Clinical Predication Rules - A Physical Therapy Reference Manual by Paul E. Glynn P Cody

I220 CHAPTER 9 Case Studies decision to incorporate these interventions be confirmed from further research. In this case, recent evidence has demonstrated the benefit of a multimodal treatment approach for patients with cervical radiculopathyY By incorporating clinical prediction rules in the management of this patient, the diagnosis (cervical radiculopathy), prognosis (positive), and intervention plan (multimodal treatment) were efficiently and effectively achieved. These tools allow the clinician to refine his or her clinical decision making and improve his or her level of confidence in these decisions. The methodological quality was considered as were the statistical parameters of the rules. Interventions with strong evidence were used in conjunction with the CPR findings to formulate a comprehensive plan of care for the patient. Despite the high quality of the current Level IV ePRs and the strength of the existing literature further confirming the CPR findings, the manage­ ment of this patient will include frequent reexamination of impairments and func­ tional level outcomes to determine the validity of the diagnosis, the effectiveness of the intervention, and the accuracy of the prognosis. References 1. Wainner RS, Fritz ]M, Irrgang jJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patiem self-report measures for cervical radiculpathy. Spine. 2003;28:52-62. 2. Cleland]A, Fritz]M, Whitman JM, Heath R. Predictors of short-term outcome in people with a clinical diagnOSiS of cervical radiculopathy. Phys 7her. 2007;87:1619-1632. -3. Childs]D, Fritz ]M, Piva S R , Whitman ]M. Proposal of a classification system for patients with neck pain.} Orthop Sports Phys 7her. 2004;34:686-696. 4. Childs]D, Cleland]A, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the imernational classification of functioning, disability, and health from the orthopedic section of the American Physical Therapy Association.} Orthop Sports Phys 7her. 2008;38:A1-A34. 5. Raney NH, Petersen E], Smith TA, et al. Development of a clinical prediction rule to iden­ tify patiems with neck pain likely to benefit from cervical traction and exercise. Eur Spine j. 2009;18:382-391. 6. Cleland ]A, Childs]D, Fritz]M, Whitman]M, Eberhart SL. Development of a clinical predic­ tion rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys 7her. 2007;878:9-23. 7. Cleland ]A, Whitman]M, Fritz]M, Palmer]A. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series.} Orthop Sports Phys 7her. 2005;35:802-81l. 8. Beneciuk]M, Bishop MD, George SZ. Clinical prediction rules for physical therapy interven­ tions: a systematic review. Phys 7her. 2009;89:114-124. 9. Kuijpers T, van der Windt DAWM, van der Heijden GJMG, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004; 1 09:420-431.

Knee I 221 CASE STUDY Knee Historical Exam A 43-year-old recreational runner with a 6-week history of worsening left anterior knee pain. She reports an insidious onset of retropatellar and infrapatellar pain. It is now limiting her ability to continue running and comfortably descend stairs. Aggravating factors: Squatting, sitting with bent knee greater than 30 minutes, running greater than 10 minutes, descending stairs Relieving factors: Rest, ice, ibuprofen, frequent position changes PMH: Noncontributory Self-Report Outcome Measures 5 2/80 2/10 left anterior knee Lower Extremity Functional Scale ( L EFS) 5/10 left anterior knee Numeric Pain Rating Scale ( NP RS): Current Numeric Pain Rating Scale ( NP RS): Worst in past 24 hours 0/1 0 Numeric Pain Rating Scale ( NP RS): Best in past 24 hours Physical Exam Observation: 5' 2\" (157 cm) otherwise healthy and athletic female; mild bilateral infrapatellar swelling Posture (standing): Bilateral genu valgus and genu recurvatum; bilateral patella alta; bilateral calcaneal valgus Gait: Bilateral and symmetrical excessive pronation with late supination (left greater than right) Palpation: Tenderness to palpation at the inferior patellar pole of the left patella; no other tenderness to palpation noted Range of motion (ROM): Bilateral knee ROM within normal limits (WNL)

I222 CHAPTE R 9 Case Studies Regional ROM Measurements Right Left Hip Internal Rotation P ROM' 40° 2 4° Ankle Dorsiflexion A ROM' 20° 20° GreatToe Extension P ROM2 BO° BO° Navicular Drop' 6mm Bmm Forefoot Valgus2 0° 0° Ti bial Varum3 r BO Manual muscl e test: 4/5 in the left hip external rotators and abductors; otherwise 5/5 and painfree throughout the bilateral LEs Anthropometric Measurements Right Left 74 mm 7 6mm Mid-foot width4 Weight bearing 63 mm 64 mm Mid-foot width4 Non-weight bearing Special Tests Right Left Patellar tilt test3 Negative Eccentric step down testS WNL Positive Hip adduction and VMO coordination testS Negative Patellar apprehension testS Negative internal rotation Positive Positive Clinical Decision Making [] Diagnosis Appropriateness for PT: There are no indications of trauma from the history, thus eliminating the need to use CPRs to screen for fracture or ligamentous injury,G,? PT diagnosis: Currently there are no CPRs available to diagnose patellofemoral pain syndrome; however, based on the patient's pain location, aggravating factors, special testing, and postural presentation, a diagnosis of left patellofemoral pain syndrome is appropriate,I,5,8,9

Knee I 223 Intervention Orthotics: The decision to use orthotics in this case is unclear. The patient does not possess any of the individual predictor variables identified in the study by Sutlive et all; however, she does meet three of the four variables identified in the CPR by Vicenzino et al,4 indicating a moderate shift in probability that she will benefit from prefabricated orthotics. Given the low risk, moderate cost, and possible benefit involved in this intervention, a trial of prefabricated orthotics is indicated. Orthotics- Sutlive2 Variable Present Forefoot valgus � 2° No Great toe extension $ 78° No Navicular drop $ 3 mm No Orthotics-Vicenzino4 Variable Present I Yes Age> 2 5 Yes Yes Height < 16 5 cm No Worst pain < 53.25 mm on VAS Mi d-foot width difference> 10.96 mm Lumbar manipulation: The patient meets four of the five criteria, indicating a large and conclusive shift in probability that she will significantly improve her pain level as well as functioning if she receives lumbopelvic manipulation. I Lumbar Manipulation1 Variable Present Hip IR difference> 1 4° Yes Ankle dorsiflexion ( DF)> 16° Yes Navicular drop> 3 mm Yes No self-report ofstiffness when sitting> 30 min No Squatting reported as most painful activity Yes Patellar taping: The patient meets both criteria, indicating a small but perhaps important shift in the probability that she will exhibit a significant reduction in pain or an immediate improvement in functioning from patellar taping with a medial glide.3

