A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction

Derivation of clinical prediction rules for identifying patients with non-acute low back pain who respond best to a lumbar stabilization exercise program at post-treatment and six-month follow-up

Low back pain (LBP) remains one of the most common and incapacitating health conditions worldwide. Clinical guidelines recommend exercise programs after the acute phase, but clinical effects are modest when assessed at a population level. Research needs to determine who is likely to benefit from specific exercise interventions, based on clinical presentation. This study aimed to derive clinical prediction rules (CPRs) for treatment success, using a lumbar stabilization exercise program (LSEP), at the end of treatment and at six-month follow-up. The eight-week LSEP, including clinical sessions and home exercises, was completed by 110 participants with non-acute LBP, with 100 retained at the six-month follow-up. Physical (lumbar segmental instability, motor control impairments, posture and range of motion, trunk muscle endurance and physical performance tests) and psychological (related to fear-avoidance and home-exercise adherence) measures were collected at a baseline clinical exam. Multivariate logistic regression models were used to predict clinical success, as defined by ≥50% decrease in the Oswestry Disability Index. CPRs were derived for success at program completion (T8) and six-month follow-up (T34), negotiating between predictive ability and clinical usability. The chosen CPRs contained four (T8) and three (T34) clinical tests, all theoretically related to spinal instability, making these CPRs specific to the treatment provided (LSEP). The chosen CPRs provided a positive likelihood ratio of 17.9 (T8) and 8.2 (T34), when two or more tests were positive. When applying these CPRs, the probability of treatment success rose from 49% to 96% at T8 and from 53% to 92% at T34. These results support the further development of these CPRs by proceeding to the validation stage.

Immediate effect of mechanical lumbar traction in patients with chronic low back pain: A crossover, repeated measures, randomized controlled trial

BACKGROUND

Lumbar traction is a treatment method traditionally used for chronic low back pain (CLBP) in many countries. However, its clinical effectiveness has not been proven in medical practice. The purpose is to conduct a multi-center, crossover, randomized controlled trial (RCT) to prove the efficacy and safety of traction on CLBP patients, using equipment capable of precise traction force control and of reproducibility of the condition based on the previous biomechanical and pre-clinical studies.

METHODS

Ninety-five patients with non-specific CLBP from 28 clinics and hospitals were randomly assigned to either the intermittent traction with vibration (ITV) first group (A: sequence ITV to ITO) or the intermittent traction only (ITO) first group (B: sequence ITO to ITV); the former was treated with repeated traction and vibration force added to preload. All patients were followed up weekly for 2 periods after study-initiation. The primary outcome measures were disability level including pain and quality of life (based on Japan Low back pain Evaluation Questionnaire; JLEQ), and JLEQ was measured repeatedly. Statistical analysis was performed using linear mixed model.

RESULTS

Comparing to pre-traction data, both traction modes significant improvement except the first intervention of ITO treatment. The differences in JLEQ scores over time showed significant improvements in the treatment to which vibrational force was added in contrast to the conventional traction treatment; Mean difference was significant to compare ITV treatment and ITO treatment (-1.75 (p = 0.001), 95% CI; -2.69 to -0.80). However, neither difference between the two sequences (p = 0.884) nor carryover effect (p = 0.527) was observed.

CONCLUSIONS

Altogether, the results indicate that lumbar traction was able to improve the pain and functional status immediately in patients with CLBP. This study contributes to add some evidence of the efficacy of lumbar traction.

Performance of Pain Interventionalists From Different Specialties in Treating Degenerative Disk Disease-Related Low Back Pain

OBJECTIVES

To examine the utilization of current common treatments by providers from different specialties and the effect on delaying spinal surgery in patients with disk degenerative disease (DDD) related low back pain.

DESIGN

Retrospective observational study using data from the MarketScan Commercial Claims and Encounters database (2005-2013).

SETTING

Not applicable.

PARTICIPANTS

Patients (N=6229) newly diagnosed with DDD-related low back pain who received interventional treatments from only 1 provider specialty and continuously enrolled in the database for 3 years after diagnosis.

MAIN OUTCOME MEASURES

Measures of treatment utilization and cost were constructed for patients who received spinal surgery within 3 years after diagnosis. Cox proportional hazards models were used to examine time to surgery among provider specialties and generalized linear models were used to examine cost differences among provider specialties.

