Clinical Examination Variables Research Articles

A decision support system to determine the amount of wergild and compensation based on forensic medicine clinical examinations

BackgroundForensic medicine is crucial in ensuring that the law and justice are carried out as swiftly, effectively, clearly, and accurately as possible. The significant number and interactions of forensic clinical examination variables, the complexity of their differentiation, and the existence of multiple decision-making paths can lead to erroneous decisions that cause irreparable harm to individuals and society. This study aimed to develop and evaluate a decision support system for determining the amount of wergild and compensation based on forensic medicine clinical examinations and the severity of the patient’s injury.MethodsA total of 264 data elements and decision-making rules were identified based on an analysis of information sources and focus group discussions. In addition, a decision tree was used to organize the decision-making rules. Then, a system was developed using algorithms for intelligent decision-making. We included 500 patients in our analysis. This system was ultimately evaluated based on the following criteria: precision and accuracy, sensitivity, specificity, usability, and documentation quality.ResultsThe results indicated that the precision and accuracy, sensitivity, and specificity of the system were 100%. Furthermore, the documentation quality (completeness) increased from 78.2 to 100%. The average score for system usability was 4.35 out of 5, indicating a highly acceptable range.ConclusionThe designed system was effective and beneficial for forensic clinical examinations and quantifying physical damage (wergild and compensation). Therefore, this system can be utilized in forensic medicine’s administrative and clinical processes, and its production and commercialization will result in an adequate market penetration rate. In addition, this will empower forensic medicine physicians and reduce decision-making errors.Graphical

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait.

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance >19 0 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.00 0 to 70.48 0, p<0.01) and external knee rotation during stance (SPM analysis, p<0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89). Conclusions This prospective study found no association between the changes in clinical examination variables and changes in crouch highlighting the likely multi-factorial aetiology of this gait pattern and the need for larger prospective studies. The variability crouch gait progression among the 27 participants highlights the pitfall of group mean values in such a heterogeneous population.

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance &gt;190 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.000 to 70.480, p&lt;0.01) and external knee rotation during stance (SPM analysis, p&lt;0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89). Conclusions The variability crouch gait progression highlights the pitfall of group mean values in such a heterogeneous population. The lack of association between changes in clinical examination variables and changes in crouch highlights the multi-factorial aetiology of this gait pattern and the need for larger prospective studies.

Predictors of laminitis development in a cohort of nonlaminitic ponies.

Quantifying risk factors for laminitis development requires improvement. To identify the most useful physical examination, metabolic and management factors to predict laminitis development in client-owned, nonlaminitic ponies. Prospective cohort study. Physical examination, metabolic and management data were collected from a pony cohort 6 monthly for up to 4years. Ponies were monitored for the development of laminitis. Metabolic data included basal plasma concentrations of ACTH ([ACTH]), adiponectin ([adiponectin]), triglycerides and glucose. Serum insulin concentrations ([insulin]) were measured in the unfasted basal state ([insulin]T0) and 60minutes ([insulin]T60) after administration of corn syrup (0.3ml/kg). Separate multivariable Cox proportional-hazards models were developed for physical, management/signalment and metabolic data and later combined into two final models. Low-, medium- and high-laminitis risk categories were defined based on basal or T60 [insulin]. Overall, 374 ponies (age 5-32years) and 891 pony-years were included in the main analysis. Laminitis incidence (95% confidence interval (CI)) was 4.8 (3.5-6.5) cases/100 pony-years. Laminitis development was associated with numerous univariable factors. Significant (P<.05) factors retained in the final multivariable models included [insulin]T0, [insulin]T60, [adiponectin] and divergent hoof growth. [ACTH] was not independently associated with laminitis. Based on [Insulin]T0, low- (<21.6 µIU/ml), medium- (21.6-45.2 µIU/ml) and high-risk (>45.2µIU/ml) categories encompassed 70, 20 and 10% of the population and had estimated 4-year laminitis incidences (95%CI) of 6 (2-9)%, 22 (10-33)% and 69 (48-82)% respectively. Based on [Insulin]T60 the low- (<53.4µIU/ml), medium- (53.4-153µIU/ml) and high-risk (≥153µIU/ml) categories comprised 60, 30 and 10% of the population and had estimated 4-year laminitis incidences (95%CI) of 3 (0-6)%, 20 (10-29)% and 73 (52-84)% respectively. Results may not apply to different insulin assays, geographical regions, breeds or management types. [Insulin]T0 or [insulin]T60 best quantify the risk of future laminitis development in nonlaminitic ponies.

