Sept. 20, 2008

Back Pain and Anger

Yikes! Looks like somebody tried to swipe her Cheerios.

Which reminds me, here’s a portion of an email I received a while back that I decided to save — not because it was unusual — but because it was so typical of the type of thing I hear over and over again…

“I was 40 yrs old and I had never had any back problems prior to this incident. I had lower back discomfort beginning over 10 months ago now from what was over exerting myself while overhead lifting some sheetrock on a scaffold. Looking back I am so regretful, what a dummy that stuff was way heavy and I just got pissed off, we where trying to get this piece to fit and with all the stress in my life at the time and it being 95 plus degrees, I just lost my cool and at the moment was not thinking about my back…”

I can just see your head nodding and you’re thinking, “Yeah… been there, done that.”

And since this is something that seems to affect us all to one degree or another, I decided to look into this problem to see if there wasn’t something we could learn from it.

In a nutshell, what I found was:

1. Anger definitely places you at risk for injury
2. You can control how you respond
3. Awareness of the risk seems to be the key to avoiding injury

Anger and Risk of Injury

Wouldn’t you know it? They actually did a study on this and proved what we already knew. Yes indeed, I kid you not. Researchers at the University of Missouri - Columbia (Go Mizzou) have demonstrated emphatically that blowing your top and kicking a fire hydrant is not a good idea.

God bless ‘em. I don’t know about you, but I’m definitely going to sleep better now that that’s settled.

But seriously, (and you know I’m always serious) they really did a very interesting study on this and came up with some rather useful observations. Not about kicking cast iron objects, but about anger and the risk factors associated with it.

What they did was survey 2,400 patients from three hospital emergency departments to determine what emotions they were feeling just prior to their injury.

Here’s what they discovered…

In case-crossover analyses, higher levels of all anger variables were significantly associated with increased injury risk among men and women combined. [1]

They then go on to give us some numbers. (These guys love numbers.)

In this study, emotions reflecting externally directed anger were common. The prevalence of anger among injured patients was as follows: 31.7% reported some degree of “irritable” just before the injury, 18.1% reported feeling “angry,” and 13.2% reported feeling “hostile”. [1]

Hang on a minute.

According to my Hello Kitty calculator, that’s over 60% of the people surveyed were feeling somewhere between irritable and downright hostile just prior to the bonehead move that earned them a ride to the ER.

That’s a lot of avoidable accidents, if you ask me. (It is an accident when you punch a wall and break your hand, isn’t it? That’s what I thought. Just checking.)

In essence, what this study discovered was that people who were feeling angry just before getting hurt faced a substantial increase in the risk of injury.

You Can Control Your Anger

Okay, let’s face it. It’s normal to get angry from time to time. There’s nothing you can do to avoid emotions (unless you’re Leonard Nimoy), but that doesn’t mean that anger has to lead to injurious behavior.

One thing the author of this study noted was that anger seldom led to injury while driving.

Hmm… Isn’t that interesting. He noted that people experiencing road rage almost never put their anger into action.

He speculated that the reason people weren’t ramming each other on the freeway was that most of us are well aware of the possible consequences. No matter how enraged we might become at the other drivers on the road, we know that it’s not worth a trip to the hospital (or the morgue).

So we yell, we fume, we make socially unacceptable gestures, but we don’t turn into Kamikaze pilots just because some bozo cuts us off on the way to work.

(California doesn’t count. They’re nuttier than Texans out there.)

Awareness of the risk, key to avoiding injury

Here’s the deal:

If we can reign in our anger on the roadway, we can do the same during life’s other stressful moments. If that piece of sheetrock doesn’t fit, take it down and try it again later. If someone at work is pushing your buttons, just walk away.

Take a breather. Think bad thoughts. Plot your revenge. But don’t act on any of it.

Instead, when you’re tempted to take your anger out on someone or something, just remind yourself of the risk factors. You can do it. You do it all the time when you’re driving.

Yell, cuss, invent new forms of sign language, but don’t kick, hit, strain or otherwise express your anger and frustration physically. It’s not worth a sore toe, a busted hand or a trip to the emergency room with a sprained back.

Okay, maybe it’s easier said than done, but I think it’s worth a try.

By the way, I believe I just found the perfect solution for rush hour traffic.

Later,
Dean

References:

1. Vinson DC, Arelli BS, State Anger and the Risk of Injury: A Case-Control and Case-Crossover Study. Annals of Family Medicine 4:63-68 (2006)

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Sept. 13, 2008

What Causes Herniated Discs?

