Physical Therapy and Low Back Pain - Brent Dodge, PT

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Brent Dodge. Mr. Dodge has a master's degree in Physical Therapy. He did his training at the University of Peugeot Sound. He also has several other certifications including a board certification in orthopaedic clinical therapy. He is also a certified manual physical therapist. Good afternoon, Brent.

Brent Dodge: It's a pleasure to be here.

Dr. Sechrest: Well, thanks for joining us, and today what I thought we would do is talk a bit about the physical therapist's role in the treatment of low back pain. I think we both know that back pain is an epidemic in this country, and, I think that one of the most useful modalities that we typically use for patients is, as soon as we make the diagnosis of what we would call nonspecific low back pain, where we've got mechanical back pain, or possibly a muscle strain, the first line of treatment is usually sending that patient to the physical therapist. So, tell us a little about when you see that patient, as a physical therapist, what is the first thing you do?

Brent Dodge: Well, as with all patients that we see, we're going to perform a clinical evaluation and get a treatment plan together based on what we find, and that's going to include a look at range-of-motion, strength, double-checking any potential neurological findings. We're interested in knowing how the person is functioning because the direction we're going to take is basically helping them understand where the breakdown is in terms of why their back is not working right, try to guide them in terms of the educational process, and help them function at their peak.

Dr. Sechrest: When you see that patient, is there anything that I, as a physician, can do to help that patient 1) make that transition to physical therapy to make it more effective, and 2) also help you, as a physical therapist, to understand maybe a little bit about what that patient needs.

Brent Dodge: I think, from a general standpoint, just helping them connect with the idea that the physical therapist is there to help A) with a treatment plan, but also B) to be a coach because we know with mechanical or what some people simple back pain, not that it's really simple, that if they have a level of optimism in their practitioner, their outcomes are going to improve.

Dr. Sechrest: Now, I think that a lot of my patients, when I mention the concept of physical therapy; they've come in, they may have their first or second very acute back strain or back pain episode, and they look at me like "there's no way I can go get on an exercise bike, get out there on a treadmill, begin doing pushups, jumping jacks". I mean, that is there concept of physical therapy. Tell me a little bit about that early phase of physical therapy when these patients are in acute pain and acute spasm. I mean, is that the time to get them to the physical therapist? Is there anything that you can do? Or should we wait a while?
Brent Dodge: I think it is excellent that people are being directed early on. The results that we get when we see people acutely, particularly when we're doing care that includes manipulative therapy, our outcomes are much better because we know from studies that if we can help people, and get our hands on them and do our treatments as physical therapists, their results are going to better, and that, right away, builds rapport to the point that we can then take them down a road that is going to work for them. You know, whether that's a home program, a gym based program, we really want to tailor a program that works for them.

Dr. Sechrest: Now tell me a little bit. You mention manipulative therapy and I think that may be a term that patients and physicians are not familiar with. I think we all are familiar with chiropractic manipulation. Is this the same type of manipulation? Or is this something different?

Brent Dodge: As a physical therapist, the tools that I use would be considered physical therapy manipulation. Now there's basically a lot in common with an orthopaedic or an osteopathic, or even a physical therapist manipulation, but the fact that we're trained as physical therapists to apply specific types of treatment that would be called manipulation, I would keep it in the realm of physical therapy.

Dr. Sechrest: Now, tell me a little bit about this manipulation. Describe what a manipulation is, and, maybe when it's appropriate to do a manipulation.

Brent Dodge: Well, particularly for acute and even subacute back pain. There is excellent literature that suggests that if a person would undergo would undergo a manipulation; now, whether that's applied by a physical therapist, chiropractor, osteopathic physician, I would venture to say that those manipulations would be equally effective. There is research that suggests that it's not really about the type of manipulation, it's about when and where. And so, by getting a person early on with back pain and doing a manipulation, simply taking the joints in the low back, in this case, to an endpoint of movement, and then doing a high velocity, I mean it's very quick, but it's low force or low amplitude, to get that joint to stretch. Some people would say, "Well, shouldn't there be a ‘pop'?" Not necessarily. Sometimes it's simply a stretching of the tissue and the results are equally good whether there is a pop or not.

Dr. Sechrest: And what do you think is occurring when you do that manipulation? What do you think that does to either the anatomy of the lumbar spine or perhaps the physiology of the lumbar spine to make the pain, I guess, lessen?

