manuelletherapie 2006; 10(3): 140-151
DOI: 10.1055/s-2006-926918
Expertenforum

© Georg Thieme Verlag KG Stuttgart · New York

Übereinstimmung zwischen Diagnosen, die aufgrund klinischer Untersuchungen und gemäß verfügbarer Referenzstandards gewonnen wurden[*]

Prospektive Studie an 216 Patienten mit lumbopelvinen SchmerzenAgreement Between Diagnoses Reached by Clinical Examination and Available Reference StandardsA Prospective Study of 216 Patients with Lumbopelvic PainM. Laslett1 , B. McDonald2 , H. Tropp3 , Ch N. Aprill4 , B. Öberg3
  • 1Dept. for Health and Society, Physiotherapy, Linköping University, S-58183 Linköping
  • 2Institute of Information and Mathematical Sciences, Massey University, NZ-Albany
  • 3Dept. for Health and Society, Linköping University, S-58183 Linköping
  • 4Louisiana State University Health Science Center, USA-New Orleans
Further Information

Publication History

Manuskript eingetroffen: 10.2.2006

Manuskript akzeptiert: 20.3.2006

Publication Date:
10 July 2006 (online)

Zusammenfassung

In etwa 70 % der Fälle lässt sich der gewebsbedingte Ursprung von Kreuzschmerzen (Low back pain, LBP) oder übertragenen Symptomen der unteren Extremität (Lower extremity symptoms, LES) mithilfe hoch entwickelter bildgebender Methoden, Diskographie und Blockaden der Wirbelbogen- oder Iliosakralgelenke feststellen. Die Techniken sind invasiv und nicht immer verfügbar. Eine klinische Untersuchung ist nichtinvasiv und sehr verbreitet verfügbar, aber ihre Validität ist fraglich. Diagnostische Studien untersuchen gewöhnlich die Aussagekraft einzelner Tests im Vergleich zu einzelnen Referenzstandards, in der klinischen Praxis allerdings setzen Therapeuten mehrere Tests ein und wählen ihre Diagnose aus einer Reihe möglicher Diagnosen aus. Daher sind Studien erforderlich, die den diagnostischen Wert klinischer Diagnosen im Vergleich zu den verfügbaren Referenzstandards beurteilen.

Verglichen wurden verblindete klinische Diagnosen mit denen gemäß verfügbarer Referenzstandards für bekannte Ursachen von LBP oder LES (z. B. Diskographie, Blockaden von Wirbelbogen-, Iliosakral- oder Hüftgelenken, epidurale Injektionen, hoch entwickelte bildgebende Techniken oder irgendwelche Kombinationen dieser Techniken). Dazu diente das Design einer prospektiven, verblindeten, auf validierte Standards bezogenen Studie. Physiotherapeuten untersuchten nacheinander jene Patienten, die wegen chronischer lumbopelviner Schmerzen und/oder übertragener LES für die Referenzstandarduntersuchungen angemeldet waren. Stimmten beide Diagnosen - unabhängig von der Komplexität des Falles - völlig überein, wurde dies als „exakte” Übereinstimmung notiert. War die klinische Diagnose in der Referenzstandarddiagnose enthalten, galt dies als „klinische” Übereinstimmung. Anhand des statistischen Kriteriums zufallsbedingter Anteil (Proportional chance criterion, PCC; Maß zur Berechnung zufallskorrigierter Übereinstimmung) wurde die Übereinstimmung hinsichtlich vielfacher diagnostischer Möglichkeiten beurteilt, da damit der Prävalenz einzelner Kategorien in der Stichprobe Rechnung getragen wird. Die Beurteilung der Übereinstimmung hinsichtlich 6 bestimmter pathoanatomischer Diagnosen erfolgte mithilfe der Kappa-Statistik.

