diagnostic accuracy of the active-computerized dynamic
TRANSCRIPT
Background
Analysis
Purpose
Methods
Diagnostic Accuracy of the Active-Computerized Dynamic Visual Acuity Test: A Systematic Review and Meta-Analysis
Austin Bloomberg, SPT, Jason Hube, SPT, Matthew McCarty, SPT, Rebecka Schafer, SPT, Adam Goode, PT, DPT, PhD, Richard Clendaniel, PT, PhD
Doctor of Physical Therapy Division, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
Conclusions
References
• The vestibular ocular reflex (VOR) maintains gaze stability during head movements by initiating an equal but opposite movement of the eyes.
• Vestibular dysfunction affects about 35% of the population over 40 years of age.
• Vestibular hypofunction can be unilateral or bilateral and cause impairments to the functioning of the VOR leading to dizziness, gait unsteadiness, and oscillopsia.
• Dizziness is estimated to affect 20% to 30% of the general population
• It is estimated that the medical costs of physician visits for dizziness or vertigo is over four billion dollars.
• Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in the design of the study
• 2-stage process of title and abstract screening/eligibility and inclusion of full text.
• Quality assessment conducted by duplicate reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS 1)
• There is heterogeneity in how the cDVA is performed. • The cDVA has good pooled sensitivity, specificity, and
negative likelihood ratio• Based on these studies, the cDVA is better used as a test to
rule out vestibular hypofunction than as a test to rule it in.
1 Agrawal,Yuri,etal."DisordersofbalanceandvestibularfunctioninUSadults:datafromtheNationalHealthandNutritionExaminationSurvey,2001-2004."ArchivesofInternalMedicine 169.10(2009):938-944.2 Goebel,JoelA.,etal."Gazestabilizationtest:anewclinicaltestofunilateralvestibulardysfunction."Otology&neurotology 28.1(2007):68-73.3 Agrup,Charlotte,MichaelGleeson,andPeterRudge."Theinnerearandtheneurologist."JournalofNeurology,Neurosurgery&Psychiatry 78.2(2007):114-122.4 Hagr,Abdulrahman."Comorbidpsychiatricconditionsofbenignparoxysmalpositionalvertigo."Internationaljournalofhealthsciences 3.1(2009):23.5 SaberTehrani,AliS.,etal."RisingannualcostsofdizzinesspresentationstoUSemergencydepartments."AcademicEmergencyMedicine 20.7(2013):689-696.6 Herdman,SusanJ.,etal."Computerizeddynamicvisualacuitytestintheassessmentofvestibulardeficits."Otology&Neurotology 19.6(1998):790-796.7 Rine,RoseMarie,etal."Newportabletooltoscreenvestibularandvisualfunction—NationalInstitutesofHealthToolboxinitiative."Journalofrehabilitationresearchanddevelopment 49.2(2012):209.
• Systematically examine the literature regarding the diagnostic accuracy of the computerized dynamic visual acuity test to assess hypofunction of the horizontal canals.
Author SN SP + LR - LR PPV NPV
Goebel et al.(2006)
0.714 0.857 5.00 0.333 0.833 0.750
Herdman et al. (1998)
0.945 0.952 19.855 0.057 0.963 0.930
Rine et al. (2012)
0.733 0.692 2.383 0.385 0.155 0.971
Pooled Results
0.869 0.745 5.925 0.204 0.533 0.944
95% ConfidenceInterval
.788 - . 933 .686-.798 .732 - 47.936 .065 - .641 .446- .618 .90 - .97
Records identified through database searching
(n = 599)
Additional records identified through other sources
(n = 5)
Records after duplicates removed(n = 297)
Records screened(n = 297)
Full-text articles assessed for eligibility
(n = 28)
Studies included in qualitative synthesis
(n = 3)
Studies included in quantitative synthesis
(meta-analysis)(n = 3)
Records excluded(n = 269)
Full-text articles excluded, with reasons
(n = 25)
Author Patients Controls ReferenceTest cDVAParameters
QUADASScore
Goebel etal.(2006)
14patientswithUVHseenbyprincipalinvestigators
14 controlsubjectsfromuniversitycommunity
Calorictesting Headvelocity:120-140degrees/secondOptotype:oritentationofletterE
10
Herdman etal.(1998)
29 patientswithUVH,26patientswithBVH
42controlsubjects
Calorictestingorrotarychairandpositiveheadthrusttest
Headvelocity:120-180degrees/secondOptotype:orientationofletterE
10
Rine et al.(2012)
15patientswithvestibularpathology
195controlsubjects
Caloric testingorrotarychair
Headvelocity:180degrees/secondOptotype:ETDRS
7
• Studies were statistically pooled where ≥ 2 studies examined the same index test and diagnosis with the same reference standard.
• Der-Simionian and Laid random effects models, which incorporate both between and within study heterogeneity, were used to produce summary estimates of sensitivity (SN), specificity (SP), positive likelihood ratio (LR+), negative likelihood ratio (LR-), and diagnostic odds ratios (DOR).
ResultsMethodsCon’t
Positive LR0.01 100.01
Herdman et al 19.85 (5.13 - 76.89)Goebel et al 5.00 (1.33 - 18.81)Rine et al 2.38 (1.65 - 3.45)
Positive LR (95% CI)
Random Effects ModelPooled Positive LR = 5.92 (0.73 to 47.94)Cochran-Q = 25.93; df = 2 (p = 0.0000)Inconsistency (I-square) = 92.3 %Tau-squared = 3.1029
Negative LR0.01 100.01
Herdman et al 0.06 (0.02 - 0.17)Goebel et al 0.33 (0.14 - 0.78)Rine et al 0.39 (0.17 - 0.90)
Negative LR (95% CI
Random Effects ModelPooled Negative LR = 0.20 (0.07 to 0.64)Cochran-Q = 9.14; df = 2 (p = 0.0104)Inconsistency (I-square) = 78.1 %Tau-squared = 0.7954
Positive LR0.01 100.01
Herdman et al 19.85 (5.13 - 76.89)Goebel et al 5.00 (1.33 - 18.81)Rine et al 2.38 (1.65 - 3.45)
Positive LR (95% CI)
Random Effects ModelPooled Positive LR = 5.92 (0.73 to 47.94)Cochran-Q = 25.93; df = 2 (p = 0.0000)Inconsistency (I-square) = 92.3 %Tau-squared = 3.1029
Negative LR0.01 100.01
Herdman et al 0.06 (0.02 - 0.17)Goebel et al 0.33 (0.14 - 0.78)Rine et al 0.39 (0.17 - 0.90)
Negative LR (95% CI
Random Effects ModelPooled Negative LR = 0.20 (0.07 to 0.64)Cochran-Q = 9.14; df = 2 (p = 0.0104)Inconsistency (I-square) = 78.1 %Tau-squared = 0.7954