lntertester Reliabilitv of the McKenzie Evaluation in ~ssesskg Patients With Mechanical low-~ack-pain

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1 Journal of Orthopaedic & Sports Physical Therapy 2OOO;3O (7) :368-%B lntertester Reliabilitv of the McKenzie Evaluation in ~ssesskg Patients With Mechanical low-~ack-pain Helen Razmjou, BScfPT), MSc, Cred. MDT1 john E Kramer, BScP7; MA, PhD2 Riki Yamada, DipP'I; DipO7; DipMDT3 Journal of Orthopaedic & Sports Physical Therapy 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: htients 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 ( years), composed of 25 women and 20 men with acute, subacute, or chronic low back pain were examined. The agreement between raters for selection of the McKenzie syndromes was K = 0.70, and for the derangement subsyndromes was K = Interrater agreement for presence of lateral shift, relevance of lateral shift, relevance of lateral component, and deformity in sagittal plane was K = 0.52, 0.85, 0.95, and 1.00, respectively. lntertester agreement on syndrome categories in 17 patients under 55 years of age was excellent, with K = Conclusions: A form of low back evaluation, using patterns of pain response to repeated end range spinal test movements, was highly reliable when performed by 2 properly trained physical therapists. 1 Orthop Sports Phys Ther 2000;30: Key Words: lumbar spine, McKenzie therapists, reliability Staff physical therapist, Orthopaedic and Arthritic Institute, Sunny Brook & Women's College Health Sciences Centre, Toronto, Ontario, Canada. School of Physical Therapy, Faculty of Health Sciences, Elborn College, University of Western Ontario, London, Ontario, Canada. Senior physical therapist, York County Hospital, Newmarket, Ontario, Canada. This study received ethics approval from the University of Western Ontario and the Orthopaedic and Arthritic Hospital Human Ethics Research Committees. Send correspondence to Helen Razmjou, Orthopaedic and Arthritic Institute, 43 Wellesley Street East, Toronto, Ontario, Canada M4Y 1 HI. helen.razmjou@swchsc.on.ca T he importance of establishing a clinical diagnosis prior to treatment has received increased attention by physical therapists as a means of clarifying practice and facilitating communication between colleagues and patient^.^^.^^ Selecting a clear clinical diagnosis is important in establishing the rationale for patient management and the determination of prognosis, as well as for the determination of change in the patient's status. Approaches to diagnostic classification of patients with low back pain (LBP) have been developed based on the patient's anatomical, pathological, or clinical presentation. Various frameworks for classifying patients with LBP have been suggested.2.4.1j.l~1rr21.22 A clinical picture of each diagnostic category is usually based on the involved anatomical structure(s), signs and symptoms, or changes in symp toms, in response to certain test movements. A standardized system of classification of spinal disorders, recommended by the Quebec Task Force (QTF), supports the concept of classifying nonspecific spinal disorders by identifying pain

2 patterns that are based on clinical signs and the locations of symptoms.22 The first 4 categories of the QTF are very similar to the derangement subsyndromes described by McKenzie.IS Recent studies have addressed the reliability and benefits of an assessment method that identifies the location and the intensity of the patient's symptoms in relation to movements and positi~ns.~j~j~ Physical therapists using the McKenzie system classify the patient's symptoms as "nonmechanical" or "me~hanical."~~ Symptoms associated with inflammatory conditions, medical conditions, and nonorganic pain may be classified as "nonmechanical." Mechanical symptoms in the McKenzie classification system are those that are consistently influenced by movements and positions. These symptoms are then classified into one of the 3 syndromes: postural, dysfunction, or derangement (Appendix A). Postural syndrome is pain caused only by prolonged end-range stretch of structures in the back and can occur in sitting, standing, or lying. Dysfunction syndrome is thought to be caused by the stretching of sensitive, adaptively shortened structures and has subsyndre mes based upon the end-range direction that elicits this pain: flexion, extension, side-glide, and multidirectional subsyndromes. Adherent nerve root syndrome and nerve root entrapment syndrome are also considered to be subsets of dysfunction (Appendix A). Derangement syndrome includes 7 different sub syndromes which are identified by location of pain and presence, or absence, of deformities (Appendix B) Classification is based, in part, on the patient's previous history and on the information the therapist collects during the assessment (Figure 1). A descrip tion of components of the McKenzie assessment include a specific style of gathering patient history and observational analysis for the presence of spinal deformities. Physical therapists using the McKenzie method identify rapid changes in range of motion, as well as location and intensity of symptoms as a result of sustained posture and a repeated end-range movement examination.'" Although the systematic method of examination outlined by McKenzie is thought to minimize the variability between examiners, there is little evidence to support the reliability or validity of the McKenzie evaluation system in classifying patient conditions or syndromes. Previous studies5j0j9 did not find the McKenzie system reliable in detecting either the lateral shift or end-range pain. The low interobserver reliability in the detection of a flat, or kyphotic, lumbar spine is in agreement with findings of Nelson et al,'%ho found that classification of lordosis and tilt (lateral shift) had a high intertester error. One important pattern of pain commonly elicited during a McKenzie evaluation is the centralization phenomenon, a change in a proximal direction of the I) Symptom not produced by repeated urt movements 2) Symplom produced by prolonged posmrcs I Classification Algorithm I DX3. DI5 I) Quick chge m pin location Deformity of Lumbar 2) Pam during Movement Kyphorb 3) May or m y not have a Dmngemmt deformity Deformity of 4) bnge of motion improved as oam cmml~abolished Incred Lordosis 5) Symptom usually kner or worse as a result ofrepeated test movements I) Pain only produced a full end range 2) Symptom not worn or kner as a mull oftnt movements 3) So