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What is the problem?
The concern is my patient’s wife needs an evidence-based explanation as to why I
have chosen specific orthopaedic tests to elicit her partner’s hip pathology symptoms.
What information do I need to gather/understand to better appreciate the scope and
impact of the concern?
Providing the logic behind using the FADDIR and FABER orthopaedic tests to
answer the clinical question test is my priority. With so many possible hip pathologies, the
clinician must utilise tests that will provoke the patient’s symptoms. Therefore, knowing the
diagnostic accuracy of orthopaedic tests is essential when obtaining an accurate diagnosis,
and in turn, maximising treatment outcomes. To convey this information onto my patient’s
wife, I believe I must explain to her the role diagnostic accuracy plays when selecting tests to
elicit symptoms.
How can I critically evaluate the information as it relates to the central concern?
Evidence-based practice recommends that I critique the information by using
evaluating tools such as critical appraisal tools that assess the study on its reliability, validity,
accuracy, authenticity, timeliness, point of view or bias to conclude whether or not the article
is a relevant and reliable source of information to use as a foundation for my research and
outcome.
I have utilised the Critical Appraisal Skills Program (CASP) tool to assess the value
of the literature presented in the review conducted by Reiman et al.3 to see if I can use this
study as evidence to answer the clinical question posed to me by my client. Based on the
CASP tool checklist results, the systematic review and meta-analysis are deemed an
acceptable level of literature to formulate my response as to why I have chosen specific tests
over others. See appendix for results.
When we begin to critically evaluate the “usefulness” of many of the orthopaedic
tests, it becomes apparent that many of them have limitations. The clinician must know
which tests are of diagnostic value, and will answer the clinical question, and which should
be omitted. However, certain orthopaedic procedures may have high sensitivity and low
specificity or vice versa. It is often difficult to determine the effect of the estimates of
sensitivity and specificity on the usefulness of a procedure in clinical practice.1 Ideally, a test
would have high sensitivity and specificity, but this is often not the case. Furthermore, even
for tests with high sensitivity and specificity, the effect of test results on the probability that a
condition either is or is not present cannot be calculated directly from these values.1 To better
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understand how test performance affects clinical decisions, positive and negative LRs can be
calculated.1
Likelihood ratios constitute one of the best ways to measure and express diagnostic
accuracy. A +LR indicates how much the odds of the pathology being present increase when
the test is positive. Therefore, the best test to use to rule in pathology is the one with the
largest positive likelihood ratio. A −LR indicates how much the odds of the pathology being
present increase when the test is negative. Therefore, the best test to rule out a pathology is
the one with the smallest likelihood ratio. The main advantage of LRs (over other measures
of diagnostic accuracy, such as sensitivity and specificity) is that clinicians can use them to
compare different diagnostic strategies and thus refine clinical judgment quickly.2
Therefore, after comparing the physiotherapist’s tests diagnostic values against mine,
in the review by Reiman et al.3, I can delineate the fact that the FABER test has a higher +LR
than any of the tests chosen by the physio. This means the FABER test has stronger odds of
detecting the condition when the test is positive for the pathology. Simultaneously, the
FADDIR test has a lower -LR than any of the tests the physiotherapist chose, which means,
the odds of the pathology being present, if the finding is negative, is very low.
Upon reflection, what concerns may become an impediment to the implementation of
this new synthesis, and how may this be communicated in a patient-centred setting?
While the clinician must understand that the diagnostic value of a test is reached by
exposing its limitations, this information can be extremely confusing for persons who are not
familiar who are not health literate. Therefore, time must be spent conveying this information
in jargon-free terms so as to put the patient at ease, whilst proving that I have taken the most
reliable evidence-based approach to reach a diagnostic outcome.
How can I apply this new synthesis research in an ideal patient-centred approach?
Limited literacy skills are one of the strongest predictors of poor health outcomes for
patients.4 Therefore, applying a friendly and safe environment where patients with limited
health literacy skills are confident they are being listened to, will help them trust that myself,
the clinician, is acting in the best interest of the patient, without a risk of a bias opinion.
Can I summarise the newly relevant issues?
I believe that by interpreting the literature in the review by Reiman et al.3 in layman’s
terms to my patient will demonstrate that I have done my due diligence in determining which
tests will elicit her partner’s particular disorder, hence the reason an emphasis is placed on
the ones that consistently reproduce the phenomenon with reliable diagnostic outcomes.
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References:
1. Denegar C, Fraser M. Understanding and applying likelihood ratios. Journal of
athletic training [Internet]. 2006 [cited 2020 Aug 12]; 41(2), 201–206. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472641/
2. McGee S. Simplifying likelihood ratios. Journal of General Internal Medicine
[Internet]. 2002 [cited 2020 Aug 12];17(8):647-650. Available from:
doi:10.1046/j.1525-1497.2002.10750.x
3. Reiman M, Goode A, Hegedus E, Cook C, Wright A. Diagnostic accuracy of clinical
tests of the hip: a systematic review with meta-analysis. British Journal of Sports
Medicine [Internet]. 2012 [cited 2020 Aug 12];47(14):893-902. Available from:
doi:10.1136/bjsports-2012-091035
4. Graham S. Do Patients Understand? The Permanente Journal [Internet]. 2008 [cited
2020 Aug 12];12(3). Available from: doi:10.7812/tpp/07-144
Appendix:
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