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Back Pain Rarely Needs Surgery · Doctor Turned Health Coach

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  Welcome to doctor-turned-health-coach. My name is Dr. Ashwari,
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  and today we're going to talk about back pain.
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  So, I myself have dealt with back pain, and as a family medicine physician,
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  I've managed a lot of patients with back pain. So, this is going to be a little
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  bit of a systematic approach.
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  So, how to think about back pain, what to do about it yourself.
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  And then also I'm going to share with you all the things that I've learned over
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  the years when it comes to back pain and some of the books I've read.
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  I think there's a lot to take away here. The good news is most of my patients
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  with back pain, it ends up being nothing serious. It goes away on its own.
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  But in general, it's a signal that something is going on.
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  And perhaps it's a it's a call to action, right?
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  To say, okay, well, there's something going on in my body, something in my mechanics
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  that I need to pay attention to and hopefully get rid of this or decrease the intensity of it.
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  Now, pain itself deserves a whole topic, which I'll get into in the future.
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  Many great physician authors have talked about pain and the fact that as human
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  beings, we can catastrophize pain, and pain itself can become an issue.
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  Long after the insult or the trauma to a part of our body is gone, the pain can persist.
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  And this often has a little bit of a psychosomatic, psychological factor to
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  it. It doesn't mean that you're not experiencing the pain.
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  Hopefully, no competent physician should ever make you feel that way,
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  but it might need a different approach.
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  Doing surgery on somebody's back because of a psychosomatic pain is only going
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  to cause trauma, but it's not going to heal the psychosomatic pain.
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  So that's pain. And when it comes to back pain, I like to think about it in
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  a few different categories. One of them is inflammatory.
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  And the reason it's the first one that I mention is because it's also one of
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  the most important ones that we have to pay attention to.
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  Maybe even just a couple of decades ago, we did not have good treatments for
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  inflammatory arthritis, the plural for arthritis.
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  And now we do. We have great medications, biologics and other specialized medications
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  that work for people with either autoimmune or inflammatory arthritis conditions.
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  So we don't want to miss that. The second one is soft tissue problems,
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  whether it's the fascia,
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  which is a tissue that covers muscles and tendons and nerves,
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  whether it's the ligaments and tendons and cells,
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  or whether it's muscle.
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  And sometimes they can all work together, creating a lot of problems.
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  They can pinch a nerve. They can put pressure on a blood vessel.
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  And they can lead to instability, a very classic issue in the sacroiliac,
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  the SI joint of the lower back.
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  And finally, I would say the actual damage to the joint, which,
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  yes, you can get that in inflammatory arthritis as well, But we usually refer
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  to that as osteoarthritis.
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  Osteoarthritis meaning it's degenerative.
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  Degeneration with age, with time, anybody after the age of 35 is going to have
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  a little bit of changes on the surface,
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  the cartilage surface of the joint, and that can cause some rubbing and friction
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  in the back, whether it's the joints themselves, whether it's the discs,
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  the facet joints, for example, and that's where we can see some issues. Now,
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  One thing that many of my patients come to me for is, their big fear is,
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  do I have a herniated disc?
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  Well, yes, you might have a herniated disc. The good news is that most herniated
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  discs will resolve on their own.
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  They'll go back in, they'll retract, they'll desiccate, they'll disappear,
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  dry out, and you'll go back to being normal.
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  And the best thing that you can do in that time is to take the pressure off
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  of that disc to let it heal. because the capsule is often damaged.
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  And that falls in that second category. It falls into the soft tissue category.
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  And when it's arthritis, you'll know because when I say arthritis,
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  I'm going to refer to osteoarthritis.
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  When it's osteoarthritis, you'll know because you wake up in the morning and
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  you're pretty stiff, pretty tight.
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  And with some movement, it actually loosens up and it gets a little bit better,
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  sometimes impact exercises. make it worse.
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  For me, classically, it's going to be bouldering, rock climbing.
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  When I jump down and fall down, boom, my back is set off, and I'm going to have
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  some pain the next day for sure.
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  And I'll wake up with some pain in the morning, and it's usually muscle-related.
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  One way that I can tease that out is I can apply a little bit of a topical numbing
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  medication, whether like an herbal one or lidocaine.
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  And usually the muscles won't spasm, so I wake up without pain.
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  The next time I do the same exercise and I wake up with pain,
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  I know it's probably my muscles. It's less likely to be the joints themselves.
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  Now, when it is joints, it can also get kind of activated with certain positions
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  where the joints will kind of rub on each other.
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  With muscles and soft tissue, it can do the same thing.