Predictive factors for CPAP failure in obstructive sleep apnea patients.

Objectives:Some patients with obstructive sleep apnea (OSA) do not respond to Continuous Positive Airway Pressure (CPAP) and for these patients, Bi-level PAP is the next level modality. This study by a theory driven hierarchical approach, tries to identify the predictors for CPAP failure among OSA patients.Methodology:The potential predictors for the model were identified from a theoretical framework rooted in clinical examination, laboratory parameters, and polysomnographic variables pertaining to OSA patients. All patients of OSA who underwent manual titration with CPAP or Bi-level PAP (in case of CPAP Failure) between June 2015 and October 2017 were included in model building. This study compared five competitive models blocks deliberated by increasing order of diagnostic complexity and availability of resources. The fitting of the model was determined by both internal and external validation.Results:Among the five competitive models, the selected model has the significant deviance reduction (−2LL = 121.99, X2 = 25.55, P < 0.0001) from the baseline model (−2LL = 217.356). This logistic regression model consists of the following binary predictors – Age >60 years (odds ratio [OR] = 3.23 [1.27–8.23]), body mass index >35 Kg/m2 (OR = 4.25 [1.78–10.13]), forced expiratory volume <60% (OR = 7.33 [2.83–18.72]), apnea-hypopnea index >75 (OR = 4.31 [1.61–11.56]) and T90 > 30% (OR = 6.67 [2.57–17.36]).Conclusion:These five factors (acronym as BIPAP) may aid to the clinical decision-making by predicting failure of CPAP and therefore may assist in more vigilant clinical care.

Risk factors associated with intra-stent restenosis after percutaneous coronary intervention.

The present study aimed to explore the correlations between clinical, biological, imagistic and procedural factors with the risk of intra-stent restenosis (ISR) in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI). An observational cross-sectional study was conducted in a high-volume PCI center over a period of 2 years. A total of 235 consecutive patients diagnosed with angina or acute coronary syndrome treated by PCI were included in the study. Diagnosis of ISR was documented by coronary angiography in patients with suggestive coronary symptoms and ischemic changes in non-invasive or invasive paraclinical investigations. Thus, they were assigned to two groups: With or without ISR. All patients underwent clinical and laboratory examination, providing clinical and paraclinical variables that could be considered risk factors for ISR. Current smokers [risk ratio (RR)=1.63; 95% confidence interval (95% CI): 1.25-2.13], arterial hypertension (RR=1.86; 95% CI: 1.41-2.45), diabetes (RR=1.83; 95% CI: 1.42-2.36), high C-reactive protein (CRP) levels (RR=1.44; 95% CI: 0.93-2.24), chronic kidney disease (CKD) (RR=1.90; 95% CI: 1.53-2.36) and thrombolysis in myocardial infarction (TIMI) score were found to have a significant role in estimating the risk for ISR. Moreover, the ISR group (119 patients) presented with a lower stent inflation pressure when compared to the control group (116 patients) (14.47 vs. 16.14 mmHg, P=0.004). An increased mean stent diameter used for PCI was not associated with a high ISR incidence (P=0.810) as well as complex coronary treated lesions with longer stents (mean length of 24.98 mm in patients without ISR vs. 25.22 mm in patients with ISR; P=0.311). There was an estimated two times higher risk (RR=2.13; 95% CI: 1.17-3.88) concerning multi-stenting and restenosis degree >70%. To conclude, smoking, hypertension, diabetes mellitus, high CRP levels, CKD, TIMI score, stent type, low pressure for stent implantation and multi-stenting were found to be associated with ISR in patients following PCI. Therefore, a close follow-up should be targeted in such patients.

A New Clustering Method for Knee Movement Impairments using Partitioning Around Medoids Model.

