1. Clinical Prediction
Rules
Kelsey Terreson, SPT
Texas Woman’s University
Complete Orthopaedic Care-Advocate Condell Lincolnshire

2. Outline
• Overview of CPRs
• CPRs related to common problems seen the outpatient
orthopedic setting
• Where to find more information
• Questions

3. About Clinical Prediction Rules 1-2
• What are clinical prediction rules?
• A clinical prediction rule is a group of signs, symptoms and
other findings that predict the probability of a specific disease
or outcome.
• Clinical prediction rules have been used to describe the
likelihood of the presence or absence of a condition, assist in
determining patient prognosis, and help the classification of
patients for treatment.
• A clinical decision rule (CDR) is a clinical tool that quantifies the
individual contributions that various components of the history,
physical examination, and basic laboratory results make toward
the diagnosis, prognosis, or likely response to treatment in a
patient. Clinical decision rules attempt to formally test, simplify,
and increase the accuracy of clinicians' diagnostic and
prognostic assessments. Existing CDRs guide clinicians,
establish pretest probability, provide screening tests for
common problems, and estimate risk. (2)

4. How Can We Use CPRs? 3-4
Validation of CPRs are required before they can be used
clinically. Validation is broken down into levels:
• Level IV – CPR without validation, or validated with
retrospective data
• Level III – has only been validated with a narrow prospective
study
• Level II – has been validated in a large prospective study
• Level I impact, practice patterns takes that and shows that it
decreases costs
Clinical Prediction Rules (CPRs) help therapists quickly
determine if a patient has a disease or if they will benefit from
a specific treatment or test.

5. CPRs
• Ottowa Ankle Rules
• Ottowa Knee Rules
• Whether a patient with with PFPS who will benefit
from patellar taping
• Presence of Hip OA
• Whether a patient WILL benefit from Lumbopelvic
manipulation
• Whether a Patient WILL benefit from a Lumbar
stabilization program
• Presence of Carpal Tunnel Syndrome
• Cervical Radiculopathy
• Canadian C-Spine Rules
• People who will benefit from Cervical Traction and
Exercise

6. Ottowa Ankle Rules Level 1 (5-7)
• Bony tenderness at the posterior distal 6cm of the fibula (posterior
lateral malleolus)
• Bony tenderness at the base of the 5th metatarsal
• Bony tenderness at the navicular
• Bony tenderness at the posterior edge or tip of the medial
malleolus
• Inability to bear weight immediately after incident or in ER for 4
steps
• With an appropriate MOI and any of these positive, patient should get
xrays. 100% Sensitive, 24% Specific, valid for people older than 6
y/o

7. Ottowa Knee Rules Level 1 8-10
• Age ≥ 55
• Isolated tenderness at
the patella (no other
bony tenderness)
• Tenderness at the fibular
head
• Unable to flex knee to 90
• Able to bear weight
immediately after and in
ER for 4 steps (limping
counts)
• Any one of these positive
with an appropriate MOI,
the patient should get an
xray. (100% sensitive,
50% specific)

8. Patients with PFPS who would
benefit from patellar taping 11
• Asked patients with
retropatellar pain
aggravated by squatting to
perform
• Defined “benefit” as 50%
improvement in NPRS or
“moderate improvement” on
GROC.
• Use of the rule improved
success with taping from
52% to 83%
• Level 4 – requires
validation
• Positive patellar tilt test
• Tibial Varum

9. Presence of Hip OA 12
• Self reported squatting is aggravating
• Scour test with adduction causes groin or lateral hip pain
• Active hip flexion causes lateral pain
• Active extension causes hip pain
• Passive IR less ≤ 25 degrees
• Level 4 – Requires validation
• 3/5 - 68% probability that x-rays would show the patient
has OA
• 4/5 – 91% probability that x-rays would show that the
patient has OA

10. Patient WILL benefit from
Lumbopelvic manipulation 13-14
• Symptoms <16 days
• No symptoms distal to the knee
• FABQ work subscale <19 (not very fearful about going
back to work)
• At least one hip with >35 degrees of IR
• Hypomobility of the lumbar spine
• Level 2

