Prescribing books to kids, teens; what to do about lower-back pain

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," meet the pediatrician who prescribes books to her patients.

Jaclyn Sisskind, MD: ... "The Poet X" is a novel in verse that has won every possible award a children's book can win, and it is about a girl who's in a difficult relationship with her mom and is trying to find her way. And the way she finds herself is through poetry and spoken word. ...

Host Amber Smith: And a doctor who specializes in physical medicine goes through the treatment options for chronic low back pain.

HeeRak Kang, MD: ... 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: All that, some expert advice about dealing with dry skin in children, and a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, a physical medicine and rehabilitation specialist discusses chronic low back pain. Then, a pediatrician addresses how to deal with dry skin. But first, a pediatrician talks about the importance of reading books.

From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."

Dr. Jaclyn Sisskind is an assistant professor of pediatrics at Upstate who believes in the power of books, so much so that she sometimes prescribes specific books to her patients. She recently wrote about her practice in the School Library Journal, and she's here to tell us about that.

Welcome back to "HealthLink on Air," Dr. Sisskind.

Jaclyn Sisskind, MD: Thank you so much for having me again.

Host Amber Smith: Now, I know you ask each of your patients what they're reading. So I'd like to ask you, what are you reading?

Jaclyn Sisskind, MD: So, last night I just finished "The Last Mapmaker." This is a book by Christina Soontornvat, and it is a fantastic book for middle-grade students about a girl who is trying to get out of where she lives and find a better life for herself. So that's the book I finished last night, but then, as far as grown-up books go, I'm reading "Tomorrow and Tomorrow and Tomorrow," which was a big book last year, and I didn't get a chance to read it.

Host Amber Smith: So you read some of the books that you may end up recommending to your patients, too, it sounds like.

Jaclyn Sisskind, MD: Absolutely. I never recommend a book to my patients that I haven't read first, and this time of year is really exciting for me, reading-wise and recommending-wise, because the American Library Association Youth Media Awards came out just at the end of January. that includes the Newbery (for children's literature) and the Caldecott (for children's picture book), and then a lot of others that people are not as familiar with.

And so for me, February and March is really just reading through that list and getting excited about all of the great books that came out last year.

Host Amber Smith: What's your impression of "Tomorrow and Tomorrow and Tomorrow" so far?

Jaclyn Sisskind, MD: I'm just at the beginning of it. I mean, I truly started the first two chapters last night because I finished "The Last Mapmaker" and wasn't quite ready for bed. It's really grabbed my attention, but I'm not that deep into it yet.

Host Amber Smith: Well, it's a controversial subject, but I know you feel strongly about the rise in book bans across the country and the impacts some of these books have had on your patients. You wrote in your essay about patients who've told you how certain books have allowed them to feel valid and worthy and not alone for the first time.

What are some of the book titles that you've seen be helpful to your patients?

Jaclyn Sisskind, MD: There are so many different books that I've recommended to my patients, and I know that you and I have spoken about that in past interviews, and I've written about them in some articles recently. I think the three books that I'm probably talking about the most with my patients right now: one is called "Different Kinds of Fruit," and that's by Kyle Lukoff, one is called "The Poet X," by Elizabeth Acevedo, and the other is "Starfish," by Lisa Fipps. These are three books that I've been recommending a lot recently because they deal with issues that my patients have been coming to me with recently.

"Starfish" is about body image and bullying. "Different Kinds of Fruit" is about a student who is struggling with their own sexual identity and learning about how they fit in with their group of friends, one of whom happens to come out as nonbinary. And "The Poet X" is a novel in verse that has won every possible award a children's book can win, and it is about a girl who's in a difficult relationship with her mom and is trying to find her way. And the way she finds herself is through poetry and spoken word.

I tend to recommend those a lot, and what really warms my heart is recently, as I've been talking about some of those books, my patients have said, "Oh, I heard about that one already, either through school or through a friend, and so it's really exciting to me that these titles are getting the traction that they deserve.

