What do Steve Nash, Randy Johnson, Robin Lopez, and 80% of Americans have in common? They have all experienced back pain.

Nash's back has bothered him for years, yet he has been named NBA Most Valuable Player multiple times. Randy Johnson had to actually undergo back surgery, yet he still found a way to win 198 more games, four Cy Young awards, and a World Series. Robin Lopez continues to play for the Phoenix Suns.

It's obvious that sports are an important part of American society and culture. Millions watch football or basketball each week, many play golf or even move to places like Arizona to play golf. But while slam-dunking a basketball is a lot different from swinging a baseball bat or golf club, these sports cause the same amount of stress to the spine.

While most don't think about sports this way, sports are really nothing more than organized, competitive exercise programs. Very few people are lucky enough to make a living playing sports or to be paid to exercise every day. But, it does not matter whether you're a weekend warrior, a golf fanatic, or a marathon running tri-athlete. The key is that sports equal exercise. When performed safely and correctly, exercise is good for the heart, kind to the waist, and excellent for the back.

However, low back pain is still a common complaint among athletes, so proper rehabilitation is imperative. Most of us use sports as a form of exercise or recreation, yet surprisingly, professional athletes are similar to amateurs when it comes to back pain and activity. One study compared Olympic level athletes to non-athletes over a four year period and showed that while athletes had significantly more x-ray abnormalities, both groups had the same frequency of back pain.

Some believe these differences exist because of differences in core strength. The core muscles act in coordination like a hoop around the lower body. The deep layers of low back muscles attach directly to the bones of the lumbar spine. The lower back muscles have a thick, tough layer of tissue overlying them called the thoracolumbar fascia. The major abdominal muscles start in the front and wrap around connecting to this fascia. These connections create an integrated band of structures surrounding and supporting the lumbar spine, which actively links upper and lower extremity motions. Passively, these connections send feedback to the brain about the position of the trunk.

When it comes to the spine, core strength is more important than total muscle strength. During daily activity only about 10% of muscle control and strength is necessary. However as the discs of the spine degenerate and the ligaments become more lax, the core muscles are required to do more work to control and stabilize the spine. This is why it is so important these muscles stay strong – they help to unload the spine, which can help decrease pain. The spine must be conditioned enough to withstand the rigors of your form of exercise and sports; otherwise, one is at higher risk for injury during sports play.

Studies have shown that the core muscles function throughout the entire range of all sports-related motions. Weak muscles and altered neurological control of the core and other muscles may actually be the cause of most low back pain. Decreased strength and control cause abnormal spine motion, which becomes magnified when the body is performing exercise. Therefore, pain with exercise may be more related to the individual and less related to the sport. Although core strength decreases the recurrence rate of low back pain after an acute episode, it probably won't reduce the duration or intensity of the episode. The goal is to prevent the episode in the first place. Core strength can be the difference.

Inflexibility and strength deficits are usually the main focus of back rehabilitation. People with low back pain have decreased control of their muscles. Ideally, the core muscles should activate simultaneously before the larger muscles that actually move the arms or legs. People with low back pain show significantly delayed firing of these muscles. People with low back pain also demonstrate far less control of these muscles. Rehabilitation for those with low back pain associated with exercise usually begins with learning to gain better control of these muscles. Inflexibility and strength deficits are usually the main focus of back rehabilitation. I encourage every patient to return to full activity without restrictions when they achieve a pain free range of motion and regain their strength.

We should all exercise more. Our backs would really appreciate it. In general, exercise benefits the body and mind. No matter what the exercise, it's imperative to build a strong core in order to prevent pain or to recover after an injury. Exercise, done correctly, usually does not cause back pain, and the benefits to the entire body are enormous both short and long-term. So, k

Osteo-What??

During our seminars, I am often approached with questions. I am commonly asked about "Osteo". I ask, "Osteo-what?" As many of you know, there is osteoarthritis, osteopenia, osteoporosis, and others. Frequently people speak of their condition and merge these problems together as they seek answers to their personal concerns. Each condition is very different and requires different treatments. Some of these conditions can be painful; some are not and each has its own characteristics, signs and symptoms. Let's take a few minutes to discuss the differences and hopefully, you will learn more about yourself and can determine if you are doing everything you can if you have arthritis or osteoporosis or osteopenia.

OSTEOARTHRITIS is a JOINT and CARTILAGE problem

Osteoarthritis, also called degenerative arthritis or wear-and-tear arthritis, is the most common form of arthritis amongst more than 100 types. Physicians often use various terms to describe osteoarthritis. Terms you may hear include joint deterioration, joint degeneration, joint narrowing, bone-on-bone, calcium deposits, bone spurs, joint diminishment or even "just" arthritis. Some patients don't realize they have arthritis because their doctor describes the problem as joint narrowing, never providing a specific diagnosis of osteoarthritis. In the spine, terms can include degenerative disc disease, bulging disc, annular tearing, facet joint arthritis or arthrosis, degenerative spondylolisthesis or vertebral slipping, spinal canal or foraminal narrowing or spinal stenosis.