Background: The movement system impairment (MSI) model is a clinical model that can be used for the classification, diagnosis, and treatment of knee impairments. By using the partitioning around medoids (PAM) clustering method, patients can be easily clustered in homogeneous groups through the determination of the most discriminative variables. The present study aimed to reduce the number of clinical examination variables, determine the important variables, and simplify the MSI model using the PAM clustering method.Methods: The present cross-sectional study was performed in Shiraz, Iran, during February-December 2018. A total of 209 patients with knee pain were recruited. Patients’ knee, femoral and tibial movement impairments, and the perceived pain level were examined in quiet standing, sitting, walking, partial squatting, single-leg stance (both sides), sit-to-stand transfer, and stair ambulation. The tests were repeated after correction for impairments. Both the pain pattern and the types of impairment were subsequently used in the PAM clustering analysis. Results: PAM clustering analysis categorized the patients in two main clusters (valgus and non-valgus) based on the presence or absence of valgus impairment. Secondary analysis of the valgus cluster identified two sub-clusters based on the presence of hypomobility. Analysis of the non-valgus cluster showed four sub-clusters with different characteristics. PAM clustering organized important variables in each analysis and showed that only 23 out of the 41 variables were essential in the sub-clustering of patients with knee pain.Conclusion: A new direct knee examination method is introduced for the organization of important discriminative tests, which requires fewer clinical examination variables.

Cardiovascular variables in eventing and endurance horses over a season

IntroductionThe objectives of this study were to describe the changes in clinical cardiovascular examination variables over a competition season in groups of competitive eventing and endurance horses and to compare these findings to non-competitive controls of the same breeds. AnimalsThis study included two eventing horses, 11 endurance horses, and 13 eventing and seven endurance control breed-matched horses. Materials and methodsCardiovascular examinations were performed before starting the competition season, in the middle and at the peak/end of the competition season. Examinations included auscultation of the heart; M-mode echocardiographic measurements and calculated values; left atrial, pulmonary artery, and aortic diameters; color flow Doppler; exercise electrocardiograms (ECG) measuring peak heart rates and quantifying premature complexes; and 24-h continuous ECGs quantifying premature complexes per hour. ResultsAuscultation, echocardiograms, arrhythmias during exercise, and 24-h continuous ECGs did not change significantly throughout the season (p > 0.05 for all variables). ConclusionCardiovascular examination variables of eventing and endurance horses throughout a competition season are reported here for the first time. Although the present study did not reveal significant changes, data should be interpreted carefully as only a small number of horses were examined.

Homeostasis model assessment of insulin resistance in relation to the poor functional outcomes in nondiabetic patients with ischemic stroke.

Whether insulin resistance (IR) predicts worse functional outcome in ischemic stroke is still a matter of debate. The aim of the present study is to determine the association between IR and risk of poor outcome in 173 Chinese nondiabetic patients with acute ischemic stroke. This is a prospective, population-based cohort study. Insulin sensitivity, expressed by the homeostasis model assessment (HOMA) of insulin sensitivity (HOMA index = (fasting insulin × fasting glucose)/22.5). IR was defined by HOMA-IR index in the top quartile (Q4). Functional impairment was evaluated at discharge using the modified Rankin scale (mRS). The median (interquartile range) HOMA-IR was 2.14 (1.17–2.83), and Q4 was at least 2.83. There was a significantly positive correlation between HOMA-IR and National Institutes of Health Stroke Scale (r = 0.408; P<0.001). In multivariate analyses, patients in IR group were associated with a higher risk of poor functional outcome (odds ratio (OR) = 3.23; 95% confidence interval (CI) = 1.75–5.08; P=0.001). In multivariate models comparing the third and fourth quartiles against the first quartile of the HOMA-IR, levels of HOMA-IR were associated with poor outcome, and the adjusted risk of poor outcome increased by 207% (OR = 3.05 (95% CI 1.70–4.89), P=0.006) and 429% (5.29 (3.05–9.80), P<0.001). In a receiver operating characteristic curve (ROC) analysis of poor outcome, the area under the curve (AUC) increased from 0.80 to 0.84 (95% CI: 0.79–0.88) by adding HOMA-IR to clinical examination variables (P=0.02). High HOMA-IR index is associated with a poor functional outcome in nondiabetic patients with acute ischemic stroke.

