Effectiveness of using a behavioural intervention to improve dietary fibre intakes in children with constipation.

BACKGROUND: Functional constipation is common in childhood; diets in affluent industrialised countries may be a significant contributory factor as a result of inadequate fibre content. Only a few intervention studies have been reported where childhood constipation has been treated by increasing dietary fibre. The present study aimed to demonstrate that dietary fibre intakes of children with constipation can be increased using a specifically-designed behaviour modification technique with a self-monitoring and reward system. METHODS: Forty-three children, aged 2-14years, with functional constipation (defined as less than three bowel movements per week with hard stools and difficulty or delay in defecation) were randomised to one of two treatment groups: Control (n=20), receiving general advice on increasing dietary fibre intake, or Intervention (n=23), using the intervention tool. Fibre intake, laxative use and stool frequency were assessed at baseline, and at 3, 6 and 12months, using parent-filled diaries. RESULTS: A behavioural intervention method significantly increases the fibre intakes of children with constipation at 3 months compared to standard dietary treatment (P=0.005), remaining so after adjusting for baseline fibre intake (P=0.007). Follow-up at 6 and 12months showed no further increase. No significant benefit in terms of a reduction in laxative use or increased stool frequency associated with additional fibre intake was demonstrated. CONCLUSIONS: The findings confirm the difficulties encountered in beginning and maintaining high-fibre diets in children.

Chylopericardium in a child with impaired venous access following small bowel transplantation.

A 10-yr-old child with impaired venous access (bilateral occlusion of internal jugular veins, subclavian veins, and inominate veins) underwent an isolated small bowel transplant. He presented with lethargy, shortness of breath 13 months into his follow-up and was diagnosed to have chylopericardium. MR venography and lymphangiography could not demonstrate the site of lymphatic leak. His chyloperciardium was treated with pericardiocentesis and MCT diet. The most likely cause for the chylopericardium was venous occlusion of the subclavian veins with backpressure resulting in a lymphatic leak. A brief review of literature along with treatment options is discussed.

Integration of subclassification strategies in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review.

BACKGROUND: There is lack of evidence for specific treatment interventions for patients with non-specific chronic low back pain (NSCLBP) despite the substantial amount of randomised controlled clinical trials evaluating treatment outcome for this disorder. HYPOTHESIS: It has been hypothesised that this vacuum of evidence is caused by the lack of subclassification of the heterogeneous population of patients with chronic low back pain for outcome research. STUDY DESIGN: A systematic review. METHODS: A systematic review with a meta-analysis was undertaken to determine the integration of subclassification strategies with matched interventions in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for NSCLBP. A structured search for relevant studies in Embase, Cinahl, Medline, PEDro and the Cochrane Trials Register database, followed by hand searching all relevant studies in English up to December 2008. RESULTS: Only 5 of 68 studies (7.4%) subclassified patients beyond applying general inclusion and exclusion criteria. In the few studies where classification and matched interventions have been used, our meta-analysis showed a statistical difference in favour of the classification-based intervention for reductions in pain (p=0.004) and disability (p=0.0005), both for short-term and long-term reduction in pain (p=0.001). Effect sizes ranged from moderate (0.43) for short term to minimal (0.14) for long term. CONCLUSION: A better integration of subclassification strategies in NSCLBP outcome research is needed. We propose the development of explicit recommendations for the use of subclassification strategies and evaluation of targeted interventions in future research evaluating NSCLBP.

NOX1 loss-of-function genetic variants in patients with inflammatory bowel disease.

Genetic defects that affect intestinal epithelial barrier function can present with very early-onset inflammatory bowel disease (VEOIBD). Using whole-genome sequencing, a novel hemizygous defect in NOX1 encoding NAPDH oxidase 1 was identified in a patient with ulcerative colitis-like VEOIBD. Exome screening of 1,878 pediatric patients identified further seven male inflammatory bowel disease (IBD) patients with rare NOX1 mutations. Loss-of-function was validated in p.N122H and p.T497A, and to a lesser degree in p.Y470H, p.R287Q, p.I67M, p.Q293R as well as the previously described p.P330S, and the common NOX1 SNP p.D360N (rs34688635) variant. The missense mutation p.N122H abrogated reactive oxygen species (ROS) production in cell lines, ex vivo colonic explants, and patient-derived colonic organoid cultures. Within colonic crypts, NOX1 constitutively generates a high level of ROS in the crypt lumen. Analysis of 9,513 controls and 11,140 IBD patients of non-Jewish European ancestry did not reveal an association between p.D360N and IBD. Our data suggest that loss-of-function variants in NOX1 do not cause a Mendelian disorder of high penetrance but are a context-specific modifier. Our results implicate that variants in NOX1 change brush border ROS within colonic crypts at the interface between the epithelium and luminal microbes.

