Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (28 page)

ERGONOMIC/WORK TIPS

Don’t stay in the same sitting or standing position for long periods. Take short, frequent breaks to get the circulation and the muscles moving.

Don’t lean forward in the chair when you write or work. You may need to pull your chair closer to the desk or the computer or to use a movable keyboard tray. Set up your workspace to minimize having to lean and twist around to do routine tasks.

A good office chair should have armrests and an adjustable lumbar support. Your lower back should be in contact with the back of the chair. The chair should support the natural curve of your lower back, minimizing pressure on muscles and vertebral disks.

the psoas, shorten and tighten. This exerts a forward pull on the lumbar spine. To maintain the spine’s normal up-and-down alignment, the erector spinae muscles have to pull back, firing constantly, which drives them into fatigue and painful contraction. It’s a perpetual tug-of-war in which both sides lose and the person whose body is the battlefield is saddled with lower-back pain. Treatment is straightforward: manually loosening the psoas and the abdominal muscles in the front, taking pressure off the back, then addressing the secondary damage created in the back.

Muscle or Joint?

Traumatic Lower-Back Pain

Holly, a young woman in her midtwenties, had no history of lower-back pain. She was helping her boyfriend install an air conditioner in their house when she felt a sharp, stabbing pain in her lower back and shooting pains running down her leg, the classic sign of a vertebral disk pressing down on the sciatic nerve or “sciatica.” Over the next week the pain worsened. Following her primary-care physician’s lead, she saw an orthopedic surgeon, who suggested some conservative chiropractic care with muscle work. She improved and her symptoms subsided.

Nowhere in the body is it harder to tease out muscular problems from joint damage than in the spine. Even in cases where the muscle is clearly the bad actor and no structural damage shows up on the MRI, something about the spinal architecture probably makes the affected muscle a little more susceptible. In Holly’s case, she does have evidence of joint damage in the form of a mildly herniated disk. But that doesn’t mean surgery to remove it is the best course of action. It’s possible that an irritated, contracted muscle in the hip rotators may have entrapped the sciatic nerve and caused the shooting or “radicular” pain down the leg. In other words, Holly’s damaged disk may be old business and unrelated to the ill-advised air-conditioner lift. Or it could have been a contributing factor, an extra measure of instability in the lumbar region that pushed her overtaxed muscles over the edge. The best and most conservative first line of action would be manual therapy, not only to relieve pain but also to rule out serious disk damage. Even if Holly’s disk herniation was the direct result of her recent back trauma, relaxing the muscles around the disk might take enough pressure off it to stop the pain.

Holly had been given the standard back-trauma diagnosis of “sprain/strain”—
back ligaments sprained, back muscles strained. Serious back-ligament sprains are notoriously hard to treat. Fortunately, her problems were mostly muscular. Dr. DeStefano found that she had strained her psoas by lifting the air conditioner in an awkward, bent-over position. In other words, she had the traumatic version of the backache to which office workers are prone—the erector spinae muscles were in pain from the constant effort of countering the forward tug of the psoas. Not only that, but a small hip muscle, the piriformis, had tightened up and clamped down around her sciatic nerve, sending the shooting pains down the leg. If the disk was involved in any of this unhappiness, it wasn’t the main player. After several manual therapy treatments, Holly was out of pain.

Chronic Lower-Back Disk Pain

Robert, in his midfifties, is a music-industry producer in Manhattan who had chronic lower-back pain, including radicular pain down one leg. Dr. DeStefano applied chiropractic manipulations along with manual therapy on his muscles, but the progress wasn’t good enough. The muscles would relax when they were manually treated, then tighten up again shortly afterward. This was a strong indication that the muscles were irritated by signals sent by a damaged disk, likely the primary source of the problem. Dr. DeStefano referred Robert to Dr. Jennifer Solomon at the Hospital for Special Surgery, who is a physiatrist specializing in the spine and sports medicine. She gave him a single injection of an anti-inflammatory corticosteroid, which quieted down the inflamed nerves and cut his pain by 90 percent. Then Robert returned to Dr. DeStefano to continue the manual therapy. When the muscles of his lower back and front trunk were firing properly and the tissue felt supple and relaxed to the touch, Robert graduated to a physical therapy program. The goal is for him is to leave PT with a handful of stretching and strength exercises that he can do daily or several times a week to keep the muscles in his midsection moving and to minimize the chance that his damaged disk will cause more trouble.

