End Back Pain Forever CHAPTER 1
“Doctor, My Back Is Killing Me!”
You feel a twitch in your low back, then a heaviness and a sudden stab of pain. It strikes without warning: when you are crossing the street, stacking the dishwasher, jogging, whacking a golf ball, lifting a baby, swatting a fly, carrying groceries, bending over, getting out of a car, or just turning on a faucet.
Now you’re afraid to move. You’re locked in place. You feel a belt of pain pulsing across your back from hip to hip. You wonder, “What’s happening? What did I do to get this?” You feel as though you’re cut in half, as the pain seems to separate you from your legs. “Will the pain go away? Will it stay?” Gingerly, you start to move, but the pain only strikes harder. No, it’s not going away, not at all. And if—this is a big “if”—the pain does ease off in a few days or go away in a couple of weeks, studies show that over time, it is certain to return in close to 50 percent of patients.
Back pain can be your personal bully. It can readily become chronic, lasting for months, years, even a lifetime. It may become so intense and disabling that your life can change dramatically for the worse. It can strip you bare financially, isolate you from family and friends, and leave you anxious and depressed. It can banish even the mere thought of sex. The curious thing about pain is that the
more you think about it, the worse it becomes. Preoccupied with your pain, you lose interest in hobbies and sports. Your decreased activity may lead to obesity, which, in turn, can increase your chances of developing diabetes and heart disease. You watch in despair as you decline physically, mentally, and spiritually.
This book means exactly what the title End Back Pain Forever says. I have written it so that you can end your back pain once and for all and avoid a life of despair. I say this as a physician who has treated more than ten thousand patients in thirty-five years of private practice and as a past president of the American Academy of Pain Medicine, the medical society that represents physicians practicing a multidisciplinary approach to the treatment of pain.
I have seen many patients so wracked by pain that they wished they were dead, and some who actually attempted suicide before they saw me. So I am aware of the helplessness that you and millions like you feel when you first hobble into the doctor’s office and exclaim, “Doctor, my back is killing me! I can’t go on like this!”
Let me describe a common scenario: after some pokes and prods, the doctor says, “Go home, take an aspirin, lie down, and rest.”
You do as the doctor says. But it does no good, and two days later, having missed work, you see the doctor again. “Well,” says the doctor, “you have a case of nonspecific low back pain. We see a great deal of it.”
The diagnosis sounds scientific, but it leaves you completely baffled and still wracked with pain.
“What does ‘nonspecific low back pain’ mean, Doctor?”
“It means that we don’t know the cause.”
“You don’t know the cause?”
Should you ask more, you’ll learn that nonspecific low back pain, also known by the acronym NSLBP, is so baffling that the International Association
for the Study of Pain devoted an entire chapter to it in Functional Pain Syndromes: Presentation and Pathophysiology, a book for professionals published in 2009. The authors draw the frustrating conclusion that “it is exceedingly difficult to identify specific pathology underlying NSLBP.” Of course, this is of no help to you or to anyone else.
“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 my 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 (a 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.
That bears repeating: when an MRI shows a herniated disc, it does not necessarily mean that the disc is causing your pain. Many people have a herniated or degenerated disc as a consequence of aging, and yet they have no back pain. Furthermore, it certainly does not mean that surgery is needed.
Actually, studies have shown that patients who get imaging tests increase their chance of undergoing an invasive treatment such as surgery or spinal nerve injections. Studies have also shown that when an MRI or CT scan for back pain indicates that something is “wrong” with the spine, patients are left to believe they will never truly be “normal” again, regardless of whether their pain is ever reduced or eliminated through any form of treatment. And bear in mind that as many as half of all spinal operations fail.
In fact, the primary source of 75 percent or more of all back pain is from the muscles, not the spine. In 2001 a study of more than twenty thousand patients at outpatient medical clinics in the United States found that sprains and strains of muscles and other soft tissue accounted for 70 percent to 80 percent of all back pain. This is strikingly similar to the findings of a study of three thousand patients with back pain conducted at Columbia Presbyterian Medical Center in New York City in 1946, which revealed that weak and stiff muscles were the source of pain in 83 percent of the participants.
