Clinical Prediction Rules That Don't Hold Up-Where to Go From Here?

Stretching and muscle-performance exercises for chronic nonspecific neck pain: who may benefit most?

BACKGROUND

Although exercise is the mainstay of treatment for neck pain (NP), uncertainty remains over optimal decision-making concerning who may benefit most from such, particularly in the long term.

OBJECTIVE

To identify the subgroup of patients with nonspecific NP most likely to benefit from stretching and muscle-performance exercises.

METHODS

This was a secondary analysis of treatment outcomes of 70 patients (10 of whom dropped out) with a primary complaint of nonspecific NP in one treatment arm of a prospective, randomized, controlled trial. All patients performed the exercises, twice weekly for 6 weeks, and a home exercise program. Blinded outcome measurements were collected at baseline, after the 6-week program, and at a 6-month follow-up. Patients rated their perceived recovery on a 15-point global rating of change scale; a rating of "quite a bit better" (+5) or higher was defined as a successful outcome. Clinical predictor variables were developed via logistic regression analysis to classify patients with NP that may benefit from exercise-based treatment.

RESULTS

NP duration since onset≤6 months, no cervicogenic headache, and shoulder protraction were independent predictor variables. The pretest probability of success was 47% after the 6-week intervention and 40% at the 6-month follow-up. The corresponding posttest probabilities of success for participants with all three variables were 86% and 71%, respectively; such participants were likely to recover.

CONCLUSION

The clinical predictor variables developed in this study may identify patients with nonspecific NP likely to benefit most from stretching and muscle-performance exercises in the short and long terms.

Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists

Background and Objective

High-velocity low-amplitude thrust spinal manipulation (SM) is a recommended and commonly used manual therapy intervention in physiotherapy. Beliefs surrounding the safety and effectiveness of SM have challenged its use, and even advocated for its abandonment. Our study aimed to investigate the knowledge and beliefs surrounding SM by Italian physiotherapists compared with similar practitioners in other countries.

Methods

An online survey with 41 questions was adapted from previous surveys and was distributed via a mailing list of the Italian Physiotherapists Association (March 22–26, 2020). The questionnaire was divided into 4 sections to capture information on participant demographics, utilization, potential barriers, and knowledge about SM. Questions were differentiated between spinal regions. Attitudes towards different spinal regions, attributes associated with beliefs, and the influence of previous educational background were each evaluated.

Results

Of the 7398 registered physiotherapists, 575 (7.8%) completed the survey and were included for analysis. The majority of respondents perceived SM as safe and effective when applied to the thoracic (74.1%) and lumbar (72.2%) spines; whereas, a smaller proportion viewed SM to the upper cervical spine (56.8%) as safe and effective. Respondents reported they were less likely to provide and feel comfortable with upper cervical SM (respectively, 27.5% and 48.5%) compared to the thoracic (respectively, 52.2% and 74.8%) and lumbar spines (respectively, 46.3% and 74.3%). Most physiotherapists (70.4%) agreed they would perform additional screening prior to upper cervical SM compared to other spinal regions. Respondents who were aware of clinical prediction rules were more likely to report being comfortable with SM (OR 2.38–3.69) and to perceive it as safe (OR 1.75–3.12). Finally, physiotherapists without musculoskeletal specialization, especially those with a traditional manual therapy background, were more likely to perform additional screening prior to SM, use SM less frequently, report being less comfortable performing SM, and report upper cervical SM as less safe (p < 0.001).

Discussion

The beliefs and attitudes of physiotherapists surrounding the use of SM are significantly different when comparing the upper cervical spine to other spinal regions. An educational background in traditional manual therapy significantly influences beliefs and attitudes. We propose an updated framework on evidence-based SM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00449-x.

Neck Pain Clinical Prediction Rule to Prescribe Combined Aerobic and Neck-Specific Exercises: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

A previous randomized controlled trial revealed that combined aerobic and neck-specific exercises yielded greater improvement than neck-specific exercises alone after a 6-month intervention in outpatients with nonspecific neck pain (NP). The aim of this secondary analysis was to identify subgroups of patients in the combined exercises group most likely to benefit from the intervention.

METHODS

Sixty-nine patients were included. The original trial was conducted in multiple physical therapy outpatient clinics twice a week for 6 weeks; follow-up was 6 months after assignment. The primary outcome was the therapeutic success rate (Global Rating of Change Score ≥ +5, "quite a bit better") after 6 weeks of training and at the 6-month follow-up. Candidate predictors from patients' medical history and physical examination were selected for univariable regression analysis to determine their association with treatment response status. Multivariable logistic regression analysis was used to derive preliminary clinical prediction rules.

RESULTS

The clinical prediction rule contained 3 predictor variables: (1) symptom duration ≤6 months, (2) neck flexor endurance ≥18 seconds, and (3) absence of referred pain (Nagelkerke R2 = .40 and -2 log likelihood = 60.30). The pre-test probability of success was 61.0% in the short term and 77.0% in the long term. The post-test probability of success for patients with at least 2 of the 3 predictor variables was 84.0% in the short term and 87.0% in the long term; such patients will likely benefit from this program.

