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Physical Therapy

Physical therapy uses different techniques, such as ultrasound, electrical stimulation, cryotherapy, massage, exercise, and heat in order to relieve muscle spasms, increase flexibility, strengthen muscles, relieve pain, and accelerate the healing process. A study in The New England Journal of Medicine found that the effectiveness of physical therapy for low back pain was about the same as that of chiropractic treatment and better than no treatment at all.
Physical therapists must graduate from an accredited physical therapy program, many of which offer master’s and doctoral degrees along with bachelor’s degrees. Most schools require two to four years of pre-physical therapy coursework before admittance. Like other physical treatment programs, physical therapists spend time in both the classroom and medical settings before graduation. After graduation, they must take exams to become licensed, and some states require continuing education to maintain that license.
After it is determined by a doctor or back specialist that you are a candidate for physical therapy—some time between two to six weeks after the onset of low back pain or sooner if the pain is severe or recurs frequently—you will meet with the therapist to determine the best plan of treatment for you. You will be asked how your back pain developed, how long you’ve had it, whether or not it’s recurring, what actions make the pain better or worse, and any relevant medical history you have. The therapist will also give you a physical exam of your spine movement, muscular flexibility, sitting and standing posture, muscle strength, reflexes, respiration, motor function, and repetitive movements. From there, he or she will determine which treatments will be best for you. There is some trial and error involved, so if one treatment doesn’t work to alleviate pain, the physical therapist may try something different.
There are basically two types of physical therapy, passive and active. Passive therapy is done to you and includes heat, cryotherapy, electrical stimulation, ultrasound, massage, and lontophoresis. In heat, or thermal, therapy, the therapist applies heating pads, heat wraps, or warm gel packs to the affected area. This works to increase the flow of oxygen to the muscle, allowing it to heal faster and relieve pain by softening muscles. In cryotherapy, cold is applied rather than heat, and is considered more effective than heat in reducing inflammation. Electrical stimulation sends mild electrical impulses to the nerves and spinal cord, which releases endorphins and blocks pain signals from the brain. Ultrasound heats the deep tissue and allows it to relax and stretch more easily. Massage breaks up scar tissue and encourages the relaxation of muscle spasms. During lontophoresis treatment, a painkiller and steroid are rubbed into the skin and a low level electrical current is applied to speed up the absorption of the drugs. It works similarly to transdermal patches used to quit smoking.
You participate in active therapy, and it includes stretching, strength building exercises, and aerobic exercise. A good physical therapist will combine passive and active treatments, as exercise is essential to treating back pain. The therapist will determine which exercises are best for your particular condition and supervise you in those exercises to ensure you are doing them correctly. You will likely be given stretches to be done daily, fifteen to twenty minutes of strengthening exercises, and thirty to forty minutes of low-impact aerobic exercise, such as swimming or walking, to be done three times a week.
You may feel some soreness or discomfort after active physical therapy, but it should go away in about twelve to eighteen hours. If it doesn’t, let your therapist know. You may need to change exercises or how you are exercising. Results vary depending upon the type of treatment done and the severity of symptoms, but a physical therapist should know in about two weeks if the treatment is working or not.

A Physical Approach

Most chronic back pain is the result of activities that have an adverse effect, such as lifting heavy objects improperly or simply sitting in a chair for long periods with bad posture. Changing our habits, therefore, can have a significant impact. Below are some of the most commonly advised physical measures to take. As always, see a physician or other qualified professional for assistance in deciding what is best for you.

Weight loss: approximately 67 percent of Americans are overweight. These extra pounds put pressure on the back and strain both back and abdominal muscles, which can weaken these muscles and compound the problem.

Improve Posture: Bad posture means your body is out of balance. When it comes to your back this means that only a small number of muscles and joints are doing most of the work. Proper posture will spread out the task and relieve the intense pressure on small areas of the back.

Exercise: A good exercise program, designed by a professional, will strengthen muscles in your back, keep them limber, and increase endurance. Though our instincts may tell us to rest until the pain passes, the proper exercise can be an effective means of pain relief or reduction.

