BeHealthy Low Back Pain - Fall 2016 by Bay State Banner

Fall 2016

Be knowledgeable. Be well. Be healthy.

SURGERY? NOT SO FAST GOING ‘UNDER THE KNIFE‘ IS OFTEN A LAST RESORT FOR LOW BACK PAIN

PATIENT STORIES PREVENTION METHODS FITNESS AND EXERCISE HEALTHY RECIPES

LOW BACK PAIN

THE LOW BACK IS A WORKHORSE, BUT SUBJECT TO WEAR AND TEAR

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Publisher Melvin Miller Health Editor Karen Miller Senior Editor Yawu Miller Art Director Daniel Goodwin Production Caleb Olson Proofreader Rachel Reardon For advertising opportunities please contact Karen Miller at (617) 936-7800 or kmiller@bannerpub.com

Be Healthy is published by Banner Publications, Inc. 1100 Washington St., Dorchester, MA 02124 Volume 4 • Number 2 Spring 2016 © 2016 Banner Publications Be Healthy is printed by TC Transcontinental Printing, 1603 Boul. Montarville, Boucherville, Québec, J4B 5Y2 Printed in Canada COVER PHOTO: THINKSTOCKPHOTOS.COM/ISTOCK/ WAVEBREAKMEDIA

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Editor’s note: The information presented in Be Healthy is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate for your age, sex, race and risk factors and make timely visits to your primary care physician.

Low back pain

A common but ancient remedy: Acupuncture

Recipe: Veggie chili

Fall 2016 The issue

Low back pain By the numbers

4 8

Focus

Neurosurgery Mental health Acupuncture Patient story: Elizabeth Kent Patient story: Bob Miller Prevention

10 11 12 13 14 15

Healthy steps

Nutrition Recipe Exercise

18 20 21

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The issue: Low back pain

The low back: A workhorse But subject to wear and tear OF ALL THE MEDICAL CONDITIONS THAT AFFLICT PEOPLE, LOW BACK PAIN AT FIRST GOES UNNOTICED. After all, it is not on the list of causes of death in this country, or in the world for that matter. But when you take into account the medical visits, cost of treatment and days of lost work — not to mention the pain itself — it begins to get your attention. LBP is actually one of the leading causes of disability and the third most common complaint for an office visit, according to the National Center for Health Statistics. It costs the U.S. economy at least $100 billion a year in lost wages and productivity and medical treatment. The cost is largely due to the volume. It is estimated that 80 percent of people in this country will suffer back pain at some point in their lives. No one gets a pass. It strikes people of all ages, races and ethnicities and both genders. A closer look at the spine will make it clear why the back is so vulnerable. The spine is an intricate curved system of 33 bones called vertebrae. In between the vertebrae are spongy pads called discs, which act as shock absorbers. At each step when walking the discs prevent the bones from rubbing together. A network of muscles and ligaments, nerves and tendons complete the system. The spine has enormous responsibility. It allows us to stand upright as well as bend forward and backward and twist from side to side. More importantly, it protects the spinal cord. The bones in the neck have to carry the weight of the head, 4 Be Healthy | Fall 2016

but the bones in the low back bear the brunt of the weight of the entire upper body. That’s an awfully big job for five relatively small bones. The spine is far from frail, however. When the system is in sync, it does a yeoman’s job. Yet, strains, injuries and diseases can throw it off kilter and pain results. Because of the spine’s intricacy, the problem can stem from a number of sources. The bone might fracture, largely due to osteoporosis; the joints can be attacked by arthritis; the disc can bulge or even burst.

Risk factors Several factors increase the risk for LBP. The bones and discs begin to wear with age. Weight and inactivity weaken the spine. Unfortunately, almost 37 percent of adults in this country are obese, according to the Centers for Disease Control and Prevention, and only 21 percent meet the recommendations for performing aerobic and muscle strengthening exercises. Tobacco smoke impedes the delivery of nutrients to the disks in the back. Poor body mechanics, such as improper

lifting or bad posture place undue stress on the spine. Even emotions have an impact. There is a link between LBP and depression and anxiety.

Acute pain Most episodes of LBP are acute and fortunately short-lived. An example is muscle strain, which may be caused by aggressive exercise, poor posture or even just bending down to pick something up from the floor. Though often excruciating, this pain is typically self-limited, and goes away with simple home remedies, such as heat or cold and NSAIDs, such as ibuprofen. In other instances the pain is not confined to the back. Rather, it travels, or radiates to the buttocks and down the back of the leg. The culprit here is the sciatic nerve — the longest and largest nerve in the body. Because of its location in the lower spine, it is directly in the line of fire. When a disc slips out of place or ruptures, expelling its cushioning gel, it pushes into sciatic territory. You will feel the impact. The pain can be accompanied by tingling, numbness or weakness. Some people get foot drop. The sciatic nerve wields an awful lot of power over the leg. When irritated, it impairs the ability to walk, jump and control the ankle. The pain is worse when sitting or standing too long. Most cases of sciatica respond to conservative treatment, although severe pain may require epidural steroid injections,

The issue: Low back pain

Dr. Zacharia Isaac, medical director, Comprehensive Spine Center, Brigham and Women’s Hospital

which are x-ray-guided infusion of anti-inflammatories.

Chronic pain: It may be in your head — literally PHOTO: COURTESY BRIGHAM AND WOMEN’S HOSPITAL

Pain that lingers three months or more — even after treatment — is considered chronic pain. The incidence of chronic LBP is on the rise. In 1990, it ranked the sixth most burdensome condition in the U.S. in terms of poor health. In 2010, it jumped to third place, according to the National Institute of Neurological Disorders and Stroke. It is chronic pain that concerns Dr. Zacharia Isaac, the medical director of the Comprehensive Spine Center of

Brigham and Women’s Hospital. He faces an uphill battle. In chronic pain the brain has somewhat short-circuited, and has not recalibrated even after the initial cause of pain has been eradicated. Researchers discovered that chronic pain is like an old memory that seems to perseverate in the part of the brain that controls emotions and learning. Isaac has a hard sell. “Pain does not equal damage,” he explained. “Pain can just be pain.” It’s not unusual for the brain to play tricks on you. Amputees often experience “phantom pain” or “phantom sensation” in which the brain keeps sending feedback that the leg still exists.

