Case Study in Cervical Imaging: The Canadian C-Spine Rule

By Andy Parsons, PT, DPT

The following article was written for Medbridge- an online, video based continuing education based company.

Over the last two months, you’ve treated Jean for weakness associated with MS and radiating low back pain. Today, she presents with a new issue. Over the weekend she fell twice, striking her head and neck against the wall. She now complains of neck pain.

Prior to the falls, she experienced diffuse chronic pain, including some neck pain. Currently, she has numbness down her right upper extremity as well. You note that she is rotating her neck approximately 60 degrees bilaterally but the motion is guarded. Her midline c-spine is tender to palpation.

What’s a clinician to do? Do you refer Jean to imaging due to the neck pain? She’s had numerous falls before and a history of chronic neck pain. Will you be wasting your physician colleague’s time and resources? Or, is this a potentially serious situation that requires imaging?

Using the Canadian C-Spine Rule

There is a well-studied clinical prediction rule (CPR) that can help you make this determination.1,2,3,4 The Canadian C-spine Rule helps you decide if imaging is needed in cases of neck trauma. The sensitivity of the Canadian C-spine Rule is reported between 95% and 100%.1,2 This means the CPR is almost 100% accurate in ruling out pathology if the rule is negative. That’s one powerful screening tool for your toolkit!

The rule is broken down into three sections. Jean must pass all three sections in order to defer imaging. Per the rule, Jean has paresthesias in the upper extremity that are worse since the fall, tenderness at mid c-spine, and possible dangerous mechanism; therefore, you would refer the patient for radiography of the c-spine.

Precautions for Implementation

The c-spine rule has gone through several steps of research validation, but it has been studied exclusively in the emergency department. Therefore, applying this rule in an outpatient setting may be considered outside of the rule’s validated use. Mindful application of this clinical prediction rule can still inform clinical decision making.

Expanding Your Toolkit

The Canadian C-spine Rule provides some additional insight and aids your clinical decision making. It’s quick, easy, and improves patient safety for radiography referrals.3,4 Add it to your references and use it when you get a case like Jean.

References

1. Stiell, Ian G., et al. “The Canadian C-spine rule for radiography in alert and stable trauma patients.” Jama 286.15 (2001): 1841-1848.

2. Stiell, Ian G., et al. “The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.” New England Journal of Medicine 349.26 (2003): 2510-2518.

3. Bandiera, Glen, et al. “The Canadian C-spine rule performs better than unstructured physician judgment.” Annals of emergency medicine 42.3 (2003): 395-402. http://dx.doi.org/10.1016/S0196-0644(03)00422-0

4. Stiell, Ian G., et al. “Multicenter prospective validation of the Canadian C-Spine Rule.” Academic Emergency Medicine 9.5 (2002): 359.

**  This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.

Exercise Prescription: The KISS Method

By Andy Parsons, PT, DPT

Over the last year, I have been thinking critically about how I prescribe exercises in the clinic. As a new grad, I focused on making exercise prescription unique and functional. After all, the PT profession did go through the "functional exercise" revolution around the new millennium. You know, each exercise that we prescribe must mimic that functional activity that our client needs to perform to get back to full function.  Well, maybe... that is, if the exercise doesn't get too elaborate for it's own good.

After all, Isn't the best exercise the one that get's done?

I'm not throwing function completely out the window, but I now balance that thought with another main principle - the KISS method  

KISS: Keep It Simple Stupid.

Yep, Keep It Simple Stupid. The "scientific" saying first introduced to me by my high school freshmen biology teacher. Okay, seriously though, my rationale is based in some science. We do know HEP performance quality is improved with 2 exercises prescribed 8 (1).  Meaning increased exercise number likely decreases quality of exercise performed. I'm also reminded of a recent study that indicated one simple abduction exercise was as effective for RTC tendinopathy as "standard care" (2).   Also, if your "functional exercise" is still taking multiple verbal cues and tactile cues for quality after a few sessions, it is NOT getting done right a home either(3).  How can we expect to maximize adherence if the client needs two weeks to learn the exercise correctly? For many of us, most of our clients are not pitchers trying to return to the mound, or hitters trying to get back to the volleyball court; they might just want to be able to reach overhead to put the dishes away.  Keep in mind prior function and prior history of exercise as it relates to the complexity of the program you're prescribing exercise (4). 

An Example of K.I.S.S.:

Anybody ever used this isometric exercise?  Yeah... me too... many times.
 

The patient holds his/her elbow at his side taking one large step sideways and back to create and shoulder external rotation isometric. This is often performed in four directions, creating moving isometrics for flexion, extension, IR, and ER.

