Pause in Blog

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Well, this experiment has been less than successful.  I have made 29 posts over the last six months and only managed to attract about 1100 page views by maybe 100 viewers.  Maybe 10% of those were from Eastern Europe, including Russia, from web sites that were apparently trying to co-opt the blog for other reasons, i.e. hack into it for some nefarious purpose.  Who would think that was something people would waste their time on?

The book has been a slow seller; maybe it will catch on, eventually.  I like it, but I wrote it.  It makes what patients' doctors tell them easier to understand.  The price was right, if you had a Kindle or a Nook, or Kindle or Nook app for a computer or electronic device.  The illustrations are informative and it is entertaining.  The printed version by Lulu is too expensive. **** Cheaper printed versions are now available from CreateSpace and Amazon; see web sites listed below:****

http://www.amazon.com/What-Your-Doctor-About-Lower/dp/1497342910/ref=tmm_pap_title_0


Anyway, thanks to those of you who read the blog.  I hope you learned something, but I can no longer justify the amount of time spent blogging.  The information will be here (and in the book) and available for you to review if you want, but I will no longer be making regular posts.  If something comes up that is newsworthy, I'll make a post.  I will continue to answer questions from readers.

I guess to bow out at the 11th minute of the 11th hour of the 11th day of the 11th month isn't a bad way to go for a veteran.  To those of you who were entertained and informed, thanks for dropping by.

Medical Tragedy

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Sorry.  This is a day late.  Had a water pipe break under the slab of my home last week.  Have spent a week getting it fixed, repainting the room and replacing the floor.  And I still have stuff to do.  It's always something!

The recent spate of meningitis caused by contaminated steroid injections was, unfortunately, avoidable for a great number of the people infected.  Steroid injections into the facet joints are statistically no better than placebos for decreasing pain.  Most should never have occurred.

The driving force behind this tragedy may be the design and function of the American medical system.  It is true that we live in a capitalistic society and that capitalism is probably the most efficient and productive way of running an economy ever devised.  Unfortunately, some portions of the economy can be abused by people who are more concerned with profit than the best interests of themselves or their customers.  This is especially true if there are no consequences for actions which lead to deaths, or the crash of the economy itself.  Regulation is not as important as honesty, I think.  We may not be able to legislate honesty, but we can certainly punish those who are overtly dishonest, especially when it leads to serious consequences for their customers.

That said, patients need to be patient.  No one likes to be in pain.  But, in spite of what the AMA, television, the pharmaceutical companies, or even your family has told you, there are no miracle cures.  There is no single procedure, injection, pill, or balm that will miraculously relieve your pain.  Your body has the power to heal itself, most of the time.  People who pay, or get their insurance companies to pay, exorbitant prices for 'cures' that have not been shown to do anything more than a placebo (see my blog post from September 4, 2012) are wasting their money.  They are spending their time undergoing procedures, etc. while their body heals, but they are not helping themselves much.  And they may be taking a big risk.  In the case of the steroid facet joints, they can be hurt by the procedure.

Every pill, every procedure, every injection, every treatment not only has its expected effects, it has side effects and sometimes the side effects are worse than the original problem.  At this point there are about 30+ dead and 400+ affected from the contaminated steroid injections into the facets, numbers that will surely rise.

Be patient.  Do the stuff that statistically works.  Avoid the placebos and hang in there.  You will get better.

12/18/2014: Final toll 64 deaths and an indictment yesterday. Fourteen owners or employees of the New England Compounding Center were charged Wednesday in connection with the outbreak that killed 64 people nationwide and was traced to tainted drug injections.

Newer Surgery

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Arthroscopic (endoscopic) minimally invasive surgery is a newer take on minimally invasive lower back surgery.  For years orthopedic surgeons have been using arthroscopic techniques on knees and shoulders.  Also, for years they have been doing minimally invasive procedures through small tubes in the lower spine and neck.  It was inevitable that the two techniques would eventually merge.

Arthroscopic surgery is done through several small incisions.  Through one incision, a camera is placed.  Through other small incisions, instruments (grinders, cutters, suction, probes, etc.) are used to remodel the joint in question.

In recent years these arthroscopic techniques have been applied to the spine.  The spine consists of many very complicated joints.  Access to them is difficult, whether open, micro, minimally invasive, or arthroscopic techniques are used.  The hope is that when arthroscopic (endoscopic) techniques are used, there will be less collateral damage to muscles, joints, ligaments, tendons, and nerves, and therefore shorter recovery times.

With micro and minimally invasive techniques visualization of the surgical fields can be difficult, increasing time under anesthesia for the patient.  With the newer arthroscopic techniques, that may change.  Shorter, more accurate, less invasive surgeries will benefit the patient and speed his recovery.

Keep this technique in mind if you face the prospect of surgery.  Understand that it is relatively new; not many surgeons are trained in it or have a lot of experience with it, yet.  Also remember, there are very few indications for surgery.  See my posts from July 12, 2012 on back surgery and August 6, 2012 on minimally invasive surgery to understand the pros, cons and reasons for having surgery in the first place.

Good Review of Imaging for Back Pain Patients

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Go to this web site for a neuroradiologist's take on imaging for lower back pain.
http://news.georgiahealth.edu/archives/6656/comment-page-1#comment-2125

When you finish that article, you might compare it to my post here from May 22, 2012.

The Plank and the Push-up

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

The Plank

Core strength diminishes lower back pain.  Two more exercises that require core strength are the Plank and the Push-up.  Start with the Plank.

Again, as with other core exercises we have discussed, start on all fours, on knees and hands.  Drop to elbows and knees and let your abdomen sag to the floor.  Your elbows should be directly below your shoulders.

For beginners, stay on your knees and straighten your body; your butt should be off the floor, but not elevated any higher than a straight line between your shoulders and knees.  That is the Plank position.  Hold that position for 5-10 seconds then relax.  Repeat until you are able to hold the position for 20-30 seconds with 5-10 repetitions.

Intermediate exercise is the same, but off your knees and on your toes.  Hold the position for 10-20 seconds.  Repeat up to ten times, increasing the hold time to 45-60 seconds.

Advanced exercise includes lifting an arm or leg off the floor and holding the proper position, like the Bird-dog we discussed earlier.

You can check out your technique by watching these videos:

http://www.youtube.com/watch?v=MHQmRINu4jU

http://www.youtube.com/watch?v=kiA9j-dR0oM

Or reading this Fox News post:
http://www.foxnews.com/health/2012/11/06/are-doing-push-ups-wrong/

The Push-up

Once you are doing the advanced Plank with ease, it is a relatively easy transition to, or add, push-ups.

Beginner push-ups start on your knees and hands, hands directly below shoulders, trunk straight as when doing the Plank.  Bend your elbows and drop your chest within 2”-4” of the floor, maintaining a straight back.  Once you can do beginner push-ups with ease, get up on your toes for intermediate push-ups.  Keep your trunk straight.  These are harder.

