Does My Patient Have Mechanically Reproducible Spine Pain?

Historically, clinicians have used non-mechanical findings, patient history, and other physical examination results to refer patients to a specialist.

By definition, a non-mechanical finding involves the inability to reproduce any of the patient’s symptoms during a deliberate clinical examination. Such failure to reproduce symptoms during a traditional spinal movement screen may be considered associated with a “red flag,” which constitutes referral for imaging. Red flags signal that clinicians should suspect tumors, vascular disorders, or other conditions that may require medical work up.

A publication in Pain Practice, in which I was the leader author, looked into the value of a “non-mechanical” finding when differentiated conditions – such as meta-static spinal cancer – are present.¹  The study found that without patient context during the assessment (i.e., the patient reporting whether the pain was associated with their condition), non-mechanical findings were not discriminating.

Why We Care About Reproducible Pain

Many clinicians have used mechanically reproducible pain to select treatment, rather than just to rule in or rule out a red flag. This approach is also known as the patient response method.

Mechanical pain specific to the patient’s familiar sign is called comparable/concordant pain. Comparable/concordant pain implies that a specific movement is tied to the disorder. In theory, if we treat the comparable/concordant symptoms, the outcome of the intervention should be better than if we target a random or a clinician-selected area of the spine.

In many musculoskeletal management philosophies, clinicians first recognize the concordant/comparable sign and then identify movements during the physical examination that reproduce the familiar complaint. These philosophies are well documented in orthopedic and manual therapy textbooks.

New Research: Passive Accessory Testing May Be More Sensitive Than Self-Reports

There are indeed differences in patients who have a concordant/comparable sign compared to those that do not exhibit this during a physical examination.²

Further, comparable/concordant finding during the passive accessory examination appears to have great importance.² In such examination, more patients reported reproduction of their symptoms (90.2%) than when asked about their chief complaint (88.4%). This suggests that clinicians were able to reproduce the patient’s comparable/concordant pain at a higher rate than the patients reported themselves!

It also reflects the high sensitivity of passive accessory movement’s ­– such as the posterior anterior glide – which is consistent with clinical evidence. In clinical practice, these movements accurately implicate selected concordant spinal level movements and thus link findings with the patient’s chief complaint. This concept has also been used in a number of clinical trials.

Is Patient Response Method Valid?

As I stated, a comparable/concordant finding demands an intervention using manual therapy that is specific to the comparable finding. This concept is likely the most common manual therapy philosophy in the clinical practice.

Our recently published clinical trial does not support the fact that a dedicated treatment addressing the comparable/concordant sign is necessary to improve a patient’s condition, versus a prescriptively applied technique. Although further study is needed, this suggests that finding a comparable sign may be more prognostic than prescriptive.