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1.  Validation of a grading system for lateral nasal wall insufficiency 
Allergy & Rhinology  2013;4(2):e66-e68.
This study was designed to validate a grading scheme for lateral nasal wall insufficiency with interrater and intrarater reliability measures. Representative endoscopic videos depicting varied degrees of lateral nasal wall insufficiency were collated into a 30-clip video (15 clips in duplicate). This was rated by five reviewers for a total of 150 observations. Interrater and intrarater reliability were determined using Fleiss kappa and intraclass correlation coefficient (ICC) statistics, respectively. Good agreement was established between reviewers (interrater reliability), with a Fleiss kappa of 0.7733 (p < 0.01). Analysis of intrarater variability with the ICC revealed a very strong agreement (ICC = 0.88; p < 0.01). The proposed grading system is shown to have good interrater and intrarater reliability. It provides a reliable instrument for assessing lateral wall insufficiency.
PMCID: PMC3793115  PMID: 24124639
Collapse; grading; internal valve; lateral nasal wall; lateral wall; nasal valve; obstruction
2.  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
3.  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
4.  Quantitative Mechanical Properties of the Relaxed Biceps and Triceps Brachii Muscles in Patients with Subacute Stroke: A Reliability Study of the Myoton-3 Myometer 
Stroke Research and Treatment  2012;2012:617694.
Objective. Test-retest reliability of the myotonometer was investigated in patients with subacute stroke. Methods. Twelve patients with substroke (3 to 9 months poststroke) were examined in standardized testing position twice, 60 minutes apart, with the Myoton-3 myometer to measure tone, elasticity, and stiffness of relaxed bilateral biceps and triceps brachii muscles. Intrarater reliability of muscle properties was determined using intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and the minimal detectable change (MDC). Results. Intrarater reliability of muscle properties of bilateral biceps and triceps brachii muscles were good (ICCs = 0.79–0.96) except for unaffected biceps tone (ICC = 0.72). The SEM and MDC of bilateral biceps and triceps brachii muscles indicated small measurement error (SEM% <10%, MDC% <25%). Conclusion. The Myoton-3 myometer is a reliable tool for quantifying muscle tone, elasticity, and stiffness of the biceps and triceps brachii in patients with subacute stroke.
PMCID: PMC3350849  PMID: 22619740
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
6.  A study of the test–retest reliability of the self-perceived general recovery and self-perceived change in neck pain questions in patients with recent whiplash-associated disorders 
European Spine Journal  2010;19(6):957-962.
The objectives of this study were to determine the test–retest reliability of two self-perceived recovery questions in patients with recent whiplash-associated disorders (WAD), and to assess whether remembering previous answers influences reliability. The self-perceived general recovery and self-perceived change in neck pain questions were administered to 46 patients with recent WAD 6 weeks after recruitment and again 3–5 days later. At follow-up, we also asked participants if they remembered their previous answers. We used the intra-class correlation coefficients (ICC) to measure the reliability of the original ordinal response structure and kappa statistics for dichotomized responses. The ICC [95% confidence intervals (CI)] for the general recovery and for the change in neck pain questions were 0.70 (0.60–0.80) and 0.80 (0.72–0.87), respectively. The kappa statistic (95% CI) for the general recovery question was 0.81 (0.64–0.99) when recovery was defined as “completely better” or “much improved”. The kappa statistic (95% CI) for the change in neck pain question was 0.80 (0.62–0.99) when recovery was defined as “very much better” or “better”. Our analysis suggests that the test–retest reliability may be higher for participants who remembered their previous responses. In conclusion, our results suggest that self-perceived recovery questions have adequate reliability for use in epidemiological research of WAD.
PMCID: PMC2899975  PMID: 20130932
Self-perceived recovery; Whiplash-associated disorders; Test–retest reliability; Patient outcomes; Outcomes research
7.  Reliability of four experimental mechanical pain tests in children 
Journal of Pain Research  2013;6:103-110.
