The BRACING Series: No. 5

By Sean M. Wheeler, M.D.

In my preceeding column in this series, we discussed the gap between the way we've learned to move throughout our lives and the ability of our bracing muscles to stabilize us enough to execute those movements.

As we grow, stability leads to coordination.  If we get injured or become sedentary, however, we lose our stability but not our coordination.

This gap between the stability we should have to move the way we do and the stability we currently have is called a bracing deficiency.

The inevitable result of this “bracing deficiency" is that our bodies must compensate or cover for our weakening bracing muscles, a process which leads to a further weakening of the bracing muscles and still more compensation. This deficiency can only be addressed with a dedicated focus on strengthening the bracing muscles in isolation.

Your body's compensations resulting from bracing deficiency occur without negotiation as the body must be stable.

For example, the hamstrings take over when the bracing muscles of the lumbar spine weaken, in an unconscious effort to stabilize the lower back. As this becomes ingrained, the hamstrings over time adjust to their new role, a job they can do better by remaining shorter and tighter, thereby causing a loss of flexibility.

A second way the body compensates for bracing muscle weakness in the lower back is by tightening the joint capsules of the lumbar spine. This process gives the spine a little more stability but takes away some of its motion. Both of these compensation scenarios are reversible.

By reclaiming the strength and endurance of your bracing muscles, you can recover from these two forms of bracing deficiency.

A third compensation scenario, however, is not reversible:

If the compensations last for years, the body will begin to build bone around the joint in an attempt to stabilize it. This bone growth is known as arthritis. Some forms of arthritis are inflammatory, but most cases of it are a form of body stabilization.

A spine which is stabilized by its bracing muscles is a spine which maintains its motion, which materially decreases the chance of experiencing chronic pain.

In contrast, a spine stabilized by inflexible action muscles, joint capsule tightening and, eventually, arthritis, achieves the "stabilization" effect through immobility. The result is a higher incidence of chronic pain.

These body compensations change the way you move, interact, play and age--in short, they change the way you live.

I see patients all the time who have bracing deficiency, patients who believe that joining a gym will somehow remedy their deficits. They begin to exercise their action muscles as a cure-all and get hurt as the compensations and lack of stability can't support their new level of activity.

I treat their pain and direct them to specialized physical therapy to re-focus on their bracing muscles to close the bracing deficiency.

This week's bracing muscle exercise targets the small muscles of the feet.

Though flexibility and mobilization of the feet are also a priority, this exercise is designed to improve endurance in the small muscles of the feet by creating oxygen debt.

When you perform the exercise in the video, remember to "dome" the foot for at least 30 seconds to achieve a prolonged decrease in blood flow in the muscle.

Do this exercise several times throughout the day.

Good luck.

Published in The BRACING Series

Most back doctors are lousy diagnosticians.

The vast majority of my patients who have seen multiple back specialists tell me that I am the only doctor who has ever actually examined their back.

The problem arises from an over-reliance on the MRI as a diagnostic tool.

Few pain doctors are skilled at giving physical exams, and fewer still read their own MRI films, instead relying on the radiologist's report.

Consequently, any finding on the MRI is assumed to be the cause of the pain.

You must empower yourself with knowledge of the many potential causes of your pain and become your own best advocate during the diagnostic process.

Especially when it comes to the back (where the causes of pain are often multiple and interconnected), you need to reverse the doctor/patient dynamic and ask a lot of questions.

One ailment where the cause of the pain is commonly misdiagnosed is sciatica. 

This is an irritation of the sciatic nerve, a large nerve made up of parts of four nerves which emerge from the spinal cord and bind together, running from the L4 vertebra down to S3.

The usual symptom pattern of sciatica is pain or numbness which runs down the back of the leg to the calf and sometimes into the foot.

Illustration 6 Lumbar Nerves Back Pain

To the uninformed patient, however, "sciatica" can mean any pain down the leg.

