Clinical Prediction Rules

In the PT world, those of us that follow the research like to quiz students on Clinical Prediction Rules, because these have become all of the rage in the Evidenced Based Practice world.  Unfortunately, few CPR’s have been validated through repeated testing and those that have are still being assessed in order to determine if the CPR actually changes the way that PT’s practice.  In my opinion the answer is no to this basic question. When we look at the clinical practice guidelines, it clearly states that manipulations are a tool to be used for patients with low back pain.

It would be great if all PT’s, in the outpatient setting were familiar and comfortable with performing grade V mobilizations (otherwise known as manipulations in the research).  This is an entirely different subject to begin with, but we should also go there.

Each profession owns certain terminology, and this varies by state.  For example, in the state of Illinois, chiropractors own the term manipulation, but therapists can use the term grade V thrust mobilization.  The end outcome is the same procedure, but we can get in trouble for performing interventions outside of our practice act if we call it by the wrong name.

Moving on to a gripe with the American Physical Therapy Association.  Many PTA’s are taught that they are not allowed to manipulate a patient.  The rationale for this is that when PT’s (Doctors of Physical Therapy) graduate from an accredited program, that the newly graduated PT is now considered an expert at performing the manipulations;whereas the PTA, because the topic wasn’t taught in school, is not an expert and therefore should not be performing the maneuver.  The problem with this rationale is that the APTA is greatly overestimating students’ ability upon graduating from a PT program.  Working closely with many students over the years, I have only had up to 3 students that were able to walk into the clinic on day one and perform manipulations without any cues.  This is up to 3 of 50 in total.  This is not a high percentage of students that are “experts”.  I would have to teach a PTA student in the same fashion that I teach a DPT student.  The maneuver didn’t change because the person’s title is different.  No where does it legally state that a PTA is not allowed to perform a manipulation.  I have worked with PTA’s that quickly grasp the concept and the mechanics of a grade V thrust mobilization and on the same note I have worked with many DPT’s that I wouldn’t want to perform this maneuver on a cadaver because the newly graduated DPT may get hurt.  That’s my axe to grind for the night.

Here’s my article for the night.  Not as exciting as above.

Beneciuk JM, Bishop MD, George SZ. Clinical Prediction Rules for Physical Therapy Interventions: A systematic review. Phys Ther. 2009;89:114-124.

 

INTRODUCTION:

1. The purpose of the review was to determine the quality of CPR’s developled for interventions used by PT’s.
2. included if the explicit purpose was to develop a CPR related to a specific

intervention approach for conditions commonly treated in PT.

1. excluded if already validated (VG: This brings up a point: would the

previously validated CPR (manip LS) be approved based on the

criteria established in this article (topic for a later debate seeing that

the authors ask readers to examine the Type IV CPR prior to

attempting utilization).

 

METHODS:

1. 18 criteria used to assess quality in the SR covering 8 qualities
2. study population
3. response information
4. follow-up
5. intervention
6. outcome
7. masking
8. prognostic factors
9. data presentation
10. high score of 18/18 correlates with high quality
11. taken from average of 3 reviewers per article.
12. high quality is >60%
13. 8 studies remained after the initial compilation of 25

 

methodological criteria

1. items rated
2. inception cohort
3. inclusion/exclusion criteria
4. Study Population
5. Nonresponders vs. responders
6. Prospective data collection
7. Follow-up at >= 6 months
8. Dropouts/loss to follow-up of <20%
9. Inforation on subjects completing study vs. loss to follow-up/dropouts
10. Intervention fully described/standardized
11. Standardized assessment of relevant outcome criteria
12. Masking of outcome assessor and treating clinician
13. Standardized assessment of subject characteristics and potential clinical

prognostic factors.

1. Standardized assessment of position psychosocial prognostic factors
2. Frequencies of most important outcome measures
3. Frequencieis of most improtan outcome measures
4. Appropriate analysis techniques
5. Prognostic model presented
6. Sufficient numbers of subjects
7. Five studies >60% (good quality), 4 rated 50-60%, 1 rated <50%

 

DISCUSSION

1. Quality of derivation studies has never been assessed.
2. Only 40% of the studies had adequate sample size.

 

CONCLUSION:

1. Follow-up validation studies are needed.