11. Patient WILL benefit from a
Lumbar Stabilization program 15-17
• <40 years old
• >91 SLR
• + Prone instability test
• Aberrant motions
• Level 4*

12. Carpal Tunnel Syndrome Level
4 18-19
• Patient reports symptoms are relieved with repositioning
or flicking of the hands*
• Diminished sensation into the median nerve distribution
of the thumb
• Wrist ratio of >.67 (distal wrist crease AP / ML)
• Symptom severity scale >1.9
• >45 y/o
• ≥ 2 (Sensitivity 98, Specificity 14)
• ≥ 3 (Sensitivity 98, Specificity 54)
• ≥ 4 (Sensitivity 77, Specificity 83)
• ≥ 5 (Sensitivity 18, Specificity 99)

13. Cervical Radiculopathy Level 4 20-21
• Ipsilateral Cervical Rotation <60 degrees
• + Spurling
• + Neck Distraction
• + Median Nerve ULTTA
• All 4 – 90% chance of true cervical radiculopathy, 3 –
65% chance of true cervical radiculopathy

14. People with neck pain who are likely to
benefit from cervical traction and
exercise Level 422
• Pt reported
peripheralization with
lower cervical with
lower cervical spine
mobility testing
• + shoulder abduction
test
• Age ≥ 55
• + Median nerve
ULTTA
• + Neck distraction
test

15. Canadian C-Spine Rules Level 1
23-25
• Not cognitively intact or have neurological symptoms
• 65 y/o or older
• Patient fearful of moving head on command
• Involved in a distraction type injury
• Demonstrates midline pain
• Any one of these positive with an appropriate MOI, patient
should get x-rays, (Sensitivity 100%, Specificity 42.5)
• Rule not valid if:
• Non-trauma cases
• GCS < 15
• Unstable vital signs
• Age < 16 years
• Acute paralysis
• Known vertebral disease
• Previous C-spine surgery

16. Patients with neck pain that will
benefit from a thrust manipulation 26-
28
• Symptom duration less than 38 days
• Positive expectation that the manip will help
• Side to side difference in cervical rotation of 10 degrees
or more
• Pain with PA mob/spring testing of the midcervical spine
• Failed validation because everyone who had neck pain
and got the manipulation got better

17. Want to know more?
• JOSPT’s publishes several of the validation studies and
is helpful for finding CPRs and their validations
• Really helpful article explaining what CPRs are and how
to use them:
• http://ptjournal.apta.org/content/86/1/122.long
• Keep in mind that it was published in 2006, some of the
studies that I have presented since then have been
validated.

18. Thanks!!!
It has been such a pleasure to work with all of you! Thank
you for all that y’all have taught me!

19. Questions?

20. References
1. Beattie P and Nelson R. Clinical prediction rules: What are they and what do they
tell us? Australian Journal of Physiotherapy. 2006 52: 157–163
2. Adams S and Leveson S. Clinical Prediction Rules. BMJ. January 2012. 16;344.
3. Adams S and Leveson S. Clinical Prediction Rules. BMJ. January 2012. 16;344
4. Learman K, Showalter C, Cook C. Does the use of a
prescriptive clinical prediction rule increase the likelihood of applying inappropriate
treatments? A survey using clinical vignettes. Manual Therapy. December
12;17(6):538-43.
5. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR
(April 1992). "A study to develop clinical decision rules for the use of radiography
in acute ankle injuries". Annals of Emergency Medicine; 21 (4): 384–90.
6. Stiell I, Wells G, Laupacis A, Brison R, Verbeek R, Vandemheen K, Naylor CD.
Multicentre trial to introduce the Ottowa ankle rules for the use of radiography in
acute ankle injuries. Multicentre Ankle Rule Study Group. BMJ. Septempter
2005; 311(7005): 594–7.
7. Dowling S, Spooner CH, Liang Y, et al. (April 2009). "Accuracy of Ottawa Ankle
Rules to exclude fractures of the ankle and midfoot in children: a meta-
analysis".Acad Emerg Med 16 (4): 277–87.
8. Stiell IG, Greenburg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, Cacciotti TF,
Sivilotti MLA. Prospective validation of a decision rule for the use of radiography in
acute knee injuries. JAMA 1996; 275:611-615.
9. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use
of radiograph in acute knee injuries. Ann Emerg Med 1995;26:405–13.
10. Nichol G, Stiell IG, Wells GA, et al. An economic analysis of the Ottawa knee rule.
Ann Emerg Med 1999;34:438–47.

