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Rheumors Volume 1, Number 1: December 1990

ARE YOU A PAIN STATISTIC?
by Phyllis Euley, R.P.T. Director, Burkland Physical Therapy

Statistics show that as many as 8 out of 10 adults will have a significant back disorder within their lifetime. Five billion dollars are spent annually for the treatment of back problems, but only 3% of all medical expenses are spent for preventive purposes.

Almost all back injuries are the result of:

• poor posture
• poor body mechanics
• faulty living and working habits
• loss of flexibility
• decline of physical fitness
  

The back has three natural curves: cervical (neck), thoracic (middle back), and lumbar (lower back). With good posture these three curves are balanced, allowing the ear, shoulder and hip to be in a straight line.

A healthy spine is supported by strong and flexible muscles of the back, abdomen, hip and leg. When the muscles lack strength and flexibility they cannot maintain the back's natural curves. This can lead to back problems or injury.

Strong and flexible hip, knee and ankle joints also help balance the back curves and allow proper movement. If these joints lack strength and flexibility they will fail to support the spinal curves, which can also contribute to back problems.

What can you do to prevent yourself from becoming a back pain statistic? Learning how to keep your back balanced when in motion through good posture, good body mechanics and good lifting techniques will help to maintain a healthy back and prevent injury.

LOW BACK PAIN - AVOIDING THE PROBLEM
by Robert L. Rosenberg, M.D.

Low back pain (LBP), one of the most common musculoskeletal problems, can begin suddenly under even the most innocent of circumstances. Even bending the wrong way to pick up a pencil can initiate acute LBP. The pain may manifest as local muscle spasm ("my back went out") or radiation of pain down one or both legs due to nerve irritation ("sciatica"). Either way, a person with sudden LBP knows that he or she will be out of action for a few days.

LBP affects 80% of us at some time and is a major cause of work related disability and medical expense. While LBP may become chronic, 70% of patients recover from the acute episode in two weeks and 95% recover in three months. Rarely is surgery necessary.

The low back is a complex structure composed of five lumbar vertebral bones stacked one on top of the other, the sacrum, and five rubber-like discs separating the bones. These discs, initially 80% water, dry out as we age and tend to become more fragile. The vertebrae are attached to one another via posterior facet joints and are further held together with ligaments. A circle of bone forms the spinal canal through which the spinal cord runs giving off nerve roots (like local telephone lines from a trunk line) at each level of the spine. Mechanical or inflammatory problems that upset this delicately balanced arrangement of muscles, bones, joints, discs, ligaments, and nerves may cause back pain. LBP may come from muscle spasm, nerve irritation, joint inflammation or increases in disc pressure resulting in a rupture or bulging disc. In addition, bone problems such as fracture, osteoporosis or tumor may also lead to LBP. Occasionally, internal organ problems may cause referred back pain. For this reason, medical evaluation with careful history and physical examination is necessary to determine the cause of the pain.

Plain and special xrays (MRI, CT, myelogram, or bone scan) may be helpful in establishing a diagnosis. Laboratory tests can check for infection, cancer, Paget's disease and other medical causes of back pain. An EMG may help determine if there is damage to a nerve. LBP usually responds to rest, heat, anti-inflammatory agents, pain relievers and physical therapy. However, recent studies show that in mechanical LBP two days of bedrest may be sufficient. Exercises can be helpful in the management of longstanding LBP. Persistent LBP not responsive to conservative measures may be treated with epidural cortisone injections. Rarely, surgery may be required to relieve pressure from a large ruptured disc.

The patient can help control his or her risk for LBP by recognizing known pre-disposing factors. LBP tends to increase with age, especially in women, poor physical condition, marked obesity, and smoking. In fact, smokers have a 2-3 fold increase in the incidence of low back pain versus non-smokers. Occupations that require -2- repetitive motions and heavy lifting also increase the risk of LBP. This also applies to mothers who lift their young children frequently. Recognition of these factors and prevention of LBP is important. You can help prevent LBP by:

• lStaying physically fit with a program of general fitness with emphasis on aerobic conditioning and muscles that support the spine thus improving posture and gait
• Performing warm-up before and cool-down after exercise
• l Learning to match your lifting capacity to the task at hand; bending the wrong way to pick up a pencil puts up to 120 pounds of pressure on your low back
• l Use back rest and lumbar supports
• l Keep work table height at a comfortable level l Change your position regularly whether sitting or standing
• l Quit smoking
• l Reduce stress
  

A little attention can pay large dividends in a helping you and your back.

