Not all back pain is back pain

“Findings such as disk height loss and disc bulges are common in individuals without low back pain.”
Disc bulges, degenerative joint disease, spinal stenosis, can all be a result of living with gravity. We have gravity acting as a compression force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. We can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you is exactly what causes your back pain. 
“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”
What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates a screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC study group), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patient’s physical complaints.
“Our results indicate that depression is a strong predictor of who will subsequently report low back pain than baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times as likely to have back pain compared with those who do not report depression.” 
There is obviously a psychosocial component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.
“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and root contact may also be risk factors for future low back pain.”
In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.
The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.  

Core stabilization compared to McKenzie method treatment


  1. “The condition has been identified as the leading contributor to ‘years of life lived with disability’ in the world including the United States.”


Big surprise, we are talking about back pain again. I see a majority of my schedule as back pain for the previous 8 years. There is no loss of people with back pain. This is an epidemic. The only reason it is not treated in such high regard has cancer, AIDS, Zika, and others is because it’s not deadly and does not cause major deformities. Because back pain is so common, it’s treated with little urgency such as the common cold.

  1. “In Australia, LBP is estimating to reduce gross domestic product by $3.2 billion annually and is the leading cause of early medical retirement for older working people.”

Think about that! You go to school and you load up on student loan debt. After school you get a job paying much less than you think you’re worth. Then you get sidelined by low back pain and are forced to retire well before you’re ready. It doesn’t have to be this way! Not all low back pain is the same, and when you figure out what type of back pain you have it becomes a lot easier to prevent recurrent issues of back pain.

  1. “Directional preference classification is characterized by a reduction in distal pain and/or observation of the centralization phenomenon with the application of repeated or sustained end-range loading strategies to the spine that remain better after assessment. Centralization is defined as a progressive change in pain from a more distal location to a more proximal location that remains better after applying repeated or sustained end-range movement to the spine… hallmark characteristic of the McKenzie derangement classification.”

There is no doubt that a directional preference correlates with great outcomes. There is no doubt that centralization correlates with great outcomes. The thing that needs to happen is that therapists need to be trained to see these during the initial evaluation. A majority of patients demonstrate a classification utilizing the McKenzie method, based on the research of Stephen May. The derangement classification is the largest classification syndrome based off of Stephen May’s previous research, but there are other syndromes. Typically, it’s the derangement syndrome that the research attempts to study. I see very few articles on the other two syndromes in the mainstream research journals.

  1. “There is some evidence that improvement in size and recruitment of the muscles of the spine, including the transverse abdominis, is associated with improved function in the short-term when patients with low back pain receive motor control exercises compared to general exercise or spinal manipulation. However, increases in transvere abdominis and lumbar multifidus thickness using real time ultrasound have also been observed immediately and one week following spinal manipulation in people with low back pain, suggesting that increases in transverse abdominal recruitment may not be specific to motor control exercises.”

OK, a muscles ability to contract is not dependent on its side. A muscle’s ability to contract is based off of that muscle’s ability to receive the nervous system input from the central nervous system. Should there be something that allows for better neural activity, we expect to see an increase in muscle contraction and possibly an increase in muscle size. This is important because we may not have to train a muscle in the traditional sense in order to making muscle contract better.

  1. “The McKenzie method was prescribed according to the principles described by McKenzie and May… Delivered by two therapists who had obtained the level of credentialed therapist from the McKenzie Institute International… Mechanical therapy, including patient and therapist generated forces utilizing repeated or sustained and range loading strategies in loaded or unloaded postures, according to the patient’s directional preference..that guided by symptom response. The aim was to reduce, centralize, and abolish peripheral symptoms… Once symptoms centralize, any movement loss was then treated with repeated and range movements in the direction of movement loss… Received a copy of treat your own back to supplement treatment and self-management.”