quick change in the nngc of Syndrome motion I) Symptom not reproduced by repeated spinal test movements or Flexion, Extmslon, S~dc-ghde, Mult~dacctlo~~, Adherent nme rms Entrapment Nomhanral Low Back Pam FIGURE 1. Algorithm for McKenzie classification of low back dysfunction. D indicates derangement (Appendix A). most distal symptoms that typically occurs during the performance of a repeated movement testing. Accurately identifying the diagnostic subsyndrome of derangement (Appendix A) depends upon simultaneous observation of these changes by the examiners. For example, in the study reported by Riddle and Roth~tein,'~ every patient completed 2 separate, lengthy assessments involving a great deal of repeated movements (provocative or reductive procedures), which could have changed the symptoms between the assessments and might have contributed to a finding of poor reliability. Riddle and RothsteinIg concluded that the intertester reliability of the partially-trained examiners was as poor as that observed for untrained examiners. They used 33 untrained physical therapists and 16 therapists who had only partial training in McKenzie methods. Although general criteria for classification into syndromes and sub syndromes were provided by the authors,i9 there ap peared to be a considerable overlap among diagnos tic syndrome and subsyndrome categories among untrained therapists. For example, some subjects who J Orthop Sports Phys Ther.Volume 30- Number 7.July 2000

3 were diagnosed with "postural syndrome" by one examiner, were classified in the derangement syndrome category (derangements 2, 3, 4, 6, and 7) by the other examiner. McKenzieIJ clearly states that in "postural syndrome" there is no referred pain, no deformity, and no pain with test movements. Patients with derangement 2 syndrome, however, present with a severe deformity of kyphotic lumbar spine. As a result of the blockage of movement in this syndrome, the patient cannot straighten up. Patients with derangement 4 or 6 present with a significant deformity of the lateral shift with or without leg pain, and those with derangement 7 present with the deformity of increased lordosis. The data from partially trained examiners, reported by Riddle and Rothstein,lY had less variability between examiners with respect to selecting the diagnostic syndromes and subsyndromes. Most of the disagreements were among the derangement subsyndromes. In the study performed by Kilby et al,i0 the confounding influence that multiple examinations of the patients could have introduced on the identification of the patient's syndrome was eliminated by single assessment. An algorithm was used to simplify the McKenzie evaluation. The partially-trained examiners were asked by an adjudicator to answer certain questions on each appropriate point in the algorithm. As the algorithm branched toward periphery, the number of observations were reduced and insufficient data were collected for most of the components of the assessment. Kilby et all0 concluded that the strong point in the McKenzie evaluation was the level of agreement (90%) on interpreting pain behavior. Inconsistency among the testing protocols, variability in the methods used to select patients, and the expertise of the examiners limits the generalization of the reliability results from previous studie~."~~'j~ The McKenzie Institute offers a series of 4 sequentially organized courses (A-D) to teach practitioners the complete system of evaluation and therapy. The completion of all 4 parts and the credentialing examination are recognition of attainment of a minimum level of competence in mechanical diagnosis and therapy. The highest level of proficiency can be attained with an additional 11-week diploma program. The results of the previous ~tudies,".~".'" therefore, may not apply to trained practitioners or be representative of the McKenzie evaluation system. The purpose of this study was to evaluate the interexaminer agreement between 2 qualified McKenzie examiners in determining diagnostic syndromes, and subsyndromes using McKenzie methods, in assessing patients with back pain. A secondary purpose was to determine the interexaminer agreement on the observation and relevance of sagittal and frontal plane deformities. METHODS Subjects Adult patients with a history of acute (<7 days), subacute (>7 days < 7 weeks), or chronic (>7 weeks) low back pain were included in the study. Patients were referred by general practitioners or specialists for assessment and treatment to the Outpatient Department at the Orthopaedic and Arthritic Hospital (Toronto), where the study was conducted. Their onset of back pain was either of a slow or sudden origin, with or without radiation into the lower extremities. Individuals meeting any of the following criteria, as determined by medical records, telephone interview, and neurological screening before assessment or during formal examination, were excluded: (1) previous spinal or hip surgery; (2) diagnosis of advanced spinal stenosis associated with neurological signs, tumor, or systemic disease, pathologies of weakness and instability such as fracture, rheumatoid arthritis, and advanced spondylolisthesis (grade 3 or higher)"; (3) constant severe leg pain with neurological deficits as a result of severe nerve root compression such as muscle weakness, saddle anesthesia, or bladder weakness; (4) individuals who were not fluent in English; (5) individuals who were receiving Workers' Compensation at the time of assessment; and (6) those who were pregnant. All subjects gave written informed consent prior to participating. The study received ethics approval from the University of Western Ontario and the Orthopaedic and Arthritic Hospital Human Ethics Research Committees. Examiners Two examiners, one with 12 years of clinical experience and one with 24, performed the evaluations. The leastexperienced examiner (H.R) was credentialed by the McKenzie International Institute in The more experienced examiner (RY) had been a faculty member of the McKenzie International Institute since 1986 and held a diploma in Mechanical Therapy and Diagnosis (1991). She had been an instructor of the McKenzie courses for 8 years ( ). Evaluation Instruments Questionnaire A history questionnaire (Appendix C), based on the original McKenzie form, was developed to standardize the format of the questions that examiners asked the subjects. The questionnaire included all the components of the original McKenzie form,'> but attempted to prevent leading questions or verbal clues by the assessor. 370 J Orthop Sports Phys Ther-Volume 30.Number 7-July 2000

