An Integrative Approach to the Patient with Back Pain
by Jay Sandweiss D.O.
Back pain is an amazingly common complaint in daily life. The causes of back pain are diverse, complex, simple and fascinating. Back pain can be, in the words of George Goodheart, Jr. , "intricately simple, and simply intricate." Its causes can be categorized into a triad of health consisting of structural, biochemical and emotional/spiritual dimensions. Some patients have back pain primarily due to structural problems, in others it is primarily due to biochemical disturbances, and in yet other patients it is due to emotional/spiritual dilemmas. Most patients have a combination of issues affecting their health and sense of well being. Those practitioners that have delved into Traditional Chinese Medicine are aware of the "Biao" and "Ben" concepts of "Bi"(pain) syndromes. The "Biao" refers to the symptoms and complaints (manifestations) and the "Ben" refers to the actual cause of the symptoms and complaints (the root). Each case can be very deep or superficial depending on the individual patient.
As we begin this journey with our patient we must develop a true relationship. All of us want to be known, to be heard, to be accepted and to be understood. Jung once said that a patient is almost never healed by a diagnosis, rather, he is healed by being allowed to tell his story. I believe that he was referring here to the "meaning" of the patients' illness being healed. Obviously, we as doctors make diagnoses that help our patients without regard to their story (e.g.comatose patient brought by ambulance). Yet whenever possible, we must allow our patient to remain at the center of the therapeutic relationship.
During an initial visit I tell my patient that I will first attempt to make a diagnosis of their current condition. We will examine the factors that led to or are perpetuating their condition. Finally, we will discuss
possible treatment options that will lead to an amelioration of their present state. The patient becomes an active partner in this process by doing his or her own "inner work" and "outer work." This may include physical exercises, dietary changes, improving techniques within a current exercise program, psychotherapy, nutriceutical and herbal therapies, lifestyle changes, ergonomically designed chairs and work environments, food and chemical avoidance, prescription medications, osteopathic treatments and acupuncture treatments. Additionally, this patient may be referred for Alexander technique, physical therapy, Feldenkrais method, Rolfing, massage, specialty homeopathic consultation, yoga, martial arts, biofeedback, hypnosis, epidural injections, facet joint injections or surgical consultation and procedures.
Using information gathering and treatment options from multiple healing paradigms increases the likelihood of achieving a successful therapeutic response. This is the beauty of complementary or functional medicine. It is not a matter of rejecting traditional allopathic medicine. On the contrary, the "new" physician makes total use of the tremendous information that can be gathered from tests, radiological and other diagnostic procedures and then integrates them within a context of total patient care.
Let's look at a sample case. A 45 year old female patient has lumbago and occasional right sided sciatica which is chronic but can vary in intensity depending on various factors. Bloating and flatulence are an ongoing problem as is chronic sinus congestion, bad breath, vaginal discharge, depression, PMS and sore throats. She works for a computer firm as a support person for program breakdowns. She is unhappily married, has one eight year old son and a five year daughter who is learning impaired. She usually has only coffee and a bagel for breakfast, fast food for lunch and eats a late dinner past 8 o'clock in the evening. She loves to eat chocolate. Her chief complaint is her lumbago and sciatica. It is painfully obvious that this patient has several concurrent health issues and that simply "treating the back" is not going to heal this woman.
On the biochemical front she is discovered to have a slightly elevated TSH but more importantly a low free T3. Great Smokies Laboratories stool testing indicates dysbiosis and leaky gut syndrome with Candida albicans overgrowth, deficient bifidobacterium, Blastocystis hominis overgrowth, excess fecal fatty acids and a high fecal pH. ALCAT blood testing reveals multiple food and chemical sensitivities including casein and gluten. Spectracell intracellular nutritional analysis reveled deficiencies in several B vitamins, zinc, magnesium, antioxidants and L-glutamine.
Osteopathic structural exam reveals multiple areas of somatic dysfunction involving cranial, cervical, thoracic, lumbar, sacral, pelvic and lower extremities including a short leg and pronation of her feet. Trigger points are found in the quadratus lumborum, psoas, piriformis and gluteus minimus. A petrojugular dislocation of the right temporal bone is discovered during cranial motion examination. It is found that the patient forgot about a whiplash accident in her early twenties which is remembered after persistent questioning from this doctor who recognized a whiplash pattern in her cranial rhythm.