CONCLUSION

A simple 3-item assessment, derived from easily obtainable baseline data, can identify patients with NP who may respond best to combined aerobic and neck-specific exercises. Validation is required before clinical recommendation.

IMPACT

Patients experiencing NP symptoms ≤6 months who have no referred pain and exhibit neck flexor endurance ≥18 seconds may benefit from a simple self-training program of combined aerobic and neck-specific exercises.

External validation of prognostic models for recovery in patients with neck pain

Background

Neck pain is one of the leading causes of disability in most countries and it is likely to increase further. Numerous prognostic models for people with neck pain have been developed, few have been validated. In a recent systematic review, external validation of three promising models was advised before they can be used in clinical practice.

Objective

The purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care.

Methods

This validation cohort consisted of 1311 patients with neck pain of any duration who were prospectively recruited and treated by 345 manual therapists in the Netherlands. Outcome measures were disability (Neck Disability Index) and recovery (Global Perceived Effect Scale) post-treatment and at 1-year follow-up. The assessed models were an Australian Whiplash-Associated Disorders (WAD) model (Amodel), a multicenter WAD model (Mmodel), and a Dutch non-specific neck pain model (Dmodel). Models’ discrimination and calibration were evaluated.

Results

The Dmodel and Amodel discriminative performance (AUC < 0.70) and calibration measures (slope largely different from 1) were poor. The Mmodel could not be evaluated since several variables nor their proxies were available.

Conclusions

External validation of promising prognostic models for neck pain recovery was not successful and their clinical use cannot be recommended. We advise clinicians to underpin their current clinical reasoning process with evidence-based individual prognostic factors for recovery. Further research on finding new prognostic factors and developing and validating models with up-to-date methodology is needed for recovery in patients with neck pain in primary care.

Identifying participants with knee osteoarthritis likely to benefit from physical therapy education and exercise: A hypothesis-generating study

BACKGROUND

The purpose of this investigation was to undertake a hypothesis-generating study to identify candidate variables that characterize people with knee osteoarthritis who are most likely to experience a positive response to exercise.

METHODS

One hundred and fifty participants with knee osteoarthritis participated in this observational, longitudinal study. All participants received a standard exercise intervention that consisted of 20-min sessions two to three times a week for three months. The classification and regression tree methodology (CART) was used to develop prediction of positive clinical outcome. Positive pain and disability outcomes (dependent variables) were defined as an improvement in pain intensity by >50% or an improvement of five or more on the Oxford knee score, respectively. The predictor variables considered included age, sex, body mass index, knee osteoarthritis severity (Kellgren/Lawrence grade), pain duration, use of medication, range of knee motion, pain catastrophizing, self-efficacy and knee self-perception.

RESULTS

Fifty-five participants (36.6%) were classified as responders for pain intensity and 36.6% were classified as responders for disability. The CART model identified impairments in knee self-perception and knee osteoarthritis severity as the discriminators for pain intensity reduction following exercise. No variables predicted reduction of disability level following exercise.

CONCLUSIONS

Such findings suggest that both body perception and osteoarthritis severity may play a role in treatment outcome with exercise. It also raises the possibility that those with higher levels of disrupted body perception may need additional treatment targeted at restoring body perception prior to undertaking exercise.

SIGNIFICANCE

Regardless age, sex, body mass index, pain duration, use of medication, knee range of motion, pain catastrophizing and self-efficacy, participants with knee osteoarthritis who report low levels of body perception disruption (a FreKAQ score ≦ 17) and minimal structural changes (KL grade I) demonstrate significantly better outcomes from exercise therapy than other participants.

Quadruple-negative breast cancer: novel implications for a new disease

Based on the androgen receptor (AR) expression, triple-negative breast cancer (TNBC) can be subdivided into AR-positive TNBC and AR-negative TNBC, also known as quadruple-negative breast cancer (QNBC). QNBC characterization and treatment is fraught with many challenges. In QNBC, there is a greater paucity of prognostic biomarkers and therapeutic targets than AR-positive TNBC. Although the prognostic role of AR in TNBC remains controversial, many studies revealed that a lack of AR expression confers a more aggressive disease course. Literature characterizing QNBC tumor biology and uncovering novel biomarkers for improved management of the disease remains scarce. In this comprehensive review, we summarize the current QNBC landscape and propose avenues for future research, suggesting potential biomarkers and therapeutic strategies that warrant investigation.

Predictive model for bacterial late-onset neonatal sepsis in a tertiary care hospital in Thailand

Background

Early diagnosis of neonatal sepsis is essential to prevent severe complications and avoid unnecessary use of antibiotics. The mortality of neonatal sepsis is over 18%in many countries. This study aimed to develop a predictive model for the diagnosis of bacterial late-onset neonatal sepsis.

