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