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There is a lack of studies examining whether mechanism-based classification systems (CS) acknowledging biological, psychological and social dimensions of long-lasting low back pain (LBP) disorders can be performed in a reliable manner. The purpose of this paper was to examine the inter-tester reliability of clinicians' ability to independently classify patients with non-specific LBP (NSLBP), utilising a mechanism-based classification method. Twenty-six patients with NSLBP underwent an interview and full physical examination by four different physiotherapists. Percentage agreement and Kappa coefficients were calculated for six different levels of decision making. For levels 1-4, percentage agreement had a mean of 96% (range 75-100%). For the primary direction of provocation Kappa and percentage agreement had a mean between the four testers of 0.82 (range 0.66-0.90) and 86% (range 73-92%) respectively. At the final decision making level, the scores for detecting psychosocial influence gave a mean Kappa coefficient of 0.65 (range 0.57-0.74) and 87% (range 85-92%). The findings suggest that the inter-tester reliability of the system is moderate to substantial for a range of patients within the NSLBP population in line with previous research.
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Original Article
Inter-examiner reliability of a classification system for patients
with non-specific low back pain
K. Vibe Fersum
a
,
*
, P.B. O’Sullivan
b
, A. Kvåle
a
, J.S. Skouen
a
,
c
a
Section for Physiotherapy Science, Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
b
School of Physiotherapy, Curtin University, Bentley 6102, WA, Australia
c
The Outpatient Spine Clinic, Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
article info
Article history:
Received 20 February 2008
Received in revised form 10 July 2008
Accepted 1 August 2008
Keywords:
Agreement
Classification
Low back pain
Reliability
abstract
There is a lack of studies examining whether mechanism-based classification systems (CS) acknowl-
edging biological, psychological and social dimensions of long-lasting low back pain (LBP) disorders can
be performed in a reliable manner. The purpose of this paper was to examine the inter-tester reliability of
clinicians’ ability to independently classify patients with non-specific LBP (NSLBP), utilising a mecha-
nism-based classification method. Twenty-six patients with NSLBP underwent an interview and full
physical examination by four different physiotherapists. Percentage agreement and Kappa coefficients
were calculated for six different levels of decision making. For levels 1–4, percentage agreement had
a mean of 96% (range 75–100%). For the primary direction of provocation Kappa and percentage
agreement had a mean between the four testers of 0.82 (range 0.66–0.90) and 86% (range 73–92%)
respectively. At the final decision making level, the scores for detecting psychosocial influence gave
a mean Kappa coefficient of 0.65 (range 0.57–0.74) and 87% (range 85–92%). The findings suggest that the
inter-tester reliability of the system is moderate to substantial for a range of patients within the NSLBP
population in line with previous research.
Ó2008 Elsevier Ltd. All rights reserved.
1. Introduction
LBP represents a common and very costly health problem and
a definite diagnosis is difficult to achieve in most cases (85%)
(Waddell, 2004). As a result, uncertainty regarding treatment of
this group of patients is common (Cherkin et al., 1998).
A number of studies have shown little or no difference between
various physiotherapy treatments for chronic LBP (Delitto et al.,
1995; Petersen et al., 1999; Ferreira et al., 2007). Several authors
have suggested that these results may reflect the heterogeneity of
the NSLBP group, with several distinct subgroups, including
psychosocial problems, each with its own potential set of beneficial
treatments (O’Sullivan, 2000; Petersen et al., 2002; O’Sullivan,
2005; Dankaerts et al., 2006b). There is growing evidence sug-
gesting that sub-classifying patients and offering them tailored
interventions matching their disorder improves patient outcome
(Frymoyer et al., 1985; Main and Watson, 1996; O’Sullivan, 1997;
Nachemson, 1999; Linton, 2000; Skouen et al., 2002; Fritz et al.,
2003; Stuge et al., 2004). It has been proposed that a classification
system (CS) for NSLBP should identify the underlying mechanisms
driving the disorder within a bio-psycho-social framework,
enabling specific therapies to be applied so as to favourably influ-
ence the outcome of the disorder (O’Sullivan, 2005).
A number of CS have been proposed (McKenzie, 1981; Spitzer,
1987;Maluf et al., 2000; Sahrmann, 2001). However, only a few are
found sufficiently reliable and valid (Petersen et al.,1999), and even
fewer consider the disorder from a bio-psycho-social perspective
(Petersen et al., 1999; Ford et al., 2003; McCarthy et al., 2004;
O’Sullivan, 2005; Dankaerts et al., 2006b).
The Quebec Task Force system was designed to classify all LBP
patients to help with clinical decision making, establishing prog-
nosis and evaluating treatment effectiveness (Spitzer, 1987).
However, it has not been tested for reliability and does not consider
the underlying mechanism (Dankaerts et al., 2006b), except for
differentiating somatic from radicular pain. Within this system
there is no subgrouping of NSLBP except on the basis of pain area,
and no specific treatment is advocated for this large group of
patients other than general exercise, therefore limiting its use for
physiotherapy assessment and treatment (Padfield et al., 2002).
The McKenzie (1981) system is based on information from
history taking, and symptom response to generated loading of the
lumbar spine. The system has been tested for reliability, and has
substantial inter-tester agreement when applied by trained
examiners (Kappa coefficients ranging from 0.6 to 0.7) (Kilpikoski
et al., 2002).
*Corresponding author: Tel.: þ47 55586711.
E-mail address: kjartan.fersum@isf.uib.no (K. Vibe Fersum).
