Mind Your Back

This is one of my occasional public service announcements.  I have at least one previous post on spinal health on this blog.  Some might wonder why a psychiatrist is interested in the spine.  I had an early interest in neurosurgery and over the years have talked with people who have sustained various spinal injuries that they have recovered from or been disabled by.  These injuries are very common and can occur along any number of trajectories. They can be associated with chronic pain and result in numerous surgical or pain intervention procedures that have varying degrees of success.  Once a chronic pain state has been established it is unlikely to be resolved completely at any time in the future.

Mapped onto that landscape of acute injuries are injuries to the aging spine.  For various reasons aging has an impact on every persons spine.  Degenerative disk disease is a normative finding on imaging studies as a person ages.  Acute injuries can make a spine image appear to be older because it looks like age-related changes.  For example, I have had athletes who injured their back tell me that their physician told them that after a certain injury their x-ray "looked like a the x-ray of a 70 year old man."  Older spines may not be as dense and I have seen many people diagnosed with acute compression fractures that were either spontaneous or they occurred after a fall.  I have talked with people who had a compression fracture as a first sign of cancer from metastatic disease but I want to emphasize that this is a rare cause of acute back pain.  The commonest cause of back pain and back injury are acute accidents and per my example - acute injury to the aging spine.

Let me give a clear example.  Consider the theoretical case of Bob X.  For 35 years Bob has worked on a railroad section crew.  Even though there is a lot of mechanization on the railroad these days, Bob's strength was legendary in terms of what he could lift off the ground.  He retired at age 66 and became relatively sedentary.  He gained a substantial amount of weight and spend most of his day watching television.  He happened to be out in his yard one afternoon and his neighbor asked him  to help him lift a mower onto trailer.  Bob looked at the mower and figured it was much less than what he was used to lifting on the railroad.  He decided to lift it up by himself and set it on the trailer.  He noticed almost immediate lower back pain and then some pain radiating down his left leg.  After persistent pain for a few days he went in to see his physician and an MRI scan of the lumbar spine was done showing a minor facet fracture and an L4-5 disk herniation.  In this case we have a man who has a physically demanding job and probably became deconditioned after retirement.  He became injured when handling a load that he estimated he could easily handle based on past experience and did not factor in the conditioning aspects.

That brings me to today's example.  I needed to grease the front axles of my riding lawn mower.  It is a large Toro model and the front end is weighted for stability.  The mower weighs about 550 pounds.  I typically pick up the front end and place it on an inverted 10 gallon plastic pail.  That is essentially a dead lift of at least a foot with a weight of about 100+ pounds.  Even though I have done spinal exercises every day for the past 15 years this is a setup for an injury.  Today I started to think about mechanical advantage and remembered a brief job I had during my youth.  I helped a guy change very large earthmover tires. In the process we used a small hydraulic jack to break the beads on these tires so that we could get them off the rim.  I decided to purchase a jack to do the job.  At the store, there were a great many jacks with different capacities.  I got one with a jack stand built right into it and it also had a wide stable base.

After placing the jack under the mower I moved it into the exact position I needed by pumping the jack about three times with three fingers.  No back strain at all.  

Today's take home message is that you need to protect your spine, especially if you are aging.  Aging is associated with a number of factors that decreases the ability of the spine to sustain a load and lift effectively.  Workers and athletes who are used to sustaining high loads on their spines need to reconsider that and slow down or stop as they age.  Practically everyone has degenerative disk disease and that leads to a characteristic radiographic appearance and generally some degree of chronic back pain.  I think that a reasonable approach with aging is to exercise your back in a manner consistent with maintaining adequate conditioning of the perispinal muscles and adequate density of the vertebrae.   Those programs need to be individualized especially if there is a prior spinal problem or illness affecting the spine.  Your physician should be able to recommend a specialty program or physical therapy who can provide the exercise regimen to maintain conditioning and flexibility.  That approach can also result in significant pain relief.  Many of these programs also have individualized programs on techniques to avoid lifting injuries.

Shortcuts at home to alleviate load on the spine like the hydraulic jack in the example should be considered. There are a number of useful products like small hand trucks designed to pick up plant pots that can also be useful.  Innovation in this area is needed as the population ages.  Small assistive devices for the home need to be designed for moving the 10-50 pound loads that homeowners typically have to move around.  The goal is avoiding a spinal or musculoskeletal injury that leads to further deconditioning and risk of future injury.

There is not enough advice and information out there on how to prevent these injuries. Once they occur, trying to get the right help can be confusing and limited to medications rather than the needed physical therapy. More importantly - these injuries can result in a marked lifestyle change and decreased physical activity required to maintain general health.  Spinal health is also a part of mental health.  About 20% of people with acute back pain develop chronic pain.  Chronic pain syndromes are typically associated with anxiety, depression, insomnia and in some cases substance use disorders. That is how psychiatrists end up seeing people with chronic back pain.

