DIAGNOSTIC PREDICTION MODELS FOR SPINAL FRACTURES IN PEOPLE WITH SPINAL PAIN OR TRAUMA: A SYSTEMATIC REVIEW WITH META-ANALYSIS

Autori

Feller Daniel (Azienda Provinciale per i Servizi Sanitari, Trento, Italia; Erasmus Medical Center, Rotterdam, The Netherlands)

Wingbermühle Roel (Erasmus Medical Center, Rotterdam, The Netherlands)

Oei Edwin (Erasmus Medical Center, Rotterdam, The Netherlands)

Koes Bart (Erasmus Medical Center, Rotterdam, The Netherlands; University of Southern Denmark, Odense, Denmark)

Chiarotto Alessandro (Erasmus Medical Center, Rotterdam, The Netherlands)

Background and aims

In this systematic review we aimed to evaluate the performance of multivariable diagnostic prediction models for identifying spinal fractures in patients with spinal pain and/or trauma.

Methods

We conducted a systematic review with meta-analysis, following a prospectively registered protocol in PROSPERO (CRD42024539898). We included studies that developed (with or without internal validation) or externally validated multivariable diagnostic prediction models for identifying spinal fractures in patients with spinal pain and/or trauma. We searched MEDLINE, EMBASE, and Web of Science (up to May 2025), and conducted backward and forward citation tracking strategies. Two independent reviewers extracted studies’ data using the CHARMS checklist, and assessed the risk of bias with the PROBAST tool. A bivariate random-effects model was used to pool classification measures, while univariate random-effects models were used for discrimination and calibration measures. We assessed the certainty of the evidence using an adapted version of the GRADE for prognostic factor studies.

Results

We included 27 studies encompassing 34 diagnostic models. All models showed an overall high risk of bias. Meta-analyses of ten studies that externally validated the use of the Canadian C-spine Rule in adults presenting with trauma to emergency departments demonstrated, with very low certainty of the evidence, excellent sensitivity (0.999; 95% CI 0.976 to 1), an high area under the curve (0.85; 95% CI 0.72 to 0.97), and a low specificity (0.188; 95% CI 0.063 to 0.443). We estimated a pooled positive likelihood ratio of 1.23 (95% CI 0.978 to 1.548) and a negative likelihood ratio of 0.007 (95% CI 0.001 to 0.082) for the same model. Other models for traumatic cervical fractures and osteoporotic fractures showed promise but lacked external validation or sufficient reporting on calibration and discrimination measures. No models for thoracolumbar fractures were deemed ready to be used clinically.

Conclusion

Our findings indicate that, while the Canadian C-spine Rule shows potential for screening traumatic cervical fractures, the very low to low certainty of the evidence limits confidence in its accuracy and appropriateness for clinical use. Notably, the Canadian C-spine Rule has only been validated in emergency department settings and is therefore not applicable to standard rehabilitation settings. Also, we did not identify any externally validated model suitable for clinical use regarding osteoporotic fractures, traumatic fractures of the thoracolumbar spine, and traumatic fractures of the cervical spine in non-emergency settings. Future research with rigorous methodological and statistical approaches should aim to fill these gaps.

REFERENCES

1. Moons KG, de Groot JA, Bouwmeester W, Vergouwe Y, Mallett S, Altman DG, Reitsma JB, Collins GS. Critical appraisal and data extraction for systematic reviews of prediction modelling studies: the CHARMS checklist. PLoS Med. 2014 Oct 14;11(10):e1001744. doi: 10.1371/journal.pmed.1001744. PMID: 25314315; PMCID: PMC4196729.
2. Wolff RF, Moons KGM, Riley RD, Whiting PF, Westwood M, Collins GS, Reitsma JB, Kleijnen J, Mallett S; PROBAST Group†. PROBAST: A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies. Ann Intern Med. 2019 Jan 1;170(1):51-58. doi: 10.7326/M18-1376. PMID: 30596875.
3. Huguet A, Hayden JA, Stinson J, McGrath PJ, Chambers CT, Tougas ME, Wozney L. Judging the quality of evidence in reviews of prognostic factor research: adapting the GRADE framework. Syst Rev. 2013 Sep 5;2:71. doi: 10.1186/2046-4053-2-71. PMID: 24007720; PMCID: PMC3930077.
4. van Smeden M, Reitsma JB, Riley RD, Collins GS, Moons KG. Clinical prediction models: diagnosis versus prognosis. J Clin Epidemiol. 2021 Apr;132:142-145. doi: 10.1016/j.jclinepi.2021.01.009. PMID: 33775387.
5. Feller D, Chiarotto A, Koes B, Maselli F, Mourad F. Red flags for potential serious pathologies in people with neck pain: a systematic review of clinical practice guidelines. Arch Physiother. 2024 Dec 4;14:105-115. doi: 10.33393/aop.2024.3245. PMID: 39639931; PMCID: PMC11618059.

