Nonspecific Low Back Pain

Most people will experience back pain at some point in their lives, unfortunately.  Odds are that if you don’t have back pain, you know at least one person who does.  Different studies estimate that between 60% and 80% of people will experience back pain.  It can range from a nuisance to debilitating.

Oftentimes, patients with low back pain ask about getting an imaging study of their spine, such as an X-ray or MRI, to help determine the cause of their pain.  Oftentimes, degenerative disc disease will be seen on imaging reports – particularly if the patient is 40 years old or older.  Disc bulges or herniation’s are another common finding, which can make patients quite anxious and worried. 

As it turns out, these findings are actually quite common – even for someone who has no back pain at all!  Let me say that again:  These are things we can see on a spine of someone who is not in pain!  On the other hand, sometimes a patient in terrible pain can have a perfect looking X-ray or MRI!  So, what on earth does this mean? It means that there is something else that is causing the pain.  We refer to this as nonspecific low back pain.

That is sometimes why you hear stories of friends and family who have had back surgery that failed.  The surgeon, in a good faith effort, eliminated what looked iffy on the MRI, but it didn’t help!  That’s because the bulging, degenerated disc wasn’t the problem, and why many doctors are reluctant to order MRI’s.  Not only are MRI’s expensive, but they can lead us down the wrong path – away from the path of recovery and down a path of injections and surgery instead.

What studies show (and what we at PDR see everyday) is that muscles and soft tissue are the root of many problems, which don’t even show up on imaging studies.  If you have tight muscles, weak muscles or imbalanced muscles, that can create a lot of strain on the spine.  And that strain can hurt a lot!  Sometimes that pain will even refer down into your buttock or thigh (oftentimes referred to as sciatica), which can seem even scarier. 

Muscular problems can happen to anyone.  An athlete can sprain a muscle, an otherwise healthy person can slip on the ice and irritate a muscle, a worker can strain their back by using poor body mechanics and/or sit with poor posture all day at work.  The wonderful news is that these problems are very manageable!

At PDR, our physicians, physical therapists and occupational therapists are highly skilled at helping you get your spine back into shape.  We are experts at knowing which stretches, strengthening exercises and manual therapies to use to get you back on track.  So try not to worry if your imaging studies show a problem, we can help

What is Workability and Why Does it Matter?

Workability is the practical capacity to succeed at something, more specifically, pertaining to a job in a workplace.  It is important from many aspects to understand just what a practical capacity is, and how it can or cannot be achievable on a daily basis.  Within the physical therapy realm, workability can be assessed and treated with a realistic approach to determine the feasibility and safety of a job or a certain aspect of a job and how it relates to a specific person.  This is obviously important because when done with correct body mechanics and muscle recruitment, most any job can be made a safe job within reason, and ultimately prevents injury and or disorders from occurring.  Incorporating proper body mechanics with methodical and realistic lifting capacities is important and effective.  

From an employer’s perspective it would be in their best interest for their employees, as well as for them to avoid work injury and compensatory reimbursement costs due to said injuries.  All too often, people experience injury due to unreasonable expectations of certain aspects of jobs, or some jobs as a whole.  When an injury occurs, many times there are temporary restrictions put on the employee by a doctor or therapist to ensure the patient re-enters the job in a safe and confident manner.  In certain cases, when the workability is determined unsafe or unrealistic for the patient/employee to return to, jobs can be modified permanently if the employer chooses so.

Physical and Occupational therapists are some of the primary professionals that are involved when workability needs to be assessed, whether restrictions need to be applied, and for how long.  With the primary goal of restoring function prior to injury, focused strength at the site of injury, as well as surrounding supportive muscles is vital to the initial success of, and the future sustainment of the recovery  With proper education to the patient, along with skilled focus on strength and injury prevention, physical therapy can be very effective in not only returning person to prior workability function.  This also prepares them to take necessary measures to prevent and reduce risk of injury as before.

Post Surgical Rehabilitation

Post surgical rehabilitation is essential for maximizing outcomes of surgical intervention.  Surgery is aimed at correcting a structural problem within the spine, however the musculature is left often times in a weakened state.  It is essential for the post surgical patient to be educated in a proper exercise program to completely regain functional use of the spine.

PDR has developed several MedX post surgical protocols that have been successful in allowing patients to regain full motion and strength following surgery.   Physical rehabilitation following spinal surgery is necessary to restore strength and range of motion while protecting the surgical site and improving repair.  Avoiding physical activity can result in muscular fibrosis, adaptive tissue shortening, loss of function, and increased risk of re-herniation.

Axial strengthening is necessary to return patients to physically demanding activities in their daily life or occupation and avoids re-injury.  Typically, along with the disc injury there is also a soft tissue injury, specifically to the paraspinal musculature. The MedX equipment allows us to isolate and administer calculated doses of exercise to the paraspinal muscles at a therapeutic level without compromising or overloading a post-surgical disc.  Isolated mechanical loading allows us to safely break up random alignment of the collagen fibers (myofacial adhesions). Continued loading during the healing process stimulates the new collagen fibers to lie down along the lines of mechanical stress, thus forming a stronger and more functional repair.

Inducing controlled segmental motion also produces facet motion, breaks up capsular adhesions, promotes the production of synovial fluid, and ultimately normalizes facet range of motion. Reintroduction of controlled activity also allows us to address the fearful patient and demonstrate that post-exercise muscle soreness is not injurious pain. Several studies have demonstrated that exercise increases levels of encephalin, endorphins, serotonin, and norepinephrine that help control pain.

Phase I: Reintroduction of Spinal Motion

The goal of phase I is to reduce inflammation and pain while slowly reintroducing normal inter-segmental spinal motion.  The patient is instructed in proper postures and body mechanics to safely return to light activities of daily living. 

Phase II: Restoration of Spinal Strength and Function

The goal of Phase II is to promote spinal AROM, continue cardiovascular conditioning, and introduce extremity and spinal extension exercises. Progressive resistance exercises (PRE’s) are used.  During this phase it is crucial to restore motion at the level of the disc, promote imbibition of fluids, and to restore normal facet motion.  Specific stretches are instructed to prevent adaptive shortening of soft tissues.

MedX equipment is introduced in this phase to safely exercise the extensor muscles while ensuring proper segmental loading. The patient’s AROM can be limited to avoid excess flexion, which would increase hydrostatic pressures on the posterior aspect of the disc.  Limiting forward flexion therefore decreases the risk of posterior disc re-herniation.

Phase III: Restoration of Lumbar Strength and Function

After 4 weeks of successful phase II rehabilitation without significant peripheralization, rehabilitation may become more aggressive. The goal of Phase III is complete restoration of lumbar AROM and strength.  This phase includes more aggressive lumbar MedX strengthening, cardiovascular, and total body strengthening exercises.  Rotary torso MedX strengthening may be introduced at week 9 if lower extremity symptoms are minimal and lumbar discomfort is controlled. If return to work is anticipated, job specific (work conditioning) exercises may be ordered. A functional capacity evaluation can be performed at the completion of the program to objectively determine safe work restrictions.