Foot Kinematics Differ Between Runners With and Without a History of Navicular Stress Fractures.

Background:A navicular stress fracture (NSF) is a common and high-risk injury in distance runners. It is not clear whether there are differences in foot structure and function between runners who have and those who have not sustained an NSF.Purpose/Hypothesis:This study compared foot structure, range of motion, and biomechanics between runners with a history of unilateral NSFs and runners who had never sustained this injury. The hypothesis was that runners with a history of NSFs will have less dorsiflexion and subtalar range of motion in a clinical examination and greater rearfoot eversion and higher eversion velocity while running than either the noninvolved feet or healthy controls.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Seven runners who sustained an NSF were matched with 7 controls without this injury history. Participants underwent a clinical orthopaedic examination, followed by a 3-dimensional running gait analysis. Clinical examination variables, foot kinematics, and ground-reaction forces were compared between injured and noninjured feet within the NSF group and between the NSF group and control group.Results:The NSF group demonstrated less plantar flexion on the clinical examination than the control group (P = .034, effect size [ES] = 0.69). The involved feet of the NSF group demonstrated greater rearfoot eversion excursion, greater eversion velocity, and reduced forefoot abduction excursion than either the noninvolved feet of the NSF group (P = .015, ES = 1.73; P = .015, ES = 1.86; and P = .015, ES = 0.96, respectively) or the control group (P = .012, ES = 1.40; P = .016, ES = 0.49; and P = .005, ES = 1.60, respectively).Conclusion:There are differences in foot kinematics but not ground-reaction forces, foot structure, or passive range of motion between runners who have and those who have not sustained an NSF. Runners who demonstrate increased rearfoot eversion and reduced forefoot abduction during stance may be more at risk for developing NSFs.

Development of a prediction model for future risk of radiographic hip osteoarthritis

To develop and validate a prognostic model for incident radiologic hip osteoarthritis (HOA) and determine the value of previously identified predictive factors. We first validated previously reported predictive factors for HOA by performing univariate and multivariate analyses for all predictors in three large prospective cohorts (total sample size of 4548 with 653 incident cases). The prognostic model was developed in 2327 individuals followed for 10 years from the Rotterdam Study-I (RS-I) cohort. External validation of the model was tested on discrimination in two other cohorts: RS-II (n=1435) and the Cohort Hip and Cohort Knee (CHECK) study (n=786). From the total number of 28 previously reported predictive factors, we were able to replicate 13 factors, while 15 factors were not significantly predictive in a meta-analysis of the three cohorts. The basic model including the demographic, questionnaire, and clinical examination variables (area under the receiver-operating characteristic curve (AUC)=0.67) or genetic markers (AUC=0.55) or urinary C-terminal cross-linked telopeptide of type II collagen (uCTX-II) levels (AUC=0.67) alone were poor predictors of HOA in all cohorts. Imaging factors showed the highest predictive value for the development of HOA (AUC=0.74). Addition of imaging variables to the basic model led to substantial improvement in the discriminative ability of the model (AUC=0.78) compared with uCTX-II (AUC=0.74) or genetic markers (AUC=0.68). Applying external validation, similar results were observed in the RS-II and the CHECK cohort. The developed prediction model included demographic, a limited number of questionnaire, and imaging risk factors seems promising for prediction of HOA.

Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort

Background ContextEvidence is lacking on the prognosis and prognostic factors of back-related leg pain and sciatica in patients seeing their primary care physicians. This evidence could guide timely appropriate treatment and referral decisions. PurposeThe present study aims to describe the prognosis and prognostic factors in primary care patients with low back-related leg pain and sciatica. Study DesignThis is a prospective cohort study. Patient SampleThe present study included adults visiting their family doctor with back-related leg pain in the United Kingdom. Outcome MeasuresInformation about pain, function, psychological, and clinical variables, was collected. Good outcome was defined as 30% or more reduction in disability (Roland-Morris Disability Questionnaire). MethodsParticipants completed the questionnaires, underwent clinical assessments, received a magnetic resonance imaging scan, and were followed-up 12 months later. Mixed-effects logistic regression evaluated the prognostic value of six a priori defined variable sets (leg pain duration, pain intensity, neuropathic pain, psychological factors, clinical examination, and imaging variables). A combined model, including variables from all models, examined independent effects. The National Institute for Health Research funded the study. There are no conflicts of interest. ResultsA total of 609 patients were included. At 12 months, 55% of patients improved in both the total sample and the sciatica group. For the whole cohort, longer leg pain duration (odds ratio [OR] 0.41; confidence interval [CI] 0.19–0.90), higher identity score (OR 0.70; CI 0.53–0.93), and patient's belief that the problem will last a long time (OR 0.27; CI 0.13–0.57) were the strongest independent prognostic factors negatively associated with improvement. These last two factors were similarly negatively associated with improvement in the sciatica subgroup. ConclusionsThe present study provides new evidence on the prognosis and prognostic factors of back-related leg pain and sciatica in primary care. Just over half of patients improved at 12 months. Patient's belief of recovery timescale and number of other symptoms attributed to the pain are independent prognostic factors. These factors can be used to inform and direct decisions about timing and intensity of available therapeutic options.

Ability of clinicopathologic variables and clinical examination findings to predict race elimination in endurance horses

OBJECTIVE To compare results of point-of-care laboratory testing with standard veterinary clinical examination findings at a single time point during endurance competition to identify horses at risk for elimination. ANIMALS 101 endurance horses participating in the 2013 Western States 160-km (100-mile) endurance ride. PROCEDURES At the 58-km checkpoint, blood samples were collected from all horses. Samples were analyzed for pH, Pco2, base excess, anion gap, PCV, and whole blood concentrations of sodium, potassium, chloride, total carbon dioxide, BUN, glucose, and bicarbonate. Corrected electrolyte and PCV values were calculated on the basis of plasma total protein concentration. Immediately following the blood sample collection, each horse underwent a clinical examination. In addition to standard examination variables, an adjusted heart rate was calculated on the basis of the variable interval between entry into the checkpoint and heart rate recording. A combination of stepwise logistic regression, classification and regression tree analysis, and generalized additive models was used to identify variables that were associated with overall elimination or each of 3 other elimination categories (metabolic elimination, lameness elimination, and elimination for other reasons). RESULTS Corrected whole blood potassium concentration and adjusted heart rate were predictive for overall elimination. Breed, plasma total protein concentration, and attitude were predictive for elimination due to metabolic causes. Whole blood chloride concentration and corrected PCV were predictive for elimination due to lameness. Corrected PCV was predictive for elimination due to other causes. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that for horses in endurance competition, a combination of breed and clinical examination and laboratory variables provided the best prediction of overall elimination.

Oral impacts on daily performances in white-collar port workers in Nellore, India - a cross-sectional study.

Oral diseases not only cause pain, but severely impair large number of individuals and can affect various aspects of life, including oral functions, appearance and interpersonal relationships. The aim of the study was to assess the interrelationship between oral impact on daily performance (OIDP) scores, socio-demographic characteristics, dental caries experience and periodontal status. A cross-sectional descriptive epidemiological study was conducted on a sample of 250 white-collar port workers who were willing to participate. OIDP was assessed using pre-validated questionnaire. Oral health status was assessed using modified World Health Organisation (1997) Proforma. Test of association was conducted between the OIDP score, socio-demographic variables, and periodontal status; loss of attachment was determined by using chi-square statistics and Mann-Whitney test. Logistic regression was performed to identify significant predictors of OIDP scores by inputting clinical oral examination variables into the equation, stepwise. A total of 250 white-collar workers in the port participated in the study with mean age of 34.67 ± 6.36. Among them, 219 were males and 31 were females. The OIDP items most commonly affected by oral health status were eating and enjoying food (48.4%), cleaning teeth (48%), sleeping and relaxing (44.4%).There was statistically significant relationship between missing teeth in the decayed missing filled teeth component and OIDP score (p < 0.001). The participants with caries have a greater odd (2.11) of having OIDP score ≥ 1 than those without caries. The participants with missing teeth have a greater odd (3.60) of having OIDP score ≥ 1. The participants in the age group of 31-40 years had a greater odd (2.80) of having OIDP score ≥ 1. Oral health had an impact on the quality of life of white-collar workers in the port. Physical functions of teeth like eating and cleaning of teeth, sleeping and relaxing were more affected.