4 FIGURE 2. Test set up: the curtain was pulled to separate the examiners during the assessment. A. Adjudicator sat in the chair at the top right corner. 0. Footprints used during postural appraisal. C. Footprints used during test movement performance. D. Bright wall with 3 vertical lines marked on it. E. Spot used to determine the presence or absence of the spinal deformities. Data coktion fm Similarly, a data collection form (Appendix D), based on the original McKenzie form, was developed, reflecting McKenzie's descrip tion of the examination procedure.ig The diagnostic categories, however, were expanded to subsyndromes to facilitate use of the form. The category of "other" included inflammatory and nonmechanical conditions, where pain was not presumed to originate from the spine, nor was it changed by maintaining postures or performing spinal movements. Procedures For practice, 4 patients were assessed using the proposed methodology and their results were reviewed by the 2 examiners. The data collected from these patients were not included in the final data set. Since repeated examination may change pain location and, consequently, the classification category, a concurrent examination was performed for evaluating the consistency of examiner judgements. The examiners were randomly assigned to be the observer and assessor, so that each examiner was an assessor in 50% of the cases. The assessor examined the patient; the observer watched and took notes. The examiners were separated by a curtain so that they were unable to see each other during the history taking and specific test examination components of the assessment. After completion of the history taking, and before specific test examination, they stood up and the visual appraisal of the patient's posture was done from the same spot (Figure 2). An independent adjudicator (staff physical therapist or physical therapy student) was used for 4 reasons: (1) to ensure that examiners did not communicate with each other. The adjudicator was positioned so that both examiners could be observed (Figure 2); (2) to demonstrate test movements or apply simple manual techniques requested by the assessor such as giving overpressure or adding side glide in lying or standing (these assessment techniques are routinely used in the process of examination to apply external forces to the patient's back when patientgenerated forces do not sumiciently affect symp toms); (3) to eliminate biasing information that the assessor could have gathered through physical contact with the patient while performing the side-glide test, which is done with hands on the patient to guide motion and to check for blockage of the frontal movements; and (4) to collect the data collection forms at the end of each assessment, so that the examiners could not see the diagnosis on each others forms. Physical Examination The examination consisted of taking a history (verbally), observational evaluation of the spinal range of motion, and completion of specified test movements in the sagittal (flexion, extension); frontal (sideglide) ; and combined planes (rotation). The subjects were only allowed to communicate with the assessor. During the physical examination, the subjects stood against a bright wall with 3 vertical lines marked on it (Figures 2, 3, and 4). Two pairs of footprints were used to mark the location of the patient's feet on the floor during postural appraisal and test movement performance. The subject's back was exposed to the level of the S1 spinal segment. Visual appraisal of the patient's posture was performed by the examiners from the same spot (Figure 2), to determine the presence or absence of an observable lateral shift, defined as the deviation of the trunk in relation to the pelvis. This deviation was measured between C7S1 by visual estimation. The therapists independently recorded the presence or absence of the centralization phenomenon, relevant lateral component (Appendix B), and deformities in the sagittal or frontal plane. At the end of each assessment, both examiners completed the datacollection forms. The datacollection forms were sealed in an envelope. The examiners were instructed not to share their views about each case until data collection for the entire study was completed. Data Analysis Cohen's' Kappa (K) was used to measure interexaminer agreement in choice of diagnostic syndrome, subsyndrome, detection of sagittal or lateral plane deformities, and their relevance to the subject's present symptoms. The number of categories associated with each of the examiner's classifications are summarized in Table 1. When evaluating a patient, it can sometimes happen that more than one diagnostic J Orthop Sports Phys Ther-Volume 30.Ni11nber 7.Julv 2000

5 FIGURE 3. Anterior view, left lateral shift. category may be exhibited. A decision was made a priori to analyze only the cases with a primary diagnosis, whereby the patient presented with underlying dysfunction, derangement, or other nonmechanical conditions. Regarding ranges of K, when obtained agreement is equal to chance agreement, K = 0, greater than chance agreement leads to positive values of K, and less than chance agreement leads to negative values. The upper limit of K is 1.00, and occurs when there is perfect agreement between the judges. Standard errors (Se), confidence Limits (CL), and Z values were calculated to indicate sampling distribution and to test K values for significance of the difference. Strength of agreement was interpreted as follows: <-0.20 = Strong Systematic Disagreement; through = Potential Systematic Disagreement; = Weak; = Slight; = Moderate; = Good; = Very Good; and = Excellent. Percentage of agreement was calculated as the following: number of cases agreed on divided by total number of cases multiplied by 100. This was done to compare the present data to previous studies that did not provide the K values. FIGURE 4. Posterior view, left lateral shift. RESULTS Forty-eight consecutive patients presenting with LBP were screened. One patient was excluded due to having lumbar fusion and a second patient was excluded due to having Rheumatoid Arthritis. A total of 46 patients (23-75 years of age) with a history of low back pain agreed to complete the assessment. One subject was excluded from the study due to multiple neurological findings. As a result, data for 45 subjects, 25 women and 20 men ( years), were collected. Demographic information about the patients is summarized in Table 2. Table 3 summarizes the interexaminer agreements, both in terms of K and percent agreement for syndromes, derangement subsyndrome, presence and relevance of lateral shift, relevance of lateral component, and deformity in the sagittal plane. Forty-one patients had previous history of LBP, dating from 9 months to 57 years. The disagreement with respect to syndrome classification (Table 4) was on one patient with subacute and 2 patients with chronic symptoms. All the patients with acute symptoms were classified as having derangement syndrome. The derangement syndrome was also the primary diagnosis for patients with subacute symptoms (1 postural, 1 dysfunction, and 16 de- J Orthop Sports Phys Ther.Volume SO Number 7.July 2000

