Low back pain exercise: curl-up for low back pain

I just recently reworked some of the video on the exercises that I often recommend for patients.  Below is video on the curl-up, an exercise described by Stuart McGill.  This exercise is an essential exercise for most any back pain rehabilitation program.

Let me know if you have feedback or comments. More videos are forthcoming to fill out the exercises that I frequently recommend.

Kettlebell Exercises for Neck and Back Pain

The Kettlebell is a cast-iron weight used for centuries to train Russian soldiers and athletes.

Kettlebell exercises for back and neck painIn the context of Crossfit and dynamic exercise programs, Kettlebell exercise programs are being applied in many different forms.

An interesting study recently published a study evaluating the potential for Kettlebell exercises to be helpful with back and neck pain.

The study, published in the Scandinavian Journal of Work and Health, looked at a group of 40 adults from occupations with a high prevalence of musculoskeletal pain symptoms.[i] 

The study participants were assigned to either a (1) Kettlebell training group where they did “full-body” kettlebell exercises 3 times per week for 8 weeks or (2) a control group.

The researchers found improvements in the Kettlebell training group in terms of: 

• Increased strength of trunk extensors
• Decreased pain intensity of the neck/shoulders
• Decreased low back pain intensity

These findings are important in several respects.

1. The spine extensors are critically important to stabilization.  Studies have demonstrated a clear connection between decreased endurance in the spine extensors and back pain (The Importance of Endurance in Spine Extensors for Runners)
2. Endurance of the spine extensors for the neck and upper back similarly have demonstrated importance in the treatment of neck pain (More Evidence for the Importance of Endurance of Spine Extensors for Neck and Back Pain)

I will post some additional video soon on the topic of which exercises with Kettlebells make the most sense for people with back and neck pain.

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[i] Scand J Work Environ Health. 2011 May;37(3):196-203. doi: 10.5271/sjweh.3136. Epub 2010 Nov 25.

Low back pain exercise: the curl-up

Here is an updated video on the curl-up exericse, one of Stuart McGill's "big three" exercises for lumbar stabilization.

Watch the video here and leave comments below.

Mattresses and Back Pain

As is often the case, I had a few patients this week ask me, “What kind of mattress is best for back pain?”

Then I received an email from a patient about this same issue.  I have included portions of the email below and will try to communicate where the data stands (or sleeps in this case) on the issue.

Hello Dr. Mangrum:

I was your patient two years ago this spring for upper back and neck pain.  You treated me fairly successfully…

Here’s the reason for me bothering you.  My wife and I need to buy a new mattress.  I’d really appreciate your thoughts on what type might be best for me.  Specifically memory foam, vs latex vs a traditional innerspring mattress…

Any thoughts, caveats or wisdom you could share would be most appreciated.

This question is more complicated than it may seem at first blush.  One reason for this is that back pain is often worse first thing in the morning, regardless of what type of bed you sleep on.

The discs in our spine tend to lose around 20–25% of their water content “due to high loads imposed by muscle tensions during the day's activity; this water is regained during the decrease in load under rest at night.”[i]  So first thing when you wake up in the morning the disc is superhydrated and more stiff.   

Similarly, joints with inflammation or arthritis often are more stiff first thing in the morning.  One of the defining factors, in fact, for osteoarthritis is stiffness that lasts for less than 30 minutes after waking up.[ii]

With that in mind, I hate to recommend someone with back pain go out and spend hundreds (or thousands for that matter) on a new mattress when the mattress may not be the source of the trouble in the morning.

Recognizing that a mattress is not the only thing that can cause pain or stiffness first thing in the morning there is some evidence that updating your mattress or certain types of mattresses can be helpful for someone with back pain.

A study published in the journal Applied Ergonomics studied a group of people with chronic low back pain.[iii]  They had these study participants report sleep quality and rate back pain/stiffness for 21 days in their own beds.  Then the participants beds were replaced with medium firm mattresses layered with foam and latex.  The study found significant improvements in sleep variables and back pain at 4 and 12 weeks after changing mattresses. 

