A lifestyle

Oh, Your Aching Back!

By Bill Gottlieb

Peter Gulke, a screenwriter from Hollywood, was a guy who really used—and abused—his back. In high school and college he competed as a gymnast. After graduation, he picked up cliff diving and surfing. But it wasn’t the sports that did him in, at least not directly. One day in his late twenties, while raking the lawn, he reached for some leaves and felt an ominous twinge in his lower back. In that swift moment, he became one of the millions of people in this country who suffer from lower back pain.

He had to stop surfing, then jogging, then golfing. The pain would plague him for a few weeks, go away, then come back again. He tried chiropractic, acupuncture, herbs, muscle-relaxing drugs, mind-body techniques. Everything helped a little, but not for long.

Gulke’s story is so typical as to be almost a cliché. No doubt you’ve heard the statistics. Eighty percent of Americans will suffer a bout of debilitating back pain at some point in their lives, with a full 80 percent having one or more recurrences. Back pain sends more people to the doctor than any other illness except colds. For Americans between the ages of 30 and 50, medical costs to treat back pain are higher than they are for any other health problem.

And how is that money spent? On thousands of operations—even though some studies show that four years after back surgery, patients fared no better than those who hadn’t gone under the knife— and on millions of prescription drugs, like anti-inflammatories and narcotics, that only temporarily ease pain. Of course, some of the alternative remedies that didn’t help Gulke, like acupuncture and chiropractic, do have good track records. But the moral of the back story seems to be that no single treatment works for all people all the time.

That’s why alternative and conventional healers alike have been hard at work seeking new solutions. Some are based on a new understanding of how the back works and why it starts hurting; others involve new approaches to pain relief. The following treatments are three of the most promising to gain credibility in recent years.

Exercises
to stabilize your spine
Until two years ago, Anne-Marie Howard*, a 32-year-old laboratory technician in Halifax, Nova Scotia, considered herself lucky. She had spondylolisthesis, a congenital condition in which the front half of a vertebra separates from the back half, but she never experienced any pain.

Then her luck changed. By the time she walked into the office of Rick Jemmett, a physical therapist in Halifax and author of Spinal Stabilization: The New Science of Back Pain, she hurt every day. At work she spent most of her time standing. By noon she was usually in pain. By quitting time, she was in agony.

Jemmett didn’t give Howard the standard exercises prescribed by most physical therapists. Instead, he instructed her in highly specific but subtle move- ments involving the transversus abdominis muscle of her abdomen and the multifidus muscles of her lower back; he calls these “spinal stabilization” exercises. After two weeks of daily practice, Howard’s symptoms improved. After a month, she was pain free—and remains so, as long as she sticks with her exercise program.

Spinal stabilization is the first regimen to show an actual decrease in recurrence rates among sufferers of back pain, according to a study published recently in the journal Spine. The study compared a group of back patients whose treatment consisted of counseling and medication with a second group who received instruction in spinal stabilization.

After one year, 80 percent of the people receiving conventional methods had a recurrence of back pain compared to 30 percent of the spinal stablization group. After three years, the recurrence rate was 75 percent among the conventional group and 35 percent among the group taught the spine-stabilizing exercises.

What’s the secret to this unusual approach? Nothing less than a new understanding of what causes a back to start hurting in the first place. Traditionally, experts thought that strained ligaments and degenerating disks were the main problem, so they prescribed exercises to strengthen the muscles supporting those structures, which are the big muscles close to the skin.

But in 1992, Manohar Panjabi, professor and director of the biomechanics laboratory of the department of orthopedics and rehabilitation at Yale University School of Medicine, challenged this notion.

Based on research with cadavers, he concluded that the spinal column alone isn’t strong enough to support the body’s weight. Other researchers later demonstrated that most of the back’s stabilizing force is, in fact, provided by the small, deep muscles of the lower back and abdomen—the multifidus and the transversus abdominis.

