Neck & Back Pain: Causes, Treatment and Everything In-between with Dr. Edward Benzel

Podcast Transcript

Nada Youssef: Hi thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and we're here with Dr. Edward Benzel.

Dr. Benzel is the chairman emeritus of the Department of Neurosurgery, and is a neurosurgeon in the Center for Spine Health at Cleveland Clinic. Today we're talking about back and neck pain. Thank you so much for being here today.

Edward Benzel: Well, thank you for having me.

Nada Youssef: Sure thing. Please remember this is for informational purposes only, and it's not intended to replace your own physician's advice. Before we jump into topic, I'm gonna go ahead and just ask you some off-topic questions to get to know you on a personal level.

Edward Benzel: Sure.

Nada Youssef: All right. So first of all, do you listen to podcasts, and if you do, what's your favorite?

Edward Benzel: The answer is no.

Nada Youssef: No, you don't?

Edward Benzel: I'm sort of don't deal with social media and these things. I'm sorry. I'm letting you down here.

Nada Youssef: You read books, though, right?

Edward Benzel: I do read a lot.

Nada Youssef: Yeah, yeah. Good. Favorite book maybe?

Edward Benzel: Well, I'm into polar exploration now, so books about going to the Antarctic or the Arctic fascinate me.

Nada Youssef: Wow, that is fascinating. What about your best vacation spot? I think you just said it. Antarctica?

Edward Benzel: Yeah, my wife and I took a trip a year and several months ago to Antarctica on a cruise ship. It was a spectacular event. It was just wonderful.

Nada Youssef: Wow. I've heard it's life changing.

Edward Benzel: Getting a bird's eye view of what's really happening to our environments, global warming and that type of thing.

Nada Youssef: Sure. How about if you were not a physician, what would you be today?

Edward Benzel: Well, I went ... in college I started off in engineering. I supposed I'd be an engineer, but I didn't really like that and I switched to medicine, and so I ended up in medicine, and ended up here at this table talking to you today.

Nada Youssef: Glad you did.

Edward Benzel: Yeah, I'm glad I did it. There is a lot of appealing aspects of being a doctor. The first of which is being able to truly help people.

Nada Youssef: Sure thing, sure thing. Thank you. All right, well let's get back on topic. So back pain is one of the most common reasons people go see a doctor. Sometimes home treatment, the proper body mechanics can heal your back, but sometimes it's more severe and needs some medical attention. Lower back pain is one of the most common complaints and can be caused by everything from strained muscles and bulging discs.

I wanna talk about back pain. We all experience back pain at some time in our lives. When is it okay to live with some back pain, and when is it time to see a specialist?

Edward Benzel: Okay. Well, that's a great question and one unfortunately that doesn't have a perfect answer for every individual. Back pain, for the most part, is going to have a benign source, benign cause. It depends on whether it's acute or chronic. In other words, it's come on very quickly or it's been around for a long time. Pain that comes on quickly probably should be given a day or two, and then if the patient doesn't see relief, then calling the doctor to see what next.

Don't expect an MRI study or an imaging study, because they're almost always not helpful, and are expensive, and don't leave us anyplace good necessarily. We want to manage the problem, which is usually, with the onset of back pain is of an episodic nature, usually comes and then goes away. If it doesn't go away, then measurements such as physical therapy, exercise, et cetera, would be the next level of care for the problem.

Nada Youssef: Okay, so you mentioned acute pain versus chronic. Can you talk a little bit more about the difference between those two?

Edward Benzel: Sure. Chronic pain is in general considered to be pain that is present for three months or more. That's just a rule of thumb. The problem associated with chronic pain, though, is bigger than just the duration. As pain lingers on and on and on, it tends to transform into something that becomes much more different to treat, a chronic pain syndrome.

Often times in those particular circumstances, sleep is disturbed. Patients don't wake up energized. They henceforth become fatigued. They have pain. They do less. They get stoved up and so they have more pain because they're not doing much, and then they don't sleep well, and then they become more fatigued and they do less, and they go on a downward spiral, if you will, that healthcare professionals need to, and the patients need to, try to nip in the bud if you will.

Nada Youssef: Mm-hmm (affirmative). Sure thing. All right, let's talk a little bit about spinal stenosis. Let's talk about what it is and if there are any special considerations or recommendations for patients that are diagnosed with this disease.

