130 | march 2011 | volume 41 | number 3 | journal of orthopaedic & sports physical therapy

[ LITERATURE REVIEW ]
L
ow back pain (LBP) continues to be a major health
problem and burden for individuals and society.
16,63
As LBP
is a heterogeneous condition, its classication into specic
subgroups or syndromes has been suggested to aid the
diagnosis of specic pathologies, assist in management decisions,
and improve outcomes.
8,25
Structural lumbar segmental instability
(LSI) is universally recognized as an
identiable subgroup of individuals with
LBP and is suggested to be a signicant
STUDY DESIGN: Systematic literature review.
OBJECTIVES: To evaluate the diagnostic accu-
racy of clinical tests used to diagnose patients with
structural lumbar segmental instability (LSI).
BACKGROUND: Patients with structural LSI
represent an important, identiable subgrouping of
individuals with low back pain. Numerous clinical
tests have been proposed to diagnose structural
LSI; however, data on the diagnostic accuracy of
these tests have not yet been evaluated through a
systematic review of the literature.
METHODS: A systematic review was conducted
in 6 electronic databases for diagnostic accuracy
studies, published between January 1950 and
March 2010, that evaluated clinical tests against
radiological diagnosis of structural LSI. The
diagnostic accuracy of the clinical tests from the
retrieved articles was independently evaluated, re-
viewed, and quality scored using the QUADAS tool.
RESULTS: Four articles and a total of 11 clinical
tests used in the diagnosis of structural LSI met
the study inclusion criteria. The majority of tests
had high specicity but low sensitivity, with posi-
tive likelihood ratios ranging from very small to
moderate. QUADAS scores ranged from 16 to 25
out of a possible 26. The passive lumbar extension
test was the most accurate clinical test, with high
sensitivity (84%), specicity (90%), and a positive
likelihood ratio of 8.8 (95% CI: 4.5, 17.3), indicating
that this clinical test may be useful in the diferen-
tial diagnosis of structural LSI.
CONCLUSION: This systematic review found
that the majority of clinical tests routinely em-
ployed to diagnose structural LSI demonstrated
only limited ability to do so. The results do, how-
ever, indicate that the passive lumbar extension
test may be useful in orthopaedic clinical practice
to diagnose structural LSI. Additional research is
required to further validate its use for diagnosing
structural LSI in all populations of those with low
back pain.
LEVEL OF EVIDENCE: Diagnosis, level 2a.
J Orthop Sports Phys Ther 2011;41(3):130-140,
Epub 2 February 2011. doi:10.2519/jospt.2011.3457
KEY WORDS: accuracy, low back pain, physical
examination, validity
1
Physical Therapist, Centre for Physiotherapy Research, University of Otago, Dunedin, New Zealand.
2
Senior Lecturer, Centre for Physiotherapy Research, University of Otago,
Dunedin, New Zealand.
3
Professional Practice Fellow, Centre for Physiotherapy Research, University of Otago, Dunedin, New Zealand. Address correspondence to Dr Anthony G.
Schneiders, School of Physiotherapy, University of Otago, 325 Great King Street, Dunedin, New Zealand. E-mail: tony.schneiders@otago.ac.nz
ABDULLAH M. ALQARNI, PT, MPhty
1
ANTHONY G. SCHNEIDERS, PT, PhD
2
PAUL A. HENDRICK, PT, MPhty
3
Clinical Tests to Diagnose
Lumbar Segmental Instability:
A Systematic Review
cause of morbidity associated with spinal
dysfunction.
23,42,48
The concept of structural LSI was
rst proposed by Knutsson,
32

who advocated the assessment of
LSI from the retrodisplacement
(anterior-to-posterior transla-
tion) of lumbar vertebrae on
lateral radiographs taken at end
range spinal exion and extension. Sub-
sequently, White and Panjabi
60
dened
the related concept of functional lum-
bar instability as loss of the spines ability
to maintain its pattern of displacement
under normal physiological loads. Pan-
jabi
44
further described functional LSI in
relation to the neutral and elastic zones
of the functional spinal unit. Functional
LSI is proposed to exist throughout spi-
nal motion; but assessment is specically
focused on midrange spinal movements,
where the neutral zone is suggested to be
more manifest.
17,19,50
While radiographic
diagnosis of structural LSI is considered
quantiable, traditionally by assessment
of vertebral translation at the end range
spinal motion,
52
the discrimination of
functional LSI has not been consistently
characterized in the literature and clini-
cal diagnostic tests for functional LSI
have not been specically evaluated. It
is, however, recognized that functional
instability can exist in the absence of ra-
diological evidence of LSI.
10
Cited causes of structural LSI include
disc degeneration,
7
postoperative spinal
fusion
40
(purported to produce abnormal
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journal of orthopaedic & sports physical therapy | volume 41 | number 3 | march 2011 | 131
pain,
42
an instability catch sensation
during return from a exed position,
41,55

and a sensation of slipping out during
the normal demands of spinal mobility.
41

Additionally, subjective patient reports
of pain exacerbation in the morning, on
standing or rolling over, and with wors-
ening weather, are all considered to be as-
sociated with structural LSI.
31
However,
to date, none of these clinical features
have been validated as accurate diagnos-
tic signs of structural LSI.
1
Orthopaedic clinical tests for structur-
al LSI have also been routinely described
in the literature and can be broadly di-
vided into either passive or active tests.
Passive tests include the posterior shear
agement strategies.
8,14,23
The diagnosis of
structural LSI currently relies on radio-
graphic conrmation, which exposes the
patient to radiation and has limitations
associated with access and cost.
47
Efec-
tive noninvasive clinical tests to identify
structural LSI would aid diferential di-
agnosis, as well as improve understand-
ing of the aetiology and management of
this condition.
Numerous clinical examination nd-
ings have been proposed and promoted
as signs and symptoms of structural LSI.
These signs include palpation of vertebral
malalignment, excessive passive interver-
tebral motion,
46
subjective patient reports
of giving away, locking, through range
stresses on adjacent cephalad or caudal
nonfused segments), postoperative disk
excision or extensive decompression, and
a history of trauma or recurrent LBP.
14

Furthermore, a number of coexisting
morphologies have been identied, in-
cluding traction spurs,
6,40
facet joint hy-
pertrophy, and osteophytic formation.
7

