Sunday, February 12, 2012

Back Pain? Do Your Squats & Eat Your Fish Oil

If you can't fix it with squats or fish oil, you are probably going to die

Rapid and early return to exercise and physical activity is one of the most important aspects in the self-management of simple mechanical low back pain, which about 80% of individuals experience sometime throughout their life. Unfortunately, conventional medicine and conventional wisdom perpetuate the belief that when someone is experiencing pain, they must rest and thus avoid all of the activities that cause their pain or discomfort. 

In a sense, that statement is true. That is, of course, if the pain is arising from the viscera (i.e. stomach, kidneys, colon, gallbladder, etc), if there are any red flags upon a doctors initial history or examination, or if there is a pathology that requires medical or surgical intervention.  The assessment of “red flags” will identify the small number of patients who need referral to a specialist, special testing/imaging (MRI, X-ray, CT, etc.) or for an urgent medical procedure. In the event of moderate-severe trauma, which isn’t too common in the gym as it pertains to back pain, imaging is most certainly warranted before advising to return to exercise. For the common complaint of back pain [or neck pain] in the absence of red flags and trauma, the best advice I can give an athlete is to get up, move around and get back to hitting those weights. You certainly might have to modify specific movements or technique but go lift something. Squat something. Overdose on some Vitamin D and fish oil. Rub fish oil on your back. Sprinkle several thousand International Units of Vitamin D over the problematic area to increase tissue healing and thus reduce pain. I’m lying on the latter part. Don’t sprinkle. Eat it.  Eat it with fat since Vitamin D is a fat-soluble vitamin. I digress.

Rapidly returning to physical activity decreases the likelihood of the athlete developing long-term or chronic issues. In many cases, getting back into the gym is the wisest decision one can make since bed rest and avoidance of activities quite often perpetuates the pain experience. Typically, the longer an injured athlete keeps from engaging in activity due to their back pain, the longer they will experience such pain. In other words, the amount of time an athlete stays away from activity is directly related to the success he or she will have in overcoming their spinal [low back] pain issues. 


When someone is experiencing low back pain in the absence of trauma, and no red-flags have been established, there are typically four (4) tissues to where the pain is arising from. These tissues, also known as pain generators, are the disc, nerve, muscle, or joint. Most people always assume their low back pain is muscular in origin.  Primary muscle pain is not as common as we all like to think. Throughout the body, our joints- including the facet joints in the vertebrae- contain a high number of pain receptors and often times are the contributing factor behind low back pain. On a side note, the lumbar vertebral joints also have pain referral patterns that are known to manifest as flank pain, buttock pain, and/or posterior leg pain. Intervertebral discs can also exhibit this same pattern. This phenomenon of referred pain is similar to an individual experiencing jaw pain or left arm pain while having a heart attack. Pain does not always arise from the specific area where the individual experiences it. It is thus a complex mechanism that is still not fully understood. Again, I digress.

Disc pain is also quite a common occurrence and often times a substrate for low back pain. Without getting too deep into the pathophysiology, when a disc is injured, specific blood cells flood the area, essentially creating inflammation and releasing specific compounds that increase pain.

Rapid return to physical activity following an injury and/or spinal pain is not always an easy process. Athletes are often fearful about returning to activity or to the same environment in which they were injured. Also, many individuals are under the impression that if they have pain, they must have damaged tissues, and they assume any form of activity can cause further damage and/or prolong the healing process. This impression is typically reinforced by their physician, friends, or conventional wisdom which, as stated above, usually recommends rest and avoidance of painful activities as part of the recovery.
 
Among the most important factors in returning to physical activity are fear of re-injury, catastrophizing (Oh my, I have back pain and I can’t do deadlifts or squats ever again), general psychological distress due to current lack of exercise or taking time off (Oh my, I haven’t squatted or deadlifted in days and I am getting fat and weak), and the athletes’ low expectations of recovery or hindrance of improvement.  After an injury, it is quite typical for an athlete to become fearful about further injury which results in avoidance behavior. Pain-related fear is associated with increased bodily awareness and hypersensitivity to pain, which can lead to an increase in time needed to return back to the gym. As a result, this causes the injured athlete to lose confidence and self-efficacy in his or her ability to recover and return to normal activities. The simple remedy for this would be returning to physical activity. 



