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1.  Reliability of maximal isometric knee strength testing with modified hand-held dynamometry in patients awaiting total knee arthroplasty: useful in research and individual patient settings? A reliability study 
Patients undergoing total knee arthroplasty (TKA) often experience strength deficits both pre- and post-operatively. As these deficits may have a direct impact on functional recovery, strength assessment should be performed in this patient population. For these assessments, reliable measurements should be used. This study aimed to determine the inter- and intrarater reliability of hand-held dynamometry (HHD) in measuring isometric knee strength in patients awaiting TKA.
To determine interrater reliability, 32 patients (81.3% female) were assessed by two examiners. Patients were assessed consecutively by both examiners on the same individual test dates. To determine intrarater reliability, a subgroup (n = 13) was again assessed by the examiners within four weeks of the initial testing procedure. Maximal isometric knee flexor and extensor strength were tested using a modified Citec hand-held dynamometer. Both the affected and unaffected knee were tested. Reliability was assessed using the Intraclass Correlation Coefficient (ICC). In addition, the Standard Error of Measurement (SEM) and the Smallest Detectable Difference (SDD) were used to determine reliability.
In both the affected and unaffected knee, the inter- and intrarater reliability were good for knee flexors (ICC range 0.76-0.94) and excellent for knee extensors (ICC range 0.92-0.97). However, measurement error was high, displaying SDD ranges between 21.7% and 36.2% for interrater reliability and between 19.0% and 57.5% for intrarater reliability. Overall, measurement error was higher for the knee flexors than for the knee extensors.
Modified HHD appears to be a reliable strength measure, producing good to excellent ICC values for both inter- and intrarater reliability in a group of TKA patients. High SEM and SDD values, however, indicate high measurement error for individual measures. This study demonstrates that a modified HHD is appropriate to evaluate knee strength changes in TKA patient groups. However, it also demonstrates that modified HHD is not suitable to measure individual strength changes. The use of modified HHD is, therefore, not advised for use in a clinical setting.
PMCID: PMC3229470  PMID: 22040119
2.  Agreement between 2 pain visual analogue scales, by age and area of complaint in neck and low back pain subjects: the standard pen and paper VAS versus plastic mechanical sliderule VAS 
This study endeavoured to determine the agreement between the standard pencil and paper pain VAS (pVAS) and a relatively newly designed plastic mechanical (slide-rule) VAS (mVAS) in assessing cervical and lumbar pain intensity in cervical pain vs low back pain (LBP) patients stratified by age (< 65 years of age (yoa) and ≥ 65 yoa).
Design Architecture:
This was a concurrent validity study assessing the agreement between the gold standard pVAS and the experimental mVAS.
Sample Size:
A sample size estimate revealed that a minimum of 9 subjects for each of 4 age-complaint subgroups (< 65 yoa) neck pain, ≥ 65 yoa neck pain, <65 yoa low back pain, ≥ 65 yoa low back pain) would be necessary.
Sample Profile:
All adults (≥ 18 yrs of age) presenting to the Canadian Memorial Chiropractic College’s Herbert K. Lee Outpatient Clinic with low back (LBP) pain or neck pain were considered eligible for the study. Three (3) essentially asymptomatic subjects were also recruited in order to provide a complete spectrum of pain severities.
Outcome Measure:
Pain intensity was measured in centimetres (to nearest one tenth) on the pVAS and in ten units on the mVAS (to the nearest one tenth unit).
The pVAS was administered by including it with either the standard intake forms which all new patients are required to complete, or by presenting it to patients visiting the Clinic for a subsequent treatment. The subject made a visual estimation of his/her pain intensity and marked it on the pVAS accordingly. The response was then measured in centimetres. One of the investigators presented the mVAS to the subject after arrival in the examination room. The mVAS instrument was presented to the subject with instructions as to how to indicate his/her level of present pain intensity. Every attempt was made to ensure that no less than five minutes and no more than 15 minutes elapsed between the completion of the two forms of Visual Analogue Scale. The data were categorized according to the subjects’ ages (≥ 65 years of age (yoa) or < 65 yoa) and their areas of complaint (neck pain or low back pain).
Statistical Analysis Strategy:
Intraclass Correlation Coefficient (ICC) analyses were performed to determine the index of agreement between the mVAS and pVAS for each of the age and complaint categories. 95% Confidence Intervals (95% CI) were calculated for each ICC value. A clinically acceptable level of agreement was judged by the investigators to be ICC ≥ 0.85; a 95% CI no wider than ± 0.25 was considered to provide statistical significance.
The Intraclass Correlation Coefficient (ICC) analysis revealed an ICC of 0.86 with a 95% CI of ± 0.25 for the group under 65 yoa with neck pain, and an ICC of 0.87 with a 95% CI of ± 0.13 for the group under 65 yoa with low back pain. ICC’s (± 95 CI) of 0.60 (± 0.64) and 0.93 (± 0.2) were calculated for the ≥ 65 yoa neck pain group and ≥ 65 yoa LBP group, respectively.
The results of this study suggest that for the most part, there is statistically significant and clinically acceptable agreement between the pencil and paper VAS (pVAS) and a mechanical VAS (mVAS). The areas of complaint assessed (neck versus low back), did not appear to affect the level of agreement within each age category; only the older male neck pain and younger female LBP groups, however, yielded clinically unacceptable levels of agreement.
PMCID: PMC2485285
visual analogue scale (VAS); pain measurement; patient outcome assessment; pain; chiropractic
3.  Interrater and intrarater reliability of photoplethysmography for measuring toe blood pressure and toe-brachial index in people with diabetes mellitus 
A reliable tool to measure arterial flow to the feet in people with diabetes is required given that they are particularly prone to peripheral arterial disease. Traditionally, the ankle brachial index (ABI) has been used to measure arterial circulation, but its application is limited due to calcification of larger arteries. More recently, toe pressure and the toe brachial index (TBI) has been suggested as superior to ABI measurements because they assess smaller digital arteries less prone to arterial calcification. However, reliability studies for the clinical use of photoplethysmography (PPG) in people with diabetes are lacking.
Sixty people with diabetes mellitus (35 males and 25 females, mean age 59.6 yrs) consented to take part in the study. The majority (92%) had type 2 diabetes and 8% had type 1 diabetes. Forty-three percent were diagnosed as having peripheral neuropathy when tested using a biothesiometer and 15% were current smokers (10 – 40/day). A podiatrist and a diabetes educator measured toe and brachial blood pressure independently and in a random order using PPG. These measurements were repeated again seven days later, and subsequently analysed with intraclass correlation coefficients (ICC), 95% confidence intervals (CI) and standard error of measurement (SEM).
