Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97 (2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints. [Laslett M, Young SB, Aprill CN and McDonald B (2003): Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy 49: 89-97]

Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests

Study Design. The presence or absence of rapidly centralizing, peripheralizing, or abolishing low back and radiating pain, as identified during a McKenzie mechanical lumbar assessment of patients with chronic lumbar pain, was compared prospectively with discographic pain provocation and anular competency. Objectives. To evaluate any relation between the responses of centralization and peripheralization with discogrophic findings. Summary of Background Data. Centralization of referred pain has been reported as a very common occurrence during McKenzie assessment and treatment. Patients whose pain centralizes have been shown to achieve superior treatment outcomes. A dynamic internal disc model has been hypothesized as an underlying mechanism for centralization that has not been studied previously. Methods. Pathients with chronically disabling low back pain who were referred for discography underwent preliminary blinded McKenzie clinical assessment and were categorized into three groups by their pain response. Patterns, or lack thereof, of pain response were then compared with blinded discographic pain provocation and anular findings. Results. During the McKenzie assessment, the referred pain of 50% centralized with 74% having positive discograms, of which 91% had an intact anulus. The pain of 25% peripheralized only (would not centralize); 69% of thes ehad positive discograms, but only 54% had an intact anulus. The distal pain of 25% did not respond at all, and only 12.5% of these had positive discograms. Conclusion. The McKenzie assessment process reliably differentiated discogenic from nondiscogenic pain (P<0.001) as well as competent from an incompetent anulus (P<0.042) in symptomatic discs and was superior to magnetic resonance imaging in distinguishing painful from nonpainful discs.

A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence.

STUDY DESIGN A test-retest design was used. OBJECTIVE To assess interexaminer reliability of the McKenzie method for performing clinical tests and classifying patients with low back pain. SUMMARY OF BACKGROUND DATA Clinical methods and tests classifying patients with nonspecific low back pain have been based mainly on symptom duration or extent of pain referral. The McKenzie mechanical diagnostic and classification approach is a widely used noninvasive, low-technology method of assessing patients with low back pain. However, little is known about the interexaminer reliability of the method, previous studies having yielded conflicting results. METHODS For this study, 39 volunteers with low back pain, mean age 40 years (range, 24-55 years), were blindly assessed by two physical therapists trained in the McKenzie method. The variability of two examiners for binary decisions was expressed by the kappa coefficient, and by the proportion of observed agreement, as calculated from a 2 x 2 contingency table of concordance. RESULTS On the basis of pure observation alone, agreement among clinical tests on the presence and direction of lateral shift was 77% (kappa = 0.2; P < 0.248) and 79% (kappa = 0.4; P < 0.003), respectively. Agreement on the relevance of lateral shift and the lateral component according to symptom responses was 85% (kappa = 0.7; P < 0.000) and 92% (kappa= 0.4; P < 0.021), respectively. Using the repeated movements and static end-range loading strategy to define the centralization phenomenon and directional preference, agreement was 95% (kappa = 0.7; P < 0.002) and 90% (kappa = 0.9; P < 0.000), respectively. When patients with low back pain were classified into the McKenzie main syndromes and into specific subgroups, agreement was 95% (kappa = 0.6; P < 0.000) and 74% (kappa = 0.7; P < 0.000), respectively. CONCLUSIONS Interexaminer reliability of the McKenzie lumbar spine assessment in performing clinical tests and classifying patients with low back pain into syndromes were good and statistically significant when the examiners had been trained in the McKenzie method.

Interexaminer reliability of low back pain assessment using the McKenzie method.

Study Design Prospective intertester reliability study investigating the ability of 2 therapists to agree on a low back pain diagnosis using examination techniques and the classification system described by McKenzie. Objectives To investigate intertester agreement in determining McKenzie diagnostic syndromes, subsyndromes, presence, and relevance of the spinal deformities. Background Reliability of the McKenzie approach for determining diagnostic categories is unclear. Previous studies have been characterized by inconsistency of test protocols, criterion measures, and level of training of the examiners, which confounds the interpretation of results. Methods Patients were assessed simultaneously by 2 physical therapists trained in the McKenzie evaluation system. The therapists were randomly assigned as examiner and observer. Agreement was estimated by Kappa statistics. Results Forty-five subjects (47 ± 14 years), composed of 25 women and 20 men with acute, subacute, or chronic low back pain were examined. ...

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Intertester Reliability of the McKenzie Evaluation in Assessing Patients With Mechanical Low Back Pain

The purpose of this systematic review was to determine the quality of the research and to assess the reliability of different types of physical examination procedures used in the assessment of patients with non-specific low back pain. A search of electronic databases (MEDLINE, PEDro, AMED, EMBASE, Cochrane, and CINAHL) up to August 2005 identified 48 relevant studies which were analysed for quality and reliability. Pre-established criteria were used to judge the quality of the studies and satisfactory reliability, and conclusions emphasised high quality studies (≥ 60% methods score). The mean quality score of the studies was 52% (range 0 to 88%), indicating weak to moderate methodology. Based on the upper threshold used (kappa/ICC > 0.85) most procedures demonstrated either conflicting evidence or moderate to strong evidence of low reliability. When the lower threshold was used (kappa/ICC > 0.70) evidence about pain response to repeated movements changed from contradictory to moderate evidence for high reliability. Most procedures commonly used by clinicians in the examination of patients with back pain demonstrate low reliability. [May S, Littlewood C and Bishop A (2006): Reliability of procedures used in the physical examination of non-specific low back pain: A systematic review. Australian Journal of Physiotherapy 52: 91–102]

Reliability of procedures used in the physical examination of non-specific low back pain: a systematic review

The Reliability of Back Pain Assessment by Physiotherapists, Using a ‘McKenzie Algorithm’

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The Reliability of Back Pain Assessment by Physiotherapists, Using a ‘McKenzie Algorithm’