Toni Lange

The reliability of physical examination tests for the diagnosis of anterior cruciate ligament rupture – A systematic review

STUDY DESIGN Systematic literature review. BACKGROUND Despite their frequent application in routine care, a systematic review on the reliability of clinical examination tests to evaluate the integrity of the ACL is missing. OBJECTIVES To summarize and evaluate intra- and interrater reliability research on physical examination tests used for the diagnosis of ACL tears. METHODS A comprehensive systematic literature search was conducted in MEDLINE, EMBASE and AMED until May 30th 2013. Studies were included if they assessed the intra- and/or interrater reliability of physical examination tests for the integrity of the ACL. Methodological quality was evaluated with the Quality Appraisal of Reliability Studies (QAREL) tool by two independent reviewers. RESULTS 110 hits were achieved of which seven articles finally met the inclusion criteria. These studies examined the reliability of four physical examination tests. Intrarater reliability was assessed in three studies and ranged from fair to almost perfect (Cohens k = 0.22-1.00). Interrater reliability was assessed in all included studies and ranged from slight to almost perfect (Cohens k = 0.02-0.81). The Lachman test is the physical tests with the highest intrarater reliability (Cohens k = 1.00), the Lachman test performed in prone position the test with the highest interrater reliability (Cohens k = 0.81). Included studies were partly of low methodological quality. A meta-analysis could not be performed due to the heterogeneity in study populations, reliability measures and methodological quality of included studies. CONCLUSION Systematic investigations on the reliability of physical examination tests to assess the integrity of the ACL are scarce and of varying methodological quality.

Interrater reliability of the modified scapular assistance test with and without handheld weights

STUDY DESIGN Prospective, blinded interrater reliability study. OBJECTIVE To determine the interrater reliability of the modified Scapular Assistance Test (mSAT) with and without the use of additional handheld weights. METHODS 110 Shoulder patients with various shoulder pathologies were consecutively recruited. Tests were performed independently and randomly on each participant by 2 different examiners, which were blinded to further clinical information (e.g. patient history, former diagnostic results). Percent agreement, Cohens kappa (Κ), proportion of positive/negative agreement, maximum Κ, prevalence and bias indexes and prevalence-adjusted-bias-adjusted kappa (PABAK) were calculated as estimates of interrater reliability of the mSAT with and without additional handheld weights. Weights were chosen according to body weight. RESULTS The reliability measures for the mSAT (Cohens Κ: 0.68, confidence interval (CI): 0.51-0.85; PABAK: 0.78, CI: 0.67-0.90) as well as for the mSAT with handheld weights (Cohens Κ: 0.63, CI: 0.44-0.81; PABAK: 0.76, CI: 0.64-0.88) showed substantial agreement according to the classification system proposed by Landis and Koch. CONCLUSIONS Based on the results of this study, the mSAT with and without additional weights can be considered as reliable for clinical use. Since both tests showed substantial agreement, the use of additional handheld weights might not be necessary in case of obvious scapula dyskinesis. However, to perform the mSAT with/without additional weights should depend not only on its reliability values. Name of the public trials registry and the registration number: German Clinical Trials Register, protocol number DRKS00005377.

The reliability of physical examination tests for the clinical assessment of scapular dyskinesis in subjects with shoulder complaints: A systematic review

STUDY DESIGN Systematic review. OBJECTIVES The aim of this systematic review was to summarize and evaluate intra- and interrater reliability research of physical examination tests used for the assessment of scapular dyskinesis. BACKGROUND Scapular dyskinesis, defined as alteration of normal scapular kinematics, is described as a non-specific response to different shoulder pathologies. METHODS A systematic literature search was conducted in MEDLINE, EMBASE, AMED and PEDro until March 20th, 2015. Methodological quality was assessed with the Quality Appraisal of Reliability Studies (QAREL) by two independent reviewers. RESULTS The search strategy revealed 3259 articles, of which 15 met the inclusion criteria. These studies evaluated the reliability of 41 test and test variations used for the assessment of scapular dyskinesis. CONCLUSION This review identified a lack of high-quality studies evaluating intra- as well as interrater reliability of tests used for the assessment of scapular dyskinesis. In addition, reliability measures differed between included studies hindering proper cross-study comparisons. The effect of manual correction of the scapula on shoulder symptoms was evaluated in only one study, which is striking, since symptom alteration tests are used in routine care to guide further treatment. Thus, there is a strong need for further research in this area. LEVEL OF EVIDENCE Diagnosis, level 3a.

