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Interesting Read. This reminds me of something during my final clinical rotation at the UIC orthopedic residency.
One of the residents was doing a research project about shoulder evaluation and special tests. Basically, You had to have your computer with you during a shoulder evaluation, and answer 3-4 questions after the subjective portion, then the objective portion.
If you answered “yes” to the question “Did you use special tests during your exam?” It would ask you if you were more confident or less confident in your diagnosis after performing the special test. A very high percentage of therapists were more confident in their diagnosis, despite the metrics on special testing in the shoulder being relatively poor.
I think that through the course series I gained a bit more of an understanding of which tests are relatively specific, and which ones are relatively sensitive, and I try to use the sensitive ones early in exam to help my reasoning and rule out things, and specific ones later in the exam after I’ve done the rest of my testing to help confirm a diagnosis.
After reading this article, however, it makes me re-think the utility and metrics of some of these tests and whether or not I bias myself with them.
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This is a good commentary. One thing that was mentioned in the article was that researchers use pain based special tests as a yes/no test not accounting for those subjects with a “maybe” answer. Which is what we see a lot in clinic. Another point from the article that I liked was “The best clinicians use fewer tests and make decisions on refined data”. Meaning that the best clinicians can use less tests as they are able to better filter subjective/objective findings to lead them to a diagnosis. This points in a way to what Mike Reiman talked about at the course 2 weekends ago. Saying that the most important thing that residents and fellowed achieve is a better ability to take a subjective history, leading them to a diagnosis.
Since starting residency, I primarily use special tests to rule out things on my hypothesis list that is still unclear based on special questions. And then use special tests to confirm a diagnosis. Often times I use one or two as an objective asterisks carried over from visit to visit. Ideally, I like to have a functional test, ROM, resisted test, and special test. So initially I may use the special test to help with a diagnosis initially and then use it as a retest throughout their care.
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Between this and the Bialosky piece, seems like cheeky extended metaphors are the way to get published these days! But really though, I love this perspective, especially since it’s coming from some of the biggest researchers in our field for this area. I think the quote, “Clinicians should quit looking for overly simplistic answers”, is perhaps the over-arching point of the article, and one that is important to keep in mind throughout our practice.
Since the start of the residency a few things about my use of special tests have changed. After the stats presentation by Dr. Cross I think I pay more attention to the inclusion criteria and gold standard in studies looking at special tests. I certainly am more interested in +/- LR than I was before the Fall. The biggest thing is not feeling wed to one particular test or particular result, except for some rare exceptions. It’s all about looking at the big picture and clustering findings, something that I think I struggled more with earlier on in the year. I think knowing that the metrics on a lot of tests are pretty dismal also lets me feel more comfortable modifying the tests slightly, looking as a measure of tissue irritability versus a straight yes or no sort of result.
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