Topics. Does Your Patient Need a Radiograph? Evidence-Informed Decision Making 6/8/2016

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1 Does Your Patient Need a Radiograph? Evidence-Informed Decision Making Morey J. Kolber, PT, PhD, OCS, Cert MDT, CSCS*D Does Your Patient Need a Radiograph? Evidence-Informed Decision Making M.S.P.T University of Miami Nova Southeastern University Associate Professor Department of Physical Therapy Fort Lauderdale, Florida Boca Raton Orthopaedic Group Director of Physical Therapy Boca Raton, Florida Topics Diagnostic imaging in physical therapist practice Clinical scenarios General indications for a radiograph Clinical prediction rules (CPRs) CPR validity False (+) versus False (-) Clinical scenarios revisited with disposition 1

2 Imaging in Physical Therapist Practice Nice to know or need to know? Imaging: Physical Therapist (PT) Practice Content is foundational in DPT curriculum based on accreditation standards = need to know for DPT students Since 1997 imaging questions on the NPTE = need to know PTs have had ordering privileges in US military since 1972 Civilian settings as well: Georgetown University Hospital, University of Wisconsin Hospital/Clinics, & Kaiser Permanente Many regulatory boards have ruled that PT may refer for imaging e.g. Maryland, DC, Wisconsin, & Colorado Physical Therapy boards Problem: Many payers, including Medicare disallow coverage for PT ordered imaging & some states have restrictions (e.g. SC) Irrespective of law...pts need to refer out when suspicious of a more sinister issue (e.g. fracture, cancer, GI/GU etc) Clinical Scenarios Take a moment and read the next four clinical cases (A-D) and ask yourself: 1. Is a radiograph indicated? 2. Would you treat this patient without radiographs? 3. Is there any evidence that could help guide a clinical decision to refer out for radiographs? 2

3 Case Scenario Case A: 30-year-old male patient arrives at your clinic with central low back pain following an overly aggressive exercise session the day prior. Has not yet seen a physician. Reports symptoms are constant and worse sitting and bending. Rates pain on VRS a 9/10 when bending and a 4/10 when standing and walking. No radiculopathy or bowel or bladder changes. Medical history unremarkable. Should you examine this patient and provide an intervention or send to physician for radiographs? Case Scenario Case B: 21-year-old male patient arrives with right lateral ankle pain following an inversion injury while playing soccer the day prior. Patient states it is a sprain and has had this before. Patient is unable to fully weight-bear and reports pain at the region of the lateral ankle pointing to the lateral malleolus. Examination reveals tenderness at posterior lateral malleolus. Should you examine this patient and provide an intervention or send to physician for radiographs? Case Scenario Case C: 66-year-old male patient arrives with right lower back pain and radiculopathy for no apparent reason. Has had symptoms prior. No recent radiographs in last 10- years. Examination reveals limited mobility all planes and no clear directional preference. PMH is positive for prostate cancer. Should you examine this patient and provide an intervention or send to physician for radiographs? 3

4 Case Scenario Case D: 35-year-old female patient arrives with right sided neck pain following a motor vehicle accident 3 days ago. Reports constant pain and is unable to turn head > 30 bilaterally. Does have referred pain past neck and into arms bilaterally but not specific to a dermatome region. Has paresthesias into hands bilaterally. Has had no hand symptoms prior. PMH is unremarkable. Should you examine this patient and provide an intervention or send to physician for radiographs? Does Your Patient Need a Radiograph? Considerations generally based on: Risk factors/concern for more serious pathology Fracture, cancer, infection, pathological instability etc. Consensus guidelines Clinical evidence from individual research studies Clinical prediction rules (CPRs) Clinical gestalt-diagnostic acumen Trauma General Risk Factors for Fracture bone mineral density Chronic corticosteroid use Cancer (skeletal) Inability to weight-bear Bone tenderness Observable acute deformity of limb Acute loss of movement* *Specific to body region e.g. elbow extension loss 4