PROFILE
MARGARET M. DIECKHONER
OFFICE ADMINISTRATOR

Margaret Dieckhoner (pronounced Dee-cone-er) has been the Office Administrator at Arthritis & Rheumatism Associates since March, 1987. Lots of you have seen her passing by the front desk, or chatting with someone in a back hallway, but haven't known exactly who she is or what she does at ARA. This is our opportunity to introduce her.

In her role as Administrator, Margaret wears many hats. In general, she oversees the operation of the practice. More specifically, she is responsible for the financial health of our group - what comes in, and how it goes out; personnel - the hiring, training and overseeing of our growing staff; insurance - Medicare regulations, coding, managed care guidelines; the legal aspects of running a medical practice - patient records maintenance, insurance fraud and abuse, IRS and personnel law; and the day to day workings of the office - those myriad of details that must mesh smoothly to maintain efficiency.

When asked in a recent interview which aspect of her job she likes best, and which least, she responded with humor and without hesitation, "They are one and the same. What I like best is that my responsibilities are so varied. I like having lots of balls in the air at once. What I like least is that I always have so many balls in the air." Her real love, though, is people. Thus, she finds working in an environment where people - patients, physicians, staff - are the main focus of her day, a most remarkable and rewarding experience.

Margaret has a B.A. in both English and Social Work from Bowling Green State University, Bowling Green, Ohio. After graduation, she was a caseworker for the Child Welfare Board in Dayton, Ohio, followed by a position as caseworker for the American Red Cross in their "Service to Military Families" department in Albuquerque, New Mexico. She found casework both stimulating and demanding, but decided to put it aside while her children were young.

During this period, Margaret taught pre-school and engaged in multiple community and school volunteer programs. It was those volunteer efforts that caught the attention of a local dentist who was looking for someone to organize his practice. He made Margaret an offer, she accepted, and her career in health-care was launched.

Since that time, she has managed a number of medical and dental facilities. "It's a natural transition for me from the social work field", says Margaret. "Both require concern for people, being a problem-solver and an enabler. I am especially comfortable at Arthritis & Rheumatism Associates because everyone on the team shares that same philosophy. We all strive to be all those things to our patients every day."

BURKLAND PHYSICAL THERAPY
Begins Classes On "THE PRINCIPLES OF JOINT PROTECTION"

Burkland Physical Therapy, in conjunction with Arthritis & Rheumatism Associates, will begin monthly evening sessions relating to "The Principles of Joint Protection", on Wednesday, February 6th. Subsequent sessions will be held the first Wednesday of every month.

Patients with arthritis may accelerate damage to their joints even during routine daily activities. Simple repetitive motions performed improperly can be harmful. By understanding the principles of joint protection and the use of assistive devices it is possible to reduce everyday stresses. This in turn reduces pain and joint damage.

Sessions will assist patients in learning the fundamentals of:

• Good posture in sitting and standing for protection of the neck and back
• Good body mechanics in lifting and bending for protection of the neck and back
• Damaging stresses that affect hands and the assistive devices that can be used to alleviate these stresses
• Assistive devices that are helpful in relieving the stresses of activities of daily living
  

If you are interested in attending one of these sessions, and in learning how to play a more active role in the management of your arthritis, please ask your doctor for further details or contact Burkland Physical Therapy directly at 593-4444.

SEVERAL OF MY RELATIVES HAVE ARTHRITIS.
DOES THIS MEAN THAT I AM MORE LIKELY TO DEVELOP ARTHRITIS IN THE FUTURE?

The genetic predisposition to various forms of arthritis is currently under careful and intensive investigation. As has been discussed in several of the past issues of Rheumors, there are many types of "arthritis". Each of these forms of arthritis may turn out to have a different mode of genetic transmission. Current theory holds that the development of an inflammatory type of arthritis, such as rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome and others, likely require both a specific genetic makeup as well as contact with some unknown (or known) factor in the environment. Certain genes which predispose to specific types of arthritis have been elucidated. These include a gene called HLA-B27 which has been correlated with ankylosing spondylitis and a few other disorders, as well as a gene known as DR-4 which may predispose people to developing rheumatoid arthritis. Inheritance of these diseases cannot be traced directly in the way, for example, brown eyes can be followed from generation to generation. Nonetheless, it is fair to say that a strong family history of inflammatory arthritis does somewhat increase ones chances of developing a similar problem at some point in the future.

Evan L. Siegel, M.D.

I HAVE BEEN TOLD THAT WEARING A COPPER BRACELET WILL HELP MY ARTHRITIS,
OR EVEN WARD OFF FUTURE PROBLEMS WITH ARTHRITIS. IS THIS TRUE?

