Background. Pain with radiation to the leg is a common presentation in back pain patients. Radiating leg pain is either referred pain or radicular, commonly described as sciatica. Clinically distinguishing between these types of leg pain is recognized as difficult but important for management purposes. The aim of this study was to investigate inter-therapist agreement when diagnosing referred or radicular pain. Methods. Thirty-six primary care consulters with low back-related leg pain were assessed and diagnosed as referred or radicular leg pain by one of six trained experienced musculoskeletal physiotherapists. Assessments were videoed, excluding any diagnosis discourse, and viewed by a second physiotherapist who made an independent diagnosis. Therapists rated their confidence with diagnosis and reasons for their decision. Data was summarized using percentage agreements and kappa (K) coefficients with two sided 95% confidence intervals (CI). Results. The therapists assessing and therapists watching the video both diagnosed radicular pain in 25 of the 36 patients. Agreement was 72% with fair inter-rater reliability (K = 0.35, 95% CI 0.07, 0.63, p<0.05). Mean confidence in diagnosis was 87% for radicular pain and 83% for referred pain. In the subgroup of patients where therapists' confidence in diagnosis was ≥ 80% (n=28), agreement was 86% with substantial reliability (K = 0.65, 95% CI 0.37, 0.93 p<0.001). Conclusion. Reliability was fair among therapists when diagnosing back-related leg pain. This concurs with current opinion that differentiating between types of back-related leg pain can be difficult. However, when confidence in clinical diagnosis is high, levels of agreement and reliability indices improve substantially

Aims. Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research. Methods. A literature review was undertaken to identify published descriptions of categories of CES. A total of 100 real anonymized clinical vignettes of patients diagnosed with CES from the Understanding Cauda Equina Syndrome (UCES) study were reviewed by consultant spinal surgeons, neurosurgical registrars, and medical students. All were provided with published category definitions and asked to decide whether each patient had ‘suspected CES’; ‘early CES’; ‘incomplete CES’; or ‘CES with urinary retention’. Inter-rater agreement was assessed for all categories, for all raters, and for each group of raters using Fleiss’s kappa. Results. Each of the 100 participants were rated by four medical students, five neurosurgical registrars, and four consultant spinal surgeons. No groups achieved reasonable inter-rater agreement for any of the categories. CES with retention versus all other categories had the highest inter-rater agreement (kappa 0.34 (95% confidence interval 0.27 to 0.31); minimal agreement). There was no improvement in inter-rater agreement with clinical experience. Across all categories, registrars agreed with each other most often (kappa 0.41), followed by medical students (kappa 0.39). Consultant spinal surgeons had the lowest inter-rater agreement (kappa 0.17). Conclusion. Inter-rater agreement for categorizing CES is low among clinicians who regularly manage these patients. CES categories should be used with caution in clinical practice and research studies, as groups may be heterogenous and not comparable. Cite this article: Bone Joint J 2023;105-B(9):1007–1012

