As a primary care physician I have treated a lot of patients with low back pain. The usual protocol was for me to examine the patient to make sure they don't have a dangerous condition (herniated disk with nerve compromise, cancer, etc.), provide a handout with some stretches, and prescribe some painkillers as needed. If the pain didn't subside, I'd refer the patient to physical therapy.
Until about 12 weeks ago, I had never personally had a significant episode of low back pain. I'm fairly athletic and frankly lift and move heavy things without paying much attention to my posture or mechanics. In fact, I almost took pride in moving and assembling very heavy items normally considered a “2 or 3 man job” just because I could, despite the concerns of my wife….”You did what? Why couldn't you get some help?”
So roughly 3 months ago I decided we needed to replace our bed and rearrange our bedroom furniture. This meant moving and lifting our old furniture and moving in new furniture which I once again did by myself without paying much attention to my body mechanics. I woke up the next morning with severe non-radiating pain in my low back.
I was not concerned. I've had aches and pains before like elbow tendinitis (aka “tennis elbow”), heel pain (aka “plantar fasciitis”), and others and I can always find a way to heal very quickly with just a few props like la crosse balls, foam rollers, and bands (video on how to use bands for knee pain) to cut off circulation to my limbs to trigger tissue remodeling.
If this sounds crazy, please be sure to read Kelly Starrett's phenomenal book, Supple Leopard and watch and subscribe to his YouTube videos which have been a lifesaver for acute pain. Any time something hurts, I turn to Kelly's book and/or videos. He has revolutionized the approach to musculoskeletal pain with an innovative approach to common issues.
Unfortunately my usual self-healing toolkit wasn't working this time. Despite mashing on my lumbar musculature with lacrosse balls, using the foam roller and doing my range of motion exercises, I wasn't getting better.
So what did I do next? I had to assemble a small village consisting of an excellent physical therapist, a phenomenal chiropractor and a world class expert on posture to help me get through this. I want to share a few things I learned along the way so you can benefit if you are every unlucky enough to experience low back pain.
You'll also learn by the end of the post why improper posture and conditions like low back pain are risk factors for heart disease and other chronic health conditions.
Become Familiar with Esther Gokhale
Esther Gokhale, author of the bestselling 8 Steps to a Pain-Free Back, has been a dear friend of mine for years and collaborator in the space of health and wellness. Even before I developed back pain, I owned her book and attended some of her classes with my wife to familiarize myself with her approach to improve my own posture and to also learn about a resource I could share with my patients who suffered from low back pain.
Since I'd never had persistent low back pain, I realize now that I never truly internalized her wisdom and applied it to my every day life. I want to share a few key principles.
1.It's not the “injury” that caused the back pain: People with low back pain try desperately to find the isolated event that “caused” their back pain. Sometimes it's something obvious like a fall, sometimes it's something minor like bending forward to pick up a pencil or tie one's shoes, or often there is no triggering event.
The reality is that the “event” may have literally been the straw that broke the back, but the true back issue developed over years. It's the poor posture while walking, standing, sitting, loading the dishwasher, etc. that has been stressing the lumbar discs and other spinal structures over years that is the real “cause” of low back pain.
It's those chronically tight hamstrings, a side effect of your addiction to sitting, which have caused more damage to your back than the weights you lifted at the gym the other day. You might be pain-free right now, but if you do not pay attention to posture with your everyday activities and the way you exercise, you will likely encounter some form of back or neck pain.
2.Simple changes bring huge rewards: Often individuals go through a process of incorporating specific stretches for their back or hamstrings in an effort to relieve their pain. Although these interventions can be useful in the interim, you will get far greater benefit from relearning and rewiring your body to stand, sit, bend, and lie down in ways that lengthen your spine, relieving the pressure on your discs.
Esther's work is masterful in helping you relearn and rewire new behaviors that protect and preserve your spine, rather than damage it. The evidence she provides comes from beautifully archived photos from ancient history and from different corners of the world where indigenous humans perform exertional work daily with virtually no back pain during all stages of life.
