A sweltering day here in Philly- with the heat index, it’s hovering around 100 degrees. Still, I would take this weather any day over the snow we had this past winter. For those of you keeping score- I’m a Miami boy at heart- and I’m one of this folks who doesn’t care if it’s summer there, or whether it’s humid. Basically, I’m not complaining!

In any case- today a viewer question from Doug:

“I’ve had back pain in my upper back and neck for for the past two years. I never had any kind of injury which triggered it- the pain just kind of started one day, and got progressively worse. I’ve been to several doctors, and have had x-rays and MRIs, none of which found any problems in my spine. A friend recommended an orthopedic surgeon who helped him with his neck pain.

I saw him a couple of weeks ago, and he told me my back pain was due to a rotator cuff tear. He decided this without any MRIs of my shoulder, and in spite of my protestations that my pain was in my back, and that I had no pain in my shoulder.

He wants me to get an MRI- which I hope will confirm the diagnosis, but which I am really nervous about. I pretty much had a panic attack in the MRI machine.

My question is this: is it reasonable for me to get this MRI, given that I have no pain in my shoulder? I’ve heard that orthopedic surgeons just want to cut, and I’m just not that interested in surgery.”

Thank you for your question Doug. Your apprehension regarding the MRI and the possibility of surgery is common, and not unreasonable.

Rotator cuff tears are an interesting thing. Often, they do not present as pain in the shoulder itself, but more so in the structures surrounding the shoulder. The reason for this is that the surrounding musculature- including those in your back- have to work extra hard to stabilize your shoulder following a tear, and protect it from further damage.

Rotator cuff injuries are pretty easy to preliminarily diagnose using simple examination techniques and movement tests done in the office. Typically, an office based diagnosis is confirmed with an MRI. Based upon the information you’ve provided me (and as always, keeping in mind this is a ‘drive by’ diagnosis made without any physical examination on my part) it is very reasonable for you to go ahead and get the MRI, and if indicated, rotator cuff repair. Hopefully you can then find relief from the pain which has been troubling you.

I hope this helps.

Best,

Andy

A beautiful view of the Southern Lights as seen from the ISS.

In the US, this is a way more complicated issue than it is where this conversation took place- Jamaica, where marijuana is often viewed as a cultural staple.

There has been a lot of discussion recently about the changing laws regarding marijuana use for medicinal purposes. Several states have modified or completely rewritten their laws in recent months to either make pot easier or harder to get, depending upon where you live and upon your particular circumstances.

I don’t want to get into the legal aspects of marijuana use- it is far too complicated an issue to get into here. This wedding guest asked me point blank whether I thought pot was useful for the treatment of low back pain.

My answer to this question is in three parts:

1) I think marijuana is a good muscle relaxant, and additionally reduces the perception of pain such that pain sufferers do not notice it as much.

2) Too much marijuana can ultimately decrease your activity levels, keeping you from going out and re-establishing good body mechanics as the source of your pain heals/resolves. And…

3) there is frequently some weight gain associated with pot smoking (the oft cited ‘munchies’ are to blame) which can get in the way of recovery.

I have several patients from around the world who use pot as a method of reducing their pain, and for them it works. I would not condone using something that is illegal, but perhaps that situation will change in the not too distant future. In the mean time, there are several legal alternatives to marijuana- not the least of which would be one of Back Together’s fine products….

Thank you for visiting today. Please keep those cards & letters coming- you help to keep the discussion interesting.

-Andy

Half Moon, Rose Hall Jamaica

Enjoy!

-Andy

The Rosetta Stone at the British Museum

There is only one steadfast rule regarding ice & heat: For the first 48 hours immediately following an injury, ice is better. Ice causes some vasoconstriction (the reduction in the diameter of the blood vessels) in the area being treated, helping to reduce swelling and promote healing. It also can partially numb the area for a short time, providing some pain relief.

In this doctor’s opinion, after the first 48 hours, it boils down to a matter of personal preference. Ice provides some of the pain relieving benefits, but heat can help to relax tense muscles- so there are potential benefits to either. Personally, my muscles recoil from cold and send me right into spasm, so I cannot really tolerate ice- so for me it’s heat, but I hear the opposite from plenty of people as well.

