The key to low back pain- stratification and the Katie Couric effect

What is the best way to treat low back pain?

I get asked this question all the time, whether I am seeing patients in my Sports & Spine clinic, lecturing at national meetings, or meeting with other experts.

There is one key to management of low back pain- stratification.

What I mean by this is that low back pain is not one diagnosis, and therefore trying to treat all low back pain with one approach is not effective. In a typical day, I may see patients who have many different causes of low back pain, all of which are best managed with different treatment approaches. The approach to managing an annular tear in a 23 year old Ironman triathlete is dramatically different than that of a 74 year old with zygapophysial joint arthropathy, which is dramatically different than the approach in a 34 year old woman with post-partum pelvic floor dysfunction.

Some of these patients I manage with an exercise program, others I may manage with an image-guided injection, and others I may manage by working in a team with the physical therapist or chiropractor. The key is that I recognize that every patient is different, and no one approach will work for everyone.

Unfortunately, many treatment recommendations are based on the assumption that low back pain should be treated as one entity, and therefore one basic approach should be used.

So, if you have low back pain, the biggest determinant in getting better is appropriate stratification into the appropriate treatment groups. Some of this is related to determining the appropriate diagnosis, but often times we can stratify patients into appropriate treatment groups even if we don't know the actual diagnosis.

For example, many patients are surprised to find out that if you want to get better, it is more valuable to know a patient's directional preference (i.e., which movements are most painful, such as putting on shoes and socks in the morning) than it is to look at an MRI. If I know that a patient hurts more with certain movements, I can design a physical therapy program that takes this into account. This is of great benefit to this physical therapist, and as Audrey Long demonstrated in her award winning research in 2004, if we design physical therapy programs with a directional preference in mind, the probability of improvement increases dramatically.

http://journals.lww.com/spinejournal/Abstract/2004/12010/Does_it_Matter_Which_Exercise___A_Randomized.2.aspx

But I have many patients say to me "I hear you, but I've always been told that if you really want to know what is causing my low back pain, I need an MRI." MRIs are wonderful tools, but the reason they are not as helpful as you might imagine is because of what I call the "Katie Couric Effect."

We all know Katie Couric. Back in 2000, in the days before we had HD televisions, we didn't notice that she was actually a woman in her 40s. When she started working for CBS on the nightly news, two things happened- Katie Couric turned 50, and many of us started watching her in HD television.

Katie Couric is a very attractive woman, but when you look at her in HD television, many things are suddenly apparent that were not apparent on a regular television. She is the same woman that she was on a regular television, but because of the higher resolution of the TV, we are now more aware of some of the natural changes associated with aging that we would have been blissfully ignorant of otherwise.

Same thing with back MRIs. Just as the natural processes of aging can bring along gray hair and wrinkles, the normal healthy spine has some age-associated changes, including degeneration of the disks and joints. Much of this is incidental, and therefore when we look at a spine MRI, most of what we are looking at is incidental findings. And often times, the main cause of low back pain may not be seen on MRI.

Which brings me back to what is the best way to treat low back pain. The key is to find someone you trust who is able to figure out what is the best treatment approach for you. That person may be a Sports & Spine PM&R physician like myself, it may be a surgeon, it may be a chiropractor, it may be a physical therapist, it may be an accupuncturist, etc.

Ultimately, you need someone who can see you as an individual, and has the skill set necessary to tailor a program that is appropriate for you.

Kinesiotape

I am on vacation at the moment, and have been avoiding posting while away, but someone asked a very good question that I've been thinking about myself while watching the Olympics- how beneficial is kinesiotape?

Probably the athlete who has stimulated the most questions is Kerri Walsh, the star beach volleyball player who, along with Misty May, is the favorite to win the gold medal in beach volleyball. She has been playing with kinesiotape on her shoulder throughout the Olympics, although she notably did not have any on last night during her semifinal match against Brazil.

Before researching the answer, my anecdotal experience from residency training was that while kinesiotape is limiting in it's ability to actually restrict motion, but it is useful as a proprioceptive cue. The theory behind this is sensory substitution. In this case, it is substituting tactile sensation to compensate for inadequate proprioception, which I will elaborate on below.

