Michael, You mentioned, "Bashing surgeons is not helpful. I have very close relationships with many top specialists around the country. I will tell you that most are doing there very best to help patients." Where in this post to you see "bashing surgeons." I do do have professional relationships with a number of spine surgeons. As you know some of the best spine surgeons now are members of the Association of Medical Ethics which grew out of the Association of Ethics in Spine Surgery (http://ethicalspinesurgeon.org) The purpose of the Association is to promote patient care and evidence-based medicine and to provide increased public awareness of the detrimental and pervasive financial influence of industry on many health care providers and patients. I would encourage you to click on the Dr. Search and see if any spinal surgeons in your area are receiving kick backs from the device industry. Transparency is not bashing. Describing patient experiences is not bashing. You cannot discount the mounting evidence against spinal fusion for pain management. Spinal fusion should not be outlawed, it should be used for what it was intended for which was stabilizing traumatically fractured spines to prevent neurological damage. I would encourage you to share the above story with your physician colleagues. I would be shocked if they felt "preventative fusion" is a good option for someone whose history suggest a chronic neuropathic pain state. Keep up the discussion! Tim

Christie, What the data continues to suggest is we are doing "Way to much imaging for simple LBP" It doesn't make us healthier and in fact puts us at risk for worsening health. So my point is that we are over doing it. I am not suggesting we do not continue to study all aspects of the human body but lets avoid applying imaging for simple LBP unless it is appropriate, i.e. ruling out serious spinal disorders (tumors, infections, etc.). Tim

Felicity,Welcome aboard. I look forward to your leadership. My goal for your first year is when Josephine Smith says "ouch my back hurts" her blink response is PT and this idea is made to stickforall patients with spinal pain. After all you got drugs, you got surgery, or you got us. Tim

All, This is another example of a profession which lacks science trying to make up for it by legislative pay outs. In Tennessee there are 3 times as many PT as chiropractors. There is also 3 state funded and 1 private Physical Therapy program at the University level. HOWEVER, the PT PAC pales in comparison to the chiro PAC. For those loyal bloggers please consider supporting the TN PAC and more importantly call your friends, family members, and classmates to get involved. Here is the link to the TN PT PAC website: http://www.tptaonline.org/Assets/PDF/tpt_pac_contribution_form.pdf Also you may want to check out the illegal legislative activity in North Carolina we have previously blogged about. It appears that the from the chiropractic state boards perspective it is acceptable behavior to make illegal payouts. http://www.newsobserver.com/102/story/558532.html

Selena, You hit the nail on the head. My post is precisely why PTs should not be in charge of PR. PR Firms should be in charge of PR. We are the consultants, we give them the facts, we give them some great evangelist patients and they craft the emotions. We have an easy sell, we are nice people, we do good work and we don't kill you. Happy New Year! Tim

The greatest profession with the softest voice. Somewhere in the DNA of physical therapists is the gene that says promoting our profession is a sin. Where did this come from? National Ad #1- We are all well aware that the healthcare system in the United States is in serious trouble. Costs continue to rise at alarming rates and markers of quality are well below other industrialized nations. Musculoskeletal costs are a large and rising portion of these costs and yet we provide no better care and at times much worse then other countries. Low back pain is one of the highest cost problems in musculoskeletal care. High priced technology and invasive surgeries have only exacerbated the LBP problem. In fact, when it comes to low back pain we disable more people than we help because of this very technology. Imaging and surgery were once designed to assist in the management of individuals with serious life threatening conditions such as tumors and significant trauma. Despite irrefutable evidence that imaging is not helpful in the vast majority of LPB cases, your doctors continue to order these tests. And if you are not careful you will end up with the newest technology spin “the artificial disk” which has poor to marginal outcomes at best. And by the way often there are financial ties between the surgeons and the manufacturers of the devices placed in your back. WHY NOT DO YOUR BACK AND SOCIETY A FAVOR? GO SEE YOUR PHYSICAL THERAPIST...the leaders in management of low back disorders.

It appears that the only clinical aggravating factor you can use for test-retest within session change is tenderness to palpation. This makes it difficult to assess response to treatment and narrow down the contributing factor if it is indeed musculoskeletal in nature. I would manually treat the lower thoracic, lumbar spine and hips. Look for impairments in symmetry right to left and move it, recheck tenderness, and move on to the next area. I would particulary look for the left or right pelvic region being elevated (ischial tuberosity prone) with tension of the lumbar PVM. My sense would be that since she appears fine with aggressive aerobic exercise that is not high impact in nature, that the problem is coming from distal to her area of complaints.

I thought this link just out from Medscape will provide some further perspectives for the discussion. http://www.medscape.com/viewarticle/540369?src=mp Tim

I would suggest that the nationalization of healthcare in some manner is not a knee-jerk government reaction. Many contributors to this blog work in either fully subsidized socialized medicine or heavily subsidized medicine. This is not a new or radical idea. It is almost 15 years since a serious national discussion on this issue occurred and the results from that debate was "leave it to private enterprise." Are we better off today? Do we have more folks covered? Are we more efficient in getting the right care to the right people?

