Lumbar Instability: Difference between revisions

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Original Editors - Anke Jughters

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Search strategy[edit | edit source]

• Databases searched: Physiopedia , Pedro , Pubmed
• Keywords searched : ‘Lumbar Instability’, ‘spine instability’, ‘exercises lumbar instability’ ,
‘Lumbar spine instability‘ , ‘‘Lumbar instability treatment’, ‘medical management lumbar
instability’, ‘low back school’ , ‘Lumbar instability physical examination’, ‘segmental instability’, ‘
physical mangement lumbar instability’

Definition/Description[edit | edit source]

Lumbar instability is an important cause of low back pain and can be associated with substantial disability.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The word ‘instability’ is still poorly defined. But it is most widely believed that the loss of a normal pattern of spinal motion causes pain and/or neurologic dysfunction. The American Academy of Orthopaedics Surgeons Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title state: ‘Segmental instability is an abnormal response to applied loads, characterized by motion in motion segments beyond normal constraints.’ Panjabi published a spinal stabilization system represented by 3 subsystems:
the passive, the active and the neural control subsystem.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Segmental instability is defined by Panjabi Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title “as a significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major
deformity, and no incapacitating pain.”
The ability to maintain an efficient coordination between these systems would allow of the patient to function without undue stress on the tissues in the body. Panjabi suggests that a loss of integrity within the passive subsystem may make segments unstable unless the neuromuscular subsystem compensates for that loss.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Within lumbar instability we distinguish functional (clinical) instability and structural (radiografic) instability. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Functional instability, which can cause pain despite the absence of any radiological anomaly, can be defined as the loss of neuromotor capability to control segmental movement during mid-range. Whereas structural or mechanical instability can be defined as the disruption of passive stabilisers, which limit the excessive segmental end range of motion (ROM). There is also a possibility to have a combined instability.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

T. Barz etal. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title proposed a new conceptual model of compensation/decompensation in lumbar segmental instability (LSI). In LSI, structural deterioration of the lumbar disc initiates a degenerative cascade of segmental instability (see figure 1). Over time, radiographic signs become
visible (see etiology). Influenced by non-functional factors (psychosocial factors), functional elements of the spine (ligaments, muscles) allow a compensation of degeneration.This may lead to an alleviation of clinical symptoms. In return, the target condition of decompensation of LSI may cause the new occurrence of symptoms and pain. Individual differences of identical structural disorders could be explained by compensated or decompensated LSI leading to changes in clinical symptoms and pain.

Figure 1

Clinically Relevant Anatomy
[edit | edit source]

The lumbar spine is intended to be very strong, so it can protect the sensitive spinal cord and spinal nerve roots and it has to cary
the most weight. Having regard to the form of the joints in the lumbar region, flexion and extension are the main motion directions. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Panjabi’s spinal stabilization systemCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,^[1]:
- Passive subsystem: intervertebral disc, ligaments, facet joints and capsules, vertebrae and passive muscle support
- active subsystem: spinal muscles and tendons, thoracolumbar fascia
- neural control system: nerves and central nervous system

The passive subsystem plays its most important stabilizing role in the elastic zone (near endrange) of spinal ROM.
Flexion of the spine is mostly stabilized by the posterior ligaments (interspinous and supraspinous ligaments), the facet joints,
the joint capsules and the intervertebral discs.
End-range extension is stabilized primarily by the anterior longitudinal ligament, the anterior aspect of the annulus fibrosus and
the facet joints. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The neuromotor control subsystem controls segmental motion during the mid-range, while the osseoligamentous (passive)
subsystem limits segmental motion at the extremes of lumbar motion.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The neutral zone is defined as a portion of the total physiologic range of intervertebral motion. The total physiologic range involves a
neutral zone and an elastic zone. The neutral zone, is the zone of movement close to the neutral position of the segment, a zone in
which movement occurs with little resistance. The elastic zone starts at the end of the neutral zone and stops at the end of physiologic
range of motion. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

For more detailed anatomy:
http://www.physio-pedia.com/Lumbosacral_Biomechanics

Epidemiology /Etiology
[edit | edit source]

Lumbar spinal instability may be caused by Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title :
• degenerative disease
• facet joint hypertrophy
• postoperative status
• postoperative spinal fusion
• trauma to spine or its surrounding structures
• development disorders, like scoliosis and other congenital spine lesions
• infection
• tumors

Abnormal segmental motion noted on kinetic MR images is closely associated with disc degeneration, facet joint osteoarthritis, and the pathological characteristics of interspinous ligaments, ligamentum flavum (hypertrophy) and paraspinal muscles. Other spine pathology such as annular tears or traction spurs has also been associated with segmental instability. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

When a disorder or injury occurs, the whole motion segment is affected and the degenerative cascade begins which can lead to the symptoms and signs of LSI (see figure 2).

Firgure 2 Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

A constant morphological modification of the spine alters the biomechanical loading from back muscles, ligaments, and joints, and can harvest back injuries.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleGranata et all., described that body mass, task asymmetry, and level of experience affected the scale and variability of spinal load during repeated lifting efforts.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In older people, bending and lifting activities produce loads on the spine that exceed the failure of vertebrae with low bone mineral density, which is linked with spinal degeneration. The degenerative transformation has influence on the intervertebral discs, ligament and bone.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The estimated prevalence of low back pain due to lumbar segmental instability is about 33% for patients with functional instability, compared to 57% for patients with evidence of structural instability, as indicated by positive flexion–extension radiograph. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Characteristics/Clinical Presentation[edit | edit source]

Patients with lumbar instability are commonly patients with chronical recurrent low back pain, a constant nagging pain which gradually increases. This pain can also be a residue of acute complaints.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title [LOE 2A]

There’s still a controversy about the exact meaning of the term lumbar instability.

Following characteristics can indicate lumbar instability Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title [LOE 2A], Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title [LOE 2A]:

- The feeling of instability, giving way.

- A visually observable or palpable hitch at a moving segment in the lumbar spine, mostly during change of position.

- Segmental shifts or hinging associated with the painful movement.

- Moving or jumping of the vertebra accompanied with pain in active trunk flexion or deflexion.

- An increased mobility at the concerned movement segment, mostly in passive segmental lumbar flexion and extension.

- Excessive intervertebral motion at the symptomatic level or an increased intersegmental motion at the level above the concerned movement segment.

- Local pain.

- Low back pain during long static load and deflexion.

- Pain during change of position and while bending or lifting.

- An abnormal motion sensation in postero-anterior movements of the vertebra.

- Decreased repositioning accuracy.

- Decreased postural control.