Fundoplication versus post-operative medication for gastro-oesophageal reflux in children with neurological impairment undergoing gastrostomy.

BACKGROUND: Children with neurological impairments (NI) frequently experience feeding difficulties which can lead to malnutrition and growth failure. Gastrostomy feeding is now the preferred method of providing nutritional support to children with NI who are unable to feed adequately by mouth. Complications may arise as a result of gastrostomy placement and the development or worsening of gastro-oesophageal reflux (GOR) has been widely reported. This has led to the frequent use of surgical anti-reflux treatment in the form of a fundoplication, or other Anti-Reflux Procedures. Fundoplication is associated with a high recurrence rate, surgical failure and significant morbidity and mortality. Since Proton Pump Inhibitors (PPIs) were introduced in the 1990s they have come to play a larger part in the medical management of GOR in children with NI. Uncontrolled studies suggest that PPIs may be a safe, appropriate treatment for GOR. Other agents currently used include milk thickeners, acid suppression drugs, acid buffering agents, gut motility stimulants and sodium alginate preparations. There are risks and benefits associated with both surgical and medical interventions and further comparison is necessary to determine the optimal treatment choice. OBJECTIVES: To compare the effectiveness of anti-reflux surgery and anti-reflux medications for children with NI and GOR who are undergoing placement of a gastrostomy feeding tube. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) up to Issue 2, 2006, MEDLINE (1966 to June 2006), EMBASE (1980 to week 33, 2006), CINAHL (1982 -to May, week 4, 2006), LILACS (1982 to June 2006), ISI Web of Science (1970 to June 2006) and the Child Health Library (searched June 2006). We also performed online searches of trial registries, medical journals, conference proceedings, dissertations and theses. Specialists in the medical and industry setting were contacted for knowledge of completed or ongoing trials. SELECTION CRITERIA: We sought to include only randomised controlled trials that recruited children up to the age of 18 years with NI and GOR who were undergoing gastrostomy tube insertion. DATA COLLECTION AND ANALYSIS: Two reviewers worked independently on selected trials and performed data extraction and assessment of trial quality. MAIN RESULTS: No trials were identified that satisfied the criteria for this review. AUTHORS' CONCLUSIONS: There remains considerable uncertainty regarding the optimal treatment when faced with the decision of fundoplication surgery versus anti-reflux medications for gastro-oesophageal-reflux in the child with neurological impairment who is undergoing gastrostomy insertion. There is a need for robust scientific evidence in order to provide data on the comparable risks or benefits of the two interventions.

The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment.

The importance of classifying chronic low back pain (LBP) patients into homogeneous sub-groups has recently been emphasized. This paper reports on two studies examining clinicians ability to agree independently on patients' chronic LBP classification, using a novel classification system (CS) proposed by O'Sullivan. In the first study, a sub-group of 35 patients with non-specific chronic LBP were independently classified by two 'expert' clinicians. Almost perfect agreement (kappa-coefficient 0.96; %-of-agreement 97%) was demonstrated. In the second study, 13 clinicians from Australia and Norway were given 25 cases (patients' subjective information and videotaped functional tests) to classify. Kappa-coefficients (mean 0.61, range 0.47-0.80) and %-of-agreement (mean 70%, range 60-84%) indicated substantial reliability. Increased familiarity with the CS improved reliability. These studies demonstrate the reliability of this multi-dimensional mechanism-based CS and provide essential evidence in a multi-step validation process. A fully validated CS will have significant research and clinical application.

Evaluation of specific serum anti-Giardia IgM antibody response in diagnosis of giardiasis in children.