Osteoarthritis by definition means Osteo=bone, Arthro-joint and Itis=inflammation but these terms don't fully explain the problem. OA is a degeneration of the articular cartilage that covers the bone ends adjacent to each other. Once this degeneration establishes, it can slowly (sometimes rapidly) cause more cartilage loss between the bones which leads to "bone-on-bone" and more pain. OA can be present and painless for years until the loss becomes enough to warrant symptoms. Depending on the severity of the loss, OA can cause a variety of symptoms. First, OA is most prevalent in the joints next to the fingernail (and toe) bed, the middle joints of the hand and the thumb base. It does not cause harm to the knuckles of the hand (like rheumatoid arthritis). It will also affect knees, hips (pain will be in the groin of the leg and inner aspect of the thigh, not on the side or buttock.) and spine. It can affect your neck and, to a lesser degree, the shoulders. Shoulder pain is usually NOT OA unless you have advanced impingement syndrome and have developed rotator cuff damage over the years. OA does not affect the elbow or ankle unless there are other circumstances such as prior fracture or flat feet. OA is a joint problem, not a systemic problem. It is possible to have more than one affected joint but there is no symmetry (as in rheumatoid arthritis). An old injury or smaller repetitive injuries can lead to a degenerative joint such as the knee or spine. Carrying extra body weight will accelerate the damage and symptoms of osteoarthritis.

There is little inflammation in osteoarthritis compared to rheumatoid arthritis. It is possible to have a swollen joint at times but it is usually not long lasting. Swelling tends to occur with joint overuse or exertion and will subside with rest. Blood tests (for blood inflammation) will prove negative because the inflammation is not in the blood but instead local in a joint. Arthritis blood tests will also be negative. Diagnosis is usually confirmed by history, examination and plain x-rays.

X-rays will reveal the joint narrowing and bone spurring but history often leads the physician to the appropriate diagnosis. Caution to those whose physicians do not listen, do not perform a physical examination or take x-rays and say, "Oh, you have arthritis" or "What do you expect? You are getting older." Comments such as these can cause some patients to feel they must "live with the condition". Although you do have to find ways to be comfortable, there are plenty of ways and specific options to help you live actively and fully.

Every condition has a "course or path of treatment". This means there is a limited set of treatments based on your diagnosis and its severity which is more reason why I emphasize the importance of knowing 1) your diagnosis, 2) its severity, and 3) options available. Medical professionals begin with the least and add more as you go along to find the most effective treatment. It is not always easy finding the best combination of treatments. But, if you are a good partner and relate honest responses to your doctor and interact with him/her, you will receive better care. Never be passive and never believe your doctor is untouchable. Doctors appreciate your involvement and do better with your help. If you have concerns, express them, if you have questions, ask them and if you are not satisfied with your treatment, speak up or seek additional help with a second opinion. Also realize there are many specialists that treat specific types of problems. The problem and its severity can help you to seek treatment with your primary care physician, or a specialist in rheumatology, orthopaedics, physical medicine & rehabilitation or more specifically, spine, hip and or knee, hand orthopaedics, or sports medicine.

Rationale of Effective Treatment

Treatment can include anti-inflammatory medications and/or analgesics. Currently there is no medication that slows the progression or damage of osteoarthritis. In all cases, medications are designed to control symptoms. In the earlier stages of a painful condition, you can also try glucosamine sulfate/chondroitin sulfate in regular doses. Simply treating osteoarthritis with medication can make you more comfortable and active but remember it's important to rehabilitate painful joints so they remain functional. We also now know that the best way to SLOW arthritis progression is through strength. Strength that surrounds a joint unloads the joint's stresses and changes the load as it transfers to the muscles. Once you know the correct exercises for your problem, a home exercise program can be excellent in the long-run.

Joints and the spine do better when we maintain a desired weight. A cane can unload a joint as well. These will not only make it less painful, it will slow the progression which is key to long term treatment. Osteoarthritis stays with us for life so we should always remember the important question: What will life be like ten years from now? Don't sit on the sidelines watching yourself grow older and lose ground when there is much we can do. Don't wait and wish for a better day. Joint damage will continue, muscles will weaken, balance and coordination can be further impaired. Treatment is most successful when combined in multiple ways. Passive treatments such as medication, topical creams, heat or cold can help temporarily but active treatment, such as appropriate and weight loss, is most helpful in protecting the joint(s) and reducing pain. Other active treatments that can provide long-term relief include using a cane, protective injections called viscosupplementation (knees only) or surgery to correct the problem. Last, be careful about remedies that aren't backed by clinical research and outcomes. People with arthritis are often prey by those who try to financially gain from selling "snake-oil" and other unproven products in the arthritis market.

