Lead from the front

“When an organization or an individual experiences success in any manner, it may be difficult to alter the path we have been following.”

I could see this being true, but only for people who have that one success as the end goal. Some people aspire for more, some people aspire for better.

“Successful leadership is not just about the leader; it is about the team. Leaders must constantly find new solutions to the problems.”

This sounds like a quote from Phil Jackson. The team is the number one priority and the star athlete has to figure out how to fit into the team. The leader’s job is to ensure that the team can play together, and play at a high-level together. In order for leaders to constantly find new solutions to the problems, the leaders have to have an open point of view in order to see the problems. I have seen many who simply stick their head in the sand and ignore that the problem exists. In order to fix problems though, things will have to change. It’s obvious that should there be no change there will be no solution to the problem. This change will cause stress to the dynamics of the team, and the team must be able to handle that stress effectively and efficiently in order to maintain that high level of productivity.

“But leaders should not be afraid to erase the chalkboard sometimes and start from scratch”

Every system has flaws. Every system can be improved. Sometimes the flaws in the system are fatal. When this occurs the entire system needs to be scratched. I don’t know if a leader though can see this. These types of issues need the 20,000 foot view in order to see the big picture. When one is so close to the problem that they are in the problem, I do not believe that that person can actually see the problem.

Excerpts taken from:

Gregersen H. Leadership: When was the last time you asked, “Why are we doing it this way?”. IMPACT. June 2016:57.

Lean Management Theory

Lean Management Theory


  1. “The concept of 5S is just one of several key elements of the lean principle, which is designed to improve efficiency in the workplace while promoting organization and cleanliness.”


I can remember my teenage years. I started working at the age of 12 as a ranch hand and continued to work through this day. During those years, I worked as much as I was needed, because $20 was more attractive than anything else that I was doing with my time. My room was a disaster. I had trails in order to go from the door to the bed and another trail to get to the dresser. Fast forward 7 years, I was working at Sam’s Club 8298 during the overnight shift. I was nicknamed “The Tornado”. I could stock off a pallet faster than anyone else in the club. At times, they had to have someone come behind me to clean up after me, because it was faster to let me do all of the heavy work and pay someone else to do the “easy” stuff”. Continue to fast forward to one year ago, I was the most productive therapist in the clinic, priding myself in how many patients I could treat in a day, and still get good results of course. Fast forward to today, I realize that none of that matters. If I can teach people to do what I do, then I can help to create systems, which is now more interesting to me than simply stocking shelves, feeding horses, or treating patients. Don’t get me wrong, I enjoy treating patients, but I can only effect one person at a time. That is not as productive as creating systems to treat 10’s of patients at once, with the same treatment philosophy and outcomes. I now realize the importance of cleaning up my room, 36 years later.


  1. “The 5 “S’s” in Japanese are Seiri (tininess), Seiton (orderliness), Seiso (cleanliness), Seiketsu (standardization), and Shitsuke (discipline)”


Am I the only one imagining Myagi-son saying these words with emphasis? It sounds do formal and warrior-like.


  1. “In its simplest form it is designed to keep the workplace safe and organized without regard to size or pace”


When I worked at Sam’s, I could do aisles per night without ever tiring. Now, I left all of the cleaning until the end of the night (unless of course they had someone come over and clean up after me). What was the problem with waiting until the end of the shift to clean? I made everyone else’s jobs harder by taking up so much space that it was hard to get a forklift down my aisle during the shift. It was very productive for me, but I slowed down the entire team. It took years to figure this out, but my zealousness of productivity may be a detriment to the team.


  1. “The goal of the 5S is to remove waste, both actual and conceptual, by eliminating excess inventory and out-of-stock supplies, and reducing wasted time searching for, getting to , and waiting for supplies”


This is but one example. Think of the 20,000 foot view of eliminating waste (both in terms of stuff not used, and time spent on stuff not needed). I try to listen to multiple podcasts per day, and this concept is spoken of in many shows such as EntreLeadership, Barbell business, Tim Ferriss, and The School of Greatness.


  1. “Keep only what is necessary”


This is hard to do, especially when thinking of “what if”. I have like 8 pairs of jeans, but will only wear the jeans that don’t restrict my squat, namely 2 pairs. This means that at the end of my closet, I have 6 pairs of jeans that haven’t been worn in a long time, just in case I need to wear a third pair of jeans. The clutter in the closet would be removed if I just donated or sold the other pairs of jeans. Parting with any thing that we “own” is hard because we can always create scenarios in which those “things” are needed. Unfortunately, that same scenario never plays out in real life.


  1. “…identify, organize, and arrange everything in the work area, so that items can be efficiently and effectively retrieved…Everything should have a place and a purpose”


I suck at this step. Good story. I am on a team that is very close in terms of trust and partnership at work. There is a long running joke that I am Oscar and my supervisor is Felix. Hang out with us enough and it becomes obvious to those that understand the metaphor. I am learning that I need to become more like Felix in order to improve professionally. (For those that don’t understand the metaphor, go look up the Odd Couple…and nothing that was produced after 1990).


