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Interobserver and Intraobserver Reliability of Clinical Assessments in Knee Osteoarthritis

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Interobserver and Intraobserver Reliability of Clinical Assessments in Knee Osteoarthritis Interobserver and Intraobserver Reliability of Clinical Assessments in Knee Osteoarthritis Nasimah Maricar, Michael J. Callaghan, Matthew J. Parkes, David T. Felson, and Terence W. O’Neill ABSTRACT. Objective. Clinical examination of the knee is subject to measurement error. The aim of this analysis was to determine interobserver and intraobserver reliability of commonly used clinical tests in patients with knee osteoarthritis (OA). Methods. We studied subjects with symptomatic knee OA who were participants in an open-label clinical trial of intraarticular steroid therapy. Following standardization of the clinical test procedures, 2 clinicians assessed 25 subjects independently at the same visit, and the same clinician assessed 88 subjects over an interval period of 2–10 weeks; in both cases prior to the steroid intervention. Clinical examination included assessment of bony enlargement, crepitus, quadriceps wasting, knee effusion, joint-line and anserine tenderness, and knee range of movement (ROM). Intraclass correlation coeffi- k kω cients (ICC), estimated kappa ( ), weighted kappa ( ), and Bland-Altman plots were used to determine interobserver and intraobserver levels of agreement. k Results. Using Landis and Koch criteria, interobserver scores were moderate for patellofemoral k k k joint ( = 0.53) and anserine tenderness ( = 0.48); good for bony enlargement ( = 0.66), quadriceps k k k wasting ( = 0.78), crepitus ( = 0.78), medial tibiofemoral joint tenderness ( = 0.76), and effusion k kω assessed by ballottement ( = 0.73) and bulge sign ( = 0.78); and excellent for lateral tibiofemoral k k joint tenderness ( = 1.00), flexion (ICC = 0.97), and extension (ICC = 0.87) ROM. Intraobserver k k scores were moderate for lateral tibiofemoral joint tenderness ( = 0.60); good for crepitus ( = 0.78), k k effusion assessed by ballottement test ( = 0.77), patellofemoral joint ( = 0.66), medial tibiofemoral k k joint ( = 0.64), and anserine tenderness ( = 0.73); and excellent for effusion assessed by bulge sign k k k ( ω = 0.83), bony enlargement ( = 0.98), quadriceps wasting ( = 0.83), flexion (ICC = 0.99), and extension (ICC = 0.96) ROM. Conclusion. Among individuals with symptomatic knee OA, the reliability of clinical examination of the knee was at least good for the majority of clinical signs of knee OA. (First Release October 1 2016; J Rheumatol 2016;43:2171–8; doi:10.3899/jrheum.150835) Key Indexing Terms: KNEE OSTEOARTHRITIS CLINICAL TESTS INTEROBSERVER RELIABILITY INTRAOBSERVER RELIABILITY From the Arthritis Research UK Centre for Epidemiology, Institute of Manchester Musculoskeletal Biomedical Research Unit, Central Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester NHS Foundation Trust, MAHSC, and Department of Manchester Academic Health Science Centre (MAHSC), University of Physiotherapy, Salford Royal NHS Foundation Trust; M.J. Callaghan, Manchester; UK National Institute for Health Research (NIHR) PhD, Arthritis Research UK Centre for Epidemiology, Institute of Manchester Musculoskeletal Biomedical Research Unit, Central Inflammation and Repair, Faculty of Medical and Human Sciences, Manchester National Health Service (NHS) Foundation Trust, MAHSC, MAHSC, University of Manchester, and NIHR Manchester Manchester; Department of Physiotherapy, and Department of Musculoskeletal Biomedical Research Unit, Central Manchester NHS Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK; Foundation Trust, MAHSC; M.J. Parkes, BSc (Hons), Arthritis Research Clinical Epidemiology Unit, Boston University School of Medicine, UK Centre for Epidemiology, Institute of Inflammation and Repair, Boston, Massachusetts, USA. Faculty of Medical and Human Sciences, MAHSC, University of Funded by Arthritis Research UK grant 20380, and special strategic Manchester, and NIHR Manchester Musculoskeletal Biomedical Research award grant 18676. The funding agency had no role in any of the Unit, Central Manchester NHS Foundation Trust, MAHSC; D.T. Felson, following: design and conduct of the study; collection, management, MD, MPH, Arthritis Research UK Centre for Epidemiology, Institute of analysis, and interpretation of the data; and preparation, review, or Inflammation and Repair, Faculty of Medical and Human Sciences, approval of the manuscript; and the decision to submit the manuscript for MAHSC, University of Manchester, and NIHR Manchester publication. This report includes independent research supported by (or Musculoskeletal Biomedical Research Unit, Central Manchester NHS funded by) the NIHR Biomedical Research Unit Funding Scheme. The Foundation Trust, MAHSC, and Clinical Epidemiology