We are going to start with Lisa Huynh, MD, who is my co-author on the
recent article "Get the Lowdown on Low Back Pain in Athletes"
published this month in the American College of Sports Medicine Health
& Fitness Journal (link requires ACSM membership)
recent article "Get the Lowdown on Low Back Pain in Athletes"
published this month in the American College of Sports Medicine Health
& Fitness Journal (link requires ACSM membership)
Lisa worked with me as Chief Resident at the
University of Pittsburgh Medical Center, and starting in July will be
starting at Stanford University in an Interventional Spine Fellowship.
Amongst other things, Lisa was the very last resident I taught at the
University of Pittsburgh, and it was such a privilege for me to work
with her.
I've invited Lisa to give her perspectives on low back pain in
athletes, her practice philosophy, and her general thoughts about
Sports & Spine Rehabilitation.
Gary: What sparked your interest in treating low back pain in athletes?
Lisa: As discussed in our article, low back pain is the second most
common reason people see their doctors. Therefore, it's important for
all physicians to understand the different etiologies of back pain and
how to treat them.
Athletes are a unique set of patients. As dedicated as they are to
their sport, they are equally dedicated to healing after an injury in
order to return to play as quickly as possible. This makes them
intensely motivated, which is welcoming as a physician.
I recall early on in my training treating a female college volleyball
player who had persistent low back pain for over a year. She had been
through generic physical therapy programs and tried oral medications
with no relief. I helped diagnose her with an annular tear, which had
been previously missed. We performed an epidural steroid injection
and prescribed a course of extension-based physical therapy. On
follow-up, she was back to playing volleyball and was pain-free. That
was a great feeling!
Gary: You have perspectives as an athlete yourself and as a physician.
Why do you think it's important that athletes with low back pain seek
out care from a specialist who is familiar with the particular needs
of athletes?
Lisa: As a physician, we learn and treat a variety of medical conditions
and see a diverse set of patients. However, athletes are a unique set
of patients, which require specialized care. As an athlete myself, I
would want a physician who understands not only an athlete's mindset,
but also the demands of his or her particular athletic activity. This
enables the physician to better tailor the treatment and
rehabilitation regimen to help heal and prevent further injuries.
Gary: One treatment that you touched upon in the article was the
Mechanical Diagnosis and Therapy (McKenzie) approach to assessing a
directional preference and centralization of symptoms. My experience
is that this is frequently overlooked in patients with low back pain, even when seen by other spine experts. Why is this so important in an assessment of patients?
Lisa: The McKenzie approach is based on finding the directional
preference (lumbar flexion or extension) of which back pain and
radiating pain is relieved. By determining a patient's directional
preference, you can better narrow down their pain generator, which
ultimately helps guide their physical therapy program. At a basic level, for example, for patients that have back pain and leg pain worse with lumbar flexion, they
should participate in an extension-based program. For those that have
pain worse with lumbar extension, they should participate in a
flexion-based program. The overall goal of this approach is to move
pain from the legs and centralize it to the back, with eventual
dissipation of the pain.
Gary: Another great point you touched up in the article was annular tears
as a common cause of low back pain. I find that many patients are
told that they have "chronic muscle strains" or "mechanical low back
pain", when they actually have annular tears. What tips do you have
for recognizing an annular tear, and how do you use that insight to
guide treatment?
Lisa: Typically, symptoms of an annular tear include a vague pain
located at midline of the back. Pain is typically worse with bending
forward, coughing, sneezing, and prolonged sitting. Oftentimes
patient may complain of stiffness in the morning or can be seen
shifting their weight from side to side while sitting. It does not
typically radiate down into the buttocks or legs like it does with
disk herniations. Since pain is typically worse with bending forward,
prescribing an extension-based physical therapy program would be most
appropriate. If pain persists despite more conservative measures,
consideration can be given to a fluoroscopic-guided epidural steroid
injection.
Gary: Since you and I haven't worked together for about a year, it's
helpful for me to gain from your perspective of what was helpful from
I had shared with you as a clinician. Did I teach you anything useful
that you still use?
Lisa: One of the greatest things you imparted to me was lifestyle
medicine. Many times, patients come to us for a quick fix such as a
"magic pill" to make their pain go away. And while it may be easy to
write a script for medications or therapy, these often do not help in
the long run. By educating the patient and providing them with the
tools to change their mindset and lifestyle, we not only help to
improve their acute injuries, but can also prevent further occurrences
down the road.
I also continue to educate them on the difference between strategy and
tactic, as you have taught me. Strategy is having an overall plan,
whereas tactics are specific, well-defined tasks that help to
accomplish an overall goal. So rather than telling a patient to lose
weight, I continue to encourage them to participate in at least 30
minutes of aerobic exercise at least 5 days a week according to ACSM
guidelines, use walking sticks if needed, and sign up for
myfitnesspal.com to track their progress, amongst many other tools.
Gary: It has been such privilege for me to be part of your development as
a physician and person. As you are evolving your personal
patient-care philosophy, how would you define your vision and
approach?
University of Pittsburgh Medical Center, and starting in July will be
starting at Stanford University in an Interventional Spine Fellowship.
Amongst other things, Lisa was the very last resident I taught at the
University of Pittsburgh, and it was such a privilege for me to work
with her.
I've invited Lisa to give her perspectives on low back pain in
athletes, her practice philosophy, and her general thoughts about
Sports & Spine Rehabilitation.
Gary: What sparked your interest in treating low back pain in athletes?
