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Helen A. Clare, MAppSc,a Roger Adams, PhD,b and Christopher G. Maher, PhDc

Background and Purpose: The poor reliability of lateral shift detection has been attributed to lack of rater

training, biologic variation, and test reactivity. This study aimed to remove the potential confounding arising from
biological variation and test reactivity and control the level of rater experience/training in making judgments of lateral
Subjects: One hundred forty-eight raters with 3 levels of clinical physical therapy experience and training in the
McKenzie method participated.
Method: The raters viewed photographic slides of 45 patients with low back pain. Slides were judged on a
numerical scale for presence and direction of a shift. Intrarater reliability was evaluated using the intraclass
correlation coefficient (ICC) and interrater reliability was evaluated using both the ICC and ␬ statistic.
Results: Reliability of shift judgments was only moderate for all groups (eg, ICC [2,1] values ranged from 0.48 to
Conclusion: Lateral shift judgements have only moderate reliability, even when trained raters judge stable stimuli.
We propose that the photo model employed can be used to explore the source of error in this process. (J
Manipulative Physiol Ther 2003;26:476-80)
Key Indexing Terms: Low Back Pain; Lumbar Spine; Lateral Shift; Reliability of Testing; McKenzie Method

recent survey of physical therapists in the United
States1 reported that a McKenzie evaluation was
one of the most common evaluations performed for
patients with low back pain (LBP) and that almost half the
therapists viewed the McKenzie method as the most useful
management approach for low back pain. Similar results
have been reported for British and Irish physiotherapists.2,3
The method has received support as an effective LBP
treatment in a systematic review of activity prescription for
back pain4 and also in Danish clinical practice guidelines,5
based on the 2 existing clinical trials.6,7 Subsequent to the
completion of both reviews, Cherkin et al8 published a
clinical trial evaluating 3 approaches (chiropractic manipulation, McKenzie therapy, and an educational booklet) and



Private practice of physiotherapy, Sydney, Australia, and PhD
candidate, School of Physiotherapy, The University of Sydney,
Sydney, Australia.
Senior lecturer, School of Physiotherapy, The University of
Sydney, Sydney, Australia.
Associate Professor, School of Physiotherapy, University of
Sydney, Sydney, Australia.
Submit requests for reprints to: Helen Clare, PT, MAppSc, 16
Ayres Road, St Ives NSW 2075, Sydney, Australia (e-mail:
Paper submitted June 6, 2002.
Copyright © 2003 by National University of Health Sciences.
0161-4754/2003/$30.00 ⫹ 0


found chiropractic manipulation and McKenzie therapy to
have similar effects and costs. However, both treatments
provided only marginally better outcomes than an educational booklet.8 In this environment, further information
about the use of the basic criteria in the method is needed.
The principal aim of the McKenzie assessment is to first
determine those suitable for treatment with this approach.
Suitable patients must fit one of 3 syndromes: postural,
dysfunction, or derangement.9 The derangement syndrome
is further divided into 7 subsyndromes on the basis of pain
location, the behavior of the pain in response to the application of repeated spinal movements, and on the presence or
absence of deformities including a lateral shift. Because
classification determines the specific treatment used by the
treating clinician, accurate classification is believed essential for the effective management of the LBP patient.
In employing the method, the presence of a lateral shift is
determined by visual inspection at the time the patient’s
posture is evaluated. If a lateral shift is deemed to be
present, lateral glide movements are performed to assess if
these alter the patient symptoms. Where this is the case, the
shift is classified as “relevant’ and directs the initial treatment approach.9 The initial step of detecting a shift is of
paramount importance, because it is only if a shift is identified to be present that its relevance is determined.
A lateral shift is defined as a lateral displacement of the
trunk in relation to the pelvis.9 The prevalence of a lateral

