Journal of Sport Rehabilitation, 2015, 24, 214 -218 http://dx.doi.org/10.1123/jsr.2013-0135 © 2015 Human Kinetics, Inc.
CRITICALLY APPRAISED TOPIC
Reliability of Clinician Scoring of the Landing Error Scoring System to Assess Jump-Landing Movement Patterns Jessica G. Markbreiter, Bronson K. Sagon, Tamara C. Valovich McLeod, and Cailee E. Welch Clinical Scenario: An individual’s movement patterns while landing from a jump can predispose him or her to lower-extremity injury, if performed improperly. The Landing Error Scoring System (LESS) is a clinical tool to assess jump-landing biomechanics as an individual jumps forward from a box. Improper movement patterns, which could predispose an individual to lower-extremity injuries, are scored as errors. However, because of the subjective nature of scoring errors during the task, the consistency and reliability of scoring the task are important. Since the LESS is a newer assessment tool, it is important to understand its reliability. Focused Clinical Question: Are clinicians reliable at scoring the LESS to assess jump-landing biomechanics of physically active individuals? Keywords: prevention, functional movement, clinical task
Clinical Scenario An individual’s movement patterns while landing from a jump can predispose him or her to lower-extremity injury, if performed improperly. The Landing Error Scoring System (LESS) is a clinical tool to assess jumplanding biomechanics as an individual jumps forward from a box.1–3 Improper movement patterns, which could predispose an individual to lower-extremity injuries, are scored as errors. However, because of the subjective nature of scoring errors during the task, the consistency and reliability of scoring the task are important. Since the LESS is a newer assessment tool, it is important to understand its reliability.
Focused Clinical Question Are clinicians reliable at scoring the LESS to assess jumplanding biomechanics of physically active individuals?
Summary of Search, “Best Evidence” Appraised, and Key Findings • The literature was searched for studies of level 3 evidence or higher that investigated clinicians’ scoring reliability of the LESS. The authors are with the Athletic Training Program, A.T. Still University, Mesa, AZ. Address author correspondence to Cailee Welch at [email protected].
214
• The literature search returned 7 studies that investigated the LESS, but 4 studies did not specifically address the clinical question and were excluded from the appraisal. • All 3 studies1–3 reported good interrater reliability for clinicians’ scoring of the LESS
Clinical Bottom Line There is moderate evidence to indicate that clinicians, even novice raters, are reliable at scoring the LESS to assess jump-landing biomechanics via 2-dimensional video analysis, as well as during real time. The LESS is very low in cost when performed in real time. There may be more cost involved if the clinician chooses to use 2-dimensional video analysis to capture an individual’s LESS performance for later evaluation. Clinicians should consider using the LESS as part of preparticipation physical examinations to identify improper landing-movement patterns. Strength of Recommendation: Grade B evidence exists that clinicians are reliable in scoring the LESS to assess the jump-landing biomechanics of physically active individuals.
Search Strategy Terms Used to Guide Search Strategy • Patient/Client Group: physically active individuals or athletes • Intervention (or Assessment): Landing Error Scoring System or LESS
LESS Reliability 215
• Comparison: None • Outcome(s): interrater reliability
Implications for Practice, Education, and Future Research
Sources of Evidence Searched
Interrater reliability is the degree of agreement among raters. It can be measured using the intraclass correlation coefficient (ICC), a descriptive statistic measuring the variability between scores.7 The ICC has a range of 0 to 1.0, with scores closer to 1.0 indicating little variation between raters. Values >.80 are considered excellent, .40 to .80 are considered fair to good, and 5 to ≤6), and poor (LESS score >6).5 A higher LESS score indicates poor technique in landing from a jump; a lower LESS score indicates better jump-landing technique.5 Therefore, individuals with a LESS score >6 (poor) may be at risk for lower-extremity injury.5 Clinicians should implement the LESS as a screening tool to identify improper landing mechanics. The LESS can be administered during the preparticipation exam to identify those at risk for lower-extremity injury. The LESS can be set up in the athletic training room with a jump box 30 cm high and a platform or force plate placed at a distance 50% of the individual’s height. If using video
• The Cochrane Library • Clinical Key • MEDLINE • CINAHL • SPORTDiscus • Additional resources obtained via review of reference lists and hand search
Inclusion and Exclusion Criteria Downloaded by York Univ Libraries on 09/16/16, Volume 24, Article Number 2
Inclusion Criteria • Studies that investigated the interrater reliability of the LESS • Studies that included participants who were deemed healthy for the study • Limited to English language • Limited to the past 5 years (2009–2013)
Exclusion Criteria • Studies that included participants that were currently injured • Studies that did not investigate the interrater reliability of the LESS • Studies using level 4 evidence or lower
Results of Search Three relevant studies4–6 were located and categorized as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 2011).
