Monday, May 21, 2007

In the clinic, on the the web, and at professional meetings, I come across PT's all the time who decry Clinical Prediction Rules (CPR's) as 'cookie cutter PT'. This sentiment seems to come from a varied number of reasons. From fear of change, a feeling that their clinical practice is being dictated to them, and a lack of understanding/ignorance. So, what are clinical prediction rules?

John Childs and Josh Cleland wrote an excellent essay in the January 2006 PT Journal that inspired this blog entry. Their message is that CPR's can:

  • Improve decision making in the PT practice.
  • Provide PTs with diagnostic information gleaned from the H&P the can serve as an accurate predictor calling for more expansive diagnostic testing.
  • Assist with subgrouping patients into more specific classifications that allow for better choices for treatment strategies.
  • Assist in determining when a particular treatment may not be beneficial.
No where does this article indicate patients are treated with a set protocol with no variation or therapist input. That's how I understand "cookie cutter" to be. It does, however, indicate there are specific interventions that need to be included or specific actions that must be completed if a patient is positive for a CPR.

The end goal for CPRs is to help us change our behavior by using treatments and diagnostics most highly supported by the literature. Unfortunately, changing practice patterns is a difficult task for many of us due to comfort, fear of change, or no desire to improve ones practice.


Anonymous said...

I agree, Jason. CPR offers practitioners increased probabilities of increasing patient outcomes or making the most appropriate and timely referral.

I think that as we gain increased clinical experience, however, the knowledged gain will temper somewhat the validity of CPR's, however to dismiss them outright by using the cookie cutter analogy is fallacious, IMHO.


Jason L. Harris, PT, DPT said...

Thanks for the comments Marc. I disagree that somehow our singular personal knowledge can make a CPR invalid. Or, in your words, "temper somewhat the validity".

I'm sure you are aware of the Ottawa ankle rules for deciding on the need for imaging on an injured ankle. Being a first year MD (DC, PA, etc) vs. one that has been practicing for 20 years has no bearing on the validity of this CPR.

That's the point of a CPR. It enhances clinical decision making throughout all settings and practice experience.

Anonymous said...

Hi Jason,

I'll clarify my comment a bit by saying that in order for CPR's to be completely valid, patients who present to our clinics need to have identical variables as the subjects used in the study. Indeed, they rarely do. Clinical experience goes a long way, and if we rely solely on evidence then a lot of common medical and therapeutic procedures wouldn't be used today.

That being said, as a new graduate I rely a lot on CPR's and evidence because my clinical experience is limited. However, after 10-15-20 years, you can start to mesh your experience and observations with the literature (or so I've been told by various health care professionals!).

Anyways, I won't disagree re: the Ottawa Ankle rules I used them this week and sure enough, a fracture! I was mainly suggesting that patients don't fit nicely into the subjects used in CPR's and a lot of CPR's have yet to stand the test of time, like the Ottawa Ankle Rules. Not they're rendered invalid, but sometimes other factors come into play.

Very best,

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