Not knowing versus not learning

“Ignorance: a limited understanding of all the relevant physical laws and conditions that apply to any given problem or circumstance”

I don’t think that this is much of a problem in the physical therapy profession for the basic concepts of the profession.  The issue of ignorance comes into play when we start discussing current evidence.  A new graduate’s primary responsibility is to pass the boards ( a national test in order to determine basic competency in order to practice as a PT).  Unfortunately, the boards are based off the books used during the physical therapy program and the books are based from research that is at least 5 years old or older.  This means that the students are being tested on material that is greater than 5 years old.  Current published research may not make its way into an educational programs curriculum due to time constraints.  In this fashion, the students may be ignorant to current research or niche research.

“Ineptitude: meaning that knowledge exists, but an individual or group fails to apply that knowledge correctly in a particular circumstance. “

This is common.  We know that therapists are not staying current with published research.  Time and access are two barriers to staying up to date on the research.  Just a quick example.  I dedicate 10 minutes per day to reading.  Even 10 minutes per day is hard to fit in with all the other hats that I must wear such as: business partner ( , father, husband, running a separate Facebook page that interviews influencers and performing community lectures.  There is only so much time in the day and I can understand how some therapists will have a difficult time fitting learning into their day.  Barriers to obtaining current research can be the cost of a subscription to get the journal articles.  For instance, I pay over $1,000/year just to have access to research.  This is a big chunk of money when you consider all the other life activities that aren’t free.  Pair this with the fact that the “average” salary for PT is 80,000 ish and that students have well over $100,000 in debt.

, that $1,000/year over the lifetime of a career becomes expensive!

“For instance, through numerous scientific breakthroughs, there has been a repudiation of ‘folk’ treatments in our profession-such as hot packs or ultrasound for heat therapy-in favor of treatments based on scientific evidence.”

Going to PT should not resemble going to a spa! If you are going to PT and getting electrodes placed on you…getting hot packs placed on you…getting rubbed with gel while someone is moving a wand on your skin…or getting a rubdown…THAT IS NOT PHYSICAL THERAPY! On the flip side, PT should not resemble personal training! Going to your therapist and getting a list of exercises for you to perform independently while your therapist is chatting with others…IS NOT PHYSICAL THERAPY! The closes profession that I can equate therapy to is that of a teacher-student (and not always is the therapist the teacher!).  This healthcare relationship should be a personal relationship that takes place in a private setting allowing for open communication between the therapist and patient.  The patient should walk out of each session with more knowledge than they walked in with. The patient should understand why interventions are performed…or better yet why some aren’t performed.  We need to get away from the tradition of PT and move towards what the evidence tells us.

“However, despite the excellent EBP (current evidence) resources now available, ineptitude remains a major 21st century challenge in medical and rehabilitation care”

I have a dare for all of you reading this.  When you go see your next healthcare practitioner I want you to ask a simple question: “How much education do you get every 2 years?” In PT, we are required to get a minimal amount of continuing education to maintain our license.  DO YOU WANT TO BE TREATED BY SOMEONE THAT IS ONLY GETTING THE MINIMAL AMOUNT OF EDUCATION OR SOMEONE THAT IS DEVOTING TIME TO FURTHER THEIR KNOWLEDGE OUTSIDE OF THE MINIMAL STANDARDS FROM EACH STATE!

“…3 types of influence that have been shown to relate to the rate of spread of an innovation: (1) perceptions of the innovation, (2) characteristics of those who adopt the innovation or fail to do so, and (3) contextual factors”

The following will discuss how these all relate.

“First, the perceived benefit of the proposed innovation relative to its cost is the most powerful influence.”

For instance, a hot pack may not give much benefit, but it is cheap and relatively safe.  You will see this frequently in a PT clinic that sees a high volume of patients because of its relative ease of use and safety…assuming the therapist is asking you how you’re doing and checking a few things before, during and after.

Cold laser treatment is slower to take off in our profession because it is an out of pocket intervention…which means that your insurance company won’t pay for it regardless of whether it works.  This intervention is slower to be used in the clinic because it may be cost prohibitive for some patients.

“Second, rapidity of change is directly related to how compatible the innovation is to values, beliefs, and history.”

There are some “treatments” that become popular during years of summer Olympics.  In 2012, a specific brand of tape was seen on many of the “big name” volleyball players.  The thought was that it “kept things more supported”.  There is no research that conclusively states anything near this type of statement…but there is a lot of research that says the opposite.  We still see it used in clinics today…which is okay, if the rationale for using it is what is intended from our current knowledge base.  For instance, we know that it reduces pain and allows for increased ROM…sometimes.  If the patients are educated in this regard and not that it “keeps things in place” …go for it.  It seems like 2016 was the year of the octopus.  If you looked at one of the “world’s most famous swimmers”, it looked like he wrestled with an octopus underwater.  This technique has been around for centuries.  Some therapists are starting to do it because patients are asking for it.

“Third, the complexity of an innovation affects the rate of its adoption, and, as expected, simple innovations spread faster than complicated ones.”

Ultrasound, electrical stimulation, and traction are all very easy to perform…since the machine does most, if not all, of the work.  These were quickly adopted into our profession and are hard to convince some clinicians to stop using…regardless of what the evidence states.

More complicated interventions such as “critical thinking” are harder to adopt.  For instance, when assessing a patient with back pain or vestibular issues, there is a plethora of research showing that if we can classify it that we have a better outcome.  Classifying the problem requires (1) knowledge, (2) assessment, (3) application, which is a lot harder than just pushing a button on a machine.

Some of the personality types are as follows: 1. Innovators, 2. Early adopters, 3. Early majority 4. Late majority, 5. Laggards

A lot of these are self-explanatory, but it trends from those that jump onto something quickly to those that just hate change.

“Organizations that foster social exchange among its members are likely to see faster adoption of innovations as compared with institutions and organizations that foster habits of isolation and tradition.”

