How to Find Relief From Your Back Pain with Dr. Phillip Mendis

Podcast Transcript

Cassandra Holloway:

Hi, thanks for joining us. You're listening to the Health Essentials podcast brought to you by Cleveland Clinic. My name is Cassandra Holloway and I'll be your host for this episode. Today we're broadcasting virtually as we are practicing social distancing guidelines during the coronavirus pandemic. We're joined virtually by spine health expert, Dr. Phillip Mendis. Dr. Mendez, thank you so much for taking the time out of your day to speak with us and welcome to the podcast.

Phillip Mendis:

Hi. Thank you for having me.

Cassandra Holloway:

Back pain can really stop you in your tracks. And most of us unfortunately know the feeling all too well. Studies show that around 80% of people will experience low back pain at least once in their lives, but back pain can be a really complicated and personal experience. What works for one person might not work for the other. Today, we'll do a deep dive into all things back pain. We'll discuss the different types of pain, from minor to serious, as well as treatment options available and how to find relief at home. We'll also provide advice for preventing future pain. Before we get into this episode, we want to take a moment and remind listeners that this is for informational purposes only and is not intended to replace your own doctor's advice. Also, please note that this interview was prerecorded and does not reflect any changes that COVID-19 precautions that may have been made after the recording. Dr. Mendis, I want to first start off by asking you if you'll tell us a little bit about your practice at Cleveland Clinic and the types of patients you see.

Phillip Mendis:

Sure. I work at the Cleveland Clinic Center for Spine Health and within the center, I am a spine medicine or a medical spine provider, also interventional spine. What that basically means is I'm treating spine related issues, mostly back pain, neck pain related issues with conservative management, up to and including injections. I'm not a surgeon. We do have surgical colleagues within our department that we would refer to if necessary. But basically I treat up until that point of needing surgery and everything in between there.

Cassandra Holloway:

When we think about back pain, I assume there are so many different kinds of back pain and it kind of falls on a spectrum between minor and really serious. I'm curious, how do doctors typically categorize back pain? Is it that kind of the lower, middle, upper part of your back? How do you label back pain?

Phillip Mendis:

Sure. That's one way to do it and most commonly, probably. Like you said, upper, mid back or lower back, so that relates to the spinal segment. Either cervical, thoracic or lumbar spine. You can also categorize based on the duration of back pain. Acute, subacute or chronic and then like you said, more typical versus more serious or concerning causes. But those concerning causes are very rare. That's an extremely small portion and the majority of people who experience back pain are not going to have something like that, they're going to have the more every day back pain issues. The main thing is for patients not always to be super focused on the worrisome things, but obviously be aware of them if need be.

Cassandra Holloway:

How does someone tell what type of back pain they have? I feel like it's really complicated between a nerve issue, like a herniated disc versus a pulled muscle strain at the gym. How do you tell when something is more serious or when something is more acute, like you said?

Phillip Mendis:

Right. Even for spine experts, that can be difficult. Back pain, the multiple different causes can kind of present in the same way or same location. It is difficult, but you mentioned nerve pain. That's probably the one that is easier to recognize. Typically when it's a nerve related pain, you have that radiating pain. The pain doesn't just stay in the back. It will travel to the leg or if you have neck pain, it may travel to the arm. And typically pretty far down the extremity, not just in the upper part. That's a little easier to recognize nerve pain. Now having said that, nerve pain can just kind of settle and sit in the back as well, but that's certainly one way to kind of recognize that.

              And then, like you said, as far as muscle strains, a lot of times you can point to a cause for those types of things, if you were doing something in the gym or bent or twisted the wrong way and if it's kind of one side of the back, seems like it's in the soft tissue, maybe that's more muscular. Something that's more right in the center could be disc related, could still be muscle strain, could be joint related pain as well. And oftentimes pain that kind of goes across the low back is joint related as well. But again, it can be hard to determine. And even when you see a specialist and they're examining you, we're using tools are kind of pre-existing knowledge to try to determine what it may be, but it's not a 100% foolproof thing to do.

Cassandra Holloway:

I'm curious if you could answer maybe in your practice or just generally speaking, what's the most common type of back pain?

