My Thoughts on Treating Low Back Pain

In this blog post, I discuss my evolution of treating patients with low back pain. In general, it’s a quick read on how my approach has changed overall. This blog post was inspired by an original post by Lenny Macrina that you should definitely read. Lenny has some really fantastic content and I highly recommend you spend some time perusing through his website.

PT School.

stanley paris yacht.jpg

I graduated from the University of Saint Augustine in Florida. So, there was an expectation that I had some decent manual therapy skills. I remember sitting for my Manual Therapy Certification exam with... Dr. Stanley Paris. Yes, the man who is credited for seeding manual therapy into the psyche and practice of Physical Therapy in America was testing me for cervical downglides.

SVP: “How would you assess that?”

Me: “I don’t think I’d treat it. It feels normal to me.”

He puts his hands where mine were and double-checks me. “Normal” doesn’t translate well into gradable material on Practical Exams, so we went on to testing cervical up-glides.

SVP: “How would you assess that?”

Me: “I don’t think I’d treat it. It feels normal to me.”

He puts his hands where mine were and double-checks my findings. Again, “normal” doesn’t translate well into gradable material on Practical Testing, so we went on to testing 1st rib caudal glides.

SVP: “How would you assess that?”

Me: “I don’t think I’d treat it. It feels normal to me.”

He puts his hands where mine were and double-checks my findings. “Check it again.”

Here’s the dilemma: if I were to fake it and say “Oh yeah, you were right…. it’s a bit restricted on the right,” then he may ask me to treat something I just faked.

Me: “I don’t think I’d treat it. It feels normal to me.”

That was it. I had to re-take the cervical portion of my MTC Exam.

The Early Years.

Young, energetic, and naive.

Young, energetic, and naive.

The early years was when I learned the difference between swimming and reading about swimming. None of it matters until you’re in the water, and I was deep in the waters of outpatient PT trying to apply everything I learned in PT school and Manual Therapy Certification. Unfortunately, I was quickly forced to confront the fact that I couldn’t really feel spinal segmental joint mobility with my hands. It all felt the same to me. Even worse, the daily grind felt a bit too routine.

I used e-stim and ultrasound liberally. I recommended the same exercises for everyone with low back pain. For that matter, I prescribed a predictable set of exercises for everyone based on the body region being treated. All with shoulder pain had the same exact exercises. All with ankle pains had the same exact exercises. You get the idea.

It all started feeling very cookie-cutter-esque, and I was becoming more aware that I wasn’t doing my best to achieve the best outcomes.

The Search.

Needing a GPS…

Needing a GPS…

I was determined to improve my outcomes by taking more courses to develop a sound foundation on which to build further skill-sets. Eventually I took a course by the Institute of Physical Art (IPA) and was quickly hooked on their approach. This led to an IPA Residency which I found invaluable as a clinician and an individual.

Since then, I’ve taken a number of other manual therapy courses and will continue to do so. I also took some courses on application of modalities, but their instructors were very non-responsive to my questions (via email) regarding these treatment options.

I should mention that reading a wide variety of books (especially outside the world of PT) has helped as well. In fact, aside from my residency, I feel like reading helped me the most by providing contexts and models of reasoning that carried over into the clinical setting in more than one way.

In addition, I’ve come to strongly believe something very obvious: the power of collaborating with and/or learning from clinicians, professionals, and other individuals outside the world of Physical Therapy in order to better serve our patients. [And yes, that doesn’t mean that there aren’t amazing individuals within our own profession that we call all learn from.]

My Current Approach.

Do I use my hands for assessment and treatment? Absolutely.

Is it all I use? Absolutely not.

The way I now approach evaluations & treatments involves:

  1. A deeper and more open-ended interview that not only includes a history (or review) of their present functional goals, but also includes:

    • A feel for his/her personality

    • Their perception/understanding of their story and why they came to PT

    • An understanding of their expectations, concerns, and/or worries.

  2. A baseline idea of how much education and/or coaching they need to move/rest in non-painful ways.

  3. Some determination of which inputs his/her system could integrate efficiently to deliver a positive response.

That last part may include reframing, alleviating fears, re/learning new/different movement and/or rest patterns, exercises, various manual therapy inputs, education, etc.

From a clinician’s perspective, I have become very interested in:
*** general movement patterns, including those that are inherent and adopted
*** self-perception and how it impacts an individual’s relationship to their body
*** gaining deeper understanding of different personality types to forge stronger therapeutic alliances
*** the application of novel/non-threatening inputs for the right mind-set & personality at the right time

The goal is to find ways to allow someone to move and return to their daily activities with adaptive and meaningful movement/rest patterns. Finally, once new patterns have been established, encourage him/her to explore other patterns of movements/positions involving the body region of focus, so that they (re)build a more diverse movement/positional palette.

Will my approach change over the next few years?

Absolutely. It has already undergone 3 major transformational changes and more than a dozen other significant clinical modifications.

I strongly believe that if nothing about your patient care changes in a year or two, then you are your own roadblock to becoming a better clinician and delivering better care.

My Quarterly Letter summarizes my favorite books read in the last quarter. If you'd like to join the growing list, then you can let me know here


Jason Boddu