Essentially, workplaces that allow for communication will allow for change faster than workplaces that keep everyone separate.  This has to do with changing a culture.  A business that has a fluid culture (one that is easily adjusted), is more apt to change than one that has a strict culture.

“Publishing our work in journals is essential-but publication of research is not, by itself, sufficient if our goal is to change clinical practice. People follow the lead of other people they know and trust when they decide whether to take up an innovation and change the way they practice!”

This is huge! Any profession is a small world and PT is no different.  To push the profession forward, we must depend on more than just published research.  There are many influencers in our sphere such as Dr. Ben Fung, Dr. Jarod Hall, the team from PT on ICE, the team from Evidence in Motion, Dr. Richard Severin, and myself (I’m always trying to sneak my way into this group of titans).  By seeing others lead the way, it is much easier to follow.  Only the innovators and early adopters will feel comfortable at the front of the pack.

As a patient and therapist, you may want to assess your therapists/mentor and determine which of the 5 personality types he/she has.


Thanks for reading.  Please leave a comment on my FB page letting me know what you think.


Jette AM. Editorial: Overcoming Ignorance and Ineptitude in 21st Century Rehabilitation. Phys Ther. 2017;97:497-498.


link to abstract


Wait…PT’s perform manipulations?!

Wait…PT’s perform manipulations?!


“Without the ability to match patients to specific interventions, clinicians are left without evidence or guidance for their decision-making”


This couldn’t be truer. If we believe that all patients with back pain are the same, then we will give all patients the same treatment. If not all patients respond to the same treatment, then we can say that not all back pain is the same. We have to be able to classify which patients are most likely to respond to a specific treatment; otherwise we are just throwing spaghetti at a wall and hoping that some sticks. When a patient walks into the clinic, I am forming hypotheses as soon as I see the patient get out of the chair in the waiting room. By watching a patient move from the chair to walking and from walking to sitting, we can start to assess pain response (facial expressions) and movement quality (upright versus bent forward or sideways in addition to stride length of the legs and how much rotation is happening with arm swing). We can also have a short chat with the patient to determine how the patient describes their symptoms. Some patients are okay with waiting until we get to the private area before telling their story and others just want to start unloading their story before I have pen to paper to write things down. These are all of the actions that I take into consideration before we even get to the room to assess the patient.


“Identifying methods for classifying patients with LBP has been identified as an important research priority”


Why do most things matter…MONEY! We as a country lose almost $100 billion per year on back pain. This is a lot of money. If we were to put in a dollar every second to pay for this, it would take 31 years to equal $1 billion! As you can see, LBP is an ailment that we have to figure out in order to keep healthcare solvent.


“The purpose of this study was to develop a clinical prediction rule for identifying patients with LBP likely to respond favorably to a specific manipulation technique.”


This is a derivation study, the first step of trying to come up with a clinical prediction rule. One must understand CPR’s prior to reading and implementing the research. Here is a quick link that has to do with the types of CPR (clinical prediction rules). Also, there is much controversy surrounding CPR’s from people such as Dr. Chad Cook, who I highly respect. I don’t know if I would go as far as he does in saying that Clinical Prediction Rules are dead, but they do have to be read thoroughly and criticized. They also have to be validated and placed into an environment in which they can be utilized in order to have an environmental impact. This has been done with diagnostic CPR’s such as the ankle or knee rules.


Me personally, I don’t believe that we should give up on a quest to determine which intervention works best for a specific set of the population. We can provide value to our customers by providing the best evidence based treatments that we have available. To kill off a method of prescribing treatment limits a therapist’s ability to confidently provide treatment.

“…patients with LBP at two outpatient facilities: Brooke Army Medical Center and Wilford Hall Air Force Medical Center…between the ages of 18 and 60 years…baseline Oswestry disability score had to be at least 30%”


This study is highly specific to a military crowd, with an average age of younger than 40. Now if this is not the patient that is being treated in my clinic, it is difficult for me to make the correlation from one population to another. The only thing that we can say for certain about the results of this study is that is pertains to the population that was involved in the study. The baseline Oswestry disability score (for more on the Oswestry see this link.


“After the manipulation, the therapist noted whether a cavitation was heard or felt by the therapist or patient.”


The cavitation is the audible pop that people think of when getting a fast manipulation. This is similar to popping your knuckles. This pop is not needed for a manipulation to occur, as the movement and speed instead of by the noise that occurs define the manipulation.


“A maximum of two attempts per side was permitted.”


This doesn’t make sense to me to perform multiple manipulations directed at the same region. The authors noted that if no cavitation was produced that another manipulation would be performed up to four maximum manipulations. We just covered that an audible pop is not needed, so I am unsure why two were allowed for the patient. Let’s just assume that a patient gets better from the manipulation, was it one manipulation or two manipulations that improved the patient? Is it possible that a patient could get better with one, but then get worse with the second…even though a cavitation is heard? There are too many variables that start to play into this study.   This is the landmark study for giving the prediction recommendations for spinal manipulation in PT. Which brings us to the next point.


“Two additional treatment components were included: 1) instruction in a supine pelvic tilt range of motion exercise…and 2)instruction to maintain usual activity level within the limits of pain.”
Now we have 3 possible variables introduced into this science experiment. Any scientist would look at this and say that there are too many independent variables, which can affect the outcome. The first is obviously the manipulation. The second is the pelvic tilt. The third is time.


“The mean OSW (Oswestry Disability Index) score at baseline was 42.4+/-11.7, and at study conclusion was 25.1 +/- 13.9.”


This means that the scores initially ranged from 31-53 and the final scores ranged from 11-39. A change of 10 can be considered significant, so there was a significant change overall for the better.


