Table.
Inter- and Intraexaminer Reliability of Bony Anatomic Landmark Asymmetry Assessment
| Study | Methods | No. of Participants and Examiners |
Landmarks Evaluated, Reliability (κ Coefficient)* |
Quality Score (%) With Breakdown† |
Author Conclusions |
|---|---|---|---|---|---|
| Kmita and Lucas, 200831 |
Double-blind assessment performed twice |
5 symptomatic and 4 asymptomatic patients; 4 examiners (2 clinicians, 2 students) |
PSIS, 0.04/0.13 SS, −0.40/0.283 ILA-S/I, −0.01/0.058 ILA-A/P, −0.03/0.095 ASIS, 0.13/0.403 |
6 (100) 1, 1, 1, 1, 1, 1 |
Alternatives to static asymmetry assessment are recommended for assessment of low back pain and/or pelvic dysfunction. |
| Holmgren and Waling, 200832 |
Independent examination performed once; only interexaminer reliability was assessed |
25 symptomatic patients; 2 examiners (experienced clinicians) |
L5 transverse processes, 0.17 SS, 0.11 ILA-A/P, 0.11 |
3.5 (58) 0, 1, 1, 0, 0.5, 1 |
Interexaminer reliability observed was only slightly better than expected by chance; low interexaminer reliability was attributed to differences in palpation technique. |
| Tong et al, 200633 | 2 rounds of evaluation; 3 methods for analyzing results; only interexaminer reliability was assessed |
24 symptomatic patients; 2 examiners (training level unknown) |
SS‡ in trunk flexion, 0.37 SS‡ in trunk extension, 0.05 ASIS, 0.15 |
3.5 (58) 0, 1, 1, 0, 0.5, 1 |
Maximum interexaminer reliability occurs when the most reliable test is used to evaluate SIJ dysfunction; this method is suggested in clinical decision making. |
| Fryer et al, 200534 | Trained group of examiners had 2 1-h training sessions; each landmark examined 3 times |
10 asymptomatic patients; 2 groups of 5 examiners (trained and untrained fifth- year students) |
Untrained: PSIS, 0.15/0.49 ILA-S/I, −0.01/0.03 ILA-A/P, −0.01/0.2 ASIS, −0.01/0.19 Trained: PSIS, 0.08/0.54 ILA-S/I, 0.04/0.2 ILA-A/P, 0.040.07 ASIS, 0.24/0.65 |
6 (100) 1, 1, 1, 1, 1, 1 |
Osteopathic physicians should reconsider these tests in evaluation of the SIJ. Training inconclusively improved assessment of anatomic landmark asymmetry; an improved understanding of these evaluation procedures is recommended. |
| Degenhardt et al, 200535 |
3 phases of experiment: phase 1, multiple tests; phase 2, consensus training over 4 mo for most reliable tests from phase 1; and phase 3, examinations with trained assessments |
42 symptomatic patients evaluated before training, 77 after training; 3 examiners (trained in manual medicine) |
L1-L4 transverse processes,§ 0.17 (untrained) and 0.34 (trained) |
5 (83) 0, 1, 1, 1, 1, 1 |
Consensus training can significantly improve interexaminer agreement for palpatory examinations. |
| Spring et al, 200136 | Fifth-year students; 3-part positional screen in neutral, hyperflexed, and extended positions; 1 h of training before examination; total of 3 examinations |
10 asymptomatic patients; 10 examiners (fifth- year students |
L4, 0.04/0.037 | 6 (100) 1, 1, 1, 1, 1, 1 |
No significant agreement above chance was found for inter- or intraexaminer reliability. Poor reliability may be attributed to anatomy of lumbar spine; caution is suggested in using static asymmetry for lumbar spine assessment. |
| O′Haire and Gibbons, 200037 |
4 assessments per examiner; 1-h training session to standardize methods |
10 asymptomatic patients; 10 examiners (fifth -year students) |
PSIS, 0.04/0.326 SS, 0.07/0.24 ILA-S/I, 0.08/0.211 |
6 (100) 1,1,1,1,1,1 |
Further studies are needed to better understand the low reliability of anatomic landmark assessment of the SIJ. |
| Paydar et al, 199438‖ | Standing and sitting landmarks assessed; 2 evaluations with second 3 h after the first |
32 asymptomatic patients; 2 examiners (student interns with ≥1 year of clinical experience |
PSIS, 0.150/0.248 | 3 (50) 1, 1, 0, 0, 0, 1 |
Palpatory findings should not be the primary factor in clinical decision making; the patient′s response to the treatment is probably the only indication that the diagnosis was correct. |
| Potter and Rothstein, 198539‖ |
Clinicians; 13 common tests assessed |
17 symptomatic patients; 8 examiners (clinicians) |
Standing PSIS,§ 35.29% agreement sitting PSIS,§ 35.29% agreement standing ASIS,§ 37.50% agreement; χ2 value calculated for goodness of fit with 90% and 70% agreement expected |
2 (33) 0, 1, 1, 0, 0, 0 |
The poor reliability observed suggests that new operational definitions for SIJ evaluation are needed; given that clinicians in the same profession evaluated the patients, this study raises issues of continuity of care. |
*
Except where otherwise explained, values represent interexaminer reliability (single κ values) or interexaminer/intraexaminer reliability. The term clinicians may include osteopathic physicians, osteopaths, chiropractors, and others.
†
Breakdown of quality score is listed in consecutive order, as found in the Figure.
‡
Patients evaluated in seated flexed and sphinx positions.
§
Other assessment methods were used during the study.
‖
Patients were seated.
Abbreviations: ASIS, anterior superior iliac spine; ILA-S/I, inferior lateral angle of sacrum, superior/inferior assessment; ILA-A/P, inferior lateral angle of sacrum, anterior/posterior assessment; PSIS, posterior superior iliac spine; SIJ, sacroiliac joint; SS, sacral sulcus.