diagnostic accuracy of the active-computerized dynamic

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


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


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


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

diagnostic accuracy of the active-computerized dynamic

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