Best Evidence The studies in Table 2 were identified as the best evidence and selected for inclusion in this critically appraised topic (CAT). These studies were selected because they were rated with a level 3 evidence or higher, investigated the LESS among physically active individuals, and measured the outcome of interest (interrater reliability). Table 1 Summary of Study Designs of Articles Retrieved Level of evidence
Study design
Number located
Reference
2b
Cohort study
1
Padua et al5
3b
Case-control study
2
Onate et al4 Padua et al6
JSR Vol. 24, No. 2, 2015
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Study design Intervention investigated
Onate et al4 Case-control A static trial was collected for calculation of the kinematic model. Three practice jumps off a 30-cmhigh box and landing with both feet on the force plate.
The jump-landing task required participants to jump forward from a 30-cm-high box, which was set at a distance of 50% of their height away from the target landing area. Participants were instructed to immediately rebound for a maximal vertical height on landing.
Padua et al6 Case-control A static trial was not collected. No practice jumps were reported.
On-the-field motion analysis, LESS, was performed and captured a frontal- and sagittal-plane view of each participant captured by 2 standard video cameras.
Electromagnetic sensors were placed on specific body landmarks. The laboratory-based motion analysis Flock of Birds, an electromagnetic motion-analysis system controlled by Motion-Monitor software, was used to assess lower-extremity kinematics at a sampling rate of 144 Hz. A nonconductive force plate collected ground-reaction forces. Force-plate data were collected synchronously with the kinematic data at a sampling rate of 1440 Hz.
A full-body kinematic model was created for each patient using Visual 3D. A Cardan-angle sequence was used to calculate joint angles.
force plates with a sampling rate of 500 Hz were used to measure ground-reaction forces. Two Sony Mini-DV Handycam camcorder DCR-HC40 video cameras with a sampling rate of 30 Hz were used to record the trials.
first trial was used to evaluate stance width, foot rotation, and initial foot contact. The second trial was used to evaluate knee and trunk frontal-plane motion. The third trial was used to assess how participants landed from the jump and knee sagittalplane motion. The fourth trial was used to evaluate trunk sagittal plane.
The jump-landing task required participants to not jump off the box but to shift their weight and lean and drop from the box as vertically as possible, in an attempt to standardize jump-height-landing requirements. Participants were instructed to imme- Participants performed 4 successful trials; no rest Participants performed 3 successful trials; no rest period was stated. An additional trial is required period was stated. No additional jump was required. A diately rebound for a maximal vertical height on to allow the rater to observe all 10 jump-landing successful jump was characterized by (1) jumping off landing. characteristics. A successful jump was characterof both feet from the box; (2) jumping forward off the Participants performed 3 successful trials with ized by (1) jumping off of both feet from the box; box, without a large upward motion after takeoff from 1-min rest periods between trials. No additional the box, to reach the force plate below; (3) landing jump was required. A successful jump was not char- (2) jumping forward off the box, without a large upward motion after takeoff from the box, to reach with the entire foot of the dominant lower extremity on acterized. Participants were not provided feedback the target landing area below; and (3) completing the force plate; (4) landing with the entire foot of the or coaching on their landing technique other than the task in a fluid motion. Participants were not nondominant lower extremity off the force plate; and task instruction. Practice trials not reported. (5) completing the task in a fluid motion. Participants Thirty-nine reflective markers were placed on spe- provided any feedback or coaching on their landing were not provided any feedback or coaching on their cific body landmarks according to the Helen Hayes technique other than task instruction. Participants landing technique other than task instruction. Partici- model. Eight high-speed video cameras were used were allowed as many practice trials as needed to pants were allowed as many practice trials as needed to monitor the motion analysis of the lower extrem- perform the task successfully. to perform the task successfully. No markers were placed on the participants. The ity, with a sampling rate of 500 Hz. Two Bertec
The jump-landing task incorporated vertical and horizontal movements as participants jumped from a 30-cm-high box to a distance of 50% of their height away from the box, down to a force platform. Participants were instructed to immediately rebound for a maximal vertical height on landing.
