back pain posts Archives

Conditioned Pain Modulation

Have you ever noticed that pain in one area took your attention away from pain in another spot?  For example, you were feeling back pain and then jammed your toe, and your back pain diminished or went away.  As the toe pain reduced, the back pain reappeared.  Conditioned Pain Modulation (CPM), formerly known as DNIC (diffuse noxious inhibitory control), is the phenomenon where pain in one area inhibits pain in a different area of the body.

Another example is seen in patients who have pain that is noticeably worse on one side of the body than the other.  Once pain is treated on their “bad” side, their “good” side seems to get much worse.  In this case, pain on the “good” side was always present, but becomes more noticeable once the worst pain was addressed.

In fibromyalgia syndrome patients, there appears to be impaired CPM. [i]  CPM is one reason why understanding a patient’s pain complaint is challenging.


[i] Davis, Mellar P. “The Clinical Importance of Conditioning Pain Modulation: A Review and Clinical Implications.” Research and Development of Opioid-Related Ligands (2013): n. pag. Print.

 

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Thoughts on pain management and the cost of care

John Bonica, M.D. a world renowned anesthesiologist at the University of Washington in Seattle was the individual most responsible for the creation of a new specialty, Pain Medicine. In 1977 The American Pain Society was founded and became the United States national chapter in the International Association for the Study of Pain. Complicated difficult to treat pain patients were usually not successfully treated by a physician representing one medical discipline and thus the multi-disciplinary pain treatment model was created.

It was understood that belief systems about the patients’ pain such as –“having pain means I am harming myself “ resulting in the avoidance of activities that produce discomfort and eventually eliminating many important activities in the patients life with resulting deconditioning, depression, pain drug use, dollars spent and ultimately disability. Pain becomes the focus of life and the more it is pondered the worse it feels. Multi-disciplinary teams composed of a pain management physician, psychiatrist, psychologist, social worker, occupational therapist, physical therapist and pain team nurses provide weeks of intensive full day treatment programs with remarkable success in restoring function to patients disabled with persistent pain.

There is an organization called Cochrane Collaborations that reviews various medical treatments to determine if they have been adequately studied and the results of the studies indicate that they are effective, ineffective or undetermined. Almost all of the treatments for back pain have been found to be neither ineffective or effective, meaning the evidence is out and more and better studies are needed- but multi-disciplinary pain centers have consistently been found to be effective for the treatment of chronic back pain. In the early 1990s there were more than a hundred pain centers certified by the Commission on Accreditation of Rehabilitation Facilities and despite the success of multi-disciplinary programs , close to half of them are no longer operating.

One reason for the closing of many centers was the pull back by insurance carriers for payments for non-interventional pain treatment services. Doing a procedure seemed to be considered more valid and worthy of payment than a non-invasive service even if it was effective in reducing pain, improving function and lowering future cost of care. Today some of the best pain centers cannot survive by depending on insurance payments and are forced to charge their patients large out of pocket sums in order to remain in operation. Some of these insurance carriers that will not pay for comprehensive pain centers will routinely pay for procedures of questionable effectiveness.

Please refer back to the past two blogs to find the background material for todays blog. Although the number of CARF approved pain centers in the US halved, the number of outpatient pain centers mushroomed. The services provided however focused on two areas:

  1. Medication management
  2. Nerve blocks and other invasive procedures.

Although many patients could be helped with one or both of these approaches, many patients in need of physical therapy and psychological services that were integrated with the overall treatment plan, would no longer receive optimal treatment. Reimbursement would be the driver of care rather than the needs of the patient. Centers could not stay in business and provide care that insurance companies would not cover. The shift toward procedures became an accepted standard of care and new organizations of pain physicians were formed whose membership focused predominantly on invasive procedures.

The cost of services for the treatment of back and neck pain, now with many less comprehensive multi-disciplinary centers, has nonetheless continued to rise at an alarming rate . Some of the increased cost is because of more numerous and complicated surgeries  . The bottom line is that we are spending more money each year on neck and back pain in the US, approximately the same as we spend on Cancer, and not getting good results.

