By Andrew Hadrich, PT, DPT
Treating chronic back and neck pain is difficult. Often, patients affected by chronic pain have difficulty recalling specifics of when their symptoms began. Most have been through extensive medical testing with minimal significant findings. Many go through courses of prescription pain medication and chiropractic procedures without significant long-term benefit. Fearing worsening of their condition, chronic pain patients commonly begin the downward spiral of activity avoidance, leading to deconditioning and weight gain, leading to more activity avoidance. This, in turn, can negatively affect their performance at their job and adversely affect personal relationships.
Unfortunately, this is the experience too many people go through during the journey to overcome their chronic back and neck pain. At Select Therapy Inc, a four-office practice based in Baxter, Minn, the practice has recognized the shortcomings facing patients who are affected by chronic back and neck pain. In response, the staff has created a physical therapy program with a strong focus on helping patients truly overcome their chronic pain.
The practice’s chronic back and neck pain programs begin with a detailed review of the patient’s past medical history and the history of this condition. We want to know what medical tests have been performed, results of those tests, treatments that have been done, what has or has not worked, and whether there are any other factors or co-morbidities contributing to the problem. A baseline of current symptoms and physical function is then established to accurately track progress. Standardized tests such as the Neck Disability Index and the Oswestry Disability Index, and documentation of objective findings, are useful in translating symptoms into quantifiable data.
The patient’s functional goals are then determined with the question: “What activities would you like to do without being limited by your pain?” This is very useful as it allows therapists to link treatments and exercises specifically to them. For example, golfers may demonstrate better compliance with a back stretching home exercise program if they know it is going to help them swing the club better.
The practice staff has found that treatment of chronic pain involves four critical factors:
1) Collaboration across medical disciplines.
Staff members are fortunate to have excellent working relationships with many primary care and specialty providers throughout Minnesota. It is critically important for the practice’s physical therapists and the patients’ medical practitioners to cross-communicate. Sharing information helps all parties remain informed about the patient’s current status, ensures expedited treatment, and avoids redundancy.
2) Accurate diagnosis of the condition/dysfunction that is driving the patient’s symptoms.
The importance of determining what is a symptom and what is the cause or driver of the symptom cannot be understated. Pain is almost always a symptom of some other medical, neurological, or mechanical dysfunction. If a practitioner evaluating a patient with chronic pain determines only where the patient hurts and moves right into treatment of the pain, the likely result would be only short-term results.
Therapists at this practice have advanced training in osteopathic manual medicine. This helps identify dysfunction of the pelvis and spinal column, not just in pathological ailments (disc lesions, stenosis, etc) but also in the position and motion of specific bones and joints. Entry-level medical and physical therapy examination and medical imaging often can determine the ailments, the “Whats,” but fail to explain the “Whys.” Staff therapists utilize their osteopathic manual medicine training to determine why the L4 disc became injured prior to L5 and L3, or why the patient experiences pain in a specific body region.
Our therapists are also trained in myofascial release and soft-tissue mobilization techniques to identify dysfunctions in muscle, ligaments, tendons, myofascia, and dura. Often, soft tissues develop altered function in the presence of pain and joint dysfunction. Through reflexes, this can reinforce the actual mechanical dysfunction and decrease the likelihood of recovery with exercise and joint mobilization alone. Similarly, stretching a muscle that has tightened and shortened due to vertebral joint dysfunction without performing any treatment to the dysfunctional joint, or treating a dysfunctional joint without addressing soft-tissue tightness, will both commonly result in minimal long-term change.
Once a patient’s joint motion and soft-tissue extensibility have been improved, posture and movement patterns of the body as a whole are assessed. It is crucial to discover the patient’s automatic patterns of how they move their body and hold their body weight.
3) Patient education and willingness to be an active participant in their own recovery.
Active participation by the patient is the key to overcoming chronic pain. Patients who will only participate in passive treatment will unlikely ever see significant change in their symptoms. It is the therapists’ job to properly educate the patient about the diagnosis and plan of care, and provide motivation and encouragement to help the patient appreciate improvements. This comes back to establishing quantifiable baselines that therapists can go back to and demonstrate to patients that they have made improvements. Often, objective improvements such as increased range of motion, normalized joint mechanics, and decreased muscle spasm occur before subjective improvements, such as pain relief.
4) Training and competency of the therapist to establish and execute a sound physical therapy plan of care.
This goes hand in hand with “accurate diagnosis.” Once the physical therapy diagnosis has been made, therapists create a plan of care that is specific to each patient. The art of this program comes down to the therapists’ ability to balance many treatment options to accommodate to the individualized needs of the patient. This is truly where knowing what are symptoms and what are drivers is critical.
Putting It All Together
In cases of severe pain, therapists often begin treatment with pain-relieving modalities such as ultrasound, soft-tissue mobilization, gentle stretching, thermo/cryotherapy, and electrical stimulation. For those needs, Select Therapy Inc’s offices utilize the Intelect Legend XT combination electrical stimulation and ultrasound machines from Vista, Calif-based Chattanooga, a DJO Company.
The Legend XT offers an intuitive color display that enables clinicians to quickly select and modify commonly used electrical stimulation waveforms such as interferential, high-volt, and premodulated current, to best fit the patient’s needs. The unit also allows users to change the intensity of the stimulation on the fly. Therapists can program custom electrical stimulation protocols into the unit for quick future access. The Legend XT also provides active feedback to the clinicians through visual on-screen graphs that ensure good electrode contact with the skin.
