TAKEBACKYOURBACK

EVERYTHINGYOUNEEDTOKNOWTOEFFECTIVELYREVERSEANDMANAGEBACKPAIN

BETHB.MURINSON,M.D.,PH.D.DirectorofPainEducationDepartmentofNeurology

JohnsHopkinsSchoolofMedicine

ToSasha,

CONTENTS

PREFACE:NOTALLBACKPAINISALIKE

INTRODUCTION:HOWTOUSETHISBOOK

1|DiagnoseandRelieveYourBackPain

CHAPTER1Muscle-RelatedBackPainCHAPTER2DiscHerniation(SlippedDisc)CHAPTER3TornandPainfulDiscsCHAPTER4SciaticandOtherNerveCompresasionsCHAPTER5Sacroiliac(SI)JointDysfunctionCHAPTER6FacetDiseaseCHAPTER7SpinalInstability(Spondylolisthesis)CHAPTER8VertebralFracture:Emergency!CHAPTER9SyndromesofSpinalCordCompression:Emergency!CHAPTER10ScoliosisCHAPTER11SpinalStenosisCHAPTER12Coccydynia

2|GettingBetter,GettingStronger

CHAPTER13FirstStepsforAcuteBackPainCHAPTER14EarlyExercisesforManagingBackPainCHAPTER15ShapingYourOwnRecoveryCHAPTER16ErgonomicsCHAPTER17BetterNights,BetterDays:SleepandIntimacyCHAPTER18MassageandAcupunctureforBackPain

CHAPTER19MeditationandMind/BodyTherapiesforPainControlCHAPTER 20 Water and Inversion Therapies for Strengthening andConditioningCHAPTER21EatingRighttoPreventPainandPromoteRecoveryCHAPTER22YourBack:AGuidedTour

ACKNOWLEDGEMENTS

ABOUTTHEAUTHOR

IMAGECREDITS

INDEX

Preface:NotAllBackPainIsAlike

It is obvious tomost people that backpain doesn’t happen to every person inexactlythesameway.Yetmuchoftoday’smedicalliteraturefailstoguidebackpain sufferers and the clinicians who care for them through the manifoldchallengesofrecoveringfromacutebackinjuryandchronicbackpain.Themostworrisome clinical reports lump all back pain together, urging physicians toattribute a patient’s “complaints” to generic low back pain unless certain “redflags” are identified. Some reports unwisely assume that all conservativetreatmentsare thesameandshouldbeequallypotentagainstall formsofbackpain.Itseemsthatbackpainresearchisdominatedbythosewhohaveminimaldirectcontactwithpeopleactuallysufferingfrombackpain.Thistreat-all-back-pain-alike approach deeply disregards the need to apply the best of modernmedicinetoalleviatetheprofoundsufferingcausedbyspecificbackproblems.

Theforcesdrivingtheoversimplificationofbackpaincarearesystem-wide.There are pressures from businesses to minimize back-related absences fromwork;fromambitiousofficemanagers toreducethedurationofmedicalvisits;from pharmaceutical companies to expand the profits from pain-relievingmedications;andfrominsurerswhomustotherwisereimburseworkersfortimespentrecoveringfrominjury.Theoverlappinginterestsofthesevariousgroupshavefosteredthecreationof“educationalsymposia.”Thesesymposiapromoteasingle perspective on back-injury science showcasing highly-paid expertswhoperpetuate the notion that the most back pain episodes cannot be preciselydiagnosed. They tell the clinicians in attendance that attempting to do so is awaste of valuable clinical effort. The simplistic ideas that pain killers are theonlyproventreatment,andthattheonlynon-pharmacologicalinterventionthatasensibledoctorcanmakeistourgepatientstocontinueactivityatnormallevelsare the take-home messages. To make matters worse, by oversimplifying theeffectsofgenderonpainprocessing,theseeducationalsymposiaoftenreinforcestereotypesthatlimitwomen’saccesstocare.

It is clear from my clinical practice, personal experience, and speaking topeoplearoundthecountrythatthisapproachtobackcarefailstheRealityTest:Insisting thatallbackpain is thesame justdoesn’tmakesense.Thespine isacomplexstructure; infact, it isabio-engineeringmiracle.Composedofbones,ligaments,nerves,andmusclesallworkingtogether,thespineallowsustostandupright with the advantages of speedy locomotion and sophisticated handfunctions.Wewouldnevergiveupthebenefitsweenjoyfromwalkingupright.And so, each of usmust come to terms with the consequences of an upright

posture. Routine exercise and diet are not enough; people need enhancedknowledgeoftheirbacksandadeeperunderstandingofhowtobuildareservoirofstrengthandattainfreedomfrompain-imposedlimitations.

Thisbookwascreatedasanopenguideforpeoplecurrentlysufferingfrombackpaindue tonon-operableback injury.Thepurposewas tobring togethertop science on back pain with both bona fide and evolving approaches torecovering from back injury. Despite hitting some serious notes here in theintroduction,thebookitselfmaintainsafriendly,optimistictone.Thisisbecauseweknowthatmaintainingapositive,proactivestancereallydoespromotebetterhealthoutcomes.Remindyourselfdailythattheglassisnotonly“halffull,”itishalffullofawonderfullife-givingliquidwithdozensofhealthbenefits.Drinkupandgoget another! It ismyvision that in reading thisbook,youwill findhelpandawealthofusefulinformation.Youwillreinforceexistinggoodhabitsand get inspired to try new back-healthy activities. This book is the best ofeverything that I could know, learn, and find to guide people in getting betterfrombackinjury.Itisheretospeedyourjourneytowardalongandhappylifewithoutbackpain.

Introduction:HowtoUseThisBook

Because your back is central to everything you do, sitting, standing,walking,and even lying down can be problematicwhen pain strikes. If you have backpainwhensitting,itislikelythatworkingatadesk,eatingatadinnertable,anddrivingarenexttoimpossible.Havingbackpainwhenstandingorwalkingputsparticipationineverydaylifeoutofreach.Andbackpainwhenlyingdownisaprescription for insomniawithout the aidof powerful drugs.Ring a bell?Youmaybeexperiencingproblemssimilar to theseorhavean importantperson inyourlifewhosuffersfrombackpain.Whateveryourreasonforpurchasingthisbook,youareintherightplace.Thisbookiswrittentoguideyou,yourfamily,andyourfriendsonthejourneytoahealthyback.Take Back Your Back is a synthesis of tested methods for improving back

pain.Thedifficultpartof this therapy is that it requiresan investmentof timeandenergy,byyouaswellasyoursupportteam:family,friends,doctors,nurses,physical therapists, and co-workers. Knowing what to do when back pain isseverewillsavehoursoffrustrationanddisappointment.Evenwhenthereisnoquick fix, many things can be done to alleviate acute back pain and speed areturntofunction.IsometimesexplainthesemethodstopatientsusingthenameAggressiveConservativeTherapy,but inreality it ismostfundamentallyaboutmaking peace with your back. Repairing, restoring, nurturing, cultivating,strengthening,building,andultimatelyhealthyenjoymentofthebackareallpartofthisapproach.

In Part I, I describe the major causes of back pain, from muscle-relatedproblemstococcydynia.Manystructuresinthebackcanbeinjuredandresultinpain. There are 12 thoracic vertebrae, 5 lumbar vertebrae, sacral bones, atailboneorcoccyx,over20discs,dozensoffacetjoints,scoresofligaments,44nerve roots,manymuscles, and hundreds of nerve branches.When several ofthesestructuresareinjuredatthesametime,asoftenhappenswithatraumatotheback, thepain isamplified.So it’softenverydifficult to identify theexactsourceofaproblem.Thisbookwillhelpyouidentifyyourpainandworkwithyourdoctortoreceivebettercare.

Tomakethebooktrulyaccessible,Ihaveputthediagnosisandprescriptionsfor each condition first, followed by information about diagnostic tests anddetailedexplanations.TakeBackYourBack isa referencebook. Idon’texpectyou to read everypage!Lookat the tableof contents to find thekindofpainyou’reexperiencing,andgodirectlytothatchapter.PartIIcontainsinformationaboutpreventingandtreatingbackpain,withchaptersonexercise,ergonomics,

andnutrition.

IT’SVITALTOKEEPYOUROWNRECORDS

Iwouldliketoemphasizetheimportanceofkeepingrecordsaboutyourhealthandbackproblemthatyouexperience.Oursocietyismobileanddynamic;mostAmericans live away from their hometowns. In most places, the retention of“permanent”medicalrecords iscontrolledbylaw,andafteracertainperiodofinactivity,yourdoctormaysimplydiscardtherecordspertainingtoyourmedicalcondition.Ifthishappens,youwon’tbeabletogobackandgetyouroldrecords;they will no longer exist. Here’s why keeping personalmedical records is soimportant:•Communicatingwithnewprovidersaboutyourproblemwillbeeasier•Havinganaccuratemedicalhistorycanpreventmedicalerrors•Reviewingrecordsisagreatwaytolearnmoreaboutyourcondition

Isuggestmakingshort-andlong-termgoalsforyourrecordkeeping:

SHORT-TERM GOAL: Make a one-page health summary that lists yourdoctors, medicines, and health conditions. Include a short timeline of eventsrelatingtoyourmajorhealthproblems.Ifyourbackpainarisesfromaspecificinjury,notethatdateandothersrelevanttoyourtreatmentcourse.Keepthisone-page summaryup to date, carry itwith you at all times, andmake a copy foryourdoctor and foryourcloseones.Also,make sure that any imagesofyourbackarekeptwithyourrecords.

LONG-TERM GOAL: Make and maintain a health file that includes notesfromdoctorvisits, lab reports, imaging reports, imagesondiscor film,apaincalendarorsymptomdiary,andnotesfromphysicaltherapy.It’sagoodideatokeepyourfileordiaryorganizedbyrecordtype,andarrangeitinchronologicalfashion. Also, because X-rays, MRIs, and other imaging representations arepicturesofasinglepointintime,makesureyoukeepcopiesofanyimagestakenofyourbackinchronologicalfiles.

Youareyourownbestadvocateforbetterhealthcare.Readontoidentifyandrelieve your back pain, and keep those records handy for recurring problems.Yourbackiscentral toeverythingyoudo,andkeepingithealthyandstrongisfundamentaltolivingwell.

PART1

DiagnoseandRelieveYourBackPain

CHAPTER1

Muscle-RelatedBackPain

Muscleinjuryandoveruseisoftentheculprit.

Reduceinflammationandshiftactivitiestoavoidre-injury.

theDIAGNOSIS

>Doyouhavepainlocatedononesideofthespine?>Doesyourpainstay focused in thebackwithout radiating into the legoranotherpartofthebody?

Pain that is focusedonone sideof thebackanddoesnot radiate into the leg,groin, or torso is often due tomuscle injury.Most typically, this type of backpainwillfollowaspecificstrainorstresstothemuscle.It’softensimplyacaseof “over-doing it,” whether from lifting something a little too heavy, twistingaroundwiththebodyforsomethingjustoutofreach,orbeingoverlyaggressivewithweekendsports.Thelargemusclesoneithersideofthespinearepronetoathleticinjury,whilethesmallermusclesclosertothespinecanbedamagedbytwistingmovements.

Backmuscle pain often has a burning quality, but when intense, it can besharplypainfulandabruptlylimitnormalmovement.Onewaytotestformusclepain isbyfirstgetting intoacomfortableposition.Now,gentlystart to initiatemovement in adirection thatyouknowwillbringoutyourbackpain. Ifyourbackpainislocatedoffcenter(notdirectlyoverthespine)anddoesnotradiatedowntheleg,intothegroin,oraroundtothefrontofthebody,youmayhaveabackmuscleinjury,andthisisthechapterforyou.

Ifthisdoesnotdescribeyourbackpain,consideralternativesbyreadingthenext chapter on radiating back pain and consulting a qualified healthprofessional.

thePRESCRIPTION

Warning!KnowWhentoSeeaDoctorBackpainduetoamuscleinjurymay respondwell to treatment at home, but if the problem persists formore than a few days or is severe enough that you are worried,professional assessment is needed. The following red flags mean youshouldseekimmediatemedicalattention:

•“Major”trauma(caraccident;fallfromaheight)

•Agelessthan20orgreaterthan50

•Historyofcancer

•Fever,chills,orweightloss

•Recentbacterialinfection

•Drugabuse

•Immunosuppression

•Painthatisworsewhenlyingdown

•Severenighttimepain

•Newbladderdysfunction(incontinenceofurine)

•Numbnessoverthegenitals

•Majororprogressiveweaknessinoneorbothlegs

•Minortrauma,inthesettingoflowbonedensityorosteoporosis1,2

Topromotehealingofyourinjuredmuscles,you’llneedtoreduceinflammationand prevent re-injury. Once inflammation and the potential for re-injury areundercontrol,yourmuscleswillstophurtingsoterriblyandhealingwillbegin.

Ifyouhaveabackmuscleinjury(sometimesreferredtoasbackmusclestrain):•Yourdoctormayrecommendphysicaltherapy,especiallyifitseemsthatyourbackstrainisnotgettingbetteronitsownoriftheproblemkeepsoccurring.

•Yourdoctormayencourageyoutostayactiveafteracoupleofdaysoftakingiteasy.

•Yourdoctorwilllikelyencourageyoutocontinueworkingandmayprovidearecommendationforpainmedicationtogetyouthroughthisepisodeofpain.

Lifestylechangesforyourbackaregoingtobeessentialinplottingyourcoursetowardpermanentrecoveryfromabackmuscleinjuryandpain.You’llneedtofocusonstretching,strengthening,andsymmetry.Butfirst,you’vegottogetthepainundercontrol.Icallthis“backmuscleFirstAid,”andoutlinetheprograminthischapter.

Medicationsarealsopartofgettingbetteraftermuscleinjury.Yourhealthcareprovidermay advise you about particularmedications andwill want to knowwhatyou’vebeentakingathome.Makesuretofollowrecommendedguidelinesfor taking medications and never, ever take someone else’s prescription painmedicine.

TheTreatment

Reducinginflammationisessentialwhenyouhaveasudden,severemusclepainproblem. But if you are having persistent back pain that your doctor says iscausedbymuscleproblems,chancesarethatyouarechronicallyre-injuringyourbackmuscles.Thefollowingstrategieswillbegintobreakthispainfulcycle.

FirstAidforAcuteMuscleStrainRest

Ice

Compression

Elevation

Medication

Phase1:HowDoYouSpellRelief?RICE-M

ThebesttherapiesforacutemusclestrainareRest,Ice,Compression,Elevation,and(anti-inflammatory)Medication.Thesetreatments,bestusedincombination,are remembered with the acronym RICE-M. Picture a young athlete with amusclestrain,sittingonatableinthetreatmentroom(Rest),icepackboundinplace with an elastic bandage (Ice and Compression), with the leg or armproppeduponablock(Elevation),beinginstructedbythetrainertotakesomefoodbeforeeachdoseofibuprofentablets(Medication).Allofthesetreatmentcomponentsplayanimportantroleinpreventingaworseningoftheinjuryandspeedingthereturntofunction.

RISFORREST

Restisaspecialchallengewhenthebackisinvolved.Wedependheavilyonourbacks for all parts of everyday life. Sitting, walking, standing, lifting thegroceries,bendingdowntopickupachildorpet;thethingswedorangefrommildlystressfulonthebacktoextremelydemanding.Oneoftheworstoffendersforbackstressishousework,thatburdenofdailylifethatweighsuponthoseofusnotyetadmittedtothejetset.Somehouseworkisundoubtedlybenignfortheback. Even though it gets a bad rap, cleaning windows can offer healthyopportunitiesforstretchingandstrengtheningthearmmusclesandupperback.

In the acute phase, rest has a very particularmeaning: putting themusclesintoapositionofneitherstretchnorcontraction,anddeferringanyactivitiesthatrequire themuscle towork. If themuscle is acutely strainedandverypainful,this couldmean a dayor two in bed, either proppeduponpillows in a semi-recumbentpositionorlyingflat,whicheverismostcomfortable.

However, and this is an important caveat—a muscle placed at rest willatrophy,perhapsbyasmuchas10percentwitha singledayofcomplete rest.Thiscanleadtoadisastrousstateofprofoundweaknessifrestingiscontinuedpast the amount necessary. So resting a muscle may be a necessary strategywhen the muscle is suddenly injured, but cannot be a successful strategy forlong-termmanagementofpainthatlastsmorethanafewdays.

AvoidTheseHouseholdTasksDuringRecovery•Vacuuming

•Mopping

•Cleaningbathtubs

•Shoveling(snow,dirt)

Warning!ReprogrammingMaybeNecessaryUnhealthypatternsofbackusearestrongly associated with persistent back pain. For most people, backmuscle injury is caused by a combination of back-stressing activitiestogetherwithinactivityinthefirstplace.Learninghowtohaveahealthybackisimportantforpreventingre-injury.Suchactivityreprogrammingisusuallybestdirectedbyaqualifiedphysicaltherapist.

Properposture at a computer.Sit uprightor slightlybackdirectly in frontofyourworkstation to reducebackmusclestrain.

Howtoresolvetheproblemofchronicmusclestrain?P-O-S-T-U-R-E.Sorrytosayit,butpositioningandergonomics(seeChapter16)playamajor role inpreventing chronicback strain and injury.Sittingwith theback supported, thefeetsquarelyontheground,andtrunkfacingforwardisfundamentallyimportantfor reducing chronic muscle strain. Likewise, proper lifting technique, re-learninghowtorisefromabed,andre-engineeringhowyouaccomplishmanytasksofdailylivingwillcontributetoyourlongtermsuccessinavoidingacuteandchronicbackmusclestrain.

Resting forbackpaingot abad reputationbecauseyears agopatientswereputtobedrestforprolongedperiodsoftimeafterabackinjury.Itturnedoutthatprolongedbedrestwasnotveryhelpfulforbackpainandcouldinfactworsenthelikelihoodofchronicdisability.Unfortunately,thependulumhasnowswungvery far in the opposite direction; many doctors have been trained to utterlyrejectrestasatherapeuticmodality.Thisisnotcorrecteither,asresthasaplaceinthetreatmentofcertaintypesofbackpain.Therealchallengeisrecognizingwhenandwherebackrestisappropriate.

Inthecaseofmusclestrain,theperiodofrestvarieswiththeseverityoftheinjury.Inmostcases,twotothreedaysofrestisallthatisneeded.Thisisnottosay that with severe muscle strain, longer periods of rest aren’t needed. Aseverely strainedor tornmusclewill takeweeks to recover.Most of the time,severemusclestrainoccurswhenthereisaclearprecipitantsuchasapreviousinjury, thekindsof strains thatare seen incompetitiveathletic settings. Ifyouhavenotbeen training fora triathlonorengaged invigorousathleticsandyoufindthatyourbackstillhurtsaftertwoorthreedaysofrestingwhatyouthinkisamusclestrain,youshouldseekamedicalopinion.

ICEISMORETHANNICE

Iceisthebestfriendwehaveforacuteinjury.Inthecaseofmanagingbackpain,iceisatwo-for-onespecial:itcontrolsinflammationandblockspainsignaling.Whenusing ice, it’sbest to limit anyone treatmentperiod to20minutes; thiswill reduce the potential for damage to the skin and soft tissues.When backmusclestrainfirsthappens,itwillbenecessarytoicethemuscleseveraltimesinaday.Fivetoseventreatmentsof20minuteseacharenotunusual.

The sooner you can apply the ice after injury, the better. Getting ice on amusclestrain“inthefield”isideal,buticeisbeneficialatanypointwithinthefirst24to48hoursafteramusclestraininjury.Everyoneshouldhaveanicygel-packinthefreezerreadytogoforoccasionalhouseholdbumpsandbruises,butifyouhavebackpainandmusclestrain,asupplyof twoicepacksmeans that

onecanbeinusewhiletheotheriscoolingbackdown.Ice can be used by many people even after the 48-hour time window has

passed.The inflammatory response toan injurysuchasmuscle strain is reallysetinmotionduringthefirstseveralhours,butishardlycompleteby48hours.In fact, if muscle fibers are actually damaged and the immune system isactivatedinresponse,theinflammatorycellsarestillfloodingintothedamagedarea at 48 hours, and will probably remain present in markedly increasednumbersforaweekormore.Somepeoplefindthatoncethefirst48hoursafteraninjuryhavepassedthatwarmcompressesaremoreeffective.

Coldtherapyhelpsbyblockingthesignalbeforeitgetstothebrain(gating)

Warning!Insulate the Ice Ice should be applied to the body wrapped in a lightcloth or dish towel. It’s best to use a moldable gel pack to get themaximum contact with the body surface, but if you use ice cubes, puttheminanicepackwithjustenoughcoldwatersothatwhentheicepackisonthebody,thewaterishelpingtodeliverthecoldfromtheice.

It is important tonote that if the ice is toocold, thecoldof the icewillitselfbepainfulandpossiblycauseharm.Thesolutionforthisistowrapanotherlayeroflightclotharoundtheicepack;t-shirtsanddishtowelsaregreatforthispurpose.Alightlywrappedicepackcanbeinconspicuouslytuckedintoawaistband.Thereareevenicepacksthatstraptothebackofa chairwith elastic bands.Car trips are notorious for exacerbatingbackpain; next time you take a trip, take along an icepack and see if thatdoesn’thelp.

Drug-FreePainkillerManyofmypatientsareinitiallyskepticalaboutthebenefitsofice.However,formuscleandjoint-relatedpain,iceisasafe,effectivetreatmentthatrelievespain and reduces inflammation. How does ice relieve pain?Acutely, the ice(whenwrapped in a light cloth) cools the skin to the point of activating the“cool-cold” receptors. These cool-cold receptors are located on nerves thatsendsignalsfairlyrapidlytothespinalcord.Whenthecool-coldsignalsreachthe spinal cord, they essentially close the gate on the slower-traveling painsignals. Thus, the cooling of a body area makes it more difficult for painsignals topenetrate into thespinalcord,where theywouldgainaccess to thepathwaysleadingtothebrainandourconsciousawarenessofpain.

COMPRESSIONCANHELP

TheCinRICE-Mstandsforcompression.Compressionhelpsreducetheamountofswellingthatoccursafteraninjurysuchasastrain.Inaddition,compressionhelps to immobilize the injured structure and allow the repair process to takeplacewithoutadditionalinjuryincurredbyexcessivemovement.

Swelling is a normal consequence of injury, part of the inflammatoryresponse. Swelling occurs in part because some of the injury response signalsleadtheneighboringbloodvesselstobecomeleaky,almostlikeasoakerhoseinthe garden. The fluid component of blood can then exit the vessels (plasmaextravasation)andenter thesurroundingtissues.Swelling ispotentiallyhelpfulbecauseitcanleadtoastateofrelativeimmobilization.Forexample,thinkhowhard it can be to bend a finger that’s been swollen by a bee-sting. But whileimmobilization is generally valuable after some injuries, the swelling is oftenpainful.Thus,preventingexcessiveswellingissometimesacriticalcomponentofcontrollingpain.Excessiveswellingcanalsoimpedethebloodsupplytothearea andmay disrupt the normal architecture of the injured tissues. For backmuscles,compressioncanbeappliedwithafoldedovertowelpressedupagainstthepainfulpart.

ELEVATIONINBACKMUSCLEINJURY

TheEinRICE-Misforelevation.Itsoundssilly,doesn’tit,topicturesomeonetrying to elevate their back after a muscle strain injury. In fact, if you can’televateyourinjuredbackmusclewithoutstretching,don’ttry.Forthefirstfewdays,thebackneedstorest,andstretchingitwouldbecountertothatprimaryneed.Perhaps thebestyoucanaccomplish is to avoidputting the injuredpartlowerthantherestofthebodyforthefirstperiodafterthemusclestrain.

Thebestwayformostpeopletorestthespineistoliewiththeirbacksonthefloor and the legs propped up on a chair or sofa with the knees bent at 90degrees.Whenyouhaveacutelystrainedaspecificbackmuscle,lyingmaynotbethebestposition.Itmaybenecessarytoadoptaside-lyingposition,withthehipsandkneesbenttoreducetensiononthespine.Yourbestbetmaybeside-lyingontheuninjuredside.Rememberthatwithside-lying,manypeoplefinditnecessary toplaceapillowbetween theknees to reduceexcess tensionon thehips.Withsidelying,youcanputtheinjuredsideupsoitiselevatedmorethanhalfofthebody.Ifyourbackisotherwisehealthy,itmaybepossibleforyoutocomfortably lie on your stomach, perhaps with a pillow or two under yourabdomenforsupport.Inthiscase,gorightaheadandlieonthestomachwiththebackfullyelevated.

MEDICATIONSSPEEDRECOVERY

The bigM in RICE-M is formedication. In the context ofmuscle strain, themedicationsofchoicearethenonsteroidalanti-inflammatorydrugs,orNSAIDs.You have probably taken NSAIDs before. The most commonly available isibuprofen,whichismarketedunderthetradenamesAdvilandMotrin.Ibuprofenisoneof a classofmedications thatnotonly interferewithpain signalingbutalsointerrupttheinflammatorycascadethatfollowsaninjury.OthermedicationsintheNSAIDfamilyavailableoverthecounterincludenaproxen,soldasAleveor Naprosyn. There are also stronger NSAIDs available by prescription,includinghigherstrengthtabletsofibuprofen.

Other medications against pain are generally lacking in anti-inflammatorybenefits. Acetaminophen, for example, is quite effective against mild-to-moderatepain, but doesn’t provide the anti-inflammatorybenefits ofNSAIDs.Thereissomeevidencetosuggestthatinsomesettings,morphine,theprimaryopioid,isactuallypro-inflammatory,whichshouldnotdiscourageitsappropriateuse, butmeans itwould not be effective in reducing inflammation, oneof thegoalsofearlytreatmentformusclestrain.

MULTIMODALTREATMENTWORKSBEST

The limitations of NSAIDs are partly why it is so important to implement acomprehensive treatment strategy using all the parts of theRICE-M approachandnotjusttakesomepillsandsoldieron.Itseemsobviousbut,ifyouthinkthatpillswill solve all your problems, youwill probablywind up inmore troublethanyou imaginedpossible.Thatsaid, ifyouhaveamusclestrainand ifyourdoctororbackcarespecialistsaysit’sokayforyoutotakeNSAIDs,thenthesecanbeanessentialpartofyourresponsetobackmusclestrain.Youmayneedtotakethemeverydayforthefirstfewdaysafterinjury,butifyoutakeNSAIDsformore than three days, you should discuss it with a healthcare provider tomakesurethatrisksandbenefitsarebeingproperlybalanced.

Warning!GIsideeffectsThetremendoususefulnessofNSAIDsislimitedbytheirsideeffects,themosttroublingofwhichistheheavytollthesemedicineshaveonthestomachandGItract.AlloftheNSAIDsincreasethechancesof developing gastric bleeding; statistics suggest that perhaps 30,000peopleayearhaveserioushealthproblemsasaresultofGIbleedingaftertakingNSAIDs.Thesemedicationscanalsobehardonthekidneys,andchronicuse formore than a short period shouldbe implementedon theadviceofaphysicianwithsoundknowledgeofhowtominimizetherisks(takingthemedicationwithsomefood)andhowtomonitorforsignsoftrouble (blood or other changes in the bowel movements, increases inbloodpressure).

Phase2:ExercisesforRestoringandStrengtheningtheBack

Thereisnoonebestexerciseforyourback.3Twotypesofexerciseareessentialwhenyouwanttoincreaseyourback’sresistancetoinjury:thosethatstrengthenthe abdominals andothers that strengthen the intrinsicbackmuscles.Thebestexercisesareabdominalcrunchesand,forlackofabetterterm,backcrunches.

What’sNew:BacktoBasicPainMedsTroubling setbacks have followed new discoveries in more selective anti-inflammatory drugs. Referred to as the COX-2 inhibitors because of theirabilitytomoreselectivelyinhibitCyclooxygenase-2(asopposedtoinhibitingbothCOX-1andCOX-2), thesedrugswerehighlyeffective formanypeoplewith chronic inflammatory pain conditions such as osteoarthritis anddegenerative joint disease. For some, the effects of these medications werenothingshortofmiraculous, restoring levelsof functionandactivity thathadseemed permanently beyond reach. Therewas even evidence to suggest thatpeople might do better after surgery if these medicines were given justbeforehand.

Unfortunately,at least some themedicines in thisgroup increased the riskofheartattack,ariskthatnoonewaswillingtoaccept.Aftermanydeaths,ahugepublicoutcry,anduntoldsumsofmoneyspent,someofthesemedicineshavebeenwithdrawnfromthemarketandtheuseofothers,includingCelebrex,hasbecomemuchmorelimitedinscope.Thebottomlineisthatformostpeople,amoderatedoseof ibuprofen takenwith food is agenerally safe and effectivechoicefortreatingbackmusclestrain.

Theability todo these exercises is determinedbyyouroverall backhealth. Ifyouhaverecentlyhadabackinjury,whetherfromanaccidentoranothermoreminorincident,beingabletodoabdominalcrunchesandbackcrunchesmaybea long-term treatment goal rather than a currently realistic expectation.Checkwith your physical therapist about how to adapt these exercises to yourlimitations.

ABDOMINALCRUNCHES

Abdominalcrunchesareabeautifulthing,asmundaneastheysometimesseem.Thehealthbenefitsof thisexercisearemultipleandessential forahappy life:abdominal cruncheswill not only strengthen your back butwill also improveposture and trim the waistline. Improved posture will greatly enhance yourresistancetobackinjury,andatrimwaistlinehasbeenassociatedwithreducedlikelihood of serious heart disease!Once your back is on themend from anyacuteproblems,abdominalcrunchesshouldbeapartofyourdailyroutine.Mydad,alifelonghealthandfitnessaficionadoandmentor,hasbeenknowntodo400 abdominal crunches a day, three times a week. I usually scrape by witharound30aday,andevenafewisbetterthannone.

Inthesimplestform,theabdominalcrunchconsistsoflyingonthebackwiththehipsandkneesbent.Thefeetshouldbeflatonthefloor.Holdingthepelvisinneutralposition, theabdominalmusclesaregradually tightenedbringingthehead up and the shoulders up off the floor. The muscles are then relaxedgraduallyandtheheadandshoulders loweredbackto thefloor.Themiddleofthe back should not rise up far from the floor, as doing a full sit-up is reallytaxingonthelowerback.

There are some differences of opinion about what to do with the arms inabdominalcrunches.Somepeopleleavethearmsattheside,whileotherscrossthemacrossthechest,andothersplacethehandsbehindthehead.Itisreallyamatter of personal preference, and the most important point is to minimizewhateverbarriersmightexistforsomeonedoingthisexercise.Ifyoupreferthehandsatthesides,thenbyallmeans,keepthemthere.Ifyouwanttocrossyourarmsacrossyourchest, thisprobablyaddstothechallenge.Ifyoudochosetoplacethehandsbehindthehead,takecarenottoapplypressuretothehead,asthiswillstraintheneck.Neverusethehandstopulltheheadforward.

Onceyouhavea routineofperforming several abdominal crunchesat leastthree times a week, you can begin to try some variations by doing obliquecrunches or by starting from a flat position and bringing the legs up togetherwith the head and shoulders.You can evendooblique cruncheswith the bent

elbowsreachingacrosstomeettheoppositeknee,butthat’sgettingreallyfancy.Ifyourbackhasbeeninjured,youwillprobablyhavetostartwithabasicpelvictiltseriesandbuilduptothebasicabdominalcrunch.Youmayfindthatamatorpaddedsurfaceisnecessaryforyoutobecomfortabledoingcrunches.Themostessential point is for you to do whatever it takes to get the basic abdominalcrunchesintoyoureverydayroutine.

BACKCRUNCHES

BeforePilates,manyhealthypeoplewerenotpayingenoughattention to theircore muscles. Now, there are lots of really cool exercises you can do tostrengthenyourcoreandincreaseyourresistancetobackmusclestrain.Manyofthese are highlighted in Chapter 14. If you ask me which exercise would Irecommend, itwouldbewhat isknown inYogaas themodified locust. In themidwest, this might be called the “Mayo exercise.” Lying on your abdomen,placeapillowunderyourstomach,sothatyoucanliecomfortably.Stretchyourarmsoutonthefloorextendingpastyourheadandpointyourtoessothatyourlegsareflatontheflooralso.Contractingthebackmuscles,raiseyourarmsandlegs off the floor at the same time, and raise your head up aswell.Hold thispositionforaseveralsecondsandthenrelaxgraduallybackdownto thefloor.Repeatthisexerciseseveraltimes,graduallyincreasingtheamountoftimethatyouholdthebackcrunch.

Manyadaptationsofthebackcrunchhavebeendevelopedtoreconditionthebackafteran injury. Ifyouarerecoveringfromanacuteepisodeofbackpain,talkabout thiswithyourdoctororphysical therapistandobtain theirguidanceon how you can progress toward improved strength in the back extensormuscles. Some variations of the exercise include raising one arm and theopposite leg, while others progress by first raising the upper body with thesupportofthearms.Thebackcrunchisabeautifulandprofoundlyempoweringexercisetodo;itshouldbeapartofthosethingsyoudojustforyourselfeveryday. Strengthening the back extensors is an essential part of increasing yourback’sresistancetomusclestrainandotherinjury.

Warning!RecoverFullyBeforeDoingBackCrunchesDoing thebackcrunch isonlypossibleonceyouhavefullyrecoveredfromabackinjuryanditisnot to be performed during the first week after an acute back musclestrain. The acutely strained back muscle should be rested, and thisexerciseisnotcompatiblewithmuscleresting.

Abackcrunch

Phase3:SixStepstoPreventChronicBackMuscleStrain

1.USEPROPERPOSTURE

Properpostureisvitallyimportantwhensittingandwhenlifting.Youwillreadlaterinthischapterabouttheconsequencesofsustainingaflexedspinepositionformore than a couple ofminutes: ligament fatigue leading tomuscle spasmleading to pain andmoremaladaptive postures. Sitting, standing, and bendingwith proper posture are essential for staying free frombackmuscle problems.(See Chapter 16 on Ergonomics to learn more about optimizing your backhealth.)

2.AVOIDTWISTINGMOTIONSANDPAYATTENTIONTOSYMMETRY

Oneof thefunctionsof thebackis tosupport theupperbody.Thismeansthatevenwhenyouarenotdoinganylifting, thebackiscarryingaloadofseveraldozenpounds.Forthisreason,twistinginafunnywaycanplaceexcessivestrainonsomeof thesmallerbackmuscles. Ifyouhavetodoa taskroutinelyorformanyhours,thinkabouthowyoucarryoutthattaskandtrytoadaptthetasktoyour body’s position. If you are loading groceries, think about how you aretwistingandturning.Ifyouareworkingatacomputerkeyboard,focusonsittingstraight forward; arrangeyourworkspace that you’re not twisting to reach thekeyboardorturningtheheadtoseethecomputerscreenfully.

3.STRETCHROUTINELY

Asemphasizedinthischapterandthroughoutthebook,stretchingisessentialtomaintainingbackhealth.Forthemuscles,stretchingmustbeavitalpartofeveryday’sroutine.Musclesthatareusedorrequiredtostayinacontractedstateforprolongedperiodseventuallyshorten toaccommodate thatposition.Whenyouchange position, those muscles may not stretch sufficiently to accommodateproper spinal alignment in the new position. Stretching daily will allow themusclestoworkcooperativelyandwillreducestrainonotherstructuressuchasdiscs and joints in the back. For most people, hamstring, calf, and iliopsoas(innerhip)musclesmustbestretchedseveraltimesaweektomaintainaproperstateofflexibilityandastablestandingposture.

4.LOSEPOUNDSIFYOU’REOVERWEIGHT

Carrying excess weight is a strain on the back that never goes away. Forsomeonewhoisoverweight,everystepplacesadditionalstresson themusclesandotherbackstructures.Ifyouareoverweight,gettingyourlifebackontrack

must include changing your diet to reduce your weight. There are manyunprovenapproachestolosingweightbuttheuniversaltruthisthatweightlossmost consistently occurs when intake is reduced and activity is increased.Increasing aerobic activity may be very difficult when you are experiencingacutebackpain.Makesure toeliminate the junkfoodsthatdon’tcontribute toyou getting vital nutrients and fiber. Increasing your consumption of freshvegetables isusuallyagreatfirststep.Freshfruitsare important too,butsomepeoplewillloaduponfreshfruittotheexclusionofotherpartsoftheirdiet,andthisisnotasuccessfulweight-lossstrategy.

5.CHANGEPOSITIONFREQUENTLY

Ifyou’resittingforseveralhourstodoatask,youshouldgetupfor10minutesofeveryhour.Butevenasyouaresitting for theother50minutes,makesureyou are shifting from time to time, stretching a little in place and giving themuscles a little inspiration. If you are standing for long periods,make sure toshiftyourweightfromsidetoside,leanagainstawallforalittlebitordosomequadstretchesinplace.Themessagehereisthatmusclesneedtomoveatleastalittletoavoidprogressivestiffness,andintheworstcase,atrophy.

6.LEARNABOUTTRIGGERPOINTSANDTRYSOMEACUPRESSURE

Thebackmusclesarepronetomusclespasms.Triggerpointapproachescanbyveryusefulforunderstandingwhycertainpartsofthebackhavethemostpain.Sometimes the answers are surprising. Learning about trigger pointswill helpyou identify certain muscles of the back and how these muscles respond tostrain,stress,andpain.Youcanthenusethisknowledgetomassagethetriggerpointthatamuscleisrespondingwith.Evenifthatmuscleisnottherootcauseoftheproblem,reducingmuscletriggerpointswillhelpcontroltheoverallpainburden thatyouorsomeoneyou love isexperiencingwithbackpain.To learnmoreabouttriggerpoints,readon!

TheThreeS’sofBackMuscleHealthStretching–neededtomaintainflexibility

Strengthening–allelsedependsonthis

Symmetry–thekeytostayingpain-free

WhatAreTriggerPoints?

Trigger points are shrouded in some controversy. In past years, trigger pointswerepoorlyacceptedbyskepticalcliniciansandresearchers.Atthesametime,theyhavebeenwidely recognizedby thosewhoperformmassageandmanualtherapies, and the pendulum is swinging toward awider acknowledgement oftriggerpointsasanimportantabnormalityinmusclefunction.Tosomedegree,the trigger point has eluded laboratory study becausemuscle is dynamic, andtriggerpointsespeciallyso.

Nonetheless, triggerpointswerecharacterizedindetailbyJanetTravellandDavid Simons.4 Travell served as the White House physician during theKennedyadministration andover the courseof severaldecades,made seminalcontributionstotheclinicalscienceofmusculoskeletalpain.Simons,originallyan aerospace physician, brought scientific rigor to the study of trigger points,workingcloselywithTravellinthewritingofthetheirhighlyinfluentialmedicaltextontriggerpoints.RecentstudiesfromtheNIHhaveaddedscientificsupportfor the presence of pro-inflammatorymolecules and enhanced pain signals inactive triggerpoints. In short, the triggerpoint is aplace in themuscle that isholding an abnormally sustained contraction.This part of themuscle becomespainfultotargetedpressureandsometimesispalpableasafirmareawithinthemorepliablemassofthesurroundingmuscle.

HOWARETRIGGERPOINTSTREATED?

Triggerpointstreatedwithaseriesoftherapeuticinterventionsthatrangefromacupressuremassagetechniquestocontrolledstretchingtoinjectionswithlocalanestheticsor saline.Theapproach to triggerpoint therapywilldependon theexperience and inclinations of the clinical specialist you are seeing. Althoughtrigger points can be successfully treated by highly motivated patientsthemselvesbyapplyingfocusedpressureonthemuscle,physicaltherapistsoftenuse a combination of approaches including trigger point massage, electricalstimulation of muscle, and “spray and stretch” techniques. In the “spray andstretch” approach, a cooling spray is applied to the skinoverlying aparticulartrigger point, and then themuscle is rapidly stretched in a controlledmanner.Trigger point injections are usually performed by certified pain specialists orotherswithspecialtraininginthismethodology.Theycanproviderapidreliefofpainassociatedwiththisprocess.

Triggerpoints (such as these,markedwith anX) result inpain that ismost intense somedistance away(markedwithshading).5

TriggerPoints•Areusuallypainful,especiallywhenfirmpressureisapplied•Aretypicallypalpableasareasofincreasedfirmnessinmuscle•Mayrespondtotherapeuticmassageorothertreatments

TriggerPointTherapies:•Acupressuremassage•“Sprayandstretch”•Electricalstimulation•Injections•“Dryneedling”

Thereareseveralbooksavailableforlearningmoreabouttriggerpoints.OneexceptionalbookistheTriggerPointTherapyWorkbookbyClairDavies.6Theauthor tells theamazingstoryofhowhiscareerasapiano tunerpreparedhimfor his subsequent work in manual therapy. It seems that his experience ofworkingouttherelationshipsbetweenthestretchedwiresofthepianomadehimveryreceptivetodevelopingadetailedawarenessofmusclefibersinrelationtoone another. His book guides the reader through the process of learningacupressuremassageandgivesdetailedinstructionsfortreatingawidevarietyoftriggerpoint-relatedpains.

TestingforBackMusclePain

When a back problem is due to back muscle injury, most of the time theevaluation will not require expensive diagnostic tests. An experiencedpractitioner will be able to detect signs of muscle injury just by examiningsomeonephysically.AlthoughseveremuscleinjurymaybedetectableusinganMRI, especially when a sprain or ligamentous injury has also occurred, thismode of testing is rarely required to establish a muscle injury diagnosis.Electricaltestingofamuscleandnervewouldonlyberequiredifanothercauseofbackpainwasalsosuspected.

TheExplanation

Back muscle injury, also called back strain, is the most common cause oftemporarybackpain.Althoughoftenminimizedbythosewhoneverexperiencedit,thepainofmusclestraincanbesurprisinglysevereandmaydisableapersonfromdoingevenbasictasksforaperiodofdaystoweeks.

WHYDOESBACKMUSCLEINJURYHAPPEN?

Themusclesofthebackarecentraltothestabilityandstrengthoftheback.Alltoooften,weaskourmusclestoworkforus,butnever“paythemback.”Whenapersonstartstocutcornersanddoesn’tinvestappropriatetimeandenergyintostayingstrongandhealthy,acuteorchronicinjurytothemuscles,tendons,andligamentsoftenproducesdisablingpainandweakness.Research indicates thatperiodsofincreaseddemandonbackmusclesmustbebalancedwithperiodsofresttoavoidmusclestrainandchronicmusclespasms.Toreachahigherlevelofbackfitnessandfunction,makesurethatyouarebalancingthedemandsonyourbackwithhealthyopportunitiesforgrowthandplay.

MUSCLESOFTHEBACK

If youwatch young children at play, they are constantly running, jumping,bending,climbing,andcrawling!Thesenaturalactivitiesall testandchallengetheback,butalsobuildstrengthandresilience.Forbetterorworse,oursocietyplacesapremiumonhighlystructuredactivitiesforadults,andwerarelygetthechancetomoveaboutspontaneouslyandwithunforcedvigor.Manyofusworkat jobs that don’t allow us tomove about freely;we either have to repeat thesame tasks over and over, sit at our desks for hours upon hours, or lift heavyobjectswithout adequate assistanceor training.All of these activities leaveuspronetobackstrain.

SPRAINSANDSTRAINS

Astrainisaninjurytoamuscle(ortendon),whereasasprainisaninjurytoaligament.Tendonsandligamentsarebothfibrousbutservedifferentfunctions.Tendons are involved in connectingmuscles to bones. They have poor bloodsupply but are capable of feeling painwhen injured or inflamed. The pain oftendonitis can be quite severe and disabling. Tendonitis often arises in peoplewho are performing strength-requiring tasks repeatedly. Although the classicexampleoftendonitisistenniselbow,moremundanetaskssuchasassistingwithwheelchair transfers canproduce this syndrome.Althoughmorecommonsitesfortendonitisincludetheelbowandknee,itispossibletohavetendonitisinthebackandshouldermuscles.

Ligaments are involved in connecting bone to bone. There are manyimportant ligaments in theback, including those thathold thevertebrae tooneanother. These ligaments can be damaged by sharp blows, very suddenstretching movements, penetrating wounds, or other traumas. Ligaments areslow to repair and can require prolonged casting or immobilization to healproperly. Because ligaments play a fundamental role in stabilizing bones andpreventingexcessivemovementinassociatedstructures,chronicpaincanresultwhendamagetoligamentsgoesunrepaired.Instabilityofthespinalcolumnhasaprofoundimpactonbackfunctionandbackpain;formoreinformationaboutthis,seeChapter6.

CausesofAcuteMuscleStrain•Sportsinjury

•Lifting

•Twisting

•Anysuddenstretch

MuscleStrainLeadsto:•Weakness(lastingfordaystoaweek)•Pain•Inflammation•Persistentdamagewhensevere•Adaptiveormaladaptivepostures

Recent researchhasshed important lighton theconnectionsbetweenstrain,sprain,andbackpain.Musclestraincanbeproducedbyasuddenloadingforceor a strong stretching ofmuscle.Commonly, acutemuscle strain is associatedwith particular sports such as soccer and hockey, but ordinary lifting can beproblematic forpeoplewhomightbeoutofshapeandnotusingproper liftingtechnique.Theconsequencesofstraincanbeveryseriousformuscle,resultinginprofoundmuscledamage, invasionof inflammatorycells,andultimatelythereplacementofhealthymusclecellsbycollagen.

Strain of amuscle is typically very painful and always produces a loss ofmuscle strength.Muscle strength drops withinminutes of the strain itself buttypicallyworsens over the first 24 hours. Laboratory studies of strain suggestthatmusclescanproduceonlyhalfoftheirnormalpoweronthefirstdayafterastraininjury.Musclepowergraduallyreturnstonormal,butthiscantakeaweekormoredependingontheseverityoftheinjury.

Whathappenswhenthestressesaremorechronic?Theeffectsofstayingbentover for even a few minutes can be quite serious. Although not technicallyproducing ligamentous sprain, the consequences of improper poster andpositioning aredamaging to ligaments.With sustained improper spine flexion,thenormallyresilientligamentsofthespinestretchbutdon’tbounceback.Thetechnicaltermforthisisviscoelasticcreep,butitisreasonabletothinkofthisasligamentfatigue.7Whenligamentsfatigue,theassociatedmusclesarerecruitedtorespond,initiallyattemptingtosupportthemovement.Themusclesultimatelydevelop a predictable pattern of spasms: random burstingmuscle contractionsthat can be detected with electromyography. Muscle spasms are typicallypainful, and interfere with normal movement. The spasms resulting fromsustainedspineflexionoccurinthemultifidus,spinalis,andlongissimusmusclesfor several hours after the improper spinemovement. Some research suggeststhatwomenareespeciallypronetotheeffectsofligamentfatigue.

Thetake-homemessageisthatfatiguingligamentsthroughimproperpostureand poor spine ergonomics results in muscle strain, inflammation, pain, andmusclespasmsthatlastforhoursandhours.Permanentdamagecanoccur,sotheimportance of maintaining proper posture and never over-reaching personalstrengthlimitsiscritical.Giventhatitcantakeseveraldaystoacoupleweeksforthebodytorepairtheseinjuriestomusclesandligaments,it’snowonderthatmillionsofpeoplehaveachingbacksthatneverfullyrecover!

CRAMPSAREDIFFERENTFROMMUSCLESPASMS

Cramps inmuscle are swiftly-evolving, unplanned contractions of themuscle.

These involuntary muscle contractions are typically painful, but can often beresolvedby slowly stretching themuscle. It isusuallypossible to feel that themuscleishardenedintheareaofacramp.Musclecrampsaremorelikelyinthesettingofvariousconditions suchaspregnancy, lowcalcium, lowmagnesium,hypothyroidism, and dehydration. They can reflect muscle fatigue and occurafterheavyexercise.Themostcommonsites formusclecrampsarenot in theback but rather in the calves (gastrocnemius), the feet muscles, the thigh(hamstringsorquadriceps),andtheribcagearea,wheretheyareresponsibletothepainofhaving“astitch.”

The most common remedies are stretching the muscle, intentionallycontracting themuscle,massage, andwarm compresses. Although the precisemechanisms of cramps remain somewhat controversial, one popular theory isthat cramps represent over-activity of the nerves controlling the musclecontractions.Inthisway,stretchingthemuscleorcontractingthecounter-actingmuscleswillinterruptthenervesignaltomuscleandmaybringthecramptoanend.

Musclespasmsarerandom,bursting,andsometimessustainedcontractionsofmuscle that are typically associated with pain and decreased motion. Whensevere, muscle spasms can result in muscle injury, especially if sudden orforcefulmovements aremadewhile themuscle is in spasm.Although there issomecontroversyaboutwhethermusclespasmsarepalpable,itistheexperienceof most trained observers that muscle spasms are readily appreciated eitherthrough direct palpation or through examining for limitations in normalmovements (decreased range of motion). Muscle spasms may not respond tostretchingascrampsdo;treatmentssuchasice,warmth,andpain-relieverscanhelp.Not infrequently the treatmentofmuscle spasms is addressedbydoctorsusingprescriptionmedications.Asatestamenttothis,musclerelaxantscontinueto be among themostwidely prescribedmedicines.The problemwithmusclerelaxantsisthattheyofteninterferewiththinkingandlevelsofalertness.Someof these medications are liable to abuse, and even without abuse thesemedicationscanleadtophysicalorpsychologicaldependence.Usethemwhenneededbutnomoreoftenthannecessary.

WhereCrampsMostOftenOccurCalfmuscles(charleyhorse)

Footmuscles

Thighmuscles

Ribmuscles(stitch)

CHAPTERRESOURCES

1. Henschke, N. and C. Maher. 2006. Red flags need more evaluation.Rheumatology45(7):920–921.

2. Bratton, R.L. 1999. Assessment and management of acute low back pain.AmericanFamilyPhysician60(8):2299–308.

3.Selby,Anna.BanishBackPainthePilatesWay.Thorsons,2003.

4.Simons,DavidG.,JanetG.Travell,andLoisS.Simons.TravellandSimons’sMyofascialPainandDysfunction:TheTriggerPointManual.2nded.Baltimore,MD:Williams&Wilkins,1999.

5.Niel-Asher, Simeon.The Concise Book of Trigger Points, Revised Edition.Berkeley,CA:NorthAtlanticBooks,2008.

6. Davies, Clair. The Trigger Point Therapy Workbook. Oakland, CA: NewHarbingerPublications,Inc.,2001.

7.Solomonow,M.2004.Ligaments:Asourceofwork-relatedmusculoskeletaldisorders.JournalofElectromyographyandKinesiology14:49–60.

Q&AwithDr.Murinson

Whatarefasciculations?These perceptible contractions of muscle, when widespread, can be a sign ofserious disease such as neurological degeneration or, quite rarely, toxicpoisoning. More commonly, fasciculations are part of the muscles’ normalresponse to fatigue or result from a decline in exercise-imposed demands.Caffeine is a potent stimulus for muscle contraction and is widely used inlaboratory studies of muscle activity. Sometimes it is worth investigatingwhether caffeine consumption is related to bothersome fasciculations. If youhavenew fasciculations that persist anddon’t seem to be related to fatigueormuscledisuse,youshoulddiscussthiswithyourdoctor.

Howdoesprolongedsittingaffectbackmuscles?Oneoftheconsequencesofprolongedsittingisatighteningormildcontractureof the hip flexormuscles.This can affect the back negatively through at leasttwomechanisms—onethroughreferredpainarisingfromthemuscleitself, theother as a consequence of the negative postural adjustments that occur whenthesemusclesarenotproperlyflexible.Thisisalmostanoccupationalhazardof

the “sedentary” butmentally engaged professions such as accounting,writing,andcomputerprogramming.Becausethesecareersrequireprolongedperiodsofsustained mental effort, often with a computer interface, the tendency is tobecomelostinthoughtanddisregardthebody’sneedtoshiftandmovearound.Sitting can also result in back muscle atrophy and chronic muscle overuse.Properpostureandergonomicseatingarrangementsarecritical.Thereareotherdeleteriouseffectsofprolongedsittingfor theback,especiallyonthevertebraldiscs.

HowlongshouldIwaitbeforegoingtothedoctor?Theamountoftimeyouwaitbeforeseekingacutecaredependsonmanyfactors,butmostofall,ontheintensityofpainyouareexperiencingandtheresponseofthat pain to the at-home therapies discussed in this chapter. If your pain isinterferingwith sleep orwork and is not responding to the at-home therapies,then you need an appointment with your healthcare provider. If your pain isunbearable and you cannot control it enough towait for an appointment, thenyou need immediate care. Your local emergency room or urgent care facilityshouldbeabletoassessyourpainandprovidesometreatmentsthatwillprovideatleastshort-termrelief.

Sittingforwardnotonlystrainsbackligaments,butleadstoovercontractionofthehipmuscles,whichmayleadtochronicbackstrainwhenstandingandwalking.

CHAPTER2

DiscHerniation(SlippedDisc)

Seekoutexpertmedicalcareandgetproperdiagnostictestssuchas

anMRIornerveconductiontest.

theDIAGNOSIS

>Doyouhavepainthatislocatedtoonesideofthespine?>Doesyourpainseemtoshootdowntheleg,radiateintothegroinorwraparoundthebody?

Painthatradiatesintothelegorgroinisusuallyduetoanerveinjury,oftenfromaherniateddisc.Backpainiscalledradiatingwhenthereisanelementofpaininthebackandintheleg.Thedegreeofpaininthebackduetoaherniateddiscisoftendescribedasratherminor;however,painmaybeprominentandcentrallylocated in the back if a disc has been previously damaged. Some peoplewithradiatingbackpainhavethesensationthatthebackandlegpainsarephysicallyconnectedtoeachother,whileothershavebackpainandlegpainsthatarefeltatthesametimewithoutaphysicalbridgeofpainconnectingthem(thereandtherebutnotinbetween).

Sometimes,certainmovementswillmakethepainworse.Onewaytotestforanerverootinjuryistodothefollowing(youwillneedahelpertodothistest):sitdowninahardchairthathasastraightback.Thechairheightshouldbesuchthat your feet are firmly on the groundwith your knees at a 90-degree angle.Have your helper gently take one ankle and pull it slowly outward and up. Ifyourbackpain suddenly increaseswith thismovement, stop immediately.Youmayhavenerverootcompression;readon!

What’sNew:AChangingDefinitionTraditionaldescriptionsofradiatingbackpainemphasizethatitismorelikelytobeduetoacompressednerveroot(anddischerniation)whenthepaingoinginto the leg extends below the knee.Recent studies indicate that even if thepain just extends into the thigh, pain could still be due to nerve rootcompression.1

thePRESCRIPTION

TheGoodNews• People with herniated discs often do better than those with other backproblems.

•Surgerycanbeveryeffectiveatrestoringpeoplewithherniateddiscstofullhealth.

Back pain due to a pinched nerve needs expertmedical assessment and care.Many times, anMRI of the back or even aCT scanwill be needed as a firstdiagnostictest.SomedoctorsstillprefertostartwithanX-ray,butthiswillonlyshowthebonesanddoesnot indicatewhat ishappeningwith thedisc. IfyourdoctorrecommendsanMRIandyousufferfromclaustrophobia,makesuretoletyourdoctorknow.Formostpeople,MagneticResonanceImagingisverysafe.

Yourdoctormayalsoorderanerveconductiontesttoevaluatetheintegrityofthenervesarisingfromthespine.ThistestandMRIsarediscussedindetaillaterin thischapter.Onceimagingandelectrical testresultsare in,aclearerpicturewillemerge.Thepossibilitiesrangefrom“nothingiswrong”toa“slippeddisc”toa“brokenback.”

Ifyouhaveaherniateddisc(sometimesreferredtoasaslippeddisc):• Your doctor may recommend physical therapy, especially if there is noperceptibleweakness.Surgerymaybeneededifnon-surgicaltreatmentsarenoteffectiveafterafairtrial.

•Yourdoctormayreferyoutoasurgeon,especiallyifthereisweaknessduetonervedamage.Surgeryhasplusesandminuses,butincasesofweaknessorincontinence,surgerymaybeneededurgentlytopreservefunction.Foranisolateddischerniation,microsurgerymaybetheanswer.

-Microsurgeryissurgerythroughoneormoresmallincisions.-Recoverytimesareusuallyfaster.

Formanyreasons,microsurgerymaynotbeanoption.-Routinesurgeryforherniateddiscsisveryeffective.-Makesuretoaskaboutexpectedrecoverytimes.- When damage to the spine is more extensive, a more involvedsurgery is needed that may involve fusing adjacent spinal boneswithmetalhardwareorbone.

AREAOFINJURY

WHATIFYOURDOCTORDIAGNOSESABULGINGDISC?

In thiscase,physical therapyandexerciseareusuallybest.Thedegreeofpainanddisabilityassociatedwithtypeofinjuryvariesgreatly,but inthiscaseyoucandoalottoimproveyourchancesofafastandfullrecovery.(SeeChapter5tolearnhowtomanageabulgingdisc.)

WHATIFYOURDOCTORFINDSANERVEROOTBEINGCOMPRESSEDBYANOVERGROWTHOFBONES(BONYSPURS)ORLIGAMENTSINTHELOWERBACK?

The overgrowth of bones and ligaments in the lower back is usually the endresult of years of accumulated trauma to the back, and carries the label ofdegenerativejointdisease(DJD).Surgerymaybeanoption,butthisdependsonthe extent of damage to the spine. Many times, physical therapy andprogrammedexerciseistherightsolution.

RareCausesofRootCompressionIn rare cases, nerve root compression is due to amass (tumor), an infection(abcess),oraspinalmalformation.ThesecausesofnerverootcompressionarereadilyassessedthroughMRIandtheotherdiagnostictestsdescribedhere.Thetreatmentfortheseconditionsisindividualized.

Warning!Don’t Wait Weeks for Help Unfortunately, many doctors have beentrained towait sixweeksbeforepursuinga fullerworkupwithMRIorEMGtestsforasuspecteddischerniation.Thepainofdischerniationisusuallysevereenoughthatsixweeksisfartoolongforanyonetoremainin agony. So if you are in a lot of pain, and especially if you haveweakness as well, don’t accept treatment that you think is second rate.Tellyourprovideryouneedaproperworkuporgoelsewhereforhelp.2

TheTreatment

Ifyourdoctorrecommendsphysicaltherapyfirst,itusuallymeansyouhavethetype of disc herniation that is best treatedwithout surgery.3 There are severaltreatment modalities that fall under the umbrella of physical therapy as theprimary treatment for disc problems: thermal therapies, electrical stimulationtherapies, manual therapies, traction/inversion therapies, conditioning, andstrengthening.

THERMALTHERAPIESREDUCEPAIN

Warmcompresses, coldpacksor both in combination canbevery effective atreducingpainlevels.4Paincontrolisanimportantpartofearlytreatmentfordiscproblems.Pain levelswithdischerniationscanaverage8onascaleof10andwillbehigherwithmovementorstress.Paincaninducecompensatoryposturesand movements that may increase disc pressures and slow progress towardrecovery.

ELECTRICALSTIMULATIONTHERAPIESRELAXMUSCLES

Electricalstimulationmaybeusedonselectedmusclegroupstoinducemusclerelaxation through a “fatigue” mechanism. The electrical stimulation can beapplied in areaswheremuscle spasms are contributing to thepressures on thediscaswellasonoveractivemusclesthatareperpetuatingabnormalpostures.

MANUALTHERAPIESRELIEVEANDREALIGN

Properalignmentof thespineandnormalposturesareessential tonormalizingpressuresonvertebraldiscs.Inthethoracicspine,apinchednervecanproducemusclespasmprofoundenoughtointerferewithproperbreathing.Triggerpointtherapy isdesigned to relaxmuscles thathaveabnormalzonesofmuscle fibercontractions known as trigger points. Low-velocity manipulations can adjustdislocatedsacroiliacjointsormisalignedfacetjoints.Insomecases,extensionofthespinemayprovidepainrelieffrompainduetodiscdisease.5

TRACTIONANDINVERSIONTHERAPIESRELEASEPRESSURE

Releasing pressure on a disc increases the likelihood that it will return to itsregular configuration.6 For some people, inversion can be carried outsuccessfullyathome,butformost,asupervisedcourseoftractionorinversiontherapyissafest.Forthepersondeterminedtotryinversiontherapyathome,itispossible to purchase an inversion table. For milder forms of inversion, an

inclined board with padding may produce some benefits. For someone withactive back pain, though, getting into position on an inclined board mayrepresentasubstantialchallenge.

CONDITIONINGISCORETOBACKHEALTH

Strengthening and conditioning are essential parts of physical therapy for discproblems whether or not surgery is undertaken. I often tell patients that theyshould expect to work hard at getting better from a back injury. I reallydiscouragepeoplefromtakingtimeofffromworkforbackproblemsunlesstheyare attending physical therapy and dedicating themselves to getting betterthroughsupervisedexercise.Ifyouhaveaherniateddiscwithradiatinglegpain,aphysicaltherapistwillneedtoguideyourfirststepsinbackstrengthening.Inmost caseswhere the disc herniation is not causing actualweakness, physicaltherapyisthepreferredtreatment.

Physical therapy is highly effective for many types of back problems,including some herniated discs. There are several advantages to pursuingphysicaltherapy,buttheprimaryadvantageisthatitavoidsthecomplicationsofsurgeryandmaybecompletelyeffective.7,8

It is not yet clear whether physical therapy is more cost-effective or time-efficientthansurgery.Theusualmedicalperspectiveisthatfordischerniationscausingmuscleweakness,backsurgery ismore likely tobeeffective thannot.For disc herniationswhere pain is the predominating problemand there is nodemonstrableweaknessduetoapparentnerveinjury,surgerywillbeconsideredasasecond-lineoptionforparticularlyseveresituations.9

KnowWhentoSeekaSecondOpinionIfyouthinkyouhavedisc-relatedweaknessandyourdoctorhasrecommendednotpursuingsurgery,makesureyouunderstandwhynot.Makesurethedoctorhas examined the muscles that you believe to be weak, and if aftercommunicating clearly about any perceived weakness, you don’t feelunderstood,seekasecondopinion.

Sometimesseverepaincancausemusclestofunctionpoorly,andthismaybedifficult to distinguish from the worrisome weakness that arises from directnerve damage. The distinction is important and critically so in patientswithdischerniation.Often,anelectromyographic(EMG)studyofthemusclescandistinguishpain-inducedweaknessfromnervedamage-inducedweakness.

TO-DOLISTFORSURGERY

Ifyourdoctor refersyou toa surgeon rightaway,chancesare thatyouhaveanerve root or roots that would be in danger without surgical decompression.Typically, surgery is needed if the herniated disc is pressing on a nerve andcausingweaknessinoneorseveralmuscles.Painisalsousuallypresent,butthesurgery that is needed to protect the function of the nerve root will typicallyrelievemuchofthepain.10

Whenyougo to see the surgeon, there are several things you should do toprepareforthevisit:gatheringrecords,makingalistofpotentialquestions,andliningupasupportpersontogoalongonthevisit.

First, make sure that you have copies of any X-rays, CT scans, MRIs, ormyelogramswith you or arrange for these to be sent directly to the surgeon’soffice. You will need copies of recent blood work and documentation of anyothermedicalconditionsyoumayhave.Takeadetailedlistofmedicationsthatyouareprescribedandincludeinthisanydietarysupplementsthatyoutake.

Second,write down a list of questions that youmay have about your backproblemandtheplannedprocedure.Thesequestionlistsarewellknowntomostphysicians; try toweedout theroutineonesand identify thequestions thataremostcriticaltoyou.Youcanlearnalotaboutyourbackproblemandtheusualapproaches to treatment before your appointmentwith the surgeon; as you dothis, some of your initial questionsmay be answered but newoneswill arise.Your surgeon may direct you to specific educational resources. Some spinepracticeshavewebsites that aredesigned toprovide routine information abouttreatments and surgeries. Your public library may have excellent resourcematerialsrangingfrombookstovideos.

ASECONDPAIROFEARS

You will need a support person to accompany you to the surgeon’s visit.Everyonewhovisitsaspecialistdoctorshouldplanonhavinga“secondpairofears.”Insomeextremecasesinwhichnooneisavailable,youcantakeanaudiorecordingdevicealong.Makesuretoaskthedoctoriftheyarecomfortablewitharecordingbeingmade.Therecordingdevice,whileuseful,isnotasgoodasafriendorafamilymember,whowilloftenbeabletoaskimportantquestionsandprovideemotionalsupportifthenewsisbad.

QuestionstoAskYourSurgeon•AreyousureIneedthissurgery?•Howmanyoftheseprocedureshaveyoudone?•HowlongwillIneedtobeoutofwork?•HowmuchpainshouldIexpectaftersurgery?•HowlongwillIneedtotakepainmedicineforafterwards?•HowlongwillIbeinthehospitalfollowingtheprocedure?•HowlongbeforeIcandriveagain?

Make sure you have a clear idea of the surgery that is planned. There areseveral possible surgical approaches that can be used for the treatment of aherniateddisc.Theextentofsurgerywillvarywith theextentofbackdisease;forproblems limited toa simpleherniateddisc, theplannedsurgeryshouldbelimited,butthespecificapproachwilldependontheparticularexpertiseofthesurgeonandshouldbeguidedbyhisorherbestjudgment.Theapproachesusedinclude an open discectomy, a micro-discectomy, and micro-endoscopicdiscectomy.

OPENDISCECTOMY

Open discectomy is the oldest, more established procedure. It involves anincision,perhapstwotothreeinchesinlength.Throughthisverticalincisiononthe back, the surgeon will cut or separate the layers of fat, muscle, andconnectivetissuesthatoverliethespine.Thereisalayerofbonethatcoversthespinalcordthatmustbepassedthroughinordertoaccessthespine.Thisboneconsistsoftheposteriorportionsofthespinalvertebraethatarestacked,oneontopoftheother,toformaprotectivecoveringoverthespinalcord.Intheopendiscectomy, it is necessary to remove part of one of these, or parts of twoadjacentvertebrae,usingatechniquecalledlaminectomyorhemilaminectomy.11Oncetheboneisremoved, itmaybepossiblefor thesurgeontoseethespinalcordanditscoveringaswellasthenerverootatthatlevel.Thedischerniationisusuallyjustontheothersideofthenerverootseenthroughthesurgicalincision.Removingtheherniateddiscmaterialisdonewithspecializedcuttingtoolsoncethe nerve and spinal cord are protected from harm. The spinal cord may begentlyheldtothesideusingatoolcalledaretractor.Oncethedischerniationisremoved,thesurgeonwillbegintoclosetheincision,oftenrepairingtheopeningin the various layers by stitchingwith suture thread. Sutures come in variousstrengthsandmaterials, andstrongsuturesareused inhigh-loadareas like theback.Theskin is thefinal layer thatmustberepaired tocomplete thesurgery,andtheskinincisionmayberepairedwithsutures,staples,orothertechniques.The recovery time for the open discectomy is usually longest of the threeprocedures,butthemethodoffersawideviewoftheproblemsinthespine,andmaybepreferredovermicro-discectomywhencertainconditionsapply.

