For Low Back Pain, Classification = Better Outcomes

Low back pain treatment is more effective if we can correctly classify a patient and give them a specific intervention to help get resolution. In this article I will talk about evidence based practice, the different classification systems we have in physical therapy, I will highlight a system that I tend to use, and I will also give you more information to be an educated consumer of your healthcare dollars.

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Dr. Murphy, earlier you talked about evidence based practice, what does that mean? There is a big push in the profession of physical therapy to provide evidence based care. Much like the profession of medicine, we have to have a clear reason why we are doing what we are doing. Often this is done through research. In its simplest form, we take a group of people with low back pain, we try and homogenize them (make them all very similar in all their characteristics, which could be pain level, previous history, how long they have had symptoms, age, weight) and then we break up that group and we try different interventions. We then have various tools we use at the start of treatment that we can consistently retest throughout various parts of the intervention process to measure if the treatments are helping the patients. When this research is done over and over with large groups of people in various parts of the country and world and all of that research shows similar positive outcomes, we adopt that intervention approach as an evidence based approach that is effective for a group of patients.


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For patient’s with low back pain there are various classification systems. There is the treatment based classification, the McKenzie Method of MDT (Mechanical Diagnosis and Therapy), and the clinical practice guidelines put out by our professional organization the American Physical Therapy Association. I don’t want to muddy the water too much, because there is quite a bit of overlap between these systems. I will highlight one that I have recently been studying.

For treatment of low back pain, The McKenzie Method of mechanical diagnosis and therapy was founded by Dr. Robin McKenzie, a New Zealand born physiotherapist. This is a comprehensive system of evaluation based on patient history, symptom presentation, and specific movement based interventions aimed at reducing the disability and pain associated with low back pain. I will highlight the three main classification’s within the McKenzie Method next.

Mechanical Diagnosis and Therapy

Mechanical Diagnosis and Therapy

The first classification is called a Derangement. A derangement is described as a mechanical obstruction of an affected joint. When I say mechanical I mean movement related. It also is highlighted by inconsistency and change. The patient states that the pain is variable during the day. A patient will say that certain postures or movements will cause symptoms to increase/decrease, produce their pain or diminish it, and finally centralize/peripheralize. This last one is worth explaining. When we centralize pain we bring it from a widespread area to a more focal area. When we peripheralize our pain we cause it to spread further from the low back area. This is the most commonly seen syndrome and this patient often responds quickly to intervention.

We now move on to the next classification which is Dysfunction Syndrome. This syndrome is less common. This happens from mechanical deformation of structurally impaired soft tissue. This abnormal tissue may have been the result of a previous trauma, an inflammatory, or degenerative process. The tissue can get contracted, adhered, or scarred and it needs to be remodeled. This patient has a very different presentation than the Derangement. They have pain that is often always local. Their pain is also always intermittent and is produced only when loading the structurally impaired tissue. In the movement assessment they show movement that will produce the symptom, which then does not remain worse.

The Final Classification is called a postural syndrome. This syndrome normally effects a younger person with a sedentary lifestyle. Symptoms are brought on by static loading of normal tissue. We can all envision a student who is sitting with bad posture while on their cell phone or computer.

As adults we have an obligation to ensure our kids don’t end up doing this in school now and in their jobs later!

As adults we have an obligation to ensure our kids don’t end up doing this in school now and in their jobs later!

It is uncommon to see this patient in the clinic because a simple cue with our hands or verbally to correct their posture abolishes their symptoms. So parents, the next time you see your kids sitting like this, tell them to sit up straight!

As you have seen in this write up, there is a lot more to physical therapy than meets the eye. Going to a good physical therapist who can spend time listening to your story and doing a thorough examination with you is critical. Don’t accept those PT clinics that pass you off to an aide or assistant. You should be seeing the same physical therapist each visit for continuity of care. Also, you should not accept doing the same thing in their office that you could do at home. They should be educating you, giving you a home program, and putting their hands on you therapeutically. You deserve more than just being another number that they are hurrying through the office.


