Hip Joint Rotation Range of Motion (ROM) in Adults: Analysis

Critical Evaluation of Article

Summary: To update the available data, P. Kouyoumdjian et al. in the ‘Clinical evaluation of hip joint rotation range of motion (ROM) in adults’, hypothesised that there was symmetry in the hip joint rotation ROM and the results showed no change with regards to patient’s position. 120 healthy Caucasian adults, between 20-60 years old, have been evaluated for external rotation (ER) and internal rotation (IR) ROM with a photographic method. No significant difference was seen between the 3 positions. Hips were symmetrical in more than half the population. The paper has received a satisfactory grade for inter-tester reproducibility. Patients with an increased BMI and/or age and/or male gender were ER predominant. The authors infer ER predominance in total hip arthroplasty (THA) in older subjects with bigger BMI.

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Abstract: The paper is well structured, has an easily understandable summary, however, it is too long and includes too much detail (Provenzale, Stanley 2006). Since results for hip joint ROM differ with cultural habits in distinct areas (Ahlberg et al. 1988), the race type used should be mentioned. Numerical typing mistake as total articular rotation (TAR) in position 3 (P3) and ER both equal 78.5⁰, when ER should equal less. The concordance correlation coefficient (ccc) appears in the text as ‘(ccc>0.7)’, while in the abstract is missing the greater than sign and the parenthesis is placed wrong. The same coefficient appears in more detail in the abstract (to the 4^th decimal place) for P2 and P3 compared to the written results.

Introduction: The introduction is concise, yet very short, having a clouded purpose stemming from the large number of issues raised (Provenzale, Stanley 2006). The authors appear subjective and their decision to write another article is based on a gross approximation rather than on a review of the available literature.

Aim and hypothesis: The aim and hypothesis are clearly defined (Provenzale, Stanley 2006). As the hypothesis was verifying 2 facts, it could have been split into 2 individual hypotheses. The study would also have benefited from 2 null hypotheses (Ramachandran, Tsokos 2015). More than 1/3 of the introduction talks about arthroplasty which creates the expectation that the hypothesis will include it as well.

Methods and statistical analysis: The method section is clear and the amount of detail makes it reproducible to a great extent (Provenzale, Stanley 2006). The researchers opt for digital photography with no explanation as to why it is better than conventional methods (Provenzale, Stanley 2006). The method and statistical analysis allow for testing both parts of the hypothesis (Provenzale, Stanley 2006). The authors should have mentioned that the table should be level and the thigh should be parallel to the floor (Van Dillen 2008). The statistics appear sound, but could have benefited from a better explanation (Marmolejo-Ramos, Tian 2010). Assessing BMI is not a clear indicator as movement can be obstructed by the amount of adipose tissue (Park et al. 2010).

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Results and statistical analysis: Most results are clearly explained but not in the order they were introduced in the method (Provenzale, Stanley 2006). Typing or mathematical calculation mistakes were apparent in TAR for positions 2 and 3; these could be software approximations since the error is small (0.1⁰). Similarly, Table 2 contains an error in P3 TAR and P2 IR recording a 0.1 difference compared to the written text. The values for inter-tester reproducibility are not written consistently with an alternation between 4 decimal places for ccc in P1, and 3 decimal places for ccc in P2 and P3. The values of IR and ER in Table 3 should have been interpreted as IR (>0.77) having a better agreement than ER (>0.69). Not all statistical values or their meanings have been explained in their representative sections. They haven’t used any graphs, even though enough statistical tests were obtained for a boxplot and scatter plot. They made good use of tables and figures, except in Table 4. Group 3 IRIR. A few inferences and conclusions are taken in this section that should actually be part of the Discussion.

Discussion: The discussion is not concise, with extensive explanation on goniometry which is not used. The authors should have focused on why photography is ‘rapid and precise’ (Kouyoumdjian et al. 2006) and acknowledge its limitations and possible errors, as done by others (Hu et al. 2006; Almeida 2012). When compared to literature, some of the non-matching results were justified (Provenzale, Stanley 2006). However, these findings were presented in a chaotic manner (Provenzale, Stanley 2006). Predominance values for balanced, ER and IR are mentioned in the discussion, while neither their calculation nor result appear in the representative sections. Table 5 should have been mentioned together with the studies appearing in the text for a good visual comparison, rather than at the start. Limitations include: skin movement, variation in the pelvis version, sport and radiology. The hypothesis is split in 2 and mixed with other observations. The authors concluded there is no significant difference with regard to position. They should have mentioned another paper to back their claim, but instead chose to compare it to an experiment on active rotation that contradicts their result (Simoneau et al. 1998). The symmetry aspect of the hypothesis is validated in conjunction with literature results. Other verified findings are being male, an increase in BMI and/or an increase in age give predominant ER.