The intrarater reliability of measuring toe pressures was excellent (ICC3,1 =0.78-0.79, SEM 8 mmHg) and interrater reliability was also excellent (ICC2,2 = 0.93, SEM 4 mmHg). The intrarater reliability for measuring brachial pressures was generally poor (ICC3,1 = 0.40 – 0.42, SEM 19 mmHg) and interrater reliability was fair-good (ICC2,2. 0.65, SEM 14 mmHg). The TBI intrarater reliability was fair-good (ICC3,1 = 0.51-0.72, SEM 0.08), whilst the interrater reliability of TBI was excellent (ICC2,2 = 0.85, SEM 0.07).
Based on these results, interrater and intrarater reliability of PPG is excellent for measuring toe blood pressure, good for TBI and only fair for brachial pressures in people with diabetes mellitus.
PMCID: PMC3431238  PMID: 22676458
Toe brachial index; Photoplethysmography; Peripheral arterial disease; Ankle brachial index; Toe pressures; Doppler; Diabetes mellitus
4.  Screening of the spine in adolescents: inter- and intra-rater reliability and measurement error of commonly used clinical tests 
Evidence on the reliability of clinical tests used for the spinal screening of children and adolescents is currently lacking. The aim of this study was to determine the inter- and intra-rater reliability and measurement error of clinical tests commonly used when screening young spines.
Two experienced chiropractors independently assessed 111 adolescents aged 12–14 years who were recruited from a primary school in Denmark. A standardised examination protocol was used to test inter-rater reliability including tests for scoliosis, hypermobility, general mobility, inter-segmental mobility and end range pain in the spine. Seventy-five of the 111 subjects were re-examined after one to four hours to test intra-rater reliability. Percentage agreement and Cohen’s Kappa were calculated for binary variables, and interclass correlation (ICC) and Bland-Altman plots with Limits of Agreement (LoA) were calculated for continuous measures.
Inter-rater percentage agreement for binary data ranged from 59.5% to 100%. Kappa ranged from 0.06-1.00. Kappa ≥ 0.40 was seen for elbow, thumb, fifth finger and trunk/hip flexion hypermobility, pain response in inter-segmental mobility and end range pain in lumbar flexion and extension. For continuous data, ICCs ranged from 0.40-0.95. Only forward flexion as measured by finger-to-floor distance reached an acceptable ICC(≥ 0.75). Overall, results for intra-rater reliability were better than for inter-rater reliability but for both components, the LoA were quite wide compared with the range of assessments.
Some clinical tests showed good, and some tests poor, reliability when applied in a spinal screening of adolescents. The results could probably be improved by additional training and further test standardization. This is the first step in evaluating the value of these tests for the spinal screening of adolescents. Future research should determine the association between these tests and current and/or future neck and back pain.
PMCID: PMC3922274  PMID: 24512306
Reliability; Measurement error; Scoliosis; Hypermobility; Intersegmental mobility; Spine; Adolescents; Mobility
5.  A Novel Tool for the Assessment of Pain: Validation in Low Back Pain 
PLoS Medicine  2009;6(4):e1000047.
Joachim Scholz and colleagues develop and validate an assessment tool that distinguishes between radicular and axial low back pain.
Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology.
Methods and Findings
Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%–97%) and specificity (97%; 95% CI 89%–100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs.
We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.
Editors' Summary
Pain, although unpleasant, is essential for survival. Whenever the body is damaged, nerve cells detecting the injury send an electrical message via the spinal cord to the brain and, as a result, action is taken to prevent further damage. Usually pain is short-lived, but sometimes it continues for weeks, months, or years. Long-lasting (chronic) pain can be caused by an ongoing, often inflammatory condition (for example, arthritis) or by damage to the nervous system itself—experts call this “neuropathic” pain. Damage to the brain or spinal cord causes central neuropathic pain; damage to the nerves that convey information from distant parts of the body to the spinal cord causes peripheral neuropathic pain. One example of peripheral neuropathic pain is “radicular” low back pain (also called sciatica). This is pain that radiates from the back into the legs. By contrast, axial back pain (the most common type of low back pain) is confined to the lower back and is non-neuropathic.
Why Was This Study Done?
Chronic pain is very common—nearly 10% of American adults have frequent back pain, for example—and there are many treatments for it, including rest, regulated exercise (physical therapy), pain-killing drugs (analgesics), and surgery. However, the best treatment for any individual depends on the exact nature of their pain, so it is important to assess their pain carefully before starting treatment. This is usually done by scoring overall pain intensity, but this assessment does not reflect the characteristics of the pain (for example, whether it occurs spontaneously or in response to external stimuli) or the complex biological processes involved in pain generation. An assessment designed to take such factors into account might improve treatment outcomes and could be useful in the development of new therapies. In this study, the researchers develop and test a new, standardized tool for the assessment of chronic pain that, by examining many symptoms and signs, aims to distinguish between pain subtypes.
What Did the Researchers Do and Find?
One hundred thirty patients with several types of peripheral neuropathic pain and 57 patients with non-neuropathic (axial) low back pain completed a structured interview of 16 questions and a standardized bedside examination of 23 tests. Patients were asked, for example, to choose words that described their pain from a list provided by the researchers and to grade the intensity of particular aspects of their pain from zero (no pain) to ten (the maximum imaginable pain). Bedside tests included measurements of responses to light touch, pinprick, and vibration—chronic pain often alters responses to harmless stimuli. Using “hierarchical cluster analysis,” the researchers identified six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain based on the patterns of symptoms and signs revealed by the interviews and physical tests. They then used “classification tree analysis” to identify the six questions and ten physical tests that discriminated best between pain subtypes and combined these items into a tool for a Standardized Evaluation of Pain (StEP). Finally, the researchers asked whether StEP, which took 10–15 minutes, could identify patients with radicular back pain and discriminate them from those with axial back pain in an independent group of 137 patients with chronic low back pain. StEP, they report, accurately diagnosed these two conditions and was well accepted by the patients.
What Do These Findings Mean?
