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Dr. Miller: Medicine may not be the only nor the best treatment for low back pain. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Tom Miller and I'm here with Dr. Rich Kendall. Rich is the Chair of the Physical and Rehabilitative Medicine Department at the University of Utah and we're going to talk about treatment of low back pain with non-medical modalities. Rich, tell us a little bit about physical therapy and how that relates to back pain and how exercise helps people improve their lower back pain. I think it's an area that's underutilized.

Dr. Kendall: Many people with back pain, just exercising on a daily basis will really reduce the intensity of their back pain quite a bit. Many studies have shown that back pain and exercise go well together. It can help with sleep, it can decrease back pain, lessen medication use, and even avoid surgery.

Dr. Miller: Rich, tell me a little about certain exercise modalities or maybe they're called stretching modalities, something like Pilates. I know that a lot of people say that Pilates is good, it improves core strength, but that may also translate into improved back strength and health.

Dr. Kendall: Well, Pilates is a very good exercise, but really there is no evidence that one form of exercise is any better than another form. Core-specific exercises, Pilates, Yoga

Dr. Miller: Yoga.

Dr. Kendall: A gym program where you lift weights. Really all of them can work in decreasing back pain. Now sometimes if an athlete is already doing a very rigorous program, they may need physical therapy with targeted exercises. But, in general, most people just sticking with a generalized exercise program and whatever they like. The key is doing something they like so you'll do it all the time.

Dr. Miller: One of the things that I struggled with is I didn't always have enough training in what physical therapists do. Do you find referring to a physical therapist to be helpful in cases where you're going to prescribe exercise therapy for people with back pain?

Dr. Kendall: I think for most people, starting with a physical therapist is a great idea. They're going to demonstrate the exercises. The therapist will watch that they can do the exercises correctly, that they have good form while doing the exercises, and also be able to look at other associated joints whether there's hip tightness or leg tightness, arm or neck tightness to try to work on some of those adjacent areas as well. But a lot of times, we'll start with a therapy and even then sometimes transfer over to a personal trainer.

Dr. Miller: Do you find that some patients are skeptical of exercises therapy? That they might seek medication instead? And how do you deal with that?

Dr. Kendall: A lot of people certainly are skeptical that exercise will do that. Nobody likes to exercise. Years ago, it was probably one of the hardest things to convince patients of. Now that everybody has to pay $35 or $50 a copay to go see a physical therapist, with two visits to a physical therapist you've paid two months of a gym membership. I can really convince people to exercise a little bit more. But many of the studies actually are showing people with degenerate discs, arthritis of the back, exercise is probably the best thing, even as well or better than surgery.

Dr. Miller: Rich, why is exercise beneficial in treating back pain compared to taking analgesics like Aspirin or Ibuprofen? How does exercise help in the long run?

Dr. Kendall: Well, there are a couple of reasons. First, you're strengthening your muscles. You really support the spine a lot better and with any arthritic joint, you strengthen the muscles around it, you load the joint a lot less and that triggers less pain from the joint. The second is you will get some change in the neuro firing patterns and how your brain perceives that pain. So overall your pain will be noticed less by your brain.

Dr. Miller: Could you explain why patients might be skeptical about utilizing exercise therapy or physical therapy to improve their condition?

Dr. Kendall: Well, one of the biggest things is that people already hurt doing very little activity and they think that doing more activity is going to hurt even more. So that is one thing that we have to overcome. The other is that they've probably been to therapy before or they've tried an exercise program and it may have helped them briefly, but then as soon as they stopped their pain came back. So they think it might be something more serious. Dr. Miller: So the key thing then is, number one, making sure they receive the proper instruction on the types of exercises that'll help strengthen the back and reduce the pain, but also encouraging them to keep up the exercise routine over time.

Dr. Kendall: That's true. Keeping it up is key and I always tell patients you can take a day here or a day there essentially Christmas and New Year's Day off, but every other day you should be doing some kind of activity. Whether it's five minutes or 10 minutes, that's great, but some kind of activity.

Dr. Miller: So, Rich, for patients that have mild to moderate back pain and who may not feel like they need to go in and see a physician, is there a website or a place they could go to find out what types of exercise might benefit them? Or do you even advise that?