Edward Benzel: All right. Spinal stenosis occurs at any level of the spine, ranging from the base of the skull down to the very bottom of the spine. I think in our case today, we're talking about back pain or low back pain. It's associated with narrowing of the spinal canal and most often also narrowing of the holes where the nerves go out to the legs, and those are called the neuroforamina. Foramina meaning passageway.

Nada Youssef: Sure.

Edward Benzel: That can cause the squeezing of the nerve, which causes it to be dysfunctional, weak, numbness, and can also cause pain down the leg. The pain down the leg can sometimes occur with just motion, but more often, the pain of spinal stenosis in the lumbar spine is associated with walking or moving or extending the back. When we extend our back, we tend to narrow those holes where the nerves are passing through, and out the spinal canal. When the patients develop this problem, lumbar stenosis or narrowing, they often walk hunched over. They like to use a shopping cart in the grocery store because they can lean forward while they're walking.

Just remember though, that this is a middle aged and above problem. It's not a problem seen in young adulthood so much.

Nada Youssef: Sure, sure. Now when you talk about the spine, something like scoliosis, can we talk a little bit more about what scoliosis is and if it can be acute.

Edward Benzel: Acute, well unless there's trauma, scoliosis is not going to be acute. It's something that's developed over time.

Nada Youssef: Sure.

Edward Benzel: Oftentimes it begins in adolescence, or early teenage years, where the spine develops a curvature, and pediatric orthopedic surgeons might deal with that problem if it progresses to the point of needing surgery.

Nada Youssef: I see.

Edward Benzel: In adults, we see it as a result of degenerative changes of the spine, where the spine is kind of wearing out, the bones are getting weaker, and the spine starts to tilt a little bit, and then once it tilts, it tends to tilt more. Deformities often progress over time, and then we can see it as a manifestation of aging, not of youth, as opposed to the other type I mentioned.

Nada Youssef: Sure. So what is the cause for that, for the bones getting weaker? I'm sure there's a lot of risk factors.

Edward Benzel: So we humans, we're designed to live about 30 years or so, but now of course with modern medicine and better foods, et cetera, and medical care, we're living into the 80s, 90s and 100s in some cases. The bones keep wearing out. The discs between the bones keep wearing out, and so the aging process, which wasn't relevant to somebody who dies when they're 30 or 40 becomes very relevant to somebody who lives into their 70s, 80s, 90s, 100, because the process continues. We call that degenerative spine disease, or degenerative joint disease, but in reality it really is a natural aging process. It's not a disease. It's a natural aging process, and if the bones gets weaker and softer because our bone in the 70s, 80s, and 90s, is softer like balsa wood, as compared to the bone in that same person as a teenager, which is like oak. It's a lot stronger and can withstand the forces that cause it to bend and deform, whereas in the mature adults, the process doesn't have as much resistance so deformities can occur.

Nada Youssef: I see. So just like you said, aging, that's what it is. It's not really even a disease at that point. It's just us aging.

Edward Benzel: Correct. We spine surgeons have ways of treating that and causing people to be less symptomatic and to live even longer. We're trying to keep up with the problems of aging that occur in multiple areas of medicine.

Nada Youssef: Sure, very interesting. Let's say you get any kind of tingling in your arms, fingers, legs, can that be related to back issues, and then how could you tell if it is?

Edward Benzel: Well it can be. There are other problems, nerve problems, et cetera that can cause tingling. There are metabolic problems, too much or too little of a variety of compounds in the body can cause tingling. Hyperventilation can cause tingling. But it also can be related to compression of a nerve root or something like that, and the best way to sort that out is to see a physician.

Nada Youssef: Okay.

Edward Benzel: Sometimes they might order an MRI scan. Sometimes they may say it's a different problem. If it's in the hand, it could be a carpal tunnel syndrome, which is related to compression of a nerve in the wrist.

Nada Youssef: Okay, okay. So it's getting warmer out, and let's say people are starting to rake their leaves, work on their lawn, a lot of people start complaining that their back goes out. I want you to explain what that means first of all when someone says, "My back went out." When that happens, do you treat it at home? Do you wait it out or do you go to the physician right away, the emergency room? How do you treat it?