I hate to call out one particular book over another because there's so many I recommend, and I don't want anyone to be left out. But I think those are the three that I'm recommending the most recently, and it's worth noting that "Different Kinds of Fruit" and "The Poet X" are on the list of some of the most challenged titles in school districts right now, and not just in school districts, but also public libraries. And so, as much as it warms my heart that when I recommend them, people have heard about it, it really makes me sad to know that the access to these books is being limited across the country.

Host Amber Smith: What is objectionable in them? I mean, your description makes them sound like lovely books. What is objectionable?

Jaclyn Sisskind, MD: They are lovely books. They're lovely, important books, and I think what is objectional about them is that they feature characters who have not traditionally been featured in the literature that came before. So there are characters that are not white, characters that are queer, characters that have traditionally been bullied.

It's not often that an overweight child is the main protagonist in a book. Often they're the sidekick, or they're treated as someone who's not intelligent, or they're the butt of the joke. And so, to put those characters that have often been marginalized in the spotlight and say, "This is my story, this is what's happening to me," I think that's the problem that people have with a lot of these books.

Host Amber Smith: What has it accomplished by making those books unavailable? If a person goes to the library to get them, they're banned, they're not there, to the school and they can't get them, what does that accomplish?

Jaclyn Sisskind, MD: I think, honestly, it's othering, is what it's doing. I think that it is working to silence the voices of the people whose voices most need to be heard. And I think it's a problem that has two prongs.

The first is that it denies kids the chance, and I'm just talking about children's literature right now, certainly adults can find themselves in these books, too, right? But it takes kids that might see themselves in that book, and it decreases their opportunity for them to see themselves on the page, to see their experience represented. And that could make them feel ashamed for who they are, especially if they're being told that book is not available because it is, quote, inappropriate, right? That's telling the child: You are inappropriate. It's also going to make the child feel erased. It may make them feel less apt to speak up about an experience that they've had because they think that it's not acceptable to others So that's a big problem.

And I think that the second problem is that it denies any child the opportunity to see the experience of others through a book, right?

So there are some people who perhaps are white, perhaps are cisgendered, perhaps consider themselves to be straight, but could certainly benefit from reading about the experience of someone else their age, who is not those things. And, in a very idealistic way, I think that could make us a more accepting, peaceful society if we all listened to each other's experiences more.

And what better opportunity to do that than in childhood, in adolescence, when your brain is so open to learning and being accepting to other people's experiences.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Jaclyn Sisskind.

She's the "readiatrician," you might say. She's a pediatrician who really respects books and uses them in her practice.

So is there any middle ground? Are there any sorts of reasonable limitations on who can read what that would make everybody happy?

Jaclyn Sisskind, MD: Of course there is. I think there are resources that we have that we could be using better.

So school librarians, English teachers, elementary and middle school teachers have been specifically trained to know what is out there in the world of children's literature and to help connect kids to the book that is right for them. And so when it comes to middle ground, I think the middle ground is: Keep the book, keep all of the books in the library and in the classrooms, and trust that the people who are trained to help connect kids to the right book are doing their job and helping kids find the right book for them or being able to gently say to them, knowing what I know about you and your current reading level, I think this book is a little bit of a stretch for you. Let's find something similar that might meet your interest but be more approachable for you. And parents can also always have a voice in what their children are reading.

But when it comes to book banning in schools and in public libraries, parents are not just making a decision for their own child. They're making a decision for every child, and I think it's very important for people to have access to these books. So if there's a particular book that a parent has a problem with, they can talk to their child or their child's educator or their child's librarian about why this particular book makes me feel uncomfortable.

It might be a great opportunity for discussion and for the parent to hear both sides of why that book is there, but to limit access to all children by taking the books out entirely is a really dangerous thing.

Host Amber Smith: Now, you being a parent yourself of readers, I'm sure you're raising your children as readers, if one of your children chose a title that you thought was a little bit of a grasp for them at that level, but they really wanted to read it, what would you do?

Jaclyn Sisskind, MD: I would let them read it. And that's happened before in our house. I think there's two kinds of reaching.

