Q & A: Physical Therapy and Back Pain

Is your truck giving you a bad back? Or does it come from being hunched over a computer all day? And how do you find the best physical therapist for you? Anthony Delitto, chairman of the University of Pittsburgh's Department of Physical Therapy, fields your questions on physical therapy and back pain:

Experts Answer Your Questions

Q: I at times have the pleasure of plowing snow with a standard transmission three-quarter-ton Ford. The only drawback is the clutch is stiff, and at the end of the day I suffer from muscular lower-back and shoulder pain. The pain can get bad enough to remove any desire for activity for a few days. Am I potentially doing permanent harm? — Mike Frey, Bigfork, Mont.

It seems as though the pain you are experiencing does subside after a few days, so it's unlikely that you are doing any permanent harm to your back. However, if the pain is severe enough to limit your activities, I think it's smart to try to prevent this.

In situations where patients can clearly relate their back trouble to a specific activity, there are two general approaches. One is to try to make the activity easier, and the other is to try to make your body more able to withstand the rigor of the task — in this case, plowing.

Seeing whether a mechanic can make the clutch less stiff might be worthwhile. In addition, make sure your seat is in the optimal position. For example, be sure that you are not reaching with your foot each time you depress the clutch. It may also help to use a lumbar roll to support your lower back.

If plowing represents a considerable change in activity level from what you normally do, then it's a good idea for you to add more aerobic activity and general fitness training into your routine so that your body is better able to withstand the physical demand of plowing snow.

Q: I heard on your program about the importance of strengthening core stomach muscles. Can you share how to do them correctly, or refer me to a Web site that does? — Dan Barolo, Alexandria, Va.

There are a number of sites that offer instruction on core-strengthening activities. But proper instruction is critical. Without it, people can easily wind up in a similar situation as the person in the NPR feature, who was doing exercises as prescribed but doing them incorrectly.

Keep in mind that the goal of core strengthening is to target deep muscles. They're hard to find, and they're hard to visualize. If you ask people to exercise their bicep, they can bend their elbow and see the muscle work. It's hard to make that connection for the trunk. Too often we see a situation where people are told to do sit-ups or abdominal exercises and when they do those exercises, they can be targeting the wrong muscles, muscles that don't at all stabilize the spine.

Q: Are there any exercises or alternative treatments to cortisone shots and nerve blocks that will actually help heal herniated discs and not just "mask" the pain? — Alan Klay, Provo, Utah

Physical therapy won't heal a herniated disc, but it can get rid of painful symptoms. Studies demonstrate that if an exercise or posture is successful in easing symptoms, the likelihood of getting better is greater.

But it's critical to find out whether a herniated disc is actually related to the symptoms. It's a very common situation for us, for someone to come in and say that they have been diagnosed with a herniated disc. And in many cases, that disc is not relevant to the pain they're feeling.

Herniated discs most commonly present with sciatica, which is pain down the leg. The pain can also be accompanied by pins-and-needles sensations or numbness. In more severe cases, there can be muscle weakness. We try to teach the patient simple ways to relieve the symptoms. For example, in many people the pain is brought on and exacerbated by sitting or bending forward. We advise people to not sit for prolonged periods of time and to sit with a lumbar roll. We teach patients postures such as bending backwards or other stretches that extend the spine.

These techniques have to be followed up with exercises that are designed to improve overall aerobic fitness and general strengthening, including core-stabilization exercises.

Q: I would like to know if physical therapy can help with sciatic pain and what treatment is done by the therapist? — Evelyne Laurin, Sarasota, Fla.

As I said in the previous question, we need to be sure that we are talking about true sciatica. There are very discrete signs and symptoms from sciatica, and the first step is to figure out whether it is sciatica. Sometimes the pain is not from a compressive nerve root, but is "referred" pain.

Referred pain is what amputees feel; they feel they have pain in their toes, but they don't have toes anymore. For back pain, referred pain usually happens when pain is in the back or trunk but is so severe that people think they're feeling it in multiple places. In these cases, we attempt to look for treatments that address other problems in the back.

Q: I am an overweight, 44-year-old woman who has recently been diagnosed with a herniated disc and stenosis. I know I need to lose weight, but physical activity is painful. What can I do to exercise but not aggravate my condition? — Pam Schrag, Moundrige, Kan.

Lumbar spinal stenosis is a narrowing of the spinal canal and neural foramen (the passageway for nerves as they leave the spine) that can cause pressure on nerve roots and result in leg pain and other neurological symptoms. Typically, people with symptomatic lumbar spinal stenosis have difficulty walking for extended periods. Walking can bring on a cramping kind of pain in the legs; it can hurt enough to make the person stop and sit down. Typically, the pain rapidly subsides once the person sits.

If this describes your symptoms, a physical therapist will commonly prescribe an exercise routine that flexes the lower back and opens up the pathways the nerves travel through. This commonly relieves the lower extremity symptoms. Lying on your back and pulling your knees to your chest is an example of this type of exercise.

Another option to consider is a water-based exercise program. The buoyancy of the water commonly allows people with lumbar spinal stenosis to tolerate exercises without bringing on symptoms. In your particular case, it is an excellent way to exercise and not make your back symptoms worse.

