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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

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

SPS within SPSS 10. set on auto focus. 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. However.48 to 0. The assessors were instructed not to share their views about each slide with others. Ill). ⫺1 ⫽ uncertain shifted to the left. The interrater reliabilities. again suggesting fair reliability. Adams. The slides were shown to the 3 sets of raters. and Maher Reliability of Shift Detection Journal of Manipulative and Physiological Therapeutics October 2003 Table 1. which resulted in 90 slides of the 45 patients. A photograph was then immediately taken. The ICC values ranged from 0. and the information was entered for analysis. whereas others may consider the data to represent ordinal data. Data Analysis Reliability of detecting a shift. 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. are shown in Table 2. expressed as ICC values. For both intrarater and interrater reliability. The intrarater reliability (ICC 2.478 Clare. as Fleiss and Cohen18 have shown that weighted ␬ and the ICC are equivalent. again in the range representing fair to good reliability.6 (14) 164 (12) 73 (15) 5. This was done for each of the 3 groups.26 to 0. The interrater reliability (as determined by the ICC and ␬) were calculated for each of the 3 groups.49 to 0. Tokyo.1) for each subject was determined and then a group mean value and 95% CI for the group was determined.7 weeks) Chronic (⬎7 weeks) Radiation into leg Radiation below the knee Working normal duties 45 50. categorical variables are percentages. This analysis considers the data as continuous data. Ninety-five percent CIs for each statistic were calculated. 1 ⫽ uncertain shifted to the right. 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. and was able to be activated from a distance. 42 graduate physical therapists who had clinical experience and had completed a minimum of 70 hours of formal training in the McKenzie method.7) 47. 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 . using the SPSS Macro ICCSF2. ranged from 0.SPS macro in SPSS 10. The second determination required them to indicate the level of certainty of the first determination by rating it either certain or uncertain. right lateral shift present. as expressed by ICC values with 95% CIs.1]) for each group. the reliability of shift detection remained unacceptably low. The instructions given to the raters were that they were to determine the presence or not of a lumbar lateral shift. The ␬ (Table 2) ranged from 0. RESULTS Intrarater reliabilities. the argument is unnecessary. Intrarater reliability was determined by comparing the judgments of lateral shifts of the first presentation of the 45 subjects with the second presentation. The data sheets were collected. Intrarater and interrater reliability were evaluated by calculating the intraclass correlation coefficient (ICC [2. The camera was placed on a tripod 3 meters from the subjects. 2 ⫽ certain shifted to the right. This was performed for all raters. ● ● 46 graduate physical therapists with some clinical experience but no formal training in the McKenzie method. These were randomly positioned in a slide tray so that the order of the second set of slides varied from the first set. Chicago. To allow comparison with other studies that have evaluated reliability with ␬. the absolute difference between groups was small and was revealed as statistically significant because of the high power of the .0 (SPSS. The patient then resumed their normal treatment.6 (1. While the McKenzie trained raters were more reliable in judging a shift than the other 2 groups of raters. inspection of the 95% CIs reveals that the McKenzie group had statistically significantly greater reliability than the other groups. which falls within the range of ICC values described by Fleiss19 as representing fair to good reliability. The first determination consisted of 1 of 3 choices: left lateral shift present.38.20 DISCUSSION Despite using a simplified model of clinical practice that removed any potential for reactivity and biologic variation. Japan). 0 ⫽ neutral. shift absent. we calculated the multirater ␬ (an unweighted form of ␬) using the MKAPPASC.3 (19) 58% 87% 51% 18% 31% 51% 56% 27% 44% Data for continuous variables are mean values with SDs in parentheses. The photographs were converted into slides and duplicates were made.64.” The assessors were provided with a data collection form and were instructed that for each subject slide they were required to make 2 determinations.59.

