3rd International conference on movement dysfunction 2009Diagnostic utility of clinical tests for spinal dysfunction
Introduction
Diagnosis is the process of identifying or determining the etiology of a disease or condition through evaluation of patient history, physical examination, and review of laboratory data or diagnostic imaging and the subsequent descriptive title of that finding (Whiting et al., 2008). Although the concept of diagnosis is historically linked to the medical physician, other professions use the same diagnostic tools to determine medical conditions upon which treatment and prognosis are based upon (Sahrmann, 1988, Delitto and Snyder-Mackler, 1995, Zimny, 2004).
Making an accurate diagnosis is considered essential in the effective management process of a patient (Whiting et al., 2008). Specific to the necessity for accuracy, is the ability to differentiate patients with symptoms that arise from non-spinal disorders or other potentially life threatening pathology (Rubenstein and van Tulder, 2008). Failure to correctly identify an appropriate diagnosis can lead to unnecessary healthcare costs (Dohrenwend and Skillings, 2009), delays in appropriate treatment (Whiting et al., 2008), and negative consequences associated with patient safety (Trowbridge, 2008). Errors in diagnosis are enhanced by a number of factors including cognitive biases (Croskerry, 2002, Croskerry, 2003), poor diagnostic thinking processes (Richardson, 2007), non-descript conditions that have no unique physical manifestations (Deyo and Weinstein, 2001), weaknesses in clinical tools such as tests and measures (Cook and Hegedus, 2008), and biases in the reporting of quality of tests and measures within the literature (Westwood et al., 2005, Whiting et al., 2008).
A recent summary of findings for the diagnostic procedures for neck and low back pain identified only a few clinical tests and measures that provide value in ruling out or ruling in a condition (Rubenstein and van Tulder, 2008). The authors divided their findings by patient history, physical examination, and special studies (imaging, diagnostic blocks, and injections) and primarily relied on systematic reviews for compilation of their tests selections. Others (Della-Giustina and Kilcline, 2000, Lurie, 2005, Hancock et al., 2007) identified best tests without providing discriminative inclusion criteria that may have biased final selections. As previously stated, biases in the reporting of quality of clinical tests within the literature can substantially inflate the diagnostic value of a clinical test (Westwood et al., 2005, Whiting et al., 2008).
The purpose of this paper was to outline the clinical tests that exhibit the highest diagnostic utility for the spine. This study endeavors to expand on the findings of Rubenstein and van Tulder (2008) and others (Della-Giustina and Kilcline, 2000, Lurie, 2005, Hancock et al., 2007) by carefully assessing the quality of the studies of diagnostic accuracy. Findings may improve the accuracy and efficiency of the evaluative process for patients with spinal conditions, specifically for those practitioners that lack imaging or laboratory assessment methods.
Section snippets
Literature search
A computer assisted search of the Medline database (1950–December 2009) was performed and combined terms related to diagnostic accuracy with terms related to physical examination and spinal pain or dysfunction and then limited the findings to articles regarding humans and the English language. Independent review of the title and abstract of all of the articles from the computer search was performed by both authors and agreement to review 21 of those articles in their entirety was made by
Literature search
The computer assisted search revealed 213 articles and we reviewed the title and abstract of all of these articles. After abstract and title review, we agreed to evaluate 21 of those articles in their entirety. In addition, references from our textbook and independent hand searches revealed an additional 57 articles. We then performed a separate and blinded application of our inclusion/exclusion criteria including assessment of study design and QUADAS scoring of all 78 articles and included in
Discussion
Using a more strict method of inclusion further reduces the potential for inflated diagnostic accuracy values and more appropriately outlines the clinical utility of stand alone clinical tests. A notable component of the strict inclusion criteria was the elimination of case control designs and studies that failed to reach a consensus score of 10/14 on the QUADAS form. Although our initial computer search strategy and subsequent independent hand searches netted more articles to review than
Conclusions
The findings of this study suggest that the majority of clinical tests for the spine with acceptable diagnostic accuracy are for non-critical diagnoses. Further research is needed involving higher quality, more detailed studies. Lastly, stand alone clinical tests provide only marginal value in diagnosis and future studies should consider clusters of clinical tests; a mechanism that more closely reflects clinical decision making.
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