BACK PAIN CAN BE AS VARIED IN CAUSE as it can be persistent, aggravating and all too common, affecting an estimated eight out of 10 people throughout the course of their lives. With this ubiquity comes frustration and myriad questions, so SRQ sat down with professionals in different specialties to discuss how we got here and how to pull ourselves back out. 


Speaking with Spine Specialists

What kind of natural deterioration do you see in your older patients and how do you combat that?  Dr. Robert Knego, Neurosurgery and Spine Specialists and Sarasota Memorial Hospital:  As people get older, a lot of postural changes come. They get tightening in the hamstrings, tightness in the hip flexors and atrophy in the muscles of the back and butt, and as a result that changes posture and the alignment of the spine. Concurrent to that happening, the discs, which are normally wedge-shaped, degenerate and become more parallel. When the discs are wedge-shaped, you have a natural curve to the spine, but if your disc is parallel you lose that curve and develop a flat back. One way to compensate for that normal aging is to extend your hips and arch your back and rotate your pelvis, but if you aren’t exercising on a regular basis and working those muscles, your ability to compensate diminishes. Bone deterioration plays a role later. It’s mainly the degeneration of the discs.  Dr. Mark Lonstein, Sarasota Spine Specialists and Sarasota Memorial Hospital: The most common disorders I see would be a herniated disc in the neck or back, or a condition called spinal stenosis, where the spinal canal narrows with the aging process and produces back and leg pain. I also treat people with spondylolisthesis, where the vertebra has slipped forward either as a developmental or degenerative condition. From the arthritic process, vertebrae can slip forward and that can put pressure on nerves, producing back and leg pain. That’s a very common condition that we would treat initially with oral medications, physical therapy, sometimes spinal injections such as a steroid injection. If that doesn’t work, then the final option would be surgical.

Do hormone levels as you age affect your spine? Lonstein: The biggest issue is in the post-menopausal females with osteoporosis. Osteoporosis accelerates tremendously in the female after hormone production goes down and it’s a big healthcare problem because the osteoporosis is leading to spine fractures, hip fractures and wrist fractures. These have tremendous morbidity and also shorten life span. That’s something that needs to be addressed in these patients. We have medications that can help preserve or improve bone density and treat osteoporosis, and it’s important that people get that treatment early on.

What are good habits you recommend to preserve spine health? Lonstein: Avoid smoking. Smokers degenerate their spine at a faster rate then non-smokers. We’ve always known that smokers did have an increased incidence of back pain, but we weren’t too sure what the reason was. Now studies have shown that smokers degenerate the discs in their spine at an accelerated rate and this can lead to disability. Also good cardiovascular fitness seems to decrease the incidence of back pain. Weight can play a role. Somebody with a problem with obesity is more likely to end up with back problems.

Bad habits? Knego:  The more we sit, the more we’re sedentary, the more we lose that flexibility and those muscles. It’s not complicated. It’s focusing on posture - sitting up straight, putting shoulders back when you stand up – and then incorporating an exercise program, which you really need to be doing from the time you’re 40. Specifically for your back, you need to be thinking about programs that incorporate flexibility as well as strength training, particularly working on your glutes and hamstrings. 

Are the abdominal muscles important in this regard?Knego: They’re important and sit-ups are part of a core program, but the core is the muscles of the torso, not just your abs. There’s a mathematical relationship between the position of your pelvis and the curve of your spine, and we measure those angles and they need to be within 10 degrees of each other to have a balanced spine. With normal deterioration as you get older, you start losing that balance. The curvature of the spine starts changing. Again, you can make adjustments in your pelvis if those muscles are flexible and strong, but if they’re weak you can’t. I’m really a stickler to not only work on cardio programs but to very diligently add some core program. Yoga is very good.

Are their surgical options should this progress beyond physical therapy? Knego: This has been really evolving in the last five to 10 years and the importance of posture and the alignment of these angles have really become much more well-understood. What we can do is recontour their spine - putting the curve back in the spine. Applying scoliosis principles, we measure those curves, look at the spine and contour a rod to bend the spine back into position and then fuse it into position. Now that’s a very drastic thing. The vertebrae are fused into that position.  

