The Best Special Test – Scientific Reasoning in the Clinical Exam (Part 3)

Success kid

Congratulations! If you’ve made it to this point, you’re one last step closer to becoming a better clinician, more adept at logical and critical thinking — and probably a better person overall;)

Today, we will discuss the best special test out there. This one test can help you immensely in your clinical exam. It’s basically the only special test you’ll ever need. Utilizing this signature special test will allow you to correctly diagnose nearly any malady thrown your way. Whether it range from a torn rotator cuff…to a cervical radiculopathy…to something more sinister. Yes, that’s right!! You can diagnose all of these conditions plus many, many more using this one test alone!

Now, before I jump to the conclusion, lets have a brief review of some of the other special tests out there…just to really hammer home the point that my special test is better. (As usual, the  Braintrust members think alike. Matt D. has already written a nice critical thinking piece about special tests. Check it out!) Back to the story…

Lets review two simple shoulder tests…Neer’s and Hawkins Kennedy:

A systematic review was performed on a cluster of shoulder tests for sensitivity and specificity and the pooled results for the Neer test was 79% and 53%, respectively; and for the Hawkins Kennedy test was 79% and 59%, respectively.(1) Now, I don’t know about you…but a 79% doesn’t cut it…much less a 59-53%!! When was the last time you took a test, got your results and said, “Hey! I got a C…good enough for me!” (Alright, alright, bad question. I know there are some slackers out there.) But really! This is just not good enough for passing in my book, and it shouldn’t be in yours. And on top of all of that, they’re only good for ruling in/out 1 flippin’ diagnosis! Pssh!

My test is way better. It’ll get you 80%(2,3) of your diagnoses right without even lifting a finger (unless you’re a hand talker), and it works for nearly any kind of pathology! Want to know what it is?? It’s called…get ready…(drum roll):

Taking a good subjective history!!

Tada! I admit the name needs a little work. It’s not too catchy and a little lengthy, but this “special test” is the best out there!

Alright, I’ll cut the crap.

We should all know this, but it seems necessary to repeat. Perform an excellent subjective history taking. Attempt to rule out your bias by asking questions down a different path every once and a while. By doing this you increase the strength of your differential.

And more importantly…in order for a good history taking to be valuable — we need to understand pathology. We need to continually brush up, study up, and read up on patient presentation, disease course, aggravating/alleviating factors, red flags, neurology, visceral referral patterns. Study the stuff you don’t know, the stuff you don’t like.

We need to be Awesome PTs…no more telling people their back pain is due to weak core musculature or flat feet. No more “PT Diagnoses.” Those are absurd (and possibly corrupt) claims with no evidence. Be a better PT. Know the biopsychosocial model for pain. Relate to your patient. Communicate with them (not to them), and finally — help them move and send them on their way with tools to self-manage should the need arise.

I hope you’ve enjoyed and/or benefited from the SRICE series. This is all part of one presentation, and it really works best that way. Check out the Intro, Part 1, and Part 2 if you haven’t.

The take aways:

1. Avoid bias in your thoughts and interactions with patients.

2. Blind your patients (save them from unnecessary or misleading pain when appropriate and possible).

3. Use good interviewing skills to establish a narrowed heading for objective findings (and attempt to search for a negative result [i.e. reject the null]).

and…

4. Beware of the research you read, use healthy skepticism.

“But I thought this was a 3-part series??” Well this is where #4 comes in:  all this talk of low quality studies and scientific reasoning gives rise to an over arching warning of something called publication bias. Publication bias is most simply explained as the tendency for research showing positive results to be published more often than research with negative results (up to twice as much!). Now, there are many layers to the publication bias onion, and as a result it comes in many forms. It happens mainly with big pharma, but we run into into it every now and then in physical therapy (RE: Post on Dry Needling, the JOSPT, and BiM). For a more entertaining and informative overview please watch Dr. Goldacre:

Thanks for reading!

-Spencer

PS – You should still use special tests to increase the strength of your differential. Don’t think I was telling you to trash them.

Some references:

1. Hegedus E, Goode A, Campbell S, et al. Physical Examination Tests of the Shoulder: A Systematic Review and Meta-analysis of Individual Tests. Br J Sports Med. 2008; 42:80–92. doi:10.1136/bjsm.2007.038406.

2. Peterson M, Holbrook J, Hales D, et al. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992; 156:163-165.

3. Hampton J, Harrison M, Mitchell J, et al. Relative Contributions of History-taking, Physical Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. BMJ. 1975; 2:486-489.

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5 thoughts on “The Best Special Test – Scientific Reasoning in the Clinical Exam (Part 3)

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