Ortho on the go
Ortho on the go
How to evaluate and treat acute lower back pain with Tessa Kothe PT, DPT, CF-L1
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Welcome back, everybody, uh, to the podcast. Uh today I have the pleasure of speaking with Tessa Cothy, our doctor Tessa Cothy. She has her doctorate in physical therapy from UW Madison, you said?
SPEAKER_02Uh UW Milwaukee.
SPEAKER_01UW Milwaukee, sorry, uh for all those UW Milwaukee people. And then uh Bachelors in Exercise Science, correct?
SPEAKER_02Yeah, and that's from UW Madison.
SPEAKER_01Excellent. And then also CrossFit Level One certified. She's the owner and operator of uh Summit Physio and Performance uh here in the local Colorado area. Um so I thought it'd be good to have Tessa on the podcast to discuss low back complaints. In, you know, um Tessa actually treated me. I have two previous back surgeries, uh L5, L4, L5S1 dyscectomies, uh, performed and occasionally have some lower back issues. I went to Tessa when I was having kind of a flare-up of my SI joint or kind of lumbar sacral area, and she helped me kind of get through that and see some deficits that I had. And I thought it'd be fun to have her on the podcast to kind of talk about common low back complaints and what we can do regarding this. So welcome to the podcast.
SPEAKER_02Thanks for having me, Chuck.
SPEAKER_01So, you know, I we were just having this conversation prior to starting things. I think, you know, me being a PA and an athletic trainer and you being a physical therapist, I think it's important that we work together regarding a lot of these low back complaints because most of these complaints can get better with mobilization, you know, and conservative measures. What are the more common things that you see in your clinic regarding patients that come in with kind of acute or chronic low back complaints?
SPEAKER_02Yeah, I'd say the the most common thing I'm seeing is like uh because my clinic is direct access, I get to see people that are like pretty acute injuries and I can get people in the clinic pretty quick. Uh, so I see a lot of like acute like strains at the back where like they were just doing a squat or deadlift or some sort of movement or whatever it was in the gym, or even just like I bent over and my back like went out basically. Um, so I see a lot of that kind of thing. And then I also see a lot of chronic back issues of people that have seen multiple providers and like need a fresh perspective and a really thorough evaluation. Um, and so I kind of see a wide range of like acute to chronic back issues, um most often low back, but I do see a lot of like TL junction, which is kind of that intersection between the lumbar and thoracic area, um, would be like another area I do see from time to time.
SPEAKER_01Yeah, I think, you know, there's in in my mind, you know, when I see patients in clinic, I think there's two typical presentations, like you said. There's the either I bent over to pick something up and I immediately felt pain in my back. And there's the, hey, I've had this back pain off and on. It tends to hurt when I do certain activities. As you said, you know, you your practice is inside a CrossFit facility. So majority of the patients you probably see are kind of these higher-level athletes, but also seeing just, you know, with a regular everyday low back pain as well. What is your thought process when evaluating these patients? Because I know my thought process changes a little bit depending upon the mechanism of injury or the kind of the um chronicity of the presentation, if that makes sense.
SPEAKER_02Yeah, absolutely. So um I always start off with like using a body body chart and mapping out the client's symptoms. Um, and then what we do is we kind of get into symptom behavior. So we're like, what makes it better or worse? What is the intensity of the pain? Like, does it travel anywhere? And then I try to map out like, are there any other areas of pain you've ever had or like history of injuries and things? And then that subjective exam typically will guide like what I'm gonna do with them objectively and what I'm gonna test. So usually like after that first like five to ten minutes of chatting with them and mapping everything out, I have a pretty good idea of like how I want to evaluate that client. If someone's like walking in the door and they're like, I'm nine out of ten pain, like I am really, really hurting. Like, I'm not gonna assess a lot of things because I'm just gonna flare them up in almost everything. And then all those tests are like maybe even some false positives because they're just everything's painful. Um, but if someone comes in and they're like, I only have pain when I'm um squatting above 200 pounds, well, that's a whole different story. I'm gonna be like really diving in super thorough assessment, um, kind of testing a lot more than I would in someone in the cute situation. So um it really depends on like that irritability level is like the first and foremost thing that guides my assessment and then um kind of what what things they're telling me. Like if they're telling me like I have pain going down uh past my like glute or butt, then I'm likely gonna do a little bit of a neurological screen and see what's going on there. Um and if they're having like ridicular, numbness and tingling symptoms, we're gonna be more thorough in that area, or if they're more localized, then we'll kind of not necessarily need to go that route. Um that's kind of a lot of my thought process when someone walks in the door.
