Pole Dancing-Specific Muscle Strength: Development and Reliability of a Novel Assessment Protocol.

BACKGROUND: Pole dancing is a physically demanding sport that combines dance and acrobatic movements on a vertical pole. Despite its highly growing popularity, there is currently limited research in the field. The aim of this study was to create and evaluate a strength assessment protocol for athletes in pole dancing, with a specific focus on functional positions on the pole. METHODS: Thirty-two female pole dancing athletes participated in this study. Maximal voluntary isometric contractions (MVIC) were measured at three different sport-specific positions on the pole (shoulder abduction and adduction, and hip adduction), on two separate days (test and re-test) with a five to seven day interval between them. A hand-held dynamometer (Activ5- Activbody) stabilized on the pole was used for this study. RESULTS: The intra-session reliability was good to excellent for all sports-specific positions and for both sides of the body, across all different movements (ICC = 0.837-0.960, SEM = 5.02Kg-2.24Kg, and SDD = 27.46%-14.92%). Slightly better results were found regarding inter-session reliability (ICC = 0.927-0.970, SEM = 3.72Kg-1.97Kg, and SDD = 22.86%-15.19%). There was not a statistically significant difference between the MVICs between the left and right or dominant and non-dominant side in shoulder abduction (p = 0.105) and hip adduction (p = 0.282), in contrast to shoulder adduction (p = 0.00). CONCLUSION: The strength assessment protocol developed in the current study has proven to be a reliable and functional tool, with the potential for utilization in clinical practice as part of objective strength testing. Further studies are needed in order to expand the protocol to other muscle groups and positions and to generalize the results in all pole dancing populations such as male athletes.

Translation, Adaptation and Validation of the Greek Version of the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score in Greek Overhead Athletes.

Athletes engaging in overhead activities often face injury risks, emphasising the need for reliable assessment tools. This study focused on the translation and psychometric evaluation of the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score into Greek (Gr-KJOC) for assessing upper limb function in Greek-speaking overhead athletes. The Gr-KJOC underwent meticulous translation and adaptation processes, ensuring linguistic equivalence and cultural relevance. A sample of 60 athletes participated in the psychometric evaluation, including assessments of internal consistency, test-retest reliability, construct validity, and structural validity. The Gr-KJOC demonstrated excellent internal consistency (Cronbach's alpha = 0.95), indicating consistent measurement of the underlying construct. Test-retest reliability was excellent (ICC = 0.95), with low measurement errors. Construct validity was confirmed through correlations with the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire. Structural validity revealed a unidimensional structure with high explained variance (75%). No floor or ceiling effects were observed, and the questionnaire proved feasible, with an average completion time of 6 min. The Gr-KJOC emerges as a reliable, valid, and feasible tool for evaluating upper limb function in Greek-speaking overhead athletes. Its psychometric properties support its utility in clinical and research contexts, contributing to the effective assessment and management of shoulder and elbow conditions in the realm of overhead sports in Greece.

The Effectiveness of External Verbal Feedback on Balance in Athletes with Chronic Ankle Instability.

Chronic ankle instability (CAI) is characterized by muscle weakness and impaired neuromuscular control. This study aimed (a) to assess the impact of external verbal feedback on the dynamic balance of athletes with CAI and (b) to examine the maintenance of dynamic balance ability after the end of the completion of the intervention balance program. Thirty athletes (mean age 21.63 ± 1.53) were randomly divided into three groups: an experimental group with external verbal feedback, 1st control group without external verbal feedback and the 2nd control group without balance training and without feedback. Assessments using a balance board and the 'Y-balance' test were conducted before and after the balance training period. Additionally, participants completed the Cumberland Ankle Joint Instability Tool. A retention test of balance ability was administered after the 4-week intervention period. Statistical analysis revealed a significant overall improvement in balance (F(2,36) =5.96, p = 0.006, partial η2 =0.249), including those with no balance training, but no significant differences between the groups. Thus, the external verbal feedback did not show a positive impact on the balance ability between the three different groups. Also, the experimental group with the external verbal feedback demonstrated maintenance of dynamic balance learning ability. Although it appears that balance training has a positive effect on the dynamic balance of individuals with CAI, a non-positive impact of external verbal feedback was found. Also, it appears that external verbal feedback significantly led to sustained retention of balance learning ability. Further research is recommended to validate these findings.

