Physical therapist are professional health care providers that specifically trained in treating musculo-skelethal disorders. Their education could have concentrated on specific disease processes. Orthopedic surgeons usually try to refer patients to therapist that are courteous, and knowledgeable in the specific disease at hand. The treatment usually begins with a through physical examination including range of motion measurement, palpation of painful areas, determination of pain intensity, and posture. Based on the initial evaluation, a treatment plan will be set forward to achieve realistic goals for each patient. Different modalities will be used by the therapist which include: Heat/Ice (or the so called Contrast therapy) application, TENS units, Iontophoresis, Ultrasound, Soft tissue mobilization/Massage. Exercise: By far the most beneficial technique used in physical therapy is exercise. Many different exercise programs are available for different conditions. Enormous amount of research is available in support of exercise programs to benefit almost every aspect of the human body. In addition to physical benefits, there is no question regarding the mental benefits of exercise. Research was also concentrated on specific exercises geared towards treating specific conditions like the McKenzie exercises to treat herniated disc. In this section we will reference weight training, endurance training, aerobic conditioning, stretching, lumbar stabilization exercises, McKenzie exercises, water therapy, and dynamic lumbar (low back) stabilization exercises. We must remember that exercise also benefit bone density, improves mental well being, improves our cosmetic appearance, prevents pain recurrence, benefits our cardio-vascular system, improves, expedites, and strengths bony fusions after surgery, and probably many other benefits still unknown to the medical community. Even though exercise is almost always beneficial, in individuals recovering from surgery, or suffering from back pain, exercise must be guided, well controlled, and supervised by your physician and therapist to avoid further injury. Consult your physician regarding these issues and use their judgment, knowledge, and experience to arrive at an appropriate exercise plan.
The table below are instructions for the physical therapist treating back conditions. The exercise program begins with the least strenuous exercises and slowly advances to more intense activities. The patient is started with simple exercises and advances up in the programs depending on their individual capacity. If the patient experiences pain then the therapist should back down and slow down the progress. Pain is not part of the protocol (specifically sharp, intense pain), however, some soreness is part of any exercise programs.
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Heat and cold therapy is often used to modify inflammation and increase blood flow to the area. Although the exact mechanism for pain relief is not yet known we suggest the use of ice in the initial periods of injury. Ice will narrow vessels that deliver inflammatory cells to the affected area. By reducing inflammation, we hope to reduce pain and swelling. Ice should be applied for 20 minutes every 2 hours. The ice should be wrapped in a towel to avoid skin irritation. In comparison, heat is recommended after the injury is stabilized and inflammation has stopped. This usually occurs after a few days. Heat therapy will relieve spasm by relaxing muscle fibers, and will open blood vessels increasing the flow of blood. This will flush away chemicals that have been concentrating in the area of soreness. Hot pack are placed for 15-20 minutes every few hours and must be wrapped in few layers to avoid skin injury.
Iontophoresis uses high frequency sound waves like ultrasound to "push" medication through the skin down deep in the soft tissues. Since steroids have the best anti-inflammatory properties, they are most commonly used. Lotions with high concentration of steroids are placed over the skin and then the ultra-sound probe is used to perform this therapy. Although effective, injections of steroids are more precise but could only be delivered to one localized area. Iontophoresis delivers the medications to a wider area.
Ultrasound produces high frequency sound waves that are targeted to the affected area. The delivered waves cause molecules in the deep tissues to vibrate and warm these tissues. The produced heat functions in the same manner as heat therapy. The advantage of ultrasound over heat pack is the effect on the deeper tissues.
Electrical stimulation is a technique used to stimulate nerves and muscles in order to desensitize affected nerve endings, and condition affected muscles. By providing electrical stimulation, sensation of pain decreases as more concentration is placed on the electrical stimulation. At the same time, muscular contractions work in a similar fashion to a massage. Some research studies pointed that this stimulation produces endorphins. Endorphins are natural chemicals produces by the body that enhances mood and make us feel better. Through these mechanisms pain decreases which in turn decreases muscle spasm, again decreasing pain. Often a TENS (transcutaneous electrical nerve stimulation) is utilized since it could be used the entire day while the patient is active in other daily activities. TENS units are prescribed by your spine surgeon.
