Medical Research

Dr. Sean Wheeler expert back pain doctorBy Sean M. Wheeler, M.D.

A recent guideline issued by the American College of Physicians discussing low back pain, and the use of opioids and their lack of effectiveness in treatment, has brought a focus on yoga as the first listed treatment alternative to opioids, and often the only one mentioned in media coverage of the guideline. 

Now many back-pain patients, intimidated by the image of themselves squeezed into yoga pants in a class with seasoned yoga practitioners, are deciding to just stretch more at home, perhaps in the belief doing so will alleviate their pain.

As a back-pain specialist, I've come to recognize the relationship between flexibility and back pain is a complicated one. 

Yoga is a group of physical, mental, and spiritual disciplines, today with a wide variety of Yoga practices and goals, including versions in which stretching is the primary focus.  Yoga as a physical discipline is our focus here.   

Choosing the correct yoga class for your specific needs is paramount.  To accomplish this, you must first understand where you rank within the Stability  Hierarchy – your body’s bracing capability – which I break into four levels:

  • Flexible and Stable
  • Inflexible but Stable
  • Inflexible and Unstable, and
  • Flexible and Unstable

Patients in the best position are those who are both flexible and stable.  They're the ones who have either worked very hard to maintain both attributes, or are young and have never been seriously injured.  To climb into this category is a worthy and attainable goal for most of us if approached correctly; those already there can start with any yoga class they choose.

The next level are patients who are inflexible but stable.  This includes the young adults who are involved in sport but have never been flexible; the middle-aged "weekend warriors" who've stayed active on a part-time basis; or the athletes with past injuries they never completely overcame.  This group needs to add flexibility to the stability they have achieved or maintained, and for them, a stretching-based yoga like hatha yoga would be very helpful.

A third group, the largest by far, has become sedentary or injured and now is both inflexible and unstable.  Many of my patients are unaware they are in this group; they think they're in the inflexible but stable group and will attempt to gain flexibility on their own.  While flexibility is important, it should only be achieved in coordination with the effort to gain stability.  Patients with chronic low back pain caused by weak bracing muscles of the lumbar spine [the definition of unstable] often have tightness in the hamstring muscles, which tighten in an essential act of compensation to stabilize the lumbar spine.  Attempts to stretch these hamstrings in isolation are counter-productive and could lead in the long term to disc degeneration and arthritis [see No. 5 in my "Bracing Series" for a more in-depth explanation].  Patients in this group must often start with physical therapy to strengthen their bracing muscles in isolation with the hope of transitioning into a yoga class that focuses on positions and poses.

The last group – flexible and unstable – is unfortunate though small, consisting mostly of those who have always been very flexible and have become weak in their bracing muscles.  Yoga is not helpful for this group, which already focuses way too much on what they're good at--flexibility.  These patients often need intense physical therapy followed by a transition to Pilates instead.

To recap our four categories:

        STABILITY HIERARCHY
HIERARCHY STAGE GENERAL CHARACTERISTICS YOGA RECOMMENDATION
Flexible & stable Those who work at maintaining both body attributes, and the uninjured young Any yoga physical discipline
Inflexible but stable Young adults involved in sports who have never been flexible, middle-aged “weekend warriors”, and athletes unrecovered from past injury Stretching-based, such as hatha yoga
Inflexible & unstable Sedentary and/or injured Physical therapy before transitioning to yoga
Flexible & unstable Flexible with weak bracing muscles Yoga not helpful

For my patients, I integrate into our TuneMe system the physical aspects of yoga which enhance stability and flexibility, even though I understand the practice of yoga at its higher levels involves elements of eastern spirituality, which as a Christian I personally reject.  I encourage my patients to continually evaluate their position within the Stability Hierarchy, and to use yoga for improving their body stability, as suggested above.

Dr. Sean Wheeler expert back pain doctorSean M. Wheeler, MD Back pain medical expert Dr. Sean Wheeler advocates the urgent need for change in how those who suffer from chronic back pain are treated and cared for within the healthcare industry, including by medical insurance companies involved in payment approvals for medical treatment.  

According to Dr. Wheeler, decreasing long-term reliance on pain medication as a treatment option is needed, as the repeated use of these medications does not address the systemic cause of chronic low back pain.  

Now comes word of a new study supporting decreased use of opioids for relief from low back pain, in this report from today's New York Times:

"People with chronic low back pain are sometimes prescribed opioids for pain relief, but a review of studies has found opioids generally ineffective.

The analysis, in JAMA Internal Medicine, pooled data from 20 high-quality randomized controlled trials that included 7,295 participants. The studies tested various narcotics...

