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Document: 30
On the accuracy of history, physical examination, and erythrocyte
sedimentation rate in diagnosing low back pain in general practice.
van den Hoogen H M, Koes B W, van Eijk J T, Bouter L M..
On the accuracy of history, physical examination, and erythrocyte
sedimentation rate in diagnosing low back pain in general practice.
Spine,
1995,
20(3),
pp.318-327
Record status
This record is a structured abstract written by CRD reviewers. The original
has met a set of quality criteria. Since September 1996 abstracts have been
sent to authors for comment. Additional factual information is incorporated
into the record. Noted as [A:....].
Author's objective
An assessment of the signs and symptoms in diagnosing radiculopathy,
ankylosing spondylitis, and vertebral cancer. Type of intervention
Diagnosis.
Specific interventions included in the review
A variety of physical examinations, patient history characteristics and
erythrocyte sedimentation rate (ESR).
Participants included in the review
Patient characteristics were dependent on the illness for which they were
being diagnosed, these included: operated patients; patients with sciatica,
bony entrapment, disc protrusion, low back pain, vertebral cancer.
Outcomes assessed in the review
Diagnostic accuracy.
Study designs of evaluations included in the review
Observational studies based on medical (hospital/general practice) series or
community.
What sources were searched to identify primary studies?
MEDLINE was searched from 1986-1992 (keywords: backache or low back and
sciatica, cancer, spondylitis). The references of included studies were also
searched.
Criteria on which the validity (or quality) of studies was assessed
Studies were rated for methodological quality using pre-defined criteria:
technical quality of the index test; technical quality of the reference test;
application of the reference test; independence of interpretation; clinical
description; study population; sample size; data presentation. Studies were
awarded points for each of the above criteria.
How were the judgements of validity (or quality) made?
Two reviewers independently, discrepancies resolved by consensus.
How were decisions on the relevence of primary studies made?
Not stated, but studies had to present data on the sensitivity only or on both
the sensitivity and specificity of history, physical examination, and ESR for
radiculopathy, vertebral cancer or metastasis, and ankylosing spondylitis.
Studies of less than 10 patients with disease were excluded.
How was the data extracted from primary studies?
Not stated.
Number of studies included
36 studies 19 - radiculopathy (4 - history, 844 patients: 8 - physical
examination, 3476 patients).
9 - vertebral cancer or metastasis (3 - history, 1518 patients: 4 - physical
examination, 2503 patients: 2 - erythrocyte sedimentation rate, 1421
patients).
8 - ankylosing spondylitis (2 - history, 587 patients: 3 - physical
examination, 1128 patients: 1 - erythrocyte sedimentation rate, 54 patients).
How were the studies combined?
Sensitivity and specificity were calculated. History, physical examination and
erythrocyte sedimentation rate were regarded as separate index tests being
positive or negative.
Sensitivity was defined as the number of patients with disease with a positive
index-test result divided by the total number of patients with disease.
Specificity was defined as the number of patients without disease with a
negative index-test result divided by the total number of individuals without
disease.
Sensitivity (true-positive rate) was plotted against 1 minus specificity
(false-positive rate).
How were differences between studies investigated?
Through a discussion of the validity assessment.
Results of the review
Radiculopathy - no single test had a high sensitivity and high specificity.
History and erythrocyte sedimentation rate - this had relatively high
diagnostic accuracy in vertebral cancer.
Getting out of bed at night and reduced lateral mobility seemed to be the only
moderately accurate items in ankylosing spondylitis.
Only 19 studies scored 55 points or more out of a maximum of 100 in the
quality assessment.
Was any cost information reported?
No.
Author's conclusions
The diagnostic accuracy of history, physical examination and ESR in general
practice settings remains unclear. However, it appears that combining positive
findings increase diagnostic accuracy.
CRD commentary
A well structured review with a good choice of validity criteria. A more
detailed description of the search strategy would have been preferable (i.e.
to include languages searched) and by restricting the search to MEDLINE it is
likely that many relevant studies have been missed. Overall, though the review
should not be overly criticised for this one short coming, in what is
otherwise a good systematic review.
What are the implications of the review?
The present literature suggests that the signs and symptoms commonly used to
diagnose radiculopathy, ankylosing spondylitis, and vertebral cancer lack
accuracy.
Subject index terms
Subject indexing assigned by NLM: Blood-Sedimentation; Low-Back-Pain/et
[etiology]; Medical-History-Taking; Physical-Examination Family-Practice;
Peripheral-Nervous-System-Diseases/di [diagnosis]; Research-Design;
Retrospective-Studies; Sensitivity-and-Specificity; Spinal-Neoplasms/di
[diagnosis]; Spinal-Nerve-Roots; Spondylitis,-Ankylosing/di [diagnosis]
Correspondence address
Dr. H. van den Hoogen, Department of General Practice and Nursing Home
Medicine, Vrije Universiteit, Van der Boechorststraat 7, 1081 BT Amsterdam,
The Netherlands.
Copyright
University of York, 1998
Database no.: DARE-978022
