The Search for a
Clinical Prediction Rule

This section was compiled by Frank M. Painter, D.C.
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Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these learned articles about chiropractors as first-contact Spinal Health Care Experts.

A Clinical Model for the Diagnosis and Management
of Patients with Spinal Pain Syndromes

A Chiro.Org article collection

Enjoy this collection of articles that reviews the diagnosis and management of spinal pain syndromes.

Chronic Neck Pain and Chiropractic
A Chiro.Org article collection

Enjoy this collection of articles abour chronic neck pain.

Low Back Pain and Chiropractic
A Chiro.Org article collection

Enjoy this collection of articles about low back pain.

Prediction of Outcome in Patients with Low Back Pain--A Prospective Cohort Study Comparing Clinicians' Predictions with those of the Start Back Tool
Man Ther. 2016 (Feb);   21:   120–127

The accuracies of predictions made by clinicians (AUC .58-.63) and the STarT Back Screening Tool (SBT) (AUC .50-.61) were comparable and low. No substantial increase in the predictive capability was achieved by combining clinicians' expectations and the SBT. In conclusion, chiropractors' predictions were associated with well-established prognostic factors but not simply a product of these. Chiropractors were able to predict differences in outcome on a group level, but prediction of individual patients' outcomes were inaccurate and not substantially improved by the SBT.

Report of the NIH Task Force on Research Standards
for Chronic Low Back Pain

Int J Ther Massage Bodywork. 2015 (Sep 1);   8 (3):   16–33 ~ FULL TEXT

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific, and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The NIH Pain Consortium therefore charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination.

Prediction of Pain Outcomes in a Randomized Controlled Trial
of Dose-response of Spinal Manipulation for the Care of
Chronic Low Back Pain

BMC Musculoskelet Disord. 2015 (Aug 19);   16:   205 ~ FULL TEXT

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.

Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain
at Risk of Developing Chronic Pain

Spine J. 2015 (Jul 1);   15 (7):   1577–1586 ~ FULL TEXT

Despite these limitations, we conclude that our study provides a clinical decision rule that is urgently needed for one of the most frequent and most costly conditions in primary care. [50] It contains 8 items for the 6-month and 8 items for the 2-year risk classification (5 are common to both) into 3 levels of risk for developing chronic pain in patients presenting in primary care with a new-onset episode of strictly defined acute low back pain. The next step is to prospectively validate this tool in an independent population.

Evaluation of a Modified Clinical Prediction Rule For Use With Spinal
Manipulative Therapy in Patients With Chronic Low Back Pain:
A Randomized Clinical Trial

Chiropractic & Manual Therapies 2014 (Nov 18);   22 (1):   41 ~ FULL TEXT

Recent literature has highlighted the lack of definitive data to emerge from RCTs evaluating Chronic Lower Back Pain (CLBP), with no treatment producing consistently superior outcomes. [29-32] In keeping with this previous literature and supporting our first hypothesis, we found clinically and statistically significant improvements in outcomes from baseline to follow up in the groups receiving Spinal Manipulative Therapy (SMT) and Active Exercise Therapy (AET), which are both recognized as evidence based interventions for CLBP. [10, 31]

An Evidence-based Diagnostic Classification System For Low Back Pain
Journal of the Canadian Chiropractic Association 2013 (Sep);   57 (3):   189–204 ~ FULL TEXT

Health professionals across such disciplines as orthopedics, physical therapy, and chiropractic have shared the goal of categorizing patients with musculoskeletal low back pain (LBP) according to evidence-based classification systems. [1, 2] To this end, several investigators have generated classification systems for LBP diagnosis and treatment. [3–8] Identifying specific pathophysiology causing LBP has the potential to positively impact clinical research and practice by providing opportunities to test, validate or reject treatments targeted at specific diagnoses. [1,2] Clinical prediction rules [4,6] and symptom or treatment-based classification systems [7,8] lack the pathophysiological component(s) clinicians sometimes use to better understand a condition and make clinical decisions. Patho-anatomic diagnoses address pain arising from more specific anatomic structures or pathological processes. However, definitively confirming pain sources for LBP continues to be a challenge.