Q: One of the conditions that no one seems to have asked about yet is repetitive strain injury (RSI). In the age of the knowledge worker, more and more of us spend large amounts of time at a computer. Any suggestions for upper-back pain sufferers? — Evan Bartlett, Houston, Texas

When your work situation appears to have a detrimental effect on your back, one of the first things to look at is the work station. There are very clear standards for keyboard height, monitor position, chair position, etc., which in many instances only require very simple adjustments. These adjustments alone can make a great deal of difference, especially for those who spend long periods of time at their computer station. Many physical therapists are well-trained in ergonomics and can help with this. Or ask if your company has someone on staff who is trained to deal with these issues.

Another problem I see quite often relates to people who concentrate so hard on their work that they sustain positions for long periods of time, a situation that can bring on musculoskeletal pain regardless of how well their work station is designed. In this case, there needs to be some sort of reminder to get out of that position, even if only for a minute or so. Standing and stretching with your hands toward the ceiling a few times every 30 minutes or so can make a great deal of difference. There are very cheap watches available that beep every hour, and I encourage people to use this feature as a reminder to get out of their chair and stretch.

Q: My husband has had several approaches to his back pain (prolotherapy, drugs and surgery two years ago). He still has lots of pain. I was interested in the part of your story about the specific problem-directed physical therapy and wondered how to find a clinic in our area that practices physical therapy this way? — Christina Cassidy, Gainesville, Fla.

Unfortunately, there are very few places that are set up to see people with chronic back problems. My suggestion is to call or visit local physical therapists and see what they have to offer in terms of long-term, supervised aerobic and general conditioning for people with low-back pain.

I always like to suggest the People with Arthritis Can Exercise (PACE) programs. These can commonly be tailored to people with back pain, especially their water program. Usually there's a certified PACE instructor at the local YMCA or Jewish community center. These programs can become a lifelong program for patients, where they can go twice a week and exercise for an hour in the pool. And usually, those exercises are the same kinds of things we try.

The thing to remember about chronic low-back pain is that it's very difficult to treat in anybody's hands. It's a multifaceted problem, and you may need contributions from a team that includes a physician, surgeon and a physical therapist to determine the best treatment course.

What works the best, however, is when a patient embraces whatever rehabilitation plan is put forward. In the beginning, with something like an exercise program, patients may feel a little pain and they want to back off. In reality, there are some pains that they have to work through, and they will feel better in the long run.

Patients also need to do the exercises not only in therapy, but outside of therapy. The exercises are going to take 45 minutes to an hour each time. That's very difficult to do, because like anyone in this country, no one likes to exercise. And that's where most of the failures occur, the inability to follow through with treatment on a patient's own time.

Q: I never paid attention to my back or lifting until I was in my early 40s and began experiencing back pain, especially after working in childcare. Where can I find of full list of "safe back" ideas? — Debbie Boyd, Acworth, Ga.

Probably the most comprehensive text that incorporates the latest evidence in low-back care and is written with the consumer in mind is the book Ultimate Back Fitness and Performance, by Dr. Stuart McGill. Dr. McGill is an investigator from the University of Waterloo who has done much of the primary experimental studies on core-strengthening exercises. I find this book extremely informative and easy to read, and recommend it to many of my patients.

A very good Web site for both consumers and physical therapists is www.evidenceinmotion.com, which is dedicated to keeping physical therapists and their consumers updated to the latest evidence.

Q: I had a spinal fusion in 1974. Keeping my back in shape and pain free has been accomplished by regular chiropractic adjustments. Why don't you recommend chiropractic treatment for people with back pain? — Toby Groyz, Prairie Village, Kan.

One of the prediction rules put forth in the NPR story was for manual therapy, specifically for thrust procedures to the lumbar spine. So I would say chiropractic treatment was included in the story. Osteopathic physicians, physical therapists and chiropractors all perform manual therapy procedures as part of their scope of practice.

The evidence suggests that thrust procedures have a positive effect in acute low-back conditions, particularly when patients meet certain criteria. Though the treating clinicians in the prediction-rule experiments were physical therapists, I do not see why the results would not apply to chiropractors who use similar techniques.

I'd like to add though, that there's a long-standing belief that regular visits to chiropractors are somehow necessary for health maintenance. I'm not aware of any evidence that suggests that these sorts of regular visits are of any benefit.

Certainly regular chiropractic adjustments are not necessary to remain pain free.

Q: Do you have any information on the non-surgical spinal decompression done by a machine called the DRX 9000? Seems to me a new method of traction! The DRX 9000 procedure makes sense to me (to stretch the discs) even though my health insurance will not cover it, and it is rather expensive. — Carrie Bassett of Tallassee, Fla.

Ask the provider for evidence, in the form of published studies, of its effectiveness.

The most reliable information about the effectiveness of using such devices remains the peer-reviewed literature, and after conducting a literature search, I couldn't find anything about this device.

When an insurance company refuses to pay for a treatment, in many instances it's because there isn't any evidence for its efficacy. We should be just as diligent for what we pay for out of our own pocket. Actually, we should want to know more about the efficacy of the treatment.

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