What should I expect from PT for low back pain? Part 1: The Evaluation

I'm going to skip past all the conflicting diagnoses, misinformation on the internet, and myriad of treatment options sufferers are inundated with for non-specific low back pain. Instead I'll explore, primarily, the physical therapy aspect of it.

Caveats everyone most know before reading:

1. "Abnormal" imaging finding become more normal the older you get. For example: if you're over 30, and DON'T have lumbar disc degeneration, disc bulges, stenosis, and some arthritis show up on X-rays and/or MRI, you are ABNORMAL. Basically, these are all signs of aging.

2. Unless you have a tumor or fracture, MRI findings do not correlate well with symptoms. This basically means a radiologist cannot look at an MRI only, and decide your symptoms are coming from your imperfect anatomical findings.



Now that that's out of the way, allow me to describe what you should expect from you PT evaluation. Unless you are in acute pain from a very recent injury, your evaluation should be very thorough. This means, that after your therapist asks you a bunch of questions, she (because the majority of us are women) should examine your posture and gait. She should then take some cursory measurements of motion, strength, and reflexes. These questions and measurements give your PT an idea of which tests to select thereafter.



TESTING PHASE - THIS IS THE DIFFERENCE BETWEEN A GOOD PT EVAL AND A BAD ONE

The testing phase is supposed to give the PT insight as to which movements or manual therapy interventions may be helpful, harmful, or neither. It is at this point that the "treatment diagnosis" is made. For this reason, the patient must be able to accurately describe the change, or lack thereof, in their symptoms. It is equally important that the therapist retests any abnormal objective findings, to see if they have changed.

For example: If the patient notes back pain while lying on his back. The PT should have the patient perform a movement and then ask the patient if he feels better, or worse, as a result, while lying on his back. Too often, patients never experience this test-retest methodology.

TREATMENT PHASE

It is our belief that the physical therapist's first job is to teach you how to relieve your symptoms. For this reason, we try to send you home, on your first day, with exercises strictly to achieve this goal. They may not thoroughly address the underlying cause of your problem, but they are intended to reduce the need for pain medication, muscle relaxors, and NSAIDS.
It is extremely important that the patient performs these exercises at home between visits 1 and 2. The patient and PT need to determine the patient's ability to independently reproduce the results found in the clinic. If the initial benefit was not reproducible at home, there can be only 2 reasons: 1. the exercises were not appropriate and the initial benefit, on evaluation day was a fluke or 2. The pt did not perform them correctly.

Stay tuned for Part 2: Treatment, Progression, and Patient Independence

Having joint pain during your workouts?

Many people suffer injuries in the gym. In some instances it is due to poor form; in others it's from doing too much too soon; and in other cases, it can be caused by an overzealous trainer.
The primary thing we should all understand is that a good workout, for a healthy person, should not be a walk in the park. Muscle fatigue and discomfort are necessary to achieve your goals. However joint pain, during or as a result of your workout, is usually not a good sign.

What most people want to know is how to determine if it's a "good hurt" or not. Sometimes you may not know until 3-4 days after your workout. The key is to learn from what your body tells you and avoid repeating mistakes in the future.


IS THIS PAIN EXPECTED OR ABNORMAL?

You should expect to feel discomfort and soreness in the muscles/tendons during and 1-5 days post workout. Any joint pain during or following your workout should be viewed as your joints warning you that they are not ready for this intensity of exercise. If the pain is during the workout, you need to reduce your resistance or intensity right away. If the joint pain occurs afterward, hold off doing the exercise(s) in question until the pain subsides. When you resume, back off the weights and/or reps by 25-50%. Re-evaluate your body's response and adjust as necessary.

Joint pain is typically due to your cartilage (the hard non-bone lining your joint surfaces) not being strong enough to tolerate the new work load. Cartilage will adapt. You need to begin with light, pain-free resistance and a higher number of repetitions. For example, if the StairMaster makes your knees hurt for 4 days after doing it, discontinue. Move to the bike; gradually increase the resistance over several workouts. After 2-3 weeks of pain-free biking, resume the StairMaster for only a few minutes. If pain-free, gradually phase out the bike as you increase your StairMaster time.


HOW DOES MY PERSONAL TRAINER KNOW WHAT IS BEST FOR ME?

In some cases they do not. Prior to beginning with a trainer or CSCS (certified strength and conditioning specialist), you should be asked a series of questions addressing your goals, injury history, and experience with the type of training you are about to undertake. Your answers will assist the trainer in determining your "training age," as well as anything that should be avoided or emphasized. If your trainer or CSCS does not thoroughly address your workout and injury history - or lack thereof - you may want to seek out someone else to design and lead you through your routines.


SO HOW DO I KNOW IF MY WORKOUT IS GOOD FOR ME OR BAD?

It's all about results. Understand that any exercise routine will involve some roadblocks and some gains. In the end it is up to the individual to decide when something is hurting him/her. Joint pain is not to be toyed with. Muscular fatigue and discomfort are expected, and a must, for most people to achieve their goals. If you're experiencing consistent joint pain from your workouts, you need to make some changes.


WHAT DO I DO IF PAIN IS STOPPING ME FROM PROGRESSING?

We would love to tell you that any local Physical Therapist is the best choice - as this is a blog written by a Physical Therapist. Instead, we suggest getting a FREE CONSULTATION with 2-3 different clinicians. Allow them to prove to you their knowledge of exercise-induced injuries and progressions.

If you still are confused as to which one may be the best choice for you, schedule an appointment with a sports-oriented orthopedic surgeon, and get his or her recommendation. If physical therapy is prescribed, demand a thorough evaluation which involves the therapist testing your body's response to each exercise.

"Runners' Knee"

Recently we have begun to see a rash of people complaining of runner's knee and related injuries. This may have to do with the fact that the marathon season is kicking into high gear, or that our clientele are just getting older yet maintaining their same training routines. Whatever the cause, we have provided a few tips below for managing these issues, and keeping you on track with your training.
But first, let's discuss some other common contributors to knee pain:

Flat feet and poor eccentric control of pronation can lead to arch and heel pain. Strengthening your tibialis posterior and calves, while also maintaining good flexibility in the same muscles will go a long way to abate the pain. It should also reduce compensation at the knee, and therefore reduce patello-femoral pain.

Poor hip strength and hip/knee muscle flexibility can also lead to knee pain. For PREVENTION, in a HEALTHY RUNNER, squats, leg press, good mornings, leg curl, and hip strengthening machines are some of the things you will want to focus on in the gym. These should be done during preseason, season, and post-season strength training sessions.

Pelvic instability can also lead to knee pain. Some people with this experience low back pain and others do not. See your physical therapist to help you determine the root cause of your symptoms. There are usually multiple, simultaneous issues occurring and they can be anywhere from head to toe.

TIPS FOR PEOPLE IN PAIN

1. Stretches must be done gently, and held for approximately 15-20 (actual) seconds. Repeat each 5 times per leg/hip, doing 2 sessions per day. Research shows that this method of stretching will lengthen your muscles in 2 weeks.

2. Abdominal strengthening builds muscle tone (involuntary state where the muscle remains partially contracted, even at rest) which lends to pelvic stability, improved posture, and decreases the chance of non-specific low back pain. When performing crunches in the hook-lying position, be sure your feet are as far away from your buttocks as possible, yet still comfortably flat on the floor.

3. Always test and retest each exercise prior to adding it to your regimen. If it increases your symptoms, it's not good for you.

4. Consult your physical therapist or doctor prior to performing any exercise program.