Since then, experts have built on Panjabi’s research and discovered that regardless of the cause of spinal damage—whether it’s trauma, arthritis, or congenital problems like Howard’s—the underlying effect is the same. The signals between the central nervous system and these deep stabilizing muscles become impaired. As a result, it takes longer for the nervous system to activate the muscles, and at times it may do so in the wrong order.

Researchers have also found that the multifidus muscles tend to atrophy after an injury; believe it or not, they can shrink by as much as 25 percent within 24 hours of a back injury—and stay that way for years. Once these small muscles are damaged, the central nervous system compensates by relying on the larger ones to stabilize the spine. But they don’t quite get the job done, so back pain recurs.

The only way to really cure back pain, according to this theory, is to help the central nervous system regain control of the transversus abdominus and multifidus muscles. That’s where the spinal stabilization program—originally created by Carolyn Richardson of the University of Queensland in Brisbane, Australia—comes in. When a patient learns to control the small stabilizing muscles, he or she can then proceed to the standard strengthening exercises taught by most physical therapists.

Unfortunately, the techniques to stimulate the muscles are difficult to learn by yourself, says Jemmett, and they’re not yet well known by many physical therapists. You can get a general list of therapists in your area from the American Physical Therapy Association at 800.999.2782; check with those on the list to see if any have been trained in spinal stabilization.

Supplements
to nourish your disks
What baby boomer hasn’t heard of glucosamine and chondroitin, the wonder-workers for aging knees? But did you know that these popular supplements, which nourish and rebuild cartilage, can also help with a certain kind of back pain? Many back sufferers have the same kind of osteoarthritis that people more commonly associate with knees and hands, only this time it’s in their disks. (Cartilage is the main material of the spongy disks that cushion the vertebrae.)

“When the disks are damaged, either by injury or the wear and tear of age, they lose their ability to hold water and absorb shock,” says Luke Bucci, a clinical nutritionist and adjunct faculty member in the department of nutrition at the University of Utah and author of Healing Arthritis the Natural Way.

To compensate, vertebrae grow new bone, which rubs against pain receptors, squeezes nerves, and can make life close to unbearable for some sufferers. The key to treating this condition, also known as degenerative joint disease, is to rebuild the cartilage of a damaged disk. That’s where glucosamine and chondroitin can help.

Many studies show that these supplements relieve arthritis, but one in particular looked at their power to ease back pain. Reporting in the journal Military Medicine, scientists gave 1,500 milligrams (mg) of glucosamine and 1,200 mg of chondroitin to Navy SEALs with low back pain; another group got a placebo, or fake pill. Those who took the two-nutrient combination had a 41 percent reduction in the level of back pain; the placebo group had a 19 percent reduction. The dose they got is considered standard. But you could safely take two to three times that amount for faster relief, Bucci says.

“You should get substantial pain relief in a week or two, and then you can start the more standard dosage,” he says. He also recommends looking for a product that contains both substances in a single supplement and taking it once a day rather than in divided doses. “You need to get blood levels of the substances to the highest possible level, so they get into the disk,” he says.

Natural Injections
to rebuild ligaments
“The fact that modern medicine attempts to relieve back pain by reducing inflammation is absolutely wrong.” That’s the strongly held opinion—which might strike some as rather inflammatory itself—of Marc Darrow, an assistant clinical professor at the University of California at Los Angeles School of Medicine and director of the Joint Rehabilitation and Sports Medical Center, also in Los Angeles.

“Anti-inflammatories are antihealing,” he says. When the body is injured, he explains, the injury triggers an immune response, starting with inflammation, which sends white blood cells to the site to clean up the damage. Other cells called fibroblasts also travel to the affected area, where they help create new collagen, the connective tissue necessary for healing. The standard anti-inflammatory medications—like aspirin, ibuprofen, and Celebrex—interrupt this process.

“When inflammation is reduced, a person does get temporary pain relief. But because healing is blocked, the person can end up with a long-term injury that causes chronic pain,” Darrow says. “True healing of back pain means working with inflammation, not against it.”