In order to study pain in children, it is necessary to determine whether pain measurement tools used in adults are reliable measurements in children. The aim of this study was to explore the intrasession reliability of pressure pain thresholds (PPT) in healthy children. Furthermore, the aim was also to study the intersession reliability of the following four tests: (1) Total Tenderness Score; (2) PPT; (3) Visual Analog Scale score at suprapressure pain threshold; and (4) area under the curve (stimulus–response functions for pressure versus pain).
Participants and methods
Twenty-five healthy school children, 8–14 years of age, participated. Test 2, PPT, was repeated three times at 2 minute intervals on the same day to estimate PPT intrasession reliability using Cronbach’s alpha. Tests 1–4 were repeated after median 21 (interquartile range 10.5–22) days, and Pearson’s correlation coefficient was used to describe the intersession reliability.
The PPT test was precise and reliable (Cronbach’s alpha ≥ 0.92). All tests showed a good to excellent correlation between days (intersessions r = 0.66–0.81). There were no indications of significant systematic differences found in any of the four tests between days.
All tests seemed to be reliable measurements in pain evaluation in healthy children aged 8–14 years. Given the small sample size, this conclusion needs to be confirmed in future studies.
PMCID: PMC3569048  PMID: 23403523
repeatability; intraindividual reliability; pressure pain threshold; pain measurement; algometer
8.  Relationship between low-back pain, muscle spasm and pressure pain thresholds in patients with lumbar disc herniation 
European Spine Journal  2005;15(1):41-47.
It is not known whether or not muscle spasm of the back muscles presented in patients with sciatic scoliosis caused by lumbar disc herniation produces muscle pain and/or tenderness. Pressure pain thresholds (PPTs) of the lower back and low-back pain were examined in 52 patients (13 of 52 presenting sciatic scoliosis) with lumbar disc herniation who complained of radicular pain and in 15 normal subjects. PPTs were measured at five points bilaterally using an electronic pressure algometer. Low-back pain was evaluated using visual analogue scale (VAS) ratings. All patients complained of radicular leg pain and were divided into the following three groups according to the presence of and the region of low-back pain: no low-back pain group, low-back pain with no laterality group, and low-back pain dominantly on the herniation side group; the VAS rating on the side ipsilateral to the herniation side was higher than that on the contralateral side. In the normal subjects, there were no statistically significant differences between sides in mean PPTs at all sites examined. PPTs were not lower in the spasmodic side (concave side) than the convex side in patients with sciatic scoliosis. PPTs on the herniation side were significantly lower than those on the contralateral side in patients with low-back pain dominantly on the herniation side. Furthermore, the areas of low PPTs were beyond the innervation area of dorsal ramus of L5 and S1 nerve root. It was considered that not only the peripheral mechanisms but also the hyper excitability of the central nervous system might contribute in lowering PPTs of the lower back on the herniation side.
PMCID: PMC3454558  PMID: 15931510
Pressure pain threshold; Muscle spasm; Low-back pain; Lumbar disc herniation; Sciatic scoliosis
9.  Interrater and Intrarater Reliability of the Active Knee Extension (AKE) Test among Healthy Adults 
[Purpose] The purpose of this study was to determine the reliability of the active knee extension (AKE) test among healthy adults. [Subjects] Fourteen healthy participants (10 men and 4 women) volunteered and gave informed consent. [Methods] Two raters conducted AKE tests independently with the aid of a simple and inexpensive stabilizing apparatus. Each knee was measured twice, and the AKE test was repeated one week later. [Results] The interrater reliability intraclass correlation coefficients (ICC2,1) were 0.87 for the dominant knee and 0.81 for the nondominant knee. In addition, the intrarater (test-retest) reliability ICC3,1 values range between 0.78–0.97 and 0.75–0.84 for raters 1 and 2 respectively. The percentages of agreement within 10° for AKE measurements were 93% for the dominant knee and 79% for the nondominant knee. [Conclusion] The finding suggests the current AKE test showed excellent interrater and intrarater reliability for assessing hamstring flexibility in healthy adults.
