Reliability of assessing end-feel and pain and resistance sequence in subjects with painful shoulders and knees

Select Manual Assessment Techniques and Clinical Reasoning Skills Used in Canine Physical Rehabilitation Before Engaging in Manual Therapy Treatment

Manual therapy is a cornerstone of physical therapy and canine physical rehabilitation. Although veterinary literature has tackled the topic of manual therapy treatments in animal patients, less attention has been paid to the assessment techniques and clinical reasoning skills that guide a practitioner toward determining if, when, and where manual therapies will be most effective. This article tackles the topics of clinical reasoning, the functional diagnosis, observational skills, and physical evaluation techniques that serve as prerequisites to the use of manual therapeutics.

Disparity in utilization and expectation of community-based maternal health care services among women in Myanmar: a cross-sectional study

BACKGROUND

Aim of this study is to assess women's utilization and expectation of community-based antenatal and delivery care services in Myanmar and determine associated factors for disparity of services received with services women expected to receive.

METHODS

A cross-sectional survey was conducted among 6-month postpartum women in three townships of Myanmar during May-September 2016. Associated factors for the services with disparity were identified using multinomial logistic regression models.

RESULTS

Of 1743 women, the percentages of antenatal care (ANC) attended by a skilled provider, at least four ANC visits, and early ANC were 89, 60 and 36%, respectively. The percentage of non-facility delivery was 65%. Many ANC services received and services expected to receive had lower than 80% coverage. Services with significant disparity included blood hemoglobin and urinary protein testing, and iron supplementation. Low access to ANC, women's socio-economic status, pregnancy and delivery complications, and out-of-pocket cost were associated with disparity of these services.

CONCLUSION

Utilization and expectation of community-based ANC services and facility delivery is low in Myanmar. Disparities of the services received with the services women expected to receive were common in ANC. Improving women's expectations on essential services during pregnancy is needed as well as strengthening community participation.

Robot-aided assessment of lower extremity functions: a review

The assessment of sensorimotor functions is extremely important to understand the health status of a patient and its change over time. Assessments are necessary to plan and adjust the therapy in order to maximize the chances of individual recovery. Nowadays, however, assessments are seldom used in clinical practice due to administrative constraints or to inadequate validity, reliability and responsiveness. In clinical trials, more sensitive and reliable measurement scales could unmask changes in physiological variables that would not be visible with existing clinical scores.In the last decades robotic devices have become available for neurorehabilitation training in clinical centers. Besides training, robotic devices can overcome some of the limitations in traditional clinical assessments by providing more objective, sensitive, reliable and time-efficient measurements. However, it is necessary to understand the clinical needs to be able to develop novel robot-aided assessment methods that can be integrated in clinical practice.This paper aims at providing researchers and developers in the field of robotic neurorehabilitation with a comprehensive review of assessment methods for the lower extremities. Among the ICF domains, we included those related to lower extremities sensorimotor functions and walking; for each chapter we present and discuss existing assessments used in routine clinical practice and contrast those to state-of-the-art instrumented and robot-aided technologies. Based on the shortcomings of current assessments, on the identified clinical needs and on the opportunities offered by robotic devices, we propose future directions for research in rehabilitation robotics. The review and recommendations provided in this paper aim to guide the design of the next generation of robot-aided functional assessments, their validation and their translation to clinical practice.

Functional Knee Extension Test (FKET): Inter-rater palpatory agreement and visual analysis during a non-weight bearing functional assessment of the knee

OBJECTIVE

The purpose of this study was to evaluate the inter-rater reliability of the Functional Knee Extension Test (FKET), a non-weight bearing functional assessment of the knee that is utilized within clinical practice.

METHODS

The design was a single-session, test-retest reliability study. Active knee extension was assessed and documented by each examiner for each of the visual, palpatory and vastus medialis obliqus (VMO) components of the FKET on fifty-seven healthcare professionals.

