Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain

The Use of Cluster Analysis by Partitioning around Medoids (PAM) to Examine the Heterogeneity of Patients with Low Back Pain within Subgroups of the Treatment Based Classification System

Background

Current evidence in low back pain (LBP) focuses on population averages and traditional multivariate analyses to find the significant difference between variables. Such a focus actively obscured the heterogeneity and increased errors. Cluster analysis (CA) addresses the mentioned shortcomings by calculating the degree of similarity among the relevant variables of the different objects.

Objective

This study aims to evaluate the agreement between the treatment-based classification (TBC) system and the equivalent 3 cluster typology created by partitioning around medoids (PAM) analysis.

Material and Methods

In this cross-sectional study, a convenient sample of 90 patients with low back pain (50 males and 40 females) aged 20 to 65 years was included in the study. The patients were selected based on the 21 criteria of 2007 TBC system. An equivalent 3 cluster typology (C3) was applied using PAM method. Cohen's Kappa was run to determine if there was agreement between the TBC system and the equivalent C3 typology.

Results

PAM analysis revealed the evidence of clustering for a C3 cluster typology with average Silhouette widths of 0.12. Cohen's Kappa revealed fair agreement between the TBC system and C3 cluster typology (Percent of agreement 61%, Kappa=0.36, P<0.001). Selected criteria by PAM analysis were different with original TBC system.

Conclusion

Higher probability of chance agreement was observed between two classification methods. Significant inhomogeneity was observed in subgroups of the 2007 TBC system.

Eligibility of the movement-based classification systems in the diagnosis of patients with low back pain: A systematic review

OBJECTIVE

To evaluate the eligibility of the movement-based classification systems in the diagnosis of patients with low back pain.

METHODS

The present systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta -Analysis guidelines. Different databases including PubMed, Science Direct, OVID, MEDLINE, CINAHL, EMBASE, ProQuest and Google Scholar were searched from January 1990 to December 2017. All studies assessed the reliability and validity of the movement-based classification systems to diagnose patients with low back pain were included. The keywords used to search the studies were: "reliability", "validity", "classification", "movement impairment" and "low back pain". Study selection and data extraction were performed by two independent reviewers.

RESULTS

Sixteen articles were met the inclusion criteria. Of these articles, 13 studies assessed the reliability and validity of movement-based classification systems to categorize patients with low back pain. Two out of 16 articles compared patients with low back pain and healthy subjects and one article had no control group.

CONCLUSIONS

The results of the reviewed studies demonstrated that movement-based classification systems are valid and reliable enough to categorize patients with low back pain.

Baseline characteristics did not identify people with low back pain who respond best to a Movement System Impairment-Based classification treatment

STUDY DESIGN

Secondary analysis of data from a randomized controlled trial.

BACKGROUND

Treatment based on the Movement System Impairment-Based classification for chronic low back pain results in the same benefit when compared to other forms of exercise. It is possible that participant's characteristics measured at baseline can identify people with chronic low back pain who would respond best to a treatment based on the Movement System Impairment model.

OBJECTIVES

To assess if specific characteristics of people with chronic low back pain measured at baseline can modify the effects of a treatment based on the Movement System Impairment model on pain and disability.

METHODS

Four variables assessed at baseline that could potentially modify the treatment effects of the treatment based on the Movement System Impairment model were selected (age, educational status, physical activity status and STarT back tool classification). Separate univariate models were used to investigate a possible modifier treatment effect of baseline participant's characteristics on pain and disability after the treatment. Findings of interaction values above 1 point for the outcome mean pain intensity or above 3 points for disability (Roland Morris questionnaire) were considered clinically relevant.

RESULTS

Linear regression analyses for the outcomes of pain and disability did not show interaction values considered clinically relevant for age, educational status, physical activity status and STarT back tool classification.

CONCLUSION

Age, educational status, physical activity status and STarT back tool classification did not modify the effects of an 8-week treatment based on the Movement System Impairment model in patients with chronic low back pain. Registered at www.clinicaltrials.gov: NCT02221609 (https://clinicaltrials.gov/ct2/show/NCT02221609).

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts

BACKGROUND

Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized.

OBJECTIVE

To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments.

DESIGN

To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments.

RESULTS

From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief.

CONCLUSIONS

The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Does a Diagnostic Classification Algorithm Help to Predict the Course of Low Back Pain? A Study of Danish Chiropractic Patients With 1-Year Follow-up

BACKGROUND

A diagnostic classification algorithm, "the Petersen classification," consisting of 12 categories based on a standardized examination protocol, was developed for the primary purpose of identifying clinically homogeneous subgroups of individuals with low back pain (LBP).

OBJECTIVES

To investigate whether a diagnostic classification algorithm is associated with activity limitation and LBP intensity at follow-up assessments of 2 weeks, 3 months, and 1 year, and whether the algorithm improves outcome prediction when added to a set of known predictors.

METHODS

This was a prospective observational study of 934 consecutive adult patients with new episodes of LBP who were visiting chiropractic practices in primary care and categorized according to the Petersen classification. Outcomes were disability and pain intensity measured with questionnaires at 2 weeks and 3 months, and 1-year trajectories of LBP based on weekly responses to text messages. Associations were analyzed with linear and logistic regression models. In a subgroup of patients, the numbers of visits to primary and secondary care were described.

RESULTS

The Petersen classification was statistically significantly associated with all outcomes (P<.001) but explained very little of the variance (R² = 0.00-0.05). Patients in the nerve root involvement category had the most pain and activity limitation and the most visits to primary and secondary care. Patients in the myofascial pain category were the least affected.

CONCLUSION

The Petersen classification was not helpful in determining individual prognosis in patients with LBP receiving usual care in chiropractic practice. However, patients should be examined for potential nerve root involvement to improve prediction of likely outcomes.

LEVEL OF EVIDENCE

Prognosis, level 1b. J Orthop Sports Phys Ther 2018;48(11):837-846. Epub 8 May 2018. doi:10.2519/jospt.2018.8083.

The interrater reliability of a pain mechanisms-based classification for patients with nonspecific neck pain

OBJECTIVE

To examine the interrater reliability and agreement of a pain mechanisms-based classification for patients with nonspecific neck pain (NSNP).

METHODS

Design - Observational, cross-sectional reliability study with a simultaneous examiner design.

SETTING

University hospital-based outpatient physical therapy clinic.

PARTICIPANTS

A random sample of 48 patients, aged between 18 and 75 years old, with a primary complaint of neck pain was included.

INTERVENTIONS

Subjects underwent a standardized subjective and clinical examination, performed by 1 experienced physical therapist. Two assessors independently classified the participants' NSNP on 3 main outcome measures.