  1. “Once you have everything sorted and set, it is important to keep it that way…requires regular cleaning”


Because I suck at the previous step, this is also not a strong point for me. I know where I want to keep things, but for some unknown reason my way is not always the best way for everyone else. I struggle with the regular cleaning step. When I worked at PT and Spine, Bill was a stickler for standard operating procedures (SOPs). It wasn’t written, but he had a way that he like the clinic cleaned every night before locking the door. There was a proper way to open and close the clinic. Because I don’t have that type of standard at the place I work now, it makes it difficult to put everything in its place. I know that it sounds corny to think that there should be a standard operating procedure for the little things, but go back and listen to barbell business’ SOPs episode and it will all make sense.


  1. “Develop written structures and standards that will support the new practices and turn them into habits”


I am hard headed at some things. When it comes to organization, I have the ability to learn it, but I am a slow learner. I can spout off statistics on back pain, I can assess/treat darn near anything coming into the door, but performing organizations skills and all of a sudden…DUH? In Bill’s clinic, I was there for 2 years and by the time I left, I was able to leave the clinic in the exact way that I found it.


Funny story though: My dad is a Vietnam Vet (101st Airborne medic) and he could tell if something in his room moved while he was at work. Needless to say, if I wanted to be discreet, I could be. Unfortunately, this same discreetness doesn’t carry over to other situations.


  1. “Standardize is one of the harder steps in 5s as it calls for changing habits”


If I were a clinic owner, I would only hire new graduates that performed a clinical with me. It just seems much easier to teach what I find works best than to unteach stuff that I don’t like or research doesn’t support and then teach what I do prefer. This being said, being in a clinic with people who have much “experience” makes creating new standards difficult. Clinicians can be set in their ways and change can be scary. It is less scary for those that don’t know any better.


Excerpts taken from:

Spradling SC. Practice Management Systems: Add value to your practice by “5S’ing”. Impact. June 2016:31-32.

Is therapy worth it?

“Value is defined as cost divided by benefits”


This is very elementary in definition, but many of us in healthcare don’t do enough to sway this equation to make the benefits match the costs. When patients come to see me they receive multiple benefits during the session: educate, educate and over educate, personal care as much as possible staying within the realm of the evidence, and entertainment during the whole process. When I teach students, I make them tell me if they believe that they are worth $100/hour. Although we don’t get paid this much, that is the average payment to the clinic. We may have an excellent front desk staff and only have to provide the same amount of value as the cost of our salary, but I believe that we should be conveying the cost of the session, which may be up to 3 x the amount we actually receive in payment.


“What are the costs associated with the care we deliver? Co-pays, coinsurance, and deductibles question? ”


These are the basics to consider when treating patients. Patients sacrifice their times to come see us. Patients sacrifice time away from family to come see us. Are we providing the value, beyond the monetary value, to the patient? Human connection has value. I provide value to my patients not just through treatment, but also through that human connection.


“Now look at the benefits: what are the benefits we offer our clients through physical therapy?”


It’s easy for me to say functional outcomes. Patients at this point in time, do not know what that means. My job is to take the patient’s wants and needs and turn those into results. I have my own functional needs, but it would be wrong of me to impose my functional needs onto the patient. Some patients are quite content to sit in a wheelchair all day long instead of putting the work in to stand up. The best I can do is to educate the patient. If after education, I can’t motivate, then I can’t help that patient. We make the assumption that patients coming to therapy are ready to get better. This is not always the case. I see patients frequently that are only coming to therapy because their doctor told them to go to therapy. There was no indication as to what therapy would actually do to help the patient. If they are not ready to change, then it is very difficult to help that patient.


“patient’s assume they will get better when they see us”


Malarkey! At no point in time am I providing divine intervention. No one gets better simply by breathing the air I breathe (although this is one of the jokes in my repertoire). I am sure that my patient understands they will only get better when they take ownership over their problems.


If you are that patient, and you are ready to change, then there is help. When patients understand the problem and takes ownership of the problem and then performed the treatments in order to treat the problem, there very few patients that will not improve. Some physical therapist, such as myself, believe that we hold the answers to fix our patients. Robin McKenzie many, many years ago stated that the patient has the answer, our job is to bring that answer out. I would be arrogant of me to think that I am that answer.


Again, I went off on a tangent, but I did not believe that the rest of this article held any additional information that would be benefit to you.


Excerpts taken from

Quatre T. WHY THEY BUY: Because They Can Calculate Your Value. Impact. July 2016: 11.

Does taping in addition to PT provide increased benefits?


This is a look at a popular form of taping using in the PT profession. This was popularized in the Summer Olympics years ago and has increased in usage in the PT profession, regardless of what the evidence states.


