Diagnosis and Treatment Options for Acute Back Pain

Dr. Zac Morgan // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses how to subjectively & objectively identify patients presenting with acute back spasms, how to treat spasm, and how to follow-up treatment with appropriate homework. 

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

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ZAC MORGAN Alright, good morning PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the cervical and lumbar division, here to bring you a Technique Thursday talking about myofascial decompression or cupping for an acute back spasm. For those of you all who work with acute back pain, so this is something that early in my career I did not see an awful lot of, but as I have kind of entered the market of seeing more and more acute low back pain, you will see these people walk through the door that are clearly in a spasm. And I want to talk today about why cupping has kind of become the treatment of choice here for that exact presentation. ACUTE BACK SPASM PRESENTATION And let's just kind of narrow in on why we're focusing on back spasms to start. And the real thing is, this is one of those diagnoses you don't read a ton about in the literature, but it's one of those things that you know it when you see it. So it's fairly empirical. So every so often, people kind of walk through the door, and they're kind of in that shape of a question mark. They're really off to the side, and you can tell as they walk through the door that the severity of their situation is really, really high. Even just watching them move about the world, their activities of daily living are extremely challenging when they're experiencing a back spasm. They're not able to freely move through space and move that spine around because their erector or QL or some of that posterior musculature is in a full spasm. So this is something you will see if you're seeing people day of within a couple of days of a back pain episode. So it's certainly one of those acute low back pain scenarios. Now the issue is, you'll see a lot within our profession of people sort of argue about, well this is just going to regress to the mean. And I don't disagree. A back spasm is going to go away on its own, for the most part. So generally speaking, untreated, in my experience watching these things happen around the gym, having some of them myself, a lot of times people have some movement limitations for ten days or so, seven to ten days, maybe a week, maybe a little bit longer, but then they're usually back to normal life after that point. So it's not one of those conditions that sticks around for months the way like a radiculopathy would. It's just something that's acute, but while it's present, it's very severe. I think it's important for us to say We know it regresses to the mean. It will get better on its own. WHAT IF REHAB CAN BEAT REGRESSION TO THE MEAN? Here's the thing. With early treatment, what I'm about to show you all, I think we can take several days off of the episode. And I think that because of empirical data here in the clinic. So I'll watch people walk in in that situation that we just described. Very put off to the side, huge spasm in that erector. You can almost see it through their shirt. and they're unable to do much, and we treat them with some cupping, we treat them with some relaxation techniques that we're going to unpack here in a moment, and often that person feels tremendously better, tremendously quickly, so within a couple of days, maybe three max, versus that seven to ten. Now that's a difference, right? That's almost a week of time different that that person is going to end up walking around with pain or not walking around with pain. Why does that matter? When you think about how influential this spasm is to their activities of daily living, they can't do much. Now deconditioning is going to set in, even on healthy people. If healthy people move around the world for a full week without really flexing their back, without allowing it to move, they're going to have some deconditioning on board. And if we could have gotten rid of that a week earlier, we've given them more of an opportunity to maintain or even gain fitness during this period of time that they have some acute pain. So I think it's really important that we focus in on this because while it's not a usually a long-term disabling diagnosis, it is a short-term disabling diagnosis. And when people are in that disabled period, they're looking for short-term help. And I think we can be helpful with that. IDENTIFYING CANDIDATES FOR CUPPING So let's talk a little bit about identifying these before we actually get into the treatment. And from an identifying standpoint, you want to start with that body chart. So if you've been to cervical and lumbar management, you know we always start out with quantifying where are the symptoms on this person's body. When someone's in an acute back spasm, it'll be a little complicated to find the exact spot of symptoms. They don't usually point to one thing. They often kind of talk about that whole erector side. They might even point to that whole area of their low back and say it just feels locked up. I've certainly had plenty of clients who reported just like local pain sort of at the waistline, like right where the waist of your pants are. I've had unilateral, bilateral, it bounces around a little bit on the body chart, but typically whatever muscle is in spasm is where the pain is. And often the person has a hard time describing it because of the severity. They just say my whole back is out, my whole back's out of whack. So it's not one of those focal diagnoses on the body chart. Subjectively, you're going to see some common aggravating factors. The biggest one's flexion. The person probably won't even allow their back to flex. And when you look at that from the active range of motion standpoint, you see it's just hip flexion. The lumbar spine is not actually actively flexing. The person's just kind of absorbing into hip flexion. Any quick movements are often painful subjectively. So they talk about transfers, they talk about when they've been lying down to get up. Really anything where they have to move quickly will often be an aggravating factor. And then things like bending, sneezing can also be pretty painful for these folks. In their history, they'll usually tell you about some sort of fatigue-based activity that onset this. So this won't usually be like a one rep max deadlift. That makes me more think of a strain. Where this presents itself is in a workout with a bunch of deadlifts. So when somebody's, you know, several