Purpose: Clinical practice guideline (CPG) concordant treatment (Ctx) has been shown to be more effective than CPG discordant care (Dtx) in a heterogeneous cohort of patients with acute lower back pain (ALBP). However, patients with underlying spine pathology (e.g. stenosis, disc degeneration, facet joint arthropathy) or without identifiable spine pathology may all present solely with ALBP. At present, it is unknown if underlying spine pathology influences the outcome of Ctx. The purpose of this study was to determine if Ctx is more effective than Dtx in patients with differing underlying spine pathology who present with ALBP.

Method: A Two-arm, randomized control trial with stratified analysis. Inclusion: Ages 19–59; QTFSD I, II ALBP < 4 weeks. Exclusion: “Red Flag” conditions, comorbidities contraindicating Ctx. The primary outcome was the difference between Ctx and Dtx Roland Morris Disability (RDQ) scores at 16 weeks post baseline between study groups. Secondary outcomes: differences in Bodily Pain (BP), Physical Functioning (PF) SF-36 domain scores at 16 weeks. Patients were assessed by a spine physician and randomized to Ctx or Dtx. Patients were stratified on the basis of CT or MRI evidence of:

spinal stenosis;

Hospital / University Ethics approval was obtained.

Results: Eighty-eight patients were recruited; 39 in Ctx & 38 in Dtx group completed the study. Baseline prognostic variables were evenly distributed between groups. Outcomes: mean difference in 16 week RDQ, BP and PF scores between Ctx and Dtx was statistically greatest in group 4 (p< 0.001). There was no significant clinical improvement in RDQ, BP or PF scores in either the Ctx or Dtx in group 2.

Conclusion: Ctx was more effective than Dtx in patients with no identifiable spine pathology and ineffective and equivalent to Dtx in patients with underlying disc degeneration.

Purpose: Screening patients for appropriate treatment is a key component of an effective hospital-based spine service. To date, a standardized and validated method for carrying out this process has not been established. In particular, studies to determine who should staff these screening services, their safety and reliability have not been reported. The goal of this study was to determine the inter-examiner reliability of patient screening assessments by Chiropractors and Spine Physicians.

Method: Prospective observational cohort. 50 consecutive patients with acute lower back pain < 16 weeks duration (QTFSD I, II) referred to a quaternary care hospital spine program were studied. The inter-examiner agreement for 10 physical examination procedures and 5 red flag conditions was calculated using the Cohen’s kappa value. Patients were assessed by one of three spine physicians and one of three Chiropractors for normal or abnormal deep tendon reflexes, nerve root tension signs; lower extremity sensory / motor deficit; muscle atrophy; Schober’s test and depth of lordosis. Any history suggestive of cauda equina, fracture, infection, spinal malignancy or progressive neurological deficit was recorded. The results were compared where applicable, with previously published kappa values for lower back examination procedures.

Results: Four of the 50 patients had one or more red flag conditions with an inter-observer reliability of 0.96; 8 of 10 physical examination procedures had a kappa value of > 0.9; the kappa for + sensory deficit was 0.66 and for + femoral nerve stretch test was 0.47.

Conclusion: In this pilot study, initial patient screening assessments carried out by Chiropractors and Spine Physicians had high inter-observer reliability in 8 of the 10 examination procedures tested and were superior to previously reported multidisciplinary inter-observer kappa values.