  1. “Low back pain is a significant public health problem that affects approximately 39% of individuals worldwide at some point in their lifetime”


This is like beating a drum. If you follow the blog, I have written many times over the year regarding how expensive back pain is in the developed countries. One aspect that surprises me is how low this number actually is. In other articles, it talks about the lifetime prevalence rate between 70-80%. I would have to surmise that “worldwide” changes this number. I don’t have the reason why, but I have my guesses. I would guess that those “undeveloped” countries are spending less time on their kiester and more time either in a deep squat or standing position.


  1. “Several interventions commonly used by physical therapists, such as manual therapy techniques and exercises, are endorsed in most guidelines as effective treatments for patients with low back pain…”


Moving is better than not moving (in most cases). It’s funny because when I was a personal trainer (many, many years ago) I used to think of Physical Therapists as overpaid personal trainers. I completely disagree…sometimes. Don’t get me wrong, there are some PT’s that only prescribe 3 sets of 10 repetitions because it is traditional and for those PT’s I would agree that they are overpaid personal trainers. When prescribing exercise, we always have to think; “what’s the goal”. If the goal is pain reduction, than 3 sets of 10 may not be appropriate. If the goal is absolute strength or power or endurance, then 3 sets of 10 may not be appropriate. If the goal is hypertrophy…you got me…it may be appropriate for some patients for some muscle groups. In the end, 3 sets of 10 for everyone is no better than 3 sets of 5.


This isn’t meant to blast the PT profession, but if you are being treated in PT…Look around! If you are doing the same exercises as everyone else, then you have to question whether you are exactly like everyone else?


  1. “Kinesio Taping method was introduced at the Olympic Games in Athens and has since gained in popularity”


We have seen these tapes for the most part. The colorful tape worn on shoulders or backs of athletes. In the summer games, especially for women’s volleyball (I’m sure other sports have them, I just seem to watch more of this than anything else except for weightlifting), these colorful tapes are apparent. I use the tape, not for the reason indicated, but it makes for a great thumb wrap when using the hook grip in weightlifting.


  1. “The evidence of the benefits that Kinesio Taping can provide for patients with chronic low back pain is still scarce”


I could sell a cup of water to a drowning person in the ocean. I could easily sell Kinesio taping to my patients and others in the athletic arena, but I have yet to read a well-performed study that shows it is better than not using Kinesio tape. It’s the modern day ultrasound…It works until it doesn’t.


  1. “There is no current evidence to support the use of this method.”


This is not to say that it doesn’t work…yet, but of the studies performed thus far…it doesn’t work. One of two things will happen over time: 1. The company(ies) that sell the tape will continue to publish their own case studies to show the efficacy and/or 2. The peer reviewed journals will stop publishing all of the negative studies because academia will stop performing studies that consistently give the same results.


  1. “…the objective of this randomized controlled trial was to compare the effectiveness of adding Kinesio Taping to a physical therapy program in patients with chronic nonspecific low back pain.”


This is a well-performed study. Randomized doesn’t mean that the study is done randomly or half-assed, but the people in the study (guinea pigs) are separated in a scientific manner.


6a. Misc: There is a bunch of instructions for how the study was actually performed in the Methods. This is boring to the non-medical reader, and sometimes boring for those of us that read research. I will spare you the details. Just know that the study is well-performed.


  1. “The group that received physical therapy plus Kinesio Taping had the elastic tape applied to the lower back at the end of the sessions”


Essentially, if the tape is to provide greater benefit than exercise alone, this group should outperform the exercise-alone group in the data measured.


  1. “The corresponding author is certified by the Kinesio Taping Association International and provided training to the therapists on how to apply the Kinesio Tape”


This is important. If there is a method to perform on a patient, but the participating therapists are not certified in the method, then it could be that the practitioner doesn’t know the method well enough to perform the method. Since at least one of the authors is certified, it would make this a moot point.


  1. “After 5 weeks of treatment, the between-group comparisons showed no advantage of using Kinesio Taping in these patients for all primary outcomes…the addition of Kinesio Taping to physical therapy did not enhance treatment outcomes at any point in time.”


Crickets chirping………….Enough said.

  1. “Our data corroborate the results of 3 previous randomized controlled trials that do not support the application of Kinesio Taping in patients with chronic nonspecific low back pain.”


This means that if you want to tape your thumbs in order to lift weights, then go ahead, but using this type of tape (there are many different manufacturers of this type of tape) for back pain may not be ideal.


QUOTES TAKEN FROM: (Also, the initials of the first author is actually MAN, that’s awesome)


Added MAN, Costa LOP, De Freitas DG, et al. Kinesio Taping Does Not Provide Additional Benefits in Patients With Chronic Low Back Pain Who Receive Exercise and Manual Therapy: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2016;46(7):506-513.

Unleashed upon the world

I work in a small community hospital. At this hospital, I have been blessed to work with people that are really good at what they do. We all expect excellence with our specific niches, and it’s great to call them colleagues.

In this location, I also get many students (physical therapy students) and volunteers (hopeful to get into PT school). There are some students that I wonder how they got into the program and they force me to worry about the direction that our profession is going. This has nothing to do with knowledge, but with passion, excitement, initiative, confidence, and people skills.

