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Melanie Cole (Host):  Low back pain, if you’ve ever had it, you know it can be debilitating and keep you form taking part in the activities that you really enjoy. But when that pain begins to interfere with your daily life; it might be time to see a physician to assess that pain. This is ChristianaCare’s Moving Freely podcast series. I’m Melanie Cole. And today we’re talking about low back pain. Joining me is Dr. Nancy Kim, she’s a Physician with ChristianaCare. Dr. Kim, I’m so glad to have you with us today. This is such a common problem, such a common complaint, so many millions of people have low back pain. What are some of the most common causes of it that you see?

Nancy Kim, MD (Guest):  Back pain is so common and there are many different reasons why it is so common. Part of everyday living is using your back so for instance, it could be something as simple as vacuuming, washing the dishes, cooking, cleaning or it could be more in a work environment where let’s say you have that sit down desk job where you are sitting all day at the computer in one spot, putting extra pressure on different structures in the spine. Part of living everyday is using our back and that’s why it is so common. Because there is a lot of wear and tear of our spine that occurs over time.

Host:  Since pain is somewhat subjective; how do you measure it and why is low back pain so difficult to treat and sometimes to diagnose?

Dr. Kim:  There are a lot of reasons for that because pain is usually happening in conjunction with something going on with the mind. It’s how you perceive the pain, how you deal with the pain. It’s a big part of why people experience what they do. We ask patients to rate their pain on a scale from 1 to 10 because it is subjective. It’s very subjective and it’s going to be based on what the patient feels is distressing to them or interfering with their life. So, we use a visual analog scale to rate their scale from 0 to 10 and that kind of gives us a general idea how much is the pain interfering with their life. So, somebody’s 5 might be different from somebody else’s 5. So, everyone’s pain threshold is different, so it is subjective. But it allows us to measure how much of that pain is affecting that individual’s life using the pain scale.

Pain is very difficult to diagnose especially back pain because we have so many different structures in our spine. So, it’s not just the back, you kind of have to think what makes up the back. So, for instance, if you are going to start like layers of a cake, on the outside is the skin and then you have muscle underneath, then you have ligaments, subcutaneous tissue and then under ligament is bone. So, we have different parts of the bone in our spine that can be potential pain generators. And then underneath the bone, we have our epidural space and nerve roots and then we have the disc and then we have this other bone called the vertebral body. So, a lot of different parts to the spine. On top of that, we have a lot of different levels in the spine.

So, it’s a lot of pieces and a very large puzzle and trying to figure out which piece is missing, or which piece is broken is very difficult to do. So, that’s why it’s important to have a really good relationship with your physician where you can really communicate to them what you are feeling, when you are feeling it, how it interferes with your life because ultimately, it’s the patient that will actually give us the diagnosis. But that’s only if you have a really good relationship with your patient where they can communicate with you freely.

Host:  So, important. That’s a really great point. So, what is the first line of defense? If someone comes to you and you have talked to them, taken that history, found out about symptoms that might be leg pain, or shooting pains down their leg, whatever it is; what do you do for them first? Tell us about some of the nonsurgical interventions that you might try right off the bat.

Dr. Kim:  Most patients do get better with conservative care. So, that means the first point is potentially starting them on an anti-inflammatory. It could be just something as simple as ibuprofen, Advil or Aleve and then you get them to ice their back or put heat on their back alternate between both to help reduce inflammation, muscle spasms and then getting them to a really good physical therapy group is the ultimate treatment for back pain.

The therapy that teaches the patient how to take good care of their back, how to do different stretches and exercises to take pressure off of those painful structures causing their back pain and then the ultimate goal of the therapist is to strengthen the core muscles that protect and cushion the spine so that every time they are vacuuming or cooking or doing household chores or doing heavy lifting at work; those are all things that protect the spine if those core muscles are nice and strong. So, the ultimate treatment before any sort of aggressive interventional care is physical therapy, anti-inflammatories, ice and heat to the back and sometimes chiropractic care can be another source of good treatment that is conservative to help manage back pain too.

Host:  I’m so glad that you mentioned that because I was going to ask you about when somebody might visit a chiropractor. What about things like acupuncture or yoga or even weightloss, if that could be something that’s contributing to that pain?

Dr. Kim:  So, acupuncture can be a good source of management of pain if it’s mostly muscle or joint pain. Because acupuncture doesn’t really help reduce inflammation which ultimately causes the pain and damage to your nerve roots. Acupuncture is a way to manage the pain. So, there have been some studies that have been done that have looked at acupuncture, how does it work because you have the Eastern philosophy, you have the Western philosophy. So, the Eastern philosophy is that you are working on the Chi or the energy, the imbalances that are in the body that lead to the pain. The Western philosophy looking at acupuncture actually says that it causes the release of endorphins which is a natural pain killer substance produced by our body that they believe helps with pain.