Phillip Mendis:

Sure. The most common pain is definitely a strain. A lumbar strain, so meaning just soft tissue muscle, maybe you'd call it a muscle pull or like we said, strain. That can seem really bad sometimes. And it can spasm up on people and kind of lock up and really feel limiting. But those types of injuries typically will as with most back pain, but especially with muscle pain, are going to get better over time progressively. And it's usually nothing to worry about, but obviously it can be painful and limiting for patients, but that would be the most common.

Cassandra Holloway:

Talking about kind of that lower back pain being the most common, what's the difference between lower back pain and sciatica? Because I feel like you hear so much about the sciatica nerve.

Phillip Mendis:

Right. Like we were talking about before, sciatica basically is kind of a misnomer term. You have the sciatic nerve, which is actually in the leg, but most of the time when we're saying sciatica or when a patient hears about sciatica, they're referring to nerve related pain in the leg, but that nerve pain is actually coming from the spine. Meaning a spinal nerve in the low back is inflamed, irritated, being pressed on in some way or another and that's referring pain down the nerves that travel to the leg. It's very rarely that it's actually the sciatic nerve in the leg that's being compressed.

              It is possible, but that's not common at all. It's typically higher up in the back where the nerve is being irritated and you feel that down in the leg. That's the easiest way to determine that. And especially if that pain is traveling below the knee, that's a pretty clear sign that it's nerve related pain. Back pain, like we talked about with disc, muscular or joint related pain, can refer kind of to the buttock area, back of the thigh, but it would be unusual for it to go all the way to the knee or definitely past the knee.

Cassandra Holloway:

Unfortunately many of us know the struggle of getting older. What is the correlation between aging and back pain?

Phillip Mendis:

When it comes to aging, it's more about, I would say, it's probably more about our change in activity level. It does have to do with the aging process, somewhat as well. Just like any other sort of joint, be it knee or hip or shoulder, the spine is similar, that there is going to be some wear and tear over time. And so obviously the older we get, the more at risk for that we are, but that doesn't necessarily mean that's going to cause pain either. It's often the activity levels and those restrictions or changes in muscle mass and bone density even, that can sometimes put us at more risk for having a back injury or back pain arising. If we stay active and healthy and strong, that can often suppress that or limit those occurrences of back pain.

Cassandra Holloway:

Sure. What are some other risk factors or things that can contribute to back pain?

Phillip Mendis:

Right. Just to reiterate the activity is a main thing there. Keeping a strong core, good posture with the spine, proper lifting technique and body mechanics so that you're not putting the spine in awkward positions. And like I said, maintaining a healthy, active lifestyle, proper diet and weight management. Obesity is a risk factor. As we gain more weight, that can put more pressure on the back and the joints and increase the risk of injury in that way. Smoking is another risk factor. There's evidence that smoking affects pain levels and it can affect our bone density and can kind of add to that wear and tear type of arthritis we were talking about. Those are some main issues. Pregnancy can put women at risk for back pain. It's just kind of goes along with the territory. That's something to be aware of that those issues can occur. Oftentimes they'll get better over time and after pregnancy is over, but that extra weight and extra curvature in the back does put more pressure on the spine and can cause pain.

Cassandra Holloway:

You mentioned arthritis, pregnancy, are there any other diseases or specific conditions that can cause back pain that listeners should just kind of be aware of?

Phillip Mendis:

Sure. In keeping with the arthritis realm, there are more immunologic or rheumatologic conditions. Inflammatory type of arthritis that can affect the spine as well as the other joints. That's something to consider. And again, that's not going to be most of our patients, but some people will have that condition. Scoliosis, so curvature in the spine can lead to pain as well. It's often able to be managed conservatively. It's not typically a surgical issue. A lot of patients are concerned when they hear they have scoliosis. How bad is it? Is it going to get worse? Is it surgical? Oftentimes it can be managed with the proper posture and strengthening techniques like we talked about, but the way the spine curves can put pressure on the joints and change the way the load is on the discs and the bones so that can cause pain.

Cassandra Holloway:

I'm curious if genetics plays a role in back pain? Do you ever hear that back pain is hereditary?

