The Diagnostic Accuracy of the Clinical Examination of the Hip

332 Pages·2016·25.3 MB·English

The Diagnostic Accuracy of the Clinical Examination
of the Hip

Steven Gordon White

A thesis submitted to AUT University in fulfilment of the requirements for the degree of
Doctor of Philosophy (PhD)

2016

School of Clinical Sciences

Supervisors
Professor Peter McNair
Dr Mark Laslett
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Table of Contents
Table of Contents ........................................................................................................................................... i

List of Figures ................................................................................................................................................ v

List of Tables ............................................................................................................................................... vi

Attestation of Authorship .......................................................................................................................... viii

Research Outputs Resulting from this Thesis .............................................................................................. ix

Acknowledgements ........................................................................................................................................ x

Ethics .......................................................................................................................................................... xii

Abstract ...................................................................................................................................................... xiii

Chapter 1 Introduction ................................................................................................................................. 16

1.1
  The problem .................................................................................................................................. 16

1.2
  Research aims ................................................................................................................................ 18

1.3
  Structure of the thesis .................................................................................................................... 20

1.4
  Significance of the research .......................................................................................................... 21

Chapter 2 General Literature Review .......................................................................................................... 22

2.1
  Introduction ................................................................................................................................... 22

2.2
  General search strategy ................................................................................................................. 23

2.3
  Intra-articular hip joint pain .......................................................................................................... 23

2.3.1
  Pain ........................................................................................................................................ 24

2.3.2
  Anatomy ................................................................................................................................ 26

2.3.3
  Innervation of intra-articular structures of the hip ................................................................ 27

2.3.4
  Review Summary .................................................................................................................. 33

2.4
  The diagnostic process .................................................................................................................. 34

2.5
  Performance characteristics of tests .............................................................................................. 37

2.5.1
  Sensitivity and specificity ..................................................................................................... 38

2.5.2
  Predictive values ................................................................................................................... 39

2.5.3
  Likelihood ratios ................................................................................................................... 40

2.5.4
  Overall accuracy .................................................................................................................... 43

2.5.5
  Review Summary .................................................................................................................. 46

2.6
  Chapter summary .......................................................................................................................... 47

Chapter 3 Pain Provocation and Pain Intensity During the Application of Physical Tests ......................... 48

3.1
  Introduction and background ........................................................................................................ 48

3.2
  Literature review ........................................................................................................................... 49

3.2.1
  Intra-examiner reliability of reports of pain reproduction and pain intensity ....................... 50

3.2.2
  Inter-examiner reliability of reports of pain reproduction ..................................................... 51

3.2.3
  Prevalence of painful responses during the application of pain provocation tests ................ 52

3.2.4
  Methodological considerations ............................................................................................. 54

3.2.5
  Review Summary .................................................................................................................. 57

3.3
  Methods and procedures of the current study ............................................................................... 58

3.3.1
  Study design .......................................................................................................................... 58

3.3.2
  Sample size calculation ......................................................................................................... 58

3.3.3
  Participants ............................................................................................................................ 58

3.3.4
  Examiner ............................................................................................................................... 59

3.3.5
  Procedures ............................................................................................................................. 59

3.3.6
  Blinding ................................................................................................................................. 61

3.3.7
  Included tests ......................................................................................................................... 61
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3.3.8
  Definition of a positive test ................................................................................................... 61

3.3.9
  Analysis ................................................................................................................................. 61

3.4
  Results ........................................................................................................................................... 63

3.4.1
  Reliability of categorical yes/no response to pain reproduction ........................................... 67

3.4.2
  Reliability of reports of pain intensity ................................................................................... 70

3.4.3
  Prevalence of positive responses ........................................................................................... 73

3.5
  Discussion ..................................................................................................................................... 75

3.5.1
  Reliability of reports of pain reproduction ............................................................................ 75

3.5.2
  Reports of pain intensity ....................................................................................................... 76

3.5.3
  Prevalence of painful responses ............................................................................................ 78

3.6
  Limitations .................................................................................................................................... 79

3.7
  Conclusion and implications ......................................................................................................... 80

Chapter 4 Measurements of Strength and Range of Movement in Painful and Non-Painful Hips ............. 82

4.1
  Introduction and background ........................................................................................................ 82

4.2
  Literature review ........................................................................................................................... 84

4.2.1
  Reliability of measures of range of movement and strength ................................................. 85

4.2.2
  Side-to-side differences in strength in people with unilateral hip pathology ........................ 88

4.2.3
  Comparisons of strength between symptomatic hips and normal controls ........................... 91

4.2.4
  Side-to-side differences in range of movement ..................................................................... 93

4.3
  Methodological considerations ..................................................................................................... 94

4.3.1
  Instrumentation ...................................................................................................................... 94

