Welcome to the Feldenkrais Summit, Move Better, Feel Better. And we’re on our track dealing with different kinds of physical challenges. And I’m very excited to be able to introduce you today to Mercedes Von Deck. Not only is she an orthopedic surgeon who graduated from Harvard Medical School, but she has degrees in art history and French. She’s a ballroom dancer, she runs Ashtanga yoga .Mercedes has kind of lived the dream in so many ways, and yet has taken all of these different influences in her life and chosen to kind of channel it towards exploring the Feldenkrais Method® and how it can help people with injuries and of course, applying it to all the different things that she does. Feldenkrais with dance, Feldenkrais with yoga, and today we’re going to be talking about back pain and how we can use the Feldenkrais Method to help ourselves as well as learn a lot about some of the causes of back pain and ways that we can address in very practical and very empowering ways.
How Mercedes Von Deck started her career as Feldenkrais Practitioner
Mercedes Von Deck:
So I first learned about the Feldenkrais Method in college when I was taking modern dance and I didn’t have any pain at that time, but I definitely had a lot of stress and tension. And I think my shoulders were up around my ears all the time. And so I found it was very helpful for me then and I had a lot of shoulder strain. So I actually had shoulder strain as opposed to back pain. And then later on when I started competing in ballroom dancing, I started doing Feldenkrais very actively. And again, it helped ground me. When I started medical school, I again developed shoulder pain, which I’m sure is related to stress. And so I actually did the Feldenkrais Awareness Movement every morning for third and fourth year of medical school in order to help me get through the day.
And then I finished medical school. I went to orthopedic surgery, and I saw that a lot of my patients really weren’t being helped that much by what I was offering them. I mean, usually, we would send everyone to physical therapy. Now at that time, we were very fortunate to have a Feldenkrais practitioner who is a physical therapist who is a Feldenkrais practitioner. So I sent a lot of patients to her, but then she left and then there was really no one. And I would try to show patients things from Awareness Through Movement®, and they would do it in the office, and they would feel better, but then they wouldn’t understand and they would go out and they didn’t have any follow up. And so they’d come back and they’d show me how they were doing the exercises with a lot of force and a lot of vigor.
So they clearly didn’t get the point. And I really didn’t have the time in orthopedics for a 15 minute office visit, to spend with them. And so I began to refer them to people in the Boston area who were Feldenkrais practitioners. And some people went but most people didn’t. And so I’ve always felt this frustration of not being able to really help people through the Feldenkrais Method. And finally, a Boston training came and so I am doing the training and I’m really excited about being able to offer even more options for patients to do Feldenkrais through the hospital eventually is my hope.
Is Back Pain Normal?
There is a lot of confusion about back pain and what people should do when they have back pain. Life doesn’t have to be a pain in the back. That there are solutions. Back pain is extremely common. There are a lot of statistics. I see this statistic all the time, that 80% of people will have back pain at some point in their lives. But I think it’s actually even more common than that. And I have seen other statistics going up to 90%.
And everyone has back pain, I’ve had back pain, my three kids have had back pain. My husband’s had back pain, we’ve all had back pain. I’ve seen different statistics for this, but it’s often the second most frequent reason for a visit to a physician. Some people say it’s the most frequent reason.
And it’s one of the most common reasons that people under the age of 45 are found that they have to limit their activity.
Why is Back Pain so Common?
It is so common because we do live in a very sedentary environment now. When I was a resident, which was back in the 1990s, we learned that kids did not have back pain unless it was something really, really serious. Something like infection or cancer or perhaps a fracture if they’d had an injury. And now I’m finding that kids really have back pain all the time. I mean, as I said, all three of my kids have had back pain. I see back pain in kids in the office quite frequently, because the pediatricians also learned that back pain in children is serious. But usually they have back pain because they’re sitting, they’re doing their homework lying in bed. They kind of do this on their computers. And it’s funny because my daughters did this and I couldn’t figure out why they were doing this. And then I asked the kids that I see in the office and they’re like, “Yeah, we lie on a bed. We do our homework clenched like this.” We have heavy backpacks which of course we know are a problem.
