Relieve Low Back Pain | Reduce Low Back Pain | Canada's Leading Authority in Human Movement | Dev Chengkalath

Putting it all together: Treatment

You’ve now completed your medical history, you’ve been observed, you’ve been put through all the physical tests…

So what does it all mean?

The treatment component of the physiotherapy visit is where everything should come together and get you started back on the path to doing what you love to do, be it playing with your kids, gardening or high performance sport.

As discussed previously, the history and observation gave us the clues to set up the physical tests. The physical tests in turn gave us your baseline data; the “what you need to fix”.

The treatment is where all that information is put to good use. This is where it is processed, analyzed and converted in to a physical rehabilitation or performance program.

What exactly does this program entail?

Well, in my books, each program should cover three major aspects.

If any of these three are lacking, there is risk of perpetuating or exacerbating the injury or dysfunction.

Using a client with low back pain as the example, this is how I would potentially set up a treatment plan.

Knowledge is power

1. Knowledge: Does my client know what component(s) of his or her life is/are causing or contributing to the low back pain? Is he or she aware of how to remove some, if not most, of these or minimize their impact? Have I helped my client realize the impact of both internal and external factors (e.g. body structure as internal factor, work environment as external factor)? Basically, does my client understand what steps need to be taken consistently to resolve the issue(s)?

2. Motor Control: This is where I make sure that my client is clear on the impact of his or her daily postures and how he or she can improve/modify them. After treatment, my client should be comfortable understanding how any muscle imbalances play a role, how mobility (excessive or lack thereof) at various joints (e.g. immobile hips, hypermobile lumbar spine) may influence tissue damage and how specific movement patterns may determine repetitive stress or overuse (e.g. poor sit to stand mechanics). Not only should my clients understand these motor control areas, they should be able to teach me what they need to do to resolve them (e.g. stretches, exercises, proper movements/postures etc).

3. Conditioning: Have you ever been injured only to use that injury as your reason to stop all physical activity? Or have you had your healthcare provider tell you to “take rest” for extended periods of time? This break from exercise has the potential to lead to significant de-conditioning and further prolong healing time. Often, it is quite possible to work “around” an injury by choosing the appropriate exercises or activities to maintain or even improve overall conditioning levels while allowing injured tissues to heal!

And there you have it.

A treatment plan outline for a client suffering from low back pain. Using this outline, the details would be specific to the individual coming in for treatment. It would represent what that individual would likely have to do to work towards relieving low back pain.

Yours in movement.

Dev Chengkalath

Range of Motion (ROM)

The range of motion of a joint is typically tested in 3 ways.

I’ll be restricting my post to the first two, which are active and passive ranges of motion.

The final range testing is done through what’s termed joint play. This is done by the physiotherapist using very specific movements of joints when they’re held in specific test positions and will give information on the integrity of the joints’ ability to glide on each other properly.

Active ROM is tested by asking you to move through as much range of motion that you can.

For example, if I were to test your shoulder’s active ROM, I’d simply ask you to lift your arm straight overhead as far as you can. I could further differentiate between shoulder flexion (straight overhead from in front of you), shoulder abduction (lifting your arm overhead from the side) and shoulder extension (moving your arm backwards and up).

While fairly easy to test, I don’t find active ROM appropriate for all areas of the body and very seldom test the lower back for active ROM. I prefer to teach a majority of my clients (especially those looking to relieve low back pain) to minimize lumbar spine movements.

Passive ROM is tested typically at the end of active ROM, and usually only if there are deficits in the available range when completed actively. This gives us a baseline level of knowledge on how far your joints are actually able to move (total range) and how far you’re able to move within that range (available range).

Strength Testing

As with ROM testing, strength testing can take o many forms but I’ll just highlight a few here today. These are: manual muscle tests (MMTs), resisted isometric movements (RIMs) and functional movement tests/screens.

MMTs can be used to test specific muscle groups by placing those muscles in specific test positions and then challenging them. This gives the physiotherapist key information on how well a certain muscle or muscle group may be functioning.

Overhead Squat Test

RIMs are tests designed to compare the function of contractile tissues (e.g. muscle) with the function of inert or non-contractile tissue (e.g. ligaments). In the proper RIM test position, contractile elements (along with nerves) are challenged. Inert tissue, should not. This allows the the physiotherapist to distinguish between damage to inert tissue (ligament sprains) or damage to contractile tissue (strains of the muscle).

Functional movement tests/screens are based on taking you through specific movements to see how you do. These can include many different positions or exercises such as squats, lunges, push ups, or planks. The results of these tests give information on qualities such as balance, control, body awareness, strength, coordination, injury risk and many others.

In fact, a failed functional test could very well become your treatment exercise!

Special Tests

The last of the tests are called special tests. These are designed to test very specific outcomes and in the hands of a skilled clinician can yield important information that may help elucidate a physiotherapy diagnosis. Some examples of these tests include ligament stability tests (e.g. Lachman’s  test for the ACL), nerve or vascular tests (e.g. Roos stress test for thoracic outlet syndrome) and specific injury tests (e.g. Neer’s test for shoulder impingement).

So there you have it, a brief outline of the information gathering process.

While these tests are important in their own right, it’s just as important to look at the whole clinical picture which includes the medical history, the observation and the results of the physical examination. By the end of this week, I’ll put it all together and show you how all this information forms the basis of a treatment plan.

Yours in movement.

Dev Chengkalath

Part 3: The Physical Testing

Note: When i originally wrote part 3, it ended up quite a bit longer than I was expecting, so I’ve actually split it into 2 parts, the first of which you’re reading here and the second, which will be posted tomorrow.

Da Vinci's Vitruvian Man

Now that your physiotherapist has completed the medical history and has been observing you non-stop, it’s time to move on to the physical testing.

