Accuracy Thessaly Test 5c6rc

Roger Zhao, MS, DPTc Spring Symposium 2012 PT 910

•  Transmit weight bearing forces •  t stability and protection •  Increases congruity and area •  Shock absorption •  Nutrition, and lubrication for the articular cartilage •  Proprioception •  *Limitation of extremes of flexion and extension •  * Load sharing, stress distribution http://www.mendmeshop.com

(Chivers 2009, Greis 2002)

•  Twisting injury or hyper-flexion •  Rotation + Compression •  Forces: +50-70% more load when in extension and +85% with 90˚ of knee flexion

(Chivers 2009; Greis 2002)

•  Tearing sensation •  Delayed effusion •  History of catching or locking •  Pain with forced hyperextension or maximum flexion •  Pain or audible click with special tests •  t Line Tenderness (JLT)

(Lorenz 2011)

•  2nd most common injury to the knee •  Incidence: 60-70 per 100,000 individuals/year (Logerstedt 2010)

(Poulsen 2011)

•  10-20% of all orthopedic injuries •  50% of knee surgeries (Harrison 2009)

(Logerstedt 2010)

•  Injured knee playing Volleyball

•  Symptoms: • Knee “stuck or locked” • Pain weight bearing •  Immediately tested: • (-) McMurray • (-) Apley • (-) t Line Tenderness (JLT)

www.creativerehab.com

•  Orthopod: Performed tests • (-) McMurray, Apley, JLT

• (+) Thessaly (Arthroscopy)

•  Magnetic Resonance Imaging (MRI): • Complex tear •  Oblique + flap •  ~50% lateral mensicus

What are the current most common meniscus special tests?

Meta-analysis of Current Tests -  Low specificity, sensitivity -  Clinical examination alone limited (Konan 2009) •  Methodological Quality: Poor to Fair (Meserve 2008) •  Large conflicting differences in diagnostic accuracy (Chivers 2009)

•  Varying criteria for diagnosing meniscus tear. (Chivers 2009)

•  History alone is insufficient as a diagnostic tool for meniscus tears (Hegedus 2007)

• Symptoms are often vague and non-specific

•  Current literature shows that knee meniscal tests are not diagnostic and there is heterogeneity between similar studies. (Hegedus 2007)

•  No current accurate tests to assess and diagnose meniscal tears •  Most current clinicians and recent studies base the Thessaly test accuracy off of only one study, Karachalios 2005, by the creator of the test. •  No current systematic reviews or meta-analysis combining all current original studies on Thessaly test

•  Arthroscopy: 90-95% accuracy Gold Standard (Konan 2009) 20% tears found on arthroscopy not diagnosed on original MRI (De Smet 2008)

•  MRI: 59-97% accuracy

(Lorenz 2011, Jee 2003)

•  No difference between MRI and exam (Korcabey 2004) •  Exam by clinician has shown greater accuracy (Lorenz 2011)

•  High cost and incidence of false positives (Konan 2009)

•  Dynamic reproduction of load transmission in the knee t performed at 5⁰ and 20⁰ of flexion. •  (+) Positive: Medial or lateral t-line discomfort and may have a sense of locking or catching (Karachalios 2005)

•  Examiner s patient by holding his or her outstretched hands while the patient stands flat footed on the floor. The patient then rotates his or her knee and body, internally and externally 3X, keeping the same amount of flexion.

(Karachalios 2005)

Rotation and Compression with Flexion

Re-created by Thessaly Test

Ellicit Symptoms

High Diagnostic Accuracy

•  Frequently treat patients with vague knee pain and variety of symptoms that could indicate meniscal pathology…. •  Accurate diagnosis of underlying injury •  Rehabilitation and Plan of Care •  Decrease cost and time saved without need for imaging (conservative treatment/direct access) •  Referral to MD for further imaging

1. Evaluate the evidence of a relatively NEW, but well accepted special test to rule in the diagnosis of meniscal tears in the knee. 2. Provide a reliable, clinical “first-line” screening tool that is accurate and easily performed.

Background: Diagnostic

Is the Thessaly Test a specific and sensitive examination tool for confirming the diagnosis of a meniscus tear?