Diagnosis of Giardia intestinalis infection is usually made by examination of stool specimens and/or by more invasive methods such as microscopy of duodenal juice or small bowel mucosal biopsies. Serological diagnostic methods have been developed but have not been evaluated in children. In this study specific anti-Giardia immunoglobulin (Ig) M, IgG and IgA antibody titres were measured by enzyme-linked immunosorbent assay. Giardia parasites were sought in jejunal mucosal biopsies and in faeces from 72 children in The Gambia, West Africa; 50 jejunal biopsies, 271 stool samples and 95 serum samples were examined for evidence of Giardia infection. As a diagnostic test, a raised specific anti-Giardia IgM antibody titre (greater than or equal to 1:800) had a sensitivity of 63% and specificity of 93%, with a positive predictive value of 85% and a negative predictive value of 81%. There was poor correlation between positive microscopical identification of Giardia and elevated specific anti-Giardia IgG or IgA antibody titres in children on admission to the study. Elevated serum anti-Giardia IgM, however, was correlated well with active Giardia infection and may prove useful in epidemiological studies of giardiasis in developing countries.

Clinical applications of epidermal growth factor.

Epidermal growth factor (EGF) is a molecule with a broad pharmacological activity which has been used clinically, with promising results, to treat patients affected by necrotizing enterocolitis, Zollinger-Ellison syndrome, gastrointestinal ulceration and congenital microvillus atrophy. In theory, EGF may find a clinical application in a variety of other pathologies of both the gastrointestinal tract and other systems. Examples of gastrointestinal diseases that could benefit from treatment with EGF include colitis, gastrointestinal ulcerations of various causes, atrophic conditions, conditions of defective maturation and development and even cancer. However, the clinical use of EGF may be associated with a variety of problems and side-effects; careful selection of patients and evaluation of risk-benefit ratios are required.

Nutritional management of acute diarrhea.

Despite recommendations from several bodies such as the World Health Organization and others that feeding should be continued during diarrhea, the practice of withholding food during the early stages of diarrhea is still widespread. This contributes to a deterioration in patients' nutritional state. The principal controversy in the nutritional therapy of acute gastroenteritis centers on the relative risks of cows'-milk feeds. The two things that need to be considered in determining the optimum approach to feeding the child with acute diarrhea are the optimum timing for feeding children in relation to the onset of and recovery from symptoms and, secondly, the effects of specific food ingredients in the diet. Recent studies have demonstrated that the vast majority of young children with acute diarrhea can be successfully managed with continued feeding of undiluted non-human milk. Routine dilution of milk and routine use of lactose-free formula are not necessary, especially when oral rehydration therapy and early feeding (in addition to milk) form the basic approach to the clinical management of diarrhea in children. Confounding factors are the severity of the diarrhea, coexistent malnutrition, and young age (< 1 y); such infants are much more likely to have complications from early feeding with undiluted milk and some would advocate use of specifically designed lactose-free formula in such children. Children who are fed exclusively with human milk and those who receive solid foods with or without human milk may safely continue to receive their usual diets during diarrhea. Those who are fed exclusively with non-human milk--especially when very young and with severe diarrhea or malnutrition--should be closely observed if they continue to consume milk or they should receive a special formulation (e.g., a cereal-milk mixture or fermented milk product). The use of nutrient-dense mixtures of common foods may be advisable to promote compensatory growth in those who lose weight during illness or because of anorexia or malabsorption.

Ultrasound assessment of swallowing in malnourished disabled children.

Oral motor dysfunction is common in children with neurological impairment. Nutritional advice depends upon an accurate assessment of feeding potential in these cases. Videofluoroscopic assessment of oral motor function has been the accepted "gold standard" investigation for several years but has significant drawbacks, including the time constraints set by the use of ionizing radiation and the problems posed by the cumbersome equipment needed in mimicking the child's normal feeding situation. Ultrasonography (US) has been suggested as an alternative or additional investigation of oral motor function in children with neurological impairment. We prospectively evaluated a scoring system derived from US assessment of oral motor function in 32 malnourished disabled children with feeding problems by comparing them with a group of matched control children without neurological impairment. US imaging provided useful information with regard to the oral cavity and the soft tissue structures, capturing the salient features of tongue/hyoid/palate activity and bolus transport across the tongue and through the hypopharyngeal area. The mean percentage score obtained by US assessment of oral motor function in children with neurological impairment was 54.3 +/- 23.2 and from children without neurological impairment 91.9 +/- 12.7 (p < 0.0001). Scores for the oral and pharyngeal phases of swallowing were also very significantly lower than that in the control group, both phases being equally impaired in the disabled children. This study has demonstrated that a scoring system based on US assessment of different components of oral motor activity detects statistically significant differences in the feeding capabilities of children with neurological impairment.

