Summary of Clinical Prediction Rules

Clinical prediction rules (CPRs) are mathematical tools that are intended to guide physical
therapists in their everyday clinical decision making. CPRs provide physical therapists with an
evidence-based tool to assist in patient management when determining a particular diagnosis or
prognosis, or when predicting a response to a particular intervention.

CPR for diagnosis

The Canadian C-Spine Rule (CCR)
It is a decision-making tool used to determine when radiography should be utilized in patients
following trauma. It is not applicable in non-trauma cases, if the patient has unstable vital signs,
acute paralysis, known vertebral disease or previous history of Cervical Spine surgery and age
<16 years.

1. Any high- risk factors which mandates radiography? Role not applied if:

Age ≥ 65 • Non-trauma cases

or • Glasgow coma scale < 15
Dangerous mechanism* • Unstable vital signs
or • Age <16
Paresthesia in extremities • Acute paralysis
• Known vertebral disease
• Previous C-spine surgery
No
• Pregnant
2. Any low-risk factor which allows safe ROM assessment?
Simple rear-end motor vehicle collision (MVC)**
or
Sitting position in ED
or
Ambulatory at any time No
or
Delayed onset of neck pain ***
Radiography
or
Absence of midline c-spine tenderness

Yes

3. Able to actively rotate neck?

45 degrees left and right

Able

No radiography

*Dangerous mechanism: ** Simple rear-end MVC excludes: ***Delayed:

• Fall from elevation ≥3 feet or 5
stairs
• Axial load to head e.g., diving
• MVC of high speed (>100 km/h),
rollover, ejection
• Motorized recreation vehicles
• Bicycle struck or collision
Figure 1 The Canadian Cervical Spine Rule
• Pushed into oncoming traffic
Not immediate onset of neck pain
• Hit by bus or large truck
• Rollover
• Hit by high-speed vehicle
1
Ottawa Knee Rules
The Ottawa Knee Rules determine the need for radiographs in acute knee injuries. If one of the
following is present, radiographs are indicated:
1. Age >55 years
2. Isolated patellar tenderness without other bone tenderness
3. Tenderness of the fibular head
4. Inability to flex the knee to 90°
5. Inability to bear weight immediately after injury and in the emergency department (4
steps) regardless of limping

Ottawa Ankle Rules

The Ottawa Ankle Rules determine the need for radiographs in acute ankle injuries.
A. Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
B. Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
C. Bony tenderness at the base of 5th metatarsal
D. Bony tenderness at the navicular
E. Inability to bear weight both immediately after injury and for 4 steps during initial evaluation

2
 CPR for hip OA:
Adults > 50 years can be classified as having coxarthrosis/ hip osteoarthritis (hip pain and
mobility deficits) when they have:
• Moderate anterior or lateral hip pain during weight-bearing activities,
• Morning stiffness less than 1 hour in duration after wakening,
• Hip internal rotation range of motion < 24° or internal rotation and hip flexion 15° less
than the nonpainful side,
• And/or increased hip pain associated with passive hip internal rotation

CPR for Carpal Tunnel Syndrome

Patients who have the following are likely having carpal tunnel syndrome
1. Shaking hands to relieve symptoms
2. Wrist ratio index >.67
3. Carpal tunnel syndrome- Symptom Severity Scale > 1.9
4. Diminished sensation in median sensory field 1 (thumb)
5. Age > 45 years old

CPR for Cervical Radiculopathy

Patient can be diagnosed with cervical radiculopathy when he/she has
• positive upper limb tension test A (ULTTa) (median nerve),
• involved-side cervical rotation range of motion less than 60 degrees,
• positive distraction test, and
• positive Spurling's test A.

CPR for cervical myelopathy

1. gait deviation.
2. positive Hoffmann’s test;
3. positive inverted supinator sign;
4. positive Babinski test; and
5. age 45 years,

Gait + + inverted + Babinski Age >45

deviation Hoffman's supinator reflex
test sign
Clustered clinic findings for diagnosis of cervical spine myelopathy.
3
Cook et al. J of Manual & Manipulative Therapy 2010;18(4):175-180

figure. The clinical prediction rule for cervical myelopathy. Cook et al. 2010
CPR for Meniscal Pathology
• History of catching or locking reported by the patient
• Joint line tenderness
• Pain with forced hyperextension (modified bounce home test)
• Pain with maximal passive knee flexion
• Pain or audible click with McMurray's maneuver

CPR for Full-Thickness Rotator Cuff Tear

Based on the Park et al[1] study, the combination of the following 3 special tests have produced
the highest post-test probability to diagnose a full-thickness rotator cuff tear:
1. The Drop-Arm Sign
2. The Painful Arc Sign
3. Infraspinatus Muscle Test
The study concluded that if all 3 tests were positive, the probability of the patient having a full-
thickness rotator cuff tear is 91%.