I224 CHAPTER 9 Case Studies Patellar Taping3 Variable Present Tibial varum> 5° Yes Positive patellar tilt test Yes Discussion This case illustrates the clinical decision making that may be used when consider- ing multiple Level IV interventional CPRs. In this instance it is recommended that interventions are prioritized based on the strength of the evidence. For this patient, the strongest evidence available for treatment of PFPS includes an impairment-based, regional approach to strengthening and stretching of the entire lower quarter. 10-12 In addition to the strong evidence supporting a lower-quarter impairment-based approach, the treating clinician may also consider the derivation-level CPRs. We recommend five strategies to help improve the likelihood of success with CPR utilization. First, consider the details of the CPR in question before incor­ porating this into practice. Second, choose CPRs with high-quality scores, thus eliminating potential bias in their findings. Third, select a CPR that was studied in populations similar to your intended patient. Fourth, consider the strength of the +LR when prioritizing treatments, and, lastly, always test a functional or impair­ ment-based measure before and after performing the intervention in question. This test-retest approach will provide immediate feedback concerning the effective- ness of the intervention. In the current case, the patient meets the criteria for the lumbopelvic manipulation CPR, the taping CPR, and the orthotics CPR. 1,3,4 Our patient meets all inclusion/exclusion criteria for the three CPRs, except for eligibil­ ity of military health care benefits; however, only the taping CPR has a quality score greater than 60%. Therefore, a trial of taping should be prioritized ahead of manip­ ulation and orthotics. The lumbopelvic manipulation and orthotic CPR have low methodological-quality scores; thus if implemented, they should be used with cau­ tion. In this case the treating therapist may consider that both interventions have been studied in prior research and have found to be beneficial in individuals with patellofemoral pain syndrome.13-15 For this reason, if it is determined that exercise and taping have not achieved their desired effects, implementation of manipulation and orthotics would be appropriate. Finally, as our patient is similar to both deriva­ tion populations, the use of lumbopelvic manipulation should be prioritized above the use of the orthotics due to its larger + LR. This case illustrates the use of multiple derivation-level CPRs in clinical deci­ sion making. Arguments have been made that Level IV CPRs are not appropriate for use in clinical decision making. We believe that they are one component of the

Knee I 225 best current evidence that exists on a continuum of quality and generalizability. We believe that if clinicians considerLevel IV ePRs in these terms as outlined above, they can be useful, along with clinical experience and patient preference, to help imptove evidence-based clinical decision making. References 1. Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule.] Orthop Sports Phys Ther. 2008;38:297-309. 2. Surlive TG, Mitchell SO, Maxfield SN, et aI. Identification of individuals with patellofemoral pain whose symptoms improved after a combined program of foot orthosis use and modified activity: a preliminary investigation. Phys Ther. 2004;84:49-61. 3. Lesher JD, Sutlive TG, Miller GA, Chine N], Garber MB, Wainner RS. Development of a clini­ cal prediction rule for classifying patients with patellofemoral pain syndrome who respond ro patellar taping.] Orthop Sports Phys Ther. 2006;36:854-866. 4. Vicenzino B, Collins N, Cleland], McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: a preliminary determina­ tion. Br] Sports Med. Epub ahead of print. 5. Nijs J, Van Geel C, Van der Auwera C, Van de Velde B. Diagnostic value of five clinical tests in pateUofemoral pain syndrome. Man Ther. 2006;11:69-77. 6. Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a decision rule for the use of radiogra­ phy in acute knee injuries. Ann Emerg Med. 1995;26:405-413. 7. Seaberg DC, Jackson R. Clinical decision rule for knee radiographs. Am] Emerg Med. 1994;12:541-543. 8. Gerbino PG, Griffin ED, d'Hemecourt PA, et aI. Patellofemoral pain syndrome: evaluation of location and intensity of pain. Clin] Pain. 2006;22:154-159. 9. Hamstra�Wright KL, Swanik CB, Ennis TY, Swanik KA. Joint stiffness and pain in individuals with patellofemoral syndrome.] Orthop Sports Phys Ther. 2005;35:495-501. 10. Reiman MP, Bolgla LA, Lorenz D. Hip functions influence on knee dysfunction: a proximal link to a distal problem.] Sport Rehabif. 2009;18:33-46. 11. Heintjes E, Berger MY, Bierma-Zeinstra SMA, et al. Exercise therapy for patellofemoral pain syndrome. Cochrane Database Syst Rev. 2003;(4):CD003472. 12. Lowry CD, Cleland JA, Dyke K. Management of patients with patellofemoral pain syndrome using a multimodal approach: a case series.] Orthop Sports Phys Ther. 2008;38:691-702. 1 3. Suter E, McMorland G, Herzog W, Bray R. Conservative lower back treatment reduces inhi­ bition in knee-extensor muscles: a randomized controlled trial.] Manipulative Physiol Ther. 2000;23:76-80. 14. Suter E, McMorland G, Herzog W, Bray R. Decrease in quadriceps inhibition after sacro­ iliac joint manipulation in patients with anterior knee pain.] Manipulative Physiol Ther. 1999;22:149-153. 15. Gross MT, Foxworth]L. The role of foot orrhoses as an intervention for patellofemoral pain.] Orthop Sports Phys Ther. 2003;33:661-670.

I�26 CHAPTER 9 Case Studies CASE STUDY Lumbar Spine Historical Exam A 32-year-old male computer programmer presents to physical therapy with a 10-day history of right lower lumbar pain that does not radiate into either buttock or lower extremity. Pain occurred several hours after doing yard work that involved approximately 4 hours of heavy lifting and repetitive forward bending. Aggravating factors: Forward bending, sitting greater than 15 minutes Relieving factors: Rest, lying on back with knees bent, pillow under knees PMH: Three episodes of mild low back pain in the past 5 years; pain usually dissi­ pates within 2-3 days without treatment; otherwise his PMH was unremarkable Self-Report Outcome Measures 34% 4/10 Modified Oswestry Disability Index (001) 8/10 Numeric Pain Rating Scale ( NPRS): Current 4/10 Numeric Pain Rating Scale ( NPRS): Worst in past 24 hours Numeric Pain Rating Scale ( NPRS): Best in past 24 hours 4 Fear Avoidance Belief Questionnaire Work Subscale ( FABQ-W) 7 Fear Avoidance Belief Questionnaire Physical Activity Subscale (FABQ-PA) 5 Modified Somatic Perception Questionnaire (MSPQ) m Physical Exam Myotomes and dermatomes: Intact bilaterally Refl exes: All 2+ bilaterally Posture: Slight forward head posture with rounded shoulders; decreased kyphosis at mid-thoracic spine; increased lumbar lordosis; symmetrical height of iliac crests, ASIS, PSIS, greater trochanters, and gluteal folds