- Decreased activation of stabilizing muscles.

- Disruptions in the patterns of recruitment and co-contraction of the large trunk muscles (global muscle system) and small intrinsic muscles (local muscle system). This affects the timing of patterns of co-contraction, balance and reflexes.

- Pain and the observation of movement dysfunction within the neutral zone.

- A painful arc.

- Gowers sign: the inability to return to erect standing from forward bending without the use of the hands to assist this motion.

- Frequently crack or pop the back to reduce the symptoms, selfmanipulation.

Differential Diagnosis[edit | edit source]

• Intervertebral disc prolapse
http://www.physio-pedia.com/Disc_Herniation

• Spondylosis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Lumbar_Spondylosis

• Facet joint syndrome (arthritis of the facet joints)
http://www.physio-pedia.com/Facet_Joint_Syndrome

• Lumbar spine fracture
www.physio-pedia.com/Lumbar_Spine_Fracture

[1]• Spondylolisthesis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Spondylolisthesis

• Hypermobility syndrome
www.physio-pedia.com/Hypermobility_Syndrome

• Osteoporosis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Osteoporosis

• Sciatica Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Sciatica

• Degenerative disc disease Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Degenerative_Disc_Disease

• Rheumatoid arthritis Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Rheumatoid_Arthritis

• Lumbar compression fracture
www.physio-pedia.com/Lumbar_compression_fracture

Diagnostic Procedure[edit | edit source]

The diagnosis of lumbar instability is commonly based on the imaging finding of abnormal vertebral motion. This only shows anatomical instability and not functional instability. Abnormal translation and/or rotation around the x-, y-, and z-axes of the three-dimensional system by Panjabi and White can be found. Lumbar instability is mostly multidirectional, but the resulting displacement is evaluated in one plane at the time. Sagittal and coronal displacements are evaluated with radiographs, displacements on the axial plane are evaluated with computed tomographic (CT) or magnetic resonance (MR). Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A}, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A}, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A}

Functional flexion-extension radiographs taken at the end-range of movement are the most frequently used, but show only the function of the passive stabilizing subsystem and fail to address the active and neural control subsystems.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A}

The relationship between imaging instability and its symptoms remains difficult to appoint. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

→ Neutral radiography:Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{LOE 2A}

Shows many indirect signs that are associated with spinal instability.

→ Functional radiography Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{LOE 2A}
Functional radiography in the sagittal plane can occur in flexion and extension or with passive axial traction and compression. Intervertebral instability or abnormal motion between two vertebrae can be observed. Dynamic radiographs obtained in both flexion and extension, determine motion segment instability and can also indicate the lesions located in specific areas.

→ Magnetic resonance imagingCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A,}Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A}

MR imaging is commonly considered to be the most accurate imaging method for diagnosing degenerative abnormalities of the spine and is often used for the diagnosis of patients with chronic low back pain.

→ Intraoperative measurement systemCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A}:

This technique is recently developed and implies in vivo measurements of vertebral segment displacement during the application of a controlled load to produce motion.
The operator grasps the spinous process to move it caudally.

A device is developed to preserve the supraspinal ligament after clearing the paravertebral muscles and hammering the two pins into the two spinous processes lying on either side of the lumbar vertebrae so the stability can be measured.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{LOE 2A}

→ Computed tomographyCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A} :

CT can show spinal degenerative changes and facet joint orientation. It can demonstrate predisposing anatomic factors, such as facet joint asymmetry.

If a CT scan shows a gap in the facet joints during rotation of the trunk, this could be an indirect sign of spinal instability.

→ Quantitative Stability Index (QSI)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{LOE 2A}

QSI is a novel objective test for sagittal plane lumbar instability.

A QSI > 2 standard deviations from normal in an asymptomatic and radiographically normal population, would indicate that the amount of translation per degree of rotation is abnormal.

A QSI = 4 would indicate far greater instability.

Outcome Measures
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- Oswestry Disability Index: subjective percentage score of level of function (disability) in activities of daily living in those rehabilitating from low back pain.
Minimal detectable chance is 5-6 points and the minimum clinically important difference is 6 points.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Scores from 0% to 20% indicate minimal disability
20% to 40%, moderate disability
40% to 60%, severe disability;
60% to 80%, crippled
80% to 100%, bedbound or exaggerating Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Oswestry_Disability_Index

- Quebec Back Pain Disability Scale:
The Quebec back pain disability scale (QBPDS) is a condition-specific questionnaire developed to measure the level of functional disability for patients with low back pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The end score will be between 0 (no limitation) and 100 (totally limited).
The minimum clinically important difference is 15 points when suffering acute low back pain of chronic low back pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Quebec_Back_Pain_Disability_Scale

- Roland-Morris Disability Questionnaire:
This questionnaire is designed to assess self-rated physical disability caused by low back pain.
o When the score at intake is < 9 points; Minimal detectable change (MDC) = 6,7 points and the minimum clinically important difference (MCID) is 2-3 points.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
o When the score at intake is between 9-16: MDC = 4-5 points and MCID = 5-9 points.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
o When the score at intake is > 16 points: MDC = 8,6 points and MCID = 8-13 points.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
MIC absolute cutoff, minimal important change = 5 points for patients with low back pain. MIC (% imporovement from baseline) = 30%Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Roland%E2%80%90Morris_Disability_Questionnaire

- Patient Specific Functional Scale:
This useful questionnaire can be used to quantify activity limitation and measure functional outcome for patients with any orthopaedic condition.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The Minimal detectable change (MDC) is for chronic pain = 2 points, for low back pain = 1,4 points and the minimum clinically important difference (MCID)= 2,0 points.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Stratford et alCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title found the average of the MCID scores for 3 activities to be 0.8 (“small change”), 3.2 (“medium change”), and 4.3 (“large change”) PSFS points in patients with chronic low back pain.

