BACK PAIN, MEDICATIONS, AND SIDE EFFECTS

There is no such thing as medication side effects; there are only effects, some of which are desired, some of which are undesired. Medications are almost always processed centrally, especially oral medications. They affect the blood stream, brain, kidneys, liver. Common medications for back pain are no exception. Anti-inflammatories don't simply affect inflammation; that's merely their targeted purpose. Muscle relaxants don't simply affect muscles, they relax everything - often making you tired, slowing your thoughts, and decreasing anxiety. Opioids (narcotics) have a wide range of effects only one of which is pain relief. They also make you sleepy, decrease diarrhea, relax muscles, decrease anxiety, and provide a great "buzz" when taken recreationally. Which effect (s) are you going for? The vast majority of meds have generalized effects which vary between patients based on hundreds of physical factors including: sex, age, race, weight, body fat, health problems, and metabolism. In a particular patient, physical effects can depend on: dose, blood serum level, tolerance, food consumption, water consumption, sleep, exercise, etc. Psychological factors can powerfully alter medication effects between and within patients including: anxiety, depression, expectation, body preoccupation, obsessiveness, compulsiveness, etc. Patients who have a history of reported intolerance to most medications tend to be anxious, hypersensitive to bodily changes, and strongly obsessive-compulsive. The desired efffects of medications for back pain must continually be measured against the undesired effects. Only you can do this; it's your body. But remember, it can take one to four weeks for some undesired effects to diminish or go away. With pain related medical problems, the goal is to increase your function, activity, and independence. If a medication for back pain makes you less functional, e.g., unable to drive, that medication or dose is a failure - period. You shouldn't be taking it. Don't tell your doctors you are allergic to most or all medicines unless you have frequent, specific allergic reactions, which involve an immune response with a surge of immunoglobulin and generalized histamine. Classic signs of allergic reaction are itchiness, rash, rapid heart rate, sense of heat, and shortness of breath. Other reactions are undesired but not allergic.

BACK PAIN, HOLIDAYS, AND THE GREATEST GIFT

Merry Christmas everyone! I love the holidays! People reach out to others and hold hands. I get a renewed sense that we're all in this together. I give myself permission to focus less on loss, and stress, and failure, and more on all the blessings I do have. I feel more connected to everything the last two weeks in December.


The greatest gift you can give your family this holiday season is to function at your best throughout each day. Your family and friends want your time, your conversation, your good spirits. Faking it is absolutely just as good as the real thing. They're not as observant as you think. Faking it means less pain behavior, defined as all the things you do verbally, facially, and behaviorally that communicate to others that you hurt. This includes moaning, groaning, wincing, limping, taking meds, complaining, being grouchy, etc. This holiday season, make every effort to minimize these behaviors, especially in front of other people. It will help if you vigorously pace yourself and set limits with activities that can increase your pain. Sit some, stand some, lie down some, move around some. Alternate frequently, every 15-30 minutes. Don't use pain meds to overdo; you will pay for it later and so will your family. The more you overdo, the more pain behvior you will engage in and the more likely you are to crash. Your family and friends don't need you to cook for 20 people; don't need a hundred presents; don't need lights everywhere; don't need everything to be perfect. So you can't play football, or fill the house with baked goods. So what?

You may need to lower your expectations for the holidays - de-emphasize the fantasy holidays you see in books, on television, or maybe had or wanted as a kid. Finances are tight for most of us. Major gifts and good health can be hard to come by. Some element of your holiday will be weird and surreal. Holidays can powerfully drive you to be miserable. Get over it. Life is happening all around you. Cut to the chase, to what's important - let go of "It's not fair" or "They deserve more." Perhaps more than any other time, from the third week in December to the beginning of the new year is a time of rebirth, of re-commitment, of making plans. On this day, in this year, just enjoy what your have.

On Christmas Eve, my small family had dinner and watched "White Christmas" and "The Santa Clause." Today, we will open some gifts and spend the day in front of the fire place playing Scrabble, drinking hot cocoa, and talking to each other. Nothing big, nothing impressive. Just our small little family; just like my daughter wants it. Me too.

As part of your blessing today, you might think about our soldiers in Iraq; so far from home, so scared, and wanting nothing more than what you have right now. Say a prayer for them.

Be good to yourself.