ILumbar Spine 227 Active Range of Motion (AROM): Inclinometry Lumbar flexion 44°to onset ofcomparable symptoms 7/10; no aberrant motion Lumbar extension 2 2° with mild increase in symptoms 5/10 Lumbar right side bending 20° with mild increase in symptoms 5/10 Lumbar left side bending 1 r with comparable symptoms 6-7/10 Hip internal rotation 40° bilaterally without a change in symptoms Straight leg raise 50-60° bilaterally without a change in symptoms Passive intervertebral motion: P-A spring testing; hypomobile throughout the thoracic and lumbar spine with reproduction of comparable symptoms at L4 and L5 with central and right-sided P-A springing; no hypermobility noted in the lum­ bar spine U Special Tests Slump and SLR' Negative for adverse neural tension bilaterally Repeated fl exion/repeated extension: No effect on location of symptoms Sacroiliac (51) testing (Gaenslen's, femoral shear, 51 compression, 51 distrac­ tion, sacral provocation): Negative for pain reproduction Prone instability test: Negative for pain reduction Clinical Decision Making U Diagnosis/Classification Research has indicated the diagnostic and prognostic shortcomings of a patho­ anatomical approach to low back pain.i,2 Despite this fact, identifying the area of the patient's primary complaint may be beneficial in directing treatment. For this reason, the CPR that pertains to the pathoanatomical diagnosis of pain arising from the sacroiliac joint was used. However, this diagnosis is unlikely given that the patient does not possess any of the predictor variables identified byLaslett et aP as predictive of sacroiliac pain, indicating a large and conclusive shift that the condi­ tion is absent.

I228 CHAPTER 9 Case Studies Diagnosis of SI Pain3 Variable Present 51 compression No 51 distraction No Femoral shear No Sacral provocation No Gaenslen's right No Gaenslen's left No Prognosis Hancock et a1.4 have derived a prediction rule to identifY patients with LBP who will rapidly recover regardless of treatment received. This patient does not meet any of the three identified criteria, thus eliminating our ability to predict prognosis based on these interventions. Recovery from LBp4 Variable Present Baseline pain :5 7/10 No Duration of current episode :5 5 days No Number of previous episodes :5 1 No PT Classification/Treatment Lumbopelvic manipulation: The use of a treatment-based classification system as originally described by Delitto et aP has demonstrated improved outcomes in the PT management of low back pain.G.? Primary subgroups include \"manipulation,\" \"stabilization,\" and \"specific exercise,\" with a currently emerging \"traction\" classifi­ cation. According to this treatment-based classification system, this patient is best classified as \"manipulation.\" He meets 5/5 criteria, indicating a large and conclusive shift in the probability that he will likely have a 50% improvement inLBP-related disability from lumbopelvic manipulation and exercise.s

ILumbar Spine 22 9 · -- Variable Present Lumbar Manipulation8 Yes Yes Pain does not travel below the knee Yes Onset :5 16 days ago Yes Lumbar hypomobility (via P-A mobs) Yes One hip has> 35° of internal rotation FABQ-Work subscale score :5 1 9 I mbar -tabilizatlon The patient does not fit well into the stabilization subgroup as he meets only one of the four predictor variables indicating that he would benefit from lumbar stabilization.9 Additionally, he meets all four variables from a CPR indicating likely failure with a stabilization approach. FABQ-Physical Activity < 8 Yes Aberrant movement absent Yes No hypermobility during P-A spring Yes Negative prone instability Yes �p cific exercise Currently a CPR does not exist to identifY patients who will benefit from \"specific exercise direction\"; however, given that his symptoms do not radiate from the low back and no directional preference was elicited in the examina­ tion, it would not be likely he will benefit from specific exercise.10 Traction This patient also meets all four criteria of a CPR for lumbar traction in a supine position, indicating a moderate shift in probability that he will benefit from this treatment.1 1 Supine Traction11 Variable Present FABQ-Work subscale < 21 Yes No neurological deficits Yes Age> 30 Yes Nonmanual work job status Yes

I230 CHAPTER 9 Case Studies Facet joint injections: fu part of the differential diagnosis process it is the respon­ sibility of the examining therapist to consider treatment options beyond those described within the PT scope of practice. For this reason the CPR identifying patients with low back pain who may or may not respond well to facet block injec­ tion is considered. This patient only met two of the seven criteria, indicating a large and conclusive shift in probability that he is not likely to benefit from this type of treatment. 12 Facet Block12 Variable Present Age � 50 No Symptoms best with walking No Symptoms best with sitting No Onset pain is paraspinal Yes Positive extension rotation test No Modified Somatic Perception Questionnaire (MSPQ)> '3 No Absence ofcentralization Yes Discussion This case illustrates the use of CPRs in a patient with low back pain to help rule out possible pathoanatomical medical diagnoses, determine whether the patient's symp­ toms are likely to improve without treatment, and to guide physical therapy treat­ ment. fu with the cervicothoracic region and knee cases, many of the CPRs utilized are Level IV, thus necessitating careful consideration of both the quality of the study as well as the specifics of the study (e.g., patient characteristics, inclusion/exclusion criteria, LR size) to determine whether the findings are applicable to the patient. A diagnosis of pain arising from the sacroiliac joint is unlikely due to the loca­ tion of symptoms (lower back only), as well as the cluster of tests by Laslett et aJ.3 However, it is important to highlight that the methodology of this study is different than a true CPR, and currently an assessment tool to evaluate the quality of Level IV diagnostic CPRs has not been established. For this reason caution should be exercised when using this rule despite the similarity between our patient and the study's sample. Prognosis for this patient cannot be established using the Hancock et al. CPR, as the patient does not meet any of the three predictor variables identified.4 However, given that the patient is young and healthy with a past history of infrequent LBP of short duration, recovery from this episode of LBP is likely with PT intervention.

