Therapist stresses movement, not rest, to treat back problems

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. If you've injured your back and all you want to do is rest, you might be doing the wrong thing. Today I'll talk about physical therapy treatment for low back pain with someone from Upstate who specializes in strength and conditioning. Steve Lounsbury is a doctor of physical therapy. Welcome to "The Informed Patient," Dr. Lounsbury.

[00:00:34] Steven Lounsbury, DPT: Thank you very much. Thank you for having me.

[00:00:37] Host Amber Smith: If someone strains their back or feels like they've pulled a muscle and it hurts to move or bend, what would you tell them to do?

[00:00:46] Steven Lounsbury, DPT: I would say in the case of an acute injury -- in our world, that's usually within the first two weeks -- the best kind of treatment for it is to stay active, to stay mobile. Our spines are made to move and we feel better with movement. I often teach my patients the phrase that "movement is medicine."

[00:01:04] Host Amber Smith: So even if it hurts, you still have to stay somewhat mobile. Do you recommend ice or heat for the pain?

[00:01:11] Steven Lounsbury, DPT: Typically in the acute phase, that early zero to two weeks, I tend to tell people that there is an inflammatory process going on, that inflammation that usually follows an injury, so ice tends to feel better.

However, once we're out of that early period, whichever one feels better for their particular symptoms is what I go with. There is no strong evidence either direction after that acute phase.

[00:01:34] Host Amber Smith: Are there different recommendations for children versus adults versus senior citizens?

[00:01:41] Steven Lounsbury, DPT: Not necessarily. What we base our treatment guidelines on are actually called clinical practice guidelines, and there are a set of documents that our governing body has developed over decades of research.

They're continuously being updated. And they develop them with the concepts in mind of treating across the lifespan. And we focus less on the age group affected by the injury and more specifically about the stage of injury they're in, that acute versus chronic stage.

[00:02:08] Host Amber Smith: Is there a difference between if it's lower back versus mid back or upper back?

[00:02:14] Steven Lounsbury, DPT: There is slight differences in the way we approach treatment. However, the generic concepts remain the same for how we approach movement, encouraging mobility or the ability to move through different ranges of motion, as well as strengthening of all the supportive muscles around the affected area.

[00:02:32] Host Amber Smith: So what happens if someone doesn't heed this advice, and they decide they're going to rest anyway because they're in pain and they're going to lay on the sofa until they start feeling better? Are they making things worse for themselves? Are they dragging it out?

[00:02:45] Steven Lounsbury, DPT: I wouldn't say the term "making it worse," so much as delaying their recovery. Typically when we have periods of immobility or not moving around, we tend to feel worse anyway. Again, our spines are made for movement. We feel better when we change postures throughout the day when we do different activities throughout the day.

There is such a thing as overdoing it in the acute phase, but more often than not, light activity such as walking or light household work is perfectly fine.

[00:03:14] Host Amber Smith: How does a person know if they need to see a doctor about an injury?

[00:03:21] Steven Lounsbury, DPT: So as a broader concept, it's tough to identify when you need to seek care, whether from your primary care physician or directly from a physical therapist. I would usually tell people if it is something that is not changing in the level of severity or how intense the pain is or the symptoms are for about one week of time, it might be time to consider that consultation with one of your doctors or a physical therapist.

[00:03:48] Host Amber Smith: So let's talk about what role physical therapy can play in treating acute back pain. Would you ideally want to see a patient soon after the injury, or do you want them to wait and see if things get better or if they change without intervention?

[00:04:04] Steven Lounsbury, DPT: So I would actually prefer to see the individual or the patient as soon as possible after an injury, for several reasons. One, because in those clinical practice guidelines I mentioned earlier, we do have a lot of good evidence for treatment techniques early on in the injury and recovery process.

And secondly, because the injury likely occurred for some underlying reason, whether it was improper lifting technique or weakness in target muscles that we would rather are stronger can take the load away from the spine, there's usually that underlying cause that we can help to address to prevent this from happening again.

[00:04:41] Host Amber Smith: For someone who's never had PT, what can they expect?

