Conquer Back and Neck Pain - Walk It Off! (26 page)

There are three goals for exercise: strength, stamina, and flexibility. Flexibility is supposedly enhanced by stretching. There are a number of stretching programs touted for treatment of back pain. Yoga, McKenzie, and Pilates are the three most popular stretching exercises for back pain. Some forms of yoga and Pilates also build strength and stamina, whereas the program proposed by McKenzie is purely a stretching type of exercise. McKenzie advocates lying on your stomach and passively hyper-extending your back by pushing your body up with your arms. The theory is that this maneuver reduces the disc herniation and relieves pressure on the nerves. I personally have experienced an exacerbation of low-back pain a day or two after trying this type of stretching, which I think comes from irritation of my facet joints by this maneuver. I may not be a candidate for the McKenzie system, and I have not been able to determine who is. I definitely do not recommend passive hyper-extension of your back if you have spinal stenosis. This maneuver will make the stenosis worse and can exacerbate the pain. I am not an advocate of the McKenzie method.

The Pilates system is based on exercise equipment that passively stretches you as you actively strengthen your muscles. It was originally popularized as a method for rehabilitation of injured ballet dancers. It is probably a good system for high-performance entertainers who are young, agile, and require a controlled exercise system to stimulate rapid healing of sprained ligaments, but I am not sure that it is a good system for most back-pain sufferers. It requires that you be attended by a physical therapist who is familiar with the system. I have not recommended it to my patients because I do not think it is a good system for people suffering from degenerative diseases of the spine. I think it should be used to assist in the rehabilitation of the injured athletes for which Pilates designed the system.

I have developed the same prejudice against yoga for chronic back pain from degenerative disc disease. I have seen numerous patients over the years who have made their pain worse as the result of the passive rotary maneuvers performed in yoga. One patient actually developed a massive disc herniation with cauda equina syndrome from a yoga maneuver. However, I must admit that many patients extol the virtues of yoga for their well being and relief of back pain. I do not recommend the vigorous twisting maneuvers performed in yoga. It is also potentially harmful to your back if you are passively twisted or stretched by someone else during yoga.

Of the three components of exercise — strength, agility and stamina — which combination is the best for managing your back pain? As you may have gathered from my discussion of the passive stretching systems such as McKenzie and Pilates, I am not an advocate of these systems. It does not make sense to passively stretch an already-weakened degenerative disc. As the disc begins to degenerate, it becomes unstable. In the late stages of disc degeneration, reparative processes cause the disc to stiffen up again. As the disc becomes stiffer it becomes less susceptible to injury, but subjecting it to repeated stretching will prevent it from stiffening. For this reason I am not a fan of passive stretching for back pain as the result of disc degeneration.

Muscle-strengthening exercises are good for your back as long as you avoid lifting heavy weights through your spine. I have seen a few athletes who have blown out a degenerated disc through heavy weight lifting. I advise my patients to use the weight machines and do only bench presses, but not to snatch weights off of the floor or lift overhead. For people who are interested in keeping good muscle tone while they are getting over an attack of back pain (yes, there are people who want to do this), I suggest light weights and multiple repetitions for the arms and the quadriceps machines for the legs (the one in which you sit and straighten your legs against resistance). If you have back pain, do not do the hamstring muscle exercise in which you lay on your stomach and bend your knee against resistance. This maneuver tends to arch your back and can exacerbate your back pain. I am not an advocate of excessive muscle-strengthening exercises for back pain, but I do advocate keeping good muscle tone.

The most important exercises that you can do to relieve back pain and prevent it are those that improve your stamina. Walking outdoors or indoors on a treadmill, bicycle exercise, and aquatic exercises are the best aerobic exercises for your back. If you have acute or chronic back pain, do whichever one you can do within the limits of your pain and stamina. Initially you may have to start out slowly doing aquatic pool exercises and gradually work up to walking an hour a day. This is what my wife and I do to keep fit and ward off back-pain attacks. These aerobic exercises not only strengthen your leg muscles, but they also strengthen the muscles around your entire spine. They also stimulate your own body’s painkillers, your endorphins. Additionally, aerobic exercise has been shown to improve your balance, reflexes, and coordination, thus making you less susceptible to falling and injuring your back. All of these benefits of aerobic exercise help relieve back pain and prevent it form recurring. Aerobic exercise is the single most important thing you can do to make your back pain go away and keep it from coming back!

The following is an actual e-mail that I received from a former patient while I was writing this book, which I share with you with the sender’s permission. She was in her mid-30s when I saw her for the first time and she suffered from chronic low-back pain from a severely degenerated disc. A spinal fusion or artificial disc replacement had been suggested to her before she consulted me. I recommended that she avoid twisting and passive stretching maneuvers and perform aerobic exercises instead of having a procedure performed on her spine. This is what she wrote:

Every back-pain book or pamphlet has diagrams of specific exercises for the spine, some of which look harmful to your back under some circumstances. When I ask patients to demonstrate the exercises that they are doing, most of them show me maneuvers that are harmful to someone with a degenerated disc. The maneuvers that require leaning back, passive twisting, and rotation of the spine are the ones that concern me. A study was published recently that confirmed my impression that back-specific exercises are actually harmful to your back!

