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

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