The View from Sports Center

Diagnostic Discrimination

Listen to this interview from NPR with a nationally recognized expert on back pain, James Weinstein, D.O. and maybe you'll hear what I heard.

Diagnostic discrimination.

Dr. Weinstein has chronic lower back pain, sometimes so bad that he's not sure if he can make it through his clinical day, yet has not been worked up for it, has not had any imaging studies, and has no diagnosis. His treatment? Ignore it, keep running, change nothing. Dr. Weinstein believes that "hurt does not mean harm." So, just because his back hurts, he can't stand up or perhaps walk, doesn't mean he has harmed himself.

He clings to the outdated notion that 90% of all back pain sufferers will be fine within a few months of the first onset of back pain. What he fails to mention that although this is true, nearly all will still be complaining of back pain and related disability one year later*.

His thinking makes no sense to me. If you spend an afternoon working in your garden and the next morning, your back hurts so bad you cannot stand up straight, you're injured. Period. All movement or activity or exercise that exceeds your body's capacity results in an injury. The only question is how badly are you injured? Injury is the transfer of energy causing an interference of cellular function resulting in physical function decline. If you go to the gym, workout, and hurt the next day, you injured yourself. Two days later, maybe you're fine. In that case, the injury was mild.  Get hit by a truck? Big injury.

I say, he's in denial. In fact, when the interviewer asked him why he had not had an x-ray or MRI, or been diagnosed, he said it was probably because he was afraid of what he might find out. Hmmm....I've had a swim or two in that river. Murky, mucky, filled with all sorts of crap that seeps its way into your brain convincing you that you're really swimming in a pristine pool of cool, clear aqua.

Dr. Weinstein does make sense though in his general approach to back pain. He believes that movement is the key to overcoming (although not solving) back pain but what he's missing is an understanding of the consequences of arbitrary movement. His advice is just to grin and bear it. Muscle through it. The result for him? Dr Weinstein has resigned himself to a lifetime of episodic back pain and that's just the way it is. He's just going to have these days when, out of the blue, as if the Back Pain Fairy sprinkled pain dust on him, he's all knotted up and crippled. He has no plan other than to just keep doing what he's been doing. He has no plan on solving his back pain because he doesn't believe it can be solved. Unfortunately, his view is what his patients get as well.

Does it make you wonder if other types of physical problems get this sort of treatment? This almost medieval, Braveheart approach? Can you imagine? Sprained ankle? Yeah, sure , run on it! Oh, and that subluxing shoulder? No problem! Just keep lifting weights! And, oh, your Achilles Tendon hurts? Sure - sprint! It'll go away!

The answer is no. Other body areas are treated entirely differently than the spine. Back pain sits at the back of the diagnostic bus. Back pain suffers from diagnostic discrimination.

And to prove my point, I'll tackle one of the most common back pain diagnoses that is actually not a diagnosis at all and tell you why clinicians still cling to it as their diagnostic woobie.

But, that's another day. For now, let's bring back pain to the front of the bus.

Make today count.
Doug Kelsey

*Croft, P. R., G. J. Macfarlane, et al. (1998). "Outcome of low back pain in general practice: a prospective study." Bmj 316(7141): 1356-9.

Reader's Digest Indigestion

The headline was more than I could resist. I looked past, "Paris Hilton's Cellulite Thighs!" and managed to avoid "Brad and Angelina Split for Good!" but when I saw "Back Pain Cures", I had to pick it up.

It was the July 2007 edition of Reader's Digest and inside I was promised "cures" for back pain. Hmmm...sounded too good to be true. And, how did I miss these gems? Where had I been? Here they are:

1. Neurostimulator. This is an electronic device implanted in your spine that sends electrical signals up your spinal cord to your brain. It's been around for a while and is usually reserved for patients who have failed everything other treatment.
   
   • Cure rating: 0
2. Infrared Belt. A belt that looks like one those worn by employees at Home Depot but emits a low level infrared energy. It's the same kind of energy used to warm your food in a restaurant. Oh, and it's not yet approved as a medical device by the FDA.
   