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Through the ages various explanations have been offered to explain the cause and how to treat it.  But it wasn’t until the 19th century that the spine and the nervous system were seen as the fundamental source of back pain. The idea that the cause of back pain was some injury or irritation in the bones and nerves of the spine was adopted by the medical community and this notion has persisted up to the present. With this in mind, recommending bed rest made sense-so bed rest became a standard treatment through most of the 20th century.  Some savvy physicians recommended staying active, but their opinion was drowned out by the bed rest proponents. If you have an injury it can take weeks to heal, and therefore it was common to have patients with back pain lie in bed, often in a hospital, sometimes without even getting up to go to the bathroom, for two or more weeks. It was only at the end of the 20th century, that the medical community recognized two facts:1. Back pain was usually not from any obvious injury. 2. Prolonged bed rest was not only not helpful, it was damaging. So patients with typical back pain began to be encouraged to remain active and to return to work as quickly as possible.

When x-rays were introduced, doctors could see the joints in the spine and the pelvis, and began to suggest that this is where the pain originated.  New phrases, such as “my sacroiliac is out” and I have a “bout of lumbago”, creeped into our conversations.  In the 1920s and 30s a variety of new creative surgeries were tried including fusing the sacroiliac joint, fusing the joint between the lumbar section of the spine and the sacrum and cutting out parts of the spinal column, all of which didn’t solve the problem and rapidly became unpopular. Some bad ideas with dreadful consequences don’t go away easily, and some physicians have reintroduced sacroiliac fusion. The joints that don’t look pretty on x-ray or now with MRI/CT scanning, although not undergoing surgery, still remain as targets for injections in pain centers.

The first report of spine surgery to remove a herniated disc to treat pain radiating down the leg (sciatica) was in 1934 and in 1935 the same operation was suggested as a treatment for back pain as well. The disc pressing on a nerve to cause pain shooting down the leg and the surgery to remove the part of the disc and bone in the spine to relieve the pressure on the nerve made sense and surgery for sciatica sometimes is indicated and successful. But looking to the disc as the cause of back without leg pain proved to be the foundation of the mistaken notion that the disc was the fundamental cause of most low back pain. This concept has led to needless surgeries, exorbitant costs and tragic suffering. Over the next twenty years surgery on the disc became one of the most common operations done by neurosurgeons.

The disc was not the reason for most back pain and many of the surgeries that were done were failures with patients experiencing no change or even worse back pain. The number of unsuccessful back surgeries was so high that a new diagnosis was created, something unique in all of medicine, “Failed Back Surgery Syndrome” , also known as “Post-laminectomy Syndrome”, referring to the part of the vertebra, the lamina, that is cut away to remove pressure from the disc. The surgeon was no longer the unquestioned authority as the answer to back pain. Many clinicians, including orthopedic and neurosurgeons, recognized that the problem of back pain was more complex than a problem in the discs and that many factors including emotions, job issues and physical conditioning, all contributed to the experience of back pain.

In the 1970s a new movement to understand pain in general, with back pain as a major focus, was spawned through the efforts of John Bonica, M.D. and his colleagues. More on Pain Treatment Centers next time.

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Back pain relief achieved when soft tissue was addressed

Oliver is an 84-year-old publisher who came to see me for pain in the middle of his low back, which sometimes radiated to his right hip and down his right thigh.  He described this pain as an intermittent aching, stabbing, shooting sensation, made worse by sitting for more than 30 minutes, standing for more than 15 minutes, and walking.  His pain made it difficult for him to stand erect.  Though his pain began 8 years before he came to see me, it was exacerbated by an automobile accident 5 years prior to treatment.  He had been to a physical therapist and a neurologist, and was diagnosed with postpolio syndrome.  Imaging studies revealed severe degenerative changes throughout the lumbar spine.Back Pain

His physical examination revealed that although he had adequate strength in his trunk and no trigger points, his hamstrings were very tight and he had atrophied muscles in his lower extremities. I suggested that he learn the exercises that were created at the Columbia University School of Medicine in the early 1960s by my mentor Hans Kraus.  These exercises were later given at the YMCA to over 300,000 people with an 80% success rate in diminishing or eliminating low back pain.  The exercises are created to produce relaxation, limbering, stretching and strengthening of key postural muscles.  Oliver also began to gradually increase the amount of walking he did each day until he reached 2-3 miles.

By addressing the deconditioned muscles in his legs, buttocks and low back, Oliver was able to find relief for the discomfort in his low back, and stand erect.  Even with a diagnosis of Post-polio syndrome and  imaging studies showing degenerative changes in his spine, Oliver found relief when the soft tissue component of his pain was addressed.

