Clinical Prediction Rules

High Ankle Sprain Cluster

TTP

(+) stress test

Presence of hematoma

96% SN

NOTE: squeeze test > specificity than kleiger test

Ottawa Ankle Rules

Valid for patients age 16+ to R/O fracture:

Ankle:

TTP along tip or medial malleolus (6cm proximal from mid-point)

TTP along posterior edge of lateral malleoli (6cm proximal from mid point; NOT anterior malleoli)

Inability to WB immediately and in ED

Foot:

TTP base of 5th metatarsal and navicular area

Inability to WB immediately and in ED

Bernese Ankle Rules

Pain w/ compression of tib and fib approx. 10cm to fib. Tip

Thumb press on medial malleolus

Compression of rearfoot and midfoot

NOTE: more SPECIFIC than Ottawa Ankle Rules

Ottawa Knee Rules

Age >55

TTP hed of fibula

Isolated tenderness of patella during palpation

Inability to flex knee to 90

Inability to WB immediately and upon ER evaluation

Pittsburgh Knee Rules

Blunt trauma or a fall as MOI PLUS one of the following:

- Age >50 or <12

- Inability to walk 4 steps in ED

Carpal Tunnel Syndrome

Shaking hands for symptom relief

Wrist ratio >0.67

Symptom severity scale >1.9

Reduced median sensory field of digit 1

Age >45

3/5 98% SN, 4/5 70%, 5/5 90%

Lumbar Spinal manipulation

Duration LBP <16 days *

FABQ (work) < 19

No symptoms beyond knee *

1 or more hypomobile segment or (+) lumbar spine test for pain

1 or both hips >35 deg IR

3/5 68%, 4/5 95%

Vertebral Compression Fracture (Henscke et all 2009)

Prolonged use of corticosteroids (+LR = 48.5)

Significant trauma (+LR = 10)

Age >70 (+LR = 11)

Female sex

3/4 100% SP +LR 218

NOTE: Vertebral compression fracture "Supine Sign" is pain lying supine and has SN 81% and SP 93%

Vertebral Compression Fracture (Roman et al 2010)

Age >52

No presence of leg pain

BMI <22

Does not exercise regularly

Female gender

NOTE: Vertebral comrpession fracture "Supine Sign" is pain lying supine and has SN 81% and SP 93%

Cervical Radiculopathy

Positive ULTT median (MOST SN)

Cervical AROM <60 to affected side

+ distraction test

+ spurling test

3/4 65%, 4/4 90%

Subacromial Pain / Impingement "HIP"

Hawkins kennedy *

Infraspinatus muscles test/painful/weak ER *

Painful arc (60-120)*

2/3 90%, 3/3 95% and +LR 10.56

others:

Jobe (empty can)

Neers

(+ = rule in)

Full thickness RTC tear

Age >65

Night pain

Weakness ER

3/3: 94% SP PPV 93% +LR 9.8, - LR 0.54

RTC pathology (Park et al)

Painful arc

Drop arm sign

Infraspinatus muscle test

2/3 69%, 3/3 91%

Anterior instability

Anterior apprehension *

Relocation *

Surprise

NOTE: apprehension not pain are more sensitivt and specific for instability

Ankylosing Spondylitis (Berlin Criteria)

Morning stiffness > 30min

Improvement in back pain w/ exercise but not w/o

Awakening because of back pain during second half of night only

Alternating buttock pain

Ankylosing Spondylitis (IBP Criteria)

Age at onset <40 y.o.

Insidious onset

Improvement w/ exercise

No improvement w/ rest

Pain at night w/ improvement on getting up

4/5 SN 77% SP 92%

Cervical Myelopathy

Gait deviation

Positive hoffman's test

Positive inverted supinator sign (MOST SP)

Positive babinski test

Age >45 (MOST SN)

3/5 94%

Cervical Closed Fracture

Age <55

Single (maritial status)

Condition involved trauma

Acute condition

Condition involved ER visit

Wells Criteria

Pulmonary Embolism Criteria

Hip OA

Squatting as aggravating factor

+ scour test w/ adduction for groin or lateral hip pain

Active hip flexion causing lateral hip pain

Passive IR <25 deg

Active hip extension causing pain

3/5 68%, 4/5 91%

Lumbar Spinal Stenosis

B symptoms

Leg pain > back pain

Pain during walking/standing

Pain relief upon sitting

>48 y.o.

