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 2^nd 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.

How I Assess & Treat People With Low Back Pain Part 1: Assessment

I get asked all the time, especially when people find out I’m a physiotherapist, “what can I do for my back pain” or “what exercises can I do for my back?” These are understandable questions as Low Back Pain (LBP) is the leading cause of disability worldwide costing the health care system millions of dollars in assessment, diagnosis and treatment.

When it comes to LBP assessment and treatment we are in a bit of a difficult spot as the vast majority (80-90% of LBP) cases are not attributable to a specific diagnosis such as a disc pressing on a nerve root, a fracture, or a lumbar muscle strain. As such most LBP cases get lumped into the “non-specific LBP” category. While attempts have been made to subgroup LBP patients the validity of most subgroups have been called into question over the last several years.

In terms of treatment the same conundrum exists as many treatment approaches are equally effective for LBP, no form of exercise seems to be better than the other, and the validity of clinical prediction rules has also came under scrutiny over recent years.

This leaves us in a bit of a tough situation – what do we do for people with LBP? Well in my article I will address how I personally assess & manage someone with LBP in the clinic….

Disclaimer 1: This is for professionals and is not intended to be medical advice. If you have any symptoms such as fevers, chills, night sweats, unremitting night pain, unexplained weight loss, sickness or unwellness, tingling/numbness in the groin, changes in bowel/bladder function and/or a loss of sexual function you may have symptoms suggestive of a serious medical pathology and may need to seek medical attention as soon as possible.

Disclaimer 2: The topic of individualized management in LBP is a controversial one so I accept full well that people (you the reader included) may or may not agree on all the points here but I do hope you will give it a read.

Side note: at the time I was working on this article I happened on this paper which is very very similar to my approach (aside from a few subtleties)

FIRST THINGS FIRST – RULE OUT RED FLAGS AND SERIOUS TISSUE PATHOLOGY

The most important reason as to why someone in pain should see a doctor and/or a physical therapist is to make sure, if anything else, that there are no major health concerns that need to be medically managed.

In the research 1-2% of LBP cases are attributable to a serious pathology such as fracture, cancer, infection, inflammatory condition, or cauda equina syndrome among others. I will not go over the symptoms suggestive of these conditions but I suggest updating yourself on these regularly if you are a professional.

AVOID UNNECESSARY IMAGING

Imaging is indicated for LBP patients if they have symptoms suggestive of a red flag or serious tissue pathology and/or if they have a significant neurological deficit (i.e. dermatomal loss of sensation and/or myotomal weakness) that isn’t improving with conservative management. This applies to a small percentage of people with LBP.

Unfortunately medical imaging is overused, particularly in the US. Now I understand that its easy for doctors to feel pressured to send patients for imaging, but a lot of research suggests that people with LBP who don’t have an indication for imaging are actually worse off getting an X-ray or MRI.

Also – its important to keep in mind that 80% of people with LBP have 1+ symptoms suggestive of a red flag condition yet only 1-2% have them. As such its important to have good clinical reasoning to order special tests.

But won’t the X-ray or MRI show me what’s wrong?

The problem is numerous studies have shown that lots of PAINFREE people have degenerated discs, arthritis, and disc lesions among other things. See the chart below for examples.

Patients often freak out about what their MRI findings say while they may be incidental.

WHAT DO I LOOK FOR IN SOMEONE WITH LBP?

I look at pain from a biopsychosocial perspective. Breaking it down

Bio – general health factors (e.g. fitness, comorbidities); aggravating/relieving movements, postures, and loads; sleep;

Side note: a lot of research claims that biomechanical factors don’t correlate with LBP which isn’t necessarily wrong but I do believe biomechanics shouldn’t be ignored. Sometimes people do have pain with specific movements/postures which may be due to overuse of those movements/postures, guarding, kinesiophobia, or other factors.

Psychosocial – factors that can be related to movement, injury and pain such as fear avoidance, catastrophizing, kinesiophobia, other maladaptive beliefs and passive coping; as well as psychosocial factors such as stress, anxiety, work situation, and depression

I also look at what the patient is working towards (in terms of occupational and/or sporting demands) as well as their goals.

Prior to assessment I’ll have each patient fill out the Orebro Questionnaire – a questionnaire designed to detect psychosocial factors & factors that can place someone at an increased likelihood of chronic pain. I’m not as interested in the overall score as I am in the score of individual items.