“Thirty-two patients (45%) were classified as treatment successes, and 39 (55%) were nonsuccesses”


A majority of patients didn’t respond to the intervention(s), but it was close to a coin flip. This indicates that if we manipulated everyone that came through the door, we would have a success (about 50% improvement in ability) in about half of the patients. This isn’t a bad ratio if it is only done in one visit.


“…duration of symptoms < 16 days, at least one hip with >35 degrees of internal rotation, hypomobility with lumbar spring testing, FABQ work subscale score <19, and no symptoms distal to the knee…were used to form the clinical prediction rule.”


Here it is! All students are expected to memorize this by the time that they graduate from PT school. All PT’s (at least those that work on backs) are expected to know these criteria for manipulation. There are of course some that will state that CPR’s aren’t very effective in practice, but this rule seems to have stood the test of time over many studies.


“…a subject with four or more variables present at baseline increases his or her probability of success with manipulation from 45% to 95%. If the criteria were changed to three of more variables present, the probability of success was only increased to 68%”


WHAAAT!? If someone has 4 of the 5 guidelines from above, the success was 95%! This is yuge. I’ll take those odds of success to the tables any day of the week. Now with this said, I have manipulated very few patients. Those that I have manipulated had immediate positive results and the pain was abolished…didn’t return upon follow-up over the course of 2 weeks. I may not be manipulating as many patients as I could, but I also give the patient the opportunity to independently manage and abolish before attempting to perform a manipulation. It’s a theory from another spine management system.


“In the present study, only one manipulation technique was used, and it is unknown whether other techniques would provide similar results.”


This is also very important to state. There was little research regarding manipulations in the physical therapy research. It must be said that not all manipulations are created equal and that performing a different technique may not have the same result. It may be better or worse. We can only extrapolate this study’s results to those that would match the type of patient treated in this study and the manipulation performed in this study.






Flynn T, Fritz J, Whitman J et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation. Spine. 2002;27(24):2835-2843.

Call a spade a spade

  1. “Although numerous propositions have been put forward in the literature about how we might usefully subclassify low back pain (LBP), we must first consider the potential utility and futility of such aspirations and ask, “Will it change the outcomes of patients?”


This first statement in the paper is great. All therapist classify patients using either a sophisticated method (which will be spoken of in this paper) or a method that lacks sophistication (a patient’s education level, income level, etc). The big question that we have to ask is “does any of it really matter”.


  1. “Within this arena, there are two schools of though-nominalist and essentialist. Nominalists define a disease by its symptom profile (CLBP = back pain of duration > 3 months). Essentialists state that each specific disease has an underlying pathophysiology, implying treatment of the disease requires treatment of the pathology”


This is fun for me to read. I never though of it this way, but I guess that I would be a nominalist in most cases. Rarely do I believe that the underlying pathophysiology must be treated in order to resolve symptoms. Let me give you an example. For patients that have degenerative disc disease (this is a very common diagnosis in the clinic and most will have this over the course of the lifetime) there is nothing that I will do to regenerate the disc, but I may be able to teach the patient how to either shut off the pain or manage the pain. This would be the nominalist in me. The essentialist in me has another example, which is also a real example in the clinic. There was a patient coming to therapy for treatment of his shoulder. In the process of treating the shoulder he developed back pain (not while in the clinic with me). Anyway, he neglected to tell me about the back pain, but later in the course of care (all within a couple of weeks) went to an urologist for urinary issues. He never told his urologist about the back pain and was advised to use a catheter to urinate! Anyway, he told me about his catheter issues and I was curious. I asked if he was experiencing any back pain or leg pain and sure enough he was. I called a surgeon that I trust and the patient was in surgery within a day. He had an issue that required surgical correction of a pathological issue. In this case, I am an essentialist. Now that I think about it, I am not sure if one can root for only one team.


  1. “These classifications can broadly be divided into three groups: (1) those that consider clinical descriptors, (2) those that describe prognosis, and (3) those that consider response to treatment.”


I am credentialed in Mechanical Diagnosis and Therapy, formerly known as the McKenzie Method. In this respect I am a little biased and it is important that you guys know that I am biased towards one method before reading the rest of the article. MDT would be a patient response approach.


Other systems, such as the Treatment Based Classification System (TBCS), which wasn’t even considered in this article it looks like, is a system that is based on clinical prediction rules. This means that if you come in and say some key words and test positive on some key tests that it would dictate a specific category of treatment, which is completely different from a patient that speaks of different key words and test negative on key tests.


  1. “We identified 28 classification systems of CLBP (chronic low back pain)…systems that described subclasses based on pathoanatomy, pahtophysiology, or clinical signs and symptoms without attempting to predict outcome or direct treatment were labeled as ‘diagnostic’…systems attempting to predict outcome irrespective of treatment were termed ‘prognostic’…systems that suggested treatments for different subclasses were termed ‘treatment based’…16 diagnostic, seven prognostic, and five treatment-based classification systems for CLBP.”


Typically, when I am writing a blog post I go to the back of my library (actually a trunk in the crawlspace) and grab an article that I read years ago. (I know…I am a nerd because I keep research articles that I read years ago). Anyway, re-reading the highlights of this article is like reading the article for the first time. I forgot that there were this many classification systems out there. Typically only a few are spoken of in the clinic and these are: the movement impairment system, Quebec Task Force, Mechanical Diagnosis and Therapy, Treatment Based Classification System and the Canadian Back Institute Classification System.


I will have to read the highlights of the article again in order to figure out which system fits into which category.


  1. “The first description of a treatment based system was by McKenzie, who classified patients into three main syndromes based on physical signs, symptom behavior, and their relations to end-range lumbar test movements”


Is it wrong that I was pounding my chest when I was typing the above sentence? This reminds me that I will have to write a blog on the history of MDT. One can see the history of MDT in the book Against the Tide.


