Chronic back pain and the capacity to live religious life

Chronic back pain and the capacity to live religious life

By Daniel Hurley M.D.

“Back pain” by definition refers to what most people would consider the low back, and thus is a rather specific malady and complaint. The span of medical diagnoses affecting the spine, however, can affect absolutely every part of the body. Chiropractors have long asserted that they can relieve a myriad of internal organ dysfunctions by simple targeted adjustments to the spine. This claim has been based on the fact that the body parts receive innervation from various locations in the spine. Well, it is not quite that simple, but let us look at how the spine is organized in the first place, how certain disease states or degenerative conditions or injuries manifest themselves, and how these may affect one’s life activities or even one’s vocation.

Basic anatomy of the spine

Essentially the spine is a flexible structure of stacked cylindrical bones, each separated by a rubbery cushion called a disc, as opposed to being one long stiff bone, such as in the thigh or the upper arm. A solid bone would be good for skeletal support and muscle anchoring roles, but would not be all that helpful to the acts of moving, bending, twisting or reaching. The price for movement, however, is wear and tear and stress points for injury.

Looking at the spine from the side, one sees that it is shaped as a subtle double “s” curve. The neck and low back each should normally curve inward. The middle spine, in the region of the ribs and shoulder blades, and the very bottom region, below the belt to the tailbone, each curve outward. Extremes of either can occur with disease, injury or age and put overloads of stress on the joints, nerves and muscles.

The classic “poor posture” position usually involves sitting with head forward, rounded shoulders, and slumped back, such that the “s” shape of the spine is turned into a big “c” shape, which strains the low back and neck. In older women it risks thoracic compression fractures, and in everyone it eventually produces the stiff, hunched, smaller “little old man” or “little old lady.” On the other hand, overweight individuals with protuberant bellies have excess arching in the low back, straining the muscles and the small joints in the back of the lower spine.

The vertebral column is the bony component of the spine complex, and can be imagined as a stack of padlocks, with the ring portion towards the back, and in between each of the solid round portions the cushion of the disc. The rings in the back of this stack all line up one on top of the other to form the spinal canal, and it is through this vertical column that the spinal cord runs from its origin at the base of the skull down to the bottom of the spine in the sacrum, where by that point it is made up of only a few remaining strands of nerves. The rest of the nerve fibers have already exited the spinal canal along the way to reach the rest of the body.

The spine is composed of three regions—the neck, thoracic region and lumbar region—each of which contains segmental levels of bone and discs. Between each of these segments along the course of the spine are pairs of exit tunnels, one each to the right and left, which allow individual nerves to leave the spinal canal and reach various specifically mapped out parts of the body. These nerves have “motor” fibers which send instructions to various muscles, and they have “sensory” fibers which bring in sensation signals of various types from specific areas of the body.

Muscles and ligaments attach to the spine and form both the support structure of the spine itself, as well as origins for the muscles of the shoulders and the hips, and head. The inner lining of the spinal canal consists of vertical cylindrical tubes surrounding the spinal cord from top to bottom. Filled with fat, fluid and blood vessels, these envelopes serve to cushion and nourish the spinal cord and delicate nerve structures. One can move and bend and twist without rubbing the nerves and spinal cord against hard rough edges.

What can go wrong with the spine

Now that you have an overall idea of the anatomy of the spine, you can better understand why it can be so vulnerable to pain and affect the body from head to fingertips to toes. It is a flexible rod made up of multiple movable segments, on top of which sits a rather heavy head (the weight of a small bowling ball). More often than not, we keep our spines in a posture of leaning slightly forward, since our eyes and arms—and thus our actions and tendencies—all focus forward and downward. This then places extra pressure on the discs, while stretching and continuously straining the muscles and ligaments of the back of the spine. The discs have very tough outer fibers, being like miniature tires lying on their sides between the bones. Inside they have a thick gel which allows for a springy-ness and the ability of the spinal bones to tilt on each other and absorb compression. On the other hand, if too much pressure is loaded onto a particular disc, this gel can burst through a weakened spot in the outer “tread” of the disc—this is a herniated disc. Often enough this occurs right where there happens to be a nerve exiting its tiny tunnel, leading to the phenomenon we know as a pinched nerve, sciatica in the lumbar region, or radiculopathy in general.