   • Cure rating: 0
3. Magic Spine Wand (no kidding).  This is a surgical procedure known as percutaneous decompression. A needle is inserted into the inner part of the intervertebral disc while a wand is rotated back and forth. This propels any loose disc material up the the needle and out of the spine. The problem with this method as a cure is that the only study I could find showed a pain reduction not elimination.
   
   • Cure rating: 0
4. Flexible Fusion. Another surgical procedure (I'm beginning to wonder if this article was funded by a surgical supply company) that fuses the spine but allows for more mobility than is found with conventional metal rods.
   
   • Cure rating: 0
5. Stem Cells. Yep - that's right. Grow a new spine. Surgeons (another surgical procedure) would plant stems cells from your bone marrow into your spine to re-grow your disc (and this might actually work). Only problem is that clinical trials are at least two years away.
   
   • Cure rating: 0
6. Site Directed Bone Growth. A surgical procedure that injects a special drug to stimulate bone growth. If it works, I'm not sure how this helps you if you have a disc herniation or an annular tear but it might help osteoporosis. At least it did in mice.
   
   • Cure rating: 0
7. A New Bed. So, if the six "cures" above fail, go buy a new bed.
   
   • Cure rating: 0

Seven "cures' none of which are even close to being a cure. Come on, I mean really. Are sales so low that you have to lie? Excuse me - I think I'm going to be sick: Reader's Digest Indigestion.

Doug Kelsey

P.S. - next week will be my last post for The View from Sports Center. I'll explain more later but, if you're interested, you can catch my musings and missives in the future on another blog. I'll share that with you too next week.

Is Back Pain Evolutionary?

Should we blame our back pain on the evolution of the human form? Do we have back pain because we were really designed to walk on all fours (or at least use all of our limbs like apes) and some tweak in the evolutionary cycle converted us to upright beings thereby squishing our discs? A doctor from Cedars Sinai Medical Center in Los Angeles, California seems to think so.

Dr. Aaron Filler, a spine specialist, has come to the conclusion that a shift in the structure of the spine, based on fossil evidence of a ape-like creature called Morotopithecus, allowed humans to walk and carry objects. This then created the perfect environment for back pain.

Great. So, now we can blame our aching backs on evolution. It's not our fault that we sit on our butts most of the day, lead exceptionally stressful lives, skip breakfast, rarely workout, and pop pain erasers as soon as we feel anything uncomfortable. Nah...it's the way we evolved. That's why we hurt.

Well, someone needs to let Nigerian and Filipino farmers know because they have four times less back pain than the citizens of wealthier countries And the reason?  Well, most farmers are active, don't sit around, use their bones, muscles, discs, and work out their stress.

If you want your back to hurt less, move. You may need helpfiguring out how to move, how much to move, how often to move, but the answer for most back pain will not be found in the fossilized remains of a questionable evolutionary link. The answer is to move.

A Touch Down For Your Neck

If you haven't read the View from the prior two weeks (two weeks ago, last week), you may feel a little lost. I promised you last week that I would explain how a Touch Down can help your neck and why a deflated beach ball is critical for neck Rock n' Roll. So, here we go.

A Touch Down is a term we use to describe an exercise that improves the flexibility of your thoracic spine and the muscles around your shoulder. A flexible, well positioned thoracic spine helps your neck function optimally. To feel what happens when your thoracic spine fails to do its job, try this:

• Sit in a chair with your feet flat on the floor.
• Allow yourself to "slump" but keep looking straight ahead.
• Now, lift both of your arms over your head but maintain the slumped position.
• Note the position of your arms, what you feel in your back and neck.
• Lower your arms back to your side.
• Now, in the slumped position, turn your head to the right as far as you can and note what you feel in your back and neck.
• Repeat all of the above while sitting up as straight as you can.

When you move your arms or turn your head while in a slumped position, your shoulder and neck motion will be less than when you sit up straight. And, for some, you may have felt a lot of tightness, pressure, or even some pain. This is why we routinely examine flexibility of the thoracic spine in people who have neck pain.

To improve your thoracic spine flexibility, here's what to do:

• Lie on your back with your lower legs on a exercise ball (a.k.a. physioball, stability ball, swiss ball). Your knees and hips should be bent to about a 90 degree angle.
• Position your arms at your side and bend your elbows. Now, allow your arms to fall away from your body.
• Slowly slide your arms up over your head. Keep contact with the floor.
• As your arms move up, try to straighten your elbows without losing contact with the floor.

