Updated Clinical Prediction Rule Resource (Again)

Clinical Prediction Rules (CPRs) are an interesting, complicated, and often misunderstood area of rehabilitation research.

To say all CPRs are not created equal would be a significant understatement.

In this most recent rehaul of the CPR Resource, I focused on not just adding to the quantity of rules included, but I spent the vast majority of time adding adequate information in order to allow the reader to discern the value of each specific rule.

From rules that have been invalidated under further investigation (Stabilization for low back pain) to those that have contradictory findings (Spinal manipulation for low back pain), enough information is available to allow the reader to make the most logical decision based on the evidence available.

In addition to the added thoroughness of the information provided, I have also added several rules that were left off the original list. See below for the additional rules provided…

Diagnostic:

Ankylosing Spondylitis (Berlin Criteria)
Ankylosing Spondylitis (IBP Criteria)

Interventional:

Exercise for Ankylosing Spondylitis
Manual Therapy and Exercise for Acute Lateral Ankle Sprain
Mobilization with Movement for Lateral Epicondyalgia

Finally, make the best clinical judgment of each rule based on your patient population, the stage of CPR development (derivation –> validation –> impact analysis –> implementation), and the literature supporting or refuting its value.

Welcome to the New Site!

This site was created to act as a resource to rehabilitation professionals, students, and patients alike…

Having spent nearly 5 years blogging, I have amassed a large amount of content and I have been able to see how my thought processes and beliefs have evolved over this timeframe. In doing so, I have recognized areas that needed to be updated in order to keep up with the current literature.

I have recently updated my Clinical Prediction Rule and Functional Testing resources to include updated information and to more accurately present the strength of each rule/test. This allows for the information to be more easily and accurately used in clinical practice.

I will be posting several articles detailing the improvement to my website and how each area has been updated.

Additionally, I am happy to announce that I am offering two Live courses and am in the process of scheduling for 2018-2019. If you are interested in hosting The Athlete’s Hip: Simplifying Examination, Treatment, and Return to Sport or Evaluation & Management of the Ice Hockey Athlete, feel free to Contact Me.

Thanks again for reading and for all the support you have given me and my content over the last 5+ years!

– John Snyder, PT, DPT, OCS, CSCS

Clinical Prediction Rule Update

I have taken the time to update the Clinical Predition Rule (CPR) Resource

Newly added CPRs include:

1. Anterior Shoulder Instability
2. Closed Cervical Fracture
3. Hip Osteoarthritis
4. Lumbar Spinal Stenosis
5. MCL Pathology
6. Vertebral Compression Fracture

Additionally, the Litaker et al. study was added to the diagnostic CPR for Rotator Cuff Pathology and the Tseng et al. study was added to the CPR for Cervical Manipulation.

This is an ongoing project and new CPRs will be added and current CPRs will be updated as new research becomes available. Also be sure to check out the Functional Testing / Return to Sport Resource as well!

Research Review: Validation of a Clinical Prediction Rule to Identify Patients with LBP Likely to Respond to Stabilization Exercises

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In the next instalment of my Research Review Series for MedBridge Education, we discuss a recent randomized controlled study investigating the validity of a clinical prediction rule for identifying patients with low back pain likely to respond favoribly to a spinal stabilization program.

Study Design

Randomized Controlled Trial.

Subjects

One hundred five patients diagnosed with LBP and referred to physical therapy at 1 of 5 outpatient clinics of Clalit Health Services in the Tel-Aviv metropolitan area, Israel, were recruited for this study. Of these 105 patients, 40 were positive on the Stabilization CPR and 65 were negative. The most evident difference between baseline differences of groups was age, with those in the stabilization group being significantly younger (one of the items of the CPR is < 40 years old).

Inclusion Criteria: 18 to 60 years of age, primary complaint of LBP with or without associated leg symptoms (pain, paresthesia), and had a minimum score of 24% on the Hebrew version of the modified Oswestry Disability Index (MODI) outcome measure.

Exclusion Criteria: History indicating any red flags (malignancy, infection, spine fracture, cauda equina syndrome), 2 or more signs suggesting lumbar nerve root compression (decreased deep tendon reflexes, myotomal weakness, decreased sensation in a dermatomal distribution, or a positive SLR, crossed SLR, or femoral nerve stretch test), history of corticosteroid use, osteoporosis, or rheumatoid arthritis. Additionally, patients were excluded if they were pregnant, received chiropractic or physical therapy care for LBP in the preceding 6 months, could not read or write in the Hebrew language, or had a pending legal proceeding associated with their LBP.