There is a well-designed prospective randomized study comparing the effect of back-specific exercises to low-stress recreational physical activity, such as walking and swimming, on acute and chronic back pain. The study found that back-specific exercises actually increased the likelihood of back pain and disability, whereas aerobic exercise decreased acute and chronic back pain, disability, and stress. People who perform the equivalent of three hours a week of brisk walking or similar aerobic exercise benefited from the most reduction in back pain, stress, and disability. It works for my family, my patients, and me, and it has been shown to work in several well-designed studies: consistent low-impact aerobic exercise is the best medicine for acute, recurring, and chronic back pain. The really good news is that you don’t have to do those ridiculous back exercises (that are hard to learn, remember, and perform) to get relief and prevent future attacks of back and neck pain.

Whether you should exercise on your own or have physical therapy depends on how physically fit you are, and whether you can do it on your own or need help from a physical therapist or trainer.

How do you know if you are physically fit enough to do it on your own without a physical therapist?

People fall into roughly four categories of fitness. These categories are not age-dependent. My mother exercised every day of her life and remained physically fit into her 90s. She rarely complained of back pain, although I remember that she had a few attacks of neck pain when she was younger. She remained in the fit category her whole life and enjoyed a great quality of life up until the time she died at the age of 97. She clearly fit into the first category, which is comprised of people who are physically fit, perform aerobic exercise regularly, are of normal weight, and do not have not chronic aliments. They also do not drink excessively and do not smoke.

The second group does not exercise regularly, are not too heavy or too thin, do not drink heavily, and do not smoke. If they have a chronic disease, such as high blood pressure or diabetes, it is under control.

The third group of people is physically sedentary, overweight or too thin, may smoke and/or drink too much, and may be taking medications for pain. This group gets short of breath from walking up a flight of stairs.

The last group of people is deconditioned from inactivity and/or chronic disease and may require a walker or wheel chair to get around. They cannot walk up a flight of stairs.

If you are in the first group, it is very likely that you can walk off an acute attack of back pain with just the reassurance from your doctor that it is safe to do so. Most of my fit patients do this on their own.

If you are in the second group, you may need the help of a physical therapist for pain relief and assistance in how to exercise in the face of pain. Some patients can do it without a therapist and some cannot. A lot of it has to do with what they can afford and what their insurance will cover. I recommend physical therapy for acute back pain for patients who don’t think they can do it on their own.

I recommend to people who are in the third category of fitness that they see their PCP to have a general medical examination. If they are over the age of 60 and/or have hypertension, diabetes, or a history of smoking, I suggest to their PCP that they have a non-treadmill cardiac stress test to be sure that their heart can tolerate an exercise program. I recommend a proper diet, no smoking, and no drinking. After I am assured that they can start an exercise program, I refer them to a physical therapist. Physical therapists teach, guide, and monitor them in the rehabilitation process.

After those who are in the fourth category have been examined by their PCP, I usually refer them to an inpatient comprehensive pain rehabilitation program where they have immediate access to multiple specialists including a physical therapist for pain control and rehabilitation. The inpatient setting is important because of the numerous problems this group of patients needs help with, i.e., diet, pain control, detoxification, conditioning, and other medical problems.

Pain management is a specialty in medicine that arose out of a need to provide a comprehensive approach to people who suffer from chronic pain from cancer, neurological diseases, arthritis, and musculoskeletal diseases such as chronic back pain. A comprehensive pain-management team may be comprised of anesthesiologists, physiatrists, neurologists, psychologists, nurses, and physical therapists. They manage pain medication, nerve blocks, epidural pumps, psychological care, and alternative approaches such as acupuncture.

In our community we have a world-renowned comprehensive pain rehabilitation center (CPRC) that offers inpatient as well as outpatient treatment for chronic pain. A CPRC offers similar specialties and services as a comprehensive pain management center with more emphasis on rehabilitation.

I recommend the CPRC approach to my debilitated chronic back pain patients. I frequently will refer patients to a pain management specialist for epidural injections for acute nerve pain from a herniated disc, but I prefer to manage their chronic pain myself. I believe it is in my patients’ best interest to have quick pain relief for acute back pain conditions. I also do not want them to become dependent on treatment, so I always plan to initiate rehabilitation along with acute pain management right from the beginning, to prevent chronic pain syndromes from occurring. It has been my observation that pain management centers do not seem to be able to do this as well. I think it takes a one-to-one relationship with the patient to make my approach effective.

What about other treatments, such as epidurals, radiofrequency ablation, Botox, sclerosing agents, cryoablation, Chymopapain, intradiscal radiofrequency therapy (IDET) for back pain? You can ask your doctor about these, but how does he or she determine what works and what is safe? I examine the evidence-based medicine (see page 108) for a specific treatment; determine whether it makes sense, is safe, and if I would personally take the treatment. Then, I decide whether to recommend it to my patients.