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Re: Chest Pain
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Re: Chest Pain - February 21, 2006 2:26:00 PM
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Dr.Wagner
Posts: 1237
Joined: January 24, 2003
From: Indianapolis
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PROS: MRA is usually available at mid size institutions. Nice computerized picture...can be enhanced. Non invasive.
PROS: Angiogram, highly specialized radiologist has fantastic specificity. Able to treat JUST as it diagnoses. Low invasiveness. Fantastic picture. One stop shop.
Cons: MRA is expensive. Need the right equipment for the best computer image. Not everyone can have an MRA (metal implants), not usually able to treat, only able to diagnose
Cons: Angiogram, requires a specialized radiologist. More invasive than MRA. Catheter itself may induce ischemia. Mechanical complications.
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Chest Pain - February 26, 2006 12:17:00 AM
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Sean_Collins
Posts: 74
Joined: October 20, 2005
From: Massachusetts
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Having read through this case - is it safe to say we have concluded:
1. VAT is for patients you are screening to rule out but do not know that there is a vascular problem in their neck? If this is the case - the false positives are not big deal, but if there are high false negatives - that would be a big deal!
Connie - your comment "the reliability and high false-positive rates are of concern from a research standpoint" is interesting. One area that I find it easiest to teach students about the close ties between research and clinical care is this area of measurement sensitivity and specificity. While research develops the values, they help the clinician immensely, by providing you with (if for example the VAT has high false positives and low false negatives) the assurance that a negative test has just ruled out with a high degree of probability the liklihood of a problem, however a positive test, while alerting to potential problems and should lead to a referral to the patients physician, might not be associated with any pathology.
This boolean logic drives what is and is not a good screen, and why Dr. Wagner is saying what he is saying. If you know there is a pathology, there is no need to do this screen. The screen only provides dichotomous information - Positive and Negative. Positive = might be a pathology; Negative = not a pathology (again assuming what was said above about the positive predictive and negative predictive power of the VAT are accurate.
In cardiopulmonary PT I teach about the sign - "Drop is Systolic BP of >10 mm Hg" during incremental exercise (increasing intensity). This sign has very low false positives - if it happens they are most (high probability) having pump dysfunction/failure; however a lack of a drop in systolic BP does not rule out the possibility that they are having pump dysfunction or failure, hence a low false negative sign. Of course if you keep exercising the patient and ignore the other signs that they are going into failure eventually their BP will drop - since its a certain result of heart failure (which is why there is such a low false positive).
The other tests are great of course. And if you have access to results of them being done then the VAT is not needed - since they are actual tests of the pathological process - altered anatomy/physiology as opposed to a sign that might be associated with teh altered anatomy/physiology. But if you dont have access, and do not have any idea of what this persons neck is like, and you want to do something to the neck that would make you concerned if there were a problem, then doing a VAT, obtaining a negative result, provides you with information regarding the very low likelihood of vascular pathology in the neck (or at least severe). So, I would not say it is only done because it is taught, or that it does not give any information.
NOW - all that said, if it has high false positives and high false negatives as a test, then i agree - why are people still using it?
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: Chest Pain - February 26, 2006 1:57:00 AM
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SJBird55
Posts: 2293
Joined: May 10, 2004
From: Michigan
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They are using it because they were taught it in school. The clinical instructor/PT person put fear in the student - fear of potential death. All the information wasn't technically, by initially providing the sensitivity and specificity of the test, so a true rationalization for using the test never occurred. Even in light of the data, clinicians have a difficult time altering their practice patterns, so the VAT continues to be performed.
Also... the fear of litigation - the fear that if an unanticipated occurrence did occur and documentation was reviewed, the probability that some attorney would question the professional's decision-making process? One could find professionals on either side of this issue regarding use the VAT or not use the VAT.
I haven't used it in years because the test doesn't definitively indicate anything with a strong conviction. It would certainly be helpful if most of the special tests that you find in teh orthopaedic texts we were taught definitely did have either or both a high specificity or a high sensitivity.
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Re: Chest Pain - February 27, 2006 2:16:00 AM
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Sean_Collins
Posts: 74
Joined: October 20, 2005
From: Massachusetts
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SJ - you seem very rational. Why then can you extend assertions that are clearly your beliefs as knowledge? You do not know what happens in all classrooms across the country when teahing VAT, nor do you know what people rationalize in deciding to do the test or not. All you know is what you have seen which can be a very limited mechanism for making assertations, especially when you extend them as things that are known as opposed to your beliefs.
Now, I believe you may be wrong. If fear of potential death keeps therapists doing evaluation techniques, then why do studies (such as Frese et al) show that most therapists do not take vital signs such as blood pressure, even in post MI patients?
One thing you did not address. Is it in fact true that there are high false positives and low false negatives for the VAT? Does anyone have the numbers on this - or should I do a search?
Thanks for the discussion -
Sean
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: Chest Pain - February 27, 2006 3:21:00 AM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
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Just in case anyone else cared, this original case actually had pain from cysts in her ovaries, pain was reproduced with abdomen deep palpation on opposite side, basic premise, if it doesn't follow an neuromusculoskeletal problem, refer back
Ben
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Re: Chest Pain - February 27, 2006 3:24:00 AM
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jma
Posts: 2312
Joined: August 24, 2000
From: NY
Status: offline
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This particular review is interesting.
"Phys Ther. 2005 Jun;85(6):589-99.
Evidence in practice. How does evidence on the diagnostic accuracy of the vertebral artery test influence teaching of the test in a professional physical therapist education program?
Richter RR, Reinking MF.
Department of Physical Therapy, Edward and Margaret Doisy School of Allied Health Professions, Saint Louis University, St. Louis, MO, USA.
PMID: 15921479 [PubMed - indexed for MEDLINE]"
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