MAIN OUTCOME MEASURES

The Cohen kappa, percent agreement, and 95% confidence intervals (CIs) were calculated to determine the interrater reliability for (1) the predominant pain mechanism; (2) the predominant pain pattern; and (3) the predominant dysfunction pattern (DP).

RESULTS

There was almost perfect agreement between the 2 physical therapists' judgements on the predominant pain mechanism, kappa=.84 (95% CI, .65-1.00), p<.001. There was substantial agreement between the raters' judgements on the predominant pain pattern and predominant DP with respectively kappa=.61 (95% CI, .42-.80); and kappa=.62 (95% CI, .44-.79), p<.001.

CONCLUSION(S)

The proposed classification exhibits substantial to almost perfect interrater reliability. Further validity testing in larger neck pain populations is required before the information is used in clinical settings.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03147508 (https://clinicaltrials.gov/ct2/show/NCT03147508).

Modic changes-Their associations with low back pain and activity limitation: A systematic literature review and meta-analysis

BACKGROUND

Previous systematic reviews have reported positive associations between Modic changes (MCs) and low back pain (LBP), but due to their narrow scope and new primary studies, there is a need for a comprehensive systematic review. Our objectives were to investigate if MCs are associated with non-specific LBP and/or activity limitation and if such associations are modified by other factors.

METHODS

A protocol for this review was registered at PROSPERO prior to commencing the work (PROSPERO record: CRD42015017350). The MEDLINE, CINAHL and EMBASE databases were searched for relevant studies from first record to June 15th 2016. Prospective or retrospective cross-sectional cohort studies and case-control studies including people of all ages from general, working and clinical study populations were eligible for inclusion. Risk of bias assessment and data extraction for associations and potential modifiers were completed independently by pairs of reviewers. Meta-analysis was performed for homogeneous studies and presented as odds ratios (OR) with 95% CI.

RESULTS

In all, 5210 citations were identified and 31 studies were included. One study had low risk of bias. Fifteen studies (48%) reported statistically significant positive associations between MCs and LBP and one study found a statistically significant negative association. Meta-analysis performed for studies using concordant pain with provocative discography as the clinical outcome resulted in an OR of 4.01 (1.52-10.61). One of seven studies reported a statistically significant positive association between MCs and activity limitation. Lumbar disc level and disc degeneration were found to modify the association between MCs and LBP.

CONCLUSIONS

The results from this comprehensive systematic review indicate that the associations between MCs and LBP-related outcomes are inconsistent. The high risk of bias and the heterogeneity in terms of study samples, clinical outcomes and prevalence estimates of MCs and LBP may explain these findings. It is likely that new studies with low risk of bias will affect the direction and strength of these associations.

Predictors of dysfunction and health-related quality of life in the flexion pattern subgroup of patients with chronic lower back pain: The STROBE study

Findings about predictors of chronic lower-back pain (CLBP) were inconsistent and inconclusive in previous studies because patients with CLBP are heterogeneous. Subgrouping patients with CLBP, according to a CLBP classification system, might thus clarify the research findings. CLBP in the direction of lumbar flexion movement, that is, the flexion pattern, is common in clinical situations. Therefore, the purpose of this study was to determine the predictors of dysfunction (pain, disability) and health-related quality of life in the flexion pattern subgroup of patients with CLBP.A cross-sectional study of prospectively collected data. One hundred eight subjects in the flexion pattern subgroup of CLBP. Thirteen variables were measured: the visual analog scale (VAS), the Oswestry Disability Index (ODI), the Short Form-36 (SF-36), the Beck Depression Inventory (BDI), hip internal rotation range of motion, hip flexion range of motion, knee extension range of motion, knee extension with dorsiflexion range of motion, ratio forward flexion, knee extension strength, hip extension strength, hip flexion strength, and lumbopelvic stability.The models for predictors of lower-back pain in the CLBP flexion pattern subgroup included knee extension and the BDI as predictor variables that accounted for 8.1% of the variance in the VAS (P < .05); predictors for disability included the BDI, age, and hip flexion strength, which accounted for 21.2% of the variance in the ODI (P < .05); predictors for health-related quality of life included the BDI, sex, knee extension with dorsiflexion range of motion, and age, which accounted for 38.8% of the variance in the SF-36 (P < .05) in multiple regression models with a stepwise selection procedure.The current results suggest that knee extension, the BDI, age, hip flexion strength, knee extension with dorsiflexion, and sex should be considered when determining appropriate prediction, prevention, and intervention in the flexion pattern subgroup of patients with CLBP.

Movement System Impairment-Based Classification Treatment Versus General Exercises for Chronic Low Back Pain: Randomized Controlled Trial

Background

Treatment for chronic low back pain (LBP) includes different forms of exercises, that to date have resulted in only small to moderate treatment effects. To enhance the treatment effects, different classification systems have been developed to classify people with LBP into more homogeneous subgroups leading to specific treatments for each subgroup.

Objective

The purpose of this study was to compare the efficacy of a treatment based on the Movement System Impairment (MSI) model with a treatment consisting of symptom-guided stretching and strengthening exercises in people with chronic LBP.

Design

The study was a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor.

Setting

The study setting was a university physical therapy clinic in Brazil.

Patients

A total of 148 participants with chronic LBP participated in the study.

Interventions

Participants were randomly allocated to an 8-week treatment of either treatment based on the MSI-based classification system or symptom-guided stretching and strengthening exercises.

Measurements

Measures of pain intensity, disability, and global impression of recovery were obtained by a blinded assessor at baseline and at follow-up appointments at 2, 4, and 6 months after randomization.

Results

There were no significant between-group differences for the primary outcomes of pain intensity at 2 months (mean difference = 0.05, 95% CI = –0.90 to 0.80) and disability at 2 months (mean difference = 0.00, 95% CI = –1.55 to 1.56). There also were no statistically significant differences between treatment groups for any of the secondary outcome measures.

Limitations

Participants and physical therapists were not masked.

Conclusions

People with chronic LBP had similar improvements in pain, disability, and global impression of recovery with treatment consisting of symptom-guided stretching and strengthening exercises and treatment based on the MSI model.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

Background

Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.

Methods

A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.

Results

Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.

Conclusions

This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1549-6) contains supplementary material, which is available to authorized users.

Intratester and intertester reliability of the movement system impairment-based classification for patients with knee pain

BACKGROUND

The methods to standardize the test items used for classification of patients with knee pain based on the movement system impairment (MSI) approach have been established. To our knowledge, no study has concentrated on establishing reliability for proposed classification for knee pain problems.