4.3.2
  Position and stabilisation of patient ...................................................................................... 95

4.3.3
  Make versus break ................................................................................................................. 96

4.3.4
  Examiner strength ................................................................................................................. 97

4.3.5
  Duration of contraction and rest intervals between repetitions ............................................. 97

4.3.6
  Number of repetitions ............................................................................................................ 98

4.3.7
  Determining end of range ...................................................................................................... 99

4.3.8
  Summary ............................................................................................................................. 100

4.4
  Methods and procedures of the current study ............................................................................. 101

4.4.1
  Study design, participants and procedure ............................................................................ 101

4.4.2
  Analysis ............................................................................................................................... 102

4.5
  Results ......................................................................................................................................... 104

4.5.1
  Reliability of strength testing measurements ...................................................................... 104

4.5.2
  Reliability of ROM measurements ...................................................................................... 106

4.6
  Discussion ................................................................................................................................... 108

4.6.1
  Strength measurements ....................................................................................................... 108

4.6.2
  ROM Measurements ........................................................................................................... 113

4.7
  Limitations .................................................................................................................................. 115

4.8
  Conclusions and implications ..................................................................................................... 116

Chapter 5 The Diagnostic Accuracy of Findings from the Clinical Examination of the Painful Hip ....... 118

5.1
  Introduction and Background ...................................................................................................... 118

5.2
  Literature review ......................................................................................................................... 119

5.2.1
  Diagnostic accuracy of physical tests .................................................................................. 124

5.3
  Review Summary ........................................................................................................................ 129

5.4
  Methodological considerations ................................................................................................... 130

5.4.1
  Study design & patient spectrum ........................................................................................ 130

5.4.2
  Reference test ...................................................................................................................... 131

5.4.3
  Index test description .......................................................................................................... 141

5.4.4
  Time between index test and reference standard ................................................................. 142

5.4.5
  Blinding ............................................................................................................................... 142
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5.4.6
  Sample size analysis ............................................................................................................ 143

5.5
  Methods and procedures of the current study ............................................................................. 144

5.5.1
  Study design ........................................................................................................................ 144

5.5.2
  Sample size .......................................................................................................................... 144

5.5.3
  Participants .......................................................................................................................... 144

5.5.4
  Referring specialists ............................................................................................................ 145

5.5.5
  Examiner ............................................................................................................................. 146

5.5.6
  Procedures ........................................................................................................................... 146

5.5.7
  Reference test ...................................................................................................................... 147

5.5.8
  Index tests ............................................................................................................................ 149

5.5.9
  Data analysis ....................................................................................................................... 149

5.6
  Results ......................................................................................................................................... 150

5.7
  Discussion ................................................................................................................................... 165

5.8
  Limitations .................................................................................................................................. 171

5.9
  Conclusion ................................................................................................................................... 171

Chapter 6 Predictors of Intra-articular Pathology of the Hip .................................................................... 172

6.1
  Introduction and background ...................................................................................................... 172

6.2
  Literature review ......................................................................................................................... 174

6.3
  Methodological Considerations .................................................................................................. 179

6.4
  Methods and procedures of the current study ............................................................................. 182

6.4.1
  Data collection ..................................................................................................................... 182

6.4.2
  Data Analysis ...................................................................................................................... 182

6.5
  Results ......................................................................................................................................... 186

6.5.1
  Reduced set of predictors .................................................................................................... 186

6.5.2
  Model Selection ................................................................................................................... 190

6.5.3
  Assessment and characteristics of the model ...................................................................... 194

6.5.4
  Screening score versus levels of positivity ......................................................................... 196

6.6
  Discussion ................................................................................................................................... 199

6.7
  Limitations .................................................................................................................................. 203

6.8
  Conclusion ................................................................................................................................... 203

Chapter 7 The Prevalence and Diagnostic Utility of Abnormal Findings Reported in Patients Undergoing
Magnetic Resonance Imaging Arthrogram of the Hip .............................................................................. 204

7.1
  Introduction and Background ...................................................................................................... 204

7.1.1
  Literature review ................................................................................................................. 205

7.1.2
  Prevalence of abnormal findings of intra-articular structures of the hip identified by MR
imaging in asymptomatic hips ......................................................................................................... 206

7.1.3
  Prevalence of abnormal findings of intra-articular structures identified by MRI/MRA in
symptomatic hips ............................................................................................................................. 208

7.1.4
  Prevalence of abnormal findings at arthroscopy ................................................................. 211

7.1.5
  Diagnostic accuracy of MRI/MRA ..................................................................................... 213

7.1.6
  Review summary ................................................................................................................. 219

7.2
  Methods and procedures of the current study ............................................................................. 220

7.2.1
  Data Collection .................................................................................................................... 221

