The reliability of the clinical tests and questions recommended in international guidelines for low back pain

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 (k). Confidence intervals (95% CIs) were calculated. Results. Eighty-six percent (n = 43) of the questions and test demonstrated k 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.