OBJECTIVE

The aim of the study was to assess intra- and intertester reliability of the knee MSI classification in patients with knee pain.

DESIGN

A cross-sectional methodological study.

SETTING

Rasul Akram Hospital.

PARTICIPANTS

Ninety-six subjects with knee pain aged 18-65 years.

METHODS

In order to examine intertester reliability, all three testers assessed the symptoms, signs and the MSI diagnosis of subjects with knee pain simultaneously. In order to assess intratester reliability, the procedure was exactly repeated after a one-week intersession period. Kappa values and percentages of agreement were calculated to analyze the reliability level.

RESULTS

The kappa values for intra- and intertester reliability of the symptom items ranged from 0.83 to 1.00 and 0.00 to 0.83, respectively. For the sign items, the kappa values ranged from 0.18 to 1.00 and 0.00 to 0.82, respectively. Finally, the kappa values of intra- and intertester reliability for patients' classification judgments ranged from 0.66 to 0.71, and 0.48 to 0.58, respectively.

CONCLUSION

The results of the present study indicate that intertester reliability for the symptoms, signs and classification judgments of patients with knee pain based on the MSI approach seemed generally acceptable. However, for intratester reliability, lower levels of the system were observed, probably due to different pain levels or pain behavior between test and retest sessions.

Classification of patients with low back-related leg pain: a systematic review

BACKGROUND

The identification of clinically relevant subgroups of low back pain (LBP) is considered the number one LBP research priority in primary care. One subgroup of LBP patients are those with back related leg pain. Leg pain frequently accompanies LBP and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back-related leg pain (LBLP) is important for clinical management and research applications, but there is currently no clear agreement on how to define and identify LBLP due to nerve root involvement. The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP, and summarise how leg pain due to nerve root involvement is described and diagnosed in the various systems.

METHODS

The search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were appraised independently by two reviewers using a standardised scoring tool.

RESULTS

Of 13,358 initial potential eligible citations, 50 relevant papers were identified that reported on 22 classification systems. Papers were grouped according to purpose and criteria of the classification systems. Five themes emerged: (i) clinical features (ii) pathoanatomy (iii) treatment-based approach (iv) screening tools and prediction rules and (v) pain mechanisms. Three of the twenty two systems focused specifically on LBLP populations. Systems that scored highest following quality appraisal were ones where authors generally included statistical methods to develop their classifications, and supporting work had been published on the systems' validity, reliability and generalisability. There was lack of consistency in how LBLP due to nerve root involvement was described and diagnosed within the systems.

CONCLUSION

Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. Further work is needed to identify clinically meaningful subgroups of LBLP patients, ideally based on large primary care cohort populations and using recommended methods for classification system development.

Movement System Impairment-Based Classification Versus General Exercise for Chronic Low Back Pain: Protocol of a Randomized Controlled Trial

BACKGROUND

Low back pain (LBP) is an important health problem in all developed countries and is associated with high levels of disability. Evidence-based clinical practice guidelines usually recommend different physical therapy interventions to manage this condition. However, those interventions usually result in small to moderate clinical effects. Recent studies suggest that interventions based on subgroup classifications may improve the effect sizes compared with rehabilitation programs where the same interventions were applied to all patients.

OBJECTIVE

This study will investigate the efficacy of treatment based on a Movement System Impairment (MSI)-based classification model for patients with chronic LBP compared with general exercise. The primary outcomes will be pain intensity and disability at 2 months after randomization.

DESIGN

The study is a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor.

SETTING

The study setting will be a university physical therapy clinic in Brazil.

PARTICIPANTS

A total of 148 individuals with chronic LBP will participate in the study.

INTERVENTION

Included individuals will be randomly allocated to participate in an 8-week treatment program based on the MSI-based classification or a general exercise program of stretching and strengthening exercises.

MEASUREMENTS

Pain intensity, disability, and global impression of recovery will be assessed by a blinded assessor at baseline and at follow-up appointments after treatment (2 months) and 4 and 6 months after randomization.

LIMITATIONS

Therapists will not be blinded.

CONCLUSIONS

The results of this study may contribute to a better understanding of the efficacy of treatments based on classification of participants with chronic LBP into subgroups.

Knowledge translation from continuing education to physiotherapy practice in classifying patients with low back pain

OBJECTIVES

Physical therapists have used continuing education as a method of improving their skills in conducting clinical examination of patients with low back pain (LBP). The purpose of this study was to evaluate how well the pathoanatomical classification of patients in acute or subacute LBP can be learned and applied through a continuing education format. The patients were seen in a direct access setting.

METHODS

The study was carried out in a large health-care center in Finland. The analysis included a total of 57 patient evaluations generated by six physical therapists on patients with LBP. We analyzed the consistency and level of agreement of the six physiotherapists' (PTs) diagnostic decisions, who participated in a 5-day, intensive continuing education session and also compared those with the diagnostic opinions of two expert physical therapists, who were blind to the original diagnostic decisions. Evaluation of the physical therapists' clinical examination of the patients was conducted by the two experts, in order to determine the accuracy and percentage agreement of the pathoanatomical diagnoses.

RESULTS

The percentage of agreement between the experts and PTs was 72-77%. The overall inter-examiner reliability (kappa coefficient) for the subgroup classification between the six PTs and two experts was 0.63 [95% confidence interval (CI): 0.47-0.77], indicating good agreement between the PTs and the two experts. The overall inter-examiner reliability between the two experts was 0.63 (0.49-0.77) indicating good level of agreement.

DISCUSSION

Our results indicate that PTs' were able to apply their continuing education training to clinical reasoning and make consistently accurate pathoanatomic based diagnostic decisions for patients with LBP. This would suggest that continuing education short-courses provide a reasonable format for knowledge translation (KT) by which physical therapists can learn and apply new information related to the examination and differential diagnosis of patients in acute or subacute LBP.

Predicting a clinically important outcome in patients with low back pain following McKenzie therapy or spinal manipulation: a stratified analysis in a randomized controlled trial

BACKGROUND

Reports vary considerably concerning characteristics of patients who will respond to mobilizing exercises or manipulation. The objective of this prospective cohort study was to identify characteristics of patients with a changeable lumbar condition, i.e. presenting with centralization or peripheralization, that were likely to benefit the most from either the McKenzie method or spinal manipulation.

METHODS

350 patients with chronic low back pain were randomized to either the McKenzie method or manipulation. The possible effect modifiers were age, severity of leg pain, pain-distribution, nerve root involvement, duration of symptoms, and centralization of symptoms. The primary outcome was the number of patients reporting success at two months follow-up. The values of the dichotomized predictors were tested according to the prespecified analysis plan.

