8/23/2010

What We’ll Cover Today

• 1. (Part 1) Differential Diagnosis (defined) The Best Tests for Diagnosis: And Why – The decision making process it's Important – Costs associated with errors in decision making • 3. (Part 2) Diagnostic Accuracy – The language of diagnosis Chad Cook PT, PhD, MBA, OCS, FAAOMPT – (studying diagnosis) Professor and Chair Walsh University • 4. (Part 3) Best tests for diagnosis

(Part 1) Differential Diagnosis My Objectives • Differential diagnosis is a systematic 1. Differential Diagnosis is Extremely Important process used to identify the proper (in the early phases of the examination but diagnosis from a competing set of possible less so in the later phases of the examination) diagnoses. 2. Recognizing Bias in Diagnosis is Half the Battle • Diagnosis is one of many necessary 3. It is Critical to Know which tests are best used components during the clinical decision early or late in the examination making process

Diagnostic Process? Who Performs Diagnoses?

• The Diagnostic process involves identifying or • Anyone who treats determining the etiology of a disease or patients condition through evaluation of patient • Certainly, physical history, physical examination, and review of therapists laboratory data or diagnostic imaging; and the subsequent descriptive title of that finding

Whiting et al. J Health Serv Res 2008

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PT’s and Diagnosis 1988 Why it’s Important

• “Physical Therapists thus must establish • Failure to correctly identify an appropriate diagnostic categories that direct their diagnosis can lead to: treatment prescriptions and that provide a – Negative outcomes (Trowbridge 2008). means of communication both within the – Delays in appropriate treatment (Whiting et al. profession and with other practitioners and 2008) consumers about the conditions that require – Unnecessary healthcare costs (Dohrenend and their particular expertise for effective Skillings) treatment and prognostication”

Sahrmann S. Diagnosis by the physical therapist: A prerequisite for treatment. Phys Ther. 1988;68:1703-6.

Can Lead to Death Most Common Types and Locations?

• 44,000 to 98,000 • Most in physician offices Americans die (primary care 31%, annually as a medical specialty 21%) result of medical • Error types: Diagnostic 36%, surgical 24%, non- errors (1999). surgical procedures 14%, medications 13%

Institute of Medicine. To err is human: building a safer health system. Kohn, Corrigan, Woods DM, Thomas EJ, Holl J. Ambulatory care adverse events and preventable adverse events and Donaldson (ed). Washington DC. National Academies Press, 1999, leading to hospital admission. Qual Saf Health Care 2007;16;127-131

ED Missed Diagnoses Worth Noting

• Leading breakdowns • Delayed Diagnosis – Failure to order 58% – Diagnosis is made but – Inadequate at a later date history/physical 42% – Incorrect test • Misdiagnosis interpretation 37% – Diagnosis is missed

Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the ambulatory setting: Both cause adverse events a study of closed malpractice claims. Ann Intern Med. 2006;145:488-96.

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Diagnosis vs. Treatment Difficult, but Preventable

• Acting on Insufficient Information* – (81% High Preventability) • Misapplication of, or failure to apply a rule or use a bad or inadequate rule – (90.3% High • 34.8% resulted in permanent disability • 86.5% of diagnostic delays were highly preventable Preventability)

Wilson R, Harrison B, Gibberd R, et al. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. MJA 1999; 170: 411-415 Wilson R, Harrison B, Gibberd R, et al. An analysis of the causes of adverse events from the Quality in Australian Health Care Study. MJA 1999; 170: 411-415

Costs associated with Too Many Lab Healthcare Costs Tests and Imaging • 50 to 53 million US dollars per million members, per year for a Referral• “Incorrect for lumbar diagnoses spine may medical misdiagnosis. radiographylead to incorrect for first and presentation of lowineffective back pain treatment in primary or care • 6.1 to 10.4 billion dollars is notunnecessary associated testing, with improved which is (adjusted) annually (for diagnostic physicalcostly functioning, and sometimes pain errors) or disability.invasive”

Medical Misdiagnosis: Overlooked opportunity for meaningful health plan improvement Kerry et al. Br J Gen Pract. 2002;52:469-74. of quality and costs. Managed Care Outlook. 2008;21(8). Reducing Errors in Health Care: Translating Research Into Practice . AHRQ Publication No. 00-PO58, April 2000. Agency for Healthcare Research and Quality, Rockville, MD. Institute of Medicine. To err is human: building a safer health system. Kohn, Corrigan, http://www.ahrq.gov/qual/errors.htm and Donaldson (ed). Washington DC. National Academies Press, 1999,

Cost Utility Analysis Old Knowledge

• An interdisciplinary early intervention • Seeing a rehab specialists treatment model was the preferred option in results in fewer loss of work over 85% of the samples within the an days per dedicated injury (whether serious or not established range of acceptable costs. serious) (N=2700) • (most of these interventions are underutilized because of physician concerns of cost and applicability) • Rogerson, Gatchel, & Bierner. Pain Pract. 2010;Apr 5. E-pub, ahead of print. Haig et al. Aggressive early medical management by a specialist in physical medicine and rehabilitation: effect on lost time due to injuries in hospital employees. J Occup Med. 1990;32:241-4.

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Misdiagnosis: A System Problem? Only Physicians?

• < 5% of Primary Care Physicians Routinely Examine for Red Flags during an Initial Screen • Bishop & Wing. Spine J. 2006: 6:282-8. • “Low rates of compliance for the assessment and documentation of yellow and red flags” • Walsh et al. Occup Med. 2008;58:485-9.

Orthopedic Surgeons? I’m Immune to your consultations (Bowie D)

• “Both orthopedic surgeons and family physicians’ • …Not in my setting knowledge of treating LBP is deficient.” • ….I’ve never been in a direct • “Orthopedic surgeons are less aware of current access environment treatment than family practitioners” • …..I work with good • Finestone et al. Spine. 2009;34:1600-3. physicians • ……The prevalence is so low….. • …. I don’t see patients with those diagnoses ..

Missed cancer diagnoses Most Commonly Missed Diagnoses?

Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145:488-96.

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What’s the Best Way to Go About the Diagnosis is Part of a Process “Process” • It is most important when the condition at hand is • A couple of thoughts unknown or a competing – Use a dedicated strategy – Understand the metrics of certain diagnosis is as likely as the findings presumed condition – Never rely too heavily on a single measure – Realize that diagnosis is a “process” not an “event”

Tekwani K, Sikka R. High Risk Chief Complaints III: Abdomen and Extremities. Emerg Med Clin N Am. 2009;27:747-65.