5 Clinical Decision Making Lumbar spine - consensus Elbow- individual research studies on risk Shoulder - individual research studies on risk Cervical spine - CPR Knee - CPR Ankle - CPR Foot - CPR Wrist - CPR Imaging Guidelines for Low Back Pain Imaging NOT indicated for somatic LBP unless: Persistent > 7-weeks Trauma Prior history of cancer, fracture, or spine surgery Exam suggests serious underlying condition or red flag Surgery or injection is an option of interest Poor historian Osteoporosis or risk for reduced BMD Age > 65 Recurrent with no radiographs past 2-years Risk factors & suspicion: cancer or infection Chou et al, Ann Intern Med, 2007; Dagenais et al, Spine J, 2010 Simmons, Spine, 1995 Elbow Fracture: Evidence Elbow extension test (acute elbow injury) N = 2127 adults & children Criteria: inability to extend elbow = fracture on radiograph Result: misses 3% fractures & 52% unnecessary radiographs Appelboam et al, BMJ, 2008 Global ROM loss (acute elbow injury) N = 102 adults & children Criteria: global loss elbow ROM Results: misses 10% & 8% unnecessary radiographs Amiri et al, Ulus Travma Acil Cerrahi Derg,

6 Shoulder Fracture: Evidence Acute shoulder pain N = 206 patients Therapeutically uninformative (TU) versus informative* * Fracture, AC separation, Cancer, Infection Result: Low risk criteria =Radiographs TU among 3 criteria 1. No fall & no swelling 2. Fall w/no swelling or pain at rest 3. Fall w/pain at rest but no swelling & full ROM Fraenkel et al, J Rheumatol, 2000 Acute shoulder pain N = 539 patients Trauma, observable deformity, & ROM = high risk Hahn et al, J Emerg Med, 2015 Clinical Prediction Rules (CPRs) CPRs have been developed in part to increase the accuracy of clinical decisions such as the need for ordering diagnostic tests or providing specific interventions. CPRs have been established for ordering radiographs at the knee, ankle, foot and cervical spine etc. They provide us with an efficient and inexpensive means of improving our clinical acumen and at the same time help remove the intuitive guess-work routinely incorporated into clinical decisions. Favorable evidence exists to support an impact of these CPRs with reduced cost and insignificant misdiagnoses. While the rules may complement existing knowledge, they are NOT an absolute tool that should replace sound clinical judgment-gestalt. Clinical Prediction Rules for Ordering Cervical Radiographs Canadian C-Spine Rules NEXUS Criteria 6

7 Canadian Cervical Spine Rules Sensitivity =.99 (99%) Specificity =.45 (45%) Stiell et al, N Eng J Med, 2003 NEXUS Criteria Sensitivity =.91 (91%) Specificity =.37 (37%) Stiell et al, N Eng J Med, 2003 Interpretation of Validity Reports People who had a fracture but CPR was negative = False Negatives Misses People who did not have a fracture but CPR was + = False Positives Unnecessary Radiograph Stiell et al, N Eng J Med,

8 Interpretation of Validity Reports Sensitivity(Sn) provides data on: 1. How many (%) with condition test + on CPR (true positive) 2. How many (%) with condition test on CPR (false negative) How many with fracture test + on CPR = Sn (99.4%) What % does CPR miss = 100 Sn = % misses (false negative) Thus 100-Sn = < 1% Interpretation of Validity Reports Specificity(Sp) provides data on: 1. How many (%) without condition test (-) on CPR (true negative) 2. How many (%) without condition test (+) on CPR (false positive) How many without fracture test (-) on CPR = Sp (45%) What % are (+) on CPR who do not have fracture = 100 Sp = % Thus 100-Sp = 55% false (+) Ottawa CPR CPRs & Consensus Guidelines for Ordering Knee Radiographs Pittsburgh CPR American College of Radiology (ACR) Consensus Guidelines Appropriateness Criteria 8

