WebMD Live Events Transcript

Who better to talk to about dealing with back pain than the man who wrote the book on the subject? Harris McIlwain, MD, author of The Pain-Free Back: 6 Simple Steps to End Pain and Reclaim Your Active Life, joined WebMD Live on May 18, 2004, to answer your questions and offer his advice.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Welcome back to WebMD Live, Dr. McIlwain. Before we dive into some questions, please tell us a little bit about the "six steps" you write about in your book.

MCILWAIN:
The six steps are for those who feel the need to control their back pain, to get old activity back.

• The first step is to show you the ways and the types of exercise that can give you great relief, even within days, and show you how to do them safely.
• The next step is the importance of your ideal weight and shows you how to achieve that with healthy eating choices that help back pain.
• The next step is showing how to use complementary and alternative medicines, such as natural dietary supplements to alleviate pain.
• The next step is making key lifestyle changes. We show how to sit, how to lift, how to do everyday activities, such as sitting at a computer without causing more back pain.
• The next step is showing how to control stress, which makes back pain worse with some easy ways to distress.
• The next step shows ways that massage and chiropractic, acupuncture and many other healing touch therapies can help you with your back pain and helps you discover which ones may be best for you.

MEMBER QUESTION:
According to studies, much back pain is the result of poor postural habits. Are you familiar with the Alexander Technique, which helps people obtain long-term relief from back pain by changing their postural habits?

MCILWAIN:
Posture is absolutely important. Many people find that some simple changes in the way they sit at a desk and how they stand and walk make a huge difference in their back pain. Massage and chiropractic are two techniques that work well. Some other techniques include Rolfing and Alexander and other types of bodywork. We think it is important to have a good therapist who can teach you proper ways to sit, stand, and lift. The Alexander technique is more than 100 years old and is used to reduce a painful muscle tension, improve posture, and reduce stress by re-educating your posture and activity.

MEMBER QUESTION:
I have had upper right back pain with no relief. I have tried PT and massage and the X-rays show nothing. Should I ask for an MRI?

MCILWAIN:
You should discuss it with your doctor, since an MRI is expensive and a nuisance, but if there is a good reason to suspect a problem that could be found by MRI, your doctor will tell you. The most common cause of back pain is in the muscles and tendons and ligaments around the spine, which would not normally show on an MRI, so it is possible that the results of the tests are negative because the pain is in the muscles, tendons, and other soft tissues, which don't show on X-ray.

In addition, you should try the solutions along with your doctor's advice, which usually include moist heat, such as hot shower or hot towels or whirlpool, and exercises to stretch and strengthen the muscles of the back. After a few weeks there is usually noticeable improvement, and the longer you do this program the better the relief. The exercises are one of the best ways to prevent back pain from returning when the pain is coming from the muscles and tendons around the spine.

MEMBER QUESTION:
I had surgery for a herniated disk last June and still have a lot of pain down the back of my leg. I'm back in PT and thinking about cortisone shots. What do you think about that treatment?

MCILWAIN:
There are different types of cortisone shots. Some types are localized to the tender areas around the lower back, and these are called trigger point injections. Then other types of shots are called blocks, and they try to stop pain by blocking the effects of the nerves that transmit the pain. In either case, depending on the type of problem you're experiencing now, it's probably worth a try if it was recommended. Either local trigger point injections or the nerve blocks, which are given usually in a series of three, when they work, may give relief for months at a time.

And of course this should be combined with the basic treatment program, including moist heat and gradually increasing exercises, which have to be guided by your doctor since everyone is different.

MEMBER QUESTION:
My mother has been prescribed Lortab for her pain, but I can't get her to take the prescribed amount -- every six hours -- she wants to take it once a day because she's afraid of getting addicted. Is this drug addictive?

MCILWAIN:
Lortab is narcotic pain medicine, and it is very common for patients to take them only as absolutely needed. The problem is that Lortab will last four or five hours and then the relief usually goes away. So if the pain is constant a regular dose is usually needed to give constant relief. Because it is a narcotic pain medicine, if taken regularly there may be some withdrawal symptoms when it is stopped unless the dose is gradually lowered and stopped.

Addiction is uncommon in this situation. Addiction means the person wants to continue the medication even though they've been told that they should stop, or that it is harmful, or that it is not effective. The problem you're having and convincing her to take the medicine regularly is a common one, and it might help to talk to her doctor to see how that can be managed best.

MEMBER QUESTION:
My mother has had problems with her back for years but recently twisted her back trying to avoid falling down stairs and is in a lot of pain. Would a good sports chiropractor be helpful for her?

MCILWAIN:
That would be fine as a start, because it needs evaluation. The possibilities include pain in the muscles, ligaments from a strain, but there may be other problems, including a small fracture in one of the bones in the spine, and it may be arthritis. So a sports medicine physician, or almost any physician, would be a good place to start.

In these cases, it's important to find the problem so that the treatment can be very specific. For instance, if there happens to be a small fracture then it might be because the bones have become thin, and there's excellent treatment available to prevent more fractures.