And everyone is becoming way too sedentary. Most jobs are sedentary now. Truck drivers have a very high incidence of back pain and sitting puts 40% more pressure on your back than standing. So I have seen a trend going toward the standing desk. And a lot of my patients do say that that’s available to them and it’s actually much healthier for the back. And back pain is not just important in terms of causing problems with the back. People who have back pain have more anger, more depression, they tend to be much less active, they don’t have as much fun, they don’t go out, they earn less. And once you have back pain, usually you will recover but recurrence is extremely common.
Why Do I Have Back Pain?
What are some reasons for back pain? In up to about 85 to 90% of acute low back pain, no cause is ever identified. But the good news is usually that people’s pain will go away. And there are a lot of pain generators in the spine, in the back. There’s a skin and you’d think well, why would skin be painful? Well, some people come and they have herpes zoster which is a very painful, weird infection of the chickenpox virus along a dermatome and that can be very painful.
- Blood Vessels
There are a lot of muscles outside the back, along the back, the bones, of course the joints, the ligaments, the discs. The fluid is bright, it’s this bright turquoise and normally normal discs will have a fair amount of fluid which is based on their proteoglycan which is a substance that makes them up. The composition and they have a lot of fluid. As we age, our discs get more degenerative. So here, there’s less fluid. You don’t see that lovely blue, and the disc is actually herniated out. So that’s a common reason for pain. The nerves, you can see the spinal cord usually ends around L2, L3, L1, L2. Some are up here. And then the nerve roots continue on. So that’s obviously a source of pain, blood vessels.
Again, back pain could be due to a problem with your aorta ruptured, aortic aneurysm. That’s not very common, but it does happen. So there are other things to think about, again, talking about pain generators. There’s just so many structures in the back that usually we don’t, or many times we don’t know what is causing the pain. So all of the vertebrae, lots of muscles, etc, etc.
Below are other possible reasons why you have back pain.
- Muscle Strain
- Ligament Sprain
- Herniated Disc
- Annular tear (Disc)
- Compression Fractures
- Spinal Stenosis
- Sacro-iliac joint dysfunction
- Scapular bursitis
- Cancer (metastatic)
- Kidney disease, bowel disease, pelvic disease, vascular disease
Some of the things that can happen, muscle strain or sprain, that’s usually an injury, herniated disk, we’re going to talk about some of these, annular tear, compression fractures, arthritis, spinal stenosis. A lot of people come to me with low back pain and they have pain in their SI joints in the back. Sometimes they have bursitis in their upper back, and then there’s some more serious reasons for pain. And this is what I find a lot of patients worry about. They worry that they have cancer because they know someone who had bone cancer in their spine.
And sometimes they just want to know that they don’t have cancer. This is very, very common. Infection is a reason, spondylosis, spondylolisthesis is the slipping of the vertebrae and then other things. So kidney disease, bowel disease, pelvic disease, vascular disease, these can all cause some back pain.
Causes of Back Pain
- Injury occurred
- Tender over area of pain
- NSAIDs help
- Pain in back only
- Most get better within a couple to a few weeks
- Slight twisting injury
- May be due to repetitive injury
- Can be extremely painful
- Will heal on its own
So usually with a back sprain or strain, there has been an injury, people will feel tenderness directly over where they feel the pain, anti-inflammatory medicines, non steroidal anti-inflammatory medicines like ibuprofen are usually helpful. The pain is only in the back, and most will get better within a couple to a few weeks. Now, some people don’t have a very big injury and they will feel severe pain and this can be a tear of the disk and often it’s just a little twisting injury, so they leaned over to pick up a pencil. It can be extremely painful, but it will heal on its own.
