ARTICLE IN PRESS

1466-853X/$ - s

doi:10.1016/j.pt

Physical Therapy in Sport 9 (2008) 165–166

www.elsevier.com/ptsp

Editorial

Confidence in clinical reasoning

Subjective history and clinical tests are the backboneof our diagnostic skills, and these skills take many yearsto learn and develop. Apart from experiential learning,how confident can we be of the results of clinical tests weemploy? Most clinicians will probably be familiar with,and know, the sensitivity and specificity of commonlyused clinical tests. However, the interpretation of thesecan be confusing when there is a large discrepancybetween these two values. The Odds ratio is anotherstatistic that can be employed for diagnostic accuracy,and this tends to be more commonly reported in themedical rather than physiotherapy literature. In the firstpaper presented in this issue, Walton and Sadi use thepositive likelihood ratio (PLR), which employs bothsensitivity and specificity in its calculation and it is aneasy statistic for the clinician to interpret. The PLR iscalculated by dividing the sensitivity by (1—specificity)and a value of between;

�

2–5 generates a small shift in the possibility that acondition exists given a positive result, � 5 and 10 generates a moderate shift in the possibility

that a condition exists given a positive result, and

� 10 generates a large shift in the possibility that a

condition exists given a positive result.

Additionally, methodological issues that can influence

studies reporting diagnostic accuracy, such as internalvalidity and how to avoid missing false negatives, arediscussed. Good internal validity is essential whendeciding how robust the results of a study are. Otherinteresting concepts, such as publication bias, areconsidered and how these can be accounted for. Finally,at the end of this article, an excellent example of acase study in clinical reasoning is presented. The paperraises many issues surrounding clinical testing that allclinicians employing sound clinical reasoning shouldconsider.

The number of diagnostic criteria and tests forshoulder pathologies seems to be increasing. Whetherthis is due to a limitation of existing clinical testsand/or an improved understanding of shoulder patho-logy and biomechanics is unclear. Walton and Sadipresent a systematic review and meta-analysis of

ee front matter r 2008 Elsevier Ltd. All rights reserved.

sp.2008.08.004

diagnostic tests for SLAP lesions and report that 14different tests had been described in the literature.Only five of these tests qualified for further analysis,and of these, only Yergason’s test was robust enough tohave an influence on clinical decision making with aPLR of 2.29.

Continuing on the shoulder theme, Whitely andcolleagues present a paper investigating the relationshipbetween humeral torsion and proprioception of theshoulder in young male baseball players. Humeralretrotorsion is associated with increased range ofmovement of external rotation of the shoulder, neces-sary in throwing actions, and an increased throwingvelocity. The authors found a strong and significantcorrelation between retrotorsion and active propriocep-tive acuity in the non-dominant arm but not in thedominant arm in this cohort. The authors suggest acognitive processing capacity model whereby greaterretrotorsion reduces processing requirements, an inter-esting concept.

The next two papers both investigate the biomecha-nics of landing, among other parameters, in healthy andACL deficient subjects, respectively. Plyometrics is atechnique employed by coaches and trainers to increasejump performance, and eccentric training (a largecomponent of plyometric training) has also been usedto decrease landing forces in female athletes. It isintuitive that decreasing these forces will contribute toinjury prevention. In a small controlled trial, Vescoviand colleagues investigated the effect of a 6-weekplyometric training programme in female collegiatebasketballers. A clinically meaningful reduction invertical ground reaction force was found in the traininggroup but without any increase in jump performance.The authors suggest that different regimens should beadopted if the training benefits are expected to includeimproved performance. In the next paper, Phillips andvan Deursen found significant differences in parametersassessed for two functional activities, namely a runningtask and a single leg hop in ACL deficient subjects. Theauthors discuss the results with respect to motor controltheory and discuss the concept that performance shouldnot just be seen as ‘how fast’ or ‘how far’. An argument

ARTICLE IN PRESSEditorial / Physical Therapy in Sport 9 (2008) 165–166166

is presented for including measures of the quality ofmovement and skill level in addition to performanceoutcome to enhance confidence in return to sportdecisions. The tests employed in the study couldpotentially be used to identify ACL deficient subjectswho are non-copers.

The concept of ‘passive’ tissues, such as neural tissueand the fascia, being able to influence range of move-ment is not new. However, in the final article Mitchelland colleagues investigate the effect of neutral andanterior pelvic position on the range of ankle dorsi-flexion during three different postures. The range ofdorsiflexion varied considerably between the threepostures but this did not relate to pelvic posture. Theauthors suggest that clinicians may want to considerthe starting position for techniques aimed at mobili-sing dorsiflexion at the ankle joint. A systematic

approach to mobilisation of the ankle is suggested totarget different tissues in different positions, with acaveat that further research be undertaken to supportthis theory.

This is the last issue for 2008 and we would like totake this opportunity of thanking all our reviewers whoare listed in the back of this issue. We really doappreciate all your time, effort and constructive com-ments, without which the peer-review process would notsucceed.

A fun-filled festive season to all our readers andcontributors, and we look forward to 2009.

Editor

Zoe Hudson