Reliability of the McKenzie spinal pain classification using patient assessment forms

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.

Treatment based classification systems for patients with non-specific neck pain. A systematic review

OBJECTIVE

We aimed to identify published classification systems with a targeted treatment approach (treatment-based classification systems (TBCSs)) for patients with non-specific neck pain, and assess their quality and effectiveness.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, PEDro and the grey literature were systematically searched from inception to December 2019.

STUDY APPRAISAL AND SYNTHESIS

The main selection criterium was a TBCS for patients with non-specific neck pain with physiotherapeutic interventions. For data extraction of descriptive data and quality assessment we used the framework developed by Buchbinder et al. We considered as score of ≤3 as low quality, a score between 3 and 5 as moderate quality and a score ≥5 as good quality. To assess the risk of bias of studies concerning the effectiveness of TBCSs (only randomized clinical trials (RCTs) were included) we used the PEDro scale. We considered a score of ≥ six points on this scale as low risk of bias.

RESULTS

Out of 7664 initial references we included 13 studies. The overall quality of the TBCSs ranged from low to moderate. We found two RCTs, both with low risk of bias, evaluating the effectiveness of two TBCSs compared to alternative treatments. The results showed that both TBCSs were not superior to alternative treatments.

CONCLUSION

Existing TBCSs are, at best, of moderate quality. In addition, TBCSs were not shown to be more effective than alternatives. Therefore using these TBCSs in daily practice is not recommended.

A prospective study of patients with shoulder pain and Mechanical Diagnosis and Therapy (MDT)

Objectives: A prospective observational cohort study was conducted to (1) determine the prevalence of Mechanical Diagnosis and Therapy (MDT) syndromes for patients with shoulder impairments and (2) report the interaction between MDT classification and clinical outcomes, including pain intensity and disability, at discharge.Methods: Clinical outcome measures were completed at intake and discharge by 115 patients. A two-way mixed model analysis of variance with subsequent pairwise comparisons was done to examine differences in clinical outcomes between the following MDT classifications: Shoulder Derangement, Shoulder Dysfunction, and Other.Results: The primary findings were that (1) 44.3 (35.3, 53.4), 40.0 (31.0, 48.9), and 15.6 (9.0, 22.3) percent of patients' conditions were classified as Shoulder Derangement, Shoulder Dysfunction, and Other, respectively, (2) all groups managed via MDT methods made clinically significant improvements in disability and pain intensity at discharge, (3) a statistically significant difference in pain intensity at discharge was observed between the Shoulder Derangement and the Shoulder Dysfunction classifications (p = 0.01), and (4) patients with the Shoulder Derangement classification were discharged, on average, 35.3 days earlier than the Shoulder Dysfunction classification and 28.3 days earlier than the Other classification.Discussion: This study confirms previous reports that the Shoulder Derangement and Shoulder Dysfunction classifications are common and represent distinct clinical trajectories when assessed and managed via MDT methods.

Reliability of the Mechanical Diagnosis and Therapy System in Patients With Spinal Pain: A Systematic Review

BACKGROUND

An updated summary of the evidence for the reliability of the Mechanical Diagnosis and Therapy (MDT) system in patients with spinal pain is needed.

OBJECTIVE

To investigate the evidence on the intrarater and interrater reliability of MDT in patients with spinal pain.

METHODS

Searches in MEDLINE, CINAHL, Embase, PEDro, and Scopus were conducted for this systematic review. We included any study design as long as reliability of the MDT method was tested in patients with spinal pain. We collected data on the reliability of MDT to identify main and subsyndromes, directional preference, the centralization phenomenon, and lateral shift. The methodological quality of studies was assessed using the Quality Appraisal of Diagnostic Reliability and the Guidelines for Reporting Reliability and Agreement Studies checklists.

RESULTS

Twelve studies were included (8 studies on back pain, pooled n = 2160 patients; 3 studies on neck pain, pooled n = 45 patients; and 3 studies recruited mixed spinal conditions, pooled n = 389 patients). Studies investigating patients with back pain reported kappa estimates ranging from 0.26 to 1.00 (main and subsyndromes), 0.27 to 0.90 (directional preference), and 0.11 to 0.70 (centralization phenomenon). Kappa estimates for studies investigating neck pain ranged from 0.47 to 0.84 (main and subsyndromes) and 0.46 (directional preference). In mixed populations, kappa estimates ranged from 0.56 to 0.96 (main and subsyndromes).

