Diagnostic Accuracy of Clinical Tests for Neurogenic and Vascular Thoracic Outlet Syndrome: A Systematic Review.

OBJECTIVE: To summarize the evidence on the accuracy of clinical tests to help confirm or refute a diagnosis of thoracic outlet syndrome (TOS). METHODS: We searched 10 databases (January 1990 to February 2016) using relevant key words and medical subject headings terms. We considered diagnostic test accuracy studies comparing clinical tests for the diagnosis of TOS against a reference test. Cross-sectional, cohort, and case-control studies and randomized controlled trials were included. Risk of bias was appraised using QUADAS-2 and the Quality Appraisal of Reliability Studies checklist. We performed a qualitative synthesis of scientifically admissible studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was used to report findings. RESULTS: A total of 3932 articles were retrieved. After removal of duplicates, 1767 articles were screened for titles and abstract, leaving 494 articles for full-text review. Ten studies met the eligibility criteria and were assessed for risk of bias, 4 of which were included in the review. None of the included studies used the same index tests when comparing with a gold standard, and quality was poor. High clinical heterogeneity and the use of different comparators prevented from pooling results. Findings suggest that prescribing magnetic resonance imaging during provocative positioning to confirm a diagnosis of TOS may be useful. However, this is associated with a high false-positive rate of venous compression. CONCLUSION: Little evidence currently supports the validity of clinical tests for the diagnosis of TOS. Future diagnostic accuracy studies should aim to use established methodological criteria and appropriate reporting guidelines to help validate clinical tests for diagnosing patients with TOS.

Quantitative Romberg's test in acute carbon monoxide poisoning treated by hyperbaric oxygen.

OBJECTIVE: The aim of this study was to evaluate whether monitoring of acute carbon monoxide-poisoned (COP) patients by means of quantitative Romberg's test (QR-test) during a hyperbaric oxygen (HBO2) therapy regimen could be a useful supplement in the evaluation of neurological status. METHODS: We conducted a retrospective study (2000-2014) in which we evaluated data containing quantitative sway measurements of acute COP patients (n = 58) treated in an HBO2 regimen. Each patient was tested using QR-test before and after each HBO2 treatment. Data were analyzed using linear mixed models (LMM). In each LMM, sway prior to HBO2 therapy was set as the fixed effect and change in sway after HBO2 therapy was set as the response variable. Patient, treatment number, weight and age were set as random effects for all LMMs. RESULTS: From the LMMs we found that larger values of sway prior to HBO2 produced a negative change in sway. We found no correlation between CO level and sway (P=0.1028; P=0.8764; P=0.4749; P=0.5883). Results showed that loss of visual input caused a significant increase in mean sway (P=0.028) and sway velocity (P⟨0.0001). CONCLUSIONS: The Quantitative Romberg's test is a fast, useful supplement to neurological evaluation and a potential valuable tool for monitoring postural stability during the course of treatment in acute COP patients.

Anosognosia and neglect respond differently to the same treatments.

Different techniques, such as optokinetic stimulation, adaptation to prismatic shift of the visual field to the right, or transcutaneous electrical nerve stimulation (TENS), have been shown to alleviate neglect, at least temporarily. We assessed the effect of these techniques on anosognosia and whether their therapeutic effect, if any, matches that on neglect. The effect of the three types of treatment on anosognosia and neglect was investigated in five patients presenting with both severe anosognosia and neglect. Patient 1 was treatment responsive to anosognosia but not to neglect, whereas patients 4 and 5 showed the reverse pattern, i.e., they were treatment responsive to neglect but not to anosognosia. This "treatment response bias" proved to be a valid means to investigate different effects of treatments in the same patient.

Positive straight-leg raising in lumbar radiculopathy: is documentation affected by insurance coverage?

OBJECTIVE: To evaluate whether differences exist in documentation of straight-leg raising (SLR), based on insurance coverage. DESIGN: Retrospective study. SETTING: Managed care organization (MCO). PARTICIPANTS: Two hundred people with a diagnosis of lumbar radiculopathy or herniated disk were referred to an MCO for authorization of further treatment. Half were self-directed under a personal injury program (PIP) after automobile collisions, and half were covered under a managed care workmen's compensation (WC) program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Documentation of an SLR test, strength, sensation, and/or reflexes were eligible for the study. The results of SLR were coded as 0, 1, or 2, for absent, positive unilateral, and positive bilateral, respectively. Additional information included subject age, sex, date of injury, provider type, and presence of attorney representation RESULTS: A positive (unilateral, bilateral) SLR in women was 7.4 times more likely if they were covered by PIP than by WC (95% confidence interval [CI], 1.4-38.7; P=.018). For men, a positive SLR was 23.5 times more likely if they were covered by a PIP (95% CI, 2.9-189.9; P=.003). The odds of bilateral SLR (radicular pain on both sides) were even more strongly associated with type of reimbursement. For women, bilateral SLR was 105.1 times more likely if they were covered by a PIP than by WC (95% CI, 11.1-992.6; P<.001). For men, bilateral SLR was 38.9 times more likely if covered by a PIP (95% CI, 11.3-133.6; P<.001). CONCLUSIONS: Reasons for reporting higher rates of positive SLR in the PIP group include an added incentive to treat, poor knowledge of proper interpretation of the SLR test, and/or an increased exaggeration of symptoms.