6 TABLE 1. McKenzie assessment hierarchy and diagnostic categories. Number of choices Cateeories Global variables Syndrome 4 1. Postural 2. Dysfunction 3. Derangement 4. Other Subsyndrome Postural 2-1. Flexion 2-2. Extension 2-3. Side-Glide 2-4. Multidirectional 2-5. Adherent Nerve Root 2-6. Nerve Root Entrapment 3-1. Derangement 11 (Dl) 3-2. Derangement 12 (D2) 3-3. Derangement 13 (D3) 3-4. Derangement 14 (D4) 3-5. Derangement 15 (DS) 3-6. Derangement 16 (D6) 3-7. Derangement 17 (D7) 4. Other Specific test variables Presence of lateral shift 2 0. No 1. Yes Relevance of lateral shift 2 0. No 1. Yes A Relevance of lateral component 2 0. No m 1. Yes V) Deformity of sagittal plane (kyphosidincreased lordosis) 2 0. No m 1. Yes > A rangement syndromes) and chronic symptoms (1 dysfunction, 19 derangement). Because concomitant degenerative conditions in elderly people may confound the examination, patients were divided into 2 groups, those 55 years of age or older, and those younger than 55. Seventeen subjects (38%) were 55 years of age or older and 28 (62%) were younger than 55 years of age. All 3 of the disagreements (Table 4) for selecting the syndrome categories, were seen in older subjects (59-72 years of age), who presented with unclear patterns of centralization. Interexaminer agreements on syndrome categories in patients under 55 years of age (28 observations) were higher, and, in fact, perfect with K = TABLE 2. Characteristics of patients. Number of subjects Sex Women 25 Men 20 Age group 55 years of age or older <55 years of age Symptom duration Acute: <7 days Subacute: >7 days < 7 weeks Chronic: >7 weeks The majority of patients (86.7% for examiner 1 and 88.9% for examiner 2) were classified as exhibiting the derangement syndrome (Table 4). The 3 disagreements between examiners were all related to examiner 2 classifying a patient as "Other" when, with 2 of those patients, examiner 1 rated the syndrome as "Dysfunction" and for the third rated the syndrome as "Derangement." The frequency of classification of the type of sub syndrome is shown in Table 5. No evaluation of in- TABLE 3. Summary table of Kappa coefficients. Cate- Pergories cent of psi blel agree- Interpretaobserved K ment tion of K Global variables Syndrome % Good Derangement % Excellent subsyndrome Specific test variables Presence of lateral shift 2R % Moderate (yeslno) Relevance of lateral % Very good shift (yedno) Relevance of lateral 2R % Excellent component (yeslno) Deformity of sagittal OO 100 /o Excellent plane (yeslno) J Orthop Sports Phy Ther.Volume 30 Number 7.July 2000

7 TABLE 4. lnterexaminer agreement for the type of syndrome. TABLE 5. Frequency of classification of the type of subsyndrome. I Examiner 2 I Diagnosis Portunl Dyslunnion Iknagemenl Other Total Postural I I I I LByslunclion 2 2 Derangement Other Journal of Orthopaedic & Sports Physical Therapy K = Standard error (Se) = % Confidence Limits (CL) Z = 2.55, K significant at P <.001. Percent Agreement 93%. Se = Standard error of estimate for K, which can be thought of as the standard deviation of the sampling distribution of K. 95% CL is the 95% confidence limits associated with K. mat is, we are 95O/0 certain that the true K is between these two values.) Z = the normal approximation of K, derived to evaluate the rarity of the agreement under the null hypothesis of chance agreement (K = 0 and Z = 0). tertester agreements for subsyndromes associated with dysfunction syndrome was done due to low incidence rates. The pattern of classifications for the derangement subsyndrome are summarized in Table 6. Examiners' derangement subsyndrome classifications were predominately Derangement 3 (51.3% and 48.7%) followed by Derangement 1 (20.5% and 23.1%), Derangement 5 (20.5% and 20.5%), and Derangement 4 (7.7% and 7.7%). The single disagreement between examiners resulted when examiner 1 classified a patient as Derangement 3, while examiner 2 classified that patient as having a Derangement 1 syndrome. There was no incidence of Derangement syndromes 2, 6, and 7. During the postural appraisal, examiners agreed on the presence of the lateral shift 78% of the time (K = 0.52) (Table 3). The incidence of lateral shift was 24.4% for examiner 1 and 42.2% for examiner 2. The one disagreement (22%) resulted from one case where examiner 1 classified a patient as having a lateral shift while examiner 2 did not, and from 9 cases when examiner 2 classified patients as having a lateral shift and examiner 1 did not. With respect to relevance of lateral shift (Table 3). examiners agreed 98% of the time (K = 0.85, indicating very good agreement). The incidence of lateral shift relevance was 6.7 % for examiner 1 and 8.9% for examiners 2. The one disagreement (2%) resulted from a case where 1 examiner classified the patient as having a relevant lateral shift when the other examiner did not. There was 98% agreement on the relevance of lateral component (K = 0.95). This indicates "excel- - Dx indicates Diagnosis; Pos, Postural; FD, Flexion Dysfunction; ED, Extension Dysfunction; SGD, Side-Glide Dysfunction; MDD, Multi-Directional Dysfunction; ANR, Adherent Nerve Root; NRE, Nerve Root Entrapment; D, Derangement; Oth, Other; and Tot indicates Total. lent" agreement. The incidence of lateral component relevance was 31.1% for examiner 1 and 33.3% for examiner 2. Agreement between examiners 1 and 2 was also "excellent" for classification of deformity in the sagittal plane. Examiners evaluated only one patient (2%) as having sagittal plane deformity. DISCUSSION Type of Syndrome In the present study, all the disagreements were categorized as "other" by one examiner, and either "dysfunction" or "derangement" by the second examiner. The "other" category was defined as nonmechanical or inflammatory LBP that did not fit the McKenzie mechanical classification system. Symptoms originating from other joints may also appear to be referred from lumbar spine. Sacroiliac joint pain, for example, may have a similar location to the pain pattern associated with derangement 3 classification, but sacroiliac pain would not respond to repeated spinal movements. Kilby et allo reported 58.5% agreement on syndrome categories. Riddle and Rothstein"' reported a K value of 0.26 (percent of agreement = 39%) for selecting the diagnostic syndrome and subsyndromes (Table 7). There seems to be a considerable overlap among diagnostic syndrome and subsyndrome categories identified by examiners who have not completed McKenzie training in the previous studies.'"j!' The patient's condition was categorized into 9 syndromes; postural, dysfunction, and 7 derangements.'" 