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A Review of Conservative Spine Treatments

Often we hear, "I don't want to have spine surgery!" The good news is ninety percent of people who experience back pain will never need spine surgery since most problems resolve with conservative care. Conservative treatments for back or neck pain include a wide spectrum of treatment options ranging from common medications to more uncommon methodologies such as acupuncture or biofeedback. Many strategies can be used together, although some are more helpful when one follows the other. The goal is to try the least invasive treatments first while more invasive options are considered when conservative options fail.

Acute and Chronic Pain

Pain can be divided into two categories: acute and chronic. Although traditionally chronic pain was defined as pain lasting more than six months, recently health care professionals view chronic pain as the persistence of pain after the original tissue damage has resolved. Although it may take six months to categorize non-resolving pain as chronic pain after major spine surgery, non-resolving pain after a simple back strain may be categorized as chronic pain much earlier.

Medical vs. Alternative Treatments

Alternative treatments usually refer to unconventional medical interventions not taught by western medicine and usually not available in hospitals or covered by insurance plans. However, alternative medicine is becoming more popular and accepted. The line between medical and alternative treatments is less defined. A good example is the increased popularity and acceptance of medical acupuncture.

Regardless of the conservative method, there is greater success when patients actively participate in their treatment with a focus on the restoration of function and not just elimination of pain.

Medications

Drug therapy is the most common medical treatment for both acute and chronic pain. Some drugs not only relieve pain but also reduce inflammation or help to relax muscle spasm. Typical medications categories that may be helpful include:

  • Acetaminophen (analgesic, over-the-counter)
  • Non-steroidal anti-inflammatory drugs (NSAIDs) (includes aspirin, ibuprofen, naproxen, and others; over-the-counter and by prescription)
  • COX-2 Inhibitors (Celebrex; by prescription)
  • Muscle relaxants (Flexeril, Zanaflex, Skelaxin, and others; by prescription)
  • Anti-Depressants (Elavil, Pamelor, Cymbalta, and others; by prescription only)
  • Anti-seizure medications (Neurontin, Lyrica and others; by prescription only)
  • Analgesics (tramadol, Darvocet; by prescription only)
  • Other Analgesics (hydrocodone, oxycodone, oxycontin; by prescription only)

Physical Therapy and Exercise

Exercise is considered the backbone of treatment in the conservative management of spine care. When back or leg pain is present it is easy to become immobile in an attempt to reduce the pain. However, prolonged bedrest or immobilization causes de-conditioning, muscle and joint stiffness, leading to a vicious cycle of more pain and weakness so inactivity should be limited.

Exercises to strengthen and stretch the back should be initiated as rapidly as possible. These exercises should not induce back, neck or extremity pain. To begin, a prescription for physical therapy (PT) can be written by any physician but best if written by a spine/pain specialist with recommendations that fits each patient's specific issues. PT prescriptions usually have multiple components that can be divided into passive versus active treatments. Weight reduction, proper body mechanics and ergonomics at work and home should be considered in the evaluation so re-injury or exacerbation of pain can be avoided during recovery and maintenance.

Passive vs. Active Treatments

There is a specific distinction between passive and active treatments. Initially they can work in combination to mobilize you but in the long run, active treatments will have a more lasting effect on your spine health.

Passive Treatment is Done TO You

Passive modalities are done initially to reduce pain so the patient can prepare to regain comfort and activities. These treatments such as (heat, ultrasound, TENS and others) focus on reducing pain whereas active treatments center on musculoskeletal training that are learned and continued at home. A home therapy program is necessary for long term pain relief and restoration of function.

Active Treatment is Done BY You

The active part of physical therapy involves exercise routines including stretching, strengthening, and endurance components. Stretching helps to increase flexibility and range of motion. Strengthening uses weights or resistance to increase muscle force. Increased muscle strength helps unload the spine and the joints of your body. Of particular importance with back disorders is core strengthening. Called dynamic stabilization, this strengthening helps unload the forces on the spine, its discs and nerves. Endurance uses prolonged repetitious movements to increase aerobic capacity which reduces pain as well.

