Back and neck pain, physical therapy for

Definition

Physical therapy for back and neck pain is the treatment of this pain using professionally accepted techniques and procedures carried out by a physical therapist .

Purpose

The ultimate purpose of physical therapy is to restore normal function to the patient. Such a goal may not be possible, since the persons most likely to experience back pain in the future are those patients who have experienced back pain in the past. Regardless, the physical therapist will seek to ameliorate pain and improve musculoskeletal function to the best of their ability. To reach this goal, the physical therapist may apply various types of therapy to assist in the healing process, ranging from education to electrostimulation therapy to physical manipulation of the spine. Due to the less invasive nature of physical therapy, it may be indicated as an alternative to surgery on the back or neck. Physical therapy may also be prescribed after surgery, either because the surgery did not completely ameliorate the pain, or to ensure the patient achieves maximum benefit from the surgery.

Precautions

There are a number of symptoms in patients with low back pain that may require immediate medical attention. These symptoms may indicate that back or neck pain is related to potentially serious non-mechanical or mechanical disease. Non-mechanical disorders that are neurological or organic in nature can cause symptoms of back pain, but in these cases treatment needs to be directed at the disease, not merely the associated pain. Bowel, bladder, kidney, or gall bladder diseases, some types of cancer , cauda equina syndrome, and other neurological disorders are among the serious conditions that should be screened for and treated directly.

If a patient has numbness in the area roughly corresponding to where a person would sit in a saddle (basically, the buttocks) with or without problems urinating, that patient should seek immediate medical attention (these symptoms may be an indication of cauda equina syndromea). Fever, confusion, back pain that occurs mostly at nighttime or when lying down, or problems with urination, bowel movements, or sexual function are other symptoms implicating non-mechanical disease that may also require immediate medical attention.

Although the following symptoms may or may not be caused by mechanical disease, patients with sudden severe or increasing weakness, numbness, or tingling should seek immediate medical attention. Other symptoms in conjunction with back pain may also require immediate attention. If any unusual symptoms arise, even should they seem unrelated to back pain, a physician should be consulted. Regardless of the severity of these symptoms, all of them should at the very least be brought to the attention of a physician.

Other precautions and contraindications will vary according to the cause of pain, the therapy used, and the presence of other diseases or conditions. Some conditions either related to or coexisting with the pain, such as severe cardiac disturbances or bone weakness due to osteoporosis or other conditions, may contraindicate exercise .

Modalities, such as electrical stimulation techniques and thermal modalities, have their own sets of precautions. Conditions that may contraindicate the use of electrical stimuli include thrombophlebitis, cardiac demand pacemaker, disturbances in cardiac rhythm, local inflammation or infection, and cancer. The use of heat may not be indicated immediately after an injury, and should always be used with special caution to prevent burns. Electrical, heat, and cold therapies may all be contraindicated for use on sensory-impaired areas. Ultrasound should not be used on tissues with metal implants, because of its deep heating properties. Manipulation techniques can aggravate disk problems, or cause compression fractures in patients with osteoporosis. The physical therapist needs to be familiar with any risks involved with each condition and modality. A doctor's diagnosis is often recommended prior to beginning treatment, and the physical therapist needs to make a careful diagnosis in order to make appropriate treatment choices.

Description

Physical therapy treatment, also called physiotherapy, is performed by, or under the supervision of, a physical therapist. A physical therapist may have a baccalaureate, masters, or doctoral degree in physical therapy, and is required to pass a national licensure exam. Physical therapy treatment includes a wide range of exercises, procedures and modalities. However, patient education is also an extremely important part of the practice of physical therapy.

According to an American Physical Therapy Association (APTA) patient education brochure on back pain, “the patient is the most important participant in the healing and prevention process.” The physical therapist can instruct correct posture and safe ways of performing activities of daily living (ADLs) and other tasks. Additionally the physical therapist can show the patient various kinds of exercise that promote relaxation , relieve pain, and improve the condition of the muscles and other tissues surrounding the spine. Patient education may extend the benefits of treatment by helping the patient to self-manage pain and avoid re-injury or recurrence of acute pain and injury. Avoiding re-injury is a goal of special importance, since most people who have one episode of back pain are likely to have another.

Before treatment begins, the patient's problem must be evaluated. Very often, a physician will have referred a patient to physical therapy. Physical therapy may be the lone method of treatment, or may be used in combination with medication, surgery, or other types of treatments. After the role of physical therapy is determined, the patient will be evaluated by the physical therapist. Evaluation includes an interview with the patient to assess the patient's medical history, and activities that affect the condition. After the interview, the therapist will proceed with a musculoskeletal exam to assess the patient's spinal movements, posture, muscular strength, and response to repeated movements. Any additional tests considered necessary for a diagnosis will be performed. The physical therapist will then provide a diagnosis of the condition and a prognosis.

The prognosis includes the predicted level of improvement, goals, and the time needed to achieve them. Then an individualized treatment plan will be designed and implemented. Treatment plans may vary widely from physical therapist to physical therapist for the same patient. Patients may wish to seek advice from a different therapist if their condition does not improve under the first therapist's care.

