Comparison of commonly used orthopaedic outcome measures using palm-top computers and paper surveys. Comparison of handheld computer-assisted and conventional paper chart documentation of medical records. A randomized, controlled trial. Checklists to improve the quality of the orthopaedic literature Risk of bias of randomized controlled trials published in orthopaedic journals Systematic Reviews of Diagnostic Test Accuracy INVITED COMMENTARY: Rating the Quality of Trials in Systematic Reviews of Physical Therapy Interventions The development of a battery of measures for assessing physical functioning of chronic pain patients Use of Condition-Specific Patient-Reported Outcome Measures in Clinical Trials among Patients with Wrist Osteoarthritis: A Systematic Review A randomized trial of physicians and physical therapists as instructors of the musculoskeletal examination. On the reliability and validity of manual muscle testing: a literature review Physiotherapy screening of patients referred for orthopaedic consultation in primary healthcare - a randomised controlled trial. Diagnostic accuracy and association to disability of clinical test findings associated with patellofemoral pain syndrome. Introducing levels of evidence to the journal. Assessing the head-to-toe physical examination skills of medical students Assessing the validity of published randomized controlled trials in podiatric medical journals. Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis. The Use of Confidence Intervals in Reporting Orthopaedic Research Findings
INTRODUCTION Measuring  patient-perceived outcomes  following orthopaedic procedures have become an important component of clinical research and patient care . General and disease-specific outcomes measures have been developed and applied in orthopaedics to assess the patients ' perceived health status . Unfortunately , paper-based , self-administered instruments remain inefficient for collecting data because of : ( a ) missing data ( b ) respondent error , and ( c ) the costs to administer and enter data . OBJECTIVE To study the comparability of palm-top computer devices and paper-pencil self-administered question naires in the collection of health-related quality of life ( HRQL ) information from patients . METHODS The comparability of administering HRQL question naires using palm-top computer and traditional paper-based forms was tested in a sample of 96 patients with complaints of hip and /or knee pain . Each patient completed mailed versions of the Medical Outcomes Study ( MOS ) , 36-item Health Survey ( SF-36 ) , and Western Ontario and McMasters University Arthritis Index ( WOMAC ) three weeks prior to presenting to clinic . At the clinic they were asked to complete the same outcomes measures using the palm-top computer or a paper- and -pencil version . ANALYSIS In the analysis , scale distributions , floor and ceiling effects , internal consistency and retest reliability of scales were compared across the two data collection methods . Because the baseline characteristics of the groups were not strictly comparable according to age , the data were analyzed for the entire sample and stratified according to age . RESULTS Few statistically significant differences were found for the means , variances and intra-class correlation coefficients between the methods of administration . While the scale distribution between the two methods was comparable , the internal consistency of the scales was dissimilar . CONCLUSIONS Administration of HRQL question naires using portable palm-top computer devices has the potential advantage of decreased cost and convenience . These data lend some support for the comparability of palm-top computers and paper surveys for outcomes measures widely used in the field of orthopaedic surgery . The present study identified the lack of reliability across modes of administration that requires further study in a r and omized comparability trial . These mode effects are important for orthopaedic surgeons to appreciate before implementing innovative data -capture technologies in their practice BACKGROUND Daily documentation and maintenance of medical record quality is a crucial issue in orthopaedic surgery . The purpose of the present study was to determine whether the introduction of a h and held computer could improve both the quantitative and qualitative aspects of medical records . METHODS A series of consecutive patients who were admitted for the first time to a thirty-six-bed orthopaedic ward of an academic teaching hospital for a planned operation or any other treatment of an acute injury or chronic condition were r and omized to daily documentation of their clinical charts on a h and held computer or on conventional paper forms . The electronic documentation consisted of a specially design ed software package on a h and held computer for bedside use with structured decision trees for examination , obtaining a history , and coding . In the control arm , chart notes were compiled on st and ard paper forms and were subsequently entered into the hospital 's information system . The number of documented ICD ( International Classification of Diseases ) diagnoses was the primary end point for sample size calculations . All patient charts were reread by an expert panel consisting of two surgeons and the surgical quality assurance manager . These experts assigned quality ratings to the different documentation systems by scrutinizing the extent and accuracy of