Spinal Injections

A variety of spinal injections can be used for diagnosis and/or treatment of pain in the cervical, thoracic, lumbar and sacrococcygeal regions. We will discuss the most common ones. Spinal procedures can be divided into either diagnostic or therapeutic, although some can serve both functions.

Spinal injections can be used for diagnosis and/or treatment of various types of pain in each region of the spine. The most common spinal procedures can be divided into either diagnostic or therapeutic, although some serve both purposes. An anesthetic agent and/or a steroid medication is used in these injections. Spinal injections are best done under imaging guidance to assure accuracy of the procedure. All injections performed for therapeutic purposes are designed to reduce inflammation and relieve pain. The type of injection used depends on your diagnosis and cause of your symptoms.

Epidural Block

An epidural steroid injection (ESI) refers to a type of steroid injection that is put into the epidural space. The term, epidural, refers to the space outside the dura or covering of the spinal cord but inside the spinal canal. There are various methods used depending on whether there was previous surgery and area of difficulty. A selective nerve root block (SNRB) is very similar to an epidural injection without the use of a steroid. This injection, used for diagnostic purposes, gives a few hours of relief helps to locate the origin of the pain.

Medial Branch Block

On each side of the vertebrae, there are the small joints where the vertebrae fit together called facet joints, which can be a common source for pain. When facet joint pain is diffuse and does not fit a particular nerve root pattern, we can use the medial branch block to diagnose pain originating from facet joint. A facet joint injection and/or medial branch block (MBB) is the gold standard. An intraarticular facet injection introduces the medication into the facet joints and is usually therapeutic. If the MBB is effective radiofrequency ablation (RFA) can be a next step, which uses radio waves to produce heat resulting in the cauterization for the medial branch responsible for facet pain. On average, one can obtain 12 months of relief with RFA.

Injections can also be used for sacroiliac joint (SI) pain which often presents after acute injuries, pregnancy and in patients with lumbosacral fusion. Injection into the joint capsule is both therapeutic and diagnostic.

Often we hear, "I don't want to have spine surgery!" The good news is ninety percent of people who experience back pain will never need spine surgery since most problems resolve with conservative care. Conservative treatments for back or neck pain include a wide spectrum of treatment options ranging from common medications to more uncommon methodologies such as acupuncture or biofeedback. Many strategies can be used together, although some are more helpful when one follows the other. The goal is to try the least invasive treatments first while more invasive options are considered when conservative options fail.

Acute and Chronic Pain

Pain can be divided into two categories: acute and chronic. Although traditionally chronic pain was defined as pain lasting more than six months, recently health care professionals view chronic pain as the persistence of pain after the original tissue damage has resolved.  Although it may take six months to categorize non-resolving pain as chronic pain after major spine surgery, non-resolving pain after a simple back strain may be categorized as chronic pain much earlier.

Medical vs. Alternative Treatments

Alternative treatments usually refer to unconventional medical interventions not taught by western medicine and usually not available in hospitals or covered by insurance plans. However, alternative medicine is becoming more popular and accepted. The line between medical and alternative treatments is less defined. A good example is the increased popularity and acceptance of medical acupuncture.

Regardless of the conservative method, there is greater success when patients actively participate in their treatment with a focus on the restoration of function and not just elimination of pain.

Medications

Drug therapy is the most common medical treatment for both acute and chronic pain. Some drugs not only relieve pain but also reduce inflammation or help to relax muscle spasm. Typical medications categories that may be helpful include:

  • Acetaminophen (analgesic, over-the-counter)
  • Non-steroidal anti-inflammatory drugs (NSAIDs) (includes aspirin, ibuprofen, naproxen, and others; over-the-counter and by prescription)
  • COX-2 Inhibitors (Celebrex; by prescription)
  • Muscle relaxants (Flexeril, Zanaflex, Skelaxin, and others; by prescription)
  • Anti-Depressants (Elavil, Pamelor, Cymbalta, and others; by prescription only)
  • Anti-seizure medications (Neurontin, Lyrica and others; by prescription only)
  • Analgesics (tramadol, Darvocet; by prescription only)
  • Other Analgesics (hydrocodone, oxycodone, oxycontin; by prescription only)

Physical Therapy and Exercise

Exercise is considered the backbone of treatment in the conservative management of spine care. When back or leg pain is present it is easy to become immobile in an attempt to reduce the pain. However, prolonged bedrest or immobilization causes de-conditioning, muscle and joint stiffness, leading to a vicious cycle of more pain and weakness so inactivity should be limited.

