OBJECTIVE Although it is common to find assertions relating functional leg length inequality (LLI) to pelvic torsion and other states of subluxation, comments and/or data concerning anatomical LLI in this same context are uncommon. This review of the literature synthesizes the evidence on pelvic torsion in relation to anatomical LLI. METHODS The literature was searched using the PubMed; Manual, Alternative, and Natural Therapy Index System; Allied and Complementary Medicine Database; Cumulative Index to Nursing and Allied Health Literature; and Index to Chiropractic Literature databases for primary studies that related LLI, either artificially created or naturally occurring, to pelvic torsion. Extracted data included natural vs artificial LLI, method of creating or detecting LLI, subject selection, methodology for measuring pelvic torsion, and results. RESULTS Nine English-language studies were retrieved published 1936-2004. Seven determined the impact of artificial, transient LLI on pelvic torsion, whereas 2 studied the effect of naturally occurring LLI. CONCLUSION Across varying methodologies for measuring LLI and pelvic torsion, a consistent, dose-related pattern was identified in which the innominate rotates anteriorly on the side of a shorter leg and posteriorly on the side of the longer leg. This finding was contrary to the common assertion that the ilium rotates posteriorly on the side of a short leg and vice versa. Practitioners of manual medicine who derive vectors for intervention based on leg checking procedures should consider the possibility that the direction of pelvic torsion may be variable depending on whether the LLI is of anatomical or functional origin.

The use of accurate and reliable clinical and imaging modalities for quantifying leg-length discrepancy (LLD) is vital for planning appropriate treatment. While there are several methods for assessing LLD, we questioned how these compared. We therefore evaluated the reliability and accuracy of the different methods and explored the advantages and limitations of each method. Based on a systematic literature search, we identified 42 articles dealing with various assessment tools for measuring LLD. Clinical methods such as use of a tape measure and standing blocks were noted as useful screening tools, but not as accurate as imaging modalities. While several studies noted that the scanogram provided reliable measurements with minimal magnification, a full-length standing AP computed radiograph (teleoroentgenogram) is a more comprehensive assessment technique, with similar costs at less radiation exposure. We recommend use of a CT scanogram, especially the lateral scout view in patients with flexion deformities at the knee. Newer modalities such as MRI are promising but need further investigation before being routinely employed for assessment of LLD. Level of Evidence: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

INTRODUCTION Femoral overgrowth is a recognised phenomenon following fractures of the femoral diaphysis in children. This study was designed to assess leg length discrepancy (LLD) following elastic stable intramedullary nailing (ESIN) and its clinical significance. MATERIALS AND METHODS A retrospective review of children who underwent ESIN with DePuy ACE Nancy nails between 1997 and 2001 for diaphyseal femoral fractures. Evaluation was by questionnaire, clinical examination and radiological measurement. RESULTS 17/26 (65%) patients were followed up for a mean time of 48 months (21-77). Average age at surgery was 9 years. Mean operative time was 78 min with a mean hospital stay of 7.8 days. Mean time to union was 10 weeks. A statistically significant LLD of +3.2 mm is demonstrated in children aged 4-8 years (P = 0.05). LLD is not statistically significant in children over 8 years. CONCLUSION ESIN is a successful treatment for paediatric diaphyseal femoral fractures and allows early mobilisation and discharge. A statistically significant LLD is observed in children aged 4-8 years although clinically only one patient in the entire series was aware of a leg length discrepancy. In addition clinical methods of leg length measurement are sensitive for LLD and we conclude that routine radiographic follow up is not necessary unless clinically indicated.

We present the outcome of non-operative management of fractures of the shaft of the femur in children. Thirty children with non-operatively managed unilateral fractures of the shaft of the femur were studied. The mean age was 6.5 years (range: 1.2 to 12). Axial, angular and rotational malunion were assessed clinically and radiologically by plain films and computed tomography (CT). All children had shortening of the fractured limb with a mean shortening of 1.8 cm (range: 0.5 to 3.5). A significant level of shortening was seen in children over 7 years. In the sagittal plane, all had anterior angulation ranging from 4 degrees to 31 degrees (mean: 17.8 degrees) and in the coronal plane, lateral angulation (varus) was seen in 90%(27 patients) with a mean angle of 8.9 degrees. Rotational malunion ranged from -43 degrees to +43 degrees (mean: 9.5 degrees), 30% had rotational malunion of > 20 degrees compared to the uninjured side; 73% had internal rotation malunion and 27% had external rotation malunion. We conclude that non-operative management of fractures of the shaft of the femur in children often results in malunion at the fracture, particularly in the older age group and in comminuted fractures. Perhaps a longer follow-up might have shown lower levels of malunion. Frequent monitoring of fracture position may reduce the occurrence of deformity. It may be appropriate to consider reduction and operative stabilisation of such fractures whenever neces-

