Healthy 850 Courtesy of The Osher Clinical Center

BACK PAIN ISSUE Read about: 

7 Myths about Low Back Pain

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Back Pain Relief at 850 Boylston Street

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Back Pain During Pregnancy

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Scientific Literature Review

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Prunes for Healthy Bones

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3 Simple Exercises for Low Back Pain

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Ice or Heat?

Programs at the Osher Clinical Center

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May 2013

7 Common Myths about Low Back Pain - Matthew H. Kowalski, DC and Donald B. Levy, M.D There is a good chance that you will experience low back pain at some point in your life. In fact, 80% of us will experience a significant episode of back pain in our lives. It may be a mild strain, such as after a day of yard work. It may come on for no apparent and be quite severe. Back pain sufferers have at their fingertips a virtual flood of information to process. In fact, most patients come to their doctor for a second opinion, having already consulted “Doctor Google”. Unfortunately, there is a lot of misinformation available. This article is to address some of the most common myths about low back pain. 1. "Get in bed and rest." On the contrary, bed rest for longer than a day may actually prolong your recovery. Rather than confine yourself to bed, walk as much as tolerable. Relief is most often gained through activity.

2. "I need an MRI to know what is wrong". First, it is important to understand that the exact cause of uncomplicated low back pain is most often not possible to identify. One in 4 adults have a herniated disc and no pain and most patients in significant pain do not have a definite anatomic diagnosis. In the absence of red flags (See “Back Pain Relief at 850”), MRI (magnetic resonance imaging) studies are reserved until we are thinking "complicated problem, consider surgery or therapeutic injections.

3. "I need a strong medication, such as a narcotic." Short-term (a few days) use of narcotic medication may be appropriate in some instance of low back pain. But, long term narcotic usage can create dependency that is harder to overcome than the back pain itself. Many of the over-the-counter medications, such as ibuprofen, naproxen sodium and acetaminophen will provide substantial short-term relief.

4. "Do sit ups to help to strengthen the back." First of all, don’t do sit-ups. They may strain the low back. Rather, learn how to do an abdominal crunch or curl-up. It is best to elevate the legs onto a couch or therapy ball. Curl the torso up to the point where the shoulder blades just lift from the floor.

5. "Disc degeneration means that I am doomed to a life of low back pain". Disc degeneration and spinal arthritis are a normal part of aging. They are like the wrinkles in our skin; they are unavoidable, some are painful, but most "are just there".

6. "Medications and injections cure back pain". Medications and injections are a bridge to feeling better, not the final destination. Use any treatments (be it medications, exercises or hands-on techniques) to help relieve your pain while you are rehabilitating to become independent from care.

7. "Back supports help prevent low back injury." Low back supports, such as those seen in some home improvement stores, do not prevent back injury. There is some evidence that the back injuries sustained when wearing a back support are more severe than those without one.

Back Pain Relief at 850 Boylston Street - Matthew H. Kowalski, DC and Donald B. Levy, MD

There is a virtual shopping mall of health care professionals to consider when you suffer low back pain. Most people get lost in trying to navigate their way through the healthcare system to identify the most appropriate care provider. Brigham and Women's Hospital is the only Boston hospital that is home to a full spectrum of traditional and complementary spine care providers. So, who should you consider?

Where to begin. Not all back pain actually requires treatment. Consider a dose of self-care as your first therapeutic choice. Often times, a combination of patience, over-the-counter medications, ice / heat (See “Ice or heat”), avoidance of injurious activities and remaining active will relieve uncomplicated low back pain. Uncomplicated low back pain is an episode of pain without any of the recognized "red flags”.

First, Pay Attention to any “Red Flags” As a general rule of thumb, there are certain "red flags" that should not be ignored when occurring with back pain. If you experience any of the following symptoms, it is important to consult a medical or chiropractic physician before waiting or seeking alternative therapies:  You have sustained a substantial trauma and / or have weak bones (osteopenia / osteoporosis)  You have a history of cancer  You experience a prolonged fever of unknown origin  Pain that is waking you from sleeping  Pain that is not relieved, to some degree, by rest  Have suddenly developed problems controlling your bladder or bowel*  You experience loss of feeling / numbness, tingling, pain or weakness in the lower extremities*  Have experienced weight loss without trying to do so.  Your pain is present for longer than 2 weeks and has not begun to respond to self care strategies. *a combination of these two red flags may represent a serious condition called cauda equina syndrome, which warrants immediate surgical consultation.

