Reliability of physical examination items used for classification of patients with low back pain. Intertester Reliability of McKenzie's Classifications of the Syndrome Types Present in Patients with Low Back Pain A systematic review of workplace interventions to prevent low back pain. The role of patients' expectation of appropriate initial manual therapy treatment in outcomes for patients with low back pain. Intertester reliability of a modified version of McKenzie's lateral shift assessments obtained on patients with low back pain. The Use of a Classification Approach to Identify Subgroups of Patients With Acute Low Back Pain: Interrater Reliability and Short-Term Treatment Outcomes Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. Course of back pain in primary care: a prospective study of physical measures. Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. The interrater reliability among physical therapists newly trained in a classification system for acute low back pain. An internet-based approach to enhance self-management of chronic low back pain in the Italian-speaking population of Switzerland: results from a pilot study Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Intertester reliability of a low back pain classification system. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale Efficacy of graded activity versus supervised exercises in patients with chronic non-specific low back pain: protocol of a randomised controlled trial
BACKGROUND AND PURPOSE The purpose of this study was to examine the interrater reliability of measurements obtained by examiners administering tests proposed to be important for classifying low back pain ( LBP ) problems . SUBJECTS Ninety-five subjects with LBP ( 41 men , 54 women ) and 43 subjects without LBP ( 17 men , 26 women ) were examined by 5 therapists trained in the techniques used . METHODS A manual was developed by the first author that described the clinical examination procedures . The therapists were trained by the first author in the test procedures and definitions . The training included instruction through videotapes , practice and a written examination . Each examination was conducted by a pair of therapists . Within a pair , a therapist was the primary examiner for half of the subjects and an observer was the primary examiner for half of the subjects . Examination findings were recorded independently , without discussion . RESULTS Percentage of agreement and generalized kappa coefficients were used to analyzed the data . Kappa values were > or = .75 for all 28 items related to the symptoms elicited and > or = .40 for 72 % of the 25 items related to alignment and movement . CONCLUSION AND DISCUSSION The results suggest that experienced therapist who had trained together were able to agree on the results of examinations and obtain an acceptable level of reliability . Future work should focus on testing of reliability when more than one therapist performs the examination and when therapist not trained by the test developer to administer the examination perform the tests . [ Van Dillen LR , Sahrmann SA , Norton BJ , et al. Reliability of physical examination items used for classification of patients with low back pain The McKenzie system for examining and treating patients with low back pain is frequently used by clinicians . The primary purpose of this multicenter study was the determine the intertester reliability of assessment s of patients with low back pain when physical therapists used the McKenzie method . A second purpose was to determine if previous postgraduate training in the McKenzie system affects reliability . Some therapists had previously undertaken postgraduate training in the McKenzie system .  All therapists were given written descriptions of the McKenzie method and the criteria used to classify patients , Classifications were made on 363 patients with low back pain by r and omly paired physical therapists in eight clinics . The Kappa value on agreement of patient classification was 0.26 , which suggests poor reliability . Therapists agreed on which syndrome was present 39 % of the time . Previous postgraduate training did not reliability . The results suggest that assessment s of the syndrome present in patients ; with low back pain appear to be unreliable when using the McKenzie system A systematic review of r and omised controlled trials was undertaken to evaluate the effectiveness of  workplace interventions  to prevent low back pain .  Potential trials were located by a computerised search supplemented with citation tracking . The method ological quality of the trials was assessed on 11 criteria and the level of evidence for each intervention was determined , based upon the amount , consistency and quality of evidence from the trials . The review located 13 trials that were generally of moderate quality . The trials suggest that work place exercise is effective , braces and education are ineffective , and workplace modification plus education is of unknown value in preventing low back pain OBJECTIVES The purpose of this study was to compare the outcomes of patients with low back pain who had a matched , unmatched , or were indifferent with their pretreatment expectation/preference to the manual therapy thrust or nonthrust intervention .  