The Process Three Diagnostic Questions when Addressing a Patient

Rule Out Sinister Problems • The first question of diagnosis: Are the patient's symptoms reflective of a visceral disorder or a serious or potentially life-threatening illness? • The second question of diagnosis: From where is Identify the the patient's pain arising? Appropriate Location • The third question of diagnosis: What has gone wrong with this person as a whole that would cause the pain experience to develop and persist?

Identify “other” Contributors to the Condition Murphy D, Hurwitz E. A theoretical model for the development of a Murphy D, Hurwitz E. A theoretical model for the development of a diagnosis- diagnosis-based clinical decision rule for the management of patients with based clinical decision rule for the management of patients with spinal pain. BMC spinal pain. BMC Musculoskeletal Disorders 2007, 8:75 Musculoskeletal Disorders 2007, 8:75

Early Stages of Diagnosis

• Specific to the necessity for accuracy, is the ability to differentiate patients with symptoms that arise from non-mechanical disorders or other potentially life threatening pathology • Tests will require high levels of sensitivity, low LR-, and reasonable reliability

Murphy D, Hurwitz E. A theoretical model for the development of a diagnosis- based clinical decision rule for the management of patients with spinal pain. BMC Musculoskeletal Disorders 2007, 8:75 Rubinstein SD, van Tulder M. A best-evidence review of diagnostic procedures for neck And low back pain. Best Practice & Research Clinical Rheum. 2008;22:471-482.

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Example Some Foreshadowing • Mr. Smith, who was seen through direct access complained of an aching pain in his left lateral thigh. • “The findings of our study suggest that the The pain was worse at night and was described as a deep, boring, ache. majority of clinical tests for the spine with The comprehensive clinical acceptable diagnostic accuracy are for non- examination yielded no mechanical critical diagnoses.” findings during provocation or reduction testing and no special test that implicated a specific finding. Palpation findings were also inconclusive.

Cook C, Hegedus E. Diagnostic utility of clinical tests for spinal dysfunction. Man Ther. 2010. (accepted for publication)

Part Two of the Process Ruling Out Location?

• The second question of diagnosis: • Using tests with high sensitivity (or From where is the patient's pain overpressures) to rule out a body part region arising? as a contributor Ruling out a Location – (e.g., Using Neer’s test to rule out the shoulder; Using a straight leg raise to rule out a disc problem; using an overpressure to the cervical Ruling in a Location (but not Three Possible knowing the diagnosis) spine to rule out the c-spine as a contributor) Parameters

Confirming a Diagnosis

Ruling in a Location (but not knowing Quibbling over Non Threatening the diagnosis) Diagnoses

Symptoms are Isolated to a • • Stop trying to Region differentiate one form of • This is Where it Gets Murky non-sinister pain from – Nonspecific low back pain another and, instead, – Internal Derangement of the knee focus on the – Neck pain determinants of success Degenerative knee problems – or failure. – Impingement syndrome

Dinant GJ, Buntinx FF, Butler CC. The necessary shift from diagnostic to prognostic research. BMC Fam Pract. 2007;8:53.

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Confirming a Known Diagnosis Does Imaging Fit in Here Somewhere?

• Requires high specificity, reasonable • Yes, in that it can confirm some conditions sensitivity and a high LR+ (more on that later) were struggle to identify • Examples? • No in that it is overused – ACL tear • Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical – Herniated Nucleus Pulposis outcomes. Therefore, clinicians should refrain from routine, – TFC Tear immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious – Ulnar Ligament Instability underlying condition

Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: a systematic review and metanalysis. Lancet. 2009;373:463-72.

Part Three of the Process Such As…

• What has gone wrong with • Depression • Somatic perceptions this person as a whole that • Anxiety • Coping Behaviors would cause the pain • Motivation • Fear Avoidance experience to develop and • Litigation Behaviors persist? • Chronicity • Perceptions • The social, psychosocial, • Employment Status and socioeconomic • Household Income contextual elements • Habits • Job environment

da Costa BR, Vieira ER. Risk factors for work-related musculoskeletal disorders: A systematic review of recent longitudinal studies . Am J Ind Med. 2010;53:285-323.

Look, I’m a PT……My Profession Says I don’t Part Two-Diagnostic Accuracy Diagnose….

• Patient Safety is our Priority (Standards of Practice, Code of Ethics) • Accuracy is • Medical Screening for Unusual Conditions Critical • Our Duty is to Refer Out

Boissonnault W. Direct Access: Where’s the Beef? The Challenge from Chiropractors. http://www.apta.org

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Diagnostic Accuracy Positive and Negative Predictive Value??

• Reliability • Positive Predictive Value and Negative • Sensitivity Predictive Value are directly proportional to the prevalence of the disease /condition. • Specificity • Thus your sample better reflect the true • Positive Likelihood population or you will see over or under Ratio estimations • Negative Likelihood • I’m not reporting these Ratio

Reliability Language Standards

• Reliability or • 0.0 to 0.4 = Poor • Sensitivity : Percentage of people who test chance corrected • 0.4 to 0.6 = Fair positive for a specific disease among a agreement is the • 0.6 to 0.8 = Good estimate to which group of people who have the disease • 0.8 to 1.0 = Exceptional a test score is free • Specificity : Percentage of people who test from error and if negative for a specific disease among a erroneous the group of people who do not have the degree in which Measured as a Kappa (dichotomous) the value varies or measured as an ICC (continuous) disease from a true score.

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Sensitivity Example Specificity Example

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

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

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Likelihood Ratios For the Math Geeks • A high LR+ influences post-test probability with a positive finding • Positive Likelihood Ratio = • A value of >1 rules in a diagnosis (sensitivity)/(1-specificity) • A low LR- influences post-test probability with a negative finding • Negative Likelihood Ratio = (1-sensitivity)/(specificity) • A value closer to 0 is best and rules out

Bossuyt P, Reitsma J, Bruns D, Catsonis C, Glasziou P, Irwig L, Lijmer J, Moher D, Rennie D, de Vet H. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Family Practice. 2004;21:4-10.

Influencing Decision Making Example (Cervical Hyperflexion)

Cook C. Orthopedic Manual Therapy. An Evidence Based Approach . Prentice Hall; Upper Saddle River,51 NJ: 52 2007.

