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The Reliability of the Clinical Tests and Questions Recommended in International Guidelines for Low Back Pain

McCarthy, Christopher James, PhD*; Gittins, Matthew, MSc; Roberts, Christopher, PhD; Oldham, Jacqueline Anne, PhD

doi: 10.1097/01.brs.0000259864.21869.26
Health Services Research

Study Design. An intertester reliability study of the questions and tests recommended in guidelines for the management of low back pain (LBP).

Objective. This study undertook a reliability study to evaluate the reliability of the items of the LBP clinical examination with a large sample of LBP patients.

Summary of Background Data. A crucial part of the diagnostic triage process, recommended by many national and international guidelines for the management of LBP, is the clinical examination. The questions and tests used in this process have never been rigorously evaluated for their intertester reliability in first contact clinicians who are not medically trained.

Methods. Patients, referred to physiotherapy departments across the United Kingdom with LBP (n = 301) were recruited in a sample of convenience. The 50 questions and physical tests were administered by a physiotherapist and then repeated by another physiotherapist within the same day. Data were analyzed using kappa and weighted kappa correlation coefficients (κ). Confidence intervals (95% CIs) were calculated.

Results. Eighty-six percent (n = 43) of the questions and test demonstrated κ of 0.41 (fair agreement) or above. Five questions and 2 physical tests (prone knee bend and myotomal assessment) demonstrated agreement of only slight levels. CIs were generally narrow and the uncertainty regarding the kappa coefficients demonstrated correspondingly low.

Conclusions. This study has rigorously evaluated the intertester reliability of the clinical examination process of the diagnostic triage. These clinicians generally demonstrated fair agreement when testing features of the “nerve root,” “yellow” and “red flag” presentations recommended in international guidelines for the management of LBP and nonspecific LBP. However, reliance on single tests with only fair levels of agreement may be unwise. Further work is required to investigate the validity of the tests.

The tests questions and tests advocated by national and international guidelines in LBP were tested for intertester reliability in 301 patients with LBP. The majority of clinical examination items were shown to be acceptably reliable when performed by a group of nonmedically trained healthcare professionals.

From the *Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, Warwickshire, UK; †Biostatisitics Group, Medical School, Manchester University, Manchester, UK; and ‡Centre for Rehabilitation Science, Manchester Royal Infirmary, Manchester University, Manchester, UK.

Acknowledgment date: May 8, 2006. First revision date: June 14, 2006. Second revision date: August 29, 2006. Acceptance date: August 29, 2006.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Federal funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint requests to Christopher James McCarthy, PhD, Warwick Medical School, University of Warwick, Gibbet Hill Campus, Coventry, Warwickshire, CV4 7AL, UK; E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.