Diagnostic Imaging Guideline for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 2: Upper Extremity Disorders
 
   

Diagnostic Imaging Practice Guidelines for
Musculoskeletal Complaints in Adults —
An Evidence-Based Approach:


Part 2:   Upper Extremity Disorders

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Manipulative Physiol Ther 2008 (Jan);   31 (1):   2-32 ~ FULL TEXT

André E. Bussières, DC, John A.M. Taylor, DC, Cynthia Peterson, DC, RN, MMedEd

Chiropractic Department,
Université du Québec à Trois-Rivières,
Québec, Canada.
andre.bussieres@uqtr.ca


PURPOSE:   To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders.

METHODS:   A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. Dissemination and implementation strategies are discussed.

RESULTS:   Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided, supported by over 126 primary and secondary citations. The overall quality of available literature is low, however. On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommendations. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines and implementation feasibility.

CONCLUSIONS:   The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.



From the FULL TEXT Article:

Preliminary Considerations and Disclaimer

What is the Role of These Guidelines?


These evidence-based diagnostic imaging practice guidelines are intended to assist primary care providers and students in decision making regarding the appropriate use of diagnostic imaging for specific clinical presentations. The guidelines are intended to be used in conjunction with sound clinical judgment and experience. For example, other special circumstances for radiographic imaging studies may include: patient unable to give a reliable history, crippling cancer phobia focused on back pain, need for immediate decision about career or athletic future or legal evaluation, history of significant radiographic abnormalities elsewhere reported to patient but no films or reliable report reasonably available, and history of finding from other study (eg, nuclear medicine or imaging of the pelvis) that requires radiograph for correlation. [8] Application of these guidelines should help avoid unnecessary radiographs, increase examination precision, and decrease health care costs without compromising the quality of care.

The descriptions of clinical presentations and proposed clinical diagnostic criteria, the recommendations for imaging studies, and the comments provided throughout this article are a synthesis of the vast body of literature consulted before and during the various phases of this research project. Where the literature was found to be of poor quality or absent, consensus based on expert opinion was used. Although the investigators and collaborators carefully searched for all relevant articles, it is probable that some have been missed. Furthermore, as many new important studies are published in the near future, these will be incorporated in subsequent revisions of the guidelines and recommendations may change accordingly.

What These Guidelines Do and What They Do Not Do

These guidelines are intended to address issues faced by first-contact professionals only. These guidelines do not address all possible conditions associated with musculoskeletal disorders, only those that account for most initial visits to a practitioner.

Like other diagnostic tests, imaging studies should only be considered if (a) they yield clinically important information beyond that obtained from the history and physical examination, (b) this information can potentially alter patient management, and (c) this altered management has a reasonable probability to improve patient outcomes. [9–11] Investigators and collaborators in the development of these imaging guidelines believe that liability insurance companies, third-party payers, and courts of law should not rely solely on descriptions of patient presentations, proposed recommendations, and/or corresponding comments found throughout the documents because patient presentations are unique and the application of any guideline always requires clinical judgment and thus needs to be considered in the proper context. In addition, laws and regulations may vary between geographical regions and should be considered when applying the proposed indications for any imaging study.

What is Evidence-Based Health Care?

Evidence based is about tools, not about rules. [12] Evidence-based health care is an approach in which clinicians and health care professionals use the current best evidence in making decisions about the care of patients. It involves continuously and systematically searching, appraising, and incorporating contemporaneous research findings into clinical practice. The overall goal is improving patient care through life-long learning. [12, 13]


Thanks to the National Guideline Clearinghouse for access to these tables!


Table 1. Adult Shoulder Disorders

Patient Presentation Recommendations
Adult patients with full or limited movement and nontraumatic shoulder pain of less than 4-weeks (wk) duration

Patients unlikely to require initial radiographic examination if: no precipitating fall, no sudden onset of pain or swelling, no palpable mass or deformity; no pain at rest, and normal range of motion (ROM) (adapted from Fraenkel et al., 2000) prospective validation needed).
Radiographs not initially indicated (B)
General indications for radiographs include:
  • No response to care after 4 wk
  • Significant activity restriction >4 wk
  • Nonmechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)
  • Red flags indicators
Most patients with chronic shoulder pain can be adequately evaluated with a history, physical examination, and plain radiographs.
If radiographs are indicated (C)

Anteroposterior (AP) internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane)

