Best Tests for Differential Diagnosis What Are the Metrics of Diagnosis?

Home , Drawer test, McMurray test, Straight leg raise

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Best Tests for Differential Diagnosis What are the Metrics Chad Cook PhD, PT, MBA, FAAOMPT of Diagnosis? Professor and Program Director Duke University Duke Clinical Research Institute

For Diagnosis, There are Analytic Diagnostic Test Metrics Metrics • Diagnostic accuracy • Reliability • Diagnostic accuracy relates to the ability of • Sensitivity a test to discriminate between the target condition and another competing condition. • Specificity • Positive and Negative Predictive Value • Positive and Negative Likelihood Ratios

Does Reliability Matter? Sensitivity and Specificity

No worries, The you will Sensitivity: Percentage of people who test positive for a condition • be fine is fatal specific disease among a group of people who have the disease • Specificity: Percentage of people who test negative for a specific disease among a group of people who do not have the disease

Kappa Intraclass Correlation www.zillowblog.com Coefficient

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Sensitivity Example Specificity Example

• 50 patients with arm pain associated • 50 patients with no arm pain with cervical radiculopathy associated with a cervical strain • Test was positive in 40 of the 50 • Test was positive in 5 of the 50 cases cases • Sensitivity = 40/50 or 80% • Specificity = 45/50 or 90% • Correct 80% of the time in cases • Correct 90% of the time in cases that were cervical radiculopathy that were NOT cervical radiculopathy

http://www.triggerpointbook.com/infrasp2.gif http://www.triggerpointbook.com/infrasp2.gif

Likelihood Ratios

• A high LR+ influences post-test probability with a positive finding • A value of >1 rules in a diagnosis • A low LR- influences post-test probability with a negative finding • A value closer to 0 is best and rules out

Bossuyt P, et al. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Family Practice. 2004;21:4-10.

Clinical Utility Fagen’s Nomogram (LR+) • Cervical • The ability of the metrics to influence post-test probability Radiculopathy (either in ruling out the condition or ruling it in) • Pretest • Or just improving your likelihood of being correct prob=18% • Spurling’s LR+=4.8 • Post test prob of a positive finding= 52%

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Fagen’s Nomogram (LR-) Confidence Intervals?

• Cervical • Wainner’s CPR for Radiculopathy CTS • Pretest prob=18% • 34% pre-test prob • ULTT (LR- = 0.14) • <4/5 of the tests • Post test prob of a • LR+ = 4.6 (95%CI negative finding = 2.5, 8.7) 2.98% • Post-test probability = 70% (56.3%, 81.7%)

Tests Should be Used in Proper Examination in Series Order R/O R/I • Some tests should High Sensitivity High Specificity typically be used early Low LR- High LR+ • E.g., SLR, ULTT, Hawkins Kennedy, • Some late in the examination R/O R/I • Spurlings, Hoffmann’s test, Intake Observation Movement Exam MMT/Endurance Well leg Raise Patient History Screening Palpation/Exam Confirmatory Tests

OTHERWISE YOUR RESULTS WILL BE BIASED 15

Fagen’s Nomogram Example One-Screening (LR-) • Hoffmann’s test (sign) for • Cervical myelopathy Myelopathy • Sensitivity = 50% and a negative • Pretest prob=5% likelihood ratio of 0.74 • Hoffmann’s LR- • Negative finding is of interest =0.74 • 50% will have a negative, but will • Post test prob of have the disease a negative finding= 4%

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Fagen’s Nomogram (LR+) Example Two-Confirming • Straight leg raise • Lumbar • Sensitivity is about 90% Radiculopathy • Specificity is about 15% and • Pretest positive likelihood ratio is 1.24 prob=25% • This means that it is positive in • SLR LR+=1.24 those that have radiculopathy • Post test prob of and those that don’t have it a negative finding= 27%

Calculations Influencing Decision Making

• Positive Likelihood Ratio= (sensitivity)/(1-specificity)

• Negative Likelihood Ratio= (1-sensitivity)/(specificity)

Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007. 22

What if You Don’t Care to Follow This? Diagnostic Clinical Utility

• You run the risk of • To what extent diagnostic testing “ruling out” improves health outcomes relative conditions that are to the current best alternative, actually present which could be some other form • You run the risk of of testing, or not testing at all. “confirming” conditions that are not really there

Bossuyt et al. Beyond diagnostic accuracy: the clinical utility of diagnostic tests. Clin Chem. 2012 Jun 33 It increases the risks of an error [Epub ahead of print] 24

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Screening

• (Technically) Screening is performed to detect the presence of a specific disease. The individual or Red Flags, Triage, and group of individuals (as in mass screenings) does not Screening present any symptoms of the disease. • The correct use involves screening of healthy Chad Cook PT, PhD, MBA, FAAOMPT subjects Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University

Natural History of Disease Spot Diagnosis or Triage Screening • Differential assessment for red flags in individual Latency Period *Detectable patients by a clinician using special tests or Sojourn Time* Preclinical standardized examinations in order to identify Period individuals needing special intervention.

Biological Detectable Symptoms Diagnosed Becomes Onset by testing begin w/ disease disabling

Dx Test

Primary Secondary Tertiary Sizer P, Brismee JM, Cook C. Medical screening for red flags in the diagnosis and management of Prevention Prevention Prevention 27 musculoskeletal spine pain. Pain Pract. 2007 (in press).

Clinical Triage Examples Differences? Screening Sport Diagnosis or Triage • Canadian C-Spine Rules are used to determine who doesn’t need an x-ray ( sensitivity-99%) X-ray is used to diagnose fracture ( specificity) • Ottawa Ankle Rules are used to determine who doesn’t need an x-ray ( sensitivity) X-ray is used to diagnose fracture ( specificity)

Healthy Population/Population based Patient Population

www-chaos.umd.edu http://www.providencecare.ca/objects/rte/Image/images/patients-main-pg-final.jpg

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Triage: Sinister Disorders (Red What is a Red Flag? Flags)

• Signs and Symptoms found in the patient history and clinical • Rare, but occasionally examination that may tie a disorder to a serious pathology. present (<1% of cases) • Sometimes is identified as a finding that is reflective of a • Most guidelines suggest delayed or poor outcome. that “when something • We call this a prognostic red flag. seems wrong, it might be wrong” is the best process

Sizer P, Brismee JM, Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine Underwood M, Buchbinder R. Red flags for back pain. BMJ. 2013 Dec 12;347:f7432. doi: 10.1136/bmj.f7432. pain. Pain Pract. 2007. 31

• Clinicians do not actually screen for red Rethinking Red Flags flags, they manage the findings; • Based on these findings, we propose that clinicians consider: • Red flag symptomology negates the utility of • (1) the importance of watchful waiting; clinical findings; • (2) the value-based care does not support clinical examination • Tests lack the negative driven by red flag symptoms; likelihood ratio to serve as a screen; • (3) the recognition that red flag symptoms may have a stronger • Clinical practice relationship with prognosis than diagnosis. guidelines do not include specific processes that aid decision-making. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med. 2017 Sep 18. pii: bjsports-2017-098352. Br J Sports Med. 2017 Sep 18. pii: bjsports-2017-098352.