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  With inflammatory arthritis, so we're talking rheumatoid arthritis,
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  rarely lupus, but psoriatic arthritis, sacroiliitis, some of these other autoimmune
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  conditions, oftentimes when you wake up, the pain is going to be a bit more intense,
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  and it's going to take much longer than 30 minutes or 45 minutes for the pain
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  to kind of loosen up, the stiffness, for the stiffness to disappear.
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  The stiffness in osteoarthritis resolves pretty rapidly after you wake up.
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  With inflammatory arthritis, you might also have changes of skin like psoriasis.
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  You might have inflammatory symptoms like fevers, chills, fatigue,
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  tired, nausea, foggy-headed, appetite might be lower, a lot of other things.
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  Weight loss can happen. And you might have other symptoms in other parts of
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  the body, whether it's the eye, the brain, the kidney, the liver, the heart.
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  So those are things and very important things to pay attention to.
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  One of the most powerful things that I think I do as a physician health coach
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  is to help my patients be more in tune with their body, to experiment a little
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  bit and feel empowered that, okay, I'm in my 30s, I'm in my 40s. This is the first sign.
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  That's often the time when people start experiencing back pain.
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  I'm in my 30s and i'm feeling this back stiffness what's going on what did i
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  do what didn't i do what activity change can i make.
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  Of course, you can certainly play around with diet, and some of my patients
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  have told me that dairy or gluten might set them off, but remember that there
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  is a lot of placebo effect in this.
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  You might experiment with something and see a huge difference,
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  and then you're convinced that it's gluten, that it's gluten intolerance,
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  and you change your gluten habit, but then the pain comes back. What do you do then?
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  So instead of being very strict about it, try to experiment more softly.
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  So you can say, all right, I'm going to slowly cut back on this and see how
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  it goes and monitor it for a few weeks.
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  I'm going to write everything down in my journal. That's very powerful,
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  by the way, keeping a journal.
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  And I'm going to see if maybe cutting out gluten next, cutting out dairy next, cutting out eggs.
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  You know, there's a FODMAP diet. There's all sorts of things that you can try.
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  Some people will do magnesium. Some people will do topical creams.
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  All of these things are fine to try. But try to do them one step at a time so
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  that you really have a good idea.
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  Classic concerns that my patients
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  tell me is when i stand for a long time my
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  back pain gets really bad but other times it's really not
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  that bad sometimes they say when when
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  i'm really stressed my back pain gets really bad standing for a long time causes
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  us to eventually slouch what happens is we lose our abdominal muscle pressure
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  and so the back will start collapsing on itself a little bit,
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  and either the vertebra can touch each other too much and put pressure on themselves,
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  or the nerves can get a little bit pinched, or the muscles actually start becoming
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  so edematous, full of fluid, that they start spasming.
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  So one of the good things that you can do regularly is to do a few gentle air squats.
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  You don't have to go all the way down and all the way up like they do on
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  tv or youtube just a little bit of
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  a quarter hip hinge uh gentle up
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  and down motion of your at the lumbar sacral kind
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  of the lower part of the back is more than enough you can do a gentle lunge
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  you can get on the ground and do do a few stretches you can do some knee raises
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  and kind of hold it to engage the ab muscles those are all the different things
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  that you can try especially when your pain gets uncomfortable with long-standing.
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  When it's stress-related, it's usually the same thing. You'll develop a lot
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  of tension in your neck muscles, in your trapezius, then in your lower back.
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  And of course, all of these things are connected. As we always say,
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  we're connected human beings.
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  And so one pain somewhere is going to translate to something else.
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  And so, of course, stress management techniques, which usually start with becoming
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  aware of what's on your mind, what's in your head.
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  Some good breathing techniques can be very helpful.
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  Classically, meditation, focusing on your breathing, focusing on each muscle,
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  really zoning in on that area that's painful and then trying to relax it.
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  Other times my patients tell me that I used to have a favorite sport,
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  I can no longer play it because if I do, my pain is going to be on fire.
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  Well, a couple of things that you can do is do some other exercises.
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  So core exercises, strengthening exercises, active stretching exercises,
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  Pilates, yoga, right before you do your activity and see if that'll make a difference.
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  Because sometimes you're simply not recruiting those parts, those muscles in
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  the lower back that you need to in order to protect your back during your activity.
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  So doing that before your activity can be very helpful.
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  Sometimes it's just a tight fascia, tight connective tissue.
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  And so after your activity, doing a good stretch routine is incredible.
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  I can tell you that when I do bouldering, rock climbing, if I don't do stretches
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  right afterwards, which is fine, I don't always do it, then I know the next
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  two days I'm going to be stiff. I'm going to have a very hard time moving around.
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  That doesn't mean I'm not functional, but every time I get up,
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  I feel it in every part of my lower back down to the glutes.