The estimated prevalence of structural
LSI reported in the literature ranges
from 12% of patients attending physical
therapy for nonspecic LBP
1
to 57% of
patients with LBP who are suspected of
having structural LSI.
23
The diferential diagnosis of LBP
subgroups, such as structural LSI, is
considered vital for more efective man-
Search strategy:
1. "low back pain" OR "instability" OR
"lumbar spine OR "spondylolisthesis" OR
"anterolisthesis " OR "posterolisthesis" OR
"spondylolysis"
2. "validity" OR "sensitivity" OR "specificity"
3. "diagnosis" OR "clinical tests" OR
"provocation tests" OR "palpation" OR
"physical examination"
4. (1 AND 2), (1 AND 3), (1 AND 2 AND 3)
Databases:
1. CINAHL (n = 483)
2. MEDLINE (n = 3741)
3. PubMed (n = 4512)
4. Scopus (n = 3343)
5. SPORTDiscus (n = 1331)
6. AMED (n = 311)
Electronic database searched
(n = 13721)
Included after title screen
(n = 230)
Full abstracts (n = 80)
Full texts (n = 6)
Full texts (n = 6)
Included in the review (n = 4)
Quality assessment
Excluded after abstracts screen
(n = 74)
Hand search reference
lists
Excluded after full text
screen (n = 2)
Duplications removed
(n = 150)
FIGURE. Search history.
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132 | march 2011 | volume 41 | number 3 | journal of orthopaedic & sports physical therapy
[ LITERATURE REVIEW ]
test,
14
the prone instability test,
33
passive
accessory intervertebral motion (PAIVM)
tests, passive physiological intervertebral
motion (PPIVM) tests,
33,35
and the pas-
sive lumbar extension (PLE) test.
30
Ac-
tive tests for structural LSI have included
symptom reproduction during the sit-to-
stand
34
and the observation of an insta-
bility catch during return from exion.
55
Despite the large number of clinical
tests proposed to diagnose structural LSI,
these tests have not yet been compared
for their diagnostic accuracy and, conse-
quently, no single test has been identied
as superior to another and, subsequently,
further investigated or incorporated ex-
clusively into clinical practice. Therefore,
the aim of this paper was to systematical-
ly review the literature related to clinical
tests for structural LSI to establish which
tests have the best diagnostic accuracy
and utility in musculoskeletal and ortho-
paedic clinical practice.
METHODS
Search Strategy
A
systematic search of relevant
literature was conducted on No-
vember 1, 2009, and the search
strategy results were monitored until
March 1, 2010. A comprehensive search,
with no language restriction, was con-
ducted in the following databases: CIN-
HAL, PubMed, MEDLINE, SCOPUS,
AMED, and SPORTDiscus from Janu-
ary 1950 to March 2010. The following
search terms were employed in various
combinations, as outlined in the FIGURE:
low back pain, instability, lumbar
spine, spondylolisthesis, anterolisthe-
sis, posterolisthesis, spondylolysis,
validity, sensitivity, specicity, diag-
nosis, clinical tests, provocation tests,
palpation, and physical examination.
There were no restrictions placed on the
age of patients in the retrieved articles.
Studies considered for inclusion re-
ported the use of clinical tests to diag-
nose structural LSI and were published
as full reports before March 1, 2010. The
inclusion criteria were that articles had
to (1) report 1 or more clinical diagnostic
tests for structural LSI, (2) establish a ra-
diographic diagnosis of translational LSI
(exion-extension radiographs),
32
and (3)
report or allow computation of diagnostic
accuracy (sensitivity, specicity, and posi-
tive and negative likelihood ratios) for the
tests used to diagnose structural LSI.
From the results of the initial search,
the rst reviewer (A.M.A.) evaluated the
titles and abstracts of retrieved articles for
possible inclusion. Retained titles were
subsequently assessed by 2 independent
reviewers (A.M.A. and P.A.H.) for poten-
tial inclusion and retrieval of the full text
article. Full text articles were screened in-
dependently for inclusion by 2 reviewers
(A.M.A. and P.A.H.). If these 2 reviewers
were unable to reach a consensus, a third
reviewer (A.G.S.) was consulted. The ref-
erence lists of all included articles were
searched for additional relevant referenc-
es. The reviewers, who were experienced
orthopaedic manipulative physical thera-
pists and active researchers, were famil-
iar with the literature and, therefore, not
blinded to the authors, date of the pub-
lication, or journals in which the articles
were published. Two international experts
in LSI research were also consulted to en-
sure full inclusion of all potential articles
on the diagnosis of LSI. A summary of the
articles selected for review is presented in
TABLE 1.
Diagnostic Accuracy Statistics
Articles investigating the diagnostic ac-
curacy of clinical binary classication
tests to diagnose radiographically con-
rmed structural LSI were required to
report, or allow calculation of, sensitiv-
ity, specicity, and the positive likelihood
ratio (+LR) and negative likelihood ratio
(LR) for each included test
24
(TABLE 2).
Quality Assessment
The methodological quality of included
articles was assessed independently by 2
reviewers (A.M.A. and A.G.S.), using the
Quality Assessment of Diagnostic Accu-
racy Studies (QUADAS) tool developed
by Whiting et al.
62
The QUADAS tool is
comprised of 14 items that are individu-
ally scored as either yes, no, or unclear
(TABLE 3). Nine of the 14 items relate to
bias, 3 to the quality of the reporting, and
2 to variability. The reviewers familiar-
ized themselves with the QUADAS and
discussed the quality items and the scor-
ing system prior to the evaluation, to pro-
vide uniform interpretation of each study
and to avoid quality assessment bias.
When studies either satised or failed to
meet the criteria, the 2 reviewers inde-
pendently scored each of the 14 items yes
or no, respectively. Items were scored as
unclear when information lacked enough
detail for the reviewers to decide whether
the study satised or met a specic item.
In the case of any disagreement, a third
reviewer (P.A.H.) was consulted and
adjudicated.
Scoring and Quality of Papers
The original QUADAS tool did not ini-
tially incorporate a system for scoring
quality. For this systematic review, we
used the methods subsequently proposed
by the original developers.
62
Item weight-
ings, based and scaled for potential bias
or variation, were used to develop the
scoring system for the studies.
61
There-
fore, items 1, 5, 10, 11, and 12 were scored
3 points for yes, while items 3 and 6 were
scored 2 points for yes, and all other
items (2, 4, 7, 8, 9, 13, and 14) were scored
1 point for yes. All items were scored zero
if the response was no or unable to be
determined (unclear), which resulted in
a total possible score of 26 (TABLE 3). As
it was considered that the number of ar-
ticles retrieved during this review would
likely be low and it was recognized that
rating scores might afect conclusions
based on the quality of estimates of diag-
nostic accuracy,
61
studies were not strati-
ed into high quality or low quality
using the QUADAS quality score.
RESULTS
T
he initial electronic database
search yielded a total of 13 721 ar-
ticles (FIGURE). After reviewing all
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journal of orthopaedic & sports physical therapy | volume 41 | number 3 | march 2011 | 133
titles for key words and context, 230
articles were selected for possible inclu-
sion in the review. After title duplica-
tions were removed, 80 article abstracts
were screened, based on the inclusion
criteria. After full text examination, 4
articles
1,23,30,34
met the inclusion crite-
ria and were vetted by 2 international
experts who conrmed that they knew
of no other published literature on this
topic. All 4 articles were subsequently as-
sessed using the QUADAS tool.
62
A total
of 11 clinical tests used in the diagnosis
of structural LSI were reviewed from the
4 retrieved articles. The quality scores on
the QUADAS tool ranged from 16
34
to 25
out of a possible 26.
23
Sensitivity, specic-
ity, likelihood ratios (LRs), and associated
condence intervals (95% CIs) were cal-
culated from the study data if they were
not specically provided in the original
articles.
24
The study by Fritz et al
23
had a high
(25/26) QUADAS quality score. The sen-
sitivity, specicity, and +LR reported for
tests to diagnose LSI in a cohort of 42
patients with chronic LBP (CLBP) were,
respectively, as follows: 46%, 81%, and
2.4 for PAIVM; 57%, 48%, and 1.1 for
the posterior shear test; 36%, 86%, and
2.5 for the Beighton hypermobility scale;
18%, 90%, and 1.9 for aberrant motions;
and 61%, 57%, and 1.4 for the prone in-
stability test (TABLE 1).
The study by Abbott et al
1
had a QUA-
DAS quality score of 19/26 and reported
high specicity (89%) but low sensitivity
(29%) for PAIVM (+LR, 2.5) to diagnose
structural LSI in a cohort of 138 patients
(mean age, 40 years) with CLBP, recruit-
ed from physical therapy clinics. PPIVMs
in exion were highly specic (99.5%)
but showed very low sensitivity (5%)
(+LR, 8.7). Extension PPIVM also had
low sensitivity (16%) and high specicity
(98%) (+LR, 7.1).
Maigne et al
34
investigated the ability
of the sit-to-stand test to diagnose struc-
tural LSI in 42 patients (mean age, 55
years) with CLBP, recruited from a physi-

TABLE 1 Summary of Diagnostic Accuracy
Abbreviations: ICC, intraclass correlation coefcient; +LR, positive likelihood ratio; LR, negative likelihood ratio; PAIVM, passive accessory intervertebral
movements; PPIVM, passive physiological intervertebral movements.
*Innite value. Positive diagnostic likelihood ratios cannot be calculated for tests with a specicity of 100.

