2003-02-22 / Columnists

Eye On Physical Therapy

By Tim Rohrs

After shoveling snow for a few days, a few of us mig ht be experiencing low back pain. Studies show that 80% of us will experience low back pain at some time in our lives. Fortunately, most acute low back pain will resolve without intervention in 6 to 12 weeks (1). For those people that continue to experience low back pain or for those whose pain worsens over time, it is a time for a visit to your M.D. He/she may initially order x-rays or an MRI depending upon the symptoms you are experiencing.

Many people who have an MRI, experience undue worry and anxiety over the results. A diagnosis of intervertebral discs that are protruding or bulging is not a life sentence to pain and discomfort. According to one prominent doctor who has studied this extensively, when studying MRI results of 60 patients that never had an episode of back pain, 67% of them had abnormal discs. If 67% of the patients in this study had bulging and protruding discs, but no back pain, is it reasonable to assume that those suffering from back pain are experiencing it because of abnormal discs?

The majority of my patients that come in with a diagnosis of herniated or bulging discs get relief from pain. Some of the patients that do not get relief are caught in a Catch-22 cycle. They come in for physical therapy wondering how I am going to get the disc to "pop back in." Or, they ask how we are going to get that disc to stop bulging. I explain to them that we can do neither. Excluding surgery, nothing can be done to "un herniated" a disc or "un bulge" it. Of course the next question is why are they there? If we can’t "un bulge" it, then what is the sense of physical therapy. I explain to them that physical therapy tries to restore normal strength, mobility and flexibility to a joint or joints. Whether that joint is a knee, ankle or low back, restoration of osteokinematics (bone mo-bility) and arthrokinematics (joint mobility), strength and flexibility is what therapy is all about. Usually when we are successful, pain diminishes as abnormal stress on tendons, ligaments and muscles are relieved. The Catch-22 comes into play when the patient disregards talk of normalizing movement and improving strength and abnormally focuses on "THE DISC". Their thought process is " well if they can do nothing for the disc then therapy is a waste of time. Since it is a waste of time, I will not participate in the exercises they have prescribed for me and I will show up intermittently for my appointments, if I show up at all". Needless to say, they now have a self-fulfilling prophecy. They have not come in the three times a week as their MD prescribed and they did not participate in the exercise program, thus they are not better.

Many of you that have had therapy, might be asking what about the electric stimulation, ultrasound, heat and massage. Surely, these will cure the back pain? These modalities are used to help your therapist achieve their goal of normalizing movement. If muscles are experiencing increased tone or spasm, heat, ultrasound and massage may be employed to decrease these spasms. For those experiencing acute pain, again these modalities are employed to help relieve some of the pain so that you can participate in the exercise program. In and of itselves, the modalities are not the treatment. Receiving heat, massage, electric stimulation and ultrasound without a carefully designed exercise program is a disservice to the patient. A study in the Archives of Physical Medicine & Rehabilitation had 285 patients from 1991 to 1994 participate in an aggressive 6 week exercise program without the use of ANY modalities. The results showed that patients that stuck with the program for 6 weeks had a statistically significant reduction in their pain over those that did not exercise.

After successfully eliminating or reducing a patient’s pain, I often ask them to recall our earlier conversation about discs. I point out to them that they have had a great reduction or complete elimination of pain yet we did nothing to affect the disc. I ask them if they still believe that their pain was caused by a bulging disc.

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