Diagnostic Accuracy Of Clinical Tests Research Articles

Physical Therapists as Evidence-Based Diagnosticians

Prior to the era of evidence-based practice, a common approach taught in entry-level physical therapy programs was relatively simplistic: (1) learn how to administer a clinical diagnostic test; (2) learn the result considered “positive” and the result considered “negative”; (3) conclude that a patient with a positive test result would likely have the target condition and a patient with a negative test result would not. Much has changed in the last 15 years. We have seen a significant shift in the way evidence is used to make clinical decisions about physical therapy interventions. However, despite these gains, more attention is needed to improve our understanding of the accuracy of commonly used diagnostic tests. Only in this way can we properly integrate evidence for diagnostic accuracy of clinical tests into our practice and truly consider ourselves as evidence-based practitioners. J Orthop Sports Phys Ther 2010;40(10):603–605. doi:10.2519/jospt.2010.0108

The Value of Clinical Tests in Acute Full-Thickness Tears of the Supraspinatus Tendon: Does a Subacromial Lidocaine Injection Help in the Clinical Diagnosis? A Prospective Study

Early repair of rotator cuff tears leads to superior results. To detect symptomatic full-thickness tears of the supraspinatus tendon at an early stage, we conducted a prospective study to evaluate the value of clinical examination with and without subacromial lidocaine within the first weeks after an acute injury to the shoulder. Of 104 patients included in a prospective investigation, 52 patients were selected to evaluate the diagnostic accuracy of clinical tests in acute full-thickness tears of the supraspinatus tendon. Clinical tests and ultrasound examination were performed at a median of 13 days (range, 3 to 49 days) after the initial injury. The study group consisted of 29 patients (median age, 56 years [range, 39 to 75 years]) who all had an acute complete tear of the supraspinatus tendon verified by ultrasound and arthroscopy. The control group consisted of 23 patients who all had an intact tendon confirmed by ultrasound (median age, 38 years [range, 19 to 73 years]). The Hawkins sign (0.83) and the painful arc test (0.97) had high sensitivity but low specificity (0.23 and 0.05, respectively). The external rotation lag sign (ERLS) and the drop-arm test (DAT) had a sensitivity of 0.39 and 0.37, respectively, and specificity of 0.91 and 0.86, respectively, in diagnosing acute full-thickness tears of the rotator cuff. After a subacromial lidocaine injection, sensitivity of all lag sign tests was reduced, whereas specificity and likelihood ratios of the Jobe test, the ERLS, and the DAT improved. Active abduction was significantly reduced in the full-thickness tear group. A positive lag sign (ERLS or DAT) is indicative of a full-thickness supraspinatus tear, but a negative lag sign does not preclude a tear. After a subacromial injection of lidocaine, the specificity improves whereas the sensitivity is reduced. Overall, in patients with suspected acute rotator cuff tear, clinical tests cannot stand alone in the evaluation the first weeks after an acute injury. Level I, diagnostic study-testing of previously developed criteria in a series of consecutive patients (by use of arthroscopy and ultrasound as the gold standard).

Diagnostic Accuracy of Clinical Tests for Superior Labral Anterior Posterior Lesions: A Systematic Review

Systematic literature review. To conduct a systematic review of case series and clinical trials that investigate the diagnostic accuracy of clinical tests for superior labral anterior posterior (SLAP) lesions. Primary contact practitioners are often presented with shoulder problems and use a battery of clinical tests to reach a diagnosis. Early detection of SLAP pathology may lead to more optimal interventions and better outcomes for patients. The OVID search interface was utilized with MEDLINE, AHMED, CINAHL, and SPORTDiscus databases searched from 1996-2006. Studies were retrieved that included patients with shoulder pain who underwent at least 1 clinical shoulder test for SLAP lesions. For an article to be included in this review, the results of the clinical tests needed to be compared with findings on arthroscopy. Quality of the manuscripts included in this review were rated using the QUADAS appraisal tool, so comparisons could be made across studies. Seventeen published manuscripts fit the inclusion/exclusion criteria and were used for this review. Eight studies were found to be of high quality. Within these 8 studies, 1 group of authors reported high diagnostic accuracy values for the crank test: sensitivity, 91% (95% confidence interval [CI], 76%-97%); specificity, 93% (95% CI, 79%-88%); positive likelihood ratio, 13.6 (95% CI, 3.6-52.1); and negative likelihood ratio, 0.1 (95% CI, 0.0-0.3). One study on the resisted supination external rotation test also scored high on the QUADAS and reported diagnostic accuracy values of 83% (95% CI, 66-92), 82% (95% CI, 52-95), 4.6 (95% CI, 1.3-16.1), and 0.20 (95% CI, 0.1-0.5), respectively. Of significance is the fact that the majority of papers reporting highly accurate clinical diagnostic tests were of low quality with the results not supported by other authors. It appears that no single test is sensitive or specific enough to determine the presence of a SLAP lesion accurately. Further research is required to determine whether subgrouping of patients by mechanism of injury or the type of SLAP lesion may improve diagnostic accuracy. Determining the diagnostic accuracy of a combination of 2 or more tests is also needed.

Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review

Do clinical tests accurately diagnose rotator cuff pathology? A systematic review of investigations into the diagnostic accuracy of clinical tests for rotator cuff pathology. People with shoulder pain who underwent clinical testing in order to diagnose rotator cuff pathology. The diagnostic accuracy of clinical tests was determined using likelihood ratios. Thirteen studies met the inclusion criteria. The 13 studies evaluated 14 clinical tests in 89 separate evaluations of diagnostic accuracy. Only one evaluation, palpation for supraspinatus ruptures, resulted in significant positive and negative likelihood ratios. Eight of the 89 evaluations resulted in either significant positive or negative likelihood ratios. However, none of these eight positive or negative likelihood ratios were found in other studies. Of the 89 evaluations of clinical tests 71 (80%) did not result in either significant positive or negative likelihood ratio evaluations across different studies. Overall, most tests for rotator cuff pathology were inaccurate and cannot be recommended for clinical use. At best, suspicion of a rotator cuff tear may be heightened by a positive palpation, combined Hawkins/painful arc/infraspinatus test, Napoleon test, lift-off test, belly-press test, or drop-arm test, and it may be reduced by a negative palpation, empty can test or Hawkins-Kennedy test.

The Reliability and Validity of Clinical Tests Used to Assess Individuals with Potential Labral Tears of the Hip (SS-20)

The purpose of this study was to determine the reproducibility and diagnostic accuracy of clinical tests used to examine individuals with potential labral tears of the hip. Specifically, the inter-tester reliability of the FABER, flexion-internal rotation impingement, and log roll tests as well as an assessment for greater trochanteric tenderness was examined. The diagnostic accuracy of the FABER, flexion-internal rotation impingement, flexion-external rotation tests in identifying individuals with a labral tear was also examined. We hypothesized that the four clinical tests would demonstrate moderate agreement (kappa coefficient >.40) in inter-tester reliability assessment. Additionally, we was hypothesized that the clinical tests would demonstrate sensitivity and specificity values >.5 with likelihood ratio for a positive test >1 for diagnosing a labral tear. All patients evaluated by an orthopaedic surgeon specializing in hip arthroscopy for a musculoskeletal hip problem were included in the study. These 85 subjects had a mean age of 41 (range 15-76 SD 14.9) with 40 females and 45 males. 41% of the subjects reported their symptom duration to be 1 year or less while 59% reported their symptom duration to be greater than 1 year. The results of the clinical tests performed by the orthopaedic surgeon were compared to the results obtained by a physical therapist with 15 years experience. Kappa coefficients were calculated to assess inter-tester reliability. As previously documented, the strength of agreement for kappa (κ) was interpreted as follows: ≤ 0=poor, .01-.2=slight, .21-.40 fair, .41-.60=moderate, .61-.80=substantial, .81-.1=almost perfect. The results of the clinical tests were compared to magnetic resonance arthrogram (MRA) results in identifying individuals with a labral tear. Diagnostic accuracy of the clinical test was assessed by calculating sensitivity, specificity, and likelihood ratios. As hypothesized clinical tests had better than moderate agreement with kappa values as follows: Flexion-internal rotation impingement test κ =.69, log roll test κ =.53, greater trochanteric tenderness κ =.72 and FABER test κ =. 45. Diagnostic accuracy of clinical tests in diagnosing individuals with a labral tear was as follows: Flexion-internal rotation impingement test sensitivity =.75, specificity =.07 and a positive likelihood ratio = .81; FABER sensitivity =.65, specificity =.19 and positive likelihood ratio =.80; Flexion with external rotation sensitivity =.29, specificity =.67 and positive likelihood ratio = .89. The flexion-internal rotation impingement test, log roll test and assessment for greater trochanteric tenderness seem to be reliable clinical tests. The reliability of the FABER test seems to less than the other clinical examination tests. While the flexion-internal rotation and FABER had very high sensitivity, the specificity was low. Contrary to this the flexion-external rotation test had low sensitivity but high specificity. Further studies are needed to examine the diagnostic accuracy of these tests when exam findings are clustered together. In conclusion, the results of this study will allow the clinical examination for an individual with a potential labral tear to be more meaningfully interpreted.

Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome

The authors evaluated the utility of eight clinical tests commonly used in the diagnosis of rotator cuff disease (RCD). Specifically, they calculated diagnostic values (sensitivity, specificity, predictive values, likelihood ratios, and posttest probabilities) for the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed's test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test across 3 degrees of severity of RCD: bursitis without a rotator cuff tear, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears.

Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome

Several tests for making the diagnosis of rotator cuff disease have been described, but their utility for diagnosing bursitis alone, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears has not been studied. The hypothesis of this study was that the degree of severity of rotator cuff disease affects the diagnostic values of the commonly used clinical tests. Eight physical examination tests (the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test) were evaluated to determine their diagnostic values, including likelihood ratios and post-test probabilities, for three degrees of severity in rotator cuff disease: bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. A forward stepwise logistic regression analysis was used to determine the best combination of clinical tests for predicting the various grades of impingement syndrome. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the eight tests varied considerably. The combination of the Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for any degree of impingement syndrome. The combination of the painful arc sign, drop-arm sign, and infraspinatus muscle test produced the best post-test probability (91%) for full-thickness rotator cuff tears. The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests. The variable accuracy of these tests should be taken into consideration when evaluating patients with symptoms of rotator cuff disease.

Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings

Purpose The purpose of this study was to explore and describe reasons for variation in diagnostic accuracy of clinical tests using Yergason’s and Speed’s tests in predicting biceps tendon pathology and SLAP lesions. Shoulder arthroscopy was used as the gold standard. Type of study Prospective blinded study of consecutive patients with a wide spectrum of shoulder conditions. Methods One hundred fifty-two subjects (65 women and 87 men) with complaints of shoulder pain were examined. Fifty subjects (16 women and 34 men) ranging in age from 24 to 79 years (mean age, 50 years; SD = 14.36) met the criteria for surgery. The validity of the Yergason’s and Speed’s tests was evaluated against findings at surgery. Results The surgical findings related to biceps pathology and SLAP lesions were as follows: 2 bicipital tendonitis, both associated with significant rotator cuff pathology; 10 biceps partial tears; and 2 complete ruptures. Fifteen patients had SLAP lesion type I, 12 type II, and 1 type IV. The sensitivity, specificity, and positive and negative predictive values were 43%, 79%, 60%, and 65% for Yergason’s test and 32%, 75%, 50%, and 58% for Speed’s test, respectively. The likelihood ratios were 1.28 and 0.91 for Speed’s test and 2.05 and 0.72 for Yergason’s test. These ratios were provided to assist clinicians in calculating the probability of biceps pathology and SLAP lesions for a single patient with a different history-specific prevalence of having the pathology. Conclusions Although Speed’s and Yergason’s tests are moderately specific, they do not generate a large change in the post-test probability and are unlikely to make a significant change in the pretest diagnosis. Clinicians should understand that clinical examination tests do not perform consistently and have variable predictive values in different patient populations and settings. Level of evidence Level I diagnostic study: testing of previously developed criteria in a series of consecutive patients (using surgery as gold standard).

D-dimer test in deep vein thrombosis - reply

Dear Sir, We thank Dr Chow and colleagues for their thorough review (p.575, this issue) of our recent paper about the D-dimer test in deep vein thrombosis (DVT) [1]. It is true that a subsequent clinical evaluation of the patients' eventual outcome could be the gold standard, but as the use of a D-dimer test always takes place in an acute setting, it would not affect the choice of initial treatment of the patient. We are well aware of the study by Wells et al. [2] on the value of assessment of pretest probability of DVT. In this study, only three (0.6%) of 501 patients who were diagnosed as not having DVT had events during the 3-month follow-up. This indicates that a clinical follow-up would not add much to our study. The main purpose of this prospective study was to evaluate how the use of D-dimer assays compares with ultrasonography in confirmation or exclusion of DVT in the acute setting, reflecting a routine scenario to many clinicians. Introduction of a nonroutine venography or a 3-month follow-up as a gold standard, would not address this purpose appropriately. Venography is often referred to as the reference gold standard for the diagnosis of DVT, but because of its invasive nature and associated side-effects it has widely been replaced by compression ultrasonography [3]. In this study, we did not include phlebography as the gold standard. This is primarily based on results from a previous Danish study from The Department of Radiology, Aalborg Hospital, on the diagnostic performance of phlebography versus compression ultrasonography [4]. In this study, the positive and negative predictive value of compression ultrasonography was 100 and 85%, respectively. It is generally recommended that reasonable methodological standards are used in the documentation of diagnostic accuracy of clinical tests [5]. In this regard, the use of venography will only provide a theoretical evidence rather than an empirical evidence.