sets in and their back is already tired and then it just fully locks up and kind of worsens throughout the evening or worsens throughout the day, that's more of the spasm presentation. It's not just in weightlifters or competitive athletes. You'll see this really with any human who has exceeded their capacity. So I've definitely had plenty of folks that were gardening all day or mulching all day and just using their back a bunch and then it wound up in spasm. So it's really whatever over challenges that musculature tends to create the spasm. So subjectively, you'll see those common ags and then you'll also see that history where the person was either fatigued entering an activity or did an activity so much that it created enough fatigue that eventually created a spasm. Objectively, again, their lumbar spine, it's not going to reverse. When they flex, it's going to stay very flat. You're going to see a lot of guarded movement. The person's probably going to be very hesitant to move, and you'll notice that quite a bit through this active range of motion exam. You will even often see cervical flexion. bother that person's symptoms because the erectors, they attach all the way up in the neck, in the suboccipital spine. So you will see cervical flexion be bothersome, but then it's not like a sensitization thing from a neurodynamics exam because the ankle won't make any difference. So, when you see that cervical component create a lot of discomfort in that acute pain scenario, and then you dorsiflex and plantarflex the person's ankle, and it doesn't make any difference, that's ruling spasm higher on my list. So, objectively, that'll often be how it presents, and then a lot of it's just observation. You'll just look at this person's back, and like I said in the beginning, they'll be twisted off to one side. They may even be kind of in the shape of a question mark. Like you can see that that erector on that side has just shortened in the area of the lumbar spine. And so the person is fairly obviously uncomfortable. A lot of times the erector itself is swollen or hypertonic or larger, whatever you want to call that. And it'll be tender to the touch. So just palpating that region, a person is going to report most of their symptoms. So like I said, a fairly obvious diagnosis. And again, it's one that I didn't see a lot of until I got that really acute back pain person in the clinic. So that's sort of how they present. TREATING BACK SPASMS Let's talk about treatment. There are a lot of things that jump into my head that I would like to do. Like if you have acute non-radicular low back pain, the first thing that jumps into my mind is spinal manipulation. But often moving these people's backs through space is just not a realistic possibility for you on day one. Team, over the last couple of years I've spent a lot more time learning about cupping and doing a lot of cupping with clients and this is the one thing that whenever you see this presentation show up, whenever we drop the cups on that region, get it nice and relaxed and it doesn't even have to be all that vigorous. The person often gets off the table stunned at how much better they feel. So cupping has definitely become the treatment of choice and I like to just keep it really really simple. Now the biggest issue from a treatment standpoint when someone's in spasm is it's really challenging for you to get that person comfortable most of the time. They don't like laying in supine, they often don't like laying in prone, and then on one side or the other they're often really uncomfortable. If you can get them in side-lying, which is typically the most successful for me, you want the erector that is in spasm up. So I have Caitlin here behind me, and you can imagine in this situation, her left erector would be the one that would be in spasm. So that's the one that I'm going to target with treatment, and that side's up. You also want to prop a pillow between the person's knees just so that hip doesn't adduct and create even more tension on that lower back region. Instead, let's keep those hips nice and neutral and get this person in a relatively comfortable position. This will often be the position they've told you in the subjective exam that they like the most. So we're going to go right to that position and then treat in that position. So I'm going to move to the other side of the table, show you sort of where I put the cups, some of the verbal cueing alongside of that, and then we'll wrap this thing up. and summarize at the end. So anytime you're doing cupping you always want to use a little bit of cream. It's just a lot easier to glide the cup around and it's a lot more comfortable for your client. So make sure you add a little bit of cream to that region that you intend to cup just so that that way it's more comfortable for your client. You're then going to grab your first cup and localize it to the region that you think is in spasm. It doesn't have to be directly over it. Reminder, these muscles are literally all the way across the spine. So if the person's too pressure sensitive, you could certainly move away from it. But you want to be in that basic region. And then you're just going to get these things on. with a little bit of tension. So a couple of pumps to start is plenty. So I don't have this thing cinched all the way down where she's in a ton of a stretch feel. Instead, I just have a little bit of air out of the cup and a little bit of domed tissue within that cup. this gives you that nice decompressive feel if you're the client a lot of times they'll be a bit uncomfortable when you first do this but they're uncomfortable anyway they've been in spasm for a few days and so it's no major deal to them these cups are probably only like 30 to 40% pulled out. So typically if I'm being more aggressive with cups, I get it a little closer to that full capacity of vacuum. But for this, I've got a very severe patient in front of me, they're very fear avoidant, they're not moving all that much, and I've just got a little bit of tension in those cups. I start out just like this, like you all are seeing. So the person just kind of gets comfortable, relaxes, feels that pull. But after they've sat here for a couple of minutes, I'm going to start to try to cue that person to do a bit of a posterior pelvic tilt. The point of that posterior pelvic tilt is just to access a little bit of their lumbar flexion while they're in this nice, friendly, non-weight-bearing position. Anytime they're in weight-bearing, that erector tends to want to be in spasm. So I'm going to get them to just relax things a little bit here in sideline in a nice