Category Archives: Clinical Prediction Rules

Clinical Prediction Rule: Hip Osteoarthritis

A patient walks into your clinic complaining of hip pain. The referral from the orthopedist says “hip OA,” but how can you be sure that the symptoms that your patient is complaining of are truly arthritic in nature? With the help of clinical prediction rules (CPRs), you can help improve your ability to accurately diagnose the patient, which will allow for you to improve your treatment outcomes.

In 2008, Sutlive et al published a report regarding the diagnoses hip osteoarthritis in patients with unilateral hip pain. Using diagnostic evidence of osteoarthritis on X-ray as the reference standard, five predictors were found to help in the diagnosis of hip osteoarthritis:

  • Self-reported squatting as an aggravating factor
  • Scour test with adduction causing groin or lateral pain
  • Active hip flexion causing lateral pain
  • Active hip extension causing hip pain
  • Passive hip internal rotation less than or equal to 25°

If 4/5 of the above predictors were present, a positive likelihood ratio of 24.3 was found (a post test probability of 91%). What’s great about this CPR is how quick it is to run through the five predictors, and once you do, you can provide your patient with a more evidence based clinical diagnosis.

So now that you feel confident with your diagnosis, how do you treat your patient? I personally tend to utilize a lot of joint manipulation/mobilization techniques with these patients, and the research supports this type of plan of care.  Hoeksma et al published a paper in 2004 comparing manual therapy to exercise in the treatment of patients with hip osteoarthritis. The findings showed a significantly higher success rate after 5 weeks of treatment in the manual therapy group compared to the exercise group. Now this does not mean that you should completely neglect the use of therapeutic exercises when treating patients with hip OA, but more importantly, should reinforce the significance of using manual therapy with this population (aka if you are not doing hip mobilizations for your patients, you should!).

Both of these articles are great ways to not only improve your own clinical skills, but to educate your patient as well. If you are able to confidently tell your patient what you believe is causing their symptoms, and more importantly that you can improve them, their trust in you as their physical therapist will grow exponentially.


Clinical Prediction Rules: Cervical Spine

Your patient walks into your clinic with neck pain that radiates into their arm…now what? How do you know what it is, what you should do, and if they are going to respond well to conservative therapy? With the help of several research studies we thankfully have the answer to some of these questions.

Wainner et al published a study investigating the reliability and accuracy of different examination procedures for cervical radiculopathy. In the study he found four key features to help rule in the diagnosis of a cervical radiculopathy, with a positive likelihood ratio of over 30 if patients were positive on the rule. These four findings were the following:

  • Positive Upper Limb Tension Test A
  • Positive Spurling A Test
  • Positive Cervical Distraction Test
  • Cervical Rotation <60 degrees (to the involved side)

By using the above clinical prediction rule, you can provide a more accurate diagnosis for your patient, as well as better direct your interventions at addressing the underlying cause of the patient’s symptoms.

Now that we know what it is, how do we fix it? Today we are going to focus on one specific intervention technique; cervical traction. In 2009, Raney et al developed a clinical prediction rule to determine whether or not a patient was more likely to benefit from traction as an intervention:

  • >55 years of age
  • Peripheralization of symptoms with C4-C7 mobility testing
  • Positive Cervical Distraction Test
  • Positive Upper Limb Tension Test A
  • Positive Shoulder Abduction Test

If your patient has 4 out of 5 of the above predictors there is nearly a 95% likelihood that they would benefit from cervical traction as an intervention technique.

Finally, is there any way to know whether or not your patient will short-term success with therapy? Cleland et al found that there were four factors that indicated that the patient will have a positive outcome within 28 days:

  • <54 years old
  • Dominant arm not affected
  • Looking down does not increase symptoms
  • Multimodal treatment approach including manual therapy, cervical traction, and deep neck flexor muscle strengthening for at least 50% of visits

When all four variables were present, Cleland found the probability of success was nearly 90%. Not a bad statistic to provide your patient with to motivate them to come to physical therapy.

By using the articles and research above, you can provide better quality care for your patients that complain of neck and arm pain. Stay tuned for more posts about how we can get these patients better faster!

Clinical Prediction Rule: Thoracic Spine Manipulation

A patient comes into your clinic complaining of neck pain…what do you do? For some patients, treating the thoracic spine may help improve their symptoms. Cleland et al published a study in 2007 in which they published a clinical prediction rule to find a subgroup of patients whom may benefit from thoracic manipulations:

  • Symptoms <30 days
  • No symptoms distal to the shoulder
  • Looking up does not aggravate symptoms
  • FABQ <12
  • Decreased thoracic kyphosis in the upper thoracic spine
  • Cervical extension range of motion <30 degrees

Cleland found that if 3 out of 6 factors were present the probability of success was nearly 86%. While this study proved to be helpful for this subgroup of patients, it was not validated. That being said, the validation study did show that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long-term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only.

So what does this mean? Take a look a the thoracic spine; if it is justified to perform a thoracic manipulation you may get your patient better faster!

Clinical Prediction Rule: Stabilization Classification

A patient walks into your clinic complaining of low back pain. You aren’t sure exercises to give them, but you think that they would benefit from “core stabilization.” Instead of using a “cookie cutter” approach to treating patients, in which everyone receives the same treatment approach, you may be able to identify those patients who would respond better to stabilization exercises by using this study by Hicks et al. In the study, the researchers identified four factors that may identify patients who would benefit from lumbopelvic stabilization exercises:

  • Positive Prone Instability Test
  • Aberrant movements present
  • Average straight leg raise >91 degrees
  • Age <40

NOTE: Instead of performing the traditional prone instability test as described in the Hicks article, I use a modified version of the test. I begin by having the patient lay prone on the examination table. Apply a posterior to anterior pressure to the lumbar spine, and make note of any pain. At this point, have the patient raise their arms off the table while applying the pressure. If pain is present in the resting position but decreases when the arms are raised, the test would be positive.

So why is it important to provide these patients with stabilization exercises? Well Hides et al conducted a study on the effects of providing patients with stabilization exercises after an onset of low back pain. The study found that in the first year, those who performed specific stabilization exercises had a recurrence rate of 30% versus over 80% for those who did not perform core stabilization exercises.

Use these articles to help educate your patients on the importance of physical therapy in their recovery process, and that completing their rehabilitation may reduce their risk of setbacks in the future.


Clinical Prediction Rules: Lumbar Manipulation

Do you ever wonder treatments will give your patient the best results? With the help of clinical prediction rules, we have the opportunity to utilize validated research studies to help with the diagnosis and treatment of individuals with a variety of different “tissue issues.” The next several posts will include various clinical prediction rules and the articles/abstracts associated with the research.

In 2004, Childs et al published the study, “A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study.” This study aimed to confirm what Flynn et al found in 2002 , which was a clinical prediction rule involving a high-velocity, low amplitude thrust technique directed at the lumbar spine. The five clinical predictors are the following:

  • Onset of symptoms less than 16 days.
  • No symptoms distal to the knee.
  • FABQ score less than 19.
  • Passive hip internal rotation greater than 35 degrees.
  • Hypomobility with PA spring testing in the lumbar spine.

The study found a 92% success rate for those who were positive on at least 4 out of the 5 clinical predictors.

An additional study by Fritz et al found that of the five clinical predictors, the most important predictors were the following:

  • No symptoms distal to the knee
  • Symptoms less than 16 days

If your patient is positive on this modified rule, the post-test chance of success is nearly 88%.

So what does this mean? If you are thorough with your clinical examination, you may be able to better treat your patients by applying these clinical predictors into your physical therapy plan of care.