the patient histories and the physical findings as assessed by daily chart notes . RESULTS Eighty patients were r and omized to one of the two documentation arms , and seventy-eight ( forty-seven men and thirty-one women ) of them were eligible for final analysis . Documentation with the h and held computer increased the median number of diagnoses per patients from four to nine ( p < 0.0001 ) , but it produced some overcoding for false or redundant items . Documentation quality ratings improved significantly with the introduction of the h and held device ( p < 0.01 ) with respect to the correct assessment of a patient 's progress and translation into ICD diagnoses . Various learning curve effects were observed with different operators . Study physicians assigned slightly better practicability ratings to the h and held device . CONCLUSIONS The preliminary data from this study suggest that h and held computers may improve the quality of hospital charts in orthopaedic surgery . LEVEL OF EVIDENCE Therapeutic study , Level I-1a ( r and omized controlled trial [ significant difference ] ) . See Instructions to Authors for a complete description of levels of evidence Several checklists have been developed in an effort to help journals and research ers improve the quality of reporting in research . The CONSORT statement and the CLEAR NPT evaluate r and omized trials . The MOOSE and QUOROM checklists evaluate meta-analyses . The STROBE checklists assists readers in evaluating observational studies and the STARD checklist was developed for diagnostic test evaluation . The checklists presented here provide an invaluable source of guidance to authors , journal editors and readers who are seeking to prepare and evaluate reports . As evidence -based medicine continues to establish itself as the new paradigm by which medicine is practice d , the need for good reporting for all research design s must also become commonplace as opposed to the exception Background The purpose of this study was to assess the quality of methodology in orthopaedics-related r and omized controlled trials ( RCTs ) published from January 2006 to December 2010 in the top orthopaedic journals based on impact scores from the Thompson ISI citation reports ( 2010 ) . Methods Journals included American Journal of Sports Medicine ; Journal of Orthopaedic Research ; Journal of Bone and Joint Surgery , American ; Spine Journal ; and Osteoarthritis and Cartilage . Each RCT was assessed on ten criteria ( r and omization method , allocation sequence concealment , participant blinding , outcome assessor blinding , outcome measurement , interventionist training , withdrawals , intent to treat analyses , clustering , and baseline characteristics ) as having empirical evidence for biasing treatment effect estimates when not performed properly . Results A total of 232 RCTs met our inclusion criteria . The proportion of RCTs in published journals fell from 6 % in 2006 to 4 % in 2010 . Forty-nine percent of the criteria were fulfilled across these journals , with 42 % of the criteria not being amendable to assessment due to inadequate reporting . The results of our regression revealed that a more recent publication year was significantly associated with more fulfilled criteria ( β = 0.171 ; CI = −0.00 to 0.342 ; p = 0.051 ) . Conclusion In summary , very few studies met all ten criteria . Thus , many of these studies likely have biased estimates of treatment effects . In addition , these journals had poor reporting of important method ological aspects Diagnosis is a critical component of health care , and clinicians , policymakers , and patients routinely face a range of questions regarding diagnostic tests . They want to know whether testing improves outcome ; what test to use , purchase , or recommend in practice guidelines ; and how to interpret test results . Well- design ed  diagnostic test accuracy studies can help in making these decisions , provided that they transparently and fully report their participants , tests , methods , and results as facilitated , for example , by the STARD ( St and ards for Reporting of Diagnostic Accuracy ) statement ( 1 ) . That 25-item checklist was published in many journals and is now adopted by more than 200 scientific journals worldwide . As in other areas of science , systematic review s and meta- analysis of accuracy studies can be used to obtain more precise estimates when small studies addressing the same test and patients in the same setting are available . Review s can also be useful to establish whether and how scientific findings vary by particular subgroups , and may provide summary estimates with a stronger generalizability than estimates from a single study . Systematic review s may help identify the risk for bias that may be present in the original studies and can be used to address questions that were not directly considered in the primary studies , such as comparisons between tests . The Cochrane Collaboration is the largest international organization preparing , maintaining , and promoting systematic review s to help people make well-informed decisions about health care ( 2 ) . The Collaboration decided in 2003 to make preparations for including systematic review s of diagnostic test accuracy in their Cochrane Data base of Systematic Review s. To enable this , a working group ( Appendix ) . was formed to develop methodology , software , and a h and book The first diagnostic test accuracy review was published