The one recommendation I will make here is to limit the time of either. If you are using ice, wrap your bag of ice in a thin towel or napkin so the cold gets applied gradually, and without ‘shock.’ Apply for 20 minutes on, 20 minutes off. With heat, the timing is not as critical, but prolonged heat can cause too much relaxation to the area, will cause vasodilation (an increase in the diameter of the blood vessels in the injured area,) and if there is still some underlying inflammation- could increase swelling. So 20 on and 20 off here is probably a good rule as well.

Hope this helps!

Insurance nightmares…

Last week, I asked you to share with me some of your health insurance nightmares. My wife and I have been dealing with a pretty complicated problem, which thankfully seems to be largely resolving. I am amazed by how many of you have had serious issues with your health insurance. I am preparing a piece or two on this topic- not strictly a back pain thing, but I felt important enough to discuss here on BackWords. Check back.

As always, thanks for visiting,

Andy

Coming soon: Back pain tips for riders of mass transit.

I grew up hearing warnings about cracking your knuckles. “If you crack your knuckles, you’ll develop arthritis when you get older.” So, now that I suffer from back pain, I’ve found different ways to “crack” my spine. For example, I’ve discovered that if my husband hugs me pretty hard around my upper back, I hear a refreshing pop. If he moves up another half inch or inch, I hear another one. If I’m in my car, I can push on the steering wheel and stretch my back in such a way that it cracks. So, what I’m trying to ask is – is this harmful and can it actually lead to more pain or back problems in the future?

-Randi

Thank you for your question Randi.

I get asked this by patients pretty much every day, and I cannot believe it took this long for me to realize I should cover this here- and the answer has two parts:

First of all, let’s talk about the ‘crack.’ Patients have come to expect a loud crack or crunch associated with osteopathic or chiropractic treatment- I can’t tell you how many times a week I hear ‘Doc- I need you to crack my back!’ In fact- with the treatment style I’ve developed over the past decade or so I actually do very little ‘craking’ at all. Some patients actually voice disappointment when they don’t have the satisfaction of the noise announcing that yes, they are cured! Sorry.

That being said, the cracking sound that so many folks associate with treatment is an interesting thing. You can make virtually any moveable joint in your body crack, but that sound should by no means be the goal of treatment. There are lots of thoughts on what is actually making the sound (One of the leading theories is the shift of nitrogen bubbles occurring inside the joint space when a corrective ‘thrust’ is applied.) Anatomically, there really isn’t much of a difference between cracking your knuckles, and cracking your back.

I’ve been a pianist most of my life, and more than one piano teacher told me I would get arthritis from cracking my knuckles, which by that time had already become a habit. I’ve done some research, and there is no evidence that cracking your knuckles, or cracking your back will cause you arthritis or any other problems.

Now, let me qualify that with two provisos: Firstly- I wouldn’t ‘crack’ my back if I were in the middle of a severe flare up of pain- you could irritate an area which is already inflamed, and potentially make your acute condition worse. Secondly- There have been numerous studies that have shown that when you ‘self-correct’ or ‘crack’ your own spine, you are very unlikely to correct the segment which actually needs to be moved. You may get the one above or below it, but you probably won’t get the one causing you discomfort.

I hope this answers your concern. And again, thanks for your contribution.

Be well!

-Andy

The minerals of the Dead Sea, thought to be so good for your joints, are apparently not so good for your bike!

Here is the link to download the show- I am one of four interviews in the show- and if I may say so, they are all good!

Thanks for the nice responses to the second part of my spinal surgery series.

Be well,

Andy

Photo from atop the beautiful Baha'i Garden, Haifa Israel...

Try it- you may be surprised at what you find!

-Andy

I was seeing a 32 year old mother of 3 for her back pain- let’s call her ‘Sue’- and after seeing her weekly for about 8 weeks, I managed to get her essentially pain free. We discussed her workout regimen, some home exercises I wanted her to do, some ergonomic things she could do around the house, and a few other things before I sent her home.

When I get someone to the point they are feeling pretty good, my goal is to see them for occasional maintenance, perhaps every 6-9 months- with the option of them coming in sooner if they ever had an exacerbation. I never got into the whole ‘I need to see you every week for the rest of your life’ thing (the exception being some of the professional athletes I work with who put themselves in harms way pretty regularly.) I booked Sue for six months, and she was so happy for her relief.

I came into my office one morning about 3 weeks later, and there was Sue- looking none-too-happy with me.

I asked Sue what brought her in. She had full return of her pain, and was incredibly frustrated by her setback. I didn’t want to discuss this in the waiting room, and scare off other patients, so we went back into the treatment room.