Padua et al5 Cohort A static trial was not collected. Two practice jumps were performed.
Table 2 Characteristics of Included Studies
Downloaded by York Univ Libraries on 09/16/16, Volume 24, Article Number 2
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217
Level of evidence Validity score Conclusion
Main findings
Outcome measures
N/A The LESS-RT demonstrates good interrater reliability and compares well with the original LESS. The LESS-RT can be used as clinical tool with the proper training, to identify individuals who may be at risk for noncontact ACL or other lower-extremity injuries.
N/A The interrater reliability between novice and expert clinicians was good for the overall LESS score.
N/A Clinician scoring of the LESS demonstrated good to excellent interrater and intrarater reliability.
The LESS can be used as a clinical tool for screening The LESS demonstrated moderate to excellent item to identify those at risk for noncontact ACL injury validity, suggesting that it can be used as a clinical and other serious lower-extremity injury. tool in ACL-injury prevention and a measure of dynamic jump-landing motion technique.
These findings indicated that the overall LESSreal-time (LESS-RT) scores have good interrater reliability (ICC .72–.81) and precision. The SEM ranged from .69 to .79. Agreement between raters was not assessed. Poor LESS-RT scores were associated with decreased knee, hip, and trunk flexion; landing heel-to-toe; knee valgus with tibial external or internal rotation; and asymmetrical foot contact and foot position. No differences were reported based on sex. 3b
Padua et al6 ICC and SEM values for interrater reliability.
Onate et al4 ICC was used between novice and expert raters. SEM was not calculated. Kappa values/statistics were used to measure agreement between raters. Phi-correlation-coefficient analysis measured the association between 2 dichotomous variables. The findings indicated that the overall LESS score Overall LESS score interrater reliability was good has good interrater reliability (ICC = .84, SEM = .71) with an ICC = .835 and P < .001. The findings and excellent intrarater reliability (ICC = .91, SEM indicated there was excellent reliability between = .42). Agreement between raters was not assessed. the novice and expert LESS overall scores (κ = Poor LESS scores were associated with decreased .459–.875). Results showed moderate to excellent knee- and hip-flexion angle, increased knee valgus agreement between raters with excellent agreement and hip-adduction angle, increased internal knee and ranging from 84% to 100%. The validity of the hip internal rotation, increased internal knee and hip LESS compared with 3-dimensional motion analyextension and anterior tibial sheer force, and increased sis varied on the item being tested. No differences internal knee valgus and hip adduction. Women had were reported based on sex. worse LESS scores than men. 2b 3b
Padua et al5 Intraclass correlation coefficient (ICC) and standard error of measure (SEM) for interrater and intrarater reliability. Compared LESS groups by sex using the chi-square test.
Table 2 (continued)
Downloaded by York Univ Libraries on 09/16/16, Volume 24, Article Number 2
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218 Markbreiter et al
scoring of the LESS, 2 cameras should be set up in the frontal and sagittal plane approximately 136 in from the force plate. The LESS with video and real-time analysis requires some training before administering. Clinicians interested in using the LESS as a screening tool should seek out an individual with expertise in administration and scoring to ensure they are properly trained. If using video analysis, then proper training and use of the video software is needed. It is suggested that clinicians wanting to implement this tool in their clinical setting should be well versed in how to score the LESS before doing so. Clinical implications for the use of the LESS are for the detection of poor biomechanics in the lower extremity that could potentially increase the chances of suffering an injury to the lower extremity. The LESS has been shown to be moderately effective when used as a clinical tool to detect individuals who may be predisposed to an ACL injury. All 3 studies4–6 suggested that the LESS could be used to detect individuals who are susceptible to ACL injury. In addition, clinicians may be able to take the information from the LESS to help identify higherrisk individuals with poor jump-landing biomechanics, determining lower-extremity injury-prevention programs, ACL-injury-prevention programs, and treatment plans specific to the higher-risk individuals. Future research should include studies focused on sport-specific patient populations and the continuation of comparison between females and males on the LESS. Future studies should be conducted after ACL-injuryprevention programs have been implemented, comparing new LESS scores with the initial LESS scores. This CAT should be reviewed in 2 years or when additional best evidence becomes available to determine whether additional best evidence has been published that may
change the clinical bottom line for the research question posed in this review.
