INTRODUCTION - Continuing ED

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Orthopedic Extremity/Foot-Ankle
Journal Club
Ed Mulligan, MS, PT, SCS, ATC
Grapevine, TX
817-488-5159
[email protected]
continuing ED
copyright© epm 2001
The diagnostic accuracy of a new clinical test (the
Thessaly Test) for early detection of meniscal tears
Article Summary
Karachalios T, Hantes M, Aibis AH, Sachos V, Karantanas AH,
Malizos, K. J Bone Joint Surg Am. 87:955-962, 2005
z
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubm
ed&dopt=Abstract&list_uids=15866956&query_hl=3
Investigation of a new diagnostic procedure
(Thessaly Test) in a series of consecutive
patients and volunteers with comparison
applied against a universally accepted “gold
standard” (MRI).
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INTRODUCTION
The Question
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The Question the
Study Proposes
What is the diagnostic accuracy of a new dynamic
clinical test for the detection of meniscal pathology
– This may be important because the current gold
standard (MRI) is expensive and not always readily
available.
– Current testing methods inaccurate? Clinical tests are
inadequate compared to MRI?
z Introduction seemed contradictory; very brief
(essentially non-existent) literature review
– A research hypothesis was not offered
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Let me do a quick literature review
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Diagnosis of Meniscal Injury
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Mechanism of Injury
–
–
How do we currently diagnose a
meniscal injury?
Diagnosis of Meniscal Injury
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Youth: Twisting Trauma
Elderly: Degeneration
Classic Signs/Symptoms
–
–
–
–
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What does the literature say about the
accuracy of common meniscal special tests?
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Joint line tenderness
True locking or catching
complaint
Mild, delayed effusion
Quad atrophy
First, let’s review what sensitivity and
specificity imply
Clinical Decision-making Mnemonics
SPIN
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Use a specific test to rule in a hypothesis
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Specific tests have very few false positives
High specificity means that if you get a positive test, you
can count on it being a true positive
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SNOUT
– Use a sensitive test to rule out a hypothesis
– Sensitive tests have very few false negatives
– High sensitivity means that if you get a negative test,
you can count on it being a true negative
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So, how sensitive and specific are
meniscal tests?
McMurray’s Test
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High specificity; Low sensitivity
–
–
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High positive predicative validity
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+ and - Likelihood ratios inconclusive
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Limited emphasis – only a “thud” on the
medial joint line was specific (not sensitive)
–
Statistical
Truth
–
–
Evans PJ. Am J Sports Med. 1993
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“Dynamic Test”
- similar to Thessaly?
Good sensitivity, poor specificity
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+ and - Likelihood ratios inconclusive
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High sensitivity and specificity (particularly
when an isolated lesion and on lateral side)
For Lateral Meniscal Tears
–
–
Solomon DH, et al. JAMA, 2002
–
85% sensitivity
90% specificity
89% accuracy
Mariani PP, et al. A prospective evaluation of a test for lateral meniscus.
Knee Surg Sports Traumatol Arthrosc, 1996; 4(1):22-26.
Eren, OT. Arthroscopy. 2003
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Ege’s Test
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Solomon DH, et al. JAMA, 2002
Malanga GA, et al. Arch Phys Med Rehabil 2003
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Scholten, et al. J Fam Pract. 2001
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Joint Line Tenderness
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Malanga GA, et al. Arch Phys Med Rehabil 2003
Corea JR, et al. Knee Surg Sports Traumato Arthrosc 1994
Systematic Review Summary
Deep squat in full LE ER for medial and LE IR for
lateral meniscus
Positive test with pain or click – typically around 90°
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Diagnostic accuracy of clinical tests is poor
–
McMurray’s
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Higher accuracy (84%), sensitivity
(64%), and specificity (90%) than
McMurray’s or joint line tenderness
–
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Akseki D, et al. Arthroscopy. 2004
Sensitivity ranged from .20 - .66
Specificity ranged from .57 - .96
Sensitivity ranged from .58 - .95
Specificity ranged from .05 - .74
Scholten RJ, et al. J Fam Pract. 2001
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Agrees with Fowler
Predictive Value of 5 Clinical Signs in the Evaluation of Meniscal Pathology
TEST
McMurray
Sensitivity
Specificity
29%
96%
80%
Apley
16%
85%
30%
Pain on Forced Flexion
51%
Blocked Extension
44%
70%
86%
Evidenced-Based Answer
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Ellis ME, et al. J Family Prac. Nov 2004.
