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.
