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User's guide to the musculoskeletal examination: fundamentals for the evidence-based clinician.

User's guide to the musculoskeletal examination: fundamentals for the evidence-based clinician. First edition. Editors: Timothy W. Flynn, Joshua A. Cleland, Julie M. Whitman. (2008), Evidence in Motion, Buckner, KY. ISBN: 978-0-9714792-3-4, Spiral-bound, soft cover. 316 pages with CD included. Retail price: US$69.95 http://www.

This book is a small spiral bound soft cover volume that contains sections for each part of the musculoskeletal system. In addition it provides an overview of the essentials of the statistics used in measuring reliability and diagnostic accuracy, patient self-report instruments, the essentials of a medical screening examination, and screening tests for the upper and lower limb neurological examination. The accompanying CD contains the whole book in Adobe Acrobat[TM] pdf format with links to embedded videos of the examination procedures. Each test is well described with excellent photographs and video.

While it is accepted that not all tests can, or should be, included in a book of 'fundamentals', the chosen compilation is a curious mixture. Many tests with known reliability and validity are included but many have no known estimates of reliability or validity. This is not the fault of the authors, but is rather a statement about how much work needs to be done in validating the clinical examination of the musculoskeletal system. What is obvious is that the selection of techniques is biased, not towards or away from an evidenced based approach to the subject, but towards the examination (evidence based and not evidence based) that the authors favour. To be fair, the authors and others they dedicate the book to have contributed much to the evidence base of the clinical examination, but the reader / purchaser should be aware of some serious omissions, inappropriate inclusions and some errors.

Serious omissions included the centralization phenomenon in the lumbar spine. This is a clinical finding that is common (1), reliable (2) and valid (3,4). Also sacral thrust, compression, distraction SIJ provocation tests. These tests are reliable and valid (5,6,7,8), as well as the crank test for SLAP lesions in the glenohumeral joint, which is valid, although reliability is unknown (9,10).

Inappropriate inclusions included two SIJ dysfunction tests e.g. the Gillet test and seated flexion test. The poor ICC scores in studies carried out by the authors, and in a number of other studies, should have excluded these tests from the book.

There are some minor irritating errors such as incorrectly referencing this reviewer's paper for something we did not report(reliability of the FABER test), but little errors in a first edition are to be expected. However, I would urge readers to take care not to regard this text as a complete, all-inclusive statement of the current evidence base for the clinical examination of the musculoskeletal system. Regardless of this criticism, the format of the book is excellent and the CD is brilliant. The type of presentation these authors have used is excellent and I would recommend it for future textbooks. I do hope that the second edition is more consistent with the title and the stated intent.


(1.) Werneke M, Hart DL, Cook D. A descriptive study of the centralization phenomenon. A prospective analysis. Spine 1999;24:676-683.

(2.) Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman T, Alen M. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 2002;27:E207-E214.

(3.) Werneke M, Hart DL. Discriminant validity and relative precision for classifying patients with non-specific neck and low back pain by anatomic pain patterns. Spine 2003;28:161-166.

(4.) Laslett M, Oberg B, Aprill CN, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. The Spine Journal 2005;5:370-380.

(5.) Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Manual Therapy 2005;10:207-218.

(6.) Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac joint provocation tests. Aust J Physiother 2003;49:89-97.

(7.) van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil 2006;87:10-14.

(8.) Kokmeyer DJ, van der Wurff P, Aufdemkampe G, Fickenscher TCM. The reliability of multitest regimens with sacroiliac pain provocation tests. J Manipulative Physiol Ther 2002;25:42-48.

(9.) Huijbregts PA. SLAP lesions: Structure, function, and physical therapy diagnosis and treatment. J Man & Manip Ther 2001;9:71-83.

(10.) Liu SH, Henry MH, Nuccion SL. A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am J Sports Med 1996;24:721-725.
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Title Annotation:User's Guide to the Musculoskeletal Examination: Fundamentals for the Evidence-Based Clinician, 1st ed.
Publication:New Zealand Journal of Physiotherapy
Article Type:Book review
Date:Nov 1, 2008
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