This lecture is on spinal pain and the clinical methods used in treating the pain. Clinical prediction rules is a research method done systematically describing when to use which method of treatment approach

1. CLINICAL PREDICTION RULES
IN SPINAL PAIN

2. CONTENTS:
 Introduction to Clinical prediction rule
 What are CPR
 Levels of CPR
 Types of CPR
 Examples
 Summary
 Reference

3. INTRODUCTION
 A trend in manual therapy has been the development of
Clinical Prediction Rules (CPR).
 CPRs are derived statistically i.e. literally “translated” from
research evidence with the aim of identifying the combinations
of clinical examination findings that can predict a condition or
outcome.
(Fritz et al., 2003; Fritz, 2009; Cook, 2008)

4. Clinical prediction rules are decision-making tools that contain
predictor variables obtained from patient history, examination,
and simple diagnostic tests; they can assist in making a
diagnosis, establishing prognosis, or determining appropriate
management.

5. WHAT ARE CLINICAL
PREDICTION RULES (CPRS)?
 Evidence-based medicine
 Clinical decision making algorithm
 Increase sensitivity and specificity of clinical examination
 Decrease use of unnecessary tests
 Decrease use of ineffective treatments
Glynn & Weisbach (2011)

6. How are they developed?
4 LEVELS OF CPRS
I: demonstrated effectiveness in a varied population on a large
scale
II: validated in a broad patient population
III: validation of the CPR in a patient sample; confirm predictor
variables weren’t due to chance or errors within the study; new
patients, new investigators
IV: rule has been developed and tested in a specific population;
predictor variables are selected
Glynn & Weisbach (2011)

7. TYPES OF CPRS
 Diagnostic: Probability that a specific condition exists.
 Prognostic: Likely outcome for patients with a specific
condition.
 Prescriptive: Determine which patients will likely respond
favorably to a specific treatment or combination of treatments.
Glynn & Weisbach (2011)

8. DIAGNOSTIC CPRS

9. Purpose: Identify signs and symptoms indicative of lumbar
spinal stenosis.
Rule:
1. Bilateral symptoms
2. Leg pain > back pain
3. Pain during walking/standing
4. Pain relief upon sitting
5. > 48 years old
Diagnosis :
Lumbar Spinal Stenosis (JS)

10. Purpose: To identify patients with neck and arm pain likely
presenting with cervical radiculopathy based on specific patient
characteristics.
Rule:
1.Positive Upper Limb Tension Test A
2. Involved cervical rotation < 60 degrees
3. Positive Distraction Test
4. Positive Spurling’s A
Diagnosis :
Cervical Radiculopathy

11. PROGNOSTIC CPRS

12. RECOVERY WITH LBP
 Predictor variables Initial pain < 8/10
 pain less than 6 days
 No more than 1 previous episode of LBP
 All three predictor variables present
 Study participants received mobilization therapy
 95% better at 12 weeks pain 0-1/10 for 1 week
Hancock et al. (2009)

13. INTERVENTIONAL CPRS

14. Mechanical Traction for Neck Pain
Purpose: Identify patients with neck pain likely to improve
with cervical traction and exercise.
Rule:
1. Patient reported peripheralization with lower cervical
spine (C4-7) mobility testing
2. Positive shoulder abduction test
3. Age > 55
4. Positive upper limb tension test A
5. Positive neck distraction test
Three or more predictor variables indicates a moderate
likelihood that traction and exercise will produced a
perceived benefit
Raney et al. (2009)

15. Variables Sensitivity Sensitivity +LR Prob of
Success
3 0.63 0.87 4.81 79.2%
4 0.30 1.00 23.10 94.8%

16. MECHANICAL TRACTION FOR
LOW BACK PAIN
Purpose: Identify patients with low back pain who
likely will respond favorably to mechanical lumbar
traction.
Rule:
1. FABQ-W score < 21
2. No neurological deficit involvement
3. Age older than 30
4. Non-manual work job status