ILumbar Spine 231 Treatment-based classification through the use of the above ePRs indicates that the patient best fits into the \"manipulation\" subgroup, as he meets five of five cri­ teria for the validated manipulation CPR. In this case, the patient is similar to the populations of both the derivation and validation studies so the CPR may be used with confidence.B,13 Prognosis for success with PT is influenced as the patient meets all the criteria for the CPR, indicating a large and conclusive shift in probability that he will experience a greater than 50% reduction in disability after only two ses­ sions of manipulation and exercise as well as significant decreases in medication use, continued medical treatment, or time missed from work due to LBP at 6 months.13 Given the similarity of our subject and the study populations along with the favor­ able prognosis for this patient after manipulation, this technique is strongly recom­ mended in this case. Other possible subgroups that may be considered for this patient are \"stabiliza­ tion\" or \"traction.\" In this case, a comprehensive lumbar stabilization program is unlikely to provide adequate relief as the patient has met all four criteria indicating failure with specific stabilization.9 There are two ePRs available to identifY patients who may benefit from trac­ tion. One found that subjects with either peripheralization with repeated extension or a crossed S LR had greater short-term benefit from prone traction.14 However, our patient does not meet the inclusion criteria of this study, as his symptoms did not change with repeated movements, and his crossed S LR was negative. The second traction CPR identifies patients likely to benefit from traction performed in the supine position.I I Our patient is similar to the subjects in this derivation study, and the quality score of the study was 78%, which is above the recommended 60%.15,16 Therefore, given the low risk and possible benefit (50% reduction in disability within three sessions) from supine traction, this treatment may be worth including. Due to the Level IV status of the supine traction CPR, it is advisable to retest the patient after the intervention to ensure progress. An example of this would be retesting in the standing forward bending position with an inclinometer to determine whether the AROM before symptom onset has improved. This case study demonstrates the preferential weighting of a validated CPR over a Level IV CPR in clinical decision making within the framework of a treatment­ based classification system. These ePRs allow the clinician to confidently migrate toward the treatment threshold and subsequently use the response to the initial treatment as an additional finding to help guide the ongoing clinical decision­ making process. It is worth highlighting once again that ePRs should never be used in isolation rather than as a component of the best available evidence in conjunc­ tion with patient values and clinical experience.

I232 CHAPTER 9 Case Studies References I. Abenhaim L, Rossignol M, Gobeille 0, Bonvalot Y, Fines P, Scott S. llle prognostic conse­ quences in the making of the initial medical diagnosis of work-related back injuries. Spine. 1995:791-795. 2. Kleinstuck F, Dvorak]. Mannion AF. Are \"structural abnormalities\" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain' Spine. 2006;31:2250-2257. 3. Laslett M, Aprill CN, McDonald B, Yourn SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10:207-218. 4. Hancock Mj, Maller CG, Latimer ], Herbert RD, McAuley jH. Can rate of recovery be pre­ dicted in patients with acme low back pain? Development of a clinical prediction rule. Eur J Pain. 2009;13:51-55. 5. Delitto A, Erhard RE, Bowling RW A treatment-based classification approach to low back syn­ drome: identifYing and staging patients for conservative treatmenL Phys Ther. 1995;75:470-489. 6. Brennan Gp, Fritz JM, Hunter S], Thackeray A, Delitto A, Erhard RE. IdentifYing subgroups of patients with acute/subacute \"nonspecific\" low back pain: results of a randomized clinical trial. Spine. 2006;31:623-631. 7. Fritz jM, Cleland JA, Childs]0. Subgrouping patients with low back pain: evolution of a clas­ sification approach ro physical therapy. J Grthop Sports Phys Ther. 2007;37:290-302. 8. Flynn T, Fritz ], W hitman], et al. A clinical prediction rule for classifYing patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843. 9. Hicks GE, Fritz jM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabi/. 2005;86: 1753-1762. 10. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exer­ cise for low back pain. Spine. 2004;29:2593-2602. II. Cai C, Pua Y, Lim K. A clinical prediction rule for classifYing patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction. Eur Spinej. 2009;18:554-561. 12. Laslett M, McDonald B, Aprill CN, Tropp H, Oberg B. Clinical predictors of screening lumbar zygapophyseal joint blocks: development of clinical prediction rules. Spine j. 6:370-379. 13. Childs jD, Fritz]M, Flynn TW, et aI. A clinical prediction rule to identifY patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920-928. 14. Fritz]M, Lindsay W, Matheson J W, et aI. Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized clinical trial and subgroup­ ing analysis. Spine. 2007;32:E793-E800. 15. Beneciuk]M, Bishop MD, George SZ. Clinical prediction rules for physical therapy interven­ tions: a systematic review. Phys Ther. 2009;89:114-124. 16. Kuijpers T, van der Windt DAWM, van der Heijden G]MG, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004;109:420-431.

IFoot/Ankle 233 CASE STUDY Foot/Ankle o Historical Exam A 23-year-old recreational basketball player with a history of recurrent ankle sprains presents to physical therapy after injuring his right ankle 2 days ago while playing basketball. He describes landing on another player's foot with a subsequent inver­ sion and plantarflexion injury. He was able to bear weight with significant pain and limping immediately after the injury. He also notes significant swelling and lateral pain during all weight-bearing activities. He has been using rest, ice, compression, elevation, and crutches over the past 2 days. Aggravating factors: Any right LE weight-bearing activities; symptoms are worse in the evening Relieving factors: Rest, ice, ibuprofen PMH: Recurrent bilateral ankle sprains Self-Report Items 36/80 Lower Extremity Functional Scale ( LEFS) 3/10 ache at rest Numeric Pain Rating Scale ( NPRS): Current Numeric Pain Rating Scale ( NPRS): Worst in past 24 hours 7/10 sharp lateral ankle with weight bearing Numeric Pain Rating Scale ( NPRS): Best in past 24 hours 3/10 ache o Physical Exam Observation: Right lateral ankle swelling with ecchymosis over the lateral malleo­ lus down to the lateral mid-foot; right foot/ankle resting position of plantarflexion Gait: Significantly antalgic on the right with absence of heel strike; onset of 7/1O pain immediately upon weight bearing, but he is able to tolerate walking 20 feet Palpation: Tenderness to palpation of the right sinus tarsi and the right tip and inferior/posterior margin of fibula; no tenderness in metatarsals, base of the fifth metatarsal, cuboid, or medial structures