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Failed Back Surgery Syndrome

Anna is a 40 year old married woman, who had been on bed rest for approximately 3 years because of her pain. After a spinal fusion, discectomy, facet blocks and physical therapy, she was still having severe pain in her low back. Another surgery was suggested.

When I examined Anna, I identified and treated 5 muscles in her low back and buttocks (lumbar paraspinals and piriformis on both sides and the left gluteus medius). Each muscle was treated with an injection technique that addresses the muscle attachments and tissue and followed with a 3 day physical therapy protocol. She was taught an exercise program, developed at the Columbia University School of Medicine in 1960 and given to 300,000 participants at the YMCA, to help keep her muscles relaxed, limber and strong. With significant relief in her pain, she traveled to Asia a few months following treatment, began working part-time, and now 5 years later still reports being able to enjoy her life again.

Failed Back Surgery Syndrome is often thought to be amenable only to palliative interventions such as Spinal Cord Stimulation or chronic administration of opioids. Anna had muscle related pain that had not been considered as a possible cause of her ongoing post-operative pain. We will be posting other patient histories where persistent pain was caused by overlooked painful muscles.

 

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Physical Examinations Result in Better Outcomes for Back Pain

Donna, a 43 year old married mother with a one year old son saw me for evaluation of severe low back and buttock pain. Her MRIs showed a disc herniation at L4-5 and moderate-to-severe spinal stenosis at the same level. She received physical therapy, 3 epidural steroids and chiropractic treatments with transient or no pain relief. Her orthopedic surgeon told her that since all conservative measures were already done the only option was spine surgery. He felt a fusion should be done.

My soft tissue examination identified 3 areas in her low back (the Quadratus Lumborum on both sides, and the right Gluteus Maximus) as possible sources of her pain. Each was treated with an injection technique that emphasizes placement of the needle into the muscle’s tendinous and bony attachments and the tissue along the course of the muscle from the origin to the insertion. A 3 day post-injection physical therapy protocol followed each injection session. Donna was taught all 21 exercises in my low back exercise program and experienced complete relief in less than a month after starting treatment. She returned to the gym, ran a half marathon and on follow up 5 years after treatment, was still pain free, hiking, biking, and running.blog post from NMPI

I believe that patients like Donna who receive spine surgery will frequently be found as Failed Back Surgery Syndrome cases.

Imaging findings often do not provide an accurate explanation for your pain. Addressing the imaging diagnosis without an examination to identify possible specific sources of muscle pain may lead to treatments that are at best inadequate and at worst damaging.

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One of our colleagues, Ronnie Gonzalez, a bereavement counselor, sent us a comment about her clients, who often felt physical pain while struggling with the loss of a loved one.

Very often, emotional stress and negative thoughts can manifest physically as tension in the muscles, which is one of the most common causes of pain. Constant exposure to stressors can cause the development of musculoskeletal pain in even healthy individuals (http://psycnet.apa.org/journals/ocp/15/4/399/, http://iospress.metapress.com/content/w8147125250687x5/) and is therefore considered a risk factor associated with the onset of pain.

fMRI (functional magnetic resonance imaging) studies of pain patients demonstrate that negative thoughts can excite areas of the brain associated with pain perceptions and intensify the sensation of pain. Studies have shown that painful muscles which are tense, especially during times of stress, can stay contracted and tight even after the stress or negative feelings are long gone. This causes the body to be more susceptible to pain.

Breathing and stress are also linked. When we suppress our feelings, we generally hold our breath. Depriving our muscles of oxygen will cause it to hurt. The advice of taking deep breaths when we’re stressed or anxious is not unfounded.

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Apparent diagnoses sometimes lead us astray …

When treating chronic back pain, over-reliance on imaging studies frequently suggest arthritis, disc herniations, spinal stenosis, degenerative disc disease, and spondylolisthesis as the underlying diagnoses. Unsuccessful treatment often results if muscles, tendons, and fascia are not considered in the differential diagnosis.

