The mission of CPA’s Orthopaedic Division is the physiotherapy through the Alan Morgan Fund
advancement of Orthopaedic physiotherapy through the (administered by the Physiotherapy Foundation of
promotion of excellence in education, practice and Canada), has an active web site, and produces five issues of
research. Having developed a standardized system of post the Orthopaedic Division Review Annually.
graduate orthopaedic education, members have access to
discounted courses and the opportunity to achieve a Scott Anderson, Chair
diploma in manipulative therapy, as well as access to the orthopaedics@physiotherapy.ca
national orthopaedic symposium held annually. The Further information available at
Division also supports research in the field of orthopaedic http://www.physiotherapy.ca/divisions.htm
Peter Huijbregts, PT, MSc, MHSc, DPT, OCS, CGIMS, FAAOMPT, FCAMT
* Assistant Professor Online Education, University of St. Augustine for Health Sciences; * Residency Coordinator/Mentor, OMPT
Residency Program Shelbourne Physiotherapy Clinic; * Consultant Physiotherapist, Shelbourne Physiotherapy Clinic Michelle
Hobby, BA, MPT
* Resident, OMPT Residency Program Shelbourne Physiotherapy Clinic; * DPT Student, University of St. Augustine for Health Sciences
Penny Salmas, BPE, BSc PT, RCAMT, CGIMS
* Mentor, OMPT Residency Program Shelbourne Physiotherapy Clinic; * Owner/Physiotherapist, Shelbourne Physiotherapy Clinic
Introduction treatment planning within the EBP paradigm, the data they
Physiotherapists establish a diagnosis and a prognosis by yield need to be reliable, valid, and responsive to clinically
way of history taking, systems review, and tests and relevant change1. In the clinical scenario introduced above
measures1. The data collected in these processes are used to of a patient presenting to physiotherapy with signs and
determine whether the patient will benefit from symptoms indicative of a scaphoid fracture, the question
physiotherapy intervention or needs to be referred for (co-) the physiotherapist needs to answer is, when is the
management with another health care provider. A patient probability of a scaphoid fracture high enough to warrant
presenting to physiotherapy with an undiagnosed fracture is referral to a physician? Knowledge of the statistical
not only a prime example illustrating the need for referral to measures associated with reliability and concurrent
a medical physician, but also a plausible scenario in criterion-related validity of available diagnostic tests is a
jurisdictions where physiotherapists are allowed to act as prerequisite to answer this question based on research
direct access health care providers. The British Columbia evidence.
Health Professions Act2 clearly limits physiotherapy scope The goal of this article is threefold:
of practice disallowing treatment of a recent fracture, ● To discuss the process of evidence-based diagnosis
except when under physician direction and, therefore, signs
and symptoms indicative of a scaphoid fracture constitute a
● To discuss the statistical measures associated with
clear indication for referral to a physician in this prvince reliability and concurrent criterion-related validity of
(and likely also in other jurisdictions). diagnostic tests and measures
Evidence-based practice (EBP) represents a recent and ● To illustrate evidence-based diagnosis (and the use of
major paradigm shift within medicine and allied health statistical measures of reliability and validity) using the
education and clinical practice from a reliance on example of a patient with a suspected scaphoid fracture
authority-based knowledge and anecdotal evidence to the Statistical measures of reliability
use of research-based evidence. However, research is not Reliability of a diagnostic test has two aspects. Intra-rater
the sole component of EBP: Sackett et al3 defined evidence- reliability refers to the stability of measurements taken by
based medicine as the process of integrating the best one rater across two or more trials; inter-rater reliability is
research evidence available with both clinician expertise concerned with the level of agreement between findings of
and patient values. For history items and tests and measures two or more raters measuring the same subject or group of
to be clinically useful for diagnosis, prognosis, and subjects4. Statistical measures used in research to establish
Accuracy The proportion of people who were correctly (TP + TN) / (TP + FP + FN + TN)
identified as either having or not having the
disease or dysfunction
Sensitivity The proportion of people who have the TP / (TP + FN)
disease or dysfunction who test positive
Specificity The proportion of people who do not have TN / (FP + TN)
the disease or dysfunction who test negative
Positive predictive value The proportion of people who test positive TP / (TP + FP)
who have the disease or dysfunction
Negative predictive value The proportion of people who test negative TN / (FN + TN)
who do not have the disease or dysfunction
contained in the statistical measures of sensitivity and quantitative approach is provided in the reference by
specificity7. We can calculate likelihood ratios as follows: Davidson7, accessible full-text on the Internet.
● Positive LR = sensitivity / (1-specificity) Evidence-based diagnosis of scaphoid fractures
● Negative LR = (1-sensitivity) / specificity Evidence-based diagnosis makes use of the best
available research evidence into properties of demographic
A positive LR tells us how likely a positive test result is in data, history items, and tests and measures used for
patients that have a certain disease or dysfunction as diagnostic purposes. As an example of the use of data on
compared to how likely it is in patients who do not have the reliability and validity for the OMPT residency program at
disease or dysfunction. A negative LR provides information his clinical workplace, the first author did a search for full-
on how likely a negative test result is in patients with the text, peer-reviewed references using the key word scaphoid
disorder as compared to how likely it is in patients without on the Infotrac and Proquest databases available to
the disorder. students and faculty through the University of St. Augustine
Davidson7 provides simple guidelines on interpreting for Health Sciences.
likelihood ratios:
Demographic data
● The higher a positive LR, the more certain one can be Scaphoid fractures account for 75% of all carpal injuries
that a patient with a positive test has the disorder for in men aged 15-308,9 and for eight percent of all sports
which you are testing injuries8. The fracture is rare in children and elderly people:
● The lower a negative LR, the greater the chance that a children more frequently fracture the distal radial epiphysis
person with a negative test result does not have the with a fall on the outstretched wrist and older people will
disorder commonly fracture the distal radius10.
● A positive or negative LR close to 1.0 provides little History items
change in the probability that a patient has or does not The mechanism of injury for a scaphoid fracture is
have a disease or dysfunction, i.e., this test is of little frequently a fall on the extended wrist. For a fracture to
diagnostic value occur, a wrist extension of greater than 95° is required8. In
A LR can be used qualitatively, but it can also be used the controlled laboratory situation, scaphoid fractures have
quantitatively to express the effect a test result has on post- been produced with wrists in more than 90° of extension
test probability of a certain disorder. We can use a and more than 10° of radial deviation with in excess of
nomogram or a mathematical solution involving the 400(kg) of force9. However, flexion and compression
calculation of pre- and post-test odds to determine the effect mechanisms are described in the literature10. A description
on post-test probability. Further information on this of a rapid onset of swelling is indicative of haemarthrosis,