I234 CHAPTER 9 Case Studies 40° 18° with pain 42° 18° with pain ROM: AROM-Sitting PROM-Sitting AROM-Sitting 20° 6° with pain PROM-Sitting 22° r with pain Ankle Plantarflexion (Goniometer) Right Left AROM-Supine 48° 32° with pain PROM-Supine 50° 33° with pain Ankle Dorsiflexion (Goniometer) Right Left AROM-Prone knee extended 7° -15° with pain PROM-Prone knee extended 8° -15°with pain AROM-Prone knee flexed 10° -15° with pain PROM-Prone knee flexed 14° -15° with pain Joint mobil ity: Unable to examine due to pain and swelling Special tests: Anterior drawer, talar tilt, navicular drop; unable to examine due to pain and swelling Figure 8 (em). 56.3 on the right; 54.1 on the left Manual muscle test: Not examined due to pain Clinical Decision Making Diagnosis Appropriateness for PT: Possible foot or ankle fracture; based on the history and physical examination, radiographs are not needed to rule out a mid-foot fracture as the patient does not meet any of the four criteria of the Ottawa Foot Rules. I

IFoot/Ankle 235 Variable Present Inability to bear weight immediately after injury No Inability to bear weight during examination No Tenderness at base of fifth metatarsal No Tenderness at the navicular No However, this patient does have tenderness at the tip and posterior edge of the lateral malleolus, and a fracture cannot be ruled out with confidence using the Ottawa Ankle Rules.1 Given the risk of delaying medical treatment for a possible fracture the patient should be referred to a physician for examination and radio­ graphs to rule out ankle fracture before initiation or continuation of PT. • No No Inability to bear weight immediately after injury No Inability to bear weight during examination Yes Tenderness at tip or distal 6 em of medial malleolus Tenderness at tip or distal 6 em of lateral malleolus Discussion In this case, a Level I CPR was used to determine the appropriateness of initiating PT. Even in validated epRs it is important to consider how similar our subject is to those used to derive or validate the CPR. In this case, our subject is similar in age, acuity, and activity level of the subjects in the derivation and several validation stud­ ies.2-5 Additionally, although this CPR was derived using ED physicians performing the tests, it has also been validated for use by PTS.5 The application of this CPR to our patient is appropriate and since ankle fracture cannot be ruled out, referral to a physician for examination is necessary prior to continuing with PT treatment. This case highlights the use of a Level I screening CPR to help determine the appropriateness of continuing PT in a direct access situation. The patient did not meet all of the criteria necessary to confidently rule out an ankle fracture and there­ fore the patient should be referred for radiograph prior to continuing PT. References 1. Sriei u se of radiography in acu re ankle inju ries. Ann Emerg Med. 1992;21:384-390. 2. Sriell lG, Greenberg GH, McKnighr RD, er aI. Decision ru les for rhe u se of radiography in acme ankle inju ries. Refinemenr and prospecrive validarion. JAMA. 1993;269:1127-1132.

I236 CHAPT ER 9 Case Studies 3. P igman EC, Klug RK, Sanford S, Jolly BT. Evalu ation of the Ottawa clinical decision ru les for the u se of radiography in acu te ankle and midfoot injuries in the emergency department: an independent site assessment. Ann EmergMed. 1994;24:41-45. 4. Leddy J], Smolinski RJ, Lawrence J, Snyder ]L, Priore RL. Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center. With a modification to increase specificity for identifYing malleolar fractures. Am] Sports Med. 1998;26:158-165. 5. Springer BA, Arciero RA, Tenuta J], Taylor DC. A prospective study of modified Ottawa ankle rules in a military popu lation. Am] Sports Med. 2000;28:864-868.

AP PENDI X A CPR Quality S cores of Level IV Prognostic Studies Question ABC0 E F GH K LMN0 PQ R Total Study No No Yes Yes Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes No 72% Cervical Spine N o No Yes Yes No Yes Yes Yes No N o Yes No Yes Yes Yes Yes Yes No 61% Cleland et al. 2007 (see page 1 0 1 ) Hartling et al. 2002 (see page 99) I 237

APPE N D I X B CPR Quality S cores of Level IV Intervention Studies Question ABC0E FGH J K LMN0 p Q R Total Study Cervical Spine Cleland et al. 2007 No No Yes Yes Yes No Yes N o Yes Yes No Yes Yes Yes Yes Yes Yes No 67 % (see page 1 08) No Yes Yes Yes Yes Yes N o N o Yes Yes No Yes No Yes Yes Yes Yes Yes 72% Emshoff et al. 2008 (see page 1 1 8) No No Yes Yes Yes N o Yes Yes No Yes N o Yes Yes Yes Yes Yes Yes No 67% Fernandez-de-Ias- No N o Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes Yes Yes Yes No 67% Penas et a l . 2008 (see page 1 1 0) No No Yes No No No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No 61 % Raney et a l . 2009 (see page 1 1 5) Tseng et al. 2006 (see page 1 04) Lumbar Spine Alonso-Blanco et al. No Yes Yes No Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No 72% 2009 (see page 1 77) 72% 67% Cai et al. 2009 No No Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No 72% (see page 1 73) 61% 61% H icks et al. 2005 No No Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes Yes Yes Yes No 56% Failure (see page 1 59) Hicks et al. 2005 No No Yes Yes Yes N o Yes No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Success (see page 1 59) Fritz et al. 2004 No No Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes Yes Yes No No (see page 1 67) Fritz et al. 2007 No No Yes Yes Yes No Yes Yes No Yes Yes Yes Yes No Yes Yes No No (see page 1 7 1 ) Laslett et al. 2006 No No Yes No No No Yes Yes No Yes Yes Yes Yes Yes No Yes Yes No (see page 1 75) 238 I

I 239 Shoulder No No Yes Yes Yes No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes No 72% M i ntken et al. 2009 No Yes No Yes Yes No Yes No No Yes Yes Yes No Yes Yes Yes Yes Yes 67% (see page 1 44) No No No Yes Yes No Yes Yes Yes Yes No Yes No Yes Yes No Yes No 56% Elbow No No Yes Yes No No Yes No Yes Yes No Yes No Yes Yes Yes Yes No 56% No No Yes Yes No No Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes 67% Vicenzino et al. 2009 No No Yes Yes Yes No Yes No Yes Yes No Yes No Yes Yes Yes Yes No 61% (see page 1 37) No Yes No Yes Yes No No No No Yes No Yes No Yes Yes Yes Yes No 50% Knee No Yes Yes Yes Yes N o Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes 83% Currier et al. 2007 (see page 208) Iverson et al. 2008 (see page 1 95) Lesher et al. 2006 (see page 1 98) Sutlive et al. 2004 (see page 203) Vicenzino et al. 2009 (see page 200) Ankle Whitman et al. 2009 (see page 2 1 4)

