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Back Pain - A general overview for a very common issue

Dr. J | a board certified Internist and Nephrologist practicing in the DC/Metropolitan area with over 30 years of clinical experience

Back pain is commonly cited as the most common medical complaint (and reason to see a doctor) in America. Mayo Clinic data noted approximately 80% of the population will at some point experience back pain that will limit functional status. It is also the most common complaint for lost job time - with an estimated $100-$200 Billion dollars of annual cost to the US economy (likely due to lost wages and productivity). The American Association of Neurological Surgeons echo support these estimates and note 75 to 85 percent of Americans will experience back pain in their lifetime. Of those, 50 percent will have more than one episode within a year. Let's take a deeper dive into this complex but sadly common issue


Back Pain Affects Work

WebMd has a useful Back Pain Health Center tool that can provide insight on the topic. It is a common issue that affects quality of life but also generally productivity and the economy as well (as this infographic below illustrates).


Back pain can be generally categorized into 2 broad categories:


1) Acute back pain - more short term - Less than 12 weeks in consistent duration. More common statistically than chronic


2) Chronic - back pain is considered to be chronic when it persists for more than 12 weeks
Health Care Cost of Back Pain

National Institute of Health notes that approximately 20 percent of individuals with acute back pain develop chronic low back pain with persistent symptoms at one year. The Georgetown University Health Policy Institute notes nearly 65 million Americans report a recent episode of back pain. Some 16 million adults — 8 percent of all adults — experience persistent or chronic back pain, and as a result are limited in certain everyday activities. This infographic somewhat depicts the public health expenditures and toll back pain can inflict:
Let's take a deeper dive in this issue!



Our spine is our backbone and runs from the base of the skull to the pelvis. It serves as a support for our body weight and allows us to function upright and have advanced mobility. It also encases the spinal cord which controls our peripheral motor and sensory functions. This image from the US National Library of Medicine shows the anatomy of our spine.


The lumbar/Sacral spine - commonly referred to as the low back - has to consistently support more pressure and has a higher risk of intervertebral disc degeneration or herniation. Low back pain/injury is the most common type of back issue. However, Back injury is not limited to this lower region - as any spinal vertebrae/disc can be damaged and lead to inflammation/pain from the cervical to the sacral. Spine-Health.com has a useful Back Pain Anatomy Video that can provide insight on the structural spine. 

Risk Factors for Developing Back Pain include:

 

  • Age - the first acute episodes typically occur between ages 30-50 with more frequency and/or chronicity of symptoms as individuals age. The intervertebral discs begin to lose fluid and flexibility with age, which decreases their ability to cushion the vertebrae with loss of cartilage. They can also have weakening of bone strength from osteoporosis which can lead to inflammation and even fractures. The risk of spinal stenosis also increases with age which can impinge on the spinal cord and lead to muscle and sensory weakness

  • Muscle or Ligament Strain / Injury
  • Overuse - heavy lifting, bending, pulling, pushing can increase strain particularly on the lower spine
  • Immune mediated Arthropathy - such as ankylosing spondylitis - a form of arthritis that involves fusion of the spinal joints leading to some immobility of the spine. ( This is a more detailed overview from WebMd )
  • Overweight/Obese - can increase strain particularly on the lower spine 

 

Symptoms of back pain include:


 

  • General Aches/Pains locally to the damaged region
  • Nerve Root irritation - shooting and stabbing pain/sensations
  • Sciatica - pain that radiates typically down the leg
  • Muscle weakness
  • Impaired Mobility
  • If severe spinal stenosis - impingement of the spinal cord can occur with marked weakness of muscles (typically lower extremities)

 

Causes of back pain include:


 

  • Degenerative Joint Disease of spine/vertebrae - Osteoarthritis usually due to combination of aging and wear/tear is the most likely etiology
  • Muscle/Ligament Strain - tissue injury typically as a result of awkward movement or repeat heavy lifting/stress
  • Disc Herniation/Bulging - the gelatinous material inside a disc can weaken/inflame which can lead to nerve root irritation/pain
  • Osteoporosis - vertebral bone weakness can lead to brittle bones and eventual compression fractures of the spine
  • Immune mediated Arthropathy - such as ankylosing spondylitis - a form of arthritis that involves fusion of the spinal joints leading to some immobility of the spine. ( This is a more detailed overview from WebMd) 

 

Therapy options for Back Pain


Acute Back Pain: The silver lining is most back pain statistically is acute in nature and the majority of these cases recover with:


 

  • Rest
  • Anti inflammatory medications and/or muscle relaxants
  • Time (usually in 1-2 weeks from initial presentation/injury)

 


Sadly National Institute of Health data does note that 20 percent of individuals with acute back pain develop chronic low back pain with persistent symptoms at one year. The overall prevalence of chronic back pain is estimated at over 20 million Americans - just a staggering number!