Preventing back injury and chronic low back pain will also prevent all of these psychiatric comorbidities.



George Dawson, MD, DFAPA      



Disclaimer:  This is a non-commercial blog.  The pictures here depict the equipment that I have purchased and am really using.  There is no promotional consideration.




            

Lessons From Physical Therapy

I remember the first time I experienced any significant knee pain.  My wife and I had just purchased an old house and as part of the sweat equity that young homeowners do we were going to refinish all of the hardwood floors ourselves.  If you have ever tried that, the most imposing part of the task is sanding all of the floors.  Hardwood floor sanders are very heavy pieces of equipment with cast iron bodies.  My first task was to carry this machine that I guess easily weighed over a hundred pounds up to a high second floor in our old house.  That was about 25 steps and a landing.  By the time I got to the top, it felt like both knees had bottomed out and were starting to creak.  At the time I was a competitive cyclist and training by putting in 200-250 miles on the roads and hills of Duluth, Minnesota.  I had never encountered this type of pain before during cycling, speedskating or weight lifting.   I compensated the best I could by taking the sander down just one step at a time and bringing it up and down again after we ruined the first staining attempt.  Eventually the pain went away, but I had learned several valuable lessons.  Cycling for example, did not cause any knee pain even after this acute injury.  I developed a strong preference for cycling and skating and decided to forget about running.

A couple of years went by and I developed some pain in my lateral knee.  I had already been diagnosed with gout in medical school and compared to gout pain most other musculoskeletal pain is minor.   My experience with physicians diagnosing gout was very mixed and I did not want to get a recommendation for medication if something else would work better.  Instead of seeing a primary care physician, I went in to see a physiatrist who happened to be a sports medicine doc.  He jerked my knee around and was satisfied it was stable and showed me some basic iliotibial band stretching exercises.   Within a week the pain was was gone.

My most foolhardy adventure in knee injuries was trying to extend my usual 40-50 miles training rides to 100 miles with no buildup.  I was out riding the roads in Washington County and remembered a theoretical 100 mile loop that I always wanted to ride.  It was a hot summer day, I felt very fast, and I had plenty of daylight so I took off.  At the 3/4 mark I was coming up a long steep grade and felt some left knee soreness that persisted the rest of the way.  My knee was burning when I stopped and I ignored it and did not ice it that night.  By morning I had developed a significant effusion and could not bend it.   I saw an orthopedic surgeon the next day who jerked my knee around, told me it was an overuse injury, and put my leg in a knee immobilizer.  Within two weeks I was out cycling again.

At other times I have allowed my body to get seriously out of whack.  After years of cycling I started to realize that I ended each session with severe neck and shoulder pain.  After numerous adjustments to the stem length on my bike, a physical therapist figured out I was was extending my neck too far to look up from my riding position and fixed the problem by modifications to my riding position and neck exercises.  At one point, I was almost exclusively cycling and got to the point it was painful to walk around the block.   The solution was again exercise modification and exercises to improve hip flexibility.  

All of this experience has led me to be very conscious of knees and other joints and keeping them in good working order as I age.  Not just my joints but the joints of my wife, family and friends.   It is kind of amazing to hear the emphasis on physical activity at all ages and yet there is no information out there on joint preservation or how to preserve your back.  Many people are surprised to learn that the circulation to intervertebral disks in the spinal column is gone at some point in the late 20s.  That makes biomechanics and muscle conditioning some of the most important aspects of joint and back function as you age.  It also makes physical therapy and exercise some of the most important tools to maintain musculoskeletal function with aging.   When I develop some kind of musculoskeletal pain, the first thing I do is call my physical therapist and schedule an appointment to see her.   She does an examination and an analysis of the biomechanics of the problem and tells me how to solve it.  I have been through the process many times with a physician and the main difference is that there is no biomechanical assessment, no actual manipulation at the time that may be useful, and no specific exercise program to make it go away and stay away.

The results of a medical evaluation are as predictable.  You have a diagnosis of muscle or joint strain.  Use ice or heat whichever one makes you feel better.  I have been told by rheumatologists that there is really no scientific basis for the heat versus ice recommendation only the subjective response.  And of course the recommendation for NSAIDs (non-steroidal anti-inflammatory drugs like ibuprofen) or acetaminophen.  I ignore the NSAID recommendations and take as few tablets of naproxen every year as I can.  I consider NSAIDs to be highly toxic drugs and avoid them even though they are effective.  I had a rheumatologist at a famous clinic tell me that the best evidence that NSAIDs were effective was the negligible amount of joint cartilage that was left when patients came in for joint replacement therapy.   Strong evidence that NSAIDs could knock out the pain as the joint deteriorated.   The only time that I was ever offered an opioid was when I had my first gout attack.  I was seen in an emergency department for severe ankle pain and discharged with a bottle of acetaminophen with codeine - a medication that is totally useless for gout pain.