374 J Orthop Sports Phy ThereVolume 3O.Nr1mber 7.Julv 200

8 TABLE 6. lnterexaminer agreement for derangement subsyndrome. I Examiner 2 I and lung conditions that may affect the patient's performance during the testing. These observations suggest that, with older patients, the McKenzie methods may be lower than with younger patients; however, further research is required to address this question. The intertester agreement with respect to selecting the syndrome categories was perfect in patients under the age of 55. The more clear pattern of centralization in younger individuals, who make up the majority of those receiving compensation for work-related injuries, could help the assessment process, and, consequently, assist in appropriate goal-setting. Relationship Between Type of Syndrome and Symptom Duration Journal of Orthopaedic & Sports Physical Therapy K = Standard error (Se) = Confidence Limits (CL) Z = 8.27, K significant at P <.001. Percent Agreement = 97%. D indicates Derangement; Dx, Diagnosis. Adherent nerve root syndrome was considered as a separate syndrome in the classification system.i0 Mc- Kenzie,I3 however, identified only 3 mechanical syndromes: (1) postural, (2) dysfunction, and (3) derangement. He divided each of these syndromes into separate subsyndromes according to location of the pain and presence, or absence, of the spinal deformities.'" Relationship Between Type of Syndrome and Age The results indicate that interexaminer agreements on diagnostic categories in elderly patients were not as high as in younger individuals. This finding was thought to occur as a result of multiple, confounding problems in the elderly, such as osteoarthritic changes at the facet joints and lateral structures associated with annular prolapse and degenerative disc diseases; stenosis; senility; and other coexisting medical problems. These problems could include heart TABLE 7. Summary table of Kappa coefficients (previous studies). All patients with acute symptoms were classified as having a derangement syndrome. It is beyond the scope of this study to comment on whether this indicates a common pathology in patients with acute symptoms. The majority of the patients with subacute and chronic pain were also classified in the derangement syndrome. This may be indicative of recurrent acute derangements. The precise nature of the structures involved, however, remains to speculation at this point. Type of Subsyndrome The examiners in our study did not select their subsyndromes from different syndrome categories (Table 5). The data from "partially trained" examiners of the Riddle and Rothstein studyl%ad far less variability between examiners than the "untrained" examiners, and most of their disagreements were among the derangement subsyndromes, consistent with the results of the present study. Kilby et all0 reported 57% agreement (n = 41) on derangement subsyndromes. The number of cases was, however, too small to allow much generalization on other components of the evaluation such as detection of the deformities (n = 5 for sagittal plane deformity and n = 9 for the deformity of the lateral shift). The apparent lack of un- Percent of agree- Authors Variable K ment Interpretation Kilby et all0 Syndrome categories Not given 58.5% Not given Kilby et all0 Derangement subsyndromes Not given 57% Not given Kilby et all0 Presence of lateral shift Not given 55% Not given Kilby et all0 Presence of sagittal plane deformities Not given 80% Not given Riddle & Rothsteinlq Syndromdsubsyndrome % Slight Riddle & Rothsteintg Syndromdsubsyndrome (partially trained PTs) % Weak Riddle & RothsteinIq Presence of lateral shift % Slight Donahue et a15 Presence of lateral shift % Potential systematic disagreement Donahue et a15 Relevance of lateral shift % Weak J Orthop Sports Phys Ther.Volnme 30.N11mber 7.J11lv

9 derstanding of the definition of diagnostic syndromes and subsyndromes among untrained examiners may have resulted in low interexaminer reliability. Thus, the results of the previous studies may not generalize well to cases where the examiners are trained as "McKenzie practitioners" at the certified or diplomat level. Deformity in Frontal Plane Observational analysis of the presence of lateral shift (Appendix B) is the first step in detecting the frontal plane spinal deformities.ig The K values reported by previous studies5j9 for presence of lateral shift were 0.00 and 0.26, with percent of agreement of 43%, and 60%, respectively. Kilby et all0 reported 55% agreement between therapists with respect to presence of lateral shift (Table 7). The higher agreement noted in this study may be attributable to using the 3 vertical lines on the wall behind the patient during postural appraisal (Figures 3 and 4) and measurement of trunk deviation between C7S1 versus LlS1, which was measured by Donahue et al.5 Lateral shift, as it was described by McKenzie,13 is the deviation of trunk in relation to pelvis, and should be measured between C7S1 rather than L1Sl. Detection of small lateral shifts between LlSl is very difficult by visual estimation. For this reason, Donahue et a15 used instruments (bubble level, ruler, and adhesive markers) to examine the presence, direction, and magnitude of the lateral shift more consistently. However, doing so did not appear to improve the ability to detect these shifts. Data obtained "visually" for assessing lateral shift or range of motion are cues that are considered, but not exclusively used, in the determination of a Mc- Kenzie classification. Classification relies more heavily on the relationship between the subjective information and the repeated movement portion of the assessment that affects the pain pattern. Relevance of Lateral Shift It is imperative to detect a relevant lateral shift during the assessment because this affects the selection of a diagnostic category and, consequently, the treatment management. According to McKenzie,l3 one of the major goals of the assessment is to determine whether any detected lateral shift is relevant to the patient's current complaints. This is determined using repeated test movements. If the lateral shift is missed, the lateral component would not be addressed and treatment may be ineffective or may aggravate sympt~ms.'