Back and neck pain can have many causes, such as: injury caused by accident or misuse, disease, general strain, postural problems, or just simple wrong movement. Specific causes of back or neck pain can include sprained ligaments, muscle strain, disk problems, joint irritation, arthritis, congenital disorders, psychological stress, spinal stenosis , osteoporosis, compression fractures, and various other conditions. Due to the large number of causes for back pain, it should not come as a surprise that there are a large number of therapies that address back and neck pain.

Exercise is generally considered an essential part of the physical therapy regime. Different kinds of exercise are used according to the condition and the stage of recovery. Some controversy surrounds what types of exercise to use, perhaps depending on the cause of the back pain as well as other factors. Individual exercises may seek to increase one or more of the following: flexibility, range of motion, overall aerobic conditioning, and muscle strength.

According to recent guidelines suggested by Malanga and Nadler, tolerable exercise is superior to bed rest for back pain. Bed rest and inactivity have been shown to weaken muscles and bones (a phenomenon known as deconditioning), and may prolong or interfere with recovery. Exercise, in general, increases strength and flexibility of the muscles and aids in healing by increasing blood flow to the affected area.

Aquatic therapy is among the exercise options available to physical therapy patients. This form of exercise has the benefits of being low-impact and gentle on joints. As a supplement to whatever forms of guided exercise are chosen by the therapist and patient, the patient is also likely to be given a home exercise program to perform independently.

Another type of treatment the physical therapist may use is manual therapy. Manual therapy is defined in the APTA's Guide to Physical Therapist Practice, Second Edition as “skilled hand movements intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissue and joints; modulate pain; and reduce soft tissue swelling, inflammation, or restriction.” Manual therapy techniques include various forms of massage, manual traction, mobilization and manipulation of the soft tissues and joints, and passive range of motion movements. Manual therapy has a long and storied history. The first mention of manual therapy in Western culture can be traced to Hippocrates, who wrote several treatises on joint manipulation and traction (traction, in the context of back and neck physical therapy, is the extension of the spine using force).

Although mobilization and manipulation have changed from the time of Hippocrates (460–355 BC), they remain important techniques today (along with other forms of manual therapy). There are a large number of manipulation and mobilization techniques available to physical therapists, based on a number of different “schools of thought.” Many of these therapies have scientific evidence supporting their efficacy, and many do not. In part because there are so many different types of manipulation, the techniques, and the level of familiarity with different techniques, can vary widely from one physical therapist to the next.

The most well-known forms of manipulation are those performed by chiropractors. Although physical therapists can be trained to perform the same manipulations as chiropractors, historically, physical therapists sought to use terminology such as mobilization to differentiate themselves from the chiropractic community. Part of this impetus was based on the bias against chiropractors found in allopathic physicians. However, the APTA has recently moved toward reclaiming the term manipulation as part of the physical therapy lexicon.

Traction has also advanced since the time of Hippocrates. In the modern era, traction to the neck or low back may be applied as steady traction, or as intermittent motorized traction (IMT). The goal of traction in both cases is to correct physical deformities of the spine. Some modern traction practitioners speculate the benefit from traction is derived from pulling the intervertebral disk back into the intervertebral space (due to the force exerted on the spine).

In steady traction (for the low back) weights are applied to the ankles and patients are required to remain in bed, flat on their backs, for a significant period of time (weeks). The constant nature of the traction, and the way in which it was applied, led to a number of important disadvantages. First, bed rest is not recommended for general back health (as previously discussed). Second, the patient's muscles might spasm, which would cause less force to be applied to the spine, the structure of interest. Third, the apparatus and the position of the patient means that much of the force being applied to the patient would be absorbed by non-spinal structures (e.g. the hips). Most importantly, patients who receive this kind of traction do not improve compared to those who do not receive this kind of therapy.

IMT seeks to avoid these complications by applying intermittent (occasional) force a few times a week directly to the area of interest. A hip belt or a neck harness, and the immobilization of the upper body allow force to be applied more directly. The intermittent nature of the force prevents excessive muscle spasm, and the patient is spared the potentially harmful effects of bed rest.

Modalities, or passive physical therapies do not require the patient to participate. These methods usually employ some special equipment that can apply heat, cold, electricity, or other elements or forms of stimulation to the patient. One such modality would be applications of cold using ice packs or a cryo-stimulation device. Heat can be applied using diathermy (for dry heat), hydrocollator packs (for moist heat) or a heating pad. Ultrasound uses sound waves to create a deep heating effect. Electrical muscle stimulation (EMS) is used to exercise and strengthen specific muscle groups, while TENS (transcutaneous electrical nerve stimulation) units provide therapeutic nerve stimulation to reduce pain.

Physical therapy services are often covered by medical insurance. The patient may want to ask the physical therapist to check with the insurance company to see what services and how many treatments are covered. Physical therapy is generally a cost-effective form of treatment, and if can be used to avoid surgery, then the expense of surgery and a hospital stay is also avoided.

