Clinical Prediction Rules and Clinical

Practice Guidelines

Jena Ogston, PhD, PT

 Objectives:
1. Identify the 3 forms and applications of clinical
prediction rules (CPR) in the field of physical
therapy
2. Describe the process of CPR development.
3. Differentiate between a systematic review and a
CPG.
4. Identify six domains of the AGREE II tool in
appraising CPG’s.
5. Explore and critically review online CPG
resources understanding the application of the
Agree II tool.
 Clinical Practice Guidelines
systematically developed
statements designed to facilitate
evidence-based decision making
for the management of specific
health conditions. CPGs
incorporate evidence from
research and clinical expertise.
 Clinical Practice Guidelines (CPGs)

“Guidelines are systematically developed

statements to assist practitioner decisions about
appropriate health care for specific clinical
circumstances.”
(Scalzitti, 2001)
 Purpose of CPGs
1. Make evidence based practice efficient and
realistic
2. Make the best available research evidence
directly applicable to clinical practice
3. Integrate research evidence with knowledge
from clinical experts
4. Consider research evidence with consideration
for patient perspectives
 Systematic Reviews vs. Clinical
Guidelines
Focus is on a single topic • Broad clinical focus
Developed by a few • Developed by a diverse
researchers/authors group and numerous
Based on best evidence researchers
• Based on best evidence,
expert opinion, and
patient input
 Examples of CPG’s in PT
Ptnow.org (now within APTA EBP resources)
 Validity Rigor of Development

1. Systematic methods were used to search

2. Criteria for selecting evidence clearly
described
3. Strengths and limitations of evidence are
clearly described
4. Methods for formulating recommendations
clearly described
 Validity Rigor
of Development (cont’d)

5. Health benefits, side effects, and risks were

considered
6. Explicit link between recommendations and
the supporting evidence
7. Externally reviewed by experts
8. Update procedure is provided
 Levels vs. Grades

• Levels: Study design hierarchy

• Grades: Confidence behind recommendation
Levels of Evidence
Grade of Evidence
 Finding Clinical Guidelines (cont’d)
• Agency for Healthcare Quality: http://guidelines.gov/

• PEDro: http://www.pedro.fhs.usyd.edu.au/

• Links from physiopedia:

https://physio-pedia.com/Clinical_Guidelines?
utm_source=physiopedia&utm_medium=search&utm
_campaign=ongoing_internal
 Example
from AHRQ
 Considerations with CPG’s
• Biased to the source?
• Recent i.e. past 5 years
• Agree II tool to critically appraise Agree II tool
should be specific and unambiguous
– Different options for management of the
condition should be clearly presented
– Key recommendations should be clear
 Limitations of CPG’s
• Very general
• May be lacking as research is either lacking
and/or low quality or rigor
Clinical Prediction Rules (CPR)
 CPR’s: similar to clinical decision
making
• SOB + chest pain + left arm pain =

• Catastrophization + fear avoidance =

 Types of CPR’s
I. Diagnostic: probability that a patient has a
particular condition

I. Prognostic: likely outcome of patients with a

specific condition

II. Interventions: which patients are likely to

respond to a type or set of intervention(s)
 Types of CPR’s: Examples
I. Diagnostic: Ottowa ankle, knee rules; C-spine
rules

II. Prognostic: Dionne et al. (2005) predictors on

return to work in patients with LBP

III. Interventions: Hicks et al. (2005) stabilization

exercises in persons with nonradicular LBP
Diagnostic Examples (Physiopedia,
2020)
Prognostic (Intervention)
 Creation of CPR’s
1. Create the CPR
-identify factors with predictive value

2. Validation
-reproduction in various populations

3. Conduct Impact Analysis

-evaluate clinical decision making (cost
difference?)
CPR: Diagnostic
 Methods
Seventy-two subjects completed the study. Each subject
received a standardized history, physical examination,
and standing AP radiograph of the pelvis.
Subjects with a Kellgren and Lawrence score of 2
or higher based on the radiographs were considered to
have definitive hip OA. Likelihood ratios (LRs) were
computed to determine which clinical examination
findings were most diagnostic of hip OA. Potential
predictor variables were entered into a logistic regression
model to determine the most accurate set of clinical
examination items for diagnosing hip OA.
 Results:
• The 5 variables that emerged from the
subsequent logistic regression analysis were
used to form the
• preliminary clinical prediction rule:
– (1) self-reported squatting as an aggravating factor;
– (2) active hip flexion causing lateral hip pain;
– (3) scour test with adduction causing lateral hip or
groin pain;
– (4) active hip extension causing pain; and
– (5) passive internal rotation of less than or equal to
25°
 Limitations of CPR’s
1. Need to ensure they are conducted on a
wide variety of populations
2. Take note of the inclusion/exclusion criteria
(specific to population)
3. Validated through subsequent study
 CPG vs. SR vs. CPR

• Clinical Practice Guidelines: make

recommendations about how to care for
patients
• Often include systematic reviews
• NOT scientific studies
• Systematic Reviews: study of studies
• Clinical Prediction Rules: results from cohort
studies creating a “ test” to predict outcome
 References
• Childs JD, Cleland JA. Development and
application of clinical prediction rules to
improve decision making in physical therapist
practice. Phys Ther. 2005;86:122-131.
• Physiopedia. https://www.physio-
pedia.com/Clinical_Prediction_Rules.
Accessed Sept. 02, 2020.