Additional views: Posteroanterior (PA) chest view, cervical spine AP and lateral views, Grashey view

Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable if there is: (C)
  • Pain and significant disability lasting over 6 mo, despite attention to occupation and sporting factors
  • In the absence of clinical improvement after 4 wk of therapy
  • If function does not improve or deteriorates
  • History of instability, or acute, severe post-traumatic acromioclavicular pain
  • In presence of a potentially serious pathology as suggested by the patient history, examination, and/or radiograph
Special investigations (B)

Magnetic resonance imaging (MRI), ultrasonography, computed tomography (CT)
Glenohumeral joint disorders

Consult specific clinical diagnoses and related patient presentations for additional help in decision making.
 
Specific Clinical Diagnoses
1. Rotator cuff disorders (tendinopathy)

MC cause of shoulder pain

Classified according to its clinical progression:

I. Acute inflammation (tendinitis/bursitis)

II. Degeneration/chronic inflammation (tendinitis)

III. Rupture and arthritis
  1. Impingement: Night pain, upper arm pain and tenderness, cuff weakness, atrophy, painful arc, painful crepitation

High-sensitivity tests (0.8): Neer, Hawkins, horizontal adduction, Jobe, impingement sign and painful arc

High-specificity tests (0.8): drop arm test, yergason, speed, passive external rotation

  1. Rotator cuff tear: Traumatic in young people and atraumatic in elderly; there is strong evidence that clinical tests are able to rule-out full tears but have questionable value for partial tears: 3 positive tests or 2 if >60 years of age (YOA) is predictive of a tear: supraspinatus weakness, external rotation weakness, Hawkins
Radiographs not initially indicated (D)

Early radiograph if soft tissue calcification is expected

If radiographs are indicated (D)

AP internal rotation, AP external rotation, axillary view

Additional view: Neer's view (y-scapula) or Acromio-clavicular joint (A-C) joint views

Special investigations (C)

MRI is gold standard.
  1. Impingement is a dynamic process which may be assessed by US
  2. Rotator cuff full and partial thickness tear: MRI, Ultrasound (US), Magnetic resonance arthrography (MRA) improves diagnostic accuracy
  3. Calcifying bursitis within cuff tendons: MRI
2. Adhesive capsulitis (frozen shoulder)
  • Onset typically between the ages of 40-65 years (y)
  • Progressive deep joint pain and stiffness of spontaneous onset and restricted activities
  • >50% loss of passive abduction and external rotation, usually loss of all ROM, pain at end range, no local tenderness
Radiographs not routinely indicated (D)

Special investigations (D)
  • MRI with direct or indirect arthrogram
  • Distended arthrogram
3. Osteoarthritis (DJD)

Usually ≥60 YOA, progressive pain, crepitus, decreased end-ROM, tender joint
Radiographs indicated if (D)
  • Unrelieved by 4 wk of conservative care
  • Suspected underlying specific cause (pathology)
AP internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane)

Additional views: Supraspinatus outlet view
4. Glenohumeral joint inflammatory arthritis

Involved in most forms of inflammatory arthritis (Rheumatoid arthritis [RA], gout, reactive arthritis [Reiter's], Juvenile rheumatoid arthritis [JRA], Ankylosing spondylitis [AS])
Radiographs indicated (D)

AP internal rotation, AP external rotation, axillary view

Additional views: Grashey view

Advanced imaging and specialist referral recommended (D/GGP)

In suspected septic arthritis, consider MRI promptly for complete assessment of glenohumeral joint, preferably with intraarticular gadolinium
5. Glenohumeral instability

Usually between the ages of 20 and 35 y, history (Hx) of dislocation or subluxation, apprehension sign

Generalized ligamentous laxity (in multidirectional and voluntary instability)
Radiographs indicated (D)

AP internal rotation, AP external rotation, axillary view, Y-scapula view (lateral in scapular plane)

Advanced imaging and specialist referral recommended (C)
  • Acute setting: conventional MRI
  • Chronic instability: MRA
  • Postoperative shoulder, multislice CT arthrography
Adult patients with significant shoulder/glenohumeral joint trauma

