Statistical Analysis of Clinical Prediction Rules for Rehabilitation Interventions: Current State of the Literature

Subject-specific sensitivity of several biomechanical features to fatigue during an exhaustive treadmill run

The aim of the present study was to examine the sensitivity of several movement features during running to exhaustion in a subject-specific setup adopting a cross-sectional design and a machine learning approach. Thirteen recreational runners, that systematically trained and competed, performed an exhaustive running protocol on an instrumented treadmill. Respiratory data were collected to establish the second ventilatory threshold (VT2) in order to obtain a reference point regarding the gradual accumulation of fatigue. A machine learning approach was adopted to analyze kinetic and kinematic data recorded for each participant, using a random forest classifier for the region pre and post the second ventilatory threshold. SHapley Additive exPlanations (SHAP) analysis was used to explain the models' predictions and to provide insight about the most important variables. The classification accuracy value of the models adopted ranged from 0.853 to 0.962. The most important feature in six out of thirteen participants was the angular range in AP axis of upper trunk C7 (RTAPu) followed by maximum loading rate (RFDmaxD) and the angular range in the LT axis of the C7. SHAP dependence plots also showed an increased dispersion of predictions in stages around the second ventilatory threshold which is consistent with feature interactions. These results showed that each runner used the examined features differently to cope with the increase in fatigue and mitigate its effects in order to maintain a proper motor pattern.

Diagnostic clinical prediction rules for categorising low back pain: A systematic review

BACKGROUND

Low back pain (LBP) is a common complex condition, where specific diagnoses are hard to identify. Diagnostic clinical prediction rules (CPRs) are known to improve clinical decision-making. A review of LBP diagnostic-CPRs by Haskins et al. (2015) identified six diagnostic-CPRs in derivation phases of development, with one tool ready for implementation. Recent progress on these tools is unknown. Therefore, this review aimed to investigate developments in LBP diagnostic-CPRs and evaluate their readiness for implementation.

METHODS

A systematic review was performed on five databases (Medline, Amed, Cochrane Library, PsycInfo, and CINAHL) combined with hand-searching and citation-tracking to identify eligible studies. Study and tool quality were appraised for risk of bias (Quality Assessment of Diagnostic Accuracy Studies-2), methodological quality (checklist using accepted CPR methodological standards), and CPR tool appraisal (GRade and ASsess Predictive).

RESULTS

Of 5021 studies screened, 11 diagnostic-CPRs were identified. Of the six previously known, three have been externally validated but not yet undergone impact analysis. Five new tools have been identified since Haskin et al. (2015); all are still in derivation stages. The most validated diagnostic-CPRs include the Lumbar-Spinal-Stenosis-Self-Administered-Self-Reported-History-Questionnaire and Diagnosis-Support-Tool-to-Identify-Lumbar-Spinal-Stenosis, and the StEP-tool which differentiates radicular from axial-LBP.

CONCLUSIONS

This updated review of LBP diagnostic CPRs found five new tools, all in the early stages of development. Three previously known tools have now been externally validated but should be used with caution until impact evaluation studies are undertaken. Future funding should focus on externally validating and assessing the impact of existing CPRs on clinical decision-making.

Development of a Clinical Prediction Rule for Treatment Success with Transcranial Direct Current Stimulation for Knee Osteoarthritis Pain: A Secondary Analysis of a Double-Blind Randomized Controlled Trial

The study’s objective was to develop a clinical prediction rule that predicts a clinically significant analgesic effect on chronic knee osteoarthritis pain after transcranial direct current stimulation treatment. This is a secondary analysis from a double-blind randomized controlled trial. Data from 51 individuals with chronic knee osteoarthritis pain and an impaired descending pain inhibitory system were used. The intervention comprised a 15-session protocol of anodal primary motor cortex transcranial direct current stimulation. Treatment success was defined by the Western Ontario and McMaster Universities’ Osteoarthritis Index pain subscale. Accuracy statistics were calculated for each potential predictor and for the final model. The final logistic regression model was statistically significant (p < 0.01) and comprised five physical and psychosocial predictor variables that together yielded a positive likelihood ratio of 14.40 (95% CI: 3.66−56.69) and an 85% (95%CI: 60−96%) post-test probability of success. This is the first clinical prediction rule proposed for transcranial direct current stimulation in patients with chronic pain. The model underscores the importance of both physical and psychosocial factors as predictors of the analgesic response to transcranial direct current stimulation treatment. Validation of the proposed clinical prediction rule should be performed in other datasets.