17. Variables Sensitivity Specificity +LR Prob of
Success
3 0.76 0.75 3.04 42.2%
4 0.36 0.96 9.36 69.2%

18. THORACIC MANIPULATION FOR
NECK PAIN
 Purpose: Identify patients with neck pain who are
likely to experience early success from thoracic spine
thrust manipulation, exercise, and patient education.
 Rule:
 1. Symptoms < 30 days
2. No symptoms distal to the shoulder
3. Looking up does not aggravate symptoms
4. FABQ-PA score < 12
5. Diminished upper thoracic spine kyphosis
6. Cervical extension ROM < 30 degrees

19. Variables +LR Prob of Success
3+ 5.49 86.o%
4+ 12.00 93.0%
5+ ∞ 100%

20. LUMBAR MANIPULATION FOR LOW
BACK PAIN
Purpose: Identify patients with low back pain who likely
will improve with spinal manipulation.
• Rule:
• 1. Duration of symptoms < 16 days
2. At least one hip with > 35° of internal rotation
3. Lumbar hypomobility
4. No symptoms distal to the knee
5. FABQ-W score < 19
Hancock et al. (2008)

21. Variables Sensitivity Specificity +LR Prob of
Success
1 1.00 0.03 1.03 46%
2 1.00 0.15 1.18 49%
3 0.94 0.64 2.61 68%
4 0.63 0.97 24.38 95%
5 0.19 1.00 ∞ 100%

22. CERVICAL MANIPULATION FOR
NECK PAIN
Purpose: Identify patients with mechanical neck pain who will
demonstrated favorable outcomes following cervical
manipulation.
Rules:
1. Symptom duration of less than 38 days
2. Positive expectation that manipulation will help
3. Side-to-side difference in cervical rotation ROM of 10° or
greater
4. Pain with poster anterior spring testing of the middle cervical
spine
(puentedura,et al 2012)

23. Variables Sensitivity Specificity +LR Prob of
Success
3 0.81 0.94 13.50 90%
4 0.50 1.00 ∞ 100%

24. SUMMARY
• Most diagnostic CPRs are in their initial development phase
and cannot be recommended for use in clinical practice at this
time.
•
• while useful as part of decision making CPRs should not
replace clinical judgment and should be seen as
complementary to that process which needs to involve
experience, clinical opinion, intuition as well as research
evidence.

25. REFERENCES
• Cook, C., Potential it falls of clinical prediction rules.
Journal of Manual & Manipulative Therapy, 2003.
• Falk, G., Fahey , T., Clinical prediction rules. British
Medical Journal , 2009.
• Fritz, J. M ., Delitto , A., Erhard , R., Comparison of a
classification - based approach to physical therapy
and therapy based on clinical practice guidelines for
patients with acute low back pain: a randomized clinical
trial. Spine 28, 2003.
• Glynn, P. E., & Weisbach, P. C., Clinical prediction rules.
A physical therapy reference manual. Boston: Jones and
Bartlett Publishers, 2011.

26. • Laupacis A, Sekar N, Stiell I. Clinical prediction rules:
A review and suggested modification of
methodological standards.
• Cook C, Brown C, Michael K, Isaacs R, Howes C,
Richardson W, Roman M, Hegedus E. The clinical
value of a cluster of patient history and observational
findings as a diagnostic support tool for lumbar spine
stenosis. Physiother Res Int. 2011;
• Waldrop MA., Diagnosis and treatment of cervical
radiculopathy using a clinical prediction rule and a
multimodal intervention approach: a case
series. Journal of Orthopedics Sports Physiotherapy,
2006;

27. • Laslett, M., Aprill, C. N., McDonald, B., & Young, S.
B., Diagnosis of sacroiliac joint pain. Validity of
individual provocation tests and composites of tests.
2005, Journal of Manual Therapy.
• Lee, D., Differential diagnosis and management
ofchronic pelvic pain. In: Chaitow, L., Lovegrove, R.
(Eds.),Chronic Pelvic Pain & Dysfunction, Churchill-
Livingstone, Edinburgh,in press.