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Who should you first consult? If you are seeking pain relief through prescription medication, you must consult a Medical practitioner, (including PAs, NPs, DOs). If you have a complex medical history, or any of the above mentioned “red flags” first consult your personal physician!

All of the following health care practitioners are able to educate you about your condition and provide advice on self-care, ergonomics and the prognosis of your condition. Due to the nature of spine pain, if you consult clinicians of different backgrounds, you may receive completely different explanations about the cause of your pain. Believe it or not, that is completely fine! We all agree on the red flags, which is most important. Although there are a number of practitioners who can perform your initial consultation, here are some general guidelines (in alphabetical order):

Chiropractor (Doctor of Chiropractic) Chiropractors can provide evaluation and care coordination for non-surgical patients. They administer manual procedures (spinal manipulative therapy and soft tissue techniques), prescribe therapeutic exercises, ergonomic advice, nutritional / dietary advice. Chiropractors do not prescribe medications or perform surgery. The patient who responds best to chiropractic is experiencing low back pain with only minor radiation to the lower extremities. There is a lot of cross over between physical therapists and chiropractors. One key difference is the chiropractor’s license to order / interpret diagnostic testing and make a “medical diagnosis”. A referral is not required, in most cases, to see a chiropractor.

Medical Internist (or Nurse Practitioner or Physician’s Assistant) Your personal medical physician really should know your medical history best. If you have a complex medical history, or have any of the previously mentioned “Red Flags”, see your primary care physician first. A primary care physician may also prescribe a short-term medication to help get you through the acute phase of pain. Referrals for other care services can also be made.

Osteopath (DO – Doctor of Osteopathy) Osteopathic physicians were originally medical practitioners who also administered manual manipulative therapy. Some osteopaths still provide manual treatments, but most function in parallel roles to medical practitioners and sub-specialize in the same fields as their MD colleagues.

Physical Therapist Physical therapists are an important part of your spine care team. They treat patients from the acute to the chronic pain suffers. They integrate manual therapies, exercise, ergonomic training and soft tissue therapies into their care strategies. If you have suffered chronic low back pain, physical therapists are often important in restoring strength and endurance through supervised exercise and conditioning programs.

Rheumatologist Rheumatologists are important when evaluating and managing certain arthritic diseases of the spine. (You have probably heard the recent advertisements for medications for ankylosing spondylitis, which is an autoimmune, inflammatory spinal condition.) Some rheumatologists enjoy performing the initial evaluation / triage process, whereas others prefer to focus on rheumatological conditions that affect the spine. Courtesy of the Osher Clinical Center for Complementary and Integrative Medical Therapies 3

Surgeon Definitely consult a surgeon early-on if you are experiencing progressive loss of feeling or weakness in the lower extremities or difficulty controlling your bowel or bladder. Otherwise, consult a surgeon after all reasonable conservative efforts have been exhausted. Many people still ask the question, “Should I see an orthopedic surgeon or a neurosurgeon”. The best answer that I can provide is “See a surgeon who is trained in spinal surgery”. I have found that the BWH surgeons of different backgrounds are excellent clinicians who are admirably conservative and do not operate unless it is absolutely indicated and conservative measure have failed to bring relief.

Phyisatrist Physiatrists are medical physicians who often have cross training in rehabilitation and pain management. Most physiatrists do not perform surgery. They can be great care coordinators who can evaluate, prescribe medications, prescribe a course of physical therapy and administer various types spinal and musculoskeletal injections when appropriate.

How long should it take to respond to treatment? Your response to treatment is dependent upon a number of factors including, the complexity of the problem, your personal health status, the number of prior episodes of pain, how you view the cause of the pain, the severity of the pain and how well you follow the advice provided. In most instances, a response to non-pharmacological and non-invasive treatment should begin to be appreciated within a couple of weeks. If you are not responding within 2-4 weeks, the problem should be further investigated, or the treatment should be modified.

Back Pain During Pregnancy Megan Tabor, DC Chiropractor – Osher Clinical Center

As happy the occasion of having a baby is, at least 50% of women experience some form of back pain while pregnant. This very common complaint has less to do with how “fit” a woman is, but more because so many changes are occurring during those nine months.

