Monthly ArchiveJanuary 2009
Writer's Block 31 Jan 2009 04:11 pm
January 31, 2009
I’ve had several readers write to me over the years and ask my opinion on massage therapy and whether or not I thought it was effective for back pain relief.
Unfortunately, at the time I was unable to answer their questions as completely as I would have liked.
You see the problem with giving an opinion — or being able to recommend a therapy — is that there is quite often a lack of reliable information on the subject. Up until now, we’ve only had anecdotal evidence to suggest that massage therapy helped to reduce pain. And as you know, anecdotal evidence leaves plenty of room for doubt.
However, I recently ran across a study published in the Annals of Internal Medicine that finally lends some credibility to this very popular technique.
Writer's Block 24 Jan 2009 08:01 pm
Here’s what’s happening in the world of health and medical blogging…
That’s it, enjoy!
Jan. 24, 2009
Overheard in the OR:
“The theme this week for Grand Rounds is women’s health issues.”
“Tell me about it.”
“So, you gonna write anything?”
“Me? I wouldn’t touch that with a ten foot pole.”
“I hear you.”
“Speaking of women, how’s your wife’s…”
“About the same.”
“You told her there’s nothing really wrong with her?”
“I’m here on my day off, aren’t I?”
Meanwhile, back at the ranch…
The Catch-22 of Rehabilitation
One of the most important goals of rebuilding your back is the healing and restoration of herniated or degenerated discs. And, as I’ve covered in previous articles, hydration is an essential part of that process.
If you missed those past articles, here’s a brief recap: In order for a disc to be healthy, it has to obtain an adequate daily supply of moisture. Loss of moisture (the source of nutrients) is one of the main causes of disc degeneration.
Therefore, in designing a comprehensive rehabilitation program, disc-hydrating exercises are a must. To put it simply, the disc cannot recover if we don’t feed it.
The only problem with the above plan is that research scientists are now telling us that hydrated discs have the greatest potential for herniation due to increased hydrostatic pressure. The higher the moisture content, the higher the pressure pushing against the nucleus.
For example, McGill wrote:
“Herniations tend to occur in younger spines (Adams and Hutton, 1985), meaning those with higher water content (Adams and Muir, 1976) and more hydraulic behavior. Older spines do not appear to exhibit classic extrusion of nuclear material but rather are characterized by delamination of the annulus layer and radial cracks that appear to progress with repeated loading (a nice review is provided by Goel, Munroe, et al., 1995).” 
And here are some excerpts from one such study courtesy of PubMed:
“Compressive loads and rotational torques (flexion/extension) were applied so that the effects of four loading histories (hydrated, neutral dehydration, flexed dehydration, superhydrated) and two failure postures (neutral, flexed) could be examined.”
“When injured in a neutral posture, superhydrated specimens had a lower strength (22–29%) than dehydrated specimens.”
“CONCLUSIONS: The spine may be more prone to injury early in the morning when the discs are at their greatest level of hydration and/or when they are in a fully flexed posture.” 
And so we have what’s known as a Catch-22.
In order to restore the degenerated disc, we have to hydrate it. If we hydrate this weak disc, it is in greater danger of herniation.
Quite a dilemma wouldn’t you say?
Does This Mean We Give Up On Rehabilitation?
Well, that’s what some people do.
In fact, one very common scenario I’m seeing with sciatica sufferers is that the person starts out with physical therapy and begins to see progress. They start to feel better and things are looking up when all of a sudden they experience a relapse.
Perhaps it’s because they became overconfident and tried to do something foolish like get back out in the garden too soon, or maybe they did nothing out of the ordinary. Either way, they find themselves back at square one with the same (or possibly even worse) symptoms than before.
At this point they get frustrated, discouraged and understandably disappointed. Just when they thought their problems were over, life throws them a curve and their hopes are dashed.
Some give up at this point and decide that rehabilitation just doesn’t work. Despite their initial improvement, they conclude that rebuilding those discs isn’t right for them.
So, they throw in the towel and decide to take what they believe to be the easy way out. They turn to surgery for the quick fix even though surgery is anything but the easy way out. It just seems like it at the time.
So What Should We Do?
All we can do — whether we’re the patient, doctor or therapist — is continue to educate ourselves on these possible pitfalls and try to avoid them if we can. At the very least, we should accept reality for what it is and not let setbacks get us down.
Continue to learn all you can about sciatica, herniated discs, physical therapy and the recovery process. Arm yourself with knowledge and the bumps in the road will at least be a little easier to handle.
Of course, it goes without saying that care should be taken during the rehabilitation process. When your physical therapist tells you not to do certain activities, they are passing on what they’ve learned from years of experience and you’ll be better off if you follow those instructions.
In addition, now that you know about the hydration Catch-22, don’t be surprised if you suffer a setback despite all your best efforts.
Just be aware that, even though you’re feeling better, it does not mean the battle is over.
