PPIVMs) and passive accessory intervertebral movements (PAIVMs) should be considered. In essence, an identical process to assessing a patient whose principal complaint is one of spinal pain. Such an approach may improve the sensitivity of the physical examination, thereby enabling the clinician to confidently exclude said spinal region as being a contributor to the patient’s symptoms. Despite low specificity, spinal manual assessment has consistently been shown to have high sensitivity - 80% (Heneghan and Rushton, 2015).
Consider a spinal fusion; a patient may have a single level fusion and yet maintain full neck ROM. The adjacent spinal levels that compensate for the segmental movement loss likely undergo repetitive micro-trauma, becoming problematic in the ensuing years (Schwab et al, 2006). Furthermore, a multilevel fusion causes greater adjacent segment disease than does a single level fusion (Liao et al, 2011), presumably because the remaining healthy segments are each required to contribute even more to maintaining a functional spinal ROM. Whilst, the spinal fusion example may be an extreme, other forms of spinal surgery, including laminectomy, discectomy and arthroplasty, yield similar levels of adjacent motion segment disease to a fusion (Liao et al, 2011). These latter-mentioned surgical interventions are thought to either restore normal segmental mechanics or increase segmental mobility, but certainly not reduce such (Yue et al, 2008). However, the ensuing adjacent segment disease suggests otherwise. Whilst many forms of elective spinal surgery demonstrate an improvement in pain and function at 1-year, these improvements are diminished at the 5-year review (Anjarwalla et al, 2007). One explanation for this may be due to altered spinal mechanics and compensatory motion at both the pathological and adjacent spinal levels. From the above, it appears that any segmental insult will alter relative segmental mobility at, above and/or below the level of insult. One may infer that relative, not absolute, motion segment dysfunction causes movement compensation at adjacent levels. However, despite these happenings, a patient may still display full pain-free spinal active ROM.
Should the above hold true in the clinical environment, then the question that must be asked is: can we confidently screen a spinal region simply by using active spinal ROM followed by passive overpressure. Much of the musculoskeletal dysfunction that physiotherapists see on a daily basis may fall into this category. Consider those with chronic peripheral joint pain and dysfunction, in whom the physical examination may need to include clearing a spinal region. Because of movement redundancy, a dysfunctional spinal segment may be masked when performing a ROM clearing test if the levels above and below the restricted segment compensate for said movement loss. In pain-free necks, cervical ROM has been shown to vary from day to day (Mercer and Bogduk, 2001) and thus using it as a reliable physical assessment tool is fraught with danger. Examination of neck ROM has been shown to have poor sensitivity in differentiating patients with neck pain (Sandmark and Nisell, 1995). ROM is considered such an unreliable measure of dysfunction that the 2013 Queensland Worker’s Compensation ‘Guidelines for Evaluation of Permanent Impairment’ specifically exclude ROM as a determinant of disability. The clinical risk is that we may erroneously clear a spinal region of any involvement in the patient’s pain state and focus our physical examination elsewhere. Additional spinal examination appears warranted to enable us to rule out spinal involvement with a higher degree of certainty.
It is not unreasonable to suggest that, in certain patient subgroups, our physical examination may be insufficiently sensitive and needs revising. An argument for better screening of a spinal region has been proffered – consideration should be given to clearing a spinal region using manual assessment in addition to active ROM with overpressure.
References
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