Purpose: Identify patients with low back pain who likely will improve with spinal manipulation.

Stage of CPR Development: Validated (Childs et al., 2004); Invalidated (Hancock et al., 2008)

Rule:

1. Duration of symptoms < 16 days
2. At least one hip with > 35° of internal rotation
3. Lumbar hypomobility
4. No symptoms distal to the knee
5. FABQ-W score < 19

Derivation Study (Flynn et al., 2002):

Variables Sensitivity Specificity +LR Prob of Success
1 1.00 0.03 1.03 46%
2 1.00 0.15 1.18 49%
3 0.94 0.64 2.61 68%
4 0.63 0.97 24.38 95%
5 0.19 1.00 100%

Validation Study (Childs et al., 2004):

Group Disability (p-Value)
One Week Manipulation vs Exercise < 0.001
Manipulation (+CPR) vs Manipulation (-CPR) < 0.001
Manipulation (+CPR) vs Exercise (+CPR) < 0.001
Exercise (+CPR) vs Exercise (-CPR) > 0.2
Four Weeks Manipulation vs Exercise 0.006
Manipulation (+CPR) vs Manipulation (-CPR) < 0.001
Manipulation (+CPR) vs Exercise (+CPR) 0.003
Exercise (+CPR) vs Exercise (-CPR) 0.127
Six Months Manipulation vs Exercise 0.001
Manipulation (+CPR) vs Manipulation (-CPR) 0.014
Manipulation (+CPR) vs Exercise (+CPR) 0.008
Exercise (+CPR) vs Exercise (-CPR) 0.112
Variables +LR -LR NNT (1 week) NNT (4 weeks)
3 13.2 0.1 1.3 1.9

Validation Study (Hancock et al., 2008):

Group Pain Scale (p-Value) Disability (p-Value)
One Week Manipulation 0.976 0.102
Status on CPR 0.077 0.069
Manipulation X CPR Status 0.578 0.205
Two Weeks Manipulation 0.306 0.014
Status on CPR 0.015 0.033
Manipulation X CPR Status 0.843 0.091
Four Weeks Manipulation 0.754 0.103
Status on CPR 0.103 0.057
Manipulation X CPR Status 0.645 0.366
Twelve Weeks Manipulation 0.592 0.066
Status on CPR 0.303 0.015
Manipulation X CPR Status 0.919 0.062

Supine vs Side-lying vs Non-Thrust Manipulation (Cleland et al., 2009):

Group Pain Scale (Mean Diff) Disability (Mean Diff)
One Week Supine Thrust vs Side-lying Thrust 0.61 3.51
Supine Thrust vs Non-thrust 2.07 11.45
Side-lying Thrust vs Non-thrust 1.46 7.94
Four Weeks Supine Thrust vs Side-lying Thrust 0.47 1.50
Supine Thrust vs Non-thrust 1.79 14.23
Side-lying Thrust vs Non-thrust 1.32 12.73
Six Months Supine Thrust vs Side-lying Thrust 0.19 -0.85
Supine Thrust vs Non-thrust 0.58 5.97
Side-lying Thrust vs Non-thrust 0.39 6.81

Manipulation vs Mechanical Diagnosis and Therapy (Schenk et al., 2013):

Between Group Changes Manipulation (CPR+) MDT (CPR+) p-Value
Disability (Mean Change) 11.13 14.56 0.31
Pain Score (Mean Change) 9.56 15.25 0.08
50% Reduction in Disability 2/8 10/18 0.155

Manipulation vs Non-Thrust Manipulation (Learman et al., 2014):

Between Group Changes p-Value
Disability 0.55
Pain Score 0.55
Patient Perception of Recovery 0.98
50% Reduction in Disability 0.98

CPR Selected vs Therapist Selected Non-Thrust Manipulation (Donaldson et al., 2016):

Timeframe Disability (Mean Diff) Disability (p-Value) Pain Score (Mean Diff) Pain Score (p-Value)
Visit Four 4.5 0.12 0.7 0.13
One Month 3.7 0.17 0.4 0.47
Six Months 1.7 0.55 0.4 0.85

Research:

1. Flynn T, 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): 2835-43.

2. Childs JD, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004; 141(12): 920-8.

3. Hancock MJ, et al. Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial. European spine journal. 2008; 17(7): 936-943. doi:10.1007/s00586-008-0679-9.

4. Cleland JA, et al. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine. 2009; 34(25): 2720-2729. doi:10.1097/BRS.0b013e3181b48809.

5. Schenk R, et al. Effectiveness of mechanical diagnosis and therapy in patients with back pain who meet a clinical prediction rule for spinal manipulation. The Journal of manual & manipulative therapy. 2013; 20(1): 43-49. doi:10.1179/2042618611Y.0000000017.

6. Learman K, et al. No Differences in Outcomes in People with Low Back Pain Who Met the Clinical Prediction Rule for Lumbar Spine Manipulation When a Pragmatic Non-thrust Manipulation Was Used as the Comparator. Physiotherapy Canada. Physiotherapie Canada. 2015; 66(4): 359-366. doi:10.3138/ptc.2013-49.

7. Donaldson M, et al. A Prescriptively Selected Non-Thrust Manipulation Versus a Therapist Selected Non-Thrust Manipulation for Treatment of Individuals With Low Back Pain: A Randomized Clinical Trial. Journal of Orthopaedic and Sports Physical Therapy. 2016; 46(4): 1-29. doi:10.2519/jospt.2016.6318.

Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial

One comment

  1. The Hancock study “Invalidating” the original CPR is deceptive, They did not provide a HVLAT to every one of the SMT patient’s, instead relied on the physical therapist’s application of a different algorithm.

    “Patients received SMT according to a treatment algorithm (Appendix 1) developed by the researchers based on the views of expert clinicians and researchers in the field [12, 18, 21]. The algorithm permitted the use of low and/or high velocity procedures that aimed to produce motion at the joints of the lumbar spine, thoracic spine, sacroiliac joint, pelvis and hip, and involved forces generated by the therapist. Consistent with contemporary clinical practice, the therapist adjusted the treatment to the clinical presentation [17, 21, 26, 29] of the patient rather than applying the same treatment to all patients. A review of patient records revealed that most participants received a variety of low velocity techniques (97%) with a small proportion also receiving high velocity thrust techniques (5%).”

    How can they claim to invalidate a CPR when they do not provide the same treatment as the original CPR?

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