Massage and soft tissue mobilization: most physical therapists get trained in massage therapy and mobilization. These techniques help reduce muscle spasm and increase fascial gliding. By increasing flexibility of soft tissues muscle and fascia pain decreases and the cycle of spasm and pain may be stopped. Massage also stimulates blood vessels to dilate increases blood flow to the region. Oxygen supply increases and irritant chemicals are flushed away. Myofascial releases improve gliding of skin and muscle over each other and increase range of motion. In addition to these techniques massage therapy increases Endorphin release from the brain enhancing the general well being of patients.
Joint mobilization and range of motion exercises: This is one of the most commonly utilized technique for the orthopedic patient. Passive range of motion refers to motions produces by the therapist and active range of motion refers to motion performed by the patient. Active resisted range of motion help increase muscle strength and endurance while passive range of motion is used in patients to increase joint lubrication and prevent adhesions within the joints. The therapist will direct these motions to prevent further injury while maximizing benefit. There are areas of controversy regarding theories of joint mobilization but in general these techniques are thought to be beneficial. The Sacro-Iliac joint is a large joint in the pelvis and is a common source of pain and disability. Orthopedic surgeons believe that there is very little motion in that joint as opposed to chiropractors and physical therapist who think otherwise. Many techniques exist for mobilization of the subluxed SI joint but their efficacy is questionable. Subluxations result from high energy traumatic events like sever car accidents not from normal daily activities. For this reason the idea of the subluxed SI joint is not commonly accepted among spine surgeons. However, the techniques utilized by therapist and chiropractors to "reduce" a "subluxed" joint are not harmful and some patient gain an unexplained relief. With that in mind we do not discourage patients from undergoing such treatments on the SI joint. Joint mobilization increases range of motion, reduces pain, and stimulates cartilage nutrition by increasing joint fluid and its recycle. Furthermore it stretches the surrounding supporting tendons and ligament improving motion and reducing pain.
Traction: This technique works on specific areas of the body by pulling the affected body part. Very beneficial to the neck, it is utilized commonly with patients suffering from nerve pain. It increases the height of the intervertebral disc and opens the tunnels of the passing nerves. It also elongates muscle fibers, ligaments, and tendons. Like range of motion exercises and massage therapy, traction increases motions and improves gliding of supporting structures. Since the neck is closer to the applied force, the effects of traction is superior in the neck as compared to the lumbar spine. Great forces, which can not be applied to the human body, are needed to cause any effect on low back conditions. For this reason we do not support the chiropractic theory of traction for the lumbar spine. We believe that any action placed on our patients must have scientific basis and will not endorse certain chiropractic theories. However, chiropractic care is beneficial if performed by competent chiropractors having realistic goals. There are few techniques in the application of traction. The traction beds are most efficient and effective. We can also provide you with relatively simple device which can be placed at home. It uses a bad filled with water. The higher the water level in the container, the more weight is applied and resultant more traction. We usually begin with lower weights and gradually increase the weight to a comfortable level. Many patients report improvement of pain within a few days.
Stretching: The spinal column is designed to maximize motion while maintaining stability. To achieve both of these tasks an intricate and complicated system is in place which includes bones, ligaments, tendons, muscles, and nerves. Disease processes begin when the balance between motion and stability is lost. An example is the degenerative disc disease which is commonly seen. When a spinal segment is diseased, motion decreases and stiffness ensues. Almost all patients will benefit from stretching but to different degree and length of time needed to achieve their goals. Patients with chronic (extended) pain may take months to achieve relief. Generally, the longer the pain was present prior to therapy, the longer it will take to achieve the desired results. Stretching of soft tissues around the spine will increase range of motion in the affected joints, increase joint lubricating fluids, and enhance flexibility. This will usually result in decrease of pain and enhanced life style.
