Problem Statement: Because of the lack of evidence in support of a pathology-based approach to low back pain (LBP), many researchers advocate the use of classification systems that classify patients with LBP based on common clinical characteristics. Treatment based on direction tolerance can improve circulation, diminish pain and inflammation, restore normal motion, and reduce fear-avoidance beliefs. Treatment performed in the standing position can functionally integrate related regions of the body, can replicate normal tissue loading in standing position, replicate normal proprioceptive demands of motion performed in standing position, and address underlying movement impairments in related regions that may contribute to compensatory tissue pathology in the low back. The problem is that none of the existing functional classification systems for evaluation and treatment of LBP are designed for this purpose. The Direction Tolerance System (DTS) is a new functional classification system that is based on direction tolerance and performed entirely in the standing position. Objectives: The purpose of this research was to investigate the reliability, outcome, and prognostic ability of the DTS for evaluation and treatment of LBP. Methods: This exploratory research was a prospective cohort study with 60 patients seeking physical therapy (PT) for treatment of LBP by 5 different therapists. All patients were evaluated and treated for 8 visits using the DTS. Reliability was measured by comparing DTS scores (DTI) on visits 1 and 2. DTS treatment consisted of a scripted flexibility and strengthening exercise program based on motions that were determined to be non-aggravating during the DTS examination. Outcome was assessed using the DTI, modified Oswestry Disability Questionnaire (ODQ), Numeric Pain Rating Scale (NPRS) and Fear-Avoidance Beliefs Questionnaire Physical Activity Subscale (PABQ-PA). Baseline variables were assessed for correlation with successful outcome and ability to predict a successful outcome. Results: (1) Group intra-rater reliability between visits 1 and 2 using ICC (3,1) was good (.80, p<.001); (2) The group success rate was 62%, which exceeded the expected 50% success rate. (3) Baseline variables were not associated with a successful outcome and did not significantly predict a successful outcome. Discussion: The DTS is a simple, reliable and effective method of evaluating and treating LBP, and with proper training, can be used by clinicians.

Magister Scientiae Dentium - MSc(Dent) / Aim: The aim of this study was to investigate the accuracy, intra- and inter-observer reliability of identifying occlusal markings made by articulating paper on complete dentures intra-orally. Methods: A series of photographs of 14 tissue borne complete dentures with occlusal markings was obtained. Articulating paper was used intra-orally at the delivery visit to make the occlusal markings. The denture sets were divided into two groups. Group 1 comprised pictures of the 14 complete lower dentures on their own, and group 2 comprised pictures of the same 14 lower dentures together with their opposing upper denture. The two groups of images were loaded into a Microsoft PowerPoint presentation as well as Keynote. Two experienced observers analysed the complete dentures independently and noted the number and distribution of the markings that they felt required adjustment. They differed, but discussed these and reached consensus. These data served as the control. Three groups of observers (10 per group) were then asked to analyse the occlusal markings of the 2 groups of denture images twice, with a two-week interval between each assessment. Before each subsequent assessment, the images were randomised by means of computer-generated random number sequence. The mean number of markings was established for each group and compared with the control mean. Intra-rater reliability was established by comparing the difference of the means of sequential observations for each rater by establishing the z-value. Inter-rater reliability within each group was established by means of analysis of variance. Results: Considering all the data, in only 17 instances (of the possible 60), did observers’ mean scores not differ from the control mean scores with good intra-rater reliability. In all other 43 instances the observers’ mean scores differed from the control mean scores and/or displayed poor intra-rater reliability. Considerable variation in inter-rater reliability was also found within every group of observers. Conclusion: The results indicate that observers are generally unable to reliably identify occlusal markings warranting occlusal adjustment, made by articulating paper on a lower complete denture. Clinical significance: Articulating paper should not be used intra-orally when delivering removable complete dentures.