RESULTS

The Kappa (κ) statistic for the inter-rater reliability for the visual, palpatory and VMO variables of the FKET were slight-to-fair (0.13-0.26), fair-to-moderate (0.39-0.50), and moderate-to-almost perfect (0.57-0.93) reliability, respectively. The p-values for all variables, besides 'Visual RIGHT: TibTubExt' and 'Visual LEFT: TibTubExt' indicated statistically significant evidence of agreement above random guessing. Estimates for κ on the 'VMO Quantity: No contact' and 'VMO Timing: Start then stop' variables could not be calculated as ratings only existed across one row of the crosstabulation.

CONCLUSION

This study demonstrated that the palpatory and VMO components of the FKET have sufficient reliability to justify utilization within clinical practice. Future research is needed to determine whether the implementation of a functional knee assessment protocol, including the FKET could enhance levels of reliability in clinical decision-making of knee function.

Effective therapeutic exercise prescription: the right exercise at the right dose

The prescription of an effective therapeutic exercise program requires the right dosage of the right exercise, at the right time for that patient. The therapist must understand and apply training principles effectively in the presence of pathology, injury, or otherwise unhealthy tissue. The intervention goal is to close the gap between current performance and the desired goal or capacity. Although there may be a preferred linear path from current performance to optimal outcome, complexities of the human body, internal factors, and external variables may create barriers to this direct path. Successful programs include key program design considerations such as ensuring a stable baseline before progression, treating the right impairments and activity limitations, understanding contextual factors, considering the principles of specificity and optimal loading, and applying dosing principles. Program progression can be achieved through increases in total exercise volume and/or through manipulation of exercise challenges at the same exercise volume. Effective application of these principles will guide patients toward their goals as quickly and efficiently as possible.

Inter-rater reliability for measurement of passive physiological movements in lower extremity joints is generally low: a systematic review

QUESTION

What is the inter-rater reliability for measurements of passive physiological or accessory movements in lower extremity joints?

DESIGN

Systematic review of studies of inter-rater reliability.

PARTICIPANTS

Individuals with and without lower extremity disorders.

OUTCOME MEASURES

Range of motion and end-feel using methods feasible in daily practice.

RESULTS

17 studies were included of which 5 demonstrated acceptable inter-rater reliability. Reliability of measurements of physiological range of motion ranged from Kappa -0.02 for measuring knee extension using a goniometer to ICC 0.97 for measuring knee flexion using vision. Measuring range of knee flexion consistently yielded acceptable reliability using either vision or instruments. Measurements of end-feel were unreliable for all hip and knee movements. Two studies satisfied all criteria for internal validity while reporting acceptable reliability for measuring physiological range of knee flexion and extension. Overall,however, methodological quality of included studies was poor.

CONCLUSION

Inter-rater reliability of measurement of passive movements in lower extremity joints is generally low. We provide specific recommendations for the conduct and reporting of future research. Awaiting new evidence, clinicians should be cautious when relying on results from measurements of passive movements in joints for making decisions about patients with lower extremity disorders.

Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review

QUESTION

What is the inter-rater reliability for measurements of passive physiological or accessory movements in upper extremity joints?

DESIGN

Systematic review of studies of inter-rater reliability.

PARTICIPANTS

Individuals with and without upper extremity disorders.

OUTCOME MEASURES

Range of motion and end-feel using methods feasible in clinical practice.

RESULTS

Twenty-one studies were included of which 11 demonstrated acceptable inter-rater reliability. Two studies satisfied all criteria for internal validity while reporting almost perfect reliability. Overall, the methodological quality of studies was poor. ICC ranged from 0.26 (95% CI -0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99 (95% CI 0.98 to 1.0) for the physiological range of finger and thumb flexion/extension using a goniometer. Measurements of physiological range of motion using instruments were more reliable than using vision. Measurements of physiological range of motion were also more reliable than measurements of end-feel or of accessory range of motion.