Let’s follow my pregnant patient, “Joy” in this article, and explain some of the reasons why she might have back pain and then give her some suggestions for what can be done about it.

Causes for Back Pain in Pregnancy 1. Hormone changes Relaxin is a hormone produced by Joy’s ovaries and placenta with important effects during pregnancy. Specifically related to her musculoskeletal system, it relaxes ligaments in her pelvis in preparation for childbirth, which affects the ligaments supporting her sacroiliac joints (those “dimples” on either side of the lower back), her lower back joints, hips, knees and even her ankles.

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2. Weight gain During Joy’s healthy pregnancy, she will gain an average of 25-35 pounds; extra weight that must be supported by her spine. Her growing baby and uterus places pressure on the low back, sacrum, pelvis, and legs, as well as the nerves and blood supply in the area. This weight gain, combined with that “relaxing” effect of the relaxin hormone, can result in some low back, buttock and thigh pain. 3. Postural changes All that frontal weight gain, in addition to her breasts swelling (increasing fat reserves and milk gland size) causes a large shift in the Joy’s center of gravity. The curve in her lower back increases. She begins adjusting how she walks—perhaps widening her stance and gait. The arches in her feet may shift under all the extra weight (and don’t forget that relaxin!). Near the latter part of her pregnancy, Joy’s growing baby and uterus may put pressure on her rectum causing some constipation. Phew! You think Joy’s muscles in her lower back, her legs and abdomen are getting a bit strained? Helping/Preventing Joy’s Back Pain 1.

Happy feet. Don’t wear heels or shoes with poor arch support (no soft flats, Joy!). Some women find support hose helps also.

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Watch your posture. Slouching strains the spine, so if you must sit for your job, use a small pillow/lumbar support and rest you feet on a small stool. If you must stand a lot, put one foot up on a small stool or box and/or consider wearing a support belt made exclusively for pregnant women. When sleeping on your side, put a pillow between your knees to take some stress off your lower back.

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Lifting objects. First of all, ask for help! But if you have to pick up something, no bending forward from the waist. Get close to the item you have to pick up, bend your knees and sit back into a squat and keep your back straight.

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Exercise. Always check with your providers, Joy, but generally exercises that are safe for you could include yoga for pregnant women, swimming, stationary biking.

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Acupuncture. Whether you have questions about morning sickness or lower back pain, stop by the Osher Center and speak with one of our acupuncturists about how and when this safe therapy could be helpful. Fergie from “Black Eyes Peas” is thrilled about how helpful it’s been for her!

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Massage. Prenatal massages can certainly help with easing the discomfort of those strained back muscles.

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Chiropractic. (You know I had to…). When performed correctly, chiropractic treatment can be a safe and effective therapy to relieve some back pain.

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Heat and/or cold compresses. Sometimes this simple therapy can help ease things a bit, but only apply these on the back only and not on the abdomen.

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Stress reduction. Emotional stress can cause muscle tension in the back and visa versa. If stress is high during this time, consider talking to a friend or counselor, or consider taking a meditation or stress reduction class.

Whether it’s advice on general maternal care, spine care support or healthy eating, there are many safe therapies out there to help you through this, Joy! Consult with your Obstetrician and associated team to find out what’s best for you.

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Prunes for Healthy Bones? - Caitlin Hosmer Kirby, RD. Nutritional Health Coach - Osher Clinical Center

Osteoporosis and low bone mass are a substantial and growing problem in our population. The National Osteoporosis Foundation (NOF) estimates that 9 million adults in the U.S. have osteoporosis and more than 48 million have low bone mass (indicated by T-scores between -1.0 and -2.5). Why is this important? Because low bone mass increases the risk of fracture; particularly of the spine and hips. Hip and spinal fractures can lead to disability, lost work time, decreased quality of life, prolonged hospitalization and even death from related complications. As we age, this risk of fracture increases as the risk of falling increases. Osteoporosis is avoidable for many at risk. By maintaining a diet rich in calcium and vitamin D, doing regular weight-bearing and muscle-strengthening exercises and by following medical treatments as prescribed, the millions at risk for osteoporosis can protect their bones," says Amy Porter, executive director and CEO, National Osteoporosis Foundation. Courtesy of Sun-Maid Growers of California

