HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Rapid Responses to:

Research Reports: Jason M Beneciuk, Mark D Bishop, and Steven Z George Clinical Prediction Rules for Physical Therapy Interventions: A Systematic Review PHYS THER 2009; 89: 114-124 [Abstract] [Full text] [PDF]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Author Response

Steven Z George, Jason M Beneciuk, and Mark D Bishop   (17 February 2009)

On “Clinical Prediction Rules for Physical Therapy Interventions…” Beneciuk JM, et al. Phys Ther. 20

Tasha R Stanton, Chris G Maher, and Mark Hancock   (3 February 2009)

Author Response 17 February 2009
Steven Z George, Assistant Professor Department of Physical Therapy, University of Florida, Gainesville, FL., Jason M Beneciuk, and Mark D Bishop Send rapid response to journal: Re: Author Response szgeorge{at}phhp.ufl.edu Steven Z George, et al.	We would like to thank Stanton et al1 for taking time to provide feedback on our recent publication in Physical Therapy.2 We also would like to thank the editor for giving us an opportunity to respond to their comments. The purpose of our systematic review was to provide quality ratings for physical therapy-specific clinical prediction rule (CPR) derivation studies. It was our suspicion that CPR derivation studies reported in the physical therapy literature frequently used cohort/prognostic study designs. This suspicion was confirmed because 9 out of the 10 retrieved studies used cohort/prognostic designs. Therefore, we believe our “yardstick” was quite consistent with our original intent. It may become necessary to implement other quality assessment criteria as physical therapy CPR evolves to include other methods, but the current tool was appropriate for the studies included in the review.3 Stanton et al1 selected a sentence from our article to indicate that we encouraged clinical use of CPRs prior to validation. Missing from their response letter were parts of the article in which we indicated the role of validation studies (“…quality scores are not a substitute for CPR validation studies.”2[p119]). Furthermore, we presented a balanced consideration of clinical application of derivation CPRs (“…our findings should not be viewed as definitive. Our data provide complementary information on which CPRs to use in clinical practice, but the ultimate decision must be made in the context of a clinician’s experience and factors specific to the encounter with a patient.”2[p120]). We agree with Stanton et al1 that practice recommendations ideally should be based on validation studies. However, there are practical limitations of such an approach, because very few validation studies have been reported in the physical therapy literature. The approach to clinical application described in our review is consistent with current models of evidence-based practice and previous discussion of derivation studies (“…clinicians can still extract clinically relevant messages from an article describing the development of a clinical decision rule.”4[p81]). That is, clinical practice can be guided by lower levels of evidence when appropriate, especially when higher levels are not available. Clinicians are the final arbiter of whether a given CPR is applied, and the data from our review may be used to assist with that decision—along with the risk-benefit ratio and other important contextual factors from the clinical encounter. Our systematic review used an appropriate search and quality assessment tool to conclude that the majority of physical therapy-specific CPR derivation studies have not been validated and that their quality varied greatly. Our review was the first to empirically consider this important issue, but similar concerns regarding methods of CPR derivation studies have been featured in recent editorials.5,6 We are hopeful that continued dialog on this topic will encourage physical therapists to design rigorous derivation studies and include an a priori plan for timely validation. Steven Z George, PT, PhD, is Assistant Professor, Department of Physical Therapy, Brooks Center for Rehabilitation Studies, Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL 32610-0154 (USA). Jason M Beneciuk, PT, DPT, FAAOMPT, is currently enrolled in the Rehabilitation Sciences Doctoral Program, Department of Physical Therapy, University of Florida. Mark D Bishop, PT, PhD, is Assistant Professor, Department of Physical Therapy, University of Florida. References 1. Stanton TR, Maher CG, Hancock M. On “Clinical prediction rules for physical therapy interventions…” [Rapid Response]. Phys Ther. Available at: http://www.ptjournal.org/cgi/eletters. Published February 3, 2009. 