Doctor explains array of treatment options

Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Lower back pain is one of the most common reasons for people to miss work or to see a doctor. Today I'm talking about lower back pain with Dr. HeeRak Kang. He's an assistant professor of physical medicine and rehabilitation at Upstate, and he specializes in pain and chronic pain management. Welcome to "The Informed Patient," Dr. Kang.

HeeRak Kang, MD: Thank you for having me on board, Amber.

Host Amber Smith: Can we begin with a bit of an anatomy lesson? I'm curious about the structures in the back that are involved in lower back pain.

HeeRak Kang, MD: Absolutely. So there's, in total, 24 what they call vertebral bodies in the spine. There's about seven in the neck, 12 in your thoracic area where your ribs are, and there's five lumbar vertebral bodies. They are usually the largest in size. And what I try to explain to patients is if you imagine a stack of cylinders, the one kind of at the lowest, or what we would medically we say inferior, are the ones bearing the most weight, and they're generally the largest in size.

Host Amber Smith: So they're stacked?

HeeRak Kang, MD: Exactly.

Host Amber Smith: What holds them together?

HeeRak Kang, MD: So there's a lot of ligaments in place. Think of it as a stack of cylinders. In between are called disks, and they're kind of like the shock absorbers. There's joints, two on each side of the cylinder, that kind of connects on each end. So that allows you to bend forward, bend back, rotate, that kind of activities. And then there's also ligaments that kind of put everything in place, actually.

Host Amber Smith: So are they attached to muscles?

HeeRak Kang, MD: They're attached to muscles at every level. And then in addition to that, there's actually nerves that come out at each level as well.

Host Amber Smith: I'm curious about the nerves. Are they inside the bone, or where do they lay?

HeeRak Kang, MD: That gets a little complicated. There are what's called sinuvertebral nerves that are actually in the bone itself and outside of each disc. There's also nerves that come out at each level. So the spinal cord, I try to explain as kind of like, you know how the power goes into your house, and it goes into that kind of circuit breaker, and at every level it kind of branches off each individual outlet? Those are what I would call the major nerves that kind of innervate your hands and your feet and your knees and that kind of big joints. And then you have smaller nerves that actually innervate various aspects of that just like in your lower back or even in the disk and the lumbar vertebral body itself.

Host Amber Smith: So when we have back pain, have we done something to injure the bone, or have we pulled muscles, or have we done something to the nerves? Like, where does the pain come from?

HeeRak Kang, MD: That's a great question. And to be quite honest, scientifically we're still trying to figure this all out. It's a very complex question.

What I try to do is I try to figure out what a person has been doing right before. If it's generally like a muscle sprain, or ligament strain, you'll have this pain, but you also have tenderness. And so if you touch it, it hurts, kind of like a bruise or if someone punched your arm.

Nerve pain's a little bit different. A lot of times you can have compression of a specific nerve, and a lot of times patients will say it feels like this shooting electric going down to my foot. And that is more indicative of a nerve pain.

That's not necessarily tender. I try to differentiate between pain and tenderness. Tenderness would be if I touched you and it hurt, whereas you can still have pain without the tenderness.

Host Amber Smith: I've heard of herniated disks, but I'm not really sure what those are or how important they are. Do you need to see a doctor if you have herniated a disk?

HeeRak Kang, MD: It really depends. You know, a lot of times a herniated disk can resolve on its own. Clinically you should see improvement on average, there's some studies that say six weeks up to nine months, it can sometimes take herniated disk to kind of reabsorb itself.

I try to explain herniate disk as kind of like a jelly donut. And the thing is, when you squeeze a jelly donut and that jelly kind of bursts back. That in itself can be irritating to your spine and your spine nerves. There's actually a study that was done in the 1970s that looked at disk pressures, and they kind of looked at it in different positions. Actually, it's very interesting, and they actually found that bending forward and rotating can increase the disk pressure four times or 400% of what you would normally experience if you're standing up straight. So if I'm standing up straight, let's say my discs are experiencing, let's say, 100% of that pressure. If I bend forward and rotate, it's going to be about four times that.

And so, a lot of times usually my patients say they were reaching for something or lifting something farther away and twisting, and they experience this sharp pain that's going down their back. I will usually tell them that a lot of times that can resolve. If they're experiencing any weakness or abnormal sensation, at that point, I would say maybe you should look to see a doctor first and maybe get checked out.

