Mechanical Spinal Pain: Science-Based Management

There are many levels of knowledge in the medical sciences. When it comes to spinal pain, there are multiple causes and multiple treatments available with a wide range of scientific evidence for effectiveness. Assuming the spinal pain is not from psychological issues, tissue other than neuro-musculoskeletal (mechanical), and is not the result of an acute, recent injury, my experience dealing with such patients as a physical therapist informed me that the most effective management has at its "core" (pun intended) the McKenzie Method. This includes a detailed appropriate history and physical evaluation followed by appropriate instruction in lifestyle, movement, posture, and proper active exercise. The use of any passive treatment is not warranted and tends to reinforce the "treatment by others" mindset that is opposite to the patient taking the ACTIVE and responsible role for success (heads-up, chiropractic fans).

Because of the highly individual nature of spinal pain, placing patients in neat experimental and control groups for research studies has produced contradictory results. However, when patients are appropriately chosen, research supports the hypothesis that the McKenzie method was better than manual treatment methods at improving long-term patient pain and disability (link)(link).

This video presents the treatment concepts, with links to more details, including a * Back Pain Self-Assessment Tool

* Disclaimer: Any exercise program addressing spinal pain should only be carried out under qualified individuals with experience using the McKenzie Method.

https://www.amazon.com/Treat-Your-Back-Robin-McKenzie/dp/0987650408/

The Effectiveness Of Common Physical Therapy Modalities

In 2016, I posted an online Continuing Education credit course I developed in 2009 shortly after I retired as a physical therapist:  Alternative Medicine and Physical Therapy (link). Since that course did not fully address heat and cold modalities that are used ubiquitously in orthopedic rehabilitation settings, as well as ultrasound, meditation, and friction massage, this post presents the current understanding of their effectiveness:

COLD

"Traditional cold therapy (e.g., topically icing the injured area) may not be helpful but rather act as a barrier to the recovery process." (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173427/)

"There is limited evidence from randomized clinical trials (RCTs) supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset muscle soreness (DOMS)." (https://pubmed.ncbi.nlm.nih.gov/25526231/)

HEAT

* "Starting of heat treatment immediately after muscle injury promoted the regeneration of muscle fibers." (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9272698/)  * study on rats

"There is limited overall evidence to support the use of topical heat in general; however, RCTs have shown that heat-wrap therapy provides short-term reductions in pain and disability in patients with acute low back pain - - - " (https://pubmed.ncbi.nlm.nih.gov/25526231/

"The positive effects of local heat applications can be observed predominantly in acute conditions." (https://www.sciencedirect.com/science/article/pii/S0003999321005050)

"It is increasingly clear that heat stress promotes signaling mechanisms involved in angiogenesis, muscle hypertrophy, mitochondrial biogenesis, and glucose metabolism through not only elevations in tissue temperature but also other perturbations, including increased intramyocellular calcium and enhanced energy turnover." (https://journals.physiology.org/doi/full/10.1152/japplphysiol.00061.2020)

ULTRASOUND

" - - - has significant promise, but conflicting data remain regarding the parameters used, and further studies are required to fully realize the potential benefits - - - "  (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8235587/)

MEDITATION

"Because the studies examined many different types of meditation and mindfulness practices, and the effects of those practices are hard to measure, results from the studies have been difficult to analyze and may have been interpreted too optimistically." (https://www.nccih.nih.gov/health/meditation-and-mindfulness-what-you-need-to-know)

"Meditation has proven difficult to define as it covers a wide range of dissimilar practices in different traditions." (https://en.wikipedia.org/wiki/Meditation)

"Meditation and mindfulness practices may have a variety of health benefits and may help people improve the quality of their lives. Recent studies have investigated if meditation or mindfulness helps people manage anxiety, stress, depression, pain, or symptoms related to withdrawal from nicotine, alcohol, or opioids. Other studies have looked at the effects of meditation or mindfulness on weight control or sleep quality. However, much of the research on these topics has been preliminary or not scientifically rigorous." (https://www.nccih.nih.gov/health/meditation-and-mindfulness-what-you-need-to-know)

FRICTION MASSAGE

"We can conclude by saying that with the limited evidence, there is still a lot of research to do about friction massage. A lot of RCT’s are lacking a control group, are limited by the small sample size and are only investigating the short-term effects. Therefore it is very difficult to draw conclusions regarding the specific effects of frictions in the treatment of tendinitis and other conditions."  (https://www.physio-pedia.com/Friction_Massage)

Therapeutic Electrical Stimulation Update

Physical therapists and other practitioners have used electrical stimulation for decades with less-than-stellar clinical results that are not backed up by good placebo-controlled, double-blind studies. Presently there are several internet advertisements for deeper electrical stimulation products claiming research in support of such (an example). Unfortunately, such research in this area is also not of high quality because of the nature of chronic musculoskeletal pain. 

I am a retired physical therapist and can testify that good instruction in science-based stretching and strengthening exercises, as well as posture/activity control, is the gold standard in the management of these types of medical problems. I never found any electrical stimulation device adding to long-term results. In summary, let the buyer beware regarding these "new" products. This article is a good update on the effectiveness of all forms of therapeutic electrical stimulation. This article is a good summary of all treatments for chronic musculoskeletal pain.