Welcome back. Last time we took a look at general spinal anatomy with a particular emphasis on just how the disc is made. In a nutshell we saw that…

The intervertebral disc is basically made up of two parts and is often compared to a jelly donut. This donut-like structure is porous much like a sponge and (when healthy) is filled with fluid.

The center of this disc contains a jelly-like sack called the nucleus that — along with the fluid in the disc itself — acts like a hydraulic shock absorber.

The outer portion of the donut is called the annulus and is a series of concentric rings of fibrous connective tissue that surrounds the nucleus much like a ring of forts built one inside the other.

We ended by asking the question how can a disc fail? I believe the answer to that question has to do with:

1. Disc degeneration
2. Hydraulic pressure

The Root Cause of Disc Degeneration

The first part of the equation lies in the fact that the disc does not have a blood flow. It obtains its moisture and nutrients by a pumping action as the vertebrae above and below lift, flex and bend in all directions. Without this pumping movement of the vertebrae, the disk will not be able to replenish its moisture content and will dry out. It will literally starve to death.

As those once tough fibrous rings lose their moisture and dry out they begin to crack and delaminate just like an old rotten piece of plywood. Allow this degeneration to continue unchecked for year upon year and it becomes quite easy to see how a soft sack of jelly could break through that once formidable fortress.

Medical professionals have named this condition degenerative disc disease.

The Effect of Hydraulic Pressure

The second part of the answer lies in simple physics.

In physics, stress is classified according to type such as tensile strength (stretching the object), torsional strength (twisting the object), shear strength (lateral tearing of the object), and compressive strength (load bearing ability).

Of course, the normal intervertebral disc is designed to withstand all of these stress factors, but the two that appear to have the most impact on herniation are twisting and compressive loading. For now, let’s just focus on compressive loading.

“Under spine compression the nucleus pressurizes, applying hydraulic forces to the end plates vertically and to the inner annulus laterally. This causes the annulus collagen fibers to bulge outward and become tensed.”
- McGill, page 44 [1]

If you’ve ever experienced a leaky basement, you’ve observed first hand the power of hydraulic pressure. Given the slightest crack, water under pressure can penetrate even the thick concrete walls of your basement.

When compressive force is applied to the disc, McGill noted that pressure is applied to the nucleus. This pressure pushes the nucleus in the opposite direction of the applied force. (In physics, this is known as “cause and effect.”)

For example, if the pressure is applied to the front of the disc — such as in the act of sitting or bending forward — the nucleus will be squeezed towards the rear. If the fortress walls of the annulus are weakened, this hydrostatic pressure will begin to force the jelly-like nucleus through those walls.

Repeatedly apply this rearward pressure on the nucleus and it will eventually work its way through the walls of the fortress until it breaks completely through into the spinal canal.

This is not a sudden process. McGill has demonstrated that this requires a great deal of pressure and many thousands of repetitive cycles of forward bending.

“While no herniations were produced with 260 N (Newtons) of compressive load and up to 85,000 flexion cycles, herniations were produced with 867 N of load and 22,000 to 28,000 cycles, and with 1472 N and only 5000 to 9500 cycles (Callaghan and McGill, 2001).” [1]

McGill’s research involved mechanically flexing spinal segments taken from swine (since they closely match the human spine) until those segments failed. While they did this, they tracked the migration of the nucleus as it pushed its way through the walls of the annulus.

It is probably not feasible to test for the effects of constant static pressure since it would most likely take months if not years before a single test specimen would fail. But I think we can safely speculate that constant hydrostatic pressure (hours spent in a sitting / bent forward posture) would most likely produce similar results.

Do You Know Where Your Nucleus Is?

If you’re spending hours in a classroom, hours riding in cars, hours a day working at a desk and hours sitting on the couch at home, your discs are probably not getting pumped enough to adequately replenish the moisture lost during all that downtime.

Add to that the constant static pressure of the bent forward posture that sitting entails — squeezing the nucleus in one direction — and you don’t have to be Einstein to figure out the end result. The nucleus is going to seek the path of least resistance.

This is starting to get lengthy and we have much more to cover on this subject, but I’m going to jump ahead a bit and give you what I initially intended to put at the end of this series:

My Personal Disc Rehabilitation Philosophy

I believe that disc rehabilitation needs to focus on two main goals:

1. Centering the nucleus
2. Restoring the moisture content of the disc

The Do’s:

• Gentle mobilization (disc hydrating) techniques are imperative and should be performed as frequently as possible throughout the day, everyday.
• Gentle stretching can be helpful especially for applying a reverse compressive load. (More on this later.)
• Apply gentle decompression techniques frequently throughout the day, everyday.

