Value of physical tests in diagnosing cervical radiculopathy: a systematic review.

BACKGROUND CONTEXT: In clinical practice, the diagnosis of cervical radiculopathy is based on information from the patient's history, physical examination, and diagnostic imaging. Various physical tests may be performed, but their diagnostic accuracy is unknown. PURPOSE: This study aimed to summarize and update the evidence on diagnostic performance of tests carried out during a physical examination for the diagnosis of cervical radiculopathy. STUDY DESIGN: A review of the accuracy of diagnostic tests was carried out. STUDY SAMPLE: The study sample comprised diagnostic studies comparing results of tests performed during a physical examination in diagnosing cervical radiculopathy with a reference standard of imaging or surgical findings. OUTCOME MEASURES: Sensitivity, specificity, likelihood ratios are presented, together with pooled results for sensitivity and specificity. METHODS: A literature search up to March 2016 was performed in CENTRAL, PubMed (MEDLINE), Embase, CINAHL, Web of Science, and Google Scholar. The methodological quality of studies was assessed using the QUADAS-2. RESULTS: Five diagnostic accuracy studies were identified. Only Spurling's test was evaluated in more than one study, showing high specificity ranging from 0.89 to 1.00 (95% confidence interval [CI]: 0.59-1.00); sensitivity varied from 0.38 to 0.97 (95% CI: 0.21-0.99). No studies were found that assessed the diagnostic accuracy of widely used neurological tests such as key muscle strength, tendon reflexes, and sensory impairments. CONCLUSIONS: There is limited evidence for accuracy of physical examination tests for the diagnosis of cervical radiculopathy. When consistent with patient history, clinicians may use a combination of Spurling's, axial traction, and an Arm Squeeze test to increase the likelihood of a cervical radiculopathy, whereas a combined results of four negative neurodynamics tests and an Arm Squeeze test could be used to rule out the disorder.

The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review.

OBJECTIVES: The aim of this systematic review is to assess the effectiveness of conservative treatments for patients with cervical radiculopathy, a term used to describe neck pain associated with pain radiating into the arm. Little is known about the effectiveness of conservative treatment for patients with cervical radiculopathy. METHODS: We electronically searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, and CINAHL for randomized clinical trials. Conservative therapies consisted of physiotherapy, collar, traction etc. Two authors independently assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group and extracted the data. If studies were clinically homogenous, a meta-analysis was performed. The overall quality of the body of evidence was evaluated using the GRADE method. RESULTS: Fifteen articles were included that corresponded to 11 studies. Two studies scored low risk of bias. There is low-level evidence that a collar is no more effective than physiotherapy at short-term follow-up and very low-level evidence that a collar is no more effective than traction. There is low-level evidence that traction is no more effective than placebo traction and very low level-evidence that intermittent traction is no more effective than continuous traction. DISCUSSION: On the basis of low-level to very low-level evidence, no 1 intervention seems to be superior or consistently more effective than other interventions. Regardless of the intervention assignment, patients seem to improve over time, indicating a favorable natural course. Use of a collar and physiotherapy show promising results at short-term follow-up.

Lack of uniform diagnostic criteria for cervical radiculopathy in conservative intervention studies: a systematic review.

PURPOSE: Cervical radiculopathy (CR) is a common diagnosis. It is unclear if intervention studies use uniform definitions and criteria for patient selection. Our objective was to assess the uniformity of diagnostic criteria and definitions used in intervention studies to select patients with CR. METHODS: We electronically searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL. Studies were included when evaluating conservative interventions in randomised clinical trials (RCTs) in patients with CR. Selection criteria and definitions for patients with CR were extracted and evaluated on their uniformity. RESULTS: Thirteen RCTs were included. Pain was used as an inclusion criterion in 11 studies. Inclusion based on the duration and location of pain varied between studies. Five studies used sensory symptoms in the arm as inclusion criterion. Four studies used cervical range of motion and motor disturbances as inclusion criteria, while reflex changes were used in two studies. Three studies included patients with a positive Spurling's test and two studies used it within a cluster of provocation tests. CONCLUSIONS: Criteria used to select patients with CR vary widely between different intervention studies. Selection criteria and test methods used are poorly described. There is consensus on the presence of pain, but not on the exact location of pain.

Practical use of the HOAC II for clinical decision making and subsequent therapeutic interventions in an elite athlete with low back pain.

STUDY DESIGN: Resident's case problem. BACKGROUND: This case report describes the diagnostic process, based on the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), and subsequent interventions in an elite athlete with subacute low back pain. It also demonstrates the clinical application of the HOAC II and shows how disablement terms, as used in the World Health Organization's International Classification of Functioning, Disability and Health model, can be integrated into patient management in a manner that we believe enhances clinical practice. It also demonstrates the practical use of validated questionnaires and how these can be used to gather necessary information for the algorithm. DIAGNOSIS: A structured, evidence-based assessment led to a multifaceted, activity limitation-based diagnosis of being unable to (1) remain in a deep squat position during speed skating, (2) accelerate in turns while speed skating, and (3) rise from a slouched position without pain. We believed that these dysfunctions were due to local limited lumbar segmental mobility, concurrent with an inability to properly and functionally stabilize the lumbopelvic area. DISCUSSION: The HOAC II requires the therapist to develop an evidence-based strategy for the examination that is based on initial hypotheses developed from the medical history and other data obtained prior to the examination. The examination was tailored to identify and quantify activity limitations and participation restrictions that we believed could help to explain why this patient had his health problem. The case demonstrates how all elements of the HOAC II can be used for what we consider to be relatively common types of patients. We believe that by applying the HOAC II on an individual-patient basis, therapists will be ideally positioned to apply evidence to patient care and to defend their interventions to colleagues and third-party payers. LEVEL OF EVIDENCE: Differential diagnosis, level 4.