He and several hundred other physicians in the United States today are working with a technique, called prolotherapy, that follows this rationale. The “prolo” in prolotherapy is short for proliferation, because the idea is to use the inflammation to produce collagen and strengthen ligaments in areas where they have become weak.

In a typical treatment, says Darrow, whose clinic specializes in prolotherapy, the therapist first numbs the sore area with lidocaine. He or she then injects it with a dextrose solution. (Some prolotherapists use other solutions, such as sodium morrhuate, a cod liver oil extract.) The dextrose draws water from the cells, damaging a small layer in the area.

This sparks an inflammatory response at the site, calling in fibroblasts, which produce collagen to strengthen the ligaments. Studies show that after eight sessions of prolotherapy, ligaments are 50 percent thicker and two to four times stronger. These stronger ligaments stabilize the spine, reducing or even eliminating back pain.

Prolotherapy may also have a neurological effect, says Jeff Patterson, an osteopath and professor in the department of family medicine at the University of Wisconsin Medical School in Madison. He thinks the injections may quiet pain by altering nerve function in the area. In this respect, the technique is similar to a widely accepted approach to pain relief called trigger point therapy, in which a therapist uses finger pressure to release knots of tension and constricted nerves.

Studies show that on average, 90 percent of prolotherapy patients with back pain get significant relief, Darrow says. Prolotherapy may briefly make the pain worse before it gets better, since it’s creating more inflammation. But according to Darrow, it’s gentler than surgery and many of the pharmaceuticals commonly used in treating back pain.

Some orthopedic surgeons aren’t convinced. They say prolotherapy works by creating scar tissue, not inflammation, and that the results are only temporary. But Darrow disagrees. “A study of post-prolotherapy tissue of a spinal ligament shows fresh layers of collagen and no scar tissue,” he says.

Usually a prolotherapy session consists of four to six injections, with one to two weeks between sessions to allow time for the growth of new tissue. Some patients may need more treatments. Costs range from $100 to $500 a visit. If prolotherapy is billed as trigger point therapy, insurance may cover it, and worker’s compensation will usually pay if it’s a work-related accident.

For Peter Gulke, the money was well spent. “I can surf again,” he says. “I can play golf again. Prolotherapy makes more sense than any other therapy I’ve had. I feel like I have a new back.”

How to Get Over a Back Injury:
Don’t be afraid to move

If you hurt your back and you’re not getting any better, your back may not be the problem: It could be your psyche.

That’s the conclusion of a recent study in the medical journal Pain. Surprisingly, researchers found that the best predictor of whether a person returns to work within one month of a back injury is whether or not the person suffers from “fear-avoidance behavior.” The notion is pretty self-explanatory. It means you fear your back pain, so you avoid any movement you think might make it worse. But this behavior pattern itself, by keeping your muscles tense and tight, might keep you on the couch.

“The spine and back are not frail structures you need to coddle during your recovery,” says Steven George, one of the authors of the study and a fellow at the Brooks Center for Rehabilitation Studies at the University of Florida in Gainesville. In fact, for most people who are under 55 and whose backs have generally been in good shape, he says, the best way to get better after an injury is keep moving and confront the pain.

No, this isn’t about telling your back to back off. It’s about knowing what it takes to recover. First, understand that you must stretch and strengthen your muscles to heal a back injury and that pain is an expected and normal part of the process. “With your doctor’s okay, start your recovery program two to three days after the injury,” says George. “Exercise or stretch about 10 percent beyond your pain threshold,” he adds, “and don’t take off from exercise more than two days in a row.”

Deep breathing can also help you overcome anxiety and relieve muscle tension, says Bruce Kodish, a physical therapist in Pasadena, California, and author of Back Pain Solutions. Any time you feel anxious about reinjuring yourself, take five deep breaths, holding the inhale to a count of five and exhaling as slowly as possible.

In some instances, though, confronting pain is not a good idea. If you’ve tried it and your aching is worse 24 to 48 hours later, if your pain moves from your back into your buttocks or leg, or if your symptoms change—from pain to numbness or weakness, for example—stop exercising and see your doctor