Including instability catch, painful arc, thigh climbing, or reversal of lumbopelvic rhythm.

Not rounded, as reported in the original article.

Authors Tests (Reported Interrater Reliability) Subjects (n) Sensitivity (95% CI) Specicity (95% CI) +LR (95% CI) LR (95% CI) QUADAS (n/26)
Maigne et al
34
42 16
Sit-to-stand test 31 (10, 61) 100 (85, 100) * 0.7 (0.5, 1.0)
Fritz et al
23
49 25
PAIVM 46 (30, 64) 81 (60, 92) 2.4 (0.9, 6.4) 0.7 (0.4, 1.0)
Posterior shear test ( = 0.27)
28
57 (37, 75) 48 (26, 70) 1.1 (0.7, 1.8) 0.9 (0.5, 1.5)
Prone instability test ( = 0.69)
28
61 (41, 78) 57 (34, 77) 1.4 (0.8, 2.5) 0.7 (0.4, 1.2)
Aberrant motions ( = 0.07)
28
18 (7, 38) 90 (68, 98) 1.9 (0.4, 8.7) 0.9 (0.5, 1.1)
Beighton hypermobility scale, 36 (21, 54) 86 (65, 94) 2.5 (0.8, 8.0) 0.8 (0.5, 1.0)
greater than 2 points (ICC = 0.72)
28
Abbott et al
1
138 19
PAIVM 29 (14, 50) 89 (83, 93) 2.5 (1.2, 5.5) 0.8 (0.6, 1.1)
PPIVM (exion) 5 (1, 22) 99.5 (97, 100)

8.7 (0.6, 134.7) 1.0 (0.9, 1.1)

PPIVM (extension) 16 (6, 38) 98 (94, 99) 7.1 (1.7, 29.2) 0.9 (0.7, 1.1)
Kasai et al
30
122 18
Passive lumbar extension test 84 (68, 93) 90 (82, 96) 8.8 (4.5, 17.3) 0.2 (0.1, 0.4)
Instability catch sign 26 (14, 43) 86 (76, 92) 1.8 (0.9, 3.9) 0.9 (0.7, 1.0)
Painful catch sign 37 (22, 54) 73 (62, 82) 1.4 (0.8, 2.3) 0.9 (0.7, 1.1)
Apprehension sign 18 (8, 35) 88 (79, 94) 1.6 (0.6, 3.8) 0.9 (0.8, 1.1)
TABLE 2
Clinical Interpretation
of Likelihood Ratios
29
+LR LR Shift in Probability Condition Is Present
>10 <0.1 Large, often conclusive
5-10 0.1-0.2 Moderate but usually important
2-5 0.2-0.5 Small, sometimes important
1-2 0.5-1.0 Very small, rarely important
Abbreviations: +LR, positive likelihood ratio; LR, negative likelihood ratio.
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[ LITERATURE REVIEW ]
cal medicine clinic. Subjects were includ-
ed in the study based on their subjective
report of pain that occurred immediately
or within 2 to 3 minutes of sitting down
and was totally or partially relieved by
standing up. This study had the lowest
QUADAS quality score (16/26). These
authors reported a specicity of 100%
and a sensitivity of 31% for this test to
diagnose LSI (+LR cannot be calculated
for tests with a specicity of 100%).
The PLE test was used by Kasai et al
30

to diagnose structural LSI. The QUADAS
quality score for this study was 18/26.
The sensitivity, specicity, and +LR for
this test were reported, respectively, as
84%, 90%, and 8.8 (95% CI: 4.5, 17.3).
The study population consisted of 122 el-
derly patients (mean age, 69 years) with
mixed lumbar pathology (89 patients
concurrently diagnosed with spinal ste-
nosis, 21 with lumbar spondylolisthesis,
and 12 with lumbar degenerative scolio-
sis). The sensitivity values for the other
structural LSI signs investigated were
26% for the instability catch sign, 37%
for the painful catch sign, and 18% for the
apprehension sign. The specicity values
of these 3 signs/tests were 86%, 73%, and
88%, respectively, and the +LRs were 1.8,
1.4, and 1.6, respectively.
The QUADAS tool identied study
criteria that were considered to be im-
portant to the methodological quality
of the retrieved articles. For instance,
the study by Maigne et al
34
was judged
to have a limited spectrum of patients,
who were not necessarily representa-
tive of patients who would receive the
test in practice, while the Kasai et al
30

study lacked sufcient description for
this criterion and, subsequently, received
the same quality score. Patient selection
criteria were clearly described by all ar-
ticles,
1,23,34
except Kasai et al
30
; however,
all studies used the same radiographic
exion-extension reference test to diag-
nose structural LSI, independent of the
clinical index result. All clinical testing
procedures were fully detailed to permit
replication, except the aberrant motion
test in the study by Fritz et al.
23
The majority of studies did not pro-
vide sufcient information about the
period between the performance of the
clinical tests and the subsequent radio-
logical examination, with the limitation

TABLE 3 QUADAS Scores for Each of the Included Studies
Abbreviations: N, no; U, unclear; Y, yes.
*Percent agreement between initial 2 reviewers.
Study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Total
Maigne et al
34
N Y Y U Y Y Y Y Y Y U U Y Y
0 1 2 0 3 2 1 1 1 3 0 0 1 1 16
Fritz et al
23
Y Y Y Y Y Y Y N Y Y Y Y Y Y
3 1 2 1 3 2 1 0 1 3 3 3 1 1 25
Abbott et al
1
Y Y Y U Y Y Y Y Y Y U U Y Y
3 1 2 0 3 2 1 1 1 3 0 0 1 1 19
Kasai et al
30
U N Y U Y Y Y Y Y Y Y U Y Y
0 0 2 0 3 2 1 1 1 3 3 0 1 1 18
Agreement (%)* 50 75 75 75 100 75 100 100 75 50 75 75 100 100
Item Criteria
1. Was the spectrum of patients representative of the patients who will receive the test in practice?
2. Were selection criteria clearly described?
3. Is the reference standard likely to correctly classify the target condition?
4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the 2 tests?
5. Did the whole sample or a random selection of the sample receive verication using a reference standard of diagnosis?
6. Did patients receive the same reference standard regardless of the index text result?
7. Was the reference standard independent of the index test (ie, the index test did not form part of the reference standard)?
8. Was the execution of the index test described in sufcient detail to permit replication of the test?
9. Was the execution of the reference standard described in sufcient detail to permit its replication?
10. Were the index test results interpreted without knowledge of the results of the reference standard?
11. Were the reference standard results interpreted without knowledge of the results of the index test?
12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?
13. Were uninterpretable/intermediate test results reported?
14. Were withdrawals from the study explained?
Item
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journal of orthopaedic & sports physical therapy | volume 41 | number 3 | march 2011 | 135
that the target condition might have
changed in the interim.
1,30,34
The blind-
ing of assessors for the clinical testing
procedures and radiographic diagnosis
of spinal instability was reported in all
studies, as was the incidence of uninter-
pretable test results and withdrawal of
patients. Abbott et al
1
and Maigne et al
34