The patients included in the study were all patients of the derangement syndrome. When assessing a patient utilizing the McKenzie method, we are attempting to classify the patient into one of three syndromes. This has a high reliability when performed by therapists that are highly trained. The hallmarks of the derangement syndrome is centralization, this occurs when symptoms move from a segment far away from the spine towards the spine. The symptoms in the furthest position from the spine have to decrease or abolish. This is accompanied by the directional preference. A directional preference is as stated, when we move you in a specific direction…your body prefers that. Your body tells us it prefers that direction by centralizing symptoms, improving range of motion, improve strength, or improving other neurological tests such as reflexes and dural tension testing. One can also have a directional preference in the absence of centralization, as extremities also demonstrate directional preferences.

  1. “Initially, promotion of independent contraction of the deep stabilizing muscles, such as the TrA and multifidus, was facilitated by pelvic floor contraction…Objectively, skill mastery of TrA recruitment was measured by palpation and visual assessment for a reduction of overactivity of the superficial trunk muscles…practice daily…attend the physical therapy clinic twice a week for the first 4 weeks and once per week for the remaining 4 weeks”

This is beat into students during PT school…understanding the impact of performing TrA contractions on low back pain. The problem with this theory is that the research is scant on cause and effect. We know that patients with low back pain have smaller multifidi and TrA muscles, but we can’t say “chicken or the egg” yet. We also can’t say if the back pain caused the smaller muscle or if the muscle was smaller and then it caused back pain. More research needs to take place. The topic of centralization and directional preference was briefly touched upon while I was in PT school and the topic of TrA was hammered into us. Now it appears that centralization and directional preference are being taught more in PT schools based on the students that I get as a clinical instructor.

  1. “Participants allocated to the McKenzie method group attended an average of 5.4 +- 2.5 treatment sessions over an average of 38.6+-18.8 treatment days, while participants in the motor control group attended an average of 6.5+-2.7 treatment sessions over 47.3+-22.7 treatment days”

This doesn’t look like a huge difference, but this indicates that those being treated by a MDT credentialed therapist, one less session was required. Think about this again. Each session is performed at a cost to insurance companies (read Medicare) of about $100. At this point, each patient would save $100 to insurance companies when seen by a credentialed MDT therapist. This, over the long term, has dramatic effects on the total cost of spending in the US.

  1. “…no statistically significant effect for treatment group for muscle thickness…at an 8-week follow-up in a population of people reporting chronic LBP classified with a directional preference. Global perceived improvement was the only secondary outcome that demonstrated a significant between-group difference, which favored the McKenzie method”

Let me say this slowly. Using a directional preference based exercise provides the same result as actually training a specific muscle in terms of muscle size! This is huge! We all are taught that to make a muscle bigger (hypertrophy) requires up to 6 weeks of performing an exercise in order to specifically improve a muscles size. This indicates that a muscle’s size can increase without any direct exercises to improve a muscle’s size.

The final piece of this is that those treated with MDT based principles actually felt better than those receiving motor control exercises (read this as core stabilization).

You walk into any clinic in America (aside from those that are doing MDT) and you will see bridges, bird-dogs, pull your belly into your spine exercises, and of course the traditional hot pack and e-stim. These types of treatments may not be the best. Ask your therapist how your back pain is classified. If they can’t give you a straight, honest, and well reasoned answer…FIND A NEW THERAPIST!

  1. I am bolding this, because it is important to read straight from the article. There will be no explanation needed.

Results from our study suggest that in patients with a directional preference, receiving exercises matched to their directional preference is likely to produce a greater sense of improvement than receiving motor control exercises.”

Excerpts taken from:

Halliday MH, Pappas E, Hancock MJ, et al. A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People with Chronic Low Back Pain and a Directional Preference. J Orthop Sports Phys Ther.2016;46(7):514-522.

Outline to back pain presentation


žCentralization, although first described by McKenzie14, has been replicated in multiple research studies15,16,17.

žCentralization is the movement of symptoms from an area distal to the spine to a more proximal segment14,18.

žPeripherilization is the movement of symptoms, originating from the spine, from a more proximal and central location to a more distal location14.

žThe centralization phenomenon, when produced in patients, correlates with good outcome9,10,18,19.

