INTER-RATER AND INTRA-RATER RELIABILITY OF ACTIVE HIP ABDUCTION TEST FOR STANDING INDUCED LOW BACK PAIN

Int J Physiot her Res 2015;3(5):1258-62. ISSN 2321-1822 1258

Original Article

INTER-RATER AND INTRA-RATER RELIABILITY OF ACTIVE HIP

ABDUCTION TEST FOR STANDING INDUCED LOW BACK PAIN

M ansi Shah *

_{, Pravin Aaron}

_{, Subin Solomen}

_.

* 1 _{Lect urer, M usculoskeletal Physiot herapy, Ashok & Rita Patel Inst it ute of Physiot herapy, Gujarat ,}

India.

2 _{Professor and Principal, Padmashree Inst it ute of Physiot herapy, Bangalore, Karnataka, India.} 3 _{Professor, Depart m ent of Physiot herapy, Padmashree Inst it ut e of Physiot herapy, Bangalore,}

Karnat aka, India.

Background: Act ive hip abduct ion t est (AHAbd) has pr eviously been show n t o be a r eliable t ool for pr edict ing low back pain developm ent during a prolonged st anding exposure in previously asym pt om at ic individuals, but t he reliabilit y of AHAbd on pat ient s w it h st anding induced occupat ional low back pain has not been est ablished. As it is an obser vat ion based t est , reliabilit y am ong differ ent rat er s and sam e rat er m ust be est ablished. The purpose of t his st udy w as to invest igat e t he inter-rat er and int ra-rater reliabilit y of t he AHAbd t est as a diagnost ic inst rum ent in subject s w it h st anding induced occupat ional low back pain.

M aterials and M ethods: A t ot al of 30 subject s w ere assessed w it h 1 day int erval t o find out int ra-rat er reliabilit y and t he sam e 30 subject s w ere exam ined independent ly on t he sam e day by t w o t herapist s t o get t he int er-rat er reliabilit y. Int ra-class cor relat ion coefficient s (ICCs) w ere calculat ed for reliabilit y stat ist ics.

Results and Discussions: AHAbd t est dem onst rat ed higher int ra-rat er r eliabilit y t hat is 0.91 (95% CI: .82-.85) t han int er-r at er reliabilit y w hich w as 0.83 (95% CI: .82-.95), alt hough bot h w ere m oderat e t o good for pat ient s w it h st anding induced low back pain.

Conclusions: AHAbd t est m ay prove usef ul as part of an ergonom ic assessm ent but it s level of reliabilit y w ar rant s caut ions for it s sole use w hen assessing low back pain induced by pr olonged st anding.

KEY W ORDS: AHAbd t est , Low back pain, Prolonged standing, Reliabilit y, Teachers, Lum bo-pelvic cont rol.

ABSTRACT

INTRODUCTION

Address for correspondence: Dr. M ansi Shah. PT., Lect urer, M usculoskeletal Physiot herapy, Ashok & Rita Patel Inst it ute of Physiot herapy, Gujarat 388 421, India. E-M ail: mbshah8@gmail.com

Int J Physiother Res 2015, Vol 3(5):1258-62. ISSN 2321-1822 DOI: ht t p:/ / dx.doi.org/10.16965/ ijpr.2015.187

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DOI: 10.16965/ ijpr.2015.187

Received: 22-09-2015 Peer Review : 22-09-2015 Revised: None

Accept ed: 01-10-2015 Published (O): 11-10-2015 Published (P): 11-10-2015

M echanical Low back pain has been show n t o be an im port ant healt h and socio-econom ic problem of occupat ional diseases, w hich plague a l ar ge segm ent o f t h e p o pu l at i o n i n indust rialized count ries [1] . It is caused by various w ork relat ed fact or w hich can lead t o w ork incapacit y and invalidit y [2, 3].Low back pains signify not only poor qualit y of life of

individuals, but also decreases labour product i-vit y due t o off-w ork, absent eeism and early ret irement [3]addit ionally, escalat ing m edical cost s are associated w it h LBP.