did not report whether interpretation of
the radiological examination occurred
without knowledge of the clinical test
results, while only Fritz et al
23
reported
on the knowledge and availability of full,
relevant clinical data for interpretation of
the clinical test results, as used in clinical
practice.
23
The quality score for each item, to-
tal score, and the percentage agreement
between the 2 reviewers is presented in
TABLE 3. All items had an initial review-
er agreement that ranged from 50% to
100%. Items 1 and 10, which were related
to patient spectrums and interpretation
of the index test results retrospectively,
had the lowest agreement (50%). Seven
items (2, 3, 4, 6, 9, 11, and 12) had 75%
agreement, while 5 items (5, 7, 8, 13, and
14) had a 100% agreement, between the
2 reviewers. The third reviewer (P.A.H.)
adjudicated in all cases where agreement
was not initially reached, resulting in the
nal scores reported in TABLE 3.
DISCUSSION
The purpose of this systematic review
was to evaluate the current evidence for
clinical tests to diagnose structural LSI
in musculoskeletal and orthopaedic clini-
cal practice. The ability of clinical tests
to diagnose structural LSI independent
of radiographic investigations is consid-
ered important to expedite diagnosis and
guide subsequent management, while
limiting the exposure of patients to as-
sociated risks and further costs.
58
A total
of 11 clinical tests used in the diagnosis
of 351 patients were identied from 4 ar-
ticles that met the inclusion criteria for
the study.
1,23,30,34
The results of the review show that
diagnostic specicity values for all tests
were consistently higher than sensitivity
values, with the exception of the poste-
rior shear test and prone instability test
(TABLE 1). A negative result for a test with
high sensitivity indicates that the test
may have value in ruling out LSI, and
a positive result for a test that has high
specicity may be useful to rule in the
condition.
12
Likelihood ratios incorporate
both the sensitivity and specicity of a
test, and provide a direct estimate of how
much a test result will change the odds of
having the condition.
15
In this study, the
+LRs for structural LSI tests ranged from
1.1 to 8.8. The clinical interpretation of
these values is presented in TABLE 2.
Two studies
1,23
examined the abil-
ity of PAIVM
33,35
to diagnose structural
LSI. The study by Fritz et al
23
reported
low sensitivity (46%) and relatively high

TABLE 4 Study Characteristics
Abbreviations: LBP; low back pain; PAIVM, passive accessory intervertebral movements; PLE, passive lumbar extension; PPIVM, passive physiological inter-
vertebral movements; RCLBP, recurrent chronic low back pain; ROM, range of motion.
*Reference tests for all studies.

Aberrant motion include instability catch, painful arc, thigh climbing, or reversal of lumbopelvic rhythm.
Study Subjects Examiners
Denition of Instability From
Flexion-Extension Radiographs* Index Tests Denition of Positive Index Test
Maigne et al
34
42 patients; mean SD age,
54.9 9.8 y; CLBP greater
than 2 mo
3 physicians Translation greater than 10%
(4.5-5.0 mm)
Sit-to-stand Pain upon sitting down and
relieved by standing up
Fritz et al
23
49 patients; mean SD age,
39.3 11.3 y; LBP, median
duration of symptoms, 78 d
1 physical therapist Translation greater than 4.5 mm
or greater than 15% of the
vertebral body width
PAIVM Hypermobility
Posterior shear test Symptom provocation
Prone instability test Symptom provocation
Aberrant motions

Any aberrant motions during

exion/extension ROM
Beighton hypermobility
scale
More than 2 points on scale
Abbott et al
1
138 patients; mean age,
40 y (range, 20-75 y);
RCLBP, greater than 3 mo
27 physiotherapists Translation greater than 2 SDs
from the reference mean of
asymptomatic individuals
using Gaussian denition
PAIVM Hypermobility and/or pain
PPIVM (exion) Hypermobility and/or pain
PPIVM (extension) Hypermobility and/or pain
Kasai et al
30
122 patients; mean age, 68.9 y
(range, 39-88 y); LBP, duration
1 mo to 5 y
3 orthopaedists; 2
examined PLE, 1
examined other tests
Translation motion of 5 mm PLE test LBP or discomfort during test
Instability catch sign Sudden LBP during movement test
Painful catch sign Sudden LBP during movement test
Apprehension sign Sudden LBP during movement test
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136 | march 2011 | volume 41 | number 3 | journal of orthopaedic & sports physical therapy
[ LITERATURE REVIEW ]
specicity (81%), while Abbott et al
1
re-
ported similar high specicity (89%) but
lower sensitivity (29%) (TABLES 1 and 4).
Diferences in selection criteria might
have afected the specicity value in the
study by Fritz et al,
23
as it included pa-
tients who were already suspected of hav-
ing LSI. Both studies reported similar
+LRs, with patients being approximately
2.5 times more likely to have a radiologi-
cal diagnosis of LSI following a positive
PAIVM test.
For a diagnostic test to be valid, it
must have acceptable reliability.
26
The
reliability of PAIVM testing is dependent
on a number of intrinsic and extrinsic
factors,
5,57
and poor interrater reliability
( = 0.02, 0.26) has been reported for
judgment of segmental mobility.
28
It is
suggested that standardization of PAIVM
testing would improve the reliability and,
potentially, the ability of these tests to di-
agnose structural LSI.
Abbott et al
1
reported that exion
PPIVM had very high specicity (99.5%)
but very low sensitivity (5%), and a mod-
erate +LR (8.7) (95% CI: 0.6, 134.7) for
the diagnosis of structural LSI. However,
the width of the +LR condence interval
indicates the imprecision of the estimate,
which was potentially due to an inad-
equate sample size to efectively evaluate
the diagnostic accuracy of this test.
20
The
authors also found that extension PPIVM
had low sensitivity (16%), high specicity
(98%), and a moderate +LR (7.1) (95%
CI: 1.7, 29.2) to diagnose LSI. These
results suggest that extension PPIVM,
compared to exion PPIVM, might have
greater clinical accuracy in the diagnosis
of LSI, which is not unexpected, given
the extension bias seen in the majority

