John suffers from lower back pain that has gradually worsened throughout the years. Like many of us, he assumes it is from sitting in front of a computer at work for multiple hours a day. But no matter how many water-cooler breaks he takes or Advils he pops, the pain persists. Frustrated, John finally decided to meet with a physical therapist who sent him home with instructions to follow a daily regimen of exercises. Eight weeks later, John’s still in pain. Unbeknownst to both the physical therapist and John, her treatment recommendations were based on flawed guidance.
As you might know yourself, and as John can attest, dealing with chronic musculoskeletal (MSK) pain can wear a person down. Beyond the pain itself, you might experience frustration and mental health issues because of your condition. In fact, those suffering from chronic pain are three times more likely to suffer from depression and anxiety and are twice as likely to be at risk for suicide. Persistent pain can also affect your work and social satisfaction. In reality, living with chronic MSK pain colors all aspects of our lives, which is why it's vital that doctors be able to prescribe treatments that will actually help us feel better.
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Continue reading to find out what clinical prediction rules (CPRs) are and how they are used by doctors to make treatment recommendations for patients with MSK conditions like carpal tunnel syndrome and back, neck, and shoulder pain. Learn about the various stages CPRs are supposed to go through to be fully vetted before doctors use them and how they frequently don't actually make it through this process the way they should, which might prevent you from getting the right treatments for your pain.
What are Clinical Prediction Rules (CPRs)?
CPRs are commonly used by physical therapists and other clinicians to support MSK treatment decisions that are made during the in-person appointment (1). The patient's examination, medical history, and diagnostic tests are all predictors that are taken into account. The CPRs help the treatment provider decide what treatment to prescribe the patient and also provide probabilities of certain outcomes depending on the patient's circumstances. There are several CPR types; prescriptive CPRs, which focus on treatment response, are more complex than the others because they are tailored to individuals based on their specific conditions.
How Are CPRs Tested Before Care Providers Use Them?
To ensure that CPRs are accurate before medical providers start using them to make treatment recommendations, they are supposed to go through an aggressive three-step verification process (2). The various stages in this procedure are called derivation (when predictors like those mentioned above are chosen), validation (when the CPR is thoroughly tested), and impact analysis (when the CPR is re-tested in tandem with patient outcomes, clinician behavior, and the consideration of costs). If clinicians are using these CPRs to figure out how to treat our pain - which they are - it seems obvious that these rules should be thoroughly tested and proven correct before they are widely used. But are they?
Many CPRs Are Not Tested Properly
A recent study that was published in the Journal of Clinical Epidemiology (3) looked at whether CPRs that are commonly used by doctors are being properly tested - per the three-step process outlined above - or not. It turns out that of the nine studies the researchers reviewed that had examined CPRs for MSK conditions, few CPRs go through all three development stages as they should. Also, in many cases, control groups weren't used during the derivation stage, which makes it hard to compare the impact of the CPRs being tested. And, in the end, the study wasn't able to find a statistically significant association between any CPR and its treatment outcome, which leads us to wonder if many clinicians are relying on faulty guidance when prescribing treatment to people like us who suffer from chronic MSK pain.
If doctors are relying on inaccurate CPRs that weren't properly tested to guide their recommendations, we might be in trouble. Like John, we could end up following advice that doesn't get us any closer to a pain-free life.
What is the alternative? Find clinicians that only use carefully picked CPRs to treat your MSK pain. In addition, make sure your treatment providers are up to date on the evolving literature on how to treat chronic MSK pain.
And rest assured, at Lin, we carefully vet our well-trained expert clinicians to diagnose and treat your conditions so you know you're getting care from a team you can trust.
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Walsh, M., French, H., Wallace, E., Madden, S., King, P., Fahey, T., & Galvin, R. (2021). Existing validated clinical prediction rules for predicting response to physiotherapy interventions for musculoskeletal conditions have limited clinical value: A systematic review. Journal of Clinical Epidemiology, 135, 90-102.