Movement: Simple measures, like using your leg strength, instead of back muscles, to lift heavy objects can make a big difference. Whether at work, home, or engaged in leisure activities, be aware of how you can alter you movements to avoid unnecessary stress on your back.

Pain Medications

A wide range of drugs are available for the treatment of chronic pain. Most commonly used are aspirin, acetaminophen, and the anti-inflammatory drugs like ibuprofen. Then there are the more powerful narcotic analgesics, such as morphine and codeine. People respond to these differently and there is no one medication that is right for everybody. Only a physician who knows your medical history and what other medications you might be taking is truly qualified to make the best recommendation for you. And, after beginning to take one, it is important to keep your physician updated on their effectiveness, not only if they are working or not, but also about any side effects you might experience.
Do not fall into the trap of thinking that a lack of effectiveness or the experience of side effects are things that must be tolerated without question. Many different drugs are available and improvements in pharmacology bring us more and better alternatives as time goes one. Regular contact with a physician is necessary to make sure the course of medication one is on is indeed the best available

METHODS OF BACK PAIN DIAGNOSIS

In order to diagnose back pain for relief treatments, generally health care professional begin by ordering a medical history and physical examination. A look at each of these in depth can shed some light into what to look for and how to find relief from pain. Then we’ll look at specific diagnostic tests. And then where to go for the diagnosis and testing follows.
No matter whether the patient has acute back pain, which is what most have and recover from with around a 4-week period, or chronic, recurring pain episodes, a medical history helps patient an doctor become familiar with one another in confidence to begin or continue a treatment program together. The medical history delves into these areas of the person seeking pain relief: family medical history and personal and work history with regards to back pain episodes and related symptoms and issues, psychological and psychosocial factors, referral source(s) for evaluation and treatment, education on the subject and treatment options, assessment throughout their working together on pain relief treatment and treatment outcomes. For example, if physical therapy needs to be added to the regimen or enhanced, it would be discussed in the medical history and updated as needed.
The medical history incorporates past and present factors of fatigue, fever and weight loss. And it notes any use of drugs or herbs, minerals and supplements. A history of past and present infections, cancer or other conditions is also noted.
The history also includes details about the back pain, focusing on the many facets of the pain: information about any initial injury or trauma, if available, onset, intensity, duration, location, associated symptoms, etc.
The physical examination includes evaluating the person generally inn the “hospital gown” with the body and especially the back in a variety of postures and movement ranges to determine pain symptoms, tenderness and range of motion. So the patient may need to sit, stand, touch toes, move arms, etc. and share any pain symptoms or other information notated with each change along the way.
Neurological testing can also be a part of the routine. A neurologic screening may consist of tests for reflexes, strength of muscles, cramping and a detailed look at sensory issues via various range of motion and movement exercises. Included in this can be an assessment of the legs, upper leg, hip and groin area and pulses for neurological and vascular conditions.
Results may point to a secondary problem like kidney stones or a slight bone fracture, for instance, in which cases, further assessment and treatment options would be considered and discussed in both the medical history and physical examination.
Noteworthy is that patients seeking relief after an extended period can tend to exaggerate or magnify their symptoms out of a variety of reasons; possibly psychological factors associated with fear of the unknown, change, coping alternatives, insurance coverage and treatment costs, previous visits with health care providers, etc. So education and patience is advised to that all bases can be covered, i.e. so that effective pain relief remedies can be determined.