APPE N D I X C Quality Assessment of Diagnostic e P Rs Item Description Yes No 1. Inception cohort 2. Prospective an d consecutive su bjective enrollment 3. Description of setting 4. Description of subject's baseline demographics 5. C lear inclusion/exclusion criteria 6. Recognized vali d/relia ble reference standard 7. Explanation for predictor varia ble selection 8. Reliable predictor varia bles ( ICC � 0.70; Kappa � 0.60) 9. Prospective application of reference standard within a reasona ble time frame after the examination 10. Detailed description of positive/negative on reference standard 11. Blin ded examiner 12. Blin ded interpretation o freference standard 13. Diagnostic accuracy of significant individual predictor varia bles reported 14. Varia bles exceeding set cut score for univariate significance entered into regression model 15 . Results of regression analysis reported with 95 % C is 16 . Statistical significance of the model reported 1 7. Full description of retained predictor variables presented 18. Ten to 15 su bjects per varia ble presented in the final clinical prediction rule 19. Were study withdrawals/dropouts < 10% 240 Tota l

APPE N D I X D CPR Quality S cores of Interventional Validation Studies Question 10 11 12 13 14 15 16 17 18 1 9 Total Study 0000 0 50% 0 50% Lumbar Spine 0 000 0 40% 00000 Childs et al. 2004 (see page 1 63) Hancock et al. 2008 (see page 1 63) Shoulder Kuijpers et al. 2007 (see page 1 32) I 2 41

APPE N D I X E C P R Decision-Making Algorithm Is it appropriatefor me to apply the resuLts to mypatient's treatment? Is the CPR Validated? Yes Decision Making No Derivation-Level CPR Internal Validity Decision Making Did the validation study design limit bias? Yes Internal Validity No Yes Is the derivation study of high If this CPR is used, do so with Use this CPR with confidence as methodological quality? extreme caution. Use only as a primary evidence-based treatment option. Yes an adjunct to other evidence-based treatments Generalizability? To your patient and to you as a i mprovement. clinician Yes Use this CPR as an adjunct to other evidence-based treatments and test-retest. 242 I

I NDE X Ach il les' reAex, 89 Simple Calculated Osteoporosis Risk Estimation Ach il les' tendon stretch, 2 1 2 (SCORE), 66-69 alphabet exercises, 2 1 3 American College o f Rheumatology brain inju ry, 53-55 osteoarthritis of hand, 1 28- 1 29 Canadian Cervical Spine Rule, 24-26, 29, 50-52 I 243 osteoarthritis of hip, 1 80- 1 8 2 Canadian CT head rules, 5 6-59 osteoarthritis of knee, 1 86- 1 8 7 carpal tunnel syndrome (CTS), 1 26- 1 27 ankle case study case study, 233-236 dorsiAexion ROM , 1 93 cervicothoracic spine, 2 1 6-220 inversion sprai n , therapy and exercise, 209 foot/ankle, 233-236 Ottawa foot and ankle rules, 36-4 1 knee, 22 1 -225 quality scores, intervention studies, 239 lumbar spine, 226-232 ankle self-eversion mob i lization, 2 1 3 central posterior-to-anterior motion testing, 1 1 2 ankylosing spondyl itis (AS), 1 5 2- 1 53 , 1 76- 1 77 cervical d istraction test, 95, 1 1 3 a n terior to posterior talocrural non-thrust cervical manipulation, 1 02- 1 04 cervical radiculopathy, 94-97, 1 00- 1 0 1 manipulation, 2 1 1 cervical ROM , 1 07 cervical spine back pain cervical spine rules, 50-52 lumbar manipulation, 1 60- 1 67 lateral translatory non-thrust manipulation, 1 40 lumbar stabilization, 1 56- 1 5 9 qual i ty scores, intervention studies, 238 prediction of recovery, 1 5 4- 1 5 5 qual i ty scores, prognostic studies, 237 cervical traction, 1 1 1 -1 1 5 Ballottement test, 1 8 8 cervicothoracic j unction thrust manipulation, 1 4 1 bias, research, 9 cervicothoracic manipulation, shoulder pain, 1 38- 1 44 blindi ng, research studies, 9 cervicothoracic spine, case study, 2 1 6-220 block design, 6 chi square, 30-3 1 bone mi neral density ( B M D) clinica l practice, application of research , 6-7 clinical pred iction rules ( C P Rs) Male Osteopotosis Risk Estimation Score (MORES), definition, 2 73-74 development of, 3-7 methodological qual i ty, 7- 1 0 Osteoporosis Risk Assessment Instrument (ORAL), cohort designs, prospective, 3-5 63-65 Osteoporosis Self-Assessment Tool (OST) , 70-72

244 I confidence i n tervals, 29-30 elbow conti ngency table, 24-25 lateral glide, 1 33 control group, 5 qual i ty scores, i n terven tion studies, 239 CPR. See clin ical prediction rules ( C P Rs) crossed straight leg raise, 1 69 evidence-based medicine, 1 CT (computed tomography) scan extension rotation test, 1 74 head inj ury, 53-59 facet j o i n t b lock, 1 74- 1 7 5 New Orleans Criteria (NOC), 60-62 Fagan's nomogram, 27-28 CTS (carpal tunnel syndrome), 1 26- 1 27 false positives, 3 1 Fear-Avo idance Beliefs Questionnaire-Physical Activity DCPRs. See d iagnostic C P Rs ( D C P Rs) decision-making algorithm, 242 Subscale, 1 05 deep neck Aexor strengthening, 1 1 4 Fear-Avoidance Beliefs Questionnai re-Work Subscale, deep-vein thrombosis (DVT) 2, 1 60 lower extremi ty, 75-79 femoral shear test, 1 48- 1 49 upper extremi ty, 80-8 1 foo t derivation, C P Rs , 3-5 derivation studies, 7- 1 0 case study, 233-236 diagnostic C P Rs ( D C P Rs) O[[awa foo t and ankle rules, 36-4 1 ankylosing spondyl i ti s (AS ) , 1 5 2- 1 5 3 fo refoot valgus measurement, 1 99 carpal tunnel syndrome (CTS ) , 1 26- 1 27 fractu res cervical radiculopathy, 94-97 cervical spine, 50-52 defined, 2-5 knee, 43-46, 48-49 knee effusion, 1 88- 1 89 midfoot and ankle, 36-4 1 low back pai n , predicting recovery, 1 5 4- 1 5 5 lumbar spinal stenosis (lSS), 1 46- 1 47 Gaenslen's test, 1 5 0 , 1 64 med ial collateral ligament ( M C l) tear, 1 90- 1 9 1 generalizability, C P Rs, 3 osteoanhritis o fhand, 1 28-1 29 Geneva Score, revised, 86-88 osteoarth ritis of hip, 1 80- 1 8 5 Global Rating of Change ( G ROC) scales, 9, 1 0 1 , 1 04, osteoarthritis of knee, 1 86- 1 87 q u al i ry assessment , 1 1 1 08, 1 1 0, 1 1 5 , 1 77, 1 95 , 1 98, 208, 2 1 4 rotator cuff tear, 1 24- 1 27 Gower's sign, 1 5 6, 1 57 sacroil iac j o i n t ( S IJ) pain, 1 4 8- 1 53 great roe extens ion, 202 subacromial impingement syndrome, 1 20- 1 23 val i d i ty measures, 24-26 Hawkins-Kennedy test, 1 20 d istal tibiofibular A-P mob i l ization, 2 1 2 headache, 1 09- 1 1 0 distal ti biofibular j o i n t mobi l i ty assess ment, 2 1 0 head i n j u ry distraction manipulation, seated, 1 06 disuaction thrust manipulation, middle thoracic spine, 1 40 computed tomography (CT) rules, 56-59 dorsiAexion self-mobilization, 2 1 3 New Orleans Criteria (NOC) , 60-62 d rop arm sign, 1 22 N EXUS I I , 53-5 5 DVT (deep-ve i n thrombosis) hip lower extremi ty, 75-79 distraction test, 205 upper extremi ty, 80-8 1 extension, 1 83 Aexion, 1 8 1 , 1 8 3

