Back pain: the latest guidelines

In the space of three days, a woman told me her father had committed suicide because of back pain; I visited a friend recuperating from an eight-hour spine surgery; I had lunch with a friend who could barely sit through our meal because of the pain from botched back surgery 20 years ago. At about the same time, the American College of Physicians published guidelines for lower back pain that says, essentially, to stay active, wait it out, and believe it can get better. They add that if the pain lasts for less than four weeks and does not radiate down the leg, there’s no need to see a doctor. They also say that scans, such as MRIs for diagnosis are useless because results are misleading.

Naturally, I subscribe to these new guidelines. On the other hand, I’ve never had serious back pain—which makes it easy for me to agree. If, like my friend recovering from surgery, the pain had lasted for years, ran down the leg, and showed serious vertebra displacement, I might opt for surgery also. This vertebra doesn’t look like it will fix itself! Another friend who has had three fusions over the course of 15 years reports complete success. But another reports nerve damage and lingering pain as a result of surgery.

The new guidelines are a response to the epidemic of opioid use and the recommendations are aimed at discouraging doctors from prescribing painkillers—even over-the-counter painkillers. Readers of the guidelines, as reported in The New York Times, had plenty to say in their online comments. They seemed to be evenly divided between those who were incensed at the idea of curtailing their pain medications and those who provided advice to the pain sufferers. Examples of the former group: “I need opiates and muscle relaxers in order to function;” “Walk a mile in my shoes or in my case pajamas.” The advice offered by the latter group included ice, stretching, probiotics, drinking a lot of water, marijuana, low acid diet, divorce and, my favorite, chewing your food 40 times. None reported surgery as having eliminated their pain.

In tallying the successes and failures of spine surgeries among my friends, I would lean towards waiting it out. But then, I've never walked a mile in a sufferer's pajamas.

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Bad bowels

I’ve been focused on bowels lately (see last week's post on the brain in your gut). It’s not something one brings up in polite conversation, but I think plenty of people suffer in silence—or maybe not. Irritable bowel syndrome, for one, accounts for about three and a half million visits to doctors every year, and doctors may not always be sympathetic. In fact, some doctors think their patients are mentally unbalanced. I read about a doctor-in-training who said he “hated” people who were suffering from functional bowel disease because they were so fixated on their intestines.

But I am sympathetic. Of the bowel diseases I’ve researched, the causes are not known and there is no cure for them, although they can go into remission. As a rule, their symptoms all include diarrhea and pain, but can also include bleeding, bloating, and constipation. Here are the four I have studied:

• Irritable bowel syndrome (IBS): The digestive system looks normal and there is no diagnostic test for it, which is why it’s called a “functional” bowel disease. It does not cause inflammation, ulcers, or other damage to the bowel. At any given time, about 20 percent of Americans are made miserable by IBS.
• Microscopic colitis: Includes collagenous colitis and lymphocytic colitis, both of which cause inflammation of the colon. Both are characterized by abnormalities in the cells that line the intestine—but each in its own way. It does not increase a person's risk of getting colon cancer and is not related to ulcerative colitis or Crohn’s disease.
• Ulcerative colitis: Causes long-lasting inflammation and ulcers in the colon, affecting the innermost lining. In severe cases, doctors remove the colon.
• Crohn’s disease: Is different from the other gut diseases in that it can appear anywhere in the intestinal tract, from the mouth to the anus, although it most commonly appears at the end of the small intestine where it joins the large intestines.

It's hard not to be fixated on your intestines when they're not working right!

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The "brain" in your gut can affect your mood

Your gut really does have a brain of sorts. It’s called the enteric brain and contains an extensive network of neurons—more neurons than in either the spinal cord or peripheral nervous system. Not only does your enteric brain handle digestion or inflict the occasional nervous pang, it partly determines your mental state and plays key roles in certain diseases. 

Your gut's brain is in constant contact with your head brain. About 90 percent the nerve fibers in your vagus nerve is carrying information from the gut to the brain and not the other way around. In fact, a big part of your emotions are influenced by nerves in your gut. Butterflies in your stomach is a simple example. But everyday emotional well-being may rely on the constant messages going from your gut brain to your head brain.

Ninety-five percent of your body’s serotonin is located in your bowels. Serotonin is a neurotransmitter and hormone that is involved in the transmission of nerve impulses and is key to mood regulation including feelings of happiness. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) increase serotonin levels—but can also provoke gut issues such as irritable bowel syndrome. Too much serotonin may also play a role in osteoporosis. But too little can make you depressed. It’s quite tricky.

Recently, scientists have discovered that the microbes in your gut are important for the production of serotonin. In fact, the cells that produce serotonin depend on microbes to manufacture it. Researchers have found that changing gut microbes in mice alters their behavior. In one experiment, researchers were trying to pinpoint the causes of irritable bowel syndrome, which is often accompanied by anxiety and depression. By introducing fecal samples of people with IBS into the guts of germ-free mice, the mice began demonstrating symptoms of IBS, including anxiety.

I don’t know what you can do with this information. It just seems important to me.

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Pre-diabetes: another thing to worry about

There’s a media campaign, initiated by the CDC, to make you worry about being “pre-diabetic.” The campaign has a website (https://doihaveprediabetes.org/) that includes a test to determine if you are either at “low risk” or “high risk” for getting diabetes. The test is easy and the user interface is good. It asks you questions about age, gender, race, whether you’ve been diagnosed with high blood pressure, whether you’re physically active, and so forth. I tried taking the test multiple times giving it different answers—specifically weight and the blood pressure question. If I told it my true weight and that I’d been diagnosed with high blood pressure (which I haven’t), the conclusion was that I was high risk. By leaving out the high blood pressure diagnosis, the conclusion was that I was at low risk.

Not everyone approves of this pre-diabetes awareness campaign. One doctor, for example, says that the test is an example of “medicalization,” that is, defining something previously considered normal as a disease that requires attention, monitoring, and treatment. Another says “…this campaign will make them [older people] feel sick.” Of course, I agree.

If you have checkups, you have probably had your blood glucose tested. According to the CDC, a reading that’s over 100mg/dL but less than 125, indicates that you are pre-diabetic. (But according to the World Health Organization a reading of over 110, not 100, makes you pre-diabetic.)

My husband, whose reading is 109, is considered pre-diabetic and has had this diagnosis for 20-or so years. The advice for pre-diabetic people is to “eat right and exercise.” While I am usually quite snarky about this sort of thing, including diagnoses of “pre” anything, we do take my husband’s blood glucose reading seriously because his family has a history of diabetes. We have been eating low carb meals for 20 to 30 years. For example, I think twice before adding a little rice to chicken soup. Toast for breakfast is a special Sunday treat. The CDC says that 15 to 30 percent of people with prediabetes progress to diabetes within five years. My husband is fine.

As a rule, I think that giving people a “pre” anything diagnosis just adds to over-medicalization. But I’ll admit to this one: we’re all pre-dead.

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