Methods

Outcome Measures: Hebrew version of the modified Oswestry Disability Index (MODI) and Numerical Pain Rating Scale (NPRS).

Randomization: Based on a computer-generated list of random numbers, which was then stratified by CPR status to ensure that adequate numbers of patients with a positive and a negative CPR status would be included in each intervention group.

Evaluation: A physical examination was conducted that included a neurological screen to rule out lumbar nerve root compression. Next, lumbar active motion was evaluated, during which the presence of aberrant movement, as defined by Hicks et al, was determined. Bilateral SLR range of motion, segmental mobility of the lumbar spine, and the prone instability testing was then also conducted. The patients’ status on the CPR (positive or negative) was established based on the findings of the physical examination.

Interventions: Patients in both the Lumbar Stabilization Exercise group (LSE Group) and Manual Therapy group (MT) received 11 treatments over an 8 week period and a 12 visit, which consisted of solely a re-evaluation. The LSE group was first educated on the function and common impairments related to the lumbar stabilizing musculature, they were then taught to perform an isolated contraction of the transversus abdominis and lumbar multifidus through an abdominal drawing-in maneuver (ADIM) in the quadruped, standing, and supine positions. Once the patient could successfully perform these actions, the demands on the musculature were increased by the addition of various upper and lower extremity movements. Finally, during the seventh session, functional movements were added to their program. Those patients randomized to the MT group received several thrust and non-thrust mobilization techniques to their lumbar spine in addition to manual stretching of several hip and thigh muscle groups. Each treatment session included up to three manual techniques (one of which had to be a thrust technique). With regards to exercise, those in the MT group performed active range of motion and self-stretching exercises, but did not perform isolated spinal stabilization exercises. All variations and progressions of exercises and manual therapy techniques can be seen in the appendix of the research report.

Results

With regards to MODI, clinical significance could not be determined after 2-way interaction between treatment group and CPR status was calculated (p = 0.17). That being said, individuals who were positive on the CPR did demonstrate less disability at the end of the study compared to those who were negative (p = 0.02). Furthermore, amongst patients who were positive on the CPR, those who received LSE also demonstrated less disability following treatment compared to those who received MT. When the authors introduced a modified CPR, which consisted of positive prone instability test and presence aberrant movement, they did find a significant interaction with treatment for final MODI. Those positive on the modified CPR demonstrated superior outcomes compared to the group as a whole and also showed improved outcomes when receiving LSE compared to MT (p = 0.005).

Limitations

The most prevalent limitations include an inadequate sample size, which resulted in a limited overall power of the findings as well as the retrospective nature of some of the findings (i.e. modified CPR). Additionally, this study had a high drop-out rate for a study of its size with an overall drop-out rate of 22.8% (33% in the LSE group and 14% in the MT group). The lower dropout rate in the MT group could potentially be due to an attention affect due to the manual contact required for the interventions within this group compared to the LSE group. Additionally, while short-term results are important, understanding the long-term implications of either MT or LSE is of greater importance. This study only included an 8 week follow-up and it would be beneficial to see the long-term implications with a 6 or 12 month follow-up to gauge the overall effectiveness of the CPR and associated interventions. Finally, it should be noted that status on CPR was determined prior to group determination, which introduces an additional level of bias. Future studies should look at results with CPR determination post priori or following allocation to groups.

Clinical Implications

Manual therapy and spinal stabilization are two very common interventions utilized by physical therapists when treating low back pain. As manual therapy is common amongst clinicians and generally considered an effective treatment option, it provides an excellent reference value in the validation of the stabilization CPR. Unfortunately, the utility of the CPR as it was constructed could not be validated based on the findings of this study. Several factors could have played into this discrepancy including attention effect by those in the MT group, small sample size, and large dropout percentage. While the original CPR could not be validated, retrospectively an abbreviated CPR was identified and ‘validated’ based on the findings of the 2-way interaction between treatment group and modified CPR status. So, while this study seems like a knock to the current lumbar stabilization CPR, the study design and execution of the study cannot allow the CPR to be disregarded as all of the aforementioned limitations may have played a significant role in the study’s results. Additionally, the creation of an abridged CPR may have more value to clinicians long-term as it provided superior results and requires less factors to be evaluated by the clinician. However, the results must be taken with a grain of salt as a prospective evaluation of the modified CPR must be conducted in order to determine its utility. Clinical prediction rules and the effectiveness of spinal stabilization are polarizing issues within the physical therapy community and this study debatably provides support to the use of spinal stabilization and indicates that future research is needed to clear up the murkiness of the current stabilization CPR. When treating the lumbar spine, no treatment should be provided with every patient and Chad Cook, PT, PhD, FAAOMPT goes into great detail in his course, “Evidence-Based Treatment of the Lumbar Spine”, with regards to the use of spinal stabilization within the Treatment-Based Classification system.

