When in Doubt, Refer Out

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So I’m typing this out while sitting in McCarran international airport, awaiting the return flight to take the missus and I back to reality and hopefully warmer temperatures than when we left. We had a great time here in Vegas, and I’m happy to be leaving on good speaking terms with both my liver and bank account.

As I’ve been keeping busy with partying, walking around and generally not making an international ass of myself, I wanted to bring you all a guest post from someone who could fill the void of intellectualization while I was away. Enter Ann Wendel. Ann is a physiotherapist with Prana Physiotherapy in Alexandra, Virginia, and has been gracious enough to write about creating the line between where strength coaching should hand off to more clinical and therapeutic professionals.

Before we dive into Ann’s piece, just a friendly reminder that Eric Cressey and Mike Reinhold have their Functional Stability Training workshop on sale for only a few more days, so get in on it now while you have a chance of saving some money.

Click here to purchase FUNCTIONAL STABILITY TRAINING

 

If you work with clients in the fitness industry for any amount of time, you are going to interact with people who have low back pain. It is important to know what to look for when you are trying to decide if you should train your client on a day that they come in and say, “I tweaked my back, I don’t know what’s wrong with it.” By asking some questions you will be able to make a decision about whether the client can do a modified training session and be referred out or if they need to see a physical therapist or physician immediately. This article will provide information about low back pain and make some general recommendations for issues that should put you on high alert. I can say almost universally, if a client comes in complaining of back pain and has not been evaluated by a physician or physical therapist, you should not train them. It can be viewed as negligence on your part if you train them and they end up seriously injured. The take home message is “when in doubt, refer out.”

 

 

Low back pain (LBP) is a common problem affecting as much as 80% of the population at some point in their lives.  People of all ages, and both males and females are susceptible to acute and chronic low back pain.  Back pain is the second most common reason for visits to the doctor’s office (outnumbered only by upper respiratory infection).  Most cases of back pain are mechanical or non-organic, meaning not caused by serious medical conditions such as fracture or cancer.  Muscular causes of low back pain or low back myofascial pain syndrome are often overlooked because they are not accompanied by structural abnormalities (i.e. not seen on imaging studies). (Gerwin, R. adapted from Mense and Gerwin, Muscle Pain, Springer, 2010).  If X-rays and MRI have ruled out serious pathology in the back, it would make sense to look at muscular causes for the pain since the client may be dealing with non-specific low back pain (NSLBP), defined as back pain without an identifiable cause. A combination of self-care, physical therapy, medications, and activity modification may be helpful in returning to prior level of function.

Let’s look at factors that may predispose clients to low back pain.  Among the many factors are obesity, lack of physical fitness, hypermobile joints, occupation, age, psychological stress, and smoking.  Smoking has been found to have an overall detrimental effect on the intervertebral discs, by causing vasoconstriction (reduced blood flow) and decreased rate of healing.  Other conditions such as osteoarthritis and osteoporosis may increase likelihood of low back pain, as may anxiety and depression.

Since you should always have the client fill out an intake and medical history form prior to starting to train them, you should already be aware of any past issues they have had with their spine. If this is a flare of chronic, non-specific low back pain, you should screen your client for any obvious signs of serious pathology that would warrant a trip to the doctor immediately. This list (although not exhaustive) includes some signs to look for along with possible causes of the problem.

Red Flags – Back Pain and:

1)   Fever – LBP accompanied by fever can be a sign of infection, especially a Urinary Tract Infection (UTI)

2)   Trauma – LBP from a serious fall, car accident or a minor fall in clients >50 years old should be evaluated immediately

3)   Numbness and tingling in one or both legs, especially if below the knee – could be a sign that the spinal cord/nerves are being impinged by a disc or some type of mass

4)   Change in bowel or bladder function – incontinence (bowel or bladder) or feeling of urinary retention (not being able to empty bladder all the way) should be evaluated by a physician

5)   History of cancer, osteoporosis or chronic corticosteroid use – client needs to be evaluated for tumors that may have metastasized to the spine (cancer) or a vertebral fracture (due to osteoporosis or steroid use)

6)   Foot drop – if the client has trouble holding their foot/toes up or is tripping over their foot they may have nerve impingement from a disc or along the course of the nerve

7)   Night pain – most pain is relieved by rest in a comfortable position. If the client says their pain is worse or intolerable at night, they need to be evaluated to rule out a herniated disc or cancer in the spine

8)   Unexplained weight loss – can be caused by an infection or a tumor

9)   Pain lasting > 6 weeks – 90% of LBP is better within 6 weeks. If not, the client should be evaluated further by a medical professional

10)  Client > 70 years old – should be evaluated for infection, tumor or illness affecting an abdominal organ

11)  Chest pain – if the client complains of back and chest pain they need to be cleared to exercise after a cardiac condition is ruled out

12)  Lower extremity weakness – increasing weakness, heaviness, or aching pain in one or both legs should be evaluated

13)  Pain with running but not walking, especially in a young athlete – high school aged athletes who play sports such as football where they block with the spine in extension or lacrosse where they may get hit or end up on the ground with another player falling on them are at risk for stress fractures of the lumbar vertebrae. They may not have pain at rest or with normal daily walking, but pain brought on by running should be evaluated to rule out a fracture

If the client has none of these red flags, it may be appropriate to see if some gentle movement helps to loosen up the muscles and joints. If pain continues or worsens, it is best to stop the session and refer the client to a healthcare practitioner.

I encourage all trainers to develop relationships with other professionals in their city, so that they can make appropriate referrals. Keep in mind that in the U.S., physical therapists in 46 states and the District of Colombia (D.C.) have the ability to evaluate a patient without a doctor’s referral. http://bit.ly/wnLDds

Knowing a few good physical therapists can help you get your client evaluated and treated promptly, without a two week wait for an appointment with a physician.