BACKGROUND Part II of this review examines the functional "short leg" or unloaded leg length alignment asymmetry, including the relationship between an anatomic and functional leg-length inequality. Based on the reviewed evidence, an outline for clinical decision making regarding functional and anatomic leg-length inequality will be provided. METHODS Online databases: Medline, CINAHL and Mantis. Plus library searches for the time frame of 1970-2005 were done using the term "leg-length inequality". RESULTS AND DISCUSSION The evidence suggests that an unloaded leg-length asymmetry is a different phenomenon than an anatomic leg-length inequality, and may be due to suprapelvic muscle hypertonicity. Anatomic leg-length inequality and unloaded functional or leg-length alignment asymmetry may interact in a loaded (standing) posture, but not in an unloaded (prone/supine) posture. CONCLUSION The unloaded, functional leg-length alignment asymmetry is a likely phenomenon, although more research regarding reliability of the measurement procedure and validity relative to spinal dysfunction is needed. Functional leg-length alignment asymmetry should be eliminated before any necessary treatment of anatomic LLI.

BACKGROUND AND PURPOSE Most patients with hip fracture do not return to prefracture functional status 1 year after surgery. The literature describing interventions, however, does not use classic overload and specificity principles. The purpose of this case report is to describe the use of resistance training to improve functional outcomes in a patient following hip fracture. CASE DESCRIPTION The patient was a 68-year-old woman who had a comminuted intertrochanteric fracture of the left hip 3 months previously. She used a cane for ambulation, and her walking was limited. The patient received 16 sessions of lower-extremity strengthening exercises, aerobic training on a stationary bicycle, functional training supervised by a physical therapist, and a home stretching program. OUTCOME The patient's isometric muscle force for involved hip extension, hip abduction, and knee extension improved by 86%, 138%, and 33%, respectively; walking endurance increased by 22.5%; balance improved by 400%; balance confidence increased by 41%; and self-reported ability to perform lower-extremity functional activities increased by 20%. DISCUSSION The authors believe that some patients can perform comprehensive exercise programs after hip fracture and that properly designed programs can affect patient outcomes beyond observed impairments.

INTRODUCTION Femoral shaft fractures treated with intramedullary nailing often heal with a leg length discrepancy (LLD). LLD is commonly evaluated by clinical examination and computed tomography (CT) scanogram. We assessed the correlation between these two techniques of calculating LLD. METHODS We reviewed 35 skeletally mature patients who sustained a femoral shaft fracture between January 1997 and December 1999. Leg length was measured clinically with direct measurement and a block test. Each patient was asked whether they felt they walked with a limp and whether they felt they had a leg length discrepancy. Each patient underwent a CT scanogram to measure femoral and total leg length. The correlation between clinical examination and scanogram was analysed using the Pearson Product Moment Correlation. RESULTS Of the 35 patients, 15 patients (43%) had a measurable LLD. There was a positive correlation between direct leg length measurement and the block test (P = 0.003), and between the block test and patient perception of limp and LLD. CT scanogram was performed on 29/35 patients. There was no correlation between CT scanogram and clinical measurement of leg length or between CT scanogram and patient perception of LLD or limp. DISCUSSION Leg length discrepancy commonly occurs following treatment of femoral shaft fractures. We found that there was a strong correlation between direct leg length measurement and the block test, and between both methods of clinical leg length measurement and patient perception of a limp or LLD. Our study found no correlation between CT scanogram and clinical leg length measurement or patient perception of limp or LLD. CONCLUSION Our study shows that physical examination (direct measurement and the block test) is more reliable and clinically relevant than CT scanogram measurement in the assessment of LLD after femoral fracture.

OBJECTIVE To determine the accuracy of instrumented prone compressive leg checking. DESIGN Repeated measures (n = 26) on single subjects (n = 3). SETTING Chiropractic college research clinic. METHODS A pair of surgical boots were modified to permit continuous measurement of leg-length inequality (LLI). Multiple prone leg-check observations of a blinded examiner on 3 subjects were tested against artificial LLI that was created by randomly inserting 0 to 6 1.6-mm shims in either boot. Accuracy was assessed both within observations (observed versus artificial LLI) and between observations (observed versus artificial changes in LLI). The intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC), Bland-Altman limits of agreement, and linear regression statistics were obtained to determine the reliability and validity of compressive leg checking compared to a reference standard. RESULTS For each shim condition, test-retest reliability was excellent (ICC =.85 and CCC = 0.95). The 95% confidence interval for the limits of agreement for observed versus artificial change in LLI was -5.44 to 5.67. The observed and artificial LLI shared 87% of their variation within observations (n = 78) and 88% between observations (n = 75). The mean examiner error was 1.72 mm and 2.01 mm, respectively. CONCLUSION Compressive leg checking seems highly accurate, detecting artificial changes in leg length +/-1.87 mm, and thus possesses concurrent validity assessed against artificial LLI. Pre-leg-check and post-leg-check differences should exceed 3.74 mm to be confident a real change has occurred. It is unknown whether compressive leg checking is clinically relevant.