Waddell Disability Index:

The WDI evaluates disability because of low back pain. The scale consists of nine items. These questions are answered with yes or no and are about impairments in activities of daily living (not related to a specific period). The final score is calculated by adding up positive items, and ranges from 0 to 9.21. ICCs = 0.79Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Physical examination[edit | edit source]

The physical examination may consist of multiple tests :
• Low midline sill sign:
First there is an inspection of the midline of the patient’s low back to detect the low midline sill sign. If lumbar lordosis increases and there is a sill like a capital “L” on the midline, the test is considered positive. Next the examiner palpates the interspinous space and evaluates the position of the upper spinous process in relation to the lower spinosus process.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title If the upper spinous process is displaced anterior to the lower spinous process, the test positive.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Figure 3

• Interspinous gap change during lumbar flexion – extension motion:
This test is used for the detection of lumbar instability. First there is an inspection of the low back to detect the interspinous gap change. The patient stands shoulder – width, flex his back and place both hands on an examination table. After inspection of the lower back in flexion, palpates and evaluates the physiotherapist the width of the individual interspinous spaced and the position of the upper spinous process in relation to the lower one.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

After this the physiotherapist will ask the patient to extend (to hollow) the low back while he evaluates the interspinous gap change during this motion. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Figure 4

• Sit – to – stand test:Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The test is positive (there is an association with instability) if the person feels pain immediately when sitting down in a chair and if the pain is (partially) relieved by standing up.
The test result might vary (time of the day, type of seat, the patients’ symptom levels before the test).
- sensitivity: 30
- specificity: 100
- LR+: cannot be calculated
- LR-: 0,7

• Passive Accessory Intervertebral Movements ( = PAIVM): Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

www.physiopedia.com/Manual_Therapy_Techniques_For_The_Lumbar_Spine#PPIVMs

- sensitivity: 46
- specificity: 81
- LR+: 2,4
- LR-: 0,7

https://www.youtube.com/watch?v=gAUFcaEw0I0

• Prone instability test : Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Prone_Instability_Test

- sensitivity: 61
- specificity: 57
- LR+: 1,4
- LR-: 0,7

https://www.youtube.com/watch?v=OrgoC3mKhXQ

[2]• Beighton hypermobility scale : Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
www.physio-pedia.com/Beighton_score

- sensitivity: 36
- specificity: 86
- LR+: 2,5
- LR-: 0,8

[3]• Passive Physiological Intervertebral Motion ( = PPIVM ):Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
http://www.physiopedia.com/Manual_Therapy_Techniques_For_The_Lumbar_Spine#PPIV Ms
The patient side lies. The test consisted of moving the patient’s spine through sagittal forward – bending ( flexion ) and backward – bending ( extension ) , using the lower extremities. Meanwhile the examiner palpates between the spinous process of the adjacent vertebrae to assess the motion taking place at each motion segment. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

PPIVM (flexion):
- sensitivity: 5 - specificity: 99,5
- LR+: 8,7 - LR-: 1,0

PPIVM (extention)
- sensitivity: 16 - specificity: 98
- LR+: 7,1 - LR-: 0,9

https://www.youtube.com/watch?v=HP6ZuG3NRNs

• Passive Lumbar Extension Test ( = PLE test ):
The patient is in prone position. The therapist elevates both lower extremities were elevated ( passive ) to a height of about 30cm. The knees maintain extended while gently pulling the legs. The examiner fixates T12 ventrocaudal. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

This test can also be done in lateral position of the patient with the legs bended. The test is positive if it provokes similar complaints.

- sensitivity: 84
- specificity: 90
- LR+: 8,8
- LR-: 0,2

https://www.youtube.com/watch?v=eUJw9pxcV-g

• Instability catch sign = active flexion test:
The patient bend his or her body forward as much as possible and then return to the neutral position. The test is positive when the patient isn’t able to return to the neutral position.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, ^[2]
This test is a provocation test.

- sensitivity: 26
- specificity: 86 LR+: 1,8
- LR-: 0,9Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

https://www.youtube.com/watch?v=63clj33mkHc

• Painful catch sign :
The patient is in supine position and then the examiner asks the patient to lift both lower extremities. The knees must be extended. Then the examiner asks the patient to return slowly to the start positon. If the lower extremities fell down instantly because of the low back pain , the test was positive. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
- sensitivity: 37
- specificity: 73 LR+: 1,4
- LR-: 0,9

https://www.youtube.com/watch?v=yb0hBo-51gY

•Apprehension sign :
The examiner asks the patient if he or she has a sensation of lumbar collapse because of the low back pain while performing ordinary acts like bending back and forward , bending from side to side , sitting down or standig up. The test was positive if the patient had a sensation of lumbar collapse. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThe condition has a unique clinical presentation that displays its symptoms and movement dysfunction within the neutral zone of the motion segment. The loosening of the motion segment secondary to injury and associated dysfunction of the local muscle system renders it biomechanically vulnerable in the neutral zone. The clinical diagnosis of this chronic low back pain condition is based on the report of pain and the observation of movement dysfunction within the neutral zone and the associated finding of excessive intervertebral motion at the symptomatic level. Four different clinical patterns are described based on the directional nature of the injury and the manifestation of the patient's symptoms and motor dysfunction. A specific stabilizing exercise intervention based on a motor learning model is proposed and evidence for the efficacy of the approach provided.^[3]^,^[4] Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

- sensitivity: 18
- specificity: 88 LR+: 1,6
- LR-: 0,9

In acute overt instability, stabilization of the spine is required in all cases. In this context, medical treatment refers to the use of external bracing for spine stabilization. If instability is due to an osseous fracture, if the fracture fragments can be reduced to near-anatomic alignment, and if there is no significant neural compression after reduction, the patient may be treated nonsurgically with a brace until the fracture heals.

In anticipated instability (eg, extensive discitis and osteomyeli)
The majorty of the tests has high specificity but low sensitivity. Data suggest that PLE is the most appropriate tests to detect lumbar instability in specific LBP. The PLE test ( = Passive Lumbar Extension test) has a sensitivity of 84% , a specificity of 90% , a LR+ rate of 8,8 and an LR- rate of 0,2.^[5]^,^[6]^,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Medical Management
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Lumbar segmental instability is considered to represent a significant sub-group within the chronic low back pain population. In chronic overt instability and covert instability, medical treatment plays a more prominent role. If not at risk for imminent neurological deterioration, the patients with these forms of instability generally undergo conservative (nonsurgical) treatment first. Fusion is reserved for those in whom conservative treatment fails.

medication:Analgesics, anti-inflammatories, muscle relaxants, tricyclic antidepressants, anti-epileptics.