Association between Psychological Status and Condylar Bony Changes in Adults: A Retrospective Survey-Based Study

Background: This article studies the association between psychological status and condylar bony changes in adults and assesses psychological questionnaires as an indicator of potential condylar bony changes. It is meaningful because condylar bony changes, a severe subtype of TMD and big concern in orthodontic treatment, would likely be ignored in patients with few TMD symptoms, in which case, even with potential psychological problems (depression, somatization and anxiety) being noticed, orthodontists may underestimate the possibility or severity of condylar bony changes and thus may not perform relevant examinations. Methods: A total of 195 adults (145 female and 50 male) who consulted orthodontists and had clinical records were included in this study. Initial CBCT images taken before orthodontic treatment were used for observing their condylar bony changes, and a comprehensive questionnaire conducted by each adult to evaluate psychological status was collected. Age, sex, TMD symptom history, scores on Patient Health Questionnaire-9 (PHQ-9), PHQ-15 and Generalized Anxiety Disorder-7 (GAD-7), and condylar bony changes of these adults were recorded. Odds ratios (OR) and 95% confidence intervals (CIs) for identifying the independent risk factors associated with condylar bony changes were calculated with univariate and multivariate logistic regression analysis. The kappa statistic was used to assess intraobserver reliability of CBCT analysis. Results: The scores of PHQ-15 (OR: 2.088, 95% CI: 1.061−4.108, p < 0.05) and GAD-7 (OR: 2.133, 95% CI: 1.082−4.204, p < 0.05) were correlated with the condylar bony changes on CBCT. Besides, the probability of having condylar bony changes was positively correlated with the number of psychological problems concomitantly present in an adult (OR: 1.440, 95% CI: 1.10−1.867, p < 0.01). The intraobserver agreement value for CBCT analysis was substantial (κ = 0.732). Conclusions: This study found that positive PHQ-15 (somatization) and GAD-7 (anxiety) scores were associated with condylar bony changes in adults. Moreover, the number of psychological problems concomitantly present in an adult was positively associated with the probability of having condylar bony changes.

Toward the Personalization of Biceps Fatigue Detection Model for Gym Activity: An Approach to Utilize Wearables' Data from the Crowd

Nowadays, wearables-based Human Activity Recognition (HAR) systems represent a modern, robust, and lightweight solution to monitor athlete performance. However, user data variability is a problem that may hinder the performance of HAR systems, especially the cross-subject HAR models. Such a problem may have a lesser effect on the subject-specific model because it is a tailored model that serves a specific user; hence, data variability is usually low, and performance is often high. However, such a performance comes with a high cost in data collection and processing per user. Therefore, in this work, we present a personalized model that achieves higher performance than the cross-subject model while maintaining a lower data cost than the subject-specific model. Our personalization approach sources data from the crowd based on similarity scores computed between the test subject and the individuals in the crowd. Our dataset consists of 3750 concentration curl repetitions from 25 volunteers with ages and BMI ranging between 20-46 and 24-46, respectively. We compute 11 hand-crafted features and train 2 personalized AdaBoost models, Decision Tree (AdaBoost-DT) and Artificial Neural Networks (AdaBoost-ANN), using data from whom the test subject shares similar physical and single traits. Our findings show that the AdaBoost-DT model outperforms the cross-subject-DT model by 5.89%, while the AdaBoost-ANN model outperforms the cross-subject-ANN model by 3.38%. On the other hand, at 50.0% less of the test subject's data consumption, our AdaBoost-DT model outperforms the subject-specific-DT model by 16%, while the AdaBoost-ANN model outperforms the subject-specific-ANN model by 10.33%. Yet, the subject-specific models achieve the best performances at 100% of the test subjects' data consumption.

