Physiotherapy visual assessment of dynamic alignment during lower extremity functional screening tests A thesis submitted to Auckland University of Technology in fulfilment of the requirements for the degree of Doctor of Philosophy February 2012 Auckland University of Technology Faculty of Health and Environmental Sciences by Chris Whatman DipPhys MAppSc Primary supervisor: Professor Wayne A. Hing Secondary supervisor: Professor Patria A. Hume TABLE OF CONTENTS Attestation of authorship ........................................................................................................................ 11 Acknowledgements ................................................................................................................................ 14 Ethical approval ...................................................................................................................................... 16 Abstract ........................................................................................................................................ 17 CHAPTER1: INTRODUCTION AND RATIONALISATION .................................................................... 18 Background ....................................................................................................................................... 18 Questions addressed in this PhD thesis ............................................................................................ 22 Structure of the PhD thesis................................................................................................................ 22 CHAPTER 2: MEASURES OF AGREEMENT WITH VISUAL ASSESSMENT: WHAT STATISTICS SHOULD BE PRESENTED? ................................................................................................................. 29 Overview ............................................................................................................................................ 29 Methods ............................................................................................................................................. 29 Findings ............................................................................................................................................. 30 CHAPTER 3: KINEMATICS DURING LOWER EXTREMITY FUNCTIONAL SCREENING TESTS – ARE THEY RELIABLE AND RELATED TO JOGGING? ....................................................................... 35 Overview ............................................................................................................................................ 35 Background ....................................................................................................................................... 35 Purpose .......................................................................................................................................... 38 Methods ............................................................................................................................................. 38 Participants .................................................................................................................................... 38 Instrumentation .............................................................................................................................. 39 Testing protocol ............................................................................................................................. 41 Data processing ............................................................................................................................. 42 2 Statistical analyses ........................................................................................................................ 43 Results ............................................................................................................................................... 44 Discussion ......................................................................................................................................... 49 Conclusion ......................................................................................................................................... 53 CHAPTER 4: PHYSIOTHERAPIST AGREEMENT WHEN VISUALLY RATING MOVEMENT QUALITY DURING LOWER EXTREMITY FUNCTIONAL SCREENING TESTS ................................. 54 Overview ............................................................................................................................................ 54 Background ....................................................................................................................................... 54 Purpose .......................................................................................................................................... 58 Methods ............................................................................................................................................. 58 Participants .................................................................................................................................... 58 Visual assessment procedure ........................................................................................................ 59 Four lower extremity functional movement tests ........................................................................... 61 Statistical analyses ........................................................................................................................ 64 Results ............................................................................................................................................... 66 Discussion ......................................................................................................................................... 71 Conclusion ......................................................................................................................................... 76 Supplementary information................................................................................................................ 77 CHAPTER 5: KINEMATICS DURING LOWER EXTREMITY FUNCTIONAL SCREENING TESTS IN YOUNG ATHLETES – ARE THEY RELIABLE AND VALID? ................................................................ 79 Overview ............................................................................................................................................ 79 Background ....................................................................................................................................... 79 Purpose .......................................................................................................................................... 82 Methods ............................................................................................................................................. 82 Participants .................................................................................................................................... 82 Instrumentation .............................................................................................................................. 83 3 Testing protocol ............................................................................................................................. 84 Data processing ............................................................................................................................. 85 Statistical analyses ........................................................................................................................ 86 Results ............................................................................................................................................... 87 Discussion ......................................................................................................................................... 