Dr. Kendall: I think searching the web is a very difficult thing. If you type in low back exercises you get about 5 million websites to look at on Google. Knowing which one is correct, knowing which one is somebody just in their living room with no certification thinking that they're an exercise fitness guru is difficult. Really, I think that most people, unless you have an exercise background, seeing a therapist just one or two times, or even going and seeing a personal trainer at the gym it'd be a great place to start.

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Interviewer: Technology can help individuals with disabilities live a full and rewarding life. That's next on The Scope.

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Interviewer: Dr. Richard Kendall is with the Rehabilitation Center of University of Utah Health Care and we're talking about the Americans with Disabilities Act 25 years later, which really kind of changed a lot of people's thinking about including people with disabilities in life. Tell me about some of the work that you do to include people with disabilities in recreation.

Dr. Kendall: Well, not just including people with disabilities in recreation, but people who have a disability, like everyone else, want to recreate, wants to socialize, wants to get out of their house and out of work and do things that are fun. Our program, here at the University of Utah and TRAILS does just that for people with spinal cord injuries.

Interviewer: And some of the equipment, the technology, and some of the things technology allows people with spinal injuries to do is amazing. Tell me about some of the things you have in your trailers. You have a whole bunch of trailers filled with lots of fun.

Dr. Kendall: Yes. Our program has three trailers full of equipment that are around the valley at any certain time. We have cart skis, we have robotic skis, kayaks that you can operate through sip and puff so really accessible to anyone with any level of any injury.

Interviewer: Let's take a little bit of a turn here and talk about technology and how technology has really changed the game for accessibility and socialization as well. There's something you have that I call robot legs, but you call it something else. Tell me a little bit about the robot legs.

Dr. Kendall: Yeah. The robot legs are exoskeletons, as they're called. They allow individuals with spinal cord injury, and soon strokes, to be able to stand and walk with the use of the robotic arms and crutches. This really is going to open a lot of opportunity for individuals with spinal cord injuries so they can stand, so they can walk, talk to their peers eye to eye. All of those are going to be very important. Technology, in general, is really opening the world and we have Bluetooth controlled prosthetic knees now. People can snowboard, people can walk in them. The technology of carbon fiber allows people to run pretty quickly if you think of Oscar Pistorius. So technology is changing and really is going to open up a lot of access for individuals with a disability.

Interviewer: I'm guessing you're about the same age as I am. When I grew up, I watched "The Six Million Dollar Man." At that point of your life, did you ever dream that that would become reality? I mean, as a physician that's pretty amazing to watch that.

Dr. Kendall: Yeah. It certainly is. While "The Six Million Dollar Man," if you think back in, I think that was the '70s, how much $6 million would have cost. If you think about it now we have neural interphases that people have an electrode put in their brain and can operate robot arms just with their thoughts. So yes, technology is coming to life and I think these are going to be things that as computer and softwares develop further, we're going to see really tremendous growth.

Interviewer: What's on the horizon? What's in the future? What next thing that we can imagine now is going to happen?

Dr. Kendall: Well, the exoskeletons are really in, what I would say is an infant stage at this point. I think that as the computer algorithms develop, you're going to be able these develop where you can stand and walk on their own. I mean, a number of companies have drones that can stand, walk, walk over rocky surfaces with no tethering devices for balance on their own. So I think you're going to see these develop into where somebody can put on the exoskeleton legs and walk even without the use of crutches, and balance, and not fall over.

Interviewer: Will that replace a wheelchair eventually?

Dr. Kendall: For many people, I think it will replace it for many things that they do and I don't think it'll be 100%, but certainly give them accessibility to be up and moving around.

Interviewer: That's incredible. I want to jump back quickly. What's a Bluetooth knee do, by the way?

Dr. Kendall: A Bluetooth knee, basically it's a knee that you can program through your smartphone and tell it to be more rigid or less rigid, depending on what activity you're doing. If you're using it for snowboarding, you can program it so it takes a real big hit and doesn't collapse easily, whereas if you're walking and you want a little more subtle joint play, then you can program for walk mode.

Interviewer: With your interaction with people that use this technology, your patients and what not, tell me the benefit. Tell me a story about how it affects their life.

Dr. Kendall: One of the things that when you see somebody stand and walk, who's been on a wheelchair for a number of years, just the look on their face and really their desire to be able to talk to you while they're standing up, it's really something that is hard to describe. It really brings a whole new phase into their life and gives them hope for the future and further access. Then there's the person who used the sip and puff kayak for the first time, had been living mostly in a nursing home or assisted living facility for many, many years. And he is a ventilator-dependent quadriplegic, can't use his arms or legs, but operated the sip and puff machine very well. The only problem was because he would laugh a number of times, couldn't use the sip and puff]to correctly steer.

