Intrarater Reliability Of Measurements Research Articles

CT measures of femoral and tibial version and rotational position of femoral and tibial components of knee replacements: limitations in reliability and suitability for routine clinical practice

ObjectivesRotational malalignment of knee replacements as measured on CT is understood to be associated with poor outcomes. The aim of this study is to measure the inter-rater and intra-rater reliability of measures of femoral and tibial version in the native arthritic knee and postoperative TKR component position using CT.MethodsEighty patients underwent CT of the knee before and after total knee replacement. Preoperative femoral and tibial version and component rotation were independently measured by two musculoskeletal radiologists.ResultsMean differences between and within raters were small (< 1.6°). Maximum 95% limits of agreement for inter-rater and intra-rater comparisons were 8.1° and 7.6° for preoperative femoral version, 9.0° and 7.9° for postoperative femoral rotation, 26.0° and 20.5° for preoperative tibial version, and 24.9° and 23.6° for postoperative tibial rotation respectively. Postoperative ICCs varied from 0.68 to 0.81 (lower 95% CI:0.55–0.72) for both intra- and inter-rater comparisons. Preoperative ICCs were lower: 0.55–0.75 (lower 95% CI:0.40–0.65).ConclusionThe lower 95% confidence level for ICC of version and rotational measurements using the Berger protocol of TKRs on CT are all less than 0.73 and that the normal range of differences between observers is up to 9° for the femoral component and 26° for the tibial component. This suggests that CT measurements derived from the Berger protocol may not be consistent enough for clinical practice.Key Points• CT is commonly used to measure the rotational profile of knee replacements in symptomatic patients using the Berger protocol.• The limits of agreement for both femoral and tibial component rotation are wide even for experienced observers.• CT measurements of the rotation of knee arthroplasty are not reliable enough for routine clinical use.

Does observational study on the effectiveness of the Twin Blocks overestimate or underestimate the results? A comparative analysis of retrospective samples versus randomized controlled trial

Class II malocclusion is one of the most common orthodontic problems. The Twin Block appliance has proven to be the most popular appliance for the correction of these malocclusions. Although randomized controlled trials (RCTs) on the Twin Block appliance have reported the changes to be mainly dentoalveolar, several nonrandomized studies have reported a significant skeletal improvement in these patients. Hence, the aim of this study was to compare the effectiveness of Twin Block appliance evaluated using an RCT or retrospectively selected cases (RSC) for the treatment of Class II Division 1 malocclusion in an adolescent population. This was a retrospective study. The results for an RCT were selected from a UK Class II multicenter study. Sixty-three patients from the trial were included. This group was matched with retrospectively selected Class II cases treated with a Twin Block functional appliance and their results submitted for Membership in Orthodontics examination in the United Kingdom, from four centers. The primary outcome was skeletal measurement ANB (A point, nasion, B point). Secondary outcomes included final peer assessment rating (PAR) scores and final overjet. Intrarater reliability of measurements was assessed. Independent samples t-test was carried out to look at the difference between the groups. The reliability assessment showed excellent agreement for all measurements. The data were normally distributed. There was a statistically significant difference favoring the RSC group for final overjet (mean difference [MD]=1.068, 95% confidence interval [CI] -0.67 to 1.47, P=0.000) and final PAR (MD=4.0, 95% CI -0.79 to 5.5, P=0.000). There was no significant difference in the scores for final ANB (MD=0.34, 95% CI -0.39 to 1.07, P=0.33). The RSCs show significantly improved overjet and PAR scores at the end of treatment and no statistically significant difference for skeletal change. The study raises the question of a potential role of observational studies in evaluating the effect of an intervention in orthodontics.

Damage of the distal radial physis in young gymnasts: can three-dimensional assessment of physeal volume on MRI serve as a biomarker?