Example (Bend Over Test) Fagen’s Nomogram

• Cervical Radic • Pretest prob=18% • Spurling’s LR+=4.8 • Post test prob = 52%

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What if the Test(s) is Weak? What Causes Errors in Diagnosis? Sacroiliac Joint syndrome • Errors are enhanced by a Pre-test Probability of 15% number of factors: Standing bend over test LR+ – Cognitive = 0.81 (Croskerry2002, 2003), – Emotions Post test probability = 12% – Bad Tools You are less likely to make a – Non-descript conditions that correct diagnosis if you get a have no unique physical positive finding!!!! manifestations (Deyo and Weinstein, 2001) Doesn’t seem to stop people from using it though…. – Bad Research – Using Tests in the Wrong Order

Cognitive Biases (Judgment Representative Heuristic Errors) • 1. Representative Heuristic • If a finding is similar to something else, it • 2. The must be that condition as well • 3. Confirmatory bias • X = Y and Y = Z therefore X = Z • 4. • Example: Groin pain? • 5. Overconfidence

http://www.sports-injury-info.com/image-files/hip-pain-hip-flexor.jpg

Klein J. Five pitfalls in decisions about diagnosis and prescribing. BMJ 2005;330:781-783. 57 58

Availability Heuristic Confirmatory bias

• We get fixated on a • Looking for things in the examination that disease process and we want or expect to find we tend to look for it • Example: Use of multiple clinical tests to • Shoulder labrum prevalence = <5% confirm the presence of a knee meniscus lesion or a should labral lesion (i.e., over- • Disc herniation prevalence = 18-28% testing) • SIJ prevalence = 7- 21% Kempainen et al. Understanding our mistakes: A primer on errors in clinical reasoning. Med Teacher. 2003;25:177-181. 59 60

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Illusory Correlation Overconfidence

• Involves linking two events when • Most diagnosticians feel that they are there is actually no correlation better decision makers than what they • Pushing for a cause when there is actually display in clinical practice no definitive mechanism • The least skilled diagnosticians are also • Pushing for a structural finding the most overconfident and most likely to when there is no actual relationship make a mistake! • Example: Illness after receiving a • Needless to say, this is a huge problem in flu shot. medicine

Berner et al. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:2-23. 61 62

Emotional Based Practice Erroneous tools

• High-quality special clinical tests are designed to discriminate or differentiate a sub-group of homogeneous characteristics from a heterogeneous pool of patients • Unfortunately, no diagnostic laboratory or clinical test for pathology is completely specific (Hollander 1978; Glas et al., 2003; Mol et al., 2003).

Jaeschke R, Meade M, Guyatt G, Keenan SP, Cook DJ. How to use diagnostic Cleland J. Orthopaedic Clinical Examination: An Evidence Based Approach test articles in the intensive care unit: diagnosing weananability using f/vt. Crit for Physical Therapists (Netter Clinical Science) [Paperback] Elsevier Care Med. 1997;25:1514-1521. 64

Radiograph (all lumbar) Magnetic Resonance Image • Problem associated with poor sensitivity (it • For Herniated Discs the tool is likely to missed a number of conditions such as catch a number of problems even in those Metastases (Sens=60), Later stage without a condition (Sens=89-100, Infection (Sens=82) and Compression Spec=43-57) fractures (Sens=70%) • Similar problems exist when detecting • Herniated Discs: Cannot be used Central stenosis (Sens=81-97, Spec=72- • Spinal stenosis: Cannot be used 100)

• Nerve root impingement: Cannot be used Jarvik and Deyo. Diagnostic evaluation of low back pain. Ann Intern Med. 2002;137: 586-597.

Jarvik and Deyo. Diagnostic evaluation of low back pain. Ann Intern Med. 2002;137: 65 66 586-597.

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Discogram Non-Descript Conditions (discography) • For Internal disc disruption: Has high • Disease: A pathological condition of a part, sensitivity (47-100) but poor specificity organ, or system of an organism resulting from (25-67) various causes, such as infection, genetic defect, or environmental stress, and characterized by an • Often yields pain in asymptomatic patients identifiable group of signs or symptoms • Not useful in cervical disc detection • Syndrome: A group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition. Shah et al. Discography as a diagnostic test for spinal pain: A systematic review. Pain Physician 2005;8:187-209. Cohen et al. Lumbar discography: A comprehensive review…Reg Aneth Pain Med

2005;30:163-183. 67 68

Disease or Syndrome? Examples

• Disease refers to a cause. Diseases Syndromes There is cause and effect • Cancer • Thoracic outlet and the effect involves signs • Femur fracture syndrome and symptoms • Torn rotator cuff • Patellofemoral Pain • Syndrome refers only to the • Lumbar radiculopathy syndrome (PFPS) set of detectable • Achilles tendon tear • Carpal tunnel syndrome (examination) characteristics • Cervicogenic (signs and symptoms), not headache • Cubital tunnel syndrome causality http://www.bbspot.com/Images/News_Features/2005/03/confused.jpg • Piriformis syndrome Thagard P. Conceptual revolutions. Princeton: Princeton University Press. 1992.

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Problems in Detecting Disease or Bad Research Syndrome?

• 1. Underlying cause is murky • Although I think that, in many cases, the research on special tests is more to blame than the tests • 2. Signs and symptoms are inconsistent themselves and that these tests should remain • 3. Disease or syndrome is ill defined part of a skilled clinical examination, I agree with the message: JMMT and other journals need • 4. The Disease evolves over its natural high-quality diagnostic studies since the history components of a physical examination influence clinical decision making . • 5. The disease has no early signs and symptoms • 6. The reference standard lacks tangibility Hegedus E. Studies of quality and impact in clinical diagnosis and decision-making. J Man 71 Manip Ther. 2010;81:5-6.

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Case Control Design Bias Case Control Bias?