References 1. Boling M, Thigpen CA, Padua DA, Marshall SW. Item specific reliability analyses of the Landing Error Scoring System (LESS). Med Sci Sports Exerc. 2005;37:S124. 2. Padua D, Marshall SW, Beutler AI, DeMaio M, Onate JA, Guskiewicz KM. Sex comparison of jump landing kinematics and technique. Med Sci Sports Exerc. 2004;36(5):S348. 3. Padua DA, Marshall SW, Onate JA, et al. Reliability and validity of the landing error scoring system: implications on ACL injury risk assessment. J Athl Train. 2004;39:S110–S111. 4. Onate J, Cortes N, Welch C, Van Lunen B. Expert versus novice interrater reliability and criterion validity of the Landing Error Scoring System. J Sport Rehabil. 2010;19(1):41–56. PubMed 5. Padua DA, Marshall S, Boling M, Thigpen C, Garrett W, Beutler A. The Landing Error Scoring System (LESS) is a valid and reliable clinical assessment tool of jump-landing biomechanics: the Jump-ACL study. Am J Sports Med. 2009;37(10):1996–2002. PubMed doi:10.1177/0363546509343200 6. Padua DA, Boling M, DiStefano L, Onate J, Beutler A, Marshall S. Reliability of the Landing Error Scoring System-real time, a clinical assessment tool of jump-landing biomechanics. J Sport Rehabil. 2011;20(2):145–156. PubMed 7. Portney L, Watkins M. Foundations of Clinical Research: Applications to Practice. 3rd ed. Upper Saddle River, NJ: Prentice Hall Health; 2008.
JSR Vol. 24, No. 2, 2015
CRITICALLY APPRAISED TOPIC
Reliability of Clinician Scoring of the Landing Error Scoring System to Assess Jump-Landing Movement Patterns Jessica G. Markbreiter, Bronson K. Sagon, Tamara C. Valovich McLeod, and Cailee E. Welch Clinical Scenario: An individual’s movement patterns while landing from a jump can predispose him or her to lower-extremity injury, if performed improperly. The Landing Error Scoring System (LESS) is a clinical tool to assess jump-landing biomechanics as an individual jumps forward from a box. Improper movement patterns, which could predispose an individual to lower-extremity injuries, are scored as errors. However, because of the subjective nature of scoring errors during the task, the consistency and reliability of scoring the task are important. Since the LESS is a newer assessment tool, it is important to understand its reliability. Focused Clinical Question: Are clinicians reliable at scoring the LESS to assess jump-landing biomechanics of physically active individuals? Keywords: prevention, functional movement, clinical task
Clinical Scenario An individual’s movement patterns while landing from a jump can predispose him or her to lower-extremity injury, if performed improperly. The Landing Error Scoring System (LESS) is a clinical tool to assess jumplanding biomechanics as an individual jumps forward from a box.1–3 Improper movement patterns, which could predispose an individual to lower-extremity injuries, are scored as errors. However, because of the subjective nature of scoring errors during the task, the consistency and reliability of scoring the task are important. Since the LESS is a newer assessment tool, it is important to understand its reliability.
Focused Clinical Question Are clinicians reliable at scoring the LESS to assess jumplanding biomechanics of physically active individuals?
Summary of Search, “Best Evidence” Appraised, and Key Findings • The literature was searched for studies of level 3 evidence or higher that investigated clinicians’ scoring reliability of the LESS. The authors are with the Athletic Training Program, A.T. Still University, Mesa, AZ. Address author correspondence to Cailee Welch at [email protected].