MEMBER QUESTION:
I have a pinched nerve (sciatic) in my left side with numbness in my foot and leg. I am having symptoms in my right leg as well (without the numbness). I have undergone an EMG and PT and am waiting to see a neurosurgeon. What types of treatment are used for this problem?

MCILWAIN:
If the problem is caused by a ruptured disc or other pressure on the nerve, then it may be necessary to see the neurosurgeon and have surgery for relief. Fortunately, many people have improvement when they do the program that was talked about earlier, including moist heat, gradually increasing exercises, and some of the other treatment possibilities.

The good news is that the majority of persons who have ruptured discs don't actually have to have surgery for relief, but I would definitely recommend seeing the neurosurgeon so you can get facts. The surgeon will make sure that you have tried everything possible before surgery.

The signs that suggest the need to see a neurosurgeon and have other tests are:

• When the pain is very severe
• When it travels down one or both legs
• When there is numbness and/or tingling in one or both legs
• When there is a change in control of the bowels or bladder
• When the pain is worse when you cough

MEMBER QUESTION:
My feet are numb. Is it possible my lower back is causing this? If it is, will it have dire consequences, like inability to walk sometime in the future?

MCILWAIN:
If the numbness in the feet were from pressure on the nerves in the lower back, then it would be important to discover that and treat it to prevent long-term problems. But remember that there are many causes of numbness in the feet, many of which are treatable, so it is always a good idea to get a diagnosis and the most specific treatment possible. This is best done by starting with your family doctor and then, if necessary, you may need to see another consultant to get the complete answer and the best possible treatment.

MEMBER QUESTION:
I have a HNP, pain anterior thigh, calf, and big toe of the left leg with occasional pain on the right big toe. It was better but came back two months ago. I am considering epidural injections because I can control it with ibuprofen but want to become pregnant. How long should I wait to consider epidural injections or even surgery? How long does it normally take for the disc to centralize and in most cases will it?

MCILWAIN:
It does sound like the way your symptoms are behaving that the problem is from pressure on the nerve. You should talk with your doctor to help decide the timing of the epidural block, which often gives relief that may last for months and may be one way to avoid surgery. With your plans for a pregnancy you need to be extra careful in making sure the timing of the treatments sits with the pregnancy. For this, your doctor or obstetrician can give you the best advice on when to actually consider medications or treatments.

MEMBER QUESTION:
What is a good mattress firmness to relieve nighttime lower back pain? If I sleep on the sofa, no lower back pain. If I sleep in my bed, I have it. Once I'm up and about, it goes away. Please advise.

MCILWAIN:
It does sound like you need to change mattresses, but there are no absolute guidelines. Probably the best advice is to have a mattress that is not too hard and not too soft, and each of us will find a firmness that is most comfortable. Some people actually have less back pain when they sleep on the floor, and some like a very soft mattress. Some patients do very well with waterbeds, while some are not comfortable. There are many different types of mattresses, some which conform to your body's contour that may be expensive. So it would be best to find a mattress that you may be able to test before you have to buy it. If you're most comfortable on the couch you may want to start with a firmness that's similar.

MEMBER QUESTION:
What can you tell me about using a pain management program for an elderly woman with osteoarthritis and back pain who is not a candidate for surgery? My mother heard about a friend who is doing this through a special pain management clinic and we wanted to find out what it's all about.

MCILWAIN:
It sounds like pain management evaluation would be a reasonable step in her case. If there is a comprehensive pain management center near you, that would be a very good choice, because they would be more likely to have available all of the ways to control pain.

A pain management clinic would be a good choice for most patients that do not plan surgery and have a diagnosis. The reason to get a diagnosis is to avoid covering up pain when there is a different treatable cause. Pain management can involve many different treatments, including physical therapy, massage, medication, psychological, epidural blocks, and other ways to manage pain, such as an implanted port, which slowly releases pain medicine.

MEMBER QUESTION:
My daughter is 8 years old and she hurt her back, once from carrying her backpack home, and then the following week she fell off the tire wheel swing at school. This was 4/8/04 when this started; she is now on her third week of physical therapy and she is still having pain all day. There are some days when it only hurts a little, but for the most it hurts badly round the clock. Even the exercise is not helping ease the pain. Nothing is broken or out of line. Any ideas?

MCILWAIN:
She needs to have a diagnosis, and the specific problem needs to be discovered. To do that, it would be a good idea to see a pediatric orthopaedist, and your doctor can help guide you to the best consultant in your area.

Backpacks at school have been increasingly found to contribute to back pain in elementary, junior high, and high school students, partly because more and more books are heavier and heavier and so are many other supplies that are carried. Some schools and other organizations have actually tried to limit the weight of some books and make other adjustments to avoid the strain of a very heavy backpack in young children.

However, it sounds like the pain is troublesome enough that it would be important to make sure there's no other problem. A pediatric orthopaedist or other orthopaedist would be a good place to start.

MEMBER QUESTION:
I hurt my back very easily; bend, lift, or sleep the wrong way and it's out! I have done the stretches, the exercises, the creams, and the pills (which I don't like). When I pull it, it's always the lower part. I can't walk or even move; my leg just won't work at all. Any suggestions on what else I can do? Pain is no fun. I like being active with my kids. By the way, I am only 29.