RESULTS

No predictors were found to produce a statistically significant interaction effect. The McKenzie method was superior to manipulation across all subgroups, thus the probability of success was consistently in favor of this treatment independent of predictor observed. When the two strongest predictors, nerve root involvement and peripheralization, were combined, the chance of success was relative risk 10.5 (95% CI 0.71-155.43) for the McKenzie method and 1.23 (95% CI 1.03-1.46) for manipulation (P = 0.11 for interaction effect).

CONCLUSIONS

We did not find any baseline variables which were statistically significant effect modifiers in predicting different response to either McKenzie treatment or spinal manipulation when compared to each other. However, we did identify nerve root involvement and peripheralization to produce differences in response to McKenzie treatment compared to manipulation that appear to be clinically important. These findings need testing in larger studies.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT00939107.

Assessment of Consistency Between the Arm-Fossa Test and Gillet Test: A Pilot Study

OBJECTIVE

The purpose of this pilot study was to test methods needed to conduct a study with adequate power to investigate consistency between the arm-fossa test (AFT) and the Gillet test.

METHODS

A convenience sample of chiropractic college students enrolled in a weekend Sacro-Occipital Technique seminar participated. Each was tested with AFT and sacroiliac orthopedic tests, including the Gillet test. Statistical testing included calculation of κ for consistency of the AFT and Gillet test and their diagnostic efficiency.

RESULTS

This study recruited 14 participants. Important issues arose in gathering and recording data, the standardization of examiner methods, and the flow of participants to examination stations. κ for AFT and Gillet test consistency = 0.55, corresponding to "moderate."

CONCLUSION

This pilot suggests that the future study should include a mix of symptomatic and asymptomatic participants; record trichotomous data, where appropriate; use washout periods between diagnostic tests; and refine the selection of orthopedic tests deployed besides the AFT. The preliminary data are consistent with but do not establish due to the very small sample size and experimental design issues, that a positive AFT may be consistent with a negative Gillet test.

Review of methods used by chiropractors to determine the site for applying manipulation

Background

With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.

Methods

Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.

Results

A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

Conclusions

A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

Patient characteristics in low back pain subgroups based on an existing classification system. A descriptive cohort study in chiropractic practice

Sub-grouping of low back pain (LBP) is believed to improve prediction of prognosis and treatment effects. The objectives of this study were: (1) to examine whether chiropractic patients could be sub-grouped according to an existing pathoanatomically-based classification system, (2) to describe patient characteristics within each subgroup, and (3) to determine the proportion of patients in whom clinicians considered the classification to be unchanged after approximately 10 days. A cohort of 923 LBP patients was included during their first consultation. Patients completed an extensive questionnaire and were examined according to a standardised protocol. Based on the clinical examination, patients were classified into diagnostic subgroups. After approximately 10 days, chiropractors reported whether they considered the subgroup had changed. The most frequent subgroups were reducible and partly reducible disc syndromes followed by facet joint pain, dysfunction and sacroiliac (SI)-joint pain. Classification was inconclusive in 5% of the patients. Differences in pain, activity limitation, and psychological factors were small across subgroups. Within 10 days, 82% were reported to belong to the same subgroup as at the first visit. In conclusion, LBP patients could be classified according to a standardised protocol, and chiropractors considered most patient classifications to be unchanged within 10 days. Differences in patient characteristics between subgroups were very small, and the clinical relevance of the classification system should be investigated by testing its value as a prognostic factor or a treatment effect modifier. It is recommended that this classification system be combined with psychological and social factors if it is to be useful.

Validity and reliability of the assessment and diagnosis of musculoskeletal elbow disorders using telerehabilitation

We examined the validity and reliability of a physiotherapy examination of the elbow, using telerehabilitation. The patho-anatomical diagnoses, systems diagnosis and physical examination findings of face-to-face physiotherapy examinations were compared with telerehabilitation examinations. Ten participants attended a single session, during which they were interviewed, a face-to-face physical examination was performed and a remote physical examination was conducted, guided by an examiner at a different location via a telerehabilitation system. Conventional face-to-face physiotherapy physical examination test results, diagnoses and systems diagnoses were compared to those produced by an examiner using the telerehabiliation system. There was substantial agreement for systems diagnosis (73%; P = 0.013) for validity and almost perfect agreement for intra-rater reliability (90%; P = 0.001). The inter-rater reliability had a weaker and non-significant agreement (64%; P = 0.11). Physical examination data demonstrated >68% agreement across all three datasets, between the examination methods. Performing a telerehabilitation physical examination to determine a musculoskeletal diagnosis of the elbow joint complex is both valid and reliable.

Reliability of a treatment-based classification system for subgrouping people with low back pain

STUDY DESIGN

Observational, cross-sectional reliability study.

OBJECTIVES

To examine the interrater reliability of novice raters in their use of the treatment-based classification (TBC) system for low back pain and to explore the patterns of disagreement in classification errors.

BACKGROUND

Although the interrater reliability of individual test items in the TBC system is moderate to good, some error persists in classification decision making. Understanding which classification errors are common could direct further refinement of the TBC system.

METHODS

Using previously recorded patient data (n = 24), 12 novice raters classified patients according to the TBC schema. These classification results were combined with those of 7 other raters, allowing examination of the overall agreement using the kappa statistic, as well as agreement/disagreement among pairwise comparisons in classification assignments. A chi-square test examined differences in percent agreement between the novice and more experienced raters and differences in classification distributions between these 2 groups of raters.

RESULTS

Among 12 novice raters, there was 80.9% agreement in the pairs of classification (κ = 0.62; 95% confidence interval: 0.59, 0.65) and an overall 75.5% agreement (κ = 0.57; 95% confidence interval: 0.55, 0.69) for the combined data set. Raters were least likely to agree on a classification of stabilization (77.5% agreement). The overall percentage of pairwise classification judgments that disagreed was 24.5%, with the most common disagreement being between manipulation and stabilization (11.0%), followed by a mismatch between stabilization and specific exercise (8.2%).

CONCLUSION

Additional refinement is needed to reduce rater disagreement that persists in the TBC decision-making algorithm, particularly in the stabilization category. J Orthop Sports Phys Ther 2012;42(9):797-805, Epub 7 June 2012. doi:10.2519/jospt.2012.4078.

