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概似率檢測肩部臨床理學檢查的定位能力:和軟組織超音波之間的相關性

Correlation between Special Physical Testing and Soft Tissue Ultrasound Findings in Evaluation of Shoulder Pain: Using Likehood Ratio

摘要


肩部疼痛是門診常見的問題。臨床上除了詳細病史的詢問之外,特殊的理學檢查推論病人可能的受傷位置目前仍有一席之地。回顧文獻可發現這些特殊理學檢查皆有很高的敏感性(sensitivity)或特異性(specificity);然而使用敏感性和特異性會受到疾病在族群中盛行率的影響,臨床參考價值受限。近年來,由於軟組織超音波的發展,對於肌腱或韌帶的細微傷害,都可以經由熟練的超音波操作技巧來達到正確的診斷。我們嘗試利用判斷檢測效力不受疾病簇群盛行率影響的概似率(likehood ratio)來檢測臨床常用評估肩部疼痛病人的特殊理學檢查,和軟組織超音波診斷的相關性。利用一年的時間來收集門診肩部疼痛的病人,進行詳細的病史詢問,包括性別、疼痛時間、疼痛位置、慣用手、疼痛評估、發作次數等,同時也進行臨床常用的特殊理學檢查,項目包括:思必得測試(Speed's test)、楊格森測試(Yergason’s test)、脊上肌測試(supraspinatus test)、後推測試(lift-off test)、尼耳撞擊測試(Neer impingement test)、霍金-肯尼撞擊測試(Hawkins-Kenney impingement test)、肱骨窩疼痛弧測試(glenohumeral painful arc)及肩峰鎖骨疼痛弧測試(acromioclavicular painful arc),最後利用肩部軟組織超音波來做病灶位置的診斷。結果發現這些常用的特殊理學檢查,對於平均年齡小於五十歲,除了尼耳撞擊測試及霍金-肯尼撞擊測試比較可以提供稍微具有意義的定位價值之外,其餘的特殊理學檢查並不能完全正確預測肩部病變的位置。

並列摘要


Shoulder pain is one of the most troublesome problems evaluated in our clinic. Numerous special physical tests have been developed to localize the origin of such pain. Soft tissue ultrasound, as an ancillary procedure, offers multiple advantages in evaluation of shoulder disorders: reliability, reproducibility, no radiation exposure, and low cost. Many authors have demonstrated that a strong correlation exists between ultrasound and magnetic resonance imaging in detecting shoulder pathology. In the current study, we determined the correlation between clinical presentation, findings on special physical tests, and findings from soft tissue ultrasonography in evaluation of shoulder pain. In order to eliminate the effect of disease prevalence, we applied the likelihood ratio combined with classified strength to evaluate the utility of special clinical tests in this patient population. Based on our results, only the Neer impingement test and the Hawkin-Kenny test increased the probability of detection of specific pathology. Our results did not reveal a strong relationship between these physical tests and ultrasonographic findings. We therefore suggest that patients with painful shoulders provide a detailed medical history and undergo a complete physical examination with ultrasonographic evaluation whenever possible.

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