Lars-Erik Strender

Interexaminer Reliability in Physical Examination of Patients With Low Back Pain

Study Design. Seventy-one patients with low back pain were examined by two physiotherapists (50 patients) and two physicians (21 patients). The two physiotherapists had worked together for many years, but the two physicians had not. The interexaminer reliability of the clinical tests included in the physical examination was evaluated. Objectives. To evaluate the interexaminer reliability of clinical tests used in the physical examination of patients with low back pain under ideal circumstances, which was the case for the physiotherapists. Summary of Background Data. Numerous clinical tests are used in the evaluation of patients with low back pain. To reach the correct diagnosis, only tests with an acceptable validity and reliability should be used. Previous studies have mainly shown low reliability. It is important that clinical tests not be rejected because of low reliability caused by differences between examiners in performance of the examination and in their definition of normal results. Methods. Two examiners, either two physiotherapists or two physicians, independently examined patients with low back pain. Results. In approximately half of the clinical tests studied, an acceptable reliability was demonstrated. Conclusion. On the basis of the physiotherapists series, the reliability was acceptable for a number of clinical tests that are used in the evaluation of patients with low back pain. The results suggest that clinical tests should be standardized to a much higher degree than they are today.

Interexaminer reliability in physical examination of the cervical spine

BACKGROUND Most of the studies of physical examinations of the cervical spine have shown poor reliability. PURPOSE To assess the interexaminer reliability in physical examinations of the cervical spine. SUBJECTS Forty-eight subjects, age range 18 to 63 years. METHODS Two physiotherapists independently evaluated a number of clinical tests of passive general and intersegmental movement. RESULTS Acceptable kappa/kappa (w) values were obtained in several of the clinical tests of passive general motion range but in few of the clinical tests of passive intersegmental movement. More clinical tests had acceptable reliability and less bias in symptomatic subjects than asymptomatic subjects. CONCLUSION Many of the clinical tests of passive general motion range were shown to be reliable. The increased number of acceptable kappa (w) values obtained in the symptomatic subjects indicates that further studies of the reliability of the clinical tests of passive intersegmental movement should be performed on patients.

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.

Nutritional status, as determined by the Mini-Nutritional Assessment, and osteoporosis: a cross-sectional study of an elderly female population

Objective:To investigate the relationship between osteoporosis and nutritional status as determined by the Mini-Nutritional Assessment (MNA).Design:A cross-sectional study.Setting:Stockholm, Sweden.Subjects:A total of 351 elderly free-living women (mean age 73±2.3 years).Methods:MNA (range 0–30 points; <17 indicates malnutrition, 17.5–23.5 risk of malnutrition and ⩾24 well nourished), measurements of bone mineral density of the left hip and lumbar spine using Hologic QDR 4500, and of the heel using Calscan DEXA-T.Results:The median MNA score was 27 (range 12.5–30). One woman was classified as malnourished and 7.4% were at risk of malnutrition. Osteoporosis of the femoral neck was observed in 22% and a fracture after the age of 50 was reported by 31% of the participants. The following items in the MNA questionnaire exhibited an increased risk of having osteoporosis in the femoral neck and/or total hip: an MNA score of <27 (odds ratio (OR)=2.09; CI=1.14–3.83); a mid-arm circumference of less than 28 cm (OR=2.97; CI=1.29–6.81); and regular use of more than 3 drugs each day (OR=2.12; CI=1.00–4.50). A body weight of more than 70 kg exhibited a decreased risk of having osteoporosis (OR=0.31; CI=0.14–0.70).Conclusions:In general, the nutritional status was good in this population of free-living elderly women. Nevertheless, half of the women who displayed an MNA score <27 points had a twofold increased risk of having osteoporosis.Sponsorship:Karolinska Institutet, Stockholm County Council.