Your goal is to reach a "touch down" position with your elbows straight, arms near your ear and in contact with the floor.

Now, about the beach ball.

The deflated beach ball does several things for your neck pain. Slow, easy motion triggers anti-pain receptors in the joints of your neck. These receptors also react to things like massage or machines that tug on your neck or if someone places their hands on your head and neck and tugs. As your move your head slowly, the beach ball helps you turn your head since the air inside of it shifts. This makes the movement almost effortless. The result is that your brain is bombarded with anti-pain signals and your pain typically subsides in a few minutes.

One of the reasons our clients like this exercise, in addition to the pain relief, is that it gives them more control. Pain is always worse when you feel like there is nothing you can do about it.

Now, you have two things to work on: Touch Downs and Rock n' Roll. Just imagine what your friends will say when you mention that Rock n' Roll helped your neck pain and you finally can do a Touch Down.

Doug Kelsey

How Rock N' Roll Helps Your Neck

Many years ago, I noticed that one of my patients, in his early 60's, was rubbing something on his knee. It was some kind of lotion or oil. So, I walked over to him and asked him about it.

"I see you're rubbing your knee. What's up?"

"This stuff, you mean? This here?" he replied.

"Right. That stuff - what is it?"

"Well, I figured that after you told me about how my knee needs some sort of lube job an' all, I figured a little WD-40 was in order. I think it's helpin' too. I do. I really do. That knee is movin' freer. I can just feel it."

A lube job. He was right. Joints that grind, crack, feel like they have sand in them, like crunchy necks, need a lube job.  Although, as far as I know, WD-40 doesn't quite do the trick.

Joints are a lot like car engines. I don't know much about cars beyond turning the key in the ignition and driving them (and I usually get lost). When something goes wrong, I might pop the hood and stare at the engine for a while to at least look like I know what I'm doing but I really have no clue.

But, I do know that you need oil in your engine; not water, or detergent, or soda, but oil. Just imagine what would happen to your engine if, instead of oil, for example, you used ginger ale. 

Oil is a highly viscous fluid. It's thick and resists deformation under stress which is good when you have metal parts moving very close to one another at very high speeds. You want the parts to move freely and the oil, because it resists deformation, provides a low friction cushion for the metal to ride on. Ginger ale is a low viscous fluid. It's thin, and watery. With ginger ale in your engine, the metal parts will rub on each other because the thin, watery quality provides very little cushioning. Ginger ale cannot withstand pressure and deforms quickly.

Turns out that joints have something inside them like oil in an engine. It's called synovial fluid and, like oil, healthy synovial fluid has high viscosity (it has the consistency of egg whites). And, just like oil in your engine, the synovial fluid resists deformation and protects your bones and cartilage from rubbing on each other. But, when the fluid gets too thin, which can happen with injury or disease, it's like having ginger ale in your joint. Things start rubbing on each other and sometimes you can feel it. Your joint will feel rough and catch.

You can change the oil in your engine by draining it and adding new oil. Not so with synovial fluid. Synovial fluid only improves from the right kinds of exercise (there are invasive options, such as SYNVISC, but your joint still needs to move to maintain the improvements).

So, what kind of exercise do you need? To begin with, low load, slow, easy motions working up to thirty minutes per day. In last week's View, I asked you if you wondered what exercise could make your neck feel so good you would want to do it for twenty minutes. Well, here's one of them.

We like to call this drill, "Rock N' Roll."

• Lie down on your back with your head on a deflated beach ball (see image). Your head and neck should be comfortable. Adjust the amount of air in the ball to find the right amount of support for you. If you have an exercise ball (sometimes called a stability ball, swiss ball, physio ball (and I think it's worth getting even just for this exercise), place your lower legs on the ball as in the image.
• Slowly turn your head to the right. Go as far as you feel comfortable. Then, slowly turn to the left. Stop mid-way and gently tuck your chin. Now, turn slowly to the left.
• Do this exercise for at least five minutes. You may find that it feels so good, you will want to keep going. If your neck starts to feel tired or if you're uncomfortable,  stop.