Exercises to strengthen and stretch the back should be initiated as rapidly as possible. These exercises should not induce back, neck or extremity pain. To begin, a prescription for physical therapy (PT) can be written by any physician but best if written by a spine/pain specialist with recommendations that fits each patient's specific issues. PT prescriptions usually have multiple components that can be divided into passive versus active treatments. Weight reduction, proper body mechanics and ergonomics at work and home should be considered in the evaluation so re-injury or exacerbation of pain can be avoided during recovery and maintenance.

Passive vs. Active Treatments

There is a specific distinction between passive and active treatments. Initially they can work in combination to mobilize you but in the long run, active treatments will have a more lasting effect on your spine health.

Passive Treatment is Done TO You

Passive modalities are done initially to reduce pain so the patient can prepare to regain comfort and activities. These treatments such as (heat, ultrasound, TENS and others) focus on reducing pain whereas active treatments center on musculoskeletal training that are learned and continued at home. A home therapy program is necessary for long term pain relief and restoration of function.

Active Treatment is Done BY You

The active part of physical therapy involves exercise routines including stretching, strengthening, and endurance components. Stretching helps to increase flexibility and range of motion. Strengthening uses weights or resistance to increase muscle force. Increased muscle strength helps unload the spine and the joints of your body. Of particular importance with back disorders is core strengthening. Called dynamic stabilization, this strengthening helps unload the forces on the spine, its discs and nerves. Endurance uses prolonged repetitious movements to increase aerobic capacity which reduces pain as well.

Spinal Injections

A variety of spinal injections can be used for diagnosis and/or treatment of pain in the cervical, thoracic, lumbar and sacrococcygeal regions. We will discuss the most common ones. Spinal procedures can be divided into either diagnostic or therapeutic, although some can serve both functions.

Spinal injections can be used for diagnosis and/or treatment of various types of pain in each region of the spine. The most common spinal procedures can be divided into either diagnostic or therapeutic, although some serve both purposes. An anesthetic agent and/or a steroid medication is used in these injections. Spinal injections are best done under imaging guidance to assure accuracy of the procedure. All injections performed for therapeutic purposes are designed to reduce inflammation and relieve pain. The type of injection used depends on your diagnosis and cause of your symptoms.

Epidural Block

An epidural steroid injection (ESI) refers to a type of steroid injection that is put into the epidural space. The term, epidural, refers to the space outside the dura or covering of the spinal cord but inside the spinal canal. There are various methods used depending on whether there was previous surgery and area of difficulty. A selective nerve root block (SNRB) is very similar to an epidural injection without the use of a steroid. This injection, used for diagnostic purposes, gives a few hours of relief helps to locate the origin of the pain.

Medial Branch Block

On each side of the vertebrae, there are the small joints where the vertebrae fit together called facet joints, which can be a common source for pain. When facet joint pain is diffuse and does not fit a particular nerve root pattern, we can use the medial branch block to diagnose pain originating from facet joint. A facet joint injection and/or medial branch block (MBB) is the gold standard. An intraarticular facet injection introduces the medication into the facet joints and is usually therapeutic. If the MBB is effective radiofrequency ablation (RFA) can be a next step, which uses radio waves to produce heat resulting in the cauterization for the medial branch responsible for facet pain. On average, one can obtain 12 months of relief with RFA.

Injections can also be used for sacroiliac joint (SI) pain which often presents after acute injuries, pregnancy and in patients with lumbosacral fusion. Injection into the joint capsule is both therapeutic and diagnostic.

Other Spinal Procedures and Treatments

There are other spinal procedures that can improve back and leg pain. Once your diagnosis is determined through history, physical examination and the appropriate imaging studies, the spine or pain specialist can recommend which procedure might be best for you.