ObjectiveTo explore the use of quantitative volume assessment to identify the presence and extent of stress-related changes of the distal radial physis in gymnasts with suspected physeal injury, asymptomatic gymnasts, and non-gymnasts.MethodsSymptomatic gymnasts with clinically suspected distal radial physeal injury, asymptomatic gymnasts, and non-gymnasts (n = 69) were included and matched on skeletal age and sex. Volume measurements were performed on coronal water selective cartilage MRI images by creating three-dimensional physeal reconstructions semi-automatically using active-contour segmentation based on image-intensity thresholding. Inter- and intra-rater reliability of the measurements were assessed using intra-class correlation coefficients (ICC) for absolute agreement.ResultsTwenty-seven symptomatic-, 18 asymptomatic-, and 24 non-gymnasts were included with a median age of 13.9 years (interquartile range (IQR) 13.0–15.0 years). Median physeal volume was significantly increased (p < 0.05) in symptomatic- (971 mm3, IQR 787–1237 mm3) and asymptomatic gymnasts (951 mm3, IQR 871–1004 mm3) compared with non-gymnasts (646 mm3, IQR 538–795 mm3). Inter-rater (ICC 0.96, 95% CI 0.92–0.98) and intra-rater (ICC 0.93, 95% CI 0.85–0.97) reliability of volume measurements were excellent. Of the 10 participants with the highest physeal volumes, nine were symptomatic gymnasts.ConclusionIncreased volume of the distal radial physis can reliably be assessed and is a sign of physeal stress that can be present in both symptomatic- and asymptomatic gymnasts, but gymnasts with suspected physeal injury showed larger volume increases. Future studies should explore if volume assessment can be used to (early) identify athletes with or at risk for physeal stress injuries of the wrist.Key Points• The volume of the distal radial physis can be reliably assessed by creating three-dimensional physeal reconstructions.• Stress-related volume increase of the distal radial physis is present in symptomatic and asymptomatic gymnasts.• Gymnasts with clinically suspected physeal injury showed larger volume increases compared with asymptomatic gymnasts and may therefore be a valuable addition in the (early) diagnostic workup of physeal stress injuries.

Can a Brief Training Session Prepare Physician Sonographers of Differing Experience to Measure the Ischiofemoral Space? A Reliability Study

The primary aim of this study was to determine the inter- and intrarater reliability of ultrasound (US) measurements of the ischiofemoral space (IFS) following a brief training session. A secondary aim was to determine if reliability correlated with sonographer experience. Prospective cohort study. Physical medicine and rehabilitation department within a tertiary care institution. Seven male and 3 female individuals were recruited to serve as models. Nine physician sonographers (3 postgraduate year [PGY]-2 residents, 3 PGY-4 residents, 3 physicians) were recruited to serve as sonographers. Sonographers received a 15-minute educational session on identifying the IFS with US, followed by 20 minutes of practice. Models were then placed in a prone position and secured to prevent hip movement. All operators measured bilateral IFSs in each model twice with a washout period between measurements. Operators were blinded to all measurements. Primary outcomes were inter- and intrarater reliability interclass coefficients (ICCs) of IFS measurements among the groups with different levels of US experience. Secondary outcomes included comparisons of inter- and intrarater reliability ICCs of IFS measurements between groups, and the difference of mean IFS measurements between groups. Intrarater reliability ICCs were 0.829, 0.680, and 0.596 for physician, PGY-4, and PGY-2 groups, respectively. Interrater reliability ICCs were 0.722, 0.427, and 0.558 for physician, PGY-4, and PGY-2 groups, respectively. No statistically significant differences in reliability were identified between groups. Mean IFS measurements were 31.2, 33.4, and 34.0 mm for physician, PGY-4, and PGY-2 groups, respectively. Physician measurements were significantly smaller than the PGY-4 and PGY-2 measurements (P < .049 and P < .01). Following a brief training session, experienced sonographers demonstrated excellent IFS measurement intrarater reliability, whereas PGY-4 and PGY-2 sonographers demonstrated fair intrarater reliability. All sonographers demonstrated fair interrater reliability. II.

