By Julie Watkins, PT, DPT, ATC
As widespread and pervasive as back pain is, physical therapists cannot treat it with a broad brush. There is no one-size-fits-all approach therapists can take to help patients find relief. Whether it’s chronic or acute pain, no two conditions are the same—and even if they were physiologically similar, the solutions could be widely different because the patients, themselves, are different.
That means that of the millions of Americans suffering from back pain, there are an equal number of possible treatments and technologies that we, as physical therapists, need to explore and administer. The statistics are astounding. Consider this:
• One in three adults say back pain impacts their everyday activities.
• More than half of the cases can be attributed to sitting at a desk all day.
• Americans spend upwards of $50 billion treating back pain, alone.
• Nine out of 10 people never learn the primary cause of their back pain.
With such massive implications, there are countless theories and products being disseminated throughout the industry. Many have been proven to work, and some have withstood the test of time. For instance, the practice of applying alternating hot and cold compresses to the pain area has been a preferred method of treating back pain for centuries. Over the years, compresses have evolved into reusable products of varying sizes designed to fit naturally along the body’s contours.
An example of these are Thermophore heat packs and Ice It! flexible cold packs from Battle Creek Equipment Company, Fremont, Ind. In this same category, Elasto-Gel hot and cold therapy products from Southwest Technologies, North Kansas City, Mo, are also on the market, and designed to have the flexibility to move with the wearer and resist puncture. Chattanooga ColPac reusable, gel-filled cold packs available from OPTP, Minneapolis, are manufactured with flexible filler formulated to never freeze so the pack remains pliant. Each company’s products are available in a variety of sizes.
Therapeutic laser represents an advanced technology that has been adopted by some physical therapy practitioners. While evidence is mixed about the use of therapeutic laser, there are clinicians who report that it can promote tissue healing and help relieve pain symptoms associated with acute or chronic conditions, or postsurgical pain. Among the sources for this technology is LiteCure, Newark, Del, which offers its LightForce line of laser therapy systems. These devices are designed to provide customized treatment that is based on patient-specific considerations.
Depending on the case, I’m more likely to refer a patient toward spinal bracing and/or electrical stimulation for home use when combined with their posture and exercise program. Both modules are supported by evidence that has been thoroughly researched, and many of my patients have found relief to their back pain through the application of certain types of these methods.
[sidebar float=”right” width=”250″]Product Resources
The following companies provide products for pain management:
Accelerated Care Plus
Amrex Electrotherapy Equipment
Battle Creek Equipment Company
Biofreeze (Performance Health)
Chattanooga, a DJO Global company
E-Z Release Myofascial Technique
Kinesio Holding Corporation
PHS Medical by Pivotal Health Solutions
Roscoe Medical/Compass Health Brands
Sombra Professional Therapy Products
Sore No More
The Psychological Effect
Just because physiological evidence should be the driving factor in how physical therapists treat their patients, the mental aspect of back pain cannot be diminished. Studies show a correlation between mental health and physical health. Additionally, almost everyone agrees that physical activity can be good for a patient’s back pain and his or her attitude. The problem is that there may be disagreement about the type of exercise to recommend.
Yoga, Pilates, running, swimming, and weight lifting each comes with its own benefits and risks, and physical therapists should exercise caution when advising their patients about these activities. While a patient’s mental health can improve simply by returning to a preferred workout, it may be wise for that person to modify his or her technique, or be protected with sports wraps and/or braces—especially if it was a sports injury that brought on the injury in the first place.
Braces that provide a high level of flexibility can also provide a solution to back pain symptoms, assuming that they restrict the ranges of motion that are harmful to the patient. Earlier spinal braces made from porcelain and steel were overly restrictive and cumbersome, treating the injury but not allowing for much else. While they improved posture for scoliosis patients or assisted the healing of a compression fracture, they did not allow the patient to perform activities of daily living (ADLs)—eating, bathing, dressing, toileting, transferring (walking), and continence. These functions, while extremely basic, are crucial for a patient’s mental health. Without them, the treatment is just one step above bed rest.
Bracing: An Option for Adult Scoliosis Back Pain
When it comes to back pain, one of the most underrated conditions is adult scoliosis. It does not come on as urgently as a sports injury or being hurt in a traumatic car accident, nor does it receive the sympathy or attention of children’s scoliosis. However, adult scoliosis can be extremely debilitating, and it impacts an estimated 3 million Americans.