RESULTS

Of the 6229 patients, 427 (6.86%) underwent spinal surgery with unadjusted mean interventional treatment costs ranging from $555 to $851. Although the differences in mean costs across provider specialties were large, they were not statistically significant. Cox proportional hazards models showed that there was no significant difference between provider specialties in the time from DDD diagnosis to spinal surgery. However, patients diagnosed with DDD at a younger age and receiving physical therapy had significantly delayed time to surgery (hazard ratio, 0.66; 95% confidence interval [CI], 0.54-0.81 and hazard ratio, 0.77; 95% CI, 0.62-0.96, respectively).

CONCLUSIONS

Although there were no statistically significant differences among provider specialties for time to surgery and cost, patients receiving physical therapy had significantly delayed time to surgery.

Examination of a Subgroup of Patients With Chronic Low Back Pain Likely to Benefit More From Pilates-Based Exercises Compared to an Educational Booklet

OBJECTIVE

To investigate whether 2 previously published classification approaches, the updated treatment-based classification system and a Pilates subgroup defined by a preliminary clinical prediction rule, could identify patients with chronic low back pain who would benefit more from Pilates exercises compared to an educational booklet.

DESIGN

Secondary analysis of a randomized controlled trial.

METHODS

Two hundred twenty-two patients received advice and were randomly allocated to a group that received an educational booklet with no additional treatment (n = 74) or a group that received Pilates-based exercise treatment (n = 148) 2 or 3 times a week. At baseline, using a treatment-based classification system, patients were classified as having a good prognosis (positive movement control) or a poor prognosis. Similarly, using the Pilates clinical prediction rule, patients were classified as having a good prognosis (positive) or a poor prognosis (negative). The analysis was conducted using linear regression models to analyze the interaction between subgroup characteristics and treatment effect size, with changes in pain and disability from baseline to 6 weeks after randomization as dependent variables.

RESULTS

None of the interaction terms for pain and disability were statistically significant. The treatment effect of Pilates versus an educational booklet was similar in all subgroups.

CONCLUSION

The treatment-based classification system and the Pilates clinical prediction rule did not differentiate subgroups of patients with chronic low back pain who were more or less likely to benefit more from Pilates compared to an educational booklet. J Orthop Sports Phys Ther 2020;50(4):189-197. Epub 23 Aug 2019. doi:10.2519/jospt.2019.8839.

Developing a clinical prediction rule to identify patients with lumbar disc herniation who demonstrate short-term improvement with mechanical lumbar traction

OBJECTIVE

To develop a clinical prediction rule (CPR) that predicts treatment responses to mechanical lumbar traction (MLT) among patients with lumbar disc herniation (LDH).

METHOD

This study was an uncontrolled prospective cohort study. The subjects included 103 patients diagnosed with LDH for which they underwent conservative therapy. The subjects received MLT for 2 weeks, and the application of any other medication was left at the discretion of the attending physician. The initial evaluation was performed prior to the initiation of treatment. The independent variables from the initial evaluation were imaging diagnosis, Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire score, visual analog scale, medical interview, physical examination. The patients whose ODI after 2 weeks of treatment improved by ≥50% of that at the initial evaluation were defined as responders.

RESULTS

Of the 103 subjects, 24 were responders, and the five predictors selected for the CPR were limited lumbar extension range of motion, low-level fear-avoidance beliefs regarding work, no segmental hypomobility in the lumbar spine, short duration of symptoms, and sudden onset of symptoms. For the patients with at least three of the five predictors, the probability of their ODI greatly improving increased from 23.3% to 48.7% compared with the patients without these predictors (positive likelihood ratio, 3.13).

CONCLUSION

Five factors were selected for the CPR to predict whether patients with LDH would demonstrate short-term improvement following conservative therapy with MLT.

Mechanical Traction for Lumbar Radicular Pain: Supine or Prone? A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to compare the effects of mechanical lumbar traction either in the supine or in the prone position with conventional physical therapy (PT) in patients with chronic low back pain and lumbosacral nerve root involvement in terms of disability, pain, and mobility.

DESIGN

Participants (N = 125) were randomly assigned to receive 15 sessions of PT with additional mechanical lumbar traction either in the supine position (supine traction group) or in the prone position (prone traction group) or only PT without traction (PT only group). Patients were assessed at baseline and at the end of the PT sessions in terms of disability, pain, and mobility. Disability was assessed using the modified Oswesty Disability Index; pain was assessed using a visual analog scale, and lumbar mobility was assessed using the modified lumbar Schober test.