The goal is thirty minutes per day of movement. You can do this in five minute sets or longer. I suggest you get at least three sessions a day working your way up to thirty minutes. After about three weeks, you should notice improvement in the "crunchiness" in your neck. It may take several months for it to subside enough that you barely notice it. In many people, it goes away completely.

This week I gave you one of two drills we use to help people with "crunchy necks". Next week, I'll explain how a Touch Down can help your neck and why the beach ball is the critical tool for Rock N' Roll.

Rock on.

Doug Kelsey

Crunchy Necks

Garden variety neck pain, the kind where your neck is tight, stiff, sore, you hear a funky grinding noise or feel a crunching sound when you turn your head, and you're forever rubbing your neck is from something called Cervical Spondylosis.

Cervical refers to your neck, "spondyl" means your spine, and "osis" means trouble. So, the term Cervical Spondylosis actually means that the spine, in your neck, is in trouble.

Most people would like to know what to do about it; if there is some treatment, pill, or procedure to get rid of the pain, stiffness and most of all, the grinding sensation. Here is what the American Academy of Orthopedic Surgeons has to say about treatment for Cervical Spondylosis:

"If you have cervical spondylosis, symptoms may last for several months or become chronic. Most of the time if symptoms are mild, the doctor may recommend a variety of non-surgical treatments. Rest, medication and physical therapy may take away most of your symptoms, but do not treat the underlying cause. The doctor may want to see you again to check if symptoms have gotten better, worse or stayed the same."

Seems a bit gloomy to me especially the part about "Rest, medication and physical therapy may take away most of your symptoms, but do not treat the underlying cause." That sounds to me like I might feel better for a while only to have the symptoms come back again and again.

I agree with the AAOS' opinion - sort of. Medication and rest will help alleviate some of the symptoms. But why do you have the symptoms? In nearly all cases of musculoskeletal pain, symptoms appear when physical demand exceeds physical capacity. If the demand is just a little beyond your capacity, you may have very mild symptoms for a short time and discover that your body is able to adapt and become stronger. But, when the demand is too great, more severe symptoms follow and sometimes hang around for days or weeks or months. Your options then are to either reduce the demand (rest) or increase the physical capacity (exercise). For example, when your neck hurts, feels stiff and cranky after sitting at your computer for an hour,  you can reasonably conclude that the force of sitting was greater than your body's ability to withstand it. You can quit sitting at your computer (reduce the physical demand) or you can increase the physical capacity of your neck by exercising.

As for physical therapy, if you insert the word "conventional" in front of physical therapy then I would agree with the AAOS.

Conventional physical therapy will involve things like heat packs or ice, ultrasound or electrical stimulation, cervical traction (a machine that stretches your neck like something out of the medieval times), massage, stretching the neck. Basically, doing a lot of stuff to your neck that bombards your brain with a whole slew of sensory inputs distracting it from feeling the pain signals coming from your neck. There is nothing inherently bad or wrong about any of these things and certainly nothing wrong with using techniques or methods to reduce symptoms. But, none of these procedures will change the fundamental health of your neck; increase the physical capacity. And changing the health of your neck is the key to reducing CS from a bowling ball chained to your leg that you drag around the rest of your life to maybe a Nerf ball.

I've been hinting around at the idea of using exercise to improve your physical capacity. Where do you start? Should you stretch your neck? Pop it? Do isometrics (see figure to the right)?  To get started, we give our clients two very simple, easy to do drills that reduce their symptoms of CS and begin restoring the health of their spine; increasing their physical capacity. These drills feel really good and even better, are good for you. They take a few minutes per day but many people feel so good doing them that they'll spend 15 - 20 minutes a day on these drills.

Wonder what could feel so good to your neck that you would want to spend 20 minutes doing it?

I'll share them next week......

Doug Kelsey

This Chair Could Ruin Your Back

I wanted to say something; yell, wave my hands, jump up and down. Anything to get her attention. The girl, in her early twenties, rail thin and lanky, about 5'6" and maybe 110 lbs., walked over to the weight training area of the gym. She picked up a 25 lb. disc weight and, cradling it in her arms, carried it over to the black, angular bench.