214
• The literature search returned 7 studies that investigated the LESS, but 4 studies did not specifically address the clinical question and were excluded from the appraisal. • All 3 studies1–3 reported good interrater reliability for clinicians’ scoring of the LESS
Clinical Bottom Line There is moderate evidence to indicate that clinicians, even novice raters, are reliable at scoring the LESS to assess jump-landing biomechanics via 2-dimensional video analysis, as well as during real time. The LESS is very low in cost when performed in real time. There may be more cost involved if the clinician chooses to use 2-dimensional video analysis to capture an individual’s LESS performance for later evaluation. Clinicians should consider using the LESS as part of preparticipation physical examinations to identify improper landing-movement patterns. Strength of Recommendation: Grade B evidence exists that clinicians are reliable in scoring the LESS to assess the jump-landing biomechanics of physically active individuals.
Search Strategy Terms Used to Guide Search Strategy • Patient/Client Group: physically active individuals or athletes • Intervention (or Assessment): Landing Error Scoring System or LESS
LESS Reliability 215
• Comparison: None • Outcome(s): interrater reliability
Implications for Practice, Education, and Future Research
Sources of Evidence Searched
Interrater reliability is the degree of agreement among raters. It can be measured using the intraclass correlation coefficient (ICC), a descriptive statistic measuring the variability between scores.7 The ICC has a range of 0 to 1.0, with scores closer to 1.0 indicating little variation between raters. Values >.80 are considered excellent, .40 to .80 are considered fair to good, and 5 to ≤6), and poor (LESS score >6).5 A higher LESS score indicates poor technique in landing from a jump; a lower LESS score indicates better jump-landing technique.5 Therefore, individuals with a LESS score >6 (poor) may be at risk for lower-extremity injury.5 Clinicians should implement the LESS as a screening tool to identify improper landing mechanics. The LESS can be administered during the preparticipation exam to identify those at risk for lower-extremity injury. The LESS can be set up in the athletic training room with a jump box 30 cm high and a platform or force plate placed at a distance 50% of the individual’s height. If using video
• The Cochrane Library • Clinical Key • MEDLINE • CINAHL • SPORTDiscus • Additional resources obtained via review of reference lists and hand search
Inclusion and Exclusion Criteria Downloaded by York Univ Libraries on 09/16/16, Volume 24, Article Number 2
Inclusion Criteria • Studies that investigated the interrater reliability of the LESS • Studies that included participants who were deemed healthy for the study • Limited to English language • Limited to the past 5 years (2009–2013)
Exclusion Criteria • Studies that included participants that were currently injured • Studies that did not investigate the interrater reliability of the LESS • Studies using level 4 evidence or lower
Results of Search Three relevant studies4–6 were located and categorized as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 2011).
Best Evidence The studies in Table 2 were identified as the best evidence and selected for inclusion in this critically appraised topic (CAT). These studies were selected because they were rated with a level 3 evidence or higher, investigated the LESS among physically active individuals, and measured the outcome of interest (interrater reliability). Table 1 Summary of Study Designs of Articles Retrieved Level of evidence
Study design
Number located
Reference
2b
Cohort study
1
Padua et al5
3b
Case-control study
2
Onate et al4 Padua et al6
JSR Vol. 24, No. 2, 2015
216
JSR Vol. 24, No. 2, 2015
Study design Intervention investigated
Onate et al4 Case-control A static trial was collected for calculation of the kinematic model. Three practice jumps off a 30-cmhigh box and landing with both feet on the force plate.
The jump-landing task required participants to jump forward from a 30-cm-high box, which was set at a distance of 50% of their height away from the target landing area. Participants were instructed to immediately rebound for a maximal vertical height on landing.
Padua et al6 Case-control A static trial was not collected. No practice jumps were reported.
On-the-field motion analysis, LESS, was performed and captured a frontal- and sagittal-plane view of each participant captured by 2 standard video cameras.
Electromagnetic sensors were placed on specific body landmarks. The laboratory-based motion analysis Flock of Birds, an electromagnetic motion-analysis system controlled by Motion-Monitor software, was used to assess lower-extremity kinematics at a sampling rate of 144 Hz. A nonconductive force plate collected ground-reaction forces. Force-plate data were collected synchronously with the kinematic data at a sampling rate of 1440 Hz.