MCL Pathology

Trauma by external force to leg

Rotation trauma

Pain w/ valgus stress test @ 30 deg

Laxity w/ valgus stress test @ 30 deg

Meniscal Cluster

History of catching/locking reported

Joint line tenderness

Pain w/ forced hyperextension

Pain w/ maximal passive kne flexion

Pain or audible click w/ McMurray

SIJ pain (Laslett cluster)

SI distraction

SI compression

Thigh thrust

Gaenslen's test

Sacral thrust (laslett) or FABER (van der wuff)

<3 4%, >3 59%

Cervical Manipulation for Neck Pain (Puentedura et al 2012)

Symptom duration <38 days

Positive expectation that manipulation will help

Side to side difference in cervical rotation >10 deg (MOST SP)

Pain w/ PA middle C-spine

3/4 90%, 4/4 10%

Cervical Manipulation for Neck Pain (Tseng et al 2006)

NDI <11.5

B involvement

Not performing sedentary work >5hrs per day

Feeling better while moving neck

Symptoms not worse w/ cervical extension

Diagnosis of spondylosis without radiculopathy

Exercise for Ankylosing Spondylitis

SF-36 physical role >37

SF-36 bodily pain >27

Bath ankylosing spondylitis Disease Activity Index >31

Hip Mobilization for Knee OA

Hip or groin pain or paresthesia

Anterior thigh pain

Passive knee flexion <122 deg

Passive hip IR <17 deg

Pain w/ hip distraction

any 2 +LR 12.9

Manual Therapy and Exercise for Acute Lateral Ankle Sprain

Symptoms worse when standing

Symptoms worse in evening

Navicular drop >5mm

Distal tib-fib joint hypomobility

3/4 95%

Mechanical Traction for LBP

FABQ (work) < 21

No neuro deficit involvement

Age >30

Non manual work job status

4/4 69%

Mechanical Traction for Neck Pain

Peripheralization w/ lower c-spine C4-C7 mobility testing

Positive shoulder abduction test

Age >55

Positive ULTT A

Positive neck distraction test

3/5 80%, 4/5 95%

Mobilization w/ movement from lateral epicondyalgia

Age <49

Affected side pain free grip >112N (25.2lbs)

Unaffected side pain free grip <335N (75.3lbs)

1/3 87%, 2/3 93%, 3/3 100%

Other: Change in pain >25% following MWM

Orthotics for PFPS (Vicenzino et al 2010)

Age >25

Height <165cm

Worst pain <53.25mm (100mm VAS)

Mid-foot difference >10.96cm

Orthotic for PFPS (Barton et al 2010)

Motion controlled properties (weighted mean) >5.0

Usual pain >22.0mm

Ankle DF knee flexed >41.3deg

Reduced pain during SL squat w/ foot orthoses

Patellar Taping for PFPS

Tibial angulation >5 deg

Positive patellar tilt test

Stabilization for LBP

Age <40

SLR >91

Aberrant movement present

+ prone instability test

MODIFIED LBP stabilization CPR

Aberrant movement present

+ prone instability test

other factor: FABQ PA < 8

3+ 67%

Thoracic Manipulation for Cervical Pain "CPR T/S"

Cervical Ext ROM <30

(PA) FABQ <12

Reduced Upper t-spine kyphosis

Thirty days or less symptoms

Symptoms not distal to shoulder

looking up does not aggravate symptoms

3/6 84% 4+ 93%

Canadian C-Spine Rules

Series 1: High risk which mandate X-Ray (yes to any)

- age >65

- dangerous MOI (fall >3ft or 5 stairs, axial load to head, MVA >100km/hr, bike collision)

- paresthesias in extremities

Series 2: low risk factors to allow for safe assessment of ROM (need yes to all)

- simple rear end MVA

- sitting position in ER

- ambulation anytime post injury

- absence of mid cervical tenderness

- delayed onset of neck pain

series 3: AROM c-spine >45 (if no then X-Ray)

NEXUS Criteria X-Ray

No painful distraction injury

Evidence of normal alertness

X-Ray no focal defects

Un-Intoxicated

Sans cervical midline tenderness

NOTE: use Canadian C-spine rules over NEXUS)