New research highlights a seemingly, but effective, food to add to the arsenal of bone health support: 10 prunes a day. (That’s right, 10; this is not a typographical error.) As you can imagine, prunes also support gastrointestinal health. Over my career, I have tested numerous fruits, including figs, dates, strawberries and raisins, and none come close to the bone density benefit that dried plums or prunes offer. All fruits and vegetables have a positive effect on nutrition, but in terms of bone health, this particular food is exceptional. Now, before you grasp your stomach and say “What! Ten prunes a day! I’ll lose all of my friends!”, consider this. One way to approach this recommendation is to simply consume prunes, “to bowel tolerance.” That means eat as many as you can comfortably. Over time you may increase the dose as your body learns to tolerate more. Another option is to combine the prunes with other things or foods that have the opposite effect on bowel transit times (BTT); foods that tend to be constipating. Calcium certainly does this to many people, as do ground poppy seeds and carob powder. It is perhaps noteworthy that, in some cultures, both ground poppy seed and prune paste have been traditionally consumed in close proximity. Fortuitously, a fair percentage of patients who are in the age that they may benefit from “prune therapy” also have relatively slow BTT (that’s the fancy way to say they are constipated) and this prune prescription may provide relief.

Bahram H. Arjmandi, Florida State’s Margaret A. Sitton Professor and chairman of the Department of Nutrition, Food and Exercise Sciences in the College of Human Sciences. Click on the following link to read more about how 100grams (approximately 10) of dried plums (prunes) can help support bone mineral density in the prevention of osteoporosis. http://www.happyhealthylonglife.com/happy_healthy_long_life/2011/09/prunes_bones.html Hooshmand, S et al "Comparative effects of dried plum and dried apple on bone in postmenopausal women," British Journal of Nutrition 106(6):923-30, September, 2011. Epub 2011 May 31.

You cannot just sit back and wait for good health to come to you. You’ve got to go out and find it.

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Notes from the Scientific Literature and Clinical Practice Guidelines: on the use of Integrative Medical Therapies for Back Pain -

Donald B. Levy, M.D.

For Low Back Pain in General “Doctors and Patients should consider the following non-drug treatments for patients who do not respond to self-care: rehabilitation, spinal manipulation, exercise therapy, massage, acupuncture, yoga, progressive relaxation or cognitive behavioral therapy….Recommendations may change as new studies become available” From the American College of Physicians and the American Pain Society—Joint clinical practice guidelines [Chou R et. al. Ann Intern Med. 2007]

Yoga for Chronic Low Back Pain Cramer H. et. al. A systematic review and meta-analysis of yoga for low back pain. Clin J. Pain; 2012. This relatively recent comprehensive review looked at 10 randomized controlled trials with a total of 967 patients with chronic low back pain that compared yoga to some other active treatment or no treatment. The shortest group ran for 3 weeks and the longest for 24 weeks. Styles of yoga were heterogeneous and included Iyengar, Hatha, Viniyoga and some hybrids. The analysis found strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness of yoga for chronic low back pain in the most important patient-centered outcomes. There was strong evidence for:   

Global improvement Decreased short-term and long-term pain Decreased back-pain specific disability

There was no evidence for significant changes in health-related quality of life. Yoga was not associated with serious adverse events. Given these findings, the authors concluded that yoga can be safely recommended as an additional therapy to patients who do not improve with education or other self-care options.

Massage for Chronic Low Back Pain Cherkin DC et. al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain. A randomized, controlled trial. Ann Intern Med. 2011 Researchers compared the effects of 10 weekly treatments of relaxation massage, structural massage and usual care on 401 patients with uncomplicated, nonspecific chronic low back pain Relaxation massage is intended to induce a generalized sense of relaxation and its techniques are taught at almost all massage schools. It is probably the most common type of massage most people experience. Structural massage includes myofascial, neuromuscular and other soft-tissue techniques and requires some additional training. Courtesy of the Osher Clinical Center for Complementary and Integrative Medical Therapies 7

