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Survey of Inspection and Palpation Rates Among Spine Providers: Evaluation of Physician Performance of the Physical Examination for Patients With Low Back Pain

Press, Joel, MD*,†; Liem, Brian, MD*,†; Walega, David, MD; Garfin, Steven, MD§

doi: 10.1097/BRS.0b013e31829ff32f
Health Services Research

Study Design. Survey from July 2011 to April 2012 of adult patients with primary complaint of low back pain (LBP).

Objective. To determine the frequency of physical examination being performed by various providers, as measured by frequency of inspection and palpation, of patients with LBP and to describe patient ratings of these examinations.

Summary of Background Data. The physical examination is a cornerstone of any evaluation of patients with LBP. With increasing reliance on diagnostic imaging, there is concern that patients are not being examined comprehensively, but to our knowledge, no studies have ever investigated how often the physical examination is performed in patients with LBP.

Methods. Survey participants were asked to list the types of physicians that they had seen for LBP within the past 1 year and for each physician encounter to answer 2 “yes/no” questions: (1) whether they had removed their clothes or put on a gown or shorts during the examination (our proxy for inspection) and (2) whether the provider had placed his or her hands on the patient (our proxy for palpation). Subjects also provided quality ratings for each provider's physical examination. Main outcome measures included frequency of inspection and palpation and subjects’ ratings of each physical examination.

Results. A total of 295 surveys were collected reflecting 696 prior physician encounters. Inspection was done in 57% of physician encounters. Across specialties, orthopedic surgeons had the highest reported rate of inspection at 72%. The worst was among chiropractors at 40%. Palpation occurred in 80% of physician encounters. Chiropractors had the highest rate of palpation at 94%. The lowest rate was among neurosurgeons at 58%.

Conclusion. Our data suggest that approximately 43% of patient visits for LBP involved no inspection and nearly 20% without palpation. These numbers reflect a need for improvement among providers who treat patients with LBP.

Level of Evidence: N/A

Physical examination is the cornerstone of the evaluation of patients with low back pain, but the frequency of its actual performance is unknown. This patient survey aimed at determining the frequency of inspection and palpation performed and found that only 57% and 80% of encounters involved inspection and palpation, respectively.

*Rehabilitation Institute of Chicago, Chicago, IL

Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL

Department of Anesthesiology, Northwestern University, Chicago, IL; and

§Department of Orthopedic Surgery, University of California, San Diego, La Jolla, CA.

Address correspondence and reprint requests to Brian Liem, MD, Rehabilitation Institute of Chicago/Northwestern University, 345 E. Superior St, Chicago, IL 606011. E-mail:

Acknowledgment date: October 15, 2012. First revision date: January 27, 2013. Second revision date: May 1, 2013. Third revision date: June 3, 2013. Acceptance date: June 6, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

No funds were received in support of this work.

Relevant financial activities outside the submitted work: consultancy, grants/grants pending, payment for lectures, royalties, and stock/stock options.

© 2013 by Lippincott Williams & Wilkins