At Shepherd Spine and Pain Institute, doctors offer a variety of treatments and comprehensive care for chronic back pain, one of the most common types of pain that people experience.
In today’s podcast, Dr. Erik Shaw, an interventional pain management specialist at Shepherd Spine and Pain Institute, addresses the causes of back pain and how to know when your pain has become a chronic problem requiring medical attention. Dr. Shaw also explains the variety of treatment options available for chronic back pain.
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Identifying and Managing Chronic Back Pain
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Learn more about Dr. Shaw
Erik Shaw, DO
Dr. Shaw is an interventional pain management specialist and medical director of the Shepherd Spine and Pain Institute. Dr. Shaw is double board certified in physical medicine and rehabilitation and pain medicine. A Texas native, Dr. Shaw graduated from Texas A&M University with a degree in biomedical engineering and earned his medical degree at the University of North Texas Health Science Center in Fort Worth.Learn more about Dr. Shaw
Transcription:
Identifying and Managing Chronic Back Pain
Melanie Cole (Host): Back pain can be debilitating and keep you from taking part in the activities that you enjoy. When back pain begins to interfere with your daily life, it might be time to see a physician to assess your pain. My guest today, is Dr. Eric Shaw. He’s an Interventional Pain Management Specialist and Medical Director of the Shepherd Spine and Pain Institute. Dr. Shaw, what are some of the most common causes of back pain that you see?
Dr. Eric Shaw (Guest): The most common causes that we see – and we see patients that are obviously referred for more severe kinds of pains, more severe degenerative disk disease, pinched nerves, pain from the degenerative disk disease. It’s not really a disease; it’s a condition. The human body degenerates over time, and everyone who gets a little older knows this as there are a little more aches and pains -- and that happens in your back too, and your neck. The things that I would say on the more mild side are more muscular pains, stretch, and strain injuries. There are little joints that interconnect the different levels of the spine called the facet joints, and those can be painful. You can get spinal stenosis as severe degenerative changes of the spine compress the nerves within the spinal canal, and that can send pain down the leg – down both legs and make it more difficult to stand and walk for long periods of times. It’s really a combination of everything that we see. It just depends on the severity and the exam of the person.
Melanie: How do you diagnose it? When someone is referred to you, and since pain can be so subjective, what are some of the methods that you use to diagnose – including maybe even an injection to diagnose really what’s going on in there?
Dr. Shaw: Sure. First, and foremost, you take a history from the patient. You as them, what makes it better or worse, how they describe the pain, and how long it’s been going on. If it’s a new pain, it can be a fracture, or it could sometimes be a tumor that can kind of come on suddenly. If they were doing some physical activity and they had a pop in their back and pain going down the leg, that could be a herniated disk causing a pinched nerve. First, just start with a good history, and make sure you understand their other medical problems.
Second, of course, is a good physical exam to see if they have any sensory changes – meaning changes in their feeling in their legs as well as reflexes – as well as check their muscle strength throughout their – if we’re talking about the low back, then the legs. And then, ask about bowel and bladder function, things that are more serious like that. Within that whole history, getting an idea of the physical exam, then you can kind of put together a picture of what might be going on.
You may need an X-ray; sometimes, you might need an MRI. Typically, you can figure out most of the problems without excessive radiologic imaging, but sometimes you might need an X-ray to figure it out. Sometimes we can do an epidural steroid, which is a very simple injection to do. I know a lot of people are maybe scared of it and think it’s invasive, but it’s really quite simple and can be quite helpful for many kinds of conditions of the degenerative disk changes that occur in the spine especially if you’re having nerve pain down one or both legs.