What’sNew:DiscLocationMayDictatetheOutcomeA recent analysis of a study on surgery for the treatment of herniated discsindicatedthattheeffectivenessofthesurgeryatreducingpaindependedinpartonthelocationofthediscinvolved.Thehigherupinthelowback,thebetterthe chance of a positive outcome from surgery. It seems that theL5-S1 discrepairswereassociatedwith lesspain reliefand lower levelsofpost-surgicalfunctioning.12

MICRO-DISCECTOMY

Likeopendiscectomy,micro-discectomy is aprocedure to removeaherniateddiscbutitisperformedusingaverysmallincision.Typically,aguidingcatheterispositionedusinganoperatingroomX-raymachinecalledafluoroscope.Thisguidecatheterismuchtoosmalltoallowthesurgerytotakeplace,soaseriesofprogressivelylarger tubesareslid intoplaceover thecatheter inaprocess thatenlarges(ordilates)theaccesspaththatthesurgeonmusttakethroughthelayersoffat,muscle,andconnectivetissueintheback.Inthisprocess,layersoffatandmuscle are spread apart rather than cut, allowing for less local damage andperhapscontributingtothefasterrecoverytimesassociatedwiththissurgery.Inordertovisualizethedischerniation,itisstillnecessarytoremovesomeoftheposteriorboneofthespine,soapartiallaminectomyisdonethroughthesurgicalaccess tube. A microscope is used to visualize the disc herniation as well assomeofthespinalnerveelements(spinalcordandspinalnerve).Theherniateddisc material is removed using a specialized cutting tool that passes downthroughthesurgicalaccess tube.Oncethedischerniationisremoved, the tubecanberemovedwithcareandtheincisionintheskinrepaired.Recoverytimesformicro-discectomyaregenerallyfasterthanforopendiscectomy,althoughinbothprocedures,patientswillgenerallybeginwalkingthedayofsurgery.

What’sNew:YoungAdultsFareWellArecentstudyofpeopleages20to35withsingle-leveldischerniationfoundthat most of these young adults have great results: although five out of 67peopleinthestudyhadtohaveasecondsurgeryfordamagetoanotherdiscintheback,noneofthepeoplewhoansweredthedoctor’ssurveyneededconstantpainmedicine,andmosthadreturnedtosportsactivitieswithoutunduepain.13

Theremovalofbone(partiallaminectomy)foramicro-discectomy

MICRO-ENDOSCOPICDISCECTOMY

Theprocedureforamicro-endoscopicdiscectomy,performedthroughakeyholeincision

Micro-endoscopicdiscectomyisaprocedurethatissimilarinmanyrespectstothemicro-discectomy. Insteadof positioning amicroscopeover the endof thetube and looking down into the incision from outside, a fiber-optic camera ispassed into the tube to visualize the structures of interest. The surgicalinstrumentsneededtoperformtheremovalofthedischerniationarealsopassedthroughthetubeasinthemicro-discectomybutmustthencompeteforlimitedmaneuveringspacewiththeminiaturecamera.

What’sNew:TheRisksandCostsofMicro-EndoscopicDiscectomyAnew study shows thatmicro-endoscopic discectomymay carrymore risksthaneitheropenormicro-discectomy,andmayintheendbemoreexpensive.14Makesure thatyouunderstand thespecificplan foryour surgery. Ifyou feeluncomfortable or have reservations, try to discuss these openly. A secondopinioncansometimesbeveryhelpfulformakingthebestmedicaldecision.

PREPARATIONFORSURGERY

Afteryouvisityour surgeon’soffice for the first time,makesure to readoverany materials that you receive from the doctor and the doctor’s assistants orofficestaff.Ifyouhaveanyseriousquestionsorworries,getincontactwiththeoffice and seek out advice from trusted sources. You may want to obtain asecondopinion ifyouhave lingeringdoubts about theplans for surgery.Onceyou make the decision to go forward, you will want to follow the surgeon’srecommendationsclosely.

Youwill be toldwhat todo toprepare for surgery. Inmost cases, youwillinstructed not to eat after midnight or perhaps earlier the evening before thesurgery.Most surgeons begin operating early in the morning, so youmay bechecking in for the procedure before dawn. A pre-operative physical exam isoftenrequiredbeforesurgery;youmaybeaskedtoseeyourregulardoctorforthis or instructed to undergo a special pre-operative examination. Someadditionaltestsmaybeorderedatthispointtomakesurethatthemedicalrisksforsurgeryarefullyknownandminimized.

WHATTOEXPECTAFTERSURGERY

Thepaceof recoverydepends to somedegreeon the typeof surgery that youhave had for the herniated disc and on the type ofwork you are returning to.Afteranopendiscectomy,thetimerequiredbeforeareturntoworkcanbemorethantwoweeks.Thetimeformicro-discectomymaybesooner.

Atfirst,itmaynotbepossibletodrive,especiallyafteranopendiscectomy.Carefully follow your surgeon’s instructions about driving. It stands to reasonthat (unless your surgeon says it’s okay) no driving also means no flyingairplanes,nodownhillskiing,noboating,etc.It issurprisinghowoftenpeoplewithexcellentcommonsenseinotherareaswilltrytocircumventthenecessaryrestrictionsonactivitythatfollowbacksurgery.Trytorememberthatyourbackhasundergoneasophisticatedandexpensiveprocedure.Yourbodyneedstimetohealandstitchitselfbacktogether;followingtheactivityrestrictionsputinplaceby your surgeon will maximize your chances of getting a good result fromsurgery!

Warning!FollowYourDoctor’sOrdersforLimitingActivities

It is really important to respect the restrictions your surgeon places onactivity followingsurgery.Overlyaggressive“rehabilitation”outside thebounds set can cause delays in healing, a relapse of the problem, orsometimesaseriousworseninginthebackproblem.

MEDICATIONSFOLLOWINGSURGERY

Yoursurgeonmayprescribepainmedicationtocontrolthepainaftersurgery.It’simportant to takepainmedicationasprescribed.Paincontrol isvery importantduringtherecoveryperiod,asitwillimproveyourchancesofagoodresultandlessen the likelihood of persistent pain after surgery. Be sure to alert yoursurgeon if there is severe pain after surgery that doesn’t respond to the painmedicineprovided.Severepaincanbeasignofunexpecteddifficultiessuchasbleedingorinfection.Youwillbeabletogaugeyourneedforthemedications,aspainquicklyescalates ifadoseisskippedordelayed.Formanypeople, thefirstthreedaysaftersurgeryaretheworstfromapainperspective,andoncethisperiodpasses,theneedforpainmedicinedeclines.

Mostof themedicationsused tocontrolpost-surgicalpainare in theopioiddrug family. These medications are notorious for causing constipation. Thisconstipationcanbeaseriousproblemsoyou’llneedtohaveaplaninplacetominimize these effects. An additional pill may be prescribed to stimulate thebowelsandastoolsoftenermayalsobeprescribed.Discussmeasuresyouwouldnormally take for constipationwith your doctor, including your usual routine.Helpfulstepstotakemightincludedrinkingsomeextrawatereveryday,takingaglassofprunejuiceoreatingsomeprunes,gettingsomeextrafiberinthediet,or takingsupplements.Formanypeople, theconstipationthatfollowswiththepost-surgical pain medications won’t stop until the meds themselves are nolongerused.

POST-SURGICALPHYSICALTHERAPY

Physicaltherapyisusuallypartoftherecoveryplanafterbacksurgery,andakeyelement tomaking a full and successful recovery fromdischerniation. Itmaybegin with an assessment immediately after surgery, or start as late as threeweekspostsurgery.Theinactivitythataccompaniedyourbackproblemandthesurgerymayhaveweakenedyourbackandstomachmuscles.Aguidedprogramofstrengthening,conditioning,andpaincontroliscriticaltopreventingarelapseorrecurrenceofdischerniation.Ultimately,youwillwanttodevelopyourownprogramofbackexercise,butduringtherecoveryfromsurgery,makesureanyexercisesyoudoareinlinewiththeexpectationsofyoursurgeonandphysicaltherapists.

TestingforNerveRootCompression

Thetestsmostcommonlyusedtodiagnosenerverootcompressionincludethe

EMG/NCS and the MRI. Neither of these tests is perfect and they servecomplementarypurposes.

BePreparedforPainTheEMGispainfulformostpeople;thedegreeofpainvarieswiththepersonand the particular muscle being studied. The hand and biceps muscles areespecially painful. It can be painful if the needle enters themuscle near thepoint where the nerve connects to the muscle (muscle endplate orneuromuscularjunction).Althoughtheneedledoesproduceveryminortraumatothemuscle,itisaninvaluabletechniqueforlearningabouthowthemusclesand nerve are functioning: this is something the bestMRI is not capable ofdoing.

ELECTROMYOGRAPHYANDNERVECONDUCTIONSTUDIES

The EMG/NCS is a fundamentally important test for determining if there isdamage to the nerves or nerve roots. The EMG portion of the test involveshavingaslenderneedleplacedintooneormoremuscles.Thespeciallydesignedneedle is a high performance instrument designed to measure the electricalactivity of the muscle with a minimum of noise and the best possiblecombination of signal detection and resolution.With this needle, it is usuallypossible to determine if the connection between brain andmuscle is workingwell.Sometimesitispossibletodetectpriorinjurytoanerve.Oncetheneedlehasbeenplacedintothemuscle,thedoctormayjust“listen”forashortwhiletoseewhetherthereisspontaneousactivityinthemuscle.Thedoctormaythenaskyoutotightenorcontractthemuscle.Thismakesitpossibletoseeifthemuscleis responding appropriately to the signals the brain is sending. It may benecessarytorepositiontheneedleinthesamemuscle,andisusuallynecessarytotestmultiplemusclesinthismanner.

The EMG can be instrumental for pinpointing damage to a specific nerveroot.However, the test resultsdodepend to someextenton the techniqueandinterpretationofthepersonconductingthetest,andsometimesthetestneedstoberepeated.Earlyafteranerveinjury,thesignsofinjuryinthemusclearenotasreadily apparent.This is because following a nerve injury, a series of changestakeplaceinthemusclethatthenervesupplies.Thesechangesmakeiteasiertodetectanerveinjurybutarenotwellestablisheduntilthreeweeksinmostcases.

EMGTest

IfYouSmoke,Stop!Ifyouarestill smoking,now is the time toquit.Smokingwill interferewithyour recovery fromsurgeryand isproven todecrease thesuccessof surgery.Some surgeons will refuse to operate on current smokers. Smoking makesfailed back syndrome (a conditionwhere the patient has severe chronic painevenafterbacksurgeries)morelikely.Smokingwillinterferewithyourabilityto get aerobic exercise and get better from your back injury. In addition, itincreasesyourriskforlungcancerby10times,increasesyourriskforhavingaheartattack,andincreaseshealthrisksforthosewhoarearoundyouwhenyousmoke. Ifyouareunable toquitonyourown,askyourdoctor forhelp.Onepredictorofsuccessateventuallyquittingthenicotinehabitisthewillingnesstoquitagain.Soevenifyou’vetriedandfailedbefore,don’tbediscouraged;resolvetostartover.

PAINFULBUTPURPOSEFULNCS

TheotherpartoftheEMG/NCSseriesisthenerveconductiontest(NCS).Thistest involves delivering a series of shocks to various nerves in the body andmeasuringtheresponses.TheNCSusuallyprecedestheEMG.ThereiscurrentlynopracticalalternativetotheNCSandtheinformationobtainedfromthestudycanbeinvaluableforfirmingupadiagnosis.Ifyourdoctorsuspectsnerverootdamageorradiculopathy,theNCScanbeanimportantinexcludingothernerveconditionsandidentifyingspecificnerverootsyndromes.

Formanypeople,theNCSisquitepainful.Itisoftenmorepainfulforpeoplewithpre-existingnervedamage,suchasthatcausedbydiabetes.YoungpeoplearealsoespeciallysusceptibletothepainofNCS,andfinally,repetitiveshocksare almost alwaysmuchmore painful than single shocks, but this depends onhowcloselytimedtherepeatedshocksare.TheNCSispainfulbecausetheskinnot only is a barrier to the current needed to electrically stimulate the nervesunderneath but it is richly innervated with pain-sensing fibers that will bedirectlystimulatedbytheelectricalcurrent.

Because theNCScanbesopainful, somepeoplehavewondered if there ispermanentdamage.ThereisnoevidencethatNCScausespermanentdamage;infact,theNCSdeliverselectricalcurrenttothenervethatactivatesthenerveinavery“normal”manner. Ingeneral, ithasnotbeencommonpractice toprovidesedationoranxiety-relievingmedicationsbeforethestudy.Thismaybebecausecooperation is required for theEMG,which isoftenpairedwith theNCS,andbecausesomeofthemorecommonanxiety-relievingmedicationscouldinterferewithsomepartsoftheEMGstudy.ItisbesttobringasupportpersonalongtotheEMG/NCS,especiallyifyouarenotsomeonewhotakesgreatprideinbeingstoic!

MAGNETICRESONANCEIMAGING

TheMRIhas become an instrumental part of confirming a diagnosis of nerveroot injury. In a perfect world, a classical nerve root compression syndromewould show such a consistent and specific pattern of radiating pain and focalmuscleweaknessarisingafterasimplebendinginjurythatanMRIwouldnotbeneeded.However, in therealworld, thereareothercausesofnerveroot injurythat are best assessed by MRI. Herniated discs are just one of the potentialcauses of nerve root injury, andMRI is an excellent test for assessing for thepresenceofotherworrisomecausesofnerverootcompression.

The quality of theMRI is critical for the doctors reviewing the study andmaking decisions about your healthcare. Make sure to check with the doctor

ordering thestudyforanypointers to facilitieswithgoodqualityMRIstudies.Some centersmay be usingmachines that are out of date or older technologythatwillnotproduceacrisppictureofyourback’sstructures.Itisalsocriticallyimportant toholdperfectly stillduringmanyportionsof the imageacquisitionprocess,sotrytolistencarefullytotheMRItechniciansinstructionsonceyourstudy is underway.Ask for a copy of the study so that you can keep this andbringitwithyoutotherelevanthealthcareappointments.Makesuretorequestthatacopyofthereportbesenttoyou(ifpossible)oryourprimarycaredoctor’soffice,aswellastoanyspecialistthatmayhaverequestedtheMRI.Ifyouhavea history of claustrophobia, thismay factor into your decision to choose openoverclosedMRI.Early“openMRI”imageswerenotalwaysofthebestqualitybecause of the technological challenges involved in producing a uniformmagnetic field in the openMRI configuration. The need for a strong, highlyuniformmagneticfieldiswhyMRImachinestendtoconsistofarelativelytightfittingtubeintowhichyouslideforthestudy.TheMRIrapidlypulsesastrongmagneticfieldoverthebodyandrecordsthe“relaxation”oftheatomicnucleiasthey reorient spontaneously when the field is very briefly switched off. Thismagnetization process occursmany times during the standardMRI study andaccountsfortheloudnoiseofmostMRIscanners.

ISITDANGEROUSTOHAVEANMRI?

PeopleoftenwonderifMRIisdangerous.It isnot.MRIisprobablythesafestimagingtechnologyavailable.UnlikeCTscans,thereisnoradiation,sothereisnoreasontoworryaboutMRIincreasingyourriskofcancer.Unlikeultrasound,there is very little energy transfer despite all the banging sounds that mayemanate from themachine. The tight-fitting spaces ofMRImachines and theloudnoiseofmostscannerscanbemildlyintimidatinganduncomfortable,butlisteningtomusicand/ormaintainingastateofmentalcalmbyfocusingonthevalueofthetestareusuallysufficienttooffsetmostworries.

Your doctor may offer premedication for the test if you express concerns,anticipate feeling claustrophobia, or have a history of anxiety with MRI.Remember that takingapre-MRIanxiety-relievingmedicationprobablymeansthatyouwillneedadriver to takeyouhomeafter.AlthoughMRIcannot“seeeverything,”itdoesofferadazzlinglydetailedpicturethatcandetectproblemsassmallasagrainofrice.Italsohasthecapabilitytodetectchangesinthebodyduetoinflammation.

Warning!MakeMedicationsKnown

BecausetheEMGisatestthatisinvasive,ifminimallyso,itisimportantto make sure that the lab knows what medications you are taking inadvance of the test. Especially if you are taking a blood thinner, theelectrodiagnosticlabneedsthisinformation,andyoushouldagainnotifythe doctor before allowing the test to be done if blood-thinningmedicationsarepartofyourmedicalregimen.Ifyouhaveproblemswithblood clotting, it is important to make sure this part of your medicalhistoryisdiscussedaswell.

WHATHAPPENSINTHEDOCTOR’SOFFICE?

Yourdoctororpractitionermayperformsomebasicmaneuverstodetermineifnerve root injury is the cause of your back pain. This will probably includetesting the muscles in your legs to determine if they have full strength. Thepractitioner may test sensation, trying to determine if there is any pattern ofsensory loss.Most often, this is donewith a sharp stick or pin.Reflexeswillprobablybetestedusingareflexhammeraspartofanassessmentfornerverootdamage. Although some of the nerve roots in the back don’t result in lostreflexeswhendamaged,theclassicalfindingofa“dropped”reflexintheankle,in concertwith other abnormalities,may indicate a specific nerve root arisingfromthebackisdamaged.

The practitioner may attempt to determine if there are signs of nerve roottensionorcompressionbyperformingthestraight-legraisetest.Inthistest,thepatientisusuallyaskedliebackonatable.Thismaybeuncomfortableforyouin theacutephasesofback injury, sobe sure to letyourexaminerknowwhatmovements or positions are especially painful. While you are lying on yourback,thedoctororpractitionerwillaskyoutorelaxwhiletheygraduallyliftoneleg,withthekneestraight,bendingatthehip.Heorsheshouldaskyoutoreportif themovementbecomespainfulatanypointbutbesuretopointoutifmuchpaindoesoccurandindicatewherethepainis.Paininthebackofthelegcanbejust“tighthamstrings,”butpaininthelowerbackthatcomesonsuddenlyastheleg is raisedhasclassicallybeen interpretedassupportiveofnerveroot injury.Afterthelegisraisedto90degreesortothepointofmaximumtolerablepain,the leg isgradually loweredand the test repeatedon theoppositeside.All thepiecesofinformationfromtheexaminationshouldbeinterpretedtogetherwiththe history you have provided during the visit and through othercommunications.Asnotedabove, themostcommonpresentationofnerverootinjuryispainandweaknesstogetherbutvariationsdooccurandtheexamisawayofsortingoutthecontributionsofvariousbackproblems.

Warning!MRIandMetalsDon’tMix

Ifyouhaveapacemaker,electricalimplants,orahistoryofworkinginthemetals industry, you need to check with the radiology center and yourdoctorbeforehavinganMRI.Inthesesituationsandselectedothers,thepresence of metal in the body can pose a hazard and means that MRIcannotbedone.

One twist in all of this is that nerve root injury often occurs as a result ofdamagetoadisc,whetherherniation,protrusion,orbulgingtear.Thedamageddiscmayitselfbepainfulandwillproduceapainthatismorecentralinthebackandmaybeacutelyworsewiththemovementsrequiredtogetintopositionforthestraightlegraisetestandotherpartsoftheexam.Thisactiveoverlayofdiscpain on top of nerve root pain may be difficult for some less “pain expert”clinicians to sort out. Don’t give up hope if your doctor doesn’t immediatelyunderstandeverythingthat’sgoingonwithyourback.Youmayneedtogotothenext level and seekoutmoreexpert care,butmake sure that ifyouhavepainsevere enough to stopyou fromgoing toworkor school thatyouare activelylookingforanswersas towhy it stillhurts.Theexamination findingsofnerverootinjurycanbesubtleinsomecases,especiallyifsomeoneisconfusedabouttheoverallpictureofyourpain.

TheExplanation

The nerves that arise from the spinal cord stream downward as they spiralaroundtothefrontofthebodyfromtheback.Wheninjured,thenervessendoutpainsignals thatcanbefeltatsomedistancefromwhere the injuryactually islocated in the back. The pain of an injured nerve can be deep and aching orelectricalandshooting,orbizarrelypainfulanddifficulttodescribe.

Radiatingbackpainistheclassicdescriptiongiventopainthatiscausedbyapinchednerveintheback.Typically,thisiscausedbyaherniateddisc,althoughotherproblemscanproducethesesamesymptoms.Aherniateddiscistheusualcausewhensymptomscomeonsuddenlyandafteraparticularevent:bendingtolift, sneezinghard, jumpingoff fromaheight.Apain iscalledradiatingwhenthereisacomponentofthepaininonelocationandanother,seeminglyrelatedpainnearby.Inthecaseofthelowerbackpainduetoaherniateddiscandnervecompression, there may be one pain in the back and another component thatextendsdownintothelegonthatside.Thefirstthingthatleapstothemindofmost doctorswhen they hear about radiating back pain is the possibility of anerverootcompressionduetoaherniateddisc.Althoughthereareothercausesofradiatingbackpain,suchascompressionof thesciaticnervein thebuttock,theclassicassociationiswithapinchednerveduetoaslippeddisc.

QuestionsYourDoctorWillAskDoes thepain in your leg extendbelow theknee? Pain below the knee ismoreoftenassociatedwiththemostcommonformsofnerverootcompression.Pain thatdoesnotextendbelowthekneemaymean there isapinchednervehigherintheback,orthatanotherproblemiscausingyourpain.

Doyouhaveadetectableareaofnumbness?Youcantestthisusinggentlepressurewithatoothpick.Noteveryonewithnerverootcompressionwillhaveanareaofappreciablenumbness.Whennumbnessispresent,youshouldalertyourdoctortothissothatheorshecaninvestigatethepatternandseeifthisfitstogetherwithnerverootcompressionsyndrome.

Do you haveweakness in one ormore specific legmuscles? People withnervecompressionsyndrome(radiculopathy)mayhavedifficultywithoneormoreofthefollowing:•risingfromasquat•walkingupontip-toe•walkingontheheels

Ifyouchecktheseareasandnoticethatsomethingdoesn’tseemright,besuretonotifyyourhealthcareproviderwhenyouareseen.Ifyoudecidetotrythesemaneuversathome,makesure tohavesomeonewithyou toprovidesupportshouldyouhaveanyunsteadinessordifficulty.

Inmostsituations,backpaincausedbyacompressednerverootinthebackisvery severe.Oftendescribed as eighton a scaleof10orgreater, thepain cantake on one of several guises. The pain can begin with some subtleness,worsening progressively over a few days, or with a popping sensation whileliftingandevolvefairlyrapidlytoanincapacitatingseverity.Itcanbefairlymildfor a period and then suddenly worsen. The one thing these pains have incommonisanelementofpaininthebackandanelementofpainrunningdownintotheleg.

Thepreciselocationofradiatingbackpaininthelegwillvarydependingonwhichnerveroot isendangered.Thereareseveralnerverootsarisingfromthelower part of the spine and each one of these nerves, when compressed, willproduce a particular pattern of pain and limitations in function. The mostcommon root to be damaged is the L5 root, the 5th lumbar root. This nervecomesoutfromthelowerback,descendsinto thelegbypassingdeepthroughthebuttock,andspiralsaroundthebackof the thightosupplysensationto thetop of the foot. If the nerve root is seriously compressed and functionallydisabledbythepressureonitintheback,specificmuscleswillbeweak—inthiscase, themuscles that control the liftingof the foot and the ability to turn thefootfromsidetoside.SometimespeoplewithnervedamageattheL5levelwillhave difficulty with frequent tripping because this nerve controls themusclesthat lift the frontof the footaswewalk.Frequent toecatchingcanalso resultfromdamageto theL4nerverootor toproblemsinotherpartsof thenervoussystem.WhentheS1nerverootisdamaged,peoplemayhavedifficultywalkingon toes. This may not be as noticeable but may lead to some fatigue withwalking or some difficulties at reaching high objects where stretching up isrequired.CompressionoftheL3nerverootcanbemoresubtletodetect,asthepainmay ormay not extend below the knee and theweaknessmay be in thethigh muscles. Since L3 nerve root compression is less common, somephysiciansmaynotbeasfamiliarwiththispattern.

Radiatingpain

In some cases, when the pain is very severe or persistent, the person canactuallyperceivethepainasoccurringpartiallyintheoppositelegaswell.Thisprobablyhas to dowith how the bodyhandles profoundpain signalswith theoverflow from one side spilling onto to the opposite side. Recent researchindicatesthatthephenomenonofoppositesidepain(contralateralpain)maybedue to the activation of the glial cells that are present in the spinal cord.Normally, these glial cells providemuch needed nutrient support to the nervecells, but in certain situations, like profound pain, the glial cells can becomeabnormallyactivated,andthisactivationhasbeenassociatedwithpainspreadingto the opposite limb. There are no medical treatment strategies currentlytargetingtheglialcellactivationprocess;however,ithasbeenhypothesizedthatearly,aggressivepaintreatmentmayhelppreventthechangesleadingtochronicpainstates.

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13. Dollinger, V., A.A. Obwegeser, M. Gabl, P. Lackner, M. Koller, and K.Galiano. 2008. Sporting activity following discectomy for lumbar discherniation.Orthopedics31(8):756.

14.Teli,M.,A.Lovi,M.Brayda-Bruno,A.Zagra,A.Corriero,F.Giudici,andL.Minoia.2010.Higherriskofduraltearsandrecurrentherniationwithlumbarmicro-endoscopicdiscectomy.EurSpineJ[Epub].

Q&AwithDr.Murinson

What is the difference between a disc bulge, a disc protrusion, and aherniateddisc?

Adiscbulgeisabulgingoutofadiscinsuchawaythatthereisnofundamentalcompromise of the ordinary relationship between the disc core (nucleuspulposus)and the toughexteriorof thedisc (annulus fibrosis).Discbulgesareincredibly common. There is no evidence to suggest that a disc bulge isnecessarily painful, and a disc bulge alone, in the absence of other spineproblems,shouldnotresultinacompressednerve.

Adiscprotrusion isa focalpouchingoutof thenerve. Inmanyinstances,adiscprotrusionisfelttorepresentatypeofdischerniationinwhichthecoreofthe disc has breached the tough outer ring, but has not extended through theligament (posterior longitudinal ligament) that lies between the disc and thespinalcanal. In some instances,adiscprotrusion isa radiologist’s term that isusedwhenadiscbulgeassumesaparticulargeometrysuchthatthediscpouchesoutverysharplyfromtheregularcontoursofthedisc.

Adischerniationisanabnormalstateinwhichtheinnercontentsofthedisc(nucleuspulposus)havepushedthroughthetoughexteriorofthedisc.Whether

thedisccontentshavepusheduptotheposteriorlongitudinalligament,pushedthroughtheligament,orburstthroughtheligamentandseparatedfromthediscproper determines whether the herniation will be described as a containedherniation, adiscextrusion,or a sequestereddischerniation, respectively. It isimportant to distinguish between the different forms of herniation as thetreatmentsandlikelihoodofsuccesswillvaryaccordingtothediagnosis.

MydoctorsaysIhaveadiscfragment.Whatisthat?Occasionally,theforceofaninjurythatleadsadisctoherniateisso great that a piece of the disc literally breaks off as the disc contents burstthrough the tough outer covering of the disc. This is referred to as a discfragment or a sequestered disc. To visualize the difference, first imaginesqueezingsometoothpastefromatubewithyourhandsasyounormallywould.The ribbon of toothpaste usually stays attached to the tube until you stopsqueezing andmove your toothbrush away.Now imagine you took that sameuncappedtubeoftoothpaste,placeditonthefloor,andstompedhardwithyourfoot. The toothpaste would fly out of the tube and a piece of the toothpastewouldseparate fromthe tubeand the restof the toothpaste.This is likeadiscfragment; when it is separated from the rest of the disc, it can move aroundwithinthespinalcanal,potentiallylodgingupagainstanerverootandcausingseverepain.

Discfragmentorsequestereddiscpushingonthenerveroot.

CHAPTER3

TornandPainfulDiscs

Physicaltherapy,patience,andmultiplemedicationsareoftennecessary.

theDIAGNOSIS

>Doyouhavepainlocatedprimarilyinthemid-line(center)oftheback?>Doesyourpainseemtoworsenwithalmostanyactivity?

Painthatismoststronglyfeltinthecenteroftheback(atthemid-line)andgetsworse with sitting, standing, rising up, bending forward, or coughing andsneezing is usually due to disc injury.Youmayhave a torndisc, especially ifyourpainstartedfairlysuddenlyafteranaccident,liftingsomethingtooheavy,orsomeotheridentifiablemishap.

Sometimes,discpainrelatestoanaccumulatedinjuryandmaybeassociatedwithdamagetothetoporbottomofthedisc.Inbothofthesesituations,thepaincanbemild-to-moderatewhenaperson is resting theback,aswhenheor sheliesstillwiththelegssupportedorwiththebodycurledupinfetalposition.Thispaincansuddenlygetworsewithstandingorsitting,aspressureonthediscrisesrapidly in these positions. If this sounds like your situation, you may havediscogenicpain.Readon!

thePRESCRIPTION

Back pain due to a damaged disc presents special challenges and requiresknowledgeable medical assessment and care. Because the disc is not a bonystructure,itcannotbeseenonX-ray,andforthisreason,anMRIofthebackwillbeneededasafirstdiagnostictestwhendiscproblemsaresuspected.Discpaincanbeexpectedtohaveamuchlongerrecoverycoursethanpainduetosimplemusclestrain.Discpainmayrespondtoanintensivecourseofphysicaltherapyandcanevenbenefitfrompainmedicineinjections.

Ifyouhaveatorndisc(sometimesreferredtoasanannulardisctear):• Your doctor should recommend physical therapy, especially if there issubstantialpainwithmovement.-Physicaltherapycantakealotofeffort.Especiallyafterthefirstphaseswhere the focus of therapymay be getting youmore comfortable andreducing associated muscle spasm, you’ll be expected to do specificexerciseseveryday.

-Sometimesphysical therapyseemstomakethepainabitworse; this ispartofthestrengtheningprocesses.Severepainshouldbediscussedwithyourdoctorandtherapist,butacertainamountofrecuperationpainistobeexpected.

• Your doctor should prescribe or recommend somemedicine to control thepain.-Makesure thatyouunderstand the instructionsfor taking themedicine.When pain is limiting your ability to work, make sure you ask abouttaking themedicine“around theclock”orona“time-contingent”basisratherthan“asneeded.”

- Be aware of potential side effects (bothersome symptoms that arise inpeople taking themedicine)aswellas thepotential foradverseevents.Adverse events are more problematic than side effects; they will varydepending on the pain medicine used, and can include a risk ofgastrointestinalbleeding,severeconstipation,orotherproblems.

•Yourdoctormayreferyoutoapainmedicinespecialist,especiallyifthereisaseveredegreeofpainthat isnotrespondingfullytomedicationsthatyoutakebymouth.-Foranisolateddisctearwithseverepain,injectionscanhelp.

-Injectionofmedicineintothediscareaisassociatedwithimprovedpaincontrolinthefirstweeksafterinjection.

- Long-term effects are minimal; if you’d rather not have an injection,don’tworrythatyourprospectsforrecoveryarenecessarilydimmer.

-Whenadisctearispartofamorecomplexbackproblem,injectionscanhelpdefinethecomponentsthatarecausingpain.

Ifyouhaveadisrupteddisc(sometimesreferredtoasend-platedamage):•Yourdoctormayrecommendphysicaltherapy.• Your doctor should prescribe or recommend somemedicine to control thepain.

•Your doctormay recommend that you see an interventional painmedicinespecialistbecauseinjectionscansometimeshelp.

•Inseverecases,yourdoctormayrecommendasurgicalevaluation.

TheGoodNewsPeoplewithtorndiscstypicallyrecoverfully.

Theprocessofrecoverycanleaveyouwithastronger,healthierback.

Adiscwithamajortear.Notethetornedgesofthediscandthedisccorematerialpushingthrough.

WhentoSeeaPhysiatristSomedoctors don’t recognizedisc tears as a potential sourceof strongpain,and theymaydismiss the report of these findings in theMRI report. If yourback hurts a lot and your doctor says there’s nothingwrong,make sure youhave copies of all your back images and the reports of those, then find aprovider who is very knowledgeable about back problems. Often times,physical medicine and rehabilitation specialists known as physiatrists areespeciallyattunedtoproblemsrelatingtoinjuryandrepairofthespine.

WHATIFYOURDOCTORDIAGNOSESABULGINGDISC?

Inthiscase,physical therapyandexerciseareusuallybest.Bulgingdiscshavebeen reported to be very common in the normal, “pain-free” population.Nonetheless,peoplevarygreatlyinthedegreeofpaintheymayexperienceforaparticular problem. If your doctor reports that a bulgingdisc is the only thingwrongwithyourbackandyoustillcannotfunctionproperlydue tobackpain,youmaywanttolookelsewhereforanswersandsupport.

Aslongasyoudon’thaveanyoftheredflags(seeChapter1)ofbackpain,it’s usually okay to pursue a course of back strengthening and stretching.Physical therapy isn’t likely to produce lasting damage and can result in astrongerbackthatputslesspressureonanirritateddisc.Youmaywanttoreadthroughthesecondhalfofthisbookwherelifestylechoicesforabetterbackarecoveredindetail.

WHATIFYOURDOCTORFINDSTHATYOUHAVEDISCDEGENERATION?

Asthebackages, thediscsgraduallybecomelessspongyandresilient.Thisisnotnecessarilyassociatedwithpain,andinfactmayreducethechances thatadiscwillbeherniatedwhensubjectedtostrongstresses.Aseverelydegenerateddisccanbeassociatedwithpain,whetherduetochronicinflammation(arthritis),alossofthedischeightleadingtonerverootcompression,orchronicactivationof pain fibers in the area. There are some cases where a degenerated disc issevere enough to warrant surgical intervention. Degeneration of the spine iscoveredinmoredetailinChapter11.

In rarecases, centralbackpainmaybedue toamass (tumor), an infection(abcess),oraspinalmalformation.Thesecausesofcentralbackpainarereadilyassessed throughMRIand theotherdiagnostic tests that arewidelyused.Thetreatmentfortheseconditionsisindividualized.

Cutawayviewofthespineshowingthelocationofthevertebralendplaterelativetothedisccoreandtheouterringofthedisc.

TheTreatmentWhen your doctor recommends physical therapy, realize that this is a

wonderfulpartofmodernmedicine.Mostphysical therapistsaredrawnto thiswork through an intense desire to promote human health and fitness. Severaldifferent kinds of treatment are included in the realm of physical therapy thatwill be useful for the treatment of vertebral disc problems: thermal therapies,manual therapies, electrical stimulation therapies, traction/inversion therapies,andconditioningandstrengthening.

THERMALTHERAPIESAREHOTANDCOLD

Althoughwe traditionally think of using ice during the first forty-eight hoursafter an injury, ice continues to be a useful part of pain control and improvesoutcomes with physical therapy. Because your physical therapy program willprogresstoexercisesthatwillpushyourmusclestonewlevelsofstrengthandperformance,icemaybeusedattheendofsessions.Icingthenwillhelpreducethe pain of muscle strain and stress on the disc as you are working on thestrengthening and conditioning parts of the physical therapy program. If yourphysicaltherapistisnotofferingiceattheendofeachsessionandyouthinkitwould be helpful, go ahead and ask. The best physical therapists are open tosuggestionsandwillcheckwithyourdoctoraboutthisifnecessary.

MANUALTHERAPIESREDUCEPRESSUREONTHEDISC

One way that manual therapy can help is by addressing the position andalignmentofthevertebrae.Althoughnotallphysicaltherapistsareskilledinthisarea, some have the capacity to make gentle adjustments to the spine andimprove the alignment of the vertebral column. This can really relieve thepressure on a disc as the bones are coaxed back into their proper relativepositions. Another way that manual therapy can help is by addressing theprofoundmusclespasmsthatfrequentlyaccompanydiscdamage.

ELECTRICALSTIMULATIONTHERAPYISWIDELYACCEPTED

In this technique, small, rapid electrical impulses are transmitted to the bodythrough“sticky-pad”electrodes.Theseelectricalimpulsescancausethemuscletorelax,whichmayloosensomeofthepressureonthediscthatnearbymusclesinspasmcanproduce.Becausetheinjureddiscsignalspainto thespinalcord,andthiscanresultinareflexsignaltoneighboringmusclestocontract,musclespasmisafrequentaccompanimenttodisc-relatedpain.

TRACTIONANDINVERSIONTHERAPIESAREHELPFUL

Withtraction,thediscwillbulgeless,andtherestingpressureonthediscwillbelowered, potentially relieving pain.Traction can range frommilder forms thatinvolve putting the legs up on a triangular bolster to more aggressive forms,whichrequiretheuseofweightsandevenbelts.Inversiontherapycanbeveryeffective in reducing painful pressures on injured discs. There are differentapproachestousinginversioninaphysicaltherapyregimen.(SeeChapter20.)

STRENGTHENINGANDCONDITIONINGAREMAINSTAYS

There are many great exercises to help strengthen the back muscles. Yourphysicaltherapistcanguideyouthroughasequencethatismostappropriatetoyourbackandpainlevel.Agoodplacetostartafteradiscinjuryisbydoingthepelvic tilt exercise. In this exercise, you strengthen the anterior abdominalmuscles that are socritical to supporting the spine.Youbeginby lyingon thebackwiththehipsflexedandthekneesbent.Gentlyatfirst,butgraduallymorestrongly,tightentheabdominalmusclesasyourollthefrontofthepelvistowardthe chest. If you are having strong back pain, thismovementmay need to bevery gentle at first; an almost subtle change in position may be all that ispossiblewithout increasingthepain.Holdthispelvic tilt for threesecondsandthenrelax.Repeatthisfivetimesonthefirstday,butincreasethelengthofholdandthenumberofrepetitionseachday.

ADVANTAGESANDDISADVANTAGESTOPHYSICALTHERAPY

Keep in mind that physical therapy is very effective for many types of backtrouble, especiallyproblems relating todiscs.Onegreat advantageofphysicaltherapyisthatitcanturnthefocusofyourattentionawayfromwhatiswrongandgraduallyimproveyourabilitytodothethingsyouenjoy.Byreducingtheneedformedicationoverthelong-term,physicaltherapycanhelpyouavoidtheawful side effects ofmost painmedications:mental cloudiness,memory loss,sleepiness, constipation, and sexual dysfunction. In fact, increased physicalactivitycanhelpimprovemood,memory,andsleep!

On the down side, physical therapy does frequently result in a temporaryincreaseinpainordiscomfort.Ifyou’rehavingalotofpainafterPT,makesuretoletyourtherapistknow.It’snormaltofeellikeyou’veworkedhardinphysicaltherapy,andsometimesit’sokaytofeelabitmorepain in thefirstdayor twoafteraphysicaltherapysession.Ifyourbackpainisbadenoughtointerferewithactivitiesatworkorhome,youshouldseeksomephysicaltherapyandexpecttoworkhardonyourwaytogettinggreatresults.

PainMedicationInjections

If you are referred to an interventional pain specialist right away, chances arethatyourdoctorthinksaninjectionofpainmedicationmaybehelpfultogettingyoubackontrack.Theinjectionofpainmedicationintotheareaofaninjureddisc is awell-establishedpainmedicine technique that canbeveryhelpful fortheimmediatereliefofpain.

Thelimitationsofthisapproacharethatinmanycases,theinjectionwillnotresultinlastingimprovements,andclinicaltrialshavesuggestedthattheeffectsonlong-termfunctioncannotbeproven.Moreover,thesepaininjectionscannotbe repeated over and over. This is because, in addition to local anesthetic—whichprovidesimmediatepainreliefbutwearsoffoverthecourseofadayortwo—mostpaininjectionsalsoincludealongorintermediate-actingsteroid.Thesteroid ishelpful in termsofprovidingpain reliefover thedays toweeks thatfollowthe injection.Theproblemis thatsteroids,whengivenrepeatedly,havebeen associated with problems like abscess formation, diabetes, osteoporosis,andworse.For these reasons, apain injection fordisc injury isbestusedas abridgingstrategytogetapersonoveraroughpatch,pain-wise.Itisnotalong-termsolution.Nonetheless,ifthepainisunbearableandisinterferingwithyourabilitytofunction,gettingsomeimmediatepainreliefisvaluableasagoal.

NERVE-DESTROYINGCHEMICALSWORKTEMPORARILY

The injectionofnerve-destroyingchemicals intoanarea is intended todisruptthepain-sensingfibersandblockpainsignalsarisingfromaninjuredorirritatedarea in the back. The problem with this approach is that nerves will almostalwaysgrowbackandsometimesmorepainfullysothanbefore.Thelong-termoutcomesofpatientsreceivinginjectionsofnerve-destroyingchemicalsforpainhave indicated that pain problemsmay be better temporarily, but often returnworsethaneverovertheensuingfewmonths.

What’sNew:TheEuropeanGastro-ProtectiveViewTheprimarylimitationofusingNSAIDsistheoccurrenceofseriousproblemsinthedigestivetract,includingbleedingfromthestomachandintestines.Thenumber of people who experience life-threatening bleeding with the use ofNSAIDsisbelievedtobemuchhigherintheU.S.thaninEurope.Thereasonforthisisthoughttobethewidespreaduseof“gastro-protective”medicationsincombinationwithNSAIDsinEurope.BecausethephenomenonofbleedingfromthestomachissocommonwithNSAIDs,somedoctorshaveadoptedthestrategy of always prescribing a medicine to protect the stomach wheneverNSAIDsareprescribed.

Yourdoctormay recommend thatyou take ibuprofenwithmeals. InEurope,they go one step further and instruct patients to take an acid-reducingmedicationatthetimeofusingNSAIDs.Examplesofthesemedicationsmightinclude ranitidine (Zantac), cimetidine (Tagamet), or Omeprazole (Prilosec).Someofthesemedicinesarenowavailableoverthecounter,meaningtheycanbeobtainedwithoutaprescription.

Although it’s sometimes uncomfortable to think about taking twomedicineswhen only one is really needed, evidence indicates that Europeans are verysuccessful in preventing the bleeding complications of NSAIDs, whereasestimates are that 30,000 Americans each year requiremedical attention forgastrointestinalbleedingduetoNSAIDs!MakesureyoudiscussbothNSAIDsandanti-ulcer(gastro-protective)medicationswithyourdoctor.

SPINALCORDSTIMULATIONMASKSPAINWITHABUZZ

Ifyourdisc-relatedpainproblemisverychronicandpainful,yourdoctormayspeakwithyouaboutaspinalcordstimulatortrial.Thespinalcordstimulatorisahigh-techapproachtoapersistentpainproblem.Itrequirestheplacementofaprecision-engineeredelectricalcontactstripontheposteriorsurfaceofthespine.Tobeeffective, the stimulator stripmustbepositionedover the spinalcord injust the right place to block the pain signal from reaching the brain. For thisreason,spinalcordstimulatorsarefirst“trialed”beforepermanentlyplaced.

While the spinal cord stimulator can be very effective in reducing thesensation of pain, it does nothing to correct the underlying problem with theback.Whenthestimulatoriscorrectlypositionedandturnon,mostpeoplewillfeel a buzzing or tingling sensation in place of their usual pain.Although thebuzzingcanfeelratherdistractingatfirst,itismuchpreferabletothesensationofstrongpain.

Thestripelectrodeisconnectedviawirestunneledundertheskintoacontrolunitthatisoftenlocatedjustundertheskininthelowerabdomen.Thecontrolunit contains batteries and a programmable control element. Working with atrained specialist, a personwhohas a spinal cord stimulator canprogressivelychange thesettings to fine-tune theareaofcoverage (thepartof thebody thatperceivesthebuzzing)aswellaschangingthestimulusprogrambyincreasingordecreasing the intensity and pattern of electrical signals to the stimulator’scontactstrip.Althoughmanypatientsreportdramaticpainreliefwiththespinalcord stimulator, it is often the case that some pain medication will still berequired for optimal pain control. The advantage is that pain control is oftenbetter overall after the stimulator and even ifmedications continue, doses areoftenlower,leadingtofewersideeffects.

TakingMedicationsbyMouth

Disc-related pain can be very strong in the first severalweeks after an injury.Whatdistinguishesdisc-relatedpainfromanordinarymusclestrainisthemuch,muchlongertimethatisrequiredformostpeopletorecoverfromadiscinjury.Musclestraintypicallylastsafewdays;discpaincanlastthreetofourmonthsin the more severe cases. In addition, the pain due to a disc injury typicallyrelates to the degree of inflammation that occurs after a disc injury.Althoughsomeinflammationisneededforhealing,theusualexperienceisthatcontrollinginflammationwillspeedrecoveryanddecreasepain.Forthisreason,itisusuallynecessarytotakemedicationsthatcontrolbothinflammationandpainafterdisc

injury;morethanonemedicationmaybeneeded.

NSAIDSBLOCKPAINSIGNALS

Onemainstayof treatment for disc-related backpain is the non-steroidal anti-inflammatorydrug,orNSAID.NSAIDsarevaluablemedicationsbecausetheybothblockpainsignalingandcanreducethebody’sinflammatoryresponsestotheinjury.Abroadclassofdrugs,NSAIDshavebeenwidelyusedbymillionsand millions of people.1 Although there are rare cases of allergy and drugreactions, formost people thesemedicines are extremely effective at reducingpain, and when used properly, are quite safe. The best known NSAID isibuprofen,soldasAdvilandMotrin.

Ibuprofen is a very effective pain-reducing medication. Available at yourpharmacy,ibuprofencomesin200mgtablets.Therecommendeddosageforanadult is usually two tablets. There are important guidelines for using thismedicationof thebottle,sopleasereadthefineprint.At the400mgdose, themedicationisexpectedtorelievepainforfourtosixhours.Thiscanmeanthatyou’dgetpartwaythroughanight’ssleepandwakeupinpain.Anotherfactoristheweightorsizeofthepersontakingthemedicine.Apersonweighing110lbswillgetmorebenefitfromthisdosagethana240-lbperson.Youshoulddiscusswithyourhealthcareproviderwhetheribuprofenisthebestmedicineforyou.Insome cases, physicians will prescribe a stronger dose of ibuprofen, butremember,themoremedication,themoresideeffects.Thehigherdoses,whilepotentially more effective, will increase the risk for gastrointestinal bleeding.You should not fill a prescription for high-strength ibuprofen withoutunderstandingyourgastro-protectivestrategy.

AnotherNSAIDgainingpopularityisnaproxen,whichissoldunderseveralnamesincludingNaprosynandAleve.Yourdoctorcanprescribethismedication,butitisnowavailableoverthecounteraswell.Thismedicineisusedatdosesthat begin around 200mg. Formany people, thismedication is very effectiveagainstpain,andithastheadvantagethatpainreliefmaylastlonger,perhapssixtoeighthours.Youdoctorcanprescribelonger-lastingNSAIDsormedicationsthathaveadifferentside-effectprofile.Insomecases,aphysicianwillchoosetoprescribeopioidsforbackpain.

You will need to communicate clearly and calmly with your healthcareprovider aboutyourpain. If you feel likeyou’rebeing ignored, patronized, orbelittled, try to findanotherproviderwhowill listen toyour reportofpain. Ifyoureallydohaveadiscinjury,therecoverycoursecanstretchoutoverseveralweeks and sometimes a fewmonths.You don’twant to be inmore thanmild

painforthatlongaperiod.Sometimesmakingapaincalendaroradailylogofyour pain intensity, recorded on a zero-to-ten scale, can be a helpfulcommunication tool andmay illustratewhat you’re going through to someonewho would otherwise have difficulty understanding how serious the problemreallyis.

Warning!ForThoseatRiskforHeartandKidneyDisease

NSAIDsareassociatedwithasmallincreaseintheriskofheartattackandacute kidney failure.2,3 Both of these effects are very, very small atordinarydosesofthesemedicines,butifyouareatriskforheartdiseaseor have a family history of kidney disease, you should discuss theseconcernswithyourdoctorsothataninformeddecisioncanbemade.Youmay want to learn more by visiting the American Heart Association’swebsiteforpatients:www.hearthub.org.Ifyouhavehighbloodpressure,ariskfactorforbothheartdiseaseandkidneydisease,youshoulddiscussNSAIDswithyourdoctorbefore startingacourseof therapywith thesemedicines.

MULTIPLEMEDICATIONSMAYBENECESSARY

Thepainofadiscinjurymaybeduetomultiplemechanisms:onerelatingtotheactualpain-sensingoftheinjury,onerelatedtotheinflammationthatresultsasyourbodytriestorepairthedisc,andonerelatedtotheresponseofthenearbynervestothereleaseofnerve-irritatingsubstanceswhichmayhavebeenreleasefrom the disc at the time of injury. For this reason, it is very important torecognize that more than one medication may be needed to control the pain.People with disc injuries may require one medicine to help reduce theinflammation-related component of pain (an NSAID, for example), onemedicine to help control the pain (sometimes an NSAID, sometimes anothermedication),andonemedicinetoreducetheneuropathicpain,ifanyispresent(amedication suchasgabapentin, for example).Although it’s alwaysbetter tokeeptoonemedicineforaproblemifoneisenough,thereareusuallymultipleaspects contributing to pain after disc injury, and multiple medicines may beappropriate. Make sure to discuss this with your doctor or other healthcareprovider.

TestingForDiscInjurySomedoctorsmayresistorderinganMRI,as theyhavebeentaught thatall

backpainnotassociatedwithdemonstrablenerverootdamageisbesttreatedbyordering the least number of tests and by dispensing more pain killers. Theproblemwiththisapproachisthatitdoesnotrecognizetheveryspecialneedsofpatientswithdiscproblems.

MRIPLAYSANIMPORTANTROLEINDIAGNOSIS

MagneticResonance Imageshavebeenveryhelpful inclarifying thenatureofdiscinjury.Infact,MRIisessentialfordefiningdiscinjuryasacauseofbackpain.Onewell-researched study concluded that itwas impossible tomake thediagnosisofdiscinjuryonclinicalexamaloneandthatMRIwasrequired.4

ThevalueofMagneticResonanceImaging(MRI)inguidingthetreatmentofpeople with low back pain has been dramatically downplayed in the medicalliterature.Discpainisterriblyintenseformany,ifnotmost,people.Ittakesanexceptionallylongtimetorecoverfromnewdiscpain,andMRIisquitegoodatdetecting new disc damage. In fact, a 1992 study showed that MRI veryselectively identified peoplewith disc damage (few false-positive results) andwasverypowerfulintermsofpredictingseverediscdamage.Thereallimitationmay be that many doctors are not properly educated about recognizing disc-

relatedbackproblems—theymaynothavehadmore thanoneor twohoursofeducationaboutspineproblemsinallfouryearsofmedicalschool!

WhatWeDon’tKnow:RecoveryTimesAfterDiscInjuryThereisnodefinitivestudydescribingthetimecourseofrecoveryafteradisctear or a diagnosis of internal disc disruption. As with any study, there arelimits,butbetterinformationaboutwhattoexpectintherecoverycoursefromdiscinjurywouldbemostwelcome.Staytuned!

If youhavebackpain, gettinganMRIcanbe thedifferencebetweennightandday.By identifying a significant disc problem, you can anticipate amuchlonger recovery course thatwill requiremore intensive efforts at pain controlandmorephysicaltherapy.Ifyoudon’thaveanMRIandyouactuallydohaveaninjureddisc,youwillmostlikelyhavesubstantialpainthattakesalongtimeto improve; however, youwon’t have a lot of physical evidence to prove thatyou have a real problem. You may experience pressure from your employer,your health insurer, and others to get back towork.Because disc injuries cantakeweeksandsometimesmonthstoheal,youwillbefacedwithaverydifficultsituationtryingtodefendyourpainasrealandpossiblybeingpressuredtomakechoicesthatwill interferewithspeedyandfullrecovery.Ifyourdoctorfails torecognizethetruenatureoftheproblem,youmayendupwithadeniedclaimforshort-termdisabilitycoverage,orworseyet,outofajob.5

PROVACATIVEDISCOGRAPHYISAMOREINVASIVETESTFORPAIN

Provacativediscographyisatestwhereinasmallcatheter-needleisplacedintothe core of the disc using fluoroscopic (multi-directional, low-intensityX-ray)guidance.Oncepositioningof thecatheter-needle in thedisccoreisconfirmedwith dye, tracer is injected into the disc under pressure. The pressure is quiteintense and is intended to stress the disc, partially simulating the pressures ofbendingandlifting.Ifthispressurizationofthedisccausespainthatislikethepainthepatientnormallyfeels,itwillbelabeled“concordantpain.”Forthetesttobe trulydiagnostic,however, thedoctorperforming the testmustalsoplacethe catheter-needle into at least one other disc in the back and pressurize thatdisc.Ifthatdiscisnormal,itshouldnotreproducethepainthatisusuallyfelt.

Tracerisusedintheseinjectionsbecauseitallowsthedoctortoalsomakeanassessmentofthephysicalintegrityofthedisc.Ifdyestayscontainedwithinthecoreofthedisc,thenthediscstructureisnormal.Ifdyebeginstoleakoutanddemonstratescracks,tears,orrupturesofthediscstructures,thisissupportiveofinternaldiscdisruptionasadiagnosis.Partofthisstudyisexpectedtosomewhatpainful,butitshouldoccurinacontrolledsettingandanyseverepainshouldbereportedto thestaff immediately.For the test tobemosthelpful, thosepresentshouldnottellthepatientwhichdiscisbeingtestedpriortoputtingpressureintothesystem,asthiscouldinfluencetheoutcomeofthetest.6

TheExplanation

Central back pain that worsens with standing or pressure on the back is the

classicdescriptiongiventopaincausedbyaninjuredvertebraldisc.Mostoften,centralbackpain isachallengebecause the limitationsonhowmuchapersoncanmovewithoutprovokingpaincanbeveryconstraining.Formostpeople,it’simpossible towork a normal schedule if every time you sit or stand formorethanfiveminutes,yourbackbeginstoscreamoutinpain.

ANATOMYOFADISC

The vertebral disc is a sometimes tough, sometimes resilient structure in theback that iscentral tomaking thespinebothflexibleandstrong.However, thedisc is subjected tomanypressuresand strains, especiallywhenheavyobjectsareliftedorwhenaccidentalinjuryoccurs.Adiscthatisinjuredordamagedbytearing at the edge can push into the adjacent vertebral bone, causing damagethere.Althoughthecenterofthediscdoesnotcontainpainfibers,theedgesarerichly innervated and pain fibers can proliferate after injury, making thechronically stressed disc more susceptible. The damaged disc can becomeextremely painful, but taking the right steps can improve your chances ofmakingpeacewithit.

THERESILIENTDISCCORE

The central core of the disc, or nucleus pulposus, is designed for durableresilience. It ismadeupofa spongy,gelatin-like substance.Although thegel-likecenterof thediscfunctionsverywellearly in life,over timethedisccoredesiccatesordriesout.Thisdesiccationprocessisconsiderednormal.OnMRIscans, it is possible for the radiologist to observe this drying out of the disc.Desiccateddiscsare thought tobemore resistant toherniationbutpresumablythe other forms of disc damage such as tears, dislocations, and internal discdisruptionareevenmorelikely.Discdesiccationisthoughttobeanirreversibleprocess,and thecenterof thediscdoesnot regenerateas farasweknow.Thecore of the disc does not contain any blood vessels and does not have anynerves: it is understood that the gel-like filling of the disc is a hostileenvironmentforlivingstructuressuchasnervesandbloodvessels.

Cut-awayviewofthespineshowingavertebralendplate

THEDISC’SOUTERRING

The outer part of the disc is a tough fibrous ring called theannulus fibrosus.Composed of many layers of strong collagen, the annulus complex serves toflexibly connect adjacent vertebral bones and contain the disc core material(nucleuspulposus).7Unlikethedisccore,theannuluscontainsbloodvesselsandnerves,usually just in theoutermostportion.Thebloodvesselsandnervesareimportant fordeliveringnutrients to theannulus, allowing for sensations tobeperceivedfromthearea,andprovidingthecapacityforrepair.Evidencesuggeststhat when discs are chronically damaged, the nerves in the outermost portionwillsproutinward,growingtowardthecenterofthedisc.Unfortunately,nervesthatsproutarepredominantlyofthepain-sensingvariety.Thisin-growthofpain-sensingfibersafterexcessivechronicbackstrainmayexplainwhysomepeoplehave discs that are especially painful following injury while others seem tobouncebackquicklyafterthesameexperience.8Itmayalsobethatovertime,ifthebackhasachancetorecuperateproperly,thepain-sensingnervefibersmaydieback to theiroriginal locationsand thebackmayonceagainbecomemorerobustagainstvariousinsultssuchasridinghorses,ridinginthebackofaschoolbus,orbouncingalongthebackofapick-uptruck.

Nervesreachingintothedisc

The outer part of the disc, unlike the core, has a capacity for repair afterinjury, although this capacity isquite limitedandoftentimes seems toadvanceveryslowly.9Thecapacityofthedisc’souterringtorepairis,inpracticalterms,restrictedtoinjuriesthatinvolveannulartears.(Moreseriousinjuries,likethoseresultingindischerniations,mayrequiresurgicalintervention.)Anannulartearis a rip in the fibrous-ring that surrounds the disc core.Often, the tear in theannulus is limited to theouterportion,as if theoutermost fibershadrippedortorn from the stress placed on the spine at the time of injury. Under somecircumstances,multiple tearsare located inoneormorediscs.Sometimes, thedisc’sringcantearinsuchawaythattheinnermostfibersoftheringseparatefromtheoutermostfibers.Therepairprocessinthedisctakesweekstomonthstocomplete;during that time, thebackwillnotbeasstrongas it isordinarily,andthepersonwiththediscinjurymayexperiencehighlevelsofpainandmayevenexperiencepainthatextendsdownintotheleg.10

THEDISC-ENDPLATE

Thedisc-endplateistheplacewherethetoporbottomofthediscconnectstothevertebralboneaboveorbelowthedisc.Inrecentyears, thevertebralend-platehas come to be recognized as an important location of disc disruption andpotential cause of pain.11 The disc-endplate can essentially shatter (like awindowinablastzone)whenadiscissuddenlypressurized.Theendplateisastructure with both blood vessels and nerves, and so the response to injuryincludes swelling, pain, placement of repair tissue, and ultimately re-establishment of a durable solid structure.12 Damage to endplates is readilyvisible onMRI and these damage-related alternations have been calledmodicchanges.Studiesofpeoplewithbackpainand thosewithoutpainhaveshownthatdiscbulgesarenotlikelytobeacauseofpainformanypeople.13End-platechanges,however,areassociatedwithpainformanypeopleandlikedisctearsmaytakealongperiodtorepair.

CHAPTERRESOURCES

1. World Health Organization (WHO). “WHO Model List of EssentialMedicines,”http://whqlibdoc.who.int/hq/2005/a87017_eng.pdf.March2005.

2.Lafrance,J.P.andD.R.Miller.2009.Selectiveandnon-selectivenon-steroidalanti-inflammatory drugs and the risk of acute kidney injury.PharmacoepidemiologyandDrugSafety18:923–931.

3.VanStaa,T.P.,S.Rietbrock,E.Setakis,andH.G.Leufkens.2008.Does thevaried use of NSAIDs explain the differences in the risk of myocardialinfarction?JournalofInternalMedicine264:481–92.

4.Schwarzer,A.C.,C.N.Aprill,R.Derby, J.Fortin,G.Kine, andN.Bogduk.1995.Theprevalenceandclinicalfeaturesofinternaldiscdisruptioninpatientswithchroniclowbackpain.Spine(PhilaPa1976)20(17):1878–83.

5. Aprill, C. andN. Bogduk. 1992. High-intensity zone: A diagnostic sign ofpainfullumbardisconmagneticresonanceimaging.BrJRadiol65(773):361–9.

6.Schwarzer,A.C.,C.N.Aprill,R.Derby, J.Fortin,G.Kine, andN.Bogduk.1995.Theprevalenceandclinicalfeaturesofinternaldiscdisruptioninpatientswithchroniclowbackpain.Spine(PhilaPa1976)20(17):1878–83.

7.Gruber,H.E.,J.Ingram,K.Leslie,andE.N.HanleyJr.2008.Geneexpressionof types I, II, andVI collagen, aggrecan, andchondroitin-6-sulfotransferase inthehumanannulus:Insituhybridizationfindings.SpineJ8(5):810–7.

8.Schellhas,K.P.,S.R.Pollei,C.R.Gundry, andK.B.Heithoff.1996.Lumbardisc high-intensity zone: Correlation of magnetic resonance imaging anddiscography.Spine(PhilaPa1976)21(1):79–86.

9.Yeung,A.T.andC.A.Yeung.2006.In-vivoendoscopicvisualizationofpatho-anatomyinpainfuldegenerativeconditionsofthelumbarspine.SurgTechnolInt15:243–56.

10.Peng,B.,W.Wu,Z.Li, J.Guo, andX.Wang.2007.Chemical radiculitis.Pain127(1–2):11–6.

11.Jensen,T.S.,J.Karppinen,J.S.Sorensen,J.Niinimäki,andC.Leboeuf-Yde.2008.Vertebralendplatesignalchanges(Modicchange):Asystematicliteraturereviewofprevalenceandassociationwithnon-specificlowbackpain.EurSpineJ.17(11):1407–22.

12. Moore, R.J. 2006. The vertebral endplate: disc degeneration, discregeneration.EuropeanSpineJournal.Vol.15,Suppl.3.

13. Rahmea, R. and R. Moussaa. 2008. The modic vertebral endplate andmarrow changes: Pathologic significance and relation to low back pain andsegmental instabilityof thelumbarspine.AmericanJournalofNeuroradiology29:838–842.

14.Schwarzer,A.C.,C.N.Aprill,R.Derby,J.Fortin,G.Kine,andN.Bogduk.

1995.Theprevalenceandclinicalfeaturesofinternaldiscdisruptioninpatientswithchroniclowbackpain.Spine(PhilaPa1976)20(17):1878–83.

Q&AwithDr.Murinson

Whatifmydoctordoesn’twanttotakeanMRIofmyback?Inalandmarkstudyofdiscdamage,researcherslookedatthequestionofhowtodiagnoseinternaldiscdisruption.Theyfoundthatthiswasacauseof40percentoflowbackpainintheirstudypopulation.Theyfurtherconcludedthatnoneoftheclinicaltests(testsyourdoctorcoulddointheexamroom)coulddistinguishbetween people with this problem and those without it. If your back pain issevereenoughtokeepyoufromyourworkformorethanafewdays,youmayneedanMRItosolidifythediagnosisandeffectivelyguidetreatment.14

IsthereanythingelseIcanaddtomydailyroutinetospeedthehealingofmyinjureddisc?There is some evidence to suggest that the dietary supplementglucosamine/chondroitinsulfatemaybehelpfulforreducinginflammatorypain.ThisisdiscussedinmoredetailinChapter21.Theexactmechanismbywhichglucosamine and chondroitin sulfate act to reduce inflammatory pain is notknownandforsome,theefficacyofthesecompoundsisquestionable.Thereislittleevidencetosupporttheingestionofglucosamine/chondroitinsulfateintheabsence of serious arthritis pain or inflammation, and routine usage is notsomething I recommend to patients. It is important to obtain all dietarysupplementsfromareputablemanufacturerastheproductionoftheseisnotastightly regulated as the preparation of actual medications.Glucosamine/chondroitin sulfate tablets are fairly expensive and a course oftherapymaycostmorethantwentydollars.

CHAPTER4

SciaticandOtherNerveCompressions

Simplestretchingexercisescanresolve

mildcasesandpreventrelapses.

theDIAGNOSIS

>Doyouhavepainthatstartsinthebuttockandrunsdownthebackoftheleg?

> Does your pain seem to get worse the longer you sit but ease off withstandingandwalkingaround?

Pain that runs down the back of the thigh and extends into the buttock anddiffuselyintothefootcanbeduetocompressionorirritationofthesciaticnerve.The sciaticnerve, the largest in thebody, is prone to compressiondeep in thebuttock; this pain is usually worse with prolonged sitting. There are actuallyseveral different syndromes of nerve compression that can occur in the back,buttock, or leg. Because sciatic nerve compression is most common, it isdiscussed first. Pudendal neuropathy, diabetic amyotrophy, post-herpeticneuralgia,andothercausesofnervepainaredescribedlaterinthischapter.Eachofthesehassymptomsparticulartothenervecompressed,butthefeaturesofthepainmaybesimilar.(NerverootcompressionatthespinallevelisdescribedinChapter2.)

The diagnosis of sciatic nerve compression ismade based on yourmedicalhistory, findings in thephysical exam, andpossibly imagingor evenelectricalstudies.Yourdoctormayperformsomephysicaltestingthatisuncomfortable.Ifanyofthetestsprovokesstrongpain,makesuretospeakupandletthedoctorknowwhatyou’refeeling.Thedoctormaybendyourlegsandapplypressure.Insomecases,anexaminermaypressdeeplyintothebuttock,tryingtodetermineifthereisappreciablemuscletightnessordeeptendernessthere.Iftheproblemisverysevereorlingersdespitetreatment,imagingorelectricaltestingbecomesmorelikely.

Nervecompressionpainisparticularlydistressing.Itcanbeburning,deeplyaching, or stabbing and producing electrical shocks. If you have pain that haselectricalshocksfromtimetotime,thisisastrongindicatorthatnervedamageispartoftheproblem.