In einer Stichprobe (n = 216) von Patienten mit chronischen Kreuzschmerzen, einem hohen Maß an Behinderung und Beunruhigung wurde gemäß verfügbarer Referenzstandards bei 67 % eine pathoanatomische Diagnose gestellt. Bei 10 % fanden sich mehr als eine gewebsbezogene Schmerzursache. Für 27 diagnostische Kategorien und Kombinationen von Kategorien wurde die zufällige klinische Übereinstimmung auf 13 % geschätzt. Die „exakte” Übereinstimmung zwischen klinischen und Referenzstandarddiagnosen ergab 32 %, die „klinische” Übereinstimmung 51 %. Für 6 pathoanatomische Kategorien (Bandscheibe, Wirbelbogen-, Iliosakral- und Hüftgelenk, Nervenwurzel, spinale Stenose) betrug das PCC 33 %, bei einer tatsächlichen Übereinstimmung von 56 %. Bei keinem Vergleich bestand eine Überlappung der 95 %igen Konfidenzintervalle. Die diagnostische Übereinstimmung hinsichtlich der 6 üblichsten pathoanatomischen Kategorien ergab einen Kappa-Koeffizienten von 0,31.

Klinische Diagnosen stimmen mehr als nur zufallsbedingt mit Referenzstandarddiagnosen überein. Mithilfe verfügbarer Referenzstandards lässt sich bei den meisten Patienten eine gewebsbedingte Schmerzquelle feststellen.

Abstract

The tissue origin of low back pain (LBP) or referred lower extremity symptoms (LES) may be identified in about 70 % of cases using advanced imaging, discography and facet or sacroiliac joint blocks. These techniques are invasive and availability varies. A clinical examination is non-invasive and widely available but its validity is questioned. Diagnostic studies usually examine single tests in relation to single reference standards, yet in clinical practice, clinicians use multiple tests and select from a range of possible diagnoses. There is a need for studies that evaluate the diagnostic performance of clinical diagnoses against available reference standards.

Blinded clinical diagnoses were compared with diagnoses based on available reference standards for known causes of LBP or LES such as discography, facet, sacroiliac or hip joint blocks, epidurals injections, advanced imaging studies or any combination of these tests. A prospective, blinded validity design was employed. Physiotherapists examined consecutive patients with chronic lumbopelvic pain and/or referred LES scheduled to receive the reference standard examinations. When diagnoses were in complete agreement regardless of complexity, “exact” agreement was recorded. When the clinical diagnosis was included within the reference standard diagnoses, “clinical agreement” was recorded. The proportional chance criterion (PCC) statistic was used to estimate agreement on multiple diagnostic possibilities because it accounts for the prevalence of individual categories in the sample. The kappa statistic was used to estimate agreement on 6 pathoanatomic diagnoses.

In a sample of chronic LBP patients (n = 216) with high levels of disability and distress, 67 % received a patho-anatomic diagnosis based on available reference standards, and 10 % had more than one tissue origin of pain identified. For 27 diagnostic categories and combinations, chance clinical agreement (PCC) was estimated at 13 %. “Exact” agreement between clinical and reference standard diagnoses was 32 % and “clinical agreement” 51 %. For 6 pathoanatomic categories (disc, facet joint, sacroiliac joint, hip joint, nerve root and spinal stenosis), PCC was 33 % with actual agreement 56 %. There was no overlap of 95 % confidence intervals on any comparison. Diagnostic agreement on the six most common patho-anatomic categories produced a kappa of 0.31.

Clinical diagnoses agree with reference standards diagnoses more often than chance. Using available reference standards, most patients can have a tissue source of pain identified.

1 Der Originalartikel kann eingesehen werden unter: www.biomedcentral.com/1471-2474-6-28. Wir danken BMCJ Muskulaskeletal Disorders für die Genehmigung zur Zweitpublikation.

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1 Der Originalartikel kann eingesehen werden unter: www.biomedcentral.com/1471-2474-6-28. Wir danken BMCJ Muskulaskeletal Disorders für die Genehmigung zur Zweitpublikation.

Mark Laslett

Dept. for Health and Society, Physiotherapy, Linköping University

S-58183 Linköping

Email: mark.laslett@xtra.co.nz