Edward Benzel: Well that's a great question. The answer to the last part, I'll just briefly touch on is there's no absolute right answer as to when to seek help. Depends how comfortable the individual is, but what you're describing is episodic back pain. Episodic back pain is very common. About 95% of people at some point in their life will have an episode of severe back pain. Usually it dissipates quickly. More often than not, it comes on after a significant exertion that has been preceded by a long period of disuse or inactivity, such as like you mentioned, springtime, 'cause winter time people are kind of lounging around more. In springtime they get out and do a lot of stuff, and now they're stressing their muscular system, so to speak, in a way that hasn't been stressed for months.

This episodic back pain is what we call a myofascial type of a pain. Myo meaning muscle. Fascial meaning the sinew that holds the muscle to the bones, and so the muscle gets overworked. There might be a little tear or something like a pulled muscle if you will. Sometimes rest initially and stretching initially are helpful, but the way to really manage this problem is to prevent it.

The way to prevent it is to use an exercise regimen that works on strengthening of the support system for the spine, both the neck and the back, and increasing the flexibility of the spine and mobility of the joints.

Nada Youssef: Sure, sure. Great. We'll get a little bit more into prevention a little bit later on. I wanted to ask you about, you said there's muscle pain. It could be disc pain. How could you tell the difference between disc or structural pain versus a muscle pain?

Edward Benzel: In general I wouldn't consider pain coming from the disc, although that would be a point of argument with some physicians. I don't wanna necessarily go there. A disc in general, if it's bulging, can cause pain by impinging upon a nerve. Then it can cause pain in the distribution of that nerve. So if I got a nerve, for example, the L5 nerve root that goes from my back down the back of my leg, wraps around the front as far as the pain goes, and into my big toe, if that occurs the doctor might say, "Aha, this is an L5 nerve root impingement, and we're gonna look in your back with an MRI to see if we can find the source of that."

Now that doesn't mean you need surgery. It just simply means that we're looking for the source of it because even when there is disc-related pain from compression of a nerve, the majority of those cases heal by themselves.

Nada Youssef: Oh, okay. So I can imagine many risk factors causing back pain. Can we talk about the most common ones, besides aging?

Edward Benzel: Well, we've talked about the myofascial aspect of back pain which is the cause of episodic back pain. There's another type of ... well, there's several other types of back pain. One of them is mechanical back pain.

Nada Youssef: Okay.

Edward Benzel: Mechanical back pain is related to the excessive motion or pathological motion between two vertebrae, okay, most commonly between L4 and L5. That's the next to the lowest and the third to the lowest from the bottom of the spine.

Nada Youssef: Okay.

Edward Benzel: When there is this kind of motion, the patient can experience deep and agonizing pain. It's a back pain. It's not leg pain. It's from this joint that's unstable in a sense. It's not like it's unstable, it's gonna fall apart and the patient's gonna become paralyzed. It's just moving a little bit more than it normally would.

This deep and agonizing pain that the patient experiences is worsened by activity, and improved by inactivity or unloading the spine sitting in a position. The patient can usually find a position of relative comfort, but with activity of walking, standing, stooping, the pain often is worsened. Now that is a type of pain that can respond to aggressive exercise program to strengthen the support system that's stabilizing the spine, and sometimes surgery. I would caution that it should be rarely surgery, but sometimes surgery can help that kind of pain.

Then there's chronic pain, and the chronic pain syndrome. With this group of people, and it's very common, the pain may or may not have had an origin in the actual anatomy of the spine or the spine proper, but it could have, but now it's taken on a life of its own. As I mentioned earlier, the patient doesn't sleep well. They become fatigued and they may be on opiates or narcotic medications which make the pain worse, not better, in the long run.

There is a relatively common phenomenon called Opiate Induced Hyperalgesia, which means that the opiates when used on a chronic basis, actually cause a worsening of the pain syndrome. These patients need much more intervention, and in dealing with the, not just the bio or biomechanical or biological aspect of pain, but also the psychosocial aspect of pain. Bio/psycho/social aspect of pain. Pain is an experience and it's a negative experience for people, but we all know that we can amplify our pain or we can minimize our pain. Patients with a chronic pain syndrome often are in a hole and they can't get out of it by themselves. They need help.

Nada Youssef: Yeah, yeah, definitely see a specialist. Well, many patients seek the advice of multiple healthcare professionals, receive conflicting opinions, which can be confusing and stressful to the patient. I wanna talk about the multidisciplinary approach that we have like the Back on TREK program, where you can partner with other needed specialists and improve your outcome.

First of all I want you to tell me Back on TREK. It's T-R-E-K. What does T-R-E-K stand for?