The drugs relieved pain slightly, but the effects were not clinically significant, and the medicines did little to improve disability...

Measured on a 100-point scale, the magnitude of relief did not reach the 20-point level the researchers defined as clinically effective, little different from NSAIDs [i.e., nonsteroidal anti-inflammatory drugs] like aspirin."

As characterized in the study:

"For people with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses."

Beyond today's news of opioid ineffectiveness, Dr. Wheeler commented:

"Fund researching on alternative effective pain management for back pain patients is a pressing need, in a field that has not seen a significant medical advance in four decades.

Research into bracing muscle® endurance as the cause — and source of relief — of chronic low back pain is overdue. 

It is time for our healthcare profession, including health insurors, to effectively address what has become the world's most disabling condition, that of chronic back pain." 

Read more about this latest research on opioid effectiveness in JAMA Internal Medicine, and in The New York Times.

 

Sean Wheeler, M.D. is board certified in both Pain Management and Sports Medicine. He is a leading expert on back pain and his recently released book UPRISE is changing the way the world approaches back pain. With a new vocabulary in aid of understanding the cause of back pain, and new medical approach, Dr. Wheeler puts patients back in charge of their health to achieve liberation from chronic back pain. 

 

An investigative review published this month in JAMA Internal Medicine, Prevention of Low Back Pain, seeks to determine the effectiveness of preventing low back pain as discussed in multiple media reports.  

Researchers affiliated with the George Institute for Global Health at the University of Sydney in Australia and other institutions, surprisingly finding few high-quality studies among some 6,000 conducted worldwide, selected 23 found to be methodologically robust for their review.

Researchers concluded "success" in preventing low back pain is “discouragingly limited,” with favorable results achieved solely through exercise – of any kind.

Professor Chris D. Maher, PhD, FACP, overseer of the review, defined pain prevention "success" in The New York Times as:

A reduction in “the risk of having an episode of low back pain in the next year by 45%.” 

An NPR report by Rae Ellen Bichell interpreted the results even more pessimistically, with exercise reducing the risk of repeated low-back pain in the year following an episode by only between 25 and 40 percent.

Think about this for a moment.

The best medical result for those who exercise is a 45% chance of a low back pain nonrecurrence for one year.

Why would medical professionals deem this a successful result: the best treatment answer to chronic back pain prevention is patients should exercise regularly, and even then less than half will achieve relief?  

Is any other disease studied so little? With conclusions revealing such unpromising results?

The most enlightened finding of this latest review should be an eye-opener to everyone in the healthcare industry: modern medicine does not understand the cause of chronic low back pain.

Lower back pain is the leading cause of disability worldwide.  According to global burden of low back pain estimates, “...further research is urgently needed.” And yet we see a scarcity of high-quality studies.

Until now, few studies systematically examine what really works against repeated back pain and what doesn’t. —Gretchen Reynolds, NYTimes Well blog

While this latest review brings attention to the lack of research, it also highlights how the medical profession's approach to the problem is wrong.

The direction of research must change.

To move forward and relieve this global burden, low back pain medical research must escape old thinking, and move to a new intelligence.

Says sports medicine and pain expert Sean Wheeler, M.D.: "The medical community, including medical insurers, must understand cause."

Yet, the answer to the causation question has been found, with the needed shift in thinking about cause of chronic back pain is maddeningly small and intuitive. Recognition of this change is what spins the entire discussion of low back pain on its ear.

Says Dr. Wheeler:

We should all be challenging the status quo of accepted back pain treatment practice.

I offer a viable alternative from our global inertia in the pages of UPRISE, where I systematically identify and challenge the manner and methodology of how my profession has understood and treated back pain during the past 40 years. In UPRISE I put forth solutions.  And call for more ideas and further research.

Is this where the revolution gains traction?

What will it take for individual healthcare professionals, insurers, and philanthropic donors to question what they’ve been taught and believe about chronic back pain?

Let us question, and challenge. It’s time for everyone within the healthcare industry to move to a new mastery for patients everywhere.

 

Dr. Sean Wheeler's new book, UPRISE: Back Pain Liberation, By Tuning Your Body Guitar, clearly presents the cause of chronic low back pain and provides a roadmap for leaving this condition behind – for good. UPRISE conversations are welcome @DrSeanWheeler, Facebook, Google+ and at LinkedIn

Sean M. Wheeler MBy Sean M. Wheeler, M.D.

