The Reliability of the Clinical Assessment of the First Ray - Assignment Example

The Reliability of the Clinical Assessment of the First Ray Introduction This paper will address the reliability of first ray assessment in the clinical diagnosis of foot problems. The examination of the reliability of first ray assessment will be done by carrying out a review of four peer reviewed articles on the subject matter. The first ray is described as the part of the foot that corresponds to the medial cuneiform, the hallux phalanges and the first metatarsals. It is advisable to carry out a clinical assessment when one is taking into consideration the medication of a patient suffering from foot problems. A clinical evaluation is carried out through the use of one hand to stabilize the four lateral metatarsals while the other hand of the examiner applies pressure on the head of the first metatarsals to cause a plantar or dorsal displacement. Even though this method is vague with reference only to inter-examiner reliability, manual testing could be adequate enough for a personal clinician to categorise the motion of the foot as being hypermobile, normal or stiff. Several comparisons with other patients are beneficial in assisting the clinician to determine whether the first foot is normal or not. The First Ray Examination First Ray Examination: essentially, the first ray is an important part of the foot as it contributes to the movement and gait of a person. Since clinical evaluations have often found first ray abnormalities to be associated with the hillux rigidus, hallux valgus and metatarsus primus varus. Medical practitioners believe that there is a mechanical explanation for these pathologic conditions (Glasoe et al 1999). The mechanical movement of the foot is imperative to locomotion and therefore, abnormality will cause difficulties in movement. Diagnosing a problem in the mobility of the first ray by using the manual model is achieved in this manner; with the ankle placed at a neutral position, a slight pressure is applied to dorsiflxion just below the first ray metatarsal head, there will be an inferior portion of the first metatarsal brought to the sagittal plane level of the smaller metatarsal heads (Cornwall et al (2004). In case the inferior element of the heads of the first ray metatarsal do not contact the smaller metatarsals’ plane, then the first ray is considered as stiff. However, in case the features of the first metatarsal head go beyond the smaller metatarsals plane, then the first Ray can be described as hypermobile (Voellmicke & Deland 2002). Since theses diagnoses are critical in a clinical setting, their reliability and validity is equally important. This is because clinical decisions that are to be made afterwards should be based on evidence proven by scientific research. This paper hence evaluates the reliability of the clinical evaluation of the first ray (Cornwall et al (2004). First, the fundamental question is what is the reliability of a test? Reliability is the extent to which a test result remains consistent over time. In simple, a test reliable if the same results are obtained repeatedly over time. It’s often very hard to calculate the exact reliability but several means exist for estimating the reliability. Test-retest is necessary in reliability tests and it’s when a test is carried out twice in varied intervals of time. The retest is confirmatory in the assessment of reliability. The retest makes the assumption that there would be no variation in the value being measured (Cornwall et al 2004). Inter-rater reliability is where a value being assessed is scored by two examiners. The values obtained are then compared for consistency of the rater’s estimations. Validity is also very critical and it’s described as the extent to which a test actually evaluates what it is intended to evaluate. The paper also rates validity because it is a vital part of assessing reliability (Shirk et al 2006). This means that when a test is not valid, then its reliability is disputable. Glasoe et al studied the reliability of a manual examination of the first ray though the use of one hand for stabilizing the lesser metatarsals while the other hand applied pressure to the first metatarsals to cause movement (Shirk et al 2006). The extent of the mobility determined the rating as being stiff, normal or hypermobile. Re-tests were carried out again and in the second round, a well validated instrument was used to perform the test and its validity was examined in terms of intra-rater and inter-rater reliability (Glasoe et al 2000). Four clinicians with different degrees of experience were used to grade the mobility of the first ray of over fifteen participants. Two of them were professional examiners having been in clinical practice for over six years while the other two examiners were inexperienced having practiced the profession for only two years each. Another different researcher was then asked to measure the dorsal mobility using a mechanical device. The repeat tests (re-test) were carried out with the purpose of evaluating the reliability of manual examination which is commonly used in clinical practice. The statistics of reliability were computed through the use of Kappa (k) statistics (Cornwall et al 2004). The relationships between mobility as was graded by a manual examination in comparison to the measurement of the measuring device were assessed through the Spearman correlation (Shirk et al 2006). The intra-rater Kappa value of the Manual assessment ranged from 0.50 to 0.85 while inter-rater ranged