CONCLUSION

The MDT system appears to have acceptable interrater reliability for classifying patients with back pain into main and subsyndromes when applied by therapists who have completed the credentialing examination, but unacceptable reliability in other therapists. We found conflicting evidence regarding the reliability of the MDT system in patients with neck pain or mixed pain locations. J Orthop Sports Phys Ther 2018;48(12):923-933. Epub 22 Jun 2018. doi:10.2519/jospt.2018.7876.

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain

OBJECTIVE

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.

METHODS

Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.

RESULTS

There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).

DISCUSSION

Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

McKenzie lumbar classification: inter-rater agreement by physical therapists with different levels of formal McKenzie postgraduate training

STUDY DESIGN

Inter-rater chance-corrected agreement study.

OBJECTIVE

The aim was to examine the association between therapists' level of formal precredential McKenzie postgraduate training and agreement on the following McKenzie classification variables for patients with low back pain: main McKenzie syndromes, presence of lateral shift, derangement reducibility, directional preference, and centralization.

SUMMARY OF BACKGROUND DATA

Minimal level of McKenzie postgraduate training needed to achieve acceptable agreement of McKenzie classification system is unknown.

METHODS

Raters (N = 47) completed multiple sets of 2 independent successive examinations at 3 different stages of McKenzie postgraduate training (levels parts A and B, part C, and part D). Agreement was assessed with κ coefficients and associated 95% confidence intervals. A minimum κ threshold of 0.60 was used as a predetermined criterion for level of agreement acceptable for clinical use.

RESULTS

Raters examined 1662 patients (mean age = 51 ± 15; range, 18-91; females, 57%). Data distributions were not even and were highly skewed for all classification variables. No training level studied had acceptable agreement for any McKenzie classification variable. Agreements for all levels of McKenzie postgraduate training were higher than expected by chance for most of the classification variables except parts A and B training level for judging lateral shift and centralization and part D training level for judging reducibility. Agreement between training levels parts A and B, part C, and part D were similar with overlapping 95% confidence intervals.

CONCLUSION

Results indicate that level of inter-rater chance-corrected agreement of McKenzie classification system was not acceptable for therapists at any level of formal McKenzie postgraduate training. This finding raises concerns about the clinical utility of the McKenzie classification system at these training levels. Additional studies are needed to assess agreement levels for therapists who receive additional training or experience at the McKenzie credentialed or diploma levels.

LEVEL OF EVIDENCE

2.

Directional preference at the knee: a case report using mechanical diagnosis and therapy

Knee pain is common amongst the sporting and general population. Numerous examination procedures are used to apply diagnostic labels to knee symptoms, such as McMurray's test, which is used to diagnose a meniscal injury. However, previously in the literature the validity compared with a 'gold standard' and the reliability between examiners of such tests has been questioned. In this case study, we report on a sports woman, diagnosed by her general practitioner with a meniscal injury and demonstrating a positive McMurry's test, who was examined using repeated movements as in the McKenzie system of mechanical diagnosis and therapy. Following self-application of extension exercises and extension exercises with over-pressure the McMurry's test became negative, and she returned to full sporting activities. The case study indicates a further caution about the use of single orthopaedic test procedures. Not only is their validity and reliability questionable, but also following treatment using repeated movements if positive tests can be made negative, this provides an additional query to their validity.

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.

DMA Clinical Pilates Directional-Bias Assessment: Reliability and Predictive Validity

STUDY DESIGN

Randomized, repeated-measures crossover design.

OBJECTIVES

To determine the interrater reliability of directional-bias assessment and to investigate its validity for predicting immediate changes in dynamic postural stability and muscle performance following directionally biased exercises.

BACKGROUND

Directional bias in dynamic postural stability deficits may be associated with outcome following intervention.

METHODS

Two researchers independently assessed 33 participants, each with a history of more than 1 unilateral lower-limb injury, for directional bias. Interrater reliability was evaluated with the kappa coefficient and a prevalence-adjusted and bias-adjusted kappa coefficient. Participants were randomly allocated to perform matched-bias (MB) or unmatched-bias (UB) exercises first, in 2 crossover groups. Two outcome measures, time to stabilization and rebound hopping, were assessed before and following each exercise intervention, using a force plate. Crossover trial data were analyzed by t tests for period, interaction, and treatment effects, and repeated-measures analyses of variance were used to investigate differences between baseline, MB, and UB.