Categorizing Red Flags Category I:

• Category I: Factors which Require Immediate Medical • Blood in Sputum Attention • Elevated Sedimentation Rate • Category II: Factors which Require Subjective Questioning • Loss of Consciousness or Altered mental state and Precautionary Examination and Treatment Procedures • Bowel and Bladder Dysfunction • Category III: Factors which Require Further Physical Testing and Differentiation Analysis • Severe Non-mechanical pain • Progressive Neurological Deficit • Heart-Related Symptoms

Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007. 35 2007, 2012. 36

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Category II: Category III:

• Age > 50 • Impairment precipitated by recent • Myelopathic Symptoms trauma • Clonus • Abnormal Reflexes • Long-term corticosteroid use • Fever • Bilateral or Unilateral Radiculopathy or Paresthesia • Gait Deficits • Long-term worker’s compensation • Unexplained Referred Pain • History of a disorder with • Non-healing sores or wounds predilection for infection or • Recent history of unexplained • Unexplained Significant Upper or Lower Limb Weakness hemorrhage weight loss • History of a metabolic bone • Writhing pain disorder • History of cancer

Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007. Cook C. Orthopedic Manual Therapy. An Evidence Based Approach. Prentice Hall; Upper Saddle River, NJ: 2007, 37 38 2012.

Best Tests for Upper Quarter Red Flags Fractures

Chad Cook PT, PhD, MBA, FAAOMPT Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University

Canadian C-Spine Canadian C-Spine Rules Rules • Sensitivity of the Canadian C-spine rule ranged from 0.90 to 1.00 with negative predictive values ranging from 99 to 100%. Sensitivity = 99 • Inter-rater reliability of the Canadian C-spine rule varied from k = 0.60 between nurses and physicians to k = 0.93 among paramedics.

Stiell et al. Canadian CT head rule study for patients with minor head injury: methodology for phase II (validation and Moser et al. Validity and reliability of clinical prediction rules used to screen for cervical spine injury in alert low-risk economic analysis). Ann Emerg Med. 2001;38(3):317-22. 41 patients with blunt trauma to the neck: part 2. Eur Spine J. 2017 Sep 22. doi: 10.1007/s00586-017-5301-6. [Epub ahead of print]

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Cervical Closed Fracture Clavicular or Humeral Fracture

Cook CE, Sizer PS, Isaacs RE, Wright A. Pain Pract. 2013 Apr 23. doi: 10.1111/papr. 12061. [Epub ahead of print] 43 44

Four Way ROM Test for Elbow Scaphoid Fracture Fracture • Recorded the patient’s ability to 1) actively extend to a full locked position (0°), 2) to actively flex to at least 90°, and 3 and 4) to actively pronate and supinate to full range of motion (180°) while flexed as close to 90° as possible.

K. Unay et al. / Injury, Int. J. Care Injured 40 (2009) 1265–1268 D.R. Vinson et al. / American Journal of Emergency Medicine 34 (2016) 235–239

Historically-Vertebrobasilar Insufficiency Cervical Artery Dysfunction

Cook C. Physical Examination Tests for Neurological Screening. In: Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2008, 2013. 48

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Wallenberg’s Extension and Other CAD Symptoms Rotation Test • Other potential symptoms associated with VBI are: (1) visual disturbances (diplopia), (2) auditory phenomena (sudden sensorineural hearing loss), (3) facial numbness or paresthesias, (4) dysphagia, (5) dysarthria, and (6) syncope (drop attacks).

49 Sizer, Brismee, Cook. Pain Practice. 2007;7:53-71 50

Modified Sharp Purser Test

Ligamentous Disorders of the Cervical Spine

Cook C. Physical Examination Tests for Neurological Screening. In: Cook C, Hegedus E.

Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; 52 Prentice Hall: 2008.

Alar Ligament Stability Test Tectorial Membrane Test

Cook C. Physical Examination Tests for Neurological Screening. In: Cook C, Hegedus E.

Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice 54 Hall: 2007.

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Paget-Schroetter Syndrome-Upper Extremity DVT • Paget-Schroetter syndrome occurs at a rate of 2 per 100,000 Upper Extremity Deep people per year in the United States, equating to approximately 3,000 to 6,000 reported cases yearly. Vein Thrombosis • Often referred to as effort thrombosis because 60% to 80% of patients with UE DVT report repetitive and vigorous overhead UE activity, such as swimming, pitching, weight lifting, or even manual or overhead labor, at the onset of symptoms.

DeLisa LC, Hensley CP, Jackson S. Diagnosis of Paget-Schroetter Syndrome/Primary Effort Thrombosis in a Recreational Weight Lifter. Phys Ther. 2017 Jan 1;97(1):13-19. doi: 10.2522/ptj.20150692.

