Inter- and intra-tester reliability of selected clinical tests in examining patients with early phase lumbar spine and sacroiliac joint pain and dysfunction

Reliability of the straight leg raise test for suspected lumbar radicular pain: A systematic review with meta-analysis

BACKGROUND

The passive straight leg raise (SLR) and crossed SLR are recommended tests for lumbar radicular pain. There are no recent reviews of test reliability.

OBJECTIVES

To summarize SLR and crossed SLR reliability in patients with suspected lumbar radicular pain.

DESIGN

Systematic review with meta-analysis.

METHOD

MEDLINE and CINAHL were searched for studies published before April 2021 that reported SLR or crossed SLR reliability in patients with low back-related leg pain. Supplemental analyses also included patients with low back pain only. Study selection, risk of bias assessment (QAREL), and data extraction were performed in duplicate. Kappa, intraclass correlation coefficients, and smallest detectable difference (SDD₉₅) quantified reliability. Meta-analysis was performed when appropriate. Confidence in the evidence was determined by applying GRADE principles.

RESULTS/FINDINGS

Fifteen studies met selection criteria. One-hundred-eighty-nine participants had low back-related leg pain. Four-hundred-thirty-nine were included in supplemental analyses. Meta-analyses showed at least fair inter-rater reliability when a positive SLR required provocation of lower extremity symptoms or pain. SLR reliability was at least moderate when testing included structural differentiation (e.g., ankle dorsiflexion). A low prevalence of positive crossed SLR tests led to wide-ranging reliability estimates. Confidence in the evidence for identifying a positive SLR or crossed SLR was moderate to very low. SDD₉₅ values for different raters measuring SLR range of motion ranged from 13 to 20°.

CONCLUSIONS

Reliability data support testing SLR with structural differentiation manoeuvres. Crossed SLR reliability data are inconclusive. Measurement error likely prohibits using SLR range of motion for clinical decision-making.

Infra-adjacent Segment Disease After Lumbar Fusion: An Analysis of Pelvic Parameters

STUDY DESIGN

Cross-sectional observational cohort study.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors associated with the development of sacroiliac joint (SIJ) dysfunction following lumbosacral fusion.

SUMMARY OF BACKGROUND DATA

Adjacent segment degeneration to both proximal and distal areas of spinal fusion is a postoperative complication of lumbar fusion. Various studies examined supra-adjacent degeneration following lumbar fusion, but few focused on infra-adjacent degeneration. In lumbosacral fusion, fusion extends to the sacrum, placing increased stress on the SIJ.

METHODS

A total of 2069 sequential patients who underwent lumbosacral fusion surgery from 2008 to 2018 at a single academic medical center were retrospectively reviewed. Patients who subsequently developed SIJ dysfunction were identified. SIJ dysfunction was defined as patients who met the diagnostic criteria with physical examination and received an SIJ injection with clinical evidence of improvement. Controls, without subsequent SIJ dysfunction, were matched with cases based on levels of fusion, age, sex, and body mass index. Pre-and postoperative pelvic parameters were measured, including pelvic incidence, pelvic tilt (PT), sacral slope, lumbar lordosis, lumbosacral angle, L4 incidence and L5 incidence.

RESULTS

Of 2069 patients who underwent lumbosacral fusion, 81 patients (3.9%) met criteria for SIJ dysfunction. Measurements were made for 47 of 81 patients who had SIJ dysfunction, that had both pre- and post-operative imaging. Measurements for 44 matched controls were taken. Postoperative PT was significantly lower in SIJ dysfunction patients compared to controls (20.82° ± 2.19° vs. 27.28° ± 2.30°; P < 0.05), as was L5 incidence (28.64° ± 3.38° vs. 37.11° ± 3.50°; P < 0.05).

CONCLUSION

Incidence of the SIJ dysfunction after lumbosacral fusion surgery was 3.9% and these patients had a significantly lower PT and L5 incidence compared to the control group. Significantly low PT may be derived from weak hamstring muscles, predisposing a patient to SIJ dysfunction. Therefore, hamstring muscle strengthening exercise for patients with decreased PT after lumbosacral fusion may decrease the incidence of SIJ dysfunction.Level of Evidence: 3.

