Posts in low back pain
Reducing Your Risk Of Developing Low Back Pain
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Death and taxes are said to be the two certainties in life for adults, but Ben Franklin may have added low back pain given its’ current prevalence. Up to 90% of adults will report an episode of low back pain during their lifetimes. Fortunately, the vast majority of these episodes are not secondary to any serious pathology in the spine and respond well to low cost, conservative treatments including Physical Therapy interventions such as manual therapy and exercise interventions. In particular, strength training is one of the most effective treatment options to get you back to 100% after these acute low back pain episodes. To paraphrase again from Franklin, if you had an ounce of prevention new research reports it would be composed of exercise.

Researchers in the American Journal of Epidemiology conducted a review of the available evidence on the prevention of low back pain (Shiri et al. 2018). Authors reviewed 13 randomized controlled trials and 3 non randomized controlled trials for the analysis. They reported exercise alone reduced a person’s risk of developing low back pain by 33%. In addition, the severity and disability of the patient’s low back was also less in the active group compared to their sedentary peers. Authors recommended combining aerobic or stretching exercise with strength training, 2-3 days per week, for reducing a person’s risk of development of low back pain.

Cost Effectiveness of Physical Therapy for Low Back Pain

Low back pain continues to affect many Americans leading to pain, loss of function, missed work days, and higher health care expenditures.  Much of this cost is attributed to the often unnecessary utilization of advanced imaging and procedures such as injections and surgery.  Previous research has shown early access to Physical Therapy without a prior MD referral saves patients on average $1000 per episode of care.  Further cost savings are noted if patients are treated early with Physical Therapy compared to national guidelines advocating a "wait and see" approach for care prior to deciding on Physical Therapy.  

A recent study was conducted to determine the cost effectiveness of primary care management with or without the use of early Physical Therapy for patients with acute low back pain (Fritz et al. Physical Therapy. 2016).  Economic data was collected on 220 patients with acute low back pain who were all treated with primary care management (education, medication) and then randomized to either 4 sessions of early Physical Therapy or primary care management alone.  The authors collected costs (health care treatments, loss time at work) associated with this episode of back pain.  The authors concluded that Physical Therapy was associated with higher quality of life scores at 1 year and was sufficiently cost effective to support its' early use for patients with acute low back pain.

Patients with low back pain are encouraged to seek out the services of a local Physical Therapist to reduce health care costs and improve symptoms and function compared to primary care management alone.  

Resolution of Lumbar Disk Herniation Without Surgery

Physical Therapy remains the first line treatment for lumbar disk injuries due to its' non invasive nature and clinical effectiveness.  The natural history of disk injuries is not well established but preliminary data covered in prior blog posts demonstrates regression of these injuries over time.  A recent case study in the New England Journal of Medicine (Hong et al. 2016) described the case of a 29 year old female with pain and pins and needles into her leg.  Her MRI is shown above on the left side of the screen.  The patient did not want surgery and was instead treated with an injection and Physical Therapy.  After 5 months a second MRI was taken, shown on the right, showing resolution of the disk injury. 

This case adds evidence to the regression and resolution of disk injuries over time with conservative care.  Patients are advised to seek care from a local Physical Therapist before attempting more invasive and costly procedures.

Resistance Training the Aging Adult and Injury Prevention

There are few treatments more effective for the prevention and treatment of injuries and musculoskeletal conditions than resistance training.  Unfortunately, many Americans are not performing enough strengthening to prevent the loss of muscle mass (sarcopenia) which begins to occur in the 3rd decade of life.  After age 30 we begin to demonstrate a progressive loss of muscle mass, strength, and endurance due to the aging process.  Thankfully, this loss can be attenuated with strength training, but not solely aerobic and endurance training (Klitgaard et al. 1990).  This loss of strength becomes a risk factor for many health conditions including low back pain and knee osteoarthritis.  

