Detecting cause of pain key to injury treatment

It is always challenging for the health care provider, case manager and company safety officer to know exactly when and how a work-related injury happened. The information that can be gathered from the employee is subjective.

Due to this challenge and for better treatment results, it is very important to detect the real cause of the injured worker's neck and back pain.

Treating injured workers with neck and back pain can even be more challenging. Successful outcomes can be found with a team approach.

Team members

The team includes physicians, physical therapists, case managers, company safety officers, and the injured worker.

Physicians are responsible for evaluating and treating diseases. Orthopedic manual physical therapists are responsible for evaluating and treating of physical dysfunctions related to the spine and extremities causing pain. Case managers assist the injured worker in returning to work by helping them find medical and physical treatments they require.

Psychiatrists and psychologists also play an important role in pain management. Physiatrists (MDs who are specialists in physical medicine) are important medical and rehabilitation experts who can facilitate the return to work at the most appropriate time.

The physical recovery from low back pain is a process. The injured worker has a personal responsibility to follow through with the program established to maximize recovery and to minimize, if not prevent a re-injury.

Cause of pain

Pain can be physical, medical, mental or a combination of all three. To have the best treatment results, it is important to quantify the cause of the pain.

Is the cause purely mechanical in origin? Is it a medical condition manifesting as physical pain? Is the cause of pain related to a mental condition? Is it a combination of all three? Is there symptom magnification and in case there is, what's the plan of action?

Treatment

Physicians play an important role in the evaluation of possible medical causes that can be related to the physical pain. They also are responsible for providing the proper medication needed after the time of injury and to order the appropriate diagnostic procedures that can help rule out the possible cause(s) of the problem.

Orthopedic manual physical therapists play in important role in the evaluation of possible movement restrictions in the spine that can result to neck and back pain. Movement restrictions due to joint, muscle, or soft tissue dysfunctions would cause compensation of surrounding related structures with a resultant pain. The assessment rationale is not to treat the pain but to examine and treat the physical cause of the pain, which is the movement restrictions in the spine.

In the practice of orthopedic manual physical therapy, the physical recovery is a three-step process. First step is to regain normal movements in the spine by utilizing joint mobilization, soft tissue mobilization, stretching exercises in conjunction with other physical therapy modalities. When the restricted movements are back to normal, then there will be less compensation therefore, less pain. The second step is to maintain the movements that were regained. Main-taining normal movements is most important because as long as there is movement restriction, there is compensation, and therefore, pain.

Once the movements are regained and maintained there can still be some pain because the muscles, which were pulling and stretching to compensate, became weak and they hurt. To maximize physical recovery, strengthening and stabilization exercises should only be initiated when normal movements are regained and maintained.

Should the cause of neck and back pain be purely physical, patients should start feeling better after few physical therapy treatments. If the pain is the same or worse after three to five treatments, then it's time to reassess. If this is the situation, it is of utmost importance for the physician and the physical therapist to coordinate. Physicians may need to further examine the patient for possible medical condition and/or more diagnostic procedures have to be performed.

Should medical findings be normal and/or movement restrictions in the lumbar spine are back to normal, then the possibility of patient's emotional reaction to pain can be considered. Use of the McGill Pain Questionnaire during initial assessment is always beneficial. Test results can reveal patient's emotional reaction to pain in relation to physical recovery. This can also be useful to physicians in case he decides to refer the injured worker to a psychiatrist and/or to a pain management program.

Return to work programs

In assisting the injured worker return to work, the following industrial rehabilitation programs can be utilized: Work Conditioning Program; Work Hardening Program; and Functional Capacity Evaluation.

(Gerry Catapang, PT, is director of physical therapy for Physical Therapy Care, Manual Physical Therapy, and Industrial Rehab Center.)