Every once in a while I come across students that make me sit back and enjoy. It’s like watching a Picasso at work. They have people skills mixed with passion, integrity, knowledge and time spent in the books.

It’s disheartening to hear of some student’s clinical internships. For instance, a recent student’s experience was nothing more than that of a PT mill. The student reports doing the same intervention to all patients with a similar diagnoses. There was no classification, there was no critical thinking and the student then passed the patient off to an aide once the manual therapy portion of the session was over.

This is why I am an CI. Students deserve to learn the craft of Physical Therapy. There are many short-cuts. There are ways to maximize profit, but the ways to maximize profit, by performing said short-cuts, doesn’t typically translate into proper patient care.

We all have what’s called the sniff test. If it smells bad…it probably is. I take mine a couple of steps further and call it the “I’m disappointed in you” test. I’m 36 years old and can remember the one and only time that I heard these words from my Dad. It hurt enough that I don’t want to hear those words again. When I am practicing and treating patients, I think to myself; “Does this pass the sniff test? Would my Dad be disappointed with how I treated a patient?” It doesn’t take much people.

We recently were required to take 3 hours of ethics courses per renewal period (every 2 years). I know…it doesn’t sound like much, and it isn’t, but these 3 hours that I spend “learning” ethics are 3 hours that could be spent learning the latest/greatest interventions to treat problems. You know why we have to take ethics courses? Because there are some in our profession that are not practicing in an ethical manner. Mr. Pelligrini from Providence (my high school), on day one, wrote a big dollar sign on the chalkboard (do they even use these anymore?) and he proceeded to walk up to the $ and bow to it. This was day one. In high school, he was probably the hardest teacher that I had, but having grown a little older and more mature, that guy was so full of knowledge that is coming true during these times. I won’t go into it, because I am trying to avoid political blogging, but just know that he was wise beyond his years.

Unfortunately, many in our profession are bowing down to the almighty $. Why? When I poll students, they are graduating with over $150,000 of cumulative student loan debt. These students have a house payment…without the house. Therefore, these students will be forced to make decisions that take salary and bonuses into account. I have listened to over years of Dave Ramsey on the Podcast and unfortunately most students don’t live by his principles. Hard at first, but allows for ethical decision making professionally. When students don’t have to worry about how they are going to pay back their student loans, they can make more altruistic and personally satisfying decisions in his/her career, instead of chasing the $.

If you are applying to PT school, do your research! How much is that school going to cost you in total? Are there scholarships? How much is that school going to cost you per month when you graduate? Can you graduate without taking on any debt? How much will your starting salary be? What type of lifestyle do you want to lead and will this profession allow for that type of lifestyle?

Having lectured to many students prior to getting into the profession, many students have never even considered these questions. It’s sad, but it becomes easier for companies to play the puppetmaster because it is known that the students have to pay that loan monthly and they can’t do it without a high paying job.

Schools need to hear this and start offering financial planning courses. It’s sad that we take a student and have them rack up $150,000 in debt, but never prepare them for how to start paying that money back, saving for retirement, choosing an ethical job position, etc.

I went on a rant, but it’s on my mind this morning.

CAT of the Oswestry and Roland Morris

A Critical Appraisal of the responsiveness of a patient specific outcome measure compared with the Oswestry Disability Index v2.1 and Roland and Morris Disability Questionnaire


P: For patients with at least a six week history of back and/or leg pain

I: is the patient specific outcome measure

C: as compared to the Oswestry Disability Index and Roland and Morris Disability Questionnaire

O: as responsive



Vincent Gutierrez, PT, MPT, cert. MDT



Ovidsp with title term of “Oswestry”. The results were limited to full text.   73 citations were found with no limit to year published.


Date of Search: February 22,2014



Frost H, Lamb S, Stewart-Brown S. Responsiveness of a Patient Specific Outcome Measure Compared With the Oswestry Disability Index v2.1 and Roland and Morris Disability Questionnaire for Patients With Subacute and Chronic Low Back Pain. Spine 2008;33(22):2450-2457.




The purpose of this study is to assess the responsiveness of the Patient Specific Activity Questionnaire compared to the Oswestry Disability Index v2.1 and the Roland and Morris Disability Questionnaire.


The inclusion criteria were subjects at least 18 years old, with at least a 6-week history of low back pain. Subjects with or without leg pain and/or neurological signs were also included. Subjects were excluded for the following: serious pathologies, gynecological problems, ankylosing spondylitis, tumors, infection, past spinal operations, pregnancy, serious spinal pathology, unable or unwilling to complete questionnaires independently, received physical therapy in the previous month or were referred for intensive functional restoration.


The subjects were randomized to either a physiotherapy advice group or an advice with additional physiotherapy intervention group, which was not described. The subjects completed the following measures both prior to intervention and after 12 months: the Patient Specific Activity Questionnaire (PSAQ), the Oswestry Disability Index v2.1 (ODI), the Roland and Morris Disability Questionnaire (RMDQ), and the Global Transition Rating Scale (GTRS).