Shoulder (upper Arm) Specific Red Flags Upper Extremity DVT • Category I Findings • Sens = 96; Spec = 48, LR+ = 1.5; LR- = 0.12 • Paget-Schroetter Syndrome • 1 The presence of venous material (catheter, venous access, or pacemaker) 1 • 2 Upper extremity, unilateral pitting edema 1 • 3 Localized upper extremity pain 1 • 4 Another diagnosis is reasonably plausible −1 • Scoring is as follows: score ≤ 0 low risk for DVT; score = 1 intermediate risk; and score ≥ 2 =higher risk for UEDVT Hegedus E, Cooper L, Cook C. Differential diagnosis of a female weight lifter with Paget’s Schroetter Syndrome. J Orthop Constans et al. Thromb Haemost. 2008;99:202-207. Sports Phys Ther. 2006;36:882-6. 57 58

Best Tests for Lower Quarter Red Flags Cancer or Metastases

Chad Cook PT, PhD, MBA, FAAOMPT Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University

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Spine Cancer Non-Mechanical, Meta-Static Pain • History sensitivity specificity • Age > 50 0.77 0.71 • Pain that cannot be produced, • previous history 0.31 0.98 changed, or reduced during of cancer your mechanical examination. • failure to improve 0.31 0.90 in 1 mo. of therapy • Pain that has an origin outside • no relief -bed rest >0.90 0.46 our practice capabilities. • duration > 1 mo 0.50 0.81 • age >50 or cancer hx or 1.00 0.60 unexplained wt loss or failure of conservative tx.

http://images.craveonline.com/article_imgs/Image/arthritis_pain.jpg Deyo RA, Jarvik JG. Diagnostic evaluation of low back pain with emphasis on

imaging. Ann Intern Med. 2002;137:586-97. 61 62

Non-Mechanical Pain-Cont. Non-Mechanical Spinal Pain

Cook C, Ross MD, Isaacs R, Hegedus E. Investigation of Nonmechanical Findings during Spinal Movement Screening for Identifying and/or Ruling Out Metastatic Cook C, Ross MD, Isaacs R, Hegedus E. Investigation of Nonmechanical Findings Cancer. Pain Pract. 2011 Nov 22. [Epub ahead of print] during Spinal Movement Screening for Identifying and/or Ruling Out Metastatic . Cancer. Pain Pract. 2011 Nov 22. [Epub ahead of print] .

Vertebral Compression Fracture

• Female sex • Age >70 years Fractures • Significant trauma • Prolonged use of corticosteroids • 1 of 4 Sens = 88, Spec = 50, LR+ = 1.8 • 3 of 4 Sens = 38, Spec = 100, LR+ = 218

Henschke et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum. 2009 Oct;60(10):3072-80.

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Compression Fracture Lumbar Compression fracture Negative Sensitivity Specificity Positive Likelihood Clustered Results (95% (95% Likelihood Ratio Ratio CI) CI) (95% CI) (95% CI) • History sensitivity specificity • age >50 0.84 0.61 0.16 (0.04- 2 of 5 positive tests .95 (.83-.99) .34 (.33–.34) 1.4 (1.3-1.8) .51) • age >70 0.22 0.96 • trauma 0.30 0.85 3 of 5 positive tests .76 (.61-.87) .68 (.68-.69) 2.5 (1.9-2.8) 0.34 (.19-.46) • corticosteroid use 0.06 0.995 0.65 (0.50- 4 of 5 positive tests .37 (.24-.51) .96 (.95-.97) 9.6 (3.7-14.9) 0.79) 0.97 (0.92- 5 of 5 positive tests .03 (.01-.08) .99 (.98-.99) 9.3 (1.4-60.2) 0.99) • in elderly trauma can be minor

NOTE. Five findings are included in the rule: (1) age > 52 years; (2) no presence of leg pain; (3) body mass index < 22; (4) does not exercise regularly; and (5) female gender. Deyo RA, Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-97.. Roman M, Brown C, Richardson W, Isaacs R, Howes C, Cook C. The development of a clinical decision making algorithm for 68 detection of osteoporotic vertebral compression fracture or wedge deformity. JMMT 2010;81:45-50.

Clinical Examination-Sacral Fracture

• CE SN = 96.4, SP =50.25 • XRAY SN=79.2, SP =99.7 • CE findings age (OR, 1.025), hip pain (OR, 4.971) internal rotation of the leg (OR, 4.880), tenderness to palpation over the sacrum (OR, 2.297) tenderness over the right or left hip (OR, 3.626) diffuse pain throughout the pelvis (OR, 16.445)

Yoder et al. Risk factors associated with sacral stress fractures: a systematic review. J Man Manip Ther. 2015 Duane et al. Am Surg. 2008 Jun;74(6):476-9; discussion 479-80. 69 May;23(2):84-92. doi: 10.1179/2042618613Y.0000000055.

Hip Flexion Test Ruling Out Hip Fractures (Negative findings of) • Sensitivity = 90, LR- = 0.10 • + Pubic Percussion Test • Helps rule out (LR+ = 9 to 313) presence of a • ER of one limb versus pelvis fracture the other

Cook C, Hegedus E. Physical Examination Tests: An Evidence Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA.

Based Approach. Upper Saddle River, NJ; Prentice Hall: 2008. 71 Diagnostic accuracy of clinical tests of the hip: a systematic 72 review with meta-analysis. Br J Sports Med. 2012 Jul 7.

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Ottawa Knee Rules Fulcrum Test-Stress Fracture • Study 1 Criteria for the Ottawa Knee Rule Sn = 1.0 • SN 93%, • SP 75%, Sp = .49 • +LR 3.7, A knee x-ray is indicated after trauma only and +LR = 1.96 • −LR 0.09; when at least one of the following is present: • Study 2 -- LR = .11 1. Patient age > 55 • SN 88%, 2. Isolated tenderness of the patella Jackson et al, Annals Int • SP 13%, 3. Tenderness over the fibular head Med, 2003 • +LR 1.0, 4. Inability to flex the knee to 90° 5. Inability to bear weight for four steps at • −LR 0.92. the time of injury and when examined

Reiman MP, et al. Br J Sports Med 2015;49:357–361. doi:10.11356/bjsports-2012-091929 74

Fracture of the Fibula

Sn = 1.0 for Foot Fx and Ankle Fx Sp = .50

75 ankle, .77 foot: Steill et al, JAMA, 1994 76

Deep Vein Thrombosis Clinical Exam

Deep Vein Thrombosis

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Combining History with Exam: The Problem: The Wells et al Clinical Tool-DVT

• “Overall, no single sign or symptom can be used to predict the Clinical Variable Score presence of DVT”- Dunn & McGinn, J Amer Ger Soc, March Active cancer (treatment ongoing or within previous 6 months or palliative) 1 2002 Paralysis, paresis, or recent plaster immobilization of the lower extremities 1 Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring general or regional anesthesia 1 • The majority of patients with venous thromboembolism will Localized tenderness along the distribution of the deep venous system 1 have no symptoms- Stuart & Bussey, AJHP, January 1997 Entire leg swelling 1 Calf swelling at least 3 cm larger than that on the asymptomatic leg (measured 10 cm below the tibial tuberosity)† 1 Pitting edema confined to the symptomatic leg 1 Collateral superficial veins (nonvaricose) 1 Previously documented DVT 1 Alternative diagnosis at least as likely as DVT −2 TOTAL