PMCID: PMC3820221  PMID: 24259893
Hamstring; Flexibility; Range of movement
10.  Intrarater and Interrater Reliability of the Flexicurve Index, Flexicurve Angle, and Manual Inclinometer for the Measurement of Thoracic Kyphosis 
Objective. This study aimed to describe the interrater and intrarater reliability of the flexicurve index, flexicurve angle, and manual inclinometer in swimmers. A secondary objective was to determine the level of agreement between the inclinometer angle and the flexicurve angle and to provide an equation to approximate one angle from the other. Methods. Thirty swimmers participated. Thoracic kyphosis was measured using the flexicurve and the manual inclinometer. Intraclass correlation coefficient, 95% confidence interval, and standard error of measurement were computed. Results. The flexicurve angle and index showed excellent intrarater (ICC = 0.94) and good interrater (ICC = 0.86) reliability. The inclinometer demonstrated excellent intrarater (ICC = 0.92) and interrater (ICC = 0.90) reliability. The flexicurve angle was systematically smaller and correlated poorly with the inclinometer angle (R2 = 0.384). The following equations can be used for approximate conversions: flexicurve angle = (0.275 × inclinometer angle) + 8.478; inclinometer angle = (1.396 × flexicurve angle) + 8.694. Conclusion. The inclinometer and flexicurve are both reliable instruments for thoracic kyphosis measurement in swimmers. Although the flexicurve and inclinometer angles are not directly comparable, the approximate conversion factors provided will permit translation of flexicurve angle to inclinometer angle and vice versa.
PMCID: PMC3875123  PMID: 24396603
11.  Subgroups based on thermal and pressure pain thresholds in women with chronic whiplash display differences in clinical presentation – an explorative study 
Journal of Pain Research  2012;5:511-521.
To investigate the presence of subgroups in chronic whiplash-associated disorders (WAD) based on pain thresholds for pressure (PPT), cold (CPT), and heat (HPT) and to compare these subgroups with respect to symptomatology, disability, and health aspects.
Two groups of female subjects – patients with chronic WAD (n = 28) and healthy controls (CON; n = 29) – were investigated. Quantitative sensory testing (QST) for thermal thresholds and algometry for PPT at four sites in the body (over the trapezius and tibialis anterior bilaterally) were determined. Habitual pain intensities, psychological strain, disability, and health aspects were registered using a questionnaire.
A cluster analysis based on PPT, CPT, and HPT identified two subgroups of chronic WAD: one sensitive subgroup (s-WAD; n = 21), and one less sensitive subgroup (ls-WAD; n = 6). S-WAD displayed widespread hyperalgesia, whereas ls-WAD had localized hyperalgesia in the neck area, with tendencies to supernormal values in remote areas of the body. Generally, s-WAD had a significantly worse situation than the CON with respect to symptomatology, disability, and health aspects. The ls-WAD group was intermediary between s-WAD and CON in these aspects.
Different explanations, eg, severity of the pain condition per se, etiological factors, and pre-trauma differences in pain sensitivity, may exist for the differences in pain thresholds between the two subgroups. Future research should investigate the role of pain thresholds in the chronic stage to determine the efficacy of treatment interventions.
PMCID: PMC3500924  PMID: 23166449
cold pain threshold; pain; pressure pain threshold; heat pain threshold; subgroup; whiplash; WAD
12.  Reliability of pain threshold measurement in young adults 
The objective was to examine reliability of pressure and thermal (cold) pain threshold assessment in persons less than 25 years of age, using intra–class correlation (ICC) and coefficients of repeatability and variability. We measured thresholds to pain from pressure algometry and ice placed at the hand and head in 10 healthy volunteers aged 18–25. Intra–rater reliability was examined with ICC. Coefficients of repeatability (CR) and variability (CV) were estimated. Reliability of repeat assessments was high as assessed by ICC, although coefficients of repeatability and variation indicated considerable inter–individual variation in repeat measurements. Pressure algometry and strategically placed ice appear to be reliable techniques for assessing pain processing in young adults. Reliability studies employing ICC may benefit from complementary estimation of CR and CV.