One is, this book is really too hard for you, right? Like you are in second grade, and this is a book that's intended for a 10th-grader, let's say. And I just don't think you have the stamina to get through this book, or you're going to have to be looking up all the vocabulary. But if you want to try it, try it. And that's happened.

And my son said, "I think this book's too hard for me."

And I said, I agree. And he put it down.

And then the other kind of reaching is, this book is at your level, grade-wise, but perhaps the concepts in it are going to be challenging for you. And when that has happened, I've had a conversation with my son to say, I think this book is going to talk about things that you might find scary. The book in question that he brought home was a book about the Holocaust. And so I said, you know, I think there may be things in this book that you find scary, but the things in this book really happened and sometimes scary things happened

So if you want, we can read this book together. This is a book I've already read, so if you want, I can give you a summary, and then you can see how you feel about experiencing it yourself.

Or, if you want, you can wait until you're a little older or the summertime, when it's not dark so early, and it won't feel scary at night, and we can read this book at a different time.

And he ended up wanting to read the book, and he did, and he said that he was glad we had had the talk beforehand because he was prepared for it.

And he knew that he could talk to me throughout the book if anything was upsetting or confusing or scary, as it was. And I think that type of template of conversation could be applied to any book: a book about gender, a book about racial inequality, a book about violence, a book about the death of a parent.

Life is full of uncomfortable things, and sometimes a book is a safe way to explore those topics because you can close it and put it down. You can talk about it with somebody. You can take your time with it. Unlike watching a TV show or a movie where it's just sort of coming at you. Of course, you can hit "pause," but it's a different type of thing. I think books are the best way to explore those uncomfortable situations.

Host Amber Smith: Now, I know with your individual patients you give personalized recommendations, but can you give us some reading recommendations for kids who are, let's say, dealing with issues of body image? I know you already mentioned "Starfish," was it?

Jaclyn Sisskind, MD: Yeah, so "Starfish" is a novel in verse by Lisa Fipps. It is such a fantastic book. I think anyone who has talked to me since probably the middle of 2020 until now has heard me talk about "Starfish."

I have a book club that I run now for pediatricians at Upstate. It's called Pedia Lit, and we read one book a month, and Starfish was our first book because I think it's so important for adults, for health care providers, anyone who was a kid or works with kids should read this book, so I recommend "Starfish" often.

Also there's a book called "Taking Up Space," by Alyson Gerber, that I think is very good.

So "Starfish" talks about a girl who is overweight and dealing with bullies.

"Taking Up Space" talks about a girl who thinks she is overweight, but she's actually working through an eating disorder. And so it's the opposite side of things. It's an excellent book and a book that shows therapy and the positive impact that teachers and guidance counselors can have, in a really approachable light. So, I love that book.

Another one that I think is just a fun one is called "Fat Chance, Charlie Vega." This is by Crystal Maldonado, and it's a book for high school students about a girl who is overweight but very proud of who she is and is dealing with the people in her life who are telling her that she should be a different size.

Host Amber Smith: What about books for dealing with the loss of a parent?

Jaclyn Sisskind, MD: "Red, White, and Whole" is a great book that deals with a girl who's losing her mother to leukemia, and it's set in the 1980s, so I liked it a lot just because the soundtrack and the styles were very much my youth. But the kids that I've recommended it to said that "Wow, this hurt my soul a little bit," but they said they liked that it was a vintage book, which made me sad because it was set in the '80s, and I'm not vintage yet. But that book is by Rajani LaRocca, and it's just a wonderful story. It was a Newbery Honor book last year.

Also, there's a new picture book that just came out called "Sitting Shiva." It's by Erin Silver, and it's illustrated by Michelle Theodore. This is a book that talks about a girl whose mother just died, and they're working through the Jewish tradition of sitting shiva, which is a seven-day mourning period right after death. And the purpose of it is that the family is not alone, and the girl does not want all these people in the house.

And then she starts to understand how that community afterwards can help you work through the emotions of sadness. And I think that this book really applies, even though it's about a Jewish tradition. It's a lovely picture book for anybody who's going through loss.

Host Amber Smith: What about some books for someone who's feeling surrounded by bad news?

