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Orthopedic Clinical Examination

Orthopedic Clinical Examination

by Michael P. Reiman

1152 Pages

Hardcover
ISBN: 9781450459945
Published: January 2016

£102.00

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eBook
ISBN: 9781492579717
Published: January 2016

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Description
Contents
Authors
Praise
Ancillaries
Excerpts

Orthopedic Clinical Examination With Web Resource provides readers with fundamental knowledge for developing proficiency at performing systematic orthopedic evaluations. Michael P. Reiman, who is internationally respected for his teaching, clinical practice, and research focused on orthopedic assessment and treatment methods, presents an evidence-based guide on the examination process for various parts of the body.

The text takes a structured approach, moving from broad to focused, that guides clinicians in examining each client and condition. The text presents specific components of the examination in the same sequence, ensuring repetition and improved consistency in learning. Screenings are used early in the examination sequence not only to determine the appropriateness of performing an orthopedic examination but also to rule out other potential pain generators and thereby narrow the focus of the examination.

Orthopedic Clinical Examination emphasizes evidence-based practice and therefore focuses on tests that are clinically relevant, providing students and clinicians with the most appropriate testing options rather than listing tests with no regard for their clinical value. Both treatment-based and pathological-based diagnostic styles are covered in detail so that readers will gain a thorough understanding of both approaches and be able to implement them separately or in tandem. In addition to musculoskeletal testing, the text provides information on including subjective history, observation, diagnostic imaging, systems and neurological screening, and performance-based measures in each examination.

The text is organized into five parts and is structured such that readers will first acquire requisite knowledge about anatomy and the examination process before advancing to acquiring specific examination skills. Part I presents information about the musculoskeletal and nervous systems as well as tissue behavior and healing. Part II introduces the principles of the examination sequence. Parts III and IV present the region-specific examination sequence for evaluating clients, including specifics on analyzing the head, spine, and extremities. Each chapter in these two parts covers the anatomy of the region, various types of injuries that occur, specific tests and measures that can be used, and cross-references to specific case studies for further review. Part V highlights additional considerations that may be necessary for special populations during the examination process.

Orthopedic Clinical Examination includes learning tools that enhance comprehension and engagement:

• Full-color photographs and illustrations demonstrate anatomy, patient conditions, and clinician positioning to serve as a visual reference and ensure proper testing techniques.

• A library of 50 videos, found in the web resource, provides students with visual demonstrations of assessments and treatments.

• Color-coding graphics throughout chapters help readers quickly discern whether evidence supporting the reported finding is ideal, good, or less than good.

• Overviews of common orthopedic conditions for each body region are in the 12 applied chapters.

• Twenty-four case studies guide users in the proper questions to ask and steps to take in conducting examinations.

• Linkss to abstracts of articles provide additional clinical learning scenarios.

With Orthopedic Clinical Examination, current and future clinicians will gain the knowledge and confidence they need in performing examinations to provide optimal patient care.

Part I. Review of Anatomy Systems

Chapter 1. Musculoskeletal System

Gilbert M. Willett, PT, PhD, OCS, CSCS; Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Bones

Joints

Skeletal Muscle and Connective Tissues

Conclusion

Chapter 2. Nervous System and Pain

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS; Adriaan Louw, PT, PhD, CSMT

Structural Divisions of the Nervous System

Neuromuscular Control

Neurophysiology of Pain

Conclusion

Chapter 3. Tissue Injury and Healing

Mark F. Reinking, PT, PhD, SCS, ATC; Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Tissue Healing

Muscle Injury

Tendon Injury

Ligament Injury

Bone Injury

Articular Cartilage Injury

Peripheral Nerve Injury

Conclusion

Part II. Concepts and Principles of Examination

Chapter 4. Evidence-Based Practice and Client Examination

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Evidence-Based Practice and Diagnostic Accuracy

Study Quality

Broad to Narrow or Funnel Examination Focus

Integration of Funnel Examination Approach

The Examination Continuum

Basic Principles of the Examination Process

Conclusion

Chapter 5. Client Interview and Observation

Jonathan Sylvain, PT, DPT, OCS, FAAOMPT; Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Effective Communication in the Client Interview and History