–
No physical exam (joint effusion,
McMurray test, Joint line tenderness, or Apley compression)
yielded clinically significant
likelihood ratios for a meniscal
tear
Fowler PJ, Lubliner JA. Arthroscopy. 1989
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Likelihood Ratios
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represent the change in the odds of a diagnosis, based
on the outcome of the test.
–
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Ellis Study
Given a positive likelihood ratio of 2, if a test result is positive,
the odds of the disease being present is doubled.
A positive likelihood ratio >10 provides strong evidence
that the disorder is present
A negative likelihood ratio <0.1 provides strong
evidence that the disorder is not present
Scores between 0.5 and 2.0 are neutral
Ellis Study
Jackson 2003
4 studies – 424 patients
Positive Likelihood ratio (95% CI)
McMurray
1.3 (0.9-1.7)
1.5 – 9.5
17.3 (2.7 – 68)
Joint Line
Tenderness
0.9 (0.8 – 1.0)
0.8 – 14.9
1.1 (0.7 – 1.6)
Aggregate Exam
2.7 (1.4 – 5.1)
Aggregate Exam,
Med Meniscus
3.1 (0.54 – 5.7)
Aggregate Exam,
Lat Meniscus
11 (1.8 – 20.2)
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in Journal of Family Practice, 2004
Solomon 2001
Scholten 2001
Jackson 2003
9 studies –1018 patients
0.4 – 0.9
0.5 (0.3 – 0.8)
Joint Line
Tenderness
1.1 (1.0 – 1.3)
0.2 – 2.1
0.8 (0.3 – 3.5)
Aggregate Exam
0.4 (0.2 – 0.7)
Aggregate Exam,
Lat Meniscus
Scholten 2001
0.8 (0.6-1.1)
Aggregate Exam,
Med Meniscus
Solomon 2001
9 studies –1018 patients
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Negative Likelihood ratio (95% CI)
McMurray
in Journal of Family Practice, 2004
Influence of Concurrent ACL Injury
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Diagnostic Accuracy is decreased
–
–
–
Akseki D, et al. Acta Orthop
Traumatol. 2003
Eren, OT. Arthroscopy. 2003
Fowler. Arthroscopy, 1989
0.19 (0.11 – 0.77)
0.13 (0 – 0.25)
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MRI Imaging for Meniscal Disorders
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Diagnostic accuracy – 72%
Sensitivity
– 88% (medial - 94%; lateral 78%)
Specificity
– 57%
+ Predicative Value – 66%
- Predictive Value – 83%
67% accurate for degenerative lesions
78% accurate for traumatic lesions
Generalization
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Decent specificity with entrapment exams
Decent sensitivity with palpatory findings
Raunest J, et al. J Bone Joint Surg Am. 1991
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Additional Special Tests referenced in Magee
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Bounce Home
–
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O’Donahue’s
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Modified Helfet
Springy block to full extension
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Childress Sign
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Duck walking causing pain or
snapping in posterior horn area
–
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Medial meniscus does not disappear with ER and
reappear with IR at 90° of flexion
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Steinmann’s Tenderness Displacement Test
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Lack of ER (lateralization of
tibial tubercle) in full extension
Retracting Meniscus
–
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Pain with rotation at 0 or 90°
Tenderness at joint line moves posteriorly with
flexion, anteriorly with extension, medially with ER,
and laterally with IR
Flexion
IR
ER
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Bragard’s Sign
–
–
Reproduction of
symptoms medially
with ER and Ext
Alleviation of
symptoms medially
with IR and Flex
Extension
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5
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Payr’s Test
–
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Medial joint line pain in the Figure 4 position
Bohler’s Sign
–
Cabot’s Popliteal Sign
–
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Medial joint line pain while
isometrically extending the
knee from the Figure 4
position
Pain with varus/valgus in
compressed compartment
Kromer’s Test
–
same as Bohler’s Sign
but also incorporates
flexion/extension motion
Lateral Pain
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Passler Rotational Grind Test
–
Medial Pain
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Circumduction movement of knee in combinations
of flex/extension, rotation, and varus-valgus
Anderson Medial-Lateral Grind Test
–
Grinding caused by Valgus/Flexion from full
extension to 45° flexion; return in Varus/Extension
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May also cause a pivot shift if ACL deficient