RESULTS

Interrater reliability of directional-bias assessment was substantial (κ = 0.75; prevalence-adjusted and bias-adjusted κ = 0.76). Following MB exercises, medial/lateral time to stabilization and time on the ground during rebound hopping were significantly shorter (P = .01 and P = .05, respectively) compared with UB exercises. Compared with baseline, pairwise change in anterior/posterior time to stabilization (P = .008) improved following MB, whereas time in the air decreased following UB (P = .036).

CONCLUSION

Directional-bias assessment demonstrates substantial reliability, and outcomes suggest validity for predicting immediate improvements following matched directionally biased exercises.

Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica

OBJECTIVE

To determine whether outcomes from treatment determined by subjects' directional preference (ie, reduction in back and/or leg pain, by performing a single direction of repeated end-range lumbar movement) would vary based on pain duration, location, or neurologic status.

DESIGN

A secondary analysis of data from a multicenter randomized clinical trial.

SETTING

Eleven physical therapy departments or clinics in 5 countries, with referrals for both acute and chronic low back pain.

SUBJECTS

Seventy-one of 80 subjects with acute to chronic low back pain, and with and without radicular leg pain, and with or without mild neurologic deficit, were found at baseline to have a directional preference and were then treated with directional exercises that matched their directional preference.

METHODS

All of the subjects were treated for 2 weeks with directional exercises and compatible posture modifications. Independent variables were pain duration, pain location, and neurologic status.

MAIN OUTCOME MEASUREMENTS

Primary measures were back and leg pain intensity and function (Roland Morris Disability Questionnare). Secondary measures were activity interference, medication use, depression (Beck Depression Inventory), and a self-report of improvement.

RESULTS

The subjects significantly improved their back and leg pain intensity, disability, and all secondary outcome measures, but pain duration, location, and neurologic status classification did not predict treatment responsiveness. Across all pain duration categories, 91%-100% either improved or resolved completely. There also was significant improvement across all pain location and neurologic status categories, with no significant differences across the outcome variables.

CONCLUSIONS

In subjects found to have a directional preference who then treated themselves with matching directional exercises, neither pain duration nor pain location and neurologic status predicted their uniformly good-to-excellent outcomes.

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 effectiveness of the McKenzie method in addition to first-line care for acute low back pain: a randomized controlled trial

BACKGROUND

Low back pain is a highly prevalent and disabling condition worldwide. Clinical guidelines for the management of patients with acute low back pain recommend first-line treatment consisting of advice, reassurance and simple analgesics. Exercise is also commonly prescribed to these patients. The primary aim of this study was to evaluate the short-term effect of adding the McKenzie method to the first-line care of patients with acute low back pain.

METHODS

A multi-centre randomized controlled trial with a 3-month follow-up was conducted between September 2005 and June 2008. Patients seeking care for acute non-specific low back pain from primary care medical practices were screened. Eligible participants were assigned to receive a treatment programme based on the McKenzie method and first-line care (advice, reassurance and time-contingent acetaminophen) or first-line care alone, for 3 weeks. Primary outcome measures included pain (0-10 Numeric Rating Scale) over the first seven days, pain at 1 week, pain at 3 weeks and global perceived effect (-5 to 5 scale) at 3 weeks. Treatment effects were estimated using linear mixed models.

RESULTS

One hundred and forty-eight participants were randomized into study groups, of whom 138 (93%) completed the last follow-up. The addition of the McKenzie method to first-line care produced statistically significant but small reductions in pain when compared to first-line care alone: mean of -0.4 points (95% confidence interval, -0.8 to -0.1) at 1 week, -0.7 points (95% confidence interval, -1.2 to -0.1) at 3 weeks, and -0.3 points (95% confidence interval, -0.5 to -0.0) over the first 7 days. Patients receiving the McKenzie method did not show additional effects on global perceived effect, disability, function or on the risk of persistent symptoms. These patients sought less additional health care than those receiving only first-line care (P = 0.002).

CONCLUSIONS

When added to the currently recommended first-line care of acute low back pain, a treatment programme based on the McKenzie method does not produce appreciable additional short-term improvements in pain, disability, function or global perceived effect. However, the McKenzie method seems to reduce health utilization although it does not reduce patient's risk of developing persistent symptoms.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12605000032651.

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.