SciaticNerveCompression

Sciaticnervecompression issometimes labeledsciatica,but that’snotentirelycorrect.Sciaticaisatermthatoriginatedinthefifteenthcenturyandwasusedatthattimetodescribepaininthehip.Ithasbeenusedformanyyearstodescribepain that is primarily experienced down the back of the leg.1 It is a broadumbrellatermlikethewordsheadacheordepression,whichactuallyencompassmanyspecificmedicalconditions.

Themedicalcausesofsciaticaasasyndromeofback,buttock,andlegpaininclude compression of the 4th or 5th lumbar nerve roots in the back,compression of other nerve roots, problems with the sacroiliac joint, andcompressionof the sciaticnerveas it courses from the spine into the leg.Themost common location for the sciatic nerve to be compressed outside of thespinalcordistheplacewhereitrunsbetweentwomusclesdeepinthebuttock.Compressionof thesciaticnervein this locationisfrequentlycalledpiriformissyndrome.2,3 It often occurs in the setting of trauma: car accidents, falls, andskiingaccidentsareexamples.Althoughpiriformissyndromeisrathercommon,it is often overlooked in medical school to the extent that the diagnosis istypicallyfirstsuggestedbythephysicaltherapistratherthanthedoctor!

PINCHEDNERVE

thePRESCRIPTION

Afirstepisodeofsciaticnervecompressionasacauseofback,buttock,andlegpainwillrequireexpertmedicalassessmentandcare.Ifyou’vehadsciaticnervecompressionbefore,beawarethatitcanflareupagain,butyoucansometimestreatamildsecondepisodewithsomesimplestretchingexercises.4

Ifyouhavesciaticnervecompression(sometimescalledpiriformissyndrome):• Your doctor should recommend physical therapy, especially if pain isinterferingwithyouractivitylevel.-Physical therapy is exactly the right treatment forpiriformis syndrome.The key to beating this problem is reducing associatedmuscle spasm.You’llbeexpectedtodospecificexerciseseveryday.

-Sometimesphysicaltherapymaytemporarilymakethepainabitworse.Ifyouhavemorethanatemporaryincreaseinpain,letyourdoctorknow.

•Yourdoctormayprescribeorrecommendsomemedicinetocontrolthepain,including over-the-counter pain relievers or, if nighttime pain is especiallyprominent,someprescriptionmedicationsthatareactiveagainstnervepain.

If you have pudendal nerve compression (associatedmorewith genital regionpain):•Yourdoctormayrecommendphysicaltherapy,especiallyifpainisinterferingwithyouractivitylevel.- Physical therapy for pudendal neuropathy is usually carried out byspecially trained therapists. The delicate nature of the structures in thelower buttock and genital areas necessitates extra training and specialtechniques.

- Sometimes injection or surgery is required. The pudendal nervecompression syndrome is not due to muscle spasm so much as to thedevelopment of fibrosis in the ligaments and other structures that thenervepassesbyasittravelsfromthespinetothepelvis.Thesetypicallyneed to be released by a surgeonwho has special experiencewith thisproblem.5

Warning!HowtoPreventaWorseningoftheCondition

Your physical therapist should make an assessment of your bodymechanics and help you become aware of how to avoid worseningpiriformis syndrome. The simple things includemaking sure that whenyou sit, your body is positioned symmetrically in front of yourworkstation.Makesuretogetupandmovearoundevery30minutesorsoifpossible.Avoidcarryingaheavywalletinyourbackpocket.Andlearnhowtostrengthenandexercisethemusclethatcomplementsthefunctionofpiriformis.Thiswillhelptotakesomeofthestressoffofthepiriformismuscle.

WHATIFYOURDOCTORREFERSYOUTOAPAINSPECIALISTORWANTSTODOANINJECTIONFORPIRIFORMISSYNDROME?

Piriformissyndromeisoccasionallytreatedwithinjectionstoreleasethemuscle.Inmost cases,however, thephysical therapist’s applicationofmanualmuscle-releasetreatments,electricalstimulationtreatments,andstretchingexerciseswillbesufficient.Beawarethatanytimeaninjectionisperformed,thereisariskofnotonlyinfection,butlonger-termdamageandscarringtothemuscleornerve.Thismightconvertashort-termproblemintosomethingmoreproblematic.

WHATIFYOURDOCTORRECOMMENDSSURGERYFORSCIATICNERVECOMPRESSION?

Surgeryisonlyrarelyconsideredforpiriformissyndromeandisusuallyreservedfor themost treatment-resistant forms of the condition. Surgery for piriformissyndromecaninvolveefforts tofreeupthenerveor tocutafibroticbandthatseemstobepressingonthenerve.

WHATIFYOURDOCTORDIAGNOSESATHORACICNERVEROOTPROBLEMSUCHASNERVECOMPRESSION,NERVEINJURY(NEUROPATHY),ORPOST-HERPETICNEURALGIA?

Inthiscase,medicationtherapyisusuallythefirst-linetreatment.Dependingonthe specific problem, other treatments may be tried. If there is a nervecompressioninthethoracicspinearea,surgeryorinjection-typeapproachesaresometimesneeded.

TheTreatment

When your doctor recommends physical therapy, be confident that physicaltherapy is thebest treatmentavailable forpiriformissyndrome.6Mostphysicaltherapists are very familiar with sciatic nerve compression and piriformissyndrome. Because piriformis syndrome is driven by muscle spasm in aparticularmuscle, the physical therapists arewell equipped to treat this usingmultiple methods including thermal therapies, manual therapy, electricalstimulation,bodyawarenesstraining,andstretching.Lesscommonly,injectionsof medications may offer temporary relief, and rarely surgery is needed forcompletelydebilitatingorstructuralproblems.

PHYSICALTHERAPYRELAXESTHEMUSCLE

The greatest aspect of physical therapy is the attitude that most physicaltherapistsbringtotheirwork:Whatyoudomakesadifference.Workingwitha

qualifiedphysical therapistwillhelpyou to remindyourselfeveryday thatyoucan take steps to make this better and then follow through on those positiveactions.Theprimarygoalofphysicaltherapytreatmentistorelaxthepiriformismuscle so that the sciatic nerve can begin to function normally and stopsignalingpain.

THERMALTHERAPIESPROVIDEIMMEDIATERELIEF

Warmtherapycanrelaxthemuscles,whilecoldtherapyblockspainsignalsandreducesinflammation.Yourtherapistmayuseoneorbothoftheseapproaches.She may also use ultrasound, which can create a gentle warming sensationdeeperinthebody.Thewarmpacksthattherapistsusecanonlypenetratesofar,and the piriformis muscle is actually pretty deep in the buttock, situatedunderneath the gluteus muscles. Ultrasound can be tuned to reach to varyingdepthsinthebodyandmayproducewarminginstructuresthataretoodeepforaccessbywarmcompresses.

MANUALTHERAPYISESSENTIAL

Yes,itmaybeuncomfortableandfeelalittleawkwardtohavesomeonepressingtheirthumbsfirmlyintoyourbuttockmuscles,butthismaybenecessary.Thereisawealthofclinicalexperiencetosupporttheuseoftriggerpointmassagefortherelaxationofspecificmuscles.7Askilledmanual therapist,whetherdoctor,nurse, physical therapist, or other person, can identify muscle spasm in thepiriformismuscleandusetheirhandstorelievethespasm.Generallyspeaking,thelocationofthepiriformismusclepreventspeoplefromreachingthismusclemanually,however.

ClairDavieshassuggestedanumberofinnovativewaysthatyoucanperformyour own trigger-point therapy on hard-to-reachmuscles.8 Davies has had aninterestingcareerpath, ashe startedout asapiano tunerandonly later in lifebecameinterested inhealthcare. It seems thathisexperience tuningpianoshasgivenhimaspecialawarenessof thedynamic tension thatexists in thehumanbodyasmuscles,nerves,andbonesworktogethertocreateanintegratedloco-motor system. His book on trigger points has become widely used andrecommended because of the straightforward explanations involved and self-empowering approach that Davies encourages throughout. Because triggerpoints are hyper-responsive to direct stimulation and because they releaseinflammatory signals, it is important to combine trigger-point massage withother treatments such as thermal therapies or electrical stimulation of themuscle.9

Warning!Don’tPullYourLeg

Donot,DONOTuseyourhandstopullyourlegtowardyourchest.Donotuseabeltorabandtopullyourlegtowardsyourchest.Useonlyyourownlegmusclestocarryoutthismaneuverandbegentlewithyourback.Ifyoumust,useyourfingertipsonly,toprovidesomegentlesupportandguidance to the leg. Ihaveseen twopatientscausedisc tearsbypullingtoohardonabeltloopedbehindtheknee.Bothofthesepatientswerewellmeaning,ifslightlyType-Apersonalitypeople,whopulledtoohardtryingto stretch out the piriformis and in the process brought on severe, iftemporary,backproblems.Please,pleasedon’tbenext!Thisisoneplacewheremyrecommendationswillsometimessplitofffromthoseofotherswhoencouragetheuseofbeltsandstraps.Itisreallybetterifyoucanuseyour own efforts at mental control to consciously relax the buttockmuscles.Nevertryto“pullthemout”byusingyourarmstrength.

ELECTRICALSTIMULATIONISAUSEFULCOMPLEMENT

Theprimarypurposeoftheelectricalstimulationistofatiguethemuscleintoarelaxed state. Although the treatment itself can produce a strong tingling orzingingsensation,afterwardsthemusclefeelsveryloose.

STRETCHINGSPEEDSRECOVERY

You will probably need to do piriformis stretches two to three times a weekforevertokeepyourbuttockmusclesproperlyflexibleandpreventarecurrenceofsciaticnervecompression.Onceanervehasbeenirritatedordamagedtothepoint of producing pain, it is much more prone to re-aggravation. The basicpiriformisstretcheswillbedemonstratedtoyoufirstbyyourphysicaltherapist,buttherearetworelatedstretchesthatarewidelyused:theknee-to-cheststretchandtheknee-to-opposite-shoulderstretch.Youbeginbothbylyingonthebackwithyourpelvisinaneutralposition.Flexbothkneesandplaceyourfeetontheflooraboutshoulderwidthapart.Nowflexyourhiponthegoodsidesothatthekneemovestowardsthechest.Yourabilitytobringthekneeuptothechestwilldependonyourabdominalgirthandyouroverallflexibility.Asyouaremakingthismovement,don’tfocusonachievingthemaximumflexion,butconcentrateyourmentalenergyonrelaxingthemusclesdeepinyourbuttock.Withtime,thismovement-with-relaxationwillbecomeeasier.

KNEE-TO-OPPOSITESHOULDERSTRETCH

Thisbeginsthesameway,withyoulyingonyourbackandyourfeetplantedonthefloor.This time,asyoubend thehip,angle themovementofyourkneesothatitisdirectedtowardstheoppositeshoulder.Obviously,you’renotgoingtoactually bring the knee up all theway to the shoulder, but angle it across theabdomenandchest as ifyouareaiming for theopposite shoulder.Again,youshouldneveruseabelt, strap,oryourhands topull the leg towardsyou.Youmayusefingertippressuretogentlyguidethelegthoughthismovement.Holdthestretchforaslongas30seconds,breathinginandout,consciouslyrelaxingthedeepermusclesof thebuttockand thenslowlyreturn the leg to itsoriginalposition. You should repeat this two to four more times and then stretch theoppositehip.

BeAwareofInjectionInclinationsWhenyourdoctorrecommendsreferral toapainspecialistorwants todoaninjection,makesureyouhavehada fair trialofphysical therapyor thatyouunderstand why physical therapy will not be performed. The currentreimbursements used by most insurers heavily reward procedural-basedmanagementofmedicalproblems,soadoctormaygetpaidseveraltimesmoremoneyformakinganinjectionthanforspeakingwithyouandlearningmoredeeplyaboutyourproblem.Mostdoctorsareonlyhuman,andyoushouldnotseethe with resentment at the first mention of injections or procedures.However, bemindful of the financial pressures that exist and recognize thatcaution is needed to protect against the undue influence of healthcarereimbursementsonmedicaldecisionmaking.

INJECTIONSOFFERTEMPORARYRELIEF

Ithasbecomeincreasingpopulartoinjectthepiriformismusclewithavarietyofagents, including local anesthetics, paralyzing agents (Botox), and steroids.10Mostoften,thesedrugsareinjectedintothemuscleusingsomekindofimagingtechnology for guidance. Frequently, fluoroscopic (X-ray) guidance is used,although ultrasound guidance has been described.11 The challenge is that themuscledirectlyoverliesthesciaticnerve.Injectionintothesciaticnerveitselfislikely tobepainfulandmay induce lastingdamage.Thesewarningsaside, forsomepeopleinjectiontherapyishelpful,buttheeffectsarenotexpectedtolastlongerthanafewweekstomonths.

SEEASPECIALISTIFSURGERYISRECOMMENDED

Whenyourdoctorrecommendssurgery,thisusuallymeansthatyourpiriformissyndromerepresentseitheralong-standingproblemorthereisclearevidencefora structural problem. Make sure you have a clear picture of what surgery isplanned,whattheexpectedoutcomesare(willIbepain-freeafterthesurgery?)andwhat theanticipated time-course is for recoveryandreturn towork.Therearedifferentsurgicalapproachestotreatingsciaticnervecompressionbyvariousstructures;youwillprobablywanttoseesomeonewhospecializesinthistypeofsurgery.

Warning!RedFlagsandBackPain

One of the reasons healthcare providers talk about “red flags” in theassessmentofbackpainisthattheredflagscanprovidecluestosomeofthemoreworrisomecausesofbackpain.Thingslikecancerandinfectionarecapableofproducingnervecompressions,butthesetypesofeventsareoften associated with other symptoms, such as recent fatigue, recentweightloss,thepresenceofaknowncancerelsewhereinthebody,recentfeversandchills,andhavinghadarecentbacterialinfection(pneumonia,urinarytractinfection,etc).Allofuswhohavehadmedicaltraininghavehadtheexperienceoffindingacanceroralife-threateninginfectioninapatientasacauseofbackpain.However,theseproblemsremainrelativelyrare.ThedetectionofproblemslikecancerandseriousinfectionarepartofthereasonitissohelpfultohaveadetailedMRIpictureofyourback,but it’s not always necessary. Be sure to let your doctor, PA, or nurseknowifyouarehavinganyredflagsymptoms(seeChapter1);itcouldbethepieceofthepuzzlethatleadstoanearlylife-savingintervention.

PudendalNeuropathy(PudendalNeuralgia)

Pudendal neuropathy, or pudendal nerve compression, is very different fromsciatic nerve compression in that the usual cause of the compression is notmuscle spasm. Pudendal neuropathy can arise from several causes includingtraumaandextensivebicycleriding.12Itmaybemorecommoninwomen.Thesyndrome of pudendal neuropathy can involve buttock pain, but usually it iscloser to themid-line of the body and extends into the region of the genitals,producing pain, numbness, or sexual dysfunction. In men there may be anassociationwith prostatitis.By comparison, sciatic nerve compression ismorecommonlyfeltinthecenterofthebuttockorevenintheupper,outerquadrantand thenextendsdown into the leg.Althougha relativelybenignsyndromeofnervecompressionduetochronicscarringorfibrosis,pudendalneuralgiacanbeincredibly painful and disabling. A perplexing and troubling cause of lowback/pelvic floor pain, pudendal neuralgia can leave the sufferer in a nearlydisabled state as normal activities like sitting, making bowel movements andengaging in sexual intercoursebecome severelypainful.Thepainof pudendalneuralgiaisoftenespeciallymiserableforthepersonexperiencingit,andhavingapelvicfloorproblemmaybesociallyisolating.

PUDENDALNEUROPATHYTREATMENTS

Because pudendal compression is not due tomuscle spasm, ordinary physicaltherapyapproachesarelesseffective;injections,nerve-destroyingtreatments,orsurgery may be used. Sometimes people with pudendal neuropathy pain aremanaged through the use of a spinal cord stimulator, a thin electrode placedinsidethespinalcanaltoeffectivelyjamthepainsignalsbeforetheycanreachthebrain.

Injections for pudendal neuropathy have been performed using localanesthetics, corticosteroids, and other drugs.13 Injections should only beperformed by people who are familiar with the technique and have receivedadvancedtraininginthisarea.Makesuretoask:Howmanytheyhavedoneinthelastyear?Howweretheytrainedtodothis?

Surgery for pudendal neuropathy usually involves the release of a fibrousbanddeepinthelowerbuttock.Makesuretodiscusswiththesurgeon,hisorhercertainty about the diagnosis, the expected outcomes of the surgery (will I bepain free after surgery?) and the anticipated time needed for recovery and areturntodailylife(howlongwillitbeuntilIcandriveagain?)andthechancesthatproblemswillarise.

What’sNew:TreatmentsforPudendalNeuropathy• There are descriptions of special tools being used that produceelectromagneticradiationtopermanentlydestroythenerve.14Althoughthishasbeendescribedaseffective,itsometimeshappensthatanervecangrowbackafterbeing“destroyed,”andwhenitdoes,thepainoftenreturnswithavengeance.

•AlargestudyfromFrancerecentlydescribedtheuseofultrasoundforthediagnosisofpudendalneuropathy,andreportedthatthiswasveryhelpfulinensuringthattherightpatientsunderwentsurgery.Youcanimaginethatifyouhaveasurgerytotreataproblemyoudon’tactuallyhave,thesurgeryisnotlikelytobehelpful.Forthisreason,it’sveryimportanttohaveasoliddiagnosisbeforeproceedingtohavesurgery.15

Thecourseofthepudendalnervethroughthepelvis

Thoracicnerverootpattern

OtherNerveConditionsThatCauseBackPain

Other conditionsmay produce nerve pain in the back area. It is important foryourdoctortoconsiderothercausesofcompressionifyouhavenervepain.

DIABETICAMYOTROPHY

Diabetes can permanently damage nerves. Many types of neuropathy areassociatedwithdiabetes,butonetype,calleddiabeticamyotrophy,isthoughttobe due to sudden nerve damage and is a potential cause of back pain. In thiscondition,thelocalbloodsupplytoanervemaybecompromised;whatdoctorssometimes think of as a mini-stroke in the nerve itself may be the cause ofdiabeticamyotrophy.Inanycase,thepersonwiththisconditionwillexperiencethesuddenonsetofseverepaininafocusedpartofthebody.Investigationsmayrevealthatthepainisassociatedwithalossoffunctionofanerveornerveroot.Diabeticamotrophycanoccurinvariouspartsofthebody,butwhenthisnervedamage occurs in nerves arising from the thoracic spine or rib area, the painextends from the back around the rib cage. The pain may be so severe thatbreathing is limited, a situation that can lead to other problems such as acompromiseinoxygensupplytothebodyorevenpneumonia.Itisimportanttonotethatstudiesofthecomplicationsofdiabeteshavestronglyshownthatgooddiabetic control is critically important to preventing complications such asneuropathyandlimitingtheirseverity.

Lyme disease can sometimes produce a syndrome of nerve injury thatpresentslikeamildcaseofdiabeticamyotrophy.

POST-HERPETICNEURALGIA(PHN)

A distinct cause of nerve-related back pain is post-herpetic neuralgia (PHN).Post-herpetic neuralgia is a chronic pain that first begins with an episode ofshingles.Shingles is causedbya reactivationof thechickenpoxvirus (herpeszoster)inthebody.Inmostpeoplewhohavebeenexposedtochickenpox,thevirusliesdormantinthebody,inpartduetosuppressivesignalsfromthebody’simmunesystem.Incertaincircumstances,thissuppressionbreaksdownandthevirusbegins togrowand cando so explosively.The results are that thenervecellsthatharborthevirusmaybedamagedordestroyed.Thecellsmostlikelytohostthistakeoverbytheherpesvirusarethesensorynervecells,oftenanervecellthatsuppliestheskinofthethorax,althoughthefaceandotherpartsofthebodycanbethreatenedbyshingles.Typically,thisoccursinasinglenerveroot,for reasons that are unknown. Shinglesmore often occurs in personswho are

around60yearsof age, so it is thought that certainage-relatedchanges in theimmunesystemraisethelikelihoodofshinglesoccurring.Also,stressisnotedinsome people who develop shingles, leading to the idea that severe emotionalstresscansometimesdisablepartoftheimmunesystem’sabilitytosuppressthevirusfromreproducing.

If treated immediately, shinglesmaynotprogress to thechronicanddeeplypainful condition of PHN. The characteristics of early shingles is an unusualtingling thatprogresses thenextday topain inavery focusedregion (asingledermatomeornerverootdistribution).Abumpyrashmayormaynotbeobviousat thisstage,butifpresent, therashshouldbefocusedonthesameareaasthepain.Youshouldcontactyourdoctorimmediatelyifyoususpectshingles.Ifyoucannotseeyourdoctor,PA,ornursethatsameday,considerseekingurgentcarethrough another route because if the shingles converts to PHN, it is thendevastatinglypainfulformonthsandsometimesevenyears.

WhatYourDoctorNeedstoKnowYour doctor needs to know if you are having the following symptoms inassociationwithyournervepain:weight loss, feversor chills, severepainatnight,painthatisworsewithlyingdown,weakness,lossofcontroloverurineor incontinenceofbowelorbladder,ornumbnessover thegenitalarea.Yourdoctorneedstoknowwhatmedicinesyou’vebeentaking, includingallover-the-countermedications, as well as what you can and cannot do because ofyourbackpain.

VERTEBRALFRACTURE

Another important potential cause of nerve compression pain is vertebralfracture, this is discussed in some detail in Chapter 8. When vertebralcompression fracture involves nerves in the thorax, it can produce a verydifficult syndrome of nerve pain that wraps around the body and makesbreathingdifficult.

NERVECOMPRESSIONAFFECTINGTHEFOOTANDLOWERLEG

Other nerve compression syndromes are not associated with back pain. Forexample, tarsal tunnel syndrome involves compression of the tibial nervesupplyingthefrontpartofthefoot(almostlikecarpaltunnel,butinthefoot)andperonealnerve compression syndrome (more recently called the fibular nerve)occursoutsidetheknee.Therearealsocompressionsyndromesofthenervestothe front of the leg (the femoral nerve and its branches), such as meralgiaparesthetica, a painful compression of the nerve supplying the skin on theoutside of the thigh, as well as compression syndromes affecting nerves thatsupplythefrontofthegroinandthelowerabdomen.Thesearealsonottypicallyassociatedwithbackpainandshouldprobablybeevaluatedbyaneurologistorotherspecialist.

TestingForNerveCompression

Testing for nerve compression is usually carried out with nerve conductionstudies. This is certainly true for the most common nerve compressionsyndromes:carpaltunnelandulnarnerveentrapment.Thesesyndromesaremostoften associated with arm, forearm, and hand pain, although in exceptionalsituations,someneckpainmaybeexperienced.Ioccasionallywillhaveapatienttellmethatcarpaltunnelsyndromeproducespainthatrunsallthewaydownonesideofthebody.Idon’thaveagreatexplanationforthisphenomenonexcepttosay thatallpain rises to the levelofconsciousnessbypassing throughseveralwaystationsinthespineandbrain.Insomeoftheseareas,armandbodysignalsmightmixandcreatefalseimpressionsofwheretheproblemactuallylies.

There are limits to using nerve conduction tests for the detection of sciaticandpudendalneuropathies.Thesenervesarelocatedprettydeepinthebody,andthe surface electrodes used to drive the electrical shocks used for the studiesdon’t penetrate that deeply. As a consequence, other approaches have beenadopted.Forsciaticnervecompression,askilledexaminerwillbeabletodetectnerveormuscletendernessdeepinthebuttock.Itissometimespossibletohave

aspecialtypeofMRI,calledMRneurography,performed.Inthesestudies,theMRI signal is optimized to detect the high fat content of the nerve, and 3-Dreconstructionsareusedtodetectnerveabnormalitieswithgreatersensitivity.Inthecaseof thepudendalnerve, itmaybepossibletouseaspecializedformofultrasound to detect blood flow through a nearby artery; increased pressure inthatarteryhasbeenassociatedwithpudendalneuropathy.16

TheExplanation

Thespinalcordisenclosedin thespine,whichprovidesessentialprotectiontospinalnerve roots that travel fromspinalcordoutward,exiting throughspacesbetween adjacent vertebral bones. Once the nerves exit the spine, they arecloaked in a sheath of fat cells that offer some cushioning, but very littleprotectionfrombluntorsharptrauma.Thisleavesnervesvulnerabletodamagefromrepetitivemotions,swollenorfibrotictendonsandligaments,orinthecaseofpiriformissyndrome,musclesinspasm.

PREVENTNERVECOMPRESSIONWITHGOODPOSTUREANDSTRETCHING

Althoughsciaticaduetopiriformissyndromeoftenfirstarisesaftersometraumasuchasacaraccidentorskiingmishap,thepredispositiontosciaticproblemsisamplifiedbyourcomputer-focusedlifestylethatdemandsthatmanyofusspendhourssittinginfrontofcomputers.Thesciaticnerve,althoughwell-paddeddeepinthebuttock,isnotreallydesignedforsittingon.Itisimportantthatyouplanactive breaks into every work hour. Make sure to get up, move around, andstretchalittle.Stretchingthepiriformismusclesissomethingthatshouldn’tjusthappenwhenyou’re recovering fromany injury. Ifyourphysical therapisthasshownyoutheknee-to-chestexercises,stickwiththeprogram.Makesureyourhamstringmusclesareproperlystretchedeachdayanddon’tforgetyourgastrocandsoleusstretches.Keepingtheweight-bearinglegmusclesinproperbalanceis essential to minimizing your risk for sciatica. Consider adding some wallslides to your routine; your physical therapist can show you how. Keepstretching everyweek.Make sure tomaintain a proper bodymass and get inplentyofwalkingaswellasother formsofexercise.Avoid liftingobjects thatareheavier thanyoucansafelymanageandalways liftwithproper technique.Strictly avoid lifting off to the side and never sit at yourworkstationwith anasymmetricalposturetopreventsciaticaandsciaticnervestrain.

CHAPTERRESOURCES

1.Konstantinou,K.andK.M.Dunn.2008.Sciatica:Reviewofepidemiological

studiesandprevalenceestimates.Spine33(22):2464–2472.

2.Filler,A.G.,etal.2005.Sciaticaofnondiscoriginandpiriformissyndrome:Diagnosis by magnetic resonance neurography and interventional magneticresonanceimagingwithoutcomestudyofresultingtreatment.JNeurosurgSpine2(2):99–115.

3. Tiel, R.L. 2008. Piriformis and related entrapment syndromes: Myth andFallacy.NeurosurgClinNAm19(4):623–7.

4.NevinLam,A.C.,S.S.Singh,andN.A.Leyland.2008.Catamenialsciatica.JObstetGynaecolCan30(7):555,556.

5. Mollo, M., E. Bautrant, A.K. Rossi-Seignert, S. Collet, R. Boyer, and D.Thiers-Bautrant. 2009. Evaluation of diagnostic accuracy of Colour DuplexScanning, compared to electroneuromyography, diagnostic score and surgicaloutcomes, in Pudendal Neuralgia by entrapment: A prospective study on 96patients.Pain142(1–2):159–63.

6.Meknas,K.,J.Kartus,J.I.Letto,M.Flaten,andO.Johansen.2009.A5-yearprospectivestudyofnon-surgicaltreatmentofretro-trochantericpain.KneeSurgSportsTraumatolArthrosc17(8):996–1002.

7. Travell, J. and D. Simons. Travell & Simons’ Myofascial Pain andDysfunction: The Trigger Point Manual, 2nd edition. Baltimore: LippincottWilliams&Wilkins,1998.

8. Davies, Clair. The Trigger Point Therapy Workbook. Oakland, CA: NewHarbingerPublications,2001.

9.Shah,J.P.,J.V.Danoff,M.J.Desai,S.Parikh,L.Y.Nakamura,T.M.Phillips,andL.H.Gerber.2008.Biochemicalsassociatedwithpainandinflammationareelevatedinsitesneartoandremotefromactivemyofascialtriggerpoints.ArchPhysMedRehabil.89(1):16–23.

10. Kirschner, J.S., P.M. Foye, and J.L. Cole. 2009. Piriformis syndrome,diagnosisandtreatment.MuscleNerve40(1):10–8.

11.Smith,J.,M.F.Hurdle,A.J.Locketz,andS.J.Wisniewski.2006.Ultrasound-guided piriformis injection: Technique description and verification.Arch PhysMedRehabil87(12):1664–7.

12. Leibovitch, I. and Y. Mor. 2005. The vicious cycling: bicycling relatedurogenitaldisorders.EurUrol.47(3):277–8.

13.Fanucci,E.,G.Manenti,A.Ursone,N.Fusco,I.Mylonakou,S.D’Urso,andG. Simonetti. 2009.Role of interventional radiology in pudendal neuralgia:Adescriptionoftechniquesandreviewoftheliterature.RadiolMed114(3):425–36.

14.Rhame,E.E.,K.A.Levey,andC.G.Gharibo.2009.Successfultreatmentofrefractorypudendalneuralgiawithpulsedradiofrequency.PainPhysician12(3):633–8.

15.Mollo,M., E. Bautrant, A.K. Rossi-Seignert, S. Collet, R. Boyer, and D.Thiers-Bautrant. 2009. Evaluation of diagnostic accuracy of Colour DuplexScanning, compared to electroneuromyography, diagnostic score and surgicaloutcomes, in Pudendal Neuralgia by entrapment: A prospective study on 96patients.Pain142(1–2):159–63.

16.Ibid.

17.Konstantinou,K.andK.M.Dunn.2008.Sciatica:Reviewofepidemiologicalstudiesandprevalenceestimates.Spine33(22):2464–2472.

18.Papadopoulos,E.C.andS.N.Khan.2004.Piriformissyndromeandlowbackpain:Anewclassificationand reviewof the literature.OrthopClinNorthAm.35:65–71.

19. CDC. “Shingles vaccine,” http://www.cdc.gov/vaccines/vpd-vac/shingles/vac-faqs.htm.AccessedJanuary9,2010.

Q&AwithDr.Murinson

Whatispiriformissyndrome?Piriformis syndrome is a condition in which the sciatic nerve is compressedbetween two muscles as it passes through the deep part of the buttock. Thetypical scenario leading to this condition is accident-related trauma, whetherfromacaraccidentorafall.Thepiriformismuscleisinvolvedinconnectingthesacrum(baseofthespine)tothetopofthethighbone(greatertrochanterofthefemur) and contributes to our ability to externally rotate the leg. When thepiriformismuscle is injuredand inspasm, theremaybea radiatingpaindownthe leg. Piriformis syndrome can produce pain that is deep, severe, especiallybothersome at night, worse with prolonged sitting, and sometime radiating toandbeyondtheknee.Thepaincanbefeltupintothelowerback.Thispainwillusuallynotrespondtoover-the-countermedicationsandcanbefairlyresistanttoprescription medications as well. If you think that you may have piriformis

syndrome,youshouldseekoutqualifiedmedicalcare.Askyourcurrentdoctor,nurse,orPAiftheyhavehadanytraininginphysicalmedicineorrehabilitationmedicine. It is important to have skilled guidance as you seek to address thisproblem.

Mydoctortellsmepiriformissyndromeisrare;howrareisit?Conservativeestimatesfortheoccurrenceofpiriformissyndromeinthosewithbackpainareaslowasfivepercent,althoughsomehavereportedestimatesashighas32percent.17Now, ifyou stop toconsider that the lifetimechancesofhavingbackpainare80percent,thenpiriformissyndromemightnotreallybesorare.Imagineacityof100,000.If80percentwillhavebackpainoveralifetime,and five percent of those are due to piriformis syndrome, which means that4,000 people in that small city will experience piriformis syndrome at somepointintheirlives.Nowmultiplythatbyover300millionAmericans!18

ShouldIgetthevaccineagainstshingles?If you are 60 years or older, the CDC recommends that you get the shinglesvaccine.Shingles is thecommonnamefor theherpetic rash that leads toPHN(post-herpetic neuralgia). Getting the vaccine will cut your chances ofdevelopingPHNbytwo-thirdsandisgenerallyconsideredsafe.Therearesomepeoplewhoshouldnotgetthevaccinesomakesuretocheckwithyourdoctorandreaduponthevaccineinadvance.19

CHAPTER5

Sacroiliac(SI)JointDysfunction

Diagnosiscanbetricky.Besuretoaskquestions

andgetanexpertmedicalopinion.

theDIAGNOSIS

>Doyouhavepainthatislocatedtoonesideofthespine?>Doesyourpainseemtositheavily in thebaseof theback justoff to theside?Doesitstabsharplywitheverysteporefforttoshiftyourweight?

Painononesideofthelowerbackthatworsenswitheverystepisusuallyduetoa dislocated sacroiliac (SI) joint. If you can take one finger and locate yourmaximal pain halfway between the spine and hip in the lower back, youmayhaveSIjointproblems.Sometimes,certainmovementswilltemporarilyrelievethepain;however,thepainofadislocatedSIjointcanbesosevereastomakenormalwalkingimpossible.ThepainofadislocatedordestabilizedSIjointmaybe aching or breathtakingly sharp. Activities such as rising from a chair orsteppingoffacurbcanmakethispainworse.

Back pain due to a dysfunctional SI joint needs expertmedical assessmentand care, but it is important to know that there is somedegreeof controversyaboutthebestwaytodiagnoseSIjointdysfunction.Asnoonetestisconsidereddefinitive, it isoftennecessary tosubjectapatient toaseriesof tests,someofwhichmayprovokepainintheSIjoint.Attimes,anX-rayoftheSIjointwillbeneeded.Itmaybenecessarytoincludeothertestsaswell,becausethepainofSIjoint dysfunction shares some features with other causes of back pain. Yourdoctormayorderanerveconduction test tomakesure that theproblem isnotcaused by damage to nerves arising from the spine. (This test is described indetailinChapter2).Onceallthetestresultsarein,aclearerpicturewillemerge.The possibilities range from “nothing is clearly wrong” to a “clear jointdisruption”to“subtlesignsofSIjointproblems.”

What’sNew:AMajorPainintheBackInresearchstudiesaboutthecausesoflowbackpain,asurprisingnumberofpeople with “low back pain” were found to be suffering from SI jointdysfunction.EstimatesofthenumberofpeopleactuallysufferingfromSIjointdysfunctionasacauseofbackpainarebetween10and30percent.Thelargeststudy found that SI joint dysfunction explained the pain of 22 percent ofpatients with low back pain. Other major causes of back pain include discproblems,suchasherniationanddisctears.1

CLUESTODIAGNOSIS

TotestforSIjointdysfunction,probeforpainfulareasontheback.Ifyoucanidentifyasinglespot,locatedtwotothreeinchesfromthemidlineofthebaseofback, where moderate pressure with the fingertip produces an extreme painresponse,youmayhaveSIjointdysfunction.Anothertestistolieonyourbackwithapartnerpositionednexttoyou.Haveyourpartnerplacehisorherpalmsonthefrontpartsofyourhipbones,onehandoneitherside.Yourpartnershouldpressdownward,applyingsteadypressure tobothsidesat thesame time.Thismaneuver is supposed to cause the front sideof theSI joints toopenandwillproduce pain in some patients with SI joint dysfunction. If this maneuverworsensyourpain,youmayneedtohaveSIjoint-focusedtherapy;readon!

thePRESCRIPTION

IfyouhaveadislocatedSIjoint:•Yourdoctorwillverylikelyrecommendphysicaltherapy,especiallyifthereisnoperceptibleweakness.TheeffectivenessofSIjointtherapydependsonthe skillfulness of the physical therapist or chiropractor; the nature of thejointdislocation; and themotivationof thepersonundergoing treatment toconsistentlyfollowexerciserecommendations.

• Your doctor may recommend injection of the SI joint with pain-activemedicationssuchas lidocaineorcortisone.Thesemedicationsmayprovidetemporaryrelief frompain,andmayallowthephysical therapistawindowofopportunity formore aggressive treatments, but injections such as thesearenotshowntoprovidealastingbenefit.

• Your doctor may recommend that you wear an SI band or belt. This willdependonwhetheritseemstobeaone-timeproblemorhappensagainandagaindespitetheuseofothertreatments.- An SI band is a moderately heavy belt that straps around the hips toprovideexternalpressureonthepelvis

-ThesuccessofSIbandtherapydependsinpartonthewearer’sabilitytogetacomfortablefitandtowearthebandwhenneeded.

PainfulSIJointsDuringPregnancyThesacroiliacjointsarepronetodeveloppainfulinstabilityduringpregnancyas a result of hormones that loosen the normally tremendous strength of theligaments. In this loosened state, a certain degree of play in the joint candevelop.Underthestressesofwalkingandcarryingadditionalweightaroundwithoutrespite,thesenormallysilentjointscanbecomeverypainful.Althoughthesurroundingmusclesnormallyplayaminimalroleinsupportingthejoint,whentheligamentsaresoftened,themusclesbecomemoreimportanttojointstabilization. Fortunately, it is possible to provide relief to the overtaxedligamentsandjointstructuresthroughmusclestrengtheningexercises.

Squeezing a ball between the knees is one example of an exercise that canrelieve sacroiliac pain. Gluteal tightening exercises and Kegel exercises arealsocriticalcomponentsofexercisingforreliefofSIjointpaininpregnancy.Ifthese measures—undertaken with medical supervision—fail to resolve theproblem, a sacral beltmay contribute some external compression to stabilizethejoint.Forsure,itisveryimportanttowearflatshoesonceproblemswithSIjoint pain in pregnancy develop. Heels will increase the amount of forcedeliveredtothebodywitheachstep,andthrowthebodyintoanalignmentthatincreasesthestressonthepelvis.

WHATIFYOURDOCTORDIAGNOSESINFLAMMATIONOFTHESIJOINT?

In this case, it may be necessary to be tested for medical conditions thatpredisposetoinflammationoftheSIjoint.

WHATIFYOURDOCTORFINDSTHATYOUHAVESYMPTOMSOFSIJOINTDYSFUNCTIONBUTNOEVIDENCEFORDISLOCATIONONX-RAY?

TheSI joint is designed to be resiliently stable, as it is subjected to profoundstressesevery timeweight is transferred from leg to leg.Your imagingstudiesmay not show clear-cut signs of dislocation, but SI joint dysfunction is adiagnosisbasedonthepatternofpainandtheclinicalexamresults.AtrialofSIjoint therapy may very worthwhile as the basic skeletal manipulations areusually not harmful and the core muscle strengthening exercises used for thetreatmentandpreventionofSIjointdysfunctionarealmostalwaysbeneficial.Inrarecases,painintheSIjointareaisduetoamass(tumor),aninfection(abcess)or a fracture. These serious but rare causes of pain in this area are readilyassessedthroughtheotherdiagnostictestsdescribedfurtherinthischapter.Thetreatmentfortheseconditionsisindividualized.

TheTreatment

Ifyourdoctorrecommends“physicaltherapyfirst,”thisusuallymeansthatyouhave the type of SI joint dysfunction best treated without surgery (the vastmajority of SI joint dysfunction is treatedwithout surgery). Several treatmentmodalitiesfallunder theumbrellaofphysical therapyas theprimary treatmentforSIjointproblems:manualtherapies,thermaltherapies,electricalstimulationtherapies,traction/inversiontherapies,andconditioningandstrengthening.

MANUALTHERAPIESAREHIGHLYEFFECTIVE

Manual therapies can reverse and resolve an initial episode of SI jointdysfunction.Infact,anecdotalevidencesuggeststhat thebestchanceofacurefor SI joint dysfunctionmay be to obtain an immediate reduction of the jointdislocation by a practitioner skilled in manual therapies. There are severalapproaches to reducing stress on the SI joint, some of which involve fairlycomplicatedpositioningofthelegsandbodyandrequiresignificantstrengthonthepartofthepersonperformingthetreatment.

One example of amaneuver that can decreaseSI joint strain is as follows:Workingwithapartner, first lieona table-firmbedwithyourbad sidedown.Keepingyourbadlegstraight,bringthekneeofyourgoodleguptowardsyour

chestbyflexingthehipandbendingtheknee,thenallowthelowerpartofyourgoodlegtorotatedownwardabit,untilyourfootisplacedinfrontandrestsflat,supportingyou from in front.Have a partner grasp the ankle of your bad leg,keepingthekneestraight,gentlymovethefootinahorizontalplaneuntilthehipisflexedatabout25degrees,andthengentlyraisetheleginaverticaldirection.If anything about this does not feel right or hurts, stop immediately and seekmedicalassessment.Whenproperlyperformed,thismaneuvercanrelievestresson the SI joint and may be used by a manual therapy practitioner such as aphysicaltherapisttorepositionthejointthatisdysfunctional.Inactualpractice,thecomplexnatureof theSI jointmeans that thedysfunctionmay result fromjointmalpositioninginoneofseveraldirections.Forexample,inmanypeople,SIjointdysfunctionlimitsthemovementofthebonesoneithersideofthejointinaforwardandbackdirection.Forothers,SIjointdysfunctionmaymeanthatthe bones of the joint have shifted their relative positions in an up-downdirection.Therapywillvarydependingontheparticularsoftheproblem.

PHYSICALANDTHERMALTHERAPIESRELAXTHEMUSCLES

Physical therapy can include the use of thermal therapies, including warmcompressesandcoldpacks.These therapiescanhelp tocontrolpainand relaxthemusclesaroundthejoint.ThemusclesthatsurroundandsupporttheSIjointcan both respond to joint pain by going into spasm, worsening the pain, andpotentially make the SI joint dysfunction more intractable and resistant totreatment.Thermaltherapiesareanimportantpartofacomprehensivephysicaltherapyprogramandarewidelyacknowledgedasmedicallynecessary.

ELECTRICALSTIMULATIONTHERAPIESAREWIDELYACCEPTED

In theory, the continuous electrical stimulation applied via sticky electrodesattached to the skin will cause the muscle to go into an exhausted state thatmimics normal relaxation. This offers yet another way to break the pain andspasm cycle that often arises in muscle and impedes normal function andrecovery. Although mildly uncomfortable for some, electrical stimulationtherapy is a useful complement to other approaches used in physicalrehabilitation. It allows the therapist to target specific muscle groups, isgenerally without side effects, and can spare patients from being exposed tohigherdosesoforalmusclerelaxants.

STRENGTHENINGANDCONDITIONINGAREESSENTIAL

Relatively fewmuscles actively contribute to holding the SI joint together, somanyof the exercisesused to treatSI jointdysfunctionare actually stretching

exercises;othersaredesignedtostrengthennearbycoremuscles.Youwillneedto consult with a skilled physical therapist, as the exercises during the acutephasewilldependonwhichside theproblemlies.Moreoften thannot, theSIjoint ispainfulononesideandlesssoontheother.Althoughopinionsonthisvary,itseemstherearemultiplewaysinwhichtheSIjointcanbecome“outofjoint.”ThisisevidentfromtheabsenceofasingledefinitivetesttodiagnoseSIjointdysfunctionandfromthevarietyofrepositioningmaneuversthatareusedto restore normal functioning. Once your physical therapist has provided youwithaspecificprescriptionforrealigningyourSIjoint,youwill likelyneedtoperformcoreexercisesinthefuturetopreventrecurrenceofthisproblem.2

INJECTIONSPROVIDESHORT-TERMRELIEF

Ifyourdoctorrecommendstreatmentwithapaininjection,chancesarethismayprovide some immediate relief and help to confirm the diagnosis of SI jointdysfunctionasacauseofyourpain.Mostofthetime,injectionoftheSIjointforpain relief is performedunderCTorX-rayguidance (fluoroscopic-guided). Inthe majority of cases, the injection will consist of a mixture of lidocaine, anumbingagent,andasustained-releaseformofcortisone.ThelidocainecanactwithinsecondstoprovidereliefofpainfromSIjointdysfunction;however,theeffects of lidocaine typically last only a few hours. It is common for pain toreturnlaterinthedayafteraninjectionhasprovidedinitialrelief.Thecortisoneagent is injectedbecauseover aperiodof a fewdays, itwillbegin toprovidesimilar pain relief, and in this case, the pain-relief may last for two or moreweeks.

In patients who have unbearable pain from SI joint dysfunction, the paininjectionmaybeanecessary intervention.However, researchsuggests that thelong-termeffectsoftheseinjectionsareinsignificant.Itisnotexpectedthattheinjection will improve the long-term prospects of a patient with SI jointdysfunction unless it is used in concert with other approaches. Repeatedinjectionsofpain-activemedicines isnotpracticalbeyonda fewattemptsasariskforinfectionisalwayspresentandthecortisoneagentmayleadtoincreasesintheinfectionriskaswellasweakeningthenearbymusclesandbones.

Core-StrengtheningExercises

1. Pelvic-neutral abdominal strengthening exercises such as a pelvic tilt,crunches,legextensions,andamodifiedbridgeposition

2.Backcrunches,whicharedescribedindetailinthemusclepainchapter,butbasicallyinvolvelyingonthestomachandraisingbotharmsandlegsfromthefloorforacountof30

3.Inner-thighstrengthening,whichcanbedonebylyingonthebackwithaballbetweenthekneesandsqueezingthekneestogetherfor15secondsandrelaxingwithfiveto10repetitionseachday

4.Outer-thighstrengthening,whichcanbeperformedusinganelasticbandaround the legs at the knee level while lying on the back in a pelvic-neutralposition.Press thekneesapartagainst theresistanceof thebandfor10secondsandrelax,repeatingseveraltimeseachday.

5.Avoid stretches that place asymmetrical strain on the pelvic structures,likethehurdler’sstretch.ThismayworsenSIjointdysfunction.

ORALMEDICATIONSALLEVIATESUFFERING

If your doctor recommends that you take painmedications bymouth, chancesare this will be just one of the necessary steps to address your SI jointdysfunction. Oral pain medicines, although helpful for alleviating pain andsuffering, are unlikely to be successful for treatment if othermeasures are nottaken.

Manymedications can be used for the treatment of pain related to SI jointdysfunction.Theseincludeover-the-countermedicationssuchasacetaminophen,ibuprofen,andnaprosyn.However,somephysiciansmayprefermedicationsthatare available by prescription only for SI joint-related pain. In your physicianadvisesyoutotakeaprescriptionpainmedication,makesuretoaskthedoctorand your pharmacist about the potential side effects. Discuss any potentialconcerns before starting themedication, and read over the literature about themedication carefully. If your physician prescribes medication that containsopioids,makesureyouhaveaplanforpreventingandtreatinganyconstipation.Opioids are known to produce profound and potentially life-threateningconstipation. The best strategy is to begin a “bowel regimen” designed topreventconstipationbeforeproblemsstart.Althoughessentialduringopioiduse,goodhydrationisunlikelytobeenoughtowardoffproblems.Moreaggressivestrategies likedrinkingprune juice, takingabulk-forming laxativewith lotsofhydration,or takingabowel stimulatingagent, suchasSenna,are likely tobeneeded.

Warning!KnowtheDifferenceBetweenSIandaPinchedNerve

ClassicalSIjointdysfunctionisdifferentfromapinchednerveinthatthepainisofftoonesidebutdoesnotradiate,meaningitdoesn’tshootdownthelegintothefootorcalf.Itmayjaborstabasitsuddenlyworsenswithcertainmovements, but it shouldnot send a zinging sensationdown theleg.Makesureyourhealthcareprovidersknowifyouhaveradiatingpain,electricshocksensations,orpainsthatoccurbelowthekneeaspartofthisproblem.

TestingforSIJointDysfunction

Severaldifferenttypesofbedsidetestscanbeusedtodeterminethenatureofaproblem suspected to be SI joint dysfunction. The following tests are widelyusedbyexperiencedclinicians.3,4

DISTRACTIONTEST

Thepatientliesonhisorherbackontheexaminationtable.Theexaminerplacesonehandoneachofthefrontfacingpartsofthehipsandpressesdowntowardthetable.ThispressureisbelievedtodistractorseparatetheanteriorpartsoftheSI joint away from each other and may produce pain in the joint that ismalfunctioning.5

COMPRESSIONTEST

The patient is asked to lie on his or her side while the examiner appliesdownwardpressureontheup-facinghip.

SACRALTHRUST

Thepatientisaskedtolieonthestomachwhiletheexaminerappliesdownwardpressureonthecenterofthesacrum.AmodificationofthistestistheYeoman’stest,whichinvolvesliftingoneleguptowardtheceilingwhileapplyingpressureoverthesacrum.

THIGHTHRUST

Thepatientwill lieonhisorherback.Theexaminerwillguide thepatient tobendonelegupatthehipuntilthekneeispointinguptotheceiling.Placingonehand under the sacrum for stabilization, the examiner will apply downwardpressuretothethighthatisverticallyoriented.

PELVICTORSIONTEST(GAENSLEN’STEST)

The patient is asked to lie on the less painful side facing away from theexaminer.Theexaminermaystabilizethetophipwithonehand,andwill thenpulltheupperleg(affectedside)backward,extendingthehipandputtingstressontheSIjoint.

FABER’STEST

FABER isactuallyanacronymforFlexion,Abduction,andExternalRotation.Thisdescribes themovementsof thehip joint as the test is performed. In this

test, thepatient is asked to lieonhisorherback.The leg is supportedby theexaminerwhobends thehip into flexion,guides the thighoutward to the side(abductionofthehip)andthenrotatesthecalfandfoot(clockwisefortherightleg)toexternallyrotatethethighatthehipjoint.ThismaneuverplacesstrainontheSIjointandmayprovokepainwhenthejoint isdysfunctional.ThisisalsocalledPatrick’sTest.

SACRALSULCUSTENDERNESS

PalpationovertheareaoftheSIjointmayprovokepaininpatientswithSIjointdysfunctionsothattendernessinthisareaissupportiveofthediagnosis,butnotdefinitive as there areother reasonswhyapersonwill have tenderness in thisarea.6

GILLET’SMOVEMENTTEST

While the patient is standing, the examiner places fingers on the back to helpidentify the relativemotionofvariousstructuresduring the test.Thepatient isthenaskedtoraiseonelegbyflexingthehipandknee,bringingthelegforwardand up as far as possiblewithout losing balance. In patientswith unrestrictedmovementattheSIjoint,thefingerlocatedoverthebonelandmarkonthehipwill move downward slightly as the SI joint accommodates this change inposition.

WhattoLookforwithLowLateralBackPain•Painismuchworsewhenyoupressonit,inanareatwotothreeinches(5to8cm)lateraltothespinebase.8

•Weaknessmaybeperceivedbutthisisonlywhenpainisverysharp;whatmay bemore evident is a feeling of instability, lacking a strong base ofsupport,ordiscombobulation.

• Signs of sacroiliac dysfunction include pain that is worse with standingfromasittingpositionandpainthatisworsewhenweightistransferredtooneleg,inparticularwhenwalkingorsteppingoffacurb.

TheExplanation

Thebackandspinearedynamicmusculoskeletalstructuresthatrelyonasolidfoundationforproperfunction.Thepelvis,aheavyringofbonelyingbetweenthehips,connectsthelegstoeachotherandprovidesfoundationalsupporttothespine that isessential forordinarymovements.7Certainconditions—especiallypregnancybutalsoaccidentaltrauma—cancausedamagetothestructuresofthepelvis.Whenthepelvicringisdisturbed,movementsthataretypicallypain-freeandseeminglyeffortlesscanbecomeimpossibletoaccomplish.

Thesacroiliacjointsareapairoflargejointsconnectingthesacrumtothehipbonesoneitherside.Earlyinlife,thesurfacesofthebonesinsidethejointaresmooth,butovertimethebonesdevelopridgesandvalleys.Themostprominentof these is a central ridge on the sacrum bone running along the longestdimension of the joint, complemented by a valley in the face of the hip bonewhere it sitsopposite the sacrum.Thisadaption in formmaycontribute to thestabilizationofthejoint.Majorcontributionstothephenomenalstabilityofthesacroiliacjointaremadebyveryheavyligamentsthatbindthesacrumandhipbonestogetherinthebackmoststrongly,butalsointhefront(insidethepelvis).This structural arrangement contributes substantial strengthbut also allows forsomeflexibilityandshockabsorption.Theringofthepelvisconsistsofthetwohipbonesoneithersidemeetinginthefront,aswellasthesacruminback.Thismeans there are a total of three joints to form the pelvic ring: two sacroiliacjointsandonejoint in thefront.Anyof thesecanbecomepainfulbutonly thetwoinbackarereferredtoassacroiliacjointsandareassociatedwithbackpain.In very elderly people, parts of the sacroiliac jointsmay fuse. In some cases,thereisafocusedinflammationofthejoint.Thisistypicalofarheumatologicalconditioncalledankylosingspondylitis.

The sacroiliac joint is richly innervatedwithpain-sensingnerve fibers.Thenerve fibers that supply the joint arise from 12 or more different nerve rootsextending from the2nd lumbar level to the3rd sacral level.ThismayexplainwhySI jointpain is sometimesdifficult topinpoint andcanmanifest inmanydifferentways.

CHAPTERRESOURCES

1.Schwarzer,A.C.,C.N.Aprill, andN.Bogduk. 1995.The sacroiliac joint inchroniclowbackpain.Spine(PhilaPa1976)20(1):31-7.

2. Hertling, Darlene and Randolph M. Kessler. Management of Common

Musculoskeletal Disorders: Physical Therapy Principles. Philadelphia, PA:LippincottWilliamsandWilkins,2006.

3.Young,S.,C.Aprill,andM.Laslett.2003.Correlationofclinicalexaminationcharacteristicswiththreesourcesofchroniclowbackpain.SpineJ3 (6):460-65.

4. Petty, Nicola J. Neuromusculoskeletal Examination and Assessment: AHandbookforTherapists.ChurchillLivingstone,1997.

5. Laslett,M., et al. 2005. Agreement between diagnoses reached by clinicalexamination and available reference standards: A prospective study of 216patientswithlumbopelvicpain.BMCMusculoskeletDisord.9(6):28.

6.Dreyfuss,P.,etal.2004.Sacroiliacjointpain.JAmAcadOrthopSurg.12(4):255-65.

7. Norris, Christopher M. Back Stability: Integrating Science and Therapy,SecondEdition.Champaign,IL:HumanKinetics,2008.

8. Fortin, J.D. and F.J. Falco. 1997. The Fortin finger test: An indicator ofsacroiliacpain.AmJOrthop(BelleMeadNJ)26(7):477-80.

9.Forst,S.L.,M.T.Wheeler,J.D.Fortin,andJ.A.Vilensky.2006.Thesacroiliacjoint:anatomy,physiologyandclinicalsignificance.PainPhysician9(1):61-7.

10.Goode,A.,E.J.Hegedus,P.Sizer,J.M.Brismee,A.Linberg,andC.E.Cook.2008.Three-dimensionalmovementsofthesacroiliacjoint:Asystematicreviewoftheliteratureandassessmentofclinicalutility.JManManipTher16(1):25-38.

Q&AwithDr.Murinson

WhatcausesSIjointdysfunction?Trauma as a result of falls and motor vehicle accidents can lead to SI jointdysfunction. This can include major trauma such as a fall landing on thebuttocks,arear-impactcaraccident,especiallywhereonefootisstabilizedonapedal, and side-impact motor vehicle accidents. In cases where ligaments aredamagedbypriorinjuryorweakened,minortraumasuchassteppingespeciallyhard off a curb or bending sideways to lift a heavy grocery basket can besufficienttoinitiateanepisodeofSIjointdysfunction.Conditionsthatresultinasymmetries across the pelvis may increase chronic stresses on the joint andpredispose people to SI joint dysfunction; these could include scoliosis, leg-lengthdiscrepancies,chronicweaknessinoneleg,andhip-flexordeconditioning

(iliopsoascontracture).9

Whatmakessacroiliacdysfunctiondistinguishablefromotherkindsofbackproblems?Sacroiliac disease worsens with standing from a sitting position and becomesworsewithprovocativemaneuvers,aseriesofbedsideteststhatsomephysicianswillusetoconfirmthediagnosisofSIjointdysfunction.Thejointmovesonlyminisculeamountsundernormalcircumstances,withoneortwomillimetersofmovement-inducedshapechangebeing the typicalextentofmotion.10For thisreason, physical therapists and other knowledgeable healthcare providers willaskpatientsifgettingupfromachairprovokespain.

AreanyotherbackproblemsassociatedwithSIdysfunction?Several specific medical conditions are associated with inflammation of thesacroiliac joint. Among these, ankylosing spondylitis is a condition in whichpatients most frequently develop inflammation of the SI joint as part of thesyndrome.ThisinflammationisusuallypainfulandcanbediagnosedwithanX-ray.Patientswithankylosingspondylitisalsoexperienceacollapseofthespine.Itisthisspinalcollapsethatproducesthecharacteristicforwardcurvatureofthespineandcaneventuallyleadtodifficultieswithholdingtheheadupright.Otherinflammatory diseases, including reactive arthritis, arthritis of psoriasis, andarthritisassociatedwithinflammatoryboweldiseasearealsoknowntoproducesacroiliacinflammationandpain.Thetreatmentsforeachofthesearetailoredtothespecificdisease.

CHAPTER6

FacetDisease

Physicaltherapyisoftenthebestcourseofaction.

theDIAGNOSIS

>Doyouhavebackpainthatisfocusedononesideoftheback?>Doesyourpaingeta lotworsewhenyou try tobendbackwards,suchaswhenyoulookatthesky,orwhenyoumakeatwistingmotion?

Painthatismuchworsewithbackwardbending(extensionoftheback)isoftenduetoaninflamedorinjuredfacetjoint.Onewaytotestforfacetjointdiseaseisto begin by standing with your feet firmly planted on the ground and then,maintainingyourbalance,bendtheupperhalfofyourbodybackas ifyouaretryingtolookataspotontheceilingwhileexperiencingastiffneck(trynottotipjustyourheadback).Ifthisworsensyourpain,facetjointdiseasemaybethecause.

Facet jointpaincanbeveryfocusedand intense.Atother times, facet jointpain can be part of a larger problem. When a vertebral disc collapses, forexample,oneorbothofthepairedfacetjointsatthesamelevelinthebackwillexperienceseverestress.Atitsmostsevere,facetjointdiseasecanleadtonerverootcompressionandpainthatradiatesintotheleg.Thebottomlineis,ifyourbackpainisinterferingwithyourabilitytotwistaroundandtobendbackwards,youmayhavefacetdisease;readon!

thePRESCRIPTION

Facetjoins

Painwhenbendingbackwards

Back pain due to facet disease needs expert medical assessment and care.Sometimes anX-ray,MRI, or CT scanwill be used as a first diagnostic test.Somedoctorsmaybefamiliarwithspecificbedsideteststocheckforfacetjointproblems,whileothersmaynot. Incaseswhere thepain inyourbackextendsdown into the leg and it’snot clearwhat the causeof thepain is, yourdoctormayorderanerveconductiontestaspartoftheevaluationforyourpain.Somedoctors,andsomeclinical trials,willonlymakeadefinitivediagnosisof facetjointpainaftershowingthatthepainisrelievedbyanumbinginjectionintothejoint,butinmanycasesthisisnotrequiredtoproceedwithtreatment.

Ifyouhavefacetjointpain(sometimesreferredtoasZ-jointpain):•Yourdoctorwilllikelyrecommendphysicaltherapy,especiallyifthisisthefirst time you’re having this pain and the pain is problematic but notunbearable. For those who prefer to avoid potential problems withmedications and needle-based approaches to treatment, physical therapy isoftenthebestcourseofaction.

•Yourdoctormayrecommendaninjectionintothejoint,especiallyifthepainissevereandifyourdoctorisfamiliarwiththesetechniques.Thefacetjointinjection is typically performed under fluoroscopic (X-ray) guidance, sotheremaybelimitationstousingthisapproachinallpatients.

WHATIFYOURDOCTORDIAGNOSESANINFLAMEDFACETJOINT?

Because facet joints are like most other joints of the body, they can becomeinflamed(orinfected)muchliketheknee,wrist,orotherjointsofthebodycan.Inthesecases,itmaybemosteffectivetobegintherapywiththeinjectionofadrugintothejointspace.Inmanycases,theinjecteddrugswillincludeaquick-actingnumbingagent;thiswillallowyouandthedoctortoknowthattherightspot has been injected. Most times, the injection will also include a longer-acting, steroid-based medication. The steroid will serve two purposes; it canreduceinflammationandwillalsotendtodecreasetheamountofpain.

WHATIFYOURDOCTORDIAGNOSESAFACETDISLOCATION?

Facetjointdislocationisrareinthelumbarspine.1Morecommonlyoccurringinthe neck, facet joint dislocation is typically the result of some trauma and isdetectedbyX-ray,CT,orMRI.Ifanactualfacetjointdislocationisidentified,thetreatmentwillvarydependingonthelocationandseverityofthecondition.In theneck,approaches to treatment rangefromstabilizationwithasoftcollarand immobilization with a “halo” or hard collar to surgery and neck fusion.

Facet joint dislocations in themid-back or lower back should bemanaged bysomeonewithmedicalexpertiseinthisarea.

WHATIFYOURDOCTORFINDSTHATTHEFACETJOINTSAREDEGENERATEDANDNERVESAREBEINGPINCHED?

Insomecases,especiallywhenfacetjointdiseaseissevereandassociatedwithvertebral fracture, bonymalformations, or collapsed vertebra or disc, surgicalmanagement of the facet joint disease may be considered. If a facet joint isseverely degenerated, itmay develop bony spurs that protrude into the spacesthat normally exist between adjacent vertebral bones.When this happens, theexiting nerve roots can be compressed and pain can radiate into the leg. Inadvanced cases, weakness can accompany the nerve root compression andsurgery will be favored as a best choice. In some cases of severe disease,physical therapy may still be beneficial. Make sure to discuss the treatmentoptionswithyourhealthcareprovider.

Warning!AWindowofPain

Onelimitationofinjectionsthatcombineanumbingagentwithalonger-acting steroid is that the numbing agent typically wears off before thesteroid agent has any noticeable effect on pain.The usual experience isthatapersonwillfeelreliefforafewhoursafteraninjection,onlytohavethe pain return later that night. The pain-relieving effects of the steroidmaynotbeperceivableuntilacoupleofdayshavepassed,andsometimeslonger.

TheTreatment

In almost all situations where facet joint disease is the cause of back pain,physical therapy will be an important part of the treatment program. Severalcomponents contribute to a comprehensive physical therapy regimen for facetjointpain: thermal therapies, electrical stimulation therapies,manual therapies,traction/inversion therapies, and conditioning and strengthening. In addition,injections may be used to manage pain or confirm the diagnosis, and in rarecases,surgerymaybeanoption.

THERMALTHERAPIESAREFIRST-LINETREATMENTS

Typically used at the start of physical therapy, thermal therapies are oftencontinued because they are very effective at getting control over mild-to-moderatepainassociatedwithfacet jointdisease. Inmostcases,warmthermaltreatmentsaresoothing,canhelpimprovethepliabilityofmuscle,andincreasebloodflow.Atthesametime,coldthermaltreatmentscanblockpainsignalingand potentially short-circuit inflammatory responses to injury and vigorousactivity.

CYSTINFACETJOINT

ELECTRICALSTIMULATIONRELAXESTHEMUSCLES

Electricalstimulationtherapiesareoneofseveralapproachesthatmaybeusedtogetspecificmusclesinthebacktorelax.Becausethebodyoftenrespondstopainbytensingvariousnearbymuscles,abnormalmusclecontractionsdooccurin association with facet joint pain. In the case of facet joint pain, thesecontractions not only contribute to the overall intensification of pain, butmayactuallyperpetuatetheproblem!

MANUALTHERAPIESCANPROVIDELASTINGRELIEF

Manual therapies for facet disease include trigger point massage andmobilization of the spine. Trigger pointmassage is a specialized technique ofusingfocusedpressureonspecificlocationsinthemuscletoinducerelaxation.This is not the same as feeling more relaxed; it is an actual physiologicalresponse of the muscle that can be measured with electrical probes, oftenpalpable to thepersonperforming the therapy, and is sometimesvisible to theeyeasabarelyperceptibletwitch.Regardless, theaccomplishedpractitioneroftriggerpointmassagecanproducelastingreliefandchangethecourseoftherapyforthebetter.

TRACTIONANDINVERSIONTHERAPIESREDUCEPRESSURE

Asweage, thediscs in thebackgradually losenotonly resiliencebutheight.The collapse of disc height means that the facet joints must change with theuppersurfaceofthejointslidingdownwardoverthefaceofthelowersurface.There is a lot of play in the covering of the joint so that this shift does notusuallystrainthejointcapsule,butthemechanicsofthejointdochangeintheprocess,andcartilageof the jointmaybestressedorerodedasaconsequence.Gentletractionorinversioncanhelpreducesomeofthisstrain.

STRENGTHENINGANDCONDITIONING

These therapies are so important to treating and preventing facet joint diseasethat this chapter should probably begin and end with back-strengtheningexercise.Becauseoftheconstructionofthespineonlyasastackofboneswouldnotbe sufficient to support a lifetimeof running,walking, lifting, sitting, etc.,themusclesmustbeviewedasanintegralpartofthespine.Itisthepartofthespine that you have the greatest direct control over. Exercises for facet jointdisease should begin with core strengthening, with the back in a supportedposition.

Beginwith thepelvic tiltexercise,describedinChapter5.Wallslidesareagreatexercisetostrengthencoremuscleswhilesupportingthebacksothatfacetjointswon’thurt.Todoawall slide, standwithyourback toawall,about15inches(38cm)fromthewall.Placeyourfeetshoulderwidthapartandpointingforward.Useyourhandstoguideyoubackuntilyou’releaningagainstthewall,thenslideyourbottomdownabitas ifyouweregoing tosit inachair.Makesure your knees are over your feet and hold this position for a few seconds.Increase the time thatyouhold thispositionuntilyoucan remain there for30seconds comfortably, then move your feet a little further out and try to slidefurtherdown.Workongoinggraduallylowerwithyourwallslidesuntilyouarecomfortable“sitting”againstthewallfor45seconds.Becarefulnottooverdoitwith this exercise, as it can flare up any knee problems. Back extensionexercises, done gently at first because the pain of the facet ismadeworse byextension,arecriticallyimportanttolong-termmanagementoffacetjointpain.The classic back extension exercise is described in Chapter 1. Other keyexercisesincludecoremuscleexercisessuchasdescribedinChapter14.