Interviewer: Because he was so excited that he was laughing.

Dr. Kendall: He was so excited, he was laughing, being out on the lake in the kayak.

Interviewer: If somebody was interested in learning more about this type of technology to make their life better, what would they do? What would be the first step?

Dr. Kendall: Well, the first step is to go to our website here at the University of Utah Rehabilitation Center and look for theTRAILS program.

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Dr. Miller: You've tried physical therapy for back pain, and you're not ready for surgery. What other options are there? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in depth information about the biggest health issues facing you today. The specialists with Dr. Tom Miller is on the Scope.

Dr. Miller: I'm here today with Dr. Richard Kendall. He's a professor of rehabilitative medicine, and he's also the Chair of the Department of Physical and Rehabilitative Medicine. Rich, tell us a little bit about what patients can do prior to surgery. I've heard about injections into the back for those patients who have sort of ongoing low back pain or pain in other parts of their back, but there are now injections that can be tried that might relieve their pain.

Dr. Kendall: So that's true. For people who have not done well with physical therapy program or medications like anti-inflammatories or Tylenol or even opiate medications, epidural injections are a tool for us to use to decrease pain. That's just what they are, they can decrease pain, they don't heal or cure a tissue, but getting rid or decreasing the pain is one option hopefully to let somebody go on, and further function before surgery.

Dr. Miller: So what exactly is an epidural injection? Where does that go on the back?

Dr. Kendall: The epidural space is the space around your spinal cord, and it's in the middle of the safe protection of the bones of the spine. It's a nice protected space that's filled with fat that we can put in some steroids and some Novocain in that can really help reduce inflammation as well as reduce pain.

Dr. Miller: Is this a difficult procedure or what does a patient expect when they come in to have this done?

Dr. Kendall: Honestly most of our patients expect the worst, but when we come in, we finish the procedure, and they say, "Wow, that's it? Are you kidding me? That's easier than the dentist." So . . .

Dr. Miller: That's pretty easy. If it's easier than the dentist, that's pretty easy.

Dr. Kendall: The thought of somebody poking a needle in your back is somewhat anxiety provoking but we do them with a lot of Lidocaine, and numbing under X-Ray guidance so most people really experience very little symptoms.

Dr. Miller: What are you injecting into that space that actually reduces the pain?

Dr. Kendall: We put in two medicines. One is corticosteroid or cortisone, and that gets rid of the inflammation. It'll sit in the fat cells for about two weeks around your spine and get rid of inflammation. The second is just a Novocain or a Lidocaine which is an anesthetic, and it'll numb those nerves and areas for several hours.

Dr. Miller: That lets you know that you're probably making a difference. I mean if the Novocain is working in the area where the back pain is emanating from, you'll know you're at the right place I guess, right?

Dr. Kendall: Yes, many people will be pain free when they leave. Some people that's only for four, five hours. However the Lidocaine does sometimes essentially stung the nerve if you will, and people's pain does disappear for much longer afterwards depending on the diagnosis.

Dr. Miller: How effective is this in reducing pain? Is it 80% effective, 50%, 30%? What's the story on that for patients that might be considering an epidural injection?

Dr. Kendall: Well in certain conditions, it can be very effective with disc herniations and people with radiculopathy or pain down the leg from that disc herniation. If you take all patients who could be surgical candidates and you do the injection, 60% of them choose not to have surgery because their pain improves significantly with the injection, and they choose to just not have the surgery because they're doing better.

Dr. Miller: So a great option to may be postpone or prevent surgery.

Dr. Kendall: So a great option for more than half the people . . .

Dr. Miller: That's great.

Dr. Kendall: . . . to really decrease pain, get them on, and avoid a surgery that lays you up for a few weeks or more.

Dr. Miller: Now can you have repeated injections if necessary or is there a limit on the number of injections one can have?

Dr. Kendall: There's not an actual limit, however we usually say three or so a year would be the most we would consider. Some people, it does take one or two injections to really get rid of that leg pain that they have and avoid the surgery. However if we do two injections and your pain comes back within a week, then actually surgery is probably a much better choice.

Dr. Miller: So you do these under imaging, and that helps direct the shot into the area that needs to be infused I guess.

