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Diagnostic accuracy of the clinical examination compared to available reference standards in chronic low back pain patients
Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

It is often stated that most cases of persistent low back pain are diagnostically indeterminate. Diagnostic accuracy estimates are obtained by comparing the results of clinical tests with diagnostic reference standards. Although data is available from past research, most commonly used clinical tests have not been evaluated in validity studies. Significant issues regarding reference standards in back pain research exist, such as availability, cost and invasiveness.

The aim of this thesis work was to explore the diagnostic accuracy of non-invasive clinical examination techniques and variables, in relation to available reference standards for diagnosis of the most common patho-anatomic sources and causes of persistent back pain. The intervertebral disc, the zygapophysial joints, sacroiliac joints are believed to be the most common sources of low back and referred pain. Spinal stenosis and herniated discs are infrequent but regularly occurring lumbar causes of causing radicular pain. A secondary aim was to evaluate the potential confounding influences of disability, psychosocial distress and inappropriate illness behaviours on diagnostic accuracy.

This work comprises two projects with different patient samples attending the same specialist interventional radiology spinal diagnostics clinic in New Orleans, USA. In Project 1 48 patients received a clinical examination that included a McKenzie-styled repeated movement's examination identifying the presence or absence of the centralization phenomenon, six pain provocation sacroiliac joint tests, and controlled (double anesthetic) blocks to the sacroiliac joints as a reference standard. In Project 2, 216 patients received an extensive clinical examination that included the tests used in Project 1, and a variety of reference standard diagnostic procedures such as; provocation discography, zygapophysial joint blocks, sacroiliac joint blocks, MRI and CT scans. Physiotherapists experienced in the McKenzie method and examination of chronic low back pain patients carried out the clinical examinations. An experienced radiologist carried out the reference standard examinations. The radiologist and physiotherapists were blinded to each other's results. Pain drawings, pain intensity VAS's, and three questionnaires were used to evaluate pain characteristics, disability and psychosocial distress.

The reference standard for discogenic pain was concordant pain production during hydraulic distention of a disc during discography in the presence of a negative control disc and post discography axial CT images demonstrating annular fissuring involving the outer annulus. The reference standard for ZJ pain was substantial relief following intraarticular joint or medial branch blocks. The reference standard for SIJ pain was substantial relief following intra-articular SIJ blocks. Reference standards for nerve root pain, spinal stenosis and herniated disc causing radicular pain, were based on a combination of clinical findings, CT or MRI imaging results and response to selective or caudal epidural blockade.

Five papers were produced reporting diagnostic accuracy of the clinical examination for disc pain, zygapophysial joint and sacroiliac joint pain. The sixth paper reports on agreement between physiotherapy clinical diagnoses and reference standard / expert opinion diagnoses.

Prediction of discography: 118 patients received discography with 70% having a positive response. The most useful clinical signs were: The centralization phenomenon (sensitivity 25%, specificity 96%); directional preference (sensitivity 49%, specificity 91%); history of persistent pain between acute episodes (sensitivity 32%, specificity 92%).

Prediction of screening zygapophysial joint blocks: 120 patients received unconfounded screening ZJ blocks and 13 had 95% or more reduction in pain. Three variables had some predictive value: Age over 55 (sensitivity 39%, specificity 85%), Walking is best activity for pain (sensitivity 31%, specificity 92%), Sitting is best position for pain (sensitivity 33%, specificity 90%). A cluster of seven clinical signs and symptoms previously thought to be a useful predictive model ('Revel's criteria') were not predictive of a 75% reduction in pain.

Prediction of controlled (double) sacroiliac joint blocks: 43 patients received double blocks and 11 had SIJ pain confirmed. The presence of 3 or more positive provocation SIJ tests had sensitivity and specificity of 91% and 78% respectively. In the subset of 34 patients without evidence of the centralization phenomenon, sensitivity and specificity of three or more positive SIJ tests was 91% and 87% respectively.