Background. Scoliosis is described as a lateral spinal curvature exceeding ten degrees on radiograph with vertebral rotation. Approximately 80% of scoliosis presentations are adolescent idiopathic scoliosis (AIS). Current management for AIS in the UK occurs in Surgeon or Paediatrician-led clinics and can be conservative or surgical. The musculoskeletal assessment and triage of AIS appears well-suited to an advanced physiotherapist practitioner (APP) skill set. The aim of this service evaluation was to scope, develop, implement and evaluate a four-month pilot of an APP-led AIS triage pathway. Method and Results. Spinal Consultant deformity and scoliosis clinics were scoped and observed. Clinic inclusion criteria and a patient assessment form was developed. An APP AIS clinic was set up beside a consultant led clinic. All patients assessed were discussed with a spinal surgeon. Consultant and APP agreement (% of total), waiting times, surgical conversion, and patient satisfaction were reviewed. A clinical competency package was developed for training and development of APPs. A total of 49 patients were seen (20 sessions). Waiting list reduced from 10 weeks to 6 weeks. 45%(n=22) of new patients seen were diagnosed with AIS, 27% (n=6) were directly listed for surgery. Consultant/ APP percentage agreement was high for Cobb angle measurement (82%), management plans (90%), and further diagnostic requests (94%). There were no adverse events and high patient satisfaction levels (n=20), (100% Very satisfied or satisfied) were reported. Conclusion. APP-led AIS clinics can provide similar levels of management and assessment as Spinal Consultants with improved waiting times and high levels of satisfaction. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Thermal sensors have been used in bracing research as self-reported diaries are inaccurate. Little is known about new low-profile sensors, optimal location within a brace, locational thermal micro-climate and effect of brace lining. Our objective is to Determine an optimal temperature threshold for sensor-measured and true wear time agreement. Identify optimal sensor location. Assess all factors to determine the best sensor option for the Bracing AdoleScent Idiopathic Scoliosis (BASIS) multicentre RCT. Seven Orthotimer and five iButton (DS1925L) sensors were synchronised to record temperature at five-minute intervals. Three healthy participants donned a rigid spinal brace, embedded with both sensors across four anatomical locations (abdomen/axilla/lateral-gluteal/sacral). Universal-coordinated-time wear protocols were performed in/out-doors. Intraclass correlation coefficient (ICC) assessed sensor-measured and true wear time agreement at thresholds 15–36oC. Optimal thresholds, determined by largest ICC estimate: Orthotimer: Abdomen=26oC, axilla=27oC, lateral-gluteal=24.5oC, sacral=22.5oC. iButton: Abdomen=26oC, axilla=27oC, lateral-gluteal=23.5oC, sacral=23.5oC. Warm-up time and error at optimal thresholds increased for moulded sensors covered with 6mm lining. Location: anterior abdominal wall. Excellent reliability and higher optimal thresholds, less likely to be exceeded by ambient temperature; not a pressure area. Sensor: iButton, longer battery life and larger memory than Orthotimer; allows recording at 10 min intervals for life of brace. Orthotimer only able to record every 30 mins, increasing error between true and measured wear time; Orthotimer needs 6-monthly data download. Threshold: 26oC is optimal threshold to balance warm-up and cool-down times for accurately measuring wear time. Sensor should not be covered by lining foam as this significantly prolongs warm-up time

Aims. The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). Methods. A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient’s MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. Results. The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. Conclusion. We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J 2021;103-B(5):971–975

Backgrounds and aim. Low back pain resulting from Intervertebral disc (IVD) degeneration is a serious worldwide problem, with poor treatment options available. Notochordal (NC) cells, are a promising therapeutic cell source with anti-catabolic and regenerative effect, however, their behaviour in the harsh degenerate environment is unknown. Thus, we aimed to investigate and compare their physiological behaviour in in vitro niche that mimics the healthy and degenerated intervertebral disc environment. Methodology. Porcine NC cells were encapsulated in 3D alginate beads to maintain their phenotype then cultured in media to mimic the healthy and degenerate disc environment, together with control NC media for 1 week. Following which viability using PI and Calcein AM, RNA extraction and RT-PCR for NC cell markers, anabolic and catabolic genes analysed. Proteomic analysis was also performed using Digiwest technology. Results. A small increase in cell death was observed in degenerated media compared to standard and healthy media, with a further decrease seen when cultured with IL-1β. Whilst no significant differences were seen in phenotypic marker expression in NCs cultured in any media at gene level (ACAN, KRT8, KRT18, FOXA2, COL1A1 and Brachyury). Preliminary Digiwest analysis showed increased protein production for Cytokeratin 18, src and phosphorylated PKC but a decrease in fibronectin in degenerated media compared to standard media. Discussion. Studying the behaviour of the NCs in in vitro conditions that mimic the in vivo healthy or degenerate niche will help us to better understand their potential for therapeutic approaches. The initial work has been then translated to investigate the potential use of iPSCs differentiated into notochordal like cells as potential regenerative cell sources. Conflicts of interest: No conflicts of interest. Sources of funding: This project has received funding from the European Union Horizon 2020 research and innovation programme under grant agreement No 825925

Objectives. Low back pain is strongly associated with degeneration of the intervertebral disc (IVD). During degeneration, altered matrix synthesis and increased matrix degradation, together with accompanied cell loss is seen particularly in the nucleus pulposus (NP). It has been proposed that notochordal (NC) cells, embryonic precursors for the cells within the NP, could be utilized for mediating IVD regeneration. However, injectable biomaterials are likely to be required to support their phenotype and viability within the degenerate IVD. Therefore, viability and phenotype of NC cells were analysed and compared within biomaterial carriers subjected to physiological oxygen conditions over a four-week period were investigated. Methodology. Porcine NC cells were incorporated into three injectable hydrogels: NPgel (a L-pNIPAM-co-DMAc hydrogel), NPgel with decellularized NC-matrix powder (dNCM) and Albugel (an albumin/ hyaluronan hydrogel). The NCs and biomaterials constructs were cultured for up to four weeks under 5% oxygen (n=3 biological repeats). Histological, immunohistochemical and glycosaminoglycans (GAG) analysis were performed to investigate NC viability, phenotype and extracellular matrix synthesis and deposition. Results. Histological analysis revealed that NCs survive in the biomaterials after four weeks and maintained cell clustering in NPgel, Albugel and dNCM/NPgel. NPgel and Albugel maintained NC cell markers and extracellular matrix. NC containing constructs excreted more GAGs over the four weeks than the acellular controls. Conclusion. NC cells maintain their phenotype and characteristic features in vitro when encapsulated into biomaterials. NC cells and biomaterial construct could potentially become a therapy to treat and regenerate the IVD. Conflicts of interest: No conflicts of interest. Sources of funding: This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 825925

