Clinical Prediction RulesKelsey Terreson, SPTTexas Woman’s University

Complete Orthopaedic Care-Advocate Condell Lincolnshire

Outline• Overview of CPRs• CPRs related to common problems seen the

outpatient orthopedic setting• Where to find more information• Questions

About Clinical Prediction Rules 1-2

• What are clinical prediction rules?• A clinical prediction rule is a group of signs, symptoms and

other findings that predict the probability of a specific disease or outcome.

• Clinical prediction rules have been used to describe the likelihood of the presence or absence of a condition, assist in determining patient prognosis, and help the classification of patients for treatment.

• A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. (2)

How Can We Use CPRs? 3-4

Validation of CPRs are required before they can be used clinically. Validation is broken down into levels:

• Level IV – CPR without validation, or validated with retrospective data

• Level III – has only been validated with a narrow prospective study

• Level II – has been validated in a large prospective study

• Level I impact, practice patterns takes that and shows that it decreases costs

Clinical Prediction Rules (CPRs) help therapists quickly determine if a patient has a disease or if they will benefit from a specific treatment or test.

CPRs• Ottowa Ankle Rules • Ottowa Knee Rules • Whether a patient with with PFPS who will

benefit from patellar taping • Presence of Hip OA • Whether a patient WILL benefit from

Lumbopelvic manipulation • Whether a Patient WILL benefit from a Lumbar

stabilization program • Presence of Carpal Tunnel Syndrome • Cervical Radiculopathy • Canadian C-Spine Rules• People who will benefit from Cervical Traction

and Exercise

Ottowa Ankle Rules Level 1 (5-7)

• Bony tenderness at the posterior distal 6cm of the fibula (posterior lateral malleolus)

• Bony tenderness at the base of the 5th metatarsal• Bony tenderness at the navicular• Bony tenderness at the posterior edge or tip of the

medial malleolus• Inability to bear weight immediately after incident or in

ER for 4 steps• With an appropriate MOI and any of these positive, patient

should get xrays. 100% Sensitive, 24% Specific, valid for people older than 6 y/o

Ottowa Knee Rules Level 1 8-10

• Age ≥ 55• Isolated tenderness at the

patella (no other bony tenderness)

• Tenderness at the fibular head

• Unable to flex knee to 90• Able to bear weight

immediately after and in ER for 4 steps (limping counts)• Any one of these positive

with an appropriate MOI, the patient should get an xray. (100% sensitive, 50% specific)

Patients with PFPS who would benefit from patellar taping 11• Asked patients with

retropatellar pain aggravated by squatting to perform

• Defined “benefit” as 50% improvement in NPRS or “moderate improvement” on GROC.

• Use of the rule improved success with taping from 52% to 83%

• Level 4 – requires validation

• Positive patellar tilt test• Tibial Varum

Presence of Hip OA 12

• Self reported squatting is aggravating• Scour test with adduction causes groin or lateral

hip pain• Active hip flexion causes lateral pain• Active extension causes hip pain• Passive IR less ≤ 25 degrees

• Level 4 – Requires validation

• 3/5 - 68% probability that x-rays would show the patient has OA

• 4/5 – 91% probability that x-rays would show that the patient has OA

Patient WILL benefit from Lumbopelvic manipulation 13-14 • Symptoms <16 days • No symptoms distal to the knee• FABQ work subscale <19 (not very fearful about

going back to work)• At least one hip with >35 degrees of IR• Hypomobility of the lumbar spine• Level 2

Patient WILL benefit from a Lumbar Stabilization program 15-17

• <40 years old• >91 SLR• + Prone instability test• Aberrant motions• Level 4*

Carpal Tunnel Syndrome Level 4 18-19

• Patient reports symptoms are relieved with repositioning or flicking of the hands*

• Diminished sensation into the median nerve distribution of the thumb

• Wrist ratio of >.67 (distal wrist crease AP / ML)• Symptom severity scale >1.9• >45 y/o• ≥ 2 (Sensitivity 98, Specificity 14)• ≥ 3 (Sensitivity 98, Specificity 54)• ≥ 4 (Sensitivity 77, Specificity 83)• ≥ 5 (Sensitivity 18, Specificity 99)

Cervical Radiculopathy Level 4 20-21

• Ipsilateral Cervical Rotation <60 degrees• + Spurling• + Neck Distraction• + Median Nerve ULTTA

• All 4 – 90% chance of true cervical radiculopathy, 3 – 65% chance of true cervical radiculopathy

People with neck pain who are likely to benefit from cervical traction and exercise Level 422

• Pt reported peripheralization with lower cervical with lower cervical spine mobility testing• + shoulder abduction

test• Age ≥ 55• + Median nerve

ULTTA • + Neck distraction

test

Canadian C-Spine Rules Level 1 23-25

• Not cognitively intact or have neurological symptoms• 65 y/o or older• Patient fearful of moving head on command• Involved in a distraction type injury• Demonstrates midline pain• Any one of these positive with an appropriate MOI, patient

should get x-rays, (Sensitivity 100%, Specificity 42.5)

• Rule not valid if:• Non-trauma cases• GCS < 15• Unstable vital signs• Age < 16 years• Acute paralysis• Known vertebral disease• Previous C-spine surgery

Patients with neck pain that will benefit from a thrust manipulation 26-28

• Symptom duration less than 38 days• Positive expectation that the manip will help• Side to side difference in cervical rotation of 10

degrees or more• Pain with PA mob/spring testing of the midcervical

spine• Failed validation because everyone who had

neck pain and got the manipulation got better

Want to know more?• JOSPT’s publishes several of the validation studies

and is helpful for finding CPRs and their validations

• Really helpful article explaining what CPRs are and how to use them:• http://ptjournal.apta.org/content/86/1/122.long• Keep in mind that it was published in 2006, some of

the studies that I have presented since then have been validated.