TABLE 5 Clinical Tests for Structural LSI
Abbreviations: LSI, lumbar segmental instability; PAIVM, passive accessory intervertebral movements; PPIVM, passive physiological intervertebral move-
ments; PLE, passive lumbar extension; ROM, range of motion.
Test Description of Test
Sit-to-stand
34
Pain immediately on sitting down and relieved by standing up.
PAIVM
23
Intervertebral motion was tested with the patient prone. The examiner contacted the spinous process with the hypothenar eminence and produced a
posterior-to-anterior force. The mobility of each segment was judged as normal, hypermobile, or hypomobile. The presence of pain was recorded as
present or absent.
Posterior shear test
23
The test was performed with the patient standing, with hands across the lower abdomen. The examiner placed one hand over the patients crossed
arms. The heel of the other hand was placed on the patients pelvis for stabilization. The examiner produced a posterior shear force through the
patients abdomen, and an anteriorly directed stabilizing force with the opposite hand. The test was repeated at each lumbar level by changing the
point of contact of the posterior hand. A positive test occurred if familiar symptoms were provoked, and is proposed to indicate lumbar instability.
Prone instability test
23
The test was performed with the patient prone, with the trunk supported on the examining table and the feet resting on the oor. With the patient in
this position, the examiner performed a PAIVM test to each level of the lumbar spine. Any provocation of pain was recorded. The patient then lifted
the feet of the oor and the PAIVM test was repeated. If pain was present in the resting position but subsided in the second position, the test was
positive.
Aberrant motion
23
Any aberrant motions that are present during exion-extension ROM, including instability catch, painful arc of motion, thigh climbing, reversal of
lumbopelvic rhythm.
Beighton hypermobility scale
23
General ligamentous laxity was assessed with the 9-point Beighton scale. One point was given for each of the following: knee hyperextension greater
than 10, elbow hyperextension greater than 10, fth nger hyperextension greater than 90, thumb abduction to contact the forearm, and ability to
ex the trunk and place hands at on the oor with knees extended.
PPIVM
1
PPIVMs were assessed with the patient sidelying, and consisted of moving the patients spine through sagittal forward-bending (exion) and backward-
bending (extension), using the lower extremities, while palpating between the spinous process of the adjacent vertebrae to assess the motion taking
place at each motion segment.
PLE test
30
The subject was in the prone position. Both lower extremities were then passively elevated, concurrently, to a height of about 30 cm from the bed, while
maintaining the knees extended, and gently pulling the legs.
Instability catch sign
30
The subject was asked to bend his/her body forward as much as possible and then to return to the erect position. A subject who was not able to return
to the erect position because of sudden low back pain was judged to have lumbar spinal instability.
Painful catch sign
30
The subject was in a supine position and was asked to lift both lower extremities, while keeping the knees extended, and then to return his/her lower
extremities slowly to the examination table. If the subjects lower extremities fell down instantly to the examination table because of sudden low back
pain, the subject was judged to have lumbar spinal instability.
Apprehension sign
30
The subject was asked whether he/she had felt a sensation of lumbar collapse because of sudden low back pain, when performing ordinary acts, includ-
ing bending back and forth, from side to side, and sitting down or standing up. The subjects who had experienced such a sensation were judged to
have lumbar spinal instability.
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journal of orthopaedic & sports physical therapy | volume 41 | number 3 | march 2011 | 137
of both active and passive testing proce-
dures for LSI.
The posterior shear test was original-
ly described by Delitto et al
14
as a test to
diagnose LSI. The results of this review
demonstrated relatively poor sensitiv-
ity (57%), specicity (48%), and, conse-
quently, a small +LR (1.1) for this test,
23

which has also been shown to have poor
intrarater ( = 0.27)
23
and interrater ( =
0.22) reliability.
28
These results indicate
that the posterior shear test has limited
overall diagnostic ability to diagnose LSI.
The prone instability test
33
demon-
strated low to moderate sensitivity (61%)
and specicity (57%), and a low +LR
(1.4),
23
which suggests that the test has
limited ability to accurately diagnose
structural LSI. Moderate intrarater re-
liability ( = 0.69)
23
and the previously
reported almost perfect interrater re-
liability ( = 0.87) for this test are sug-
gested to support this nding.
28
The Beighton hypermobility scale
4
has
been previously shown to have a positive
correlation with structural LSI.
23
This
test had low sensitivity (36%) and high
specicity (86%), and a relatively small
+LR (2.5). The high intrarater reliabil-
ity (ICC = 0.72) and specicity values
in the retrieved study,
23
combined with
previously reported high reliability coef-
cients (ICC = 0.79),
28
suggest that this
test may be of some clinical use to rule in
patients with a positive diagnosis of LSI.
However, the low +LR, which in clini-
cal interpretation is considered to be of
greater diagnostic value than sensitivity
and specicity values alone, makes this
unlikely.
Maigne et al
34
examined the ability of
the sit-to-stand test to diagnose struc-
tural LSI. The study compared patients
whose LBP occurred immediately upon
sitting down and was relieved on stand-
ing up, with a control group whose LBP
did not show this pattern. The sit-to-
stand test had a specicity of 100% and
a sensitivity of 31% within this patient
population. However, recruitment bias
might explain the high specicity, as
only patients who previously reported a
positive sit-to-stand test were selected
for the study group. This article had the
lowest QUADAS score, and the authors
reported that the test result might vary,
depending on time of day that the test
was conducted, the type of seat employed,
and the patients symptom levels before
the test.
46
The authors also reported that
these symptoms were observed in only
1 of 70 patients presenting with CLBP,
which is much lower than the expected
incidence of structural LSI in the CLBP
population.
49,59
Due to these factors, ad-
ditional research is needed to address
identied study limitations and to deter-
mine the tests true diagnostic ability and
clinical utility.
The PLE test is a relatively new meth-
od for examining structural LSI origi-
nally reported by Kasai et al.
30
The test
requires the patient to lie prone, while
the clinician lifts both lower extremities
into extension to a height of approxi-
mately 30 cm, while providing some
traction to the lower extremities. During
this maneuver, a positive test is based on
an increase in pain that disappears on
return to the starting position. In an at-
tempt to diagnose structural LSI, Kasai
et al
30
used the PLE test to examine 122
patients with mixed lumbar pathology
(TABLE 4). The PLE test was standardized
and performed twice, at an interval of 2
to 4 weeks, by 2 independent orthopae-
dists. They reported no disparate test
results between the 2 sessions, which
suggests substantial test-retest reliabil-
ity. The sensitivity, specicity, and +LR of
the PLE test were reported as 84%, 90%,
and 8.8 (95% CI: 4.5, 17.3), respectively,
indicating that the PLE test is a poten-
tially efective clinical test to diagnose
structural LSI. However, the prevalence
rate for structural LSI in this study was
relatively high (31%), which might be due
to the studys elderly population sample,
with high rates of spinal degeneration,
stenosis, spondylolisthesis, and concur-
rent LSI. Therefore, although these re-
sults are promising, further investigation
of this test should be undertaken in other
patient populations, across diferent age
groups, and with diferent assessors, to
further evaluate its reliability and accu-
racy to diagnose structural LSI.
Kasai et al
30
also investigated a range
of active movement signs/tests to diag-
nose structural LSI (TABLE 1). The instabil-
ity catch sign, painful catch sign, and the
apprehension sign all had relatively low
sensitivity and high specicity, resulting
in very small +LRs. These results sug-
gest that these tests would more likely
produce high false negative rates if used
to diagnose structural LSI in research
and clinical practice (TABLE 1). Similarly,
Fritz et al
23
reported that a selection of
aberrant motion test procedures dem-
onstrated the same pattern of diagnostic
accuracy and poor intrarater reliability (
= 0.07), conrming the limited value of
these signs/tests to diagnose structural
LSI.
Clinical tests, such as those described
in this review (TABLE 5), are not the only
measures reported in the literature that
are suggested to aid the diagnosis of
structural LSI. Patient history of asso-
ciated signs and symptoms suggestive
of LSI has also been reported. Kasai et
al
31
interviewed 368 patients with lum-
bar degenerative disease, of which 88
patients had structural LSI identied
by imaging (translation greater than or
equal to 5 mm). The results showed that
pain on standing up and rolling over had
the highest sensitivity (58% and 55%,
respectively) and specicity (88% and
93%, respectively) for LSI, and a report
of morning pain, with morning being the
most painful time of day, had a sensitiv-
ity of 74% and specicity of 80%. Symp-
toms exacerbated by worsening weather
had 65% sensitivity and 94% specicity.
These results highlight the possibility
that symptoms exacerbated by specic
movements and the timing of symptoms
could assist clinicians in diagnosing
structural LSI.
The clinical implications of a positive
diagnosis of structural LSI are inevitably
related to either surgical or conservative
management of this condition. Lumbar
spinal fusion is usually suggested for
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138 | march 2011 | volume 41 | number 3 | journal of orthopaedic & sports physical therapy
[ LITERATURE REVIEW ]
patients with severe symptoms and ra-
diographic evidence of hypermobility
(greater than 4 mm of vertebral transla-
tion), who do not respond to conservative
treatment.
53
More commonly, conserva-
tive treatment is indicated; however,
there are few studies that have speci-
cally addressed the conservative man-
agement of radiologically determined
structural instability.
38,39,43
Reported con-
servative management has included brac-
es or corsets
14,54
and patient education to
avoid overloading the passive stabilizing
structures of the spine at end range.
21,22