• Case Control Design – Two Groups: One with the disease – Another without the disease (and in many cases any problem) • Case-Based, Case Control Design – Two groups with similar diseases – The test is used to differentiate disease types

Rutjes AW, Reitsma JB, Di Nisio M, et al. Evidence of bias and variation in diagnostic accuracy studies. Canadian Medical Cook C, Hegedus E. Diagnostic Utility of Clinical Tests for Spinal Dysfunction. Man Ther. Association Journal 2006;174:469-76. 2010 (accepted)

Sample Size? Well Defined Spectrum

• Does Size matter? • A “Spectrum” is • The mean sample size for the characteristic diagnostic accuracy is ~35 and representation patients of a population • It needs to have a full • Thus, the sample spectrum of should reflect that representation population

Flahault A, Cadihac M, Thomas G. Sample size calculation should be performed for Hegedus E, Moody J. The many faces of spectrum bias. J Man Manip Ther. 2010;18(2) Design accuracy in diagnostic test studies. J Clin Epidemiol. 2005;58:859-62.

Improper Reference Standards Reference Standard

• AKA Criterion standard or “Gold Standard” • “A perfect embodiment of a concept” • Surgical Confirmation (top shelf) • Usually it’s surgery () • Imaging Confirmation of a • To a lesser extinct it’s imaging clinical finding • Worst case scenario, it’s clinical • Imaging Finding findings • Clinical Finding (change in condition) • Expert Opinion

http://www.goldpaq.com/wp-content/uploads/2008/02/stacked-gold-bars1.jpg 77

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Examples Multidisciplanary Agreement

• How is a torn rotator cuff diagnosed? • All health care providers share a common (surgery is the most accurate method) definition for the disease process • How is cervical radiculopathy diagnosed? – SIJ? (EMG or NCV is most accepted method) – Fibromyalgia? • How is a herniated disc diagnosed? – TMD? (surgery is the most accurate method) – TOS • How is Thoracic outlet syndrome – Piriformis syndrome diagnosed (ummmm) – Instability

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Let Metrics Drive Use Out of Order Metrics

• Use Tests with High Sensitivity and Low • Tests should typically Negative Likelihood Ratios early in the be used early examination to “rule out” – E.g., SLR, ULTT, • Use Tests with High Specificity and Hign Hawkins Kennedy, Positive Likelihood Ratios early in the • Or late in the examination to “rule in” examination • Don’t use tests that don’t have either at all. – Spurlings, Hoffmann’s test, Well leg Raise

OTHERWISE YOUR RESULTS WILL BE BIASED 81 82

Rule Out Contenders Cervical Shoulder RCT Radicular Pain

Shoulder Referred Pain Capsulitis Non-Radicular

Visceral Shoulder Disorder Instability

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Rule In Possibilities QUADAS • 10/14 or higher affects scoring • Tests with high LR+ and • (Qu ality Assessment of Diagnostic Accuracy specificity (e.g. Rent test Shoulder RCT •Studies) Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C. Physical examination tests of the and lift off sign • 14 shoulder:items (scoreda systematic 0 reviewto 14) with meta-analysis of individual – 1.tests. Appropriate Br J Sports selectionMed. 2008 ofFeb;42(2):80-92; patient spectrum discussion 92. • Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. – 2.Physical Appropriate examination reference tests for standard assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports • Tests with high LR+ and – 3.Phys Absence Ther. 2007 of reviewSep;37(9):541-50. bias (both test and diagnostic) specificity (e.g., Surprise •– 4. Cook Clinical C, Hegedus review E. biasOrthopedic Physical Examination Tests: An Shoulder Evidence-Based Approach . Upper Saddle River NJ; Prentice Hall: test) Instability – 5.2008. Reporting of ininterpretable/ indeterminate/ •intermediate Cook C, Cleland results J, Huijbrets P. Creation and critique of studies of diagnostic accuracy: use of the STARD and QUADAS tools. J Man Manipulative Ther. 2007;15:93-102.

Whiting et al. BMC Medical Research Methodology. 2003, 3: 25

Example: Spurlings How Am I Supposed to Remember all This? • “When reviewing the quality of the tests • Two Ways that reported in the Spurling’s sign, we – Pattern Recognition (heurism) found that those with • Or lesser bias, identified – Clusters, Decision Rules, the test as a specific Clinical prediction rules, etc. test….”

Cook C, Cleland J, Huijbregts P. Creation and Critique of Studies of Diagnostic Accuracy: Use of the STARD and QUADAS Methodological Quality Assessment Tools. JMMT. 2007;15:93-102. 87 88

Decisions Made by Pattern Recognition Is this Good Enough?

• It’s a heuristic • Not in most cases approach to • Most healthcare providers use tools or decision making. decision making instruments that are of • Experienced little value!! clinicians have • Most diagnosticians make errors in better pattern recognition diagnosis (on complex and non-complex cases)!!

Kabrhel et al. Clinical gestalt and the diagnosis of pulmonary embolism: Does Croskerry et al. Overconfidence in clinical decision making. Am J Med. 2008;121:24-29 89 90 experience matter? Chest 2008;127:1627-1630.

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Decisions Making By Clinical Decision Rules Take Home Message?

• If designed well the • All clinical tests are a little right and a little outcome is typically wrong better than the lay • Most tests are either very sensitive or very clinician’s ability to specific diagnosis • No single test can identify a condition with utmost accuracy • We ALWAYS function with some element of doubt during our examination

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Part Three-Best Tests for A Better Order of Examination Screening and Diagnosis • Patient history • Case Based, Case Control Design – Tests with high sensitivity and • Acceptable reference standard LR- • More patient history • Need moderate to large sample sizes • Patient examination (N=60 or greater) – More tests with high • Minimized Spectrum Bias sensitivity • QUADAS score of 10 or greater • Patient examination http://www.vhct.org/case399/images/physical_therapist.jpg – Tests with high specificity and LR+

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QUADAS Acceptable Metrics • 10/14 or higher affects scoring • (Qu ality Assessment of Diagnostic Accuracy • For Screening, Sensitivity of 90, or a LR- of .20 •Studies) Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, or less • 14 Moormanitems (scored CT 3rd, Cook 0 to C. Physical14) examination tests of the shoulder: a systematic review with meta-analysis of individual • For Diagnosis, a LR+ or 5.0 AND a LR- of .20 – 1.tests. Appropriate Br J Sports selectionMed. 2008 ofFeb;42(2):80-92; patient spectrum discussion 92. • Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. • Or, if critical, something close – 2.Physical Appropriate examination reference tests for standard assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports – 3.Phys Absence Ther. 2007 of reviewSep;37(9):541-50. bias (both test and diagnostic) •– 4. Cook Clinical C, Hegedus review E. biasOrthopedic Physical Examination Tests: An Evidence-Based Approach . Upper Saddle River NJ; Prentice Hall: – 5.2008. Reporting of ininterpretable/ indeterminate/ •intermediate Cook C, Cleland results J, Huijbrets P. Creation and critique of studies of diagnostic accuracy: use of the STARD and QUADAS tools. J Man Manipulative Ther. 2007;15:93-102.

