RRS Education Research Reviews DATABASE

Research Review By Joseph Brence©

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Date Posted:

January 2014

Study Title:

Does the use of a prescriptive clinical prediction rule increase the likelihood of applying inappropriate treatments? A survey using clinical vignettes

Authors:

Learman K, Showalter C, Cook C

Author's Affiliations:

Department of Physical Therapy, Youngstown State University, Youngstown, OH; Maitland Australian Physiotherapy Seminars, Cutchogue, NY; Division of Physical Therapy, Walsh University, North Canton, OH.

Publication Information:

Manual Therapy 2012; 17: 538-543.

Background Information:

Clinical Prediction Rules (CPRs) have garnered a significant amount of publicity and research interest over the past decade. In essence, CPRs are algorithmic decision tools, which aid clinicians in their decision making (1). These rules can either assist in the development of a diagnosis, prognosis or the prescribing of treatment (2). In 2002, Flynn et al. developed one of the most commonly used prescriptive CPRs in the practice of manual therapy – aiming to inform clinicians when to use spinal manipulation in acute low back pain patients (3). This CPR included: duration of symptoms < 16 days, at least one hip internal rotation > 35 degrees, hypomobility of at least one lumbar segment with spring testing, FABQ < 19, and no symptoms distal to the knee. When four out of these 5 predictors were present, a mean reduction of 73% on the Oswestry was noted in acute LBP patients receiving spinal manipulation. (EDITOR’S NOTE: we have reviewed much of this literature on RRS – please refer to the Lumbar Spine – Clinical Prediction Rule section of the RRS Education Research Reviews Database)

Since the inception of the concept of CPRs, there has been concern over the quality of research performed to assess and develop them, as well as their true clinical utility and impact on healthcare visits, patient outcomes and costs. In 2003, the Flynn et al. CPR mentioned above did go through a validation phase (4), however some have expressed concern that a prescriptive rule such as this one undermines the ability of a practitioner to clinically reason. To date, there have been no studies assessing potential adverse events that may arise from the application of this CPR, or any qualitative studies to assess the influence of this CPR on clinical decision making. These were the goals of this project, with data collected from a survey of practicing clinicians.

Pertinent Results:

Study Population:
  • 535 Physiotherapists in the United States, who use spinal manipulative therapy (SMT) participated in this study. These participants were separated into two groups: those who utilize the lumbar CPR clinically (n = 171), and those who do not (n = 254).
  • Each participant completed a 9-step clinical vignette which progressed through a fictitious patient scenario.
  • A 2 x 9 chi-square was used to analyze the progression of clinical decision-making.
Clinical Vignette (also in Study Methods):
  1. A 58 year-old retired businessman presents to your clinic with LBP of 12 days duration. He is highly motivated to get well, is of average build, height and weight. He is well tanned and seemingly fit. He exhibits 4/5 lumbar spine manipulation CPR variables (FABQ score was not evaluated).
  2. He tells you he is an avid golfer and plays 7 or 8 full rounds each week. He stretches before and after every round.
  3. He tells you that his LBP is bilateral and located above his iliac crests, and he says he has been having difficulty finding a comfortable position to sit, stand or lie down.
  4. He tells you that he has tried changing his golf swing, his mattress, and the chair he likes to sit in, but none of these have helped in any way.
  5. He tells you that his pain is worse at night and he has difficulty getting to sleep. He awakes as many as 4 times each night and has difficulty falling back to sleep.
  6. He tells you that he takes 400 Mg Ibuprofen before going to bed but awakens within an hour of falling asleep. He takes more Ibuprofen each time he awakes but it doesn’t seem to have any effect. He describes his nights as “very restless and uncomfortable with constant pain throughout the night”.
  7. He tells you that his diet, eating and recreation habits have not changed; yet he has lost 12 pounds in the last month.
  8. He tells you that he has noticed a significant increase in recent months in the frequency of his urge to urinate, and yet when he attempts to void his bladder he feels that his stream is “weak” and he never feels that he has fully emptied his bladder.
  9. He tells you that he had a positive PSA test result about 1 month ago but has been too terrified to follow up with his urologist.
Clinician Survey Results:
  • In general, males (P < 0.01), and those who were APTA Board Certified (P = 0.04) used the lumbar CPR more than females (P < 0.01). Further, the number of SMT courses attended was also significant, with those attending more courses more likely to implement the lumbar CPR (P < 0.04).
  • Those following the McKenzie philosophy (P < 0.01) were less likely to use the lumbar CPR.
  • However, overall – credentialing (P = 0.16) and philosophical approach (P = 0.08) in general were not found to be significantly different between groups.
  • Participants who reported use of the lumbar CPR were more likely to choose to manipulate the subject in the two least complicated scenarios of the vignette (points 1 and 2 above), with P < 0.01 and P = 0.02 respectively.
  • For each of the other seven steps of the vignette, there were no statistically significant differences in the selection of manipulation between the two groups.