The identification of preliminary prognostic indicators that predict treatment response for exercise therapy in patients with nonspecific chronic low back pain: A multiple-arm cohort study design

BACKGROUND

For patients with nonspecific chronic low back pain (CLBP), exercise therapy is stated to be the most effective intervention strategy but it is unclear which kind of exercise therapy is most beneficial.

OBJECTIVE

To identify preliminary prognostic indicators that predict outcome for exercise therapy in patients with nonspecific CLBP.

METHODS

Patients were recruited in two hospitals and received 18 intervention sessions: stabilization therapy, isometric training therapy or a combination therapy. The primary outcome measure was the change in the Modified Low Back Pain Disability Questionnaire after nine weeks.

RESULTS

A total of 59 patients completed the study which represents a statistical power of 90%. In total, 30 patients were categorized as having treatment success and 29 as treatment failure. After using regression analyses to determine the association between standardized examination variables and treatment response status, prognostic indicators were identified for predicting therapy success (positive likelihood ratio [LR], 3.8) and failure (negative LR, 0.19).

CONCLUSIONS

The most important variables were the prone instability test, pelvic tilt test, straight leg raise, body weight, visual analogue scale and the short form 36 health survey.

Existing validated clinical prediction rules for predicting response to physiotherapy interventions for musculoskeletal conditions have limited clinical value: A systematic review

OBJECTIVE

To systematically review clinical prediction rules (CPRs) that have undergone validation testing for predicting response to physiotherapy-related interventions for musculoskeletal conditions.

STUDY DESIGN AND SETTING

PubMed, EMBASE, CINAHL and Cochrane Library were systematically searched to September 2020. Search terms included musculoskeletal (MSK) conditions, physiotherapy interventions and clinical prediction rules. Controlled studies that validated a prescriptive CPR for physiotherapy treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility. Original derivation studies of each CPR were identified. Risk of bias was assessed with the PROBAST tool (derivation studies) and the Cochrane Effective Practice and Organisation of Care group criteria (validation studies).

RESULTS

Nine studies aimed to validate seven prescriptive CPRs for treatment response for MSK conditions including back pain, neck pain, shoulder pain and carpal tunnel syndrome. Treatments included manipulation, traction and exercise. Seven studies failed to demonstrate an association between CPR prediction and outcome. Methodological quality of derivation studies was poor and for validation studies was good overall.

CONCLUSION

Results do not support the use of any CPRs identified to aid physiotherapy treatment selection for common musculoskeletal conditions, due to methodological shortcomings in the derivation studies and lack of association between CPR and outcome in validation studies.

Knowledge Translation in Physical Medicine and Rehabilitation: A Citation Analysis of the Knowledge-to-Action Literature

OBJECTIVES

To (1) provide an overview of the use of the Knowledge-to-Action Cycle (KTA) to guide a clinical implementation project; (2) identify activities performed in each phase of the KTA; and (3) provide suggestions to improve KTA activities in physical medicine and rehabilitation.

DATA SOURCES

Google Scholar and PubMed were searched through December 31, 2019.

STUDY SELECTION

Two reviewers screened titles, abstracts, and full-text articles to identify published studies that used the KTA to implement a project.

DATA EXTRACTION

Two reviewers examined full-text articles. Data extraction included activities performed in each phase of the KTA, including measurements used to evaluate the project's effectiveness.

DATA SYNTHESIS

Commonly performed KTA activities were identified and country of study, area of rehabilitation, and other factors related to the use of the KTA in rehabilitation were described. A total of 46 articles that met the study's inclusion criteria provided an overview of the use of the KTA in rehabilitation. Strengths and weaknesses of the articles are discussed and recommendations for improved KTA use are provided.

CONCLUSIONS

Implementation of evidence-based practice requires focused engineering and efforts. This review provides an overview of the knowledge translation activities occurring in physical medicine and rehabilitation and considerations to improve knowledge translation research and practice.