in the Cochrane Data base in October 2008 . In this paper , we review recent method ological developments concerning problem formulation , location of literature , quality assessment , and meta- analysis of diagnostic accuracy studies by using our experience from the work on the Cochrane H and book . The information presented here is based on the recent literature and up date s previously published guidelines by Irwig and colleagues ( 3 ) . Definition of the Objectives of the Review Diagnostic test accuracy refers to the ability of a test to distinguish between patients with disease ( or more generally , a specified target condition ) and those without . In a study of test accuracy , the results of the test under evaluation , the index test , are compared with those of the reference st and ard determined in the same patients . The reference st and ard is an agreed-on and accurate method for identifying patients who have the target condition . Test results are typically categorized as positive or negative for the target condition . By using such binary test outcomes , the accuracy is most often expressed as the test 's sensitivity ( the proportion of patients with positive results on the reference st and ard that are also positive on the index test ) and specificity ( the proportion of patients with negative results on the reference st and ard that are also negative on the index test ) . Other measures have been proposed and are in use ( 46 ) . It has long been recognized that test accuracy is not a fixed property of a test . It can vary between patient subgroups , with their spectrum of disease , with the clinical setting , or with the test interpreters and may depend on the results of previous testing . For this reason , inclusion of these elements in the study question is essential . In order to make a policy decision to promote use of a new index test , evidence is required that using the new test increases test accuracy over other testing options , including current practice , or that the new test has equivalent accuracy but offers other advantages ( 79 ) . As with the evaluation of interventions , systematic review s need to include comparative analyses between alternative testing strategies and should not focus solely on evaluating the performance of a test in isolation . In relation to the existing situation , 3 possible roles for a new test can be defined : replacement , triage , and add-on ( 7 ) . If a new test is to replace an existing test , then comparing the accuracy of both tests on the same population and with the same reference st and ard provides the most direct evidence . In triage , the new test is used before the existing test or testing pathway , and only patients with a particular result on the triage test continue the testing pathway . When a test is needed to rule out disease in patients who then need no further testing , a test that gives a minimal proportion of falsenegative results and thus a relatively high sensitivity should be used . Triage tests may be less accurate than existing ones , but they have other advantages , such as simplicity or low cost . A third possible role of a new test is add-on . The new test is then positioned after the existing testing pathway to identify false-positive or false-negative results after the existing pathway . The review should provide data to assess the incremental change in accuracy made by adding the new test . An example of a replacement question can be found in a systematic review of the diagnostic accuracy of urinary markers for primary bladder cancer ( 10 ) . Clinicians may use cytology to triage patients before they undergo invasive cystoscopy  , the reference st and ard for bladder cancer . Because cytology combines high specificity with low sensitivity ( 11 ) , the goal of the review was to identify a tumor marker with sufficient accuracy to either replace cytology or be used in addition to cytology . For a marker to replace cytology , it has to achieve equally high specificity with improved sensitivity . New markers that are sensitive but not specific may have roles as adjuncts to conventional testing . The review included studies in which the test under evaluation ( several different tumor markers and cytology ) was evaluated against cystoscopy or histopathology . Included studies compared 1 or more of the markers , cytology only , or a combination of markers and cytology . Although information on accuracy can help clinicians make decisions about tests , good diagnostic accuracy is a desirable but not sufficient condition for the effectiveness of a test ( 8) . To demonstrate that using a new test does more good than harm to patients tested , r and omized trials of test- and -treatment strategies and review s of such trials may be necessary . However , with the possible exception of screening , in most cases , such r and omized trials are not available and systematic review s of test accuracy may provide the most useful evidence available to guide clinical and health policy decision making and use as input for decision and cost-effectiveness analysis ( 12 ) . Identification and Selection of Studies Identifying test accuracy studies is more difficult than search ing for r and omized trials ( 13 ) . There is not a clear , unequivocal keyword or indexing term for an accuracy study in literature data bases comparable with the term r and omized , controlled trial . The Medical Subject Heading sensitivity and specificity may look