Radiographic examination is appropriate if there is trauma sufficient to produce fracture, or dislocation, with accompanying signs/symptoms compatible with fracture or dislocation.
  • Loss of normal shape, palpable mass or deformity
  • Severely restricted shoulder mobility
  • Examination is unable to localize anatomical structure responsible for patient symptoms
  • History of epileptic seizure or electrical shock
Clinical decision rule in suspected shoulder dislocation may include*:
  • First-time dislocation
  • Blunt trauma (fall >1 flight of stairs, assault, or motor vehicle crash)
  • When the clinician is uncertain of the joint position
Clinical decision rule in suspected fracture-dislocation may include*:
  • First-time dislocation
  • Blunt trauma (fall >1 flight of stairs, a fight/assault episode, or motor vehicle crash) or a motor vehicle crash
  • Age >40 y
* Prospective validation needed
Radiographs indicated (B)

AP neutral view (do not move the shoulder), Y-scapula view (lateral in scapular plane), axillary view (if possible)

Additional view: Transthoracic lateral

Advanced imaging and specialist referral recommended (D)

Repeat films in 10 days if a fracture remains a possibility after normal initial evaluation or refer for Computed tomography (CT) scan. Callus formation or abnormal alignment may be present.
  • MRI
  • Ultrasound (US) and CT arthrography
A-C joint disorders

Teenage to 50 YOA; usually secondary to trauma or osteoarthritis; pain localized to the AC joint and possible swelling
Radiographs not initially indicated in non traumatic origin (C)

If radiographs indicated (D)

AP view in a 15° cephalic angulation

Stress radiographs (bilateral comparison): the value of stress views remains uncertain.

Special investigations (D)

CT/MRI useful for pathological/surgical cases, especially in separations of types IV-VI as vascular/ neurological complications can result.
  • US if CT and MRI not available



Table 2. Adult Elbow Disorders

Patient Presentation Recommendations
Adult patients with full or limited movement and nontraumatic elbow pain of less than 4 wk duration Radiographs not initially indicated (C)
General indications for radiographs include:
  • No response to care after 4 wk
  • Significant activity restriction >4 wk
  • Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)
  • Red flag indicators
    • History of cancer, signs or symptoms (S&S) of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained elbow pain with no previous films (tumor?)
    • Red skin, fever, systemically unwell (infection?)
    • History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?)
    • Trauma, acute disabling pain and significant weakness
    • Unexplained significant sensory or motor deficit (neurological lesion?)
Indicated before other imaging studies (B)

AP in full extension, lateral at 90° and medial oblique views

Additional views: AP in pronation, tangential (axial)

Advanced imaging and specialist referral recommended even if conventional radiographs are unremarkable if there is: (C)
  • Pain and significant disability despite attention to occupation and sporting factors
  • In the absence of clinical improvement after 4 wk of therapy
  • If function does not improve or deteriorates
  • History of instability, or acute, severe posttraumatic injury
  • In presence of a potentially serious pathology as suggested by the patient history, examination and/or radiograph
  • High-field-strength MRI provides greater detail than mid-field or low-field MR systems
  • CT and US may be more optimal than a low-field magnet in evaluation of the elbow
Chronic elbow pain in the adult patient Radiographs indicated (C)

AP in full extension, lateral at 90° and medial oblique views

Additional views: AP in pronation, tangential (axial)

Medical referral recommended and advanced imaging recommended (C)

When the etiology is uncertain and the patient has failed appropriate conservative therapeutic trials (see recommendation above).
Specific Clinical Diagnoses
1. Lateral epicondylitis (tennis elbow)

Epicondylar pain AND tenderness at the elbow laterally AND pain on resisted wrist extension—Cozen test:

2. Medial epicondylitis (Golfers' elbow)

Epicondylar pain AND tenderness at the elbow medially AND pain on resisted wrist flexion.
Radiographs not initially indicated (C)

Special investigations not indicated (C)



Radiographs not initially indicated (D)

Special investigations not indicated (C)
Adult patients with localized elbow pain following trauma

Elbow extension test: The inability to fully extend the elbow is a reliable indicator of osseous/joint injury

Instability tests: Lateral pivot-shift apprehension test (most sensitive), lateral pivot-shift test, posterolateral rotary drawer test, and stand up test
Radiographs indicated (C)

AP in full extension, lateral at 90° and medial oblique views

Additional views (C): AP in pronation, tangential view (axial), lateral stress view

Special investigations (GPP)
  • Increasing use of MRI for the determination of associated injuries of the lateral and medial collateral ligaments and cartilage
Diffuse non-specific pain in the forearm (or wrist) Radiographs not initially indicated (D)
Forearm pain following trauma Radiographs indicated (D)