PMCID: PMC3451574  PMID: 16440140
Pain; Threshold; Pressure; Algometry; Thermal; Reliability
13.  Test-retest reliability of Motricity Index strength assessments for lower extremity in post stroke hemiparesis 
The Motricity Index was used to measure strength in upper and lower extremities after stroke. The weighted score based on the ordinal 6 point scale of Medical Research Council was used to measure maximal isometric muscle strength. There is dearth of articles dealing with the reliability of this method. Therefore, the aim of this study was to determine the test retest reliability of Motricity Index strength assessments for paretic lower limb in 20 chronic stroke patients with one week interval.
In a cross sectional study, intrarater reliability of lower extremity Motricity Index strength assessments with one week interval were measured.
The SPSS 18 was used for analysis of data. Two-way random-consistency model of ICC was used for assessment of test-retest reliability. The ICC values showed high reliability of strength measurement of Motricity Index (ICC=0.93).
The Motricity Index can be a reliable instrument for measuring the strength of involved lower extremity when assessment is done by one rater following chronic stroke.
PMCID: PMC3587895  PMID: 23483112
Reliability; Motricity Index; Hemiparesis; Chronic stroke
14.  Algometry with a clothes peg compared to an electronic pressure algometer: a randomized cross-sectional study in pain patients 
Hypersensitivity of the central nervous system is widely present in pain patients and recognized as one of the determinants of chronic pain and disability. Electronic pressure algometry is often used to explore aspects of central hypersensitivity. We hypothesized that a simple pain provocation test with a clothes peg provides information on pain sensitivity that compares meaningfully to that obtained by a well-established electronic pressure algometer. "Clinically meaningful" was defined as a medium (r = 0.3-0.5) or high (r > 0.5) correlation coefficient according to Cohen's conventions.
We tested 157 in-patients with different pain types. A calibrated clothes peg was applied for 10 seconds and patients rated the pain intensity on a 0 to 10 numerical rating scale. Pressure pain detection threshold (PPdt) and pressure pain tolerance threshold (PPtt) were measured with a standard electronic algometer. Both methods were performed on both middle fingers and ear lobes. In a subgroup of 47 patients repeatability (test-retest reliability) was calculated.
Clothes peg values correlated with PPdt values for finger testing with r = -0.54 and for earlobe testing with r = -0.55 (all p-values < 0.001). Clothes peg values also correlated with PPtt values for finger testing with r = -0.55 (p < 0.001). Test-retest reliability (repeatability) showed equally stable results for clothes peg algometry and the electronic algometer (all r-values > 0.89, all p-values < 0.001).
Information on pain sensitivity provided by a calibrated clothes peg and an established algometer correlate at a clinically meaningful level.
PMCID: PMC3158560  PMID: 21787399
15.  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
16.  Cognitive Modulation of Psychophysical, Respiratory and Autonomic Responses to Cold Pressor Test 
PLoS ONE  2013;8(10):e75023.
In healthy subjects with high hypnotisability (highs) under hypnosis, subjectively effective suggestions for analgesia abolish the increases in blood pressure associated with cold pressor test (cpt) by reducing the peripheral vascular resistance. The aim of the present study was to investigate the effects of the suggestions of analgesia on the responses to cpt in healthy highs (n = 22) and in low hypnotisable participants (lows, n = 22) out of hypnosis. Cpt was administered without (CPT) and with suggestions for analgesia (CPT+AN). Psychophysical (pain intensity, pain threshold, cpt duration (time of immersion) and pain tolerance, defined as the difference between cpt duration and pain threshold), respiratory (amplitude and frequency) and autonomic variables (tonic skin conductance, mean RR interval (RR = 1/heart rate), blood pressure, skin blood flow) were studied. The suggestions for analgesia increased cpt duration and RR in both groups, but decreased pain intensity and enhanced pain threshold only in highs; in both groups they did not modulate systolic blood pressure, tonic skin conductance and skin blood flow; thus, increased parasympathetic activity appears responsible for the heart rate reduction induced by suggestions in both groups. In conclusion, our findings show that suggestions modulate pain experience differentially in highs and lows, and are partially effective also in lows. We hypothesize that the mechanisms responsible for the efficacy of suggestions in healthy lows may be involved also in their efficacy in chronic pain patients with low hypnotisability.