MEDICATIONS

Among the common pain relief medications prescribed by physicians are muscle relaxants, antidepressants, NSAIDs (nonsteroidal inflammatory drugs) and COX –2 inhibitors. Some popular muscle relaxants are cyclobenzaprine (Flexeril), carisoprodol (Soma), methocarbamol (Robaxin) and gabapentin, in seizure medications. The NSAIDs help with stiffness and in reducing inflammation. Opiates like Duragesic or OxyContin may be prescribed but are not a popular choice with a low risk of possible addiction.
With all medications, other treatment strategies should be combined into the relief program. So physical therapy, movement and posture techniques and other treatment options should be carefully assessed to see which combination best helps relief over time.
Doctors may also prescribe injections, such as Sacroiliac joint blocks, Thoracic Facet Joint injections, Epidural steroid injections, selective nerve root block, and Facet rhizotomy.
Muscle relaxants act on the brain, not on the muscle. They help relieve pain so that patients are able to exercise and have other physical treatments that would otherwise be too painful. Muscle relaxants are sedatives, so doctors may prescribe them to be taken at night to avoid daytime drowsiness. They should not be taken when driving or operating heavy machinery. Muscle relaxants have been shown to be effective alone or in conjunction with anti-inflammatory medications within a week of the onset of severe muscle spasm in the lower back. Side effects include drowsiness, dizziness, addiction after one week of use, dry mouth and urinary retention. Some common muscle relaxants are carisoprodol (Soma), cyclobenzaprine (Flexeril), diazepam (Valium), metaxalone (Skelaxin), methocarbamol (Robaxin).
Low doses of tricyclic antidepressants have been used to relieve chronic back pain. They work by increasing the level of certain chemicals in the brain that change the way the brain perceives pain. They are not used for sudden and acute pain, and usually take two to three weeks to go into effect. Side effects include constipation, dry mouth, blurred vision, drowsiness, fatigue, low blood pressure, weight gain, increased appetite, sweating, and urinary retention. Since side effects vary from medication to medication, it is worth trying another antidepressant if one does not work well. Some common antidepressants used to treat back pain are amitriptyline (Amitril, Elavil, Endep), doxepin hydrochloride (Sinequan), imipramine hydrochloride (Janimine, Tofranil), nortriptyline (Pamelor), and desipramine (Norpramin).
NSAIDS and COX-2 inhibitors are effective in relieving pain and reducing inflammation. They are generally the first line of treatment in acute low back pain. NSAIDS are usually taken for one to three weeks but can be taken for four weeks or longer. People under the age of twenty should not take NSAIDS because they can cause Reye’s syndrome, a central nervous system disorder. Other people who should not take NSAIDS include those taking blood thinners, corticosteroids, lithium, and oral antidiabetic medication. Before taking NSAIDS you should let your doctor know if you are pregnant, trying to get pregnant, breastfeeding, or have a peptic ulcer, history of gastrointestinal bleeding, nasal polyps, kidney or liver disease, allergic reactions to aspirin or related drugs, anemia, or a blood-clotting defect. Short-term side effects can include stomach irritation, which can be minimized by taking them with food and a full glass of water. Taking NSAIDS long term can cause ulcers. In rare cases, naproxen, ibuprofin and rofecoxib have caused meningitis. A common nonprescription NSAID is aspirin (Anacin, Bayer, Bufferin). A common prescription NSAID is naproxin (Naprosyn). Some common COX-2 inhibitors are celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra).
COX-2 inhibitors are less likely to cause stomach problems, but they may increase the risk of heart attack. If you have a history of heart trouble, talk to your doctor to see if COX-2 inhibitors are best to treat your back pain.

Massage Therapy

Massage therapy breaks down scar tissue and releases muscles from spasms. It is becoming increasingly more recognized as a form of medical treatment; a study by the American Massage Therapy Association found that 54% of healthcare providers encourage massage therapy, along with other types of therapy for back pain. Studies have shown that massage therapy is more effective than both chiropractic and acupuncture for relieving pain due to muscle spasms. The benefits of massage therapy include improved circulation, which helps alleviate muscle soreness; muscle relaxation, which helps muscles move without pain; and increased endorphins, the body’s natural pain relievers. If muscle spasms do not relax with massage therapy, that means inflammation is likely present and cannot be treated with massage. So if you know your back pain is due to inflammation, it won’t help to seek out massage therapy.
You should be aware that the kind of massage you receive in a spa is not the same kind of massage used to treat back pain. Swedish massage is the most common type of massage found in spas and similar places that offer massages, and while it feels good, it is too superficial to reach deep tissue and muscles and have any lasting affect on back pain.
The kind of massage used to treat back pain is called Neuromuscular therapy (NMT), or trigger point myotherapy. This type of massage works to relieve pain by balancing the musculoskeletal and nervous systems. NMT incorporates special massage therapy techniques, myofacial release, and stretching to relive both acute and chronic patterns of pain.
There are many massage training schools throughout the United State. Along with massage, neuromuscular therapists study neurological laws governing pain, the roles of soft tissue in pain, and palpation, as well as anatomy, physiology, and the function of the spine. In order to practice, massage therapists must be licensed and you should make sure that when looking for a massage therapist, you choose one that has had training in neuromuscular therapy. To find a massage therapist, get a referral from your doctor or contact the American Massage Therapist Association.
A neuromuscular therapist will ask you for all of the information that other therapists do and examine your spine to determine where exactly the pain is and what’s causing it. She will determine where nerves are compressed and where they are trapped within soft tissue. The therapist will work to relieve your back pain with her hands, fingers, elbows, and pressure bars, which are used to reach deeper into spinal muscles and tendons. She will use some kind of lubrication and start first on superficial tissue before moving deeper. This should not hurt, but you will feel pressure, and you may be sore afterwards due to the muscles releasing lactic acid. The therapist will also palpate trigger points, elevated neurological areas deep within the muscles. This may hurt initially, but the pain should go away quickly as the therapist continues to work. Back pain should respond to massage within four treatments over six weeks. If not, massage is clearly not the best treatment.