  1. “Riddle and Rothstein assessed 49 physical therapists with varying clinical experience, in their ability to classify 363 patients according to the McKenzie system. Their ability to agree at the subsyndrome level was poor…Agreement among examiners was only marginally improved for classification into the three main syndromes…Agreement among examiners was better in three studies that assessed physical therapists who completed a certification in the McKenzie method with percent agreement ranging from 74% to 91% for subsyndromes and 93% to 100% for main syndromes.”


This tells us a few things. First is that those certified in using a method are actually good at using the method and those that aren’t certified aren’t as good at using a method. I think that this thought process would hold true for many aspects of different professions. I actually had a discussion on FB about this topic and I don’t think that it is the magic of the certification that increases agreement, but the hours upon hours of studying that went into preparation for the test that increases therapist’s competency of using a method. When a therapist is certified though, the agreement is close to perfect.


  1. “Movement System Impairment classification…proposed by Van Dillen et al and includes five categories based on signs and symptoms elicited with direction-specific tests in the direction of lumbar flexion, extension, rotation, rotation with flexion, or rotation with extension…shown to be reliable in three different studies”


I’ll have to read more about this system because at a glance it sounds eerily similar to McKenzie’s method. Both appear to have a “directional preference” based treatment and avoidance (I’ll assume only temporarily) of the aggravating factors.


  1. “Canadian Back Institute Classification system…recognition of syndromes or patterns of pain with no direct reference to pathoanatomy…the classification was based on the location of dominant pain, whether the pain was constant or intermittent, and which movements or postures exacerbated or alleviated the symptoms…shown to be reliable in one study.”


Again…these systems are starting to sound familiar and similar to each other. Figure out the symptom location, what makes them worse, what makes them better, is it mechanical or chemical and then name it for what it is. This appears to be the same in the three classification systems.


  1. “Movement and Motor Control Impairment (MCI) classification system by O’Sullivan proposed treatment based on subgroups of patients with CLBP categorized by five distinct patterns based on a specific direction of MCI…flive categories included flexion pattern (loss of motor control into trunk flexion resulting in excessive abnormal flexion strain), flexion/lateral shifting pattern (MCI around the lumbar spine with a tendency to flex and laterally shift at the symptomatic segment), active extension pattern (MCI around the lumbar spine with a tendency to hold the lumbar spine actively into extension), passive extension pattern (loss of lumbar motor control around the lumbar spine with a tendency to passively overextend at the symptomatic segment), and multidirectional pattern (MCI around the lumbar spine in multiple directions)…The percent agreement was 70%.”


It seems like this system is all about a loss of control at the lumbar spine. The agreement of classification isn’t bad at 70%. I struggle with this system because it does not appear to be a patient response based system. I’ll have to read more into this system. The first thing that I think of is “how do we know if we are doing the right thing and how long do we have to wait in order to determine if we are moving in the right category.


  1. “An RCT assessed the classification system by McKenzie by randomizing 260 patients into two groups: Group A was treated with the McKenzie method, and group B was treated with intensive dynamic strengthening training…tendency toward a difference in reduction of disability using the Low Back Pain Rating Scale in favor of the McKenzie group at the 2-month follow-up assessment, but no differences at the end of treatment (4 months) and at the 8-month follow-up evaluation.”


Some would look at this and say that MDT was no better than strengthening at 4 and 8 months. Others would look at it and say that MDT was better than strengthening at 2 months. If you were a patient, which would you rather have? Would you rather be better at 4 months or two months…knowing that you would be at the same place in 8-months? This study doesn’t seem too realistic in that once a patient is improved with MDT, then the treatment would transition towards a functional strengthening phase.


  1. “…overall strength of evidence …is High for the McKenzie and Movement Impairment Classification systems, especially when examiners have been extensively trained; Insufficient for the Canadian Back Institute Classification; and Moderate for the MCI Classification”


This sentence sums it up. MDT has moderate evidence to support that it is highly reliable. The Canadian Back Institute Classification system has low evidence to show that it is insufficiently reliable.


If I were a therapist going to learn a new method, I would have to start with MDT based on the volume of studies demonstrating reliability.


  1. “Once it is established that patients can be classified reliably, it then must be demonstrated that by directing a specific treatment at the subgroup, one can expect an improvement in treatment outcomes.”


This means that once we know what we are seeing…can we fix what we see? What is the purpose of classifying a patient into a group if the treatment for that group is ineffective?


  1. “This suggests that the ideal classification system should minimize the number of subgroups to ensure that the user can become confident (and competent) it its use with little training.”


Holy smoly do I disagree. We just said that the subgroups must lead to a specific treatment that performs better than other forms of treatment. If we minimize the number of subgroups, then we are minimizing the impact of subgrouping. For instance, if we state that there is only one subgroup, then what is the likelihood of the treatment for that one subgroup helping all of the patients? We already know that it’s pretty low…this is how we got into this mess to begin with. In the past, all low back pain was treated very similarly, with horrible effects. Now, if there is only one subgroup, we can be assured that most people would fit into this subgroup. Therefore, the therapists would be highly reliable in choosing the group in which to place the patient. THIS DOESN’T MEAN THAT IT WILL ACTUALLY BE EFFECTIVE TREATMENT!

Back pain is very costly in the US. We need to do a better job of minimizing the disability from LBP and educating the patients regarding back pain natural course and how to live and manage this ailment. There have been other systems created since this article was published in 2011 and we will see how these systems fair over time.

Excerpts from:

Fairbank J, Gwilym SE, France JC, et al. The Role of Classification of Chronic Low Back Pain. Spine. 2011;36(215):519-542.


link to article

What should you avoid if you have back pain?


  1. “ Low back pain (LBP) is though to occur in almost 80% of adults at some point in their lives”


This is an article from the 1980’s. It’s been over 20 years since this article was written and these statistics still hold true over time. As much as we have advanced technologically, it doesn’t really seem to be helping the prevalence of back pain. I’ve seen in places where this is called the common cold of musculoskeletal issues because it will affect so many people over the course of a lifetime.


