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

doi:10.1016/S0031-9406(10)63053-2

Physiotherapy

Volume 76, Issue 9, 10 September 1990, Pages 579-583

https://doi.org/10.1016/S0031-9406(10)63053-2 Get rights and content

Summary

This paper describes an algorithm developed to clarify and simplify the McKenzie approach to back pain assessment. A study which tests the reliability of the algorithm is then described and discussed. Forty-one patients were examined once by two physiotherapists, and me findings plotted on the algorithm to measure inter-therapist agreement. Kappa is reported where numbers of observations allow reliable interpretation by this statistic. The algorithm is reliable in examination of pain behaviour and pain response with repeated movement, but unreliable in the detection of end-range pain and lateral shift. Its primary use is as a research tool for examination of inter-therapist agreement, but it may also be helpful in education and data recording.

Section snippets

Biography: Julia Kilby (née Knight) qualified from Guy's Hospital School of Physiotherapy in 1982 and worked in London before her present post in Nottingham. She has been involved in research into physiotherapy for low back pain since March 1988.

Mark Stigant gained a BSc(Hons) degree in sports science at Liverpool Polytechnic before qualifying as a physiotherapist at Liverpool School of Physiotherapy. He worked in Lancaster and Gloucester before taking his present post as research

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Cited by (63)