PMCID: PMC3794039  PMID: 24130680
17.  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
18.  An initial application of computerized adaptive testing (CAT) for measuring disability in patients with low back pain 
Recent approaches to outcome measurement involving Computerized Adaptive Testing (CAT) offer an approach for measuring disability in low back pain (LBP) in a way that can reduce the burden upon patient and professional. The aim of this study was to explore the potential of CAT in LBP for measuring disability as defined in the International Classification of Functioning, Disability and Health (ICF) which includes impairments, activity limitation, and participation restriction.
266 patients with low back pain answered questions from a range of widely used questionnaires. An exploratory factor analysis (EFA) was used to identify disability dimensions which were then subjected to Rasch analysis. Reliability was tested by internal consistency and person separation index (PSI). Discriminant validity of disability levels were evaluated by Spearman correlation coefficient (r), intraclass correlation coefficient [ICC(2,1)] and the Bland-Altman approach. A CAT was developed for each dimension, and the results checked against simulated and real applications from a further 133 patients.
Factor analytic techniques identified two dimensions named "body functions" and "activity-participation". After deletion of some items for failure to fit the Rasch model, the remaining items were mostly free of Differential Item Functioning (DIF) for age and gender. Reliability exceeded 0.90 for both dimensions. The disability levels generated using all items and those obtained from the real CAT application were highly correlated (i.e. > 0.97 for both dimensions). On average, 19 and 14 items were needed to estimate the precise disability levels using the initial CAT for the first and second dimension. However, a marginal increase in the standard error of the estimate across successive iterations substantially reduced the number of items required to make an estimate.
Using a combination approach of EFA and Rasch analysis this study has shown that it is possible to calibrate items onto a single metric in a way that can be used to provide the basis of a CAT application. Thus there is an opportunity to obtain a wide variety of information to evaluate the biopsychosocial model in its more complex forms, without necessarily increasing the burden of information collection for patients.
PMCID: PMC2651163  PMID: 19094219
19.  Reliability and Usefulness of the Pressure Pain Threshold Measurement in Patients with Myofascial Pain 
Annals of Rehabilitation Medicine  2011;35(3):412-417.
To assess the usefulness of a pressure algometer to measure pressure pain threshold (PPT) for diagnosis of myofascial pain syndrome (MPS) in the upper extremity and trunk muscles.
A group of 221 desk workers complaining of upper body pain participated in this study. Five physiatrists made the diagnosis of MPS using physical examination and PPT measurements. PPT measurements were determined for several muscles in the back and upper extremities. Mean PPT data for gender, side, and dominant hand groups were analyzed. Sensitivity and specificity of Fischer's standard method were evaluated. PPT cut-off values for each muscle group were determined using an ROC curve.
Cronbach's alpha for each muscle was very high. The PPT in men was higher than in females, and the PPT in the left side was higher than in the right side for all muscles tested (p<0.05). There was no significant difference in PPT for all muscles between dominant and non-dominant hand groups. Diagnosis of MPS based on Fischer's standard showed relatively high specificity and poor sensitivity.
The digital pressure algometer showed high reliability. PPT might be a useful parameter for assessing a treatment's effect, but not for use in diagnosis or even as a screening method.
PMCID: PMC3309218  PMID: 22506152
Pressure algometer; Pressure pain threshold; Reliability
20.  Minimizing the source of nociception and its concurrent effect on sensory hypersensitivity: An exploratory study in chronic whiplash patients 
The cervical zygapophyseal joints may be a primary source of pain in up to 60% of individuals with chronic whiplash associated disorders (WAD) and may be a contributing factor for peripheral and centrally mediated pain (sensory hypersensitivity). Sensory hypersensitivity has been associated with a poor prognosis. The purpose of the study was to determine if there is a change in measures indicative of sensory hypersensitivity in patients with chronic WAD grade II following a medial branch block (MBB) procedure in the cervical spine.