Whiting et al. BMC Medical Research Methodology. 2003, 3: 25

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Deep Vein Thrombosis Clinical Combining History with Exam: Exam The Wells et al Clinical Tool-DVT

Wells et al. JAMA 2006

Rule Out Pulmonary Embolism Pre-test Probability of a DVT (PERC) Score Probability of a DVT • Age 50 years < 0 LOW • Pulse 100 beats/min • Pulse ox 94% 1-2 MODERATE • No unilateral leg swelling • No hemoptysis (coughing up blood) > 3 HIGH • No recent surgery • No prior DVT or PE • High or Intermediate vs. low risk: • No oral hormone use sensitivity = .89, specificity = .47. LR+ = • The PERC score had a LR- of 0.17 (95% CI 0.11– 1.68 0.25) for low risk groups

Goodacre et al. Meta-analysis: The value of clinical assessment in the Carpenter CR, Keim SM, Seupual RA, Pines JM. Differentiating Low-risk and No-risk diagnosis of deep venous thrombosis. Ann Intern Med. 2005 Jul 19;143(2):129-39. PE Patients: The PERC Score. The Journal of Emergency Medicine . 2009;36(3);317–322.

Framingham Diagnostic TIMI Risk Score Criteria for Heart Failure Diagnosis of CHF requires the simultaneous presence of at least 2 major criteria • Age > 65; Known CAD; 3 cardiac risk factors, or 1 major criterion in conjunction with 2 minor criteria. ST-segment deviation ; >2 anginal events in past • Major criteria: • Minor criteria: Paroxysmal nocturnal dyspnea • • Bilateral ankle edema 24 hours; aspirin use in the past 7 days, • Neck vein distention • Nocturnal cough elevated cardiac marker level • Rales • Radiographic cardiomegaly • Dyspnea on ordinary exertion • Sensitivity = 98 (C.I. 94-100) (increasing heart size on chest • Hepatomegaly radiography) • Specificity = 19 (C.I. 16-21) • Pleural effusion • Acute pulmonary edema • Decrease in vital capacity by one • LR+ = 1.2 • S3 gallop third from maximum recorded • Increased central venous pressure • Tachycardia (heart rate>120 (>16 cm H2O at right atrium) • LR- = 0.12 beats/min.) • Hepatojugular reflux • Weight loss >4.5 kg in 5 days in Tong et al. Myocardial contrast echocardiography versus Thrombolysis In Myocardial response to treatment Infarction score in patients presenting to the emergency department with chest pain • and a nondiagnostic electrocardiogram. J Am Coll Cardiol. 2005 Sep 6;46(5):920-7.

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Framingham Diagnostic Ankle-Brachial Index Criteria for Heart Failure

• Overall Heart Failure • Assessment of – Sens = 92 Peripheral Vascular – Spec = 79 Disease – LR+ = 4.35; LR- = 0.10 • Lower ratio suggests • Systolic Heart Failure blockage in leg – Sens = 97 • Measure blood – Spec = 79 – LR+ = 4.6; LR- = 0.04 pressure at the ankle • Diastolic Heart Failure and at the arm – Sens = 89.1 (Systolic) while a – Spec = 79 person is at rest. – LR+ = 4.2; LR_ = 0.13 • Ankle / Arm

Maestre et al. Diagnostic accuracy of clinical criteria for identifying systolic and diastolic Guo et al. Sensitivity and Specificity of Ankle-Brachial Index for Detecting Angiographic Heart failure. Cross sectional study. J Eval Clin Pract. 2009;15:55-61. Stenosis of Peripheral Arteries. Circ J 2008; 72: 605 –610

Ankle-Brachial Index San Francisco Syncope Rule

• Normal: 0.9 to 1.3. • Identifies patients with serious short term adverse outcomes after partial or complete loss • Abnormal: Less than 0.9 is abnormal. of consciousness with interruption of awareness Sensitivity = 76, Specificity = 90, LR+ = 7.6 of oneself and ones surroundings • If the ABI is: • Abnormal ECG, a complaint of shortness of – 0.41 to 0.9, you likely have mild to breath, hematocrit less than 30%, systolic blood moderate peripheral arterial disease. pressure less than 90 mm Hg, or a history of – 0.4 or below, you likely have severe CHF peripheral arterial disease. • Sensitivity = 96% • Specificity = 62% LR+ = 2.52

Quinn et al. Derivation of the San Francisco Syncope Rule to predict patients Guo et al. Sensitivity and Specificity of Ankle-Brachial Index for Detecting Angiographic with short-term serious outcomes. Ann Emerg Med. 2004 Feb;43(2):224-32. Stenosis of Peripheral Arteries. Circ J 2008; 72: 605 –610

Clinical Prediction Rule- Myelopathy Cervical Myelopathy Cluster

+ - Posttest Sensitivity Specificity Likelihood Likelihood N = 249 patients with cervical pain: 88 with Clustered Prob of (95% CI) (95% CI) Ratio (95% Ratio (95% Results CSM (%) CSM CI) CI)

1 of 5 positive 1.4 0.18 – Age >45 years .94 (.89-.97) .31 (.27-32) 43 tests (1.2-1.4) (0.12-0.42) – + Hoffmann’s Sign 2 of 5 positive .88 3.3 0.63 .39 (.33–.46) 64 – + Inverted Supinator Sign tests (.84–.92) (2.1–5.5) (0.59-0.79) 3 of 5 positive .99 30.9 0.81 – + Babinski Test .19 (.15–.20) 94 tests (.97–.99) (5.5-181.8) (.79-.87) – + Gait Abnormality 4 of 5 positive 1.0 Inf 0.91 .09 (.06–.09) 99+ tests (.98-1.0) (3.9-Inf) (0.90-0.95)

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

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Vertebral Compression Compression Fracture