~j~ In our study, the relevance of lateral shift was assessed with sideglide test movements, while carefully monitoring the patient for a centralization response during these movements. Donahue et a15 reported 47% agreement (K = 0.16) for the relevance of the lateral shift. The side-glide test was used by these authors to examine the relevance of the lateral shift. Therapists were able to reliably determine the alteration of the location and intensity of the pain with this test (K = 0.74), but they were not able to interpret and use this information for detection of shifts and the presence (K = 0.00) and the relevance (K = 0.16) of lateral shift. The poor correlation between the results of the side-glide test and determination of presence and relevance of lateral shift among untrained therapists highlights the importance of proper training in interpretation of the components of the McKenzie evaluation system such as the side-glide test. The results of the previous studies5j9 may be due to the fact that the examiners either relied on the observational analysis only, or the blind examination of bilateral side-glide movements for the relevance of the lateral shift. Relevant "Lateral Componentff In the McKenzie evaluation system,13 the reported pain in derangements 3 and 5 (Appendix A) is unilateral or asymmetrical. In this model, patients with unilateral symptoms do not necessarily present with an obvious postural deformity of lateral shift. In the majority of these patients, the lateral component is considered to be insignificant and centralization can be achieved simply by performing extension exercises. Conversely, if unilateral or asymmetrical symptoms worsen or peripheralize with sagittal movements (flexion or extension), there is a strong possibility that procedures such as side-glides or rotational movements (Appendix B) are required in the treatment. In our study, there was "excellent" agreement on the relevance of lateral component. Although this component of the examination is very important clinically for identifying the correct syndrome and subsyndrome classification, and for determining the principles of treatment, relevance of the lateral component has not been addressed in previous studies. If symptoms worsen or peripheralize with both flexion and extension movements, the possibility of a relevant lateral component, lateral blockage, or an undetected shift should be considered.'j4 Deformity in Sagittal Plane Individuals of different sex and racial backgrounds tend to have varying degrees of lumbar lordosis. A deformity in the lumbar spine is a change in the spinal curve that cannot be reversed by active movements (Appendix B). For example, a kyphotic deformity in the lumbar spine is caused by blockage of extension as a result of inability to cross the midline in J Orthop Sports Phys Ther.Volume 30. Number 7.July 2000

10 the sagittal plane. A deformity of lordosis is defined as a blockage of flexion that presents as an inability to cross the midline in the sagittal plane.i4 The examiners in our study agreed on the absence of the sagittal plane deformities on 44 patients and on the presence of the deformity of lumbar kyphosis on one patient who had derangement 4 (which sometimes presents with a deformity of kyphosis and scoliosis at the same time). It may be argued that homogeneity of the sample may have artificially inflated the K value. The imbalance of the frequency counts in the K cells, however, is due to specific definition of the sagittal plane deformities described by Mc- Kenziels and the low prevalence of the derangements 2 and 7, in general. The percent of agreement reported by Kilby et all0 was 80% for detection of the flat, or kyphotic lumbar spine. The number of observations, however, was only 5 and was considered insufficient for any statistical analysis. Limitations Our study was limited to 45 subjects who had been referred to a single hospital, by a group of local physicians. For these reasons, the extent to which the patients included are representative of all patients with LBP is unclear. We noted that there were no patients with derangements 2, 6, and 7. The results on the intertester reliability of the subsyndromes associated with the "dysfunction" syndrome suggests good agreement, but the number of cases presented with this particular syndrome is too small to allow much generalization. Both examiners in our study had several years of experience using McKenzie techniques. The interexaminer agreement among examiners who are qualified, but have different levels of experience, needs to be determined. CONCLUSION Therapists trained in the use of the McKenzie evaluation system can be highly reliable in reaching the same conclusion with respect to classifying patients into diagnostic syndromes and subsyndromes, especially in patients under the age of 55. In contrast to other published studies, the high intertester agreement found with our examiners for certain components of the evaluation procedure such as presence and relevance of the sagittal and frontal plane deformities, emphasizes the importance of advanced training for interpretation of symptom behavior, leading to selection of the correct diagnosis. ACKNOWLEDGMENTS The authors acknowledge and thank Dr Kevin Spratt for his extensive contribution in constructing the strength of agreement classification categories and for his other statistical support. We thank Audrey Long for her valuable contribution and constructive comments. We also thank the following individuals: Deborah Kennedy, Colin Davies, and Linda Woodhouse for their interest and valuable ideas; Andrea Bean for her assistance in data tabulation; Don Newel1 for posing for the photographs; Grifith Mercer for his illustrative assistance; Sharon Thornton and JoAnne Piccinin (the Director of the Rehabilitation Department at the Orthopaedic and Arthritic Institute of the Sunnybrook and Women's College Health Sciences Centre) for their continuing support and encouragement throughout the study. REFERENCES 1. Cohen J. A coefficient of agreement for nominal scales. Educational and Psychological Measurement ;20: Cyriax J. Fibrositis. Br Med). 