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- Laslett, Mark, 1950-, et al.
(författare)
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Agreement between diagnoses reached by clinical examination and available reference standards : A prospective study of 216 patients with lumbopelvic pain
- 2005
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Ingår i: BMC Musculoskeletal Disorders. - : Springer Science and Business Media LLC. - 1471-2474. ; 6
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Tidskriftsartikel (refereegranskat)abstract
- 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 single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and 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%. "Exact" agreement between clinical and reference standard diagnoses was 32% and "clinical agreement" 51%. For six pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33% with actual agreement 56%. There was no overlap of 95% confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31. Conclusion: 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. © 2005 Laslett et al, licensee BioMed Central Ltd.
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- Laslett, Mark, 1950-, et al.
(författare)
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Clinical predictors of lumbar provocation discography : A study of clinical predictors of lumbar provocation discography
- 2006
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Ingår i: European spine journal. - : Springer Science and Business Media LLC. - 0940-6719 .- 1432-0932. ; 15:10, s. 1473-1484
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Tidskriftsartikel (refereegranskat)abstract
- Discography is the only available method of directly challenging the discs for pain sensitivity. However, it is invasive, expensive and there is a 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 possesses specificity between 80 and 100% depending on levels of disablement and psychosocial distress. Less than half of positive discography patients reports centralization and there is a need to identify other potentially valuable predictors. This study estimated the diagnostic accuracy of clinical variables in relation to provocation discography. In a blinded, prospective reference standard design in a private interventional radiology clinic, chronic low back patients received a detailed clinical examination followed by discography. Patients were typically disabled with high levels of psychosocial distress. Logistic regression modelling identified potentially useful clinical variables, and sensitivity, specificity and likelihood ratios were calculated for promising specific variables and combinations of variables. Of 118 consecutive discography cases, 107 had unconfounded data on discography results. History of persistent pain between acute episodes, a significant loss of extension and a subjective report of 'vulnerability' in what is termed as the 'neutral zone' had specificities of 83-92% and likelihood ratios between 2.0 and 4.1. Two combinations of variables were highly specific to positive discography, but no suitable screening test useful for ruling out positive discography was established. Three clinical variables have modest predictive power in relation to lumbar discography results and two combinations of variables were highly specific to positive discography. © 2006 Springer-Verlag.
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- Laslett, Mark, 1950-, et al.
(författare)
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Clinical predictors of screening lumbar zygapophyseal joint blocks : development of clinical prediction rules
- 2006
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Ingår i: The spine journal. - : Elsevier BV. - 1529-9430 .- 1878-1632. ; 6:4, s. 370-379
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Tidskriftsartikel (refereegranskat)abstract
- Background: Only controlled intra-articular zygapophyseal joint (ZJ) injections or medial branch blocks can diagnose ZJ-mediated low back pain. The low prevalence of ZJ pain implies that identification of clinical predictors of a positive response to a screening block is needed. Purpose: To estimate the predictive power of clinical findings in relation to pain reduction after screening ZJ blocks. Study design: As part of a wider prospective blinded study investigating diagnostic accuracy of clinical variables, a secondary analysis was carried out to seek evidence of variables potentially valuable as predictors of screening ZJ block outcomes. Patient sample: Chronic low back pain patients received screening ZJ blocks (n=151) with 120 patients included in the analysis after exclusions. Outcome measures: Pain intensity was measured using a 100-mm visual analog scale, and responses were categorized according to 75% through 95% or more pain reduction in 5% increments. Methods: Patients completed pain drawings, questionnaires, and a clinical examination before screening lumbar ZJ blocks. History, demographic and clinical variables were evaluated in cross tabulation and regression analyses with diagnostic accuracy values calculated for variables and variable clusters in relation to different pain reduction standards. Results: At the 75% pain reduction standard, 24.5% responded to screening ZJ blocks and 10.8% responded at the 95% standard. The centralization phenomenon is not associated with pain reduction using any standard. No variables were useful predictors of post-ZJ block pain reduction of less than 90%. Seven clinical findings were associated with 95% pain reduction after blocks. Five useful clinical prediction rules (CPRs) were found for ruling out a 95% pain reduction (100% sensitivity), and one CPR had a likelihood ratio of 9.7, producing a fivefold improvement in posttest probability. Conclusions: A negative extension rotation test, the centralization phenomenon, and four CPRs effectively rule out pain ablation after screening ZJ block. One CPR generates a fivefold improvement in posttest probability of a negative or positive response to ZJ block. © 2006 Elsevier Inc. All rights reserved.
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- Laslett, Mark, et al.
(författare)
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Diagnosis of Sacroiliac Joint Pain : Validity of individual provocation tests and composites of tests
- 2005
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Ingår i: Manual Therapy. - : Elsevier BV. - 1356-689X .- 1532-2769. ; 10:3, s. 207-218
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Tidskriftsartikel (refereegranskat)abstract
- Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP. © 2005 Elsevier Ltd. All rights reserved.
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