9 Ottawa CPR: Knee Radiographs Ottawa knee rules Patients with an acute knee injury and any of the following: Age 55 years or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex knee to 90 degrees Inability to walk four weight-bearing steps immediately after the injury and in the emergency department Sensitivity % Specificity 27% Stiell et al, JAMA, 1996 Ottawa CPR: Knee Radiographs Ottawa knee rules: Validation for Children ( 5) Patients with an acute knee injury and any of the following: Age 55 years or older Tenderness at head of fibula Isolated tenderness of patella Inability to flex knee to 90 degrees Inability to walk four weight-bearing steps immediately after the injury and in the emergency department Sensitivity 99% Specificity 46% Vijayasankar et al, Emerg Med J, 2009 Pittsburgh CPR: Knee Radiographs Pittsburgh decision rules Blunt trauma or fall mechanism of injury plus either of the following: Age younger than 12 years or older than 50 years Inability to walk four weight-bearing steps immediately & in ER Sensitivity 100% Specificity 79% Seaberg & Jackson, Am J Emerg Med,1994 9

10 ACR Guidelines for NOT Ordering Knee Radiographs following Acute Injury American College of Radiology Appropriateness Criteria Radiograph NOT indicated if the following criteria are met: Able to walk without a limp No effusion following twisting injury Sensitivity 100% Specificity 29% ww.acr.org Weber et al, Ann Emerg Med, 1995 Ottawa Ankle Clinical Prediction Rules Ankle radiographs required if there is any pain in malleolar zone & any of the findings below: Bone tenderness at A or B Inability to weight bear both immediately and in the ER. Pooled (Sensitivity 98% Specificity 40%) Bachmann, BMJ, 2003 Modified Ottawa Ankle CPRs Modified Buffalo Rule (children & adults) Tenderness from mid-portion (crest) of malleoulus to tip Purpose: reduce unnecessary radiographs & validity **Outcome: modification specificity 17% (same cohort) Sensitivity 100% Specificity* 40-59% Springer et al, Am J Sports Med, 2000 Leddy et al, Med Sci Sports Exerc, 2002 Leddy et al**, Am J Sports Med,

11 Ottawa Foot Clinical Prediction Rules Foot radiographs are required if there is any pain in the midfoot zone & any of the findings below: Bone tenderness at C or D Inability to weight bear both immediately and in the ER Pooled (Sensitivity 99% Specificity 38%) Bachmann, BMJ, 2003 Amsterdam Wrist Rules General wrist fractures in adults with trauma: 1. Age 2. Male 3.Wrist swelling 4.Snuffbox swelling 5.Visible deformation 6.Tenderness distal radius 7. Pain with radial deviation 8. Pain with axial compression of the thumb ( probability) *Calculation based on predictor model from 1-8 **If score < 4% no radiograph indicated: Sensitivity = 100% Walenkamp et al, BMC Musculoskelet Disord, 2015 Amsterdam Pediatric Wrist Rules General wrist fracture risk following trauma 1. Age ( probability) 2. Swelling of distal radius 3. Visible deformation 4. Tenderness distal radius 5. Tenderness anatomical snuffbox( probability) 6. Painful or abnormal supination *Calculation based on predictor model from 1-6 **If score < 4% no radiograph indicated: Sensitivity = 96% Slaar et al, Pediatr Radiol,

12 Summary: Guidelines Consensus-based guidelines offer direction Specific research studies require interpretation & often do not comprise comparable sample size to many of the clinical prediction rules Clinical prediction rules go through stages &generally are valid tools that prevent misses Down-side to many CPRs = false (+) Do not under-estimate clinical gestalt Case Scenario Disposition: Case A: 30-year-old male patient arrives at your clinic with central low back pain following an overly aggressive exercise session the day prior. Has not yet seen a physician. Reports symptoms are constant and worse sitting and bending. Rates pain on VRS a 9/10 when bending and a 4/10 when standing and walking. No radiculopathy or bowel or bladder changes. Medical history unremarkable. Should you examine this patient and provide an intervention or send to physician for radiographs? This patient does not have risk factors for serious pathology and does not meet indications for lumbar radiographs. Young age, no medical history, local pain without radiculopathy, recent onset, and no prior surgery or risk factors. Case Scenario Disposition: Case B: 21-year-old male patient arrives with right lateral ankle pain following an inversion injury while playing soccer the day prior. Patient states it is a sprain and has had this before. Patient is unable to fully weight-bear and reports pain at the region of the lateral ankle pointing to the lateral malleolus. Examination reveals tenderness at posterior lateral malleolus. Should you examine this patient and provide an intervention or send to physician for radiographs? This patient meets the Ottawa CPR for radiographs (malleolus zone pain, bone tenderness-posterior, and inability to weight-bear) thus, it is necessary to send this patient to physician for radiographs. Would provide the patient crutches, teach NWB gait and send to physician. Could we potentially further assess to reduce false positives? 12