suitable but is inconsistently applied in most electronic bibliographic data bases . Furthermore , data on diagnostic test accuracy may be hidden in studies that did not have test accuracy estimation as their primary objective . This complicates the efficient identification of diagnostic test accuracy studies in electronic data bases , such as MEDLINE . Until indexing systems properly code studies of test accuracy , search ing for them will remain challenging and may require additional manual search es , such as screening reference lists . In the development of a comprehensive search strategy , review authors can use search strings that refer to the test(s ) under evaluation , the target condition , and the patient description or a subset of these . For tests with a clear name that are used for a single purpose , search ing for publications in which those tests are mentioned may suffice . For other review s , adding the patient description may be necessary , although this is also often poorly indexed . A search strategy in MEDLINE should contain both Medical Subject Headings and free text words . A search strategy for articles about tests for bladder cancer , for example , should include as many synonyms for bladder cancer as possible in the search strategy , including neoplasm , carcinoma , transitional cell , and hematuria . Several method ological electronic search filters for diagnostic test accuracy studies have been developed , each attempting to restrict the search to articles that are most likely to be test accuracy studies ( 1316 ) . These filters rely on indexing terms for research methodology and text words used in reporting results , but they often miss relevant studies and are unlikely to decrease the number of articles one needs to screen . Therefore , they are not recommended for systematic review s ( 17 , 18 ) . The incremental value of search ing in language s other than English and in the gray literature has not yet been fully investigated . In systematic review s of intervention studies , publication bias is an important and well-studied form of bias in which the decision to report and publish studies is linked to their findings . For clinical trials , the magnitude and determinants of publication bias have been identified by tracing the publication history of cohorts of trials review ed by ethics committees and research boards ( 19 ) . A consistent observation has been that studies with significant results are more likely to be published than studies with nonsignificant findings ( 19 ) . Investigating publication bias for diagnostic tests is problematic , because many studies are done without ethical review or study registration ; therefore , identification of cohorts of studies from registration to final publication status & NA ; Physical therapists seeking to use evidence to guide their practice may have limited time to read research reports . One way to reduce the time required to identify and read about the research that is relevant to a particular clinical question is to read a systematic review that summarizes multiple studies . This paper explains the process that is used to conduct systematic review s , which includes the establishment of a protocol , comprehensive search ing , appraisal of the quality of the included studies , data extraction and meta analysis , and consideration of the clinical and research implication s of the findings . We also consider how the reader of a systematic review can determine whether the review is likely to provide an unbiased ( believable ) estimate of the treatment effect . A systematic review of r and omized trials of a  cardiopulmonary physical therapy intervention is used as an example . The issue of appraisal of quality is then discussed further , with a demonstration of how one vali date d tool for quality appraisal ‐‐the PEDro scale‐‐can be used to evaluate a r and omized trial in cardiopulmonary physical therapy & NA ; The physical performance of chronic pain patients is of major concern both for their assessment and for treatment evaluation . However , there are few widely used physical tests , a shortage of reliability and validity data on published tests , and an over‐reliance on self‐report or on clinical measures of dubious generalisability . A set of tests was design ed to cover speed and endurance in walking , stair climbing , st and ing up from a chair , sit‐ups , arm endurance , grip strength , and peak flow . St and ard instructions and testing conditions were used by a trained tester on a population of chronic pain patients before and after a cognitive‐behavioural chronic pain management programme .  Reliability , validity , and acceptability of each test was examined , and recommendations made for their relative utility Background . This paper aim ed to identify condition-specific patient-reported outcome measures used in clinical trials among people with wrist osteoarthritis and summarise empirical peer- review ed evidence supporting their reliability , validity , and responsiveness to change . Methods . A systematic review of r and omised controlled trials among people with wrist osteoarthritis was undertaken . Studies reporting reliability , validity , or responsiveness were identified using a systematic reverse citation trail audit procedure . Psychometric properties of the instruments were examined against predefined criteria and summarised . Results . Thirteen clinical trials met inclusion criteria . The most common