Efectos a medio y largo plazo sobre la marcha de un programa de ejercicio domiciliario y ortesis de uso nocturno en niños con equinismo idiopático

IntroductionIdiopathic toe walking (ITW) is a common paediatric gait disorder characterised by excessive plantar flexion during the gait cycle. There is no consensus in the literature about the best therapeutic approach to treat ITW and different conservative and surgical options are used in clinical practice.The main objective of this study is to evaluate the clinical impact of a home-based exercise program associated with the use of a night splint (AFO) for managing gait problems in children with ITW. Material and methodsThis is a comparative kinematic study. Long-term follow-ups were conducted at 6, 12, and 18 months with 29 children with ITW and 15 healthy children. The proposed treatment was a home-based exercise associated with a night splint for 12 months. ResultsThe therapeutic approach improved several kinematic values by the 18-month follow-up. We found statistically significant differences for gait kinematics (A1, A3, A5 and GDI) and one of the clinical examination variables (ankle passive dorsiflexion). All the differences showed a normalization of gait kinematics, with critical kinematic values close to the normalcy data. Conclusions3D gait analysis is an assessment tool for gait disorders and for long-term follow-up of children with ITW. Our home-based exercise associated with a night splint showed good results for gait disorders treatment in children with idiopathic toe walking.

Clinical Examination Results in Individuals With Functional Ankle Instability and Ankle-Sprain Copers

Why some individuals with ankle sprains develop functional ankle instability and others do not (ie, copers) is unknown. Current understanding of the clinical profile of copers is limited. To contrast individuals with functional ankle instability (FAI), copers, and uninjured individuals on both self-reported variables and clinical examination findings. Cross-sectional study. Sports medicine research laboratory. Participants consisted of 23 individuals with a history of 1 or more ankle sprains and at least 2 episodes of giving way in the past year (FAI: Cumberland Ankle Instability Tool [CAIT] score = 20.52 ± 2.94, episodes of giving way = 5.8 ± 8.4 per month), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers: CAIT score = 27.74 ± 1.69), and 23 individuals with no history of ankle sprain and no instability (uninjured: CAIT score = 28.78 ± 1.78). Self-reported disability was recorded using the CAIT and Foot and Ankle Ability Measure for Activities of Daily Living and for Sports. On clinical examination, ligamentous laxity and tenderness, range of motion (ROM), and pain at end ROM were recorded. Questionnaire scores for the CAIT, Foot and Ankle Ability Measure for Activities of Daily Living and for Sports, ankle inversion and anterior drawer laxity scores, pain with palpation of the lateral ligaments, ankle ROM, and pain at end ROM. Individuals with FAI had greater self-reported disability for all measures (P < .05). On clinical examination, individuals with FAI were more likely to have greater talar tilt laxity, pain with inversion, and limited sagittal-plane ROM than copers (P < .05). Differences in both self-reported disability and clinical examination variables distinguished individuals with FAI from copers at least 1 year after injury. Whether the deficits could be detected immediately postinjury to prospectively identify potential copers is unknown.

Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain

BackgroundDespite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort.MethodsConsecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (XylocaineTM) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O’Brien’s test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests.ResultsTwenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84).ConclusionsIn this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort.

Smallest detectable differences in clinical functional temporomandibular joint examination variables in juvenile idiopathic arthritis

Temporomandibular joint (TMJ) arthritis in juvenile patients may interfere with optimal joint function and mouth opening patterns. Clinical assessment of maximal mouth opening capacity, laterotrusion and protrusion is critical to TMJ arthritis diagnosis, treatment choice and evaluation of a therapeutic intervention. The aim of the study was to determine the smallest minimal threshold at which differences in maximal mouth opening capacity, laterotrusion, and protrusion between two consecutive observations can be determined. Department of Orthodontics, University of Aarhus, Denmark. Forty-two consecutive patients with juvenile idiopathic arthritis. Two experienced dentists used a calibrated metallic ruler to measure maximal mouth opening capacity, laterotrusion, and protrusion. Each measurement was carried out thrice by each observer. Intra- and inter-observer variation and the smallest detectable difference were calculated for each variable. The smallest detectable differences were as follows: maximal mouth opening capacity 4.9 mm, laterotrusion 2.4 mm, and protrusion 2.8 mm (one observer and one measurement). These differences declined when measurements were repeated; maximal mouth opening capacity 3.3 mm, laterotrusion 1.4 mm, and protrusion 1.8 mm (two observers with three measurements each). We found no support for a relationship between measurement variation and patient age, measurement variation and TMJ pain, or between measurement variation and previous/current TMJ arthritis. The importance of the implementation of a standardized measurement protocol is emphasized including repeated measurements to reduce the smallest detectable difference.