79 Wells et al. JAMA 2006 80

Pre-test Probability of a DVT

Score Probability of a DVT Peripheral Vascular <0 LOW Disease 1-2 MODERATE

>3 HIGH

Ankle-Brachial Index Ankle-Brachial Index

• Assessment of Peripheral • Normal: 0.9 to 1.3. Vascular Disease • Abnormal: Less than 0.9 is abnormal. Sensitivity = 76, Specificity • Lower ratio suggests blockage = 90, LR+ = 7.6 in leg • If the ABI is: • Measure blood pressure at the ankle and at the arm (Systolic) • 0.41 to 0.9, you likely have mild to moderate while a person is at rest. peripheral arterial disease. • Ankle / Arm • 0.4 or below, you likely have severe peripheral arterial disease.

Guo et al. Sensitivity and Specificity of Ankle-Brachial Index for Detecting Angiographic Guo et al. Sensitivity and Specificity of Ankle-Brachial Index for Detecting Angiographic Stenosis of Peripheral Arteries. Circ J 2008; 72: 605 –610 Stenosis of Peripheral Arteries. Circ J 2008; 72: 605 –610

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Best Tests for Visceral, Cardiac, and General Medical Diagnoses Cardiopulmonary Chad Cook PT, PhD, MBA, FAAOMPT Professor Duke Doctor of Physical Therapy Division Disease Duke Clinical Research Institute Duke University

Coronary Heart Disease Coronary Heart Disease

Croat Med J. 2012;53:432-41 Croat Med J. 2012;53:432-41

Heart Disease in a Low Prevalence Setting R/O Heart (Marburg Heart Score)

S Bösner, A Becker, M Abu Hani, et al. British Journal of General Practice, June 2010 Br J Gen Pract 2012; DOI: 10.3399/bjgp12X649106.

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Rule Out Pulmonary Embolism PE Revised Geneva rule (PERC) • Age 50 years • Sensitivity, • Pulse 100 beats/min 0.91; • Pulse ox 94% specificity, • No unilateral leg swelling 0.37 • No hemoptysis (coughing up blood) • -LR=0.14 • No recent surgery • No prior DVT or PE • No oral hormone use • The PERC score had a LR- of 0.17 (95% CI 0.11– 0.25) for low risk groups 0 - 3 points indicates low probability (8%) 4 - 10 points indicates intermediate probability (28%) Carpenter CR, Keim SM, Seupual RA, Pines JM. Differentiating Low-risk and No-risk 11 points or more indicates high probability (74%) PE Patients: The PERC Score. The Journal of Emergency Medicine. 2009;36(3);317–322. 92 Lucassen et al. Ann Intern Med. 2011 Oct 4;155(7):448-60.

Visceral Referred Pain

The Viscera

Clinical Breast Examination (Cancer) Murphy’s Sign for Cholecystitis Initial Screen Test Values Palpatory Mammogra CBE + • Sensitivity = 97 Breast Exam m Mammogra m • Specificity = 48 • LR+ = 1.9 SN 26.7 90.1 94.9 • LR- = .06

SP 98 95.4 93.7

LR+ 13.3 18 15.1

LR- 0.74 0.10 0.05

Singer et al. Ann Emerg Med. 1996;28:267-272.

Chiarelli et al. J Natl Cancer Inst. 2009 Sep 16;101(18):1236-43. 95 96

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Palpation Liver Palpation Aorta

97 98

Palpation Appendix Nixon’s Percussion Spleen

99 100

Kidney Palpation/Percussion

• No diagnostic studies have evaluated the utility of kidney Best Tests for physical testing Neurological Diagnoses

Chad Cook PhD, PT, MBA, FAAOMPT Program Director and Professor Duke University Duke Clinical Research Institute

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General Neurological Screen

Cervical Myelopathy

N.H. Al Nezari et al. / The Spine Journal 13 (2013) 657–674

Myelopathy Tests Reliability Hoffmann’s Test

• • Κ < 0 No agreement • 0.0 — 0.20 Very low agreement • 0.21 — 0.40 Low agreement • 0.41 — 0.60 Moderate agreement • 0.61 — 0.80 full agreement • 0.81 — 1.00 Almost perfect agreement

• Hoffmann's test= Kappa = 0.73 (% agreement = 0.88) (95% CI= .54-.92) SE=0.096 p<0.01 • Deep Tendon reflexes =Kappa=0.76 (%agreement=0.88) (95%CI=0.56-.93) SE=0.09 p<0.01 • Inverted suppinator sign =Kappa=0.56 (%agreement=0.78) (95%CI=.35-.77) SE=0.11 p<0.01 • Suprapatellar Quads (Isaacs Sign)=Kappa=0.65 (%agreement=0.83) (95% CI=.46-.84) SE=0.1 p<0.01 • Hand withdrawal =Kappa=0.59 (%agreement=.8) (95%CI=.38-.79) SE=0.11 p<0.01 • Babinski = Kappa=0.57 (%agreement=.92) (95%CI=.25-.89) SE=0.16 p<0.05 • Clonus = Kappa = 0.79 (%agreement=.98) (95%CI=.39-.99) SE=0.20 p<0.01 Cook C. Physical Examination Tests for Neurological Screening. In: Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Cook et al. Diagnostic accuracy of tests for myelopathy. JOSPT 2009. 105 106 Prentice Hall: 2008.

Inverted Suppinator Sign Myelopathy (Babinski and Clonus)

• Look for finger flexion and elbow extension • Cook et al. Sensitivity = 67 • Most sensitive tool for CSM available

http://academic.uofs.edu/faculty/kosmahle1/courses/pt351/lab351/babinski.htm Cook et al. found clonus sensitivity = 14 and Babinski = 24 Cook C. Physical Examination Tests for Neurological Screening. In: Cook C, Cook et al. Reliability and Diagnostic Accuracy of Clinical Special Tests for Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2008. Myelopathy in Patients seen for Cervical Dysfunction. 2009 JOSPT. 107 108

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Clinical Prediction Rule-Myelopathy Cervical Myelopathy Cluster

N = 249 patients with cervical pain: 88 with CSM • Age >45 years • + Hoffmann’s Sign • + Inverted Supinator Sign • + Babinski Test • + Gait Abnormality

NOTE. Five tests are included in the rule: (1) Gait deviation; (2) +Hoffmann’s test; (3) Cook et al. JMMT. 2010;18(4). Hyperreflexia of the brachioradialis; (4) +Babinski test; and (5) age >45 years. The associated posttest probability values are based on a pretest probability of 35%.