Wearable Sensor Data to Track Subject-Specific Movement Patterns Related to Clinical Outcomes Using a Machine Learning Approach

Wearable sensors can provide detailed information on human movement but the clinical impact of this information remains limited. We propose a machine learning approach, using wearable sensor data, to identify subject-specific changes in gait patterns related to improvements in clinical outcomes. Eight patients with knee osteoarthritis (OA) completed two gait trials before and one following an exercise intervention. Wearable sensor data (e.g., 3-dimensional (3D) linear accelerations) were collected from a sensor located near the lower back, lateral thigh and lateral shank during level treadmill walking at a preferred speed. Wearable sensor data from the 2 pre-intervention gait trials were used to define each individual’s typical movement pattern using a one-class support vector machine (OCSVM). The percentage of strides defined as outliers, based on the pre-intervention gait data and the OCSVM, were used to define the overall change in an individual’s movement pattern. The correlation between the change in movement patterns following the intervention (i.e., percentage of outliers) and improvement in self-reported clinical outcomes (e.g., pain and function) was assessed using a Spearman rank correlation. The number of outliers observed post-intervention exhibited a large association (ρ = 0.78) with improvements in self-reported clinical outcomes. These findings demonstrate a proof-of-concept and a novel methodological approach for integrating machine learning and wearable sensor data. This approach provides an objective and evidence-informed way to understand clinically important changes in human movement patterns in response to exercise therapy.

Treatment Success of Hip and Core or Knee Strengthening for Patellofemoral Pain: Development of Clinical Prediction Rules

CONTEXT

  Patellofemoral pain (PFP) is a common injury that interferes with quality of life and physical activity. Clinical subgroups of patients may exist, one of which is caused by proximal muscle dysfunction.

OBJECTIVES

  To develop clinical prediction rules that predict a positive outcome after either a hip and core- or knee-focused strengthening program for individuals with PFP.

DESIGN

  Secondary analysis of data from a randomized control trial.

SETTING

  Four university laboratories.

PATIENTS OR OTHER PARTICIPANTS

  A total of 199 participants with PFP.

INTERVENTION(S)

  Participants were randomly allocated to either a hip and core-focused (n = 111) or knee-focused (n = 88) rehabilitation group for a 6-week program.

MAIN OUTCOME MEASURE(S)

  Demographics, self-reported knee pain (visual analog scale) and function (Anterior Knee Pain Scale), hip strength, abdominal muscle endurance, and hip range of motion were evaluated at baseline. Treatment success was defined as a decrease in visual analog scale score by ≥2 cm or an increase in the Anterior Knee Pain Scale score by ≥8 points or both. Bivariate relationships between the outcome (treatment success) and the predictor variables were explored, followed by a forward stepwise logistic regression to predict a successful outcome.

RESULTS

  Patients with more pain, better function, greater lateral core endurance, and less anterior core endurance were more likely to have a successful outcome after hip and core strengthening (88% sensitivity and 54% specificity). Patients with lower weight, weaker hip internal rotation, stronger hip extension, and greater trunk-extension endurance were more likely to have success after knee strengthening (82% sensitivity and 58% specificity).

CONCLUSION

  The patients with PFP who have more baseline pain and yet maintain a high level of function may experience additional benefit from hip and core strengthening. The clinical prediction rules from this study remain in the developmental phase and should be applied with caution until externally validated.

Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests

Objective

To assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.

Design

Prospective diagnostic study.

Settings

Orthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.

Participants

Consecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2).

Interventions

Not applicable.

Main outcome measures

History elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated.

Results

Forty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24).

Conclusion

Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.

Initial derivation of diagnostic clusters combining history elements and physical examination tests for symptomatic knee osteoarthritis

INTRODUCTION

The aim of the present study was to assess the validity of clusters combining history elements and physical examination tests to diagnose symptomatic knee osteoarthritis (SOA) compared with other knee disorders.

METHODS

This was a prospective diagnostic accuracy study, in which 279 consecutive patients consulting for a knee complaint were assessed. History elements and standardized physical examination tests were obtained independently by a physiotherapist and compared with an expert physician's composite diagnosis, including clinical examination and imaging. Recursive partitioning was used to develop diagnostic clusters for SOA. Diagnostic accuracy measures were calculated, including sensitivity, specificity, and positive and negative likelihood ratios (LR+/-), with associated 95% confidence intervals (CIs).