žPatients presenting as non-centralizers are six times more likely to require surgical intervention19.

žCentralization is shown to highly correlate with a discogenic lesion20.


  • Spinal Stenosis= reduction of the surface area of the spinal canal or foramen

–No clinical feature or diagnostic test can confirm that stenosis is the cause of symptoms

–A literature review determined that “all studies favored decompressive surgery for improvement of pain, function and quality of life, as well as in terms of patient satisfaction” compared to conservative care24

  • The advantage of surgery was noted within 3-6 months and remained constant for up to 4 years.
  • Surgery is more cost-effective for this group of patients
  • Appropriate for patients that have not improved with 12 weeks of conservative care.


žThere are multiple systematic reviews demonstrating that ESI’s can be effective in the short term and long term for managing back pain for both discogenic pain and stenotic pain21,22

žFollowing an ESI, about 45% of patients then demonstrate centralization and report 90% satisfaction of results after 1 year23

žAny questions?


1.Garzillo MJD, Garzillo TAF. Review of the Literature: Does Obesity Cause Low Back Pain? JMPT 1994;17(9):601-604.

2.Hill JC, Whitehurst DGT, Lewis M, et al. Comparison of stratified primary care management for low back pain with the current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378:1560-1571.

3.Walker BF, Williamson OD. Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Manual Therapy 2009;14:314-320.

4.Fritz JM, Cleland JA, Speckman M, et al. Physical Therapy for Acute Low Back Pain: Associations with Subsequent Healthcare Costs. Spine 2008;33(16):1800-1805.

5.Shin G, Mirka G. An in vivo assessment of the low back response to prolonged flexion: Interplay between active and passive tissues. Clin Biomech 2007;22:965-971.

6.Kelsey JL, Githens PB, White AA, et al. An Epidemiologic Study of Lifting and Twisting on the Job and Risk for Acute Prolapsed Lumbar Intervertebral disc. J Orthop Research 1984;2:61-66.

7.Pople IK, Griffith HB. Prediction of an Extruded Fragment in Lumbar Disc Patients from Clinical Presentations. Spine 1994;19(2):156-158.

8.Natural history of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome. J orthopedic surg 2001;9(1):1-7.

9.Long A, Donelson R, Fung T. Does it Matter Which Exercise? A Randomized Control Trial of Exercise for Low Back Pain. Spine 2004. 29(23):2593-2602.

10.Long A, May S, Fung T. Specific Directional Exercises for Patients with Low Back Pain: A Case Series. Physiotherapy Canada 2008;60:307-317.


  1. Kovacs FM, Urrutia G, Alarcon JD. Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials. Spine 2011;36(20):1334-1351.
  2. Urquhart DM, Bell R, Cicuttini FM, et al. Low back pain and disability in community-based women: prevalence and associated factors. Menopause 2009;16(1):24-29.
  3. Konstantinou K, Dunn K. Sciatica: Review of Epidemiological Studies and Prevalence Estimates. Spine 2008;33(22):2464-2472.
  4. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand: Spinal Publication Ltd;2003.

15.Delitto A, Cibulka MT, Erhard RE, et al. Evidence for an extension-mobilization category in acute low back syndrome: A prescriptive validation pilot study. Phys Ther 1993;73:216-228.

16.Donelson R, Silva G, Murphy K. The centralizaiotn phenomenon: Its usefulness in evaluationg and treating referred pain. Spine 1990;15:211-215.

17.Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion: A multi-centered, prospective randomized trial. Spine 1991;16:S206-212.

  1. Werneke MW, Hart DL, Cutrone G, et al. Association Between Directional Preference and Centralization in Patients with Low Back Pain. JOSPT 2011;41(1): 22-31.
  2. Skytte L, May S, Peterson P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine 2005;30(11):293-299
  3. Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.


  1. Manchikanti L, Kaye AD, Manchikanti K, et al. Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesth Pain Med. 2015;5(1):e23139.
  2. ManchikantiL, Buenaventura RM, Manchikanti K, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245.
  3. van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal Epidural Steroid Injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Med. 2014;15(7):1100-1108.