RANGE OF MOTION AS A PROGNOSTIC FACTOR IN PATIENTS WITH SPECIFIC AND NON–SPECIFIC SPINAL PAIN: A SYSTEMATIC REVIEW

Autori

Feller Daniel (Azienda Provinciale per i Servizi Sanitari, Trento, Italia; Erasmus Medical Center, Rotterdam, The Netherlands)

Bortoli Michela (Azienda Provinciale per i Servizi Sanitari, Trento, Italia)

Rigo Adriano (Azienda Provinciale per i Servizi Sanitari, Trento, Italia)

Maini Irene (Azienda Provinciale per i Servizi Sanitari, Trento, Italia)

Hayden Jill (Dalhousie University, Halifax, Canada)

Chiarotto Alessandro (Erasmus Medical Center, Rotterdam, The Netherlands)

Background and aims

Identifying prognostic factors—variables that help predict clinical outcomes—is essential for improving patient care and guiding treatment decisions. Range of motion (ROM) is routinely assessed in clinical practice, yet its prognostic value in patients with spinal pain remains unclear. Therefore, this systematic review aimed to determine whether reduced spinal ROM predicts outcomes such as pain intensity, disability, or global recovery in individuals with specific or non-specific spinal pain.

Methods

(CRD42024583518). We included prospective and retrospective cohort studies, case-control studies, and secondary analyses of randomized controlled trials evaluating ROM as a prognostic factor in adults (≥18 years) with spinal pain. We included studies assessing active or passive ROM using any objective method. Databases searched included MEDLINE, Embase, CENTRAL, and CINAHL up to May 24, 2024. Risk of bias was assessed using the QUIPS tool, and certainty of evidence was rated using the GRADE approach. Two authors independetly performed the study selection, data extraction and risk of bias assessment phases. Due to clinical and methodological heterogeneity, results were synthesized narratively.

Results

A total of 35 studies were included: 11 on acute low back pain (LBP), 10 on chronic or unspecified LBP, 4 on chronic neck pain, 2 on lumbar spinal stenosis, and 8 on whiplash-associated disorders. No studies addressed acute neck pain. ROM was most commonly measured using inclinometers and goniometers, though methods varied widely. Across all conditions, the certainty of evidence was very low due to high risk of bias (particularly inadequate adjustment for confounders), inconsistent findings, and methodological heterogeneity. While some studies reported significant associations between reduced ROM and worse outcomes (especially in whiplash and lumbar stenosis), most showed no consistent relationship. Many studies showed inadequate reporting, often presenting only statistical test results without point estimates or confidence intervals, which limits the clinical interpretability of the findings.

Conclusion

There is currently low to very low-certainty evidence that reduced spinal ROM is a prognostic factor for pain, disability, or recovery in patients with spinal pain. Therefore, routine ROM assessment may have limited value for prognosis alone. However, ROM remains clinically relevant for identifying movement-related dysfunction and informing treatment decisions. Future high-quality, prospective studies with robust adjustment for confounders are needed to clarify the independent prognostic role of spinal ROM, especially in underexplored populations such as those with acute neck pain.

