The Manual Therapy Institute
Wells’ Clinical Decision Rule for DVTClinical PresentationPossible ScoreClient’s ScoreActive cancer (within 6 months of diagnosis or receiving palliative care)1Paralysis, paresis, or recent immobilization of lower extremity1Bedridden for more than 3 days or major surgery in the last 4 weeks1Localized tenderness in the center of the posterior calf, the popliteal space, or along the femoral vein in the anterior thigh/groin1Entire lower extremity swelling1Unilateral calf swelling (more than 3 cm larger than uninvolved side)1Unilateral pitting edema1Collateral superficial veins (nonvaricose)1An alternative diagnosis is as likely (or more likely) than DVT (e.g., cellulitis, postoperative swelling, calf strain)-2Total PointsKey-2 to 0Low probability of DVT 3% (95% confidence interval [CI] 1.7%–5.9%)1 to 2Moderate probability of DVT 17% (95% confidence interval [CI] 12%–23%)3 or moreHigh probability of DVT 75% (95% confidence interval [CI] 63%–84%)Medical consultation is advised in the presence of low probabilityMedical referral is required with moderate or high score.CANADIAN C SPINE RULESQuestion 1: Are there any high risk factors (age>65, or dangerous mechanism or paresthesiae in the extremities)? If YES – X ray is indicated. If NO – Question 2: Are there any low risk factors that allow safe assessment of ROM? (simple rear end collision or sitting in ER department or ambulatory since injury or delayed onset neck pain or absence of midline cervical spine tenderness) If any of these questions is answered NO - X ray indicated, if YES – Question 3: Able to actively rotate neck 45 degrees left and right. If NO – X ray indicated, if YES – X ray not indicated.Diagnostic accuracy: Sensitivity = 99.4% Specificity = 45.1%OTTAWA KNEE RULESAged >55, isolated patellar tenderness, tenderness at the head of the fibula, unable to achieve 90 degrees flexion, or is unable to bear weight immediately and on examination (4 steps) regardless of limping. If any of these 5 rules is positive, radiographs should be ordered.Diagnostic accuracy: Sensitivity = 1.0 Specificity = .49 -LR = 0 OTTAWA ANKLE RULESAnkle: pain in the malleolar area and tenderness over the posterior edge or tip of the lateral or medial mallleolus, or unable to bear weight immediately and on examination. Foot: pain in the midfoot region, tenderness of base of 5th metatarsal or navicula, or unable to bear weight immediately and on examinationDiagnostic accuracy: Sensitivity = .98-LR = .10ELBOW EXTENSION TESTPatients who cannot fully extend their elbow after injury should be referred for radiography, as the have a 50% chance of fracture. For those able to fully extend the elbow, radiography can be deferred if you are confident that an olecranon fracture is not present. Patients who don’t undergo radiography should return if symptoms have not resolved within 7-10 days.Diagnostic accuracy: Sensitivity: 97.3% Specificity: 69.4%Appelboam A et al. Elbow extension test to rule out fracture: multicentre prospective validation and observational study of diagnostic accuracy in adults and children. BMJ Dec 2008Lumbopelvic Manipulation for LBP4 of 5 present = +LR 24.4First 2 items present = +LR 12.6Duration <16 daysNo sx distal to the kneeFABQW <19At least one hypomobile segment in L-spineAt least one hip with >35? IRLumbar Stabilization Training3 or more present = +LR 4.0Predictors of Dramatic Success+Prone instability test+Aberrant motionsAverage SLR >91?Age <40Cervical Manipulation for Neck Pain3 of 4 present = +LR 13.5Symptom duration <38 daysPositive expectation that manipulation will helpSide to side difference in cervical rotation ROM >10 degreesPain with P-A spring testing of middle cervical spineT-spine Manipulation for Neck Pain4 of 6 present = +LR 12.03 of 6 = +LR5.5Sx duration <30 daysNo sx distal to the shoulderPt reports looking up does not aggravate sxFABQ PA <12Diminished upper thoracic spine kyphosisCervical extension <30?Cervical Traction for Neck Pain3 of 5 present = +LR 4.814 of 5 = +LR 11.7Pt reported peripheralization with lower cervical spine (C4-C7) mobility testingPositive shoulder abduction signAge ≥55Positive ULTTARelief of sx with manual distractionDiagnosis of Cervical Radiculopathy3of 4 present = +LR 6.1All 4 present = +LR 30.3Positive SpurlingsDecreased sx with distractionPositive ULTTAC-spine rotation <60? to involved sideDiagnosis of Hip OA4 of 5 present = +LR 24.33 of 5 present = +LR 5.2Self-reported squatting as agg factorPassive IR of involved side ≤25?Active hip flexion causing lateral hip painActive hip extension causing hip painScour test causing lateral hip painHip Mobilization for Knee OA1 variable present = +LR 5.12 variables present = +LR 12.0Ipsilateral anterior thigh painIpsilateral pain or paresthesia in hip/groinIpsilateral knee flex <122?Ipsilateral hip IR <17?Pain with ipsilateral hip distractionCompression Fracture Thoracic Spine6731002742565 ................
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