The bench consisted of two, three foot metal posts attached to a rectangular metal base. On the top of one post was a large padded bolster. On the other post was a firm, dense foam or rubber pad. The young woman positioned herself face down with her upper thighs on the larger padded bolster and hooked her feet under the rubber pad. I was screaming inside my head, "YOU HAVE GOT TO BE KIDDING ME! WHERE DID YOU LEARN THAT !?!?" but I knew better. I watched, waited, and then realized it was time for a View on the ghastly, the dreaded, the evil, ROMAN CHAIR.

She held the weight close to her chest and then lowered herself down toward the floor. When her head was pointing at the floor, she suddenly whipped herself back up, up, up until her lower back arched into a reverse "C" ((like this). She repeated this over and over until she couldn't do it any more. She dropped the weight on the floor, and slowly got off the black, angular bench. She then bent over and stretched.

If there is one sure way to over load your spine, it's the Roman Chair. The enemy of the spine is compression and the Roman Chair exercise creates very high levels of spinal compression; nearly 1000 lbs. (anything over about 740 lbs. correlates highly with more lower back injury and pain according to the National Institute for Occupational Safety and Health (NIOSH)). I think the machine should be banned from every gym, health club, fitness center on the planet. I call it the Ruin Chair.

Most people who use the Roman Chair are trying to strengthen the back muscles and it may do that for you but you run the risk of creating small cracks in the outer wall of the intervertebral disc or injuring the bone due to the very high levels of compression. If you're looking for an exercise that works your muscles like the Roman Chair but with lower spinal compression loads, try the Bird Dog.

This exercise activates the spinal muscles and forces you to balance on one knee. You extend one arm and the opposite leg (see the image on the right). Once your arm and leg are straight, make sure your midsection is also straight and brace it - like you're about to get hit in the stomach. Hold the position for a slow count to five. Then, switch to the other arm and leg. Repeat this cycle 15-20 times.

There are a number of other ways to strengthen your spine safely. Some of the movements used in Pilates or Yoga, for example, challenge the spine muscles and are spine friendly. Just stay away from the Roman Chair. Let it collect dust and rust in some dark corner of the gym. Your spine will thank you for it later.

Doug Kelsey

P.S. - You have one more week to email a one page cover letter explaining why you want to become part of Sports Center's team along with your resume to jobs@sportscenteraustin.com to snag the one physical therapist position we have open. Don't shillyshally - you'll miss the opportunity.

                                        

A Doctor and Back Pain

Susie Okie, MD was in a hurry during a yoga class, slipped and tore her hamstring muscle. The result of that injury lead to lower back pain, a herniated disc, leg pain, and countless struggles to overcome it all. She shares her story in the Washington Post.

Physical injuries force you to develop the very thing you lack mentally and emotionally. If you're an over-achiever, an injury forces you to slow down. If you tend to run on the lazy side of life, an injury will give you a swift kick in the butt. Either way, a physical injury packs a mental and emotional punch whether you like it or not.

Susie's quest to beat her back pain helped her develop a new mental and emotional agility. Read Susie's story closely. She has a lot to offer those of you who feel dismayed, discouraged, or just plain ticked-off.

Onward....

Puffy Eyes and Back Pain

You wake up one morning to look in the mirror and discover a bloated and swollen face, especially around your eyes. You think, "Man, I need to back off the wine. This is bad." After splashing cold water on your face hoping to shock yourself into an semi-alert state, you take one more look. Better, but still a little swollen.

As the day goes on, your face seems to shrink to its normal size and shape; your energy comes back up. You feel fairly good. But, the next morning it's back. The puffy, swollen eyes look like something out of a horror film. You finally decide after a week of this scenario, you had better find out what's wrong.

There's something awry in this story. Something bad. And, it comes disguised as puffy eyes.

The culprit is Superior Vena Cava Syndrome secondary to cancer. You have lung cancer and it shows up as a puffy, swollen face.

So, imagine how you would feel to hear your doctor say, "It's just some swelling. Just rub your face a few times a day and it'll go away."

Not so good. Right?