RISK FACTORS n Age: Although back pain can occur at any age, its incidence increases as you get older n Excess weight n Lack of exercise: Weak back muscles can lead to pain n Improper lifting n Diseases of the spine, such as osteoarthritis n Behavioral conditions: People with anxiety or depression seem more prone to back pain n Smoking: Tobacco can limit nutrients to the discs in the back n Poor posture baystatebanner.com/news/be-healthy | Be Healthy 5

The issue: Low back pain

THE SPINE: THE BODY’S ‘BACKBONE’ — A COMPLEX SYSTEM WITH MANY MOVING PARTS The lumbar region of the spine, referred to as the lower back, consists of five large moveable vertebrae (bones) that are labelled L1 to L5. It has a slight inward curve known as lordosis. The lumbar spine is very strong. It supports the weight of the entire torso. It is also very flexible, and allows the body to bend forward and backward and twist from side to side. Because of its flexibility and stress, however, it is more prone to injury.

NORMAL DISC

Discs, which are located between the bones of the spine, serve as shock absorbers. Each disk has a tough outer ring called the annulus and a soft inner core, or nucleus. The nucleus is composed of a gel-like substance that is designed to withstand compression and movement.

RUPTURED DISC

L2 L3 L4 L5

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LUMBAR REGION A ruptured disc is a common cause of low back pain and sciatica. The disc breaks open allowing the inner gel to escape. The gel can then push against the sciatic nerve, causing radiating pain down the leg. A bulging disc occurs when the disc is compressed and pushes out but remains intact. If it touches the sciatic nerve, it will also cause sciatica. Most often a herniated or bulging disc can be resolved with conservative treatment. In some cases, it will require surgery. A disc can rupture and bulge without pain, however. Pain is caused when the sciatic nerve is pressed.

ILLUSTRATIONS: CALEB OLSON

The issue: Low back pain

“

Pain does not equal damage. Pain can just be pain.” — Dr. Zacharia Isaac It may be a little easier for amputees to tolerate this miscue since visual cues — the leg is obviously not there — can help more easily override the messages from the brain. People suffering from LBP don’t have the luxury of actually seeing the insides of the spine. Isaac tries to encourage normalcy. “People fixate on anatomy [LBP] instead of the entire body,” he explained. “That starts a real bad cycle. People begin to avoid activities.” He pushes exercise, but not only for a strong core. Exercise causes the brain to release endorphins, the body’s natural pain-killers.

Treatment

PHOTO: COURTESY BRIGHAM AND WOMEN’S HOSPITAL

Because LBP involves so many organ systems it requires a comprehensive approach to care, said Isaac. Physical therapy and exercise, acupuncture, chiropractic, yoga and t’ai chi are key players. Surgery is generally restricted to acute cases that impair urinary functions or result in severe or progressive weakness, for example, as well as potential candidates who have not improved after a couple of months of conservative treatment. Emotional support in the form of cognitive behavior and mindfulness is pivotal. A recent study published in JAMA found that among adults with chronic LBP, treatment with mindfulness or cognitive behavioral therapy resulted in greater improvement in back pain than did usual care. The improvements persisted for a year. There is not a quick fix for chronic LBP. There’s no magic pill. However, newer techniques are available now to “reprogram” the brain’s pain signals.

Dr. Zacharia Isaac, who specializes in pain management, counsels a patient at Brigham and Women’s Hospital.

ADDITIONAL COMMON CAUSES OF LOW BACK PAIN n S prains and strains: Tearing or stretching of muscle or ligaments. Generally results from undue stress on the lower back caused by sudden movements or heavy lifting n S pinal stenosis: Narrowing of the channel occupied by the spinal nerves and spinal cord. Symptoms can include tingling, weakness or numbness that radiates from the low back and into the buttocks and back of the legs especially with activity nO steoarthritis: Inflammation of the joints that allow movement of the spine. Characterized by stiffness and pain in the lower spine nO steoporosis: Weak or porous bones. Can cause painful compression fractures that may result in loss of height and stooped posture known as kyphosis nD egenerative disc disease: Wear and tear of the discs. Characterized by an ache made worse by sitting or movements like lifting, twisting or bending n S pondylolisthesis: A forward slippage of one vertebra on an adjacent vertebra in the lower back. Symptoms run from none at all to pain, stiffness and weakness in legs

CALL THE DOCTOR! Most cases of low back pain subside fairly quickly and require only conservative treatment. Other cases require the attention of a provider, according to Medline Plus. Call if you experience: n Significant leg weakness n Loss of bladder or stool control n Loss of sensation in your buttocks, thigh, leg or pelvis back of legs n Severe pain that does not allow you to get comfortable n Unexplained fever with back pain n Back pain after a severe blow or fall baystatebanner.com/news/be-healthy | Be Healthy 7

By the numbers: Low back pain

80% The percent of the population that at some point experiences low back pain

MILLION

The number of Americans that have low back pain at any given time

90% The percent of the cases of low back pain that are resolved within six weeks â&#x20AC;&#x201D; only about 5 percent of the cases require surgery

# 39% 52 1

MILLION

The total number of health care visits for low back pain in 2010

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The percent of the cases of low back pain that limited tasks of daily living

Low back pain is the number 1 cause of disability worldwide

Focus:Low back pain A leading cause of disability » Neurosurgery 10 » Mindfulness 11 » Acupuncture 12 » Patient stories 13, 14 » Prevention 15

“

I can’t run. The best I can do is shuffle. ... I do the best I can with what I’ve got. I know what my limits are.”