90 Conclusion ......................................................................................................................................... 94 CHAPTER 6: THE RELIABILITY AND VALIDITY OF PHYSIOTHERAPIST VISUAL RATING OF DYNAMIC PELVIS AND KNEE ALIGNMENT IN YOUNG ATHLETES ................................................. 95 Overview ............................................................................................................................................ 95 Background ....................................................................................................................................... 95 Purpose .......................................................................................................................................... 98 Methods ............................................................................................................................................. 98 Participants .................................................................................................................................... 98 Visual assessment procedure ........................................................................................................ 99 Data processing ........................................................................................................................... 101 Statistical analyses ...................................................................................................................... 101 Results ............................................................................................................................................. 103 Rater agreement .......................................................................................................................... 103 Validity ......................................................................................................................................... 104 Discussion ....................................................................................................................................... 108 Conclusion ....................................................................................................................................... 112 CHAPTER 7: THE ASSOCIATIONS BETWEEN 2D ALIGNMENT AND 3D KINEMATICS DURING LOWER EXTREMITY FUNCTIONAL TESTS IN YOUNG ATHLETES ............................................... 113 Overview .......................................................................................................................................... 113 Background ..................................................................................................................................... 113 Purpose ........................................................................................................................................ 115 4 Methods ........................................................................................................................................... 115 Participants .................................................................................................................................. 115 Instrumentation ............................................................................................................................ 115 Testing protocol ........................................................................................................................... 116 Data processing ........................................................................................................................... 117 Statistical analyses ...................................................................................................................... 118 Results ............................................................................................................................................. 119 Discussion ....................................................................................................................................... 121 Conclusion ....................................................................................................................................... 123 CHAPTER 8: VISUAL AND KINEMATIC ASSESSMENTS OF DYNAMIC ALIGNMENT DURING LOWER EXTREMITY FUNCTIONAL SCREENING TESTS: A REVIEW OF THE LITERATURE ..... 124 Overview .......................................................................................................................................... 124 Introduction ...................................................................................................................................... 125 Methods ........................................................................................................................................... 126 Findings ........................................................................................................................................... 126 Common lower extremity functional screening tests ................................................................... 126 Reliability of lower extremity kinematics in functional screening tests ........................................ 127 Reliability and validity of visual assessment of functional screening tests .................................. 136 Inter-rater agreement ................................................................................................................... 137 Intra-rater agreement ................................................................................................................... 140 Validity of visual assessment ....................................................................................................... 142 Conclusion ....................................................................................................................................... 149 Practical recommendations ............................................................................................................. 150 CHAPTER 9: DISCUSSION / CONCLUSION ..................................................................................... 151 The reliability of kinematics during functional tests and their association with actual function (running and landing) ....................................................................................................................... 152 5 The reliability and validity of visual assessment of movement quality/dynamic alignment during functional screening tests ................................................................................................................ 154 The influence on visual assessment of various factors including rater experience, rating method and movement velocity ........................................................................................................................... 155 Thesis limitations ............................................................................................................................. 156 Recommendations for future research ............................................................................................ 157 Conclusion ....................................................................................................................................... 158 References ...................................................................................................................................... 160 APPENDIX 2: LOWER EXTREMITY FUNCTIONAL TESTS – ARE THEY RELIABLE AND DO THE PREDICT ACTUAL FUNCTION? ........................................................................................................ 170 APPENDIX 3: PARTICIPANT INFORMATION SHEETS .................................................................... 172 APPENDIX 4: PARTICIPANT CONSENT FORMS ............................................................................. 