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I offer a FREE discovery visit at my office or over the phone to help you make a decision about how to best deal with your pain and limitation. Don’t continue to let it interfere with your life; get back to doing the things you love and enjoy.



Call or text me at 501-529-2010. I look forward to helping you reach your PINNACLE.



Pinnacle Physical Therapy

5507 Ranch Dr Suite 203

Little Rock, AR 72223

brian@pinnacledpt.com








To Sit or to Stand, that is the question?

When it comes to low back pain, we are told that sitting for too long is not good for our backs. Why is that the case? What does sitting do to our low back?

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There are low back pain studies that have been conducted that measure the pressures in the spinal discs with various activities. One study in particular 1, involved a 45 year old male who had a pressure device inserted into his L4/L5 disc. This allowed researchers to measure the amount of pressure change in a variety of different activities. Running, sitting in various postures, lifting with both good and bad mechanics and even stair climbing were measured. What we observed from this study is that there are different pressures that the disc undergoes with differing positions. You may be asking, how is this relevant to me?


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What is critical to remember with patient’s is that if we treat a large group of people who have low back pain with the same interventions, we are going to help some people and we will not help others. This is where subgrouping comes into play. Subgrouping is when we take a history from the patient about their issue. From experience and research we have found certain subgroups of patients have certain characteristics and presentations. It makes logical sense that if we can subgroup patient’s with low back pain, that we can offer them more specific interventions that will better address their impairments. This is much more effective than just giving everyone the same interventions and only some people get better. More on the subgrouping in next weeks article!

Matching  interventions to patient’s with specific presentations allow for better outcomes.

Matching interventions to patient’s with specific presentations allow for better outcomes.

Low back pain treatment can revolve around the reduction of your pain. When you go see a practitioner it is often because you are in pain, which is an unpleasant experience. When we are given medication, offered injections, or prescribed a specific treatment, one of the goals is to help reduce your pain. Physical therapists often take a similar approach to low back pain. There are often movements/positions that make your pain better and some that make your pain worse. There is a phenomenon called peripherilization and centralization. Some patient’s have low back pain that is associated with radiating pain that goes down the leg (sciatica). One of our goals with this type of patient is to help centralize their pain. If we can take the pain out of the leg and move it toward the center of the back we can predict that the patient has a good prognosis (they will get better with our interventions).

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When it comes to treating low back pain there are studies that will show sitting is bad for your back and just as many studies that show sitting and standing create similar stresses on the back. You may now be asking, “What is the best position?” I will tell you that in my opinion it is somewhere in-between. I advise my patient’s to not go longer than 1 hour without getting up out of your chair or if you start in standing, sitting down. This variability will help to off load some of the structures that could be affecting your back. Set the alarm on your phone so that you have to get up and move around.

It may get awkward if you are doing a head stand in the office, but tell your co-workers to join in!

It may get awkward if you are doing a head stand in the office, but tell your co-workers to join in!

You may already know intuitively that one position is better for your back because the other causes pain. Another concept that needs to be addressed is the concept that not all hurt = harm. As I am writing this, I am coming up with more ideas for blog posts! More on the hurt = harm later!


The moral of the story when it comes to low back pain and in that matter, reducing the risk of developing low back pain is that you need to move your body. Motion = lotion is what I tell my patients.


If you found this article helpful, share it with a friend. If you need more specific advice, call or text me at 501-529-2010, or you can shoot me an e-mail at Brian@pinnacledpt.com. My name is Dr. Brian Murphy, I am a physical therapist and owner of Pinnacle Physical Therapy located in Little Rock, AR.

Thanks and here’s to helping you reach your PINNACLE!

5507 Ranch Dr, Suite 203

Little Rock, AR 72223

Brian@pinnacledpt.com

Reference

  1. Wilke, Hans–Joachim, et al. "New in vivo measurements of pressures in the intervertebral disc in daily life." Spine 24.8 (1999): 755-762.