PHOTO: COURTESY BOB MILLER

— Bob Miller

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FOCUS: Low back pain

Surgery for low back pain … not so fast! Often only as a last resort your low back pain and its impact on your day-to-day life. Is the pain confined to your back, or does it spread to your buttocks and down the leg he wants to know. Have you tried more conservative treatment, such as physical therapy for at least six weeks? Is the pain the same, or has it gotten worse? Are there activities of daily living you can no longer do? In some cases actions speak louder than words. Those afflicted are sometimes easy to spot. “They can barely take a step,” he said. Groff is the director of the Neurosurgical Spine Service at Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital. Yet, he is not that eager to put someone under the knife for LBP. “Seventy to 80 percent of the people get better with physical therapy,” he explained. “You should see improvement in the first four weeks.” However, if at six weeks there is no improvement or the pain is worsening, a different course of action is needed. “At this point the likelihood of getting better [with conservative therapy] is less than 20 percent,” he said. Very few patients with LBP need to resort to surgery. Only about 5 percent are good candidates, according to a white paper published by Johns Hopkins Medicine. Groff agrees with that. For him it’s a combination of the story and the results of imaging tests, which can identify a structural cause for the pain. If the two are in sync, surgery is a good bet. The severity of the pain is not always correlated to the need for surgery. Some spine conditions tend to respond 10 Be Healthy | Fall 2016

to surgery more than others. Herniated discs occur when the inner gel of the disc oozes out and hits a spinal nerve. The radiating pain down the leg is a telltale sign. In spinal stenosis, the open area of the spine that houses the spinal cord is compromised, again leading to pain. Surgery for LBP has made huge strides since the 1990s. Traditional open surgery required a six-inch incision and retraction, or pulling of the attached muscles in order to allow a better view of the problem. This technique, however, affected more anatomy than the surgeon required, and increased the potential of muscle injury and pain. LBP can often now be treated with minimally invasive surgery. The halffoot incision has been whittled down to an inch or two, while still allowing the surgeon good access to the spine. The instruments as well as the technique have improved. “We have better microscopes and a better understanding of the goals of surgery,” Groff said. The outcomes of the two approaches are similar. However, the recovery from MIS is easier. Those treated for a herniated disc can return to work in about two weeks. Those who had spinal fusion, a procedure designed to inhibit movement in a painful vertebral segment, require four weeks to heal and a possible stint of physical therapy, according to Groff. There are some instances where surgery is indicated as the first line of treatment. Profound weakness in the foot is one of them. Abnormality of urinary function is another. “You don’t have the luxury of time,” Groff said. Not all low back conditions can be treated with MIS. If the deformity is too advanced or the pathology of the spine

Dr. Michael Groff, director, Neurosurgical Spine Service, Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital

“

Seventy to 80 percent of the people get better with physical therapy. You should see improvement in the first four weeks.” — Dr. Michael Groff too complicated, traditional open surgery is probably better. The goal of MIS is to “achieve the same surgical objective as open surgery with less trauma.” Groff ’s philosophy is to do the least possible for the most benefit. “Actually the surgery you don’t do is the best MIS,” he explained.

PHOTO: COURTESY BRIGHAM AND WOMEN’S HOSPITAL

IF YOU WANT TO GET DR. MICHAEL GROFF’S ATTENTION, YOU HAVE TO TELL HIM A STORY. You have to tell him all about

FOCUS: Low back pain

An alternative treatment Mindfulness: You control the pain AT FIRST GLANCE IT’S HARD TO SEE THE CONNECTION BETWEEN ONE’S MOOD AND THE LOWER BACK. The two are connect-

PHOTO: THINKSTOCKPHOTOS.COM/ISTOCK/MACTRUNK

ed, but which comes first? It’s a twoway street, according to Mayo Clinic. Depression can result in back pain, and back pain can lead to depression. What’s worse is that the two begin to battle it out. Low back pain can worsen symptoms of depression and the resulting depression then worsens LBP. Researchers at Sydney University studied clinical trials of almost 23,000 people who were diagnosed with clinical depression. Their study, which was published in Arthritis Care and Research, suggests that people who suffer from depression have a much greater chance of developing LBP in their lifetime in comparison to those without depression. Moreover, the more severe the depression, the greater the risk. Earlier studies had similar findings. Although the link is clear, the cause is not. However, if you line up the symptoms of chronic LBP and depression, the similarities become more apparent. In both conditions, sleep and concentration are impaired; people withdraw from regular activities; physical activity and exercise are not common. This is further evidence that the chemical pathways in the brain that impact depression control chronic pain as well. Time is a factor. “If you are depressed for a length of time, it can show up in your body,” explained Diana Freeland, a licensed clinical social worker at The Menninger Clinic. It’s a tricky situation when the chronic LBP comes first. The focus is so much on the pain, that the symptoms of depression can go undetected, both by the doctor as well as the patient. But major depression is thought to be four times greater in people with chronic back pain than in the general population.

There is a link between depression and chronic low back pain. Mindfulness has been found to be an effective pain management alternative.

Poorly treated or untreated depression has been shown to worsen LBP if it continues to go unrecognized. For better outcomes both conditions need to be treated at the same time. Treating clinically depressed people with chronic LBP is a challenge, particularly in light of the opioid epidemic. Doctors are encouraged to look at alternative therapies for treatment of pain. Two such therapies are cognitive behavioral therapy and mindfulness. CBT, a type of talk therapy, helps a person become aware of inaccurate or negative thinking so he or she can view challenging situations more clearly and respond to them in a more effective way. “It’s based on the premise that the way you think affects the way you feel,” explained Freeland. Another technique, mindfulness, is a mental state that is achieved by focusing on one's awareness in the present moment. It involves acknowledging and accepting everything around you, including your feelings, thoughts and bodily sensations. “It makes you be aware of

what’s going on around you and not only on the pain,” said Freeland. For instance, a person will be asked to tell everything that he or she is experiencing at the moment. In mindfulness, one acknowledges the pain, but then focuses on other things — the feel of the chair, a sound, a smell, your breathing. The purpose is to shift awareness to other things going on — and not just the pain. These two techniques are gaining in favor as effective therapeutic tools. A recent study published in JAMA found that among adults with chronic LBP, treatment with mindfulness or cognitive behavioral therapy resulted in greater improvement in back pain and functional limitations than did usual care, such as medications or exercises. The improvements persisted for a whole year. For some people with depression and chronic LBP pain, mindfulness is an appealing pain management option because it puts the person in control. Unlike pain medications or medical procedures, meditation is not done to you. It is something you can do for yourself. baystatebanner.com/news/be-healthy | Be Healthy 11

