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

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.

Schlüsselwörter

Kreuzschmerzen - klinische Diagnosenstellung - Referenzstandards - prospektive Studie

Key words

Low back pain - clinical diagosis - reference standars - prospective study

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

Literatur

• 1 Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms - a systematic review.  Manual Therapy. 2004;  9 134-143
• 2 Altman D G, Machin D, Bryant T N. et al . Statistics with confidence.  British Medical Journal. 2000; 
• 3 Andersson G BJ, Pope M H, Snook S. Occupational low back pain: Assessment, treatment and prevention. St Louis; Mosby Year Book 1991
• 4 Andersson G BJ, Deyo R A. History and examination in patients with herniated lumbar discs.  Spine. 1996;  21 10S-18S
• 5 Baber Y F, Robinson A H, Villar R N. Is diagnostic arthroscopy of the hip worthwhile? A prospective review of 328 adults investigated for hip pain.  J Bone Joint Surg Br. 2000;  81 600-603
• 6 Battie M C, Cherkin D C, Dunn R. et al . Managing Low Back Pain: Attitudes and Treatment Preferences of Physical Therapists.  Phys Ther. 1994;  74 219-226
• 7 Bogduk N, McGuirk B. Medical management of acute and chronic low back pain.  Pain research and clinical management. 13
• 8 Bogduk N. The anatomical basis for spinal pain syndromes.  J Manipulative Physiol Ther. 1995;  18 603-605
• 9 Bogduk N, Modic M T. Controversy. Lumbar discography.  Spine. 1996;  21 402-404
• 10 Bogduk N. Clinical anatomy of the lumbar spine and sacrum. Churchill Livingstone London; 1997
• 11 Bogduk N. Commentary on a prospective study of centralization and lumbar and referred pain: A predictor of symptomatic discs and anular competence.  The Pain Medicine Journal Club Journal. 1997;  3 246-248
• 12 Bogduk N. An analysis of the Carragee data on false-positive discography.  International Spinal Injection Society Scientific Newsletter. 2001;  4 3-10
• 13 Bryant T N. Confidence Intervals Analysis. In 2.0 Build 41. Bristol; BMJ Books 2000
• 14 Carragee E J, Tanner C M, Yang B. et al . False-positive findings on lumbar discography. Reliability of subjective concordance assessment during provocative disc injection.  Spine. 1999;  24 2542-2547
• 15 Carragee E J, Tanner C M, Khurana S. et al . The rates of false-positive lumbar discography in select patients without low back symptoms.  Spine. 2000;  25 1373-1381
• 16 Cherkin D C, Deyo R A, Berg A O. Evaluation of a physician education intervention to improve primary care for low back pain II.  Spine. 1991;  16 1173-1178
• 17 Cyriax J. Textbook of Orthopaedic Medicine. Diagnosis of Soft Tissue Lesions, Vol. 1. London; Ballière Tindall 1975
• 18 Daker-White G, Carr A J, Harvey I. et al . A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments.  J Epidemiol Community Health. 1999;  53 643-650
• 19 Donelson R, Silva G, Murphy K. Centralisation phenomenon - Its usefulness in evaluating and treating referred pain.  Spine. 1990;  15 211-213
• 20 Donelson R, Grant W, Kamps C. et al . Pain response to sagittal end range spinal motion: A multi-centered, prospective, randomized trial.  Spine. 1991;  16 S206-S212
• 21 Donelson R, Aprill C, Medcalf R. et al . A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and anular competence.  Spine. 1997;  22 1115-1122
• 22 Dong G X, Porter R W. Walking and cycling tests in neurogenic and intermittent claudication.  Spine. 1989;  14 965-969
• 23 Dreyfuss P H, Dreyer S J, Vaccaro A. Lumbar zygapophysial (facet) joint injections.  The Spine Journal. 2003;  3 50-59
• 24 Ehara S, Shimamura T. Paradoxical motion in spondylolisthesis due to two-segment instability.  Arch Orthop Trauma Surg. 1997;  116 435-436
• 25 Fogel G R, Esses S I. Hip Spine syndrome: management of coexisting radiculopathy and arthritis of the lower extremity.  The Spine Journal. 2003;  3 238-241
• 26 Fortin J D, Dwyer A P, West S. et al . Sacroiliac Joint: Pain referral maps upon applying a new injection/arthrography technique. Part 1: Asymptomatic volunteers.  Spine. 1994;  19 1475-1482