Brent Dodge: I think of it in terms of kind of ‘resetting' the nerves in that area; sort of a reboot of the spinal nerve where the location of pain might be. I think there is also a good amount of stretching that goes on that acts as what we call a counter-irritant that helps to actually override pain, and that's through neurological system. I think that just through that manipulation you get a lot of relaxation of muscles that automatically then helps people feel better. It gets them moving better and our goal with that is to get them where they can get back to their activity soon rather than later.
Dr. Sechrest: A couple of questions. One is: You mentioned that the timing is important. When do you do manipulations? Is this the first thing you do? Is this something down the road during the physical therapy sessions? When?

Brent Dodge: Generally speaking, if it's a recent occurrence of onset of back pain, there is no contraindications meaning, obviously, no evidence of fracture or something, you know like a tumor or something that wouldn't be appropriate to manipulate, the sooner the better. And the research that we've looked at really suggests that within the first 3-4 weeks is an optimum time to apply that type of treatment and expect even better results that way. Those findings, too, by the way, when I do the clinical exam, I'm looking for very specific findings that help me make a decision to do that stretch.

Dr. Sechrest: So not everybody would qualify, so to speak, for manipulative therapy.

Brent Dodge: That's true, but many do.

Dr. Sechrest: And you mentioned that they feel better. Is something that the minute you do this modality that, if it works, you're going to have instant pain relief? Or is this something that builds up over a few days?

Brent Dodge: The results I've seen have been stellar and rather quick in terms of providing a spinal manipulation and having people go, "Wow, I feel better." and that, right away again, is building rapport, it feeds into the whole process of I'm going to help train you now that you're moving better, how to put that good movement to practice.

Dr. Sechrest: Now tell me a couple of other things. What would make you not consider manipulation? What are some of the things? Now we're assuming that this patient has been evaluated by a physician or you've evaluated the patient. They may have had x-rays or something to confirm that they don't have an infection, a tumor, they may have even had an MRI scan that confirms that they don't have a herniated disc or anything that we would consider a little more serious, perhaps dangerous, with manipulation. What are the things that you are looking for that would tend to make you not consider manipulation?

Brent Dodge: Primarily neurological signs and symptoms. We would say that if there are nerve symptoms such as a radiating pain beyond the knee, symptoms such as numbness, tingling, any findings of weakness where the nerves go, we would immediately back off and say this is probably not a good candidate for manipulation. But, again, if it's borderline, sometimes a manipulation makes all the difference and helps with those symptoms so it becomes a clinical process of saying, "Hey, I've got to look at the history, really understand where the patient is coming from, combine that with other clinical findings to say I will or I will not manipulate."

Dr. Sechrest: Now let's move on beyond manipulation for a moment and let's assume that you've either made the decision; this patient is a candidate for manipulation and you've done that successfully; or you've decided that this patient is not necessarily a candidate for manipulation. What's next? I mean, what are you going to do and what sort of a program are you going to set up for this patient in order to try to reduce their symptoms of low back pain and perhaps teach them some things that may help them in the future. Where do you go next?

Brent Dodge: I'm a real believer in helping people understand their condition, but I'm also a believer in helping people feel better. I feel if I can make a substantial improvement in the way they feel on visit #1 there is a pretty good chance they're going to come back for visit #2. And part of that is people with nonspecific low back pain, from what we're told, will get better 95% of the time within 6 weeks no matter what you do or don't do, I have my own opinions on what better is, but I do want to make an impact in terms of how they feel because then, as they start to move and feel better, I can get them confident again in doing their normal activities, and people that get back to normal activities after an episode of nonspecific low back pain, when they do that faster, they recover faster.

Dr. Sechrest: We probably should step back a moment and just explain this term we're using - nonspecific low back pain. From a physician's standpoint, what that means is that I've looked at the patient, the patient has back pain, does not have pain down in the legs, does not have any of the neurological symptoms that you talked about. We may have done an evaluation, done a good history on the patient, maybe even have done x-rays, maybe even have done an MRI scan, but at that point, we still cannot tell that patient unequivocally, without a doubt, what is causing their back pain. So it could a host of different things. It could be ligaments, it could the disc, it could be the joints, it could be the muscles, it could be lots of things that tend to give you the same type pain, and the whole concept of nonspecific is that we're not trying to fool anybody. We don't know where the pain is coming from. Now interestingly, in our experience and in the literature, that is a huge segment of the population with back pain. Probably 85% of the people that go through that initial evaluation have nonspecific back pain and in only 15% of the cases can we say, without a doubt, we think this is what is causing your pain, the so-called pain generator in the back. Now is that the same concept, I guess this is a long question, but is that the same concept that the physical therapist is using to talk about nonspecific low back pain.