Host Amber Smith: Is herniated disk the same thing as a slipped disk?

HeeRak Kang, MD: Yes, that can be interchangeable. With the disk, there's actually, interesting enough, there's different terminology that radiologists use. You know, it depends on the size of the disk that's protruding out back. You also have to realize, the body is a 3D structure, so a herniated disk not only can push back, but when it pushes back, it can actually push up and down as well. So if you squeeze, like I said with the jelly donut, it's not going back in one plane, it's, it's going in a lot of different planes as well. And so a lot of times an MRI is great for actually figuring how much of that is happening.

Host Amber Smith: So when you initially injure yourself, that's an acute injury or acute pain. When does acute pain turn into or become chronic pain?

HeeRak Kang, MD: Usually acute pain is defined as three weeks. I think medically we've kind of put these lines in the sand. And chronic pain is defined as three months.

So, subacute pain will be in between that. So it's less than three weeks is acute pain. Three weeks to three months is subacute. And then after three months is chronic pain.

Obviously for a patient, these terms don't really mean a lot to them. You know, they're in pain, they're in a lot of pain, and they want to figure out what I can do to help them. But that's kind of where we draw the line and try to figure out how we can help.

Host Amber Smith: You were telling us all the different ways that patients of describe the pain that they're experiencing, and it seems all across the board. Does lower back pain ever spread into other areas of the body?

HeeRak Kang, MD: Absolutely it can. You know, the challenge is, the spine is connected to all other joints, right? All the joints are connected to the spine, and spine is connected to all other joints in the body as well, right?

And so a lot of times we consider this what's called a kinetic chain. And so patients will generally have some kind of knee pain, and so their gait is altered. And then they'll start to have hip pain. And then they'll start to have back pain. And so sometimes it can be kind of challenging. It's almost like a Sherlock Holmes approach where you actually have to kind of backtrack of when the pain started and to figure out what's causing this.

But yes, a lot of times we can have back pain that spreads as well. What we call that is referred pain. So you may have pain in the lower back, but then it's also spreading to the back of your legs, which is different actually than radiating pain, which is back pain that goes down to the right foot. So it can be very challenging for patients because they're having pain kind of all over, and it's very hard for them to differentiate where this pain is coming from.

Host Amber Smith: What happens if a person is in pain and it doesn't get treated, they don't seek treatment, they don't get any care for it -- will the pain resolve on its own? Or will the pain just keep getting worse?

HeeRak Kang, MD: That's one of the challenges with chronic pain. A lot of times there's different methods of treating pain, whether it's medications or injections or conservative management, right? But a lot of times when you have ongoing untreated pain, what you generally have is a centralizaiton of pain. And what that means is, pain is not only what is happening, but also your perception of pain.

And so a lot of times, when patients have this chronic low back pain, they're very guarded with their movements. They can be very anxious and depressed. And so that kind of takes what is a pain, let's say a six out of 10 into a nine out of 10. And so now a lot of times the challenge is how do we treat the pain and also treat the perception of pain, which is very real. People are feeling this pain. It's not something made up in their head. Pain is very challenging in that way.

Host Amber Smith: So it is important to treat it?

HeeRak Kang, MD: Absolutely.

Host Amber Smith: So let's talk about what causes lower back pain. How often do you see people with congenital diseases?

HeeRak Kang, MD: I actually don't see a lot of patients with congenital diseases where I am at. What I see is someone has a herniated disk that happened all of a sudden, whether they were lifting something heavy, or a lot of times I see more chronic neck and back pain. Over time, there can be degenerative changes just as patients age, unfortunately.

Host Amber Smith: So arthritis, inflammatory diseases, things like that?

HeeRak Kang, MD: Exactly, exactly. And one of the challenges as patients get older is, the disks that act as a shock absorber between those lumbar vertebral bodies, which are kind of like the stacks of cylinders, they basically lose the fluid. So your jelly donut actually becomes just a donut. It loses that jelly. And so what happens is, it actually puts more pressure on the joints that are between the lumbar of vertebral bodies. And so that can lead to arthritis. And the challenge with arthritis is once you have bone on bone, ironically, that actually creates more bone, what are called osteophytes. And kind of similar to in the knee and the shoulder and things like that, you just, or the hip, you just have this narrowing. And that in itself can be very painful.