There are numerous versions of push-ups, some very advanced, others extreme.  Many can be seen at this web site:

http://artofmanliness.com/2009/07/21/push-ups-exercises/

Pick the one you like.  The best exercise is one that you will do.  If an exercise is too hard or it causes you pain, it the wrong exercise to be doing.

As with most core exercises I have recommended, there is very little compression of discs or facet joints with these exercises, cutting down on irritation of those structures.  If these exercises cause you pain, then you should not be doing them.  Start slowly.  There is no rush.  If you can only add one push-up a month, you will still be doing 12 by the end of the year and 24 by the end of two years.

 

One More Exercise

The Sidebridge

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

The sidebridge also strengthens abdominal, lateral side, and back muscles, without compressing the disc spaces or the facet joints.  If it is painful, stop.  You may have to start with just one cycle and gradually increase the number, or you may not be able to do this exercise. 

Beginners start on the floor or mat lying on one side or the other and leaning on that elbow.  They have their knees bent.  By tightening the muscles on the side away from the mat they straighten their body and lift their hip from the mat until it is in a straight line between knees and shoulders.  Hold that position for a count of 3-5, and repeat 10 times as you get better.  Do both sides.

The intermediate exercise is done on the toes, rather than knees.

Advanced exercise is rolling from one elbow to the other while on the toes, and dipping to the mat.

You can see the beginner and intermediate versions at this website: http://www.youtube.com/watch?v=Yh2U0XSPIv8

No Post This Week

We are visiting the grandchildren in Virginia this week.  Have limited internet access. Should resume posting next week.

Cat-Camel Stretch

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Cat-Camel stretches are just that: stretches.  They won't increase the strength of your abdominal muscles or back muscles, but they will stretch the ligaments, tendons, and smaller intrinsic muscles of the vertebral column.  Although there is some increase in intra-abdominal pressure, there is little compression of the disc spaces, so there is little chance of injury to discs, facet joints, or vertebrae.  It is a good way to start and finish the day, if you have morning and evening stiffness.  Most people with osteoarthritis of the spine do begin and end their days with mild to moderate stiffness of the lower spine and neck.

Remember, this is only a stretch.  You should only do 3 to 5 repetitions to relieve the stiffness.  If you do more, or if you have pain, then you may be damaging rather than helping your spine.

Start this stretch on all fours: hands and knees.  Slowly arch your back and tuck your head into your chest.  Slowly count to three.  Then slowly allow your back to sag and tilt your chin upward.  Again, hold this position for a count of three.  Repeat 3 to 5 times.

If you'd like to see this exercise done correctly, then go to the following YouTube site:
http://www.youtube.com/watch?v=xGrv3JTEliw

What Causes Low Back Pain?

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Grab your right thumb with your left hand.  Now bend your right thumb toward your right elbow until you feel pain.  Got some pain?  Good.  Now stop bending your thumb.

How does that relate to back pain?  Bend at the waist into any position you like.  Hold that position long enough and you will eventually have pain somewhere.  Just like in your thumb, you are stretching muscles, tendons, nerves, and ligaments farther and longer than they were designed to be stretched.  You may also be compressing cartilage, discs, nerves, and bone longer and harder than they were designed to be compressed.  The pain is your body asking you to stop doing whatever it is that causes pain.  You have stressed your back.  If you stop stretching or compressing before you feel pain, or as soon as you feel pain, there is little chance you have done any permanent damage.  I.e., stop pulling on your thumb!

If you continue to pull on your thumb, or stress you back, then worse things happen.  A strain is a torn muscle or tendon.  A sprain is a torn ligament.  You can also damage nerves, tear cartilage, tear discs, and break bones, if you allow the stress to continue long enough.  Torn muscles, ligaments, and tendons take 2-12 weeks to heal, depending on how much damage you did.  Some cartilage doesn't have the blood supply to heal well, but most heals in about the same amount of time.  A bone contusion or fracture can take 6-18 weeks to heal.  Nerves can take three months to heal.

Most severely damaged tissue heals with scar tissue, which is not as strong as the original tissue.  To make up for the lost strength, surrounding tissue must be stronger than it was before the injury, or repeat injuries become common.

Chronic stress on your back causes pain, i.e. if you stretch or compress long enough you will have pain.  Poor posture, overwork, being overweight, sudden motions, etc. all can lead to back pain.  Most of our low back pain is due to accumulated stress: we sit too long with poor posture; we lift incorrectly, or too often, or too heavy an object; we weigh too much.

Some low back injuries occur from sudden changes in direction, i.e., trauma: falls, motor vehicle accidents, collisions in sports, etc.  The healing process is the same for both types of stress. 

After enough accumulated stress our pain becomes semi-permanent.  It doesn't go away when you let loose of your thumb.  Then you have to take time to heal; 2 -12 weeks.  Avoid the damage.  Change positions a lot.  Monitor your posture.  Lift with your legs and a neutral spine.  Get help lifting heavy objects.  Lose weight if necessary.  Keep active.  Exercise in moderation.  STOP WHEN YOU HAVE PAIN!

Bird Dog

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

The bird dog is a great core strengthening exercise.  The bird dog can be used by most people with low back pain.  If it causes you increased pain, or numbness, or any other symptoms, stop and consult your physician.  Some exercises make back pain worse, depending upon the source of the pain.  In any event, you should not be doing back exercises during the acute period following an injury.

The bird dog strengthens most of the abdominal and back muscle groups, without compressing the spine.  Compression of the spine is what causes, or worsens, bulging disks and irritated facet joints.  The bird dog also strengthens the ligaments and tendons that hold the spine in alignment, again without compressing the spine.

To do the bird dog, start out on all fours, on your hands and knees, preferably on a soft surface so you don't irritate your knees.  Begin by lifting one hand off the floor and straightening your arm to point straight ahead.  Hold that position for a count of ten, then go back to four on the floor.  Then point with the other arm and return to the starting position.  Next straighten one leg at a time.  That's the basic bird dog.  When you can do 4 or 5 cycles of the basic, you are ready for the next step.

In a more difficult version of the bird dog, you lift and point with left arm and right leg at the same time, then right arm and left leg, holding for a count of ten.  Repeat 4-5 times.

When that becomes too easy, you are ready for the advanced version of the bird dog.  Maintaining your balance on one leg and the opposite arm, you will move the arm and leg pointing.  Bend your leg and bring your knee forward.  Bend your arm, bring your opposite hand back; touch your hand to your knee, then straighten them out again.  Repeat 4-5 times, then use the opposite hand and leg and repeat.

For a visual check of technique, go to the following YouTube video: http://www.youtube.com/watch?v=3KiN9CAqvFY

What Does Work

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

In large scientifically planned studies of individuals with back pain, the following treatments have been found to have some merit statistically, i.e. they appear to be more useful than placebo treatments.  They apparently accelerate the healing process and/or diminish pain while healing occurs.