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
1356-689X/$ – see front matter Ó2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2008.08.003
Manual Therapy 14 (2009) 555–561
Petersen and co-workers (2004) have proposed a McKenzie-
based CS with good inter-tester reliability, but it has a patho-
anatomical orientation and lacks clear guidelines for management.
Sahrmann and co-workers have developed another CS,
comprising five categories based on testing of muscular stability,
alignment, asymmetry, flexibility of the lumbar spine, pelvis, and
hip (Maluf et al., 2000). Reliability of the individual tests used for
classification has been shown to vary from fair to almost perfect
(Van Dillen et al., 1998, 2003). However, there are no reports on
reliability in classification of the patients into the five categories,
nor does this system consider patho-anatomical or psychosocial
dimensions.
Since 1997 Peter O’Sullivan has developed a novel system, based
on the Quebeck Task Force, incorporating multiple dimensions in
the classification of patients into subgroups based on proposed
underlying pain mechanisms. Initially, this mainly targeted
a subgroup of patients with localised NSLBP where provocative
movement behaviours and positions of the spine, associated with
a loss of spinal control, represent a mechanism for ongoing pain.
These patients are classified as LBP patients with motor control
impairment (MCI). The evidence validating this subgroup is
growing (O’Sullivan et al., 1997, 2005; O’Sullivan, 1997, 200 0, 2003;
Dankaerts et al., 2006a) and the reliability of clinicians to identify
these different subgroups has been established (Dankaerts et al.,
2006b). Lately, this approach has also incorporated classification of
patients with lumbo-pelvic pain and a wider range of pain mech-
anisms linked to their disorder (O’Sullivan, 2005; O’Sullivan and
Beales, 2007a). This system differentiates between specific LBP
versus NSLBP. NSLBP is further split into subgroups based on the
proposed driving mechanism behind the disorder (Fig. 1). The
classification is based on a systematic examination process
(subjective history, objective examination and available medical
information). Within this system psychosocial factors are accoun-
ted for, acknowledging their potential to amplify pain and drive
disability. To date the ability of clinicians to agree on this broad
classification process has not been formally tested.
Validating the system has been a multi-step process, in which
establishing inter-tester reliability is crucial. The aim of this study
was therefore to examine the inter-tester reliability of clinicians’
ability to independently classify a wide range of patients with
NSLBP, utilising an extended mechanism-based classification
method lately developed by O’Sullivan.
2. Methods
The study was conducted from March 2006 to June 2006, and
was approved by the regional ethics committee of medical research
in western Norway.
2.1. Patients
Patients were recruited consecutively from physiotherapy
clinics around Bergen and from The Outpatient Multidisciplinary
Spine Clinic, Haukeland University Hospital. After recruitment,
a telephone screening was performed, and the first 30 patients that
fit the inclusion criteria, were tested (Table 1). Since the patients
were tested twice on each occasion, a 0–10 pain numerical rating
scale was conducted prior to each testing. If a patient’s pain score
changed 2 levels between two examinations on the same day, this
was considered to be a threat to the classification validity and the
patient would then be excluded. Four patients were excluded after
further examination: three did not fulfil the inclusion criteria and
one reported a two-level change in pain between examinations on
the given day.
This left 26 patients participating in the study. See Table 2 for the
patients’ characteristics. Prior to the study, design and possible
risks were fully explained to each subject, and all signed a consent
form.
2.2. Examiners
There were four physiotherapists, each with several years of
experience in examination and treatment of LBP patients (mean
12 years, range 7–20 years). Three of the four examiners were
physiotherapists with a masters degree in manual therapy. One was
the developer of the system.
2.3. Training
All the examiners had been educated in the CS during several
workshops with the developer, and were using it in their clinical
practice. Prior to the study, O’Sullivan explained procedures and
classifications were discussed using a series of case studies. The
examiners also underwent a pilot training period where O’Sullivan
examined and classified six patients, while the three others
observed. The aim was to refine the specific criteria for assessment,
as well as making testers more familiar with the system. The esti-
mated training time for each therapist ranged from 69 to 140 h, the
average being 106.3 h (workshops and pilot study included).
2.4. Clinical procedure
A test–retest design was utilised. A classification manual was
developed by O’Sullivan prior to the study. The patients underwent
acomprehensive interview and full physical examination by each of
the four physiotherapists. Rather than assess the reliability of
individual tests, this system involved making a disorder classifica-
tion based on compilation of subjective and physical examination
findings in relation to other medical tests and radiological imaging.
The subjective assessment included pain area (pain drawing),
intensity and nature, pain behaviour (aggravating/easing move-
ments), identification of primary impairments, disability levels,
avoidance behaviours, pain coping and pain beliefs. The examina-
tion involved assessment of spinal range of movement, analysis of
the patient’s primary physical impairments (pain provocative and
easing postures, movements and functional tasks). Specific muscle
and movement tests were performed to identify the relationship
between the control of the lumbo-pelvic region and the pain
disorders (O’Sullivan, 2000), as well as specific articular tests for the
lumbar spine and pelvic region as indicated to identify the struc-
tural source of pain and the presence of movement impairments
(MI). These are important elements in the classification of the pain
disorder and in determining whether the habitual movements or
postures are provocative or protective (O’Sullivan, 2000, 2005;
O’Sullivan and Beales, 2007a,b). The process consists of several
stages before reaching a classification (Fig. 1):
1. The first part involves screening; determining if the condition
is specific LBP or NSLBP (O’Sullivan, 2005).