So, acupuncture can be helpful for muscular, ligament arthritic joint pain. With regards to nerve root pain; not quite as helpful for that. It’s more for management of more of the superficial structures of the spine for acupuncture. Yoga can be really excellent form of exercise but it’s more advanced. So, for someone who is in acute pain; yoga is really way too much. The person will end up having more pain because in yoga, there’s a lot of flexion, a lot of using of the core muscles so if you don’t have the basics that a therapist would teach you; the yoga can actually cause more pain. So, that’s usually the last step after the patient has worked with a therapist, a chiropractor, has learned the basic core muscle exercise program. Then acupuncture would be the ultimate goal to continue to strengthen the core muscles.

Host:  When does the subject of injections for that pain come up? And what does that discussion look like? Tell us about some of those options because we’ve heard about steroid injections and epidurals, there are so many different injections for the back now. Tell us about some of them.

Dr. Kim:  The role of an injection, it’s not the first treatment that you rush too. This is a treatment where either A:  somebody has tried physical therapy for six weeks or more or chiropractic care for six weeks of more and they still have pain. They’ve also been let’s say on anti-inflammatories, muscle relaxants even a steroid taper that they take by mouth so pills for about a week and a half and they are still having a lot of pain in the back going down the leg with weakness or numbness. And that’s the role where the lumbar injection becomes quite helpful. So, there are different types of lumbar epidurals, but the ultimate goal of the injection is to deposit an liquid steroid solution behind the disc and nerve root causing the person’s pain to help reduce the inflammation. And then this allows them to progress in their therapy, focus on the core muscle exercises, the prevention of the pain returning.

The other time an injection is done when the person is in excruciating pain. I’ve had patients come to the office where they can barely move, they are bent over, they come in a wheelchair. So, a therapist really can’t do anything with them and if a chiropractor touches them, they are in excruciating pain. And this is where the injection has a role to get that pain and inflammation down so that the therapist or chiropractor can actually work with them. And it really does help facilitate the treatment. But the injection alone, is not the best way to go because if you inject someone, the pain level goes down, if they are not doing any exercises or back preventative care or chiropractic care to maintain the health of the spine; the pain will come back pretty quick.

Host:  So, when then, do you discuss surgery? And people don’t want to have back surgery if they don’t have to. I know it is a last resort. When would you discuss that?

Dr. Kim:  The discussion of surgery would occur if the patient has tried physical therapy, chiropractic care, anti-inflammatories, different types of neuropathic medications, lumbar injections and the pain is – the patient is still having excruciating pain and there’s weakness that’s accompanied with it too. That’s when that discussion of surgery becomes reality. Or it can be a patient who has a very large disc herniation who has significant weakness in the legs or their feet or they start to lose control of their bowel or their bladder. If those things occur; then they automatically go to the surgeon bypass all of the conservative care and get treated by getting that disc removed.

Host:  As we wrap up, I’d like for you to give us your best advice Dr. Kim, on prevention of back issues. You mentioned if we sit at a desk all day, so there’s workplace ergonomic issues. Give your best advice to the listeners about keeping a strong, healthy back and when you feel it’s time that they visit a physician to get it checked out?

Dr. Kim:  So, the advice I would give is number one, it is important to do some form of light exercise for your back as well as cardio conditioning. So, that could be something as simple as power walking during your lunch break or it could be if you’re lucky, you have a small tiny gym at your workplace were you can do a little bit of a workout. I know there are some facilities at some large companies that actually offer yoga classes, take it if you have the opportunity. The other is, be mindful of how you move. Be mindful of your body’s importance. So, that means that if you’re going to let’s say put down Christmas decorations or do yard work; be mindful that you have to take good care of your back, take breaks so in other words don’t clean the house all in one day. You might want to break it up into three different sections over three different weekends. Have a good set of back stretches that you are doing daily. And the most important thing is also to make sure that if that pain really flares up; the first thing you should do is put an icepack on your back, whatever you have in your freezer, leave it on for about 15 minutes. Ice is a great natural anti-inflammatory. If you don’t have any contraindications to anti-inflammatories, if you have two Aleve’s or potentially three Advil, you take that along with applying an icepack on your back; that usually will do the trick. But ultimately, best advice I can give is to do some form of stretching exercise or program for your spine. That’s the best way you’ll avoid seeing somebody like me.

Host:  Well thank you so much. What great advice and so informative. Dr. Kim, thank you again for joining us. To learn more about orthopedic programs and services please visit our website at www.christianacare.org/orthopedics. That concludes this episode of ChristianaCare’s Moving Freely podcast series. Please remember to subscribe, rate and review this podcast and all the other ChristianaCare podcasts. I’m Melanie Cole.