Compare it to the good ol' isometric vs the wall

The wall isometric isn't as "functional" as the reactive or stepping isometric, but does that make it worse? I used to prescribe the stepping isometric to every shoulder patient, that wasn't ready for isotonics, but now I only occasionally do. Why? Barriers to adherence limit this exercise:

1. It requires equipment that you have to provide or the patient has to buy

2. The equipment must be set up each time and available

3. If the elbow is tucked too tightly to the side of the body, load through the shoulder is mitigated

4. Steeper learning curve and reduced self efficacy (3)

Now I go with the standard isometric. The only equipment needed for adherence is a wall, and let's face it, most people a one "lying around"...

I never thought I'd be thinking about my eccentric, freshman biology teacher on a daily basis... Keep It Simple Stupid

References

1. Henry, Kristin D., Cherie Rosemond, and Lynn B. Eckert. "Effect of number of home exercises on compliance and performance in adults over 65 years of age." Physical Therapy 79.3 (1999): 270-277.

2. Littlewood, Chris, et al. "A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: A randomised controlled trial (the SELF study)."Clinical rehabilitation (2015): 0269215515593784.

3. McLean, Sionnadh Mairi, et al. "Interventions for enhancing adherence with physiotherapy: a systematic review." Manual therapy 15.6 (2010): 514-521.

4. Der Ananian, Cheryl, et al. "Factors associated with exercise participation in adults with arthritis." J Aging Phys Act 16.2 (2008): 125-143.

Images:

Flickr Via Ben Russel "Teacher"

Thank you MedBridge for permitting use of the isometric images.

**  This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.

Ottawa ankle rules: A practical example of EBP in motion

By Andy Parsons, PT, DPT

I find that many clinicians still misunderstand what EBP is and what it can do for them. The following is a practical example of how I used EBP in the clinic the other day to aide quick, quality clinical reasoning. 

I was working with a 76 y/o female on balance and generalized weakness after a recent string of falls. She was progressing well, so we were increasing difficulty of dynamic balance activities. The patient was performing lateral step-overs across a short hurdle (which she had performed many times successfully). Unfortunately, the patient missed and rolled her ankle on the hurdle. She had immediate pain, and had difficulty weight-bearing through her foot. I let her rest about 5 minutes, but she was still ambulating with an antalgic pattern. The question was: Did she sprain her ankle or fracture a bone in her foot or ankle? Did I need to refer her to PCP, ED, or MD? Did she need imaging?

I decided to utilize a clinical prediction rule (CPR) called the Ottawa ankle rules. The Ottawa ankle rules were developed to aide in clinical decision making when assessing if an ankle or foot injury requires radiography. This CPR is extremely well established and has been through 1. preliminary identification of factors 2. validation(1) 3. Impact analysis.(2)  The Ottawa ankle rules has been found to have nearly a 100% sensitivity which means its ability to rule out fracture with a negative result if excellent (1).

Here is what the rule looks like:

Source: Stiel et al. JAMA 1994 http://dx.doi.org/10.1001/jama.1994.03510350037034

My patient had bone tenderness at location C and had difficulty weight bearing. This took much of the guess work out of the equation. I referred her to urgent care because her PCP was booked and she received foot/ankle x-rays. The final images were negative, but the CPR allowed me to make an appropriate referral quickly vs. telling the patient to wait and see how she felt. Even when I was oblivious the the Ottawa ankle rules, I would have referred the patient due inability to weight-bear, but this made the decision more efficient, and gave me something concrete to communicate to the physician. A tool like this can help convince and apathetic patient of what they need as well. 

CPRs are one phenomenal way the evidence can aide in day to day clinical reasoning. Here are a few other examples:

• Ottawa Knee Rules

• Well's Clinical Decision rule for DVT

• The Canadian C-spine rule

Dr. John Snyder has a great list of CPRs most related to PT over at his website.  Just know, that many of these CPRs have not gone through sufficient validation or impact analysis, so the may not be ready for "prime time" use. 

Accessibility is one major barrier against using tools like the Ottawa ankle rules.  My solution is Evernote. Evernote is a multi-platform app that stores just about anything you'd want to remember.  I use a laptop all day for documentation so it's easy to pull up content. I can typically have a resource like the Ottawa ankle rules pulled up within 5-10s. This is especially true if you utilize tagging systems and organize notes into separate notebooks. The same is true for a smart phone or tablet. I have over 2000 personal and work related notes after using it heavily for about 4 or 5 years now. It's a smart tool for any clinician! (Did I mention the basic version is free?)

Disclaimer- I am by no means sponsored by Evernote; I just love their product!

References:

1. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review.BMJ : British Medical Journal. 2003;326(7386):417.

2. Stiell, Ian G., et al. "Implementation of the Ottawa ankle rules." Jama 271.11 (1994): 827-832.

Banner Image: "Broken Ankle- Side X-ray" via Flickr by Jared Zimmerman
Image: "Evidence of Organized Light" via Flickr by Jared Tarbell

**  This information is not intended to replace the advice of a physician/ physical therapist. Andy Parsons, PT, DPT disclaims any liability for the decisions you make based on this information.