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

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.

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.

The inter-rater and intra-rater reliability of passive physiological accessory movement assessment of lumbar spine in novice manual therapists

Passive Physiological Accessory Movements (PPAVMs) are commonly used assessment and treatment techniques in patients with low back pain. Many physiotherapists, including novices, consider PPAVMs an important tool for assessment and treatment of low back pain. Reliability is important as a judgement on the reproducibility of assessment procedures between therapists. However, the reliability of PPAVMs seems to have some problems, and reliability of PPAVMs has not yet been established amongst novice manual therapists. This study aimed at investigating inter-rater and intra-rater reliability of PPAVMs in novice physiotherapists. Fifty two healthy participants were recruited for the study. PPAVMs were applied by two novice physiotherapists and accessory movements were assessed, and both the raters were blinded from each others' findings to avoid bias. The mobility was graded on a three point scale with grade 1 being considered as hypomobile, 2 as normal and 3 as hypermobile. This procedure was performed on all five lumbar segments. Each participant was assessed on the same day for inter-rater reliability, and for intra-rater reliability the participant was assessed by one rater a week later. Kappa (κ) was calculated for all the levels of lumbar spine which ranged between 0.01 and 0.30 for inter-rater reliability and 0.24 to 0.57 for intra-rater reliability. Percentage exact agreement was also computed which showed a range between 38.4% and 57.6%. The values of 'κ' showed poor intra-rater and inter-rater reliability. However, further research is advisable in order to assess the role of experience in reproducibility of PPAVMs.

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.