In my last blog I explained what is called the “natural history” of back pain and elaborated on how the overwhelming majority of all back pain will be significantly better or fully resolved in 6 weeks or less---if you do nothing. In other words, it most oftentimes gets better on its own. I also mentioned that the problem is, the pains usually recur. That is to say, the pains come back, usually repeatedly and over the course of months or years the episodes of pain can become progressively worse.
As a result, the best course of action is to embark on a treatment plan that places a heavy emphasis on the prevention of recurrence. The good news is, this can be done and very successfully. Ok, so if this is the best way to go, why doesn’t everybody do it? The reasons fall into two broad categories:
Let’s assume your pain began early in the day, and by evening, not only has your lower back gotten no better, but you are now beginning to experience an increasing pain going from your lower back down your right leg. Any attempts to bend either forward or to straighten up are met with additional sharp pains. When you stand slightly bent forward, this seems to be the position that very slightly reduces your pain, but lying down is your best position for now.
What I’ve just described is a very common clinical scenario for someone with acute lower back pain. In a case like this, it would be highly counter-intuitive for you to make repeated attempts to straighten up or bend backward. After all, attempting to straighten up increases your pain. Additionally, when attempting to straighten up or bend backward, you feel like something inside your lower back is "blocking" you from going in that direction. But yet, this may well be exactly what is needed for you to not only decrease the pain, but to abolish it altogether and in a rapid manner. Most importantly this may well the first step with regard to successfully preventing future episodes. And prevention of future episodes of pain is after what we are after.
What you need at this point is a coach. Someone with training and experience who can confidently, clearly, and yes, repeatedly explain and demonstrate to you that beginning the process of bending backward and straightening up, although initially painful in the lower back, will decrease the pain in your leg. This coach will also repeatedly and diplomatically explain to you that increases in the center of your lower back are a good sign and should be taken as an indicator that the exercises and position prescribed are taking you down the correct path to fully resolving your pains. Fully convincing a patient of all this, a patient that is already anxious, in pain, frightened and probably agitated is not easy, to say the least. It requires patience, persistence, repetition, repeated demonstrations and resolve---on the part of the coach. In short what you need is a good physical therapist. And a good physical therapist, with all of the above qualities, is rare indeed.
Much more likely is the chance that you will receive a therapist that will provide some low-grade palliative treatment such as some form of heat, therapeutic ultrasound, low level traction, electrical stimulation, massage, manual mobilization and instructions to assume positions of least pain, positions which you have already intuitively discovered to provide you with some minimal pain relief. This type of treatment will be given for several sessions as the passage of time provides its reductions of your pain (the natural history). In a few weeks to a few months your pain will, in all likelihood, return, and the whole cycle will be repeated.
Now let’s move on to what I meant when I said, “It’s difficult.” I meant its difficult, not just for the patient experiencing the pain, but also for the therapist. To tolerantly explain to a patient that straightening-up and beginning the process of bending backward is the best therapeutic approach, with some patients, can be very time consuming, tedious, frustrating, stressful and understandably met with some resistance and hesitation on the part of the patient. After all, broadly speaking, the therapist is now trying to convince the patient that an increase in pain is a good thing. Keep in mind, the patient has sought out professional help, is paying a fee and has taken the time and effort to come into a clinic to get one thing and one thing only: pain relief, not pain increases.
The process of reducing pain in the leg, at the expense of (temporarily) increasing pain in the lower back is definitely a good sign and is, in fact, one of the best indicators with regard to determining the correct movements and exercises. Additionally, there are now good scientific studies showing that if your pain moves toward the center of your spine (even at the expenses of temporarily increasing central back pain), and the pain decreases in the leg, your chances for a full recovery are excellent. Nevertheless, this can be a “tough sell” to a patient already in pain and desiring quick relief.
For the therapist providing care in a busy clinic, where the therapist is under the pressure of productivity quotas and ratings, in a clinic where other therapists are providing only temporary, palliative treatments, easy-to-apply treatments that are met with minimal, if any, resistance by the patient and doing so in a much less stressful environment, with less time commitment, it can be very tempting for the therapist to take the path of least resistance and begin treating patients with a less labor intensive approach.
Combine 1)Human Nature and the inherent 2) Difficulty of providing better quality care and it is understandable why “not everyone does it”.
There is one additional issue I want to mention: The reward that comes from doing the right thing. (And yes, many patients do in fact appreciate it.) There is also the satisfaction that comes from being able to successfully treat a patient using your intellectual skills and knowledge rather than simply doing what is “easy”. The choice for a physical therapist, as to which treatment approach to select, is still, red pill or blue pill. I made my choice many years ago.