MCILWAIN:
You definitely should take some action. The first step is to get a diagnosis and be sure that no other problem is present by talking to your doctor. If no other problems are found to explain the back pain, then it is possible you have the most common cause of back pain, which comes from muscles and tendons and ligaments around the spine, most commonly in the lower back. The attacks often come without warning and last a few days to a week or two and come on a few times a year. Typically, it is not from abuse of the back and one patient said it might come on if they reached over to pick up a feather.

It is known, however, that the best treatment, as outlined in the book and we discussed earlier, includes moist heat, such as a hot shower, hot bathtub, or whirlpool, the correct exercises to strengthen the back, which is almost the only treatment that has a good chance of making the attacks come less often and less severe, and then using other treatments, such as massage, chiropractic treatment, or others, as we have talked about, to get relief.

Medications can be used, but they are not the main part of the treatment in this situation.

It would be important to be sure you're doing the correct exercises and the correct number of exercises, so you may want to see a physical therapist or discuss these with your doctor to be sure you're getting the best effect from the exercise. If the muscles get stronger the back has fewer attacks and your down time will be much less.

MEMBER QUESTION:
My knee doesn't want to bend causing me to walk with a limp. Is this causing my back pain or is by back causing my knee pain? What kind of specialist should I see?

MCILWAIN:
Both may be correct. If the back hurts you walk differently, which puts more stress on the knee. If your knee hurts, it makes the weight different on the back and can certainly cause strain in the muscles of the back. So just like the other problems we've talked about, it would be a good idea to get a diagnosis by talking to an orthopaedist or an arthritis specialist, or your family doctor. Then treat the main problem while you gradually add moist heat and exercises safely. But your point about which pain started the problem is a good one.

MEMBER QUESTION:
The VA has diagnosed me with stenosis of the lumbar area. This has been going on since 2002 and I have had one treatment: an injection of steroids and a painkiller. It gave me one week with no pain. I was to have another treatment this coming Wednesday, but the VA has rescheduled it another month away. That will be four months between injections. Is there anything else I can do to relieve the constant pain I am in? I have a painkiller med along with Tylenol and an arthritis med. This is really to the debilitating stage. I cannot stand, walk, or sit for any length of time without pain.

MCILWAIN:
If the pain is severe enough then it may be a good idea to go to a clinic outside the VA system if you don't think you can wait for treatment. However, it sounds as if you're getting proper treatment, although it has been delayed by the appointment. It would be a good idea to be sure that you understand what else you can do, which usually includes moist heat, exercises for the back, and medication for pain control. It would be a good idea to discuss the problem of the appointment with your primary care physician and see what arrangements can be made, so that you can become more comfortable.

MEMBER QUESTION:
I have upper back pain under the shoulder blade. The pain is a stabbing pain that sometimes radiates to the front under the breast. I have had X-rays along with PT exercises, massage, and meds with no relief. I also have neurofibromatosis, tendonitis in my right elbow, and just had bilateral cubital tunnel surgery done. In the past I have had bilateral carpal tunnel done. I have had a synovitis in the wrist along with tendonitis and a tear that was repaired. I have parithesis maralgia in the right leg, which gets intense and painful at times. I also have a mass on the sciatic nerve on the left side that causes problems with my left leg. I also have acromioclavicular arthrosis. I am trying to find out what is causing my back pain and why it seems that instead of getting better new things pop up.

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MCILWAIN:
You have some complicated problems, and because of the neurofibromatosis it would be important to talk with your main doctor and the doctor taking care of the neurofibromatosis to let them sort out which problem is causing that specific pain, because the pain could be caused by the neurofibromatosis or a complication, but it may also be caused by more common problems such as arthritis or pain in the muscles, ligaments or tendons, or the problems we've talked about today.

MEMBER QUESTION:
My husband had back surgery in '97. He still has numbing, tingling, etc. in his legs and feet. One foot is now completely flat. What should his next step be? He states that he never got back his feeling in his leg/foot.

MCILWAIN:
Well, there are several possible problems. There may be not complete recovery from the original pressure on the nerve, even though everything was done correctly, especially if it was severe or was present for a long time before surgery. Also, sometimes scar tissue can build up and make symptoms return. In addition, there are other problems that can develop and be added to cause these symptoms.

So the best plan might be to go back to the surgeon, if that surgeon is still available, to be sure there is not a specific problem that can be corrected, then talk with your primary care doctor or a neurologist to see what may be causing the problems to persist. It's important to get the diagnosis as close as possible so that treatment can be planned to be as accurate and specific as possible.

MODERATOR:
We are almost out of time, Dr. McIlwain. Do you have any final words on beating back pain for us?

MCILWAIN:
It's very important to understand you don't have to live with it; it can be controlled, and there are simple things you can do at home to improve back pain, improve the strength of the back, and get around to do the things you want to in reasonable comfort.

MODERATOR:
Thanks to Harris McIlwain, MD, for sharing his expertise with us today. For more information please read his book, The Pain-Free Back: 6 Simple Steps to End Pain and Reclaim Your Active Life .

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