Ergebnisobjektivierung bei Knietotalendoprothesen

ZusammenfassungHintergrundDie endoprothetische Versorgung bei fortgeschrittener Gonarthrose ist eine weltweit durchgeführte und effektive Methode zur Verbesserung von Schmerz und Funktion und ist in Deutschland einer der häufigsten Routineeingriffe in der Orthopädie und Unfallchirurgie.DiskussionVor dem Hintergrund des relativ hohen Anteils an Patienten, die mit dem Ergebnis nach Knirtotalendoprothesen- (Knie-TEP-)Implantation nicht zufrieden sind, erscheint gerade im Hinblick auf „shared decision making“ die Patientenperspektive besonders wichtig. Die „Patientenzufriedenheit“ mit dem Operationsergebnis kann diese Patientenperspektive abbilden, ist aber als einziges zu erhebendes Outcome nicht ausreichend. Allerdings existiert hinsichtlich der zu messenden Outcomes nach Implantation einer Knie-TEP derzeit kein international akzeptierter Konsens.SchlussfolgerungAufgrund dieser Tatsache können und werden verschiedene Messinstrumente zur Erfassung von unterschiedlichen Outcomes genutzt, um die Ergebnisse nach Implantation einer Knie-TEP zu objektivieren. Diese sollten jedoch kritisch in Bezug auf Reliabilität, Validität sowie Änderungssensitivität betrachtet werden. Im Rahmen dieses Artikels werden verschiedene Messinstrumente im Überblick dargestellt.AbstractBackgroundArthroplasty is an effective treatment for end-stage osteoarthritis of the knee and is one of Germany’s most frequently performed orthopedic procedures.DiscussionHowever, a considerable number of patient are not satisfied with the results after knee arthroplasty. The patient’s perspective is particularly important for shared decision making. “Patient satisfaction” with the surgery is an expression of the patient’s perspective, but might not be sufficient as the only outcome measure. There is no international consensus which outcome measures should be used after knee arthroplasty.ConclusionTherefore, different measurement tools are used for the acquisition of a variety of outcome measures in order to quantify the results of knee arthroplasty. These tools should be used according to their reliability, validity, and responsiveness. This article provides an overview about available measurement tools.

[Objectifying results in total knee arthroplasty: Is "patient satisfaction" adequate].

ZusammenfassungHintergrundDie endoprothetische Versorgung bei fortgeschrittener Gonarthrose ist eine weltweit durchgeführte und effektive Methode zur Verbesserung von Schmerz und Funktion und ist in Deutschland einer der häufigsten Routineeingriffe in der Orthopädie und Unfallchirurgie.DiskussionVor dem Hintergrund des relativ hohen Anteils an Patienten, die mit dem Ergebnis nach Knirtotalendoprothesen- (Knie-TEP-)Implantation nicht zufrieden sind, erscheint gerade im Hinblick auf „shared decision making“ die Patientenperspektive besonders wichtig. Die „Patientenzufriedenheit“ mit dem Operationsergebnis kann diese Patientenperspektive abbilden, ist aber als einziges zu erhebendes Outcome nicht ausreichend. Allerdings existiert hinsichtlich der zu messenden Outcomes nach Implantation einer Knie-TEP derzeit kein international akzeptierter Konsens.SchlussfolgerungAufgrund dieser Tatsache können und werden verschiedene Messinstrumente zur Erfassung von unterschiedlichen Outcomes genutzt, um die Ergebnisse nach Implantation einer Knie-TEP zu objektivieren. Diese sollten jedoch kritisch in Bezug auf Reliabilität, Validität sowie Änderungssensitivität betrachtet werden. Im Rahmen dieses Artikels werden verschiedene Messinstrumente im Überblick dargestellt.AbstractBackgroundArthroplasty is an effective treatment for end-stage osteoarthritis of the knee and is one of Germany’s most frequently performed orthopedic procedures.DiscussionHowever, a considerable number of patient are not satisfied with the results after knee arthroplasty. The patient’s perspective is particularly important for shared decision making. “Patient satisfaction” with the surgery is an expression of the patient’s perspective, but might not be sufficient as the only outcome measure. There is no international consensus which outcome measures should be used after knee arthroplasty.ConclusionTherefore, different measurement tools are used for the acquisition of a variety of outcome measures in order to quantify the results of knee arthroplasty. These tools should be used according to their reliability, validity, and responsiveness. This article provides an overview about available measurement tools.