Reliability of novice raters in using the movement system impairment approach to classify people with low back pain

Observational cross sectional study. To examine the inter-rater reliability of novice raters in using the Movement System Impairment (MSI) approach system and to explore the patterns of disagreement in classification errors. The inter-rater reliability of individual tests items used in the MSI approach is moderate to good; however, the reliability of the classification algorithm has been tested only preliminarily. Using previously recorded patient data (n = 21), 13 novice raters classified patients according to the MSI schema. The overall percent agreement using the kappa statistic as well as the agreement/disagreement among pair-wise comparisons in classification assignments were examined. There was an overall 87.4% agreement in the pairs of classification judgments with a kappa coefficient of 0.81 (95% CI: 0.79, 0.83). Raters were most likely to agree on the classification of Flexion (100%) and least likely to agree on the classification of Rotation (84%). The MSI classification algorithm can be learned by novice users and with training, their inter-rater reliability in applying the algorithm for classification judgments is good and similar to that reported in other studies. However, some degree of error persists in the classification decision-making associated with the MSI system, in particular for the Rotation category.

Pathoanatomy and classification of low back disorders

Over the past decade research into the effectiveness of low back disorders (LBDs) has focused on the classification of subgroups more likely to respond to specific treatment. Much of this research has explicitly excluded a focus on pathoanatomical factors based on a questionable interpretation of the biopsychosocial model. Common justifications and potential issues with this approach are explored with recommendations made for future clinical and research practice.

Fingertip-to-floor test and straight leg raising test: validity, responsiveness, and predictive value in patients with acute/subacute low back pain

OBJECTIVES

To investigate the validity over time of the fingertip-to-floor test (FTF) and the straight leg raising test (SLR) using the Roland Morris Disability Questionnaire (RMDQ) and correlation coefficient (r), and to assess the predictive value of factors related to the change in RMDQ over 12 months using multivariate regression analysis.

DESIGN

Longitudinal study.

SETTING

Outpatient physical therapy clinic.

PARTICIPANTS

Subjects (N=65) with acute/subacute low back pain (≤13 wk of symptoms). Thirty-eight (58%) had radicular pain as determined by the slump test.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reported disability was used as a reference variable and was measured using the RMDQ at baseline and after 1 and 12 months. The FTF and SLR were measured at baseline and after 1 month. Responsiveness and imprecision were assessed by using effect size (ES) and minimal detectable change (MDC). The sample was stratified by the presence or absence of radicular pain (categorized by the slump test).

RESULTS

The change in FTF results was significantly correlated to the 1-month change in RMDQ, both in the entire sample (r=.63) and in the group with radicular pain (r=.66). Similar analysis for the SLR showed a weak relationship to RMDQ. FTF showed adequate responsiveness (ES range, 0.8-0.9) in contrast to SLR (ES range, 0.2-0.5). The MDC for FTF and SLR were 4.5 cm and 5.7°, respectively. The change in FTF results over 1 month was independently more strongly associated with the 12-month (R(2)=.27-.31) change in RMDQ than any of the other variables and multivariate combinations.

CONCLUSIONS

Our results suggest that the FTF has good validity in patients with acute/subacute low back pain and even better validity in those with radicular pain. The change in FTF results over the first month was a valid predictor of the change in self-reported disability over 1 year. In contrast, the validity of SLR can be questioned in the present group of patients.

Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/expert survey

BACKGROUND

Several classification schemes, each with its own philosophy and categorizing method, subgroup low back pain (LBP) patients with the intent to guide treatment. Physiotherapy derived schemes usually have a movement impairment focus, but the extent to which other biological, psychological, and social factors of pain are encompassed requires exploration. Furthermore, within the prevailing 'biological' domain, the overlap of subgrouping strategies within the orthopaedic examination remains unexplored. The aim of this study was "to review and clarify through developer/expert survey, the theoretical basis and content of physical movement classification schemes, determine their relative reliability and similarities/differences, and to consider the extent of incorporation of the bio-psycho-social framework within the schemes".

METHODS

A database search for relevant articles related to LBP and subgrouping or classification was conducted. Five dominant movement-based schemes were identified: Mechanical Diagnosis and Treatment (MDT), Treatment Based Classification (TBC), Pathoanatomic Based Classification (PBC), Movement System Impairment Classification (MSI), and O'Sullivan Classification System (OCS) schemes. Data were extracted and a survey sent to the classification scheme developers/experts to clarify operational criteria, reliability, decision-making, and converging/diverging elements between schemes. Survey results were integrated into the review and approval obtained for accuracy.

RESULTS

Considerable diversity exists between schemes in how movement informs subgrouping and in the consideration of broader neurosensory, cognitive, emotional, and behavioural dimensions of LBP. Despite differences in assessment philosophy, a common element lies in their objective to identify a movement pattern related to a pain reduction strategy. Two dominant movement paradigms emerge: (i) loading strategies (MDT, TBC, PBC) aimed at eliciting a phenomenon of centralisation of symptoms; and (ii) modified movement strategies (MSI, OCS) targeted towards documenting the movement impairments associated with the pain state.

CONCLUSIONS

Schemes vary on: the extent to which loading strategies are pursued; the assessment of movement dysfunction; and advocated treatment approaches. A biomechanical assessment predominates in the majority of schemes (MDT, PBC, MSI), certain psychosocial aspects (fear-avoidance) are considered in the TBC scheme, certain neurophysiologic (central versus peripherally mediated pain states) and psychosocial (cognitive and behavioural) aspects are considered in the OCS scheme.

The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To compare the effects of the McKenzie method performed by certified therapists with spinal manipulation performed by chiropractors when used adjunctive to information and advice.

SUMMARY OF BACKGROUND DATA

Recent guidelines recommend a structured exercise program tailored to the individual patient as well as manual therapy for the treatment of persistent low back pain. There is presently insufficient evidence to recommend the use of specific decision methods tailoring specific therapies to clinical subgroups of patients in primary care.

METHODS

A total of 350 patients suffering from low back pain with a duration of more than 6 weeks who presented with centralization or peripheralization of symptoms with or without signs of nerve root involvement, were enrolled in the trial. Main outcome was number of patients with treatment success defined as a reduction of at least 5 points or an absolute score below 5 points on the Roland Morris Questionnaire. Secondary outcomes were reduction in disability and pain, global perceived effect, general health, mental health, lost work time, and medical care utilization.

RESULTS

Both treatment groups showed clinically meaningful improvements in this study. At 2 months follow-up, the McKenzie treatment was superior to manipulation with respect to the number of patients who reported success after treatment (71% and 59%, respectively) (odds ratio 0.58, 95% confidence interval [CI] 0.36 to 0.91, P = 0.018). The number needed to treat with the McKenzie method was 7 (95% CI 4 to 47). The McKenzie group showed improvement in level of disability compared to the manipulation group reaching a statistical significance at 2 and 12 months follow-up (mean difference 1.5, 95% CI 0.2 to 2.8, P = 0.022 and 1.5, 95% CI 0.2 to 2.9, P = 0.030, respectively). There was also a significant difference of 13% in number of patients reporting global perceived effect at end of treatment (P = 0.016). None of the other secondary outcomes showed statistically significant differences.