The passive straight leg raising test in the diagnosis and treatment of lumbar disc herniation: a survey of United kingdom osteopathic opinion and clinical practice.

STUDY DESIGN: Postal questionnaire survey. OBJECTIVES: To carry out a confidential postal survey of United Kingdom osteopaths in order to record and assess their use of the passive straight leg raising test in the diagnosis of, and choice of, manipulation for lumbar disc herniation. The study also sought to determine whether an association existed between osteopaths' manipulation of suspected lumbar disc herniation and their use of the straight leg raising test, the length of their working hours, and their use of manipulation for the treatment of other lumbar conditions. SUMMARY OF BACKGROUND DATA: The literature is not agreed on important aspects of the straight leg raising test, or on the use of spinal manipulation for suspected lumbar disc herniation. This is thought to be the first study to investigate opinion and practice in a large group of spinal manipulators, in this case United Kingdom osteopaths. METHODS: A questionnaire was sent to all 1030 United Kingdom osteopaths registered with the General Osteopathic Council in January 2000. It comprised four sections: personal characteristics, professional characteristics, background to low back pain cases, details of straight leg raising test understanding and use within the diagnosis and treatment of lumbar disc herniation. RESULTS: A response rate of 44% was achieved. United Kingdom osteopaths' opinions of low back pain and lumbar disc herniation clinical presentations, details of straight leg raising test mode of action, procedure, and interpretation were in keeping with the literature. Fifty-four percent of respondents sometimes employed manipulation in the treatment of lumbar disc herniation, but most of the others described the practice as "dangerous." The literature is similarly divided on the practice. Chi-square and Cramer V analysis implied that respondents were not influenced in choosing manipulation for lumbar disc herniation by their use of the straight leg raising test (chi2 = 4.002, df = 3, Cramer V = 0.0959, P = 0.261, alpha 0.05, n = 435). A moderate association implied that the frequency of use of such manipulation for all lumbar conditions influenced the choice of that treatment for lumbar disc herniation (chi2 = 81.808, df = 4, Cramer V = 0.4302, P < 0.001, alpha = 0.05, n = 442). There was also a weak association suggesting that hours worked per week influenced the choice of manipulation for lumbar disc herniation (chi2 = 9.840, df = 3, Cramer V = 0.1499, P = 0.020, alpha = 0.05, n = 438). CONCLUSIONS: Respondents to this survey frequently treated low back pain and often employed the straight leg raising test in its diagnosis. Their recognition of the clinical presentation of lumbar disc herniation and their use and understanding of the straight leg raising test were in keeping with the literature. Respondents were divided nearly equally between those who would expect patient benefit from the use of manipulation for lumbar disc herniation and those who criticized the practice. There is a need for further research into the clinical reasoning employed for the manipulative treatment of lumbar disc herniation.

A novel quality of life instrument for deep brain stimulation in movement disorders.

OBJECTIVE: To develop a short instrument to examine quality of life (QoL) which specifically addresses patients with movement disorders treated by deep brain stimulation (DBS). DESIGN: The instrument was developed within an existing concept of a modular questionnaire (questions on life satisfaction: "general life satisfaction" QLS(M)-A, and "satisfaction with health" QLS(M)-G), in which each item is weighted according to its relative importance to the individual. METHODS: Items were generated by interviews with 20 DBS patients, followed by item reduction and scale generation, factor analysis to determine relevant and final questionnaire items, estimation of reliability, and validation based on the medical outcome study 36 item short form health survey (SF-36) and the EuroQol (EQ-5D) (data from 152 patients with Parkinson's disease, essential tremor, or idiopathic torsion dystonia, including 75 patients with DBS). RESULTS: Initial questionnaires were reduced to 12 items for a "movement disorder module" (QLS(M)-MD), and five items for a "deep brain stimulation module" (QLS(M)-DBS). Psychometric analysis revealed Cronbach's alpha values of of 0.87 and 0.73, and satisfactory correlation coefficients for convergent validity with SF-36 and EQ-5D. CONCLUSIONS: QLS(M)-MD and QLS(M)-DBS can evaluate quality of life aspects of DBS in movement disorders. Psychometric evaluation showed the questionnaires to be reliable, valid, and well accepted by the patients.