Rest, but not prolonged bed rest.
Ice, applied to areas of pain.
Heat, applied to areas of pain, muscle spasm.
NSAIDs (aspirin, Aleve, Motrin, etc.) taken as directed.
Muscle relaxing medication taken as directed.
Massage by PT, chiropractor, massage therapist.
Mobilization of joints by PT, chiropractor, or massage therapist.
TENS unit use.
Walking, slowly increasing activity.
Yoga
Instruction on lifting techniques, posture, body mechanics.
Rarely, surgery for severe stenosis, severe spodylolithesis, sequestered herniated disc fragments, intractable pain, neurological deficits, or hemorrhage into the spinal cord.

Compare these to the placebos listed in the previous article.  Most of this stuff is relatively inexpensive (with the exception of the surgeries).  Most of the placebos are expensive and unwarranted.

You might also compare the above listing to the suggested low back pain treatment regimen listed in Chapter 1 of my book, viewable under.Initial Post and Blog Information.

Placebo Back Treatments

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Sorry this is late.  My wife and I went to visit friends in the Florida panhandle over the Labor Day weekend.

A placebo is a device that simulates treatment for a medical problem.  It is an inert substance, procedure, or device that has no known effect on a disease or healing process.  Even though it is given to a patient, the patient has no idea whether it is a placebo, a new active substance, or something already known to help his condition.

The best example I know of was the large study done with polio vaccinations.  In the 1950s, tens of thousands of children were given polio vaccine while thousands of others were given placebos (non-vaccine shots, saline).  After waiting to see which group got more cases of polio, it was statistically obvious that the vaccine protected children from the polio infection and the placebo did not.  The remainder of the children were then given the real vaccine.  I remember this because I got the experimental vaccine; my sister did not and she had to get a second injection.  Boy, was she upset.  Fortunately she did not get the disease.

Sometimes physicians will devise studies in which a sugar pill is given in place of an active substance, a sham surgery is done in place of a real one, or a sham exercise or device is used.  These studies are usually done with the patients' knowledge.  The patients know someone is getting a placebo, but not who until the study is over.  With luck the treatment proves effective and then all the patients can receive the treatment  The best studies have thousands of participants (better statistics), are blinded or double-blinded (limited number of people know who is in each group), and are prospective (planned ahead of time).  The more participants, the more accurate the statistics are at the end of the study.

Anecdotal results are unplanned serendipitous results.  "My cousin broke an egg on his head and his low back pain went away."  Such reports are generally worthless. When 80-90% of back pain goes away on its own, it is tough to attribute a reason for the recovery.

The following treatments for low back pain have not been proven more effective than placebo in large, controlled, medical studies, at least so far.  Don't waste your money paying for these things to treat your low back pain:

1.   Any form of traction, including VAX-D, DRS, DRX, Inversion Therapy, Lordex, etc.
2.   Trigger point injections.
3.   Facet injections.
4.   Sacro-iliac injections.
5.   Acupuncture
6.   Paleo (or any other fad) diet
7.   Magnetic Therapy (of any type)
8.   Prolotherapy
9.   Reflexology
10. Over the counter nutritional supplements
11. Qigong
12. Cupping

Osteoarthritis

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

I hate to be the bearer of bad news but realistically, you need to know this: There is no cure for osteoarthritis of the spine, the most common cause of chronic low back pain.  Your lumbar spine is a weight bearing structure, similar to your knees, your hips, and ankles.  (Reminder, this discussion has very little to do with your neck or thoracic spine; they have different purposes.)

There are some blogs and websites that insist you can "rebuild" your back.  That's not possible for people with osteoarthritis.  People with sprains and strains that have not progressed to osteoarthritis can "rebuild" or strengthen their back.  There are ways of decreasing pain and cutting down on re-injuries, too.  However, the only person who could "rebuild" an osteoarthritic back would be a surgeon, and he is only resurfacing or remodeling.  The structure is what it is.

Osteoarthritis is the chronic degeneration of the structures that make up the spinal column: mainly the discs, the cartilage, and the ligaments.  The discs dehydrate and collapse; the cartilage cracks and breaks down; the ligaments become stiff and less flexible.  Even without external factors caused by overwork, this process is related to aging.  Until someone comes up with a fool proof method of reversing aging, osteoarthritis will not be reversible.

I'll use the knee as an example of a weight bearing joint.  The same things I will mention here apply to the hips, lower back, and ankles.

There aren't many people claiming they can rebuild your knees, although doing so may be easier for the surgeons than rebuilding your back.  A serious knee injury, say a torn ACL (anterior cruciate ligament), leads invariably to osteoarthritis of the knee.  This is true whether the ACL is reconstructed or not.  The osteoarthritis (degeneration of the cartilage, collapse of the joint space, loss of flexibility of the ligaments) is inevitable.  The time it takes to degenerate can be affected by life style, however.  Serious injury makes the joint too mobile, allowing structures to move too far stressing other structures, leading to premature aging.

At age 19, I had my right knee severely damaged playing spring football in college.  I tore the MCL (medial collateral ligament), the medial meniscus (cartilage), and the ACL.  In 1967, they didn't surgically repair ACLs like they do today.  They did remove the damaged cartilage, however.  MCLs heal on their own; they have good blood supply.  ACLs do not heal, having poor blood supply.  The orthopedic surgeon told me that I didn't need an ACL.  As long as I kept my quadriceps muscles strong, he said, my knee would function normally.  I believed him and I spent a lot of time exercising my legs.  I had some problems, but overall, my knee has served me well.  It has been essentially pain free for 45 years.  I played soccer until I was 45.  At 65, I continue to run 5-8 miles twice a week.  However, if you x-ray my knee, it looks like it should hurt a lot.  I have bone spurs, a flattened joint, and nearly bone on bone collapse of the joint space -- a typical severe osteoarthritis x-ray.

Exercise of joints with osteoarthritis is important.  This is true for backs, hips, knees, and ankles.  Motion is the lotion, as one neurosurgeon I met told me.  Under-exercise and over-exercise can lead to more degeneration and pain.  When an ACL is repaired, the athlete can continue to exercise.  His knee joint will still develop osteoarthritis, but more slowly than if he stopped exercising.  When you suffer a back injury, motion is an important part of recovering, and keeping the muscles strong in your abdomen and back help protect you from further injury.  Gradual onset of osteoarthritis is almost inevitable with a severe injury, but moderate exercise delays the progression.  So, even if osteoarthritis can't be cured, it can be delayed and the pain minimized.  Being active is important.

In addition to being active, decreasing the load your lower spine has to bear also slows the progression of osteoarthritis.  So if you are overweight, losing weight helps your back.  Avoid lifting very heavy objects.

Osteoarthritis is a chronic, progressive medical condition with no cure.  That does not mean having this disease is a death sentence.  Many people live very well with it.  It's not reversible, but you can slow its progression if you remain active.  To minimize discomfort lose weight and don't overdo it. 

Red Flag

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Last week, I sent the following letter to the editor of the Florida Times Union, Jacksonville's newspaper.  It appeared in the paper August 22, 2012.  Although it makes a case for having health insurance, its most important aspect in this blog is to point out another Red Flag, one I had not foreseen, have never seen before, or put in my book.  I don't have a preference as to how everyone gets health care, just that they get it.  (Romney's plan in Massachusetts or Obama's plan for the country aren't that different, and there may be others that work better.) There is no reason for anyone to die of a preventable or treatable disease in the United States.  I admit, none of us are going to live forever, so the care of terminally ill people needs to be addressed.  Those expenses shouldn't bankrupt the country, but preventive care, vaccines, and treatment for significant illnesses and trauma need to be taken care of in order to prevent the premature death of individuals.

