Crack, Twist, Heat, Then Stretch, Electrify and Knead
This is not a hot new dance routine, nor are we baking soft pretzels. This is the typical treatment for those who suffer from neck and/or lower back pain.
I often have the opportunity (and sometimes the misfortune) to be the last practitioner to see patients who suffer with back and/or neck pain.
Usually prior to seeing me, the patient has seen a medical doctor and received muscle relaxants and/or pain medicine. The patient has seen an orthopedic doctor and received epidural injections (an injection of the steroid cortisone into the spine). The patient has also seen a chiropractor for the crack and twist and a physical therapist for heat, stretch and electrify--using EMS (which stands for electrical muscle stimulation)--and knead (massage), followed by stretching.
When the patient arrives at my office he or she is still in pain. Were the treatments incorrect? Were the doctors wrong? Should the back or neck be "cracked"? Is ice better than heat? Are all exercises created equal?
The answers to all of the above questions are "yes, no, maybe and it depends".
Let's start from the beginning. When someone experiences persistent neck or back pain that comes on gradually or seemingly "out of nowhere" and not always a result of an injury he or she usually sees a primary care physician (PCP) first. That doctor's job is to listen, assess and perform an exam regarding the complaint and then make a recommendation or referral to a specialist and/or prescribe a medicine so the patient is not in pain.
The patient returns, still in pain, and the PCP refers to an orthopedic doctor. The orthopedic doctor has the following choices: determine whether surgery is indicated, offer an injection (epidural or anesthetic) and/or prescribe medicine to decrease the pain, or refer to a physical therapist.
Sometimes the injection and medicine do not work and the patient presents to a physical therapist. The physical therapy facility provides heat, ice, electrical muscle stimulation, ultrasound, massage, manual therapy and/or exercise. This appears to be a sound treatment program and the patient reports temporary relief but is still in pain, and sometimes worse after treatment. Depending upon the insurance carrier, the patient might have only one or two months of treatment, and all services may not be covered.
The patient is still in pain and now tries chiropractic care. Most chiropractic offices offer essentially the same treatments modalities as physical therapists: electrical muscle stimulation, ultrasound, massage, exercise, etc. The difference is that chiropractors perform spinal manipulation or adjustments. The result can be favorable, but in the case of this particular patient it is not; just as when he or she received physical therapy, there was temporary relief but the pain returned.
This is a common presentation in my facility. All these procedures are sound and supported by evidence. I also refer patients to these practitioners (medical doctors, orthopedic doctors, physical medicine and rehabilitation, neurologists, physical therapists, chiropractors, etc). It is the timing of these procedures that is not in sync.
The patient's best bet for treatment of a neuro-musculoskeletal (nerve, muscle and bone) complaint is a multidisciplinary facility where the doctors communicate with each other and treat patients from a team perspective.
First and foremost, the team has to determine the true cause of the pain. Sometimes special tests are required, such as MRI (magnetic resonance imaging), CT/CAT scan (computer tomography or computer-assisted tomography), myelogram (injection of a special dye and then X-ray) or EMG/NCV (electromyography/nerve conduction velocity, an assessment of the nerves).
The job of any physician is to rule out the "bad guys" first. The bad guys are tumors and infections. Once these types of dysfunctions are ruled out, the doctor's goal is to determine if a neuro-musculoskeletal condition is caused by nerve impingement (pinched nerve), ligament irritation, disc herniation or bulge, or myofascial syndrome (irritation of the muscle and tissue, commonly referred to as muscle knots or trigger points, which could cause local and/or referred pain). Sometimes it's a little bit of everything.
Unfortunately, testing does not tell us the whole story. Studies have demonstrated MRI results showing disc herniation and disc bulges in people who have no pain whatsoever. For example, a patient who reports to the facility with lower back pain may have had an MRI that revealed a disc herniation or bulge at a certain level, but the pain does not correspond with the level that has the disc herniation. Interesting, but not related. Then there are the patients who have CT scans and MRI's that reveal degenerative disc disease (loss over time of the disc material that acts as a shock absorber between the spinal vertebrae) and think that is the reason for their pain. Yet when patients are questioned about the start of the pain and the answer is "six weeks ago," it is unlikely that degenerative disc disease is the cause of the pain. Again, interesting, but not related. Then we have the opposite that occurs with testing. How about the patient who reports with arm pain and weakness but the EMG/NCV and the MRI are negative (do not reveal any pinched nerve)?