Proprioception refers to the ability to know where your body is in space. For example, if you close your eyes, you can flex and extend your elbow and know the position of your elbow- that's proprioception. Proprioception is important in sports activities, because to function at a high level, an athlete needs to properly place their limbs in a location to optimally contract their muscles to deliver a movement quickly and forcefully. A few examples where this can be especially important:

1. The knee- when an athlete lands, the knee needs to be optimally located to allow for smooth tracking of the patella (knee cap) along the groove of the femur (thigh bone). Improper positioning (usually of the femur) can cause abnormal tracking of the patellofemoral joint, causing patellofemoral syndrome.

2. The shoulder- the shoulder is one of the most mobile joints in the body, and requires an intricate interaction between multiple muscles (including the rotator cuff muscles, serratus anterior, trapezius, levator scapula, and several others). A typical pattern may include using the rotator cuff muscles to pull the head of the humerus into the glenoid fossa of the scapula (shoulder blade), co-contracting the serratus anterior and lower trapezius to position the scapula into the optimal position, and then contracting the teres major and latissimus dorsi to position the humerus throughout the range of motion. From just that description, one could see how the coordination of the muscles at the optimal time and in the optimal proportions could be challenging.

So, how does kinesiotape theoretically help? Well, the tape is a semi-rigid tape that stays relatively loose and comfortable when the joint is moving throughout the proper range of motion, but becomes uncomfortably tight when moving the joint outside of that ideal range, creating tension on the skin. This helps use the tactile sensation of the pulling on the skin to substitute (or reinforce) the proprioception of the joint. In combination, this helps reinforce the optimal positioning and movement of the joint.

So, back to the readers question- does it work?

Anecdotally, it is a useful reminder to maintain posture. I've used it experimentally, just for kicks, to see if I could remember to keep my back straight while lifting. It did help, although it could also be annoying every time I tried to sit down. So, there is the balance between reminding one of proper positioning, and an annoying tugging of the skin.

What is the evidence?

A search on pubmed on the term "kinesiotape" yields one article:

Res Sports Med. 2007 Apr-Jun;15(2):103-12.
The effect of kinesio taping on lower trunk range of motions.
Yoshida A, Kahanov L.

This article looked only at range of motion, not the more complicated question of athletic performance. It found it helped to some extent.

I then checked out the kinesiotape website: http://www.kinesiotaping.com/

To their credit, they have a grant process available, where they will supply tape to interested researchers to help conduct studies. They also have links to a few studies that are germane to the reader's questions:

J Orthop Sports Phys Ther. 2008 Jul;38(7):389-95. Epub 2008 May 29.
The clinical efficacy of kinesio tape for shoulder pain: a randomized,
double-blinded, clinical trial.
Thelen MD, Dauber JA, Stoneman PD.

This study looked at 42 participants with presumed rotator cuff pain, and randomized them into 2 groups, one of which used kinesiotape. The results aren't overwhelming, but the kinesiotape group did have some increased range of motion.

There are a few other studies cited for other conditions listed on the website.

So, back to the key questions:

1. Does kinesiotape work, in general?

Maybe. I don't think the evidence is overwhelming, but absence of evidence is not evidence of absence. I think it probably does offer some sensory substitution that is useful as part of an integrated physical therapy program in training an athlete to use their joint through an optimal range of motion.

2. In the specific case of Kerri Walsh, does it help?

Maybe. She's been playing pretty well, although it is interesting that many of the teams have aggressively challenged her defensively. Also, she ended up pulling it off for her semifinal match against Brazil. With an athlete like Kerri Walsh, who may be the best ever in her sport, it is difficult to attribute any one component of her success to any one intervention. Probably the largest benefit is providing her the confidence to play all-out.

3. Would I prescribe it?

Yes. I have prescribed it. My closest friend from training (the late Jim McLean) used it regularly for his patellofemoral syndrome, and he attributed it to being of the keys to him running marathons again.

Please share with me your thoughts.

Gary