Injections

Spinal injections have been used to as an alternative to surgery in treating back pain since the early 1900s. Studies have shown injections to be effective in up to 50% of patients. They are typically given after medication and physical treatments have been utilized, but before surgery. Injections tend to be more effective than oral pain medication because they deliver medicine right to the source of the pain.
Sacroiliac (SI) joint blocks are injections used to treat low back pain. The sacroiliac joints are located next to the spine and connect the sacrum to the pelvis. Painful joints cause pain in the lower back, buttocks, abdomen, groin, and legs. SI joint blocks work in three ways: 1) they are used to determine if the SI joint is the source of back pain (if the injection makes the pain better, that’s where the pain is coming from), 2) the numbing medication used in the block gives temporary relief so the patient can have chiropractic or other physical treatments immediately after the block is administered, and 3) a time-release steroid gives extended pain relief by reducing inflammation.
During an SI block, the patient lies on his stomach and live x-ray, known as fluoroscopic guidance, is used to allow the doctor to see the joints. The skin is sterilized and numbed. The doctor then inserts a very small needle into the joint and injects it with lidocaine (a numbing agent) and a steroid (an anti-inflammatory). After treatment the legs sometimes feel numb or weak for a few hours. Side effects are rare and include allergic reaction, infection, excessive bleeding, nerve damage, and chemical meningitis.
Thoracic Facet joints are small joints about the size of a thumbnail and are located in pairs along the back of the spine. If they become irritated, middle back pain occurs. Thoracic facet joint injections have the same purpose as SI joint injections, are performed in exactly the same manner, and have the same side effects. The only difference is they treat middle back pain instead of lower back pain.
Epidural steroidal injections are similar to SI and thoracic facet join injections, except the cortosteroid is injected into the spinal canal surrounding the spinal cord. They are used to treat chronic and not acute low back pain. This procedure has the same side effects of other injections. Relief generally lasts anywhere from one week to one year.
Selective nerve root blocks (SNRB) are used primarily as a diagnostic tool and secondarily as treatment for pain. Back pain can occur when nerve roots become compressed and inflamed. While MRIs can be used to show which nerves are causing the pain, they don’t always work successfully. In cases when this happens, an SNRB injection can be performed in order to isolate the source of the pain. SNRBs are also used to treat disc that rupture outside of the spinal canal, or far lateral herniated discs. The procedure is the same for other types of injections. As with other injections, SNRBs should not be performed more than three times per year. SNRBs are considered more difficult to perform than other types of injections and should be done only by a physician experienced in them.
Facet rhizotomy may be recommended if three facet blocks have been performed but more pain relief is needed. Facet rhizotomy injections disable the sensory nerves that lead to the facet joint, thereby providing pain relief. The procedure for facet rhizotomy injections is different from that of other injections. A needle with a probe is inserted just outside the joint, is heated with radio waves, and applied to the sensory nerve. This disables the nerve and keeps it from sending pain signals to the brain.