3. Sit better: There has been a lot of press behind the dangers of prolonged sitting. However, there is a way to sit that can be healthier for the spine.
Standing with poor posture is more harmful than sitting with good posture.
Esther's approach to “stretch sitting” is a game changer. It takes some practice and a prop is necessary to help create the traction your spine needs. Watch her TEDx talk below:
4. Work on those glutes: Most people focus their workouts on anterior (front-facing) muscles but neglect the posterior chain, in particular a muscle on the outer quadrant of the buttocks called the gluteus medius. Now you can use equipment to develop your gluteus medius, like kicking your leg back and out against resistance using ankle weights or cables, using the hip abductor machine or doing the classic Jane Fonda leg lift workouts. These exercises are actually called Jane Fondas (watch this video) which I know conjures up images of slender woman in leotards wearing leg warmers, but guys need to put their pride aside and just do these.
However, keep in mind that our primal ancestors didn't have access to gym equipment or Jane Fonda fitness videos.
Their gluteus medius developed from the way they carried out their everyday activities. Take a look at the photo on the far right below from Esther Gokhale's book. Look at the bulging gluteus medius musculature accentuated as these Ubong tribesmen stand with their feet pointed slightly outward.
Every time you walk, stand, or do the dishes, what Esther calls “Downtime Training,” is an opportunity to engage this mostly neglected muscle. Read Esther's post, These Glutes are Made for Walking, for an engaging analysis which compares athletic and primal buttocks to the more common underdeveloped glutes in modern humans (check out Taylor Swift as a prime example of glute deficiency in her post!).
Esther's book teaches techniques such as “glidewalking” and “stretchlying” which in addition to “stretchsitting” are fundamental components of downtime training. Below is a picture of Esther assisting me with the art of “stretchsitting.”
If you have never had back pain and are a sedentary human who does not pay attention to posture, I will boldly predict that at some point you will likely have at least one episode of back, neck or some other musculoskeletal strain or injury that can be completely prevented if you learn some of these principles.
I had the help of a great physical therapist, Colleen O'Kane at Bodies in Motion and a phenomenal chiropractor, Dr.Shervin Parvini, at Silicon Valley Chiropractic Center. Colleen was relentless in making sure I worked my core and essential muscles to support my spine, especially that posterior chain.
Dr.Parvini was incredible in explaining my spinal condition in great detail including an enlightening explanation of my lumbar x-ray, which made the exercises and my care plan much more relevant. I used to be skeptical about chiropractors, but his gentle adjustments were key in restoring some of my very limited range of motion and he and his colleague, Dr. Lynnard Cabanas, helped loosen years of chronically tight hamstrings.
Like Esther, Dr.Parvini also highlighted for me that the simple act of bending, twisting and lifting even something as light as a pencil puts tremendous shear forces on the disk that can lead to herniation. Just think of how you load/unload your dishwasher from the sink, how you load/unload your washer/dryer, or how you pull weeds in your garden.
Deficient core strength and improper form while repeatedly performing such mundane, seemingly non-exertional tasks causes far more back injuries than traumatic automobile or sports-related accidents.
The guy in the picture below is lifting a concrete block, but he could be lifting a piece of paper while still exerting tremendous shear stress to the disk from the dangerous combination of bending, lifting and twisting. Notice how his legs are barely involved. Ideally he would re-position his body so he faces the object he's lifting and then use a squat motion implementing his powerful legs and glutes instead of his spine.
Yes, I recruited an all star team for my back pain not because I'm high maintenance (ok, maybe a little), but because I wanted to gain a more comprehensive understanding of what led to my back pain. My back pain is now 95% resolved, but I am now much more back and posture-aware which is a good thing since it motivates me to constantly fidget, move, stretch and incorporate some key exercises throughout my work day.
When I exercise and lift weights I'm hyperaware of posture, and for those heavy boxes and packages, I now recruit help rather than trying to heave these on my own. Remember, doing a yoga class a few times a week or simply stretching after your usual workouts are not sufficient to counteract hours and hours of sitting!
