FAQ Category: Lumbar Spine

Very small (20 gauge) spinal needles are used in this procedure. After the skin is cleaned (to avoid infection), the physician may inject a local anesthetic under the skin in the area to be treated. You will feel the pinprick of the needle that delivers the numbing agent. But after that, you won’t feel the actual prolotherapy injections.

Your doctor may inject specific sites such as the spinal ligaments and the spinal (facet) joints. Or he or she may palpate for tender points and just inject those areas. With the palpation technique, a numbing agent isn’t used. The patient may find that pushing on the tender points is uncomfortable.

The physician may be able to decrease the number of needle pokes by targeting several ligaments from one needle insertion point. After placing the needle under the skin, it is gently pulled out slightly and redirected to another area without removing and reinserting it.

A very small number of doctors perform prolotherapy with the patients fully sedated (asleep). Patients who are extrememly anxious may want to request this approach, but it does require treatment at a surgical center.

Every insurance company has a list of treatments covered by their plan. Most third-party payers reimburse for traction. If not, a typical session usually costs between $50 and $100. If you are self-paying, the therapist or provider may offer you a discount for a cash payment.

Traction can be provided by physical therapists, chiropractors, or medical physicians trained in the use of this modality. Your policy may specify a certain number of sessions allowed per episode or per year. Be sure and ask about this when making your scheduled appointments.

If you are going to receive benefits from this treatment, you should observe changes in your symptoms within three to six sessions. You may not be completely better, but you’ll have enough improvement to know it’s helping.

If you aren’t getting better, it’s possible that the type of traction needs to be adjusted. Different amounts of force, timing, and direction of pull can give different results. Be sure and talk with your therapist about what is and isn’t working.

Your basic understanding of traction is quite accurate. But the use of traction has been modified and updated as technology has improved and as our understanding of the use of traction has changed.

First, traction may be sustained (held steady) or intermittent (on and off in a repeated cycle). It may be applied manually (the therapist distracts and holds the body part) or by motorized means (on a mechanized table). The force applied may be considered a distraction or traction. Distraction tells us the therapist is attempting to use the force at a specific level or area of the spine. Traction is more of a general dispersion of the force throughout the spine.

Traction can be applied with the patient in many different positions. You may be lying on your back, face down, suspended upright, or even inverted (upside down). Sometimes a special table is used to put the patient’s spine in a specific posture. These tables are split with the upper portion stable and the lower portion adjustable. No harness is needed when using a split table because the force is provided by the body posture or motion of the table.

It sounds like you are in good hands. Finding a therapist who understands how traction works and who doesn’t just apply the same type of traction to all patients is important. However, you may want to ask your therapist more about what she meant and what is intended for future sessions.

Chronic pain affecting any part of the body can be a real challenge to treat. In fact, most experts agree that the goal isn’t to cure as much as it is to manage the pain. Improving function without necessarily decreasing the pain is often the underlying approach to chronic pain.

Pain specialists take a careful history of the patient’s health, past medical treatment, and current health condition. They assess the pain’s severity, duration, and type. A psychosocial history is also taken. This looks at the patient’s values, circumstances, and beliefs. There’s plenty of evidence from studies to show that paying attention to the psychosocial aspect of healing is as important as treating the biologic side of injuries, illness, or disease.

Treatment is usually multimodal, meaning many different tools and approaches are used. This might include a rehabilitation protocol with an occupational and a physical therapist. Medications such as antiinflammatories and analgesics (pain relievers) are used. Analgesics can range from mild choices such as Tylenol to stronger opioids such as Darvocet or Oxycontin.

Drug treatment should be just one part of the overall plan. Keeping in mind the goals of improving pain (if possible) and decreasing disability, the pharmacologic approach is not the central focus of the plan. If necessary, steroid injections may be considered. Surgery is often not helpful so it is not an early treatment option unless there is a clear-cut biologic cause that can be aided by surgery.

When all else fails and pain is unrelieved by any other means, then a spinal pump may be considered. The pump is implanted inside the body with a reservoir or supply of opioid medication. It has a pump delivery system that injects small doses of the pain-relieving drug into the epidural space of the spine. The drug is taken up quickly directly into the nervous system so there is an immediate effect without adverse side effects.

Opioid (narcotic) analgesics are a useful tool for some patients when treating chronic pain. Usually, all other treatment options have been explored without success. Exercise and physical activity, nonopioid analgesics, and anti-inflammatory drugs are the front-line approaches to this problem.

In some cases, steroid injections may be helpful. In all cases, patients should be assessed for fear-avoidance behaviors (FABs) and treated accordingly. FABs have been identified as a major psychosocial factor preventing recovery after a back injury.

The patient is afraid of a reinjury or afraid of doing something that will cause painful symptoms. He or she starts to avoid certain movements or activities out of fear. Some experts say that motion is lotion. Eventually, pain is made worse by this movement avoidance strategy.