RESULTS

One hundred eighteen patients completed the trial. All groups improved significantly in the Oswesty Disability Index, visual analog scale, and modified lumbar Schober test (P < 0.05). In the between-group analysis, improvements of Oswesty Disability Index and visual analog scale were found significantly better in the prone traction group compared with the PT only group (adjusted P = 0.031 and 0.006, respectively).

CONCLUSIONS

Addition of traction in the prone position to other modalities resulted in larger immediate improvements in terms of pain and disability, and the results suggest that when using traction, prone traction might be first choice. Further research is needed to confirm the benefits of lumbar traction in the prone position.

Lumbar mechanical traction: a biomechanical assessment of change at the lumbar spine

BACKGROUND

Lumbar traction is a traditional treatment modality for chronic low back pain (CLBP) in many countries. However, its effectiveness has not been demonstrated in clinical practice because of the following: (1) the lack of in vivo biomechanical confirmation of the mechanism of lumbar traction that occurs at the lumbar spine; (2) the lack of a precise delivery system for traction force and, subsequently, the lack of reproducibility; and (3) few randomized controlled trials proving its effectiveness and utility.

METHODS

This study was planned as a preparatory experiment for a randomized clinical trial, and it aimed (1) to examine the biomechanical change at the lumbar area under lumbar traction and confirm its reproducibility and accuracy as a mechanical intervention, and (2) to reconfirm our clinical impression of the immediate effect of lumbar traction. One hundred thirty-three patients with non-specific CLBP were recruited from 28 orthopaedic clinics to undergo a biomechanical experiment and to assess and determine traction conditions for the next clinical trial. We used two types of traction devices, which are commercially available, and incorporated other measuring tools, such as an infrared range-finder and large extension strain gauge. The finite element method was used to analyze the real data of pelvic girdle movement at the lumbar spine level. Self-report assessments with representative two conditions were analyzed according to the qualitative coding method.

RESULTS

Thirty-eight participants provided available biomechanical data. We could not measure directly what happened in the body, but we confirmed that the distraction force lineally correlated with the movement of traction unit at the pelvic girdle. After applying vibration force to preloading, the strain gauge showed proportional vibration of the shifting distance without a phase lag qualitatively. FEM simulation provided at least 3.0-mm shifting distance at the lumbar spine under 100 mm of body traction. Ninety-five participants provided a treatment diary and were classified as no pain, improved, unchanged, and worsened. Approximately 83.2% of participants reported a positive response.

CONCLUSION

Lumbar traction can provide a distractive force at the lumbar spine, and patients who experience the application of such force show an immediate response after traction.

TRIAL REGISTRATION

University Hospital Medical Information Network - Clinical Trial Registration: UMIN-CTR000024329 (October 13, 2016).

Mobilization of the lumbar spine in a 76-year-old male with mechanical low back pain and an abdominal aortic aneurysm: A case report

BACKGROUND

Abdominal aortic aneurysms (AAAs) are found in 1-12% of older males. Low back pain (LBP) is prevalent with incidence increasing with age and can respond to manual therapy (MT). To date, the safety of the application of MT for LBP in the presence of a known AAA has not been reported. This case reports on the short-term effects of MT in a patient with LBP and AAA and pre- and post-therapy imaging.

CASE DESCRIPTION

A 76-year-old male presented with mechanical LBP, groin pain, and a known 4.2-cm AAA. A lumbar magnetic resonance imaging showed significant multilevel abnormalities. Abdominal screening did not elicit back or groin pain. Lumbar and hip range of motion and accessory motion testing reproduced his complaints. He was treated with lumbar and hip MT.

OUTCOMES

After three visits, he reported that his groin pain resolved, and his back pain could be managed with home exercise. He reported a +6 on the global rating of change. Repeated follow-up imaging of his AAA demonstrated no significant change of his AAA.

DISCUSSION

No immediate adverse events were recorded, and repeated follow-up imaging indicated no significant AAA expansion. Considering that mobilization causes similar displacement to active motion, research into the safety of MT in this population is warranted as are guidelines for appropriate initial and ongoing clinical screening during treatment in this population.

