Ask Dr. Hainline

• I am in constant pain. I've been suffering with sciatic pain for many years, but now I have pain everywhere. I always think that I need to exercise to rid myself of pain, but any exercise, including Yoga, Pilates and light weights, just makes the pain worse. I am constantly fatigued, I don't sleep well, and all of my joints hurt. Someone told me that I might have fibromyalgia. I don't know where to begin to obtain a diagnosis. I am 54 now and I can't imagine what I'll be feeling like when I'm 64.
  
• I am in constant pain. I've been suffering with sciatic pain for many years, but now I have pain everywhere. I always think that I need to exercise to rid myself of pain, but any exercise, including Yoga, Pilates and light weights, just makes the pain worse. I am constantly fatigued, I don't sleep well, and all of my joints hurt. Someone told me that I might have fibromyalgia. I don't know where to begin to obtain a diagnosis. I am 54 now and I can't imagine what I'll be feeling like when I'm 64.
  
  The symptoms you describe may well be from fibromyalgia, but you also want to be certain you do not have a rheumatologic condition. I would first consult with a rheumatologist. Fibromyalgia is a real medical condition that manifests with joint and muscle pain, fatigue, and other symptoms that diminish one’s quality of life. Myofascial pain, which I describe in my book, is a more regional manifestation of fibromyalgia. If the rheumatologist does confirm the diagnosis, there are many helpful mind-body and medication recommendations in my book as well. Ultimately, you want to be certain your physician hears you, and can help provide you with a multi-disciplinary approach to managing your pain.
• My 90-year-old mother, who is otherwise in good health, has been diagnosed with severe lumber stenosis at L4-L5. She is now on a morphine patch. Her physician said she would soon lose bladder control and leg muscle weakness if we do not intervene. What can possibly be done at her age to improve her quality of life?
  
• My 90-year-old mother, who is otherwise in good health, has been diagnosed with severe lumber stenosis at L4-L5. She is now on a morphine patch. Her physician said she would soon lose bladder control and leg muscle weakness if we do not intervene. What can possibly be done at her age to improve her quality of life?
  
  Firstly, one cannot predict loss of bladder or motor control from an imaging study alone. Even with severe lumbar stenosis, many patients never develop neurological problems. A physician who specializes in the spine should assess her. For pain control, morphine and other narcotics are often unsatisfactory in treating lumbar stenosis because patients have no pain while sitting, and the amount of morphine necessary to treat the pain upon standing can cause drowsiness or mental clouding. Therapeutic injections (epidural injections and facet injections), as explained in my book, can be explored. In addition, if your mother is in good health, other treatments are not helpful, and if the stenosis does not extend over many levels, than you can even consider surgery. I explain the rationale and expected outcomes for surgery in my book as well.
• I am 81 years old. I wake in the morning with such severe pain that I can hardly walk to the bathroom. All tests show that I am in relatively good health. After I am up and walk around my pain is relieved, and aspirin helps as well. If I sit in a chair it hurts when I try to stand. I live a busy life and am active, but do not do regular planned exercise. Will reading your book help me?
  
• I am 81 years old. I wake in the morning with such severe pain that I can hardly walk to the bathroom. All tests show that I am in relatively good health. After I am up and walk around my pain is relieved, and aspirin helps as well. If I sit in a chair it hurts when I try to stand. I live a busy life and am active, but do not do regular planned exercise. Will reading your book help me?
  
  Of course reading my book will help you! My book will help you understand the importance of certain types of exercise. It will also help you make an informed decision about treatment. By description, I suspect you have degenerative discs, and your facet joints are becoming irritated. Treatment may include a combination of therapeutic injections (Chapter 6), good manual physical therapy (Chapter 6), an understanding of the mind-body (many chapters) and appropriate use of medication (Chapter 5).
• I have chronic muscle spasms in my lower back. The pain travels down the front of my thigh area into the shin bone. At times I cannot move from the waist down. Can this type of pain improve with exercise? If so, what kind of movement would benefit my particular pain?
  
• I have chronic muscle spasms in my lower back. The pain travels down the front of my thigh area into the shin bone. At times I cannot move from the waist down. Can this type of pain improve with exercise? If so, what kind of movement would benefit my particular pain?
  
