“What do you mean you ‘blacked out’ at physical therapy?” I asked, trying to hide my look of incredulity behind my facemask. I was sitting in front of a tall 40-something-year-old man, who had been referred to me for back pain. As he told me his story of how his function had declined over the last few years, no longer able to work as a heavy equipment mechanic because of his back pain, we got on the topic of his past treatments. “Yeah doc, I don’t know what happens. They ask me to do these exercises on the ball, and when I do them, I blackout because of the pain.”

As a Targeted Pain Treatment specialist, I often hear patients complain that physical therapy somehow was intolerable, or that it made their pain worse, for a time. Many stopped therapy because it “wasn’t helping”. This was one of the more extreme cases that I’d heard recently, but the underlying principle was the same. This patient had an anatomic cause of pain – in his case, a disc bulge in his back that was pressing on a nerve but was not “bad enough” for surgery. In turn, the nerves in his back were sending shooting pains down his legs whenever he did certain activities – including core strengthening exercises at physical therapy. This resulted in an otherwise healthy 40-year-old male who was unable to do basic bending and lifting, and could no longer perform his job, or for that matter, play ball with his 7-year-old son. So, he stopped therapy.

Physical therapy is a vital component of a comprehensive targeted pain treatment plan designed to improve a patient’s function and quality of life. As a result, physical therapy is often recommended early in the treatment course for a patient’s pain complaint. Therapy has many benefits, including restoring strength, flexibility, stability, and overall function. But in order to see these benefits, the patient must be able to participate in the treatments and progress towards his or her functional goals. That’s hard to do if you “blackout” or otherwise have severely increased pain during or after a therapy session.

This is where it’s important for both physicians and health plans to be flexible in our care pathways and make sure we appropriately address the underlying cause of pain. When patients are not making expected functional progress during therapy, either due to severely increased pain, or just inability to fully participate in therapy, it is important to pause and assess why the patient is not progressing. It may require a deviation from the standard insurance protocol to require, say, 6 months of physical therapy or conservative treatment before specialist referral or advanced imaging. In other instances, it may actually be detrimental to the patient, both physically and financially, to continue a fixed course of therapy without meaningful functional progress – using up their allotted number of annual visits, and costing them out-of-pocket copay amounts with minimal functional progress.

Often when my patients come to me with complaints about physical therapy and increased pain, I will have them pause their therapy sessions to allow us to further investigate the underlying cause of pain. Sometimes this involves getting advanced imaging such as an MRI to make a more accurate diagnosis. Other times it involves performing more targeted treatments such as injections or medication adjustments, and then returning to therapy once the pain is better controlled.

This flexible approach to the timing of physical therapy serves several purposes. First, it expedites the patient’s pain relief by ensuring we are working with the most accurate diagnosis, and by addressing the underlying cause of pain prior to physical therapy. Second, it allows the patient to resume therapy without the trepidation of anticipating debilitating pain following sessions. Finally, the patient is able to progress more effectively through the stages of therapy because he or she is no longer as limited by the anatomic or physiologic cause of pain. 

It also provides important value to the patient, who often will have a limited number of therapy sessions covered by insurance. Rather than burning through sessions with limited progress due to pain, the patient is now able to better participate in therapy sessions and see the functional improvement he or she is seeking. In this way, insurers and insurance policies that allow for flexibility to pause therapy and assess why the patient is not progressing functionally actually do both the patient and the system a great service.

In the case of our heavy equipment mechanic, I already had the advanced imaging I needed – a recent lumbar MRI. Based on his history and physical exam, and review of the available tests, we honed in on the specific lumbar disc and nerves that were the likely source of much of his pain.  I recommended a targeted injection to calm down the nerves that were affected by the disc bulge in his back. I also adjusted his medications, adding a muscle relaxer to address the back spasm that he experienced with bending and twisting movements.

He returned to physical therapy after treatment and was able to do his core exercises without “blacking out”. The next goal is to get him to be able to play with his son, and hopefully back to the work he loves. We’ll make sure his physical therapist is aware of the diagnosis and the causes of his pain and work together on achievable micro-goals, improving his function one session at a time.