When would you go that far? Knego:When the discs collapse to the point where there’s pressure on the nerves. People come in not with back pain, but with pinched nerves. If I just unpinch their nerves, the pain will get better transiently but they still have an unbalanced spine and will in fact just come back with worse pain. The second scenario is when the back pain is intolerable. You try to work with as much therapy as you can, but at some point there are extreme cases. If you can rebalance – bring those angles back into good measurement – you can markedly improve quality of life, with the caveat being these are big surgeries. These people are older, and if they have poor bone quality then the surgery can fail. 

Has robotic surgery entered the program when it comes to the spine? Lonstein:I wouldn’t say completely. There is a robotic surgery being advertised now and there is a robot-type thing out there, but it’s really not so much a robot. The surgeon is dressed and in the room, the robot is basically a device that allows you to use imaging to place some of the implants. It’s been referred to as robotic, but it’s more an imaging device to help place screws.  Knego:It’s helpful in scoliosis surgery, because you’re placing screws into the vertebrae down a very narrow trajectory and it has to be precisely placed. An experienced surgeon can do it almost without X-ray in a healthy spine because the angles are consistent, but once you have deformity changes it gets very difficult. You can either call it robotic or computer-assisted.

When it comes to back surgery, how long should someone expect to be in the hospital? Lonstein:When I first was in town in 1988, I’d do a disk surgery and those people sometimes were in the hospital for three or four days. Now, it’s done as an outpatient. Depending on medical problems they may stay overnight but many go home same day.

What remains unfixable? What’s the big hurdle? Knego:One of the big hurdles of course is in traumatic spinal cord injury. There’s a lot of research going into how we can repair the nervous system, to repair the spinal cord and get them up and walking again. They have developed some exo-devices that attach to the skeleton and people can get up and walk again. But it’s technology causing the parts to move; it’s not coming from the neurological system. They’re looking at stem cells.

Anything coming down the pipeline? Knego:The big thing coming down the pipe is stem cell technology. Right now there’s a limited use of patient stem cells and using them to heal different processes. At Sarasota Memorial Hospital we use a fair amount of stem cells when trying to enhance bone growth and bone fusion, but I’m hoping that in five or 10 years I could look at a spine that’s starting to degenerate and inject a stem cell into it and instead of putting in rods and screws and recontouring, have the disc regenerate itself.


Speaking with Chiropractors

What do you see as the most common causes of back pain? Dr. Roger Romano, Romano Family Chiropractic and Wellness Center: By far, sitting jobs and computer work. They’re saying that sitting is the new smoking. There’s more pressure on your lower back sitting than standing, and a lot of workplaces are switching to standing desks. But I rarely get people who hurt their back lifting stuff. Mainly sitting.  Dr. Charles Liott, Liott Back and Neck Care Center: We live sedentary lifestyles. We don’t give our back the proper spinal alignment and are causing our bodies a disservice. The muscles lose their tonicity and, as a result, you get changes in the spine. You get more compression on the joints, and compression over time results in arthritis, which leads to immobility, which leads to possible nerve irritation, which means pain. There’s a domino effect as a result of our lifestyle and we have to take ownership. Once we take ownership of ourselves, strengthen our core and try to be more ergonomically aware, we get stronger. There are simple ways to do that. You don’t need a gym. 

What good habits can you recommend for maintaining a healthy spine? Liott:  Sitting in a good, firm chair, getting our spines with a little bit of a curve in our back, with our head back and up and looking eye-level. And the plank. The plank works every muscle in your body and you can do it in bed. Eat right. Cut down on the sugars. Walk. Be active. Romano: At work, try to stand as much as possible if you have a desk job. Or get a wobble disc and put it in your chair. When you sit at a desk you’re just stuck there, even if you’re typing. But with a wobble disc, you move just a little bit and your whole lower back is activated, so it causes your muscles to constantly contract and relax. This gives better blood flow and actually strengthens core stability.

What are some other bad habits people should avoid? Romano:  Sleeping on their stomach. When you lay on your stomach and your lungs expand to breathe, they have to lift your whole body up. It also causes pressure on your lower back, and when you’re laying on your stomach you have to turn your head to the left or right and that leads to a lot of neck problems. Sleeping on your side is the best position, with a pillow between your knees. The pillow keeps your knees pretty much the same width as your hips.   Liott:  At home, lying in bed reading is not a good thing to do. Most people will prop themselves up at a 45-degree angle, rest the book on their chest and look down at it for a half hour or 45 minutes. When you go to bed, don’t force your head up. Use one pillow. In our society, we’re always having our head propped forward. This adds up and takes a toll. 