REFERENCES

1. Hayden JA, van der Windt DA, Cartwright JL, Côté P, Bombardier C. Assessing bias in studies of prognostic factors. Ann Intern Med. 2013 Feb 19;158(4):280-6. doi: 10.7326/0003-4819-158-4-201302190-00009. PMID: 23420236.
2. Huguet A, Hayden JA, Stinson J, McGrath PJ, Chambers CT, Tougas ME, Wozney L. Judging the quality of evidence in reviews of prognostic factor research: adapting the GRADE framework. Syst Rev. 2013 Sep 5;2:71. doi: 10.1186/2046-4053-2-71. PMID: 24007720; PMCID: PMC3930077.
3. Riley RD, Hayden JA, Steyerberg EW, Moons KG, Abrams K, Kyzas PA, Malats N, Briggs A, Schroter S, Altman DG, Hemingway H; PROGRESS Group. Prognosis Research Strategy (PROGRESS) 2: prognostic factor research. PLoS Med. 2013;10(2):e1001380. doi: 10.1371/journal.pmed.1001380. Epub 2013 Feb 5. PMID: 23393429; PMCID: PMC3564757.

Shoulder pain: To image or not to image?

Autori

Brindisino Fabrizio (Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise, Campobasso, Italy)

Paul Salamh (Krannert School of Physical Therapy, University of Indianapolis, 1400 East Hanna Avenue, Indianapolis, IN)

Chad Cook (Department of Population Health Sciences, Duke University, Durham, NC, USA)

Jeremy Lewis (Therapy Department, Central London Community Healthcare National Health Service Trust, Finchley Memorial Hospital, London, UK)

Alvisa Palese (Department of Medical Sciences, University of Udine, Udine, Italy)

Germano Guerra (Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise, Campobasso, Italy)

Jacopo Bonavita (Neurorehabilitation Unit, Villa Rosa Hospital, APSS Trento, Trento, Italy)

Giacomo Rossettini (School of Physiotherapy, University of Verona, Verona, Italy)

Background and aims

Imaging findings should be interpreted within the broader context of an individual’s shoulder symptoms [1]. While imaging is valuable in identifying specific structural pathologies, findings are often equivocal. Defining what imaging changes constitute “normal”, “abnormal”, “unrelated”, “solely causative” findings, and which are, “contributory”, or “associated” with symptoms is a clinical minefield. It is arguable that many so called “abnormalities” have been labeled as such because they represent deviations in structure from idealized and flawless anatomical drawings.

Methods

To promote consideration for the role of “bio” in shoulder symptoms and encourage debate among clinicians and researchers, this opinion paper aims to stimulate discussion on the value of imaging in management of musculoskeletal shoulder pain. We sought to capture diverse perspectives by incorporating input from various health disciplines working within the musculoskeletal field, aimed at providing a comprehensive perspective to our manuscript.

Results

Although the judicious requests of imaging may improve clinician understanding of a specific clinical scenario, between 20–50% of imaging requests are inappropriate or of “low value” (e.g., a service offering no or minimal benefit) [2]. Conversely, strategies aimed at reducing low-value imaging have the potential to decrease costs by as much as 95% without compromising patient well-being [2].

Studies investigating this issue, question the clinical utility of routine imaging for treatment planning, given the high prevalence of anatomical variations in asymptomatic shoulders [1,3]. Indeed, while imaging may identify tissue pathology, it often cannot reliably determine the clinical significance of these findings or their correlation with specific symptoms. Acceptance of imaging findings (i) without defining what abnormal is based upon and (ii) without stating the prevalence of such findings in people without symptoms, may lead to over medicalization and detrimentally impact on healthcare sustainability [4].

Conclusion

Clinical practice frequently lacks balance and frequently is conducted at the ends of a spectrum. With one end being rigid reliance on structural imaging and the other its rejection in favor of a psychosocial narrative. To promote a judicious, resourceful, and evidence-based utilization of imaging, research should emphasize a comprehensive bio-psycho-social care pathway. Within this framework, all relevant domains should be engaged and weighted according to the specific clinical context. A balanced, context-driven use of imaging, grounded in clinical reasoning and embedded in a biopsychosocial model, can enhance diagnosis, inform treatment, and support shared decision-making. Imaging is a valuable tool when used wisely: the question is not whether to use it, but when, why, and for whom.