She has had a reoccurring dream in which she is trying to get to a departing ship but cannot because her right leg is dragging behind her. In her awake life, she has difficulty asserting herself, is always pleasing and wishes she would have gone to medical or law school. She feels that she may have come from a "dysfunctional family." She denies past sexual or physical abuse.
At work she sits on a substandard chair with her computer below eye-level and her mouse pad awkwardly high. She has been too busy and tired to exercise for several years but used to feel wonderful stretching, dancing and swimming. Most of her free time is spent with her children and family events. She rarely has any "alone-time."
Her pulses are mostly slippery with kidney and spleen positions weak and gallbladder excess. Her tongue is wet, pale and flabby with tooth marked edges. There is a thick white greasy coat primarily in the middle and lower burner areas of the tongue.
Neurological and orthopedic testing are essentially benign with no focal deficits appreciated. Her straight leg raising was positive on the right at 80 degrees but it appeared more related to hamstring tension. An MRI done last year had shown some slight posterior bulging of her lumbar discs at L4-L5 and L5-S1 levels without any evidence of spinal chord compression or foraminal encroachment. Mild degenerative joint disease was noted throughout the lumbar region.
So what should we do for this poor woman? Prescribe Prozac and Motrin? Teach her to live with her pain? What does managed care do for a case like this? An integrated approach to her care would encompass all the components that were illuminated in her case. Biochemically, she needs to eliminate the offenders and add the helpers. This would mean avoiding all foods, spices and chemicals that were found to create adverse reactions. She would begin a program to eradicate yeast and blastocystis overgrowth while adding agents that would replace and repair her internal milieu. These might include pancreatic enzymes, hydrochloric acid supplements and high potency bifidus and acidophilis, along with other probiotic agents. An anticandida or a "zone" diet would be instituted. She would take therapeutic doses of the nutrients found lacking on her Spectracell analysis. Perhaps a low dose of Armour Thyroid would help stimulate her metabolism and improve digestion. Chinese herbs which resolve phlegm and dampness and that strengthen spleen and kidney would be useful here.
Structurally, she needs to receive manual medicine treatments that resolve the somatic dysfunctions that are perpetuating her condition. These could include any number of the six osteopathic systems: Myofascial Release, Strain/Counterstrain, Muscle Energy technique, Functional Release, Cranial Osteopathy and High Velocity Thrust procedures. An exercise program that would encourage stretching the tight areas and strengthening the weak areas would be a must. Furthermore, she needs aerobic exercise that will help treat her stagnation patterns. An ergonomically designed chair and work area would prevent daily repetitive strain injury. Rolfing, Alexander Technique or Feldenkrais Method might be added to improve posture and body use patterns. Acupuncture treatment would be very helpful to resolve pain and to treat the underlying problems of dampness and kidney/ spleen deficiencies.
This patient would be encouraged to work with a talented psychotherapist on the core issues affecting her emotional-mental-spiritual health. Hopefully, treatment would involve dream work since she is having a reoccurring dream that is no doubt a call from her unconscious begging to be heard. Biofeedback, hypnosis, meditation, creative visualization and other mind/ body therapies might be helpful for additional stress management. Overall, it is paramount that she develop a healthier psychology.
This patient is not unlike people that we encounter daily in our medical practices. The preceding is but a brief sketch for an integrated approach to back pain management. I have seen patients truly transform when treated in this fashion. Like a phoenix rising from the ashes of their former selves their eyes shine, their thoughts change and the body enters into a new state of being. It takes desire, patience and hard work on the part of both the patient and physician to make this process successful. But it can be done!
Many physicians have become frustrated and bored with the current medical model, especially in the face of managed care. I encourage them to seek out courses that will expand their paradigm and tools for healing. This will allow them to offer more to their patients and to themselves.
Again, this involves an integration of all the available therapeutic modalities - not a choosing of one over the other. Those physicians interested in acquiring new skills should contact my office for more information.