Host Amber Smith: Do you ever find that the back pain is actually because of a problem somewhere else in the body?

HeeRak Kang, MD: I do. I do. Usually I see it in hip pain, which is actually. Patients, when they say hip, they sometimes get confused because they think of the fashion hips at the waist. But hip pain is actually more groin pain actually. And then also sometimes with knee pain as well. And a lot of times it's because they're just because they're painful on one side, they're shifting their weight to the other side, and so now their back is actually taking a bit more load there. And so therefore I can definitely see where their pain is coming from.

Host Amber Smith: Let's talk about risk factors for developing low back pain. Why is it that back pain becomes more common as we get older?

HeeRak Kang, MD: You know, unfortunately a lot of it is patients are getting older, they've had a long history of maybe treating their body a little bit more aggressively, they put on a little bit of weight, maybe they're smoking and drinking alcohol. And so a lot of these can have a detrimental factor for low back pain. Maybe their work is very sedentary and they're not moving around as much.

With back pain we're kind of focused on keeping that core strong. And so, especially in Central New York, there's a big risk factor, especially for females, for osteoporosis. And a lot of times that can lead to compression fractures, which is at that thoracic lumbar junction. The thoracic is kind of where your ribs are, and your lower back. And the reason why that is, is because the thoracic area is very stiff, and the lower back is very flexible. And so generally you have a compression fracture in that stiffness and the kind of flexible portion.

A lot of times we'll see this, and it's very unfortunate, because these patients, you know, we aren't the sunny state of Syracuse. And so their bone structures are not the greatest, and then they'll have some kind of fall, and then that can lead to compression fracture, which can lead to a lot of significant mid-back and also low back pain as well.

Host Amber Smith: So that's an issue for women in Central New York, because we don't have the sunshine like Florida or California?

HeeRak Kang, MD: Exactly. We're just at risk for more osteoporosis, which you know makes your bone brittle, unfortunately.

Host Amber Smith: Because we need that vitamin D.

HeeRak Kang, MD: Yes. Yes. So, it's a prescription for a flight to Florida, actually.

Host Amber Smith: OK. Well, let me ask you about a person's fitness level. Does being active increase or decrease your risk of developing lower back pain?

HeeRak Kang, MD: It can definitely increase it if you're at that kind of extreme level, but for most patients it definitely decreases your risk, especially if you're flexible. You're preserving what's called your range of motion with your back and your legs, and your focus on that core strengthening. Increasing fitness level is helpful in a lot of aspects.

Host Amber Smith: And what about weight?

HeeRak Kang, MD: Weight, unfortunately, isn't the greatest for low back pain. There's a lot of more research actually for knee pain. If you lose a lot of weight, you can actually decrease your knee pain and your hip pain and your lower back pain as well. And so I always tell patients that it's really beneficial for them. Let's say they can try physical therapy or even just looking at the local YMCA or the local gym to get a better handle on that.

Host Amber Smith: Do genetics play a role? If you had parents that you know struggled with back pain, are you more likely to have that yourself?

HeeRak Kang, MD: I honestly haven't seen a lot of research in that. Anecdotally, I've had a lot of patients that have told me about their parents low back pain and neck pain, and it kind of correlates to what they're seeing. But the science is a little bit mixed on that right now.

Host Amber Smith: Can people do anything to protect themselves if they have a job, say, that requires heavy lifting?

HeeRak Kang, MD: Absolutely. And so I would say for if you work in a job that's having heavy lifting, you really need to be able to kind of lift weights close to your body. And so what I explain to people is if you imagine your back is like at a seesaw, where your back is like that, the crux where all that weight is on. As you move further away, you actually need less weight, right? And so the idea is if you're doing any heavy lifting, it has to be close to you, because the further away that you're moving away from your body, then it's actually putting a lot more leverage basically on your lower back. And so I would recommend patients squat and kind of lift close to their body. And that's something that they can protect themselves.

Host Amber Smith: That's more in reference to adults, but I'm thinking of little kids with backpacks, which some of those backpacks can be pretty heavy. Are they setting themselves up for problems as an adult?

HeeRak Kang, MD: I haven't seen a lot of studies on that recently, but to me, it makes a lot of sense that if you're putting a lot of weight on a developing spine, then it's probably not a great idea, actually.

Host Amber Smith: Let me ask you about mental health. Does that have an effect on back pain?