However, the mainstay of conservative
management for instability-related lum-
bar spine pain has focused on exercises
to improve neuromuscular control of the
spine.
9
Various strengthening programs
targeting specic groups of muscles have
been reported in the literature
36,37,42,51
;
however, no one specic program has
demonstrated superiority over another.
9,21

Further research is needed to identify
the most efective strategies for patients
with identied instability classications.
21

Conversely, the clinical implications of
negative test ndings for structural LSI
are that alternative diagnoses need to be
made and, in patients whose symptomol-
ogy remains suggestive of lumbar insta-
bility, a potential diagnosis of functional
LSI could be considered.
As with most diagnostic studies for
lumbar pathology, limitations exist that
may afect the validity of the results.
Firstly, the literature that has reported
the accuracy of clinical tests to diagnose
structural LSI is limited, and only 4 of
the articles retrieved met this literature
reviews inclusion criteria. Secondly, all
4 articles
1,23,30,34
used exion-extension
radiographs to identify abnormal ver-
tebral translational motion to diagnose
structural LSI.
1,27
While exion-extension
radiographs have historically been con-
sidered the radiological reference test
of choice for LSI, they have been sug-
gested to be complicated by false positive
rates and have signicant variation in
asymptomatic persons.
27,45
Additionally,
diferences in patient positioning might
account for the 10% to 15% variation in
observed vertebral displacement.
11
The reported cutof values for ver-
tebral translatory motion employed to
diagnose the presence of structural LSI
also remain somewhat contentious and
vary between 3 to 5 mm in the litera-
ture.
17,18,27,32,52
The majority of studies in
this review employed cutof values for
translational motion greater than 4.5 to
5.0 mm, with Abbott et al
1
using transla-
tion beyond 2 SDs from the mean of an
asymptomatic population as the cutof
value. The efects of difering translation-
al cutof values on the diagnostic ability
of clinical tests to diagnose structural LSI
are not currently known.
It has also been proposed that aber-
rant motion and dysfunction from struc-
tural LSI exist not only at end range but
during midrange spinal movements,
which these tests might not identify.
35

Flexion-extension radiographs simply
assess vertebral displacement statically
at end range,
32,52
which, theoretically,
would only detect the function of the pas-
sive stabilizing subsystem.
22
This might
have signicant limitations in detecting
dysfunction from structural LSI that oc-
curs within the neutral zone (midrange
spinal motion).
44,48
Digital video uoroscopy has also been
utilized to identify normal and abnormal
lumbar motion in vivo.
3,56,64,65
This type
of imaging has recently demonstrated an
ability to identify movement abnormali-
ties in patients with suspected functional
LSI
2
; however, further research is needed
to conrm and substantiate these nd-
ings in a population with structural LSI.
Despite these recognized limitations,
exion-extension radiographs remain, at
present, the most common criterion ref-
erence standard to diagnose structural
LSI.
47
A possible limitation of the methods
used in this study was that only 1 reviewer
searched the literature to identify articles
for inclusion. Another factor that may
limit the generalizability of the results of
LSI diagnostic studies is the heterogene-
ity and sample size of the cohort under
investigation. Study sample sizes identi-
ed in this review ranged from 42
34
to
138
1
patients (TABLE 4). These relatively
low samples might have afected the in-
ternal validity and diagnostic accuracy of
the results, and it has been suggested that
studies of this nature should, theoretical-
ly, contain over 600 participants to have
meaningful diagnostic value.
20
Additionally, quality assessment of
retrieved articles is considered to be an
essential component of most systematic
reviews.
13
The QUADAS tool was used to
assess the quality of articles in this study;
however, this and other well-utilized
tools are suggested to have a number
of associated limitations. These include
the possibility that even well-conducted
studies may score poorly if the methods
and results of the study are not reported
in sufcient detail,
62
and that most qual-
ity assessment tools used in diagnostic
studies do not include items that assess
statistical power, which can subsequently
afect a studys validity.
Almost all of the clinical tests inves-
tigated in this systematic review, due to
their high specicity, demonstrated the
ability to diagnose patients with LSI,
when the tests were positive. However,
the trade-of for the majority of tests was
the low sensitivity, which means that
these tests may not be able to rule out
people who test negative for structural
LSI. Both PAIVM and PPIVM appear to
have modest ability to diagnose structural
LSI. The PLE test, however, had both the
highest +LR (8.8) and lowest LR (0.2)
of the tests investigated, demonstrating
a moderate but important role for both
ruling in and ruling out structural LSI.
These results suggest that the PLE test
may be useful in clinical practice to diag-
nose structural LSI.
It is, however, important to note that
the reliance on a single test in isolation
is not usually recommended in muscu-
loskeletal and orthopaedic clinical prac-
tice, and it is likely that a combination of
valid and reliable tests, and the inclusion
of patient-specic signs and symptoms,
including historical elements, might fur-
41-03 Alqarni.indd 138 2/24/2011 4:35:15 PM
journal of orthopaedic & sports physical therapy | volume 41 | number 3 | march 2011 | 139
ther assist clinicians in diagnosing and
managing patients with LSI. Further in-
vestigation of these combined diagnostic
factors is required in future studies that
include larger patient populations, difer-
ing age ranges, and diferent assessors, to
ensure the validity and diagnostic accu-
racy of the tests.
CONCLUSION
T
his is the rst systematic re-
view that has been conducted to
identify the accuracy of clinical tests
for diagnosing structural LSI. A total of
11 clinical tests were identied from the
literature that met the study inclusion
criteria. The reviewed articles were con-
sidered to be of sufcient quality to as-
certain the diagnostic value of each test
evaluated. The majority of tests had high
specicity but low sensitivity. The PLE
test was found to have the highest com-
bined sensitivity and specicity, as well as
the highest +LR, suggesting that in the
absence of, or as an adjunct to, radiologi-
cal imaging this test might be of use in
musculoskeletal and orthopaedic clinical
practice to diagnose structural LSI. How-
ever, additional research of the diagnostic
accuracy of the PLE test across a range of
patient populations with diferent asses-
sors is recommended to further evaluate
its validity to diagnose structural LSI.