Facetjointinjection

INJECTIONSCANCONFIRMTHEDIAGNOSIS

Ifyourdoctorrecommendsafacetjointinjectionrightaway,makesurethatthisseemslikethebestchoiceforyou.Manydoctorswillusefacetjointinjectionstodefinitively establish the diagnosis of facet joint pain. The injection typicallyincludesacombinationofmedicinesdesignedtoimmediatelynumbthejoint(alocal anesthetic) and reduce any inflammation in the joint (a steroid). Thesemedicinesareinjectedasamixturethroughasingleneedle.Besuretoletyourdoctor know if you might be allergic to drugs in either of these classes ofmedication.Thefacetjointinjectionistypicallydonewithfluoroscopic(X-ray)guidance and should be performedby someonewho is very familiarwith thisprocedure.

SURGERYTOMANAGESEVERECASES

Ifyourdoctorindicatesthatsurgeryisthebesttreatmentoption,makesurethatyouhaveaclearpictureofwhat’swrongwithyourbackandwhattheplannedsurgery entails. There are times when surgeons will recommend surgery formanagement of facet joint problems that are especially severe. Possibilitiesmight include surgery to relieve potential pressure points on nearby nerves,removalofpartofthebonycoveringofthespineandevenfusionofthespineincertain circumstances. You will probably want to consult with two or moresurgeonsbeforeproceedingtosurgeryforthetreatmentoffacetjointproblems.Askthesurgeonwhattheirexpectationsareforyourrecoveryfromsurgery.Dothey expect that this surgery will relieve the pain completely, mostly, orpartially?Willyoustillneedtotakepainmedicine?Howlikelyisthesurgerytoimproveyourqualityoflife?Whatarethechancesforproblemsdowntheroad?

Warning!BewareofNerveBlockProcedures

In some cases of facet joint disease, the pain specialist may propose anerve block procedure. In extreme cases, somedoctorswill recommenddestruction or ablation of the nerve believed to be carrying the painsignals.Ifsomeonesuggeststhistypeofproceduretoyou,makesurenotonly that you understand the immediate risks (and benefits) of theprocedure, but also that you are told, in clear terms, how likely it is toprovidepainreliefsixmonthsorayearlater.Manytimes,nerveablationisa temporary fix toa long-lastingproblem.Despiteappearing tobeanidealsolution,it’snotpracticaltojustcutthenervetoapainfulpart,evena little part like the facet joint. This is almost never effective for tworeasons: 1) severe pain seems to induce lasting changes in the nervoussystemsothatevenifthenerveiscut,apersistentpainsignalmayalreadybeembeddedinthesystem,and2)thenervealmostalwaystriestogrowback.It’sbeenobservedclinicallythatevenwhencuttingthenervefixestheproblematfirst,mostpeoplewillexperienceareturnoftheproblemover themonths that follow,andmany times theproblem isevenworsethanitwasinitially.

TestingforFacetDisease

Oneproblemwithbedsidetestingforfacetjointdiseaseisthat,assimpleasthetechniques are, very few “regular” medical doctors will have had sufficienttraininginthisareatobeabletoperformthestudiesinashortofficevisit.2 Inordertoobtainacleardiagnosisoffacetjointdisease,youmayneedtoseektheopinionofanexpertinpainmedicine,rehabilitation,orphysicaltherapy.Ifyouthink that facet joint disease is part of your back problem, you may need topromptyourdoctortothinkofthisdiagnosisandpossiblyreferyouforanexpertassessment.

Onetestforlocatingfacetjointdiseaseistohaveapersonliedownontheirstomach.Theexaminerwillthenapplypressurewiththefingertipsovereachofthefacetjointsinturn.Thistestrequiressomeexperienceinordertoknowhowmuchpressuretosafelyapplytothespine.Anexaminerwhoistoogingerwillnot uncover the problem effectively, and one who is to forceful will produceunnecessarysuffering.Itisnotrecommendedtotrythisathome.

TheExplanation

Thebonesofthespinalcolumnareconnectedtoeachotherthroughaseriesofjoints.Themost familiarof these is the jointat thedisc (discussed indetail inChapters2 and3), but there are also two important joints at the back of eachvertebracalledfacetjoints.3Thefacetjointsarepaired,oneoneithersideofthespinal canal.Theyare almond- toovoid-shapedconnectionsbetweenvertebralbonesthataddsupportandflexibilitytothespine.Comparedtothejointatthedisc,thefacetjointsaremoreliketheotherjointsofthebodyinconstructionandare prone to some of the same problems that other joints suffer: arthritis,dislocation,inflammation,degeneration,andeveninfection.Thefacetjointsarelocatedat eachof the spinal levels.The locationof thepain associatedwith aparticularfacetjointoftenfollowsacharacteristicpattern.

The facet joints are designed to provide both stability and flexibility to thespinalcolumn.Orientedinaverticaldirectionbetweenthevertebraeatthebaseof the spine, the facet joints allowmovement forwardandback (bendingoverandarchingback).The facet joints in the thoracicspineareangledand in thispartofthespine,movementisrelativelyrestrictedduetothepresenceoftheribsand rib cage. In the neck, the facet joints are more horizontally oriented, anarrangement that permits the turningmovement of the head. In the low back,facetjointsarealignedvertically,allowingforbendingforwardandback.

Inmanycases,thefacetjointisdamagedbyyearsofchronicuseandabuse.

Asthevertebraldiscsdryoutandflattenwithage,additionalstressisplacedonthefacetjoints.Thereisafairamountof“slack”inthecoveringofthejointinearlylife,whichallowsthetwosidesofthejointtoglidepasteachotherwhenbending and twisting motions occur. When the vertebral disc flattens down,however, the two sides of the joint assume new—more or less permanent—positionsrelativetoeachother,placingachronicstrainonthejoint.Thebonesofthejointwilloftenrespondtochronicstrainbyaprocessofovergrowthcalledosteophyteformation.Osteophyteformationisaprocesswherebytheedgesandcorners of boneswill heap up and develop protrusions and bony spurs. Theseareasofovergrowthcanintrudeintothespacesusuallyoccupiedbynerves,andwhenthishappens,nervepaincanresult.

What’sinaName?The facet joint is more properly known by its anatomical name, thezygapophyseal joint (try saying that three times fast!). It is also known inshorthandastheZ-joint.

Another consequence of chronic facet joint strain is degeneration of thecartilage in the joint.When this happens, you essentially have arthritis in theback.Like any jointwith arthritis, the facet joint can be persistently inflamedandachinglypainful.Thetypicalmeasuresfortreatingthisaredescribedinthischapter but include stretching, strengthening, mild traction, the use of anti-inflammatory medicines, and even ice. More extreme measures can includenerveinjections,nervedestroyingprocedures,andinrarecases,spinalfusion.

CHAPTERRESOURCES

1.Cox,J.E.andW.J.Vanarthos.1995.Unilateraldislocationofthelumbosacralfacetjoint:Imagingfeatures.JournalEmergencyRadiology2(4):234–6.

2.Young,S.,C.Aprill,andM.Laslett.2003.Correlationofclinicalexaminationcharacteristicswiththreesourcesofchroniclowbackpain.SpineJ3(6):460–5.

3.Giles,LyntonandKevinSinger.ClinicalAnatomyandManagementofLowBackPain.Butterworth-Heinemann,1997.

4.Bogduk,Nikolai.ClinicalAnatomyof theLumbar Spine andSacrum. NewYork:Elsevier,1987.

5.Dreyfuss,P.,C.Tibiletti,andS.Dreyer.1994.Thoraciczygapophyseal jointpainpatterns.Spine19(7):807–11.

Q&AwithDr.Murinson

Whatisaparsdefectandhowdoesitrelatetofacetdisease?Thepars ispartof theposterior ringofeachvertebra, linking thesuperiorandinferior facet joint faces.The full nameof thepars is thepars interarticularis(loosely translating as “the part between the joint faces”). A pars defect is adeficiencyinthepars,dueeithertoafailureofthebonetoformproperlyafterbirthorafracture.Theparsdefectdisconnectstheposteriorpartofthevertebralringfromtheanteriorpartofthevertebra.

Theparsdefectrelatestofacetdiseaseduetotheinterlinkingaspectsofthespine’s construction: each vertebra is stabilized from in front and in back. Inorderforafacet joint tobecomedislocatedorseriousdamaged,eitherthediscwillhavetoshiftortheboneswillhavetogive,whichtheydobyfracturing.Apars defect can be present from birth as part of aminor spinalmalformation.Alternatively,aparsdefectcanbeafractureofthevertebralring.Thesefracturescanresultfromaspecificaccidentortrauma,butcanalsooccurwhenexcessive

forceisappliedtothespinethroughheavylifting.4Aparsdefectmayeitherbeof minimal significance or require management by a surgical specialist,dependingofthelocationandextentoftheproblem.

Whatdoesfacetjointpainfeellike?Facetjointpaincanoccurineitherthelower,middle,orupperback,orevenintheneck.5Itisusuallymostintenseofftoonesideofthespine,andthelevelofthe pain is usually near but not necessarily limited to the specific level of theproblem. The pain of facet joint disease is usually due to arthritis orinflammation,sosensationsofdullaching,strongpain,andevensharptwingesare not atypical. Facet joint pain is different from the pain of a back muscleproblem,inthatitlastsformuchlongerperiodsoftimeandisespeciallybroughton by extending the back. Activities such as painting ceilings, changing lightbulbs in suspended fixtures, or trimming trees are likely to provoke pain inpeoplewithfacetjointdisease.

CHAPTER7

SpinalInstability(Spondylolisthesis)

OTCmedications,heatingpads,exercise,andcorsetstostabilize

thespineareoftenthebestremedyforpain.

theDIAGNOSIS

>Doyouhavepainthatisverysevereattimesandatothertimesisalmostnothing?

>Doesyourpainseemtoflareupindiscreteepisodesandsettledown,onlytoflareupagain?

> During an episode, do you have difficulty standing upright and developmuscletightnessespeciallyinthehamstrings?

Painthatissevereattimesandcomesandgoesindiscreteepisodescanbedueto spinal instability. In this condition, simplemovements such as standing upfromalowtoiletmaybeenoughtotriggerashiftofthevertebralbonesrelativetooneanother.Sometimes,thebonesshiftintoapositionthatismoreproperlyaligned;whenthishappens,painisrelieved.Atothertimes,onevertebralbonewillshift forwardorbackrelative to theonebelowit.When the twovertebralbonesarenotlinedupproperly,thisiscalledaspondylolisthesis(spon-di-lo-lis-thee-sis). The ligaments, disc, and joints are all stressed, and incapacitating,severepainmayresult.

The syndrome of spondylolisthesis is especially characterized by tighthamstringmuscles. One way to check if your hamstrings are tight is to do astraightlegraisetest.Whenyoulieonyourbackandhaveahelperliftoneofyour legsgraduallyup in theair,bendingonlyat thehip,yourhamstringsaretightifthereistightnessorpaininthebackofyourthighthatlimitstherangeofupwardmovement in your leg. (Pain in the backwith thismovement ismoreindicativeofanerverootcompressionfromadisc.)Havethehelperchecktheotherlegwithyouaswell.

RareCausesofSpinalInstabilityInrarecases,spinalinstabilityisduetoamass(tumor),aninfection(abscess),or a spinalmalformation. These problems are readily assessed throughMRIandtheotherdiagnostictestsdescribedhere.Thetreatmentfortheseconditionsisindividualized.

Another characteristic of spondylolisthesis is that the pain in the backworsensasthespineisextended,aswhensomeonebendsbackwardstolookupattheceiling.Thisisbecausespondylolisthesisismosttypicallyassociatedwithdamage to the boney arch portion of the vertebra, and this part is pressurizedwithbackwardsbendingofthespine.

Ifyouhavelivedwiththeexperienceof“havingyourbackgoout”repeatedlyand the cause is not a bulging disc or muscle spasm, you may have spinalinstability;readon!

DISPLACEDVERTEBRACAUSINGPRESSUREONNERVE

thePRESCRIPTION

Backpainduetospondylolisthesisneedsexpertmedicalassessmentandcare.Ifyouhaveaspondylolisthesis (sometimesreferred toasaspinal instabilityoraspinalmisalignment):• Your doctor may recommend over-the-counter pain medication andconservative measures such as a heating pad, especially if the spinalmisalignmentisbelievedtobeoldandnotrelatedtoyourpain.

•Yourdoctormayrecommendphysicaltherapy,especiallyifthemisalignmentismildandthereisnoevidenceofnervecompression.Surgerymaystillbeneeded if non-surgical treatments are ineffective and if the misalignmentappearstobeworseningovertime.

•Chiropractictherapymaybeappropriateforsomeformsofspondylolisthesis.Sometimesmorethanonetreatmentvisitisneeded.

•Non-surgicaldecompressiontherapymaybebeneficial,butsolidevidenceinsupportofthisnewapproachisstillaccumulating.

•Acorsetcanbeusedtohelpstabilizethespineandrelievepain.•Yourdoctormay referyou toa surgeon,especially if there isnerve-relatedweakness, persistent disabling instability, or advanced spinal degeneration.Surgery has advantages and disadvantages; however, if there is obviousweaknessor lossofcontroloverbowelorbladder,emergencysurgerymaybenecessarytopreservefunction.

ACorset,OfCourseYoumaybeadvisedtowearacorset,andthismayhelptoreducemovementaround a hyper-mobile spine segment. You might wonder if the corset is apermanent state of affairs, but with proper rehabilitation and careful self-awareness,itispossibleforthemusclestogainstrengthandsupportthespine,for the ligaments to repair somewhat, and for thepain-amplification cycle towind-down.

WHATIFYOURDOCTORDIAGNOSESAPULLEDMUSCLE?

A pulled muscle will usually improve in three to five days. The differencebetweenapulledmuscleandaspondylolisthesisisthatspondylolisthesisattacksoccuragainandagain,alwayswith thesame typeofpain.Usually, thepain isdeeperandsharperthanthetypicalburningqualityofmusclepain.

WHATIFYOURDOCTORDIAGNOSESABULGINGDISC?

In thiscase,physical therapyandexerciseareusuallybest.Thedegreeofpainanddisabilityassociatedwith this typeof injuryvariesgreatly,but in thiscaseyoucandoalottoimproveyourchancesofafastandfullrecovery.

WHATIFYOURDOCTORFINDSTHATANERVEROOTISBEINGCOMPRESSEDBYANOVERGROWTHOFBONES(BONYSPURS)ORLIGAMENTSINTHELOWERBACK?

The overgrowth of bones and ligaments in the lower back is usually the endresult of years of accumulated trauma to the back. It carries the label ofdegenerative joint disease (DJD). Surgery may be an alternative, but thisdependsontheextentofdamagetothespine.Manytimes,physicaltherapyandprogrammedexerciseistherightsolution.

TheTreatment

Ifyourdoctorrecommendsphysicaltherapyfirst,thisusuallymeansyouhaveamild spondylolisthesisorone that is prone to reductionwithmild-to-moderatelevelsofpressureortraction.Thetypesofphysicaltherapytreatmentsusedforspondylolisthesis are similar to those used for injured discs (see Chapter 3).Treatment for spondylolisthesis may emphasize manual therapy and tractionapproaches inorder to restore thenormalalignmentof thevertebralbones.1 Ifyou want to avoid surgery now or in the future, you will need to do yourrecommended back-strengthening exercises every day. Some of the exercisesthatareusefulforstrengtheningthespineandpreventingshiftingintoandoutofspondylolisthesis are described in Chapter 14. Butmake sure you checkwithyourdoctororphysicaltherapistbeforeproceeding.

AGOODEXERCISEFROMPILATES

One exercise that is good for building stronger spine muscles comes fromPilates.Beginby lyingonyourback;make sure tohold a solidpelvicneutralpositionatthestartandthroughout.Straightenonelegandbendthekneeoftheother,placingthefootonthefloorfirmly.Now,extendthearmsfullyasifyou

are lifting themover your head (see below).Raise the heel of the straight legaboutfourinches(10cm)offthefloor,thenflexthekneeandhip,bringingthekneeuptowardthechest.Asyoudothis,bringbotharmsoveryouinanarcthataimstoplaceonearmoneithersideoftheflexedleg.Asyoudothis,youshouldslightlybendyourupperbodyup in amodified abdominal crunch.Return thearmsandtheflexedlegtotheirextendedpositionandrepeatthismovementfiveto10times.Thenswitchlegsandreadjust thearcofyourarmstoexercisetheothersideofthebody.

COSTLYCOMPUTER-CONTROLLEDTHERAPY

If your doctor recommends decompression therapy, be aware that manyinsurancecompaniesarenotgoingtopaythistherapy.Inthepast,Medicarehasnot paid for this, so it is essential that you check with your medical insurerbeforemakingadecision,asitcancostthousandsofdollars.Therearedifferentforms of this device; however, one machine is designed to apply controlledtractiononthespinewhilesimultaneouslydeliveringelectricalstimulationtotheback.Theideais that if theelectricalstimulationcanrelaxthebackandblockmusclespasms,thetractionwillbemoreeffective.Manypatientshavereporteda benefit from this therapy, but the ordinary standards for proving that thetherapyworkshavenotyetbeenmet.

SPINALADJUSTMENTSBYACHIROPRACTOR

If your doctor recommendsmanual therapy or spinalmanipulation,make surethat you feel comfortablewith the treatment plan.Many insurance companieswillpayforspinaladjustmentsandchiropracticcare.Askwhetherthetreatmentis expected to work in one or a few visits, or whether protracted therapy isanticipated. Spinal adjustments to the lumbar spine are generally safe andeffective.

In terms of caring for the lower back, chiropractors often have a distinctadvantageoverthegarden-varietyM.D.intheextentoftrainingthattheyreceiveindisordersofthebackandspine.Chiropractortrainingisessentiallyfocusedonthespineandhowdisordersofthespineimpacttheoverallhealthofthebody.2The well-prepared chiropractor will have received a much more detailedtheoreticalunderstandingofspinemechanicsandgreaterworkingknowledgeofeffective mechanical solutions to spine problems through their training. Thechiropractor will usually approach a back problem with a can-do, hands-onattitudeandwillexcelindoctor-patientcommunication.Ingeneral,chiropractorsdonotprescribemedications,as this iscounter to thephilosophy that theyare

trainedin,andtheydonotperformsurgeries.ThenumberofchiropractorsintheU.S. is still small, comparedwith the number of physicians and surgeons, butthesenumbersareexpectedtogrow,accordingtotheBureauofLaborStatistics.

Warning!

Therehavebeendocumentedcasesofmajorstrokestothebrainoccurringat five times the baseline rate in adults younger than 45 years of agefollowing chiropractic treatments.3 It has been proposed that this isespecially associated with high-force chiropractic manipulation of theneck.4Thereason thestrokesarebelieved tooccur isbecause thebloodvessels thatsupply thebackhalfof thebrainare threadedthroughsmallholes on the sides of the neck vertebral bones (like a thread runningthroughbeadsonastring).Theexplanationthatseemstofollowisthatasthehigh-forcemanipulationcauses theneckvertebralbones to twistandslide against each other, the blood vessels can be exposed to shearingforcesandbecomeblockedasthevesseliscompressedordamaged.

X-rayofthelumbarspinewithaspinalfusion

ChecklistfortheFirstVisittotheSurgeon(BeforetheSurgery):CopiesofimagingstudiesListofquestionsforsurgeonBriefsummaryoftheproblemListofothermedicalconditionsListofmedicationsPaincalendarSupportperson

SurgeryMeansSpinalFusion

Ifyourdoctor refersyou toa surgeon rightaway,chancesare thatyouhaveaspinal instability that isputtingyour spinal cordornerve roots at riskwithoutsurgical intervention. The surgical procedures that may be used to address aspondylolisthesis include spinal fusion. Other surgical procedures may beconsideredasappropriatebythesurgeon.Spinalfusionisamajorprocedure.It’saprocessoffusingorpermanentlylinkingdifferentvertebralbonestogetherintooneunit.Fusion can involve fusing twoadjacent vertebrae togetherwithbonefrom elsewhere, sometimes harvested from the patient’s own hip (boneautograft).Atothertimes,anothersourceofboneispreferred;ifthebonecomesfromsomeoneelse,itisreferredtoasanallograft.Theusualsourceofboneforallografts is deceased donors; youwill hear this called the bone bank. Spinalfusioncanalsoentailtheplacementofmetalrodsandscrewsalongsideandintothe spine.Fusions that usemetal rods and screws are sometimes called fusionwithinstrumentation.Theuseofmetalrodsallowsforthespinetobestabilizedovermultiplespinalsegmentsatonce,andcanbeusedtostabilizeabonefusionuntilitissolidlyfused.Abriefdescriptionoftheactualprocedurefollows.

NUTSANDBOLTSOFSPINALFUSION

Spinal fusion is an established surgical procedure that usually requires a longincisionontheback.Althoughsomesurgeonsareadoptinganewtypeoffusionsurgery that is done through surgical keyholes in the abdomen, most spinalfusionscontinuetobeperformedusingalong-incision-over-the-backapproach.Once the incision has beenmade, the surgeon will separate the layers of fat,muscle,andconnectivetissuesthatareattachedtothebone,whichwillanchorthefusionhardware.Holesaredrilled into thebonethatformsthesidesof theboneyarchonthebackpartofthetargetvertebrae.Theseholesmaybetestedtomakesurethattheyarestableandcanholdascrew.Thescrewsaredesignedtoconnecttoplatesorrodsthatwillfixthevertebraeinplace.Oftentimes,screwsandplatesareusedtogetherwithgraftedboneinafusionsurgery,asthesemetalstructures will prevent shifting as the bone solidifies and hardens. Thematurationofthefusingbonetakesseveralweeks.Oncetheplatesorrodsareinplace,thescrewscanbetightenedandlockedintoplace.Thesurgeonwillthenclosetheincisionintheback,cleansingtheincisionandworkingtocontrolanybleeding as needed.A dressingwill be placed in the operating room and thisdressingwillremaininplaceuntilthesurgeondeterminesitshouldberemoved.

PREPARATIONFORSURGERY

Before seeing the surgeon, there are some things you should do to prepare:gather your relevant medical records, make a list of potential questions, andmake sure you have a support person who will stay with you throughout thevisit.Makesure thatyouhave thenecessary imagingstudies,both reportsandfilms. Ifbloodworkorother testshavebeenperformed,bringcopiesof thosereports as well. Have an accurate list of your medications including dietarysupplements, and take a list of your prior surgeries. Make sure to alert thesurgeonandstafftopriorproblemswithanesthesia,bleeding,orprocedures.

Consider taking a notebook or an audio recording device to the visit asinformationcan flowveryquicklyonce treatmentdecisions aremade.Alwaysaskpermissionbeforemakinganaudiorecordingofyourvisit.Ifthesurgeonisrecommendingsurgery,makesureyouknowwhatprocedureisplanned,whethertheproceduremightchangebasedonfindingsat the timeofsurgery,andwhatthe anticipated course of recovery might be. Have a reasonable sense of theexpectedlimitationsonactivityaftersurgery.Ifyouareplanningairplanetravel,makesuretogetspecificguidelines.Ifyousmoke,youmustquitbeforespinalfusion surgery. The biggest risk factor for failed fusions is smoking; it isbelievedthatthenicotinekillsbonecells.

Afteryourfirstsurgicalofficevisit,readoverthematerialsthatyoureceive.Makesureyouunderstandwhatprocedureisplanned,howmanydaysyouwillstayinthehospital,whetherarehabcenterstayisexpected,andhowmuchtimeoff fromworkwill be needed.Make sure you feel comfortablewith the plan.Youwillneed toknowhow toprepare for thesurgery, includingwhen tostopNSAIDs(potentiallycontributingtoexcessblood-thinning)andhowlongtofastbefore thesurgery.Ask ifyouwillneed tocompleteapre-operativeexamanddetermineifanyexerciseisrecommendedorrestrictedbeforehand.

The day of surgery, youwill bemeeting someone from the anesthesiologyteambeforethesurgerybegins.Makesurethattheyknowhowlongyou’vebeenfasting,whatmedicationsyounormallytakeandhavetakeninthelast24hours,and how long you have been off NSAIDs (including aspirin, ibuprofen,naprosyn,etc).

ChiropracticInterventionsGainSupportThe research in support of chiropractic interventions is building. Studiessuggest that chiropractic care is beneficial, but these studies are small andusually focus on chronic low back pain generally rather than any specificdiagnosis.5Studiesalsoindicatethatchiropracticcareiseffectiveatrelievingpainanddisability,associatedwithhighlevelsofpatientsatisfaction,andlessexpensivethanprimarycaremanagementofbackpain.6

POST-SURGICALCONSIDERATIONS

Aftersurgery,youwillhavesomedegreeofpain.Mostofthetime,post-surgicalpain iscontrolledwithstrongpainmedication.Opioidsarewidelyusedduringandafterspinesurgery.Ifyouhavebeenonpainmedicationsbeforethesurgery,you may need to make sure the pain team is aware of this and makes anynecessaryadjustments.

What’sNew:SmokingPutsFusionatRiskArecentstudyonspinalfusionindicatedthatsmokingdoublesthatchanceoffusion failure. Just 10 cigarettes a day were enough to put people into thehigherriskcategoryforfusionfailure.Thosewhoquitsmokingreducedtheirrisktofusionfailuretonear-normallevels.7

Properstandingposture

Detailsonwhat to expect after surgery are covered inChapter2, butmakesureyou follow recommendationsonwhen toget out of bed,when to ask forassistance,andhowtomovearoundinthefirstfewdays.Youwillneedtohaverehabafterspinalfusionsurgery.Becarefulnottooverdoit,becausethespinalfusion takes several weeks to become strong against the ordinary pressuresplacedonthespine.

Take thepainmedication that is recommended,butbesure tocommunicatewithyournursesanddoctors ifyou think thepain ismore thanyouexpected.Out of the ordinary pain after surgery can be a sign that something is amiss;don’tsufferinsilence.Inaddition,toomuchpaincaninterferewiththenormalrecoveryprocess.Thebodywillreleasestresshormonesinresponsetopainandthiswillblockhealing.Peoplewithexcesspainarepronetofalls,youdefinitelydon’twanttoriskfallingatthisstage!

Youshouldnotsmokeafterspinalfusionsurgery.Makesuretoeatadietthatis varied andhigh in fiber.Staywell hydrated and act aggressively topreventanyconstipationwhileonopioids (sometimescallnarcotics) suchasPercocet,oxycodone,orcodeine.

TestingForSpinalInstability

Many times, a basic X-ray of the back is the best test for the diagnosis of aspondylolisthesis.8 However, it is possible that the X-ray may not reflect theproblemifitistakenatatimewhenthealignmenthasself-corrected.Ifthespineisveryunstable, itmaybehelpful tohaveflexion-extensionX-rays,wherethepicturesof thespineare takenas thepersonbendsforwardandback.AnMRImay or may not be helpful. If you have pain that is shooting down the leg,especially pain that extends below the knee, or if you have actual weaknessalongwithpain,yourdoctormayrecommendanerveconductiontesttoassesswhetherthenervesinthebackarestillintact.ThistestisdescribedindetailinChapter 2. Once imaging and other test results are in, a clearer picture willemerge. The possibilities range from “nothing is wrong” to a “mildmisalignment”to“high-grademisalignmentofthespine.”

Aspondylolisthesisisdescribedbyspecialistsusingtwosystems.Thefirstisa system that tries to identify the causes or origins of the problem. Thisdiagnostic classification system includes labels such as dysplastic (meaningimproperly formedduringdevelopment), isthmic (pertaining to theboneyarchstructure),traumatic,anddegenerative.Theotherdescriptivesystemisbasedonthedegreeofslippagethathasoccurredbetweentheinvolvedvertebralbones.In

this system, a grade is assigned. A Grade I slippage is less than 25 percentdisplaced, a Grade II is 25–50 percent displaced, and so on. The higher thegrade,themorelikelythespondylolisthesisistocompressnerverootsandotherstructures. It is asserted in themedical literature that low-grademisalignmentthat is stably displaced is not necessarily painful. A low grade slippage thatmovesinandoutofalignmentismorelikelytobepainful.

Warning! Using NSAIDs May Interfere with Bone Healing afterSurgery

MedicalliteraturesuggeststhatNSAIDsmayinterferewithbonehealing,and laboratory-based research isquotedas supporting this.Recently, therecommendationwasmadethatsurgeonsshouldnotonlyavoidtheuseofNSAIDs immediately before and after surgery, but that they shouldcounselpatientstodiscontinueNSAIDusewellinadvanceofthesurgery.

ItisimportanttonotethatmostsurgeonswillrequireNSAIDsbestoppedforaspecificperiodoftimepriortosurgerybecauseoftheriskofblood-thinningeffects.9

TheExplanation

Thevertebralbonesof thespinalcordarestackedoneon topof theother likeblocks inachild’s tower.Mostof the time,extraordinarilystrong ligaments inthebackholdthesebonesinproperalignment,butinsomecases,ifthespinehasbeen injured or stressed, one of these bonesmay begin to shift in and out ofalignment.Themostcommonscenarioisthatthevertebralbonethatsitsontopwill slide forward (an anterolisthesis). The less common scenario is that thevertebralboneon topwill slideback (a retrolisthesis).Although thatare somemisalignmentsthatarethoughttoberelativelystable,otherswillbemeta-stableand will slip in and out of alignment. For these people, this slippage cansometimes be accompanied by excruciating pain and difficulty getting into afullyuprightposture.

Anatomyofthespine

TheProsandConsofSpineSurgeryIf you are contemplating spinal fusion surgery for treatment ofspondylolisthesis, don’t expect miracles. The spine fusion is intended toimmobilize part of the spine. Youwill need to exercise care in returning todailylife.Thereisagoodbodyofevidencethatshowsthatthespineaboveandbelowthe levelof the fusion is subject to increasedstresses.Forpeoplewhodon’t adaptwell to life after spine fusion, it can almost seem like there is apattern of spreading spine degeneration. Increased body awareness can behelpful if it does notmakeyou so fearful of doing anything that yourworldbeginstocontract.Stayfocusedonpositivehealthbutasyoudo,includeaplantocareforyourbackinyouroverallhealthpicture.

Itiswidelybelievedthathavinganexaggeratedlowbackcurvature(lordosis)or sway back posture with the buttocks protruding increases the chance ofspondylolisthesis occurring. This is because the L5 vertebral body sits on asloping angle and this slope is exaggerated when the low back curvature isincreased.Thisisanimportantremindertokeepaconstantwatchonthespineandworkonmaintainingapelvicneutralpositionevenwhenstanding.Onewaytofacilitatethisistothinkabouttighteningyourbuttocksandcurvingyourtailboneunderasyoustand.Anotherhelpfulvisualizationistothinkaboutpullingyourbellybuttontowardyourspine.

CHAPTERRESOURCES

1.McNeely,M.L.,G.Torrance,andD.J.Magee.2003.Asystematicreviewofphysiotherapyforspondylolysisandspondylolisthesis.ManTher8(2):80-91.

2. Bureau of Labor Statistics, U.S. Department of Labor, “Chiropractors,”Occupational Outlook Handbook, 2010–11 Edition.http://www.bls.gov/oco/ocos071.htm.Accessed12/24/2009.

3. Rothwell, D.M., S.J. Bondy, and J.I. Williams. 2001. Chiropracticmanipulation and stroke: A population-based case-control study. Stroke32:1054–1060.

4.ChirowebEditorialStaff.StrokeafterchiropracticneckmanipulationA‘smallbut significant risk,’ says American Heart Association.http://www.chiroweb.com/mpacms/dc/article.php?id=41126.Accessed12/27/09.

5.Wilkey,A.,M.Gregory,D.Byfield,andP.W.McCarthy.2008.Acomparisonbetweenchiropracticmanagementandpainclinicmanagementforchroniclow-back pain in a national health service outpatient clinic. J Altern ComplementMed14(5):465–73.

6.Grieves,B.,J.M.Menke,andK.J.Pursel.2009.Costminimizationanalysisoflow back pain claims data for chiropractic vs medicine in a managed careorganization.JManipulativePhysiolTher32(9):734–9.

7. Andersen, T., F.B. Christensen, M. Laursen, K. Høy, E.S. Hansen, and C.Bünger. 2001. Smoking as a predictor of negative outcome in lumbar spinalfusion.Spine(PhilaPa1976)26(23):2623–8.

8. Irani, Z. and J.J. Patel. “Spondylolisthesis,” eMedicine.http://emedicine.medscape.com/article/396016-overview.Accessed12/20/2009.

9.Thaller, J.,M.Walker,A.J.Kline, andD.G.Anderson. 2005. The effect ofnonsteroidal anti-inflammatory agents on spinal fusion. Orthopedics 28 (3):299–303.

10. Lowe, W. March 2006. Spondylolisthesis: An elusive cause of low backpain. Massage Today, 6 (3).http://www.massagetoday.com/mpacms/mt/article.php?id=13380. Accessed12/30/2009.

11. Towers, S.S. and W.B. Pratt. 1990. Spondylolysis and associatedspondylolisthesisinEskimoandAthabascanpopulations.ClinOrthopRelatRes250:171–175.

Q&AwithDr.Murinson

Whatarethetriggersforepisodicspondylolisthesis?Theusualscenarioforapersonwithepisodicspondylolisthesisisthatheorshewillhavehadanepisodeofstrongbackpainthatresolvedbeforeanythingwasdone about it. He or she will do well for a period of time, and then all of asuddenthebackpainwillreturn.Thethingsthat triggertheepisodemayseemrelativelyminorbutincludegettingupfromalowtoiletseat,bendingoverintothetrunkofacar,playingweekendsportstoovigorously,orevensneezing.

Ifyouhaveepisodicspondylolisthesis,youwillneedtobecomeakeenstudentofyourownbodymechanics.10Youmayneed toscrupulouslyavoidactivitiesthatputyourbackout.Youmayneedtoavoidlowseating,getaspecialadapterfor low toilet seats inyourhome,andgiveuponshovelingsnowandmovingfurniture!

Besidesthosewithswaybacks,whoislikelytogetaspondylolisthesis?Certain activities and sports increase the occurrence of a spondylolisthesis.Populations as special risk include gymnasts, rowers, weightlifter, divers, andfootball players. Certain professional groups are at increased risk, includingloggersandthosewhocarryveryheavypackssuchasfootsoldiers.Onegroupthat has consistently been identified as having higher occurrence ofspondylolisthesis is the Eskimos. There is some indication that a geneticcomponent may contribute to this.11 Overall, it is thought that aspondylolisthesisispresentinlessthan5percentofthepopulation,althoughthedegenerativeformincreaseswithadvancingage.AnL4-L5spondylolisthesisismore characteristic of an early-in-life problem, whereas L5-S1 slippage istypicaloflater-in-lifedegenerativespondylolisthesis.

CHAPTER8

VertebralFracture:Emergency!

Self-treatmentcanresultinpermanentdisability.Getemergency

medicalhelpassoonaspossible.

theDIAGNOSIS

>Haveyoubeentoldbyadoctorthatyouhaveafracturedvertebra?

A vertebral fracture can cause the spine to be unstable. Seemingly simplemovements, such as trying to sit up, can cause the bones to shift abnormally,crushingthespineorseveringbloodvessels.Vertebralfractureisoftenprecededby some trauma, such as a motor vehicle accident, a fall down stairs, or aswimming/divingaccident,butinolderadultswithosteoporosis,thetraumathatcauses vertebral fracture may be less obvious. If you have osteoporosis or acollapsingspine,thesuddenonsetofstrongpaininthecenterofthebackmaybeyouronlysignthatseriousdamagehasoccurredtotheback.

Warning!DoNotSelf-DiagnoseaVertebralFracture

Mostofthechaptersinthisbookarewrittenasaguidetolearninghowtobetterunderstandwhatmaybegoingonwithyourback.Thischapter isdifferent: it is intended as a guide for those who have been told by aphysicianthattheyhaveexperiencedvertebralfracture.Youshouldnottryto self-diagnose vertebral fracture. It is a critically serious medicalproblem that can result in permanent disability if one wrong move ismade.Ifyoususpectthatyouhaveavertebralfracture,stopreadingandcall911.

thePRESCRIPTION

Suspected vertebral fracture is amedical emergency for the reason that sometypesoffracturecanresult incompressionofthespinalcordorinjurytoothernearby structures. Emergency personnel are trained in how to move peopleminimizingtheofriskforprovokingfurtherdamagetothebodyintheeventthatthere is a spinal instability due to a fracture. They will need to methodicallyevacuate someone with a suspected spine injury, typically using animmobilizationboard.Atthehospital,someoneskilledinassessingthespineforfracture will determine if it is “safe tomove” by obtaining amedical history(sometimes very abbreviated), doing a physical exam, and evaluating anynecessaryX-rays or images. The treatmentswill varywith the severity of thefractureandthedegreeofassociatedspinalinstability.

Ifyouhaveafracturedvertebraintheneck:• Your doctor will have determined the particular characteristics of yourfracture on the basis of X-rays and potentially other imaging studies (CT,MRI).

•Yourneckmayneedtobeimmobilizedorsurgicallyfused.• Itmayseemthat fusion isadrasticsolutiongiven that it results inreducedmovementintheneckpermanently,butifyoucanstillmoveyourarmsandlegs,thatissomethingtobegratefulfor.Cervicalspinefractureispotentiallyfatal.

Ifyouhaveafracturedvertebrainthemiddleoftheback(thoracicregion):• Your doctor will have determined the particular characteristics of yourfractureonthebasisofX-rays;sometimesotherimagingwillbeneeded.

•Youmayneedtotakemedicationforpain.•Yourdoctorwilldiscusswithyouanyproceduresthatmayhelpstabilizethebrokenvertebra.

• Make sure you understand if your spinal cord is in any danger ofcompression.

•Makesureyouknowthewarningsignsofspinalcordcompressionandwhento see urgent medical care. (See Chapter 9 for more on spinal cordcompression.)

Ifyouhaveafracturedvertebrainthelowerback(lumbarregionandsacrum):

• Your doctor will have determined the particular characteristics of yourfractureonthebasisofX-raysandpotentiallyotherimaging.

•If thespineisunstable,yourdoctormayrecommendsurgerytostabilize it.Depending on the situation, spinal fusion may be required to stabilize afracturedvertebra.

•Sometimesabraceorcorsetisusedtostabilizethespineifthisisconsideredsufficienttopromotehealing.

•Youmayneedtotakemedicationforpain.•Youmaybeinstructedtoeliminatecertainactivitiesforseveralweeksafterfracture. It takes a long time for bones to heal after a break, possibly sixweeksorlonger.Makesureyouknowhowmuchactivityispermittedduringthis time and follow your doctor’s directions very carefully. Failure toobserveactivity restrictioncan result inpersistentpainandaworseningofthespinalstability.

Warning!IfYouSuspectaVertebralFracture,DoNotMove!

Vertebral facture isamedicalemergency thatmay result immediately inpermanent paralysis or other serious harm. If you ever suspect that avertebrahasjustfractured,donotmove.Havesomeonecall911andlettheemergencymedicalteamknowthatyoumayhavespineinjury.

IfYouSmoke,QuitImmediatelyIfyousmokecigarettesandyou’veexperiencedavertebralfracture,youmustquitimmediately.Smokinginterfereswiththebody’sabilitytodeliveroxygentobonesandrecuperationfromvertebralfracture.

What’sNew:ControversyoverVertebroplastyEfficacyMajor controversy erupted with the publication of two articles in the NewEnglandJournalofMedicinedescribingstudiesofthetechniqueforthereliefofbackpainandreportingthatnobenefitwasproven.5Theleaddoctorononestudyexpressedshockwiththestudy’sconclusions,ashaveothers.6Ithasbeentheexperienceofmanyphysicians thatvertebroplasty isveryhelpfulwhenapatientisexperiencingseverebackpainfromvertebralfracture.Inallfairness,itseemsthatthelargerofthetwostudiesshowedthattherewasimprovementinclinicallymeaningfulpainreliefatonemonth.Acceptanceofthisresultwaslimitedhowever,becausetheresulthadborderlinestatisticalsignificance.Thepatientswho received both the actual vertebroplasty and thosewho receivedtheshamtreatmentwerebothbetterimmediatelyaftertheprocedure.Thismayreflecttheeffectsofsedation,localanesthetic,orthenormalstressresponseinsomeone undergoing amedical procedure. For reasons that aren’t clear fromthepublishedworks,neitherofthestudieswasabletorecruitthefullquotaofpatients originally planned by the researchers.TheSociety for InterventionalRadiologyhasweighedinwithaCommentarythathighlightsthelimitationsofthe study and demonstrated pretty effectively that just one additional patientcouldhaveswayedtheconclusionsoftheU.S.-basedstudyinthedirectionofdefinitely endorsing the treatment. Interestingly, many more sham treatmentpatients elected to have a second procedure in hopes of pain relief than didvertebroplastypatients.7

TheTreatment

The treatment of vertebral fracture depends of the location and extent of thefracture.Yourdoctorswill assess the stabilityof the spine and treatmentswillinclude pain control measures and any necessary steps to prevent shifting orcollapseofthespinalcolumn.

USEICEPACKSFREQUENTLYFORDAYSORWEEKS

Vertebralfracturewilloftenrequireicepackstobeusedseveraltimesdaily,foraweekorlonger.Inotherpartsofthisbook,icepacksarestronglyrecommendedforthefirst48hoursafteraminorinjuryorpainflare,situationsofmusclepain,minor insult, or acutebackpain.Withvertebral fracture,however, ice isoftenrecommended for the duration of the first week, and warm compresses areavoidedduringthistime.1Thisisbecauseinvertebralfracturethereisalongertimewindow for swellingand inflammation thatmayultimately interferewithhealing.Icewillhelpreducebothpainandexcessiveinflammation.Makesuretowrapyouricepackinaclothbeforeapplyingit,andleaveitinplacefornomorethan20minutesatatime.

PRESCRIPTION-STRENGTHMEDICINEWILLALLEVIATEPAIN

When your doctor recommends medication, it is entirely possible thatprescription-strengthpainmedicationswillbeproposed.ThereissomeevidencetosuggestthattheNSAIDs(non-steroidalanti-inflammatorydrugs)caninterferewith bone healing, and some orthopedic surgeons avoid NSAIDs after bonesurgery. Although a certain percentage of people with vertebral fracture willexperiencerelativelymodestpainlevels,bonesarepainfulwhenfracturedandavertebral fracture can result in nerve compression (also painful). For thesereasons,itissometimesnecessarytouseprescription-strengthpainmedications,and even still, it is observed that thesemay not always work for the pain ofvertebralfracture.Aslongasthefractureishealing,youcanexpectaneventualreductioninbackpain.

PHYSICALTHERAPYISOKAYIFTHESPINEISALIGNEDANDSTABLE

When your doctor recommends physical therapy, this is usually because theintegrity and alignment of the spine has not been compromised. Because thespine is an interdependent structurewhere bones andmuscles dependon eachotherforsupportandstrength,corestrengtheningisanessentiallong-termgoalfor addressing the problems that are associated with vertebral fracture. In the

short run, physical therapy can address factors such as pain control, reflexmusclespasm,correctingandreinforcingproperbodymechanicsinthewakeofvertebralfracture,andpreventingdeconditioningduringtheacutepainphase.

Physical therapists know exactly how to use ice packs for optimal results;they will position you with bolsters and pillows to place the spine in a restpositionandhavehuge icepacks that theyapplyovera towel.Theywillsetatimer so that the requisite time is not exceeded, dim the lights, and encourageyou to relax for the treatment. It is a good idea to follow thismodelwith icetreatments at home.As you are getting better fromyour fracture, the physicaltherapist will show you a series of stretches and exercises. It is absolutelyessential to follow throughwith these. Improving strength and stability of thespineisthesinglebestprotectionagainstchronicproblemsafteraspinefracture.

VERTEBROPLASTYSTABILIZESTHESPINEWITHGLUE

When your doctor recommends vertebroplasty, youwill want to consider thisrecommendation carefully. Originally devised in the early 1980s in France,vertebroplasty is a procedure in which specialized glue is injected into thefracturedvertebratostabilizeandperhapspartiallyrestorethenormalvertebralconfiguration.2,3 It is considered a minimally invasive procedure that isperformedwith the patient awake or verymildly sedatedwithmedications torelieveanxiety.AneedleisinsertedintothefracturedvertebrausinglightX-ray(fluoroscopy) toprovideguidanceandconfirmcorrectplacementof theneedletip.Theglueispreparedonthespotintheproceduralroombecauseithardensquickly,changingfromsomethinglikethetextureoftoothpastetoaharder-than-bonestateinlessthan15minutes.Vertebroplastyhasbeenusedformanyyearsand has been believed to be a very successful treatment for severe pain aftervertebral fracture. Widely considered a safe procedure, the major limitationswere the cost factor and the fact that the technique had never been definitelyproventobeeffective.4

ACORSETSUPPORTSANDSTABILIZESTHESPINE

When your doctor recommends a brace or corset, this usuallymeans that thespinemaybemildlyunstablebut isconsideredsufficientlystable thatacorsetwill serve to support and prevent abnormal motion of the spine during thehealing process. It is especially important to follow your doctor’s instructionsabout activity restrictions very carefully.Wear the corset as instructed, as thepurpose of the corset is to prevent motions in the spine that will impede orreverse healing of the bones and ligaments of the spine. It is expect that the

corset will aid in relieving pain. This is because if the spine is even mildlyunstableandthebonesareshiftingsmallamounts,forsomepeople,thisisverypainful. There are rich supplies of pain-sensing nerve fibers that go to all thestructures of the back (except the interior of the vertebral discs). Persistentmovements, even when small, can inflame these nerve endings and result inserious pain. A chronic state of mild spinal instability may take the form ofintermittentspondylolisthesis(seeChapter7formoreaboutspondylolisthesis).

The illustration here shows a type of brace that might be used for spinalimmobilizationafter avertebral fractureof themidor lowback.Thisbrace iscalledacruciformanteriorspinalhyperextension,orCASHbrace. It stabilizesthespine inamoreuprightpositionandpreventsforwardbending,whichmayplace further pressure on the vertebra and impede healing.8 Another type ofbraceusedforthispurposeistheJewettbrace.

Onetypeofbraceusedfortreatmentofvertebralfracture

SpeakUpIfYou’reinPainYou don’t need to suffer in silence. If back pain after vertebral fracture iskeepingyouawakeatnight,interferingwithyourabilitytofunctionduringtheday, or just generally making you miserable, talk with your doctor abouttreatment options. If that doctor has run out of ideas for pain control, getanotheropinion.Undertreatmentofspinepainisnotanacceptableoutcome.

SURGERYISNEEDEDIFTHESPINEMIGHTCOLLAPSE

Whenyourdoctorrecommendssurgery,thisusuallymeansthatadeterminationhasbeenmadethatyourspineisunstableandthatwithoutsurgeryyouareatriskforhavingthespineshiftorcollapseandcrushpartofthespineorsomenerveroots. Surgery for vertebral fracturemay involve spinal fusion to stabilize thespine. Spinal fusion is described in detail in Chapter 7. In certain cases, it isnecessaryforspecialhardwaretobeplacedinthespinetoreplaceorstabilizeaseriouslydamagedvertebralbone.Thisisdoneatthetimeofspinalfusionandispart of that surgery. Your surgeon will discuss this with you if it becomesnecessary. You should read the sections on the preparation for surgery, thesurgeryitself,andthepost-surgicalconsiderationsinthatchapter.

TestingForVertebralFracture

Testingforvertebralfracturewillusuallyoccurinanemergencyroomsetting,atleast initially.Yourdoctorswillwant toobtainandreviewX-raysof theback.CTscanscanbeveryusefulforvisualizingthebonesofthebackinmoredetail,and3-Drenderingsaresometimesused.AnMRImaybeorderedtoevaluatetherelative location of structures such as nerves, muscles, joint capsules, andligaments.Ifsomeonehasbeeninanaccidentandplacedonanimmobilizationboardattheaccidentscene,heorshemayhavetowaitforimagingstudiesforthespinetobe“cleared,”andthenheorshewillbeunstrappedfromtheboard.

TheExplanation

Vertebral fracture is distressingly common. Car accidents, including head-oncollisions, vehicular roll-over accidents, and accidents involving impact withwindshield and steering wheel are associated with spinal injury.9 Two maingroupsofpeoplesufferfromvertebralfracture:youngadults(mostlymale)andolder adults who have osteoporosis. In the young adult population, vertebralfractureusuallyresultsfromserioustrauma.Vertebralfractureisassociatedwithspinalcord injuryandsadly, therearestill11,000spinalcord injuries reportedeachyear.10Mostoftheseareduetomotorvehicleaccidents,butviolentinjuryand injuries related to sports such as downhill skiing, diving, and football areimportantcausesofspinalcordinjuryaswell.

X-rayofaspineshowingthemetalscrewsandplatesusedinthefixationoffracturedspinalvertebrae.

RedFlagsforPeoplewithVertebralFractureThe followingwarning signs, forpeoplewhohavepreviouslybeen told theyhavevertebralfracturebyaqualifiedphysician,couldindicate that thespinalcordornerverootsarebeingcompressedordamaged.•Lossofsensationoverthegenitals•Lossofcontroloverurineorfeces(incontinence),especiallyifthisisanewproblem

•Having difficulty starting a stream of urine as a new problem after backinjury

•Newseverepainintheback•Painornumbnesswrappingaroundthebodyorleg•Recentfeverornoticeableweightloss

Whenthespinalcordisinjured,communicationsfromthebraintootherpartsof the body are slowed or stopped. And this is the real danger of vertebralfracture:Whenavertebralbone isbroken, it canbreak in suchaway that thespinalcolumnbecomesunstable;bonescanshiftormoveandwinduppressingon the spinal cord itself, compressing nerve roots or even damaging nearbyblood vessels. If you have had a vertebral fracture, a doctor will need todetermineyourrisksforthiskindofproblem.Theconsequencesofspinalcordinjuryarepotentiallysevere.Acord injury in theneckcanparalyze thehands,arms,andlegs,andevenstopapersonfrombreathing.Thesesortsofinjuriesarepotentiallyfatalwhenmedicalcareisnotprovidedimmediately.Whenvertebralfracture damages the spinal cord lower down in the back, itmay result in legparalysisandlossofcontroloverthebowelsandbladder.Thesesortsofinjuriescan leave someone permanently confined to a wheelchair and dramaticallyshortenthelifeexpectancy.Forthesereasons,vertebralfractureisconsideredamedicalemergencythatrequiresimmediatemedicalevaluation.

CLASSIFICATIONOFVERTEBRALFRACTURES

Vertebralfracturesareclassifiedbasedonthemechanismofinjuryandextentofdamage.Themajorclassesofinjurymechanismincludeflexion-compression(asinlandinginaseatedpositionfromaheight),axial-compression(asinlandingwithpressure transmitted straightonto the spine), flexion-distraction (as in theinjury produced by a lap belt–only restraint as the spine flexes forward withdeceleration),rotational(occurswithextremeside-bendingortwistingmotions),andshearinjuries(wheretwistingandfront-to-backmotionsarecombined).Thedoctor’s evaluation will focus on determining the type of injury, and alsowhetherthevariouspartsofthespineareaffectedbytheinjury.Insituationsofvertebralfracture,attentionisfocusedonthreeverticalcolumns,onedefinedbythefrontpartofallthevertebralbones;onethatrunsthroughthemiddleofallthevertebralbones, top tobottom;andone that runs through thebackedgeofeachofthevertebralbones.

With this information in hand, itwill be possible to determinewhether thespine is stable, somewhatunstable,ordangerouslyunstable.Thebackedgeofthe spinal bones is bounded by a very strong, fibrous ligament that addstremendouslytotheintegrityofthewhole.Iftheposteriorpartofthevertebralbone isdamagedandordetached from the ligament, thismakes itmore likelythat thevertebral fracturewill be anunstableone. In the illustration, the frontcolumnisshadedinblue,themiddlecolumninyellow,andtheposteriorcolumninred.Thevertebralfracturecandisruptone,two,orallthreeofthesecolumns.

Fracturesthatdisruptonlythefrontcolumnandsomefracturesthatdisruptthefrontandmiddlecolumnsatthesametimearestillconsideredstable.

Some examples of how the fracture classificationmethod is applied canbeseeninthenextillustration.Vertebralburstfracturesoccurasaresultofstrongpressure applied directly to the top or bottom of the spine. In the topmostfracture, the front, middle, and back columns of the vertebral bone are alldisrupted.This is anunstable fracture. In themiddle fracture, the anterior andmiddle columns are disruptedwhile the posterior column remains intact. Thisfracture may be stable. In the bottom fracture, only the middle column isdisrupted, and this fracture shouldbe stable.Ananteriorwedge fracture is themost common fracture associated with osteoporosis. It is most often a stablefracture,butprofessionalevaluationisnecessarytomakethisdetermination.

OSTEOPOROSISANDCANCERPRESENTHIGH-RISKS

There are some people who can expect to face significant challenges aftervertebral fracture. Two groups in particular are at risk for serious long-termconsequences: those with osteoporosis and those who have had a vertebralfracture because cancer is present in the spine. These two situations requiredifferentapproaches.

Forpeoplewithosteoporosis,itisimportanttoadoptaprogramdesignedtoaddress problems with bone density and bone frailty. If you are not alreadytakingbone-strengtheningdietarysupplements,thismaybeyoursignaltostart.Discuss osteoporosis with your doctor. Find out what tests you need done toassess the severity of your osteoporosis and to determine how intensive yourtreatment forosteoporosisshouldbe.TheAmericanAssociationofOrthopedicSurgeons recommendsaDEXAscanas thebest test to assessbonedensity. Ifyou have already had a vertebral fracture but you don’t know if you haveosteoporosis, you should probably talk to your doctor about getting this veryaccuratetest.Thereisonlyaverysmallamountofradiationinvolvedinthetest,aboutthesamethatyouwouldreceivefromso-calledbackgroundradiationjustbylivingintheUnitedStatesforthreedays!Thereareotherteststhatareusedforscreeningthatarenotasaccurateandwon’tprovidethatmuchinformationabout what to expect about your risk for future vertebral fractures. At aminimum,everyadultneedsat least1000mgofcalciumdailyandvitaminD.(SeeChapter21formoredetails.)

Osteoporosisisusuallyseeninpeopleovertheageof50,andcertainpeopleare at increased risk. If you are female, tall, slender, and have had minimalweight-bearingexercise throughoutyour life,youmaybeatparticular risk forosteoporosis.TheNIH reports that asmanyashalfofolderwomenmayhave

osteoporosis.Peoplewhohavebeentreatedwithlong-termcorticosteroidssuchasprednisonehaveanevenhigherriskforosteoporosis.Althoughsteroidscanbe life-saving in situations such as asthma and autoimmune disease, it is thelong-termeffectsonbone(andskinandmuscle)thatreallylimitthebenefitsofsteroidsforchronicuse.

Vertebralfracturesareclassifiedbymechanismandbydisruptionofthreeverticalcolumns

THREETYPESOFSPINAL“BURST”

If you or someone you love is living with cancer and has had a vertebralfracture because cancer has weakened the spine, serious measures may beneeded tostabilize thespine.Particularcancers, includingbreast,prostate,andlung, will spread to the bones of the spine. Be aware that pain can be animportant symptom of serious problems, and attend to new pain problemscarefully.Makesureyourdoctorknowsifthereisneworpersistentpaininthespine.Therearemanytreatmentsforcancerinthespine,andyoushouldexpectthatanypainduetothisproblemwillbetakenseriouslyandasolidactionplanput into place. Treatment options can include medications, radiation, andsurgery,aloneorincombination.

Sometimesvertebralcollapseorfractureisduetoaninfectiononthespine.Inyears past, tuberculosiswas seen to invade the spine; this is very rare nowastuberculosishasbeeneffectivelytreatedandreducedintheU.S.Otherinfectionsof the bone, such as osteomyelitis, can cause vertebral collapse, and for thisreason, fever isconsideredawarningsign inconcertwithsudden-onset strongbackpain.

CHAPTERRESOURCES

1.Kochan,Jeffrey.“VertebroplastyandKyphoplasty,Percutaneous,”eMedicine.http://emedicine.medscape.com/article/423209-overview. Accessed January 17,2010.

2.Ibid.

3. Deramond, H., et al. 1998. Percutaneous vertebroplasty withpolymethylmethacrylate.RadiolClinNorthAm36(3):533–46.

4.Kochan,Jeffrey.“VertebroplastyandKyphoplasty,Percutaneous,”eMedicine.http://emedicine.medscape.com/article/423209-overview. Accessed January 17,2010.

5. Buchbinder, R. 2009. A randomized trial of vertebroplasty for painfulosteoporotic vertebral fractures.New England Journal of Medicine 361:557–568.

6.Goodman,B.Newstudies raisedoubts about thebenefitsofvertebroplasty.ArthitisToday,2009.

7. Kallmes, D.F., et al. 2009. A randomized trial of vertebroplasty forosteoporotic spinal fractures.NewEnglandJournalofMedicine 361 (6): 569–

79.

8. Kulkarni, Shantanu. Spinal Orthotics. eMedicine.http://emedicine.medscape.com/article/314921-overview. Accessed January 20,2010.

9. Reiter, GT. Vertebral Fracture. eMedicine.http://eMedicine.medscape.com/article/248236-overview Accessed January 12,2010.

10.Ibid.

11.AmericanAcademyofOrthopaedicSurgeons(AAOS).“OsteoporosisTests,”AAOS website. http://orthoinfo.aaos.org/topic.cfm?topic=A00413. AccessedJanuary17,2010.

12. NIH. “Osteoporosis,” www.nlm.nih.gov/medlineplus/osteoporosis.html.AccessedJanuary17,2010.

13.MayoClinicstaff.“Exercisingwithosteoporosis:Stayactivethesafeway,”MayoClinic.com.www.mayoclinic.com/print/osteoporosis/HQ00643/.AccessedJanuary17,2010.

14. “Spinal Compression Fractures.” www.eorthopod.com/node/10860.AccessedJanuary20,2010.

Q&AwithDr.Murinson

CanIexerciseafterspinalfracture?Exerciseafterspinalfracture,onceyou’vebeenclearedforthisbyyourdoctor,is critically important for staying healthy and avoiding additional problems.11You should choose the exercise that you do based uponwhat is safe for yourback, but also chose todo something that you enjoy.For some, exercise is anopportunitytoengageinsocialinteractions:Socialexerciserscanenjoydancing,taking fitness classes, walking with a friend, or working out at the gym.Sometimes,exerciseprovidesatimetobemorefocusedononeself.Peoplewhoare pulled in many directions can find a few moments of contemplation inactivities such as swimming, lifting weights at home, working out withheadphones,orgoingtothegymveryearlyinthemorning.

It’s important to choose your exercise with safety in mind. If you haveosteoporosisoranotherconditionthatplacesyouatriskforadditionalvertebralfractures, you may need to avoid exercises that require higher impacts orbending and twisting movements.12 Examples of these include tennis, golf,

rowingmachines,andrunning.13Exercisebicyclesarenotconsideredidealforthe prevention of osteoporosis, as the exercise they provide is not weight-bearing. However, they are exceptionally good at promoting cardiovascularfitnesswhile increasing strengthand flexibilityof the legs.For this reason, anexercise bike can be an excellent complement to other exercise activities thatspecificallytargetbonebuilding.

WhatifIstillhavepaininmybackafterfiveweeks?Ifyourpainisgraduallydecreasingfromthetimeofyourinjurybutislingeringonat fiveweeks,youprobablyneed tohang in thereandanticipate that slow,steadyimprovementwillbethenameofthegame.

If,however,yourbackpainisgettingworseorchangingfortheworsequitesuddenly,youmayneedtoletyourdoctorknowthisishappening.Ifyou’restillgettingphysicaltherapyatfiveweeksafterinjury,askyourtherapistwhathisorhersenseofyourrecoveryis.Vertebralfracturesrepairslowly,butthegoalistofinishupwithastablespinethatwillallowyoutoreturntoeverydaylifeandtheactivitiesyouenjoy.14

CHAPTER9

SyndromesofSpinalCordCompression:Emergency!

Cancerorsevereinfectionarerarebutdooccur.

Don’tdelayproperdiagnosisandtreatment.

theDIAGNOSIS

> Have you recently developed back pain, or has your mild back painsuddenlygottenmuchworse?

>Haveyourlegsbecomeweak,orareyourecentlyhavingtroublegettingtothebathroomwithoutsoilingoraccidents?

Ifyouhavebackpainwithlegweaknessorbowelorbladderincontinence,youneedtoseekimmediatemedicalattention.Legweaknessand/orincontinenceareconsidered red flags in the context of new or worsened back pain, as thesesymptomscansignalproblemswiththespinalcordorspinalroots.Thesekindsof problems when presenting together are not infrequently due to seriousproblemslikecancer,aggressiveinfections,orproblemswithbloodflowtothespine.Tobesure,plentyofpeoplehaveurinaryincontinenceforotherreasons,such as prostate enlargement or pelvic floor problems after childbirth.But forsomeone who previously did not have these concerns to suddenly findthemselveswithoutgoodcontroloverbodilyfunctions,thisisacauseforpromptassessment.

Thetreatmentsprescribedwilldependontheidentifiedcauseoftheproblem.Althoughthecausesofspinalcordcompressionaretypicallyquiteserious,iftheproblemiscaughtwithinafewhoursofitstarting,goodtreatmentoptionsmaybeavailable.Everythingheredependsontiming,though.Gethelpimmediately.

thePRESCRIPTION

Ifyouhavespinalcordcompressionintheneck:• Your doctor will have determined the particular cause of spinal cordcompression on the basis of X-rays and potentially other imaging studies(CT,MRI).

•Yourneckmayneedtobeimmobilizedorsurgicallyfused.

Ifyouhavespinalcordcompressioninthemiddleoftheback(thoracicregion):• Your doctor will have determined the particular cause of your spinal cordcompression using a variety of tests. Blood tests, fluid samples, X-rays,MRIs,andCTscansmayallbeused.

•Youmayneedtotakemedicationforpain.• Your doctorwill discusswith you any procedures that will be required tostabilizethespine.

If youhave spinal cord or root compression in the lower back (lumbar regionandsacrum):•Yourdoctorwillhavedetermined theparticular causeofyourcompressionsyndromeonthebasisofX-raysandothertesting.

•Yourdoctormayrecommendsurgerytostabilizethespine.Dependingonthespecificsofthesituation,spinalfusionmayberequired.

•Youmayneedtotakemedicationforpain.• You may be instructed to eliminate certain activities for several weeks ifspinesurgeryisneeded.

What’sNew:SteroidswithinEightHoursofCompressionFormanyyears,theurgenttreatmentofspinalcordcompressionincludedtheadministration of high-dose steroid medications. The medications, althoughhelpful in certain circumstances, are associatedwith serious side effects likebleeding from the stomach or intestines, transient diabetes, weight gain,thinningofthebones,atrophyofmuscles,andincreasedskinfragility.Large-scale studies have indicated that steroids are only demonstrably beneficialwhengivenveryearlyafter theonsetofan injury to thespinalcord.Currentrecommendations indicate that eight hours is the timewindow duringwhichsteroidsmaybehelpful,butleaveit tothediscretionofthetreatingdoctortoproceedornot.1

TheTreatment

Dependingonthecausesofspinalcordcompression,treatmentsmayvaryfromemergencysurgerytomedicationstoradiation.Makesurethatyouaskquestionsalong the way and let your providers know immediately if new problemsdevelop.

IDENTIFYASUPPORTPERSONBEFORESURGERY

Ifyourdoctorsaysyouhavetoundergosurgery,makesurethatyouunderstandthenature and expectedoutcomeof the plannedprocedure.Thingsmaymoveveryquicklyifyouhavecordcompression,soyou’llwanttohaveyourfamilymembersorcloseonesawareofwhatishappening.Youwillbeunconsciousforthesurgery,andyoursurgeonmayhaveimportantinformationtocommunicatetoyouafterthesurgery.Youwillwanttohavesomeonepresentasmuchofthetime as possible, just to help get through the first few hours and days of thisprocess.Itwouldbeagoodideatohaveadesignatedfamilyspokesperson.Thisshould be someone who understands your personal opinions about healthcareand can speak for you. Ideally, this person should be comfortable talking todoctors,nurses,andsocialworkers.Thelegalstructurethatexiststosupportthisisthehealthcarepowerofattorney.Thelawspertainingtothisvarybystate,butbe aware that the best decisions usually follow a willingness to be proactiveaboutmakingsureyourmedicalwishesareknownandrepresented.

DIFFERENTTYPESOFSURGERY

The use of surgery for spinal cord compression will vary depending on thenatureoftheproblem.Iftheproblemisatumorofthespinalcorditselfandthetumorisstillrelativelysmall,surgeryitselfmaybecurative.2Thelimitationhereis that tumorsof thespinalcorditselfareoftendiscoveredfairly late,after thetumor has grown in size and is damaging delicate structures. In the case of afocal infection such as an epidural abscess, the treatment may require acombination ofmedications and surgery.3 In this situation, surgery is used todrainanypusandtostabilizethespineifneeded.

ASKABOUTSIDEEFFECTSOFMEDICATIONS

Ifyourdoctorsaysyouneedpowerfulmedications,thetypeofmedicationwilldependonthenatureoftheproblem.Forsomeproblems,steroidsmaybeused;forothersituations,strongantibioticsmaybenecessary.Makesuretoaskaboutexpected side effects and whether there are any symptoms that might be

especiallyworrisomeandthatdoctorswouldwanttoknowaboutrightaway.

MRIimageofametastatictumormassintheupperthoracicspinalcanalandcausingcompressionoftheunderlyingspinalcord.

MRIimageofaneurofibroma.

EXPECTATIONSFORREHABILITATION

Ifyourdoctorrecommendsrehabilitation,askaboutwhathisorherexpectationsare for rehabilitation. Do people with your condition expect to make a fullrecovery,oraretheproblemspersistent?Rehabforspinalcordcompressioncangoquicklyifthecompressionwasminorandbrief,butwhenthecompressionismoreseriousandpersistsformorethanafewhours,rehabcanrequiremonthsofhard work. Hours of exercises, learning to walk safely, and keeping one’sbalancewillbepartoftherehabplan.