Rabin A, Shashua A, Pizem K, Dickstein R, Dar G. A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(1): 6–18, B1–13. 

Research Review: Validation of a Clinical Prediction Rule to Identify Patients with LBP Likely to Respond to Stabilization Exercises

Untitled

Study Design

Randomized Controlled Trial.

Subjects

One hundred five patients diagnosed with LBP and referred to physical therapy at 1 of 5 outpatient clinics of Clalit Health Services in the Tel-Aviv metropolitan area, Israel, were recruited for this study. Of these 105 patients, 40 were positive on the Stabilization CPR and 65 were negative. The most evident difference between baseline differences of groups was age, with those in the stabilization group being significantly younger (one of the items of the CPR is < 40 years old).

Inclusion Criteria: 18 to 60 years of age, primary complaint of LBP with or without associated leg symptoms (pain, paresthesia), and had a minimum score of 24% on the Hebrew version of the modified Oswestry Disability Index (MODI) outcome measure.

Exclusion Criteria: History indicating any red flags (malignancy, infection, spine fracture, cauda equina syndrome), 2 or more signs suggesting lumbar nerve root compression (decreased deep tendon reflexes, myotomal weakness, decreased sensation in a dermatomal distribution, or a positive SLR, crossed SLR, or femoral nerve stretch test), history of corticosteroid use, osteoporosis, or rheumatoid arthritis. Additionally, patients were excluded if they were pregnant, received chiropractic or physical therapy care for LBP in the preceding 6 months, could not read or write in the Hebrew language, or had a pending legal proceeding associated with their LBP.

Methods

Outcome Measures: Hebrew version of the modified Oswestry Disability Index (MODI) and Numerical Pain Rating Scale (NPRS).

Randomization: Based on a computer-generated list of random numbers, which was then stratified by CPR status to ensure that adequate numbers of patients with a positive and a negative CPR status would be included in each intervention group.

Evaluation: A physical examination was conducted that included a neurological screen to rule out lumbar nerve root compression. Next, lumbar active motion was evaluated, during which the presence of aberrant movement, as defined by Hicks et al, was determined. Bilateral SLR range of motion, segmental mobility of the lumbar spine, and the prone instability testing was then also conducted. The patients’ status on the CPR (positive or negative) was established based on the findings of the physical examination.

Interventions: Patients in both the Lumbar Stabilization Exercise group (LSE) and Manual Therapy group (MT) received 11 treatments over an 8 week period and a 12 visit, which consisted of solely a re-evaluation. The SG group was first educated on the function and common impairments related to the lumbar stabilizing musculature, they were then taught to perform an isolated contraction of the transversus abdominis and lumbar multifidus through an abdominal drawing-in maneuver (ADIM) in the quadruped, standing, and supine positions. Once the patient could successfully perform these actions, the demands on the musculature were increased by the addition of various upper and lower extremity movements. Finally, during the seventh session, functional movements were added to their program. Those patients randomized to the MT group received several thrust and non-thrust mobilization techniques to their lumbar spine in addition to manual stretching of several hip and thigh muscle groups. Each treatment session included up to three manual techniques (one of which had to be a thrust technique). With regards to exercise, those in the MT group performed active range of motion and self stretching exercises, but did not perform any exercises that included significant activation of the trunk musculature. All variations and progressions of exercises and manual therapy techniques can be seen in the appendix of the research report.

Results

With regards to MODI, clinical significance could not be determined after 2-way interaction between treatment group and CPR status was calculated (p = 0.17). That being said, individuals who were positive on the CPR did demonstrate less disability at the end of the study compared to those who were negative (p = 0.02). Furthermore, amongst patients who were positive on the CPR, those who received LSE also demonstrated less disability following treatment compared to those who received MT. When the authors introduced a modified CPR, which consisted of positive prone instability test and presence aberrant movement, they did find a significant interaction with treatment for final MODI. Those positive on the modified CPR demonstrated superior outcomes compared to the group as a whole and also showed improved outcomes when receiving LSE compared to MT (p = 0.005).

