The Oxford Debate 2011: Clinical Prediction Rules Dead or Alive?

It seems appropriate that the next logical step in physical therapists’ practice, clinical prediction rules, would be politicized at the Oxford Debates at the American Physical Therapy Associations’ Annual Meeting in Washington DC.

A question that should never have been framed allowed the student-led body of voters on Friday, June 10th to move their feet to one side of the giant auditorium in the Gaylord Hotel in response to emotionally-charged arguments from the debaters.

Arguing AGAINST clinical prediction rules:

  • Stanley Paris, PT, PhD argued that clinical prediction rules “dumbed down” the practice of physical therapy.
  • Chad Cook, PT, PhD argued that clinical prediction rules were incomplete.
    • One of Dr. Cook’s students, from the audience, called out that she was sure she had learned clinical prediction rules from Dr. Cook’s class within the last two years. That earned a big laugh. (Typically, Oxford debates pit advocates arguing positions contrary to their stated beliefs or published findings).
  • Margaret Elaine Lonnemann PT, DPT argued that derivation level rules may find associations due only to chance.

Arguing FOR clinical prediction rules:

  • Julie Fritz, PT, PhD, from the audience, argued that the question is not “either/or” and that clinical prediction rules are incomplete and evolving.
  • Stephen George, PT, PhD argued that physical therapists’ training traditionally prompted a biomechanical approach to problem-solving and that newer evidence indicates “who” you treat is more important than “how” you treat them.
  • Anthony Delitto, PT, PhD used the analogy of a hammer. Just as you would not build a house using just a hammer, so physical therapists should not approach decision-making using just clinical prediction rules. Dr. Delitto then drew a big laugh from the audience when he expressed his urge to use a hammer on the opposing team’s argument.
  • Nicole Raney, PT, DSc argued that physicians are required to use clinical prediction rules in medicine. To not use clinical prediction rules is to practice below the standard of care. Further, she argued that clinical prediction rules are merely the starting point for fully informed medical decision making.

The end result was that many more audience participants, led by student members, got up and ran to the “CON” side of the room – winning the debate for those arguing against clinical prediction rules.

But, I blame Washington’s political climate that falsely dichotomizes every debate into “either/or”.   

Remember “You’re either for us or you’re against us!”?

The debate should not be whether or not to accept or reject clinical prediction rules.

The debate should be how we can most efficiently integrate validated rules into the clinical workflow so that physical therapists can ALWAYS have the option to use clinical prediction rules as their FIRST decision in patient care.

Tim Richardson, PT

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