RESULTS

A total of 129 patients had a diagnosis of SOA (46.2%). Most cases (76%) had combined tibiofemoral and patellofemoral knee OA and 63% had radiological Kellgren-Lawrence grades of 2 or 3. Different combinations of history elements and physical examination tests were used in clusters accurately to discriminate SOA from other knee disorders. These included age of patients, body mass index, presence of valgus/varus knee misalignment, palpable knee crepitus and limited passive knee extension. Two clusters to rule in SOA reached an LR+ of 13.6 (95% CI 6.5 to 28.4) and three clusters to rule out SOA reached an LR- of 0.11 (95% CI 0.06 to 0.20).

DISCUSSION

Diagnostic clusters combining history elements and physical examination tests were able to support the differential diagnosis of SOA compared with various knee disorders without relying systematically on imaging. This could support primary care clinicians' role in the efficient management of these patients.

Functional Strength Training and Movement Performance Therapy for Upper Limb Recovery Early Poststroke-Efficacy, Neural Correlates, Predictive Markers, and Cost-Effectiveness: FAST-INdiCATE Trial

BACKGROUND

Variation in physiological deficits underlying upper limb paresis after stroke could influence how people recover and to which physical therapy they best respond.

OBJECTIVES

To determine whether functional strength training (FST) improves upper limb recovery more than movement performance therapy (MPT). To identify: (a) neural correlates of response and (b) whether pre-intervention neural characteristics predict response.

DESIGN

Explanatory investigations within a randomised, controlled, observer-blind, and multicentre trial. Randomisation was computer-generated and concealed by an independent facility until baseline measures were completed. Primary time point was outcome, after the 6-week intervention phase. Follow-up was at 6 months after stroke.

PARTICIPANTS

With some voluntary muscle contraction in the paretic upper limb, not full dexterity, when recruited up to 60 days after an anterior cerebral circulation territory stroke.

INTERVENTIONS

Conventional physical therapy (CPT) plus either MPT or FST for up to 90 min-a-day, 5 days-a-week for 6 weeks. FST was "hands-off" progressive resistive exercise cemented into functional task training. MPT was "hands-on" sensory/facilitation techniques for smooth and accurate movement.

OUTCOMES

The primary efficacy measure was the Action Research Arm Test (ARAT). Neural measures: fractional anisotropy (FA) corpus callosum midline; asymmetry of corticospinal tracts FA; and resting motor threshold (RMT) of motor-evoked potentials.

ANALYSIS

Covariance models tested ARAT change from baseline. At outcome: correlation coefficients assessed relationship between change in ARAT and neural measures; an interaction term assessed whether baseline neural characteristics predicted response.

RESULTS

288 Participants had: mean age of 72.2 (SD 12.5) years and mean ARAT 25.5 (18.2). For 240 participants with ARAT at baseline and outcome the mean change was 9.70 (11.72) for FST + CPT and 7.90 (9.18) for MPT + CPT, which did not differ statistically (p = 0.298). Correlations between ARAT change scores and baseline neural values were between 0.199, p = 0.320 for MPT + CPT RMT (n = 27) and -0.147, p = 0.385 for asymmetry of corticospinal tracts FA (n = 37). Interaction effects between neural values and ARAT change between baseline and outcome were not statistically significant.

CONCLUSIONS

There was no significant difference in upper limb improvement between FST and MPT. Baseline neural measures did not correlate with upper limb recovery or predict therapy response.

TRIAL REGISTRATION

Current Controlled Trials: ISRCT 19090862, http://www.controlled-trials.com.

Diagnostic validity and triage concordance of a physiotherapist compared to physicians' diagnoses for common knee disorders

BACKGROUND

Emergence of more autonomous roles for physiotherapists warrants more evidence regarding their diagnostic capabilities. Therefore, we aimed to evaluate diagnostic and surgical triage concordance between a physiotherapist and expert physicians and to assess the diagnostic validity of the physiotherapist's musculoskeletal examination (ME) without imaging.

