Restoring the Lost Art of the Clinical Examination
By: Zachary Walston
Tags: Medicine, Physical Therapy, Bias, Health, Healthcare

Over the past several decades, healthcare providers have relied more on clinical special tests, laboratory tests, and imaging. Here’s the problem. Those tests don’t translate into better outcomes for patients.

The reliance on these types of tests has resulted in a decline in the capacity of musculoskeletal clinicians to perform a skilled clinical examination, resulting in incorrect diagnoses and more costly management strategy. The ability to take a history and learn from the patient has deteriorated. This interferes with personalized care and patient-centric treatment. How can we remedy this?

Barriers to Comprehensive Clinical Examinations?

Laboratory tests, imaging, clinical algorithms, and special tests do not eliminate the human element of an examination. Many of the clinical tests performed have meta-analytic data to defend their usage, particularly the more advanced testing physical therapists are not able to order (e.g. blood tests). In addition, clinicians are prone to many biases that influence a clinical examination. Here are a few common ones:

Anchoring Effect : Anchoring happens when a clinician remains anchored to salient features in the patient’s initial presentation too early in the diagnostic process without adjusting the outcome when further information is available. This error may be severely compounded by the confirmation bias

: Anchoring happens when a clinician remains anchored to salient features in the patient’s initial presentation too early in the diagnostic process without adjusting the outcome when further information is available. This error may be severely compounded by the confirmation bias Availability Bias : It is a general disposition of human thought to evaluate things as being more probable if they easily come to mind. In medicine, recent experiences with clinical problems often provoke availability bias resulting in diagnostic errors.

: It is a general disposition of human thought to evaluate things as being more probable if they easily come to mind. In medicine, recent experiences with clinical problems often provoke availability bias resulting in diagnostic errors. Confirmation Bias: Confirmation bias is a common bias in medicine that happens when clinicians misinterpret symptoms and remember things as they wish they had happened. They may notice and consider only those signs and symptoms consistent with their favored diagnosis and ignore aspects inconsistent with it.

Confirmation bias is a common bias in medicine that happens when clinicians misinterpret symptoms and remember things as they wish they had happened. They may notice and consider only those signs and symptoms consistent with their favored diagnosis and ignore aspects inconsistent with it. Diagnosis Momentum : It happens when an initial, possible diagnosis becomes definite (even if it is not really the right one) and all the other possibilities are excluded

: It happens when an initial, possible diagnosis becomes definite (even if it is not really the right one) and all the other possibilities are excluded Representative Bias : In medicine, it is a cognitive distortion that makes people judge the probability or frequency of a diagnostic hypothesis by considering how much the hypothesis resembles available clinical data

: In medicine, it is a cognitive distortion that makes people judge the probability or frequency of a diagnostic hypothesis by considering how much the hypothesis resembles available clinical data Satisfaction of Search: We may stop our search after finding the first plausible answer (common in radiologists)

Layer on the time constraints and other tasks vying for a clinician’s attention, such as notes or concurrent patients, and the desire for using a quick test intensifies.

For physical therapists, special tests can be perceived as their only “diagnostic” tool. Without the ability to order an MRI, they use special test clusters to determine the likelihood of a rotator cuff tear. Without access to x-rays in their clinics, they use the Ottawa Ankle Rules and Canadian C-Spine Rules to rule out fractures. These tests, particularly the latter two, are effective tools for knowing when to refer a patient for medical treatment outside our scope of practice. No manual therapy technique will fix a dens fracture. But what about the other tests? Do they guide clinical decision making? Are they the best use of our time?

Which Tests Should Be Used In The Clinic?

Image: By SuperOhMo

Special tests may be used under the assumption they are the best tool available. Better to use a test with some support than nothing at all, right? Accuracy matters, and what clinicians tell patients matters. If clinicians take a patient through a series of clinical tests — many eliciting a pain response which leads to an assumption they “found” something — the patient will want to know what the tests mean. What is the prognosis? The clinician runs the risk of emphasizing a pathoanatomic reason for their pain and potential catastrophizing. Nothing says you need surgery like a suspected tendon tear.

If a test lack diagnostic accuracy and utility, the risk often outweighs the reward. Take a suspected knee meniscus tear as an example. Studies show special tests are often unreliable. Furthermore, most positive tests don’t tell clinicians what the best course of action is. Even if muscle or tendon damage is suspected, the course of care may not differ.

Do ‘Positive’ Findings During an Exam Matter?

Previously, I wrote about the dangers of relying on MRI results. Let’s take a look at the outcomes of interventions targeting positive MRI findings.

One of the most well-known surgery placebo studies in history looked specifically at meniscus tears. The paper “Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear” was published in the New England Journal of Medicine in 2013. The study randomly allocated 146 patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear to either meniscectomy surgery or sham surgery. All interactions pre and post-surgery were identical, including rehabilitation and prescribed medicine. At the 12-month mark, there were no statistical or clinical differences between the groups. Similar results were noted in a study assessing rotator cuff tear treatment.