Surgerical management[edit | edit source]

Once the decision has been made to fuse a particular spine segment, there may be several surgical methods to accomplish this task. After a particular method is selected, the etiology of instability is no longer relevant, as the technical steps would be the same.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Posterior and posterolateral noninstrumented lumbar fusion The lumbar spine is exposed in standard fashion through a posterior midline incision. Bilateral exposure of the laminae is extended further laterally to completely expose of the facet joints and transverse processes of the vertebrae to be fused. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Instrumented lumbar fusion with pedicle screws

The spine is exposed (and decompressed if necessary) as for a noninstrumented fusion. Pedicle screws are inserted into the pedicles above and below the motion segment to be fused. The main concern during pedicle screw insertion is to avoid breach of the pedicle wall and injury to the exiting nerve root. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

The indications for spinal fusion in the treatment of degenerative instability are controversial. The basic problem lies, as discussed earlier, in the definition and the diagnosis of the disorder. However, despite the fact that indications for the procedure are uncertain, that costs and complication rates are higher than for other surgical procedures performed on the spine, and that long-term outcomes are uncertain, the rate of lumbar spinal fusion is increasing rapidly in the United States.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The rate of back surgery and especially of spinal fusion operations is at least 40% higher in the US than in any other country and is five times higher than in the UK.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Although there have been no randomized trials evaluating the effectiveness of lumbar fusion for spinal instability, the feeling remains that the operation should be reserved for patients with severe symptoms and radiographic evidence of excessive motion (greater than 5 mm translation or 10° of rotation) who fail to respond to a trial of non-surgical treatment.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The latter should consist of a combination of patient education, physical training and sclerosing injections.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Physical Therapy Management
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Patient education may be important in the treatment of patients with segmental instability. Education should, first of all, focus on preventing loaded flexion movements, as they may create a posterior shift of the disc. ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 1A}] End-range positions of the lumbar spine should also be avoided because these overload the posterior passive stabilizing structures. Physical therapy for segmental instability focuses on exercises designed to improve stability of the spine. As the lumbar erector spinae muscles are the primary source of extension torque for lifting tasks, strengthening of this muscle group has been supported.^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{, level of evidence 1B ]}Intensive dynamic exercises for the extensors proved to be significantly superior to a regime of standard treatment of thermotherapy, massage and mild exercises in patients with recurrent LBP.^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^,Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 1B]}The abdominal muscles, particularly the transversus abdominis and oblique abdominals, have also been proposed as having an important role in stabilizing the spine by co-contracting in anticipation of a tested load. However, exercises proposed to address the abdominal muscles in an isolated manner usually involve some type of sit-up manœuvre that imposes dangerously high compressive and shear forces on the lumbar spine ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 5 ]} and may provoke a posterior shift of the (unstable) disc (see figure 3). Alternative techniques should therefore be tested when training these muscles. Some authors strongly suggest that the transversus abdominis ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{, level of evidence 2A ]} and the multifidus muscles make a specific contribution to the stability of the lower spine ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{, level of evidence 2B ]}^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 2A ]} and an exercise programme that proposes the retraining of the co-contraction pattern of the transversus abdominis and multifidus muscles has been described. ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 1C ]}The exercise programme is based on training the patient to draw in the abdominal wall while isometrically contracting the multifidus muscle, and consists of three different levels:
• First, specific localized stabilization training is given. Lying prone, sitting and standing upright, the patient performs the isometric abdominal drawing-in manœuvre with co-contraction of the lumbar multifidus muscles. = Segmental control over primary stabilizers (mainly TrA, deep multifidus, pelvic floor and diaphragm) ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{, level of evidence 5 ]}
• During the phase of general trunk stabilization, the co-contraction of the same muscles is carried out on all fours, and then elevating one arm forwards and/or the contralateral leg backwards, or on standing upright and elevating one arm forwards and/or bringing the contralateral leg backwards. = Exercises in closed chain, with low velocity and low load ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 5 ]}
• Third, there is the stabilization training. Once accurate activation of the co-contraction pattern is achieved, training is given in functional movements, such as standing up from a sitting or lying position, bending forwards and backwards and turning. All daily activities are then integrated. A significant result from a randomized trial has recently been reported comparing this exercise programme with one of general exercise (swimming, walking, gymnastic exercises) in a group of patients with chronic LBP.^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 1B ]}= Exercises in open chain, with high velocity and load ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 5 ]}

Despite the positive results with muscular training programmes, it remains difficult to understand how training of the lumbar and abdominal muscles can improve segmental stability. Not only do the muscles (except for multifidus) have multisegmental attachments to the lumbar vertebrae, but also they are not very well oriented to resist displacements. Because they mainly run longitudinally, they can only resist sagittal rotation and are not able to resist anterior or posterior shears. However, whenever the muscles contract, and especially when they do this simultaneously, they exert a compressive load on the whole lumbar spine, as well as on the unstable segment. By compressing the joints, the muscles make it harder for the joints and for the intradiscal content to move. ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 2B ]} The most important contribution of trained muscles to spinal stability may therefore be the creation of a rigid cylinder around the spine and increased stiffness. It is important, however, for exercises to be prescribed as a means of prevention only after the actual problem – usually a discodural interaction – has been solved by manipulation, mobilization, traction or passive postural exercises.^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 2A ]}

Figure 3: Intradiscal pressure in % of that of the standing position

For excercises : www.physio-pedia.com/Exercises_for_Lumbar_Instability

The effectivity of back school program has been shown and is more effective than any educational intervention in general health status and in decreasing acetaminophen and NSAID intake. It was ineffective in the other quality of life domains, in pain, functional status, anxiety and depression. ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title ^{, level of evidence 1B ]}

Other RCT of the effectivity of back school: Sahin N, Albayrak I, Durmus B, Ugurlu H.. Effectiveness of back school for treatment of pain and functional disability in patients with chronic low back pain: a randomized controlled trial. J Rehabil Med. 2011 Feb;43(3):224-9.
In this RCT was the addition of back school more effective than exercise and physical treatment modalities alone in the treatment of patients with chronic low back pain. ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{, level of evidence: 1B]}

On Physiopedia : http://www.physio-pedia.com/Back_School
There moderate evidence suggested that back schools have better short- and intermediate-term effects on the functional status and pain than other treatments for patients with recurrent and chronic low back pain (LBP) Moderate evidence suggests that a back school for chronic LBP in an occupational setting are even more effective than the other treatments.