  I believe it is important to first undergo a thorough evaluation to determine the source of your pain. Whether it is myofascial pain (Chapter 15) or from degenerative discs (Chapter 11) is not clear from your description. Although exercise in general is helpful, you may also need to work with a physical therapist who understands the importance of muscle balance and core stabilization. I emphasize this repeatedly in my book. There is not a simple cookbook treatment for all back pain. Sometimes we need to understand our body’s unique responses, and then how best to work with our body’s unique responses.
• I have back pain each day from my right neck down to my right hip. It seems to be the worst in the middle of my back. The only time the pressure is relieved is when I lay flat on the floor, or after exercising. I stretch by touching my toes. That also seems to alleviate the pressure. Any suggestions?
  
• I have back pain each day from my right neck down to my right hip. It seems to be the worst in the middle of my back. The only time the pressure is relieved is when I lay flat on the floor, or after exercising. I stretch by touching my toes. That also seems to alleviate the pressure. Any suggestions?
  
  By description, you appear to have myofascial pain, which is well described in my book. I believe this diagnosis needs to be secured. If this is the diagnosis, it is not simply exercise that is important, but also understanding why the body is so hypersensitive as to cause pain from the neck to the hip. This is the essence of mind-body medicine.
• My physical therapist thinks I have a ruptured disk and now I only do pressups and traction. Regarding exercise, do you have an opinion regarding spinning, yoga or Pilates?
  
• My physical therapist thinks I have a ruptured disk and now I only do pressups and traction. Regarding exercise, do you have an opinion regarding spinning, yoga or Pilates?
  
  All of these exercises are potentially useful for the back. In your case, it is first important to try to understand why your disc ruptured. Sometimes this is simply because of a genetic predisposition, but it can also arise because your back is fundamentally out of balance. This balance involves both the support musculature, as well as how you balance stress in your life. That is the cornerstone of applying mind-body medicine to your situation, which is the dominant theme throughout my book.
• I am 46 yr. old male suffering from chronic back pain. I have tried every method possible for pain relief. Now I take pain killers and anti-depressants. The pain killers help alleviate the pain, but I am still depressed. Is there a particular anti-depressant medication that is more effective for chronic back pain?
  
• I am 46 yr. old male suffering from chronic back pain. I have tried every method possible for pain relief. Now I take pain killers and anti-depressants. The pain killers help alleviate the pain, but I am still depressed. Is there a particular anti-depressant medication that is more effective for chronic back pain?
  
  There is not one magic anti-depressant for chronic pain, and the choice of anti-depressant depends on many factors: weight gain; sleep patterns; the nature of the pain; your response to previous medications; other medical conditions. I describe this and more in some detail in my book, especially in the chapter regarding medications. In addition, depression can be treated in many ways, including group therapy, insight-oriented therapy, or cognitive-behavioral therapy. Mindful exercise can also be beneficial. My book describes all of these approaches in greater detail.
• I am a 43-year-old female and I have terrible back pain that radiates down to my ankles and into my right great toe. I also have numbness across my buttock and groin area. My physical abilities have decreased due to pain. I admit that I am depressed because there is always something new that is wrong with me. I've done physical therapy, aqua therapy, about 18 epidural shots, and I have undergone both a laminectomy and spinal fusion with a titanium disc. Now my pain management doctor wants to perform nerve ablation, but my neurosurgeon is considering a morphine pump. I'm emotionally and physically exhausted. I don't know what to do. What do you think?
  
• I am a 43-year-old female and I have terrible back pain that radiates down to my ankles and into my right great toe. I also have numbness across my buttock and groin area. My physical abilities have decreased due to pain. I admit that I am depressed because there is always something new that is wrong with me. I've done physical therapy, aqua therapy, about 18 epidural shots, and I have undergone both a laminectomy and spinal fusion with a titanium disc. Now my pain management doctor wants to perform nerve ablation, but my neurosurgeon is considering a morphine pump. I'm emotionally and physically exhausted. I don't know what to do. What do you think?
  