Chronic Back Pain Therapy options consist of usually an algorithm based treatment plan to help alleviate/maintain symptoms:



1) Nondrug/Non surgical Therapies:


a. Physical therapy/Exercise - strengthen/stabilize muscles around the affected joint/area


b. Weight Loss – Alleviate pressure from particularly the weight bearing vertabrae



2) Medications - used to control inflammation/pain:


a. NSAIDs – Non Steroidal Anti-inflammatory Drugs – one of the most commonly used medications in the world. Advil / Aspirin / Motrin / Aleve / Naproxen / Ibuprofen / Motrin / Diclofenac are all examples of NSAIDs. The issue is they are to be Cautioned/Avoided in individuals with multiple medical issues such as Chronic Kidney Diseae / Congestive Heart Failure / Gastritis or Stomach ulcers / Resistant hypertension. 


b. Acetaminophen – commonly recommended when physicians ask patients to avoid NSAIDs. Ex: Tylenol Arthritis – the problem is multiple past studies (and decades of our clinical patient encounters) have shown minimal (if any) anti-inflammatory effectiveness 


c. Opioids – Controlled narcotics pain medication that is classified as an unfortunate epidemic in the USA. These medications bind to opioid receptors in the brain/spinal cord and blunt to pain signals. The issue is they have dangerous side effect profile (can be fatal) and also patients develop tolerance and are in need of larger dosages which can lead to a potential addiction or overdose



3) Surgical Options


a. Joint injection – commonly performed by orthopedic surgeons or rheumatologists – typically are either a corticosteroid injection to suppress inflammation locally or a hyaluronic acid injection to provide some degree of joint cushion. The issue is both are short term solutions that typically lead to recurrent issues


b. Joint Surgery – commonly performed by an orthopedic surgeon. Such as a spinal laminectomy and/or fusion procedure. The issue is these are invasive surgeries that carry risk of anesthesia/cardiac events/infections/blood clots and may be difficult especially in the elderly population



Above is a detailed overview of this complex but sadly common issue that is rising across our country and in our world. As a practicing Nephrologist (Kidney Doctor) - I generally never get consulted to manage osteoarthritis but end up playing a large role in the symptom control of my patients.


The most common reason for a patient to see a Nephrologist is for a diagnosis of chronic kidney disease . Our goal is to help slow the progression of this CKD by optimizing risk factors that historically damage kidneys and attempt to avoid progression to a need for renal replacement therapy (dialysis or kidney transplant). Every Nephrologist I know would immediately ask a patient to stop all NSAIDs such as Advil / Motrin / Alleve / Naproxen / Ibuprofen along with several prescription strength NSAIDs such as Diclofenac / Voltaren / Celebrex / Indomethacin / Meloxicam. The only regular recommended alternative is Tylenol (Acetaminophen) Extra Strength or Arthritis at recommended dosages to control aches/pains/inflammation. The issue: Acetaminophen has weak data on arthritis/inflammation control 


More often than not our patients come back to us saying they are not achieving adequate management without NSAIDs. Opioids are almost never the right answer for osteoarthritis related pain management (they do not suppress joint inflammation and have a very unfavorable risk profile). Injections/surgeries are invasive and have their drawbacks especially in patients with more advanced chronic kidney disease. We had to research this field to find a safe and effective alternative for our patients!


Several herbs have been used in holistic medicine for generations for inflammation control such as curcumin, capsaicin extracts, ginger, willow bark, cloves, fenugreek, or nigella sativa. There is a multitude of bench data as well as clinical trial data (including several randomized control trials) for several of these herbs/extracts. We began looking into herbal/holistic substances and we parsed basic science/bench as well as clinical research databases. Our ingredients have shown to suppress the inflammatory cascade with the caveat of no known issues with kidney function / Sodium retention or swelling / Blood Pressure elevation / stomach lining erosion that plague chronic NSAID use. In 2014 after some testing and adjustments - we solidified a powder based regimen and would at times suggest patients seeking alternative/additional relief try it. We did not commercially sell it but would just suggest individuals obtain and try the ingredients on their own.


