Panel Discussion: What do you think we are missing from prevention and rehabilitation of low back pain and injury?
At some point in life, most individuals (65 – 85% of the population) will grapple with at least one episode of low back pain, and the recurrence of low back pain within a year of the first episode is incredibly high, ranging from 60-80% (Hoyt et al. 2012, Hides et al. 1996 ).
Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
This Panel Discussion was originally posted on my facebook page – https://www.facebook.com/brent.brookbush – 10/10/15
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Comment deleted regarding neck and teeth alignment and its potential effect on low back pain.
Brent Brookbush Hey Henry Halse,
Certainly was not expecting that to be our first comment - way to think outside the box wink emoticon
I have to admit I think that teeth alignment and vision problems (especially asymmetries) would most likely result in cervical pain and dysfunction before low back pain. However, there was study that showed a decrease in the recurrence of low back pain when a protocol for correcting forward head posture was added to physical therapy - Correcting Forward Head Posture affects Lumbosacral Radiculopathy - October 10 at 10:39am
Mark Jamantoc Brent, There's so many ways to answer this and scenarios that I can give. In terms of Functional Outcomes, I use Care Connections to capture how they are doing before and after in terms of work, sports, etc. In terms of testing and re-testing, I stick with the basic ROM and strength testing for spine, I do make sure I check on multifidi and definitely educating patients is the key. Most of my HEP include Core strengthening and definitely multifidi work. For Lower Back pain, I use the clinical prediction rules from John Childs Et Al. Funny I just googled this and it showed up. http://www.udel.edu/…/spine/Childs-ClinPredictRules.pdf
At the outset, I do explain to patients to have a 6 month follow up with me and a 1 year follow up to ensure they are doing the exercises correctly and having a "tune-up" assessment of their spine and function. After all, you have an annual check up for your car and even a 6 month prophy for your teeth. Why not your entire body? - October 10 at 12:01pm
Brandon Trujillo Outcomes obviously are important. But in this case many times people try to correct something that is not correctable. Depending on the condition that is causing it will dictate whether or not we are successful. To be successful in this there are sever…See More
The use of the T1 sagittal angle in predicting overall sagittal balance of the spine. -…
ncbi.nlm.nih.gov|By Knott PT , et al.
October 10 at 12:04pm
Brent Brookbush So if you had to pick one of those things Mark Jamantoc… where do you think most practitioners are missing? - October 10 at 12:04pm
Mark Jamantoc You mean Physical Therapists Brent? - October 10 at 12:06pm
Brent Brookbush Sure… we could start there. - October 10 at 12:08pm
Brent Brookbush Interesting Brandon Trujillo - Although you paint a picture that people are different without entirely explaining whether that difference is correlated with pain. It sounds like you may be leaning toward prevention? Is there any gross statement or suggestion you could make that you think would decrease the rate or recurrence of back pain overall?
Like · Reply · 1 · October 10 at 12:20pm · Edited
Brandon Trujillo Brent, the reference from Spine address that question. I'm about to go through security. - October 10 at 12:14pm
Brent Brookbush Just reposting for everyone else's ease here -
- Spondylolisthesis, Pelvic Incidence, and Spinopelvic Balance: A Correlation Study Labelle, Hubert MD; Roussouly, Pierre MD; Berthonnaud, Éric PhD; Transfeldt, Ensor MD; O’Brien, Michael MD; Chopin, Daniel MD; Hresko, Timothy MD; Dimnet, Joannes PhD
- Spine, 15 September 2004, Vol. 29 - Issue 18: pp 2049-2054
October 10 at 12:18pm · Edited
Brent Brookbush Well thanks for getting that in before getting patted down Brandon Trujillo - October 10 at 12:15pm
Mark Jamantoc Oh man, this is a loaded question. Most of us PT's miss training the Deep muscles. I can't even tell you how many patients walk through my office and stated their previous PT only gave strengthening and modalities and then said they're always going to be in pain for life. Also, how many of your patients walk through the door 1-2 months after their initial back pain onset because the MD placed them on NSAID therapy for 1 month and since it did not work, now they are in PT? I have a program called "Low Back Pain Revolution" where I tell patients to talk to their physicians regarding PT FIRST and that they are willing to try Physical Therapy first before furthering the medication route. Another thing that bothers me with our "traditional" PT route is that we are so in a hurry to discharge them that we sometimes fail to do a follow up appointment 6 months from now, 1 year from now. I feel that is crucial and (sorry to say) this is where Chiropractors have mastered this skill. A good 6 to 12 month follow up not only works in the patient's favor, but it allows the patients to gain accountability knowing that they get the best follow up from a clinician who cares about them. I feel this is what most PTs are missing. - October 10 at 12:18pm
Brent Brookbush I totally agree Mark Jamantoc - it's often the little things that go unchecked, whether deep muscles, a stuck facet or an asymmetry in the lower extremities. I also agree that PT should precede most forms of treatment, not because we are necessarily better, but because we don't come with a list of potential side-effects.