  1. “…back problems are the most frequent cause of limitation of activity (work, housekeeping, or school) in persons younger than 45 years.”


This is a problem. If I have to take time off of work because of back pain, then there is less food on my table. I’m sure that this holds true for many of those reading this blog. We have to do better. Back pain doesn’t have to disable a person. We need to do a better job of educating the public regarding back pain. There was a recent article that notes that people should try drug-free options first for low back pain. PT is one of those “drug-free” options.


Every day about 1,000 people are treated in the emergency department for misuse of opioids. About 40 people per day die of opioid overdose. These numbers are staggering! It doesn’t have to be so.


stats on opioids


  1. “Only routine examination, postoperative checkups, and upper respiratory tract symptoms surpass back problems as a cause of office visits to physicians.”


This may have changed in the past 20 years. I read recently that back pain accounts for more visits than all other issues except for respiratory tract symptoms (i.e. the common cold). This is a lot of people with back problems. Not many patients are referred to PT. There is an article that reports about 7% of patients seek out PT. When they do get referred, not all PT’s practice with the same treatment parameters. Do your research as to what clinic you are attending, because they are not all the same in regards to cost and effectiveness.


  1. “A variety of exercise regimens for LBP has been advocated. The three most commonly recommended regimens are (1_ hyperextension exercises to strength paravertebral muscles; (2) general “mobilizing exercises” to improve overall spinal range of motion; and (3) isometric flexion exercises designed to strengthen both abdominal and lumbar muscles, creating a “corset of muscles.”


Lots has changed in the research, but unfortunately not a lot has changed in practice from my point of view. I still see the same “core stability” training done on many patients even though the research doesn’t support one type of “core training” over another. There have been more interventions added to the research and application, such as thrust manipulations, directional preference based exercises, cognitive behavioral therapy and others just to name a few.


  1. “Several trials shoed no advantage of traction over alternative treatments, but statistical power was not reported.”


This article is over 20 years old! The advice at that time is similar to the current stance based on the research. The problem with this is that there are still many therapists using traction. Saying this differently, there are still some therapists that frequently use traction. This could only be for one of two reasons:

  1. Ignorance. As much as I would love to say that all therapists are reading journal articles at home, we know that this is not the case. Based on some research, there are therapists that don’t even know how to find the research and if they can find it, they won’t take the time out of their day to read it. This is a problem because it is our profession. I never stop wearing the hat of physical therapist, in the same light as I never stop wearing the hat of husband and father.
  2. Greed. A therapist doesn’t need to spend much time with the patient while they are on traction. Traction is paid whether the therapist is by your side or not. In this fashion, the therapist can spend time with another patient and charge that other patient for his/her time while the therapist is charging you for traction.


Don’t get me wrong; there are cases in which to use traction. When it is the last viable option to try to get a patient better or to keep the patient from an unwanted surgery. In other words, it is used as a last case scenario. You can see a previous post on traction if you are interested.


  1. “For these reasons, its (bed rest) value for patients with typical findings of a herniated disk is not disputed…Thus, there is suggestive evidence for the efficacy of strict bed rest for some patients without sciatica…”


Wholly Moley! This has changed dramatically. Bed rest is rarely recommended for anything. The repercussions of spending hours to days in bed far outweigh standing with benign low back pain. This article summarizes the negative effects.


  1. “Spinal manipulation remains highly controversial, partly because in the United States it is often equated with the practice of chiropractic.”


Physical Therapists are able to manipulate the spine and other areas of the body. No one profession owns this treatment. Chiropractors have done a much better job of educating the public about the treatments that they perform. Don’t be surprised if your therapist wants to perform a manipulation. Lot’s has changed in 20 years.


  1. “This study did serve to demonstrate that placebo effects with a nonfunctioning stimulator are common”


This is interesting that the thought of TENS (a form of treatment in which pads are placed on a specific body part and an electrical current is introduced throughout the pads in order to reduce pain) 20 years ago was that it could also be the placebo effect that is creating the change. Patients seem to like it in the short-term, but there is major controversy over this intervention. So much so that medicare questions its effectiveness for back pain.


  1. “The use of corsets, TNS (TENS), and conventional traction are not yet supported by any rigorous trials.”


This was stated 20 years ago! I believe that if you walked into any physical therapy clinic that you would still see these interventions applied to the patient…because insurance companies continue to pay for them. Although there is much research to indicate that these interventions have little to no place in therapy, many times their use is due to the two reasons given above. If you are in a place in which these are the treatments that take up a majority of your sessions, question your therapists. This is the advice given by the professional organization of physical therapists, the APTA.


Excerpts taken from:


Deyo R. Conservative Therapy for Low Back Pain: Distinguishing Useful From Useless Therapy. JAMA. 1983;250(8):1057-1062.


Post 88: The anatomy of the “pain in the ass”

“To better understand the medical enigma of low back pain (LBP) it is necessary to thoroughly understand all structures that could potentially refer pain to this region.”


This is an excellent start. Any researcher that can throw the word “enigma” into an article already has my respect. Back pain is a mystery because so many people have it and so many people have had it and yet we are no better at reducing the incidence of this problem…even with all of our modern conveniences. There are a few sources of low back pain that are spoken of in PT, the back and the sacroiliac joint (SIJ). Obviously there are other sources such as some of the vital organs, but this is for another topic.




“The sacral articular (auricular area is c shaped and located on the lateral spect of this bone. During the fetal and prepubescent years, the sacral surface is flat, smooth and lines with hyaline cartilage. The articular surface of the ilium is also c shaped, but in contrast to the sacral articulating surface it is covered by firbrocartilage. The smooth and planar articular surfaces of the SIJ…permit movement in all directions…restraint by the strong inerosseous sacroiliac (SI) ligament.”


