Back specialist: Who can help you? (And who to avoid?)

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Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine 

“I have back pain, which back specialist should I consult?”

This is a question that often comes up in forums, and with people who suffer from back pain. The first instinct is often to go see your family doctor. Depending on the symptoms and the duration of the problem, it could be referred to a specialist doctor. In other cases, he suggests a therapist.

One of your colleagues swears by his osteo, while your friend saw his pain fade away after seeing the chiropractor. You may have already been referred to a physiotherapist (or physiotherapist) who has prescribed exercises and stretches for you. As you feel lumbar tension, you may feel that a good massage could relieve you.

In short, which of these therapists will be most able to help you? Which door to knock on when you have back pain?

The following article will list each back specialist with a role to play in the treatment of low back pain (WHO to consult?). Then, we will discuss the characteristics of each, as well as the situations where it would be interesting to consult (WHEN to consult?). Finally, we will discuss 5 characteristics of a bad therapist.

The doctors

 

Generalist

 

As mentioned, the general practitioner is often the first person consulted after an episode of back pain.

Because he knows you quite well, your family doctor will be able to review your medical history and/or injury history and relate it to your low back pain.

Another major diagnostic element is the exclusion of a serious harm. Fortunately, the vast majority of low back pain does not stem from a serious cause, and the prognosis is generally favorable. On the other hand, some pathologies are manifested by back pain. The family physician's role will therefore be to rule out these conditions based on warning signs (called red flags or “red flags”).

If you fear that your condition is serious, fill out this questionnaire which will allow you to tell if your back pain comes from a serious attack: I have back pain: is it serious?

In terms of treatment, the GP could prescribe medication aimed at relieving your symptoms. Once again, the fact that he knows your file will allow him to be more efficient in his prescription (for example, by avoiding side effects and/or drug interactions). Sometimes the prescription can be combined with a work stopping, especially when your occupation is an obstacle to your optimal recovery.

If deemed necessary, the general practitioner may prescribe a medical imaging. Admittedly, an x-ray or an MRI may not necessarily reflect the whole situation, but these modalities can be useful in certain cases (for example, to eliminate the serious damage).

Finally, the general practitioner is the one who will be able to refer you to other professionals depending on your condition. He will follow up on your progress from time to time to ensure favorable progress. Its role is extremely important, especially to avoid chronic low back pain.

 

physiatrist

 

In Quebec, the physiatrist is the medical specialist in musculoskeletal disorders (spine, bones, muscles, tendons, etc.). Thus, he will usually have more experience with low back pain compared to your family doctor. In France, this specialty is called "Physical and Rehabilitation Medicine (PRM)".

Physiatry is distinguished by its diagnostic methods which place great emphasis on clinical examination. Considering his vast field of expertise, the physiatrist could, for example, prescribe a medical imaging more "advanced" if ever the need arises (discogram, Scanner or computed tomography, etc). He will examine your movements, reflexes, strength, to get a better picture of your condition.

Regarding treatment, the physiatrist will cover all non-surgical treatments related to your back pain. In addition to the medication, he could give you a cortisone infiltration, prescribe exercises in collaboration with the physiotherapist (kinesitherapist) and the occupational therapist, etc.

 

Rheumatologist

 

Like the physiatrist, the rheumatologist specializes in bones, joints, tendons, ligaments, etc. In the case of low back pain, we call on his expertise, especially when we suspect a inflammation of the spine, an autoimmune disease, osteoarthritis, rheumatism in general, etc.

This back specialist can help clarify the diagnosis, including ordering further testing. For example, a test for bone densitometry may be prescribed to diagnose osteoporosis. Or, blood tests or other biological analyzes could highlight an inflammatory condition such as ankylosing spondylitis.

He will also ensure that your medication is effective and adjusted to your needs. Like many other medical specialists, the rheumatologist could perform certain medical procedures such as infiltrations as needed.

  

Orthopedist

 

When we refer to orthopedics, we generally consider the lumbar surgery. This back specialist will first analyze your imaging exams, then do a physical examination allowing him to have a detailed portrait of your back pain.

Surgical indications are often related to severe damage, or persistent pain that has not responded to conservative treatment and which greatly limits quality of life. Depending on your case, the orthopedic surgeon will assess the benefits and risks of "going under the knife".

In addition to surgery, the expertise and experience of the orthopedist in relation to conservative treatments should not be underestimated. In some cases, the orthopedist will even advise against the operation. Indeed, many patients imagine that an operation will instantly make their chronic low back pain disappear. Unfortunately, pain is multifactorial, and surgery alone is usually not the magic bullet.