These findings indicate that a standardized assessment of pain-related signs and symptoms can provide a simple, quick diagnostic procedure that distinguishes between radicular (neuropathic) and axial (non-neuropathic) low back pain. This distinction is crucial because these types of back pain are best treated in different ways. In addition, the findings suggest that it might be possible to identify additional pain subtypes using StEP. Because these subtypes may represent conditions in which different pain mechanisms are acting, classifying patients in this way might eventually enable physicians to tailor treatments for chronic pain to the specific needs of individual patients rather than, as at present, largely guessing which of the available treatments is likely to work best.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Giorgio Cruccu and and Andrea Truini
The US National Institute of Neurological Disorders and Stroke provides a primer on pain in English and Spanish
In its 2006 report on the health status of the US, the National Center for Health Statistics provides a special feature on the epidemiology of pain, including back pain
The Pain Treatment Topics Web site is a resource, sponsored partly by associations and manufacturers, that provides information on all aspects of pain and its treatment for health care professionals and their patients
Medline Plus provides a brief description of pain and of back pain and links to further information on both topics (in English and Spanish)
The MedlinePlus Medical Encyclopedia also has a page on low back pain (in English and Spanish)
PMCID: PMC2661253  PMID: 19360087
6.  Clinical measurement of the thoracic kyphosis. A study of the intra-rater reliability in subjects with and without shoulder pain 
Clinical sagittal plane assessment of the thoracic kyphosis angle is considered an essential component of the postural examination of patients presenting with upper body pain syndromes. Cervical headaches and conditions involving the shoulder, such as subacromial pain syndrome, have all been associated with an increase in the thoracic kyphosis. Concomitantly a decrease in the thoracic kyphosis as a result of a stretching and strengthening rehabilitation programme is believed to be associated with a reduction in symptoms and pain and improvement in function. Clinicians generally measure the sagittal plane kyphosis angle visually. There is no certainty that this method is reliable or is capable of measuring angular changes over time or in response to intervention. As such a simple and reliable clinical method of measuring the thoracic kyphosis would enable clinicians to record this information. The aim of this investigation was to determine the intra-tester reliability of measuring the thoracic kyphosis angle using a clinical method
Measurements were made in 45 subjects with and 45 subjects without upper body symptoms. Measurements were made with the subjects in relaxed standing. Two gravity dependent inclinometers were used to measure the kyphosis. The first was placed over the region of the 1st and 2nd thoracic spinous processes. The other, over the region of the 12th thoracic and 1st lumbar spinous processes. The angle produced by each inclinometer was measured 3 times in succession. Each set of 3 measurements was made on two occasions (separated by a minimum of 30 minutes and additional data collection involving 46 further measurements of posture and movement on the same and an additional subject before the thoracic kyphosis measurements were re-measured) by one rater. The reliability of the measurements was analyzed using 2-way ANOVA intraclass correlation coefficients (ICC), 95% confidence intervals (CI) and standard error of measurement (SEM) for precision, for a single measurement [ICC(single)] and the average of 3 measures [ICC(average)]. The assessor remained 'blinded' to data input and the measurements were staggered to reduce examiner bias.
The measurement of the thoracic kyphosis as used in this investigation was found to have excellent intra-rater reliability for both subjects with and without symptoms. The ICC(single) results for the subjects without symptoms were, .95; (95% CI .91-.97). The corresponding ICC(average) results were; .97; (95% CI .95-.99). The results for the subjects with symptoms were; 93; (95% CI .88-.96), for ICC(single) and for ICC(average); .97; (95% CI .94-.98). The SEM results for subjects without and with symptoms were 1.0° and 1.7°, respectively.
The findings of this immediate test-retest reliability study suggest that the clinical measurement of the thoracic kyphosis using gravity dependent inclinometers demonstrates excellent intra-rater reliability. Additional research is required to determine the inter-rater reliability of this method.
Trial registration
National Research Register: N0060148286
PMCID: PMC2845095  PMID: 20193055
7.  Reproducibility of tender point examination in chronic low back pain patients as measured by intrarater and inter-rater reliability and agreement: a validation study 
BMJ Open  2013;3(2):e002532.
To evaluate the reliability and agreement of digital tender point (TP) examination in chronic low back pain (LBP) patients.
Cross-sectional study.
Hospital-based validation study.
Among sick-listed LBP patients referred from general practitioners for low back examination and return-to-work intervention, 43 and 39 patients, respectively (18 women, 46%) entered and completed the study.
Main outcome measures
The reliability was estimated by the intraclass correlation coefficient (ICC), and agreement was calculated for up to ±3 TPs. Furthermore, the smallest detectable difference was calculated.
TP examination was performed twice by two consultants in rheumatology and rehabilitation at 20 min intervals and repeated 1 week later. Intrarater reliability in the more and less experienced rater was ICC 0.84 (95% CI 0.69 to 0.98) and 0.72 (95% CI 0.49 to 0.95), respectively. The figures for inter-rater reliability were intermediate between these figures. In more than 70% of the cases, the raters agreed within ±3 TPs in both men and women and between test days. The smallest detectable difference between raters was 5, and for the more and less experienced rater it was 4 and 6 TPs, respectively.
The reliability of digital TP examination ranged from acceptable to excellent, and agreement was good in both men and women. The smallest detectable differences varied from 4 to 6 TPs. Thus, TP examination in our hands was a reliable but not precise instrument. Digital TP examination may be useful in daily clinical practice, but regular use and training sessions are required to secure quality of testing.
PMCID: PMC3586147  PMID: 23444448
Rheumatology; Statistics & Research Methods; Pain Management
8.  Validation of the Korean version of the Roland–Morris Disability Questionnaire 
European Spine Journal  2011;20(12):2115-2119.
We evaluated the reliability and validity of an adapted Korean version of the Roland–Morris Disability Questionnaire (RMDQ). Translation/retranslation of the English version of RMDQ was conducted, and all steps of the cross-cultural adaptation process were performed. The Korean version of the Visual Analog Scale (VAS) measure of pain, RMDQ, and the previously validated Oswestry Disability Index (ODI) were mailed to 100 consecutive patients with chronic lower back pain (LBP) of at least 3 months. Eighty-one patients responded to the first mailing of questionnaires and 63 of the first-time responder returned their second survey. The average age of the 63 patients (45 female, 18 male) was 47.8 years. Reliability assessment was determined by estimating kappa statistics of agreement for each item, the intraclass correlation coefficient (ICC), and Cronbach’s α. Concurrent validity was evaluated by comparing the responses of RMDQ with the results of VAS and responses of ODI by using Pearson’s correlation coefficient. The constructed Bland–Altman plot showed a good reliability. All items had a kappa statistics of agreement greater than 0.6. The RMDQ showed excellent test/re-test reliability as evidenced by the high ICC for 2 test occasions (ICC = 0.932, P < 0.001). Internal consistency was found to be very good at both assessments with Cronbach’s α (0.942 and 0.951 at first and second assessments, respectively). The RMDQ was correlated with the VAS (r = 0.692; P = 0.000 and r = 0.668; P = 0.000 at first and second assessments, respectively), and with the ODI (r = 0.789; P = 0.000 and r = 0.802; P = 0.000, respectively). The adapted Korean version of the RMDQ was successfully translated and showed acceptable measurement properties, and as such, is considered suitable for outcome assessments in the Korean speaking patients with LBP.