Preparation

The patient should provide all appropriate medical records for the physical therapist to review. The patient may also wish to keep a journal before attending physical therapy, detailing times and activities that cause pain.

Aftercare

Since physical therapy focuses on patient education, the patient may be better equipped after the physical therapy program to pursue self-care through proper posture and performance of activities, and by continuing a home exercise program. According to an APTA patient education guide, the goal of physical therapy is to help the patient return to normal activities as soon as possible and to teach the skills needed to avoid re-injury. The patient will not necessarily require additional episodes of therapeutic care.

Complications

Possible complications related to physical therapy treatments for back and neck pain depend on the cause of pain, other conditions present, and the type of interventions used. In general, physical therapy is a safe, gentle treatment option designed to work in harmony with the body's natural structure and movement mechanisms. Severe complications are not common, as long as the diagnosis and plan of care are accurate and carefully made. The therapist should be aware of possible complications related to exercise in general, as well as those involved with various primary and coexisting conditions, and with any of the modalities used. Some forms of manipulation can lead to injury in the case of bone weakness or other pathological conditions. Patients whose conditions cause excessive fatigue should be monitored closely during exercise.

If the precautions or contraindications relating to the patient's condition, evaluation, medical history, and diagnosis are properly attended to and procedures used are observed, the risk of complications will be minimized. The patient may feel some additional pain or soreness when beginning exercise, but this should be mild and temporary. In rare cases, the patient may have an allergic reaction to gels and creams used in ultrasound or massage.

Results

Results vary widely based on the cause of the dysfunction, the therapy used, and the skill of the therapist. The goal of returning patients to their original level of function may not occur. However, since physical therapy focuses on patient education, the patient may be better equipped after the physical therapy program to pursue self-care through proper posture and performance of activities, and by continuing a home exercise program.

KEY TERMS

Co-morbidity —A disease or condition that coexists with the disease or condition for which the patient is being primarily treated.

Disk (disc) —Soft, flexible, shock-absorbing material between each vertebra.

Modalities —Passive physical therapies that are done to the patient rather than requiring their active involvement. These may not require constant attendance by the physical therapist.

Soft tissue/joint mobilization —Application of specific stretching techniques to the body's soft tissues and joints.

Spinal stenosis —A condition caused by the narrowing of the spinal canal leading to compression of nerves in the back.

Ultrasound —A treatment modality that uses high frequency sound waves to effect deep heating of soft tissue.

Caregiver concerns

Physical therapists may work together with physical therapist assistants and aides, physicians, nurses, social workers, occupational therapists, or other health care professionals. Doctors may provide a diagnosis and prescription for physical therapy and recommend duration or types of therapy. The physical therapist assistant, under the physical therapist's direction and supervision, may undertake various aspects of the patient's treatment. Occupational therapists and social workers may also work with the patient to supplement physical therapy's role in the patient's return to normal life and work or adaptation to disability.

Resources

APTA. Guide to Physical Therapist Practice, 2nd Edition. American Physical Therapy Association, 2001.

Paris, S.V., and P.V. Loubert. Foundations of Clinical Orthopedics Seminar Manual. Institute Press, 1999.

PERIODICALS

Lewis, Carol. “What to Do When Your Back Is in Pain.” FDA Consumer (March/April 1998).

Malanga, G.A., and Nadler S.F. “Nonoperative treatment of low back pain.” Mayo Clinic Proceedings 74 no. 11 (November 1999): 1135–1148.

ORGANIZATIONS

Academy of Orthopaedic Surgeons. 6300 North River Road. Rosemont, Illinois 60018–4262. (800) 346-AAOS. http://www.orthoinfo.aaos.org/.

American Physical Therapy Association (APTA). 1111 North Fairfax Street. Alexandria, VA 22314. (703) 684-2782. (800) 999-2782. http://www.apta.org.

McKenzie Institute USA. 600 E. Genesee St., Ste. 124. Syracuse, NY 13202. [email protected]. (800) 635-8380. http://www.mckenziemdt.org.

OTHER

The Agency for Health Care Policy and Research. Acute low back problems in adults. http://hstat.nlm.nih.gov/ftrs/pick?dbName=lbpc&ftrsK=40050&cp=1&t=996953656&collect=arahcpr.

Agency for Health Care Research and Quality. Care for Acute Low Back Pain. http://www.ahrq.gov.

Campo, Marc, MS, PT, Cert. MDT. The McKenzie System. http://www.spineuniverse.com.

Cluett, Jonathan, M.D. Back Pain: Understand Causes and Treatment of Back Pain. October 29, 2007. http://www.orthopedics.about.com/cs/backpain/a/backpain.htm.

How a physical therapist can help with exercise. http://www.spine-health.com.

Mayo clinic web-site. http://www.mayoclinic.com.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Web page. http://www.nih.gov/niams/.

Poesnecker, G.E. “Intermittent motorized Traction & Allies Therapies.” It's Only Natural. http://www.oneflesh.org/only-4.html.

Diane Fanucchi C.M.T., C.C.R.A.