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.




            

The Spine In Psychiatric Practice

I am not talking about the spine as a metaphor, I am talking about the real spine.  I am also not going to discuss some alternate therapies affecting the spine, I am going to refer to it only in the context of actual medical practice.  Maybe it was my interest in chronic pain and neurosurgery that led me to the observations, but many years ago I started to notice the high number of patients who were seeing me and had associated spine problems either associated with their psychiatric disorder or making it worse. As far as I can tell, this problem is really not well addressed in the psychiatric literature.

The spectrum of spinal disorder presentations varied from undiagnosed, to incorrectly diagnosed, to diagnosed and treated many times.  There is also the issue of how normal imaging studies vary greatly with age and eventually produce radiology reports that sound pathological but do not necessarily explain the observed pain or disability.  The usual psychiatric diagnoses included depression, anxiety, insomnia, and chronic pain.  The correct diagnoses were most often only possible by a detailed discussion of the problem.  In many cases the patients I was seeing had never actually seen a physician for back pain.  Let me illustrate with a couple of examples (none of these vignettes represent actual patients).

Patient A is a 35 year old woman being seen for depression.  She is in a stressful work situation because she is expected to be physically vigorous and move many 40 pound boxes of paper per day, but she is limited by neck pain and muscle atrophy in the left arm.  She injured her neck at a different job 5 years earlier lifting a heavy piece of equipment down from a shelf.  She felt immediate neck pain and over the next several weeks had muscle twitching in her left arm.  She did not have health insurance from her employer and was never assessed for the injury.  She has had daily pain since the injury and on days where she has more physical activity, she has more pain and more depression.  She is interested in treating the depression.

Patient B is a 50 year old man being seen for depression and insomnia.  He has a 5 year history of taking zolpidem for insomnia.  He is referred by his primary care physician because he has had to increase the dose of zolpidem to 20 mg/day because of worsening insomnia.  The patient gives a history of no longer being able to sleep on his right side because he has neck pain with radiation to the shoulder that resolves when he changes his sleeping position.  He has seen the Silenor and Lunesta commercials and is interested in changing his sleep medication.

Patient C is a 60 year old woman with a history of multiple upper and lower back procedures including fusions, discectomies, and foraminotomies.  She has also had surgical complications including infections and a cerebrospinal fluid leak.  She is taking oxycodone 40 mg QID with addition 5-10 mg prn doses of oxycodone.  She is also taking lorazepam 1 mg TID for anxiety and drinks wine on a daily basis.  She is referred for treatment of depression and chronic pain.

These three descriptions of patients highlight a number of problems unique to psychiatric practice.  Psychiatrists often see people with degenerative or traumatic changes to their spine that have never been assessed by a physician.  We also see patients who have had intensive surgical treatment and who have been treated in pain clinics for a long time before anyone thought to refer them to a psychiatrist.  In both cases an antidepressant seems to be a proxy for a psychiatric evaluation or an interview that seeks to determine if the spinal problem is a cause of depression, insomnia, or anxiety.  That type of evaluation is fairly straightforward but it does require time and the ability to do a medical and neurological review of systems and recognize common patterns of spinal syndromes.  The risks are minimal and the potential rewards are great for the patient.  I have had people ask me why I was asking them so many "medical" questions or report that their primary care physician wanted to know the same thing.   But I have also had people tell me that they were glad to know that they really had chronic pain from a fixable spinal problem rather than chronic insomnia and a need to take sleep medication forever.

This issue also highlights the issue of a physical exam in psychiatric practice.  When is it necessary and in what context can it be done?  In my first job I recall asking the clinic administrator whether she would provide a room and basic equipment for a physical exam.  She said that she would but in the three years I worked there it never happened.  If there is no adequate place to examine a patient I don't think an examination should be done.  There is also the question of the emotional relationship with the patient.  Many people seeing psychiatrists consider them to be their primary physician and have had many intense discussions with them over the years.  Psychiatrists should be aware of this emotional context and the meaning of any physical touch that occurs in that context and keep the assessment at the verbal level.  Referral to a physician who you know does a thorough neurological and spine exam is indicated for most cases, but in many cases you are seeing people referred from these physicians and it has already been done.  What about imaging studies?  My rule of thumb is to do them only if the patient has been physically examined.  I have physically examined people only in acute care settings and ordered imaging studies (CT and MRI) in that context.

On the positive side a lot can be done within the constraints outlined above, first and foremost is a detailed evaluation of the problem.  How is it that insomnia from neck pain can be treated for years as primary insomnia without any attention being paid to the cervical spine pain as being the likely source of that insomnia?  The only explanation I can come up with is a cursory evaluation of the pain.  Borrowing a page from Engel any psychiatric evaluation of a person with depression or anxiety, insomnia, and pain needs to be as comprehensive as possible.  The evolution of those problems since childhood and the relationship to physical and psychological trauma as well as other major life events needs to be detailed.  Assessing the patient for any possible addictions is another requirement.  A description of the pain and associated neurological symptoms is critical.  I like to review old records, imaging reports and the images themselves if possible.  There are a few of the highlights of what is necessary to come up with a psychiatric plan of care for people with spinal problems.  In many cases, a psychiatrist is the only person addressing their pain, even though they have a known diagnosis of degenerative disk disease and chronic back pain.  It is very useful to have referral patterns and treatment plans established to be able to offer treatment of the pain or associated spinal problem in addition to addressing the identified psychiatric syndrome.

The ability to help this group of patients also has training implications.  You don't learn about the spine, neurosurgery or neurology doing psychiatry rotations in medical school.  I was fortunate enough to have intensive exposure to these areas and to excellent clinicians.  I was also fortunate to work in a multispecialty clinic for 23 years where I had the benefit of discussing these cases with specialists from all fields.  I was also able to walk down to Radiology and discuss films with an excellent neuroradiologist.  The training suggested by Insel with a clinical neuroscience in psychiatry, neurology, and neurosurgery would enhance the evaluation of these problems. 

It pays to focus on both the central and peripheral nervous system when indicated.

George Dawson, MD, DFAPA