19 reasons why you have back pain.

Fairmont Banff Springs Hotel and Resort (Dr. Noorali Bharwani)
Fairmont Banff Springs Hotel and Resort (Dr. Noorali Bharwani)

If you look at the spine you wonder how it was created.

Spine is a column of bones (vertebrae) held together by muscles, tendons and ligaments and cushioned by shock-absorbing disks. If you have a backache then the problem can be in any one or more of the elements forming your spine.

Low back pain is one of the most common and costly musculoskeletal problems in modern society. It is experienced by 70 to 80 per cent of adults at some time in their lives.

Your symptoms can vary from simply being an annoyance or it can be excruciating and disabling pain.

Good news is most back pain goes away on its own or with some medical treatment within four weeks. Surgery usually isn’t needed and generally is considered only if other treatments are not effective.

Most common reasons for strains and sprains are improper lifting, poor posture and lack of regular exercise. In one article, I saw a list of 19 causes of back pain. Some common problems are herniated disk, obesity, osteoarthritis, osteoporosis, poor posture, sciatica, spinal fractures, spinal stenosis and sprains.

When do you need tests like X-ray, CT scan, or MRI?

According to the guidelines in Choosing Wisely, most people with low back pain do not need these tests because these tests do not help.

There are three reasons why you should not rush into getting these tests. First, most people with lower-back pain feel better in about a month. Second, people who get these tests do not get better faster compared to people who took over-the-counter pain medicine and followed simple steps, like walking, to help their pain. Lastly, these tests lead to surgery and other treatments that you do not need.

That does not mean imaging test for back pain is a bad idea. In some cases, you may need an imaging test right away.

For example, if your back pain is associated with weight loss that you cannot explain, fever over 39 degrees C, loss of control of your bowel or bladder, loss of feeling or strength in your legs, problems with reflexes, and if you have a history of cancer.

These symptoms may suggest nerve damage or a serious problem such as cancer or an infection in the spine. If you do not have any of these symptoms, Choosing Wisely recommends waiting a few weeks for x-rays.

How much bed rest is too much?

For many years, getting bed rest was the normal advice. However, newer data have shown that there is little to no role for bed rest in the treatment of low back pain.

Research suggests if you find comfortable positions and move around sometimes, you may not need bed rest at all. Research also shows more than 48 hours of bed rest may actually increase pain, by increasing the stiffness of the spine and the muscle.

The sooner you start physical therapy or return to activities such as walking, the faster you are likely to recover.

A study published in 2015 by Furlan AD et al (Massage for low back pain) found massage therapy has the potential to minimize pain in the short term and speed return to normal function. More study is required to see if massage has long-term benefits.

According to Harvard Men’s Health Watch, yoga is a gentle practice that is ideal for maintaining back strength and flexibility. It’s also one of the more effective tools for helping reduce low back pain. It should be done gently and carefully.

The benefits of yoga go beyond muscles. The slow movements and the continuous focus on proper breathing can improve the emotional aspect of back pain by helping to lower stress and alleviate anxiety and depression.

It is important to keep moving to maintain muscle strength and flexibility. With bed rest, you lose about one per cent of your muscle strength each day. And you can lose 20 to 30 per cent in a week. Then it is harder to return to regular activity.

Most people with lower-back pain should apply heat or ice. Some people can get pain relief from an over-the-counter anti-inflammatory medication.

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Horrors of Fentanyl Abuse Continue to Grow

Camões' tomb in the Jerónimos Monastery, Belém, Lisbon. (Dr. Noorali Bharwani)
Camões' tomb in the Jerónimos Monastery, Belém, Lisbon. (Dr. Noorali Bharwani)

Narcotics are the oldest (since 4000 BC) as well as the strongest pain-relieving drugs known to mankind. Narcotics or opioids (means the same thing) are drugs that act on the nervous system to relieve pain. Continued use and abuse can lead to physical dependence and withdrawal symptoms.

Is there a difference between narcotics, opioids and opiates? Opioids include opiates, an older term that refers to drugs derived from opium, including morphine. In some jurisdictions all controlled drugs are legally classified as narcotics. Now the term opioid is used for the entire family of opiates. 