Sometimes we can do a facet block, which are those joints that I mentioned earlier, and we can either put steroids into the joint just like you would do for degenerative arthritis for the knee or the hip, or we can do a nerve branch block to the nerves that supply sensation to that nerve and that joint. We can numb those up and see if that relieves the pain. If it does, then we can come back later, after appropriate diagnostic criteria have been satisfied and perform something called a Radiofrequency Ablation where we destroy those nerves with heat. That can keep the back pain away for six to twelve months, or longer. It’s really important that the patient really takes advantage when they’re feeling better from whatever intervention that we provide and really exercise and get stronger. Maintaining flexibility of the buttock muscles, the hamstrings, the thigh muscles, the muscles of the low back as well as maintaining strength of what is called the core – and that includes abdominal muscles, the lumbar spine muscles, the muscles around the hip area, the front of the thigh, the buttock area, and all of that makes up the core and helps take a lot of pressure off the spine. If you’re having back pain, sometimes pain is preventing you from getting stronger so that you can maintain good health. If it is, then with these injections and other methods with medications can help to make the pain better. That’s not really a long-term fix. A long-term fix is activity and strengthening, and that’s what we really try to focus on is a functional improvement.
Melanie: So then, speak about functional improvement. When you speak about the core, and you want people to strengthen their core and their lower back, what do you mean by that, and is that strictly physical therapy? Are there things that people can do on their own that you would like them to do to keep that good, strong back?
Dr. Shaw: Sure, the physical therapy is only to get the patient started. Physical therapy, no insurance company is going to pay for it for longer than twelve or maybe eighteen visits. It’s not indicated for forever. It’s indicated for short-term to get the patient started, to teach them a home exercise program, to teach them the exercises that they can do to help themselves, and then they’re really – even within the time course that the physical therapy is happening, when they’re not in therapy, they’re supposed to do their exercises at home. And then after physical therapy is completed, then they can continue that home exercise program and really work on strengthening those muscles.
We really concentrate on --- especially for people with severe back pain; we concentrate on something called isometric strengthening. Iso, meaning same, and metric is Latin, for distance. The muscle is not moving, but it’s contracting. If you’re on your hands and knees and you stick your leg out behind you, your abdominal muscles and your lumbar muscles will contract and stabilize your body, and then you can stick the opposite arm out, straight ahead of you – like Superman, but just one arm. That really activates those core muscles, and that’s a simple exercise that you can do at home. You can certainly make it a little harder by doing a plank exercise or other things as you tolerate, but it’s really important to maintain those kinds of activities.
The isometric strengthening is much easier than concentric strengthening. If someone was to think about lifting a dumbbell and doing a bicep curl, the elbow is moving, and that muscle is shortening in length. It’s called a concentric because it’s squeezing together. The muscle is not staying the same length. With these exercises I’m talking about, the muscle is not contracting as you would with a sit-up or an abdominal crunch; the muscle is not squeezing together. It’s contracting, but the length of the muscle is staying the same, and that’s really much easier on the person and actually serves to maintain very good strength over time, but it doesn’t make the patient too bulky, which a lot of people don’t necessarily want to be. It maintains good strength, it’s much easier on the spine, and it’s a good way to get started with a home conditioning program.
Melanie: And now, let’s speak about medications for a minute because people hear about opioids for pain, and they’ve heard about all of the different anti-inflammatories on the market, and you mentioned epidural steroid injection. Explain a little bit – and there are even antidepressants sometimes recommended for certain types of pain – speak about where medications fit into this comprehensive picture of taking a good history and a good exercise program to strengthen – where do medications fit in?
Dr. Shaw: Sure. Medications can be helpful for short-term, and if they’re really promoting functional improvement – meaning the patient is able to get around and do more when they take the medications, and they’re really helpful. We’ve tried a couple of injections and maybe done physical therapy, and that hasn’t really been of long-term benefit, and the patient really needs medications maybe in combination with the exercise program and everything else, and maybe period injections – but medications really, when the patient takes them – they’re able to get around, do more, be functional at home or at work, spend time with their family, get out and do things. If you’re complaining of 8 out of 10 pain, and you’re sitting on the couch, you shouldn’t be getting more pain medicine, right? Because there might be something more at play. If your pain is well-controlled with the medications and you’re up and doing the things that are meaningful to you, then that’s a good quality of life, and that’s what we’re really looking for.
