Bo C. Bertilson

Reliability of clinical tests in the assessment of patients with neck/shoulder problems: Impact of history

Study Design. A clinical trial on patients receiving neck/shoulder physical examinations. Objectives. To analyze reliability of clinical tests, prevalence of positive findings in the assessment of neck/shoulder problems in primary care patients, and the impact of history, including pain drawing, on these parameters. Summary of Background Data. Reliability of clinical tests varies, perhaps partly because of the impact of history. To our knowledge, this has not been studied before. Methods. Two examiners independently assessed 100 patients with a set of 66 clinical tests divided into 9 categories. Half of the patients were examined with and the other half without knowledge of history. Reliability as expressed by percentage agreement, kappa coefficients, and prevalence of positive findings was calculated. Results. Reliability of clinical tests was poor or fair in several categories and did not alter with history. Only a bimanual sensitivity test reached good kappa values. With known history, prevalence of positive findings increased. Bias was apparent in all test categories except sensitivity tests. Four out of five patients were diagnosed to have neurogenic dysfunction in the affected area. Conclusions. Our sensitivity test was the most reliable and also exempt from bias and should be studied further. Some common tests may not be reliable. History had no impact on reliability of our tests but increased the prevalence of positive findings. Neurogenic dysfunction seems very common in patients with neck and/or shoulder problems and should be screened for.

Inter-examiner reliability in the assessment of low back pain (LBP) using the Kirkaldy-Willis classification (KWC)

Reliable classification systems and clinical tests are sought for the care of patients with low back pain (LBP). The objectives of this clinical study were to evaluate inter-examiner reliability in the classification of patients with LBP, the influence of radiological findings on the classification and the reliability of some clinical tests. Two examiners independently assessed 50 outpatients with LBP. Inter-examiner reliability in classification of patients with LBP using Kirkkaldy-Willis classification (KWC) system and in 30 clinical tests was calculated as percentage agreement and kappa coefficients (κ). Inter-examiner reliability was excellent (κ>0.8) for classification according to KWC. Radiological findings did not influence the reliability. Age of the patient, movement range, and pain and neurological signs seemed to guide the decision on classification. The reliability of clinical tests was good (κ>0.6) in 6 tests and moderate (κ>0.4) in 12 tests. Good inter-examiner reliability was found for the SLR test, movement range and sensibility testing with spurs in dermatome areas. We conclude that the KWC for classifying patients with LBP seems to be a reliable classification system depending on a few key observations and that moderate and good inter-examiner reliability can be achieved in several clinical tests in the assessment of LBP.

The pain drawing as an instrument for identifying cervical spine nerve involvement in chronic whiplash-associated disorders

Objective The aim of the study was to investigate the psychometric properties of a standardized assessment of pain drawing with regard to clinical signs of cervical spine nerve root involvement. Design This cross-sectional study included data collected in a randomized controlled study. Patients: Two hundred and sixteen patients with chronic (≥6 months) whiplash-associated disorders, grade 2 or 3, were included in this study. Methods The validity, sensitivity, and specificity of a standardized pain drawing assessment for determining nerve root involvement were analyzed, compared to the clinical assessment. In addition, we analyzed the interrater reliability with 50 pain drawings. Results Agreement was poor between the standardized pain drawing assessment and the clinical assessment (kappa =0.11, 95% CI: −0.03 to 0.20). Sensitivity was high (93%), but specificity was low (19%). Interrater reliability was good (kappa =0.64, 95% CI: 0.53 to 0.76). Conclusion: The standardized pain drawing assessment of nerve root involvement in chronic whiplash-associated disorders was not in agreement with the clinical assessment. Further research is warranted to optimize the utilization of a pain/discomfort drawing as a supportive instrument for identifying nerve involvement in cervical spinal injuries.

Correlation of MRI findings of intervertebral disc water content and disc height with self-rated quality of life, pain and disability.

Aims: To investigate (1) the correlation between MRI findings of Intervertebral disc water content and disc height, with self-rated quality of life (QoL), pain, and disability respectively, and (2) the correlation between QoL and pain, and QoL and disability respectively. Study Design: Clinical diagnostic study. Place and Duration of Study: Ersta hospital radiological department, Stockholm, between February and september 2004. Methodology: Eighty-eight patients referred for MRI of the spine due to suspect spinerelated discomfort and with no previous surgery of the affected spinal region, were included. In conjunction with the MRI examination, the patients filled out questionnaires to assess QoL, pain and disability. QoL was assessed with Euro-QoL-5D (EQ), pain was self-assessed with a Visual Analogue Scale (VAS), neck-related disability with Neck Disability Index (NDI), and low back-related disability with Oswestry Disability Index (ODI). Results: Correlations between disc water content and EQ, VAS, NDI and ODI were Original Research Article British Journal of Medicine & Medical Research, 4(14): 2639-2652, 2014 2640 0.09,0.13, -0.23 and 0.18, respectively. Correlations between disc height and EQ, VAS, NDI and ODI were 0.05, -0.11, -0.23 and -0.05, respectively. Correlation between EQ and VAS was -0.17, correlation between EQ and NDI was -0.5, and correlation between EQ and ODI was -0.49. Conclusion: No correlation was found between MRI findings of reduced Intervertebral disc water content and disc height with QoL, pain and disability. Other variables may be sought to explain self-rated QoL, pain, and disability among patients referred to MRI of the spine. In our study, the correlation between QoL and pain was not significant. However, the correlation between QoL and disability was significant, indicating that disability may have a greater impact on self-perceived QoL than pain.

Irritable bowel syndrome - a neurological spine problem.

Aim: To investigate if patients with Irritable bowel syndrome (IBS) have more findings in the physical examination indicating nerve involvement from spine segments Th7-L1 than people without gastrointestinal disorder. Study Design: Clinical randomized blinded case-control diagnostic study. Place and Duration of Study: Torvalla back and sports medical clinic and CeFAM at Karolinska Institutet, Stockholm, Sweden, Mars-May 2012. Methodology: Ten patients with IBS and six age-matched controls were randomly scheduled to a physical examination by two independent examiners who were blinded to the status of the person they examined. The physical examination followed a predetermined protocol focused on neurological examination and palpation of the abdomen and the spine. Fischer s exact test and Cohen’s kappa (K) test were used to analyze prevalence respectively inter-examiner reliability of examination findings. Results: Disturbed sensibility to pain in one or more of dermatomes T7-L1 was more prevalent in patients with IBS than controls (p=0.007 for both examiners). Tenderness on palpation of one or more of spinal processes T7-L1 was more prevalent in patients with Original Research Article British Journal of Medicine & Medical Research, 4(24): 4154-4168, 2014 4155 IBS than controls (p=0.001 for examiner 1, p=0.008 for examiner 2). Inter-examiner reliability in the physical examination test for sensibility to pain and palpation of the abdomen was 100% (K=1.0). Conclusion: Patients with IBS have significantly more findings in the physical examination indicating nerve involvement from spine segments Th7-L1 than people without gastrointestinal disorder. Further work in larger cohorts and with added diagnostic methods is required to confirm our findings and if confirmed may open up for new treatment strategies of IBS.