Letter to the editor, Florida Times Union:

Dear Sir;

The following is a case for the Affordable Health Care Act.

I am a physician.  I work in an urgent care in Jacksonville part-time.  A patient came in complaining of back pain for a week after working on a friend’s car.  This 48 year old gentleman is normally an auto mechanic, but has been out of work and is uninsured.  He paid the urgent care fees out of his pocket – about $85 for the visit.

His story was a little unusual in that his pain was so bad that his legs buckled three times in the previous week and he had fallen to the ground.  I am usually very skeptical of patients complaining of back pain because of previous patients who have been drug seeking.  However, his pain was new, not chronic.  As part of my back pain exam, I look for aortic aneurysms by checking for aortic and femoral pulses.  He had neither.  Neither did he have pulses in any other place I checked on his legs or feet.

I did not know the exact source of his back pain, but there was a good chance he had obstructed his aorta, which can be fatal.  The patient needed an MRI or other imaging to determine why he had no pulses.  I sent him to an ER in Jacksonville and I called the physician there to tell him he was coming.  They did the MRI and determined he had a large blood clot in his aorta.  Then they told the patient he needed surgery and discharged him.  When he balked at leaving the hospital with a potentially fatal medical problem, someone on staff allegedly told him, ‘You would not put a transmission in someone’s car unless he paid you, would you?’

Fortunately, the patient’s family took him directly to Shands Hospital, where he underwent a 7 hour surgery and had the blood clot removed.  His prognosis is good.  He will not be paralyzed; his kidneys continue to function, and he will eventually return to being a productive member of society.

A 48 year old man should not die of a surgically treatable medical problem.  As a tax-payer, I am going to pay several times for his care, because it took two ER visits (they sent him to the fast track and tried to discharge him with pain medication when he first went to the hospital) and two hospital admissions, emergency surgery, and recovery.  If he had become paralyzed or his kidneys had shut down, tax-payers would be supporting him for the rest of his life.  Of course, it would have been cheaper if he had had the common sense to just die.

Under the Affordable Health Care Act, this man would have had insurance and probably a primary care physician.  He would not have been discharged untreated.  His surgery might have been unnecessary or if not unnecessary, maybe elective and not emergent.  This will be a more efficient system and overall will cost the taxpayer less.  Also it tells the medical providers that the days of unlimited greed are over, which will also lower costs.  Maybe if we get rid of some hospital, insurance, and HMO CEOS who make multiple millions of dollars while auto mechanics die, people’s perspective on medical care will change.  We all are entitled to Life, Liberty, and the Pursuit of Happiness.  I think Life includes treatment for medical problems.

Update: September 4, 2012

After several replies on the Times-Union web site suggested that the patient was at fault for not having health insurance, I responded with this:

I guess I didn’t get my point across. Preventive medicine saves a lot of money. Going to the ER to have delayed definitive care when you could have prevented the problem (in this case a hypercoagulable state that led to the blood cot – which still needs to be addressed and treated in this patient) is way too expensive. This whole problem might have been prevented by taking an aspirin per day, pennies versus thousands of dollars. With 50 million people without health insurance and avoiding doctor visits and preventive care, you end up with millions of diabetics, hypertensives, and others who then go on to have very expensive strokes, heart attacks, cancer, etc. Taxpayers support all these people through Medicare, SSI, Medicaid, and other programs. And people with health insurance pay much higher premiums to cover losses generated by the uninsured. These problems are much easier and less expensive to treat early rather than later. When 1/6th of the nation is without health care, and people die from preventable or treatable diseases, something is out of whack. This is not a third world country; in fact it is the richest country in the world.

I don't have a preference as to how everyone gets health care, just that they get it and preferably before it is the expensive, last ditch version. (Romney's plan in Massachusetts or Obama's plan for the country aren't that different, and there may be other plans that work better and less expensively.) There is no reason for anyone to die of a preventable or treatable disease in the United States. I admit none of us are going to live forever so the care of terminally ill people needs to be addressed. Those expenses should not be allowed to bankrupt the country. Preventive care, vaccines, and treatment for significant illnesses and trauma are relatively inexpensive and need to be taken care of in order to prevent the premature death of individuals.

Who among you would condemn a teenager to death because he chose to ride a motorcycle, or chose to ride a bicycle without a helmet? Didn't wear her seat belt? An unemployed adult who chooses to feed his family or pay rent instead of buy health insurance? It happens too often. People sometimes make bad choices or have bad gambles forced upon them by circumstances beyond their control.

We have the best medicine in the world, and the worst delivery system.

Read more at Jacksonville.com: http://jacksonville.com/business/columnists/2012-08-22/story/st-augustine-physician-talks-improvements-needed-health-care#ixzz25XDpwiZo

Whoops

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.


I've got to stop reading the newspaper.  I made the mistake of taking Dr. Donohue's advice about a month ago.  A reader wrote in about his gaining a pot belly that only showed when he stood, not when he was supine, even though he was about the correct weight.  Dr. Donohue reminded the reader that in addition to being the correct weight, he needed strong abdominal muscle to hold his intestines in place and that crunches wold be a good way of strengthening his abdominal muscles.

So, since I have a bit of a bulge also, I thought that was good advice.  I am about the correct weight,(BMI 24; 5'10", 165#) although I weigh about 10 pounds more than I did in high school 50 years ago.  In addition, I have had several abdominal surgeries that weakened the muscles.  Although I run twice a week, I don't do a specific exercise for my abdominal muscles.

Crunches are not a good idea!  Specifically, they are a bad for people with back pain.  I knew that.  I even wrote that in the book.  I tell patients the same thing in the office.  As I point out in one of the appendices, I have several herniated disks and lumbar stenosis.  I have undergone two back surgeries.  Well, my stomach is slightly stronger.  Still no six pack, though.  But my back is way worse.

Every time you do a crunch, or a partial or complete sit-up, you tighten all your abdominal muscles and back muscles.  This has the effect of pulling your head toward your feet, squeezing vertebrae closer together.  The end result is your discs bulge more and any stenosis is worse.

This episode will take about two weeks to blow over.  Relative rest, some Aleve, some ice, and some time and I'll be back to my normal self.  Guess I'll have to cut down on the calories and/or rely more on the Side-bridge, Cat-camel, or Bird-dog exercises to strengthen my abdominals.  You should, too, if you have lower back pain.

Minimally Invasive Back Surgery

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

There are three levels of surgery, for those few patients who need it.   