  From what you are describing, you have aspects of both a chronic pain syndrome and a post-laminectomy syndrome. Both are described in my book. The problem is that there may not be a nerve or nerves to ablate because your nervous system has become hypersensitive. In addition, it is difficult if not impossible to treat chronic pain effectively if depression exists, so this can become a vicious cycle. I would consider first exploring multi-disciplinary treatment, the kind that is described in my chapter “Mind-Body and Integrative Strategies” and throughout the book. Following this, the right treatment may become more obvious, but it will unlikely be one simple procedure.
• About six weeks ago I abused my back by carrying ten new heavy shrubs to replace several that had died over a cold snap last winter. The result was a herniated disk at L4-L5. Pain was excruciating but temporary for approximately one week. My main complaint is a left leg weakness that can fluctuate from non-existent to mild to annoyingly weak, especially when I have to walk up steps but not down. I have seen two Spine specialists. One recommended surgery immediately and claimed I must have this surgery within six weeks of the injury or the time frame for success will pass. Additionally he claims that seeing a neurologist is a waste of time. The second specialist wants me to see a neurologist for testing and states even surgery may not correct the weakness regardless of the time frame. I tend to agree with the second MD but want your opinion on the weakness. Is there any hope?
  
• About six weeks ago I abused my back by carrying ten new heavy shrubs to replace several that had died over a cold snap last winter. The result was a herniated disk at L4-L5. Pain was excruciating but temporary for approximately one week. My main complaint is a left leg weakness that can fluctuate from non-existent to mild to annoyingly weak, especially when I have to walk up steps but not down. I have seen two Spine specialists. One recommended surgery immediately and claimed I must have this surgery within six weeks of the injury or the time frame for success will pass. Additionally he claims that seeing a neurologist is a waste of time. The second specialist wants me to see a neurologist for testing and states even surgery may not correct the weakness regardless of the time frame. I tend to agree with the second MD but want your opinion on the weakness. Is there any hope?
  
  Seeing a neurologist is not a waste of time. I recommend that you give a copy of my book to the first neurosurgeon. The six-week time frame is not a cut-off for success. Furthermore, the type of weakness you describe is not, normally speaking, an absolute indication for surgery. I describe this in my book in the chapter “Lumbar Disc Herniation.” The decision for surgery depends on many factors, including the extent of the disc herniation, the degree and severity of nerve compression, your underlying medical health, and the type of treatment you have received, which should include good-quality physical therapy, mind-body considerations, and possibly a selective nerve root injection. All of these options are well described in the book as well.
• Are your ideas on back pain similar to those of Dr. John Sarno?
  
• Are your ideas on back pain similar to those of Dr. John Sarno?
  
  Dr. Sarno has referred me many patients over the years, and I have also cared for many of his patients who had previously tried his behavioral treatment plan. I believe Dr. Sarno opened an important door in mind-body medicine by the way he describes myofascial back pain. In essence, he says that such pain is a result of repressed anger, and the treatment is to understand and then overcome this anger. The theory is that repressed anger can express itself via physical pain. Thus, his treatment is mind-over-matter. I do not advocate simplistic mind-over-matter, but rather describe the intimate mind-body relationship, which is a two-way communication. Yes, our bodies express themselves emotionally, but also genetically and from injury. A simplistic mind-over-matter approach is successful with many patients, but it is erroneous to think that this is “The Way” for everyone. In some of my detailed case studies, I describe how the mind and body constantly interact, and coming to terms with chronic pain is somewhat like peeling one layer of an onion after another. Each layer has its own mind-body issues.
• I am 42 and have had chronic back pain for nine months. Although I had some back pain since I was 30 or so, it was always associated with a certain activity such as skiing, and after a week or so went away. My last episode was brought on by hitting one golf ball. MRI showed two mildly herniated discs at L4-L5 and L2-L3. Both of these abnormalities accurately explain the pathway of pain I am experiencing. However, I can't help but think there is an emotional component. I am not interested in surgery but I would like to resolve this. Hence, my question: Although a patient expresses pain exactly where one would expect given the MRI results, could the chronic condition still be explained by an emotional state?
  
• I am 42 and have had chronic back pain for nine months. Although I had some back pain since I was 30 or so, it was always associated with a certain activity such as skiing, and after a week or so went away. My last episode was brought on by hitting one golf ball. MRI showed two mildly herniated discs at L4-L5 and L2-L3. Both of these abnormalities accurately explain the pathway of pain I am experiencing. However, I can't help but think there is an emotional component. I am not interested in surgery but I would like to resolve this. Hence, my question: Although a patient expresses pain exactly where one would expect given the MRI results, could the chronic condition still be explained by an emotional state?
  