7.2.2
  Data Analysis ...................................................................................................................... 222

7.3
  Results ......................................................................................................................................... 222

7.4
  Discussion ................................................................................................................................... 226

7.5
  Limitations .................................................................................................................................. 229

7.6
  Conclusions ................................................................................................................................. 230

Chapter 8 Summary, Key Findings and Conclusions ................................................................................ 231

8.1
  Key Findings ............................................................................................................................... 232
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8.2
  Recommendations for future research ........................................................................................ 241

8.3
  Conclusion ................................................................................................................................... 241

References .................................................................................................................................................. 243

Appendices ................................................................................................................................................ 269

Appendix 1.
  Ethical approval for interview and reliability studies ....................................................... 270

Appendix 2.
  Reliability study information sheet ................................................................................... 271

Appendix 3.
  Consent form for reliability study ..................................................................................... 274

Appendix 4.
  Screening and baseline questionnaire for reliability study ............................................... 275

Appendix 5.
  Consent form for interviews .............................................................................................. 283

Appendix 6.
  Interview study information sheet ..................................................................................... 285

Appendix 7.
  Operational definitions of tests and measures ................................................................... 288

Appendix 8.
  Between-session influencing factors ................................................................................. 298

Appendix 9.
  Ethical approval for diagnostic accuracy studies .............................................................. 300

Appendix 10.
  Screening form for diagnostic accuracy study ................................................................ 302

Appendix 11.
  Diagnostic accuracy study information sheet ................................................................. 303

Appendix 12.
  Consent form for diagnostic accuracy study ................................................................... 307

Appendix 13.
  Medical screening questionnaire for diagnostic accuracy study ..................................... 309

Appendix 14.
  Lower limb tasks questionnaire (LLTQ) ......................................................................... 311

Appendix 15.
  Self-report Leeds assessment of neuropathic symptoms and signs (S-LANSS) ............. 313

Appendix 16.
  Baseline data collection form for diagnostic accuracy study .......................................... 314

Appendix 17.
  Body chart for diagnostic accuracy study ....................................................................... 321

Appendix 18.
  Physical examination form for diagnostic accuracy study .............................................. 322

Appendix 19.
  Percent change in pain intensity following anaesthetic injection ................................... 324

Appendix 20.
  Coordinates of the ROC curves for mean internal ROM ................................................ 325

Appendix 21.
  Coordinates of the ROC curves for the difference in range of movement between painful
and non-painful hips .................................................................................................................................. 326

Appendix 22.
  Coordinates of the ROC curves for age .......................................................................... 327

Appendix 23.
  Coordinates of the ROC curves for mean BKFO ROM ................................................. 328

Appendix 24.
  Quadas 2 Critical Appraisal of DA studies for MR Imaging .......................................... 329

Appendix 25.
  MRA standardised reporting form .................................................................................. 330
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List of Figures
Figure 5.1 Fluoroscopy guided anaesthetic injection ................................................................................ 148

Figure 5.2 ROC curve for mean range of internal rotation of the painful hip ........................................... 157

Figure 5.3 ROC curve for mean differences in range of movement between painful and non-painful hips
prior to the FGAI ....................................................................................................................................... 158

Figure 6.1 Best value of AICc for each predictor as a function of model size .......................................... 191

Figure 6.2 Area under the curve versus AICc for each model with 7 or less predictors ........................... 193

Figure 6.3 Receiver operator characteristic curve for screening scores. ................................................... 195
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List of Tables
Table 3.1 Prevalence of positive results for physical tests in symptomatic hips (%) .................................. 53

Table 3.2 Frequency of reported symptoms ................................................................................................ 64

Table 3.3 Region of pain ............................................................................................................................. 64

Table 3.4 Pain behaviour ............................................................................................................................. 65

Table 3.5 Pain intensity (NPRS) .................................................................................................................. 65

Table 3.6 Cause, history and activity levels ................................................................................................ 66

Table 3.7 Baseline composite pain intensity, functional and neuropathic pain scores ................................ 66

Table 3.8 Within-session reliability for yes/no reports of pain reproduction .............................................. 68

Table 3.9 Between-session reliability for yes/no reports of pain reproduction ........................................... 69

Table 3.10 Within-session reliability for reports of pain intensity .............................................................. 71

Table 3.11 Between-session reliability for reports of pain intensity ........................................................... 72

Table 3.12 Prevalence of positive test responses ......................................................................................... 74

Table 4.1 Between-session mean peak force measurements for symptomatic hip (n=18) ........................ 105

Table 4.2 Peak force measurements for asymptomatic versus symptomatic hip1 (n=16) ......................... 105

Table 4.3 Within-session ROM measurements in degrees for symptomatic hip (n=18) ........................... 107