13 Case Scenario Disposition: Case C: 66-year-old male patient arrives with right lower back pain and radiculopathy for no apparent reason. Has had symptoms prior. No recent radiographs in last 10-years. Examination reveals limited mobility all planes and no clear directional preference. PMH is positive for prostate cancer. Should you examine this patient and provide an intervention or send to physician for radiographs? This patient does have indications for radiographs based on age, history of cancer, and no recent radiographs. It would be acceptable to complete examination and treat patient, however, would need radiographs to be certain symptoms are not of a more serious matter. Case Scenario Disposition: Case D: 35-year-old female patient arrives with right sided neck pain following a motor vehicle accident 3 days ago. Reports constant pain and is unable to turn head > 30 bilaterally. Does have referred pain past neck and into arms bilaterally but not specific to a dermatome region. Has paresthesias into hands bilaterally. Has had no hand symptoms prior. PMH is unremarkable. Should you examine this patient and provide an intervention or send to physician for radiographs? Radiographs are potentially indicated based on NEXUS criteria (trauma and questionable neurological deficit given paresthesias) and definitely indicated based on the Canadian C-Spine CPR as patient had trauma, has paresthesias, and can not rotate head 45. This patient may have a serious condition, thus it would be reasonable to hold physical therapy until radiographs are reviewed. Case Scenario Next week you identify a patient who meets the CPR for a radiographic evaluation of his ankle. You contact the patient s physician office requesting this, however, physician is not present. Thus, the MA asks you the following question: What views should be ordered? 13

14 Now that you know who may require a radiographic evaluation the next step is understanding the standard & specialty views to order. Mark your calendar: An Introduction to Radiographic Views & Anatomy Webinar Date: Thursday 6/23/16 Time: 8-9:30 P.M. Eastern Thank You Questions? mkolber@brog.com References Chou R et al. Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med Oct 2;147(7): Slaar A et al. A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules.PediatrRadiol Jan;46(1): Walenkamp MM et al. The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma. BMC Musculoskelet Disord Dec 18;16:389. Appelboam A et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ Dec 9;337. Amiri H et al. Does preservation of active range of motion after acute elbow injury rule out the need for radiography? Ulus Travma Acil Cerrahi Derg Nov;18(6): Fraenkel L et al. Improving the selective use of plain radiographs in the initial evaluation of shoulder pain. J Rheumatol Jan;27(1): Hahn B et al. Predictors of Clinically Significant Radiographic Shoulder Pathology in the Emergency Department. J Emerg Med Oct;49(4):

15 References Stiell IG et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med Dec 25;349(26): Stiell IG et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA Feb 28;275(8): Bachmann LM et al. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ Feb 22;326(7386):417. Weber JE et al. Clinical decision rules discriminate between fractures and nonfractures in acute isolated knee trauma. Ann Emerg Med Oct;26(4): Walenkamp MM1 et al. The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma. BMC Musculoskelet Disord Dec 18;16:389. Vijayasankar D et al. Can the Ottawa knee rule be applied to children? A systematic review and meta-analysis of observational studies. Emerg Med J Apr;26(4): Leddy JJ et al. Implementation of the Ottawa ankle rule in a university sports medicine center. Med Sci Sports Exerc Jan;34(1): Seaberg DC & Jackson R. Clinical decision rule for knee radiographs. J Emerg Med Sep;12(5):