Original Article
A study of the noninstrumented physical examination of the knee found high observer variability

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Abstract

Objective

This study estimated the inter- and intraobserver reliability of a set of noninstrumented physical examination measures for knee pain in older adults.

Study Design and Setting

Forty-five patients from primary care, and 13 patients from secondary care, were each examined by two out of a team of three physical therapists, and were reexamined by one of these observers 1 month later. The examination items were standardized and included dichotomous, ordinal and continuous variables considered relevant to a primary care context.

Results

For individual dichotomous items, median interobserver and intraobserver agreement (κ) was 0.22 (interquartile range IQR = 0.12–0.35) and 0.41 (IQR = 0.28–0.56) respectively. For ordinally rated variables, weighted kappa ranged from −0.08 to 0.43 for interobserver agreement, and from 0.00 to 0.79 for intraobserver agreement. The median intraclass correlation coefficient for continuous examination variables was 0.80 (range 0.68–0.89) for interobserver agreement, and 0.84 (range 0.67–0.95) for intraobserver agreement.

Conclusion

For trained but nonexpert examiners, agreement was generally poor for dichotomous and ordinal examination items; however, κ-values are liable to be depressed by the low prevalence of clinical signs in this sample. Agreement on continuous variables was notably better.

Introduction

Knee pain is a common complaint in the general population and results in a large number of primary care consultations [1]. Clinical decision making rests largely on the findings of the clinical history and the physical examination, the latter being a common method of evaluation of osteoarthritis of the knee in primary care [2].

A number of studies have provided estimates of the reliability of the physical examination of the knee [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. The setting, design, conduct, and analysis of reliability studies in this field has varied considerably, however, with the result that a consistent conclusion on the reliability of the physical examination of the knee has yet to emerge. To the extent that reliability estimates vary in relation to aspects of study design, it becomes important to consider the group (in terms of both patients and examiners) to which estimates are to be applied. Our interest centered on the inter- and intraobserver reliability of the physical examination of knee pain in primary care. In this setting, an emphasis on simple, noninstrumented physical examination by nonspecialist examiners, in patients with predominantly mild clinical severity, appears to be appropriate. Although elements of this focus have been included in the design of previous studies, few have focused on reliability in primary care.

Section snippets

Subjects and observers

Potential participants were identified by retrospective record review from four sources. The computerized consultation records of two general practices were searched for all Read-coded knee consultations and consecutive patients meeting the eligibility criteria were invited to participate. Inclusion criteria were (a) men or women age 50 years or over and (b) consultation in primary care with a knee problem within the last 18 months. Exclusion criteria were (a) previous knee joint replacement;

Results

A total of 58 patients (16 male; 42 female) meeting the eligibility criteria participated in the study (45 from general practice, 13 from secondary care) between September 2001 and April 2002. The median age of the subjects was 63 years (range 50–86 years). Their median WOMAC scores for pain, stiffness, and physical function were 6 (range 1–14), 2.5 (range 0–6), and 20.5 (range 0–53), respectively, suggesting mild to moderate severity. Average pain intensity over the previous 6 months, as rated

Discussion

This study of examination items considered appropriate for use in the everyday clinical situation was based on clinical examinations by three physical therapists who were experienced in musculoskeletal practice but not likely to be considered clinical experts. The examination items were selected in relation to their appropriateness and feasibility in primary care, and the patients participating in the study were drawn for the most part from primary care consulters, but were enriched with a

Acknowledgments

This work was funded by the Medical Research Council and HNHS R&D funding to Staffordshire Moorlands Primary Care Research Consortium. The authors wish to thank the staff and patients of the clinical centers involved in this work, the administrative and health informatics staff at PCSRC involved in this work, and Peter Croft for advice on the manuscript.

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