AP and lateral views


Table 3. Adult Wrist and Hand Disorders

Patient Presentation Recommendations
Adult patients with nontraumatic localized wrist and hand pain symptoms Radiographs not initially indicated (D)
General indications for radiographs include:
  • No response to care after 4 wk
  • Significant activity restriction >4 wk
  • Non mechanical pain (unrelenting pain at rest, constant or progressive symptoms and signs, pain not reproduced on assessment)—(e.g., Keinbock's disease)
  • Red flag indicators
    • Signs and Symptoms (S&S) of cancer, unexplained deformity, palpable enlarging mass, or swelling, significant unexplained wrist pain with no previous films (tumor?)
    • Red skin, fever, systemically unwell (infection?)
    • History of noninvestigated trauma, loss of mobility in undiagnosed condition, loss of normal shape (unreduced dislocation? Instability?) (Trauma section)
    • Trauma, acute disabling pain and significant weakness
    • Unexplained significant sensory or motor deficit (neurological lesion at the wrist?)
    • Suspected associated inflammatory arthropathies of wrist and hand
Specific indications for radiographs include:
  • Noninvestigated chronic wrist and hand pain
  • Multiple sites of Degenerative joint disease (DJD) as visualized on radiographs
  • Possible Triangular fibrocartilage complex (TFCC) abnormality
  • Possible wrist instability, including perilunate instability, dorsal and volar intercalated segmental instability, scapholunate advanced collapse, scapholunate dissociation, ulnar translocation of the wrist—Trauma section
  • Possible operative candidate
Consult clinical presentation with related specific clinical diagnoses for additional help in decision making
If radiographs are indicated (C)

PA, lateral, and medial oblique views of the wrist Additional views: Radial and ulnar deviation views or clenched fist views are reserved for more subtle problems

Special investigations (D)
  • The combination of standard radiographs and US can diagnose a wide variety of disorders.
  • MRI is the procedure of choice to exclude osteonecrosis, marrow, and joint disease including infection.
Specific Clinical Diagnoses
1. Tendinopathy of the wrist

Pain and tenderness over a specific tendon or tendon group are the hallmarks of this condition. Other findings include localized swelling, impaired function, crepitus, pain with passive stretching of the tendon, and positive provocative testing. Tendinosis, however, can be asymptomatic.
Radiographs not initially indicated (D)

If radiographs are indicated (D)

PA, lateral, and medial oblique views of the wrist

Consider conventional radiography, in persistent painful "soft tissue injuries," not only to exclude bony injury but also to aid diagnosis (Dx) of rare cases of acute spontaneous calcific peritendinitis of the hand and wrist
2. De Quervain's tenosynovitis (stenosing tenosynovitis or tenovaginitis)

Pain over the radial styloid AND tender swelling of first extensor compartment AND EITHER pain reproduced by resisted thumb extension OR positive Finkelstein's test

Associated symptoms include warmth and crepitus (Naredo et al, 2002)
Radiographs not initially indicated (D)
3. Carpal Tunnel Syndrome (CTS)

Pain OR paraesthesia OR sensory loss in median nerve distribution in at least 2 of the first 4 fingers AND either one positive Tinel's or Phalen's, Thenar atrophy, female gender, obesity (body mass index ≥30), worsening of symptoms at night/awakening, or abnormal nerve conduction time

Clinical prediction rule (level IV):
  1. Age >45 y
  2. Shaking hands for symptom relief
  3. Reduced median sensory field of thumb
  4. Wrist ratio index (carpal canal volume) >.67
  5. Symptom Severity Scale (SSS) score (Brigham and Women Hospital) >1.9
Likelihood of CTS increase with number of positive tests (18.3 or 90% when all 5 tests positive)
Radiographs not initially indicated (C)

Special investigations (D)

Advanced imaging reserved for patients with equivocal presentation or with diabetes and diffuse peripheral neuropathy that confounds electrodiagnostic studies
  • MRI may be used to image anatomical abnormality (e.g., space-occupying lesion such as a ganglion).
  • US may be a useful alternative.
  • High-resolution sonography may show median nerve enlargement and increased hypoechogenicity
4. Osteoarthritis
  1. History: age >50 y, morning joint stiffness <30 minutes (min)
  2. Physical examination: crepitation, bony tenderness, bony enlargement, no palpable warmth
Other characteristics include: long standing pain, no extraarticular symptoms; nonresponsive to Nonsteroidal Antiinflammatory Drugs (NSAIDs), or corticosteroid medication; relieved with rest; deformity or fixed contracture, joint effusion; insidious onset
Radiographs not initially indicated (D)