Self Administered Examination

Cervical Radiculopathy

Kobayashi et al. BMC Musculoskeletal Disorders 2010, 11:268 http://www.biomedcentral.com/1471-2474/11/268

Upper Limb Tension Test Cervical Distraction Test (Median Nerve Bias) • Sensitivity = 97, LR- = 0.14 • Helps rule out the presence of cervical radiculopathy when performed early in the examination

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007. Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007. 113 114

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Spurlings Test Valsalva Test

Specificity = 92, • Specificity = 94, LR+ = 3.7 LR+ = 4.87 • Used to rule in presence of Rules in cervical radiculopathy presence of cervical radiculopathy

Cook C, Hegedus E. Physical Examination Tests: An Evidence Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007. 115 Saddle River, NJ; Prentice Hall: 2007. 116

Cervical Radiculopathy Arm Squeeze Test

1 • Used to differentiate shoulder and neck • Spurlings, ROM<60 radiculopathy degrees, Distraction test, 2 • The test consists in squeezing the middle and ULTT third of the upper arm. The test was positive when score on a VAS Scale was 3 • Sens = 24, Spec = 99, points or higher on squeezing the middle LR+ = 30.3 (all 4 tests third of the upper arm (3 times) compared positive) to acromioclavicular (AC) joint and 3 4 anterolateral-subacromial area. • QUADAS = 10 • Caution, many of the controls were healthy and the QUADAS was not good • Sensitivity of 0.96 and specificity from 0.91 to 1.

Wainner et al. Reliability and diagnostic accuracy of the clinical examination and 117 patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52-62.

Systematic Review for Cervical Radiculopathy Compression Neuropathies

Thoomes et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J. 2018 Jan;18(1):179-189.

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Carpal Tunnel Compression Test Carpal Tunnel-Phalen’s Test • Sensitivity = 83, LR- = 0.2 • Sensitivity=79 • Rules out presence of • Specificity=92 CTS • LR+ =9.9 • Specificity = 92, LR+ • LR- = 0.2 = 10 • Rules in presence of CTS

Cook C, Hegedus E. Physical Examination Tests: An Evidence 121 Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007.

Cubital Tunnel-Pressure Provocation Test Carpal Tunnel Syndrome • Rules out ulnar nerve entrapment • Sensitivity = 89, LR- = 0.11

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007. 123 124

Cubital Tunnel-Elbow Flexion Test

• Cubital Tunnel Syndrome • Hold 3 minutes Lumbar Radicular Disorders

125

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Pain Provocation Based Straight Leg The Straight Leg Raise Raise • Bilateral lower extremity weakness or numbness • The Straight leg raise

J Back Musculoskelet Rehabil. 2012;25(4):215-23. doi: 10.3233/BMR-2012-0339. The pain provocation-based straight leg raise test for diagnosis of lumbar disc herniation, lumbar radiculopathy, and/or sciatica: a Scaia V, Baxter D, Cook C. 127

The Slump Test Sciatica-Seated Piriformis Test

SN SP LR+ LR- 52 90 5.22 0.53

journal of orthopaedic & sports physical therapy | volume 45 | number 8 | august 2015

Sciatica Sciatica-Active Piriformis Test

SN SP LR+ LR- • Sciatica is a description and not a diagnosis 78 80 3.9 0.27 • Pain that radiates along the sciatic nerve and is typically felt in the buttocks, down the back of the leg, and possibly to the foot.

Martin et al. Knee Surg Sports Traumatol Arthrosc (2014) 22:882–888 Savage et al. Journal of orthopaedic & sports physical therapy | volume 44 | number 7 2014

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Cauda Equina Sensitivity of Symptoms • Fortunately, this entity is quite rare, accounting for an estimated Jalloh & Minhas. Emerg Med. 0.04% of LBP cases. 2007;24:33-4 • Rapid symptoms within 24 hours: 89% sensitivity Shapiro S. Spine. 2000;25:248- 52. • History of back pain 94%: sensitivity Small et al. Orthopedic pitfalls. Am J Em Med. 2005;23:159-63. • Urinary retention 90% sensitivity • Loss of sphincter tone 80% sensitivity • Sacral sensation loss 85% sensitivity • Lower extremity weakness or gait loss 84% sensitivity

Best Pract Res Clin Rheumatol. 2005 Aug;19(4):557-75. What diagnostic tests are useful for low back pain? 133 Lurie JD

Best Tests for Neuropathic, Brain Trauma or Tumor, or Neuropathic Disorders Central Sensitization

Chad Cook PhD, PT, MBA, FAAOMPT Program Director and Professor Duke University Duke Clinical Research Institute

Neuropathic Pain Neuropathic Pain-DN4

Author SN SP LR+ LR- • Neuropathic pain: Pain caused by a lesion or disease (of Abdallah 90 60 2.25 0.17 influence of the CNS) or alteration of the nervous system. Markman 62 44 1.11 0.86 • Examples include post herpetic (or post-shingles) neuralgia, Mick 87 57 2.02 0.23 reflex sympathetic dystrophy / causalgia (nerve trauma), Perez 88 88 7.33 0.14 components of cancer pain, phantom limb pain, entrapment Sadler 78 70 2.60 0.31 neuropathy (e.g., carpal tunnel syndrome), and peripheral Haroun 100 45 1.82 0.00 neuropathy (widespread nerve damage). Spallone 80 92 10.00 0.22 Lasry-Levy 100 92 12.50 0.00 Hallstrom 93 75 3.72 0.09

Canadian Agency for Drugs and Technology in Health. Diagnostic Methods for Neuropathic Pain: A Review of Diagnostic Accuracy

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Central Sensitization

• Central sensitization (CS) represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable Central Sensitization plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. • CS involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. • Sensitized patients are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well, which obviously should not hurt.

J Pain. 2009 Sep; 10(9): 895–926.

