Back pain, 2011

This was posted on Health Beat by Maggie Mahar.   I liked it so much I took the post and have added some comments of my own. 

Dr. Nortin Hadler, author of Worried Sick: A Prescription for Health in an Overtreated America and , more recently, Stabbed in the Back: Confronting Back Pain in an Overtreated Society. I admire both books because they are so well-written and richly referenced..

Hadler is Professor of Medicine and Microbiology/Immunology at the University of North Carolina at Chapel Hill and Attending Rheumatologist at the University of North Carolina Hospitals.
His commentary on “The Predicament of Backache” is adapted from, Stabbed in the Back. It puts my posts on spinal surgery in a larger context, illustrating how “cutting” is not always a cure for life’s problems


The text starts off with some basics on back pain that therapists hear on a regular basis.

To live a year without a backache is abnormal. Here, I am speaking of the commonest form of low back pain: the backache that bedevils working-age adults who are otherwise totally well. This is a pain that does not involve the legs, and that comes on suddenly, seemingly without cause.

Low back pain is one of many recurring predicaments of life, like heartburn and heartache. To be well is not to be spared. To be well is to have the wherewithal to cope till the pain goes away, cope so well that the episode is not even memorable.

I have commented recently on the importance of posture, strength, and mobility and how it affects our everyday movement.  Our bodies will naturally adapt to the outside forces around it, to be able to continue to function.  After awhile, sometimes it does not matter, it just hurts. 

Low back pain relates to posture and movement. It hurts less recumbent. It hurts more slouched forward in a chair or propped up on pillows, let alone bending over. One is forced to choose between less pain and less invalidity. Compelling science says less pain is not worth it. Feeling useless just enhances the suffering without enhancing the rate of healing. Take an over-the-counter analgesic and get on with life as best you can.

I have mentioned previously that there are many people out there that will promise pain relief if you buy into their system.  Back pain typically does not start from a specific event, it is a combination of many events over time that eventually catch up with us. 

Low back pain will go away, but seldom overnight. Weeks are more like it, and months for a few. One should never despair. Nor should one feel so desperate that one grasps at straws. And there are many offering straws, many who would gird your loins, empty your pockets, push pull and poke you, offer you potions and pills, and attempt to excise the evil.

This response to back pain serves as an object lesson. We live in a time when science seems to be bursting with promise. Details of the very latest for diagnosis and treatment find their way into the headlines of print media and the features of broadcast media. We are told to expect cures. All of us respond with baited breath, some with speculative investing. Yet if we give way to the promise of cure, we risk compromising our sense of well being, our belief that we can cope. We succumb to what some call the medicalization of life, brought to us by an industry dedicated to the proposition that none of us are well.

I believe that physical therapists are better at coming up with dysfunctions that lead to back pain, better than any other health care professional.  That is my own opinion, and do not have any research to support that.   However, I do agree with the next comment, that there is no one specific "modality" that can decrease your pain.   It is a matter of finding the dysfunctions, and addressing them.   This is why PT's are the best qualified to treat back pain.  It is typically a multitude of dysfunctions that casue back pain. 

Realize that despite all the jargon, there is no one who can reliably pin point the cause of the common backache. Realize that despite all their theories and all you hear on the street, no one has a “modality” they can apply to you that can be shown to benefit you. All these helpful people are engulfing you and your pain in their frame of reference, in their belief system. You will no longer suffer alone. But your narrative of illness will change, as will your self-image, permanently. Despite these ministrations, you will not return to your prior state of well-being any more rapidly. If you return at all, you will greet any recurrence of the back pain with idioms that were taught to you. If all this is a pleasing prospect, go for it. But do so informed.

I really enjoy this final paragraph.   There is quite a bit of research that shows job satisfaction is a key indicator for return to work after a back injury.  A person's overall satisfaction with life at home will also contribute to their ability to cope with back pain and return to life.  I have learned recently that we continue to make destructive decisions, not because we like to, but because we do get something out of it.  Until you determine what you are getting out of your decisions, you will have trouble improving your coping, and therefore trouble treating back pain. 

Granted, for some of us, coping becomes impossible. Certainly, that could reflect the severity of the pain. But science informs us that another explanation is far more likely. It is not the pain, but other aspects of life that blunt our coping skills. Leading the list of confounders are adverse aspects of life at home or at work. If you can not cope any longer, find someone trustworthy to discuss the possibility that the pain is surrogate for some assault on your coping skills. In all likelihood, you coped with similar predicaments in the past. If you are unwilling to countenance the possibility that something in life is more a pain than the pain in the back, you run the risk of feeling so desperate that you submit to pills, potions, magical thinking or ineffective surgery before you come to grips with your psychosocial adversity. Surgery can not excise an intolerable job, nor can an intolerable home situation yield to manual therapy. Don’t let the pain cloud your thinking. Don’t let preconceived notions lead you astray.

Take care of your back, but understand when you do have pain, we will be there.   Sometimes to listen, sometimes to advise, and  when needed to treat. 

"Never underestimate the ability of spine surgery to make your back pain worse. . ."