Acupuncture, back schools, behavioural therapy, and spinal manipulation may reduce pain in the short term, but effects on function are unclear. In this systematic review,they don't know whether back schools are more effective than placebo gel, waiting list, no intervention, or written information at reducing pain ( low-quality evidence ). Compared with other treatments: They don't know whether back schools are more effective than spinal manipulation, non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy, callisthenics, or exercise at reducing pain (low-quality evidence). ^[Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title^{, Level of evidence: 1A]}

Key Research[edit | edit source]

• McGill SM. Estimation of force and extensor moment contributions of the disc and ligaments at L4–L5. Spine 1988;13:1395–402. Level of evidence: 1A
• Callaghan JP, Gunning JL, McGill SM. The relationship between lumbar spine load and muscle activity during extensor exercises. Phys Ther 1998;78:8–18. Level of evidence: 1B
• Manniche C, Hesselsoe G, Bentzen L, et al. Clinical trial of intensive muscle training for chronic low back pain. Lancet 1988;24– 31;2(8626–8627):1473–1476. Level of evidence: 1B
• Manniche C, Lundberg E, Christensen I, et al. Intensive dynamic back exercises for chronic low back pain: a clinical trial. Pain 1991;57:53–63.Level of evidence: 1B
• Hansen FR, Bendix T, Skov P, et al. Intensive dynamic back-muscle exercises, conventional physiotherapy, or placebocontrol treatment of low back pain. Spine 1993;18:98–107. Level of evidence: 1B
• O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997;22: 2959–67.Level of evidence: 1B
• L.H. Ribeiro, F. Jennings, A. Jones, R. Furtado, J. Natour. Effectiveness of a back school program in low back pain. Clinical and Experimental Rheumatology 2008; 26: 81-88. Level of evidence: 1B

Resources
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http://www.allaboutbackandneckpain.com/understandingconditions/segmentalinstability.asp

http://back-in-business-physiotherapy.com/physiotherapy-teaching/clinical-instability-of-the-lumbar-spine

http://emedicine.medscape.com/article/310353-differential

Clinical Bottom Line[edit | edit source]

Patient education may be important in the treatment of patients with segmental instability. Education should, first of all, focus on preventing loaded flexion movements, as they may create a posterior shift of the disc. Therapy and excercices is usefulll herefor.
The effectivity of back school program has been shown and is more effective than any educational intervention. , level of evidence 1C ]The exercise programme is based on training the patient to draw in the abdominal wall while isometrically contracting the multifidus muscle, and consists.

Recent Related Research (from Pubmed)
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Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1X3iPH1T_Q46BOv5FNkJFsK1JFmtizHcll3VxmJrGNBHOLIUs-|charset=UTF-8|short|max=10: Error parsing XML for RSS

• A literature review of clinical tests for lumbar instability in low back pain: validity and applicability in clinical practice.
• An exploratory examination of the association between altered lumbar motor control, joint mobility and low back pain in athletes.
• Comparison of chronic low-back pain patients hip range of motion with lumbar instability.
• Effects of hip exercises for chronic low-back pain patients with lumbar instability.
• Prevalence and individual risk factors associated with clinical lumbar instability in rice farmers with low back pain.
• http://www.ncbi.nlm.nih.gov/pubmed/?term=lumbar+instability
• http://www.ncbi.nlm.nih.gov/pubmed/?term=spine+instability
• http://www.ncbi.nlm.nih.gov/pubmed/?term=lumbar+spine+instability

References
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↑ Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Dis. 1992;5:390-397. Level of evidence: 4
↑ Kasai, Yuichi, et al. "A new evaluation method for lumbar spinal instability: passive lumbar extension test." Physical therapy 86.12 (2006): 1661-1667. Level of evidence: 3b
↑ P.B. O'Sullivan. Masterclass. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Manual therapy Volume 5, Issue 1, Pages 2–12, February 2000. Level of evidence: 2B
↑ James R Beazell, Melise Mullins and Terry L Grindstaff .Lumbar instability: an evolving and challenging concept. J Man Manip Ther. 2010 Mar; 18(1): 9–14. Level of evidence: 2A
↑ Abdullah M .Alqarni et al. Clinical tests to diagnose lumbar segmental instability&amp;amp;amp;amp;amp;amp;nbsp;: a systematic review. Journal of orthopaedic and sports physical therapy. March 2011. Level of evidence&amp;amp;amp;amp;amp;amp;nbsp;: 2A
↑ Ferrari et al. A literature review of clinical tests for lumbar instability in low back pain&amp;amp;amp;amp;amp;amp;nbsp;: validity and applicability in clinical practice. Chiropractic &amp;amp;amp;amp;amp;amp;amp;amp; Manual Therapies. 2015. Level of evidence&amp;amp;amp;amp;amp;amp;nbsp;: 2A

[1] Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Dis. 1992;5:390-397. Level of evidence: 4

[2] Kasai, Yuichi, et al. "A new evaluation method for lumbar spinal instability: passive lumbar extension test." Physical therapy 86.12 (2006): 1661-1667. Level of evidence: 3b

[3] P.B. O'Sullivan. Masterclass. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Manual therapy Volume 5, Issue 1, Pages 2–12, February 2000. Level of evidence: 2B

[4] James R Beazell, Melise Mullins and Terry L Grindstaff .Lumbar instability: an evolving and challenging concept. J Man Manip Ther. 2010 Mar; 18(1): 9–14. Level of evidence: 2A

[5] Abdullah M .Alqarni et al. Clinical tests to diagnose lumbar segmental instability&amp;amp;amp;amp;amp;nbsp;: a systematic review. Journal of orthopaedic and sports physical therapy. March 2011. Level of evidence&amp;amp;amp;amp;amp;nbsp;: 2A

[6] Ferrari et al. A literature review of clinical tests for lumbar instability in low back pain&amp;amp;amp;amp;amp;nbsp;: validity and applicability in clinical practice. Chiropractic &amp;amp;amp;amp;amp;amp;amp; Manual Therapies. 2015. Level of evidence&amp;amp;amp;amp;amp;nbsp;: 2A