It includes techniques that are intended to engage and release identified restrictions in myofascial tissues. Neuromuscular techniques are used to resolve soft-tissue abnormalities by mobilizing restricted joints, lengthening constricted muscles and fascia, balancing agonist and antagonist muscles and reducing hypertonicity. All groups showed improved function after 10 weeks but improvement was greater with either type of massage. The benefits of both types of massage lasted for 6 months and to a less clinically significant degree at 1 year. There were no clinically or statistically significant differences between types of massage. The authors point out that all the massage therapists had at least 5 years of experience and had some degree of knowledge of structural techniques. If patients with more complicated back problems were included such as those with disc herniation, sciatica or prior back surgery, the structurally focused massage may have shown additional benefit. [Editor’s note: The massage therapists at the Osher Clinic would be considered very experienced by the standards used, have training in multiple techniques and do see patients with the more complicated back pain syndromes]

Acupuncture for Chronic Low Back Pain 

American College of Physicians and the American Pain Society—Joint clinical practice guidelines: “Consider acupuncture as one possible treatment option for patients with chronic low back pain who do not have an adequate response to self-care measures” [Chou R et. al. Ann Intern Med. 2007]

 North American Spine Society: “When compared with no treatment, there is evidence that acupuncture is effective in pain relief and functional improvement immediately after a series of treatment sessions and in the short term follow-up…The most consistent evidence appears to be for the addition of acupuncture to other therapies…” [Ammendolia C et. al. Spine J 2008.]

 U.K. National Institute for Health and Clinical Excellence: “Recommends acupuncture as a treatment option for low back pain.” (The National Health Service provides up to 10 sessions of acupuncture for low back pain that has persisted more than 6 weeks). [Clin Guideline No. 88; 2009]

3 Simple Exercises to Help Care for Your Low Back - Matthew H. Kowalski, DC Chiropractor – Osher Clinical Center

Try these three simple exercises to help relieve some of your daily low aches and pains. These movements may also have preventive benefits. There may be some discomfort due the first few days of doing these exercises, but they should not cause severe pain. Expect some stiffness only. If more severe pain occurs, stop immediately.

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Bend over backward to reverse the effects of sitting. If you sit a lot at work, consider standing every hour and bend over backward ten times. Place the hands on your hips and lean backward over this fulcrum.

Pelvic Bridges While lying on your back with the knees bend to about 90 degrees, begin by contracting your abdominal and gluteal muscles. Next raise the pelvis from the floor until the shoulders, hips and knees form one straight line. Pause and repeat 10 times.

Bird Dog (Quadruped, alternating arm and leg raises) Get into the “all 4s” position, with the knees beneath the hips and the hands beneath the shoulders. Draw the naval toward the spine, contract the gluteal muscles and raise the opposite arm and leg from the floor. This may look easy, but it a test of you balance! Pause and repeat 10 times on each side. Don’t attempt to lift the arm and leg on the same side; you will likely fall over.

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Ice or heat? Which is best? 

In general, cold and hot packs may be applied for 15-20 minute intervals with 1 hour between applications.

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If the treatment increases the symptoms, discontinue immediately and consult your doctor.

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Do not apply cold or heat to a desensitized area (e.g., a region that was previously frostbitten or affected by diabetes).

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Never sleep on a hot or cold pack. You can get burned by either.

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After an acute (new) injury, apply ice for the first 24-72 hours.

Hot Packs Hot packs are commonly used to relieve pain and stiffness from chronic arthritis and muscle tension. We recommend using moist hot packs, rather than a dry heating pad. Moist heat is less dehydrating to the skin and seems to penetrate deeper than dry heat. Do not apply heat to an acute injury (under 48 hours). Although it feels good when applied, heat may increase any underlying swelling. Commonly, heat packs feel good when applied to a new injury, but, several hours later, the pain worsens as the swelling increases. Ice Packs In order to avoid the sudden cold shock feeling when applying an ice pack, place a warm, damp towel over the region being treated before applying the ice. A flexible ice pack works best. If you use ice cubes, crush them before placing them in the ice bag. This will increase the surface area of the ice and provide a more effective treatment. (Frozen peas work nicely also.) Flexible, reusable ice packs are available at most drug stores.

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Please join us in sharing your health tips and feedback. For comments on the content of this newsletter, please contact Donald Levy, MD at [email protected] To submit ideas for future newsletters, please contact Matthew H. Kowalski, DC at [email protected]

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