Will Marathon Running Hurt Your Back?

A patient who came in earlier this week asked if I still did any running. He had signed up for the Singapore marathon early next month and was worried that he may hurt his back taking part. He wanted my views since he had heard about my compression fracture (pictured below) as he had the occasional back ache.

Spot my compression fracture at L1?

I shared with him what I did and showed him the evidence that running definitely did help my low back pain. Of course I am not running as fast nor as long as when I used to race. I hardly run more than 7 km at a go now. Mainly due to a lack of time rather than an inability to.

I also shared with him other evidence of how researchers studied a group of runners who had never attempted a marathon before. 

28 runners (14 males, 14 females) with an average age of 30 signed up for their first marathon and were recruited by researchers. They went for a high resolution MRI screening 16 weeks before (time period 1) the race and another 2 weeks after the race (time period 2). 

The scans were subsequently assessed by senior musculoskeletal radiologists. At time period 1, 61 percent (17 out of the 28) of the runners had disc degeneration at mainly L4-L5 and L5-S1 levels. However, none of them had any back pain nor other symptoms.

Subsequently, the subjects underwent a 16 week training program. 21 out of the 28 runners completed both the 500 miles (800km) training and the race. The other 7 did not complete the training nor started the race. None of them dropped out due to spine related issues.

During time period 2, the researchers found no progression (or worsening) in those who had the disc degeneration in the second MRI. In fact, there was a regression in 2 out of 8 patients with bone marrow oedema in their sacroiliac joints (SIJ). Meaning their scans improved!

The only 'blemish' was one participant who had a small increase in the size of a subcondral cyst. However, this participant remained pain free.

Still thinking about doing that first marathon? Well, you know that running will not wear out your knees nor worsen your back. In fact your joints and connective tissues love movement. Movement lubricates your joints and hydates your connective tissues. So go run that marathon!

Reference

Horga LM, Henckel J, Fotiadou A et al (2021). What Happens To The Lower Lumbar Spine After Marathon Running: A 3.0T MRI Study Of 21 First-time Marathoners. Skeletal Radiol. 51: 971-980. DOI: 10.1007/s00256-021-03906-5.

My L1 is 'collapsed' compared to above and below

X-ray of my back 2 weeks after my first accident above.

Is Yoga Helpful For Low Back Pain?

Please let me be clear, I have nothing against anyone doing yoga or any yoga instructors. I'm just sharing what I read from a published Cochrane review.

This latest Cochrane review that was just published 2 days ago, evaluated whether yoga was beneficial or harmful for treatment of non specific low back pain. Review articles from the Cochrane Database of Systematic Reviews are highly respected and trusted.

The review wanted to find out if yoga helps improve function (getting dressed, walking or housework), quality of life and pain associated with low back pain. Medical databases searched for randomized controlled trials of yoga compared to sham (fake) yoga, no treatment, any other treatment and yoga added to other treatment.

Altogether 21 trials with 2223 participants (mostly women in their 40's or 50's) were found. 10 trials from USA, 5 from India, 2 form UK and 1 each from Crotia, Germany, Sweden and Turkey.

10 studies compared yoga to no exercise control group which received usual education and were put on a waiting list for yoga. 6 studies compared yoga to back-focused exercise or similar core exercise programs.  5 studies compared yoga, no exercise and qigong.

At 3 months, there was low to moderate evidence that yoga was slightly better than no exercise in improving back function and pain, although the difference were not sufficiently important to the person with low back pain. 

There was low quality evidence for better clinical improvement with yoga while there was moderate quality evidence for a slight improvement in both physical (able to be active) and mental (emotional problems) quality of life.  Evidence was of very low quality for helping depression. In addition there was moderate quality evidence that there was little or no difference between yoga and other types of exercise in improving back function and pain.

Increased low back pain was the most commonly reported 'harmful' reaction and there were no reported cases of serious side effects. There was low quality evidence that the risk of harm was higher with yoga than no exercise and back-focused exercise.