I 245 internal rotation, 1 6 1 , 1 65, 1 80, 1 84 osteoanhritis, 1 86- 1 87 , 204-208 mobilization, knee osteoanhritis, 204-208 Ottawa knee rules, 43--46 osteoarrh ritis, 1 80- 1 8 5 Pittsburgh rules, 48-49 side-ro-side inrernal rotation, 1 92 qualiry scores, i n tervention srudies, 239 hisrory, patienr, 4 ICPRs. See i nrervenrional C P Rs ( I C P Rs) lateral epicondylalgia, 1 33-1 37 impact analysis, 6-7 l i kelihood ratios, 26-29 impi ngemenr test, Neer, 1 39 logistical regression, 1 0, 3 1 -32 index of diversiry, 32 longitudinal cohon srudies, 7-8 infraspinarus muscle test, 1 2 1 low back pain instabi l i ry teS(, prone, 1 57 i n rervenrional CPRs ( I C P Rs) facet joint block, 1 74- 1 7 5 l u mbar manipulation, 1 60- 1 67 ankle inversion sprain, therapy and exercise, 209-2 1 4 l umbar stab il ization, 1 5 6- 1 5 9 ankylosing spondylitis (AS ) , 1 76- 1 77 prediction of recovery, 1 5 4- 1 5 5 cervical manipulation, mechanical neck pain, 1 02- 1 04 supine lumbar mechanical traction, 1 72- 1 73 cervical traction, mechanical neck pain, 1 1 1 - 1 1 5 lower extremiry deep-vein thrombosis ( OVT), 75-79 defined, 2 , 3-5 lumbar spine headache, trigger points, 1 09- 1 1 0 case study, 226-232 knee osteoanhritis, h i p mobil ization, 204-208 hypo mobiliry, 1 60 , 1 6 5 lateral epicondylalgia, 1 33- 1 37 lumbar spina l stenosis (LS S ) , 1 46- 1 47 low back pain, facet j o i n t block, 1 74- 1 7 5 manipulation, 2 , 1 60- 1 67 , 1 92- 1 9 5 low back pain, l umbar manipulation, 1 60- 1 67 mechanical traction, 1 68- 1 73 low back pain, lumbar stabilization, 1 56- 1 5 9 qualiry scores, i n rervenriona l validation studies, 24 1 low back pain, supine lumbar mechanical traction, qualiry scores, intervention studies, 238 1 72- 1 73 Male Osteoporosis Risk Esti mation Score ( M O RES), nerve roOt compression, 1 68-1 7 1 73-74 patellofemoral pain syndrome ( P F PS) , 1 92-203 qualiry assessment, 1 1 , 1 2 , 1 5 manipulation qualiry scores, 238-239 cervical manipulation, 1 02- 1 03 shoulder pain, cervicothoracic mani pulation, 1 3 8- 1 44 lower extremiry manipulation temperomandibular (TMJ) pain, 1 1 6- 1 1 8 proximal t i b i o fi b u l a r posteroa nrerior, thoracic manipulation, mechanical neck pain , 1 05- 2 1 0-2 1 1 rearfoot distraction, 2 1 0-2 1 1 1 08 thoracic manipulation validation studies, qualiry scores, 241 cervicothoracic junction, 1 4 1 in traclass correlation coefficienr, 30 lumbopelvic, 1 6 1 , 1 66, 1 94 intracranial inju ry, rule out, 60-62 prone middle and lower thoracic, 1 42 seated middle thoracic distraction, 1 06, 1 40 kappa (K) statistic, 30 supine middle thoracic, 1 07, 1 42 supine upper thoracic, 1 06, 1 4 1 knee case srudy, 2 2 1 -225 M C I O ( m i n i mal clin ically imponant d i fference), 4 effusion, 1 8 8- 1 89 M O C ( m i nimally detectable change), 4 medial collateral ligament (M CL) tear, 1 90- 1 9 1 mean, statistical, 30-33