Textual content, health problems and diagnostic codes in electronic patient records in general practice

Objective - To investigate textual content, health problems and diagnostic codes in everyday electronic patient records. Design - Retrospective and observational database study. Setting - Primary health care in Stockholm. Subjects - Twenty randomly selected general practitioners with 20 records each. Main outcome measures - The frequency of use of problem-oriented medical records. The number of words, problems and diagnostic codes. The completeness and correctness of the diagnostic codes. Results - About 14.5% of 400 studied records were problem-oriented. The mean number of words per record was 99.4, and the mean number of problems managed per record was 1.2. On average, there were 1.1 diagnostic codes per record and this differed widely among GPs and also among the electronic patient record systems. The mean number of codes per problem was 0.9, and the proportion of correct codes was 97.4%. Conclusions - The electronic patient records in general practice in Stockholm have an extensive textual content. A vast majority of the problems are coded and the completeness and correctness of diagnostic codes are high. It seems that problem-oriented electronic patient record systems enforce coding activities. It is feasible to establish a database of diagnostic data for research and health care planning based on electronic patient records.

Types of morbidity and categories of patients in a Swedish county Applying the Johns Hopkins Adjusted Clinical Groups System to encounter data in primary health care

Objective – To elucidate types of morbidity and categories of patients in a large population. Design – A one-year retrospective study of encounter data from electronic patient record databases in primary health care, with application of the Johns Hopkins Adjusted Clinical Groups System. Setting – Blekinge County Council, southeastern Sweden, with 149 552 inhabitants. Subjects – All patients with a diagnosis-registered encounter with a GP in 2002 at 13 publicly managed PHC centres. Main outcome measures – Anonymous identification number, age, gender, type of morbidity (Aggregated Diagnostic Groups), and category of patient (Adjusted Clinical Groups). Results – About 45% of the countys inhabitants had at least one diagnosis-registered encounter with a GP during the year. The most common types of morbidity were “time limited” (24.0% of all types), “likely to recur” (19.6%), and “signs/symptoms” (19.0%). About 33.3% of all patients had one and only one time-limited condition, about 16.8% had one and only one recurring condition, and about 12.1% of the patients had only a chronic condition. Conclusion – Types of morbidity in primary health care are dominated by nearly equal proportions of “time limited”, “likely to recur”, “chronic”, and “signs/symptoms”. The predominant categories of patients are those with only one type of morbidity, while about one-third of the patients had a constellation of two or more types of morbidity during a one-year period.

Management of heart failure in primary health care. A retrospective study on electronic patient records in a registered population

Objective - To study the prevalence, patient characteristics and management of patients with heart failure, and the feasibility of using everyday electronic patient records for research. Design - A 4-year retrospective database study. Setting - Primary health care in Stockholm. Subjects - Forty-six general practitioners, with a registered population of 100 222 inhabitants. Main outcome measures - Number of patients with heart failure, frequencies of their comorbidity, investigations and treatments. Results - Out of the registered population, 667 (0.7%) patients had the diagnosis heart failure and fulfilled the diagnostic criteria in our study, and 98.7% had a comorbidity. The most frequent were ischaemic heart disease (37.2%), hypertension (27.3%), chronic atrial fibrillation (23.7%) and diabetes (22.3%). Major investigations were chest radiograph (66.3%) and echocardiograph (16.9%). Frequent pharmacological treatments were diuretics (90.9%), cardiac glycosides (48.1%), platelet aggregation inhibitors (32.7%), vasodilators (31.6%), angiotensin-converting enzyme inhibitors (27.4%) and beta blockers (14.5%). Diuretics were more frequent for females (p = 0.016) and angiotensin-converting enzyme inhibitors for males (p < 0.001). Conclusion - Heart failure was common among the elderly and constituted a complex clinical problem. It seemed that these patients could have been managed more adequately. There were gender differences concerning comorbidity and management. Electronic patient records were feasible for research, although several areas needed improvement.

Collection and retrieval of structured clinical data from electronic patient records in general practice. A first-phase study to create a health care database for research and quality assessment.