PMCID: PMC3229737  PMID: 21479853
Low back pain; Roland–Morris Disability Questionnaire; Korean version
9.  Reliability and Agreement of Measures Used in Radiographic Evaluation of the Adult Hip 
Several mechanical derangements reportedly contribute to the development of noninflammatory arthritis of the hip. Diagnosis of these derangements involves the use of specific radiographic measures (eg, alpha angle, lateral center edge angle, cross-over sign). The reliability of some of these measures is not known, whereas others have not been confirmed.
We examined the reproducibility of 20 radiographic parameters of the hip used in clinical practice.
Twenty radiographic parameters on standardized digital AP and cross-table lateral radiographs were evaluated by two observers on two different occasions. The parameters were evaluated from the standpoint of reproducibility (reliability and agreement). The intraclass correlation coefficient (ICC), kappa coefficient, and standard error of measurement were calculated. The minimal detectable change was calculated where possible.
Interrater reliability ranged from 0.45 to 0.90 for ICC depending on the measure. Intrarater reliability ranged from 0.55 to 0.99. Measurements that could be measured directly (femoral head diameter) were more reliable than measurements requiring estimation on the part of the observer (Tönnis angle, neck-shaft angle). Categorical parameters had interrater and intrarater reliability kappa values greater than 0.90 for all parameters measured. Agreement between repeated measurements, as given by the minimal detectable change, showed many parameters with low absolute reliability have clinical use in the context of the large changes seen in clinical practice.
Radiographic hip measures show clinical utility when evaluated from the perspective of agreement and reliability.
Clinical Relevance
All measures investigated show clinical utility when evaluated from the perspective of reliability and agreement.
Level of Evidence
Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3008883  PMID: 20596806
A variety of methods exist to measure ankle dorsiflexion range of motion (ROM). Few studies have examined the reliability of a novice rater. The purpose of this study was to determine the reliability of ankle ROM measurements using three different techniques in a novice rater.
Twenty healthy subjects (mean±SD, age=24±3 years, height=173.2±8.1 cm, mass=72.6±15.2 kg) participated in this study. Ankle dorsiflexion ROM measures were obtained in a weight-bearing lunge position using a standard goniometer, digital inclinometer, and a tape measure using the distance-to-wall technique. All measures were obtained three times per side, with 10 minutes of rest between the first and second set of measures. Intrarater reliability was determined using an intraclass correlation coefficient (ICC2,3) and associated 95% confidence intervals (CI). Standard error of measurement (SEM) and the minimal detectable change (MDC) for each measurement technique were also calculated.
The within-session intrarater reliability (ICC2,3) estimates for each measure are as follows: tape measure (right 0.98, left 0.99), digital inclinometer (right 0.96; left 0.97), and goniometer (right 0.85; left 0.96). The SEM for the tape measure method ranged from 0.4–0.6 cm and the MDC was between 1.1–1.5 cm. The SEM for the inclinometer was between 1.3–1.4° and the MDC was 3.7–3.8°. The SEM for the goniometer ranged from 1.8–2.8° with an MDC of 5.0–7.7°.
The results indicate that reliable measures of weight-bearing ankle dorsiflexion ROM can be obtained from a novice rater. All three techniques had good reliability and low measurement error, with the distance-to-wall technique using a tape measure and inclinometer methods resulting in higher reliability coefficients (ICC2,3=0.96 to 0.99) and a lower SEM compared to the goniometer (ICC2,3=0.85 to 0.96).
Level of Evidence:
PMCID: PMC3362988  PMID: 22666642
goniometry; inclinometer; talocrural joint
11.  Inter- and intra-observer reliability of clinical movement-control tests for marines 
Musculoskeletal disorders particularly in the back and lower extremities are common among marines. Here, movement-control tests are considered clinically useful for screening and follow-up evaluation. However, few studies have addressed the reliability of clinical tests, and no such published data exists for marines. The present aim was therefore to determine the inter- and intra-observer reliability of clinically convenient tests emphasizing movement control of the back and hip among marines. A secondary aim was to investigate the sensitivity and specificity of these clinical tests for discriminating musculoskeletal pain disorders in this group of military personnel.
This inter- and intra-observer reliability study used a test-retest approach with six standardized clinical tests focusing on movement control for back and hip. Thirty-three marines (age 28.7 yrs, SD 5.9) on active duty volunteered and were recruited. They followed an in-vivo observation test procedure that covered both low- and high-load (threshold) tasks relevant for marines on operational duty. Two independent observers simultaneously rated performance as “correct” or “incorrect” following a standardized assessment protocol. Re-testing followed 7–10 days thereafter. Reliability was analysed using kappa (κ) coefficients, while discriminative power of the best-fitting tests for back- and lower-extremity pain was assessed using a multiple-variable regression model.
Inter-observer reliability for the six tests was moderate to almost perfect with κ-coefficients ranging between 0.56-0.95. Three tests reached almost perfect inter-observer reliability with mean κ-coefficients > 0.81. However, intra-observer reliability was fair-to-moderate with mean κ-coefficients between 0.22-0.58. Three tests achieved moderate intra-observer reliability with κ-coefficients > 0.41. Combinations of one low- and one high-threshold test best discriminated prior back pain, but results were inconsistent for lower-extremity pain.
Our results suggest that clinical tests of movement control of back and hip are reliable for use in screening protocols using several observers with marines. However, test-retest reproducibility was less accurate, which should be considered in follow-up evaluations. The results also indicate that combinations of low- and high-threshold tests have discriminative validity for prior back pain, but were inconclusive for lower-extremity pain.