SUBJECTIVE ASSESSMENT

Peter O’Sullivan taught me to open my assessment with “tell me your story.” I say that, shut up, and let the patient say what they have to say. I find this gives me probably 65-70% of the useful information I need and it gives the patient a chance to get whatever they need to get out there & off their back. Sometimes just talking can be therapeutic.

Examples of specific questions (aside from ones to rule out red flags) that I’ll ask are

-          Any recent life changes in your family, work, hobbies, or financial life? You don’t have to tell me the specifics if you don’t want to.

-          Have you had any X-rays or MRIs recently?

-          Have you gotten any advice from your doctors, friends/family members, or the internet on what is going on and how to address it?

-          What do you think is going on?

-          How have you been doing in managing this?

-          Any stress, anxiety or depression?

-          Any issues with sleep before or after this started?

-          How has this impacted your life?

-          Where do you see yourself in 6 months?

-          What would you like to do that you aren’t already doing?

-          Have you had to stop or modify any activities?

-          What do you think would happen to you if you did <insert activity here>?

Some may disagree with me, but aside from workers comp cases, I don’t ask a lot of questions specifically about pain except for

-          Whether it’s constant or intermittent

-          Type

-          Aggravating/relieving factors

I find the 0-10 pain scale highly subjective plus I don’t like the idea of feeding into a patient who may be ultra pain focused & causing them to ruminate about it even more.

Two papers I recommend for people wanting to learn more about a good biopsychosocial subjective history are the papers “Listening Is Therapy” and Peter O’Sullivan’s recent “Cognitive Functional Therapy” paper.

OBJECTIVE ASSESSMENT

My objective assessment is basically a hybrid of the McKenzie (MDT) assessment as well as the assessment Stu McGill describes in his books Low Back Disorders, Back Mechanic and Gift Of Injury. These assessments guide my exercise, movement & postural recommendations towards what is more tolerable and (temporarily) away from what’s not tolerated in the early going. For the sake of not giving away their work (and keeping this article from getting ridiculously long) I recommend you buy and read those books.

In addition to these I also do a simple neurological assessment (ie dermatomes, myotomes, reflexes & cord signs). As I’ve written about before motion palpation & positional palpation are unreliable so I just quite frankly don’t bother with them.

I also, in a SFMA-ish style, will look at gross function of the surrounding joints (ie hips, shoulders, ankles) to see if a deficit in one of those areas may be causing a client to have to “overdo” painful movements due to a lack of mobility, strength, or motor control at a distal joint. An example of this could be someone who has pain with lumbar flexion but has to flex the lumbar spine everytime they bend over due to a lack of hip mobility.

This isn’t so much of a subgrouping approach but it enables me to pick and choose what is important to the individual’s treatment plan. I’ve had patients with no psychosocial factors and patients with a ton of psychosocial factors involved.

I hope this helps give you an idea of how I assess people with LBP. In Part 2 of this series I get down to the treatment side of things. As always - thanks for reading.

Random Thoughts April 2018 - Is Any Exercise Good Or Bad, How I Go About Challenging Patient Beliefs … Before I Actually Challenge Them, The “Bottom Up” Prioritization Pyramid – How I Wear Multiple Hats, And Are Trainers Bad At Coaching Or Just Uneducated

Are burpees (or any exercise) good or bad?

A lot of good discussion lately on burpees and whether exercises are good or bad.

My simple thoughts are it depends on ...

1) The medical/injury history of the individual

Someone who has flexion-aggravated back pain would be best served to temporarily stay away from burpees. Someone who has knee pain that worsens with repeated knee extensions may be best to take a break from the leg extension machine.

2) The baseline fitness level

Does the individual have the ability to perform the exercise "correctly?" Yes there is a wide range of correct form with many exercises but I'm not a fan of having someone squat with their knees moving in & out like a baby giraffe's legs and their back looking like its gonna collapse at any second.

By contrast to 1 & 2 people who are healthy & capable of doing these exercises properly are probably OK as long as they
- progress their volume appropriately
- provide appropriate rest & deloads
- don't max out all the f*cking time
- manage sleep, nutrition, hydration and psychosocial factors

3) The goals of the individual

The McGill and Weingroff biomechanically influenced guy in me uses the goals to determine the acceptable risk/benefit ratio of an exercise.

If you satisfy 1 & 2 - and enjoy doing burpees and/or competing in CrossFit or bootcamp or whatever that's fine - do em. If not there may be other options to give you a good workout with low impact.

If you're like me who enjoys powerlifting than heavy (by my standards :) ) squats & deads are a part of the sport. If you're training for general health/fitness there may be better options.