I have low back pain, now what?

When it comes to low back pain, there is no shortage of providers you can go see. You can see your primary care physician, a chiropractor, a massage therapist, a physical therapist, a yoga instructor, an orthopedic physician and even a neurosurgeon.

You may be asking, how do I then decide who is the right choice for me?


Who do I go see and more importantly how much does each option cost?

Who do I go see and more importantly how much does each option cost?

Some people want to avoid medications, surgery, and injections at all costs. This narrows the field of potential practitioners off the bat. If you are to see a physician, very likely you will be prescribed medication, given some kind of diagnostic test (X-ray or MRI) and then prescribed physical therapy. The involvement of specialists (orthopedic spine physicians and neurosurgeons is often not the first line of defense).


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Some practitioners offer more conservative approaches to treatment of low back pain. Massage therapists offer soft tissue work and stretching to address pain and limitations. Yoga instructors offer movement based interventions. Some pure Chiropractors believe that disease processes stem from a malalignment of the vertebrae (bones in your spine.) Their treatment is thus geared toward adjusting the spine so that the nervous system can function properly.

I can speak the most intelligently about physical therapists. We are movement specialists who address our patient’s impairments to help them stay active and pain free. A good physical therapist looks at the movements of your whole body to see if there are compensations in the normal patterns of movement, to find muscle weakness, to find joint restrictions, tight muscles, poor balance, and assess how a patient’s environment and activities may be affecting their pain and limitations. From there, we start to address those impairments and very often pain subsides and we can ramp activity back up.

Another difference I see in good practitioners is the ability to help patients with low back pain become independent. If you are constantly receiving care and are not taking an active role in your own recovery and health, I think you are not being properly cared for. I don’t know too many practitioners that you can take on vacation with you to help you when your back gets flared up. Because there are so many factors that play a role in a patient’s pain a very multimodal approach to intervention is indicated.

Brian, what do you mean by multi-modal approaches in low back pain treatment? I mean that there has to be a combination of manual therapy (hands on techniques) and active exercise. I do not believe in passive approaches to care. I am not going to stick you on a TENS unit (thing that makes your skin tingle) with an ice pack for 15 minutes while I catch up on notes. What in life has come easy to you without having to put in work or effort? I am telling you now that dealing with your body is no different and in fact often is harder work.

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I don’t like to give generic advice and exercises, but there are recommendations and movements that are well researched that can help reduce the risk of injury and also help alleviate current pain that may be stemming from your back. This advice does not mean that you should not go see a skilled medical provider that will employ the above mentioned approaches to your care.

Over the next weeks I will be providing this information on how you can get back to doing the things you love, after all, we can all live with some pain, but when it starts to interfere with our hobbies and interests, we have to say enough!

If this advice and these movements help you, please feel free to let me know. Write it in the comments below.

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I appreciate you reading and let me know if I can be of further service to you.

Here’s to helping you reach your PINNACLE!

Dr. Brian Murphy , DPT, OCS, ATC, PES, TPI II Medical

Owner of PInnacle Physical Therapy

5507 Ranch Dr Suite 203

Little Rock, AR 72223

501-529-2010

Brian@pinnacledpt.com

Doc I have low back pain but I think it might be Cancer! Help!

In treating patients with low back pain, it is not uncommon for me to have them come in with a very well researched, self-made diagnosis. We can thank Google for so much of the information we have at our finger tips today. It is so easy to look up what WebMD or Mayo Clinic says about our condition.

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I am going to tell you know that there is no substitute for a skilled medical provider. Physical therapists have a huge asset on our side, TIME. We have time to sit down and let you tell us your story. The reason I say this is because there are clear things that come from the history section of the examination that will point to a more serious condition that may be masking itself as low back pain.

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“Dr. Murphy, I am convinced that my low back pain is from a spinal tumor, can you please tell me I am wrong?”




I am now going to go into discussing the possible more serious pathologies that could be related to low back pain. This article is meant to ease your mind about the slim chance of you having one of these more serious issues.