Edward Benzel: It's an acronym. It stands for transform, restore, empower, and knowledge. So transform means, particularly with a person who's got this chronic pain syndrome, transforming their life from one of misery, in which it's not just back pain, their whole life and their family's life is disrupted and turned upside down.

Restore means restore function. Restore vitality. Restore activity. Empower, that's probably the most important of those four letters. Empower the individual to take this problem by the horns and deal with it themselves. Empower them to manage their own healthcare and their own pain problem. Knowledge, doing all of this stuff through knowledge, understanding the anatomy of the spine to a certain degree. Understanding the muscle component of the pain. Understanding the psychosocial aspect of the pain, and having the patient in a way understand that maybe they gotta work through it a little bit, and there's the pain may hurt them, but it's not gonna harm them.

So many people are afraid to move because the pain feels like their back is gonna split apart, or their nerves are gonna be severed or whatever, and a lot of the principles involved with our pain programs are trying to teach the patient that no, it's pretty safe. We need to move forward just like an athlete who has a knee surgery. It could be a season-ending injury to have the knee surgery, but if the athlete doesn't go through a rehabilitation process that is painful, they will not play the next year.

Nada Youssef: Okay. So a little bit of pain is okay.

Edward Benzel: Yeah.

Nada Youssef: Yeah. So they get to see a spine specialist and other needed specialists for the one individual. Is that how it works?

Edward Benzel: The patient will see a behavioral specialist. That is a term that we use to imply a clinical pain psychologist. They will see physical therapists who are trained in cognitive behavioral therapy. The key here is not just doing physical therapy, because that doesn't do the trick. I stated earlier here today that physical therapy may not be all that effective for managing back pain in a silo, but when it's used in the educational melliou of the patient understanding their pain, understanding the other factors that affect their pain such as medications if they're taking opiates and getting off of bad medicine, maybe getting on to good medicine, and working through this whole thing with a multidisciplinary approach using the behavioral medicine specialist as well as a physical therapist, our results in our program, I don't do this program, I just support this program, has been extraordinarily successful in nearly all of the parameters that we studied. We see a statistical improvement in patients' outcome.

Nada Youssef: That's amazing. So you see they see a behavioral specialist or psychologist for pain, and then also a physical therapist.

Edward Benzel: Correct. And then there's multiple sessions and working through things, and working through issues such as fatigue and sleep and activities. It's working on energy levels and ...

Nada Youssef: Quality of life. Not just your back pain.

Edward Benzel: Right.

Nada Youssef: So who's eligible for this? Is this anybody with back pain?

Edward Benzel: In general, we are trying to focus, although we'll take practically all comers, trying to focus on people who are at risk ... early on in the course, trying to prevent them from getting to the end game, which can be very difficult to treat. We have other programs that will deal with patients who have been in chronic pain for three, four, five, six, 10 years, whatever.

The patients that are within a year or two of the pain starting, we can have much more effect with a simpler program, and this is a relatively simple program.

Nada Youssef: Great. Does this program help you cope with pain versus treat it, or both?

Edward Benzel: That's a great question and I'm gonna hedge a little here. It most certainly causes one to cope with the pain. From my clinical psychology associates, will use the term, "My pain is so bad, I can't see you. It's in between us." They're gonna teach the person to put the pain over here. We're gonna live our life and you're gonna deal with the pain, but it's out of sight.

Now, can it manage the pain and make patients pain free? Absolutely. I think it can treat the pain too. There's a little bit of both. The response to people who have had success with this when nobody else could help them, and they felt the world was coming to an end essentially has been incredible and emotional on their parts. They find significant gratification and satisfaction for having done this program. They succeeded because we allowed them to empower themselves.

Nada Youssef: That's amazing.

Edward Benzel: So empowerment, remember I said that on the TREK?

Nada Youssef: Yes, the most important one. Yes, absolutely.

Edward Benzel: Empowerment. They need to fix themselves.

Nada Youssef: All right. Now do you need a referral to get into this program?

Edward Benzel: Yes.

Nada Youssef: You do. Okay. All right, so if our listeners would like to read more about the Back on TREK program, you can visit ccf.org/BackOnTREK.

So other treatments besides this program for back pain? When is surgery needed? When is it time for surgery?