Gastrostomy feeding versus oral feeding alone for children with cerebral palsy.

BACKGROUND: Children with cerebral palsy (CP) can be significantly disabled in terms of their ability to suck, chew and swallow. This can lead to significant impairment in feeding ability and, eventually, to under-nutrition. It can also result in aspiration of food into the lungs. Feeding time may be considerably increased and, instead of being an enjoyable experience, mealtimes may be distressing for both the child and carer. Increasingly for children unable to maintain a normal nutritional state feeding by mouth, gastrostomy or jejunostomy tubes are being used to provide the digestive system with nutrients. A gastrostomy tube is a feeding tube inserted surgically through the abdominal wall directly into the stomach. A jejunostomy feeding tube is inserted into the jejunum, part of the small intestine, either directly or via a previous gastrostomy. Although gastrostomy or jejunostomy placement may greatly facilitate feeding of children with CP, many carers find it very difficult to accept this intervention emotionally. The treatment is also relatively costly. For all of these reasons, its effectiveness requires assessment. OBJECTIVES: To assess the effects of nutritional supplementation given via gastrostomy or jejunostomy in children with feeding difficulties due to cerebral palsy. SEARCH STRATEGY: We searched the Cochrane Library's register of controlled trials (CENTRAL) up to Issue 4, 2003, MEDLINE 1977 - December 2003, EMBASE 1980 - December 2003, CINAHL 1982 - December 2003, LILACS 1980 - end 2003, ASLIB 1983 - 2003 and Dissertation Abstracts 1980 - 2003. SELECTION CRITERIA: Only randomised controlled trials which compared delivery of nutrition via a gastrostomy or jejunostomy tube compared with oral feeding alone for children up to the age of 16 were considered for this review. DATA COLLECTION AND ANALYSIS: Selection of trials, data extraction and assessment of trial quality were undertaken independently by two reviewers. MAIN RESULTS: No trials were identified that met the inclusion criteria for this review. REVIEWERS' CONCLUSIONS: On the basis of this systematic review, considerable uncertainty about the effects of gastrostomy for children with cerebral palsy remains. A well designed and conducted randomised controlled trial should be undertaken to resolve the current uncertainties about medical management for children with cerebral palsy and physical difficulties in eating.

Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis.

STUDY DESIGN: A randomized, controlled trial, test--retest design, with a 3-, 6-, and 30-month postal questionnaire follow-up. OBJECTIVE: To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and a radiologic diagnosis of spondylolysis or spondylolisthesis. SUMMARY OF BACKGROUND DATA: A recent focus in the physiotherapy management of patients with back pain has been the specific training of muscles surrounding the spine (deep abdominal muscles and lumbar multifidus), considered to provide dynamic stability and fine control to the lumbar spine. In no study have researchers evaluated the efficacy of this intervention in a population with chronic low back pain where the anatomic stability of the spine was compromised. METHODS: Forty-four patients with this condition were assigned randomly to two treatment groups. The first group underwent a 10-week specific exercise treatment program involving the specific training of the deep abdominal muscles, with co-activation of the lumbar multifidus proximal to the pars defects. The activation of these muscles was incorporated into previously aggravating static postures and functional tasks. The control group underwent treatment as directed by their treating practitioner. RESULTS: After intervention, the specific exercise group showed a statistically significant reduction in pain intensity and functional disability levels, which was maintained at a 30-month follow-up. The control group showed no significant change in these parameters after intervention or at follow-up. SUMMARY: A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.

Lumbar segmental 'instability': clinical presentation and specific stabilizing exercise management.

Lumbar segmental instability is considered to represent a significant sub-group within the chronic low back pain population. This condition has a unique clinical presentation that displays its symptoms and movement dysfunction within the neutral zone of the motion segment. The loosening of the motion segment secondary to injury and associated dysfunction of the local muscle system renders it biomechanically vulnerable in the neutral zone. The clinical diagnosis of this chronic low back pain condition is based on the report of pain and the observation of movement dysfunction within the neutral zone and the associated finding of excessive intervertebral motion at the symptomatic level. Four different clinical patterns are described based on the directional nature of the injury and the manifestation of the patient's symptoms and motor dysfunction. A specific stabilizing exercise intervention based on a motor learning model is proposed and evidence for the efficacy of the approach provided.

Altered abdominal muscle recruitment in patients with chronic back pain following a specific exercise intervention.

