I see a lot of patients with chronic pain. Pain that started some time ago, maybe without specific cause, and has been consistently intermittent with activity. I get asked a lot of questions about pain and the effect of injury and I’ve answered a lot of people. Often. A lot of times those questions share similar themes, so I thought maybe I should put something together about these questions to better help the next person. The following would best be described…
The painful truth with cold, hard FAQs
Are you going to be able to help me?
I might be able to. There are a great deal of factors that may limit or improve your chances of feeling better. Firstly, how long has this been going on and how did it start? If this has been bothering you for 40 years and started after you got into a major motor vehicle accident causing multiple major injuries with multiple surgeries that followed, PT may help to remove some of the compensations including weaknesses and immobility developed over time.
It would be unethical to tell you that PT will always make you feel better. For some people in certain situations it will bring them greater than 100% relief, for some, you will have absolutely no improvement. This could be for multiple reasons, one of which is psychological state of being.
If you believe PT will do no benefit…
If you believe you are disabled and will be forever…
If you believe the the severity of your injury is directly correlated to intensity of pain…
…You will likely to put yourself into a self-fulfilling prophecy. The information on pain education is VAST, but focuses on patient understanding and interpretation of pain.
I’ve seen a lot of physical therapists already and no one helped. Why are you different?
I trust physical therapists. I know what they have gone through to become one. I know that to call themselves a PT, they must study day and night for weeks on end to pass a very rigorous boards certification.
That being said, not every PT is good for every patient
Some PTs feel that the best way to get a patient better is with exercise. Some feel that the best way to get a patient better is with manual treatment. Some therapists realize that many things could help out patients, but we (PTs) must seek to understand what is most needed for that one person, so we need to spend time and get our hands on them and see how they move, etc…
Every PT has entry level knowledge in their field, assuming they are board certified. After school ends, the real education begins and some PTs keep an ear to the ground and know what would be the best next move, while others have a prefabricated exercise plan and stick to it. Seek to find the former and you will be rewarded.
Should I use Ice or heat?
Do I need Ice?
Ice goes great in a rum in coke, maybe even better in a venti mocha Frappuccino- But on your back from chronic pain? Probably not.
Ice is great for acute injuries, but ice is one of the modalities to fall out of use on the spine for chronic issues (with the exception of use after exercise or physical activity). Ice reduces blood flow (thus inflammation) and decreases pain thru numbing- However, it is most beneficial on purely musculoskeletal issues (primarily knee pain/shoulder pain). The muscular issues in your back are due to them being always compensating for other muscles, meaning you would probably do better with heat. So as far as heat goes, do you need it?
Maybe. But maybe save your time/money. Yes, you’re in pain and yes, heat therapy may help- however the benefit is mostly superficial and can be replicated with nice warm shower as opposed to a costly hot pack
Would you recommend getting electric stimulation, ultrasound, and/or a massage?
My former professor would answer this question in the following manner…
Are you lacking electric in your body?
Are you lacking ultrasound?
The answer is obviously no. However, I find they have their place in the world of rehab and I tend to use, at least the electric stimulation, sometimes. Electric stimulation and ultrasound have their benefits (blocking pain and deep heating respectively), but in the world of chronic pain- they are still a subpar use of time with your physical therapist. My answer to this? I order my patients electric stim units to use on their own time.
What about going out for a massage? I will say this, massages are great to manage high tone (increased tension in the resting contractile state of a muscle) which is seen in compensatory muscle use like in the lower back and neck. However, this MUST be an adjunct to normal treatment or else you will reinjure yourself down the line.
Do I need a special brace or belt/collar?
Bracing is a necessary for certain types of acute fractures in the spine to prevent major injury. Belts are great for providing VERY short term relief (and also can be a fashionable way to hold up your pants if you don’t care for suspenders). I’ll leave bracing to the MDs who prescribe it. Belts (or soft collars for the neck) are great in the acute or extremely painful subacute (>2 wks) setting, for 24-48 hours AT MAX. I think of this as a last ditch reset for your muscles. Any collar or belt will take the place of the stabilizing muscles and thus by using an object to stabilize your spine, the muscles get weaker and eventually atrophy. Not a huge fan
Should I stop (favorite activity)?
I treat all types of patients, but it seems the ones who deal with chronic pain participate less and less with their favorite physical activities. The truth is, for most people, if you decrease the intensity and stay away from the end ranges of your motion, you can still do just about anything. Due to my background, I see many prowrestlers- this group will push through chronic pain and keep bumping around despite the pain. I wouldn’t recommend getting into a wrestling ring, but if they can do that, you can play a round of golf or doubles tennis.
Once you make me better, will I be better for good?
This one is tricky.
There are 3 stages to rehab. The first is the pain/symptom mgmt. stage. Here we focus on decreasing pain to allow people to complete normal everyday activity with a little better ease. If you stop PT after this stage, you will almost definitely come back with pain down the line.
The next stage is improving strength and restoring full ROM. Here we push you a little more within your pain-free range to get you to move better and remove restrictions. If you stop PT after this stage, you likely will come back with pain down the line.
The final stage of rehab is functional training. Here we focus on your specific activities and sports needs and train you in all types of motion to allow you to return to high level activity without issues. If you stop PT after this stage… you may still come back with pain down the line.
Why? Recidivism. Recidivism is the returning of symptoms. As much as you train, it is possible to have symptoms return afterwards no matter what. However, with increased training and proper ROM/strength, research has shown fewer days needed to return to your normal daily life and activities as well as decreased intensity of pain.
What is (herniated disc, stenosis, spondylosis, degenerative disc disease, etc…), How do I make it better?
Super quick version
Herniated disc: Jelly donut between spinal vertebrae squeezed outward and lying on a nerve. Most likely not the cause of new pain after 40 years old. Better with extension, worse with flexion of spine
Stenosis: narrowing of spinal canal (central) or where nerves exit spine (foraminal). Poor nerve function causing weakness. Better with flexion, worse with extension of spine
Spondylosis: Arthritis of spine. Best with neutral spine
DDD: jelly donut with minimal filling. Best with neutral spine
So there you us have it, Most questions are somehow related to these core 8 tips.
Did I miss any?
As always, be well and don’t forget to like and share this article.
Dr. Daniel Davids PT