2. The second stage considers whether specific LBP disorders have
an adaptive or maladaptive response to the disorder (O’Sulli-
van, 2005). If the disorder is classified as non-specific, then
consideration of whether the disorder is predominantly cen-
trally or peripherally mediated is made. The presence of
localised and anatomically defined pain, associated with
specific and consistent mechanical aggravating and easing
factors, suggests that physical/mechanical factors are likely to
dominate the disorder resulting in a peripheral nociceptive
drive. Constant, non-remitting widespread pain, not influenced
by mechanical factors, could on the other hand indicate
inflammatory or centrally driven pain (O’Sullivan, 2005).
K. Vibe Fersum et al. / Manual Therapy 14 (2009) 555–561556
3. Centrally mediated pain can then be further sub-classified into
the presence of non-dominant or dominant psychosocial
factors. Peripherally mediated disorders are sub-classified into
either LBP or a pelvic girdle pain disorders.
4. Peripherally mediated lumbar spine pain disorders are divided
into MI or MCI disorders and peripherally mediated pelvic
girdle pain into excessive or deficit of force closure. Both these
classifications have been described in detail elsewhere
(O’Sullivan, 2005; O’Sullivan and Beales, 2007a,b).
5. If the lumbar spine is the source of pain, the primary directional
provocation bias as well as the symptomatic spinal level is
noted.
Classification process adapted from Peter O’ Sullivan
Chronic back pain disorders
- Spondylolisthesis
- disc herniation + radicular pain
- degenerative disc + modic
changes
- foraminal and central stenosis
- Multi-
disciplinary
management
Psychological
(CBT), medical,
functional
rehabilitation
Non-specific back pain disordersSpecific back pain disorders
Dominant
psycho-
social
factors
Non-
dominant
psycho-
social factors
- Medical
management
- Functional
rehabilitation
Control
impairment
(directional
subgroups)
- Motor
learning
within
cognitive
framework
(enhance
control)
- Functional
restoration
Red flag disorders
Cancer
Infection
Inflammatory disorder
Fracture
Adaptive response
Patients response to
disorder is adaptive /
protective
Mal-adaptive
Patients response to
disorder is mal-adaptive
Management
Advise, medical,
surgical – as
appropriate
Management
- Cognitive / Motor
learning
- Medical
Pelvic girdle pain Low Back Pain
Reduced
force closure
Excessive
force closure
- Motor
learning
within
cognitive
framework
(reduce force
closure/
relaxation)
- Functional
restoration
- Motor
learning
within
cognitive
framework
(enhance
force closure)
- Functional
restoration
+/- central pain modulation based on contribution of
psycho-social factors
Directional
subgroups
(+ level of
dysfunction)
Directional
subgroups
(+ level of
dysfunction)
Level 4
Level 3
Level 2
Level 5
Level 6
Movement
impairment
(directional
subgroups)
Level 1
Centrally mediated back pain Peripherally mediated back pain
Fig. 1. Classification process adapted from Peter O’Sullivan (O’Sullivan, 2005; O’Sullivan and Beales, 2007a,b).
K. Vibe Fersum et al. / Manual Therapy 14 (2009) 555–561 557
6. The final decision is to indicate if significant psychosocial
factors are associated with the disorder, based on all informa-
tion from the examination process. The evaluation of psycho-
social factors considers the presence of underlying fear
avoidance behaviour, as well as psychological and social drivers
considered to contribute to the pain disorder. Within this
reasoning process, consideration is given to whether the
patient has adapted in a positive (confrontation, active coping
and minimal avoidance behaviours) or negative manner
(passive coping and fear avoidance).
Each testing took about 1 h. The patient was examined inde-
pendently twice on two days, within a 1-week period. Each ther-
apist filled out a classification form (see Supplementary Appendix
A.1) and put it in a sealed opaque envelope after their patient
assessment. After examination the patient completed several
questionnaires to formally assess their disorder. This included
a pain drawing, a functional assessment chart from the Dartmouth
Primary Care Cooperative Information Project (COOP/WONCA),
Oswestry Disability Index (ODI), Hopkins Symptoms Check List
(HSCL), Fear Avoidance Beliefs Questionnaire (FABQ) and Ørebro
Musculoskeletal Pain Screening Questionnaire (Ørebro MSPSQ).
2.5. Analysis
After completed examinations, the results were compared and
logged. The developer’s classification of each patient was used as
the gold standard to which the other results were compared. Kappa
coefficients and percentage of agreement were calculated using
SPSS 13.0 for Windows. Cohen’s Kappa statistic was used to
calculate inter-tester reliability and Landis and Koch’s (1977) values
for interpretation of the reliability scores were used. Kappa values
<0.20 indicate poor agreement, 0.21–0.40 fair, 0.41–0.60 moderate,
0.61–0.80 substantial, and 0.81–1.00 indicate almost perfect
agreement. The data was analysed based on agreement of overall
classification (specific LBP vs NSLBP), centrally or peripherally
mediated, adaptive or maladaptive movement disorders, and
whether it was considered to be a pelvic girdle pain or LBP disorder.
Kappa agreement of the primary directional pain provocation, the
spinal level of pain provocation and the presence of psychosocial
influence on their LBP disorder was calculated.
3. Results
In the first part of the classification process, all patients were
classified with NSLBP with 98% agreement for this level. All patients
in the study had pain arising from a peripheral pain source, with
99% agreement for this. One patient was classified by all four testers
as having pelvic girdle pain (100% agreement); the rest were clas-
sified as LBP disorders (99% agreement). The fourth level consid-
ered increased or decreased force closure for pelvic pain (one
patient, 100% agreement), MCI (24 patients, 99% agreement) or MI
(one patient, 75% agreement) for low back. In the fifth level, Kappa
agreement could be calculated, deciding the directional pattern of
provocation (Fig. 2). For the primary direction of provocation,
Kappa (K) and percentage agreement had a mean between the four
testers of 0.82 (range 0.66–0.90) and 86% (range 73–92%) respec-
tively. Increased familiarity with the system also increased the
reliability results (<100 h K¼0.66, >100 h K¼0.90). In the final
level of decision making, the mean Kappa coefficient for detecting
psychosocial influence was 0.65 (range 0.57–0.74) and the mean
agreement 87% (range 85–92%).
