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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients


 
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5 Systematic Reviews Refute the Clinical Applicability of CPRs

March 05, 2015

RESEARCH COMMENTARY

Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

The Following commentary includes some information previously presented in our March 1, 2012 commentary

5 Systematic Reviews Refute the Clinical Applicability of CPRs

Clinical Prediction Rules (CPRs) are clinical tools designed to assist clinicians in decision making regarding individual patients based upon a combination of components including the history, physical examination, and other factors that allow the clinician to make predictions regarding a patient’s diagnosis, prognosis, or likely response to a particular intervention. (Beattie 2006)

CPRs have been widely discussed in the literature in recent years. Advocates call for their widespread clinical adoption and further suggest incorporating them into clinical practice guidelines (CPGs). Others argue that the CPRs are emerging tools that frequently lack validation and impact analysis studies. Thus the CPRs may prove to be useful as a single component of overall assessment and clinical decision making, but are not yet robust enough to be relied upon in clinical practice.


CPRs were debated at the APTA National conference in 2011 at a “standing room only” Oxford debate. 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:

http://www.apta.org/AnnualConference/2011/OxfordDebate/


Important Background Information (Toll 2008, Haskins 2015)

CPRs must go through 3 specific phases of development to be considered robust:

  1. Derivation

    In this phase the CPR is derived using various multivariable statistical procedures to identify which components of a patient’s condition are independently related to a certain diagnosis or outcome.

  2. Validation

    The derived CPR undergoes a process of validation where it is applied to new groups of patients, in different settings, to evaluate the CPRs ability to accurately predict the same diagnosis or outcome found in the derivation phase.

  3. Impact Analysis

    Following validation, the CPR undergoes impact analysis by which the CPR is tested to determine whether the clinical application of the CPR leads to improved patient outcomes or efficiencies in resource consumption


One of the problems with the CPRs is that many suffer significant design flaws and few have been adequately validated or undergone impact analysis. 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.

 

To date, there are FIVE Systematic Reviews (SRs) that raise serious concerns regarding the clinical utility of CPRs. These SRs, demand that we consider the CPRs with healthy skepticism, and understand that they are not yet ready for integration into clinical practice or clinical guidelines.

 

The most recent SR to study this topic is “Diagnostic Clinical Prediction Rules for Specific Subtypes of Low Back Pain: A Systematic Review” (Haskins 2015).  This study screened 10,014 studies, identified 13 CPR studies, and then evaluated them using the Quality Assessment of Diagnostic Accuracy Studies-2 (QADAS) rating scale (Whiting 2011).  Haskins 2015 results and conclusions are as follows:


RESULTS:

  • 13 diagnostic CPRs have been derived for diagnosing LBP.
  • ONLY 3 CPRs have undergone the validation phase:

1 for identifying lumbar spinal stenosis

2 for identifying inflammatory back pain 

  • NO studies have undergone the impact analysis phase


CONCLUSIONS:

  • “Most diagnostic CPRs for LBP are in their initial development phase and cannot be recommended for use in clinical practice at this time.
  • “Validation and impact analysis of the diagnostic CPRs are warranted, particularly for those tools that meet an identified unmet need of clinicians who manage patients with LBP.”

 

FOUR more SRs ALSO refute the clinical applicability of CPRs for various conditions, and interventions.  

“Clinical prediction rules in the physiotherapy management of low back pain: A systematic review” (Haskins 2012)

  • 23 included CPR studies
  • “Current body of evidence does not enable confident direct clinical application of any of the CPRs.”

“Critical appraisal of clinical prediction rules that aim to optimize treatment selection for musculoskeletal conditions.” (Stanton 2010)

  • 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”

“Prescriptive clinical prediction rules in back pain research: a systematic review” (May 2009)

  • 16 included CPR studies
  • “Most [CPRs] need further evaluation before they can be applied clinically…most did not pass the lowest level of evidence hierarchy.”
  • “Manipulation CPR, 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.”

 

“Clinical prediction rules for physical therapy interventions: a systematic review.” (Beneciuk 2009)

  • 10 included CPR studies
  • “[CPR Studies] were poor to moderate quality, BUT most lacked validation studies”



Cheers and Enjoy

Chris R. Showalter PT, OCS, COMT, FAAOMPT

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars


Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website (www.ozpt.com) is permissible.


Summary of the Haskins 2015 article:

http://www.jospt.org/doi/abs/10.2519/jospt.2015.5723#.VPX92C71KJ8


Diagnostic Clinical Prediction Rules for Specific Subtypes of Low Back Pain: A Systematic Review

Haskins, R, Osmotherly P, and Rivett D


Abstract

Objectives To identify diagnostic clinical prediction rules (CPRs) for low back pain (LBP) and to assess their readiness for clinical application.

Background Significant research has been invested into the development of CPRs that may assist in the meaningful subgrouping of patients with LBP. To date, very little is known about diagnostic forms of CPRs for LBP, which relate to the present status or classification of an individual, and whether they have been developed sufficiently to enable their application in clinical practice.

Methods A sensitive electronic search strategy using 7 databases was combined with hand searching and citation tracking to identify eligible studies. Two independent reviewers identified relevant studies for inclusion using a 2-stage selection process. The quality appraisal of included studies was conducted by 2 independent raters using the Quality Assessment of Diagnostic Accuracy Studies-2 and checklists composed of accepted methodological standards for the development of CPRs.

Results Of 10,014 studies screened for eligibility, the search identified that 13 diagnostic CPRs for LBP have been derived. Among those, 1 tool for identifying lumbar spinal stenosis and 2 tools for identifying inflammatory back pain have undergone validation. No impact analysis studies were identified.

Conclusion Most diagnostic CPRs for LBP are in their initial development phase and cannot be recommended for use in clinical practice at this time. Validation and impact analysis of the diagnostic CPRs identified in this review are warranted, particularly for those tools that meet an identified unmet need of clinicians who manage patients with LBP.


Where to find the Articles


1. http://www.ncbi.nlm.nih.gov/pubmed/16942450 Beattie P and Nelson R, Clinical prediction rules: what are they and what do they tell us?  Aust J Physiother. 2006;52(3):157-63.

2. http://www.ncbi.nlm.nih.gov/pubmed/22007046 Toll DB, Janssen KJ, Vergouwe Y, Moons KG. Validation, updating and impact of clinical prediction rules: a review. J Clin Epidemiol. 2008 Nov;61(11):1085-94.

3. http://www.ncbi.nlm.nih.gov/pubmed/22007046 Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM; QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011 Oct 18;155(8):529-36.

4. http://www.ncbi.nlm.nih.gov/pubmed/20413577 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

5. http://www.ncbi.nlm.nih.gov/pubmed/20413577 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”

      

6. http://www.ncbi.nlm.nih.gov/pubmed/20046564 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”

      

7. http://www.ncbi.nlm.nih.gov/pubmed/19095806 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”

     


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