Preliminary Insights into the Diagnostic Accuracy of the Modified Arm Care Screen Test for Overhead Athletes: An On-Field Tool for Injury Prevention.

BACKGROUND: The Arm Care Screen was developed to detect musculoskeletal limitations that could affect performance or even increase the risk for shoulder injuries in overhead athletes. This study aimed to assess the discriminant validity of the modified Arm Care Screen in overhead athletes. METHODS: Sixty-two overhead athletes (mean age: 24.5 ± 4.2 years) were recruited. The athletes underwent a comprehensive Arm Care Screen evaluation, including reciprocal shoulder mobility, total body rotation, lower body diagonal reach, and rotary stability assessments. Ten different musculoskeletal measurements were independently measured by two physical therapists. RESULTS: The modified Arm Care Screen showed moderate to strong associations (phi values ranged from 0.273 to 0.905) with the respective musculoskeletal range of motion and balance measurements. Sensitivity ranged from 81.25% to 88.57%, indicating a high true positive rate, and specificity ranged from 43.75% to 94.44%, indicating a moderate to strong positive rate. Positive and negative likelihood ratios ranged from 1.48 to 15.92 and 0.12 to 0.38, respectively. The positive and negative predictive value ranged from 58.14% to 92% and from 73.68% to 93.18%, respectively. The accuracy of the modified ACS ranged from 62.90% to 91.94%. CONCLUSION: The modified Arm Care Screen demonstrated promising diagnostic accuracy in identifying significant movement restrictions.

Greek Cross-Cultural Adaptation, Reliability, and Validity of the Quick Foot and Ankle Ability Measure Questionnaire.

CONTEXT: An easy-to-administer, function-based questionnaire to assess patients with various foot problems was required for a Greek-speaking population. This study aimed to translate and cross-culturally adapt the Quick Foot and Ankle Ability Measure (Quick-FAAM) into Greek and evaluate its reliability and validity. DESIGN: Cross-sectional study. METHODS: Established international guidelines for the cross-cultural adaptation of questionnaires were followed. The face and content validity of the Greek version of the Quick-FAAM (Quick-FAAM-GR), as well as the internal consistency and test-retest reliability upon repeated administration after 5 days, were examined. In addition, the construct validity of the scale was examined via exploratory factor analysis as well as by testing for associations with the Manchester Foot Pain and Disability Index, the 12-item Short-Form Survey (version 2), and a functional balance assessment test-the Y-Balance Test. RESULTS: Sixty participants (18 women) with self-reported chronic ankle instability symptoms, with a median (interquartile range) age of 27 (7.7) years, participated in the study. Half of the participants were included in the test-retest reliability study. The Quick-FAAM-GR demonstrated face and content validity. Excellent internal consistency (Cronbach α = .961) and intrarater test-retest reliability (intraclass correlation coefficient ICC[2,1] = .93) were demonstrated, with a comparable error margin to the original version (standard error of the measurement = 2.1, 95% minimum detectable change = 5.9). Associations of the Quick-FAAM-GR scores to other questionnaires ranged from weak to strong (Spearman rho), all being statistically significant (Manchester Foot Pain and Disability Index from -.26, P = .04, to -.67, P < .001, and 12-item Short-Form Survey, version 2, between .41 and .72, P < .001), and to the Y-Balance Test between lower-limb differences (-.35 to -.58, P < .001). The exploratory factor analysis confirmed the single-factor structure of this scale. No floor/ceiling effects were observed. CONCLUSIONS: The Greek Quick-FAAM has proven to be a valid and reliable tool for evaluating chronic ankle instability and can be used for clinical and research purposes in Greek-speaking individuals.

A Pilot Test of the Measures of the Greek Version of Upper Extremity Functional Index in Patients with Lateral Elbow Tendinopathy.