Last year, almost 2,500 Canadians died from opioid-related overdoses. These are usually young and otherwise healthy individuals. There is no doubt we are in the midst of a drug crisis, with about 200 per cent increase in the rate of opioid overdose deaths in the last decade.

There are three kinds of opioid drugs. These are synthetic opioids (example fentanyl), semi-synthetic opioids (oxycodone, heroin), and natural opioids (opium, morphine, codeine). Natural opioids are from a natural source – opium poppy.

Fentanyl is a fully synthetic opioid, originally developed as a powerful anaesthetic for surgery. It is also administered to alleviate severe pain associated with terminal illnesses like cancer. The drug is up to 100 times more powerful than morphine. Just a small dose can be deadly. Illicitly produced fentanyl has been responsible in the number of overdose deaths in recent years. Fentanyl in intravenous form is 70 to 100 times more potent than morphine.

Comparatively, codeine is only about 1/10th as powerful as morphine. Opioid that is more powerful than morphine includes hydromorphone (Dilaudid) and others. But the strongest opioid in community use is fentanyl.

Doctors know their regular patients. Their relationship is based on trust and faith. When a person says he is in pain then the doctor has to decide what kind of painkiller would help. There are two main types of painkillers: non-narcotic analgesics for mild pain, and narcotic analgesics for severe pain.

Because pain is very subjective, it makes it challenging to prescribe appropriate painkillers. Patients with chronic pain are looking for quick relief of pain on a regular basis. Heroin is a faster-acting painkiller than morphine. Heroin is beneficial for those patients troubled by the adverse effects of morphine, like nightmares, nausea, constipation and hallucinations. With heroin the risk of addiction and abuse is high. Tolerance and dependence will develop with continuous use.

The biggest drug abusers are addicts who buy their fentanyl and other narcotics on the streets. The quality of these drugs is not good. Addicts are at a very high risk of dying from complications and overdose.

There is help for them. Alberta’s opioid crisis response team is available to help. Their website has all the details. Call 911 immediately if an overdose is suspected. Canada’s new Good Samaritan law can protect you, a relative, a friend or a bystander. Naloxone is an antidote can reverse an opioid overdose. This includes fentanyl. You don’t need a prescription and it is free at sites across Alberta. Find a naloxone kit near you. Keep it handy. Check with your doctor, health unit or pharmacist. You never know when you will need it.

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Painkiller Use in Seniors with Non-Cancer Pain

Relaxation in Maui. (Dr. Noorali Bharwani)
Relaxation in Maui. (Dr. Noorali Bharwani)

An article in a newsletter published by the College of Physicians and Surgeons of Alberta (May 1, 2017) provides guidelines to physicians on safe prescribing of painkillers to seniors with non-cancer pain.

The article uses an example of John, a 78-year-old man who has experienced chronic low-back pain due to arthritis for several years, with gradual worsening over time. There is no indication John needs surgery.

John has several medical conditions that include mild cognitive impairment (problems with memory, language, thinking and judgment), high blood pressure, diabetes mellitus type 2, mild chronic renal impairment and falls.

His current medication regimen includes acetaminophen 500 milligrams (mg) when needed and naproxen 200 mg twice daily (over the counter supply). These painkillers do not relieve his pain. He wants a stronger medication.

As we know chronic pain is common in older adults. There are concerns regarding the potential adverse effects of painkillers in this population. But should we let them suffer? No. A person should be treated as a whole taking into consideration other medical problems.

Management of John’s pain includes appropriate assessment of the pain and other medical issues. That should include involvement of John’s family in the future management plan.

The article says, “Treatment-related goals should generally be directed toward improvements in function rather than in pain intensity as function-related goals are often more evident in patients with chronic pain.”

What kind of painkillers can we use safely?

Acetaminophen is the first line of treatment for older adults with mild-to-moderate pain. Acetaminophen at recommended doses is considered safe. Maximum recommended daily dose is 3,000 mg. Dose is lower if a person has liver disease or those who consume three or more alcoholic beverages daily. Acetaminophen should not be used if a person has severe liver failure.

Oral NSAIDs (non-steroidal anti-inflammatory drugs) are recommended to be used with caution and for the shortest time possible. This recommendation stems from the high risk of side effects, particularly with long-term use. It can adversely affect the stomach, heart and kidneys.