METHODS

This is a prospective diagnostic study where 179 consecutive participants consulting for any knee complaint were independently diagnosed and triaged by two evaluators: a physiotherapist and one expert physician (orthopaedic surgeons or sport medicine physicians). The physiotherapist completed only a ME, while the physicians also had access to imaging to make their diagnosis. Raw agreement proportions and Cohen's kappa (k) were calculated to assess inter-rater agreement. Sensitivity (Se) and specificity (Sp), as well as positive and negative likelihood ratios (LR+/-) were calculated to assess the validity of the ME compared to the physicians' composite diagnosis.

RESULTS

Primary knee diagnoses included anterior cruciate ligament injury (n = 8), meniscal injury (n = 36), patellofemoral pain (n = 45) and osteoarthritis (n = 79). Diagnostic inter-rater agreement between the physiotherapist and physicians was high (k = 0.89; 95% CI:0.83-0.94). Inter-rater agreement for triage recommendations of surgical candidates was good (k = 0.73; 95% CI:0.60-0.86). Se and Sp of the physiotherapist's ME ranged from 82.0 to 100.0% and 96.0 to 100.0% respectively and LR+/- ranged from 23.2 to 30.5 and from 0.03 to 0.09 respectively.

CONCLUSIONS

There was high diagnostic agreement and good triage concordance between the physiotherapist and physicians. The ME without imaging may be sufficient to diagnose or exclude common knee disorders for a large proportion of patients. Replication in a larger study will be required as well as further assessment of innovative multidisciplinary care trajectories to improve care of patients with common musculoskeletal disorders.

Validity of Combining History Elements and Physical Examination Tests to Diagnose Patellofemoral Pain

OBJECTIVE

To assess the validity of diagnostic clusters combining history elements and physical examination tests to diagnose or exclude patellofemoral pain (PFP).

DESIGN

Prospective diagnostic study.

SETTINGS

Orthopedic outpatient clinics, family medicine clinics, and community-dwelling.

PARTICIPANTS

Consecutive patients (N=279) consulting one of the participating orthopedic surgeons (n=3) or sport medicine physicians (n=2) for any knee complaint.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

History elements and physical examination tests were obtained by a trained physiotherapist blinded to the reference standard: a composite diagnosis including both physical examination tests and imaging results interpretation performed by an expert physician. Penalized logistic regression (least absolute shrinkage and selection operator) was used to identify history elements and physical examination tests associated with the diagnosis of PFP, and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios with associated 95% confidence intervals (CIs) were calculated.

RESULTS

Two hundred seventy-nine participants were evaluated, and 75 had a diagnosis of PFP (26.9%). Different combinations of history elements and physical examination tests including the age of participants, knee pain location, difficulty descending stairs, patellar facet palpation, and passive knee extension range of motion were associated with a diagnosis of PFP and used in clusters to accurately discriminate between individuals with PFP and individuals without PFP. Two diagnostic clusters developed to confirm the presence of PFP yielded a positive likelihood ratio of 8.7 (95% CI, 5.2-14.6) and 3 clusters to exclude PFP yielded a negative likelihood ratio of .12 (95% CI, .06-.27).

CONCLUSIONS

Diagnostic clusters combining common history elements and physical examination tests that can accurately diagnose or exclude PFP compared to various knee disorders were developed. External validation is required before clinical use.

Diagnostic Validity of Combining History Elements and Physical Examination Tests for Traumatic and Degenerative Symptomatic Meniscal Tears

BACKGROUND

The current approach to the clinical diagnosis of traumatic and degenerative symptomatic meniscal tears (SMTs) proposes combining history elements and physical examination tests without systematic prescription of imaging investigations, yet the evidence to support this diagnostic approach is scarce.

OBJECTIVE

To assess the validity of diagnostic clusters combining history elements and physical examination tests to diagnose or exclude traumatic and degenerative SMT compared with other knee disorders.

DESIGN

Prospective diagnostic accuracy study.

SETTINGS

Patients were recruited from 2 orthopedic clinics, 2 family medicine clinics, and from a university community.