Common Barriers to Effective Communication

Qualities of an Effective Interview

Standard Client Interview

Client Interviews Relative to Musculoskeletal Pain

Outcome Measurements

Observation

Clinical Reasoning

Conclusion

Chapter 6. Triage and Differential Diagnosis

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Triage Screening for Red and Yellow Flags

Diagnostic Imaging

Vital Signs

Differential Diagnosis and Medical Screening Examination

Treatment Based Classification

Conclusion

Chapter 7. Orthopedic Screening and Nervous System Examination

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS; Adriaan Louw, PT, PhD, CSMT

Musculoskeletal Screening

Examination of the Physical Health of the Nervous System

Peripheral Nerve Examination

Conclusion

Chapter 8. Range of Motion Assessment

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Range of Motion and Flexibility

Goniometry

Qualitative Assessment of Motion

Conclusion

Chapter 9. Muscle Performance and Neuromuscular Control

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Components of Muscle Performance

Factors Affecting Muscle Performance

Clinical Measures of Muscle Performance

Conclusion

Chapter 10. Special Tests

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Examination Procedure

Diagnostic Application of Special Tests

Conclusion

Chapter 11. Palpation

B. James Massey, PT, DPT, OCS, FAAOMPT

Palpation Procedure

Palpation Components of the Musculoskeletal Examination

Abdominal Palpation

Pulse Palpation

Bony Landmark Palpation

Joint Motion

Conclusion

Chapter 12. Physical Performance Measures

Robert J. Butler, PT, DPT, PhD

Overview of Testing Hierarchy

Single Body-Weight Physical Performance Measures

Single Body-Weight Loading

Single Body-Weight Loading and Momentum

Agility

Aerobic Capacity

Upper Extremity

General Core Stabilization

Conclusion

Chapter 13. Gait

Janice K. Loudon, PT, PhD, SCS, ATC

Walking Gait

Running Gait

Biomechanical Analysis of Walking and Running

Conclusion

Chapter 14. Posture

Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS

Body Type

Optimal Standing Posture

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Evidence-based practice (EBP) has been defined as "the conscientious and judicious use of current best evidence in making decisions about the care of individual patients." Central to the concept of EBP is the integration of evidence into the diagnoses and management of clients. Today, there is a strong push toward EBP as the conscientious utilization of the strongest and most recent evidence purported in the literature. Clinical expertise is also vital to the practice of EBP, as stated by Sackett and colleagues:

It is possible to have statistical significance without having clinical relevance, to have both statistical significance and clinical relevance together, to have clinical relevance without having statistical significance, or to have neither statistical significance nor clinical relevance. The clinical relevance of research findings is typically not reported in research findings, and it has been suggested as paramount to clinical practice. Current best evidence is therefore a balance of the best available evidence supported in the literature and the clinician's sound clinical reasoning. The practicing clinician must rely on the interweaving of these tenets to make the most conscientious, sound decisions when examining and subsequently treating clients.

For these reasons, this text would like the reader to also think in terms of the terminology of evidence-informed practice (EIP). The purpose of EIP is to make clinical decisions with the information of best evidence. Decisions cannot always be based on evidence alone. This is particularly the case when the evidence supporting or refuting clinical testing is poor. The clinician is referred to the limitations of each component of the examination, particularly special testing (as discussed in chapter 10). Many of these tests have less than good ability to assist with differential diagnoses decisions. All components of the examination, including components not described as standard examination components (e.g., the client's goals, the client's health status), should be used when making clinical diagnosis and treatment decisions.

Diagnostic tests and measures are distinct components of an EBP model of client examination. A diagnostic test and its results are important tools guiding the clinician to the appropriate diagnosis by revealing the likelihood of whether or not a client has a specific disorder. Diagnostic research should evaluate the validity of the complete diagnostic process and study the evidence of the added value of the different tests used. Not all components of the examination process are equal in their ability to differentiate the presence, absence, or severity of a particular disease or condition present in a client. This likely also depends on the particular pathology. Specific components of the examination process have a stronger diagnostic ability depending on several variables including, but not limited to, the prevalence of the disease, the diagnostic accuracy of the examination component, and the strength of the literature investigating the pathology or examination component.

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

The entire diagnostic process entails each component described in this text. This examination focus or sequence will be referred to as broad to narrow or the funnel approach as advocated by the author and colleagues.