Gold-coated horizontally aligned carbon nanotube (Au-HA-CNT) substrates were fabricated for surface-enhanced Raman spectroscopy (SERS). The Au-HA-CNT substrates, which are granular in nature, are easy-to-prepare with large SERS-active area. Enhancement factors (EFs) of ∼10(7) were achieved using the Au-HA-CNTs as substrates for rhodamine 6G (R6G) molecules. Maximum enhancement was found when the polarization direction (E-field) of the incident laser beam was parallel to the aligned direction of the HA-CNTs. Simulations using the finite-difference time-domain (FDTD) method were carried out for the granular Au-HA-CNT samples. Enhancement mechanisms and determination of EFs were analyzed. Biological samples, including (13)C- and deuterium (D)-labeled fatty acids and Coccomyxa sp. c-169 microalgae cells, were also measured using this SERS substrate. The limits of detection (LODs) of D- and (13)C-labeled fatty acids on the SERS substrate were measured to be around 10 nM and 20 nM, respectively. Significantly enhanced Raman signals from the microalgae cells were acquired using the SERS substrate.

BACKGROUND Obesity and related conditions, notably subfertility, are increasingly prevalent. Paternal influences are known to influence offspring health outcome, but the impact of paternal obesity and subfertility on the reproductive health of subsequent generations has been overlooked. METHODS A high-fat diet (HFD) was used to induce obesity but not diabetes in male C57Bl6 mice, which were subsequently mated to normal-weight females. First-generation offspring were raised on a control diet and their gametes were investigated for signs of subfertility. Second-generation offspring were generated from both first generation sexes and their gametes were similarly assessed. RESULTS We demonstrate a HFD-induced paternal initiation of subfertility in both male and female offspring of two generations of mice. Furthermore, we have shown that diminished reproductive and gamete functions are transmitted through the first generation paternal line to both sexes of the second generation and via the first generation maternal line to second-generation males. Our previous findings that founder male obesity alters the epigenome of sperm, could provide a basis for the developmental programming of subfertility in subsequent generations. CONCLUSIONS This is the first observation of paternal transmission of diminished reproductive health to future generations and could have significant implications for the transgenerational amplification of subfertility observed worldwide in humans.

OBJECTIVE: Adequate fluid intake has been well documented as important for health but whether it has adverse effects on overall energy and sugar intakes remains under debate. Many dietary studies continue to refrain from reporting on beverage consumption, which the present study aimed to address. DESIGN: A cross-sectional survey investigated self-reported measures of dietary intake and anthropometric measurements. SETTING: Primary and secondary schools in south-west London, UK. SUBJECTS: Boys and girls (n 248) aged 9-13 years. RESULTS: Boys consumed 10 % and girls consumed 9 % of their daily energy intake from beverages and most children had total sugar intakes greater than recommended. Beverages contributed between a quarter and a third of all sugars consumed, with boys aged 11-13 years consuming 32 % of their total sugar from beverages. There was a strong relationship between consumption of beverages and energy intake; however, there was no relationship between beverage type and either BMI or BMI Z-score. Fruit juices and smoothies were consumed most frequently by all girls and 9-10-year-old boys; boys aged 11-13 years preferred soft drinks and consumed more of their daily energy from soft drinks. Milk and plain water as beverages were less popular. CONCLUSIONS: Although current health promotion campaigns in schools merit the attention being given to improving hydration and reducing soft drinks consumption, it may be also important to educate children on the energy and sugar contents of all beverages. These include soft drinks, as well as fruit juices and smoothies, which are both popular and consumed regularly.

BACKGROUND & AIMS Malnutrition can increase morbidity or mortality and hospitalization may further increase the risk of nutritional deterioration. This study aimed to assess the prevalence of malnutrition and nutritional risk in hospitalized children and to identify any associated factors. METHODS Nutritional status and risk was defined in 157 hospitalized children using anthropometry and a nutritional risk score (NRS). RESULTS The frequency of wasted, stunted, overweight and obese children was 4.5%, 8.9%, 15.1% and 10.4% respectively. Half (52.6%) of the undernourished children were aged less than 2 years of age. Forty-eight percent of the overweight or obese children were aged between 10 and 18 years of age. Based on their NRSs, 47.8% of the children assessed were at high risk of nutritional deterioration whereas 28.7% were at no nutritional risk. Children with higher nutritional risk scores had lower weight for age (p=0.02), lower BMI percentiles (p=0.001) and longer hospitalization (p=0.001) than children at no risk. CONCLUSIONS One quarter of these hospitalized children were overweight or obese. NRSs identified a group of children at increased risk of nutritional deterioration who subsequently had longer hospital stays. Use of NRSs at admission can identify children requiring focused nutritional assessment.