The efficacy of specific exercise interventions that advocate training the co-contraction of the deep abdominal muscles with lumbar multifidus for treating chronic back pain conditions has not been tested. A randomized controlled trial involving 42 subjects with a specific chronic back pain condition investigated whether this form of intervention results in changes to the ratio of activation of the internal oblique relative to the rectus abdominis. Data were collected before and after the intervention, using surface electromyography, while subjects performed different abdominal maneuvers. Subjects were randomly allocated to either a specific exercise group or control group. Following intervention, the specific exercise group showed a significant (p < 0.05) increase in the ratio of activation of the internal oblique relative to the rectus abdominis. The control group showed no significant change. The study findings provide evidence that the conscious and automatic patterns of abdominal muscle activation can be altered by specific exercise interventions.

Small intestinal mucosal histology in the syndrome of persistent diarrhoea and malnutrition: a review.

Prolonged injury to the small intestinal mucosa is probably the final common pathway by which a variety of noxious influences--nutritional, infective and possibly allergic--perpetuate the syndrome of persistent diarrhoea in children in developing countries. Animal studies have helped to separate the individual effects of malnutrition and diarrhoea on the gut in a way that is not possible in the clinical situation. Early studies in children provided somewhat subjective or semi-quantitative data on intestinal morphology. More recently, the application of computer-assisted quantitative morphological techniques to intestinal mucosae from children with persistent diarrhoea have revealed a spectrum of changes consistent with a cell-mediated immune form of damage. The nature of the antigens that provoke these responses remains to be elucidated. Several reports indicate that in children with persistent diarrhoea clinical severity and prognosis do not necessarily correlate with the degree of small intestinal mucosal damage. Nutritional rehabilitation can be shown to produce a demonstrable improvement in small intestinal crypt cell proliferative activity in children with persistent diarrhoea. It is not yet known for how long nutritional rehabilitation should be continued to ensure complete recovery of the intestinal damage following persistent diarrhoea.

Food allergy and food intolerance in childhood.

Food intolerance is a reproducible adverse reaction to a specific food ingredient that is not psychologically based. Food allergy is a form of food intolerance in which there is evidence that the response is caused by an immunological reaction to food. Other mechanisms of food intolerance include enzyme defects (e.g. lactase deficiency), pharmacological effects (e.g. histamine), toxic properties (e.g. haemagglutinating lectins) and irritants (e.g. spices). Food allergy in children is a highly contentious subject and there is often a striking lack of published evidence from which to base clinical decisions. The true prevalence of food allergy in children is unknown, although there is evidence of an increasing incidence of allergic reactions to some foods, especially peanuts. Our understanding of why some children are unable to tolerate certain foods (e.g. cow's milk, egg), or how they grow out of this intolerance, is very poor. Symptoms of food allergy in children are diverse and include vomiting, poor weight gain, abdominal pain, malabsorption, cough, wheeze, rhinitis, atopic eczema, urticaria and angioedema. Despite the lack of objective data to support the notion that food intolerance contributes to behaviour in children, this is a belief firmly held by many parents and some professionals. The gold standard for diagnosing food intolerance is the double-blind placebo-controlled food challenge (DBPCFC). There is often a poor correlation between the results of food provocation tests and those of skin prick tests of radioallergosorbent tests for specific food antibodies. For proven food allergy, elimination diets are the mainstay of management. In children these must be closely supervised to avoid nutritional deficiency and compromise of growth. Some children who have had severe (anaphylactic) reactions after food need to have a supply of self-injectable adrenaline made available to their parents and teachers and must also practice strict avoidance of the offending food.

Genetic variation in the beta-2 adrenergic receptor is associated with chronic musculoskeletal complaints in adolescents.

