Measuring Up to Expectation: Cognitive Bias in Wrist Range-of-Motion Measurement - PDF

[ research report ] NIRIT ROTEM-LEHRER, PT, MSc1 NATALI SINGER, PT2 OFRI R...

[ research report ] NIRIT ROTEM-LEHRER, PT, MSc1 NATALI SINGER, PT2 OFRI RESHIT, PT2 SHMUEL SPRINGER, PT, PhD2 Measuring Up to Expectation: Cognitive Bias in Wrist Downloaded from www.jospt.org at Long Island University Library on January 12, 2024. For personal use only. No other uses without permission. Range-of-Motion Measurement P hysical therapy assessment and diagnosis is the process by Most daily thought processes are ac- which information is sought and gathered from various sources, complished by relying on the intuitive using several tools, including specific tests and measures.12 The system, as it is a proficient way to deal with the abundance of information avail- information gathered is important in establishing the correct able and the constant need for decision diagnosis, assessing impairments, setting up relevant treatment goals, making.13 However, at times, this auto- and following up on patients’ progress.15 Thus, the test and measures matic process can lead to erroneous deci- Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. used in this process need to be valid, reliable, and insusceptible to bias. sions, and there is often a link between intuitive thinking and cognitive errors.22 Cognitive bias is defined as systematic vironments.5 The term cognitive bias in The role of cognitive biases and their error in judgment and decision making clinical reasoning was introduced by so- effect on diagnosis, treatment, and out- common to all human beings that may be cial scientists as part of the dual-process comes have become the focus of a grow- due to cognitive limitations, motivational theory, which splits decision making into ing body of research in medical practice, factors, and/or adaptations to natural en- intuitive and analytical processes.9,23,26 based on a greater understanding of their effects.7,8,10 A cognitive bias that has been especially well studied in medicine is the TTSTUDY DESIGN: Controlled laboratory study, Journal of Orthopaedic & Sports Physical Therapy® An analysis of covariance was applied to test for anchoring bias, a focus on one feature cross-sectional design. differences between the 3 groups while controlling of the patient’s presentation such that TTBACKGROUND: The role of cognitive biases for any potential sex and experience effects. other information gathered in the diag- and their effect on a wide range of aspects relevant TTRESULTS: The analysis of covariance yielded a to clinical medicine has become the focus of a nosis process is neglected.31 For example, significant group effect (P =.009), with no signifi- growing body of research, yet their effect in physi- cant effect for sex and experience. The adjusted Pothier et al27 demonstrated that the in- cal therapy is not well established. mean wrist ROM was 80.2° for the no-bias group, troduction of a subliminal anchor, such TTOBJECTIVES: To test whether anchoring 74.5° for the moderate-bias group, and 72.4° for as writing the last 2 digits of a mobile information provided to physical therapists prior to the substantial-bias group. Post hoc tests dem- telephone number, affected the decision assessment of wrist range of motion (ROM) may onstrated significant difference only between the making of medical students who were induce bias in the measurement. group with no bias and the substantial-bias group given questions in which a numerical es- TTMETHODS: A total of 120 physical therapists (mean difference, 7.7°; P =.009). timation was required. participated in the study. Participants were asked TTCONCLUSION: Anchoring information was Another method to evaluate cognitive to measure passive wrist extension ROM of a associated with differential results of an objective bias is by investigating how the patient’s 65-year-old woman with no history of injury to the test. Physical therapists should increase their upper limb using a universal goniometer. Before clinical history affects the subsequent awareness of biases and consider employing initiating the measurement, some participants re- interpretation of test data. A study by debiasing strategies. J Orthop Sports Phys ceived a clinical description, which included sham Hatala et al18 demonstrated that for phy- Ther 2016;46(12):1037-1041. Epub 30 Oct 2016. information about the patient’s health history. sicians at all levels of expertise, clinical doi:10.2519/jospt.2016.6845 Three groups were differentiated according to the TTKEY WORDS: anchoring information, history may influence echocardiogram provided clinical content: no bias (n = 38), moder- ate bias (n = 41), and substantial bias (n = 41). assessment, diagnosis, physical therapy diagnostic accuracy, improving it when the history suggests the correct diagnosis 1 Department of Physical Therapy, Hadassah Medical Center, Jerusalem, Israel. 2Department of Physiotherapy, Faculty of Health Sciences, Ariel University, Ariel, Israel. The study was approved by the Institutional Review Board of the Department of Physiotherapy at Ariel University. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Shmuel Springer, Department of Physiotherapy, Hubert Building, Room 412, Ariel University, Ariel, Israel 40700. E-mail: [email protected] t Copyright ©2016 Journal of Orthopaedic & Sports Physical Therapy® journal of orthopaedic & sports physical therapy | volume 46 | number 12 | december 2016 | 1037 46-12 Lehrer.indd 1037 11/16/2016 5:55:52 PM  [ research report ] and reducing it when the history suggests to clear bony landmarks. However, the volunteer in a seated position, with her an alternative diagnosis. susceptibility of ROM measurements to forearm resting on a supporting surface The possibility of cognitive bias in expectations and anchoring bias has not and her hand free to move, the shoulder physical therapy decision making has been studied. positioned at 90° of abduction, and the also been acknowledged.19,24 However, the The aim of the present study was to forearm perpendicular to the floor (90° biasing effect of anchoring information ascertain whether anchoring information of flexion at the elbow). When the exam- Downloaded from www.jospt.org at Long Island University Library on January 12, 2024. For personal use only. No other uses without permission. was not always shown. For example, Sol- provided to physical therapists, prior to iner was satisfied that each participant omon and Prkachin29 examined whether wrist ROM testing, would affect the re- had completed the measurement, the ex- providing data on compensation status sult of the measurement. aminer documented the angle in whole of patients would influence pain ratings