Working with people with low back pain can seem daunting. Where do you get started? How do you progress them? Luckily, it’s not as complicated as it seems.
Here’s how we like to start by categorized the symptoms, then building a plan just like any other joint.
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#AskMikeReinold Episode 266: Strategies for Treating Low Back Pain
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Show Notes
Transcript
Ben Fisher:
Jackson from Charleston asks, “As a PT student, I’ve had some difficulty in approaching low back pain and understanding what treatments I would need to give based on my findings. Do y’all have any advice on developing a strategy for evaluating low back pain and knowing which treatments are best for the patient?”
Mike Reinold:
That’s a great question, Jackson, and I think I’ve had that question. I think, I know Kevin and I talked about this a little bit ago. I mean, I think we’ve all had that question. For some reason, call me crazy, you guys agree with this… Low back pain tends to be one of the most generic things people talk about. What the heck is low back pain? It can literally be a million different things, depending on the person, the activity, the age, there’s so many things low back pain can be. We’re even doing research on that, on low back pain… What is low back pain? That’s like saying body pain, I have body pain, and man, nothing seems to be effective with my body pain, right? It seems enormous to me with low back pain.
Mike Reinold:
So Jackson, I get it. I remember when I was super self-conscious that I didn’t know how to work with back pain patients, because I felt like I was missing a little bit something. I’m sure maybe we can kind of share it though. But I think what I like here is Jackson’s looking for a strategy and approach and I kind of like that. I don’t know, who wants to start? Maybe Kevin? I know you’ve kind of like, I know you wrapped your head around this a little bit yourself, personally. So how, how do you go… your approach, from being in Jackson’s shoes to where you are now?
Kevin Coughlin:
Yeah… Hopefully you guys can hear me with the connection out in the Ayer, Mass, but it was something that I definitely struggled with when I was a student coming out because of the things you just said, Mike, you know, what is low back pain? There’s so many different types of back pain and I think the first step for me was really just trying to access the clinical practice guidelines for some sort of guidance on how do we categorize back pain. And I think that’s the big thing when you look at the literature, some of the stuff that, you know, Julie has published and, you know, stuff like that. I think was worth diving into.
Kevin Coughlin:
Some of the things that you see over and over again is trying to put different types of back pain into a specific category. And that’s a good place to start, and then kind of what you’ll see from there is, you know, acute back pain, you really want to rule out red flags, make sure that it’s someone who is… Appropriate for physical therapy, and then encourage movement and stuff like that. But it all starts with a good examination and trying to figure out what category you can put this person into.
Mike Reinold:
I don’t think there’s anything more important than that, right Kevin? I think you totally nailed that. And I think orthopedically, we’ve tried to do this with things like patellofemoral pain, right? Where again, junk terms that just mean so much. I like that you have to categorize. All right. So, so Kevin then, what categories would you… What do you look at? How do you characterize low back pain?
Kevin Coughlin:
Sure. Yeah. So just some of the categories that are out there that the research tells us we should look at is, is this someone with a mobility depth? Is this someone with radicular back pain? Those are going to be treated very differently, right? If it’s someone with radicular back pain, we’re kind of looking for a directional preference… Some way to centralize their pain, that type of thing, versus if this is someone with like a chronic low back pain. We’re trying to figure out any lifestyle modifications that we might be able to make, because that’s going to be a big, a big driver of maybe why they’re having some of this pain and then really get them moving in a safe way. We’re not going to dive right into a strength and conditioning program with someone with radicular pain, if certain movements might be causing their pain to get a little worse. We have to make sure we’re moving them in the right direction. Those are some of the categories I generally tend to think about.
Mike Reinold:
I actually, I think I agree with you, like really well here, that it really could be that simple. It’s like, do you have neurological back pain or non neurological back pain, right? Are there some sort of neuro symptoms, like anything, you know, radiculopathy, like, you know, more than just my low back hurts in pointing to my low back. I think that’s probably the best, like easy, broad categorization… That you could probably do, you know what I mean? I like that. I would say when you don’t think of it this way, sometimes we can apply the wrong treatments, right? Let’s use a different body part to kind of talk about that, because I think this will make more sense to people. What we’re saying right there, let’s say it’s shoulder pain, right?
Mike Reinold:
We oftentimes have some acute pain and inflammation that we’re trying to work on, but then we have underlying things that are sub optimal that we need to optimize to get them to function better to maybe get them to not have this in the future again. I think it was the same thing. The neurological issues with the back is almost like the acute pain, right? So you have to do treatments to get through that neurological flare up, for whatever that may be. But then you have this whole other thing of just take a step back and do what we do best. We work on mobility, we work on control, and then we work on loading the body once they have mobility and control, so that way they can be a little bit more resilient in the future, right? And I think a lot of people make back pain, like super more complicated than that sometimes, right? So, yeah. Who else? Dan, what do you think?
Dan Pope:
Well, I think, and I’m curious if he’s asking this question, just because there’s a lot of research out there showing that a lot of things work for low back pain. Walking programs, yoga, pilates, strength training, motor control exercises, I’ve seen some studies where people are doing like one rep max deadlights, and it’s helping with their low back pain. So, when you see that, it’s hard to know what do I use, right? I think at least a big thing for me is that it probably comes down to the patient and what they want to do, right? If you have, you know, I posted something on social media today about doing safety squat bar good mornings, right, for folks who have low back pain. And to be honest, that’s phenomenal for, let’s say a power lifter that has back pain, you know, with reps above 80% of the max, but if my mom came to me and she’s like, you know, my back is hurting, I wouldn’t say, well, safety squat bar good mornings, mom, you got to get in the squat rack.
