"Defeat Chronic Pain Now:" Book Review

I recently found Defeat Chronic Pain Now at the library and read the first chapter last night. I was happy to see that the topic of chapter one is low back pain, which is terribly common, especially among sufferers of chronic pain. It was even better reading that the authors (Bradley Galer, MD and Charles Argoff, MD) recommend Physical Therapy within the first few lines!

Myofascial Cause of Back Pain?

They talked a lot about myofascial pain and trigger points as a main cause of low back pain (and referred leg pain), which I do not completely agree with. Being trained in the McKenzie method of Physical Therapy, which involves mechanical treatment of back pain (or moving the spine in specific directions in order to decrease pain), I have found that trigger points are not a great factor in treating low back pain.

Combining Treatments for Back Pain

I agree with Galer and Argoff about the need for a combination approach to treatment, which often includes medicine and "Active PT," the term they use to describe Physical Therapy that involves active exercise and movement to treat the painful condition. They discuss various medicines used for back pain and their benefits. 

Work Injuries and Chronic Back Pain

Page 15 briefly talks about chronic back pain related to being unhappy at work. There is research that shows a correlation between chronic back pain among those who are unsatisfied in their jobs. This is among individuals who have sustained a back injury at work. I totally disagree with their discussion of this research. Their second paragraph states that if you do not like your job, you are at risk for chronic low back pain. Research does not say why there is a correlation between work satisfaction and back pain. It only shows if there is a correlation among the researched population. Clearly, the population being studied included only those with work-related injuries. There is no endnote identified about this research, so it is hard to clarify this matter.  

I have never treated someone who developed low back pain because he/she was unhappy at work. Low back pain usually has a specific cause and can be treated very effectively. Individuals with work-related back injuries are a completely different demographic than the general population and any research involving them should not be applied to those without work-related back injuries.

Active Physical Therapy for Low Back Pain

Galer and Argoff list some other possible treatment options for chronic low back pain and briefly discuss their benefits and precautions. Again, they include Active Physical Therapy at the top of the list, which I truly appreciate and also highly recommend!

One statement I must rebuttal is: "Many--if not most--physical therapists are trained in only passive, 'feel good' therapies, such as warm baths, gentle massage, and ultrasound" (page 22). This may have been more true 50 or 30 years ago but not anymore. Passive modalities such as these were only part of one class out of my three years of graduate school, so clearly we are trained in much more than that. Otherwise our "Active PT" would not be so highly recommended throughout chapter 1.

Recommended Book for Chronic Pain?

So do I recommend this book? Based on chapter 1, yes. It is worth reading if you have chronic low back pain. But you may also want to look at some other back books to see how their treatment approach is different (such as Robin McKenzie's Treat Your Own Back).

Reference: Galer BS, Argoff CE. Defeat Chronic Pain Now! 2010: Fair Winds Press. Chapter 1: Beating Your Back Pain.

Mattress Firmness And Low Back Pain

Firm Mattress and Low Back Pain? Traditionally, you have heard that a firm mattress is the best for your back. I have known many individuals that have less back pain when sleeping on a very firm bed or even on the floor instead of a soft bed. Those are the same people that do not lie in bed to sleep more than 6-8 hours, even on Saturday morning! They do so after finding that sleeping in too long increases their low back pain.

Soft Mattress and Low Back Pain? There are also many individuals with low back pain that sleep on various types of mattresses that do not aggravate their backs. It would be extremely obvious to me if softer mattresses were the culprit of back issues because all my patients over the years would have reported this to me. So I cannot say that softer mattresses are bad. 

There is one statement that I have heard repeatedly from patients: "I need to replace my bed because it is old and I sink into it too much." Clearly, if you sink down into the mattress excessively, your spine is likely being pushed out of alignment (so your back is not in a comfortable, neutral resting position at night). On the other hand, a too-firm mattress could also potentially put your spine out of alignment if your hips or buttocks cannot sink in sufficiently.