Measures of sensory hypersensitivity were taken via quantitative sensory testing (QST) consisting of pressure pain thresholds (PPT's) and cold pain thresholds (CPT's). In patients with chronic WAD (n = 18), the measures were taken at three sites bilaterally, pre- and post- MBB. Reduced pain thresholds at remote sites have been considered an indicator of central hypersensitivity. A healthy age and gender matched comparison group (n = 18) was measured at baseline. An independent t-test was applied to determine if there were any significant differences between the WAD and normative comparison groups at baseline with respect to cold pain and pressure pain thresholds. A dependent t-test was used to determine whether there were any significant differences between the pre and post intervention cold pain and pressure pain thresholds in the patients with chronic WAD.
At baseline, PPT's were decreased at all three sites in the WAD group (p < 0.001). Cold pain thresholds were increased in the cervical spine in the WAD group (p < 0.001). Post-MBB, the WAD group showed significant increases in PPT's at all sites (p < 0.05), and significant decreases in CPT's at the cervical spine (p < 0.001).
The patients with chronic WAD showed evidence of widespread sensory hypersensitivity to mechanical and thermal stimuli. The WAD group revealed decreased sensory hypersensitivity following a decrease in their primary source of pain stemming from the cervical zygapophyseal joints.
PMCID: PMC2829507  PMID: 20144214
21.  The Reliability of an Instrumented Device for Measuring Components of the Star Excursion Balance Test 
The Star Excursion Balance Test (SEBT) is a dynamic test that requires strength, flexibility, and proprioception and has been used to assess physical performance, identify chronic ankle instability, and identify athletes at greater risk for lower extremity injury. In order to improve the repeatability in measuring components of the SEBT, the Y Balance Test™ has been developed.
The purpose of this paper is to report the development and reliability of the Y Balance Test™.
Single limb stance excursion distances were measured using the Y Balance Test™ on a sample of 15 male collegiate soccer players. Intraclass Correlation Coefficients (ICC) were used to determine the reliability of the test.
The ICC for intrarater reliability ranged from 0.85 to 0.91 and for interrater reliability ranged from 0.99 to 1.00. Composite reach score reliability was 0.91 for intrarater and 0.99 for interrater reliability.
This study demonstrated that the Y Balance Test™ has good to excellent intrarater and interrater reliability. The device and protocol attempted to address the common sources of error and method variation in the SEBT including whether touch down is allowed with the reach foot, where the stance foot is aligned, movement allowed of the stance foot, instantaneous measurement of furthest reach distance, standard reach height from the ground, standard testing order, and well defined pass/fail criteria.
The Y Balance Test™ is a reliable test for measuring single limb stance excursion distances while performing dynamic balance testing in collegiate soccer players.
PMCID: PMC2953327  PMID: 21509114
Y Balance Test; lower extremity; postural stability
22.  Intra- and interrater agreement of pressure pain thresholds in children with orthopedic disorders 
Pressure algometry is widely used to obtain measures of mechanical pain sensitivity in adults, both in experimental and clinical pain conditions. Only very few studies describe the use of pressure algometry in children. The purpose of this study was to produce reference values of pressure pain thresholds and to determine the intra- and interrater agreement, in order to introduce pressure algometry as a standardized method for the assessment of pain thresholds in children with orthopedic disorders.
Pressure pain thresholds were determined at the leg and at the thenar in 50 children aged 4–12 years. All were scheduled for physical examination at the outpatient Orthopedic Clinic at Aarhus University Hospital, Denmark, because of various orthopedic disorders such as clubfoot and Baker’s cyst. Pressure pain thresholds were determined by two different raters: 20 children were examined twice by rater 1 (intrarater agreement), and another 20 children were examined by both rater 1 and rater 2 (interrater agreement). An additional ten children were examined once by rater 1 to increase the number of children used to determine the reference values.
The pressure pain threshold was 183.1 kPa (mean, SD: 90.7) at the leg and 179.1 kPa (mean, SD: 97.4 kPa) at the thenar (n = 50). Pressure pain thresholds were similar in boys (n = 27) and girls (n = 23). Also, pressure pain thresholds were not affected by age. Bland–Altman plots showed excellent intrarater agreement and satisfactory interrater agreement.
Pressure algometry has excellent intrarater agreement and satisfactory interrater agreement. Pressure algometry was well-tolerated even by very young children. The method deserves more widespread use both in clinical and experimental settings.
