Monday, August 12, 2013

Seven Questions To Ask In The Workup Of Low Back Pain


Up to 85% of the time in the primary care setting, back pain patients cannot be given an exact diagnosis for their back pain.

One of the most important parts of the low back pain workup is the patient history which includes basically the How, What, and Why types of questions.

How long has the pain been going on and when it occurs how long does it last? Most back pain resolves within 6 to 12 weeks, a longer duration means it's chronic and may need additional workup.

Is there a specific time of day that it occurs? For instance pain that occurs while sitting at one's desk is very different than during recreational activity after work. If pain comes on out of the blue there is a higher chance it could be associated with a tumor or infection. The vast majority of the time (over 90%) with acute back pain the cause is non life threatening, but the answer to the question should be placed into the context of other answers for a concern level.

What is the quality of the pain and where is it? Pain that is burning and goes into the legs from the back is often indicative of sciatica from a pinched nerve. Pain that is simply located in the back and irritated by activity is often caused by facet joint arthritis, called facet syndrome, and is a normal part and parcel of aging.

Does it radiate somewhere else? Pain that radiates into the lower extremities is often indicative of a pinched nerve and may necessitate imaging studies such as an MRI to define where the disc herniation or spinal stenosis is occurring.

Does it wake you up at night? Pain that wakes the patient up at night is concerning and may represent a tumor or infection. This is called a red flag symptom.

How did it start? If there was an injury or a fall a patient may have a fracture or ligamentous injury. For instance if the patient is a diabetic then infection is a significant concern especially if the blood sugars are not controlled and a recent hospitalization has occurred secondary to that problem. Let the patient explain fully the circumstances, it can open up the yellow brick road to the diagnosis.

Any problems with bowel or bladder function? If there is a problem in the spine that is pressing on the anatomic area called the Cauda Equina, the most common problem seen is urinary retention. One also may have loss of bladder or bowel control. This is a red flag surgical emergency, as if it's not surgically addressed within 24 to 48 hours that function may not return. Narcotics may cause constipation as well and that's obviously not a surgical emergency.

The most important part in obtaining a patient history is understanding what constitutes a red flag versus what is simply a normal back pain situation. The red flag situation requires further workup with potential imaging studies, bloodwork, or in rare circumstances like cauda equina syndrome emergency surgery.

Sunday, August 11, 2013

Low Back Pain Or Sciatica in the Morning?


I'm sure you are familiar with it. You wake up in the morning, go to get out of bed BUT are stopped in your tracks by the pain and stiffness in your lower back or sciatic nerve. It can then take a few minutes or much longer to straighten up and become more mobile again... Why is your back so stiff and painful in the morning?

Well, contrary to popular belief, it is more than likely NOT due to the bed/mattress you are sleeping on! That's right, I believe this is a myth well worth busting, as it may save you a fortune by avoiding the unnecessary replacement of your current bed.

There are also those that may say you are stiff and painful first thing in the morning due to the fact you have moved relatively little for the previous few hours. Although I would agree that there is an element of truth in this last statement, once again I do not believe it is likely to be the main cause.

So why is your back so stiff and painful in the morning?

More often than not, it is not due to the bed itself, but rather the position you are sleeping in or what you have been doing the few hours before retiring to bed which is the problem... it is the former which I am going to be discussing with this article.

So what is the best position for me to sleep in then?

The best position for you to adopt would primarily depend upon what is the cause of your low back/sciatic pain. However, as a rule of thumb, the most comfortable position to sleep in is usually side lying (either side) with your bottom leg fairly straight and your top leg bent at the knee and supported by a couple of pillows, so that this top leg is more or less parallel with the bed.

By sleeping in this position, keeping the bottom leg straight is encouraging your lower back to be in a neutral position. Yet with the top leg being supported by pillows, it is preventing it from dropping 'across & down' and therefore twisting your low back and stretching your sciatic nerve in the process.

If you were to lay on your side but forget to support your top leg, this would just place a twisting stress upon the lower back which would be maintained for several hours while you were asleep. Therefore it should come as no surprise that your low back or sciatic nerve may be stiff and painful first thing when you wake up.

As I alluded to above, there are other positions which could be more beneficial, but this depends upon the cause of your pain, but side lying with pillows supporting your top leg is usually a good comfortable position to get in no matter what your diagnosis.

It is also important to realise that it may not necessarily be your sleeping position which is the problem, but rather the things you are doing to your lower back or sciatic nerve before going to bed. If you try different sleeping positions, including the one given here and yet you are still having difficulty sleeping, it is likely what you are doing before going to bed is also a problem. This will need to be assessed before thinking of replacing your bed.

