Monday, 28 May 2018

How I Assess And Treat People With Low Back Pain Part 2: Treatment

In Part 1 of this series I discussed how I assess people with Low Back Pain (LBP). In this article I get down to the treatment side of things. I want to thank everyone who took the time to read the article & provide such useful feedback. Hence this article is out later than desired as I wanted to reformat it & do it right.

Disclaimers: As I said in Part 1 this is not intended to be medical advice. Plus I don’t expect that everyone’s going to agree with every single point that I make – that’s fine. Also this is going to be a long article and is very context and assessment dependent. It’s not a recipe.

My approach comes down to 4 basic tenets

1) Minimize what exacerbates the issue

I didn’t say “take away” or “remove” as for some people, such as patients with chronic pain and central sensitization, that may not be realistically doable. But I still believe in modifying and reducing (and if possible eliminating) what exacerbates the issue. These can be
-          Specific movements, postures, loads, behaviours, activities (or volumes of activities) or repeated movements OR
-          General health factors such as poor sleep, stress, depression, or being overweight

Going step by step through these…

Movement/Posture: My movement recommendations depend a lot on the mechanism.

If someone is aggravated by very specific directions or postures (i.e. what some would consider flexion intolerant or extension intolerant) than yes I get people to move in a way that’s not provocative (or is at least less provocative). This may involve using a neutral spine/hip hinge technique (I teach a modified sumo lift technique for people with sciatica and for tall people), emphasis on using the gluteal muscles more (they are never turned off short of a neurological injury) and bracing … or conversely relaxing the core musculature and breathing deeply as some patients are very tense & guarded and need to relax.

 For posture – oddly enough (and there’s a bit of research and anecdotal support on this) that some people tend to sit or stand in the same posture that provokes their symptoms and some are very rigid & overprotective!!! For these people I will have them adjust their lordotic curve to find a position that’s comfortable for them. I’m more of a fan of teaching people how to find movements & postures that are comfortable for them rather than trying to find an ideal.

One of the reasons why I look at movements and repeated movements is to give people ways to do their day to day tasks that (hopefully) don’t aggravate their symptoms. While I’m not a fan of telling people to avoid movements forever it doesn’t make sense to force people through movements that can aggravate and worsen their symptoms with repetition. Sometimes you need to take a break from the exacerbating issues to facilitate recovery. How long movements are avoided is a contentious topic that depends on a variety of different factors.

For people who have more of a central sensitization (CS) pattern it may be that everything (including hip hinging) hurts to some degree. In these populations I’m not as concerned about movement technique as I am about other variables (more on that below) but I will still teach some biomechanical principles (i.e. keeping loads to the body, avoiding excessive muscle tensing or bracing) to make things easier in theory.

General health: In terms of other risk factors and contributors to LBP
-          Sleep: I educate patients on simple sleep hygiene (which I will write about in another article) and on the importance of sleep. Past that if there are other issues I will refer to sleep specialists especially if I have bigger clientele who may have sleep apnea or people who may have major psychosocial issues.
-          Stress, Anxiety, Depression and other psychosocial factors: I’m gonna get some heat for saying this but I don’t believe; unless it’s related to movement, injury, pain or activity; that physios should be trying to treat psychosocial factors other than educating patients about their importance, giving them some exercise to do (which can help with psychosocial factors) and again referring out.
-          Body weight management: Same principles apply – educate the patient about the importance of it, get them moving, and if need be refer out to other health professionals who can help fill in the blanks with diet and hormone management.

The 2nd key principle of my approach to back pain is that

2) Well tolerated movement & exercise are good

A lot of research has shown that general exercise and “core stability” exercises are equally effective for LBP management. While I don’t disagree with the research I’ve found (anecdotally) that some people with LBP may not tolerate certain exercises well – be it core training, walking, cycling, general strength training, or directional exercises.

For home exercises my first go to are generally repeated movement/McKenzie style assessments based on the directional preference of the person I’m working with. If a client I’m working with doesn’t have a directional preference my home exercises are generally
-          For more nociceptive/neuropathic cases: usually exercises that address “painless dysfunctions” (I hate the term but that’s what people understand) that may limit an individual’s ability to move in non-painful (or less painful) patterns such a lack of hip, ankle or shoulder mobility and/or a lack of hip/core strength or endurance
-          For people with more of a CS presentation: some people I work with who have CS are insanely deconditioned and have some MAJOR mobility or strength limitations. In those situations I give people 1-2 low dose exercises (ie sets of 2-5 2-4x/day working into a bit of pain but not blowing through it) to either address these limitations or maintain the mobility that’s already there

In the clinic I am also a fan of core, glute, and general cardiovascular exercise for most people with LBP who tolerate them. Some may criticize me – but given the poor adherence of patients to home exercise programs I’d rather see them do a few exercises in the clinic rather than f*cking around with a TENS machine or ultrasound. For people who tend to have more of a CS presentation I spend more time talking and a lot less time with exercise & manual therapy.