1948;2: Dekker I, Van Baar ME, Curfs EC, Kerssens JJ. Diagnosis and treatment in physical therapy: an investigation of their relationship. Phys Ther. 1993;73: Deyo RA. Early diagnosis evaluation of low back pain. ) Gen Intern Med. 1986;1: Donahue Ms, Riddle DL, Sulivan MS. Intertester reliability of a modified version of McKenzie's lateral shift assessments obtained on patients with low back pain. Phys Ther. 1996;76: Donelson R, Silva G, Murphy K. The centralization phenomenon: its usefulness in evaluating and treating referred pain. Spine. 1990;15: Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: a prospective, randomized, multicentered trial. Spine. 1991;16:S Donelson R, Aprill Ch, Medcalf R, Grant W. A prospective study of centralization of lumbar and reffered pain: a predictor of symtomatic discs and anular competence. ) Orthop Sports Phys Ther. 1997;22: Jette AM. Diagnosis and classification by physical therapists: a special communication. Phys Ther. 1989;69: Kilby J, Stigant M, Roberts A. The reliability of back pain assessment by physiotherapists, using a "McKenzie algorithm." Physiother. 1990;76: Kopp JR, Alexander AH, Turocy, RH, Levrini MG, Lichtman DM. The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. Clin Orthop. 1986;202: Long AL. The centralization phenomenon: its usefulness as a predictor of outcome in conservative treatment of chronic low back pain (a pilot study). Spine. 1995;20: McKenzie RA. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publication Limited; McKenzie RA. Mechanical Diagnosis and Therapy Manual (Pdrt D, Advanced Problem Solving Practical Workshop). NewMarket, Ontario: The Robin McKenzie Institute Canada; Mooney V. The syndromes of low back pain. Orthop Clinics. 1983;14: Nelson MA, Allen P, Clamp S, DeDombal F. Reliability J Orthop Sports Phys Ther.Volume 30. Number 7.July 2000

11 and reproducibility of clinical findings in low back pain. Spine. 1979;4: O'Donoghue DH. Treatment of Injuries to Athletes. 4th ed. Philadelphia, Pa: WB Saunders Co; 1984:402. Porter RW. Mechanical disorders of the lumbar spine. Ann Med. 1989;21: Riddle DL, Rothstein JM: intertester reliability of Mc- Kenzie's classifications of the syndrome types present in patients with low back pain. Spine. 1993;18: Sahrmann SA. Diagnosis by the physical therapist-a prerequisite for treatment: a special communication. Phys Ther. 1988;68: Saunders HD. Classification of musculoskeletal spinal conditions. ) Orthop Sports Phys Ther. 1979;1:3-15. Spitzer W. Scientific approach to the assessment and management of activity-related spinal disorders: a monograph for clinicians, report of the Quebec Task Force on spinal disorders. Spine. 1987;12:9-54. APPENDIX A Diagnostic Syndromes, Subsyndromes and Their Clinical Presentations, McKenzieI3 1. Postural Syndrome Age: usually 30 years and under Poor posture; no movement loss Intermittent, local pain, better when on the move "Repeated movements" do not reproduce the pain originated from postural syndrome Pain can "only" be reproduced by sustained positions or posture Not progressively worse; no rapid changes in symp toms 2. Dysfunction Syndrome a. Flexion Dysfunction Syndrome Age: usually over 30, unless trauma or derangement is the causative factor May present with poor posture, and the patient always has a loss of movement or function Intermittent pain, only at end range of flexion No pain during movement; no radiation Repeated movements reproduce pain at end range of flexion, but pain is not worse as a result of repeated flexion Not progressively worse; no rapid changes in symp toms b. Extension Dysfunction Syndrome Age: usually over 30, unless trauma or derangement is the causative factor Poor posture, and the patient always present with a loss of movement or function Intermittent pain, only at end range of extension No pain during movement; no radiation of symp toms Difficulty sleeping in prone position Repeated movements reproduce pain at end range of extension; symptoms are not worse as a result of repeated extension Not progressively worse; no rapid changes in symp toms c. Side-glide Dysfunction Syndrome Age: usually over 30, unless trauma or derangement is the causative factor Poor posture, and the patient always present with a loss of movement or function Intermittent pain, only at end range of sideglide No pain during movement; no radiation of symp toms Repeated movements reproduce pain at end range of sideglide, but pain is not worse as a result of repeated sideglide Not progressively worse; no rapid changes in symp toms d. Multidirectional dysfunction Clinical presentation and principles of treatment depend on the direction of dysfunction (please see single-plane dysfunction subsyndromes) e. Adherent Nerve Root Intermittent sciatica Flexion in standing produces leg pain, which stops upon return to the upright position Flexion in lying has no effect on symptoms Repeated extension has no effect on symptoms Leg symptoms are produced at end range of flexion in standing The symptoms do not remain worse after the test movements are stopped 378 J Orthop Sports Phy Ther.Voliime 3O.Number 7-July 2000

12 f. Nerve Root Entrapment No postural deformity Long standing, constant radicular-type pain or par- ' flexion usually increases the pain aesthesias Pain may remain worse as a result of repeated flexion Repeated extension usually decreases the pain, if ~e~eated flexion may ~duce the pain temporarily* pain dose not decrease or centralize with extenbut no better as a result sion, then side-glide with extension decreases the Range increases temporarily pain Repeated extension may increase symptoms tempokrily, but the patient does not remain worse after testing d. Derangement 4 3. Derangement Syndrome Usually constant unilateral or asymmetrical pain, with or without buttock or thigh pain a. Derangement 1 Deformity of sciatic scoliosis (lateral shift) Central/symmetrical pain, rarely buttock or thigh pain No postural deformity Repeated flexion usually increases; peripheralizes pain Pain often remains worse as a result of repeated flexion Repeated extension usually reduces, centralizes, and abolishes the pain Pain usually remains better as a result of