Core outcome domains in incontinence-associated dermatitis research

AIM To report the development of a core set of outcome domains for clinical research involving adults with incontinence-associated dermatitis or at risk, independently from any geographical location or skin colour. BACKGROUND The management of incontinence-associated dermatitis is important in caring for incontinent patients. The lack of comparability of clinical trial outcomes is a major challenge in the field of evidence-based incontinence-associated dermatitis prevention and treatment. Core outcome sets may therefore be helpful to improve the value of clinical incontinence-associated dermatitis research. DESIGN Systematic literature review, patient interviews and consensus study using Delphi procedure. METHODS A list of outcome domains was generated through a systematic literature review (no date restrictions-April 2016), consultation of an international steering committee and three patient interviews. The project team reviewed and refined the outcome domains prior to starting a three-round Delphi procedure conducted between April-September 2017. The panellists, including healthcare providers, researchers and industry were invited to rate the importance of the outcome domains. RESULTS We extracted 1,852 outcomes from 244 articles. Experts proposed 56 and patients 32 outcome domains. After refinement, 57 panellists from 17 countries rated a list of 58 outcome domains. The final list of outcome domains includes erythema, erosion, maceration, IAD-related pain and patient satisfaction. CONCLUSION Erythema, erosion, maceration, incontinence-associated dermatitis -related pain and patient satisfaction are the most important outcome domains to be measured in incontinence-associated dermatitis trials. Based on this international consensus on what to measure, the question of how to measure these domains now requires consideration. Registration: This project has been registered in the Core Outcome Measures in Effectiveness Trials (COMET Initiative) database and is part of the Cochrane Skin Group-Core Outcomes Set Initiative (CSG-COUSIN).

Indication Criteria for Total Knee Arthroplasty in Patients with Osteoarthritis – A Multi-perspective Consensus Study

Background and Objectives Knee osteoarthritis (OA) is a significant public health burden. Rates of total knee arthroplasty (TKA) in OA vary substantially between geographical regions, most likely due to the lack of standardised indication criteria. We set out to define indication criteria for the German healthcare system for TKA in patients with knee OA, on the basis of best evidence and transparent multi-stakeholder consensus. Methods We undertook a complex mixed methods study, including an iterative process of systematic appraisal of existing evidence, Delphi consensus methods and stakeholder conferences. We established a consensus panel representing key German national societies of healthcare providers (orthopaedic surgeons, rheumatologists, pain physicians, psychologists, physiotherapists), payers, and patient representatives. A priori defined consensus criteria were at least 70% agreement and less than 20% disagreement among the consensus panel. Agreement was sought for (1) core indication criteria defined as criteria that must be met to consider TKA in a normal patient with knee OA, (2) additional (not obligatory) indication criteria, (3) absolute contraindication criteria that generally prohibit TKA, and (4) risk factors that do not prohibit TKA, but usually do not lead to a recommendation for TKA. Results The following 5 core indication criteria were agreed within the panel: 1. intermittent (several times per week) or constant knee pain for at least 3 - 6 months; 2. radiological confirmation of structural knee damage (osteoarthritis, osteonecrosis); 3. inadequate response to conservative treatment, including pharmacological and non-pharmacological treatment for at least 3 - 6 months; 4. adverse impact of knee disease on patients quality of life for at least 3 - 6 months; 5. patient-reported suffering/impairment due to knee disease. Additional indication criteria, contraindication criteria, and risk factors for adverse outcome were also agreed by a large majority within the multi-perspective stakeholder panel. Conclusion The defined indication criteria constitute a prerequisite for appropriate provision of TKA in patients with knee OA in Germany. In eligible patients, shared-decision making should eventually determine if TKA is performed or not. The next important steps are the implementation of the defined indication criteria, and the prospective investigation of predictors of success or failure of TKA in the context of routine care provision in Germany.

Reliability of specific physical examination tests for the diagnosis of shoulder pathologies: a systematic review and meta-analysis

Background Shoulder pain in the general population is common and to identify the aetiology of shoulder pain, history, motion and muscle testing, and physical examination tests are usually performed. Objective The aim of this systematic review was to summarise and evaluate intrarater and inter-rater reliability of physical examination tests in the diagnosis of shoulder pathologies. Methods A comprehensive systematic literature search was conducted using MEDLINE, EMBASE, Allied and Complementary Medicine Database (AMED) and Physiotherapy Evidence Database (PEDro) through 20 March 2015. Methodological quality was assessed using the Quality Appraisal of Reliability Studies (QAREL) tool by 2 independent reviewers. Results The search strategy revealed 3259 articles, of which 18 finally met the inclusion criteria. These studies evaluated the reliability of 62 test and test variations used for the specific physical examination tests for the diagnosis of shoulder pathologies. Methodological quality ranged from 2 to 7 positive criteria of the 11 items of the QAREL tool. Conclusions This review identified a lack of high-quality studies evaluating inter-rater as well as intrarater reliability of specific physical examination tests for the diagnosis of shoulder pathologies. In addition, reliability measures differed between included studies hindering proper cross-study comparisons. Trial registration number PROSPERO CRD42014009018.

