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Concurrent Validity of a Patient Self-Administered Examination And Open access Original article BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000574 on 10 October 2019. Downloaded from Concurrent validity of a patient self- administered examination and a clinical examination for femoroacetabular impingement syndrome Kwadwo Adu Owusu-Akyaw ,1 Carolyn A Hutyra ,1 Richard J Evanson,2 Chad E Cook ,3 Mike Reiman,3 Richard C Mather4 To cite: Owusu-Akyaw KA, ABSTRACT What are the new findings? Hutyra CA, Evanson RJ, et al. Objective Telehealth has been established as a viable Concurrent validity of a patient option for improved access and timeliness of care. self-administered examination ► A patient’s self-performed examination was more Physician-guided patient self-evaluation may improve and a clinical examination for accurate for the diagnosis of femoroacetabular im- the viability of telehealth evaluation; however, there are femoroacetabular impingement pingement syndrome than a traditional examination little data evaluating the efficacy of self-administered syndrome. BMJ Open performed by a clinician. Sport & Exercise Medicine examination (SAE). This study aims to compare the 2019;5:e000574. doi:10.1136/ diagnostic accuracy of a patient SAE to a traditional bmjsem-2019-000574 standardised clinical examination (SCE) for evaluation of femoroacetabular impingement syndrome (FAIS). How might it impact on clinical practice in the ► Additional material is published online only. To view Methods 75 patients seeking care for hip-related pain near future? please visit the journal online were included for participation. All patients underwent Protected by copyright. (http:// dx. doi. org/ 10. 1136/ both SAE and SCE and were randomised to the order of ► These data establish the validity of a patient’s bmjsem- 2019- 000574). the examinations. Diagnostic accuracy statistics were self-performed examination that may be imple- calculated for both examination group for a final diagnosis mented into a telehealth model to help improve early of FAIS. Mean diagnostic accuracy results for each diagnosis of hip pathology and streamline access to Accepted 22 August 2019 group were then compared using Mann-Whitney U non- care. parametric tests. Results The diagnostic accuracy of individual SAE and SCE manoeuvres varied widely. Both SAE and SCE decision-making in musculoskeletal care. demonstrated no to moderate change in post-test Effective and comprehensive telehealth probability for the diagnosis of FAIS. Although low, SAE approaches to musculoskeletal care must demonstrated a statistically greater mean diagnostic evaluate the marginal impact on diagnostic accuracy compared with the SCE (53.6% vs 45.5%, accuracy of and/or reproduce this element p=0.02). of the evaluation approach. A patient-per- Conclusion Diagnostic accuracy was statistically http://bmjopensem.bmj.com/ © Author(s) (or their significantly higher for the self-exam than for the formed screening physical examination may employer(s)) 2019. Re-use traditional clinical exam although the difference may not offer a solution; however, the diagnostic permitted under CC BY-NC. No utility of such an examination must first be commercial re-use. See rights be clinically relevant. Although the mean accuracy remains and permissions. Published by relatively low for both exams, these values are consistent evaluated. BMJ. with hip exam for FAIS reported in the literature. Having Although the number of arthroscopic 1Orthopaedic Surgery, Duke established the validity of an SAE, future investigations will hip surgeries for intra-articular pathology University, Durham, North need to evaluate implementation in a telehealth setting. continues to increase, accurate diagnosis of Carolina, USA 2 patients with hip pain remains a diagnostic Sports Medicine and Spine challenge.6 7 Increasing focus has been placed Center, Plano Orthopedic, Plano, Texas, USA on the role of clinical examination in the on September 30, 2021 by guest. 3Physical Therapy, Duke INTRODUCTION differential diagnosis of intra-articular and University, Durham, North Telehealth has become an increasing subject periarticular sources of hip pain.6 8 9 This is of Carolina, USA 4 of study due to the potential for providing particular interest given variability in the diag- Orthopedic Surgery, Duke equitable access to care1–3 and improving nostic accuracy of radiographic testing10–13 University Medical Center, 4 5 Durham, North Carolina, USA triage to the appropriate providers. The and the associated costs and barriers in access integration of telehealth into clinical practice associated with such studies. may also have economic benefits, contrib- The primary objective of this study is to Correspondence to 5 Dr Kwadwo Adu Owusu-Akyaw; uting to improved costs