No studies comparing yoga to sham yoga were found, so there is no evidence how yoga would affect low back pain if people did not know they were doing yoga. All the participants knew they were doing yoga and this may influence their interpretation of whether their back pain has changed.

There you have it, quite different from what you have been told, heard or read. Our goal is to help patients confidently take up different movement, postures, physical activity, social and work engagement so you can can a healthy and pain free life.

There are free educational resources to support these processes if you do have low back pain and have not seen us in our clinics.

You can watch this Youtube video or visit this site for more details. This will help reduce stress and build self sufficiency for you to better self manage your LBP and make better informed choices about your care.

Our spine is strong, robust and adaptable. A campaign to change this may encounter resistance even in the physiotherapy and ergonomic professions as their business model may not be in line with what we now know to be best practice for managing low back pain.

So here's my take, whether it's yoga, pilates, stationary cycling or any exercise, it is your choice, as long as you keep doing it consistently, it will help your low back pain. Find an exercise you enjoy and keep at it. 

Reference

Wieland LS, Skoetz N, Pilkington K et al (2022). Yoga For Chronic Non-specific Low Back Pain. Cochrane Database of Systematic Reviews. Issue 11. Art. No : CD010671. DOI: 10.1002/1465.CD010671

What Happens When Patients Are Sent Too Early For An MRI

Picture by Naiserie from Flickr

My patient came in to our clinic yesterday complaining of some mild low back pain. He had been referred by his family doctor to have an MRI done as the doctor was not sure what was the cause of the back pain.

I was surprised, after examining him, that he was referred for an MRI so soon. His back pain did not seem sinister. At the end of yesterday's session, his back was completely pain free.

I shared with him a really interesting article I had just come across. The researchers studied data of patients seeking treatment for non-specific low back pain without a red flag (warning or danger) condition and no low back pain in the previous six months.

More patients had back surgery if they were referred for an MRI within the first six weeks of an initial visit to the doctor (1.48 % versus 0.12 % in cases without an early MRI). 

The patients also complained of a higher pain score when they had an early MRI. In fact, overall outcomes were worse, including greater use and potential harm for prescription medication (35.1 % versus 28.6 %). There were also higher costs for other medical care ($8,802 versus $5,560).

This association was also true when patients had to pay for their treatment (compared with not having to pay at all).

Perhaps this information will help bring down costs for Singapore's Integrated Shield Plans since there was such an outcry when it was announced that premiums were going higher despite increasing coverage.

Reference

Jacobs JC, Jarvik JG et al (2020). Observational Study Of The Downstream Consequences Of Inappropriate MRI Of The Lumbar Spine. J Gen Int Med. DOI: 10.1007/s11606-020-06181-7.

Physical Activities Does Not Wear Out Our Spine

I've written more than five other posts on our back / spines recently, well here's another article to align with our Instagram and Facebook posts this week. You can watch the three videos here.

We've all been sitting a whole lot more, myself included during the circuit breaker. Here's what research is suggesting, that it is actually physical inactivity and not physical labor that is associated with degenerative (or wear and tear) changes in the thoracic and lumbar spine.

The researchers studied 385 subjects on the relationship between short and long term physical inactivity and degenerative changes of the thoracic and lumbar spine over a period of 14 years. They grouped the subjects into those who did no physical activity, or did so irregularly for 1 hour a week, regularly for 1 hour a week, or regularly for more than 2 hours a week.

In addition, physical labor, walking and cycling were investigated additionally.

Correlations between physical inactivity and thoracic and lumbar disc degeneration were analyzed after accounting for sex, age, Body Mass Index, hypertension, diabetes and back pain.

Subjects with disc degeneration in the thoracic and lumbar spine were more common in those with no physical activity, irregular activity < 1 hour compared than those with regularly activity > 1 hour or more a week.

You'll be happy to know that there was no obvious significant association statistically for subjects who did physical labor, walking or cycling with disc degeneration.

The researchers concluded that physical inactivity over the 14 years they studied demonstrated a strong correlation with disc degeneration of the thoracic and lumbar spine.