INTRODUCTION The work activities of an Intensive Care Unit (ICU) nurse is frequently dynamic and variable. The activities are not necessarily linear actions that occur in a structured manner but are more complex and not well documented. A greater understanding of the type and level of activity assists in informing workload models. OBJECTIVE The aim of this study was to describe and analyse the work activities of bedside Intensive Care Unit (ICU) nurses during the day shift. METHODS Time and motion observational methodology was used to observe 10 bedside ICU nurses during the day shift, Monday to Friday. All activities undertaken by the nurses during their shift were timed and recorded and then were coded according to whether they involved direct or indirect patient activities, or were unit or personally related. RESULTS Just over 76h of observations occurred over 10 days and 3081 activities documented during this time. The major work activity groups for the ICU nurses were;'direct care' 1857 activities and 40.5% of their time,'indirect care' 986 activities and 32.4% of their time,'personal' activities 140 activities and 21.9% of their time and 'unit-related' 98 activities and 5.0% of their time. The ICU nurses undertook two activities simultaneously for 43% of the study timeframe. CONCLUSION This study provides baseline evidence on the activities nurses undertake on a daily basis, with only about a quarter of their time not being spent on patient care activities, either directly or indirectly.

Supplementing diets with n-3 fatty acids from fish oil has been shown to improve reproductive performance in dairy cattle and sheep, but there is little published literature on its effects in sows. The aim of this study was to evaluate the reproductive performance of sows fed fish oil as a source of n-3 PUFA prefarrowing and during lactation. From d 107.7 ± 0.1 of pregnancy, 328 sows ranging in parity from 0 to 7 (parity 1.95 ± 0.09, mean ± SE) were fed either a diet containing tallow (control) or an isocaloric diet containing 3 g of fish oil/kg of diet (n-3). Diets were formulated to contain the same amount of DE (13.9 MJ/kg), crude fat (54 g/kg), and CP (174 g/kg). Sows were fed their treatment diet at 3 kg daily for 8 d before farrowing and continued on treatment diets ad libitum until weaning at 18.7 ± 0.1 d of lactation. After weaning, all sows were fed a gestation diet without fish oil until their subsequent farrowing. There was no effect (P > 0.310) of feeding n-3 diets prefarrowing on piglet birth weight, preweaning growth rate, piglet weaning weight, or sow feed intake. However, n-3 sows had a larger subsequent litter size (10.7 ± 0.3 vs. 9.7 ± 0.3 total born; 10.2 ± 0.3 vs. 9.3 ± 0.3 born live; P < 0.05). In conclusion, this is the first study to demonstrate that feeding sows a diet containing n-3 PUFA from fish oil fed before farrowing and during lactation increased litter size in the subsequent parity independent of energy intake.

Summary.  Factor XI (FXI) deficiency results from genetic defects of the F11 gene and is generally considered to be inherited in an autosomal recessive manner. However, the homodimeric structure of FXI allows, in some cases, the dominant-negative transmission of the disease. The aim of this study was to characterize novel missense mutations in three unrelated patients and verify the dominant-negative effects of these mutations on the secretion of wild-type FXI protein by expression studies. The F11 gene was PCR amplified, from genomic DNA extracted from peripheral blood, and sequenced on an ABI 3100 Genetic Analyzer. Human wild-type FXI and FXI mutants were expressed in BHK570 cells using Lipofectamin transfection reagents. Conditioned media and cell lysates were collected for the measurement of luciferase activity, FXI antigen and Western blot analysis. DNA sequencing revealed three novel missense F11 mutations; c.127G>A in exon 3 (Ala43Thr), c.723C>G in exon 7 (Phe241Leu) and c.1207G>A in exon 11 (Val403Met). In vitro expression studies showed that the mutation Ala43Thr, Phe241Leu or Val403Met remarkably decreased the extracellular secretion of mutant FXI, rather than reducing synthesis of the mutant proteins. Cotransfection of wild-type FXI with mutant FXI constructs indicated that the mutation Ala43Thr, Phe241Leu or Val403Met reduced the secretion of wild-type FXI by 75.9%, 68.6% or 71.4%, respectively. Our study suggests that dominant-negative mutations in FXI-deficient patients of non-Ashkenazi Jewish origin may be more prevalent than thought, resulting from FXI's unique dimeric structure.