Phillip Mendis:

Yeah. We actually get a lot of patients asking us that question. What I can say is most everyone at some point in time will have that sort of arthritic degenerative change that's going to happen. As we age, those things are bound to happen. A lot of patients are scared of the term degenerative disc disease and it does sound scary and I feel like maybe we probably overuse it in the sense that it worries patients. That's something that's going to happen as we age. It's going to happen in some people more than others, but everyone will have that eventually.

              Now there's some evidence that maybe some patients with that occurring in a younger age group, maybe there's a genetic component to that and maybe there are some links there. There's not a specific treatment for that, though. It would still be the same sort of treatment. And just because someone has those findings earlier in life, that doesn't mean that they're set up for pain for the rest of their life. We can still manage that. And I think that it's very important for patients to understand that just because there's arthritis or some sort of degenerative change, it doesn't have to be a scary thing. It doesn't have to be a lifelong problem that they still can get better and likely will.

Cassandra Holloway:

Dr. Mendis, how does stress and anxiety play into back pain? Are they related?

Phillip Mendis:

Yeah. There's evidence as with most diseases that stress and anxiety do play a role. It's kind of a bit of a cycle. You're in pain, you're stressed and anxious because you're in pain and then the stress and anxiety seem to aggravate the pain. Some of us are more stressed out or anxious people just in general and so that can kind of lead to some more aggravating back pain. Somebody who's maybe not as stressed, maybe those pain levels aren't as high for that person, but the stressed and anxious person, that's kind of ramped up for them and they're feeling the pain is at a higher level.

Cassandra Holloway:

Just another reason why we need to manage our stress and anxiety, especially now.

Phillip Mendis:

Absolutely.

Cassandra Holloway:

Oftentimes you hear of someone sleeping wrong on their back and kind of complaining of back pain after that, after they wake up, what is the likely cause of hurting her back in your sleep?

Phillip Mendis:

Sure. It's probably going back to what we talked about earlier. It's probably muscle related. A muscle strain for some sort of position that we had our body contorted in during the night. Important things are trying to kind of maintain a good straight spine alignment while we're sleeping, not necessarily curling into a ball or a fetal position. There are different mattresses that are going to be helpful for some people, a lot of patients will ask about that. There's not one mattress that's right for everybody, it's about finding something that's comfortable. But again, something that maintains a relatively normal spine alignment, doesn't create a lot of extra curves is what you're looking for.

              And then same goes for the pillow. When we're sleeping on the pillow, we want whether you're on your back or side, you want to maintain a position there where your head's kind of sinking into the pillow so that it's level with the rest of your spine. There's some support under the neck, but your head's not bent up in an uncomfortable position. Some patients with pain will feel better if they're on their back with a pillow under their knees. Sometimes that can be helpful. If you're a side sleeper, putting a pillow between the knees as well, kind of take some pressure off the spine and again, maintains a good alignment there.

Cassandra Holloway:

What about sleeping on your stomach? I feel like that's always a no-no. Is that true for back pain? Should we avoid sleeping on our stomachs?

Phillip Mendis:

I wouldn't say avoid it. It can lead to some awkward positions and maybe put some more stress on the back for some people. But again, it's what you're comfortable with. If you're used to being a stomach sleeper and that works for you, that's fine. There's still ways to do that safely and again, not be all contorted while you're doing it. It might be a little more difficult than the back and side sleepers, but it's still okay.

Cassandra Holloway:

Can back pain ever be so serious that it causes other issues or symptoms elsewhere in the body? Can back pain ever be so bad that it causes a headache or a stomach ache or constipation is a big one that people have been talking about. If their back pain is so terrible that it causes them to be constipated. Is there any truth to these?

Phillip Mendis:

I think that's true with all pain. If your pain is severe enough, the body does have a tendency to respond in various ways and everything you just mentioned is possible. It's not solely that way for back pain, but there are other cases where the back pain may be more directly related or spine pain. Headaches, neck pain, cervical pain can refer to the head and can cause headaches. That is a known condition. Back pain or I should say more of a spinal impingement. Narrowing around the spinal nerves in the low back, if it's serious enough could lead to changes in the bowel and bladder function, could be incontinence or retention. That is a possibility. But again, those are the rare, severe conditions. It's not typically the case.