PMCID: PMC3552977  PMID: 23273285
Military; Motor control; Reproducibility; Screening; Sensitivity; Specificity; Validity
12.  Reliability of the Woodway CurveTM Non-Motorized Treadmill for Assessing Anaerobic Performance 
A curved treadmill offers a practical method of assessing anaerobic power by enabling unrestricted running motion and greater sport specificity. The purpose of this research was to determine reliability of a curved treadmill (cTM) sprint test and to compare performance measures to the traditional Wingate anaerobic power test (WAnT) performed on a cycle ergometer. Thirty-two recreationally active men and women (22.4 ± 2.8 yrs; 1.73 ± 0.08 m; 74. 2 ± 13.2 kg) performed four familiarization trials on cTM, followed by two randomly assigned experimental trials consisting of one 30-second maximum effort on either cTM or WAnT. Each trial was separated by at least 48 hours. Repeated measures analysis of variance (ANOVA), interclass correlations (ICC), standard error of measurement (SEM), and minimal differences (MD) were used to determine reliability of familiarization trials on cTM, and Pearson product moment correlations were calculated to compare cTM and WAnT. ANOVA results showed significant differences (p < 0.05) during the four familiarization trials. Post hoc analysis showed significant differences (p < 0. 05) between the first two trials. Familiarization trials 3 and 4 showed a high reliability for each performance variable (distance: ICC2,1 = 0.969, %SEM = 2.645, p = 0.157; mean velocity: ICC2,1 = 0. 969, %SEM = 2.622, p = 0.173; peak velocity: ICC2,1 = 0.966, %SEM = 3.142, p = 0.033; mean power: ICC2,1 = 0.940, %SEM = 4.140, p = 0.093; and peak power: ICC2,1 = 0.887, %SEM = 11.244, p = 0.669). Participants elicited an average peak power of 1050.4 ± 338.5 Watts on cTM and 1031.4 ± 349.8 Watts on WAnT. Pearson product moment coefficients indicated high correlations between peak power, mean power, and peak velocity (r = 0.75, p < 0.001; r = 0.84, p < 0.001; and r = 0.76, p < 0. 001, respectively) derived from cTM and WAnT. In conclusion, results suggest that after two familiarization trials, cTM is a reliable sprint test for recreationally active men and women. In addition, there are strong relationships between cTM and WAnT in assessing anaerobic performance.
Key pointsThe Woodway Curve 3.0TM is a non-motorized treadmill utilizing a curved platform which allows individuals to simulate an unrestricted sprint test in a laboratory setting, offering a practical and sport specific method of assessing anaerobic power.The curved treadmill provides a reliable sprint test for recreationally active men and women.There are strong relationships between the curved treadmill and cycle ergometer in assessing anaerobic performance.
PMCID: PMC3761752  PMID: 24149732
Anaerobic capacity; power; Wingate anaerobic power test; sprint speed
13.  Reliability and validity study on the Hungarian versions of the Oswestry Disability Index and the Quebec Back Pain Disability Scale 
European Spine Journal  2013;22(5):1010-1018.
Patient-reported outcome measurements (PROMs) are widely used in spine care. The development of reliable and valid National versions of spine-related disability questionnaires is strongly recommended from both the clinical and scientific points-of-view. The aims of this study were to adapt and validate the Oswestry Disability Index (ODI) and the Quebec Back Pain Disability Scale (QDS) for use with the Hungarian language.
After translating and culturally adapting the ODI and QDS, 133 patients with lumbar degenerative spinal disorder filled in the questionnaire booklet twice within 2 weeks. Subjects completed the Hungarian versions of the two PROMs as well as the WHOQoL-BREF validated as a general life quality questionnaire and Visual Analogue Scale of pain. Internal consistency, reliability and construct validity of the questionnaires were determined, as were the standard error of measurement (SEM) and minimal detectable change (MDC) scores.
The Hungarian ODI consisted of one factor that showed good internal consistency (Cronbach-α 0.890). The QDS showed a four-factor structure with Cronbach-α values between 0.788 and 0.917. No significant floor or ceiling effects were observed. The test–retest analysis showed excellent reliability of the Hungarian ODI and QDS. The intraclass correlation coefficients (ICC) were 0.927 and 0.923, respectively. SEM values of 4.8 and 5.2 resulted in a MDC of 13 and 14 points in the Hungarian ODI and QDS, respectively. The correlation coefficient (r) between pain and ODI was 0.680 (p < 0.001) and the correlation between the ODI and the physical subscale of WHOQoL was also very good (r = −0.705, p < 0.001). The QDS total score and its four subscales correlated significantly with pain and with the physical subscale of WHOQoL (r > 0.4, p < 0.001). The level of disability measured by the Hungarian ODI and QDS was significantly higher in the surgical subgroup than in non-surgically treated patients (p < 0.001).
Translation and cultural adaptation of the ODI and QDS were successful. Hungarian versions of the ODI and QDS proved to be reliable, valid PROMs confirming that they can be used in future clinical and scientific work with Hungarian-speaking spine patients.
Electronic supplementary material
The online version of this article (doi:10.1007/s00586-012-2645-9) contains supplementary material, which is available to authorized users.
PMCID: PMC3657068  PMID: 23321978
Low back pain; Oswestry Disability Index; Quebec Back Pain Disability Scale; Hungarian version; Cross-cultural adaptation; Validity
14.  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 
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.
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.
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).
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.
PMCID: PMC1858690  PMID: 17407580
15.  Reliability of the Dynavision™ D2 for Assessing Reaction Time Performance 
Recently, the Dynavision™ D2 Visuomotor Training Device (D2) has emerged as a tool in the assessment of reaction time (RT); however, information regarding the reliability of the D2 have been limited, and to date, reliability data have been limited to non- generalizable samples. Therefore, the purpose of this study was to establish intraclass correlation coefficients (ICC2,1) for the D2 that are generalizable across a population of recreationally active young adults. Forty-two recreationally active men and women (age: 23.41 ± 4.84 years; height: 1.72 ± 0.11 m; mass: 76.62 ± 18.26 Kg) completed 6 trials for three RT tasks of increasing complexity. Each trial was separated by at least 48-hours. A repeated measures ANOVA was used to detect differences in performance across the six trials. Intraclass correlation coefficients (ICC2,1) standard error of measurement (SEM), and minimal differences (MD) were used to determine the reliability of the D2 from the two sessions with the least significant difference score. Moderate to strong reliability was demonstrated for visual RT (ICC2,1: 0.84, SEM: 0.033), and reactive ability in both Mode A and Mode B tasks (Mode A hits: ICC2,1: 0.75, SEM: 5.44; Mode B hits: ICC2,1: 0.73, SEM: 8.57). Motor RT (ICC2,1: 0.63, SEM: 0.035s) showed fair reliability, while average RT per hit for Modes A and B showed moderate reliability (ICC2,1: 0.68, SEM: 0.43 s and ICC2,1: 0.72, SEM: 0.03 s respectively). It appears that one familiarization trial is necessary for the choice reaction time (CRT) task while three familiarization trials are necessary for reactive RT tasks. In conclusion, results indicate that the Dynavision™ D2 is a reliable device to assess neuromuscular reactivity given that an adequate practice is provided. The data presented are generalizable to a population of recreationally active young adults.
