title: Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality. The Value of Medical History and Physical Examination in Diagnosing Sacroiliac Joint Pain Physical Impairment Index: Reliability, Validity, and Responsiveness in Patients with Acute Low Back Pain Intra- and interobserver reliability of passive motion palpation of the lumbar spine. The interrater reliability among physical therapists newly trained in a classification system for acute low back pain. Intertester reliability of a modified version of McKenzie's lateral shift assessments obtained on patients with low back pain. Intertester reliability of judgments of the presence of trigger points in patients with low back pain. The occurrence and inter-rater reliability of myofascial trigger points in the quadratus lumborum and gluteus medius: a prospective study in non-specific low back pain patients and controls in general practice. Reliability of physical examination items used for classification of patients with low back pain. Interexaminer Reliability of Low Back Pain Assessment Using the McKenzie Method Intertester reliability of a low back pain classification system. Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. Intertester Reliability of McKenzie's Classifications of the Syndrome Types Present in 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 Preliminary study of the reliability of assessment procedures for indications for chiropractic adjustments of the lumbar spine. Correlation of clinical examination characteristics with three sources of chronic low back pain. Manipulative physiotherapists can reliably palpate nominated lumbar spinal levels.
abstract: The interexaminer reliability of noninvasive methods of examining lumbar spinal segments is not well established . In this project the interexaminer reliability of three experienced chiropractic examiners , who evaluated 21 symptomatic and 25 asymptomatic subjects , was explored . Eight noninvasive segmental examination strategies ( dimensions ) were employed at each spinal segment from T11/T12 through L5/S1 . Marginal to good agreement beyond chance was noted for palpatory pain over osseous structures and in paraspinal soft-tissues . Weaker and less frequently , significant concordance between examiners was noted for detection of temperature differences ( greater than or equal to 1.5 degrees F ) between adjacent segments and for visual inspection for segmental abnormality . Little significant agreement between examiner was found for active and passive motion palpation , muscle tension palpation and misalignment palpation . This study suggests that " subjective " findings ( pain ) may be among the most reliable of conservative spinal observations . Weak but significant correlations were found when positive findings for the eight dimensions at each lumbar segment were summed to form a composite joint abnormality index . When the multidimension index was developed using the four most reliable dimensions , slightly stronger correlations were found . The strongest agreement between examiners tended to be found in the lower lumbar spine Study Design This prospect i ve study evaluated the diagnostic utility of historically accepted sacroiliac joint tests . A multidisciplinary expert panel recommended 12 of the “ best ” sacroiliac joint tests to be evaluated against a criterion st and ard of unequivocal pain relief after an intra‐articular injection of local anesthetic into the sacroiliac joint . Objectives To identify a single sacroiliac joint test or ensemble of tests that are sufficiently useful in diagnosing sacroiliac joint disorders to be clinical ly valuable . Summary of Background Data No previous research has been done to evaluate any physical test of sacroiliac joint pain against an accepted criterion st and ard . Methods Historical data was obtained , and the 12 tests were performed by two examiners on 85 patients who subsequently underwent sacroiliac joint blocks .  Ninety percent or more relief was considered a positive response , and less then 90 % relief was considered a negative response . Results There were 45 positive and 40 negative responses . No historical feature , none of the 12 sacroiliac joint tests , and no ensemble of these 12 tests demonstrated worthwhile diagnostic value . Conclusion Sacroiliac joint pain is resistant to identification by the historical and physical examination data from tests evaluated in this study Study Design . Cohort study of patients with acute low back pain undergoing physical therapy .  Objectives . Examine the reliability and validity of the Physical Impairment Index in a group of patients with acute low back pain and determine the responsiveness and minimum detectable change of the index and its component tests . Summary of the Background Data . The Physical Impairment Index was originally described as a reliable and valid means of assessing physical impairment in patients with low back pain . The psychometric properties of the index have not been reported in patients with acute low back pain , nor has its responsiveness been examined . Methods . Seventy-eight patients with acute ( <3 weeks duration ) low back pain participating in a clinical trial were assessed at baseline and after 4 weeks .  