When Is It Time to Move Beyond Physical Therapy for Back Pain?

When you’re dealing with nerve pain or a spine condition, it’s easy to feel stuck in a cycle of physical therapy, medications and waiting for things to improve. For many patients, the big question becomes: How long is too long to wait before exploring other options? And just as important: How do you know when something more serious is going on?

According to spine surgeon Arthur L. Jenkins III, M.D., knowing when to move beyond conservative care (and when to act urgently) can make a significant difference in outcomes. From recognizing red-flag symptoms to understanding the full spectrum of treatment options, he emphasizes the importance of being informed, proactive and willing to advocate for yourself.

Most people with nerve pain or spine issues try physical therapy and medication first. How long should someone wait before considering other options after conservative treatment?

Arthur L. Jenkins III, M.D.: The duration for conservative treatment depends on the severity of the pain and how long it has been ongoing. If a condition has not improved with any reasonable noninvasive intervention after three to six months, or if it is getting worse after six to 12 weeks despite physical therapy and medications, that’s when you need to consider increasing the scale or severity of the intervention. If you’re dealing with pain in the back or leg without weakness, this conservative approach is a good strategy.

What specific symptoms or changes should be a signal to a patient that it’s time to have a more serious conversation with a specialist?

AJ: New bowel or bladder symptoms (like loss of control or being unable to urinate) should definitely be evaluated by a doctor, as these can be emergency conditions, and if new leg or arm weakness develops, that should always be immediately evaluated by a doctor. Other concerning signs include spine or limb pain after trauma. Fortunately, most people don’t develop these symptoms, so it’s important to know the signs of bigger problems.

Changes in a limb, arm or leg, such as changes in color, skin texture or condition, or swelling, are signs that there may be a vascular problem affecting the limb. This vascular problem could be in front of or adjacent to the spine and may require intervention, or it could be a peripheral vascular problem.

When things aren’t improving despite repeated conservative treatment. “Doing the same thing over and over and expecting a different outcome,” what’s that called again?

A lot of patients worry that “more advanced care” automatically means surgery. What do options actually look like between conservative treatment and the operating room?

AJ: There are various options between conservative treatment and the operating room. Different types of injections are available. While social media promotes stem cells and platelet-rich plasma, the evidence for their utility in the spine is very limited. Instead, targeted injections are used both to assist in diagnosis of conditions where the actual cause may still be somewhat in question, as well as to help tide the person over while their body tries to heal the problem, or to numb up the nerves bringing pain from a region that may be damaged or arthritic but perhaps not bad enough to need surgical stabilization or replacement. Additionally, many minimally invasive surgical procedures have been developed to treat conditions such as disk herniations, spinal instability, spinal arthritis and spinal stenosis. It’s important to understand which procedures are best performed by a pain management doctor and which should be reserved for a surgical specialist.

Are there any symptoms that should skip conservative treatment entirely and go straight to a specialist — things that should never be waited out?

AJ: While theoretically any back specialist should recognize which conditions shouldn’t be observed or managed conservatively, some pain doctors suggest continuing conservative management even with acute foot drop since some patients improve. However, if acute foot drop is surgically addressed within eight hours, the probability of a great outcome is approximately 90% rather than just “some” patients. Any new onset of foot, leg, hand or arm weakness should immediately present either to an emergency room or to a spine specialist if accessible (such as if you’re already seeing one or have connections for quick specialist access). Any significant trauma resulting in loss of consciousness or inability to walk shouldn’t be managed at home — immediate medical attention should be sought, including calling for an ambulance to the hospital.

How does a patient find the right specialist for their situation, and what should they look for or ask when they get there?

AJ: Finding the right specialist requires due diligence. Because many different specialists treat back problems — pain management, orthopedics, neurosurgery, neurology and rehabilitation/physiatry — it’s important to investigate beyond online information, which can be manipulated. Speaking to knowledgeable human beings with specific experience with physicians is valuable. This may include anesthesiologists who work at particular hospitals and can provide perceptions of the best surgeons or pain management doctors. Primary doctors often have extensive experience with different specialists through treating common patients. Older, more experienced doctors likely have a broader base of insight than fresh graduates from residency.

Important questions to ask include the following:

• How long have you been in practice? What is the full scope of your practice (do you do other things than this)?
• How many patients with your condition do you see monthly?
• How many of these procedures have you performed?
• What are the best and worst outcomes?
• And the classic question: If this were your family member, what would you tell them?

For someone who has been told to just “manage” their nerve pain long-term, what would you say to help them advocate for themselves at their next appointment?

AJ: For someone told to manage nerve pain long-term, self-advocacy at appointments is crucial. Ask what other potential options could be considered, even if they’re not preferred or recommended. If a full and reasonable spectrum of options isn’t provided, this constitutes malpractice — deliberately misinforming patients about surgical and nonsurgical options. While providers don’t need to give an exhaustive laundry list, they must provide a reasonable spectrum of more and less invasive options, or they’re being deceptive. Anyone being deceptive should be avoided. Some doctors believe surgery is “never good,” which is clearly not a healthy approach.

There are various support groups, in person or online, that may cater to one condition or another. Seek these out, as clinicians are often discussed in these groups, but beware: Not all groups are as open or independent as they may seem. Some are founded by patients and fill a void in their ability to share experiences. Others may be run by former patients, but have become echo chambers, where only certain views are acceptable. And then there are those that are run as shadow referral machines for specific docs looking to do as many procedures as possible. Caveat emptor. Do your due diligence.

Finding someone with a more holistic approach to treating patients is recommended, even if it means going outside your network. This may be challenging in today’s world of insurance companies with ghost networks — lists of doctors who don’t actually participate but are kept on lists so regulators think there are enough in-network doctors to meet regulatory requirements. It’s sometimes difficult to find an in-network doctor who understands your condition. However, the most important consideration is that it’s incredibly more expensive to be miserable, disabled or not enjoying life than to get the best care possible, even at higher out-of-network costs.

Patients from around the world seek treatment with me for specialized and complicated conditions that cannot be managed locally, because I provide insight that wouldn’t be available otherwise. Finding someone who actually understands your condition, and has not just one treatment option, but a treatment strategy tailored to your condition’s severity and presentation, is essential before giving up on meaningful change.

While hope may not be a valid medical strategy, it is necessary to have to continue to search for treatment even when others have given up. Have hope.