When all efforts at corrective treatment have been exhausted, then opioids may be considered. They do have a place in pain management for some patients. These drugs can give eight to 24 hours of pain reduction or pain relief. Their effectiveness depends somewhat on the patient’s biologic ability to absorb and metabolize (use) the drug.

In each case, the drug must be titrated carefully for the patient. This means the type, amount (dose), and frequency is determined by each patient’s response. With proper management, toxicity, dependence, and addiction can be avoided. Sometimes the amount of opioid needed to get the same amount of pain relief increases over time. This may be because the patient develops a tolerance to the drug. Tolerance is not the same as addiction.

When the opioid is working, the patient can start to do more. With increased function, there may be increased pain at the same time. It may be necessary to increase the dose until the pain is under control again. With careful titration, there is a balance between pain, activity level, and side effects.

Together, the patient and the physician monitor the beneficial effects of the medication. Any side effects are reported and treated as needed. Some opioids are meant to be used short-term. Others are known for their long-term effectiveness. Used properly, this class of drug is both safe and effective.

With careful management, they can be used to break the pain-spasm cycle and help patients recover drug-free. Or for patients with chronic pain, they can be used indefinitely to control symptoms, improve function, decrease disability, and increase quality of life for the patient.

You may be helped by a treatment referred to as medicine-assisted manipulation or MAM. The patient is sedated while the therapist performs more forceful stretches and joint mobilizations. For therapists trained in manual therapy, a high-velocity, short-amplitude thrust may be applied to the tight spinal segments. The patient’s upper body and legs are held or stabilized to focus the motion at the spinal segment.

Manipulation under anesthesia may work because the patient’s muscles are relaxed and not resisting the therapist’s efforts to stretch muscles and/or joints. Sedation also makes it more likely that fibrous adhesions blocking motion can be released more effectively.

The therapist is able to stretch the hip and lumbrosacral joints in all planes of motion. Muscles that are holding or shortened cannot relax enough to be stretched. While under anesthesia, these muscles can be lengthened to a more normal position.

Using MAM requires a team approach. It usually involves an anesthesiologist, a trained manual therapist, and a nurse. The manual therapy team is often made up of a chiropractor or osteopath and a physical therapist. Communication among the various team members is important to a successful outcome.

You may want to check with your physician and/or your therapist to see if this treatment is possible in your area. If they do not perform MAM, then perhaps someone else is available to offer this service.

When patients are under the influence of anesthesia, pain, spasm, and muscle guarding or muscle tension is greatly reduced. Manual therapy such as stretching, joint mobilization, and connective tissue release can be done with much less force. Without anesthesia, it can be difficult to overcome muscle resistance from patient apprehension or from uncontrolled muscle spasm.

The theory behind this treatment is that manipulation and mobilizations when properly done can break up fibrous adhesions without causing inflammation that leads to more scar tissue formation. Manipulation can be done after injection of a numbing agent. This is usually lidocaine combined with a steroid. With this type of injection, manual therapy can address both the inflammatory and restrictive factors.

Patients must qualify for this treatment in one of two ways. First, they must be approved by the anesthesiologist. Health problems such as bleeding disorders or heart disease can prevent the use of anesthesia.

Secondly, they must have nonspecific mechanical chronic low back pain. That means there’s no infection, tumor or fracture causing the problem. There’s just something about the way the spine is positioned or moves that is causing the pain. Often there is one or more spinal segments that are hypomobile. Hypomobile means the joint doesn’t move or has less motion than needed for normal movement.

Usually, other less expensive and less invasive forms of treatment are used first before trying medicine-assisted manipulation (MAM). A physical therapist works with the patient to restore normal joint motion and movement in general. Hands-on techniques can be used to stretch muscles and break adhesions in the connective tissue.

If you have hypermobile joints (excessive motion), then you aren’t a good candidate for MAM. Likewise, the presence of tumors, osteoporosis, or spinal stenosis (narrowing of the spinal canal) will exclude you from this treatment.

Chronic lower back pain is very common and, according to statistics, the third most common reason why Americans visit a doctor. Back pain can interfere with the quality of life and in how you live your life.

That being said, there are many causes of back pain and just about as many ways to treat it. It is likely that during your examination, your doctor determined that your back pain isn’t acute or something that could deteriorate into a worse condition. Once this has been ruled out, there are options that the doctor can consider.

One option is called watchful waiting. While it may seem as if nothing is being done, watchful waiting involves keeping a close eye on you and your back, looking for signs of improvement or deterioration. Experience and research have shown that this is a good approach to take in many cases of chronic lower back pain.

If you are concerned with how your back pain is being managed, it is important that you speak with your doctor and as ask as many questions as you need to in order to feel comfortable with your care.

