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Scaphoid fracture: A case report illustrating evidence-based diagnosis and discussing measures of reliability and concurrent criterion-related validity

Peter Huijbregts, PT, MSc, MHSc, DPT, OCS, CGIMS, FAAOMPT, FCAMT; Michelle Hobby, BA, MPT;
Penny Salmas, BPE, BSc PT, RCAMT, CGIMS

Peter Huijbregts, PT, MSc, MHSc, DPT, OCS, CGIMS, FAAOMPT, FCAMT

* Assistant Professor Online Education, University of St. Augustine for Health Sciences; * Residency Coordinator/Mentor, OMPT Residency Program Shelbourne Physiotherapy Clinic; * Consultant Physiotherapist, Shelbourne Physiotherapy Clinic Michelle Hobby, BA, MPT

* Resident, OMPT Residency Program Shelbourne Physiotherapy Clinic; * DPT Student, University of St. Augustine for Health Sciences Penny Salmas, BPE, BSc PT, RCAMT, CGIMS

* Mentor, OMPT Residency Program Shelbourne Physiotherapy Clinic; * Owner/Physiotherapist, Shelbourne Physiotherapy Clinic

Introduction
Physiotherapists establish a diagnosis and a prognosis by way of history taking, systems review, and tests and measures1. The data collected in these processes are used to determine whether the patient will benefit from physiotherapy intervention or needs to be referred for (co-)management with another health care provider. A patient presenting to physiotherapy with an undiagnosed fracture is not only a prime example illustrating the need for referral to a medical physician, but also a plausible scenario in jurisdictions where physiotherapists are allowed to act as direct access health care providers. The British Columbia Health Professions Act2 clearly limits physiotherapy scope of practice disallowing treatment of a recent fracture, except when under physician direction and, therefore, signs and symptoms indicative of a scaphoid fracture constitute a clear indication for referral to a physician in this prvince (and likely also in other jurisdictions).

Evidence-based practice (EBP) represents a recent and major paradigm shift within medicine and allied health education and clinical practice from a reliance on authority-based knowledge and anecdotal evidence to the use of research-based evidence. However, research is not the sole component of EBP: Sackett et al3 defined evidence- based medicine as the process of integrating the best research evidence available with both clinician expertise and patient values. For history items and tests and measures to be clinically useful for diagnosis, prognosis, and treatment planning within the EBP paradigm, the data they yield need to be reliable, valid, and responsive to clinically relevant change1. In the clinical scenario introduced above of a patient presenting to physiotherapy with signs and symptoms indicative of a scaphoid fracture, the question the physiotherapist needs to answer is, when is the probability of a scaphoid fracture high enough to warrant referral to a physician? Knowledge of the statistical measures associated with reliability and concurrent criterion-related validity of available diagnostic tests is a prerequisite to answer this question based on research evidence.

The goal of this article is threefold:

  • To discuss the process of evidence-based diagnosis
  • To discuss the statistical measures associated with reliability and concurrent criterion-related validity of diagnostic tests and measures
  • To illustrate evidence-based diagnosis (and the use of statistical measures of reliability and validity) using the example of a patient with a suspected scaphoid fracture

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