Intrarater reliability of measurement of submandibular glands under ultrasound: prospective study

Intrarater reliability of measurement of submandibular glands under ultrasound: prospective study

Intra-rater and inter-rater reliability of ultrasonographic measurements of acromion-greater tuberosity distance in patients with post-stroke hemiplegia

Background:Glenohumeral subluxation (GHS) is reported in up to 81% of patients with stroke. Ultrasonographic measurements of GHS by measuring the acromion-greater tuberosity (AGT) have been found to be reliable for experienced raters.Objectives:The primary aim was to assess the intra-rater reliability of measurements of AGT distance in people with stroke following a short course of rater training. A secondary aim was to compare the inter-rater reliability of these measurements between novice and experienced raters.Methods:Patients with stroke (n = 16; 5 men, 11 women; 74 ± 10 years) with 1-sided weakness who gave informed consent were recruited. Ultrasonographic measurements were recorded at the bedside by two physiotherapists with patients seated upright in a hospital chair. Reliability was assessed by intra-class correlation coefficients (ICCs) and the standard error of measurements (SEM). Minimum detectable change (MDC90) scores were used to estimate the magnitude of change that is likely to exceed measurement error.Results:Mean ± SD AGT distances on the affected and unaffected sides for rater 1 were 2.2 ± 0.7 and 1.7 ± 0.4 cm, respectively. Corresponding values for rater 2 were 2.5 ± 0.6 and 2.0 ± 0.4 cm. Intra-class correlation coefficient values for the affected and unaffected shoulders for rater 1 were 0.96 and 0.91, respectively. Corresponding values for rater 2 were 0.95 and 0.90.SEM and MDC90 for both affected and unaffected shoulders were ≤ 0.2 cm. Inter-rater reliability coefficients were 0.86 (affected) and 0.76 (unaffected) shoulders.Conclusion:Ultrasonographic measurement of AGT distance demonstrates excellent intra-rater reliability for a novice rater. Inter-rater reliability of ultrasonographic measurement of AGT also demonstrates good reliability between novice and experienced raters.

173. Reliability of Three Objective Hand Measures: Joint Circumference, Composite Finger Flexion and the Grip Ability Test

Background: Prior to a feasibility study evaluating compression gloves in rheumatoid arthritis (RA), we searched AMED (1985- April 2013) and MEDLINE (1988 - April 2013) to identify reliable methods of evaluating objective measures of hand joint swelling, finger motion and hand function. As data were being collected by therapists as part of their usual glove provision, measures needed to be brief, replicable in practice, and use easily obtainable, low-cost equipment. The feasibility study included multiple assessors, therefore we evaluated inter- and intra-rater reliability of measures. Methods: We selected the Figure of Eight method (hand swelling), composite finger flexion (CFF) to the distal palmar crease (DPC) (finger motion), and the Grip Ability Test (GAT, hand function). During piloting (n=3), therapists had difficulty performing the Figure of Eight and CFF (DPC) methods and we changed to measuring metacarpophalangeal and proximal interphalangeal joint (MCPJs, PIPJs) circumference using a pressure garment tape measure and CFF to the distal wrist crease (DWC). The GAT measures function bilaterally with the dominant hand performing most actions. As gloves can be prescribed for one hand only, we revised instructions to repeat the GAT for both left and right hands and further standardised instructions. A hand assessment manual was developed. Eleven therapists completed reliability testing. Following training, they practiced the measures with each other and two patient research partners for 1.5 hours, then were tested twice at one hour intervals on subjects’ right hands. Ten performed the GAT. Paired t-tests were used to identify differences between therapists’ test 1 and 2 (T1,T2) measurements (intra-rater reliability). Intra-class correlation coefficients were calculated (two-way random, consistency model) using ICC (2,11) across the 11 assessors (ICC(2,10), for the GAT) (inter-rater reliability). Results: For all joint swelling measures, there were no significant differences between tests indicating good intra-rater reliability (e.g., 2nd-5th MCPJ swelling: T1 = 18.75 (SD 0.13); T2 = 18.77 (SD 0.14); p = 0.72). Inter-rater reliability (ICC (2,11)) varied from 0.19 (poor) for the wrist to 0.91 (almost perfect) for the 2nd PIPJ. For CFF, there were no significant differences between tests, indicating good intra-rater reliability (e.g., 2nd digit T1=9.38 (SD 0.31), T2=9.40 (SD 0.29); p = 0.74). Inter-rater reliability (ICC(2,11) ranged from 0.76 - 0.93 (i.e. strong to almost perfect). For the GAT, there were no significant differences indicating good intra-rater reliability (T1=24.66 (SD 4.24), T2= 24.59 (SD 4.20); p = 0.82). Inter-rater reliability (ICC (2,10) was 0.98 (almost perfect). Conclusions: To our knowledge this is the first reliability testing of joint circumference measured using pressure garment tape measures in RA and CFF to the DWC. Joint circumference, CFF and GAT measures had good intra- and mostly good inter-rater reliability.

