Physical Examination of the Spine.

Albert TJ, Vaccaro AR. New York, NY 10001, Thieme, 2005, paperback, 130 pp, illus, ISBN: 0-86577-916-3, $69.95.

At first sight, many experienced physical therapists will find that this book looks very similar to Hoppenfeld's text, Physical Examination of the Spine and Extremities. This new book has the same high-quality line drawings illustrating relevant points, and the authors generally keep to Hoppenfeld's format of presenting each new idea or technique on a separate page. The new text focuses exclusively on the spine and does add some examination techniques not found in Hoppenfeld. The authors, who are both physicians, have designed the book to appeal to "medical students, residents, fellows, and allied health professionals. ..." Their stated goal is to improve patient care by emphasizing the importance of physical examination in differential diagnosis.

Each region of the spine (cervical, thoracic, lumbar, and sacral) is covered in a similar format that parallels the physical exam: observation, range of motion, muscle testing, sensory testing, and reflexes. The authors have achieved a simplicity of presentation that should appeal to beginning clinicians in all the health care professions. One useful technique not found in many texts (including Hoppenfeld's) is palpation of the anterior bodies of the lumbar spine. This technique is useful to identify psoas muscle dysfunctions, among other purposes. The authors also include palpation techniques for various sacral reflexes, which are not commonly available in texts.

Although beginning clinicians will appreciate the clarity of presentation, there are some serious flaws that may make the text less useful to experienced clinicians and may lead beginning clinicians into difficult situations. For example, the vertebral artery test is recommended to evaluate the patency of blood flow in the vertebral arteries, which supply the majority of blood to the anterior cervical spinal cord and go on to supply the brain stem and the circle of Willis at the base of the brain. Most tests of this kind have questionable validity. However, the authors recommend a test that

appears to be completely nonspecific (ie, it does not isolate the vertebral arteries--many other structures and systems are involved--such as the cervical facets, vestibular apparatus, and proprioceptive inputs), as well as potentially dangerous. They recommend that the vertebral artery test be performed with the patient standing and "rapidly turning the head from side to side for 10 seconds or until symptoms are reproduced." Besides the immediate risk of vertebral artery damage from the test itself, the authors should warn beginning clinicians that the resulting dizziness and potential syncope also may cause the patient to collapse to the floor and sustain further injury.

In similar fashion, the authors recommend percussing over the vertebrae posteriorly with the patient standing and bent at the waist in order to detect pathologic fractures, without warning of the potential untoward consequences, such as loss of balance and a potential fall, resulting from a sudden unexpected jolt of excruciating pain if a fracture is encountered. For the benefit of less experienced clinicians, it would be helpful if the authors discussed safety considerations and perhaps showed safer alternative positions for these tests.

Finally, although many tests are mentioned (eg, Neri, Bragard, Oppenheimer, Lhermitte, to name a few), no references to the original description of the test or information on its properties are provided. In the age of evidence-based medicine, good patient care demands a familiarity not only with the mechanical performance of a technique but also with sensitivity, specificity, positive predictive value, and intertester reliability. The authors have only done part of the job of updating Hoppenfeld's classic text, and, despite some very valuable additions, most practicing clinicians will find the usefulness of this text somewhat limited.

Roy Bechtel, PT, PhD University of Maryland School of Medicine Baltimore, Md

Dr Bechtel is Assistant Professor in the Department of Physical Therapy and Rehabilitation Science. His research and clinical interests focus on the efficacy and mechanisms of manual therapy interventions for prevention and rehabilitation of pain of spinal origin.

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