Subjects were divided into three groups, based on the GTRS, after 12 months: better, same or worse. The change score was calculated by subtracting the baseline scores from the follow-up scores for the ODI, RMDQ and the PSAQ. A relationship was established between the GTRS and each of the latter three outcome measures using 1 way analysis of variance (ANOVA).


Of the 286 subjects randomized initially, 201 completed the follow-up questionnaire. The PSAQ is responsive among subjects noting improvement, but is less sensitive to those reporting no improvement, when compared to the ODI and RMDQ.



The validity of the study is questionable, as there are flaws in the design. The authors do not account for the patient’s lost to follow-up, which may alter the results of the study. The authors fail to note the differences between the two groups at baseline, with regards to demographics. The authors note that a P value of <0.01 was utilized to differentiate among the outcome measures, which provides for a more limited confidence interval to detect true change.


The authors note the area under an operating receiver operator curve as follows: ODI as 0.752, PSAQ as 0.751 and RMDQ as 0.689. This indicates the order of responsiveness to change respectively.


Because the study results indicate that the tested outcome measure (PSAQ) is less sensitive to those patient’s with little change in status pre-post intervention, it would be prudent to utilize an outcome measure than can assess both small and large changes in status, such as the ODI and RMDQ.



With patients presenting to the clinic with complaints of at least a six week history of low back pain, with or without leg symptoms, the ODI would be the most effective to assess change.



Good Ole Days…Gone!

  1. “When I graduated from physical therapy school, therapists expected to work for someone and had abundant choices in location and specialties. The expectation was for a good paying job with ample opportunity to learn from mentors and a patient load that would allow for generous one-to-one patient time. It was also expected that the salary would afford an improved lifestyle and cover the payment of their low-interest student loans”


Wow! This was a mouth full! Let me start by saying…those were the days (in the Edith Bunker voice). If you don’t know Edith, go get some culture!


Prior to the balance budget of 1997, jobs were a plenty and the salary was good. Unfortunately this is also one of the situations responsible for the need of a balanced budget. People were seeing patients for such a long time and Medicare, and other insurance companies, continued to pay for any and all treatment issued. This was regardless of need. Can you imagine that in today’s day and age? We shot our own foot by over treating and creating the spa-type environment in which everyone got ultrasound, hot packs, electrical stimulation, and massage. That’s not very physical for being physical therapy. Those days are long gone and welcome to modern times. Students are taking out between 100-200K in order to earn the right to make 65K to start. Doesn’t sound like living the dream to me.


  1. “The emphasis on cost containment and required documentation has created an atmosphere that does not support the very reason that most of us went into this field in the first place: ‘patient care’….Student loan debts compared to starting salary make a potential physical therapy student consider other options that have better financial outcomes.”


I have this discussion with prospective students often. If you think that being a Doctor of Therapy sounds lucrative, think again. Depending on school choice and loan terms, the school could cost in excess of 500K (when interest over time is accumulated). We make good money, but retirement will have to be sacrificed in order to pay off student loans. Once ours are paid off, then we have to worry about providing an education for our children. Good luck in this profession! It has treated me well, but I don’t live an extravagant life either.


Quotes taken from:


Brown TC. From the President: Come Together Right now. IMPACT. July 2016:5.

key to unlocking pain

The Audrey Long article is commonly cited as one of the landmark articles for those of us that treat spines utilizing directional preference and centralization.  As well it should be! The results are unbelievable.  This researcher…I take that back…clinician performing research in the clinic published an article that, up until this time, was only speculation.  How could patients not get better using evidence based practice?  For a long time, the evidence was based on expert opinion and not really research.  I enjoy reading the publications on spine and it is interesting to read the changes in the Clinical Practice Guidelines for Low Back, published in JOSPT over the years.  Prior to the most recent publication, flexion based exercises were the rage and directional preference was only moderately supported.  Thanks to clinicians such as Audrey Long, this type of treatment has gained more support in the practice guidelines.  When I was in PT school (I sound like an old man, and year to year this is true, but not yet) this was a very small talking point in our curriculum.  Students now come out of school with a better awareness, though not a true understanding, of the concept of directional preference.


A Critical Appraisal of Directional Preference Exercises Compared to Two Other Exercise Paradigms


P: For patients with low back pain, with or without leg pain, demonstrating a directional preference

I: is treatment with a directional preference

C: as compared to treatment in the opposite direction of the directional preference or an evidence based approach

O: more beneficial when compared with subjective outcome measures



Vincent Gutierrez, PT, MPT, cert. MDT



Pedro.org with the keyword terms “directional preference and low back pain”. Nine results were found and the article with the highest score was chosen.


Date of Search: February 15,2014



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.