comfortable position. So I might have them move through 10-20 reps here, maybe even cueing some deep breathing in between if they're very severe. So 4-7-8 breathing pattern is often a helpful one, that physiological sigh. Either one of those are typical go-to's while we're in this position and the person's nice and relaxed. Now, for those of you all who treat human beings, you know a lot of times our female clientele is a little tougher than our male clientele. Sometimes the men are already sweating in this position and they're already having a lot of challenge. If that's the case, I'm going to stay right here and just have them work those pelvic tilts. If I do perceive that the person, if they're telling me, hey, this feels quite a bit better, you know, it seems like they would like a little bit more treatment, the next move I'm going to have them carefully make is getting into the position of quadruped. So they don't like prone and supine, so I'm going to leave the cups on and the person is going to ease their way to quadruped. And then from this position, they're just going to do some gentle angry cats. So I'm going to cue them up into some spinal flexion, telling them to separate the cups. They do have a tendency to pop off, so you want to keep that gun handy. But I'm essentially just going to cue her through 10, 15 reps here of angry cats, thinking about really elongating this whole erector. If you want to make it a little bit more vigorous, you can have them gently flex their cervical spine as they go into the cat position. That's going to give you even more stretch across the erectors and often feel pretty tight for the person, but quite good. Once we're done with that, I'm going to have them just lay back down in sideline in the original position. And this is where I think a nice little bit of massage can be helpful. So just popping the cups off, you may have some light bruising, but then getting in here and just showing that area some love and getting a little bit of massage going to that region. Team, I realize what I just showed you is quite simple. and I'm not trying to be overdramatic, but simplicity often makes this person pop off the table and feel dramatically better. FOLLOW-UP TO CUPPING I think what we follow it up with is very important as well. Earlier in my career, it was always, hey, let's load, load, load. Let's make sure we're getting this person moving. This person is overloaded. That's why they ended up in spasm. So what I'm actually going to target these days is a lot more relaxation techniques. So maybe that breathwork pattern we did with the cups on, I assigned for homework. I need five minutes of this a day minimum. Convince that person to give you some breath work. Convince that person to up their hydration by a bottle or two of water over the next few days. Hey, I really think this is going to help. If you're in a little bit more hydrated state, I think that muscle can relax more. Convince them maybe to add some electrolytes. Heck, I'm fine with a warm bath at night with some Epsom salts. It doesn't matter to me. I'm going to get this person to relax. I'm not going to go have them do more deadlifts. Their problem isn't necessarily that they're weak with deadlifts. It's that they got fatigued. Do we need to build the endurance of that region? Possibly. Maybe that's why it contributed to a spasm. But for right now, my main goal is relaxation. And team, I'm always going to argue for more treatment in this scenario. Earlier and more treatment. The reason being is imagine Kaitlyn is that person who has the back spasm. And she then loses 7 days of not just training, but also moving around like a normal human being. We only have 52 weeks in a year. I don't want to sacrifice an entire week of that person's life to fear avoidance, to lack of ability to move like a normal human being just because it's going to regress to the mean. Not when I could simply get in, assess it, help that person feel like, you know what, I think I'm going to be better in the long term. get them gently moving, teach them some relaxation techniques, and get rid of this thing seven days faster. It's gonna be hard to convince me that that is a harmful approach, even though we are utilizing passive tools to help that person relax. I think this is exactly why we need those tools, is to help put that fire out, and then in that process, convince this person to start addressing some of their lifestyle factors, to start addressing that ramped up nervous system, getting them to calm it down, to start addressing hydration. Some of the basics, right? Just the basics of what it means to be a human, people mess up quite a bit. So, we want to make sure that we check those basic boxes, and often you're going to follow up with this person in 48 hours, and they're going to say, Zach, feels tremendously better. Can't believe how much relief we have. and now we can perhaps get after some of that loading or regional interdependence or anything that you think might have contributed. But team, I think it's a simple approach and I don't think you should feel bad about treating people with acute back pain even though you know that they're going to regress to the mean. It's worth it to save them that week in my mind. I'm always going to opt towards more treatment. SUMMARY So team, that's all I've got for you this morning. Last couple things I want to leave you with is just the upcoming spine courses. So if you're looking for cervical spine this weekend in the DFW area, make sure you jump over to Hazlet, Texas. That course will be right there near Dallas-Fort Worth Airport, kind of north of Fort Worth. If you're looking a little bit later in the month, Simi Valley, California, that one's getting closer to a sellout, so don't wait if you're in that region, you want to take that course. There's not too many seats left. And then March 9th and 10th, will be in Kuna, Idaho. If you're looking for Lumbar, March 23rd and 24th, Brookfield, Wisconsin, that's right outside of Milwaukee, that'll be at Onward Milwaukee. And then April 6th and 7th, we have two courses going on, one on the west side of the country over in Carson City, Nevada, and then one right here in Hendersonville, Tennessee. And again, that's April 6th and 7th. So we hope to catch you at some of those on the road. We'd love to catch up with you, talk more shop like this, talk about the main patterns that show up in the back of the neck and how to best utilize them. Team, I hope you have a great rest of your Thursday. Crush it in clinic today and I will see you soon here on the podcast.

SPEAKER_00: Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.