Persistent Low Back Pain: The Physical Therapist’s Role

Low back pain is the most common cause of disability and lost work time in industrialized countries.   Persistent low back pain is characterized by periods of high and low pain intensity which can persist for years.  Periodic “flare- ups” are common and often result in the seeking of medical treatment.  Medications and surgery are often ineffective and may be harmful in some situations.  Physical therapy is a non-invasive treatment approach which is often considered in those with persistent low back pain.  However, improvements are often short-term for those with longstanding pain.  Similar to surgery and medications, the long-term success of physical therapy treatments for chronic back pain is questionable.

Traditional approaches utilizing physical therapy involve a short, but intense course of treatment such as 12 visits over a 4 to 8 week period.  However, this type of treatment approach is likely insufficient to positively influence a person’s beliefs and behaviors about their pain.  Changing these beliefs and behaviors are crucial if an individual with persistent pain is to self-manage through physical activity and lifestyle changes.

Persistent Low Back Pain is Complex

When pain persists beyond expected time frames, changes occur within our nervous system.  These changes include abnormal pain processing pathways and poor execution of movement patterns.  Because the nervous system is so complex, individual “pain experiences” vary greatly among those with persistent low back pain.  Diagnostic tests and scans, including MRI, are of little help because the primary problem is in the nervous system, not the low back.

The low back muscles of those with persistent pain undergo substantial changes over time.  This is believed to be caused by changes in the central nervous system.  These changes include atrophy (loss of muscle) and deposits of fatty tissue in the place of the lost muscle.  In particular the lumbar multifidus muscle has been shown to be selectively atrophied in many, but not all, individuals with persistent back pain.  Not only does the structure of muscle change with long-standing pain, but so does the nervous system’s ability to activate certain muscles.  Some muscles may become underactive while others become overactive.  These patterns differ among individuals with back pain making symptoms highly variable.   A common strategy is when many muscles of the low back contract simultaneously resulting in an unhelpful stiffening or bracing of the trunk.

Persistent Low Back Pain & Exercise

Altered pain processing pathways in the nervous system and changes in the back muscles leads to difficulty learning low back exercises.  A long term stimulus is likely needed to overcome atrophy of spinal muscles and to regain proper muscle function.  Performing low back exercise several times per week for 1 to 2 months is not adequate dosage.  Therefore, those with persistent pain may require repeated practice for several months in order to master the most basic of exercises.

In order to restore normal movement patterns exercise prescription must be matched to the individual’s beliefs and functional problems.  Ongoing types of cognitive interventions, such as education about the science of pain are beneficial to facilitate participation in exercise and physical activity.  An emphasis on education and a gradual progression of physical activity then becomes the long-term treatment.

The Role of the Physical Therapist in Helping Those with Persistent Low Back Pain

A recent episode of low back pain often responds well to manual therapy treatments such as mobilization, manipulation, or massage.  Sometimes, ice or hot packs can be helpful in these situations. However, passive interventions are of little help for those with persistent pain.  Instead, treatments that effectively involve the patient in long-term performance of physical activity are likely to be most valuable. These approaches seek to empower the patient by emphasizing their own preferred types of physical activities which can be progressed and modified as needed over time by the physical therapist.

There is no one-size fits all approach to prescribing exercise for those with persistent low back pain.  Core stabilization exercise receives a great deal of attention but this form of treatment is only helpful in some.  The same goes for stretching, resistance exercise, and aerobic exercise.  All these forms of exercise can be helpful in some but not all.  Therefore, the physical therapist and the patient should collaborate to develop an exercise plan which the patient finds enjoyable or preferable.  This is the only way the program will be adhered to for the long-term.

Final Thoughts on Physical Therapy for Persistent Low Back Pain

The traditional approach of attending physical therapy sessions 2 to 3 times a week for 4 to 8 weeks is not optimal.  Instead, the physical therapist and patient should seek to develop a long-term working relationship over time.  Initially, physical therapy sessions may occur multiple times a week but only for a few weeks.  Sessions should then be spaced out over time.  The physical therapist can assist the patient in progressing or modifying their exercise program at each session.

The physical therapists primary role is as a coach or guide who empowers the individual to self-manage for the long-term.   The ultimate goal is for the individual to manage and be prepared for fluctuations in their back pain.  Those with persistent back pain are ideally suited to directly access the services of a physical therapist without a physician referral.  In these instances, sessions are best when spaced out every few months or as needed.

Finished Your Physical Therapy: What’s Next?

The day has come.  You’ve dedicated your time and put in the work now you and your physical therapist have decided you’re ready for discharge.  So what happens after you have completed physical therapy?

Some patients leave physical therapy feeling 100% and return to their regular active lifestyle and prior fitness routine.  In many cases, though the patients we see are ones that do not live an active lifestyle and have no prior fitness routine. Some patients may only feel 80% better and insurance benefits or financial limitations will not allow continued care. These patients, in particular, are the ones who may leave therapy feeling uneasy or unsure.  They may have many questions they are asking themselves:

  • What if I never feel 100%?
  • When will I find time to continue the home exercises on my own?
  • How long will I have to continue these exercises for?
  • What if the exercises feel like they aren’t helping me anymore?
  • Will I be disciplined enough to do them?
  • What if the pain starts to come back?
  • What if I stop doing the exercises?