 

Therapists

 

Physiotherapist (physiotherapist)

 

You probably know the physiotherapist (or physical therapist) because your doctor has recommended sessions for your back. In some countries, on the other hand, it is possible to consult a physio (physiotherapist) without first consulting a doctor.

Either way, this therapist will use a combination of education, manual techniques, andtherapeutic exercises to treat your back problem. What makes it unique is its emphasis on a active approach, and the responsibility he delegates to the patient. Indeed, many physios/physiotherapists minimize passive modalities to promote mobility, strengthening or breathing. These movements will also be incorporated as part of a home exercise program. This is essential if you want to treat and prevent back pain in the long term.

Because they base their practice on evidence (basically, in line with modern scientific evidence), physiotherapists have earned the respect of physicians who refer so many patients to this profession.

On the other hand, I advise you to be wary of physiotherapists/physiotherapists who use passive modalities to excess. Unfortunately, some patients only benefit from a heat pack, ultrasound machine, and electric current during their sessions. This practice is outdated, and not effective in the long term according to recent studies. Certainly, they can provide relief and be used sparingly. But never forget that the solution to back pain is movement!

ostéopathe

 

No, the osteopath does not deal only with the bones. This is something I often hear, probably because of the confusing term "OSTeopath".

Osteo is more concerned with correcting imbalances in the sympathetic, parasympathetic and visceral systems, through manual therapy techniques. This approach relieves (back) pain, reduces muscle tension and optimizes overall health.

The manipulations, often gentle, will integrate several regions of the body. As the causes of pain are multiple depending on the bones (both osteo-articular and visceral), these therapists will use a holistic approach to treat your symptoms.

If you want learn more about osteopathy, I invite you to read the article written by my colleague David Ferreira, osteopath.

 

Occupational therapist

 

Unfortunately, occupational therapy is a little-known profession. Yet, these professionals can greatly help those with back pain get back to their usual activities (like work and chores around the house).

Through a functional assessment, the occupational therapist can identify the physical, psychological and social limitations related to their patient's back pain. This speaker will then be able to propose some concrete and effective solutions. For example, a kitchen remodel could help limit the excessive bending or twisting that normally increases your symptoms. Or, an adjustment of your workstation, associated with postural advice, may decrease your pain while sitting.

The other important element covered by the occupational therapist is the return to work. For those who cannot work because of their back pain, the occupational therapist will make sure to identify the barriers to returning to work, and establish a plan aimed at resuming your professional activities gradually and safely.

Kinesiologist

 

Le kinesiologist is often associated with a sports coach for people with no injuries (at least, in Canada). However, these professionals can offer interesting solutions for those who wish to remain active despite their back pain.

It's no longer a secret that physical exercise has been shown to be one of the most effective solutions for treating low back pain in the long term. A kinesiologist is an ally of choice for getting back in shape, losing weight, improving your cardiovascular capacity, or gaining muscle strength. These benefits will have a positive impact on your back, and on a larger scale on your overall health. Based on a clinical evaluation, this professional will give you a program adapted to your condition and your preferences.

It should be noted that some kinesiologists work in collaboration with other health professionals as part of a multidisciplinary team. For example, many chronic pain centers have kinesiologists in their ranks.

Chiropractor

 

These therapists are less common in France compared to North America. When we imagine a chiropractor, we visualize a patient being cracked all over to relieve pain. It's not false. But chiropractors also have other tools in their therapeutic arsenal.

Already, chiropractors can prescribe x-rays to show the alignment of the spine, and the integrity of the cartilages and spaces between the vertebrae. On the other hand, this type of imaging is debated among health professionals, in particular because a dysfunction observed on medical imaging is not necessarily representative of reality. This is also why many chiropractors no longer integrate radiography into their practice.

When it comes to treatment, don't think a chiropractor will "realign your vertebrae”, or “to put your back in place following subluxations”. It's a myth, and any professional who tells you otherwise is not basing their practice on the latest scientific evidence. It is also for this reason that you have to ask yourself questions when an ill-intentioned chiropractor asks you to come 3 times a week for a period of several months, in order to ensure an "optimal" alignment of your back!

