Back pain is the leading cause of work absence and keeping you on the sidelines when it comes to hobbies and recreational fun. You would be hard pressed to find many people that have not had an episode of low back pain. If it is your first time experiencing low back pain you will be glad to know that it often resolves on it’s own. Studies show that around the six-week mark you will see almost complete resolution of pain (Menezes Costa, et al). Am I telling you to just stick it out? Not at all. In some instances pain can linger up to a year or longer.

One major problem exists in the way that our medical system is set up. Despite increased freedom granted to us by medical insurance companies, we still feel the need to get a referral from a medical doctor before attempting conservative care (massage, physical therapy, chiropractor, acupuncture, etc.).

Time Is Money!

The dilemma here is that getting hands on care sooner could make a huge difference in how you feel right now. It could also prevent the reoccurrence of back pain in the future. If you are faced with the dilemma of deciding which medical provider to see, stay tuned!

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 “How long should I wait to see someone?”

That depends. Most of us will Google search in an effort to find a solution. This might be what brought you to our website. Now, it is important that you understand the general guidelines that medical doctors are supposed to provide when you step in their office.

1. A general timeline for recovery.

As we discussed above, most encounters with low back pain will last about six weeks when making some attempt to resolve it.

2. Continue to stay active. Do not resort to bed rest.

Attempting some form of activity modification, stretching or self-soft tissue treatment is a good place to start.

Here are some recommendations:

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1. Be more active!

If you weren’t very active the recommendation would be to gradually improve how mobile you are during the day. Sitting is a death sentence.

2. Be less active.

Well that’s contradicting! This only applies to those who enjoy two a days at the gym and get utter joy from self inflicted pain. Consider backing off from the exercises that worsen your pain while your body goes through the wonderful process of healing.

3. Check your posture.

It is not about being in good or bad postures. It is about not staying in any one posture for too long. 

4. Get more sleep. Zzzzzzzz.

5. Start Foam Rolling.

Also known as the “poor mans massage.” Stretching is wonderful. But getting some deep tissue work can make all the difference.

If the pain has not resolved within 2 weeks let’s set up an appointment with a medical provider.

 

“What medical provider should I see?”

 

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Let me start by saying that you are more than welcome to see your primary medical doctor. They can often direct you to someone they trust to manage your recovery. Those who are unfamiliar with chiropractic, massage, physical therapy, and so on may find more relief simply by seeing someone they trust first. If you are ready to get down to the nitty gritty we can skip seeing your primary medical doctor. Often times, they will give you the speech above, recommend some anti-inflammatories and encourage that you see a medical provider that can provide some hands on care (PT, chiropractor, massage, etc.).

What’s even more interesting, studies show that the costs of medical care for an episode of low back pain dramatically decrease when a physical therapist is seen first (Fritz et. al, 2012). {I only have data for physical therapy. This is not downplaying the effectiveness of any other providers}. Besides feeling better quicker, you are also saving some CASH! Can a I get a YEHAW?

 

To keep things simple, I will give you a quick explanation of what treatments tend to work best with ACUTE low back pain (Acute~ less than three months). We are only listing different kinds of treatments. In the past, certain medical professions often reserved a certain treatment. Physical therapists had exercise. Chiropractors manipulated the spine. Masseuses gave massages. It is not as cut and dry today. This is a good thing! Many quality treatments are stored under one roof. Saving you time and money. 

Treatment Options:

Manipulations: This is your good old fashion back crack! People always assume that chiropractors and physical therapists don’t get along. I love chiropractors. People also assume that only chiropractors manipulate joints. This is not true, physical therapists and osteopathic doctors also perform manipulations. Not all physical therapists are versed in this maneuver however. Manipulations have high quality evidence supporting the fact that it helps relieve acute low back pain relatively well (Delitto et al, 2012) .

 

“Core” Exercise: In a study done by Childs et al., back pain was 8x more likely to reoccur if exercise was not prescribed following manipulation. We also find that people who are more “loosey goosey” benefit from stabilization exercises (core exercises). For instance, if you find that your hamstrings are super flexible or you can make your fingers touch the back of your forearm. This also includes our “double jointed” friends. Sudden onset of back pain does not mean you need to do core exercises, but it doesn’t hurt!

Centralization Exercises: This sounds fancy. It is basically the act of repeatedly performing a motion (bending backwards or touching your toes) that causes your pain down the leg to go away. Often time’s people will report that they only feel pain at the back after performing this motion. Hints the term “centralization.” It is the ultimate quick fix for some.

This also falls into the exercise realm. Good evidence supports the idea that performing repeated movements in a direction that reduces or “centralizes” your pain (spine flexion, extension or side-bending) can be effective at resolving acute low back pain that travels down the leg. Often coined “sciatica.”

You could easily test this yourself. See which movement reduce your pain. Perform that motion 10-20x, 3-5x/day. This is a general recommendation. Getting evaluated can make this treatment more effective. Physical therapists are often familiar with this treatment, often referred to as McKenzie Therapy. To see if other providers are familiar you would need to consult with them first.

 

Education: Often overlooked, but critical for the BEST possible outcome. The education you consume can have a significant impact on your present and future recovery with injuries. Both good and bad. A prime example is searching back pain on Goggle only to find four articles that make you think you have cancer or a life altering bulging disc. Serious pathology is rare. Your medical provider can help you sort through all of the noise that the Internet provides to give you some clarity.