Computer-assisted image analysis for measuring body segmental angles during a static strength element on parallel bars: validity and reliability

This study aimed to introduce a technique using computer-assisted image analysis for measuring body segmental angles during a static strength element on parallel bars. Criterion validity and intra-rater reliability of measurements were evaluated using digital photography, skin markers and a gravity-reference goniometer. Twenty male former gymnasts participated in this study. They performed a strength hold element on parallel bars (V-sit) and they were photographed with legs extended and stabilized at the highest possible level. The leg to horizontal, trunk to vertical and arm to vertical angles were calculated and examined for reliability using image-pro software. The leg angle was also examined for its validity, by simultaneously using a Myrin goniometer. The two goniometric techniques indicated high leg angle measurements agreement (R = 0.997, p < 0.001). However, Bland-Altman analysis showed that there was a slight leg angle measurement overrating using image-pro software, especially at smaller angles. The Intra-class Correlation Coefficient (ICC) values were high for leg angle (R = 0.971), trunk angle (R = 0.957) and arm angle (R = 0.945), showing an excellent test-retest agreement. It was ascertained that the measurement of segmental angles during V-sit on parallel bars using digital photography and computer-assisted image analysis can be highly reliable when taken by the same experienced examiner.

Measurement and Determinants of Anogenital Distance in Healthy, Newborn Infants

ISEE-0808 Background: In toxicological animal studies, anogenital distance (AGD) is a sexually dimorphic trait that is a well established reproductive toxicity endpoint. AGD develops under the influence of dihydrotestosterone during fetal development, yielding a longer AGD in males when compared to females. A shortened AGD is associated with a variety of genital abnormalities in animal studies of male offspring, but little data exists on the determinants and normal variance of the measurement in humans. Methods: We conducted a standardized training to learn AGD measurement methodologies in the University of Washington newborn nursery in 2008. Inter-rater and intra-rater reliability of measurements, was evaluated prior to the start of the study. We measured 173 (86 male, 87 female) newborn infants for AGD. Standard anthropometric data was collected (weight, length, and occipital head circumference) along with race and gestational complications. We examined AGD for sexual dimorphism and predictors of the measurement in infants using linear regression modeling. Results: Within the standardized training, intra-rater reliability was 0.96 for females and 0.98 for males, and inter-rater reliability was 0.56 for females and 0.92 for males. Mean male AGD was 51.98 mm (SD ± 5.53) and mean female AGD was 37.19 mm (SD ± 3.73). Weight, length, occipital head circumference, and gestational age were independent, significant predictors of AGD. Race was not a strong predictor of AGD. Conclusion: We found that AGD is an easily learned and performed measurement in newborn infants. We demonstrated that AGD is a sexually dimorphic measurement in humans that is most strongly predicted by weight. The application of this measurement to clinically relevant outcomes related to in utero androgenization remains to be explored in further depth.

Reliability of the Beighton Hypermobility Index to Determinate the General Joint Laxity Performed by Dentists

The findings in the literature concerning an association between general joint laxity (GJL) and temporomandibular disorders (TMDs) are inconsistent. Both differences in study designs and the lack of information about the precision of GJL measurements may be contributing to this inconsistency. The aim of this study was thus to investigate the reliability (the inter-rater and intra-rater test-retest reliability and internal consistency) of GJL measurements taken by dentists in a general dental practice setting. A cohort of 50 patients ranging from 20 to 60 years in age (56% female) from a general dental practice was examined twice by two dentists addressing the GJL according to the Beighton Index. The second exam took place after 4 weeks. The inter-rater and intra-rater reliability of measurements was calculated using the intraclass correlation coefficient (ICC). Cronbach's alpha was used to assess the measurements' internal consistency. Inter- and intra-rater reliability was found to be very good to excellent (ICC: 0.84-0.94). Cronbach's alpha (mean 0.75, range 0.66-79) yielded acceptable internal consistency measurements. The Beighton Index is a reliable instrument for dentists when assessing general joint laxity.