Yes, I stole that from another PT.   But it rings so true.   The great therapists at Evidence in Motion continue to help get the word out to Physical Therapists and the public that back pain is best treated by. . . . . (I know your going to be surprised)  A PHYSICAL THERAPIST.  A recent post talks about the increasing rates of spinal fusion for management of low back pain.

I have also frequently commented on this blog (see here and here) about the outrageous nature of spine surgery, particularly lumbar fusion in managing low back pain.  Typically I use data to make my point.  Unfortunately I believe we have become immune to big numbers and what those number mean in terms of human suffering.  The numbers do not convey the darnage that is happening to real people day in and day out. 

There is mounting evidence that having surgery for back pain leads to poor outcomes.  This is not meant to bash spine surgeons.   This is meant to inform that there are other options to having surgery, especially fusion, for your back pain.   Back pain is multi faceted.   Back pain does not just 'go away' with fusion.   There was a reason you had pain prior to surgery, and without making changes to your lifestyle, chances are your back pain will be unchanged.  Lifestyle choices, like so many other health problems can be a big factor in back pain.  (Smoking, overweight, no exercise)  But, how can I exercise or lose weight if I have all this back pain.   Well, that is the reason you need to seek out the help of your physical therapist.   I really can't help you quit smoking, but can help point you in the right direction.  Assessment of your flexibility, strength, movement patterns, and making changes to improve the areas that are deficient  are waht PT's do on a daily basis.  I have typically found most of my patients have weakness that affects their ability to support the spine.  They have poor flexiblity that creates poor movement patterns.  By improving the flexilbity and stability of the spine, force can be spread throughout the body, and decrease pain.   Its  is really wonderful hearing from patients how much better their back pain is with the start of exercise and strength program. 

Are you ready to start working on your back pain?   It probably won't get better overnight.   I do not have a magic wand.   I do have the tools to help you manage your pain and help provide long term relief.  Get started, see a physical therapist for you back pain. 

1000 Awesome Things about Physical Therapy

The great therapists at Evidence In Motion (EIM) are taking the idea by Neil Pasricha who authors a blog entitled 1000 Awesome Things into the Physical Therapy profession.  A list of 1000 Awesome Things about Physical Therapy is currently being developed.  These are ideas submitted by physical therapists from patients to be posted about the Awesome things Physical Therapy does for them.   Just to get you started, here are the first 6 that have been posted, There are sometimes little stories or comments that go with these.

1.  Walking Again, Sleeping comfortably
2.  Friendly, Caring place to be
3.  Realizing surgery and medication are not the only option
4.  Walking down the aisle

         "Awesome thing about PT, I was invited to a 75 year wedding anniversary. His goal was to be      able to walk down the aisle to renew their vows. He met his goal."

5.  Not complaining about pain all day
6.  Actually listening. 

"Thank you for being the first person in the

health care system to actually listen to me."

  I am so happy as a PT I get to be involved in so much of people's lives.   I hear about their families, work, and everyday life, and am so blessed to be a part of it.  I occassionaly need to remind myself when I get to explaining a treatment plan or therapy diagnosis that 'nobody cares how much you know, until they know how much you care'.   I hope I have listened well over the years.   Can you tell me something awesome about physical therapy that I can add to the list?  Let me know. 
 



Snow is falling, dont get hurt shoveling

As I sit here answering the phone about patients cancel their appointments because of the falling snow, I was thinking about shoveling all the snow. We have about 2-3 inches of snow right now, and the roads are getting slippery. But it makes me think about injuries that can happen from shoveling snow.
Some tips to try to avoid getting hurt.

* Lift smaller loads of snow, rather than heavy shovelfuls. Bend your knees and lift with your legs rather than with your back.

* Using a shovel that's too long makes the weight at the end heavier.

* Try to use a shovel with a handle that lets you keep your back straight while lifting. A short handle will cause you to bend more to lift the load.

* Avoid twisting as much as possible. The spine does not tolerate twisting movements well. Step in the direction in which you are throwing the snow to prevent the low back from twisting.

* Take frequent breaks when shoveling. Stand up straight and walk around periodically to move your spine out of the forward bent posture.

* Standing backward-bending exercises will help reverse the excessive forward bending that occurs while shoveling: stand straight and tall, place your hands toward the back of your hips, and bend backward slightly for several seconds.

* Take care not to over exert yourself. Take your time to shovel the snow. The cold weather can affect you, and if you are out of shape, can hurt yourself more.

*Last but not least, find a friend with a snowblower. This alsways make the shoveling much easier.

With proper precautions and the correct snow shoveling technique, injuries to the shoulders and lower back can often be avoided. If you or someone you know has back pain, consult a licensed physical therapist. Physical therapists are experts in restoring and improving motion in people's lives. They can treat pain without surgery, in many cases, and reduce the need for prescription medications, help patients avoid side effects.

Enjoy the snow. Stop by and see me if you do hurt your back.

Physical Therapy and Back Pain

I treat back pain on a regular basis. I have known for a long time that early physical therapy led to better results with less intervention. Finally, I have additional research to back me up from a recent APTA news release.