Carbon monoxide poisoning: correlation of neurological findings between accident and emergency departments and a hyperbaric unit.

OBJECTIVES: To investigate and quantify the differences in neurological examination findings in patients acutely poisoned with carbon monoxide, between initial assessment at accident and emergency (A&E) departments and subsequently at a hyperbaric unit. METHODS: Retrospective case note review of all patients referred to the Hull Hyperbaric Unit for treatment of acute carbon monoxide poisoning between August 1998 and August 1999. Patients who were ventilated or less than 16 years old were excluded because of difficulty in assessing their neurological status. RESULTS: Thirty patients were included for analysis. The mean duration from exposure to assessment in A&E was four hours while patients were reviewed on average three hours later at the hyperbaric unit. Referrals came from 14 different hospitals. A history of loss of consciousness accounted for 70% of referrals. A mean of 3.2 neurological signs per patient was documented in A&E compared with 9.2 at the hyperbaric unit. Seventy nine per cent of abnormal neurological signs were not detected at A&E departments compared with 3% at the hyperbaric unit. The major source of discrepancy was in sharpened Rhomberg's test and heel-toe gait, in 13% of patients examined in A&E departments these signs were recorded as abnormal compared with 90% at the hyperbaric unit. CONCLUSION: There is a large discrepancy in neurological findings between assessment in A&E departments and the Hull Hyperbaric Unit. A number of factors may account for this including interobserver variation, patient deterioration during transfer, poor documentation, lack of understanding of the sequelae of carbon monoxide poisoning and inadequate examinations. Further research is required to quantify the impact of the various factors that may contribute to the differences in neurological findings.

Neurological abnormalities in schizophrenic patients and their siblings.

OBJECTIVE: The aim of this study was to investigate the prevalence and type of neurological abnormalities in schizophrenic patients and their nonpsychotic siblings. METHOD: A comprehensive neurological assessment, including evaluation of both hard and soft signs, was performed for 60 schizophrenic patients, 21 siblings, and 75 normal comparison subjects. RESULTS: None of the comparison subjects scored higher than 6 on the neurological assessment scale, but a score of 7 or higher was given to 67% of patients and 19% of siblings. Both patients and siblings scored significantly higher than comparison subjects on total neurological abnormalities, hard signs, soft signs, primitive reflexes, integrative sensory functions, and motor functions. The most conspicuous abnormalities were motor coordination problems and involuntary movements in the patients and cranial nerve deviations and mirror movements in their siblings. Levels of neurological abnormality were positively correlated within patient-sibling pairs. The total battery and hard signs best discriminated patients from comparison subjects. CONCLUSIONS: High levels of neurological abnormality characterize both schizophrenic patients and their siblings. The constellation of abnormalities and absence of overt psychopathology in siblings may represent the mildest form of disturbance within the schizophrenia spectrum. Levels of neurological abnormality covary positively in patients and siblings within the same family, suggesting common genetic and/or environmental pathogenic factors. An extended assessment battery provides optimal discrimination of patients from normal subjects, and hard signs are more differentially associated with schizophrenia than are soft signs. The neurological abnormality has no consistent localizing profile, and nearly all functional domains are involved.

Principal components analysis of an evaluation of the hemiplegic subject based on the Bobath approach.

An evaluation based on the Bobath approach to treatment has previously been developed and partially validated. The purpose of the present study was to verify the content validity of this evaluation with the use of a statistical approach known as principal components analysis. Thirty-eight hemiplegic subjects participated in the study. Analysis of the scores on each of six parameters (sensorium, active movements, muscle tone, reflex activity, postural reactions, and pain) was evaluated on three occasions across a 2-month period. Each time this produced three factors that contained 70% of the variation in the data set. The first component mainly reflected variations in mobility, the second mainly variations in muscle tone, and the third mainly variations in sensorium and pain. The results of such exploratory analysis highlight the fact that some of the parameters are not only important but also interrelated. These results seem to partially support the conceptual framework substantiating the Bobath approach to treatment.

An evaluation of the hemiplegic patient based on the Bobath approach: a reliability study.

The intra- and inter-rater reliability of a motor function evaluation of stroke patients, based on the Bobath approach, was studied. The intraclass correlation coefficient (ICC) was used to determine the degree of agreement between repeated measurements on the same patient taken by the same rater and between measurements taken by three raters on the same patient. In the intra-rater study, each of 19 patients was evaluated in three different sessions by one of 19 raters. In the inter-rater study 18 patients were each evaluated by three different raters. The intra-rater data were highly reliable, with ICCs of 0.95 and 0.97 for the upper and lower limbs respectively. For the inter-rater study, the ICCs were 0.79 and 0.77 for the upper and lower limbs respectively. It can therefore be concluded that this instrument, previously demonstrated to quantify patient progress, is also reliable both in intra- and inter-rater dimensions.