Immediate and short-term effects of mulligan concept positional sustained natural apophyseal glides on an athletic young-adult population classified with mechanical neck pain: an exploratory investigation

Objectives: Mechanical neck pain (MNP) is common in the athletic population. While symptoms may present at the cervical spine for patients complaining of MNP, thoracic spinal alignment or dysfunction may influence cervical positioning and overall cervical function. Clinicians often employ cervical high-velocity low-amplitude (HVLA) thrust manipulations to treat MNP, albeit with a small level of inherent risk. Mulligan Concept positional sustained natural apophyseal glides (SNAGs) directed at the cervicothoracic region are emerging to treat patients with cervical pain and dysfunction, as evidence supporting an interdependent relationship between the thoracic and cervical spine grows. The purpose of this a priori study was to evaluate outcome measures of patients classified with MNP treated with the Mulligan Concept Positional SNAGs. Methods: Ten consecutive young-adult patients, ages ranging from 15 to 18 years (mean = 16.5 ± 1.78), classified with MNP were treated utilizing Mulligan Concept Positional SNAGs. The Numeric Rating Scale (NRS), Patient-Specific Functional Scale (PSFS), Neck Disability Index (NDI), Disablement in the Physically Active (DPAS), and Fear-Avoidance Based Questionnaire-Physical Activity (FABQPA) were collected for inclusion criteria and to identify patient-reported pain and dysfunction. Results: Patients reported decreases in pain on the NRS [5.4 to .16, p = .001], increases in function on the PSFS [5.2 to 10, p = .001], and increases in cervical range of motion (CROM) [ext p = .003, flex p = .009, left rot p = .001, right rot p = .002] immediately post-treatment and between treatments. Discussion: Positional SNAGs directed at the cervicothoracic region may address a variety of patient reported symptoms for MNP, and the number of treatment sessions needed for symptom resolution may be closer to a single session rather than multiple treatments. Level of Evidence: 4.

Prevalence and reliability of treatment-based classification for subgrouping patients with low back pain

Objectives

To observe the distribution of patients who presented with low back pain (LBP) and to determine the between therapists' interrater reliability of assessments in a private outpatient setting using treatment-based classification (TBC) subgroups.

Methods

An observational and methodological study was conducted. Four hundred and twenty-nine patients (231 male; 198 female) presenting LBP symptoms and referred to conservative treatment were assessed by 13 physical therapists who conducted a 60-min examination process utilizing TBC subgroups. Interrater reliability analyses from six raters were assessed using Fleiss' kappa and previously recorded data (n = 30).

Results

In this study, 65.74% of patients were classified in only one subgroup, the most prevalent being stabilization (21.91%), followed by extension (15.38%), traction (11.89%), flexion (10.96%), manipulation (5.13%), and lateral shift (0.47%). Approximately 20.98% of patients were classified in two subgroups, where the most frequent overlaps were flexion + stabilization (7.46%), extension + stabilization (6.06%), flexion + traction (4.20%), extension + manipulation (1.86%), and 13.29% of patients were not classified in any TBC subgroup. Analysis of interrater reliability showed a kappa value of 0.62 and an overall agreement of 66% between raters.

Discussion

LBP is a heterogeneous clinical condition and several classification methods are proposed in the attempt to observe better outcomes for patients. Eighty-five percent of patients assessed were able to be classified when using the TBC assessment and reliability analysis showed a substantial agreement between raters.

Level of Evidence

2c.

Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review

Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders.

Manual unloading of the lumbar spine: can it identify immediate responders to mechanical traction in a low back pain population? A study of reliability and criterion referenced predictive validity

BACKGROUND

To date, no research has examined the reliability or predictive validity of manual unloading tests of the lumbar spine to identify potential responders to lumbar mechanical traction.

PURPOSE

To determine: (1) the intra and inter-rater reliability of a manual unloading test of the lumbar spine and (2) the criterion referenced predictive validity for the manual unloading test.

METHODS

Ten volunteers with low back pain (LBP) underwent a manual unloading test to establish reliability. In a separate procedure, 30 consecutive patients with LBP (age 50·86±11·51) were assessed for pain in their most provocative standing position (visual analog scale (VAS) 49·53±25·52 mm). Patients were assessed with a manual unloading test in their most provocative position followed by a single application of intermittent mechanical traction. Post traction, pain in the provocative position was reassessed and utilized as the outcome criterion.