When a patient presents with chronic back pain, the doctor must do a physical examination and take a patient history to try to determine the cause of the back pain. Additional tests may be ordered to look further into the problem.

Several types of back injuries have treatments that are automatically done for that type of problem. However, when it comes to chronic back pain that is not causing severe issues with quality of life, doctors often have to choose what they feel is both best for the patient and what they are most comfortable doing as a physician.

As medications are created and used for their original purpose, doctors often find that these medications also can help with other problems. When this happens often enough, some medications start getting prescribed as off-label, or used for an issue that has not been FDA approved.

In the case of several antidepressants, doctors found that some of them also help relieve pain, although how they do it, researchers aren’t entirely sure. In your mother’s case, if the doctor is monitoring the dosage and any potential side effects, your mother’s pain appears to be responding well to the prescribed medication.

Your fellow EMT may need additional testing to sort out what’s going on. It’s entirely possible there is some underlying serious pathology present that wasn’t detected early on. A medical doctor should be consulted for this. Perhaps a follow-up visit with the evaluating physician is in order.

In some states, Worker’s Compensation requires regular re-evaluation by an occupational health physician. If you do not have this in your state, then returning to the original physician may be a good idea for your partner. Or your co-worker may want to seek a second opinion with a separate, independent doctor.

Another possibility is that your partner is exhibiting fear-avoidance behaviors (FABs). Studies show that psychologic factors can lead to the belief that certain movements will always cause pain or reinjury. Such beliefs lead the person to avoid movement that can actually cause a continued cycle of chronic pain and disability.

An occupational or physical therapist can test for FABs. A special questionnaire called the FABQ is used. The FABQ has two main sections: one on avoidance of general physical activity and one related to work activity. If a person scores high on the test, the therapist can provide a program to work through this.

Many medications are used for illnesses and problems unrelated to their original purpose. In cases of chronic lower back pain, for example, doctors have found that some antidepressants and some antiepileptics are useful in reducing pain, although they don’t really understand how or why.

If your doctor feels that the medication you are taking now is helping you and not harming you, there is likely no reason to worry. Any side effects that you could experience would be side effects that someone with seizures may get. The medication itself shouldn’t cause problems, such as seizures.

The McKenzie method is a unique way to assess and treat patients with low back pain (LBP). It doesn’t work for everyone, but you’ll know early on if you are a good candidate for the treatment.

Most McKenzie practitioners are physical therapists who have taken special training to use this method. The therapist will take a history and perform special tests to find out what patterns of movement make you better or worse. Movements are repeated at the end of the full range of motion until symptoms are improved.

The direction of spinal motion that decreases or relieves pain is referred to as unidirectional preference. Knowing this information guides the therapist in showing you how to manage your own pain. You’ll be given specific exercises to perform. You’ll be shown what positions and movements to avoid for now. And you’ll be instructed in correct postures to help with the healing process.

Patients for whom symptoms cannot be centralized with this technique may have a poor prognosis. Centralization means that symptoms going down the back into the buttock and leg retreat. In other words, the pain moves to the central portion of the low back region. Over time (and sometimes right away), the pain gets less and goes away.

The therapist will work with you to find the best treatment for your situation. If the McKenzie approach isn’t successful, there are other treatment methods to use. The therapist is trained to use many different approaches. Current evidence supports treatment of LBP patients based on classification and subgroups. The McKenzie approach includes a method by which the therapist makes this decision.

Back in the 1950s, a physical therapist by the name of Robin McKenzie made a new discovery about back pain. He found that although certain movements seem to make back pain worse, repeating these movements or holding a specific position for a period of time actually made the symptoms better.

Over the years, this idea has been explored and studied and is now referred to as the McKenzie method. Physical therapists trained in the McKenzie approach test patients until they find the unidirectional preference.

This is the motion or position at end range of spinal movement that provides centralization or relief of pain. Centralization means the pain moves from further down the leg and/or buttock up into the middle of the low back region.

The McKenzie method divides or classifies patients into one of three groups. These include derangement, dysfunction, and postural syndrome. Each of these types of back presentation have distintive pain responses. Treatment is based on which group the patient is in.

Pain is centralized with derangement syndromes. Directional preferences are easily identified for these patients. Dysfunction syndrome occurs in patients with chronic low back pain (LBP). No quick changes are observed with repeated movements. Most often this syndrome is caused by scar tissue around the spinal nerve root. The pain occurs when the nerve root is stretched and the scar tissue constricts or presses on the nerve.

The postural syndrome comes and goes and is not usually associated with chronic LBP. Staying in one position too long seems to bring on the symptoms of this condition. Postural training to correct normal spinal positions and movement is usually successful with this group.

Once you have been diagnosed, treatment begins based on the classification group you are in. The fact that your symptoms can be altered or provoked (made worse) suggests that the McKenzie approach may be the right treatment for you.