patient-reported outcome was the disabilities of the arm , shoulder , and h and question naire ( DASH ) . The DASH , the  Michigan H and Outcomes Question naire ( MHQ ) , the  Patient Evaluation Measure ( PEM ) , and the  Patient-Reported Wrist Evaluation ( PRWE ) had evidence supporting their reliability , validity , and responsiveness . A post-hoc review of excluded studies revealed the AUSCAN Osteoarthritis H and Index as another suitable instrument that had favourable reliability , validity , and responsiveness . Conclusions . The DASH , MHQ , and AUSCAN Osteoarthritis H and Index instruments were supported by the most favourable empirical evidence for validity , reliability , and responsiveness . The PEM and PRWE also had favourable empirical evidence reported for these elements . Further psychometric testing of these instruments among people with wrist osteoarthritis is warranted OBJECTIVE To evaluate the effectiveness of physicians vs physical therapists as instructors of the musculoskeletal examination to second year medical students . METHODS A r and omized trial conducted over 3 consecutive years in a physical diagnosis course at The University of North Carolina . During the first ( baseline ) year , medical students received education about the musculoskeletal examination from a lecture and supervision by clinical preceptors . This increased in the second and third ( intervention ) years where r and om halves of each class received supplementary clinical instruction which included a structured manual , a videotape , and supervised practice with either general internal medicine physicians or physical therapists . Outcomes were measured from student performance on a practical test of clinical skills , and by written student evaluations of the supplementary instruction . RESULTS As measured on the clinical examination , performance during the intervention years improved over that during the baseline year in both intervention groups . Measures of medical students ' clinical skills did not correlate with measures of academic aptitude . CONCLUSIONS Clinical education about the musculoskeletal examination should be structured and systematic . Medical students prefer clinical education that is active , provides clear directions , and gives them performance feedback INTRODUCTION A body of basic science and clinical research has been generated on the manual muscle test ( MMT ) since its first peer- review ed publication in 1915 . The aim of this report is to provide an historical overview , literature review , description , synthesis and critique of the reliability and validity of MMT in the evaluation of the musculoskeletal and nervous systems . METHODS Online re sources were search ed including Pubmed and CINAHL ( each from inception to June 2006 ) . The search terms manual muscle testing or manual muscle test were used . Relevant peer- review ed studies , commentaries , and review s were selected . The two review ers assessed data quality independently , with selection st and ards based on predefined method ologic criteria . Studies of MMT were categorized by research content type : inter- and intraexaminer reliability studies , and construct , content , concurrent and predictive validity studies . Each study was review ed in terms of its quality and contribution to knowledge regarding MMT , and its findings presented . RESULTS More than 100 studies related to MMT and the applied kinesiology chiropractic technique ( AK ) that employs  MMT  in its methodology were review ed , including studies on the clinical efficacy of MMT  in the diagnosis of patients with symptomatology . With regard to analysis there is evidence for good reliability and validity in the use of MMT for patients with neuromusculoskeletal dysfunction . The observational cohort studies demonstrated good external and internal validity , and the 12 r and omized controlled trials ( RCTs ) that were review ed show that MMT findings were not dependent upon examiner bias . CONCLUSION The MMT employed by chiropractors , physical therapists , and neurologists was shown to be a clinical ly useful tool , but its ultimate scientific validation and application requires testing that employs sophisticated research models in the areas of neurophysiology , biomechanics , RCTs , and statistical analysis A large proportion of patients who consult primary healthcare for musculoskeletal pain are referred for orthopaedic consultation , but only a small number of these patients are appropriate for orthopaedic intervention . Experienced physiotherapists have the appropriate knowledge to manage musculoskeletal disorders . The primary aim of this r and omised study was therefore to evaluate a screening by a physiotherapist of patients referred for orthopaedic consultation compared to st and ard practice in primary care . Patients referred for orthopaedic consultation ( n=203 ) were r and omised to physiotherapy screening or st and ard practice .  