Yes, the chiropractor will often crack certain joints to relieve you. Yes, a joint crack in the spine can be heard. On the other hand, the noise associated with these “adjustments” is not synonymous with realignment, but rather with a change in pressure in the synovial fluid surrounding your joints. This leads to the formation of gas bubbles responsible for the famous "crack" (also called cavitation)! Moreover, be aware that a manipulation which does not no noise can be just as effective.

Be that as it may, spinal manipulations have demonstrated certain benefits in the management of chronic back pain. If you ever feel relief when your back "creaks", do not hesitate to consult a chiropractor. 

  

Massage therapist

 

Revelation of the day: The massage therapist does massages. And it does a lot of good! Myofascial release, continuous pressure, passive stretching, all these techniques can provide relief from back pain.

Small downside. It has been shown that a proactive approach is THE solution to back pain. Thus, the management of low back pain should primarily incorporate techniques where the patient does the work (such as mobility exercises, Stretching, muscle building).

If you doubt the importance of moving after back pain, discover our article where we explain why you should exercise after back pain.

In short, massage practitioners are an excellent resource for relieving your pain, as long as your visits are complemented by an approach where the emphasis is on active and preventive methods.

  

Acupuncture

 

Don't worry, the acupuncturist is not going to stick needles in your veins. The fine dry needles used in acupuncture only penetrate the skin superficially, and are intended to "ensure a good flow of vital energy along the meridians" via fine needles. This is an approach that has been used for thousands of years in traditional Chinese medicine.

In the treatment of back pain, acupuncture is believed to relieve both recent and chronic pain, as well as reduce inflammation and restore an optimal level of vital energy (called Qi). As it is connected to the meridians, do not be surprised if your acupuncturist places needles all over your body (and not specifically at the lumbar level). This holistic approach characterizes acupuncture, and differentiates it from needles under the dermis used in physiotherapy.

Frequently asked question: Does acupuncture hurt? The answer: It depends on your pain tolerance threshold, and acupuncture points! But in general, the pain is minimal (or non-existent), and some patients experience an almost instantaneous feeling of relaxation.

For the most "rational" of you, you should know that acupuncture is debated within the scientific community. This is progressing, but to date there are very few quality studies demonstrating the benefits of this method of treatment. If you choose an acupuncturist, make sure that he demonstrates impeccable hygiene (disinfections, disposable needles, etc.).

Homeopath

 

As with acupuncture, this is a relatively taboo subject in conventional medicine. Many homeopaths offer natural products to relieve back pain. Most of these products used in phytotherapy have not been scientifically proven, although they show some benefits if we trust the statements of the population with low back pain.

Most important when consuming natural products, is to ensure that his homeopath AND his attending physician are aware of ALL the drugs consumed (natural and pharmacological). This will make it possible in particular to avoid possible drug interactions, and to regularly evaluate the effects of drugs on the symptoms in order to avoid consuming them unnecessarily.

Podiatrist

 

Do you have a lower limb length difference? A staggered basin? Flat feet? Inward-pointing kneecaps? A hallux valgus?

The first thing to understand is that these anatomical changes are not not always correlated with back pain. How do we know? Simply because these same changes are regularly observed in healthy subjects (ie. having no pain). Wearing orthopedic insoles alone cannot therefore guarantee certain relief from back pain.

On the other hand, it also happens that anatomical changes cause dysfunctions that accentuate joint pain (for example, a difference in the length of the lower limbs of more than 2 cm). With this in mind, you may have already been told about orthopedic insoles aimed at correcting flat feet, aligning the knees, or even correcting a shorter leg. In this case, the podiatrist will take care of you!

The podiatrist's examination is initially static, where he notes the various postural imbalances. Then, he makes you walk on a special mat where he notes your walking pattern. It also takes your fingerprints via a podo-barometer. In light of this assessment, he may prescribe orthopedic insoles (also called Plantar orthoses) made to measure, which must be changed approximately every 2 years.

 

Psychologist

 

Yes yes, the psychologist has a very important place in the management of low back pain, especially those that are chronic. Not because the pain is only in your head (although pain is technically a sensory message from the brain!). But because the managing emotions and appearance psychological is intrinsically connected to your healing.

Back pain has been shown to be multifactorial in origin. Certainly, an irritated nerve root can cause a sciatica or an cruralgia. But a period of intense stress at work can also increase muscle tension, and have a negative effect on the healing of your low back pain. In addition, chronic back pain often interferes with social activities, and can lead tosocial isolation…and even depression.

With this in mind, it may be interesting to call on a psychologist. Some are even specialized in chronic pain, and work in close collaboration with other health professionals in a multidisciplinary context.