The practice of homeopathy was founded by a German physician (Samuel Hahnemann) in the late 1700s. He discovered that by giving substances called remedies to healthy people, he could produce certain symptoms.

Then he took those substances and diluted them down and gave them to patients with the same symptoms. The effect of taking a small amount of the remedy was to alleviate or reduce the patient’s symptoms.

More and more people are seeking non-traditional care for their health concerns. People suffering from chronic back pain who have not been helped by traditional treatment may seek out homeopathic treatment.

There aren’t very many studies comparing homeopathy to other treatments. And the studies that are being done are conducted in other countries with publication in languages other than English. There is a definite need for further investigation into the mechanisms, effects, and safety of homeopathic remedies.

Devil’s claw (also known as harpagophytum procumbens) is an herb used by some in the treatment of low back pain. It comes from a plant in South Africa and has several medicinal uses.

Scientists are trying to unravel the mechanisms behind treatment with herbal supplements like Devil’s claw. This plant (along with many others) has been the subject of many biochemical research projects.

Review of current studies show that a daily dose of 50 mg of Devil’s claw reduced back pain more than placebo (sugar pill with no known benefit). One study comparing Devil’s claw with an antiinflammatory drug (rofecoxib) showed that Devil’s claw worked just as well as the drug.

Devil’s claw can cause GI upset such increased stomach acid. Blood sugar problems can occur, decreased blood pressure, and changes in how drugs are used in the body. The effects are minimal and temporary. Only a small number of people have any side effects or adverse response to this herb.

Usually a letter of justification supporting the medical necessity of such a program is needed by the patient’s physician. Your doctor will summarize all of his or her findings. Reasons for this recommendation are outlined.

Studies support the benefit of FR when looking for ways to manage chronic low back pain that help the patient get back to work. A team approach with nursing, physical therapy, occupational therapy, and nutritional and behavioral counseling is used.

At first glance, FR may seem more costly than usual or standard care. But studies show that over time, usual care ends up costing twice as much as FR. The reason for this is that FR reduces disability and reduces the risk of reinjury. With standard care, many patients end up coming back to see the health care provider over and over.

If your insurance carrier does not change their policy for you, there may still be a way to obtain the services you need. Reimbursement can be billed for on an individual basis.

There are codes that each health care provider relies upon for payment. For example, the physical therapist can bill for therapeutic exercise, biofeedback, or neuromuscular re-education. The psychologist can bill for individual psychotherapy or behavior modification. Other codes are available for other health care specialists.

You’ll have to check and find out what services your policy covers and pay out-of-pocket for those that are not covered.

Actually, it’s likely that he would benefit from a combination of both treatments. Study after study shows that addressing all aspects of the biologic, psychologic, and social factors is very helpful. A psychologist can offer your father better ways to think about his condition and better coping skills. The end result may not be less pain but improved function despite the pain.

A specific type of psychosocial approach often used with chronic pain patients is called cognitive behavioral therapy (CBT). The psychologist using this method will help your father identify ways in which his thoughts and behaviors might make his pain worse. Replacing those with more adaptive coping skills often helps reduce pain and anxiety. Overall, the patient’s quality of life is improved.

At the same time, a program of activity and exercise can help improve fitness and may even reduce pain. Exercise has been shown to increase endorphins in the body. These natural opioid substances reduce pain and enhance a sense of well-being. Exercise improves circulation, which can help tissues heal. And physical fitness is always a good tool against reinjury.

In addition to CBT and exercise, good nutrition is always advised. Getting the right kinds of food in the right amounts helps patients avoid the added stress of being overweight or obese. Exercise combined with good diet and good thinking will result in overall improved health and happiness for many people suffering from chronic pain syndromes.

Encourage your father to seek all avenues of improving his health. Starting with psychologic counseling can’t hurt and may very well help.

You ask a very good question, however, it has no easy answer. There is no one specific person who is best equipped to treat back pain. While the back pain may seem common from person to person, the different causes of pain and the individual patient circumstances can change who would be the best treating professional.

Some people feel best by going to what is called allied professional, such as chiropractors. Others would prefer to only see a doctor – but it could be one of many different specialties. A family physician with experience treating back pain may be the logical choice for some people, but not others.

The problem with treating back pain is that there are so many options that you could have five people with very similar back pain all being treated differently.

Acupuncture falls into the alternative or complementary medicine category. Many people rely on acupuncture to help them with various health issues.

For the most part, if you are seeing an acupuncturist who is well versed in the profession, uses sterile needles and technique, there should be no reason not to try this form of treatment if you wish to.

However, that being said, your treating physician or physicians should always be made aware of any additional treatments you are receiving – whether it is by taking products from a naturopath or receiving acupuncture.