- May not remember an injury
- Pain radiates down leg, generally below knee
- May have numbness or tingling
- May have weakness in leg
- NSAIDs may or may not help
Degenerative Disc Disease
- Moderate continuous back pain
- Could have pain in buttocks, groin, thighs
- Painful flare-ups
- Feeling of “giving out”
- Pain with sitting
- Pain with twisting/bending
- Relief with walking
People often come in saying they have sciatica. They may or may not have sciatica. So sciatica is usually caused when a disc herniation presses on a nerve root in the spine. And usually the pain will radiate down the whole leg to the foot. The sciatic nerve goes down to the foot. They may not have any back pain, they may just have the pain which usually is a burning pain. Sometimes they have numbness and tingling going down into the foot.
Occasionally other reasons for sciatica could be a spondylolisthesis. The vertebrae here should be lined up and then this vertebrae just slipped forward, it’s L5. So it slipped a little bit in front of L4, and actually in front of L5. Now, I know a lot of patients who have spondylolisthesis and they do fine, they don’t even know. Sometimes it’s just an incidental finding. And usually sciatica due to disc herniations will get better within four weeks. So often people with sciatica, they may not even remember an injury. As I said, the pain radiates generally below the knee. Numbness or tingling, sometimes weakness. Anti-inflammatories that are nonsteroidal like Motrin can be helpful. Then there’s degenerative disc disease and a lot of people get this diagnosis. Apparently because as we get older, our discs degenerate but this doesn’t mean that they’ll cause pain. So often what happens is people will have some chronic back pain, it continues and then an MRI is eventually obtained and you see that the discs are not. They don’t have as much fluid, they’re a little flatter. And so we give them this diagnosis of degenerative disc disease.
In degenerative disc disease, usually there’s sort of continuous back pain. Sometimes it goes down into the buttocks, down into the upper thigh or into the groin area. They can have flare ups, feeling that the back is going to give out. Often pain with sitting, twisting and bending. They can feel better with movement.
And the thought is that with time actually, but years of time, the degenerative disc spine will become more stable as the disc gets even flatter and there’ll be less pain with time.
- Back pain with twisting or lifting , bending over
- Stiffness in back
Now another reason that you might have back pain is in the joints. So in the back of the spine, there are facet joints between each vertebrae. So the vertebrae, they’re connected by the discs which would be in here, and then in the back each vertebrae is attached to the one above and below it by the facets joints. Any joints, you can become arthritic, and the cartilage can wear out and that can cause pain. The joints themselves, like our joints in our fingers, can swell, they can get larger as we age. And so a lot of people can have some back pain from facet arthritis or facet arthroscopy.
- Balance/coordination problems
- Numbness or weakness in arm, hand, leg or foot
Lumbar Lower Back
- Back pain
- Numbness or weakness in foot or leg
- Pain/Cramping calves when standing or walking – relieved by stopping or bending forward
In spinal stenosis, it’s sort of the same thing. As we get older, the discs will bulge out the back as they’re sort of doing here. There are also ligaments. So there’s a longitudinal ligament, which is a ligament here, the facet joints are here. So here’s one vertebrae attaching to the facet of another vertebrae. And they hypertrophy, they get larger, the joint capsule expands. And then the nerves don’t have enough space. This space in here is where the nerves run. It gets smaller and smaller. That’s what happens with spinal stenosis.
And it’s more common as we get older. In the lower back, there’s a fair amount of space and the spinal cord is stopped. So usually they’ll just be pressure on the nerve. Often what happens is that the space for the nerve as the tissue swells as you walk a certain amount, you’ll start having pain often in the calves. And so you can get more serious problems with balance coordination and countenance and numbness and weakness in the arm and hand as well as in the leg and foot.
- Back pain, gradual or sudden
- Can be minor or no injury
- May have known history of osteoporosis
- Loss of height
- Dowager’s hump
And then of course, compression fractures, as we get older again, especially for women, we don’t have as much bone density to start with and then as we lose bone density, as we get older after menopause, we can develop these compression fractures is really no trauma whatsoever. Some people have no idea that they’ve had an injury. Sometimes they don’t have pain, but sometimes they can be quite painful. This is one reason why we lose height. One reason is because the disks get flatter, but then another reason is the disk, the vertebrae compress and the Dowager’s hump where people are very hunched over is from multiple compression fractures.