CONCLUSIONS

Inter-rater reliability for the measurement of passive movements of upper extremity joints varies with the method of measurement. In order to make reliable decisions about joint restrictions in clinical practice, we recommend that clinicians measure passive physiological range of motion using goniometers or inclinometers.

Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain

STUDY DESIGN

Prospective cohort/predictive validity study.

OBJECTIVE

To determine the diagnostic accuracy of common clinical examination items and to construct a preliminary clinical prediction rule for diagnosing hip osteoarthritis (OA) in individuals with unilateral hip pain.

BACKGROUND

The current gold standard for the diagnosis of hip OA is a standing anteroposterior (AP) radiograph of the pelvis. Other than for Altman's criteria, little research has been done to determine the accuracy of clinical examination findings for diagnosing hip OA.

METHODS AND MEASURES

Seventy-two subjects completed the study. Each subject received a standardized history, physical examination, and standing AP radiograph of the pelvis. Subjects with a Kellgren and Lawrence score of 2 or higher based on the radiographs were considered to have definitive hip OA. Likelihood ratios (LRs) were computed to determine which clinical examination findings were most diagnostic of hip OA. Potential predictor variables were entered into a logistic regression model to determine the most accurate set of clinical examination items for diagnosing hip OA.

RESULTS

Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. A clinical prediction rule consisting of 5 examination variables was identified. If at least 4 of 5 variables were present, the positive LR was equal to 24.3 (95% confidence interval: 4.4-142.1), increasing the probability of hip OA to 91%.

CONCLUSION

The preliminary clinical prediction rule provides the ability to a priori identify patients with hip pain who are likely to have hip OA. A validation study should be done before the rule can be implemented in routine clinical practice.

The Kappa Statistic in Reliability Studies: Use, Interpretation, and Sample Size Requirements

Purpose. This article examines and illustrates the use and interpretation of the kappa statistic in musculoskeletal research. Summary of Key Points. The reliability of clinicians' ratings is an important consideration in areas such as diagnosis and the interpretation of examination findings. Often, these ratings lie on a nominal or an ordinal scale. For such data, the kappa coefficient is an appropriate measure of reliability. Kappa is defined, in both weighted and unweighted forms, and its use is illustrated with examples from musculoskeletal research. Factors that can influence the magnitude of kappa (prevalence, bias, and nonindependent ratings) are discussed, and ways of evaluating the magnitude of an obtained kappa are considered. The issue of statistical testing of kappa is considered, including the use of confidence intervals, and appropriate sample sizes for reliability studies using kappa are tabulated. Conclusions. The article concludes with recommendations for the use and interpretation of kappa.

Diagnosis of shoulder pain by history and selective tissue tension: agreement between assessors

STUDY DESIGN

Evaluation of agreement between assessors.

OBJECTIVE

To evaluate agreement between an expert in selective tissue tension (STT) and 3 other trained assessors, all using STT in conjunction with a preliminary clinical history, on their diagnostic labelling of painful shoulders.

BACKGROUND

Consensus on diagnostic labelling for shoulder pain is poor, hampering interpretation of the evidence for interventions. STT, a systematic approach to physical examination and diagnosis, offers potential for standardization, but its reliability is contentious.

METHODS AND MEASURES

Four trained assessors, 1 of whom was considered an expert, separately assessed 56 painful shoulders in 53 subjects (32 male [mean+/-SD age, 51+/-13 years], 21 female [mean+/-SD age, 57+/-12 years]), using STT in conjunction with a preliminary clinical history. Assessors labelled each painful shoulder as "rotator cuff lesion," "bursitis," "capsulitis," "other diagnosis," or "no diagnosis." Combinations of diagnoses were allowed.

