CPR…not that kind

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.



  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).



  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%



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



  1. Follow-up validation studies are needed.

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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