New Clinical Prediction Rule for Lumbar Stabilization?

Ok, this post it a little more focused for PTs and other medical professionals (which may or may not actually be reading this) but I noticed how Clinical Prediction Rules (CPR) are becoming more popular and recognized.  CPR, if your not familiar, are a combination of medical signs, symptoms, and other clinical findings/tests in predicting the probability of a specific disease or intervention. The CPR can be very beneficial as it helps justify what we do and assists in focusing our care for the most optimal manual/exercise combo that will benefit the patient the most.  Personally I really think it comes down to just 1-2 techniques that make the most difference. 10% of what you do provides 90% of the benefits, so why not be confident in that one technique that make the most difference.  I like to describe it to interns (and patients) as funneling down to the perfect 'thing' for the pt. 
 I often will spend 15 minutes assessing a patient, complete one 'corrective exercise', and reassess the (hopeful) improvement, be it ROM or pain then build on that.  My flow chart looks pretty blank but that's fine with me when the assessment states "abolished pain and improved ability to lift objects off ground following active leg lowering and pattern assist" for example. 
So I can appreciate how a CPR can funnel our clinical decision-making. One particular CPR is stabilization for low back; basically it states someone will benefit from a exercises focused on "core stability" interventions. Although I don't like the word "stability",( Ill save that for another post [hopefully if people read this one]) the idea of narrowing down our plan of care is useful.  Additionally, if you ask 10 therapist to make a 'stability program', you ll probably receive 10 completely different answers. Still ,were narrowing down our focus, to get to that 1 awesome-sauce technique.  
But as I read over the' stabilization for low back CPR' I realized why its successful... (Specificity: 0.56 (2+ Variables), 0.86 (3+ Variables), Sensitivity: 0.83 (2+ Variables), 0.56 (3+ Variables) Positive Likelihood Ratio: 1.9 (2+ Variables), 4.0 (3+ Variables)) rules out mobility issues.  This is exactly what a certain assessment tool called the 'Selective Functional Movement Assessment' will do.  The SFMA is is a series of 7 movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known musculoskeletal pain. When the clinical assessment is initiated from the perspective of the movement pattern, the clinician has the opportunity to identify meaningful impairments that may be related to the main musculoskeletal complaint. The SFMA beaks movement down into segments and from loaded to unloaded positions to differentiate between mobility and motor control (stability) deficits.  And a back stabilization program will only be successful once we rule out and clean up mobility (tissue or joint) issues first.  And that's what the back stabilization tries to do with its criteria listed below:
 1. Age < 40
2. Straight leg raise > 91°
3. Aberrant (abnormal) movement present 
4. Positive prone instability test ( a special test)

So take the straight leg raise above 90degr.  Basically its saying the hamstrings (HS) aren't actively involved and influencing your back pain from a mobility standpoint.  The SFMA assesses HS mobility and its influence in the toe touch (trunk flexion). And you wouldn't assess the HS if the toe touch was normal, but if its dysfunctional, or aberrant, than you have something to assess.  Touching your toes can be aberrant is several ways, be it a catching, pain with rising back up, poor continuity of the curve on your low back, uneven weight shift just to name a few.  The SFMA toe touch breakout can further assess the need for stability similar to the prone instability test by assessing long sit toe touch and active straight leg raise. These tests are similar to other clinical findings including the 'instability catch sign' and the 'painful catch sign' which actually have better specificity (86 and 73% respectively)  than the prone instability test (57%).(View full article).  Additionally, your looking at two signs rather than one test.  So the SFMA has efficiently examined 3 of the 4 criteria of the stability CPR.   But here is where I think we can improve on the sensitivity and specificity: but adding more criteria already found in the toe touch/flexion breakout below. 
courtesy of SFMA
Namely,  we also could examine, as above, spinal flexion mobility and hip flexion mobility. This way we rule out any mobility issues that may impede toe touch leaving us with only a motor control deficit to fix.  

So there you have it, my updated CPR for spinal stabilization:

 1. Aberrant (abnormal) movement present with toe touch
2. Passive straight leg raise > 90°
3. Ability to bring knees to chest in supine
4. Ability to bring chest to thighs in a prone rocking(prayer) position

I should add there are other things I look at, such as movement preference(McKenzie assessment), better special tests such as the prone limb extension and my palpation skills to further help me funnel my clinical decision for best intervention.  I should also add SFMA is just one tool (be it very successful for me) that can be used.  I think its important to recognize one test will even be useful enough to funnel a decision. 

So what do you think about my CPR?  What other positives are you all looking for to improve your clinician decision?  Please leave me your thoughts and thanks for reading.  I hope to become more consistent with this blog.