Eleven clinics, from five separate countries, participated in the study. Consecutive patients presenting for treatment of LBP, with or without leg pain, were asked to participate in the study. The inclusion criteria is as follows: consecutive patients with low back pain, with or without one neurological sign, age 18-65 years and demonstrating a directional preference. The exclusion criteria is as follows: cauda equina, two or more neurological signs, spinal fractures, post surgical, off work for one year or more due to low back pain, medical causes, uncontrolled medical conditions, pregnancy, inability to read English (except for those from Germany), patients with prior knowledge of, or specific physician referral for, the Mckenzie method, or no directional preference (DP) elicited.

Therapists credentialed or diplomaed in the McKenzie method performed the assessments. The directional preference was noted as either extension, flexion or lateral, but the subjects were shielded from the significance of directional preference. The subjects were then randomized to one of three groups: matched directional preference exercises, opposite directional preference (ODP) exercises, or evidence-based care (EBC). There were no baseline differences among the groups regarding demographics

The subjects attended at least three and no more than six sessions over the course of two weeks. Those in the DP group received exercises that matched the DP and were instructed to avoid all activities that increase intensity or radiation of symptoms. Those in the ODP group received exercises that were opposite to the DP, and the EBC group performed mid-range exerices and stretches for the hips and thighs. The final two groups also were instructed to return to remain active.


The outcome measures utilized in the study are as follows: back and leg pain intensity ratings using an 11 point visual analogue scale, the Roland Morris Disability Questionnaire (RMDQ), and medication use.


Five hundred three subjects were assessed and 230 demonstrated a DP as follows: 83% extension, 7% flexion and 10% lateral. Twenty-nine dropped out of the study at two weeks, and the remaining 201 were eligible for analysis. There were 36 withdrawals, which indicated that the subjects worsened or had no change in symptoms and were transitioned to alternative care. None of the DP group withdrew, but 16 in the ODP and 20 in the EBC withdrew. All outcome measures improved in the three groups over the course of two weeks, with the DP group demonstrating significant improvement compared to the ODP and EBC.



The authors satisfied eight of the ten questions regarding the Quality Appraisal Checklist. The subjects’ group design was not blinded to those enrolling the subjects and this was a comparison study of varying interventions, which indicates that a true control group was absent.


This study will have a direct impact for clinical therapists. Because this study compared three different interventions, opposed to identifying the efficacy of a single intervention compared to a control group, it mimicked clinical practice. The authors compared evidence based care with a directional preference treatment paradigm, which would be similar to a question asked in clinical practice.



Directional preference exercises are superior to performing exercises opposite to the directional preference or “evidence based care”. Patients that demonstrate a directional preference and are treated accordingly perform significantly better in outcomes measured in this study. There appears to be no harm in treating a patient with directional preference exercises, but the same does not hold true for performing exercises opposite of the directional preference or “evidence based care”.

The following is breakdown of the systems involved in “assessing” research articles.


  1. Were the subjects randomly assigned into groups?

Yes. The subjects were randomly assigned to one of three groups.


  1. Was each subject’s group assignment concealed from the people enrolling individuals in the study?

No. Because the study is a multi-centered study in outpatient practice, it was not acceptable to the authors to have patients drop out of the study due to changing therapists.


  1. Did groups have similar characteristics at the start of the study?

Yes. The authors note that there were “no differences among the three treatment groups in any baseline demographic characteristics or outcome measures.”


  1. Were subjects masked or blinded to their group assignment?

Yes. Although subjects couldn’t be blinded to the treatment, they were unaware of the specific grouping (i.e. matched vs unmatched vs EBP)


  1. Were clinicians and/or outcome assessors blinded to the subjects group assignment?

No and yes. Although the clinicians were not blinded, which is common in practice, the assessors of the outcome measures were blinded. The outcome measures were subjective measurements in order to minimize therapist bias.


  1. Did the investigators manage all of the groups in the same way except for the experimental investigation?

No. Because this is an intervention study in patient’s seeking treatment, it was impossible to withhold treatment to establish a true control group. The types of treatment for the opposite direction and EBP groups were vaguely described.


  1. Did the investigators apply the study protocol and collect follow-up data on all subjects over a time frame long enough for the outcomes of interest to occur?

No. There was a 12% dropout rate, which was anticipated by the authors when determining the number of patients needed to maintain a power of .90. Thirty-eight patients withdrew from the study, as opposed to dropped out, due to no improvement or worsening of symptoms in the EBP and unmatched group. Two weeks was long enough in order to assess change.


  1. Did subject attrition occur over the course of the study?

Yes. Twenty-nine subjects dropped out of the study, with 12 of the 29 dropping out due to no change or worsening of symptoms. Although these participants did not “drop out”, indicating that follow-up information was unattainable, 36 subjects withdrew early due to no change or worsening of symptoms. No subjects from the matched group withdrew. Those that withdrew completed the outcome measures prior to 2 weeks in order to seek alternative care.

Slump test: what’s it mean?

This is a common test performed in the clinic. The article goes into great detail (again not written about here because I don’t really have an opinion about the technique) of how to perform the test. I highly recommend reading the article for all health care practitioners that care for patients with spinal pain.


