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Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)

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4 Systematic Reviews Refute the Clinical Applicability of CPRs

March 01, 2012


Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

4 Systematic Reviews Refute the Clinical Applicability of CPRs

Clinical Prediction Rules (CPRs) have been widely discussed and advocated in the literature in recent years. Many CPRs offer thrust manipulation as the preferred manual therapy intervention. Advocates call for their widespread adoption as the epitome of Evidence Based Practice and further suggest incorporating them into clinical guidelines.

Others, including myself, argue that the CPRs are tools that may prove to be useful as a single component of Clinical Decision Making including the Assessment and Clinical Reasoning approach that is the cornerstone of the Maitland Concept.

CPRs were debated recently in a “standing room only� Oxford debate at the APTA Annual Conference in 2011. The debate was titled "CPR (Clinical Predication Rules): Dead or Alive?" The debate was scored overwhelmingly against the CPRs.

APTA Members can login and view a partial video (37 Min.) of the debate here:

The problem with the CPRs is that most suffer significant design flaws and have not been adequately validated. When validation studies have been performed they fail to include heterogeneous populations of patients, populations that are true to real life clinical practice. Thus, the CPRs may not be ready for adoption into clinical practice.

I prefer to think of the CPRs as newborn children. Their proud parents espouse their offspring’s many talents. Others recognize the innate potential for greatness, but reserve the right to bestow honors until they have had a chance to be validated and prove themselves as clinically useful.  

In short the CPRs may represent promise in the future…when properly validated AND shown to be applicable to real world patient populations.

To date there are 4 Systematic Reviews (SRs) that raise serious concerns regarding the clinical utility of the CPRs.

This Level 1 Evidence, demands that we consider the CPRs with healthy skepticism, and understand that they are not yet ready for integration into clinical practice or clinical guidelines.

Here is the PubMed Abstract from the most recent edition of the journal Manual Therapy.

Co-Author Darren Rivett discussed aspects of this article during his Keynote Address at MAPS Symposium in Chicago, IL October 21-23, 2011

I have detailed all 4 SRs for you below, including links to PubMed where you can view abstracts and full articles (where available).



Chris R Showalter

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website ( is permissible.

Summary of the Haskins article from PubMed:

Man Ther. 2012 Feb;17(1):9-21. Epub 2011 Jun 8.

Clinical prediction rules in the physiotherapy management of low back pain: a systematic review.

Haskins R, Rivett DA, Osmotherly PG.


School of Health Sciences, The University of Newcastle, NSW 2308, Australia.



To identify, appraise and determine the clinical readiness of diagnostic, prescriptive and prognostic Clinical Prediction Rules (CPRs) in the physiotherapy management of Low Back Pain (LBP).


MEDLINE, EMBASE, CINAHL, AMED and the Cochrane Database of Systematic Reviews were searched from 1990 to January 2010 using sensitive search strategies for identifying CPR and LBP studies. Citation tracking and hand-searching of relevant journals were used as supplemental strategies.


Two independent reviewers used a two-phase selection procedure to identify studies that explicitly aimed to develop one or more CPRs involving the physiotherapy management of LBP. Diagnostic, prescriptive and prognostic studies investigating CPRs at any stage of their development, derivation, validation, or impact-analysis, were considered for inclusion using a priori criteria. 7453 unique records were screened with 23 studies composing the final included sample.


Two reviewers independently extracted relevant data into evidence tables using a standardised instrument.


Identified studies were qualitatively synthesized. No attempt was made to statistically pool the results of individual studies. The 23 scientifically admissible studies described the development of 25 unique CPRs, including 15 diagnostic, 7 prescriptive and 3 prognostic rules. The majority (65%) of studies described the initial derivation of one or more CPRs. No studies investigating the impact phase of rule development were identified.


The current body of evidence does not enable confident direct clinical application of any of the identified CPRs. Further validation studies utilizing appropriate research designs and rigorous methodology are required to determine the performance and generalizability of the derived CPRs to other patient populations, clinicians and clinical settings.

Where to find the Articles


Haskins R, Rivett DA, Osmotherly PG. Clinical prediction rules in the physiotherapy management of low back pain: A systematic review. Man. Ther. 2012 Feb;17(1):9-21.

  • 23 included CPR studies
  • "Current body of evidence does not enable confident direct clinical application of any of the CPRsâ€?


Stanton TR, Hancock MJ, Maher CG, Koes BW. Critical appraisal of clinical prediction rules that aim to optimize treatment selection for musculoskeletal conditions. Phys Ther. 2010;90(6):843-854.

  • 18 included CPR studies
  • “There is little evidence that CPRs can be used to predict effects of treatment for musculoskeletal conditionsâ€?
  • “Validation of these rules is imperative to allow clinical applicationâ€?


May S, Rosedale R. Prescriptive clinical prediction rules in back pain research: a systematic review. J Man Manip Ther. 2009;17(1):36-45.

  • 16 included CPR studies
  • “Most need further evaluation before they can be applied clinically…most did not pass the lowest level of evidence hierarchyâ€?
  • “Manipulation CPRs evidence to date for its clinical utility is limited and contradictoryâ€?
  • “Stabilization CPR has limited evidence that may be considered but only with similar patientsâ€?


Beneciuk JM, Bishop MD, George SZ. Clinical prediction rules for physical therapy interventions: a systematic review. Phys Ther. 2009;89(2):114-124.

  • 10 included CPR studies “were Poor to Moderate Quality BUT most lacked Validation studiesâ€?

Back To Research Commentary
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