Background. Guidelines recommend epidural steroid injections (ESI) for treating severe disc-related sciatica based on trial data showing modest reductions in leg pain, disability and surgery avoidance. Despite their widespread use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica to include in data collection in a future cohort study. Methods. A list of potential predictors of outcome following ESI was generated from existing literature and a consensus meeting with seven experts. Items were subsequently presented in a two-round on-line modified Delphi study to generate consensus among experts on which items are agreed as potential predictors of outcome from ESI (consensus defined as 70% agreement with ranking of remaining items). Results. An initial list of 53 items was generated and 90 experts were invited from seven countries to participate in the on-line Delphi study. Response rates were 48% (n=44) and 73% (n=33) for round 1 and 2 respectively. Twenty-eight additional items suggested by participants in round 1 were included in round 2. Of the 81 items, 14 reached consensus; across domains of medication use, previous surgery, pain intensity, psychosocial factors, imaging findings and type of injection. Highest ranked of remaining items included work-related and clinical assessment items. Conclusion. Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI. These will be tested in a future multicentre cohort study. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Purpose of study and background. Clinical researchers use Pfirrmann classification for grading intervertebral disc degeneration radiologically. Basic researchers have access to morphology and instead use the Thompson score. The aim of this study was to assess the inter-observer reliability of both classifications, along with their correlation. Methods and Results. We obtained T2-weighted MR images of 80 human lumbar intervertebral discs with various stages of degeneration to assess the Pfirrmann-score. Then the discs were dissected midsagittally to obtain the Thompson-score. The observers were typical users of both grading systems: a spine surgeon, radiology resident, orthopaedic resident, and a basic scientist, all experts on intervertebral disc degeneration. Cohen's kappa (CK) was used to determine inter-observer reliability, and intra-class correlation (ICC) as a measure for the variation between the outcomes. For the Thompson score, the average CK was 0.366 and ICC score 0.873. The average inter-observer reliability for the Pfirrmann score was 0.214 (CK) and 0.790 (ICC). Comparing the grading systems, the intra-observer agreement was 0.240 (CK) and 0.685 (ICC). Conclusion. With substantial variation between observers, the inter-observer agreements for the Pfirrmann and Thompson grading systems were moderate. This may explain the poor relationship between radiological and clinical observations in patients and raises questions about the validity of the Pfirrmann score. The mediocre intra-observer agreement between the Pfirrmann and Thompson score shows that there is no clear definition of intervertebral disc degeneration. The field is in need for a new, objective and quantitative classification system to better define and evaluate disc degeneration. There are no conflicts of interest. Funded in part by Annafonds Netherlands and Dutch Spine Society

Aims. The aim of this study was to investigate the agreement of physician assistants (PAs) in the triaging of patients with Low Back Pain (LBP) based on self-reported data. Patients and methods. A cross sectional vignette study among four PAs was carried out. Vignettes (cases) were constructed including 26 factors that can be self-reported, identified in literature that have predictive value in treatment outcomes (for example red flags indicating serious underlying conditions and yellow flags indicating psychosocial factors). All vignettes were randomly assigned to the PAs who should determine what intervention would be most optimal to the patient (rehabilitation, injections, medications, surgery, primary care psychology, primary care physical therapy). PAs were allowed to advise more than one intervention. Per vignette, 3 PAs were assigned randomly to advise on intervention. Fleish kappas were calculated to determine the interrater reliability. Results. Twenty-five vignettes were judged by 3 of the 4 PAs. Per advise, Fleish kappa values varied between k=0.65 for surgery and medication to k=0.77 for rehabilitation, which can be interpreted as substantial agreement. Conclusion. Based on self-reported data provided by patients, PAs can triage patients with substantial agreement. Adding more information based on history, physical examination and imaging, may influence these outcomes. This study adds to the merit of using questionnaires for guiding clinicians in their triaging process. No conflicts of interest. No funding obtained