of care. The measure the diagnostic accuracy of a patient kwadwo. owusuakyaw@ duke. clinical exam provides key diagnostic infor- self-administered examination (SAE) of the edu mation to support accurate diagnosis and hip versus a traditional standardised clinical Owusu-Akyaw KA, et al. BMJ Open Sp Ex Med 2019;5:e000574. doi:10.1136/bmjsem-2019-000574 1 Open access BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2019-000574 on 10 October 2019. Downloaded from examination (SCE) for diagnosis of femoroacetabular Patient SAE impingement syndrome (FAIS). A secondary objective A review of the literature was performed to identify a was to evaluate the individual diagnostic accuracy metrics series of self-performed manoeuvres associated with peri- of both forms of examination and evaluate their influence articular and intra-articular hip pathology (see table 1 of post-test probability of FAIS. FAIS was selected because for further details).21–25 Subjects met with the instructing of its relatively high prevalence, increasing diagnosis provider in a private clinical exam room. The instructing and surgical prevalence, and questionable examination provider was blinded to the final diagnosis. Reproduction utility in comparison to reference imaging. We hypoth- of concordant pain (ie, pain consistent with that typically esised that there would be no difference in diagnostic experienced by the patient) was considered a positive accuracy between the patient-administered SAE and the result for SAE manoeuvres. clinician-performed SCE. Standardised clinical examination A literature review was performed to identify a series of METHODS clinician-performed examination manoeuvres to develop Study design the SCE (see table 2 for further details).6 15 21 24–26 This This was a prospective, case-based, case–control study standardised examination protocol was conducted by design. The Standard for Reporting Diagnostic Accuracy a different provider from the SAE. The examination guidelines were used in development of the method- included tests of passive range of motion and specialised ology. provocative manoeuvres (eg, flexion adduction internal Participants rotation (FADIR)) to assess for intra-articular pathology Following institutional review board approval, 80 patients (table 2). Providers performing the SCE were blinded seeking care from a fellowship-trained hip arthroscopy to the administration and findings of the SAE and vice specialist for hip-related pain or mechanical symptoms versa. were recruited for participation in an outpatient clinical Reference standards setting. Consecutive patients were identified in an outpa- A diagnosis of FAIS was defined according to the Warwick Protected by copyright. tient clinic of a tier-one institution from July 2017 until Agreement which includes the presence of hip pain, March 2018. Five patients were unable to complete the clicking, catching or stiffness which is reproduced with entire examination due to time constraints. The final impingement testing in the presence of cam or pincer number of participating subjects was 75. Testing was morphology on plain radiographs in the absence of performed in the same outpatient clinical setting for all radiographic osteoarthritis (Tonnis grade 0 or 1).27 A subjects. All patients underwent both SAE and SCE and diagnosis of osteoarthritis was defined as the presence of were randomised to the order of the examinations. hip pain, clicking, catching or stiffness in the presence of radiograph findings of joint space narrowing, osteophyte Inclusion criteria formation and/or subchondral sclerosis/cyst formation Ages 18–80 years; seeking care for hip-related pain and/ (Tonnis grade 2 or 3). A diagnosis of trochanteric bursitis or clicking, catching, giving way or stiffness, able to sign was defined as primary pain localised to the lateral hip, or verbalise study consent, without confounding medical over the greater trochanter and reproduced with palpa- conditions (eg, gynaecological or urinary pathology) tion. http://bmjopensem.bmj.com/ and English speaking were approached for inclusion. No subjects declined. Power analysis The study is powered for the primary objective of the Exclusion criteria study, which is to measure the diagnostic accuracy of a Patients with known lumbar spine or sacroiliac pathology, patient-performed clinical examination versus a standard previous hip surgery, previous hip injury that would clinical examination. We powered the study by expected normally exclude from examination as standard practice, cell frequencies for those with and without an intra-artic- or inability to sign or verbalise consent were excluded. ular disorder. Our previous works28 have shown a higher percentage of ‘True Positives (TP)’ for the intra-articular Index tests group (than false
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