By Niki Varveris, PT, DPT, MSPT, MBA
Nonspecific Low back pain (LBP), characterized as pain occurring anywhere between the 12th rib and the gluteal fold, is perhaps one of the most common conditions managed by physical therapists. Physical therapists have succeeded in establishing themselves within the medical community as experts in the field of musculoskeletal function and disorder. In doing so, along with the advancement of the scope of physical therapy practice and the increase in direct access (providing treatment without a physician referral), a greater emphasis is placed on the therapist’s assessment skills, development of an effective plan of care, and utilization of suitable interventions. Thanks to the profession’s emphasis on evidence-based practice and guidelines, physical therapists treating LBP in an outpatient setting should be more proficient in both differential diagnosis and establishment of a plan of care with appropriate and safe interventions, thus meeting the patient’s goals and achieving better outcomes.
Despite the overwhelming amount of literature devoted to the efficacy of conservative treatment of LBP, there appears to be a lack of consensus regarding the most favorable physical therapy approach to the management of this patient population. Today, treatment-based classification system (TBC), grouping patients in one of four subgroups (manipulation/mobilization, specific exercises, stabilization, and traction), as well as psychosocial patient education are among the most promising evidence-based tools warranting consideration in the physical therapy clinic when addressing patients with LBP. Furthermore, recent systemic review of the literature has failed to support the value of therapeutic modalities such as ultrasound, electrical stimulation, cold light laser, and radial pulse therapy as an efficacious treatment approach to LBP based on low statistical significance and lack of scientific data.
Practitioners should use caution, however, before concluding that physical therapists utilizing modalities such as ultrasound and electrical stimulation fall outside the “small minority of scientists and unusually alert clinicians” and are practicing in the dark ages. One may argue that studies of spinal fusions have shown no better long-term outcomes in the management of LBP compared to cognitive intervention and exercises, yet hospital charges related to such surgeries have risen steadily since 1998.
[sidebar float=”right” width=”250″]Product Resources
The following companies provide products for pain management:
Battle Creek Equipment Company
Chattanooga, a DJO Company
Sombra Professional Therapy Products
Sore No More
The Integration Game
Proper and timely medical and physical therapy intervention is of significant importance in the management of patients with LBP, to not only address the etiology of the condition, attend to present signs and symptoms, and restore functional mobility, but also to prevent future complications. While there may be a lack of agreement as to the effectiveness of physical therapy modalities as a stand-alone treatment, one clinic in Southwest Florida has found great success integrating these modalities and other technology with the treatment-based classification system in the management of patients suffering from LBP. PhysioNetics, Naples, Fla, an outpatient physical therapy practice, has distinguished itself in its service area by providing results-driven, high-quality, innovative rehabilitation services. Owner Niki Varveris, PT, DPT, MSPT, MBA, along with Shane Smith, PT, DPT, and John Tyschyk, PT, DPT, MPT, CSCS, identify themselves first and foremost as movement experts specializing in the conservative assessment and treatment of neuromusculoskeletal disorders.
PhysioNetics’ utilization of technology to facilitate the diagnostic and recovery process of LBP begins with the Valedo-Shape instrument by Hocoma, Norwell, Mass. This device allows precise, non x-ray measurements of both spinal shape and mobility using 3D visualization. Therapists use the full spine sagittal and frontal images generated in a matter of minutes to identify structural deviations as well as to educate patients. Additionally, the instrument’s ability to quantify segmental spinal mobility assists in the delivery of more specific manual mobilization and manipulation techniques. The objective measurements the Valedo-Shape determines have benefitted the supportive documentation of the patient’s symptoms as it relates to change in spinal shape and mobility over time.
Protocol Backed by Technology
The adopted physical therapy protocol for management of LBP at PhysioNetics follows a systematic approach consisting of pain control, soft-tissue mobilization and range of motion restoration, strength and conditioning improvement, neuromuscular retraining, sports re-entry or return to full functional activities, and injury prevention. The practice uses the Opton Pro Class IV cold light laser (CLL) and the Soleo SonoStim ultrasound to facilitate the rate of tissue healing and reduce subjective pain in the early phases of treatment. Both devices are manufactured by Zimmer MedizinSystems, headquartered in Irvine, Calif. The frequency of use of these modalities is decreased as pain ratings improve and tissue reactivity is diminished; however, they still serve a purpose for the practice in the preparatory phase for myofascial release and soft-tissue mobilization.
The clinicians have noted an immediate positive response following these modalities as reported by the patient’s reduction in pain. In fact, there appears to be a greater reduction in pain when ultrasound precedes the delivery of CLL. It should be noted that the practitioners are well versed in the safe application of these two modalities, especially the Class IV CLL. They take extra caution in selecting the most appropriate intensity (1.0 W-7.0 W) and duration based on skin pigmentation, tissue integrity, and area of coverage. Furthermore, the practice has used these modalities during dynamic motion when addressing musculoskeletal deficits of the upper and lower extremities.