REFERENCES

[1] Tran G, Cowling P, Smith T, Bury J, Lucas A, Barr A, et al. What Imaging-Detected Pathologies Are Associated With Shoulder Symptoms and Their Persistence? A Systematic Literature Review. Arthritis Care & Research. 2018;70:1169-84.

[2] Kjelle E, Brandsæter IØ, Andersen ER, Hofmann BM. Cost of Low-Value Imaging Worldwide: A Systematic Review. Applied Health Economics and Health Policy. 2024;22:485-501.

[3] Gill TK, Shanahan EM, Allison D, Alcorn D, Hill CL. Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Int J Rheum Dis. 2014;17:863-71.

[4] Ingraham B, Miller K, Iaia A, Sneider MB, Naqvi S, Evans K, et al. Reductions in High-End Imaging Utilization With Radiology Review and Consultation. Journal of the American College of Radiology : JACR. 2016;13:1079-82

Association Between Pain Intensity, Range of Motion, Disability, and Health-Related Quality of Life Variables in Frozen Shoulder: A Cross-Sectional Study

Autori

Brindisino Fabrizio (Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise, Campobasso, Italy)

Feller Daniel (Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands)

Andriesse Arianna (Medical Translation Private Practice c/o Andriesse Medical Translator, Lecce, Italy)

Venturin Davide (Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise, Campobasso, Italy)

Poser Antonio (Physiotherapy private practice Kinè c/o Viale Venezia 13/Q San Vendemiano, Italy)

Background and aims

While the relationship between disability and pain is well established [1], recent studies have highlighted the association between health-related, social and psychological factors, and negative functional outcomes in patients with Frozen Shoulder (FS) [2]. This study analyzes the association between pain, disability, health-related quality of life domains, and range of motion (ROM) during the first physiotherapy consultation in FS patients.

Methods

This cross-sectional study followed the STROBE guidelines [3]. Participants were recruited between January and October 2024. Each participant anonymously filled out the Shoulder Pain and Disability Index, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the 36-Item Short Form Health Survey. ROM restrictions in flexion, abduction, and external rotation with the arm by the side were assessed. Statistical analysis was performed using multivariable linear regression —modeling all independent variables simultaneously— and adjusting for confounding factors.

Results

A total of 149 subjects were included (53% female). Significant correlations were found between pain and disability (standardized coefficient = 13.65, 95% CI 10.38 to 16.92, p < 0.01), as well as between pain and flexion restriction (standardized coefficient = -3.95 95%CI -7.43 to -0.47, p=0.03).

Conclusion

Our findings confirm that pain is a primary determinant of disability in FS patients, even at early stages. A significant association between pain and flexion limitation was also observed, with flexion being the most sensitive movement to pain. The lack of correlation with health-related quality of life variables suggests that, while pain limits physical function, its psychological impact—assessed through such outcome measures used—may not yet be evident. This study provides strong evidence of the association among pain, disability, and ROM in flexion during the initial physiotherapy consultation for FS, suggesting that early clinical focus on pain management may help reduce disability, improving overall patient outcomes.

REFERENCES

[1] Mertens MG, Struyf F, Verborgt O, Dueñas L, Balasch-Bernat M, Navarro-Ledesma S, et al. Exploration of the clinical course and longitudinal correlations in frozen shoulder: The role of autonomic function, central pain processing, and psychological variables. A longitudinal multicenter prospective observational study. Musculoskeletal Science and Practice. 2023;67:102857.

[2] Brindisino F, Silvestri E, Gallo C, Venturin D, Di Giacomo G, Peebles AM, et al. Depression and Anxiety Are Associated With Worse Subjective and Functional Baseline Scores in Patients With Frozen Shoulder Contracture Syndrome: A Systematic Review. Arthroscopy, sports medicine, and rehabilitation. 2022;4:e1219-e34.