PMCID: PMC3100461  PMID: 22654978
Pressure algometry; Pressure pain thresholds; Reliability; Children
23.  A New Transient Sham TENS Device Allows for Investigator Blinding While Delivering a True Placebo Treatment 
This study compared a new transient sham TENS that delivers current for 45 seconds to an inactive sham and active TENS to determine the degree of blinding and influence on pain reduction. Pressure pain thresholds (PPT), heat pain thresholds (HPT), and pain intensities to tonic heat and pressure were measured in 69 healthy adults before and after randomization. Allocation investigators and subjects were asked to identify the treatment administered. The transient sham blinded investigators 100% of the time and 40% of subjects compared to the inactive sham that blinded investigators 0% of the time and 21% of subjects. Investigators and subjects were only blinded 7% and 13% of the time, respectively, with active TENS. Neither placebo treatment resulted in significant changes in PPT, HPT, or pain intensities. Subjects using higher active TENS amplitudes (≥17mAs) had significantly higher PPTs and lower pain intensities to tonic pressure than subjects using lower amplitudes (<17mAs). HPTs and pain intensities to tonic heat were not significantly changed. The transient TENS completely blinds investigators to treatment and does not reduce pain, thereby providing a true placebo treatment.
PMCID: PMC2922105  PMID: 19945354
24.  Phenotyping Chronic Pelvic Pain Based on Latent Class Modeling of Physical Examination 
Pain Research and Treatment  2013;2013:891301.
Introduction. Defining clinical phenotypes based on physical examination is required for clarifying heterogeneous disorders such as chronic pelvic pain (CPP). The objective of this study was to determine the number of classes within 4 examinable regions and then establish threshold and optimal exam criteria for the classes discovered. Methods. A total of 476 patients meeting the criteria for CPP were examined using pain pressure threshold (PPT) algometry and standardized numeric scale (NRS) pain ratings at 30 distinct sites over 4 pelvic regions. Exploratory factor analysis, latent profile analysis, and ROC curves were then used to identify classes, optimal examination points, and threshold scores. Results. Latent profile analysis produced two classes for each region: high and low pain groups. The optimal examination sites (and high pain minimum thresholds) were for the abdominal wall region: the pair at the midabdomen (PPT threshold depression of > 2); vulvar vestibule region: 10:00 position (NRS > 2); pelvic floor region: puborectalis (combined NRS > 6); vaginal apex region: uterosacral ligaments (combined NRS > 8). Conclusion. Physical examination scores of patients with CPP are best categorized into two classes: high pain and low pain. Standardization of the physical examination in CPP provides both researchers and general gynecologists with a validated technique.
PMCID: PMC3885108  PMID: 24455240
25.  The Benefit of a Mechanical Needle Stimulation Pad in Patients with Chronic Neck and Lower Back Pain: Two Randomized Controlled Pilot Studies 
Objectives. The objective was to investigate whether a treatment with a needle stimulation pad (NSP) changes perceived pain and/or sensory thresholds in patients with chronic neck (NP) and lower back pain (BP). Methods. 40 patients with chronic NP and 42 patients with chronic BP were equally randomized to either treatment or waiting list control group. The treatment group self-administered a NSP over a period of 14 days. Pain ratings were recorded on numerical rating scales (NRSs). Mechanical detection thresholds (MDTs) and pressure pain thresholds (PPTs) were determined at the site of maximal pain and in the adjacent region, vibration detection thresholds (VDT) were measured at close spinal processes. The Northwick Park Neck Pain Questionnaire (NPQ) and the Oswestry Disability Index (ODI) were utilized for the NP and BP study, respectively. Results. NRS ratings were significantly reduced for the treatment groups compared to the control groups (NP: P = .021 and BP: P < .001), accompanied by a significant increase of PPT at pain maximum (NP: P = .032 and BP: P = .013). There was no effect on VDT and MDT. The NPQ showed also a significant improvement, but not the ODI. Conclusions. The mechanical NSP seems to be an effective treatment method for chronic NP and BP.
PMCID: PMC3446809  PMID: 22997531

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