Key PointsThe Dynavision™ D2 is a light-training reaction device, developed to train sensory motor integration through the visual system, offering the ability to assess visual and motor reaction to both central and peripheral stimuli, with a capacity to integrate increasing levels of cognitive challenge.The Dynavision™ D2 is a reliable instrument for assessing reaction time in recreationally active young adults.It is recommended that one familiarization trial is necessary for the choice reaction time task assessment to learn the test protocol, while three familiarization trials are needed for reactive ability in Mode A and Mode B before a subsequent reliable baseline score can be established.Significant training effects were observed for all reaction time tests and should be taken into account with continuous trials.
PMCID: PMC3918550  PMID: 24570618
Assessment; visual; motor; choice reaction time
16.  Bony abnormalities of the hip joint: a new comprehensive, reliable and radiation-free measurement method using magnetic resonance imaging 
To develop comprehensive and reliable radiation-free methods to quantify femoral and acetabular morphology using MRI
32 hips (16 subjects, 6 with intra-articular hip disorder (IAHD); 10 controls) were included. A 1.5T magnetic resonance system was used to obtain 3D fat suppressed gradient echo images at the pelvis and distal femora. After acquisition, pelvic images were post-processed to correct for coronal, axial and sagittal rotation. Measurements performed included acetabular version (AV), femoral version (FV), lateral center edge angle (LCEA), femoral neck angle (FNA) and alpha angle (AA) at 3, 2, 1 and 12 o’clock. Two experienced raters, a musculoskeletal radiologist and an orthopaedic physical therapist, and a novice rater, a research assistant, completed reliability testing. Raters measured all hips twice with minimum 2 weeks between sessions. Intraclass Correlation Coefficients were used to determine rater reliability; standard error of measurements was reported to estimate the reasonable limits of the expected error in the different raters’ scores.
Interrater reliability was good to excellent for all raters for AV, FV, FNA, and LCEA (ICCs: 0.82–0.98); good to excellent between experienced raters (ICCs: 0.78–0.86) and poor to good between novice and experienced raters (ICCs: 0.23–0.78) for AA. Intrarater reliability was good to excellent for all raters for AV, FV and FNA (ICCs: 0.93–0.99); for one experienced and novice rater for LCEA (ICCs: 0.84–0.89); moderate to excellent for the experienced raters for AA (ICCs: 0.72–0.89). Intrarater reliability was poor for the second experienced rater for LCEA (ICC: 0.56), due to a single measurement error and for the novice rater for AA (ICCs: 0.17–0.38).
We described MRI methods to comprehensively assess femoral and acetabular morphology. Measurements such as AV, FV and FNA and the LCEA can be made reliably by both experienced and novice raters, however the AA measurement was reliable only among experienced raters.
PMCID: PMC4280561  PMID: 25558377
hip pain; hip dysplasia; femoroacetabular impingement
Study Design:
Clinical Measurement, Reliability, Descriptive Study
To establish intrarater and interrater reliability of the Side-lying Thoraco-lumbar Rotation Measurement (STRM) and to explore frequencies and magnitude of rotational differences that exist in various musculoskeletal conditions.
Limitation in thoracic rotation could lead to increased motion at adjacent areas (i.e., shoulders and low back). This could potentially lead to excessive strain and subsequent injury from repetitive stress. Currently, there is no well-established method to reliably measure and objectively quantify thoraco-lumbar spine rotation.
Intrarater reliability was assessed by a single investigator performing three STRM measurements on 10 participants on two consecutive days. Interrater reliability was assessed by two independent examiners, performing the STRM on 30 participants. Reliability was assessed using the intraclass correlation coefficient (ICC) statistic. To explore the incidence and magnitude of side-to-side thoraco-lumbar rotation differences, the STRM was measured on 156 participants of various musculoskeletal conditions.
The intrarater reliability of the STRM was excellent (ICC=.94). The interrater reliability was good (ICC=.88). Fifty four percent of the sample exhibited greater than a 10% side-to-side difference in the STRM while twenty percent exhibited greater than a 20% side-to-side difference.
The STRM can be used as a reliable and objective method to quantify thoraco-lumbar spine rotation. It also appears that a large percentage of patients with varied musculoskeletal complaints may have greater than a 10-20% asymmetry in spinal rotational movement. Future research is needed to determine the clinical applicability and relevance of these findings.
Level of Evidence: 4
PMCID: PMC3096141  PMID: 21655378
Thoraco-lumbar rotation; reliability
18.  Reliability and validity of spinal coordination patterns during treadmill walking in persons with thoracic spine pain – a preliminary study 
Persons with low back pain fail to show the same transition as healthy individuals from in-phase to anti-phase rotation of the thorax and pelvis as walking speed increases. The purpose of this study was to determine if the relative phase of the thorax and pelvis during walking was a reliable (within day test-retest) and valid measure for persons with thoracic pain.
The time series motion of the spine over C7, T8 and sacrum were measured at five treadmill walking speeds (0.67, 0.89, 1.12, 1.34, 1.56 m/s) in 19 persons with thoracic spine pain and 19 healthy control subjects. After a 20 minute rest, all tests were repeated. The average relative phases of the transverse plane rotation between C7-T8, C7-sacrum and T8-sacrum during a one-minute walk were calculated. The standard error of measurement (SEM) and the intra-class correlation coefficient (ICC) were used to estimate test-retest reliability. Three-way repeated measures analyses of variance were performed to determine the influence of group, walking speed and session on the relative phases.
The minimum transverse plane motion amplitudes, across all participants and speeds, for the C7-T8, C7-sacrum, and T8-sacrum were 2.9, 5.1 and 2.8 degrees, respectively. The C7-T8 relative phase changed little with speed. The C7-sacrum and T8-sacrum relative phases showed increases as subjects walked faster, but both groups had similar patterns of change. Only the C7-T8 relative phase at 0.67 and 0.89 m/s exhibited good reliability (ICC > 0.80, SEM 4.2-5.7, no significant time effects) for both groups. The C7-T8 and T8-sacrum relative phases demonstrated significant group by speed effects.