Lateral elbow tendinopathy (LET) is a common upper limb pathology in people involved in manual occupations. The upper extremity functional index (UEFI) was specifically designed to evaluate functional limitations in patients with upper limb pathology. The UEFI was developed in English and has been translated into several languages, including Greek. However, it has been assessed only in patients with shoulder pathology. Thus, the aim of this study was to pilot-test the Greek version of the UEFI (GV-UEFI) questionnaire and assess its measurement properties in patients with LET. Thirty patients with LET were recruited and asked to fill in the GV-UEFI twice and the disabilities of arm, shoulder, and hand questionnaire (DASH) once. The internal consistency and test-retest reliability were examined using Cronbach's alpha and the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the minimum detectable change (MDC) were calculated and possible ground or ceiling effects were also examined. Convergent validity was evaluated with the Greek DASH using Pearson's correlation. Lastly, the unidimensionality of the scale was examined through principal component analysis to verify construct validity. Internal consistency was high for the GV-UEFI (Cronbach's a = 0.98) and test-retest reliability was excellent (ICC = 0.98). The SEM was 2.95 and the MDC was 6.85. Test-retest reliability of each item was good (ICC > 0.87). The correlation analysis demonstrated a strong correlation between the GV-UEFI and the DASH. No floor or ceiling effects were found. Principal component analysis verified the construct validity and the unidimensionality of the scale. The GV-UEFI was successfully tested in patients with LET. It seems that the GV-UEFI can be used reliably in Greek-speaking patients with LET. However, the measurement properties of this scale should be examined in a larger sample of LET patients.

Reliability and measurement error of tests used for the assessment of throwing performance in overhead athletes: A systematic review.

BACKGROUND: Throwing Performance (TP) is important in throwing sports. Several tests have been designed to assess TP, and the reliability of these tests was examined in various studies. The aim of this systematic review was to critically appraise and synthesize the studies that examined the reliability of TP tests. METHODS: A systematic search was conducted on PubMed, Scopus, CINAHL and SPORTDiscus to identify studies related to TP and reliability. The quality of the included studies was examined through the Quality Appraisal of Reliability Studies (QAREL) tool. Reliability was assessed using the intraclass correlation coefficient (ICC), while responsiveness was assessed using the minimal detectable change (MDC). Sensitivity analysis was conducted to identify whether low-quality studies may have biased the recommendations of this review. RESULTS: Seventeen studies were found eligible. The results showed a moderate level of evidence to suggest that TP tests have good reliability (ICC≥0.76). This recommendation was also applied separately when TP tests were used to measure throwing velocity, distance covered, endurance and throwing accuracy. Also, summated MDC scores were reported to assist coaches in decision-making when using TP tests to detect real performance changes. However, sensitivity analysis showed that there is a significant number of low-quality studies. CONCLUSIONS: This review revealed that the tests used for throwing performance assessment are reliable; however, due to a significant number of low-quality studies, these results should be used cautiously. Important recommendations of this review may be used in future studies to design high-quality studies.

Is manual therapy of the diaphragm effective for people with obstructive lung diseases? A systematic review.

BACKGROUND: Diaphragm dysfunction is common among people with obstructive lung disease (OLD). The effectiveness of manual therapy (MT) techniques specifically targeting this region remains unclear. The scope of this systematic review is to investigate the effectiveness of MT on the zone of apposition (ΖΟΑ) of the diaphragm in lung function, diaphragm excursion (DE), chest expansion, exercise capacity (EC), maximal inspiratory pressure (PImax) and dyspnea in people suffering from OLD. METHODS: Key databases were systematically searched. Two independent reviewers screened the papers for inclusion. Methodological quality and the quality of evidence were assessed using the PEDro scale and the GRADE approach, respectively. RESULTS: Two studies were included. One showed that diaphragmatic stretching and the manual diaphragm release technique (MDRT) improved DE and CE (p<0.001, p<0.05, respectively). The other showed that MDRT improved DE and EC (p<0.05, p<0.05, respectively). CONCLUSION: This systematic review provides preliminary evidence on the effectiveness of MT on the ZOA of the diaphragm in people with COPD. Further research is needed in order for definitive conclusions to be drawn. REGISTRATION NUMBER IN PROSPERO: CRD42022308595.

The Changing Landscape in Upper Limb Sports Rehabilitation and Injury Prevention.

This editorial aims to feature authors who intend to submit their research to this Special Issue of Sports entitled "Clinical Advances in Upper Limb Sports Rehabilitation and Injury Prevention" in areas that need special consideration [...].

A Systematic Review of the Aerobic Exercise Program Variables for Patients with Non-Specific Neck Pain: Effectiveness and Clinical Applications.