246 I mechanical neck pain painful arc test, 1 2 1 cervical manipulation, 1 02- 1 04 P-A spring test, 1 58 cervical traction, 1 1 1- 1 1 5 patellar taping, 1 97 thoracic manipulation, 1 05- 1 08 patellar tilt test, 1 97 patellofemoral pain syndrome (PFPS), 1 92-203, 222, medial collateral l igament (M Cl) tear, 1 90- 1 9 1 minimal clinically i m portant difference (M C I D ) , 4 224 min imally detectable change (M DC), 4 PCPRs. See prognostic C P Rs (PCPRs) mobil ization with movement (MWM) , 1 33- 1 37 peripheral neuropathy, 89-9 J MO RES (Male Osteoporosis Risk Estimation Score) , physical exam, 4 Pi ttsburgh knee rules, 48-49 73-74 potential predictor variables, 4 m ultivariate analysis, 3 1 -33 predetermined amount of time, 3-5 predictive value, CPRS, 3 navicular drop test, 1 93, 202, 209 predictor variables, 5, 26-29 neck distraction test, 1 1 3 prescriptive C P Rs. See i n tervemional C P Rs ( I C P Rs) neck pai n , mechanical probability (p), 1 0, 30-33 prognostic C P Rs (PCPRs) cervical manipularion, 1 02- 1 04 cervical traction, 1 1 1 - 1 1 5 cervical radiculopathy, 1 00- 1 0 I thoracic manipulation, 1 05- 1 08 defined, 2 , 3-5 , 7-8 Neer imp ingement test, 1 39 quality assessmem, 1 1 , 1 2 , 237 nerve root com pression, 1 68- 1 7 1 shoulder pain, persistent, 1 30- 1 32 neuropathy, peripheral, 89-9 1 whiplash-associated disorders (WAD) , 98-99 New Orleans Criteria (NOC) , 56-62 prone instability test, 1 5 7 Nexus I I , 53-55 prone lumbar traction, 1 68- 1 7 1 N PRS, 1 04, 1 98, 2 1 4, 22 1 , 226, 233 prospective cohort design, 3-6 Numeric Pain Rating Scale, 1 0 1 , 1 04, 1 32, 208, 22 1 , proximal tibiofibular posteroanterior thrust manipulation, 226, 233 210 psychosocial factors, 4 occlusal splint, 1 1 6 pulmonary embolism ( PE) orthorics, 1 99-203 osteoarthritis Revised Geneva Score, 86-88 Wells Score, 82-85 hand, 1 28- 1 29 hip, 1 8 0- 1 8 5 quality assessment knee, 1 86- 1 87, 204-208 diagnostic C P Rs, quality assess ment of, 240 osteoporosis interventional validation studies, 2 4 1 Male Osteoporosis Risk Estimation Score ( M O RES) , intervention studies, 238-239 overview, 1 1 - 1 5 73-74 prognostic studies, quality scores, 237 Osteoporosis Risk Assessment I nstrument (ORAl ) , radiography 63-65 cervical spine, Canadian rules, 50-52 Osteoporosis Self-Assessment Too l (OST), 70-72 knee, Otrawa rules, 43-46 Simple Calculated Osteoporosis Risk Estimation (SCORE) , 66-69 Ottawa foo t and ankle rules, 36-4 1 Ottawa knee rules, 43-46 outcome measures, 3, 4, 9- 1 0

I 247 knee, Pi ttsburgh rules, 48-49 statistics midfoot and ankle, Ottawa rules, 36-4 1 confidence i n tervals, 29-30 rad iohumeral j oint, 1 34 derivation studies, 1 0 random ized clin ical trial ( RCT) , 5 l ikelihood ratios, 26-29 rear foot distraction thrust manipulation, 2 1 0 multivariate analysis, 3 1 -33 receiver operating characteristic, 3 1 overview, 23-24 recursive partitioning, 32 receiver operating characteristic, 3 1 reference standard test, 3-5, 24-26 reli ab i l i ty measures, 30 reAex, Achilles', 89 sensitivity and specificity, 24-26 regression analysis, 1 0 t-test and chi square, 30-3 1 reliability, research, 1 0 , 30 research designs, 3-5, 7- 1 0 straight leg raise, 1 56, 1 57 retrospective self-repon measures, 9 subacromial i m p i ngement syndrome, 1 20- 1 23 ROM supine upper-thoracic spine manipulation, 1 06 ankl� 1 93, 201-202 cervical, 94, 1 05 , 1 07 talocrural non-thrust manipulation, 2 1 1 hip, 1 57, 1 6 1 , 1 6 5 , 1 80- 1 8 1 , 1 83- 1 84 , 1 92 , 205 target condition, selecting, 3 knee, 204 temperomand ibular (TMJ) pain, 1 1 6-1 1 8 shoulder, 1 3 8- 1 39 thoracic extension, supine, 1 43 rotaror cuff tear, 1 20- 1 27 thoracic manipulation, mechanical neck pain, 1 06- 1 08 R2 values, 1 0 thoracic manipulation, shoulder pain, 1 40- 1 4 2 thromboembolism sacral provocation, 1 5 0 sacro iliac joint (SI]) pain , 1 48- 1 53 lower extremi ty, Wells Criteria, 75-79 sample size, 8 upper extremity deep-vein thrombosis, 80-8 1 SCORE (Simple Calculated Osteoporosis Risk thrust manipulation, cervicothoracic j unction, 1 4 1 thrust manipulation, thoracic spine, 1 4 1 - 1 42 Estimation), 66-69 tibial varum measurement, 1 96 Scour test, 1 84 tibiofibular joint mobility assessment, 2 1 0 seated distraction manipulation, 1 06 translatory non-th rust manipulation, cervical spine, self-repon instruments, 4, 9 sensitivi ty, 24-26 1 40 shoulder trigger-point therapy, 1 09- 1 1 0 t-test, 30-3 1 abduction test, I I I cervicothoracic manipulation, 1 38- 1 44 upper extremity deep-vein thrombosis, 80-8 1 interventional validation studies, 24 1 upper-limb tension test A (ULTT A) , 9 5 , 1 1 2 pain, 1 20- 1 23 , 1 30- 1 32 upper-thoracic spine manipulation, 1 06- 1 07 SI compress ion test, 1 48- 1 49 SI distraction test, 1 4 8- 1 49 valgus measurement, 20 1 Simple Calculated Osteoporosis Risk Estimation valgus stress test, 1 90 validity, 3, 5-6, 24-29 (SCORE), 66-69 variable selection, 8-9 specific investigation treatment, 3-5 variance, derivation studies, 1 0 specificity, 24-26 VAS (visual analogue scale), 1 1 0 , 1 1 6-1 1 7, 1 7 5 , 1 99- spring test, 1 58 Spurling's A test, 96 200, 203, 223

248 I venous thromboembolism Wells Score, pulmonary embolism, 82-85 lower extremi ty, deep-vein thrombosis ( DVT), 75-79 whiplash-associated disorders (WAD), 98-99 pulmonary embolism, Revised Geneva Score, 86-88 women pulmonary embolism, Wells Score, 82-85 upper extremity deep-vein thrombosis (DVT), 80-8 1 Osteoporosis Risk Assessmem Insuumem (ORAl), 63-65 visual analogue scale ( VAS), 1 1 0 , 1 1 6- 1 1 7, 1 7 5 , 1 99- 200, 203, 223 Osteoporosis Self-Assessmem Tool (OST), 70-72 Simple Calculated Osteoporosis Risk Escimation WAD (whiplash-associated disorders) , 98-99 Wells Criteria, 75-79 (SCO RE) , 66-69 wrist-ratio index, 1 26