Sometimes we need to adjust the dose of the medications to optimize that, but a lot of times, these medicines have a limited benefit, so it’s really important to ask those questions and to look at side-effects and make sure the quality of life is not actually worsening because opioids can sometimes trigger depression through other effects that they have on the central nervous system, mostly the brain, and can actually worsen quality of life. Antidepressants can be beneficial. There are different ones on the market that work on different neurotransmitters, mostly the norepinephrine pathway, which can actually serve to improve pain.
Anti-inflammatories – my personal practice is that I don’t typically use them that often. As we get older, especially over 50 or 55, the risk of heart attack, stroke, kidney disease, and a stomach bleed is quite high, and it’s not – they do have long-term effects for people, but I’m not sure long-term if they’re safe. The FDA has a black-box warning actually on every anti-inflammatory that’s on the market specifically for those warnings. With caution and appropriate doses, they can be helpful, but they also do carry their own amount of risks, so it’s important to think about these things, ask the questions, and be aware if you’re’ experiencing any of these symptoms and talk to your doctor about it immediately.
Melanie: Really, really good information, Dr. Shaw. Wrap it up for us, with what you would like listeners to know about what they can expect with a visit from a pain management specialist, such as yourself, and what you want them to know about maintaining activity, keeping that good, strong back, and when you feel that they might need a referral to Shepherd Center.
Dr. Shaw: Well, obviously, they have to live in and around the Atlanta area to see the Shepherd Center. First of all, exercise, keep your weight down, eat healthy, limit alcohol, limit sugars, try to be as active and healthy as you can be. If you have an injury or age-related changes that are really causing you to have a lot of pain first and foremost, maybe physical therapy, maybe try some anti-inflammatories, maybe go see an acupuncturist or massage and see how that works.
If it’s more serious and it’s just not getting better after a few months, probably it’s time to seek expert help. We take everybody from the age of 18, all the way up to 100 with all sorts of conditions. You do not have to have a spinal cord injury or brain injury to come to see us in the pain center here. Really, the expectation should be to listen – the doctor should listen to you and understand how it has changed your functional quality of life, and then do anything that’s appropriate to examine what the cause of it is, and if it’s not a simple thing that can be easily remedied, then we’d be happy to take the referral to see if we can help at all.
Melanie: Thank you so much, Dr. Shaw, for being with us today and sharing your expertise as an Interventional Pain Management Specialist. Thanks again. You're listening to Shepherd Center Radio. For more information on managing your chronic back pain, please go to Shepherd.org, that’s Shepherd.org. This is Melanie Cole. Thanks so much, for tuning in.
Identifying and Managing Chronic Back Pain
Melanie Cole (Host): Back pain can be debilitating and keep you from taking part in the activities that you enjoy. When back pain begins to interfere with your daily life, it might be time to see a physician to assess your pain. My guest today, is Dr. Eric Shaw. He’s an Interventional Pain Management Specialist and Medical Director of the Shepherd Spine and Pain Institute. Dr. Shaw, what are some of the most common causes of back pain that you see?
Dr. Eric Shaw (Guest): The most common causes that we see – and we see patients that are obviously referred for more severe kinds of pains, more severe degenerative disk disease, pinched nerves, pain from the degenerative disk disease. It’s not really a disease; it’s a condition. The human body degenerates over time, and everyone who gets a little older knows this as there are a little more aches and pains -- and that happens in your back too, and your neck. The things that I would say on the more mild side are more muscular pains, stretch, and strain injuries. There are little joints that interconnect the different levels of the spine called the facet joints, and those can be painful. You can get spinal stenosis as severe degenerative changes of the spine compress the nerves within the spinal canal, and that can send pain down the leg – down both legs and make it more difficult to stand and walk for long periods of times. It’s really a combination of everything that we see. It just depends on the severity and the exam of the person.
Melanie: How do you diagnose it? When someone is referred to you, and since pain can be so subjective, what are some of the methods that you use to diagnose – including maybe even an injection to diagnose really what’s going on in there?