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 == Physical examination  ==
-The physical examination may consist of multiple tests&nbsp;:<br>• Low midline sill sign&nbsp;: first there is an inspection of the low back to detect the low midline sill sign. The examiner palpates the interspinous space and evaluates the position of the upper spinous process in relation to the lower spinosus process.<ref>McGill SM. Estimation of force and extensor moment contributions of the disc and ligaments at L4–L5. Spine 1988;13:1395–402. Level of evidence: 1A</ref><br>• Interspinous gap change during lumbar flexion – extension motion&nbsp;: first there is an inspection of the low back to detect the interspinous gap change. Then the patient is asked to stand with his or her feet shoulder – width apart , flex their back and place both hands on an examination table. Then the examiner inspects the patient’s back at flexion , focusing on the gaps between interspinous processes.&nbsp;<ref name="34">McGill SM. Estimation of force and extensor moment contributions of the disc and ligaments at L4–L5. Spine 1988;13:1395–402. Level of evidence: 1A</ref><br>o Flexion&nbsp;: Palpation of the low back at flexion. The examiner palpates individual interspinous spaces of the patient’s back and evaluates the width of individual interspinous spaces and the position of the upper spinous process in relation to the lower spinous process. <ref>Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability&amp;amp;amp;amp;amp;amp;amp;nbsp;: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence&amp;amp;amp;amp;amp;amp;amp;nbsp;: 2B</ref><br>o Extension&nbsp;: Palpation of the low back at extension. The patient is asked to extend his or her upper body and push their buttocks toward the examination table as both hands are on the examination table , which reproduces lumbar extension from the flexion state. The examiner evaluates the interspinous gap change.&nbsp;<ref name="46">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability : low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence : 2B</ref><br>• Sit – to – stand test&nbsp;: pain immediately on sitting down and relieved by standing up.<ref name="47">Abdullah M .Alqarni et al. Clinical tests to diagnose lumbar segmental instability : a systematic review. Journal of orthopaedic and sports physical therapy. March 2011. Level of evidence : 2A</ref>
+The physical examination may consist of multiple tests&nbsp;:<br>• <u>Low midline sill sign</u>:<br>First there is an inspection of the midline of the patient’s low back to detect the low midline sill sign. If lumbar lordosis increases and there is a sill like a capital “L” on the midline, the test is considered positive. Next the examiner palpates the interspinous space and evaluates the position of the upper spinous process in relation to the lower spinosus process.<ref name="32">McGill SM. Estimation of force and extensor moment contributions of the disc and ligaments at L4–L5. Spine 1988;13:1395–402. Level of evidence: 1A</ref>&nbsp;If the upper spinous process is displaced anterior to the lower spinous process, the test positive.<ref name="33">McGill SM. Estimation of force and extensor moment contributions of the disc and ligaments at L4–L5. Spine 1988;13:1395– 402. Level of evidence: 1A</ref><br>
-• Passive Accessory Intervertebral Movements ( = PAIVM )&nbsp;: the intervertebral motion was tested with the patient prone. The examiner contacted the spinous process with the hypothenar eminence and produces a posterior – to – anterior force. Each segment was judged as normal mobility , hypermobility or hypomobility. Pain was writtes as present or absent.<ref name="47" /><br>• Posterior shear test&nbsp;: the patient is standing with his hands across the lower abdomen. The examiner place one hand over the patient’s crossed arms. The other hand was placed on the patient’s pelvis ( stabilisation ). There is a posterior shear force produced by the examiner through the patient’s abdomen. An anteriorly stabilizing force was produced with the other hand. The examiner repeats the test at each lumbar level by changing the point of contact of the posterior hand. The test is positive if familiar symptoms were provoked.&nbsp;<ref name="47" /><br>[http://www.physio-pedia.com/Posterior_pelvic_pain_provocation_test www.physio-pedia.com/Posterior_pelvic_pain_provocation_test]<br>• Prone instability test&nbsp;: The test is performed with the patient prone , with the trunk supported on the table and with the feet on the floor. Then the examiner performed a PAIVM test to each level of the lumbar spine. Any provocation of pain was recorded. Then the examiner repeats the test but now with the patient’s feet off the floor. The test was postive when pain was present in the resting position but subsided in the second position.&nbsp;<ref name="47" /><br>[http://www.physio-pedia.com/Prone_Instability_Test www.physio-pedia.com/Prone_Instability_Test]<br>• Beighton hypermobility scale&nbsp;: Ligamentous laxity measured with a 9-point Beighton scale. One point was given for each of the following aspects&nbsp;: knee hyperextension greater than 10° , elbow hyperextension greater than 10° , fifth finger hyperextension greater than 90° , thumb abduction to contact the forearm , and ability to flex the trunk and place hands flat on the floor with knees extended.<ref name="47" /><br>[http://www.physio-pedia.com/Beighton_score www.physio-pedia.com/Beighton_score]<br>• Passive Physiological Intervertebral Motion ( = PPIVM )&nbsp;: the patient sidelies. The test consisted of moving the patient’s spine through sagittal forward – bending ( flexion ) and backward – bending ( extension ) , using the lower extremities. Meanwhile the examiner palpates between the spinous process of the adjacent vertebrae to assess the motion taking place at each motion segment.&nbsp;<ref name="47" /><br>• Passive Lumbar Extension ( = PLE test )&nbsp;: the patient is in prone position. Then both lower extremities were elevated ( passive ) to a height of about 30cm. The knees maintain extended and the examiner gently pulls the legs of the patient.&nbsp;<ref name="47" /><br>• Instability catch sign&nbsp;: the patient bend his or her body forward as much as possible and then return to the neutral position. The test is positive when the patient isn’t able to return to the neutral position. <ref name="47" />&nbsp; &nbsp;
+[[Image:Figure_C.jpg]]<br>Figure 3<br><br>• <u>Interspinous gap change during lumbar flexion – extension motion</u>:<br> This test is used for the detection of lumbar instability. First there is an inspection of the low back to detect the interspinous gap change. The patient stands shoulder – width, flex his back and place both hands on an examination table. After inspection of the lower back in flexion, palpates and evaluates the physiotherapist the width of the individual interspinous spaced and the position of the upper spinous process in relation to the lower one.<ref name="33">McGill SM. Estimation of force and extensor moment contributions of the disc and ligaments at L4–L5. Spine 1988;13:1395– 402. Level of evidence: 1A</ref>