L4, L5, S1 Low Back Pain - Meet Your Psoas Muscle


Low back pain that is characterized by pain in the L4, L5, S1 region means that you need to have your psoas muscle lengthened. The psoas muscle attaches from the lumbar area (i.e., L4, L5, S1) to the upper thigh region. The psoas muscle is easily susceptible to contraction. When it gets shortened, it creates pressure on the discs in the L4, L5, S1 area, causing low back pain. Few people know about the effect of the psoas muscle on low back pain. And fewer people know how to lengthen the psoas when it becomes contracted. The best method is through Active Isolated Stretching therapy (also known as AIS).

The psoas muscle lies deep inside the stomach, so it is the flip side of the low back region. Is attaches at numerous points along the spinal column, over twenty-six locations. Sitting for long periods of time and doing full sit-ups are common reasons for the psoas to tighten. Modern society requires humans to sit most of the day, which is why low back pain is so prevalent. Tightness in the psoas muscle is not the only reason why people experience low back pain. But it is almost always a principle factor.

When a person undergoes Active Isolated Stretching treatment, a therapist helps the client to stretch the psoas muscle. This involves a client leaning on a massage table and the therapist pulling the leg away from the torso. This AIS technique properly lengthens the psoas muscle without risking injury to the discs of the low back. Opening the psoas muscle will radically improve low back pain; it is necessary but not the entirety of solving low back pain.

Other methods unsuccessfully try to address psoas tightness. Some massage therapy techniques try to manually lengthen the psoas muscle by pushing the hands deep into the stomach and trying to massage the muscle. This technique fails because the psoas is too deep inside the stomach to reach manually. And even if it can be touched, the psoas has too many attachment points along the vertebrae that need to be released. Its impossible to adequately lengthen the psoas muscle through massage techniques.

Back surgery is another option for low back pain in the L4, L5, S1 region. In some cases, a surgeon will shave off part of the disc that is herniating/bulging/degenerating. The disc is the cushion that lies in between the vertebrae (sections of the spinal column). The reasoning for shaving off the disc is that the protrusion is pushing into the nerve and causing low back pain. This procedure is regarded as minimally invasive back surgery. A more aggressive surgery involves removing the disc entirely and fusing the vertebrae together. This procedure is known as spinal fusion.

In either case, the issue that is being ignored is why is the disc being negatively affected? What is causing the disc in the low back to bulge, herniate, or degenerate? Part of the answer is contraction of the psoas muscle. Tightness in the psoas muscle is squeezing the vertebrae together. The excessive force is causing the discs around L4, L5, or S1 to spill out of normal position or wear down.

The approach in Active Isolated Stretching is to get to the root cause of low back pain. If the psoas muscle and numerous accompanying muscles can be restored back to normal length then the discs in the low back can return to normal position. Herniation can slide back inside when the excessive squeezing is terminated. The body can repair its own problems when the critical muscles are balanced. Even physicians emphasize investigating every option before considering back surgery. Active Isolated Stretching therapy is the safe/effective method that needs exploration.

Conventional Treatment Methods For the Relief of Back Pain


Conventional treatment methods for back pain patients are a large healthcare expense. Some conventional approaches focus only on the symptoms rather than the primary source of the pain. Once the source of the back pain is corrected, a patient may experience long-term relief. The following types of treatment methods are the most commonly used.

Occasionally, bed rest is prescribed for back pain patients. The downfall of this treatment method is that patients may be more likely to develop depression and experience other negative effects.

Another common treatment method for back pain is physical therapy. Certain exercises can improve the general function and strength of the spine, but may not address the primary cause of a patient's back pain.

Oral and injectable pain medications will normally function by temporarily decreasing inflammation, muscle spasm and pain. This treatment method will only alleviate symptoms, but seldom does it deal with the primary cause of pain.

One treatment method introduced over 2,500 years ago is called acupuncture. It is a form of treatment where by needles are inserted into various parts of the body, such as in ankles, knees, or fingers for the treatment of back pain.

A treatment method that attempts to correct the primary source of back pain is surgery. Some patients report significant relief of pain after surgery, but the risks involved make this option a last resort for many.

A commonly used technique is called traction. Manual traction can be performed by a therapist, utilizing their weight to change both the force and direction of pull. Auto traction is when the patient controls the traction forces by grabbing and pulling on the end of the traction table. There are other forms of traction available such as bed rest traction, underwater and gravitational traction.

A relatively new treatment method for the relief of chronic low back pain is called non-surgical spinal decompression. A highly recognized device called the DRX9000 True Non-surgical Spinal Decompression System™ [http://axiomworldwide.com/drx9000.aspx] is designed to provide pain relief for compressive and degenerative injuries of the spine. Through the application of spinal decompressive forces to these injuries, patients have found relief from their back pain problems.

