• Piotr Solowiej

Unintended Consequences

Updated: May 8, 2019

A common misconception I encounter is people assuming they should stop their activities when starting physical therapy. During the evaluation, they will sheepishly ask, "So I guess you want me to stop what I have been doing, right?" Not right! Nine times out of ten, I will recommend the opposite. This scenario came up during a number of evaluations in recent weeks. The thought probably stems from a long history of providers recommending complete cessation of activities. For years R.I.C.E (rest, ice, compression, elevation) was the mantra of many front line healthcare providers in regard to pain and injury.

Complete rest produces fickle outcomes.

To see why, I will tell a story of two similar situations, and follow them to their conclusion. Let's assume two identical symptom presentations and mechanisms of pain only separated in time of occurrence. Same demographics, same phenotype, but approached from two extremes in the rehabilitation continuum.

Linearco - Where the dots are easy to connect

Abby, a teenage dancer arrives at 'Scrape and Tape' Physical Therapy clinic with low back pain, especially when jumping. The clinic specializes in athletes and promotes a modern approach with all the latest in rehabilitation technology at their disposal. If you have pain, one of their tools will provide the fix.

Abby's therapist learns her pain intensity has progressively worsened over several weeks and now even sitting and standing are uncomfortable. There is concern about lumbar stress fracture given her age, mechanism of pain, and choice of activity. Thankfully X-Ray imaging rules out this possibility.

Multiple channels have urged Abby to take things easy and stretch, but she is unsure. Her dance coach recommends she gets lots of massages because she had intense back pain once, and that really helped her. What does her therapist think about the situation? Not wanting to make the pain any worse, the therapist instructs the dancer on a series of stretches and delivers a course of the latest modality technology: tool assisted massage, cupping, alternating cool and heating pads, electrical stimulation with dry needling (very fancy), as well as tape to better support her spine. Add some core exercises and after 4 weeks of this routine the dancer no longer has any pain at rest. Abby is very happy with her progress, as she has an important tryout for a dance team in a number of weeks. She returns to dance practice after thanking you for your hard work.

Some time passes since Abby returned to regular practices. She notices a familiar, but unwelcome sensation developing in her low back. She tries to brush it off, but just as before, it continues to worsen. What gives? Did she not rest long enough? Should the massages have been more forceful? Maybe she isn't keeping her back straight during dance routines, or what if her core is still weak? But how could it be, she has been doing the exercises religiously since graduating from physical therapy. She should be fixed now. Frustrated and unsure about her future, she returns to her physician for further evaluation.

Considering physical therapy has been a failure, the physician discusses the remaining options with Abby and her mother: steroid injections, surgery, or stop dancing.

Unaware of any of this, Abby's therapist is smugly cupping her 3rd patient of the day. This works so great at getting rid of pain, she thinks. Everyone should be doing it!

Herein lies part of the problem: it is assumed that rest and modalities are synonymous with physical therapy. For some time they were, and unfortunately for Abby, fate led her to a clinic that continues to belabor the passive methodologies like doctrine.

This approach, where tools and techniques are selected a-la-carte to maximize comfort and protection is outdated and sometimes lucky in the short term, but often adverse in the long run. Rehabilitation is a process. A process where an individual learns about their capabilities as well as their limitations, and how they can adjust their habits to optimize their body for their needs. Pain, on the other hand, is an experience with many variables playing a role. Tools and gadgets solely focus on the unpleasant sensation, but miss completely the meaning behind the pain. Pain modulation is temporary, and sometimes necessary. However leading with gadgets as a primary strategy continually masks an underlying problem, or host of problems. If pain were both the cause and the symptom - then treating it should be a cure. Why else would it return? This has been tried, in fact we as a society have pounded this strategy into the ground. Look no further than the consequences of opioid over-utilization.

It has failed. Tremendously.

The second part of the problem: a major risk factor for developing low back pain...is previously having low back pain. Despite what many claim, we are not doing a good job (society) at curbing the prevalence of back pain. If you have had an episode, you are more likely to have another versus a person so far exempt from its grasp.

Claiming to eliminate pain, rather than understanding and managing, also robs the individual of control over their future. It turns them into a broken object needing fixing. Objects are not sentient to their problems and need some sort of external tool or technician to be repaired or restored to function. And since people experiencing back pain are likely to experience it more than once, taking the passive road where things are done to them, leaves them ill prepared for the future. It can effectively teach a person to be helpless, creating fear of movement, a sense of vulnerability, and dependence on others to fix their problems for them. Even though the aim was to help the person out of pain, the resulting fragilized mindset can perpetuate and amplify the problem in the future.

Let's go to the other side of town and observe the outcome of a different approach.