A full-body kinematic model was created for each patient using Visual 3D. A Cardan-angle sequence was used to calculate joint angles.
force plates with a sampling rate of 500 Hz were used to measure ground-reaction forces. Two Sony Mini-DV Handycam camcorder DCR-HC40 video cameras with a sampling rate of 30 Hz were used to record the trials.
first trial was used to evaluate stance width, foot rotation, and initial foot contact. The second trial was used to evaluate knee and trunk frontal-plane motion. The third trial was used to assess how participants landed from the jump and knee sagittalplane motion. The fourth trial was used to evaluate trunk sagittal plane.
The jump-landing task required participants to not jump off the box but to shift their weight and lean and drop from the box as vertically as possible, in an attempt to standardize jump-height-landing requirements. Participants were instructed to imme- Participants performed 4 successful trials; no rest Participants performed 3 successful trials; no rest period was stated. An additional trial is required period was stated. No additional jump was required. A diately rebound for a maximal vertical height on to allow the rater to observe all 10 jump-landing successful jump was characterized by (1) jumping off landing. characteristics. A successful jump was characterof both feet from the box; (2) jumping forward off the Participants performed 3 successful trials with ized by (1) jumping off of both feet from the box; box, without a large upward motion after takeoff from 1-min rest periods between trials. No additional the box, to reach the force plate below; (3) landing jump was required. A successful jump was not char- (2) jumping forward off the box, without a large upward motion after takeoff from the box, to reach with the entire foot of the dominant lower extremity on acterized. Participants were not provided feedback the target landing area below; and (3) completing the force plate; (4) landing with the entire foot of the or coaching on their landing technique other than the task in a fluid motion. Participants were not nondominant lower extremity off the force plate; and task instruction. Practice trials not reported. (5) completing the task in a fluid motion. Participants Thirty-nine reflective markers were placed on spe- provided any feedback or coaching on their landing were not provided any feedback or coaching on their cific body landmarks according to the Helen Hayes technique other than task instruction. Participants landing technique other than task instruction. Partici- model. Eight high-speed video cameras were used were allowed as many practice trials as needed to pants were allowed as many practice trials as needed to monitor the motion analysis of the lower extrem- perform the task successfully. to perform the task successfully. No markers were placed on the participants. The ity, with a sampling rate of 500 Hz. Two Bertec
The jump-landing task incorporated vertical and horizontal movements as participants jumped from a 30-cm-high box to a distance of 50% of their height away from the box, down to a force platform. Participants were instructed to immediately rebound for a maximal vertical height on landing.
Padua et al5 Cohort A static trial was not collected. Two practice jumps were performed.
Table 2 Characteristics of Included Studies
Downloaded by York Univ Libraries on 09/16/16, Volume 24, Article Number 2
JSR Vol. 24, No. 2, 2015
217
Level of evidence Validity score Conclusion
Main findings
Outcome measures
N/A The LESS-RT demonstrates good interrater reliability and compares well with the original LESS. The LESS-RT can be used as clinical tool with the proper training, to identify individuals who may be at risk for noncontact ACL or other lower-extremity injuries.
N/A The interrater reliability between novice and expert clinicians was good for the overall LESS score.
N/A Clinician scoring of the LESS demonstrated good to excellent interrater and intrarater reliability.
The LESS can be used as a clinical tool for screening The LESS demonstrated moderate to excellent item to identify those at risk for noncontact ACL injury validity, suggesting that it can be used as a clinical and other serious lower-extremity injury. tool in ACL-injury prevention and a measure of dynamic jump-landing motion technique.
These findings indicated that the overall LESSreal-time (LESS-RT) scores have good interrater reliability (ICC .72–.81) and precision. The SEM ranged from .69 to .79. Agreement between raters was not assessed. Poor LESS-RT scores were associated with decreased knee, hip, and trunk flexion; landing heel-to-toe; knee valgus with tibial external or internal rotation; and asymmetrical foot contact and foot position. No differences were reported based on sex. 3b
Padua et al6 ICC and SEM values for interrater reliability.