My purpose in this blog is not to train you in diagnosis, but to give you a quick overview of this pain's many possible causes and empower you to question a rubber-stamp diagnosis made by a doctor who has failed to properly examine you.

We'll discuss the two most common causes, and in an accompanying video I will summarize several of the more obscure ones.

The most common cause of sciatica is a disc irritating a nerve. 

As your spinal cord descends through the spinal canal, nerves are given off at each level. A disc can irritate or compress these nerves, causing pain along the path.

The location of the pain or numbness helps us ascertain where the disc problem may be.

Illustration 13 Piriformis Sciatic Back Pain

 

A second common cause of sciatica is piriformis syndrome.

The piriformis muscle runs from the pelvis to the hip and is one of the muscles which stabilizes the hip. When the sacroiliac joint in the hip or the hip joint has dysfunction, this muscle will spasm to protect the joint in question. The problem occurs with the sciatic nerve as it passes under this muscle.

The pattern of pain and numbness this causes is very difficult to differentiate from that caused by a disc.

Here is a classic case of where the MRI can lead to a misdiagnosis. Some studies have suggested that 30% of twenty-year-olds with no pain symptoms have disc bulges and over 90% of sixty-year-olds with no symptoms have significant findings (disc bulges or stenosis) on a spinal MRI.

In other words, many people have disc issues which don't bother them.

 

But the diagnostic instinct here is to blame the disc bulge for the symptoms and be done with it.

This brings us to a horror story we see too often, one in which the patient is assumed to have "sciatica" and, coincidentally, is found to have a disc bulge on the MRI. Three epidurals provide some relief but not enough, and surgery is performed.

If the cause of the pain down the leg is something other than nerve irritation, the patient does not get better and falls into a rabbit hole of a diagnosis: "Failed Back Syndrome."

By empowering yourself with knowledge and carefully considering all the other causes of pain down the leg, you can be your own best advocate and help to arrive at your best treatment option in the process.

Published in Dr. Sean Speaks

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. 

 

Published in Medical Research

weeblesWeebles®

The POSTURE Series, No. 4

By Sean M. Wheeler, M.D.

There is a difference between a teenager slouching and an adult slouching.

It is gratifying, as a nagger [a skill learned from my mother] to constantly bug a teenager about slouching and watch them follow your advice and obtain great posture. Gone is the insecure 16 year old and in their place is the confident 19 year old.

One can’t help but to look upon that young adult and feel a sense of pride in the constant badgering that accomplished such a feat. And yet, the same adult is unable to fix their own posture. Braces, electronic reminders, Lenten resolutions, shock collars, etc. and nothing seems to stick. Sure they sit up taller for a while, but the head is still forward and the middle of the back begins to hurt. It is not lack of willpower, no matter how much one beats themselves up over their posture.

Something has changed.

The fundamental make-up of a teenager slouch verses an adult slouch is completely different. Until the adult is able to understand the difference, they will always have posture problems.

ONE

The tissue isn’t the same.  We joke as adults that a child can stab themselves with a fork and watch themselves heal, but adults pull a muscle putting their belt on and two weeks later they still hurt. It is only funny because it is so true. A young person’s tissue just holds them together better.

Imagine a huge tent for a wedding that has a single large pole in the center. The cloth of the tent is new and taunt. The ropes and stakes that support the tent are strong. The whole structure is stable. Then someone runs into the center pole hard enough to make it wobbly. The tent as a whole is not as stable as it was, but because the cloth and the ropes and stakes are in such good condition, enough stability is maintained to make the tent functional. [This is the case of a young adult who begins to lose their bracing muscle strength.]

As the tent ages, the cloth begins to give a lot more. Tears easier and cannot be relied upon as much to provide stability. The ropes stiffen and become more brittle while the stakes bend. In an older tent, a wobbly center pole becomes an issue that must be dealt with if the tent is to stay up. [Please no comments on tent repair or stability, this is a parable on the aging body, not a treatise on tents.]

