Conflicting Back Pain Information

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It’s easy to get confused when reading and listening to information about health, wellness, fitness, and exercise. We are often caught in the collision between valid science and pseudoscientific snake oil mumbo jumbo. Even when good research is discussed in the press it’s often reported without nuance by reporters who don’t understand the statistical methodology.

With that in mind, here are three recent articles which overlap in their coverage of back pain. Two reflect the current evidence on back pain. The other, in my opinion, is off the mark and may actually help reinforce back pain and the fear of pain.

Posture has little to do with pain

I like the article titled Are you sitting comfortably: the myth of good posture. I recommend you read it because the sources discuss the current evidence around posture and back pain. Pain researcher Dr. Peter O’Sullivan is one source. He says,

“O’Sullivan says that rather than focus on the right posture, the ability to vary it and shift easily may be more important: ‘While it is appealing to think that if you sit up straight you will not get back pain, this is not supported by big studies across many countries.’ Indeed, while many websites swear that bad posture (usually defined as slumping, leaning forwards or standing with a protruding belly) causes everything from back pain to varicose veins and indigestion, there is no evidence that it causes general health problems.”

“…If you don’t have back pain, then do not give your posture one second’s thought – think about being healthy. Sleep deprivation and stress are more important than the lifting you do. Stress has a strong inflammatory role; it can make muscles tense. Most people don’t get that their back can become sore if they are sleep deprived.”

One thing to think about is the chicken-or-egg paradigm. That is, does “bad” posture cause back pain? (Evidence suggests it doesn’t.) Or could pain force us to adopt a certain type of posture that looks bad? My bet is on the latter. Related to low-back pain misinformation is the fearmongering around the myth of “text neck.”

Misguided treatment

If our concept of what causes back pain is misguided then it’s no surprise that many diagnostic and treatment strategies are ineffective. An article from the BBC titled Many back pain patients ‘getting wrong care’ discusses guidelines from a series of papers written by pain experts for the Lancet, a British medical journal. Several points to consider:

  • Strong drugs, injections and surgery are generally overkill, they say, with limited evidence that they help.
  • Most back pain is best managed by keeping active, they advise.
  • UK guidelines recommend a mix of physical exercise, advice, and support to help patients cope with symptoms and enjoy a better quality of life.
  • Health staff should not treat back pain or sciatica with equipment such as belts, corsets, foot supports or shoes with special soles.
  • They should not offer acupuncture, traction (stretching the back using weights or machines), or electrotherapy (passing electric current or ultrasound waves through the body), says the National Institute for Health and Care Excellence.

My favorite is this list of 10 Things You Should Know About Your Back:

1) Your back is stronger than you may think – the spine is strong and not easily damaged, so in most instances, the pain will be down to a simple sprain or strain.

2) You rarely need a scan.

3) Avoid bed rest and get moving (but avoid aggravating activities).

4) Do not fear bending or lifting – do it in a way that is comfortable, using the hips and knees.

5) Remember that exercise and activity can reduce and prevent back pain.

6) Painkillers will not speed up your recovery.

7) Surgery is rarely needed.

8) Get good quality sleep if you can, because it will help you feel better overall.

9) You can have back pain without any damage or injury.

10) If it doesn’t clear up, seek help but don’t worry – book an appointment to see your doctor or physiotherapist if the pain persists.

Questions about bending and lifting

Lost Art Of Bending Over: How Other Cultures Spare Their Spines comes from National Public Radio. I am a little bit conflicted about it.

The article suggests that we in the US bend forward “incorrectly” and thus we suffer more back pain than agrarian societies where they bend forward “correctly” and thus suffer less back pain. Is this claim true? Do we suffer more back pain than less-developed countries? Do people in other cultures bend forward differently than we do? The article offers no evidence beyond the writer’s casual observations to support the claims. Ironically, the article shows a picture of two rice farmers in Madagascar. One is bent forward “correctly” with a hip hinge, the other is bent “incorrectly” more through the low-back. I’m not sure how to interpret that picture.

My problem with the article is that it suggests there is a wrong way to lift and implies that doing so is a direct cause of back pain. Such fears lead to fear-avoidance beliefs (FABs).  I’ve experienced this phenomenon and I’ve seen it in others.

With FABs, we tend to believe that adopting certain “bad” postures or using “unsafe” lifting strategies will certainly equal pain. As a result, we brace our backs with extreme rigidity and we use a super-strict technique to lift everything from heavy objects down to something small and light like a pair of shoes. The irony of FABs and the resulting extreme diligence is that we are actually at greater risk of incurring more pain. In other words, the fear of pain is more of a problem than the biomechanics of lifting.