  1. “neuropathic pain (NeP) as “pain caused by a lesion or disease of the somatosensory system”


This is a great start to what will be a good read. If I were to say this to most PT students that come into my clinic, I would get the “Bambi in the head light look”. The fastest way to say this is that neuropathic pain is a pain that may be coming from a structure that is innervated (has nerves). This doesn’t really tell me anything though.


  1. the presence of NeP has been linked with poor recovery, along with higher health care costs and lower quality of life.”


This makes sense to me. If you have pain, that is coming from somewhere, you are more likely to require more treatment than someone that has pain coming from nowhere and are less likely to enjoy your life than someone that is pain-free.


  1. “The diagnosis of NeP typically consists of a thorough history and an extensive neurosensory examination to identify both positive (exaggerated responses to stimuation, such as allodynia) and negative (various sensory and motor losses) signs…usually performed by a specialist, requires a lot of time to complete, and in many regions involves a long waiting period for the consultation”


As a Doctor of Physical Therapy, I happen to be said specialist. This type of patient typically takes longer to evaluate than someone that only consists of weakness or deconditioning. There is much more to look at. I don’t know if I would say that it involves a long waiting period for the consultation. I think that this has more to do with a person’s type of insurance regarding wait time. For instance, if you are willing to pay out of pocket for the assessment, and pay what the “chargemaster” (an inflated charge board that no one ever really pays…unless they can’t afford insurance) states, then I am sure that I can fit you in for a $400-600 evaluation tomorrow. (We don’t actually make that much for an evaluation, but insurance companies would love you to believe that we do).


  1. “The straight leg raise (SLR) test is the most commonly used neurodynamic test for the lower extremity. The slump test is another…”


The SLR test is easy to perform and most physicians are aware of its implication in discogenic pain. I include it when I am trying to make a point to physicians and insurance companies regarding a possible pain generator. I prefer to use the slump test because it is easier for me to test when I already have the patient sitting in the chair testing lower extremity strength (testing nerve electrical power). If I have a positive slump test, then I will typically perform a SLR test in order to “paint a better picture” of the patient to the insurance company.

  1. “Key components of the clinical exam included pain (location, behavior, quality), motor function (strength/weakness, reflexes), sensory function (mechanical/thermal sensation), autonomic function (sweating, hypotension), and the SLR test”


You’d be surprised (or may you wouldn’t if this also describes you) regarding how many patients are surprised that a PT would take their blood pressure. I read a statistic years back regarding the following: 50% of patients seen in an outpatient clinic have undocumented hypertension. I can’t tell you how many times I have had to stop a session to call a doctor to inform them of a patient’s hypertension. I had one patient argue with me years ago that he wasn’t there for blood pressure issues, but to have his pain fixed. Unfortunately, his BP was higher than the maximal allowable threshold for exercise and I sent him back to the doctor. (Mind you, my current state is not a direct access state, which means that the patient had to be referred by someone prior to coming to therapy). The patient was apologetic the next session when the doctor told him what the numbers could mean regarding DEATH! That’s right…I save lives. Just kidding, but not really. If you see a therapist, your blood pressure should be checked at least on the first visit. If it is not, question the intentions/ignorance of the therapist. Could be oversight on the therapist’s part. I used to be that therapist.


Also, your sensation and strength should be tested in certain circumstances. Again, just ask your therapist why/why not the above testing was/wasn’t completed. There should be a good rationale for the answer. We love to teach…at least I do.


  1. The authors of the article did an excellent job of describing positioning for testing, so if you are in health care and would use the slump test, it is a good refresher. Highly recommend it.


  1. “…designated as positive if the following conditions were met: (1) pain or sensations were reduced with neck extension, and (2) there was a right-to-left difference in pain distribution or there was a difference between right and left knee extension.”


This is something that most PT students, and I must surmise that new professionals miss while in the clinic. This is the small details of the test. Is there a loss of knee extension on one knee? The only way to know is to have someone teach it to the student or for the student to go out on his/her own to learn it. What profession are you in? In your profession, who is the best in your workplace? What separates that person from anyone else in the workplace? Usually it is initiative, persistence, self-learning, confidence, experience, etc. This same thing can be said for the PT profession. We aren’t all born with these characteristics; they are honed over years of working and studying. If all we do is work, then we may gain experience, but the experience may be that of missed details.


  1. “From these data, a difference of 10 degrees or more was used to indicate a positive slump test component.”


Again, small details. Many students are not looking at the angle change in the slump test and although 10 degrees is small when eye-balled, it can be huge when it is the difference between being able to stretch out and push the gas pedal with or without pain.


  1. “very little can be interpreted when the slump test is positive but the pain does not extend below the knee.”


Students need to know this stuff! We learn in school that if it produces pain, that the test is positive, especially if the pain is reduced when the patient is then asked to look up. This means little in terms of telling us important information.


  1. “The sequential combination of the 2 tests provided an effective means of ruling out those without NeP and ruling in a large proportion of those with NeP.”


