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Friday, May 16, 2008

The Four Stages of Low Back Pain Care and Recovery : Part 2

A Physician’s Help
You can do Back Rx or a similar program entirely on your own. But a physician’s expert guidance can help keep your recovery on track and progressing optimally. Primary care physicians are well equipped to manage low back pain, coordinate the efforts of specialist physicians, physical therapists, and other caregivers, and coach you through your recovery. During Stage I care, they can provide the insight and support you need to stick with Back Rx or a similar program long enough for full healing to occur.

The specialist physicians most often involved in low back care are physiatrists, neurologists, anesthesiologists, orthopedic surgeons, and neurosurgeons. Except for physiatrists, specialist M.D.s do not participate much in Stage I care. In later stages of care, a neurologist can be helpful if a person is suffering from foot drop or other signs of neurological weakness. If it becomes necessary to explore surgical interventions such as a discectomy, orthopedic surgeons and neurosurgeons with fellowship training in spinal surgery have state-of-the-art spinal surgical skills. They also have the expertise to offer informed second opinions on prospective surgery. In cases of ongoing severe pain, especially pain that persists after surgery, anesthesiologists with pain management fellowship training should be consulted.

The first consultations with specialist physicians should occur within six months of injury, if possible. After six months, healing becomes a lot harder and the prognosis for full recovery from a low back problem becomes less favorable.

As primary care physicians for the musculoskeletal system and specialists in physical medicine and rehabilitation, physiatrists can play a healing role at every stage of low back care. All physiatrists receive extensive training in conservative nonsurgical care for the low back. Additional subspecialty training in physiatry, such as a fellowship in spine and sports medicine, can be particularly useful in later treatment stages, because it provides expertise in minimally invasive, nonsurgical spinal treatments combined with proper rehabilitation.

All things considered, in the event of a low back problem you should probably turn first to your present primary care physician and his or her referral network. Someone who knows you and your medical history, and whom you trust and feel comfortable with, has a better chance of getting your recovery in high gear quickly and managing it smoothly than a doctor who is meeting you for the first time.

If you do need to find a doctor from scratch, whether a general practitioner or a specialist, the best way to find any good caregiver is through word-of-mouth recommendations from people you trust. You can also learn about different medical specialties and find referrals on the websites of physicians’ groups. At the end of the book you’ll find an appendix with a list of organizations and websites that can help you with your search.

Other Caregivers
In addition to general practice and specialist M.D.s, a number of other caregivers treat low back pain, including physical therapists, osteopaths, massage therapists, chiropractors, and acupuncturists. Whereas M.D.s and physical therapists are said to practice conventional medicine, the other caregivers are often said to practice integrated medicine. I find these labels a little awkward. Every good healer wants to take an integrated, holistic approach to patient care. “Leave no stone unturned to help the patient” should be every caregiver’s motto.

Granted that, and granted that equally good healers can have very different credentials, you want to make sure that the caregivers you go to have the appropriate credentials for their different fields. Keep in mind that whereas conventional medicine regularly tests its practices in controlled studies, most of integrated medicine has not yet been documented with the same rigor. Of the common alternatives to conventional medical care for the low back, only massage therapy and osteopathy have so far been proven effective in clinical trials. There is other, if less rigorous, medical evidence for the value of acupuncture and chiropractic, however, and I have seen many patients helped by each of them.

To find a good practitioner of one of these treatments, ask around. Personal recommendations from people you know and trust are the best way to find a good healer. After that you have to follow your instincts. Everyone is different, and every case of low back pain is different. As long as you are making an informed choice, you should feel free to pick and choose the therapies that seem best suited to your individual needs, perspective, and lifestyle. The proof is then in the pudding. A therapy may be very appealing for one reason or another, and it may help other people. But if it doesn’t help you over the course of a few weeks or months, you should abandon it and move on to something else. As with conventional medical care, you should try to find the right integrated medical care for your case within six months of your injury. After that point, healing becomes much harder, no matter what the treatment is.

I’ll have more to say about these varied treatment options in Chapter 11. Here I would only caution that where chiropractic is concerned, you should not have any high-velocity manipulations of the head and neck. They can cause spinal cord injuries and strokes. It’s not a high risk, but why take the chance that you’ll be the one person in many thousands who is crippled or killed?

Self-Care Makes All the Difference
I’ve already emphasized the importance of self-care in treating low back pain. Good habits of self-care build physical, mental, emotional, and spiritual resilience. When it comes to receiving low back treatments from others, the enhanced body awareness that develops from effective self-care will help you to choose the treatments that are best suited to your own case and to get the most out of those treatments.