Edward Benzel: First of all, I am what some would call a very conservative surgeon. I give you a different answer that other people. You asked a question earlier that people get different opinions from different providers. That's natural. People will say, "Why can't you doctors agree on things?" I hear that all the time. I say, "Okay, for example, let's take a theological question to a priest and a rabbi, they're both scholars, they're gonna give us different answers. Or a political question to a Republican or a Democratic senator. We're gonna get different answers." They're scholarly people, they have opinions, and they differ.

In general if somebody has significant, unremitting pain from for example a disc herniation that's impinging on a nerve, and they simply are not responding after two or three or four weeks, surgery is reasonable. But if we look at the population of people down the road a year or two our, those who have surgery and those who don't are in about the same boat, so we're treating with surgery the acute pain. What you don't want to have happen in that person is for the pain to go on and on and on, and turn into a chronic pain problem.

On the other side of the coin, a person could have surgery for their spine problem and end up with some sort of a scarring or complications. There are so, so many people who have had multiple spine operations and remain very unhappy campers. We need to be very selective, I think, with surgery.

So nerve compression, I mentioned neurogenic claudication, the patient can't walk very far, or the older patient who has stenosis of the spine, but there are medications that can help with this too. Patients should ask their doctor if they could try a medication that we call membrane stabilizers, would that be appropriate. An example of that would be Gabapentin.

Nada Youssef: Okay, you said it's membrane stabilizers?

Edward Benzel: Membrane stabilizers.

Nada Youssef: Mm-hmm (affirmative). What's that do?

Edward Benzel: They are seizure medicines. What a seizure medicine does for somebody who has a, say an irritation in the brain, which causes their arms to shake for example, the seizure medicines quiet down the cells, the membranes of the cells, so they don't fire and send a bad message to the arm.

Nada Youssef: Interesting.

Edward Benzel: This works in reverse. The nerve could be irritated or whatever, but it's sending a message back to the brain that my legs hurt when I walk. Membrane stabilizers work in about 50 to 60% of people. They're not for everybody, that's for sure, but it beats a complication with spine surgery by a long shot.

Nada Youssef: Sure, and that was actually my next question. Some individuals avoid back surgery because of perceived complications or the notion that surgery may not help or make things worse, so you're saying try to do other treatments and kind of see what your quality of life looks like before versus after surgery and kind of make your own choice.

Edward Benzel: I like to live by the golden rule and do unto others as what you would have done unto you. I most certainly would want to give every reasonable alternative a shot before I have surgery.

Nada Youssef: Right.

Edward Benzel: You would be surprised at the other end of the spectrum, how many people want surgery and do not want trying conservative or other strategies. They want the quick fix.

Nada Youssef: Yeah.

Edward Benzel: And I'm sorry, that can backfire.

Nada Youssef: Right, right. Let's talk about that. Let's talk about, first of all, some popular natural remedies for back pain, let's talk about massages, chiropractic treatments, acupuncture, adding to that yoga, Pilates, decompression, dry needling. There's so much stuff that could be labeled as a back pain relief. What do you think of that?

Edward Benzel: There's very little data to back that up. We must keep in mind that the placebo affect, which is the percentage, say a person takes a sugar pill versus a pill for pain, the placebo effect is about 30%, so 30% of the people who take a non-treatment, if they think they might be taking a treatment medication will get better. The same thing with massages and a lot of the treatments including surgery. People sometimes get better or get worse based on their preconceived notion of what they would experience.

Massage, heat, ice, et cetera, are symptomatic treatments. If they make somebody feel better, they should do it. What is to be lost from that? Chiropractic, acupuncture, and other strategies, I don't understand, but I do believe there's some effect with these strategies. I don't prescribe them because I don't understand them.

We have in our group here at the Cleveland Clinic a physician who does manipulation. As a matter of fact, he has manipulated me twice, and it was positive for a neck problem.

Nada Youssef: So it's like a chiropractor.

Edward Benzel: Yeah, he's an osteopath. A chiropractor is not an MD or a DO. He's a DO, Doctor of Osteopathy. They learn in their training, as opposed to MDs, manipulation strategies. Now most of them don't employ that in their practice, but he does, with a significant effect, positive effect. Others like Pilates and yoga and things, those are bordering on physical therapy. I think they're good.

Anything that gets the patient to do something, I think is good. Do more, not less. Hurt versus harm.

Nada Youssef: Good. So let's talk about forward flection. What is that and should it be avoided when an individual's experiencing back issues?

Edward Benzel: I'm not sure what exactly you're getting at here. I mentioned earlier that the patient with stenosis of the spine will relieve some symptoms by leaning forward because that opens up the holes where the nerves are passing through.