Bakgrund En handhållen dynamometer (HHD) är ett kliniskt användbart mätverktyg för att mäta muskelstyrka. På Akademiska sjukhuset i Uppsala finns en HHD av märket MicroFET2® (Hoggan Scientific). Det finns ett fåtal studier gjorda som undersöker intrabedömarreliabiliteten vid mätningar av isometrisk muskelstyrka av knäledens muskelgrupper med denna dynamometer. Syfte Syftet med studien var att undersöka den absoluta och relativa reliabiliteten vid mätningar av maximal muskelstyrka i knäledens muskelgrupper med en HHD. Metod Psykometrisk design med test-retest förfarande. Totalt undersöktes 24 friska vuxna vid två mättillfällen med 6–8 dagars mellanrum. Den relativa reliabiliteten presenterades med Intraclass correlation coefficient (ICC 2,1). Den absoluta reliabiliteten presenteras i standard error of measurement (SEM), SEM% samt smallest detectable change (SDC). Resultat Resultaten visade mycket hög relativ reliabilitet för knäledens extensioner (ICC = 0,950,96) och för knäledens flexorer (ICC = 0,94–0,96). SEM varierade mellan 33,58N-34,81N för knäledens extensorer och 14,16N-17,16N för knäledens flexorer. SDC varierade mellan 93,08N–96,49N för knäledens extensorer och 39,25N-47,57N för knäledens flexorer. Konklusion Resultaten indikerar att HHD har mycket hög relativ reliabilitet för bedömning av styrka i knäledens stora muskelgrupper hos ett bekvämlighetsurval med friska vuxna människor.  Den relativa och absoluta reliabiliteten bedömdes överlag vara i enlighet med tidigare studier. För implementering i klinik behöver framtida studier utvärdera absolut och relativ reliabilitet på specifika patientpopulationer. / Background Hand held dynamometry (HHD) is a practical device for testing muscle strength. There is currently a HHD (MicroFET2® - Hoggan Scientific) available at Uppsala University hospital. Few reliability studies excist where the objective is to examine the intra-rater reliability of isometric maximal knee-strength using this device. Objective To examine the absolute and relative reliability of isometric maximal knee-strength using a MicroFET2. Method Psychometric design through test-retest with 6–8 days between measures on 24 healthy adults. The relative reliability expressed as Intra-class correlation coefficient (ICC 2,1) and the absolute reliability as standard error of measurement (SEM), SEM%, and smallest detecatble change (SDC). Results The results of this study showed very good reliability for both knee extensors (ICC = 0,950,96) and knee flexors (ICC = 0,94–0,96). Regarding the absolute reliability SEM ranged from 33,58N-34,81N for knee extensors and 14,16N-17,16N for knee flexors. SDC ranged from 93,08N-96,49N for knee extensors and 39,25N-47,57N for knee flexors. Conclusion The results indicate that HHD has a very good relative reliability for assessing strength in the large muscle groups of the knee joint when examined on a group of healty adults. The relative and absolute reliability was generally in accordance when compared with previous studies. Before being implemented in praxis, future studies need to evaluate absolute and relative reliability on specific patient populations.

Background: Muscle thickness, pennation angle, and fascicle length describe the architecture of a muscle. These properties can be observed alongside subcutaneous fat thickness using ultrasonography; however, measurement is sensitive to the angle of the transducer against the skin. Typically, the transducer is held perpendicular to skin for imaging. Nonetheless, a convenient, reliable method to ensure transducer angle consistency has not been reported. Objectives: The purpose of this study was to determine the influence of transducer angle on muscle architecture and subcutaneous fat measurements of quadriceps muscles (vastus lateralis and rectus femoris) in healthy young adults. A secondary objective was to determine intra- and inter-rater reliability. Methods: Thirty men and women were recruited (25±2.5 years; BMI: 22.6±3.0 kg/m2). Ultrasound images were acquired from two muscles. An image was taken at an estimated perpendicular angle to the skin. Then, using a 3D-printed device with a protractor that attached to the ultrasound transducer, images were taken at measured angles 5-10˚ medial and lateral to perpendicular. Agreement and error were determined using intraclass correlation coefficients (ICCs) and standard error measurements (SEMs). Results: Good to excellent agreement was demonstrated for muscle and fat thicknesses regardless of transducer angle (ICC >0.66). Intra-rater reliability was excellent for all outcomes within both muscles (ICC >0.89). Inter-rater reliability for the rectus femoris was good to excellent for all transducer angles except for measurements of fascicle lengths at 85° (ICC: 0.33–0.99). Inter-rater reliability improved >20% for the vastus lateralis with the device. Conclusion: Measurements of muscle pennation angle and fascicle lengths, but not muscle or subcutaneous fat thicknesses, were sensitive to transducer angle. Reliability of pennation angle and fascicle lengths improved with the use of our device. Using our device, reliable muscle architecture measures can be made for the rectus femoris and the vastus lateralis in healthy young adults. / Thesis / Master of Science (MSc) / The arrangement of small muscle components, known as fascicles, can be observed in humans using ultrasound imaging. These fascicle arrangements can be measured to improve understanding of muscle function and disease processes. A potential problem of viewing muscle with ultrasound is that the angle of the probe head against the skin can alter the appearance of the muscle fascicles. The goal of this research was to improve current methods of ultrasound imaging of two thigh muscles. We have created a novel 3D-printed device to attach to the existing ultrasound probe. This 3D-printed device stabilizes the ultrasound probe head; and accurately determines the angles between the ultrasound probe head and the surface of the skin. In this study, the use of this device improved reliability of our ultrasound images by >20%. Future use of this device may improve measurements of muscle fascicles acquired with ultrasound imaging.