Interrater reliability of the index was examined in a subgroup of 20 patients . Validity was examined through correlations with concurrent measures of pain , disability , and psychosocial variables . Changes in the index over 4 weeks were used to assess responsiveness and minimum detectable change . Results . Interrater reliability of the index was high ( intraclass correlation coefficient = 0.89 ) , and its validity was generally supported by the pattern of correlations . The index was more responsive to change than any of its component tests but was less responsive than the Oswestry disability score . The minimum detectable change on the index was approximately 1 point . Conclusions . The Physical Impairment Index appears to be a reliable and valid measure of physical impairment for patients with acute low back pain and may be useful as an adjunct outcome measure for studies involving these patients . Further research on patients with chronic pain is needed before it can be advocated for outcomes research with this population Sixty student volunteers were assessed for fixation in the lumbar spine using a passive motion palpation protocol . Subjects were examined in r and om order by two experienced chiropractors . Every subject was evaluated twice by each examiner . Fixations were judged present or absent for each of five lumbar motion segments . Moderate test-retest agreement beyond chance was noted at L1/2 , minimal reliability at L4/5 , and no significant agreement within examiners was detected for mid-lumbar segments . Interexaminer agreement beyond chance was poor for all segments assessed . When segments were grouped regionally and re-evaluated , some increase in intrarater agreement was evident , especially at L4/5/S , but interrater agreement was still absent 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 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 The purpose of this study was to determine the intertester reliability of assessment s of the presence of trigger points in the region of the lumbar spine of patients with low back pain ( LBP ) . A total of six trigger points described by Travell and Simons were studied . The trigger point examination procedures described by Travell and Simons were used by 12 physical therapists . R and omly paired therapists examined 50 patients for 197 trigger points . The Kappa coefficient , percent agreement , the observed proportion of positive agreement ( Ppos ) , and the observed proportion of negative agreement ( Pneg ) were used to describe reliability . Kappa values ranged from .29 to .38 . Percent agreement ranged from 76 % to 79 % . Ppos ranged from .43 to .52 . The low Kappa and Ppos values suggest different therapists are unable to reliably determine when a trigger point is present in a patient with LBP . This study suggests the usefulness of examining for the presence of trigger points in patients with LBP should be question ed The presence of a trigger point is essential to the myofascial pain syndrome . This study centres on identifying clearer criteria for the presence of trigger points in the quadratus lumborum and gluteus medius muscle by investigating the occurrence and inter-rater reliability of trigger point symptoms . Using the symptoms and signs as described by Simons ' 1990 definition and two other former sets of criteria , 61 non-specific low back pain patients and 63 controls were examined in general practice by 5 observers , working in pairs . From the two major criteria of Simons ' 1990 definition only ' localized tenderness ' has good discriminative ability and inter-rater reliability ( kappa > 0.5 ) . This study does not find proof for the clinical usefulness of ' referred pain ' , which has neither of these two abilities . The criteria ' jump sign ' and ' recognition ' , on the condition that localized tenderness is present , also have good discriminative ability and inter-rater reliability . Trigger points defined by the criteria found eligible in this study allow significant distinction between non-specific low back pain patients and controls . This is not the case with trigger points defined by Simons ' 1990 criteria . Concerning reliability there is also a significant difference between the two different criteria sets . This study suggests that the clinical usefulness of trigger points is increased when localized tenderness and the presence of either jump sign or patient 's recognition of his pain complaint are used as criteria for the presence of trigger points in the M. quadratus lumborum and the M. gluteus medius 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 Study Design . A test – retest design was used . Objective . To assess interexaminer reliability of the McKenzie method for performing clinical tests and classifying patients with low back pain . Summary of Background Data . Clinical methods and tests classifying patients with nonspecific low back pain have been based mainly on symptom duration or extent of pain referral . The McKenzie mechanical diagnostic and classification approach is a widely used noninvasive , low-technology method of assessing patients with low back pain . However , little is known about the interexaminer reliability of the method , previous studies having yielded conflicting results . Methods . For this study , 39 volunteers with low back pain , mean age 40 years ( range , 24–55 years ) , were blindly assessed by two physical therapists trained in the McKenzie method .  