In clinical practice I see a lot of people with chronic pain.   I notice that many of them are taking NSAIDs on a chronic basis and experiencing complications of that therapy like renal insufficiency.   I notice that practically nobody sees a physical therapist.  I notice that many people are now started on oxycodone or hydrocodone for mild sprains and injuries involving much less tissue injury than many of the injuries I have sustained during sports.   There are also many people who do not receive adequate advice on modifying their activities once an injury or series of injuries has been sustained.   For example, should a person keep running if they have sore knees, are 30% overweight, and have radiographic and physical exam evidence of degenerative joint disease?  Many people seem to have the idea that they can just wear out joints and have them replaced and the replacements will be as good as new.   Some will decide that it is just time to hang it up and start to sit on the couch and watch television.  They are surprised that their pain worsens with months of inactivity.   Some of the patients with back pain decide: "This pain is so bad that physical therapy is not going to do anything.  I am going to get surgery as soon as I can."  The widespread ignorance and neglect of musculoskeletal health is mind boggling to me.

I got into an exchange with an orthopedic surgeon in our doctor's lounge one day - over lunch.  He wanted to talk about narcissistic personality disorder and I wanted to talk about the biomechanics of the knee and hip joints.  It was a lively exchange and in the end he agreed with me about the huge importance of biomechanics during physical activity and as a way to prevent injury and degenerative disease.  It turned out he just wanted to hear about the personality disorder and did not have an opinion on it one way or the other.

I teach a lot about central nervous system plasticity in a neurobiology course that I give several times a year to different audiences.  Widely defined, plasticity is experience dependent changes in the nervous system.  There are a number of mechanisms that can lead to these changes.  Kandel and others have pointed out that these are the mechanisms of animal learning.  Two examples jump out of those lectures.  The first is a physical therapy example of knee extension exercises in the treatment of knee injuries.  It has been known for some time that quadriceps strength and balance through the knee are critical factors in knee rehabilitation and the prevention of future injuries.  Research in this area shows that increased quadriceps strength can occur in the same session.  The other example I use is a guy who wants to go to the gym to increase the size of his biceps.  He starts doing curls and within 6 weeks his strength has increased by 25% but there is no muscle hypertrophy.  His biceps diameter is unchanged.  What do these two examples have in common?

The common thread here is CNS plasticity and everything it allows us to do.  Plasticity will allow your to keep your joints healthy and relatively pain free if you allow it to.  You have to be willing to accept the idea that pain can come from deconditioning and biomechanical problems that are reversible by plastic mechanisms.  The only additional information needed is if it is safe to exercise and that can be provided by a physician and a physical therapist.

And the lesson for psychiatry?  Chronic pain patients certainly need to hear this information especially if they are deconditioned.   People addicted to opioid pain medications who are not getting any relief need to hear this information.  Patients in general with exercise modifiable conditions who see psychiatrists need to hear this message.  There is also a lesson for psychotherapy no matter how it is delivered.  Kandel's original example of plasticity was a psychotherapy session.  If your brain is modified by exercise there is no reason to think it can't be modified by anything from straightforward advice to more complicated therapies.   Success in that area can lead to the limited or no use of medications and a conscious focus on what is needed to maintain health like I discuss from my own experience.  I certainly don't take any medication for pain that physical therapy or exercise adequately treats.  The same argument can be applied to anxiety and depression that can be adequately addressed by psychotherapy or other psychological interventions.  On the other hand if most people don't know that physical therapy, exercise and activity modification successfully treats musculoskeletal pain and other problems they are unlikely to try.    


George Dawson, MD, DFAPA

Supplementary 1:  There are currently only 4 Medline references on biomechanics plasticity sports.  This seems like a promising area for sports medicine, physical therapy, and rehab medicine.

Supplementary 2:   The photo at the top of the page is an exercise I do to alleviate knee pain that I learned from the book The Knee Crisis Handbook by Brian Halpern, MD with Laura Tucker.  The exercise is called the quad set (p. 238) and although the author suggests a towel under the knee, I am doing it on a styrofoam roller.  This book contains a wealth of information on knee health.  I do not recommend doing what you see in the picture without reading the book.  I have no conflict of interests related to this book and purchased it online entirely for my education.

Supplementary 3:  I could not figure out where to fit it in above but after 25 years riding with 175 mm crankarms on my bike, I dropped them back to 172.5 mm.  The bike fit expert for my new bike was convinced it was a good thing to do.  My new bike rides so much differently it is difficult to know what to attribute to crankarm length.