PATIENTS

A total of 279 consecutive patients who underwent consultation for a new knee complaint.

METHODS

Each patient was assessed independently by 2 evaluators. History elements and standardized physical examination tests performed by a physiotherapist were compared with the reference standard: an expert physicians' composite diagnosis including a clinical examination and confirmatory magnetic resonance imaging. Participating expert physicians were orthopedic surgeons (n = 3) or sport medicine physicians (n = 2). Penalized logistic regression (least absolute shrinkage and selection operator) was used to identify history elements and physical examination tests associated with the diagnosis of SMT and recursive partitioning was used to develop diagnostic clusters.

MAIN OUTCOME MEASURES

Diagnostic accuracy measures were calculated including sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CIs).

RESULTS

Eighty patients had a diagnosis of SMT (28.7%), including 35 traumatic tears and 45 degenerative tears. The combination a history of trauma during a pivot, medial knee pain location, and a positive medial joint line tenderness test was able to diagnose (LR+ = 8.9; 95% CI 6.1-13.1) or exclude (LR- = 0.10; 95% CI 0.03-0.28) a traumatic SMT. Combining a history of progressive onset of pain, medial knee pain location, pain while pivoting, absence of valgus or varus knee misalignment, or full passive knee flexion was able to moderately diagnose (LR+ = 6.4; 95% CI 4.0-10.4) or exclude (LR- = 0.10; 95% CI 0.03-0.31) a degenerative SMT. Internal validation estimates were slightly lower for all clusters but demonstrated positive LR superior to 5 and negative LR inferior to 0.2 indicating moderate shift in posttest probability.

CONCLUSION

Diagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of SMT. These results represent the initial derivation of the clusters and external validation is mandatory.

LEVEL OF EVIDENCE

I.

Knowledge Translation in Rehabilitation: A Shared Vision

PURPOSE

Advances in rehabilitation provide the infrastructure for research and clinical data to improve care and patient outcomes. However, gaps between research and practice are prevalent. Knowledge translation (KT) aims to decrease the gap between research and its clinical use. This special communication summarizes KT-related proceedings from the 2016 IV STEP conference, describes current KT in rehabilitation science, and provides suggestions for its application in clinical care.

SUMMARY OF KEY POINTS

We propose a vision for rehabilitation clinical practice and research that includes the development, adaptation, and implementation of evidence-based practice recommendations, which will contribute to a learning health care system. A clinical research culture that supports this vision and methods to engage key stakeholders to innovate rehabilitation science and practice are described.

CONCLUSIONS

Through implementation of this vision, we can lead an evolution in rehabilitation practice to ultimately prevent disabilities, predict better outcomes, exploit plasticity, and promote participation.

Clinical prediction rules for prognosis and treatment prescription in neck pain: A systematic review

Clinical prediction rules (CPRs) developed to identify sub-groups of people with neck pain for different prognoses (i.e. prognostic) or response to treatments (i.e. prescriptive) have been recommended as a research priority to improve health outcomes for these conditions. A systematic review was undertaken to identify prognostic and prescriptive CPRs relevant to the conservative management of adults with neck pain and to appraise stage of development, quality and readiness for clinical application. Six databases were systematically searched from inception until 4th July 2016. Two independent reviewers assessed eligibility, risk of bias (PEDro and QUIPS), methodological quality and stage of development. 9840 records were retrieved and screened for eligibility. Thirty-two studies reporting on 26 CPRs were included in this review. Methodological quality of included studies varied considerably. Most prognostic CPR development studies employed appropriate designs. However, many prescriptive CPR studies (n = 12/13) used single group designs and/or analysed controlled trials using methods that were inadequate for identifying treatment effect moderators. Most prognostic (n = 11/15) and all prescriptive (n = 11) CPRs have not progressed beyond the derivation stage of development. Four prognostic CPRs relating to acute whiplash (n = 3) or non-traumatic neck pain (n = 1) have undergone preliminary validation. No CPRs have undergone impact analysis. Most prognostic and prescriptive CPRs for neck pain are at the initial stage of development and therefore routine clinical use is not yet supported. Further validation and impact analyses of all CPRs are required before confident conclusions can be made regarding clinical utility.