Recall that in the first article I discussed, we learned that sitting posture doesn’t relate much to back pain and that in fact emotions and lack of sleep were stronger predictors of back pain. My bet is that we might see a similar dynamic with regard to lifting posture.

Some of the information is useful, specifically the instructions on hip-hinging (a technique I regularly teach to clients) are worth knowing. By using a hip-hinge method to lift things from the ground, you will engage the glutes and hamstrings which are big, strong muscles. The hip hinge should allow a lifter to generate more force so he or she can lift a heavier object. The hip hinge also effectively distributes the forces of the lifting of a heavy object throughout the body rather than concentrating it in one place.

As a counterpoint to my own statement though, look at this. It’s Austrailian strong-woman Sue Metcalf picking up 246 lb. atlas stone with a technique that the NPR article would call unsafe.

I think that if lifting a heavy object, then it’s prudent to use as many muscles as possible to do the job and to generally be careful. Nothing wrong with that. But if bending down to pick up a pen, a shoe, a ball — or possibly a giant atlas stone— and if there’s no underlying acute injury, then we should feel free to move the spine. The spine is comprised of 33 bones, 24 of which are moveable. So why not move them? I wish the press were better at discussing these nuances.

Extra credit

If the problems inherent to bad science interest you, then you might want to pay attention to the words of  Dr. Ben Goldacre, epidemiologist, has to say.

Tiger Woods’ Back Pain Mythology

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For effective management of persistent pain, provide a clear understanding of the factors that drive pain, develop graduated strategies to normalise and optimise movement patterns while controlling pain, and couple these steps by prescribing sports specific conditioning and a graduated return to sport. Addressing psycho-social stressors and unhealthy lifestyle factors is part of this process, especially where ‘central’ pain features are dominant. Magic bullets don’t exist, so don’t promise them.
– Dr Peter O’Sullivan, Curtin University, West Australia

Tiger Woods received a lot of coverage earlier this month for withdrawing from a golf tournament due to back pain. Tiger mentioned back spasms in interviews and made the following statement:

“It was a different pain than what I had been experiencing, so I knew it wasn’t the site of the surgery. It was different and obviously it was just the sacrum,” Woods said. “The treatments have been fantastic. Once the bone was put back in the spasms went away, and from there I started getting some range of motion. My physio is here. If it does go out (again), he’s able to fix it.”

So the implication here is that the sacrum can in fact pop out and be put back in place. And that once the sacrum is back where it belongs–presto!–the pain was gone. This is the type of statement that perks up the ears of numerous therapists, coaches and trainers. This is also the type of information that grabs the attention of multitudes of back-pain sufferers. There’s hope! A magic treatment is at hand!

First, can a sacrum pop out? For that question, I like these words from UK physiotherapist Adam Meakins aka the Sports Physio:

“The notion of anyone’s sacrum just ‘popping out’ is complete and utter nonsense, let alone the sacrum of a fit athletic professional male golfer without any past risk factors or history of significant trauma…

SACRUMS DONT JUST POP IN AND OUT…

The robust pelvis.  Made to last.

All that white webbing-type stuff are ligaments. Very strong stuff.  The sacrum is underneath it between the hip bones at the bottom of the spine.

For starters the pelvis is an incredibly strong and stable structure with many, many strong ligaments and muscles across it. The sacroiliac joint does have some small amount of movement, and yes some have more or less than others, but the variation is minimal and the ridiculous belief that many therapists have in thinking that they can 1) feel this joint move 2) decide if it’s in the right or wrong position and 3) adjust it with manipulations is just again complete and utter nonsense based in pseudo science and nothing more than palpation pareidolia as I have discussed before in my previous blog here and on the assessment of the painful SIJ here and its management here.”

So why did Tiger think his sacrum had ‘popped out’ well there are two possible reasons.”

One very competent and observant trainer is Boulder’s Mike Terborg. He sent me an informative article from the British Medical Journal Blogs called Common misconceptions about back pain in sport: Tiger Woods’ case brings 5 fundamental questions into sharp focus. It was written by physiotherapist Dr. Peter O’Sullivan. I won’t go into every detail of the article but I’ll summarize the big pieces. (Emphasis is mine.) O’Sullivan lists five quotes related to Tiger’s pain and then asks questions of those observations. He cites research to support his answers. Go to the article to read the whole shebangabang.

  1. “Tiger has a pinched nerve in his back causing his pain.”
    What is the role of imaging for the diagnosis of back pain?

    O’Sullivan: “Disc degeneration, disc bulges, annular tears and prolapses are highly prevalent in pain free populations, are not strongly predictive of future low back pain and correlate poorly with levels of pain and disability. (Deyo 2002, Jarvik JG 2005).”