•  Is the Thessaly test more accurate at 5⁰ or 20⁰? •  Detecting lateral or medial meniscus tears?

Null H0:

For confirming the diagnosis of a meniscal tear the Thessaly test is not a a) sensitive b) specific or c) both sensitive and specific examination test.

Alternative Ha:

For confirming the diagnosis of a meniscal tear the Thessaly test is a a) sensitive b) specific or c) both sensitive and specific examination test.

•  Limited to 1-5 studies •  High sensitivity and specificity •  Useful examination tool to be used in the clinic

•  PubMed, PEDro, CINAHL, Cochrane Database, Google Scholar •  Checked reference lists and related articles

Search : ü  Thessaly ü  Test ü  Diagnos* ü  Accuracy ü  Menisc* ü  Knee

•  Inclusion Criteria: •  English •  2005 to current (creation of test date) •  Adults with diagnosis of meniscal tear based off history and MOI •  Original validation study of Thessaly test

•  Exclusion Criteria: • Other Knee Injuries Articles Excluded: 1 Non-English, 1 with concurrent ACL tears, 6 non original study (meta-analysis in larger meniscus test study or clinical commentary)

• Sensitivity, Specificity, Diagnostic Accuracy, Likelihood ratios, Receiver Operating Characteristic (ROC) Curve •  At 5 degrees (Karachalios and Konan studies)

• At 20 degrees (all 3 studies)

(Hing 2009)

*Secondary reviewer confirmed that the studies met the inclusion criteria

Study

Reference Standard

Outcomes

#Tests (n=subjects)

Karachalios Arthroscopy et, al. 2005 and MRI

-Thessaly 5⁰ & 20⁰ -Medial vs Lateral tear -McMurray, Apley, JLT

Tested: 1640 (n=410)

Arthroscopy Harrison et, al. 2009

-Thessaly at 20⁰

Tested: 116 (n=116)

-Thessaly 5⁰ & 20⁰ -Medial vs. Lateral tear -McMurray, Apley, JLT

Tested: 320 (n=109)

Konan et, al. 2009

Arthroscopy and MRI

•  All papers high methodological quality:

1b

“Independent blind comparison of an appropriate spectrum of consecutive patients, all who have undergone the diagnostic test and the reference standard.” - Sackett et, al. Diagnostic Criteria

Data  

True  +  

True  -­‐  

 

Thessaly  Test  +  

413.00  

93.00  

506.00  

Thessaly  Test  -­‐  

166.00  

1,404.00  

1,570.00  

 

579.00  

1,497.00  

2,076.00  

Study

Sensitivity

Specificity

Diagnostic Accuracy

Karachalios

80%

95%

91%

Harrison

90%

98%

93%

Konan

44%

85%

65%

Meta-Analysis

71%

94%

88%

71% of individuals with a meniscus tear will have a (+)Positive Test 94% of individuals without a meniscus tear will have a (-)Negative test

Study

PPV(%)

NPV(%)

LR+

LR-

Karachalios

80%

94%

15.07

0.22

Harrison

98%

86%

39.72

0.10

Konan

74%

62%

3.02

0.66

MetaAnalysis

82%

89%

11.48

0.31

82% of individuals with a (+)Positive Test will have a meniscus tear 89% of individuals with a (-)Negative test will not have a meniscus tear

Sensitivity Study

5⁰

Specificity

20⁰

5⁰

LR+

20⁰

LR-

5⁰

20⁰

5⁰

20⁰

Karachalios

69%

90%

93%

96%

10.15

24.09

0.33

0.11

Harrison

NA

86%

NA

98%

NA

39.72

NA

0.86

Konan

35%

53%

83%

88%

2.08

4.31

0.78

0.54

MetaAnalysis

59%

78%

92%

95%

7.38

16.73

0.43

0.23

Thessaly at 20⁰ significantly more accurate at sensitivity, specificity, and likelihood ratios.