Topical NSAIDs, such as diclofenac gel, are generally preferred for localized musculoskeletal pain such as osteoarthritis.

Opioids (produces morphine like effect) use in older adults with chronic non-cancer pain has been associated with decreased pain intensity and improved function. However, there is a lack of data on long-term efficacy as existing studies have been only short-term. It is a narcotic and can cause confusion, increased risk of falls, fractures, hospitalization and mortality.

For mild to moderate pain, the recommendation is to use codeine or tramadol. Second-line opioid treatment for mild-to-moderate pain, and first-line for severe pain is morphineoxycodone or hydromorphone.

Antidepressants should be used in patients who have co-existing depression and pain.

Non-pharmacologic Management

This involves a psychologists and a social worker. They can be helpful in terms of teaching coping strategies, providing emotional support and accessing appropriate programs. A physiotherapist can help with flexibility, balance and endurance exercises.

Pain management in the elderly with multiple medical conditions is not easy but a team effort can do a lot to help and relieve suffering.

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The Science Behind Massage Therapy

Hot stone massage therapy. (iStockphoto/Thinkstock)
Hot stone massage therapy. (iStockphoto/Thinkstock)

What do you do when you have tired aching muscles and joints? What do you do when you have stiff neck, low back pain and aching feet?

Your instinct would be to take some painkiller or phone your massage therapist. Painkillers are cheap, quick (you don’t need an appointment for that) and handy. But painkillers can have side-effects which may hurt your health. Massage therapist makes you relax, feel good, provide longer lasting relief of pain and discomfort. But they are not cheap and they are not available instantly when you need them. An aggressive massage therapist can leave you with sore muscles.

Massage involves the application of varying degrees of pressure on muscles and soft tissues to reduce tension and pain, improve circulation, and encourage relaxation. There are many kinds of massage therapies. From therapeutic massage to tantric massage. Massage therapy is performed by trained, licensed massage therapists.

A Swedish massage is the most common type of massage. It can be slow and gentle (relaxation), or vigorous and bracing (therapeutic), depending on what the therapist wants to achieve. It comprises five basic strokes (stroking, kneading, friction, percussion, and vibration). The movement is rhythmic and free-flowing. Like music or waves in the ocean. Surely, it puts me to sleep!

Therapeutic massage can be quite intense to achieve medical benefits for long-term or chronic issues. The most common examples would be a deep tissue massage or sports massage. The therapist uses more pressure and cross-fiber friction in order to get knots (also known as adhesions) to release.

It is estimated that 18 million individuals undergo massage therapy annually in the U.S., making it the fifth most widely used form of complementary and alternative medicine. Many clinical trials have proved that long-term massage therapy reduces chronic pain and improves range, but the biological effects of massage on muscles have remained unclear.

In a recent (February, 2012) study from McMaster University in Hamilton and the Buck Institute for Research on Aging in Novato, Calif., found that massage therapy triggers biochemical sensors that send inflammation-reducing signals to muscle cells. This reduces pain just like the painkillers.

Second important thing massage does is to send signals to boost the ability of muscles’ cells to make new mitochondria – the energy producing centres within cells – which can affect muscle endurance and recovery.

Third important finding debunked one long-held belief about massage. Some exercise specialists have assumed that massage aids the recovery of fatigued muscle by helping to flush away lactic acid, a byproduct of exercise. Researchers noted there was no difference in the lactic acid levels in the massaged and unmassaged leg.

Other studies of interest are: Massage Eases Low Back Pain in Randomized Controlled Trial (July 4, 2011), Adults Demonstrate Modified Immune Response After Receiving Massage (Sep. 8, 2010), Massage Therapy May Have Immediate Positive Effect On Pain And Mood For Advanced Cancer Patients (Sep. 15, 2008), Alexander Technique Offers Long-Term Relief For Back Pain (Aug. 19, 2008).

Finally, the importance of human touch is well established. Experiments of World War II and later experience in Eastern European orphanages, where babies who were fed and maintained in bed, but not held or given the benefit of human touch, showed that babies who were denied human touch withered and died.

So, massage provides therapy on two levels: physical and psychological. Add meditation to this and you can elevate yourself to a spiritual level – whether you are a believer or a non-believer in a higher being. If I can stay awake during massage therapy, then surely, there is hope for me as well.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!