OSTEOPOROSIS is a BONE problem

Osteoporosis is most often confused with osteoarthritis since often people have both. While OA is a degeneration of a joint, osteoporosis is the loss of BONE mass which causes risk of fractures, even spontaneously. Osteoporosis is PAINLESS and if you indeed have pain, let's say in your back, you could have both conditions. In the spine, it is called degenerative disc disease and it is part of the arthritic process. Osteoporosis on the other hand (and while you have degenerative disc disease) can affect your bone quality. Bone density testing called, DXA, or dual-energy-x-ray-absorptiometry, most accurately determines your bone health. Osteoporosis is painless until you sustain a fracture. Osteoporosis begins with low bone mass usually around age 50. In women, it's common after menopause. Low bone mass, called osteopenia, is the precursor to osteoporosis and can lead to osteoporosis. Bone mass peaks around 35 years of age.

For example, if you have about 100% of your bone mass at age 50 (menopause), you will lose about 3% of your bone mass silently for about 5 years after menopause. That's 15%. Then as you grow older, you will lose about 1% every year. Over a 20 year period that computes to an additional 20%. By the time you are 75, you could reach 35% bone loss. When you have about 30% bone loss, fractures can begin to occur. To determine your bone density, never rely on a plain x-ray. Plain films will not identify bone loss until there is a loss between 30-50%. We all experience these changes differently but a DXA scan can help you know where you stand. Once you have had your DXA, learn what a "T-score" is so you can monitor your own bone health along with your doctor. If you do indeed have a diagnosis for osteoporosis, you will require medical treatment to slow this problem and prevent a fracture. Osteoporosis is not uncommon; half of all women over 65 have osteoporosis. Be aware, not all physicians routinely test for osteoporosis and some even will wait until you ask for the scan. There are specific risk factors for osteoporosis including being Caucasian or Asian, being thin or small boned, smoking, drinking alcohol, not ingesting enough calcium or vitamin D, a sedentary lifestyle and certain medications. Medications include steroids of any kind, some blood thinners, excessive thyroid, and some anti-convulsants. If you have had a hysterectomy before your menopause, you are also at an increased risk.

If you learn you have osteopenia, you have options. Some may need treatment, some don't. Calcium and vitamin D supplements can be provided to those who lack enough calcium in the diet. There are many fortified foods you can rely on as well. Be careful about unproven remedies. Many dollars are spent on alternative supplements that have no track record except the testimonial, which is quite different from clinical research. Testimonials are claims from those who have something to say but clinical research tracks every patient and every event and under controlled conditions.

Options for Improving Bone Health

Treatment for osteoporosis is pretty simple. It includes 1) sufficient calcium and vitamin D, 2) weight-bearing exercise, and 3) medication. First, one must have sufficient calcium and vitamin D. Next, weight-bearing exercise stresses bone, making it stronger. Last, medication is prescribed if you have full-blown osteoporosis. You cannot do less and expect improvement of your bone mass.

There are effective medications available that are safe for most. First line of treatment using medication includes Actonel, Fosamax, Boniva or Reclast (all of the category called biphosphonates). There is a new medication call Prolia. For those who either can't take these medications or they are ineffective, you can consider another option. Forteo (parathyroid hormone) requires a daily injection for 2 years but is effective when biphosphonates fail. Your physician can help you decide which is best for you with the least risk. Most importantly, don't ignore osteoporosis because it is not painful. Instead, think of osteoporosis like hypertension (high blood pressure). Uncontrolled hypertension can cause a heart attack or stroke while osteoporosis can cause a fractured bone. If you are not sure where you stand or you are losing bone in spite of treatment, consider consulting with a rheumatologist or endocrinologist, both of whom specialize in osteoporosis. Some spine specialists also treat osteoporosis of the spine.

If you experience a fracture of a spinal vertebra, it usually heals in a few months. This is acceptable as long as you are being treated for the underlying condition. However, if the pain is severe, you can consider a simple surgical procedure called Kyphoplasty, which restores the vertebral height and helps you stand straight. Kyphoplasty includes a very small incision (2) at the fracture level, the insertion of a balloon and then it's inflated. The balloon is withdrawn and a small amount of cement is inserted. By the time you wake up after the procedure, your pain is gone and you can go home and resume your usual activities the next day. Another procedure, vertebroplasty is also available for these types of fractures but it's noted not as safe. Vertebroplasty does not restore vertebral height. To undergo these procedures, see a spine specialist before the fracture is fully healed. An MRI helps determine the degree of healing so the spine specialist knows whether you can be considered for one of these procedures.