A similar story plays out thousands of times per day all over the world but the characters are different. Instead of a puffy, swollen face, you have back pain. Instead of cancer, you have disc disease. But, patients with back pain are often told, "You'll just have to learn to live with it," or, "Try some ice or stretching or maybe acupuncture." The back pain is treated with just about anything imaginable to get rid of the pain and without regard for the underlying cause. Just like rubbing your face when you have cancer.

Pain from a musculoskeletal injury or disease is a symptom that deserves as much attention and as much thoughtful decision making as the pain from cancer. But, it doesn't. Why? Who's fault is it? Everyone's. From the clinicians who tout a quick fix to the the patients who want one. But, fundamentally it's the clinician who makes the call. It's the clinician who's the patient's agent; acting in his or her patient's best interest. It's the clinician who understands that pain is a symptom and the course of action is derived from the cause of the symptom. And, when a clinician doesn't know the cause, you keep searching, visiting other specialists until you have exhausted every avenue, every possible answer. The treatment of symptoms is important, of course, but it is like fixing a flat tire with a rubber patch. When the road gets rough, you're in trouble. What you need is a comprehensive solution that you understand and can implement over the course of your life; not a patch.

The quickest way to determine if a proposed course of treatment is a solution you should follow is to ask this question: "Is this what you would do for your mother?" Cuts right through the craposphere. Any hesitation, fumbling, or lack of clarity, keep looking. Bottom line, folks - if you hurt and someone tells you, with about as much care as you can put in a thimble, to "live with it" or "rub it a little" or "take this and call me if it still bothers you.", then keep looking. Don't just "rub your face".

Doug Kelsey

PS - We have an awesome seminar on back pain. If you have back pain or know someone who does, call now to get your seat. This is a standing room only talk every time we hold it.

Hanging a Picture and Solving Back Pain

Have you ever had something like this happen? You need to hang something on your wall like a large, heavy, framed picture. You know you need something to go in the wall and have a vague idea that it needs to be some sort of anchor but you're not exactly sure. So, you make a trip to your local hardware store and notice a section on "wall anchors." But, there are rows and rows of anchors: small, medium, large, plastic, metal, toggle bolts, molly bolts, flushed mount, flange, solid wall, hollow wall. It's overwhelming. All you wanted to do was hang a picture.

So, as you're standing there feeling slightly dazed by all of the choices, a smiling, friendly face appears asking if you need any help. You explain your situation and he asks you a few questions: how heavy is the picture, do you know if the wall is hollow or not, have you ever hung a picture before. By the time you finish your discussion, the handy helper has found just the thing for your problem and you walk out of the store feeling completely confident in your selection.

If you had just guessed and purchased an anchor, it might have worked. But, because your handy helper took the time to get to know your particular problem, you got your problem solved.

The best solution is one that matches your needs.

Solving your back pain is just like needing to hang a picture but not knowing exactly what you need for the job or how to do it. You just know you want it done.

Hundreds of thousands of people each day wander into the "pain store" to find something to fix their problem. As they stare at all of the options, instead of asking a handy helper who helps them figure out exactly what they need, they have a solution picked for them from the generic rack of "pain relievers" and are hurried on their way. Sometimes, they get lucky and whatever it is they bought seems to fix the problem. But, in most cases, what they bought doesn't last. It's like just picking some sort of anchor for your picture only to discover your prized possession shattered in pieces on the floor.

The best solution is one that matches your needs.

For something like back pain, you'll have to learn more about it in order to get a solution that matches your needs just like discovering more about hanging your picture. So, like the handy helper asking you about hanging your picture, we would ask you some questions too. Things like:

• What makes your pain better or worse?
• Do you hurt sitting or standing still?
• How do you feel when you wake up in the morning?
• What movements worsen your pain?
• What does the pain feel like (e.g. aching, burning, stabbing, searing)?
• Do you hurt then after moving around a bit feel better?
• Has your pain caused you to modify any of your daily routines?

The answers to these questions will help us and you better understand what kind of "anchor" you need. Then, you can walk out of the "pain store" feeling confident that what you're buying will work and last.

Remember, the best solution is one that matches your needs and knowledge helps you define those needs.

Doug Kelsey