Open surgery is the old fashioned kind where the surgeon opens up a surgical field big enough to use carpentry tools and play golf: hammer, saw, wedge and putter.  This was the way all surgeries were done until the arthroscope and laparoscope were invented.  I have  two 4 inch scars on my right knee from a knee exploration done in 1969.  The surgeon could have driven a BMW through the holes he made, and he still missed the fact that I had torn loose my ACL.  Didn't matter at the time, though, because they didn't repair ACLs back then.  The recovery time for open surgery is the longest because many supporting structures are cut (damaged by the surgeon) and they have to heal.

Microsurgery followed the advent of the arthroscope and operating microscope.  The tools are smaller, so the incisions are smaller: 1-2 inches instead of 4-6 inches.  Because the incision is smaller, fewer supporting structures (ligaments, muscle, and bone) are damaged and healing takes less time.  The trade-offs include the loss of visual field for the surgeon, so finding and getting to the part needing repair takes longer.  Also the tools are microscopic, so it may take a long time to remove damaged structures one small bite at a time.  This means more time under anesthesia, something some patients can not tolerate.

Minimally invasive surgery leaves the smallest scars and recovery time is the shortest because fewer tissues are damaged.  The surgeon makes a one inch incision and then pushes a solid instrument into the hole.  Over this instrument he passes larger and larger dilators until he has a tunnel through which his instruments fit.  Instead of cutting structures, he is pushing them to one side.  Healing time for stretched muscles is a lot shorter than for cut muscles.  Time under anesthesia goes up, again, because of the smaller visual field and smaller instruments.

Some surgeons will tell you they can only do one level of minimally invasive surgery at a time and that may be true, depending upon what they are fixing.  Sometimes they just want to do more than one procedure.  They get paid for each one.  I had spinal stenosis on both sides at three levels in my lumbar spine.  One physician I know would have required me to have 3-6 separate procedures.  The man who actually did the surgery did all six locations in one operation.  I was really uncomfortable for about a week, but I only had to undergo anesthesia and recovery one time.

Think about your choices and get the surgeon to explain them thoroughly if you need surgery.

Chiropractors vs. Physical Therapists

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

It is fine if you want to see a chiropractor, as long as you understand what he cannot do.  There is no scientific evidence chiropractic manipulation can fix infections, eye problems, heart disease, kidney problems, tumors, etc.  Neither can he rearrange (or adjust) your spine to remove an offending alignment in order to relieve your pain.  An x-ray taken by your chiropractor before adjustment will look no different after adjustment provided the positioning is exactly the same.  (Don’t do this, because the radiation exposure is unnecessary and excessive.  In fact, most people with back problems don’t need x-rays by anyone.  See my blog discussion X-rays, MRIs, and CAT Scans from May 22, 2012.)

However, a chiropractor (or a physical therapist) can stretch soft tissues, like ligaments, tendons, and muscles, to help relieve pain; and he can help patients who are fearful of using their backs understand that they can, in spite of their pain, be active.  Mobilizing a patient with back pain is one of the first steps in resolving the pain.  (See Initial Post and Blog Information – Chapter 1 of What Your Doctor Won't Tell You About Your Lower Back.)

He, or a threrapist, can also use ice, heat, stretches, massage, electrical stimulation, etc. to relax muscles in spasm and to relieve pain.

Taking repeated x-rays, keeping you in therapy for endless periods of time, selling balms or copper or elastic bracelets, etc. do nothing but add to your bill.  This is true whether it is done by a chiropractor, a therapist, or a physician.  Most back pains are limited entities.  Chronic pain may require chronic care, but that is rare.  (Again, see Initial Post and Blog Information – Chapter 1 of What Your Doctor Won't Tell You About Your Lower Back.)

So, if your chiropractor, therapist, or physician insists on a lot of x-rays, repeated visits, months of care, etc., there is a chance that he is lining his wallet and lightening yours or your insurance company's.  Get a second opinion, or maybe read my book, What Your Doctor Won't Tell You About Your Lower Back.

Pain

The are several ways to classify pain.  Two ways of describing pain are generally used to define low back pain.  The first is centered around acuity.  Acute pain is pain less than 6 weeks in duration.  Subacute pain lasts from 6-12 weeks.  And chronic pain is defined as lasting more than 12 weeks.  These divisions are arbitrary, but they help the physician decide what the chances are your pain will diminish on its own.

Another clssification has to do with the way your brain perceives pain.  If you are receiving pain from pain receptors within your body, then that is called nocioceptic pain.  Non-nocioceptic pain information is sent by nerve fibers not attached to pain receptors.

Nocioceptic pain can be visceral (from organs) or somatic (from the rest of the body).  Non-nocioceptic pain can be neuropathic (peripheral nervous system) or sympathetic (from the parasympathetic nervous system).

Most back pain  is sent by pain receptors: it is somatic and nocioceptic.  Some back pain is neuropathic (sent by compressed nerves).  That pain is non-nocioceptic.

Each type of pain has a characteristic pain pattern.  The patterns are not 100% reliable, but they help the physician decide where the pain originates.

To help delineate patterns, the doctor will also ask you to describe the pain: sharp, dull, squeezing, buring, itching, etc.; if the pain is steady, intermittent, or occasional; how long it lasts; and how long periods without pain last.  In addition, he will want to know how severe the pain is and if it radiates (travels) to different places, what makes it better or worse, and what triggered the initial occurrence.

The difficulty in diagnosis usually occurs when there are multiple sources of pain, or the patient is unable to describe the pain.  It's not easy to tease out the information sometimes.

Back Surgery

This posting is early.  First time that has happened!  The grandkids will be here next week.  Don't think I'll have time to make a post between entertaining them at the beach and pool, or sight-seeing.

Surgery has a very limited role in the treatment of back pain.  Although it is probably offered to patients more often than is necessary (this is, after all, how surgeons make their living), there are a few good reasons to have surgery.  A small number of surgeons think the only way to cure a medical condition is with cold, hard steel.  There are also some surgeons whose only interest in the patient is in the fee they collect; they collect more for doing surgery than for talking patients out of surgery.  Honest, ethical surgeons give the patient options and honest opinions.  The problem may be in figuring out who is being honest and who isn't.

Most insurance companies, especially workers compensation companies, would prefer not to pay for surgery, or long term rehabilitation instead of, or following, surgery.  The less they pay out for procedures or physical therapy, the more profit they make.  Stock holders like that; patients don't.  And if insurance companies can find a way to no longer be the financially responsible party, all the better.

Keeping the above two paragraphs in mind, some times surgery is a necessity.  Statistically, necessary surgery probably falls in the range of 5% of cases.  In another 5% of cases surgery may be appropriate because it saves the patient healing time and time off work, even if it does not affect the eventual overall outcome.  This means that in 90+% of back pain cases, surgery is not needed!  All surgery has the potential for complications, from pain to numbness to paralysis to death.  Think hard about your choices.

In general, a patient needs surgery when surgery can save his life, repair an injury the patient’s body cannot, or shorten significantly the recovery from an injury or disease.  When it comes to the lower back, there are five absolute indications for surgery, but several elective reasons.  The absolute indications for surgery are the following:

1.  Cauda equina or conus medullaris syndrome.  These situations happen when there is a very large central herniated disc that compresses severely the nerves in the lower spinal cord.  Without surgery, the compression would lead to eventual loss of function of those nerves, paralysis of muscles, and/or loss of sensation.

