Robin Haskins

Clinical prediction rules in the physiotherapy management of low back pain: A systematic review

OBJECTIVE To identify, appraise and determine the clinical readiness of diagnostic, prescriptive and prognostic Clinical Prediction Rules (CPRs) in the physiotherapy management of Low Back Pain (LBP). DATA SOURCES MEDLINE, EMBASE, CINAHL, AMED and the Cochrane Database of Systematic Reviews were searched from 1990 to January 2010 using sensitive search strategies for identifying CPR and LBP studies. Citation tracking and hand-searching of relevant journals were used as supplemental strategies. STUDY SELECTION Two independent reviewers used a two-phase selection procedure to identify studies that explicitly aimed to develop one or more CPRs involving the physiotherapy management of LBP. Diagnostic, prescriptive and prognostic studies investigating CPRs at any stage of their development, derivation, validation, or impact-analysis, were considered for inclusion using a priori criteria. 7453 unique records were screened with 23 studies composing the final included sample. DATA EXTRACTION Two reviewers independently extracted relevant data into evidence tables using a standardised instrument. DATA SYNTHESIS Identified studies were qualitatively synthesized. No attempt was made to statistically pool the results of individual studies. The 23 scientifically admissible studies described the development of 25 unique CPRs, including 15 diagnostic, 7 prescriptive and 3 prognostic rules. The majority (65%) of studies described the initial derivation of one or more CPRs. No studies investigating the impact phase of rule development were identified. CONCLUSIONS The current body of evidence does not enable confident direct clinical application of any of the identified CPRs. Further validation studies utilizing appropriate research designs and rigorous methodology are required to determine the performance and generalizability of the derived CPRs to other patient populations, clinicians and clinical settings.

Validation and impact analysis of prognostic clinical prediction rules for low back pain is needed: a systematic review

OBJECTIVES To identify prognostic forms of clinical prediction rules (CPRs) related to the nonsurgical management of adults with low back pain (LBP) and to evaluate their current stage of development. STUDY DESIGN AND SETTING Systematic review using a sensitive search strategy across seven databases with hand searching and citation tracking. RESULTS A total of 10,005 records were screened for eligibility with 35 studies included in the review. The included studies report on the development of 30 prognostic LBP CPRs. Most of the identified CPRs are in their initial phase of development. Three CPRs were found to have undergone validation--the Cassandra rule for predicting long-term significant functional limitations and the five-item and two-item Flynn manipulation CPRs for predicting a favorable functional prognosis in patients being treated with lumbopelvic manipulation. No studies were identified that investigated whether the implementation of a CPR resulted in beneficial patient outcomes or improved resource efficiencies. CONCLUSION Most of the identified prognostic CPRs for LBP are in the initial phase of development and are consequently not recommended for direct application in clinical practice at this time. The body of evidence provides emergent confidence in the limited predictive performance of the Cassandra rule and the five-item Flynn manipulation CPR in comparable clinical settings and patient populations.

The clinical utility of cervical range of motion in diagnosis, prognosis, and evaluating the effects of manipulation: a systematic review

BACKGROUND Clinicians commonly assess cervical range of motion (ROM), but it has rarely been critically evaluated for its ability to contribute to patient diagnosis or prognosis, or whether it is affected by mobilisation/manipulation. OBJECTIVES This review summarises the methods used to measure cervical ROM in research involving patients with cervical spine disorders, reviews the evidence for using cervical ROM in patient diagnosis, prognosis, and evaluation of the effects of mobilisation/manipulation on cervical ROM. DATA SOURCES AND STUDY SELECTION A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted, addressing one of four constructs related to cervical ROM: measurement, diagnosis, prognosis, and the effects of mobilisation/manipulation on cervical ROM. STUDY APPRAISAL AND SYNTHESIS Two independent raters appraised methodological quality using the QUADAS-2 tool for diagnostic studies, the QUIPS tool for prognostic studies and the PEDro scale for interventional studies. Heterogeneity of studies prevented meta-analysis. RESULTS Thirty-six studies met the criteria and findings showed there is limited evidence for the diagnostic value of cervical ROM in cervicogenic headache, cervical radiculopathy and cervical spine injury. There is conflicting evidence for the prognostic value of cervical ROM, though restricted ROM appears associated with negative outcomes while greater ROM is associated with positive outcomes. There is conflicting evidence as to whether cervical ROM increases or decreases following mobilisation/manipulation. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS Cervical ROM has value as one component of assessment, but clinicians should be cautious about making clinical judgments primarily on the basis of cervical ROM. FUNDING This collaboration was supported by an internal grant from the Faculty of Health, The University of Newcastle.

