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Chronic Back Pain – Here Are Your Options

by Pain Doc | Mar 26, 2014 | Low Back Pain

From my casual observation as a clinician, about 80% of people suffering from back pain fit a certain demographic profile:

Male
Age 35-60
10-20+ pounds overweight
Works in manual labor or;
White collar- prolonged sitting
Sedentary or moderate physical activity

Of secondary association, there are these traits:

History of past injury
History of contact sports or sports involving jumping (i.e. gymnastics)
Familial history of back pain
Smoker
Stressed
Insufficient sleep
Unbalanced diet: junk food, excess carbs, insufficient vegetables

Now of course there are people who have back pain who don’t have any of these characteristics, but those individuals are a very small minority.

If half of these factors apply to you, there is a good chance you have back pain in some form.

The problem with “non-specific” chronic back pain that is not associated with a single-event trauma like lifting something heavy is that, by the time you feel the pain, the internal structures that are causing it have degenerated to a point where it is difficult to completely resolve. And, males in general usually defer seeing a doctor or specialist when they feel the first signs of something wrong; they are more likely to ignore it until it gets to a level where it interferes with their activities in some way.

Non-specific low back pain is often difficult to diagnose because there are usually multiple things happening simultaneously:

spondylosis (bony projections indicative of joint degeneration)
stenosis (narrowing of spaces where nerves pass through)
arthritis (inflammation within the joint surfaces)
vertebral slippage (spondylolisthesis; retrolisthesis)
disc degeneration
ligament calcification
sometimes osteopenia (loss of bone mass)
sometimes paraspinal muscle spasms/ hypertonicity
sometimes spontaneous fracture

There is a lot of debate among physical therapists, chiropractors and orthopedic specialists regarding how far can a degenerated disc and associated spondylosis recover, and if it is even possible at all. Is it “once you have it, you have it for life?” or is there still a miraculous chance that your body can repair degenerated areas in the spine if you just give it the right conditions?

The answer has big ramifications; after all, getting diagnosed with chronic pain due to lumbar degenerative disc disease at age 40 can be devastating if it means that you have to live the rest of your life with low back pain. We all want not just to live, but to live with vitality; right? We don’t want to go through life sitting down, watching everybody else have fun; we want to engage life and live it to its fullest.

What we do know is that once you develop osteophytes (spondylosis)– those bony spikes that protrude from the edges of vertebral structures– they do not resorb, no matter what. Thankfully, they are “slow growing,” and it is possible to stem that growth by doing things like losing weight if you’re overweight, eating healthy, exercising and strengthening your back and core muscles to improve support. But once they reach a certain point and obstruct nerve passageways, you’re looking at surgical intervention (spinal decompression surgery), which often works but also often causes new problems, or provides temporary results as the osteophytes resume growing.

But with discs, there is more hope. Discs are mostly water. If you can re-hydrate your discs and get them healthy, they will increase in thickness and in the process create more space between your vertebrae, potentially relieving pressure from pinched nerves and impacted facet joint surfaces. However, some people have passed the point of no return where the disc is functionally “dead” (looks solid black on MRI). In these situations, the vertebrae eventually fuse together which accelerates stenosis, requiring surgical decompression.

So, if you have chronic back pain, your alternatives are to engage in lifestyle modification habits that strengthen the body and promote healing; work with a chiropractor, physiatrist or other rehab specialist to see if improving joint movement and muscle balance are enough to resolve the problem; or consult with an orthopedic MD and see if you are a candidate for surgery.

Stay tuned, as I will soon be coming out with a Healthy Lifestyle Education instructional course designed to help those with chronic pain.

If you wish to be notified of it when it launches and receive a preview, submit your name and email to this form below:

Notify me when the Get Rid of Chronic Pain Healthy Lifestyle Education course launches!

Study Shows Benefit to Stratified Care for Low Back Pain

by Pain Doc | Mar 19, 2014 | Low Back Pain

A recent study (ImPact Back Study) published in the Annals of Internal Medicine demonstrated that low back pain sufferers had statistically significant improved treatment outcomes, at a lower cost when the case was classified as either low, medium or high “risk” for persistent disability and received a standardized treatment method for that level.

Specifically, low-risk patients received a single session of intervention comprising assessment, education and support for self-management.

Medium-risk patients receive physical therapy interventions that focus on reducing pain and disability, encouraging physical exercise and facilitating early return to work.

Meanwhile, high-risk patients receive “psychologically informed” physical therapy that integrates cognitive behavioral techniques with traditional physical therapy to reduce pain and disability, improve psychological functioning and facilitate self-management.