Evidence Based Medicine

“Evidence  based”  practice  or  medicine  appears  to  be  the  phrase  of  the   current  generation  of  health  care  professionals.    A  general  search  utilizing  Ovidsp   resulted  in  over  200  journal  articles  with  the  phrase  “evidence  base”  in  the  title.     Although  the  basis  of  evidence  based  medicine  was  first  established  in  the  1970’s,   the  evidence  has  grown  exponentially  in  the  previous  twenty  years1,2.    Evidence   based  medicine  is  the  “use  of  current  best  evidence  in  making  decisions  about  the   care  of  individual  patients3.”       As  professionals,  but  more  specifically  as  APTA  members,  we  can  agree  that   the  utilization  of  evidence  is  important  for  our  profession4.    There  are  a  plethora  of   articles  establishing  evidence  for  various  types  of  medicine,  but  it  is  important  to   understand  that  evidence  based  practice  also  presents  with  limitations.    For   example,  Jette  et  al4  reports  that  physical  therapists  have  a  positive  attitude  towards   evidence  based  practice.    A  limitation  of  this  study  is  that  the  survey  was  issued  only   to  APTA  members.    It  may  be  argued  that  those  that  have  joined  their  respective   professional  organization  are  more  proactive  than  those  that  have  not  joined.    This   study  surveyed  motivated  therapists,  which  may  have  led  to  the  positive  attitude   regarding  evidence.    Another  limitation  related  to  positive  results  is  “publication   bias”,  which  indicates  that  research  with  negative  results  is  less  likely  to  be   published1.    Because  not  all  research  is  published,  specifically  negative  research,  the   audience  (physical  therapists)  is  inundated  with  positive  outcomes,  which  may  bias   the  reader  that  the  intervention  is  statistically  effective  in  treating  patients.       It  has  been  established  that  randomized  controlled  trials  (RCT)  are  the  gold   standard  for  providing  the  best  evidence  for  interventions5.    It  is  the  physical   therapist  responsibility  to  thoroughly  assess  the  RCT  in  order  to  determine  if  it  is   applicable  to  the  population  treated  clinically2.    Maher  et  al1  concluded  that   individual’s  ability  to  critically  assess  an  article  is  a  limitation,  as  not  all  therapists   critique  an  article’s  validity  to  the  population  treated.    Another  limitation  to   evidence  based  practice  noted  by  Maher  et  al1  is  FUTON  bias  (full  text  on  the  net),   which  means  that  therapists  are  more  likely  to  quote  and  utilize  only  the  articles   which  are  available  in  full  text.    I  am  guilty  of  this  bias,  as  I  do  not  find  that  utilizing   an  abstract  is  valid  for  patient  care  if  I  cannot  assess  the  methodology  of  the  study.       Additionally,  conflicts  of  interest  serve  as  a  limitation  to  evidence  based   practice6.  Croft  et  al6  states  that  professional  groups  that  have  an  interest  may   promote  a  specific  intervention.    Because  of  this  financial  conflict  of  interest  the  use   of  evidence-­‐based  practice  may  be  used  as  a  marketing  tool  for  individual   professions.       To  answer  the  question:  Do  I  think  that  evidence-­‐based  practice  will  require   a  change  in  the  profession?  Based  on  Jette  et  al4,  I  do  not  believe  a  change  is   required.    Time  will  eventually  dispense  of  the  therapists  that  are  uncomfortable   with  research,  lack  the  database  knowledge,  or  are  unable  to  critically  appraise   research.    According  to  the  article,  younger  therapists  are  more  inclined  to  be   researched  based  practitioners,  as  they  are  more  confident  and  able  to  critically   appraise  the  research  out  of  school.    Based  on  Vision  2020,  it  is  hard  to  believe  that  a   change  needs  to  take  place  in  order  for  our  profession  to  become  more  research   based.



1. Maher  CG,  Sherrington  C,  Elkins  M,  et  al.  Challenges  for  Evidence-­‐Based   Physical  Therapy:  Accessing  and  Interpreting  High-­‐Quality  Evidence  on   Therapy.  Phys  Ther.  2004;84(7):644-­‐654.

