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
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”
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”
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”
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”