It is a condition that develops over time as years of wear and tear are racked up on one’s spine, causing it to become misshaped. The result can be excruciating and somewhat surprising because the patient cannot pinpoint the cause. It is often dismissed as just another part of getting older and assumed that nothing can be done.
Braces can provide a solution for relieving pain associated with adult scoliosis. The Peak Scoliosis Bracing System, available from Aspen Medical Products, Irvine, Calif, is an unloader brace designed to relieve pain and enhance quality of life for those affected by adult scoliosis. The brace is built to be worn comfortably, be easily adjusted, and can be tailored to target the areas of the body that generate the most pain. The Peak Scoliosis Bracing System also includes anterior and posterior tension straps, an adjustable thoracic pad, an adjustable trochanter pad, malleable aluminum struts, ergonomically designed molded pull tabs, and an optional chest strut. The brace is considered durable medical equipment and assigned an L-Code by Medicare for reimbursement.
For patients with indications that have historically been a challenge to treat, such as compression fractures, burst fractures, kyphosis, and fusions, another option is the Summit 456, also available from Aspen Medical Products. It is worn like a backpack and built to create a dynamic environment for healing throughout the thoracic and lumbar spine. Its malleable aluminum support can be conformed to fit varying body types and is designed to restore balance and reduce daily pain.
Stimulating Recovery from Home
Not all the components of a program to relieve back pain can be performed in the office. Much of it falls to the patient to provide though compliance with home programs. To fully address back pain, it is critical for patients to maintain posture in their daily lives outside the clinic. Likewise, and when recommended, wearing a brace can help relieve back pain symptoms in addition to therapeutic activity and exercise.
Other products that can help patients find temporary pain relief outside of the clinic include topical analgesics. These products serve as an easy-to-use and affordable solution patients can apply themselves as needed, and a wide range of topical analgesics is available to the professional and consumer market. A natural, pain-relieving gel that can be used to address back pain is Sore No More, available from Moab, Utah-based company Sore No More. It is formulated with menthol, capsaicin, and witch hazel to provide temporary pain relief. Flexall, available from Ari-Med, Tempe, Ariz, is formulated with aloe vera and can be applied at home and in the clinic to enhance modalities or be used by itself.
Electromodalities for Clinic or Home
Some transcutaneous electrical nerve stimulation (TENS) and Interferential Current (IFC) devices can be easily self-administered from the patient’s home, and oftentimes those types of products are the most successful in providing relief from back pain.
One device that is helpful for treating back pain after hours is the NexWave from Zynex, Lone Tree, Colo. It provides relief of chronic acute, and postoperative pains. The electrical current can be controlled through a simple battery-powered controller and set to the patterns (burst, continuous, or modulation) recommended by a physical therapist. This device has been successful in my own clinic because of the versatility it provides, including IFC, TENS or Neuromuscular electrical stimulation (NMES) options to treat low back pain.
Another tool designed to relieve pain is the Dynatron Solaris Plus 708, from Dynatronics, Salt Lake City. This device is built to deliver three channels of stim in addition to ultrasound, and TriWave Light or ThermoStim simultaneously. The device has the optional ThermoStim Probe soft tissue mobilization tool that can deliver heat or cold therapy combined with e-stim.
As the population ages, the probability of developing aches and pains in the back slowly climbs. There is a special consideration for pain symptoms among Baby Boomers, one of the fastest-growing segments of the nation’s alarming opioid epidemic, who turn to opioids to manage back pain or recover from invasive spinal surgery. Older adults, too, are more likely to develop adult scoliosis, and physical therapists should be vigilant about looking for signs of this condition among the retirement-age population. By embracing a global view of pain management technologies, from electromodalities to bracing systems and even traditional standards such as hot/cold and topicals, therapists can help provide safe alternatives to opioid pain relievers, and help their clients feel as physically capable as possible. PTP
Julie Watkins, PT, DPT, ATC, is the clinical director and lead clinician at Brain & Spine Physical Therapy at St Luke’s Hospital in Chesterfield, Mo. Julie began her career as a certified athletic trainer in 2001 working with high school and college athletes. Since completing her doctorate in physical therapy from Washington University in St Louis, Julie has worked in the outpatient orthopedic setting for 13 years. She has been with Brain & Spine Physical Therapy since its inception in 2006 and currently specializes in the treatment of acute and chronic neck and low back pain. Julie has worked cooperatively with surgeons and pain management at The Brain & Spine Center and continues to further her education through courses aimed at postural correction and manual therapy. For more information, contact [email protected].