2.  Intractable pain, i.e. unremitting, severe pain.

3.  Progressive neurological deficit, loss of sensation, proprioception, muscle control, etc.

4.  New incontinence or retention, bowel or bladder.

5.  Hemorrhage into the spinal cord.

The relative indications generally center on the relief of discomfort (less than intractable) and the shortening of recovery time from various problems: herniated disk, compression fractures, severe stenosis, severe spondylolysis, and severe spondylithesis, etc.

There are also several types of surgery: open, micro, and minimally invasive (and endoscopic).  Open takes less time, usually.  The surgeon has a better view of the surgical field, but more structures are damaged and recovery is longer.  Micro surgery takes longer; the field of view is smaller, but fewer structures are damaged and recovery is shorter.  Minimally invasive surgery, in general, takes the longest; is the most difficult; has the narrowest field of view, but the shortest recovery time.  There are trade-offs.  Get the surgeon to explain them all to you.  If he can't or won't, find another surgeon.

If someone uses the words, laser surgery, he is trying to impress you.  Nothing more.  Lasers have their place in surgery -- usually cauterizing blood vessels.  Very little surgery is done with a laser.  A laser produces too much heat.  Laser is a buzz word only.  And the person using it is a salesman first  -- surgeon second.  He wants your money; he's not concerned with your best interests.

Decompression

Decompression is the opposite of compression.  Bulging discs, arthritis, inflamed or thickened ligaments, or combinations of these entities can compress nerve tissue causing pain in the lower back.

There are multiple ways of decompressing, or relieving this compressive force.  The most commonly known way is surgical, either non-invasive or micro-discectomy, or laminectomy.  Since only 3% of herniated discs and a slightly larger percentage of stenotic spines benefit from surgery, non-surgical methods of decompression have been tried.

Most of the non-surgical forms of decompression involved traction (stretching) of the spine.  An attempt is made, either by hanging upside down or right side up, or by supine traction, to stretch the spine.  The theoretical goal is to increase the distance between the lumbar (lower back) vertebrae.  This would (again, theoretically) cause the protruding disc or nucleus propulsus to be sucked back into the annulus and to increase the flow of nutrition to the nucleus and annulus to promote healing.

Unfortunately, none of this has been proven to happen, or to be effective.  Long term, studies suggest that the pain relief achieved is no better than physical therapy in general.

Vax-D, Inversion Therapy, Antalgic-trak, IDD, or traction by any other name can be expensive, and not very helpful.  Save your money.

Herniated Disc (or Disk)

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

The space between two vertebrae (vertebras) is filled by a disc.  This disc is made up of several parts.  The central portion is the nucleus.  When we are young this is a viscous material not that much different in consistency from silly putty.  As we get older, the nucleus tends to dry out.  If a disc is injured, then this drying out takes place quicker than it would with just aging. 

The outer portion of the disc is called the annulus.  It is made up of fibrous connective tissue.  Outside the annulus there is a thin layer of stronger connective tissue known as ligament.  Depending upon which direction you look, the ligamentous tissue can be very thick or very thin or somewhere in between.

Gravity tends to squeeze vertebrae together.  Because of this, almost everyone on planet Earth will have bulging discs as they age.  This process is generally painless.  Should you squeeze a double stuff Oreo (TM) cookie, you will see how the white filling bulges out in all directions.  If we kept our spine straight, our discs would bulge in all directions, too, but we don't.  When we sit, or bend forward, we put much more pressure on the front of the disc, pushing the nucleus backward.

Fortunately, one of our strongest ligaments is directly behind the disc and helps to prevent large bulges in that direction, since this is where the spinal cord is located.  Unfortunately, this strong ligament doesn't protect the entire rear portion of the dics.  The edges closest to the sides of the disc are relatively weak.  It's in these areas that the disc will occasionally rupture, allowing a portion of the nucleus to escape.  This is known as a herniated disk.  A herniated disc can be painless, too.  Sometimes, however, the nucleus will put pressure on nerves causing pain.

Stenosis

We have all seen the little old man who walks slowly, leaning forward on a cane or a walker.  Frequently, that is a sign of stenosis.  Stenosis means narrowing.  People can have stenotic coronary arteries, for which they receive stents or by-passes in order to increase blood flow to the heart and prevent heart attacks.  What we are talking about here is different.  It is stenosis (narrowing) of the canals through which the nerves in your lower back pass.

There are two main type of stenosis, central and foraminal.  Central stenosis is the narrowing of the central spinal canal.  This is usually caused by a combination of arthritis, increased thickness of ligaments, and bulging discs.  Most commonly it is found in older men, who are more likely to have those conditions.  Women can also have stenosis, as can young people, especially if they are cursed by inheriting short spinal pedicles.  With short pedicles, the spinal canal is narrow to begin with, and it is easy to narrow it further with arthritis, thickened ligaments, and/or bulging discs.

Foraminal stenosis is the narrowing of the canal in which the major nerve roots leave the spinal cord and go to the peripheral nervous system.  It is usually caused by the same things that cause central stenosis.

Now, the reason the old man walks bent forward is this: that opens the space in his spine between the vertebrae, taking pressure off the spinal card and/or peripheral nerve roots, relieving his pain.  If you remember the little guy Arty Johnson played on Laugh-in, with the white hair and mustache and leaning on the cane, you'll have an idea of what stenosis looks like.  If you picture him, you can make the diagnosis, too.

Sciatica

Well, I'm two days late this week.  Maybe I shouldn't have a deadline for myself.  But without deadlines, how does anything ever get done on time, or late? ;-D

The sciatic nerve is the biggest nerve in your body.  Pain in this nerve results from compression of the nerve from swollen or displaced tissue.  That tissue can be a herniated disc, a pulled muscle, a torn ligament or tendon, a hematoma, or a fracture. 

The hallmark of sciatica is the radiation of discomfort, usually pain, from the lower back down the leg.  The sciatic nerve is a bundle of nerves that starts near your lower spine and branches all the way to the tips of your toes.  Most people with sciatica suffer with pain that radiates some distance down the nerve.  Most doctors would agree that if your pain radiates below your knee, then the sciatic nerve is involved.  But, you can suffer other problems with compression of a nerve. 

Nerves not only send pain information, they send information to your brain about body position, touch, hot, cold, vibration, and compression.  In addition they send information from the brain to the muscles, telling them to contract or relax.  Sciatica could therefore involve not only pain, but numbness, loss of position sense, inability recognize vibration, heat or cold, or to contract or relax a muscle.

Loss of communication between the brain and your leg via the sciatic nerve may cause many different symptoms: pain, stumbling, foot drop, or injury due to cold or heat, depending upon which nerve fibers are compressed.

Back Exercises

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Doing specific back exercises is championed by any number of back gurus.  However, most people do not need to strengthen their backs.  They need to become active.  Aerobic activity by itself can decrease back problems.  As an Atlanta neurosurgeon says, “Motion is the lotion.”  Immobility leads to increased pain.