180 APPENDIX 5: ETHICS APPROVAL .................................................................................................... 184 Ethics Application Number 06/143 - Reliability and validity of physiotherapy screening of lower limb function. ........................................................................................................................................... 184 Ethics Application Number 08/258 - Relationship of hip strength to running mechanics in young athletes. ........................................................................................................................................... 185 6 LIST OF FIGURES Figure 1.1: Overview of the structure of the thesis. .......................................................................... 24 Figure 3.1: Participant instrumented with markers (note medial knee and ankle anatomical markers used for skeletal model construction are not shown as they were removed during functional tests). ... 40 Figure 3.2: Example scatter plots showing the association between SKB and jogging. Plot A shows peak transverse plane angles (-ve = external rotation), plot B shows peak frontal plane angles (-ve = abduction). ........................................................................................................................................ 48 Figure 4.1: Visual rating sheet used in the study allowing both Segment and Overall ratings. ........ 61 Figure 4.2: Formula for calculating the AC1 in the general situation of more than two raters and a rating scale with greater than two categories (Blood & Spratt, 2007) .................................................... 78 Figure 5.1: Participant instrumented with markers (note medial knee and ankle anatomical markers used for skeletal model construction are not shown as they were removed during functional tests). ... 84 Figure 5.2: Example scatter plots showing the association between Small Knee Bend (SKB) and Drop Jump for peak hip rotation angles (º) (R leg -ve = external rotation, L leg -ve = internal rotation). Each point represents the mean of three trials for a given participant. ................................................. 90 Figure 7.1: Example of (A) Knee frontal plane projection angle and (B) 2D lateral pelvic tilt, during a Single Leg SKB. ................................................................................................................................... 118 7 LIST OF TABLES Table 3.1: Description of the five functional tests used in the study. ............................................... 42 Table 3.2: Peak angle (º) during the knee flexion phase of each functional test for three trials (all 25 participants, mean ±SD). ................................................................................................................... 45 Table 3.3: Within-day reliability of the peak angle (º) and medial knee displacement (cm) for all five functional tests ................................................................................................................................. 46 Table 3.4: Between-day reliability of the peak joint angle (º) and medial knee displacement (cm) for all five functional tests ....................................................................................................................... 47 Table 3.5: Correlations between peak joint angles during the functional tests and jogging expressed as Pearson correlation coefficients ...................................................................................... 48 Table 4.1: Description of the four lower extremity functional movement tests. ............................... 63 Table 4.2: Data format used for the calculation of the AC1 statistic. ............................................... 66 Table 4.3: Mean intra-rater agreement for the Segment and Overall rating methods. .................... 68 Table 4.4: Inter-rater agreement for the Segment and Overall rating methods. .............................. 69 Table 4.5: Differences in mean intra-rater AC1, (90% CL), percentage likelihood the difference is clinically meaningful (> than the smallest worthwhile difference, Cohen 0.2), [group with the higher agreement E=experienced, N=novice, I=inexperienced]. ...................................................................... 70 Table 4.6: Difference in inter-rater AC1, (90% CL), percentage likelihood the difference is clinically meaningful (> Fisher 0.1), [group with the higher agreement E=experienced, N=novice, I=inexperienced]. .................................................................................................................................... 70 Table 4.7: Difference in agreement (AC1) between the Dichotomous ratings and the Ordinal ratings (90% CL), percentage likelihood the difference is clinically meaningful (intra > Cohen 0.2, inter > Fisher 0.1). ........................................................................................................................................ 71 8 Table 5.1: Description of the small knee bend functional tests used in the study. .......................... 85 Table 5.2: Within-day reliability (Typical Error; Intraclass Correlation Coefficient) of the peak angle (º) or medial knee displacement (cm) for all three functional tests for 23 young athletes. .................... 88 Table 5.3: Between-day reliability (Typical Error; Intraclass Correlation Coefficient) of the peak joint angle (º) and medial knee displacement (cm) for all three functional tests for ten young athletes.89 Table 5.4: Associations between peak joint angles during the Small Knee Bend and Drop Jump and between the Single Leg SKB and Running expressed as Pearson correlation coefficients (90% CL). ........................................................................................................................................ 90 Table 6.1: Description of the three lower extremity functional tests. ............................................. 100 Table 6.2: Intra-rater agreement. ................................................................................................... 105 Table 6.3: Inter-rater agreement based on initial ratings. .............................................................. 105 Table 6.4: Accuracy of all physiotherapist initial visual ratings (percent) when compared to consensus expert ratings. .................................................................................................................... 106 Table 6.5: Comparison between rating ability (diagnostic odds ratio) of more and less experienced physiotherapists. .................................................................................................................................. 106 Table 6.6: Mean angle difference between groups rated yes (poor alignment) or no (good alignment) by the three experts. .......................................................................................................... 107 Table 7.1: Description of the small knee bend functional tests used in the study. ........................ 117 Table 7.2: Angle and segment positions (°) at maximum knee flexion (mean ± SD) for 23 healthy young athletes. ..................................................................................................................................... 120 Table 7.3: Associations between knee frontal plane projection angle and 3D joint/segment transverse and frontal plane kinematics expressed as Pearson correlation coefficients (90% CL). ... 120 Table 8.1: Reliability of kinematics during lower extremity functional screening tests. ................. 133 9 Table 8.2: Studies investigating the reliability and validity of visual rating of lower extremity movement quality/dynamic alignment during functional screening tests. ............................................ 146 10