What generally speaking is the patient experience coming in for chiropractic? Romano:  We check posture, range of motion and generally we take X-rays so we can see what the alignment looks like. From a front view, hips are supposed to be level, shoulders level, head level and spine straight up and down. From the side view, there are supposed to be three arcs in the spine – one forward in the neck, one reversed in the upper back and then forward in the lower back again. Those arcs allow your spine to be about 2000 percent more flexible. When you jog you exert about five to seven times your bodyweight through your spine. That’s a lot of constant force, and these curves in your back act like a c-spring. Sitting forward at a desk all day straightens the curve in the lower back. And one of the most common things we see is that when people sit at a desk most of their day, they lose the curve in their neck. When you lose that curve, your neck can’t bend and with every step your head comes crashing into your spine. The same thing happens in the lower back. With posture, with range of motion and with X-rays, we have a blueprint and adjustments of the spine are designed, along with rehab exercises, to get the spine back into proper alignment, and we verify that by checking posture down the road and taking progress X-rays.

What is happening during chiropractic manipulation or mobilization? Liott:  You’re looking for joint immobilization – where the joint doesn’t move properly. So when I look at the cervical spine - the neck - I’m looking for degrees of lost motion. My job is to pinpoint that particular segment that doesn’t have the mobility that it should and then deliver a mild correction to stimulate increased range of motion. And along with that comes other benefits.

In terms of this mild correction, are you affecting muscle, shifting bone? What’s happening under the skin? Liott:  The receptor theory is the basis. All joints have good and negative receptors, and you’re stimulating the receptors in the joint. The receptors that are there, the brain detects as restrictive and perceives pain associated with that. So by delivering a response into the joint, you increase the good receptors and allow the body to have a sense of well-being.

What are those rehab options, other than spinal realignment? Romano:  We do therapy on the wobble disc for core strength, and we do back and neck strengthening exercises. We also do standing repetitive traction, stretching the arc in your neck. As the alignment comes back, people are generally anywhere from half-inch to three quarters of an inch taller after about six months. Liott:  The latest is the warm laser. If you have a hip or shoulder replacement, we can work the laser over that particular joint and speed the healing. In addition, we have electrical stimulation, an ultrasound that uses high-frequency sound waves that penetrate to a certain depth and help repair and heal injured tissue.

What is one of the biggest misconceptions surrounding the practice of chiropractic? Liott:  That we treat only the spine. We treat disorders other than the spine. Chiropractic is the treatment of neuromuscular disorders, mainly associated with the spine, but in that sense we treat other parts such as shoulders and hips and knees. We don’t treat just the spine, we treat joints and associated issues.  Romano:  That it’s for pain only. Whereas if the spine is out of alignment and putting pressure on the nerves going towards your digestive system, it’s like taking a dimmer switch to the light. So the digestive system isn’t working properly, but it’s not a problem with the digestive system per se. We don’t claim to treat problems of the body, we do one thing – correct the alignment of the spine – but when that’s done your body starts healing better overall. Liott:  I tell people that we’re going to finish here and they have to take the responsibility and own it and get themselves stronger through yoga, pilates–simple exercises. If you build up your core, then there’s less compression, less eventual deterioration of the spine where it goes from a normal, supple, full range of motion spine to a restrictive, arthritic system. My goal is to empower the person.

 The Osteopathic Approach

What sets apart the osteopathic approach to spine care? Dr. Philip Miller, Lake Erie College of Osteopathic Medicine:  It’s our philosophical approach more than anything. We’re strong advocates of preventative care, preventative medicine and maintenance. We encourage good body mechanics and for patients who do present with back pain, one of the first things I emphasize is home exercise and therapy to assist with muscular-skeletal imbalance because that is one of the most common findings in someone with lower back pain. The other thing that sets osteopathic physicians apart is we practice osteopathic manipulative medicine, which is very similar to what a chiropractor or massage therapist might do 

What kind of home exercises and therapy do you recommend as a starting point? Miller:  In a common muscular-skeletal imbalance, some muscles are tight where other muscles are too lax and stretched out. So we focus on strengthening core musculature and stabilizing muscles in the back, while we stretch out muscles that over time become hypertonic or really tight just to make up for the difference in those other muscles we’re trying to strengthen. We’ll prescribe exercises like stretching the hamstrings and the hip flexors while we’re strengthening the abdominals and gluteus muscles. 