Widespread pain is often diagnosed as Fibromyalgia Syndrome (FMS). In 1990 the American College of Rheumatology (ACR) presented classification criteria for the diagnosis of FMS [http://bit.ly/1bCzlC4.] 11 of 18 specified tender points as well as widespread pain defined as pain experienced on the left and right side, in the upper and lower body, and axially. Most patients are diagnosed with FMS by their primary care physician. However, most primary care physicians do not perform a physical examination of tender points. Because of this the ACR in 2010 proposed an additional set of diagnostic criteria for FMS that did not rely on a physical examination (http://bit.ly/1bCzlC4).

Three conditions must be met to satisfy the criteria:

  1. Threshold scores on two new indices created by the ACR- the widespread pain index and the symptom severity scale score based on the presence of fatigue, waking un-refreshed and cognitive symptoms.
  2. Patients must have similar symptoms at approximately the same intensity for at least three months.
  3. No other disorder would reasonably explain the pain.

Although there is reasonable correlation between patients diagnosed with the 1990 criteria and the 2010 criteria, the absence of the physical examination may lead to overlooking patients whose diffuse pain can be successfully treated by addressing peripheral pain generators. Painful tissue peripherally (for example muscle or joint) can sensitize muscles diffusely [Woolf CJ, Central Sensitization: Implications for the diagnosis and treatment of pain. Pain 152 (2011) S2-S 15].

I welcome your comments on the complexities of diagnosing and treating FMS; more on central sensitization in my next post.

 

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Back Pain: Opinion vs. Evidence

I Googled back pain and got 649,000,000 hits. I am sure that the opinions of all those who posted their successful approaches were in there.

Overall I would say the consensus, based on cost and outcomes analysis, is that we do too much treatment of low back pain. Back pain is a symptom that may be caused by a variety of factors.

Deconditioning, muscles, tendons, operable lesions of the skeleton and neuraxis, are all possible causes. It is important to recognize that all the clinicians who posted their very different theoretical models and treatment approaches, believed they were achieving success with a majority of their patients.  How could this be true unless each clinician was treating a unique subgroup of back pain patients?  A recent article (http://bit.ly/1fjuCUT) demonstrated that pain clinicians publishing their outcomes reported an approximately 300% greater success rate than non-pain clinicians reporting on the outcomes of the same procedures.  We are invested in believing that what we do works.

I try to consult the Cochrane Library of Systematic Reviews (www.thecochranelibrary.com) to get a sense of the validity of various approaches for the treatment of back pain. The literature on prolotherapy, trigger point injections, nerve blocks and surgery for chronic low back pain uniformly is found to be inadequate to make a case for the routine use of these approaches.

We need randomized controlled studies that report on function as well as pain intensity and with adequately long follow up data to improve our ability to know what works and for whom.

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One reason for the closing of many centers was the pull back by insurance carriers for payments for non-interventional pain treatment services. Doing a procedure seemed to be considered more valid and worthy of payment than a non-invasive service even if it was effective in reducing pain, improving function and lowering future cost of care. Today some of the best pain centers cannot survive by depending on insurance payments and are forced to charge their patients large out of pocket sums in order to remain in operation. Some of these insurance carriers that will not pay for comprehensive pain centers will routinely pay for procedures of questionable effectiveness. Although the number of CARF approved pain centers in the US halved, the number of outpatient pain centers mushroomed. The services provided however focused on two areas:

  1. Medication management
  2. Nerve blocks and other invasive procedures.

Some patients could be helped with one or both of these approaches, but many patients in need of physical therapy and psychological services that had been integrated in a comprehensive treatment plan, would no longer receive optimal treatment. Reimbursement would be the driver of care rather than the needs of the patient. Centers could not stay in business and provide care that insurance companies would not cover. The shift toward procedures became an accepted standard of care and new organizations of pain physicians were formed whose membership focused predominantly on invasive procedures.

The emphasis on medication management was in part fueled by the belief that most patients with persistent pain could be treated successfully and safely with strong pain medications, such as opioids like morphine and oxycodone. We have a better understanding now of problems encountered when we freely offered potent pain medications to too many patients. Strong pain medications not only treat pain but also affect mood. Many patients with or without pain have anxiety and/or depression. Pain medications can provide emotional relief and patients would take them consciously or inadvertently for psychological rather than pain relief. Prescribed pain medication have become more popular than street drugs such as heroin for people who were drug abusers and some patients feigned pain and sold the prescribed pills for a handsome profit.

The cost of services for the treatment of back and neck pain, now with many less comprehensive multi-disciplinary centers, has nonetheless continued to rise at an alarming rate. Next time let’s look at the phenomenon of unintended consequences.