And last, I absolutely agree with the follow up model. Most of my patients are in and out very fast (about 3 sessions), but that does not mean they are quite done. They are generally discharged with mild symptoms that should resolve with a concerted effort to stick to their home exercise program (in essence, I discharge when I don't think I am necessary for further recovery). There will likely be flair-ups (as there are with many conditions) and progression is always necessary from time to time. So I talk to all of my clients about a 1 month follow up, and then a 2 month follow-up after that, and then maybe 6 moths after that (depending on the condition), etc…. More PT's should likely be trying to spread sessions out a bit instead of the 6 - 12, discharge and forget model. - October 10 at 12:27pm
Mark Jamantoc Brent, my service includes email access to me and it is convenient for follow ups. Although not very many email me after a while, it is a great follow up tool as well, if you have a secretary or someone to do the email correspondence follow up for you - it simply works - and patients feel great with that. Thank you for bringing up the facet and asymmetry. That is part of the process as well. I do include a recent skill set in my tool box (as you may have seen in a few posts I have made) about the Fascial Distortion Model. It has decreased my utilization rates from 6 visits for a typical condition to 2-3 visits. Still examining this technique and doing some in house study on my own patient population regarding outcomes for this new technique which apparently just opened for approval for PTs this year. - October 10 at 12:37pm
Brandon Trujillo Happy to report that the TSA at LAX just gave me a clean bill of health. Sad to report that I just received a more thorough physical examination than most health care professionals offer. - October 10 at 1:03pm
Brent Brookbush LOL… - October 10 at 1:04pm
Steve Middleton Most clinicians misunderstand the time of the sacroiliac joints (SIJ) in low back pain. Throughout history, bonesetters then osteopaths then chiropractors would treat the SIJ as the primary cause of low back pain and sciatica; lest we forget that the sciatic nerve originates from the nerve roots of L4 and L5 but also S1 and S2. A single study in 1934 by Mixter and Barr identified the intervertebral discs as being pathogenic or able to produce pain. This changed the way low back pain was both assessed and treated which coincides with the increase in the number of people on disability due to chronic lo back pain. Keep in mind that imaging is taking a static picture to figure out why someone has pain with movement.
Robin McKenzie also focused on the disc as the primary cause of low back pain in his Mechanical Diagnosis and Treatment (MDT). However, this fails to consider pain from the facets or Myofascial pain syndromes. There is also debate as to whether the fluid dynamics of central centralization of the nucleus proposed by McKenzie is actually what occurs.
In regards to lumbar surgeries, Stanley Paris has proposed that the surgery works not because of the need for internal stabilization but rather the process of the surgery itself: in order to get to the spine, the surgeons cut through various layers of tissue which leads to denervation of the thoracolumbar fascia, the paraspinal musculature and the facets joints. In those with so called failed surgeries, perhaps it is because their symptoms are related to the SIJ, not the lumbar spine.
Ultimately, most of this is now due to out sedentary population. Due to prolonged sitting, we begin to lose hip mobility. In order to try to move normally, often the SIJ becomes hypermobile to compensate for the hypomobile hip joint; when the SIJ can no longer compensate, the lumbar spine becomes hypermobile to try to further compensate.
In regards to muscle weakness, individuals are often too tight to let the movement occur. The thoracolumbar fascia is essentially the tendon of the transverse abdominis (TrA). If there are sufficient fascial restrictions, the TrA is too tight and therefore cannot contract more which leads to core instability. However, contrary to most people's train of thought, Myofascial techniques applied to the thoracolumbar fascia can decrease the tone leading to the restoration of the length-tension ratio of the TrA which will allow it to contract to provide core stabilization as well as stable attachment points for the gluteus Maximus and latissimus dorsi to contract against.