Thanks!!!It has been such a pleasure to work with all of you! Thank you for all that y’all have taught me!

Questions?

References1. Beattie P and Nelson R. Clinical prediction rules: What are they and what do they

tell us? Australian Journal of Physiotherapy. 2006 52: 157–1632. Adams S and Leveson S. Clinical Prediction Rules. BMJ. January 2012. 16;344.3. Adams S and Leveson S. Clinical Prediction Rules. BMJ. January 2012. 16;3444. Learman K, Showalter C, Cook C. Does the use of a

prescriptive clinical prediction rule increase the likelihood of applying inappropriate treatments? A survey using clinical vignettes. Manual Therapy. December 12;17(6):538-43.

5. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR (April 1992). "A study to develop clinical decision rules for the use of radiography in acute ankle injuries". Annals of Emergency Medicine; 21 (4): 384–90.

6. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, Naylor CD. Multicentre trial to introduce the Ottowa ankle rules for the use of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. Septempter 2005; 311(7005): 594–7.

7. Dowling S, Spooner CH, Liang Y, et al. (April 2009). "Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis".Acad Emerg Med 16 (4): 277–87. 

8. Stiell IG, Greenburg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, Cacciotti TF, Sivilotti MLA. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA 1996; 275:611-615.

9. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiograph in acute knee injuries. Ann Emerg Med 1995;26:405–13.

10. Nichol G, Stiell IG, Wells GA, et al. An economic analysis of the Ottawa knee rule. Ann Emerg Med 1999;34:438–47.

References continued11. Lesher JD, Sutlive TG, Miller GA, Chine NJ, Garber MB, Wainner RS. Development of a clinical prediction rule

for classifying patients with patellofemoral pain syndrome who respond to patellar taping. Journal of Orthopedic and Sports Physical Therapy. November 2006; 36(11):854-66).12. Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT, Boyles RE, Childs JD. Development of a

clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain. JOSPT, 2008 Sept; 38(9):342-50.13. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal

manipulation. Spine. December 2002.15;27(24):2835-43.14. Childs JD, Fritz JM, Flyyn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of Internal Medicine. December 2004. 21;141(12):920-8.15. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining

which patients with low pack pain will respond to a stabilization exercise program. Archives of Physical Medicine and Rehabilitation. September 2005; 86(9):1753-62.16. Rabin A, Shasua A, Pizem K, Dickstein r, Dar G. a clinical prediction rule to identify patients with low pabck

pain who are likely to experience short-term success following lumbar stabilization exercises: a randomized controlled validation study. Journal of Orthopedic and Sports Physical Therapy. January 2014;44(1):6-B13.17. Ribaudo A. Management of a patient with lumbar segmental instability using a clinical predictor rule. HSS J. 2013 Oct;9(3):284-818. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Archives of Physical Medicine and Rehabilitation. April 2005; 86(4):609-18.19. Pryse-Phyllips WE. Validation of a diagnostic sign in carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 1984;47:870-872.20. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine. January 2003; 28(1):52-62.21. Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a multimodal intervention approach: a case series. Journal of Orthopedic and Sports Physical Therapy. March 2006;36(3):152-9.

References continued22. Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Devle GD, Childs JD.

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. European Spine Journal. March 2009;18(3):382-91.

23. Stiell IG, Clement CM, O’Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C, MacKenzie T, Wells GA. Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ. August 2010; 182(11):1173-9.

24. Stiell IG, Clement CM, Grimshaw J, Brison R, Rowe BH, Schull MJ, Lee J, Brehaut J, McKnight D, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, MacPhail I, Ross S, Perry JJ, Holroyd BR, Ip U, Lesiuk H, Wells GA. Implementation of the Canadian C-Spine Rule: A Prospective 12-Centre Cluster Randomized Trial. British Medical Journal. October 2009;29(339).

25. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, WorthingtonJR, Eisenhauer WA, Cass D, Greenburg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesuik H, Wells GA. The Canadian C-Spine Rule Versus the NEXUS Low Risk Criteria in Patients with Trauma. New England Journal of Medicine. 2003;349:2510-2518.

26. Cleland JA, Childs JD, McRae M, Palmer JA, and Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: A randomized control trial. Manual Therapy. May 2005; 10:2, (127-135).

27. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Physical Therapy. January 2007;87(1):9-23.

28. Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Childs JD. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical cervical range of motion exercise : a multicenter randomized clinical trial. Physical Therapy. September 2010; 90(9): 1239-50.