Exercise After Physical Therapy

Chances are if you are asking yourself any of these questions, you may be someone who requires or would benefit from more guidance moving forward.  Ideally, you would benefit from a long-term fitness routine or group exercise program.  If you are someone who did not exercise regularly prior to staring physical therapy there is a good chance that you will not continue to do the exercise once you are done.  The intentions may be good but many people do fall short.  Some people are disciplined self-motivators but many are not.  Also, it is easy enough to say “I can’t find the time” or “life just got in the way”.   Anyone at anytime can find the excuse as to why they haven’t been able to continue with a routine.

Building Healthy Habits

Most of the time patients attend physical therapy for 2 or 3 visits a week for a few weeks, most commonly between 4 and 8 weeks.  Research says it can take 2 months or more (66 days on average) to form a new habit.  It takes repetition for the new behavior pattern to become imprinted in your neural pathways. In fact, research by Kaushal and Rhodes suggests it takes at least 4 gym sessions per week for 6 weeks to establish an exercise habit. That doesn’t mean you can’t develop an exercise habit by going less frequently; it just means it will probably take longer for it to become automatic.

If you have already been attending physical therapy 2-3 times per week DO NOT stop dedicating that time to yourself when you are done. DO NOT take a week off and decide to figure out the next step later. DO NOT lose your momentum! If you know that you are someone who needs that continued guidance and motivation ask your physical therapist to help you find the right exercise program to start with.  Depending on your fitness level, behavior characteristics and health goals there will be options that are better for some than others.  Fitness is a booming business right now and there are plenty of options out there.  Some people don’t know where to start.  Your physical therapist will have a general knowledge of what types of exercises are done at different fitness facilities, however, depending on where you live these places vary.

Local Recommendations

The physical therapists at BSR Physical Therapy have been doing the research locally here in the Manahawkin, NJ area.  We are helping to build a library of long-term fitness options for our patients.  We want you to succeed in your health goals.

Most recently Dr. Amanda Higgins, Morgan Gamble and I attended a barre class at Black Sheep Studios on LBI.  The fitness studio had a welcoming earthy vibe.  We met with one of the owners Devon who was as personable as they come and full of energy.  It only took one class to know that this is a place where you won’t get lost in the numbers as the class sizes are small and intimate and everyone called everyone else by name.  The instructors paid close attention to form and corrective technique which is a must to get the recommendation from a physical therapist.  Their instructor Wendy provides individualized programs for people with the use of pilates transformers which is a hard find in this area.  They also provide a menu of other unique exercise classes that may be the perfect fit for some of you.

This place is one of many that can help you stay on track.  We want to see you succeed with your health and fitness long term.  Let us help you transition from physical therapy to fitness.

-Dr. Amy McMahon

 

Physical Therapist-Patient Relationship

The relationship, or alliance, between a patient and medical provider has been considered a critical factor in the success of any treatment plan. The therapeutic alliance refers to the sense of collaboration, warmth, trust, and support between a patient and their medical provider (physician, physical therapist, etc). There are three proposed components which contribute to the therapist-patient relationship. These components are therapist-patient agreement on goals, therapist-patient agreement on the treatment plan, and the affective bond between the patient & therapist.

The Therapeutic Alliance in Mental Health & General Medicine

A positive therapeutic alliance has been associated with positive mental health outcomes for depression, anxiety, mood, interpersonal problems, and overall psychological well being. Trust is an important factor in the patient-physician relationship. Research shows that a patient’s trust in his or her general practitioner is positively correlated with improved pain, general health, and quality of life. Trust forms the basis for self-efficacy which in turn leads to improved patient adherence and health outcomes. A positive therapeutic alliance has been associated with improved treatment outcome in psychotherapy and general medicine but what about physical therapy? Physical therapy involves a high level of patient-therapist interaction where patients often attend multiple clinic visits per week each lasting 30 to 60 minutes. Therefore, it is plausible that maximizing the therapeutic alliance can positively influence outcomes for patients attending outpatient physical therapy.

The Therapist-Patient Relationship in Physical Therapy

In 2010, Hall and colleagues reviewed the research investigating the influence of the therapeutic alliance on physical therapy outcomes. Not surprisingly, the researchers found the alliance between the physical therapist and patient has a positive effect on multiple domains of treatment outcome in physical therapy. In particular the alliance between the patient and therapist positively correlates with an improved ability to perform activities of daily living, reduced pain levels, improved physical functioning, decreased depression, improved overall health, and improved patient satisfaction.

In order to maximize the positive impact of the therapist-patient relationship a practitioner must measure and continually seek to improve their abilities in this domain. The Working Alliance Inventory is the most frequently cited method to measure this relationship or alliance. At our Barnegat and Manahawkin outpatient physical therapy clinics we have chosen to utilize the Consultation and Relational Empathy (CARE) Measure to track the strength of the relationships we develop with our patients. Our physical therapists collectively discuss and seek to improve skills in fostering the therapist-patient relationship. From the available research in this area, this only improves the overall outcome patients achieve at our clinics.

Thank you for reading!

Ernie