Had she fallen, been injured, over did it in the gym?  No- none of the above- her pain was back and she was pissed.

She got up on my treatment table and I began to palpate her spine. Lo and behold, her spine was right back where we had started. It was as though I had done nothing at all. It was at this point, I pursued a different line of questions….

Had Sue taken any of the ergonomic suggestions we discussed for her house? No.

Had Sue been doing any of the specific exercises I had prescribed to help keep her back moving? No.

Had Sue changed her child care situation to involve her husband a little more, so she wouldn’t be the only one picking them up? Nope.

Basically, she left my office the previous visit feeling great- did none of the things we discussed to help maintain her wellness, and was really annoyed when her pain came back.

Here’s the bottom line: If you are going to a Chiropractor, Osteopath  -or anyone else who does manual medicine or body work- you are wasting your time and money if you don’t address the lifestyle issues which caused your back pain in the first place. Back pain is not just a structural  thing. I talk about the pain triad with many of my patients- that is the essential 3 things which I feel contribute to back pain. They are as follows:

Structural issues: These are what they sound like- problems associated with basic structure and function. These things can usually be measured or imaged with x-rays or MRIs, and they can usually be fixed with manual medicine, therapy, and addressing underlying ergonomic concerns.

Psychological Amplifier: This is the part of your mind which gets frustrated or annoyed with the effect back pain has on your life, and can actually make it worse.

The Learned Neurological Response: This is the part of your central nervous system which controls modification of your normal body mechanics in order to find less painful ways of functioning following an injury or compromise, and sometimes has a difficult time resetting once the structural cause of pain has been addressed.

Almost all of my patients have each of these factors contributing to their discomfort- perhaps to different degrees, but they are all there.

For you to really control your back pain, rather than having it control you- you need to look into each of the components of your back & neck pain, otherwise you will forever be at the mercy of physicians and therapists to find relief from your discomfort- and throwing money out the window. Really- give this some thought the next time you experience an exacerbation. Take your practitioners suggestions and information- and use them!! This is the only way you will find lasting relief.

Best,

Andy

One week to the Philadelphia Flower Show- Spring is four weeks away!

Surgery is the most aggressive treatment option available for relief from back pain, and should be considered only after all more conservative options have been weighed. Many patients in my own practice have come to me as a last resort before deciding whether or not to have surgery.

If you google information about the outcomes of spinal surgery, you may find that the statistics are a little discouraging. The overall statistics for patients in my own practice who have had surgery for their back pain is not too different from most of the numbers you see out there- I have observed that about 30% of patients get some relief from the surgery, 30% have virtually no improvement, and about 30% report that they actually felt worse following surgery. Now, while these numbers sound kind of dismal, they improve significantly when patients are well screened, and when you are dealing with a particularly talented surgeon (and no, I ain’t namin names!)

In the next posts, I will review a few of the more common surgical procedures for treating back and neck pain as well as radicular pain such as sciatica. We will review the foraminotomy, spinal fusion, disc repair, and disc replacement.

Now, in this introduction, let me give you some basics that apply to all types of spinal surgery;

-If you have exhausted all conservative approaches to your pain, and you are considering surgery- as with any surgery, when possible get a second opinion.

-In your area, try to find people who have had surgery, and gather information about their experiences- not only about their own outcome, but about their experiences with the surgeon, their hospital, recovery, therapy, etc…

-As with any surgery, there are inherent risks such as hemorrhage, infection, etc… I am wary of any physician which describes anything as ‘risk free’ or ‘minor surgery.’ In the world of spinal surgery, there is no such thing as minor surgery- only degrees of ‘major.’

-Be prepared to do any post operative therapy your surgeon recommends- for many procedures, the follow up is just as important as the procedure itself when it comes to a favourable outcome.

-Try and recruit friends and family members to provide a network of support both pre and postoperatively. There can be significant anxiety as well as pain & discomfort associated with any of these procedures. Having emotional support before and after surgery can help hasten recovery.

These are just a few considerations when gearing up for surgery. Over the next few installments, I hope to provide you a basic understanding of what these procedures entail. If you have had surgery for back or neck pain, please share your experiences.

Best,

Andy

I hope you all had a great Valentine’s Day and Chinese New Year. We celebrated both events yesterday with the whole family in Chinatown, where we saw the Dragon traveling up and down Race Street ushering the new year. I attached a short video of the dragon leaving one of the restaurants in the city (It was WAY too crowded to try and capture the Dragon in the restaurant- but it was really a beautiful spectacle.)