TestingForSpinalCordCompression

Testingforspinalcordcompressionwillmost typicallyoccur inanemergencyroom setting, at least initially. Your doctor will want to make a detailedexamination of the nervous system’s functioning, especially with regard tofunctioningofthelegsandthebowels.Adigitalrectalexammaybeperformedaspartofthis.Imagesofthebackwillbeobtained;thismayincludeX-rays,CTscans,andMRIs.Eachoftheseimagingtechniqueshasparticularstrengths,andallthreemaybeusedatsomepoint.CTscanscanbeveryvaluableintermsofvisualizing the bones of the back in detail. MRI is usually needed to assessstructuressuchasmasses,nerves,muscles,jointcapsules,andligaments.Undercertain circumstances, other imagingmethodswill later beused tohelp assesswhateverprocessledtothecordcompressiontostartwith.

TheExplanation

Syndromes of spinal cord compression are divided into threemain classes asfollows:

1. extradural,meaning those that press on the spinal cord fromoutside thespinalcanal

2. intradural-extramedullary, meaning those that compress the spinal cordfromoutsideofthecorditselfbutfrominsidethespinalsac

3. intramedullary,meaningtheyarisefrominside thestructureof thespinalcord.4

The course of back pain in these different classeswill vary. In the case ofcompressions that are due to problems within the spinal cord, the pain thatresultsmaystartverygraduallyandremainvaguelydefinedintermsoflocationuntil theproblemisquiteadvanced.A lossofsexual functionmaybe the first

signofarealproblem.Compressiveproblemsthatstartoutsidethespinalcordmayfirstpressonanerveroot;inthiscase,thepainwillbeveryspecifictothelevel of the spine that is involved. If not addressed immediately however, thelocalizingnervepainmayeaseoffasthenerveiscompletelydisabledandpainmayprogresstoadeeper,bonytypepainasthevertebralbonesareinvolved.

MRIimageofcollapsingandinflammedspinalstructures.

Thecausesof spinalcordcompressionaremultiple.Cancer isan importantcause;spinalcordcompressioncanbeduetolocaltumorsortotumorsthathavespreadfromelsewhereinthebody.5Certaintumorshaveatendencytospreadtothe spinal column (the vertebral bones) and from there extend to the point ofcompressing the spine. These spine compression syndromes may becharacterizedbyaperiodofnaggingbackpainthatsuddenlyevolvestoincludelegweaknessorincontinence.Thecancersthatfollowthispatternmostoftenarethoseoflung,breast,andprostate.Torestoreorpreservefunctionandminimizepain, it is important toget help immediately.There are several treatments thatcan be used to reduce the effects of these tumors and to control any resultingpain.

Another typeof cancer that causes spinal cordcompressionare tumors thatarisedirectlyfromthespinalcorditself(cordtumors).Thesetumorsincludetheependymomas, the astrocytomas, and the hemangioblastomas.6 Of these, theependymomasaremorecommoninadults,buteventheseareuncommon,withanestimatedoccurrenceoflessthanonein100,000persons.Theusuallocationforthecordtumorsisintheneck,wheretheycanaffectfunctionsofthelowerbodyaswellascausingweaknessinthearms.Thepaincausedbycordtumorsmaycomeonverygradually.Problemscausedbycordtumorsdevelopsoslowlythat a patient typically has had some symptoms for two years at the time ofdiagnosis.Thehallmarkofpain from these tumors is that thepain isworse atnight as the person is lying on their back.Most patients have someweaknessprior todiagnosis,butsexualdysfunctionandurinary incontinencemaybe theproblems that prompt a patient to seek medical attention. In the case ofependymomas, the tumor may be growing within a capsule or covering.Removal of these sorts of tumors is curative. There are circumstances wherespinal tumors aremore aggressive, however, so it is important towait for thepathologist’sreportbeforereachinganyconclusions.

In some cases, spinal cord compression is caused by an infection. Theinfectioncancomefromanotherpartofthebody:urinarytractinfections,lunginfections, skin abscesses, and implanted devices are potential sources ofinfection. Recent surgery, dental procedures, interventional procedures thatrequire catheters or needles, and spinal injections are possible contributoryfactorsaswell.Peoplewithunderlyingimmunodeficiencyareatincreasedrisk,asarealcoholicsandthoseusingIVdrugs.Peoplewithdiabeteshaveincreasedrisk for all kinds of infections including epidural abscesses. The traditionalpicture of spinal abscess is that of a patient with fever, back pain, andneurological problems, but this is not always evident in each patient. The

averageageofpatientswithspinalabscessissurprisinglyhigh,beingaroundage50.7Becauseoftheseriousnessofthisinfection,othersystemsofthebodycanbecomedestabilizedandastateofshockcanfollow.

Thisconditionisamedicalemergency.Bothsurgeryandmedicaltreatmentsmaybeuseddependingonthecircumstances.Medicationsforatypicalabscessdue tobacterial infectionmaycontinue for fourweeksormore. Inyears past,tuberculosiswasacauseofspinalcordcompression,butthisisveryrareintheU.S.at this time.Thetreatmentfor tumors thatarepressingonthespinalcordfromoutside thespinalcovering (dura)willdependon the tumor typeand theextentofdamage.Insomecases,wherevertebralbonesarepartiallydestroyed,aspinalfusionisneeded.ThisprocedurewasdescribedindetailinChapter7.

CHAPTERRESOURCES

1. Schreiber, Donald. “Spinal Cord Injuries: Treatment and Medication,”eMedicine. http://emedicine.medscape.com/article/793582-treatment. AccessedMarch16,2010.

2. Ogden, Alfred, Nicholas Wetjen, and Thomas Francavilla. “IntramedullarySpinal Cord Tumors,” eMedicine.http://emedicine.medscape.com/article/251133-overview. Accessed January 31,2010.

3. Huff, Stephen. “Spinal Epidural Abscess,” eMedicine.http://emedicine.medscape.com/article/1165840-overview.AccessedJanuary31,2010.

4. Dickman, Curtis, Michael Fehlings, and Ziya Gokaslan. Spinal Cord andSpinalColumnTumors:PrinciplesandPractice.NewYork:Thieme,2006.

5. Schick, U., G. Marquardt, and R. Lorenz. Intradural and extradural spinalmetastases.JournalNeurosurgicalReview,2001,24(1):1–5.

6. Ogden, Alfred, Nicholas Wetjen, and Thomas Francavilla. “IntramedullarySpinal Cord Tumors,” eMedicine.http://emedicine.medscape.com/article/251133-overview. Accessed January 31,2010.

7. Huff, Stephen. “Spinal Epidural Abscess,” eMedicine.http://emedicine.medscape.com/article/1165840-overview.AccessedJanuary31,2010.

Q&AwithDr.Murinson

Whenwilltherebeacureforspinalcordinjury?Scientists are working furiously to find treatments that reverse the effects ofspinal cord injury.Until recently, therewas little hope of recovery for peoplewith damaged spinal cords, but the future holds much promise. Scientificresearch has uncovered biological responses that actually interfere with theabilityof the spinal cord to recover froman injury, and scientists aredevisingnew strategies to promote effective healing and regrowth. The fundamentalchallengeisthatthespinalcordservesasaconduitfornerveprocesses(axons)thatextendfromthebaseofthespinetothebrain,sometimesoverthreefeet(91cm) in length.When these connections aredamagedor even severed, it is notsimplyamatterofrestoringtheconnectionattheinjurysite;theaxonsactuallyhavetogrowfromthatpointonwardstowheretheyusedtoterminate,findtheappropriate target and re-establish functional communications. To accomplishthiswouldbe a taskof profound complexity.Fromstudiesof lab animals,weknow that if thegoal isbeingable towalkabit, it’snot actuallynecessary torestorealltheoriginalcircuits.Inratsatleast,afewpioneeraxonsareenoughtobringbacksomewalkingfunction.Althoughrepairofhumanspinalcordinjuryremains a tantalizing goal, and some intractable mysteries are beginning tounravel,effectivetreatmentsremainjustoverthehorizon.Ifyouknowsomeonewith a spinal cord injury, and you want to get the latest on cutting-edge(experimental)treatments,visittheclinicaltrials.govwebsiteandenterthesearchterm“spinalcordinjury.”

Arethereanyotherconditionsthatpresentlikeaspinalcordcompression?Occasionally,whatappearstobeaspinalcordcompressionsyndromeisactuallyaspinalcordstroke.Thebloodsupplytothespineismainlycarriedbytwolargearteries: one that forms at the top of the spine in the neck and another thatpenetrates the spinal column in the mid-to-lower back. Blockage of either ofthesearteriesor theirmajorbrancheswillhave severeconsequences includingsomepain,paralysis,incontinence,andsometimeslossofsensation.Inthiscase,an immediate intervention to restore blood flow may be the only chance toprovidemeaningfulrecovery.

CHAPTER10

Scoliosis

Earlydiagnosisandregularre-evaluation

isthekeytoagoodoutcome.

theDIAGNOSIS

>Areyou (or doyouknow) ayoungpersonwith a curvatureof the spinefromsidetoside?

>Doesyourbackacheonmostdaysoftheweek?

Scoliosis is a side-to-side curvature of the spine that usually affects youngpeople in themid-teen to early adult years.Girls aremore often affected thanboys. The common scenarios for scoliosis include chronic daily back pain,feelings of fatigue, and some shortness of breath. Scoliosis shows up as adifference in shoulder height, an obvious curvature of the spine, or somethingmoresubtle,suchasaneedtoadjustabrastraptobeshorterononeside.1Earlytreatmentofscoliosisisimportantforgoodoutcomes.

thePRESCRIPTION

Backpaindue to scoliosisneedsexpertmedicalassessmentandcare.Becausethis problem occurs most commonly in adolescence, most pediatricians arefamiliarwith thescreeningprocedures. Ifscoliosis issuspectedon thebasisofthephysicalexam,usuallyanX-raywillbeneeded.Therearespecialmethodsformeasuring the degree of curvature of the spine. The treatment depends onhow severely the spine is curving andwhether the curvature is gettingworsequickly. Most commonly, scoliosis develops between the ages of 10 and 14.Exactnumbersaren’tknown,butmoststudiesfindthatgirlsare10timesmoreoftenaffectedthanboys.Ifsurgeryisneeded,thereisapreferencefordelayingthesurgery ifpossibleuntil after the lastgrowthspurt so that therewillbenoneedforlaterrevision.

Ifyouhavemildscoliosis:•Yourdoctorwillverylikelyrecommendphysicaltherapy,especiallyifthereis no evidence that the curvature of the spine is rapidly worsening. Theeffectiveness of physical therapy for scoliosis depends both on the type ofexercises prescribed and on the consistency of the person following theexerciserecommendations.

•Yourdoctorwillwanttore-evaluateyourspineinthenextfewmonths.

Ifyouhavemoderatescoliosis:•Yourdoctorwillverylikelyrecommendfittingforabrace.Bracingiswidelyused to stabilize the spine and preventworsening of scoliosis in situationswherethereismoderatecurvatureofthespine.Inordertobeeffective,thebrace must be worn nearly all the time. It is important to have the bracereassessedforfitatintervalsasthepersonwearingthebracewillbegrowingandadjustmentmaybenecessary.

• Again, your doctor will want to re-evaluate your spine in the next fewmonths.

GeographyIsaFactorThe percentage of young people developing scoliosis varieswith geographiclocation. There is a tendency for people from more northern countries todevelopmorescoliosis.Itisbelievedthatthereisaneffectfromsunexposure(orlackofit)andpossibleeffectsinthosewithlaterpubertytobemoreatrisk.Whateverthemechanism,theoccurrenceofscoliosisintheU.S.isreportedtorangefrom2to5percentingirlsaged10to14.2

Ifyouhavemoreseverescoliosis:•Yourdoctormayrecommendassessmentforsurgery.Dependingontheover-all medical picture, surgery is currently recommended for scoliosis wherethereisamoresubstantialcurvaturetothespine.Therisksofleavingseverescoliosis untreated include chronic pain, breathing problems, and risks forinfection.

• Your doctor may recommend a brace for a period of time to allow for agrowth period to be completed prior to surgical intervention. Althoughsurgerymayeventuallystillbeneeded,theresultsofsurgeryareoftenmorefavorableifgrowthiscompletedornearlyso.

• Make sure that you discuss the risks and benefits of surgery thoroughlybeforeproceeding.Whataretheexpectationsforreliefofpain?Howstraightwillthespinebeaftersurgery?Willfuturesurgerybeneeded?

Whatifyourdoctordiagnosesaspecificproblemcausingthescoliosis?Inthiscase,thetreatmentmaydependonwhetherthatspecificcauseofscoliosisisreversibleorcurable.Inrarecases, theremaybeatumor,infection,orotherabnormalitythatisinducingthecurvatureinthespine(secondaryscoliosis).

HighRiskforSurgicalComplicationsAskyoursurgeontoprovidespecificdetailsabouttherateofcomplicationintheir surgery practice. It is recognized that surgery for scoliosis carries arelativelyhighcomplicationrate.6Inadditiontotheusualconcernsassociatedwith a major spine surgery, such as blood loss and infection, surgery forscoliosiscarriescertainneurologicalrisksandoverthelongrunmayincreasethe rate of degenerative spine disease at levels above and below the area ofstabilizedspine.Itisknownthatmoreaggressiveeffortstofullyreducespinecurvatureareassociatedwithaddedstressonnearbystructures.Forthisreason,spinal surgery for scoliosisdoesnot seek toattainaperfect result.The long-termconsequencescouldbequitenegative.Someoftherisksassociatedwithscoliosissurgeryaremorepronouncedinyoungpeoplewhohavescoliosisasaresultofanunderlyingnerveormuscledisease(neuromusculardisease),suchas myopathy or muscular dystrophy. Most of the patients with idiopathicscoliosis are otherwise healthy andwould be considered good candidates forsurgery.

TheTreatment

If your doctor recommends physical therapy first, this usuallymeans that youhave amild or early formof scoliosis. It is very important to pursue physicaltherapywithacommitmenttomakingthiswork,asafailureofphysicaltherapyusuallymeansmovingon tomoreexpensive,uncomfortable, andcumbersometreatmentssuchasabracethatiswornfull-timeoramajorspinesurgery.

PHYSICALTHERAPYREDUCESTHECURVATURE

The essential goal of physical therapy is to reduce the curvature of the spine.This is usually done with exercises that strengthen the spine. One approach,called Scientific Exercises Approach to Scoliosis (SEAS), teaches patients torecognize the location of their most pronounced spine curvature and activelylearnhowtoreducethiscurvatureintentionally.3Thisrequiresatrainingperiodwherein the patient is assisted by a treatment specialist who assists in thisprocess of neuromuscular training. The patient then performs a series ofexerciseswhileconsciouslycorrectingtheareasofcurvature.Thisisreferredtoasactiveself-correction.Otherapproachestophysicaltherapyinvolvestretchingframes and exercise equipment to reduce the curvature of the spine morepassivelyinresponsetocertainposturesorexercises.4Thebenefitsofphysicaltherapy are debated by some but there is accumulating evidence that certainformsmaybedemonstrablebenefits.5

ABRACEFORMODERATESCOLIOSIS

Ifyourdoctorrecommendsabrace,thisusuallymeansyouhaveamoderateorgraduallyprogressiveformofscoliosis.Thereiswidespreadagreementthatforbracing to be effective, the bracemust beworn all daywith short breaks forbathingandotherselectedactivities.Thebraceneedstobeworntobedatnightandshouldbecomfortableenoughthatitcanbewornduringtheschooldayandtoall socialactivities.Somespecialists recommend23hoursofbracewearingdaily,butcheckwithyourprovidertodeterminetheirspecificinstructions.

Scoliosisbracescomeindifferentforms.Themosttraditionalisahardplasticbracethatfitsaroundthewaistandextendsupwardtotheunderarmsanddowntothehipsasrequiredforthespecificspinecurvature.Therigidbraceisusuallymadeoutofwhiteplasticandisstrappedtothebody.Becauseitextendsdowntothehips,itisimportanttohaveitcheckedforfitsohipgrowthisnotimpeded.ThebracecanbefitfromamodularsystemsuchastheBostonbraceorcustommanufacturedbyalocalprosthestist.Anotherbracetypeconsistsofelasticstraps

andapelvicstabilizationbelt;itmayrequirebandsthatwraparoundtheupperthighandgroin.

SURGERYFORSEVERESCOLIOSIS

Ifyourdoctorrecommendssurgery,thisusuallymeansyouhaveamoresevereor frankly progressive form of scoliosis. The surgery for scoliosis usuallyinvolvestheplacementofrodsincertainsectionsofthespinetopartiallycorrectthe curvature of the spine. When scoliosis is severe, there is danger ofneurologicaleffectssuchascompressionofthespinalcordornerves.Breathingproblemsmaydevelop,leadingtorecurrentpneumonia,andrepeatedinfectionscan have life-threatening consequences. Lifelong poor body mechanics andseriouschronicpaincandevelop.

Inlightofthesenegatives,theeffectsofsurgerymayseemminimalbutitisimportantnottounderestimatetheimpactofmajorspinalsurgery.Afairnumberofpatientshavesomepersistentpainaftersurgery.Usuallythispainisdescribedasmild-to-moderate,ratingabout3outof10points,onaverage.Thecumulativeeffectsofdailymildpain arenotknownbut arenotpositive in anycase.Thespine will never bend normally once spinal rods are in place. This is aconsequencethatmustbeaccepted.Itisprobablyprudenttoexercisesomecareinthechoiceofphysicalactivitiesaftertheplacementofspinalrods.Excessivestressontherodsmayleadtolooseningoftheattachmentswithpainasaresult.

Makesurethatyoudiscuss thespecificplansforsurgerywithyoursurgeonbeforehand. Know what to expect in terms of recovery time, time off fromschool,andimpactoffutureactivities.Askiftherodswilleverberemovedandunderwhatcircumstancesthismighthappen.

Theproceduresofsurgeryforscoliosisareessentiallythoseofspinalfusionsurgery, but may or may not include a bone-graft type fusion per se. Onecommonly performed surgery is referred to as spinal fusion withinstrumentation. Instrumentation is the technical term for the hardware that isused to stabilize the spine. The general aspects of spinal fusion surgery aredescribedinChapter7.

Scoliosisbracesareoftencustom-builtfor therapeuticeffectandforcomfort.Thecustombraceshownismadeofmultiplematerialsshowninwhite,lightgray,andmediumgray.

TestingForScoliosis

Testingforscoliosiswillinitiallytakeplaceintheprimarycareprovider’soffice.Thedoctor,nurse,orPAwillwanttomakeanexaminationofthebackandwillneedtoseethehowthebackrespondstomovement,especiallybendingforward.Imagesof thebackwillbeobtained; this typically includesspecialX-rays thatvisualizemost of the spine from top to bottom. The radiologists will make ameasurementofthecurvesinthespineandthenumberswillbereportedbacktothereferringprovider.

Spinewithscoliosis

TheExplanation

Scoliosisisusuallyaconditionofthespinethatbecomesproblematicduringthepre-teen and early teen years. The precise cause ofmost patients’ scoliosis isunknown.Itismorecommoninpopulationswherepubertyoccurslater.Oneofthedebated topics in themedical literature is theusefulnessof largescreeningprogramsforscoliosis.Thebottomlineisthatifaside-to-sidecurvatureofthespineissignificantenoughthatyouhavenoticedit,itdeservesevaluation.

Each form of scoliosis is unique, although common patterns are seen. Asinglecurvescoliosiswillbedescribedashavinga“C”shape;whenasecondcurveappears, it isusuallycompensatory innatureandwillcauseanS-shapedcurvatureofthespine.Ascoliosiswillbenamedforthepartofthespinethataremostaffected,describedasbeinga rightor leftscoliosisbasedonwhether themost pronounced part of the curve is to the right or left. Imagine an arrowpointingintothemajorcurveandthatarrowwillpointtothesidethatisusedtolabelthescoliosis.

Althoughthemostcommonformofscoliosisisidiopathic(meaningwedon’tknow the cause), there are actually some forms of scoliosis that have specificcauses. These might include a compensatory scoliosis due to a leg-lengthdiscrepancy, where the body tries to compensate for an angled pelvis withcurvatureof thespine.Rarely, tumorscan inducea shapechange in thespine;musclespasmcancause thespine tocurve tooneside;andproblemswith thepelvisitselfcancauseacurvature.7

CHAPTERRESOURCES

1. Dreeden, Olga. Introduction to Physical Therapy for Physical TherapistAssistants.Sudbury,MA:JonesandBartlettPublishers,2007.

2.Grivas,T.B.,etal.2006.Associationbetweenadolescentidiopathicscoliosisprevalenceandageatmenarcheindifferentgeographiclatitudes.Scoliosis1:9.

3.Romano,M.,etal.ScientificExercisesApproachtoScoliosis(SEAS):InTheConservativeScoliosisTreatment,T.B.Grivas,ed.Amsterdam:IOSPress,2008.

4. Weiss, H.R. and A. Maier-Hennes. Specific exercises in the treatment ofscoliosis.InTheConservativeScoliosisTreatment,T.B.Grivas,ed.Amsterdam:IOSPress,2008.

5. Negrini, S., et al. 2008. Specific exercises reduce brace prescription inadolescentidiopathicscoliosis.JRehabilMed40(6):451–5.

6.Weiss,H.R.,andD.Goodall.2008.Rateofcomplicationsinscoliosissurgery:AsystematicreviewofthePubMedliterature.Scoliosis3:9.

7. Tecklin, Jan Stephen. Pediatric Physical Therapy, Fourth Edition.Philadelphia,PA:LippincottWilliams&Wilkins,2007.

Q&AwithDr.Murinson

Issurgerytheonlywaytotreatscoliosis?The treatment of scoliosis depends on the severity and progression of theabnormalcurvaturesofthespine.Scoliosiswillsometimesrespondtotheuseofa brace, but the brace must be worn for most of the day and night. This isawkwardforsomepatients,particularlyasscoliosisusuallystrikesatatimeoflifewhenissuessurroundingbodyimageareveryimportant.

WhathappensifIdon’ttreatthescoliosis?Initsmildestforms,scoliosiscanbeaself-resolvingprocess,becomingmilderasthepersongrows.Inmanycaseshowever,untreatedscoliosisworsens.Itcanlead to spinal collapse, chronic severe pain, breathing problems, andcompressionofvitalorgans. Ioncesawanactive lady inhermid-thirtieswhohadgraduallyworseningbackpainandspasms.She’dbeentoldthathernerveswerethecauseoftheproblemandwasgivenheavydosesofmusclerelaxantstotakefor this.Despite theuseofmultiplemedications,herpaingot tothepointwhereshewaslimitedtoworkingthreedaysaweek.Shewasmiserableinhermarriage and felt that she was failing as a mother. She began to travel fromdoctor to doctor looking for a solution. She came to my clinic desperate forsolutionsandwebeganwitha freshevaluation.Althoughshe’dbeen toldasayoungpersonthatshehadscoliosis,itseemedthatnoneofthedoctorswhosawherasanadulthadtakenthisseriously.Atthetimeofherfirstvisitwithme,shewas innearlycontinuousmuscle spasmsandpain.Her spinewascurved fromside to sidewith her shoulders and hips tilted at biomechanically unfavorableangles. We obtained new X-rays and a new MRI. The images showed apronounced scoliosis of the thoracic and lumbar spine. Inher lowerback, onevertebraappearedtobeslowlyslippingofftothesideandforward,compressingnerves and straining ligaments.This in itself probably accounted for her dailyseverepain.Armedwiththenewinformationaboutherworseningscoliosis,shesoughttreatmentfromalocalsurgeonandultimatelydidwell.Althoughitwasajoytofinallygetthisbraveladyconnectedwithacorrectdiagnosisandbackonthe path to a normal life, itwas a pity that this could not have been properlytreated earlier in life before her family and work activities were so severely

disrupted.

CHAPTER11

SpinalStenosis

Medication,physicaltherapy,andexercisemayhelp,butsometimes

surgeryisthebestsolution.

theDIAGNOSIS

>Areyoumorethan60yearsofage?>Haveyoubeenfindingthatyoucanonlywalkorstandforsolongbeforeyourbackandlegsbegintohurt?

Manypeoplefindastheymaturethatthebackislessresilientthanitwasinprioryears. Inpart, this isbecause thediscsof thebackdryoutstarting in themid-twentiesandareremarkablylessspringyastimegoeson.Otherpeoplefindthattheyhaveoneortwoproblemareasintheirbacks,perhapsanSIjointthattendstogooutoraparticularmusclestrainthatrecursfromtimetotime.Stillotherpeople,especiallythosewithanadventuresomespirit,willfindthattheirbackisjust disabling them. They can barely walk, they wake up each morning withsubstantialpain,theysleeppoorlyatnight,andtheycan’tdomostofthethingsthey had looked forward to in retirement. If this sounds like you, then adiagnosisofspinalstenosismaybetheexplanationforyourtroubles.

Mostpeoplewithspinalstenosisfindthatflexingthespinewillrelievesomeof thesymptoms.So ifsittingdownforabitseems tomake thingsbetter, thismightbeasign thatspinalstenosis isproducingyoursymptoms.Theclassicalsignofspinalstenosis,recognizedbytheold-timedoctors,wasthatitwaseasierfor people with this condition to walk uphill than down. This is because thespine flexes a bit as we walk uphill and extends as the pelvis tilts back toaccommodatedownhillwalking.

thePRESCRIPTION

What’sNew:ProfileofStenosisPatientThelastseveralyearshaveseenaflurryoflargeclinicaltrialslookingatspinalstenosis.Throughthesestudies,aclearerpictureofwhatspinalstenosisisandhow to best treat it has emerged. The picture of the patient with stenosis issomeone in their mid-sixties, tipping the scales at the high end of theoverweight range, and possibly suffering with hypertension and some otherarthritis.Womenareslightlymorelikelytobeaffected.

Theimpactofspinalstenosisonqualityoflifeissubstantial,withbodilypainand inability to functioncausingmore interference than limitations inmentalfunction.Peoplewithspinalstenosismaystillbeworkingbutmoreoftenareretired. The symptoms that predominate include difficulty with walkingdistances (pseudoclaudication) and pain that wraps around the leg from thebuttockintothefoot.1

Backpaindue to spinal stenosisneedsexpertmedical assessmentandcare. Inmildcases,physicaltherapymaybeusedtorelievepain.Dependingonthelevelofconcernandlocalpracticepatterns,yourdoctormaywantyoutohavesomekind of injection. Surgery is beneficial for patients with moderate to severestenosis.

Ifyouhavespinalstenosis:•Yourdoctormay recommendphysical therapy,especially ifyourdisease ismild or there are reasons that surgery would not be feasible. Theeffectiveness of physical therapy for spinal stenosis depends on theskillfulnessofthetherapist,thedegreeofstenosis,andthemotivationofthepatient.

• Your doctor may recommend injection of the back with pain-activemedicationssuchas lidocaineorcortisone.Thesemedicationsmayprovidetemporaryrelieffrompainandmayallowthephysicaltherapistawindowofopportunityformoreaggressivetreatments,butinjectionssuchasthesemaynotprovidealastingbenefit.

•Yourdoctormayrecommendthatyouhaveasurgicalconsultationforspinaldecompression and fusion.Thiswill dependon the severity of your spinalstenosisatthispointandyouroverallmedicalpicture.

WHATIFYOURDOCTORDIAGNOSESASLIPPEDDISC?

Inthiscase,youmaystillneedsurgery.PleaseseeChapter2ondischerniation.

WHATIFYOURDOCTORFINDSTHATYOUHAVESYMPTOMSOFSPINALSTENOSISBUTNOEVIDENCEFORITONMRIORX-RAY?

The clinical description of spinal stenosis is someonewho has difficultywithwalkingdistances.Itissometimespossibletohaveproblemslikethisfromothercauses.Possibilities includeproblemswith theheart,problemswithcirculationofbloodto the legs,andproblemsinotherpartsof thenervoussystem.Ifyouare experiencing shortness of breath, you need to seek immediate medicalattention.Especially if your pain is limited to thebackof the calf and alwayscomesonafterwalkingaspecificnumberofblocks,youshouldencourageyourdoctortocheckoutyourlegcirculation.

Inrarecases,spinalstenosisisduetoamass(tumor),aninfection(abscess),orafracture.Theseseriousbutrarecausesofspinalstenosisareusuallyassessedthrough the diagnostic tests described later in this chapter. The treatment for

theseconditionsisindividualized.

TheTreatment

Ifyourdoctor recommendsphysical therapyfirst, thisusuallymeans thatyourspinalstenosisisnotideallytreatedwithsurgeryatthistime.Ifyouhaveseveresymptomsfromspinalstenosisandsurgery isnotbeingconsidered,makesureyouunderstandwhy.Doesthedoctorhaveparticularhealthconcernsthatmakesurgery a poor option? Is there some aspect of your stenosis that precludessurgery, or does the doctor view your problem as not severe enough for asurgicalreferral?

PHYSICALTHERAPYISWIDELYUSED

Physicaltherapyiswidelyusedasatreatmentforspinalstenosis.2Severalformsof physical therapy are effective for limiting the impact of spinal stenosis. Inaddition, I often encourage patients to pursue some physical therapy beforesurgery,dependingontheircircumstances.Thisisbecausesurgerycanbeverydemandingonthebodyandpeoplewhoareinbetterphysicalconditioncangetthrough theprocessmoreeasily.The typesofphysical therapyused for spinalstenosiscan include thermal therapies,electrical stimulation,manual therapies,andconditioningandstrengtheningwork.

Warning!SomeExercisesAreHarmful

Avoid exercises that extend the spine; examples of this could includecertain types of standing aerobic exercise machines. Arching the back(extendingthespine)islikelytoworsenthesymptomsofspinalstenosis.

MANUALTHERAPIESEASESYMPTOMS

Manual therapies such asmassage andgentle spinalmanipulation canprovidesomerelieffromthesymptomsofspinalstenosis,especiallyifbackpainispartof the overall symptoms. Sometimes, people with spinal stenosis don’t haveappreciablebackpain,andsometimespeopledon’trealizehowmuchdiscomforttheydidhaveuntil theyget some treatmentand start to feelbetter.Given thatspinalstenosisisbelievedtoresultfromanaccumulationofminorinjuriestotheback over time, perhaps some people who develop spinal stenosis don’t havevery sensitive backs, andmaybe they develop spinal stenosis because a lot ofdamagehasoccurredwithoutmuchpainbeingexperiencedtoslowthemdownandmakethemstopaharmfulactivity.

THERMALTHERAPIESACCOMPANYPT

Particularlywithspinalstenosis,itisimportanttopreventanystrainorswellingofthelowbackstructures.Warmcompressescanhelpreducemusclestrainandpromoterelaxation.Icepackswillhelptopreventandreduceswellingandcanblockpainsignalingfromthenearbystructures.Ifyouthinkawarmcompressoranicepackwouldhelp,makesuretoaskyourphysicaltherapistiftheyhaven’talreadyofferedit.

ELECTRICALSTIMULATIONMIGHTIMPROVEBLOODFLOW

Electricalstimulationmayormaynotbeused,dependingontheexperienceofyour therapist and local practices. Electrical stimulation may be helpful forrelaxingmusclesand secondarily improvingblood flow. Itmayormaynotbebeneficialwithspinalstenosis.

STRENGTHENINGANDCONDITIONINGREQUIRESPROFESSIONALGUIDANCE

The process of spinal stenosis can make sustained exercise more hazardous.Somerecommendedexercisesincludetheuseofanexercisebike,asthetypicalpostureforthisflexesthespineandshouldbebettertoleratedbysomeonewithspinalstenosis.3Yourphysicaltherapistwillhavemanygoodideasforhowyoucanimproveyourmusclestrengthandmaintainyourleveloffitnessevenwhilelivingwith spinal stenosis.You shoulddobalance exercises, as theywill helpyouavoidfalls.Consciouslytryingtochallengeandimproveyourbalancewillhavepositiveeffects.

Oneexercise thatworkswell is thebent-kneesidestep.Check thisoutwithyourdoctoror therapist first, but itworks as follows.First findaplacewhere

youwillhavegoodsupport ifyouneed to reachoutandstabilizeyourstance.Oftenahallway that is not toowideworkswell for this.Turn so that youarestandingsidewaysinthehallwayandplaceyourfeetaboutshoulder-widthapart.Bendyourkneesslightlyandtuckyourtailbone;tightenyourstomachmusclesandholdthemtightenedthroughouttheexerciseoraslongasyoucan.Tobegintheexercise, liftyourright footand takeasidestepofaboutsix tonine inches(15to23cm)totheright.Asyourweighttransferstotheright,bringyourleftfootoverwithamatchingstep.Takefourmorestepstotheright,movingslowlyuntilyouaremoreconfidentwiththisprocess.Maintainyourbalanceandtrytodistributeyourweightevenlybetweenyourtwofeetinbetweensteps.Nowtakefivestepstotheleft.Repeatthisexercisethreemoretimesbackandforth.

Anatomyofthespine

Anotherexercise thatcanhelpsupportbalanceand isaccomplishablewhilemaintaining a flexed spine position comes from the dance world. Stand in aplacewhereyoucanreachoutforsupportifnecessary.Beginbystandingontwofeet,withyourfeetabout10inches(25cm)apart,widerifneededforstability.Bendyourkneesslightlyasyoutuckyourtailbone.Transferringyourweighttoyourrightfoot,liftyourleftfootandswingitgentlytothesideandbringitbackasyoumaintainbalanceontherightfoot.Continuetoswingyourleftfootouttothesideandbacktocenterseveralmoretimes.Thenswitchyourstanceto theleft foot andmove the right leg out and back. This exercise provides a gooddynamicchallengetotheanklemuscles.Itwillstrengthenthemwithoutoverlytaxingyourbackanddoesn’trequireanyspecialequipment.

PAININJECTIONSPROVIDEIMMEDIATERELIEF

If your doctor recommends treatment with a pain injection, this may providesome immediate relief—but it may not be a lasting solution. Usually, paininjections are performed using a mixture of fast-acting local anesthetic and asteroid toreducepainover the longer term.While these injectionscanprovideimmediaterelief,theydocarrycertainrisks,suchasasmallriskofinfectionandlonger-rangerisksofproblemsassociatedwithsteroiduse.Theseinjectionsareaway to make someone who is in terrible pain comfortable more quickly, andoccasionallysomeonewillhaveadramaticandlastingimprovementinresponsetoan injectionor two.Mostof the time,however, these injectionscanonlyberepeated a few times and they are not a good long-term solution to spinalstenosis.

ORALMEDICINESDULLTHEPAIN

Many medications can be used for the treatment of pain related to spinalstenosis. The specific choice of medication will depend on the type andsuspectedcauseofthepain.Ifyourpainisduetocompressionofspecificnerveroots, your doctor may recommend prescription medication. If it seems thatarthritisorinflammationisamajorpartofyourpain,thenanover-the-counterorprescription anti-inflammatorymedication (NSAID)may be prescribed. Long-termdrugtherapyislikelyinthetreatmentofspinalstenosis.Ifopioidsareused,addressthepotentialforconstipationevenbeforetreatmentstarts.Makesuretokeepthesemedicationsstoredsafely,especiallyifthereareotherpeoplecomingandgoinginyourhome.

Eachmedicationwill have specific side effects. If antidepressants areused,they can include weight gain, sleepiness, bizarre feelings, delay in urinary

function,oralossoflibido.Somepeoplewillexperiencenosideeffects,whileotherswillnotbeable to takeevena smalldoseofmedicine.At thispoint intime, the only predictor of whether a medication will cause troublesome sideeffects is your prior experience with it, so it is often helpful to keep a briefjournalaboutyourpainanditstreatment.IfNSAIDsareused,askyourdoctorabout something to protect your stomach. Some European doctors routinelyprescribe an additional medicine to protect against gastric bleeding withNSAIDs.Ifyoudoctorisn’tcomfortableaddinganextramedication,discussitwithyourpharmacist,whomayhavesomegoodrecommendations.

Whileoralmedicationswillprobablyhelpwith thepain, it isquitepossiblethat other stepswill be necessary to address the limitations of spinal stenosis.Oralpainmedicineswillhavelimitedeffectonthecompressionofnerverootsandrestrictionsonlocalbloodflowthatresultfromspinalstenosis.

Warning!PutaLockonIt

Opioids as a group, although generally safewhen taken as your doctorprescribes, are subject to a growing problem of prescription drug useamongyoungpeopleaged18to25.The2008U.S.nationalstudyshowedthatnearly5percentofyoungadultshavetriedpainrelievermedicationsthatwerenotprescribedtothem,most illegallyobtainedfromfriendsorfamily.4

SURGERYISRECOMMENDEDFORSEVERESTENOSIS

Surgerymay well be the best treatment for spinal stenosis, depending on thediseaseseverityandyourothermedicalconditions.Recentclinicalresearchhascompared standard medical management of spinal stenosis with spine fusionsurgeryandfoundthatsurgeryhasbetterresultsintermsofpain,function,andpatientsatisfaction.Spinalfusionsurgeryisaseriousundertaking(seeChapter7fordetails),butpeoplewithmoderate-to-severespinalstenosiscanbesolimitedintermsofactivityandqualityoflifethatthesurgeryisworthwhile.Theusualsurgeryforspinalstenosisislumbardecompressionandfusion.Decompressionis the process of removingbuilt-upportions of bone and sometimes removingtheroofofthespinalcanal.Thisisdonetorelievepressureontransitingnervesandnerverootsandispartoftheoverallsurgery.

TestingforSpinalStenosis

Thediagnosisofspinalstenosiscanoftenbemadeclinicallyonthebasisofyourrecentmedicalhistoryand the examination in theoffice.However, sincemostadvancedcasesofspinalstenosisneedtobeevaluatedforsurgicalintervention,itisimportanttoknowthatimagingwithbothMRIandX-raymayberequired.In some situations, itmay be necessary to include other tests aswell. This isbecause spinal stenosis is a complex disorder that shares aspects with othercausesofbackpain.Yourdoctormayalsoorderanerveconductiontesttobetterdefine the extent of anypossiblenervedamage. (SeeChapter2.)Once all thetest results are in, a clearer picture will emerge. The possibilities range from“nothing is clearly wrong” to “moderate spine degeneration” to “severedegenerationofthespine.”

What’sNew:SurgeryProducesGoodResultsThelateststudiesarenowreportingonthemulti-yearfollow-upfromtheinitialfavorable reports of surgery, and these longer term results continue to favorsurgerywhenpossibleandappropriate.5

TheExplanation

Spinal stenosis, in itsmost common form, is an advanceddegeneration of thespine where progressive compression of the vertebral discs, accumulatedtraumas to the joints, overgrowth of the bones from repeated strains, andenlargementof the ligamentsallcometogether tomakesmoothpassageof thenerves to and from the spinal cord impossible. In spinal stenosis, the back isfunctioning at a permanent mechanical disadvantage. Ongoing arthritis andinflammation create a vicious cycle of persistent pain, and compressed nervesfireoffpainsignalsthatworsenwitheverystep.Foryears,medicaldoctorshavebeentryingtotreatspinalstenosistheybesttheyknowhow.Medicines,physicaltherapy,heatingpads,aquatherapy,braces,sometimesevenwalkersareusedtorelieve pressure on the spine. A recent landmark study indicated that surgicalinterventions,ifapersonisingoodhealthtotolerateamajorspinesurgery,mayhavethebestchanceofhelpingpatientsmakeameaningfulrecovery.Someofthemajorspecialistsinthefieldindicatethatpeoplewithspinalstenosismayormaynothavemuchbackpain.

CHAPTERRESOURCES

1. Weinstein, et al. 2007. Surgical versus nonsurgical treatment for lumbardegenerativespondylolisthesis.NEnglJMed356(22):2257–70.

2.Weinstein,J.N.,etal.2007.Surgicalversusnonsurgicaltreatmentforlumbardegenerativespondylolisthesis.NEnglJMed356(22):2257–70.

3.Reed,Stephen,PennyKendall-Reed,MichaelFord,andCharlesGregory.TheCompleteDoctor’sHealthyBackBible.Toronto:RobertRose,Inc.,2004.

4. “Results from the2008NationalSurveyonDrugUse andHealth:NationalFindings,”U.S. Department of Health andHuman Services, SubstanceAbuseand Mental Health Services Administration, Office of Applied Studies.http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm. AccessedFebruary9,2010.

5.Weinstein, J.N., et al. 2009.Surgical comparedwithnonoperative treatmentforlumbardegenerativespondylolisthesis:Four-yearresultsintheSpinePatientOutcomes Research Trial (SPORT) randomized and observational cohorts. JBoneJointSurgAm91(6):1295–304.

Q&AwithDr.Murinson

Whatcausesspinalstenosis?Thespine isanengineeringmiracle,andmostofusexperienceyearsofgood,productiveservicefromourbackswithminimaleffort.Spinalstenosisisusuallytheresultofmanyyearsofmoderatestrainontheback,sometimespunctuatedbyspecifictraumas:Afallfromahorse,acaraccident,thattimeyoupulledthelawnmower up a flight of stairs, shoveling snow, moving furniture, a bikeaccident,andgardeningalladduptoalifetimeofinsultstotheback.Overtime,the back responds in severalways. The discs compress down to a fraction oftheir original height, dramatically narrowing the space available for nerves toenter and exit the spine and, at the same time, reducing the biomechanics ofspinemovement.Thediscswilloftenbulgeout,whichmightnotbesobad,buttheligamentsandfacetjointsonthebacksideofthespinalcanalareenlargingatthe same time. It’s kindofmysterious, but part of ourbiological nature is notunlikebricksand stone thatwear awaywith timeandpressure,ourbonesandligamentsrespondtostressandstrainbyovergrowingorhypertrophying.Ifyouhavespinalstenosisoradvancingspinaldegeneration,andyouareabletogetahold of your MRI report, you may read terms such as “ligamentoushypertrophy,”“facetjointenlargement,”or“narrowingoftheneuralforamina.”Allofthesearetermsthattheradiologistwillusetodescribethebasicdiseasecomponentsthattogethermakeupspinalstenosis.

CHAPTER12

Coccydynia

Managecoccydyniapainbyreducingstressfulactivities,

usingacushion,andlosingexcessbodyweight.

theDIAGNOSIS

>Doyouhavepainatthebottomendofyourspine?>Doesyourpaingetsubstantiallyworsethelongeryousitonahardsurface?

Peoplewithcoccydyniaknowaspecialmisery.Thesearethepatientswhopacethewaitingroom,carryingtheirdonutcushionandwincingeverytimesomeoneasksthemtotakeaseat.Thepainofcoccydyniaiscenteredattheverybottomofthespine,deepinthecreaseofthebuttocks.Althoughsmallandtuckedawayinside the body, the tailbone serves an essential function as an anchor forligamentsandmusclesinthebuttockandrectumarea.

Although the cause of coccydynia is not always identified, it can certainlyarise from a trauma such as a slip-fall type accident, such as landing hard onyourbottomwhileiceskating.Whenaspecificcausativeinjuryisidentified,thechancesofrecoverymaybeevenbetterthanwhenthesyndromeoccurswithoutadefinablecause,althoughthereasonforthisisunknown.

CoccydyniaAggravators•Bicycling•Sittingonastadiumbench•Horsebackriding•Jarringcarnivalrides•Motorcycleriding•Unicycleriding(!)•Childbirth

thePRESCRIPTION

DealingwithPainwhileSittingLeaningforwardwhilesittingtransfersweightawayfromthetailboneandontothe sitz bones,while leaning back increases the pressures of sitting. For thisreason, people with coccydynia will often naturally lean forward when theymust sit. There are specialized chairs that have been used by people withcoccydynia.Whilenotespeciallyportable, thesechairsmaynormalize lifeathomeandwork.

Coccydynia pain is usually increased during the moment of transition fromsittingtostanding.Thisiswhenthemechanicalstressesarefocusedonthetail-bone. You may need to let people know that you’ll need to stand duringmeetings.

Thefirstmajorgoalistoavoidre-injuryofthetipofyourspine.Itisimportanttotakeallreasonableprecautionsnottofall;thismaysoundsilly,buttakeextracarewhenwalking.Avoidactivitieswherefallsandtraumaarelikely,includingskating, skiing,motorcycle riding, tractors, school buses, and amusement parkrides.Especiallyifyouarehealingfromsuchaninjury,specialcareisneeded.

You will probably need to combine medication and non-medicationtreatments to get through an episode of coccydynia. Medications can includeNSAIDs, acetaminophen, or prescription pain medications. Non-medicationtreatmentswillcertainlyincludeusingacushionbutmayalsoincludestretches,manual therapy, hot and cold packs, and any of the non-medication therapiesdiscussedinthesecondpartofthisbook.• Reducing inflammation will aid in control of coccydynia. Your tools forreducing inflammation will include rest (as appropriate), ice, and anti-inflammatory medications (NSAIDs). Your doctor may recommend theinjection of an anti-inflammatorymedicine such as a steroid. This can behelpfulifeverythinggoeswell.Consideryouroptionscarefully.

•Youwillneedtobuyandcarryacushion.Thedonutisthemostcommonbutthere are other types of cushions that relieve pressure on the coccyx.Coccydynia is usually worsened by pressure on the buttock while sitting.Youneedtothinkbeforeagreeingtogosomeplaceunfamiliaranddetermineif an extra cushion will carry you through. Some activities, like sportingeventsthattakeplaceinastadiumwithbenchseating,arebestavoideduntilarecoveryismade.

•Peoplewhoareoverweightorobeseplaceaddedstrainon the tailboneandforthisreason,weightcontrolmayberecommendedwhenappropriate.

•Constipationisanotheraggravatorofcoccydynia,somakesuretostaywellhydrated and have an active treatment regimen (fiber, laxative) to preventconstipation.

ChronicCoccydyniaRequiresExpertHelpMost people recover after a period but there are rare instances of chroniccoccydynia. If you suspect chronic coccydynia, you will need expert help.Make sure that your healthcare provider under-stands the seriousness of theproblem.Becausecoccydyniacanmakeitimpossibletositforlongerperiodsof time, ask for help getting your work schedule and work arrangementsmodifiedsothatyoucankeepgoingwithoutmakingtheproblemworse.

Wedgecushionwithcoccyxcutout.

TheTreatment

Pain control for coccydyniawill proceed along the lines of therapy formanyother conditions: first, heat and cold therapies are used. Sometimes electricalstimulation is considered and some practitioners will apply ultrasound or tryiontophoresisofmedicationsthroughtheskin.Onoccasion,manipulationofthetailbone will be tried; however, support for this in the medical literature islimited.1 One older clinical report suggests that manual manipulation incombinationwithinjectionismoreeffectivethaneithermethodalone.2

DONUTCUSHIONSREDUCETHEPRESSURE

Ifyourdoctortellsyouthatyouneedacushion,youwillprobablybeadvisedtostartwithadonut.Donutcushionsarenamedfortheirshape;theylooklikegiantdonuts. The rationale of the donut is that it will reduce the pressure on thetailbone and thereby alleviate pain. Theymaywork for some people, but noteveryonewill respondaswell.Sometimes the cushion is not firmenoughanddoesn’t take enough of the pressure off the tailbone. Other times the donutcushion just doesn’t feel right; itmight causepressurepoints elsewhere in thebuttock.Theotherpartsof thebodythatbearsmostof theweightwhenwe’reseatedarethesitzbones,moreformallycalledthe ischial tuberosities.Eachofthebonyspotsinthebuttockarecushionedwithafluid-filledsaccalledabursa.There are many bursas in the body and they are usually found at points ofmechanical stress. They are greatwhen theywork: the bursas in the shoulderallow smooth glidingmovements evenwhen someone is lifting a heavy load.Theproblemisthatbursascanbecomeinflamed,andwhentheydo,lookout—it’sawholenewcauseofpainthatcancompoundanalreadydifficultsituation.

The donut can irritate the bursas in the buttock, somany people use othertypesofcushions:therearetriangularwedgecushionsthathaveacut-outalongthe back edge to relieve tailbone pressure, and there are fancy commercialcushionswith a groove down themiddle, designed to relievemidline buttockandpelvicpressures.Formostpeople,anycushionisbetterthannone,andtheworstsituationiswheresomeoneiscompelledtositforlongperiodsonahardsurface. This can occur a lot in the spring when students are graduating, orduringsportsseasons.Ifyou’refacinganordeallikethis,don’tgowithoutyourcushion!

Warning!AskQuestionsBeforeGettinganInjection

If your doctorwants to perform an injection,make sure that the personperforming the procedure is experienced and has performed this manytimesinthelastyear.Youcansimplyask:

•Howmanyoftheseinjectionstothecoccyxhaveyouperformedinthelastyear?

•Whatisyourcomplicationrate?

•Howlongwilltheeffectsoftheinjectionlast?

•Whatarethechancesthatthisinjectionwillrelievemypain?

Coccyxinjectionsareusuallydonewithfluoroscopicguidance.Thishelpsavoidinjurytodelicatestructuresinthevicinityofthetailbone.Anothertype of injection that is sometimes used is a ganglion impar block.Althoughrecentstudiessuggestthatthismaybeaneffectivetreatment,ithas traditionally been used in cases where there is a serious structuralproblem.3

PHYSICALTHERAPYIMPROVESBODYMECHANICS

Ifyourdoctortellsyouthatyouneedphysical therapy,youmaybewonderingwhat canbedone.Several thingsmaybehelpful in the settingof coccydynia:paincontrolwillbethefirstorderofbusiness,thenfocusingongettingthebodymechanicsright,andsomestretchingandstrengtheningmaybeneeded.Rarely,peoplewill need to havemanual therapy done in this area. If this is the case,make sure to obtain a specific recommendation for someone with advancedtraining. Most physical therapists will shy away from the somewhat invasivemethodsrequired.

SURGERYISARADICALOPTION

Ifyourdoctorrecommendssurgery,youshouldconsiderthisstepverycarefully.Removalofthecoccyxisaradicalsurgerythatremovesananchoringpointforacomplexmusclethatiscriticallyimportantforthefunctioningofthebowelsandthestabilityofthepelvicfloor.Themusclesthatallowtheanustocloseproperlyare connected to the coccyx, and removal of this anchor can produce lastingdifficulties with bowel movements. This surgery is usually reserved forsituationswherethereisdemonstratedinstabilityofthecoccyxthatisassociatedwithdisablingpain, or in caseswhere there is a tumor.Be sure todiscuss thepossible alternatives to surgery and make sure that your doctor paints a veryclear picture of what to expect in terms of recuperation and return to dailyactivitiesafter thesurgery.Removalof thecoccyxhasbeenreported tohaveaveryhighinfectionrate.Thisisbecausetheareaofthesurgeryisveryclosetothe bowels, and it is really difficult to keep the area clean. In addition, therecovery is hard to endure, as it is necessary to limit sitting until adequatehealinghastakenplace.

TestingforCoccydynia

The first step in the evaluation of coccydynia is a physician’s assessment.Diagnostic testing usually begins with an X-ray, although other imaging testsmay follow.Based on the results of the clinical assessment including any testresults,yourproviderwilldetermineifyouhaveaclearstructuralproblemthatiscausingthepain,orwhethertreatmentwillproceedonthebasisofaclinicaldiagnosis.

The examination for coccydynia can consist of a external exam and aninternal exam. The external exam will involve the doctor looking at certainstructuresandpalpatingvariouslocationsinthebackandbuttock.Someofthis

will be done to make sure that the problem is not something other thancoccydynia.Theinternalexamforcoccydynia isperformedfor thesimplefactthat the tailbone inmost people is located deep in the buttock, right near therectum. This is a hard-to-reach location. The internal exam may require thedoctortoplaceafingerinsidetherectumandfeelforthepositionandtendernessoftheboneytailinthismanner.

Some highly specialized physical therapists have been trained to performmanual therapy using this approach. You can imagine that the people whoexperienceproblemswithmusclespasminthetailboneareareallyvaluepeoplewhoarewillingtolearnaboutanddeveloptheskillsneeded,butthistrainingisnot always appreciated because of the cultural taboos and sensitive nature ofthesestructures.

Pelvicfloormuscles

Aviewofthecoccyxseenfrominsidethepelvisfrominsidethepelvis

TheExplanation

Pain emanating from the tail bone is a surprisingly prevalent and troublesomebackpaincondition.Itoftenisprecipitatedbyafall inwhichthepersonlandssuddenly on their bottom. These types of falls are incredibly common. Theactualrisksthatmakepersistentlypainfultailbonefractureorinjurymoreorlesslikelyarenotknown.Childbirth isanimportant triggerofcoccydynia,andnotsurprisingly,itisestimatedtobefivetimesmorecommoninwomen.

COCCYDYNIAINCHILDBIRTH

The human tailbone is a small, rudimentary bone that varies from person toperson.Oneimportantcharacteristicofeachcoccyxisthedegreetowhichitisangled or “tucked under.” Under ordinary circumstances, having a small tail-remnant that sits more or less tucked under into the rear end of the body iscompletely without problems. There is one critical juncture however, wherehaving a small bone in this location can be problematic: the moment ofchildbirth.During theninemonthsofpregnancy,adeveloping fetussits safelyinside the abdomen and pelvis of the expectantmother.During thesemonths,hormones gradually work to increase the flexibility and stretchiness of theligamentsthatbindthebonesofthepelvistoeachother.Asnotedelsewhereinthis book, this can cause pain that ranges from mild aching to sharplydebilitatingifproperstepsaren’ttaken.Duringlabor,thebabydescendsthroughthelargeringofthepelvis,aprocessthattakestime.Towardstheveryendofthedeliveryprocess,thebabyhastoslidepastthetailboneonitswayintotheworld.Dependingontheconfigurationofthecoccyx,thebabywillhavemoreorlessdifficultypassingbythisspot.

OTHERPREDISPOSITIONSFORCOCCYDYNIA

Anotherfactorthatinfluencesthetendencyforpainarisingfromthetailboneisbody weight. A variety of factors that predispose obese people to experiencecoccydynia;oneisatendencytoanglethepelvisinawaythatplacesadditionalstress on the tailbonewhen sitting.4 It has been proposed that plopping downintochairsmaybeanaggravatingfactor.

Some people develop coccydynia in association with a minor skeletalmalformationofthespinethatincludesaspiculeorsharpspineprojectingfromthetailendofthecoccyx.Peoplewiththeselittlespineswilltypicallyalsohaveasmalldimpleintheoverlyingskin,suggestingthatthisistheresultofaveryminorbirthdefect.5

Finally, therearerareinstancesoftumororaggressiveinfectionthat leadtococcydynia. These conditions require highly specialized treatment andsometimesnecessitateconsiderationofsurgicaloptions.

CHAPTERRESOURCES

1. Maigne, J.Y., G. Chatellier, and M.L. Faou, et al. 2006. The treatment ofchronic coccydynia with intrarectal manipulation: A randomized controlledstudy.Spine31(18):E621–7.

2.Wray,C.C., S.Easom, and J.Hoskinson. 1991.Coccydynia:Aetiology andtreatment.JBoneJointSurgBr73(2):335–8.

3. Foye, P.M. “Coccyx Pain,” Emedicine.http://emedicine.medscape.com/article/309486-overview. Accessed January 26,2010.

4. Patel, R., A. Appannagari, and P.G. Whang. 2008. Coccydynia.Curr RevMusculoskeletMed1(3–4):223–26.

5. Foye, P.M. “Coccyx Pain,” eMedicine.http://emedicine.medscape.com/article/309486-overview. Accessed January 26,2010.

6. Cleveland Clinic. Coccydynia,http://my.clevelandclinic.org/disorders/Coccydynia/hic_Coccydynia_Tailbone_Pain.aspxAccessedJanuary26,2010.

7. Foye, P.M. “Coccyx Pain,” eMedicine.http://emedicine.medscape.com/article/309486-overview. Accessed January 26,2010.

Q&AwithDr.Murinson

Ihavecoccydyniaandfeelblue.Isthatnormal?Coccydynia can be a very difficult and demoralizing condition to live with.When coccydynia becomes chronic, the impact on daily living is profound.Alifeinwhichonecannotsitnormallymeansthatregularmeals,formaldinners,going to movies, attending cultural events, taking longer car rides, boating,socializing,andmanyotherenjoyableactivitiesareoutof thepictureuntil theconditionsettlesdown.Thiscanplaceasubstantialstrainonfamilymembersaswell,especiallywhenexpectationsarehighforsocialinteractionsorwhenthereareotherswhomayalsoneedcaresuchasyoungchildrenoragingparents.For

this reason, it is important to stay attentive to your state ofmind and generalmood while living with coccydynia. Feeling down might almost be expectedgiventhechallenges,butthereisnoreasontosufferinsilence.6Therearemanymedications available that can help improve a depressed mood, and effectivenon-pharmacological treatmentsaswell.Someof themedicationsused to treatdepressedmoodarealsoknowntobeeffectiveinreducingpain.Ifyourdoctorproposesamedicationtohelpyou“feelalittlebrighter,”askif themedicationmightalsohelpwiththepain.Ashortlistofantidepressantsthatareknowntobepain active includes amitriptyline, desipramine, duloxetine, and venlafaxine.Eachofthesemedicationswillhaveadifferentsetofsideeffects,soadiscussionof options with your doctor is needed. If you would prefer to go the non-medicationroutewhenaddressingdepressedmood,askyourdoctoriftheyknowofanypsychologistsorpsychiatristswhoarewellversedinaddressingchronicpain.Not all practitioners are tuned in to the needs of patientswith persistentpain.

Whyisthecoccyxsoimportant?Anumberofkeystructuresanchoronto thecoccyx.7These includepartof thegluteusmuscles (majormuscles in thebuttock) andmuscles that runoneithersideoftherectumtoformpartofthefloorofthepelvis.Ligamentsarepresentaswell. Some of these stabilize the coccyx onto the sacrum,while others runfrom the coccyx to the ischial tuberosities (sitzbones)on either side.Surgicalremoval of the coccyx is obviously complicated by the presence of theseanchoringsupportelements.Ifthecoccyxisremoved,difficultieswiththepelvicfloorcanfollowastherectumandotherpelvicstructuresbegintosagdownwardor“prolapse.”Theconsequencescanincludechronicsoiling,incontinence,andincreasingpain.

PART2

GettingBetter,GettingStronger

CHAPTER13FirstStepsforAcuteBackPain

Seeapractitionerearlyandoftentoensurethereisnopermanentdamageanddevelopatreatmentplan.

theDIAGNOSIS

Acutemanagementshouldbeginassoonasyoudevelopseriousbackpain.Youwill know if the pain is serious by the intensity or degree of pain. Anotherindicator is if the pain stops you from doing your normal activities. Mostdoctors,nurses,andotherhealthcareprovidersusea10-pointscale tomeasurepainintensity.Ifyourpainiseightorgreater,itisprobablyseriousandyouneedto seek help. If your pain is less than eight but prevents you from sitting orstandingnormally, it isseriousandyoushouldcheck inwithyourdoctor.Youwillprobablywanttofollowtheplaninthisbook.

Theprimaryreasonforseekingadiagnosisforseriousbackpainistoensurethepropertreatmentcourse.Youwillwanttoseeadoctor,physician’sassistant(PA),ornursepractitionerearlyinthecourseofbackpaintomakesurethereisno danger to the spinal cord, nerve roots, or other vital structures. Once thedangerousconditionsareeliminatedasacauseofyourbackpain(RedFlagsforBack Pain), finding a diagnosis may become more challenging, as not allphysiciansarewelltrainedinthecomplexitiesofbackstructureandfunction.

REDFLAGSFORBACKPAINIf your pain was preceded by a trauma or is associated with weakness or

inability to control bowel or bladder functions, you may be dealing with amedicalemergencyandshouldseekimmediatemedicalcare.Don’tdoanythingelse until you see a doctor or qualified medical professional to assess yourproblem.TheRedFlagsare:•Majortrauma(caraccident,fallfromaheight)•Agelessthan20orgreaterthan50•Historyofcancer

•Fever,chills,weightloss•Recentbacterialinfection•Drugabuse•Immunosuppression•Painthatisworsewhenlyingdown•Severenighttimepain•Newbladderdysfunction(incontinenceofurine)•Numbnessoverthegenitals•Majororprogressiveweaknessinoneorbothlegs•Minortrauma,inthesettingoflowbonedensityorosteoporosis

>Areyouexperiencingseriousbackpain?> Are you free of any weakness, bowel or bladder incontinence, ornumbness?

AllprimarycarephysiciansshouldbetrainedtorecognizethebackpainRedFlags,atermcoinedbytheU.S.AgencyforHealthCarePolicyandResearchtoaidcliniciansinidentifyingaspectsofapatient’smedicalhistoryorexaminationthatpotentiallyindicatedangerousconditionsrequiringimmediateintervention.Thesepotentiallydangerousconditionsincludespinalfracture,spinalinfection,spinal compression, cancer, and nerve root compression. The problem is thateventhoughtheredflagswereestablishedbyapanelofexpertsandhavebeenaround for over a decade, their value in making a diagnosis has not beenaccuratelyestablished,andnooneknowsforsurehowhelpful theyareas truemarkersofdisease.Suffice it tosay that if there isadangerouscondition,youwant your doctor to catch it early. The best thing you can do is to provideinformationaboutyourhealthasclearlyandcalmlyaspossible.YoumaywanttosharetheRedFlaglistwithyourdoctor.

YourClinicianNeedstoKnow:•Severityofpain(ona0–10scale)•Whatthepainfeelslike(sharp,dull,etc.)•Locationofthepain(whereitis,whereit“goes”)•Whenthepainstarted•Whatmakesitbetter•Whatmakesitworse•Yourlimitationsduetopain

thePRESCRIPTION

Thereareseveralveryimportantthingsthatyoucandoforbackpainassoonasitstarts:• Prevent further injury. If you’re doing something that has caused you toinjureyourback,youneedtostopdoingit.

•Seekmedicalassessment.Youneedthehelpofamedicalprofessionaltosortoutwhetheryournewbackpaincouldbecausedbyaseriousproblem.Oncethese issuesare resolved,youcango forwardwith treatmentand recovery.This step involves findingaphysicianor care teamwhowill acknowledgethe serious nature of your back problem, endeavor to find a diagnosis,address your needs for pain control, connect you with exceptionally goodphysicaltherapy,andsupportyourneedsforsickleaveappropriately.

• Initiatepaincontrol.Earlyandadequatepaincontrol isvitally important toreduce a person’s period of disability, restore normal movement patterns(preventing secondary injury), and reduce the chances of long-term pain.Whenbackpainisserious, itusuallyrequiresmorethanaspirin, ibuprofen,oracetaminophen.

COMMUNICATIONISVITALTOPAINCONTROL

Itissometimeshardtoexplaintoaphysicianorothercareproviderhowbadlyone’sback ishurting.Forone thing,manyphysicians,especiallywhenyoung,have never experienced serious pain. In our studies, upwards of 30 percent ofmedicalstudentshaveneverexperiencedseriousphysicalpain,andmanyhaveneverconsideredtheimpactofpainonthepersonwhoisfeelingit.Ontheotherhand, older physicians will occasionally become hardened toward the pain ofothers. Still other physicians hold preconceived notions about back injury andwill pigeon-hole patients based on social, economic, gender, or ethnic factorsandconcludethatthepainisbeingoverstated.

This is critically important because the current medical system reliesabsolutely on a physician, PA, or nurse to recognize and acknowledge a painproblembeforeseriousmedical therapycanbestarted.Therefore, thefirstpartofbeginningpaincontroliscommunication.

TheTreatment

Ifyouhavetowaitformedicalassessment,youhavesomechoicestomake.Youcantryusingsomeover-the-countermedications,althoughseriousbackpainis

often onlyminimally betterwith non-prescriptionmedications.Your doctor ornurse will want to know if the pain was relieved by the more commonmedications, as thiswill give thempotentiallyvaluablediagnostic informationabout your problem. You should always be thinking about whether massage,acupuncture, ice, warm packs, stretches, rest, or some other non-medicationtreatmentcanworkwithwhateverelseyou’reusingforpain.

PUTSOMEICEONIT

Onetreatment that isoftenoverlookedandunder-appreciated isstartingwithacoldpack.Youcanalmostalwayshelpacutebackpainwithsomeice.Whyisthis?Iceapplicationcanhelpinseveralimportantways.Applicationoficeoracoldpackwillboth reduce inflammationafter injuryandblockpain signaling.Oftentimes,patientswillgivemethatlookwhenImentionicepacks.Thatlookusually seems tomean “You’re kidding. I came to see you so that you couldrecommend ice packs?” I tell medical students that medical therapy for painshouldalways,alwaysincludenon-medication-basedtreatmentsinparallelwithmedicationsforpain.

HEATANDTOPICALAGENTSHELPAFTER48HOURS

Althoughwarm therapy isveryhelpful for chronic lowbackpain, heating thebackmaynotbeverybeneficialduringtheacutephase.Mosttypically,thefirst48hoursafter an injury is reserved for cold treatments.After thatperiod, it isoftenhelpfultoalternatecoldandwarmtherapies.Warmheatcanbedeliveredinvariousways:itispossibletoapplywarmmoisttowels,microwaveasachetofbuckwheat,useaheatingpad,orrubonsomemedicinalagentsthatpromotewarming.

Coldtherapyhelpsbyreducinglocalinflammation.Coldworksbestwhenusedinthefirst24to48hours.

TakingTimeOfffromWorkIsNoVacationOne of the biggest problems faced by a person with serious back pain isconvincing his or her employer that time off is needed. A concerned andcompassionate care providermay be your key to recovery.Many employersrequireaphysician’ssignatureformedicalabsencefromwork.But,andthisisacriticalbut,undernocircumstancesshouldyoutaketimeofffromworkandnotattendphysical therapy. Ifyourbackpain is seriousenough tomerit sickleave,yourequireskilledphysicaltherapy.Sickleaveisnotvacation,itistimeforhealingandyoumustdoyourpartingettingbetter.

BEDRESTHELPSWITHSOMEBACKPAIN

Properbedrestisneededforcertaintypesofbackpain:•Adisctearcanbeexcruciatinglypainfulandisusuallymorepainfulwhenthediscisplacedunderpressure.Notinfrequently,whenthereisabackinjury,adiscistorn.Thepaincanbequitesevere,dulltosharp,andtypicallylocatedinthecenterofthebackorjusttotheside.Gettingoffyourfeetwilldecreasethepressureonthediscandhelptoreducethepain.Anacutedisctearcanrequireaweekofbedrestwithagradualincreaseinactivity,butthisshouldonlybeundertakenwiththesupervisionofaphysicianexperiencedinbackcare. Surprising research showed that the disc has nerve endings; thiswasnot widely appreciated even five years ago. In fact, the outer ring of thespinaldiscisrichlysuppliedwithpain-sensitivenerveendings.