Eligibility of the movement-based classification systems in the diagnosis of patients with low back pain: A systematic review
2020, Journal of Bodywork and Movement Therapies
Citation Excerpt :
The articles used classification based on MSI had substantial to good reliability (Van Dillen et al., 2003; Gombatto et al., 2007; Trudelle-Jackson et al., 2008; Harris-Hayes and Van Dillen, 2009; Henry et al., 2012). Of six articles classified patients with LBP based on MDT, four studies reported high reliability () and only two articles showed poor reliability (Kilby et al., 1990; Riddle and Rothstein, 1993; Razmjou et al., 2000; Kilpikoski et al., 2002; Clare et al., 2004, 2005). The studies assessed patients according to OCS and PBC demonstrated various values from substantial to high for the reliability (Dankaerts et al., 2006a, 2006b, 2006c; Fersum et al., 2009; Petersen et al., 2004).
To evaluate the eligibility of the movement-based classification systems in the diagnosis of patients with low back pain.
The present systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta -Analysis guidelines. Different databases including PubMed, Science Direct, OVID, MEDLINE, CINAHL, EMBASE, ProQuest and Google Scholar were searched from January 1990 to December 2017. All studies assessed the reliability and validity of the movement-based classification systems to diagnose patients with low back pain were included. The keywords used to search the studies were: “reliability”, “validity”, “classification”, “movement impairment” and “low back pain”. Study selection and data extraction were performed by two independent reviewers.
Sixteen articles were met the inclusion criteria. Of these articles, 13 studies assessed the reliability and validity of movement-based classification systems to categorize patients with low back pain. Two out of 16 articles compared patients with low back pain and healthy subjects and one article had no control group.
The results of the reviewed studies demonstrated that movement-based classification systems are valid and reliable enough to categorize patients with low back pain.
Movement-based subgrouping in low back pain: Synergy and divergence in approaches
2016, Physiotherapy (United Kingdom)
Classification systems for low back pain (LBP) aim to guide treatment decisions. In physiotherapy, there are five classification schemes for LBP which consider responses to clinical movement examination. Little is known of the relationship between the schemes.
To investigate overlap between subgroups of patients with LBP when classified using different movement-based classification schemes, and to consider how participants classified according to one scheme would be classified by another.
Cross-sectional cohort study.
University clinical laboratory.
One hundred and two participants with LBP were recruited from university, hospital outpatient and private physiotherapy clinics, and community advertisements.
Participants underwent a standardised examination including questions and movement tests to guide subgrouping.
Participants were allocated to a LBP subgroup using each of the five classification schemes: Mechanical Diagnosis and Treatment (MDT), Movement System Impairment (MSI), O'Sullivan Classification (OSC), Pathoanatomic Based Classification (PBC) and Treatment Based Classification (TBC).
There was concordance in allocation to subgroups that consider pain relief from direction-specific repeated spinal loading in the MDT, PBC and TBC schemes. There was consistency of subgrouping between the MSI and OSC schemes, which consider pain provocation to specific movement directions. Synergies between other subgroups were more variable. Participants from one subgroup could be subdivided using another scheme.
There is overlap and discordance between LBP subgrouping schemes that consider movement. Where overlap is present, schemes recommend different treatment options. Where subgroups from one scheme can be subdivided using another scheme, there is potential to further guide treatment. An integrated assessment model may refine treatment targeting.
Targeting interventions to patients: Development and evaluation
2013, Spinal Control: The Rehabilitation of Back Pain: State of the art and science
Centralization and directional preference: A systematic review
2012, Manual Therapy
Centralization is a symptom response to repeated movements that can be used to classify patients into sub-groups, determine appropriate management strategies, and prognosis. The aim of this study was to systematically review the literature relating to centralization and directional preference, and specifically report on prevalence, prognostic validity, reliability, loading strategies, and diagnostic implications. Search was conducted to June 2011; multiple study designs were considered. 62 studies were included in the review; 54 related to centralization and 8 to directional preference. The prevalence of centralization was 44.4% (range 11%–89%) in 4745 patients with back and neck pain in 29 studies; it was more prevalent in acute (74%) than sub-acute or chronic (42%) symptoms. The prevalence of directional preference was 70% (range 60%–78%) in 2368 patients with back or neck pain in 5 studies. Twenty-one of 23 studies supported the prognostic validity of centralization, including 3 high quality studies and 4 of moderate quality; whereas 2 moderate quality studies showed evidence that did not support the prognostic validity of centralization. Data on the prognostic validity of directional preference was limited to one study. Centralization and directional preference appear to be useful treatment effect modifiers in 7 out of 8 studies. Levels of reliability were very variable (kappa 0.15–0.9) in 5 studies. Findings of centralization or directional preference at baseline would appear to be useful indicators of management strategies and prognosis, and therefore warrant further investigation.
Influence of Directional Preference on Two Clinical Dichotomies: Acute Versus Chronic Pain and Axial Low Back Pain Versus Sciatica
2012, PM and R
Citation Excerpt :
Directional preference (DP) refers to that single centralizing direction of testing, for example, flexion, extension, side-glide, or rotation. The inter-rater reliability for eliciting CP and DP is excellent (agreement 90%, κ = 0.79-1.0) [32-39] but only for practitioners who have passed a credentialing examination from The McKenzie Institute. CP and DP are clinical findings that have been shown to transcend classifications and are commonly elicited across all 3 QTF duration and the first 4 QTF pain location and neurologic status categories [36,40-48].
To determine whether outcomes from treatment determined by subjects' directional preference (ie, reduction in back and/or leg pain, by performing a single direction of repeated end-range lumbar movement) would vary based on pain duration, location, or neurologic status.
A secondary analysis of data from a multicenter randomized clinical trial.
Eleven physical therapy departments or clinics in 5 countries, with referrals for both acute and chronic low back pain.
Seventy-one of 80 subjects with acute to chronic low back pain, and with and without radicular leg pain, and with or without mild neurologic deficit, were found at baseline to have a directional preference and were then treated with directional exercises that matched their directional preference.
All of the subjects were treated for 2 weeks with directional exercises and compatible posture modifications. Independent variables were pain duration, pain location, and neurologic status.
Primary measures were back and leg pain intensity and function (Roland Morris Disability Questionnare). Secondary measures were activity interference, medication use, depression (Beck Depression Inventory), and a self-report of improvement.
The subjects significantly improved their back and leg pain intensity, disability, and all secondary outcome measures, but pain duration, location, and neurologic status classification did not predict treatment responsiveness. Across all pain duration categories, 91%-100% either improved or resolved completely. There also was significant improvement across all pain location and neurologic status categories, with no significant differences across the outcome variables.
In subjects found to have a directional preference who then treated themselves with matching directional exercises, neither pain duration nor pain location and neurologic status predicted their uniformly good-to-excellent outcomes.
McKenzie Method
2012, Evidence-Based Management of Low Back Pain

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Andrew Roberts qualified at Birmingham University Medical School in 1980 and has trained in orthopaedics since 1985. He is currently spinal research Fellow at Harlow Wood Orthopaedic Hospital, Nottingham.

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

Summary

Section snippets

The New Collins Concise Dictionary of the English Language

‘A more precise diagnosis for low-back pain’

Spine

‘The reliability of selected techniques in clinical arthrometrics’

The Australian Journal of Physiotherapy

‘Using physical measurements to assess low back pain’

The Journal of Musculoskeletal Medicine

The Lumbar Spine: Mechanical diagnosis and therapy