The C7-T8 relative phase showed reasonable reliability and some discrimination between groups, but changes in response to walking speed were small. The T8-sacrum relative phase showed some discriminative ability, but reliability was not adequate.
PMCID: PMC4029448  PMID: 24321275
Thoracic spine pain; Gait; Spinal coordination; Reliability; Validity
19.  Test of Intrarater and Interrater Reliability for the Star Excursion Balance Test 
Journal of Physical Therapy Science  2014;26(8):1139-1141.
[Purpose] The aim of this study was to examine the intrarater and interrater reliability of the Star Excursion Balance Test (SEBT), thereby increasing understanding of its efficient utilization. [Subjects and Methods] There were 67 subjects (49 female; 18 male). For the SEBT, eight lines were made using tape at 45-degree angles from the center of a circle. The experiment was conducted in the following order: the anterior, anterior-medial, medial, posterior-medial, posterior, posterior-lateral, lateral, and anterior-lateral directions. Intraclass correlation coefficients (ICC) (3,1) were used to evaluate the intrarater and interrater reliability (2,1) for each reach distance, while the standard error of measurement (SEM) and smallest detectable distance (SDD) were employed to assess absolute reliability. [Results] For intraratar reliability, the ICC values for all directions ranged from 0.88 to 0.96, SEM values ranged from 2.41 to 3.30, and SDD values ranged from 6.68 to 9.15. For interrater reliability, the ICC values for all directions ranged from 0.83 to 0.93, SEM values ranged from 3.19 to 4.26, and SDD values ranged from 8.85 to 11.82 [Conclusion] The SEBT is a highly reliable tool for measuring dynamic balance. Measurements for intrarater reliability are more reliable than measurements for interrater reliability. When measurement for eight directions was difficult, the SEBT was used. While the anterior, posteromedial, and posterolateral directions employed in the Y Balance Test KitTM can be utilized, this study recommends using the reverse Y Balance Test KitTM method with the posterior direction, not the anterior direction.
PMCID: PMC4155207  PMID: 25202168
Star excursion balance test (SEBT); Dynamic balance; Reliability
20.  How reliably do rheumatologists measure shoulder movement? 
Annals of the Rheumatic Diseases  2002;61(7):612-616.
Objective: To assess the intrarater and interrater reliability among rheumatologists of a standardised protocol for measurement of shoulder movements using a gravity inclinometer.
Methods: After instruction, six rheumatologists independently assessed eight movements of the shoulder, including total and glenohumeral flexion, total and glenohumeral abduction, external rotation in neutral and in abduction, internal rotation in abduction and hand behind back, in random order in six patients with shoulder pain and stiffness according to a 6x6 Latin square design using a standardised protocol. These assessments were then repeated. Analysis of variance was used to partition total variability into components of variance in order to calculate intraclass correlation coefficients (ICCs).
Results: The intrarater and interrater reliability of different shoulder movements varied widely. The movement of hand behind back and total shoulder flexion yielded the highest ICC scores for both intrarater reliability (0.91 and 0.83, respectively) and interrater reliability (0.80 and 0.72, respectively). Low ICC scores were found for the movements of glenohumeral abduction, external rotation in abduction, and internal rotation in abduction (intrarater ICCs 0.35, 0.43, and 0.32, respectively), and external rotation in neutral, external rotation in abduction, and internal rotation in abduction (interrater ICCs 0.29, 0.11, and 0.06, respectively).
Conclusions: The measurement of shoulder movements using a standardised protocol by rheumatologists produced variable intrarater and interrater reliability. Reasonable reliability was obtained only for the movement of hand behind back and total shoulder flexion.
PMCID: PMC1754152  PMID: 12079902
21.  Measurement Properties of Performance-Specific Pain Ratings of Patients Awaiting Total Joint Arthroplasty as a Consequence of Osteoarthritis 
Physiotherapy Canada  2008;60(3):255-263.
To estimate the test–retest reliability of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain sub-scale and performance-specific assessments of pain, as well as the association between these measures for patients awaiting primary total hip or knee arthroplasty as a consequence of osteoarthritis.
A total of 164 patients awaiting unilateral primary hip or knee arthroplasty completed four performance measures (self-paced walk, timed up and go, stair test, six-minute walk) and the WOMAC. Scores for 22 of these patients provided test–retest reliability data. Estimates of test–retest reliability (Type 2,1 intraclass correlation coefficient [ICC] and standard error of measurement [SEM]) and the association between measures were examined.
ICC values for individual performance-specific pain ratings were between 0.70 and 0.86; SEM values were between 0.97 and 1.33 pain points. ICC estimates for the four-item performance pain ratings and the WOMAC pain sub-scale were 0.82 and 0.57 respectively. The correlation between the sum of the pain scores for the four performance measures and the WOMAC pain sub-scale was 0.62.
Reliability estimates for the performance-specific assessments of pain using the numeric pain rating scale were consistent with values reported for patients with a spectrum of musculoskeletal conditions. The reliability estimate for the WOMAC pain sub-scale was lower than typically reported in the literature. The level of association between the WOMAC pain sub-scale and the various performance-specific pain scales suggests that the scores can be used interchangeably when applied to groups but not for individual patients.
PMCID: PMC2792776  PMID: 20145758
arthroplasty; numeric pain rating scale; osteoarthritis; performance measures; reliability; WOMAC;  arthroplastie; échelle numérique d’évaluation de la douleur; arthrose; mesures de performance; fidélité; WOMAC
22.  Three dimensional evaluation of posture in standing with the PosturePrint: an intra- and inter-examiner reliability study 
Few digitizers can measure the complexity of upright human postural displacements in six degrees of freedom of the head, rib cage, and pelvis.
In a University laboratory, three examiners performed delayed repeated postural measurements on forty subjects over two days. Three digital photographs (left lateral, AP, right lateral) of each of 40 volunteer participants were obtained, twice, by three examiners. Examiners placed 13 markers on the subjects before photography and chose 16 points on the photographic images. Using the PosturePrint® internet computer system, head, rib cage, and pelvic postures were calculated as rotations (Rx, Ry, Rz) in degrees and translations (Tx, Tz) in millimeters. For reliability, two different types (liberal = ICC3,1 & conservative = ICC2,1) of inter- and intra-examiner correlation coefficients (ICC) were calculated. Standard error of measurements (SEM) and mean absolute differences within and between observers' measurements were also determined.