FOCUS: Low back pain

A common remedy for low back pain IT’S A LITTLE ODD THAT THE RELATIVELY NEW KID ON THE BLOCK IN MAINSTREAM MEDICINE IN THIS COUNTRY IS ACTUALLY 2,000 YEARS OLD. Acupuncture, a form of traditional Chinese medicine, is transitioning from alternative medicine to a staple in many U.S. clinics and medical practices. At the core of acupuncture is the belief that life force, or energy called qi (“chee”) flows through 14 basic pathways called meridians. “There are 300 points on the body connected by these meridians,” explained professor Bing Yang, chair of the Chinese Herbal Medicine Department at the New England School of Acupuncture, MCPHS University. “Stops along these meridians are connected with each other in a network of energy points.” When something goes amiss in the body it is believed that there is a blockage in qi that causes stagnation in the flow of energy. If the qi flows freely, there is no pain; if the qi is blocked, pain ensues. The purpose of acupuncture is to break up the blockage. Hair-thin needles are used to penetrate the skin in order to promote the flow of energy. The choice of size and length of the needle depends largely on body type and the extent of the disease, Yang explained. In addition, various techniques are applied to enhance results. For instance, in tonifying and dispersing techniques the needles are rotated and thrust differently. Moxibustion uses an herb called moxa to stimulate the flow of qi. The herb is burned close to, but not on, the insertion point. Patients feel a sense of warmth, but the smell of the moxa is not a fan favorite. 12 Be Healthy | Fall 2016

Cupping is a technique that uses suction cups for the desired effect. “Cupping is used for muscle pain,” Yang explained. It is believed that the blood has stagnated, and the cupping actually draws a small amount of blood, but in so doing, allows new blood circulation. It leaves its telltale mark, as noted on the back of Michael Phelps during the recent Olympics. Although acupuncture is associated more with relief of pain, it is actually used for several different ailments. The World Health Organization in 2004 developed a list of more than 40 conditions for which acupuncture can be used. The list might surprise you: Depression, Parkinson’s disease and even drug addiction are examples. Most common is low back pain, such as herniated discs and spinal stenosis. “Acupuncture helps with inflammation,” Yang explained. The theory behind acupuncture is that it stimulates the brain to release endorphins, the body’s natural pain-killing chemicals. It may also stimulate the production of serotonin, which controls mood. In other words, it stimulates the body to heal itself. Acupuncture is not boilerplate treatment. There is no established protocol, explained Yang. Although a patient

Bing Yang, MSTCM, Lic.Ac., Chair, Department of Chinese Herbal Medicine, New England School of Medicine, Massachusetts College of Pharmacy and Health Sciences

GET IN TOUCH To verify the licensure of an acupuncturist in Massachusetts, call the Commonwealth of Massachusetts Board of Registration in Medicine at 800-377-0550.

comes with a “Western” diagnosis, such as herniated disc, the treatment will vary by body type and symptoms. Generally, once the needles have been inserted, they stay in place for about a half hour. Often six to 10 sessions is considered one course of treatment. Yang readily accepts that not everyone will respond to acupuncture. Emotions may play a role. People suffering from depression take longer, as well as people who are over-thinkers. “In general, older and weaker people are slower to respond because it takes more time to improve the flow of qi,” she said. Also, those who continue to have chronic low back pain after surgery might not get the desired results in comparison to those who have not had surgery for the same condition. Acupuncture has its share of naysayers. But Yang is not buying it. Nor is the National Center for Complementary and Integrative Health. In a recent report published in Mayo Clinic Proceedings, randomized clinical trials found that acupuncture and yoga were effective for chronic low back pain. But the 14 million people who have used acupuncture already know that.

PHOTO: COURTESY BING YANG

Acupuncture: A 2,000-yearold treatment in modern times

FOCUS: Low back pain

Often a seemingly mild activity, such as carrying groceries, sets low back pain into motion.

The unruly spine A pinched nerve largely to blame ELIZABETH KENT, 51, HAD NO IDEA THAT AN ORDINARY TRIP TO THE GROCERY STORE WOULD SET INTO MOTION YEARS OF LOW BACK PAIN.

PHOTO: THINKSTOCKPHOTOS.COM/STOCKBYTE/JUPITERIMAGES

Kent (not her real name) experienced a sharp pain in the back while carrying her groceries up the stairs. That’s not unusual. A seemingly minor event can strike the final blow. “I got to the porch and couldn’t move,” she explained. That pain sent her to the emergency room. When x-rays did not detect the problem, the doctors assumed it was muscle strain and advised her to try a conservative treatment of both heat and cold. But the pain did not respond. A week later an MRI revealed a compression fracture in one of the bones of the spine. This sequence of events is common. Although roughly 700,000 people in the