RESULTS

The test of unloading demonstrated substantial intra and inter-rater reliability K = 1·00, P = 0·002, K = 0·737, P = 0·001, respectively. There were statistically significant within group differences for pain response following traction for patients with a positive manual unloading test (P<0·001), while patients with a negative manual unloading test did not demonstrate a statistically significant change (P>0·05). There were significant between group differences for proportion of responders to traction based on manual unloading response (P = 0·031), and manual unloading response demonstrated a moderate to strong relationship with traction response Phi = 0·443, P = 0·015.

DISCUSSION AND CONCLUSION

The manual unloading test appears to be a reliable test and has a moderate to strong correlation with pain relief that exceeds minimal clinically important difference (MCID) following traction supporting the validity of this test.

A Comparison of Two Strategies for Building an Exposure Prediction Model

Cost-efficient assessments of job exposures in large populations may be obtained from models in which 'true' exposures assessed by expensive measurement methods are estimated from easily accessible and cheap predictors. Typically, the models are built on the basis of a validation study comprising 'true' exposure data as well as an extensive collection of candidate predictors from questionnaires or company data, which cannot all be included in the models due to restrictions in the degrees of freedom available for modeling. In these situations, predictors need to be selected using procedures that can identify the best possible subset of predictors among the candidates. The present study compares two strategies for selecting a set of predictor variables. One strategy relies on stepwise hypothesis testing of associations between predictors and exposure, while the other uses cluster analysis to reduce the number of predictors without relying on empirical information about the measured exposure. Both strategies were applied to the same dataset on biomechanical exposure and candidate predictors among computer users, and they were compared in terms of identified predictors of exposure as well as the resulting model fit using bootstrapped resamples of the original data. The identified predictors were, to a large part, different between the two strategies, and the initial model fit was better for the stepwise testing strategy than for the clustering approach. Internal validation of the models using bootstrap resampling with fixed predictors revealed an equally reduced model fit in resampled datasets for both strategies. However, when predictor selection was incorporated in the validation procedure for the stepwise testing strategy, the model fit was reduced to the extent that both strategies showed similar model fit. Thus, the two strategies would both be expected to perform poorly with respect to predicting biomechanical exposure in other samples of computer users.

Prediction of pain outcomes in a randomized controlled trial of dose-response of spinal manipulation for the care of chronic low back pain

Background

No previous studies have created and validated prediction models for outcomes in patients receiving spinal manipulation for care of chronic low back pain (cLBP). We therefore conducted a secondary analysis alongside a dose-response, randomized controlled trial of spinal manipulation.

Methods

We investigated dose, pain and disability, sociodemographics, general health, psychosocial measures, and objective exam findings as potential predictors of pain outcomes utilizing 400 participants from a randomized controlled trial. Participants received 18 sessions of treatment over 6-weeks and were followed for a year. Spinal manipulation was performed by a chiropractor at 0, 6, 12, or 18 visits (dose), with a light-massage control at all remaining visits. Pain intensity was evaluated with the modified von Korff pain scale (0–100). Predictor variables evaluated came from several domains: condition-specific pain and disability, sociodemographics, general health status, psychosocial, and objective physical measures. Three-quarters of cases (training-set) were used to develop 4 longitudinal models with forward selection to predict individual “responders” (≥50 % improvement from baseline) and future pain intensity using either pretreatment characteristics or post-treatment variables collected shortly after completion of care. The internal validity of the predictor models were then evaluated on the remaining 25 % of cases (test-set) using area under the receiver operating curve (AUC), R², and root mean squared error (RMSE).

Results

The pretreatment responder model performed no better than chance in identifying participants who became responders (AUC = 0.479). Similarly, the pretreatment pain intensity model predicted future pain intensity poorly with low proportion of variance explained (R² = .065). The post-treatment predictor models performed better with AUC = 0.665 for the responder model and R² = 0.261 for the future pain model. Post-treatment pain alone actually predicted future pain better than the full post-treatment predictor model (R² = 0.350). The prediction errors (RMSE) were large (19.4 and 17.5 for the pre- and post-treatment predictor models, respectively).

Conclusions

Internal validation of prediction models showed that participant characteristics preceding the start of care were poor predictors of at least 50 % improvement and the individual’s future pain intensity. Pain collected shortly after completion of 6 weeks of study intervention predicted future pain the best.