Studies have shown that aerobic exercise (AE) may improve symptoms related to non-specific neck pain (NNP); however, the variables of the exercise programs and the overall effectiveness of AE have not been evaluated in a systematic review. Therefore, this review aimed to describe and discuss the variables of the AE programs used in clinical trials for patients with NNP. Included studies were analyzed for the selected AE variables such as intensity, frequency, duration, delivery, supervision, and adherence. The PEDro scale was used to assess the methodological quality of the studies. From the literature search, six studies met the inclusion criteria and were evaluated. After reviewing all the included studies, it was found that a range of AE interventions were used such as cycling, brisk walking, aerobics, stationary bike, treadmill running, circuit training, and swimming. Further, the duration was between 30 and 45 min for each session, with or without progressive increases from week to week. The intervention periods ranged from 1 month to 6 months in duration. Most studies used AE three times per week. Furthermore, exercise intensity was measured with either subjective (BORG) or objective measures (heartrate reserve). Justification for the specified intensity and reporting of adverse events was reported only in two studies and differed between studies. Exercise interventions were poorly reported. This review showed that moderate-intensity AE undertaken three times per week, in patients with NNP, may be beneficial for pain and function; however, the development of reporting standards is essential for the successful replication of studies.

The effectiveness of neuromobilization exercises in carpal tunnel syndrome: Systematic review and meta-analysis.

PURPOSE: To examine the effectiveness of Neuromobilization Exercises (NE) on pain, grip and pinch strength, two-point discrimination, motor and sensory distal latency, symptom severity, and functional status using the Boston Carpal Tunnel Questionnaire (BCTQ) in Carpal Tunnel Syndrome (CTS). METHODS: Major electronic databases were searched from inception up to September 2021 for randomized trials comparing the effects of NE with or without other interventions against no treatment, surgery, or other interventions in patients with CTS. Standardized Mean Differences (SMD) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model according to the outcome of interest and comparison group. Methodological quality was assessed with PEDro and quality of evidence with the GRADE approach. RESULTS: Twenty-five articles were included and sixteen of them demonstrated high methodological quality. NE was superior to no treatment on pain (very low-quality evidence; SMD = -2.36, 95% CI -4.31 to -0.41). NE was superior to no treatment on the functional scale of the BCTQ (low-quality evidence; SMD = -1.27 95% CI -1.60 to -0.94). Most importantly, NE did not demonstrate evidence of clinical effectiveness. CONCLUSION: Low to very low-quality evidence suggests that there are no clinical benefits of NE in patients with mild to moderate CTS.

The Effectiveness of Neuromobilization in Patients With Cervical Radiculopathy: A Systematic Review With Meta-Analysis.

CONTEXT: Neuromobilization exercises (NE) could be a useful therapeutic tool to induce analgesia and increase function and range of motion (ROM) in patients with musculoskeletal pathologies with neuropathic components; however, the effectiveness of this intervention in patients with cervical radiculopathy (CR) is unknown. OBJECTIVE: To determine the effectiveness of NE in CR on pain, function, and ROM. DESIGN: Systematic review and meta-analysis. EVIDENCE ACQUISITION: An electronic search was performed in the MEDLINE, Scopus, PEDro, and EBSCO databases from inception until June 2022. The authors included randomized clinical trials that evaluated the effectiveness of NE against control groups or other interventions that aimed to treat patients with CR. EVIDENCE SYNTHESIS: Seven clinical trials met the eligibility criteria, and for the quantitative synthesis, 5 studies were included. For the studies that compared NE with a control group, the standardized mean difference for pain was -1.33/10 (95% confidence interval [CI], -1.80 to -0.86; P < .01; I2 = 0%), for function with the Neck Disability Index was -1.21/50 (95% CI, -1.67 to -0.75; P < .01; I2 = 0%), and for neck flexion and extensions was 0.66 (95% CI, 0.23 to 1.10; P < .01; I2 = 0%) and 0.47 (95% CI, 0.04 to 0.90; P < .01; I2 = 0%), respectively, with evidence of clinical effectiveness. These findings were based on moderate-quality evidence according to the Grading of Recommendation, Assessment, Development, and Evaluation rating. In studies that compared NE with other interventions, the meta-analysis failed to demonstrate the statistical or clinical superiority of NE. CONCLUSIONS: Moderate quality of evidence suggests that NE may be superior to no treatment for pain, function, and ROM in patients with CR. In contrast, NE are not superior to other interventions in the same outcomes, based on low- to very low-quality evidence. More high-quality research is needed to assess the consistency of these results.

