Test: Bicycle Test

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Background/Purpose

The Bicycle Test, also known as the Van Gelderen Bicycle Test or simply the "bicycle test," is a clinical examination tool designed to differentiate between neurogenic intermittent claudication caused by lumbar spinal stenosis and vascular intermittent claudication caused by peripheral artery disease (Dyck & Doyle, 1977; Physiopedia). Intermittent claudication is defined as pain in the legs when walking, and can result from either narrowing of blood vessels (vascular origin) or compression of spinal nerves caused by spinal stenosis (neurogenic origin) (Physiopedia). The test was developed by van Gelderen in 1948 as a simple clinical adjunct to routine neurological examination (Dyck & Doyle, 1977). The diagnostic principle is based on the observation that patients with lumbar spinal stenosis experience relief of symptoms when the spine is flexed forward, as this position decompresses and reduces irritation of the spinal nerves, whereas patients with vascular claudication do not experience positional relief (Physiopedia; Evolve PT, 2023). Studies have shown that preoperatively, approximately 44-94% of patients with confirmed lumbar spinal stenosis have a positive bicycle test, with the test demonstrating high sensitivity for detecting neurogenic claudication (Yukawa et al., 2002). The test is particularly useful for patients who cannot undergo treadmill testing due to orthopedic or neurologic comorbidity or fear of falling (Physiopedia).

Procedure

Patient Position:

The patient is seated on a stationary bicycle (Physiopedia; Dyck & Doyle, 1977)
The patient should be positioned comfortably with feet on the pedals
The seat height should be adjusted appropriately for the patient

Procedure:
Phase 1 - Upright Position:

Initial Setup: Have the patient sit upright on the stationary bicycle with the spine in an extended or neutral lordotic position (Samarpan Physio, 2023; Physiopedia)
Cycling in Upright Position: Instruct the patient to begin pedaling the bicycle while maintaining an upright posture that emphasizes lumbar lordosis (extension) (Samarpan Physio, 2023)

The patient cycles at a comfortable pace
Monitor the patient for symptom development

Record Distance/Time: Note the distance or time the patient can cycle before symptoms develop (Dong et al., 1989)

Document when claudication symptoms (pain, cramping, weakness, numbness) occur
Record the specific symptoms and their location



Phase 2 - Forward-Leaning Position:

Position Change: After symptoms develop or after a standardized time period, have the patient lean forward on the bicycle, flexing the lumbar spine to approximately 30 degrees of flexion (Dong et al., 1989; Physiopedia)

The forward-leaning posture should reduce lumbar lordosis
The patient should maintain this flexed position throughout the second phase
Cycling in Flexed Position: Instruct the patient to continue cycling while maintaining the forward-leaning position (Physiopedia)

Monitor for symptom relief or persistence
Note the distance or time the patient can cycle in this position

Record Distance/Time: Document the distance or time the patient can cycle in the flexed position before symptoms return (Dong et al., 1989)
Compare to the upright position results

Alternative Testing Approaches:
Some protocols perform the test on a second day to assess reproducibility (Dong et al., 1989)
Both submaximal and maximal bicycle testing may be used for detecting intermittent claudication (Physiopedia)

Important Notes:
The test can be combined with treadmill testing for comprehensive functional evaluation (Tomkins et al., 2000; Yukawa et al., 2002)
In patients with neurogenic claudication, the flexed posture may improve cycling distance by more than 100% in some cases (Dong et al., 1989)
Some patients with spinal stenosis may be able to cycle unlimited distances in the flexed position despite having claudication pain when walking (Dong et al., 1989)
The bicycle test is combined with other clinical information from routine neurological assessment for diagnosis (Physiopedia)
Performed: Bilaterally

Dialog

The patient cycles on a stationary bicycle first in an upright position and then in a forward-leaning flexed position, with symptom reproduction and relief patterns distinguishing neurogenic from vascular claudication.

Criteria

• No increase in symptoms upright
• No decrease in symptoms with flexion

Measurement

LOINC Code

Scale/Grading

selection range; grade - LOINC ID
Option - Value option selection range; grade - LOINC IDNo change in symtpoms = ; Pass - Relief with fwd flexion = ; Fail - Worse upright and flexion = ; Fail -