CONCLUSION

In patients with low back pain for more than 6 weeks presenting with centralization or peripheralization of symptoms, we found the McKenzie method to be slightly more effective than manipulation when used adjunctive to information and advice.

Effect of 2 lumbar spine postures on transversus abdominis muscle thickness during a voluntary contraction in people with and without low back pain

OBJECTIVE

The present study investigated the effect of 2 different lumbar spine postures, neutral and flexed lumbar postures, on transversus abdominis (TrA) muscle function during a voluntary contraction (hollowing and draw-in maneuver) in people with and without low back pain (LBP).

METHODS

Thirty participants with LBP and 30 healthy participants were recruited for this cross-sectional study. Transversus abdominis muscle function was measured as a change in thickness with ultrasound imaging. Participants performed voluntary TrA contraction in a supine lying position with the lumbar spine in neutral and flexed postures. Data were analyzed using a 2-way (groups, postures) analysis of variance.

RESULTS

Lumbar posture influenced TrA function during a voluntary contraction in people with and without LBP. There was a significant main effect of posture (F(1,58) = 16.140, P < .001). Neutral lumbar posture improved participants' ability to recruit TrA in both group (mean difference, 7.5%; 95% confidence interval, 3.8%-11.3%). No significant differences were found between healthy subjects and those with LBP.

CONCLUSIONS

The results of the present study showed that, in subjects performing a voluntary TrA contraction, the neutral lumbar posture improves the ability to increase change in TrA thickness. This study found no significant difference in TrA thickness change between healthy subjects and those with nonspecific LBP.

The reliability of clinical judgments and criteria associated with mechanisms-based classifications of pain in patients with low back pain disorders: a preliminary reliability study

Mechanisms-based classifications of pain have been advocated for their potential to aid understanding of clinical presentations of pain and improve clinical outcomes. However, the reliability of mechanisms-based classifications of pain and the clinical criteria upon which such classifications are based are not known. The purpose of this investigation was to assess the inter- and intra-examiner reliability of clinical judgments associated with: (i) mechanisms-based classifications of pain; and (ii) the identification and interpretation of individual symptoms and signs from a Delphi-derived expert consensus list of clinical criteria associated with mechanisms-based classifications of pain in patients with low back (±leg) pain disorders. The inter- and intra-examiner reliability of an examination protocol performed by two physiotherapists on two separate cohorts of 40 patients was assessed. Data were analysed using kappa and percentage of agreement values. Inter- and intra-examiner agreement associated with clinicians' mechanisms-based classifications of low back (±leg) pain was 'substantial' (kappa  = 0.77; 95% confidence interval (CI): 0.57-0.96; % agreement  = 87.5) and 'almost perfect' (kappa  = 0.96; 95% CI: 0.92-1.00; % agreement = 92.5), respectively. Sixty-eight and 95% of items on the clinical criteria checklist demonstrated clinically acceptable (kappa ⩾ 0.61 or % agreement ⩾ 80%) inter- and intra-examiner reliability, respectively. The results of this study provide preliminary evidence supporting the reliability of clinical judgments associated with mechanisms-based classifications of pain in patients with low back (±leg) pain disorders. The reliability of mechanisms-based classifications of pain should be investigated using larger samples of patients and multiple independent examiners.

Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders

Background

Low back disorders are a common and costly cause of pain and activity limitation in adults. Few treatment options have demonstrated clinically meaningful benefits apart from advice which is recommended in all international guidelines. Clinical heterogeneity of participants in clinical trials is hypothesised as reducing the likelihood of demonstrating treatment effects, and sampling of more homogenous subgroups is recommended. We propose five subgroups that allow the delivery of specific physiotherapy treatment targeting the pathoanatomical, neurophysiological and psychosocial components of low back disorders. The aim of this article is to describe the methodology of a randomised controlled trial comparing specific physiotherapy treatment to advice for people classified into five subacute low back disorder subgroups.

Methods/Design

A multi-centre parallel group randomised controlled trial is proposed. A minimum of 250 participants with subacute (6 weeks to 6 months) low back pain and/or referred leg pain will be classified into one of five subgroups and then randomly allocated to receive either physiotherapy advice (2 sessions over 10 weeks) or specific physiotherapy treatment (10 sessions over 10 weeks) tailored according to the subgroup of the participant. Outcomes will be assessed at 5 weeks, 10 weeks, 6 months and 12 months following randomisation. Primary outcomes will be activity limitation measured with a modified Oswestry Disability Index as well as leg and back pain intensity measured on separate 0-10 Numerical Rating Scales. Secondary outcomes will include a 7-point global rating of change scale, satisfaction with physiotherapy treatment, satisfaction with treatment results, the Sciatica Frequency and Bothersomeness Scale, quality of life (EuroQol-5D), interference with work, and psychosocial risk factors (Orebro Musculoskeletal Pain Questionnaire). Adverse events and co-interventions will also be measured. Data will be analysed according to intention to treat principles, using linear mixed models for continuous outcomes, Mann Whitney U tests for ordinal outcomes, and Chi-square, risk ratios and risk differences for dichotomous outcomes.

Discussion

This trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000834257.

The Nordic back pain subpopulation program: can low back pain patterns be predicted from the first consultation with a chiropractor? A longitudinal pilot study

BACKGROUND

It is widely believed that non-specific low back pain (LBP) consists of a number of subgroups which should be identified in order to improve treatment effects. In order to identify subgroups, patient characteristics that relate to different outcomes are searched for. However, LBP is often fluctuating or recurring rather than clearly limited in time. Therefore it would be relevant to consider outcome after completed treatment from a longitudinal perspective (describing "course patterns") instead of defining it from an arbitrarily selected end-point.

AIMS

The objectives of this pilot study were to investigate the interobserver reliability of a diagnostic classification system and to evaluate whether diagnostic classes or other baseline characteristics are associated with the LBP course pattern over a period of 18 weeks.

METHODS

Patients visiting one of 7 chiropractors because of LBP were classified according to a diagnostic classification system, which includes end-range loading, SI-joint pain provocation tests, neurological examination and tests for muscle tenderness and abnormal nerve tension. In addition, age, gender, duration of pain and presence of leg pain were registered in the patient's file. By weekly SMS-messages on their mobile phones, patients were asked how many days they had LBP the preceding week, and these answers were transformed into pain course patterns and the total number of LBP days.