This is the part that we are taught in school. The SIJ can move in all directions and this could cause pain. It appears that this has changed over the years, because students are coming out of school biased that the SIJ doesn’t cause pain. I believe that the pendulum may have swung too far in the other direction. There are some therapists that believe that the SIJ causes a significant percentage of back pain (this is based on my experience and tends to be older therapists…based on what I was taught in school, I can understand their perspective). There are others that believe that the SIJ doesn’t cause back pain (I don’t believe this either, but will lean more towards it doesn’t cause pain than it causes all pain). There is some research that indicates SIJ dysfunction correlates with 7-13% of all patients with complaints of back pain.


Big picture from the above quote: when we are young, the SI joint is very smooth (picture two bars of wet soap on top of each other), covered in cartilage that makes it slippery (think the chewy stuff on the end of a chicken bone) and is very mobile aside from a ligament holding it in place. THIS IS ONLY WHEN WE ARE YOUNG! More on this later.


“As early as the third decade of life ridges and depressions begin to form, making the joint surfaces nonplaner…increases the frictional resistance to motion and imparts greater stability to the joint…taking on a coarser quality…limits movement by increasing the coefficient of frictional resistance between opposing articular sufaces”


Do this experiment for me. Go wash your hands. Get them very soapy and slide your palms together. How well do they slide over each other? They should slide very well. This is similar to how it is when we are younger. The SIJ slides back and forth with little resistance. Now…wash off most of the soap (this will increase the friction between the two surfaces) and then make a fist with each hand. Put your left and right knuckles together and try to rub them over each other. It’s not hard to rub back and forth, but you can feel more resistance from the knuckles making it a little harder to rub back and forth. This is what happens to the SIJ around the third decade of life. So as not to leave this example of washing the hands (I just created it, so if you don’t like it…it didn’t take much of my brainpower and I’m not offended). Now, I want you to lock your fingers together (left and right hand will be locked together (almost like when you see a child praying in the movies) and then try to move your hands left and right. They don’t move well right? Your wrists may move more than your hands if you are watching closely. SPOILER ALERT: This is what happens when we get around the 6th decade of life.


“The purpose of the study is to document and quantify the surface topography of the Interosseous region of the SIJ complex”


This article is very interesting for me to read. I typically don’t like to read cadaveric studies (studies on dead bodies), but the research for the SIJ is really limited and this one came across my desk at some point. Topographical maps: go way back to grade school for this one (As big as the word is, it was taught to most of us before high school). A map that has the contours of the earth built in is a topographical map. If you were to slide your hand over the map, you would feel the mountains, the valleys, hills etc. This same type of map can be made over a joint. It would be easier now than when this study was performed with the advent of the 3D printer.


“Moderate or extensive ridging of the Interosseous surfaces of the ilium and sacrum was identified in all 10 specimens with average age of 69 years. Ridging was extensive in 6 specimens (age range, 55-91 years), while moderate ridging was found in 4 specimens (age range, 58-80 years).”


Moderate or extensive ridging indicates that the joint has soft-fused together. This means that the joint has essentially joined together like two gears or a zipper would joint together. It would make movement of the joint, gear, zipper very difficult.


“In contrast, in the 20-year-old specimen only a slight ridging and depression pattern was observed on both the iliac and sacral surfaces”


This is more like sliding two hands together. The surfaces are relatively smooth and slide-able over each other.


“…there did appear to be a relationship with respect to age. Slight ridging was found in the 20-year-old specimen, while the median age of specimens with moderate ridging and extensive ridging was 58 years and 75 years, respectively”


This means that the older we become, the more ridges there are between the joints. These ridges serve to reduce the available movement between the two bones.


“…beyond their sixth decade, 6 were observed to have distinct regions within the SIJ complex where the Interosseous SI ligaments had become ossified …effectively fused the posterior aspect of the sacrum and ilium”


This is a big debate in PT. Does it move or doesn’t it move? The SI Joint that is. When we age, it appears based on this research study, that the SIJ loses motion over time. Any joint that can move can cause pain. If the joint is unable to move, then we hope that it is not in a painful position because the likelihood of moving it out of the painful position is unlikely. The good thing though is that it is a low prevalence of being the cause of pain, which means that if it didn’t cause pain when it moved, it may not cause pain when it doesn’t move. That’s logical, but there isn’t much research to prove or disprove it.


“60% of the specimens in or beyond the sixth decade of life had parial ossification…fused the ilium and sacrum posteriorly, which can be extrapolated to suggest that no movement through the SIJ complex was possible in these specimens.”


There you have it folks! In a majority of people over the age of 60, it doesn’t move. This means that it is still a possibility for causing pain. When a patient has pain that is in the buttock, it has to be ruled in as a cause until it is ruled out. It can be ruled out/in using Laslett’s rules. Laslett’s clinical prediction rules for the SIJ.


“…in all 10 specimens (100%) aged 55 years and over…more extensive ridging…reduced joint mobility”


The older we get, the less likely the SI joint is to move and the less likely we will find a problem that we can fix with movement of the specific joint.


“Mobility tests for the SIJ have been found to be unreliable and their regular use as diagnostic tools is questionable…hence the 1 to 2 mm of movement that may occur, it at all, is likely to be difficulty, if not impossible, for most clinicians to perceive.”


My manual skills are good, but I am not good enough to feel 1 mm of change. This is like feeling a change in position the distance of a tip of a pencil through layers of skin, adipose tissue (fat), muscle and ligaments. I readily admit that my skills suck for detecting this movement, but I think that I am in the majority on this one. With that said, in school we learned a bunch of tests to see how much movement happened in the SI joint. Needless to say, we didn’t learn much about this in school that still holds true today…aside from the anatomy.


I’ll finish this post with a quote that finished the article because it summarized my thoughts well.


“Assessing mobility in the SIJ in the older population is not likely to yield any meaningful information.”


