When it comes to hip assessment, is subjective history more important than objective tests to arrive at an accurate diagnostic conclusion?
Qualified medical history is an important skill as it plays an important role in the diagnostic process, in clinical decision-making and in establishing a therapeutic relationship between patient and clinician. Some studies report that subjective medical history alone is over 75% accurate in patient diagnosis prior to objective testing, but many of these studies are medically focused.
The recent emphasis on telehalth and the use of questionnaires to assess self-reported symptoms due to panedmic has put even more pressure on the subjective anamnesis, but how good is it in physical therapy practice?
Learn to correctly differentiate hip pain
One of the most common conditions in physiotherapy of the musculoskeletal system is hip pain. In the US, around 14% of adults report hip pain most days of the week. The evidence for the physiological assessment of the hip has largely focused on “specialty tests”. The more research that is conducted, the more we understand that it provides little to no valuable information for the clinician to diagnose hip-related pathology. So should we rely more on the subjective than on the objective evaluation?
A new systematic review published in the Archive for Physical Medicine and Rehabilitation aims to find out how accurate a subjective anamnesis is when diagnosing hip pathology.
Methods
The systematic review was in accordance with PRISMA guidelines and the protocol was published in PROSPERO, both hallmarks of good review practice. The databases used for the search were PubMed, MEDLINE, CINAHL and WoS using an appropriate search strategy. The strategy used hip-specific search terms combined with diagnostic accuracy and subjective / self-report-based history-based terms using Boolean operators
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Articles could be included if:
This included patients with hip pain
The statistical assignment of at least one subjective examination finding or a self-report of the patient was given
The study design was appropriate for diagnostic accuracy
Participating adults aged 18 and over
Was written in English
An acceptable reference standard for the diagnosed hip pathology was used (e.g. surgery, MRI).
Articles were excluded if they only evaluated the diagnostic value of blood or imaging, if red flags were present during the evaluation or if no suitable reference standard was used for the diagnosis.
Two authors reviewed the studies to determine if they were eligible and a third was used to reach an agreement in the event of disagreement. The two authors also rated the methodological quality of each study with the QUADAS-2 tool.
"Anterior thigh / groin pain and persistent back / buttock pain are better indicators of hip OA than standalone tests ."
A total of 9 studies were included in the final review, and of these 9 examined six hop osteoarthritis, two on femeroacetabular impingement (FAI) +/- labral pathology and one on intra-articular pathology. In all studies, the greatest risk of bias was most strongly associated with patient selection. Further details can be found in the article itself.
The results were presented using sensitivity, specificity, positive probability ratio, negative probability ratio and / or diagnostic odds ratio. The following video explains the importance of these statistical tools when using a diagnostic test.
Clinical take-away
When comparing objective tests that are commonly used for hip osteoarthritis, the Trendelenberg sign (+ LR 1.83), resistance to hip abduction (+ LR 3.5) and the FABER test (+ LR 1.9 ) no better and sometimes worse than some elements of the story. In particular, reports of pain in the front thigh or in the groin area (+ LR 3.86) and constant pain in the lower back / buttocks (+ LR 6.50) seem to be better than independent tests.
No patient history articles reported a higher probability ratio for FAI than objective tests such as the Thomas test, FADDIR or FABER. One study reported several anamnesis points that showed high specificity. However, due to the high risk of bias, these results should be interpreted with caution.
A single study was included to assess intra-articular hip pathology, and the main subjective sign is crepitus with a probability ratio of +3.56. This makes intuitive sense in view of the crepitus.
Brief summary of why subjective history is important for hip pain
Front thigh / groin pain and constant back / buttock pain are better indicators of hip OA than standalone tests .
The reported hip crepitus is a strong indicator of intra-articular hip pathology which makes intuitive sense.
No patient history is effective in indicating FAI. The internal rotational-flexion-axial compression test remains the most useful non-radiologic test for the dignified FAI.
The results of this study do not ignore the importance of an objective assessment, but remind us of the role of various assessment instruments. During the anamnesis, we form hypotheses that we want to question through our objective test results. Since we had to move on to video consultations, we need to understand where the diagnostic strengths of the story lie in order to confirm or refute our hypotheses.