-&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;{{#ev:youtube|uCeqDALoi9E|300}}<br>• Painful catch sign&nbsp;: the patient is in supine position and then the examiner asks the patient to lift both lower extremities. The knees must be extended. Then the examiner asks the patient to return slowly to the begin positon. If the lower extremities fell down instantly because of the low back pain , the test was positive.&nbsp;<ref name="47" /><br>
+After this the physiotherapist will ask the patient to extend (to hollow) the low back while he evaluates the interspinous gap change during this motion. <ref name="35">Abdullah M .Alqarni et al. Clinical tests to diagnose lumbar segmental instability : a systematic review. Journal of orthopaedic and sports physical therapy. March 2011. Level of evidence : 2A</ref>, <ref name="33">McGill SM. Estimation of force and extensor moment contributions of the disc and ligaments at L4–L5. Spine 1988;13:1395– 402. Level of evidence: 1A</ref><br><br>[[Image:Figure_4.jpg]]<br>Figure 4<br>
-&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;{{#ev:youtube|FCmYMfv7Sm8|300}}
+• <u>Sit – to – stand test</u>:<ref name="47">Abdullah M .Alqarni et al. Clinical tests to diagnose lumbar segmental instability : a systematic review. Journal of orthopaedic and sports physical therapy. March 2011. Level of evidence : 2A</ref><br>The test is positive (there is an association with instability) if the person feels pain immediately when sitting down in a chair and if the pain is (partially)&nbsp;relieved by standing up.<br>The test result might vary (time of the day, type of seat, the patients’ symptom levels before the test).<br>- sensitivity: 30<br>- specificity: 100<br>- LR+: cannot be calculated<br>- LR-: 0,7<br>
-<br>&nbsp;• Apprehension sign&nbsp;: The examiner asks the patient if he or she has a sensation of lumbar collapse because of the low back pain while performing ordinary acts like bending back and forward , bending from side to side , sitting down or standig up. The test was positive if the patient had a sensation of lumbar collapse. <ref name="47" />The&nbsp;condition has a unique clinical presentation that displays its symptoms and movement dysfunction within the neutral zone of the motion segment. The loosening of the motion segment secondary to injury and associated dysfunction of the local muscle system renders it biomechanically vulnerable in the neutral zone. The clinical diagnosis of this chronic low back pain condition is based on the report of pain and the observation of movement dysfunction within the neutral zone and the associated finding of excessive intervertebral motion at the symptomatic level. Four different clinical patterns are described based on the directional nature of the injury and the manifestation of the patient's symptoms and motor dysfunction. A specific stabilizing exercise intervention based on a motor learning model is proposed and evidence for the efficacy of the approach provided.<ref>P.B. O'Sullivan. Masterclass. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Manual therapy Volume 5, Issue 1, Pages 2–12, February 2000. Level of evidence: 2B</ref><sup>,</sup><ref>James R Beazell, Melise Mullins and Terry L Grindstaff .Lumbar instability: an evolving and challenging concept. J Man Manip Ther. 2010 Mar; 18(1): 9–14. Level of evidence: 2A</ref><br>• The PLE is the most informative clinical test: sensitivity (0.84, 95% CI: 0.69 - 0.91) and high specificity (0.90, 95% CI: 0.85 -0.97).<br>• The diagnostic accuracy of AMP depends on each singular test. <br>• The PIT and the PST have a moderate sensitivity and specificity:<br>o PIT sensitivity = 0.71 (95% CI: 0.51 - 0.83), specificity = 0.57 (95% CI: 039 - 0.78); <br>o PST sensitivity = 0.50 (95% CI: 0.41 - 0.76), specificity = 0.48 (95% CI: 0.22 - 0.58).<br>The PLE showed a good reliability (k = 0.76), but needs more invesagation because this is the result of one study. <br>The inter-rater reliability of the PIT ranged by slight (k = 0.10 and 0.04), to good (k = 0.87).<br>The inter-rater reliability of the AMP ranged by slight (k = −0.07) to moderate (k = 0.64), whereas the inter-rater reliability of the PST was fair (k = 0.27). <ref>Silvano Ferarri et al., A literature review of clinical tests for lumbar instability in low back pain: validity and applicability in clinical practice. Chiropr Man Therap., April 2015; 23:14. Level of evidene: 2A</ref><br>
+• <u>Passive Accessory Intervertebral Movements ( = PAIVM)</u>: <ref name="34">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence:2B</ref>
-<br>
+www.physiopedia.com/Manual_Therapy_Techniques_For_The_Lumbar_Spine#PPIVMs
-In acute overt instability, stabilization of the spine is required in all cases. In this context, medical treatment refers to the use of external bracing for spine stabilization. If instability is due to an osseous fracture, if the fracture fragments can be reduced to near-anatomic alignment, and if there is no significant neural compression after reduction, the patient may be treated nonsurgically with a brace until the fracture heals.<br>In anticipated instability (eg, extensive discitis and osteomyeli)<br>The majorty of the tests has high specificity but low sensitivity. The PLE test ( = Passive Lumbar Extension test ) was found to have the highest combined sensitivity and specificity , as well as the highest LR+. The PLE test has a sensitivity of 84% , a specificity of 90% , a LR+ rate of 8,8 and an LR- rate of 0,2. <ref>Abdullah M .Alqarni et al. Clinical tests to diagnose lumbar segmental instability&amp;amp;amp;amp;amp;amp;amp;nbsp;: a systematic review. Journal of orthopaedic and sports physical therapy. March 2011. Level of evidence&amp;amp;amp;amp;amp;amp;amp;nbsp;: 2A</ref><sup>,</sup><ref>Ferrari et al. A literature review of clinical tests for lumbar instability in low back pain&amp;amp;amp;amp;amp;amp;amp;nbsp;: validity and applicability in clinical practice. Chiropractic &amp;amp;amp;amp;amp;amp;amp;amp;amp; Manual Therapies. 2015. Level of evidence&amp;amp;amp;amp;amp;amp;amp;nbsp;: 2A</ref><sup>,</sup><ref name="57">Silvano Ferarri et al., A literature review of clinical tests for lumbar instability in low back pain: validity and applicability in clinical practice. Chiropr Man Therap., April 2015; 23:14. Level of evidene: 2A</ref><sup></sup><br>
+- sensitivity: 46<br>- specificity: 81 <br>- LR+: 2,4<br>- LR-: 0,7
+https://www.youtube.com/watch?v=gAUFcaEw0I0<br><br>
+• <u>Prone instability test&nbsp;</u>:&nbsp;<ref name="34">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence: 2B</ref>,<ref name="75">Waddell G. The Back Pain Revolution. Edinburgh: Churchill Livingstone, 1998. Level: 2b</ref><br>[http://www.physio-pedia.com/Prone_Instability_Test www.physio-pedia.com/Prone_Instability_Test]
+- sensitivity: 61<br>- specificity: 57<br>- LR+: 1,4<br>- LR-: 0,7
+https://www.youtube.com/watch?v=OrgoC3mKhXQ<br>
+[http://www.physio-pedia.com/Prone_Instability_Test ]• <u>Beighton hypermobility scale</u>&nbsp;:&nbsp;<ref name="34">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence: 2B</ref>,<ref name="75">Waddell G. The Back Pain Revolution. Edinburgh: Churchill Livingstone, 1998. Level: 2b</ref><br>[http://www.physio-pedia.com/Beighton_score www.physio-pedia.com/Beighton_score]
+- sensitivity: 36 <br>- specificity: 86<br>- LR+: 2,5<br>- LR-: 0,8<br>