Back pain does not have to be a serious disease; in fact it is quite common. Almost all of us will experience back pain throughout our life and it is often recurring. It should not cripple you nor really interfere with your ability to perform unless you let it. The important thing is for you to get on with your life. How your backache affects you depends on how you react to the pain and what you do about it yourself. Acute low back pain is best treated with minimal rest and rapid return to exercise and normal activities. There are no instant answers. You will have your ups and downs for a while—that is normal. But look at it this way. There are two types of sufferers: The avoider and the coper. Which one are you?

- The avoider gets frightened by the pain, refrains from any physical activity, and worries about the future. Their perception of health change as a result of the injury is usually negative.
- The avoider is afraid that pain always means further damage—it doesn't. They do not “challenge” their pain. In their mind they have a serious condition.
- The avoider rests a lot, harps on their pain, uses it as an excuse, and waits for the pain to get better.
- The coper knows that the pain will get better, deals with it accordingly, and does not fear the future.     They “get it”.
- The coper carries on as normally as possible, goes about their daily activities, and wants to get back to   the gym as quickly as possible.
- The coper deals with the pain by being positive, “challenging” the pain, and staying active.


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available through this web site is for general information purposes only.  The author makes no representation and assumes no responsibility for the accuracy of information contained on or available through this web site, and such information is subject to change without notice. You are encouraged to confirm any information obtained from or through this web site with other sources, and review all information regarding any medical condition or treatment with your physician.


Dr. Wayne J. Broth earned a Bachelor of Science degree in Animal Science, pre-veterinary medicine, from Rutgers University, New Brunswick, NJ, and is a graduate from Palmer College of Chiropractic Florida. He was a recipient of the Clinical Excellence Award, Clinical Service Award, nominated for the Virgil Strang Philosophy Award, and also served as a Clinical Teaching Assistant at the Palmer College of Chiropractic Florida outpatient clinic. He obtained certification in electrodiagnosis and acupuncture and completed his clinical internship at the Rhode Island Spine Center under the guidance of renowned physician, Donald R. Murphy, DC, DACAN.

  Dr. Broth’s clinical focus is the diagnosis and treatment of spine pain including headache, neck pain, and back pain. He has a keen interest particularly in low back pain, active rehabilitation, nutrition, and exercise. He utilizes the most current evidence-based approach to treat patients non-surgically. Dr. Broth currently maintains his practice, Florida Spine and Rehab, in North Palm Beach. He is also the co-owner of Gardens CrossFit, a CrossFit affiliate located in Palm Beach Gardens, Florida. When he is not at his Chiropractic office he is coaching many of the athletes at Gardens CrossFit in nutrition and its implications for improved health, disease prevention, and increased performance both inside and outside of the gym. He has taken the CrossFit Level 1 Trainer course and the CrossFit Endurance course. In April, 2012, Dr. Broth will be starting coursework for his masters degree in nutrition and functional medicine through University of Western States.

References:
Lawrence JP, Greene HS, Grauer JN. Back pain in athletes. J Am Acad Orthop Surg. 2006 Dec;14(13):726-35.
Sucato DJ, Micheli LJ, Estes AR, Tolo VT. Spine Problems in Young Athletes. Instr Course Lect. 2012;61:499-511
Van der Giessen RN, Speksnijder CM, Helders PJ. Disability Rehab. The effectiveness of graded activity in patients with non-specific low-back pain: a systematic review.
Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskeletal Disorders 2007.
Picavet H Vlaeyen J, Schouten J; Pain catastrophizing and kinesiophobia predictors of chronic low back pain; Am J Epidemiol, 2002;156:1028-34.
Liddle SD, Baxter GD, Gracey JH. Pain. Exercise and chronic low back pain: what works?  2004 Jan;107(1-2):176-90.
Hayden JA, van Tulder MW, Tomlinson G. Ann Intern Med. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. 2005 May 3;142(9):776-85.

