Conquer Back and Neck Pain - Walk It Off! (23 page)

This test is useful in detecting some chronically painful conditions of the spine. One of my sons could not play soccer because of chronic low-back pain localized to one side of his spine. He was in the middle of his growth spurt, played soccer for his high school team, and was lifting weights as most young men do at that age. He could not stand on one leg and lean backward without experiencing the pain. I suspected that he had a stress fracture of one of his pars interarticularis (see page 87), a common cause of chronic back pain in growing athletes who are required to hyperextend their back (lean backward) while playing their sport. Gymnasts, soccer players, golfers, tennis players, and football linemen are susceptible to this type of stress fracture of the spine.

My son’s x-rays and MRI scan did not show the problem, but a bone scan pinpointed a stress fracture in his pars. I explained the problem to him and told him it would require at least seven months of not playing soccer or weight lifting to alleviate his pain. I did not advise him to wear a back brace, which was a common treatment for this condition at the time, because most young athletes will not wear one even if it is prescribed by the doctor. He listened to my advice, and he stayed in shape by swimming and bicycling exercises, both of which can be performed in flexion so as to keep stress off of the stress fracture. His pain went away in seven months and he was able to resume playing soccer for the remainder of his high school career.

There are several types of arthritis of the spine that can cause chronic generalized spine pain, one of which is ankylosing spondylitis (bone-forming inflammation of the spine), an inherited type of arthritis. The symptoms of ankylosing spondylitis (AS) first begin in young men (but rarely women) and are characterized by night pain and a feeling of stiffness on first arising in the morning. At first this disease is hard to diagnose, but later it becomes painfully apparent because it causes the spine to become bent forward (kyphosis). You may have seen someone with this condition walking on the street, bent over so far that it was difficult for them to see where they were going.

A bone scan and a blood test can detect this disease in its early stages and alert your doctor to begin treatment with anti-inflammatory medications and exercises to help ward off the deformity. Unfortunately in some cases the deformity occurs in the late stages of the disease despite the best treatment. In these cases the bent-forward spine can be straightened with surgery, which has become more effective with the use of pedicle screws.

Chronic pain that awakens you every night is serious and requires a specific diagnosis. If you can sleep in certain positions, e.g., on your side with your legs curled, you probably have spinal stenosis. But if you have to get up and walk around to relieve the pain and the pain is gradually getting worse each night, then you should question the possibility of a tumor (see page 26). Tumors may arise from the nerves in your spine or from the bone. The bad news is that breast and prostate cancer can metastasize to the vertebrae in your spine and cause chronic back pain. The good news is that most chronic back pain is not cancer, but is instead the consequence of one or more degenerated discs in your back.

The most common cause of chronic back pain stems from overzealous attempts at treating discogenic low-back pain, which is pain coming from the degenerated discs. Yes, that is correct — the treatment of discogenic pain may become part of the problem! Not a clinic day goes by that I do not see a patient who has a story that goes like this: “I have had this pain for so long that it’s controlling my life. I have tried chiropractic, pain management, epidurals, acupuncture, you name it, and nothing seems to help.” They are usually taking some combination of narcotics, muscle relaxants, and anti-inflammatory medications. They are depressed, can’t sleep normally, and their whole world is falling apart around them. They have seen numerous different doctors and had numerous diagnostic tests. They say, “No one can find out what is wrong with me,” or, even more ominously, “I have been told I need a fusion.”

On delving into their problem further, I usually find something along these lines: initially they had an acute attack of back pain that was treated with a narcotic and a muscle relaxant; they were in bed for more than a few days; the pain did not get better, so they went to a chiropractor, whose treatments helped at first, so they kept going on a frequent basis so the pain would not come back. Eventually the pain returned, so they had an MRI scan which showed one or more degenerative dark disc(s); they were told they had a herniated disc and were referred to a pain-management specialist for a series of epidurals (see page 58). So, they were treated with more bed rest, physical therapy, acupuncture, traction, change of bed, corset, brace, facet injections, and intradiscal radiofrequency therapy (more about these in
Chapter 9
), but the pain still continued. When they finish telling me all of this, they are in tears and at their wits’ end. They are convinced that something is drastically wrong because nothing has helped despite having spent thousands of dollars for health care.

Obtaining an accurate history from a patient who is suffering from chronic back pain is one of the most difficult tasks that I do. I have found that the best way to get to the bottom of the patient’s problem is to listen until they finish telling their story without interrupting them. That is a very difficult thing for us doctors to do, because we immediately want to get to the bottom of the problem. We try to hurry up the process by interrupting just when you are getting to what is really troubling you. Try to tell your doctor exactly what you are thinking and the questions you want answered. Make sure your doctor answers these questions. This is very important when it comes to finding a solution to your chronic back pain.

After taking a thorough history from my patients, I perform a thorough physical examination. (Remember my aunt’s story? She went to numerous doctors and no one examined her to determine she had pressure on her spinal cord that was causing her chronic pain.) Then I look at all of the patient’s previously performed tests, x-rays, MRIs, CAT scans, etc. I get new tests if they are outdated or of poor quality (open MRI, see page 54), or if an essential test has not been performed. Once I am satisfied that the chronic pain is coming from degenerative disc disease, I explain this to my patient and reassure them that they have a good prognosis to be cured!

At this stage I try to determine whether they are significantly depressed. Most patients who have been taking narcotics and/or muscle relaxants for their pain for more than two weeks have some component of depression. If they had a predisposition to depression before they developed back pain, then pain medications may make it worse.