I would encourage us to move this discussion to another blog. There are plenty unobjective left and right spin zones in ether space. There is a reason neither O'Reilly nor Al Franken will be moderators of the next presidential debate. It has to do with objectivity. Thus a Jim Lehrer, a journalist, is chosen not the Spin Doctors of the left and right masquerading as journalists. Tim

John an excellent post on a recurrent topic. In my current clinical setting I see individuals whose complaints are approximately 90% chronic and musculoskeletal in nature. If after applying current best evidence (for example manipulation, exercise, and cognitive-behavioral type approaches for chronic LBP) and not achieving clinically meaningful change I will discuss with the patient and if in agreement I may try additional approaches that could be labeled "alternative." I do some intervention techniques where I place my hands on the patient's skull and lower ribcage/upper diaphragm, etc. These are when viewed pretty standard soft tissue and tender point type work (albeit lacking evidence). I think the "story" is what makes it alternative. It is when we create fancy/bogus stories about rhythyms and viscera that we now become alternative. I would say that even worse is if we actually propagate the stories/myths surrounding these techniques such as I am releasing your x organ (i.e. kidney, liver, etc.). In this instance you can make a reasonable argument that we are treating outside our scope of practice. I am occassionally asked that since I occassionally do these things why aren't you regularly teaching them? My response is simple. Teach and practice the evidence first. If patients actually got the evidence based treatment during the acute phase would we have the same level of chronicity? As new treatment and evidence emerges perhaps we will see some of these alternative therapies have demonstrated effectiveness. Then we should rapidly adopt them into our clinical skill set. I sound like a broken record ("White Stripes" to be exact) but we don't need more stories. Lets gets some published case studies, case series, and trials using these techniques and see if they work or not. If they work, the story really doesn't matter...if they don't... move on. Tim

I haven't done a recent search for the use of traction post fusion. However, I think a couple of larger issues should be considered. The answer and decision-making by the physical therapist should be based on what is best for the patient irregardless of whether the patient enters your facility via direct access, a new referral source, or a "#1 referral source." By definition this patient appears to be a "failed back syndrome," the term used for unsuccesful surgery for LBP. Unfortunately, the rate of success for second surgical operations in the case of failed back syndrome is no greater than it was for the initial operation, and declines with further attempts. It is worth reflecting on Jerome Groopman's classic article A Knife in the Back (http://www.jeromegroopman.com/knife.html). I assume the patient was hospitalized for "pain" as the adverse event. Or was it a serious condition such as cauda equina symptoms? If pain is the case I would want to know what the patient's FABQ scores were, baseline depression scores, and what cognitive-behavioral intervention strategies were considered. The literature supports that a more comprehensive approach for these failed back paitents is on order. Tim

I could not agree more with the call for standardized language to describe what we do. This I believe will happen sooner rather than later. Lets add to Jason and Mary's call for what is needed. Patient Position: General Vertebral Level: Direction of Movement: Grade: Now many times the language is really a short hand to the therapist. For instance, I am a recovering biomechanist... but I still think in terms of direction of movement when it comes to treatment. So if you say FRS I can visualize a 3D motion to treat. However, this does not mean anything more than a perception of motion. My opinion is that the jargon often comes about as a way to decrease the volume of words to describe a movement. The problem is when the jargon is not consistent and takes the place of reality. Tim

Tony, Might I say a breath of "Fresh Air!" Tony keep "driving us crazy." Rockin in the Free World, Tim

Carina, In response to 2. When do you decide to stabilize using a SIJ belt? It appears that compression improves symptoms. Have you tried a gait belt as a cheap way to test if an SI belt might work? 1. Pre-test walking tolerance on treadmill. Measure time to 1st onset of pain. 2. Sit until symptoms subside. 3. Place a small gait belt around the pelvic, tighten it below the ASIS. 4. Retest on treadmill. 5. If symptoms improve it would be a could way to increase her tolerance. Tim

John, I appreciate your concern for the increasing length and depth of my forehead. However, an EBP practitioner knows when to refer clients when there is a high probability that the presenting diagnosis is outside his/her scope of practice. Therefore I will defer to my clinical expert in these matters who I frequent on 3-4 week basis...it is not spiked, it is "product." Tim

As a recovering biomechanist I could not help but chime in. I agree that basic and applied research can and should complement each other. I also agree that at different times different approaches may be more pressing and appropriate. The point I would like to make is regarding the discovery of the "mechanism" of action for the positive outcomes of aspirin. It was implied that this knowledge came about "faster" than say spinal manipulation. The components of aspirin were known to be effective around 400 BC and the "mechanism" of action was understoon around 1970 AD. Given this, I am not convinced I will know the exact mechanism of action of manipulation in my lifetime. http://www.bayeraspirin.com/questions/hundred_aspirin.htm