"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Sunday, June 12, 2011

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.


  1. Tim,
    I was at the debate as well, and found it quite frustrating. If one considers that the results of a CPR is just data that gets integrated into decision-making, then according to the con side, we should have broad based validation for any test or measure we use to make decisions. Obviously that is ridiculous, and does not match practice. The systematic reviews on CPRs that suggest broad based validation before clinical use are making that recommendation based on the suggestions from the medical community, where the risk benefit ratio is quite high. In PT, we deal in low risk interventions, so I believe inclusion of derivation level CPRs is appropriate in the greater context of clinical reasoning.
    I know the debate was supposed to be fun, but I think it negatively influence the decision-making of many young, impressionable clinicians.
    If it was called a "tool" instead of a "rule" would we even be having this debate?

  2. Great point Cody!

    I know some clinicians are uncomfortable with the new paradigm but I always thought students were embracing these new tools - I guess not!

    Is the threat of clinical decision rules a threat to the person - or to the professional?

    I'm reminded of a quote by Douglas Rushkoff in Program, Or Be Programmed:
    "...Thinking itself is no longer - at least no longer exclusively - a personal activity. It's something happening in a new, networked fashion...The human response...must be a wholesale reorganization of the way we operate our work." (p.11)

  3. If we get locked inside a rigid algorithm, our profession will cease to grow and adapt and will therefore shrink and disappear.


Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

Share PTD with your Peers!

American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.