Validation and impact analysis of prognostic clinical prediction rules for low back pain is needed: a systematic review

J Clin Epidemiol. 2015 Jul;68(7):821-32. doi: 10.1016/j.jclinepi.2015.02.003. Epub 2015 Feb 14.


Objectives: To identify prognostic forms of clinical prediction rules (CPRs) related to the nonsurgical management of adults with low back pain (LBP) and to evaluate their current stage of development.

Study design and setting: Systematic review using a sensitive search strategy across seven databases with hand searching and citation tracking.

Results: A total of 10,005 records were screened for eligibility with 35 studies included in the review. The included studies report on the development of 30 prognostic LBP CPRs. Most of the identified CPRs are in their initial phase of development. Three CPRs were found to have undergone validation--the Cassandra rule for predicting long-term significant functional limitations and the five-item and two-item Flynn manipulation CPRs for predicting a favorable functional prognosis in patients being treated with lumbopelvic manipulation. No studies were identified that investigated whether the implementation of a CPR resulted in beneficial patient outcomes or improved resource efficiencies.

Conclusion: Most of the identified prognostic CPRs for LBP are in the initial phase of development and are consequently not recommended for direct application in clinical practice at this time. The body of evidence provides emergent confidence in the limited predictive performance of the Cassandra rule and the five-item Flynn manipulation CPR in comparable clinical settings and patient populations.

Keywords: Clinical prediction rule; Decision support techniques; Derivation; Impact analysis; Low back pain; Prognosis; Systematic review; Validation.

Publication types

  • Review
  • Systematic Review
  • Validation Study

MeSH terms

  • Adult
  • Databases, Factual
  • Decision Support Techniques*
  • Health Services Needs and Demand
  • Humans
  • Low Back Pain / therapy*
  • Prognosis
  • Reproducibility of Results
  • Sickness Impact Profile