In orthopaedic and neurological testing, some tests can be performed using more than one patient position. In some situations, this is by design. In others situations, it is a result of adapted use. The focus here is on variation by design, specifically three common examples of patient position varying by design: Kemp's test, the straight leg raise test and the Adams test.
Kemp's Test
Kemp's test is used for patients with back and leg pain. The test is performed with the patient either standing or sitting with his/her arms folded across the chest. Once the patient is positioned, the doctor laterally bends, extends and rotates the patient's lumbar region.
Back pain during the test indicates possible facet joint or disc pathology. Leg pain during the test indicates possible radicular pathology. In theory, these results should be consistent between the seated and standing positions.
Results are usually consistent if the clinician performs the versions uniformly. The key to uniformity is limiting testing movements to the patient's lumbar spine. This is easier with the patient seated because the pelvis is stabilized. In the standing position, the pelvis is more mobile. If pelvic movement occurs, results are influenced.
Another concern with the standing position comes from the patient bending his/her knees to achieve balance as the lumbar spine is extended during testing. If the clinician does not assure that the patient's knees remain locked, results are influenced.
Since the seated version of Kemp's stabilizes the pelvis and removes knee flexion as a factor, the seated position is the better choice for patient examination. If the seated version is negative, then there usually isn't a need to perform the standing version.
The standing version may be helpful, if performed correctly, to confirm results of the seated version or to screen for malingering. If the seated and standing versions are both performed uniformly and the findings are diverse, it raises suspicion.
Straight Leg Raising
The straight leg raise test is used for patients with leg pain. The test is performed with the patient either supine or sitting. In the supine position, the doctor raises the extended leg, maintaining knee extension while flexing the hip. Posterior leg pain radiating below the knee indicates possible radicular pathology or sciatica.
In the seated version, the patient is asked to extend the knee completely, straightening the leg. Posterior leg pain radiating below the knee indicates possible radicular pathology or sciatica. The same findings and diagnoses for the supine version apply.
There are fewer variables with the SLR test than with Kemp's test, so more consistent results are to be expected between the two versions of the test. This gives more credibility to straight leg raising in the assessment of malingering. In fact, comparing the results of supine and seated straight leg raising is the classic example of comparing two versions of a test to detect malingering.
Adams Test
Adams test is used to screen patients for scoliosis. The test is performed with the patient standing and sitting. Testing starts with observation of the standing patient from behind. In this position, the doctor looks for signs of scoliosis, deviations of the spine, rib cage deformities, etc. The doctor then asks the patient to bend forward as if to touch his/her toes. While the patient is in this position, the doctor observes the patient's spine for any changes in deviations and deformities that were noted prior to the patient bending forward.
If deviations or deformities remain when the patient bends forward, the scoliosis is considered structural. If deviations or deformities improve or resolve when the patient bends forward, the scoliosis is considered functional.
Structural scoliosis is usually a permanent condition; functional scoliosis is generally a reaction to another condition or problem and less permanent. It is a compensating action by the body. A common problem that results in a functional scoliosis is an anatomically short leg.
The results for the standing and seated versions of Adams should be the same. However, results indicating functional scoliosis can differ between the standing and seated positions if an anatomically short leg is a causing factor.
The short leg creates an oblique pelvis and a corresponding convexity of the lumbar spine on the low side. The spinal region(s) above the lumbar spine usually compensate for this by curving in the opposite direction. Performing Adams test in the seated position removes the leg length from the testing factors. In this case, scoliosis findings that remain during the standing version may disappear during the seated version.
Unlike Kemp's and SLR, Adams has no value for detecting malingering. Positive and negative findings are not dependent upon subjective information from the patient. The findings are based on objective observations by the doctor. It is hard to fake scoliosis.
Author's Note: My next article looks at the second reason for varying orthopedic and neurological testing positions: adapted use.
Resources
- Centeno CJ. The Spine Dictionary: A Comprehensive Guide to Spine Terminology. Philadelphia: Hanley & Belfus, 1999.
- Dutton M. Orthopaedic Examination, Evaluation and Intervention, 2nd Edition. New York: McGraw-Hill, 2008.
- Evans,R. Illustrated Orthopedic Physical Assessment, 3rd Edition. St. Louis: Mosby, 2009.
- Magee DJ. Orthopedic Physical Assessment, 5th Edition. St. Louis: Saunders/Elsevier, 2008.
Click here for more information about K. Jeffrey Miller, DC, MBA.