All of the "liberal" ICCs were in the excellent range (> 0.84). For the more "conservative" type ICCs, four Inter-examiner ICCs were in the interval (0.5–0.6), 10 ICCs were in the interval (0.61–0.74), and the remainder were greater than 0.75. SEMs were 2.7° or less for all rotations and 5.9 mm or less for all translations. Mean absolute differences within examiners and between examiners were 3.5° or less for all rotations and 8.4 mm or less for all translations.
For the PosturePrint® system, the combined inter-examiner and intra-examiner correlation coefficients were in the good (14/44) and excellent (30/44) ranges. SEMs and mean absolute differences within and between examiners' measurements were small. Thus, this posture digitizer is reliable for clinical use.
PMCID: PMC2077332  PMID: 17892559
23.  Modifying patterns of movement in people with low back pain -does it help? A systematic review 
Physiotherapy for people with low back pain frequently includes assessment and modification of lumbo-pelvic movement. Interventions commonly aim to restore normal movement and thereby reduce pain and improve activity limitation. The objective of this systematic review was to investigate: (i) the effect of movement-based interventions on movement patterns (muscle activation, lumbo-pelvic kinematics or postural patterns) of people with low back pain (LBP), and (ii) the relationship between changes in movement patterns and subsequent changes in pain and activity limitation.
MEDLINE, Cochrane Central, EMBASE, AMI, CINAHL, Scopus, AMED, ISI Web of Science were searched from inception until January 2012. Randomised controlled trials or controlled clinical trials of people with LBP were eligible for inclusion. The intervention must have been designed to influence (i) muscle activity patterns, (ii) lumbo-pelvic kinematic patterns or (iii) postural patterns, and included measurement of such deficits before and after treatment, to allow determination of the success of the intervention on the lumbo-pelvic movement. Twelve trials (25% of retrieved studies) met the inclusion criteria. Two reviewers independently identified, assessed and extracted data. The PEDro scale was used to assess method quality. Intervention effects were described using standardised differences between group means and 95% confidence intervals.
The included trials showed inconsistent, mostly small to moderate intervention effects on targeted movement patterns. There was considerable heterogeneity in trial design, intervention type and outcome measures. A relationship between changes to movement patterns and improvements in pain or activity limitation was observed in one of six studies on muscle activation patterns, one of four studies that examined the flexion relaxation response pattern and in two of three studies that assessed lumbo-pelvic kinematics or postural characteristics.
Movement-based interventions were infrequently effective for changing observable movement patterns. A relationship between changes in movement patterns and improvement in pain or activity limitation was also infrequently observed. No independent studies confirm any observed relationships. Challenges for future research include defining best methods for measuring (i) movement aberrations, (ii) improvements in movements, and (iii) the relationship between changes in how people move and associated changes in other health indicators such as activity limitation.
PMCID: PMC3466154  PMID: 22958597
Low back pain; Movement disorders; Randomized controlled trial; Exercise therapy; Posture
24.  Evaluation of multi-segmental kinematic modelling in the paediatric foot using three concurrent foot models 
Various foot models are used in the analysis of foot motion during gait and selection of the appropriate model can be difficult. The clinical utility of a model is dependent on the repeatability of the data as well as an understanding of the expected error in the process of data collection. Kinematic assessment of the paediatric foot is challenging and little is reported about multi-segment foot models in this population. The aim of this study was to examine three foot models and establish their concurrent test-retest repeatability in evaluation of paediatric foot motion during gait.
3DFoot, Kinfoot and the Oxford Foot Model (OFM) were applied concurrently to the right foot and lower limb of 14 children on two testing sessions. Angular data for foot segments were extracted at gait cycle events and peaks and compared between sessions by intraclass correlation coefficient (ICC) with 95% confidence intervals (95%CI) and standard error of measurement (SEM).
All foot models demonstrated moderate repeatability: OFM (ICC 0.55, 95% CI 0.16 to 0.77), 3DFoot (ICC 0.47, 95% CI 0.15 to 0.64) and Kinfoot (ICC 0.43, 95% CI -0.03 to 0.59). On the basis of a cut-off of 5°, acceptable mean error over repeated sessions was observed for OFM (SEM 4.61° ± 2.86°) and 3DFoot (SEM 3.88° ± 2.18°) but not for Kinfoot (SEM 5.08° ± 1.53°). Reliability of segmental kinematics varied, with low repeatability (ICC < 0.4) found for 14.3% of OFM angles, 22.7% of 3DFoot angles and 37.6% of Kinfoot angles. SEM greater than 5° was found in 26.2% of OFM, 15.2% of 3DFoot, and 43.8% of Kinfoot segmental angles.
Findings from this work have demonstrated that segmental foot kinematics are repeatable in the paediatric foot but the level of repeatability and error varies across the segments of the different models. Information on repeatability and test-retest errors of three-dimensional foot models can better inform clinical assessment and advance understanding of foot motion during gait.
PMCID: PMC3832939  PMID: 24176241
Foot; Paediatrics; Gait
25.  Reliability of measures of impairments associated with patellofemoral pain syndrome 
The reliability and measurement error of several impairment measures used during the clinical examination of patients with patellofemoral pain syndrome (PFPS) has not been established. The purpose was to determine the inter-tester reliability and measurement error of measures of impairments associated with PFPS in patients with PFPS.
A single group repeated measures design was used. Two pairs of physical therapists participated in data collection. Examiners were blinded to each others' measurements.
Thirty patients (age 29 +/- 8; 17 female) with PFPS participated in this study. Inter-tester reliability coefficients were substantial for measures of hamstrings, quadriceps, plantarflexors, and ITB/TFL complex length, hip abductors strength, and foot pronation (ICCs from .85 to .97); moderate for measures of Q-angle, tibial torsion, hip external rotation strength, lateral retinacular tightness, and quality of movement during a step down task (ICCs from .67 to .79); and poor for femoral anteversion (ICC of .45). Standard error of measurement (SEM) for measures of muscle length ranged from 1.6 degrees to 4.3 degrees. SEM for Q-angle, tibial torsion, and femoral anteversion were 2.4 degrees, 2.9 degrees, and 4.5 degrees respectively. SEM for foot pronation was 1 mm. SEM for measures of muscle strength was 1.8 Kg for abduction and 2.4 Kg for external rotation.
Several of the impairments associated with PFPS had sufficient reliability and low measurement error. Further investigation is needed to test if these impairment measurements are related to physical function and whether or not they are useful for decision-making.
PMCID: PMC1557500  PMID: 16579850

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