This is where the massive amounts of information from the the former two components are digested, analyzed and tested more rigorously. This is where those theories ruminating in our minds about what may be ailing you or what may be stopping you from your optimal level of performance are challenged, supported or rejected.

The physical testing will form the active part of your rehab or performance treatment. Unfortunately, this may also be the part of your visit that could cause discomfort or recreate your pain. This should be short lived and in the interest of gaining as much information about your situation as possible which will be used to create your treatment plan to get you out of pain and back to function.

There is typically a structured order by which we take our clients through the process so that we may gather the most pertinent information in a logical sequence. That being said, there is no one ideal method of running through a physical examination and you may find that various practitioners will have different approaches to testing for the same information.

In the end, it’s not so much how the information is gathered that matters most.

What matters most is what’s done with it.

That will ultimately make the positive or negative impact on your health or performance status.

Before I break down the physical testing, here’s my caveat: this is by no means an exhaustive or comprehensive discussion on the subject. This is merely a VERY brief overview to give you a basic understanding of why we do what we do and what we hope to achieve by doing it.

For the sake of brevity, I’ll be focusing tomorrow’s blog post on 3 areas:

1. Rage of Motion (ROM) (active, passive, joint play)

2. Strength (RIM, MMT, movements: squats, lunges, etc)

3. Special tests

Yours in movement.

Dev Chengkalath

The physical assessment: observation

Physiotherapy Medical History

In the first part of this series I outlined the importance of a client medical history. This medical history will typically highlight some, if not all, of the potential root causes and contributing factors of your low back pain.

This medical history gives us the foundation upon which to structure the next component of our physiotherapy assessment: the physical exam. This is where we can test and observe how your body moves, works and functions both as isolated parts and in unity as a whole. This is where we can figure out if you have any mobility issues, postural dysfunctions or biomechanical faults. Using this information then helps us figure out how we can work collaboratively (that’s right, you have to be an active participant for this to work!) to resolve them.

The physical assessment can be broken down in to two components:

1. Observation
2. Physical Testing

In today’s blog post, we’ll be focusing on observation.

Observation of your movement and postures starts from the minute you step in to the clinic. While it’s listed under the physical exam, this component can actually take place before, during, and after the medical history. In fact, I’ve secretly followed clients out to their cars (and corrected how they get in and out of them!) to see how they move without knowing they’re being watched.

Here's looking at you.

We physiotherapists like to watch how you move, if you have any compensation patterns, how you hold your body, how you shift your weight, how you walk, how you remove your jacket, and a host of other seemingly ordinary activities.

All of these can give us clues as to the cause and/or the source of your low back pain (see my post on “cause vs source” for more information). All of these can give us clues as to how we can help you fix them!

For example, a client who winces or has difficulty bending forward to remove her shoes tells us that her body doesn’t like flexing forward, all without saying a word. In fact, even how she bends forward furnishes useful information on potential movement issues.

Slouched Sitting Postures: Over time can lead to injury.

The client who who resists twisting while removing his suit jacket let’s us know he isn’t a fan of rotation. This information will allow us to set up further tests during the physical testing. Again, without saying a word.

The client who sits on the examination table, slumped and slouched, with shoulders rounded forwarded and chin protruding gives us an idea of his body awareness and the types of postures he likely adopts for long periods of time during the day.

This is but a small sample of how these vital bits of information that can be garnered without a word spoken.

As you can see, observation is one of physiotherapy’s most powerful tools. It directly impacts and influences what physical tests we’ll choose and ultimately what interventions we’ll apply to help you relieve you low back pain, get you back to function and performing optimally.

Stay tuned as next week I’ll break down the physical testing component of the physical exam.

Yours in movement.

Dev Chengkalath

Over the next couple weeks, I’ll take you through a general physiotherapy assessment to figure out what you’ve been doing to beat up your back for so long and what you can do about it.

• In part one, I’ll detail the often ignored importance of a basic medical history.
• In part two, which will be posted in a few days, I’ll delve into the first component of the physical assessment: observation
• In part three, to follow next week, I’ll discuss physical testing.
• In part four, I’ll outline some potential treatment options.
• And in part five, I’ll outline what you need to do to stay out of pain.

So stick around for the next couple weeks and stop beating up your back!

Part 1: Medical History

While this component of the assessment may seem a bit mundane, it’s probably one of the most important aspects of the whole process.

My clients come in thinking they’re going to get answers. The first thing they get are questions. Lots of them!

This is where my clients always wonder why I’m asking them so many open ended questions, or whether or not those questions have anything to do why they’ve come to my clinic to see me. This is also where they wonder, sometimes out loud, why they’re paying me to “chat” with them instead of treating them!

Believe it or not, your medical history will almost always give clues as to the cause and extent of any of your mobility problems. As I’ve stated numerous times before, without knowing the nature of the root cause of your physiotherapy issues, it’s almost impossible to resolve them.

This remains the case with relieving low back pain as well.

Not only does your medical history help with ruling out red flags or serious pathology that require medical intervention, it’ll also give me the clues that I need to figure out what you’ve done, how you’ve done it and potential methods on how we can fix it.

This could be something as simple as you telling me that you work 60 hours a week sitting at a computer or hunched over a drafting table.

It could be you describing what time of day the pain is better or worse.

It could be you just stating, in your own words, what types of activities are easy or challenging for you.

Or it could be you simply describing the type or quality of your pain and discomfort.

And these questions are just the first steps. Gathering all the pertinent information from the medical history sets the foundation for your physiotherapy assessment that follows.

What may seem simple or innocuous to you might actually be the clue that opens up another direction of questions and queries, all intent on helping you find your path to pain free living.

Yours in movement.

Dev Chengkalath