Other benefits associated with stratified care as compared with usual care included significantly more risk-appropriate referrals to physical therapy, a 39% relative reduction in sickness certifications, a 50% relative reduction in time off work sick, a decrease in use of non-opioid medications and concurrent increase in use of mild opioids.

This study was done in the U.K., so there are likely differences in the protocols for treating low back pain compared to the U.S. It is interesting that common procedures in the U.S. for “high risk” low back pain such as facet injection and decompression surgery were not mentioned. Perhaps it is their experience that such procedures have not demonstrated efficacy in resolving low back pain, and that psychotherapy combined with traditional physical therapy is more effective.

The bottom line is that, if you have low back pain, an accurate diagnosis is obviously very important. Granted, in many cases the origin is difficult to pin down, it is prudent to take into consideration the possible role of the patient’s psychology and use appropriate interventions like CBT. Defaulting to opioid and non-opioid drugs may be counterproductive, as addiction and liver and kidney toxicity is always a risk.

The Origins of Musculoskeletal Pain – Which Describes Yours?

by Pain Doc | Mar 7, 2014 | Hand and Wrist Pain, Low Back Pain, Myofascial Pain

Musculoskeletal pain refers to pain affecting the muscles, ligaments, tendons, joints and sometimes bones. Sometimes it is straight-forward; other times it is not. Before you convince yourself that you know the origin/cause of your musculoskeletal pain, consider the following:

Pain can be due to trauma/injury where the tissue itself is generating the pain due to ruptured cells and the effects of inflammation. This is the most unambiguous case because it is connected to an identifiable event. This pain can be acute, meaning relatively recent onset; sub-acute, referring to a state where the injury still is healing but pain and some swelling is still present; and chronic, which basically means symptoms that remain after the body has done all it can at the moment to heal the injury.

Pain can manifest in one area of your body due to abnormal movement in a distal location. The abnormal movement might be caused by a previous trauma event like a car accident or sports injury, it can be congenital (developed at birth) and it can be from repetitive movements required by a certain occupation or hobby/sport. Abnormal movement (called dyskinesia) can also arise from muscle imbalances, where one muscle loses strength due to inactivity, decreasing joint stability and facilitating excessive, restricted, or other abnormal movement of that joint, forcing distal joints to make up the difference in lost movement or compensate to create more stabilization. The distal muscle(s)/joint(s) then work in a fashion that they were not designed for, leading to strain, spasm and even injury to the muscle or joint.

This is the most tricky type of pain manifestation because it is often mis-diagnosed resulting in the wrong treatment approach and lack of resolution. An example of this is sciatica (pain in the buttock) from a spasmed piriformis muscle scissoring the sciatic nerve due to an unlevel pelvis coming from hyperactive same-side erector spinae musculature. If the back muscle and pelvic imbalance is not corrected and the patient simply gets massage to the piriformis muscle, you can see how this pain will never go away with this type of treatment.

Pain can be referred pain. In referred pain, the brain senses the pain to be in one area of the body when the abnormal site is actually in another area. Despite an increasing amount of literature on the subject, the mechanism of referred pain is still unknown. Going back to the heart attack example, myocardial infarction can cause referred pain to the left jaw and left arm. The image below illustrates commonly observed types of referred pain and their true source (credit to Wikipedia).

Pain can arise from hypoxia (insufficient oxygen to the tissues). An extreme example of this kind of pain is a myocardial infarction, or “heart attack” where a major artery to the heart muscle is blocked, preventing oxygen from reaching a section of the heart. Biochemical reactions take place when this happens, which generate pain.

Thoracic outlet syndrome is a condition where the nerves and blood vessels supplying the arm get compressed in the neck region by tight scalene muscles or the collar bone. The resulting hypoxia can contribute to pain in the arms and hands.

Pain can come from trigger points, also known as trigger sites or muscle knots, are described as “hyper-irritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers.” Trigger points are usually only a few centimeters in diameter.

Clinical textbooks on the subject establish the following requirements to meet the definition of trigger points:

Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.
The painful point can be felt as a nodule or band in the muscle, and a twitch response can be elicited on stimulation of the trigger point.
Palpation of the trigger point reproduces the patient’s complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point.
The pain cannot be explained by findings on neurological examination.

As in referred pain, the mechanism of trigger points is still being debated. Trigger point tissues have been biopsied, and findings indicate the presence of hyperactive muscle spindles, special cells whose function is to detect the rate of lengthening in a contracting skeletal muscle and initiating the firing of complementary muscles to complete the desired goal.

