Study Design: A prospective methodological interrater reliability study. Objectives: To calculate the interrater reliability among clinicians newly trained in a classification system for acute low back pain and to determine the level of agreement at key junctures within the classification algorithm. Background: The utility of a classification system for patients with low back pain depends on its reliability and generalizability. To be practical, clinicians must be able to apply the system after a reasonable amount of training. Identifying key points in the classification algorithm where disagreement occurs can lead to better operational definitions. Methods: Four physical therapists read an article and attended a 1-day training session in the classification system. Randomly paired therapists classified patients referred for treatment of acute low back pain and noted decisions at key junctures in the system algorithm. Results: Forty-five patients were classified. Repeated examinations did not increase the patient’s pain (P>.05). For 3 out of the 4 therapists, the interrater reliability showed a kappa value of 0.45. The fourth therapist, excluded from the overall analysis, exhibited a bias towards the immobilization classification. Among the 3 therapists, major disagreement occurred with the determination of symmetry with trunk side bending and the effects of repeated movements. Conclusions: Three out of 4 clinicians newly trained in the system showed moderate reliability. The reliability was slight when the fourth therapist was included. Refinement of the operational definitions and criteria for determining lumbar capsular patterns are needed. One day of training is probably not adequate for all therapists, especially for those biased towards specific low back pain syndromes.

J Orthop Sports Phys Ther. 2004;34(8):430-439. doi:10.2519/jospt.2004.1555

Key Words: examination, evaluation, low back syndrome, lumbar spine, rehabilitation

Some clinical approaches to the treatment of low back pain evaluate and treat observed asymmetries of pelvic posture and motion. Scientific evidence suggests the motion available between the innominate bones is small and variable in nature. The purposes of this investigation were 1) to determine if interinnominate motion of subjects without low back pain was symmetrical in reciprocal test posture combinations, 2) to assess innominate bone symmetry in standing, and 3) to determine if a difference in the magnitude of interinnominate motion was present between a subject group which performs more frequent flexibility activities compared with a subject group representing the general population. Thirty-four subjects (8 male gymnasts, 9 female gymnasts, 8 male nongymnasts, and 9 female nongymnasts) were evaluated in standing and 3 other reciprocal postures (modified standing, modified sitting, and half-kneeling). In each posture, the Metrecom Skeletal Analysis System was used to obtain coordinates for the anterior and posterior iliac spines. Projection angles were used to determine the relative positions of the right and left innominate bones. Results suggest that stand to right modified standing and stand to left modified standing oblique sagittal interinnominate composite motions were symmetrical; stand to right modified sitting and stand to left modified sitting oblique sagittal interinnominate composite motions were asymmetrical; and stand to right half-kneel and stand to left half-kneel oblique sagittal interinnominate composite motions' symmetrical properties were mixed depending on the group. Gymnasts as a group were found to have asymmetrically positioned innominate bones while nongymnasts as a group had symmetrically positioned innominate bones.

J Orthop Sports Phys Ther. 1996;23(5):309-319.

Key Words: sacroiliac, innominate, joint motion

Study Design: Prospective test-retest, intrarater reliability study. Objectives: To estimate the intrarater reliability, asymmetry, and associated error with measurement of the cross-sectional area (CSA) of the bilateral S1 multifidi when measured by a physical therapist following a short course of self-directed training in ultrasound imaging. Background: There is increasing interest in the assessment of the lumbar multifidus during the recovery from low back injury. It is important to know the error associated with the CSA measurements obtained by a physical therapist with limited experience in ultrasound imaging when using a portable unit. Methods and Measures: Thirty healthy females (mean ± SD age, 23 ± 2 years; mean ± SD mass, 63.1 ± 9.2 kg; mean ± SD height, 1.63 ± 0.06 m) participated. Fourteen subjects returned within 1 to 4 days for repeated measurements. Results: For all 30 subjects, the average (±SD) CSA of the left S1 multifidus (4.18 ± 0.55 cm 2 ) was larger (P<.05) than the right (4.11 ± 0.57 cm 2 ), with a standard error of the measurement (SEM) of 0.13 cm² and average ± SD asymmetry of 3.5% ± 3.4%. For a subset of 14 subjects, the between-day intrarater reliability for the right S1 multifidus muscle was ICC 3,1 = 0.80 (95% CI, 0.49-0.93), while the ICC for the left side was 0.72 (95% CI, 0.34-0.90). The day-to-day average differences for the left and right side were 0.02 cm² and 0.04 cm² , respectively. For the most conservative estimate, the between-day SEM was 0.37cm². Conclusions: A physical therapist, newly trained in ultrasound imaging, obtained reasonable between-day intrarater reliability when imaging the S1 multifidus. A high degree of symmetry was found between the bilateral S1 multifidi in a sample of healthy subjects, which is consistent with previous reports from measurements by skilled ultrasonographers.

J Orthop Sports Phys Ther. 2006;36(1):10-18. doi:10.2519/jospt.2006.2049

Key Words: low back, lumbar spine, muscles, reliability, sonography

Objectives: To determine whether anterior, middle, and posterior scalene muscles rotate the cervical spine to the same (ipsilateral to the muscle) or opposite (contralateral to the muscle) side.

Background: Some physical therapy and anatomy textbooks indicate that all 3 scalenes rotate the cervical spine to the same side, some indicate that all rotate to the opposite side, and the rest ascribe different functions to the different scalenes.

Methods and Measures: While under anesthesia, macaques (n = 3) already scheduled for euthanasia were implanted with stimulating electrodes in each scalene muscle on one side, and then a neuromuscular junction blocker was administered to prevent confounding movement from brachial plexus stimulation. Three observers independently rated the direction of rotation produced by electrical stimulation. Postmortem dissection of the macaques was used to determine which direction of passive rotation stretched each scalene. Postmortem analyses in 2 human cadavers were also conducted to determine which direction of rotation stretched the human scalenes.

Results: Electrical stimulation in the macaque produced rotation to the same side for each of the 3 scalenes. Passive rotation to the opposite side put each scalene muscle of the macaque on stretch. In the human, rotation to the opposite side also stretched each scalene.

Conclusions: All 3 scalene muscles produce rotation of the cervical spine to the same side. Maximum stretching of the scalenes should include rotation to the opposite side.

J Orthop Sports Phys Ther 2002;32(10):488–496.

Keywords: electrical stimulation, stretching, thoracic outlet syndrome

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