Limitations

The most prevalent limitations include an inadequate sample size, which resulted in a limited overall power of the findings and the retrospective nature of some of the findings (i.e. modified CPR). Additionally, this study had a high drop-out rate for a study of its size with an overall drop-out rate of 22.8% (33% in the LSE group and 14% in the MT group). The lower dropout rate in the MT group could potentially be due to an attention affect due to the manual contact required for the interventions within this group compared to the LSE group. Finally, while short-term results are important, understanding the long-term implications of either MT or LSE. This study only included an 8 week follow-up and it would be beneficial to see the long-term implications with a 6 or 12 month follow-up to gauge the overall effectiveness of the CPR and associated interventions.

Clinical Implications

Manual therapy and spinal stabilization are two very common interventions utilized by physical therapists when treating low back pain. As manual therapy is common amongst clinicians and generally considered an effective treatment option, it provides an excellent reference value in the validation of the stabilization CPR. Unfortunately, the utility of the CPR as it was constructed could not be validated based on the findings of this study. Several factors could have played into this discrepancy including attention effect by those in the MT group, small sample size, and large drop-out percentage. While the original CPR could not be validated, retrospectively a abbreviated CPR was identified and ‘validated’ based on the findings of the 2-way interaction between treatment group and modified CPR status. So, while this study seems like a knock to the current lumbar stabilization CPR, the study design and execution of the study cannot allow the CPR to be disregarded as all of the aforementioned limitations may have played a significant role in the study’s results. Additionally, the creation of an abridged CPR may have more value to clinicians long-term as it provided impressive results and requires less factors to be evaluated by the clinician. However, the results must be taken with a grain of salt as a prospective evaluation of the modified CPR must be conducted in order to determine its utility. Clinical prediction rules and the effectiveness of spinal stabilization are polarizing issues within the physical therapy community and this study debatably provides support to the use of spinal stabilization and future direction needed to clear up the murkiness of the current stabilization CPR.

Rabin A, Shashua A, Pizem K, Dickstein R, Dar G. A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(1): 6–18, B1–13. 

Clinical Prediction Rule Resource

Clinical decision making is integral to becoming an effective clinician, regardless of profession. One tool that we, as physical therapists, have is the clinical prediction rule (CPR), which is the best combination of medical signs, symptoms, and/or other findings in predicting the probability of a specific disease or outcome. There have been many CPRs developed over the years (some better than others), but I thought it was necessary to provide these CPRs with their accompanying statistical significance to my readers. These CPRs may help in determining what physical examination tests to choose and/or what interventions to utilize based on your patient’s clinical presentation.

If you are ever curious as to what patients tend to respond favorably to spinal manipulation or if you cannot quite remember what symptoms tend to coincide with carpal tunnel syndrome, you can find the answers in the new ‘Clinical Prediction Rules‘ section. In the top right corner of this webpage, you can find ‘Clinical Decision Making’, click on this tab and you will be taken to the menu leading you to 19 of the most relevant CPRs to physical therapists. Or, you can CLICK HERE

Manual Therapy… Why the Apprehension?

According to a survey of 813 british physical therapists conducted by Foster et al, Only 58.9% Physical therapists utilize spinal mobilization (Grade I – IV) and only 2.8% use spinal manipulative therapy (Grade V) when treating patients suffering from low back pain (LBP). Additionally, a survey of 274 canadian physical therapists published by Li et al found that when treating a patient with acute LBP, only 44.4% of therapists utilized spinal mobilization and only 5.0% used spinal manipulation. In the same study, utilization of mobilization and manipulation actually increased when treating a patient in the sub-acute stage at 83.7% and 9.0%, respectively. This finding is especially concerning since one of the variables of the spinal manipulation clinical prediction rule (CPR) is an onset of < 16 days. So, we as a profession are unwilling to perform manual therapy on those individuals that could benefit most. This practice pattern may be because of our apprehension in using such an ‘invasive’ technique on patients that are in such acute distress. However, if the patient is properly screened and is appropriate for manual therapy, the benefits of following through with the treatment will far outweigh the patient’s initial discomfort.