Mike Reinold:
I bet your mom would though, but yes.
Dan Pope:
Yeah. And I think when people see those studies, it’s, it’s worrisome. It’s like, well, what the heck do I do? You know, there’s so much, what’s best? Well, you know, when I see studies like that, you know, a counterpoint to that is, a lot works. Right? So again, make sure you’re safe and you’re choosing a good intervention. You’re not like blowing through a bunch of neuro symptoms and the person’s getting foot drop. Like, that’s definitely not good, but you probably have a lot of options that suit the patient that’s in front of you and you can choose the ones that you think they’re actually going to do and enjoy, you know?
Mike Reinold:
Right. I think that’s a good add on to what kind of Kevin started with there, too, like when you start trying to figure out what to do with that person, like get them through their acute neurological symptoms, focus on the basics, right? Work on mobility, soft tissue work, you know, joint, whatever it may be, work on their mobility. Maybe their hips are tight, it’s putting extra strain on the back, who knows, right? Work on their mobility, work on their control, which is often lumbopelvic, right? So, core, hips, right? And then load them, right? Get them to these patterns. Some people, that loading is walking. Some people that loading is, what did you say your mom was doing? Safety squat good mornings?
Dan Pope:
Yeah. She’s doing one rep maxes, you know?
Mike Reinold:
I mean, that is…this is mama Pope. And if I, if I knew if I knew her, but yeah. What do you think, Dave? So Dave, you, you have a lot more like, in addition… I guess there’s a whole nother category, right? But like the acute injury too. But, anyway, go with what you were going to say. Sorry.
Dave Tilley:
Yeah. I was going to say that I’ve unfortunately seen a lot of people with the acute side of both, I guess the most common, which is discogenic kind of flexion intolerant and then extension based. They have pars defects from gymnastics. So I find myself the more and more I do and the more and more I learn about this, I’m actually keeping things much more simple during the acute flare up phase. I think that, that’s where a lot of new grads and me in particular, and I think Kevin, I had this conversation with him when he was a student, he’s like that first two weeks and someone’s really flared up, is really hard to manage sometimes because they’re in so much pain, man. It’s brutal when you have acute back pain. So, for people who have either discogenic issues, inflexion intolerance or extension, I’m trying my best to spend more time on the subjective eval and figure out what, what triggers your pain, what makes it better?
Dave Tilley:
And oftentimes you can tease out someone with inflexion tolerance, he’s like, actually I feel okay when I get up and I walk around, I just can’t, I can’t get through like a long car ride to work. And the other person, like a gymnast, is like, I feel pretty crappy when I walk for a long time, but if I sit, I feel a little bit better for a while. So, you have to tease out their directional preference. And I find myself trying to have a better conversation about what they’re doing the other 20 to, you know, 16 to 20 hours of the day, that doesn’t involve PT, that doesn’t involve a home program, more so than like these seven exercises are going to make you feel amazing.
Dave Tilley:
So it’s about, you know, get up and walk if you have a flexion intolerant back pain, try to sit with like a towel roll on your lower back, try to do 10 to 15 cat camels or light press-ups every two hours for a couple of days. I’m trying to like overdose a very few exercises, multiple times throughout the day consistently, the same way we would do like, getting knee extension back and someone who has a stiff knee, we wouldn’t blast through an hour of crazy intense exercise.
Dave Tilley:
And it’s the same for someone who has extension based back pain. It’s like try your best to get up and you know, not stand for a long period of time if you’re like a strength coach and your back hurts when you stand for a while. So I would just say, keep it really simple and try to educate the person on why that tissue is really sensitive then trying to give, I just see so many people with back pain have like literally pages and pages and pages of exercises that they have to do every day. I mean, anybody in this call wouldn’t do an hour of their own home program, probably, we prescribe it for a living. So the busy person with a painful back is probably not going to do a 40 minute exercise routine.
Mike Reinold:
That’s a very solid point, but no, I mean, I think that kind of like summarize a little bit here too. I mean, I think Jackson, I think what we’re getting at is, you probably feel a little overwhelmed because you don’t have a ton of experience working with low back pain, and it takes a while to get experience for working with low back pain, because again, it’s so generic, right? So you may have 10, your first 10 low back pain patients of your career may all have completely different reasons why they have low back pain. So it seems daunting, it seems like there’s a lot going on, but that doesn’t necessarily mean there is. Stick to your principles and it’s the same principles you’d use with other joints, right? Get them out of their acute phase, right? Reduce tone, reduce, you know, whatever sort of like reciprocal inhibition that happens or guarding that happens from something, and then work on your fundamentals, mobility, control, load, right?
Mike Reinold:
Like we kind of, we say that all the time, that was like our big fundamentals. And I think you’ll do a much better job. And as you see more, you’ll get more comfortable. So, you know, great episode. Great advice. Good stuff. Thanks so much for asking, Jackson. I bet you a ton of people feel the same way. So don’t feel bad about that and I think that hopefully this will be a helpful thing. Of course, there’s tons to learn, right? Like Kevin, didn’t get to this point in his educational process without going to a bunch of courses and stuff. So, you know, if you really want to get better at low back pain, start saying like, okay, man, I feel like I’m really good at the category of like of neurogenic, but not so much on like the acute trauma, like Dave said, like a pars. So seek out that information and do that. And I think, I think you’ll do great. So really appreciate it. Again, thanks so much. Please head to iTunes, Spotify, rate, review us so we can keep doing this and we’ll see you on the next episode. Thanks again.