a value similar to the findings of Nelson et al. ␬ ⫽ 0. Forty-nine physical therapists from 8 clinics examined 363 patients. and the reliability estimates are in the range poor to moderate. and graduate physiotherapists with a minimum of 70 hours training in the McKenzie method. working status. location of symptoms. McLean et al15 investigated 3 different techniques for measuring trunk list and concluded that the use of a plumb line provided the most reliable measures. The criteria for inclusion were that they were currently experiencing low back pain with or without radiation to the leg. citing a prevalence of 5. Sixteen of the therapists had attended at least 1 postgraduate course in the McKenzie method. They visually determined whether a lateral shift deformity was present for each patient. these studies did not provide ␬ values. weight.17 One way to explore the first hypothesis is to use a model of clinical practice that allows for greater control than would be possible in the clinic. It is therefore worthwhile to explore the source of disagreement. Number 8 shift has proved hard to establish. METHOD Project Overview The design of the experiment required raters to inspect a set of photographic slides of patients with low back pain and to judge whether a shift was present. However. The aims of the study were to investigate: ● the intrarater/interrater reliability of judgements of lateral shift made from inspection of photographs of patients with low back pain. and Maher Reliability of Shift Detection The attribute is inherently unstable and changes with repeated examination. They found a high error rate in the determination of the presence of a lateral shift (60% agreement. Patients attending a private physiotherapy clinic for low back pain were invited to participate in the study. duration of symptoms. To explore the effect of clinical experience and training. Based on the research to date. ␬ ⫽ 0. pain intensity. we selected a cross section of raters. This method avoids the potentially confounding effect of the biologic variation of the shift. The photographs of the patients had been taken by the first author on the same day that she performed a full clinical examination of these patients.6%. Porter and Miller10 suggest that it is an uncommon feature. but the reported ␬ value for the decisions indicated very poor reliability. Donahue et al12 attempted to improve the reliability of the determination of the presence and direction of a lateral shift by using a simple measuring device. Adams.26) and concluded that this was a possible source of error in the determination of the syndrome classifications.12 The reliability of therapists in determining the presence of a lateral shift has been evaluated in 6 studies to date.52) was demonstrated by Razmjou et al16 for therapists observing the same patient assessment.16 2. for example. Subjects Patients with low back pain.14 who reported that the detection of lumbar tilt (lateral shift) had high interobserver error. later studies report approximate prevalences of 20%11 and 80%. 1. In the Kilby et al13 study. and there was insufficient data to allow calculation of this statistic. 2 physiotherapists with some training in the McKenzie method simultaneously evaluated 41 patients. including first-year undergraduate students. The raters consisted of: ● 60 first-year undergraduate physical therapy students with no clinical experience or training in the McKenzie method. Raters. probably because of the problems with measurement of this attribute. with a time interval between examinations. ● whether interrater reliability and discriminability were influenced by level of education in the McKenzie method. Information was collected from the subjects regarding their gender. the use of photographs as the stimuli to be rated rather than real patients. age. it remains unclear whether a lateral shift can be detected with acceptable reliability. height. They also aimed to determine whether training in the McKenzie method influenced reliability. 477 . All subjects gave written consent prior to participating. graduate physiotherapists with no formal training in the McKenzie method. Improved reliability in determining the presence of a lateral shift (78% agreement. and functional status (Table 1). there was no summary reliability statistic reported to allow comparison to other studies. There was only 55% agreement on the presence or absence of a lateral shift. and clinical experience and training are necessary to reliably measure a lateral shift. On the same visit. The measuring devices used to date do not seem to improve reliability.Journal of Manipulative and Physiological Therapeutics Volume 26. The 2 physical therapists involved in this study were both trained extensively in the McKenzie method and assessed the patients simultaneously in an attempt to reduce the error related to repeated examinations. however. allows for an unlimited number of repetitions of the same stimuli. The paired assessments were completed consecutively. Riddle and Rothstein11 examined the intertester reliability of assessments of LBP patients made by physical therapists using the McKenzie method. demographic and clinical data were recorded for each patient. previous history of LBP. however. Two hypotheses have been offered for the poor reliability observed: Clare. The attribute is subtle. and also allows for a much larger panel of raters than is practical in a traditional clinical reliability study. frequency.

