Validation studies for the diagnosis of lumbar instability test are all based on bias by the absence of "gold standard", since none can compare their results with those obtained with another test that is universally accepted reference.
In Critical reading of a study on diagnosis , there are 10 questions to assess the validity of the study:
- Is there a test compared to "gold standard"? (Bias due to lack of gold standard)
- Amount of sample (bias interpretation / selection bias)
- Is there an adequate description of the test? (Reporting bias)
- Is a blind study? (Confirmation bias / selection bias)
- Is an independent study? (Confirmation bias)
- Is there data specificity, sensitivity and predictive value?
- What is the accuracy of the results?
- "The test is applicable in the clinic?
- Is it acceptable to do it? (Risks, discomforts, costs generated by the diagnosis)
- diagnose Is it a benefit?
90% of patients with low back pain have an accurate diagnosis. There is great difficulty in establishing the structure involved in pain, so some authors propose to classify on the basis of movement dysfunction in them.
The detailed description and classification of lumbar instability is far from Peter O'Sullivan.
clinical O'Sullivan directional
Based on observation and scientifically invalid
Common to all: the lack of control in the movement.
Pattern Bending (most common)
- Central pain
- Vulnerability in flexion + rotation activities
- Inability to maintain semi-flexed postures (making the bed, brushing teeth in the sink, etc.).
- Loss of lumbar lordosis in segmentp, which is accentuated in sitting, prone to subsequent pelvic scale and visible loss of extension in lumbar extension movements.
- Increased tone of the erector spinae in lumbar and thoracic high low to compensate.
- Need to rest your hands on your knees to return the trunk flexion.
- Inability to dissociate lumbar extension, pelvic anterior scale and thoracic extension.
- Inability to control segmental flexion movements such as squat, sit with your knees straight or hip flexion, "from sitting to standing, prone to bending of the segment, posterior pelvic scale and thoracic extension compensation.
- Inability to activate the multifidus at that level in co-contraction with the TrA.
- Many are not able to maintain the neutral segment fours and sitting.
- Increasing mobility in flexion and rotation of that segment.
Extension Master
- central pain.
- Vulnerability in extension activities + rotation (standing or bring your arms up, throw something, running, swimming).
- Increase in the unstable segment lordosis
- Increased muscle activity at that level often anterior pelvic scale.
- Associate to sway back posture.
- Test of hip extension and knee flexion in prone position shows a loss of control of abdominal and lumbar lordosis increased.
- Tendency to maintain lordosis in trunk flexion and hiperlordosar back from the position.
- Return of trunk flexion is often painful and need to assist the movement with his hands on his knees.
- Inability to start the subsequent scale pelvic and hip flexion independent activation of buttocks, rectus abdominis and external oblique.
- Muscle Test. Inability to contract the multifidus TrA unstable segment next to the neutral position rebound tendency to block the column.
- Increasing mobility in extension / rotation on the symptomatic level.
pattern Shift Lateral (Lateral Displacement)
- Unidirectional
- unilateral pain.
- Vulnerability in rotation + flexion activities
- Loss of lordosis at that level, associated with a lateral shift of the segment.
- Palapación standing multifidus inhibition reveals a side of the shift, and a decrease in tone / atrophy contralteral
- The shift is more pronounced in ipsilateral monopodal support and transfer weight to that side.
- Arco pain halfway through the trunk flexion.
- Loss of control in rotation and lateral shift in the direction of the supine leg raising, to make the bridge supported by one leg (unilateral bridge), in fours flexing an arm, "sitting to stand "and the squat (squat) usually reveal a trend toward the side of the shift.
- Inability to contract the multifidus bilaterally in co-contraction with the TrA, with dominance of the quadratus lumborum, erector spinae and ipsilateral lumbar multifidus and an inability to activate multifidus contralteral, associated with increased wall tone abdominal and respiratory blockage.
- Palpation revealed an increase of bending on that side (increased rotation and tilt in the direction of shift).
Multidirectional pattern
- Associated trauma.
- High level of pain and dysfunction.
- All weight loads are painful and hard to find relief.
- Locking in flexion maintained rotation or extension.
- The patient assumes a posture in flexion, extension, or lateral shift.
- Difficulty to assume the neutral lordotic.
- Irritability.
- Do not tolerate compressive loads.
- usually require IQ, poor prognosis with conservative treatment (exercise condition).
Lumbar Segmental Instability : clinical presentation and specific Stabilizing Exercise management. O'Sullivan PB. Manual Therapy (2000) 5 (1), 2-12
O'Sullivan clinical patterns are described in terms of impaired movement. Are themselves altered patterns of movement. With the Panjabi definition of instability and loss of the neutral zone, any alteration of the movement and seems to assume a static instability. Any lack of control seems to be an instability. Any person who benefits from the exercise of instability appears to be stabilizing.
ends not be clear that everything revolves around instability. O'Sullivan patterns seem very successful, and I think they are signs, symptoms and common findings in each of the patterns described, but do not seem very different from other patterns of movement disorder, described by other authors. In fact, O'Sullivan subdivides the extension pattern of active extension pattern and the pattern of passive extension. The pattern described above correspond to extension active. The pattern of passive extension is described in other texts as "sway back".
Is it useful to treat a disorder of movement and posture stabilization exercises to regain the "neutral zone"? I am sure it is.
Are these patterns are used to diagnose lumbar instability specifically? And beyond that, is it useful and specific classification of instability as a subgroup of patients with low back pain? Perhaps, in order to answer these questions, first we should agree on the definition of instability back, which is not the same as it is radiologically, for example.
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