Reliability of physical functioning tests in patients with low back pain: a systematic review

PURPOSE

The aim of this study was to provide a comprehensive overview of physical functioning tests in patients with low back pain (LBP) and to investigate their reliability.

DATA SOURCES

A systematic computerized search was finalized in four different databases on June 24, 2017: PubMed, Web of Science, Embase, and MEDLINE.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed during all stages of this review. Clinical studies that investigate the reliability of physical functioning tests in patients with LBP were eligible. The methodological quality of the included studies was assessed with the use of the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. To come to final conclusions on the reliability of the identified clinical tests, the current review assessed three factors, namely, outcome assessment, methodological quality, and consistency of description.

DATA SYNTHESIS

A total of 20 studies were found eligible and 38 clinical tests were identified. Good overall test-retest reliability was concluded for the extensor endurance test (intraclass correlation coefficient [ICC]=0.93-0.97), the flexor endurance test (ICC=0.90-0.97), the 5-minute walking test (ICC=0.89-0.99), the 50-ft walking test (ICC=0.76-0.96), the shuttle walk test (ICC=0.92-0.99), the sit-to-stand test (ICC=0.91-0.99), and the loaded forward reach test (ICC=0.74-0.98). For inter-rater reliability, only one test, namely, the Biering-Sörensen test (ICC=0.88-0.99), could be concluded to have an overall good inter-rater reliability. None of the identified clinical tests could be concluded to have a good intrarater reliability.

CONCLUSIONS

Further investigation should focus on a better overall study methodology and the use of identical protocols for the description of clinical tests. The assessment of reliability is only a first step in the recommendation process for the use of clinical tests. In future research, the identified clinical tests in the current review should be further investigated for validity. Only when these clinimetric properties of a clinical test have been thoroughly investigated can a final conclusion regarding the clinical and scientific use of the identified tests be made.

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.

Anatomical landmark position--can we trust what we see? Results from an online reliability and validity study of osteopaths

BACKGROUND

Practitioners traditionally use observation to classify the position of patients' anatomical landmarks. This information may contribute to diagnosis and patient management.

OBJECTIVES

To calculate a) Inter-rater reliability of categorising the sagittal plane position of four anatomical landmarks (lateral femoral epicondyle, greater trochanter, mastoid process and acromion) on side-view photographs (with landmarks highlighted and not-highlighted) of anonymised subjects; b) Intra-rater reliability; c) Individual landmark inter-rater reliability; d) Validity against a 'gold standard' photograph.

DESIGN

Online inter- and intra-rater reliability study.

SUBJECTS

Photographed subjects: convenience sample of asymptomatic students; raters: randomly selected UK registered osteopaths.

METHODS

40 photographs of 30 subjects were used, a priori clinically acceptable reliability was ≥0.4. Inter-rater arm: 20 photographs without landmark highlights plus 10 with highlights; Intra-rater arm: 10 duplicate photographs (non-highlighted landmarks). Validity arm: highlighted landmark scores versus 'gold standard' photographs with vertical line. Research ethics approval obtained.

RATERS

Osteopaths (n = 48) categorised landmark position relative to imagined vertical-line; Gwet's Agreement Coefficient 1 (AC1) calculated and chance-corrected coefficient benchmarked against Landis and Koch's scale; Validity calculation used Kendall's tau-B.

RESULTS

Inter-rater reliability was 'fair' (AC1 = 0.342; 95% confidence interval (CI) = 0.279-0.404) for non-highlighted landmarks and 'moderate' (AC1 = 0.700; 95% CI = 0.596-0.805) for highlighted landmarks. Intra-rater reliability was 'fair' (AC1 = 0.522); range was 'poor' (AC1 = 0.160) to 'substantial' (AC1 = 0.896). No differences were found between individual landmarks. Validity was 'low' (TB = 0.327; p = 0.104).

CONCLUSION

Both inter- and intra-rater reliability was 'fair' but below clinically acceptable levels, validity was 'low'. Together these results challenge the clinical practice of using observation to categorise anterio-posterior landmark position.

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.