So the answer isn't as black & white as people think and requires some good reasoning behind it to make smart training decisions that will maximize results & minimize injury risk.

How I go about challenging patient beliefs … before I actually challenge them

On challenging patient beliefs...

It's tricky. I don't necessarily start by trying to confront patients or change their beliefs right from the get go as I found it gets more push back than anything else.

What I do do is

1) Just simply be a good person, listen to and validate the patients' story. Nothing replaces this.

2) Try to educate patients about all the different factors that can contribute to pain. I find when some patients hear about the false +ves on their imaging they feel invalidated and feel like we're brushing them off. This is a better strategy to listen to and acknowledge the patients concern but also still honour the complexity of pain.

3) I try to empower them by
- showing them what they can do and
- giving them a plan to manage pain and get back to what they want to do

4) Educate patients that hurt doesn't always mean harm and in certain situations (ie chronic pain, post surgery) where painful exercise/movement may be unavoidable - educate them on what level of pain & pain response is acceptable and what is going on.

5) Don't scare the shit out of them with nocebo-ic language

To me that steers the ship and gets it sailing in the right direction. Then later on, after the trust is built, we can start to work on changing beliefs.

Some people may disagree with some of my points, that's fair enough, but that's how I go about belief changes & empowering patients.

The “Bottom Up” Prioritization Pyramid – How I Wear Multiple Hats

Over the last week in the clinic I’ve been asked a lot how I manage being a physiotherapist, educating through my UW curriculum work & website, training for powerlifting, and also being there for my family without burning out.

It took me a lot of trial & error but I basically figured out what I call the “Bottom Up” Prioritization Pyramid which was influenced a lot by Stan Efferding, Will Kuenzel and Nicholas Licameli.

Let’s start with the foundation. The foundation enables you to fulfill your priorities, maintain morale & not burn out. For me that includes

-          7+ hours of sleep a night

-          Adequate high quality food in the right amounts

-          Adequate down time and contact with friends

This doesn’t mean be lazy as f*ck – it means build in proper recovery (both physically & psychologically) to enable you to do the hard work. You can only work or train as hard as what you can recover from. The size of the foundation enables you to determine how high you can go and how much time you can put into your other priorities. I don’t know of too many people (yes there are some) that function highly on 4-5 hours of sleep a night.

I design the rest of the pyramid from a bottom-up perspective. The #1 priority, whatever that is to you, is at the bottom as it has the most size (and time given to it) and is most influenced by the foundation. Priority #2 goes next and so on & so forth.

To give a visual example of what this looked like during my storm stayed week in Fergus.

Family time and contact was fairly minimal as I was storm-stayed and couldn’t see anyone. The lifting (which was modified due to the CPU Coaching Certification) was condensed & done earlier in the week. Hence my priority (on top of a 40 hour week of treating patients) was working on professional content for both my website and in my UW curriculum work.

The priorities change for me based on what I have on the go in my life and what time of the year it is. If I’m getting ready for a meet or losing bodyfat lifting is a bigger priority. If it’s a long weekend with family that becomes #1 priority. This enables me to manage multiple big priorities in life while keeping me from burning out.

If you’re someone who wears multiple hats I hope this helps you.

Are personal trainers bad at coaching exercises or just uneducated?

Quick rant for you trainers & strength coaches out there.

I'm tired of seeing posts like "if your client can't do X exercise or doesn't get X exercise than you are bad trainer/coach/person" all over the interwebz.

Maybe the problem is that the trainer wasn't properly educated in the first place.

Back in 2012 when I first started in cardiac rehab, aside from learning from Stu McGill, I was never trained on how to properly coach or teach exercises. And in physio school we didn't cover much exercise other than TVA/glutes/rotator cuff/scapular muscles. Even some of the big trainer certifications fall short in that regard.

When I help out at the UW KINNection event I see the way I was back in 2012 - underconfident, way too wordy with coaching, stumbling & fumbling, and unsure of what to do if an exercise was too hard for a client or if the client didn't get it.

Over the last 5-6 years my ability to coach/regress/progress/modify exercises has improved a lot thanks to learning from, networking, and working with top level trainers, strength coaches, and exercise-based therapists.

So keep in mind not every health or fitness has discovered these resources or has access to them when making comments online. Instead of berating someone's ability - take the time to show them some of what you're learned and pay it forward. It's likely that you didn't know this stuff before trainers, strength coaches or therapists showed you these tricks and tidbits either in person or through video.

Rant over.