Dr. Jay Sandweiss - Integrative Medicine

An Integrative Approach to the Patient with Back Pain

                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. 
            
 
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