Dr. Tim

BACK PAIN, HOLIDAYS, AND COPING

The holiday season is a special challenge when you hurt. Holidays can be difficult anyway as the fantasy and the reality clang together. The fantasy - loving family, tender moments, grateful appreciation for hard work and thoughtfulness, petty differences put aside, people coming together united in family or friendship. The reality – hurt feelings, lack of appreciation, petty differences on display. Worse yet, too much stress, too much alcohol, too many demands, too little money, old wounds surfacing; the pain of recognizing the difference between the Hallmark holiday and your dysfunctional family.

One way or another, holidays are immediately stressful times. Increased physical demands, i.e., house cleaning, cooking, grocery shopping, traveling, etc will increase pain. The emotional and mental aspects of holidays can also increase pain. It is taxing to gear up emotionally to socialize with family and friends and be charming even if you are the one being fed and watered. Difficult interactions, avoiding landmine topics of conversation, dealing with toxic relatives, discussing your medical condition, etc. can all increase pain.

The holiday season is almost inevitably a time for some reflection, looking back at the past year and forward to the next. It is natural to become aware of all the difficult, painful, challenging aspects of your life. When you hurt all time, this reflection can either cause the holiday blues or worsen depression, especially if you compare how you wish things were with the way they are. When you hurt you may find your self focusing on the negative until it seems all there is.

What can you do to help yourself survive and even enjoy the holidays? I have developed a list below to help you get the most of this holiday season.

1) Recognize that your life has changed. You have persistent pain along with your own unique sequella – impaired finances, troubled relationships, etc. Acknowledge that change and organize yourself around that reality. You may need to grieve the losses associated with these changes.
2) Lower your expectations for the holidays. Don’t expect to or commit to creating a magical time for yourself and others. Lower your family’s expectations for the holidays by discussing necessary changes in advance. Don’t let “tradition” trap you into unhealthy behavior. Grieve this loss if need be.
3) Don’t try to accomplish everything you did before you had pain. Respect your challenges. Give yourself permission to do less if need be.
4) Be creative about pacing yourself and setting limits with activity. Make the holiday meal potluck. Agree to exchange a single gift with family members or family units with a price limit. Enlist the help of someone with meal preparation or household chores.
5) Consider focusing on or a return to a traditional (old fashioned) holiday in terms of gifts, trees, family visits, etc. This allows you to focus more on family and friends and less on material stuff.
6) Give a gift (s) to the less fortunate. Donate to a needy family, give something to your church or temple. Donate some time to a mission. Volunteer at hospital or nursing home. The saddest thing over the holidays is to feel lonely. Help someone else not be lonely, and in the process, help yourself.
7) Make a deliberate attempt to count your blessings. Focus on the good things in your life. Each day, post one positive thing you are thankful for.
8) Reconcile with an estranged friend or relative.
9) Make a commitment to changing certain behaviors in the coming year. Set specific
goals for yourself. Forgive yourself or another person for a transgression. Accept what happened and let go the pain. The APEX strategy for forgiving can help.

Back Pain, Blessings, and Liberty

This is a blog about back pain, but people with back pain are people first, patients second. There will always be issues and events that transcend and envelop people and patients everywhere. This post is from a newsletter I have sent out each holiday season since 2002.