Microdiscectomy is the most commonly performed spine surgery in the world. Due to its technical simplicity and low complication rate, this was the first spine surgical procedure transitioning for one-day surgery. However, the economic assessment of this outpatient transition was never performed and the question on the real impact in the burden of spine care remains. This economic study aims to access the cost-utility of outpatient lumbar microdiscectomy when compared with the inpatient procedure. To do so, a cost-utility study was performed, adopting the hospital perspective. Direct medical costs were retrieved from the assessment of 20 patients undergoing outpatient lumbar microdiscectomy and 20 undergoing inpatient lumbar microdiscectomy, from a in a Portuguese NHS hospital. Utilities were calculated with quality-adjusted life-years were derived from Oswestry Disability Index values (ODI). ODI was assessed prospectively in outpatients in pre and 3- and 6-month post-operative evaluations. Inpatient ODI data were estimated from a meta-analysis. both probabilistic and deterministic sensitivity analyses were performed and incremental cost-effectiveness ratio (ICER) calculated. A willingness to pay (WTP) threshold of €60000/QALY gained with inpatient procedure was defined. Out results showed that inpatient procedure was cost-saving in all models tested. At 3-month assessment ICER ranged from €135753 to €345755/QALY, higher than the predefined WTP. At 6-month costs were lower and utilities were higher in outpatient, overpowering the inpatient procedure. Probabilistic sensitivity analysis showed that in 65% to 73% of simulations outpatient was the better option. The savings with outpatient were about 55% of inpatient values, with similar utility scores. No 30-day readmissions were recorded in either group. The mean admission time in inpatient group was 2.5 days. Since there is an overall agreement among spine surgeons that an uncomplicated inpatient MD would only need a one-day admission, an analysis reducing inpatient admission time for one day was also performed and outpatient remained cost-effective. In conclusion, as the first economic study on cost-utility of outpatient lumbar microdiscectomy, this study showed a significant reduction in costs, with a similar clinical outcome, proving this outpatient transition as cost-effective

Purpose of the study and background. The preliminary study aimed to establish clinical and research expert opinion with regards to the key components of an assessment of a person with Mechanical Low Back Pain (MLBP). We aimed to identify the key subjective questions and objective tests which would be helpful for clinicians to develop the most appropriate self-management exercise programme. This is the first part of the study to develop the ‘Back-to-Fit’ digital tool offering personalised self-management exercise solutions for people with MLBP. Summary of the methods. A Bristol online survey which included a questionnaire with a series of open and closed questions was developed using the literature and was distributed among clinicians/researchers with a background in the clinical management of MLBP. The questionnaire included 6 demographic questions followed by sections related to subjective questions and objective tests of the MLBP assessment. 71 participants responded to the survey. Results. In the subjective assessment component, ≥80% level of agreement was obtained for 17 of 26 proposed subjective questions and 05 of the 21 suggested objective tests. Two more questions and two objective tests to be included in the assessment had been suggested by the partcipants. Conclusion. These expert agreements on questions and opinions provides an indication of the key subjective and objective components to be included in a self-assessment tool in a personalised self-management platform for MLBP. Further testing with a multiple round Delphi study in a large sample of experts is now required to obtain consensus for the above findings. Conflicts of interest: No conflicts of interest. Sources of funding: Biomechanics and Bioengineering Research Centre Versus Arthritis, Cardiff University, UK

Purposes of the study and background. Clinical assessment of spinal function is a routine part of low back pain (LBP) assessment, yet there is no clear consensus on what constitutes ‘spinal dysfunction’ and how this informs treatment. This study's aims to develop a spinal function classification framework by gaining expert academic and clinical consensus on (i) spinal function assessment tests (ii) encountered LBP motor control/movement impairment (MCI/MI) sub-types (iii) their characteristics and (iii) exercises and feedback for each sub-type. Methods and Results. An online 2-round Delphi-survey of 4 world-leading academic experts and 36 clinical physiotherapists world-wide was employed. A five-point response scale was used to rate level of agreement on 174 items with a priori consensus defined by a ≠>80% level of agreement (LOA). Out of 15 spinal function assessment tests, 5 reached consensus with forward bend and sitting/standing tests highest scoring. 7 MCI/MI sub-types reached consensus as clinically encountered. 12 out of 128 of posture/movement descriptors within the 7 sub-types reached consensus. 7 exercises gained consensus in being considered as ‘important’ or ‘very important’ with exercises involving sitting, standing, forward bend scoring highest. Consensus was reached on MCI/MI sub-type specific exercises, compensation strategies and feedback to remedy these compensations. Conclusion. Academic and clinical expert consensus derived list of movement/posture descriptors, assessment tests and exercises considered clinically important provides a first to date, spinal function assessment classification framework for non-specific LBP. This offers a conceptual model for developing technologies (e.g. wearable sensors) to harness clinically useful information relating to spinal function, exercise performance and feedback for effective implementation of exercise therapies for non-specific LBP. No conflicts of interest. Sources of Funding: Health and Care Research Wales, RCBC Postdoctoral Research Fellowship