4. Discussion
The principal finding of our study suggests that therapists with
substantial training in this CS (O’Sullivan, 2005) demonstrated fair
to excellent agreement (Landis and Koch, 1977) in primary classi-
fication of the disorder, identification of directional patterns of
provocation and the presence of psychosocial factors associated
with the disorder, when applied to a range of NSLBP patients. Our
findings are in accordance with a recent study (Dankaerts et al.,
2006b), who also found moderate to excellent agreement between
testers examining patients within the MCI subgroup. Their study
consisted of two separate parts. The first part demonstrated almost
perfect agreement between two expert clinicians when classifying
35 patients with MCI identified from a clinical case load, into the
various directional patterns (K¼0.96, agreement 97%). In the
second part, 25 out of 35 patients with MCI in the first study were
randomly selected. These were videotaped and classified into
directional groups by 13 other therapists based on the video and
subjective complaints of the patients. The agreement between the
13 different raters was moderate to excellent (mean Kappa 0.61,
agreement 70%).
As in Dankaerts et al.’s study (2006b), familiarity with the CS
also influenced the reliability results, demonstrating higher
agreement among raters with more CS training. These findings are
in line with Strender’s study (1997), concluding that reliability of
clinical tests requires sufficient time for examination and confor-
mity of performance, definitions and evaluations. The protocol of
our study followed a similar examination procedure as the first part
of Dankaerts et al.’s (2006b) study. By including any patient with
localised low back pain in our study, we anticipated a more het-
erogenic NSLBP population with the inclusion of patients with back
pain associated with MI as well as pelvic girdle pain disorders.
However, 24 out of the 26 patients were classified as having MCI,
which is in line with the findings of Dankaerts et al. (2006b).
Furthermore, the current study involved four therapists examining
the patients versus two in the first part of Dankaerts study (2006b).
Table 1
Inclusion/exclusion criteria.
Inclusion criteria Exclusion criteria
Patients with non-specific LBP
(NSLBP) (6 weeks)
Sick-listed for more than 4 months
continuous duration during last year
Male or female Acute exacerbation of LBP
Age between 18 and 65 years Radicular pain. Positive neural tissue
provocation tests (primary peripheral
symptoms)
Localised LBP: primarily in the area
from T12 to gluteal folds
Any low limb surgery on the last 3 months
Moderate ongoing LBP, VAS >2/10
and Oswestry >14 %
Surgery involving the lumbar spine (fusion)
Mechanical provocation of pain:
postures, movement and activities
Pregnancy
Psychiatric disorders
Widespread non-specific pain disorder (no
primary LBP focus)
Specific diagnoses: active rheumatologic
disease, progressive neurological disease,
serious cardiac or other internal medical
disease
Table 2
Patients’ characteristics.
Number of patients 26
Female 11
Male 15
Mean age (years) 32.4
Mean pain intensity 6/10
Mean duration (years) 4.9
Mean Oswestry 21.2/100
Mean HSCL 1.53/4
Mean Ørebro score 87.5/210
K. Vibe Fersum et al. / Manual Therapy 14 (2009) 555–561558
Flexion pattern n =24
79,1
04,2 4,2 8,3
04,2
0
10
20
30
40
50
60
70
80
90
100
Flexion
Lateral shift
Active Extension
Passive Extension
Multidirectional
Sacroiliac
Movement
Impairment
Correct
Incorrect
Classification per
pattern (%)
Flexion
Lateral shift
Active Extension
Passive Extension
Multidirectional
Sacroiliac
Movement
Impairment
0
10
20
30
40
50
60
70
80
90
100
Classification per
pattern (%)
Lateral shift n= 8
75
00000
12,5 12,5
Active extension n=8
25
0
25
00
50
0
10
20
30
40
50
60
70
80
90
100
Flexion
Lateral Shift
Active Extension
Passive Extension
Multidirectional
Sacroiliac
Movement Impairment
Classification per
pattern (%)
Passive extension n=12
000 000
0
10
20
30
40
50
60
70
80
90
100 100
Flexion
Lateral Shift
Active Extension
Passive Extension
Multidirectional
Sacroiliac
Movement Impairment
Classification per
pattern (%)
Multidirectional n=44
75
11,4
04,5 2,3 2,3 4,5
0
10
20
30
40
50
60
70
80
90
100
Flexion
Lateral Shift
Active Extension
Passive Extension
Multidirectional
Sacroiliac
Movement Impairment
Classification per
pattern (%)
Classification per
pattern (%)
Classification per
pattern (%)
Sacroiliac n=4
75
25
00 00 0
0
10
20
30
40
50
60
70
80
90
100
Flexion
Lateral Shift
Active Extension
Passive Extension
Multidirectional
Sacroiliac
Movement Impairment
Movement impairment n=4
75
00
25
0
0
10
20
30
40
50
60
70
80
90
100
Flexion
Lateral Shift
Active Extension
Passive Extension
Multidirectional
Sacroiliac
Movement Impairment
Correct
Incorrect
Correct
Incorrect
Correct
Incorrect
Correct
Incorrect
Correct
Incorrect
Correct
Incorrect
0
00
Fig. 2. Classification per different pattern (in %) by all examiners; n¼total number of that specific pattern included 4 (total number of examiners).
