4 Systematic Reviews Refute the Clinical Applicability of CPRs

When I first designed my blog a year and a half ago (when it was known as physiotherapyinfo.com) I summarized all of the known clinical prediction rules.  Since doing this, I get several hits a day through searches for these but have been debating taking them down.  While these rules provide a guidance toward diagnosis and/or intervention, their significance is questionable and many have not yet been validated.  It is my opinion that they may be more prognostic tools, and simply determine who will get better, no matter intervention is applied. Lets take the CPR for manipulation of the lumbar spine for individuals with low back pain.  The indicators for using this rule describe an individual is healthy and likely would have gotten better with any intervention.  This rule states: symptom duration less than 16 days (ie. acute pain), no radicular symptoms past the knee (ie. likely not a disc or stenotic), a FABQ score < 19(ie. they aren’t avoiding things because of the pain), at least one hypomobile segment (ie. not sure how this snuck in due to inter-rater reliability issues with determining this), and one hip with greater than 35 degrees of IR (ie. an active individual).   As a Maitland trained therapist, I read a fantastic post a few weeks ago by Chris Showalter, the clinical director of the Maitland-Australian Physiotherapy Seminars on their website www.ozpt.com about this very subject .  I recently contacted Chris and asked if I could repost this to my site.  Here it is:
4 Systematic Reviews Refute the Clinical Applicability of CPRs
By: Chris Showalter, PT, OCS, COMT, FAAOMPT
Clinical Prediction Rules (CPRs) have been widely discussed and advocated in the literature in recent years. Many CPRs offer thrust manipulation as the preferred manual therapy intervention. Advocates call for their widespread adoption as the epitome of Evidence Based Practice and further suggest incorporating them into clinical guidelines.
 Others, including myself, argue that the CPRs are tools that may prove to be useful as a single component of Clinical Decision Making including the Assessment and Clinical Reasoning approach that is the cornerstone of the Maitland Concept.
 CPRs were debated recently in a “standing room only” Oxford debate at the APTA Annual Conference in 2011. The debate was titled “CPR (Clinical Predication Rules): Dead or Alive?” The debate was scored overwhelmingly against the CPRs.
 APTA Members can login and view a partial video (37 Min.) of the debate here
 The problem with the CPRs is that most suffer significant design flaws and have not been adequately validated. When validation studies have been performed they fail to include heterogeneous populations of patients, populations that are true to real life clinical practice. Thus, the CPRs may not be ready for adoption into clinical practice.
 I prefer to think of the CPRs as newborn children. Their proud parents espouse their offspring’s many talents. Others recognize the innate potential for greatness, but reserve the right to bestow honors until they have had a chance to be validated and prove themselves as clinically useful.
 In short the CPRs may represent promise in the future…when properly validated AND shown to be applicable to real world patient populations.
 To date there are 4 Systematic Reviews (SRs) that raise serious concerns regarding the clinical utility of the CPRs.
 This Level 1 Evidence, demands that we consider the CPRs with healthy skepticism, and understand that they are not yet ready for integration into clinical practice or clinical guidelines.
 Here is the PubMed Abstract from the most recent edition of the journal Manual Therapy.
 Co-Author Darren Rivett discussed aspects of this article during his Keynote Address at MAPS Symposium in Chicago, IL October 21-23, 2011
 I have detailed all 4 SRs for you below, including links to PubMed where you can view abstracts and full articles (where available).
Chris R Showalter
 Summary of the Haskins article from PubMed:
Man Ther. 2012 Feb;17(1):9-21. Epub 2011 Jun 8.
 Clinical prediction rules in the physiotherapy management of low back pain: a systematic review.
 Haskins R, Rivett DA, Osmotherly PG. Source:
School of Health Sciences, The University of Newcastle, NSW 2308, Australia.
To identify, appraise and determine the clinical readiness of diagnostic, prescriptive and prognostic Clinical Prediction Rules (CPRs) in the physiotherapy management of Low Back Pain (LBP).
MEDLINE, EMBASE, CINAHL, AMED and the Cochrane Database of Systematic Reviews were searched from 1990 to January 2010 using sensitive search strategies for identifying CPR and LBP studies. Citation tracking and hand-searching of relevant journals were used as supplemental strategies.
Two independent reviewers used a two-phase selection procedure to identify studies that explicitly aimed to develop one or more CPRs involving the physiotherapy management of LBP. Diagnostic, prescriptive and prognostic studies investigating CPRs at any stage of their development, derivation, validation, or impact-analysis, were considered for inclusion using a priori criteria. 7453 unique records were screened with 23 studies composing the final included sample.
Two reviewers independently extracted relevant data into evidence tables using a standardised instrument.
Identified studies were qualitatively synthesized. No attempt was made to statistically pool the results of individual studies. The 23 scientifically admissible studies described the development of 25 unique CPRs, including 15 diagnostic, 7 prescriptive and 3 prognostic rules. The majority (65%) of studies described the initial derivation of one or more CPRs. No studies investigating the impact phase of rule development were identified.
The current body of evidence does not enable confident direct clinical application of any of the identified CPRs. Further validation studies utilizing appropriate research designs and rigorous methodology are required to determine the performance and generalizability of the derived CPRs to other patient populations, clinicians and clinical settings.
 Where to find the Articles

  1. http://www.ncbi.nlm.nih.gov/pubmed/21641849
    Haskins R, Rivett DA, Osmotherly PG. Clinical prediction rules in the physiotherapy management of low back pain: A systematic review. Man. Ther. 2012 Feb;17(1):9-21.