Clinical predictors of a positive response to guided diagnostic block into the subacromial bursa

To compare the accuracy of combinations of clinical examination findings for predicting a positive response to injection of local anaesthetic into the subacromial bursa. Prospective, cohort, diagnostic validity design. Consecutive patients with shoulder pain recruited from primary care physiotherapy and general medical practices. All subjects underwent a standardised clinical examination (index test) followed by a diagnostic injection of xylocaineTM into the subacromial bursa (reference standard test) performed under ultrasound guidance. Clinical examination variables associated with a positive anaesthetic response (≥ 80% post-injection reduction in pain intensity) were identified (p < 0.20) and diagnostic accuracy was calculated. Of the 196 subjects who received a subacromial bursa injection, 66 subjects (34%) reported a positive anaesthetic response. Strain injury (adjusted odds ratio (AOR) 2.3), anterior shoulder pain (AOR 2.3) and absence of pain with external rotation at 90º abduction (AOR 3.9) were the strongest clinical predictors of positive anaesthetic response. Clinical prediction model variables demonstrated 100% specificity (3 positive tests) but low sensitivity (maximum 40%) for a positive anaesthetic response. Combinations of 9 other clinical variables also demonstrated 100% specificity (7 or more positive tests), and improved sensitivity (95 to 100%) for a PAR compared with clinical prediction model variables when less than two findings were present. Combinations of these clinical tests may assist the clinician to differentiate subacromial pain from other shoulder conditions and guide selection of targeted pain management interventions. Additional diagnostic tests may be required when clinical criteria are not satisfied.

Predictors of Response to Physical Therapy Intervention in Patients With Primary Hip Osteoarthritis

Few studies have investigated or identified common clinical tests and measures as being associated with progression of hip osteoarthritis (OA); fewer still are longitudinal studies exploring prognostic variables associated with long-term outcome following physical therapy treatment. The purpose of this study was to determine a set of prognostic factors that maximize the accuracy of identifying patients with hip osteoarthritis (OA) likely to demonstrate a favorable response to physical therapy intervention. This was a prognostic study. Ninety-one patients with a clinical diagnosis of hip OA were analyzed to determine which clinical measures, when clustered together, were most predictive of a favorable response to physical therapy intervention. Responders were determined based on OMERACT-OARSI response criteria, which included percent and absolute changes in pain, function, and global rating of change over 1 year. These data served as the reference standard for determining the predictive validity of baseline clinical examination variables. Using multivariate regression analyses and calculations for sensitivity, specificity, and positive and negative likelihood ratios, a cluster was identified. Five baseline variables (unilateral hip pain, age of ≤58 years, pain of ≥6/10 on a numeric pain rating scale, 40-m self-paced walk test time of ≤25.9 seconds, and duration of symptoms of ≤1 year) were retained in the final model. Failure to exhibit a condition of 1 of the 5 predictor variables decreased the posttest probability of responding favorably to physical therapy intervention from 32% to <1% (negative likelihood ratio=0.00, 95% confidence interval=0.00-0.70). Having at least 2 out of 5 predictor variables at baseline increased the posttest probability of success with physical therapy intervention from 32% to 65% (positive likelihood ratio=3.99, 95% confidence interval=2.66-4.48), and having 3 or more of 5 predictor variables increased the posttest probability of success to 99% or higher. A comparison with a control group that did not receive physical therapy further substantiated the cluster. The small sample size and the number of variables entered into the logistic regression model may have resulted in spurious findings. This study must be validated in replication studies before it can be considered for use in clinical practice. This study completed the first step in the development of a preliminary cluster of baseline variables that identify patients with hip OA as positive responders to physical therapy intervention.