Copper bracelets, as well as many other nonconventional home remedies (Vitamin C, bee venom therapy, herbal medicines, cod-liver oil, etc.) have been tried by large numbers of arthritic patients at great expense, in the hope of improvement. Many of these claims have been researched in an attempt to prove medical benefit. None thus far have been shown to be effective. Although most of these unproven therapies are essentially non-toxic, some are associated with unacceptable side effect profiles. At best, use of these therapies may be expensive and ineffective, at worst they may be harmful or interfere with more accepted treatments. Therapy for arthritis should be carried out under the supervision of a qualified physician trained in the treatment of arthritis, and new or unusual therapies should be evaluated through recognized study protocols.

Evan L. Siegel, M.D.

WHAT ARE NSAIDS?
DO THEY HAVE SIDE EFFECTS?
CAN THEY HARM MY LIVER OR KIDNEYS?

Non-Steroidal Anti-Inflammatory Drugs form a class of medications referred to as NSAIDS. Aspirin, Motrin, Naprosyn, Feldene, Clinoril, Voltaren and Indocin are among the most commonly prescribed NSAIDS. All of these drugs are effective in the treatment of the various forms of arthritis. Certain diseases respond better to some of these agents than others. Likewise, some patients with the same illness do better on one drug than another. It may take trials with a few of these medicines before you and your doctor find the one that helps your condition best.

NSAIDS are usually very well tolerated. Like all medicines, they can have side effects in some patients. The most common side effects relate to stomach upset which may range from mild "indigestion" to ulcers and bleeding. Fortunately, bleeding is very rare. Certain precautions, however, are always advisable. Most important is to take these medications with food, never on an empty stomach. Secondly, mixing NSAIDS with alcohol can be very dangerous. We usually recommend periodic blood checkups to monitor for anemia due to slow blood loss from the stomach or intestines.

Serious liver damage is rarely encountered. Kidney problems are also infrequently seen, but seem to occur most commonly in people with pre-existing kidney or heart problems. Liver and kidney function disturbances caused by NSAIDS can be checked with blood testing. The NSAID you take may determine how often you need to be monitored for such effects. Your doctor can provide you with specific information about the drug you are taking.

Herbert S. B. Baraf, M.D.

WHEN I HAVE BACK OR NECK PAIN WHAT IS BETTER, HEAT OR ICE?

That all depends on you. There really is no good answer. Heat, particularly moist heat, may be soothing and helpful in conditions characterized by muscle spasm. Ice can provide an anesthetic affect and thereby lessen pain. In conditions caused by an injury or associated with sudden swelling, ice may be preferable. Sometimes it pays to try both heat and ice applications and decide for yourself which is best!

Herbert S. B. Baraf, M.D.

THE PERILS OF WINTER
by Norman S. Koval, M.D.

The warm days of autumn with the splendor of leaves changing colors have passed. Winter is upon us, and its cold temperature and inclement conditions will affect our arthritis patients.

Raynaud's phenomenon, a three-color change of the hands and/or feet (white to bluish to red) precipitated by exposure to cold, frequently worsens in winter. Staying warm by dressing in layers, wearing gloves and avoiding contact with cold objects helps to prevent Raynaud's and its discomfort. Skin lubrication will help prevent ulcerations. Avoidance of cigarette smoking and alcohol consumption will also help.

Sunshine supplied Vitamin D will be missed by many of our elderly patients who stay indoors throughout the winter, thus increasing their risk for Vitamin D deficiency. Vitamin D supplements will help to promote calcium absorption through the intestinal tract, preventing loss of bone and therefore reducing the chances of osteoporosis.

Sjogren's syndrome, a connective tissue disorder characterized by dryness of the eyes and mouth, is often aggravated during the winter months. Heating systems without proper humidification will promote dryness of the nasal lining leading to nosebleeds, increased respiratory complications with cough and thickened mucous and dryness of the eyes. Proper humidification and appropriate eye lubricants (artificial tears) will reduce eye dryness. Artificial saliva or frequent sips of water will help relieve mouth dryness. Salt water soaks to the nasal passages are also helpful in reducing nasal irritation.

Winter storms present the hazards of snow and ice, increasing the risk of falls to everyone. Patients with brittle bones (osteoporosis) are especially at risk for fractures from even minor falls. Extreme caution is the rule to prevent falls in the coming inclement weather. Viral infections are more frequent during winter. Some viruses may be associated with arthritis symptoms. These types of viruses are called "arthritogenic" and may produce temporary joint symptoms lasting up to twelve weeks. Though viruses are often unavoidable, prevention may be best achieved with the time honored approach of proper rest, nutrition and warm dress.

With winter upon us . . . . . can spring be far behind???