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Inter-examiner reliability in the assessment of low back pain (LBP) using the Kirkaldy-Willis classification (KWC)

Abstract

Reliable classification systems and clinical tests are sought for the care of patients with low back pain (LBP). The objectives of this clinical study were to evaluate inter-examiner reliability in the classification of patients with LBP, the influence of radiological findings on the classification and the reliability of some clinical tests. Two examiners independently assessed 50 outpatients with LBP. Inter-examiner reliability in classification of patients with LBP using Kirkkaldy-Willis classification (KWC) system and in 30 clinical tests was calculated as percentage agreement and kappa coefficients (κ). Inter-examiner reliability was excellent (κ>0.8) for classification according to KWC. Radiological findings did not influence the reliability. Age of the patient, movement range, and pain and neurological signs seemed to guide the decision on classification. The reliability of clinical tests was good (κ>0.6) in 6 tests and moderate (κ>0.4) in 12 tests. Good inter-examiner reliability was found for the SLR test, movement range and sensibility testing with spurs in dermatome areas. We conclude that the KWC for classifying patients with LBP seems to be a reliable classification system depending on a few key observations and that moderate and good inter-examiner reliability can be achieved in several clinical tests in the assessment of LBP.

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Acknowledgement

This study was supported by funds from Stockholm county council.

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Correspondence to Bo C. Bertilson.

Appendix

Appendix

Clinical test procedures and definitions on what was evaluated as not normal (NN)

First with patient standing

  • Posture. Increased or decreased lumbar lordosis respectively scoliosis NN.

  • Movement range. Decreased lumbar forward flexion, extension and lateral bending NN.

  • Movement pain. Pain on lumbar flexion, extension and on lateral bending NN.

  • Foramen compression test was performed with lateral bending and rotation of the lumbar spine to the tested side. Provoked pain radiating down below the knee NN.

Second with patient lying in prone position

  • Femoral nerve stretch test (Ely’s test). The tested leg was passively extended in the hip joint and flexed in the knee joint. Provoked pain radiating down to the anterior thigh NN if it could be increased by flexion of the head and/or plantar flexion in the ankle joint.

  • Muscle stiffness of rectus femoris NN if the heel of the foot did not reach the gluteal skin.

  • Springing test. One hand placed on fingers of the other hand positioned on each side of the spinal processes. Tenderness or decreased elasticity NN.

  • Sacroiliac compression pain was evaluated as the lateral edge of the sacrum was compressed using both hands. Increased pain on either side NN.

  • Paravertebral tenderness. Evaluated in the lumbar area between the spinal processes and the midaxillary line. Tenderness and/or a difference between left and right side NN.

  • Inter-segmental tenderness in the lumbosacral segment and the segment immediately above. Tenderness on palpation with fingers NN.

Third with patient lying on one side with the hips and knees flexed

  • Inter-segmental mobility (angular and translational) in the lumbosacral segment and the segment immediately above were evaluated by palpation while passively moving the patients knees and classified as decreased, normal or increased.

Fourth with patient lying in supine position

  • Ischiadicus nerve stretch test (straight leg raising or SLR) and hamstring stiffness test was performed simultaneously. The examiner fixed one leg to the table to stabilise the pelvis, while elevating the tested leg with the knee in extension. SLR NN if pain radiated below the knee and if the pain increased either when the head was flexed or when the foot was dorsiflexed. Hamstring test NN if less than 80° flexion in the hip was reached.

  • Sensibility was tested with a pinwheel, one side at a time, in the dermatome areas according to the maps of Netter. Deranged or asymmetrical sensibility NN.

  • Strength in the ankle and in large toe dorsiflexion NN if decreased or asymmetrical.

  • Patellar and Achilles reflexes NN if the response was deranged or asymmetrical.

  • Internal hip rotation. Evaluated with the hip and knee in 90° flexion. Decreased range and/or asymmetry in the joint motion NN.

  • Patrick’s test. Performed as described by K. Lewit in Manuelle Medizin from Munchen-Wien-Baltimore, 1987. Pain in the dorsal region of the sacroiliac joint on the same side and/or decreased range of movement with an increased resistance at the end point NN.

  • Iliopsoas muscles stiffness was tested with the tuber os ischi at the lower end of the examination table. To maintain the lower back flat on the table, the opposite leg was maximally flexed in the hip joint and held by the patient against the chest. If the thigh on the side tested did not reach the horizontal plane of the examination table NN.

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Bertilson, B.C., Bring, J., Sjöblom, A. et al. Inter-examiner reliability in the assessment of low back pain (LBP) using the Kirkaldy-Willis classification (KWC). Eur Spine J 15, 1695–1703 (2006). https://doi.org/10.1007/s00586-005-0050-3

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  • DOI: https://doi.org/10.1007/s00586-005-0050-3

Keywords

  • Low back pain
  • Classification
  • Inter-examiner reliability
  • Assessment of clinical tests
  • Kirkaldy-Willis