Going Forward

As you can see, osteoarthritis and osteoporosis are very specific diseases and require proper diagnosis and treatment. There are very effective options for these conditions. It's simply a matter of knowing about the conditions and which options are best for you.

There are many types of spinal conditions. To effectively treat a spinal condition, obtaining a correct diagnosis is first. Once your spinal diagnosis is determined, you can read more about it and better understand the options for treatment. If you have questions about your spinal condition of a general nature, feel free to ask us.

You may also find additional help by visiting these spine-related websites:

• spineuniverse.com
• back.com
• iscoliosis.com
• necksurgery.com
• esurgeon.com
• maturespine.com

Back pain is as common as it is enigmatic. An estimated 90% of the population will experience at least one episode of back pain with the vast majority of symptoms resolving within one month. However, for certain people, back pain can become chronic and disabling.

There are multiple causes of back pain. These include the muscles of the back, ligaments, nerves and the bony architecture of the spine to name a few. Unfortunately, the normal process of aging is responsible for the majority of changes in our spinal anatomy, some of which can cause pain. However, degenerative change is commonplace. In fact, a study was done on asymptomatic patients in their twenties and 30% were found to have some changes found by MRI. By the time people are fifty approximately 97% of the population will have degenerative changes found on MRI. While the process of aging cannot be stopped, its effects can be minimized.

Symptoms from degeneration manifest themselves usually as back pain and/ or leg pain. These symptoms come from nerves that are being irritated as they exit the spine or spine anatomy that is wearing out and becomes painful when stressed.

The spine is very similar to a car. An automobile is a series of moving parts that allow the vehicle to move in space. The more miles you put on the car, the more likely the vehicle will have some component wear out (tires, shocks, etc.). Our spine is the same way. As we get older, the various moving parts of our anatomy degenerate (discs, facet joints). One of the first areas to begin to degenerate is the discs. The disc serves two functions: motion and shock absorption. As we get older, the disc will lose this ability and shrink in height and distribute more stress to other areas (bone and joints). This change in stress distribution will cause arthritic change to occur in our surrounding anatomy. This degenerative cascade will manifest itself as increased back pain and stiffness.

Nerve "pinching" or stenosis follows the same degenerative cascade. Nerves exit the central canal through holes in the spine called foramen. The foramen are bordered by disc, facet joints and ligaments. As the disc loses height and bulges, our facet joints are simultaneously becoming arthritic (enlarged from bone rubbing bone), the foramen becomes smaller and the exiting nerve becomes "pinched". We notice this as leg pain.

Another common manifestation of age is the fact our bones lose their mineral content over time (osteoporosis). This is more commonly seen in post menopausal women but occurs in men with increasing age. Our vertebra (spine bones) are unique in that they are designed to absorb stress. The bony architecture is similar to the Greek Pantheon. The bone has columns which support the roof and floor. With time, as we lose mineral, our vertebra lose columns and the roof is more at risk of collapse. If the spine sees a significant stress, you are at risk of sustaining a compression fracture. These injuries are extremely painful and may take weeks to months to heal.

Patients with back pain secondary to degeneration usually respond to conservative treatments which include physical therapy (P.T.), anti-inflammatories (Ibuprofen) and steroid shots. P.T. is important to strengthen our trunk, neck and shoulder girdle musculature, which helps to minimize the wear and tear to which our spine is exposed. The increase in muscular endurance and strength from P.T. is similar to getting new shocks on the car. The speed bumps you encounter in life are not as significant. Anti-inflammatory medication helps break the pain cycle and minimizes the effects of the arthritic change. Steroid shots are used to decrease the irritability of the nerve roots. The shots also can decrease the swelling that nerve roots may exhibit from being "pinched". The effects are similar to being stuck in Phoenix traffic, without an air conditioner, and taking a valium. You are still in traffic but you are less angry about your situation.

If symptoms do not improve with conservative management then a surgical consultation may be needed. Surgical intervention should be viewed as a last resort and usually involves "altering" your anatomy to alleviate the pain source. This can be anywhere from a decompression (making the foramen bigger and relieving the "pinching" the nerve is experiencing) to a fusion (stopping moving parts which are causing pain from moving). There are new techniques which focus on minimizing the physical insult of surgery by using smaller incisions (minimally invasive surgery) to "Kyphoplasty". Kyphoplasty involves using a balloon to expand a compression fracture and fill the bone with bone cement to stabilize the fracture. All these techniques involve fewer days in the hospital and more rapid recovery.

To conclude, conservative measures and surgery do not "turn back the odometer". These treatments are attempting to improve quality of life and increase function. Everybody has some back discomfort and degeneration of the spine is a fact of life. Our goal at Sonoran Spine is to do whatever is needed to get your "car" running as efficiently as possible for the rest of your life.