Jaclyn Sisskind, MD: "Everywhere Blue," by Joanne Fritz, is a book about a girl whose family is struggling. Her parents aren't communicating well, her older brother has run away from college, and she's just trying to deal with all of that. Plus the regular stresses and drama of being a middle school girl. And I think it's a book a lot of people can identify with.

But also, sometimes when you're feeling like you're surrounded by bad news, you just want to read a book that makes you feel happy and hear about a person who was in a bad situation and came out OK. And so for me, that book is "Donuts and Other Proclamations of Love," by Jared Reck. Written for high school students, it's funny, and it's sweet, and it's got some sad, deep parts to it, but in the end it just has the ending that you want it to.

Host Amber Smith: And what about for kids who are struggling with loneliness?

Jaclyn Sisskind, MD: There are two books by the same author that I just love for this sort of thing. Both of the books are by Erin Entrada Kelly.

One is called "We Dream of Space." The other is "Hello, Universe."

"We Dream of Space" is about a girl -- it's also set in the '80s -- it's a girl who feels lonely in her family. Her parents are on the brink of divorce. She and her brothers aren't connecting very well, and she really hooks into the astronauts that are going up in the (space shuttle) Challenger and wants to be an astronaut and really connects with them. And the story brings you through leading up to and then after the disaster and how she finds friends and solace in her family.

And "Hello, Universe," also by the same author, is about a boy who's just a loner and finds his group of friends in a very unconventional way.

Host Amber Smith: Well, Dr. Sisskind, thank you so much for making time to talk with me.

Jaclyn Sisskind, MD: Thank you so much for having me. And Amber, I just wanted to say at the end, if people are interested, and want to know what they can do about book banning in their community, there are a couple very small things that make a big difference. One is just to speak up, talking about the books that you love and why you love them.

If you are on social media, putting out a tweet or an Instagram post, this was a great book and here's why, it makes a big difference, especially if you tag the author in it. Speaking up at school board meetings and supporting your teachers and librarians, especially if you see that something like this is happening in your community.

The first thing to do is reach out to teachers and librarians and say, how can I help? When's the next meeting? Writing letters of support. Those are always to get voices out there fighting for the books and for everyone to have access to them.

Host Amber Smith: My guest has been Dr. Jaclyn Sisskind, a pediatrician from Upstate Medical University who's enthusiastic about reading.

I'm Amber Smith for Upstate's "HealthLink on Air."

What are the options for treating chronic low back pain? Next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." 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 "HealthLink on Air", 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 disk. 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 a herniated disk to kind of reabsorb itself.

I try to explain herniate disk as kind of like a jelly doughnut. And the thing is, when you squeeze a jelly doughnut 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 3-D 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 doughnut, 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 doughnut actually becomes just a doughnut. 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: Please stay tuned to Upstate's "HealthLink on Air." We'll be back after this short break.

Welcome back to Upstate's "HealthLink on Air." This is 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 (under the skin surface) map. Or, if it's, let's say a radiculopathy (irritation or injury to a spinal nerve root), 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 EMG, 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 "RICE," 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 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 "RICE," 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: You're listening to Upstate's "HealthLink on Air," 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.

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 the 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. 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 an 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 (specialists) 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. 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. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Steven Blatt, from the department of pediatrics at Upstate Medical University. How do you advise people to deal with dry skin in the winter?

Steven Blatt, MD: At this time of year, one of the most common problems we see in children -- and I'm pretty sure in adults, too, although I don't take care of adults -- is dry skin. During the summer, the air around us is so moist -- and we live in a, especially in Syracuse, in a moist environment -- we don't have dry skin. But during the winter and the cold weather months, a number of things happen.

First, when the temperature drops, the air is able to hold less moisture. It's more dry. That's No. 1. Then we go inside our homes, we turn the heat on. The furnace dries out the air even more. If you live in a home or an apartment that has leaks in the doors and windows, there's more cold air coming in. The furnace is on more. It dries out even more. So we live in a very dry environment.