A structured review of spinal stiffness as a kinesiological outcome of manipulation: Its measurement and utility in diagnosis, prognosis and treatment decision-making

PURPOSE To review and discuss the methods used for measuring spinal stiffness and factors associated with stiffness, how stiffness is used in diagnosis, prognosis, and treatment decision-making and the effects of manipulative techniques on stiffness. METHODS A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted. Included studies addressed one of four constructs related to stiffness: measurement, diagnosis, prognosis and/or treatment decision-making, and the effects of manipulation on stiffness. Spinal stiffness was defined as the relationship between force and displacement. RESULTS One hundred and four studies are discussed in this review, with the majority of studies focused on the measurement of stiffness, most often in asymptomatic persons. Eight studies investigated spinal stiffness in diagnosis, providing limited evidence that practitioner-judged stiffness is associated with radiographic findings of sagittal rotational mobility. Fifteen studies investigated spinal stiffness in prognosis or treatment decision-making, providing limited evidence that spinal stiffness is unlikely to independently predict patient outcomes, though stiffness may influence a practitioners application of non-thrust manipulative techniques. Nine studies investigating the effects of manipulative techniques on spinal stiffness provide very limited evidence that there is no change in spinal stiffness following thrust or non-thrust manipulation in asymptomatic individuals and non-thrust techniques in symptomatic persons, with only one study supporting an immediate, but not sustained, stiffness decrease following thrust manipulation in symptomatic individuals. CONCLUSIONS The existing limited evidence does not support an association between spinal stiffness and manipulative treatment outcomes. There is a need for additional research investigating the effects of manipulation on spinal stiffness in persons with spinal pain.

Diagnostic Clinical Prediction Rules for Specific Subtypes of Low Back Pain: A Systematic Review

STUDY DESIGN Systematic review. OBJECTIVES To identify diagnostic clinical prediction rules (CPRs) for low back pain (LBP) and to assess their readiness for clinical application. BACKGROUND Significant research has been invested into the development of CPRs that may assist in the meaningful subgrouping of patients with LBP. To date, very little is known about diagnostic forms of CPRs for LBP, which relate to the present status or classification of an individual, and whether they have been developed sufficiently to enable their application in clinical practice. METHODS A sensitive electronic search strategy using 7 databases was combined with hand searching and citation tracking to identify eligible studies. Two independent reviewers identified relevant studies for inclusion using a 2-stage selection process. The quality appraisal of included studies was conducted by 2 independent raters using the Quality Assessment of Diagnostic Accuracy Studies-2 and checklists composed of accepted methodological standards for the development of CPRs. RESULTS Of 10 014 studies screened for eligibility, the search identified that 13 diagnostic CPRs for LBP have been derived. Among those, 1 tool for identifying lumbar spinal stenosis and 2 tools for identifying inflammatory back pain have undergone validation. No impact analysis studies were identified. CONCLUSION Most diagnostic CPRs for LBP are in their initial development phase and cannot be recommended for use in clinical practice at this time. Validation and impact analysis of the diagnostic CPRs identified in this review are warranted, particularly for those tools that meet an identified unmet need of clinicians who manage patients with LBP. LEVEL OF EVIDENCE Diagnosis, level 2a-.