Fracture Positive Negative Specificity Sensitivity Likelihood Likelihood Clustered Results (95% (95% CI) Ratio Ratio (95% • Female sex CI) (95% CI) CI) 0.39 (0.07-2.1) • Age >70 years 1 of 5 positive tests .97 (.89-.99) .06 (.06-.07) 1.04 (.92-1.1) 0.16 (0.04-.51) • Significant trauma 2 of 5 positive tests .95 (.83-.99) .34 (.33–.34) 1.4 (1.3-1.8) 0.34 (.19-.46) • Prolonged use of corticosteroids 3 of 5 positive tests .76 (.61-.87) .68 (.68-.69) 2.5 (1.9-2.8) 0.65 (0.50-0.79) • 1 of 4 Sens = 88, Spec = 50, LR+ = 1.8 4 of 5 positive tests .37 (.24-.51) .96 (.95-.97) 9.6 (3.7-14.9) 0.97 (0.92-0.99) • 3 of 4 Sens = 38, Spec = 100, LR+ = 218 5 of 5 positive tests .03 (.01-.08) .99 (.98-.99) 9.3 (1.4-60.2) 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) Henschke et al. Prevalence of and screening for serious spinal pathology in female gender. patients presenting to primary care settings with acute low back pain . Roman M, Brown C, Richardson W, Isaacs R, Howes C, Cook C. The development of a clinical decision Arthritis Rheum. 2009 Oct;60(10):3072-80. making algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity. JMMT 2010;81:45-50.

Ruling Out Hip Fractures (Negative findings of) Spine Cancer • History sensitivity • Listen for specificity sound – Age > 50 0.77 0.71 – previous history 0.31 0.98 differences of cancer between sides – failure to improve 0.31 0.90 in 1 mo. of therapy • Sensitivity = – no relief -bed rest >0.90 0.46 78%; LR- = – duration > 1 mo 0.50 0.81 0.23; LR+ = – age >50 or cancer hx or 1.00 0.60 unexplained wt loss or 7.9 failure of conservative tx. – Insidious onset Adams SL, Yarnold PR. Clinical use of the patellar-pubic percussion sign in – constitutional symptoms hip trauma. Am J Emerg Med. 1997 Mar;15(2):173-5. Deyo RA, Jarvik JG. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137:586-97..

Ankylosing Spondylitis Canadian C- Spine Rules • History sensitivity specificity – age at onset <40 1.00 0.07 – pain not relieved by supine 0.80 0.49 – morning back stiffness 0.64 0.59 Sensitivity = 99 – pain duration >3 months 0.71 0.54 LR- = 0.01 – 4 of 5 questions above positive 0.23 0.82 also: improved by exercise

+LR = 1.27

Deyo RA, Jarvik JG. Diagnostic evaluation of low back pain with emphasis on Stiell et al. Canadian CT head rule study for patients with minor head injury: methodology for imaging. Ann Intern Med. 2002;137:586-97.. phase II (validation and economic analysis). A nn Emerg Med. 2001;38(3):317-22.

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Ottawa Knee Rules Criteria for the Ottawa Knee Rule Sn = 1.0 ! Sp = .49 A knee x-ray is indicated after trauma only and when at least one of the following is present: +LR = 1.96 1.Patient age > 55 -- LR = .11 ! 2.Isolated tenderness of the Jackson et al, Annals patella Int Med, 2003 3.Tenderness over the fibular head 4.Inability to flex the knee to 90° 5.Inability to bear weight for four steps at the time of injury and Sn = 1.0 for Foot Fx and Ankle Fx Sp = .50 ankle, .77 foot when examined Steill et al, JAMA, 1994

PA of the Cervical Spine

• Sensitivity = 89 • Specificity = 47 • LR+ = 1.7 Regional Testing • LR- = .23 • *pooled results

King et al. The validity of manual examination in assessing patients with neck pain. Spine J. 2007;7:22-6.

Regional Tests-Best Tests for Diagnosis QUADAS • 10/14 or higher affects scoring • Case Based, Case Control Design • (Qu ality Assessment of Diagnostic Accuracy Studies) • Acceptable reference standard • Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C. Physical examination tests of the • 14 shoulder:items (scoreda systematic 0 reviewto 14) with meta-analysis of individual • Need moderate to large sample sizes – 1.tests. Appropriate Br J Sports selectionMed. 2008 ofFeb;42(2):80-92; patient spectrum discussion 92. • Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. (N=60 or greater) – 2.Physical Appropriate examination reference tests for standard assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports • Minimized Spectrum Bias – 3.Phys Absence Ther. 2007 of reviewSep;37(9):541-50. bias (both test and diagnostic) •– 4. Cook Clinical C, Hegedus review E. biasOrthopedic Physical Examination Tests: An • Close to a LR+ of 5.0, Sensitivity of 90, Evidence-Based Approach . Upper Saddle River NJ; Prentice Hall: – 5.2008. Reporting of ininterpretable/ indeterminate/ and a LR- of .20 or less •intermediate Cook C, Cleland results J, Huijbrets P. Creation and critique of studies of diagnostic accuracy: use of the STARD and QUADAS tools. J • QUADAS score of 10 or greater Man Manipulative Ther. 2007;15:93-102. Whiting et al. BMC Medical Research Methodology. 2003, 3: 25

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Maximal Mouth Opening

• Sensitivity = 22 Best Tests for the • Specificity = 98 • LR+ = 11 Temporomandibular Joint • LR- = .80

Dworkin et al. (maximal mouth opening of <35mm for men and <30mm for women)

Best tests for the Cervical Best Tests for Shoulder Spine Problems

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Rent Test Biceps Load Test II

Sensitivity is 96, LR- = 0.04 Rules out presence of a rotator cuff tear Specificity = 97, LR+ = 32 Rules in presence of a rotator cuff tear Sensitivity = 90, LR- = 0.11. Rules out the presence of a SLAP lesion

Specificity = 97, LR+ = 26.4. Rules in the presence of a SLAP lesion

Hegedus E. Physical Examination Tests for the Shoulder Complex. In: Cook C, Hegedus E. 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 125 Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice 126 Hall: 2007. Hall: 2007.

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Crank Test Surprise Test

• Sensitivity = 91, LR- • Sensitivity = 92, LR- = 0.10 = 0.08 • Used to rule out the • Used to rule out presence of any labral presence of anterior tear of the shoulder instability • Specificity = 93, LR+ • Specificity = 89, LR+ = 7.0 = 8.4 • Used to rule in a • Used to rule in labral tear of any presence of anterior form instability

Hegedus E. Physical Examination Tests for the Shoulder Complex. In: Cook C, Hegedus E. 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 127 Physical Examination Tests: An Evidence Based Approach. Upper Saddle River, NJ; Prentice 128 Hall: 2007. Hall: 2007.