ISSN 2321-1822 t eachers mobilize t heir physical, cognit ive, and affect ive capacit y t o reach t eaching product ion obj ect ives, gener at ing over ef f o r t of t heir psycho-physiologic funct ions. Work of teachers i n vo l v es a co n si d er ab l e p h ysi cal l oad , est ablished by t he educat or remaining in t he orthostatic position during up to 95% of activities [5].

Recent musculoskeletal researches have proved that muscle co activat ion of glut eus medius (GM ) act as precursor t o LBP developm ent during prolonged st anding [6, 7, 8, 9].Based on t his finding, Act ive hip abduct ion test w as developed as a simple screening t ool t o provide a general assessment of an individual’s abilit y t o maintain t r un k an d pel v is ali gn m en t du r i ng l ow er ext r em i t y m o v em en t w h en p laced i n an inherent ly unst able side lying posit ion. The scoring crit eria included t w o ordinal scale one for par t icipant and ot her for exam iner. The part icipant is asked t o rate t he difficult y of t he t ask on 6 point ordinal scale and t he examiner rat es front al plane cont rol of t he pelvis during act ive hip abduct ion on a 4 point ordinal scale, for t he examiner rat ed scale t he score from t he w orse of t he 2 sides is used [10].

Alt hough int er-rat er and int ra-rat er reliabilit y of AHAbd t est in asym pt om at i c sub j ect s has already been est ablished [11], it is surprising t hat it s reliabilit y in clinical populat ion is st ill unknow n. If AHAbd t est for assessing st anding induced LBP is found t o be reliable in clinical p op u l at i o n, i t m i gh t al l o w cl in i cian s t o st andardize screening and evaluat ion met hods in occupat ional set t ings and t hereby help in prevent ion of occurrence of st anding induced LBP w hich w ould ult imat ely result in increased w ork product ivit y and less economic burden. Therefore, t he aim of t his st udy w as t o assess t he reliabilit y of AHAbd t est as diagnost ic t est in t eachers w it h st anding induced mechanical LBP.

M ATERIAL AND M ETHODS

Design: Reliabilit y st udy

Par t icip an t s: A co n ven i en ce sam p l e o f volunt eer subject s- t eachers having mechanical l ow b ack pai n w as r ecr u i t ed f r o m t h e government high schools, Bangalore, India. And 2 Pract icing physical t herapist s w orking in a similar clinical set up w ere chosen t o find out inter-rater reliabilit y.

Inclusion criteria for subjects: Age bet w een 30 t o 45 years, bot h t he gender, t hose w ho are st anding for more t han 2 hours, having low back pain during or im m ediat ely aft er prolonged standing task, no previous episode of surgery, fract ures, or syst em ic diseases in spine and low er limbs w ere included in t he st udy.

Inclusion criteria for raters: Holding master ’s degree in or t hopedic physiot herapy, act ive engagem ent in clinical pract ice- pr ef erably m uscu lo skel et al d ep ar t m en t an d h avi n g minimum of 3 years of clinical experience.

Tra in in g of rat e rs: Jou r n al ar t i cle w hi ch descr ibed t he developm ent of t est , scoring crit eria of t est , scoring sheet and video t ut orial of t est ing and scoring w as mailed t o bot h t he r at er s 2 w eek s p r io r i t y. AHAbd t est an d p r oced ur e of p er f o r m i n g an d r at i n g w as demonst rat ed in person t o bot h rat ers prior t o t h e day o f dat a co ll ect io n an d any d ou bt regarding execut ion and int er pret at ion w as solved.

Both the raters were direct ly called to the schools w here t he data collect ion w as conducted. Rat ers w ere made t o stand in such a way t hat t hey have a clear view of pat ient ’s frontal and axial view of pelvis. They were not allowed to discuss about any part icipant ’s score.

The t est w as assessed sim ult aneously and independent ly by t w o rat ers t o get int er-rat er reliability for a tot al of 30 subject s. And t he same 30 subject s w ere assessed by researcher w here t he t est was repeated after 24 hours to see int ra-rater reliabilit y.