Selection accuracy for orthopaedic intervention and other referrals were analysed with proportion analysis . Patient views of the quality of care were analysed with Mann-Whitney U-test , waiting time with Independent t-test . There was higher selection accuracy for orthopaedic intervention in the physiotherapy screening group ( p=0.002 ) . A smaller proportion of patients in the screening group were referred back to their general practitioner ( GP ) ( p<0.001 ) and a larger proportion to the physiotherapy clinic ( p<0.001 ) compared to st and ard practice . The proportion of patients referred for further investigations was significantly lower in the physiotherapy screening group ( p<0.039 ) . Waiting time was shorter in the screening group ( p<0.001 ) . A large proportion of the patients reported no hesitation to attend the clinic for future care , no difference between the groups ( p<0.95 ) . The findings in this study suggest that an experienced physiotherapist effectively can screen patients referred for orthopaedic consultation in primary healthcare PURPOSE To investigate the diagnostic accuracy and association to disability of selected functional findings or physical examination tests for patellofemoral pain syndrome ( PFPS ) in patients with anterior knee pain . METHODS A sample of 76 consecutive patients with anterior knee pain was further subdivided into PFPS and other diagnoses . Routine physical examination tests were examined in a prospect i ve , consecutive-subjects design for a cohort of patients with anterior knee pain . Diagnostic accuracy findings , including sensitivity , specificity , positive ( PPV ) and negative ( NPV ) predictive value , and positive ( LR+ ) and negative ( LR- ) likelihood ratios , were calculated for each test . PPV and NPV reflect the percentage of time of positive or a negative test ( respectively ) accurately captures the diagnosis of the condition . LR+ and LR- reflect alterations in post-test probability when the test is positive or negative ( respectively ) . Lastly , associations to disability ( International Knee Documentation Committee ( IKDC ) subjective form ) were calculated for each clinical finding . RESULTS Diagnostic accuracy analyses of individual functional assessment and situational phenomena suggest that the strongest diagnostic test is pain encountered during resisted muscle contraction of the knee ( PPV=82 % ; LR+=2.2 ; 95 % CI : 0.99 - 5.2 ) . Clusters of test findings were substantially more diagnostic , with any two of three positive findings of muscle contraction , pain during squatting , and pain during palpation yielding the following values : PPV=89 % ; LR+=4.0 ( 95 % CI : 1.8 - 10.3 ) . No individual or clustered test findings were significantly associated with the IKDC score . CONCLUSION Combinations of functional assessment tests and situational phenomena are diagnostic for PFPS and may serve to rule in and rule out the presence of PFPS . Single findings are not related to disability scores ( IKDC ) Orthopaedic surgeons have always based their clinical care on evidence . Surgeons use evidence to make decisions tailored to an individual patient 's needs and circumstances . The primary sources of evidence for clinicians are studies published in the medical and surgical literature , such as The Journal of Bone and Joint Surgery . In June 2000 , The Journal introduced the quarterly Evidence -Based Orthopaedics section 1 . This section introduces orthopaedic surgeons to recent r and omized trials relevant to the practice of orthopaedic surgery published in forty-two journals other than The Journal of Bone and Joint Surgery . Structured abstract s of these studies are Second-year medical students performed a head-to-toe screening physical examination on trained patient instructors ( PIs ) as a high-stakes examination before beginning clinical clerkships . PIs completed a 138-item checklist and instructed the students in the proper performance of any incorrectly executed or omitted items . To assess the accuracy of the PI ratings , ' monitor ' PIs watching the encounter by video completed checklists for 11 retests of failed students in 2001 and for 28 r and omly selected encounters in 2002 . Checklist-level discrepancies measured by mean absolute checklist difference were 8 % in 2001 and 9 % in 2002 . Case-level mean difference between raters in 2002 was -2.9 % . The inter-rater reliability for a single rater , estimated by the intra-class correlation coefficient for total encounter scores , was 0.95 . The assessment and feedback were well received by the students . The Head-to-Toe examination provides a reliable assessment of a student 's ability to carry out a complete screening physical examination . Patient instructors can be trained to acceptable accuracy and reliability despite the length and complexity of the exercise , and can provide effective feedback and teaching targeted to individual student deficiencies The purpose s of this study were to develop an instrument to assess the validity of r and omized controlled trials and to report on the differences in the validity of r and omized controlled trials between two podiatric medical journals and a mainstream medical journal . The study demonstrated that after adequate training , there can be agreement among review ers evaluating the quality of published r and omized controlled trials using an established instrument and guidelines . The results of the study indicate that r and omized controlled trials published in podiatric medical journals are less credible than those published in a mainstream medical journal BACKGROUND CONTEXT Objective measures including neurological findings , radiographic evaluation , and the Japanese Orthopaedic Association ( JOA ) score are commonly used for the evaluation of surgical outcomes . Because many surgeries are performed primarily to improve quality of life , a patient 's subjective evaluations are also important for accurately assessing surgical outcomes . Currently