2. Vaccaro  AR,  Fisher  CG.  Evidence  and  Impact:  Should  these  articles  Change   the  Practice  of  Spine  Care?  An  Evidence  Based  Medicine  Process  [Published   Ahead  of  Print].  DOI:  10.1097/BRS.0b013e3181d4ea37.  Accessed  on  January   25,  2012.

3. Sackett  DL,  Rosenberg  WMC,  Muir  Gray  JA,  et  al.  Evidence-­‐based  medicine:   what  it  is  and  what  it  isn’t.  MBJ.  1996;312:71-­‐72.

4. Jette  DU,  Bacon  K,  Batty  C,  et  al.  Evidence-­‐Based  Practice:  Beliefs,  Attitudes,   Knowledge,  Behaviors  of  Physical  Therapists.    Phys  Ther.  2003;83(9):786-­‐ 805.

5. National  Health  and  Medical  Research  Council.  How  to  Use  the  Evidence:   Assessment  and  Application  of  Scientific  Evidence.  Canberra,  Australia  Capital   Territory,  Australia:  Biotext;2000.

6. Croft  P,  Malmivaara  A,  Van  Tulder  M.  The  Pros  and  Cons  of  Evidence-­‐Based   Medicine.  Spine.  2011;36(17);1121-­‐1125.

Mission Statement

My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations.   I choose to be a leader of example, and not words, all the while reducing negativity in my life.

I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment.

I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.



centralization and the correlation to discogenic pain

Critical Appraisal for a Reference-Standard Validity Study


P: For patients with chronic low back pain, with varying levels of distress,

I: can the centralization phenomenon

C: as compared to discography results

O: provide diagnostic power for discogenic pain



Vincent Gutierrez, PT, MPT, cert. MDT



Ovidsp with keyword terms “low back pain and centralization and specificity and sensitivity”.   44 citations were found between the years 2004 and 2014.


Date of Search: January 21,2014

Re-evaluation date: January 25, 2014



Laslett M, Oberg B, Aprill C, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine Journal 2005;5:370-380.



This validation study has two purposes. The first is to investigate the predictive value of the centralization phenomenon (CP) in relation to provocation discography, which is the only reference standard available for discogenic pain. The second is to investigate the role of distress and disability with regards to the predictive value of the centralization phenomenon in relation to provocation discography.


The inclusion criteria were patients with persistent low back pain (LBP), with or without lower extremity (LE) symptoms, whom were referred to a private radiology practice. Patients were excluded for the following reasons: a normal magnetic resonance imaging (MRI) assessment, severe degeneration associated with spondylolisthesis, and if the discography was contraindicated or a referral ruled out discography. The patients that were included were assessed consecutively.


Prior to the evaluation by a physical therapist, the patient completed a visual analog scale (VAS) for pain and the Roland-Morris Disability Questionnaire (RMDQ). The Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ) and the Distress Risk Assessment Method (DRAM) were also completed prior to the physical therapy (PT) evaluation. The evaluation was performed prior to the discography and the physician performing the discography was blinded to the therapist’s results. The therapist was blinded to the results of the subjective outcome measures.


The physical evaluation consisted of a McKenzie evaluation. The exam required 30-60 minutes and also included sacro-iliac joint (SIJ) provocation tests. Centralization or peripheralization was noted and at this point the examination was terminated.


Discography was performed using standard technique and the patient was required to report pain in at least one disc, without pain at an adjacent disc in order to receive a positive test result.


One hundred eighteen patients participated in the PT evaluation and discography. One hundred seven patients were included in the initial analysis. Of the 107 patients, 69 received a full PT evaluation, 21 received a partial evaluation and 17 did not receive an evaluation. Of the above, the physical therapist offered an opinion regarding CP for 83 patients.



The authors utilized the only reference standard studied, provocation discography, in order to determine if CP is predictive of discogenic pain. The physician was blinded to the physical therapists’ evaluation and the physical therapist was blinded to the patients subjective outcome measures. Not all patients received both the PT evaluation and discography.