Cassandra Holloway:

I want to walk through a scenario. Say a listener is in the first day or two of their back hurting, whether it's a muscle strain, we might not know the exact cause yet, but they're in a lot of pain in their back. What are some of those first line defenses and treatments that they can try at home to try to relieve some of that pain themselves?

Phillip Mendis:

What we typically recommend is trying to be active as tolerated. We don't recommend that anybody be completely in bed rest, if possible. Any sort of movement is still better. Even if you're just getting up, walking around a little bit is better than just sitting or lying down all day. Obviously in those early days, it can be limiting, but still some movement is beneficial. If the patient can tolerate some gentle stretching and range of motion with the spine. Those types of exercises are beneficial. It doesn't have to be anything extreme, just basically moving the spine. And then things like heat and ice can be beneficial. There's not necessarily a recommendation for one versus the other. It's whatever is better for that patient. Over the counter treatments like Tylenol, ibuprofen, as long as there's no other reason the patient can't take those medications, those can be beneficial. Let's see, if they can tolerate some gentle massage, those types of things. And you can extend the medications to over the counter patches, lidocaine patches or over the counter pain creams, those things as well.

Cassandra Holloway:

It's so interesting you mentioned that complete bedrest is never really recommended. You always want to try to be moving at least a little bit or stretching at least a little bit. Why is that?

Phillip Mendis:

It's just that we know as far as not just the spine, but the body in general, when it comes to especially musculoskeletal system, basically lack of movement is going to lead to more pain because those joints and those tissues need to be stretched, needed to be worked and activated. When they're not, they become tight, stiff and can lead to more pain. Also, not moving will decrease your muscle mass, decrease your bone mass and those things are going to put you at further risk for pain as well. And so when you're already in that state of pain, you want to do as much as you can to avoid worsening it. Again, the activity as tolerated, I'm not saying that patients have to go out immediately and run a race or go weight lifting. That's not what I'm recommending. Eventually, hopefully getting back to those things, but just general movement and light stretching and range of motion in the beginning.

Cassandra Holloway:

What's the timeframe here for back pain? Kind of what's the timeframe that someone should wait it out at home and try to treat it themselves? And when should they see a doctor for their back pain?

Phillip Mendis:

It varies and not every taste is going to be the same, but for those first few days to a week, like we were talking about if the patient can kind of manage the symptoms at home with the things we were discussing. And if it seems like things are starting to get better, they're not in as much pain as , that first day and they're seeing some progression then probably it's going to keep getting better with what they're doing. If it doesn't seem like it's letting up or if it's getting worse at all, then certainly that's a reason to seek care. Doesn't have to be a spine specialist right away. Your family doctors or primary care doctors are capable of handling that initial episode of pain or at least kind of recognizing if it's something that they can't handle or something that's more serious. Seeing them in the beginning is fine. And then if whatever that initial treatment with them is, does not seem to be working or again if it's just lingering or worsening pain, then that's when you might want to seek help from a spine specialist and get further treatment.

Cassandra Holloway:

How is back evaluated when you go in to see a doctor? Kind of what questions do you ask? And what tests do you run?

Phillip Mendis:

When a patient comes to see me, what I'm looking for is really trying to narrow down the location of the pain. If there was an event or an injury that occurred trying to understand what that was. And then based on those things and the location of the pain, we'll try to see what sort of movements or positions make the pain better, make the pain worse and including the patient telling us themselves and during our exam. And then we'll look for, we'll examine the neurologic system, meaning strength, sensation, reflexes and we'll be looking for those signs of maybe a more serious injury to a nerve or a condition that might need further testing sooner rather than later. But oftentimes we're not finding those things, we're just seeing that they have back pain or nerve related pain even without those deficits.

              It's important to rule those other things out. But once we have an idea, we try to narrow down what the cause may be and then decide a treatment plan from there. Oftentimes testing is not necessarily required. A lot of patients will come in and say, "Doctor, I need an x-ray or I have to see what's going on." And a lot of times that's not going to give us any different answer. We would use that again, if we were more concerned about something specific, like a fracture or an alignment issue in the back, but typically you don't have to get any testing right away. We would just recommend whatever care we see fit at that time and then it's the patients that after that time, after that treatment are not getting better, that we would say, "Okay, maybe we need to look into this further with other imaging," such as an MRI, typically sometimes would be a CT or CAT scan to get a better look at things. The MRI though, will show more of those other tissues, like nerve, disc and the spinal canal and spinal cord.

