Along with the pandemic comes all the associated side effects of being isolated: weight gain, anxiety, depression, and, yes, back pain.
Here, Jang Won Yoon, an assistant professor of clinical neurosurgery at the Perelman School of Medicine, explains what people can do to mitigate this discomfort and describes how spinal evaluations are being conducted through telemedicine.
How is the pandemic affecting back care?
Because of the pandemic, everyone is forced to stay inside and people [who are typically] going to the gym are unable to do so. People have a more sedentary and less active lifestyle than before. And because of that, especially in patients with chronic spine disease that’s longstanding, being active and outside and exercising is critical to their spine health. That aspect of being forced to stay home has made it more difficult for spine patients to do their exercises.
In the beginning, all of the clinics were closed, and a lot of providers were not able to see their patients. And now it’s gotten easier around Philadelphia, but it’s hard for them to get pain meds they normally take and also get physical therapy. All those things have led to a worsening of a lot of patients’ back pain. In the beginning of the pandemic, what was difficult was the only way to really reach them was through the phone. And unless they were in excruciating pain, we were not allowed to see the patient. Or, if they have a neurological deficit, then we are able to see them through the ER. That certainly was a barrier to care, but now things are beginning to return to some level of normalcy and we’re able to see a lot of patients through telemedicine, which has been a great platform for patients to ask questions and have face-to-face time with them. Then, if needed, we bring them into the office for further evaluation.
To answer the question: I think the pandemic affected the access to care for back issues. And certainly we’re finding ways to work around it with telemedicine, but in the bigger picture, I think people are less active than before and keeping up activity levels is difficult if someone is going to the gym or getting physical therapy, and those places are closed. That may be hard. But it’s important for people to still stay active, walk outside with a mask, try to at least get some cardio exercise in, and then certainly home exercises there are lots of options. For instance, I love Peloton and a lot of the indoor workouts people can do without exposing themselves to the coronavirus.
What exercises would be good for the back during this time?
There aren’t any magic bullets, but I’d say for a majority of patients we see who are a little older and have arthritis, I think it’s about walking, getting a cardiovascular workout. A light walk, biking, swimming is great—water exercises are great. Anything that gets the heart rate up is good for the patient. There isn’t any fancy workout you can do for the back. Just staying active, keeping a light frame.
The back is sort of like a foundation of the house: the more weight you carry around, the faster that’s going to deteriorate. If someone has a chronic back arthritis, the best thing to do is keep the frame lighter: losing weight, keeping BMI around the normal range of 18 to 25. If you can get your BMI in that range, you can potentially help with some of the pain of chronic arthritis.
What is the relationship between cardio exercises and the back?
There isn’t a direct relationship, but with heart rate, if you do exercises that push your heart rate up then you can lose weight faster. A light cardio workout might push your heart rate to 100 to 120 bpm, a more intense workout can push you to 130, but what your heart rate should be depends on your age. Any kind of exercise that can push your heart rate up and allow you to burn calories and lose weight can potentially help with chronic back issues.
One thing I do like to mention is not all exercises are [great]. Heavy weights, deadlifts, some of the exercises that strain the back. We’ve seen some injuries from those. If you have chronic back conditions, I tell patients to stay away from any exercise that loads the spine. Exercises where you swing heavy weights above your shoulders, squats and things that put a lot of weight on your spine, I recommend against those. Rather, do something that does not stress the spine. For instance, if you’re working out your shoulders, do the shoulder presses at an incline, so it’s not directly putting weight onto your spine. And instead of doing a deadlift, do other exercise that still exercise your lower back, but not with so much weight on it.
With DIY exercises right now, I’m sure that can get tough. I see people using cinderblocks to exercise as dumbbell replacements.
People are using bodyweight more, which I’m a big fan of. Instead of doing something really heavy, do more reps, and if you can focus on the form you can do good exercises. I’m a fan of those bodyweight-only exercises for the back instead of heavy weights.