The study, published in the journal Spine, showed Medicare patients who
received physical therapy in the acute phase following an episode of low
back pain were less likely to receive epidural steroid injections, lumbar
surgery, or frequent physician office visits in the year following their
initial physician visit as compared with patients who received physical
therapist treatment later.

The study shows a decrease use of services for those who receive physcial therapy early after an episode of low back pain. This study was guided towards Medicare patients but applies to everyone. The earlier you start to treat your back pain, the better recovery with less use of services. When you have back pain, you will search high and low for treatment options. There are many out there, but few take the approach that a good physical therapist will. Investigate the problem, find the source of the problem, and treat the problem. Too many people want quick fixes for their back pain, and typically, quick fixes don't work over the long run. Massage may be helpful at first to decrease the muscle guarding that goes with back pain. Manipulation may be helpful only for the areas in the spine that are not moving correctly. These are good ways to initiate treatment, but are only a part of the problem with back pain.

Most people that I see have weakness in the legs, hips and spine that contribute to their back pain. A combination of massage, manipulation, and exercise is truly what is needed to treat back pain. To reduce the amount of services people with back pain must also understand that more testing does not reveal the need for different treatment options. Many times it leads to more treatment. An MRI may be recommended, but is it really something you need. A previous post on the number of MRI machines in your area, increases you chance of back surgery. An MRI that shows degenerative disc disease or a bulging disc, is probably considered normal for most people. The spine is poorly taken care of by the owner (yes, that is you). Generally, most people that I see have chronic dysfunctions (weakness, flexibility, posture, etc) that lead to increased back pain. Finding and treating the dysfunctions in the spine is what physical therapists do. There is no magic wand to 'fix' back pain. It takes some effort, a little time, and a physical therapist to help you get to feeling better.

Do yourself a favor the next time you have back pain, find your physical therapist! Even better, if you have had back pain recently that seemed to go away on its own, call your physical therapist and set up an appointment to find what is wrong and how you can best treat it.

Small Changes for Big Results

In my last post, I was talking about posture and how it affects everything we do. Today, I was reading One Small Change, a blog that we refer to here quite often. The Core Performance website has great exercises that I use not only for my patients but also for myself. In the blog, they are making the challenge to start working on posture and give a great quick workout you can do to get started.

A great activity to start working on your posture is to lay on your back with knees bent and feet on the floor. Try not use a pillow under your head. Place your arms at your side and turn your palms up. Lay in that position for 5 minutes 2-3 times a day. This is a great way to use gravity to stretch those muscles that are problematic for you.

Work on sitting better. Sitting better means lifting your collar bones. Pulling your shoulders straight back is not the answer to better sitting posture. Think of lifting from the top of the sternum (breastbone). Women pretend you have a huge diamond necklace and you want to show it off, men lift the knot from your tie. This will place the head, neck, shoulders and spine in best position for posture. Hold that position for 1 minute and do that once an hour throughout the day. One minute per day is a goal you can accomplish. This also makes you more aware of your posture throughout the day.

The post goes through some other quick ideas you can do to work on your posture throughout the day. Posture is something that takes time to change. To improve your posture, you need to be aware of how you sit and stand now, and what needs to be done to improve it. The exercises to get started are great beginners, and will really help to make a difference in your posture.

Early Christmas, Posture Presents

As I was getting caught up on some reading, I revisited some articles on posture. I started reviewing some of my treatment plans and how much posture plays in the problems that I treat as a physical therapist. Poor strength, flexibility and stability all contribute to poor posture and it's effect on our body's performance. A recent post from Joe Kita on "One Small Change" on CorePerformance.com discusses postures effects on athletes.

"Posture doesn’t get much respect from athletes because they think it’s the
domain of prissy etiquette experts. But I’m not Miss Manners, and this
program isn’t going to entail walking around with books on our heads.
Posture is the secret weapon to enhancing performance and—no
exaggeration—life itself.

“About 75 percent of my work with athletes is spent helping them improve
posture, whether they realize it or not,” says Sue Falsone, PT, CSCS, the
director of performance physical therapy for Athletes’ Performance. “The body
needs to have some element of stability in order to produce mobility. When that
foundation isn’t there, you’re going to have a hard time doing just about
anything well.”

So what does this all mean when it comes to the average person that does not think they are an athlete. The last part of the quote tells you everything. "you're going to have a hard time doing just about anything well." This may including standing, walking, doing laundry, performing you job, reaching, lifting, pushing and pulling. Sound like anything you do during the day? Most of these activities are included in our daily lives.

There are exercises that can help you to improve you posture, core strength and stability. Changes in posture can happen in 4 weeks or less with some time spent on correcting the muscular imbalances that happen from poor posture. Who needs help with posture? Just about everyone. Most (read between the lines, ALL) of my patients need some work on posture and core stabilization. Core Performance has an excellent program that I try to incorporate into a program of strength and flexibility for everyone I treat. From the high school athlete with shoulder pain to the truck driver with back pain to the grandmother that had a knee replacement, they can all benefit from some sort of core stability.

Stop in to Hardin Rehabilitation and Wellness to find out how core strength and flexbility can help improve your posture and help you feel and look better. Give yourself an early Christmas present! Work on your posture!