Lisa: As discussed in our article, low back pain is the second most
common reason people see their doctors. Therefore, it's important for
all physicians to understand the different etiologies of back pain and
how to treat them.
Athletes are a unique set of patients. As dedicated as they are to
their sport, they are equally dedicated to healing after an injury in
order to return to play as quickly as possible. This makes them
intensely motivated, which is welcoming as a physician.
I recall early on in my training treating a female college volleyball
player who had persistent low back pain for over a year. She had been
through generic physical therapy programs and tried oral medications
with no relief. I helped diagnose her with an annular tear, which had
been previously missed. We performed an epidural steroid injection
and prescribed a course of extension-based physical therapy. On
follow-up, she was back to playing volleyball and was pain-free. That
was a great feeling!
Gary: You have perspectives as an athlete yourself and as a physician.
Why do you think it's important that athletes with low back pain seek
out care from a specialist who is familiar with the particular needs
of athletes?
Lisa: As a physician, we learn and treat a variety of medical conditions
and see a diverse set of patients. However, athletes are a unique set
of patients, which require specialized care. As an athlete myself, I
would want a physician who understands not only an athlete's mindset,
but also the demands of his or her particular athletic activity. This
enables the physician to better tailor the treatment and
rehabilitation regimen to help heal and prevent further injuries.
Gary: One treatment that you touched upon in the article was the
Mechanical Diagnosis and Therapy (McKenzie) approach to assessing a
directional preference and centralization of symptoms. My experience
is that this is frequently overlooked in patients with low back pain, even when seen by other spine experts. Why is this so important in an assessment of patients?
Lisa: The McKenzie approach is based on finding the directional
preference (lumbar flexion or extension) of which back pain and
radiating pain is relieved. By determining a patient's directional
preference, you can better narrow down their pain generator, which
ultimately helps guide their physical therapy program. At a basic level, for example, for patients that have back pain and leg pain worse with lumbar flexion, they
should participate in an extension-based program. For those that have
pain worse with lumbar extension, they should participate in a
flexion-based program. The overall goal of this approach is to move
pain from the legs and centralize it to the back, with eventual
dissipation of the pain.
Gary: Another great point you touched up in the article was annular tears
as a common cause of low back pain. I find that many patients are
told that they have "chronic muscle strains" or "mechanical low back
pain", when they actually have annular tears. What tips do you have
for recognizing an annular tear, and how do you use that insight to
guide treatment?
Lisa: Typically, symptoms of an annular tear include a vague pain
located at midline of the back. Pain is typically worse with bending
forward, coughing, sneezing, and prolonged sitting. Oftentimes
patient may complain of stiffness in the morning or can be seen
shifting their weight from side to side while sitting. It does not
typically radiate down into the buttocks or legs like it does with
disk herniations. Since pain is typically worse with bending forward,
prescribing an extension-based physical therapy program would be most
appropriate. If pain persists despite more conservative measures,
consideration can be given to a fluoroscopic-guided epidural steroid
injection.
Gary: Since you and I haven't worked together for about a year, it's
helpful for me to gain from your perspective of what was helpful from
I had shared with you as a clinician. Did I teach you anything useful
that you still use?
Lisa: One of the greatest things you imparted to me was lifestyle
medicine. Many times, patients come to us for a quick fix such as a
"magic pill" to make their pain go away. And while it may be easy to
write a script for medications or therapy, these often do not help in
the long run. By educating the patient and providing them with the
tools to change their mindset and lifestyle, we not only help to
improve their acute injuries, but can also prevent further occurrences
down the road.
I also continue to educate them on the difference between strategy and
tactic, as you have taught me. Strategy is having an overall plan,
whereas tactics are specific, well-defined tasks that help to
accomplish an overall goal. So rather than telling a patient to lose
weight, I continue to encourage them to participate in at least 30
minutes of aerobic exercise at least 5 days a week according to ACSM
guidelines, use walking sticks if needed, and sign up for
myfitnesspal.com to track their progress, amongst many other tools.
Gary: It has been such privilege for me to be part of your development as
a physician and person. As you are evolving your personal
patient-care philosophy, how would you define your vision and
approach?
Lisa: I'm just starting out so I'm sure that my vision and approach will
evolve over the years. However, my personal patient-care philosophy
is one that empowers the patient to take charge of their treatment
plan of care, because that is what will ultimately motivate them to
improve. When I first see a patient, I want to find out what their
overall goals are, what they think their limitations are, and what
tools they have to accomplish their goals. Utilizing that information
allows me to develop a treatment plan WITH the patient so that we are
BOTH in agreement on how to achieve his or her goals. I find that
patients are more inclined to complete tasks and stay motivated when
they have had direct involvement in their treatment plan.
Gary: I'd like to extent a great thanks to Lisa Huynh, MD. She is a
spectacular physician, and I look forward to checking in with her to
see how her perspectives develops in the coming years.
evolve over the years. However, my personal patient-care philosophy
is one that empowers the patient to take charge of their treatment
plan of care, because that is what will ultimately motivate them to
improve. When I first see a patient, I want to find out what their
overall goals are, what they think their limitations are, and what
tools they have to accomplish their goals. Utilizing that information
allows me to develop a treatment plan WITH the patient so that we are
BOTH in agreement on how to achieve his or her goals. I find that
patients are more inclined to complete tasks and stay motivated when
they have had direct involvement in their treatment plan.
Gary: I'd like to extent a great thanks to Lisa Huynh, MD. She is a
spectacular physician, and I look forward to checking in with her to
see how her perspectives develops in the coming years.
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