3) Address negative beliefs about movement, the body, pain and activity

As I said above I’m not a fan of physios trying to be psychiatrists. Just as you wouldn’t want a personal trainer trying to treat a client’s broken arm … I don’t believe a physio should be trying to treat a client’s PTSD from combat or trying to grief counsel a mother who’s lost her kid.

But anything related to movement, activity, pain, injury or the body is within our ballpark IMO.

Therapists such as Peter O’Sullivan have written about the importance of beliefs as they relate to LBP. While pain science education is important sometimes patient education has to take different paths based on the individual.

In my experience some people respond quite well to pain science education and others have a hard time changing their view of pain. Behaviour change and belief change is a long, time consuming process for some people and some may never change their beliefs. We as a society have become so engrained in the idea that pain is always due to “issues in the tissues” that some patients may never change their beliefs. We as therapists have to accept that we can’t change everyone.

In more “non-specific” cases I point out how a patient’s pain is due to changes in their nervous system and body that make them more sensitive and more likely to experience pain. This allows me to put a “feeler” out there to determine if the patient is interested in more pain science education. If they are – great. If not, no harm no foul.  If they want to learn more than I will draw a bubble diagram outlining all the factors contributing to the situation and will go into more detail about pain science in coming appointments.

In patients where there is a legit tissue injury, or in cases where a patient is dead-set that their MRI findings are the cause of the problem, I point out how a lot of back injuries can heal given proper management.

A big component of my work is positive coaching and cueing. Some health and fitness professionals freak patients out by pointing out numerous dysfunctions that either can’t be reliably assessed and/or don’t correlate well with pain. I don’t coach certain people to do certain movements or exercises by saying “do this or your back will explode.” I coach movement and positional strategies in a way that empowers patients to move in ways that are comfortable for them. Sometimes showing people ways to move and exercise that are comfortable for them alleviates a lot of the anxiety and enables people to trust in their bodies a lot more.

I also believe that getting people to do things they never thought they could do (within reason of course) and progressively working them towards the activities they want to do also helps build confidence & change beliefs.

4) Build people back to the activities that they want to do

This is where we tackle the first elephant in the room … spinal flexion

 Yes – most of my patients that I see on Day 1 (arguably over 97%) don’t tolerate much spinal flexion. As such I try to minimize that in the early stages. However, while I’m still reluctant to have people flex 100 million times a day or to do it under heavy load, I do believe we should be able to move our spines as needed.

When patients are getting closer to full recovery I start to ease them back into spinal movements through low-load exercises such as cat camels & prayer stretches and progress them to being able to move fully in standing. There are however situations where I will stick to the “minimize spinal movement” approach such as….
-          People with a recurrent flexion or extension or motion intolerant low back pain that is more nociceptive and/or neuropathic in nature
-          People with moderate to severe osteoporosis who are at higher risk of fracture
-          Athletes who require a great degree of spinal stiffness in their sports such as powerlifters

In these three populations I often encourage people to hip hinge as much as possible. I don’t say “don’t bend your back or your spine will blow out” but I do believe that hip hinging is a better option to achieve their goals.

If a certain exercise or activity is a goal of the individual (e.g. returning to walking) than the activity itself (or some close derivative) is part of the exercise program and is progressed based on the individual’s activity tolerance in increments of 5-20% per week based on how the patient responds. As Tim Gabbett has said (yes his research is in athletes but I believe it applies here too) people respond differently to different increases in activity and as such you have to be flexible to adjust the rate of progression to your clients tolerance.

For people with nociceptive or neuropathic pain I prefer having people do activities in shorter bursts, stopping just before their pain would increase, and repeating those bursts through the day. I find anecdotally that many of my patients who use this technique for walking or activities experience a huge increase in their pain free walking tolerance within a couple weeks.

For people who have more CS with walking (or any activity) I just advise that it’s OK to work into a little bit of pain, not to blow aggressively blow through pain, and work with them to slowly increase the amount that’s done.

 What about the other elephant in the room – manual therapy?

I’ll confess that I use manual therapy less than most therapists do. If it’s a patient that’s had chronic back pain for years and has already sought out a bunch of passive treatment modalities than manual therapy isn’t going to be the first thing that I’ll do with them. In addition I find manual therapy, no matter how gently its done, just makes some people really sore.

By the same token if I have a case that’s so irritable that they can barely tolerate any activity, someone who’s overdone it, or someone who is limited in ability to exercise due to deconditioning or medical comorbidities, than manual therapy (or even modalities) can play a role but in my opinion it’s not as important for overall treatment as many therapists think.

When doing manual therapy for the back (or for other joints) I try to direct it towards painless limitations (I hate the word dysfunctions) first and then afterwards painful areas. Since manual therapy’s effects are non-specific, if I can reduce pain and improve function in another of the body that kills 2 birds with 1 stone.

So that is basically how I go about treating people with LBP. As always, thanks for reading.


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