Assessment of lumbar radicular pain. Validity and predictive value of clinical tests

Radicular pain is in the majority of cases caused by a disc herniation with a coexisting inflammation. It is characterized by positive neural tension tests, such as the Slump test, and by decreased range of motion (ROM) in the straight leg raising test (SLR) and lumbar flexion (Fingertip-to-floor test[FTF]). This may suggest that improvement in ROM correlates to reduction of self-reported disability in patients with radicular pain as determined by the Slump test. It may also suggest that a locally administered anti-inflammatory treatment, such as transforaminal epidural steroid injection (TESI), provides greater leg pain reduction in subjects with positive Slump test compared to those with a negative test. The aims of this thesis were, in a sample with acute/sub-acute low back pain (Cohort A), to distinguish a subgroup with radicular pain as determined by a positive Slump test and to evaluate the validity and predictive value of FTF and SLR for subjects with and without radicular pain, and in a sample with chronic low back related leg pain (Cohort B) to evaluate the predictive value of the Slump test in determining the response to TESI. In addition, other methods to determine radicular pain, i.e. neurologic examination and magnetic resonance imaging (MRI), were used as comparison. Reference standards and primary outcomes were reduction of self-reported disability and leg pain after 3-4 weeks and one year. Validity and predictive value were evaluated using correlation (r) and regression analysis, respectively. For the group with positive Slump test in Cohort A, good validity of FTF was found as 4-week improvement in FTF correlated well to 4-week reduction of disability (r=0.66). A fair respective correlation was found between disability and SLR (r=0.28). The 4-week improvement in FTF predicted one-year reduction of disability. In Cohort B and at a time point when the greatest effect was expected (at 3-week follow-up), the greatest reduction of leg pain after TESI was found for subjects with positive Slump test. The negative Slump test group had no or minor 3-week effect of TESI. However, the Slump test failed to predict the one-year response to TESI, in contrast to MRI-verified nerve root compression. Neurologic examination results failed to predict 3-week and one-year response to TESI. In conclusion, for the group with acute/sub-acute radicular pain as determined by the Slump test, in contrast to SLR, we found good validity and predictive value for FTF. The Slump test was the best predictor of 3-week response to TESI and is, thus, suggested as a valid method to determine radicular pain in subjects with chronic low back related leg pai

Validity of the fingertip-to-floor test and straight leg raising test in patients with acute and subacute low back pain: a comparison by sex and radicular pain.

OBJECTIVE: To use self-reported disability (Roland-Morris Disability Questionnaire [RMDQ]) to assess the criterion validity of straight leg raising (SLR) test and flexion range of motion (ROM) (fingertip-to-floor test) before and after stratification by sex and presence/absence of radicular pain. DESIGN: Cross-sectional study. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Subjects with acute/subacute low back pain with (n=40) and without (n=35) radicular pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We examined the relationship between RMDQ (reference variable) and SLR test and fingertip-to-floor test. The sample was stratified by presence/absence of radicular pain (categorized by the dichotomous slump test). RESULTS: In the entire sample, fair correlations were found between both physical impairment tests (ie, SLR test and flexion ROM) and self-reported disability (.27.44). After stratification by sex, the correlation between RMDQ and flexion ROM and between RMDQ and nonside-specific SLR test increased in women but decreased in men. In those with radicular pain, good correlations were found between RMDQ and flexion ROM (r=.68 for men and r=.70 for women), and moderate correlation was found between the RMDQ and SLR tests of the affected side in women (r=.60), but only fair correlation was found between the RMDQ and SLR tests of the affected side in men (r=.28). CONCLUSIONS: After stratification by sex and presence/absence of radicular pain, the present study supports a good validity of the fingertip-to-floor test for both men and women with radicular pain. The SLR test, however, was of less value as an indicator of self-reported disability after stratification, especially for men

Fingertip-to-Floor Test and Straight Leg Raising Test: Validity, Responsiveness, and Predictive Value in Patients With Acute/Subacute Low Back Pain.

OBJECTIVES: To investigate the validity over time of the fingertip-to-floor test (FTF) and the straight leg raising test (SLR) using the Roland Morris Disability Questionnaire (RMDQ) and correlation coefficient (r), and to assess the predictive value of factors related to the change in RMDQ over 12 months using multivariate regression analysis. DESIGN: Longitudinal study. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Subjects (N=65) with acute/subacute low back pain (≤13wk of symptoms). Thirty-eight (58%) had radicular pain as determined by the slump test. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported disability was used as a reference variable and was measured using the RMDQ at baseline and after 1 and 12 months. The FTF and SLR were measured at baseline and after 1 month. Responsiveness and imprecision were assessed by using effect size (ES) and minimum detectable change (MDC). The sample was stratified by the presence/absence of radicular pain (categorized by the slump test). RESULTS: The change in FTF results was significantly correlated to the 1-month change in RMDQ, both in the entire sample (r=.63) and in the group with radicular pain (r=.66). Similar analysis for the SLR showed a weak relationship to RMDQ. FTF showed adequate responsiveness (ES range, 0.8-0.9) in contrast to SLR (ES range, 0.2-0.5). The MDC for FTF and SLR were 4.5cm and 5.7°, respectively. The change in FTF results over 1 month was independently more strongly associated with the 12-month (R(2)=.27-.31) change in RMDQ than any of the other variables and multivariate combinations. C CONCLUSIONS: Our results suggest that the FTF test has good validity in patients with acute/subacute low back pain and even better validity in those with radicular pain. The change in FTF results over the first month was a valid predictor of the change in self-reported disability over 1 year. In contrast, the validity of SLR can be questioned in the present group of patients