Nada Youssef: Okay.

Edward Benzel: Forward flection though in general is probably not good because it induces the tendency for the spine to curve forward. I'm guessing you're talking about somebody like a dentist who learns over a lot. They have [crosstalk 00:31:31]-

Nada Youssef: I mean we all ... I feel like with technology everything, we're leaning over all the time.

Edward Benzel: You know, there probably is a cause and effect from cell phone use and emailing and all that kind of stuff, but it would be very difficult to prove that, but we do know, there's a strong suggestion that dentists who spend a lot of time leaning over people have more neck problems than the regular population.

Nada Youssef: Sure. All right, so I wanna talk a little bit about prevention. Back pain can stem from other diseases, medical conditions, arthritis, fibromyalgia. Are there self-help strategies we can adopt to prevent back pain or keep it from returning?

Edward Benzel: Yes, I think that in general, people should just lead a healthy life. General wellbeing augmentation, if you would say, I think that losing weight if one is overweight, cessation of smoking if they're smoking, and people say, "Why smoking?" Well, let me just add another reason why you shouldn't smoke, because smoking is associated with back and leg and arm and neck pain. People who have those problems who stop smoking have a statistically significant chance of their symptoms improving.

There is evidence to suggest that smoking is bad for the back, bad for the spine. Many surgeons won't operate electively on patients if they're going to do a bone fusion, if the patient is smoking, because there's a somewhere between a 15 and 25% reduction in fusion rates success with the surgery in smokers, who have a lesser rate of success than nonsmokers.

Nada Youssef: Sure. I wanted to bring up exercise.

Edward Benzel: Okay.

Nada Youssef: So exercising is needed.

Edward Benzel: Yeah.

Nada Youssef: But when you were mentioning someone has a lot of pain from movements, what are your recommendations for exercise for someone that has a lot of pain when they're moving or walking?

Edward Benzel: First of all, I'm going to assess ... if I'm seeing that patient in my clinic, I am going to assess whether motion is potentially harmful. Is there instability that could cause harm if the patient moves? Once I determine there is not, then I encourage them to work through the pain to a certain degree. A little while ago we talked about the athlete who needs knee surgery, and if they don't go through the levels, the plains of pain, with each progression through the rehabilitation process, they're not gonna play next year. I would look at a patient with back pain in the same way. We need to go from one level to the next level to the next level of activity and we need to have the courage, the strength, the perseverance to accomplish that.

Nada Youssef: Sure.

Edward Benzel: If a patient doesn't have that, they may not be successful in managing their problem and they end up in that chronic pain syndrome pool of people.

Nada Youssef: Right. How about sleeping positions?

Edward Benzel: I really don't think it matters. I think people should sleep in the position that in which they're most comfortable. Since I think about things like this, because I am a spine surgeon, I have about five positions that I rotate between on my back, semi-lateral and far lateral turning. Sometimes it feels good just to switch positions at nighttime.

In general the position that's most comfortable for people with back pain is the fetal position, laying on the back curled up a little bit, and just kind of stretching the back muscles, un-stressing them, et cetera, which is also a pretty good position for a pregnant lady to be in.

Nada Youssef: Right, right.

Edward Benzel: Pregnancy and obesity share a spine commonality, and that is when a person puts a lot of their weight out in front of them, they have to lean backwards to balance themselves so they don't fall over on their snout. When they do that, they load the spine in a different way, which actually can exasperate back pain. When is possible, like with obesity, losing that weight 'cause it causes a lot of stress on the spine just by virtue of the weight and the loads that are applied, that also because of the nature of the way the loads are actually applied can be altered by losing weight.

Pregnancy's a different story. I think starting before pregnancy or in early pregnancy with good abdominal and back strengthening and flexibility exercises are a way to stay ahead of the curve if possible for pregnant ladies, but it can become problematic towards that last trimester.

Nada Youssef: Yeah, it's difficult. So let's talk about posture. We talked about electronics and how something like text neck isn't an official medical diagnosis, but I read about it all the time. Can we talk a little bit about what that strain is doing to our necks?

Edward Benzel: In general, learning forward with the neck is basically putting our neck into a posture that we don't want as we age. Let me clarify that. Aging is kyphogenic. I'll define kyphogenic right now.

Nada Youssef: Yes, please.

