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Robert Vining, DC, and Nancy Kime, DC
My Patient Has Hip Pain—Are My Assessment Procedures Effective?
J Amer Chiropr Assoc 2011 July;48(5):15-17
|Abstract: Evidence in Action shows how practitioners can combine their background and experience with helpful elements from the literature for best patient outcome.|
A 55-year old man enters your practice with a complaint of hip, thigh, and low-back pain.
Weight-bearing increases his hip pain, causing him to limp slightly. Walking provides relief for his low back, but aggravates his hip. There is no posterior thigh or leg pain. However, his hip pain seems to travel to the anterior thigh.
Can I use this study to help my patient?
Review of the Maslowski et al. article
Neither researchers nor patients were blinded to any aspect of this study. All physicians utilizing the diagnostic maneuvers were reportedly employing them in the same manner. However, no standardization process was reported.
Results: Investigators reported sensitivity values (how good a test is at detecting IAHP) at 0.88-0.91 for IROP and 0.81-0.82 for FABER. Sensitivity for the Stinchfield and Scour tests was poor. Specificity values (how good a test is at ruling out IAHP) for all tests were low. Positive and negative predictive values (how well tests predict response to intra-articular injection) were also low for all tests.
Sensitivity values of 0.8 or more are considered good for these types of tests. A value in the 0.8 – 0.9 range means the test is good to excellent at indicating the presence of a condition when positive. The results in this study indicate that the FABER and IROP tests were fairly good at detecting IAHP, but the Scour and Stinchfield tests were not.
Confidence intervals (CI’s) for the two most sensitive tests were 0.57-0.96 (FABER) and 0.67-0.99 (IROP). One can think of a CI as predicting the value if the study were performed again, or as an indicator of the variability of the data in this study. These indicate that FABER and IROP demonstrated mild to high sensitivity in this study.
Conclusion: Based on these results, the authors concluded that the IROP and FABER tests were sensitive enough to recommend for use when evaluating patients with potential IAHP but not for predicting response to intra-articular injection. The Scour and Stinchfield tests were not recommended as useful for IAHP evaluation because their sensitivity and specificity values were low. When found to be negative, none of the four tests were effective at ruling out an intra-articular pain generator.
Limitations: All patients in this study presented a clinical picture consistent with an intra-articular pain source. Because this patient population was pre-selected in this manner, one should not assume the sensitivity of the studied tests is equal in a general or first-exposure hip pain population.
Low-back pain leading to pain in the hip region was not specifically evaluated in this study. Therefore, patients with spine-related conditions were not excluded from participation. Including these patients could confound results.
Key clinical information including symptom duration, history of injury, and the presence of mechanical symptoms was not collected, nor was information regarding the location of pain before and after injection, which could have further defined the source of pain and the utility of injections. Finally, the injection volume (10 ml) was large enough to potentially overflow the joint space, which can reduce pain in extra-articular tissue, leading to potential false negative and false positive results.
Are the study findings applicable to this patient?
You may decide to search for sensitivity and specificity values for other common evaluation maneuvers. Using the PubMed search terms hip, manual, diagnosis and predictive, you can find an article by Youdas et. al. that examines the Trendelenburg test as a potential tool for identifying patients with hip osteoarthritis.2
What is your decision?
Description of tests and key terms:
Stinchfield: “…performed with the subject supine. The tested leg was raised to 300of hip flexion with the knee in full extension. The subject held his or her leg in place while the examiner exerted downward force proximal to the knee…”
Scour: ”…performed with the subject supine. The affected hip was maximally flexed and adducted. Then, with a compressive force applied to the joint in the direction of the shaft of the femur, the examiner moved the femur through a circular arc of motion…”
IROP: “…performed with the subject supine. The affected hip was flexed to 900 and the knee flexed to 900. The examiner internally rotated the hip by rotating the leg laterally while stabilizing the knee at the same time. Internal rotation overpressure was administered with further gentle rotation of the ipsilateral leg. The pelvis was stabilized , when necessary, by the examiner’s other hand at the contralateral anterior superior iliac spine to reduce contralateral ilial rotation…”
Confidence Interval: “the computed interval with a given probability, e.g., 95%, that the true value of a variable… is contained within the interval.”3
Robert Vining, DC, is assistant professor and senior research clinician at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.
Nancy Kime, DC, is assistant professor and coordinator of clinical academics in the Capstone department at Palmer College of Chiropractic, Davenport Iowa.
1. Maslowski E, Sullivan W, Forster Harwood J, Gonzalez P, Kaufman M, Vidal A, Akuthota V. The diagnostic validity of hip provocation maneuvers to detect intra-articular hip pathology. American Academy of Physical Medicine and Rehabilitation’s PM&R. 2010 Mar;2(3):174-181.1.
2. Youdas J, Madson T, Hollman J. Usefulness of the Trendelenburg test for identification of patients with hip joint osteoarthritis. Physiother Theory Pract. 2010 Apr 22;26(3):184-94.
3. Last JM, A Dictionary of Epidemiology Fourth Edition, Oxford University Press, 2001