RESULTS

A diagnosis was made in every case, with less than 7% of the diagnoses being combined. With the diagnostic categories pooled, agreement (kappa and 95% confidence interval [CI]) between the expert assessor and each of the other assessors was good, ranging from 0.61 (0.44-0.78) to 0.75 (0.60-0.90). For single diagnostic categories, agreement between the expert and each of the others (dichotomized data) ranged from 0.35 (-0.03-0.73) to 0.58 (0.29-0.87) for bursitis; 0.63 (0.40-0.86) to 0.82 (0.65-0.99) for capsulitis; 0.71 (0.49-0.93) to 0.79 (0.61-0.96) for rotator cuff lesions; and from 0.69 (0.35-1.00) to 0.78 (0.48-1.00) for other diagnoses.

CONCLUSIONS

Overall, STT in conjunction with a preliminary clinical history enables good agreement between trained assessors. Future work is required to evaluate its criterion validity.

Reliability of classifications derived from Cyriax's resisted testing in subjects with painful shoulders and knees

STUDY DESIGN

Intrarater and interrater reliability.

OBJECTIVES

Examine intrarater and interrater reliability of the resisted-testing component of Cyriax's selective tension testing for patients with painful shoulders and knees.

BACKGROUND

Clinicians make diagnostic and intervention decisions about lesions in contractile tissues based on resisted testing. Diagnostic and intervention decisions require reliable data gathering, especially when more than 1 physical therapist manages a patient. No studies have examined agreement of the results of the resisted tests used in selective tension testing, either within or between physical therapists, in subjects having pathology.

METHODS AND MEASURES

Subjects with pain in 1 knee (18 male, 22 female; mean age +/- SD = 31.8 +/- 9.5 years) or shoulder (21 male, 25 female; mean age +/- SD = 34.3 +/- 12.9 years) were examined twice. Referring diagnoses included ligament injuries, overuse syndromes, joint instability, and postsurgical symptoms, with some subjects seeking initial diagnosis. Two physical therapists used standardized positions to evaluate 2 knee motions or 6 shoulder and elbow motions. Evaluators applied maximal isometric manual resistance and rated the contraction as strong or weak while subjects identified the presence or absence of pain during the contraction. Evaluators did not interview the subjects and were masked to previous test results. Analyses included percentage of agreement, kappa coefficients, confidence intervals, and maximum kappa coefficients.

RESULTS

Intrarater kappa coefficients ranged from 0.44 to 0.82 and interrater coefficients ranged from 0.00 to 0.46. The small number of subjects who were classified as weak affected the kappa coefficients. In the intrarater condition, evaluators averaged 91% of maximum kappa for the knee and 66.5% for the shoulder. In the interrater condition, they averaged 60.4% of the maximum kappa for both the knee and the shoulder.

CONCLUSIONS

Based on 2 physical therapist evaluators with previous education in the selective tension system and an additional 6 hours of formal training on the methods, intrarater reliability of resisted tests was generally acceptable for the knee but not for the shoulder. Interrater reliability of these tests, however, was generally not acceptable. Results were limited by subjects who were younger and had mostly chronic conditions that were mildly to moderately severe and by the small subject samples in the analyses. Reliability might be improved by more intensive training of the evaluators and by standardizing the magnitude of the applied resistance and stabilization of the subjects.

Effect of PNF stretch techniques on knee flexor muscle EMG activity in older adults

The effects of proprioceptive neuromuscular facilitation (PNF) stretch techniques on older adults are unknown and the physiological changes associated with aging may lead to differential responses to PNF stretching. Therefore, the purpose of this experiment was to examine the effects of PNF stretch techniques and EMG activity in older adults. Three PNF stretch techniques: static stretch (SS), contract-relax (CR), and agonist contract-relax (ACR) were applied to 24 older adults aged 50-75 years. The subjects were tested for knee extension range of motion (ROM) and knee flexor muscle EMG activity. The results indicated that ACR produced 29-34% more ROM and 65-119% more EMG activity than CR and SS, respectively. It was concluded that PNF stretch techniques can increase ROM in older adults. However, a paradoxical effect was observed in that PNF stretching may not induce muscular relaxation even though ROM about a joint increases. Care should be taken when applying PNF stretch techniques to older adults due to age-related alterations in muscle elasticity.