CPR for intervention

CPR for Lumbar Stabilization
1. Age less than 40 years old
2. SLR greater than 91 degrees
3. Aberrant motion present
4. Positive prone instability test

Lumbar Spinal Manipulation

The patients that received the most benefit from spinal manipulation for LBP are those that meet
at least four out of the five criteria for spinal manipulation
1. Pain lasting less than 16 days
2. No symptoms distal to the knee
3. Fear avoidance belief questionnaire (FABQ) score less than 19
4. Internal Rotation of greater than 35 degrees for at least one hip
5. Hypomobility of a least one level of the lumbar spine
Two most important identifiers for manipulation are: Pain lasting less than 16 days; No
symptoms distal to the knee

CPR for cervical manipulation for neck pain:

The following six factors are the criteria for immediate responders to cervical manipulation:[7]
1. Initial scores on Neck Disability Index <11.5
2. Having bilateral involvement pattern
3. Not performing sedentary work >5 h/day
4. Feeling better while moving the neck
5. Without feeling worse while extending the neck
6. Diagnosis of Spondylosis without Radiculopathy
The presence of four or more of these predictors increased the probability of success with
manipulation to 89%

4
Thoracic spine manipulation for patients with mechanical neck pain
• symptoms duration < 30 days,
• no symptoms distal to the shoulder,
• subject reports that looking up does not aggravate symptoms,
• Fear-avoidance Beliefs Questionnaire-Physical Activity Scale < 12,
• diminished upper thoracic kyphosis (T3-5), and
• cervical extension < 30°.

Notes on vertebrobasilar insufficiency (VBI):

There has been no development to date of a clinical prediction rule (CPR) or reliable criteria that
can accurately identify which patients are at risk for VBI.24 In other words, if there is a high
suspicion of VBI based on the patient’s history, then passive end range provocative testing
should be avoided and the patient should be referred to the appropriate medical practitioner.24
Part of the patient’s history that may help in the decision making is the mechanism of injury. The
most common cause of sudden-onset VBI is trauma, specifically from high-velocity, flexion-
distraction and rotational forces that may occur during a whiplash.24,26 As a result, if a patient
presents with history of a high-velocity trauma, proceed with a heightened suspicion of possible
VBI. When conducting a physical examination assessing for possible VBI involvement, proceed
with the intent to minimize the challenges placed on vertebral artery complex.
The author use an active approach, instructing the sitting patient to look up and over your
shoulder (extension, rotation, and sidebending to one side). Alternatively, this can be done from
supine with therapist hold the patient’s head off the bed (see figure). If the patient moves through
full ROM with no complaints that are typically associated with VBI, the author then proceeds to
the next step, a pre-manipulative hold.86 This consists of maintaining the patient’s head in the
position that the procedure will be performed for a period of 10 to 15 seconds prior to imparting
the force, assessing signs and symptoms consistent with VBI.24 If any of the signs and/or
symptoms described earlier in this text are observed, the hold should be terminated. The intended
manual therapy intervention is contraindicated and consideration for further medical evaluation
may be warranted.
If the patient is unable to actively move through full range and stops short, an inquiry is made of
the patient. “What stops you from going further?” If the response is similar to a VBI sign or
symptoms like, “I will get dizzy if I go further,” or “I feel like I will pass out if I go further,”
then the examination is stopped, and no intervention is attempted beyond the patient’s choice of
active ROM. If the patient stops short of full ROM, an inquiry is made of the patient. “What
stops you from going further?” If the reply is something like, “I just can’t go any further, it is
stiff;” the author will then apply a gentle passive ROM in an attempt to take the patient further
into the range (extension, rotation, and sidebending).

5
 Figure. Positions to test for VBI; supine left, sitting right

The above physical examination procedures described has no supporting peer-reviewed

evidence, but the method represents cautionary but progressive approach to physical examination
of the vertebral artery complex. In the clinic, if there is any uncertainty, there is certainly no
harm in proceeding down a conservative path when managing patient with possible VBI
involvement.