Just like we wrote previously that running more miles does not wear out your knees, being active, doing physical labor will not wear out your spine too.

Keep moving.


Reference

Maurer E, Klinger C et al (2020). Long-term Effect Of Physical Inactivity On Thoracic And Lumbar Disc Degeneration- An MRI-based Analysis of 385 Individuals From The General Population. Spine DOI: 10.1016/j.spinee.2020.04.016


My boys wanted the same picture as me, so here's my older boy.

And here's my younger boy below.

10 Helpful Facts About Low Back Pain

Favia Dubyk on her hangboard

Last week I discussed the myths about low back pain (LBP). This week I will write about 10 helpful facts about LBP once anything sinister and serious pathology are excluded. A positive mindset regarding LBP definitely helps with lower pain levels, disability and seeking healthcare.

Fact 1: LBP is not a serious life-threatening condition.

Fact 2: Most episodes of LBP improve and LBP does not get worse as we age.

Fact 3: A negative mindset, fear-avoidance behavior, negative recovery expectations, and poor pain coping behaviors are more strongly associated with persistent pain than is tissue damage.

Fact 4: Scans do not determine prognosis of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes.

Fact 5: Graduated exercise and movement in all directions is safe and healthy for the spine.

Fact 6: Spine posture during sitting, standing and lifting does not predict LBP or its persistence.

Fact 7: A weak core does not cause LBP, and some people with LBP tend to overtense their core muscles. while it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren't needed.

Fact 8: Spine movement and loading is safe and builds structural resilience when it is graded.

Fact 9: Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.

Fact 10: Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centered and fosters a positive mindset, and coaching people to optimize their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment.

There you have it. Quite different from what you have been told, read or heard. We seek to help patients confidently take up different postures, movement, graded loading physical activity, social and work engagement so you can live healthily. There are free educational resources to support these processes if you do have low back pain and have not seen us in our clinics.

You can watch this Youtube video or visit this site for more details. This will help reduce stress and build self sufficiency for you to better self mange your LBP and make better informed choices about your care.

In my next post, I will address how strengthening your 'core' (Transverse Abdominis and Multifidus) muscles was rapidly adopted by the Pilates, Physiotherapy and fitness community and if we should continue down that path.


References

Lin I, Wiles L, Waller R et al (2019). What does Best Practice care for Musculoskeletal Pain Look Like? Eleven Consistent Recommendations From High-quality Clinical Practice Guidelines: Systematic Review. BJSM. DOI: 10.1136/bjsports-2018-099878

O' Sullivan PB, Caneiro JP et al (2019). Back To Basics: 10 Facts Every Person Should Know About Back Pain. BJSM. DOI: 10.1136/bjsports-2019-101611.

Dorian Yates And His Christmas Tree Back

Dorian Yates

As a teenager, I used to go to Times bookstore, Kinokuniya and Borders especially, browsing books and magazines. Other than the cycling, running and triathlon magazines, I used to be fascinated by the bodybuilding magazines. That's when I first learnt about Dorian Yates and his Christmas tree back. I was truly amazed with the definition and shape of his back. (Arnold Schwarzenegger had retired from competitions by then).

Arnold Schwarzenegger's back

Talking about backs, I never really had any low back pain (LBP) before I broke my back. Now it aches from time to time, especially if I see too many patients in a row or sit still for too long.

Many of the patients we see in our clinics have LBP too. LBP is the leading cause of disability worldwide and often associated with ineffective and costly care. Myths about LBP often causes disability, time off from work, taking too much medication and pain. These unhelpful beliefs are often reinforced by the media, health industry groups and well meaning clinicians.

Due to unhealthy beliefs, people with LBP may avoid slouching, bending, physical activities and other activities that load the spine. Meaningful activities and activities of daily living and work are affected.

This may lead to unhelpful protective behaviors such as muscle guarding, bracing 'core' muscles, slow and cautious movement.