Many mammals exhibit a periparturient relaxation of previously established immune responses (PPRI) to gastrointestinal nematodes culminating in increased worm burdens. It has been suggested that the extent of PPRI may have a nutritional basis as it is considerably augmented when protein supply is scarce. Subsequent studies have shown that increased dietary protein intake can ameliorate this phenomenon. However, this effect is often confounded with increased food intake and thus increased energy levels. Herein, we aimed to dissect the effects of protein and energy nutrition on the immune status and resistance to re-infection with gastrointestinal nematodes in the periparturient host. The lactating, Nippostrongylus brasiliensis re-infected rat was utilised as an established model for mammalian PPRI. Experimental animals were assigned to restricted feeding regimens designed to achieve four pre-determined levels of crude protein (CP) at one of two levels of metabolisable energy (ME) and parasitological and immunological measurements taken at either day 6 or day 9 post re-infection. We clearly show that increased supply of dietary CP, but not increased dietary ME, significantly reduced worm burdens. The increased magnitude of worm expulsion with increased dietary CP supply strongly correlated with mucosal mast cell accumulation in the small intestine. In addition, increased CP and not ME supply increased mucosal eosinophil numbers. Furthermore, increased CP led to higher levels of total IgG at high ME only and there were interactive effects of CP and ME on serum levels of IgG1 and IgG2a. Perhaps surprisingly, CP nutrition did not affect expression of either Th1 (IFN-γ) or Th2 (IL-4, IL-13) cytokines in the mesenteric lymph nodes. These data emphasise the role of immunonutrition, and particularly dietary protein, in combating infectious disease such as gastrointestinal parasitism.

Summary.  Defective hemostasis in haemophilia patients with FVIII inhibitors results in a dramatic decrease in thrombin generation forming unstable fibrin clots that are susceptible to fibrinolyisis. In this study we tested whether the combination of plasma derived activated prothrombin complex concentrate (pd-aPCC) with tranexamic acid (TXA) may improve fibrin clot stability in FVIII inhibitor plasma. A microplate assay for clot lysis time was used to assess clot stability in FVIII inhibitor plasma. The effect of pd-aPCC on clot stability was first tested using the commercial FVIII inhibitor plasma. TXA (5 ∼ 10 mg mL(-1)) increased clot lysis time, but pd-aPCC (0.25 ∼ 1.0 U mL(-1)) had no effect on it. The combination of pd-aPCC and TXA significantly increased clot lysis time compared with TXA alone. The effect appeared to be limited to fibrin clot resistance to fibrinolysis, as TXA was found to have no effect on thrombin generation induced by pd-aPCC. The effect of pd-aPCC and TXA on clot stability was then tested and verified in plasma samples from ten patients with severe haemophilia A and inhibitors. The combination of TXA (10 mg mL(-1)) and pd-aPCC (0.5 U mL(-1)) significantly increased clot lysis time compared to TXA alone. Our results suggest that the combination of pd-aPCC with TXA improves clot stability in FVIII inhibitor plasma without additional increases in thrombin generation.

The objective was to investigate the effects of moderate restriction of pre- and peri-pubertal liveweight gain on ovarian development and oocyte meiotic competence. At 70 d of age, and 27.7 ± 0.4 kg liveweight (LW), 64 Large White/Landrace crossbred gilts were allocated to two treatment groups (n = 32 gilts/treatment); one group was fed to attain a LW of 70 kg at 161 d of age (LIGHT), while the other group was fed to reach 100 kg LW (HEAVY). At 161 d of age, half of the gilts in each group (n = 16) were fed to gain LW at 0.5 kg/d (LOW), while the remaining half (n = 16) were fed to gain LW at 1.0 kg/d (HIGH) between 161 and 175 d of age, at which point they were killed and ovaries collected. For each gilt, surface antral follicles were counted and aspirated according to three size categories: 1-2.9 mm (small); 3-6 mm (medium); and > 6 mm (large). Follicles were pooled for each size class and treatment. Cumulus-oocyte-complexes (COC) recovered from small and medium follicles were matured in vitro (IVM) for 44 to 46 h, and meiotic maturation assessed. There was an effect of treatment (LIGHT versus HEAVY) on the number of medium sized follicles: 25.1 ± 2.59 versus 34.3 ± 2.60 (P < 0.05). The ovaries of LOW gilts had more small follicles and fewer medium follicles compared to those of HIGH gilts: 92.8 ± 8.35 versus 59.8 ± 5.24, and 25.1 ± 2.59 versus 32.5 ± 2.86 (P < 0.05). Target LW at 161 d did not affect meiotic progression of oocytes. However, LOW compared to HIGH LW gain between 161 and 175 d resulted in fewer oocytes reaching MII (0.40 versus 0.54; P < 0.05). In conclusion, moderately restricting feed intake impaired follicle growth beyond 3 mm and reduced oocyte meiotic competence. Further, although a carry-over effect of long-term feed restriction on follicle growth was evident, acute changes in feed intake during the 14 d prior to ovary collection had the greatest effect on oocyte nuclear maturation in vitro.