Therapy And Chiropractic Quackery (Part 3)

Trademarked Treatment Methods

"'Modality empire' is my own term1 for a proprietary method of manual therapy — a sub-discipline — championed and promoted by a single entrepreneur who is likely to suffer from a serious case of healer syndrome. It’s important to know this if you have a chronic pain problem, because so many of the therapies that will be offered to you are the dubious products of modality empires. If you are a manual therapist, especially a massage therapist or chiropractor, you need to understand it too: continuing education should mainly be about acquiring knowledge — with an emphasis on “how to think, not just what to think” (Jason Erickson, HealthArtes.com) — and not just on buying the right to say that you use a trademarked technique."

Click on the link below for an in-depth look at this problem.

The trouble with the toxic tradition of ego-driven, trademarked treatment methods in massage therapy, chiropractic, and physiotherapy

Therapy And Chiropractic Quackery (Part 2)

Structuralism: It's Not Just Chiropractic

"To understand injuries and pain problems and to recover from them more effectively, both patients and professionals need to stop trying to think of the body as a machine that breaks down, and start thinking more in terms of squishy, messy physiology, especially neurology and biochemistry, and even messier psychology and lifestyle factors. Curve balls like medication side effects and subtle pathologies are major drivers of pain.4 Exhaustion, emotional distress,5 smoking,6 and being really out-of-shape are all more important risk factors for pain than any typical “misalignment” has ever been. And then there’s the way chronic pain seems to be a disease in its own right, and the bizarre phenomenon of central sensitization, basically turning up the “volume” on all pain.7 Pain itself is much weirder and more useful to understand — its volatility, its inherent unpredictability8 — than the many mechanical glitches that supposedly cause it."

Click on the link below for an in-depth look at the fallacy of over-interpreting misalignment's cause for pain.

Your Back Is Not Out of Alignment

Therapy And Chiropractic Quackery (Part 1)

Massage Therapy Update

"If scientifically unsupportable practices are surprisingly common with medical massage therapists, they are close to universal among barely-trained and untrained bodyworkers. Many of them aspire to greater skill, but usually don’t do so by studying orthopedics and physical therapy — a project that could occupy anyone for a lifetime — but instead by increasing their repertoire of certifications in proprietary hands-on techniques, most of which are either silly and/or medically unimportant (i.e. pleasant and harmless, but producing no significant therapeutic effect for any important health problem — hot stone massage would be a good example of this).

"And that is why most people still go to a doctor or physiotherapist when they have an obvious injury." 

The link below is one of the best and most recent and complete science-based reviews of the state of research on the effects of massage. If one is interested in availing themselves of this procedure, one had best click on and read the link below.

A review of the science of massage therapy ... such as it is

A review of the science of massage therapy … such as it is

Physical Therapists Do This Now, So Why Bother?

"The blunt truth is that if Walker and his chiropractic colleagues transition their profession to evidence-based practice and do so with intellectual honesty, they will almost certainly find that their profession is not all it's cracked up to be."

The Answer is "No."

Another Activity Used By Athletes With Little Research Support

"It’s incredibly tempting to take health advice from someone who looks like the quintessential picture of good health. Laird Hamilton looks like 50 million bucks in swim trunks, and it’s hard to argue with that. But just as it’s plausible to reason that Hamilton has a healthy respect for the power of the ocean, let’s remember to maintain a healthy respect for medical research, and the health information that flows from it."

For Back Pain, Surfing King Loves Inversion Therapy. Should You?

Dry Needling

Sad to see my former profession, physical therapy, continue to drift into the land of Woo.

If dry needling is not acupuncture, then a PT or a DC or an ND or whoever is free of those onerous requirements and can needle without the worry of acupuncture boards and regulations.

NOTE: I have received a private email from Liz Martin, who is involved with a website called Healthy But Smart. This article generally is supporting my contention on this topic. Just another resource attempting to objectively evaluate acupuncture and dry needling.

Tai Chi And Physical Therapy For Knee Osteoarthritis

"No, exercise works, whether it’s Tai Chi, yoga, Qi Gong, or the regimen developed by a physical therapist. No woo is needed, but that’s not how studies like this are reported by CAM advocates.

Unfortunately, 'rebranding' works."

How CAM rebranding works.

"Alternative Medicine And Physical Therapy": A Course

Many of you know that I am a retired physical therapist and am very vocal against alternatives to medicine in general and chiropractic in particular.  In an attempt to be "Fair and Balanced", this post is a course I presented on-line to physical therapists for Continuing Education credit shortly after I retired in 2008.  Even with the several-year gap, all of it is essentially still pertinent and accurate.  ça se lit bien (it's a good read).

Alternatives To Chiropractic

As a retired orthopedic physical therapist with over 38 years of experience, I believe I have something to offer in the discussion regarding chiropractic.

First of all, it is important to understand the rationale and methods used in the practice of chiropractic that is at odds with known science.  These articles will serve as an introduction to such:

Why Has Physical Therapy Not Replaced Chiropractic?

A review, and update, of the quackery of chiropractic.  I would add, as a retired physical therapist, that the physical therapy profession has also "dropped the ball."  I would have thought by THIS time, my former profession would have achieved recognition for the experts that they (and I was) are in conservative treatment of all neuro-musculo-skeletal dysfunctions.  SMH

https://www.sciencebasedmedicine.org/the-enigma-of-chiropractic-a-brief-review-with-a-perspective-on-chiropractic-as-a-specialty/