A related study published in Spine compared the effects of sleeping on:  (1) waterbed (Akva), (2) body-conforming foam mattress (Tempur), and (3) a hard mattress (Innovation Futon) for one month.[iv]  The researchers found that “Both the waterbed and the foam mattress seemed superior to the hard mattress” in terms of decrease in back symptoms, improved function and sleep.[v] 

So if nonthing else I know that my dad was off base when he told me it would be better for my back to sleep on the floor.

These studies, though, are complicated.  There is not an easy way to do a placebo controlled trial for mattresses.  As a result there are no great head-to-head studies for innerspring mattresses versus latex foam mattresses.  If one mattress maker touts their product as being scientifically proven to be superior to other mattresses you may want to take pause.  The range of sleep position preferences and varied anthropomorphic characteristics of the human body likely make a one fix for everyone impossible.

All this being said, there actually is pretty good evidence that getting a new mattress (especially if your mattress is older than 9 years old) can improve back pain.[vi]  This effect of new bedding improving symptoms plays out in a number of different studies (each with different “new” bedding systems).  This could be a placebo effect of sorts. 

Hopefully this information is useful for those of you considering buying a new mattress.  Let me know if you have comments or a preference for one specific type of mattress.  Leave comments below.  I am sure others are interested in a range of opinions and experience with this issue.

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[i] August 1993 Radiology, 188,351-354.

[ii] http://www.spine-health.com/conditions/arthritis/osteoarthritis-symptoms

[iii] Appl Ergon.  2010 Dec;42(1):91-7. Epub 2010 Jun 26.

[iv] Spine.  2008 Apr 1;33(7):703-8.

[v] Spine.  2008 Apr 1;33(7):703-8.

[vi] J Chiropr Med. 2009 March; 8(1): 1–8

Weight Loss Can Improve Back Pain

I had and experience in the office last week where a patient called me an #%$ for bringing up the subject of weight loss in relationship to back pain.

This kind of conversation is always complicated and I try to be sensitive to the complicated situation of being in pain and having someone tell you to “just lose some weight.”  I understand that the cycle of pain often perpetuates issues of weight and I want to be helpful to facilitate change.

Still smarting from being called an #%$, I found this recent article published in the Spine Journal interesting.

At study by Roffey et al[i] looked at the efficacy of a pilot, multidisciplinary, medically supervised, nonsurgical weight loss program on the severity of low back pain.

The program was not for the faint of heart but does highlight the potential for a person that is committed to decrease severity of back pain symptoms by working on this issue.

The program considered in this study was 52 weeks in duration and was administered by a team of physicians, dietitians, exercise specialists, and nurses. 

• The initial phase of the program involved liquid meal replacements for 12 weeks. 
• Then the participants transitioned into a phase of supervised caloric restriction diets for 13 weeks.
• The participants attended weekly group therapy and educational meetings for the first 26 weeks. 
• All participants were instructed to continue the caloric restriction diets after the initial supervised portion. 
• Finally, the participants were instructed to engage in 60 to 90 minutes of daily physical activity.

Results: 

The study participants were 46 obese adults (mean body mass index [BMI] 44.7±7.6 kg/m2). 

In this study, the participants all reported having back pain at baseline.  About 60% reported mild back pain, 30% reported moderate back pain and roughly 10% reported severe back pain.

By week 14 in the study the researchers found significant improvement in pain scores, weight loss and disability.  Reduction in BMI during the course of the study was significantly associated clinically important improvements in pain and disability.

Don't be an #%$.  Talk about weight loss.  There is good data supporting the fact that in lifestyle and activity can translate into real improvements in pain and function.

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[i] Spine J. 2011 Mar;11(3):197-204.

Want to be Taller? Measure your height early in the morning. Low back pain and diurnal changes in disc height.

If you have back pain you probably have experienced difficulty putting on your socks first thing in the morning.  Ever wonder why?

It’s a disc issue.  That is, the intervertebral disc receives nutrition through the flow of fluid into and out of the disc.  This flow of fluid alters the height of the disc.  Over the course of a night lying on your back, the discs have imbibed fluid and are usually at a maximum height or relative fullness of fluid.  As a result, people with back pain are often “more stiff” first thing in the morning.

Studies have demonstrated a diurnal (or daily cycle) of variation in spine length.  One study showed that we can lose as much as 19mm of sitting height over the course of a day.[i]   Another study found that the lumbar disc lose about 10% of their height over the course of the day.[ii]  What is more noteworthy is that about 50% of this height loss occurs in the first 30 minutes after getting out of bed.