Sensitivity, specificity, and likelihood ratios (LR) of Thessaly test for detecting medial vs. lateral meniscus tears.   Study       MetaAnalysis (Karachalios + Konan)  

Sensitivity(%)   Specificity (%)   Medial   Lateral  

70  

65  

LR+  

LR-  

Medial  

Lateral  

Medial  

Lateral  

Medial  

Lateral  

94  

93  

11.98  

9.75  

0.32  

0.37  

*Confidence intervals incalculable due to absence of raw data.  

ROC Curve for Thessaly Test

Sensitivity (True Positive Rate)

1 0.9

20⁰

0.8 0.7

5⁰

0.6 0.5 0.4 0.3 0.2 0.1 0 0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

1 - Specificity (False Positive Rate)

0.8

0.9

1

Test

Sensitivity

Specificity

McMurray*

70%

71%

Apley*

60%

70%

JLT*

63%

77%

Thessaly at 20⁰

78%

95%

*Meta-analysis by Hegedus et, al 2007; JOSPT

• 12 patients excluded in study by Konan et, al., could not complete test due to pain or were not confident. • Karachalios et, al. reported at 20 degrees, 3.3% of patients in the symptomatic group had an exacerbation of knee symptoms requiring analgesics. One patient had the knee lock requiring manipulation under anesthesia.

•  No additional cost to perform this test to the clinic •  Simple physical examination that can be quickly performed in a few seconds. •  Reduce the need for magnetic resonance imaging (MRI) for diagnostics. Average Cost/Year

Thessaly Test

MRI

Operating

$0

$165

Procedure

NA

$2000

Machine

NA

$2,000,000

Maintenance (annually)

$0

$800,000

(Pogetti 2008)

•  REJECT Null H0: For confirming the diagnosis •  High Sensitivity and Specificity of a meniscal tear the Thessaly test is not a •  High Accuracy and Validity of studies a) sensitive b) specific or c) both sensitive •  High LR+, LRand specific examination test. •  Area under ROC curve: Excellent •  ACCEPT Alternate Ha: For confirming the diagnosis of a meniscal tear the Thessaly test is a a) sensitive b) specific or c) both sensitive and specific examination test.

•  Small number of studies (n=3) •  >75% weighting from paper by Karachalios (1640/2076 tests) •  Strict Exclusion Criteria: • Early clinical or radiographic signs of OA • Excluding many differential diagnosis or pathologies likely to result in a positive Thessaly test and decrease accuracy. • No acute patients, only 4-6 weeks post injury •  Difficult measure knee ROM 5⁰ vs 20⁰ •  Unclear Instructions • Rotation from spine versus from hip and knee

•  Recommendation for future studies: • Include with other tests and symptoms to find combination with best diagnostic accuracy • Create a less aggressive test to decrease harm • Larger scale studies in general population without strict knee exclusion criteria • Long-term follow up cost comparison

•  The Thessaly test is an accurate and valuable diagnostic tool in assessing meniscal tears in patients. •  Easily performed examination maneuver that all physical therapists can learn quickly. •  May be too aggressive for acute or irritable patients • 5⁰ - no harm reported • 20⁰ - harm, but more accurate •  Use subjective history, symptoms, current function, and clinical judgment before deciding to use test due to reported harm.

•  Thessaly test is an accurate and valid valuable diagnostic tool in assessing meniscal tears. •  High diagnostic accuracy in of sensitivity and specificity. •  20⁰ more accurate than at 5⁰ •  Physical therapists should incorporate the Thessaly test into their physical examination when a meniscus tear is suspected.

•  •  •  •  •  •  •  • 

Jeanette Lee, PT, PhD Deepak Kumar, PT, PhD, OCS Diane Allen, PT, PhD Thomas Tsai, DPTc Tin Pham, DPTc Bryan Ausink, DPTc Dan Lorenz, PT, OCS, CSCS UCSF/SFSU Class of 2012

•  Primary • 

• 

• 

1. Karachalios T, Hantes M, Zibis AH, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. The Journal of bone and t surgery. American volume. 2005;87(5):955-62. Available at: http:// www.ncbi.nlm.nih.gov/pubmed/15866956. Accessed September 2, 2011. 2. Harrison BK, Abell BE, Gibson TW. The Thessaly test for detection of meniscal tears: validation of a new physical examination technique for primary care medicine. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine. 2009;19(1):9-12. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19124977. 3. Konan S, Rayan F, Haddad FS. Do physical diagnostic tests accurately detect meniscal tears? Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2009;17(7):806-11. Available at: http://www.ncbi.nlm.nih.gov/ pubmed/19399477. Accessed September 2, 2011.