SPEAKER_01Yeah, I love it. Yeah, I think our thought processes are very similar. And and, you know, like I said, uh, you know, with the athletic training background I have, I kind of think more functional oftentimes when I'm examining patients. But as you said, you know, if somebody comes in with an acute onset of low back pain, they're nine out of 10 or 10 out of 10 pain. You know, your straight leg rate tests, a lot of your tests that you're gonna do that are gonna put them in these provocative positions are probably gonna be false positives because essentially everything's gonna hurt. Um, and and really my answer, and it sounds like you're in a similar thought process, is let's calm your acute inflammatory symptoms down, let's get your symptoms to settle down, and then maybe we can get a more functional examination of you and see if there's something that we find on examination that's you know reproducible that we could correct that prevent this pain from coming back in the future. What are some of the modalities you can do? I I think one of the things we often get asked in my clinic when patients come and see me in the orthopedic urgent care is when should I start physical therapy? Um, and what's your kind of thought process behind that? Should we start right away? Should we give it three days with heat and kind of you know modified activities? What's your thought process?
SPEAKER_02Yeah, um, well, I am kind of probably a little biased in this area, but I typically do recommend people kind of seek out some care as soon as possible. Um, because there's a lot of things we can do um in that acute pain situation. So first and foremost, we can kind of guide like what exercises are like very tolerable, which is like a zero to three out of ten pain. So I'm often kind of trying to figure out that first day of like, okay, what are exercises that are very minimal pain? And we can have you do these often to at least get some gentle movement through there, maybe some isometrics through the bath or the core. Um, and then things we can do right away that really decrease pain is I'd say dry needling is probably one of my uh best tools I can do that can really, really calm symptoms down. Um, it really depends on like where we're gonna go, like with the location of dry needling, but um, like in the low back instance, we can go directly at the area. Um, but sometimes we don't want to go like right at ground zero. We'll maybe go a few segments above or below to get some muscles pumping. Um, or we can even go like a little bit loose depending on if things are referring down. Uh, but that's probably one of my best things that like people can get dry needling. Um, and even just some soft tissue perks and gentle like grade one, two mobilizations, that can help quite a bit in that very acute onset.
SPEAKER_01Yeah, I feel like dry needling has kind of been a game changer for multiple reasons. Um, because it's kind of a modality that you can do that can help this acute soft tissue, you know, muscle spasm type pain. Um, and I'll often send patients, you know, to you guys. And um, I don't like to, you know, necessarily, you know, I most of our prescriptions are evaluate and treat, and then modalities is necessary. But I think in this acute situation, the dry needling, the more manual work is is quite helpful for these patients to calm their acute inflammatory symptoms down. And then, as you said, maybe then we can you can get a more functional evaluation once those acute symptoms are settled down. I, you know, go ahead.
SPEAKER_02Oh, I was just gonna say um the cool thing too about dry needling, um, a lot of my training with dry needling is uh dry needling with addition of electrical stimulation. There are specific like settings we can do. So an alternating current is like most supported for pain relief. We can also do something that's more of like a neuromuscular if someone's going to have some strength uh benefits we want to get at. And then you can also do like recovery dry needling, which is swelling management, or like delayed onset muscle soreness, like DOMS management. So uh that's a cool thing too. Like the dry needling I'm probably mostly referring to is it with ESTEM and um either a pain relief or like a swelling type protocol. Um, because if someone comes out with like acute, really swollen ankle spray and really swollen knee, I'm gonna probably do a bit more of a recovery protocol and then target some muscles that really have a big muscle pumping effect to help with um improving that lymphatic system.
SPEAKER_01I love that. It's yeah, I, you know, my I my athletic training, you know, in the training room stuff has been quite a few years ago. And I remember we used to do, you know, ESTEM for a lot of these acute patients and iontopuresis and phonophoresis type stuff, but now you know that things have advanced, you guys have those modalities which you know act as a similar way, but I think are much more effective. So that's amazing that you can do those types of things acutely on the patients. What if, let's say, somebody's listening to this at home and we just kind of had this conversation, um, you know, heat versus ice, um, mobility versus, you know, lying on the couch and are in bed for a couple days and doing nothing. Um, what is your kind of thought process as far as, hey, I bent over to pick, let's say, my kid or something up. I had this acute onset of low back pain. You know, what are you recommending that first 72 hours if they don't necessarily want to come see you in clinic? Um, what are home things that they can potentially do?
SPEAKER_02Yeah, so even if like someone was just like reaching out, like, hey, I'm not sure what to do, I'll usually kind of ask them a few questions in in the area of a back pain. I'm gonna say like I try to screen out like, does it feel really way worse if you bend forward or bending backwards? So I kind of try to see if they have any sort of directional preference at all because I can cue me in of like maybe I can give them like one or two exercises that will be tolerable for them. Um, and then I'm usually telling them, like, let's see if you can find some sort of movement that you that feels okay and like is not causing that pain to go above a three. So we're trying to find like a couple things that keeps the pain pretty low and they can still move through some movements because gentle movement is gonna just help flush out like low-foil inflammation and just kind of help um from things really stiffening up because things can just start to stiffen up if you just lay around. Um, and so the other thing that's like supported if people can tolerate um some sort of cardiovascular thing, if it's like a bike or even just walking fast, something like that, like getting systemic um circulation going can also be really helpful. So it kind of depends on the person, but I'm usually asking them a few questions of like how we can figure out a few things that I can give them that they can try for exercises that will be tolerable for them.