The confidence interval was 95%. For non-distressed patients, the following statistical measures were calculated: sensitivity of 37%, specificity of 100%, positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were incalculable due to a specificity of 100%. For distressed patients, the following statistical measures were calculated: sensitivity of 45%, specificity of 89%, LR+ of 4.1, and LR- of 0.61. For not severely disabled patients, the following statistical measures were calculated: sensitivity of 35%, specificity of 100%, LR+ and LR- are incalculable due to 100% specificity. For severely disabled persons, the following statistical measures were calculated: sensitivity of 46%, specificity of 80%, LR+ of 3.2 and LR- of 0.63



Performing a McKenzie evaluation in order to determine the presence of CP is a good test for determining a positive discography, especially in patients without severe disability or distress. The presence of CP improves the pre-test probability to post-test probability of positive discography from 39% to greater than 75% in patients with severe disability or distress. CP is a strong predictor of positive discography in patients without severe distress or disability.

If the shoe fits


Understanding the difference among shoes with regards to function

Vincent Gutierrez, PT, MPT, cert. MDT


1.To briefly relate the history of the modern athletic shoe

2.To explain the differences regarding functionality among dress shoes, classic footwear, minimalist footwear and barefoot.

3.To provide general recommendations of footwear for varying populations.

  • The Shoe
  • The worlds oldest shoe is roughly 6,000 years old and was meant for foot protection. Prior to this it is theorized that all activities took place barefoot1.
  • Through the years
  • First athletic shoes
  • Keds Champions: unchanged since 19172,3
  • Modern (Classic) Shoe
  • Designed with the foot anatomy in mind (i.e. motion control)3,4,5
  • Minimalist shoes
  • In the recent years these shoes have noted increased sales and are advertised to mimic barefoot activities.
  • These shoes offer no support and increase the intrinsic/extrinsic strength of the foot musculature
  • When compared to barefoot, wearing standard walking shoes increases stride length by 6%14.
  • Heel strike is more pronounced with larger stride length and varum stresses at the knee were found (9%).
  • Impact on medial compartment OA.
  • For every 1% increase in stress, there is 6x greater risk of knee OA
  • “Flat flexible footwear are associated with significant reductions in dynamic knee loads during ambulation, compared to supportive, stable shoes with less flexible soles.”15
  • Running
  • (1980) It was advised to buy a shoe with built in support mechanisms for the arch and cushioned heel7
  • The authors make this recommendation based on the gait cycle and apply the same gait cycle to running.
  • Recent running analysis challenges this basis of running as fast walking
  • To understand this lets talk GFR
  • By incorporating arch supports, there is a reduction in elastic recoil of the spring ligament and posterior tibialis, thereby reducing force output at the foot intrinsic/extrinsic3
  • Running
  • Minimalist shoes are more economical compared to classic running shoes in that the the runner utilizes less energy to run9
  • The weight of the shoe was controlled for by using ankle weights.
  • Neuropathic foot8
  • Most ulcers occur in forefoot
  • Study compares barefoot walking in patients with DM neuropathy and those without neuropathy
  • Results
  • Pt with neuropathy place more stress on the forefoot when barefoot (2x more) than controls
  • Possibly due to hammer toe formation and a lack of distribution among toes
  • Unable to feel increased stresses at the forefoot resulting in injury under met. Heads.
  • Balance
  • 100 older women (mean=82 y/a) examining usual footwear vs. barefoot on balance6
  • 68% required AD
  • 42% wore walking shoes, 17% sandals, 11% moccasin
  • Subjects with poorest balance (BBS) benefitted most from usual footwear
  • Post CVA subjects demonstrate increased gait speeds when using a classic shoe compared to barefoot or slippers11
  • Wearing dress shoes (>.5 inch heel) resulted in 15% worsening of balance testing compared to barefoot and a 12% worsening when changing from standard shoe to dress shoe. The TUG improved in standard shoes compared to barefoot12.
  • Healthy older adults demonstrate increased postural sway when wearing traditional walking shoes compared to barefoot13
  • Authors postulate due to sensory deprivation due to footwear
  • Pediatric population
  • “Influence of footwear on the prevalence of flat foot”
  • Study of 2300 children between 4 and 13 y/a
  • 1555 used footwear and 745 never wore shoes
  • 9% of shodded children presented with flat foot and only 3% of children without footwear presented with flat foot.
  • Closed toed shoes appeared to inhibit arch formation moreso than sandals/slippers.
  • The authors suggest that children should play barefoot or in sandals/slippers.
  • Recommendations
  • Running:
  • Classic Running shoes influence a RFS, which increases impact loading into the LE and runners sustain 2.5x more injuries (LBP, LE pain) when running with a RFS3,9
  • Barefoot running fosters a FFS, which strengthens the muscles of the foot3,10
  • Balance:
  • Those with poor balance are advised to wear shoes6 and avoid higher heeled shoes12
  • Healthy individuals are advised to wear minimalist shoes for static balance
  • Neuropathic foot
  • Therapeutic shoes to reduce plantar pressure at the metatarsal heads
  • Walking
  • s/p CVA should wear classic shoes for improved gait speed.
  • Healthy individuals are advised to wear minimalist/barefoot shoes to decrease risk of knee OA
  • Kids
  • barefoot or minimalist shoes
  • What’s the difference between running barefoot and running in standard/classic shoes?
  • What are two benefits and limitations of classic shoes?
  • Did this presentation add to your knowledge base and is there a change in your confidence level when recommending shoes for patients/friends?
  • References