In some cases, there is benefit to seek chiropractic manipulation or osteopathic manual medicine. Both approaches can be used on the symptoms and diagnosis of the problem and usually provide the best relief when used in conjunction with active therapies such as an consistent exercise program to help restore functionality.

Other treatments to consider with varying success include acupuncture, prolotherapy and biofeedback. Specifically psychotherapy can help to reduce pain medication intake and increase activity levels through modifying behaviors through thoughts and self-awareness.

When Conservative Care Fails

When conservative care fails, it may be appropriate to evaluate whether you could benefit from spine surgery. Spine surgery is usually done for either nerve pinching or spinal instability. If non surgical options have not been helpful in reducing pain or restoring your desire level of functionality, spine surgery could be helpful. Remember, spine surgery outcomes are best when the spine surgeon evaluates you and confirms that it is the next step. It is imperative to select the right procedure for the right patient at the right time. There are other spinal procedures that can improve back and leg pain. Once your diagnosis is determined through history, physical examination and the appropriate imaging studies, the spine or pain specialist can recommend which procedure might be best for you.

When conservative care fails, it may be appropriate to evaluate whether you could benefit from spine surgery. Spine surgery is usually done for either nerve pinching or spinal instability. If non surgical options have not been helpful in reducing pain or restoring your desire level of functionality, spine surgery could be helpful. Remember, spine surgery outcomes are best when the spine surgeon evaluates you and confirms that it is the next step. It is imperative to select the right procedure for the right patient at the right time.

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Solutions for Back Pain

If you have never experienced back pain, odds are one day you will. The big question is, HOW ACTIVE DO YOU WANT TO BE? What if your back pain stays roughly the same, where do you see yourself ten years from now? For most people, a completely sedentary lifestyle spent sitting on the couch with a remote control in hand is not a reasonable alternative. For motivated patients wanting to get their life back again, there are several pathways to achieving a higher level of function with less pain. Here at Sonoran Spine, we have experience and expertise in spine. In fact, it is all we do.

A Wellness Approach

For some patients, a wellness approach with primary focus on healthy lifestyle, proper diet and nutrition, and a daily exercise program is ideal. Many people seek out treatment from nontraditional sources such as chiropractic and acupuncture. These can be helpful at treating specific and nonspecific causes for pain in many patients. We have also seen significant improvements in baseline pain for patients who regularly participate in yoga. Pilates and other similar exercise programs have also been helpful in many of our patients.

Conservative Options

For other patients, focused and supervised physical therapy from a quality spine physical therapist is the best way forward. For these patients, often the wellness approach has been tried and the expertise of a spine focused physical therapist can be invaluable. Antiinflammatory medications and a daily exercise program added to the work of the physical therapist is often all that is needed to feel better or at least live with back pain.

Should Surgery Be Considered?

When back and neck pain become problematic, it is imperative that a specific diagnosis be obtained so that treatment can be focused at treating the specific diagnosis. Patients with nerve root compression caused from a disc herniation are very different than patients with nerve root compression caused from degenerative spinal stenosis. Both of these groups can be helped with therapy, and often an epidural steroid injection.

If your diagnosis includes a spinal instability secondary to arthritis, a slipped vertebra, fractured vertebra or other conditions that causes activity-related back pain, you may require some type of surgery to stabilize the part of your back that is affected. If this is required, we have long-term data that shows 85 to 90% of our patients return to a high level of functionality. Patients with spinal curvature, patients who are stooped or bent over, or patients with congenital or developmental spinal deformity can be dramatically helped through surgical correction of the deformity and stabilization of the spine restoring a new and improved posture.

Getting Your Life Back

So, the question remains, how active do you want to be? Where do you see yourself in ten years? If your pain is bothersome enough, you deserve a clear diagnosis, a treatment program tailored to your particular problem, and the optimal chance for improvement with expert therapy and treatment. We have high expertise for treatment of spinal disease, whether in the arena of wellness, acupuncture and yoga, formal physical therapy, medication and a home exercise program, or surgical correction of problems that will not respond to anything else. Our long term research has been presented at national and internal meetings and published in major spine journals. Our work is presented to spine specialists worldwide along with our research data shows that excellent outcomes are achievable in most patients with most conditions, when the diagnosis is correctly made and treatment is correctly applied. There are many solutions for back pain, depending on the underlying cause. Our goal is to analyze your particular problem and help you find the solution to a higher level of function and less pain for a happier and more productive future.