Dr. Shaw: Sure. First, and foremost, you take a history from the patient. You as them, what makes it better or worse, how they describe the pain, and how long it’s been going on. If it’s a new pain, it can be a fracture, or it could sometimes be a tumor that can kind of come on suddenly. If they were doing some physical activity and they had a pop in their back and pain going down the leg, that could be a herniated disk causing a pinched nerve. First, just start with a good history, and make sure you understand their other medical problems.
Second, of course, is a good physical exam to see if they have any sensory changes – meaning changes in their feeling in their legs as well as reflexes – as well as check their muscle strength throughout their – if we’re talking about the low back, then the legs. And then, ask about bowel and bladder function, things that are more serious like that. Within that whole history, getting an idea of the physical exam, then you can kind of put together a picture of what might be going on.
You may need an X-ray; sometimes, you might need an MRI. Typically, you can figure out most of the problems without excessive radiologic imaging, but sometimes you might need an X-ray to figure it out. Sometimes we can do an epidural steroid, which is a very simple injection to do. I know a lot of people are maybe scared of it and think it’s invasive, but it’s really quite simple and can be quite helpful for many kinds of conditions of the degenerative disk changes that occur in the spine especially if you’re having nerve pain down one or both legs.
Sometimes we can do a facet block, which are those joints that I mentioned earlier, and we can either put steroids into the joint just like you would do for degenerative arthritis for the knee or the hip, or we can do a nerve branch block to the nerves that supply sensation to that nerve and that joint. We can numb those up and see if that relieves the pain. If it does, then we can come back later, after appropriate diagnostic criteria have been satisfied and perform something called a Radiofrequency Ablation where we destroy those nerves with heat. That can keep the back pain away for six to twelve months, or longer. It’s really important that the patient really takes advantage when they’re feeling better from whatever intervention that we provide and really exercise and get stronger. Maintaining flexibility of the buttock muscles, the hamstrings, the thigh muscles, the muscles of the low back as well as maintaining strength of what is called the core – and that includes abdominal muscles, the lumbar spine muscles, the muscles around the hip area, the front of the thigh, the buttock area, and all of that makes up the core and helps take a lot of pressure off the spine. If you’re having back pain, sometimes pain is preventing you from getting stronger so that you can maintain good health. If it is, then with these injections and other methods with medications can help to make the pain better. That’s not really a long-term fix. A long-term fix is activity and strengthening, and that’s what we really try to focus on is a functional improvement.
Melanie: So then, speak about functional improvement. When you speak about the core, and you want people to strengthen their core and their lower back, what do you mean by that, and is that strictly physical therapy? Are there things that people can do on their own that you would like them to do to keep that good, strong back?
Dr. Shaw: Sure, the physical therapy is only to get the patient started. Physical therapy, no insurance company is going to pay for it for longer than twelve or maybe eighteen visits. It’s not indicated for forever. It’s indicated for short-term to get the patient started, to teach them a home exercise program, to teach them the exercises that they can do to help themselves, and then they’re really – even within the time course that the physical therapy is happening, when they’re not in therapy, they’re supposed to do their exercises at home. And then after physical therapy is completed, then they can continue that home exercise program and really work on strengthening those muscles.
We really concentrate on --- especially for people with severe back pain; we concentrate on something called isometric strengthening. Iso, meaning same, and metric is Latin, for distance. The muscle is not moving, but it’s contracting. If you’re on your hands and knees and you stick your leg out behind you, your abdominal muscles and your lumbar muscles will contract and stabilize your body, and then you can stick the opposite arm out, straight ahead of you – like Superman, but just one arm. That really activates those core muscles, and that’s a simple exercise that you can do at home. You can certainly make it a little harder by doing a plank exercise or other things as you tolerate, but it’s really important to maintain those kinds of activities.
The isometric strengthening is much easier than concentric strengthening. If someone was to think about lifting a dumbbell and doing a bicep curl, the elbow is moving, and that muscle is shortening in length. It’s called a concentric because it’s squeezing together. The muscle is not staying the same length. With these exercises I’m talking about, the muscle is not contracting as you would with a sit-up or an abdominal crunch; the muscle is not squeezing together. It’s contracting, but the length of the muscle is staying the same, and that’s really much easier on the person and actually serves to maintain very good strength over time, but it doesn’t make the patient too bulky, which a lot of people don’t necessarily want to be. It maintains good strength, it’s much easier on the spine, and it’s a good way to get started with a home conditioning program.