It is common to have incomplete concordance between pathologic changes, radiographic and clinical features in osteoarthritis (OA).
5. Inflammatory or crystal induced arthropathy (excluding Rheumatoid arthritis[RA])

Gout, Calcium pyrophosphate dihydrate crystal deposition disease (CPPD), etc

Dx of inflammatory arthritis is primarily based on history and physical examination:
  • Unrelenting morning stiffness >30 min
  • Pain at rest
  • Pain or stiffness better with light activity (during remission)
  • Polyarticular involvement, especially the hands
  • Palpable warmth
  • Joint effusion
  • Diffuse tenderness
  • Decreased ROM
  • Fever/chills or other systemic symptoms
  • Responsive to NSAID or corticosteroid medication
  • Flexion contracture in long-standing arthritis
Radiographs indicated (C)

PA, lateral, and medial oblique of the wrist and hand

Special investigations (C)
  • If routine radiographs are normal or nondiagnostic, MRI is the study of choice; biopsy/aspiration to rule out (R/O) infection
  • Gadolinium-enhanced MRI of the hand and wrist is a superior technique for detection of tenosynovitis in inflammatory arthritis
6. RA

Symmetrical involvement of wrist, metacarpophalangeal and proximal interphalangeal finger joints

RA diagnostic criteria (≥4/7 required):
  • Morning joint stiffness >1 hour (h)
  • Arthritis involving ≥3 joints for at least 6 wk
  • Hand arthritis (wrist, metacarpophalangeal joint (MCP), proximal interphalangeal joint [PIP])
  • Symmetric arthritis
  • Rheumatoid nodules
  • Serum Rhesus (Rh) factor
  • Radiographic changes
Radiographs indicated (C) PA, lateral, and medial oblique views of the wrists and hands (Norgaard's/ball catcher projection)

Radiographs of the hands, feet, and chest are recommended at the initial evaluation

Special investigations (C)
  • MRI is the modality of choice in early Dx and management of RA. MRI helps differentiate erosive from nonerosive disease.
7. Osteonecrosis (avascular necrosis [AVN])

Nonmechanical pain
  • Unrelenting pain at rest
  • Constant or progressive symptoms and signs
  • Pain not reproduced on assessment
  • Swelling, tenderness
Radiographs indicated (C)

PA, lateral, and medial oblique

Special investigations (D)

MRI modality of choice to evaluate bone marrow changes in early stages
8. Complex regional pain syndrome (CRPS)

Synonyms:
  • Reflex sympathetic dystrophy
  • Sudek's atrophy
At least 4 of the following must be present in order for a Dx of CRPS to be made:

Examination findings:
  • Temperature/color change
  • Edema
  • Trophic skin, hair, nail growth abnormalities
  • Impaired motor function
  • Hyperpathia/allodynia
  • Sudomotor changes
Associated conditions:
  • Fractures or other trauma
  • Central nervous system (CNS) and spinal disorders
  • Peripheral nerve injury
Radiographs indicated (D)

PA, lateral, and medial oblique

Special investigations (D)
  • MRI is useful in detecting numerous soft tissue and earlier bone and joint processes that are not depicted or as well characterized with other imaging modalities
  • 3-phase Nuclear medicine (NM) scan recommended if radiograph is not diagnostic
9. Suspected Triangular fibrocartilage complex

(TFCC) lesion (articular disk)

Typically produces ulnar-sided wrist pain, which may become chronic and associated with clicking or popping sounds with certain movements
Radiographs indicated (D)

PA, lateral, and medial oblique

Special investigations (D)

MRI and gadolinium-enhanced MRI
10. Trigger finger (TF) (stenosing tenosynovitis)

Intermittent, troublesome locking of the digit in flexion. More common in women 40-60 YOA and in patients with diabetes, RA, gout, and other connective tissue disorders

Patients typically present with an insidious onset of morning pain and snapping, clicking, locking, or stiffness in the affected digit. A painful nodule may be palpable at the distal palmar crease. The nodule may move during active movement
Radiographs not initially indicated (D)
Acute wrist trauma in the adult patient