When it comes to deterioration of the back and spine, do you find most is due to the natural aging process or poor habits? Miller:  Poor posture is the number one thing. The second is previous injuries. It could be a back injury or even a leg or foot injury, where over time the body had to compensate. That sets off a chain reaction where a patient may lean to one side or put more pressure on one foot, which gets transmitted up through the pelvis into the tailbone and finally into the lower back.

What is the importance of the holistic aspect of osteopathic care? Why can’t the back simply be fixed mechanically? Miller:  Because you deal with the patient’s personality and lifestyle and anything else that could be bugging them. It’s easy to say, “Look at the anatomy and go in there and fix it,” but not everybody is exactly the same. Anatomically there can be many variations, and at the same time you may have somebody who has completely different mental health or lifestyle. People who suffer from depression and anxiety tend to feel pain even worse and that’s another factor you have to consider. It’s easy to give a pill or do surgery, but when you consider the patient’s personality, their feelings, their emotions and their beliefs it strengthens the doctor-patient relationship. Patients are then more willing to comply with what you advise and at the same time are more willing to share information with you.

Can you illuminate the manipulation process a little bit? Miller:  We believe that structure and function are reciprocally related. So if the spine and muscles are perfectly aligned and we have full range of motion, then the result is going to be health, because that plays along with normal physiologic function. A lot of patients that come in not just with back pain, but with cardiac issues or gastronintestinal issues, once it gets adjusted they notice that there is an improvement and maybe even a complete resolution of the underlying complaint.

How often does it come to surgery? Miller:  I haven’t referred anyone to surgery yet. A lot of people I see really want to stay with conservative managements, so it’s consisted of osteopathic treatments such as pain control through use of medication and home exercises. The ones who do the best are the ones who stick with the regimen of exercise and stretching every day and are compliant with physical therapy and come for regular osteopathic treatment. They may not have 100-percent pain relief, especially if they have underlying arthritic or degenerative disease, but it can certainly knock it down quite significantly.

Final thoughts? Miller:  More people are becoming aware of osteopathic physicians and the osteopathic philosophy. Not many people realize that DOs are fully licensed physicians. We can go into any specialty and practice in all 50 states. But we have a unique approach to our training because we incorporate osteopathic principles into almost everything we do since the first day of We’re always striving not so much to interfere with the disease process, but to help the body heal itself, and osteopathic manipulation certainly helps with that. There is a strong relationship between the muscular-skeletal system and every other system of the body. If one is affected, so will the other be affected.



Robert S. Knego, M.D  A graduate of the University of Florida College of Medicine, where he also completed his internship and residency, Dr. Knego is board-certified in neurological surgery and specializes in complex spinal reconstruction and spinal surgery. Knego enjoys privileges at both Sarasota Memorial Hospital and Doctors Hospital.

Mark Lonstein, M.D.   Dr. Lonstein earned his medical degree at Baylor College, following with an internship in internal medicine at George Washington University and an internship in general surgery at the University Health Center Hospitals of Pittsburgh, before returning to George Washington to complete his residency. He then completed a spine fellowship at the University of Texas Southwestern Medical School.

Roger Romano, D.C.   Serving Sarasota since 1988, Dr. Romano earned his doctorate of chiropractic at Life University, graduating with honors before moving on to serve as team doctor for the U.S. National Wrestling, Weightlifting and Judo teams and co-authoring two New York Times best-selling books.

Charles Liott,   D.C., D.A.C.A.N. Dr. Liott earned his doctorate of chiropractic from the Palmer College of Chiropractic, graduating cum laude, taking on additional training in radiology and physical therapy before earning his Diplomate of the American Chiropractic Academy of Neurology and becoming a board- certified chiropractic neurologist.

Philip Miller, D.O. A 2006 graduate of the College of Osteopathic Medicine, Miller currently serves as course director for Osteopathic Manipulative Medicine and Clinical Examinations at LECOM Bradenton. Specializing in neuromuscular medicine and osteopathic manipulation, Miller completed his residency at St. Joseph Medical Center and fellowship at Millcreek Community Hospital.