As you’ve probably gathered by now, the lower back can be a minefield. All the major components—the nerves that branch off from the spinal cord, the cartilage disks that protect the spine, and the postural muscles that support it—work together in proximity. When they get in each other’s way, inflammation, irritation, and pain result. But as Robert’s case shows, even when the disk is the primary problem, it doesn’t necessarily follow that surgery is always the best treatment. In our experience,

CORTICOSTEROID INJECTIONS

An injection of a corticosteroid around a nerve or in a joint reduces local inflammation, which gives the area a break from irritation and the chance to heal. Drugs such as cortisone and prednisone are similar to the steroid hormones your own body produces. When conservative measures such as chiropractic and muscle therapy aren’t enough by themselves, the corticosteroids can be a useful addition to the treatment toolbox, but if they’re overused, they can damage tendons and ligaments. No more than three injections in a given area over a year is the usual rule of thumb.

the best orthopedic surgeons are cautious about operating on disks. But as our colleague Dr. Solomon says, “I have patients who come into my office who will never get better because they’re convinced that surgery is the answer to all their back problems.” We subscribe to what Dr. Solomon calls a “big-picture approach” to the spine: chiropractic, muscle therapy to address muscular tightness, physical therapy to retrain posture and movement, and, when necessary, medical or surgical intervention. With Robert and other patients, she’s had excellent success treating them with a single corticosteroid injection to break the chronic-pain cycle and give the body a chance to heal.

Joint/Orthopedic

Lower-Back Disk Pain (with Severe Neurological Symptoms)

If the nerve pain that radiates down through the body is severe and unrelenting and the muscles connected to those nerves are getting progressively weaker, medical attention is crucial, and surgery is likely your best option.

Facet Joint Syndrome

Branching off each pair of vertebrae are small protrusions, the facets, which form joints with the facets above and below them. They help stabilize the vertebrae and allow for a limited amount of movement. And just like the knee or the hip, the facet
joints can wear out, becoming one source of persistent back pain in older people. The disks, the shock absorbers between the vertebrae, shrink with age, increasing the pressure on the facets and the likelihood that cartilage will wear away and bone will wind up grinding against bone—possibly causing arthritis.

Surgery to fuse the vertebrae and the facets is one treatment option that, when necessary, has good results. Patients are usually older, however, and may not tolerate the considerable risks of the operation. Whenever possible, we take the most conservative approach, focusing on the things we do for patients (manual therapy for muscle tightness; corticosteroid injections if necessary) and things patients must do for themselves (losing weight to take pressure off the lumbar spine; going to physical therapy and incorporating PT exercises into a daily routine; getting the body moving in a low-impact way with walking, aqua exercises, or cycling).

Spinal Stenosis

Like arthritis, spinal stenosis is a structural problem that doesn’t usually have a good structural solution. The spine changes with age—the vertebrae can develop bone spurs, disks can bulge—which can narrow the space inside the spinal column through which the nerve fibers travel. When the fit is so tight that the nerve fibers get compressed, the diagnosis is spinal stenosis. The symptoms are muscle pain and weakness, sometimes accompanied by numbness and tingling. Patients are usually seniors, who are not good candidates for surgery to open up the spinal canal. Sometimes treating the symptoms can eliminate pain for patients who cannot tolerate surgery.

Our point is that diagnoses such as facet-joint arthritis and spinal stenosis aren’t, or shouldn’t be, the last word on what you can and can’t do in life. Yes, the ability of your lumbar spine to do its job has been compromised by structural changes inside the joints. So the onus is on you to get more out of the function you do have by addressing muscle strength, weight control, and exercise. We have a patient, a ninety-two-year-old gentleman, who had been a vigorous long-distance walker all his life until classic spinal stenosis symptoms reduced him to a shuffle. A few sessions of manual muscle therapy had won him only modest gains. The next time we saw him, he had returned from spending the winter in Arizona, where a resourceful physical therapist had worked on strengthening exercises to build up those leg muscles that were still connected to the nerves. He was back up to walking a mile a day. Although his condition wasn’t corrected, he had fewer symptoms.

LOWER BACK

The lower back has a complex of muscles that both stabilize the back and create a wide variety of movements. The lower back is affected by all the core muscles, which form a muscular corset around the lower torso and hips. Any imbalance or restriction can put strain on the back muscles and have an adverse affect on posture.

LOWER BACK

Purpose:
To target and remove any restrictions and restore a full range of motion to the erector spinae muscles (the main postural muscles of the back) by manually releasing tight, short, and damaged muscles.

Starting out:
Sit on a stability ball with your feet spread shoulders’ width apart. Rotate slightly toward the treatment side and arch your back. Grip a F.A.S.T. Stick™ or other treatment stick, such as a TheraCane
^®
, behind the back, with both palms facing forward, and place the knob on the thick muscle on the treatment side of your spine. This muscle is divided into three zones: zone one is closest to the spine, zone two is in the middle of that thick muscle, and zone three is on the outside edge of this large muscle group.