Should We Follow the ‘Rules’?

Posted on in Clinical, News
Should We Follow the ‘Rules’?

Clinical prediction rules are a helpful tool to help guide clinicians when managing the care of patients.  The key word is ‘guide’.

I find it difficult to place a specific patient into a clinical prediction tool that completely matches the criteria.  There is too much variability between individuals and every present symptom differently not only regarding current symptoms at the clinic, but their functional mobility during everyday tasks.  Also, patients respond differently to various interventions so it can complicate the decision-making process when determining a plan of care. 

There are many flaws that are inconsistent with methodological standards.1 Case-control design, differential verification, and inadequate sample size should be considered on the side of caution when evaluating these validation studies; case-control design was associated with the greatest overestimation of predictive performance. 1 Childs et al2 indicates how clinical prediction rules can influence not only the clinical decision making of physical therapists, but how it can influence other factors including health care costs and efficiency.  These guidelines can help direct our treatment approach, however, may involve more than one clinical prediction rule.

I find that patients tend to fall into multiple clinical prediction rules/classification systems. 

For example, a patient with low back pain can fit the clinical prediction rules for spinal manipulation and a stabilization program. 2 I found it interesting to read the 3-step process in developing clinical prediction rules and how they are validated with multiple steps involved.  There currently is only one clinical predication rule that is validated for spinal manipulation.4 Stanton et al4 indicated that researchers have been developing new rules, however, are not validating the old ones.

There are many components to consider as we continue to treat our patients utilizing the information from clinical prediction rules.  Clinical prediction rules may be useful in addition to diagnostic imaging, subjective information, among other variables regarding diagnostic and treatment guidelines.  Clinical prediction rules may provide support to our clinical judgement.3 However, we still need further research.  

Take home message…use CPRs as a ‘guide’ for your clinical decision making.

Article Written By Eric Trauber, PT, DPT, OCS, CSCS, FAAOMPT


  1. Ban J-W, Emparanza JI, Uretta I, Burls A. Design characteristics influenceperformance of clinical prediction rules in validation: a meta-epidemiological study. PLOS One. January 5th, 2016.
  2. Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther. 2006;86(1):122-131.
  3. Sanders S, Doust J, and Glasziou P. (2015). A systematic review of studies comparing diagnostic clinical prediction rules with clinical judgement. PLOS One. 1-25.
  4. Stanton T, Hancock MJ, Maher CG, and Koes BW. (2010). Critical appraisal of clinical prediction rules that aim t optimize treatment selection for musculoskeletal conditions. Physical Therapy, 90(6): 843-854.