Conclusion: The conclusion is part of the discussion and is not clearly defined (Provenzale, Stanley 2006). The first part of the hypothesis (symmetry) is reiterated and confirmed, while for the second part (position), the authors states their findings without comparing them to appropriate literature. The paper infers that ER predominance might apply to patients with THA that are older with a high BMI, but states that further tests should be done.

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Formatting a paper: The article has a clear and short title with contributing authors mentioned below. It is split into the aforementioned appropriate sections, tables and figures have numbers and well written captions, a reference list is provided, abbreviations follow after the full words have been used once (e.g. ROM) but should not be found in the abstract (Hull 2014). The article is not written concisely throughout and a few observations from the results section are repeated in the discussion. The text is not cohesive or organised (Hull 2014).

The language: The article uses formal scientific language in first and third person, past tense, active voice, in short sentences with minimal empty phrases (Carter 2013). But the authors are inconsistent with the words used e.g. patients/subjects (Provenzale, Stanley 2006). The discussion contains one misspelled word ‘by’ where authors meant ‘but’. ‘Cylindrical’ would be the more appropriate word, rather than the archaic ‘cylindric’. Translation mistakes from French are observed in the method, where ‘et’ is used instead of ‘and’ and in Table 5 where M/W appear as H/F (homme/femme).

Final conclusion: The purpose was unclear and the main questions have been answered before. The method was good, but the results section was unorganised and filled with errors. The discussion compared many studies but hasn’t talked about the results obtained in this study. The hypothesis is not proven in its entirety and assumptions are made at the end for THA patients. Overall there was no need for another paper on this topic.

References.

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Ahlberg A, Moussa M, Al-Nahdi M, 1988 On geographical variations in the normal range of joint motion Clinical orthopaedics related research 234:229–231

Almeida GPL, De Souza VL, Sano SS, Saccol MF, Cohen M, 2012 Comparison of hip rotation range of motion in judo athletes with and without history of low back pain Manual therapy 17:231-235

Carter M, 2013 Designing scientific presentations [e-book] Elsevier Academic Press Available through: Science direct website http://www.sciencedirect.com/science/article/pii/B9780123859693000118 [accessed 26^th February 2015]

Hu H, Li Z, Wang X, Xiao W, Ja D, Zheng L, 2006 Measurements of voluntary joint range of motion of the Chinese elderly living in Beijing area by a photographic method International journal of industrial ergonomics 36:861–867.

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Hull E, 2014 EASE guidelines for authors and translators of scientific articles to be published in English [e-book] Available through: EASE website http://www.ease.org.uk/sites/default/files/ease_guidelines-june2014-english.pdf [accessed 23^rd February 2015]

Kouyoumdjian K, Coulomb R, Sanchez T, Asencio G, 2012 Clinical evaluation of hip joint rotation range of motion in adults Orthopedic and traumatology: surgery and research 98:17-23

Marmolejo-Ramos F, Tian TS, 2010 The shifting boxplot. A boxplot based on essential summary statistics around the mean International journal of psychological research 3:37-45

Park W, Ramachandran J, Weisman P, Jung ES, 2010 Obesity effect on male active joint range of motion Ergonomics 53:102-108

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Provenzale JP, Stanley JS, 2006 A systematic guide to reviewing a manuscript Journal of nuclear medicine technology 34:92-99

Ramachandran KM, Tsokos CP, 2015 Mathematical statistics with applications in R (2nd ed.) [e-book] Amsterdam: Elsevier Academic Press Available through: Elsevier website http://booksite.elsevier.com/samplechapters/9780123748485/Sample_Chapters/01~Front_Matter.pdf [accessed 25^rd February 2015]

Simoneau GG, Hoenig KG, Lepley JE, Papanek PE, 1998 Influence of hip position and gender on active hip internal and external rotation Journal of orthopaedic sports and physical therapy 28:158-64

Van Dillen LR, Bloom NJ, Gombatto SP, Susco TM, 2008 Hip rotation range of motion in people with and without low back pain who participate in rotation-related sports Physical Therapy in Sport 9:72–81

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