Onate et al4 ICC was used between novice and expert raters. SEM was not calculated. Kappa values/statistics were used to measure agreement between raters. Phi-correlation-coefficient analysis measured the association between 2 dichotomous variables. The findings indicated that the overall LESS score Overall LESS score interrater reliability was good has good interrater reliability (ICC = .84, SEM = .71) with an ICC = .835 and P < .001. The findings and excellent intrarater reliability (ICC = .91, SEM indicated there was excellent reliability between = .42). Agreement between raters was not assessed. the novice and expert LESS overall scores (κ = Poor LESS scores were associated with decreased .459–.875). Results showed moderate to excellent knee- and hip-flexion angle, increased knee valgus agreement between raters with excellent agreement and hip-adduction angle, increased internal knee and ranging from 84% to 100%. The validity of the hip internal rotation, increased internal knee and hip LESS compared with 3-dimensional motion analyextension and anterior tibial sheer force, and increased sis varied on the item being tested. No differences internal knee valgus and hip adduction. Women had were reported based on sex. worse LESS scores than men. 2b 3b
Padua et al5 Intraclass correlation coefficient (ICC) and standard error of measure (SEM) for interrater and intrarater reliability. Compared LESS groups by sex using the chi-square test.
Table 2 (continued)
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218 Markbreiter et al
scoring of the LESS, 2 cameras should be set up in the frontal and sagittal plane approximately 136 in from the force plate. The LESS with video and real-time analysis requires some training before administering. Clinicians interested in using the LESS as a screening tool should seek out an individual with expertise in administration and scoring to ensure they are properly trained. If using video analysis, then proper training and use of the video software is needed. It is suggested that clinicians wanting to implement this tool in their clinical setting should be well versed in how to score the LESS before doing so. Clinical implications for the use of the LESS are for the detection of poor biomechanics in the lower extremity that could potentially increase the chances of suffering an injury to the lower extremity. The LESS has been shown to be moderately effective when used as a clinical tool to detect individuals who may be predisposed to an ACL injury. All 3 studies4–6 suggested that the LESS could be used to detect individuals who are susceptible to ACL injury. In addition, clinicians may be able to take the information from the LESS to help identify higherrisk individuals with poor jump-landing biomechanics, determining lower-extremity injury-prevention programs, ACL-injury-prevention programs, and treatment plans specific to the higher-risk individuals. Future research should include studies focused on sport-specific patient populations and the continuation of comparison between females and males on the LESS. Future studies should be conducted after ACL-injuryprevention programs have been implemented, comparing new LESS scores with the initial LESS scores. This CAT should be reviewed in 2 years or when additional best evidence becomes available to determine whether additional best evidence has been published that may
change the clinical bottom line for the research question posed in this review.
References 1. Boling M, Thigpen CA, Padua DA, Marshall SW. Item specific reliability analyses of the Landing Error Scoring System (LESS). Med Sci Sports Exerc. 2005;37:S124. 2. Padua D, Marshall SW, Beutler AI, DeMaio M, Onate JA, Guskiewicz KM. Sex comparison of jump landing kinematics and technique. Med Sci Sports Exerc. 2004;36(5):S348. 3. Padua DA, Marshall SW, Onate JA, et al. Reliability and validity of the landing error scoring system: implications on ACL injury risk assessment. J Athl Train. 2004;39:S110–S111. 4. Onate J, Cortes N, Welch C, Van Lunen B. Expert versus novice interrater reliability and criterion validity of the Landing Error Scoring System. J Sport Rehabil. 2010;19(1):41–56. PubMed 5. Padua DA, Marshall S, Boling M, Thigpen C, Garrett W, Beutler A. The Landing Error Scoring System (LESS) is a valid and reliable clinical assessment tool of jump-landing biomechanics: the Jump-ACL study. Am J Sports Med. 2009;37(10):1996–2002. PubMed doi:10.1177/0363546509343200 6. Padua DA, Boling M, DiStefano L, Onate J, Beutler A, Marshall S. Reliability of the Landing Error Scoring System-real time, a clinical assessment tool of jump-landing biomechanics. J Sport Rehabil. 2011;20(2):145–156. PubMed 7. Portney L, Watkins M. Foundations of Clinical Research: Applications to Practice. 3rd ed. Upper Saddle River, NJ: Prentice Hall Health; 2008.
JSR Vol. 24, No. 2, 2015
