Health Features

Stop the Pain

The late legendary comedian Henny Youngman often would use the following quip in his stand-up routines: The patient says, “Doctor, it hurts when I do this.” The doctor says, “Then don’t do that!” If only this was the real answer to get rid of all pain. Unfortunately, pain often results from hereditary conditions or aging. But some is caused by avoidable behaviors, and all that’s needed to fix the discomfort is to identify what those are.

neck and back pain
The spine is a remarkable feat of natural engineering. Its 33 vertebral bones support the body’s weight while anchoring robust muscles and delicate nerves. The spinal cord connects 31 pairs of spinal nerves that carry messages and commands from the brain to the rest of the body.

possibility for injury
“Every muscle, organ and tissue are affected by spinal mechanics,” says Rob Elder, a chiropractor at Metro Chiropractic in Maryland Heights. “Very small aberrations in spinal function can lead to compensatory changes in the body. One injury can start to torque the entire spinal column.” Neck and back injuries can result from trauma, cancer or cancer treatments, and simple use. “People are living longer, and there is lot more wear and tear on the back, knees, hips and shoulders,” says Dr. Rajiv Shah, an anesthesiologist and pain management specialist at Washington University School of Medicine. “Neck and back pain are the things we see patients for the most. Back pain is common because it doesn’t target one specific age group. We see high school and college athletes who come in with disk herniations. The pain also can be related to cancer or develop after cancer treatment; chemotherapy and radiation can weaken bones. As patients get older, we talk to them about spinal stenosis.

The thoracic vertebrae in the middle of the back are well supported, but the cervical vertebrae in the neck and the lumbar vertebrae in the lower back are on their own. “Your chest cavity is protected because you have ribs on both sides,” Shah says. “Unfortunately, the neck and lower back are more vulnerable. Often, as we are developing, the natural curvatures of these regions can be at risk of scoliosis.” Elder says, “Any patient who comes into our office is going to get a thorough orthopedic-neurologic exam and X-rays. We put the X-rays through a digitization program that enables us to analyze more than 500 biomechanical functions. We can see the minutiae of spinal function.” While it is standard practice for doctors to say they individualize treatments to each patient, neck and back doctors individualize treatments to each vertebra, disk and nerve. “We have a multitude of techniques,” Shah says. Patients may require surgery to address fractures or disk herniations. Epidural steroid injections can be administered to nerves compressed by injuries or arthritis. “We may try radiofrequency ablation to burn nerves, and we’re looking more and more into spinal cord stimulation. Electrical stimulation may help prevent the propagation of nerve impulses.” A tiny chiropractic technique “can adjust very specifically to create better function, which will decrease pain and protect the patient from herniation over time,” Elder says. “Our massage therapist does a unique type of massage that works very well with spinal-mechanical chiropractic.”

proper prescription
Activity prescriptions for spinal pain patients can be complicated. “It is very difficult for a patient with chronic pain to exercise, but we want to get them working on their core once their biomechanics are functioning better,” Elder says. “Exercising a dysfunctional spine will make it worse.” Shah agrees. “There is benefit in doing weight-bearing exercise because you are strengthening the muscles, but weightlifting can be dangerous,” he notes. “It is important to get physical therapy or appropriate instruction on how to do the techniques.” Medication, of course, can be the first defense against pain, but Elder notes there is a real opioid addiction problem in this country, much of it because of people dealing with chronic back pain. “The goal is to avoid opiates,” Shah says. “If there are no other risk factors, we consider NSAIDs (non-steroidal antiinflammatory drugs) like Advil, Aleve and ibuprofen. We could consider a nerve pain medication such as Lyrica or gabapentin or will start muscle relaxants if a muscle issue is causing the pain.”

Some people are just more likely to suffer from headaches than others, says Sarah Keenan, a family nurse practitioner in the SLUCare otolaryngology service at Saint Louis University, which includes a headache clinic. “There is a genetic predisposition to migraines. If you have a first-degree relative who has migraines, you are three times more likely to have them, too.”

treatment options
Keenan says headaches are one of the top seven reasons people go to a primary care doctor. “They are our body’s signal that something is not quite right,” she says. “I always try lifestyle modification with a patient because headaches often are triggered by something in our environment. I spend a lot of time talking with patients about what might cause their headaches.” Traditional oriental medicine also approaches headaches through environmental links. “A headache is a symptom as opposed to a diagnosis,” says F. Afua Bromley, an acupuncturist and oriental medicine practitioner at Acupuncture St. Louis in Webster Groves. “Not every headache is super complex, sometimes even in people who get frequent headaches. It can be something as simple as an unknown food allergy, a chemical allergy, light triggers, dehydration, barometric pressure changes, or hormones.”

