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1. If I have a herniated disc, won't I need surgery?

herniatedA herniated disc is not a catastrophe. Annoying, certainly, but a condition with a favorable natural history. Many people feel that this is a serious injury that always needs an operation. In fact, over 90% of people who herniate a disc go on to uneventful recoveries without surgery and do quite well. A famous study done in 1983 compared patients with surgically treated herniated discs with similar patients treated non-operatively (Reference 1). The study found that at the 5 and 10 year point there was no difference in the results between those treated surgically and those treated conservatively. The American Academy of Orthopedic Surgeons considers a herniated disc to be a 12 week syndrome and recommends at least 3-6 months of conservative care prior to surgery. Click HERE to see how PNBC treats disc herniations.

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2. I've talked to surgeons, therapists, chiropractors, and family members with bad backs. Everyone tells me something different. Who's right and who's wrong?

womanlowerbackpainBack pain is rather unique. There is very little consensus about the proper treatment for chronic problems. If you break your ankle it doesn't matter much where you are treated. You are likely to get the same advice regardless. Not so with back pain. Every provider seems to have a different spin. The chiropractor may say you are out of alignment and need manipulation. The surgeon may say you have a degenerative disc and may need surgery. The pain clinic physician may suggest injections, and a therapist may have a different recommendation.

The dirty little secret is this: most of the time we "professionals" cannot be certain about the cause of back pain. According to experts, we can only determine the precise cause of back pain about 15% of the time (e.g.,a disc herniation pushing on a nerve causing leg pain). But we all have opinions and most providers are not shy about sharing them. Some day the mystery of back pain will be solved but for now we often have to live with some uncertainty (see reference "What Causes Low Back Pain").

At PNBC we view the issue a bit differently. We make sure you don't have a catastrophic condition (tumor, infection, new fracture, gastric ulcer mimicking back pain, etc.) but then we ask a different question. What can be done to improve your pain and function, regardless of the underlying condition? Our studies have shown (see outcome data) that aggressive reconditioning is effective for many different spinal conditions. We therefore concentrate on strengthening your weak link so you can get back on the road to healthy activity.

To see what the New England Journal of Medicine says about this topic click here.

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3. I just had a lumbar laminectomy a month ago. Is it safe for me to engage in rehab?

Post-surgical patients are well served by rehab but must be careful not to disrupt the surgical repair. For a simple laminectomy/discectomy the soft tissues are usually well healed and able to withstand maximum work-outs after 8 weeks. Until that point patients are placed in our sub-maximal program. Proper exercise during the post operative period, while the soft tissues are still healing, can influence the way in which the collagen is laid down. Collagen tends to line up along the lines of force and if the force is applied in a controlled manner the collagen that is laid down is more biomechanically sound. Usually, a strong back will help to protect against recurrent problems after your surgery..

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4. How is working on my back going to make the tingling in my foot go away?

feetExtremity pain associated with a back injury is either radicular (due to a "pinched nerve") or referred. Radicular symptoms are those that are associated with neurologic deficits (e.g., weakness, sensory disturbance, loss of reflex) and usually involve a sharp band of pain radiating all the way down to the foot or arm (for neck problems). Usually only one leg or one arm will be involved.

Referred pain can be caused by injuries to ligaments or disc fibers and tends to be patchy and vague or aching. Most of the time it will not be associated with any neurologic deficit. It may involve both legs or both arms and oftentimes will only go down to the knee or the elbow. To better understand the concept of referred pain consider a patient experiencing a heart attack. These patients will often feel severe pain in their left arm or jaw; but there is nothing wrong with the arm or jaw; the problem is in the heart. Why doesn't the patient have pain in the heart? What happens is complex but essentially the pain signals get mixed up and the brain interpets the signals as arm or jaw pain even though the problem is the heart. A similar pattern can occur with the spine but the referral pattern for the low back is into the buttock and into the legs and the referral pattern for the neck is into the trapezius muscles and into the arms.

The key point is this: even though your leg or arm may be painful, the problem is in the back or neck. Therefore the treatment must be directed at the source. When the source improves, the extremity pain also usually improves. One of our published studies (Reference 5) showed that the majority of patients with leg symptoms showed significant improvement after they improved the fitness level of their spine.