Brent Dodge: Well, I would just back up and say that physical therapists have tended to like to name things and to assess to the point that we can say, "Hey, we think we have a disc problem, we think we have a joint problem, or a nerve problem." But the reality is, as you've mentioned, the likelihood that we're on track and have that nailed down is fairly slim. I find it much more relieving to say we think this might be what's going on, but really what we're dealing with is a back that's not working right. Whether that's through the muscles, you know, they've been confused through a pain episode. The joints might be tight. There is a host of things that can happen and in the back there is a lot of structure that can be involved with a mechanical type problem, and I think it's relieving to clients to know that it's not just this specific thing. It may be a global problem. Yes, the disc might be sore and maybe there is a slight annular tear, we can start naming things, but the reality is the back is not working right and needs some help and the person needs some coaching to get back to that normal function.
Dr. Sechrest: Now we've done a lot of talking about movement, about manipulation, about getting back to activities. One of the things that we haven't talked a lot about is what is commonly referred to as modalities. A modality can include ice packs, it can include heat packs, it can include ultrasound that some physical therapists use; all of these modalities are used for pain relief. What is your take on those? When do you use modalities and which ones do you really like to use and feel like are beneficial, and when do you not want to use modalities.

Brent Dodge: In general, because I'm a manual physical therapist and went through an entire certification process for that. Therapists that work in orthopaedic settings are kind of moving in that direction to embrace a body of knowledge and be able to competently use those skills. So from my standpoint, the more I can do with my hands early on and get a feel for what is going on, I feel like that brings the rapport, it brings a connection with patients, and it helps me, as a clinician, to be able to identify whether I've got muscle spasm, whether I think a joint may be tight or locked up. But there are times, in especially acute situations, where you can't do a lot of hands on, and that's where I find that, particularly ice, I think there is better literature for using acutely in low back pain than perhaps heat. I think electrical stimulation is an effective form of treatment early on. It's not something that we'd use long-term necessarily though it can be applied for chronic problems, what we would call a tens application. That's a little bit different than that first early on setting. But electrical stimulation and ice are probably bread and butter early on in combination with whatever manual things we can do. Even gentle massage combined with that can be helpful.

Dr. Sechrest: So you're using that for symptom relief. You're trying to reduce the symptoms so that that patient is more comfortable with movement, getting back into a normal routine, and that sort of thing.

Brent Dodge: Yes.

Dr. Sechrest: Let's drop back a moment and look a little bit at the natural history and the course of physical therapy, and what you as a physical therapist are actually trying to accomplish. You mentioned earlier that no matter what you do with these patients they are going to get better in 6 weeks. So, why do anything? Why do anything with these patients? What's the rationale?

Brent Dodge: Well, two things. One, I would need to define the word ‘better' because I've heard this statement so many times, in fact, I read in a literature today that 95% of people are going to get better within 6 weeks. No one stopped really to say what does ‘better' mean? Well, symptomatically, they feel better so their symptoms are reduced or gone. But it doesn't explain what's gone on in their body from the episode of back pain and from that standpoint and, particularly as a physical therapist who's looked at a lot of studies on muscle recruitment, we know that even one episode of back pain can impact the way the muscles work, and, if the muscles aren't working right and we tell them, "Hey, you're better", even though the muscles aren't working right, are doing them a service when we know that 9 out of 10 people that have had back pain once will have it again, that recurring problem, and it seems to be that there is even a possible relationship there between the episode, the muscles not working right, and a recurring situation. So even though they might be feeling better, I want to make sure that they are able to recruit the right muscles again and put it into action with exercise, activity, and work. The other part of it is in that first 6 weeks when somebody is uncomfortable, I think it is of value to be able to help them feel better during that first couple weeks so that they can, in fact, speed the healing process so that they can get back to their usual activity, particularly as it relates to work. Because with people that aren't back at work sooner, there tends to be some potential complications that lead to chronic and disabling problems with back pain.

