Physiotherapy visual assessment of dynamic alignment during lower extremity functional screening

187 Pages·2012·3 MB·English

by  Peter Maulder

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
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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
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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
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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
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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

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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

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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
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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
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Table 8.2: Studies investigating the reliability and validity of visual rating of lower extremity
movement quality/dynamic alignment during functional screening tests. ............................................ 146

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