Biceps Squeeze Test

• Rules out presence of a biceps tear Best Tests for Elbow/Wrist • Sensitivity = 96, LR- Hand Problems = 0.04 • Rules in presence of a biceps tear • Specificity = 100, LR+ = ~

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 130 River, NJ; Prentice Hall: 2007.

Wrist Flexion-Compression Median Nerve Compression Test Test • Sensitivity = 86, • Sensitivity = 100, LR- LR- = 0.1 = ~ • Rules out presence • Rules out presence of of Carpal Tunnel Carpal Tunnel Syndrome Syndrome • Specificity = 95, • Specificity = 97, LR+ LR+ = 17 = 33 • Rules in presence • Rules in presence of of Carpal Tunnel Carpal Tunnel Syndrome Syndrome

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 131 Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 132 River, NJ; Prentice Hall: 2007. River, NJ; Prentice Hall: 2007.

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Carpal Compression Test

• Sensitivity = 83, LR- = 0.2 Best Tests for Thoraco- • Rules out presence of CTS Lumbar Problems • Specificity = 92, LR+ = 10 • Rules in presence of CTS

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 133 River, NJ; Prentice Hall: 2007.

Percussion Test Centralization (Boney Vibration Test)

• For Disc problems in non-surgical patients • Sensitivity = 96 • Specificity = 72 • LR- = 0.05

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

Hancock et al. Systematic review of tests to identify the disc, SIJ, or facet joint as the 135 Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 136 Source of low back pain. Eur Spine J. 2007;16:1539-1550. River, NJ; Prentice Hall: 2008.

Fist (Percussion) Test

• For upper lumbar compression fractures • Sens=87.5 Best Tests for the • Spec=90 Pelvis/SIJ • LR+=8.7 • LR-=0.14

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Palpation of the Long Dorsal Ligament • Sensitivity = 98, LR- = 0.02 • Helps rule out the Best Tests for the Hip presence of a sacroiliac joint disorder

Vleeming et al. Possible role of the long dorsal sacroiliac ligament in women With peripartum pelvic pain. Acta Obstet Scand 2002;81:430-436.

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 139 River, NJ; Prentice Hall: 2008.

Thessaly Test at 20 Degrees

• Sensitivity = 89, LR- = 0.11 (medial mensicus) • Sensitivity = 92, LR- = 0.08 (medial mensicus) Best Tests for the Knee • Helps rule out the presence of a meniscus tear • Specificity = 96, • +LR = 23 (lateral) • Specificity = 97, LR+ = 29 (medial) • Use to rule in presence of a meniscal tear

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 142 River, NJ; Prentice Hall: 2008.

Dynamic Test Lachman’s Test

• Sensitivity = 85, LR- • Sensitivity = = 0.17 96, LR- = ~ (specificity is • Helps rule out the 100) presence of a • Helps rule out meniscus tear the presence • Specificity = 90, of an ACL tear • +LR = 8.5 • Specificity = 96, +LR = 6.2 • Use to rule in • Use to rule in presence of a presence of an meniscus tear ACL tear

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 143 Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 144 River, NJ; Prentice Hall: 2008. River, NJ; Prentice Hall: 2008.

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What do we now Know? Not Buying it?

• Most tests either rule in or rule out a • Please Read the disorder literature • There aren’t many special tests for the • Cook and Hegedus 2010 ankle, hip, or SIJ, that are useful in singular use • Hegedus et al. 2008 • Hegedus et al. 2009 • There are no tests that rule in SIJ by themselves • Rubenstein and van Tulder 2008 • Some of the old “stand bys” have limited value • Hancock et al. 2007

145 146

Fast and Frugal Heuristic Another Option? Decision Making? • Clustering findings is • It’s a philosophy compass similar to how we • Making quick decisions normally make clinical without complete information decisions • A fast heuristic is easy to use • It’s called “patterning” and allows one to make or “fast and frugal” judgments quickly. A frugal heuristic relies on a small decision making fraction of the available evidence in making judgments.

Please note In Some Cases…

• Typically, clustering improves the • Tests can do both. specificity at the expense of sensitivity • For example, if few of the clustered items are – What does this mean? there then it rules out the condition • You can improve the sensitivity, at the • If most of the clustered items are there it rules expense of specificity in the condition – How do you do this?

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Clinical Examples?

• SOB + Chest Pressure + Left Arm Pain = Refer to ED • Elderly women + Fall + Inability to weight Clustered Findings bear + ER deformity of the hip = Hip Fracture • Immobility + Fear + Inactivity = Candidate for Activation

Cervical Radiculopathy CPR-RTC in Older Adults

• Spurlings, ROM<60 1 2 • Night pain, degrees, Distraction age >60, test, and ULTT weakness in • Sens = 24, Spec = external 99, LR+ = 30.3 (all 4 rotators, and tests positive) 3 4 pnful arc = • QUADAS = 10 LR+ 14 for RTC tear

Litaker D, Pioro M, Bilbeisi HE, Brems J. Returning to the bedside: using the history and physical Wainner et al. Reliability and diagnostic accuracy of the clinical examination and examination to identify rotator cuff tears. J Am Geriatr Soc , 2000, Volume 48, pp. 1633-1637. 154 patient self-report measures for cervical radiculopathy. Spine . 2003;28(1):52-62. 153

Impingement or RCT

• Impingement • Rotator Cuff Tear • LR+ = 10.5 • LR+ = 15.6 • All 3 tests + • All 3 tests + • Analyzed the combination of tests: • Hawkins Kennedy • Hawkins Kennedy – Hawkins/Kennedy • External rotation • External rotation strength test strength test – Painful arc sign • Painful arc sign • Painful arc sign – Infraspinatus muscle tests

155 156

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Combinations of Findings Stenosis ( N=1448 ) Study Sensitivity Specificity QUADAS Posttest Score (0- Clustered Sensitivity Specificity LR+ (95% CI) LR- (95% CI) Prob of 14) Results (95% CI) (95% CI) CTS (%) Thigh thrust, distraction, sacral thrust, and compression tests