•Amilddischerniationisnotbest treatedwithsurgery.Unlessyouresort tochiropracticmanipulation,spinerestcanthebestwaytocoaxthediscbackintoplace.Bedrestcanbecombinedwithgentletractionimplementedbyaphysicaltherapist,chiropractor,orback-carespecialist.Seektheguidanceofanexperiencedrehabilitationspecialistregardingthetreatmentofmilddischerniationwithbedrest.Severalweeksofgraduatedactivitymaybeneededwiththistreatmentapproach.Beawarethateven“mild”discherniationshurta lot; studieshaveshown that theaverageamountofpainwithaherniateddisciseightoutof10!

•Amildflare-up/overdoingittypebackpain:oftenthistypeofpainisbetterwithadayortwooftakingiteasy.

Warning!ExerciseCautionwithHeatingPads

It is importanttoexercisespecialcarewhenapplyingwarmtherapies.Aheatingpadshouldneverbeapplieddirectlytotheskin.Itshouldnotbeinplaceformorethan20minutes,andoneshouldnotlayontopofit.Itismost prudent not to set the temperature of the heating pad above low.Peoplewhohaveanykindofneuropathyandpeoplewhohavediabetes,should not use a heating pad unless it is approved by their neurologist.Neuropathy can lead to poor awareness of skin temperatures anddamagingburnscanresult.

BEDRESTISNOTHELPFULFORMUSCLEPULLS

•Amuscle pull is best treatedwith cold packs, over-the-countermedicines,andavoidingreinjury;bedrestisnotideal,althoughintermittentrestperiodscanhelp.

THESPINEATREST

Bestposition:spineatrest.Allpossibleweightisremovedfromspine.

Okayposition:spineatpartialrest.

TheExplanation

Pain control is a fundamental need for patients with serious back pain. Thebenefits of pain control include better quality of life, better prospects forrecovery,lessdisruptionofsleep,andapotentialreductioninchronicpain.

You must communicate your pain to someone knowledgeable enough tounderstandtheproblemandable toorderappropriate therapies.This isusuallycommunicatedusinga10-pointscalewherezeroisnopainand10istheworstpainimaginable.The“painscore”or“painnumber”isreproducibleandchangesquickly when someone obtains relief from pain. Themain difficulty with thepain score is that it is subjective, meaning there is no tool or test that willconfirmyourpainnumbertosomeonestandingoutsideofyourbody.Thisleadsto the next major problem with the pain score: both doctors and nurses willsometimes discount or underestimate a patient’s pain score. The obviousconsequenceisthatunperceivedpaingoesuntreated.Forthisreason,makesureyourclinicianaccuratelyperceivestheseriousnessofyourbackpainasyouarefeelingit.

For some people, sketching a picture ofwhat the pain onset looked like ishelpful.

RISKSWITHPAINCONTROL

Usually, youwillworkwithyour clinician to reduce the risksof pain control.TheycanbesummarizedwiththreeR’s:Reactions,Reinjury,andReducedcash.

ThefirstR,forreactions,isthemostimportant.Anyandallmedicationsusedforpaincontrol carry somesideeffects, ranging frommild to life threatening.For example, many thousands of people each year suffer gastrointestinal(internal)bleedingasa serious sideeffectofnon-steroidalpainmedicines likeibuprofen. It’s estimated that more than 16,000 people in the U.S. died fromNSAID-induced gastrointestinal bleeding in one year alone! If you take amedicine, be aware of the potential side effects; know the important warningsignsanddiscussthesewithyourpharmacist.Commonmedicationsideeffectsthat may be serious include rashes, excessive fatigue, yellow jaundice, fever,headache,anddecreasedordiscoloredurineproduction.Makesureyourdoctor,nurse,or careprovider speakswithyouabout themajorpotential risksof anymedication.Write down any questions you have about your prescriptions andcallorseeyourcliniciantodiscussthem.It’sagoodideatokeepapaindiaryandincludeanymedicationchanges,notingmedicinesthatyoutakeasneeded.Thisisagoodplacetomakenotesaboutwhichmedicinesseemtoworkbestand

anysymptomsyouareconcernedabout.

WordstoDescribetheTimeCourseofPain•Explosiveonset•Gradualworsening•Comingandgoingforawhile•Rampingupquickly•Intermittentlysevere•Mildandthensuddenlyworse

TheRisksofPainControlMedicationReaction

BackReinjury

CashReduction

The secondR is for re-injury,whichwill hold you back from returning toyourlife.Thisbookwillteachyouseveraltechniquestoavoidre-injury,rangingfrom ergonomics and proper back use to core strengthening and positivepsychological messaging. Avoiding re-injury seems like the most natural,reasonablegoalforsomeonewithseriousbackpain,andthisbookiswrittenforjust those people seeking a deeper knowledge of the back and spine.Unfortunately,re-injuryhasbecomeahot-buttonissueinthebackcareindustrybecause fear of re-injuryhasbeen identified as slowing the return towork. Inreality, you will need to distinguish between reasonable concern arising fromexperienceandunreasonablefearbornofanxiety,pressure,andstress.Youwillhave tomake conscious decisions in order to protect your back from this dayforward;youwillneedtothinkabouthowtobend,howtolift,whennottomoveheavyobjects,whentotakerestbreaksandhowtoselectandmodifyyourshoes.In theshort run,havinga littlepain towarnyouaway fromback-endangeringactivitiescanbehelpful.

ThethirdRisnotsomuchariskasareality.Alltreatmentscostmoney;theobjective is to find a highly effective treatment for the lowest cost. Ask yourdoctor to consider generic alternatives, especially if your insurance will notcover thecostofyourmedication.It’sokayto letyourdoctorknowifyouarehaving trouble paying for medicines and to discuss how your treatment canincludelower-costoptions.Keepincontactwithyourinsurancecompanyabouttherangeoftreatmentsthatmaybeneededforyourback.Bearinmindthatnottreatingabackinjurywillalsohaveacost,andyouwillneedtobalancethecostof treatmentwith the cost of continuedpain.Amajormessageof this book isthat the consistent application of non-drug therapies such as cold, heat,ergonomic-positioning, physical therapy, and clinical psychological techniqueswill help to reduce dependence on medications and potentially make themedicationsyoutakemoreeffectiveagainstyourpain.

Q&AwithDr.Murinson

Iinjuredmyback,butitwasn’tuntilhourslaterthatitbegantohurt.Whyisthat?

Atfirstitmaybehardtobelievethatyouhavebeenhurt,especiallyifyouareotherwise busy, healthy, and active. Accidents occur unexpectedly and are afrequentcauseofbackpain.It’seasytounderstandthatshockandsurprisecandelay people from recognizing the seriousness of a problem. Sometimes, theprecipitating back injury seems inexplicably minor compared to the pain that

follows, and thiswill delay problem recognition.And although back pain canstartalmost immediatelywithaccidental injury, itoften takesseveralhoursforthepaintosetin,andsometimesevenlonger.Dayscanpassbeforepainpeaks.Delayed pain is common for people that are injured under “battlefield”conditions, reflecting physiological factors like the release of stress hormones.Delayed pain can happenwhen someone is focusing intently on completing atask, reflecting psychological factors such as attention and pain distraction.Delayed pain can occur in performance-related settingswhere all eyes are onyouandapremiumispaidfor“goingonwiththeshow.”Finally,delayedpainmaybeduetothenatureoftheinjuryandtheunderlyingdiseaseprocessatwork(pathophysiologicalfactors)suchasdelayedswellingorinflammation.

Mypainchangesfromdaytoday.HowcanIcommunicatethatonapainscale?

Oneveryvaluabletoolforcommunicatingwithyourdoctorsandcareprovidersaboutyourpainisthepaindiaryorpaincalendar.Itcanbeassimpleasjottingasingle pain score on awall calendar each day, or as elaborate as a keeping adetailedjournalofeachday’sexperiences.Withthebasicpaintallyeachday,itisveryeasyforyourdoctortotellhowthingsaregoingataglance.Itwillmakeitpossibletogaugewhetheranewtherapyisworkingandalternatively,canhelpyouassessyourprogressasyou return toworkor school.Also,peoplegainasenseofcontrolovertheirpainsimplybywritingitdown.Gainingcontroloveryourpainandgettingyour lifeback is theultimategoalof treatment forbackpain.

CHAPTER14EarlyExercisesforManagingBackPain

WithLinaMezei,certifiedyogainstructor.Gentleyogacanoffersignificantpainreliefandincreasemobility.

thePRESCRIPTION

Warning!EasyDoesIt

Never push yourself to the point of pain. Yoga for back pain is notsupposedtobestrenuous;rather,itismeanttoberestorativeandhealing.

Warning!CheckwithYourDoctor

Be sure to check with your doctor for specific warnings against any of theexercisesdescribedinthischapterbeforebeginning.

Ifyouareintheearlystagesofrecoveringfrombackpainandyouareabletositfor20minutes,standupfromachairwithoutwincing,andtieyourownshoes,theseearlyexercisesforacutebackpainmayberightforyou.

It’s time to learn about yoga, a system of poses, breathing, and thoughtfulmeditationthathasbeenusedforthousandsofyearstopromotehealth.Youcantakeagentleyogaclass,borrowbooksfromthelibrary,getayogaDVD,ortalkitoverwithaknowledgeablefriend.•Yourfirstyogapracticeshouldbeverygentleandwellwithinyourcomfortzone.Ifyoufeelpain,itistimetobacktrackandgetmoreguidance.Thereisan excellent DVD produced by Yoga Journal called Yoga for YourPregnancy.Whileyoumaynotbepregnant,youcanimaginethatyogaforpregnancyisvery,verygentle.Thisiswhereyouwanttobegin.

•Theyogaexercisesinthischapterwereadaptedfromstandardyogapostures.They reflect the recommendations for improved core stability and gentlestretching.

TheTreatment

Thebestwaytostartistopracticeyogabreathing:refreshingbreathsthatreachdeepintothelowerabdomen.Thisissometimesmorechallengingforwomen,asmanywomenhave learnedover timetobreathwith thechestandnotasmuchwiththeabdomen.Babiesbreathewiththeabdomen;thinkaboutthegentleriseandfallofthebellywitheachbreath.

In yoga, we use a technique called Ujjayi breathing, which translates intovictorious breathing. Breathing should be completely unrestricted, eachinhalationslowandexpansive.Asyoupracticecontrollingyourbreathingsoitislonger and stronger, you should eventually be able to feel your breath deepinsideyourbelly.Thistypeofdeepbellybreathingrequiressomepractice;eachexhaleshouldbesteadyandcompletelyemptying.

TherearetwoexercisesonecandotopracticeUjjayibreathing.Onemethodis to take a deep, full inhalation and exhale as if you were fogging up a carwindowonacoldday.Anothermethodis towhisper theword“home.”Whilewhispering,drawouteachsoundofthewordsothatittakesroughlythreetofiveseconds foryou tocompleteeachwhisper. Ifdoneproperly,youshould feel aslightconstrictionofairinthebackofthethroatandtheexhaleshouldbeveryaudible.Thesebreathingexercisescanalso increase lungcapacityandstaminafor performing your yoga sequences. Additionally, practicing controlled yogicbreath work is attributed to creating balance within the autonomic nervous

systemandfosteringphysicalandmentaltranquility.1,2Differentyogictraditionsplace varying degrees of emphasis on control of the breath.3 Although manyadvocatebreathinginthroughthenoseandoutthroughthemouth,itispossibletobreathinandoutthroughthenose;ifbreathinginthroughthenosefeelstoorestrictive,tobreathinandoutthroughthemouth.

WheretoPracticeYogaYoga is primarily practiced on a yoga mat in a warm room, which aids inmaking your muscles more loose and flexible. For extra padding, you maywanttoplaceyouryogamatonacarpetedsurface.Throughoutalloftheyogaposes, be conscious of your breathing. If, while in a posture, your breathbecomeslabored,itmeansyouneedtobackoffabit.Itisimportantthatyoulistentoyourbodyandmodifytheextentofposesandstretchesasyouseefit.

LIEDOWNFORBASICVINYASA

Yogaisstructuredintospecificsequencescalledvinyasas,whichtranslatesinto“flowingmovement.”Youryogapracticeshouldmovewithfluidity,eachposeflowing into the next in correlationwith your breathing tomake each posturemorerestorativeandbeneficial.Thegoalsofthisbasicvinyasaaretowarmup,gainfocus,concentrateonbreathing,stretch,andawakenthespine.

1.LyingdownTadasana(MountainPose)willprepareandprovidefocusforyouryogasequence.Thisposewillgetyouacquaintedwithyouryogamataswell.Layyourbody face-upon themat.Adjust yourself so that yourbodyexperiencesmaximumcontactwiththemat.Thismayrequireyoutomove the flesh around your sitz bones in order to make better contact.Gently rock your spine side to side and up and down until you feel animprintinthemat.Keeplegstogetherandyourfeetflexedasthoughyouare standing on an imaginary floor.Your arms should be placed next toyoursides,handsopenwithyourpalmstouchingyourthighsorinprayerat thecenterofyourchest.Becomeawareofyourbodyasyoupullyourbelly in towards your spine.There should be no tension in this pose, somake sure your shoulders are down away from the ears and relaxed.Concentrateonalignmentwhilebreathing.Imagineyouareassteadyandstrongasamountain.Asyoubegin,youmayneedasmallsupportundertheheadandasmallbolsterundertheknees.Bytheendoftheearlybackpainphase,yourgoalistobeabletolieflat.

2. Transition from Mountain Pose to lying down Vrksasana (Tree Pose).Vrksasana is a nice hip-opening posture that will also help to releasetensioninthepelvis.Simplybringuponelegandplacethesoleofthefootagainsttheinnerthigh.Ifthisisdifficult,placethefootfirmlyontheinnershin.Adjust yourself so that the pelvis and hips are in a neutral/straightposition,andnotjuttingouttowardthesidethatyourfootispressingon.For complete engagement, flex the foot of your outstretched leg. Pressyourhandstogetherinaprayerpositioninthecenterofthechest.Foranevengreaterstretch,liftyourarmsoveryourhead,interlaceyourfingers,and turnyourhands so that thepalms faceaway fromyourhead.Relax,takeafewdeepbreaths,andrepeatwiththeotherleg.

AprecursortoBandhasana(BridgePose)

3. Now that your pelvis has been stabilized, practice a precursor to SetuBandhasana (Bridge Pose). In this early phase, the posture will bepresentedaspre-bridgepelvic tilts.While laying flatonyourback,bendyourkneesandwalkyourheelstowardyourbuttocks.Yourfeetshouldbeflat on the mat and a hip-width apart. Place your fingertips toward theheels while lengthening your neck and pressing the lower back into themat.Pressallfourcornersofthefeetfirmlyintothemat.Asyouexhale,engage your abdominal muscles and buttocks. Begin to tilt your pelvis,making your tailbone curl up as yourwhole lower back presses into themat.Thesmallofyourlowerbackshouldfeelcompletelyflat.Holdhereforthreebreathsandslowlyreleaseonanexhale.Repeatthesemovementsthreetofivemoretimeswhilemovingwithyourbreath.Thispostureaidsintoningandrelievingpressureinthelowerspine.

4. Roll over onto the belly to prepare for a modified Ardha Salabhasana(HalfLocustPose).Thisvariationistheleastdifficultlocustposture,yetitis capableof relievingmuch tension in the lowerback.4Lie flat,placingyourpalmsfacedownalongsidethehips,ortuckedunderneaththethighs.Push firmly down on the hands, pelvis, and pubic bone as you gentlyinhale and raise the right leg upward two to four inches off of themat.Make sure the raised leg is straight and the toes are pointing directlybehindyourbody.Exhaleasyouslowlyloweryourrightlegbackdowntothemat.Repeat threetofivemoretimes, thenswitchtotheleft leg.Thispostureactivatestheextensormusclesalongthespine,namelytheerectorspinaeandmutifidusmuscles.

Balasana(Child’sPose)

5. A wonderful counter-stretch to Ardha Salabhasana, which is a backextensionexercise, is agentle spinal flexion suchas supportedBalasana(Child’sPose).Youwillneedapillowforthesupportedversion.Beginbygetting onto your knees, resting the tops of the feet flat on themat, andpositioningthemdirectlybehindthebuttocks.Thekneessplayouttowardthefrontcornersofthemat.Placethepillowcomfortablyunderneathyourbellyandchest.Takeadeepbreathin,andonyourexhale,slowlybegintoloweryourbelly,chest,andforeheaddowntowardthemat,allowingyourhearttosinkintothepillow.Placeyourarmsoutstretchedinfrontofyouwithyourpalmsfacingdownon themat.Allowtherestofyourbody tosinkintothefloorandbegintomeltawayintoyourmat.Relaxinthisposewhiletakingfivetotendeep,restorativebreaths.

6.AfterreleasingBalasana,movethepillowawayandgentlyrolloverontoyour back to prepare for the next posture, amodifiedArdha Apanasana(HalfWind-RelievingPosture).Apanasanaisaflexionposturedesignedtoopenyourhipsandtostabilizeyourpelvisandlowerback.While layingflatonyourback,allowthewholespinetopressdownintothemat.Raisetherightkneeupandintowardthechestonaninhale.Ifstrainiscausedbytryingtobringyourkneetothechest,justliftyourlegsothatyourthighandkneearedirectlyaboveyourhipandyourcalfisata90-degreeanglefromyourthighwithyourfootflexed.Oneachlonginhalation,allowthebellytoexpand.Oneachlongexhalation,continuetopullthekneeclosertowardyourchest.Onyourthirdbreath,gentlyglidethekneetowardtheopposite side so that the knee cap is pointing in the direction of the leftshoulder.Holdyourleghereforthreebreaths.Switchlegsbyreleasingandextendingyourrightlegasyoubringyourleftkneeuptowardyourchestandrepeatthesequence.

AmodifiedVirabhandrasana(WarriorPose)forwardlungewithhandsprovidingbalanceandsupport

STANDINGPOSESINBASICVINYASA

1. Prepare for a modified Virabhandrasana (Warrior Pose) by bringingyourselftoastandingposition,inwhichyourbodyisuprightandyouarerestinglightlyonyourfeet.Itisagoodideatoplaceyourmatovercarpetandnext toawall incaseyouneed to reachout for stability.Placeyourrightfootabouttwofeetinfrontofyourbody,andleanforward,aligningtherightkneedirectlyovertheheel.Asyouleanforwardontherightleg,trytokeeptheheeloftheleftfootonthegroundasyoustretchyourcalfandhipmuscles.Asyouaremorecomfortableinthispositionandwouldlike to experience a more intense stretch, move your right foot furtherforward, working towards a distance of three feet between your feet.Remain in this gentle lunge position as you visualize reaching upwardthrough the crown of your head for five to eight breaths. Keep yourshouldersdownbacksothattheyarenotscrunchinguptowardstheears,withyourhandsbyyoursides.After three to fivebreaths, return toyouroriginalstandingpositionandswitchtostretchyourleftleg.Itisbeneficialto incorporatepostures that stretch thehip flexors, as lowbackpain andlumbarlordosisareoftenexacerbatedbytightnessinthesemuscles.5

Onceyou are comfortablewith the supported forward lunge, you canprogresstoaVirabhadrasanaI(WarriorIPose)byfirstbringingyourtorsointoanuprightposition.Breathing in throughyournose, raiseyourarmsstraightupandreachfortheceiling,framingyourearswithyourforearms.Engageyourleftlegbyliftinguponthequadricepsandleftkneecap.Tuckyourtailbone,suckyourbellyintowardyourspine,andcontinuereachingupwithyour fingertips.MakesureyourshouldersaredownandbackasyouholdWarriorIpose.Afterfivebreaths,bringyourleftfootforwardtoprepareforstretchingontheotherside.

2. Now that your quadriceps and hips have been stretched, it is time toengage your leg and coremuscles in awall-assistedUtkatasana (FiercePose).Ithasbeenrecognizedinbackpainsufferersthatweaknessincoremusculaturecreatesabiomechanicaldeficit.6Itiscrucialtostrengthenthecore,whichhelpstostabilizethespine,whichinturnhelpstorelievepain.Tostart,walkovertothenearestflatwall.Positionyourbodysothatyourbuttocksarerestingcomfortablyagainstthewall.Yourfeetshouldbeoutinfrontofyouso thatyourheelsareapproximatelyafoot(30cm)orsoaway from thewall. Standwith the feet hip-width distance apart as you

begintoslideyourbuttocksdownthewall.Youshouldappeartobesittinginachairbutleaningforwardabit.Raiseyourarmsupoverhead,framingyour earswith your forearms.Bemindful that there is no tension in theshoulders,astheshoulderbladesshouldbedownandback.Makesurethatyour tailbone is tucked under and that you are sucking your belly intowardsyourspine.Concentrateonthebreathasyoureachfortheceilingoneveryinhaleandsinkabitloweranddeeperoneveryexhale.Holdforfivebreaths.Asanalternativetothispose,itispossibletosubstituteawallslideuntilthebackisstrongenoughforyoutoleanforwardawayfromthewall.

3.Turn so that the frontofyourbody is facing towarda support suchasawalltoprepareforamodifiedAdhoMukhaSvanasana(Downward-FacingDogPose).Standfacingthewallwithyourarmsoutstretchedatshoulderwidth.Press thepalms flatagainst thewallatchest level.Youshouldbestandingwithyourfeetapartathip-widthdistance.Whilefirmlypressingboth hands into the wall, slowly begin to walk your feet back. Yourshoulderbladesshouldbedown,awayfromtheears.Begintofeelahugeopeninginyourshouldersandspineasyouallowyourheadandchest tosink down past your arms. Your feet should be planted firmly into thegroundwithyourlegsstraightorwithaslightbendintheknees.Holdherefor eight long, restorative breaths. Thismodified version of Downward-FacingDogprovidesamultitudeofbenefits includingstretchingmostofthelongmusclesofthebody.Thisposealsoprovidesactivelengtheningofthe erector spinae and latismus dorsi muscles. Lengthening the backextensormusclesgreatlyreduceslowbackcompression.

4.While still facing thewall, prepare for a variation on a primer pose forNatarajasana(Dancer).Standarm’s-lengthawayfromthewallandplaceyour right palm flat against it at shoulder height. Kick your right legbehindyourbody.Bendthekneetobringtheheeloftherightfootclosetotherightbuttock.Takethelefthandandreachbackandaroundtograbtheinsideoftherightarch.Activelyliftthatrightfootwithyourlefthandtofeelawonderfulopeninginthequadricepsandiliopsoasmuscles.Repeatontheleftside.

5.Now that thequadricepsand iliopsoasmuscleshavebeen stretched, it istime for a gentle back extension posture, Anuvittasana (StandingBackbend).StandinTadasana,reachingthecrownoftheheadtowardtheceilingwhileliftingthechestandribcage.Bringthepalmsofthehandsto

the lower back, right above the buttocks. As you exhale, drop the headslightly back and press your hips and thighs forward. Bring your gazeupward. On your fifth breath, slowly inhale the head back to verticalfollowedbytherestofthebody.

6.OnefinalbackflexionexercisethatreleasestheentirespinalcolumnisaseatedUttanasana (ForwardFold/Ragdoll).Sit in a chair andplaceyourfeetfirmlyontheground.Takeabiginhalationasyouraiseyourarmsupoverhead, creating length along the entire spine. Sustain that length byreachingoutandforwardwithyourarmsasyoubegintoflexatyourhipsto loweryourbellyontoyour thighs.Yourarmsshouldhang loose,withonearmatthesideofeachshin.Lettheheadhangheavyoveryourkneesasyoubegintoreleasealltensionintheneck.Duringtheearlyphaseafterbackpain,itisbettertoleanforwardintoabolster.

7.AlwaysendyouryogapracticewithfiveortenminutesofdeepbreathingmeditationinSavasana(CorpsePose).Abolsterunderthekneesandshinsis a good prop to incorporate during this early phase, as itwill assist inrelieving tension in the lowback.This is the total relaxationpose,whichformany is themost difficult pose tomaster.While laying flat on yourback,closeyoureyes,spreadyour legsabouthips-widthapart,andplaceyourarmsoutbyyoursideswith thepalmsfacinguptowardtheceiling.Trytoloosenallthemusclesinyourfaceandbodyandbegintotakeslow,steady,deepinhalationsandexhalationsthroughyournoseandmouth.Bestill, clearyourmind, andvisualizeyourself asbeingweightless.Donotunderestimatethepowerofrelaxationforbackpainrelief.Generalmuscletightness,tension,andspasmsresultingfromlife’sdailystressescontributetobackpain.7

Practicetheseposesdaily.Forbestresults,tryformultipletimesthroughouttheday.Afterafewweeksofpersistentandsteadypractice,youshouldbereadytomoveontosomemorerestorativeandstrengtheningposes.8,9

Savasana(CorpsePose)

TheExplanation

Yogaisaphenomenalwaytogetintouchwithyourbody.Asyoupracticeyoga,youwill begin to notice improvements in breathing, body awareness, posture,mobility, stability, and agility.Many of the physical therapy exercises that areusedtodayhavedirectcorrelatesinthecenturies-oldyogaposesdescribedhere.

CHAPTERRESOURCES

1. Brown, R.P. and P.L. Gerbarg. 2009. Yoga Breathing, Meditation, andLongevity.Longevity,Regeneration, andOptimalHealth.Ann.N.Y.Acad. Sci.1172:54-62.

2.Nayak,N.N.andK.Shankar.2004.Yoga:ATherapeuticApproach.PhysicalMedicineandRehabilitationClinicsofNorthAmerica15:783-798.

3.McCall,T.YogaasMedicine:TheYogicPrescriptionforHealthandHealing.BantamBooks,NewYork,2007.

4.Coulter,D.H.AnatomyofHathaYoga:AManuelforStudents,Teachers,andPractitioners.Honesdale,PA:BodyandBreath,2001.

5. Borg-Olivier, S. and B.Machliss. “Yoga for Low-Back Pain: Simple YogaStretchesAndExercisesCanHelpAlleviateTheHighestCauseOfSickLeave,SayPhysiotherapistsSimonBorg-OlivierandBiancaMachliss.”ComplementaryMedicineJournal,November/December2005.

6. Sorosky, S., S. Stilp, and V. Akuthota. 2008. Yoga and pilates in themanagementoflowback.CurrRevMusculoskeletalMed1:39-47.

7. Borg-Olivier, S. and B.Machliss. “Yoga for Low-Back Pain: Simple YogaStretchesAndExercisesCanHelpAlleviateTheHighestCauseOfSickLeave,SayPhysiotherapistsSimonBorg-OlivierandBiancaMachliss.”ComplementaryMedicineJournal,November/December2005.

8.Sherman,K.J.,D.C.Cherkin,J.Erro,D.L.Miglioretti,andR.A.Deyo.2005.Comparing yoga, exercise, and a self-care book for chronic low back pain:Arandomized,controlledtrial.AnnalsofInternalMedicine143(12):849-56.

9.Williams,K.A.,etal.2005.EffectofIyengaryogatherapyforchronic lowbackpain.Pain115(1-2):107-17.

CHAPTER15ShapingYourOwnRecovery

Consistentself-careisjustasimportantasmedicalintervention

theDIAGNOSIS

BackpainisthemostcommonpainproblemintheU.S.today.Itisthenumber-onecauseofwork-relateddisabilityandahugeexpenseintermsofdoctorvisits,over-the-counterandprescriptionmedications,physicaltherapytreatments,andsurgicalprocedures.Forallthisinvestmentoftime,effort,andmoney,wehavelittle positive to show.Most of the therapies that we doctors have are at bestpartiallyeffective.Thecurrentstandardsforpaintreatmentsarethattheyhavetoreducepainby50percent.Usuallybythetimesomeonehashadbackpainforseveralmonths,there’sachancethatwhateverwedotomakeitbetterwillonlyhelpalittlebit.

Thisbookiswrittentobeanewsolutiontobackpain,andthischapteristhekeyelement.All theotherchaptersof thisbookaredesignedtobring togetherthe best thatmedicine and science has to offer about the back and to put thisinformationintoyourhands.Butthischapterasksthequestion:“Whatareyougoing todo tomakeyourbackpainbetter?”Youmust be the captainof yourownship.Youareanadultandhavearesponsibilitytoyourselfandyourcloseonestotakecommandofyourhealth.

In truth, whatever positive steps you take will have a greater cumulativeimpactthanallthemedicalinterventionsoutthere.Thisistrueforalmostalltheproblemsthatarenotclearlymedicalemergencies.Takesmoking,forexample.If all the smokers in the country were to stop smoking, most of our highlytrainedcardiologistswouldbesittingaroundwaitingforthenextpatienttoshowup.Wewouldprobablyneedathirdfewerhospitalbedsandmedicalequipmentmakers would have a drastic drop in demand. The same applies for obesity,excessive alcohol consumption, and most other long-term health problems.Honestly, some people have a genetic predisposition to certain problems. Buteachpersonwhomakespeacewith theirbackhascome toacertainpoint: theplace where outside solutions aren’t working anymore and a new, custom-

tailoredplanofactionisborn.Ifyou’renotthereyet,Ihopeyoucanstarttotakesmallstepsandlookcarefullyforimprovement.Askthequestions:“WhatwillIdo for my back today?” followed by “What can I do better?”, “What can Ilearn?” “Is there something new that I haven’t tried yet for my back?”, and“Whocanteachme?”

Ifyouarereadytobethemasterofyourback’sdestiny,readon!

>Haveyouhadbackpainforlongerthatyoueverthoughtyouwould?>Haveyoubeentryingeverythingthedoctorstellyouwithoutgoodresults?>Areyouunsurethatanyonereallyunderstandswhat’shappeningwithyourback?

thePRESCRIPTION

RestWorksWondersWhileyouarelivingwithbackpain,startanytaskearlyandtakebreakstoliedown.Puttingthebacktorestandtakingsomedeepbreathswillmakeaworldofdifference.Itiswidelyrecognizedamongexperiencedpainpractitionersthataperiodofoverdoing it is inevitably followedbyaperiodof increasedpain;thisissometimesreferredtoasthepain-restcycle.1

•Identifyhealthcareprofessionalsandtreatmentsthatworkforyou.• Advocate for your own health needs. Speak openly with your doctor andothers about your back pain and how treatments are working. A paincalendarorjournalisagreatwaytokeeptrackofyourprogressandpitfalls.

• Pace yourself. Don’t let others intimidate you into pushing too hard.Overdoingitwhileyourbackisgettingbetterisamistakeandmayleadtolong-termproblems.

•Usealltherapieswithpropercare.Manyofthetreatmentsforbackpainhaveunintended side effects, including physical therapy. Be well informed andspeakupifsomething’snotright.

•Acknowledgethatpainprobablyhasphysicalandpsychologicalcomponents.•Avoidoroptoutofactivitiesthatrepeatedlymakeyourbackpainworse.Atoneendofthespectrum,thismeansnotgoingonaskitrip;attheotherend,acareerchangemaybethemostimportantlifechangeyoucanmake.

•Usepainrelieversjudiciously.Thereissuchathingastoomuchand,believeit or not, too little. Severe pain early after an injury can actually lead tochronicpain.

•Visualizeyourlifewithoutbackpain.Youcandothisasaformofmeditationorwritesomeaffirmationsandpastethemtoyourmirror.

•Letpeopleknowhowyou’redoing.Youwillfindthatallthecaringyou’vesharedwithothersovertheyearswillcomebacktoyou.

•Learn aboutyourback anddevelopyourown strategies for aback-healthylifestyle.Buildapersonalizedplanofexercise,movement,medication,andmeditation.

TheTreatment

If your recovery is difficult and takes longer than initially expected, youmayneedtoswitchtherapistsordoctors.It’sfairtosaytosomeone,“Iappreciatethatyou’vebroughtmethisfarandthankyou,”andmoveonforafreshperspective.

Warning!AllergicReactionsDemandImmediateResponse

If you think you are having a medication allergy, it is best to get helpimmediately. Some medications, especially muscle relax-ants,anticonvulsants,andanti-depressantscanhaveseriouseffectswithabruptwithdrawal. If you stop a prescribed medicine suddenly, you need tocontactyourdoctorortheon-callphysicianaboutthis.

ALTERNATIVETREATMENTSALSOCARRYRISKS

TheprescribedmedicationsavailableintheU.S.aresubjecttocarefulscrutinybefore approval for use and are subsequently manufactured with stringentstandards. Despite this, problems still arise. In stark contrast, dietarysupplements are manufactured under loosely regulated conditions and arecompletely unproven in terms of providing a health benefit. The essentialstandard for a dietary supplement is that itmust not be harmful and that anyclaimsmademust be backed up by scientific studies. However, the safety ofdietary supplements is not tested before they are brought to market. As thesupplementsaresold,theFDAmonitorsforharmfuleffectsandwillcompelthewithdrawal of a product that proves to be unsafe.2 If you take a dietarysupplement, you are part of a real-time social experiment that may result inpeople like you suffering harm.One example of a potentially harmful dietarysupplement is vitaminB6.WhenB6 is taken atmega-vitamin levels, it causespainfulneuropathythatmaytakemonthstorecoverfrom.

Chiropracticmanipulationcancausestrokeswhenperformedwithexcessivevigorintheneckregion.Acupuncturecanbehazardousifthepractitionerisnotreputableandexperienced.Manyof theconventional treatments forbackpain,including lumbar epidural steroid injections, radiofrequency ablation, surgery,andmedicationscanallbeharmfulifnotusedwithappropriatecautionandcare.

PAINISSTRONGLYIMPACTEDBYSTRESS

For most people, pain is a complex mixture of physical and psychologicalcomponents.

Thisdoesnotmean theproblem is inyourhead. Itmeans that stress levelshaveabigimpactontheperceptionandexperienceofpain.I’vehadplentyofpatientswithseriouslypainfulnerveproblemswhofindthatpainisbetterduringvacation. This doesn’t mean that the pain is made up; it means that copingmechanismsmaynotbefunctioningaswellundereverydaycircumstancesandthatwithpropersteps,someofthepainrelieftheyexperiencewhileonvacationcouldbebroughttobearin“real-time.”

LEARNMOREABOUTPAINRELIEVERS

Manypainrelieverscanbeusedforthetreatmentofbackpain:classicNSAIDs,acetaminophen,andopioids;pain-activeantidepressantsincludingtricyclicsandnewerserotonin-norepinephrinereuptakeinhibitors;anticonvulsantssuchasthenewergabapentinandpregabalinaswellasolderonessuchascarbamazepine;

and neuro-modulating agents that are sometimes injected or used locally,including lidocaine and methylprednisolone acetate (Depomedrol). Eachmedication within a class has slightly different side effects and properties ofaction:howlongitstays in thesystem,whether it ismetabolizedbykidneyorliver, andhow it interactswithothermedications.Thecost, too, can influencewhetheritisrightornot.

Oneothermedicationoption is theuseof topicalmedications.Lidocaine isnowavailableinapatchplacedrightoverthepainfularea.Asurprisingnumberof people experience relief from this treatment. Also, some formulations ofNSAIDs come in topical creams that are rubbed into the body. The opioidmedicationfentanyl isavailableasaprescriptionpatch.Thisdoesnotworkbylocal action, but rather delivers themedication in away that affects the entirebody.

Thespecificsofyourbackproblemwilldeterminewhichmedicationsmightberightforyou.Ifthereisanervepaincomponenttoyourbackpain(zinging,burning, or shock-like pains), you may need to take prescription medication.Your doctor can provide instructions for a special compounding pharmacy tomakecustomizedmedications.Therearemanyoptions,sodon’tgiveuphopeofgettingrelief.

TheBenefitsofAerobicExercise•Reducedstress•Greatereaseinaccomplishingeverydaytasks•Painrelief•Improvedpaintolerance•Bettermentalfunctioning•Aidsweightcontrolandweightloss

DON’TLETJOBWORRIESRUINYOURLIFE

Ifyouareabletoworkwhileyourbackrecovers,great.Ifyouneedtimetofocuson getting better, you’re going to have to ask. But don’t attempt to game thesystem and use this time to engage in activities that will interfere with yourrecovery.Askyour care provider to support your need for timeoff during theacute phase and recovery. You’ll need to do your part by attending physicaltherapy,keepinggoodrecords,andtakingmedicationsappropriately.

Ifyouarepronetobackpainwithprolongedsitting,seeifyoucandoyourjobwhile standing up from time to time. Itmight be possible tomake phonecallswhilestandingorgetanadaptedworkstationthatallowspositionchanges.Youmayevenneed tochange jobs toaccommodateyourphysical constraints.ThisisthemostdifficultdecisionthatI’veseenpatientsmake,butsometimesanecessarychoice,andthebestoneintermsofcorrectingachronicpainproblem.

DEVELOPANEXERCISEANDRECOVERYPLANTHATWORKSFORYOU

Gettingbacktoanimprovedstateofhealthisthebestdefenseagainstbackpain.Perhapsthemostdistinctivefeatureofahealthylifestyleisexercise.Simplyput,the value of getting aerobic exercise three times aweek cannot be overstated.Choosinganexercisethatyoufindenjoyableandrewarding,andgettingintothehabitofbreakingasweatthreetimesweeklyisthesinglebestthingyoucandoto prevent a recurrence of back pain. Frequent exercise will make everythingelse you do easier; it will reduce overall stress, increase your pain tolerance,reduceyourresidualpain,andimproveyourchancesofstayingmentallysharpforyearstocome.Althoughyoushouldcheckwithyourdoctorbeforestartinganewexerciseroutine,pushaheaduntilyougetthatclearanceandthengo!

AskforHelpFriendsandfamilyareespeciallyimportantasyougothroughanexperienceofseriousbackpain.Especiallyifyouhavesmallchildrenorpets,theliftingandbendingtasksareendless.Justfindingsomeonewhocanliftachildintothecarcanbeawonderfulactofkindness.Iftheyareopentobeinghelpful,don’tbeembarrassedtoarrangeforhelpagain.

ExceptionalResourcesforShapingYourOwnRecoveryOverallManagingChronicPainWorkbookbyJohnD.Otis

7MinutesofMagicbyLeeHolden

Exercise-focusedMindfulnessYogabyFrankJ.Boccia

BanishYourBackPainthePilatesWaybyAnneShelby

TakingcareofyourbodyTheTriggerPointTherapyWorkbookbyClairDavies

MoveintoLifebyAnatBaniel

TheExplanation

Increasingly,medicalresearchersarefindingthatpeoplewithcertainpersonalityfeatures are more likely to get better from an injury. One of the essentialelementsofdoingwellafterabackproblemisasenseofself-efficacy,abeliefthatyouhavethepowertomakepositivedecisions.Theeffectsofself-efficacywere recognizedseveraldecadesago in thenursing research literaturewherearelated concept called the internal locus of control was described. In this, aperson believes that they are responsible for events and the outcomes of theirexperiences.Peoplewithoutthisfeelthatothershavecontroloverthem.Peoplewith a good internal locus of control are generally healthier and have betterhealth outcomes.3,4 This is being echoed in the current pain literature, whichfinds that people with better self-efficacy survive and even go on to thrive,despiteadverseevents.5

Like all doctors with back pain patients, I’ve had people come in saying“Doc,I’lldoanythingyoutellme.”Mostoften,thisisthepatientwhorefusestochangeanythinginresponsetoourconversations.Theyrefusetostartphysicaltherapybecausethey’vetriedthatbeforeanditdidn’twork;theyrefusetotryanew medicine because their primary care doctor (friend, neighbor) didn’tapprove; they refuse to start exercising because they just don’t have the time.The simple fact is thispatient isnot ready togetbetter.Theyare trapped inacycle of believing that someone somewhere is going to solve their problemwithout any effort from them. This won’t happen. No one, not even yoursurgeon,isgoingtohavethemagicsolutiontofixallbackpain.You’regoingtoneedanswers,butinreality,theansweris:you.

CHAPTERRESOURCES

1.Otis,J.D.ManagingChronicPain.NewYork:OxfordUniversityPress,2007.

2. NCCAM. “Using Dietary Supplements Wisely,”http://nccam.nih.gov/health/supplements/wiseuse.htm. Accessed February 12,2010.

3.Waldron,B.,etal.2010.Healthlocusofcontrolandattributionsofcauseandblameinadjustmenttospinalcordinjury.SpinalCord[Epub].

4. Nyland, J., B. Cottrell, K. Harreld, and D.N. Caborn. 2006. Self-reportedoutcomes after anterior cruciate ligament reconstruction.Arthroscopy 22 (11):1225-32.

5. Foster, N.E., et al. 2009. Distinctiveness of psychological obstacles torecoveryinlow-backpainpatientsinprimarycare.Pain[Epub].

CHAPTER16Ergonomics

Designyourhomeandworkenvironmentforoptimalbackhealth

thePRESCRIPTION

Warning!UseProperTechnique

Partoftakingbackyourbackischanginghowyoudothosetasksthatareespecially hard on the back. You must use proper technique to resumecertainactivities.

DidYouKnow?The study of ergonomics extends back in time to the ancient Romans andperhapsbeyond.BernardoRammazini(1633–1714),however,isrecognizedasthe founder of occupational medicine.1 His landmark work, translated intoEnglishasATreatiseontheDiseasesofTradesmen,containedmanychaptersdevotedtothemaladiesofaparticularoccupation.Ofthosewhosit,henoted“Allsedentaryworkers...areabadcolor,andinpoorcondition...forwhenthebodyisnotkeptmoving,thebloodbecomestainted,itswastematterlodgesintheskin,andtheconditionofthewholebodydeteriorates.”2

WhatIsErgonomics?

Ergonomics is a “new” word created in the late 1940s by a British scientistinterestedindesigningbetterworkenvironments.HywellMurrellwasachemistby training; onewondershowhedeveloped an interest inwork environments,butclearlytheprocessofstudyinghowhumansfunctionbestandhowtomaketheirenvironmentsmoreproductiveandlesspain-provokingwasarevolutionaryidea.

There are some basic principles of ergonomics that will allow you tomaximize your back health. Especially if you sit at a desk or work on thecomputerformuchoftheday,therearesomesimplethingsthatyoucandotoease pressure on the spine. Reducing spine pressure is critical for speedingrecovery fromback injuryand increasingyourqualityof life in the long term.Not only discs but ligaments, muscles, and joints will respond negatively toexcess pressures and strains. There are special ergonomic considerations thatapplytospecifictypesofbackproblems.

Thereareadozeneasythingsyoucandotopreserveyourbackatworkifyoufeel as though you’re working hard to get simple tasks accomplished or asthoughyourenviornmentisworkingagainstyou:

WhenSitting:

1.Getalumbarcushionforyourchairandleanbackintoit.Byleaningbackyoucantransfertheweightofyourupperbodyontothechairandreducethepoundsofpressureonthediscsandotherbackstructures.

2.Adjusttheheightofyourchairsothatyourfeetrestlightlyontheground.Ahealthysittingstancedependsongettingyourpelvis intoneutral.Thiscanonlyhappenifyourfeetareabletoprovidesupportandyourlegsarenotslopingupordown.Ifyoucannotgetachairthatistheproperheight,considercarryingalightweightfootrest.

3.Sitdirectly in frontofyour taskarea, sitting square to theworksurface.Symmetry is an essential element of succeeding against back pain everyday.Situpstraightwheneverpossible.

WhenStanding:

4.Wearshoesthathavecushionedinsoles.Thiswillreducetheimpacteach

stephasonthespine,knees,andhips.Especiallyifyouspendalotoftimewalkingoverhardfloors,youshouldstriveforthebestfootwearpossible.Youcansometimesimprovelessexpensiveshoesbyaddinganathleticorhigh-densityheelcushionorfullfootsupport.

5.Asyoustand,tightenyourabdominalmusclesandtrytomaintainapelvicneutralposition.Visualizehowadancerwouldstandanddrawyourselfuptall.Holdthisaslongaspossibleandthenrelaxwithsomedeep,cleansingbreaths.

6.Ifyoumuststandfora longperiodof time,afirmrubberfloormathelprelievepressureonyourbackandreducefatigueandpain.

7.Standasifyourheadisfloatingoffofyourshoulders,liftedbyaheliumballoon.ThisapproachcomesfromtheAlexanderTechnique.Itisagreattensionreliever.Standasifyourheadisbeinggentlyliftedupandforwardby a string; this will immediately improve your posture (and may evenbrightenyouroutlook).

8. Hold your shoulders back and take deep abdominal breaths through thenose. Shift your weight and intermittently contract key posture musclesliketheabdominalsandthemusclesofthebuttock.Stretchalittleasyoubendfromsidetosideandpullyourshoulderbladestogether.

WhenLifting:

9.Ifyoumustcarryaload,makeitlightandputitintoabackpackwornonbothshoulders.Betteryet,considerarollingcartorrollingbag.Becarefulnottogethurtwhenliftingthebagorcartintoacaroroveranobstacle.

10.Whenlifting,neverbendforwardortothesidewithyourbackbent.Topickupobjectssafely,youmustbendat thekneesandkeepyourbottomlow;lift with the legs. You won’t be ready to lift again until you’ve 1)strengthenedyourbuttockandthighmuscles;and2)stretchedoutyourcalfmusclestostabilizetheheelontheground.

11.Bend your knees and tighten your abdominals asmuch as possiblewhenlifting or shoveling. You shouldn’t start lifting or shoveling until yourrecoveryphaseiscompletedandyoufeelstrongandpain-freeforseveralmonths.Whenyouarebacktogoodhealth,usepropertechniquetoavoidnewbackproblems.Setarealisticgoalforyourself likebeingable todo20crunchesbeforepitchinginwithashovelingorliftingproject.

12.Takeabreakeveryhourandputthebacktoresttwoormoretimesaday,once a day if recovery is complete. It is important to stretch andmoveabout,especially ifyouaresitting inachairmuchof theday.Your legs,eyes,neck,lungs,andheartwillalsobenefit.

Lean back about 70 degrees to rest your back. Spine pressure is reduced by the transfer of upper bodyweighttothechairback.

DiscPressurefromActivities3,4

Lyingonback 25kg

Standing 100kg

Bendingforward

150kg

Slouchinginchair

180kg

Afullsit-up 210kg

TheTreatment

Theamountofpressureonthespinaldiscs is lowestwhenweare lyingdown.The pressure increases with standing and sitting. In the sitting position, theamountofpressuredependsonhowmuchweightiscomingdownwardsonthespine.Sowhenpeopleareinacutediscpain,theymaygrabthearmsofachairas they lower themselvesgentlydown into the seat.This reduces the transientpressurepeakthatoccursatthemomentwesitbutdoesnotchangethepressureoncesitting.

LEANBACKWHENSITTINGWhensittingisverypainful,itisbesttominimizethetimespentsitting.Once

sittingbecomespossibleagain, it isbeneficial to leanback. Ithasbeenshownthatbyleaningback,wecantransfertheweightoftheupperbodyontothechairback.Byleaningbackeven10degreesfromthevertical,itispossibletoreducediscpressuresbyasubstantialamount.Howmuchis10degrees?Thinkoftheminutehandofaclockatthreeminutespastthehour;thatisninedegreesoffthevertical.Soundssimple,right?Tryitandseeifitwillworkforyou.

LUMBARCUSHIONSBRACETHESPINE

A lumbar cushion will help to place the spine in a protective curvature andtransfer weight off of your back and onto the chair. There are a number ofdifferentlumbarcushions,andwhatfeelsgoodforyouearlyafteraninjurymaynotberightforyoulater.Yourphysicaltherapistmaybeabletosupplyalumbar

rollorMcKenzieroll,ormaybeabletodirectyoutogoodresourcesforthem.Youmayalsowanttoaskyourdoctortoprescribeone.

AHEADSETMAKESSENSE

Trygettingatelephoneheadsetifyoudon’thaveonealready.Theabilitytotalkwithoutcradlingaphoneonyourshoulderistrulyliberatingandwillchangethetoneofyourconversations!Youcanalsopositionyourselfsquaretoyourmainworkstationwhilecarryingonaconversationoransweringcalls.Tryswitchingtoalaptopcomputerifyoucan;itspositioniseasilyshifted,youcanpropituponbooks,changetheangleofthescreen,eventakeitwithyouifyouneedtoliedown.

WEARSENSIBLESHOESANDPURSES

Nothingwillruinyourbacklikecarryingaheavyload.Don’tfoolyourselfintothinking a purse is not heavy enough to cause problems. Purses are almostalwaysheldononesideortheotherandtheasymmetrycausesproblems.Thinkabout temporarily trading in your purse for a fanny pack or a stylish mini-backpack.Asaguideline,don’tcarryabagthatisheavierthanyoucanliftwithasinglefinger.Youmayneedtoholdoffontotingaroundyourlaptop,ortradein for a netbook. Even better, put the battery pack into a rolling bag whentravelling.

Wear the best athletic shoes you can afford. Consider buying shoes a sizelarger and adding in a high-density insole; several are available at your localdrugstore.Theserangeinpriceupto$20butareworththeexpenseintermsofprotectingyourbackfromtherepeatedmicro-traumaofwalkingalldayonhardfloors. Never underestimate the importance of good footwear to your overallprogramofrecoveryfrombackpain.Gettingintotherightshoeswiththeproperamount of cushioning can make a real difference. If you add inserts to yourshoes,make sure your toes and instep still havewiggle room.You can easilyidentify potential pressure points bywearing a newpair of shoes for 2 hours,then inspecting the foot for red spots. Sometimes minor adjustments can bemadeattheshoeretailerorcobbler.

Standingposture,asideview.

What’sNew:DiscsUnderPressureAlthough there has been recent controversy in terms of whether sitting discpressures are actually higher than standing disc pressures, the details areimportant.5Studieshaveshownthatslouchingforwardwhensittingincreasesdiscpressuresbyanadditional50percent.Leaningbackintotheseatbackwilltransferweight from theupper body to the seat-back andwill further reducediscpressures.

DON’TSTANDSTILL

Remember that standing is not a static activity.6 In addition to shifting yourweight back and forth, front and back, try to sit down for a fewminutes.Dosome stretches, lunges, and calf stretches if you’re waiting for someone orsomething.Amatinfrontofthekitchensinkcanrelievesomeofthestrainthatcomes with dish washing and other food prep tasks. If you have no balanceproblems, the kitchen can be a great place for stretching your leg and hipmuscles;thecounteredgemakesagreatbalancebar.Butifyouhaveahistoryoffallsorarefindingbalancetobeaproblem,bemindfulthatkitchenfloorscanbeunforgivingsurfacestolandon.

SQUEEZETHESHOULDERBLADESTOCOUNTERACTTHEHUNCH

Holdingyourarmsatyoursides,bendyourelbowssothatyourhandslevelwithyour elbows. Now pull your elbows back as if you are trying to bring themtoward thecenterof theback.Asyoudo this,yourshoulderbladeswillcometowardseachother.Gowith thisand try to tighten thesemusclesandhold forseveral seconds.Rest and repeat fourmore times.The feeling of the shoulderblades moving together occurs with the tightening of two muscles called therhomboids. Strengthening the rhomboids will help reverse the effects ofprolongedsitting,reading,andhunchingoverpaperwork.

WALLSLIDESHELPBUILDLEGSTRENGTHFORLIFTING

You should always ask your doctor and your physical therapist before youresumeliftingafteraninjury.Ifyoumust,trytoliftobjectsthatarepositionedata waist-high location. Proper lifting involves keeping the spine as vertical aspossibleandusingthemusclesofthethighsandbuttocks.Thismeansthatyouwon’tbe ready to lift until your legs are strongenough to supportyouasyoubenddowndeeply. If you are not used to this kindof bending, it canbeveryhardon theknees,butasyougetstronger, itwillbecomeeasier.Oneexercisethat is helpful in reestablishing the neededmuscles is thewall slide exercise.(Seepage103).Always remember that in order to pick upobjects safely, youmustbendatthekneesandkeepyourbottomlow;liftwiththelegs.Wheneverpossiblegethelp,andifalotofliftingisneeded,weightheadvantagesofhiringsomeonetodoit.

GetUpfor10MinutesofEveryHourAtfirst,itmaybeoverlyambitioustositfor50minutes.Ifyouhavejusthadabackinjury,youmaynotbeabletositatall.Sometimes,it’sthetransitionfromlyingtoanyotherpositionthatisespeciallypainful.Ifyouareintheveryacutestagesofabackinjury,don’tpushyourselftodomuchsitting,especiallyifitisexcruciatinglypainful.Onceyouarerecoveredenoughtositforaperiod,makesureyoulearntorecognizehowlongthisperiodmaybe.Whenpainbeginstorampup,stopsittingandnotehowlongyouwereabletositcomfortablyfor.Youmayneedtosetatimertomakesureyoudon’toverdoit.Onceyouhavemade an excellent recovery, youwill still need to take breaks every hour topreventmusclestrainandatrophy.

TheExplanation

The central purpose of ergonomics is to adapt the environment to allow foroptimal functioning of the human body, to improve people’s tolerance forsustainedactivitiesandtoallowthemtolivelargelypainfree.Thescienceofthespine is justbeginning toexplore theunderlyingmechanisms thatexplainwhyit’ssoimportanttomaintaingoodbodymechanicsallthetime.7

Thespineisheldtogetherbymuscles, tendons, joints,andligaments.Whenweslouchoverorleanforward,theligamentsthatnormallybindthebonesareplaced under strain. Yes, the ligaments will work hard to hold the spine inposition, but even 20 minutes of strain on the spinal ligaments will result inlasting overstretch of the ligament that is measurable over a day later.8 Thesignificance of the overstretched ligaments is that they lead to back musclehyper-excitability,musclespasm,andultimately,pain.

CHAPTERRESOURCES

1.Pope,MalcolmH.2004.BernardinoRamazzin.Spine29(20):2335–8.

2. Hedge, A. “Ergonomics, Anthropometrics, Biomechanics,”http://ergo.human.cornell.edu.AccessedFebruary10,2010.

3. Nachemson, A.L. 1976. The lumbar spine: An orthopedic challenge. Spine1:59-71.

4. Finneson, B.E. Low Back Pain, Second edition. Philadelphia, PA: JBLippincott,1980.

5.Claus,A.,etal.2008.Sittingversusstanding.JournalofElectromyographyandKinesiology18:550–558.

6.Boccia,F.J.MindfulnessYoga.Boston,MA:WisdomPublications,2004.

7. Hertling, D. and R.M. Kessler.Management of Common MusculoskeletalDisorders.Philadelphia,PA:LippincottWilliams&Wilkins,2006.

8. Solomonow, M. 2004. Ligaments. Journal of Electromyography andKinesiology14:49–60.

CHAPTER17BetterNights,BetterDays:SleepandIntimacy

Simple, inexpensive bedding can make sleep and sex significantly morecomfortable.

theDIAGNOSIS

>Do youwake up in themorning feeling like you’ve been run over by atruck?

>Doyouwakeupinthemiddleofthenightunabletosleepbecauseofbackpain?

>Isyourbadbackruiningyoursexlife?

Restful sleep is essential fornormalalertnessand functionduring theday.Yetpain is increasingly recognized as amajor cause of sleep disruption.Whetheryouarealife-longinsomniac,someonewhointermittentlyexperiencesdisruptedsleep, or a relative newcomer to being awake in thewee hours, youwill findhelpfulguidanceinthischapter.

Andsleepisnottheonlythingyoudoinbed.Regardlessofhowtraditionalornon-traditionala life-partnershipmaybe, theneed toexperience themutualjoysofsexualfulfillmentareindisputable.Physicalintimacycanbeawonderfulsourceofrenewalandreassurance.Ifyouhavebackpain,yoursexlifeisgoingtofacesomechallenges.Thesecondpartofthischapterwillexploresomeideasinthisarea.

thePRESCRIPTION

FORBETTERSLEEP:

•Chooseawell-constructedmattressorfutontoppedwithtwoormorelayersoffoam.Addasoftpillowandlegsupportpillowstoeasebackstrain.

•Ifyou’recurrentlyhavingbackpain,makesuretotakesomepainmedicineone to two hours before bed so that you are as comfortable as possible atbedtime.

• Engage in soothing activities before bedtime. Avoid caffeine or vigorousexerciseintheevening.

•Minimizenon-sleepactivitiesinthebedroom.Ifyoucan’tsleep,getupanddosomethingquietlyinanotherroom.

•Asmuchaspossible,restrictsleepingtothenighttimehours.

FORABETTERLOVELIFE:

•Youwillneedtogentlyletyourpartnerknowwhatworksbestandwhatyouare afraid might hurt. You may have to try out some new positions oralternativewaysofsharingphysicalpleasureinordertoavoidmakingbackpain worse. Most authorities recommend that the person with back painavoidthetopposition.1

•Usereliablestrategiesforpainmitigationbeforeandaftersex.Trytakingawarmbath or cozying upwith the heating pad ahead of time.Afterwards,youmay need to treat your backwith an ice pack. So as not to spoil thefleetingpleasuresoftheafter-glow,youcanhavethiswrappedinatoweland

handyatthebedsideevenbeforebeginning.

TheTreatment

Propersleepallowsthebodyandmindtorecharge.Youspendnearlyathirdofyourlifesleeping,soitmakessensetoinvestsometime,energy,andresourcesinto improvingyoursleepexperience.Areyousleepingonamattress thatwastop-of-the-line when you bought it 20 years ago? Has it been more than sixmonthssinceyou turnedand rotatedyourmattress?Areyouwakingup in themiddleofthenightwithachingjoints?Areyoufallingasleepduringthedayandlying awake at night? Answering yes to these questions indicates the need totakeahard lookatyour sleepingarrangements.Experiencedpeoplewithbacktroubleknowthebenefitsofapropersleepenvironment.

STARTWITHAFIRMMATTRESS

Your choice of mattress has a big impact on your ability to sleep well whenlivingwithbackpain.Youwantamattressthatisfirmenoughtoprovidegoodsupportfortheheaviestpartsofyourbody,butonethatofferssomeresiliencetoaccommodatethebody’snaturalcurves.2Aspringcoilmattressisagoodstart,butmanypeoplepreferthefeelofafuton.Eitherway,youwillneedtoaddsomecushioning at least initially during the back recovery process. When you arerecoveringfromabackinjury,itmaybenecessarytoliestillforlongerthanyouwerepreviouslyusedto—first,becauseitmaybepainfultochangepositiontoooften; second, because it may be necessary to rest your spine by holding aparticularposition;andthird,becausesleeppositionsthatyouusedtoenjoymaynotbecomfortable.

PADYOURNESTFORMOREREST

Theneedforpaddingon topofafirmmattresscannotbeunderestimated.Thenumberofpatientswhoinitiallyexpressskepticismaboutthissimplechangeisprettylarge,andthenumberwhodeliverenthusiasticfeedbackisnearlyaslarge.Infact,ifyoucandoonethingtomakeyourlifewithbackpainbetter,itistoinvestafewdollarsincushioningyourfirmmattress.Thekeyhereistogoformoreratherthanless;notmoremoney—morelayers.

Thebestthingtodoistobuyaking-sizedegg-cratestylefoampadandfolditoverafewtimesuntilitisthesizeofyoursleepingareaonyourbed.Youmaywindupwithtwo,three,orfourlayersoffoam.Themostcommonmistakethatpeoplemake is toaddonlya single layer.This isnot enough.Startbyaddingfour layers of foamand cut back if it feels too cushy.Ahigh-qualitymattress

cover will reduce the sense of limited breathability that people sometimesexperiencewhenlyingonfoammattresspads.

Abetterbed.Useawedgepilloworothersupportforyourlegs.

What’sNew:FutonsCauseMorePainRecentresearchhasshownthatsleepingonahardmattress,suchasafuton,isassociatedwithmorepain inpeoplewith lowbackpain. Ifyouowna futon,addanegg-cratestylemattresspad,foldedtocreateatleasttwolayersoverthefuton.

The secondmistake that peoplemake is to get too fancy. By this, I meaninvesting hundreds of dollars in the latest high-tech foam product available.Generally speaking, a couple of egg-crate style foam pads are better than thesuper-expensivehigh-techfoampadsandarealotlessexpensive!Theegg-cratestylefoampadswillnotlast,though;afterafewmonths,youwillwanttorotatethepiecesfromhighpressurezonesofthebody(underthehips)tootherareasandextendthelifeofafoampadforanotheryear.

Asoft,supportivepillowfor theheadandneckwillmakeiteasier tolieonyour back during the night and can be folded over if needed for side-lying.Again, amodest investmentwillmake a big difference in your nighttime anddaytime comfort levels.Test somedifferent pillows and shop for sales so thatyoucangowiththetop-of-the-lineifneeded.Ifyoudon’tlikeaparticularpillowforyourhead,youcanalwaysrotateittosupportyourlegsorarms.

While recovering frombackpain, youwill need to use a support pilloworwedgeforthelegs.Thepurposeofthissupportistoputthespineintoapositionofrest.Rememberthatduringtheday,thisinvolveslyingonthebackwiththelegs propped up on a chair or sofa. Most people can achieve this extremepositioningwhileinbedbutsomelegsupportwillbehelpful.Experimentwithdifferentarrangementstodeterminewhatworksbestforyou.Somepeoplelikejustasmallrollundertheknees,otherslikeatriangularcushionundertheknees,andyetothers like tohave theentire lower legelevated.One thing tokeep inmind is the potential for pressure points. If you are propping up the knees, itmight increasepressureon theheelsoron thebuttock.Thisdoesn’tmeanyoushould give up on a leg-supported sleeping arrangement; it just means thatfurtheradjustmentisnecessary.Yourgoalistofindasleepingarrangementthatfeelscomfortableandhealthful.

YOURSLEEPENVIRONMENT:PUTTINGTHEPIECESTOGETHER

Mostpeopleenjoysleepinginclean,softsheets.Ifyourbackpainismoresevereatthemoment,youmayneedhelpchangingthesheetsandgettingthelaundrydone.It’salwaysokaytoaskforhelp,butit’sevenmoreokayifyou’resuretoaskgraciouslyandexpressappreciation.Mostpeopleliketohelpbutmostalsoliketoknowthattheirhelpisnoted.

Youwillwant tocreateabedroomspacethat isconducivetosleep.Ideally,thereshouldnotbeatelevisionorcomputerinthebedroom.Exerciseequipmentshouldbesetupsomewhereelse.Makesurethatthereisnoexcesslightenteringtheroomduringyoursleepinghours;youmayneedtopurchasealight-blockingshadeor some room-darkeningcurtains.To the extentpossible, insist onquiet

duringsleeptimes.Youmayneedtopurchasesomeearplugs;eveninexpensiveearplugsareveryeffectiveandcanreallyhelpensuredeeper,morerestfulsleep.

Gotobedonlywhenyou’resleepy.Thismaymeanstayingupalittlebitpastbedtime,butit’sbettertohitthepillowreadytosleepthantoliedownwiththeproblemsof theworldswirlingaroundinyourmind.Sometimes it’shelpful todevelopapre-bedtimeroutine.Awarmbath,ahotcupoftea,afavoritebookofcalculus—well,maybenotcalculus—canallhelpbringonfeelingsofcalmandcomfort. There are evening yoga routines and meditation practices that helpready the mind for sleep. An evening session of Qi Gong can help clear thethoughtsandbringonasenseofserenitybeforebedtime.

Alwaysmake yourself get up on time. If you’re having trouble sleeping atnight,snoozinglateintothemorningwillonlypushtheproblemforwardtothenextnight.Ifyouaretroubledbyinsomnia,resistthetemptationtosleepinonweekends and stringently avoid daytime naps. Nothing will wreck nighttimesleeplikeanafternoonsiesta.Ifyouarenottroubledbynighttimewakefulness,napaway—butthereisagrowingsensethatpropersleeppatternsarenecessaryforoverallhealthandlongevity.

Makeconsciouschoicesduringthedaytoimproveyoursleepatnight.Thisincludesgettingsomemoderatelyvigorousexerciseeachdaybutavoidingsuchexercise in the four-to-five hours before bedtime. Cut back on caffeine oreliminate it altogether. Studies have shown that cutting out caffeine not onlymakes it easier to fall asleep, but lengthens sleepduration and improves sleepquality.3Drinkalcoholonly inmoderationandavoid italtogetherwhile takingmedication for back pain. Although coffee liqueurs are popular with youngerdrinkers,theyhavedisastrouseffectsonsleepinitiationandmaintenance.

IntimacywithBackPain

Keepingintouchwithyourintimatepartnerduringanexperienceofbackpainisalso important to getting better quickly. Modern strategies for coping withpersistentpain recognize the importanceof incorporatingpleasurable activitiesinto everyday life.4 Sex is an important part of how adults play and findenjoyment.It’simportanttodowhatyoucantokeepthisapositiveforceinyourlife.

However,acutepaincan interferewithaperson’ssexdrive.So ifyou’re inthe midst of a severe bout of back pain, don’t expect miracles. If you arereceiving treatment with prescription medications for chronic back pain, beawarethatmanyofthesemedicationscaninterferewithlibidoandperformance.Thismay be a good reason to pursue the non-pharmacological approaches to

treatingbackpainmoreaggressively.

FloatonaWarmWaterBedIfyoulovethefeelofawaterbed, this isanotheralternativeforpeoplewithback pain. However if you’re not used to this kind of mattress, it can bedifficult and intimidating to get into and out of.Water mattresses are oftentemperature controlled, making it possible to benefit from some thermaltherapywhilesleeping.

PACEYOURSELF

The first part of pacing for better sex is to knowwhen to jumpback into thegame.Ifit’stoosoontoreturntoheavyaction,yourbodywillletyouknow.Onewaytogetbetterresultsistoslowdownandenjoyeachmomentasithappens.Watch a movie together; sit a little closer than usual, try massaging yourpartner’sshouldersorfeet.Allofthesethingscanbringyoutogetherandletyouacknowledge the importance of staying physically connected while makingadjustments forbackpain.Partofpacing ismakingsure thatyou’reallocatingenoughtimeforsextohappenataneasypace.Thiscanbedifficultwithwork,school,family,andfriendsallcompetingforyourtime.Don’tletyourlovelifebethevictim.