Over time all discs wear down, much as break pads in a car or sponges in the kitchen. When this occurs, the little guiding, gliding facet joints in the back of the spine can become more stressed and altered in shape, leading to facet degeneration or arthritis. When the discs and facets and bones all change their shapes due to wear and tear, they can take up space in the areas where the nerves are supposed to be, and this narrowing of the nerve spaces is called spinal stenosis. Shrinking of the discs also leads to the forward bent posture of the elderly, and sometimes a sideways curving called scoliosis, which can be painful also.

Impact of spinal disorders on everyday life

Here are some quick rules of thumb for how problems with these spinal conditions may manifest themselves, and how they may affect what one can and cannot tolerate with regard to activities, work, self-care or recreation. Disc problems in the low back are generally worse in sitting or bending forward (in the neck often more with turning or leaning back). Facet joints are usually more painful with standing or leaning back or lying on one’s stomach. Stenosis is usually worse with standing or walking. Muscles can hurt in any position, but more often when they are being strained in the leaning forward position or coming back up from bending maneuvers.

Thus, someone with a “discogenic” pain problem is usually worse in what others would consider a restful position, i.e., sitting—in a car, at a desk, in a movie or on a soft, poorly supportive couch or chair. Facet arthritis makes it hard to do anything requiring a lot of prolonged standing or repetitive side-to-side twisting. Spinal stenosis can severely limit one’s ability to walk even half a block at a time. Muscle pain and disc pain can make it nearly impossible to sustain simple, minimal forward-bent positions such as in cooking, doing the dishes, vacuuming, loading and unloading the trunk of a car or a washing machine. Spinal disorders in the neck can lead to severe shoulder and upper back pain, as well as terrible, nauseating, blinding headaches often misdiagnosed and repeatedly treated as migraines (usually unsuccessfully). This can make simple computer work or talking on the phone continuously very difficult without proper ergonomics.

A key issue in the medical evaluation of spinal disorders is to ascertain whether there is ongoing nerve injury or pressure, as opposed to more musculo-skeletal mechanical pain. Nerve damage usually calls for a more aggressive medical approach. “Pinched nerves” manifest as pain or electrical tingling or numbness or weakness in the arms or legs, depending on the nerve pinched. Spinal cord pressure, when occurring over time as a result of stenosis, can lead to tingling and clumsiness of both hands, balance problems, and spasticity or heaviness of the legs. Acute bowel and bladder dysfunctions are considered spinal emergencies.

Treatment options, coping with pain

Treatments for spinal disorders run the gamut from rest, ice and heat to physical treatments such as physical therapy, chiropractic and massage. There are, of course, the myriad of anti-inflammatory, pain, muscle relaxant and nerve medicines, in addition to all the exercise and complementary care options. Almost any part of the spine can be reached with an injection of medicine or with more intricate catheter devices. And then there is surgery, which either serves to decompress (open up) a tight space or to stabilize a loose disc or joint region. There are now artificial discs for some people who qualify for this option. Being limber, being strong and being of relatively normal body weight with good posture are certainly helpful starting points for everyone.

Generally disc herniations, pinched nerves and muscle strains are problems of 20-to-50-year-olds. Degenerative discs and multiple-level fusion surgeries are problems of people in their 40s and 50s, and severe arthritis and spinal stenosis are problems of those in their 60s or older. These statements are, of course, major generalizations, but when wondering how spine disorders may affect a community of people committed to long term co-existence, awareness of some trends can be enlightening.