repeated extension b. Derangement 2 Usually constant central or symmetrical pain, with or without buttock or thigh pain Deformity of lumbar kyphosis Repeated flexion progressively increase and peripheralize the pain Pain usually remains worse as a result of repeated flexion Time factor is important in derangement two (correction of blockage in extension requires time for a successful reduction) Repeated extension, therefore, may not be possible initially Sustained positioning is attempted if a major deformity of kyphosis exists Pain initially decreases with prone lying in flexed position; derangement reduces gradually by increasing the extension in unloaded position c. Derangement 3 Unilateral or asymmetrical pain, with or without buttock or thigh pain Repeated flexion and extension usually increases and peripheralizes the pain Symptoms usually remain worse as a result of sagittal movements (flexion and extension) due to the existence of the deformity of the lateral shift Correction of lateral shift decreases and centralizes the pain If the lateral shift can be successfully corrected, extension procedures often complete the reduction of the hypothesized derangement e. Derangement 5 Unilateral or asymmetrical pain, with or without buttock or thigh pain No postural deformity Leg pain extending below knee joint (constant or intermittent sciatica) Repeated flexion usually increases; peripheralizes pain Symptoms remain worse as a result of repeated flexion Repeated extension usually decreases and centralizes pain Symptoms remain better as a result of repeated extension Repeated extension usually decrease the pain, if unsuccessful, extension with side-glide, or rotation techniques decreases the pain f. Derangement 6 Unilateral or asymmetrical pain, with or without buttock or thigh pain Leg pain extending below the knee (usually constant sciatica) Deformity of sciatic scoliosis (Lateral shift) J Orthop Sports Php Ther.Volume 30.Number 7.Julv

13 Repeated flexion and extension increase, or peripheralize the symptoms Symptoms usually remain worse as a result of sagittal movements (flexion and extension) due to the existence of the deformity of the lateral shift Correction of lateral shift decreases and centralizes the pain If the lateral shift can be successfully corrected, extension procedures often complete the reduction of the hypothesized derangement g. Derangement 7 Symmetrical or asymmetrical pain, with or without buttock or thigh pain Deformity of accentuated lordosis Repeated extension increases and may peripheralize the pain Symptoms remain worse as a result of repeated extension Repeated flexion decreases and centralizes the pain Symptoms remain better as a result of repeated flexion 4. Other Nonmechanical low back pain Pain not of spinal origin such as SI joint dysfunction 8 Inconclusive mechanical pain pattern Further clinical examination and testing is required APPENDIX B Definitions and Operational Terms Centralization Phenomenon: The term "cenmlization" describes a change in the distal-most extent of symptoms in a proximal direction or toward the midline. Centralization is the pain response that occurs only in the "derangement syndrome" when the stimulation or deformation of the pain-sensitive structures is being "reduced," using mechanical means such as static positions or repeated end-range test movements. Derangement: In this syndrome, symptoms would quickly change in intensity and in location by performance of certain movements, or maintenance of certain positions. In severe cases, loss of spinal movement(~) would cause nonstructural deformities (acute lateral shift, kyphosis, or lordosis) that can be corrected by reduction of the hypothesized derangement. The term "derangement syndrome" is being used throughout to imply disc and possibly other structures (the posterior longitudinal ligament, dura, and occasionally the nerve root), instead of "disc derangement syndrome" because the disc may not be the only source of pain when centralization phenomenon is observed. Deformity: Deformity may be a feature of some acute derangements. The patient has a sudden loss of movement that corresponds to the onset of pain. This loss of movement is severe enough to cause the patient to be unable to actively move out of that abnormal posture. Depending on the direction of the blockage of the movement, patients may present with the deformity of kyphosis (unable to straighten up), deformity of increased lordosis (unable to bend forward), or lateral shift (unable to cross the midline in frontal plane). A deformity is relevant only when attempted correction influences the symptoms. Directional Preference: The direction of repeated or static test movement that decreases or abolishes the most distal symptoms, and produces centralization or abolition of symptoms in derangement syndrome. Distal Symptoms: These symptoms may be somatic referred or radicular, presumably depending on the structure being mechanically deformed or compressed. During the spinal mechanical evaluation, the examiner monitors the most distal symptoms in order to determine the directional preference. Move- ment(~) or position(s) that centralize or abolish these symptoms are, therefore, prescribed as treatment and those that peripheralize or increase the symptoms are avoided. End-Range Pain: Pain does not appear until endrange is reached, and disappears when end range is released. (Relevant) Lateral Component: This term is used for patients with unilateral or asymmetrical symptoms who do not centralize by movements in the sagittal plane. Centralization can only be achieved with asymmetrical lateral movements such as side-glides or rotations. If symptoms can be resolved simply by performing extension in the sagittal plane, the lateral component is considered to be insignificant. Lateral Shift: Lateral displacement or deviation of the trunk, in relation to the pelvis in the frontal plane, viewed from behind (C751), while the patient is in the standing position. If the trunk is shifted to the right, relative to the pelvis, this is a right lateral shift. (Relevant) Lateral Shift: A shift that is related to the patient's present symptoms, ie, patient's symp toms centralize to the lumbar spine while attempt is made to correct the deformity of the lateral shift. Loaded and Unloaded Tests Loaded test movements are tests that are done in upright positions 380 J Orthop Sports Phys Ther.Volume 30 Number 7. July 2000

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