The pain may be reduced or even gone completely, but until the disc has had a chance to fully heal, it’s important to understand that the nucleus can easily be forced back through the walls of the annulus.
In other words, keep in mind that once breached the annulus will provide little resistance to the nucleus under pressure. You may incur another herniated disc from something as simple as bending down to tie your shoes.
Just remind yourself that it too, will heal and don’t let it throw you off track.
I wish I could tell people that rebuilding your back is going to be easy. For some people it is. But for others, it can be a real struggle.
I still feel that the outcome — and the possibility for full recovery — is worth the effort.
Hang in there,
1. McGill, S. Low Back Disorders, Evidence-Based Prevention and Rehabilitation, 2nd Edition. (p. 44-47) Human Kinetics (2007)
2. Gunning JL, Callaghan JP, McGill SM. Spinal posture and prior loading history modulate compressive strength and type of failure in the spine: a biomechanical study using a porcine cervical spine model. Clin Biomech (Bristol, Avon). 2001 Jul;16(6):471-80.
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Writer's Block 17 Jan 2009 06:29 pm
Jan 17, 2009
Okay, you’re correct, sciatica has nothing to do with health care reform, but it’s been such a busy month that I’ve decided to give you a tufor… that is two blog posts for the price of one. Both are short and I promise to get right to the point.
First off, since the theme for Grand Rounds this week is Health Care Reform, I will start with that one, which I have aptly named…
Part One: Health Care Reform
I don’t know about you, but I’m not too enthusiastic about what some would call socialized medicine, however, it looks like we’re going to get a national health care plan whether we like it or not. With that in mind, let’s hope they come up with one that’s not a bureaucratic nightmare.
Naturally, the ultimate goal of a national health care plan would be to lower costs while maintaining and improving quality of care. With that in mind, here’s a brief shopping list of what I’d like to see as a consumer.
I. A National Health Insurance Policy
The ideal plan would include the following points:
- It should be optional, not mandatory
- It should be affordable so that most will purchase it
- Its main purpose should be to cover major medical expenses
- Minor expenses such as routine office visits, etc., need not be covered or could be a secondary optional policy (a rider) with some form of deductible or co-pay provision
Having two separate policies would allow major medical to be less expensive. Furthermore, two separate policies would allow for independently adjusting rates to match the cost of each area of coverage. Major medical would not have to bear the weight of routine care and vice versa.
II. Malpractice Tort Reform
Perhaps we should also have a national medical malpractice insurance program.
Key points would be:
- Coverage for lost wages and medical-related expenses only
- Create a victim’s fund that cannot be used for any other purpose
- Eliminate punitive damages in malpractice lawsuits
To clarify that last point:
Suing an insurance company for punitive damages amounts to whipping Paul because Peter did something wrong. The errant physician suffers punitive repercussions from the malpractice suit itself.
The public is not served by attaching a monetary value to some esoteric concept of punishment. We consumers end up paying the cost in higher health care expenses.
Eliminate punitive damages and you will eliminate the incentive to sue for profit. Frivolous lawsuits fueled by greed or other ulterior motives would be greatly reduced.
Cutting the burden of malpractice insurance would have a major impact on cutting health care costs.
III. Medical School Student Loan Reform
Student loan repayment should be waived for any medical student that agrees to serve a certain number of years in primary care upon graduation.
- Medical students could simply apply for a “primary care” deferment upon graduation, which would become permanent after serving the required number of years in the field
- Taxpayers would not fund students who fail to become primary care physicians
- Physicians would still have the flexibility to change their specialty if primary care turned out not to be right for them
The above scenario would not change the educational process and would provide students with the flexibility to choose a specialty in the usual manner while still offering an incentive for those desiring to enter the less lucrative field of primary care.
IV. Serious Medical Intervention
Lastly, I think doctors should go back to passing out lollipops. I distinctly remember my pediatrician used do this following the exam. The last one I got was green. I felt much better.
Part Two: Sciatica Recovery
Okay, now back to business.
Since I get a lot of email asking for my advice or opinion on the topic of sciatica, I’ve decided to start out the New Year by condensing all of my usual answers into one concise list. Here it is…
Key points to remember when dealing with sciatica:
- Sciatica symptoms are caused by a pinched or irritated sciatic nerve
- The symptoms will persist as long as the nerve continues to be irritated
- There is no time frame for how long it will take to get the bulging disc, bone spur, scar tissue, (or whatever) off the nerve so it can begin healing
- Once the source of irritation is removed from the nerve, it will still take a minimum of (an additional) six months for the nerve to heal
So there is no set timetable for recovery. Most find it to be a long, slow — sometimes-frustrating — process.
Rehabilitation is the ideal outcome, but sometimes isn’t possible.
Some rehabilitation exercises may irritate the nerve and have to be modified or eliminated from your program. For example, when dealing with herniated discs, some people find that skipping the forward bending exercises (and avoiding forward bending / sitting postures as much as possible) helps considerably.
How’s that for keeping it short and to the point?
Till next time,
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