Transcription:
Non Surgical Management Options for 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. Welcome to Back to Health from the Department of Rehabilitation Medicine at Weill Cornell Medicine. Our topic today is non-surgical management options for back pain. My guest is Dr. Michael Sein. He's a physical medicine and rehabilitation physician specializing in comprehensive spine care and musculoskeletal medicine at Weill Cornell Medicine. Welcome to the show, Dr. Sein. Describe a little bit for us about the impact of back pain on the economic workplace, and for doctor visits.

Dr. Michael Sein, MD (Guest): Hi, thanks for having me. That's a great question. Well first of all, back pain is extremely common, and it's estimated as probably the second or third most common reason that people will see their doctor in general. It's probably only behind the common cold as a reason to go see your doctor. So it's very common and it's something that most people eventually experience in their lifetime.

Now as far as the economic impact, this has been estimated time and again, and it's impressive just how expensive back pain is. It's estimated at about $100 billion a year that cost Americans when dealing with back pain, and about two thirds of that is just from lost wages and reduced productivity.

Melanie: Wow, that's quite a staggering number. What are some of the most common causes of back pain that you see?

Dr. Sein: Well in the back, there's a few structures that typically cause symptoms. One that many people hear about is called the disc, or what we call the intervertebral disc. Now this is a piece of cartilage that sits between the bones of the spine that we call vertebrae, and you may have heard of somebody who had a disc herniation, or heard the term of bulging disc, and this is the disc they're talking about. It's extremely common for that to cause back pain, but there's many other structures around there. There's the joint for the low back, there is a nerve that exits the spinal cord in the lumbar spine, and then there are all the muscles that attach to the low back.

Melanie: Tell us a little bit about your philosophy of dealing with back pain, some of the approaches that you use to help people.

Dr. Sein: Sure, I'd say my philosophy to caring for back pain or any sort of musculoskeletal issue is pretty simple. I'm always amazed at how well the body is able to heal when given the right amount of time, and maybe put in the right situation. Our bodies have a tremendous ability to heal damaged tissue in painful areas, and when I get started with patients, usually figuring out why the body's not doing that. My typical approach is to start with simple treatments first. Things like exercise or physical therapy can be helpful. When that's not sufficient, occasionally we would then consider trying some medications that can maybe help people get back into activity. And then down the line if we're really not making progress with those simple treatments, there are certain injections that we can do that can be helpful.

Melanie: When do you recommend that a specialist be seen if someone is suffering from back pain? As so many people have back pain that comes and goes, when is a time to see a specialist?

Dr. Sein: It's a great question, and a question I get all the time. There's no magic formula, but typically I like to see if this back pain doesn't improve with simple treatments like a home exercise program or some physical therapy, then it's probably time to be evaluated by a specialist such as a physiatrist or a neurologist.

Melanie: Dr. Sein, what are some tests that you use to help determine the cause of the pain? And sometimes back pain can be non-specific, so what if no distinct cause is found? Or do you usually find one?

Dr. Sein: Good question. I think the diagnosis first starts with talking to the patient, getting kind of the story of where the pain is coming from, what makes it worse, what makes it better, and then the physical exam. I'd say the majority of my diagnoses can be obtained from the story of the pain, and also the physical examination.

Now sometimes that's not enough, and you're correct that sometimes back pain is not very specific, so in those cases other testing can be helpful. One specific test we will often get is a magnetic resonance image, or an MRI, and that can give us some information about the discs, the bones, the muscles, as well as the nerves and the soft tissue. And with this test, there's no radiation exposure. Now other tests can be performed if the MRI is not sufficient, of if we're worried more about a nerve injury or a pinched nerve. There's a specific test for this called an EMG/NCV, and that stands for an electromyogram. Basically it's like an EKG for the nerves. It's an electrical test done by a neurologist that can tell us how the back nerves are doing, if they're getting pinched, or if there's some other injury to them.

Now oftentimes people will get x-rays of their back. I find this test not to be less helpful. It can be helpful to tell us information about the bones of the back, but rarely is that the main cause of pain. And unfortunately, there is radiation exposure with x-rays, so they're not completely benign.

Melanie: What is the first line of defense for acute low back pain? Describe for us a little bit about the difference between acute low back pain and then chronic. And Dr. Sein, explain a little bit if the treatment is different if this is a chronic back problem or if it's something that just happened.

Dr. Sein: Yeah, so with back pain whether it's acute or chronic, it sort of changes our suspicion on the diagnosis, but at the end of the day, we really do need to kind of figure out a diagnosis to get the best treatment plan in place. For acute low back pain, I'd say more likely that's going to be an injury to either the nerves, like a pinched nerve, also called sciatica, or an injury to the disc. Those are the typical structures that can cause pain quickly.