It is important to note age does not seem to influence an individuals ability to perform strength training exercise.  A review article reported an average strength increase of 25-33% in older adults who began a strength training program (Peterson et al. 2010).  Participants performed 2-3 sets of 8-10 repetitions per exercise targeting major muscle groups 2 to 3 days per week.  These programs have also been shown to improve an adult's quality of life and prevent conditions such as osteoporosis, knee osteoarthritis and back pain.  

It is never too late to begin an exercise program and adults are encourage to speak with a local Physical Therapist to design a safe and effective exercise program to improve their quality of life and athletic performance.  

Does One Size Fit All in Physical Therapy?
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In our fast paced, instant gratification world we want solutions to our problems the same day as their arrival.  This is no different in low back pain, a common, costly condition affecting over 90% of adults.  Patient's hurting from low back pain symptoms often turn to the internet, friends, or their primary care physician for quick solutions to their problem.  Although low back pain is common, the reasons behind the pain are multifactorial in nature limiting the effectiveness of a one size fits all approach.  Thus, patients seeking advice online, from friends, or their physician may be given an inappropriate or ineffective treatment plan leading to lost time, lost employment and money.  In the past, clinical guidelines on low back pain have been created by medical and government agencies in an attempt to help guide decision making for all patients with low back pain.  Not surprisingly, research has shown the limitation of this one size fits all approach with lower costs and improved outcomes observed with Physical Therapy compared to guidelines.  

A more recent article in British Journal of Sports Medicine was published to compare the outcomes between general advice and patient specific Physical Therapy treatments (Ford et al. 2016).  200 patients with low back pain, less than 6 months in nature, were randomized to either an education group or to 10 sessions of Physical Therapy interventions including manual therapy and exercise.  Consistent with prior research a patient specific plan of care showed better outcomes at 10, 26, and 52 weeks compared with an education only approach.  

This article adds to the existing literature indicating the importance of early, patient specific Physical Therapy treatment compared to advice or a wait and see approach.  To learn more on how Physical Therapy can help get accelerate your recovery from low back pain contact a local Physical Therapist. 

Dry Needling for Low Back Pain

Dry needling treatments performed by Physical Therapists have gained in popularity among both clinicians and patients.  The treatment is designed to reduce pain and restore muscle function.   Inserting small, monofilament needs into trigger points within painful muscle groups can lead to immediate changes in pain and movement.  While the mechanism of these treatments is still being investigated early research indicates beneficial changes in circulation, nervous system, and muscle function are noted after Dry Needling.  Consistent with many other treatments for a patient's pain there is likely a group of patients with pain who will benefit most from this Physical Therapy intervention.    

Prior research has identified baseline examination items which help predict success with this treatment (Koppenhaver et al. JOSPT. 2015).  72 patients with low back pain underwent an examination followed by a single treatment of dry needling by a Physical Therapist.  These patients were re assessed one week after treatment.  Patients who experienced pain during the exam on a muscle activation test had the best response to the dry needling.  These findings make sense given the treatment's attempt to decrease muscular or myofascial pain often provoked by muscle contraction or stretch.  

This same author recently completed a second study to determine which clinical changes are associated with reductions in pain and disability following Physical Therapy dry needling (Koppenhaver et al. Man Ther. 2016).  66 patients with low back pain underwent one session of dry needling to the lumbar muscles following a Physical Therapy examination and ultrasound assessment of their low back muscles.  Pain threshold was assessed based on the patient's ability to tolerate pressure across the lumbar spine.  The authors found the individuals with the greatest improvement in symptoms and function after needling also had the greatest improvements in pain tolerance and muscle function at 1 week post needling.  

This evidence adds to our knowledge on the effects of dry needling in patients with low back pain.  Those who respond best to this treatment may be individuals who have the greatest improvements in pain and lumbar muscle function.  To learn more on how dry needling can decrease your pain and improve your function contact your local Physical Therapist.