If you’re young and healthy, you may be able to get away with it, but if you know you have a spine issue and have seen doctors for that before, sometimes you can do too much, which can set you back. In this time of the pandemic, I think if you know that you have limited access to doctors and have back issues, I recommend still being active but with precautions. And do smart workouts, being easy on the back and doing more cardio.
How can we be better about things like posture and where we sit? People who may not typically work from home and suddenly are probably have few ergonomic options. Work stations default to the sofa.
There’s definitely a lot of forced in-house working and a lot of people are spending time on the couch doing work, or sitting down at a desk. And that’s instead of the time spent commuting that forces people to get out and walk more. I think the best way to put this is if you’re sitting at a desk and working, just remind yourself to get up and stretch every hour or so. Remind yourself to get up and stretch your back, move around, change your posture, and if you’re sitting down … there are standing desk options that allow you to work standing up, so instead of sitting down you can stand up and do your work, and sit down if you get tired. Some of those strategies, it may be difficult given the situation, but you can always change position and stretch, even when you’re staying at home, and be mindful of it.
Have you seen any upticks in a type of back pain?
No. For the most part, what we see is, in the beginning mostly, people were having problems but reluctant to get care due to the fear of contracting COVID-19. Or reluctant to get surgery even if there was something that needs operated on. We saw a lot of that, and now it’s a bit better, but some older patients have underlying disease and rightfully so they’re nervous about coming to the hospital to get surgery. And in the beginning that was a big concern. But now things have gotten better with telemedicine and things like that.
Beyond COVID, what is the focus of research with the back?
I think one of the things I’ve mentioned that came in with a bang this year is we’ve expanded our role with telemedicine. Before, telemedicine existed and there was a subset of specialties like stroke, where there was no access to the neurologist and the patient is having a stroke, and telemedicine allowed a stroke neurologist to evaluate a patient who was far away. The role of telemedicine was really limited to a certain section of the medicine. Because of the pandemic, that really [became more widely] adopted by physicians and providers as we stay apart, social distancing. Since the pandemic shutdown in March, you’re seeing neurosurgery have a big surge in telemedicine usage. Just to give an idea, we have this in publications. Before March, we only had a few cases of telemedicine at Penn for the entire calendar year. And since the pandemic, we’ve had telemedicine go up to 700 or 800 cases per month. And that number has stayed relatively consistent.
Now, in Philadelphia, which shut down pretty early, we’ve seen a return of in-office patients as well, but telemedicine still plays a large role. And moving forward, I think telemedicine is here to stay. And neurosurgery at Penn, we’re conducting a study right now of how to conduct telemedicine and do a proper physical examination. One limit of telemedicine is you can’t physically touch patients, therefore, a comprehensive neurological exam cannot be done in a traditional fashion. One way to get around it is to ask them to perform a set maneuvers and visually assess their strength through video conference. If someone has weakness in their legs, there are ways to pick up subtle strengths by doing squats—if you are able to do a squat with your bodyweight then, your quads are working well. So, we came up with this scheme to standardize a way to test strength using telemedicine. We published our methodology using that and now we are studying whether this novel methodology can be applied across different providers. We’re actively doing that kind of research.
We’ve recently started a Second Opinion program, where patients can submit cases and images for us to review and we meet them virtually. Not only will telemedicine open the doors to people who physically can’t be here, but open more access to everybody. And I think that’s here to stay.
Anything to add?
Throughout this pandemic I think we learn a lot. The pandemic and coronavirus, we’re nowhere near the end, and this thing is probably here to stay until we get a handle on a vaccine, and who knows when that will come. But through this process we’re able to adapt, patients and providers alike, and we’re learning as we go and trying to navigate this. And Penn Neurosurgery, I think we quickly and successfully pivoted using technology and programs to still provide care to our patients through the pandemic, and I think because of that—of quickly adapting—we did not miss a beat, and now our number of visits and surgery is back to where it was. We quickly recovered to pre-COVID levels. We’re here to treat everybody and if anyone has any spine issues and would like to speak to us about their back issues, our doors are open.