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Yoga For Low Back Pain

Every day I am asked to recommend the best exercise plan for improving low back pain. My first response is that any exercise done on a consistent basis helps reduce pain in the majority of low back pain sufferers. A commitment to exercising on a consistent basis is the first hurdle most must overcome to get lasting benefit from exercise. Incorporating an exercise program into your life is as important as taking daily medications, getting adequate sleep, controlling your weight, and stopping smoking. For those who suffer daily with low back pain, its time to realize that you don't have time NOT to exercise. Through appropriate exercise, you can reclaim your back health!

Yoga and Spine Health

The second hurdle to obtaining lasting benefits from exercise is to choose a program that you are able to follow for LIFE. There are no quick fixes for nonsurgical low back pain. An exercise program that increases flexibility and range of motion of the spine, increases core strength to support the low back, relieves muscle spasms that result from dysfunctional movement patterns must be continued to sustain its benefits. Often physical therapy can help one to recover from a bout with back pain but when the exercises are not continued at home, back pain is apt to return. To continue the benefit, one must continue the exercises that made the improvement.

Lifelong exercises such as biking, swimming, and water aerobics can be started at any age or fitness level, although my most recommended exercise is yoga. Yoga is an excellent choice for enhancing spine health that cannot be duplicated by any other fitness program.

There is a wise saying in yoga, "Everything that gets worse with age, gets better with yoga". From professional and personal experience, I wholeheartedly agree. Yoga IS a lifestyle. It incorporates not only breathing, meditation, and physical postures, but also a commitment to living with a light heart, less stress and consumerism, more compassion and love. While embracing yoga as a lifestyle may not be for everyone, learning to breathe, reduce stress, focus the mind more effectively, and regain lost body flexibility is important for everyone. Letting go of the incorrect notions that yoga is incense burning, chanting hippies that sit around cross legged and mediate all day and that it is simply easy stretching is crucial to success in yoga. Yoga can be one of the most physically, mentally, and emotionally challenging practices available. The good news is that yoga meets you where you are physically and your success in yoga depends on your commitment level. Yoga is referred to as an "inside out" practice meaning that the goal of yoga is to go to the core of your limitations and slowly unfold one layer at a time until there is renewal of life. With regular practice, yoga can realign your spine, lessen muscle spasms, and lengthen shortened muscles to let emerge a freer, healthier, mobile body.

Physical and Mental Benefits

Additional benefits gained from a regular yoga practice far outweigh the physical achievements of touching your toes again. Yoga focuses attention to deep breathe and fully exhale all stale air. Deep breathing through yoga helps calm your mind, focus your attention and lower your cortisol level. Cortisol is a hormone in your body that is released in response to stress that causes increased blood pressure, weight gain, anxiousness, high blood sugar, depression and insomnia. It also reduces our immune system and increases our response to pain. Reducing the body's circulating cortisol lessens all of the major health risks and at the same time makes us stronger and healthier.

Currently an estimated 14.9 million people practice yoga in the United States. The main type of yoga that is practiced in the U.S. is Hatha, the physical practice of yoga. Although Hatha yoga can be practiced in a heated or non-heated environment, heated yoga practice is not recommended for anyone who has chronic medical problems or as yoga therapy for patients with chronic back pain. Iyengar yoga, a specialized study that incorporates typical Hatha yoga postures with specific focus on alignment of the joints and spine, was developed by yoga master B.K.S. Iyengar. For over 70 years, he has applied therapeutic variations of classic poses to most health conditions including low back pain. Iyengar yoga has been the most studied style of yoga by medical doctors for treatment of medical disorders. The American Cancer Society has incorporated yoga therapy as an adjunct to chemotherapy protocols in women with breast cancer. Their studies reveal that women who practiced yoga during their cancer treatments had fewer side effects from the treatments, less anxiety and depression, and a more hopeful outlook on their survival.