An appreciation of the changes that occur at the level of the disc have prompted experts like Dr. Stuart McGill to recommend that people “should not undertake spine exercises – particularly those that require full spine flexion or bending – just after rising from bed given the elevated tissue stresses that result.”[iii]

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[i] Spine. 1994 Apr 15;19(8):935-40.

[ii] Yonsei Med J. 1997 Feb;38(1):8-18.

[iii] Low Back Disorders.  Stuart McGill.  2007.

A Carrot A Day to Keep the Back Doctor Away: effect of beta carotene on lumbar spine degeneration

People have claimed that antioxidants are important for treating or preventing all kinds of diseases.  The argument has been that “free radicals” are produced in the body and can cause harm to tissues through injury to proteins, DNA and lipids. 

Antioxidants are supposed to slow down or reverse these degenerative changes associated with free radicals.  Vitamin E, for example, has been suggested as a treatment for heart disease.  Recent studies, though, have failed to demonstrate clearly positive results with Vitamin E supplementation.[i]

On a theoretical basis, the notion of consuming antioxidants to slow or reduce degenerative changes makes some sense.  That is in part why I found a recent study published in the journal Spine interesting.[ii]

The study looked at the relationship of bone spurring (lumbar osteophyte formation) on x—rays with serum levels of antioxidants (carotenes, Vitamin A, Vitamin E). 

In the study 286 people were screened with x-rays, serum levels of antioxidants, triglyceride levels, history of alcohol intake, osteoporosis, back muscle strength and other factors.  The investigators found that “a low beta-carotene level was the strongest risk factor for osteophyte formation [or the development of bone spurring].” [iii]

Bone Spurring (Osteophyte Formation) in the Lumbar Spine

A related study showed that Vitamin E can have an inhibitory effect on the onset of knee osteoarthritis.[iv]

It should be noted that this study is not commenting directly on issues of pain. There are not any studies to date showing a direct line between pain and antioxidant consumption.  However, the emerging evidence certainly highlights the association between beta-carotene and lumbar spine degeneration.

So if you want to prevent degenerative changes in the spine it may be worth eating more carrots (or whatever antioxidant rich foods you choose). 

Beta-carotene: It does a body good.

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[i] Cardiovascular Ther.  2011 Apr 1. doi: 10.1111/j.1755-5922.2011.00266.x. [Epub ahead of print]

[ii] Spine.  2011 Dec 15;36(26):2293-2298.

[iii] Spine.  2011 Dec 15;36(26):2293-2298.

[iv] J Orthop Sci.  2010; 15:477-84.

Recurrent Disc Herniation after Lumbar Discectomy: "I Still Haven't Found What I am Looking For"

A discectomy is a procedure where material from a herniated disc is cut out or removed by a surgeon.  Before the disc material is removed usually some of the bone of the affected vertebra may be also cut out.

Lumbar discectomy is the most common surgical procedure performed for people with low back and leg pain related to herniated discs in the United States.  Generally patients do very well after a discectomy procedure.  In terms of outcomes, patients usually report significant improvement in radicular leg pain after a discectomy.  Improvement in axial low back pain often occurs but is less reliably predictable than leg pain symptoms.

A recent study published in Spine looked at the incidence of recurrent disc herniation during the first two years after a lumbar discectomy surgery.

The study found that after a lumbar discectomy nearly 25% of patients demonstrated radiographic evidence of recurrent disc herniation at the level of prior surgery within the first two years after surgery.[i]  About 10% of these recurrent disc herniations were symptomatic and a source of pain/disability. [ii] 

I see people in the office with disc issues and they tell me they want a “fix” for their symptoms.  We live in a quick fix culture.  Surgery is a good fix for certain issues.  However, this recent study highlights the issue  that surgery is not a permanent cure-all.  Unless we address the underlying issues that create degenerative disc conditions we are at risk for recurrent disc herniation. 

And how do we address these “underlying issues”?  Exercise, correct postural deficits, improve cardiovascular health[iii] and stop sitting too much.  And maybe listen to our moms a little more...

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[i] Spine.  2011.  36(25): 2147-2151.