Three week results of transforaminal epidural steroid injection in patients with chronic unilateral low back related leg pain: The relation to MRI findings and clinical features.

Transforaminal epidural steroid injection (TESI) is a frequently used intervention for lumbar radicular pain

Accuracy of Clinical Tests in Detecting Disk Herniation and Nerve Root Compression in Subjects With Lumbar Radicular Symptoms

Objectives: To investigate the accuracy of 3 commonly used neurodynamic tests (slump test, straight-leg raise [SLR] test, femoral neurodynamic test) and 2 clinical assessments to determine radiculopathy (radiculopathy I, 1 neurologic sign; radiculopathy II, 2 neurologic signs corresponding to 1 specific nerve root) in detecting magnetic resonance imaging (MRI) findings (extrusion, subarticular nerve root compression, and foraminal nerve root compression). Design: Validity study. Setting: Secondary care. Participants: We included subjects (N=99; mean age, 58y; 54% women) referred for epidural steroid injection because of lumbar radicular symptoms who had positive clinical and MRI findings. Positive clinical findings included the slump test (n=67), SLR test (n=50), femoral neurodynamic test (n=7), radiculopathy I (n=70), and radiculopathy II (n=33). Positive MRI findings included extrusion (n=27), subarticular nerve compression (n=14), and foraminal nerve compression (n=25). Interventions: Not applicable. Main Outcome Measures: Accuracy of clinical tests in detecting MRI findings was evaluated using sensitivity, specificity, and receiver operating characteristics analysis with area under the curve (AUC). Results: The slump test had the highest sensitivity in detecting extrusion (.78) and subarticular nerve compression (1.00), but the respective specificity was low (.36 and.38). Radiculopathy I was most sensitive in detecting foraminal nerve compression (.80) but with low specificity (.34). Only 1 assessment had a concurrent high sensitivity and specificity (ie, radiculopathy II) in detecting subarticular nerve compression (.71 and.73, respectively). The AUC for all tests in detecting extrusion, subarticular nerve compression, and foraminal nerve compression showed ranges of.48 to.60,.63 to.82, and.33 to.57, respectively. Conclusions: In general, the investigated neurodynamic tests or assessments for radiculopathy lacked diagnostic accuracy. The slump test was the most sensitive test, while radiculopathy II was the most specific test. Most interestingly, no relationship was found between any neurodynamic test and foraminal nerve compression (foraminal stenosis) as visualized on MRI

The 1-Year Results of Lumbar Transforaminal Epidural Steroid Injection in Patients with Chronic Unilateral Radicular Pain : The Relation to MRI Findings and Clinical Features

OBJECTIVE: In patients with chronic radicular pain, we aimed to evaluate subgroup differences in 1-yr response to transforaminal epidural steroid injection. DESIGN: In this longitudinal cohort study of 100 subjects, 170 transforaminal epidural steroid injections were performed for 1 yr. The sample was stratified by type of disc herniation (protrusion n = 57, extrusion n = 27), by location of disc herniation (central/subarticular n = 60, foraminal n = 24), by grade of nerve root compression (low-grade compression n = 61, high-grade subarticular nerve compression n = 14, high-grade foraminal nerve compression n = 25), and by positive Slump test (n = 67). Treatment response was evaluated by visual analogue scale leg pain and self-reported disability (Oswestry Disability Index). Logistic regression was used to analyze the predictive value of baseline characteristics including the stratified subgroups. RESULTS: High-grade subarticular nerve compression predicted the 1-yr improvement in both visual analogue scale leg pain (P = 0.046) and Oswestry Disability Index (P = 0.027). Low age (P < 0.001), short duration of leg pain (P = 0.015), and central/subarticular disc herniation (P = 0.017) predicted improvement in Oswestry Disability Index. CONCLUSIONS: In patients treated with one or several transforaminal epidural steroid injections due to chronic lumbar radicular pain, clinical findings failed to predict the 1-yr treatment response. Low age, short duration of leg pain, central/subarticular disc herniation, and high-grade subarticular nerve compression predicted a favorable 1-yr response to transforaminal epidural steroid injection