Evidence Based Physical Therapy

Clinical Prediction Rules: The Newest Flavor in Physical Therapy Research

Michael Rinaldi, PT, OCS

Another study purporting a possibly useful clinical prediction rule (CPR) appeared in this month's JOSPT. This article examined the variables which would most likely identify a sub-grouping of patients who would benefit from a single session of lumbar manipulation to improve symptoms of patello-femoral pain symptoms (PFPS).

This is another in a seemingly regular stream of studies on the utility of CPRs which have made their way into our professional journals in the past two years. We've seen them as they relate to neck and back pain, as well as on patellofemoral taping. The overall thrust of CPRs is to help aid in the rapid and accurate identification of sub-groups of patients who would benefit from a particular treatment by identifying variables that preclude them to being sub-grouped as such.

Used in cardiology for some time, CPRs can help the clinician arrive at a starting point for delivering seemingly useful and appropriate treatment.

But therein lies a pitfall.

Few (if any) of the PT CPR studies published have assessed meaningful long term outcomes of their patients. Long term in one study may be defined as six months or a year. But in reality, to paying beneficiaries and some clinical specialists long term often means permanent. Cancer patients, for example, aren't generally considered clear unless they've been clear on lab/diagnostics routinely for five years in some cases.

Few patients have the desire to experience recurrence time and again, and given the well-documented recurrence rates of back and neck pain, this is a point that any of the CPR studies have yet to address.

Another downfall is that few of the CPR studies give insight into managing a patient throughout a full, corrective plan of care. The most recent studies look only at how certain homogeneous sub-groups of patients respond to one or two interventions once indentified appropriately. Clinically, this is near meaningless as the percentage of patients who recover satisfactorily in one or two visits for any musculoskeletal problem is very, very low.

Most patients who use PT services, do so upon referral from a physician, and often times, are weeks or months into the progression of the affliction. Therefore, it appears as though application of the CPR will only work on certain sub-groups of patients.

But... let's not throw the baby out with the bath water.

Next page, please.

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