Want to avoid Spine Surgery? See a Physiatrist.

WikimediaA study recently published in Spine reported that consultation with a physiatrist (specialist in Physical Medicine & Rehabilitation) decreased rates of spine surgery by 25%, reduced overall costs to the healthcare system and improved patient satisfaction. (Spine 2013; 38: E178-E184)

According to the study authors physiatric consultation:

• May give patients a more balanced understanding of their diagnosis, prognosis and treatment options
• Spend more time counseling about these issues
• May change the diagnosis or find treatable secondary musculoskeletal pain generator
• Detect psychosocial factors that may make surgery inappropriate
• And may be more effective than consultation with a primary care physician 

So, if you have low back pain it would seem worthwhile to at l 100 east talk to a physiatrist before going under the knife.  I am surely a little biased (being a physiatrist).  That being said, I live in a town where the rate of lumbar fusion is 20X the average in other parts of the country.  So I would like to have an impact for the positive in terms of patient health.

Cialis and Exercise Performance

This may seem far afield for a back exercise blog.  I was asked, though, about the effects of medications like Cialis on exercise by a patient the other day.  I thought the question relevant and worth addressing with a review of some basic information on this subject.

The medication Cialis (tadalafil) has been used for the treatment of erectile dysfunction for a number of years now.  Over time the use of this medication has expanded to include the treatment of pulmonary artery hypertension and benign prostatic hyperplasia.

 In simplistic terms Cialis acts by relaxing muscles and increasing blood flow to particular areas of the body.

Cialis and the related medication Viagra have been studied in relationship to athletic performance (in addition to the more traditional associated uses). 

There is evidence that taking tadalafil (of Cialis) may:

• Amplify cortisol and testosterone responses to a maximal exercise-related stress in healthy trained humans[i]
• Decrease time to achieve peak power with exercise[ii]

However, controversy remains about whether taking Cialis will improve physical fitness-related parameters such as exercise tolerance, VO2max or performance.[iii]

It goes without say that anyone considering using these medications should consult with a physician first.  Research is ongoing in this area and more insights will certainly be forthcoming.

Leave comments below if you know anyone that has used these medications and noted changes or improvements with exercise.

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[i] J Clin Endocrinol Metab. 2008 Sep;93(9):3510-4. doi: 10.1210/jc.2008-0847. Epub 2008 Jun 17.

[ii] Br. J Sports Med. 2008 Feb;42(2):130-3. Epub 2007 Jun 22.

[iii] Int J Sports Med. 2008 Feb;29(2):110-5. Epub 2007 Jul 5.

Ever wonder how you can heal faster from injury?

What is prolotherapy?

I prefer the term "regenerative injection techniques" to prolotherapy.  It communicate more of the essence of what we are doing with this technique.

I like exercise as a focus for treating most musculoskeletal pain issues.  However, there are times when exercise alone is not enough (or not fast enough).  In these cases, treatments likely prolotherapy or PRP or acupuncture can really facilitate progress with exercise.

Following are some slides from a presentation I am giving on running injuries and how to heal/recover faster.  I thought this content would be useful for all those patients (and others) who wonder how this emerging (or re-emerging) technique can help fix pain issues.

What causes butt or hip pain in a cyclist (or runner)?

I have a friend that is a cyclist and has struggled with pain in the posterolateral hip (butt and side of the hip) for about a year.  I see similar issues all the time in my office, with people referred for back pain who have pain in the posterior and/or lateral hip as their main complaint.

As I help people to fix these pain issues, there are a few important points to clarify.

1. Is the pain caused by a problem with the hip joint itself, the sacroiliac joint, or is it a muscle/tendon issue.  This is not an insignificant point in that the fixes may be very different for these issues.
2. Generally pain related to the hip joint (or the joint where the femur meets up with the pelvis in the acetabulum) is associated with pain in the groin as opposed to butt or lateral hip pain.  Pain in the hip joint can be secondary to among other things arthritis in the joint, tears in the labrum, or an issue called femoroacetabular impingement.
3. Pain associated with the sacroiliac joint is usually localized to the butt or lower back.  The joint may cause pain to be referred to the buttock but most of the time not further downstream in the leg.  Pain from the SIJ may be hard to distinguish from muscle/tendon pain in the buttock region.