These studies, along with follow-up studies assessing surgical intervention effectiveness for tears and chronic pain, call into question what interventions are needed for tissue tears.

Another consideration is the similarities of shoulder MRI findings to spine MRI findings. A review article in the International Journal of Sports Physical Therapy reported on the epidemiological data of rotator cuff tears. Here is a summary of the findings:

Sher et al observed tears in 34% of asymptomatic individuals, with 15% of those classified as full-thickness tears and 20% as partial thickness

Tempelhof et al reported an overall prevalence of full-thickness rotator cuff tears in asymptomatic individuals to be 23%, with 51% of individuals over 80 years of age displaying tears.

Yamaguchi et al reported that if patients had a symptomatic rotator cuff tear, there was a 35% chance of a cuff tear on the opposite side which increased to 50% if the patient was 66 years of age or older.

While not as high as the asymptomatic rates of spine MRIs, the studies demonstrate many people have asymptomatic tears. Furthermore, conservative treatment for shoulder rotator cuff tears is effective. All this information finally brings us to the question: if a patient has a positive rotator cuff special test, will a clinician treat them differently?

A case can be made for immediate surgical referral following traumatic rotator cuff tears, especially in young athletes. Large rotator cuff tears, greater than 1–2 cm of separation, also may benefit more from surgery, provided the surgery is conducted within a few months of the tear as chronic adaptations can worsen outcomes. Do all these findings require a special test? Many of these qualifiers are determined with a thorough patient history. If a patient lacks a traumatic episode, would diagnosing a rotator cuff tear in the clinic be valuable? Or would the therapist perhaps create the same cascading maladaptive thoughts associated with reading a lumbar MRI report?

What is the art of the patient examination?

Image: By Ridofranz

Circling back to the beginning of this article, what tests matter. Here is a summary from the review article “The lost art of the clinical examination: an overemphasis on clinical special tests:”

Others have recently denigrated the value of peripheral-based clinical special tests such as those associated with meniscal testing of the knee,13 shoulder labrum testing,14 and hip labrum testing,15 and textbooks are available that outline the diagnostic value of many special clinical tests used commonly in practice.11,16 The common finding among each of the works is the incapacity of the clinical special tests to be used as stand alone findings for significantly altering one’s clinical decision making. Adding insult to injury is the potential bias that each test presents by virtue of ‘when’ it is used during the examination… Our discussion of the overemphasis on special tests is likely old news to many practicing manual therapists. Yet to some, this finding may be a refreshing or unacceptable surprise. It is my hope that the clinical examination makes a comeback and receives the emphasis it deserves

When performing a clinical examination, the tests clinicians choose to apply matters. Every interaction in the clinic can impact the treatment. Tests are interventions and interventions are tests. The author of the last referenced paper was none other than Chad Cook, the lead author of the blue special tests book every physical therapist reviews in PT School.

What then, does an appropriate and useful clinical examination looks like. Here are the most valuable components:

Establishing patient-driven goals

Shared decision making

Understanding how the patient’s complaints are affecting their life

Much of the evidence looking at injury prevention and predicting future pain is poor. Weakness, poor mobility, and imbalances are not predictors of future pain and dysfunction. A patient does not ‘normal’ gluteus medius strength to prevent future low back pain. Leg length discrepancies’, sacral torsions, and asymmetrical hip rotation do not increase the risk of pain or injury. Relaying this message to patients only induces nocebo and creates a dependency on the medical system. Instead, a clinician’s emphasis needs to be on building self-efficacy and promoting healthy lifestyle decisions.

When conducting an examination, clinicians will create more benefit for our patients by determining their goals, fears, lifestyle habits, understanding of pain, and previous education received regarding their presentation. This information will allow clinicians to appropriately educate the patient and provide coaching for achieving the patient-driven goals.

For goals with substantial physical demands, the examination should encompass current aerobic and anaerobic capacity, training history, nutritional and sleep habits, and activity level. Through motivational interviewing, clinicians can assess a patient’s current mindset and the amount of education and treatment that will be needed to influence current lifestyle habits and build a treatment plan for outside the clinic.

No two examinations should look the same. Everyone is unique. Presentations and goals may be similar, but a thorough evaluation will tease out subtle differences that allow a clinician to provide a personalized approach. That evaluation may include some tests and measures. Special tests by no means are comprehensive. Strength, mobility, and functional movement assessments can provide value. Don’t only focus on the negatives though (everything wrong with the patient). Recognize the positives patients bring to the table. Above all, the emphasis on what is ‘broken’ (e.g. special tests) doesn’t help with outcomes.

For the clinicians reading this, I encourage you to throw away the cookie-cutter evaluation approaches and home in on the individual sitting on the treatment table. Take a holistic approach instead of hunting for the ‘reason’ someone is in pain. Pain is more complex than a single area of tissue damage.

For the patients, don’t settle for lazy evaluation and treatment. The goals should be directed by you. A clinician’s job is to help you achieve your goals and return to the life you want to live.