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  Now, we didn't touch on piriformis syndrome and sciatica,
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  but in general, they fall into this middle category of soft tissue,
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  because you can either have a
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  little bit of pressure on one of the roots of the
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  nerve near the sciatic nerve or the
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  muscles can spasm or be so loose that you
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  put pressure on the in the
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  performance muscle and then that'll translate over to the sciatic nerve oftentimes
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  some good physical therapy exercises can be beneficial you're going to have
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  to experiment no one particular exercise is magic sometimes the leg crossover
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  and stretching your torso the other way.
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  That stretch is amazing for some people.
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  Doing a hip lift, hip thrust, when you're laying flat on the ground,
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  can be very effective for some people, but totally ineffective for others.
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  Squats can be amazing for some people, and not so effective for others.
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  So, if you have a good physical therapist, that's the best person to work with.
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  Now, what I do is I always refer my patients to physical therapy,
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  and because my medical practice is virtual, because it is online, it's Quite easy.
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  I can send my patients for a virtual consult with a great physical therapist
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  that I like, and they do those exercises together. They come back to me,
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  we assess, we determine if anything else is missing.
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  Now, finally, we'll get to some treatment regimens for back pain. I like everything.
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  Topical magnesium, Epsom salt baths, oral magnesium, topical lidocaine cream,
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  which you can even purchase over the counter. There is the popular badger sore
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  muscle rub. That's the one I use a lot.
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  Now, I haven't mentioned any medications, but certainly you can use topical
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  Voltaren gel like an anti-inflammatory.
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  But I generally want to first know what's going on before I have a patient use
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  any topical anti-inflammatories or take any either prescription or over-the-counter
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  medications because otherwise we might just be masking a problem that's going
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  to become a bigger problem in the future.
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  A lot of my patients are worried about herniated discs. Again,
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  I just want to stress this one more time.
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  Herniated discs are usually not a problem, and especially if it's going on for
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  a long time, it's even less likely to be herniated discs because a herniated
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  disc often happens in an acute time frame, in a short time frame,
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  and it either gets really, really bad or it just kind of goes away.
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  For it to be going on for a very long time, it's just a little bit less likely.
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  Now the people that I often refer to for more complicated cases is a non-surgical
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  sports medicine doctor.
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  So usually this is an ER doctor or family medicine doctor or internal medicine
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  doctor who did a fellowship in sports medicine.
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  The reason I like this option is because if I send somebody to a surgeon,
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  most surgeons are really good at surgery. They know how to fix a back problem with surgery.
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  The complication is, I've taken care of a lot of patients who've had back surgery
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  who may have needed other back surgeries in the future.
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  So even though it is one option to go, there are better options available.
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  Physical medicine and rehabilitation doctor. The cool kids call them PM&R doctors, PM&R doctors.
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  They're also great, fantastic people to go to. They really understand the functional
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  aspect of the lower back.
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  An orthopedic surgeon is perfectly fine to send a patient to,
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  ideally a sports orthopedic surgeon, somebody who did a fellowship in sports medicine.
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  I also like sending my patients to physical therapists, as I mentioned.
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  I think that's also great.
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  And rarely will I send somebody to nutritionists, but I have referred patients
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  to massage and acupuncture.
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  Absolutely, if you believe in those things, they can help. If you don't believe
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  in it, unfortunately, the chance of it working is lower. That's the same thing with medication.
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  If you don't believe in a medicine, if you take it, you may not have any results.
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  Somebody else who has a strong belief in medications is going to have fantastic results.
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  Now, a lot of my patients will ask me about glucosamine, chondroitin.
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  Now, I've done the research myself. It hasn't been that strong.
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  And again, we need to know what kind of back pain you're actually dealing with
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  before recommending any supplements.
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  But by all means, if you have a great herbalist or supplement expert that you go to, go to them.
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  Ask for something that's trustworthy, and you can always give that a try.
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  Write it in your journal.
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  In general, a combination of stretching, local massages, stress management,
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  And those three things are probably the biggest ways of managing back pain.
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  And remember, one of the most important things is also not to catastrophize back pain.
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  Just because you have some back pain now, it doesn't mean you're going to have
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  terrible back pain in the future. It doesn't mean you're going to be bed bound.
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  It just means you have some discomfort in the lower back.
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  And there are a few things that you can try to see if you can improve it.
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  So I hope this content is of value to you.
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  Please share this podcast episode with anybody
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  that might benefit if you're someone in your 30s or
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  40s and looking for a health coach looking for a physician who understands health
• 17:02
  and helps you with healthy aging i would love to be that physician go to my
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  website drashori.com you'll find the link in the show description and thank you for tuning in.