Risk Factors for Low Back Pain
- Previous episodes of back pain
- High physical demands of work
- Low job satisfaction
- Back weakness
If you’ve had a previous episode of back pain, you’re more likely to have another episode, which of course, is everyone. Sometimes it’s the high physical demands of work, but sometimes it is just a sitting job. Often people who are less happy with their job will have more back pain as we get older and more back pain as we get weaker. We have more pain. And then smoking is a huge risk for back pain. People who smoke have 2.7 times the risk of back pain probably because the nicotine will constrict the blood vessels that nourish the vertebrae, the M plates so they themselves don’t really have a blood supply.
Do I Need An MRI?
So the question of do I need an MRI? One of my pet peeves is a patient that comes in and says that their sister told them, their physical therapist told them, someone told him that they needed an MRI. Now, most people do not need an MRI, but everyone wants an MRI. When I was a resident, MRIs were newer. Actually, the beginning of the ’80s was when they really became popular but they were fairly common. But now they’re even more common, and there is a recent study that showed that disc degeneration is present in pretty much everyone after the age of 60, but most of these people do not have any symptoms. And even in patients who are 30 to 39 years of age, on their MRI, they’ll have disc bulges, they’ll have just disc herniations, they’ll have disc degeneration and they have absolutely no symptoms whatsoever. So getting an MRI and finding something on it really doesn’t mean anything unless the patient has seen symptoms that go along with the findings on the MRI, and often they don’t. So if you are considering surgery, yes, you need an MRI. There’s an epidural steroid injection. Another good reason to get an MRI is because you need to know where you have a problem.
MRI Diagnostic Red Flags
- History of trauma
- Fever/night sweats
- Unexplained weight loss
- IV Drug use
- Intense localized pain
- Inability to get into a comfortable position
- History of cancer
- Saddle Anesthesia
- Long term steroid use
- Back pain at night
- Severe or rapidly progressive neurologic deficit
There are some other reasons to get studies and we call these red flags. And there are reasons why you should get an MRI, and might need surgery. So history of trauma, fevers and night sweats which could indicate infection. Incontinence could be a very bad disk herniation, unexplained weight loss, again, infection or cancer, IV drug use, infection. So some of these things. Having a history of cancer. Saddle anesthesia is numbness in the inner thighs, long term steroid use, back pain at night or severe and rapidly and progressive neurologic deficit. This could be an epidural abscess or something like that. So these are reasons but most people don’t present them.
Treatments for Back Pain – Mainstream Western Medicine
- Anti-inflammatory medications (NSAIDs)
- Steroidal medications
- Opioid medications
- Cortisone injections
- Physical therapy
- Radiofrequency ablation (RFA)
- Spinal cord stimulation
- Peripheral nerve stimulation
So when you have back pain, what should you do? Usually people will take Motrin, ibuprofen if they don’t have any reasons not to take it. And these work for most, everything it will help. Most of the patients I see are the ones that have tried this and it doesn’t help. So then the next line of defense often is especially if they have nerve root pain such as pain going down the leg would be a steroidal medication such as prednisone, usually given in a taper.
Often what is painful, the disc herniation may press on the nerve root. If you can just cut down the inflammation around the nerve, then the pain will go away and you don’t need to do anything. Over time the body will reabsorb some of that disk and people can be fine. So the prednisone is a stronger anti-inflammatory than the nonsteroidal anti-inflammatory. And so we can give a short dose of those. Opioid medications now of course, it’s a national crisis. So we really try to limit oxycodone, Percocet, and Vicodin. It can be helpful in the short term, but usually only for a couple of days, and after that, it’s probably not so helpful for cortisone injection. So the epidural steroid injection again, this is for a disc herniation
They haven’t been shown to make a difference at six months whether you’ve had one or not, but in the short term, it can sometimes be very helpful. If you’re really limited, you can’t do the things you need to do. Often people will feel dramatic relief from pain, physical therapy is sort of the mainstay of what we do, what we recommend. A lot of patients don’t like physical therapy. A lot of them need it and they’re de-conditioned, they don’t do much exercise, if they’ve had back pain before.
