Bad Week for Physical Therapists
This week’s New York Times “Well” column reports that “Physical Therapy May Not Benefit Back Pain.“ A new study, published in JAMA, compared two groups experiencing lower back pain. One received 4 sessions of Physical Therapy (PT). The other was simply told that low back pain usually gets better and to be as active as possible. Results showed no differences between the two groups in reported “pain intensity”, “quality of life” and their number of visits to other health care providers. The PT group did experience significant improvement on the “disability” scale after 3 months, but by a year were the same as the non-PT group in this area.
It’s possible to read this headline as an opportunity to dismiss the value of PTs, and that is unfortunate. I believe a good PT can play a significant role in rehabilitation from injury or serious pain.
But in my experience as a teacher, I have seen evidence why the long-term results are as reported in this study. The study does not look at pain causation. For some people, that causation relates to ongoing excessive strain, tension, compression or other physical misuse. If there is not a change in those daily habits (which is different than simply doing assigned PT exercises), then the misuse returns when the trigger of the daily activities resume. An example: if you develop lower back pain from compression in the spine due to chronic slouching while sitting at a desk 8 hours a day, then it follows that when you return to your desk without addressing the habit of sitting, the pain will return.
Shifting focus to the “comments” section of this article: in 60+ responses from people well-versed in back pain (pain sufferers or medical professionals) only one person mentioned the importance of changing daily habits (and the use of the Alexander Technique to do so – brava, “Karen from Manhattan”!). Many people defended PT or mentioned the value of yoga for providing exercises and stretches to do, but seemed to miss the element of what not to do.
And now my lament: AT really suffers from a PR problem - it is not in the wider consciousness as a resource for back pain. Some of the obstacles:
· Insurance only rarely covers the cost of AT for rehabilitation. That creates a major barrier for someone with back pain and related medical expenses to undertake study.
· AT addresses the whole person. When someone comes in with shoulder pain, an AT teacher will look at how that person uses their neck, head, spine and limbs together for overall balanced coordination. In that way, we indirectly address the area of pain, and for many it does bring about change in experience of pain. But this indirect approach is not always a popular approach.
· Sometimes you have to commit to a course of study over time. It’s an educational method, rather than a therapy (although may have therapeutic value). So an AT practitioner doesn’t give you a treatment, but instead asks you to be an active participant in learning. Many people start to experience changes from their first lesson, but how quickly you progress depends on a whole host of factors, including the seriousness of your issues and how your work on your own. It requires becoming aware of how you are using yourself, and then applying some of the tools AT offers to halt and redirect habits that may be contributing to pain. It does not aim to be a quick fix, but rather a lasting one.
So back to the study, which really suggests an extremely quick fix, with just four sessions of PT. And the results are – MEH. No long-term success.
At the end of the article, the lead author of the study concludes: “Most treatments that are effective have only modest effects. The pattern of low back pain is one of recurrence and remission, and changing that pattern is a real challenge. There are no magic answers.”
And there it is: changing that pattern is a real challenge. It’s hard because it requires breaking strong habits. But I am reminded of the BMJ study in which the post-back surgery patients given only six AT lessons had a demonstrable reduction of pain recurrence even a year after the lessons. So it’s possible that just a little awareness, coupled with a little information, could help someone to begin to experience things differently. Perhaps there’s some light at the end of that tunnel.
But we have to solve the AT PR problem, so that people know it exists. I’ve laid out some challenges, but I’ve not yet found the solutions.