  The chronic condition is likely a result of both emotions and mechanical dysfunction. Interestingly, our emotions often manifest through our physical vulnerabilities, including the back and such conditions as asthma and heart disease. This does not mean that every medical condition is from a repressed or imbalanced emotion. The beauty of mind-body is to understand the relationship between the two, and not to assume everything is simply from the mind (or emotion). In your case, you may have developed inadequate core muscle stability and compensation for the herniated discs, and your repressed emotions may compound the problem because they lead to dysfunctional muscle contraction in the same region. The key is to find the balance – with your core stability and with your emotional being.
• I have severe pain across my entire lower back. I feel somewhat better if I am walking or performing light exercise, but the pain usually has a life of its own. My doctor diagnosed me with myofascial pain even though I have a degenerated lumbar disc on my MRI at L4-5. Isn’t myofascial pain a psychosomatic condition?
  
• I have severe pain across my entire lower back. I feel somewhat better if I am walking or performing light exercise, but the pain usually has a life of its own. My doctor diagnosed me with myofascial pain even though I have a degenerated lumbar disc on my MRI at L4-5. Isn’t myofascial pain a psychosomatic condition?
  
  Firstly, myofascial pain is not a psychosomatic condition. Psychosomatic means that there is no “real” medical condition, and that the patient’s problems are simply emotionally based. This is a somewhat punitive view, and given what we know about the mind-body, such terminology is outdated. Secondly, myofascial pain is a real physical ailment, somewhat similar physiologically to migraine. Treatment is not directed simply at the level of pain, but on the many possible triggers of pain, including physical and emotional triggers. Finally, degenerated lumbar discs are very common findings, and they are not necessarily a cause of pain.
• My mother and father both have lumbar stenosis. Is there anything I can do to prevent this condition from developing in me?
  
• My mother and father both have lumbar stenosis. Is there anything I can do to prevent this condition from developing in me?
  
  The best thing you can do is to maintain a regular exercise program that includes keeping your core muscles in balance and in good condition. The core muscles are all of the support muscles of the spine, including the back muscles, the gluteal muscles, the abdominal muscles, and the thigh and hamstring muscles. Even with this, you may develop lumbar stenosis because heredity plays a significant role in the degeneration of lumbar discs, which is the precursor for lumbar stenosis.
• I fell down a flight of stairs and herniated a lumbar disc. My doctor says my spine will never again be normal, and that I should stop running for the rest of my life. Is there no hope?
  
• I fell down a flight of stairs and herniated a lumbar disc. My doctor says my spine will never again be normal, and that I should stop running for the rest of my life. Is there no hope?
  
  If the fall caused a sudden tear in your lumbar disc, thus leading to a herniation, then it is true that your spine will never again be “normal.” After a disc herniates, it loses some of its inner water content, and becomes somewhat like a sponge out of water. As the herniated disc loses its water, the herniated portion will usually recede, thereby relieving pressure on any pain-sensitive structures. Even with a “dry” lumbar disc, you can usually return to full activity, but this assumes that your spine is stable, and that you have progressed successfully with a good spine stabilization physical therapy program.
• I have had low back pain for over 1 year. My doctor treated me with epidural injections, but I am not much better. He now wants to put in a spinal cord stimulator because the pain is so debilitating. Is this the best way to proceed?
  
• I have had low back pain for over 1 year. My doctor treated me with epidural injections, but I am not much better. He now wants to put in a spinal cord stimulator because the pain is so debilitating. Is this the best way to proceed?
  
  It is difficult to answer this question without knowing more details about your situation. Chronic low back pain can be caused by many conditions, some of which are best treated by surgery, some by physical therapy, some by medication, and some by a mindfulness approach. The most important point of treatment is to first get a solid diagnosis. Is the pain from a disc? Is it myofascial pain? Is the pain part of a chronic pain syndrome? Once there is a good diagnosis, then the treatment must be tailor-made to your specific needs. Too often, physicians jump quickly in placing a spinal stimulator, before the patient has undergone a thorough, multi-disciplinary treatment. In your case, failure to respond to epidural injections does not constitute a failure of treatment. There are more options to explore.
• I suffered a large disc herniation at L4-5 after a fall, and I underwent surgery because of severe pain and foot weakness. I recovered completely after surgery, but 2 months later, while bending over to tie my shoes, I developed a recurrence of severe pain, with the same problem as before my first surgery. My doctor has diagnosed a herniated disc at the same level, and he proposes another surgery. Does this make sense?
  