Objective To evaluate prerequisites, practicalities, attitudes and limitations related to the collection of structured clinical data in everyday general practice for use in the future establishment of a national registration network. Design Prospective study. Setting Primary health care centres in south-western Sweden. Subjects Fourteen participating general practitioners in five primary health care centres. Main outcome measures Feasibility and workload involved in structured data entry and in the retrieval of data from different record systems. The accuracy of clinical data in terms of clinical variables, correctness and representativeness. Results All four record systems could deliver basic data on the patient population. One centre had to be excluded from further data retrieval because of limitations in the data retrieval export format. Collecting data in everyday practice was feasible with acceptable data accuracy and moderate workload. Conclusion It was feasible to collect, retrieve and store structured clinical data with respect to accuracy and extra workload. Interest in a national registration network and an increasing demand for information about primary health care in order to optimise clinical practices and support research, creates prerequisites for establishing a valid and reliable database. However, developmental work focusing on classification limitations, coding tools and routines for data retrieval is necessary.

Subacute and chronic, non-specific back and neck pain: cognitive-behavioural rehabilitation versus primary care. A randomized controlled trial

BackgroundIn the industrial world, non-specific back and neck pain (BNP) is the largest diagnostic group underlying sick-listing. For patients with subacute and chronic (= full-time sick-listed for 43 – 84 and 85 – 730 days, respectively) BNP, cognitive-behavioural rehabilitation was compared with primary care. The specific aim was to answer the question: within an 18-month follow-up, will the outcomes differ in respect of sick-listing and number of health-care visits?MethodsAfter stratification by age (≤ 44/≥ 45 years) and subacute/chronic BNP, 125 Swedish primary-care patients were randomly allocated to cognitive-behavioural rehabilitation (rehabilitation group) or continued primary care (primary-care group). Outcome measures were Return-to-work share (percentage) and Return-to-work chance (hazard ratios) over 18 months, Net days (crude sick-listing days × degree), and the number of Visits (to physicians, physiotherapists etc.) over 18 months and the three component six-month periods. Descriptive statistics, Cox regression and mixed-linear models were used.ResultsAll patients: Return-to-work share and Return-to-work chance were equivalent between the groups. Net days and Visits were equivalent over 18 months but decreased significantly more rapidly for the rehabilitation group over the six-month periods (p < .05). Subacute patients:Return-to-work share was equivalent. Return-to-work chance was significantly greater for the rehabilitation group (hazard ratio 3.5 [95%CI1.001 – 12.2]). Net days were equivalent over 18 months but decreased significantly more rapidly for the rehabilitation group over the six-month periods and there were 31 days fewer in the third period. Visits showed similar though non-significant differences and there were half as many in the third period. Chronic patients:Return-to-work share, Return-to-work chance and Net days were equivalent. Visits were equivalent over 18 months but tended to decrease more rapidly for the rehabilitation group and there were half as many in the third period (non-significant).ConclusionThe results were equivalent over 18 months. However, there were indications that cognitive-behavioural rehabilitation in the longer run might be superior to primary care. For subacute BNP, it might be superior in terms of sick-listing and health-care visits; for chronic BNP, in terms of health-care visits only. More conclusive results concerning this possible long-term effect might require a longer follow-up.Trial registrationNCT00488735.

Mini nutritional assessment and 10-year mortality in free-living elderly women: a prospective cohort study with 10-year follow-up

Background/Objectives:Mini nutritional assessment (MNA) is the most frequently used screening test for malnutrition in elderly populations in continental Europe and Asia. Most studies on MNA’s ability to predict mortality have only included persons admitted to hospital, living in nursing homes or at home with professional help with activities of daily living. The aim of this cohort study was to examine if MNA can predict 10-year mortality in the general elderly female population.Subjects/Methods:Of the 584 free-living elderly women invited, 351 agreed to participate and were tested with MNA between 1999 and 2000. A 10-year follow-up was conducted in 2010 with dates of death obtained from the Swedish death register.Results:Participants whose MNA score was ⩽23.5 points at inclusion had a significantly higher age-adjusted 10-year mortality risk than participants with a MNA score of >23.5 points. The hazard ratio was 2.36 (95% confidence interval 1.25–4.46), P <0.01.Conclusions:Participants with a MNA score, indicating an increased risk for malnutrition, were more than twice as likely to die during the 10-year follow-up as participants whose MNA score indicated normal nutritional status. Hence, MNA can predict mortality in a general, free-living, elderly female population.