Procedure: Principals of 9 governm ent high schools w ere contact ed by t elephone t o request a meet ing t o explain t he st udy procedure and discuss t he feasibilit y of doing t he st udy in t heir schools. Follow ing t he m eet ing all t he st aff m em ber s having m echanical LBP dur ing or immediat ely after prolonged st anding t ask were screened. Demographic details like name, age, Approval for t his research st udy w as grant ed by

Int J Physiot her Res 2015;3(5):1258-62. ISSN 2321-1822 1260 gender, address, phone number was recorded

and hist ory w as obt ained from t he subject s eli gi b le f o r p ar t i cip at i on , em p h asizi ng o n inclusion and exclusion crit eria. Part icipant s w ere request ed t o ret urn complet ed consent forms t he next day w hen act ual dat a collect ion was t o happen and t hey w ere asked t o w ear loose fitt ing clot hes t he next day, t o allow free m ovem ent and easy ob ser vat ion of pelvic movement.

To carry out t he AHAbd test , subjects w ere asked t o lie on t heir side, w it h bot h of t heir low er limbs fully ext ended, in neut ral hip rot at ion and a relaxed ankle posit ion, and t heir t op upper ext remit y rest ing on t he ribcage and t he hand on t he abdomen. The invest igat or t hen ensured t hat t he subject ’s shoulder, t runk, and bilateral low er ext remit ies w ere in alignment . Subject s w ere not allow ed t o pract ice t he movement ; t o avoid the pract ice effect [12]how ever, they w ere passively moved t hrough t he AHAbd t est prior t o each t rial so t hey could get a sense of t he m ovem ent sequence and r ange of m ot ion. Invest igat or provided subject s w it h t he verbal inst ruct ions used in a clinical set t ing: “ Please keep your knee st raight and raise your t op t high and leg t owards t he ceiling, keeping t hem in line w it h your body, and t ry not t o let your pelvis t ip forwards or backwards.” Subjects performed t he t est bilat erally and w orse score from t w o sides was taken int o considerat ion [10].

D at a An a lysis: St at i st i cal anal y si s w as performed by using SPSS soft w are (version 17) compat ible w it h Window s. Alpha value w as set at 0.05. Descript ive st atist ics w as used t o assess dem ogr aphic variables and variables of t he act i ve h ip abd uct i on t est . The i nt r a-r at er reliabilit y w as assessed using t he int ra-class correlat ion coefficient . The guidelines used for t he int erpret at ion of t he ICCs w ere as follow s: 0.00 t o 0.25 indicat ed lit t le if any correlat ion; 0.26 t o 0.49 indicat ed low correlat ions; 0.50 t o 0.69 indicat ed moderat e correlat ions; 0.70 t o 0.89 indicated high correlat ions; and 0.90 t o 1.00 indicat ed very high correlat ion. [11].

RESULTS

and one for int ra-rater reliabilit y.

The mean of t he age of subject s w as 37.50 ± 2.58 years (mean ± SD). For int ra-rater reliabilit y, mean of examiner scale score on day-1 w as 1.57 ± 0.82, and day-2 score w as 1.43 ± 0.86. The minimum value w as 0 and maximum value w as 3. And for inter-rater reliabilit y, mean of rater-1‘s score was 1.03± 0.76 and rater 2’s mean score w as 1.03± 0.81.

The int ra rat er reliabilit y for t he examiner-scale w as found t o be high w it h ICC value of single measures being 0.915 (95% CI-0.82-0.95) and for average measures being 0.956 (95%CI-0.90-0.97) w hich w as st at ist ically significant (p= <.0001). The int ra rat er reliabilit y for t he subject -scale w as also found t o be high w it h ICC value being 0.933 (95%CI- .86-.96).

A t ot al of t hirt y subject s, ranging from 35 t o 45 years of age, were assessed during performance of the AHAbd t est by 3 rat ers, t w o for int er-rat er

Table 1: Int ra-rat er reliabilit y, ICC (single& average), 95% CI & result s for exam iner scale.

Sl No M easurement ICC 95% CI p value 1 Single M easures 0.915 .829-.959 < 0.0001

2 Average M easures 0.956 .907-.979 < 0.0001

Table 2: Int er-rat er reliabilit y, ICC (single& average), 95% CI for exam iner scale.

Sl No M easurement ICC 95% CI p value 1 Single M easures 0.833 .829-.959 < 0.0001 2 Average M easures 0.909 .907-.979 < 0.0001

DISCUSSION

Ob j ect ive o f t h is st ud y w as t o det er m i ne reliabilit y of AHAbd t est as diagnost ic t est in teachers w ith standing induced OLBP. The result s from t his study revealed moderat e t o high inter-r at einter-r and in t inter-r a-inter-r at einter-r inter-r eli abilit y in physical t herapist scoring of t he AHAbd t est .