A clinical diagnosis of Myofascial Pain Syndrome (MPS) requires manual palpation for the identification of at least one clinically relevant trigger point (TP). However, few comparable, high quality studies exist regarding the robustness of TP examination. Our aim was to determine the inter-observer agreement of TP examination among four examiners and whether reproducibility is influenced by examiner clinical experience. Two experienced and two inexperienced clinicians each performed a standardized palpation of the upper Trapezius musculature. Each observer was asked to judge the presents/absence of clinically relevant TP(s) using clinician global assessment (GA). A random case mix of 81 female participants was examined, 14 being asymptomatic and the remainder suffering from neck/shoulder pain. Examiners received psychomotor training and video analysis feedback provided prior to and during the study in order to improve protocol standardization. Kappa co-efficients were calculated for all possible examiner pairings. Good agreement was noted between the experienced pairing (κ= 0.63). Moderate levels of agreement were observed among the two mixed pairings (κ=0.35 and 0.47 respectively). However, poor agreement was observed for the inexperienced pairing (κ=0.22). Inter-observer agreement was not stable with the experienced pairing in particular, exhibiting a sharp decline in agreement during the latter portion of the study. Identification of clinically relevant TPs of the upper Trapezius musculature is a reproducible procedure when performed by two experienced clinicians. However, an experienced-inexperienced observer pairing can yield acceptable levels of agreement. A protracted period of data collection may be detrimental to inter-observer agreement

Purpose and background:. Implementation fidelity (IF) is the extent to which an intervention is implemented as intended by its developers, and increases confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. The aim of this study was to evaluate the IF within a behaviour-change self-management intervention for people with chronic low back pain and/or osteoarthritis, consisting of six weekly sessions (SOLAS ISRCTN49875385). Methods:. In a sample of data, the intervention was delivered by physiotherapists (n=9) in seven sites. IF was assessed using self-report (by physiotherapists) of all sessions (n=60), direct observations (by the research team) of 40% of the sessions (n=24) and audio-recorded observations (by the research team) of all sessions (n=60) using checklists. Data were analysed in SPSSv20 to assess % agreement between methods and fidelity scores. Results:. Agreement between direct observations and audio-recordings was 86.6%, with inter-rater reliability of 84.6% of the audio-recordings. Agreement between the direct observations and self-report was 74.6%. Four sites scored above 80% (‘high’ fidelity) with three scoring between 70 and 80% (‘moderate fidelity’). Four physiotherapists scored between 83–100% with five scoring from 72.5% to 78.8%. There was no significant difference in the fidelity scores across sessions with scores ranging from 74% to 88.8%. Conclusions:. Self-report data may be of limited use for assessing IF, though it may have benefits in terms of enhancing IF. Overall, fidelity levels ranged from moderate to high which will provide valuable information for the interpretation of the trial's clinical effectiveness

Aims

To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

Background and purpose. The musculoskeletal system is recognized as a possible source of pain in patients with chest pain. The objectives of the present study were (1) to investigate the interobserver reliability of an overall diagnosis of musculoskeletal chest pain using a standardized examination protocol in a cohort of patients with chest pain suspected to be of non-cardiac origin, (2) to investigate the interobserver reliability of the single components of the protocol, and finally, (3) to investigate the importance of clinical experience on the level of interobserver reliability. Methods and results. Eighty patients with acute chest pain were recruited from a cardiology department. Four observers (two chiropractors and two chiropractic students) performed a physical examination and an extended manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs and overall. Musculoskeletal chest pain was diagnosed in 44.0 % of patients. Interobserver kappa values were substantial for the chiropractors and overall, and moderate for the students. For single items of the protocol, both pairs showed fair to substantial agreement regarding pain provocation tests and poor to fair agreement regarding spinal segmental dysfunction tests. Conclusions. Suspected musculoskeletal chest pain can be identified with substantial interobserver reliability using this standardized protocol if used by experienced and trained observers. Agreement for individual components of the protocol showed, however, considerable variation. Provided training of observers, the examination protocol can be used in selected patients and can be implemented in pre- and post-graduate clinical training