Edward Benzel: Kyphosis means a bending forward of the spine. You look at somebody when they're 20, they stand in the military position, the head is roughly over the bottom of the neck, which is roughly over the bottom of the spine. The spine has an S-shape curve to it, so all those points meet.

As that average person matures through middle life and into early and later adulthood, they tend to lean forward in both the neck and the low back region. As they lean forward it puts more and more stress on the spine, and the muscles that are supporting the spine will then try to bring things back up but they can't, because the bones have developed arthritic changes and sometimes they just won't go back into that extended, normal posture. This happens over years, over decades.

A good way to initiate that process would be to spend all your life doing this, or I don't know, how many hours a day does the aggressive texter do that? Maybe two or three hours.

Nada Youssef: Yeah, a long time.

Edward Benzel: That's a lot of time. When you talked about sleeping posture, one thing I didn't mention is too many pillows are not good either. You should have a pillow on the side of your head if you're leaning, so your head doesn't go like this when you're sleeping, but you shouldn't have a lot of pillows underneath your head so you're sitting like this when you're sleeping because that does the same thing as doing the text thing. So now you got two hours at night with too many pillows, two or three hours in the daytime with texting, and that person is setting themselves up for the potential of having a lot of neck problems later in their life.

Nada Youssef: Okay. Are there products that you can purchase that can help with your posture? 'Cause I know there's things that work that you can put on a chair to keep your back straight. Are there things like that that you recommend?

Edward Benzel: No. I'm sure a lot of people will swear by this strategy or that strategy, but again show me the data, okay? I think this being cognizant of posture is very important. I struggle with that 'cause I tend to lean forward and be slumpy.

Nada Youssef: We all do.

Edward Benzel: I try to focus on that. You know, any tool that forces you back into position is actually gonna make your muscles weaker, but if you have something on your chair that causes you to lean backwards further, that could be good, but not necessarily because of the pillow, but because it's reminding you every time you sit down, oh yeah, I gotta be cognizant of my posture. I'm gonna sit up straight.

Nada Youssef: All right, now I have a question about myself. I crack my back a lot, daily.

Edward Benzel: How do you do that?

Nada Youssef: I twist from side to side and it cracks my back.

Edward Benzel: Okay.

Nada Youssef: It doesn't feel bad. It feels good. I don't know if I'm messing up my back. Is this a good thing? Should I stop? What do you think?

Edward Benzel: That's called crepitus, which means ... it's sort of like cracking your knuckles. It is not good or bad by and large. There may be specialists who will say I'm crazy for saying this, but I don't think it's bad or good. I was actually ... now that you bring this up, I was treated by a chiropractor when I was 16 years old because I was working on a farm throwing hay bales around, and I "threw out my back," at age 16. My mother took me to the chiropractor which was about 40 miles in our old '54 Bel Air Chevy, and I felt every bump in the road. It was exceedingly painful.

So I get into the chiropractor's room. He puts me in on his slide on the table, and he manipulates my hip and my shoulders and then does a quick motion, and it was like I felt every bone in my body pop all the way down, and my pain went away. You go figure. I don't know what happened there, but I know that that popping was good for me.

Nada Youssef: Okay. Good, 'cause that's what it feels. It feels sometimes like my back is stiff and if I do that, I feel better, but I always hear that cracking your knuckles and stuff is bad.

Edward Benzel: I wouldn't worry about it.

Nada Youssef: Okay, good, good. All right, so I wanna talk about something like shoes. Can shoes be a reason for back pain?

Edward Benzel: That's another one of these things, you know. You gotta buy an expensive bed with a bunch of numbers on it. You've got to use pillows. You gotta use shoes that are designed to make your back better. Well, I'm not sure, I think whatever is most comfortable is what you should wear. I would caution against, particularly if a person has back problems, against high, high heels, because it puts the spine and the entire body into a position of significant deviance from normal.

Nada Youssef: Sure, sure. So is there a proper way of someone, let's say again, prevention, stretching your back. Is stretching your back something that you should do daily so you can make sure that you have a good posture, that you're not having any issues, and what is the best way to stretch your back?

Edward Benzel: I do a couple exercises for my back. I lay on a carpeted floor, in my case, on a throw rug in the bathroom before I shower in the morning, and I'll push on the floor and let my back sag. That stretches it in the extended position. Then I will go down as far as I can and touch my toes, or if I can't ... if a person doesn't have that much flexibility, they might go down and be three or four inches from the floor. Another person may be able to palm the floor. We need to work within reason there.

