POV it’s a Monday morning. You’re tired, you wish it was still the weekend, and you’re not quite ready to “PT” again today. You look at your schedule and to make matters worse first thing you have is an eval for . . . low back pain. You think “Ugh, this Monday is about to be ROUGH”.
Many of us know this situation all too well. Many of us would not put low back pain under the “favorite things to treat column”. Unfortunately, we see A LOT of it already. It’s going to be a loooong career if we let a diagnosis we see so often give us that “ugh” feeling.
When I started working in outpatient I was determined not to let the low back pain blues get the best of me. So far it’s worked out pretty well! Most of the time I don’t find myself dreading a low back pain eval or even if I have several low back pain treats on my schedule for the day. Below are four things that helped me get to this point and conquer low back pain burnout.
#1. Educated Myself on Multiple Treatment Approaches
There is A LOT of arguing among PTs about the best treatment approaches to low back pain. Some are McKenzie enthusiasts. Some swear by their manual therapy techniques such as Maitland or dry needling. Many consider themselves pain science gurus. Some love the core stabilization route. Finally, some live and die by good ol’ fashioned progressive overload.
Here’s the thing though, you might have your favorite, but your favorite isn’t gonna work on everyone. Over time I’ve tried to learn at least a little bit about several different approaches. I’ve taken some dry needling and pain science CEUs. I had coworkers teach me some manual therapy and McKenzie techniques. I also try to stay current on ways to effectively load and build resilience through the spine.
Oftentimes we fall in love with the next shiny new technique and we think it’s going to work for everyone. For some reason our thought process has become very siloed when it comes to treating the back. Anyone else agree? We think we must pick one approach to be an expert in and know that one technique really well. Then we become frustrated when some of our patients don’t respond to our “secret weapon”.
Do I use some approaches more than others? Absolutely. But I have had far more success using a combination of a few of these versus trying to be a purest in one. It’s helped me feel like I always have lots of options when it comes to treating my patients with back pain. I never find myself feeling “stuck”. If the patient isn’t responding to one approach I always feel comfortable pivoting to something else.
#2. I Remember the Basics
There are so many different approaches to LBP now it’s easy to make things more complicated than they need to be. Basic principles sometimes get forgotten or completely thrown out the window.
For example educating my patients on sitting time vs standing time. SO many of my patients have trouble finding the right balance of activity and rest. Once they do though, they usually start feeling a lot better.
Anatomically and biomechanically the back is pretty unique in the way it works compared to other parts of the body, but again that doesn’t mean we need to get overly fancy. Especially when it just comes to something like spinal OA. How would you normally treat knee OA for example? Probably ROM and strengthening around the knee and the joints above and below right? Maybe look at some soft tissue quality in those areas as well?
The back is no different. Still strengthen what needs to get stronger, stretch what needs to be stretched, and make sure to look at the areas above and below. Not that wild right? You know what to do, it just looks a little different than say working on knee pain.
Closely related to this idea, always remember to treat the patient not a diagnosis. Their imaging might SAY disc protrusion or stenosis. If their primary symptoms don’t act like it, I wouldn’t get too bogged down in treating it like one.
Part of treating the patient is also listening to their personal goals and relating the treatment to this. If the patient wants to lift heavy shit I wouldn’t recommend just doing a bunch of McKenzie exercises. If they’re really concerned with being able to touch their toes then maybe McKenzie exercises are the move.
Choosing exercises that directly relate to patient goals vs their diagnoses has gotten me MAJOR buy-in from a lot of my patients suffering from low back pain. Even the ones with chronic conditions. They become way more committed to the process and their HEP. Then both of us are happy because we’re making progress!
#3. I Realized Low Back Pain is Often Multifactorial
You’ve probably heard pain is multifactorial before. This becomes ESPECIALLY true with back pain. It’s no coincidence those with low back pain also frequently deal with depression and/or anxiety.
As PTs, our wheelhouse is the musculoskeletal, but we’re going to be extremely frustrated if we don’t at least acknowledge other influential factors such as mental health, sleep, and diet.
I’ve found patients are quick to acknowledge this as well. I also find they’re thankful when I bring this up. Due to the healthcare system being what it is, many patients feel reduced to a diagnosis, rather than a person. When I address these factors patients are often appreciative they’re being looked at as a whole vs just one piece.
While the musculoskeletal piece is primarily my focus, I’ve begun doing some education on mental health, sleep, and/or diet and inflammation reduction. For mental/emotional I may turn them to our psych services or make suggestions for stress relief. For sleep I provide a “sleep health” resource. When it comes to diet I get a lot of questions on how gut health can affect moods, energy, and inflammation. I confirm the relationship and give general nutrition advice and for more complex questions I refer to dietary services.
I don’t get many patients who do an ENTIRE overhaul of their lifestyle, but I do get a lot that make 1-2 changes that lead to big differences. Some start forms of meditation or begin therapy. Others make their sleep or their diet a priority. Many find these changes, along with PT, help their pain immensely.
4.) Not Everyone is Going to Get Better – or Wants to
Just like some of our other patients, not everyone we see with low back pain is going to improve. Sometimes this will be due to severity of pathology and sometimes it will be because the patient is their own worst enemy.
Patients with back pain, particularly chronic low back pain, are infamous for being “difficult” or “wanting to stay broken”. Personally, I think this is a large, mis-generalization. This mis-generalization has led to prejudice towards patients with back pain from all levels of the healthcare system.
However, back pain can be difficult to treat and it definitely takes effort from the patient just as much as the healthcare provider. And sometimes you’re going to get those who just don’t want to take the necessary steps. Or, they’re not at a place where they’re ready to.
I might get some hate for this because I do see messages on social media that it’s our job as PTs to get buy-in from the patient or make them care. There’s some truth to that – to a certain extent. There’s certainly things we can do or say to help encourage patient buy-in or motivate them to make changes, but at the end of the day they have to decide they want it too.
Toxic relationships – we’ve all known them. We’ve seen them. Maybe even been in one ourselves. At a certain point one person isn’t giving the effort or making the changes the other person needs. Eventually one person ends up getting their ass dumped because they couldn’t get their act together. Now we wouldn’t say to the other person – “It’s your fault it didn’t work out. You should’ve said or done something that made them want to change.” (P.s. if you would say this, you need help.)
Sometimes it’s like that with our patients too. We could be THE BEST GODDAMN PT and they still don’t get better. We may say all the right things, do all the right things, be patient and empathetic and the patient still might not do their HEP, or stop sitting for hours, or stop NOT sitting for hours.
Very cliché of me, but you have to focus on what you can control. You know what they say – “You can lead a horse to water, but you can’t make it drink.” Someone doesn’t get better, no matter the reason, but you know you did the best you could? Let that shit go. I guarantee you for every person that didn’t get better, at least three others did. It’s just always so much easier to focus on the ones that didn’t.
If you’re someone who sees a lot of patients with low back pain I hope you found something helpful in this post! Any tips or tricks that you’ve found particularly helpful when treating low back pain? Let’s all drop ours in the comments to improve each other’s arsenal and fight the low back pain burnout. If you missed last week you can catch up here. Hit subscribe below to get updates on new PT Page content and follow on Instagram @the_pt_page!
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