The Search for a
Clinical Prediction Rule

This section was compiled by Frank M. Painter, D.C.
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Reference Materials

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

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

Pain Management and Chiropractic
A Chiro.Org article collection

Explore this collection of articles that discusses the relationship between tissue injury and various pyschosocial factors that may contribute towards developing chronic pain.

Chronic Neck Pain and Chiropractic
A Chiro.Org article collection

Review this extensive collection of studies detailing how chiropractic and spinal manipulation are effective for the relief of spinal pain.

Neck and Back Pain in Children and Chiropractic
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for spinal pain in children.

Radiculopathy and Chiropractic Page
A Chiro.Org article collection

We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for radiculopathy.

Low Back Pain and Chiropractic
A Chiro.Org article collection


The Biopsychosocial Model
A Chiro.Org article collection

The late George Engel believed that to understand and respond adequately to patients’ suffering — and to give them a sense of being understood — clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness. He offered a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century. [1] His new model came to be known as the biopsychosocial model.

Integrated Health Care and Chiropractic
A Chiro.Org article collection

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.

The Prescription Rights and Expanded Practice Debate
A Chiro.Org article collection

There is a growing desire within [a very small percentage of the] chiropractic profession to expand the scope of practice to include limited medication prescription rights for the treatment of spine-related and other musculoskeletal conditions. Such prescribing rights have been successfully incorporated into a number of chiropractic jurisdictions worldwide. If limited to a musculoskeletal scope, medication prescription rights have the potential to change the present role of chiropractors within the healthcare system by paving the way for practitioners to become comprehensive specialists in the conservative management of spine/ musculoskeletal disorders.


Clinical Prediction Rule Articles

Who will have Sustainable Employment After a Back Injury?
The Development of a Clinical Prediction Model in a Cohort of Injured Workers

J Occup Rehabil. 2017 (Sep);   27 (3):   445–455

Our analysis suggests that using information gathered during the initial clinical encounter may assist health care practitioners to better predict an injured worker’s post-back injury employment pattern. We created a promising clinical prediction model to predict sustainable employment following a work-related back injury. Our models suggest that clinicians might gain insight about sustainable employment approximately 1 month after claim-initiation by measuring back pain intensity, mental health-related quality of life (SF-12), claim litigation and type of employer. Similarly, examining physical and mental health-related quality of life (SF-12), claim litigation, and type of employer are adequate for predicting those with a sustainable employment pattern approximately 6 months post-injury.

Clinical Classification in Low Back Pain:
Best-evidence Diagnostic Rules Based on Systematic Reviews

BMC Musculoskelet Disord. 2017 (May 12);   18 (1):   188 ~ FULL TEXT

This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Failure to Define Low Back Pain as a Disease or an Episode
Renders Research on Causality Unsuitable: Results of a Systematic Review

Chiropractic & Manual Therapies 2017 (Jan 9);   21:   6 ~ FULL TEXT

Recent literature concerning the causality of LBP does not differentiate between the ‘disease’ of LBP and its recurring episodes mainly due to a lack of a clear definition of absence of LBP at baseline. Therefore, current research is not capable of providing a valid answer on this topic.

Validity and Reliability of Clinical Prediction Rules used to Screen for Cervical
Spine Injury in Alert Low-risk Patients with Blunt Trauma to the Neck:
Part 2. A Systematic Review from the Cervical Assessment and
Diagnosis Research Evaluation (CADRE) Collaboration

European Spine Journal 2017 (Sep 22) [Epub] ~ FULL TEXT

Our review adds new evidence to the Neck Pain Task Force and supports the use of clinical prediction rules in emergency care settings to screen for cervical spine injury in alert low-risk adult patients with blunt trauma to the neck. The Canadian C-spine rule consistently demonstrated excellent sensitivity and negative predictive values. Our review, however, suggests that the reproducibility of the clinical predictions rules varies depending on the examiners level of training and experience.

How Can Latent Trajectories of Back Pain be Translated
into Defined Subgroups?

BMC Musculoskelet Disord. 2017 (Jul 3);   18 (1):   285 ~ FULL TEXT

This study was the first to demonstrate that suggested definitions of LBP trajectory subgroups can be readily applied to individuals’ observed data resulting in subgroups that match well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with infrequent and mild LBP. Further, we suggest that minor fluctuations in pain intensity might be conceptualised as ‘ongoing LBP’. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP.

Leg Pain Location and Neurological Signs Relate to Outcomes in
Primary Care Patients with Low Back Pain

BMC Musculoskelet Disord. 2017 (Mar 31);   18 (1):   133 ~ FULL TEXT

The Quebec Task Force categories (QTFC) identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals' outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.

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 ~ FULL TEXT

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.

Do Participants with Low Back Pain who Respond to Spinal Manipulative Therapy Differ
Biomechanically From Nonresponders, Untreated Controls or Asymptomatic Controls?

Spine (Phila Pa 1976). 2015 (Sep 1);   40 (17):   1329–1337 ~ FULL TEXT

After the first SMT, SMT responders displayed statistically significant decreases in spinal stiffness and increases in multifidus thickness ratio sustained for more than 7 days; these findings were not observed in other groups. Similarly, only SMT responders displayed significant post-SMT improvement in apparent diffusion coefficients.   Those reporting post-SMT improvement in disability demonstrated simultaneous changes between self-reported and objective measures of spinal function. This coherence did not exist for asymptomatic controls or no-treatment controls. These data imply that SMT impacts biomechanical characteristics within SMT responders not present in all patients with LBP. This work provides a foundation to investigate the heterogeneous nature of LBP, mechanisms underlying differential therapeutic response, and the biomechanical and imaging characteristics defining responders at baseline

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.

Clinical Examination Findings as Prognostic Factors in Low Back Pain:
A Systematic Review of the Literature

Chiropractic & Manual Therapies 2015 (Mar 23);   23:   13 ~ FULL TEXT

A total of 5,332 citations were retrieved and screened for eligibility, 342 articles were assessed as full text and 49 met the inclusion criteria. Due to clinical and statistical heterogeneity, qualitative synthesis rather than meta-analysis was performed. Associations between clinical tests and outcomes were often inconsistent between studies. In more than one third of the tests, there was no evidence of the tests being associated with outcome. Only two clinical tests demonstrated a consistent association with at least one of the outcomes: centralization and non-organic signs.

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.

Development of a Clinical Prediction Rule for Guiding Treatment of
a Subgroup of Patients With Neck Pain: Use of Thoracic Spine
Manipulation, Exercise, and Patient Education

Phys Ther. 2007 (Jan);   87 (1):   9–23 ~ FULL TEXT

The clinical prediction rule (CPR) provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.

Pragmatic Application of a Clinical Prediction Rule in Primary Care
to Identify Patients with Low Back Pain with a Good Prognosis
Following a Brief Spinal Manipulation Intervention

BMC Fam Pract. 2005 (Jul 14);   6 (1):   29 ~ FULL TEXT

Individuals with "non-specific" LBP are not a homogenous group, and different sub-groups of patients are likely to preferentially respond to different therapeutic management strategies. One sub-group consists of those patients with a good prognosis following spinal manipulation intervention. The results of this study demonstrate an association between two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, and outcome of a manipulation intervention.

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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