Dr. Sechrest: I totally agree with that. I think that in our patients, when we refer to a physical therapist, the two things that we tell patients are that 1) I'm sending you to a physical therapist because I think it's going to make you feel better, I think it's going to improve your symptoms, and I think it's going to shorten the course of this acute back strain. The second thing I tell them is that even if you feel better after the second visit, this is preventative. This is an education. Now, some of them have already had that education, and with them I'm more interested in just the symptom relief perhaps, but I always ask patients if they feel like they've had a good solid back education program. If they haven't, I'm going to tell them to stick it out for at least a month, maybe 6 weeks, maybe even 2 months, to really get that education, internalize it so that the next time this happens, they've got tools to fall back on. Hopefully they'll work in the meantime to try to strengthen the back muscles and that sort of stuff as you've mentioned.

Brent Dodge: I just really appreciate the fact that you provide that education because I've seen numerous times where people come in, they haven't gotten the educational piece, we do our treatments and we're successful early on, those people think "hey, I'm feeling good, I don't have a problem" and away they go and they show up on the schedule 6 months later with a recurrent problem. I think the fact that you're presenting that to them makes it a little easier for the physical therapist whose sometimes like a car salesman saying, "I know I can make you feel better, but there is more to back pain than just symptom relief."

Dr. Sechrest: Well, let's talk a little bit about the duration of physical therapy because I think a lot of patients are a little bit impatient. They start feeling better and they don't want to make those physical therapy appointments. They may not even want to engage in an exercise program. It takes a minimum of 3 weeks, I guess, is the party line, 3 weeks to establish a new routine. So a new habit or something such as an exercise program, you're going to have to do it for 3 weeks before you even have a breath of a chance to continue it. When you start with a patient, let's say they've had that 2nd or 3rd episode of low back pain, the physician has sent them to the physical therapist, you've got them comfortable maybe on the 1st week; how long should they plan on being in physical therapy, formal physical therapy with a therapist at that point? Is this a 4 week process? An 8 week process? A 6 month process? How long do you think it typically takes?

Brent Dodge: You know everyone is different. Everyone's learning style and speed may be different. I think from a very general and broad approach, if I could have 4 weeks with someone to help them through that learning curve with 2 times a week guidance. Some people say, "Well, we should be able to do it in one visit." I know we're good but I don't know that we're that good, because I feel like the added visit a week gives that reinforcement of the educational piece that we're trying to deliver to folks. But within a month, true, like you mentioned the 21 day period where you're creating that habit, but to have that coaching along the way in case something goes awry, there's a bit of a flare-up, reviewing the principles of taking care of that, I would say on average, if I could have 4 weeks with people, I seem to have a good impact and cover the curricula that we want them to know.

Dr. Sechrest: And what about a patient that you feel like, let's say it's one of your patients that 2 years ago went through that initial program with your clinic. 2 years later they've had a new episode of low back pain. Do they need to come back and see you? Is there any utility in that? Or should they have the tools to deal with this themselves?

Brent Dodge: Well, I wouldn't want to underestimate the problem of low back pain. I would like to think that people that go through that we help get better balance in their body, get their muscles working again, provide them educational tools, even tools that they can refer back to in the event of a flare-up would be adequate to help them through a potential flare-up. I know back pain can be troubling to the point they do need some symptomatic relief and it's at that time, when they come in, we can review things and just make sure that they're clear. If it's been two years, out of sight out of mind, it's a good time to review, but if they've got a foundation and certainly move through that information a little more quickly. But, again, back pain being such a recurring problem, I think that's when they can come back, get the help they need, and they're 2 steps ahead.

Dr. Sechrest: And what about manipulation at that point? I'm assuming that that still provide some symptomatic care. So, if I'm 2 years out from my initial episode, my back is tweaked again so to speak, manipulation can help those people?

Brent Dodge: Oh, indeed. Again, for acute onset, whether that's the first episode, a recurring episode, those seem to be the ones that fit that category the best and we use it most definitely for a recurring problem. Again, I don't know that a manipulation just fixes problems. There are some schools of thought that say, "If I could just manipulate this everything is going to be fine." There is even some suggestion that if I can manipulate it I can the muscles reactivated and working right. To an extent I've seen literature that supports that, but I think that getting that body back in tune and then doing the treatments that help them get back to function would be the piece that they can't do on their own, for sure.