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5. The other doctor told me that all I would have to do is lose weight and my back pain would go away. What do you think?

It's true that extra weight puts more pressure on a back and is associated with more low back pain. But the truth of the matter is that 95% of people that try to lose weight are unable to do so long term. Therefore, if a doctor's primary method of treating back pain in overweight patients is to recommend dieting, he will fail 95% of the time. Even people who are overweight can improve their back pain significantly by engaging in active rehab. If they can lose weight also, so much the better.

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6. Can stress cause pain?

stressYes. Stress seems to be related to both back and neck pain, especially pain in the upper back and neck area. When a person is under stress the upper back and neck muscles will contract involuntarily. It's as if these muscles are lifting weights all day long and eventually they wear out and become painful. Learning to relax helps to avoid this problem as does exercise.

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7. I've tried everything. Do you really think you can help me?

Assuming surgery has already been ruled out, people at this stage basically have three options:

  1. Decrease activity to try to eliminate all things in their lives that cause pain;
  2. Increase their function to the point where they can do the things that they want, even in the face of pain; or
  3. Do some combination of one and two.

Obviously the first choice is a poor one. Giving up everything that makes life enjoyable is not something that should be contemplated lightly. The best choice is number two. If you can increase your function to the point where you can do everything you want, this is a pretty good outcome. Even if you continue to have pain, as long as you can do what you want, you're better off. If the second option doesn't work, then the next best option is some combination of the first two. It's better to only eliminate a few things than to become completely inactive. In our experience, the people that become inactive are the people who do poorly.

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8. I know my back can't be weak because I work out all the time.

A person can be strong everywhere else in the body but still have a weak back. In effect, the back becomes the weak link in the chain. We have seen this over and over in people who appear to be extremely well conditioned but who have very weak backs. This is a common scenario in athletes who exercise continually.

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9. I've been working out on the Nautilus and Eagle low back machines for months at my health club. How could my back possibly be weak?

weightliftingThe Nautilus and Eagle "low back machines" are really pelvic extensor machines. The muscles that push up the weight stack are actually the hamstring and the gluteus muscles. If you watch people from the side while they are working out on those machines, the spine really does not move much at all. Almost all of the motion is the pelvis rocking back and forth on the hip joints. Therefore, the lumbar muscles get very little, if any, workout. A controlled study done at the University of Florida (Reference 2) showed that people who worked out on either the Eagle or the Nautilus "low back machine" for 12 weeks actually gained no strength at all in their lumbar extensor muscles, although their hamstring and gluteus muscles did improve significantly.

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10. How does a back or neck get weak?

That's easy to explain. Whenever a person injures his or her back they tend to take it easy. Because of the pain they begin to utilize other body parts to substitute for their back/neck, and therefore the back/neck does not get used much. This happens involuntarily. When the muscles are not used they atrophy and lose strength and become deconditioned. In addition, if the back and neck are not continually moved they become stiff. It is well known that joints that are not moved will deteriorate. Think of a leg in a cast. When the cast is taken off, the leg is usually shrunken and weak and the knee is very stiff. This deterioration comes from disuse. The same thing happens with the back and neck. With each new episode the spine loses a bit more strength and the cycle repeats itself.

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11. All I've ever had to do before was rest and my pain went away. Why do I have to exercise now?

Pain will often diminish when people rest. The problem is that you can't rest forever and often the pain will simply return when you try to return to normal activities. Most people we see have what we call " activity related pain". The more they try to do, the more pain they have. Reconditioning is by far the best type of treatment for these types of complaints. Moreover, there are costs associated with rest. Muscles atrophy, blood flow is diminished, and joints deteriorate. The goal must be to try to diminish pain while preventing these adverse effects and that can be done through proper rehab.

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12. Lately I see a lot of ads promoting super traction devices with space age sounding names like DRX-9000 and Vax-D. Do these treatments actually work?

According to the scientific studies, the answer is no. Which is why none of the major insurance companies pay for it. If you are interested in what the real science is behind these devices click here.

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