I used to intermittently do exercises like plank, but now all variations of plank have become a staple part of my workout. Please check out my post on my favorite exercises to prevent pain and improve athletic performance here. I also listed out some of the exercises that I thought were key to my recovery and nearly all are derived from yoga.
By the way, using improper form during yoga class, especially if your core is deconditioned, can seriously injure your back as well. Work within your limits and recruit a seasoned instructor to guide you.
Just Google or Youtube some of the exercises below for guidance. I also did a dedicated blog post on some of the most important exercises you can do to eliminate common aches and pains (back pain, knee pain, etc.) which you can find here.
- Plank (standard and side)
- Quadruped arm raise (aka “Balancing Table Pose” in yoga)
- Upward (aka cobra) and Downward Dog
- Doing slow Sun Salutations, emphasizing and pausing at lengthening postures
- Glute bridge with marching (thanks to Dr.Lynnard for this one)
- Hamstring stretches with assistance from multi-strap yoga band like this
- Exercises targeting gluteus medius (Jane Fondas mentioned above, leg abduction exercises using cables, ankle weights, etc.)…don't ignore your glutes!
How Did I Get Taller, Slimmer and Faster?
Improved hamstring mobility, core strength, and a developed gluteus medius had some unanticipated athletic benefits. I'm rarely sore now after running, sprinting, cycling or playing basketball and I can definitely run longer and faster than before despite no additional aerobic training. My legs move almost effortlessly. I thought being sore after these activities was a function of my age, but now I realize it was poor mobility and structure.
What about becoming taller and slimmer? Standing more upright with better core engagement, looser hamstrings that no longer push my spine forward, and spinal decompression from doing lengthening exercises (including Esther's stretch sitting and lying) and Dr.Parvini's adjustments, helped me gain another 1/2 inch thanks to restoring some fluid back into my disk spaces.
This also has an overall slimming effect over the waistline as a result of my entire body being stretched and my core more activated. Many of my sedentary patients in the clinic are often shocked when my nurse reports their height. They argue…. “you measured wrong because I've always been 5ft 8 in, not 5 ft 6 in.” I have bad news. My nurse is usually right.
They are in utter disbelief that sitting for hours hunched in front of a computer or over their smartphone can actually make them shorter. It can and more often does!
By the way, gaining a little height is a novel way to reduce body mass index (BMI), which is your weight in kg divided by your height in meters squared. Most people only focus on lowering their weight (numerator) to lower BMI, but adding some height (denominator) can have the same effect!
Why Am I Talking About Back Pain?
You might ask why I decided to discuss low back pain on this particular blog where I tend to focus on topics like insulin resistance, nutrition, sleep and stress. Keep in mind that I've repeatedly emphasized through my work that inflammation is the root cause of most chronic health conditions like heart disease, cancer and Alzheimer's disease.
Low back pain or any significant musculoskeletal pain is one more potential source of inflammation that contributes to our overall lifestyle-induced burden of inflammation resulting from poor nutrition, stress, inactivity and sleep deprivation.
Eating an unhealthy diet affects the health and nutrition of your spinal disks and may be both a risk factor for low back pain and may impair recovery. There is a burgeoning field of medicine called integrative pain management where practitioners are finding that combining lifestyle factors like an anti-inflammatory, nutrient dense diet and stress reduction can have a profound impact on healing pain. This site provides a good overview.
I will tell you that during the time I experienced low back pain, I was less active, more stressed, had more difficulty sleeping and my overall sense of wellness and vitality took a major hit. I held onto my good eating habits, but in many of my patients even their diet spirals downward when one of these injuries occur.
Weight goes up, which means even more strain to the back, and metabolic numbers (glucose, lipids, etc.) deteriorate. This study done in Korea found a significant correlation between metabolic syndrome, a key risk factor for heart disease, and low back pain.
So I ask each of you to start being mindful of your posture in every aspect of your life until proper form becomes ingrained into you as it had been in our ancient ancestors. Improper posture is a significant risk for chronic conditions like diabetes and heart disease and is as important to our health as nutrition, exercise, stress and sleep.
– Read this post by me on my favorite exercises to prevent/eliminate common aches and pains
– Learn about the Gokhale method here