While back pain is a common and debilitating condition, patients today have more treatment options than ever before.

This article is not intended nor should be used as a substitute for professional medical advice. Consult your physician before considering any medical treatment method available.

Stomach and Back Pain - Responsible for Digestion Troubles and Grim Condition


When you think of back pain, the most common type of discomfort that comes to mind is that which stalk from the lower part of the back and into the hip area. While this type of back pain is indeed the most frequent complaint in back pain sufferers, stomach back pain is another sort of discomfort that can be difficult to deal with over the long term. Stomach back pain refers to the area in the center of the spine. It is made up of twelve vertebrae that run along the middle of the back, where the rib cage attaches.

Most of the time, stomach and back pain stem from a strained muscle in the area, but it can also be caused by a herniated or slipped disc. These types of problems can be easily diagnosed through the use of an x-ray, and treatment can be determined by you and your doctor. On the other hand, a pulled or strained muscle in the stomach area can occur from lifting something that is too heavy or overdoing your exercise program. This type of stomach back pain will usually respond to a variety of home treatment options.

Symptoms of Stomach Back Pain:

Most people will experience some kind of back pain in their lives. Stomach t pain and back pain are closely related. However, Stomach pain doesn't always need a trip to the doctor, or emergency room. Still, if it does occur, it is better to go and get a piece of mind then to leave it and keep worrying if it is something else. When you come across abdomen pain, it usually means you ate something you shouldn't have.

When you acknowledge stomach and back pain symptoms, you should never turn a blind eye towards them. Most people don't know that stomach and back pain, specifically, is the leading cause of disability in people. However, whether its stomach and back pain, or any other pain associated with the back, you should have a specialist examine you immediately to ensure that you aren't getting worse, for the pain may be an indicator of worse things to come.

Pay Attention to Stomach and Back Pain:

Doctors will agree that if you are suffering from stomach and back pain [http://www.backpainreliefhelp.com/Back_Pain_Medication/], you should limit your time in bed to a day or two. The best position to treat back pain is to lie on your back with your knees and lower legs elevated with pillows, or to lie on your side with a pillow between your legs. Generally, activity is the best therapy for stomach back pain. Once you are feeling better, you can begin an exercise program that will gently strengthen your muscles in your back and abdominal area. This will help to ensure that you do not suffer from additional stomach back pain in the future.

How Stress Causes Low Back Pain


The stress connection to low back pain is one of the more common scenarios seen with patients who are suffering from this sometimes debilitating condition. Back pain is a 60 BILLION dollar problem in the U.S. and stress is one of the biggest factors involved. Stress is defined here as anything that is having a negative affect on our nervous systems and consequently influencing our musculoskeletal systems. Stress can be dietary, physical, emotional, occupational, etc. It all counts and it is all accumulative regarding the potential to impact our physiology in a manner that is far from positive.

The U.S. is one of the most stressful countries to live in. Americans work longer hours and take less time off than the rest of the industrialized world. Dealing with ever increasing required government demands, taxes, etc. to keep the treadmill running is a fact of life here. Combine that with the Standard American Diet (SAD) and it is a recipe that guarantees physical ailments like low back pain and chronic degenerative disease. Americans consume more junk food (756 doughnuts per person per year), more refined sugar, and use more prescription drugs than any other people in the world. The different sources of stress also feed off each other. For example, many who are emotionally stressed, may find comfort in high sugar snacks or alcohol. Because of their stress they can't sleep or have panic attacks and wind up taking prescription drugs for these problems. Their short term solutions may exacerbate the stress response in the body.

What happens physically when we are under stress? The body secretes stress hormone (cortisol) that has a flight or fight function. This is very good if you are running away from a tiger, but very bad if this response is going on all the time. Excess cortisol depletes your immune system, which is why people get sick when they are continually stressed. Cortisol also leaches calcium from your bones causing osteoporosis, puts a toxic load on your liver and kidneys, contributes to diabetes, and makes you fat. It also affects the brain, lowering intelligence and causing memory loss. There's more, but you get the picture. This is not a good thing.

What does this have to do with your back? Under stress, it is the adrenal glands that must respond. If they are over stimulated they become exhausted. When the adrenals fatigue, there are direct consequences to the musculoskeletal system. For starters, the nerves supplying the adrenals are affected. Nerves are two ways streets. They can not only be affected at the spinal level of origin, but also peripherally, at their destination, back to the spine. One of the common lumbar areas affected is at the third lumbar vertebra. Muscles are also affected. All muscles innervated by the irritated nerve can contract. Trigger points can develop. There are muscle-organ correlations. The work of Dr. Goodheart in the 1960's has withstood the test of time. There are predictable muscle imbalances with organ stress. In the case of the adrenal glands, one of the primary muscles involved is the sartorius. It is a major pelvic as well as medial knee stabilizer. This is why so many people, including athletes, injure their knees when under stress. There was a pre-existing imbalance from the adrenals causing an improper or inadequate response on the part of the sartorius muscle. The demand on the muscle exceeded its threshold to handle it resulting in an injury. Another affect from exhausted adrenals is ligament weakness. Ligaments hold joints together. Put a demand on a joint and the body responds by getting stronger to resist that demand. When one has an adrenal syndrome issue, there is an opposite affect. There will be weakening of the joint when challenged. This is another major reason why people injure themselves under stress.