Methods

A case-control study was conducted at Queen Sirikit National Institute of Child Health, Bangkok, Thailand. Data were derived from the medical records of 52 sepsis cases and 156 non-sepsis controls. Only proven bacterial neonatal sepsis cases were included in the sepsis group. The non-sepsis group consisted of neonates without any infection. Potential predictors consisted of risk factors, clinical conditions, laboratory data, and treatment modalities. The model was developed based on multiple logistic regression analysis.

Results

The incidence of late proven neonatal sepsis was 1.46%. The model had 6 significant variables: poor feeding, abnormal heart rate (outside the range 100–180 x/min), abnormal temperature (outside the range 36^o-37.9 °C), abnormal oxygen saturation, abnormal leucocytes (according to Manroe’s criteria by age), and abnormal pH (outside the range 7.27–7.45). The area below the Receiver Operating Characteristics (ROC) curve was 95.5%. The score had a sensitivity of 88.5% and specificity of 90.4%.

Conclusion

A predictive model and a scoring system were developed for proven bacterial late-onset neonatal sepsis. This simpler tool is expected to somewhat replace microbiological culture, especially in resource-limited settings.

Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study

OBJECTIVE

St. Paul's Early Discharge Rule was derived to determine which patients could be safely discharged from the emergency department after a 1-hour observation period following naloxone administration for opiate overdose. The rule suggested that patients could be safely discharged if they could mobilize as usual and had a normal oxygen saturation, respiratory rate, temperature, heart rate, and Glasgow Coma Scale score. Validation of the St. Paul's Early Discharge Rule is necessary to ensure that these criteria are appropriate to apply to patients presenting after an unintentional presumed opioid overdose in the context of emerging synthetic opioids and expanded naloxone access.

METHODS

In this prospective, observational validation study, emergency medicine providers assessed patients 1 hour after administration of prehospital naloxone. Unlike in the derivation study the threshold for normal oxygen saturation was set at 95% and patients were not immediately discharged after a normal 1-hour evaluation. Patients were judged to have a normal 1-hour evaluation if all six criteria of the rule were met. Patients were judged to have an adverse event (AE) if they had one or more of the preestablished AEs.

RESULTS

A total of 538 patients received at least one administration of prehospital naloxone, were transported to the study hospital, and had a 1-hour evaluation performed by a provider. AEs occurred in 82 (15.4%) patients. The rule exhibited a sensitivity of 84.1% (95% confidence interval [CI] = 76.2%-92.1%), a specificity of 62.1% (95% CI = 57.6%-66.5%), and a negative predictive value of 95.6% (95% CI = 93.3%-97.9%). Only one patient with a normal 1-hour evaluation subsequently received additional naloxone following a presumed heroin overdose.

CONCLUSION

This rule may be used to risk stratify patients for early discharge following naloxone administration for suspected opioid overdose.

Examination of the Validity of a Clinical Prediction Rule to Identify Patients With Shoulder Pain Likely to Benefit From Cervicothoracic Manipulation

Study Design Secondary analysis of a randomized controlled trial. Background Prognostic variables identifying patients with shoulder pain who are likely to respond to cervicothoracic manipulation have been reported; however, they have yet to be validated. Objective To examine the validity of previously reported prognostic variables in predicting which patients with shoulder pain will respond to cervicothoracic manipulation. Methods Participants (n = 140) with a report of shoulder pain were randomly assigned to receive either 2 sessions of range-of-motion exercises plus 6 sessions of stretching and strengthening exercises (exercise group), or 2 sessions of cervicothoracic manipulation and range-of-motion exercises followed by 6 sessions of stretching and strengthening exercise (manipulative-therapy-plus-exercise group). Outcomes of disability (Shoulder Pain and Disability Index, shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire) and pain (numeric pain-rating scale) were collected at baseline, 1 week, 4 weeks, and 6 months. Time, treatment group, status of predictor variables, and 2-way and 3-way interactions were analyzed using linear mixed models with repeated measures. Results There were no significant 3-way interactions for either disability (P = .27) or pain scores (P = .70) for time, group, and predictor status for any of the predictor variables. Conclusion The results of the current study did not validate the previously identified prognostic variables; therefore, we cannot support using these in clinical practice. Further updating of the existing prediction rule may be warranted and could potentially result in new prognostic variables and improved generalizability. Limitations of the study were a mean duration of symptoms of greater than 2 years and a loss to follow-up of 19% at 6 months. Level of Evidence Prognosis, level 1b. Trial prospectively registered March 30, 2012 at www.clinicaltrials.gov (NCT01571674). J Orthop Sports Phys Ther 2017;47(4):252-260. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7100.

September 2016 Letter to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: "One More Cause of Failure to Validate a CPR: Overfitting" with Author's Response J Orthop Sports Phys Ther 2016;46(9):811-812. doi:10.2519/jospt.2016.0202.