Physical Therapy Continuing Education: Clinical Prediction Rule Vs Segmental Dysfunction

As a Physical Therapist, ever wondered when to use the clinical prediction rules for manipulation Vs assessing for a specific joint dysfunction?

We recently had a chance to ask that exact question to a spinal manipulation expert. This is what he said:

Interviewer: I’d like you to expand a little bit more on that thinking. I think as a manual therapist, with our assessment we enjoy the part of the puzzle of trying to figure out is there a specific level joint dysfunction going on and comparing that to a clinical prediction rule. Could you just give us some of your thoughts on the use of the clinical prediction rule versus trying to address specific level joint dysfunction?

Spinal Manipulation Expert: I think that’s a very good question. I almost think it’s really a sequence, in my mind. Kind of the first pass of the patient coming in with say acute back pain, if they meet this rule go ahead and employ that technique. Then your second pass you begin to look – okay continued pain and disability, now I’m going to start my second pass through, begin to see if I can find areas that might be additional contributors to that patient’s presentation.

Interviewer: Right.

Spinal Manipulation Expert: So, I don’t see this really discounting us trying to be segmental in orientation and looking segmentally at different levels of joint dysfunction or perhaps specific levels of muscle-joint complex dysfunction.

Also, I would comment that we went through an examination process, through flexion-extension ranges and palpation at segmental levels to determine if dysfunction was present, but that dysfunction just wasn’t – first of all, the reliability is not very good there and those factors weren’t very predictive of this particular technique being responsive. But again, I grew up in the manual therapy world on lots and lots of practice of trying to find “Is this one more left, right? Is this one worse in flexion, extension?” I always tell folks that I never discount that training in making my hands I think softer and much more tuned into a patient response, and so I always looked at that training was very helpful.

I think the stories behind it or our ability to really discern these small movements is probably – not probably, I think we can say pretty strongly in the lumbar spine it’s really an illusion that we’re actually palpating those things or rotations. That doesn’t mean that we’re not gaining information. In other words, we do know the pain responses and a sense that there’s a difference here. We may not know it as right or left but it just, there’s a sense that there’s something not right, per se at L2 versus L4 or something. So again, I don’t discount our ability to do that. I think there’s something therapeutic about someone laying their hands on in a way that’s very methodical and done methodically and from the patient’s perspective knowing that someone’s really trying to figure out what’s going on in my body and I think there’s a therapeutic element of that whether we want to like it or not. That there is probably some effect that occurs with that.