[ii] Spine.  2011.  36(25): 2147-2151.

[iii] http://www.backexercisedoctor.com/journal/2010/3/15/nutrition-and-low-back-pain.html

MRI and Epidural Steroid Injections for Low Back Pain and Sciatica

Low back pain one of the three top reasons people seek medical care and a leading cause of disability worldwide.

Despite all the people walking around with back pain, consensus about how best to treat back pain is an evolving issue. 

A recent study published in the Archives of Internal Medicine highlights issues with decision making about how best to treat low back pain.[i]  The study results are most informative in the context of a clinical scenario that presents itself to me every day.

A patient walks into the office describing low back and leg pain.  He (or she) has a history and examination suggestive of sciatica (or radiculopathy).  The patient has tried physical therapy or other conservative interventions without success.  What do we do now?  Often these people will (1) get an MRI and (2) have (or at least consider having) an epidural steroid injection.

A study from a group at Johns Hopkins School of Medicine raised a question about whether getting an MRI before an epidural steroid injection improved outcomes. [ii]  The researchers conducted a randomized controlled trial.  For the patients in group 1 the treating physician was blinded as to MRI results.  In group 2 the physician decided on the treatment after reviewing the MRI.   A total of 132 patients were randomized into these two groups.  The results researchers found that outcomes at one and two months were very similar for both groups.

The authors concluded that “the results suggest that although MRI may have a minor effect on decision making, it is unlikely to avert a procedure, diminish complications, or improve outcomes. Considering how frequently ESIs are performed, not routinely ordering an MRI before a lumbosacral ESI may save significant time and resources.” [iii]

The results are interesting, at least to a treating physician that routinely performs epidural injections.  Often I feel like I know what we are going to do but order an MRI to cover myself from a medicolegal perspective.  That is not to say that MRIs are not a useful tool.  I order a lot of MRI studies and they are very appropriate in a wide range of medical situations.  As we consider, though, reform of our medical system and better using our resources this study provides insight into a common clinical situation and maybe give direction about how we can better use resources.

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[i] Arch Intern Med. Published online December 12, 2011

[ii] Arch Intern Med. Published online December 12, 2011

[iii] Arch Intern Med. Published online December 12, 2011

Natural Treatments for Migraine Headaches

I have a lot of patients ask me about natural or supplement-based treatment options.  I wanted to briefly share some information on the use of magnesium, co-enzyme Q10 and riboflavin for migriane headaches.  In a separate post I will share more detail on this subject.

Magnesium:

Evidence is emerging to suggest that a deficiency of magnesium occurs in people with migraine headaches.  This may be especially true for women with migraine headaches associated with premenstrual symptoms.  Studies have reported positive results with the use of magnesium supplementation in the range of 600mg daily.  Three to four months of supplementation at this dosage is likely needed to achieve the preventative benefit for headache symptoms.  What is more, magnesium dicitrate seems to be the preferred form for this supplementation.[i]

Riboflavin:

Riboflavin is the water-soluble vitamin B2.  This vitamin has effects on energy metabolism in the body.  Riboflavin has been shown to have positive effects on preventative migraine treatment (prophylaxis).  The mechanism of action for this effect is unclear but it may be related to effects on oxygen metabolism in cells.  Studies have shown an effective dose to be 400mg daily of riboflavin.[ii]

Coenzyme Q10:

Coenzyme Q10 is a substance made naturally by the human body.  It acts as a catalyst that is used by enzymes in the body in the process of energy production.  As a supplement, CoQ10 is used in many conditions including: high blood pressure, breast cancer and Alzheimer’s disease.  The recommended dose of coenzyme Q10 for migraine treatment is 100mg three times per day.  On study showed that the frequency of migraine headaches was reduced by 50% in a group of patients using coQ10. [iii]

Larger randomized controlled trials are certainly needed to clarify the effects of these supplements in the treatment of migraine headaches.  That being said, there is encouraging evidence that magnesium, riboflavin and coenzyme Q10 have the potential to be helpful with migraine headache prevention.  And they are all safe, generally well tolerated substances that may have wide-ranging positive effects.

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[i] Vitam Horm.  2004;69:297-312.

[ii] Vitam Horm.  2004;69:297-312.

[iii] Vitam Horm.  2004;69:297-312.