K. Vibe Fersum et al. / Manual Therapy 14 (2009) 555–561 559
This may explain the greater reliability in this aspect of Dankaerts
study, in comparison to ours. With regards to the second part of
Dankaerts et al.’s study (2006b), it was acknowledged that the use
of previously collected information (both subjective and video)
represented a bias for the 13 clinicians. In our study, the testers did
not have any prior information regarding the patient’s disorder as
this could influence the classification reliability, as different raters
may gather information from patients in different ways.
Eight subjects in our study out of 26 with disorders classified as
peripherally mediated NSLBP were also identified as having
moderate, but significant psychosocial factors contributing to their
disorders. Analysis of the questionnaire data collected after all
assessments, confirmed that these eight patients scored signifi-
cantly higher on HSCL and Ørebro MSPSQ (p<0.05). Linton and
Hallden (1998) identified potential psychosocial risk factors asso-
ciated with future sick absenteeism in a study, using the Ørebro as
the screening instrument. High total scores were related to
outcome and to cut-off points that correctly identified the prog-
nosis of nearly 80% of the patients. Psychosocial factors can
modulate pain behaviour, which then can increase disability via
fear avoidance, as well as promoting pain levels via central mech-
anisms (Vlaeyen and Linton, 2000). However there is little evidence
to date that physiotherapists can identify these subjects at risk,
based on subjective examination.
It has been emphasised (Dankaerts et al., 2006b) that the
development of a multi-dimensional mechanism-based CS based
on a bio-psycho-social framework should be seen as a critical
development of a CS. The Quebeck Task Force has been considered
by many as the first CS that included biomedical, psychological and
social considerations in the classification process (McCarthy et al.,
2004). The system used in our study, developed by O’Sullivan,
utilises the Quebeck Task Force as an underlying framework, by
classifying specific LBP versus NSLBP, the stage of the disorder, and
the presence of red and dominant yellow flags. However, patients
are sub-classified further, identifying the primary direction of
provocation and the proposed underlying mechanism of the
disorder. Furthermore, very specific interventions are indicated for
the different classifications (O’Sullivan, 2005; O’Sullivan and Beales,
2007a,b).
In contrast, the McKenzie CS is a bio-system that lacks validity
within a chronic LBP population, as only about 40% of patients have
a directional pain preference (Donelson et al., 1990). Consistent
with our findings, 45% of the subjects were classified as having MCI
with multi-directional pain provocation, suggesting that a uni-
directional preference was not present. This lack of uni-directional
preference limits the use of directional treatment methods as
advocated by McKenzie.
Interestingly, 25 of the patients in our study had MCI, and only
one had MI. This finding is consistent with reports that impair-
ments of range of motion are often not present in chronic low back
pain disorders (Nattrass et al., 1999). However the lack of subjects
with MI disorders in this study limits the ability to confirm the
reliability of physiotherapists when identifying this subgroup.
The Sahrmann CS for NSLBP proposes a single mechanism for
LBP (movement dysfunction), but does not consider specific diag-
nosis of LBP, CNS mediated pain, MIs or psychosocial factors,
limiting its application within a chronic LBP setting. Petersen et al.
(2004) in contrast proposed a system that demonstrated substan-
tial reliability, but it lacked clear guidelines for management.
Reliability can be influenced by many different factors. The
participants seemed representative of the population normally
seen in primary health care, but the small sample may not be
representative of the chronic LBP population. The first part of the
classification process in this study was to determine whether the
patient’s condition was specific or non-specific. Secondly, an
assessment was made to classify the source of the underlying
mechanism as being centrally or peripherally driven. Our study’s
inclusion criteria were aimed at subjects with localised NSLBP that
was mechanically provoked, making it more likely that they had
a peripheral pain disorder. None of our subjects were classified
with neurogenic pain. This fits with Bogduk’s study (1995), which
concluded that most NSLBP disorders are peripherally mediated,
having a pain source that most likely is discogenic or from the facet
joint and less commonly from the sacroiliac joint.
It can be argued that the Kappa scores could have been higher if
all the testing procedures had been standardised. However, the
study’s intention was to evaluate the reliability as a result of the
whole examination as performed in clinical practice, and stand-
ardising the examination for this heterogenic group of patients
could have influenced the validity.
5. Conclusion
The findings provide evidence that the inter-tester reliability of
O’Sullivan’s CS is substantial for a range of patients within the
NSLBP population in line with previous research. Using a mecha-
nism-based CS has implications in terms of treatment being
directed towards identified subgroups. The use of the CS is
currently being evaluated in a randomised controlled trial in order
to compare the efficacy of different interventions for any given
category.
Appendix A. Supplemental material
Supplementary information for this manuscript can be down-
loaded at doi: 10.1016/j.math.2008.08.003.
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... Clinical guidelines consistently recommend screening for PS factors in all patients with LBP, regardless of its mechanical nature [24][25][26], using validated patient-reported outcome measures in combination with clinical judgment [27,28]. Research reflects contradictory findings between the poor ability of physical therapists (PTs) to identify individual constructs such as fear avoidance, kinesiophobia, or emotional distress [29][30][31] as well as to allocate LBP patients into risk stratification groups [32] and those suggesting their adequate intuition in this regard [33][34][35]. ...
