Combining Physical Therapy
With Epidural Injections

uestions & Answers features staff members of Rockhill Orthopaedics and the Baptist Medical Center Rehabilitation Pavilion. This issue we feature Mary Jo Hegstrom, PT, who specializes in back therapy and work rehabilitation.

Q: Why is it important that back patients having fluoroscopically guided injections or regular epidural steroid injections also receive physical therapy?
A: The injections help reduce inflammation, allowing a patient to be more mobile and functional. If there were no physical therapy to help the patient regain mobility and function, it would be comparable to having a tree branch rubbing against an electrical wire, then repairing the wire without cutting the branch: You would almost certainly experience the problem again.

Q: When do you start the physical therapy?
A: It depends on how much discomfort the patient is in. If a patient is going to get injections, he or she has definitely been experiencing pain. Ideally, we like to start within a couple days of the first injection. Sometimes we actually start therapy before the first injection.

Q: In order to prescribe the right therapy, what do you need to know about patients?
A: We generally begin by compiling a detailed history so we can find out how much they sit and stand at work, how much walking they do, and how much time they spend in a car. Once we know their physical habits, we can isolate which ones contribute to their back discomfort and we can work with them on changing these. This will allow them to maintain the relief that comes with their injections.

Q: What does physical therapy typically consist of?
A: Education is the most important component of our treatment. Often, our patients don't understand the proper ways to use their muscles to protect their backs. We teach them how to sit, stand, and walk properly. We teach them exercises to help strengthen the muscles that support the back. Typically we see people who have tight hamstrings and weak lower abdominals. The lower abdominals help protect the spine when you bend, squat, or lift. By improving lumbar stabilization, we teach patients to increase the use of large joints to help bear stress and body weight. This helps deflect the stress on the spine caused by lifting, pushing, bending, and twisting.

Q: How long does therapy typically last?
A: Most patients receive three injections. If they get good results with the first, or the first and second, we may see them only two weeks-just long enough to ensure that they understand the back exercises they're to do and that they're clear on how to protect their backs at work and at home. We see a patient longer if the injury is acute.

Q: Because injections usually make patients feel better fairly quickly, do they sometimes tend to overdo physically?
A: Oh, yes. My father's a perfect example of this. He started a series of injections after he hurt his back playing golf. The first injection helped so much that instead of taking it easy, he overdid. Consequently, he lost some of the value of the injection and also suffered some discomfort.

Q: Did the subsequent injections help?
A: His improvement wasn't as dramatic with the second injection, but by the time he had the third one, he was just about back to normal. He had to learn to take a gradual approach to increasing activity and to respect his body's limits.

Q: Is the relief patients gain from the injections permanent?
A: It varies. For some people, nothing more is needed. But the majority of people must pay careful attention to how they use their backs in order to prevent further problems. If they have both injections and therapy, they're far less likely to have a recurrence of back problems, provided they avoid putting stress on their backs and stay in good shape. Most people do very well with the follow up because the injections may solve their back pain and they want to do whatever they can to avoid the need for back surgery in the future.

Q: Does the combination of injections and therapy pose any special challenges with workers' comp patients?
A: Some workers' comp patients have had difficulties with their employers and with the medical system, and when they come to us, they may be full of worry about their jobs or that they'll re-injure themselves if they go back to work. One of our challenges is helping them with their fears so the injections and therapy can assist them as much as possible.

For selected articles from previous issues of "On Track" and other publications, visit the Orthopaedic Health Library.

Return to "On Track" Winter 1999