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.
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.