Broad to Narrow or Funnel Examination Focus

The entire diagnostic process entails each component described in this text. This examination focus or sequence will be referred to as broad to narrow or the funnel approach as advocated by the author and colleagues. The clinician generates a differential diagnosis for each client based on the history (client interview), observation, triage, motion, muscle performance, special tests, palpation, and physical performance measures (figure 4.1). Based on the probability of a particular diagnosis to exist, the findings of each of these components will make shifts in posttest probability based on their diagnostic accuracy (SN, SP, likelihood ratios). Utilizing only one component as the gold standard from which the diagnosis is made is inappropriate clinical practice.

Figure 4.1 Funnel approach of the examination process.
Funnel approach of the examination process.
© Michael Reiman

This approach, while comprehensive, is also systematic; it moves from broad to narrow in its approach from the beginning to the end of the examination process. The intent is to start the examination process as comprehensively as possible, including all potential diagnoses. As a result of each systematic step in the examination process, the clinician should narrow down the differential diagnosis list as far as possible. Additionally, the broad-to-narrow approach of the examination is in the sense of moving from less to more isolated examination procedures. For example, in the client interview, the clinician asks broad, open-ended questions that are likely to include multiple potential diagnoses. As the examination continues, the examination process becomes more focused. This is particularly the case after the section for triage or screening and sensitive tests, which is intended to rule out not only the potential for red flags or nonmusculoskeletal disease processes but also potential pain generators in other joints, as well as other potential diagnoses common to the pain-generating joints.

Integration of Funnel Examination Approach

A systematic approach to using findings (especially those from special tests) reporting SN and SP is suggested in figure 4.2. The use of tests of high SN and low -LR is suggested early in the examination (Triage and Sensitive Tests), with red flags first ruled out. Once it is determined that the client is appropriate for examination or treatment, the clinician continues through additional examination components (e.g., motion tests, muscle performance testing, special tests). Particular emphasis is on motion testing and muscle performance testing to delineate if the client's actual symptoms are reproduced. Additionally, special tests (and possibly imaging) of high SP are helpful to rule in pathology of the determined pain-generating joint(s). Again, caution should be taken when using special tests for diagnosis. Figure 4.2 shows a systematic approach for integrating diagnostic accuracy findings of both high SN (early in the examination - triage and screening) and high SP (later in the examination - special tests - for determination of ruling in pathology). The suggestions for ideal and good diagnostic accuracy values are again provided here.

Figure 4.2 Algorithm approach for use of special tests or findings reporting SN and SP. SN = sensitivity; SP = specificity; +LR = positive likelihood ratio; -LR = negative likelihood ratio
Algorithm approach for use of special tests or findings reporting SN and SP. SN = sensitivity; SP = specificity; +LR = positive likelihood ratio; -LR = negative likelihood ratio
© Michael Reiman

The Examination Continuum

The examination of a client should also be recognized as an assessment along a continuum (figure 4.3). Many examination procedures described, including those in this text, are on the isolated examination side of the continuum (e.g., ROM, muscle performance, radiology findings, special tests). Integrated examination would include measures more applicable to daily tasks, such as sport- and work-related activities (e.g., function). These measures might include administering the physical performance measures section of this text (see chapter 12), as well as simply assessing the client's quality and big-picture quantity assessment of their daily tasks, work tasks, and sports tasks.

Figure 4.3 The examination continuum.
The examination continuum.
© Michael Reiman

Note that clients likely will move back and forth along this continuum at different points in their rehabilitation process. For example, a client progressing appropriately along post knee injury, but who still has pain with jumping, may require a reassessment where they enter the continuum with a jumping assessment first (toward the integrated side of the continuum). This will help the clinician determine the potential limitation or pain generator from which to then focus the isolated examinations, as described previously.

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Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Eliciting a good history and therefore conducting an organized and fruitful client interview and history requires several skills, not the least of which are organizational and communication abilities. Effective communication on the part of the clinician when interviewing a client requires several skills. The clinician must be able to not only ask appropriate questions but also listen to the client, ask follow-up questions based on information the client shares, redirect the line of questioning dependent on this information, and so on.