Dusior TE.59) 0. Hurly DA. Refshauge K. 6. 1981. Ciol MA.2) and direction of a lateral shift (␬ ⫽ 0. the authors reported perfect agreement in judging lateral shifts. a protocol may be able to be developed to improve the reliability of detection of the lateral shift. Spine 1995. Barlow W.53-0. Relative therapeutic efficacy of the Williams and McKenzie protocols in back pain management. Intertester reliability of McKenzie’s classifications of the syndrome types present in patients with low-back pain. Phys Ther 1996. Physiother Pract 1985. 3.38 (0. Riddle DL. with the model that we utilized in this study. 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. A 5-year follow-up study of two methods of treatment.1:1106. The lumbar spine: mechanical diagnosis and therapy.37) 0. McDonough SM. Spine 1999. Rothstein JM. Cherkin DC.12 that have noted major problems with the detection of lumbar shifts. study.21 Interestingly. Our study had unusually high power because we used a model that allowed for a large rater pool (range 42-60 raters). Baxter GD. Frequency. Without further investigations to determine which cues are influencing the decision of the raters. Nwuga G. Donahue MS.37-0. Baxter GD. A comparison of physical therapy. Number 8 Clare. the reliability of the raters in this study was unacceptable. 12. 11.36 (0. Management of nonspecific low-back pain by physiotherapists in Britain and Ireland. they reported a similar value for agreement on detecting the presence (␬ ⫽ 0.19 Our result is consistent with other studies11. Biopsychosocial screening questionnaire for patients with low-back pain: preliminary report of utility in physiotherapy practice in Northern Ireland. As for the difference in ICC values not being large in absolute terms. Subsequent to completing this study. chiropractic manipulation. Street J. Maher C.64 (0.56 (0. Latimer J. Battie MC.48 (0.45:12132.20:469-72. Foster NE. management and prevention from an HITA perspective. and we have now developed a protocol that allows physical therapists to accurately judge stiffness. Spine 1986.42-0.53) 0.339:1021-29. 11:596-600. intraclass correlation coefficient. 24-6. Back pain and trunk list. 7. Managing low-back pain: attitudes and treatment preferences of physical therapists. and Maher Reliability of Shift Detection Table 2. whereas the typical reliability study has 2 raters. † Point estimate and 95% CI for a single ICC or Kappa that compares multiple raters. *Group mean value and 95% CI of the point estimate ICC for each subject. 2. Clin J Pain 2000. Intertester reliability of a modified version of McKenzie’s lateral shift assessments obtained on patients with low-back pain. Once these have been established. Allen JM.4) between 2 experienced McKenzie trained physical therapists.63) 0. Moore AP. an additional study has been published that has evaluated the reliability of shift detection. and visual accuracy of the raters. Porter RW. Deyo R.71) 0.49 (0. N Engl J Med 1998. Phys Ther 1994. Lowback pain.22 In contrast to all other reliability studies. Thompson KA. 4.76: 706-16.43-0.25-0. Cherkin D. McKenzie RA. Prescription of activity for low-back pain: what works? Aust J Physiother 1999. 16:214-28. Johnell O. 8. 479 . anthropometric variables of the stimuli.75) suggested by Fleiss. Riddle DL. Linton SJ. we are unable to provide an explanation for the difficulty in determining the presence of a lateral shift. Wheeler K. We are unable to offer an explanation for this result.39) ICC. Waikanae.35-0. 9.46-0.55-0.Journal of Manipulative and Physiological Therapeutics Volume 26.51) 0. New Zealand: Spinal Publication Limited.1:99-105. Danish Health Technol Assess 1999.74:219-26.27) 0. we could rigorously evaluate factors such as training. ACKNOWLEDGMENTS This study was approved by the Human Research Ethics Committee of the University of Sydney.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.24:1332-42. Associates also alerted us to an earlier study that similarly used slides of patients as the stimuli to be rated. 10.59 (0. 5. Sulivan MS.53 (0. the highest value still did not reach the benchmark for excellent reliability (0.61) 0. Intrarater and interrater reliability of shift judgements Interrater† Intrarater* Raters ICC ICC Kappa First-year students Graduate physical therapist McKenzie trained physical therapists 0. 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. Miller CG.26 (0. Nwuga V. p. and provision of an educational booklet for the treatment of patients with low-back pain. However. Conservative treatment of acute lowback pain. Danish Institute for Health and Technology Assessment. Spine 1993.57-0. Battie M. Adams.18:1333-44. A series of studies has led us to a greater understanding of the issue. Dunn R. REFERENCES 1. Stankovic R.

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