Clinical Application & Conclusions:

The authors of this study were able to assess the ability of clinicians who utilize SMT to clinically reason, through a fictitious patient scenario. They also compared the results of those who utilize the lumbar CPR to those who do not. In the early phases of this clinical scenario, the authors made it appear that a thrust manipulation would be beneficial based upon the information given. As more information was provided in later phases of the scenario, the treatment was considered to be contraindicated. Results indicated that participants in both groups were inclined to alter their clinical decision making as more information became available...overall this is good news!

The authors found that Physiotherapists who were male, had attended SMT courses and were board certified in Orthopedics were more likely to use the CPR for their clinical decision making. Alternatively, those who reported to utilize a “McKenzie” philosophy/treatment approach were less likely to follow the CPR when deciding whether or not to perform SMT (arguably, some in this group may not provide SMT very often at all?). Another interesting finding was that those who reported utilizing the lumbar CPR were more likely to provide early SMT. No reason for this could be gleaned from this data but this approach does fall within widely accepted clinical practice guidelines from around the world. Further research should continue to investigate the impact of CPRs on clinician behavior and patient outcomes.

Study Methods:

After reading and giving informed consent, participants were given a 26-question survey. This survey consisted of questions regarding practice, beliefs and demographics. The survey concluded with the following 9-phase clinical vignette which asked how likely they would be to manipulate the patient in the following scenario:
  1. A 58 year-old retired businessman presents to your clinic with LBP of 12 days duration. He is highly motivated to get well, is of average build, height and weight. He is well tanned and seemingly fit. He exhibits 4/5 lumbar spine manipulation CPR variables (FABQ score was not evaluated).
  2. He tells you he is an avid golfer and plays 7 or 8 full rounds each week. He stretches before and after every round.
  3. He tells you that his LBP is bilateral and located above his iliac crests, and he says he has been having difficulty finding a comfortable position to sit, stand or lie down.
  4. He tells you that he has tried changing his golf swing, his mattress, and the chair he likes to sit in, but none of these have helped in any way.
  5. He tells you that his pain is worse at night and he has difficulty getting to sleep. He awakes as many as 4 times each night and has difficulty falling back to sleep.
  6. He tells you that he takes 400 Mg Ibuprofen before going to bed but awakens within an hour of falling asleep. He takes more Ibuprofen each time he awakes but it doesn’t seem to have any effect. He describes his nights as “very restless and uncomfortable with constant pain throughout the night”.
  7. He tells you that his diet, eating and recreation habits have not changed; yet he has lost 12 Lbs. in the last month.
  8. He tells you that he has noticed a significant increase in recent months in the frequency of his urge to urinate, and yet when he attempts to void his bladder he feels that his stream is “weak” and he never feels that he has fully emptied his bladder.
  9. He tells you that he had a positive PSA test result about 1 month ago but has been too terrified to follow up with his urologist.

Study Strengths / Weaknesses:

Study Strengths:
  • The study was the first attempt to assess a clinician’s ability to clinically reason and alter prescriptive interventions, when following a CPR.
  • The study was able to extract data to assess who is more inclined to utilize the lumbar CPR.
  • The study was able assess the safety of CPR application
  • This was an inexpensive and valid method for evaluating the potential behavior of clinicians who utilize SMT.
Study Weaknesses:
  • This study was based on a “fictitious” scenario. It followed an obvious progressive nature of a medical complication, and in true clinical situations, the presentation may be a bit more vague.
  • It is impossible to blind participants in a study such as this.
  • The authors were able to determine IF clinical decision making changed, but failed to determine WHY it changed.

Additional References:

  1. Glynn P, Weisbach C. Clinical prediction rules: a physical therapy reference manual. Sudbury, MA: Jones and Bartlett; 2010. p. 2.
  2. Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in physical therapist practice. Physical Therapy 2006; 86(1):122-131.
  3. Flynn T, Fritz J, Whitman J et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002; 27(24): 2835-2843.
  4. Childs JD, Fritz JM, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Internal Med 2004; 141(12): 920-928.

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