The number of cases with spinal stenosis and herniated disc causing radicular pain was low, so diagnostic accuracy results for the clinical examination were not reported separately.

Patients were typically chronic, with 51% being distressed, 60% being severely disabled, 30% exhibiting overt illness behaviours and 24% had abnormal pain drawings. Severe disability and the presence of three or more signs of inappropriate illness behaviour reduced the specificity of the centralization and directional preference for positive discography by 20%. Psychosocial distress categorization and pain intensity did not substantially confound the diagnostic accuracy of centralization or directional preference.

Overall agreement between diagnoses based by the physiotherapist's examinations and the reference standard diagnoses was evaluated compared to what could be expected based on chance agreements. Agreement on patho-anatomic sources and causes of pain was 56% (kappa 0.31). Proportional Chance Criterion estimate of chance agreement was 33%.

In conclusion, the physiotherapy clinical examination can identify a subset (up to 5O%) of positive discography cases; is unable to predict the outcome of screening blocks for ZJ pain; and can identify approximately 88% of painful SIJ cases. Agreement on pathoanatomic sources and causes of pain occurs in over 50% of cases.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2005. , 120 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 894
National Category
Social Sciences
Identifiers
URN: urn:nbn:se:liu:diva-31457Local ID: 17246ISBN: 91-85299-03-0 (print)OAI: oai:DiVA.org:liu-31457DiVA: diva2:252280
Public defence
2005-05-13, Berzeliussalen, Hälsouniversitetet, Linköping, 13:00 (Swedish)
Opponent
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-10-03Bibliographically approved
List of papers
1. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests
Open this publication in new window or tab >>Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests
2003 (English)In: Australian Journal of Physiotherapy, ISSN 0004-9514, Vol. 49, no 2, 82-97 p.Article in journal (Refereed) Published
Abstract [en]

Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97 (2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints.

Keyword
Physicalm examination, reproducibility of results, sacroiliac joint, sensitivity and specificity
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-24141 (URN)12775204 (PubMedID)3724 (Local ID)3724 (Archive number)3724 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
2. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power
Open this publication in new window or tab >>Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power
2005 (English)In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 5, no 4, 370-380 p.Article in journal (Refereed) Published
Abstract [en]

Background context

The “centralization phenomenon” (CP) is the progressive retreat of referred pain towards the spinal midline in response to repeated movement testing (a McKenzie evaluation). A previous study suggested that it may have utility in the clinical diagnosis of discogenic pain and may assist patient selection for discography and specific treatments for disc pain.

Purpose

Estimation of the diagnostic predictive power of centralization and the influence of disability and patient distress on diagnostic performance, using provocation discography as a criterion standard for diagnosis, in chronic low back pain patients.

Study design/setting

This study was a prospective, blinded, concurrent, reference standard-related validity design carried out in a private radiology clinic specializing in diagnosis of chronic spinal pain.

Patient sample

Consecutive patients with persistent low back pain were referred to the study clinic by orthopedists and other medical specialists for interventional radiological diagnostic procedures. Patients were typically disabled and displayed high levels of psychosocial distress. The sample included patients with previous lumbar surgery, and most had unsuccessful conservative therapies previously.

Outcome measures

Diagnosis: results of provocation discography. Index test: The CP. Psychometric evaluation: Roland–Morris, Zung, Modified Somatic Perception questionnaires, Distress Risk Assessment Method, and 100-mm visual analog scales for pain intensity.

Methods

Patients received a single physical therapy examination, followed by lumbar provocation discography. Sensitivity, specificity, and likelihood ratios of the CP were estimated in the group as a whole and in subgroups defined by psychometric measures.