Depression accentuates chronic pain, and chronic pain accentuates depression. I have found that people who suffer from chronic pain almost always have significant depression. It brings to mind the question “which came first, the chicken or the egg?” It is important to know, because if the depression is the result of the treatment and pain, then discontinuing the pain medication, thus breaking the pain cycle, can resolve the depression and help alleviate the pain. But if the patient suffered from depression before the chronic back pain, they may require treatment with anti-depressant medication in order to obtain relief. If the patient has a PCP who knows them well, I work with that doctor to sort these issues out. If not, then I recommend a comprehensive pain rehabilitation center (more about them later).

I then explain to the patient that the key to their cure is to stop seeing doctors and stop all treatment for their pain except what they can do for themselves! At first this is a hard sell, so I explain to them that nothing has worked thus far to relieve their pain, therefore what do they have to lose by trying my approach? I explain that the pain will not get worse when they stop pain medication; in fact, they will feel better as soon as their own body’s painkillers (endorphins) take over.

In order to stimulate their own body’s painkillers, I tell them to walk a little more each day. Exercise is known to increase the endorphins in your body. The first day they should walk as far as the pain and their stamina will permit. I tell them not to be afraid of the pain, that it will not harm them even though it hurts. If they cannot tolerate walking I tell them to use a treadmill, stationary bicycle, or pool (aquatic) exercises. Any form of aerobic exercise is good, but it must be done every day. The goal is to build up to an hour a day of aerobic exercise (more about exercise for back pain in
Chapter 9
). If they smoke I advise them to stop right away and to lose weight or gain weight, whichever is appropriate for them. I tell them that this approach to their pain will not kill them, but continuing the treatment that they are getting might! My approach to chronic pain is safe and affordable. I reassure them that I will follow them in my clinic as frequently as they want and as long as it takes for their pain to subside. I also tell them that they can expect to have a markedly improved quality of life within three months of trying this approach. I tell them that if they do not have significant relief of their pain within three months, despite trying, we will perform new tests to determine what is wrong. This later advice is to reassure them, but it is rarely necessary because the majority of these patients are significantly improved by the end of three months. I also tell them that if their pain is not improved by these measures (no more treatments, no smoking, weight control, and exercise), and if it is determined that they would benefit from surgery, then it will be safe to have the surgery. Following this discussion most patients are extremely relieved and grateful. These are the patients who I know will be able to cure themselves of their chronic back pain.

It has been my observation that most patients who suffer from chronic discogenic back pain will obtain relief from the program that I described above. There is a well-designed study in the medical literature that supports this observation. The authors randomized people who suffered from chronic back pain into three treatment groups. One group was prescribed the usual physical therapy modalities of massage, ultrasound, and stretching. The second group was prescribed a moderate exercise program, and the third group more vigorous exercises. Within a three-month period, both exercise groups had significant relief of their chronic pain compared to the traditional physical therapy group. The results of this study are at first counterintuitive. You would at first think that more exercise would lead to more pain.

If you think back to the first chapter in this book, it will help you understand why exercise works. Recall that the disc is a living structure with living cells that depend on physical activity to live. When you walk around, water is squeezed out of the disc, and when you lie down the water is absorbed back into your disc. The flow of nutrients into and waste out of your discs keeps the cells healthy and allows them to keep your discs in repair. Lack of exercise and smoking kill the cells in your discs and cause them to become painful. It makes sense that controlled aerobic exercises will improve the health of the discs in your back and make them less painful.

The second reason my regime works is that it is aimed at restoring your own body’s painkillers, endorphins, instead of depending on drugs that depress your endorphins and lead to mental depression, both of which increase your pain.

In the next chapter I will discuss most of the proven and unproven therapies out there for back pain. I will also describe the treatments that I have found to consistently work for my patients, the rationale behind them, their nature, benefits, risks, and costs.

Every time I think that I have finally heard of all of the treatments foisted on the public for back pain, another one comes along. Recently a patient asked me about “astronaut chambers for back pain.” It seems she had read an advertisement for this and was curious about my opinion of the treatment. I had to suppress a smile and formulate a hopefully intelligible answer at the same time. I asked her to send me the advertisement so that I could try to determine the rationale for this approach. Invariably patients will show me infomercials on the back-pain cure du jour. They ask me for my opinion concerning some new treatment that I have never heard of. I am usually suspicious of these treatments, since I have not seen or heard any qualified medical evidence to support the claims of their efficacy or safety. I should have come across something about them since I am on the editorial board of four medical journals and a member of 10 professional societies, all of which evaluate new treatments on a regular basis. I will discuss some of these treatments if they are widely advertised, used, of historical interest, or new on the horizon. I will also discuss the theoretical basis and any evidence that is available in the medical literature to support or debunk their use.

In this chapter I will review the nature, benefits, risks, and costs of most of the back-pain treatments that I have heard of. I am positive I will miss a few, since new treatments for back pain appear on TV on a daily basis. Even on the way to work this morning I heard a so-called “public announcement” on NPR radio for minimally invasive spine surgery. I have organized this chapter into categories of treatments such as commonly prescribed medications, physical medicine modalities, injection therapies, pain management, and alternative treatments for back pain.

Throughout this book I have given you my approach to treatment of back pain. I will tell you throughout this chapter what I think works and what to avoid in the way of treatment for your back pain. But first, let’s take a look at how the medical community evaluates the effectiveness of a particular treatment.