ACKNOWLEDGEMENTS: We gratefully acknowl-

edge the assistance of Masahiro Takemura for
translation of the Japanese articles.
REFERENCES
1. Abbott JH, McCane B, Herbison P, Moginie
G, Chapple C, Hogarty T. Lumbar segmental
instability: a criterion-related validity study
of manual therapy assessment. BMC Mus-
culoskelet Disord. 2005;6:56. http://dx.doi.
org/10.1186/1471-2474-6-56
2. Ahmadi A, Marou N, Behtash H, Zekavat H,
Parnianpour M. Kinematic analysis of dynamic
lumbar motion in patients with lumbar segmen-
tal instability using digital videouoroscopy.
Eur Spine J. 2009;18:1677-1685. http://dx.doi.
org/10.1007/s00586-009-1147-x
3. Auerbach JD, Wills BP, McIntosh TC, Balderston
RA. Evaluation of spinal kinematics following
lumbar total disc replacement and circumfer-
ential fusion using in vivo uoroscopy. Spine
(Phila Pa 1976). 2007;32:527-536. http://dx.doi.
org/10.1097/01.brs.0000256915.90236.17
4. Beighton P, Horan F. Orthopaedic aspects of the
Ehlers-Danlos syndrome. J Bone Joint Surg Br.
1969;51:444-453.
5. Binkley J, Stratford PW, Gill C. Interrater reliabil-
ity of lumbar accessory motion mobility testing.
Phys Ther. 1995;75:786-792; discussion 793-785.
6. Bram J, Zanetti M, Min K, Hodler J. MR abnor-
malities of the intervertebral disks and adjacent
bone marrow as predictors of segmental
instability of the lumbar spine. Acta Radiol.
1998;39:18-23.
7. Brown MD, Holmes DC, Heiner AD. Measurement
of cadaver lumbar spine motion segment stif-
ness. Spine (Phila Pa 1976). 2002;27:918-922.
8. Childs JD, Fritz JM, Piva SR, Erhard RE. Clinical
decision making in the identication of patients
likely to benet from spinal manipulation: a
traditional versus an evidence-based approach.
J Orthop Sports Phys Ther. 2003;33:259-272.
9. Cleland JA, Schulte C, Durall C. The role of ther-
apeutic exercise in treating instability-related
lumbar spine pain: a systematic review. J Back
Musculoskelet. 2002;16:105-115.
10. Cook C, Brismee JM, Sizer PS, Jr. Subjective
and objective descriptors of clinical lumbar
spine instability: a Delphi study. Man Ther.
2006;11:11-21. http://dx.doi.org/10.1016/j.
math.2005.01.002
11. Danielson B, Frennered K, Irstam L. Roent-
genologic assessment of spondylolisthesis. I. A
study of measurement variations. Acta Radiol.
1988;29:345-351.
12. Davidson M. The interpretation of diagnostic
test: a primer for physiotherapists. Aust J Phys-
iother. 2002;48:227-232.
13. Deeks JJ. Systematic reviews in health care:
systematic reviews of evaluations of diagnostic
and screening tests. BMJ. 2001;323:157-162.
14. Delitto A, Erhard RE, Bowling RW. A treatment-
based classication approach to low back
syndrome: identifying and staging patients for
conservative treatment. Phys Ther. 1995;75:470-
485; discussion 485-479.
15. Denegar CR, Fraser M. How useful are physi-
cal examination procedures? Understanding
and applying likelihood ratios. J Athl Train.
2006;41:201-206.
16. Di Fabio RP, Boissonnault W. Physical therapy
and health-related outcomes for patients with
common orthopaedic diagnoses. J Orthop
Sports Phys Ther. 1998;27:219-230.
17. Dupuis PR, Yong-Hing K, Cassidy JD, Kirkaldy-
Willis WH. Radiologic diagnosis of degenerative
lumbar spinal instability. Spine (Phila Pa 1976).
1985;10:262-276.
18. Dvorak J, Panjabi MM, Chang DG, Theiler R,
Grob D. Functional radiographic diagnosis of
the lumbar spine. Flexion-extension and lateral
bending. Spine (Phila Pa 1976). 1991;16:562-571.
19. Farfan HF, Gracovetsky S. The nature of instabil-
ity. Spine (Phila Pa 1976). 1984;9:714-719.
20. Flahault A, Cadilhac M, Thomas G. Sample size
calculation should be performed for design
accuracy in diagnostic test studies. J Clin
Epidemiol. 2005;58:859-862. http://dx.doi.
org/10.1016/j.jclinepi.2004.12.009
21. Fritz JM, Cleland JA, Childs JD. Subgrouping
patients with low back pain: evolution of a clas-
sication approach to physical therapy. J Orthop
Sports Phys Ther. 2007;37:290-302.
22. Fritz JM, Erhard RE, Hagen BF. Segmental
instability of the lumbar spine. Phys Ther.
1998;78:889-896.
23. Fritz JM, Piva SR, Childs JD. Accuracy of the
clinical examination to predict radiographic
instability of the lumbar spine. Eur Spine J.
2005;14:743-750. http://dx.doi.org/10.1007/
s00586-004-0803-4
24. Greenhalgh T. How to read a paper. Papers
that report diagnostic or screening tests. BMJ.
1997;315:540-543.
25. Hall H, McIntosh G, Boyle C. Efectiveness of a
low back pain classication system. Spine J.
2009;9:648-657. http://dx.doi.org/10.1016/j.
spinee.2009.04.017
26. Haneline M, Cooperstein R. Weighing the reli-
ability and validity of clinical tests. J Amer Chi-
ropr Assos. 2006;43:19-22.
27. Hayes MA, Howard TC, Gruel CR, Kopta JA.
Roentgenographic evaluation of lumbar spine
exion-extension in asymptomatic individuals.
Spine (Phila Pa 1976). 1989;14:327-331.
28. Hicks GE, Fritz JM, Delitto A, Mishock J. Inter-
rater reliability of clinical examination measures
for identication of lumbar segmental instability.
Arch Phys Med Rehabil. 2003;84:1858-1864.
29. Jaeschke R, Guyatt GH, Sackett DL. Users
guides to the medical literature. III. How to use
an article about a diagnostic test. B. What are
the results and will they help me in caring for
my patients? The Evidence-Based Medicine
Working Group. JAMA. 1994;271:703-707.
30. Kasai Y, Morishita K, Kawakita E, Kondo T,
Uchida A. A new evaluation method for lumbar
spinal instability: passive lumbar extension test.
Phys Ther. 2006;86:1661-1667. http://dx.doi.
org/10.2522/ptj.20050281
31. Kasai Y, Morishita K, Takegami K, Uchida A.
Clinical symptoms of patient with lumbar spinal
instability [in Japanese]. Clin Orthop Surg.
2003;38:463-467.
32. Knutsson F. The instability associated with disk
degeneration in the lumbar spine. Acta Radiol.
1944;25:593-609.
33. Magee DJ. Orthopedic Physical Assessment. 3rd
ed. Philadelphia, PA: W.B. Sauders Company;
1997.