For those that do address the SIJ, the problem exists that most CE courses teach 1 translation and 2 rotations. Reality shows 4 translations and 8 rotations. This lack of appropriate diagnostic ability leads to SI dysfunction being greatly under diagnosed at 15-18% of the population. - October 10 at 2:25pm
Brent Brookbush Great Post Steve Middleton, I do assess and treat SIJD regularly and need to update my article on the topic, but I actually find that the number of translations and rotations to have little consequence on management, carry-over and recovery. I do find that post SIJ mobilization techniques, addressing soft tissue relative to SIJ to be a bigger issue. - October 11 at 8:39am
Sue Hitzmann MELT. I need you to see our research and what we can scientifically measure to help people reduce low back pain. - October 10 at 3:52pm
Brent Brookbush Hey Sue Hitzmann, let me know when the study is published. Maybe we could feature it in one of our research reviews. Like these - https://brentbrookbush.com/online-courses/online-courses/category/research-cornerrelease-techniques/ - October 10 at 6:21pm
Kennet Waale Brent,
Coming from a coaching snd trainer's point of view working mainly in conjunction with therapists in post-rehab and injury prevention, we commonly see educational faults and misinformation regarding pain science and movement inefficiency to two factors we often look at with great success.
Relaxation through mobility, sleep and hydration, technique in strength exercises, tissue strength and endurance all seem to be what many therapists here in Australia avoid, but yet seem to help all of our clients. - October 10 at 9:49pm
Kevin C Moore
The failure to treat the dominant and non-dominant sides as distinct within the same individual and predictable in their kinematic specialisation across individuals. - October 11 at 6:23am
Brent Brookbush Kevin C Moore are you implying that there are things that should be done to the dominant and non-dominant sides for low back pain, regardless of which side is exhibiting actual symptoms? - October 11 at 8:28am · Edited
Kevin C Moore
I am, Brent. The location of the pain symptoms are a data point, telling us something about the way impact forces are traveling though the system. By applying that and other relevant data (injury history, chronic conditions, etc.) to a model of the predictable behaviour of the dominant and non-dominate sides, it's easier to isolate the dysfunctional pattern. After that, it's just a matter of introducing and coaching a new, more robust pattern. - October 11 at 8:45am
Kevin C Moore
The new pattern might be achieved by addressing the injured area, or side, but then it might not: depends on the patient. But what I can tell you is that having that predictive model of laterality accelerates the process significantly. - October 11 at 8:49am
Brent Brookbush I agree that having a predictive model enhances lateral thinking - https://brentbrookbush.com/online-courses/online-courses/category/postural-dysfunction-movement-impairment
I just didn't understand how dominant versus non-dominant sides plays a role in exercise and technique selection. Can you explain? - October 11 at 8:55am
Kevin C Moore
Alright, let's divide the behaviour of each leg into two basic tasks during gait: from initial contact to the beginning of single support let's call that "loading;" from the beginning of single support to push off, let's call that "launching." As we walk (or run) the two legs trade off between being "loader" and "launcher." Each of these tasks is associated with a specific set of local behaviours in the joints: the "loader" leg is in the process of supinating at the forefoot, everting at the subtalar joint, flexing at the knee, etc. Well, what I have found to be overwhelmingly—for all intents and purposes, universally—true, is that the dominant leg more readily adopts the internal joint relationships associated with being a "launcher:" plantar flexion, knee extension, internal rotation at the hip, etc. Why? I'm not sure (I have my own personal hypotheses, but that's a different conversation). All I can tell you is that it happens. So, if someone comes to me and says, "I have low back pain," first, I'll find out which is their dominant side. Then, the side of the pain. Next, I'll cross-reference my model of the various local joint behaviours associated with loading and launching with the observable specialisations in the dominant and non-dominant side. I can tell you that by far the most common pattern I encounter is the following: failure of the dominant leg to swiftly adopt a "loading" geometry leads to inhibition of the dominant side glute. The resulting compensation overburdens either A) the ipsilateral QL or B) the contralateral Lat. In either case, every time the dominant leg is applied to the loading behaviour, forces that should be loaded and unloaded via the glute instead "leak" into vulnerable lumbopelvic tissue, most commonly the intervertebral disks and/or the labrum. SO . . . . - October 11 at 9:17am
Kevin C Moore
. . . I would selective apply exercises that facilitate loading behaviours in the dominant leg and specifically inhibit launchers. I have a whole system of novel manipulations and exercises that revolve around this method, and they have been very successful. - October 11 at 9:19am
Kevin C Moore
Additionally, I could potentially achieve the same effect by facilitating launching behaviours in the non-dominant leg, because the end result would still be the relative rotation of the pelvis toward the dominant side, which would place the inhibited glute into the desired geometry. If the patient was overly muscular in that dominant leg, for example, and it was too difficult to inhibit tissues traumatized by excessive hypertrophy, I might use the non-dominant leg approach. - October 11 at 9:22am
Brent Brookbush Interesting, do you plan on publishing any of this model? - October 11 at 9:23am
Kevin C Moore
I do. In fact, as a method of working to improve athletic performance, I've already started. I published a paper recently in the Procedia Engineering journal about the biomechanics of the the lunge attack in sabre fencing. My coauthors and I have decided to pursue a new paper, still focused on fencing, but that attempts to assess fencer's vulnerability to knee injury by looking at their use of the dominant foot as an impact surface. - October 11 at 9:27am
Cassandra Forsythe I dream of an answer to low back pain. My is from a legitimate cause though (spondylolithesis, grade 2, L5, with herniation at L4, hypermobility of my whole body, and thoracic scoliosis…fun times) and won't likely ever go away, so I just do my best to work around/with the pain, which is (not surprisingly) worst in the morning. I try to avoid certain exercises and emphasize others, stretch in the smartest way possible, only in areas I should mobilize, constantly focus on correct breathing and posture, etc. I've just bought a new mattress too, but it still isn't a lot better.