HeeRak Kang, MD: Absolutely. You know, patients want to get better. I think that is a struggle. They're trying to figure out ways, and they're trying to get out of this process where they have this back pain. And a lot of times, maybe their coping mechanism is to smoke or to drink or to eat, and so therefore they're putting on weight or they're using these crutches. And so, a lot of times they end up being depressed and anxious, and they're very stressed out. And so it kind of creates this cycle. And, I feel like as providers we don't really talk enough of how we can help mental health first, and then that can also help with their back pain.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast with your host, Amber Smith. I'm talking with Dr. HeeRak Kang. He's an assistant professor of physical medicine and rehabilitation at Upstate, specializing in pain and chronic pain management.

What do you do for someone who comes to you complaining of lower back pain? What's involved in the diagnosis?

HeeRak Kang, MD: I try to get a, first, good solid history. My role is to try to figure out where this pain is coming from, how this pain occurred, where it's going. I try to correlate it to a specific dermatome map. Or, if it's, let's say a radiculopathy, a lot of times I'll start with a lumbar X-ray before I progress with an MRI.

Host Amber Smith: I'll usually prescribe them a home exercise program or physical therapy. If it's a certain nerve distribution that I'm suspecting, I'll order what's called an E M G, a nerve conduction study. It's kind of an uncomfortable exam, but it really tries to isolate what specific nerve could be involved. Well, starting with acute pain, let's talk about how back pain is treated.If someone comes in with acute back pain, and you are able to sort of determine what you think is the cause, how do you begin treatment?

HeeRak Kang, MD: We're kind of at this phase now, where we're moving away from bedrest, to be quite honest. A lot of times if it's acute back pain, we'll start with kind of the "R I C E," you know, with the Rest, Ice, Compression, Elevation. Back pain is kind of hard to elevate, to be quite honest. And rest is relative rest. It's not you're actually in bed.

We're also trying to move away from back braces as well, unless you have a specific issue like a compression fracture. A lot of the recent literature has shown that back braces can a kind of lead to weakness in the back, and that's not what we're trying to do. We're trying to strengthen those back and core muscles like the abdomen. We'll also start with some basic Tylenol, ibuprofen, naproxen, or I can also prescribe what's called meloxicam, which is a long-acting NSAID (non-steroidal anti inflammatory drugs).

Host Amber Smith: Now what about, I guess with the "R I C E," ice is part of it. Does heat ever get used? Do you switch over to heat at some point?

HeeRak Kang, MD: Usually I will start with ice, because the thought process of any kind of acute process is that you have an inflammatory process. And so ice is supposed to kind of calm that down. And so heat is generally not something that will help in an acute phase.

In a chronic phase, to be quite honest, I've had a lot of patients that say heat really helps. And so I always trust what the patient is telling me and try to go by what works with them. And so a lot of my visit with a patient is trying to figure out what they've tried before and what else they haven't tried. And so, heat can definitely be helpful.

Host Amber Smith: So for people who have chronic low back pain, let's talk about what their options are for treatment. So these are people that have had pain for more than three months generally.

HeeRak Kang, MD: Yeah. I always tell my patients that there's generally, with myself or any other provider, there's five things you can really do. One, you can do nothing and you can live with it, which is probably what a lot of patients have done.

Two, you can try conservative measures such as like acupuncture, chiropractor, physical therapy, home exercise program. Three, you can try medications. And I try to explain to them medications do have side effects, and I can list those specific ones for the patients.

Four, you can try injections, and understanding that there's always risk and complication with any kind of intervention.

And five, you can do surgery, understanding their risks and possible complications. But surgery would be something I would actually refer them out to.

Host Amber Smith: So you actually go over those five options with the individual because there's got to be pros and cons for each of those, right?

HeeRak Kang, MD: Absolutely. I try to go through those five options mainly because I want to also figure out what they've tried. A lot of times they've said they've tried chiropractor or tried PT (physical therapy,) but they haven't tried acupuncture. Or they've tried some medications but maybe they haven't tried them all. So it's kind of my role to figure out what they haven't tried and see if if it's worth it.

Host Amber Smith: Have you seen people where conservative measures like acupuncture or physical therapy or the chiropractor, have those been effective? Do you have patients that have gotten relief through conservative measures?