Our goal is to reduce the fear that you have related to your pain. We did not always do the best job at this in the past. However, with the help of research we know that helping you understand the structural strength of the human spine is important. In the past, we showed you bulging discs and compressed nerves. This only increased fear and disability. During this time we did not realize how common these findings were in people without pain. Now we attempt to explain the science behind pain, good coping strategies to reduce fear, ways to keep moving without pain and all the non-drug related treatments that can make a difference. Not getting this insight with your care would be unfortunate.

 

Traction: Surprisingly, traction does not have much evidence supporting its use with acute lower back pain. This is surprising because it is heavily used in physical therapy settings. The one instance where we do see some positive benefits is people with signs of nerve compression and pain that travels down the leg. In this instance, receiving traction while lying on your stomach is the recommended treatment position.

 

Nerve Glides: Not familiar with this? It is basically an attempt to gently stretch a nerve. In many instances, it is thought that nerve tension can be a source of pain. Whether the nerve is trapped in between tissues or sustained some type of injury. Some evidence supports lower leg nerve gliding (i.e. sciatic nerve) to help relieve pain in instances where people have pain down the leg.

Manual Therapy (joint mobilization, massage, cupping, instrumented assisted techniques, active release techniques, dry needling, and many more)

We do not have an overwhelming amount of evidence to say that these techniques are a sure shot. By no means are these treatments less effective than the next, we just do not have a lot of high quality evidence at this point in time. Variations in how people perform acupuncture, massage, dry needling and so on can make it hard to find consistency among multiple studies.

It is hard for me not write this section with an unbiased position because I use many of these techniques with great success. Dry needling has been a tool that has dramatically improved patient outcomes. It has also reduced the amount of sessions necessary to make positive change.

What you need to consider is that the effectiveness of these treatments really depends on the skill and experience of the provider applying it. Getting a massage from your six year old son will probably be less effective than seeing a skilled professional.

Most studies do show that these treatments have a positive effect on reducing acute low back pain. The big takeaway here is that resorting to any one of these options early on will likely lead to quicker outcomes compared to just sitting on your hands.

What about over the counter medication like Aspirin and Tylenol?

Always consult with your doctor on this one.

Tylenol: High quality evidence shows that Tylenol (acetaminophen) has no benefit compared to placebo for treating acute low back pain. Considering the potential harmful effects on your liver and other organs this is not recommended.

Aspirin and Ibuprofen (NSAIDS): These medications have been shown to have positive outcomes for people with acute low back pain compared to placebo. Similar to Tylenol, these drugs can harm your kidneys, gastrointestinal system and cardiovascular symptom. Consult with your physician to make sure this is an appropriate choice for you.

 

What about Money, Money, Money, Money…. Money!

“Some people got to have it!” Sorry I got carried away, great song.

The last consideration is the almighty dollar. In an effort to save money we often just go to a place that takes our insurance. When choosing a heart surgeon do you want to just go to the surgeon that takes your insurance? I feel the same way about conservative care medical providers. The provider you select may not take your insurance. However, if they are skilled at what they do you may save money in the long run by paying out of pocket or using your Health Savings Account.

Four visits with the skilled provider at $100/session will be cheaper than 12 visits with the next provider who has $45/copays each session ($400 vs. $540). Often times it takes a skilled provider way less sessions to make a difference. More often than not, you do not need to be seeing a therapist 2-3x/week for 6-8 weeks unless you are rehabbing a sport specific injury (i.e. ACL repair).

 

Big Takeaway!

The reason we listed treatments and not specific medical providers is that a lot of overlap exists today. It is a beautiful thing for the patient because it actually saves money in the long run. No longer do you have to jump between multiple providers when something is not working. Medical providers are becoming well versed in the techniques that have shown to be more effective.

 

When choosing a provider you need to:

1. Ask them what treatment options they offer? Consider the list above.

 

2. You also want some background into how effective their treatment sessions are.

*Google reviews and discussions with people in your community can help with this.

If you learn nothing else, understand that many of the treatments above were found to be more helpful when combined with other treatments. For example, manipulation or massage combined with exercise and proper education. If your medical provider is only offering a quick “back crack” and sending you out the door, you may want to look elsewhere. Get your moneys worth! You should walk out the door more resilient to pain and more knowledgeable on how to prevent it from re-occurring.

 

Go forth and conquer.

 

-Dr. Mike Infantino, DPT

 

 

Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipula- tion: a validation study. Ann Intern Med. 2004;141:920-928.

Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–491. doi: 10.7326/0003-4819-147-7-200710020-00006

Delitto, A., George, S. Z., Van Dillen, L., Whitman, J. M., Sowa, G. A., Shekelle, P., … Godges, J. J. (2012). Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. The Journal of Orthopaedic and Sports Physical Therapy, 42(4), A1–57. http://doi.org/10.2519/jospt.2012.42.4.A1

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Fritz, Julie M. PT, PhD, ATC^*; Childs, John D. PT, PhD^†; Wainner, Robert S. PT, PhD^‡; Flynn, Timothy W. PT, PhD^§. Primary Care Referral of Patients With Low Back Pain to Physical Therapy: Impact on Future Health Care Utilization and Costs. Spine, Dec. 2012. Volume 37; Issue 25.   

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Menezes Costa, L. da C., Maher, C. G., Hancock, M. J., McAuley, J. H., Herbert, R. D., & Costa, L. O. P. (2012). The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ : Canadian Medical Association Journal, 184(11), E613–E624. http://doi.org/10.1503/cmaj.111271

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