When injuries or bad positions occur, adolescents spring back into position like a Weeble. ["Webbles wobble but they don't fall down."] Adult tissue is like the part of the couch that one hates to sit on, because they sink in way too far. It is just not the same tissue.

TWO

Gluteus muscles are weaker. The muscles in the buttock that hold the leg into the hip in a stable position are bracing muscles. Muscles that have to work all day stabilizing the hip joint. As adult sits at their job, or find increasingly more efficient ways of completing their jobs, they slowly begin to lose the endurance of these bracing muscles. Sure, the gluts are still strong, but how is their endurance? When standing, how long until they lean into one hip? This is a sign of endurance in the stabilizing function of the gluteus. When the gluteus is weak, psoas tightens [see The Posture Series, No 3].

THREE

Pelvis is in the wrong position. Adults not only sit more, but have better chairs. Kids sit in terrible chairs and can’t wait to get out of them. Adults take their hard earned money and get the chairs they deserve. Then they lean back into them. They role their pelvis back, allow their tummy to pooch out and sit like this for hours. The days turn into weeks and months and then years and decades. The pooched out tummy becomes a norm that one would never see in teenagers. It becomes a sign of decreased deep bracing muscle strength around the lumbar spine. A teenager with their pelvis in the wrong position is okay because their tummy is drawn in all the time. An adult has to have their pelvis in the correct position because of this lack of endurance in the tummy muscles (not situps).

Adults then try to get their posture back and think all they need do is make a commitment to sitting up straight. Instead, getting their pelvis in the correct position is going to take a serious 180-day commitment to drawing the tummy in correctly, stretching hamstrings and hip flexors, strengthening the gluteus bracing muscles and deep bracing muscles. Add to this, knowing where the pelvis is supposed to be, rather than pretending they have an adolescent slouch.

CONCLUSION

These steps might even make putting on a belt less dangerous to one's health.

 

[Weebles is a trademark for several lines of roly-poly toys designed by Hasbro‘s Playskool Division.]

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 and new medical approach, Dr. Wheeler puts patients back in charge of their health to achieve liberation from chronic back pain. 

Published in The Posture Series

The POSTURE Series, No. 3

By Sean M. Wheeler, M.D.

In part 2 of our Posture Series I explained how to get your pelvis in the correct position. This correct pelvic position is the essence of good posture, to assist in avoiding chronic low back pain.

Drawing the tummy in, pulling the pelvis into the correct position, achieves good posture and builds the endurance strength to the very muscles which stabilize the spine.

Psoas Quadratus LumborumPsoas & Quadrates Lumborum
The concept may sound simple, but so much could go wrong.

Two Muscles At Work

There are two muscles around the spine called psoas and quadratus lumborum that work to lock the low back into a fixed position.

The psoas [red pointer in the image] runs up from the hip along the front of the spine and attaches to the spine above the level of the belly button. It is a very strong muscle that helps stabilizes the hip and causes many problems when it is not functioning correctly.

The quadratus lumborum [blue pointer] is a smaller muscle that runs from the top of the pelvis to the lowest rib, and most of the time, works with the psoas to lock the spine down.

Dr Sean Wheeler Locked Down SpineCollege student to-be practices moving to campusHeavy Lifting

Most of the day your spine is stabilized using deeper muscles called bracing muscles that stabilize while allowing normal motion of the spine.

When you pick up something heavy, this is the only time you switch to the psoas and quadratus lumborum. They provide an extra level of stability needed during lifting. So in a perfect world, 99% of the day your bracing muscles stabilize you and 1% of the day the psoas and quadratus lumborum lock you down to lift something heavy.

Spasm

With back pain, sometimes the psoas goes into spasm in a failed attempt to protect the back and hip. When the psoas spasms, it pulls the pelvis into a poor position and the lumbar spine forward. 