Persönlichkeitsprofil und Komorbidität: Gibt es den „schwierigen Patienten“ in der primären Hüftendoprothetik?

BACKGROUND Concomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty. OBJECTIVES To describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction. MATERIALS AND METHODS Review of relevant clinical studies, meta-analyses, and presentation of our own results. RESULTS Comorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction. CONCLUSIONS It is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.ZusammenfassungHintergrundDer Behandlungserfolg in der Hüftendoprothetik wird von vielen unterschiedlichen Faktoren beeinflusst. Dazu gehören auch zum Zeitpunkt der Operation bestehende Begleiterkrankungen, die Persönlichkeit des Patienten und die sozioökonomischen Rahmenbedingungen.Ziel der ArbeitEs soll ein Überblick über den Einfluss von Komorbiditäten und Persönlichkeitsfaktoren auf das Behandlungsergebnis gegeben werden.Material und MethodikZusätzlich zur Darstellung eigener Erfahrungen werden die Ergebnisse eines Literaturüberblicks präsentiert, die wesentliche Arbeiten zum Thema zusammenfassen.ErgebnisseBegleiterkrankungen – vor allem das Vorliegen mehrerer Komorbiditäten gleichzeitig – haben einen relevanten Einfluss auf das perioperative Komplikationsprofil. Auch sozioökonomische Faktoren (Ausbildungsdauer, berufliche Tätigkeit, soziale Deprivation) und psychologische Variablen (Depressivität, Optimismus, Typ-D-Persönlichkeit, Erwartungen) können sich in nicht unerheblichem Umfang auf Verlauf und Ausmaß der postoperativen Erholung von Funktion und Lebensqualität sowie Patientenzufriedenheit auswirken.DiskussionEin Zugang zu angemessener operativer Versorgung muss auch für Patienten mit erhöhtem Risikoprofil erhalten bleiben. Sofern möglich, sind Präventivmaßnahmen zu nutzen, um das Risiko von Komorbiditäten zu reduzieren. Präoperative Schulungsmaßnahmen und eine gute Kommunikation können unrealistischen Erwartungen auf Patientenseite begegnen.AbstractBackgroundConcomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty.ObjectivesTo describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction .Materials and methodsReview of relevant clinical studies, meta-analyses, and presentation of our own results .ResultsComorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction.ConclusionsIt is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.

Ergebnisobjektivierung bei Knietotalendoprothesen@@@Objectifying results in total knee arthroplasty: Reicht die „Patientenzufriedenheit“?@@@Is “patient satisfaction” adequate

ZusammenfassungHintergrundDie endoprothetische Versorgung bei fortgeschrittener Gonarthrose ist eine weltweit durchgeführte und effektive Methode zur Verbesserung von Schmerz und Funktion und ist in Deutschland einer der häufigsten Routineeingriffe in der Orthopädie und Unfallchirurgie.DiskussionVor dem Hintergrund des relativ hohen Anteils an Patienten, die mit dem Ergebnis nach Knirtotalendoprothesen- (Knie-TEP-)Implantation nicht zufrieden sind, erscheint gerade im Hinblick auf „shared decision making“ die Patientenperspektive besonders wichtig. Die „Patientenzufriedenheit“ mit dem Operationsergebnis kann diese Patientenperspektive abbilden, ist aber als einziges zu erhebendes Outcome nicht ausreichend. Allerdings existiert hinsichtlich der zu messenden Outcomes nach Implantation einer Knie-TEP derzeit kein international akzeptierter Konsens.SchlussfolgerungAufgrund dieser Tatsache können und werden verschiedene Messinstrumente zur Erfassung von unterschiedlichen Outcomes genutzt, um die Ergebnisse nach Implantation einer Knie-TEP zu objektivieren. Diese sollten jedoch kritisch in Bezug auf Reliabilität, Validität sowie Änderungssensitivität betrachtet werden. Im Rahmen dieses Artikels werden verschiedene Messinstrumente im Überblick dargestellt.AbstractBackgroundArthroplasty is an effective treatment for end-stage osteoarthritis of the knee and is one of Germany’s most frequently performed orthopedic procedures.DiscussionHowever, a considerable number of patient are not satisfied with the results after knee arthroplasty. The patient’s perspective is particularly important for shared decision making. “Patient satisfaction” with the surgery is an expression of the patient’s perspective, but might not be sufficient as the only outcome measure. There is no international consensus which outcome measures should be used after knee arthroplasty.ConclusionTherefore, different measurement tools are used for the acquisition of a variety of outcome measures in order to quantify the results of knee arthroplasty. These tools should be used according to their reliability, validity, and responsiveness. This article provides an overview about available measurement tools.