Obviously any malady has the capacity to interfere with our schedules, routines or plans, along with our physical and mental states of well-being. Spinal problems mostly affect us through pain, but a significant minority of people are also affected through weakness, loss of normal sensation or loss of basic bodily functions. The challenge of pain is that it is invisible, intimate, intensely personal and subjective. Pain tolerance is a complex concept going far beyond the technicalities of biology and nerve endings. It is manifested in the context of culture, family history, incentives and disincentives, spiritual motivation, etc. In religious circles, many have been taught the principle of sacrifice and “offering it up” when it comes to pain, disappointment, loss and suffering. In cultural or gender terms, some have been taught to be tough, silent and “take it like a man,” while others are used to expressing any type of disease vocally and overtly in order to elicit the care and attention felt to be needed and deserved.

Almost all activities can be better tolerated by changes in position, arrangements of breaks, and alternation of different types of tasks. Medications can provide amazing relief but can be limiting due to their side effects. For example, muscle relaxants can make one drowsy. They are better taken at night. Some strong pain medicines can also make one drowsy, as well as constipated. New medicines are now available to naturally help keep one alert during the day. There are medicines which contain caffeine which can be used during the day, while the more sedating ones can be used at night.

Strong pain medicines, unlike alcohol, which affects judgment and reaction time, can be used and still allow one to drive. This must be done with caution and with the awareness that one is responsible for one’s actions behind the wheel. The longer the list of one’s medicines for all one’s conditions, the more the possible combined side effects.

Many people worry about becoming addicted to pain medicines. Addiction is often a consequence of a tendency to look for quick fixes, find external solutions to one’s problems, and avoid of any sense of pain or even emotional discomfort. Chronic smokers and alcoholics have higher risks of becoming addicted to narcotic (opiate) pain medicines if not watched closely by their physicians. Nearly everyone will become somewhat “physiologically dependent” on opiates if they take them for more than a month or two. This just means that one should not stop them “cold turkey” without consulting one’s physician and that, over time, one might find that higher doses are needed to maintain pain relief. The physician and patient must maintain mutual close and honest monitoring of such situations. Members of communities must resist the urge to judge another’s pain tolerance, while at the same time being responsible in noticing whether a fellow member is becoming too dysfunctional or focused purely on a drug-based approach to pain management. Vocation directors evaluating a person with spinal problems who uses medication for pain relief might want to discuss these matters in detail. The vocation director might ask an applicant if he or she has tried other forms of pain management apart from drugs. Is the person open to alternatives? Who is monitoring him or her? What side effects does the current drug treatment have? Evasive answers could indicate a problem.

Injections, usually consisting of a steroid type medicine and local anesthetic, can be used to manage spine pain. Epidural steroid injections are most often used for pinched nerves or spinal stenosis. Facet injections are used for arthritis. Muscle trigger point or botox injections are used for chronic muscle or soft tissue pain. Newer heat based treatments for joints and discs can serve to extend the relief obtained when medicine injections are good but not long-lasting. Most spine injections are now done with x-ray (fluoroscopic) guidance, and, if necessary, with some light sedation. Most low back injections are tolerated with just local anesthetic however.

Spine injections can be spaced out every two-to-four months, especially in older people, if that is the medical treatment most effective for a particular person. One can return to regular activity within one day of most spine injections. A younger person cannot plan on using steroid injections every two-to-four months indefinitely and so must seek out other effective alternatives. Physical and occupational therapy can dramatically impact how much more functional an individual can be through direct pain-relief techniques, coaching on stretches and exercises, and sometimes amazingly simple changes in body mechanics and the use of adaptive devices.

Impact on community and ministry

When people who have spinal problems live in a religious community, the way they handle pain and dysfunction, and the way they express pain and communicate their needs impacts the lives, routines and duties of the rest of the community. Some bear up as soldiers, while others become “lame” and “paralyzed” by sometimes the smallest of discomforts. Vocation ministers would do well to understand where on this continuum a candidate with chronic pain falls. They may become aware of this only by spending time with the prospective member, living and working with the person. When looking at community life, those with ongoing back pain must be responsible—to some degree—for their duties to others in spite of their own discomforts, while the community is responsible for caring for members who just can’t keep up anymore. When individuals carry certain diagnoses, it is helpful to be aware of some of the true, inherent limitations as well as what may allow someone to be more functional in spite of a spinal disorder. For vocation ministers this means good communication with medical experts is essential.