A secondary purpose was to explore baseline patient characteristics affiliated with a preference of manual therapy treatment type ( thrust or nonthrust manipulation ) . METHODS The study is a secondary analysis of a prospect i ve r and omized controlled trial that enrolled 149 patients with low back pain , from 16 distinct outpatient physical therapy practice s within the United States . Patient 's pretreatment expectations were identified before r and omization . The intervention included manual therapy ( thrust or nonthrust manipulation ) with a st and ardized exercise program , which was carried out for 2 treatment sessions . Six outcomes captured the constructs of ( a ) disability , ( b ) pain perception , ( c ) care intensity , ( d ) fear avoidance behaviors , and ( e ) perception of extent of recovery . Descriptive statistics , analysis of variance ( and Tukey , a post hoc test ) , Fisher exact test , and a multivariate logistic regression analysis were used for analysis . RESULTS There were no statistical differences in any of the 6 dedicated outcomes measures between the matched , unmatched , and no preference groups . Therapist-determined patient " irritability " was associated with patient preference of nonthrust treatment , and higher body mass index was associated with patient preference of thrust treatment . CONCLUSIONS This study shows that patients demonstrated no statistical difference in disability or pain outcome measures when matched , unmatched , or indifferent to the intervention BACKGROUND AND PURPOSE McKenzie described a two-step process for assessing patients with low back pain for a lateral shift . The purpose of this study was to determine whether reliable judgments about lateral shifts could be obtained . SUBJECTS Forty-nine patients with low back pain were each examined separately by two r and omly paired physical therapists . METHODS Assessment s of the presence and direction of lateral  shifts ( step 1 ) were obtained by use of a simple instrument . The relevance of the lateral shifts to the patients ' pain complaints ( step 1 ) also was assessed by use of the side-glide test sequence . RESULTS Generalized kappa coefficients were calculated to determine reliability . The kappa value for the two-step process of lateral shift assessment was .16 . The percentage of agreement was 47 % . CONCLUSION AND DISCUSSION Each step in this two-step process was examined separately for possible sources of error . The kappa value for determinations of the presence and direction of lateral shifts was .00 , indicating very poor reliability . The kappa value for the determination of the presence of a positive side-glide test sequence was .74 , indicating high reliability . The role of lateral shift assessment in the McKenzie system should be reconsidered , given the strong research evidence for poor reliability of determinations of the presence and direction of lateral shifts Study Design . A prospect i ve , consecutive , cohort study of patients with acute low back pain classified into subgroups based on examination data and treated with a specific treatment approach . Objective . To calculate the interrater reliability of a classification system , and to compare initial patient characteristics and outcomes of physical therapy treatment when a classification approach is used . Summary of Background Data . Classification of patients with low back pain into homogeneous subgroups has been identified as a research priority . Identifying relevant subgroups of patients could improve clinical outcomes and research efficiency . Methods . Consecutive patients referred to physical therapy for treatment of acute low back pain were evaluated and classified into one of four subgroups ( immobilization , mobilization , specific exercise , or traction ) before treatment . Physical therapy treatment was based on the patient ’s classification . The classifications were compared for initial patient characteristics , frequency and duration of physical therapy , and improvement in Oswestry scores . Results . In this study , 120 patients were evaluated and classified . Analysis of interrater reliability showed a kappa value of 0.56 . Differences were found among the classifications for age , initial Oswestry score , history of low back pain , symptom distribution , and average change in Oswestry score with treatment . Conclusions . Reaching a consensus regarding relevant patient subgroups requires data on the reliability and validity of existing classification systems . Further work is required to vali date improvement in treatment outcomes using a classification approach STUDY DESIGN Prospect i ve intertester reliability study investigating the ability of 2 therapists to agree on a low back pain diagnosis using examination techniques and the classification system described by McKenzie . OBJECTIVES To investigate intertester agreement in determining McKenzie diagnostic syndromes , subsyndromes , presence , and relevance of the spinal deformities . BACKGROUND Reliability of the McKenzie approach for determining diagnostic categories is unclear . Previous studies have been characterized by inconsistency of test protocol s , criterion measures , and level of training of the examiners , which confounds the interpretation of results . METHODS Patients were assessed simultaneously by 2 physical therapists trained in the McKenzie evaluation system .  