U.S. are afflicted with such fractures each year, approximately two-thirds of the cases are not diagnosed and therefore not treated, according to Spine-Health. Compression fractures usually result from osteoporosis, or bone weakness, and can be quite painful. Kent eventually underwent an epidural steroid injection, a minimally invasive procedure that can relieve pain caused by inflammation of the spinal nerves. The injection, physical therapy and chiropractic services did the trick. Another flare-up four years later, however, resulted in another steroid injection. All was well until last year when Kent said she couldn’t get off her bed. “I had a sharp pain like never before,” she said. Another trip to the emergency room; another x-ray that revealed nothing. An MRI this time discovered a herniated

disc with the accompanying sciatica. “Pain was going down the back of my leg and in front of my foot,” Kent explained. The painkillers she was given helped, but not enough. Walking and standing were so painful Kent used a wheelchair for a period of time. Two additional spine injections alleviated the pain enough to enable her to transition to a walker and eventually walk on her own. Because of her long history of back pain Kent considered surgery, but she was told there were no guarantees. Some people get better, some don’t, the surgeon explained. Kent decided to stick with the non-surgical approach. With physical therapy she is learning exercises to strengthen her core and stretch her spine. More important are tidbits to prevent exacerbation of her pain, like good posture and safe lifting — little things she never paid attention to. Kent admitted she could not overlook stress as a player in her back pain. “I was a single mom,” she explained raising her daughter by herself. She was new to the country and lacked the support and comradery of family. Her job in accounting was demanding. She confessed that when the back pain erupted she lost interest in many things. “The only thing that put a smile on my face was my daughter,” she explained. Kent sees a psychologist to help her deal with the anxiety and stress of pain. She even confessed that she herself may be an accomplice in her back pain. She has gained a few pounds and weighs more than her five-foot-six-inch frame allows. Excessive weight is a risk factor for low back pain. Her next stop is to a nutritionist to help her shed a few pounds. Although pain continues to be part of her life, she can now control it better. The ibuprofen helps as do modifications of activities of daily living. She is careful to not sit too long; she props up a foot on a stool when standing to do the dishes; she sleeps with a pillow between her knees to help relax her back. She continues deep breathing and other relaxation techniques. “You need to slow down,” she said. “You don’t have to finish everything in one day.” baystatebanner.com/news/be-healthy | Be Healthy 13

FOCUS: Low back pain

Sciatica – a real pain in the butt A simple move can set it off THE SCIATIC PAIN THAT BOB MILLER’S DOCTOR SAID WOULD PROBABLY GO AWAY ON ITS OWN HAD OTHER IDEAS. IT DECIDED TO GO UP A NOTCH OR TWO THE NEXT MORNING.

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minimally invasive spinal surgery. Instead of a six-inch incision, the neurosurgeon could fix the problem through a two-inch opening. He was discharged home the same day. Although his surgery was more than two years ago, Miller said he is not at 100 percent and accepts that he probably never will be. “I have about 70 percent of the feeling in my leg,” he explained. His calf muscle, which is controlled by the sciatic nerve, is a little smaller than the one on the right. The sole of his foot is numb, which prevents him from walking barefoot. He can’t sit for long periods of time. Nor can he drive for more than two-anda-half hours in a stint. “I have to get up and walk around,” he said. If he doesn’t,

he will get low back pain. As the cofounder of Tidemark Corporation, a consulting firm, that can be a problem. He is often glued to his computer for hours on end or has to drive long distances to meet clients. Miller recognizes other changes. “I can’t run,” he explained. “The best I can do is shuffle.” Crossing busy streets then is a challenge. “Chances are I wouldn’t make the light,” he said. But Miller is not complaining. He can walk … but not too fast. He rides a bike with no problems at all. He walks on his treadmill and can use an elliptical exercise machine. He knows to lift with his legs and not with his back. “I do the best I can with what I’ve got,” he said. “I know what my limits are.”

PHOTO: COURTESY BOB MILLER

“I was getting out of bed the next day and made a quick turn,” Miller said. “I had the worst pain in my entire life. I couldn’t move.” The pain, which started in the buttocks, was accompanied by numbness and tingling down his entire left leg. No position offered comfort. The prescription pain medication helped calm it down. An MRI the next day pinpointed the problem. Miller had minor changes in the spine that occur in everyone beyond the age of 30. The culprit, though, was a protruding disc at L5/S1, a location at the lower end of the spine near the pelvis. A large percent of the problems of low back pain occur at this site, and with good reason. This area is subject to a large amount of stress and movement; it allows the torso to twist and bend in all directions. It bears the weight of the entire upper body. The disc was intruding in the sciatic nerve’s territory. And the nerve was pushing back. Because of his symptoms and the findings in the MRI, surgery was the only option. “This will not heal,” his doctor told him. “It will cause more damage.” Miller asked what caused the problem. A good question, but one that his and other doctors cannot always answer. It’s hard to identify the exact cause of pain in the back. His doctor theorized that the problem has been long in the making perhaps from a fall or other trauma years ago. It just took several years for it to finally materialize. Fortunately, Miller was eligible for

Bob Miller, the co-founder of Tidemark Corporation, had a herniated disc several years ago. It was successfully treated through minimally invasive surgery.

FOCUS: Low back pain

Get up and walk Prevention of low back pain IT’S BAD ENOUGH THAT YOU WILL PROBABLY GET LOW BACK PAIN AT SOME POINT IN YOUR LIFE. But to make matters worse, up to 50 percent of those afflicted will suffer a recurrence within a year. The odds are against you, but all is not lost. It may be possible to reduce the risk of recurrence or even that first bout of low back pain. It’s impossible to turn back the clock. Age is indeed a significant risk factor for LBP. The bones, joints and discs of the spine begin to wear. Regardless, the same oft repeated mantra to reduce the risk of cancer, diabetes and heart disease applies to low back pain as well: exercise, maintain a healthy weight, follow a healthy eating plan and do not smoke.

Exercise Exercise is essential to preventing low back pain. A recent study published in JAMA Internal Medicine analyzed the results of clinical trials including almost 31,000 participants. The findings suggest that exercise alone or in combination with education on the benefit of exercise is effective in preventing LBP. Most people automatically think of the abdominal muscles, or “abs” to strengthen the torso, more familiarly called the core. Indeed the abs are important. They help pull you out of bed each morning, but they’re a part of a group of muscles — many of them hidden — that work together for core strength. Actually, aerobic exercises, like walking and swimming are great core exercises that provide a high benefit but low risk. At first glance it may seem that the legs are doing all the work, but in fact the core is doing its job. The core muscles are stabilizers and work in unison to keep you erect. If the muscles are not working, you wouldn’t even be standing, let alone walking. Exercises like planks that stabilize the torso, are recommended to increase core strength. Yoga and tai chi improve posture, balance and body alignment as well as strength.