UNLABELLED Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:"; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"Times New Roman"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} STUDY DESIGN Controlled laboratory study. OBJECTIVES To investigate the reliability and concurrent validity of photographic measurements of hallux valgus angle compared to radiographs as the criterion standard. BACKGROUND Clinical assessment of hallux valgus involves measuring alignment between the first toe and metatarsal on weight-bearing radiographs or visually grading the severity of deformity with categorical scales. Digital photographs offer a noninvasive method of measuring deformity on an exact scale; however, the validity of this technique has not previously been established. METHODS Thirty-eight subjects (30 female, 8 male) were examined (76 feet, 54 with hallux valgus). Computer software was used to measure hallux valgus angle from digital records of bilateral weight-bearing dorsoplantar foot radiographs and photographs. One examiner measured 76 feet on 2 occasions 2 weeks apart, and a second examiner measured 40 feet on a single occasion. Reliability was investigated by intraclass correlation coefficients and validity by 95% limits of agreement. The Pearson correlation coefficient was also calculated. RESULTS Intrarater and interrater reliability were very high (intraclass correlation coefficients greater than 0.96) and 95% limits of agreement between photographic and radiographic measurements were acceptable. Measurements from photographs and radiographs were also highly correlated (Pearson r = 0.96). CONCLUSIONS Digital photographic measurements of hallux valgus angle are reliable and have acceptable validity compared to weight-bearing radiographs. This method provides a convenient and precise tool in assessment of hallux valgus, while avoiding the cost and radiation exposure associated with radiographs. J Orthop Sports Phys Ther 2012;42(7):642-648, Epub 25 January 2012. doi:10.2519/jospt.2012.3841.

BACKGROUND The evidence on the role of leg-length discrepancy (LLD) in low back pain (LBP) is contradictory, possibly due to the diversity of measurement methods. PURPOSE To assess the reliability of a laser-based ultrasound method and its agreement with the radiographic method. MATERIAL AND METHODS The measurement device consisted of a laser measure fixed to a rod holding the scanning head of the ultrasound and could be moved automatically by a linear actuator. The reliability of the measurement was evaluated using 20 healthy voluntary subjects with no known previous LLD (90% women, mean age 23 years). We assessed the agreement of the ultrasound method with a radiographic LLD measurement using 19 voluntary patients (95% men, mean age 38 years), who had had radiographic LLD measurements taken during the previous year. We used intraclass correlation co-efficients (ICC) and Bland & Altman analysis in the statistical analysis. RESULTS The ICC value for agreement between methods was 0.97 (95% confidence intervals [CI] 0.93-0.99) indicating almost perfect agreement. The ICC values for both raters indicated almost perfect agreement between repeated measurements (ICC 0.996 and 0.994, respectively). In the Bland and Altman analysis, the mean difference was close to zero (0.56 mm and 0.40 mm), indicating minimal systematic error. CONCLUSION The ultrasound-laser technique is quick and easy to perform. Both reliability and agreement with the radiographic method are excellent. The ultrasound measurement is non-invasive and therefore a potential alternative to radiographic methods in the evaluation of LLD.

OBJECTIVES To examine the intrarater and interrater reliability and agreement of the Danish version of the Dynamic Gait Index (DGI) in hospitalized and community-dwelling older people with balance impairments. DESIGN Reliability study. SETTING University hospital and outpatient rehabilitation. PARTICIPANTS A convenience sample of older people (≥65y); 24 subjects from a hospital and 24 from an outpatient rehabilitation center. All subjects had either 1 or more falls within the last year or balance impairments evaluated by a physical therapist. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All subjects carried out the DGI twice with a 1.5-hour interval. Each subject was rated by 3 physical therapists in the first attempt (1 for intrarater and 2 for interrater comparison) and by the intrarater in the second attempt, in both settings. The reliability was calculated using the intraclass correlation coefficient (ICC, 2.1), while agreement was calculated as the smallest real difference (SRD). RESULTS The ICC for intrarater and interrater reliability of the total DGI was .90 and .92 at the hospital, while the SRD was 2.72 and 2.58 points, respectively. Correspondingly, the ICC for intrarater and interrater reliability of the total DGI at the rehabilitation center was .89 and .82, while the SRD was 3.49 and 3.99 points, respectively. CONCLUSIONS The intrarater and interrater reliability of the total DGI ranged from good to excellent in hospitalized and community-dwelling older people. Improvements of 3 and 4 DGI points for hospitalized and community-dwelling older people, respectively, should be regarded as a real change (with a 95% certainty).