... The ability of PTs to rate chronicity risk according to PS aspects has been reported to be adequate for high and low risk cases, but not for moderate risk cases in a survey study also based on LBP patient vignettes [46]. Correct estimates of BPS risk of chronicity by PTs were also reported by comparing clinical assessments of actual LBP patients, with respect to patient responses on the Orebro Musculoskeletal Pain Questionnaire (OMPQ) [33,34], as well as from PTs who followed a BPS training program (35). However, Wassinger et al. recently reported slight agreement between the PTs' ratings and OMPQ during the evaluation of musculoskeletal conditions [47]. ...
... All these conflicts in findings may be partly explained by the methodology, either in relation to the use of actual patients versus patient vignettes or the use of different assessment tools. However, underreporting by some of these authors of PT characteristics that could have influenced their results has also been detected, such as those characteristics mentioned above [29,32,34,35]. ...
Article
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Clinical guidelines consistently recommend screening psychosocial (PS) factors in patients with low back pain (LBP), regardless of its mechanical nature, as recognized contributors to pain chronicity. However, the ability of physiotherapists (PTs) in identifying these factors remains controversial. This study aimed to assess the current identification of psychosocial risk factors by physical therapists (PTs) and which characteristics of PTs are associated with the identification of the main risk for chronicity (physical or psychosocial). A cross-sectional descriptive study surveying Spanish PTs in public and private health services was conducted, including questions on PT characteristics and three low back pain (LBP) patient vignettes with different biopsychosocial (BPS) clinical presentations. From 484 respondents, the majority of PTs agreed regarding the main risk for chronicity for each vignette (PS 95.7% for vignette A, PS and physical 83.5% for vignette B and PS 66% for vignette C). Female PTs were more likely to rate psychosocial compared with males (p < 0.05). PTs with higher levels of social and emotional intelligence (both, p < 0.05) were more likely to identify the main risk for chronicity. However, only gender and social information processing for vignette A (p = 0.024) and emotional clarity for vignette B (p = 0.006) were able to predict the identification of psychosocial and physical risk, respectively. The main risk for chronicity was correctly identified by a large majority of PTs through patient vignettes. Gender, social and emotional intelligence played a relevant role in the recognition of psychosocial risk and biopsychosocial factors.
... Movement control impairment is specific, either provoked by flexion, extension, rotation or multidirectional movements [4]. We used four outcome measures out of which the test battery of six tests for which acceptable reliability has been demonstrated in previous research, were they evaluated with ten movement control tests [11,12,13]. We refrained from testing six movements in random order because we assume that this procedure best represents clinical practice where routines are often developed [14]. ...
... Benefits of specific exercise were demonstrated in other subgroups of patients with LBP. Specific stabilizing exercises are more effective than general exercises [10,11]. Brennan et al (2006) showed that the outcomes are better if patients receive treatment adapted to their clinical presentation. ...
... O'Sullivan developed a classification system of LBP; the first distinction is between centrally evoked and peripherally evoked LBP. The centrally evoked pain is associated with psychological factors, such as fear avoidance, catastrophizing or depressive mood (approximately 30% of LBP patients) [11]. The peripherally evoked LBP is mechanically caused and includes movement impairment (each approximately 30%). ...
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Background: Low back pain is the most common condition that affects the majority of the population with up to 84% lifetime prevalence. A specific diagnosis of low back pain is only possible in 15% of patients and the majority of cases the pain is non – specific low back pain (NSLBP). The main objectives were to assess the effect of movement control spinal exercises (MVCSE) on NSLBP and to examine the effect of MCSE on mobility. Methods: The study was conducted in the physiotherapy out-patient department. After screening of the inclusion and exclusion criteria, 35 individuals with NSLBP were selected. A pre-test assessment was done, the protocol included warmup sessions, exercise protocol and cool down sessions. Exercises were demonstrated to the patients according to the spinal movements control impairment, the total duration of the protocol was of 6 weeks with one session of 1 hour per day. Later the post- test assessment was done and further statistical analysis was done. Results: After 6 weeks post evaluation, patients with flexion movement control impairment (MVCI) had improvement in their movement control; extension, lateral and rotational movement control impairments were the same as before. Conclusion: The patient- specific functional complaints and disabilities improved significantly after implementation of the individual based specific exercise programme, along with the regular physiotherapeutic interventions. Movement Control Spinal Exercise treatment has shown results in improving mobility and disability in the short term and long term for individuals with NSLBP and MVCI to than other interventions.
... 34,35 For health-care practitioners, gaining insight into pain mechanisms can be achieved through careful clinical examination, quantitative sensory testing and validated questionnaires. 27,36 Cognitive factors such as negative LBP beliefs, catastrophizing and fear of movement are predictive of disability and are linked to PLBP. [37][38][39][40] Many of these negative beliefs gain their origins from health-care practitioners and can have a devastating impact on LBP trajectories. ...
... [56][57][58] There is growing evidence that they can be characterized based on the presence of functional impairments and directional pain sensitization, providing an opportunity for targeted interventions. 36,59 Deconditioning may also occur secondary to activity avoidance, sedentary lifestyles and habitual postures, and may act to reinforce maladaptive movement behaviours associated with the disorder. 37,60 In contrast, endurance copers may present as overconditioned through 'over activity'. ...
... Underpinning research has assessed the inter-tester reliability of different aspects of the CRF and shown substantial agreement between trained health-care professionals. 36,59 The effi cacy of CFT in patients with PLBP, has been compared with physiotherapy-led exercise and manual therapy in a randomized trial, in primary care, demonstrating long-term benefi ts. 12 Further research is underway to assess CFT in different care and geographical settings. ...
... These and related studies often rely on qualitative assessments of LBP symptoms [16] or highly trained individuals [17] to classify patients according to their respective phenotypes, making these methods liable to misdiagnosis due to either the subjective nature of the assessment [15,18] or clinical inexperience [19]. ...
