Patients presenting to physical therapy with complaints of low back pain (LBP) historically progress well over the course of treatment. Depending on the patient’s signs & symptoms, a successful treatment regimen may consist of a combination of patient education, manual therapy, stretching, postural and/or ergonomic changes, and a home program for long-term success. Unfortunately, a recent editorial by Beattie, PF et al., in the Journal of Orthopedic Sports Physical Therapy, stated that the improvements made in physical therapy when treating patients with LBP decrease when reassessed at long-term follow-ups. At Life’s Work Physical Therapy (LWPT), we have also noticed this trend, and the treatment strategies that Beattie suggests in this article are the same strategies we use in order to improve long-term outcomes in patients with chronic LBP. Below is a summary of the suggestions he states to improve treatment success:
- Emphasize the importance of self-management by making it a fundamental goal of treatment right from the beginning. Part of the lack of success in long-term outcomes is the failure to comply with a long-term home program for self-management. Most patients present with chronic LBP cannot be quickly treated. Setting the stage of expectations from the patient from the start, and getting the patient to be a part of the rehab process early helps with this compliance. The patient must understand what is going on with their back, why they have not had success in the past, and their home program must make sense to them with regards to their condition in order for them to comply for the long-term. They must also understand how to self-check various objective findings that the PT feels adversely affects their low back, and have strategies in place to improve those findings on their own in order to manage their own back pain for the long-haul.
- Consider patient preference as the fundamental construct of the program. Active participation for the long-term requires the patient to ‘buy-in’ to the program, and a recent article by Jeffrey and Foster found that physical therapists often face conflicts with patients regarding treatment approaches. There are two parts to this:
- If the patient has a different feeling of what will improve their pain, it is the PT’s job to spend the time educating the patient why a shift in belief is important. At LWPT, we do not actively treat until the patient understands ‘why’ first. When a patient understands the process, and believes in it, fear of their problem and pain levels tend to begin improving.
- As Mark Twain once said, “There are many ways to skin a cat.” If a patient is set that certain things will help, it is not bad to find ways to incorporate that philosophy into the program, as long as you feel it is safe for the patient and the objective findings are improving like they should over the course of treatment. PT’s need to be flexible in their thinking too, just like the PT expects the patient to be open-minded in the rehabilitation process.
Also, the home program has to be one that is appropriate for the patient. Never make a gym program for a patient that does not use a gym outside of PT. Your physical therapist should ask the patient what their activity preference is, and formulate a program that matches those desires if it is expected to be completed over the long-term.
- Maintain the therapeutic alliance with long-term follow-ups. Back pain, over the long-term, will come and go. Expecting ‘flare-ups’ after discharge is to be expected, but the patient should have strategies to combat those exacerbations when they occur. Physical therapists are slowly becoming primary care providers for musculoskeletal disorders, and once you find a physical therapist you trust, they should be your physical therapist for the course of your life. Infrequent follow-up visits, or check-ups, allow the therapist to reexamine the low back, look at the home program and ability to comply to it, and tweak it as needed depending on what he/she feels is relevant for each patient.
At Life’s Work Physical Therapy, we track our patient outcomes on a quarterly basis. Our outcomes are consistently better than the national averages when treating LBP because we take this approach in managing patients with chronic LBP. Each patient is different, and must be treated individually. Each home program is individually designed to meet their individual goals, expectations, and the therapist must be courteous to each patient’s beliefs regarding their low back pain. When this occurs, good things happen, and self-management for the long-term becomes a reality.
Beattie PF, Silifies SP. Improving long-term outcomes for chronic low back pain: time for a new paradigm. JOSPT. 2015 (45)4;236-239.