Let a skilled Physical Therapist interview you to assure you that you don’t have a more serious life threatening condition.

Let a skilled Physical Therapist interview you to assure you that you don’t have a more serious life threatening condition.


”Brian, how do you know whether I have something more serious? I am convinced that I have cancer!” Some of the things we do include administering a questionnaire about your general health. It could ask questions about your 24 hour pain patterns, previous history of cancer, when you saw your primary care physician last, signs of tingling and numbness, coordination problems and history of any recent trauma. All of these questions clue us into then asking further questions to determine if your pain is of mechanical nature. What I mean by that is basically are you appropriate for physical therapy care because we are mechanical/movement specialists.

The first condition I will discuss is cancer. Spinal cancers are rare and can be picked up quite easily on plain film X rays. If you have not had an X ray performed before you come in to see us we will ask questions about your age, previous history of cancer, any recent weight loss, your pain patterns (what makes it better, worse, 24 hour response). Quite often pain stemming from cancer is constant, there is nothing you can do to make it go away, it will wake you up at night and keep you up for hours.

The large, white blob just behind the bones of the neck is a spinal tumor.

The large, white blob just behind the bones of the neck is a spinal tumor.

The next condition that I will discuss is a stress fracture or spinal fracture. There are some clear indicators that this may be a possibility when a patient comes into our clinic. This patient is typically a 50+ year old female, who has a recent history of a fall or motor vehicle accident, she has pain and tenderness in her back and she may have been using corticosteroids. With Arkansas being a direct access state, we may see this patient before they had films in the ER or at their doctors office. In this case, we would refer them out to get X rays of their back to rule out this condition.

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The final condition I will discuss today is called Cauda Equina Syndrome. This condition stems from the nerves that come out of your low back. This condition can cause serious damage to those nerves which can be a problem because those nerves give energy to your bowel and bladder! Once again, the history here is critical. One of the hallmark symptoms of this condition is bowel and bladder changes. We ask the patient if they have had issues initiating or voiding their bladder. The patient feels that they did not expel all of their urine. The patient often has saddle paresthesia, tingling and numbness around your anus and genital area. Another thing we do as physical therapists is perform a thorough neurological examination. The nerves that come from your low back give strength to key muscles in your lower legs, it gives sensation to the skin and it also controls your knee jerk and achilles reflexes. We will test all of these things to see if everything is working smoothly. We of course do not want to see a decline in any of the functions of these structures.

Changes in bowel and bladder function are a major red flag and often require immediate surgery to maintain the normal function of your nerves.

Changes in bowel and bladder function are a major red flag and often require immediate surgery to maintain the normal function of your nerves.

In the state of Arkansas you can see your physical therapist directly without seeing a physician first. We are very skilled Doctors with advanced training in neuromusculoskeletal pain and should be at the forefront of your mind when determining who to see concerning your pain and limitations.

At Pinnacle PT, I offer a free 20 minute discovery visit either in my office or over the phone. I listen to your story and ask you relevant questions to see if you are appropriate for my care. I also make appropriate referrals to medical providers I trust in the community if you need to be seen by a physician for something that I am not able to treat. All too often we just ignore our pain because we are scared and think that it is just going to go away. Don’t let your pain get any worse, because often that will lead to compensation and development of pain in other areas and a further decline in your function.


E-mail me today at brian@pinnacledpt.com, or call/text me at 501-529-2010 and let me help you get through this trying time!

Here’s to helping you reach your PINNACLE!


5507 Ranch Dr Suite 203  Little Rock, AR 72223

5507 Ranch Dr Suite 203

Little Rock, AR 72223



What is Causing my Low Back Pain?

Doc, what is causing my low back pain?

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Does low back pain bring you in to see your doctor? I know for me, that pain and limitation in my daily activities spurs me to get examined. With the prevalence of low back pain in our population today, I have many patient’s who want to know what is wrong with them. Here is where I will dive into the research to tell you why low back pain in medicine is a tricky condition.