Radiofrequency ablation, this is where they burn the nerve, either to the facet joints, sometimes to the disc. It can be helpful. These other things are usually for very chronic pain that just doesn’t get better. The spinal cord stimulation electrical devices implanted that will give electrical stimulation to the spine, the same with peripheral nerve stimulation and then of course surgery.
Alternative Treatments for Back Pain
- Qi gong
- Lifestyle Modifications
- CBD oil/cream
Chiropractic treatment, there was one big study recently looking in the military where they weren’t really looking at what people were doing and it wasn’t blinded in any way, but it did seem that people got a little bit better if they had regular medical treatment as well as the chiropractor. Most studies are not really high quality studies. And so it’s a little bit unclear how much it helps. People who get chiropractic treatment seem to be happier than people who just go to physical therapy, maybe because they get a lot of visits.
Same with acupuncture, studies have not been done that really show that it is helpful for back pain. Other alternative things, these really haven’t been said that much. Yoga, there’s been a lot of research actually looking at yoga and back pain, it seems to be as good as physical therapy. And some people find a greater psychological benefit from doing yoga. So their lives improved, in addition to their back pain more than if they were just to do physical therapy. There have been very few studies on the Feldenkrais Method. In fact, only a couple looked at Feldenkrais Method and back pain. Again, it hasn’t been conclusive. It just shows that it’s as good as other treatments that are there.
Key Difference Between Yoga and Feldenkrais
Well, definitely Feldenkrais, can be more gentle. And people in the yoga classes part of the problem with these big yoga classes is that you can see the other people and what they’re doing and then you feel like you need to do that. And even if the teacher’s telling you you don’t need to do that, other people are doing it and so you do tend to go a little farther than perhaps you should, either in holding the pose or going a little “deeper” into the pose and in Feldenkrais, really, it’s emphasized throughout that everything is small, you don’t have to go as far. You should not go as far as you can go. It’s more about experiencing that feeling. And in yoga, it could be that way, but I think it has become more of a visual physical. You want to feel yourself working. A lot of teachers emphasize physicality and working hard.
If you keep going every day and working hard, then that’s how you improve and I think people do get injured that way. Well, Feldenkrais has more awareness of the joints, the softening of the body and increasing the flexibility through that softening actually, I find is very helpful.
How to Prevent Back Pain?
Definitely moving around frequently. So even if you’re sitting, taking breaks, stretching, walking, which a lot of people don’t feel that they can do, or they’re at a job that doesn’t allow them to do that. So again, you have to change things in the work environment. There are these people that make this chair, there’s the ball chair. But then there’s this chair, this guy in Vermont is making them. And again, you’re constantly moving while you’re sitting, which is a great way to be or the standing desk can be useful. But I think it’s important to keep physically fit. Of course, keep your weight down. But do things that increase your mobility and things that you like to do.
It’s very important for people to find some form of exercise or recreation that they enjoy, that they can do. I see people all the time as they get older, they just become less and less active and they think that this is normal and they just accept it and then it’s too late. They almost can’t go back and get the fitness that they need to be healthy. I think Feldenkrais is a great thing to do to prevent back pain, but even if you don’t do that, you just need to stay active. Don’t just sit watching TV. Try to avoid all of the poses of technology.
Source: This is a short excerpt from a longer interview held with Mercedes Von Deck during the 2019 Feldenkrais Awareness Summit. To see the entire summit offerings go to: https://www.futurelifenow-online.com/course-catalogs/