Living in community requires different people to handle different tasks for the benefit of all. If a person with spinal disorders is responsible for upkeep of a home or landscape, body mechanics and pacing will be key. Those with herniated discs that worsen with bending and lifting probably will have a harder time. Those with stenosis or facet pain can often bend without problems. Those whose jobs or duties require lots of walking or prolonged standing likely will not do well if they have severe spinal stenosis or facet joint arthritis. Those with severe headaches and shoulder pain due to neck problems will probably need breaks from constant computer work or from situations requiring lots of interactions with others in face-to-face contexts and expectations of sustained pleasant moods.

Some may find their pain worst first thing in the morning and may take longer to get “oiled up” and moving, taking pain medicines right out of bed. They need to do a regular stretching routine at night and in the morning and would do well to take a muscle relaxant, pain medicine or anti-inflammatory medicine before going to bed. If sleep is fitful, sometimes antidepressant medicines are very effective for both pain relief and sleep, in addition to decreasing the depression and low energy that comes from chronic pain and poor sleep.

Others get worse as the day goes on and fatigue in their activities and pain tolerance by late morning and again into late afternoon. They must schedule activities in short task formats and use common sense in not overloading themselves with back-to-back commitments. Such self-induced demands will only backfire. They need to do stretches, meditation, centering prayer or stress relief exercises at regular intervals. A brief nap is simple and effective for many. Time has to be put aside for physical therapy treatments when they are called for. Massage therapy, thought to be a luxury by many, is often a rejuvenating saving hour taken out of one’s schedule every one or two weeks if that is what keeps muscles less achy and stiff.

Acupuncture works for many people, but it is an entire system and approach of care, not merely the one-or-two session quick fix that we Americans often seek. Chiropractic adjustments are good when this is the modality that provides relief of intermittent acute episodes of pain or lack of mobility. Long-term weekly into monthly adjustment schedules are, by definition, not really exhibiting lasting effectiveness. One should usually at least seek an evaluation with a spine specialist physician and physical therapist who may design a more active, less passive approach to diagnosing and treating the problem at hand. One should learn as much self-care as possible and beware of any caregiver— physician, physical therapist, chiropractor, acupuncturist— who merely runs on and on with frequent, but ineffective treatment approaches.

There is the very real discernment of determining whether one goes on by just “offering it up.” That is the case when the issue is one of pain, not of neurologic injury in the context of spine disease. Weakness, numbness and loss of coordination, bowel or bladder function are urgent signals that one needs medical attention. God does not ask us to be foolish in the care of our body temples.

Pain, in the end, all too often does have to be borne and suffered, but there are many ways to be assisted in managing pain. Simply “being the martyr” does not really help anyone if one’s behavior also irritates and impacts others in one’s community in a negative way. Jesus was quite practical in many of his lessons and his actions. We are called to seek out the help and expertise made available to us in the gifts of those around us. God may be asking you to seek out relief so that you can be of better service to others. God asks others to seek you out to help you, and asks you to be open and humble and gracious enough to receive that help.

Despite the wonderful intentions of those who want to live lives of service, sometimes pain interferes too greatly to adequately live such a vocation. Vocation ministers are called on to wisely assess the capacities of applicants with spinal disorders. It’s important to consult with medical professionals to get a full picture of such applicants’ abilities, treatment and prognosis. Hopefully this article has served as a primer for vocation ministers to understand chronic back pain and better discern whether an applicant with this condition can contribute and thrive in a religious community.

Daniel Hurley, M.D. is a board certified spine, pain and disability specialist in the field of physiatry, or physical medicine and rehabilitation. He is a graduate of Harvard University and University of Cincinnati College of Medicine. He did his residency training at the Rehabilitation Institute of Chicago and presently practices as a member of the Chicago Institute of Neurosurgery and Neuroresearch. Dr. Hurley recently published the book, Facing Pain, Finding Hope: A Physician Examines Pain, Faith and the Healing Stories of Jesus (Loyola Press).



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