Anticipation is where much of the most intense pleasure in life is found.Thinkbacktoyourchildhoodyears.Theincredibleyearningthatprecededyourfavorite holiday or a special birthday, the happy anticipation of knowing thatsummervacationwascomingat last.Especiallywhen trying to adjust tobackpainor tolivethroughanepisodeofbackpain,buildingontheanticipationofsex isapain-freeway toextend theenjoymentofyourexperience.Ofcourse,anticipationisreallyonlyfunformostpeopleifthereisagenuinerewardintheend,soit’s importantnot tooverextendtheanticipationphaseandendupwithempty exasperation. Anticipation and fulfillment are both important for mostpeople.

MEANINGFULWORDSANDACTIONS

Weallhavespecialsignalsortriggersthatspeakmostclearlytous.Somepeopleloveagoodstronghug,othersdeeply relishacupofcoffee in themorning, ahome-cookedmeal, or tickets to the new show in town. In life, it’s criticallyimportanttoknownotonlyyourowndeepestdesiresarebutalsotounderstandthe inner heart of your intimate partner. Is this someone who comes homeexhausted andwould love 15minutes to lie down before starting the eveningtogether,oristhisapersonwhogetshomereadytorunfulltilt?Isthissomeonewhogetsathrillfromseeinganewoutfit,or is theoldandfamiliarbetterandmoreattractive?Arewhisperedsentimentsofaffectioncloyingorthestartofanexciting night together? The key to increasing happiness in a relationship isunderstandingwhatyourpartnermostdeeplyvaluesandbringingthatforwardtotheextent thatyoucan.Makeeverymoment reallycountby speaking toyourpartnerinwordsandactionsthataremostmeaningful.Youwilladdlifetoyouryears.

AMPITUPWITHFANTASYORSCENTS

Addinganelementoffantasytoyourintimaterelationshipisagreatwaytohavefunasadults.Youcandothissimplyandwithalight-heartedtouch.Theidealisnottohavetheotherpersonfulfillyourfantasybutrathertosparkanewseriesof imaginationsthatarisespontaneouslyforbothofyou.Whatworksbestwilldepend on you and your partner. Some people aremore responsive tomusic,otherstofood,andstillotherstoclothing.Itisoftensaidthatvarietyisthespiceof life, but playful variations of the familiar are where greater enjoyment isfoundformostpeople.

Pleasing scentscanplayan important role increatingmoodandsetting thepace for an intimate encounter.The fragrances that stimulatemale and femaleresponsesarenotalwaysthesame.Lavenderhasbeenshowntocreateastateofrelaxationandarousalforwomen.Menmayrespondmorestronglytothescentsofvanillaandorangeaspositivesignals.Youcanincorporatescentsinyourlovelife in many different ways: perfumed massage oils, scented candles, sachetstucked into a pillow case, as a soothing bath beforehand, or the recentlypopularizedroomfragrancesprays.Alittledabofessentialoilontovariouspartsofthebodycanhaveapowerfulpositiveeffect.Musiccaneithersoothorinspirethe object of your desire; consider creating a bit of ambiencewith your lovedone’sfavoritetunes.

SAFEPOSITIONSFORACHINGBACKS

Theactualdoingofsexualintercoursemayrequiresomeadjustmentsduringanepisode of back pain.5 The ordinary activities of intercourse can involvemovements of the spine and pelvis that are frankly pain-provoking and maymake thingsworse rather than better. It is generally held that the personwithbackpainshould take the lowerposition. Ifyoucanarrange thingsso that thespine is supported as you lie on your back, this is usually ideal. A pillowunderneath the buttocks can be supportive while further improving themechanicsabit.6Agoodalternativeformanypeopleistostartwiththepersonwho has back pain taking up a side-lying position. This can accommodate avarietyofrelativepositionsfromthepartner.Womenwhoareexperiencingbackpainwilloftenfindthataposteriorentrypositionismoreproblematicbecauseofthe extension or arching of the spine that this entails. When returning tointercourseafteranepisodeofparticularlyseverebackpain,beginslowlyatfirstand limit encounters to relatively shorter sessions until experience shows justhowmuchactivityistolerablewithoutprovokingpain.Considerresearchingthisareaabit,asthereareseveralrecommendedbooksonthemarket.

PREPARATIONANDRECOVERY

Youmaywanttoprepareaheadoftimewithahotshower,warmbath,ora20-minute session with the heating pad. This will have the effect of increasingrelaxation,looseningupthenecessarymuscles,anddecreasingpain.Afterwards,itisusuallyagoodideatotreatyourbacktosomeice.Sexisoftentimesjustlikehavingagoodworkout,intermsofthephysicaldemandsthatareplacedonthebackandspine.Treatitlikeyouwouldanyotherphysicalexertion.Anicepackwrappedinclothappliedtothebackwillmakeyourmemorieshappyonesanddecreaseyourchanceofpersistingpainafterwards.

TheExplanation

It’s a catch-22: painwill disrupt sleep, and disrupted sleepwill amplify pain.More and more studies are showing that getting pain under control is veryimportant to reduce sleep disruption in a lot of people with ongoingmusculoskeletalproblemssuchasarthritis.Disruptedsleepalsointerfereswithaperson’scapacitytocopewithpainandmakegooddecisionsabouthowtobestmanageanongoingpainproblem.

Mostpeopledonotgetsufficientsleep.Thenormalamountofsleepneedediseight hours.Most of us are running around getting substantially less. This isbecausewebudgeteighthoursintoourbusyscheduleforsleep,whichmakesthefalseassumptionthatsleepbeginsimmediatelyuponlyingdownandendsattheprescribed moment in the morning. To the extent possible, you should allowmore time for sleep rather than less. Especiallywhen recovering from a backproblem,yourbodyneedstimetoheal.Themorechancesyoucangiveyourselftogetagoodnight’srest,thebetteryouwillbeoverall.

CHAPTERRESOURCES

1.White,A.A.andA.E.White.BackCare,2ndEdition. Issaquah,WA:MedicPublishingCo.,1996.

2.Bergholdt,K.,etal.2008.Betterbacksbybetterbeds?Spine33(7):703–708.

3. Sin, C.W., J.S. Ho, and J.W. Chung. 2009. Systematic review on theeffectivenessofcaffeineabstinenceonthequalityofsleep.JClinNurs18(1):13–21.

4. Otis, J.D. Managing Chronic Pain, A Cognitive-Behavioral TherapyApproach.NewYork:OxfordUniversityPress,2007.

5.Maigne,J.Y.andG.Chatellier.2001.Assessmentofsexualactivityinpatients

withbackpain comparedwithpatientswithneckpain.ClinOrthopRelatRes385:82–7.

6.White,A.A.andA.E.White.BackCare,2ndEdition. Issaquah,WA:MedicPublishingCo.,1996.

Q&AwithDr.Murinson

IfIcan’tsleepbecauseofmybackpain,shouldItakeasleepingpill?

Manypeoplehaveturnedtomedicationstoimprovesleep.Youwillnoticethatnoneof the recommendations in this chapter include anything about drugs forsleep.Asarule,drugsforsleepareatemporarysolution.Theyarealso,byandlarge, a bandage over a problem that really needsmore serious fixing. If youmustaskyourdoctorforsleepmedicines,doso,butrecognizethattakingapillbeforeaddressingthefundamentalsofgoodsleephygieneisafool’swager.Askyourself about the quality of your sleep; see if you really feel better the nextmorningaftertakingasleepingpill.Ifnot,startmakingbetterchoicesthatallowfornaturalsleeptooccur.

CHAPTER18MassageandAcupunctureforBackPain

Highlyeffectivetherapieswithoutthesideeffectsofmedication.

theDIAGNOSIS

>Doyouhavechronicmuscletensioninyourback?>Areyouwalkingaroundfeelinglikeyou’rejustnotyourselfanymore?

Ifyouansweredyestothesetwoquestions,therearetwothingsyoushoulddorightaway:1)undertakea trialofmassageand/oracupunctureand2)fixyourdailyergonomics(Chapter16).

Massage and acupuncture usually don’t get the credit they deserve aspotentially effective therapies without the side effects of most medications.Massage especially is generally safe andwill result in almost immediate painrelief. Acupuncture is also widely practiced and usually requires significanttrainingonthepartofthepractitioner.Still,insomeplaces,peoplecanbecomelicensed inacupuncturewithonly200hoursof training(fiveweeksfull time),butobviouslyittakesalotlongertobecometrulyskillfulatthistechnique.Topursueacupuncture,youwillwanttostartwitharecommendationfromsomeonelocalwho’shadgoodexperiencewiththistreatment.

thePRESCRIPTION

More and more people are looking to alternative therapies as a way tocircumvent the potential problems that come with medication and surgery.Amongthemosteffectivetreatmentsaretriggerpointmassageandacupuncture.Other therapiessuchascranial-sacralmassageandmyofascial releaseareverypopularinsomelocales.•Ifyouhaven’ttriedbackmassageforyourbackpain,makeanappointmentwithaqualifiedmassagetherapistinyourareaandgiveitatry.

• Check out a book on trigger point techniques. The best available is ClairDavies’s Trigger Point Therapy Workbook. Other books include SimeonNiel-Asher’s beautifully illustrated paperback guide and Travell andSimons’s encyclopedic work, but few match Davies for clarity andinclusiveness.1,2,3

• Call your insurance company to determine if it will provide coverage formassageoracupuncture. Insurancecoverageforalternative therapiesvarieswidely. Some larger companies include acupuncture in their range ofbenefits;somestatesevenrequire thiscoverage.Checktomakesurethatafailure to meet pre-conditions for coverage, such as obtaining a doctor’sprescription,won’tpreventyoufromgettingtheclaimpaid.

• Ask your friends and family if they know someone who performsacupuncture and what their experience was like. Although the thought ofhavingacupunctureneedlesinsertedcanbeabitintimidating,theneedlesarealways sterile and precision manufactured to produce as little pain as

possible. Most of the time, there is very little pain associated with theacupuncturetreatmentitself.Sometimesamildburningsensationisall thatisfelt.

• Consider trying acupressure. Acupressure uses self-massage techniques tostimulatetheflowofQi(energyinthebody)bypressingparticularpointsonthebody.Onemethodofacupressureforreliefofbackpainisdescribedinthischapter,butyoumaywanttoconsultaspecialisttolearnmore.

HowLongWilltheBenefitsLast?Youmayhaveheardfromnaysayersthatmassageonlyhelpsforalittlewhile,andthenextdaythepainwillbeback.Thismightbetrueinsomecases,butforcertainproblems—suchas suddenmuscle injury fromacaraccidentorasportingmishap—massagecanfixtheprobleminoneorafewsessions.Someconditionssuchasspinaldegenerationormusclespasmcompoundedbynervecompressionmaytakelongertoaccruelastingbenefits.

Askyourmassagetherapistoracupuncturistiftheyhaveanyrecommendationstoensurethemaximumbenefitfromtherapy.Manytimesit’sprudenttotakeashortnapandgoeasyfortherestoftheday,butsometimesthisisn’tpractical.Ifyourmassageoracupuncturetreatmentsdon’tseemtobeworkingthewayyouthinktheyshould,makesureyou’refollowingthroughaftereachsessionandnotjustjumpingbackintoyourlifeatbreakneckspeed.

TheTreatment

There aremany options formassage therapy, including trigger pointmassage,myofascial release, cranio-sacral work, and acupressure. Acupuncture is anancientEasterntherapythatcontinuestomakeinroadsintheWest.Massageisespeciallyhelpfulinthefirstfewweeksofapainproblem,asitcaninterrupttheviciouscycleofpainleadingtospasmleadingtomorepain.Oncethemusclesarerelaxedviamassage,normalbloodflowcanreturnandhealingcanresume.

Referredpain.Triggerpointmassagehelpsrelievetensioninyourback.

TRIGGERPOINTMASSAGERELEASESTENSION

If your doctor recommends a trial of massage for your back pain, seek outsomeone skilled in trigger point methods. You may find that your physicaltherapistisalreadyusingtheseapproachesonyourback.Triggerpointmassageis an offshoot of one of the most effective approaches to addressingmusculoskeletalpain:triggerpointtherapy.

You can take one of two approaches to trigger pointmassage: let someoneelsedoitordoityourself.Triggerpointtherapyforthebackisabittrickyforthe newcomer, although there are products such as the “theracane” that aredesignedtomakeiteasytogettoinaccessiblepointsontheback,lowerleg,andshoulders. One low-tech approach that works well is to put one or tworacquetballballsintoasockanddanglethesockbehindyouasyoumovebackand forth against a wall.4 These D-I-Y approaches will probably work betteronceyou’vehadachancetolearnabouttriggerpointsandbecomefamiliarwiththebasicprocessthroughtheexperienceofreceivingprofessional triggerpointtherapy.Althoughpractitionerswilluseavarietyoftechniquestoreleasetriggerpoints, including theuseofacupunctureneedles, injectionof localanesthetics,andsprayingwithafreezy-coldaerosol,youcanactuallylearntoapplypressuretothemuscleandtrainyourselftorelaxthemusclesoncue.Thepressureitself,whencorrectlyapplied,will inducea relaxation response in themuscle triggerpoint.

Trigger pointswere described byDr. Janet Travell as having four essentialfeatures: 1) a palpable tight band within the muscle, 2) a focused spot oftendernesswithinthetightband,3)reproductionofpaininanearbypartofthebodywhen the tight band is compressed by pressure from the fingers, and 4)relaxationof the tightbandwithpropermassage technique.5Once someone istrainedtofeeltriggerpoints,itbecomesimmediatelyapparentthatmanypeoplearewalkingaroundwithtriggerpoints,someofwhichproducepainandothersthatdon’tseemtobebothersomeatall.Thenon-bothersometriggerpointsarereferredtoaslatent,andthetriggerpointsthatproducepainarecalledactive.6

One featureof triggerpoints is that theyarenotonlypainfuldirectlywhenpressedupon,buttheyalsoresultinpainatadistance.Thisisprobablybecauseof thewaymuscles travel fromone part to another, as the hamstringmusclestravelfromhiptoknee,butmayalsohavetodowithotherfeaturesofthebody’spain sensing system. This sets trigger points apart from an ordinary musclespasm.Forexample,a triggerpoint in thecalfcanproduceankleorfootpain.Thismaybebecausethatcalfmusclehasatendonthatextendsintothefootbut

couldhavetodowithnervecompressionsorotherproblems.Asyoulearnaboutyour back, you will come to know that many of themuscles in the back areassociated with pain that’s actually in the muscle. One back muscle, thequadratuslumborum,connectsthetopofthehipbonetotheribcage.Itstriggerpointpainsyndromeresultsinsacroiliacpain.

MYOFASCIALRELEASELOOSENSFIBROUSCONNECTIONS

Myofascial releasemassage isbasedon the idea that fibrousconnectionsbuildup between adjacent tissues that are not subjected to full and vigorousmovements. Over time, these fibrous connections progressively tighten andshorten.Thisprocessleadstoworseningstiffnessandrestrictionsinmovementthatcanleadtoabnormalmovementpatternsbecomingentrenchedandleadingto chronic pain.8 The overall objective of myofascial release massage is torelease these fibrous connections, leading to freer, fuller, and less painfulmovements. This is accomplished through a serious of kneading, rolling, anddeeppressuremovements.Myofascialreleasemassagecanfeelabitstrangeasitfocusesonthe“spacesbetweenthemuscles”ratherthanworkingonthemusclesthemselvesatsomephasesofthemassage.Itmaybecombinedwithotherformsofmassage,butcanhavetremendouslybeneficialeffectsinandofitself.

Thewordmyofascialisderivedfromacombinationofmyo,meaningmuscle,and fascial,meaning fascia. Fascia is a fibrous connective tissue in the body.Fine andweblike in some places, fascia can also be very strong and tough insomepartsofthebody.Fasciahasbeendescribedasbeinglikeplasticwrap,inthatitisnormallyniceandsmooth.9Whenonesectionofthefasciaisentrappedby abnormal fibrous attachments to a body part (muscle, internal organ, etc.),thisproducesadistortioninthefasciathattugsorpullsonanotherbodypartandwillrestrainnormalmovements.Painistheinevitableresult.Myofascialreleaseuses a series of pulling or stretching movements to loosen these abnormalfibrousbands.Asusuallypracticed,itrequiresthetherapisttolistencarefullytowhat his or her hands perceive and to adjust the treatment to address eachperson’stroublespots.

What’sNew:RecognitionofPulsatingSpinalFluidTherehasbeenlittlesupportforcranio-sacraltherapypublishedinthestandardmedical literature.7 However, most medical practitioners have been slow torecognizethatthereisapatternedflowofspinalfluidthroughthecentralspinalcanal.Further,thefactthattheflowofspinalfluidispulsatilehasonlyrecentlybeenmorewidelyacknowledged.

Rolfingisastructuredapproachtomyofascialreleasethatleadstoastateofstructural integration.10 The goal of rolfing is to correct abnormalities inmusculoskeletal alignment and reorient thevariousbody segments so they arealigned with the earth’s gravitational field. Once upon a time, rolfing wasconducted inaveryvigorousmannerand theresulting therapyexperiencewassometimes painful, although with good results. More recently, rolfingpractitionershavefocusedonaccomplishingthegoalsofmyofascialreleaseandstructuralre-alignmentinamoretolerablemanner.Ingeneral,rolfingfollowsaspecificsequenceof techniques tosystematicallyreleasemyofascialadhesions,beginningwiththefeetandworkingupwardsthroughvariousbodyparts.

Warning!JellyMayRoll

Makesuretocheckwithyourmassagetherapistaboutrecommendationsfor activity after myofascial release massage. Following a vigoroussession, you may be a little more loosely held together than usual.Vigorousorespeciallyeffortfulactivitiesmayresultininadvertentmusclestrains as your movement patterns will shift immediately after thistreatment.

CRANIO-SACRALMASSAGEMANIPULATESTHESKELETON

Cranio-sacraltherapyaroseattheturnofthetwentiethcenturyoutofapostulateabouttherelativemotionofskullandsacrum,andideasabouttheflowofspinalfluidthroughthebrainandspinalcord.Theideathatthebonesoftheadultskullcan move and are subject to manipulation is inconsistent with publishedresearch.Yetcranio-sacraltherapyappearstobesafe.Itisperformedusinglighttouch while a person is resting, fully clothed, on the back. Through gentleapplicationofpressureand re-positioningof thehead, shoulders, spine,pelvis,hips,andback,thecranio-sacraltherapistseekstore-establishsubtlerhythmsofthebody.

ACUPRESSUREMASSAGEINCREASESTHEBODY’SENERGY

Acupressure massage utilizes the philosophy of energy (Qi) from Chinesemedicine to map out a series of pressure points on the body that, whencompressedproperly,arebelievedtostimulatetheflowofQi.Originatingmorethan 5,000 years ago, acupressure actually was practiced before acupuncture,which required the development of needles, and more recently, electricalstimulationmethodologies.11 The location of acupressure points is establishedbasedonaseriesofmeridiansthatmapouttheflowofQithroughthebody.12

Acupressure is widely used for the treatment of back pain. Severalapproachescanbeused.Onepopular techniqueforbackpain involvesplacingpressure on a on a spot located on either side of the spine at about thewaistlevel.Thispoint is sometimes identifiedas theB23spot.13Youcan locate thespot as follows:Sit upright on the edgeof a chair or standwith feet shoulderwidthapart.Holdoutyourhands,palmsidedownwardswiththethumbstickingoutfromthehand.Nowpositionyourhandssothattheyaretouchingyourwaistoneitherside,yourthumbshouldbelightlytouchingyourbackandyourelbowsstickingouttotheside.Moveyourhandsclosertothemidlineofyourback,stillholding them in the palm-down position, until your thumbs are about threeinchesapart fromeachotheroneithersideof thespine.You’vebeenapplyingverylightpressuretotheskinwiththethumbsuntilnow.Atthispointyouwillincrease the pressure that the thumbs are applying by pressing your elbowsbackwardandarchingthebackgently.Inapplyingthispressure,youshouldnotfeelpainofanysignificance.Youmayfeelthatthemusclesunderlyingtheskinarefirmorsoft;thepressuremaybecompletelypainlessorfeelasthoughthereissometension.Holdthispressureforseveralseconds,ortwotothreeminutesifit seems helpful. A similar technique is described in Lee Holden’s book 7

MinutesofMagic:TheUltimateEnergyWorkout.14 Ifyourbackpainworsenswiththisprocedure,stopimmediately.Thisdescriptionshouldnotbereadasarecommendationofmedical therapy inanysense,and isprovidedhereonly toopen up new possibilities in your self-management of back pain. You shouldalways have your back pain fully evaluated for serious causes by a qualifiedhealthprofessional.

SWEDISHMASSAGEUSESRELAXINGSTROKES

Swedishmassage(sometimescalledclassicalmassage)isatraditionalmassagemodality that uses specific massage strokes to produce an overall sense ofrelaxation and well-being. There are five types of massage strokes used inSwedishmassage, ranging from fingertip pressure to deep, kneading pressure.Everyoneisalittledifferent,andyoumayfindthatSwedishmassageisrightforyou.

ACUPUNCTURESHIFTSTHEBODY’SENERGYFLOW

Acupuncturehasgenerallygainedacceptanceasapotentiallyhelpful treatmentforavarietyofdisorders,chiefamongwhichisbackpain.Surveyshaveshownthatmore than threemillionAmericanshaveusedacupuncture in the lastyearandthatthisisincreasing.15Itcouldbethetopicofaverylongbook(orseveralbooks),butafewwordsherewillhavetosuffice.

AcupunctureisbasedontheEasternbeliefsystemofshiftingenergyflowsinthe body. The energy flows are organized intomeridians that run through thelimbs and torso and aremainly named for various internal organs: lung, largeintestine, stomach, spleen, heart, small intestine, bladder, kidney, pericardium,gallbladder,liver,andtriplewarmer.16Thesetwelvemeridiansandanadditionaltwochannels(theconceptionvesselandthegovernorvessel)make14intotal.

TheMiracleBallThe miracle ball is a product designed to apply just the right amount ofpressure to the body. The idea behind the miracle ball is that in order forpressuretowork,ithastohavenotonlytherightfirmness,butalsotherightgeometry.Themiracleballattemptstosolvebothofthesechallenges.Usuallyprovidedasapair,theyareaboutfourinches(10cm)indiameterandmadeofresilientplastic.Whenproperly inflated, themiracleballs are fairly firmandcansupporttheweightofthebodyasyoulayonthem.Theballscomewithaguidebook,whichisveryhelpfulintermsofdescribingthedifferentwaysinwhich the balls can be used for relief of neck and back pain.Mid-back andsacroiliacpainmayalsorespondtotreatmentwiththemiracleballs.

Inmodernpractice,verythin,sterileneedlesthatareprecisionmanufacturedareinsertedintothebodythroughtheskin.Thesensationofacupuncturevarieswiththetreatmentplanandtheinsertionsite;however,theactualplacementofneedles canbepainless.Thenumberof needlesusedwill varybut one aspectthatstrikesWesternersasunusualistheemphasisonplacingneedlesindelicatestructures such as the outer ear and the nose. Although acupuncture can beperformed while the patient is seated when appropriate, most of the timeacupunctureiscarriedoutwhilesomeoneislyingdown.

What’sNew:BeliefinAcupunctureMattersThescientificevidenceinsupportofacupunctureispatchy.Therearestudiesthat claim to show a benefit for specific conditions, such as dental pain andarthritisoftheknee,andthenthereareotherstudiesthatshownobenefitatall.One recent study of back pain showed that acupuncture was better thanplacebo,butitalsoshowedthatsimulatedacupuncturewashelpfulandnotanyworse than the real thing.18 Several studies have indicated that the patient’sexpectations foracupuncturehaveamajor impacton theoutcome.19Put intoplain language, if you think itwillwork, it probablywill.For some itmightseemlikeanexpensivesugarpill,butforthosewhobelieveinacupuncture,thepainrelievingeffectsarephenomenal.

TheExplanation

Althoughtheuseofmassageforthetreatmentofbackpainisoftendismissedasunproven,ineffective,orsoftscience,massageplaysanimportantroleformanypeople with back injury or back pain.17 Its value depends on at least threefactors:thenatureofthebackproblemitself,thepersonalityandinclinationsofthepersonwiththebackproblem,andthetypeofmassagethatisbeingusedfortreatment.Formassagetobesuccessful,allthreefactorshavetobealignedwitheachotherandtheskillofthemassagetherapistaswell.

Asafirstpoint,mostbackproblemswillnotbeworsenedbymassage,buttheexceptions to this rule are quite serious andwhen unrecognized could lead toconsequences as serious as spinal cord injury and permanent nerve damage.Conditions such as fracture of the vertebra or spinal abscess should not betreatedbymassage,asthiscouldeitherworsenthedamageorneedlesslydelayessential treatment. These caveats aside, themanagement ofmost back injuryproblems will be complemented and even greatly enhanced by massage. Thereasonforthisissimple:evenbackproblemswhicharenotprimarilymuscularto begin with often evolve to have a component of muscle spasms as asignificantsourceofpainanddisability.

CHAPTERRESOURCES

1.Simons,D.G.,J.G.Travell,andL.S.Simons.TravellandSimons’MyofascialPainandDysfunction:TheTriggerPointManual.2ndEdition.Baltimore,MD:Williams&Wilkins,1999.

2.Niel-Asher,S.TheConciseBookofTriggerPoints,RevisedEdition.Berkeley,CA:NorthAtlanticBooks,2008.

3. Davies, C. The Trigger Point Therapy Workbook. Oakland (CA): NewHarbingerPublications,Inc.,2001.

4.Ibid.

5.Wilson,V.P.2003.JanetG.Travell,MD:Adaughter’srecollection.TexHeartInstJ30(1):8–12.

6.Shah, J.P., et al. 2008.Biochemicals associatedwithpain and inflammationare elevated in sites near to and remote from activemyofascial trigger points.ArchPhysMedRehabil89(1):16-23.

7.Downey, P.A., T. Barbano, R.Kapur-Wadhwa, J.J. Sciote,M.I. Siegel, and

M.P.Mooney.2006.Craniosacraltherapy:Theeffectsofcranialmanipulationonintracranialpressureandcranialbonemovement.JOrthopSportsPhysTher36(11):845-53.

8. Finley, J.E. “Myofascial Pain,” eMedicine.http://emedicine.medscape.com/article/313007-overview. Accessed January, 242010.

9. Manheim, C.J. The Myofascial Release Manual. Thorofare, New Jersey:SLACKInc.,2008.

10. Rolf, I.P. Rolfing: Reestablishing the Natural Alignment and StructuralIntegrationof theHumanBodyforVitalityandWell-Being.Rochester:HealingArtsPress,1989.

11.Gach,M.Acupressure’sPotentPoints.NewYork:BantamBooks,1990.

12. NIH. “Acupuncture for Pain,”http://nccam.nih.gov/health/acupuncture/acupuncture-for-pain.htm. AccessedJanuary,242010.

13. Averoff, S.E. Acupressure and Reflex Points for Common Ailments,http://www.lind.com/quantum/acupoints%20for%20good%20health.htm.AccessedJanuary,242010.

14.Holden,L.7MinutesofMagic.NewYork:PenguinGroup(USA)Inc.,2007.

15.Burke,A.,D.M.Upchurch,C.Dye,andL.Chyu.2006.AcupunctureuseintheUnitedStates:FindingsfromtheNationalHealthInterviewSurvey.JAlternComplementMed12(7):639-48.

16.Hecker,H.-U.,A.Steveling,E.Peuker,J.Kastner,andK.Liebchen.ColorAtlasofAcupuncture.NewYork:Thieme,2001.

17.Furlan,A.D.,M.Imamura,T.Dryden,andE.Irvin.2009.Massageforlowbackpain:AnupdatedsystematicreviewwithintheframeworkoftheCochraneBackReviewGroup.Spine(Phila.Pa,1976)34(16):1669-84.

18.Cherkin,etal.2009.Arandomized trialcomparingacupuncture,simulatedacupuncture,andusualcareforchroniclowbackpain.ArchInternMed169(9):858-66.

19. Kong, J., et al. 2009. An MRI study on the interaction and dissociationbetween expectation of pain relief and acupuncture treatment.Neuroimage 47(3):1066-76.

20. Wasan, A.D., et al. 2010. The Impact of Placebo, Psychopathology, andExpectationsontheResponsetoAcupunctureNeedlinginPatientsWithChronicLowBackPain.JPain[Epub].

Warning!NewNeedlesRequired

Acupuncture is generally very safe, and the major risks of infection orperforation of a major organ are rare.20 Because re-using acupunctureneedlescouldresultinthetransmissionofseriousillnesses,itisimportanttoreceiveacupuncturefromareputablepractitionerandtobecertainthatthe needles used on you are coming from a freshly opened (sterile)package.

Q&AwithDr.Murinson

ShouldIusemassageoil?

There aremanydifferent commercially available oils, creams, and lotions thatcanbeusedformassage.Inmostcases,youwillwanttoperformmassagewithsomethingtoease thepassageof thefingersandhandsover theskin.Thefirstcriterion for choosinga lubricant is that it notbe irritating.Everyone’s skin isslightly different, and you may need some trial and error to determine whatworksbest.Ifyouseerednessorrashorexperienceburningafterusingacertainproduct, discontinue its use right away. Mineral oil is a petroleum-derivedproductthatispartofmanycommerciallyavailablecreams,lotions,andoils.Ifyouwant to use something plant-based instead, sweet almond oil is a popularchoicethatisoftenavailableinhealthfoodstores.

Thesecondcriterionforchoosingamassageproductisgoodaesthetics.Itisimportanttonotehowtheproductsmellsandhowitfeelsontheskin.Nowhereisthesaying“oneman’strashisanotherman’streasure”moretruethanwhenitcomes to scents and fragrances. Popular choices include floral scents such asrose, jasmine, or lavender. Herbal scents such as rosemary, menthol, andeucalyptus can give a refreshing feel, and food-based aromas such as vanilla,nutmeg,andorangearesoothingtosomepeople.

Thematerialshouldfeelsmoothandsoothingontheskin.Somepeoplepreferaproductthefeelsinvisible,inthatverylittleperceptibleawarenessofthecreamor lotion is felt. There aremany products thatwould like to assert a potentialhealthbenefit,but inmostcases theseclaimsare tightlyregulated.Asidefromover-the-counter medicinal creams (such as those containing aspirin-relatedmedications and possibly menthol) typically used for sports injuries, there islittlesolidevidencetosupporttheuseofspecificadditivestomassageproducts.Thatsaid,mentholdoeshaveaprovencapacitytointerferewithpainsignalsandmay be very helpful for some people in relieving their pain. Oregano is verypopularwith somemassage therapists, but oreganooil canbedamagingwhenundiluted and care is needed. Lavender oil has been shown to contain manyactivecompounds,someofwhicharenotedtopromoteastateofrelaxationandpain-relief, andothers that have anti-inflammatory effects.Eucalyptus oilmayalsohaveactivepain-relievingproperties,butfurtherstudiesareneeded.

CHAPTER19MeditationandMind/BodyTherapiesforPain

Control

Focusthemindtorelievebackpainandmovetowardsphysicalwellness.

theDIAGNOSIS

>Doyousometimesfeelthatbackpainisruiningyourabilitytoenjoylife?> Do you sometimes feel that life is spiraling out of control since youdevelopedbackpain?

ListentoYourBodyMaybeyou’vehadthefeelingthatyourbackisalittlebetterwhenyou’reonvacation,butyouhaven’twantedtotellanyoneincasetheywouldthinkyourpainisallinyourhead.Itdoesn’tmeanthatatall—itjustmeansyourbodyistryingtotellyousomethingaboutyourlife,andthemessageis:It’stoomuch,slowdown!

Meditationandothermind-bodytherapiesareonewaypeoplecantakechargeoftheirownhealthandwellness.Ultimately, thehealthcarechoices thatwemakeare an expressionof ourdeeplyheldvalues.Unfortunately,manypeoplehavethe experience that the regular healthcare system is too strongly focused onillness as a state of being, and is designed to generate revenues and not topromote health. This state of affairs is demonstrated by the willingness ofinsurers to pay $20,000 or more for surgery, but not one cent for massage,meditation,orotheralternativetherapies.Butdon’tletthisbethefinalarbiterofrightandwrong.Thechoiceisyours;youhavethisbookinyourhands,andthischapter is written to open your awareness to a healthy new life beyond backpain.Ifyouwanttomakepeacewithyourback,readon!

thePRESCRIPTION

Oneofthebestwaystosuperchargeyourrecoveryfrombackpainistopursuehealth-directed therapies that will reorient your mind’s eye toward physicalwellness and connect you to people exuding energy, vitality, and enthusiasm.Especially if other therapies have failed to fix the problem, it’s time to startthinkingoutsidethebox.•Learnmoreaboutmeditationandmind-bodymedicine.Beginwithatriptoyourpublic library to findbookson the therapiesdescribed in thischapter.Youcanalso find informationonline.TheNIHhascreateda seriesof factsheetsonalternativetherapies.

•Begintomeditateorreinvigorateyourpractice.• Talk to your doctor, other healthcare providers, friends, and family aboutmind-bodytherapies.Theiropennessmaysurpriseyou.

•SeekoutamovementtherapyspecialistandtakeafewlessonsinAlexanderTechnique,Feldenkrais,orQiGong.

• Consider trying an energy-based therapy such Reiki, which manipulates aperson’senergyastheyremainpassive.

•Askyourself:Isself-hypnosisisworthatry?

TheTreatment

Most of the therapies described in this chapter are safe, although for some,question marks remain as to their effectiveness. I will try to point out thelimitationsofeach.Inrealitythough,asmanyofthesetherapiesrequirearather

profound level of personal commitment, persistence, and openness to newexperience,itwillbeverydifficulttocarryoutstudiesthatdefinitivelyproveabenefit.Butagain,thechoiceisyours.Formanypeople,alifecenteredonmind-body awareness and therapies is a path to peace, happiness, and trueproductivity.1

WhatYouNeedtoMeditate•Quietspace•20–45minutes•Comfortableposition•Astateofwakefulness•Apreferredmethod

MeditationHasProvenBenefits

If meditation were a drug, your doctor would be recommending it, yourinsurance company would be paying for it, and millions of people would betakingit.2,3Butmeditation isnotadrug; it isa techniqueyoucanmasteronlywith determination and effort. There aremany approaches tomeditation. Thekey is to start nowand remainopen-minded about thebenefits until youhavetried more than one kind of meditation. Although most practitioners andresourcesadvocatemeditatingoneormore timesaday, it ispossible toobtainbenefitsfrommoresporadicmeditation.

The basic principle of meditation is to focus the mind to the exclusion ofintrusive thoughts.4Thiscaneitherbedone throughdirectingallattention toaparticularthought(concentration)orbyintentionallydirectingallattentionawayfrom particular thoughts (mindfulness). The efficacy of meditation in clinicaltrialsvaries,butseveralstudieshavereportedthebenefitsofmeditativetrainingforbackpain.Inonestudy,eightweeksofmeditation-basedtherapywasnearlyequivalent to eightweeks of physical therapy in reducing pain and improvingqualityoflife.

The space you chose for meditation is important. It should be as quiet aspossible, although some natural background noise is okay. Calm breezes anddistantsoundsareusuallynotproblematic. Ifyoudon’thaveaspace like this,you may want to find some way to create it. There are meditation audiorecordings; somepeople like the soundofa small fountainora sound-makingmachine; and noise cancellation headphones might be helpful if outsidedistractionscan’tbeavoided.Thetemperatureshouldbecomfortable—youwillfindithardtomeditateeffectivelyifyouarechilly,andacoldenvironmentmaycauseyourbackmusclestostiffen.Althoughsomereligiousformsofmeditationencourage the use of incense, until your practice develops in a particulardirection,itisbesttoavoidexcessiveodors,aswellasotherextremesofsensoryinput.

Recumbentmeditationposition

WHENALLELSEFAILS,MEDITATE

Althoughtheprimarypurposeofmeditation isnot tobringorder intoanover-packedschedule,manypeoplehavefoundthatmeditationisawaytogentlyyetfirmly reassert control over one’s life, experiences, thoughts, and destiny.Clinical studies have shown that meditation, when routinely practiced, hasimportant positive effects in the lives of peoplewith back pain. It seems thatmeditationcanhelpwhenallelsedoesnotseemtowork.And,ifthisisacourseyoupursueonyourown,thefinancialcostsareminimal—itwillcostyouonlythe time that you would have spent running around doing tasks you won’tremember having done a year fromnow anyway.What have you got to lose?Perhapsit’stimeyoutriedmeditation.

FormsOfMeditation

The principle challenge to a personwith back pain seeking tomeditate is thenearly universal instruction that meditation is best accomplished in a sittingposture. Rather, it’s most important that the posture adopted for meditationshouldbepain-freeor provokepain to the least extent possible.The first key,then,istoadoptaposturethatwillminimizeyourbackpain;mostoftenthisisalying posture. It is ideal to strive to keep the two sides of the body assymmetricalaspossiblewhenmeditating.Findaposition tomeditate inwhichyouwillbecomfortablefor20–30minutes.Thismaymeanlyingonyourbackorproppingyourlegsonasofa,chair,orsomepillowsasyouarelyingonyourback.Make sure that there are no pressure points underneath you.Lying on asurface that is too firm will provoke inflammation and pain in the body’sprotectivefatpadsovertheback.Whenlyingontheback,makesuretheheadiscomfortablysupported.Mostoftenthiswillrequireapillowthatraisestheheadbytwotothreeinches(5to8cm).Trytomeditateatatimewhenyouarenotsleepy, but it is okay to feel drowsy, especially if you are takingmedicine forpainor ifyourpainhasdisruptednighttime sleeping.Nowplaceyourarmsatyoursideoracrossyourbodycomfortably,takesomecleansingbreaths,andyouarereadytobegin!

MUSCLERELAXATIONMEDITATION(PROGRESSIVERELAXATION)

The technique of purposeful relaxation of various muscles of the body wasformalizedandpromotedbyEdmondJacobson,whoworked in this area fromthe1920sthroughthe1960s.Themethodbeginswithattentiononthefeet.Byfocusingintentiononthemusclesofthefeet,firsttensethosemusclesandthen

relax them.Attention nextmoves to the lower part of both legs and themindfocuses on tightening and then relaxing the muscles there. Slowly, calmlybreathing inandoutand relaxing themusclesof the lower legmoreandmorefully. Attention then proceeds to the upper leg and onward part by part. Themeditation can proceed more or less slowly up the body depending on theprogressoftherelaxation.Iftherelaxationisnotfullenough,moretimeshouldbespentoneachpartandattentionshouldbeturnedtosmallerandsmallerpartsuntil the relaxation is successful. A large analysis of clinical studies for backpain showed that progressive relaxationhad a largepositive effect in termsofreducingbackpain.5

Seatedmeditationposition

MANTRA-GUIDEDMEDITATION

A widely known form of meditation involves the use of a mantra or simplesound that is repeated over and over to serve as a focal point for the mind.Mantra-guidedmeditationarisesfromtheBuddhisttraditionandhasalongandrichheritage.

ENERGY-BASEDORCHAKRA-CENTEREDMEDITATION

Chakrameditation isanoffspringofhathayogaand isasequentialmeditationthat focuses attention on various centers in the body. These body centers areassociatedwith certain forms of personal energy andwith various colors.TheChakra meditation begins by focusing attention at the tail-bone region of thespine,wheretheassociatedenergyisofbeinggroundedandthecolorisadarkruby red.ThenextChakracenter is in thepelvis,where theenergy iscreativeand the color is tangerine. The third chakra lies in themid-abdomen over thesolarplexus,andhasanenergyofpowerandstrengthandacolorof sunshineyellow.Thefourthchakra is theheartchakra,which lies in themid-chest.Theassociated energy is love and the color is bright green. The fifth chakra iscenteredinthethroat,withenergythatpromoteseffectivecommunicationandacolorofgreen-blue.Themind’s eyechakra is centeredbetween the eyebrows,andtheenergyhereisforesight.Theassociatedcolorisdeepblue.Theseventhandfinalchakraradiatesfromthetopoftheskull,withatranscendent,spiritualenergy that is between purple and magenta. The meditation progresses bymovingfromthefirstenergycentertotheseventh,focusingoneachoneinturn.Several breaths are taken for each chakra.As the breathmoves deeply in andout,themindisbroughttofocussimultaneouslyonthelocationoftheChakra,avisualizationof itscolor,andacontemplationof thevalueorparticularenergyassociatedwitheach.Thepurposeof this sequentialmeditation is tobring theChakrasintoappropriatealignmentandtoleavethemeditationpractitionerinastateofbalance.Itisimportantwiththismeditationtokeepthetwohalvesofthebodyandmindequallyactivated.

GUIDEDIMAGERYMEDITATION

Guided imagery meditation is especially effective for those who are new tomeditation, for the very young, and for those who may not be as open tomeditation per se. Guided imagery may be incorporated into meditationsequences along with other elements such as relaxation and breath-centering.Thebasicprocessofguidedimageryistostartoutwithaplanthatwillwalkthemind through a series of events or a journey. The imagery should focus on

relaxingeventssuchasa trip toawarmsunnybeach,awalk in thepark,oravisit tosomeoneyou love.Forabeachmeditation, imagine the feelingsof thehotsunasitwarmsthesurroundingsandasaltybreezeblowinggentlyoverthedunesfromtheshore.Focusonthesoftcrunchingsoundofsandunderfootoraloudersoundofpeoplewalkingonaboardwalk.Thesoundsoftheoceancanbeheardinthesoftcrashingofthewavesandthefamiliarseagulloverhead.Focusonsensationsthatarefamiliarandcomforting.Withvisualization,itispossibletoanticipatechallengesandsuccessfullyresolvethem.Itcanbecomeamethodfortappingintoinnerstrengthandsolvingproblemsbeforetheyoccur.

PAIN-DISSOLVINGMEDITATION

Althoughpain-dissolvingmeditationhasevolvedindependentlybypainsuffersinresponsetopaintheyfeeltheycannototherwisecontrol,thereisatraditionofmeditationthatacknowledgespaindissolutionasastage(Vipassanameditation).Thecoretenetisthatintensemeditationleadsone’smindtoeventuallyletgoofthepain.Themeditationisactivelydirectedtothesiteofpain,andseekstousethemind’spowerstodissolve,dilute,ordissipatethepain.

Thebasicsofthisapproacharefairlystraightforward.Themeditationbeginsby finding a quiet space in which one can get into a position of maximumpossible comfort. After taking some cleansing breaths, the mind should bedirected to thepartof thebody that is experiencingpain.Themind shouldbefullyconcentratedonthisbodypartandthesensations—painfulandotherwise—thatarearisingfromthatarea.Slowlyconcentrateonseekingoutthecenterofthepain.Itmaybenecessarytocreepinfromtheedgesofthepainorpossibletozeroinimmediately.Slowlyenvisionthatyouaretakingthispainandspreadingit over the entire body.As it spreads out, it diminishes in intensity almost aswaveslappingattheshorewillspreadout,becomepaperthin,andthenvanishas the tide pulls back. Continue to go into the pain and allow it to extendoutward until the strength of yourwhole body absorbs and dilutes its effects.Don’tbediscouragedifthereisabriefworseningofthepainintensity.Remainaware of the other sensations that are arising from your painful body part.Celebrate those normal non-painful sensations and allow them to grow.Eventually,youwillfindyourselfworkingatthecenterofthepain.Youmaybeabletoabsorbitintothewholeofyourbodyandsuspendit,ifonlybriefly.

Pain-dissolvingmeditation requires a lot attention. Inmost cases, you willneed to focusexclusivelyon thismeditationandwon’tbeable todoanythingelse.Andalthoughthereare timeswhenapainflare-upiscompletelyresolvedwith a single pain-dissolvingmeditation session (e.g.,migraine), it is also thecase that pain returns once themeditation is complete.Nonetheless, this is an

importantpain-relievingtechniquetolearnaboutandpractice.

ABridgetoPainReliefAlthough the traditional Eastern approaches to meditation recommend theavoidance of chemical substances, the pain-dissolving meditation describedhere isanexcellentway toengageyourmindwhilewaitingforyour“rescuemedication” to take effect. It is well established that most pain medicationsrequire20ormoreminutestopassbeforepainreliefisperceived.Thiswaitingperiod canbe unbearably difficult sometimes, andknowing that you canusethepain-dissolvingmeditationtobridgethisperiodandpossiblyevenenhancetheeffectsofthemedicationisimportant.

VALUE-CENTERED(CONCEPT-FOCUSED)MEDITATION

This meditation category encompasses a wide variety of meditations. Yourmeditation may focus on values such as loving-kindness, compassion,forgiveness, resilience, or non-violence (Ahimsa). Thismeditation follows thebasicprinciplesoffindingacomfortable,quietplacetomeditateandarrangingyourschedulesothatyoucanmeditatefor25–45minuteswithoutfallingasleeporbeing rushedaway.Somepeoplewillapproachconcept-centeredmeditationby only allowing the concept itself to be focused upon. Others haverecommended an approach in which you allow instances of the concept’sopposite to arise into your consciousness as you visualize the events andmeditate on how a stronger influence of the desired value would resolve theconflict or problem. This form of meditation may be especially powerful forpeoplewhoarestronglyvalue-orientedandthosewhofeelthataparticularvalueisunder-expressedintheirdailylives.

MINDFULNESSMEDITATIONFOCUSESONTHEPRESENT

Mindfulnessmeditation has its origins inBuddhist practice and includes threeessentialelements:“observeprecisely,haveequanimity,andbesensitivetohowthingschange.”6Aswidelyconceptualizedanddeveloped in the late twentiethcentury,however,mindfulnessmeditationisanon-religiousinterventionthathasbeen shown to be especially effective for the control of chronic pain.7 Theprocessofmindfulnessmeditationincludesabodyscanmeditation,ahathayogameditation,andabreath-centered(prana)meditation.Thebodyscanmeditationfocusesattentiononeachbodypartinturn,breathingintothatpartofthebodywith thebreath in and “feeling” that part of thebodydissolvewith thebreathout.Thebodyscanmeditationisintendedtobringthepractitionertoastateofacceptanceornon-striving.

Themedicalbenefitsofmindfulnessmeditationarewellestablishedandhaveevenbeenshowninclinicaltrials.Infact,thebenefitsofmindfulnessmeditationhave been specifically proven helpful for back pain. In one study, a group ofolderadultswasofferedaneight-week-longmindfulnessmeditationcourse forthe purpose of improving low back pain.8 The results were impressive: thepatients as a groupweremore active and less impaired due to their pain.Theaverageamountofmeditationwasjustmorethan30minutespersession,fourtofivetimesaweek!

BREATHEINENERGY,BREATHEOUTNEGATIVITY

Itispossibletofocusonenergyanytimeoneismeditating.Theflowofenergymaybevisualizedasenteringandleavingthebodythroughthefeet,throughthebreath,orthroughthepartofthebodythatisclosesttotheground.Usually,itisbestiftheenergyflowsintothebodywitheachbreathin,andnegativeenergyisvisualizedasdepartingfromthebodyasthebreathisexhaled.Itisimportanttousedeepbreathsthatconnectdeeplyintothelowestpartsoftheabdomen.Starteach breath as if it originated from below the belly button and as you slowlybreatheinthroughthenose,graduallyfeelyourchestfillupwithair.Astheairenters,concentrateonfillingup the lowestpartsof thechest firstand then themiddle.Theupperpartof thechestwillbe the last to fillwithair.Pauseforamomentat theendofeach inhalationandslowlybegin to release theair fromyour lungs, chest, and body, starting at the top of the chest and graduallylowering down.This type of breathing has been calledWavebreathing and ishelpful for centering the mind, releasing negative tension, and bringing thethoughtstoafreshbeginning.9

OtherMind/BodyTherapies

ALEXANDERTECHNIQUE:MEDITATIONOFTHESTARS

The Alexander Technique is a comprehensive system of bodymovement andmotortrainingdesignedtooptimizethefunctioningofthebodyandreducethephysicalstressofeverydayactivities.Thetechniquehaslongheldpopularityintheworld of actors,musicians, and performance artists, amongwhom closelyattuned body awareness is considered essential. The Alexander Techniqueoriginated from the discoveries and teachings of F. Matthias Alexander ofAustraliaandLondon.ItisavidlypursuedinpartsofEnglandandcontinuestobetaughtattheJulliardSchoolinNewYorkandbyteachersthroughouttheU.S.Althoughitisalmostalwaystaughtthroughone-on-onelessons,someexerciseshave been published as the Liebowitz Procedures. In these procedures, thepractitioner is guided through a series of movements while thinking of keydirections that instruct the body to relax in certain areas that ordinarily carryexcessivetension.

One place that usually carries excessive muscle tension is the base of theskull.As such, theAlexander Technique instructs the practitioner to relax theneck and skull, allowing the head to float on the spine as through it is beingpulled upward and slightly forward by a heliumballoon.AsLeibowitzwrote:“Letmyneckbefree,letmyheadgoforwardandup,letmytorsowiden…”10Insomeparts,thestudentisinstructedtorelaxspecificmusclegroupsandareasofthebodyinordertoattainthedesiredresult.Theseskillsofrelaxationarevery

usefulandcanhelpreducestressandthepainresponsewhenmedicalproceduresarerequired.

TheAlexanderTechniquehasbeenendorsedbymanyperformersashelpingtorelievepainassociatedwithrigorouspracticeschedulesandhasbeenshowninclinicaltrialstoprovidelong-termrelieffromchronicorrecurrentbackpain.In one study, six lessons were found to be nearly as effective as twenty-fourlessons.11

FELDENKRAISINTEGRATESMOVEMENTANDTHOUGHTS

Feldenkrais is a movement-training methodology developed by MosheFeldenkrais,ajudomasterandphysicistofthetwentiethcenturywithaninterestinphysiologyandneurologicalaspectsoffunction.Theapproachisdesignedtore-teachthebodytomovemoreintuitively,andinsodoingmakethemovementsofeverydaylifelessstressful.Thephilosophyofthemovement’sfoundernotesthattheselfconsistsofmovements,sensations,feelings,andthoughts,andthatthe unfolding of the true self occurs through the conscious alignment of theseelements.12 You can learn the Feldenkrais method through classes or privatelessons that teach a series of movements or exercises. The objective of thistraining is to learnhow to functionmore fluidly and fullywith less chanceofharmtothebody.

Anat Baniel has written a book that brings together some of the physicalmovements of Feldenkrais technique with a beautiful reorientation towardsdevelopingimprovedvitalityindailylife.13ItiscalledMoveintoLife.AlthoughitiswidelyacknowledgedthatFeldenkraiscanbebeneficialtothosewithbackpain,one technique inparticular is likely tobehelpful to thosewithsacroiliacpain.Looselydescribedasavariationon thebutterflystretch, theexercisehasthestudentperformavarietyofbutterflystretcheswhilesittinguprightandlyingdown.TheexerciseisentitledUnexpectedFreedombecauseoftheeffectthatithasonfreeingupthehipjoints.Itisessentialtofollowtheproceduresclosely,soborrowing or buying the book will be necessary. The exercises seem to takeadvantageofnormalpressuresarisingfromrockingmovementsofthelegs,hips,and sacrum to gently coax the sacroiliac joint back into position, increasingmobility and potentially reducing pain. Even if you don’t sufferwith SI jointpain,theseexercisesarelikelytoimprovethestabilityofyourstanceandyourflexibility.

QIGONGFOCUSESONENERGYFLOW

QiGongissometimesreferredtoas“movingmeditation,”designedtopromote

theflowofenergyandclearthemind.AsthepractitionerofQiGongfollowstheseriesofmovements, theyare to focuson the flowofenergy intoand throughthe body.14 Qi Gong is an ancient Eastern practice involving the use ofmovement and breathing to influence themind and center the person.Widelypracticed and accepted as beneficial by thousands and possibly millions ofEastern practitioners, Qi Gong has been the subject of some politicalcontroversy.

AsadaptedforWesternuse,QiGongisagenerallysafeandpotentiallyverypositivepractice.Aseriesofcomplexmovements,QiGongpracticecanhelptoimprove breath awareness, foster a sense of peaceful presence-in-the-moment,and promote overall health consciousness. Qi Gong will help increase yourbalance and improve lower body strength. Several avenues for learning moreaboutQiGong are available.An excellent series ofQiGongvideos has beenproduced by Lee Holden, and Qi Gong practices are described in books aswell.15

HowtoDoQiGong’sSpinalBreathingOne practice from Qi Gong that is especially helpful for someone recoveryfrombackpainiscalledspinalbreathing.Tobegin,firststandwiththefeetawide shoulder-width apart. Holding a good pelvic neutral stance, bend thekneesslightly,keepingthetailtuckedandthespineupright.Positionyourarmsso they stick straightout from the shoulderswithhands facing forward, thenbendtheelbowstoarightangleandmakeasoftfistwiththehands.Now,asyou exhale, bring the arms forward and down in front as you flex the spineforwardandloweryourchin;attheendofyourfullexhaleyoushouldalmostbeinastandingfetalposition.Asyoubegintobreathin,uncurlthespineandbring the arms (still bent) through the starting position and move towardsextendingthespineasyoutilt thechinupwardsandtheheadgentlyback.Attheendoftheinhale,youwillfeelyourchestfullyexpandedasyoureyesgazeskywards and your throat and airways fully open. You should feel a goodstretch in the chestmuscles and a gently distributed tension in the extendedbackmuscles.Donotdothisexercisetothepointofanypain;thisshouldnothurtinanyway.Repeatthespinalbreathingprocessforatotalofeightormorebreaths.

REIKITAPSINTOUNIVERSALENERGY

Reikiisanenergy-basedalternativetherapythatarosefromtheworkofMikaoUsui in the 1920s.16 The term Reiki is a combination of two words fromJapanese, Rei andKi, that together mean “universal energy.” The process ofReikiinvolvestheplacementofhandsoverorlightlyonthefullyclothedbodywith the intention of manipulating the flow of energy. According to Reikiteachings,therearespecificpatternsofenergyinthebodythatmaybeinneedofhealing through the infusion of positive energy.17 The overall purpose of thetherapyistoreducestressandpromoterelaxationandhealing.

Reikiforthetreatmentofbackpainhasnotbeenformallystudied,andwhilesmaller-scale studies have not been able to show its specific benefit forconditions such as fibromyalgia, there is evidence to suggest that touchtherapies,includingReiki,maybebeneficial.18,19ArecentlypublishedstudyonReikiforthecontrolofstressandbodilysymptomshadasurprisingresult.20Itfound a benefit to participants who were unaware that the treatment wasoccurring!

SELF-HYPNOSIS

Hypnosis has been widely used, abused, and disparaged over the centuries.Despite this, there continue to be very helpful applications of hypnosis.Hypnosisisusedsuccessfullybypediatriciansandpediatricanesthesiologiststorelievechildren’sanxietiesaboutpainandprocedures.Thisisbelievedtoworkwell because children are much more fluid in their sense of reality and theiropenness to suggestion. Nonetheless, a majority of adults are consideredhypnotizable.

Self-hypnosis is a process of training the mind to enter a state of relaxedwakefulness in which awareness of external events is filtered. It has beendescribedasa relaxedstate inwhichaccess to the subconsciousmind ismoredirectwhileconsciousawarenessismorerestrictedthanusual.21Legislation inthestateofConnecticutdefinedhypnosisas“anartificiallyinducedalteredstateof consciousness, characterized by heightened suggestibility and receptivity todirection.”22

Hypnosis has been used for a variety of health-related concerns includingchildbirth,smokingcessation,weight loss,andpainmanagement.Averyearlyclinical trial indicatedthathypnosiswasaseffectiveasrelaxationtherapywithrespect to pain control and resulted in better sleep and less problematicmedication usage.23 Hypnosis (of others) is regulated in some states and not

permitted in some places unless practiced by licensed medical professionals.Self-hypnosisis,obviously,apersonalchoiceandisnotregulated,perse.Thereare many resources available for those interested in self-hypnosis. A recentlypublished study, funded by the National Institutes of Health, found that self-hypnosis was effective at reducing pain and anxiety in women undergoing alarge-needlebiopsyof thebreast.24 Ifyouarecuriousabout self-hypnosisasatreatment for back pain, ask your doctor, explore your options, and considerinvestinginsomeaudio-recordingsofscriptedself-hypnosissessions(justdon’tlistentothemwhiledriving).

TheExplanation

While there are many skeptics of mind-body therapies, there are also manypeoplewhosupportthem.Onerecentstudyofacupuncturesuggestedthatpeoplewhoderivedthemostbenefitfromacupuncturewerethosewhomostexpectedittohaveabenefit.25Doesthismeanthatacupuncturedoesn’twork?Itmaymeanthat the person who has the strongest intention to receive a benefit from atherapyisabletoexperiencethattherapymorepositivelyandrecruitthebody’snatural healthmechanisms in response to the treatment.Despite the persistentdoubts of some, millions of people have experienced benefit frommeditationandrelatedspiritualpractices.Intheend,eveniftherearenoimmediatehealthbenefits that can be proven in stringent clinical trials, if meditation or othermind-body approaches help youmakemore healthful choices in life, that is apositiveoutcome.

CHAPTERRESOURCES

1. Barnes, P.M., E. Powell-Griner, K. McFann, and R.L. Nahin. 2004.Complementaryandalternativemedicineuseamongadults:UnitedStates,2002.AdvData343:1-19.

2. Kabat-Zinn, J., L. Lipworth, and R. Burney. 1985. The clinical use ofmindfulnessmeditation for the self-regulationof chronicpain.JBehavMed 8(2):163-90.

3.Sherman,K.J.,etal.2004.Complementaryandalternativemedicaltherapiesforchroniclowbackpain.BMCComplementAlternMed4:9.

4.Boccio, Frank J.MindfulnessYoga. Somerville,MA:Wisdom Publications,2004.

5.Ostelo,R.W., et al. 2005.Behavioural treatment for chronic low-backpain.

CochraneDatabaseSystRev1:CD002014.

6.Young,Shinzen.BreakthroughPain.Boulder,CO:SoundsTrue,Inc.,2004.

7.Kabat-Zinn,Jon.FullCatastropheLiving.London:PiatkusBooks,2007.

8.Morone,N.E.,C.M.Greco,andD.K.Weiner.2008.Mindfulnessmeditationforthetreatmentofchroniclowbackpaininolderadults.Pain134(3):310-19.

9.Holden,Lee.7MinutesofMagic.NewYork:PenguinGroup,2007.

10.Leibowitz,JudithandBillConnington.TheAlexanderTechnique.NewYork:HarperPerennial,1991.

11. Little, P., et al. 2008. Randomised controlled trial ofAlexander techniquelessons,exercise,andmassage(ATEAM)forchronicandrecurrentbackpain.BrJSportsMed42(12):965-8.

12. Feldenkrais, Moshe. Awareness Through Movement. New York:HarperCollins,1972.

13.Baniel,Anat.MoveIntoLife.NewYork:HarmonyBooks,2009.

14.Tse,Michael.Qigong forHealingandRelaxation.NewYork:St.Martin’sGriffin,2005.

15.Holden,Lee.7MinutesofMagic.NewYork:PenguinGroup,2007.

16.“Reiki.”http://nccam.nih.gov/health/reiki/.AccessedJanuary3,2010.

17.Rand,W.L.“HowdoesReikiwork?”http://www.reiki.org.AccessedJanuary3,2010.

18.Assefi,N.,etal.2008.Reikiforthetreatmentoffibromyalgia:Arandomizedcontrolledtrial.JAlternComplementMed14(9):1115-22.

19.So,P.S.,Y.Jiang,andY.Qin.2008.Touchtherapiesforpainreliefinadults.CochraneDatabaseSystRev4:CD006535.

20.Bowden,D., et al. 2010.A randomised controlled single-blind trial of theeffectsofReikiandpositiveimageryonwell-beingandsalivarycortisol.BrainResBull81(1):66-72.

21. MacKenzie, Richard. Self-Change Hypnosis. Victoria, BC: TraffordPublishing,2005.

22. Hypnotherapists Union. Summary of State Laws Regarding Hypnosis,http://www.hypnotherapistsunion.org.AccessedJanuary4,2010.

23. McCauley, J.D., et al. 1983. Hypnosis compared to relaxation in theoutpatientmanagement of chronic low back pain.Arch PhysMed Rehabil 64(11):548-52.

24. Lang, E.V., et al. 2006. Adjunctive self-hypnotic relaxation for outpatientmedicalprocedures.Pain126(1-3):155-64.

25. Kong, J., et al. 2009. An fMRI study on the interaction and dissociationbetween expectation of pain relief and acupuncture treatment.Neuroimage 47(3):1066-76

Q&AwithDr.Murinson

WhyshouldItrymeditation?

Themostimportantreasontotrymeditationistogaincontroloveryourpainandyourlife.AsShinzenYoung,amasterofmeditationhaswritten,“Thehorriblepartofchronicpainisthatthemoreithurts,themoresensitiveyoubecometothe pain. Your pain circuits become pain magnifiers, so that even ordinarysensations are experienced as painful.” It is through meditation that you willbegintoloosenthetangledknotofpainandmovement,andmove(instillness)toabetterlife.

CHAPTER20WaterandInversionTherapiesforStrengtheningandConditioning

Gravity-reducing therapies provide immediate pain relief, speed healing,andpromotehealthyalignmentofbackstructures.

theDIAGNOSIS

>Doyousometimesfeelthatyourbackisachingwitheverystep?>Doyouwishyou could escape the effects of gravity for awhile andgetbacktofeelinglikeyouroldself?

ListentoYourBodyMaybeyou’vehadthefeelingthatyourbackisalittlebetterwhenyou’reonvacation,butyouhaven’twantedtotellpeopleincasetheywouldthinkyourpainisallinyourhead.Itdoesn’tmeanthatatall,itjustmeansyourbodyistryingtotellyousomethingaboutyourlife,andthemessageis:It’stoomuch,slowdown!

Ifyourbackhasbeeninjuredandyouhavebulging,torn,orherniateddiscs,youareprobablylivingwithsubstantialamountsofpain.Gravity-reducingtherapiescanprovideimmediatereliefforyourbackpain.Inaddition,studieshaveshownthat reversing gravity’s pull may speed the healing of injured discs; helpdistorted discs and other back structures return to their normal shape; andprovidemorespacefornervesandspinalcordasthesedelicatestructurestransitthroughnarrowpassagesintheback.

In the upright configuration, the spine is under constant pressure. It’s clearthatstandingandsittingupputsubstantialpressureson thediscs,especially inthelowerback.Thisiswhypeoplewithlumbardisctearsgetsomuchpainrelieffromlyingdown.Whenyou’reinthewater,youarenearlyweightless,andthiswillproviderespiteforthespine.Whenyouareonaninversiontable,theupperpartofyourbodyactuallycreates somemild tractionon the lower spine.Thisprocessmayactuallyhelpcorrectbulgingdiscsandrelaxtightenedmuscles.

WHATIFYOURDOCTORRECOMMENDSAQUATHERAPY?

Feelgoodthatyouhavesuchanopen-mindedhealthcareproviderandaskforaprescription. Some insurance companies will cover supervised aquatherapy ifprescribed by a physician. If prescription aquatherapy is notwhat your doctorhasinmind,askaboutspecificprograms,frequency,anddurationofworkouts,andwhethertheaquatherapyisbeingrecommendedaspartofacardiovascularfitness program or your back-strengthening program. There are also online,print, andmedia-based resources to helpwith designing a soundwater-fitnessprogram.

WHATIFYOURDOCTORRECOMMENDSINVERSIONTHERAPY?

Askyourdoctorwhatheorsheknowsabout this treatmentandhowheorshecame to recommend it.Theclinical trialson inversion therapyare limited,butthereisawealthoftestimonialsthatattesttothebenefitsofthisapproach.Askyour doctor to write a prescription for an inversion table or to complete thepaperworktosupportthisrecommendation.SomeHealthSavingsAccountswillreimburseyouforthepurchaseofatableifit’sdoneontheadviceofadoctor.

thePRESCRIPTION

Gravity-reducing therapies will largely be self-directed, although you shoulddiscussthemwithyourdoctortoseeifheorshehasspecificrecommendationsforaquatherapyortheuseofaninversiontable.

•Findoutaboutpoolsinyourarea.Thereisnobetterwaytorelievestressonthe back than to spend some time in thewater. Especially if back pain ispreventingyoufromgettingtheexerciseyouneedandcrave,lookintowateraerobics, takesomeswimminglessons,orsliponawaterbeltand take theplunge.

•Ifyouare trulyuncomfortablegoingtoapublicorprivateswimmingpool,thinkaboutspendingafewminuteseverydayinyourbathtub.Ofcourse,it’snotpossibletogetaerobicexerciseinthebathtub,butyoucanbenefitfrommusclerelaxationandminimizingtheeffectsofgravityonthespine.

•Findanaquatherapyspecialistinyourareaandattendafewsessions.Somemedical insurers or healthcare reimbursement programs will coveraquatherapy-relatedexpensesifthetreatmentisprescribedbyyourdoctor.

•Whileon land,make sureyou’regetting rest several timesdaily.Thiswilltemporarily stop gravity’s effects on your back.The details are inChapter13,butyoucanstartbylyingdownflatonthefloorwithyourlegsproppeduponasofa.Ifyouwanttoreversetheeffectsofgravity,aslant-boardcanbeagentlewaytogetstarted.

•Considertryinganinversiontable.Checkinwithyourlocalgymtoseeifithastheseavailable.Longpopularwithathletic-types,inversiontabletherapymaynotbe foreveryone.But, ifyouare inprettygoodphysicalshapeandwant to maximize your at-home therapy for back pain, an inversion tablemayberightforyou.Checkwithyourdoctorandstartgradually.

TheTreatment

Water therapy and inversion therapy counteract the effects of gravity on yourback.Haveyounoticedthatyouarequiteabitshorterintheeveningthanyouare in themorning?Mostofusare.Try this:Next timeyouget intoyourcar,checktoseeifyouhavetoadjustthemirrorupordown.Chancesareyouadjustthe mirror up in the morning and down every afternoon. Over the years, wegradually losesomeofourheight,althoughdramatic lossesareonly typicalofdiseasessuchasosteoporosisandankylosingspondylitis.