Research on Mattress Firmness and Back Pain:

I recently found one research article about this topic. The study included over 300 individuals with chronic low back pain, and they were divided into two groups: firm mattress or medium firm mattress. To my surprise, the study showed a better response to medium-firm than firm mattresses. Those in the medium-firm mattress group reported better outcomes about their back pain during various daily tasks than the firm mattress group.

Conclusion: Despite common recommendations, there is not overwhelming research that associates firm mattresses with less low back pain. Clearly, there is at least one study (see above) that links a medium-firm mattress with better back outcomes than a firm one. So find what works for you. Take the time to try out a lot of beds, and save up so you can afford the one you prefer, as some are very expensive. If you shop around, you should be able to find a good-quality name brand for $300-$400 (which includes a 10-year warranty).

Specific Mattresses with Good Back Support: Out of my recent personal experience of mattress shopping, here are some mattresses that I liked. Keep in mind that there is a wide range of mattresses within each name on this list, so you will need to shop around to find the one you prefer. Higher-quality mattresses come with longer warranties, so it may be worth it to pay more for a longer-lasting mattress.
1. Sealy Posturepedic
2. Simmons Beautyrest
3. Simmons Beautysleep (a cheaper option)

Reference: Kovacs FM, Abraira V, Pena A, et al. "Effect of firmness of mattress on chronic non-specific low back pain." Evid Based Med 2004;9: 119.

4 Components of Weight Loss

            It is never too early or late to lose weight if you are overweight or obese. Even if you became obese at a young age, you can change habits now and lose weight! It takes determination, discipline and hard work, but the rewards are countless! One of the biggest benefits of weight loss is having less pain, including back pain. Moreover, it is easier to prevent obesity than to treat it. So if you have found yourself 10 or 20 lbs overweight, start working to reverse the trend. Otherwise that could turn to 50 or 100 excess pounds that you never expected to have.

4 Components of Weight Loss  

1. Change in mindset. Admit that food controls you and recognize why you overeat. Until you know what your problem is, you cannot fix it. 

2. Change in activity level. You must increase your daily amount of activity and exercise in order to lose weight. No pill or diet by itself can replace the benefits of regular exercise. 

3. Change in eating habits. You cannot eat the same amount or kinds of foods that you have been eating and lose weight. Look at your eating habits and start to modify them. 

4. Perseverance over time. There is no easy way to lose a lot of weight, no matter what the ads may say. It takes time and hard work. Do not give up! Keep working at it and you will succeed. Find the help you need, whether it is an exercise partner, a weight loss group, a gym membership or an appointment with a nutritionist or dietitian. 

Most importantly, do not leave out any of these four components or you are less likely to get the weight off and keep it off.  Do not forget to consult your physician about your weight, in case it is related to a medical problem.

Additional reading on WEIGHT LOSS:

http://thinklikeapt.blogspot.com/2012/04/weight-loss-perseverance.html

Recommended Weight Gain During Pregnancy

Table 1. Institute of Medicine Weight Gain Recommendations for Pregnancy
Prepregnancy Weight Category	Body Mass Index*	Recommended Range of Total Weight (lb)	Recommended Rates of Weight Gain† in the Second and Third Trimesters (lb) (Mean Range [lb/wk])
Underweight	Less than 18.5	28–40	1 (1–1.3)
Normal Weight	18.5–24.9	25–35	1 (0.8–1)
Overweight	25–29.9	15–25	0.6 (0.5–0.7)
Obese (includes all classes)	30 and greater	11–20	0.5 (0.4–0.6)
*Body mass index is calculated as weight in kilograms divided by height in meters squared or as weight in pounds multiplied by 703 divided by height in inches. †Calculations assume a 1.1–4.4 lb weight gain in the first trimester. Modified from Institute of Medicine (US). Weight gain during pregnancy: reexamining the guidelines. Washington, DC. National Academies Press; 2009. ©2009 National Academy of Sciences.

Source: The American College of Obstetricians and Gynecologists. "Committee Opinion: Weight Gain During Pregnancy." Number 548. January 2013.