The Don’ts:

I maintain that gentle rehabilitation techniques should be utilized at all times, therefore:

• Forceful twisting motions should never be applied.
• Sudden, high velocity motions should never be applied.
• Weight bearing exercises or any similar strenuous activity that increases compression loading on the disc should be avoided until the annulus has been fully restored to a healthy state. The time frame for this will vary with the individual.

With all of the above, be sure to check with your doctor or physical therapist before proceeding on your own. There may be extenuating circumstances that will require you to modify your particular home exercise program.

In most instances, you can rebuild your herniated discs with a home exercise program, but enlisting your doctor or a well-trained physical therapist to help you monitor the situation — and advise you along the way — may just mean the difference between success and failure.

Yes, it is possible to go it on your own. But why not make a little extra investment and, thereby, stack the odds in your favor?

Until next time,
Dean

References:

1. McGill, S. Low Back Disorders, Evidence-Based Prevention and Rehabilitation, 2nd Edition. (p. 44-47) Human Kinetics (2007)

2. Tampier C, Drake JD, Callaghan JP, McGill SM. Progressive disc herniation: an investigation of the mechanism using radiologic, histochemical, and microscopic dissection techniques on a porcine model. Spine. 2007 Dec 1;32(25):2869-74.

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Sept 6, 2008

Sciatica and Epidural Injections - Risks and Side Effects

So far in this series we’ve discussed what epidural injections are, what they are not, and how to determine if you are a candidate for the procedure.

What we haven’t discussed are the risks and potential side effects that go along with getting these injections.

Since we all want to be informed consumers, let’s first take a look at the risks involved with epidural steroid injections.

There is Always a Risk

Every form of medical intervention involves risks and potential side effects.

There are risks involved with simply taking an aspirin or over-the-counter cold remedy. There are even risks associated with taking vitamins and herbal supplements especially when you’re taking them for medicinal purposes.

So it should come as no shock that there are risks that you need to be aware of before you decide to undergo a series of epidural steroid injections. Here are the main ones:

Infection

There is always the risk of infection whenever you undergo an invasive medical procedure. With an epidural injection, your doctor will be puncturing the skin and injecting medication into the lumbar region of your back.

Fortunately, serious infections from this procedure are rare (less than one tenth of a percent) and minor infections only occur in about 2% of all patients.

Dural Puncture

A dural puncture sometimes does occur, however this is also extremely rare. When this does happen, it can result in a headache that normally clears up in a couple of days. If it doesn’t, there is a simple procedure called a blood patch that your doctor can use to stop the leak.

Bleeding

Bleeding caused by the injection is also extremely rare and usually only occurs in patients who have a bleeding disorder.

Nerve Damage

Whenever you stick sharp objects into your body, there is always the possibility that some nerve damage can occur. This might be the result of a nerve coming in direct contact with the needle or from one of the other risks mentioned above such as an infection. Again, this is extremely rare, but something you should be aware of just the same.

What are the Side Effects

In addition to the risks mentioned above, a small number of patients will experience some form of side effect from the medication. These are usually temporary - lasting no more than a day or two - but can include one or more of the following:

• Increase in lumbar pain
• Headaches
• Facial redness or warmth (flushing)
• Anxiety or mood swings
• Sleeplessness
• Fever
• High blood sugar
• Brief reduction in immunity

The only long-term side effects associated with corticosteroids appear to be the result of excessive or prolonged steroid usage - not due to the limited number of injections we’re talking about. These included such things as stomach ulcers, cataracts, osteoporosis and arthritis.

Again, these disorders have only been shown to occur in people with long-term use of corticosteroids and not to people who merely undergo epidural injection for sciatica. In other words, they don’t really apply to this discussion.

Who Should Not Get the Injections

Lumbar epidural steroid injections should not be performed if you have any of the following:

1. Bacterial infection
2. Bleeding problems
3. Back pain due to a tumor or infection
4. High blood pressure
5. Diabetes

In addition, you should not get the injections if you are pregnant, if you are allergic to the medication, or if you are on blood thinners such as aspirin or Plavix.

Cover All Your Bases

As always, be sure to inform your primary care physician that you are considering this procedure so that you can discuss any medical conditions that might affect the outcome. Then be sure to inform the doctor performing the injections about any of these conditions.

He or she will attempt to minimize the risks and potential side effects by administering the lowest dose possible. And will also be more than happy to discuss everything we’ve discussed here and answer any additional questions you have in more detail.

Next time we’ll wrap this series up by going over exactly how the procedure is performed and what you can expect to happen the day you go in for the shots. (That is unless I think of something we haven’t covered yet.)

So stay tuned,
Dean

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