IMG_0176

Onto Fibromyalgia Part 3: Medications for Fibromyalgia…

Thanks for returning for Part 3 of the fibromyalgia mini-series- So far we’ve covered what fibromyalgia syndrome (FMS) is, how it is diagnosed, some lifestyle modifications and considerations which can help FMS, as well as some psychological approaches to dealing with the discomfort of FMS.

As you may be aware if you are a regular visitor to BackWords, I generally try to find the most conservative ways of dealing with pain, so it is no surprise that I have saved the medications portion of the series for last.

I should start off by saying that there are no great medications for FMS- just a few things which can help the symptoms to varying degrees. I group then broadly into three categories: Pain medications, Neurological medications, and ‘others.’

Pain Medications:

Several weeks ago, I did a post about pain medications which you can review here. Any of the categories of pain medications can be used to help reduce FMS pain- although as a rule, these medications, regardless of category seem to be less effective for FMS pain than they are for other pain conditions/syndromes.

I will often meet new patients with FMS who have come from other physicians with myriad prescriptions for everything from anti-inflammatory (such as ibuprofen) to narcotics (such as Percocet or Oxycontin), and pretty much all of them are frustrated with the poor level of pain relief they get, and are also often saddled with all of the side effects which go along with those medications. I discussed the side effects at length in the aforementioned post. As you already know, FMS carries with it a whole host of symptoms, and the side effects are not a welcome addition to the discomfort patients are already suffering.

That being said, I will still use pain medications during a ‘fibro flare’ where patients have a severe exacerbation of their symptoms due to drastic changes in the weather, increased stress, or other factors.

Neurological Medications:

There are several medications which work on the neurological component of FMS- the four most common are Nuerontin (gabapentin), Lyrica (pregabalin), Klonopin, and Savella (milnacipran.) These drugs all began their lives as anti-siezure medications, and found their way into the FMS world over time.

These medications work by raising the firing threshold of a nerve, or the minimal amount of stimulation required to cause a sensory nerve to respond. The theory is that ‘fibromites’ have increased sensitivity to pain because their firing threshold is too low.

These drugs are a mixed bag in terms of efficacy. They seem to be really effective for some people, and provide practically no results for others. The most common side effect for all of them is fatigue and somnolence- which is a problem in itself as fatigue is already one of the most prevalent symptoms of FMS. The good things about this group of medications is that they are pretty benign (Neurontin in particular), in as much as they don’t interfere with many medications. A key recommendation I make to patients is that if they try these medications (Neurontin and Lyrica in particular) is that they should start with a low dose and taper up slowly. In this way you can a) get away with the smallest dose possible and b) minimize the side effects.

Others:

There are several other medications and supplements which patients have used with varying efficacy for their FMS symptoms, and they are in several categories- let me just give you a couple of examples…

Guaifenesin is a mucolytic / expectorant medication common in many cold medications. Many physicians feel it helps lubricate soft tissue and improve flexibility by reducing stiffness. I have had some success with patients utilizing this medication- and here, the good news is that this med is relatively low in side effects. For most patients there is no real down side to trying it.

Patients with the worst fatigue symptoms have reported success utilizing a medication known as Provigil (modafinil) to help reduce their fatigue. I personally have little clinical experience with this medication. If you are considering it, be sure to have a conversation with your physician to understand its use/ benefits/ and risks.

There are many other medications and nutritional supplements out there with  claims to be beneficial for FMS. There are too many to review here. The bottom line here is that there are lots of options, all with varying degrees of efficacy, and highly variable side effects profiles- so my parting though with medications is that if you are trying medications, try one at a time in order to really gauge what they are or aren’t doing for you.

Conclusion:

I hope this 3 &  1/2 part introduction to FMS has given you some useful information. In my clinical experience treating this enigmatic condition, it has slowly become clear to me that the thing we are calling Fibromyalgia is likely several separate conditions that we do not yet possess the knowledge to accurately differentiate. This is supported by the observation that things that can provide fantastic benefit to some patients have absolutely no benefit for others.

One thing is abundantly clear: no matter what the ‘flavor’ of FMS a patient is experiencing, all forms benefit from an active lifestyle.

Thanks for visiting. Look for my series on spinal surgeries to begin later this week.

Be well!

-Andy