  2.  “Tiger had a micro-discectomy for a pinched nerve which had lasted for several months.”
    What is the role of microdiscectomy for the management of back pain?

    O’Sullivan: “The role of decompressive surgery (micro-discectomy) should be limited to nerve root pain associated with progressive neurological loss (e.g., leg weakness)… (O’Sullivan and Lin 2014).  Micro-discectomy is not a treatment for back pain.”

  3. “My sacrum was out of place and was put back in by the physio.”
    What role do manual therapies play to treat back pain?

    O’Sullivan: “Passive manual therapies can provide short-term pain relief. Beliefs such as ‘your sacrum, pelvis or back is out place’ are common among many clinicians.

    These beliefs can increase fear, anxiety and hypervigilance that the person has something structurally wrong that they have no control over, resulting in dependence on passive therapies for pain relief (possibly good for business, but not for health). These clinical beliefs are often based on highly complex clinical algorithms associated with the use of poorly validated and unreliable clinical tests (O’Sullivan and Beales 2007). Apparent ‘asymmetries’ and associated clinical signs relate to motor control changes secondary to sensitised lumbo-pelvic structures, not to bones being out of place (Palsson, Hirata et al. 2014). In contrast, there is strong evidence that movements of the sacroiliac joint is associated with minute movements, which are barely measurable with the best imaging techniques let alone manual palpation (Kibsgård, Røise et al. 2014).”

  4. “I need to strengthen my core to get back to playing golf again.”
    What is the role of core stability training?

    O’Sullivan: “’Working the core’” has become a huge focus of rehabilitation of athletes and non athletes in recent years.

    Recent studies have also demonstrated that positive outcomes associated with stabilisation training are best predicted by reductions in catastrophising rather than changes in muscle patterning (Mannion, Caporaso et al. 2012), highlighting that non-specific factors such as therapeutic alliance and therapist confidence may be the active ingredient in the treatment – rather than the desired change in muscle.

  5. What should clinicians do? The paradigm shift required for managing a complex multidimensional problem like back pain.

    O’Sullivan: “Firstly, clinicians need to realise that back pain does not mean that spinal structures are damaged – it means that the structures are sensitised…There is growing evidence that low back pain is associated with a combination of genetic, pathoanatomical, physical, neurophysiological, lifestyle, cognitive and psychosocial factors for each domain. The presence and dominance of these factors varies for each person, leading to a vicious cycle of tissue sensitisation, abnormal movement patterns, distress and disability (O’Sullivan 2012, Rabey, Beales et al. 2014).”

O’Sullivan makes these recommendations to clinicians:

To adopt this new approach clinicians require at least two things:

  • Change of mindset: Abandon old unhelpful biomedical beliefs, and embrace the evidence to change the narrative to help people with pain understand the underlying mechanisms linked to their disorder.
  • New and broader skills for examining the multiple dimensions known to drive pain, disability and distress. These assessment skills need to be complemented by the skill of developing innovative interventions that enhance self management, allow the patient to engage in relaxed normal movement. The clinician also needs to encourage the patient to adopt healthy lifestyles and positive thinking about backs (O’Sullivan 2012).

The change he advocates for is sloooowly happening in some areas of health care. The strictly biomechanical model (pain = injury) is still king.

Stuart McGill, Born to Run & Ketogenic Eating

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Here’s what I’m into right now:

Stuart McGill

I recently finished Stuart McGill’s Ultimate Back Fitness & Performance.  It has definitely contributed to how I view conditioning and care of the spine.  For instance:

  • I’m very careful to avoid much if any bending or twisting at the lumbar spine.
  • According to McGill, the core musculature responds best to endurance-type training, so I now go for time rather than out-and-out strength.
  • McGill makes the observation that excellent athletes tend to have a very rigid core–but very mobile hips and shoulders.
  • Here are two videos with McGill.  The first has McGill discussing several myths regarding low back pain and core strength.  In the second video we see demonstrations of three exercises often prescribed by McGill.  These are often called the Big 3: the curl up, side plank and bird dog.?

Born to Run

I’m a little late to the party but I recently finished Chris McDougal’s Born to Run. This book has done more than almost anything to push the popularity of minimalist running.

Born to Run is more than a book about running.  Much of the book concerns the history and culture of the Tarahumara people who live in the isolated Copper Canyon region of Mexico.  Non-runners with any interest in other cultures will find this book very interesting.

The book and author have generated some controversy. Any runner knows about the hot debate over minimalist/barefoot-type running.  I won’t go into all that.  (For just about the most thorough discussion on minimalist running, you can’t do better than the Sports Scientists dissection of the subject.)

