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Special Test

Valsalva Test Procedure

Valsalva Test for lumbar spine is used to increase intrathecal pressure and thereby exacerbate pain due to spinal cord or nerve root compression.

It was first described in 1704 by Antonio Maria Valsalva, who was an Italian physician.

See Also: Slump Test

How do you perform the Valsalva Test?

  • With the patient sitting, and the examiner is sanding within arms’ reach in front of the patient.
  • The patient is asked to put the thumb in his mouth and attempts to push the thumb out by blowing out hard.
  • or, the patient takes and holds a deep breath while bearing down similar to performing a bowel movement.

The test should be performed with care and caution because the patient may become dizzy and pass out during the test or shortly afterward if the procedure blocks the blood supply to the brain.

Valsalva Test with thumb blowing
Valsalva Test with thumb blowing
Valsalva Test with performing a bowel movement
Valsalva Test with performing a bowel movement

What does a positive Valsalva maneuver mean?

Bearing down in this manner increases the intraspinal pressure, revealing the presence of space occupying masses such as extruded intervertebral disks, tumors, narrowing due to osteophytes, and soft tissue swelling. This leads to radicular symptoms entirely confined to the respective dermatome or dermatomes.

The test should be performed with great caution, because the patient may lose consciousness during or after the test due to the increased pressure that may alter venous function and cause dizziness or unconsciousness.

See Also: Lasegue Test

A modification of Valsalva test was described:

The Valsalva maneuver is performed with the patient standing and the lumbar spine flexed to 35° to 75° (Cecin’s sign). The patient stands and leans forward until pain or paraesthesia is experienced. This position is held, and the patient is asked to cough. The test is positive if symptoms worsen. If pain is not experienced at this point, the spine is flexed to approximately 35° and the test repeated.

modified Valsalva Test
Modified Valsalva Test

Reliability

The Sensitivity and specificity of this test for lumbar spine lesions was:

  • Sensitivity: 73%
  • Specificity: 95%

The Inter-rater Reliability was 0.63.

Another diagnostic accuracy study found the sensitivity and specificity of Valsalva Test were: 22% and 94%, respectively.

Notes

The patient often self-reports these findings rather than being identified clinically.

If the patient is embarrassed or apprehensive about simulating a bowel movement, he or she may be instructed to blow into a closed fist as if inflating a balloon.

The test increases intrathecal pressure throughout the spinal column, resulting in a slowing of the pulse, decreased venous return, and increased venous pressure, all of which may cause fainting.

The Valsalva maneuver has references in multiple clinical domains ranging from the evaluation of autonomic dysfunction to the treatment of arrhythmias and a marker for heart failure.

This maneuver must be avoided in patients with retinopathy and intraocular lens implantation. And caution is necessary for patients with pre-existing coronary artery disease, valvular disease, or congenital heart disease.

References

  1. Nachemson AL, Andersson BJ, Schultz AB. Valsalva maneuver biomechanics. Effects on lumbar trunk loads of elevated intraabdominal pressures. Spine (Phila Pa 1976). 1986 Jun;11(5):476-9. PMID: 3750086.
  2. Cecin, HA: Cecin’s Sign (“X” Sign): Improving the diagnosis of radicular compression by herniated lumbar discs. Rev Bras Reumatol, 50:44, 2010.
  3. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976). 2003 Jan 1;28(1):52-62. doi: 10.1097/00007632-200301010-00014. PMID: 12544957.
  4. Srivastav S, Jamil RT, Zeltser R. Valsalva Maneuver. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: Pubmed
  5. Clinical Tests for the Musculoskeletal System 3rd Edition.
  6. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
  7. Sarvdeep S. Dhatt, Sharad Prabhakar – Handbook of Clinical Examination in Orthopedics.
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