1.Ravilious, K. National Geographic News. June 2010. Available at: Accessed on July 10, 2013.

2.Keds Shoes Official Site. July 2013. Available at: Accessed on July 10, 2013.

3.Altman AR, Davis IS. Barefoot Running: Biomechanics and Implications for Running Injuries. Curr Sports Med Reports. 2012;11(5): 244-250.

4.Griffith I. Choosing Running Shoes: The Evidence Behind the Recommendations. February 2011. Available at: Accessed on July 10, 2013.

5.McPoil TG. Footwear. Phys Ther. 1988;68: 1857-1865.

6.Hrogan NF, Crehan F, Bartlett E, et al. The effects of usual footwear on balance amonsgst elderly women attending a day hospital. Age and Ageing. 2009;38:62-67.

7.Heckman B. Selection of a Running Shoe: If the Shoe Fits-Run. JOSPT. 1980;2(2):65-68.

  1. Mueller MJ, Zou D, Bohnert KL, et al. Plantar Stresses on the Neuropathic Foot During Barefoot Walking. Phys Ther. 2008;88:1375-1384.
  2. Perl DP, Daoud AI, Lieberman DE. Effects of Footwear and Strike Type on Running Economy. Med Sci Sports Exer. 2012;44(7):1335-1343.
  3. Lieberman DE. What We can Learn About Running from Barefoot Running: An Evolutionary Medical Perspective. Exerc Sport Sci Rev. 2012;40(2):63-72.
  4. Ng H, McGinley JL, Jolley D, et al. Effects of footwear on gait and balance in people recovering from stroke. Accessed on July 6, 2013.
  5. Arnadottir SA, Mercer VS. Effects of footwear on Measurements of Balance and Gait in Women Between the Ages of 65 and 93 Years. Phys Ther. 2000;80:17-27.
  6. Brenton-Rule A, Bassett S, Walsh A, Rome K. The evaluation of walking footwear on postural stability in healthy older adults: An exploratory study. Clinical Biomechanics. 2011;26:885-887.
  7. Keenan GS, Franz JR, Dicharry J, et al. Lower limb joint kinetics in walking: The role of industry recommended footwear. Gait and Posture. 2011;33:350-355.
  8. Shakoor N, Sengupta M, Foucher K, et al. The effects of Common Footwear on Joint Loading in Osteoarthritis of the knee. Arthritis Care Res. 2010;62(7):917-923.