The response was tremendous and more often than not this became their go to relief agent. The only consistent suggestion (and complaint) was the taste of the powders and the need for a tablet to ease delivery/use. We adjusted the extract ratios/concentrations and were able to manufacture (made in the USA at an FDA registered and GMP certified facility) a coated (should be tasteless) tablet also scored to decrease size to help ease use. The feedback and reviews have

been phenomenal (click here to see our Amazon  reviews). We sincerely hope Organic Arthritis assists you in staying active and on your path to healthy and meaningful living. Thanks for taking time out to join me on this journey! Thank you for sharing your time with me on this blog!

Glucosamine and Chondroitin: What Does the Data Show

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialist with over 30 years of clinical experience • 08 Aug, 2022
Osteoarthritis is commonly referred to as the “wear and tear” degenerative joint disease. It typically results from the gradual loss of cartilage - the tough connective tissue that is within/between joints. In a way too simple analogy of this complex mechanism - this cartilage serves as essentially a shock absorber preventing direct shear force or “bone on bone” pressure. Once the shock absorber is weakened/gone – trauma will slowly lead to inflammation and erosion of the joint (PAIN!). This leads to a pretty straightforward question - is there a way to repair or at the least slow down the decline of cartilage? Enter Glucosamine - which is an amino sugar and precursor in the synthesis of glycosylated lipids and proteins. It is a natural compound that exists in our cartilage. 

Osteoarthritis: Clinical Manifestations

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialist with over 30 years of clinical experience • 31 Jan, 2022
Osteoarthritis is one of the most common medical conditions in the world and is commonly referred to as “wear and tear” degenerative joint disease. It typically results from the gradual loss of cartilage within/between joints. This cartilage serves as a type of shock absorber preventing direct shear force and “bone on bone” pressure. Once the shock-absorber is gone it will slowly lead to inflammation and erosion of the joint. US Centers for Disease Control data estimate approx 60 million people with doctor diagnosed arthritis – and remember many people live with joint aches/pain without seeing a physician or getting a formal diagnosis of OA. Sadly the symptoms of OA simply do not stop at the joint. The Arthritis Foundation notes that individuals with OA are almost three times more likely to develop cardiovascular disease (CVD) or heart failure than those without OA. Also, people with osteoarthritis experience as much as 30 percent more falls and have a 20 percent greater risk of fracture than those without OA. These links are especially strong when arthritis is in certain weight bearing/balance joints, such as the knee/back/hip. It makes sense – pain/weakness especially in our stabilizing joints such as knees/hips/spine will limit mobility and lead to risk factors such as weight gain, cardiovascular disease, diabetes coupled with stability issues. These patients would have difficulty following American Heart Association recommendation s that recommend increased physical activity and note that becoming more active can help lower blood pressure and also boost levels of good cholesterol. Without regular physical activity, the body slowly loses its strength, stamina and ability to function well - People who are physically active live about 7 years longer than those who are not active and are obese (American Heart Association). Studies have shown that adults who are inactive/minimally active more than 4 hours a day had a 46% increased risk of death from any cause and an 80% increased risk of death from cardiovascular disease! So now let us focus on some of the clinical presentations of Osteoarthritis (OA). In general there is a marked variability of disease expression. Although most patients present with joint pain and functional limitations, the age of disease onset, sequence of joint involvement, and disease progression vary from person to person. OA ranges from an asymptomatic, incidental finding on clinical or radiologic examination to a progressive disabling disorder eventually culminating in "joint failure" with impaired mobility and quality of life. The primary symptoms of osteoarthritis (OA) are joint pain, stiffness, and motor restriction. Symptoms usually present in just one or a few joints in a middle-aged or older person. Other manifestations in patients with OA include sequelae such as muscle weakness, poor balance, and associated conditions such as fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues).