Cassandra Holloway:

Are there any red flag symptoms that someone should watch out for when it comes to back pain? Can back pain ever be so severe that you need to go to the emergency room for it?

Phillip Mendis:

Yeah. When it comes to the red flag symptoms or serious symptoms or conditions, what patients want to look out for are especially the more neurologic type things. If you have back pain and leg pain and you're also having weakness or a sudden loss of sensation, difficulty using a limb as far as coordination or putting weight through your leg because it feels weak or uncoordinated. Those are the scary things that you want to get looked at quicker. Bowel and bladder related issues, sudden inability to control bowel and bladder or inability to urinate or have a bowel movement. Those are included as well.

              Balance related issues can be a sign of a problem of impingement or narrowing in the neck. That's important. Lack of ability to use or function with your hands as well. And then other things like fevers, chills, unexpected weight loss, those could be a sign of either infection or malignancy, cancer. Those are reasons to get that looked at as well. And then the other subset would be just the patients that are in such severe pain that they're really unable to do anything, unable to function and they're just not going to be able to manage like that. Then some of those patients will need to seek a treatment right away.

Cassandra Holloway:

Can you walk us through a couple treatment options that may be available to someone suffering from back pain from a medical perspective? They're past the point of that over the counter medicine, maybe they've gone to physical therapy before, is surgery ever an option? What are kind of those bigger term treatment options available for back pain?

Phillip Mendis:

Sure. You mentioned physical therapy and that's important because some patients may have already done that either on their own, seeking out a physical therapist, depending where they live or what their insurance allows or they may have been referred by their primary doctor, but if they haven't been, which is often the case, then that's typically going to be the first line of treatment as long as they can tolerate that, which most people can. The important thing about therapy is that they're going to evaluate the patient and see what sorts of exercises and movements are good for them, which ones seem to be problematic and then formulate a treatment plan and exercise program based on that. And those are spine specific movements. A lot of patients will say, "Well doctor, I already exercise or I've done some stretching," and that's great, but they might not know all of the other things that the therapist is going to recommend. I think it's important to have that evaluation and that treatment.

              Beyond that, if they're not getting better or even at the same time, there are medications we can use. Other than the over the counter ones we talked about, there are prescription anti-inflammatories and some may work for one person and not for another, those are options for back pain, especially the pain that's kind of just sitting there in the back, maybe muscle related then there are muscle relaxers that can be helpful. Now they do cause drowsiness so patients have to be aware of that. And for the nerve related pain that we've discussed, there are medications that treat that. That sort of block that signal in the nerve and calm that pain down. We can provide those as well. Some doctors will use an oral steroid, which is a stronger anti-inflammatory and sometimes that can be beneficial to, again, just calm down the pain and inflammation and that sometimes will allow the patient to do more as well. Those are the typical starting things.

              Now, beyond that, like I said, I am an interventional spine physician so I do provide injections as well. That's not going to be the treatment option for everybody, but we certainly will consider it if necessary. And so those could include epidurals, which are mainly designed for treating nerve and disc related pain. There are joint injections for the low back. And so just like you would have a knee joint injected or shoulder, we can do that for the small, tiny joints in the back. Or you can even block the little tiny nerves that supply those joints with sensation. Those are a couple different ways to treat that type of pain. You mentioned surgery. Our goal is to avoid surgery if possible. And most patients are not going to be candidates for surgery, are not going to need surgery.

              For the ones that are not getting better and we think there might be a surgical indication, then we will refer them to the spine surgeons. Those are typically going to be the patients that do have a disc related injury or an arthritis that is severe enough that it is narrowing around a spinal nerve. That nerve related pain, that leg pain or arm pain that's coming from the spine, those are the pains that are typically more capable of being managed with a surgery and that can have good outcomes. The pain that just sits there in the back, like we said, whether it's muscle, joint or sometimes even disc related pain without a nerve involvement, those pains are more difficult to manage from a surgical standpoint and so oftentimes the surgeons will not recommend anything for that because they've seen that the outcomes are not as good and not as likely to treat that pain. The exception may be a instability in the back where there's actually movement between the joints where there shouldn't be between the vertebrae. That might be a case where a surgeon would recommend it for pain that's only in the back.