During consultation, the client must be considered the most valuable source of information. Many clinicians take control during the examination process, not allowing the client to express the reasoning for seeking care. Beckman and colleagues found that in 69% of visits, physicians interrupted client's statements and directed questions toward a specific concern. In another study, physicians redirected clients during their opening statement after a mean of 23.1 seconds. Clients allowed to complete their opening statement required an average of only 6 seconds longer to state their primary concerns. Many clients will not divulge additional relevant information after being interrupted.

The fact that a client interview can be done more or less effectively is demonstrated by the fact that essential diagnostic information can be uncovered from the client interview. One's efficiency in communication can be improved through training. It is unlikely that any future technological advances will negate the need and value of compassionate and empathetic two-way communication between clinician and client. The published literature also expresses belief in the essential role of communication: "It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider rather than from any failing in the technical aspects of medical care. Improvements in provider-patient communication can have beneficial effects on health outcomes." Professional conversation between clients and clinicians shapes diagnosis, initiates therapy, and establishes a caring relationship.

The development and improvement of communication and clinical reasoning skills leads to the clinician "developing an accurate clinical hypothesis, developing an examination and intervention approach to meet the individual's cultural, communication, anatomic, and physiologic needs and abilities, recognizing patient symptoms and signs that necessitate communication with other health care providers, and participating in the decision-making process regarding the selection of appropriate diagnostic testing."

Despite these facts, many health care providers have poor communication skills and perform inadequate client interviews. Many times failure to take a sufficient medical history with proper client communication can lead to mistakes that have clinical and economic consequences. In fact, many complaints about health care providers are not about the medical care provided but in regard to poor or insufficient communication. A complex relationship exists between clients' opinions of physician communication and physicians' malpractice history. Clinicians must learn to adapt and tailor their communication styles to each individual client due to variations that exist in clients' intellectual and emotional needs. Clinicians must also develop an understanding of each individual client's desired communication needs.

Communication in primary care physicians is also a significant variable in malpractice claims. Physicians without such claims educated patients on what to expect during their visit, laughed and demonstrated humor, spent more time with patients during routine visits, and sought and facilitated the expression of the patient's opinions, values, and beliefs. For a successful and humanistic encounter at an office visit, the clinician needs to be sure that the client's key concerns have been directly and specifically solicited and addressed. To be effective, the clinician must gain an understanding of the client's perspective on their illness. The whole client must be evaluated because a plethora of conditions may present with manifestations similar to musculoskeletal conditions. Furthermore, client concerns can be wide ranging. Client values, cultures, gender, and preferences need to be taken into consideration.

Clinician skill, rapport, and health-related communication behaviors are key elements of a client interview. Clients are more likely than clinicians to report behaviors demonstrating thoroughness in routine examinations as essential to a quality office visit, such as spending enough time with them, engaging them, and treating them with courtesy and respect. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the clinician.

Certain observable history-taking behaviors are evident between good and poor diagnosticians. Furthermore, these behaviors are evident during the first 3 minutes of the encounter. Behaviors characteristic of good diagnosticians are thoroughness of inquiry about the chief complaint, asking questions in close proximity within a line of reasoning, clarifying or verifying information provided by the client, and summarizing the information at hand. Characteristic behaviors of bad diagnosticians are repeating questions unnecessarily, changing the topic before completing a line of inquiry, inquiring about systems, and inquiring about past history.

A positive working relationship between clinician and client has a positive effect on treatment outcomes, although further research is needed to determine the strength of the relationship. Poor communication, though, can leave clients with an undefined understanding of their diagnosis, prognosis, future management plans, and the therapeutic intent of treatment.

Communicating with a client is a must in order to set up an effective therapeutic alliance. The approach taken is important. Physical therapists tend to apply a paternalistic approach even though clients prefer to share decisions or provide their opinions about treatment options.

The communication relationship with the client encompasses many aspects, including verbal and nonverbal communication, a client-centered interview, the use of empathy, active listening, facilitation, summarization, clarification, and reflection skills. Each of these aspects has specific considerations that the clinician must take into account when engaging in the therapeutic relationship with the client.