Although somewhat remote from the spine, the Hamstring muscles play a major role in the function and posture of the spine. The Hamstrings are the muscle found in the back of the thigh. Frequently, patients with bad posture and back pain have tight hamstrings. The cause and effect of this situation is unknown, but we know that hamstring stretching increases motion of the spine and improves pelvic tilt leading to a better posture. This posture may translate into less back pain and decreases the recurrence of pain attacks. We regard the posture of the pelvis as the back bone of our posture. Try tilting your pelvis back and forth while paying attention to the positional changes of your neck. As your pelvis tilts back, your neck will be better positioned over your shoulders. This is the basis for trunk stabilization exercises and postural enhancement. Pressure should be applied to raise and extend the knee (making it straight) while the patient lays in their back. Bending towards the floor while keeping knees straight is another method. Other methods are to place the legs on a chair in front of you while seated. Keep the knee straight and stretch the tendons in the back of knee and thigh. Stretching exercises should be performed daily to achieve effective results. Morning stretching exercises are good since the activity is regarded as a morning routine.
Aerobic conditioning and endurance training: Patients that are aerobically conditioned will have fewer back problems and decreased recurrence rates of painful episodes. Knowledge from research have shown that female patients with weaker backs as compared to their male counterparts benefit from back muscle strengthening and males with strenuous occupations benefit more from endurance training. Endurance training refers to the length of time a patient participates in an exercise while strength training refers to the amount of weight the back muscle can lift. Well conditioned patients are more likely to stay active and functional while patients that have pain and not conditioned are likely to loose even more function since they use their back muscle less often. In order to have aerobic benefit, exercises need to be continuous for minimum of 20 minutes ideally for 30-40 minutes at least three times a week. Often chemicals are released into the blood stream called Endorphins. This are chemical like Morphine which are produced naturally by the body and give us an elevated mood. Runner often refer to "runner high" which is the result of endorphin release by the athlete. Other forms of aerobic exercises include walking, Stairmaster climbing, the Eclipse machine, swimming, and use of the treadmill.
Water therapy is a relatively new form of exercise. Advocates of this technique emphasis on the fact that water has a protective function by reducing the perceived weight of our body and providing increase resistance to motion. However, the relative weightlessness that water provides prevents bone forming stimulation to maintain healthy dense bone. Some surgeons will not recommend this treatment since this therapy does not place the necessary forces on our joints to stimulate cartilage nutrition and strengthening. These controversial issues exist mainly due to lack of appropriate research. We hope that in the near future well designed studies will provide more insight into this issue. Post operative patients should avoid participation in water therapy for at least 4 weeks after the surgical procedure. Even though patients can take showers 10 days after surgery, their wound should not be submerged in water for one month to avoid wound problems.
McKenzie exercises: This type of exercise is very common and is used frequently with patients suffering from herniated lumbar discs. It was introduced in New Zeeland and found its way throughout the world. The basic concept of this exercise is extension of the spine in the hope of squeezing the herniated material back into the disc space. Many forms of extension exercises exist like laying on ones stomach while performing back extension or laying of a large rubber ball performing the same basic motions. Even though these exercises could be quit effective in treating a herniated disc, some patients may have sever enough pain to prevent participation in any exercise program. If possible these exercises should be performed at home even without a therapist. If the diagnosis is not clear then this exercise program could stimulate and increase pain. Patients with spinal stenosis or facet arthritis will feel more pain with extension (straightening) of the spine. Patient with facet arthritis or spinal stenosis usually benefit from flexion (bending) exercises.
Dynamic lumbar stabilization exercises: It is well known that the pelvis is the base of the spine and its posture and position will help and guide the posture and position of the spine. If the pelvis is mal-aligned or held in a tilted position, the spine in turn will assume an unnatural position as well. We must look a bit further at the legs since the hamstring muscle group is connected to the pelvis. The Hamstring muscles reside in the back of the thigh and connect the legs to the pelvis. In cases of hamstring tightness the pelvis is pulled down assuming a bad position. Stretching of the hamstrings will help and enhance pelvic position. When the pelvis is positioned correctly the spine will assume better posture and eventually may reduce back pain. Even neck position can be improved with pelvic stabilization exercises. After the correct position is found, appropriate exercises are designed to maintain that position. These exercises rely on proprioception (awareness of body part position) to hold the correct position. Performed regularly, these exercises could maintain correct posture and spinal balance resulting in less recurrence of back pain.