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Chronic low back pain (cLBP) is a prevalent and multifactorial ailment. No single treatment has been shown to dramatically improve outcomes for all cLBP patients, and current techniques of linking a patient with their most effective treatment lack validation. It has long been recognized that spinal pathology alters motion. Therefore, one potential method to identify optimal treatments is to evaluate patient movement patterns (i.e., motion-based phenotypes). Biomechanists, physical therapists, and surgeons each utilize a variety of tools and techniques to qualitatively assess movement as a critical element in their treatment paradigms. However, objectively characterizing and communicating this information is challenging due to the lack of economical, objective, and accurate clinical tools. In response to that need, we have developed a wearable array of nanocomposite stretch sensors which accurately capture the lumbar spinal kinematics, the SPINE Sense System. Data collected from this device are used to identify movement-based phenotypes and analyze correlations between spinal kinematics and patient-reported outcomes. The purpose of this paper is twofold: first, to describe the design and validity of the SPINE Sense System; and second, to describe the protocol and data analysis towards the application of this equipment to enhance understanding of the relationship between spinal movement patterns and patient metrics, which will facilitate the identification of optimal treatment paradigms for cLBP.
... Many clinicians acknowledge the value of performance assessments yet often rely on skilled observation to document them. 32 Historically some combinations of standardized protocols and measurement tools have been synergized to measure static postures (goniometers, flex tape, rulers) or maximum movement (inclinometers and dynamometers). 33 However, tools exist to measure performance with higher precision and resolution than well-trained observation. ...
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Objective: Biomechanics represents the common final output through which all biopsychosocial constructs of back pain must pass, making it a rich target for phenotyping. To exploit this feature, several sites within the NIH Back Pain Consortium (BACPAC) have developed biomechanics measurement and phenotyping tools. The overall aims of this paper were to: 1) provide a narrative review of biomechanics as a phenotyping tool; 2) describe the diverse array of tools and outcome measures that exist within BACPAC; and 3) highlight how leveraging these technologies with the other data collected within BACPAC may elucidate the relationship between biomechanics and other metrics used to characterize low back pain (LBP). Methods: The narrative review highlights how biomechanical outcomes can discriminate between those with and without LBP, as well as the severity of LBP. It also addresses how biomechanical outcomes track with functional improvements in LBP. Additionally, we present the clinical use case for biomechanical outcome measures that can be met via emerging technologies. Results: To answer the need of measuring biomechanical performance our results section describes the spectrum of technologies that have been developed and are being used within BACPAC. Conclusion: and future directions: The outcome measures collected by these technologies will be an integral part of longitudinal and cross-sectional studies conducted in BACPAC. Linking these measures with other biopsychosocial data collected within BACPAC increases our potential to use biomechanics as a tool for understanding the mechanisms of LBP, phenotyping unique LBP subgroups, and matching these individuals with an appropriate treatment paradigm.
... This approach has good inter-tester reliability [39][40] with a number of studies supporting the validity of the different subgroups on the physical domains [41][42][43][44][45][46] as well as cognitive domains [23]. It has been more effective at reducing pain, disability, fear beliefs, mood and sick leave at long-term follow-up than Manual Therapy and exercise [23]. ...
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The biomedical approaches managing low back pain have led to an exponential increase in health-care costs, with a concurrent increase in disability and chronicity, due to the lack of person-centred management and the failure to adopt a biopsychosocial framework based on contemporary evidence. The need of potential treatments to take the complexity of low back pain into account and encompass a representative range of medical disciplines and disciplines allied to medicine, combined so as to offer maximum benefit to patients has emerged. Cognitive Functional therapy is a multidimensional, patient-centred intervention that directly explores and manages cognitive, psychological and social factors deemed to be barriers to recovery in chronic low back pain. This review presents a new treatment method of chronic low back pain, cognitive functional therapy and describe the principals of this approach. This approach could potentially help physiotherapists who seek to treat chronic low back pain in a more multidisciplinary way.
Article
Zusammenfassung Bei muskuloskelettalen Beschwerden gibt es wissenschaftlich nachgewiesen keine wirkungsvollere Behandlung als eine auf Bewegung und Übungen basierende Therapie. Zur Diagnostik gehören das Beurteilen der Bewegungsqualität und Tests, die Aufschluss über mangelnde Bewegungskontrolle und Bewegungsdysfunktionen geben. Angepasste Übungen, Training und ein verbessertes Bewusstsein für das eigene Bewegungsverhalten sowie eine verbesserte Wahrnehmung für den eigenen Körper durchbrechen bei vielen Betroffenen muskuloskelettale Schmerzmechanismen und führen zurück in ein schmerzfreies Leben. Die folgenden Artikel zeigen exemplarisch am Beispiel Rückenschmerzen die Bedeutung von Bewegungskontrolle und Körperwahrnehmung.
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Low back pain classification systems are structured assessments used to guide choices of more specific treatments. Classification systems examined in randomised controlled trials have limited effects on pain intensity and disability compared to non classified interventions. Potential reasons for the lack of efficacy include: (1) failing to assess multidimensional factors that contribute to pain, (2) relying on clinician judgement, (3) low accessibility and (4) poor classification reliability. Overcoming these limitations is critical to deciding whether classification systems can improve clinical practice. Only once these limitations are addressed can we feel certain about the efficacy, or lack thereof, of classification systems. This Viewpoint guides the reader through some limitations of common classification approaches, and presents a path forward to open-access, reliable and multidimensional precision medicine for managing low back pain.