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METHODOLOGY
Materials and Methods
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How the Study
was Conducted
Sample of convenience from 780 patients referred to
their department with a knee injury
– Inclusion Criteria:
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–
Knee complaint with suggestive history and appropriate MOI for
meniscal pathology
Exclusion Criteria:
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Multiple injuries
Evidence of OA
Previous Sx
Abnormal Radiographs
Acute Injury (less than 4 weeks)
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Demographics
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Experimental Group A (had MRI and scope)
–
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213 patients
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z
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Clinical Examination
29 years old (18-55)
74% male;
female
–
26%
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–
(had MRI only)
–
197 volunteers
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–
Age, sex, gender,
size matched
–
Medial or Lateral Joint Line Tenderness
McMurray Test
Apley Compression/Distraction Test
Thessaly Test at 5°
Thessaly Test at 20°
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Unsure what made two MDs experienced and two MDs
inexperienced
Examination consisted of five specific tests or findings
–
Control Group B
–
All patient (experimental and control group) were
examined by 4 physicians
McMurray Test
Assuming a positive
test was reproduction
of symptomatic
complaint with
palpation
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Application of varus or valgus
stress while the knee is extended
and rotated
–
–
–
–
Varus stress compresses medial
meniscus
Valgus stress compresses lateral
meniscus
Flexion compresses posterior
meniscus
Rotation stretches meniscal
attachments and distorts the tear
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Apley Compression-Distraction Test
Thessaly Test
Reproduction of
symptoms with
compression
and rotation;
alleviation of
symptoms with
distraction
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With balance assist, the patient
internally and externally rotated their
body while in unilateral stance with the
knee in 5° and 20° of flexion
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Positive test was present when patient
reported joint line discomfort or a
sense of locking or catching
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Essentially a weight-bearing
replication of the McMurray and Apley
tests in a greater degree of extension
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Blinding
(in regard to “true” meniscal status according to the
MRI Gold Standard or to the Thessaly Test findings)
MRI
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Presence of Mensical Injury
was judged against gold
standard of T1 weighted MRI
–
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Interpreted by an “experienced”
and “fellow” radiologist
–
–
ICC agreement not reported
z Referenced MRI accuracy as 98%
during introduction
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2 x 2 Table
for Statistical Truth
Sensitivity - Specificity
is (+)
is not (-)
Positive Test
(+)
true positive
a
false positive
b
total who test
positive
a+b
Negative Test
(-)
false negative
c
true negative
d
total who test
negative
c+d
total with
condition
a+c
total without
condition
b+d
a+b+c+d
Sensitivity
z
Specificity
–
–
a/a+c
d/b+d
z
% False Positive
z
% False Negative
z
Accuracy
–
–
–
b/a+b+c+d
c/a+b+c+d
Positive
Test
(+)
Negativ
e Test
(-)
is (+)
is not (-)
true positive
false positive
a
b
false negative
true negative
TOTALS
total who test positive
a+b
total who test negative
c
d
c+d
total with
condition
total without
condition
total population
a+c
b+d
a+b+c+d
a+d/a+b+c+d x 100
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Thessaly 20° Raw Data
Positive
Test Accuracy
Medial Meniscus
z
total population
Accuracy Results
Lateral Meniscus
ACL + Meniscus
McMurray’s
78%
84%
72%
Apley’s
75%
82%
59%
Joint Line
81%
89%
80%
Thessaly 5°
86%
90%
82%
Thessaly 20°
94%
96%
90%
Exam
Radiologists – yes
Group Allocators - no
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Statistical Analysis
TOTALS
Patients - no
Examiners - yes
Investigators
Negative
Total
Medial Meniscal Injury
Positive
124 (a)
9 (b)
133 (a+b)
Negative
15 (c
262 (d)
277 (c+d)
139 (a+c)
271 (b+d)
410
Total
Lateral Meniscal Injury
Positive
34 (a)
15 (b)
49 (a+b)
Negative
3 (c
358 (d)
361 (c+d)
37 (a+c)
373 (b+d)
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Also reported sensitivity, specificity, false positives and negatives for each test
Total