BACKGROUND: There is significant evidence to suggest that psychological and stress-related factors are important predictors of the onset of chronic widespread pain (CWP) and fibromyalgia (FM). The hypothalamic-pituitary-adrenal axis, together with the efferent sympathetic/adrenomedullary system, influence all body organs (including muscles) during short- and long-term threatening stimuli. The aim of this study was to investigate the relationship between genetic variants in adrenergic candidate genes and chronic musculoskeletal complaints (MSCs) in adolescents. METHODS: Adolescents from the Western Australian Pregnancy (Raine) Cohort attending the 17-year cohort review completed a questionnaire containing a broad range of psychosocial factors and pain assessment (n = 1004). Blood samples were collected for DNA extraction and genotyping. Genotype data was obtained for 14 single nucleotide polymorphisms (SNPs) in two candidate genes - beta-2 adrenergic receptor (ADRB2) and catecholamine-O-methyltransferase (COMT). Haplotypes were reconstructed for all individuals with genotype data. RESULTS AND CONCLUSION: Both female gender and poor mental health were associated with (1) an increased risk for chronic, disabling comorbid neck and low back pain (CDCP); and (2) an increase in the number of areas of pain. Of the 14 SNPs evaluated, only SNP rs2053044 (ADRB2, recessive model) displayed an association with CDCP [odds ratio (OR) = 2.49; 95% confidence interval (CI) = 1.25, 4.98; p = 0.01] and pain in three to four pain areas in the last month (OR = 1.86; 95% CI = 1.13, 3.06; p = 0.02). These data suggest that genetic variants in ADRB2 may be involved in chronic MSCs.

'I am absolutely shattered': the impact of chronic low back pain on Australian Aboriginal people.

BACKGROUND: Aboriginal people in Australia have been uniquely identified as less susceptible to chronic low back pain (CLBP) disability when compared to non-Aboriginal populations, reportedly due to cultural beliefs about pain. A qualitative, culturally secure research approach was used to explore this assumption. METHODS: In-depth interviews were undertaken with 32 Aboriginal men and women with CLBP in regional and remote areas of Western Australia. Interviews were conducted collaboratively with male and female Aboriginal co-investigators, and with the support of local Aboriginal community organizations. A primary focus was to investigate the impact of CLBP from the perspective of Aboriginal people living with the condition. RESULTS: The experience of CLBP was found to be multidimensional, impacting on activities of daily life, employment, sport and family participation, emotional and cultural well-being. CONCLUSIONS: Contrary to previous assumptions, CLBP is profoundly disabling for some Aboriginal people and a priority health concern. Issues of gender, cultural obligations and the emotional consequences of CLBP are important consideration for health care. These findings, and the contextual approach used to gain an in-depth understanding of CLBP, may be relevant to populations elsewhere.

Neck/shoulder pain is more strongly related to depressed mood in adolescent girls than in boys.

A cross-sectional study of 1258, 14 year old girls and boys used self-report and physical examination measures to assess neck/shoulder pain in the last month, depressed mood, physical fitness, body composition, self-efficacy, global self-worth, family functioning and social advantage. The data was used to compare the relationship between depressed mood and neck/shoulder pain (NSP) in adolescent girls and boys. The prevalence of NSP in girls (34%, 211/621) was significantly greater than in boys (21%, 134/637; p < .001). After controlling for covariates, girls with medium (OR = 4.28; CI = 2.31-7.92; p < .001) and high depressed mood (OR = 8.63; CI = 4.39-16.98; p < .001) were significantly more likely to report NSP than girls with low depressed mood. Depressed mood was also a significant correlate of NSP in boys after controlling for covariates, although the association was substantially weaker (OR = 2.44; CI = 1.29-4.61; p < .001). After controlling for relevant biological, psychological and social covariates, depressed mood was a significant correlate of NSP in both sexes; but the association between depressed mood and NSP was significantly stronger for girls than for boys.

Inter-examiner reliability of a classification system for patients with non-specific low back pain.

There is a lack of studies examining whether mechanism-based classification systems (CS) acknowledging biological, psychological and social dimensions of long-lasting low back pain (LBP) disorders can be performed in a reliable manner. The purpose of this paper was to examine the inter-tester reliability of clinicians' ability to independently classify patients with non-specific LBP (NSLBP), utilising a mechanism-based classification method. Twenty-six patients with NSLBP underwent an interview and full physical examination by four different physiotherapists. Percentage agreement and Kappa coefficients were calculated for six different levels of decision making. For levels 1-4, percentage agreement had a mean of 96% (range 75-100%). For the primary direction of provocation Kappa and percentage agreement had a mean between the four testers of 0.82 (range 0.66-0.90) and 86% (range 73-92%) respectively. At the final decision making level, the scores for detecting psychosocial influence gave a mean Kappa coefficient of 0.65 (range 0.57-0.74) and 87% (range 85-92%). The findings suggest that the inter-tester reliability of the system is moderate to substantial for a range of patients within the NSLBP population in line with previous research.