    • 23 included CPR studies
    • “Current body of evidence does not enable confident direct clinical application of any of the CPRs”
  2. http://www.ncbi.nlm.nih.gov/pubmed/20413577
    Stanton TR, Hancock MJ, Maher CG, Koes BW. Critical appraisal of clinical prediction rules that aim to optimize treatment selection for musculoskeletal conditions. Phys Ther. 2010;90(6):843-854.

    • 18 included CPR studies
    • “There is little evidence that CPRs can be used to predict effects of treatment for musculoskeletal conditions”
    • “Validation of these rules is imperative to allow clinical application”
  3. http://www.ncbi.nlm.nih.gov/pubmed/20046564
    May S, Rosedale R. Prescriptive clinical prediction rules in back pain research: a systematic review. J Man Manip Ther. 2009;17(1):36-45.

    • 16 included CPR studies
    • “Most need further evaluation before they can be applied clinically…most did not pass the lowest level of evidence hierarchy”
    • “Manipulation CPRs evidence to date for its clinical utility is limited and contradictory”
    • “Stabilization CPR has limited evidence that may be considered but only with similar patients”
  4. http://www.ncbi.nlm.nih.gov/pubmed/19095806
    Beneciuk JM, Bishop MD, George SZ. Clinical prediction rules for physical therapy interventions: a systematic review. Phys Ther. 2009;89(2):114-124.

    • 10 included CPR studies “were Poor to Moderate Quality BUT most lacked Validation studies”
Article Categories:

All Comments

  • Wise thoughts of caution regarding CPRs. Dr. Stanley Paris called the CPRs into question, and challenged the quality of PT research at the AAOMPT conference here http://www.aaompt.org/education/conference11/handouts/Distinguished_Lecture_Paris.pdf

    Don Reagan March 23, 2012 7:11 am Reply
  • Pingback: Suggested Readings: Clinical Prediction Rules, Publishing in Science, The Saints

  • Good Post Joseph.
    My comment:The most LBP patients I see do not fit in the CPR for manipulation. As a McKenzie therapists I would classify the most of these patients as a patient with a derangement. Under these acute patients there is still an good self healing tendency. In contrary to what some (including myself) see clinically, it has not been possible so far to proof that the Mckenzie treatment give relevant better or faster outcomes than the advice to keep moving. As the most of these patients have a derangement with a direction of preference for extension, it is understandable these acute patients have this good prognosis, as long as they sit and keep moving upright (walking firmly is extension-rotation and don’t exercise against there direction of preference. The most do already this following there instincts. With our advices and right directed exercises we may prevent by a few of the acute patients to become chronic. The far more bigger deal in the acute patients is to make them understand the mechanics and to learn them what they can do to prevent the next (even worse) relapse. This will make them independent from any therapy in future. No manipulation or other passive therapy can offer this.

    koenoverdijk March 23, 2012 4:18 pm Reply
  • Don’t take down the CPRs – they represent the future direction of medical decision making. If anything, continue to add to them and supplement them as the evidence matures. An interesting discussion on LinkedIn (from which I found your post) could use your input:
    Also, I posted about the June 2011 Oxford Debate in Washington DC at my blog, PhysicalTherapyDiagnosis.com
    Thank you for the video for APTA members – I didn’t know that was available.
    Tim Richardson, PT

    Tim Richardson, PT March 26, 2012 8:27 am Reply
  • acute pain is of course annoying, i always take some OTC pain medications to relieve it.;
    Newest brief article on our own webpage

    Coleman Waiters January 24, 2013 12:58 am Reply
  • I agree that CPRs are being applied a bit prematurely by many clinicians and are touted as EBP when they have not even been validated (thus being poor ebp). However, I believe that the diagnostic CPRs can be more immediately valuable (compared to prescriptive ones) if one considers the face validity of the clusters that they are composed of, as well as the sample characteristics. For patients for whom a diagnosis is not clear after history and physical exam one would normally apply some special tests, hopefully using some that are sensitive and others that are specific to the pathology in question. If one is using a group of special tests, then considering a cluster such as that developed by Park et al for SAI could add additional information. The same goes for Laslett et al for SIJ pain. The trouble arises from taking invalidated CPRs as gospel rather than utilizing them in appropriate situations to inform clinical decisions. I believe judicious use can be beneficial.
    Here is an example: prior to learning about the CPR for cervical myelopathy, I performed the Hoffman’s or Babinski and myotatic reflexes to screen for central pathology. Performing the CPR for screening is arguably more sensitive than those individual tests that lack diagnostic accuracy. I think applying the CPR to screen is improving my practice, if I maintain the understanding that it has not been validated. The CPRs thus are treated more as sets of signs and special tests and less as prediction rules or “decision rules”. I also believe that those that are validated, such as the Ottawa ankle rule, can be useful for direct access and all PTs should know these.

    Sami Sivén April 29, 2014 9:21 am Reply
    • Thanks for this comment. I think the same. CPR are for me only one of the numerous instruments to make a decision. Althought they aren’t validated I think it’s necessary but not indispensable for a good use. CPR can be a bridge from the old protocol rehabilitation and the ultra-specific patient condition (when we have to fight with the lack of the time in the first visit!). Important are the validation studies and important are new CPR

      Denis Pennella May 25, 2014 1:17 pm

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