And then one of the messages that health care professionals have been saying a lot over the past few years is "wash your hands to get rid of those germs, get rid of the bad viruses." And that actually dries our hands out even more. And right around this time of year, hands and arms and legs, they come in and they're getting dry. They're getting cracked, and very itchy. And when they itch, we scratch, and that damages the skin even more. So we are a perfect storm to have really bad skin in Syracuse during the winter.

So what could people do? There's been a lot of controversy about bathing because we know that if you remember when you were a little kid and you would sit in the bath for an hour, your skin gets all crinkly because the oils come out. So we know bathing will actually dry your skin. But bathing is OK, as long as we moisturize as soon as we get out. You could put baby oil in the bathtub, and then when they get out, you want to put moisturizers on the same way you would put ketchup all over your hamburger. You want to slather it on and get your skin very moist and silky-smooth. And you could do that many times a day, and it's a lot of moisturizer. So what I tell my patients is start off with the least expensive moisturizer you could find. If that doesn't work, try another one, and everybody likes something different.

The next thing is when you get out of the bathtub or the shower, don't take a towel and rub it on you. That's like putting sandpaper on your skin. Just pat yourself dry, and that'll cause less damage. For people that have more involved dry skin, hydrocortisone cream, which is over the counter, hydrocortisone either half percent or 1% is very safe to use once or twice a day, especially on the areas that are more dry.

So the things that we want to do is moisturize, moisturize, moisturize. If that doesn't work, add a little bit of hydrocortisone.

And then the last thing is when it's more than you can handle at home, go to the doctor quickly. It is much easier to take care of skin before it gets bad. Once it gets real cracked, and it could even bleed, then you need really high-potency steroids. You're much better off going early on. This is a case where early treatment is the best treatment.

Host Amber Smith: You've been listening to Dr. Steven Blatt from the department of pediatrics at Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Health care professionals often wonder if patients see them. See how hard they are working to gain trust, provide comfort, speed healing. Pam Freeman, a poet and actor in Upstate Medical's standardized patient program, wrote us a gorgeous poem that pays tribute to nurses' heroic work. Here is "Request Line":

The acute floors were full so instead of going upstairs

I lay on a gurney at the far end of the ER

A whole room all to myself

Unused because the heat didn't reach there

They apologized and offered blankets

But I bathed gratefully in the chill

While a fever roasted me

No thank you I said and drew the sheet up

Letting my feet float in cool air

Was it sepsis I still don't know

That was before they told you things

Not wanting to scare you

All I knew at the time was

My sed rate was high and everything hurt

So when the nurse peeked in from the door

Spoke my name like a secret password

And finding me awake padded in

How did that nurse know the one thing he could do

Without causing more pain was give my toe a small squeeze

While saying how are you dear

Just give my toe the merest wiggle

And I would relax

He smiled under his walrus mustache

Told me his first name which I've long forgotten

Then with simple instructions

Made a quick neat task of the dreaded bedpan

Which I thought would never work

But it did and he whisked it away

Saying thank you dear

I learned that he was also a firefighter

And played bagpipes

What was his name I wish I could remember

Why bagpipes I asked

He said well you know dear

Someone has to

There must have been other nurses

I was there for days

But he's the only one I recall

The firefighter bagpiper hello-dear nurse

With the cartoon mustache

Who saw my toe sticking out from a thin sheet

In a cold room

And used it like a telegraph key

Pressing messages onto it such as

It's all right

You are safe

You will heal

You are worth a careful touch

You are worth your questions

You are worth knowing that I dress in other outfits

And hoot like a band of owls

Or run uncoiling a fire hose

All within this wild romp of a world

To whose possibilities we will soon return you

And so

This goes out to the nurse

In his scrubs

In his kilt and sporran

In his helmet and asbestos

A uniformed doorman to the world

Waving right this way dear

This way to the music and fires

The songs and battles

Who gives my toe a last confident handshake

Yes please this goes out to him

A tendril of melody

A thin distant chant

Over the daily drone of living

His greeting is still on my playlist

In case I need to hear it again

Once in a while

When all I can seem to get is

The all-night insomniac

Radio station of my mind

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," how sleep troubles are linked to dementia.

If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.