Pain that is to blame on muscle or tendon issues in the butt region is exceedingly common.  Studies have shown that 30-40% of people in pain clinics for back pain have lateral hip pain (Br J Rheum. 1990 Oct;29(5):354-7.)  The specific muscles involved in these pain issues are several, and can include: gluteus medius, gluteus minimus, piriformis, gluteus maximus or other stabilizers of the hips and pelvis.    

Typically, issues of tendonitis and muscle pain around the posterolateral hip are caused by tissue overload.  In a simplistic sense, the root cause of this overload is often weakness in the muscles that perform hip abduction and extension.  This is surely overly simplistic and issues like knee arthritis, joint anatomy and other factors play a role.  However, more often than not people develop “gluteal amnesia” and the muscle on the back and side of the hip forget to “pull their weight” in a sense.  This weakness and inhibition then leads to overload, tendonitis, bursitis and pain.

Going back to the case of my cyclist friend, he certainly had weakness in the muscle groups around the posterior and lateral hip.  Also, some review of his bike fit, with attention to the seat height pedal stroke made a dramatic difference in re-engaging the hip extensors.

In a follow-up post I will discuss in more detail exercise fixes for posterolateral hip pain.  I often an educating patients in the office on these exercises and need to have pictures or video to help reinforce these exercises.

How many of you have struggled with pain in the butt or posterolateral hip?  And if you have had pain in this area, what have you done to treat it?  

Interesting case: knee pain in a frequent leg crosser

History:

40ish year-old woman with a history of chronic low back discomfort.  She has had in times past pain referred from the low back to the buttock but not further downstream in the leg.

However, during the past few months she has developed pain in the lateral aspect of the knee, just behind the fibular head.  She has not noted any significant weakness or numbness but primarily pain in the area of the knee that is worse with fully flexing the knee.

Exam:

This patient had normal strength and sensation in the lower limbs.  Reflexes and neurologic examination were normal.  She was very tender to palpation over the fibular head but also tender over the area of the piriformis muscle.

Findings:

Electrodiagnostic testing to evaluate the nerves in the lower limbs.  The study was normal except for some mild slowing of peroneal nerve conduction around the fibular head.

Assessment:

This patient seems to have a case of compression to the peroneal nerve at the fibular head.  This issue is observed in people that are frequent knee crossers (as was this patient) and in other conditions.  It is hard to separate out her symptoms entirely from her more chronic history of low back and buttock pain.

She may have an element of what is called “double crush syndrome” with some compression (or at least irritation) to the sciatic nerve in the area of the piriformis muscle in the buttock. 

Treatment:

Because this observed nerve compression is mild the easiest starting point is to change behavior (avoiding leg crossing).  Surgery may not be necessary.  Other things that would be helpful would be a good therapy program for neural flossing (mobilizing the sciatic nerve), strengthening hip extensors (glutes), hip external rotators (piriformis) and lumbar stabilization.

Take-home points:

• Leg crossing is not always as sexy as it may seem
• Pain issues that occur distally in the limbs are usually connected to proximal dysfunction and cannot be treated in isolation.

5 Easy Tips for a Healthier Back in 2013

Back pain is an enigma.  There is often not an easy answer to fix back pain.  That being said, here are 5 tips that can help to decrease either back pain symptoms or the likelihood of getting back pain:

1. Get up and out of the chair.  Studies have shown that sitting for more than half a workday increases significantly the risk of back pain and sciatica. (Eur Spine J. 2007 February; 16(2): 283–298).
2. Avoid bending forward at the waist in the morning: Research has shown that just by avoiding bending activites early in the morning decreased back pain symptoms significantly (McGill. Low Back Disorders)
3. Take care of your heart health: A body of interesting research has shown a strong correlation between the degree of arterial disease or stenosis and back pain or sciatica symptoms.  This likely relates to the circulation and nutrition provided to disks.  (Acta Radiol. 2009 Jan;50(1):48-54.)
4. Try some Yoga: The practice of Yoga has been shown in several studies to be helpful with chronic low back pain.  This idea sounds intimidating to some folks.  But just to incorporate a couple of easy exercises like the Cobra pose or Chair pose can be extremely helpful for back pain.
5. Avoid positions that increase back pain symptoms: This sounds overly simplistic but can be a helpful approach to back pain.  If sitting increases your pain, try using a standing table or if this is not a possibility use a lumbar support pillow to decrease lumbar flexion.  If standing is bothersome, try focusing on decreasing the degree of pelvic tilt that can feed into this issue (see separate post on how to address back pain that is worse with standing).