Results

A total of 107 patients received the clinical examination and discography at two or more levels and post-discography computed tomography. Thirty-eight could not tolerate a full physical examination and were excluded from the main analysis. Disability and pain intensity ratings were high, and distress was common. Sensitivity, specificity, and positive likelihood ratios for centralization observed during repeated movement testing for pain distribution and intensity changes were 40%, 94%, and 6.9 respectively. In the presence of severe disability, sensitivity, specificity, and positive likelihood ratios were 46%, 80%, 3.2 and for distress, 45%, 89%, 4.1. In the subgroups with moderate, minimal, or no disability, sensitivity and specificity were 37%, 100% and for no or minimal distress 35%, 100%.

Conclusions

Centralization is highly specific to positive discography but specificity is reduced in the presence of severe disability or psychosocial distress.

National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-33598 (URN)10.1016/j.spinee.2004.11.007 (DOI)19632 (Local ID)19632 (Archive number)19632 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
3. A study of clinical predictors of lumbar provocation discography
Open this publication in new window or tab >>A study of clinical predictors of lumbar provocation discography
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background Context

Discography is the only available method of directly challenging the discs for pain sensitivity. However, it Is invasive, expensive and there is debate about its clinical value. There Is a need to identify clinical signs that may indicate the need for a discography examination. Pain centralization (retreat of referred pain to towards the spinal midline) has been associated with positive discography and recently has been shown to possess speclflclty between 80 and 100% depending on levels of disablement and psychosocial distress. Centralization can only be elicited during a repeated movement examination, and cannot be tolerated by a proportion of patients. There is a need to identify other predictors besides centralization.

Purpose

To estimate diagnostic accuracy for clinical variables in relation to discography.

Study design / setting

A blinded, prospective reference standard design in a private interventional radiology clinic in Louisiana.

Patient Sample

Chronic low back patients receiving discography were examined (N=118) with 107 unconfounded cases being used to calculate diagnostic accuracy. Patients were typically disabled with high levels of psychosocial distress.

Outcome measures

Diagnosis: results of provocation discography. Index tests: history, questionnaire and physical examination variables.

Methods

A detailed clinical examination was followed by lumbar provocation discography. Logistic regression modeling identified potentially useful clinical variables, and sensitivity, specificity and likelihood ratios were calculated for promising specific variables.

Results

Unconfounded discography was achieved in 107 patients. History of persistent pain between acute episodes, a significant loss of extension and a subjective report of 'vulnerability' in what is termed the 'neutral zone' produced likelihood ratios between 2.0 and 4.1.

Conclusions

Three clinical variables have modest predictive power in relation to lumbar discography results and may be helpful in selection of patients for discography.

Keyword
Chronic low back pain, Diagnosis, Discography, Physical examination Physiotherapy, Sensitivity, Specificity
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84266 (URN)
Available from: 2012-10-03 Created: 2012-10-03 Last updated: 2012-10-03Bibliographically approved
4. Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test
Open this publication in new window or tab >>Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test
2004 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 5, no 43Article in journal (Refereed) Published
Abstract [en]

Background

Only controlled blocks are capable of confirming the zygapophysial joints (ZJ) as the pain generator in LBP patients. However, previous workers have found that a cluster of clinical signs ("Revel's criteria"), may be valuable in predicting the results of an initial screening ZJ block. It was suggested that these clinical findings are unsuitable for diagnosis, but may be of value in selecting patients for diagnostic blocks of the lumbar ZJ's. To constitute evidence in favour of a clinical management strategy, these results need confirmation. This study evaluates the utility of 'Revel's criteria' as a screening tool for selection of chronic low back pain patients for controlled ZJ diagnostic blocks.

Methods

This study utilized a prospective blinded concurrent reference standard related validity design. Consecutive chronic LBP patients completed pain drawings, psychosocial distress and disability questionnaires, received a clinical examination and lumbar zygapophysial blocks. Two reference standards were evaluated simultaneously: 1. 75% reduction of pain on a visual analogue scale (replication of previous work), and 2. abolition of the dominant or primary pain. Using "Revel's criteria" as predictors, logistic regression analyses were used to test the model. Estimates of sensitivity, specificity, predictive values and likelihood ratios for selected variables were calculated for the two proposed clinical strategies.

