My response to the UCLA Vital Signs Article
Dear Vital Signs Staff,
Thank you for Vital Signs. I usually enjoy the magazine as it’s informational and shows cutting edge Medical Care.
The article "Addressing Back pain in the Primary Care Setting" omits Primary Care Physical Therapy. Statistically only 7% of patients going to MD’s offices with Low Back Pain(LBP) are referred by MDs to Physical Therapy.
I treat the other 93% -the patients who are in pain, afraid to move, rest is not helping, fearful of not being able to support their families, fearful there is something more seriously wrong, fearful on not being taken seriously, fearful of being dependent on medications, often feeling broken.
Dr Duru shares 85% of patients visiting a primary care MD have “non- specific back pain. 70-90% improve within 7 weeks with conservative treatment.
Unfortunately chronic pain and opioid dependency are very real. The medical model of 4 groups is a diagnostic model, and handouts with positions and exercises are no substitute for guided care by a compassionate and skilled PT(Physical Therapy) professional who explains the why based on condition, anatomy, biomechanics, how to fix it, how long it takes and what to expect along the way.
Exercises on their own will not make a lasting impact on reducing back pain. Loading muscles already in spasm and inflamed joints does not calm pain- it fatigues, braces, develops trigger points(TrPs). Soft Tissue Mobilization(STM), Stabilization and treatment of TrPs is necessary. Treating and calming long muscles, activating deep stabilizers(multifidi, rotores which are inhibited with injury)and reintroducing normal movement decreases inflammation, pain and spasm.
If the goal is High Quality Practices, Primary Care Physical Therapy - direct care by a Physical therapist should not be withheld for the first 6-8 weeks.
I work as a Primary Care Physical Therapist. If movement aggravates the pain, PT is very effective, particularly ATM2 , class IV laser, kinesiotape , positions of active relaxation, breathing for relaxation addressing the musculo-skeletal system and the muscle spasm, many patients have had a 50% reduction in pain within the first treatment.
If movement relieves the pain, PT can educate,teach exercises , positions of active relaxation, use of tools like a foam roller, breathing for relaxation.
If movement has no effect on patient’s pain, these patients need early medical screening and further assessment and referral.
Early pain management(Primary care PT included) decreases pain amplification, reactive, hotline and autonomic pain, pain sensitization, development of glial cells at specific spinal levels, decreases muscle compensations and repetitive abnormal movement patterns.
MDs often tell people with back pain to take it easy or rest. That often gets misconstrued and people stop doing any exercise and feel bad. then they have a good day so enter the BOOM or BUST cycle. On a good day they play catch up or do the “Honey-do” list around the house, repack the garage, do 3 weeks of laundry, mow the lawn then find themselves back in bed resting for the next 3 days.
What they should be told:
Do some exercise while resting or backing off from activities or postitions that make your back worse. If activity causes sharp shooting pains, refrain from that activity/back off exercise or that position; correct form or modify position and most importantly PROTECT the injured area /stabilizing while strengthening tissues around it. Simple exercises done in hook lying decrease inflammation, improve circulation and help healing.
The back has 3 layers of muscles with different functions:
Core stabilizers(deep small muscles work 24/7 to stabilize spine(keep joints in correct alignment).
Long muscles of the back-designed to work as needed for specific movements such as flexion/bending forward; extension/bending back; lateral flexion/side bending and rotation/turning. Not designed to work more than intermittently.
Multijoint muscles eg. Lats,hip,shoulder mobilizers, muscles designed to move limbs on stable spine.
Core stabilizers become inhibited when trauma or injury. The middle layer attempts stabilization, the muscles fatigue, increase tension, spasm and become very painful- sharp shooting pains,splinting and preventing further movement. Mobilizers then attempt stabilization and mobilization. pain spreads as these muscles fatigue and develope trigger points(TrPs) that may spread pain.
Physical Therapists are musculoskeletal experts. High quality practices include early and dosed care by a primary care Physical Therapist to:
Activate Core stabilizers.
Calm muscle tension, decrease spasm, address TrPs.
Find out the root cause.
Address the root cause.
Correct biomechanical alignment.
Re-introduce movement, muscle activation in the correct sequence and time frame.
Explain the problem, make sure it makes sense, educate how to fix, when and by whom.
Teach breathing for relaxation, breathing for exercise.
Direct hands on care.
Protect and stabilize the injured area.
Educate re inflammation, pain behaviour ie. Stage 1,2,3,4 and keep inflammation down.
Provide evidence based treatments that work, tools for self management and corrective exercises as well as home exercise programs.
I welcome dialogue with Dr. Duru. I can be reached at 818 535-8661.
Dedicated to restoring health,
Caren Lieberman PT
Physical Therapy Studio