Enthusiasm for prescriptive clinical prediction rules (eg, back pain and more): a quick word of caution

Prescriptive clinical prediction rules (CPRs) are commonly used in rehabilitation practice. Multiple systematic reviews have noted concern about the value of these rules and the violations of these tools. More recently, additional concerns have been outlined involving modelling errors, poor precision and fragility of the rules. This editorial outlines updated concerns about prescriptive clinical predication rules. CPRs use baseline criteria called treatment effect modifiers,1 which are gathered from a physical examination to inform the type of treatment that a patient should preferentially receive. Many CPRs exist and have been enthusiastically incorporated in clinical practice. For example, CPRs exist to help identify which patients with back pain should receive spinal manipulation and stabilisation exercises. Their purpose is to better match patients to treatments, based on their predicted responsiveness to that treatment, independent of a diagnosis. Prescriptive CPRs are mentioned in clinical practice guidelines2 for patients with spinal pain and the premise …

Australian physiotherapists’ priorities for the development of clinical prediction rules for low back pain: A qualitative study

OBJECTIVE To identify the types of clinical prediction rules (CPRs) for low back pain (LBP) that Australian physiotherapists wish to see developed and the characteristics of LBP CPRs that physiotherapists believe are important. DESIGN Qualitative study using semi-structured focus groups. SETTING Metropolitan and regional areas of New South Wales, Australia. PARTICIPANTS Twenty-six physiotherapists who manage patients with LBP (77% male, 81% private practice). RESULTS Participants welcomed the development of prognostic forms of LBP CPRs. Tools that assist in identifying serious spinal pathology, likely responders to interventions, patients who are likely to experience an adverse outcome, and patients not requiring physiotherapy management were also considered useful. Participants thought that LBP CPRs should be uncomplicated, easy to remember, easy to apply, accurate and precise, and well-supported by research evidence. They should not contain an excessive number of variables, use complicated statistics, or contain variables that have no clear logical relationship to the dependent outcome. It was considered by participants that LBP CPRs need to be compatible with traditional clinical reasoning and decision-making processes, and sufficiently inclusive of a broad range of management approaches and common clinical assessment techniques. CONCLUSION There were several identified areas of perceived need for LBP CPR development and a range of characteristics such tools need to encompass to be considered clinically meaningful and useful by physiotherapists in this study. Targeting and incorporating the needs and preferences of physiotherapists is likely to result in the development of tools for LBP with the greatest potential to positively impact clinical practice.

A systematic review of diagnostic clinical prediction rules for low back pain

for eight weeks. Oxidative stress and antioxidant activity were measured by Free Radical Analytical System 4. Statistical analysis was performed by IBM SPSS Statistics 21.0 and Scheffe’s test was used for multiple comparison among the three groups with statistical significance of P< 0.05. Results: When these animals grew to adulthood eight weeks after starting the experiment, oxidative stress at rest was significantly high only in Group J by 28.2% relative to Group C (P< 0.05). Oxidative stress at rest significantly increased in all groups at eight weeks compared to the preexperimental state (all P< 0.001). A comparison of preand post-experimental antioxidant activity in all groups showed a significant decrease in Groups C and T at eight weeks (all P< 0.001). Conclusion(s): An increase in oxidative stress can surpass anti-oxidative stress activity depending on the intensity, duration, and types of exercise. Our study also implied that oxidative stress may increase with musculoskeletal growth in adulthood. Particularly for exercise in the growth stage, it was suggested that active oxygen produced by muscle damage through anaerobic exercise such as jumping had a greater effect on oxidative stress than that by aerobic exercise. It was also indicated that antioxidant activity constantly changes to control oxidative stress within a certain level in response to an increase in oxidative stress. Implications: Our study suggested that anaerobic exercise in the growth stage can help enhance antioxidant activity. However, exercise itself can possibly inflict serious damage on the living body. Therefore, exercise in the growth stage should be demonstrated with good consideration of exercise modality and load. These results are helpful as preclinical data for pediatric physiotherapy.