The Accuracy of the VISA-P Questionnaire, Single-Leg Decline Squat, and Tendon Pain History to Identify Patellar Tendon Abnormalities in Adult Athletes

Study Design Cross-sectional clinical assessment. Background Patellar tendinopathy is not always accompanied by patellar tendon abnormalities (PTAs). Thus, clinical screening tools to help identify patients with patellar tendon pain who have PTAs could enhance clinical decision making and patient prognosis. Objectives To test the diagnostic accuracy of the Victorian Institute of Sport Assessment-Patella (VISA-P) questionnaire, a single-leg decline squat (SLDS), tendon pain history, age, and years of sports participation to identify athletes with symptomatic patellar tendons who have PTAs confirmed on imaging. Methods Data provided by ultrasound examination, the VISA-P questionnaire, the SLDS, tendon pain history, age, and years of sport participation were collected in 43 athletes. A classification and regression tree (CART) model was developed to verify variables associated with PTA occurrence. Likelihood ratios (LRs) were computed for positive and negative tests. Results The SLDS, VISA-P questionnaire, and tendon pain history were associated with PTA occurrence. Athletes with negative results on all 3 tests (CART model) had a lower likelihood of having PTAs (negative LR = 0.3; 95% confidence interval [CI]: 0.2, 0.5). The isolated use of the SLDS or tendon pain history (positive LR = 4.2; 95% CI: 2.3, 7.14 and 4.5; 95% CI: 1.8, 11.1, respectively) had similar influence on probability of PTA presence compared to the CART model (positive LR = 4.1; 95% CI: 2.5, 6.3). Conclusion Although the objective was to investigate a clinical test to identify PTAs, the combined use of the tests had greater accuracy to identify individuals without PTAs. Level of Evidence Diagnosis, level 3b. J Orthop Sports Phys Ther 2016;46(8):673-680. Epub 3 Jul 2016. doi:10.2519/jospt.2016.6192.

Driving Away the Bad Guys

The previously uninvestigated role of work drive as a moderator of perceptions of politics–job outcomes relationships was examined in a series of field studies. Consistent with the underpinnings of sensemaking theory, we hypothesized that those with high levels of work drive would experience fewer adverse consequences when coupled with heightened perceptions of politics relative to those reporting less work drive. Across two independent studies, hypotheses were strongly supported. Specifically, perceptions of politics demonstrated a significant, direct influence on job satisfaction, job tension, and emotional exhaustion for those with less work drive in Sample 1 (municipal employees) and only a minimal impact for those with higher levels of drive. Results were replicated in Sample 2 (members of a management association). Implications of these findings for science and practice, strengths and limitations, and future research directions are discussed.

Psychosocial factors associated with bulimia nervosa during pregnancy: An internal validation study

OBJECTIVE

The aim of this paper was to internally validate previously reported relations (Knoph Berg et al., Aust N Z J Psychiatry, 42, 396-404, 2008) between psychosocial factors and bulimia nervosa (BN) outcomes during pregnancy.

METHOD

This study is based on the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Participants were women enrolled during pregnancy (N = 69,030). Internal validity was evaluated by way of bootstrapped parameter estimates using the overall sample and a split sample calibration approach.

RESULTS

Bootstrap bias estimates were below the problematic threshold, and extend earlier findings (Knoph Berg et al., Aust N Z J Psychiatry, 42, 396-404, 2008) by providing support for the validity of the models at the population level of all pregnant women in Norway. Bootstrap risk ratios indicated that prevalence, incidence, and remission of BN during pregnancy were significantly associated with psychosocial factors. The split sample procedure showed that the models developed on the training sample did not predict risks in the validation sample.

DISCUSSION

This study characterizes associations between psychosocial exposures and BN outcomes among pregnant women in Norway. Women with lifetime and current self-reported psychosocial adversities were at a much higher risk for BN during pregnancy. Psychosocial factors were associated with BN remission during pregnancy, inviting the prospect of enhancing therapeutic interventions. We consider the findings in the context of reproducibility in science.

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.

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-.

Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration

The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.