An Expert Guide to Low Back Pain

LOW BACK PAIN

A Powerful Expert Guide

Skip to the Bottom for Summary of What to Do About Your Back Pain

ALL TOO COMMON OCCURRENCE
Daily, I see patients who are concerned about the course they should take to heal their back pain. They clump their low back pathology with every terror story they have encountered through the years. They receive advice or tips that can sometimes be ineffective or misleading.

As a result, medical treatments can be considered failed methods in their mind, because they have heard of the many  inappropriate applications to heal through these misguided interventions. I met three different individuals last week alone that all had similar stories of social media, friends, medical practitioners and internet telling them of all the varied and troublesome things they may have to look forward to with their back pain. It is no wonder they are fearful and confused by over analysis on what to do to fix their low back. My aim with these individuals is to demonstrate an effective and powerful method to quickly determine best course of treatment. I felt it would be useful to utilize the following steps to aid in this succinct and powerful way to approach LBP:

• Locate Region of Pain
• Classify Low Back Pain
• Prognosis, Thorough Education
• Evidenced Based Treatment according to Classification
• Restore Functional Abilities
• Follow-up and Prevention

A FEW STATS
Statistically, we know that approximately 80% of all Americans will experience low back pain in their life and 80% of those conditions will be recurrent in nature.  What has not been well defined statistically is the proper categorization of low back pain (partly due to the diverse levels of opinions on what should be done with the low back). In fact, some literature reports that 85% of back troubles are of unknown origin.  This further leads to the indecisiveness experienced by many with their spine.  The truth is that Classification can both help diagnose and prescribe Low back Pain with or without numbness into the leg (radiculopathy). A “Key” stat that all practitioners should be aware of is that 77% of all mechanical low back pain can be abolished and restored to within functional limits without requiring advanced treatments.

CLASSIFICATION
We can classify back pain into three main categories, that can be further sub-classified to give your expert a strong ability to treat with confidence.  The main categories and their treatments are as follows:

1. BEHAVIORAL – This category indicates that the patient’s back pain is associated with a lifestyle modification.  Usually the behavior of the patient with their perceived low back pain is mainly in the part of the brain that receives pain and is driven by social factors.  Psychological consultations assist these individuals more than any other physical treatments.
2. CHEMICAL – We know there are over 10 unique chemicals found in the center of the disc (which is the cushiony part of the spine) For example, PLA2 is well known to create an imbalanced pH in the outer ring of the disc when ruptured and can create a chemical pain.  Treatments that are effective for reducing chemical pains are chemical interventions, such as injections or medications.
3. MECHANICAL – By far the greatest reason for musculoskeletal low back pain is mechanical low back pain.  This can be pain from instability of the spine, ruptured discs (known as derangements), stenosis (narrowing of bones on nerves),  sinister conditions that cause lesions, scar tissue and on and on.  Understanding how to sub- classify these individuals will lead to successful prescription and treatment.  Skilled mechanical therapy is a FIRST option for these individuals. Surgery at times may be required when properly diagnosed for these individuals, but is few and far between.   Injections and medications most likely prolong and mask the issue with mechanical low back pain.

Too often we try to categorize a patient in one of these main classifications only to discover that there is a little interplay between all three.  It is important to understand that most back pain cases have a least a little of all three categories.  Because of this we find the main constraint and use context of the other two classifications to move the patient forward and restore function.

SUB-CLASSIFICATION
If Classification were as easy as stated above, we may not have such confusion in the medical community regarding treatment of low back pain.  However, with proper sub-classification, individuals have exponentially better outcomes because of the principle, “diagnose before you prescribe”.

Sub-Classifications of Mechanical Low Back Pain lead to optimal and most powerful treatments.  The following sub-classifications perform amazingly well with their associated treatments. As with main classifications, we find there is usually a dynamic interplay between sub-classifications.  For example, an individual with disc herniation is likely to also have instability due to the effect of injury on the deep spinal stabilizers. Thus, the practitioner should select the most constraining bottle-neck and proceed with context during prescription.

Starting with skilled mechanical physical therapy is a potent way to determine if conservative mechanical treatment will solve the problem.  Not all physical therapy is created equally. For example, a therapy group may emphasize stabilization for patients but not understand how to reduce a derangement or remodel a dysfunction.  The sub -classification system helps to quickly identify if therapy will help or if surgery is needed.  Two gems for timing that should be used include the concept “if it takes a year to walk into a forest it may take a long time to walk out”.  This means that the longer it took the patient to get proper treatment for their condition, the longer it will most likely take to solve it.  Secondly, if an individual is not seeing substantial improvements within 2 weeks of high end mechanical therapy, they may require more assertive treatments.