• 

•  •  •  • 

• 

• 

• 

• 

Meserve BB, Cleland J a, Boucher TR. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clinical rehabilitation. 2008;22(2):143-61. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18212035. Accessed September 2, 2011. Greis PE, Bardana DD, Holmstrom MC, Burks RT. Meniscal injury: I. Basic science and evaluation. The Journal of the American Academy of Orthopaedic Surgeons. 2002;10(3):168-76. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12041938. Majewski M, Susanne H, Klaus S. Epidemiology of athletic knee injuries: A 10-year study. The Knee. 2006;13(3):184-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16603363. Accessed July 8, 2011. Poulsen MR, Johnson DL. Meniscal injuries in the young, athletically active patient. The Physician and sportsmedicine. 2011;39(1): 123-30. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21378495. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clinical orthopaedics and related research. 2007;455(455):123-33. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17279041. Accessed August 28, 2011. Hegedus EJ. Physical Examination Tests for Assessing a Torn Meniscus in the Knee: A Systematic Review With Meta-analysis. Journal of Orthopaedic and Sports Physical Therapy. 2007;37(9):541-550. Available at: http://www.jospt.org/issues/id.1307/ article_detail.asp. Accessed August 18, 2011. Hing W, White S, Reid D. Validity of the McMurrays Test and Modified Versions of the Test: A Systematic Literature Review. The Journal of manual & 2009;17(1). Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704345/. Accessed January 3, 2012. Chivers MD, Howitt SD. Anatomy and physical examination of the knee menisci: a narrative review of the orthopedic literature. The Journal of the Canadian Chiropractic Association. 2009;53(4):319-33. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2796951&tool=pmcentrez&rendertype=abstract. Noyes FR, Heckmann TP, Barber-Westin SD. Meniscus repair and transplantation: a comprehensive update. The Journal of orthopaedic and sports physical therapy. 2012;42(3):274-90. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21891878. Accessed March 10, 2012.

• 

• 

• 

•  • 

•  • 

•  • 

Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2004;20(7): 696-700. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15346110. Accessed March 30, 2012. Miller GK. A prospective study comparing the accuracy of the clinical diagnosis of meniscus tear with magnetic resonance imaging and its effect on clinical outcome. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 1996;12(4):406-13. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8863997. Karachalios T, Hantes M, Zintzaras E. Do physical diagnostic tests accurately detect meniscal tears? Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2011;19(7):1226-7; author reply 1228. Available at: http:// www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3116132&tool=pmcentrez&rendertype=abstract. Accessed December 13, 2011. Jee W-H, McCauley TR, Kim J-M, et al. Meniscal tear configurations: categorization with MR imaging. AJR. American journal of roentgenology. 2003;180(1):93-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12490485. Mirzatolooei F, Yekta Z, Bayazidchi M, Ershadi S, Afshar A. Validation of the Thessaly test for detecting meniscal tears in anterior cruciate deficient knees. The Knee. 2010;17(3):221-3. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19751979. Accessed January 3, 2012. Jewell D. Guide to evidence-based physical therapy practice. Jones & Bartlett Learning; 2008. Yelland M. Review: clinical examination is often as accurate as magnetic resonance imaging for diagnosing meniscus tears. Evidence-based medicine. 2007;12(5):151. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17909242. Accessed January 3, 2012. Corbet D. The Thessaly test. Australian family physician. 2010;39(4):185; author reply 185. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20391645. Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ. Knee pain and mobility impairments: meniscal and articular cartilage lesions. The Journal of orthopaedic and sports physical therapy. 2010;40(6):A1-A35. Available at: http://www.ncbi.nlm.nih.gov/ pubmed/20511698. Accessed August 28, 2011.