In my experience, this has been the trend that I have seen in the clinic. Honestly, prior to beginning PT school, I had no idea that manual or manipulative therapy was within a physical therapist’s scope of practice. I had the opportunity to work with many talented and experienced therapists throughout my own rehabilitation and during my required ‘observation hours’ and never once did I see anything that resembled manual therapy. So I ask, why are there so many therapists that refuse to utilize such an effective treatment option?

Is it a lack of quality evidence?

When discussing the application of manual therapy to LBP, I find it hard to believe that a lack of evidence is the problem. Erhard et al conducted a small randomized controlled trial (RCT) investigating the effectivness of exercise based on directional preference versus manual therapy. The treatment group was treated with a supine lumbopelvic roll and the hand-heel rock exercise, while the exercise group was treated with an extension-oriented program similar to that proposed by McKenzie. The results showed that 9/12 patients in the manipulation group were discharged at 1 week, while only 2/12 were discharged from the extension-only group. Discharge from PT was determined by obtaining a score of < 11 on the Oswestry Disability Index (ODI). While this study had a small sample size and lacked adequate follow-up data, it did show an increase in positive outcomes when manual therapy was included in a patient’s treatment plan.

In 2002, Flynn et al developed a CPR for the use of spinal manipulation, which was later validated by Childs et al in 2004. The Flynn prospective cohort study showed that when a patient met the CPR and was subsequently treated with manipulative therapy, their likelihood of success increased from 45% to 95%. According to the Childs randomized controlled trial, when a patient met this CPR and was subsequently treated with the supine lumbopelvic roll and lumbar ROM exercises, 44.3% (31/70) achieved success after 1 week versus only 11.5% (7/61) in the exercise-only group. After 4 weeks, 62.9% (44/70) had achieved success, while only 36.1% (22/61) had achieved this same success in the exercise group. Additionally, at the 6 month follow-up, 27.8% of patients in the matched manipulation group were taking pain medication for their back compared to 43.8% in the exercise group. Even patients that did not meet the CPR and were treated with manual therapy used less pain medication as a group (41.2% v. 70.8%). These studies not only showed the benefit of manual therapy, but also gave clinicians an additional tool in identifying patients who would respond favorably. Also, when comparing ODI scores at 6 months post-treatment, the manipulation groups are still superior to the exercise groups. One of the most common arguments against spinal manipulation is that it is a short-term fix with no long-term effects. This study seems to contradict these beliefs.

Cleland et al also investigated the efficacy of manual therapy when applying the Spinal Manipulation CPR. In this case series, 12 patients who satisfied the CPR were treated with the sidelying lumbar roll. After just 2 treatments, 11/12 (91.7%) patients had at least a 50% reduction in the ODI. This study shows continued support for this treatment approach as well as evidence that more than one manual therapy technique can be applied.

Evidence for the efficacy of manual therapy does not stop at the lumbopelvic region. There is also evidence to support its use for neck pain, tension headaches, shoulder impingement, knee osteoarthritis, hip osteoarthritis, and many other diagnoses.

Is it because manual therapy can cause harm to our patients?

According to a systematic review by Assendelft et al, the incidence of serious complications, such as cauda equina syndrome, due to spinal manipulation is < 1/1,000,000. While complications due to cervical manipulation was found to be slightly more prevalent at ~ 1/1,000,000, it was still minuscule when compared to the complication rates of NSAIDs, spinal surgery, or even vigorous exercise.

So, what is it that stops us from using the best evidence to treat our patients? It could be a lack of emphasis on manual therapy and EBP in many PT programs, especially for those therapists who graduated before this material began to emerge in physical therapy curriculums. Even though this material may not have been taught to some of us, it is our responsibility as healthcare professionals to provide the highest quality of care. To achieve this level of care it is necessary to step outside of our clinical practice patterns and implement new treatments when they are applicable. Also, our profession has such a negative perception of the chiropractic profession that I believe this negativity spills into our understanding of their primary intervention. If you ask the general population where they go to be treated for LBP or neck pain almost every individual would respond, “my chiropractor”. This is in part due to their superior marketing and autonomy, but it also has to do with the interventions they use to treat these patients. While I do not agree with how many DCs market themselves or some of the treatment strategies they employ, this is one aspect that I do agree with (even if it is over utilized). Change is a difficult process when you have been treating patients a certain way your entire career, but if it improves your patient outcomes, why not try?