14 comments:

  1. Damn good article. I recently (2 months ago) hurt my back deadlifting and was diagnosed with a herniated disc. I called bullshit and got a second opinion and found out it was just a little nerve damage. A steady diet of squats, fish oil, and (gasp) deadlift have me back to almost 100% in only a months time.

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  2. Ok, so let me throw this out there. My L4 slips out under heavy squat weight, originally believed to be a herniated disk. My Chiro pops it back in and the only pain is from the previous swelling. I am assuming it is nerve damage. Should I just go light squats for a long while and add on the reps or rest it? I want to heal the ligament up so it does not hurt, and get back at it ASAP.

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  3. Good question Spelhaug. First off let me clarify something. The term "slipped" disc is a misnomer. Discs cannot slip as they are held tightly onto the adjacent vertebrae. They can bulge, herniate, or sequester, but cannot slip. I know, conventional medicine uses that term quite often. Kinda like the term "my back went out." Oh yeah? It went out? Where did it go? Is it having fun? When is it coming back? Backs cannot go out!
    Anyway, to answer your question I would need more information to give a prudent and fair answer. But,as a rule of thumb if the pain is non-radiating, i.e. you do not get numbness, tingling, or pain into the buttocks or lower extremities, or the pain does not interfere with your ability to engage in daily activities or physical activity,then just lift while being incredibly conscious of proper technique. Long term self-care of low back pain includes deep spinal stabilization exercises and nutritional recommendations i.e. an "anti-inflammatory" diet.

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  4. Biggest piece of advice I can offer (personal experience after i pulled my lower back) go hit up mobilitywod.com if you haven't ever been there. Do the stretches and as KStar says stay "supple" in a weeks time my back was back to normal (after 4 weeks of chiro appts and taking it easy).

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  5. Needed that pep talk today...back doesn't feel great, but moving on. :)

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  6. Dr Broth, So much knowledge, glad you're speading it!

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  7. In reference to discogenic pain, I believe it is important to note the cumulative nature of disc-related trauma. Discs in asymptomatic, healthy individuals have little to no pain receptors. Excessive repetitive loading without sufficient rest leads to a series of microfractures in the endplate (which supply nutrients to the disc) thus creating scar tissue. The scar tissue reduces the ability for the disc to receive the adequate amount of nutrients/liquid, thus changing the material properties of the disc (add a few more steps here). This in turn could lead to disc bulging/herniation. From here, studies from Mike Adams (one of them: Clinical Biomechanics 25(2010) p.961-971) have postulated the growth of nerves in the periphery of the disc which is a potential source of pain. Also, in a series of studies from my laboratory, we have found that most people cannot sense load on the spine (Le P et al 2012 – (Ergonomics), Psychophysics and Spinal Loading). In essence, if sensation (disc) is felt, the damage is most likely already done.

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    Replies
    1. please- continue! are you saying that this article is tots wrong?

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  8. This is a great topic. I have 5 herniated discs from being hit by a car on my bike.
    Whenever I squat or deadlift more than 300# I always wake up with back pain. Even doing singles or low rep work, a day or two later I'm in pain and have a hard time walking.
    It then usually takes me 2-4 weeks before I feel well enough to squat or deadlift again.
    I cope with the pain and work through it, but if I try to lift past 300# I end up in pain again. This is a cycle I've been trying to break for a while now, and have yet to get any serious info on how to stop this.
    Any feedback would be awesome. Cheers.

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  9. Discs are one thing my problem comes from a broken coccyx I got from a fall, and my hips were sitting so crooked from it that I'd get extreme low back pain once I'd squat or deadlift 400+. But I found abductor exercises have brought me back to my old form on deads and squats, other than the numerous adjustments too. But my push press is still down and out going from 260 to now a lowly 225. :(

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  10. About three years ago I was on a jet ski and t-boned by another jet ski going full speed. The front of the other ski was thrust upward by the impact and hit me in the back. Luckily the 1 inch of foam in my life vest helped disperse and lessen the impact force but it threw me into the water and had me walking with a limp for months! A month after the accident I went to the gym and worked through the pain doing squats, deadlifts, SLDL's, all with very light weight of course. After about 2 months of this I considered myself fully recovered and haven't had any problems since. In fact my back is now the strongest it has ever been in my entire life.

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