The therapists were r and omly assigned as examiner and observer . Agreement was estimated by Kappa statistics . RESULTS Forty-five subjects ( 47 + /- 14 years ) , composed of 25 women and 20 men with acute , subacute , or chronic low back pain were examined . The agreement between raters for selection of the McKenzie syndromes was kappa = 0.70 , and for the derangement subsyndromes was kappa = 0.96 . Interrater agreement for presence of lateral shift , relevance of lateral shift , relevance of lateral component , and deformity in sagittal plane was kappa = 0.52 , 0.85 , 0.95 , and 1.00 , respectively . Intertester agreement on syndrome categories in 17 patients under 55 years of age was excellent , with kapp = 1.00 . CONCLUSIONS A form of low back evaluation , using patterns of pain response to repeated end range spinal test movements , was highly reliable when performed by 2 properly trained physical therapists OBJECTIVE To describe physical measures used in patients with back pain when no specific treatment is given , to examine associations between change over time in these measures and changes in pain and back-related disability , and to study the value of physical measures at baseline and at a 4-week follow-up to predict outcome at 12 months . DESIGN A prospect i ve consecutive study . SUBJECTS Forty-four patients presenting with low back pain in primary care . METHODS The patients underwent a physical examination at baseline and at 4 weeks . Follow-up was carried out using question naires until 12 months . Linear regression was used to identify predictors . RESULTS Most measures had improved significantly at the 4-week follow-up . Thoracolumbar rotation , isometric endurance back extensors , and fingertip-to-floor distance at 4 weeks were significant predictors for pain intensity and back-related disability at the 12-month follow-up . Eighteen out of 44 patients reported an increase in pain after the assessment of the physical measures at baseline . This group of patients improved more in physical measures between baseline and the 4-week follow-up . CONCLUSION Physical measures assessed at the 4-week follow-up , but not at baseline , could provide important additional information for identifying those patients at risk for worse outcome in pain or back-related disability at 12 months Background Evidence -based clinical practice guidelines may improve treatment quality , but the uptake of guideline recommendations is often incomplete and slow . Recently new low back pain guidelines are being launched in Denmark . The guidelines are considered to reduce personal and public costs . The aim of this study is to evaluate whether a complex , multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy . Methods / design In a two-armed cluster r and omised trial , 100 general practice s ( clusters ) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included . Practice s are r and omly allocated 1:1 to a simple or a complex implementation strategy . Intervention practice s will receive a complex implementation strategy , including guideline facilitator visits , stratification tools , and quality reports on low back pain treatment . Primary outcome is referral to secondary care . Secondary outcomes are pain , physical function , health-related quality of life , patient satisfaction with care and treatment outcome , employment status , and sick leave . Primary and secondary outcomes pertain to the patient level . Assessment s of outcomes are blinded and follow the intention-to-treat principle . Additionally , a process assessment will evaluate the degree to which the intervention elements will be delivered as planned , as well as measure changes in beliefs and behaviours among general practitioners and patients . Discussion This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice , and will provide insight on essential elements to include in future implementation strategies in general practice .Trial registration Registered as NCT01699256 on Clinical Trials.gov BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain STUDY DESIGN A prospect i ve method ological interrater reliability study . OBJECTIVES To calculate the interrater reliability among clinicians newly trained in a classification system for acute low back pain and to determine the level of agreement at key junctures within the classification algorithm . BACKGROUND The utility of a classification system for patients with low back pain depends on its reliability and generalizability . To be practical , clinicians must be able to apply the system after a reasonable amount of training . Identifying key points in the classification algorithm where disagreement occurs can lead to better operational definitions . METHODS Four physical therapists read an article and attended a 1-day training session in the classification system .  