available instruments for assessing quality of life include the Short-Form 36 ( F-36 ) , the Oswestry disability index ( ODI ) , and the visual analog scale ( VAS ) clinical pain scale . PURPOSE The aims of this study were to measure surgical outcomes by using both objective measures and subjective measures including patient self- assessment s and psychological changes ; to assess the adequacy of the JOA alone for measuring outcome ; and to determine which measures , the SF-36v2 , ODI , VAS , or JOA correlate with the VAS pain scale score in lumbar canal stenosis . STUDY DESIGN We performed a prospect i ve study to measure surgical outcomes for lumbar canal stenosis using traditional objective measures such as neurological findings and subjective measures such as performance of ADLs , patient self- assessment s , and psychological changes . PATIENT SAMPLE Forty-two surgical patients with a mean age of 66.8+/-10.9 years at the time of surgery were included in the study . All cases were followed for more than 2 years . Surgical indications included no response to conservative treatment and neurological deterioration . Neurological symptoms were classified as nerve root type , cauda equine type , or combined type . We performed surgical decompression at the location of the dural or root indentation by myelography . The concomitant diagnosis causing the spinal stenosis was degenerative spondylolisthesis in 20 cases undergoing posterolateral fusion with pedicle screws . OUTCOME MEASURES Surgical outcomes were assessed by comparing preoperative and 24-month postoperative JOA scores for low back pain , SF-36v2 , ODI-v2 , and VAS scores . Statistical analysis was performed by using the analysis of variance . A p value<0.05 was considered statistically significant . METHODS Objective clinical measures , patient self- assessment s , and psychological changes were measured before and at 24 months postoperatively . We also examined which measurements correlated with the VAS scale for pain evaluation , thereby relating patient satisfaction to surgery outcome . RESULTS All JOA , SF-36v2 , ODI-v2 , and VAS scores significantly improved postoperatively . The physical component summary ( PCS ) of the SF-36 v2 showed significant improvement , although all scores remained less than the Japanese norm-based scores ( NBSs ) . The mental component summary ( MCS ) exhibited such a significant improvement that all postoperative subscales were higher than the Japanese NBS . JOA scores significantly correlated only with postoperative lower-extremity VAS score . All PCS and two MCS scores significantly correlated with the VAS score for low back pain . Parts of the PCS and MCS significantly correlated with the lower-extremity VAS . The ODI significantly correlated with both the preoperative and postoperative VAS scores for low back pain as well as with the postoperative lower-extremity VAS score . CONCLUSIONS The JOA , SF-36 , ODI , and VAS question naires are all useful instruments for measuring surgical outcomes . The VAS score is a better assessment of physical rather than mental health . The ODI is more reflective of patients ' subjective symptoms . Finally , the SF-36 is particularly informative because it includes questions addressing both psychological and physical status . Therefore , when combined , the SF-36v2 , VAS , and ODI scores are a valuable complement to the JOA scores in evaluating outcomes of surgery for lumbar canal stenosis Conflict between clinical importance and statistical significance is an important problem in medical research . Although clinical importance is best described by asking for the effect size or how much , statistical significance can only suggest whether there is any difference . One way to combine statistical significance and effect sizes is to report confidence intervals . We therefore assessed the reporting of confidence intervals in the orthopaedic literature and factors influencing this frequency . In parallel , we tested the predictive value of statistical significance for effect size . In a r and om sample of predetermined size , we found one in five orthopaedic articles reported confidence intervals . Participation of an individual trained in research methods increased the odds of doing so fivefold . The use of confidence intervals was independent of impact factor , year of publication , and significance of outcomes . The probability of statistically significant results to predict at least a 10 % between-group difference was only 69 % ( 95 % confidence interval , 55%–83 % ) , suggesting that a high proportion of statistically significant results do not reflect large treatment effects . Confidence intervals could help avoid such erroneous interpretation by showing the effect size explicitly
No tests for impingement or acromioclavicular ( AC ) joint pathology demonstrated significant diagnostic accuracy .
Based on pooled data , the diagnostic accuracy of the Neer test for impingement , the Hawkins-Kennedy test for impingement and the Speed test for labral pathology is limited .
Currently , almost without exception , there is a lack of clarity with regard to whether common OSTs used in clinical examination are useful in differentially diagnosing pathologies of the shoulder
OBJECTIVE To compile and critique research on the diagnostic accuracy of individual  orthopaedic physical examination tests in a manner that would allow clinicians to judge whether these tests are valuable to their practice .