The following evaluation helps predict or rule out (R/O) fractures when no deformity is present:
  • Pain on passive and active motion
  • Localized tenderness and edema
  • Pain with grip and resisted supination
Radiographs indicated (C)

PA, lateral and pronation-oblique views (medial oblique) of the wrist
  1. Additional views (D) PA ulnar deviation (20°), lateral oblique, maximal wrist extension and ulnar deviation
  2. Additional views (D) stress tests (include PA with closed fist to stress scapholunate ligament)
A. Carpal navicular (scaphoid) fracture:

Accounts for 70%-80% of all carpal fractures; Most common (MC) in young active males

Anatomical snuffbox tenderness

Longitudinal thumb compression

Resisted supination

B. Suspected lunate instability:

Pain centered over the dorsal wrist immediately ulnar to the extensor carpi radialis tendons; pain and abnormal movement noted on Watson test; Specialized testing may be indicated earlier in such case.
Special investigations (C)

Increasing use of MRI as only examination for:
  • Scaphoid fractures
  • Pisiform and hamate
  • Scaphotrapezium-trapezoid joint
  • Scapholunate instability
Acute hand and finger trauma in the adult patient

Traumatic injuries to the hand can be evaluated routinely by conventional radiography.
Radiographs indicated (D)
  1. Hand: PA, lateral and pronation-oblique (medial oblique)
  2. Isolated finger: PA, lateral, pronation-oblique (AP for the thumb)
Additional views (GPP) Stress view of the thumb to identify gamekeeper's thumb (possible avulsion fracture of the thumb proximal phalangeal base)

Special investigations (D)
  • Consider advanced imaging (MRI, US, or arthrography) in suspected Stener lesion (entrapment of the ulnar collateral ligament) with gamekeeper's fractures.

Definitions

Levels of Evidence

Classification based on Stroke Prevention and Educational Awareness Diffusion (SPREAD) validated methodological criteria.

1++:   High-quality meta-analyses without heterogeneity, systematic reviews of randomized controlled trials (RCTs) each with small confidence intervals CI), or RCTs with very small CI and/or very small alpha and beta

1+:   Well-conducted meta-analyses without clinically relevant heterogeneity, systematic reviews of RCTs, or RCTs with small CI and/or small alpha and beta

1−:   Meta-analyses with clinically relevant heterogeneity, systematic reviews of RCTs with large CI, or RCTs with large CI and/or alpha or beta

2++:   High-quality systematic reviews of case-control or cohort studies. High-quality case-control or cohort studies with very small CI and/or very small alpha and beta

2+:   Well-conducted case-control or cohort studies with small CI and/or small alpha and beta

2−:   Case-control or cohort studies with large CI and/or large alpha or beta

3:   Nonanalytic studies, (e.g., case reports, case series)

4:   Expert opinion

− (minus): Meta-analyses with clinically relevant heterogeneity; systematic reviews of trials with large confidence intervals; trials with large CIs, and/or large alpha and/or beta



Grades of Recommendation

This tool has been developed to grade recommendations according to the strength of available scientific evidence (level A to D)

A:   At least one meta-analysis, systematic review or RCT rated as 1++, and directly applicable to  the target population; or a systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+,directly applicable to the target population and demonstrating overall consistency of results

B:   A body of evidence including studies rated as 2++, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+

C:   A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++**

D:   Evidence level 3 or 4; or extrapolated evidence from studies rated as 2+; or evidences from trials classified as (minus) regardless of the level

Good practice point: Recommended best practice based on the clinical experience of the guideline development group, without research evidence.

This tool aims to evaluate the scientific evidence according to prespecified levels of certainty (1++ to 4). In this study, Good Practice Point also represents consensus of the Delphi panel. CI indicates confidence intervals.

CLINICAL ALGORITHM(S)

None provided



EVIDENCE SUPPORTING THE RECOMMENDATIONS

REFERENCES SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").



BIBLIOGRAPHIC SOURCE(S)

Bussieres AE, Peterson C, Taylor JA.
Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults —
An Evidence-Based Approach: Part 2: Upper Extremity Disorders

J Manipulative Physiol Ther 2008 (Jan); 31 (1): 2-32
GUIDELINE DEVELOPER(S)

Canadian Protective Chiropractic Association - Professional Association
l'Université du Québec à Trois-Rivières - Academic Institution

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