Anunderwatertreadmillusedinwater-basedphysicaltherapy

Water-BasedTherapies

Our bodies are 70 percentwater.The rest of our bodies aremade up of otherthings likeproteins,minerals (bone),and lipids (fat).To theextent thatpeoplehave a lot of lipids in their body, they are lighter thanwater andwill be verybuoyant.Someonewhoisveryleanwillberelativelyheavyinwater,butevenstillwillfeel70percentlighter.Howcanyoutellhowmuchbodyfatyoumightbe carrying around?TheNationalHeart, Lung, andBlood Institute states that“Bodymass index(BMI) isameasureofbodyfatbasedonheightandweightthatappliestobothadultmenandwomen.”1YoucanlearnmoreandcheckoutyourBMInumbersinChapter21.

Ifyouhaveatypicalbodybuild,meaningyouaren’tsuper-athleticorsuper-sedentary,andyouareamiddle-agedman,yourBMIisafairapproximationofyour percent body fat.2 Women should add about 11 percent to the BMI toestimatepercentbodyfatbyvirtueofourdifferentphysiology.Thebadnewsisyoumayhavealotmorebodyfatthanyourealized.Thegoodnewsisthatfatfloats,andbuoyancywillworktoyouradvantageinthewater.Soasyouenterthewater,youwillfeeltheweightdrainingawayfromyourbody,youwillfeellightandrelaxedasyoufloataround.Ifyouwearafloatationbelt,thiswillmakeiteasiertokeepyourselfuprightbutyouwon’tgetasmuchexercisejuststayingafloat. Insomeplaces,weightsareaddedto theankles toproducesomegentletraction on the spine. However, you don’t want to do anything that mightjeopardizeyourabilitytokeepyourheadabovewater.Itiswisetoalwaysswiminasupervisedsettingorwithsomeoneyouknow.

WATERWALKING

Theexercisethatyougetfromwaterwalkingdependsonthevigoryouapplytoit.Waterwalkingcanbeagentleandsoothingwaytoremobilizeafterapainfulback injury.Asyouprogress,waterwalkingcanbecomemoredemandingandevengetyougoingwithsomecardiovascularfitness.3Youmaywanttochangeyourapproachfromtimetotimebyputtingonaflotationbeltanddoingsomewaterjogging.Inwaterjogging,youaresuspendedinthewater,andasyoufloatyoumove your legs as if jogging. It’s essentially a vigorous form of treadingwater. Make sure to seek out advice on water walking; there are DVDs andbooksavailable.

Warning!StretchComfortablyandSymmetrically

Wheneveryoudostretches,inthewateroronland,trytofindapositionthat iscomfortableenoughtoholdforacountof30seconds.Takebabystepsifyou’rerecoveringfrombackpain,andalways,alwaysmakesuretostretchonbothsidestokeepyourmovementpatternssymmetrical.

WATERAEROBICS

This is a wonderful way to maintain and improve physical fitness for peoplewithcurrentorresolvedbacktroubles.Thebestwaytopickupwateraerobicsisto join a class. In some areas though, water aerobics is the domain of seniorcitizens, and thismay ormay not be the best fit.Ask if you can visit a classbeforesigningup.Youcancheckoutsomebooksatyourlibraryiftherearenoclassesneartoyourhome.4

Youwill want to have access to some special equipment to facilitate yourwateraerobicsworkout.Aflotationbeltwillboostyourcomfortandconfidencein thewater by allowing you to concentrate on your exercise routine and getyourmusclesworking.Waterbarbellsarenotheavy,butworkbyincreasingthedrag on your arms as theymove through thewater. Onewonderful aspect ofwateraerobics is thatyouarebuildingmuscleasyoumove inbothdirections,whereas on land, you are usually only building muscle as you move againstgravity.Swimglovescanaddresistancetoyourhandmovementsbutareusedinplace of dumbbells, and flippers may build strength but should not be usedduringanacuteepisodeofbackpainas theymay increase strainon the lowerback.

WATERSTRETCHINGANDYOGA

You can use the buoyancy that you gain in water to great advantage instretching.5 Find a spot along the wall and practice some lunges and partialsplits. You will find that you can focus on the stretch and worry less aboutstraininganklesandkneesthankstotheweightlessness.Todothewater-lunge,standnexttothewallwithonehandontheedgeofthepool.Putthefootclosestto thewall back about 30 inches (76 cm) andbendyour other kneegraduallyuntilyoufeelastretchinthefrontofyourextendinghip(thebackleg)andthehamstringsoftheflexinghip.Trytokeeptheheelofthebacklegplanteddownifpossible.Ifyoucandothisstretchcomfortably,moveyourfrontfootfurtherforward and repeat this stretch for 30 seconds each time, three to five times.Thenturnaroundandstretchtheotherside.

Inversiontherapy

WATERRELAXATION

Thisisawonderfulwaytoendanytriptothepool.Simplyfindaquietspotandlieback.Letyoubodyrelaxasyoufeelthewavesofthepoolgentlyflexingandextending your spine. Close your eyes and empty your mind of worryingthoughts and troubles. You can consciously direct relaxation to your backmusclesorjustletgoandfeelatonewiththewater.Don’trush,justletyoubodyabsorbthebenefitsofyourtriptothepool.

InversionTherapies

Although traction has been widely used for the treatment of back and neckproblems, the use of inversion therapies has been relatively slow to gainwidespread acceptance in the mainstream medical community. However,inversiontherapieshavelongbeenpopularwithfitnessbuffsandyogaexperts.Thosewhosubscribetoinversiontherapytoutwide-ranginghealthbenefits,butthisisnottheobjectivehere;thereasontoconsiderinversiontherapyaspartofaback-health lifestyle is to ease thepressures on theback and to evenbegin toreversetheeffectsofgravity.

Inversiontablesofferthewidestrangeofflexibilityintermsofbeingabletocontrol the angle of inversion. You can begin (and continue) with a milddownwardtiltofthehead.Someinversiontablesallowyoutosetthemaximumangle of incline. Others prefer full, hanging-upside-down inversions, and forthis,youeitherneedsomekindofbaror trapezearrangementoryourneedaninversiontable.Forpeopleofordinaryfitness levels,gettingsuspendedfromabarisnotentirelyfeasible.

Besidesthehealthrestrictionsonusinginversiontables,asnotedabove,theydo require an up-front investment. Even a basic inversion tables is relativelyexpensive, costing $200 or more, and more sophisticated models range intoseveral hundred dollars. It is not clearwhy inversion tables have not receivedmore formal testing from the medical community. It could be that inversiontablessimplydon’twork.Itcouldalsobethattheeconomicsofinversiontablesaren’t optimal for our healthcare system: they cost just enough to prohibitindividuals from wanting to buy them and not enough to be attractive toprovidersaspartofafee-basistreatmentprogram.Nonetheless,therearemanypeople that really believe that inversion therapy has radically improved theirquality of life and taken awaymost of their back pain. The rationale for thisseems sound, but the tables themselves will require further testing before themedicalcommunitywillacceptandpromotethistreatment.

SLANTBOARD,ACOST-EFFECTIVEMETHOD

Aslantboardisalessexpensivealternativetoaninversiontablethatofferssomeofthebenefits,butalsosomechallengesintermsofgettingupanddownfromthepartial-inversionposition.Formany,aslantboardisafitnessitemdesignedto increase the amount of work associated with abdominal crunches. It isintendedthattheuserwillhookhisorherlegsoverthebarsandthattheupperbodywilllieonthenegativeinclineoftheboard.Dependingontheconditionofyourkneesandoverallphysicalcondition,thismaynotsoundveryrestful.

The goal of resting on the slant board is to get the pelvis into a neutralposition(hencetheneedtosupportthefeet)andtoletgravityassistinstretchingout the spine and muscles. Besides making sure that your slant boardarrangement is stable, the real problem is gettingon andoff theboard. If youhaveanacutediscoracutelypainfulbackproblem,itisnotatrivialexercisetogetyourselfpositionedona slantboard. Ifyou try togetonto the slantboardfroma sittingposition, youmayactually experience some strongpressuresonthediscwhilegettingintoposition.Ifyourbackisacutelypainful,youmayhavetoliedownonthefloornexttotheboardandslowlyscootyourselfuptheslopeoftheboard.

Once in position, remember that you need a two-to-three-inch support foryour head tomake the neck comfortable. You should avoid sliding down theboardandpressingonthetopofthehead,asthiscancreateloadingpressureonthespine,especiallyintheneck.

SlantboardWaterandInversionTherapiesforStrengtheningandConditioning

Warning!InversionTherapyIsNotforAll

First, it is important that your general health is good.Peoplewith heartconditions, high blood pressure, a history of blood clots, problemswithcirculation such as swelling of the leg, and breathing difficulties shouldnot consider inversion therapies without prior clearance by a qualifiedphysician.Ifyouhaveparticularconcernsabouttryinginversiontherapy,asafealternativemightbetotrya“zero-gravity”chair.

Do-it-YourselfSlantBoardIt’s possible to set up a slant board at home using a sturdy support, a solidboard, a good foam cushion, and some pillows. You can actually create anarrangementwherebyyoupositionyourheadandspineonanegative inclineandhaveaplacethatwillsupportyourfeetasyouflexyourhipsandknees.

INVERTEDYOGAPOSES

Someyogaposestakeadvantageofgravity,especiallythedownwarddog.Thereisalesswidelyusedyogapositioncalledthehangingdogthathasbeenadoptedbysometoinvolvehangingovervariousstationaryobjects.6Itmaybebeneficialto suspend yourself upside down from a chair in a supported headstandconfiguration,butitalsomaynot;you’llhavetoexperimentandseeifyoucanfindrelieffrombackpainthisway.

TheExplanation

Humansenjoytremendousbenefitsbyvirtueofstandingontwofeet,but,asyoulookaroundatothermembersoftheanimalkingdom,onecuriousfactbecomesclear. Although myriad creatures from dinosaurs to goldfish follow the samebasicoutlineofhavingboneyspinerunningthroughthemiddleofthebody,weare virtually alone in turning this spine upright. This means that gravity isconstantlyworkingagainstus.Theproblemismostacute in the lumbarspine,where the discs and other spine structuresmust bear the weight of the upperbody.Butthecervicalspineisalsocompressedbygravityduetotheweightofthehead,andthiscanworsencompressionofnerverootsbybulgingdiscsandbonespursonthespine.7

It has been shown by applying traction to the body that unloading thepressuresofthelowerbackcancorrectdiscabnormalitiesandrelievepain.8Onestudy that looked at the effects of traction using serial CT scans of the spinefound that tractioncould reduce thesizeofdischerniationsby25percentandincrease the space available for nerves exiting the spinal canal by another 25percent.9Tractionmaybeprescribedforyourbackproblem,appliedtoyoubyaphysical therapist, or used by a chiropractor, but you can apply the basicprinciplesoftractiontoyouradvantageusingwater-basedtherapiestoneutralizegravityorinversiontherapytopartiallyreverseeffectsofgravity.

CHAPTERRESOURCES

1.NHLBI.“BodyMassIndex,”www.nhlbisupport.com/bmi.AccessedJanuary10,2010.

2.Deurenberg,P.,J.A.Weststrate,andJ.C.Seidell.1991.Bodymassindexasameasureofbody fatness:Age-andsex-specificprediction formulas.BrJNutr65(2):105-14.

3.Huey,Lynda andRobert Forster.TheCompleteWaterpowerWorkoutBook.NewYork:RandomHouse,Inc.,1993.

4.PappasBaun,MaryBeth.FantasticWaterWorkouts.Champaign, IL:HumanKinetics,2008.

5.Huey,Lynda andRobert Forster.TheCompleteWaterpowerWorkoutBook.NewYork:RandomHouse,Inc.,1993.

6. Levin-Gervasi, Stephanie. The Back Pain Sourcebook. Lincolnwood, IL:LowellHouse,1998.

7.Takasaki,H.,T.Hall,G.Jull,S.Kaneko,T.Iizawa,andY.Ikemoto.2009.Theinfluence of cervical traction, compression, and spurling test on cervicalintervertebralforamensize.Spine(Phila,Pa.1976)34(16):1658-62.

8.Horseman,I.andM.W.Morningstar.2008.Radiographicdiskheightincreaseafter a trial of multimodal spine rehabilitation and vibration traction: Aretrospectivecaseseries.JChiroprMed7(4):140-145.

9. Sari, H., U. Akarirmak, I. Karacan, and H. Akman. 2005. Computedtomographic evaluation of lumbar spinal structures during traction.PhysiotherTheoryPract21(1):3-11.

CHAPTER21EatingRighttoPreventPainandPromote

Recovery

Moderateweightlossandavoidingtriggerfoodscanimprovebackpain.

theDIAGNOSIS

Alwaysincludevegetableswiththemainmealsoftheday,choosegrainsthatarehigh in fiber, and seek out calcium, because it is a good defense againstworseningspinediseaselaterinlife.Ifyouwanttoeatbetterforimprovedbackhealth,readon!

>Areyoumorethan10pounds(4.5kg)overweight?>Doyoueatmorethanfiveservingsadayofvegetables?>Doyougetgaspains?>Doyouhaveaburningfeelinginyouresophagusaftermeals,oroftenfeeloverlyfull?

>Doyoudrinkeighttallglassesofwateraday?>Doyouhaveagoodfeelingaboutanydietarysupplementstake?

TheTreatment

There is no magic food that will cure back pain, but there are a number ofpositivechangesthatyoucanmakeinyourdiettoshiftthebalancetowardbetterbackhealth.

GETAGRIPONYOURWEIGHT

Becausealotofbackpainisdrivenbymechanicalstresses,howmuchapersonweighshasaprofoundimpactontheback’sfunction.Withoutquestion,obesityisamajorcontributortobackpainandback-relateddisability.Forthesereasons,weightcontrolisapriorityforthosewithbackpain.

Youneedtoknowyournumbers.Tomorrowmorning,weighyourselfwithareliable scale.Then, get your heightmeasured; youmayneed help to do this.Havesomeonemakeamarkonthedoorframeandmeasurethedistancefromthefloor.Youshouldnothaveshoesonwhenmeasuringyourheightorweight.Youcanusethebodymassindextableinthischaptertofindyourbodymassindex(BMI): find your height in the left column of the table; mark this with ahighlighterallthewayacrossthetable.Followuntilyoufindthenumberclosesttoyourweightinpounds.Followthiscolumnuptothetoprow,andthisisyourBMI number. If your BMI is 24.9 or below, you are in the normal weightcategory. If your BMI is greater than 25 but less than 29.9, you are in theoverweight weight category. If your BMI is 30 or greater, you are obese andshouldseekmedicalsupervisionforaweight-lossplan.Ifyourweightisgreaterthan normal, you should determine themaximumweight you can have to bewithin normal limits. Do this by following the row for your height until youreach theweight columns forBMI levels of 24 and 25.Your targetweight isbetweenthesetwonumbers.

Lastingweightlosscanonlyoccurthroughacombinationofdecreasedfoodconsumptionandincreasedexercise.Itissometimestruethatapersoncanavoidgainingweightbyeithercuttingbackonfoodintakeor increasingactivity,buttrue weight loss requires both. If your back is healthy enough that you canengage incardio-typeexercise three timesaweek,youcan realisticallyplananew lifestyle thatwill include reaching a lower targetweight. If your back ispainful enough that you can’t exercise moderately three times weekly, youshouldnotbetoohardonyourselfifyoucan’tseemtoshakeexcessweight.Infact,forpeoplesufferingthroughanepisodeofstrongbackpain,thebest,mostrealisticgoalistoavoidweightgain.

BODYMASSINDEXTABLE

WHOLEGRAINS,VEGETABLES,ANDCALCIUM

Yourdietisanimportantpartofyourrecoveryandpreventionplan.Dietplaysan important role in preventing or reversing obesity, ensuring lifelong overallhealthmaintenance,andprovidingadequatestoresofcalciumforstrongbones.

Fiberisanimportantpartofstayinghealthy.Thebenefitsofahigh-fiberdietinclude the prevention of both constipation and diarrhea, potentially reducingcholesterol,areductionincancerrisk,and(supposedly)thesensationoffullness.Vegetablesareanexcellentsourceofdietaryfiber,butfibersupplementscanbehelpfulinreachingdailyfibertargets.Choosingwholegrainswheneverpossiblehas become more attractive with the wide array of high-fiber breads nowavailable. Lightly toasting whole grain breads can make them even moreappealing.

Vegetables are the best food that you can include in any meal plan. Anexcellent source of fiber, vitamins, andminerals, they are the best choice forpeoplewhosnackand shouldbeapartofdailymealplanning.Try to includetwoormorevegetableservingswiththemainmealoftheday.Itisbesttoavoidfryingvegetables,butifyoulovethatextraflavor,trysautéingorgrillingtheminstead.Friedvegetablesmaytastegreat,buttheextracaloriesarewaytoomuchforthebodytohandle.MostAmericansaresufferingfromcaloricoverload,andtheconsequenceshavebeendisastrousforthehealthcaresystem.

The need for calcium is also high. TheU.S. government recommends thatmostadultstakeinover1,000mgaday.1Dairyproductsareanobviouschoiceforpeoplewhocantoleratedairy.An8oz(230g)cupofplainyogurt(nofruit)has just over 400 mg. Other sources include calcium-enhanced orange juice,sardines,orcannedsalmon.Spinachappearstohavehighlevelsofcalcium,butit also contains oxalic acid, which binds the calcium and interferes withabsorption.Kaleisabetteralternativeasavegetablesourceofcalcium.Turnipgreenshavetwiceasmuchcalciumaskale,butalsopossessastrongflavor.Youmay want to consider the use of dietary supplements, discussed later in thischapter.

Greenvegetablesareanessentialpartofahealthydietbecauseinadditiontocalciumtheycontainmagnesium,iron,andpotassium.Eatyourgreens!

TheCAPSDietFoodstoavoid:

C–CaffeineandChocolate

A–Alcoholicbeverages

P–Peppermint

S–Spicyfoods

Tomatoesareespeciallyhighinacidandshouldbeavoidedaswell.

FOODSTHATWORSENBACKPAIN

Youmaybewonderingwhatyoushouldn’teattoreduceyourbackpain.Thereare a coupleofdietary changes thatmayhelp, chief amongwhich is reducinggasinthedigestivetract.Becausetheintestinesandcertainstructuresinthebackshare common nervous system pathways, abdominal gas can increase theamountofpainperceivedasarisingfromtheback.2Andwhilesomepeopledonothaveanypainwithabdominalgas,othershaveasurprisingamountofpain.Lookover the table and identify foods thatmightbepartof theproblem.Thebestwaytotestthisistoeliminateasuspectedfoodforaweekortwoandseeiftheabdominalpainsgetbetter.

Spicyfoodmightalsoenhancebackpainthroughasimilarmechanism.Somepeople experience a strongdull pain in the lower abdomen several hours afterconsuming foods rich in redhotpepper.Becauseof the timedelay, sometimesthislowstomachpainseemsunrelatedtoyourdiet,butkeepitinmind.

CAPSFOODSAFFECTTHESTOMACHANDESOPHAGUS

If all the stress of living through an episode of back pain has your stomachchurning, try taking control of your diet with the CAPS plan.3,4 Some of theCAPS plan foods increase stomach acid production, while others cause aloosening of the closed ring that connects the esophagus and stomach. Thisclosedring,calledtheloweresophagealsphincter,normallyopenstoallowfoodinto the stomach and stays closed at all other times. Loosening this closureallowsstomachacidtoentertheesophaguswhereitcanburnthedelicatelining(thestomach’s lining isheavilyprotectedagainst stomachacid).Peppermint isone food that loosens the ring between the esophagus and the stomach, sopeppermint should be avoided by people with reflux symptoms. There areseveralmechanismsinplacetokeepstomachacidateffectivelevels,however,the stress of back pain and some aspects ofmanaging back pain can weakensomeof thebody’snaturaldefensesagainstacidreflux.Makesure tocutbackon alcohol, as it promotes esophageal damage from reflux—and doesn’t mixwith many of the medications used for back pain. The association betweensmokingandgastroesophagealrefluxdisease(GERD)is lesswellestablished,but it isbelieved thatsmoking irritates theesophagealsphincterandshouldbeavoidedtoreduceGERD.

DRINKEIGHTFULLGLASSESOFWATER

Drinkingadequatewaterisimportantforahealthyback.Whileitispossibletodrinktoomuchwater,gettingeight8oz(235ml)glassesofwatereachdayisagood goal. Especially if you are taking anNSAID (ibuprofen, naproxen), youwillwanttostaywellhydratedasthecombinationofdehydrationandNSAIDscanbeespeciallytaxingonthekidneys.Don’tmakethemistakeofthinkingthatsoda, sweetened teas, or juice can replace your need for water. Many sugar-sweetenedsodascontainsomuchsugarthattheyareactuallydehydratingtothebody.Dietsodasseemtobesingularlyineffectiveathelpingpeopleloseweight.Thinkofalltheskinnypeopleyouknowwhodrinkdietsoda;nowthinkofalltheheavypeopleyouknowwhodrinkdietsoda:whichlistislonger?

Thebenefitsofdrinkingwateraretremendous,fromimprovingoralhygieneto reducing food consumption. Most diet experts recommend limiting waterintakeatmealtimetoafewsips.Itseemsthatdrinkingwaterinbetweenmealsandespecially20minutesbeforemealtimesisagoodstrategy.

KnowYourSupplements

GLUCOSAMINEANDCHONDROITINSULFATEFORJOINTS

Glucosamine and chondroitin sulfate is themost commonlyusednon-nutritivedietarysupplementforthetreatmentofarthritis.Derivedfromcow’shoovesandshark cartilage, glucosamine and chondroitin sulfate are compounds that arenormallyfoundinjoints.Thesupplementationofthesecompoundsinthedietisbelieved to contribute to jointmotions that are smooth and relativelypainless.Thereissomescientificevidencetosupporttheiruseinosteoarthritisofthekneeandhip.5,6Aspecificbenefitforspinearthritishasnotyetbeenshown.7

Additionalmechanismsmayexplainthebeneficialeffectsofthecompoundsagainst pain. One possibility is that glucosamine in particular may block thereleaseofsignalingfactorsthatdriveinflammation,butthishasbeenshowninlaboratorystudiesonly.8Anotherpossibility,showninseverallab-basedstudies,itthatchondroitinmayblock thesproutingonpain-sensingnerves,whichmayhelp prevent pain after back injury as a normally vigorous sprouting responsecontributestoextrapainsensitivity.9Therearenorecommendeddoses for thissupplement as it is not a nutritive element. A $12 million NIH-funded studyexaminedtheeffectsofglucosamine1,500mgandchondroitin1,200mgdailyandfoundnobenefitinthemainstudygroup;howeverthosepatientswithmoreseverepainmayhavehadabenefitfromthetreatment.10

FactorsThatIncreaseStomachAcidReflux•Stress

•IbuprofenandotherNSAIDs

•Lyingdownsoonaftermeals

•CAPSfoods

•Frequentbendingover

•Heavylifting

•Obesity

•Fattyfoods

CALCIUMFORBONES

Calcium is clearly important for bone health.MostAmericans are not gettingenoughcalcium,and theconsequencesareanationalepidemicofosteoporosisand pathological fractures. The bones prone to fracture include the vertebralbones,pelvicbones,andhips,allpotential sourcesof severebackandbuttockpain. As noted above, the daily requirement for calcium is at least 1,000mgdaily. Most adults have difficulty reaching this goal. The two main forms ofcalcium supplements available are calcium carbonate and calcium citrate.Calciumcarbonateisusuallylessexpensiveandmorereadilyavailable.Calciumcitrate is probably better absorbed by peoplewith low levels of stomach acid(thosewhomaybe takingmedicationforGERD/refluxfall into thiscategory).Additionally,itisrecommendedthattheamounttakenatanyonetimeduringthedayis500mg,asthiswillimproveoverallabsorptionandlimittroublesomesideeffectssuchasconstipationandbloatingthatoccurathigherdoses.

VITAMINDFORBONES,NERVES,MUSCLES,ANDIMMUNITY

VitaminDisvitallyimportantforbonehealth.WithoutvitaminD,calciumisnotproperly deposited into bones and bones become thin and fragile.Not gettingenough vitamin D can lead to osteoporosis and osteomalacia (severedecalcification of the bones), predisposing to vertebral fracture and ultimatelyspinalcollapse.

The NIH has reported that vitamin D is also involved in the function ofnerves, muscles, and the immune system (ODS/NIH). Vitamin D has beenshowntoreduceinflammation.MorecontroversialaretheclaimsthatvitaminDinsufficiencyisaleadingcauseofchronicpain.Thereareanumberofstudies,summarizedbyLeavitt,thatsuggestapossiblelinkbetweensupplementationofvitaminDandacessationofchronicpain.11,12Morestudiesareneededbeforedefinitiverecommendationscanbemade;however,manyphysiciansareofferingtoordertestingofvitaminDlevelsfortheirpatientsbecauseoftheseriousrisksofvitaminDdeficiency.FactorsthatcontributetotheneedforincreaseddietaryintakeincludedecreasedlevelsofsunexposureandtheuseofsunscreensthatblockUV-Brays.TheNIHrecommends limitingvitaminD intake tonomorethan 2000 IU daily. Interestingly, the recommended intake of vitamin Dincreaseswithage,sowhileadultsunder50yearsoldareadvisedtotakein200internationalunits(IU)aday,adults50to70shouldconsume400IUdaily,andadultsover70shouldconsume600IU.

SpecialTips:•Rinsecanned tunaandpackaged lunchmeats; thiswill loweryoursodiumintake. Avoid canned vegetables; substitute fresh or frozen whereverpossible.

•Onlybuylow-fatmilk,orfat-freeifyoucantoleratethe“skim-milk”taste.•Useonlylow-fatcheese.•Useyourmicrowavetocookyourvegetables:Theycomeoutbrighterandtastierthanstove-topveggies.

•Make soup once aweek in thewinter (but get someone to help lift thatheavysouppotoffthestovewhennecessary).

•Growyour ownherbs for seasoning: chives, dill, andbasil are especiallyeasytocultivate.

•Makesuretoincludefishinyourdiet.

VITAMINBFORMUSCLESANDNERVES

VitaminB12mayhelpalleviatebackpain,asshowninaclinicaltrial.13Itisanessential element in the metabolism of muscles and nerves. In conditions ofdeficiency,peopleexperiencedepression,bizarre tinglingsensations,andoftentimesdiffuse, poorly explainedpains.The associationofB12 andbackpain isprobably limited in younger adults, although it is now believed that B12deficiency ismoreprevalent thanpreviously thought.The tendency tovitaminB12deficiencyincreaseswithageandmayexceed15percentofthepopulation.ThereisessentiallynoupperlimittotheconsumptionofvitaminB12;however,recommendedintake levelsarerelativelysmall:2.4microgramsdailyformostadults.GoodfoodsourcesofvitaminB12 includebeef liver, trout,salmon,andfortifiedbreakfastcereal.

An important challenge tomaintainingnormal levels of vitaminB12 is thattheabsorptionofthisvitamindependsonaproteinmadeinthestomachandalsoonnormalstomachacidity.Inmanyolderadults,thereisafailureofvitaminB12absorption; as the stomach fails tomake the necessary chaperone protein,B12levels in the blood gradually fall and the onset of deficiency is creeping andinsidious.AsupplementofB12dissolvedunderthetonguemaybeaneffectivereplacement for the vitamin shots that have been prescribed in past years;however, this therapy should be implemented under the supervision of yourdoctor. It seems that many of the medicines used for acid reflux may alsointerferewithvitaminB12absorptionbyreducingstomachacid.Talkwithyourdoctor about checking your levels regularly if you are on long-term treatmentwiththesemedications.

DIETARYSUPPLEMENTSTHATMIGHTCAUSEHARM

• Vitamin B6 taken at high doses may actually cause a painful neuropathy.TakingvitaminB6 at doses significantly above the daily recommendationshas been shown to destroy nerves and cause pain. It is prudent not toconsumemore than250percentof thedaily recommendedamountsofB6:Add up the percentages from all your vitamins to determine your currentintake.

• Excessive intake of the fat-soluble vitamins A, D, E, and K should beavoided.Itisdifficultforthebodytoremoveanyunneededamountsofthesevitamins,andtoxicaccumulationscanoccur.

FOODSWITHANTI-INFLAMMATORYPROPERTIES

Turmericcontainsacompound,curcumin,whichhasbeenshowninlaboratorystudiestohaveactivityagainstmoleculesthatsignalinflammation.However,theabilityofthiscompoundtoenterthebloodstreamislimited,andthebenefitsofconsuming turmeric as a food or supplement have not been definitivelyproven.14

AVOIDPRO-INFLAMMATORYFOODS

Omega-6oilsareprecursorstopro-inflammatorycompoundsinthebody,calledeicosanoids. Eicosanoids drive inflammatory and pain signals in the body.Omega-6oilsareespeciallyrichincorn,safflower,andsunflowercookingoils.Itisbettertolimittheuseoftheseoils;substituteoliveandcanolaoils.15

MORERESOURCES

While losingweightwhenyou are sidelinedbybackpainmaybe impossible,youcanvaryyourdiettohelpwithyourback.Inthischapter,I’vehighlightedsomepossible changes thatmaybehelpful to you in your quest for improvedback health. You will find other valuable resources at the American HeartAssociation, theNationalCenter forComplimentaryandAlternativeMedicine,theNIH,andtheNationalDigestiveDiseasesClearinghousewebsites.

CHAPTERRESOURCES

1. NIH. “Calcium Fact Sheet,”http://dietarysupplements.info.nih.gov/factsheets/calcium.asp.Accessed January31,2010.

2. Gao, J., et al. 2006. Enhanced responses of the anterior cingulate cortexneurones to colonic distension in viscerally hypersensitive rats.JPhysiol 570:169–83.

3. Mullick, T., and J. E. Richter. 2000. Chronic GERD: Strategies to relievesymptomsandmanagecomplications.Geriatrics55:28–43.

4.Kahrilas,P.J.1996.Gastroesophagealrefluxdisease.JAMA276:983–88.

5.Herrero-Beaumont,G., et al. 2007.Glucosamine sulfate in the treatment ofkneeosteoarthritissymptoms.ArthritisRheum56(2):555–67.

6.Pavelká,K.,etal.2002.Glucosaminesulfateuseanddelayofprogressionofkneeosteoarthritis.ArchInternMed162(18):2113–23.

7.Leffler,C.T.,etal.1999.Glucosamine,chondroitin,andmanganeseascorbatefordegenerativejointdiseaseofthekneeorlowback.MilMed164(2):85–91.

8. Walsh, A.J., C.W. O’Neill, and J.C. Lotz. 2007. Glucosamine HCl altersproduction of inflammatorymediators by rat intervertebral disc cells in vitro.SpineJ7(5):601–8.

9.Grimpe,B.,etal.2005.TheroleofproteoglycansinSchwanncell/astrocyteinteractions and in regeneration failure at PNS/CNS interfaces. Mol CellNeurosci28(1):18–29.

10.Clegg,D.O., et al. 2006.Glucosamine, chondroitin sulfate, and the two incombinationforpainfulkneeosteoarthritis.NEnglJMed354(8):795–808.

11. Leavitt, S.B. “Vitamin D – A Neglected ‘Analgesic’ for ChronicMusculoskeletal Pain, An Evidence-Based Review and Clinical PracticeGuidance.”MedicalReviewersBruceHollis, Ph.D.,Michael F.Holick,M.D.,Ph.D.,etal.June2008,http://Pain-Topics.org/VitaminD.

12.Schwalfenberg,G.2009. Improvementofchronicbackpainor failedbacksurgerywithvitaminDrepletion:Acaseseries.JABFM22(1):69–74.

13. Mauro, G.L., et al. 2000. Vitamin B12 in low back pain: A randomised,double-blind,placebo-controlledstudy.EurRevMedPharmacolSci4(3):53–8.

14. Henrotin, Y., et al. 2010. Biological actions of curcumin on articularchondrocytes.OsteoarthritisCartilage18(2):141–9.

15. Baskette,Michael and EleanorMainella. The Art of Nutritional Cooking,SecondEdition.UpperSaddleRiver,NJ:PrenticeHall,1999.

CHAPTER22YourBack:AGuidedTour

Knowthemechanismsofyourbackpain.

theDIAGNOSIS

Learningabouttheanatomyofyourspineandthephysiologyofhowpainworkscan help you answer questions such as these.This chapterwill take you on aquick tour of the spine and provide a brief description of how your bodyprocessespain.

>Doyou everwonder howyou canbe hurting somuch, but your doctorsdon’tknowreasonwhy?

>Whydoessomepainseemtolastforever,whileotherpaingoesawaywhenthewoundheals?

AnatomyoftheSpine

Regardless of size, spines followa one-design-fits-all biologicalmodel,whichinvolvesbonystructurescalledvertebraestackedontopofeachotherinacanal.Dinosaurs,humans,monkeys,mice,andallrelatedcreatureshavevariationsofthesamemodel.Remarkably,theyallsharethesamecombinationofvertebrae,from delicate structures in the neck to sturdier structures in the lower back.These common characteristics are where we get the name for our species:vertebrates.

Thereisonemajordifferenceinthespinesofsomevertebrates.Humansandothercloselyrelatedanimalshaveverticallyorganizedspinalcolumnsandwalkon two legs. Most other vertebrates—from big black bears to mice—havehorizontallyorganizedspinesandwalkonallfours.Theverticalspinehassomeadvantages. For example, being upright gives us the use of our hands whilewalking or running, and we are taller than we would be on all fours. Thedownsideisthatouruprightpostureleavesuspronetowearandtearofthediscsandrelatedstructuresofthespine,aswellasotherproblemsoftheback.

SpineshavethreecurvesforminganSshape.Theyarethecervical,thoracic,and lumbrosacral curves, named for the types of vertebrae they include.FollowingtheS-shapedpath,yourspinesitsinacanalthatrunsdownthelengthofyourback fromyourbrain toyourbottom.The spine ismadeupofbones,ligaments, tendons, large muscles, weight-bearing joints, and highly sensitivenerves.It’sthecenterofcontrolforyourpostureandprovidesstabilitywhenyoustand. It also houses and protects your all-important spinal cord, thecommunicationrouteforyourbrainandnervoussystem.Unfortunately,becausethespinehassomanytasks,itishighlysusceptibletoinjury,whichcanstrikeitsvertabrae,ligaments,discs,ormuscles.Bonespursorscartissuealongthespinecanalsopressagainstnerverootscausingpain.

VERTEBRAESUPPORTMUSCLESANDALLOWFORMOTION

Vertebraearethebox-shapedbonesthatprovidethearchitectureforyourspineand carrymost of theweight placedon it.They are formed inpart by strong,sturdy, and flexible cancellous (spongy) bone containing a core of marrow,whichproducesredbloodcells.Mostadults’spineshave32vertebrae,stackedon top of each other. The vertebrae meet at joints, which allow for slightmovement.Sometimespeoplehaveonefeweroroneextravertebra,but this isnotmechanicallyadvantageous.

BackFacts:TheSpine•Istheplatformforandprovidesflexibilityforyourhead,whichweighsintheneighborhoodof11pounds(5kg).

• Supports and provides flexibility for your upper body.Your spine allowsyoutobendforward,backward,andsideways.

•Providesshelterforandprotectsyourspinalcordandnerves.• Is one of the key structures in your skeleton, and has many essentialmusclesandligamentsattached.

Therearefivedifferenttypesofvertebrae:•Cervical vertebrae:Sevenvertebrae that hold upyour neck and allow it tomoverightandleft.

• Thoracic vertebrae Two vertebrae that are located in themiddle back andextendforwardastheribs.Theyhelpprotecttheheartandlungsandsupporttheweightofthearmsandshoulders.Becausetheyarelimitedinmovement,theyrarelyhaveherniateddiscs.

• Lumbar vertebrae: Five vertebrae located in the lower back. They are thelargest vertebrae and carry most of your body’s weight, which is why somany people have pain in this area. These vertebrae allow forward andbackwardmotion.

•Sacrum:Fivevertebrae locatedbelowthe lumbarvertebrae.Theyarefusedtogether in one triangular section.The sacrumprovides attachment for thehipbonesandprotectsorgans.

•Coccyx:Three vertebrae located at the verybottomof the spine.They arealsofused.Theysupportthemusclesofthebuttocks.

FACETJOINTSLINKTHEVERTEBRAE

Housedbetweenyourvertebraearestructurescalledfacetjoints.Thefacetsarebony knobs that link the vertebrae together andmake it possible for them tomoveagainsteachother.Thefacetjointsgivethespineitsflexibility.Asmoothlining called the synovium sits between the facet joints. The lining producessynovialfluid,whichnourishesandlubricatesthejoint.

THESPINALCORDCARRIESCELLSANDNERVES

Partofthecentralnervoussystem,yourspinalcordisrichwithcellsandnervepathwaysthatrunabout18inches(46cm)fromthebottomofyourbrainstemallthewaydowntoyourlowerback.Althoughitplaysaleadingroleinthenervoussystem, thespinalcord is relativelydelicateandsmall. (It is thewidthofyourlittlefinger.)Thespinalcordisprotectedbythe32vertebraeofthespine.

Spinal cords have two types of nerves:whitematter,which are also calledlong tracts because as nerves go, they are quite long, and grey matter. Longtractscontrolmessages from thebrain todistantpartsof thebody.Theydon’tstopalongthewaytoconversewithindividualneurons(cellsthatsendelectricalsignalstootherneurons).Theyalsoconnectdifferentsectionsofthespinalcordtoeachother.Greymattermakesconnectionsbetweenindividualneurons.

AnatomyoftheSpine

THESPINALCANALHOUSESTHESPINALCORD

The spinal cord sits in the spinal canal.Vertebral bodies form the floor of thecanaland flatbonescalled lamina form the roof.Ductswherenervesexit andenter thespinesiton thewallsof thecanal.Betweeneachwallaresupportingstructurescalledpedicles.

DISCSABSORBSHOCKS

Discs sit between the vertebrae where they serve as spacers and providecushioning.Thediscscontainagel-likefluidcallednucleuspulposus,which isprimarilywater.

Vertebraediscsaresupportedinpartbyatoughouterlayercalledtheannulusfibrosis. Along with the vertebrae, the discs and annulus fibrosis cushion thespine.When pressure occurs, such aswhen you lift something heavy or twistaround,thenucleuspulposusiscompressed.Whenthelifting,twisting,orotheractivity stops, thegelgoesback to itsoriginal shape.Thevertebraediscsalsosafeguardtheopeningswherethenervesexitthespinalcord.

Vertebrae discs are often the guilty party behind back pain. The nucleuspulposuscanrupture,leakingorbulgingoutandpressingagainstnervesthatlinethe spine. The discs in the cervical and lumbar regions are themost likely torupture.Thispainfulbackconditionmaybeatorndisc,herniateddisc,slippeddisc,ruptureddisc,bulgingdisc,prolapseddisc,orprotrudingdisc.

MUSCLES,TENDONS,ANDLIGAMENTS

Themuscles runningup anddownyour back support your spine.When thesemusclesarestrong,theyalsoprotectyourbackandhelpyoumovearoundwithease. But if they becomeweak due to lack of exercise, aging, obesity, or forotherreasons,yourspineisfarlessflexibleandmoreeasilyinjured.

Themusclesinyourstomachareaandtrunkalsohelpsupportyourspineandaid mobility. In addition, tendons connect your muscles to your bones, andligamentsjoinyourvertebraetogether.Ligamentsalsoprovideyourspinewithflexibilityandcontrol.

PainPathways:AGuidedTour

Itishelpfultoyourunderstandingofbackpaintoknowhownervesignalsleavethe siteof an injury, travel toyourbrain, and returnas a feeling thathurts. Inaddition,therearemysteriousfeaturesofpainthatyoumayencounterandwouldliketounderstandbetter.Forexample,painmayoccurforwhatappearstobeno

reason at all. The cause of the pain has long since healed, has probably evenbeenforgottenabout,butpaincontinues,sometimesforaverylongtime.Thisiscalledneuropathicpain,andIdiscussitandotherpainconceptsinthefollowingsections.

THENERVOUSSYSTEMCOMMUNICATESPAIN

Yournervoussystemisyourbody’scommunicationhighwayforpain.Ithastwoparts:•Thebrainandspinalcord,alsoknownasthecentralnervoussystem(CNS).• The peripheral nervous system (PNS), which includes all the sensory andmotornervesthatgotoandfromyourCNS.

NERVECELLSSENDSIGNALS

Painisaresponsetoaninjurybyspecifictypesofnervecells(neurons)inyourPNS called nociceptors. Their job is to warn your brain when an injury hasoccurred.Inthecaseofbackpain, theinjurymaybetheresultofanyharmfuleventfromsmalltocatastrophic,suchasapinchednerveoracarcrash.Therearefourothersconceptsinthepainprocessthatyoushouldbefamiliarwith:•Sensitizationoccurswhennervecellsreleaseneurotransmitters thatactuallyincreasethestrengthofthepainmessagesbeingsenttoyourbrain.

• Inflammation is your body’s response from an injury that may result inredness,heat,pain,swelling,andlossoffunction.Itoftenpilesonadditionalpainintheareasurroundinganinjury.Inflammationcanalsobeacauseofsensitization.

•Allodyniaispaincausedbysomethingthatdoesnotnormallyelicitit,suchasabrushstrokeorbedsheets.Allodyniacanaccompanymanyotherpainfulconditionssuchasneuropathiesandsevereinjuries.

•Hyperalgesiaisanamplifiedpainresponsetoaninjurythatnormallywouldprovokefarlesspain.Inmedicalterms,thismeansthattheindividual’s“painthreshold”isreduced.Hyperalgesiacanstrikeadiscreteareaofthebodyorbewidespread.Theconditionhasthreesubtypes:

- Primary hyperalgesia is increased pain sensitivity in the damagedtissues.

- Secondary hyperalgesia is increased pain sensitivity in surroundingundamagedtissues.

-Opioid-induced hyperalgesia is increased pain sensitivity caused by

long-termopioid(narcotic)use.

TypesOfPain

Therearethreemajortypesofpain:nociceptive,inflammatory,andneuropathic.Allthreetypesofpainareimportantforbackpain:Theycanco-existoroccurseparately.Treatmentstrategiesvarydependingonpaintypeinvolved.

NOCICEPTIVEPAIN

Asthenamesuggests,nociceptivepainoccurswhenpain-sensingnerveendingsare stimulated by injury or an injurious stimulus. Anything that potentiallydamagesbodytissues,suchasablow,acut,oraburn,canresultinnociceptivepain.

INFLAMMATORYPAIN

Inflammatory pain arises from changes in the pain signaling system due toinflammation.Wheninflammationarises,thereisanincreaseinthelocalprod-uctionof“inflammatorysignalingmolecules;”thesechangehowsensorysignalsareprocessed.

Often, inflammatorypain is characterizedby a strong amplificationof painsensation:amildlypainfulstimulusgetstranslatedintoastronger,sharperpain.Inflammatorypaincanalsobecharacterizedbypain in response to a stimulusthat is not normally painful, for example gently bumping an ingrown toenail.NSAIDsareusuallyhelpfulforinflammatorypain.

NEUROPATHICPAIN

Neuropathicpainiscausedbydamagetoormalfunctionof thebody’ssensorysystem. In neuropathic pain, the body’s pain sensing system is no longer afaithful reporter of injury.Neuropathic nerveswill signal damagewhere noneexists and over-amplifyminor insults. The result is amarked increase in painand suffering.Neuropathicpaincanoccur after a stroke, spinal cord injury,ordiabetes.NSAIDsusuallydonothelppatientswithneuropathicpain.

ACUTEVERSUSCHRONICBACKPAIN

Acute pain leaves when the injury is healed. Chronic pain lingers on, oftengreatlyaffectingthequalityoflifeofthepatient.Sometimestheculpritbehindchronic pain is a health problem such as rheumatoid arthritis, which bydefinition causes continuing and persistent damage to body tissues and keepspainpathwaysbusy.Sometimesthenervoussystemdoesnotgetthemessageto

stopsendingpainsignals.Inotherwords,itdoesn’tshutdowneventhoughtheinjuryhaslongsincehealed.Insuchcases,theactualcauseofthestubbornpainprocesscanbedifficulttodetect.

Chronicbackpaincommonlyhits(andstayswith)youinoneoftwoways:•Constant:It’spresentformorethanthreemonths.•Recurring: The pain stays for long periods of time. Then it leaves only tocomebackagain.Thismaddeningpatterncancontinueformonthsoryears.

KNOWLEDGEISPOWERFORYOURBACK

Thepain-sensingsystemplaysavitalroleinhelpingustoprotectourselvesfrombodilyharm.Itisatragic,butvaluablelessontolearnthatchildrenwhoarebornwithout an intact pain systemareprone to recurrent injuries, andoftendonotsurvive to adulthood. Nonetheless, if the sales of pain-medications are anyindicator,wecollectivelyhavealotmorepainthanwearereallycopingwith.

Thisbookwasdesignedtoequipyouwiththeknowledgeandskillstoliveabetter and healthier life, and “make peace with your back.” If the measuresdescribedherearenotsufficienttogetyoucomfortableandmovingagain,you’llneedtospeakwithyourdoctoraboutsurgeryorprescriptionmedications.Iftherecommendation is formedication, it’s important toknow that therearemany,manymedications that can be used in the treatment of back pain. Sometimes,thesemedicationsworkbetterwhenused together; sometimes findinga singlemedicationthattargetsthecoreofaproblemissufficient.Learn,askquestions,andlearnsomemore.Learningmoreaboutyourbodyandyourbackwillonlyhelpyounavigatethischallengingcourse.

ACKNOWLEDGMENTSWith thanks to JillAlexander,my senior editor at FairWinds Press,who hasbroughtthisprojecttohappyfruition;toLauraB.Smith,whoranlikethewindwiththismanuscript, infusingpositiveenergyalongtheway;totheproductionstaff,whogavethebooksparkle.ToMarilynAllen,anagentparexcellenceandaconnoisseurofbeautifulbooks.

Many people contributed to the conceptualization and realization of thisproject: Pamela Talalay, for her indefatigable encouragement and keen wit;ThomasBrushart,whoinspiredmetowritemyownbook;JustinMcArthur,whohasatmanyturnssupportedmycareerdevelopment;DickMeyer,JimCampbell,JackGriffin,MarcoRizzo,LewLevy,SteveWaxman, andBobKalb for theirsupportofmyinterestinpain;DinaAdamsforlendingherexpertiseinphysicaltherapyandher contributions to the therapeuticplan in earlierversionsof thisproject;MichaelShearforhisdemonstrationthatanexcellentphysicianmust,asHippocrates said, be prepared to “make the patient, the attendants, and theexternalscooperate.”

Thanks to those who have read and provided sage comments on themanuscript:AnnFrontera-Rial,ChaimandMindyLandau, andZanVautrinot.Thankstomychildren:Eitanfordoinghishomeworkat the tableandkeepingmecompany,andRachel,whohas taughtmetosay“goodnightcomputer.”ToEleanorMainella,forhercarefulreadingofandguidancethatimprovedthedietchapter.Tomymom,EilaMae,forteachingmetobeahappylearner,andtomydad,Donald,whohas alwaysbelieved I could accomplishmydreams.ToSolMilgrome, who taught me to “take a negative and make a positive.” And toSasha, my beloved, for his partnership, encouragement, and kindness in allthings.

ABOUTTHEAUTHOR

BethB.Murinson,M.S.,M.D.,Ph.D., is an attendingphysician, scientist, anddirector of pain education in Neurology at the Johns Hopkins School ofMedicine,whereshealsochairsthePainManagementTaskForce.

Murinson, a 2001 Diplomate in Neurology, American Board of Neurologyand Psychiatry, trained in neurology atYaleUniversity under the direction ofStephenG.Waxmanandcompletedathree-yearclinicalandresearchfellowshipatJohnsHopkinsSchoolofMedicineunderthedirectionofJohnW.Griffin.SheiscurrentlypartofasmallteamofHopkinsneurologistswhospendsignificantclinical time in intraoperative monitoring. In this, she utilizes allelectrodiagnostic modalities including electromyography; nerve conductionstudies;electroencephalography;sensory,motor,andauditoryevokedpotentials;andcorticalmapping.Murinsonhasclinical expertiseonneuropathicpainandbackpain, and shemanages patientswith both immune-mediatedneurologicaldisease as well as chronic pain due to injury or neuro-degenerative disease.Murinson is skilled in performing nerve and muscle biopsies. She has beenrecognized by peers as an outstanding physician and was selected as one ofBaltimore’s“TopDoctors”for2007.

Murinson has an active laboratory research program and has directed thetraining of numerous students in this context. Her current laboratory researchfocuses on two questions. The first is a translational science project thatexamines theoriginsofdrug-inducedeffectson theperipheralnervoussystem.Takingahighlynovelapproach, shehas leda teamofexperts in investigatingtheeffectsofwidelyprescribeddrugsonnervesandrelatedcellsinculture.Theresults indicate that pathways related to neurotrophin signaling are likely tomediate these effects. The second is the development of a novel model ofneuropathicnerve injury. In thismodel,Murinson isendeavoring to isolate theeffectsofneuronaldegenerationandbetterdefinetheroleoftheintactnerveinsignaling the effects of injury.Murinson is the author of more than 20 peer-reviewedpublications,aswellasnumerousbookchaptersonpain.Sheisapeer-reviewerforAnnalsofNeurology,Neurology,andBrainandNature.

Murinson is one of a select group of core faculty members committed tomedical education and chosen for inclusion in the Johns Hopkins CollegesAdvisory and Clinical Skills Program. She leads a multidisciplinary teamseekingtounderstandtheemotionaldevelopmentofmedicalstudentsandhowmedical trainees learn best about pain.Results of her educational research arepublished in the Journal of Pain and Academic Medicine and have beenpresentedattheAmericanPainSocietyandtheInternationalAssociationfortheStudyofPainmeetings.Shehasservedasco-directorof the researchprogram

for the 2007 national Learning Communities meeting in conjunction with theAAMC meeting and has served on a Panel for the U.S. National Board ofMedicalExaminers.Directorofanew,clinically-focusedcurriculuminpainatJohnsHopkins,Murinson isa2005Diplomateof theAmericanBoardofPainMedicine.

Murinsonisawifeandthemotheroftwochildren.Sheenjoysreadingbookswithherkidsandexcelsathelpingwithmathhomework,pianolessons,andartprojects.

IMAGECREDITSPage 21: originally published inYoga Beats the Blues; page 26: © UniversalImagesGroupLimited/Alamy;page35:©NucleusMedicalArt,Inc./Alamy;page 65: MEDICAL RF.COM / SCIENCE PHOTO LIBRARY; page 88: ©medicalpicture /Alamy; page 100, top:NEILBORDEN / SCIENCEPHOTOLIBRARY; page 114: SCOTT CAMAZINE / SCIENCE PHOTO LIBRARY;page117:©NucleusMedicalArt,Inc./Alamy;page127:ALAINPOL,ISM/SCIENCE PHOTO LIBRARY; page 129, top: © NucleusMedical Art, Inc. /Alamy; page 136, top: LIVING ART ENTERPRISES / SCIENCE PHOTOLIBRARY; page 136, bottom: LIVING ART ENTERPRISES / SCIENCEPHOTO LIBRARY; page 137: DU CANE MEDICAL IMAGING LTD /SCIENCEPHOTOLIBRARY;page146:©SebastianKaulitzki/Alamy;page153:©NucleusMedicalArt, Inc. /Alamy; page 163, top: BOVEISLAND /SCIENCEPHOTOLIBRARY;page182:originallypublishedinTamileeWebb’sDefyGravityWorkout;

page 183: originally published in Yoga Turns Back the Clock; page 184:originally published in Yoga Turns Back the Clock; page 186: originallypublished in Yoga Turns Back the Clock; page 224: Tony Hutchings / GettyImages; page 225: istockphoto.com; page 238: istockphoto.com; page 260: ©NucleusMedicalArt,Inc./Alamy

INDEXacupunctureenergyflow,216–217insurancecoverage,212introduction,211maximizingbenefits,212overview,216–217safety,218scientificresearch,217

acutebackpainbedrest,172–173changes,177communicating,170,171,174,177delayedpainafterinjury,177diagnosis,169–170employersand,172explanation,174icetherapy,172paincontrolrisks,174,176RedFlags,169–170thermaltherapy,172,173topicalagents,172

Alexander,F.Matthias,228aquatherapyaerobics,239bathtubs,237doctorrecommendations,236explanation,242introduction,235,238pools,237relaxation,240specialists,237stretching,239–240walking,239yoga,239–240

backanatomyacutebackpain,263–264cells,260chronicbackpain,263–264discs,261inflammatorypain,263ligaments,261muscles,261nerves,260,262nervesignals,261–262nervoussystemand,262neuropathicpain,263nociceptivepain,263spine,258,261tendons,261vertebrae,259,261

backstrain.Seemuscle-relatedbackpain.chiropractictherapyspinalinstability,111,113,115strokesand,113,191

coccydyniachildbirth,163chroniccases,161,165constipation,160cushions,160,161depression,165diagnosis,159electricalstimulationtherapy,161explanation,163icetherapy,161importanceofcoccyx,165inflammationcontrol,160injectiontherapy,161,162manualmanipulation,161obesityand,160physicaltherapy,162

predispositions,164surgery,162testing,162–163thermaltherapy,161

conditioningandstrengthening.Seealsoexercises.discherniation,37facetjointdisease,103–104sacroiliac(SI)jointdisfunction,92spinalstenosis,152–154tornandpainfuldiscs,58

Davies,Clair,25,75,212dietandnutritionanti-inflammatory,255BMI(bodymassindex),246,247–248calcium,249,253CAPSdiet,250,252gas-causingfoods,251glucosamine/chondroitinsupplements,69,252–253harmfulsupplements,254introduction,245painenhancementand,250pro-inflammatory,255resources,255specialtips,254vegetables,249vitaminB12supplements,254vitaminDsupplements,253–254water,252weightloss,246wholegrains,249

discherniationareasofnumbness,49causeofpain,47–49conditioningandstrengthening,37

delayingtreatment,36diagnosis,33discbulge,51discfragment,51discprotrusion,51electricalstimulation,36EMGs,43,45inversiontherapy,37legweakness,49manualtherapies,36medicationtherapy,34–35micro-discectomies,40–41MRIs,34,44–45NCSs,44painbelowtheknee,48secondopinions,38smokingand,44spinalinstabilitycomparedto,112surgery,34,38–42testing,46–47thermaltherapy,36tractiontherapy,37

electricalstimulationtherapycoccydynia,161discherniation,36facetjointdisease,103sacroiliac(SI)jointdisfunction,92sciaticcompressions,76spinalstenosis,152tornandpainfuldiscs,57

ergonomicsdiscpressure,197,198explanation,199introduction,195

knee-to-oppositeshoulderstretches,76leaning,197lifting,196lumbarsupport,197purses,197–198shoesand,198shoulder-bladesqueezes,198sitting,195,197,199standing,196,198telephoneheadsets,197wallslides,198–199

exercises.Seealsoconditioningandstrengthening.abdominalcrunches,20–21backcrunches,21facetjointdisease,103–104muscle-relatedbackpain,19–21Pilates,112–113resttherapyand,21sleepand,205

facetjointdiseaseconditioningandstrengthening,103–104diagnosis,99electricalstimulationtherapy,103explanationof,105–106facetdislocation,101facetjointdegeneration,101inflamedfacetjoints,101injectiontherapy,100,101,104inversiontherapy,103manualtherapies,103namevariations,106nerveblockprocedures,105painof,107parsdefect,107

physicaltherapy,100surgery,104testing,99,105thermaltherapy,102tractiontherapy,103

Feldenkrais,Moshe,229foods.Seedietandnutrition.

heattherapy.Seethermaltherapy.

icetherapyacutebackpain,172,173coccydynia,161RICE-Mtherapyand,16–17vertebralfractures,124

injectiontherapy.Seealsomedicationtherapy.coccydynia,161,162facetjointdisease,100,101,104piriformissyndrome,74sacroiliac(SI)jointdisfunction,92–93sciaticandothernervecompressions,77spinalstenosis,150,154steroids,135

intimacyacutebackpainand,205back-safepositions,207communication,202fantasies,206–207icetherapy,202importance,201pacing,206painmitigation,202personalvalues,206preparation,207recovery,207–208scentsand,207

inversiontherapydischerniation,37doctorrecommendations,236explanation,242facetjointdisease,103introduction,235,240inversiontables,237medicalconditionsand,241restas,237slantboards,241tornandpainfuldiscs,58yogaposes,242

Jacobson,Edmond,224

Leavitt,S.B.,253

manualtherapiescoccydynia,161discherniation,36facetjointdisease,103sacroiliac(SI)jointdisfunction,91sciaticcompressions,75spinalstenosis,152tornandpainfuldiscs,57

massagetherapyacupressure,212,215–216cranio-sacralmassage,214,215explanation,217insurancecoverage,212introduction,211maximizingbenefitsof,212miracleballs,216myofascialreleasemassage,214–215oils,219

post-massageactivity,215rolfing,215Swedishmassage,216triggerpoints,212,213–214

medicationtherapy.Seealsoinjectiontherapy.COX-2inhibitors,20EMGsand,45muscle-relatedbackpain,14,19NSAIDs,19,60,61–62,124opioidabuse,155piriformissyndrome,74sacroiliac(SI)jointdisfunction,89,93sciaticcompressions,73–77sideeffects,19spinalcordcompression,135spinalinstability,111spinalstenosis,154–155sleepingpills,209surgeryand,42tornandpainfuldiscs,54,55,59–62vertebralfractures,124

meditation.Seealsomind/bodytherapies.benefits,223,224breathing,228chakra-centered,225energy-based,225,228explanation,231guidedimagery,226introduction,221locations,223mantra-guided,225mindfulnessmeditation,227–228musclerelaxationmeditation,224–225pain-dissolving,226–227,233value-centered,227

mind/bodytherapies.Seealsomeditation.AlexanderTechnique,228–229

education,222energy-basedtherapies,222explanation,231Feldenkraistechnique,229introduction,221movementtherapyspecialists,222QiGong,230Reiki,230self-hypnosis,230–231spinalbreathing,230

MRI(MagneticResonanceImaging)bodymetals,46discherniation,34,44–45MRneurography,82necessity,69safety,45spinalstenosis,151tornandpainfuldiscs,62–63,69

muscle-relatedbackpaincauses,25,27compressiontherapy,18crampscomparedto,29diagnosis,13elevationtherapy,18icetherapy,16–17ligamentfatigue,22,28medicalattention,14,31medicationtherapy,14,19posture,16,28preventiontherapy,16,22–23prolongedsittingand,31reprogrammingand,16restorationexercises,19–21resttherapy,15–16RICE-Mtherapy,15–19spinalinstabilitycomparedto,112sprainsandstrains,27–28

testing,25

nervecompressions.Seesciaticandothernervecompressions.

physicaltherapycoccydynia,162facetjointdisease,100piriformissyndrome,74–75sacroiliac(SI)jointdisfunction,89,90,92sciaticnervecompression,73,74,75scoliosis,142,144spinalinstability,111,112spinalstenosis,150,151surgeryand,42tornandpainfuldiscs,54,58vertebralfractures,125

piriformissyndromeinjectiontherapy,74overview,85physicaltherapy,74–75prevention,74rarity,85

prescriptions.Seemedicationtherapy.preventiontherapyacupressure,23muscle-relatedbackpain,22–23,28position-changes,23posture,22,28sacroiliac(SI)jointdisfunction,83,91stretches,22symmetry,22triggerpointsand,23weightloss,23

Rammazini,Bernardo,195recoveryaerobicexercises,192jobworries,192painrelievers,191–192plancustomization,192–193restand,190riskofalternativetherapies,191self-advocacy,189,190,193stresslevelsand,191supportfor,193

RedFlagsacutebackpain,169–170importance,80medicalattention,14spinalcordcompression,133vertebralfracture,128

sacroiliac(SI)jointdisfunctionbackproblemsassociatedwith,97bandtherapy,89causes,97compressiontest,94conditioningandstrengthening,92core-strengtheningexercises,93diagnosis,87–88distinguishingtraitsof,97distractiontest,94electricalstimulationtherapy,92explanationof,82,95–96FARBERtest,94–95Gillet’smovementtest,95injectiontherapy,92–93“lowbackpain”and,88manualtherapies,91

medicationtherapy,89,93MRneurography,82pelvictorsiontest,94physicaltherapyfor,89,90,92pinchednervecomparedto,94pregnancyand,90,91prevention,83,91sacralsulcustendernesstest,95sacralthrusttest,94symptoms,95testing,82,88,94–95thermaltherapy,92thighthrust,94

sciaticandothernervecompressionsdiagnosis,71–72electricalstimulationtherapy,76foot/lowerlegpain,81injectiontherapy,77knee-to-oppositeshoulderstretches,76–77manualtherapy,75medicationtherapy,73–77physicaltherapy,73,74,75post-herpeticneuralgia(PHN),80–81pudendalnervecompression,73pudendalneuropathy,78–79sciaticacomparedto,72stretchingduringrecovery,76–77surgery,74,77thermaltherapy,75thoracicnerverootproblems,74triggerpointsand,75

scoliosisbracing,142,144diagnosis,141explanation,146geographiclocationand,143

lackoftreatment,147occurrencesof,143physicaltherapy,142,144surgery,143,144,145,147testing,145

sex.Seeintimacy.Simons,David,24sleepdietand,202environment,204–205exerciseand,205explanation,208futons,204introduction,201mattresses,202,203medications,209padding,202,203–204soothingactivities,202,205supportpillows,202,204watermattresses,205

slippeddisc.Seedischerniation.spinalcordcompressiondiagnosis,133explanation,136–138lowerbackregion,134medicationtherapy,135middlebackregion,134neck,134research,139rehabilitation,136spinalcordstrokecomparedto,139steroidtherapy,135supportfor,135surgeryfor,135testing,136

spinalinstability(spondylolisthesis)

bulgingdisccomparedto,112chiropractictherapy,111,113,115computer-controlledtherapy,113corsets,111,112decompressiontherapy,111diagnosis,109–110explanation,117–118high-riskgroups,119medicationtherapy,111physicaltherapy,111,112Pilatesand,112–113pulledmusclecomparedto,112surgery,111,114–116,118testing,116–117triggers,119

spinalstenosiscauses,157clinicaltrials,150conditioningandstrengthening,152–154diagnosis,149electricalstimulation,152exercisesand,152explanation,156injectiontherapy,150,154manualtherapies,152medicationtherapy,154–155MRIs,151physicaltherapy,150,151surgery,150,155,156testing,155thermaltherapies,152X-rays,151

spondylolisthesis.Seespinalinstability.surgerycoccydynia,162discherniation,34

effectiveness,39facetjointdisease,104medications,42micro-endoscopicdiscectomy,40–41NSAIDsand,117opendiscectomy,39post-opexpectations,41post-opphysicaltherapy,42post-oprestrictions,42preparationfor,41pudendalnervecompression,73pudendalneuropathy,79questionstoask,39sciaticcompressions,74,77scoliosis,143,144,145,147smokingand,44,115,116spinalcordcompression,135spinalfusion,114–116spinalinstability,111,118spinalstenosis,150,155,156supportfor,38–39to-dolist,38vertebralfractures,127

thermaltherapyacutebackpain,172,173coccydynia,161discherniation,36facetjointdisease,102sciaticcompressions,75sacroiliac(SI)jointdisfunction,92spinalstenosis,152tornandpainfuldiscs,57

tornandpainfuldiscsbulgingdiscs,56diagnosis,53discanatomy,64

disccore,65discdegeneration,56disc-endplate,67explanation,64–67glucosamine/chondroitin,69medicationtherapy,54,55,59–62MRIsfor,62–63,69outerdiscring,66–67painmedicationspecialists,55physicaltherapy,54,58provacativediscography,63–64recoverytime,63,69secondopinions,56spinalcordstimulators,60testing,62–64tractiontherapy,58

Travell,Janet,24,213triggerpointsdischerniation,36facetdisease,103introduction,24–25preventiontherapyand,23researchon,24sciaticcompressionsand,75therapies,25,212,213–214

Usui,Mikao,230

vertebralfracturescancerand,130classificationsof,128–129corsets,126diagnosis,121exerciseand,131explanationof,127–130

icetherapy,124immobilization,122,123,126lowerbackregion,123medicationtherapy,124middlebackregion,122neck,122nervecompressionand,81osteoporosisand,121,127,129physicaltherapy,125prolongedpain,131redflags,128self-diagnosis,121smokingand,123surgery,127testing,127vertebroplasty,124,125

watertherapy.Seeaquatherapy.

yogaaquatherapyand,239–240breathingexercises,180BridgePose,182Child’sPose,183CorpsePose,186DancerPose,185Downward-FacingDogPose,185explanation,186FiercePose,184–185ForwardFold/Ragdoll,186HalfLocustPose,182HalfWind-RelievingPosture,183introduction,179inversiontherapyand,242locationsfor,180

lying-downvinyasa,181–183MountainPose,181StandingBackbendPose,185standingvinyasa,184–186TreePose,181WarriorPoses,184

Young,Shinzen,233

Text©2011BethB.Murinson,M.S.,M.D.,Ph.D.

FirstpublishedintheUSAin2011byFairWindsPress,amemberofQuaysidePublishingGroup100CummingsCenterSuite406-LBeverly,MA01915-6101www.fairwindspress.com

Allrightsreserved.Nopartof thisbookmaybereproducedorutilized, inanyform or by any means, electronic or mechanical, without prior permission inwritingfromthepublisher.

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ISBN-13:978-1-59233-406-3ISBN-10:1-59233-406-7

Digitaledition:978-1-61059-377-9Softcoveredition:978-1-59233-406-3

LibraryofCongressCataloging-in-PublicationData

Murinson,BethB.Takebackyourback:everythingyouneedtoknowtoeffectivelyreverseandmanagebackpain/BethB.Murinson.p.cm.Includesindex.ISBN-13:978-1-59233-406-3ISBN-10:1-59233-406-71.Backache—Poularworks.I.Title.RD771.B217M8672010617.5’64—dc222010031796

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Theinformationinthisbookisforeducationalpurposesonly.Itisnotintendedto replace the advice of a physician or medical practitioner. Please see yourhealth-careproviderbeforebeginninganynewhealthprogram.