Unit, Boston views expressed in this publication are those of the author(s) and not University School of Medicine; T.W. O’Neill, MB, BCh, BAO, Arthritis necessarily those of the NHS, the NIHR, or the Department of Health. The Research UK Centre for Epidemiology, Institute of Inflammation and Research in Osteoarthritis Manchester group is supported by the MAHSC. Repair, Faculty of Medical and Human Sciences, MAHSC, University of N. Maricar is supported by an NIHR Allied Health Professional Clinical Manchester, and NIHR Manchester Musculoskeletal Biomedical Research Doctoral Fellowship. Unit, Central Manchester NHS Foundation Trust, MAHSC, and N. Maricar, BSc (Hons), MSc, PhD, Arthritis Research UK Centre for Department of Rheumatology, Salford Royal NHS Foundation Trust. Epidemiology, Institute of Inflammation and Repair, Faculty of Medical Address correspondence to Dr. N. Maricar, University of Manchester, and Human Sciences, MAHSC, University of Manchester, NIHR Arthritis Research UK Centre for Epidemiology, Institute of Inflammation Personal non-commercial use only. The Journal of Rheumatology Copyright © 2016. All rights reserved. Maricar, et al: Reliability of OA knee tests 2171 Downloaded on October 7, 2021 from www.jrheum.org and Repair, Faculty of Medical and Human Sciences, MAHSC, Manchester downstroke = 1, spontaneously returned to medial side after upstroke = 2, M13 9PT, UK. E-mail: [email protected]; so much fluid that it was not possible to move the effusion out of the medial [email protected] aspect of the knee = 3)4. The examination also included assessment of Full Release Article. For details see Reprints/Permissions at jrheum.org effusion using the ballottement test [absent = 0, present without click = 1, Accepted for publication August 31, 2016. present with click (tap) = 2], and the following, all scored absent = 0, present = 1: patellofemoral joint tenderness, pes anserine tenderness, medial tibiofemoral joint tenderness, and lateral tibiofemoral joint tenderness. Clinical assessment of the knee forms an integral part of any Goniometric knee range of movement (ROM) assessment included flexion joint examination in osteoarthritis (OA) and includes a and extension, measured to the nearest degrees14. Assessments were under- variety of specific clinical tests including assessment of taken prior to the participants having their steroid injections. Description of tenderness1,2,3, presence of effusion4,5,6,7,8 or bony enlarge- the assessment and outcome categories is available from the authors on ment1,3,9, muscle atrophy9, and crepitus2,9. As with any request. clinical test, clinical examination of the knee is subject to Interobserver reliability assessment. An opportunity sample of 25 unselected participants who presented at the screening visit of the TASK study was measurement error. There are, however, few studies that have assessed independently by 2 observers (TON, NM), typically within a formally measured reliability in the assessment of common 30-min to 60-min interval between each other’s assessment. One was an clinical signs for knee OA and in those studies that have experienced rheumatologist (TON) and the other (NM) was an Advanced reported reliability, findings have been somewhat incon- Musculoskeletal (MSK) Practitioner (senior physiotherapist) with more than sistent2,3,4,9,10,11,12. Some contributing factors to the incon- 15 years of experience in MSK. The assessors were blinded to each other’s assessments, and the examination findings were recorded on different sistency include lack of clarity and uniformity in the 2,3,4,9,10,11,12 summary sheets. During the clinical examination, the individual clinicians assessment procedures and the grading criteria . performed each test a few times as needed for a consistent recording. For Reliable clinical assessment is important, because poor relia- instance, during the performance of bulge sign, the sequence (the upstroke bility may result in misclassification in clinical and research on the medial aspect of the knee followed by the downstroke on the lateral studies of knee OA and reduce the chance of finding clini- aspect of the knee) could be repeated a few times when attempting to observe reappearance of fluid. cally important biological associations between clinical Intraobserver reliability assessment. features of the disease and outcome or response to therapy. An opportunity sample of 88 unselected subjects who attended the screening and baseline visits of the TASK study The aim of our study was to determine intraobserver and was assessed for intraobserver reliability. One assessor (NM) undertook a interobserver reliability for commonly used clinical tests in single repeat clinical assessment of the 88 subjects separated by an interval the assessment of knee OA. of between 2 to 10 weeks, prior to their steroid injections. It
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