ISSN 2321-1822

st anding fact ors, numerous ot her fact ors could also hav e a r ol e in d ev el op i n g OLBP l i ke psychosocial fact or, ergonom ical fact ors and gender as most of the subject s were female, few o f t h em w er e nu l l ip ar ou s an d f ew w er e m ult iparous, but it w as out of our scope t o cont rol each of t he fact ors. The t raining session for t he rat ers employed mail conversat ion and face t o face conversat ion on t he day of dat a collect ion, so t heir underst anding of the t est and scoring w ould have been affect ed.

Fut ure st udies can be done t o measure validit y of AHAbd t est ; also a prospect ive cohort can be conducted on the asympt omat ic individuals who w ere graded 2 or more on examiner scale, t o explore t he development of low back pain in t hose subject s.

act ivit y as eit her a com pensat i on f or or a precipit at or of passive subsyst em damage and t his pre-mat ured elect rical act ivit y it self could be considered as a possible underlying source of recurrent or chronic back pain sympt om.

The high int er-rat er reliabilit y found in present st udy could be due t o several fact ors like in t his st udy t he subject s w it h low back pain w ere t est ed for w hom alt er ed m uscle act ivat ion pattern is not difficult t o not ice. M oreover, t he scr eening t ool is very sim ple w it h very less chance of misint erpret at ion. And it is possible t hat high int er-rat er reliabilit y in t he present st udy might have been achieved because w e included only a small number of experienced (>3years) t herapist s. The reliabilit y value may be different if more rat ers are involved, as in t he reliabilit y st udy done on healt hy subject by Alice et al, where 16 pract icing physical therapist o f d i f f er en t exp er i en ce l ev el s agr eed t o part icipat e.

The result s of t his st udy align w ell w it h ot her reliabilit y st udies of observat ional t est s used t o assess lumbo-pelvic cont rol during low er limb movement . And in fact t hese all st udies show s t hat t h e AHAbd t est h as h i gh er l evel s o f reliabilit y t han many ot her m ovem ent -based t est s used in clinical pract ice [11] .This high reliabilit y along w it h t he high specificit y values (0.85)[9] indicat es t hat t he t est may be useful for ruling in pain development during st anding, although the validity has to be established before u si ng i t as a scr een i ng t oo l in er go no m i c evaluat ion.

M any aut hors have suggest ed t hat diagnosis based on m ovem ent cont r ol im pair m ent is considered t o be a relevant w ay t o subgroup low back pain pat ient s [13]and out comes can be im proved w hen t his sub-grouping is used t o guide t reat ment decision making. The result of t his st udy suggest s t hat AHAbd t est may assist in ident ifying sub-group of pat ient s at risk of d evel o pi n g st and i n g i n du ced OLBP. Su ch predict ive models w ould help prevent sickness absence on t he individual level and economic cost s at communit y level.

Lim it at ions include convenient t echnique for sampling w hich might not have demonst rat ed t he scope of movement pat t erns t ypically seen in t he backache populat ion. Along w it h t he

CONCLUSION

The AHAbd t est can be considered t o be a reliable observat ional t ool for assessing

lumbo-pelvic move­ment patterns in adults having

mechanical back pain during\ aft er prolonged st anding t ask. As t here is a need t o provide effect ive early int ervent ions t hat prevent s t he development of persistent pain and disabilit y, ident ifying pat ient s at risk for t his development is an important step and Predict ive models like AHAbd t est could be of value in isolat ing such pat ient s, alt hough validit y in clinical populat ion should be est ablished first before using t he t est for ergonomic evaluat ion.

Conflicts of interest: None

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M ansi Shah, Pravin Aaron, Subin Solomen. INTER-RATER AND INTRA-RATER RELIABILITY OF ACTIVE HIP ABDUCTION TEST FOR STANDING INDUCED LOW BACK PAIN. Int J Physiot her Res 2015;3(5):1258-1262. DOI: 10.16965/ ijpr.2015.187

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