Death is not a tragedy. A wasted life is. Don’t get me wrong. Life has value all by itself. This isn’t about abortion, capital punishment, stem cell research, or vegetarianism. From single cell bacteria to your own children, life has value. It means something. It wants to keep on living, even if it hurts. It gets one chance to participate in the circle; one chance to shout at the moon and echo through the ages.
Though we are born with value, we give life real meaning and purpose by the way we live. At the end, we get to look back and see where and how we made a difference. Erik Erikson labeled the final stage of life maturation "ego integrity vs. despair". We need to believe that we did some good; that we accomplished something meaningful, perhaps even more important than our own lives--something that will transcend our deaths and mark our place in the universe; or we feel an existential despair from which we cannot return. For people like Einstein or Bill Gates, this is easy. For the rest of us, it’s a little more subtle.
I don’t know that I am a Christian, a Muslim, or a Jew. I attend a Presbyterian church a half dozen times a year. But I always attend at Easter and Christmas. There is something enriching, universal, and powerful about the cycle of birth and death along with the primitive, archetypal belief that in some way we can transcend death. I believe that life has transcendent meaning when there is something more important than death, and by extension our own lives.
And so we come to Iraq. It matters not what you think of the war in Iraq. I think it’s a horribly misguided enterprise driven by the “war on terror” and a president who looked America in the eye and lied to us, not the first or the last to do so. George Bush will end up just a blip in American History, but not so for our armed forces. They transcend Tweedle Dum. The red, white, and blue of the American flag doesn’t simply stand for freedom, but the willingness to fight for freedom, to die for freedom, so our children’s, children’s children will have the opportunity for life, liberty, and a fair chance at happiness. The armed forces stand proud and resolute as perfect symbols of the strength in freedom, democracy, and individual rights.
What the armed forces do is at the pleasure of the current president, the commander-in-chief. But their underlying purpose is forever. Whether in the glorious rightness of World War’s I and II or the mire of moral paralysis that was Vietnam, the armed forces embody the best in all of us; honor, fidelity, commitment to a just cause, and true bravery defined as “integrity in action.” They make their lives and so their deaths meaningful. They live a principle and by a code that transcends the petty machinations of politicians, so that we can make our dreams real.
This holiday season, as with all others, we will spend some time reflecting on our lives, making plans for the coming year, and maybe getting back in touch with what’s really important, things like health and family. You can look back on the blur of the past year and wonder how it passed so quickly. You can think about your core values and whether or not you’re living up to them. Therein lies one path to meaning and purpose; having the integrity to live in accordance with moral beliefs.
America’s strength and national integrity survives in and through our armed forces. They have an absolute code of honor, and by God and country they live in accordance. From Corporal Roberto Abad to Private First Class Casey Zylman there are 3897 heroes who must now live on in our memories. Sometime this holiday, during one of our toasts, let’s honor the men and women who will never again be home with their families as well as those who will. Please go to www.cnn.com/specials/2007/iraq/forces/casualties and maybe toast one particular hero by name. You might also donate a prepaid phone card so that a soldier can call home.
Corporal Abad stood on a wall in the dark and cold beside a fallen comrade and said “I won’t let them hurt you. Not tonight. Not on my watch. You can sleep safe, now. All secure sir.”
God bless America and God bless our Armed forces. May their holidays and yours be safe and warm.

Dr. Tim

The Number One Cause of Back Pain

People with back pain often spend years in a wasted search for the "true" diagnosis of their back pain, usually in the belief that once discovered, an "accurate" diagnosis will lead to cure. The years go by and they rail at the incompetence of doctors who can't give them a diagnosis or simply add another to the growing list. Degenerative disc disease, spinal stenosis, bulging disc, herniated disc, foraminal narrowing, facet arthropathy, spondylosis, spondylolisthesis, compressed nerve root, arachnoiditis, arthritis, myofascial pain, radiculopathy, and scoliosis are just a few of the diagoses you may be given. But the reality is that the longer you have experienced back pain, the less likely that there is one overarching diagnosis. Your pain is almost inevitably "multifactoral", i.e., there are multiple factors causing, maintaining, and exacerbating your pain. Effective treatment requires attacking all the various factors contributing to your pain. From a tissue perspective, pain triggers can come from muscles, discs, nerves, tendons and ligaments, joints, bone, or scar tissue. The inflammatory process is a major culprit in maintaining back pain. Even your immune system can be a pain trigger. Another complicating factor is that as time passes, your pain triggers morph, with some disappearing, some appearing, and others waxing or waning in intensity. Back pain is an erratically but constantly moving target. Thus, there is a tremendous amount of trial and error with medical treatments and medications. Today's effective treatment may not work tomorrow and vice versa. This can be frustrating, but is as it should be. Don't shoot the messenger, whether it's me, your pain doc, or an ancillary provider.

BACK PAIN, LUMBAR FUSION, AND COGNITIVE BEHAVIORAL TREATMENT

A recent study in the Journal of Pain (122, 2006, pp 145-155) compared the effectiveness of lumbar fusion with a course of cognitive education and exercise in patients who had undergone previous, less invasive surgeries (failed back). This was a prospective study with sixty patients cleared for fusion surgery, randomized either to lumbar fusion or cognitive education and exercise. One year post treatment, there was no statistical difference between fusion and cognitive/exercise groups in the primary outcome of back specific pain and disability as measured by their score on the Oswestry Disability Index. The success rate was 50% in the fusion group and 48% in the cognitive/exercise group. Specific secondary measures at one year were also assessed including mean pain severity, general function, emotional distress, fear avoidance, work status, and fingertip to floor distance. There was no significant difference between groups except that the cognitive education and exercise group had less fear avoidance and greater fingertip to floor distance. The authors concluded there was no evidence of greater benefit from lumbar fusion following a failed back surgery over cognitive education and exercise. This is an extraordinary finding for those people with failed back surgery who are considering lumbar fusion, especially given the risks of fusion and the grueling post op period. There are situations where lumbar fusion after failed back surgery is medically necessary, but the authors express great concern about the high rate of unnecessary fusions after back surgery.