Now that can be a little different if someone's been injured from a traumatic experience such as a car accident or a fall. That's typically what I think causes more acute back pain. And in that situation, oftentimes the best first line of treatment is an anti-inflammatory medicine. That can help reduce any inflammation in these structures and kind of reduce the duration and severity of the symptoms.

For chronic low back pain, a lot of different structures can cause that pain, and so we need to kind of figure out the most likely diagnosis to get the best treatment plan in place. Oftentimes with chronic back pain, the issue isn't that there's some inflammatory process, though there can be, but sometimes it's more of a structural issue or an issue with the alignment of the spine. And typically in those situations, with chronic pain, our treatments have to be focused a little bit more longitudinally. We have to look down the line to how can we keep this back pain from coming back, and fix any issues that are underlying that back pain?

Melanie: People hear the words stenosis, and scoliosis, and they don't know what all of these mean. But if it's a degenerative issue that will get worse over time, does that change your treatment, Dr. Sein?

Dr. Sein: Oh that's an excellent question. Now the first thing I'd say is I don't like the term degenerative. It's oftentimes thrown around in the lumbar spine, especially when somebody has had an MRI, we use terms like degenerative disc disease. The reason I don't like the term degeneration is because it's not exactly accurate. Many of these conditions may be related to wear and tear or changes that we see over time in everybody. So it's not really a degeneration any more than getting a white hair or a gray hair is degeneration of the scalp. So because of that, I try to use terminology that's more accurate.

Certainly with chronic back pain, there can be changes that we see in the spine over time, and certainly changes we see with aging, but it doesn't mean that it's a terminal condition that can't be improved, and doesn't mean that you're on a one-way street to having severe back pain in the future.

Melanie: Let's speak about medications just a little bit, Doctor. People know Tylenol, and Ibuprofen, and you mentioned that there are medications that you would try as a first line of defense, so speak about some of those, and when does it come to a prescription strength? And even people have heard that anti-depressants might be used for back pain, or opioids, and then on to epidural.

Dr. Sein: Well for my philosophy I try to avoid too many medicines. I'm certainly a 'less is more' kind of doctor when it comes to medication. That being said, certain situations- certain medicines can help reduce discomfort and make it easier to do more conservative treatments like physical therapy. For short-term medicines like anti-inflammatories, what we call non-steroidal anti-inflammatory drugs, or NSAIDs, can be helpful. Now the drawback to these medicines is that they can have wide raging effects on our stomachs, our kidneys, and on our heart. So long-term, they're not very good. Now in terms of using a prescription strength medicine versus the non-prescription strength medicine, oftentimes that's best dealt with on a case by case basis between the provider and the patient. But in my experience, I find that most of the anti-inflammatories are more similar than they are different, and while there might be some variations, it's really more about finding the best anti-inflammatory for you.

Now other medicines have certainly been used for back pain as well. In terms of opioids, we try to stay away from those as best we can. In the short-term issues, opioids can be very helpful such as after an injury or after an operation, but more longer term we find these medicines can cause more issues than they do cure, and more often than not using opioids puts people at risk of dependence, and because of that I've tried to really reduce the amount of opioids that I prescribe in my practice, and it's very rare that I ever suggest opioids for patients with back pain.

In the setting of anti-depressants, more and more were realizing that the same nerve chemicals or neurotransmitters that are present for pain - physical pain that is - are also present for emotional pain. And so the same kind of chemicals that can cause chronic emotional pain has been implicated in chronic muscle and joint pain as well. And in those situations, a medicine such as an anti-depressant can actually help with the pain. Not that we're treating depression, we're treating pain, we're just using the same chemical to treat their physical pain as what some people use for emotional pain.

Melanie: That is absolutely fascinating, Dr. Sein, and what a great explanation of the medications that might be used. What about middle and upper back pain? What makes that kind of pain different from lower back pain, which so many people suffer from? And how does somebody know when to seek care for middle and upper back pain.

Dr. Sein: Well lower back pain is usually a result of the forces of walking, and standing, and moving on the spine. And at the very base of the spine is where all the forces are most concentrated. So more typically, the lower back we're seeing issues with disc herniation, or pinched nerve from there being compression. Now in the upper back and in the neck, there's not as much pressure on the spine. There's not as much of a tendency for those, though they can still occur. In the upper back, I tend to see more muscle pain. This is the area where we tend to carry our stress and that can definitely play a role in our neck and muscle pain. Because of that, oftentimes we have to treat the muscle in this region to get people feeling better.

Melanie: So what are some other non-surgical approaches to back pain management? You've talked a little bit about the medications, but speak about how exercise and physical therapy and possibly even meditation and relaxation techniques if it is stress-related musculoskeletal pain, how these things work into a complete program?

Dr. Sein: Ultimately I think for me, my goal is to get people exercising. In my view, we can strengthen the back muscles and what we call the core muscles. That can go a long way in providing stability for the lumbar and even cervical and thoracic spine. The other treatments we do are really just to get people into the best position to be able to do those exercises. So whatever means we need to do to get people comfortable enough and moving well enough to do good back exercises is what I try to do.