In 2009, a prestigious spine journal published an outcome based study evaluating the value of weekly Iyengar yoga sessions in patients with chronic low back pain. The study divided 90 patients, average age of 48, into two groups with half of the patients beginning a yoga program, participating in yoga twice weekly for 6 months. The researchers documented significant improvements in the yoga-treated group. The yoga patients reported a 50% decrease in pain with significant improvement in their disability index scores compared to traditional treatments. Additionally, the yoga group had a major reduction in pain medications usage. The most encouraging finding was that 67.9% of the yoga-treated group continued practicing yoga more than 3 days a week for longer than six months after the study ended. Differing from other exercise treatments, yoga appears to be successful in alleviating chronic low back pain and disability and worthy of making a long commitment.

Getting Started

So how do you get started with yoga? Some helpful tips include—

  • Ask for a referral to a good instructor or studio. Before your first class, speak with your instructor so he/she is aware of your needs and limitations. This will help the instructor provide you modifications for your condition to insure your safety and comfort. Try various classes or instructors that are at your level since instructors can be different and finding right one for you is important for long term success.
  • Keep an open mind and realize that yoga is a journey. Your first classes may seem awkward. Pick a comfortable spot on the side and enjoy the calmness, practice the breathing and postures. Do give yourself at least a month to decide.
  • Be humble and modest allowing yourself not to be competitive or judgmental. Yoga is an extremely individual practice that is, oddly, often done in groups where you can watch and compare yourself to others. Try to keep your eyes on your own mat and the focus on your own goals. You are there to heal your back, lessen your stress and cortisol level, and heal yourself from the INSIDE out. The outside isn't important if you are focusing on inside yourself. The best yoga practitioners are those who have found peace and freedom.
  • Remember, the more you are overweight, deconditioned, inflexible, or hurried and on a strict time table, the more you need to get into a yoga class ASAP!

In summary, yoga is likely the best overall exercise regimen for back pain sufferers. Yoga concentrates on strengthening the abdominal core, increasing the flexibility of the spine, and lengthening hip, leg and shoulder muscles that are essential for back rehabilitation. The additional heath benefits from yoga practice are simply a bonus!

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Stressss-ed?

When I first realized that everybody has something big going on, it was a real eye opener. It helps me put things into perspective everyday whether I'm at work, in traffic, dealing with others and while I play. Everyone deals with stress, but there are strategies that can help to deal with stress and enjoy life more even when we are doing things that are uncomfortable and undesirable. Let me share with you some of my favorite ways to break up, reduce and prevent stress.

What You Can Do to Break Up Stress

  1. Get moving. All forms of exercise and physical activity increases improves mood and refocuses your mind. Consider anything that keeps you active.
  2. Learn to Let It Go. At the moment it may look monumental. But in the course of life, it probably isn't. Take a deep breath and re-examine it tomorrow. It may even make you laugh as you made so much of it yesterday and realized it wasn't even deserving of your concern.
  3. Say no and learn to set boundaries. You don't have to save the world in a day and you aren't obligated to do everything for everybody. When you take care of yourself, your heart opens up and you will naturally do more for others rather than feel obligated and resentful because someone asked you to do one more thing.
  4. Bad things happen to good people and to all of us. How we react will determine how long this will affect us in a negative way. Learn to see the silver lining in everything around you.
  5. Stop trying to control what you can't. Realize when it is not your problem.
  6. Smile, grin, laugh, listen, look and genuinely enjoy the small stuff. It is what makes the world go round. Eat healthy, listen to music, take time for yourself, and spend time with friends. Life is too short for anything else.

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Spine Wellness Without Surgery

Most spine problems can be improved and even resolved without surgery. Only a small percentage of patients need surgery. Prevention through diet and exercise, ergonomics and proper body mechanics can help you live pain-free from a spine problem. However, once you have a spinal condition, there are many treatments that can get you back on track to an active lifestyle. Our website is still growing and more conservative management articles will be added. In the meantime, if you have a question, feel free to ask us. You will be glad you did.

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