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Objective: To determine if classification systems improve patient-reported outcomes for people with low back pain (LBP). Design: Systematic review with meta-analysis. Literature search: MEDLINE, EMBASE, CINAHL, Web of Science Core Collection and CENTRAL were searched from inception to 21 June, 2021. Reference lists of prior systematic reviews and included trials were screened. Study selection criteria: We included randomized trials comparing a classification system (e.g. McKenzie and STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (e.g. fractures and tumors) were excluded. Data synthesis: Outcomes were patient-reported LBP intensity, leg pain intensity and disability. We used the Cochrane RoB2 tool to assess risk of bias, and the GRADE approach to judge the certainty of evidence. We used random effects meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustment to estimate standardized mean differences (Hedges g) and 95% confidence intervals (95%CI). Sub-group analyses explored classification systems, comparator type, pain type and duration. Results: Twenty-four trials assessing classification systems and 34 assessing sub classes were included. There was low certainty of a small effect at end of intervention for LBP intensity (-0.31[-0.54,-0.07], p=0.014, n=4416, trials=21) and disability (0.27[ 0.46,-0.07], p=0.011, n=4809, trials=24) favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful. Conclusions: For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems above generalized interventions when managing LBP. J Orthop Sports Phys Ther, Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.
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Study design: Numerous authors have attempted to sub-classify low back pain in order that valid homogenous subsets of low back pain presentations might be recognised. This review systematically appraises these papers. Methods: Medline, Embase, Cinahl, AMED and PEDro electronic databases were searched with subsequent hand searching of bibliographies. Papers were included between June 1983 and June 2003. Two reviewers independently reviewed 32 papers using a standard scoring criteria for assessment. A third reviewer mediated disagreements. Results: Thirty-two papers were reviewed, with classification systems being grouped by method of classification. Classification has been attempted by implication of patho-anatomical source, by clinical features, by psychological features, by health and work status and in one case by a biopsychosocial weighting system. Scores were generally higher for systems using a statistical cluster analysis approach to classification than a judgemental approach. Both approaches have specific advantages and disadvantages with a synthesis of both methodologies being most likely to generate an optimal classification system. Conclusions: The classification of NSLBP has traditionally involved the use of one paradigm. In the present era of biopsychosocial management of NSLBP, there is a need for an integrated classification system that will allow rational assessment of NSLBP from biomedical, psychological and social constructs.
Article
In patients with low-back and radiating leg pain, a clinical phenomenon has been described known as "centralization," which occurs during a mechanical evaluation protocol described by McKenzie. Relocation of the most distal pain in a proximal or central direction characterizes the pain behavior when patients are assessed in this fashion.
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A literature search identified eight classification systems that subdivide non-specific low back pain. These eight systems were selected on the basis of the following criteria: they were all developed for the purpose of guiding choice of physiotherapeutic treatments, and they were all based on symptoms and clinical tests. A critical appraisal was performed using a systematic approach including evaluation of validity, reliability, feasibility, and generalizability. None of the classification systems fulfilled all of the requirements and none were considered to have included all relevant categories separated in a way suitable for the purpose. Studies concerning reliability and validity were rarely reported. Generally aspects of validity and reliability were only tested for a few of the criteria used for categorizing patients and construct validity and reliability of the classification systems as a whole were not tested. Future studies ought to focus on the evaluation of existing classification systems and/or the development of new ones, which are capable of meeting basic measurement criteria.
Article
Background: Diagnoses and treatments based on movement system impairment syndromes were developed to guide physical therapy treatment. Objectives: This masterclass aims to describe the concepts on that are the basis of the syndromes and treatment and to provide the current research on movement system impairment syndromes. Results: The conceptual basis of the movement system impairment syndromes is that sustained alignment in a non-ideal position and repeated movements in a specific direction are thought to be associated with several musculoskeletal conditions. Classification into movement system impairment syndromes and treatment has been described for all body regions. The classification involves interpreting data from standardized tests of alignments and movements. Treatment is based on correcting the impaired alignment and movement patterns as well as correcting the tissue adaptations associated with the impaired alignment and movement patterns. The reliability and validity of movement system impairment syndromes have been partially tested. Although several case reports involving treatment using the movement system impairment syndromes concept have been published, efficacy of treatment based on movement system impairment syndromes has not been tested in randomized controlled trials, except in people with chronic low back pain.
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Despite increasing advances in medical technology, the cost of musculoskeletal incapacity, particularly low-back pain, in terms of sickness benefits, invalidity benefits and associated allowances has led to a fundamental reconsideration of the nature of chronic incapacity. Recent reports from the United Kingdom and the United States of America, in their recommendations for a comprehensive multidisciplinary assessment for patients still symptomatic at six weeks, are based on the clear assumption that a significant proportion of chronic incapacity is preventable. Such a proposition represents a fundamental challenge to much of current medical practice.
Article
A literature search identified eight classification systems that subdivide non-specific low back pain. These eight systems were selected on the basis of the following criteria: they were all developed for the purpose of guiding choice of physiotherapeutic treatments, and they were all based on symptoms and clinical tests. A critical appraisal was performed using a systematic approach including evaluation of validity, reliability, feasibility, and generalizability. None of the classification systems fulfilled all of the requirements and none were considered to have included all relevant categories separated in a way suitable for the purpose. Studies concerning reliability and validity were rarely reported. Generally aspects of validity and reliability were only tested for a few of the criteria used for categorizing patients and construct validity and reliability of the classification systems as a whole were not tested. Future studies ought to focus on the evaluation of existing classification systems and/or the development of new ones, which are capable of meeting basic measurement criteria.
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This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.