title: The reliability of a 10-test package for patients with prolonged back and neck pain: could an examiner without formal medical education be used without loss of quality? A methodological study.
abstract: BACKGROUND
  In the rehabilitation of patients with prolonged back and neck pain, the physical impairment should be assessed. Previous research has exclusively engaged medically educated examiners, mostly physiotherapists. However, less biased evaluations of efforts at rehabilitation might be achieved by personnel standing outside the treatment work itself. Therefore, if medically untrained examiners could be used without cost to the quality, this might produce a better evaluation at defensible cost and could also be useful in a research context. The aim of this study was to answer the question: given a 10-test package for patients with prolonged back and neck pain, could an examiner without formal medical education be used without loss of quality? Five of the ten tests required the examiner to keep a firm hold against the foundation of those parts of the participant's body that were not supposed to move during the test.
  
  
  METHODS
  Examination by an experienced physiotherapist (A) in performing the package was compared with that by a research assistant (B) without formal medical education. The reliability, including inter- and intra-rater reliability, was assessed. In the inter-rater reliability study, 50 participants (30 patients + 20 healthy subjects) were tested once each by A and B. In the intra-rater reliability study, the 20 healthy subjects were tested twice by A or B. One-way ANOVA intra-class-correlation coefficient (ICC) was calculated and its possible systematic error was determined using a t-test.
  
  
  RESULTS
  All five tests that required no manual fixation had acceptable reliability (ICC > .60 and no indication of systematic error). Only one of the five tests that required fixation had acceptable reliability. The difference (five vs. one) was significant (p = .01).
  
  
  CONCLUSIONS
  In a 10-test package for patients with prolonged back and neck pain, an examiner without formal medical education could be used without loss of quality, at least for the five tests requiring no manual fixation. To make our results more generalizable and their implications more searching, a similar study should be conducted with two or more examiners with and without formal medical education, and the intra-rater reliability study should also include patients and involve more participants.
authors.affiliation: Center for Family Medicine, Karolinska Institutet, Huddinge, Sweden. odd.lindell@ki.se
authors.forename: Odd
authors.initials: O
authors.lastname: Lindell
authors.forename: Lars
authors.initials: L
authors.lastname: Eriksson
authors.forename: Lars-Erik
authors.initials: LE
authors.lastname: Strender
mesh_terms: D000328:Adult; D001416:Back Pain / Q000175:diagnosis* / Q000503:physiopathology; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control*; D004185:Disability Evaluation; D005260:Female; D006801:Humans; D008297:Male; D008511:Medicine / Q000592:standards; D008875:Middle Aged; D019547:Neck Pain / Q000175:diagnosis* / Q000503:physiopathology; D009460:Neurologic Examination / Q000379:methods; D015588:Observer Variation; D010808:Physical Examination / Q000379:methods*; D026761:Physical Therapy Specialty / Q000592:standards; D011237:Predictive Value of Tests; D012016:Reference Values; D015203:Reproducibility of Results; D013038:Specialization