Table 4.4 Between-session ROM measurements in degrees for symptomatic hip (n=18) ........................ 107

Table 4.5 ROM measurements in degrees for asymptomatic versus symptomatic hip1 (n=16) ................ 107

Table 5.1 Overview of search terms and results per database ................................................................... 120

Table 5.2 Overview of systematic reviews of diagnostic accuracy studies investigating physical tests for
intra-articular pathology of the hip ............................................................................................................ 122

Table 5.3 Summary of quality assessment of individual studies (QUADAS-2) ....................................... 124

Table 5.4 Baseline information .................................................................................................................. 151

Table 5.5 Comparison between surgeon and sports physician participants .............................................. 151

Table 5.6 Demographics and history ......................................................................................................... 152

Table 5.7 Aggravating activities & associated symptoms ......................................................................... 153

Table 5.8 Nature and area of pain .............................................................................................................. 154

Table 5.9 Functional and neuropathic pain status ..................................................................................... 155

Table 5.10 Range of movement in degrees ............................................................................................... 156

Table 5.11 Diagnostic accuracy of ‘impingement’ tests ........................................................................... 161

Table 5.12 Diagnostic accuracy of resisted movements (as pain provocation tests) ................................. 161

Table 5.13 Diagnostic accuracy of end-range ‘rotation’ tests ................................................................... 162

Table 5.14 Diagnostic accuracy of ‘weight-bearing’ tests ........................................................................ 162

Table 5.15 Diagnostic accuracy of ‘miscellaneous’ tests .......................................................................... 163

Table 5.16 Diagnostic accuracy of variables from history that have a significant association with PAR (p
< 0.05) ........................................................................................................................................................ 163

Table 5.17 Post-test probability of a positive anaesthetic response .......................................................... 164

Table 6.1 Characteristics of the initial set of variables considered for inclusion in multiple logistic
regression analysis (continued on next page) ............................................................................................ 188

Table 6.2 Summary of variables included in the reduced set of predictors ............................................... 189

Table 6.3 Details of AICc-optimal models for each model size ................................................................ 192
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Table 6.4 Details of AUC-optimal models for each model size ................................................................ 192

Table 6.5 Coefficients and odds ratios of the variables in model predicting a PAR ................................. 194

Table 6.6 Rescaled test coefficients (weightings) ..................................................................................... 196

Table 6.7 Accuracy statistics associated with rescaled screening score for predicting a PAR ................. 198

Table 6.8 Accuracy statistics associated with various levels of positivity for predicting a PAR .............. 198

Table 7.1 Prevalence of reported pathology PAR versus NAR (n=67) .................................................... 224

Table 7.2 Diagnostic accuracy of imaging findings (n = 67) .................................................................... 225
viii
Attestation of Authorship
I hereby declare that this submission is my own work and that, to the best of my
knowledge and belief, it contains no material previously published or written by another
person (except where explicitly defined in the acknowledgements), nor material which
to a substantial extent, has been submitted for the award of any other degree or diploma
of a university or other institution of higher learning.

Signed:

Dated: 9 August 2016
ix
Research Outputs Resulting from this Thesis
Peer-Reviewed Publications
White S.G., McNair P., Laslett M., Hing W. (2015).
Do patients undergoing physical testing report pain intensity reliably?
Arthritis Care Res. 2015; 67(6):873-879.

Submitted Publications
White S.G., McNair P., Laslett M. (2016).
The diagnostic accuracy of symptoms and physical tests of the hip for intra-
articular pathology. American Journal of Sports Medicine
Smythe E., White S.G. (2016) Methods of practice: listening to the story. Physiotherapy
Theory and Practice (accepted).
Invited Seminar Presentation
White S.G., McNair P., Laslett M., Hing W. (2012). Diagnosis of hip pain
Nelson Hip Symposium. Nelson, New Zealand.
Conference Presentation
White S.G., McNair P., Laslett M., Hing W. (2014).
Do patients undergoing physical testing report pain intensity reliably?
Physiotherapy New Zealand Biennial conference. Auckland, New Zealand

Oral Presentations
White S.G., McNair P., Laslett M. (2015).
Diagnostics and clinical reasoning. New Zealand Manipulative Physiotherapists
Association Certificate in Orthopaedic Manual Therapy. Otago University,
Dunedin, New Zealand.
White S.G., McNair P., Laslett M. (2015).
Assessment and management of the hip. New Zealand Manipulative
Physiotherapists Association Certificate in Orthopaedic Manual Therapy. AUT
University, Auckland, New Zealand.
White S.G., McNair P., Laslett M. (2015).
Assessment and management of the hip. New Zealand Manipulative
Physiotherapists Association Certificate in Orthopaedic Manual Therapy. Hutt
Hospital, Wellington, New Zealand.