The array of potential treatments for low back pain is enormous. Conventional medicine, osteopathy, physical therapy, massage, acupuncture, and chiropractic can all benefit people with low back injuries, but in my experience, some are more effective at one stage of recovery than another. And at every stage of recovery, some of these things work better for some people than they do for others. Moreover, none of them can guarantee a cure. Good self-care can make all the difference, enabling you to leverage the power of the treatments you receive from others. Professional athletes can often heal astonishingly quickly, simply because of how well they have learned to listen to their bodies and how they are able to use their body knowledge to guide those who care for them.

At the core of what Back Rx teaches are habits of self-care and self-attunement that can ultimately transform your relationship with your body. Most of all, Back Rx trains you to tune clearly and surely into the stream of signals that the body is always processing. When you make a habit of listening to these signals on a regular basis, they tell you which muscles need stretching and strengthening and what the limit of the effort should be. They guide you to apply the gradually increasing, moderate stresses that aid healing, and to avoid the extreme stresses that retard it. The body’s proprioceptive faculties also “tell” you more and more accurately when you are in proper alignment and balance for any activity and when you’re not, helping you to maintain the good posture and flowing movement that ultimately keep back injuries from occurring.

As you build a habit of listening to your body while you do the Back Rx exercises, you develop the ability to “listen” more and more at a subliminal level throughout the day, without the need for conscious attention. Eventually you’ll reach the point where you notice right away when stress and overuse are beginning to affect your back, and you’ll then be able to take proactive steps to moderate and even prevent episodes of low back pain before they occur. Ultimately you’ll become able to direct this sharpened mental focus and enhanced energy to boost your performance in every area of your life.

One of the best ways to help further this process, after the initial inflammation and severe pain of an acute injury have subsided, is through self-massage and partner massage. All healing needs the human touch, and none more so than low back pain. The first thing to realize about self-massage is that you can’t hurt yourself. At most, if you really got carried away, you might give yourself a superficial bruise, but you can’t exert enough pressure with your own unaided hands to damage anything below the skin level.

But if you can’t apply enough pressure to hurt yourself more than a little bit, you can easily apply enough pressure to help yourself a lot. You can massage and manipulate your own body to a remarkable degree, if you do so with a sense of play and a willingness to experiment.

The way to start is to put your fingers or hands on the injured areas and rest them there for a moment. You’re about to get reacquainted with your body—you’ve probably been injured so badly in the first place because you’ve literally lost proprioceptive touch with your body—and there’s no need to rush.

Now focus on your breathing. Slow it down. Exhale fully. Empty your lungs. Inhale slowly and deeply. Hold the breath for a count of three. Exhale slowly and continue the cycle for ten breaths.

As you rest your hands or fingers on the injured areas of your body and breathe in this slow, controlled, sustained way, your body will begin to tell you how it wants to be touched, rubbed, kneaded, pressed, and prodded into alignment. The knots in the muscle tissue that are keeping your body from relaxing into its natural alignment are bunched up around, and are themselves largely composed of, small sacs of water. As Rick Sharpel, a leading medical massage therapist in New York, puts it, “Massage works by moving those tiny sacs of water so that they spread out smoothly along the entire length of the muscle, rather than being bunched up in the belly of the muscle.”

Medical massage generally treats the belly of tight muscles by rubbing crossways— called cross-fiber massage—more than lengthwise. You can use any part of the fingers, knuckles, hands, wrists, or forearms to do this. A massage therapist or a gentle, trusted partner might also use the elbows to apply sufficient steady pressure to reach and unkink severe muscle strains.

You can even use objects to do massage. There are many household objects you can use, from a solid doorjamb to a bag full of tennis or golf balls. Put a towel over the bag of golf balls or other object—some people even like to use a rock with a definite edge or point— and then carefully lie down on the floor on your back. Rest your lower back on the object and begin to apply the pressure where and how your body says it helps. If you are doing some rehabilitation work at a gym or under the supervision of a therapist, you might also use an extra-large-diameter sports ball to lie back and roll around on.

The amount of pressure that you apply or a massage therapist applies is obviously a critical factor. As a general rule, the more relaxed you are, the more that steadily increasing pressure will be pleasurable rather than painful. But when massage therapy reaches the point of maximum tenderness—some massage therapists call it the point of exquisite pain—you have to be willing to endure some increased short-term discomfort in the interest of better healing. This healthy stress is produced by slow, sustained, controlled movements and gradual increases in pressure to a point just below your pain threshold, not by sharp, stabbing actions or sharp, stabbing pain at or above that threshold.

Excerpted from

Back Rx: A 15-Minute-a-Day Yoga-and Pilates-Based Program to End Low-Back Pain
by Vijay Vad
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