What can a shrink do to help you get better? He will be able to apply certain therapies such as cognitive-behavioral therapy, acceptance and commitment therapy, or for example offer you the mindfulness meditation technique. If you are going through difficult times with your spouse, the psychologist could add couple therapy. If you have false beliefs, he can discuss them, and correct your misperceptions.

Each psychologist has different skills. Be sure to find one who has experience with lower back pain, or more generally with chronic pain cases.

For more information on the role of the shrink in the management of back pain, read this article by Catherine, psychologist, who will answer all your questions.

 

Recognize a bad therapist (5 tips)

 

You may have already consulted for your back, but were not satisfied with the specialist. Whether it's his approach, his techniques, his explanations, you didn't feel comfortable. Unfortunately, bad therapists do exist!

Here 5 attitudes and gestures showing a lack of professionalism and expertise. If you ever consult and notice that your healthcare professional meets the criteria mentioned, beware! And above all, do not hesitate to ask him questions and question some of his decisions.

 

1. No initial assessment

 

Before applying any treatment technique, a therapist must ask you several questions, and perform certain tests beforehand. This will eventually guide the treatment, and adapt it according to your condition.

Not all back problems are the same, and everyone reacts differently depending on several factors. For this reason, your therapist must absolutely adapt his approach based on his initial assessment. If he does not take the time to do it from the start, one should be wary of the therapist in question.

2. Restrictive approach

Back pain is complex. And it's not just about “displaced” vertebrae, "tight" or weak muscles, bad posture, one leg “shorter” than the other, etc. Numerous studies have shown that low back pain also has an important emotional and psychosocial component.

A good therapist will therefore have to cover several aspects (such as your level of stress, your breathing, your interpersonal relationships, etc.) to optimize your recovery.

It is therefore essential that your therapist educates you on the link between these “external” factors and your back pain. Or he may prescribe breathing exercises and relaxation aimed at relaxing you. If your therapist doesn't address these outside (but equally important) factors, they won't cover the full range of treatment options to improve your back condition.

 

3. Overly Passive Techniques

If your therapist spends all of his time giving you massages, or if he continually uses an ultrasound or electrotherapy device, he is mistaken. Recent studies clearly show that a proactive approach is much more effective in treating low back pain over the long term.

Certainly, several techniques and machines available on the market can be helpful in relieving symptoms in the short term. On the other hand, a complete treatment plan must absolutely incorporate therapeutic exercises to optimize your healing.

 

4. Lack of listening

No matter how skilled your therapist is, remember that you are the expert on your own body! Sure, your therapist knows more about the human body than you do, but don't forget that you are the one who lives with pain on a daily basis. You are the one who knows the factors that aggravate your symptoms, what relieves you, your fears, your goals, etc.

Thus, the treatment of low back pain requires the involvement of the patient; the therapist can only guide you through the process. And if he doesn't take the time to listen to you, how is he going to be able to help you? Some therapists think that arguing with the patient will only waste their time...beware at all costs of this type of "professional".

5. Lack of empathy

When you have back pain, you experience a moment of vulnerability. Some are less patient than usual. Others more emotional. Others are simply depressed at times. And that's okay!

If you don't feel supported on your journey, your therapist is not doing their job in the best way. And I'm not talking about giving you relief when you're in more pain than usual. A good therapist is also a guide, a motivator, a moral support.

Certainly, some therapists such as psychologists, psychiatrist or even your family doctor may be better qualified to treat the cognitive and psychological aspect related to your back pain. But your therapist can also help you better manage your daily symptoms, find ways to overcome pain, identify ways to be active despite pain, etc.

 

Conclusion

Reading this article, I wouldn't be surprised if you were slightly confused about choosing the right therapist for your back! After all, it should be understood that several therapists can use similar techniques. For example, it is not uncommon to see a physiotherapist (kinesitherapist) performing joint manipulations, or a chiropractor offering postural exercises to a client.

The difference between these professions lies mainly in their basic philosophy. Thus, it is more important to find a therapist you trust, and who gives you positive results. And above all, someone who will become your ally in your fight against back pain.

In several countries, sessions with health professionals can be reimbursed by Social Security, mutual insurance, or private insurance. It is always a good idea to get information from the appropriate resources.

In short, do not delay before asking for help, because persistent pain can sometimes become chronic, and affect several spheres of your life. All therapists generally wish you well! (Beware of the " bad » therapists!)

Good recovery!

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