34. 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. http://dx.doi.
org/10.1097/01.BRS.0000065569.76853.E9
41-03 Alqarni.indd 139 2/24/2011 4:35:16 PM
140 | march 2011 | volume 41 | number 3 | journal of orthopaedic & sports physical therapy
[ LITERATURE REVIEW ]
@
MORE INFORMATION
WWW.JOSPT.ORG
35. Maitland GD. Vertebral Manipulation. 5th ed.
London, UK: Butterworth & Co Ltd; 1986.
36. McGill SM. Low back stability: from formal
description to issues for performance and reha-
bilitation. Exerc Sport Sci Rev. 2001;29:26-31.
37. McGill SM, Grenier S, Kavcic N, Cholewicki J.
Coordination of muscle activity to assure stabil-
ity of the lumbar spine. J Electromyogr Kinesiol.
2003;13:353-359.
38. Moller H, Hedlund R. Surgery versus conserva-
tive management in adult isthmic spondylolis-
thesis--a prospective randomized study: part 1.
Spine (Phila Pa 1976). 2000;25:1711-1715.
39. Nelson BW, OReilly E, Miller M, Hogan M,
Wegner JA, Kelly C. The clinical efects of in-
tensive, specic exercise on chronic low back
pain: a controlled study of 895 consecutive
patients with 1-year follow up. Orthopedics.
1995;18:971-981.
40. Nizard RS, Wybier M, Laredo JD. Radiologic
assessment of lumbar intervertebral instability
and degenerative spondylolisthesis. Radiol Clin
North Am. 2001;39:55-71, v-vi.
41. Ogon M, Bender BR, Hooper DM, et al. A
dynamic approach to spinal instability. Part I:
Sensitization of intersegmental motion proles
to motion direction and load condition by insta-
bility. Spine (Phila Pa 1976). 1997;22:2841-2858.
42. OSullivan PB. Lumbar segmental instability:
clinical presentation and specic stabilizing
exercise management. Man Ther. 2000;5:2-12.
http://dx.doi.org/10.1054/math.1999.0213
43. OSullivan PB, Twomey L, Allison GT. Altered
abdominal muscle recruitment in patients with
chronic back pain following a specic exer-
cise intervention. J Orthop Sports Phys Ther.
1998;27:114-124.
44. Panjabi MM. The stabilizing system of the spine.
Part II. Neutral zone and instability hypothesis. J
Spinal Disord. 1992;5:390-396; discussion 397.
45. Panjabi MM, Lydon C, Vasavada A, Grob D,
Crisco JJ, 3rd, Dvorak J. On the understanding
of clinical instability. Spine (Phila Pa 1976).
1994;19:2642-2650.
46. Paris SV. Physical signs of instability. Spine
(Phila Pa 1976). 1985;10:277-279.
47. Pitkanen MT, Manninen HI, Lindgren KA, Sih-
vonen TA, Airaksinen O, Soimakallio S. Segmen-
tal lumbar spine instability at exion-extension
radiography can be predicted by conventional
radiography. Clin Radiol. 2002;57:632-639.
http://dx.doi.org/10.1053/crad.2001.0899
48. Pope MH, Frymoyer JW, Krag MH. Diagnosing
instability. Clin Orthop Relat Res. 1992;60-67.
49. Pope MH, Panjabi M. Biomechanical deni-
tions of spinal instability. Spine (Phila Pa 1976).
1985;10:255-256.
50. Posner I, White AA, 3rd, Edwards WT, Hayes WC.
A biomechanical analysis of the clinical stability
of the lumbar and lumbosacral spine. Spine
(Phila Pa 1976). 1982;7:374-389.
51. Richardson CA, Jull GA. Muscle control-pain
control. What exercises would you pre-
scribe? Man Ther. 1995;1:2-10. http://dx.doi.
org/10.1054/math.1995.0243
52. Shafer WO, Spratt KF, Weinstein J, Lehmann
TR, Goel V. 1990 Volvo Award in clinical sci-
ences. The consistency and accuracy of roent-
genograms for measuring sagittal translation
in the lumbar vertebral motion segment. An
experimental model. Spine (Phila Pa 1976).
1990;15:741-750.
53. Sonntag VK, Marciano FF. Is fusion indicated for
lumbar spinal disorders? Spine (Phila Pa 1976).
1995;20:138S-142S.
54. Spratt KF, Weinstein JN, Lehmann TR, Woody J,
Sayre H. Efcacy of exion and extension treat-
ments incorporating braces for low-back pain
patients with retrodisplacement, spondylolisthe-
sis, or normal sagittal translation. Spine (Phila
Pa 1976). 1993;18:1839-1849.
55. Taylor J, OSullivan P. Lumbar segmental in-
stability: pathology, diagnosis and conservative
management. In: Twomey L, Taylor J, eds. Physi-
cal Therapy of the Low Back. Philadelphia, PA:
WB Saunders; 2000:201-247.
56. Teyhen DS, Flynn TW, Childs JD, et al.
Fluoroscopic video to identify aberrant
lumbar motion. Spine (Phila Pa 1976).
2007;32:E220-229. http://dx.doi.org/10.1097/01.
brs.0000259206.38946.cb
57. Wadsworth C, DiFabio R, Johnson D. The spine.
In: Wadsworth C, ed. Manual Examination and
Treatment of the Spine and Extremities. Balti-
more, MD: Williams and Wilkins; 1988:70-71.
58. Wall BF, Kendall GM, Edwards AA, Boufer S,
Muirhead CR, Meara JR. What are the risks from
medical X-rays and other low dose radiation?
Br J Radiol. 2006;79:285-294. http://dx.doi.
org/10.1259/bjr/55733882
59. Weiler PJ, King GJ, Gertzbein SD. Analysis of
sagittal plane instability of the lumbar spine in
vivo. Spine (Phila Pa 1976). 1990;15:1300-1306.
60. White AA, Panjabi MM. Clinical Biomechanics
of the Spine. 2nd ed. Philadelphia, PA: J.B. Lip-
pincott Company; 1990.
61. Whiting P, Harbord R, Kleijnen J. No role
for quality scores in systematic reviews
of diagnostic accuracy studies. BMC Med
Res Methodol. 2005;5:19. http://dx.doi.
org/10.1186/1471-2288-5-19
62. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM,
Kleijnen J. The development of QUADAS: a tool
for the quality assessment of studies of diag-
nostic accuracy included in systematic reviews.
BMC Med Res Methodol. 2003;3:25. http://
dx.doi.org/10.1186/1471-2288-3-25
63. Williams CM, Maher CG, Hancock MJ, et al.
Low back pain and best practice care: A survey
of general practice physicians. Arch Intern
Med. 170:271-277. http://dx.doi.org/10.1001/
archinternmed.2009.507
64. Wong KW, Luk KD, Leong JC, Wong SF, Wong KK.
Continuous dynamic spinal motion analysis.
Spine (Phila Pa 1976). 2006;31:414-419. http://
dx.doi.org/10.1097/01.brs.0000199955.87517.82
65. Zheng Y, Nixon MS, Allen R. Lumbar spine
visualisation based on kinematic analysis from
videouoroscopic imaging. Med Eng Phys.
2003;25:171-179.
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