The Effects of Motor Imagery on Pain in Lower Limb Sports Injuries: A Systematic Review and Meta-Analysis.

This review evaluated the efficacy of Motor Imagery intervention in athletes with lower limb sports injuries that could affect their pain levels during rehabilitation. We carried out a thorough research of the scientific literature for RCT studies in athletes with lower limb musculoskeletal sports injuries including search terms Motor Imagery AND pain, Motor Imagery AND sport injuries, Motor Imagery AND lower limb. We searched 3 major databases, PubMed, Scopus, and ScienceDirect, with the search period ranging from their inception until May 2022. We assessed the quality of the studies using the PEDro Scale and the data was recorded and extracted with the use of Mendeley software. The search criteria resulted in a pool of 10.107 possible articles. Upon completion of the selection procedure, only 3 RCT studies met the inclusion criteria with a total of 60 injured athletes (n = 18 with ankle sprain and n = 42 with ACL injuries). The meta-analysis showed no statistically significant positive effects of MI intervention on pain intensity after lower limb sports injuries (n = 60; MD = -1.57; 95% CI: -3.60 to 0.46; I2 = 50%; p = 0.13). The limited number of studies could justify the statistically insignificant effect of MI, but although the methodological quality of the studies was moderate to high, the heterogeneity of them was also relatively high. More RCT's are required to explore the effect of MI on pain in athletes with lower limb injuries in order to address psychophysiological processes during rehabilitation.

The Effectiveness of Spinal, Diaphragmatic, and Specific Stabilization Exercise Manual Therapy and Respiratory-Related Interventions in Patients with Chronic Nonspecific Neck Pain: Systematic Review and Meta-Analysis.

Patients with nonspecific chronic neck pain (NSCNP) exhibit respiratory dysfunction. This systematic review aimed to analyze randomized controlled trials (RCTs) investigating the effect of spinal and/or diaphragmatic and/or specific stabilization exercise manual therapy and/or respiratory exercises on musculoskeletal and respiratory diagnostic outcomes in patients with NSCNP. A systematic search and selection of RCTs was performed in three scientific databases (Pubmed, Scopus, and Physiotherapy Evidence Database (PEDro)) and one search engine (Google Scholar) from inception to April 2022. Relevant studies published in the English language were extracted, evaluated, and independently rated for methodological quality (PEDro scale). The quality of the evidence was assessed with the GRADE approach. Out of 1089 studies collected in total, 1073 were excluded (i.e., did not meet the inclusion criteria or were duplicates). Sixteen RCTs were finally included, rated on 5.62/10 (PEDro score) on average for methodological quality. Overall, there was sparse evidence that spinal and/or diaphragmatic manual therapy and/or trunk stabilization exercises and/or respiratory exercises significantly improved pain, disability, and respiratory outcomes in patients with NSCNP immediately post-treatment. However, the clinical heterogeneity between studies was significant, and the level of certainty of the evidence was low to very low. More, high-quality RCTs are required, contributing to the holistic diagnostic monitoring and management of patients with NSCNP.

The adjunctive benefits of mirror cross education on kinetic chain exercise approach in volleyball athletes with scapular dyskinesis.

BACKGROUND: Volleyball players as overhead athletes have the highest risk of developing scapular dyskinesis. The kinetic chain exercise-approach has gained a lot of attention because of its claims to provide an improved motor control and scapular kinematics. A form of cross exercise, known as mirror therapy, may enhance the effects of a kinetic-chain-approach on scapular posture, upper and lower limb performance. The aim of this study was to investigate the adjunctive benefits of mirror cross education in a kinetic chain approach, in volleyball athletes with SD. METHODS: Thirty-nine professional volleyball athletes were randomly assigned to three groups of 13 each, two experimental, the mirror cross education and kinetic chain approach, and one control. Both experimental groups performed a kinetic chain approach program, however, the mirror cross education group performed the exercise program with the addition of two mirrors that allowed athletes to observe their opposite non-dyskinetic scapula. Scapular posture asymmetries in cm, the Y-Balance and the Upper-Quarter Y-Balance after normalizing by limb length the reach distance in each direction, were assessed before and after performing each intervention for 6 weeks. RESULTS: 3×2 two-way Mixed ANOVAs detected significant interactions on scapular posture (P=0.001) on both experimental groups when compared with the control. The Y-Balance and the Upper Quarter Y-Balance scores at both mirror cross education and kinetic chain approach groups showed significant differences when compared with the control (P<0.05). Overall, variables showed significant superiority of the mirror cross education group. CONCLUSIONS: The Mirror-Cross-Education demonstrated significant effects in scapular posture and in the functional balance tests of volleyball athletes with scapular dyskinesis.