MECHANICAL LOW BACK PAIN DE-MYSTIFIED
Sub-classifications are best discovered through clinical prediction rules, mechanical responses, subjective reports and interplay of special tests.  The following list comprises main sub- classifications:

1. Mechanical Therapy– Mechanical therapy is all about patient and therapist generated forces in the correct plane, with the correct forces, with the appropriate direction and repetitions in the clinic and at home.  This is why all of WPT  doctors of physical therapy are close to certification level if not already certified (Cert. MDT).  You will never seek “adjustments” again if you understand the depth of effectiveness through this classification system.  Derangements are another term for herniated discs, but hold broader meaning. Dysfunctions are another term for scar tissue. Entrapments, Adherent Nerve Roots and Scar Tissue fall under requiring mechanical treatment from a skilled doctor of physical therapy.
2. Traction or Decompression – Usually, one who requires stability training does not do well with traction, or decompression treatment.  High level traction devices use dynamic on and off decompression times and are found in Wright Physical Therapy clinics.  However, only about 10% of individuals truly require this type of treatment to reduce pathology and regain function.  Usually these individuals require a form of therapeutic exercise as well.
3. Mobilization and Manipulation – Manipulation is a common treatment, especially credited to chiropractors.  “Manipulation” is also known as “adjusting” or “popping” the low back.  In Physical Therapy, we call this a grade V mobilization or a high velocity low amplitude (HVLA) thrust.  Mobilizations can be properly applied from Grade I all the way to Grade V.  With the right clinical prediction rules in place, a manipulation for some low back pain is just the right thing.  However, “adjusting” is used far too often to the detriment of medical costs and patient worsening.  “Adjustments” without the right clinical prediction rules is like shooting a gun without aiming.  Always use a skilled mechanical doctor of physical therapy for this need.
4. Instability (HyperMobility with symptoms) – This term describes when the spine is unstable at the middle layer, usually evidenced by prone passive instability, younger age group, active instability test, springing and concordant  signs.  These individuals require progressive therapeutic exercise with optimal interaction between Maximum Volitional Contraction (MVC) and reducing shear force on the spine.
5. Other – This category becomes the “gathering basket” for diagnoses such as stenosis, sinister low back pain related to systemic issues, inconclusive low back pain and any other not categorized as above.

Clinically, the 77% rule has held true to those that require mechanical skilled physical therapy.  Approximately 4 out of 5 patients who perform advanced physical therapy in our clinics recover fully with reduction in low back pain and leg symptoms like sciatica or drop foot.  Those that do not fully recover require more advanced treatments and we quickly get them back to their primary referrer, or a specialist to fix the problem.

Low back pain disorders require diligent study and skill development to classify and treat at effective levels.  Wright Physical Therapy spends a significant amount of personal and professional study time to understand low back pathology so we can be highly effective in healing you.  Feel free to contact Bryan at Wright Physical Therapy via 208-736-2574 or email bryan@wrightpt.com with questions.

PRACTICAL STEPS FOR YOU

1. STOP ASSOCIATING BACK PAIN WITH EXTRA WEIGHT – IT IS A CONTRIBUTOR IN SOME CASES BUT NOT A MAIN CAUSE OF BACK PAIN.  FIND THE ROOT OF YOUR PAIN.
2. DO NOT SETTLE ON ADVICE OF FRIENDS AND INTERNET ALONE.  THIS CAUSES COSTLY HEALING TIME AND BUILD UP OF SCAR TISSUE AND WEAKNESS.
3. DO NOT SEEK FOR “ADJUSTMENTS ALONE”.  CLINICAL PREDICTION RULES SHOULD BE USED FOR RIGHT TIMING OF MANIPULATION AND PROPER STRENGTHENING SHOULD ACCOMPANY MANIPULATION IF NEEDED.
4. GIMMICKS ARE MADE TO MAKE MONEY OFF OF YOU.  DO NOT FALL FOR TV GIMMICKS OR THOSE BEING SOLD BY “SELF-PROCLAIMED EXPERTS”.
5. EVERY LOW BACK PROGRAM, REGARDLESS OF YOUR CLASSIFICATION, SHOULD HAVE AN ACCOMPANYING ROBUST HOME EXERCISE PROGRAM FOR ONGOING HEALING.  IF YOUR PROGRAM DOES NOT HAVE AN EXCELLENT HOME EXERCISE PROGRAM, IT WILL NOT HAVE STAYING POWER FOR YOU.
6. IF YOU NEED EXPERT CONSULTATION, WRIGHT PHYSICAL THERAPY OFFERS A COMPLIMENTARY SCREEN TO HELP ANSWER YOUR QUESTIONS.  JUST CALL 208-736-2574 TO ASK FOR A SCREEN AND THE FRONT OFFICE WILL SCHEDULE YOU A 10 MINUTE APPOINTMENT, AT NO COST TO YOU.