• 27 Fortin J D, Aprill C, Pontieux R T. et al . Sacroiliac Joint: Pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation.  Spine. 1994;  19 1483-1489
• 28 Freund J E. Modern elementary statistics. London; Prentice-Hall International 1988
• 29 Fritz J M, Erhard R E, Delitto A. et al . Preliminary results of the use of a two-stage treadmill test as a clinical diagnostic tool in the differential diagnosis of lumbar spinal stenosis.  J Spinal Disorders. 1997;  10 410-416
• 30 Fritz J M, Delitto A, Welch W C. et al . Lumbar spinal stenosis: A review of current concepts in evaluation, management, and outcome measurements.  Arch Phys Med Rehab. 1998;  79 700-708
• 31 Guyer R D, Ohnmeiss D D. Contemporary Concepts in Spine Care. Lumbar Discography.  Spine. 1995;  20 2048-2059
• 32 Hakelius A. Prognosis in sciatica.  Acta Orthop Scand. 1970;  129 (Suppl) 1-70
• 33 Hicks G E, Fritz J M, Delitto A. et al . Interrater reliability of clinical examination measures for identification of lumbar segmental instability.  Arch Phys Med Rehabil. 2003;  84 1858-1864
• 34 Hockin J, Bannister G. The extended role of a physiotherapist in an out-patient orthopaedic clinic.  Physiotherapy. 1994;  80 281-284
• 35 Hourigan P G, Weatherley C R. Initial assessment and follow-up by a physiotherapist of patients with back pain referred to a spinal clinic.  J R Soc Med. 1994;  87 213-214
• 36 Hourigan P G, Weatherley C R. The physiotherapist as an orthopaedic assistant in a back pain clinic.  Physiotherapy. 1995;  81 546-548
• 37 Huberty C J. Issues in the use and interpretation of discriminant analysis.  Psychological Bulletin. 1984;  95 156-171
• 38 Katz J N, Dalgas M, Stucki G. et al . Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination.  Arthritis & Rheumatism. 1995;  38 1236-1241
• 39 Kilpikoski S, Airaksinen O, Kankaanpaa M. et al . Interexaminer reliability of low back pain assessment using the McKenzie method.  Spine. 2002;  27 E207-E214
• 40 Kosteljanetz M, Bang F, Schmidt-Olsen S. The clinical significance of straight-leg-raising (Lasègue sign) in the diagnosis of prolapsed intervertebral disc.  Spine. 1988;  13 393-395
• 41 Landis R J, Koch G G:. The measurement of observer agreement for categorical data.  Biometrics. 1977;  33 159-174
• 42 Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology.  Spine. 1994;  19 1243-1249
• 43 Laslett M, Van Wijmen P. Low back and referred pain: diagnosis and a proposed new system of classification.  NZ Journal of Physiotherapy. 1999;  27 5-14
• 44 Laslett M, Young S B, Aprill C N. et al . Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac joint provocation tests.  Aust J Physiother. 2003;  49 89-97
• 45 Laslett M, Oberg B, Aprill C N. et al . Zygapophysial joint blocks in chronic low back pain: A test of Revel’s model as a screening test.  BMC Musculoskeletal Disorders. 2004;  5 43
• 46 Laslett M, Oberg B, Aprill C N. et al . Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power.  The Spine Journal. [in press]; 
• 47 Main C J. The modified somatic perception questionnaire (MSPQ).  J Psychosom Res. 1983;  27 503-514
• 48 Main C J, Wood P L, Hollis S. et al . The distress and risk assessment method. A simple patient classification to identify distress and evaluate the risk of poor outcome.  Spine. 1992;  17 42-52
• 49 Manchikanti L, Pampati V, Fellows B. et al . The inability of the clinical picture to characterize pain from facet joints.  Pain Physician. 2000;  3 158-166
• 50 McKenzie R A. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae; Spinal Publications 1981
• 51 McKenzie R A, May S. Mechanical diagnosis and therapy: The lumbar spine. Waikanae; Spinal Publications 2002
• 52 McPhillips-Tangum C A, Cherkin D C, Rhodes L A. et al . Reasons for repeated medical visits among patients with chronic back pain.  J Gen Intern Med. 1998;  13 289-295
• 53 Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle; IASP Press 1994
• 54 Nachemson A. Instability of the lumbar spine. Pathology, treatment, and clinical evaluation.  Neurosurg Clin N Am. 1991;  2 785-790