Osteoarthritis - a Complex (Metabolic) System

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialist with over 30 years of clinical experience • 24 Nov, 2021
Osteoarthritis is oftentimes characterized in simple terms - typically referred to as a “wear and tear” injury to a specific joint. This usually involves the weight bearing joints of the body such as the lower back (lumbar spine), the hips, or the knees but can also include common repetitive use joints such as the fingers/toes and also the ankle (especially if historical trauma/injury is noted). In actuality - osteoarthritis is a complex system with many mediators that can affect degradation of joints/cartilage. There are multiple mechanisms that can help trigger erosive joint disease - including several metabolic triggers. In this excellent review by Wang/Hunter et a l from Osteoarthritis and Cartilage - they have an interesting info graphic highlighting potential metabolic contributors to OA (shared below).

Falls - Let us discuss risk factors and also fall prevention strategies

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialist with over 30 years of clinical experience • 20 Sep, 2021
Falls are a major issue especially in our elderly population and falls are the leading cause of injury, both fatal and nonfatal, among older adults in the United States . I can not even count the number of lives that were significantly (and often times permanently) changed after a fall through my decades of practice as a Nephrologist and Internist.

Yoga and Arthritis

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialist with over 30 years of clinical experience • 05 Sep, 2021
Cultures around the world, originally in eastern philosophy, have utilized mind body movement exercises for generations for various potential mental and physical benefits. These practices have increased in popularity and scope and are now truly global disciplines such as yoga and tai chi . Yoga likely was founded in Indi a and entails discipline in physical, mental, and spiritual realms with originally strong followings in the hindu and buddhist doctrines. It has morphed from being tied to a single country and also bypassed religious connotations. The term "yoga" in the Western world often denotes a modern form of hatha yoga and posture-based physical fitness, stress-relief, and relaxation techniques sometimes accompanied with breathing exercises The focus of yoga in this modern sense is to blend posture based positions/poses to help facilitate exercise for the body and potentially mind. There are many different disciplines/variations of Yoga with significant fluctuations in their physical demands. Many researchers/physicians attempt to quantify the strenuousness of exercises by their energy cost of exercise commonly measured in metabolic equivalent of task (MET). Less than 3 METs counts as light exercise; 3 to 6 METs is moderate; 6 or over is vigorous. American College of Sports Medicine and American Heart Association guidelines count periods of at least 10 minutes of moderate MET level activity towards their recommended daily amounts of exercise. For healthy adults aged 18 to 65, the guidelines recommend moderate exercise for 30 minutes five days a week, or vigorous aerobic exercis e for 20 minutes three days a week. Treated as a form of exercise, a complete yoga session with asanas (body posture) and pranayama (focusing on breath) discipline provides 3.3 ± 1.6 METs which would be classified as an average/moderate workout in strenuousness. There have been several hundred published articles/scientific trials on Yoga and its potential health benefits. Let us focus on some of the data for arthropathy. In one randomized control trial by Deepeshwar et al - Sixty-six individual diagnosed with with knee osteoarthritis (ages between 30 and 75 yo) were randomized into two groups. One group would then participate in yoga for 1 week at a yoga center ( n = 31) and then a control ( n = 35) group who did not participate in any yoga activities. Multiple functional tests were performed on day 1 and then at day 7 - including the Falls Efficacy Scale (FES), Handgrip Strength test (left hand LHGS and right hand RHGS), Timed Up and Go Test (TUG), Sit-to-Stand (STS), and right & left extension and flexion. Results indicated a significant reduction in TUG ( p < 0.001), Right ( p < 0.001), and Left Flexion ( p < 0.001) whereas significant improvements in LHGS ( p < 0.01), and right extension ( p < 0.05) & left extension ( p < 0.001) from baseline was found in the yoga group. This would suggest improved muscular strength, flexibility, and functional mobility in the yoga group. This was a small study that also was completed over a short time frame (1 week) but did show marked functional improvements. Let us look at more data via a large review by Haaz et a l . Researchers combed through peer-reviewed clinical trials (published from 1980-2010) that used yoga as an intervention for arthritis patients and reported quantitative findings. Eleven studies were identified, including four randomized control trials and four non randomized trials. The trials reviewed data is below in the table.