Wikipedia gives a nice summary of what causes trigger points to form:

Activation of trigger points may be caused by a number of factors, including acute or chronic muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psychological distress (via systemic inflammation), homeostatic imbalances, direct trauma to the region, collision trauma (such as a car crash which stresses many muscles and causes instant trigger points) radiculopathy, infections and health issues such as smoking.

Finally, there are more highly-complex causes of pain related to dysfunction of the central nervous system, sympathetic nerves, biochemical and hormonal issues, and even psychosomatic. These types of cases are difficult to diagnose and are often treated using pharmacological agents, and on the other side of the spectrum, holistic approaches with mixed results.

NO MATTER what pain you may be experiencing, know that it always, always helps to detoxify your body as best you can via a nutritionally-dense diet centered on naturally-occurring, non-GMO, organic unprocessed food sources; reducing your processed sugar and grain intake; regular exercise, getting enough sunshine to your body; targeted supplementation, meditation or other relaxation methods, and even nurturing social support. This is the theme of this blog, because there is no shortage of treatment methods for pain and not enough emphasis coming from doctors or the government on prevention, wellness and health optimization; i.e. Healthy Lifestyle Education.

In the next couple of blog posts, I will talk about real, practical ways you can reduce your pain without the help of your doctor by making strategic lifestyle modifications. Your body has a potent array of disease-fighting systems and has an innate ability to repair and regenerate itself. The problem is that in many pain sufferers, these systems are burdened by unhealthy habits and are not running at their full potential. Imagine what can happen if those systems were brought back on line, constantly doing what they are naturally programmed to do– protect you and keep you alive; fighting germs, cancer cells and developing diseases; and repairing injured sites so that you can function better. Isn’t this a goal worthy of your efforts?

More to come, stay tuned!

Dr. Perez

The Bad Health Effects of Frequent, Prolonged Sitting

by Pain Doc | Sep 25, 2013 | Uncategorized

I’ve been saying for many years that one of the best things you can do to improve your health is to be more active. And one of the ways to do it that is low tech and doesn’t require a heck of a lot of thought is making a conscious effort to stand more than you usually do throughout your day; especially for those who have sedentary desk jobs.

When you stand, you burn more calories because you engage your erector spinae muscles, gluteal muscles and of course leg muscles. You can burn at least 100 more calories a day simply by standing for two hours more. It’s also better for your posture. And get this, other research says that sitting can cause your bad cholesterol levels to rise because it deactivates spinal muscles that prefer to burn fatty acids for energy.

A study just a few years ago revealed a positive correlation between hours spent sitting and premature death. The American Cancer Society study found that women who sit for more than six hours a day were about 40% more likely to die during the course of the study than those who sat fewer than three hours per day. Men were about 20% more likely to die. Now that is a risk factor that can easily be avoided.

If you have a desk job that requires sitting two or more hours straight, or is such that it is easy to get caught up in your work and sit for that amount of time or longer (common for software programmers, researchers, accountants and attorneys to name a few) you need to find a way to remind yourself to stand periodically and ideally do some simple exercises while you are at it, like squats, lunges or doing a couple of laps in your building’s staircase or stair well. Incorporating such a simple routine can have a huge impact on your health, now and in the future.

Lastly, check out this modern concept office workstation by Focus. It is much better for your back than traditional workstations that place max pressure on your lumbar discs, potentially increasing your chances of developing degenerative disc disease. The unique design of the Focus workstation results in much less pressure on your lower back and engages the spinal muscles and leg muscles more than a traditional chair with a back rest. This will allow you to work longer hours without as much risk. But still, it’s better to get off your butt every 20-30 minutes and walk to prevent the bad stuff from happening.

Spinal Stenosis – What it Is, and What to Do

by Pain Doc | Sep 14, 2013 | Leg Pain, Sciatica

Spinal Stenosis

Recently, Carrie Ann Inaba, one of the judges of the show Dancing With the Stars publicly announced that she has been suffering for quite some time from cervical spinal stenosis– a condition in which the canal that encases the spinal cord in the neck narrows and obstructs nerve tissue. She explained how her condition impacts her life, limiting her from doing the things she loves to do. To Carrie Ann’s dismay, she no longer dances with a partner for fear of getting whiplash and paralysis. That’s quite unfortunate for someone whose entire career revolved around dancing.

