I've seen the phenomenon of improving neck pain and ROM by manipulating the thoracic spine and the abatement of knee pain by manipulating or modulating the lumbar spine well before Cleland, Wainner, Iverson, Childs and co. started reporting on it. DiMaggio has seen the same for decades, as have others. This is certainly not a new phenomenon.

A panacea, they are not, as I'm sure most people involved with clincial research would agree. They have their limitations in applicabililty. For instance, a few of the CPR studies recruit subjects/patients from military bases. This is obviously a convenience (if not a sample of convenience, much like studying shoulder impingements in athletes at the college sponsoring a study). In the last eight years of private practice, I can count on two fingers the number of fit, motivated, trained, military employees who walked into my clinic suffering from back or knee pain. Both, incidentally, were still referred by physicians, months after their problems began.

Because of such samples, true applicability of a "rule" has to be questioned. Finding a patient in everyday practice homogenous to those in such a study is simply not feasible. In the Midwest, my typical patient is white, over 55 and female, more likely to be on an anti-hypertensive, hyperlipidemia or cholesterol-lowering drug, and/or anti-depressant medication. I don't see many college overhead athletes or military personnel because I don't work at those facilities.

It's because of the lack of true universality and (current of June 2008) lack of randomized trials, that I feel CPRs should more appropriately called "clinical prediction proposals", unless use of the CPR is restricted to a narrow psycho-geo-demographically defined subject/patient.

But what CPRs do give us is:

• a method to begin looking at the presence of reliable clinical features that can point to the potential generators of patient symptoms,
• a process to begin addressing problems of somatic dysfunction in an efficient & effective manner that is most likely directed at a generator of the symptom,
• a better understanding of the complexity of musculoskeletal problems by regional interdependencies,
• a sense of assuredness that we should be able to affect a patient's symptoms quickly and effectively,
• further substantiation of the value of PT in the health care continuum,  

I recently had a mid-thirties female referred to me with a three year history of bilateral knee pain. Former government worker, married to military person. Very fit lady and a recent mom. She got to the point where she needed to do something about her knees as she felt her kneecaps would "shatter" when getting up from the floor after playing with her child. What's interesting is that she does not fit the CPR in the PFPS study exactly, though she has components of them that are close.

What was her story?

Next page, to read on.

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