Here are some thoughts on both the book and discussions that have followed:

  • The story is quite entertaining.  It’s possible that the entertainment value of the book and a subsequent New York Times article from McDougal have somewhat overshadowed some facts.
  • Alex Hutchinson who writes the Sweat Science blog for runner’s world describes an interview with McDougal that clashes with later statements from McDougal.
  • Hutchinson brings up several points in his response to McDougal’s article titled The Once and Future Way to Run.  One is this:

“4. The one part of the article that made me kind of angry was this passage, about McDougall’s visit to the Copper Canyon in Mexico that led to Born to Run:

I was a broken-down, middle-aged, ex-runner when I arrived. Nine months later, I was transformed. After getting rid of my cushioned shoes and adopting the Tarahumaras’ whisper-soft stride, I was able to join them for a 50-mile race through the canyons. I haven’t lost a day of running to injury since.

I actually interviewed McDougall back in 2009, shortly before Born to Run came out. And that’s not the story he told me. Here’s what I wrote then:

Long plagued by an endless series of running injuries, he set out to remake his running form under the guidance of expert mentors, doctors and gurus. He adjusted to flimsier and flimsier shoes, learning to avoid crashing down on his heel with each stride and landing more gently on his midfoot. It was initially successful, and after nine months of blissful training, he achieved the once-unthinkable goal of completing a 50-mile race with the Tarahumara. But soon afterwards, he was felled by a persistent case of plantar fasciitis that lingered for two years. “I thought my technique was Tarahumara pure,” he recalls ruefully, “but I had regressed to my old form.” Now, having re-corrected the “errors” in his running form, he is once again running pain-free.

I’m in New York right now, and won’t be back home until Monday night, otherwise I’d see if I can dig up my actual notes from the interview. But I remember McDougall telling how stressed out he’d been, because he’d spent all this time working on a book about the “right” way to run — but as the publication date loomed ever nearer, he’d been chronically injured for two years. It was only shortly before publication that he was able to get over the injuries and start running again.”

McDougal responds to Hutchinson’s post here and Hutchinson replies back.

Personally this doesn’t do much to bother me or take away from a) a great story that’s told in Born to Run or b) the value and importance of minimalist running. I think it does suggest that McDougal is not a scientist and that the need to create a compelling story may persuade a writer to drift towards a bit of exaggeration.

What’s your take on this back-and-forth?

Ketogenic Diet (high-fat/low-carb/moderate protein intake)

Here’s another party to which I’m a bit late: the high-fat ketogenic diet.  In fact, most people who’ve tried it probably abandoned it back in the early 2000s. (I think they should’ve have.) You’ve heard of the Atkins diet.  That’s largely what I’m doing now.

In reality, I’m becoming more focused and precise with this type of eating.  I switched to a higher-fat diet when I became familiar with the Perfect Health Diet.My current efforts are informed by the Art & Science of Low-Carbohydrate PerformanceJeff Volek, PhD, RD & Stephen Phinney, MD, PhD are the authors. I like their credentials and their experience. To me, it lends weight to their words. Here’s a rundown of the main points of the book:

  • Their book is well-referenced and fairly easy to understand.
  • They present convincing evidence (to me) in favor of a) greatly reducing carbohydrate and b) greatly increasing fat intake and c) why this strategy can be very effective for athletes.
  • How?
    • Burning fat for fuel (aka ketogenesis) is a cleaner process.
    • Inflammatory stress is lower compared to using carbs for fuel
    • You’ll be less damaged from exercise and you’ll recover faster
    • You have a nearly limitless supply of fat for fuel compared to a limited supply of glycogen.
    • By shifting your metabolism to prefer fat, you’ll avoid bonking.
    • Also, by shifting your metabolism to prefer fat you’ll improve your body composition.  Besides the aesthetic appeal of a lean physique, if you’re lighter then you’ll have a better ability to produce power.  If you’re lighter then you should be able to run and bike faster.
    • Endurance athletes who experience GI distress may do very well on the high-fat diet.

I was motivated to dig into this type of eating after I spoke with my former client and friend Mike Piet.  He’s moved in the low-carb direction after his friend and accomplished ultra-distance runner  Jon Rutherford.  Jon’s experience as an athlete who’s increased his performance is described in  the Art & Science of Low-Carbohydrate Performance. Thus far, I like the results. I’ll talk more about them as this experiment continues.

Look for Mike Piet’s guest blog post as he describes his very interesting low-carb/high-fat experience during the Savage Man Olympic and half-Iron distance triathlons–done on consecutive  days.