In his research, as reported in his book Low Back Disorders, exercise physiologist Stuart McGill makes a good case for not doing a number of exercises.  These are frequently the same exercises doctors tell their patients with low back pain to do.  Don’t do them!!  They are listed below.  He also shows why certain exercises are better at rehabilitating an injured back than others.  He compares the back to a tall tower with supporting guy wires.  The tower supports itself against gravity by the way it is constructed, i.e., it isn’t easily compressed.  The guy wires keep the tower from buckling or falling over.  The tower is your vertebral column.  The guy wires are your back and abdominal muscles.

If you think you need specific exercises or think they may help your back, take the following advice from McGill into account: there are some specific exercises to avoid.  Any exercise that increases intra-abdominal pressure increases compression of the discs and the facet joints, increasing the likelihood of injury or irritation of these structures.  Even though strong abdominal muscles contribute to back stability, true sit-ups and bent leg sit-ups can be injurious.  They increase the compressive force between vertebrae to unacceptable limits.  Unless you are an athlete bent on competition and willing to take that risk in order to improve your performance, avoid doing them.  For the rest of us, endurance in those muscles is more important than strength.  Pull-ups, believe it or not, also compress your discs.  Most extension exercises are a bad choice.

All exercises should be done with the back in a neutral position, including any stretching such as hamstring, quadriceps, and psoas stretches.  McGill also goes over nerve flossing (a way of decreasing the compression on segmental nerves), but it has the potential to worsen pain.  It is best to receive specific instructions from a physical therapist who has a lot of experience with the technique.

Back exercises that are acceptable include the cat-camel, partial squats, curl-ups, side bridge, plank, push-up, and bird dog.  These increase core strength and back stability by strengthening the rectus abdominis, obliquus externus abdominis, and obliquus internus abdominis muscles (the guy wires to your towering vertebral column).  Aerobic exercises, like brisk walking, jogging, swimming, and – depending upon your posture – riding a bike are also good for your lower back.  They increase your overall stamina and the stamina and strength of the muscles in your back.

Gravity

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

The number one cause of lower spine problems is too much gravity, although you could throw in inertia, too.  There would be no inertia without gravity, I guess.  Anyway, the constant downward force of our upper body's weight on our lower spine squeezes discs, causing them to bulge.  No gravity, no squeezing, except for trauma caused by changes in inertia, changes in direction, and sudden stops.  Obviously, if you fall from a height, come to a sudden stop, or change direction violently in an accident, your spine can also be compressed, and the discs will bulge then also.  However, gravity is also a necessary part of normal disc function.

There is no escaping gravity, unless you have millions of dollars and can pay your way into space as a tourist or you are an astronaut, cosmonaut, or taikonaut.  But even space travelers have back pain.  Their back pain is caused by the lack of gravity. This situation also occurs on planet Earth, when you lie down for too long.  Gravity no longer compresses your spine.  The lack of compression allows the discs to expand.  This expansion is necessary on Earth because it allows nutrients to enter the disk.  Compression pushes waste products out of the discs.  In the outer space, zero-g environment (and if you lie in bed for too long) there is no compression of the spine to relieve the expansion of the discs.  Then expansion leads to pain.

The take home message here is that your spine needs active compression (standing or sitting in a gravitational field) and expansion (which occurs at rest).  Without both phases you decrease the well-being of your discs.  Be active.  Also, rest when needed.  Your lower back will thank you, and hurt much less often.

X-rays, MRIs, CAT scans

I'm late again for my self-posed deadline.  Tuesdays are the new Mondays, I guess.

As the fictional presentation below will show, x-rays, MRIs, and CAT scans are not very helpful in diagnosing joint pain (including backs).  It was just easier to construct a story around knees.  Enjoy.

            Dr. Evans used the remote to turn down the lights in the auditorium, and then turned on the first slide in his presentation.  “I’m going to show you three sets of bilateral knee x-rays,” he said.  “One set is from someone with severe arthritis, another from a person who has severe, incapacitating knee pain, and another from a marathon runner.  I want you to tell me which set of x-rays you think goes with each patient history.”

            The first set of x-rays towered over Evans, the projector showing twelve foot high x-rays on the screen.  In the shadows, Evans pointed his red laser at the x-rays, specifically at the joints.  “You can see here nice smooth cartilage on both femurs and both tibia in the anterior-posterior views.  Lateral views and tunnel views show no abnormal bone, bone spurs, or unusual calcifications.  Anyone see anything else I should point out?”

            There were no suggestions.  Evans continued, “Any of you think this is our marathoner?” 

            The show of hands was almost unanimous, with the exception of a few students who had been fooled by Evans in the past.  “Okay, the second set,” Evans said, pushing a button on the remote.  Two more large knee x-rays replaced the first ones on the towering screen.  “This left knee appears to be normal.”  Evans played the pointer across the joints.  “The right is a disaster, though.  Look.  No joint space medially.  Large bony spurs medially, with smaller spurs laterally.  Could this be our patient with severe, incapacitating knee pain?”  There was a murmur of assent, again with a couple students demurring.

            The third set of knee x-rays appeared on the screen.  “Now, this patient has narrowed joint spaces in both knees.  There are bony cysts underlying the cartilage in both joints, and small spurs medially and laterally in both knees.  Is this the arthritis?”

            “That wasn’t so hard, professor,” one of the skeptical students suggested.  “Are we treating x-rays now?”

            Evans smiled.  The student had heard Evans harp on just this point in the past.  “No, Tony, we are not treating x-rays, as you well know.  Let’s look at these again, and I’ll point out some things you, as a group, may have missed.”

            The first set of x-rays magically reappeared.  “As I said, these are totally normal x-rays.  However, this is not our marathoner.  It is our patient with severe, incapacitating knee pain.  What I did not point out, and what you did not see since no one else pointed it out, was this.”  Evans used the pointer to outline the soft tissue surrounding the knees.  The gray shadow was that of a huge, obese individual.  “Arthritis doesn’t show up on x-ray for years.  It takes sometimes a decade for cartilage and bone changes to be visible.  This patient never does any exercise, and eats way too well.  As a consequence, he weighs 373 pounds.  The compression of his joints will eventually destroy the cartilage.  His knees already hurt terribly.  He uses that as an excuse not to exercise.  Soon he will have severe osteoarthritis.  Not only will his x-rays remain normal for several more years, but all his lab tests will be normal for several more years.  Then he will become a Type II diabetic.  In order to save his knees and preserve his life, he needs to ignore the pain, exercise and lose weight.” 

            “The second set of x-rays,” Evans continued, pointing to the x-ray with one normal knee and one severely arthritic knee, “are from a patient with severe osteoarthritis.  He had a meniscus tear and a destroyed anterior cruciate ligament while playing football in high school.  This was in the days before anterior cruciate repair.  The medial meniscus was removed; the knee has collapsed on itself.  But, and this is a big but, this patient has very little pain.  He was told to keep exercising and to keep his leg strong, which he has.  He runs 4-5 miles 2-3 times a week, occasionally taking Ibuprofen or Naprosyn when he overdoes it.  Exercise protects joints, if it’s not overdone.”