• 55 Offierski C M, Macnab I. Hip-Spine Syndrome.  Spine. 1983;  8 316-321
• 56 Ombregt L, Bisschop P, ter V eer HJ. et al .A system of orthopaedic medicine. London; WB Saunders 1995
• 57 O’Sullivan P B. Lumbar segmental „instability”: clinical presentation and specific stabilizing exercise management.  Manual Therapy. 2000;  5 2-12
• 58 Petersen T, Laslett M, Thorsen H. et al . Diagnostic classification of non-specific low back pain. A new system integrating patho-anatomic and clinical categories.  Physiotherapy Theory and Practice. 2003;  19 213-237
• 59 Petersen T, Olsen S, Laslett M. et al . Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain.  Aust J Physio. 2004;  50 85-91
• 60 Pitkanen M T, Manninen H I, Lindgren K A. et al . Segmental lumbar spine instability at flexion-extension radiography can be predicted by conventional radiography.  Clin Radiol. 2002;  57 632-639
• 61 Pruitt S D, Von Korff M. Improving the management of low back pain: a paradigm shift for primary care. Psychological Approaches to Pain Management: a practitioner’s handbook. 2nd ed. New York; The Guilford Press 2002
• 62 Razmjou H, Kramer J F, Yamada R. Inter-tester reliability of the McKenzie evaluation in mechanical low back pain.  J Orthop Sports Phys Ther. 2000;  30 368-383
• 63 Revel M, Poiraudeau S, Auleley G R. et al . Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints.  Spine. 1998;  23 1972-1977
• 64 Richardson C, Jull G, Hodges P. et al .Therapeutic exercise for spinal segmental stabilization in low back pain. Scientific basis and clinical approach. London; Churchill Livingstone 1999
• 65 Roland M, Morris R. A study of the natural history of back pain. Part I: Development of a reliable and sensitive measure of disability in low-back pain.  Spine. 1983;  8 141-150
• 66 Roland M, Morris R. A study of the natural history of low back pain. Part II: Development of guidelines for trials of treatment in primary care.  Spine. 1983;  8 145-150
• 67 Saal J S. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques.  Spine. 2002;  27 2538-2545
• 68 Sackett D L, Haynes R B, Guyatt G H. et al .Clinical epidemiology: a basic science for clinical medicine. Boston; Little Brown 1991
• 69 Schwarzer A C, Aprill C, Derby R. et al . Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?.  Spine. 1994;  15 1132-1137
• 70 Schwarzer A C, Aprill C N, Derby R. et al . The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints.  Pain. 1994;  58 195-200
• 71 Schwarzer A C, Aprill C N, Derby R. et al . The relative contributions of the disc and zygapophyseal joint in chronic low back pain.  Spine. 1994;  19 801-806
• 72 Schwarzer A C, Derby R, Aprill C N. et al . Pain from the lumbar zygapophysial joints: a test of two models.  J Spinal Disord. 1994;  7 331-336
• 73 Schwarzer A C, Aprill C, Derby R. et al . The prevalence and clinical features of internal disc disruption in patients with chronic low back pain.  Spine. 1995;  20 1878-1883
• 74 Spangfort E V. The lumbar disc herniation. A computer-aided analysis of 2,504 operations.  Acta Orthop Scand. 1972;  142 1-95
• 75 Spitzer W O. Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders.  Spine. 1987;  12
• 76 Spivak J M. Current concepts review: Degenerative lumbar spinal stenosis.  Journal of Bone & Joint Surgery. 1998;  80-A 1053-1066
• 77 Stamathis G. Arthrography of the hip. Arndt RD, Horns JW, Gold RH Clinical arthrography. 2nd ed Baltimore; Williams & Wilkins 1985
• 78 Waddell G. The back pain revolution. Edinburgh; Churchill Livingstone 1998
• 79 Walsh T R, Weinstein J N, Spratt K F. et al . Lumbar discography in normal subjects.  J Bone Joint Surg (Am). 1990;  72 1081-1088
• 80 Weinstein S M, Herring S A, Derby R. Contemporary concepts in spine care. Epidural steriod injections.  Spine. 1995;  20 1842-1846
• 81 Young S B, Aprill C N, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain.  The Spine Journal. 2003;  3 460-465
• 82 Zung W WK. A self-rating depression scale.  Arch Gen Psych. 1965;  12 63-70

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