HeeRak Kang, MD: Absolutely. You know, a lot of times herniated disks get better with conservative management. And I would argue that a lot of times they get better without any providers being involved. And so, I always recommend to my patients, "you don't have to see me. You don't have to see a physical therapist. You don't have to see a chiropractor. You know, you could sign up for the YMCA and use the therapy pool for the next four weeks and see if that will help."

You know, if they're not in severe debilitating pain, they're not having neurological symptoms, weakness, that kind of strange sensation down their leg. If they're not having bowel or bladder issues, then I absolutely encourage patients to do that.

And, you know, a lot of them actually, they get better. And, it's a win for the patient and for myself, even though I don't see them as much as I want to. It's, you know, I, I consider that a win.

Host Amber Smith: In terms of medications, are there medications that can relieve pain that are not opioids, that a person won't be at risk of becoming dependent on?

HeeRak Kang, MD: Absolutely. There's a few medications. We call them neuropathic pain medications. The big one is probably what a lot of people have heard of gabapentin. Not everyone finds success with these, but a lot of studies show that an effective dose of gabapentin, let's say, is 1,200 to 800. And a lot of literature shows it can reduce pain by 30 to 50%. And I try to be upfront with patients in saying, "Hey, if this medication works for you, and we're able to get up to that level, this is kind of what I would expect as a win. And if that's acceptable to you, then I think we can definitely try it."

And so I think managing patients' expectations on what they can expect, and what the side effects are, such as nausea, dizziness, fatigue, abdominal pain, and if they're able to kind of weigh the pros and the cons, I think it's definitely a good option for a lot of patients.

Host Amber Smith: You mentioned injections, and I wanted to learn more about that. Is that a one-time thing where you get an injection of something, and that takes it away for good?

HeeRak Kang, MD: So unfortunately, injections do have a limitation under the duration, right? And so a lot of times what I try to determine is whether this is a therapeutic or a diagnostic injection. And a lot of the injections I do is for the spine, neck and the lower back.

And a diagnostic injection is one where I just use a anesthetic. It's not a steroid. It's really if the patient is planning for surgery. And usually I do it in coordination with ortho spine or neurosurgery. And that's really to confirm the surgical level that they're having the surgery.

A therapeutic injection, that's where I'm just using a mixture of anesthetics, like lidocaine or bupivocaine and a steroid. And that is for patients with a severe chronic pain that's kind of radiating down their legs, let's say. It doesn't have to go right down their legs. You know, a good block can be on average three to four months. And so, at that point, my question to the patient is, "we can try this, see if it works for you. We can try to do a mixture of the injection and the medication to try to elongate that, but it will most likely if you have chronic pain, be something you may need on a routine basis."

And I try to have an ongoing conversation with the patient about that. I also offer them physical therapy as well, so they can try to figure out what, if there's any stretches that they can do to kind of prevent the pain. But unfortunately, there is no one injection that's going to last forever.

Host Amber Smith: Well, if a person is a candidate for surgery and they go and they have surgery, will they ultimately come back to see you, or not necessarily?

HeeRak Kang, MD: You know, not necessarily. You know, we have some great surgeons here at Upstate, not only the neurosurgical department here, but at the ortho spine surgeons I work with: Dr. Tallarico, Dr. Lavelle, and Dr. Sun. They're excellent. There are some patients, unfortunately, who do come back after surgery with some pain. Chronic pain is very tricky to treat. But there is a lot of patients that get a lot better, and I don't see them afterwards. And I think that's a win for everyone involved.

Host Amber Smith: Well, that's what I wanted to ask. Lower back pain is just so prevalent, and you hear about people that struggle with it, but you do have patients that you've seen who've been able to eliminate the pain and get on with their life, is that right?

HeeRak Kang, MD: Absolutely. And it's great. I had a woman last week talk about how she's been able to go grocery shopping without pain. And she said she didn't realize she could do something simple like that and have no pain. She was amazed. She was walking up and down the aisles. And I'm thankful for that. I'm thankful for the opportunity to be here serving the patients of Central New York and trying to add value to their lives in some meaningful manner.

Host Amber Smith: Dr. Kang, thank you so much for making time for this interview.

HeeRak Kang, MD: You're very welcome.

Host Amber Smith: My guest has been Dr. HeeRak Kang. He specializes in pain and chronic pain management at Upstate, where he's an assistant professor of physical medicine and rehabilitation. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.