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Figure 4.1 Funnel approach of the examination process.
Funnel approach of the examination process.
© Michael Reiman

Integration of Funnel Examination Approach

The Examination Continuum

Figure 4.3 The examination continuum.
The examination continuum.
© Michael Reiman

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Figure 4.1 Funnel approach of the examination process.
Funnel approach of the examination process.
© Michael Reiman

Integration of Funnel Examination Approach

The Examination Continuum

Figure 4.3 The examination continuum.
The examination continuum.
© Michael Reiman

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Figure 4.1 Funnel approach of the examination process.
Funnel approach of the examination process.
© Michael Reiman

Integration of Funnel Examination Approach

The Examination Continuum

Figure 4.3 The examination continuum.
The examination continuum.
© Michael Reiman

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

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Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Figure 4.1 Funnel approach of the examination process.
Funnel approach of the examination process.
© Michael Reiman

Integration of Funnel Examination Approach

The Examination Continuum

Figure 4.3 The examination continuum.
The examination continuum.
© Michael Reiman

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Optimizing interviews with clients

Effective Communication in the Client Interview

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What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Integration of Funnel Examination Approach

The Examination Continuum

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Integration of Funnel Examination Approach

The Examination Continuum

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Integration of Funnel Examination Approach

The Examination Continuum

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Integration of Funnel Examination Approach

The Examination Continuum

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

What classifies as evidence-based practice and why does that matter?

Evidence-Based Practice and Diagnostic Accuracy

Prior to discussion of the diagnostic accuracy of various musculoskeletal tests and measures, it is necessary to define terminology central to EBP.

Reference standard - The criterion that best defines the condition of interest. The reference standard should have demonstrated validity that justifies its use as a criterion measurement.
Reliability - The degree of consistency with which an instrument or rater measures a particular attribute. Measurements can be affected by random error. In determining the reliability of a measurement, we are determining the proportion of that measurement that is a true representation and the proportion that is the result of measurement error.
Validity - The degree to which a study or test appropriately measures what it intends to measure. Validity attempts to answer the question: Does the test truly measure what it is designed to measure? A test must be reliable to be valid, but a test does not have to be valid to be reliable. Tests that are valid should measure the abilities vital to the sport, occupation, or aspect of activity of daily living.
Sensitivity (SN) - The percentage of people who test positive for a specific disease among a group of people who have the disease. The true positive rate.
Specificity (SP) - The percentage of people who test negative for a specific disease among a group of people who do not have the diagnosis or disorder. The true negative rate.
Positive likelihood ratio (+LR) - The ratio of a positive (+) test result in people with the pathology to a positive test result in people without the pathology. A +LR identifies the strength of a test in determining the presence of a finding, and it is calculated by the following formula: SN / (1 - SP).
Negative likelihood ratio (-LR) - The ratio of a negative (-) test result in people with the pathology to a negative test result in people without the pathology. It is calculated by the following formula: (1 - SN) / SP. The higher the +LR and lower the -LR, the more the posttest probability is altered. Posttest probability can be altered to a minimal degree (+LRs of 1-2, or -LRs of 0.5-1), to a small degree (+LRs of 2-5 and -LRs of 0.2-0.5), to a moderated degree (+LRs of 5-10, -LRs of 0.1-0.2), and to a significant and almost conclusive degree (+LRs greater than 10, -LRs less than 0.1).
Positive predictive value (PPV) - Given a (+) test result, the probability that the client has the condition. Some researchers and clinicians feel that PPV is better than SN since it takes into account the amount of false positives (FP). PPV = TP / (TP + FP), where TP is true positives. Therefore, if the test is (+), the client has X% chance of having the disorder.
Negative predictive value (NPV) - Given a (-) test result, the probability that the client does not have the condition. Again, some believe this is better than SP since it takes into account the number of FNs. Therefore, if the test is (-), the client has X% chance of not having the disorder.
- SN and SP are properties of the measure, while PPV and NPV are properties of both the test and the population that was tested.
- Reading the PPV and NPV from the 2 Ã— 2 contingency table is accurate only if the proportion of diseased clients in the sample is representative of the proportion of the diseased people in the population.
Overall accuracy - Proportion of clients who are correctly diagnosed.

Learn more about Orthopedic Clinical Examination.

Focusing your examination approach

Broad to Narrow or Funnel Examination Focus

Integration of Funnel Examination Approach

The Examination Continuum

Save

Learn more about Orthopedic Clinical Examination.

Optimizing interviews with clients

Effective Communication in the Client Interview

Learn more about Orthopedic Clinical Examination.

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