Dietary Patterns and Progression of Knee Osteoarthritis: Data from the Osteoarthritis Initiative

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialists with over 30 years of clinical experience • 22 Aug, 2021
Let us review an interesting study from the Harvard medical system published in the American Journal of Clinical Nutritio n and also Osteoarthritis and Cartilage Journal by Xu et all dealing with the potential impacts of dietary intake patterns and progression of Knee osteoarthritis. There is an age old saying - "You are what you eat" and there has been past data on certain foods/nutrients linked with outcome effects on knee arthritis such as (click the links below for reference articles): Soft drink consumption (potential increased risk of OA progression) Milk consumption (potential decreased risk of OA progression particularly in women) Dietary fat intake (potential increased risk of OA progression) Strawberrie s (potential decreased risk of OA progression particularly in obese adults) Fiber intake (potential decreased risk of OA progression) We also know of many herbs that have varying arthritis control data (some very convincing) and our own Organic Arthritis Herbal Supplement is composed of strong data driven herbs for arthropathy control. There have been past study links between a general Mediterranean diet having a relative lower risk of and improved overall symptom control of knee OA. This study focuses more on overall diet classes and effects on osteoarthritis. This study compares two diet classes based on the Scree test via individual diet questionnaires: Western Diet - composed of high intakes of red and/or processed meats, refined grains, and french fries Prudent Diet - composed of high intakes of vegetables, fruit, fish, whole grains, and legumes

Arthritis - More than Physical Discomfort - Let’s Talk About Social Interaction

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialists with over 30 years of clinical experience • 06 Aug, 2021
Arthritis is one of the most common medical conditions diagnosed in the United States and world-wide. CDC US data notes there are approximately 60 million individuals battling arthropathy with that estimate rapidly growing to an estimated 78 million (26%) US adults aged 18 years or older projected to have doctor-diagnosed arthritis by 2040 .

Painsomnia - sleep issues caused by pain

By Dr. J | American Board of Internal Medicine certified Nephrologist and Internal Medicine specialists with over 30 years of clinical experience • 12 Jul, 2021
Many of us have heard of the medical term INSOMNIA . It refers to a medical condition in which individuals have difficulty falling, staying, or getting back to sleep. There can be short term sleep issues lasting nights or weeks, termed acute insomnia , or long term sleep disturbances ranging months to years, termed chronic insomnia . This can lead to a multitude of general health ramifications. The first question - how much sleep is recommended daily? According to United States Centers for Disease control recommendations - adults should generally have 7 or more hours of sleep nightly to help ensure optimal functional status. This CDC table below helps show National Sleep Foundation and American Academy of Sleep Medicine recommendations:
Knee Arthritis - a review on exercise, weight loss, and physical therapy!

Knee Arthritis - a review on exercise, weight loss, and physical therapy!

By Dr. J | a board certified Internist and Nephrologist practicing in the DC/Metropolitan area with over 30 years of clinical experience • 13 Jun, 2021
Knee Arthritis - a review on exercise, weight loss, and physical therapy!

NSAIDs use in Chronic Kidney Disease - a growing problem!

By Dr. J | a board certified Internist and Nephrologist practicing in the DC/Metropolitan area with over 30 years of clinical experience • 11 Jun, 2021
There is a strong chance all of us are aware of or have used non-steroidal anti-inflammatory drugs (commonly referred to as NSAIDs) in our lifetimes. There also is a good chance many have been told by their medical providers to avoid using NSAIDs especially long term given the risk factors for particular those with chronic kidney disease, congestive heart failure, resistant hypertension, gastritis/stomach ulcers, or even those with electrolyte concerns such as hyperkalemia (high potassium) or hyponatremia (low sodium). Despite these risks – NSAIDs are simply the most recommended/prescribed anti-inflammatory medications in the world today. This class of medications includes such commonplace names as (click underlined links below for more info): 1) Advil 2) Aleve 3) Ibuprofen 4) Motrin 5) Naprosyn/Naproxen 6) Diclofenac/Voltaren 7) Celebrex/Celecoxib 8) Mobic (Meloxicam) 9) Indomethacin/Indocin Though often times effective for inflammatory control - there are several noted risks to NSAIDs particularly in those with chronic kidney disease. NSAIDs provide their analgesic, anti-inflammatory, and antipyretic actions through inhibition of cyclooxygenase (COX) enzymes – which convert arichidonic acid (released from cell membranes) to prostaglandins and thromboxanes. This graphic in the American Journal of Kidney Disease highlights this COX cascade pathway affects:
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