Keep a healthy weight PHOTO: ERNESTO ARROYO

Too much weight can do its share of damage to the spine. It stresses not only the back muscles but also the bones and joints. Distribution of the weight is a factor as well. Beer bellies put an unusually high stress on the back, which can result in an increased lower back curvature. According to the American

Tai chi, a gentle exercise that can improve posture, balance and strength, is recommended for core strength. Master Heg Robinson practices and teaches tai chi out of his academy in Roxbury. baystatebanner.com/news/be-healthy | Be Healthy 15

FOCUS: Low back pain Obesity Association, women who are obese or who have a large waist size are particularly at risk for low back pain. Normal waist size for women is 35 inches or less, 40 inches or less for men. A normal body mass index, or BMI, ranges from 18.5 to 24.9. The BMI is not perfect. It cannot distinguish between muscle and fat and can push a muscular person into the “overweight” category. Calculate your BMI using the following formula: BMI = Weight in pounds / (Height in inches x Height in inches) x 703 Healthy eating — a diet rich in whole foods, such as veggies, fruits and whole grains — goes hand-in-hand with a healthy weight.

every organ in the body, according to the American Cancer Society. It also increases the risk of LBP. A study published in the Annals of Rheumatic Diseases found that smoking, regardless of lifestyle, jobs and activity levels, increased the risk of back pain by roughly 30 percent. It is unclear how smoke affects the spine. Some researchers suggest that nicotine from tobacco might influence how the brain processes awareness of pain. Another theory is that smoking reduces the flow of nutrients to the joints and muscles of the back.

Use proper body mechanics

The spine is very strong but works more efficiently when the parts are in alignment. That’s why slouching and other forms of poor posture place undue stress Don’t smoke on the spine. For instance, a study by Here’s another good reason not to Dr. Kenneth Hansraj, a New York back smoke. Roughly 90 percent of all cases surgeon, found that looking down at a of lung cancer are linked to smoking or cell phone is the equivalent of placing a second-hand smoke. But cigarettes do a 11:23:26 AM60-pound weight on one’s neck. lynette_banner_ad_SRN_final.pdf 1 9/7/2016 lot more damage. Smoking harms nearly Improper lifting causes even more

CMY

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TIPS FOR SAFE LIFTING n Stand as close to the load as possible. n Bend at the knees, not at the waist. Let your thigh muscles do the work. They can take the weight. n Hold the load close to your body, not at a distance. n Stand up using your thigh muscles dramatic changes in the lower spine. It’s all about physics. When you lift an object the lower spine must bear the weight of the upper body as well as the weight of the object. If you lean forward when lifting you are not only changing the back’s alignment, you are moving the center of balance of the body forward. This action can exert tremendous force on the back, particularly if the object is heavy. If you have good general health and follow these suggestions to take care of your back, you may be one of the 20 percent that manages to go through life without a painful low back.

Healthy Steps Eat right, stay active, live well » Nutrition 18 » Recipe 20 » Exercise 21

Yoga: A recipe for a sound back

PHOTO: THINKSTOCKPHOTOS.COM/STOCKBYTE/JUPITERIMAGES

In a recent study sponsored by the National Center for Complementary and Integrative Health, yoga and acupuncture were found to be effective tools for helping to manage back pain. Hatha Yoga, which involves gentle movements, breathing and relaxation, is recommended for people with low back pain. baystatebanner.com/news/be-healthy | Be Healthy 17

HEALTHY STEPS: Nutrition

BY: KATHY

CUNNINGHAM M.ED., R.D., L.D.

A healthy diet … a healthy back What’s on your plate might make a difference IF HEALTHY EATING COULD COMPLETELY STAVE OFF LOW BACK PAIN, THE SHELVES OF GROCERY STORES WOULD BE BARE. Surely people would trade that stabbing back pain for an apple any day. Although healthy foods are not a cure-all, a diet rich in fruits and vegetables, whole grains and unsaturated fats very much like the Mediterranean diet can certainly help. These foods contain vitamins and minerals for strong bones and muscles and nutrients to reduce inflammation. When a back injury occurs — a pulled muscle, for example — the injured cells become bruised and begin to swell. In response, the body sends vitamins, minerals, protein and fluids to the area to support healing. If your body is adequately nourished, these healing factors will reduce damage. When your body is low on certain nutrients, however, the healing process takes longer, and the pain persists. A wholesome diet also helps prevent weight gain. Excessive weight unnecessarily taxes the spine. Food therefore should be part of therapy to manage pain.

Helpful tips To relieve back pain and perhaps even avoid the need for medications or invasive procedure, here are several healthy eating tips you can use. Drink water! We need water — and lots of it — to maintain good health. 18 Be Healthy | Fall 2016

Dehydration weakens and stresses the body, including the back. The discs between the vertebrae of the spine are composed mostly of water and must be well hydrated to maintain strength and flexibility. Water also lubricates the joints in the back to keep us nimble. Although the daily recommended amount of water varies by the individual, the Institute of Medicine determined that an adequate intake of total beverages a day is roughly 13 cups for men and nine cups for women. We take in fluids from foods, coffee, tea and other beverages; however, plain old water hydrates more efficiently and may actually relieve pain. Reduce inflammation! Where there’s pain, there’s inflammation, the body’s response to injury. Some inflammation you can see. The area becomes red, swollen and tender. Inflammation can occur inside the body as well and is linked to serious health conditions, such

as heart disease, cancer, diabetes and even back pain. Some foods facilitate inflammation, while others suppress it. Choice of foods therefore is critical to relieving pain. Polyphenols are nutrients that are particularly effective against inflammation. Polyphenols are antioxidants, or chemicals that fend off free radicals, which are reactive atoms that contribute to tissue damage in the body. This damage sets the stage for inflammation. Food sources for polyphenols are dark color fruits and vegetables, especially cherries, berries and pomegranates. Often 100 percent unsweetened juice of these fruits is the easiest way to get a good dose. Green tea, coffee, dark chocolate, olives and extra virgin olive oil provide moderate amounts of the nutrient, as do herbs and spices such as curry and turmeric. Another antioxidant called resveratrol found in wine, grapes and grape juice can have an analgesic effect similar to aspirin, according to a handful of preliminary studies. If you treat yourself to a glass of wine for pain relief, keep in mind that more is not better. Experts recommend no more than five ounces a day for