from 0.09 to 0.16. The manual assessment method was not related (r = - 0.21) to the absolute measure of the total dorsal mobility obtained from the measuring device. This is the cause of concern over the reliability and validity of the manual method of assessing first ray mobility because if the method does not offer considerable reliability, it should not be relied on yet it’s common in clinical practise. From this experiment, Glasoe et al findings have been very controversial in the critical decision making stage as the experiment indicated there was doubt in the reliability of the manual test of the metatarsal-cuneiform instability (Grebing & Coughlin 2004). The clinical application of this method has been questioned; whether or not it should be valid for the decision of carrying out surgery (Osteotomy). For the non – surgery evaluations however, this test is helpful but not a conclusive way of determining the dynamics of the foot. This means that several other tests have to be done to make comparisons and this will assist in determining the normal functioning of the foot. In clinical practice, manual methods are commonly used for assessing the position and mobility of the first ray. Glasoe et al suggests that assessment techniques for mobility have to be reliable like the manual techniques which offer moderate to considerable intra-rater reliability (Glasoe et al 1999). According to Glasoe et al, the manual technique was poorly validated compared to the results of the measuring device. Cornwall et al on the other hand indicated poor reliability of the manual techniques assessed by Glasoe to measure the mobility of the first ray. Poor reliability was also recorded when measurements were recorded and compared between measuring devices and manual methods of assessing first ray mobility (Shirk et al 2006). This means that both the methods do not have strong basis to support them to be legally valid for clinical use; this presents room for further research. There have been so many cases of lower inter-rater reliability among professional examiners and even the non-experienced. This has evoked doubt and a lot of questioning on the clinical worth of Glasoe et al assessment techniques for mobility of the first ray and the role played by experience when carrying out these clinical assessments. Glasoe et al have suggested several theories that explain locomotion and the impact effects of mobility on the first ray. They have also explained that these factors contribute to injuries of the lower extremities. Regrettably, these theories lack substantial evidence to back them. Due to these reasons, it has been impossible for clinicians to base their work on these facts (Voellmicke & Deland 2002). Clinical evaluations cannot therefore be done based on these theories. It has also been noted that many clinicians mistakenly assume that since these theories have been in existence for very long, they are correct and relevant basis for offering treatment (Cornwall et al 2004). In an attempt to validate the theories for practical application in clinical practise, extensive scientific research should be done (Voellmicke & Deland 2002). This means a lot of case studies will be done using more experienced clinicians who will be able to establish what normal functioning of the first ray should be like and reach a consensus on what abnormal functioning should be. Collective research by several clinicians could propel the practitioners to come up with a guide or a manual to do the tests. Conclusion It is important that clinicians appreciate that manual methods have very poor reliability when it comes to measuring first ray abnormalities and more so when critical medical decisions have to be made. Additionally, further research has to be carried out to establish the effect of force application on the first ray. It’s also important to note that pathologies that relate to stiffness or hyper-mobility of the foot could result from several factors regarding muscles and the body structure. First ray examinations could be a very small part of the test. This means that the information obtained through this means could be useful but not a complete representation of the true dynamics in the clinical evaluation. In future, research should be done to assess how the first ray position and mobility affect gait and assess the possibility of improvement in the treatment of individuals with feet problems. References Cornwall, M.W.et al (2004). Reliability and Validity of Clinically Assessing First-Ray Mobility of the Foot. Journal of the American Podiatric Medical Association. 94 (5), pp. 470 – 476 Glasoe, W.M., et al (2002). Comparison of Two Methods Used to Assess First-Ray Mobility. Foot & Ankle International. 23 (3), pp. 249 – 254 Glasoe, W.M., Yack, H.J., Saltzman, C.L. (1999). Measuring First Ray Mobility with a New Device. Archives of Physical Medicine and Rehabilitation. 80, pp. 122 – 124. Glasoe WM, Yack HJ, Saltzman CL. (2000). The reliability and validity of a first ray measurement device. Foot Ankle International. 21: pp 240–246. Grebing BR & Coughlin MJ. (2004). the effect of ankle position on the exam for first ray mobility. Foot Ankle International. 25: pp 466 – 476. Shirk C. Sandrey M.A. & Erickson. M. (2006). Reliability of First Ray Position and Mobility Measurements in Experienced and Inexperienced Examiners. Journal of Athletic Training. 41 (1), pp. 93 – 101. Voellmicke KV. & Deland JT. (2002). Manual examination technique to assess dorsal instability of the first ray. Foot Ankle International 23 (11): pp1039 -3 .   Read More