I have taught (clinically, not academically) a variety of students from different DPT schools and backgrounds. More specifically, many come to me after having past clinicals utilizing McKenzie, Postural Restoration Institute, and even cookie-cutter approaches for low back pain. The latter kills me, as written on the knee in the past, but even some of the other classification systems can be unfavorable to patient care. Unfavorable doesn’t mean improper, but utilizes a one-way street.
Even clinical prediction rules, which claim to obtain superior functional outcomes, has not reached full potential yet. I do like the idea of subgrouping patients, but we have a long ways to go to show superior results. Fitting patients into the fantastic four of low back pain classification systems: directional preference, motor control exercises (aka stabilization), traction and manipulation may not happen, and in many cases, doesn’t happen. Staunton et al 2010 & Haskins, et al 2012 showed clinical application of CPRs is not applicable currently. And we know that some patients do not fit into just one category, and some do not “fit” into a category at all.
Sometimes the students can lose direction based on trying to fit the patient in their system, or a system at that. A square peg can’t fit in a round hole. They can have tunnel vision, or railroad track vision; while losing track of lateral thinking. Most of the other treatment approaches utilize this model, but it gets pushed away like a runt in the litter to make up for the bigger name. The students lose reality of a more broader and successful foundation that should form the roots of the overall treatment approach.
This foundation bears no one’s name and doesn’t make money. It has been the basis of patient care in physical therapy prior to the modern era of research and is one of those good ‘ol characteristics that should get passed down to other generations. It is not an up and coming treatment, nor is it sexy.
It is the patient response model. The patient response model simply utilizes the patient’s report of symptoms to assist you in classifying them into an intervention group. Pain reproduction or reduction is typically the response of choice. This in turn should dampen fear of movement, improvement of movement patterns and then function. This is exactly what CPRs are intended to do, but just have not yet. With overwhelming choices to treating low back pain, this is my foundation for intervening. It is simple, effective, satisfying (for patients and myself) and obtains good outcomes. If you perform an intervention and are able to obtain within session improvement, between session improvement, educate on self-management strategies and improve function while decreasing disability, then it may be the right approach for the patient.
What leads to the right approach: the patient response model. Yes, level 5 opinion and a broad approach. But, it is supposed to be broad, it is the foundation.