It is truly astonishing that so many physicians who treat back pain have failed to make use of these findings. For years, medical schools have paid very little attention to the muscular system, even though muscles account for approximately half the weight of the body. Medical practice in recent decades has relied increasingly on high-tech imagery for diagnosis. Although high-tech imagery is certainly of great value—as is surgery, when required—neither X-rays nor MRIs nor CT scans are designed to detect the subtle nuances associated with muscle as a source of pain.
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 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.
It was during one of these crippling occasions that Stephanie went to a major teaching hospital, where an orthopedic surgeon ordered an MRI. The results showed that a disc in her lower spine was flattened, and the surgeon felt that the best treatment for this condition, called degenerative disc disease (DDD), would be a lumbar disc replacement. Stephanie wanted a less aggressive treatment and saw another surgeon, who referred her to a physiatrist (a doctor who treats physical impairments and disabilities). The physiatrist felt that her problem arose from one of the small joints in her spine, known as facet joints, rather than from the DDD. He treated her with injections of a local anesthetic to block the nerve that innervates the facet joint, which relieved some of her pain. Since the nerve block had proved partly successful, Stephanie’s doctor suggested that the nerve be “turned off” temporarily with a procedure known as radiofrequency ablation. The physician would make a small incision in the skin and then use a handheld probe to deliver radio waves to the offending nerve, heating it until it can no longer transmit pain signals. Fearful of tampering with her nerves, Stephanie rejected this option. With no other conventional pain treatment options, and although there was no good indication for it, she agreed to an epidural steroid injection into her lower spine but this was ineffective. Five courses of physical therapy were also unsuccessful, and some of the sessions made her feel worse.
Stephanie first saw me in 2006 during one of her periods of muscle spasms. Her pain was so severe that she had been unable to work for two weeks. The pain had spread on this occasion from her right low back to both sides of her back and buttocks, with pain going to her hips and groin and also to her lower legs,
feet, and toes. It consisted of a dull ache in her legs and a sense of pressure in the region of her spine. Her family, alarmed by the severity of the attack, urged her to finally have back surgery and “get it over with once and for all.” Since she needed to “fix” the “damaged” disc sometime, why not now?
I examined her with an electrical instrument I devised that can identify specific muscles causing pain. This device works by stimulating a specific muscle to contract. If that contraction produces pain, it suggests that that muscle is a source of your pain. Using electrical stimulation, I determined that five muscles in her low back and buttocks were tender. But continued stimulation reduced the pain and actually eliminated it in most of the muscles. This told me that it was her muscles causing the pain, and that it was due to spasms, tension, and stiffness. I treated her with my spasm protocol: electrical stimulation to fatigue the muscle, followed by a different form of electrical stimulation to make the muscle move gently, followed, in turn, by gentle limbering exercises that I will teach you in Chapter 10
After Stephanie’s first visit, her pain was reduced by 60 percent. She returned for two additional sessions to relieve the spasm and was taught all twenty-one exercises found in Chapter 10
. This brought her total relief. She now does the exercises every day, and four years later remains completely pain free.
Stephanie had “abnormal” findings on her MRI. Nerve blocks to the facet joints of her spine had managed to relieve some of her pain. But with my treatment, she never needed or had a disc replacement or long-term blocking of the nerves that serve her facet joints. She had received a host of well-meaning, costly interventions and suggestions for even more. But all of her pain could have been treated from the start simply, inexpensively, and safely by addressing tense, stiff muscles.
Given Stephanie’s previous experience with doctors, she well understands the quotation that hangs on my office wall. It is from Eugene Bauer, an internist at the University of Vienna Medical School, who said in 1931, “A word in the mouth of a physician is as dangerous as a scalpel in the hands of a surgeon.”
By showing her the results of X-rays and MRIs, her doctors led her to believe that she was permanently damaged goods. What they saw on the MRI was definitely there. But in her case, as in so many others, the true source of her pain was elsewhere: in her muscles. The truth is that without a muscle examination, we do not have an accurate explanation for your pain or anyone’s pain.
My professor of anatomy at SUNY Upstate Medical University, Philip Armstrong, MD, used to say, “Reiteration without irritation is the essence of good education,” and so to repeat the mantra for you: the primary source of 75 percent or more of all back pain is from the muscles, not the spine.