This study determined reliability and concurrent validity of measurements of the single leg squat made by novice examiners. Twelve video recordings of individuals performing a single leg squat were evaluated by six student physical therapists. Students assessed movement quality on an ordinal scale and manually measured frontal plane knee movement quantity on a video monitor. Inter- and intrarater reliability of ordinal scale ratings were determined via quadratically weighted kappa. Inter- and intrarater reliability of frontal plane knee measures were determined through intraclass correlation coefficient models 2,k and 3,k (k = 3 ratings), respectively. Concurrent validity of frontal plane knee measures was examined by comparison with Vicon-Peak motion-tracking system measures via Bland-Altman scatterplots. Ordinal scale measures displayed intrarater reliability ranging from 0.38 to 0.94 and interrater reliability of 0.68 (0.46-0.87). Intrarater reliability of frontal plane knee measures ranged from 0.88 to 0.98 and interrater reliability of 0.99 (0.97-1.00). Difference scores between student and computer-generated measures of frontal plane knee movement were significantly different as determined through Bland-Altman scatterplots and calculation of the upper and lower limits of agreement.

BACKGROUND: Early discharge from a rehabilitation center is only possible, if patients are able to do basic transfers independently (e.g., get up from bed and walk to the toilet). Against this background, the Lie-to-Sit-to-Stand-to-Walk Transfer (LSSWT) test was developed in order to quantify complex transfer abilities in older adults. This study was to evaluate the reliability and validity of this instrument. MATERIAL AND METHODS: A total of 24 older patients (80.25±8.10 years) of a geriatric rehabilitation unit performed the LSSWT test. Expert ratings were used to measure criterion validity. The Timed Up & Go test (TUG) was administered to assess construct validity. Furthermore, the time score of the LSSWT test was correlated with the Trunk Control Test (TCT), balance performance, the Chair Stand Test (CST) and gait speed. Intra- and interrater reliability were measured, conducting the LSSWT test on consecutive days. RESULTS: The coefficients of correlation between the LSSWT test and the expert ratings as well as the TUG test were r=-0.82 and r=0.83, respectively. Furthermore, the association with the TCT, balance, CST, and gait speed were r=-0.51, r=-0.45, r=0.47, and r=-0.72, respectively. The results of intrarater reliability and interrater reliability were ICC=0.96 and ICC=0.77, respectively. CONCLUSION: The study shows that the LSSWT test is a valid measure for quantifying difficulties in transfer abilities of patients during geriatric rehabilitation. The good correlation between LSSWT test and TUG test indicates good construct validity, but also that the LSSWT test provides additional information. Interrater reliability was moderate; therefore, the training of the supervisors should be re-evaluated. Further research is needed to establish cut-off values for discharge decision and to analyze the use of the LSSWT test in different subgroups.

Radiographs are the main outcome measure in epidemiological studies of osteoarthritis (OA). Ultrasound imaging has unique advantages in that it involves no ionising radiation, is easy to use and visualises soft tissue structures. Our objective was to measure the inter-rater reliability and validity of ultrasound imaging in the detection of features of knee OA. Eighteen participants from a community cohort, had both knees scanned by two trained musculoskeletal sonographers, up to six weeks apart. Inter-rater reliability for osteophytes, effusion size and cartilage thickness was calculated by estimating Kappa (κ) and Intraclass correlation coefficients (ICC), as appropriate. A measure of construct validity was determined by estimating κ between the two imaging modalities in the detection of osteophytes. Reliability: κ for osteophyte presence was 0.77(right femur), 0.65(left femur) and 0.88 for both tibia. ICCs for effusion size were 0.70(right) and 0.85(left). Moderate to substantial agreement was found in cartilage thickness measurements. Validity: For osteophytes, κ was moderate to excellent at 0.52(right) and 0.75(left). Substantial to excellent agreement was found between ultrasound observers for the presence of osteophytes and measurement of effusion size; it was moderate to substantial for femoral cartilage thickness. Moderate to substantial agreement was observed between ultrasound and radiographs for osteophyte presence.