• I suffered a large disc herniation at L4-5 after a fall, and I underwent surgery because of severe pain and foot weakness. I recovered completely after surgery, but 2 months later, while bending over to tie my shoes, I developed a recurrence of severe pain, with the same problem as before my first surgery. My doctor has diagnosed a herniated disc at the same level, and he proposes another surgery. Does this make sense?
  
  Unfortunately, even under the best of surgical circumstances, up to 5 percent of patients may develop a recurrent disc herniation at the same level where surgery was performed. Most surgery for a single-level disc herniation involves a laminectomy and discectomy, which means that part of the bone is removed, and the ruptured disc material is removed. The rest of the disc is left in place. Thus, some of the remaining disc material can herniated as well. However, most patients with disc herniations can be treated non-surgically. The absolute indications for surgery include incontinence or severe muscle weakness from nerve damage. A relative indication for surgery is ongoing pain that has not responded to good, comprehensive non-surgical management, including, but not limited to, physical therapy, medications, therapeutic injections such as epidural injections, and mindfulness exercises.
• About once or twice a year, my back goes out. Sometimes I am simply bending over to brush my teeth, and the next thing you know, I cannot stand up because of excruciating back pain. The severe pain usually lasts for about 1 week, and then I am fine for another 6 months or so. Chiropractic adjustment helps me during these crises, and my chiropractor ordered an MRI and told me I have a subluxation. Should I be concerned?
  
• About once or twice a year, my back goes out. Sometimes I am simply bending over to brush my teeth, and the next thing you know, I cannot stand up because of excruciating back pain. The severe pain usually lasts for about 1 week, and then I am fine for another 6 months or so. Chiropractic adjustment helps me during these crises, and my chiropractor ordered an MRI and told me I have a subluxation. Should I be concerned?
  
  Subluxation has a different meaning to chiropractors than it does to medical doctors. A chiropractic subluxation complex simply means that there is something abnormal with the lumbar joint, usually at the level of the disc. Even a mildly degenerated disc can be labeled a chiropractic subluxation complex. To medical doctors, subluxation means that one vertebral body has slipped forward or backward relative to another vertebral body. Sometimes the subluxation is stable, and other times there is spinal instability. Your story is consistent with a disc that is undergoing degenerative changes, possibly with small herniations. When the disc undergoes a sudden change, such as a small herniation, this leads to the attack of severe pain. Sometimes, the disc is degenerated already, and the severe pain is a locking of the facet joints. In either case, you may have a genetic predisposition to degeneration of the lumbar disc. However, you can minimize the attacks of pain with a steady diet of good exercise, especially exercise that balances and strengthens the core muscles around your lumbar spine.
• I have been suffering with back pain for many years. I have been treated with epidural injections, physical therapy, chiropractic and acupuncture. A spine surgeon says I have a degenerated lumbar disc, and he recommends lumbar disc replacement. I have read that this surgery is the wave of the future, but is its time now?
  
• I have been suffering with back pain for many years. I have been treated with epidural injections, physical therapy, chiropractic and acupuncture. A spine surgeon says I have a degenerated lumbar disc, and he recommends lumbar disc replacement. I have read that this surgery is the wave of the future, but is its time now?
  
  Although lumbar disc replacement surgery may become a very important treatment option, it will not replace all other spine surgery. For now, lumbar disc replacement surgery should be performed in patients who have a clearly identifiable faulty lumbar disc that is the mechanical source of the patient’s pain. Just because someone has a degenerated lumbar disc does not mean that the disc is the source of pain. Sometimes chronic low back pain is part of a myofascial pain syndrome, or from chronic muscle maladaptation. I recommend obtaining another opinion so that you can be certain that your disc is the primary cause of your pain. If it is not, then lumbar disc replacement surgery will not help you.
• My internist recommended that I begin yoga. I develop frequent back pain, and I usually feel better when I exercise. However, I heard that yoga is bad for the back. What do you think?
  