Central Sensitization Disorders? Central Sensitization Inventory

• Chronic regional pain • Irritable Bowel Syndrome • Threshold of >40 syndrome • Chronic fatigue syndrome • Fibromyalgia • Pelvic Girdle Pain syndrome • Chronic Low Back Pain • Cancer Pain • Chronic Headaches • Chronic Temporomandibular Joint Pain

https://anjumsultanablog.wordpress.com/

Brain Tumor

• An assessment of the published measurement studies of the CSI suggest the tool generates reliable and valid data that quantify the severity of several symptoms of CS.

Scerbo T, Colasurdo J, Dunn S, Unger J, Nijs J, Cook C. Measurement Properties of the Central Sensitization Inventory: A Systematic Review. Pain Pract. 2017 Aug 29. doi: 10.1111/papr.12636.

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Finger Tap Test Pronator Drift Test Monohemispheric Monohemispheric Dysfunction-Tumor Dysfunction-Tumor

• Sens = 73.3 • Sens = 92.2 • Spec = 87.5 • Spec = 90 • LR+ = 5.9 • LR+ = 9.2 • LR- = 0.31 • LR- = 0.09 • Tap the tip of the index finger to the IP • Palms up, elbow joint of the thumb as extended (pronation many time as possible in 10 seconds drift is positive finding)

Teitelbaum et al. Can J Neurol Sci. 2002;29:337-44. 145 Teitelbaum et al. Can J Neurol Sci. 2002;29:337-44. 146

Finger Rolling Test-Monohemispheric Arm Rolling Test-Monohemispheric Dysfunction-Tumor Dysfunction-Tumor

• Sensitivity =41 • Sensitivity=16 • Specificity=93 • Specificity=100 • LR+ =5.86 • LR+= Inf • LR-=0.63 • LR- =0.84

Maranhao et al. J Neurologic Phys Ther. 2010;34:145-49. Maranhao et al. J Neurologic Phys Ther. 2010;34:145-49.

Module Fourteen Best Tests for Upper Quarter Orthopedic Conditions

Chad Cook PT, PhD, MBA, FAAOMPT Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University

149 150

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Shoulder SLAP Lesion

• None of the tests are useful

Type I SLAP lesion Type II-IV SLAP lesion

Michener et al. Journal of Athletic Training 2011:46(4):343–348 Michener et al. Journal of Athletic Training 2011:46(4):343–348

Biceps Load Test II SLAP Tests • SLAP only

• SLAP + Sensitivity = 90, LR- = 0.11. Rules out the presence of a SLAP lesion other

Hegedus E. Physical Examination Tests for the Shoulder Complex. In: Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007. 155 Cook et al. Journal of Shoulder and Elbow Surgery, Volume 21, Issue 5, May 2012,

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The Crepitus Test

LR+ LR-

3.4 0.4 Shoulder Rotator Cuff 2.4 0.2 1.3 0.6 Disorder 3.0 0.2 0.5 3.0

4.0 0.3 0.4 3.4

Ponce et al. J Shoulder Elbow Surg (2014) 23, 1017-1022

Bear Hug Test Belly Press/Napoleon Test • Sens 40 Spec 98 LR+ • Sensitivity=60 20.0 LR- 0.61 • Specificity=92 • LR+ =7.23 • Sens 25 spec 98 LR+ • LR-= 0.44 12.50 LR- 0.77

Lateral Jobe Test Drop Arm Sign • Passively Abduct Arm • Sensitivity =81 • Have patient lower arm in abducted • Specificity=89 position • LR+=7.36 • Look for uncontrolled drop • LR-=0.10 • LR+ = 3.3 (1.0, 11.0) • LR- = 0.82 (0.70, 0.87)

Hermans et al. Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. JAMA. 2013 Aug 28;310(8):837-47.

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Painful Arc Sign External Rotation lag Sign

• Meta-analysis • Sensitivity=46 • Patient actively abducts their • Specificity=94 arm to full range • LR+ =7.2 • Look for painful arc around 60 • LR- =0.60 to 120 degrees • LR+ =3.7 [95% CI, 1.9-7.0] • LR- =0.36 [95% CI, 0.23- 0.54]

Hermans et al. Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. JAMA. 2013 Aug 28;310(8):837-47.

Internal Rotation Lag Sign Meta-analysis BJSM • Specificity = 96, LR+ = 24.3. • Based on data from the original 2008 review and this update, the use of any single ShPE test to make a pathognomonic • Use caution, QUADAS = diagnosis cannot be unequivocally recommended. 8 • There exist some promising tests but their properties must be • Used to rule in presence confirmed in more than one study. Combinations of ShPE tests of subscapularis tear provide better accuracy, but marginally so.

Cook C. Orthopedic Manual Therapy: An Evidence Based Approach. Upper Saddle River NJ; Prentice Hall: 2007. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, 165 Wright AA. Br J Sports Med. 2012 Nov;46(14):964-78.

Conflicting Results

• A positive painful arc test result was the only finding with a positive LR greater than 2.0 for RCD (3.7 [95% CI, 1.9-7.0]), and a normal painful arc test result had the lowest negative LR (0.36 [95% CI, 0.23-0.54]). • Among strength tests, a positive external rotation lag test (LR, 7.2 Impingement Tests [95% CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95% CI, 2.6-12]) were the most accurate findings for full-thickness tears. • A positive drop arm test result (LR, 3.3 [95% CI, 1.0-11]) might help identify patients with RCD. • A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95% CI, 0.0-0.58]). Hermans et al. Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. JAMA. 2013 Aug 28;310(8):837-47.

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Hawkins-Kennedy Test Internal Rotation Strength Test

• Sensitivity = 92, and LR- = 0.18 • Rules out the presence of impingement

Sensitivity = 88, LR- = 0.12. Rules out presence of impingement of the shoulder

Hegedus E. Physical Examination Tests for the Shoulder Complex. In: Cook C, Hegedus Cook C, Hegedus E. Physical Examination Tests: An Evidence Based E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Approach. Upper Saddle River, NJ; Prentice Hall: 2007. 169 Prentice Hall: 2007. 170

Surprise Test • Sensitivity = 92, LR- = 0.08 • Used to rule out presence of anterior instability Stability Tests • Specificity = 89, LR+ = 8.4 • Used to rule in presence of anterior instability

Hegedus E. Physical Examination Tests for the Shoulder Complex. In: Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle172 River, NJ; Prentice Hall: 2007.