[00:04:46] Steven Lounsbury, DPT: So physical therapy is not a one-size-fits-all generic treatment. There is no magic pill to it. Every physical therapy session that you would receive through somewhere like Upstate is led by a licensed doctor of physical therapy. We are a doctorate level profession who goes through a long course of schooling, across a wide domain of different specialties and ways of assessing different systems.

And when you come see a doctor of physical therapy, our treatments involve many different approaches. It's called a multimodal approach. So sometime there is heat, or sometimes there's hands on mobilization or manipulation of the spine or the joints. There's a lot of therapeutic exercise, which is targeted strengthening and stretching of the muscles in the area of the injury.

And quite often what we also look at is not only the immediately affected area, but also adjacent areas or areas near to the injury, because we operate on this concept that one area affects the next one. It's that old song, "The head bone's connected to the neck bone." It's just a lot more complicated than that.

[00:05:54] Host Amber Smith: So if a person wants to see a physical therapist, they don't necessarily have to ask their primary care provider. They can just call the physical therapist directly, is that right?

[00:06:04] Steven Lounsbury, DPT: In New York State, we operate under a term called direct access, which means that a patient can just walk in from the street and see a doctor of physical therapy for either 30 days or 10 treatment visits, whichever occurs first before they're required to have a script or a referral from their primary care doctor or an orthopedic doctor.

Unfortunately, at Upstate we are unable to do that, per our accrediting body guidelines. We do require that script or referral.

[00:06:29] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Steve Lounsbury. He's a doctor of physical therapy specializing in strength and conditioning, and we're talking about the role of physical therapy to treat low back pain.

Is everyone a candidate for physical therapy, or is there any person who would not be a good candidate for physical therapy?

[00:06:52] Steven Lounsbury, DPT: That's a good question to bring up and a good moment to talk about what we would call red flags in the medical community. These are signs or symptoms that might suggest you need further medical assessment rather than treatment from a physical therapist.

They might suggest some more serious underlying pathology or other condition that might be explaining why your back pain is persistent. And those could be multiple. We won't dive into all of them today. But the red flags that I'm usually looking for is something more systemic, like fevers and chills, a change in sensation in the region of your groin, what we usually call a saddle area, if you were sitting on the saddle of a horse, any kind of sudden unexplained weight loss recently, especially if it was unintentional, pain at nighttime or at rest that does not change with a change in position, a failure to improve over the course of about one month, and there are many more. We could keep going for a while. But there are certain red flags like that that would say to either your primary care doctor or if you are being seen by a physical therapist, we're trained to recognize those to say, PT might not be the most effective treatment at this moment, and you should seek further medical attention.

[00:07:59] Host Amber Smith: So it sounds like you look at like the whole patient, not just where their pain is, but you look at them as a whole person and try to figure out what else might be going on.

[00:08:09] Steven Lounsbury, DPT: Absolutely.

[00:08:11] Host Amber Smith: So are the exercises that you prescribe, are they meant to relieve the pain or prevent further injury?

[00:08:20] Steven Lounsbury, DPT: Yes, to both. And the approach to treatment changes slightly depending on the individual patient in front of you. And I think this is where the nuance of what physical therapy is as an art and a science kind of meets in the middle to say that if we've had pain for only a couple of weeks, my goal is to help you get completely out of that pain, to eliminate it entirely, and then to prevent it recurring in the future or happening again.

However, if this is something that's been going on for a couple of decades, you've lived with chronic back pain for 20 plus years, we know per all the research that we've done that the pain is unlikely to ever go away entirely at that point. There are changes in the brain that mean you're more sensitive to that pain now, and it's likely to be lasting.

But what we can do is take you from, let's use our typical numeric rating scale of zero to 10, 10 being the worst pain you've ever felt, and zero being no problem. If I have a patient who's had 20-plus years of back pain and they come in at an eight out of 10, well, I would see success if we could bring them down to a 2 or 3 out of 10, knowing that the pain is still there, but we've given them ways to manage that on their own and be more active, accomplish what they might want to do.

[00:09:30] Host Amber Smith: So when a person comes for physical therapy, they're going to be active, right? I'm just wondering, do they need to dress like they're going to a gym?