            The projector advanced to the third slide.  “Here is our marathoner.  Notice, he has mild osteoarthritis in both knees.  He has absolutely no pain in his legs.  The x-rays were taken as part of a knee study in geriatric patients, which will be published in an orthopedic journal next year.  I shouldn’t say he has absolutely no pain.  He does complain about knee stiffness after 3-4 days if he is unable to run.  Again, exercise protects joints.”

            Evans eyed the students with a smile.  “Okay, anyone up for treating the x-rays?”  There were no hands raised.  “Good.  X-rays confirm diagnoses.  They do not make diagnoses.”  He paused to make certain the point was absorbed by all.

            “Now we are going to look at another set of x-rays.  I’ll give you a history and you tell me what the x-rays confirm.  Fair enough?”  Most of the students nodded, with the exception of the skeptical students.

            This is a 19 year old volleyball player.  She missed half the season with a severe ankle sprain.  After returning to the sport, she has practiced for one week and now complains about severe knee pain when getting up from a seated position or running down hill.  The first x-ray flashed on the screen was a chest film.  With the students’ new found appreciation of soft tissue shadows, it was apparent to most of them that this patient was tall, thin, and had large dense breasts.  “Okay,” Evans laughed and spoke in a high falsetto voice, “Doctor, my knees are down here!”  The class laughed.

            Evans hit the remote and a set of knee x-rays appeared on the screen below the chest x-rays.  “They are normal,” a bewildered student said.

            “Correct,” Evans agree.  “But what does that confirm?”

            “Nothing,” another suggested.

            “Wrong,” said Evans.  “It confirms she has Patello-Femoral Syndrome.  I gave you the classic history: athlete sidelined for an injury, pain on rising from a seated position, and pain running downhill.  The x-ray shows there are no other lesions that might cause similar symptoms.  Now you could order an MRI to look at the soft tissues.  Would you want to?  MRIs are expensive.”

            “Be better to treat her for PFS.  Save the MRI in case she doesn’t improve,” one of the skeptics suggested.

            Evans beamed.  “Don’t treat x-rays, MRIs, CAT scans, blood tests, etc.  Use these tests to prove or disprove the diagnosis if the treatment isn't working.”

Drugs

To relieve discomfort, mankind has relied on medications and herbs for thousands of years.  At the present time we most commonly rely on medications in four classes for pain relief: acetaminophen, NSAIDs, steroids, and narcotics.  The potency of these medications follows in about the same order, with Tylenol (acetaminophen) being the least and narcotics being the most powerful.  The side effect profile also follows in about the same order, fewest for Tylenol and most for narcotics.  An overdose of Tylenol can damage or destroy your liver.  NSAIDs include aspirin, ibuprofen, naprosyn and about fifty other drugs.  The most common side effects include stomach upset: gastritis and ulcers, decreased kidney function, and increased blood pressure.  As such they should be used sparingly by diabetics and people with stomach issues.  Steroids can cause the same issues with greater severity.  Narcotics cause constipation and sedation and can be addictive.  Make sure you understand what your doctor is trying to accomplish with the medications he gives you.  If you are medicating yourself, remember that all medications have side effects.  Follow the directions carefully.  Don't hurt yourself while trying to help yourself.

More Travel

My wife and I flew to Denver to see youngest son last week, and flew home this week.  More reminders that sitting is not good for backs.  Fortunately, we had to walk and wait for about thirty minutes for our baggage, so our lower backs were ready for the challenge of lifting suitcases when they arrived.  If you have read  the book, you know that I suffer with spinal stenosis and several herniated discs.  The discs are worse when seated; the stenosis is better.  And the discs are better standing and the stenosis is worse standing for long periods of time.  As you may be guessing, it is important for everyone to change positions frequently, in order to avoid discomfort if you have back issues, and to prevent back issues.  This is not easy on an aircraft flying through turbulence.

Update: Travel

I have been out of town for the last week.  Went to Houston to pick up a used van I bought on the web and drove home (950 miles).  There's nothing like a long drive to remind me that sitting is the worst thing for your lower back.  It is important to stop frequently, walk around, extend (lean backward) your lower spine, and do some knee bends.  Sitting increases the pressure on the anterior (frontal portion) discs tremendously.  It is no coincidence that most disc ruptures are posterior (rearward).  The increased anterior pressure over a lifetime causes migration of the nucleus of the disc backward.  The posterior longitudinal ligament isn't very thick or strong at the posterior margins of the disc and this is where most ruptures occur.  Getting out of the seated position and leaning backward helps to relieve that pressure and slow the migration.

Another suggestion is you walk around for an hour or so after arrival at your destination before you lift heavy objects (known as luggage).  This hour allows your discs to recover before you overload them with even more pressure.

Diagnosis and Treatment

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

Since I am just learning how to manage a blog, I will start by posting interesting information about low back pain. This blog will very rarely, if ever, discuss neck pain.  The two are rarely related and they are treated differently, or should be, for optimal pain relief.

I will try to update the blog weekly.  As of today, that will happen on Mondays until I change my mind.

The first bit of interesting information is the abstract for an article published in American Family Physician, February 15, 2012; Volume 85, Number 4, by Brian A. Casazza, MD.  The article is filled with good information for physicians, although patients should not have too much difficulty working through it.  It's not flashy; it just reports the facts, as we know them to this point in time. Of course, all scientific theories are open to change as more information becomes available.

As the abstract points out, this article is important because it affirms a couple points I discuss in my book.  These are the following:  Taking x-rays, CTs, or MRIs of new onset back pain are usually worthless initially.  Unless the patient has a Red Flag problem, not much will be learned.  Second, surgery has only a limited place in the treatment of back pain.  Statistically, very few people benefit from surgery, and those are limited to patients with intractable pain, neurological deficits, and other severe back problems like bleeding into the spinal cord.  Lastly, the article points out some of the Red Flags, which indicate that back pain is a symptom of a very serious medical problem that needs to be addressed urgently.

Diagnosis and Treatment of Acute Low Back Pain

BRIAN A. CASAZZA, MD, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Acute low back pain is one of the most common reasons for adults to see a family physician. Although most patients recover quickly with minimal treatment, proper evaluation is imperative to identify rare cases of serious underly­ing pathology. Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and sus­pected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required. Although there are numerous treatments for nonspecific acute low back pain, most have little evidence of benefit. Patient education and medications such as nonsteroidal anti-inflammatory drugs, acet­aminophen, and muscle relaxants are beneficial. Bed rest should be avoided if possible. Exercises directed by a physical therapist, such as the McKenzie method and spine stabilization exercises, may decrease recurrent pain and need for health care services. Spinal manipulation and chiropractic techniques are no more effective than established medical treatments, and adding them to established treatments does not improve outcomes. No substantial benefit has been shown with oral steroids, acupuncture, massage, traction, lumbar supports, or regular exercise programs. (Am Fam Physician. 2012;85(4):343-350. Copyright © 2012 American Academy of Family Physicians.)