The direct connection to the low back from stress is that the sartorius imbalance in the front of the thigh has an impact on the sacroiliac (SI) joint integrity on the posterior side of the pelvis. When the SI is affected by either the sartorius or from weak ligaments, there can be pain directly at the joint, or the lower lumbar vertebrae may be the source of discomfort since their position may be altered. Further, the gluteus maximus muscle on the involved SI side will be weakened. Muscles that attach to or cross an involved joint will be affected as well. The gluteus maximus muscle is a strong, major lifting and anti-gravity muscle. People with weakness will experience difficulty getting up from a seated position. They will usually put their hands on their knees and push themselves up. In grocery stores, these people are often leaning over their shopping carts to support themselves.

Treatment should be muti-faceted. Balancing the adrenals is a must. This needs to be done specifically based on individual needs, but some of the common natural supports are choline, licorice, ashwaganda, rhodiola, and Siberian and American ginseng. Structural work, focusing on involved nerve roots and muscle balancing techniques work well to eliminate or reduce pain. I also utilize a cold laser to "reset" the adrenals (techniques from Dr. George Gonzalez, Quantum Neurologist). Of course, emotional stress must be dealt with to change one's response to the triggers. A counselor, aromatherapy, journalling, etc. may be useful. Exercises should focus on the extensor muscle groups and forward flexion movements should be limited. Over exertion should be avoided. Tai-Chi and Chi-Gong are excellent. A low sugar and carbohydrate diet is essential. Higher protein and vegetable consumption is recommended. Organic sodium should be increased, as sodium is dumped in the urine when one is stressed. Zucchini, squash, green beans, and celery fit this need. Proteolytic enzymes help pain as do anti-inflammatories like turmeric, ginger, and yucca.

http://www.CrawfordNaturalHealthCenter.com
Dr. Dennis K. Crawford
916-962-3101

"Dedicated to Vibrant living"

Low Back Pain and Sciatica: Only Two Diagnoses - Surely Not?


There are many medical diagnoses attributed to low back pain and sciatica, yet how relevant are they?

When it comes to conservative treatment, I would suggest that it is not really that important, as these medical diagnoses identify the source of the pain, but not necessarily the cause of it.

For arguments sake, let's say you have a herniated disc/slipped disc. While I accept that this may well be the source of your pain, it is not really going to help us if we are to set out a treatment strategy to resolve your pain, We need to find out why the disc herniated in the first place i.e. what caused the disc to herniate in the first place.

Non-Specific Low Back Pain

It is widely accepted throughout the health profession that nearly all low back pain suffered by the general population is non-specific low back pain (NSLBP), where no single structure can be truly identified as the source of pain.

Therefore, I believe we should concentrate on a functional diagnosis as opposed to a medical one, as it is typically our functional day-to-day activities which lead to NSLBP.

I believe we need only concern ourselves with two diagnoses:

Flexion Dominated Pain (FDP)

Extension Dominated Pain (EDP)

FDP refers to pain which is aggravated by the movement of leaning forward (flexion) or any movement or posture which has a similar influence on the spine.

EDP refers to pain which is aggravated by the movement of leaning backwards (extension) or any movement or posture which has a similar influence on the spine.

So are you suffering with FDP or EDP?

If a position such as lying on your stomach helps ease your pain (maybe place a pillow or two under your stomach, because if your pain is quite sensitive laying on your stomach alone may aggravate your pain a little) it is likely you are suffering with FDP.

Alternatively, if sitting down and leaning forward to rest your forearms on your knees or maybe lying on your back and gently hugging one or both knees to your chest eases your pain, your functional diagnosis is probably EDP.

NB. If your pain is still quite acutely inflamed, then it is likely that most positions and postures will increase your pain. Under these circumstances, the first thing to do is to settle the inflammation present.

As always with the human body, it is not quite as black and white as this and some postures of flexion or extension can be quite subtle and not always that easy to identify straight way. Nevertheless, nearly all NSLBP can be given a functional diagnosis which will allow you to specifically treat the cause of your problem and consequently resolve the pain you are suffering with.

You will also need to take note of your aggravating and easing factors, but that's for another article...