Aim:. To simplify sagittal plane spinal assessment by describing a single novel angle in the lumbar spine equivalent to the difference between pelvic incidence (PI) and lumbar lordosis (LL) and evaluate its reliability. Methods:. New sagittal modifiers in the classification of adult degenerative spinal deformity have been shown to be valid and reliable with the greatest variability being for pelvic incidence minus lumbar lordosis (PI-LL). This measurement can be simplified to a new angle (alpha) without the need to determine either PI or LL. This angle is between a line intersecting the bicoxofemoral centre and perpendicular to the L1 endplate (alpha line) and a line from the bicoxofemoral centre to the centre of the sacral endplate. Two readers graded 40 non-premarked cases twice each, approximately 1 week apart. Inter- and intra-rater variability and agreement were determined for PI-LL and alpha angle separately. Fleiss' kappa was used for reliability measures. Results:. Inter-rater kappa for PI-LL showed substantial reliability and alpha angle showed almost perfect agreement. Intra-rater kappa showed substantial reliability for PI-LL but almost perfect agreement for alpha angle across both readers. Discussion:. Alpha angle can be used as a surrogate for PI-LL and is easier and more reliable to measure. When PI=LL, alpha angle is 0, so the alpha line bisects the sacral plate. Conflict Of Interest Statement: No conflict of interest

Introduction. Sensory profiles classified in Low Registration, Sensory Sensitive, Sensation Avoiding and Sensation Seeking may be used in patients with non-specific chronic low back pain (CLBP) to develop a more personalized treatment program. Although psychometric properties have not been studied up till now the Adult Adolescent Sensory Profile (AASP) can be used to measure sensory profiles in CLBP patients. Objectives. The study aim was to asses internal consistency, test-retest reliability, agreement and construct validity of the AASP in a CLBP population with nociplastic pain. Method. A non-experimental, cross-sectional study design was used, with two measurements with a two weeks interval. All self-reported questionnaires were used at t0 and t1 to assess outcome in comparison to the AASP and SP. Reliability was evaluated by assessing internal consistency and test-retest reliability. To assess construct validity, the a priori hypothesis on the four profiles, correlation was analyzed. Results. Ninety CLBP patients were included, with a mean duration of CLBP of 232 weeks. Internal consistency for each sensory profile, Cronbach's alpha varied from 0.91 to 0.92. Test-retest reliability varied from intra-class correlation coefficient (ICC) 0.90–0.92. Construct validity correlated positively between sensory profiles, Low Registration, Sensory Sensitive and Sensation Avoiding, and negatively with Sensation Seeking. Conclusion. The AASP is considered to be a suitable instrument for measuring sensory profiles in CLBP patients in primary care. Conflict of interest: No conflicts of interest. Source of funding: No funding obtained

Background and purpose. Modic changes (MC) are a risk factor for development of chronic low back pain (CLBP). There is no agreement about the cause of inflammation in MC, but autoimmunity has been suggested. The aim of the study was to investigate whether treatment with lactic acid bacteria for 100 days was associated with change of disability and pain, via a change in the gut microbiota inducing a change in the immune system, in patients with CLBP and type 1 MC during one year follow-up. Methods. Eighty-nine patients with CLBP and type 1 MC were randomized to receive either one capsule Lactobacillus Rhamnosis GG or placebo capsules twice daily for 100 days. Results. Missing values at one year were 4% and 3% in the disability and pain variables, respectively. The predefined outcomes disability and back and leg pain only changed little during follow-up with no statistically significant differences between groups. At one year, back pain had decreased by 1.1 more on a 0–10 scale (95% CI 0.20- 1.97) in the experimental group than in the control group. There were no differences regarding other predefined outcomes, i.e. global effect or percentage with minimal disability at one year. Nine percent of the patients reported gastrointestinal side-effects without difference between groups. Conclusions. No differences were found between groups regarding the predefined outcomes. Overall, the study confirmed that CLBP with MC1 is a grave back pain disorder, with little tendency to improvement. During follow-up, disability of the whole cohort was reduced by just 17%. Conflicts of interest: No conflicts of interest. Sources of funding: The study has been supported by The Danish Rheumatism Association and Peter and Helga Kornings Fond