+[http://www.physio-pedia.com/Beighton_score ]• <u>Passive Physiological Intervertebral Motion ( = PPIVM )</u>:<ref name="34">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence: 2B</ref>,<ref name="76">Maigne JY, Lapeyre E, Morvan G, Chatellier G. Pain immediately upon sitting down and relieved by standing up is often associated with radiologic lumbar instability or marked anterior loss of disc space. Spine (Phila Pa 1976). 2003; 28: 1327– 1334. Level of evidence: 2b</ref><br><span style="font-size: 13.28px;">http://www.physiopedia.com/Manual_Therapy_Techniques_For_The_Lumbar_Spine#PPIV Ms
+</span><br>The patient side lies. The test consisted of moving the patient’s spine through sagittal forward – bending ( flexion ) and backward – bending ( extension ) , using the lower extremities. Meanwhile the examiner palpates between the spinous process of the adjacent vertebrae to assess the motion taking place at each motion segment.&nbsp;<ref name="47" /><br><br>PPIVM (flexion): <br>- sensitivity: 5 &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - specificity: 99,5<br>- LR+: 8,7 &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - LR-: 1,0
+PPIVM (extention) <br>- sensitivity: 16 &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - specificity: 98 <br>- LR+: 7,1 &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;- LR-: 0,9
+https://www.youtube.com/watch?v=HP6ZuG3NRNs<br><br><br>• <u>Passive Lumbar Extension Test ( = PLE test )</u>:<br>The patient is in prone position. The therapist elevates both lower extremities were elevated ( passive ) to a height of about 30cm. The knees maintain extended&nbsp;while gently pulling the legs. The examiner fixates T12 ventrocaudal. <ref name="34">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence: 2B</ref>,<ref name="26">Kasai, Yuichi, et al. "A new evaluation method for lumbar spinal instability: passive lumbar extension test." Physical therapy 86.12 (2006): 1661-1667.
+Level of evidence: 3b</ref>
+This test can also be done in lateral position of the patient with the legs bended. The test is positive if it provokes similar complaints.
+- sensitivity: 84<br>- specificity: 90<br>- LR+: 8,8<br>-&nbsp;LR-: 0,2<br><br>https://www.youtube.com/watch?v=eUJw9pxcV-g<br><br>• <u>Instability catch sign</u><u>&nbsp;= active flexion test</u>:<br>The patient bend his or her body forward as much as possible and then return to the neutral position. The test is positive when the patient isn’t able to return to the neutral position.<ref name="34">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence: 2B</ref>, <ref>Kasai, Yuichi, et al. "A new evaluation method for lumbar spinal instability: passive lumbar extension test." Physical therapy 86.12 (2006): 1661-1667.
+Level of evidence: 3b</ref><br>This test is a provocation test.
+- sensitivity: 26<br>- specificity: 86 LR+: 1,8<br>- LR-: 0,9<ref name="34">Kang Ahn et al. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion – extension motion. BMC Muscoluskeletal Disorders, 2015. Level of evidence: 2B</ref>
+https://www.youtube.com/watch?v=63clj33mkHc&nbsp; &nbsp; &nbsp;
+&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;{{#ev:youtube|uCeqDALoi9E|300}}<br>• <u>Painful catch sign</u>&nbsp;: <br>The patient is in supine position and then the examiner asks the patient to lift both lower extremities. The knees must be extended. Then the examiner asks the patient to return slowly to the start positon. If the lower extremities fell down instantly because of the low back pain , the test was positive.&nbsp;<ref name="47" /><br>
+- sensitivity: 37 <br>- specificity: 73 LR+: 1,4<br>- LR-: 0,9 &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<br>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;{{#ev:youtube|FCmYMfv7Sm8|300}}<br>https://www.youtube.com/watch?v=yb0hBo-51gY&nbsp;<br><br>&nbsp;•<u>Apprehension sign</u>&nbsp;: <br>The examiner asks the patient if he or she has a sensation of lumbar collapse because of the low back pain while performing ordinary acts like bending back and forward , bending from side to side , sitting down or standig up. The test was positive if the patient had a sensation of lumbar collapse. <ref name="47" />The&nbsp;condition has a unique clinical presentation that displays its symptoms and movement dysfunction within the neutral zone of the motion segment. The loosening of the motion segment secondary to injury and associated dysfunction of the local muscle system renders it biomechanically vulnerable in the neutral zone. The clinical diagnosis of this chronic low back pain condition is based on the report of pain and the observation of movement dysfunction within the neutral zone and the associated finding of excessive intervertebral motion at the symptomatic level. Four different clinical patterns are described based on the directional nature of the injury and the manifestation of the patient's symptoms and motor dysfunction. A specific stabilizing exercise intervention based on a motor learning model is proposed and evidence for the efficacy of the approach provided.<ref>P.B. O'Sullivan. Masterclass. Lumbar segmental ‘instability’: clinical presentation and specific stabilizing exercise management. Manual therapy Volume 5, Issue 1, Pages 2–12, February 2000. Level of evidence: 2B</ref><sup>,</sup><ref>James R Beazell, Melise Mullins and Terry L Grindstaff .Lumbar instability: an evolving and challenging concept. J Man Manip Ther. 2010 Mar; 18(1): 9–14. Level of evidence: 2A</ref>&nbsp;<ref name="26">Kasai, Yuichi, et al. "A new evaluation method for lumbar spinal instability: passive lumbar extension test." Physical therapy 86.12 (2006): 1661-1667.
+Level of evidence: 3b</ref>
+- sensitivity: 18<br>- specificity: 88 LR+: 1,6<br>- LR-: 0,9 &nbsp;<br><br>In acute overt instability, stabilization of the spine is required in all cases. In this context, medical treatment refers to the use of external bracing for spine stabilization. If instability is due to an osseous fracture, if the fracture fragments can be reduced to near-anatomic alignment, and if there is no significant neural compression after reduction, the patient may be treated nonsurgically with a brace until the fracture heals.<br><br>In anticipated instability (eg, extensive discitis and osteomyeli)<br>The majorty of the tests has high specificity but low sensitivity. Data suggest that PLE is the most appropriate tests to detect lumbar instability in specific LBP. The PLE test ( = Passive Lumbar Extension test) has a sensitivity of 84% , a specificity of 90% , a LR+ rate of 8,8 and an LR- rate of 0,2.<ref>Abdullah M .Alqarni et al. Clinical tests to diagnose lumbar segmental instability&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;: a systematic review. Journal of orthopaedic and sports physical therapy. March 2011. Level of evidence&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;: 2A</ref><sup>,</sup><ref>Ferrari et al. A literature review of clinical tests for lumbar instability in low back pain&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;: validity and applicability in clinical practice. Chiropractic &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Manual Therapies. 2015. Level of evidence&amp;amp;amp;amp;amp;amp;amp;amp;nbsp;: 2A</ref><sup>,</sup><ref name="57">Silvano Ferarri et al., A literature review of clinical tests for lumbar instability in low back pain: validity and applicability in clinical practice. Chiropr Man Therap., April 2015; 23:14. Level of evidene: 2A</ref><sup></sup><br>
 == Medical Management <br>  ==

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