Unless there is an acute herniated disc or some other problem that the patient knows about, these things are good, but they should never bounce. In other words, bounce down and try to touch the floor. It's a gradual thing. How from can I go today, and I just go there and hold it for a little bit, then I come back up.

Bouncing can ... it's really stressing the spine. If there's a disc getting ready to pop out or herniate, it could induce that. That's why I'm saying no bouncing.

Nada Youssef: Sure. But then if you do have lower back issues, bulging disc, you should still do these stretches, correct?

Edward Benzel: I believe so, yeah.

Nada Youssef: Okay, great.

Edward Benzel: In most cases, now there might circumstances in which the provider may say, "No, that's not a good idea." I'd go along with that.

Nada Youssef: Sure. So you stretch your back every morning?

Edward Benzel: I actually do that four days a week. I have a routine. Different things different days.

Nada Youssef: Great, great. Definitely like to hear that.

Edward Benzel: People ask me, "Why are you doing all these things? You don't have back or neck pain." And I said, "Bingo."

Nada Youssef: Yeah, exactly.

Edward Benzel: 'Cause I have had episodic back pain in the past and I said, "I got into this routine and it's been a good routine so far." As I age further, or let me rephrase that, as I mature further, I may need to do more, because the person who ages needs to work harder and harder and harder at staying ahead of the curve.

Nada Youssef: Sure. Sure thing. You're doing all the right things. How about hydration? Can hydration affect disc health?

Edward Benzel: In general, no. The disc is sort of hydrated ... it is hydrated in youth, and in early adult life through a mechanism of compressing and relaxation. Compressing and relaxation basically sucking water into the disc, because there's no blood vessels that go into the disc.

Nada Youssef: I see.

Edward Benzel: Hydration in general is just good for us. We should all drink multiple glasses of water a day, and whatever else to stay hydrated. It doesn't have any major effect on spine and spine care.

Nada Youssef: Okay, good to know. Okay, so I wanna talk a little bit about physical therapy, but first, what is McKenzie Method and do you recommend this for a patient that's suffering with back issues?

Edward Benzel: Yeah. There's various strategies of physical therapy. They're sort of like religions, okay? People believe in one strategy versus another strategy, so I have to be careful here. We in general support ... and there's like the Williams Method, the McKenzie Method, we in general here at the clinic support the McKenzie strategies, which focus on extending the spine. It's a little bit of a different strategy than others, but extending the spine, causing more posture-related improvements, et cetera, but also putting the spine back into a normal alignment, so that the posture is better and the pain is better.

There is some thought that if there's a disc bulge with the McKenzie therapies that some of discs can be caused to be moved back into their normal position. I'm not sure that's true, but by and large, patients in our experience do best with McKenzie physical therapy.

Nada Youssef: Okay, and that could be implemented in the Back on TREK program?

Edward Benzel: Yes, they would use that as one of their tools.

Nada Youssef: Sure.

Edward Benzel: Just one their tools.

Nada Youssef: One of their many.

Edward Benzel: Right.

Nada Youssef: Excellent. Well that's all I've got for you today unless you have something else you want to talk about?

Edward Benzel: This has been an enlightening session for me, and I thank you for this wonderful conversation. You made me think, and asked great questions. If I had one recommendation for people, is that be leery of surgery. Be appropriately cautious. I have estimated that we do two or three times as much spine surgery as we should be doing in the United States. There's a lot of people that are hurt very badly by having one then another then another spine surgery. I would seek people providers that provide a multidisciplinary approach to the problem, that listen and take things seriously that you say, and that don't think surgery first.

Surgery first is in general, not the right way to go about at least pain of spinal origins.

Nada Youssef: Sure. Well, thank you. It's been a pleasure. Thank you so much for stopping in today.

Edward Benzel: Thank you.

Nada Youssef: Thank you. If you would like to make an appointment with the Center of Spine Health, please call (216) 636-5860, or for more information you can go to ClevelandClinic.org/spine. And thanks again for our listeners for joining us today. If you would like to listen to more of our Health Essentials podcasts from Cleveland Clinic experts, make sure you go to ClevelandClinic.org/HEpodcast or you can subscribe on iTunes, and for more health news, tips and information, make sure you're following us on Facebook, Twitter, Snapchat and Instagram at ClevelandClinic just one word. Thank you. We'll see you again next time.