Results

Earlier results were not replicated. Sensitivity of "Revel's criteria" was low sensitivity (<17%), and specificity high (approximately 90%). Absence of pain with cough or sneeze just reached significance (p = 0.05) within one model.

Conclusions

"Revel's criteria" are unsuitable as a clinical screening test to select chronic LBP patients for initial ZJ blocks. However, the criteria may have use in identifying a small subset (11%) of patients likely to respond to the initial block (specificity 93%).

Keyword
zygapophysial joint, low back pain, lumbar spine, diagnosis, sensitivity, specificity physical examination
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-23862 (URN)10.1186/1471-2474-5-43 (DOI)3391 (Local ID)3391 (Archive number)3391 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
5. Clinical predictors of screening lumbar zygapophysial joint blocks: a prospective study of chronic low back pain patients
Open this publication in new window or tab >>Clinical predictors of screening lumbar zygapophysial joint blocks: a prospective study of chronic low back pain patients
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

A screening block followed by a confrrmatory block using different anesthetic agent is a common method used to identify the zygapophysial joint (ZJ) as a tissue origin of LBP. While previous studies have identified potentially valuable clinical tests, identification of patients unlikely to respond to the initial screeuing block is desirable.

Purpose

To estimate the predictive power of specific clinical findings in relation to screening ZJ blocks.

Study Design

A prospective blioded study carried was out in a private radiology clinic specializing in the diagnosis of spinal pain.

Patient sample

Chronic LBP patients received screening ZJ blocks (N=151) with 120 patients included in the analysis after exclusions.

Outcome Measures

Pre and post procedure pain intensity was measured using a standardized VAS. A 95% reduction in pain following ZJ block was defmed as a positive response.

Methods

Patients completed pain drawings, psychosocial distress and disability questionnaires. Thereafter they received a clinical examination and screening lumbar zygapophysial blocks. History, demographic and clinical variables were evaluated in logistic regression models with sensitivity, specificity and likelihood ratios being calculated for potentially useful variables.

Results 

A positive screeulng ZJ block was reported by 10.8% of patients. Sensivity of the extension rotation test was 100% and specificity 22%. No positive responders reported centralization or peripheralization of pain. The best predictors of a positive response to ZJ block were: age over 55 (odds ratio 3.55, p=0.06); report that walking (odds ratio 4.79, p=0.02) and sitting (odds ratio 4.27, p=0.04) were the best activities for pain.

Conclusions 

A negative extension rotation test, centralization or peripheralization can rule out ZJ mediated pain. Age over 55 and report of walking and sitting being the best activities for pain, are associated with a positive response to screening ZJ blocks.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84271 (URN)
Available from: 2012-10-03 Created: 2012-10-03 Last updated: 2012-10-03Bibliographically approved
6. Strength of agreement between diagnoses reached by clinical examination and available reference standards: a prospective validity study of 216 patients with lumbopelvic pain and/or symptoms referred into the lower extremity
Open this publication in new window or tab >>Strength of agreement between diagnoses reached by clinical examination and available reference standards: a prospective validity study of 216 patients with lumbopelvic pain and/or symptoms referred into the lower extremity
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background

The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70% of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine tests in relation to single reference standards, yet in clinical practice, clinicians select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards.

Methods

We compared blinded clinical diagnoses with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, "exact" agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, "clinical agreement" was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on six pathoanatomic diagnoses.

Results

In a sample of chronic LBP patients (n=216) with high levels of disability and distress, 67% received a patho-anatomic diagnosis based on available reference standards, and 10% had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13.3%. "Exact" agreement between clinical and reference standard diagnoses was 31.9% and "clinical agreement" 51.4%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33.5% with actual agreement 56.2%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatornic categories produced a kappa of 0.31 (0.18, 0.44).

Conclusions

Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84272 (URN)
Available from: 2012-10-03 Created: 2012-10-03 Last updated: 2012-10-03Bibliographically approved

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