Excerpts taken from:


Rosatelli AL, Agur AM, Chhava S. Anatomy of the Interosseous Region of the Sacroiliac Joint. JOSPT. 2006;36(4):200-208.


Post 86: back pain classification

“…it is often not possible to make a specific pathoanatomical diagnosis reliably for patients with low back pain (LBP)…85% to 95% of patients with LBP are diagnosed by their general practitioner as having nonspecific LBP”
This is very controversial. We know that back pain exists and exists as an epidemic in terms of how many people. At one point, (again I will try to find the study for a later blog) I read a study that reports at any one point in time there are 5 million Americans with back pain. Put into perspective, this is about the equivalent of the total population of 7 combined states. That’s a massive number of people.
RANT: Now for all of these people, we can give a reliable diagnosis to about 500,000 people. OKAY…follow me here. For 4.5 million people, we can not tell them why they are having pain based on population research and prevalence research. The reason why this is controversial is because there is one back specialist in specific, Stu McGill PhD that has said on record many times that there is no such thing as non-specific back pain…only a non-specific assessment. I agree with him partially, there are many patients with a diagnosis of back pain that can be subgrouped into a more specific diagnosis, but I am not willing to say that we can subgroup all patients with back pain into specific diagnoses. Americans should be pissed off. This is an epidemic! Research tells me that I can classify back pain, depending on which classification system I use, in about 75-80% of the cases.
Let’s do some math again.
Research states that I can classify (doesn’t always mean fixable) about 80% of back pain patients. This correlates to about 4 million of the 5 million people with back pain, we can at least start to give them some answers. This is assuming that they have made it into a clinic that has a physical therapist trained and using (this is another topic for another day) a classification method such as the Treatment-Based Classification System, Movement Impairment System, Mechanical Diagnosis and Therapy, Quebec Task Force system or another system that I may be forgetting off the top of my head, but these are the major systems in the research.
Now…research shows that only 7% of patient that have back pain get referred to physical therapy!!! ARE YOU F’NING KIDDING ME! This means that 350,000 patients are seeing a therapist. Continuing with the math that we can classify about 80% of the patients, we can classify 280,000 patients with back pain and 4.6 million are not being assessed by a physical therapist in order to be educated or classified into a syndrome that could be treated.
Physical therapists that are well trained can classify patients. This is assuming that there are no other conflicts of interest, such as treating the patient like a bank to simply supply the therapist (more likely the company that the therapist works for) with income. I say to patients many times… “you have the right to choose your therapists. Don’t let your physician tell you that you have to go to a certain therapist.” On the flip side, if you have chosen a physician and have not seen progress in 6 visits, you have to question whether or not that therapist is going to help you. You are not looking for someone that will string you along for 12-30 visits over the course of the year, but instead looking for someone that will give you the guidance and empower you in order to improve. This may or may not include manual therapy, modalities (this will rattle many of my previous students to hear me say that I am okay with using modalities), but will definitely include education and movement. I have heard from many people, including my own personal family, of the stories about going to therapy only to perform all of the exercises on their own and being followed by someone that looks like a high school student. If you are in this type of facility, go seek a therapist that will provide you with personalized care, because that is what you are paying for. I am taking a strong stance on this in this blog because I heard from multiple patients and family members this holiday week about the crappy therapy they are receiving. It upsets me because there are many therapists that are awesome at their job. Unfortunately, these people have only had the experience of the crappy ones, which formulates their opinions of all therapists. It hurts me to the core when I hear a patient say that therapy doesn’t work. It works very well if physical therapy is not seen as a treatment, but an assessment with recommendations either for therapy interventions/treatment or a referral to a specialist outside of therapy. Therapy can’t be seen as treatment, but assessment.
END RANT: it’s funny because I’ve already written 2 pages on the blog, but only covered one sentence of the research article.
“…most clinicians use pattern recognition and patient profiling in an attempt to optimize treatment outcomes.”
I don’t know if I would say that MOST clinicians use pattern recognition to treat patients. I’ve been assessing back pain for a long time now as a therapist and I still see many therapists that use one-size fits all attempt to treat back pain. For instance, as a clinical instructor there are many students that want to give a “shake and bake” style to treating back pain. This means that every patient gets massage, stretching, bridges, abdominal exercises, bird-dog, hollow-out maneuvers, stability ball work and finishes the session with either a hot pack alone or a hot pack with electrical stimulation. If every patient gets the same treatment, then we must believe that every patient has the same problem. If a thorough assessment is not performed, then every patient does have the same problem…low back pain. This needs to be subgrouped into patterns that will give us better outcomes than we have had in the past from just treating everyone the same way. I am by no means saying that this style of treatment won’t benefit some patients, as there is a category of patient that may benefit from this style of therapy. It won’t benefit ALL patients and at that point, we are no longer treating patients as individuals with individual needs.  
All of the above systems of categorizing patients stated in the rant are pattern recognition systems. This means that we take a thorough history and hear certain themes in the history that lead us into a specific subgrouping. We perform tests and measures that either rule in the initial theory or rule out opposing theories and then from that point initiate treatment.
The second type of treatment approach is called the HOAC (Hypothesis Oriented Approach for Clinicians: all students, at least my students, should know this approach also). This approach is commonly called the test-retest method of treatment. It is not specifically based on patterns and can be better utilized by novice therapists that have not seen thousands of spines from which to recognize patterns.
“One of the attempts is a classification-based treatment approach initially developed by Delitto et al and subsequently updated using more recent research”
Delitto…this is one of the “oh great gurus of physical therapy” and I say that seriously. As a therapist, I stand on the backs of the greats, and Tony is one of the greats in our profession. I read an article years ago in which he makes a statement that still holds true for me today. “All therapists classify their patients, but the classification system may not be very sophisticated”. For instance, if someone comes into the clinic and is unkempt, with a low level of education, and is looking to dictate treatment, we can make the assumption that this patient may not do well with therapy. This is great and all because we are at least trying to classify, but this type of patient can do excellent in therapy if a more sophisticated way of classifying is used.
