Practitioner Seed #7 – Test Don’t Guess!

Objectivity is the concept of truth independent from individual subjectivity (bias caused by one’s perceptions, emotions of imagination).

Whether we like it or not, we all have individual biases when it comes to clinical practice. The ‘Recency Bias’ is one that over the years, I have encountered on a regular basis!

If you are reading this, you are very eager to learn and become the best clinician that you can be! This manifests as an investment into learning in your first years out of uni – Courses, podcasts, research articles  – Learning new techniques and exercises.

When you hit the clinic on the Monday morning after that weekend manips course, every patient must need a HVLA thrust!

Everything seems like a square peg for a square hole!

The variability that presents in the human condition, often makes it difficult to remain objective.

Joint end feel & palpation of muscle tone are 2 valuable pieces of the assessment puzzle, that lack objectivity. As a new graduate your experience for detecting changes in these qualities is quite weak, so we need to be thinking about quantifiable objective metrics.

Take knee joint effusion measurement for example – We use sweep test, patella tap test or the balloon sign – then grade as mild, moderate or severe. Maricar et al (2016) have highlighted very poor intra & interrater reliability, however they do report that clinical experience seems to improve reliability. Measuring the knee circumference might be a solution provided the test is standardised to position on the patella.

The ‘old school’ goniometer has been superseded by it’s tech savvy equivalent in the tilt-meter & i level. Great for measuring hip flexion ROM, passive straight leg raise and MHFAKE.

The evolution of testing muscle force has seen hand held dynamometry progress toward fixed dynamometry. While Thorborg et al (2010) highlighted the reliability of HHD testing, inherent issues in set up & operator strength has meant that fixed system dynamometry has taken the mantle.

Sophisticated systems such as the Vald force frame & Kangatech are now commonplace in elite sporting organisations. Ryan et al (2018) have shown that the Vald force frame is reliable in measuring adductor strength in AFL footballer with a measurement error (CV) of 6.3%.

Peak force is a simple dynamometer that we use in our clinic to measure force.

Watch here to learn how to set up an objective hip strength test

The gold standard here is force plate testing, however in most clinical settings this resource is not readily available.

The MyJump app has been proven to be reliable and valid compared to force plates, when measuring contact times during a drop jump from a 20cm platform. If you have been following our series on RFD, you will know that anything <250ms ground contact time, is considered excellent.

For upper limb testing, the Athletic Shoulder Test (ASH test) has been shown to be a reliable testing method, with ICC 0.94-0.98, CV <10% and MDC 13.2- 25.9N (Ashworth et al, 2018). Limitations here include the testing of isometric force only. As shoulder instability episodes occur under high speed conditions ie sudden forceful shoulder extension or horizontal flexion, it would be suitable to gain some accurate measurements around RFD.

If we have access to force plates, we can dig down into the weeds of eccentric RFD, impulse, contact time, concentric RFD. Key metrics that might tell a story about ability to produce and distribute forces efficiently.

Now………………………..

We suggest that you aim to identify 3 key objective measures for each patient, that you:

Measure

Intervene

Re-measure periodically (ie every 6-8 weeks)

This is in addition to your 1-2 asterisk tests that are usually pain provocation tests that are tracked session to session.

In this way, you are gaining patient buy in while communicating the truth about the individuals improvements or deterioration in key areas relating to their injury.

&

We are keeping the insurance companies happy, while leaning into the morality of providing the truth underlying our patients rehabilitation!

Reference:

Maricar, N., Callaghan, M. J., Parkes, M. J., Felson, D. T., & O’Neill, T. W. (2016). Clinical assessment of effusion in knee osteoarthritis-A systematic review. Seminars in arthritis and rheumatism, 45(5), 556–563. https://doi.org/10.1016/j.semarthrit.2015.10.004.

Thorborg K, Petersen J, Magnusson SP, Hölmich P. Clinical assessment of hip strength using a hand-held dynamometer is reliable. Scand J Med Sci Sports. 2010 Jun;20(3):493-501.

Samuel Ryan, Thomas Kempton, Emidio Pacecca and Aaron J Couttsa. (2018).Measurement Properties of an Adductor Strength Assessment System in Professional Australian Footballers. International Journal of Sports Physiology and Performance. DOI: https://doi.org/10.1123/ijspp.2018-0264.

Haynes, Tom & Bishop, Chris & Antrobus, Mark & Brazier, Jon. (2018). The validity and reliability of the My Jump 2 app for measuring the reactive strength index and drop jump performance. The Journal of sports medicine and physical fitness. 59. 10.23736/S0022-4707.18.08195-1.