HEALTHY STEPS: Nutrition

Grapes contain an antioxidant called resveratrol, which can have an analgesic effect similar to aspirin.

women and 10 ounces a day for men. Conversely, foods that stimulate inflammation should be limited. Examples are added sugars, like sugar-sweetened beverages, processed meats, such as bacon and sausage, artificial food additives and foods that have trans fat. Cakes, cookies and fried fast foods are good examples. Commercially-raised as opposed to grass-fed red meat and some common cooking oils — grape, cottonseed, corn and sunflower oils, for example — have a high content of omega-6 fatty acids. Although crucial for normal growth and development, omega-6 fats tend to promote inflammation. Foods that stimulate the production of inflammation contain compounds that create acidity. Recent studies show that chronic, low-grade acidity creates inflammation throughout the body, which can lead to decreased muscle mass, osteoporosis and kidney stones, all of which are potential sources of back pain.

Increase omega-3 and Vitamin D! It’s a stretch to see the link between

PHOTO: THINKSTOCKPHOTOS.COM/DIGITALVISION/ ALEXANDRA GRABLEWSKI

salmon and cheese. But if the dairy animals have been grass-fed rather than grain-fed, the connection is stronger than one might think. Both are rich in pain-relieving omega-3 fats and vitamin D. Unlike omega-6 fats, omega-3 fats suppress rather than promote inflammation. Unfortunately, the typical American diet tends to contain 14 to 25 times more omega-6 than omega-3 fatty acids. In addition, a large percentage of the U.S. population — particularly African Americans — is deficient in vitamin D. Yet there's a strong link between low levels of vitamin D and chronic pain. Research suggests that supplementing your diet with vitamin D may not only increase bone strength, it may help ease discomfort.

A natural approach The good news is that low back pain can often be managed without the benefit of over-the-counter and prescription drugs. It just takes a bit more work. If you drink plenty of water, eat a variety of foods that reduce inflammation and exercise regularly, as recommended by your healthcare provider, you might be able to fend off or manage low back pain naturally. baystatebanner.com/news/be-healthy | Be Healthy 19

HEALTHY STEPS: Recipe

Veggie chili INGREDIENTS

n 1 (14½-oz.) can no-salt-added

n 1 tbsp. olive or canola oil n ½ large onion, chopped n 1 medium red bell pepper, chopped n 1 garlic clove, finely chopped n 1 jalapeño pepper, seeded,

n 1½ tbsp. tomato paste n 1 cup water n 2 (15-oz.) cans black beans,

deribbed, and minced

n 1 tbsp. ground chili powder n 1½ tsp. ground cumin n 1½ tsp. dried oregano

DIRECTIONS Heat oil in large saucepan. Add onions, bell pepper, garlic and jalapeño pepper and cook until onion is translucent, about 5 minutes. Add chili powder, cumin and oregano and cook, stirring, for 1 minute.

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diced tomatoes in juice

rinsed and drained n ½ tsp. salt n Fresh cilantro, chopped, for garnish n Chopped scallions, for garnish n Reduced-fat sour cream, for garnish (optional) Add canned tomatoes, tomato paste and 1 cup water, then beans and salt. Bring to boil, reduce heat and simmer, uncovered, for 30 minutes. Serve garnished with chopped cilantro, scallions and a dollop of sour cream, if desired.

* Makes 4 servings (5 cups)

A HEALTHY WEIGHT CAN REDUCE THE RISK OF LOW BACK PAIN. It puts less stress on the bones and muscles of the spine. Foods high in protein and fiber are not only filling, they keep you feeling full longer. Each serving of this recipe has 11 grams of protein and 12 grams of fiber and only 214 calories.

Source: American Institute for Cancer Research

NUTRITIONAL ANALYSIS (PER SERVING): n Calories: 214 n Total fat: 5 g n S aturated fat: < 1 g n C arbohydrate: 35 g n Protein: 11 g n Fiber: 12 g n S odium: 367 mg

HEALTHY STEPS: Exercise

Exercise for low back pain It’s all about the core WHEN A PERSON HAS ACUTE LOW BACK PAIN, EXERCISE IS NOT HIGH ON THE LIST OF THINGS TO DO. The bed is so much

PHOTO: COURTESY BRIGHAM AND WOMEN’S HOSPITAL

more enticing. But health professionals warn against bed rest for acute LBP. One day perhaps, two at most. Bed rest weakens muscles, which actually can aggravate the situation. While many bouts of LBP can be resolved with over-the-counter painkillers, cold compresses or heat, some cases just stubbornly persevere. According to Mayo Clinic, if the pain persists for about a week or gets worse, professional help is needed. Most often that help comes in the form of physical therapy … and exercise. The challenge is figuring out the source of the pain, according to Dr. Clare E. Safran-Norton, a clinical supervisor and physical therapist in the Department of Rehabilitation Services at Brigham and Women’s Hospital. “Is the pain originating from the back, hip or sacroiliac joint (point where the base of the spine connects to the pelvis)?” she asks. If the person has sciatica, it may be associated with a disc that is bulging or ruptured. If the culprit is spinal stenosis, a narrowing of the space that houses the spinal cord, the person may feel more pain when walking. The source of the pain is key, as it dictates the treatment. For instance, a herniated disc benefits from exercises that extend the spine backwards, according to Safran-Norton, while exercises that bend the spine forward help relieve the pain of spinal stenosis. Although exercise for LBP is not cookie-cutter, the goal is the same. “We want to ultimately restore the level of function,” she said. “We hope to reduce pain and restore strength, range of motion and basic

