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If you go to the APTA website, you’ll find a nice header logo that states, “The Science of Healing.  The Art of Caring.”  For years, those within the profession have talked about what we do as an “art” – with experience and professional judgement as the brush’s guide.  This idea has lead to a “treat-on-the-fly” mentality that is too hit-and-miss for health care.

 What do I mean by this?  Take low back pain for instance.  Experience, professional judgement, and personal bias often leads Physical Therapists to provide care that is backed by little or no medical evidence.  These treatments may be chosen for many reasons from “it’s worked before” to “I just had a feeling”.  Is that really provided best quality care?

 Isn’t it time we standardize practice a little?  When strong evidence exists that supports a certain intervention or system, should we not be using it?  This is true for Physical Therapists across the board, not only the ones doing the research.  Classifying low back pain patients based on signs and symptoms and providing matched interventions is the perfect example.  Studies that have examined this system show that patients receiving matched interventions based on classification get better and get better faster.  So…what’s the hold up?

 Some argue that these “simplified” ideas take the “art” out of our profession.  I beg to differ.  Like the logo from the APTA displays, the “art” of Physical Therapy lies in our ability to interact in a empathetic way with our patients.  To make them better – not just physically, but mentally, maybe spiritually.  It speaks to our ability to holistically treat our patients. 

 Some say standardization pigeon-holes practitioners, taking experience and judgement out of the picture.  Wrong.  It simply says that as a profession, we support scientific research — know it — and use it to get our patients better, get them better faster, and in the most cost effective manner.

 Physical Therapy IS both art and science.  Both are important and necessary for good Physical Therapists.  However, relying on outdated theories or “gut instinct” isn’t the providing best practice.  Our patients deserve better.


As I mentioned in another post, the autonomy of Physical Therapists is under heavy attack from those practitioners who desire to fill their own pockets and disguise it as quality care.  Yes, chiropractors fit in this group.

 For years, chiros have spread mystical theories about vertebral subluxation and how the minor changes in alignment can cause all the world’s problems.  By cracking your neck or back, they can cure all your pain, organ diseases, and my personal favorite – childhood bed wetting.  Patients walk into their offices, are exposed to unnecessary radiation, then told that it will take 85 visits to fix their problems. 

Chiros even offer a little “physical therapy” too!  WAIT – only licensed PT’s can do real Physical Therapy.  Not according to chiros.  They claim they are trained to provide rehabilitation.  That’s a laugher.  Most chiros offer some nutritional supplements, some e-stim, maybe heat and ultrasound.  This is Physical Therapy?  Of course not, see the previous posts here.

 So what’s the difference?  Despite the effectiveness of spinal manipulation in some subgroups of patients, it is not the treatment for EVERY problem.  Electrical stimulation, ultrasound, and a hot pack aren’t either.  Physical Therapists are trained to provide manipulation to patients.  In fact, it’s Physical Therapists who are putting out the research to identify the patients who are likely to benefit from thrust manipulation – funny that chiros aren’t leading the push huh?  We (PT’s) also provide thorough therapeutic exercise to ensure you don’t have to come see us 85 times to get better.

 Let me end with this, chiropractors hang their hat on the bogus theories of vertebral subluxation when the evidence clearly shows otherwise.  They survive on one treatment (spinal manipulation) that they believe NO ONE but chiros should perform.  There are many professionals that have been performing spinal manipulation for a long time and doing it well.  More and more, it looks like Physical Therapists are able to combine quality therapeutic exercise with manual techniques such as manipulation to provide the BEST care for many musculoskeletal problems.  Remember, only licensed PT’s provide Physical Therapy and chiropractors aren’t the only providers skilled and trained to perform spinal manipulation.

In this, the third post of the “Low Back Pain and You” series, we will discuss evidence-based interventions provided by Physical Therapists.  Hopefully, you will see why we should be the first person you see for your back pain and learn what to expect from you Physical Therapist.

Classification and Clinical Prediction Rules (CPR)

As we’ve discussed before, not all back pain is created equal.  So, why do many practitioners continue to treat every case of LBP with the same advice and the same medication?

Fortunately, Physical Therapists have developed a classification system that matches patients with appropriate and effective treatments.  The treatment-based classification system (Delitto et al, 1995) consists of categories based on the response of the patient to active motion.  These groups include active exercise with directional preference, traction, mobilization/manipulation, and stabilization.  In clinical studies, the TBC system has been shown to result in better outcomes than therapy based on clinical practice guidelines. (Fritz et al, 2003) 

More recently, Physical Therapists have developed clinical prediction rules to further identify patients who are most likely to benefit from certain treatments.  There are two clinical prediction rules related to low back pain.  These include the lumbar stabilization CPR (Hicks et al, 2005)and the manipulation CPR (Flynn et al, 2002).  Studies show significant improvements in patients who meet the clinical prediction rules and are treated with matched interventions.

Patients most likely to benefit from spinal stabilization exercises (74-97%  improvement in probability of success if patient fits 3 or more of the following):

  • Younger than 40 years old
  • Straight leg raise > 90 degrees
  • Positive prone instability test
  • Aberrant movement patterns
  • FABQ physical activity subscale < 9

Patients most likely to benefit from spinal manipulation ( presence of 4/5 resulted in an increased likelihood of success to 95%)

  • Duration of symptoms < 16 days
  • FABQ work subscale < 19
  • No symptoms below the knee
  • At least one hip with internal rotation motion > 35 degrees
  • At least one hypomobile lumbar segment

What does all this mean to you as a patient?  If your therapist is treating all back pain the same – find a new therapist.  Modalities such as hot packs, electrical stimulation, and ultrasound have been shown to provide little or no benefit in the treatment of low back pain.  Ask your Physical Therapist if they use classification systems or clinical prediction rules. 

To find a quality Physical Therapist in your area, click HERE

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