R and omly paired therapists classified patients referred for treatment of acute low back pain and noted decisions at key junctures in the system algorithm . RESULTS Forty-five patients were classified . Repeated examinations did not increase the patient 's pain ( P>.05 ) . For 3 out of the 4 therapists , the interrater reliability showed a kappa value of 0.45 . The fourth therapist , excluded from the overall analysis , exhibited a bias towards the immobilization classification . Among the 3 therapists , major disagreement occurred with the determination of symmetry with trunk side bending and the effects of repeated movements . CONCLUSIONS Three out of 4 clinicians newly trained in the system showed moderate reliability . The reliability was slight when the fourth therapist was included . Refinement of the operational definitions and criteria for determining lumbar capsular patterns are needed . One day of training is probably not adequate for all therapists , especially for those biased towards specific low back pain syndromes Summary Objective : To illustrate the development and pilot evaluation of a website design ed to enhance self-management of chronic low back pain for the Italian-speaking population of Switzerl and . Methods : 20 patients affected by chronic low back pain used a website – specifically created for the project – for a period of five months , under the monitoring of a team of health professionals . Evaluation was carried out by means of a telephone question naire administered at baseline and at the end of the intervention , and intermediate online user-testing performed in the fourth month of the intervention . A control group of 15 patients was created to assist the evaluation . Results : Compared to the control group , results from the pilot evaluation suggest a decrease in the intensity of back pain in people with access to the website ; an increase in physical activity ; a reduction in both medical consultation and the use of painkillers , and a gain in declarative and procedural knowledge . This coincides with a general positive assessment of the website . Conclusion : The study supports the need to test the proposed approach on a wider scale OBJECTIVE To develop a clinical prediction rule to predict treatment response to a stabilization exercise program for patients with low back pain ( LBP ) . DESIGN A prospect i ve , cohort study of patients with nonradicular LBP referred to physical therapy ( PT ) . SETTING Outpatient PT clinics . PARTICIPANTS Fifty-four patients with nonradicular LBP . INTERVENTION A st and ardized stabilization exercise program . MAIN OUTCOME MEASURE Treatment response ( success or failure ) was categorized based on changes in the Oswestry Disability Question naire scores after 8 weeks . RESULTS Eighteen subjects were categorized as treatment successes , 15 as treatment failures , and 21 as somewhat improved . After using regression analyses to determine the association between st and ardized examination variables and treatment response status , preliminary clinical prediction rules were developed for predicting success ( positive likelihood ratio [ LR ] , 4.0 ) and failure ( negative LR , .18 ) . The most important variables were age , straight-leg raise , prone instability test , aberrant motions , lumbar hypermobility , and fear-avoidance beliefs . CONCLUSIONS It appears that the response to a stabilization exercise program in patients with LBP can be predicted from variables collected from the clinical examination . The prediction rules could be used to determine whether patients with LBP are likely to benefit from stabilization exercises STUDY DESIGN This prospect i ve study of intertester reliability examined pairs of therapists ' ability to agree independently on a patient 's low back pain diagnosis . OBJECTIVE To determine the intertester reliability of a low back pain classification system among experienced and novice clinicians . BACKGROUND Many of the disparate categorization schemes for patients with low back pain are purely nominal , assigning design ations based on the presumptive source of the problem without providing any practical guide for rehabilitation . A useful classification scheme reliably groups patients into treatment-directing categories . METHODS The study included 204 patients with low back pain referred to 10 clinics across Canada . Paired physiotherapists performed separate physical examinations on each patient . Both examiners then completed a simple ballot choosing one of five pain patterns . RESULTS Agreement on patient classification by independent examiners was 78.9 % ( kappa = 0.61 ) . CONCLUSION This clinical ly relevant and clearly defined pain pattern system uses key elements of the history and examination to classify patients with low back pain . The pattern provides a framework for initiating active rehabilitation strategy . Using this approach , clinicians agreed on the categorization of 78.9 % of mechanical low back pain cases Study Design . A prospect i ve , cohort study of patients with nonradicular low back pain referred to physical therapy . Objective . Develop a clinical prediction rule for identifying patients with low back pain who improve with spinal manipulation .  