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Thessaly 20° Test Results
Intra/Interexaminer Reliability
z
> 95%
–
Medial
Meniscus
Lateral
Mensicus
ACL +
Meniscus
–
Sensitivity
89%
92%
80%
–
Specificity
97%
96%
91%
False Positive
2%
4%
9%
False Negative
4%
1%
1%
Accuracy
94%
96%
90%
If true, certainly indicates
reproducibility amongst
practitioners
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Discussion
Provocative Maneuvers
Meniscal MOI – S/S
z Meniscal Provocative Maneuvers
z Traditional Testing Accuracy
Clinical interpretation and utility of the
Thessaly Test
z
z
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Paper divides meniscal provocation maneuvers
into palpatory and rotational reproduction
techniques
I would argue they differ based on degree of
–
–
–
–
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Precaution
Reproduces MOI
–
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Weight bearing compression vs. distraction
Medial vs. lateral compartment
compression (varus-valgus)
Rotational distortion
Flexion to extension movements
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Strength of Proposed Special Test
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How was intraexaminer reliability evaluated?
No difference based on experience?
What were the ICCs?
“monopodal rotation in the position of function (20°
flexion) squeezes apart the meniscal fragments
causing pain on the peripheral, innervated rim”
Identifies a potentially suitable screening tool
for allied health professionals and general
practitioners to accurately detect meniscal
pathology
z
3% of patients had a
significant exacerbation
of symptoms
(requiring an analgesic
tablet or MUA to unlock)
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Issue
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Clinical Calculator
Evaluations of diagnostic accuracy should be
prescribed with confidence intervals
–
95% is typical
With CI, reader can not know the range within which
the true values of the indices are likely to lie
–
http://faculty.vassar.edu/lowry/clin1.html
–
http://faculty.vassar.edu/lowry/clin1.html
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Thessaly Test Findings
Medial Meniscal
Findings with Confidence Intervals
89 (82-94)
97 (94-98)
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Findings with Confidence Intervals
A reason to tap the brakes
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SLAP Test History
–
Active compression test had nearly perfect
sensitivity and specificity but has never been
replicated
2 (1-7)
3 (1-6)
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Issue
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Issue
Should an MRI only be used when the clinical
history, MOI, and clinical findings contradict a
positive test?
–
–
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Overall Impression
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Unique study investigating a new technique
Paper written in a clear, concise way
Inadequate reflection on results as
compared to earlier studies
apprehension indicates rotary instability
Joint line pain (Merke’s sign) implies
meniscal pathology
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Practical Application
z
Yet an exclusion criteria was acute knee injuries
(less than 4 weeks old)
Isn’t the Thessaly Test is same as
Losee’s “disco test”?
z
z
–
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Was test order randomized?
What specifically constituted a positive test?
How were ACL injuries identified?
Should a dynamic rotation test be performed on a
subject with suspected ACL deficiency?
–
Early detection (that’s what the title says)
How many surgeons rely strictly on clinical exam
and do not confirm necessity of surgery
with an MRI?
How would they know to include the test
if the history, MOI, and clinical findings
do not suggest the problem?
Questions?
z
z
Research Appraisal Sites
Will your clinical practice change
as a result of this study?
If so, how?
no extraction posted
not posted as it is really
not an “intervention” study
No follow-up research was
suggested – do the conclusions
merit additional investigation
If so, what?; how?
Scholten study referenced
as a systematic review
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Questions - Discussion
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Comparison of Home vs. Physical Therapy
Supervised Rehabilitation Programs after ACL
Reconstruction: A Randomized Clinical Trial
Grant JA, Mohtadi NG, Maitland ME, Zernicke RF. Am J
Sports Med. 2003 33:1288-1297.
Mark Beckett, PT
Thursday 2/2/06 11:00 AM CST
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INTRODUCTION - Continuing ED

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