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Fragestellung und Zielsetzung: Ausgehend von dem Ziel, kommunikative Fähigkeiten von Studierenden der Humanmedizin objektiv zu messen, sollte in dieser Studie untersucht werden, ob eine ins Deutsche übersetzte Kurzversion des „Calgary-Cambridge Observation Guide for the Medical Interview“ (CCOG) von Kurtz und Silverman (1996) valide und reliabel ist und sich damit die Kommunikationsfähigkeit von Studierenden der Medizin bewerten lässt. Methode: Eine Auswahl von Ärzten, wissenschaftlichen Mitarbeitern und Studierenden des klinischen Studienabschnittes evaluierten im Abstand von mindestens drei Monaten fünf Anamnese-Videos mittels der ins Deutsche übersetzten „CCOG-Kurzversion“. Die Videos bestanden aus je einem Gespräch zwischen einem Studierenden des ersten klinischen Semesters in der Rolle des Arztes bzw. einer approbierten Ärztin und einem Schauspielpatienten – in unterschiedlicher Kommunikationsqualität. Die Auswertung erfolgte deskriptiv nach folgenden Kriterien: Bewertungszeitpunkt, Geschlecht bzw. Gruppe der Rater, Qualität der Videogespräche. Darüberhinaus wurden eine explorative und eine konfirmatorische Faktorenanalyse berechnet und die Retest-Reliabilität (Intra-Rater-Reliabilität) sowie die Intra-Class-Correlation (Inter-Rater-Reliabilität) bestimmt. Ergebnisse: 30 Rater beteiligten sich an der Studie, davon drei als sog. „Goldstan-dard“. Die Gesamtbewertung aller fünf Anamnese-Videos zeigte eine geringfügige Verbesserung in der Notenvergabe beim zweiten Bewertungszeitpunkt. In der Benotung waren professionelle Rater generell etwas strenger als Laien, Ärzte etwas strenger als Studierende und weibliche Rater etwas strenger als männliche. „Gold-standard“ und übrige Rater unterschieden sich bei einzelnen Items bis zu 1,6 Notenpunkten (z.B. beim Item „verbale/nonverbale Unterstützung des Patienten“). In der Originalversion enthält der CCOG 28 Items, die in sechs Skalen (mit jeweils 3 bis 7 Items) zusammengefasst sind. Diese Struktur ließ sich in der hier gerechneten Faktorenanalyse nur bedingt abbilden. Gemäß Eigenvalue > 1 genügten 5 Faktoren zur Abbildung bzw. Aufteilung der Items. Darüber hinaus zeigte sich eine andere Skalenzuordnung als im Original und über die Hälfte der Items (15/28) lud auf demselben Faktor. Auch die Inter-Rater-Übereinstimmung in der Beantwortung einzelner Items war nicht optimal (ICC-Range: 0,05 bis 0,57). Schlussfolgerungen: Die CCOG-Kurzversion zeigte relativ gute Übereinstimmun-gen bei der Retest-Reliabilität. Schwierigkeiten zeigten sich bei der Benotung einiger Items im Vergleich zwischen dem „Goldstandard“ und den übrigen Ratern. Die Skalen-Struktur der Items und die Inter-Rater-Reliabilität sind nur bedingt akzeptabel. Vielleicht hätte eine dreistufige Bewertungsskala oder eine homogene Rater-Gruppe oder auch eine bessere Schulung das Ergebnis der ICC verbessert. Es sollten einige Items gestrichen, sprachlich trennschärfer formuliert oder anders zusammengefasst, neue Items hinzugefügt und Skalen neu strukturiert werden.