RESULTS

A total of 110 patients were included and 76 (69%) completed follow-up. Thirty-five patients were examined by two chiropractors. The agreement regarding diagnostic classes was 83% (95% CI: 70 - 96). The diagnostic classes were associated with the pain course patterns and number of LBP days. Patients with disc pain had the highest number of LBP days and patients with muscular pain reported the fewest (35 vs. 12 days, p < 0.01). Men had better outcome than women (17 vs. 29 days, p < 0.01) and patients without leg pain tended to have fewer LBP days than those with leg pain (21 vs.31 days, p = 0.06). Duration of LBP at the first visit was not associated with outcome.

CONCLUSIONS

The study indicated that there is a clinically meaningful relationship between diagnostic classes and the course of LBP. This should be evaluated in more depth.

Kinematic analysis of dynamic lumbar motion in patients with lumbar segmental instability using digital videofluoroscopy

The study design is a prospective, case-control. The aim of this study was to develop a reliable measurement technique for the assessment of lumbar spine kinematics using digital video fluoroscopy in a group of patients with low back pain (LBP) and a control group. Lumbar segmental instability (LSI) is one subgroup of nonspecific LBP the diagnosis of which has not been clarified. The diagnosis of LSI has traditionally relied on the use of lateral functional (flexion-extension) radiographs but use of this method has proven unsatisfactory.Fifteen patients with chronic low back pain suspected to have LSI and 15 matched healthy subjects were recruited. Pulsed digital videofluoroscopy was used to investigate kinematics of lumbar motion segments during flexion and extension movements in vivo. Intersegmental linear translation and angular displacement, and pathway of instantaneous center of rotation (PICR) were calculated for each lumbar motion segment. Movement pattern of lumbar spine between two groups and during the full sagittal plane range of motion were analyzed using ANOVA with repeated measures design. Intersegmental linear translation was significantly higher in patients during both flexion and extension movements at L5-S1 segment (p < 0.05). Arc length of PICR was significantly higher in patients for L1-L2 and L5-S1 motion segments during extension movement (p < 0.05). This study determined some kinematic differences between two groups during the full range of lumbar spine. Devices, such as digital videofluoroscopy can assist in identifying better criteria for diagnosis of LSI in otherwise nonspecific low back pain patients in hope of providing more specific treatment.

The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain

Pregnancy-related lumbopelvic pain has varying clinical presentations and effects among subgroups. Different lumbopelvic pain subgroups require different specific management approaches which require the differentiation between lumbar and pelvic girdle pain (PGP). Thirty-one consecutive pregnant women with non-specific lumbopelvic pain were evaluated by two examiners and classified into lumbar pain, PGP, or combined pelvic girdle and lumbar pain. A standard history about different positions/activities of daily life such as bending, sitting, standing, walking, and lying, was followed by a standardised mechanical assessment of the lumbar spine (Mechanical Diagnosis and Therapy), including tests of repeated end-range movements to standing and lying, pelvic pain provocation tests (distraction test, posterior pelvic pain provocation test, Gaenslen's test, compression test, and sacral thrust) a hip-rotation range-of-motion test, the active straight-leg-raising test, and a neurological examination. Agreement for the three syndromes (lumbar pain, PGP, or combined pelvic girdle and lumbar pain) was 87% (27/31), with a kappa coefficient of 0.79 (95% CI 0.60-0.98). It was possible to perform the classification procedure throughout pregnancy. There was substantial agreement between the two examiners for the classification of non-specific lumbopelvic pain into lumbar pain and PGP in pregnant women.

Inter-tester Reliability in Classifying Acute and Subacute Low Back Pain Patients into Clinical Subgroups: A Comparison of Specialists and Non-Specialists. A Pilot Study

Many systems have been suggested for classifying low back pain (LBP); the most commonly used among physiotherapists involves a pathoanatomical/pathophysiological tissue classification system. Few studies have examined whether this form of classification of LBP disorders can be performed in a reliable manner between specialists with advanced training, or between specialists with advanced training and non-specialists who lack advanced training. The purpose of this paper was to examine the inter-tester reliability of two specialists, and the ability of a specialist and non-specialist to independently classify patients with LBP, utilizing clinical tests and history-based classification methods after a short educational course on the classification system. Subjects were acute or sub-acute patients with LBP who visited their occupational healthcare or municipal healthcare center. Inter-tester reliability between the specialist and non-specialists was at almost the same level: overall Kappa 0.60 (95%CI; 0.40 to 0.85), overall agreement 70%, as between the two specialists: overall Kappa 0.65 (95%CI; 0.33-0.86), overall agreement 77%. The findings suggest that a short educational course can provide rather reliable examination tools to allow non-specialized physiotherapists to classify patients according to tissue origination.

Interrater reliability of a new classification system for patients with neural low back-related leg pain

The aim of this study was to investigate the reliability of a new classification system for low back-related leg pain arising from neural tissue dysfunction. Leg pain is a frequent accompaniment to back pain and is an indicator of the severity and prognosis of the disorder. For optimal patient care, treatment should be directed according to the identified pathophysiological mechanisms. The authors have proposed a sub-classification of neural low back-related leg pain into four categories, each requiring a different management strategy: Central Sensitization (CS), comprising major features of sensitization of the somatosensory system; Denervation (D), arising from significant axonal compromise without evidence of major central nervous system changes; Peripheral Nerve Sensitization (PNS), arising from nerve trunk inflammation without clinical evidence of significant denervation; and Musculoskeletal pain (M), referred from non-neural structures such as the disc or facet joints. The purpose of this study was to investigate the interrater reliability of this classification system. Forty consecutive patients with unilateral low back-related leg pain were independently assessed by five pairs of examiners using a physical examination protocol, screening for central sensitization of the somatosensory system, neurological deficit, and nerve tissue mechano-sensitization. Subjects were classified as follows: CS 30%, D 27.5%, PNS 10%, and M 32.5%. Interrater reliability was good with 80% agreement and a k of 0.72 (95% Confidence Interval (CI) .57-.86). The findings of the study demonstrate that patients with low back-related leg pain can be reliably classified to one of the four proposed groups.