• My internist recommended that I begin yoga. I develop frequent back pain, and I usually feel better when I exercise. However, I heard that yoga is bad for the back. What do you think?
  
  Yoga can be quite beneficial for patients with back pain, given the right circumstances. Some people jump into yoga too quickly, meaning that they try to become adept with many complicated postures, but their body is not ready for these postures. Yoga is best begun with the intent of becoming very aware of your breathing and your body’s response to breathing. The exercises and postures become an extension of this mindful approach, always within the comfort zone of mindful breathing. Ultimately, yoga can be extremely beneficial for developing and maintaining the core muscles around the spine.
• I have heard that acupuncture is an excellent treatment for low back pain, but I am afraid of needles. Isn’t this a painful treatment?
  
• I have heard that acupuncture is an excellent treatment for low back pain, but I am afraid of needles. Isn’t this a painful treatment?
  
  Acupuncture was developed over 4000 years ago by the Chinese, and is recognized by the World Health Organization as a valid treatment option for pain. Acupuncture may work by obtaining a regional relaxation of the muscles. Acupuncture can stimulate the release of pain-relieving chemicals from the body. In addition, acupuncture can lead to a balancing of Chi, which is the “life force” of the body. Acupuncture needles are quite small in diameter and are delicate. It is unusual for needle placement to hurt, and most patients feel rather relaxed after a treatment.
• I have had 2 bleeding ulcers in the past, but each time my back goes out, I obtain relief when I take a nonsteroidal anti-inflammatory drug. My doctor suggests I use Celebrex during these circumstances, but I am worried that this drug is very similar to Vioxx and Bextra, which have been removed from the market.
  
• I have had 2 bleeding ulcers in the past, but each time my back goes out, I obtain relief when I take a nonsteroidal anti-inflammatory drug. My doctor suggests I use Celebrex during these circumstances, but I am worried that this drug is very similar to Vioxx and Bextra, which have been removed from the market.
  
  It is true that Celebrex is similar to Vioxx and Bextra. All 3 medications are COX-1 inhibitors, which means that they selectively inhibit one part of the inflammatory pathway, but do not affect the pathways that lead to stomach irritation or potential bleeding problems from platelet inhibition. Other nonsteroidal anti-inflammatory drugs inhibit both COX-1 and COX-2 enzymes, and these medications are more irritating to the stomach, and they inhibit platelets. Vioxx and Bextra were removed from the market because of concerns that these medications were associated with a higher than normal risk of stroke and heart attack. Since their removal, Celebrex has been under intense scrutiny, but to date, there is no evidence that Celebrex is associated with a similar adverse risk profile. Given the circumstances, judicious use of Celebrex seems to be a reasonable option.
• I have had back pain and migraine for years. My doctor wants me to take an antidepressant medication, but I am not depressed. She says that some of these medications help relieve pain, but this does not make sense to me. I think she just feels the pain is in my head, and I am annoyed at her. What do you think?
  
• I have had back pain and migraine for years. My doctor wants me to take an antidepressant medication, but I am not depressed. She says that some of these medications help relieve pain, but this does not make sense to me. I think she just feels the pain is in my head, and I am annoyed at her. What do you think?
  
  Antidepressant medications have been used for years to treat pain. Many years ago, doctors discovered that amitriptyline – a first generation antidepressant – relieved diabetic nerve pain regardless of whether the patient was depressed. This was around the same time that scientists discovered that we generate our own internal pain relieving chemicals, including opiates, which are very similar to morphine. Some antidepressant medications make serotonin and norepinephrine more available, and these chemicals interact with the opiate system in modulating pain perception. Thus, some antidepressant medications help to relieve pain by altering the body’s physiology and ultimate perception of pain, independent of mood. In addition, for patients who are depressed or anxious because of pain, these medications can be quite beneficial in improving coping mechanisms. Finally, if a patient has chronic pain and is depressed, it is extremely difficult, if not impossible, to treat effectively the pain if the depression is not treated effectively. In your case, the antidepressant may be used simply to address the chronic back pain and migraine. If the medication is amitriptyline, or similar to amitriptyline, it will also promote sleep.