Neck Pain and Headache: referred pain from trigger points in the neck can cause headache

Headaches are a complicated issue.  There are numerous different types of headache, including tension-type headache, migraine headache, cluster headaches and others.

A common pattern that I see in the office is that of headache that is brought on or triggered by neck pain.  I have patients tell me that "The pain starts here [indicating a point in the neck] and will travel up to the head and cause a headache."

Frequently these people will have so-called "trigger points" in the muscles along the neck and/or base of the head.  These trigger points are areas that are tender when pressed upon and will "refer" or send pain to other parts of the body.  

The term "trigger point" was coined by Dr. Janet Travell in 1942.  She brilliantly described how these tender points in muscle can be a source of broader patterns of pain.

A recent article in the Journal of Headache Pain documented the ability to reproduce head pain in people with trigger points in people with chronic tension-type headache. (J Headache Pain. 2011 February; 12(1): 35–43.)

While not ground-breaking in terms of concept, this study highlights the relevance of muscle as a source of headache symptoms.  When treating headaches, the solution does not always lie in throwing more medication at the issue.  Rather, addressing posture, sleep and exericse interventions can be an important part of headache treatment.  What is more, techniques such as trigger point release (or injection), acupuncture and exericse can go a long ways to address the underlying source of tension-type headache symptoms.

Below is a diagram from this study showing common patterns of pain referred from the neck to the head.

J Headache Pain. 2011 February; 12(1): 35–43.

Lower back pain: What can I do to prevent its progression?

I received an email the other day from a person visiting my blog.  She raised a question that I hear with some frequency, both in the office or other inquiriies.  So I thought I would share her question and my response.

I am a 47 year old woman, and suffer from Severe Degenerative Disc Disease...  I was first diagnosed in 2000, and my previous xray was taken in 2009. I have recently had another xray and the degeneration in that 3 years has been enormous. It is in my Lumbar Spine, L4-L5 and L5-S1 if that means something to you. My question is, is there anything I can do to prevent it's progression? 

Example of x-rays showing degenerative disc disease 

I can appreciate your concerns.  Back pain is a complicated thing and we certainly do not often have easy fixes.

L4-5 and L5-S1 are very common levels to see degenerative disc changes on x-ray or MRI.  The thing that is reassuring for me is that there is not always a 1:1 correlation between the level of degenerative change on imaging and a persons pain experience.  There was an interesting study done on people with no back pain.  They took MRIs of a group of people without pain and looked at how common degenerative changes were apparent.  The researchers found that these changes are very common in people with no pain at all (http://www.backexercisedoctor.com/journal/2009/12/17/the-language-we-use-to-describe-back-issues-and-its-impact-o.html).

So hopefully you don't have to be too disheartened by the changes on the x-rays.

As far as what to do to prevent further change, the thing that would make the most sense is exercise. To work on back-specific exercises should help to "unload" in a sense the discs and joints of the back by having the muscles take up that slack.  I would suggest you see a good physiotherapist and/or physician with expertise in this area and try to get some recommendations tailored to your specific type of pain (not everyone responds to the same exercises).

I have tried to lay out exercises that make sense in my blog posts and more recently in my eBook.  

Hopefully this helps.  Let me know if you have any further questions or need more information.

Lower back pain relief: McKenzie pressup exercise for lower back pain

For patients with lower back pain I often show them how to do certain back-specific exercises during an office visit.  I then refer them to my blog to reinforce the exercise.  Here is a video demonstration of the McKenzie pressup exercise - a great exercise for lots of different types of back pain.

Lower back pain relief

Exercise is the one tool that empowers us to treat our own back pain. 

lower back pain relief