Melanie: And now, let’s speak about medications for a minute because people hear about opioids for pain, and they’ve heard about all of the different anti-inflammatories on the market, and you mentioned epidural steroid injection. Explain a little bit – and there are even antidepressants sometimes recommended for certain types of pain – speak about where medications fit into this comprehensive picture of taking a good history and a good exercise program to strengthen – where do medications fit in?
Dr. Shaw: Sure. Medications can be helpful for short-term, and if they’re really promoting functional improvement – meaning the patient is able to get around and do more when they take the medications, and they’re really helpful. We’ve tried a couple of injections and maybe done physical therapy, and that hasn’t really been of long-term benefit, and the patient really needs medications maybe in combination with the exercise program and everything else, and maybe period injections – but medications really, when the patient takes them – they’re able to get around, do more, be functional at home or at work, spend time with their family, get out and do things. If you’re complaining of 8 out of 10 pain, and you’re sitting on the couch, you shouldn’t be getting more pain medicine, right? Because there might be something more at play. If your pain is well-controlled with the medications and you’re up and doing the things that are meaningful to you, then that’s a good quality of life, and that’s what we’re really looking for.
Sometimes we need to adjust the dose of the medications to optimize that, but a lot of times, these medicines have a limited benefit, so it’s really important to ask those questions and to look at side-effects and make sure the quality of life is not actually worsening because opioids can sometimes trigger depression through other effects that they have on the central nervous system, mostly the brain, and can actually worsen quality of life. Antidepressants can be beneficial. There are different ones on the market that work on different neurotransmitters, mostly the norepinephrine pathway, which can actually serve to improve pain.
Anti-inflammatories – my personal practice is that I don’t typically use them that often. As we get older, especially over 50 or 55, the risk of heart attack, stroke, kidney disease, and a stomach bleed is quite high, and it’s not – they do have long-term effects for people, but I’m not sure long-term if they’re safe. The FDA has a black-box warning actually on every anti-inflammatory that’s on the market specifically for those warnings. With caution and appropriate doses, they can be helpful, but they also do carry their own amount of risks, so it’s important to think about these things, ask the questions, and be aware if you’re’ experiencing any of these symptoms and talk to your doctor about it immediately.
Melanie: Really, really good information, Dr. Shaw. Wrap it up for us, with what you would like listeners to know about what they can expect with a visit from a pain management specialist, such as yourself, and what you want them to know about maintaining activity, keeping that good, strong back, and when you feel that they might need a referral to Shepherd Center.
Dr. Shaw: Well, obviously, they have to live in and around the Atlanta area to see the Shepherd Center. First of all, exercise, keep your weight down, eat healthy, limit alcohol, limit sugars, try to be as active and healthy as you can be. If you have an injury or age-related changes that are really causing you to have a lot of pain first and foremost, maybe physical therapy, maybe try some anti-inflammatories, maybe go see an acupuncturist or massage and see how that works.
If it’s more serious and it’s just not getting better after a few months, probably it’s time to seek expert help. We take everybody from the age of 18, all the way up to 100 with all sorts of conditions. You do not have to have a spinal cord injury or brain injury to come to see us in the pain center here. Really, the expectation should be to listen – the doctor should listen to you and understand how it has changed your functional quality of life, and then do anything that’s appropriate to examine what the cause of it is, and if it’s not a simple thing that can be easily remedied, then we’d be happy to take the referral to see if we can help at all.
Melanie: Thank you so much, Dr. Shaw, for being with us today and sharing your expertise as an Interventional Pain Management Specialist. Thanks again. You're listening to Shepherd Center Radio. For more information on managing your chronic back pain, please go to Shepherd.org, that’s Shepherd.org. This is Melanie Cole. Thanks so much, for tuning in.