“[A]s an industry, we must work together to prove ourselves worthy of the esteem this [profession]...holds. We demand...high prices for our product, and our clients...place both their trust and money with us without question. We must continually raise the bar above “selling” and provide our clients with the best, unbiased and unexaggerated points of view possible."

These are fighting words from guitar maker Gerald Sheppard. And beliefs I share in my chronic back pain management practice.   

According to Sheppard, selling shenanigans in guitar sales include “developing an artificial reputation of mystique about the wood” to move inventory off the shelf.

In the chronic back pain industry, selling also exists: of the Same Old Thing. For the past 40 plus years, the medical establishment treats back pain based on misunderstood and incomplete knowledge. Some are needle jockeys who push higher revenue injections, rather than treatment addressing the real cause of the patient's chronic back pain. Patients do not get better, or they get better only to have their pain quickly return.

And so it continues.

Needed systemic change has yet to occur within not only the medical profession, but also among the health insurance industry, the latter in relation to treatment insurance carriers approve for payment. 

Whether in lutherie or medicine, as professionals we must set our egos aside to put our patient first. We expect more from ourselves, and from each other, given the trust our patients award us.

In my first years of practicing medicine, a mentor taught me to pause while making a diagnosis or patient treatment decision, and ask: “Is this about me, or is this about the patient?

Armed with this awareness and more questions – through medical fellowships in sports medicine and pain management, I soon arrived at an inevitable crossroads.  Would I remain complicit in “selling” our dinosaur of a treatment process?  Or question it?

I questioned it, and answers came.  Answers with far-reaching potential to emancipate humankind from chronic back pain, as I share in UPRISE, a self-empowerment manual for chronic back pain patients, and a new understanding tutorial for healthcare professionals, from which both learn how to tune, keep in tune, and play their low back, their Body Guitar, liberated from chronic pain.

Each day a patient’s experience and outcome improves is an enormous win.  But for things to truly change, as professionals we must raise the bar:

  • Continue to put the patient first. 
  • Free ourselves from the status quo flawed approach.
  • Ask questions.
  • Share the responsibility. 
  • Push the conversation beyond assumptive thinking and current comfort levels.
  • Communicate and share innovative understanding such as Tune Me
  • Move forward with research.

I trust those of you in pain management will be open to and share the concepts of Body Guitar and Tune Me with your patients – putting them first - as reflected beautifully in the philosophy expressed by our thoughtful luthier in Tennessee: 

"...to help the guitarist present a piece of music to the best of his or her ability, and for it to sound the way it was intended to sound.”

As in lutherie so in medicine, as responsible medical professionals we must set our egos aside to put our patients first.

It's a decision we can each easily make.

 

217369119484610699vfpoab0icBy Sean M. Wheeler, M.D.                                     September 18, 2015

While reading the New York Times this past week, I was drawn to this story of how runners slow with age, and how strength training may help restore speed as they age, based on a new study published in Medicine & Science in Sports & Exercise, the journal of the American College of Sports Medicine

To maintain running speed as the years pass, the study concludes runners should strengthen their calf and ankle flexor muscles.

Through strength training.

This conclusion is incomplete, as it ignores the power to remain motionless.

Whether or not a runner, as we age our bodies experience the loss of power affecting everyday mobility.

For specialized bracing muscles located in six high-performance locations within the body — ankles, feet, low back, neck, shoulders, hips — this loss of power is caused by a decrease in endurance, rather than a lack of strength. 

At peak capability and as the label implies, bracing muscles brace, providing stability by not moving through spontaneous all day endurance, while our action muscles move intermittently only when called upon.

Understanding how our bodies must simultaneously retain the power to remain motionless AND the power to move, offers deep insight into how our bodies may retain mobility and achieve liberation from chronic pain.

At any age.

In aging, as diminished circulation — blood flow — to our bracing muscles cause them to lose their endurance and the power to remain motionless — to brace — our bodies attempt to make up for this loss by altering movements through, for example, shortening gait, restricting joint motion, and substituting action muscle strength for bracing muscle endurance.

These altered movements too often result in other physical ailments, leading to a remaining lifetime of decreased mobility and often chronic pain.

Begin the UPRISEing to refresh your power. For yourself, and those you care about. 

To defy these limitations of aging.

Ask your healthcare provider and insurance plan for circulation training rather than strength training — to pump blood flow rather than pump iron — to restore endurance in affected bracing muscles. 

Whether a dedicated runner or focused more simply on everyday mobility, together the power to remain motionless AND the power to move offers lifetimes of enjoyment.

For you.

And those for whom your everyday body mobility ensures your presence.

Surface your inner revolutionary.  UPRISE

[Image source: Indulgy]

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