It is very important to take complaints of back pain seriously. In 20 years of practice, I have seen numerous cases where serious injuries/illnesses were missed or went untreated for far too long because clients have put off further diagnostic testing. I have been very happy that I referred out in multiple cases, which ended up being UTI’s, tumors, severe disc herniations with atypical presentation, or stress fractures of the lumbar vertebrae. Less than a month ago a family member called me regarding his son’s low back pain following a lacrosse game (he had ended up on the bottom of a pile up of players). He had no signs of nerve involvement based on the questions I asked, and had been evaluated at the Emergency Room (X-Rays had not been taken). I advised him to rest, ice and avoid practice to see if the muscles would loosen up. He called several days later to say that his son had no pain at rest or walking; but, onset of pain with running. I advised him to see a spine specialist. He called me a few days later to say that imaging studies showed a stress fracture of a lumbar vertebrae, and that the treatment would be 6 weeks in a back brace with no activity. This could easily have been missed and he could have kept playing all season with “nagging pain when running.” This example highlights the fact that without proper imaging studies we actually have no idea what is going on. I certainly don’t want to take that risk as a physical therapist, and you shouldn’t as a trainer or coach!

By using these guidelines and always erring on the conservative side, you can be sure that you are providing the highest quality care for your clients. They will thank you for taking the time to listen to their concerns and will appreciate your recommendations and referrals when you think something may be outside your scope of practice. By working together, all members of the healthcare team can ensure the best outcomes for clients, to keep them healthy throughout their active lives.

 

Ann holds a B.S. in P.E. Studies with a concentration in Athletic Training from the University of Delaware, and a Masters in Physical Therapy from the University of Maryland, Baltimore. She is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT).

Over the past two decades, Ann has continually developed as a health care professional. She started her career working with high school, college and professional athletes, and later went on to work at an area hospital treating patients with a wide variety of Orthopedic and Neurological conditions.

To contact Ann, click HERE.

 

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  • http://twitter.com/PranaPT Ann Wendel

    Thanks for the opportunity, Dean!

  • Kyle Schuant

    The problem is that if we refer out everyone who presents with back pain, we’ll immediately reject 5 in 10 of all new clients, and we’ll have to refer out 4 of the remaining 5 at some point in the next three months. Then in many cases the client visits two or three different medical professionals who give contradictory advice. 

    You’re speaking as though the person goes to a physio or wherever, and is immediately put on a course of treatment which at least partially solves the problem. More commonly, the person goes to one medical professional, after three months nothing is improved, so they go to another, this one might improve things but the person doesn’t give it three months because they didn’t like the advice, so they go somewhere else, etc. As a fitness professional, I am morally and legally bound (not directly, but on pain of possible lawsuit) to follow all medical advice given my clients. But what to do when it’s contradictory? This is especially difficult when the field is full of people who are generally ignorant about exercise (eg general practice doctors) or whose claim to the title “medical professional” is doubtful, like chiropractors, etc. Just the other day we had a staff meeting at the gym, a couple of chiropractors showed up and told us things like, “shoulder pain may be caused by pec tightness, which may have to do with dysfunction in the liver.” No, my client does not have liver dysfunction, he’s just sitting at a desk all bloody day, that’s why his shoulder hurts. He doesn’t need a liver cleansing diet, he needs to stretch his chest and do rowing movements with good scapular retraction. But should I recommend the client follow that advice? Should I be second-guessing the advice given the client? With some quack like that it shouldn’t be a problem, but with less clearly nonsense advice it could get dangerous. 

  • Mike

     Kyle,

    I’m a chiropractor in the states, and I feel your pain. My recommendation is, form a relationship with a proper doc that knows the value of an enlightened fitness professional. The first database I would go after is Gray Cook’s SFMA docs. That particular list holds a myriad of docs that are all fundamentally sound in movement and orthopedic analysis. If one of those names is in your area, forming a relationship with them will most likely result in numerous referrals for post rehab exercise programming.

    As for the chiro that pointed toward liver dysfunction as a cause of shoulder pain, he/she was close, but no cigar. The gallbladder can refer pain to the right (typically) shoulder or shoulder girdle, but the liver doesn’t usually follow that particular referral pattern. I’m not sure if that was what he/she was trying to get across, but if so, that particular chiro was ineffective in doing so.

    There are many intelligent docs out there that are dying for personnel to help transition from post rehab ADL work to functional strength. Find them and they will be a golden goose for you.

    Cheers,
    Mike      

  • http://twitter.com/PranaPT Ann Wendel

    Hi Kyle,
    I can hear your frustration in your comment “The problem is that if we refer out everyone who presents with back
    pain, we’ll immediately reject 5 in 10 of all new clients, and we’ll
    have to refer out 4 of the remaining 5 at some point in the next three
    months.”   The whole purpose of this article was to identify those clients that really DO need to be referred out for their safety and your liability. It can be difficult to coordinate a team approach to care sometimes – that’s why I recommend networking in your community, so that you can find a really good family practitioner, orthopedic surgeon, physical therapist, etc to refer patients to. That way, you can give their card to your clients when you refer them out. You may be frustrated by “contradictory advice;” but, I can assure you that if your clients have any of the 13 signs listed in the article, you should refer them out. The risk of deciding to not to refer these clients out outweighs the benefit of having 5 more clients on your books. As I said, patients in your state may have Direct Access to physical therapy, and if you have networked with a good one, you can refer the client out to them, and have the client return once they are cleared.
    I am not giving you any advice I wouldn’t take myself. As a physical therapist who has patients come in for an evaluation under Direct Access every day, I would NEVER treat a patient with one or more of these 13 symptoms prior to having them evaluated by a physician.