What are we missing? Patience and understanding; really spending quality time with the patient to educate them and understand why they continue to have pain.
Brent Brookbush, if you have any new answers, I'll be down for a visit - October 11 at 7:51am
Brent Brookbush You're issue is a tough one. There are some more exoctic techniques that may be helpful in your situation, for example anterior to posterior lumbar mobilizations, multifidus activation, quadratus lumborum release, but in the end, you will still have a spondy… For you, careful and sophisticated exercise selection is key. You are already in a habit of working our hard and regularly, your best bet is making each of the workouts count toward optimal motion and stabilization of your lumbar spine. I think we have done a pretty good job when you have come down, and you are always welcome at my office - October 11 at 8:33am
Adam Wolf The understanding that in the majority of instances it's not the low backs fault the low back hurts.
Victims and criminals. - October 11 at 8:00am
Brent Brookbush Nice analogy. I am a big advocate for addressing asymmetry, whether it be ankle, knee, hip, spine, or even shoulder girdle when it comes to low back pain. It amazes me how people with symmetrical imbalances often last years without symptoms, but as soon as they are asymmetrical right to left it is a downward spiral. Thoughts Adam Wolf? - October 11 at 8:36am
Daniel Newkirk
No matter how much rehab we do on our clients,If they are not doing their homework. Any rehab work is going to be harder for the client to trust the PT. I think back to my ACL tare my years ago before I was MT. My PT told me I have to do my exercise to help my knee return to form. I said sure I will do them walking away inn pain. Lets just say the next three week was hell for me not the PT. she smile at me as I struggle saying did you do your exercise. Sweat dropping down my face pain shooting to my brain, Noooo! Lesson learned do what I was told better out come the week following. My Teacher in MT school always said, "You can lead you client to the table, but you can't make them do their homework.."When you have your clients true heart mind and soul they will change their old habits to line up with their treatment with you. Changing their posture, working, sleeping, and standing, sitting habits even the way they pick up the baby off the floor. All of these changes are apart of the clients homework to help with the Rehab work of your PT and MT. I express this to my client every visit! - October 11 at 12:25pm
Brent Brookbush I love it - "you can lead a patient to the table, but you can't force them to do their homework." - October 11 at 3:30pm
Mark Jamantoc If they pay cash to see me for PT, they're pretty good at doing their homework. - October 11 at 3:47pm
Brent Brookbush I have had the same experience for the most part… it's a pretty easy sell… "You can come back and see me session after session, or learn how to manage the problem on your own… I love seeing you, but there are other ways you could spend your money" - October 11 at 7:10pm
Brandon Trujillo I set up fitness solutions inside the clinic. Personal Training before and after regular treatment times for patients who fall into this category. - October 11 at 7:29pm
Mary Williams Nearly everyone can fully recover from chronic back pain by addressing its causes and reversing the cycle of pain.