Normal Weight: It is clear that there is a range of recommended pregnancy weight gain based on your pre-pregnancy weight. Pregnant women always hear the general statement that 25-35 pounds of weight gain is the recommended amount, but based on the above chart, that is only the case for women who were "normal weight" prior to pregnancy.

Underweight: Underweight women are recommended to gain more, even up to 40 pounds. This may be harder for you than your "normal" and "overweight" counterparts because likely you do not overeat nor do you gain weight easily. Also, it may be hard for you to gain enough weight because you may be concerned about losing the weight after Baby is born. You need to be more inintentional about how to increase calories in order to gain sufficient weight during these 40 weeks. Try not to worry too much about "getting fat" because pregnancy is the one time in your life it is actually good to gain weight!

Overweight: The recommended range for you to gain is lower than the "normal" and "underweight" categories, so work with your OB to form a strategy for proper weight gain. Otherwise, you may gain too much and risk having difficulty losing that weight postpartum. This may be difficult if you generally enjoy overeating and are indulging yourself even more now that you are pregnant. Or if you generally diet to lose weight, do not be afraid to gain the recommended 15-25 pounds now that you are pregnant.

Obese: Unfortunately, you have the lowest recommended amount to gain compared to the other groups of women. The only way to successfully gain under 20 pounds is to have a plan. Be sure that your plan includes accountability in order to ensure you are following through on your OB's guidelines. Gaining excessive pregnancy weight would only contribute further to your obesity and make your long term weight goals harder to achieve. Be sure to get specific advice from your doctor about how to keep your weight gain in the recommended range of 11-20 pounds.

Postpartum Weight Loss: How To Lose Baby Weight Quickly

Photo: Cornell University Library

2 ways to ensure postpartum weight loss and to return to pre-pregnancy weight are:

1. Do not gain excessive amounts of weight during pregnancy.

2. Breastfeed for at least 6 months, and ideally for 12+ months.

According to a research article in The American Journal of Clinical Nutrition, among a Danish population, postpartum weight loss was associated with breastfeeding. That population was selected because Danish women tend to breastfeed more and for a longer period of time than in other countries. The two major factors they considered were pregnancy weight gain and breastfeeding.

Is pregnancy weight gain correlated with postpartum weight retention? Researchers found that more weight gain during pregnancy was associated with more postpartum weight retention. In other words, the more weight they gained, the more weight they retained afterwards. This was true after 6 and 18 months postpartum.

Is breastfeeding correlated with postpartum weight retention? Researchers found that breastfeeding was associated with more postpartum weight loss for all groups of women except the heaviest.

There are obviously many strategies for postpartum weight loss, including healthy diet, exercise, belly binding, etc, but breastfeeding alone may be the single most effective way to lose your baby weight! Personally, I have found this to be true three times in the past four years. Each pregnancy, I gained ~35 pounds, and within 6-9 months (while breastfeeding) I returned to pre-pregnancy weight.

The women I know who have lost their baby weight in less than 6 months all gained much less weight than I did. For example, a friend who gained 15 pounds during pregnancy lost it within 1-2 months. A friend who gained 20-25 pounds lost it within a few months. Some women even lose it immediately, within days or weeks.

Do not fret if you gained a lot during pregnancy because breastfeeding can help you lose that weight. You just may have to work harder to lose the weight or it may take longer for you. Clearly, there are times when your OB may recommend you gain more or less weight during pregnancy, based on many clinical factors. Remember that your baby's health is more important than your size, so be sure to follow doctor's orders.

Tune in tomorrow for a discussion about how much weight you should gain during pregnancy based on your pre-pregnancy size.


Reference:  Baker JL, Gamborg M, Heitmann BL, Lissner L, Sorensen TIA, Rasmussen KM. "Breastfeeding Reduces Postpartum Weight Retention." American Journal of Clinical Nutrition. Dec 2008. Vol 88. No 6. 1543-1551.