[3] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. International journal of surgery (London, England). 2014;12:1495-9

 

 

Passaggio dalla diagnosi basata sugli item a quella sul punteggio totale nella Coma Recovery Scale–Revised: uno studio di accuratezza diagnostica

Autori

Caselli Serena (Unità Operativa Complessa di Medicina Riabilitativa, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy)

Pellicciari Leonardo (IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy)

Leonardi Matilde (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

Magnani Francesca Giulia (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

Cacciatore Martina (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

Barbadoro Filippo (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

Ippoliti Camilla (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

Kreiner Svend (Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark)

La Porta Fabio (IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy)

Background and aims

The Coma Recovery Scale-Revised (CRS-R) is the gold standard for diagnosing patients with Disorder of Consciousness (DOC). Five items out of six provide scores linked to a diagnosis of Unresponsive Wakefulness Syndrome (UWS), Minimally Conscious State (MCS), or emergence from MCS (eMCS). However, no diagnostic criteria are linked to the total score.

Therefore, this study proposes to define and compare the diagnostic accuracy of total score cutoffs based on item-level diagnostic criteria proposed recently[1] as a reference standard, and to improve the diagnostic accuracy of these total score cutoffs using a modified version of the original rule (i.e., the diagnostic category coincides with the highest category defined at least by one item)[2] currently in use.

Methods

Patients with DOC as a consequence of a severe acquired brain injury and admitted to post-acute and follow-up neuro-rehabilitation services were included. Diagnostic accuracy (DA) of the total score cutoffs based on each of the item-level diagnostic criteria set proposed recently[1-4], and the agreement indexes between item-level and total score-level diagnosis were computed. Finally, the comparison of the diagnostic accuracy of the total score cutoffs according to Giacino’s original rule[2] and the “modified rule” (i.e., the diagnostic category coincides with the highest category defined at least by two/three/four items) with Caselli’s criteria[1] was performed.

Results

380 patients with DOC (mean±SD: 52.1±16.8 years, 65% male) were included for a total of 727 CRS-R assessments.

The comparison of total score cutoffs for each diagnostic criterion showed that for MCSplus and eMCS, the DA value is 90-95% (Table I), with high false negatives (FN) for most criteria sets (MCSplus: Bodien 12pt 22.5%; Caselli 11pt 16.7%; eMCS: Giacino and Bodien 19pt 23%; Weaver 16pt 19%). For MCSminus, the four cutoffs (8pt) had high specificity, essential for identifying patients with early signs of consciousness. Weighted Cohen’s k between the item and total score diagnoses was 0.82 for all four criteria sets.

Applying the “modified rule” with Caselli’s criteria resulted in the highest DA values for both MCSplus (14pt 97%) and eMCS (19pt 99%), with a lower FN rate (<11%) (Tables II and III).

Conclusion

Being the diagnosis based on individual items, the initial total score cutoffs partly addressed the low reliability of item-level cutoffs. The introduction of the “modified rule,” which requires at least two items per diagnostic category for diagnosis, allowed for advancing from item-level to a reliable total score-based diagnosis with less measurement error.

REFERENCES

1. Caselli S, Leonardi M, Magnani FG, Cacciatore M, Barbadoro F, Ippoliti C, Kreiner S, Pellicciari L, La Porta F. Comparing the Different Sets of Item-Level Diagnostic Criteria of the Coma Recovery Scale-Revised (CRS-R): A Measurement-Based Approach Driven by Rasch Analysis. Arch Phys Med Rehabil. 2024 Dec 18:S0003-9993(24)01406-0. doi: 10.1016/j.apmr.2024.12.009.
2. Giacino JT, Kalmar K, Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehabil. 2004 Dec;85(12):2020-9. doi: 10.1016/j.apmr.2004.02.033.
3. Bodien YG, Chatelle C, Taubert A, Uchani S, Giacino J T, Ehrlich-Jones L. Updated measurement characteristics and clinical utility of the Coma Recovery Scale-Revised among individuals with acquired brain injury. Arch Phys Med Rehabil. 2021;102(1):169-171. doi: 10.1016/j.apmr.2020.09.369.
4. Weaver JA, Cogan AM, O’Brien KA, Hansen P, Giacino JT, Whyte J, Bender Pape T, van der Wees P, Mallinson T. Determining the Hierarchy of Coma Recovery Scale-Revised Rating Scale Categories and Alignment with Aspen Consensus Criteria for Patients with Brain Injury: A Rasch Analysis. J Neurotrauma. 2022 Oct;39(19-20):1417-1428. doi: 10.1089/neu.2022.0095.