Dr. Kendall: We do these all under X-Ray guidance, so we know exactly where we're going, we know exactly where the needle tip is. We inject a little bit of contrast die to make sure we're not in a nerve or a blood vessel. So overall these are very, very safe injections.

Dr. Miller: Now how would a patient find a physician that would be qualified to do these kinds of treatments? I don't think they necessarily need to go to a surgeon per se, do they?

Dr. Kendall: No, in fact most surgeons don't do these epidural injections. Most are non-operative either anesthesiology or physical medicine rehabilitation physicians. Most people who are pain board certified have done significant amounts of injections, and finding a physician who specializes in back pain and pain will certainly have enough training to do these.

Dr. Miller: Now last question is, if the injection is effective, how long could someone expect to have the effect last?

Dr. Kendall: Most of the time, I tell people until they do something that irritates their back again, it's really not easy for us to say a time frame. It's mostly until you bend funny again or slip or shovel too much snow or do something again that may irritate that disc again.

Dr. Miller: I'm assuming you'd also have them follow up with exercise therapy and physical therapy as another modality to continue to strengthen the back and prevent further injury.

Dr. Kendall: Yes, we always have our patients continues with their exercise program throughout this even before and afterwards just because that's going to decrease the likelihood of you flaring it up again.

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Dr. Miller: If you're a cyclist and you have neck and back pain, what is the best way to avoid that or treat it? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm here with Rich Kendall. Rich is a doctor of osteopathy and he is the chair of the Department of Rehabilitative Medicine. Rich is going to talk to us a little bit about how we can keep our necks and shoulders healthy when we're on the bike for long periods of time. Now Rich, I know you're an avid cyclist and so you have a good sense about these problems and probably have a lot to do with how to prevent them.

Dr. Kendall: That's true. I've been on a bike a lot of miles and done a lot of neck stretches and postural exercises to get rid of my neck pain.

Dr. Miller: Yeah, I saw you blow by me one day. You were going 100 miles an hour and I was only going about 5, so I know you're a good cyclist.

Dr. Kendall: I must have been doing my neck stretches. Yes, neck pain is very common in cyclists. The funny positions that we get ourselves into both on mountain and road bikes can really put a lot of strain on the neck, especially when most of us sit at a computer most of the day and have the head forward posture, which will increase some of the stress on our necks.

Dr. Miller: What's the best way to deal with that?

Dr. Kendall: One of the best ways is a good bike fit and making sure that your handle bars are about the level of your saddle, not trying to be in an overly aggressive arrow position for 100 mile ride because you just won't really do that unless you're a nice, pliable 25-year old. We want to make sure that everybody has a really well-supported neck, that their head is not forward, that their upper back is not rounded too much, and they are supported pretty well with their arms.

Dr. Miller: As a younger cyclist, it sounds like it's a little easier to avoid the problem, but as you get older, are there certain stretches you can do prior to getting on the bike?

Dr. Kendall: Probably the three most helpful exercises that I give to cyclists all of the time is one, they really need to stretch their hip flexors and quadriceps. So for a yoga warrior pose to really stretch your hip flexors and quadriceps out because in cyclists these are very tight. Your hip angles are very narrow and that's going to make your back round quite a bit. The other is to really strengthen your back muscles, exercises like Supermans or back extension exercises where you really can strengthen your back muscles. If you've ever gone that 100 mile ride, you come back, your triceps are the sorest muscles that you have, it's because your back isn't supporting you and you're supporting yourself with your tiny little cyclist arms the whole time.

Dr. Miller: So a professional bike fit would also help, you think or are most people able to do their own bike fitting? What do you recommend there?

Dr. Kendall: I think a professional bike fit is a good idea for most people who are going to spend more than token time on their bike. If you're riding 100 miles or more a week, you really need to have a bike fit done. Especially long term, especially early in the season where all of your muscles are tight, your chest muscles are tight, your hips are tight, you're going to want to have a nice bike fit where you're not overextending.

Dr. Miller: What happens if you're riding long enough that even if you're doing these exercises, you develop pain coming down one of the arms and your fingers or you've got pain in your neck that won't go away?

Dr. Kendall: If you've done all of these things and you are having continued neck pain or you start to get shooting pain down your arm or numbness in your hands and fingers, you really should be checked by your physician to make sure that you don't have a pinched nerve in your neck as a cause of these.

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