21. References continued
11. Lesher JD, Sutlive TG, Miller GA, Chine NJ, Garber MB, Wainner RS. Development of a clinical
prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping.
Journal of Orthopedic and Sports Physical Therapy. November 2006; 36(11):854-66).
12. Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT, Boyles RE, Childs JD.
Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip
pain. JOSPT, 2008 Sept; 38(9):342-50.
13. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical
prediction rule for classifying patients with low back pain who demonstrate short-term improvement with
spinal manipulation. Spine. December 2002.15;27(24):2835-43.
14. Childs JD, Fritz JM, Flyyn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. 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. December 2004. 21;141(12):920-8.
15. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for
determining which patients with low pack pain will respond to a stabilization exercise program. Archives of
Physical Medicine and Rehabilitation. September 2005; 86(9):1753-62.
16. Rabin A, Shasua A, Pizem K, Dickstein r, Dar G. a clinical prediction rule to identify patients with low
pabck pain who are likely to experience short-term success following lumbar stabilization exercises: a
randomized controlled validation study. Journal of Orthopedic and Sports Physical Therapy. January
2014;44(1):6-B13.
17. Ribaudo A. Management of a patient with lumbar segmental instability using a clinical predictor rule.
HSS J. 2013 Oct;9(3):284-8
18. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a
clinical prediction rule for the diagnosis of carpal tunnel syndrome. Archives of Physical Medicine and
Rehabilitation. April 2005; 86(4):609-18.
19. Pryse-Phyllips WE. Validation of a diagnostic sign in carpal tunnel syndrome. J Neurol Neurosurg
Psychiatry 1984;47:870-872.
20. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and Diagnostic Accuracy
of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine. January
2003; 28(1):52-62.
21. Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a
multimodal intervention approach: a case series. Journal of Orthopedic and Sports Physical Therapy.
March 2006;36(3):152-9.

22. References continued
22. Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Devle GD, Childs JD.
Development of a clinical prediction rule to identify patients with neck pain likely to
benefit from cervical traction and exercise. European Spine Journal. March
2009;18(3):382-91.
23. Stiell IG, Clement CM, O’Connor A, Davies B, Leclair C, Sheehan P, Clavet T, Beland C,
MacKenzie T, Wells GA. Multicentre prospective validation of use of the Canadian C-
Spine Rule by triage nurses in the emergency department. CMAJ. August 2010;
182(11):1173-9.
24. Stiell IG, Clement CM, Grimshaw J, Brison R, Rowe BH, Schull MJ, Lee J, Brehaut J,
McKnight D, Eisenhauer MA, Dreyer J, Letovsky E, Rutledge T, MacPhail I, Ross S,
Perry JJ, Holroyd BR, Ip U, Lesiuk H, Wells GA. Implementation of the Canadian C-
Spine Rule: A Prospective 12-Centre Cluster Randomized Trial. British Medical Journal.
October 2009;29(339).
25. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, WorthingtonJR,
Eisenhauer WA, Cass D, Greenburg G, MacPhail I, Dreyer J, Lee JS, Bandiera G,
Reardon M, Holroyd B, Lesuik H, Wells GA. The Canadian C-Spine Rule Versus the
NEXUS Low Risk Criteria in Patients with Trauma. New England Journal of Medicine.
2003;349:2510-2518.
26. Cleland JA, Childs JD, McRae M, Palmer JA, and Stowell T. Immediate effects of
thoracic manipulation in patients with neck pain: A randomized control trial. Manual
Therapy. May 2005; 10:2, (127-135).
27. Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. 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. Physical Therapy. January
2007;87(1):9-23.
28. Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Childs JD. Examination of a
clinical prediction rule to identify patients with neck pain likely to benefit from thoracic