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.

Stratified models of care

Stratified care for back pain involves targeting treatment to subgroups of patients based on their key characteristics such as prognostic factors, likely response to treatment and underlying mechanisms. It aims to tailor therapeutic decisions in ways that maximise treatment benefit, reduce harm and increase health-care efficiency by offering the right treatment to the right patient at the right time. From being called the 'Holy Grail' of back pain research over a decade ago, stratified care is becoming the zeitgeist in research and clinical practice. In this chapter, we introduce and evaluate the quality and underpinning evidence for three examples of stratified care for back pain to highlight their general principles, research design issues and clinical practice implications. We include consideration of their merits for implementation in practice. We conclude with a set of remaining, key research questions.

Quantitative sensory testing changes in the successful management of chronic low back pain

Individuals with chronic low back pain (LBP) represent a significant percentage of patients in physical therapy practice. The clinical pattern often includes diffuse pain and a variety of sensory complaints, making categorization difficult and leading to diagnoses such as non-specific LBP. Objective measures of sensory changes through quantitative sensory testing may help identify central sensitization of nociceptive pathways in this population. Identification of these somatosensory changes may contribute to clinical decision making and patient management. The purpose of this case report is to present objective evaluation findings, including altered somatosensation, in a patient with a 2-year history of LBP, and to describe changes in function and quantitative sensory testing with successful management.

Preliminary state of development of prediction models for primary care physical therapy: a systematic review

OBJECTIVE

To summarize the methodological quality and developmental stage of prediction models for musculoskeletal complaints that are relevant for physical therapists in primary care.

STUDY DESIGN AND SETTING

A systematic literature search was carried out in the databases of Medline, Embase, and Cinahl. Studies on prediction models for musculoskeletal complaints that can be used by primary care physical therapists were included. Methodological quality of the studies was assessed and relevant study characteristics were extracted.

RESULTS

The search retrieved 4,702 references of which 29 studies were included in this review. The study quality of the included studies showed substantial variation. The studied populations consisted mostly of back (n=10) and neck pain (n=6) patients, and patients with knee complaints (n=4). Most studies (n=22) used "perceived recovery" as primary outcome. Most prediction models (n=18) were at the derivation level of development.

CONCLUSIONS

Many prediction models are available for a wide range of patient populations. The developmental stage of most models is preliminary and the study quality is often moderate. We do not recommend physiotherapist to use these models yet. All models reviewed here are in the developmental stage and need validation and impact evaluation before using them in daily practice.

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.

Critical appraisal of clinical prediction rules that aim to optimize treatment selection for musculoskeletal conditions

BACKGROUND

Clinical prediction rules (CPRs) for treatment selection in musculoskeletal conditions have become increasingly popular.

PURPOSE

The purposes of this review are: (1) to critically appraise studies evaluating CPRs and (2) to consider the clinical utility and stage of development of each CPR.

DATA SOURCES

Pertinent databases were searched up to April 2009. Studies aiming to develop or evaluate a CPR for treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility and extracted methodological data, stage of development, and effect size information. STUDY SELECTION/DATA EXTRACTION AND SYNTHESIS: Eighteen studies, evaluating 15 separate CPRs, were included. Fourteen CPRs were at the derivation stage, and all CPRs had been evaluated using a single-arm trial design, thus it is not possible to determine whether the CPRs identify prognosis (regardless of treatment) or specifically response to treatment. The CPR at the validation stage investigated spinal manipulative therapy (SMT) for low back pain and had been evaluated in 2 separate well-conducted randomized controlled trials. The first trial demonstrated a clinically meaningful effect of the SMT CPR; the additional effect from SMT in patients "positive-on-the-rule" was 15 Oswestry disability units at week 1 and 9 units at week 4. The second trial showed that the CPR did not generalize to a different clinical setting, including a modified treatment.

LIMITATIONS

Due to differences in methods of reporting and journal publication restraints (eg, word count restrictions), some quality assessment items may have been completed in the included studies, but not captured in this review.

CONCLUSIONS

There is, at present, little evidence that CPRs can be used to predict effects of treatment for musculoskeletal conditions. The principal problem is that most studies use designs that cannot differentiate between predictors of response to treatment and general predictors of outcome. Only 1 CPR has been evaluated within an RCT designed to predict response to treatment. Validation of these rules is imperative to allow clinical application.