Though seemingly an easy procedure to perform, there is no universally accepted approach to the measurement of waist circumference (WC) in the clinical setting. Measurement of WC can be affected by a myriad of factors including patient movement or position changes, poor positioning of the measuring tape or differences in tension applied to the tape by the clinician. Changes in any one of these factors can reduce the validity and reliability of the measurement. This is of particular importance in clinical trials where changes in WC represent a therapeutic endpoint. Recognition of the need for a more standardized and reliable means to perform WC measurement led to the development of a novel, validated technique. The Height of Iliac Crest (HIC) method uses a standardized technique that increases the reliability of measurement by minimizing some of the weaknesses and variations of previous methods. The purpose of the following study was to validate the accuracy and reproducibly of the HIC method for obtaining WC measurement data. This study demonstrates that accurate and reproducible results can be obtained through the application of the HIC method for measuring waist circumference.

Vertical jump is one of the most prevalent acts performed in several sport activities. It is therefore important to ensure that the measurements of vertical jump height made as a part of research or athlete support work have adequate validity and reliability. The aim of this study was to evaluate concurrent validity and reliability of the Optojump photocell system (Microgate, Bolzano, Italy) with force plate measurements for estimating vertical jump height. Twenty subjects were asked to perform maximal squat jumps and countermovement jumps, and flight time-derived jump heights obtained by the force plate were compared with those provided by Optojump, to examine its concurrent (criterion-related) validity (study 1). Twenty other subjects completed the same jump series on 2 different occasions (separated by 1 week), and jump heights of session 1 were compared with session 2, to investigate test-retest reliability of the Optojump system (study 2). Intraclass correlation coefficients (ICCs) for validity were very high (0.997-0.998), even if a systematic difference was consistently observed between force plate and Optojump (-1.06 cm; p < 0.001). Test-retest reliability of the Optojump system was excellent, with ICCs ranging from 0.982 to 0.989, low coefficients of variation (2.7%), and low random errors (±2.81 cm). The Optojump photocell system demonstrated strong concurrent validity and excellent test-retest reliability for the estimation of vertical jump height. We propose the following equation that allows force plate and Optojump results to be used interchangeably: force plate jump height (cm)= 1.02 × Optojump jump height + 0.29. In conclusion, the use of Optojump photoelectric cells is legitimate for field-based assessments of vertical jump height.

OBJECTIVE To investigate validity and reliability of the Functional Gait Assessment (FGA)(German version) as a measure for balance abilities during walking in subacute stroke patients. DESIGN Cohort study. SETTING Inpatient rehabilitation center. PARTICIPANTS Ambulatory subjects (N=28) at a maximum of 6 months after stroke participated in this study. One direct observer and 2 video observers rated the FGA. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Performance of the FGA was video recorded and directly rated. For testing concurrent validity of the FGA, subjects also completed testing in the Berg Balance Scale, fast walking speed, the Functional Ambulatory Category, the Rivermead Mobility Index, and the Barthel Index. Intrarater reliability, interrater reliability, and concurrent validity of the FGA were analyzed. RESULTS Intrarater (intraclass correlation coefficient=.97) and interrater reliability (intraclass correlation coefficient=.94) were almost perfect for total scores. Reliability of single items varied between substantial and almost perfect values. Analysis revealed significant correlations between the FGA and other measures of gait and balance functions between Spearman rho values of .71 and .93. The FGA differs significantly between levels of gait ability (Functional Ambulatory Category)(P< or =.01). CONCLUSIONS Almost perfect intrarater and interrater reliability for total FGA scores and good concurrent validity were shown in this study. Therefore, the FGA (German version) can be used as a reliable and valid tool to assess functional gait performance of patients in subacute stages after stroke.

OBJECTIVE To determine the validity and interobserver reliability of visual observation to assess partial weight-bearing. DESIGN Validation and interobserver reliability study. SETTING University medical center. PARTICIPANTS Patients (N=10) with a total hip arthroplasty operated 1 to 12 months prior to the study referred by 10 physical therapists (5 experienced and 5 inexperienced in training patients in partial weight-bearing). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The amount of weight-bearing assessed by visual estimation (visual analog scale score) in percentage body weight (BW). Actual weight-bearing (percentage BW) as measured with the Pedar Mobile system. The mean difference (systematic error) between visual estimation and the Pedar system and the SD of the differences (random error) were determined by the limits of agreement (LOA) method with multiple observations per subject. The intraclass correlation coefficient (ICC) was calculated as a measure for the interobserver reliability. RESULTS The mean difference +/- SD between visual observation and the reference method was -9.5+/-20.1 percentage BW (95% confidence interval,-24.0 to 5.0 percentage BW) with LOA ranging from -49.8 to 30.8 percentage BW. The ICC was .57. The therapists' experience in partial weight-bearing training had no effect on the mean difference (P=.349) between the 2 methods. CONCLUSIONS Visual observation is not a valid and reliable method to assess partial weight-bearing.