European guidelines for the diagnosis and treatment of pelvic girdle pain

A guideline on pelvic girdle pain (PGP) was developed by "Working Group 4" within the framework of the COST ACTION B13 "Low back pain: guidelines for its management", issued by the European Commission, Research Directorate-General, Department of Policy, Coordination and Strategy. To ensure an evidence-based approach, three subgroups were formed to explore: (a) basic information, (b) diagnostics and epidemiology, and (c) therapeutical interventions. The progress of the subgroups was discussed at each meeting and the final report is based on group consensus. A grading system was used to denote the strength of the evidence, based on the AHCPR Guidelines (1994) and levels of evidence recommended in the method guidelines of the Cochrane Back Review group. It is concluded that PGP is a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP. PGP generally arises in relation to pregnancy, trauma, arthritis and/or osteoarthritis. Uniform definitions are proposed for PGP as well as for joint stability. The point prevalence of pregnant women suffering from PGP is about 20%. Risk factors for developing PGP during pregnancy are most probably a history of previous LBP, and previous trauma to the pelvis. There is agreement that non risk factors are: contraceptive pills, time interval since last pregnancy, height, weight, smoking, and most probably age. PGP can be diagnosed by pain provocation tests (P4/thigh thrust, Patrick's Faber, Gaenslen's test, and modified Trendelenburg's test) and pain palpation tests (long dorsal ligament test and palpation of the symphysis). As a functional test, the active straight leg raise (ASLR) test is recommended. Mobility (palpation) tests, X-rays, CT, scintigraphy, diagnostic injections and diagnostic external pelvic fixation are not recommended. MRI may be used to exclude ankylosing spondylitis and in the case of positive red flags. The recommended treatment includes adequate information and reassurance of the patient, individualized exercises for pregnant women and an individualized multifactorial treatment program for other patients. We recommend medication (excluding pregnant women), if necessary, for pain relief. Recommendations are made for future research on PGP.

Diagnosis and classification of pelvic girdle pain disorders--Part 1: a mechanism based approach within a biopsychosocial framework

The diagnosis and classification of pelvic girdle pain (PGP) disorders remains controversial despite a proliferation of research into this field. The majority of PGP disorders have no identified pathoanatomical basis leaving a management vacuum. Diagnostic and treatment paradigms for PGP disorders exist although many of these approaches have limited validity and are uni-dimensional (i.e. biomechanical) in nature. Furthermore single approaches for the management of PGP fail to benefit all. This highlights the possibility that 'non-specific' PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity. This paper examines the current knowledge and challenges some of the common beliefs regarding the sacroiliac joints and pelvic function. A hypothetical 'mechanism based' classification system for PGP, based within a biopsychosocial framework is proposed. This has developed from a synthesis of the current evidence combined with the clinical observations of the authors. It recognises the presence of both specific and non-specific musculoskeletal PGP disorders. It acknowledges the complex and multifactorial nature of chronic PGP disorders and the potential of both the peripheral and central nervous system to promote and modulate pain. It is proposed that there is a large group of predominantly peripherally mediated PGP disorders which are associated with either 'reduced' or 'excessive' force closure of the pelvis, resulting in abnormal stresses on pain sensitive pelvic structures. It acknowledges that the interaction of psychosocial factors (such as passive coping strategies, faulty beliefs, anxiety and depression) in these pain disorders has the potential to promote pain and disability. It also acknowledges the complex interaction that hormonal factors may play in these pain disorders. This classification model is flexible and helps guide appropriate management of these disorders within a biopsychosocial framework. While the validity of this approach is emerging, further research is required.

Subclassification of low back pain: a cross-country comparison

Various health professionals have attempted to classify low back pain (LBP) subgroups and have developed several LBP classification systems. Knowing that culture has an effect on LBP symptomatology, assessment findings and clinical decision making, the aim of this review is to perform a cross-country comparative review amongst the published classification systems, addressing each country's similarities and differences as well as exploring whether cultural factors have been incorporated into the subclassification process. A systematic search of databases limited to human adults was undertaken by Medline, Cinahl, AMED and PEDro databases between January 1980 and October 2005. Classification systems from nine countries were identified. Most studies were classified according to pathoanatomic and/or clinical features, whereas fewer studies utilized a psychosocial and even less, a biopsychosocial approach. Most studies were limited in use to the country of the system's developer. Very few studies addressed cultural issues, highlighting the lack of information on the impact of specific cultural factors on LBP classification procedures. However, there seem to be certain 'cultural trends' in classification systems within each country, which are discussed. Despite the plethora of classification studies, there is still no system which is internationally established, effective, reliable and valid. Future research should aim to develop a LBP classification system within a well identified cultural setting, addressing the multi-dimensional features of the LBP presentation.

Classification by McKenzie mechanical syndromes: a survey of McKenzie-trained faculty

OBJECTIVE

The purpose of this survey was to identify the percentage of patients with spine pain who can be classified by McKenzie-trained faculty as having one of either derangement, dysfunction, or postural syndromes.

METHODS

McKenzie Institute International faculty members in 20 countries, who are highly trained and are experienced users of the classification system, recorded details on 15 consecutively discharged patients.

RESULTS

Responses were received from 57 therapists in 18 countries (89% of potential sample), and details were collected on 607 patients with spine pain. Eighty-three percent were classified in one of the mechanical syndromes; derangement was the most common syndrome. Therapists recorded a mechanical classification in a mean of 82% (SD, 15.1; range, 44%-100%) of their patients with spine pain.

CONCLUSIONS

For this study, the McKenzie mechanical syndromes were commonly diagnosed in a large consecutive group of patients at multiple sites by experienced therapists. This classification system may have valuable clinical use in managing patients with spine pain.

Reliability of procedures used in the physical examination of non-specific low back pain: a systematic review

The purpose of this systematic review was to determine the quality of the research and to assess the reliability of different types of physical examination procedures used in the assessment of patients with non-specific low back pain. A search of electronic databases (MEDLINE, PEDro, AMED, EMBASE, Cochrane, and CINAHL) up to August 2005 identified 48 relevant studies which were analysed for quality and reliability. Pre-established criteria were used to judge the quality of the studies and satisfactory reliability, and conclusions emphasised high quality studies (> or = 60% methods score). The mean quality score of the studies was 52% (range 0 to 88%), indicating weak to moderate methodology. Based on the upper threshold used (kappa/ICC > 0.85) most procedures demonstrated either conflicting evidence or moderate to strong evidence of low reliability. When the lower threshold was used (kappa/ICC > 0.70) evidence about pain response to repeated movements changed from contradictory to moderate evidence for high reliability. Most procedures commonly used by clinicians in the examination of patients with back pain demonstrate low reliability.

The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach

STUDY DESIGN AND OBJECTIVES

Meta-analysis of randomized controlled trials to evaluate the effectiveness of the McKenzie method for low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The McKenzie method is a popular classification-based treatment for LBP. The faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials.

METHODS

MEDLINE, EMBASE, PEDro, and LILACS were searched up to August 2003. Two independent reviewers extracted the data and assessed methodologic quality. Pooled effects were calculated among homogeneous trials using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie.

RESULTS

Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up. Heterogeneity prevented pooling of studies on chronic LBP as well as pooling of studies included in the sensitivity analysis.

CONCLUSIONS

There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.