[00:09:38] Steven Lounsbury, DPT: Yes. That is typically something that we do run into on occasion. We know it is tough because quite often you are coming to physical therapy from work or from picking up your kids or from anything else. It does make it harder depending on, especially if we're looking at your low back, if you're wearing clothing that doesn't allow us access to at least visualize your low back or see it, and we are pretty good about draping with towels and stuff like that to maintain a patient's modesty, of course. But it is nice to have exercise clothes. It allows you greater freedom of movement.

So for men, if you're wearing a dress shirt that's tucked in very tightly, it might be tough to assess how far you can truly move if the shirt is what's limiting you. For females, showing up with either a skirt on or leggings or jeans that might restrict your movement of your lower legs, that might also be an issue. Because like I mentioned, when we look at the low spine, we're also considering the role of the hips, the knees, the feet, and how they play into that.

[00:10:30] Host Amber Smith: So for someone with an acute pain injury, how soon might they expect to notice improvement?

[00:10:38] Steven Lounsbury, DPT: There are a couple different ways of noticing improvement. One, in terms of pain relief. Hopefully we can achieve something within a session, especially if it is that acute. Most of our treatment that we apply, especially for acute injuries, is focused on quick reduction of that pain. We don't want to let it become something chronic or disabling for the long term. We want to try and get you out of that moment of pain and discomfort as soon as possible. So hopefully within the first session or two, they would start to realize that there is some pain relief.

Building strength takes a little bit longer. That's a matter of weeks as we go. Usually, I would like to tell patients that a clinically meaningful change in their strength -- meaning something they'll notice the difference in their daily life, not just something we could measure with a tool here --will take on average, about six weeks to start to be noticeable to the patient. It is a slow initial curve and then it speeds up over time.

[00:11:31] Host Amber Smith: So your relationship with a patient might last a period of weeks or months typically, is that right?

[00:11:38] Steven Lounsbury, DPT: Correct.

[00:11:39] Host Amber Smith: Well, we've been talking mostly about acute pain from recent injuries, but you did mention, people with chronic pain. Can they still get some relief? Have you seen that work for people through physical therapy?

[00:11:52] Steven Lounsbury, DPT: I certainly have. We have quite a large percentage of our treatment caseload that we see that is chronic back pain. In fact, one of the leading causes of disability worldwide is chronic back pain. It's the six month costly condition in the US.

And one of those things that we try to do, like I mentioned earlier, is focus on not only relieving some amount of pain, but finding ways for them to manage it throughout their day. Some of that might be setting reminders on their phone to be up and be moving for a certain period of time if they sit for work. It might be teaching exercises to maintain mobility every morning, every evening, because if we think about sleep as the longest period of inactivity in our day. Where we're largely in the same position, that's when most people feel worse. It's late at night and first thing at the morning.

[00:12:39] Host Amber Smith: Oh, that's a good point. I wanted to ask you about massage. Have you ever seen that helping someone with acute back pain?

[00:12:46] Steven Lounsbury, DPT: I certainly have, and it's actually one of those recommended interventions we have within our clinical practice guidelines. We are not massage therapists. That is a separate profession. However, we can utilize soft tissue massage or soft tissue manipulation. It is skills that most physical therapists have been trained in rather extensively. Everybody entering the field has some amount of training in it. You can go on to do continuing education within that area as well. So it is typically one of those treatments we'll apply early on for an acute injury.

[00:13:18] Host Amber Smith: Are there stretches or movements that you would recommend that people can do regularly to strengthen their backs and then hopefully prevent injury in the first place?

[00:13:28] Steven Lounsbury, DPT: There is no particular movement because it is so patient specific. Speaking in a generic sense, trying to get out of the forward bent posture that most of us spend the day in typing, writing, driving, cooking, cleaning, everything is largely in front of our body. I made a joke when I had a community presentation last night that we don't often dice an onion or fold laundry behind our back. So most of us spend the day very forward and rounded with our shoulders. Our chin creeps forward. So working on bringing ourselves up out of that position helps to relieve some of the back pain that comes just from being in one position for too long.

[00:14:06] Host Amber Smith: Well, that's really good to know. Thank you so much for making time for this interview, Dr. Lounsbury.

[00:14:11] Steven Lounsbury, DPT: Thank you very much for having me.

[00:14:12] Host Amber Smith: My guest has been doctor of physical therapy, Steven Lounsbury from Upstate Medical University. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.