Sulcus Sign • Finger width sulcus is considered positive Biceps Tendinopathy

173

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Upper Cut Test (Biceps Tendinopathy) • SN = 73 • SP = 78 Shoulder AC Joint • LR+ = 3.38 • LR-= 0.34 Problem

Kibler et al. Am J Sports Med 2009;37:1840-1847. 175

Acromioclavicular Joint AC Resisted Extension Test • Specificity = 85, LR+ = 4.8 • Used to rule in presence of AC joint

Cadogan et al. BMC Musculoskeletal Disorders 2013, 14:156 Cook C. Orthopedic Manual Therapy: An Evidence Based Approach. Upper Saddle River NJ; Prentice Hall: 2007. 178

Cross Body Adduction Test AC Joint Palpation

179 180

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Clustering Shoulder Tests

• Analyzed the combination of tests: • Hawkins/Kennedy • Painful arc sign • Infraspinatus muscle tests

182

Impingement or RCT • Impingement • Rotator Cuff Tear • LR+ = 10.5 • LR+ = 15.6 • All 3 tests + • All 3 tests + • Overall, no physical examination test of the scapula was found to • Hawkins Kennedy • Hawkins Kennedy be useful in differentially diagnosing pathologies of the shoulder. • External rotation • External rotation strength test strength test • Painful arc sign • Painful arc sign

183 Wright AA, Wassinger CA, Frank M, Michener LA, Hegedus EJ. Br J Sports Med. 2012 Oct 18. [Epub ahead of print]

Biceps Squeeze Test Cozen’s Test

• Rules out presence of a biceps tear • Sensitivity = 96, LR- = 0.04 • Rules in presence of a biceps tear • Specificity = 100, LR+ = ~

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based 185 Approach. Upper Saddle River, NJ; Prentice Hall: 2007.

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Moving Valgus Test

• Rules out presence of Module Fifteen instability in the medial elbow Best Tests of the Lower • Sensitivity = 100, LR- = ~ Extremity Chad Cook PT, PhD, MBA, FAAOMPT Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University

Cook C, Hegedus E. Physical Examination Tests: An Evidence

Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007. 187

Hip Scour

• Several studies have investigated pathology in the hip. Few of the current studies are of substantial quality to dictate clinical decision- making.

• Used to rule out a hip problem Reiman MP, Goode AP, Hegedus EJ, Cook CE, Wright AA. Br J Sports Med. 2012 Nov 7. [Epub ahead of print] 190

30 Second Single Leg Stance for Trochanteric Bursitis Trochanteric Bursitis • Caution, low • Sensitivity=100 QUADAS score • Specificity=97.3 • Used • LR+=37 Asymptomatic • LR- =0.0 patients as references

JOURNAL OF WOMEN’S HEALTH. Volume 00, Number 00, 2017. ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2016.5889

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Resisted External De-rotation Test FADDIR • SN 94%, • Patient lies supine and has the hip and knee at 90 • SP 8%, degrees • +LR 1.02, • The clinician passively takes • −LR the hip and externally rotates • 0.48 it to end range • The patient internally rotates the hip back to a neutral position against resistance

Reiman MP, et al. Br J Sports Med 2015;49:357–361. doi:10.11356/bjsports-2012-091929

Flexion Internal Rotation Test Squeeze Test for Sports Hernia • SN 96%, • SN 30%, • SP 17%, • SP 91%, • +LR 1.12, • +LR 3.3 • −LR 0.27 • −LR • 0.66

Composite Test for Arthritis Thessaly Test at 20 Degrees

• Sensitivity = 86, LR- = 0.19 • 6 studies • Includes test for 1) hip pain, 2) IR<15 degrees, 3) pain with IR, 4) • 3 of the 6 have LR+ of morning stiffness up to 60 minutes, 6.2 to 30.0 for the and 5) age>50 years lateral meniscus And • Helps rule out the presence of osteoarthritis at the hip 1.8 to 23 for the medial meniscus Those with poor results had >medial problems and older populations

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Cook C, Hegedus E. Physical Examination Tests: An Evidence 197 Approach. Upper Saddle River, NJ; Prentice Hall: 2008. 198 Based Approach. Upper Saddle River, NJ; Prentice Hall: 2008.

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McMurray’s Test Pooled Data for Meniscus • Sensitivity=51 • Specificity=91 • LR+=6.3 • LR- =0.53 • McMurray’s = 8 studies • JLT = 6 studies • Thessaly = 3 studies

Smith et al. Evid Based Med June 2015 | volume 20 | number 3 |

Knee Meniscus Injury

Yan et al. Swiss Med Wkly. 2011;141:w13314 Blyth et al. Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley's, McMurray's and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis. Health Technol Assess. 2015 Aug;19(62):1-62. doi: 10.3310/hta19620.

ACL Anterior Drawer Test

• Sensitivity=91 • Specificity=89 • LR+=8.3 • LR-=0.10

Wakemakers et al. Arch Phys Med Rehabil 2010;91:1452-9.

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Lachman’s Test Pivot Shift Test

• Sensitivity = 96, LR- = ~ (specificity is 100) • Helps rule out the presence of an ACL tear

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2008. 205 206

Lever Sign Posterior Drawer Test • Sensitivity = 90, LR- = 0.10 SN = 100 SP =100 • Helps rule out the presence of a torn posterior cruciate ligament

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2008. Lilli and Turi, 2014: Knee Surg Sports Traumatol Arthrosc. DOI 10.1007/s00167-014-3490-7 208

PCL MA MPP Test for Plica • Participant in supine and the knee extended. • Using the thumb, a manual force is applied to the inferomedial portion of the patella. • Whilst maintaining the force, the knee is flexed to 90° flexion. • The MPP test was defined as positive when the participant reported pain with the knee in extension but eliminated markedly when the knee was at 90° of flexion during this test • Meta-Anal: sensitivity=0.90; specificity=0.89)

Kopkow et al. journal of orthopaedic & sports physical therapy 43 | number 11 | 2013

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Functional Tests PFPS

• A majority of the studies that have investigated diagnostic accuracy of clinical tests for PFPS demonstrate notable design or reporting biases, and at this stage, determining the best tests for diagnosis of PFPS is still difficult.

211

PFPS Composite None are Great

• There is need for future research with more stringent study design criteria so that more accurate diagnostic power of ankle/lower leg special tests can be determined.