Subsequently, this may lead to the patient opting for other medical and/or invasive interventions to ease symptoms (taking medication, injections) to 'fix' postural faults or allegedly damaged structures through surgery.

Here are 10 common unhelpful beliefs about LBP which are culturally endorsed and not supported by evidence (O' Sullivan et al, 2019).

Myth 1 : LBP is usually a serious condition.

Myth 2 : LBP will become persistent and deteriorate in later life.

Myth 3 : Persistent LBP is always related to tissue damage.

Myth 4 : Scans are always needed to detect the cause of LBP.

Myth 5 : Pain related to exercise and movement is always a warning that harm is being done to the spine and a signal to stop or modify activity.

Myth 6 : LBP is caused by poor posture when sitting, standing and lifting.

Myth 7 : LBP is caused by weak 'core' muscles and having a strong core protects against future LBP.

Myth 8 : Repeated spinal loading results in 'wear and tear' and tissue damage.

Myth 9 : Pain flare-ups are a sign of tissue damage and require rest.

Myth 10 : Treatments such as strong medications, injections and surgery are effective, and necessary, to treat LBP.

All the above factors can cause stress, anxiety and depression.

I will write about the 10 actual real facts about LBP in the next post. Stay tuned.


Reference

O' Sullivan PB, Caneiro JP et al (2019). Back To Basics: 10 Facts Every Person Should Know About Back Pain. BJSM. DOI: 10.1136/bjsports-2019-101611.

Another look at Arnie's back - not in competition

Back Pain? Check The Psoas

See the how the Psoas attaches to the spine

Here's a patient who came to our clinic this past week complaining of perpetual low back pain. He seemed more frustrated because he had not been able to do his "normal" exercise for over two weeks. The patient is young medical doctor in his mid thirties and among other things does a thousand sit ups a day (2 sets of 500 each).

At Physio and Sports Solutions, our challenge is always to find out the cause of the patient's problem. (and not just treat the pain). It's quite similar to detective work. We look for clues from the moment they walk into the clinic/ treatment room, how they sit/ stand when we are talking to them.

Next is asking the patient many questions about their condition, their exercise routine (if they have one) and their daily routine followed by a physical assessment.

When he told me about his 1000 sit ups a day routine (in addition to his 12-14 hours of desk bound job), I knew that this was a key component to his pain.

Physical assessment revealed exquisite discomfort to his Psoas and Illiacus muscles among other things. Now the Psoas muscle has been described as "the most important and vital skeletal muscle" in the human body for it connects the spine to the legs.

It is structurally the deepest muscle we have in the core/ tummy. They start at the thigh bone (see picture above) and finish at the 12th thoracic vertebrae and all five lumbar vertebrae. That's how it can cause your back pain!

Any force on the Psoas muscle (muscular contractions) is also thought to support our internal organs and work like hydraulic pumps allowing blood and lymph to pushed in and out of the area. Organs stimulated include the intestines, kidneys, liver, spleen, pancreas, bladder, stomach and the reproductive organs. This is why after my accident, every time my stomach hurts (usually from eating something that my stomach doesn't like), my back hurts too.

These deep organs are often referred to as viscera, and communication from theses organs to the brain is called visceral messaging. (Aized can do visceral manipulation if you need).

Connection between the diaphragm and psoas

Here's another remarkable fact. Your diaphragm (main breathing muscle) is connected to the spine where the Psoas muscle attaches. The diaphragm's medial arcuate ligament also wraps around the top of the Psoas along with fascia that connects to the other hip muscles.

These connections connect your ability to walk, run and breathe and also how you respond to fear and excitement - a direct influence on your fight or flight response.

So I addressed my patient's Psoas problem and got rid of his back pain without even touching his back.  As a medical doctor he and his previous physio had been attempting to treat his back for over a month with no real improvement. He was totally amazed as everyone else had told him it was his back that gave him problem.

Having back pain and not better after your back is treated? Make sure you get your physiotherapist/ healthcare practitioner to check your psoas and your internal organs/ viscera (although your healthcare practitioner may think you're nuts if they're not trained in that area).