Inter-rater and Intra-rater Reliability when Measuring Interphalangeal Joints: Comparison between three hand-held goniometers

Summary Objective To establish the inter-rater and intra-rater reliability of measurement using a hand-held goniometer within a team of therapists and to discover if this reliability differs when measuring the proximal and distal interphalangeal joint, or when using different goniometers. Method Forty hand therapists comprising physiotherapists and occupational therapists from four hospitals within one trust who measure hand joints within their working practice were involved in data collection. Using a set protocol they placed three different goniometers over the dorsum of the proximal and distal interphalangeal joints of two fingers immobilised within a splint. Measurements were read and recorded by an independent therapist. Each joint was measured three times so that the intra-rater reliability of the therapists' goniometer placement with each instrument could be measured alongside inter-rater reliability. Results The results were analysed using descriptive statistics and appropriate non-parametric statistical methods (Spearman's rank correlation and Friedman's test). The results showed the importance of one therapist measuring the same patient and how therapists can be consistently low or high with their reading. The analysis indicated that the therapists were generally more reliable using the goniometer that 75% of the staff regularly used. Results also indicated that measuring a flexed distal inter-phalangeal joint produced less reliable results but this was not the case for an extended distal interphalangeal joint. Conclusion The therapists in this study were more consistent in their measurements when placing the goniometer that most were using within their clinical practice. Teams should ensure that they standardise the goniometer used and its placement in order to achieve good reliability by one therapist over repeated measurements and between therapists in clinical practice.

Glenoid inclination is associated with full-thickness rotator cuff tears.

Anatomic factors, such as a hooked acromion, have been associated with rotator cuff disorders. Orientation of the glenoid relative to the scapula has been implicated in shoulder instability, but it has not been linked to rotator cuff disorders. The purpose of the current study was to test the hypothesis that superior inclination of the glenoid is associated with full-thickness rotator cuff tears. Glenoid inclination angles were measured from 16 shoulder radiographs of a convenience sample of eight cadavers in which one shoulder had an intact rotator cuff and the other shoulder had a full-thickness rotator cuff tear. Glenoid inclination angles for shoulders with rotator cuff tears were compared with contralateral normal shoulders using nonparametric statistical analysis. The glenoid inclination angle was greater in cadaver shoulders having full-thickness rotator cuff tears (98.6 degrees ) than in shoulders without tears (91.0 degrees ). A second experiment was done to assess the reliability of using 34 Grashey view radiographs from a clinical population to measure glenoid inclination angle. A method to measure the glenoid inclination on Grashey views was tested and was found to correlate with the inclination angles measured on cadaveric scapulae. Intrarater reliability of measurements from clinical Grashey views was 0.93, and interrater reliability was at least 0.88.

Criterion-related validity of a clinical measurement to determine the medial/lateral component of patellar orientation.

Repeated measures design using a sample of convenience. To assess the criterion-related validity and intrarater reliability of a clinical measurement used for determining the medial/lateral position of the patella. Patellar taping is a common treatment for patellofemoral pain. Application of this intervention requires accurate assessment of patellar orientation; however, the validity of this clinical procedure has not been documented. Fourteen subjects (10 women, 4 men; average age, 41 +/- 16 years) were evaluated. Clinical assessment of medial/lateral patellar orientation using the technique described by McConnell was compared with the actual position of the patella as determined through magnetic resonance imaging (MRI). Imaging was done on 7 knees of 4 subjects who were asymptomatic and 11 knees of 10 subjects who were symptomatic. Both clinical and MRI assessments were made with the subjects supine, the knee extended, and the quadriceps relaxed. Agreement between the 2 techniques and the intrarater reliability of each measurement were quantified by means of the intraclass correlation coefficient (ICC). Both the clinical and MRI measures of medial/lateral patellar displacement were found to demonstrate good intrarater reliability (ICC = 0.91 and 0.85, respectively). The agreement between the clinical and MRI determinations of medial/lateral patellar position was poor (ICC = 0.44). The average amount of lateral patellar displacement as determined by the clinical method was more than twice that established through MRI. The clinical assessment of the medial/lateral position of the patella overestimates the true amount of lateral patellar displacement. A more valid clinical method of assessing the medial/lateral component of patellar orientation is necessary.