Predictors of Outcome in Neck Pain Patients Undergoing
Chiropractic Care: Comparison of Acute and Chronic Patients

Chiropractic & Manual Therapies 2012 (Aug 24);   20 (1):   27 ~ FULL TEXT

The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients.
There are many similar articles at our Diagnosis and Management Page

Predictors for Identifying Patients With Mechanical Neck Pain Who
Are Likely to Achieve Short-Term Success With Manipulative
Interventions Directed at the Cervical and Thoracic Spine

J Manipulative Physiol Ther 2011 (Mar);   34 (3):   144–152 ~ FULL TEXT

This newly published JMPT study attempted to identify those prognostic clinical factors that may potentially identify, a priori, patients with mechanical neck pain who are likely to experience a rapid and successful response to spinal manipulation of the cervical and thoracic spine. Data from 81 subjects were included in the analysis, of which 50 had experienced a successful outcome (61.7%). Five variables were found to be associated with a positive response.

Psychosocial Risk Factors For Chronic Low Back Pain in Primary Care —
A Systematic Review

Fam Pract. 2011 (Feb);   28 (1):   12–21 ~ FULL TEXT

Twenty-three papers fulfilled the inclusion criteria, covering 18 different cohorts. Sixteen psychosocial factors were analysed in three domains: social and socio-occupational, psychological and cognitive and behavioural. Depression, psychological distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors were not. The predictive ability of a patient's self-perceived general health at baseline was difficult to interpret because of biomedical confounding factors. The initial patient's or care provider's perceived risk of persistence of LBP was the factor that was most consistently linked with actual outcome.

A Diagnosis-based Clinical Decision Rule For Spinal Pain
Part 2:   Review Of The Literature

Chiropractic & Osteopathy 2008 (Aug 11);   16:   7 ~ FULL TEXT

Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.

A Primary Care Back Pain Screening Tool:
Identifying Patient Subgroups For Initial Treatment

(The STarT Back Screening Tool)
Arthritis Rheum. 2008 (May 15);   59 (5):   632–641 ~ FULL TEXT

We have developed and validated a simple, brief, and practical way to subgroup patients with nonspecific low back pain in primary care. The new STarT Back Screening Tool identifies potentially modifiable prognostic indicators that may be appropriate targets for primary care interventions. The tool included 9 items: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0–3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk.

Predictors For Immediate and Global Responses to Chiropractic
Manipulation of the Cervical Spine

J Manipulative Physiol Ther 2008 (Mar);   31 (3):   172–183 ~ FULL TEXT

Data were collected from 28,807 treatment consultations (in 19,722 patients) and 13,873 follow-up treatments.

The presenting symptoms of:
“neck pain”,
“shoulder, arm pain”,
“reduced neck, shoulder, arm movement, stiffness”,
“upper, mid back pain”, and
“none or one presenting symptom”

emerged in the final model as significant predictors for an immediate improvement.   The presence of any 4 of these predictors raised the probability for an immediate improvement in presenting symptoms after treatment from 70% to approximately 95%.

A Theoretical Model for the Development of a Diagnosis-based
Clinical Decision Rule For The Management Of Patients
with Spinal Pain

BMC Musculoskelet Disord. 2007 (Aug 3);   8:   75 ~ FULL TEXT

In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.

A Clinical Model for the Diagnosis and Management of Patients
With Cervical Spine Syndromes

Australasian Chiropractic & Osteopathy 2004 (Nov);   12 (2):   57–71 ~ FULL TEXT

Neck pain and related disorders are a group of conditions that are common and often disabling. It can be argued that the importance of these disorders is under-appreciated. Because of the prevalence of low back pain and its great cost to society, much clinical attention and research dollars are focused on the low back. But epidemiological research suggests that cervical related disorders are as common and may be more costly to society than low back disorders. [1–4]

A Clinical Prediction Rule To Identify Patients with Low Back
Pain Most Likely To Benefit from Spinal Manipulation:
A Validation Study

Annals of Internal Medicine 2004 (Dec 21);   141 (12):   920–928 ~ FULL TEXT

Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7).

A Clinical Prediction Rule for Classifying Patients with Low Back Pain
who Demonstrate Short-term Improvement with Spinal Manipulation

Spine (Phila Pa 1976). 2002 (Dec 15);   27 (24):   2835–2843 ~ FULL TEXT

Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear-avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%.

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