Here comes the important part--the patient interview and the physical examination. We have to question the patient regarding the initiation of the pain. When did the pain really begin? Did it come on gradually or occur immediately after performing a certain activity (golf, baseball, gardening, etc.) or a certain movement (bending, lifting, turning, etc.)? Have you ever had this pain before? How were you before this injury or current complaint? Is the pain an ache or a throb, dull or sharp, and what can you compare it to? Does the pain radiate down your arms or legs? Do you have tingling or numbness or weakness in your legs and feet or arms and hands? Do you have pain upon bowel movement, sneezing or coughing (ruling out a disc herniation)?
The multidisciplinary facility should also have the patient complete an ADL (activities of daily living) scale. This scale will allow the doctor to understand how the person's ADL's (standing, sitting, driving, recreational activities, washing and dressing, working, lifting, sleeping and social life) are affected in terms of their life.
The physical examination usually consists of orthopedic testing (maneuvers to determine a condition (is it nerve, muscle, disc?), neurologic exam (reflexes, motion and strength), ROM (range of motion to determine how well a joint or body part can flex forward, back and side to side and rotate), palpation (manual exam to determine the extent and location of muscle spasm and trigger points) and functional movement exam (to determine whether the patient can squat, get up from a chair, perform a wall squat, perform a sit-up, twist against resistance, raise the arms above the head, perform a push-up, etc.).
In a multidisciplinary facility, a team of doctors interprets the results of the testing and examination. This team could consist of medical doctors, chiropractors, physical therapists, psychologists, acupuncturists, naturopaths, or anyone from one or more of the healing art disciplines. Regardless of the types of doctors or therapists, the most important aspect is the communication factor. These professionals must put egos aside and work for the betterment of the patient.
As stated previously, the treatment for this patient was out of sync. Of course we look to medicine initially because we are in pain. But the current medications cannot decrease a disc bulge and half the time cannot decrease muscle spasm (many patients report that they just get very fatigued with muscle relaxants or, if they are on anti-inflammatory medicine, that their stomachs hurt). The reason physical therapy did not work is that the patient was in too much pain to perform the exercises and, in turn, the pain got worse. The chiropractor performed spinal manipulation, which might have aggravated the condition because the patient was not ready to undergo this type of procedure.
The initial goal is to reduce the patient's pain before progressing to an exercise regime. Initial treatment could consist of manual therapy if it is a muscle-tissue dysfunction (a technique to decrease trigger points, improve range of motion and reduce pain). This technique is usually applied by a chiropractor and/or physical therapist. In conjunction with manual therapy, the patient can receive injections to the muscles if it is a muscle problem. If it is a disc problem and epidurals have failed, the patient can receive a different type of treatment specifically for the disc problem. If it is a nerve problem, the patient can receive a nerve block or a specific type of hands-on therapy. The advantage of a multidisciplinary facility is that it's all in-house.
Once the cause of the pain is determined, it is much easier to treat and reduce the pain. Only when the pain is reduced and the patient's range of motion has improved should he or she progress to a rehabilitation program. This program should be based upon the patient's specific needs as determined by the ADL scale. It's not a matter of just lifting some weights or performing push-ups. The patient should first begin with stretching the injured tissues and then incorporate whole-body stretching, and then progress as follows: stretching to posture movements; posture movements to balance and core (deep spinal muscles); balance and core to functional movements (progressive resistance training for activities of daily living). It is important to note that the patient will most likely experience flare-ups of pain while initiating these movement patterns. These flare-ups should be addressed immediately to avoid downtime from the rehabilitation program. At the end of the treatment program the patient will have a thirty-minute exercise regime incorporating the learned movement patterns, from stretching to functional movements, and will also have learned the movement patterns to use during flare-ups.
To conclude, if you choose a multidisciplinary facility, ask to learn more about the types of care and patient management before you agree to treatment. You want to find out if the doctors communicate with each other. Doctors who work together in the same facility don't necessarily speak with each other. Remember that you want a true team approach. You also want to find out if the facility has treated problems like yours and what the specific outcomes have been. Often, by the time the patient reaches this type of facility, insurance benefits have been exhausted. It is important to learn all the costs that will be associated with your care at the facility of your choice. To learn more about management of chronic pain log onto http://www.frompaintopersonalgain.com
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