Cassandra Holloway:

I know we talked about this a little bit earlier in that episode, but I kind of want to make it very clear to our listeners. What are some things that people can do right now every day to help avoid back pain?

Phillip Mendis:

Sure. Basically maintaining an active, healthy lifestyle. Continuing an exercise program, including aerobic exercise, including stretching, strengthening, maintaining a strong core so back and abdominal muscles and healthy eating, maintaining proper weight management. Those are going to all be very, very important. Good posture, so we're both sitting here on a computer right now talking to each other and I'm on a computer often throughout the day and bending over and typing is going to lead to bad posture, sitting on the couch watching TV or some of those bad sleeping positions like we talked about, those are going to affect our posture and our mechanics in the spine. We need to be aware of that and try to maintain a nice upright and aligned pasture. Lifting, appropriate lifting techniques. Bending at the hips and knees, not rounding the back and bending forward like that when you're doing lifting, especially any sort of heavy lifting, those are things to remember and we hope that doing those things will help us prevent back pain in the future.

Cassandra Holloway:

Yeah. And I think it's really important just to be aware of your own triggers. If you know that you've hurt your back in the past by a really long car ride or by sitting too long in an awkward position at work, I think just being aware of your body and what has hurt you in the past, I think should help you avoid this back pain to begin with again, I guess.

Phillip Mendis:

Yeah, absolutely. There are times where a patient can point to a specific cause. It sounds funny sometimes, but I'll say, "Well, don't do that then." And it seems like the obvious thing, but we don't always think that way or maybe it's an exercise or activity that they still want to do, but we have to be mindful of our bodies and sometimes accepting of those things that are harmful and find other things to do or other ways to manage. But yeah, certainly avoiding those triggers is important.

Cassandra Holloway:

Since back pain is so common, there are so many numerous products on the market offering to provide pain relief to people suffering from back pain, from shoe inserts, to these massaging or stretching devices. What should listeners keep in mind these products?

Phillip Mendis:

In regards to those, I would say you definitely want to make sure that they're safe first and foremost. Asking them physician about them is worthwhile if you have something in mind. And the other thing is just managing your expectations, I think. There's always going to be some hot new item on the market that promises to abolish back pain. And maybe it does, maybe it doesn't and maybe it helps one person and not another, I'm not saying that they're not helpful and there's no place for them, but some of the exaggerated claims I think is where the problems come in.

              Typically what I tell my patients is if there's something that they want to try and I don't think it's going to harm them, then I really don't have a problem with them using it. And if it works for them, great, if it doesn't then hey, they tried something and they figured out that's not the answer. But yeah, and sometimes we try multiple things and find the right balance, find the right ones that work for us. It's not wrong to try these new items or the commercial items out there and see what works, but I just want people to be kind of temper their expectations and not get too excited that it's going to be the magic bullet for them.

Cassandra Holloway:

Absolutely. The last thing I want to ask you about today is for your general advice to listeners who are suffering from back pain right now, why is it important to seek help for their back pain from an expert instead of suffering on their own?

Phillip Mendis:

Well, if they've done the things that we've talked about already and they're still not getting better then there's no need to just struggle through it and hope that it gets better. Oftentimes these things will get better over time, but our role as physicians is to A, make sure it's not something more serious or something to be worried about. And as long as it's not, then B, is basically finding ways to help them get better or help them manage until that pain resolves. And so we'll use whatever is at our disposal and find the right fit for them.

Cassandra Holloway:

Dr. Mendis, that was awesome advice to end on. You've been excellent today. Thank you for sharing your insight. We really appreciate it.

Phillip Mendis:

This was great. Thank you for having me and I hope everybody gets to listen to this and benefits from it.

Cassandra Holloway:

For the latest news about back pain, visit clevelandclinic.org/backpain. If you want to listen to more Health Essentials podcasts, featuring experts like Dr. Mendis at Cleveland Clinic, subscribe wherever you get your podcasts from or visit clevelandclinic.org/hepodcast. Also, don't forget to follow us on Facebook, Twitter and Instagram @clevelandclinic, all one word, to stay up to date on the latest health news and information. Thanks again for listening.