Several other manufacturers provide additional Class IV laser devices to the physical therapy market for pain relief applications. The Watertown, SD-headquartered company Pivotal Health Solutions-PHS Therapeutics manufactures the Apollo Class IV cold laser system, with units available as desktop or handheld models. LightForce Therapy Lasers, Newark, Del, offers the LightForce line of Class IV lasers, including the LightForce FX and LightForce EXP, both of which operate in continuous or pulsed mode. There are numerous devices that use red and near-infrared light as a healing modality, which the term “low level laser therapy (LLLT)” is often used to describe. Recently, however, steps have been taken to assign a more specific name to this type of treatment. In 2014, an accord was reached between the North American Association for Laser Therapy and the World Association of Laser Therapy, which resulted in an agreement to add the term “photobiomodulation therapy” to the vocabulary of the Medical Subject Headings (MeSH) database.
Although used significantly less than CLL and ultrasound, interferential current (IFC) set at parameters to enhance blood flow and mitigate pain has been the preferred electrical stimulation modality at PhysioNetics during the initial pain management phase. The practice utilizes the SysStim from Mettler Electronics Corp, Anaheim, Calif, with four electrodes covering the general area of reported pain while applying either heat or ice. The clinicians have applied occasional IFC when increased pain associated with strenuous exercises was reported during a treatment session. The practice has found better patient compliance with home programs and follow-up return to subsequent visits when the patient left the clinic with less pain than when they entered the facility as compared to leaving their physical therapy session in more pain. Other manufacturers of electrotherapy devices include Richmar, headquartered in Chattanooga, Tenn, which offers the Winner ST EVO with two or four channels of electrical stimulation, and quadpolar IFC, bipolar IFC, Russian, hi-volt, and microcurrent waveforms available. Vista, Calif-based Chattanooga, a DJO Global Company, offers the Intelect Legend XT System in this product category.
Smith likes to refer to fascia as “the glue that holds us together.” Though this statement is not entirely correct, it serves as a good visual for patients to understand its role and significance in the body. The clinical consensus among the therapists at PhysioNetics’ is that this layer of tissue accounts for painful stimuli with motion due to its high level of nerve innervation, and increased tensile forces placed upon it when constrained. Thus, myofascial restrictions must be addressed before joint mobilization, muscle stretching, and strengthening. The practice’s use of Graston Technique in conjunction with the Zimmer enPulse allow for effective myofascial release in a comfortable, minimally painful manner. Although the enPulse is not advertised for its use on fascial restrictions, PhysioNetics’ application for this purpose has proven extremely effective. Generally speaking, for the treatment of LBP, the clinicians have found faster and better outcomes when using the radial pulse to address the superficial posterior, lateral, and spiral fascia lines.
The practice recommends the initial application of the Graston technique and radial pulse therapy to the affected area in a static position. As myofascial restrictions improve, positioning changes and functional movements that originally caused pain are performed while the tissue is exposed to these modalities and techniques. Positional changes implemented for LBP consist of side-lying or prone position, followed by seated and forward bending of the trunk, progressing to stretching positions such as child’s pose or quadruped, and finishing with functional motions such as a golf swing. Once adequate fascial tissue mobility is reached during static and functional movement, the practice tackles the latter part of the previously mentioned protocol. The last phase addresses return to functional activities, sports re-entry, and prevention.
Topicals, Hot and Cold
Some of the tools available to manage LBP include topical analgesics and hot/cold products. Both represent resources that are widely available as over-the-counter items, or can be sold through practices. Among the topical analgesics used by the PT market are gel pain relievers such as Sombra, manufactured with natural formulas by Albuquerque, NM-based Sombra Professional Therapy Products. In that same category is Sore No More, made with natural pain relievers by Moab, Utah-based Sore No More, and appropriate for treating back pain, sports injuries, and other muscle aches and pains. Hot and cold treatment, too, may be helpful in managing pain symptoms. Moist heat can increase circulation, promote the body’s healing processes, and relax muscle tissue. Theramophore Classic Plus Automatic Moist Heat Packs from Battle Creek Equipment Company, Fremont, Ind, are manufactured to provide this type of relief, and designed in sizes that can provide heat therapy to the entire spinal area. Southwest Technologies Inc, North Kansas City, Mo, offers a line of more than 40 differently shaped and sized hot and cold therapy products that includes Elasto-Gel therapy products. The Elasto-Gel Therapy Pack can provide dry or moist heat, or be used for cold therapy with the ability to hold heat or cold for up to 40 minutes.
A Measure of Success
Historically, patients referred to PhysioNetics suffering from LBP have received physical therapy elsewhere with minimal success. In describing their previous treatments, most patients say, “I was put on the bike for 10 minutes and was told to do 10 reps of exercises that I can do myself at home.” Or, “They just put electrodes on me with a hot pack for 20 minutes.” These statements are often followed by, “If you are going to do the same thing, I will not come back!”
The clinic’s cancellation rate is less than 5%, and continues to grow its physician referral source based on patient outcomes. The practice attributes this success to not only the skill of its practitioners but also the effective integration of modalities, advanced technology, and evidence-based practice in a one-on-one setting. PTP
Niki Varveris, PT, DPT, MSPT, MBA, founder of PhysioNetics, earned her Doctor of Physical Therapy from the University of Saint Augustine. With 23 years of hands-on clinical experience, she is currently one of two physical therapists in the State of Florida achieving CAPP-OB certification from the American Physical Therapy Association. For more information, contact [email protected].