Clinician as Patient: What I Learned About the Role of Physical Therapy in Pain Management
This past winter I experienced an acute back injury that resulted in severe low back pain. It was difficult to stand or walk without pain. At first I thought the cause was back strain or muscle spasm. But since I was also experiencing radiating pain into my right hip, I was suspicious.
I was scheduled to leave for Southern California for a month of sun and golf, so I thought a little rest in a long car trip would help. With the help of ibuprofen and stretching, I made it from Portland to Palm Springs. However, my back pain was not getting better.
I then went to the Eisenhower Immediate Care Center where I met a wonderful physician by the name of Denny Mauricio, MD. After his careful assessment, he prescribed tramadol (50 mg, 3 times a day), and carisoprodol (Soma) at bedtime to help with sleep. In addition, he administered an intramuscular shot of the nonsteroidal anti-inflammatory agent ketorolac (Toradol), with a referral to the Eisenhower Medical Center for a lumbar magnetic resonance imaging (MRI). I scheduled a follow-up for the next week, where I learned the results of my MRI. The results were remarkable for degenerative lumbar disc disease plus 3 bulging discs at L3/4, L4/5, and L5/S1. The L4/5 disc bulge was the most significant, which explained the radiating pain into my right hip.
It was an awkward situation since my time in Palm Springs was limited, but Dr. Mauricio agreed to see me weekly for my ketorolac injections. Over the next 3 weeks, I tried to practice what I preach, which involved relaxation exercises and stretches in the hot tub, but no golf. Toward the end of 3 weeks, my pain started to subside, so I headed home to Portland to rain and cold weather, which did not help.
When I got home, I scheduled a visit with Ruhul Desi, MD, an interventional radiologist who runs a clinic called Restore PDX. I wanted him to look at my MRI and give me his opinion. He recommended physical therapy and referred me to an excellent physical therapist by the name of Brad Simpson, DPT.
I worked with Brad for 12 weeks, 2 times per week. At the end of 12 weeks of therapy, my back pain had subsided from severe (range of 8/10 on a visual analog scale) to mild (2/10) and I started playing golf and tennis again. I still do my stretches and I am limiting my swing in both golf and tennis, but it feels good to be back in the game!
Over the course of my rehabilitation, I considered a surgical consult, but my common sense said to hold off and trust my body to repair itself with the help of physical therapy.
I have always been a strong supporter of physical therapy, going back to my time at Oregon Health & Science University (OHSU), where we had a dedicated physical therapist in our pain management program who evaluated every referral. I knew right away that Brad was very knowledgeable, so I asked him if he would be willing to be interviewed. Below is my conversation with Dr. Simpson on the role of physical therapy in the management of pain.
Q: What made you want to become a physical therapist?
Dr. Simpson: I knew in high school that I wanted to be in a profession where I could help people. I shadowed various health care professions, and felt physical therapy was the best fit for me. It seemed to be a well-respected profession that was growing due to an aging population. Physical therapy is truly a positive profession, in that we have the benefit of seeing people “get better” every day. I can help the small population whom I feel I am not helping to get better get to other health care professionals in the hope of getting them on the right path toward improvement. Our mission is to help maximize people’s potential, which is an amazing goal to strive for every day.
Q: Talk about your background, experience, and education, and how your experience has changed in the past few years.
Dr. Simpson: I graduated from Oregon State University in 2002, with a Bachelor of Science in Exercise & Sports Science. I received my Doctorate of Physical Therapy (DPT) from Pacific University in 2005. Since the start of my career, I have been fortunate to have brilliant mentors who taught me to continue learning, and to always ask the question “Why?” with patients.
For example, after examining a person with insidious-onset left-sided knee pain, I would be challenged by mentors with questions such as, “Why did this happen to his left side, not his right side?” Early on, I was educated as to the benefits of residency or fellowship, and was introduced to the North American Institute of Orthopedic Manual Physical Therapy (NAIOMT), which is where I completed my manual therapy fellowship in 2012. I successfully completed all the requirements of the NAIOMT clinical fellowship program in 2012, and received my COMT, which is a Certified Orthopaedic Manipulative Therapist. I also received the designation of Fellow (FAAOMPT) through the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in 2012. I am also a CSCS, which is a Certified Strength and Conditioning Specialist.
Throughout my career, it has been interesting to see how some people improve and others have a more difficult time rehabilitating from what seems to be the same condition. For the majority of my career, I worked in a clinic that attracted a high percentage of complex, chronic pain patients, and I began adopting a more biopsychosocial model for treating clients.
When a person becomes injured, the fear-avoidance model (FAM) suggests there are 2 paths a patient’s recovery process can take, depending on psychological factors such as negative affect, threatening illness information, pain catastrophizing, fear of pain, and pain anxiety. If these variables are not present, normal recovery takes place. If they are present, there is a higher likelihood of fear-avoidance behaviors, which may lead toward chronic musculoskeletal pain syndromes.
Although there are biological dysfunctions that need to be addressed, there are also psychosocial aspects that may be affecting the patient’s ability to properly heal. Unless these barriers to successful rehabilitation are addressed, the patient will likely not improve, or may struggle with long-term success.
Another main concept emphasized through my fellowship was foundation building. It was stressed that “good physical therapists do the simple things well.” In addressing patients with chronic pain, this concept helped when I realized these patients were simply not managing well. They have no foundation to build their recovery on; therefore, they continue to hit a wall every time they try to progress. I began helping them form foundations, normalizing their “normal” prior to progressing their home program.