Dr. Sechrest: This has been an incredibly good discussion about what I would say is the most conservative route for the treatment of low back pain in an age where most people are thinking, "Gosh, my back's hurting. Do I need surgery? Gosh, my back's hurting. Do I need an injection or something or pain pills or whatever?" I think that what you've just described is the most efficient and most effective, and probably the least risky approach, at least initially, for most people with nonspecific low back pain. Now I'm going to put you on the spot and I'm going to ask you a question because there has been some discussion all over the country about whether or not back pain patients may not be better off directly seeing a physical therapist rather than seeing a physician, going to the emergency room, or anything. What are your thoughts on that?

Brent Dodge: Well, I know that there are some countries where that's expected. That a person would go first to a physical therapist, and, I think, with the educational piece that we've been working through over the last 15 years, I've been in physical therapy now almost 18 years, physical therapists are equipped to be able to see somebody, do an assessment, and define if this person right for physical therapy, or does this person need to see a specialist, a physician, a chiropractor, somebody that might provide a different level of service? We know what constitutes an appropriate candidate for physical therapy from a musculoskeletal standpoint, meaning there's not a tumor, there's not a fracture, these kinds of things. We can rule that out and make a determination that this person is at the right place right now and I happen to work in a setting where there is 4000 members of a fitness facility that walk in my door and have direct access to me and need to be able to know is that a sport injury? Is that overuse? Is that simple back pain? Or is there more going on here and not be hesitant to say, "I need you to go see your doctor before we can implement physical therapy".

Dr. Sechrest: Do you think that in this country, in the foreseeable future, we will see the physical therapist becoming what we would consider a primary care practitioner that actually has that direct access as just a matter of course?

Brent Dodge: Well, I know more and more states are going to a direct access model and it largely becomes a matter of our educational piece where now nearly all physical therapy schools have moved to a doctoral program and specifically are implementing educational pieces on, you know, clearing people of red flags, making sure that they're appropriate. So, I think that leads to the next logical piece, yes, we're the practitioner of choice for, particularly, simple back pain. Whether or not that becomes something that insurance companies will pay for, some are, and I think there is a benefit because people can get right in, they don't need to wait around, they can get the care they need, and knowing what guidelines are available for physical therapists and for physical therapists that know how to classify people, we can go right in and get the right treatment quickly, get them on a treatment plan, and see good results.

Dr. Sechrest: Well, I think that we've covered just about everything that I had hoped we would cover during this discussion. Is there anything that you think patients should know that we have not covered tonight?

Brent Dodge: I think there is. One of the pieces of our examination that may not make sense to clients is, "Why are you putting me through a movement assessment when I don't really feel like I have that pain?" Like if my symptoms are gone now, why would you want to assess my body? And from my perspective, particularly working with athletes, and specifically golfers, we put them through a rigorous movement assessment. They think they don't have pain, but we find areas where there are joints or muscles that aren't working right. It won't necessarily require manipulation but, based on the movement screen, we can know that this is tight, this is weak, this is imbalanced, and that will further direct care to make sure that they are back in balance so that this recurring problem doesn't affect them, or hopefully doesn't affect them. So patients find it strange when we're putting through a movement assessment and one movement doesn't hurt, but yet we key in on that because it may be affecting something that otherwise was painful. For example, somebody may have pain right at the end of back bending. They arched their back and they feel pain. But then I watch them and they can't touch their toes and I think, "Okay, not everybody has to be able to touch their toes, but I want to see a reasonable semblance of flexibility through the low back, the hips, and the hamstring muscles." And as soon as I start treating the dysfunctional movement, the one that wasn't necessarily painful, a lot of times they can go back into extension and they don't have pain.

Dr. Sechrest: So we're back to that point being that physical therapy is not just about reducing symptoms, it's preventative.

Brent Dodge: Exactly.

Dr. Sechrest: And you have to key in to those things and really stick to it to have some long-term impact and we're really back to a wellness model. A model of trying to optimize function and reduce pain in that way rather than just sort of focus on when you have pain.

Brent Dodge: Right. And it's totally true with out athletic folks because they want to perform better. Sometimes it isn't a matter of pain, but can you look at my body and tell me how to perform better? Well, a lot of times we're picking up movement problems that we can then address through hands-on treatment, manipulation, a home exercise program, specific exercises they can carry out at their gym, and they not only feel better, they perform better.

Dr. Sechrest: Well, this was an excellent discussion and I really appreciate you coming by and clarifying the role of the physical therapist and really giving patients excellent information on how to access physical therapy and what to expect. Thank you.

Brent Dodge: Excellent. Thanks for having me.