Mirror Cross-Exercise on a Kinetic Chain Approach Improves Throwing Performance in Professional Volleyball Athletes With Scapular Dyskinesis.

CONTEXT: Volleyball players have shown to be at an increased risk of developing scapular dyskinesis. The kinetic chain exercise approach has gained a lot of attention because of its claims to provide an improved motor control and scapular kinematics. A form of cross exercise, known as mirror therapy, may enhance the effects of a kinetic chain exercise approach in throwing performance. OBJECTIVE: To examine the effects of mirror cross exercise (MCE), based on a kinetic chain exercise approach in the throwing performance of volleyball athletes with scapular dyskinesis. DESIGN: Randomized controlled trial. SETTING: Biomechanics laboratory. METHODS: 39 volleyball players with scapular dyskinesis were randomly allocated into 3 groups. The first group completed a 6-week kinetic chain approach (KCA group), the second group completed a kinetic chain exercise approach program in addition to MCE group, and the control group followed only their regular training program. Before and after delivering both interventions, throwing accuracy, speed, and force were determined while measuring the ground reaction forces of the drive leg during throwing. Two-way mixed analysis of variance investigated the effects of intervention and time and their interaction. RESULTS: The results showed intervention × time statistically significant interactions for throwing accuracy, speed, and force for the MCE and the KCA groups. Over the 6-week training period, the MCE and the KCA groups showed significant improvements in throwing accuracy (P < .01) and speed (P < .01), while the ground reaction forces did not change (P > .05). Throwing force increased significantly in the MCE group (P = .01). Between-group comparison showed statistically significant improvements in the throwing accuracy for the MCE and KCA groups against the control group (P < .01) at posttesting. The MCE demonstrated superior results over the KCA in the aforementioned measures. CONCLUSIONS: This study suggests that the addition of MCE in a KCA program enhances energy transfer throughout the distal and proximal segments, thus improving kinetic chain recruitment and potentially preventing shoulder pathology.

Reliability of assessment methods for scapular dyskinesis in asymptomatic subjects: A systematic review.

OBJECTIVE: The aim of this systematic review was to evaluate the available published evidence on the intra- and inter-rater reliabilities of assessment methods used for identifying and measuring scapular dyskinesis (SD) in asymptomatic subjects. METHODS: A systematic electronic literature search was performed in PubMed, Physiotherapy Evidence Database, Scopus, and the Cochrane Library, and studies on the intra- and inter-rater reliabilities of physical examination tests used for identifying SD in asymptomatic people were identified. Methodological quality of the studies meeting the inclusion criteria was assessed using the Quality Appraisal of Reliability Studies (QAREL) checklist by two reviewers. The overall level of evidence of this systematic review was determined by the Modified Cochrane Back Pain Criteria based on previous research which was modified for reliability studies of the shoulder complex. RESULTS: The literature search generated 388 results, and only 14 articles met the inclusion criteria. In these studies, reliabilities of two qualitative and five quantitative methods for the assessment of SD were analyzed. The QAREL checklist revealed that 12 studies had moderate risk of bias and 2 had high risk of bias. Additionally, none of the studies were of high quality. On the basis of the Modified Cochrane Back Pain Criteria, the overall level of evidence was moderate. Most of the studies including quantitative measurement methods found good to excellent inter- and intra-rater reliability values. Most of the studies including qualitative methods found low-to-moderate intra- and inter-rater reliability values. CONCLUSION: Considering the available published evidence, there is lack of high-quality studies evaluating the inter- and intra-rater reliabilities of qualitative or quantitative methods used for the assessment of SD. There are no qualitative methods with high reliability that are fit for clinical applications. Some quantitative methods with higher reliability are present, but clinicians should be aware of the methodological flaws that studies evaluating these methods suffer from. LEVEL OF EVIDENCE: Level II, Diagnostic study.