Journal of Rehabilitation Medicine 51-7 | Page 18

Examination of the LHBT in the clinical setting (active compression test, anterior slide test, crank test, and Speed test). They found that the anterior slide test was statistically inferior to the 3 other tests; this can be appreciated when looking at their ROC curves. In our review, the curve for the anterior slide test resembles the 3 others. This inconsistency may be explained by the 3 studies included in our analysis that were pu- blished after their review (22, 32, 33). After reviewing the literature on the same research question, Walton et al. (13) performed a meta-analysis for the OSTs that have been evaluated at least 3 times in the literature. They provided estimates of the pooled LR+ for, among others, the active compression test (1.07), crank test (1.51), and Speed test (1.12). Our pooled LR+ estima- tes were 1.37 for the active compression test, 1.63 for the crank test, and 1.24 for the Speed test. Our values are slightly higher for the active compression test be- cause we included 3 studies that have been published after their work (26, 34, 35). Also, for the Speed test, they incorporated Holtby & Razmjou’s (31) as well as Bennet’s (36) studies in their analysis, which evaluates not only SLAP lesions, but any LHBT pathology. Strengths and weaknesses of the review Strengths. First, this systematic review was based on a rigorous search of the literature, which resulted in the inclusion of 30 articles. Secondly, a recommended appraisal tool was used to determine the risk of bias of included studies. In addition, the statistics presented in the included studies were double-checked by back- calculating 2×2 tables. Where we observed discrepancy between text and tables, or when values presented had arithmetical errors, the study was excluded. Finally, judicious use was made of meta-analysis’ tools: they were used when there was a minimum of 4 primary studies identified, as suggested by Sotiriadis et al. (20). Weaknesses. In our protocol design, we chose to exclude non-English or French studies, which may have led to selection bias. There was one study in Persian and one in Turkish languages that could have been eligible. We also recognize the possibility of information bias in the studies included. More specifically, as appraised with QUADAS-2 instrument, there is a possibility of misclassification due to spontaneous recovery or pro- gression of disease. Of the 30 included studies, 9 had an inadequate interval between index test and reference standard. In the same vein, misclassification in the primary studies due to inaccurate reference standard is another possibility to consider. It was “unclear” if the reference standard was likely to correctly classify the target condition in 8 of the 30 included studies. For instance, in order to assess the accuracy of OSTs in diag- nosing tendinopathy, HRUS was the reference standard in the only individual studies identified in the literature 487 (Fig. S4 1 ). Since the role of ultrasound in the diagnosis of biceps tendinopathy is still poorly understood, this area of uncertainty would need to be addressed before a more definitive conclusion can be drawn (2). Applicability of findings to the review question From the findings of this systematic review, HRUS had variable Sn and thus would be of lower interest as a screening test. Nevertheless, it can be considered a highly specific clinical tool for the diagnosis of disloca- tion, rupture and tendinopathy of the LHBT; it can be useful in ruling-in disease. Besides its effectiveness, HRUS has several advantages over other imaging modalities: there is no contraindication, it has high spatial resolution, dynamic assessment is possible as well as correlation of findings with patients’ symptoms. Furthermore, it has been shown to be cost-effective in specific situations, such as in the context of rotator cuff disease (37), and proved to be a reliable method for the measurement of the LHBT in healthy shoulders (38). With regard to OSTs, the evidence was more limited by the variability of the test accuracies across different study settings. A promising screening test (high Sn) for SLAP II–IV lesions is passive compression test, but the test has been evaluated only by its originators. No other test demonstrated high Sn. For ruling-in specific diagnosis, several tests seem to be valuable. The anterior slide test and biceps load II test had high Sp for diagno- sing SLAP I–IV lesions. Passive compression test and passive distraction test were highly specific for SLAP II–IV lesions, but only the test’s originators assessed their accuracies. For LHBT tendinopathy, Yergason’s manoeuvre proved highly specific. For proximal LHBT pathology except SLAP lesions, Heuter’s sign (one study) and Yergason’s manoeuvre had high Sp. Whereas no single clinical finding, either OSTs or HRUS, is accurate enough to confirm diagnosis and guide subsequent clinical decisions, it is appealing for clinicians and researchers to improve diagnostic accuracy by clustering clinical information. Further- more, combining clinical findings more closely reflects how clinicians make decision in practice. Combining the more sensitive clinical information with the more specific data could be quite helpful in improving our ability to diagnose LHBT pathology. Future research on the subject should focus on the development of such clusters. Conclusion In order to rule in LHBT pathology, HRUS has proven its diagnostic efficacy. However, evidence is lacking to recommend its use for the purpose of ruling out pa­ thology. There is insufficient evidence to recommend individual OSTs. In the future, rigour in diagnostic test J Rehabil Med 51, 2019