as Fleiss and Cohen18 have shown that weighted ␬ and the ICC are equivalent. the absolute difference between groups was small and was revealed as statistically significant because of the high power of the .1]) for each group. expressed as ICC values.64.49 to 0. right lateral shift present. Subject characteristics Characteristic Number of subjects Age (y) Height (cm) Weight (kg) Pain intensity (VAS cm) Quebec Disability score Female gender Past LBP Frequency of pain (% constant) Duration of symptoms Acute (ⱕ7 days) Subacute (⬎7 days . ● ● 46 graduate physical therapists with some clinical experience but no formal training in the McKenzie method. The patient then resumed their normal treatment. Intrarater and interrater reliability were evaluated by calculating the intraclass correlation coefficient (ICC [2. This was performed for all raters.38. 42 graduate physical therapists who had clinical experience and had completed a minimum of 70 hours of formal training in the McKenzie method. The instructions given to the raters were that they were to determine the presence or not of a lumbar lateral shift. the reliability of shift detection remained unacceptably low. The assessors were instructed not to share their views about each slide with others. To allow comparison with other studies that have evaluated reliability with ␬. Chicago. as expressed by ICC values with 95% CIs. and was able to be activated from a distance. The ICC values ranged from 0.26 to 0. inspection of the 95% CIs reveals that the McKenzie group had statistically significantly greater reliability than the other groups. A photograph was then immediately taken. This analysis considers the data as continuous data. The intrarater reliability (ICC 2. RESULTS Intrarater reliabilities.” The assessors were provided with a data collection form and were instructed that for each subject slide they were required to make 2 determinations. While the McKenzie trained raters were more reliable in judging a shift than the other 2 groups of raters. Ninety-five percent CIs for each statistic were calculated. shift absent. again in the range representing fair to good reliability.1) for each subject was determined and then a group mean value and 95% CI for the group was determined. using the SPSS Macro ICCSF2. The interrater reliabilities. again suggesting fair reliability. The ␬ (Table 2) ranged from 0. The raters’ judgements were converted to a 5-point scale of confidence that the patient had a right shift: ⫺2 ⫽ certain shifted to the left. 1 ⫽ uncertain shifted to the right. Intrarater reliability was determined by comparing the judgments of lateral shifts of the first presentation of the 45 subjects with the second presentation.20 DISCUSSION Despite using a simplified model of clinical practice that removed any potential for reactivity and biologic variation. The second determination required them to indicate the level of certainty of the first determination by rating it either certain or uncertain. we calculated the multirater ␬ (an unweighted form of ␬) using the MKAPPASC. Adams. and the information was entered for analysis. They were read the following: “McKenzie 1981 defines a lateral shift as when the top half of the patient’s body has moved laterally in relation to the bottom half. These were randomly positioned in a slide tray so that the order of the second set of slides varied from the first set. Ill). set on auto focus. and Maher Reliability of Shift Detection Journal of Manipulative and Physiological Therapeutics October 2003 Table 1. which falls within the range of ICC values described by Fleiss19 as representing fair to good reliability. 2 ⫽ certain shifted to the right.7) 47. Japan).6 (14) 164 (12) 73 (15) 5. whereas others may consider the data to represent ordinal data. ranged from 0. The interrater reliability (as determined by the ICC and ␬) were calculated for each of the 3 groups.48 to 0. The photographs were converted into slides and duplicates were made.SPS within SPSS 10. are shown in Table 2.7 weeks) Chronic (⬎7 weeks) Radiation into leg Radiation below the knee Working normal duties 45 50. Data Analysis Reliability of detecting a shift. The data sheets were collected. which resulted in 90 slides of the 45 patients. The first determination consisted of 1 of 3 choices: left lateral shift present.0 (SPSS. Procedure Investigator HC conducted a complete clinical examination of each patient and then asked the patient to stand within a doorway with their back toward a camera (Cannon EOS 3000 88.0.59. categorical variables are percentages. For both intrarater and interrater reliability. Tokyo.478 Clare.3 (19) 58% 87% 51% 18% 31% 51% 56% 27% 44% Data for continuous variables are mean values with SDs in parentheses.6 (1. The slides were shown to the 3 sets of raters. ⫺1 ⫽ uncertain shifted to the left. the argument is unnecessary. This was done for each of the 3 groups. The camera was placed on a tripod 3 meters from the subjects. 0 ⫽ neutral.SPS macro in SPSS 10. However.

2) and direction of a lateral shift (␬ ⫽ 0. Clin J Pain 2000. Physiother Pract 1985. Spine 1993. As for the difference in ICC values not being large in absolute terms. and Maher Reliability of Shift Detection Table 2.56 (0.59 (0.48 (0. 24-6. 1981.38 (0. A comparison of physical therapy.53 (0.37) 0. ACKNOWLEDGMENTS This study was approved by the Human Research Ethics Committee of the University of Sydney. Baxter GD. 6. Lowback pain. 7.24:1332-42. Wheeler K. Battie MC. Back pain and trunk list. Hurly DA. 12. and we have now developed a protocol that allows physical therapists to accurately judge stiffness. Battie M. Moore AP. Johnell O. Cherkin D. A 5-year follow-up study of two methods of treatment.27) 0. Our study had unusually high power because we used a model that allowed for a large rater pool (range 42-60 raters). Adams.49 (0. intraclass correlation coefficient. Spine 1995. We would view this endeavor as similar to the one we embarked on 7 years ago when we reported similarly low reliability for physical therapists’ judgements of lumbar posteroanterior spinal stiffness. Cherkin DC.12 that have noted major problems with the detection of lumbar shifts. Stankovic R.71) 0. REFERENCES 1. Refshauge K.61) 0. McDonough SM. Subsequent to completing this study. Associates also alerted us to an earlier study that similarly used slides of patients as the stimuli to be rated. Riddle DL.64 (0. Miller CG. p. Dusior TE. Thompson KA. 16:214-28. N Engl J Med 1998.20:469-72. New Zealand: Spinal Publication Limited. 11:596-600.46-0. 9. with the model that we utilized in this study. Donahue MS. Waikanae. A series of studies has led us to a greater understanding of the issue. we are unable to provide an explanation for the difficulty in determining the presence of a lateral shift. 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We recommend that this model utilizing photographs of LBP patients be used to further study the features of the lateral shift that influence the rater’s decision as to its presence and direction. Latimer J. Phys Ther 1994. 8.53-0. Intertester reliability of McKenzie’s classifications of the syndrome types present in patients with low-back pain. 5. Conservative treatment of acute lowback pain. Street J. Biopsychosocial screening questionnaire for patients with low-back pain: preliminary report of utility in physiotherapy practice in Northern Ireland. Danish Institute for Health and Technology Assessment.Journal of Manipulative and Physiological Therapeutics Volume 26.75) suggested by Fleiss. Foster NE.55-0. and visual accuracy of the raters.23 CONCLUSION Despite the task of judging the presence or absence of a lateral shift being simplified by the removal of biologic variation and test reactivity.1:99-105. 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