Complexico - Where uncertainty, is the only certainty

Across town a teammate of Abby's, Katy, is being seen at 'Listen, Modify, Guide and Adapt' Physical Therapy. The name isn't as catchy and they don't have any cool gadgets, but it's closer to home for Katy so she gives them a shot. Plus, Abby is still in pain after a month at the other place.

Just like Abby, Katy also experiences back pain when jumping. Her therapist goes through appropriate precautions to rule out spine fracture. At the end of evaluation she too teaches Katy some stretches. As circumstance would have it, Katy leaves for a weeklong family vacation after the eval, and after a week of lounging, stretching, and no dance - her symptoms are unchanged when returning to therapy. Upon Katy's return, the therapist abandons the initial approach. Katy's therapist is a bit more reactive. Apparently missing something, she speaks with Katy's mom who reveals she recently experienced a growth spurt. Over a few short months, she is 6 inches taller and almost 25 lbs heavier. Mom is very concerned about her daughter's ability to perform for an upcoming dance team tryout next month. There are limited roster spots and if she doesn't make the team, it will be more difficult next year without the experience, as well as the looming disappointment Katy will likely feel if she is cut.

Katy's therapist changes tact. Despite pain Katy is instructed to continue participating in dance activities, although not always fully. Rather than ceasing dancing, her participation is modified to minimize aggravating factors like jumping by taking long breaks between jump attempts or sitting out during some of the intensive skills.

Could the growth spurt be the reason Katy is experiencing back pain? There is some logic to that - same skills but a significantly higher demand considering the increase in mass and the forceful nature of jumping and flipping - but maybe there are other factors as well. She asks Katy to film jumping skills from practice for further analysis. Maybe there are biomechanical contributions to her pain. Her form could be off. Maybe the pressure of tryouts approaching and still being in pain is having an amplifying effect. What will happen if she is still in pain during the week of tryouts? Will she be able to perform her best? Why does there have to be a singular reason? It's possible all those factors are contributing.

At the next PT session, video review of Katy's jumping skills doesn't reveal anything dramatic. However, she is not able to execute her skills consistently. Is muscle weakness the problem? Manual muscle testing of the quads, lower leg, and hip extensors isn't remarkable. Jumping requires a heck of a lot more force than pushing on someone's leg. It's hard to say if strength, or lack of it is playing much of a role. This case is turning out to be more complex than initially anticipated.

Katy is sent home with a program focusing on improving leg strength and power. Internally unsure of what the outcomes will be, Katy's therapist shows no sign of hesitation when instructing Katy on her exercises, ensuring her this is a prudent course of action. She is astutely aware that her confusion can be met by skepticism. Any doubt on Katy's part could potentially have a nocebic effect on her ultimate outcome.

At subsequent follow ups, Katy reports small improvements in her pain. She is able to do a little bit more each dance session before her pain presents. It's not gone, but improving. This process of minor but steady improvement, continues for the next several weeks, culminating in Katy confidently participating in dance tryouts, despite continuing to experience some minor pain.

In the end, what was it that helped Katy? There is no way of knowing for sure if it was the strengthening exercises alone, the confidence building alone, the combination of both, just time, or some completely abstract factor(s) that is unknown. But, Katy's therapist can rest easy knowing her client has developed active coping and management strategies. Should her symptoms return, she will be better prepared.

Playing the Wrong Game

Unless there is an acute trauma to the body, cessation of movement for many pain problems is not the course to take. Even in cases of trauma, best practice is to keep rest relative. Pain is multifactorial. Structure is just one factor. Strength is another. Expectation is a major one. There are many more. To claim to be able to fix pain is both bold and naive.

In my opinion, physical therapists are only casually in the business of pain management. I see it as a beneficial side effect of what we offer, and by no means our primary objective. Unfortunately, many see pain elimination as our primary role. I know I did for a long time, and reflecting on that time period makes me realize that I probably wasn't very good at my job. It is much easier to make someone temporarily comfortable, then to get them to work hard, strain, and get their body to adapt - what is harder is realizing that you can't do anything to fix their symptoms - and harder yet, getting that person to realize they are the ones that are in control of their outcome.

Not being a fixer doesn't mean we can't be a helper. The physical therapist's role is to guide. If you have "failed" physical therapy, but your care consisted of passive modalities, then you have a lot to gain from a more active approach.

Back to the original point at the start of this post, I don't want anyone to stop their activities, without first trying to modify them. Pain is unreliable. It is a complex, multifactorial, personal experience. Healing and pain relief are results of fostering an appropriate environment. Unless proven otherwise, when you work with me you'll be dancing, climbing, swimming, biking, running throughout the episode of care and beyond.

#physicaltherapy #lowback #pain #northbrook


Address: 1942 Raymond Dr, Northbrook, IL

Phone: 630-447-9746

Fax: 630-385-0124

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