Combination Legend XT units also provide therapeutic ultrasound that can be modified before and during active use. The unit pre-warms the soundheads prior to use, and will alert the therapist if there is poor soundhead contact during use. Although ultrasound is not one of our practitioners’ primary interventions, it can be effective at providing deep heat to soft tissues that in turn increases blood flow and improves soft-tissue extensibility.
Another combination unit on the market is the Winner CM EVO from Richmar, Chattanooga, Tenn, which combines ultrasound, e-stim, and laser. The Winner CM series is built to provide two- or four-channel electrical stim outputs while also offering an ultrasound user interface and e-stim user interface.
A variety of electromodalities are offered to the clinical market as tools for pain relief. Not all of those technologies are used by this facility, yet other practices may find they serve a certain niche. For example, one pain-management tool offered to the clinical market and in use at some PT clinics as a pain-relieving tool is therapeutic laser treatment, also referred to as low level laser therapy (LLLT). Manufacturers that offer these type of technologies include Watertown, SD-headquartered Pivotal Health Solutions-PHS Therapeutics, which manufactures the Apollo class IV cold lasers. Likewise, the Newark, Del-based company Lightforce Therapy Lasers also provides class IV lasers to the physical therapy market.
Thermo/cryotherapy is often not reimbursed by payors, but it is something that many of our clinicians utilize to serve as an adjunct to other interventions and create a synergistic effect. For example, using clinical-grade moist heat with traction can help the muscles relax, thus allowing the traction to have an optimal effect on the intended vertebra versus fighting against muscle spasms. Likewise, cryotherapy can be paired with interferential current electrical stimulation on acute injuries to reduce pain and inflammation. Among companies that offer hot/cold therapy products is Fremont, Ind-based Battle Creek Equipment Company, which manufactures the Theramophore line of moist heat packs, and the Ice It! ColdComfort therapy products.
High Value of Modalities
In addition to the direct therapeutic effects of modalities, they also help clinicians demonstrate to the patient that they can help reduce the patient’s pain and, most importantly, will not make the pain worse, which builds trust between the patient and therapist. Regardless of reimbursement, our practice sees high value in the utilization of modalities as a part of our larger treatment approach. For example, patients may be less hesitant to exert themselves on strengthening exercises if they know they will be using moist heat and electrical stimulation afterward. This improves overall patient satisfaction, increases active patient participation, and, in turn, improves therapeutic outcomes.
After the patient trusts that the therapist can actually help reduce pain, the therapist may have better success treating the “drivers” of the symptoms with joint mobilization, strengthening, and traction. However, if therapists find themselves limited to treating symptoms only, they should re-evaluate the patient and/or make a referral for further medical testing/treatment.
In most other cases, the practice’s therapists typically perform a blend of treatment to the patient’s symptoms as well as to the drivers of the symptoms. Typically, therapists begin with joint techniques such as muscle energy techniques (MET) and joint mobilization to restore normal joint mechanics. Soft-tissue mobilization and myofascial release are then utilized to restore balance to extensibility, tension, and resting tone of the muscles, fascia, and connective tissues of the body.
When providing soft-tissue mobilization, many of Select Therapy’s practitioners utilize Free-Up Massage Cream, PrePak Products Inc, Oceanside, Calif, to glide over the skin and better appreciate tissue texture abnormalities. Other topical analgesics commonly used are Biofreeze from The Hygienic Corp, Akron, Ohio, and Tiger Balm, from Prince of Peace Enterprises Inc, Hayward, Calif. Additional brands of topical analgesics include Sombra pain-relieving gel from Albuquerque, NM-based Sombra, Sore No More natural pain-relieving gels from Moab, Utah-headquartered Sore No More, and Flexall from Ari-Med Pharmaceuticals, Tempe, Ariz.
Therapists follow that with stretching of muscles and soft tissues that are “tightness prone” and strengthening of muscles that are “weakness prone.” And, finally, therapists may utilize modalities such as electrical stimulation, thermo/cryotherapy, and/or traction for pain relief, circulation, as well as the unloading of pinched nerves and herniated discs. For spinal traction, our clinics utilize Chattanooga TX traction units that can be easily customized from static hold, intermittent hold, and incremental hold traction. The patient is also set up with home exercises to help maintain gains made at each physical therapy session. A line of traction systems, including the CT800 Cervical Traction Device, is also available from Everyway4all, LLC, based in Chino, Calif.
A crucial element of treatment is re-examination of the patient’s dysfunction to determine the effectiveness of treatment. Based on the re-examination, the therapist should modify the plan of care accordingly.
Challenges such as fear-avoidance behaviors are also discussed. Even in the absence of symptoms, patients often can be reluctant to return to their prior level of function as a means to prevent their pain from returning. Throughout the plan of care, therapeutic exercises are used to break down certain motions (such as squatting and lifting) into simple motions. As the patient becomes stronger and more comfortable with a motion, therapists add elements to the exercise until the desired motion can be performed. The patient then knows a certain task or motion can be performed without fear or recurrence of symptoms.
Using the approaches described here, a significant level of improvement has been achieved among the majority of the practice’s patients, and helped keep the practice strong among the areas it serves. PTP
Andrew Hadrich, PT, DPT, is director of operations and a lead physical therapist at Select Therapy Inc. He received his Doctorate of Physical Therapy from The College of St. Scholastica in Duluth, Minn, and he has completed advanced postgraduate training in Osteopathic Manual Medicine at Michigan State University. Clinically, he specializes in treating chronic back and neck pain as well as orthopedic and sports injuries. For more information, contact [email protected].