Summary of Background Data . Development of clinical prediction rules for classifying patients with low back pain who are likely to respond to a particular intervention , such as manipulation  , would improve clinical decision-making and research . Methods . Patients with nonradicular low back pain underwent a st and ardized examination and then underwent a st and ardized spinal manipulation treatment program . Success with treatment was determined using percent change in disability scores over three sessions and served as the reference st and ard for determining the accuracy of examination variables . Examination variables were first analyzed for univariate accuracy in predicting success and then combined into a multivariate clinical prediction rule . Results . Seventy-one patients participated . Thirty-two had success with the manipulation intervention . A clinical prediction rule with five variables ( symptom duration , fear – avoidance beliefs , lumbar hypomobility , hip internal rotation range of motion , and no symptoms distal to the knee ) was identified . The presence of four of five of these variables ( positive likelihood ratio = 24.38 ) increased the probability of success with  manipulation  from 45 % to 95 % . Conclusion . It appears that patients with low back pain likely to respond to manipulation can be accurately identified before treatment Background Patients with signs of nerve root irritation represent a sub-group of those with low back pain who are at increased risk of persistent symptoms and progression to costly and invasive management strategies including surgery . A period of non-surgical management is recommended for most patients , but there is little evidence to guide non-surgical decision-making . We conducted a preliminary study examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation . The results suggested this approach may be effective , particularly in a more specific sub-group of patients . The aim of this study will be to examine the effectiveness of treatment that includes traction for patients with low back pain and signs of nerve root irritation , and within the pre-defined sub-group . Methods / Design The study will recruit 120 patients with low back pain and signs of nerve root irritation . Patients will be r and omized to receive an extension-oriented treatment approach , with or without the addition of mechanical traction . R and omization will be stratified based on the presence of the pre-defined sub-grouping criteria . All patients will receive 12 physical therapy treatment sessions over 6 weeks . Follow-up assessment s will occur after 6 weeks , 6 months , and 1 year . The primary outcome will be disability measured with a modified Oswestry question naire . Secondary outcomes will include self-reports of low back and leg pain intensity , quality of life , global rating of improvement , additional healthcare utilization , and work absence . Statistical analysis will be based on intention to treat principles and will use linear mixed model analysis to compare treatment groups , and examine the interaction between treatment and sub-grouping status . Discussion This trial will provide a method ologically rigorous evaluation of the effectiveness of using traction for patients with low back pain and signs of nerve root irritation , and will examine the validity of a pre-defined sub-grouping hypothesis . The results will provide evidence to inform non-surgical decision-making for these patients .Trial Registration This trial has been registered with http:// Clinical Trials.gov : Background Low back pain is a relevant public health problem , being an important cause of work absenteeism worldwide , as well as affecting the quality of life of sufferers and their individual functional performances . Supervised active physical routines and of cognitive-behavioral therapies are recommended for the treatment of chronic Low back pain , although evidence to support the effectiveness of different techniques is missing . Accordingly , the aim of this study is to contrast the effectiveness of two types of exercises , grade d activity or supervised , in decreasing symptoms of chronic low back pain . Methods / design Sample will consist of 66 patients , blindly allocated into one of two groups : 1 ) Grade d activity which , based on an operant approach , will use time-contingent methods aim ing to increase participants ’ activity levels ; 2 ) Supervised exercise , where participants will be trained for strengthening , stretching , and motor control targeting different muscle groups . Interventions will last one hour , and will happen twice a week for 6 weeks . Outcomes ( pain , disability , quality of life , global perceived effect , return to work , physical activity , physical capacity , and kinesiophobia ) will be assessed at baseline , at treatment end , and three and six months after treatment end . Data collection will be conducted by an investigator blinded to treatment allocation . Discussion This project describes the r and omisation method that will be used to compare the effectiveness of two different treatments for chronic low back pain : grade d activity and supervised exercises . Since optimal approach for patients with chronic back pain have yet not been defined based on evidence , good quality studies on the subject are necessary . Trial registration
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 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 .