Once the pain cycle is reversed, (re)learn how to balance posture, regularly move, and address stressors and the physiological response to stress. Proper nutrition, ergonomics, and self-care also help. - October 12 at 11:23am
Brent Brookbush Which should would you say is the largest weakness in our current paradigm of core (from the perspective of PT's, ATC's, CPT's, LMT's and DC's)? - October 12 at 11:47am
Mary Williams Treatment is very effective, but without addressing causes, it keeps coming back. IMO, stress, movement, and balanced posture are all equally effective at contributing to/recovering from back pain. Education in these areas would be a great compliment to treatment. - October 12 at 11:51am
Brent Brookbush Nice Mary Williams. I like the focus on education. It would seem as the "Pain Science (MOM and BPS focus)" practitioners try to find practical applications for the new research regarding pain, that their best weapon may be education. This may lead to more of a focus on education across all sub-professions of human movement practice. - October 12 at 12:18pm
Michael Adam Clark Sorry I'm late answering. I don't think enough attention has been given to testing and improving torsional control. Dr. McGill has developed tests and exercises (improving torsional control) to help clients with LBP and help prevent LBP. Also, since the gluteus medius plays a major role on torsional control of frontal plane movement, this muscle seems to be often overlooked. - October 13 at 11:26am · Edited
Brent Brookbush Part of the problem may be individuals creating there own vocabulary, although I love Dr. McGill's he tests everything against his own model, which is a bit suspect… and he bashes the idea of intrinsic stabilization.
Now back to "Torsional Control" - how is anybody supposed to work on it, if they don't even know what it means? - October 13 at 12:13pm
Michael Adam Clark I don't think he made up "torsion" or "control". - October 13 at 1:25pm
Brent Brookbush I don't think he made up either term, but relative to his work what does it mean? Is this just rotation? is it rotation of the spine and hip, or just the spine? For example is a quadruped torsion control as there is a rotatory torque during the exercise, or is it only motion with explicit torsion control like a static chop, does control imply static, dynamic or both? What set of exercise does he suggest, for which conditions?
The question is one of connotation versus denotation. Denotation is a rotatory stress, but the connotation is what he is implying in regard to how it affects practice. - October 13 at 2:02pm
Michael Adam Clark In my understanding, torsion control refers to being able accelerate, decelerate, and stabilize counteracting torques (rotation) that is being placed on the joints. - October 13 at 2:28pm
Ryan Chow In regards to nonspecific chronic LBP…just wait lol - October 13 at 2:55pm · Edited
Brent Brookbush Seems to be in direct contradiction of the research I cited in the post, doesn't it Ryan Chow? wink emoticon - October 13 at 9:14pm · Edited
Ryan Chow I didn't get to read the study but the key word is nonspecific low back pain. If there's a spondy or a herniated disc, it obviously won't get better by itself but I don't think that's the case with many chronic cases. - October 13 at 9:33pm
Ryan Chow And to be clear, my statement was not meant to be trolling or combative, it's to point out that many people have chronic low back pain and most of the time we don't know why it happens and what makes it better. - October 13 at 9:35pm
Brent Brookbush I would disagree… chronic and non-specific are generally the same case. Spondy and herniated disk type disorders are specific low back pain. You have to be careful with CPR's, you will find that many of them use treatment protocols that could hardly be called up-to-date, specific, or optimal care. I have made a living treating many chronic conditions… I would say with a thorough assessment I can usually find correlating causes and effective treatments… and I know many of my colleagues feel the same way. - October 13 at 9:37pm
Ryan Chow http://www.apta.org/PTinMotion/News/2015/10/14/LBPTimeVsPT/
Activity, Education, and Time May Play Biggest Role in Recovery From…
Steve Middleton I agree with you, Brent, that most of the issues lie in muscular imbalances but when I nominate rotations are left long enough, the ligaments will remodel (shorten or lengthen) creating the needs for manipulation, either thrust or via muscle energy techniques, to correct the malposition.
Brent Brookbush I agree 100% Steve Middleton, I was not referring to the fact that SIJ issues were not pivotal and that fascial and articular techniques were not necessary to wholly treat this compensation pattern; but… I have found that the deeper I get into the osteopathic model of SIJ treatment the less I get back in return. On the other hand, adding treatment for muscle imbalance based on innominate rotation after mobilizing the stiff side SIJ has been very rewarding. BI HMS Rule #1 - All systems are involved in all human movement (and dysfunction): Articular, Muscular, Fascial and Neural
Steve Middleton Neuromyofascia. Some researchers believe that the joint capsule/synovium is just a thickening in the fascia similar to a retinaculum.
Brent Brookbush I'd buy that, it is quite amazing to feel muscles let go (release) as a mobilization or manipulation renders a stiff joint mobile again. An inhibitory pathway via myofascia that includes the joint capsule would be a an elegant design for the human body and possibly add to the explanation of this phenomenon.