Now other treatments that are complimentary to the medications and the exercise and even the injections include treatments like acupuncture, which is an Eastern medicine approach, and although we don't know how acupuncture exactly works, there have been studies to show that it can help reduce pain and discomfort for back pain.

Other treatments I oftentimes will use are things like meditation or yoga because I think oftentimes we have- another treatment I use is something like meditation or even yoga, and I think that there's a strong mind / body connection between our pain and our body, and if we don't address both of those areas it's much harder to get a positive result. So that's oftentimes what I recommend to people, trying something like mindfulness.

Melanie: So interesting, and where does posture fit into this as we all sit at our desks in front of workstations hunched forward? We can get that upper back pain, pain in the shoulders and around that area, and even low back pain from chairs and sitting improperly.

Dr. Sein: Yeah, excellent question. Well basically I believe that our bodies weren't meant to be in a fixed position for too long. I don't think we were meant to sit at a desk for eight to ten hours a day. Our bodies are meant to move. Our joints are a muscle, they like movement, and that's the reason I usually recommend to my patients that they try a workspace that's adjustable, whether or not that's an adjustable height desk, or a sit to stand desk, or even moving their computers to different areas if it's portable.

Melanie: That's really good advice. Please describe for us a patient case study where maybe you had a patient that tried some other specialties or treatments before coming to see you, and how you were able to help them in a way no other specialty could.

Dr. Sein: It's not uncommon that I see patients after they've tried many other treatments from other providers and they still haven't gotten relief. I can think of a very common case that I see. There was a young gentleman in his thirties who saw me for neck pain. He had had an MRI, and it had showed maybe a little wear and tear in the disc. He had tried a cortisone shot which didn't help, he had even tried multiple injections, and was even referred for surgery, and this was all without any real diagnosis. And just sitting with him and talking with him about where he was getting the pain, the distribution of the pain, what makes it worse, what makes it better, it was clear to me that most of his pain was coming from the muscle, and not because of the disc in his neck. Instead of doing a treatment for the disc or going in and having a surgeon take out that disc, started doing treatments for his muscles with some exercises, some acupuncture, and over time he had amazing relief of his pain.

Really I think what that highlights is we have a lot of very good treatments out there, we just have to match those treatments with the right diagnosis. So it all starts at the very beginning with finding out what's causing the pain and matching up the best treatment we have.

Melanie: Dr. Sein, I love your philosophy of treating back pain. So wrap it up for us with your best advice, because so many people have back pain, and as you described in the beginning, the economic impact of this is quite staggering. Give us your best advice, what you want people to know about preventing back pain and taking good care of their backs.

Dr. Sein: Yeah I've seen many, many people over the last years, and I think there are a lot of people with back pain of all ages, and in my experience the people that I see who are still moving really well into their seventies and eighties and nineties are the ones that never stopped exercising.

I truly believe that exercise is the fountain of youth, and especially for back pain. I think that any program where we can get back muscles stronger, improve range of motion, improve the stability of the spine can go a long way in treating pain. Now it's very tough to tell people to exercise when they're in pain. I understand that it's a big paradox. What my job is to do is get people into a good position where they're comfortable enough to do that exercise.

Melanie: So how can patients be proactive in terms of educating themselves about these many types of procedures and treatments available, and how do you know that you're getting the right diagnosis and treatment plan?

Dr. Sein: It's always tough to be certain about the treatment plan you're getting. I think being a good advocate for yourself is the best. Really at the end of the day, you want your physician to be hearing you, listening to what you're saying, and spending time examining you to really kind of hammer out what the right diagnosis is for you.

Again, as I was saying earlier, a lot of the diagnosis I give is not from tests, it's really from talking to people and examining them specifically. So if your physician isn't taking time with you, it's probably not a good guy.

Melanie: Tell us about your team at Weill Cornell Medicine in the rehabilitation department.

Dr. Sein: Well we have care providers from all sorts of walks of life that specialize in a lot of different ailments. We have physicians who specialize, like myself, in mostly musculoskeletal medicine or pain from joints and muscles. And on the opposite end we have physicians that specialize in neurologic rehabilitation, caring for individuals that have had a stroke or a spinal cord injury, and everything in between.

I guess ultimately what we're interested in is function. We're function doctors, whether that function is being an elite athlete or if it's just trying to walk better. I think oftentimes what we're trying to do is get people to do the things they want to do and get them to be able to do it better.

Melanie: Thank you so much, Dr. Sane, for being with us. What amazing information that you've given us today. Thank you for joining us today. This concludes today’s episode of Back To Heath. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back To Health on Apple Podcast, Spotify, and Google Play Music. For more health tips go to weillcornell.org and search podcasts. Parents – don’t forget to check out Kids Health Cast!