This is important for students and PT’s to understand. If the patient has no pain production with the slump test, then “nerve pain” can effectively be ruled out due to the small rate of false negatives. When a patient has pain below the knee, then “nerve pain” can be ruled in.


This was an excellent article going more in depth than anything we learn in school. I have been using this test for years and have slowly incorporated the information into practice over the years, but I now know that there is a good reason to look at the knee extension change. When studying the McKenzie Method (MDT), we are taught to look at the angle changes when performing these “dural tension” based tests. It is informal when taught in the course, but here is the formal information.


Quotes taken from:


Urban LM. Macneil BJ. Diagnostic Accuracy of the Slump Test for Identifying Neuropathic Pain in the Lower Limb. J Orthop Sports Phys Ther. 2015;45(8):596-603.

Traction: useful or not?

I use traction sparingly. It is a last resort if the patient is going to have a surgery. If I have tried everything in my power and knowledge to help a patient, and the patient continues to not improve, then traction it is. It is my Hail Mary.

  1. “Physical therapists may choose from myriad intervention options for LBP, but the effectivenss of many of these options is questionable”

Do you feel good about coming to therapy yet? An awesome question to ask your therapists is; “What does the research say about xyz?” or better yet “Does the research support xyz for my condition?”

It’s funny, in school we all learn that ultrasound brings more blood flow to an area…SO FRIGGIN WHAT? Does that blood flow actually fix me? Not really, but it brings more blood flow! That’s an expensive transportation of blood. Do you know what else brings more blood flow…Hickies. That brings more blood flow. Ask your therapists to suck on your skin for a while to see if that will also bring more blood flow. It will probably cost you a little more for that service though…I digress. There is not much, if any, CURRENT research that supports the use of ultrasound for back pain. If your therapist tells you that ultrasound will help, ask how? If they tell you the blood flow thing…ask them to pucker up.

  1. “Authorities have recommended traction for conditions including protruding Intervertebral discs, spinal muscle spasm, and general pain and stiffness”

This is what I learned when I was in school. Seems archaic that we were taking general recommendations from “authorities” to try to fix the second largest complaint to the common cold. At least research has advanced from the opinion of authorities.

  1. “several systematic reviews and clinical guidelines conclude that the effectiveness of traction is limited…little evidence to recommend traction…clinically important benefits of lumbar traction were demonstrated for neither acute nor chronic back LBP…traction should not be used…41% of the physical therapists in the UK used traction”

Boy can those statements be any stronger. Traction should not be used because it is not very effective for low back pain (LBP). Now if you want to use traction because it makes you feel better, then go ahead. Sugar pills work for some people also. (Not trying to come across as sarcastic, but I’m sure it sounds that way). If you have preference for a specific intervention, then that intervention may be likely to help you. I have a patient that believes that ultrasound of the back muscles helps. No matter how much education I have provided, I’d be better off talking to the wall. Needless to say, we have a great conversation during the ultrasound, while the patient is propped up on his elbows and lying on his belly. For those that know, these positions can help/fix up to 65% of back pain patients.

  1. “Our findings suggest that a majority of APTA Orthopaedic Section members use traction…In contrast, approximately one third of respondents indicated that they would use tractions for patients in a manner that is contrary to that classification”

There is a clinical prediction rule in the derivation (creation) phase that indicates a certain type of patient may benefit from traction. This is less than 10% of the patients in the clinic. This rule has not been replicated yet, so it is more like an educated guess at this point. Other research has reported the above, in which traction has no added benefit to an exercise program. Also, exercise increases blood flow (see above). The sad part is that about 1 in 3 therapists are using traction contrary to how it should be used. Have you seen that therapist? They are typically the ones applying hot packs, Hickies and massage.

  1. “employing soft tissue mobilization or massage was identified by approximately 65% of our respondents as a supplement to traction. Given limited evidence for the effectiveness of massage for treating LBP…the extent to which physical therapists in the United States use soft tissue mobilizations/massage in managing LBP may be concerning”

WOW! I was totally talking out of my a$$ in the above paragraph, but my a$$ is also supported by research. Who knew?

  1. “there is a growing body of evidence that higher levels of professional preparation influence clinical decision making and, potentially, patient outcomes”

Look there has been a backlash in our profession for what is called “alphabet soup” after our names. This means that some therapists have gone on for “extra” training and certifications. This is important. Unfortunately, our profession has deemed it inappropriate to put down all of the certifications after our name. The only way to know what your therapist knows is to ask. I personally have the initials:

DPT (Doctor of Physical Therapy), cert. MDT (certified in Mechanical Diagnosis and Therapy). None of the above initials were given to me…I earned them.

Thanks for reading this. If I go overboard at times and offend you, there are other blogs to read. Have a good night.

Quotes taken from:

Madson TJ, Hollman JH. Lumbar Traction for Managing Low Back Pain: A survey of Physical Therapists in the United States. J Orthop Phys Ther. 2015;45(8):586-595.