DrSeanWheeler Pelvis Position Illustration2The quadratus lumborum is then forced to contract all day to fight this spasm and it leads to irritation of the quadratus lumborum and muscular back pain.

Some people who have back pain then have two problems, the original cause of pain, plus the body trying to stabilize them further and causing more problems.

How can you unintentionally cause psoas spasm? By drawing your tummy in too forcefully when attempting to get your pelvis in the right spot. In this case, improving your posture can actually lead to back pain.

What To Do

Here’s what you do: draw your tummy in to pull your pelvis into a correct position where your head feels comfortable over your shoulders. Then rock your shoulders side-to-side to see if your lower back feels locked down. If it does, take a deep breath and start over.

Over time this will become easier and feel much more natural. Holding this position all day is very difficult as it takes bracing muscle endurance and that endurance strength takes 6 months to achieve. So be patient and persistent.

When To See A Medical Professional

If all of this sounds like gibberish and you can’t get your pelvis to do any of these things, you may need to see a professional. If your back is locked down when not heavy lifting and you suspect your psoas is in constant spasm, you may need to see a professional. Otherwise, let’s keep following this path towards better posture.

More To Come

Coming soon, why adult posture problems are different than those of the teenager.

 

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 and new medical approach, Dr. Wheeler puts patients back in charge of their health to achieve liberation from chronic back pain. His oldest son Duke tried to imagine that he was lifting the pictured box while moving to college, but at the time of this column, he still has 4 months to wait.

Published in The Posture Series

For chronic low back pain, there is no quick fix.

Which is good news.

Good news as the "quick fix" fantasy must be dispelled, to achieve long overdue medical progress in treating chronic back pain. 

For those who suffer from chronic back pain, the desire of a passive "fix me" quick fix, while not uncommon, ignores a component absolutely necessary to recovery:

Active participation by the patient in their healing. 

Projecting the fantasy of a quick fix expectation upon a back pain doctor or physical therapist achieves the opposite of both "quick" and "fix" if the back pain sufferer is not also committed to investing in themselves, by investing the time to improving their body.  

The powerful reality to achieve the "fix" is for the patient to be fully invested in their recovery.

Like that of an athlete with their coach, the patient's relationship with their medical team remains important:

Overall, the coach–athlete relationship is…at the heart of achievement and the mastery of personal qualities such as leadership, determination, confidence and self-reliance. – Sophia Jowet for The British Psychological Society

Just as athletes training for the 2016 Olympics and Paralympics work hard to win a place on their teams, the chronic back pain sufferer must also actively invest time in improving their body to relieve chronic back pain.

[My coach] basically said that there is no shortcut to success. If you want to be good enough to be on the team you’ve got to work hard. That mentality has kept me going through my whole career. –Michael McKillop, Irish middle distance runner and Paralympic athlete

If a back pain sufferer, owning your power to return to and maintain good health means you are bringing a halt to the spiraling fear and worry that come from backache and potential disability.

When you no longer wait for the hope of someone to "fix me," you take the all important first step to healing.

As McKillop says, there are no shortcuts to success and the work is time consuming. But the good news is the reality of pain freedom is achievable by most any sufferer committed to improving themselves with knowledgable "coaching" from their medical team over a period of 180 days.  

As back pain expert Dr. Sean Wheeler encourages chronic back pain sufferers in Chapter 2 of his new book, UPRISE:

Don’t let [the reality that only you can do the strengthening] scare you, though – it should be empowering.  Let’s not wait on the medical establishment to catch up. Let’s each and every one of us start the revolution now… More than a new plan for treating back pain…Tune Me is a revolution in how we think about, care for, and maintain our bodies.

While the medical establishment is in need of its own revolution in back pain treatment, for you a “revolution of one” can begin any time, with you taking control of your own back pain treatment with direction and support from knowledgeable medical assistance.

The revolution and your healing begins by embracing pain freedom reality with your active participation.

And banishing the passive quick fix fantasy.

Published in Back Pain Relief
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