“

We hope to reduce pain and restore strength, range of motion and basic activities of daily living.” — Dr. Clare E. Safran-Norton

Clare E. Safran-Norton, P.T., Ph.D, OCS Clinical Supervisor, Rehabilitation Services, Brigham and Women’s Hospital

activities of daily living.” The treatment is comprehensive, and can include manipulation of the spine, soft tissue mobilization and exercise. Education on proper posture and good body mechanics is pivotal to prevent a recurrence. A typical treatment plan is one to two sessions per week for about six weeks. While the majority of cases of LBP can be relieved by physical therapy, some require another level of care. There are telltale signs, such as a functional loss of strength that can result in a foot drop or severe pain or loss of urine when a person sneezes or coughs. In these cases, surgery may be indicated and the patient should consult his or her doctor right away. Physical therapy and exercises can resume following the surgery. Physical therapy is one of the most effective treatments to improve LBP. In a recent Gallup study, one in four adults had sought care for significant neck or back pain in

the past 12 months. Forty-one percent of the respondents indicated that physical therapy was very effective in relieving the symptoms of LBP in comparison to only 15 percent who received surgery.

Work out before your back goes out LBP should not be the only reason to start an exercise program. Actually, if you exercise regularly using good form, you might be able to ward off an episode of LBP altogether. It’s all about the core. That’s more than just the abdominals, or “abs” for short. Of course abs, which bend the spine forward, are principal players of the core, but they often don’t act alone. Rather, the core is a group of muscles that surround your torso like a sheath. The muscles actually prefer to work in a group instead of singly. They contract together to help stabilize the spine. They keep you upright. Most people engage in aerobic activities to improve the cardiovascular baystatebanner.com/news/be-healthy | Be Healthy 21

HEALTHY STEPS: Exercise

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PLANKS The plank is a simple but effective exercise to strengthen the core. Although there are many variations of the plank, the general purpose is to hold the torso in a straight line, which enables all the core muscles to work together.

Straight arm plank In the straight arm variation, the weight is on the hands similar to the position for a push-up. n Begin on your hands and knees with your hands underneath your shoulders. n Raise yourself onto your toes and

straighten legs. Keep your body straight from head to toes. n Hold for at least 10 seconds. n Return to the starting position. n Repeat five times. As strength improves increase the number of reps.

Side plank The side plank is more challenging. It brings in the muscles on the side of the torso that might not get as strong a workout in other plank positions. n Lie on your side. n Raise yourself onto your forearm making sure your shoulder is directly above your elbow. n Keep your shoulders, hips and knees in a straight line. n Hold for at least 10 seconds. n Return to the starting position.

n Repeat on the other side. n Repeat five times. As strength improves increase the number of reps. For an added challenge, extend both arms while holding the plank.

PHOTOS: YAWU MILLER

system. Activities like walking and bicycling get the heart pumping, but are working the core as well. With every step the core keeps you standing and moving. Although sit-ups and crunches to increase core strength are the mainstay in many fitness centers, Safran-Norton is not a big fan of either. She is not alone. These exercises have fallen out of favor, according to HEALTHbeat from the Harvard Medical School. Sit-ups are hard on the back and work the hip flexors as well as the abs, which really might have the opposite impact than intended. Tight or overly strong hip flexors pull on the lower spine and increase its normal curvature, which can result in LBP. “They can be harmful if you have a herniated disc,” Safran-Norton explained. Contrary to common belief, it is possible to have a herniated disc without pain. Pain ensues if there is pressure on the sciatic nerve. Crunches, especially if done incorrectly, just might give the nudge to painful sciatica. Instead she is a fan of planks, and side planks at that. In exercise you prefer a simple movement that provides the greatest benefit. That’s a good description of planks. In these exercises you hold your trunk off the floor in a straight line. There are many variations of the plank. In a forearm plank the forearms remain on the ground while holding your core off the ground in a straight line from head to feet. In the straight-arm variation, the weight is on the hands similar to the position for a push-up. You can also perform planks on your knees if being on your toes is too difficult at first try. While all planks strengthen the core, side planks tend to bring in the muscles on the side of the torso that might not get as strong a workout in other plank positions. There are several benefits of planks. They don’t require equipment or much space. They actually provide a full body workout, since they work your shoulders and hips as well as your core. They can also improve balance and posture. Generally, you hold a plank for 20 to 30 seconds, and repeat three to five times. Increase the hold time and reps as you improve, up to two minutes. Although exercise is critical for core strength, it goes hand-in-hand with a healthy diet, weight control and not smoking for overall good health.

HEALTHY STEPS: Exercise

THE SUPERMAN The superman exercise can help strengthen the low back. n Lie on your stomach. n Raise an arm off the floor. n Hold for at least 10 seconds. n Return to the starting position. n Repeat with the other arm and each leg. For a greater challenge, lift both arms at both legs at the same time.

THE BRIDGE

PHOTOS: YAWU MILLER

Improves the strength of core muscles and hip muscles (glutes) n Lie on your back with your knees bent. n Raise your hips off the floor until your hips are aligned with your knees and shoulders. Hold for at least 10 seconds. n Return to the starting position. n Repeat five times. As strength improves increase the number of reps. Model: Brandy Cruthird of Body by Brandy, is the acting Health and Wellness director of the Roxbury YMCA. baystatebanner.com/news/be-healthy | Be Healthy 23

One of the nation’s leading spine teams is now at Brigham and Women’s Faulkner Hospital. We’ll get you back in swing. Brigham and Women’s orthopedic and neurosurgery programs, ranked among the nation’s best by U.S. News & World Report, are also based at Brigham and Women’s Faulkner Hospital in Jamaica Plain. You’ll see the same experts providing the same exceptional care in a very convenient location. Spine specialists, as well as physicians from neurology, physiatry and pain management, work together to offer the best back pain solution. If surgery is needed, we have new operating suites, and a new inpatient center with all private rooms. We’ll get you back on course. To request an appointment, call 617-983-7500, or visit brighamandwomensfaulkner.org.