“The aim of this study was to determine whether the effectiveness of this classification-based approach was generalized to another health care system, other clinicians, and another population. In this study, we compared classfication-based treatment with usual physical therapy care in patients with subacute (6-12 wk) and chronic (>12 wk) LBP.”
This is huge. Very rarely are two types of therapy facing off against each other to see which type of therapy is more effective. Typically, the research compares a type of therapy to either no therapy or a placebo type of therapy. Another aspect that is important is this: if I treat a group of patients and they all do well, does that mean that my style of treatment is good for all patients and all other therapists to use? Maybe or maybe not, but the only way to know is to test it.
“Participants were recruited by physical therapists from 21 private physical therapy clinics in the city of Amsterdam and the surrounding (rural) areas”
This is a large number of clinics that are participating in the research. There is more room for error based on the total number of clinics and difficulty in oversight, but having a large number of clinics allows for better generalization of the results. For instance, a study that demonstrates excellent results with patients in a rural area may not translate well to doing the same type of treatment with patients in an urban area.
“On the basis of their clinical presentation, patients could fit 1, more than 1, or none of the classification categories, that is, direction specific exercises, manipulation, or stabilization exercises”
Direction specific exercises: when categorizing patients with back pain, there is a high number of patients that respond to one specific exercise in order to either reduce or abolish back pain. This is found through both a thorough history and movement assessment. Typically, the direction is extension, but it is not always the case. Previous research on MDT indicates that of those that are classified into the derangement category.
Manipulation: This is a thrust manipulation. Means that the therapist will twist the patient in such a way that a small movement will create a change in the joint position and cause the brain to interpret sensations differently. This may or may not be accompanied with an audible “pop” or cavitation.
Stabilization exercises: everyone that has been to a physical therapist is familiar with the term core stabilization. This indicates that the patient will be performing exercises in order to activate the muscles from the mid-thigh to the armpit.
One category that is left out of this study is the traction category. I am unsure if it is left out because there are so few patients that would benefit from traction that the authors decided not to use this category.
“Baseline characteristics…they were largely similar in both groups”
This means that before starting treatment that there were no major differences in the patient population. For instance, if one group has all younger patients and another group has all older patients, this study would not be very telling. The younger patients are expected to respond/heal better than older patients.
“The classification procedure classified 54% as direction-specific exercises, 27% as manipulation, and 19% as stabilization exercises…The percentage of patients meeting the criteria of a “clear classification” was 74.4%”
Let’s break this down. Using the McKenzie method, we can classify about 80% of the patients. Of these patients, about 70-80% are classified as a derangement, indicating that they may have a directional preference. This would be about 56-64% of the patients that may respond to a directional preference exercise. The statistics from the McKenzie method are very similar to those of this study, so I am not too surprised that about half of the patients that in a study or in the general population would be classified according to a single direction.
About 25% of the patients were classified as manipulation and less than 1/5th were classified according to core stability. Although core stability is traditionally offered in PT, and throughout my career has been the largest intervention issued by many of my colleagues, only 1/5th were categorized into this category.
“We hypothesized that patients would benefit most from classification-based treatment; however, we found no support for this hypothesis.”
Both the control group and the treatment based classification group improved. This is not to say that the classification group is incorrect, but that it is no better than another system…at least in this study.
“We did not include the subgroup traction because the Dutch LBP guidelines discourage traction in patients with LBP”
A lot of the studies that I am blogging on I have read over the course of 7 years. I forgot the reason that traction wasn’t included, but having read much research reporting that traction is slowly falling out of favor, it makes sense to take it out of the intervention approach.
“Ideally, a classification algorithm should classify patients into 1 subgroup only. In this study, using only the first part of the algorithm, 24% of all patients did not meet any of the subgroups and 16% met more than one subgroup”
This is concerning in that this system can’t precisely classify 40% of the patients. This is better than no classification system at all, but it needs to be improved. The authors do a good job of providing ways to improve the system. One way is to change directional specific exercises to centralization.
“We attempted to provide optimal training and guidance for our treating physical therapists in the classification-based group; however, this support may have been insufficient for optimal competence and may therefore have caused an underestimation of the effectiveness of the direction-specific exercises and consequently also of the classification-based treatment approach”
This is the strongest statement of the entire article. Training a therapist is important and I am glad that the authors make the statement that maybe the therapists weren’t trained well enough to utilize this method, which would then make this method unreliable. Not all researchers are trained in the methods to the highest extend in the subject that they are researching. I can tell you that I treat patients in such a different manner than I did 7 years ago, using the same McKenzie method. I still use the same techniques and principles, but my critical thinking skills and pattern recognition skills have advanced over the years to such an extent that I am faster to make decisions and move on from an intervention that is not giving me the desired effect.
This brings forth a previous comment that I read from Tony Delitto in an article regarding physical therapists. It is paraphrased, so don’t judge me. Are you a therapist practicing for 20 years with 20 years of experience or are you a therapist that has been practicing for 20 years with one year of experience repeated 20 times?
I’d like to think that I am the former.
As I said, I go back and write these blogs long after having actually read the study. This study has some of the heavy hitters of spine care as the authors. I had the privilege to hear Hans van Helvoirt and Maurits W van Tulder speak at varying conferences and these people are among the greats. Julie Fritz has written many of the articles that I blog on. Essentially, this research was done by the “who’s who” of back pain.
Excerpts taken from: Apeldoorn AT, Ostelo RW, Helvoirt H et al. A Randomized Controlled Trial on the Effectiveness of a Classification-Based Syste for Subacute and Chronic Low Back Pain. Spine. 2012;37(16):1347-1356.

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.