 

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John Bonica, M.D. a world renowned anesthesiologist at the University of Washington in Seattle was the individual most responsible for the creation of a new specialty, Pain Medicine. In 1977 The American Pain Society was founded and became the United States national chapter in the International Association for the Study of Pain. Complicated difficult to treat pain patients were usually not successfully treated by a physician representing one medical discipline and thus the multi-disciplinary pain treatment model was created.

Clinicians observed that patients with persistent pain had misconceptions about their condition that inhibited their ability to recover. Patient would frequently say “ if I have pain it means I am harming myself “ resulting in the avoidance of activities that produce discomfort and eventually eliminating many important activities in their life with resulting deconditioning, depression, drug use, dollars spent, and ultimately disability. Pain becomes the focus of life and the more it is pondered the worse it feels. Multi-disciplinary teams composed of a pain management physician, psychiatrist, psychologist, social worker, occupational therapist, physical therapist and pain team nurses were created to address all of the factors associated with perpetuating the patient’s inability to function. Multidisciplinary pain centers provided weeks of intensive full day treatment programs with remarkable success in restoring function to patients disabled with persistent pain.

There is an organization called Cochrane Collaborations that reviews commonly provided treatments for various medical conditions to determine if the treatment is effective, ineffective or undetermined. Almost all of the treatments for chronic back pain have been found to be neither ineffective or effective, meaning the evidence is inconclusive and more and better studies are needed- but multi-disciplinary pain centers have consistently been found to be effective for the treatment of chronic back pain. In the early 1990s there were more than a hundred pain centers certified by the Commission on Accreditation of Rehabilitation Facilities and despite their success, close to half of them are no longer operating. “So what’s up with that?”

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A number of my patients who have been struggling with pain management for more than a year may report that although their pain began in one specific spot, over time, it began to spread. Sometimes, over time, neck pain would involve the lower back pain as well. Many of these patients were thought to possibly have fibromyalgia syndrome and were given anticonvulsant or serotonin-norepinephrine reuptake inhibitors (SNRIs). The spread of pain may be from central sensitization (CS) (http://bit.ly/1aVsdg0, http://bit.ly/1bHgSDU). With some of these patients when the worst pain was treated and resolved from one area it could appear in another and muscles not recognized on the initial examination would now be found to be causing discomfort. This could be a function of diffuse noxious inhibitory control (DNIC) http://bit.ly/14Ac4GL,

These confounding problems appear to represent two opposing and confusing phenomenon: CS and DNIC [currently referred to as conditioned pain modulation (CPM)] (http://bit.ly/1aVuish). Do these issues enter into your evaluation and treatment protocols?

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The study published in JAMA today demonstrated that from 1999-2010 in 3 key areas, guidelines for the treatment of back pain are being ignored:

  1. Use of recommended NSAIDs and APAP as first line drugs decreased by ~35% whilst not recommended opioid use increased by ~50%.
  2. Not recommended referral from PCPs to specialists for back pain increased by ~106%.
  3. Not recommended use of imaging increased ~50% for MRI and CT and for x-ray remained the same.

Is this a problem? If so, how should it be addressed?

Read more: http://bit.ly/13touQu

 

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Spine surgery and exercise

I was interviewed, on Doctor Radio on Sirius XM. One of the callers told us that after she had spine fusion her pain was eliminated but if she didn’t do exercises at least every other day her muscles above and below the surgical site would tighten up and  pain would begin to return. Even when surgery is indicated for back pain, proper conditioning of the postural muscles is still important.

If she didn’t have a good physical therapist and she wasn’t motivated to doing her exercises her surgery might have been considered a failure, another Failed Back Syndrome. Too often the need to address muscle health is overlooked in the treatment of persistent pain problems. As I emphasize in End Back Pain Forever, exercise and physical conditioning should be taught in grade school and encouraged throughout our life.