NEXUS CT Scan Rule "ABC's"

Altered level of alertness

Behavior change - abnormal

Coagulopathy - clotting disorder

Deficits - neurological

Evidence of skull fracture

Frequent vomiting

Greater than 65 years old

Hematoma skull

Pilates Based Exercise for LBP

Total trunk flexion ROM 70deg or less

Duration of current symptoms 6 months or less

No symptoms in leg for past week

BMI >/= 25 (obese)

Mean hip rotation 25deg or more (either hip)

3/5 93%

AC joint cluster

cross body adduction test or scarf test

AC resisted extension

O'briens test (pain by AC joint)

3/3 80.5%

very SP

Supraspinatus Tendinopathy

age >39

painful arc

self reported popping/clicking

2 +LR 3.82, 3/3 +LR 32.3

Successful short term outcome of C-Spine Manipulation for shoulder pain

Symptomatic < 90 days

Not taking any meds for their shoulder pain

(-) Neer's

Pain-free flexion <127

IR <35 at GH 90 ABD

3/5 85%

SIJ manipulation or PFJ Mobilizations for Knee Pain

Difference in hip IR >14

Ankle DF >16

Navicular drop >3mm

No stiffness with sitting >30min

Squatting is most painful activity

>/= 4 100%

Imaging for hip OA

Painful w/ IR

Hip IR <15 deg

ESR 50

Predictors of Response to PT in hip OA

Unilateral hip pain

Age <58

Pain >6/10

40m self-pased walk test <35.9s

Duration of sx <1yr

>/=3 99%

Hand OA

Hand pain, aching or stiffness AND:

Hard tissue enlargement of 2 or more of 10 selected joints (bilateral DIP, PIP of 2nd/3rd digits and 1st CMC) AND:

- <3 swollen MCP joints and either:

1. hard tissue enlargement of 2 or more DIP joints OR

2. Deformity of 2 or more of 10 selected joints

CPR for DVT "ABC's"

Active cancer

recently Bedridden >3 days or major surgery

Calf swelling >3cm

alternative Diagnosis as likely or greater than dvt

pitting Edema

Focal tenderness along deep venous system

Gross LE swelling

Has collateral superficial veins (non-varicose)

paralysis, paresis or recent plaster Immobilization of LE

1-2 17%, 3+ 75%

F/U tests: Dimer (to R/O), if (+) then US

CPR for PE "PULM CPR"

Puke up blood - hemoptysis (1pt)

Unmoved from surgery last 4 weeks (1.5pt)

Lack of alternative diagnosis (3pt)

Malignancy (1pt)

Clinical signs of DVT (3pt)

Previous DVT/PA (1.5pt)

Rate of Heart >100bpm (1.5pt)

<2pts low risk, 2-6pts mod risk, >6 pts high risk

Hip Microinstability

AB-HEER

prone instability (hip)

HEER

3/3 = 95% likelihood

Beighton Score

- passive DF and hyperextension of 5th MCP >90deg (2)

- passive opposition of thumb to flexor aspect of arm (2)

- passive hyperexrtension of elbow >10deg (2)

- passive hyperextension of the knee >10deg (2)

- active forward flexion of trunk with the knees fully extended and palms flat on the floor

Adults 4/9 positive and children 6/9 positive

ACL Coper criteria

- no more than one episode of the knee "giving way"

- at least 80% LSI in timed 6m hop test

- at least 80% on KOS-ADL

- at least 60% on the Global Rating of knee function

Posterior Instability

posterior apprehension test

99% SP and only 19% SN

Inferior Instability

at least 2 directions of postiive testing w/ instability (hyperabduction test>105 SP 89%)

Beighton score >5/9 adolescent 6/9 pre pubescent

NOTE: sulcus sign tests LAXITY, not instability

SLAP/Labral Tear

2 clusters:

1. passive distraction test and active compression (SN 70% SP 90%)

2. h/o popping clicking or catching with a positive anterior slide test (SP 93% and low sensitivity)

Coronary Artery Disease

- sex and age (female >65, male >55)

- known clinical vascular disease (coronary artery, oclusive vascuar idsease, cerebrovascular disease )

- pain worse during exercise

- pain not reproducible by palpation

- patient assumes pain is of cardiac origin

3/5 SN 87%, SP 80% +LR4.52