Talk:Clinical Prediction Rules

Peer Review by Erik Thomes May 23rd 2013[edit source]

Clinical prediction rules (CPRs) for treatment selection in musculoskeletal conditions have become increasingly popular. There is much debate with regards to their validity and clinical applicability and taking in to consideration results from contemporary research, we should caution clinicians in using them.[1][2][3] The results from the available data do not support the use of clinical prediction rules in the management of non-specific low back pain.[1] The current body of evidence does not enable confident direct clinical application of any of the identified CPRs.[2] There is, at present, little evidence that CPRs can be used to predict effects of treatment for musculoskeletal conditions. The principal problem is that most studies use designs that cannot differentiate between predictors of response to treatment and general predictors of outcome.[3] Currently only 1 CPR, the one classifying patients in a group likely to benefit from spinal manipulation, is at the validation stage of development within an RCT designed to predict response to treatment.[4][5][6][7] All other CPRs are still at a derivation level. Validation of these rules is imperative to allow clinical application.

For now, CPRs are in no way able to replace sound clinical reasoning. Assessment of patients should still rely on a continuous process of testing of (multiple) hypotheses through history taking, physical examination using validated clinimetrical instruments and outcome measures incorporated in clinical expertise.[8][9][10]  The P.I.T. demonstrated in this article is sometimes unjustly used as a specific test to include a potential “instability”; clearly that is not it’s function. It should only be used within the specified CPR.
Last but not least, using CPRs clinician tend to classify patients into just one group, where it is highly unlikely that one would treat patients with low back pain with just one single intervention (manipulation). It is more likely that patients will benefit from multimodal therapy incorporating a combination of interventions. A regime of manual therapy and exercise has been shown to be the more effective treatment in many spinal musculoskeletal problems, such as cervicogenic headache, radiculopathy, hip, ankle and shoulder problems.[11][12][13][14][15][16] 

So perhaps using a CPR as “hindsight”, to underpin the hypothesis derived after a sound clinical reasoning process, is a better clinical way forward.

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