Although spinal stenosis is a generalized term for narrowing of the spinal canal by any cause, the most common type, which will be discussed here, is the type caused by osteophytes— growth of bony projections that narrow the openings where nerves pass through. Advanced osteophytic activity is also referred to as spondylosis. When it is severe enough to narrow the spinal canal (foramen) it then creates the condition known as spinal stenosis. For your information, other forms of spinal stenosis are those caused by herniated discs, spondylolisthesis, tumors or any mass that encroaches into the spinal canal.

In her article, Carrie Ann mentioned that spinal stenosis is a form of arthritis and that she is anxious to find a cure for it. Unfortunately spinal stenosis is not one of those conditions that can resolve on its own with rest, exercise and time and other non- invasive measures. And since the inflammation from spinal stenosis is secondary to irritation of nerves, it is technically not a type of arthritis. That is why anti-inflammatory medications have minimal effect on the pain associated with spinal stenosis, which is typically deep, sharp and radiating in nature.

Spinal stenosis occurs when vertebrae, the bones that comprise the spinal column gradually morph in a way that constricts the spinal foramen (canal), or space where the spinal cord resides. When there is less space for the spinal cord to move, it is subject to more abrasion with spinal movement; i.e. bending and turning your neck. The cord (actually, meninges or covering of the cord) rubs against sharp edges of the bony projections into the foramen with movement causing inflammation and injury to the nerve tissue, sometimes causing sclerosis (hardening). In advanced cases, especially cases of lumbar spinal stenosis (due to the more significant weight burden) the narrowing gets so advanced that there is constant pressure on the nerve roots. At this point, it is an emergency situation as renal function and sensation to the legs are affected.

Signs of advanced spinal stenosis include paresthesias, sharp pain with movement, weakness in the extremities, and muscle atrophy in legs and/or arms. Symptoms can be permanent if not treated early.

And what is the treatment for spinal stenosis? First of all, doctors will usually order MRI and x-ray to determine extent of narrowing. If it is caught early, physical therapy and lifestyle modification is recommended. The goal is to slow down or stop the progression of the narrowing.

Surgery is the only option for advanced cases. Since spinal stenosis involves physical structures compressing nerve tissue, there are surgical procedures that can enlarge the spinal canal by scraping off the encroaching bone material and buy the patient more time. Since bone is comprised of live cells, the movement of bony projections (called osteophytes) into the spinal canal is still likely after surgery and many who have had such spinal decompression surgeries develop the same problem several years later.

It’s not quite evident why some people suffer from spinal stenos more than others. But those who have a history of physical trauma to the spine like car accidents, sports injuries and falls are at a higher risk. The theory is that the injury event disrupts the normal alignment of the spinal segments resulting in accelerated wear and tear over time; much like how a loose screw in a machine accelerates mechanical failure. Some orthopedists hypothesize that the appearance of bony projections is the body’s attempt to fuse and stabilize adjacent vertebrae so they can no longer move separately; thus reducing the probability of injury. However, the nerves that share the space with the vertebrae get damaged in the process. If this theory holds true, then it is an inherent design flaw of the body’s self-healing mechanisms.

Also, heavy smoking and obesity, and general poor health can increase your chances of developing spinal stenosis.

I’m sure more than one doctor broke the news to Ms. Inaba that there basically is no “cure” for spinal stenosis once it is in its advanced stages, which appears to be her case based on her own description of her symptoms. It is a mechanical condition that mandates mechanical intervention. No amount of drugs will cure spinal stenosis from advanced osteophyte formatioin. Her only option at this point is spinal decompression surgery to widen the spinal canal and hope that the nerve tissue did not sustain permanent damage.

The best strategy for dealing with spinal stenosis is prevention. If you sustained injury to your spine from a car accident (even a low impact one that did not require medical treatment), a sports injury (including repetitious trauma like that related to gymnastics and football) or slip and fall, realize that “the seed” for spinal stenosis may have been planted in you already. If your injury event was over five years ago, get an x-ray to identify any levels where osteophytes are present; these are the sentinels of potential areas of spinal stenosis as they identify areas of biomechanical weakness. If there are some, the first course of action is to not worsen things. Avoid or reduce activities that regularly place trauma to your spine. Engage in specific exercises that strengthen the neck and lower back to offer more stability. Stretch often (yoga is a great choice) and take care of the insides of your body as well with proper diet, nutrition, hydration and adequate rest.

Lastly, the Cervical and Lumbar Posture Pump is a home rehabilitation device that tractions and separates vertebrae to hydrate the discs and increase nutrient absorption which can slow down the progression of spinal stenosis if done diligently on a regular basis. I have personally used them in my practice, and patients reported positive results.