SPEAKER_01Yeah, I I I completely agree with you. And I think it's the same way when when friends, family, or people reach out, it's it's you know, do a screening to see if there's any red flag symptoms, you know, ridicular pain, you know, neuropathic type pain that's more constant, causing any weakness that may require, you know, imaging. And then, you know, as as we talked about before, we kind of started this. I'm more of a heat than an ice, especially on the low back, because most of the literature shows it wants blood flow to that area, wants movement to the area. I'm always recommending they get up at least once an hour and do some light exercise or light movement. Um, you know, similar to the DOMs, you always kind of feel better if you're up and moving and getting blood flow to the area versus just staying stagnant and causing you know increased, you know, um lactic acid buildup and/or stiffness within the area. So I think the movement's quite helpful for a lot of the patients. Although it seems counterintuitive and they don't want to do it, I think it will help them in the long term.
SPEAKER_02Yeah, absolutely. Yeah, I think I think going the heat route is typically the way to go for the back in these cases. And and frequent movement is definitely preferred over just even like once per day.
SPEAKER_01Yeah, and like you said, I think these low back pains, especially the acute low back pains, kind of present in a um a typical fashion where that first kind of three to five days are are most painful. Um and so just kind of calming their inflammatory inflammatory symptoms down, using the heat, using the movement, using some light stretching activities, like you said, maybe some light exercise, maybe not even weight bearing, they could do an exercise bike or something like that, like you said, just to get that systemic blood flow to the area. And then if by day five or day seven those things settle down, you know, as you've mentioned, you can maybe do more uh of an exercise or kind of a light stretching activities, you know, um, more functional type testing to see if there's anything that potentially you can improve at that point. Um and I often just recommend the simple, you know, cat camel and bird dogs and just, you know, light stretching exercises just to keep keep the mobility within the area.
SPEAKER_02Yeah, and we're often like looking at the hips as well. I find so many clients with back pain have a lot of like hip weakness, inherent hip weakness. So that's like a big area, too, that I'll um be looking at, especially in someone if it's not as acute, um, of like where, you know, some little bit more root contributing factors of like, yeah, we're we don't have outer hip strength, we don't have hip extension strength limited. Um, we may have some like nerve tension going on, even if they're not having some leg pain. So there's definitely a lot of factors that can contribute to like why people have recurrent issues too.
SPEAKER_01Definitely. And you know, I something I I I feel like I've seen a lot, and maybe you've seen this as well, is how much do you think this SI joint kind of plays into these acute onset of low back pain? I I think a lot of these patients have this kind of lower L5S1, SI, you know, gluteal ridicular type symptoms when they have these acute pains. And, you know, some believe that there is some mobility within that SI joint that can be manipulated or that can be kind of thrown out of position that can cause the muscle spasms to happen. How often are you seeing that? And how much do you think that plays into these patients presenting?
SPEAKER_02That's a really good question. Um, I'm probably on the Morris school thought where I think the SI joint is moving very little. Um, I will do my SI joint cluster of special tests. Um so usually if like the first two tests I do, which are a thigh thrust and a distraction test, if those are two are negative, I'm not really going down to test a ton more of those, unless there's other things that are like cueing me into that. But um I often find that people think their SI is like the main issue, but then they're like, then when they point to like their symptoms, they're like way up into their lumbar, um, or they're it just not like adding up in the clinical exam. So I I find that like um there's more issues with like hip weakness than just like local SI, like if I were to kind of stress test that joint. Um that's just kind of my clinical background and my experience with SI. I think it can be really tough, but on that, like really always trying to like make sure that SI is the perfect alignment. I really think that's like detrimental to the client and having this like mindset of like, oh my gosh, if things are not 100% perfectly aligned, I'm going to be in pain. Um, because that's lemonas are the case. It doesn't really add up um clinically.
SPEAKER_01Yeah, I feel like we get a lot of patients that come in that say, oh, I have one leg longer than the other, and you know, I've been told this by multiple physicians, and this is leading to my symptoms. And, you know, I think naturally we all have that, so that's not always a key factor into playing to the role of why that's causing the little back pain. Um and so uh maybe, and and we'll add to this, but um, maybe you can add a video of some exercises that we can put on for you know people that are watching that they can do for more of this acute low back pain. Um, just simple kind of stretching and mobility type exercises.
SPEAKER_00Um Tessa was kind enough to provide us with a video uh that she shot in her clinic uh for the podcast for exercises that individuals can do uh for lower back pain, especially the acute lower back pain. Um I've included that into the YouTube video. So if you'd like to see those exercises, you can listen to the podcast on YouTube and or just go to the end of the video and see the exercises that Testa filmed for this. Please join us uh next week andor uh at the next podcast for the second part of this series when I have a discussion with Testa regarding chronic low back pain and how we can um diagnose this, treat this, uh, especially in our higher-level athletes and individuals uh that maybe have some functional abnormalities causing this chronic low back pain. Again, thank you for listening to the podcast. Please follow us on social media, both Instagram and Facebook. And please feel free to reach out regarding any topics you'd like to hear covered or possible conversations you'd like for me to discuss. Uh, thank you again.