it’s always something
Headache triggers can be found all over the map—and the kitchen, bathroom, yard or department store. The National Headache Foundation lists 24 types of headaches, with causes including allergies, arthritis, caffeine withdrawal, depression, eye strain, hangovers, hunger, hypertension, menstruation, fevers and tumors. Bromley notes that people often are surprised at what can be labeled as a trigger. “Caffeine sometimes can treat headaches, but it also can be a trigger,” she says. “Sulfites and nitrates, which are used as preservatives, affect some people. I was surprised about bananas, but they have an enzyme that a number of people are sensitive to.” She knows patients who have to avoid perfume counters at department stores. “Scents are some of the most common causes, especially artificial ones,” Bromley says. “Synthetic chemicals used as scents in household products can trigger a hyperactive, allergy-like response that can cause a headache.”

simple connection
“I did my dissertation on how dizziness and migraines are related,” Keenan says. “Inadequate hydration is the biggest trigger I found. Dehydration affects your blood pressure, and it dries you out because there is not enough blood volume circulating. It often will not cause a horrible migraine, but there will be a lingering, dull headache. I tell people who are having headaches to drink at least 64 ounces of water a day.” A couple of other simple solutions tend to be overlooked, too, she says. “If you are not getting enough sleep, that can be a problem,” Keenan says. “Or, if you skip meals, your blood sugar goes down, which can cause a headache.” Bromley says Oriental medicine views headaches as symptoms affected by channels of connected systems throughout the body. Three acupressure points are believed to relieve headaches according to the position of the head affected. Two points can be squeezed on the hands, one in the muscle between the thumb and forefinger and another on the outer edge of the hand. The third pressure point is on the outside of the leg, a palm’s width above the ankle. In general, Keenan advises to take care of yourself. “After lifestyle modifications, you can take ibuprofen and acetaminophen, but be careful to not overdo it.

foot pain
For millions of years, our ancestors walked barefoot and enjoyed strong, healthy (although dirty!) feet. “In countries where people still don’t wear anything but sandals, there aren’t many foot problems,” says Dr. Michael Horwitz, a podiatrist at Feet for Life Podiatry Centers in University City and Chesterfield. “In America, we have an epidemic of plantar fasciitis because we are overly supporting our feet.” Dr. Meghan Arnold, a podiatrist at the Mercy Clinics in Town & Country and Sunset Hills, says about half of foot pain is caused by improper shoes; the rest is a result of issues like bunions, hammertoes or flat feet.

too much support
“The number one problem we see is people who are born with flat feet,” Arnold says. “Although that doesn’t mean they will always cause problems.” People who are bothered by flat feet may rely too often on the temporary relief of inserts or comfy shoes, Horwitz explains. “You should not get dependent on wearing plastic arch supports,” he says. “That potentially weakens your foot and leaves a lack of stretch in your Achilles tendon.” The foot’s arch plays a key role in cushioning the rest of the body, Arnold adds. “The arch is the shock absorber of the foot,” she says. “Every time you take a step, the arch moves up and down to accommodate uneven surfaces and take the stress off your feet. When it is up or down too much or not able to move, you tend to have problems.” Narrow, high-heeled shoes have long been blamed for foot pain in women. “A higher heel puts more pressure on the toes or ball of the foot and shifts the pressure,” Arnold says. “I am seeing more foot pain in men because of pointed-toe dress shoes with tighter toe boxes.” Horwitz says flat tennis shoes and moccasins are good for you. “These shoes preserve the strength of the foot and the stretch of the Achilles tendon,” he says. “A combination of supportive footwear during certain activities and flat footwear the rest of the time is best.” Feet also like variety, Arnold continues. ”Don’t wear the same shoes every day,” she recommends. “Rotate them so you are constantly challenging the muscles, tendons and ligaments.

lending a hand and a foot
Proper shoes cannot cure all foot problems as many issues are more involved and might require surgery. Plantar fasciitis, inflammation of the plantar fascia ligament along the bottom of the foot, can cause excruciating pain in the heel and arch. Bunions are bony prominences at the base of the big toe that can cause the toe to turn inward. A hammertoe is one that curls downward instead of pointing forward. Foot pain often radiates. “Flat feet are a leading cause of hip, knee and back pain and often go undiagnosed,” Horwitz says. “The biomechanical faults in your feet cause your back to torque and your knees to bend in ways they aren’t used to.” Arnold says to see a doctor if you have foot pain for more than 10 to 14 days that is not improving. “I tell patients they are ready for surgery when they are no longer able to do the activities they want or wear the shoes they like most of the time,” she says. She says most foot surgeries will require six to 10 weeks of recovery. Some patients with flat feet are candidates for a metallic implant that realigns the ankle and heel bones, Horwitz says. “The procedure takes five minutes, and patients can be back in tennis shoes in two weeks.”