213

Achilles Tendinopathy Anterior Drawer Test

Sensitivity Specificity LR+ LR- Self reported Pain 78 77 3.39 0.29 Morning Stiffness 89 57 2.07 0.19 Tendon Thickening 58 90 5.80 0.47 Crepitus 3 100 30.00 0.97 Palpation 84 73 3.11 0.22 London Royal Test 51 93 7.29 0.53 The Arc Sign 25 100 250.00 0.75 Passive Dorsiflexion 13 87 1.00 1.00 Single Heel Raise 22 93 3.14 0.84 Hop Test 43 87 3.31 0.66

A.-M. Hutchison et al. / Foot and Ankle Surgery 19 (2013) 112–117 216

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Morton’s Neuroma

QUADAS is low

J Orthop Sports Phys Ther 2013;43(12):911-919. Epub 30 October 2013. doi:10.2519/jospt.2013.4679 D. Mahadevan et al. / The Journal of Foot & Ankle Surgery 54 (2015) 549–553

Syndesmosis Testing Syndesmosis Testing

Sman AD, Hiller CE, Rae K, et al. Br J Sports Med Published Online doi:10.1136/ bjsports-2013-092787 Großterlinden et al. Knee Surg Sports Traumatol Arthrosc. DOI 10.1007/s00167-015- 3604-x

Syndesmosis Testing-History and Observation Lateral Impingement Test

222

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Best tests of the TMD, Spine and

Chad CookPelvis PT, PhD, MBA, FAAOMPT Professor Duke Doctor of Physical Therapy Division Duke Clinical Research Institute Duke University • Only 3 studies presented in this literature review were of high quality. Because all of the included studies assessed diagnostic accuracy among subclassifications of individuals suspected of having TMD, the ability of any of these tests to distinguish between patients with TMD versus patients without TMD remains unknown.

223

Maximal Mouth Pain During Active Assistive Opening Opening • Sensitivity = 22 • Specificity = 98 • Sensitivity =55.4 • LR+ = 11 • Specificity=90.8 • LR- = .80 • LR+=6.02 • LR-= 0.49

Orsini et al. J Dent Res. 1999;78:650-660. Dworkin et al. (maximal mouth opening of <35mm for men and <30mm for women)

Pain During Palpation Lateral Glide

227 228

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Auscultation

Cervical Spine

229

Flexion-Rotation test C0/1-C1/2-C2/3 Differentiation

• Sensitivity=62 • Sensitivity = 86% • Specificity= 87 • Specificity = 100, LR+ = ~18+ • LR+=4.9 • Rules in and out the presence of • LR-=0.43 a cervicogenic headache with an origin at C1-2

Cook C, Hegedus E. Physical Examination Tests: An Evidence 232 Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007.

Cervicogenic Headache Posterior Anterior • 100% Sensitivity at identifying a lesion of any sort • Helps rule out presence of cervical pain on any origin

J. Rubio-Ochoa et al. / Manual Therapy 21 (2016) 35e40 Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice Hall: 2007. 234

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For Cervical Facet Dysfunction Cervical Rotation, Lateral Flexion • Testing left side in photo • Rotation and SB are opposite

• palpation for segmental tenderness [PST] • Extension rotation [ER] test, • manual spinal examination [MSE]) (UPA)

Schneider et al. Archives of Physical Medicine and Rehabilitation 2014;95:1695-701 236

Adam’s Forward Flexion ROOS test (for TOS) • Tests for scoliosis • Hold for a full minute

237 238

Thoracic Outlet Syndrome Centralization

Specificity = 94, +LR = 6.7; LR- = .12; Used to rule in and out the presence of discogenic disorder

Cook C, Hegedus E. Physical Examination Tests: An Evidence 240 239 Based Approach. Upper Saddle River, NJ; Prentice Hall: 2008.

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Extension Rotation Test Spondylosis

• Sensitivity=100 • Specificity=22 • LR+=1.28 • LR- =0.00

Spondylolisthesis The Passive Lumbar Extension Test

• Sensitivity=84.2 • Specificity=90.4 • LR+ =8.78 • LR- =0.17

A.M. Alqarni et al. / Physical Therapy in Sport 16 (2015) 268e275

Stenosis (N=1448) Cook et al. Sacral Thrust

Posttest Clustered Sensitivity Specificity LR+ (95% CI) LR- (95% CI) Prob of Results (95% CI) (95% CI) CTS (%) • Sensitivity=45

1 of 5 positive 0.19 (0.12- • Specificity=89 .96 (.94-.97) .20 (.19-21) 1.2 (1.1-1.2) 44 tests 0.29) • LR+=4.39 2 of .68 (.65-.71) .62 (.60–.64) 1.8 (1.6-2.0) 0.51 55 5 positive tests (0.45-.58) • LR-=0.60 3 of 0.80 .29 (.27-.31) .88 (.87–.90) 2.5 (2.0-3.1) 63 5 positive tests (.76-.85) 4 of 0.95 .06 (.05-.07) 98 (.98-.99) 4.6 (2.4-8.9) 76 5 positive tests (0.94-0.97) 5 of <.01 (.001- 0.99 (0.99- 1.0 (.99-1.0) Inf (.77-Inf) 99+ 5 positive tests .003) 1.0) Five findings are included in the rule: (1) Bilateral symptoms; (2) Leg pain more than back pain; (3) Pain during walking/standing; (4) pain relief upon sitting; and (5) age 245 >48 years. Pretest probability of 40.3%.

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Thigh Thrust Sit to Stand Test

• Pain during the very first stage of sit to stand is what you are looking for

247 248

Combinations of Findings CPR for Detecting Sacroiliac Joint Pain

• Distraction, thigh thrust, Gaenslen test, Compression, and sacral thrust • Sensitivity = 91 • Specificity = 87 • LR+ =7 • LR- =.10

Laslett et al. 249

CPR for Detecting Sacroiliac Joint Pain Sacroiliac Pain (Sacroilitis)

• Distraction, thigh thrust, Gaenslen test, Compression, and Patrick’s test • Sensitivity = 85 • Specificity = 79 • LR+ = 4.0 • LR- =.18

Van der Wurff et al. 252

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CPR for Detecting Pelvic Girdle Pain

• ASLR, Lunge, or Thigh Thrust (any 1 of 3) • Sensitivity = 94 • Specificity = 66 • LR+ = 2.8 • LR- = 0.09 Thank You

Cook et al. JMPT 2007