So what do I mean by tricky condition? Remember I told that most of my patient’s come in to me asking what is causing my low back pain?The answer is anything but clear. The term pathoanatomy is how much of medicine is taught in medical school, physical therapy school, and many other schools for  body workers. This term means that we are looking for an anatomical reason for what the patient is telling us.


For low back pain this would include looking at films to help us determine the cause of pain. It seems logical that this would point us in the right direction of how to best treat patient’s with low back pain. However, this is far from the truth. The research tells us that most diagnostic tests (X-ray, MRI, CT scan) when assisting in diagnosing the low back are of very little value. Why you might ask? Because of false positives. Many of these tests find so called “pathology” or abnormalities in patient’s who don’t even have pain!

Did you know that  herniated discs can actually be reabsorbed by the body and heal completely on their own when given the right conditions and time?

Did you know that herniated discs can actually be reabsorbed by the body and heal completely on their own when given the right conditions and time?


That is confusing! Brian, you are telling me that if I go to my doctor and he orders an MRI and it shows degenerative disc disease but that the finding of DDD may not be causing my pain? Yes, my friend, you are exactly right! According to the research study by  Savage et al1 it reported that 32% of asymptomatic subjects had had ‘abnormal’ lumbar spines (evidence of disc degeneration, disc bulging or protrusion, facet hypertrophy, or nerve root compression) and only 47% of subjects who were experiencing low back pain had an abnormality identified.1


If it were as simple as looking at an MRI to find the “cause” of low back pain, it would be much better cured and would not be such a burden to us and our medical system. Just the sheer fact that you can see a massage therapist, internist, orthopedist, spine surgeon, yog instructor, chiropractor, physical therapist tells us that there is no clear concensus on how best to treat patient’s with back pain.



Now, I am not saying that those diagnostic tests are not valuable, what I am saying is that often they are not needed on the first appointment to your medical provider. Say for instance that you go to your internist for an episode of low back pain, you may be prescribed a steroid, some pain medication, an X ray will be ordered and you will be sent to PT. If you add up the cost to you and the system of this approach, it will be exorbitantly more than going directly to your physical therapist.

No thank you, I’ll try PT first. #getPT1st

No thank you, I’ll try PT first. #getPT1st

Yes, that right, in the state of Arkansas, you can go directly to your PT first. What does that mean? It means no medications, no expensive diagnostic tests, no injections, no surgery and often a very effective non invasive way to get pain relief. We are trained to determine if your low back pain symptoms are of mechanical origin. There is a small chance that you may have a serious underlying issue that needs medical attention, but we are well educated in screening for those conditions and making appropriate referrals when necessary.


So you may be asking, if there is no specific problem in my back, then how do I get relief?This is where as physical therapists we are taught to subgroup patient’s with low back pain. Based on the signs and symptoms of your condition we do a thorough history to start to determine what are the factors related to your back pain. Is there mechanical stress from work, poor postures, anxiety or depression, is there signs of instability, are you having pain that radiates below the knee, are you in a chronic state of pain? All of these questions and of course our movement examination will allow us to determine a specific treatment plan for you! Your medical provider should be spending at least 15 to 20 minutes just talking to you to determine the best course of care to get to the root cause of your problem.


All the medication in the world will not help if you are constantly sitting with poor posture at work, or if you are bending and lifting improperly. It is time we expect our medical providers to look holistically at all the factors that are playing a role in our limitations, so we can have a multimodal way to attack those impairments so we can get back to enjoying our active lives in a pain free/reduced manor.



Why not try conservative care first?

Why not try conservative care first?

As always I am here to be a resource for you, I am available via e-mail at brian@pinnacledpt.com or by phone call or text at 501-529-2010. I offer a FREE phone consultation to help guide you to a full return to the things you love. Please reach out.

Here’s to helping you reach your PINNACLE!

Brian  

Reference

  1. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106–114.

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5507 Ranch Dr Suite 203

Little Rock, AR 72223

Dogwood Crossing Building