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Many Back Surgeries Unnecessary

In the United States we are faced with the highest per capita health costs in the world. One would think that massive expenditures could provide the best care and treatment outcomes, but this is not the case. In many aspects the US is worse or no better than countries spending 50% of what we do on health care. One reason is that we often inappropriately provide costly evaluation and treatment interventions. We provide surgery too frequently on conditions that could be treated more cost-effectively. Having a step- care model (using the least invasive and potentially harmful, and most cost-effective approaches first) for various conditions would offer models of care for the majority of problems whilst still allowing for modifications in unusual circumstances. —Dr. Norman Marcus

 

By Ryan Sabalow

Some doctors estimate the national rates of unnecessary hysterectomies and back surgeries are even higher than the 25 percent cited by state health officials questioning the Redding area’s high rates of the procedures.

Dr. Ernst Bartsich, a clinical associate professor of obstetrics and gynecology at Weill Cornell Medical College in Manhattan, N.Y., said as many as one in three women in the U.S. has had her uterus removed by the time she’s 60. That number increases to one in two by 65.

Bartsich, an outspoken critic of what he calls the overuse of hysterectomies, said he believes that 85 percent of such procedures could have been avoided through less invasive methods, such as removing painful fibroid tumors from the uterine wall or through medication.
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How can we know what back pain treatments make sense?

If the cost of health care is to be reduced in the US, new methods should be established to pay clinicians, pharmaceutical companies and device manufacturers. If graduating medical students are so laden with debt that paying it off is more important than the possibility of ongoing study and academic pursuit, we must lower the cost to the student of medical education. If the cost of drug development is so high that huge prices must be charged for pills, we must find ways to reduce the cost of development of new pharmaceuticals. These fundamental issues in health care have an impact on the standard of care of back pain in the USA. Read the rest of this entry

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Bedside Manner and the power of suggestion in back pain

Prior to drawing blood, saying a word to patients that suggested pain increased the likelihood of them experiencing pain. You might think of this study as just another example of the importance of “Bedside manner”- the awareness of the importance of the behavior and speech of the physician or other care-takers, on the feeling of well-being of the patient. Eugene Bauer, M.D., a Viennese physician, said in 1931: “A word in the mouth of a physician is as important as the scalpel in the hands of a surgeon”. Words can cut, soothe, and rattle. How you are approached by a doctor is determined not only by their personality but also by the beliefs concerning your problem.

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Obesity, poverty, and community influence- back pain

Obesity is more prevalent in neighborhoods with a high incidence of poverty. A study in the New England Journal of Medicine showed that encouraging families to relocate to higher income neighborhoods could lower the rate of obesity and signs of diabetes. This finding may lead to a better understanding of how we can combat the obesity epidemic. Read the rest of this entry

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In the last part of Chapter 1 from End Back Pain Forever, we turn to the story of “Stephanie”. Please review this blog for the complete chapters 1 and 2 from my book.

“Doctor, My Back is Killing Me!”, Part 3

 

Take the case of a patient whom I shall call Stephanie. She is a married attorney who in 2004 began to experience stiffness whenever she she got up out of a chair. She also had problems straightening up if she bent over. This was bothersome, but it was nothing compared to her first attack of spasms in her low back, on the right side. The spasms were incapacitating. She couldn’t walk and had to lie in bed for four days, taking painkillers and muscle relaxants. When the spasms broke, she still felt an inkling of discomfort that would frequently and unexpectedly morph into repeat episodes of painful spasms.

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Here is Part 2 of Chapter 1 from my book, End Back Pain Forever.  Click here for Part 1.

Chapter 1

“Doctor, My Back is Killing Me!”, Part 2

“I can put you on strong medication to dull the pain,” says the doctor. “It may be that your spine is the problem.”

“Does that mean surgery?”

“It could. Surgeons do a million spinal operations a year.”

Surgery on your spine is the last thing you want to do, but your back pain is horrendous. And, of course, you want to get better. So you say, “Can’t we do an MRI or a CT scan to see if there’s anything wrong with the spine?” MRI, or Magnetic Resonance Imaging, is a picture generated by magnetic fields, while a CT (computed tomography) scan is a picture generated by X-rays.

When you are shown the test results, the doctor points out that the images of your spine show that you have, say, a herniated disc (in which the cushion between two bony vertebrae is either protruding or has ruptured) or spinal stenosis (narrowing of the spinal column that houses your spinal cord), or some other spinal anomaly–and that, apparently, is the cause of your pain.

But if it were true that the abnormality on the MRI or CT scan was indeed the cause of your pain, I wouldn’t have written this book–because almost no one has a “normal” MRI or CT scan of the lower spine, and what is read as abnormal is frequently not the cause of your pain.

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