Validation of the Lumbar Stabilization Clinical Prediction Rule…Musings, Memory, and Leverage

A recent issue of JOSPT has a paper from Alon Rabin where his team attempted to validate the clinical prediction rule previously developed by Greg Hicks et al to identify patients likely to benefit from lumbar spine stabilization exercise. As many of our blog readers know well, CPRs have gotten a bad rap in some cases because of the misperceptions about the term “rule” (hard and fast benchmark from which a clinician dares to deviate) and unrealistic “ivory tower” expectations that data should never be used for clinical decision-making until it’s in its most definitive and complete form (ie. only data at the top of the evidence hierarchy should be used). The editorial that Tim Flynn and I wrote as an introduction to the paper discuss these issues in more detail, and I hope that each of you will take a few minutes to peruse. I actually re-read it myself this morning (even though I wrote it!) and picked up a few tidbits as a reminder to myself!

In any event, the science of this paper and defending the utility of decision rules is really not the purpose of this post. Rather, I’d like to briefly put the paper in context on a more personal note. This paper hits close to home for me because Alon was a graduate student with me at the University of Pittsburgh when I was working on my PhD from 2000-2003 and when Greg Hicks was working on the original development study. I vividly remember the debates that went on (and they were sometimes rather heated) regarding whether the stabilization intervention should be comprised of a more “specific” approach focused on selective activation of the TrA, multifidus, etc. vs. a more “general” approach focused more on the global musculature system. Both Gwen Jull and Stuart McGill were on Greg’s dissertation committee, and as many of you might suspect, the two of them had somewhat different views on the issue (I am understating a bit!). Gwen was persuaded around the more contemporary “selective activation” approach a la her Australian colleagues and Stuart was the more pragmatic biomechanist advocating a more brute “fire the heck out of the muscles as hard as you can” approach. To be fair to each of them, I am overly generalizing for the sake of brevity and to make a point, primarily that the development of a research question can often be a windy and testing road, especially for the doctoral student who wonders if his committee will ever be able to come to a concensus and let him get started (Greg, remember those days?)! Time has proven that selective activation of the TrA/multifidus may not be all that it’s cracked up to be (realizing this too is an oversimplication of the answer to the question), but the lessons learned in the process and advancement of future research are what counts most.

It was a highly productive several years during that time with a world class faculty in individuals like Tony Delitto, Julie  Fritz, Jay Irrgang, and Kelly Fitzgerald (each of whom are foremost mentors and now dearest of friends), among others. There was also an incredible group of doctoral students at that time, individuals like Steve George, Greg Hicks, Sara Piva, and yours truly. Rob Wainner had recently completed his dissertation work on the diagnosis of patients with cervical radiculopathy as well (one of the earliest diagnostic “clusters” in PT btw). I am absolutely positive that I am omitting someone important from this list (so please forgive me in advance), but Alon’s paper brought back a flood of memories for me because he was around during this time and engaged in some of the early debate regarding how to optimally strengthen the low back. The evolution of a solid research agenda leans on lots of informed opinion, heated debate (I remember Tony trashing my first case report…it was awful), experiential learning (with lots of mistakes along the way), and great science. However, most of all, and not unlike predicting success in any setting, I would argue that it’s dependent upon a vibrant environment of great people willing to subject themselves to a team concept and desirous of being a part of something larger then themselves such that the incremental sum of the parts is far greater than any single individual’s contribution.  In business and finance, we call this “leverage”. The good news is that there are many productive research environments in PT these days, but I’d put this group from 2000-2003 up against anyone over time. We had leverage coming out of our ears, and the fruits of this period are still being felt today, as evidenced by this terrific contribution by Alon and his colleagues. Perhaps it’s the anticipation of CSM next week and getting a chance to reunite with so many dear friends and colleagues that has me waxing philosophical this morning, but those were great times. Safe travels everyone to Vegas and CSM!

John

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