1 of 5 positive 0.19 (0.12- Laslett et al. (2 of 4) 88 78 12 .96 (.94-.97) .20 (.19-21) 1.2 (1.1-1.2) 44 tests 0.29) Distraction test, compression test, thigh thrust, Patrick sign, Gaenslen 2 of .68(.65-.71) .62(.60–.64) 1.8(1.6-2.0) 0.51 55 van der Wurff et al. (3 of 5) 85 79 12 5 positive tests (0.45-.58) Distraction, thigh thrust, Gaenslen test, Compression, and sacral thrust 3 of 0.80 .29(.27-.31) .88(.87–.90) 2.5(2.0-3.1) 63 5 positive tests (.76-.85) Laslett et al. (3 of 5) 91 87 13 4 of 0.95 ASLR, Gaenslen, or Thigh Thrust .06(.05-.07) 98(.98-.99) 4.6(2.4-8.9) 76 5 positive tests (0.94-0.97) Cook et al. (1 of 3) 88 66 11 5 of <.01 (.001- 0.99 (0.99- 1.0 (.99-1.0) Inf (.77-Inf) 99+ 5 positive tests .003) 1.0) ASLR, Lunge, or Thigh Thrust Cook et al. (1 of 3) 94 66 11 Five findings are included in the rule: (1) Bilateral symptoms; (2) Leg pain more than 157 back pain; (3) Pain during walking/standing; (4) pain relief upon sitting; and 158 (5) age >48 years. Pretest probability of 40.3%.

CPR for Detecting Sacroiliac Joint CPR for Detecting Sacroiliac Joint Pain Pain

• Distraction, thigh thrust, • Distraction, thigh thrust, Gaenslen test, Compression, Gaenslen test, Compression, and sacral thrust and Patrick’s test • Sensitivity = 91 • Sensitivity = 85 • Specificity = 87 • Specificity = 79 • LR+ =7 • LR+ = 4.0 • LR- =.10 • LR- =.18

Laslett et al. Van der Wurff et al.

CPR for Detecting Pelvic Girdle Composite Test for Arthritis Pain

• ASLR, Lunge, or Thigh Thrust • Sensitivity = 86, LR- = (any 1 of 3) 0.19 • Sensitivity = 94 • Includes test for 1) hip • Specificity = 66 pain, 2) IR<15 degrees, • LR+ = 2.8 3) pain with IR, 4) • LR- = 0.09 morning stiffness up to 60 minutes, and 5) age>50 years • Helps rule out the presence of osteoarthritis at the hip

Cook C, Hegedus E. Physical Examination Tests: An Evidence Based Approach. Upper Saddle 162 Cook et al. JMPT 2007 River, NJ; Prentice Hall: 2008.

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Tests for Torn ACL and Anterior Tests for Torn Tibial Meniscus Rotary Instability • Composite Physical Exam • Composite Physical Exam (ACL Tear) Sensitivity – • Rose & Gold Sen-100, LR+ N/A QUADAS Rose & Gold (Medial) sensitivity=92, LR+ = 10 2.3 QUADAS = 10 • Kocabey et al. Sen-100, LR+ N/A QUADAS Jackson et al. (Lateral) sensitivity=88, LR+ = 10 11.0 QUADAS = NA

163 164

Tests for Torn PCL and Posterior Tests for Torn Collateral Ligament Rotary Instability • Composite Physical Exam • Composite Physical Exam (Medial • O’Shea et al. Sen-100, LR+ N/A Collateral Ligament (MCL) Tear • QUADAS = 9 • Simonsen et al. Sen-88, LR+ 3.3 • Jackson et al. Sen-81, LR+ 16.2 • QUADAS = 12 • QUADAS = 12

165 166

Tests for Torn Collateral Ligament CPR-RCT in Older Adults

• Composite Physical Exam (Lateral • Night pain, Collateral Ligament (LCL) Tear) age >60, • Simonsen et al. Sen-100, LR+ N/A weakness in • QUADAS = 12 external rotators, and pnful arc = LR+ 14 for RTC tear

Litaker D, Pioro M, Bilbeisi HE, Brems J. Returning to the bedside: using the history and physical examination to identify rotator cuff tears. J Am Geriatr Soc , 2000, Volume 48, pp. 167 1633-1637.

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Notably Missing Can we do better than Clusters?

• Sharp Purser (low QUADAS) • Alar Ligament (not tested) • Any TOS test (low QUADAS) • VBI (low QUADAS) • Slump Sit (low sensitivity/LR-) • Prone Instability Test (low LR+ and LR-) • Well Leg Raise (low QUADAS) • DTR’s, MMT, and sensory testing (low QUADAS and low sensitivity values)

Not just Patterns, Temporal Linking Too Tree Analyses • I’m prompted to test for a herniated disk when I hear……. • I’m prompted to test for a rotator cuff tear if I see…… • I’m prompted to test for myelopathy if I hear…… • I’m prompted to test for an ACL tear if I find that the patient……….

Improves Pre-Test Probability in Fagen’s Nomogram Each Temporal Phase • Setting the table • Cervical for success Radic • Pretest • A high pre-test prob=18% probability improves your • Spurling’s likelihood of LR+=4.8 success despite • Post test your intervention prob = or tool for 52% diagnosis

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What if Arm Pain was Required First? Shoulder Labral Tear Diagnosis

• Cervical • Kim et al. looked at overhead throwing Radic athletes with dislocation injuries to • Pretest improve the likelihood of a post test prob=48% diagnosis. • Spurling’s • Subjects were more likely to have a labral LR+=4.8 tear since it’s generally a traumatic injury. • Post test prob = 80% Kim et al. The Kim test: a novel test for posteroinferior labral lesion of the shoulder— a comparison to the jerk test. Am J Sports Med. 2005;33(8):1188-92.

SIJ Pain Diagnosis Different than Clusters

• Laslett et al. improved their post test odds • CPR • Temporal (Time) of a sacroiliac joint diagnosis by removing • This and This and Series subjects with lumbar spine related This and This and • This then this then pathology. This (all at once) this then this • Involves higher • Involves a very finite • They used tests and measures specific to numbers, but includes group once the the lumbar spine to remove subjects. groups that aren’t ratcheting is finished targeted

Laslett et al. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10(3):207-18.

So what’s next?

• Worth pondering – Can diagnoses be different but have the same label? – Can spectrum influence diagnosis so much Thank you! that different tests (or values) are needed depending on the population – Can we start analyzing decision making tools through tree analysis, versus single assessments?

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