2. Beneciuk JM, Bishop MD, George SZ. Clinical prediction rules for physical therapy interventions: a systematic review. Phys Ther. 2009;89:114–124. 3. Kuijpers T, van der Windt DA, van der Heijden GJ, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004;109:420–431. 4. McGinn TG, Guyatt GH, Wyer PC, et al. Users’ guides to the medical literature, XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. JAMA. 2000;284:79–84. 5. Simoneau GG. Making use of published guidelines to assist with study design and research. J Orthop Sports Phys Ther. 2008;38:658–660. 6. Cook CE. Potential pitfalls of clinical prediction rules. J Man Manip Ther. 2008;16:69–71.
On “Clinical Prediction Rules for Physical Therapy Interventions…” Beneciuk JM, et al. Phys Ther. 20 3 February 2009
Tasha R Stanton, PhD Candidate Musculoskeletal Division, The George Institute for International Health, The University of Sydney, Chris G Maher, and Mark Hancock Send rapid response to journal: Re: On “Clinical Prediction Rules for Physical Therapy Interventions…” Beneciuk JM, et al. Phys Ther. 20 tstanton{at}george.org.au Tasha R Stanton, et al.	We would like to commend the authors for undertaking a systematic review on this topic,1 but we have serious reservations about their methods and conclusions. Clinical prediction or decision rules (CPRs) can be used to make a diagnosis, predict disease progression, predict prognosis, or select therapy. In this study,1 the authors reviewed CPRs developed to select therapy but then evaluated the quality of these CPRs using quality criteria designed for prognosis studies. This is unfortunate because the optimal design and analysis strategies for a prognosis study are not the same as for a therapy study. For example, randomization and concealed allocation are regarded as important design features of studies evaluating therapy but are not relevant in a prognosis study because there is no control group. Accordingly, the authors’ comments about the methodological quality of the studies they have reviewed are in doubt because they have used the wrong yardstick to judge quality. We also are concerned that the authors encourage the use of CPRs before their value has been clearly established. They confined their review to CPRs that were still in the derivation stage but then concluded that “several CPRs may be appropriate for clinical applications involving patients and clinical environments similar to those used in the CPR derivation process.”1(p118) This recommendation ignores guidelines for CPR development that recommend a 3-step process: derivation (level of evidence: 4), validation (narrow–level of evidence: 3; broad–level of evidence: 2), and impact analysis (level of evidence: 1).2 It is recommended that a CPR only be applied after there is at least level 3 of evidence (narrow validation) and then only if the population being treated matches that of the population used to derive the CPR.2,3 We feel that CPRs for selecting therapy have the potential to greatly enhance physical therapy management but would caution that premature promotion of inadequately evaluated CPRs is quite unwise. McGinn and colleagues2 provide 3 reasons why CPRs that have been derived but not validated are not ready to be applied clinically. First, CPRs may reflect associations that are primarily due to chance; second, predictors may be specific to the setting of the study; and lastly, clinicians may fail to implement a CPR successfully in the clinical setting.2 In any case, suggesting to apply a derivation-stage CPR in a clinical setting promotes improper use of research findings. Our patients deserve a more rigorous approach to physical therapist practice. TR Stanton, MScRS, is PhD Candidate, Musculoskeletal Division, The George Institute for International Health, The University of Sydney, Level 7, 341 George St, Sydney, New South Wales 2000, Australia. Chris G Maher, PhD, The George Institute for International Health, The University of Sydney. M Hancock, PhD, Back Pain Research Group, Discipline of Physiotherapy, The University of Sydney. References 1. Beneciuk JM, Bishop MD, George SZ. Clinical prediction rules for physical therapy interventions: a systematic review. Phys Ther. 2009;89:114–124. 2. McGinn TG, Guyatt GH, Wyer PC, et al. Users’ guides to the medical literature, XXII: how to use articles about clinical decision rules [reprinted]. JAMA. 2000;284:79–84. 3. Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther. 2006;86:122–131.