The variability of two examiners for binary decisions was expressed by the kappa coefficient , and by the proportion of observed agreement , as calculated from a 2 × 2 contingency table of concordance . Results . On the basis of pure observation alone , agreement among clinical tests on the presence and direction of lateral shift was 77 % ( & kgr ; = 0.2;P < 0.248 ) and 79 % ( & kgr ; = 0.4;P < 0.003 ) , respectively . Agreement on the relevance of lateral shift and the lateral component according to symptom responses was 85 % ( & kgr ; = 0.7;P < 0.000 ) and 92 % ( & kgr;= 0.4;P < 0.021 ) , respectively . Using the repeated movements and static end-range loading strategy to define the central ization phenomenon and directional preference , agreement was 95 % ( & kgr ; = 0.7;P < 0.002 ) and 90 % ( & kgr ; = 0.9;P < 0.000 ) , respectively . When patients with low back pain were classified into the McKenzie main syndromes and into specific subgroups , agreement was 95 % ( & kgr ; = 0.6;P < 0.000 ) and 74 % ( & kgr ; = 0.7;P < 0.000 ) , respectively . Conclusions . Interexaminer reliability of the McKenzie lumbar spine assessment in performing clinical tests and classifying patients with low back pain into syndromes were good and statistically significant when the examiners had been trained in the McKenzie method 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 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 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 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 OBJECTIVE To assess the intraexaminer and interexaminer reliability of clinicians trained in flexion-distraction technique  to determine the need for chiropractic adjustment of each segment of the lumbar spine . DESIGN This was an intraexaminer and interexaminer reliability study of commonly used chiropractic assessment procedures , including static and motion palpation and visual observation . SETTING Chiropractic college ; by four licensed chiropractors trained in flexion-distraction technique , two with more than 20 years ' experience and two with 3 or fewer years ' experience . SUBJECTS Subjects were 18 volunteers ; 16 were symptom free , and 2 had low back pain at the time the study was conducted . MAIN OUTCOME MEASURE The kappa statistic was computed for all comparisons and interpreted in categories ranging from " poor " ( < 0.00 ) to " almost perfect " ( > 0.80 ) . RESULTS Intraexaminer reliability was greater than interexaminer reliability . For intraexaminer reliability there was considerable variation by segment and among the four examiners , but intraexaminer reliability appeared generally higher than interexaminer reliability . Overall , more subluxations were identified on the second examination than on the first . For interexaminer reliability , kappa scores were generally in the " poor " to " slight " categories . DISCUSSION The results of this study , similar to those of other studies , indicate that even chiropractors trained in the same technique seem to show little consensus on the indications for the necessity to adjust specific segments of the spine . A more st and ardized assessment approach might be helpful in improving the reliability of diagnostic assessment BACKGROUND CONTEXT Research has demonstrated some progress in using a clinical examination to predict discogenic or sacroiliac ( SI ) joint sources of pain . No clear predictors of symptomatic lumbar zygapophysial joints have yet been demonstrated . PURPOSE To identify significant components of a clinical examination that are associated with symptomatic lumbar discs , zygapophysial joints and SI joints . STUDY DESIGN A prospect i ve , criterion-related concurrent validity study performed at a private radiology practice specializing in spinal diagnostics . PATIENT SAMPLE The sample consisted of 81 patients with chronic lumbopelvic pain referred for diagnostic injections .  OUTCOME MEASURES Contingency tables were constructed for nine features of the clinical evaluation compared with the results of diagnostic injections . Statistical analysis included chi-squared test for independence , phi and odds ratios with confidence intervals . METHOD Patients received blinded clinical examinations by physical therapists , and diagnostic injections were used as the criterion st and ard . RESULTS Significant relationships were found between discogenic pain and central ization of pain during repeated movement testing , and pain when rising from sitting . Lumbar zygapophysial joint pain was associated with absence of pain when rising from sitting . Sacroiliac joint pain was related to three or more positive pain provocation tests , pain when rising from sitting , unilateral pain and absence of lumbar pain . CONCLUSIONS Significant correlations exist between clinical examination findings and symptomatic lumbar discs , zygapophysial and SI joints . The strongest relationships were seen between SI joint pain and three or more positive pain provocation tests , central ization of pain for symptomatic discs and absence of pain when rising from sitting for symptomatic lumbar zygapophysial joints Palpating a nominated spinal level is a prerequisite to more complex tasks such as palpating the level most likely to be the source of the patient 's symptoms . The aim of this study was to investigate the reliability of physiotherapists with a post-graduate qualification in manipulation ( manipulative physiotherapists )  in palpating the lumbar spines of  patients  in a clinical setting . Three pairs of manipulative physiotherapists palpated the r and omly-nominated lumbar spinal levels of 20 patients presenting to their practice s for treatment of low-back pain . Each therapist marked the skin overlying the spinous process of the nominated spinal level with an ultraviolet pen and these marks were transcribed onto transparencies for analysis . The therapists obtained an overall weighted kappa of 0.92 indicating almost perfect agreement for locating the nominated spinal level . The results of this study indicate that manipulative physiotherapists can reliably palpate nominated lumbar spinal levels , suggesting further training in spinal therapy enhances the palpatory skills of physiotherapists in palpating nominated lumbar spinal levels
target: 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
background: 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 .