degrees. Participants were instructed to evaluated by physical and occupational METHODS refrain from conversing with the patient, therapists. Therapists were shown a video and she was instructed to do the same. of patients undergoing painful shoulder Procedure Three measurements were taken by each T tests and were asked to rate the pain the he study was approved by the participant. The average value of the 3 patients were experiencing based exclu- Institutional Review Board of the repetitions was used for data analysis. sively on their facial expression of pain. Department of Physiotherapy at Before initiating the measurement, In this study, prior knowledge of compen- Ariel University, Israel. All participants each participant received a short de- sation status did not affect the ratings by signed an informed-consent form in scription of the clinical background of the the therapists.29 which the purpose of the study was stat- measured volunteer. In order to induce a Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. While the effect of cognitive biases ed to be reliability parameters of wrist cognitive bias, some participants received on interpretation of test data has been ROM testing. The study was conducted a clinical description that included mis- investigated, recognized, and well estab- during the annual conference of the Is- leading information regarding the tested lished,7,8 cognitive biases may also affect raeli Physical Therapy Society in 2015. volunteer’s health history. The false infor- the way of performing tests and mea- A convenience sample of physical thera- mation given to the participant was de- sures. A bias affecting the performance of pists attending the conference was asked veloped by the researchers on the basis of a test or measure diminishes its reliability to participate in the study. The inclusion common clinical scenarios and patients’ and validity, thus negatively affecting the criteria were active clinical practitioners, presentations. The final methodology in- utility of the test in making clinical deci- previous experience with the use of a cluded 3 levels of clinical content, a true Journal of Orthopaedic & Sports Physical Therapy® sions.21,23 However, the effect of bias on goniometer, and no visual or motor im- clinical background and 2 other back- execution of clinical tests has not been pairments that may affect the ability to grounds with fictitious information. The studied. In fact, some of the tests are a use a goniometer. The participants were true background was, “The tested volun- part of what is considered in physical asked to measure wrist extension pas- teer is a 65-year-old healthy female.” The therapy nomenclature as “objective ex- sive ROM using a universal goniometer. 2 bias-inducing false backgrounds were, amination,” implying that they are less A large poster describing the standard “The tested volunteer is a 65-year-old or not prone to bias that will affect their wrist passive ROM procedure, including healthy female who had a distal radius execution.2,16 pictures of exact placements of the go- fracture 1 year ago,” regarded as inducing The measurement of joint range of niometer arms, was posted in the booth moderate bias; and “The tested volunteer motion (ROM) is a procedure often uti- where the test took place to ensure that is a 65-year-old healthy female who had lized by physical therapists, being part it would be visible to participants. There a distal radius fracture 1 year ago and of the basic curricula in physical therapy were no special instructions regarding suffers from pain and functional limita- and regarded as an essential skill for cli- the level of overpressure during the test. tions,” regarded as inducing substantial nicians.16 The psychometric properties The patient to be tested in this study was bias. The patient was blinded to the of ROM tests have been well researched a 65-year-old female volunteer who had group allocation of the participants. The and evaluated,16,34 specifically in the most no history of musculoskeletal or neu- description of the clinical background common way of testing ROM, which is rological injury to the upper limb. The was altered so that every 5 participants by using a goniometer.25 Wrist ROM go- testing session was performed at a des- received a different background descrip- niometry has been described and used in ignated isolated booth in the conference tion, of the 3 available. research and clinical settings4 and found hall. A standard protocol used for wrist to be reliable, with relatively small varia- passive ROM measurement by univer- Data Analysis tion of results.2,6,14,16,30 It also should be sal goniometry was used and provided Three groups were differentiated accord- noted that wrist ROM goniometry has a to the participants.25 The wrist passive ing to the provided clinical content: no simple measuring technique, mainly due ROM was measured with the tested bias, moderate bias, and substantial bias. 1038 | december 2016 | volume 46 | number 12 | journal of orthopaedic & sports physical therapy 46-12 Lehrer.indd 1038 11/16/2016 5:55:52 PM  Descriptive statistics were used to pres- ent participants’ characteristics and the Participant Characteristics TABLE 1 ROM measurement results (mean  and Passive ROM Measure for Each Group SD) for each group. Analysis of covari- ance (ANCOVA) was applied to test for No Bias (n = 38) Moderate Bias (n = 41) Substantial Bias (n = 41) differences between the 3 groups while Passive ROM measure, deg* 79.9  9.6 74.7  12.3 72.5  11.5 Downloaded from www.jospt.org at Long Island University Library on January 12, 2024. For personal use only. No other uses without permission. controlling for any potential sex and ex- Sex, n perience effects (covariates). In addition, Male 18 18 14 the mean differences, the 95% confidence Female 20 23 27 intervals, the standard error of measure- Seniority as physical therapist, y* 15.5  11.2 12.3  8.9 12.6  11.0 ment (SEM), and the effect size based Abbreviation: ROM, range of motion. *Values are mean  SD. on partial eta-square were calculated. A partial eta-square equal to or greater than 0.01 presents a small effect, equal to or greater than 0.06 presents a medium Analysis of Covariance–Adjusted TABLE 2 effect, and equal to or greater than 0.14 Passive ROM Measure for Each Group presents a strong effect.20 The ANCOVA was followed by pairwise comparisons Group Adjusted Passive ROM Measure, deg* Standard Error, deg based on the Šidák correction for t test- No bias 80.2 (76.5, 83.8) 1.8 Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. ing. SPSS (IBM Corporation, Armonk, Moderate bias 74.5 (71.0, 78.0) 1.8 NY) was used for statistical analyses. The Substantial bias 72.4 (68.9, 75.9) 1.8 significance level was set at P