Back Pain? How to Address the Root Cause

Almost everyone will struggle with back pain at some point in their lives. For some it comes and goes, for others it’s a once in a while thing, and for others it becomes a part of their lives.

What’s even more concerning is that the outcomes for surgery for back pain are not that great. Several studies have shown that long term results for patients who had surgery for their back pain were the same as those who were treated with exercise and cognitive therapy.

Why doesn’t surgery work?

Our spines are complex, we humans are complex! The thinking that the source of the pain is always at the location of the pain is almost always wrong unless you had a direct trauma to that area.

This is because we compensate, and we do it really darn well.

Have you ever had to wear a cast or boot after spraining (or breaking) your ankle or your foot? Maybe you even had to use crutches. Soon, your arms, neck, and hips and probably some other body parts will start to hurt. (Don’t worry, I’ll get back to the back pain soon, stick with me here!)

But there was no direct injury to anything except your ankle! The pain in those other areas occur because you are compensating for not being able to use your foot properly.

The problem is, we all have histories of injuries that make us compensate slightly, and underlying all of that we have an asymmetrical brain and an asymmetrical body that will make us prefer to do things differently on one side than the other.

That’s not really a problem if you’re a wild human foraging for berries or climbing trees all day. But if you’re a modern human, you’re forced into positions (sitting at your desk or your car) and actions (writing, typing, opening doors) that your body will do over and over and over again on the same side.

This creates asymmetries that become ingrained, and now we have to compensate somehow.

So what does this have to do with back pain?

The Postural Restoration Institute, or PRI, clarifies how these asymmetries affect us and can cause problems. Here is a brief synopsis of why and how our asymmetrical nature impacts our lives…

We have a more stable, domed, strong diaphragm on the right accompanied by a flatter, weaker diaphragm on the left. this makes us feel much more comfortable standing over our right leg.

This orients our pelvis slightly to the right.

But nobody walks around with their body pointed to the right! No, we compensate to bring our chest back around to the left, so we can see where we’re going.

So, basically, our pelvis is pointing right, while our ribcage is pointing left. With walking and other alternating activities, we alternate by turning our pelvis to the left and ribcage to the right, but because of the strong anatomical tendencies listed above, we can lose this ability to alternate symmetrically.

Over time, or with repetitive activity, or injuries, we can become “stuck” in this twist. Some degenerative changes can occur, but the research unequivocally shows that disc degeneration or arthritis is usually NOT the cause of back pain (in studies where they scanned hundreds of people, some with back pain and some without, there was no correlation with back pain and arthritis/disc disease or other imaging findings. In fact, some people had severe pain and no findings on imaging, while others had severe degeneration, arthritis, and bulging discs, but no pain)!

The key to getting out of back pain for good is not going under the knife, but rather learning how to bring your pelvis back around to the left, and your trunk back around to the right.

To do so, breathing must become re-organized and re-balanced (remember that the diaphragm is the start of all this asymmetry!) and new movement patterns need to be established.

One very simple thing you can do to start training your body out of compensation is working on getting your left lower ribs down, in, and back. This will promote doming of the left diaphragm and bring your trunk back to a neutral position over your pelvis.

Here’s how to start re-orienting your ribcage to untwist your spine:

References:

Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). 1983;8(2):131.

Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009;34(10):1094-1109. doi:10.1097/BRS.0b013e3181a105fc

Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69(9):1643-1648. doi:10.1136/ard.2009.108902

Rao D, Scuderi G, Scuderi C, Grewal R, Sandhu SJ. The Use of Imaging in Management of Patients with Low Back Pain. J Clin Imaging Sci. 2018;8:30. Published 2018 Aug 24. doi:10.4103/jcis.JCIS_16_18

Wáng YXJ, Wu AM, Ruiz Santiago F, Nogueira-Barbosa MH. Informed appropriate imaging for low back pain management: A narrative review. J Orthop Translat. 2018;15:21-34. Published 2018 Aug 27. doi:10.1016/j.jot.2018.07.009

Lateef H, Patel D. What is the role of imaging in acute low back pain?. Curr Rev Musculoskelet Med. 2009;2(2):69-73. doi:10.1007/s12178-008-9037-0

June 2, 2020June 4, 2020

What you Need to Know About Creating a Vibrant Life: How to Contract and Expand

Last year I was dealing with some health issues, and I felt that working long days was contributing to my symptoms. After much deliberation, I reduced my hours in hopes of finding some relief and more time for rest. At first it was great. I had more time to nap, rest, and do other things that felt restorative to me.

But it wasn’t long before I started filling that free time with more “stuff.”

Before I knew it, I had eaten up all that time with classes, volunteer work, and self-imposed deadlines and projects. I was just as busy (if not more so!) than before I reduced my hours!

Bewildered, I asked myself, “how did this happen?”

It was as if part of me could not STAND having time to be quiet and relax. There was an inherent guilt to resting, to having time that wasn’t “productive.”

All over again, I ended up giving away all of myself, to the point where it wasn’t sustainable.

It wasn’t my job that was draining me, it was my own inability to save a little of my power for ME.

You could even say that I was opening my heart TOO MUCH.

My life was missing a natural oscillation that is present in all of nature, that play of intensity and calm, of effort and ease.

It was seeming to me that my whole life, and the messages I was getting from the society around me, was all about effort and opening; doing as much as you possibly can…

without the bit about quieting, softening, and going inward.

Peter Levine, an industry leader in studying and treating trauma, describes this process as “pendulation.”

He believes that rediscovering expansion and contraction is the key to living a full and abundant life, with the ultimate goal of living a more expanded life.

Too much contraction is undesirable, this is established. Thinking too much, worry, fear, over planning, narrow focus (staring at a computer)… this creates a contracted state.

You can feel that contraction in your body- your neck, shoulders, face and maybe lower back become tense.

On the other hand, expansion is always desirable, and always the goal. This happens when you consciously relax your body, get a wider view (look out a window for 30 seconds and notice how your body changes), and settling into the present moment by noticing your breath and bodily sensations.

However, there is a trap that I call “FAKE expansion,” which is also undesirable and can even be harmful.

So what is “fake expansion?”

Over filling your life with STUFF and convincing yourself that it’s REALLY important (cringe, yup, that’s me!) at the expense of your own wellbeing.

Fake expansion is “opening your heart” in a situation where you feel exhausted and unbalanced.

It’s saying yes to so many things that you don’t leave any room to take care of yourself. It’s giving more than you have to give.

We do this ALL THE TIME. Sorry ladies, but women do this more than men, but the guys definitely do their fair share.

And maybe instead of asking how you can open your heart more, you should be asking “can you make space inside your heart for YOU before opening it up to everyone else?”

A.k.a. how do you keep some of that loving care and attention for yourself, so that when you give to and care for others, you can do it from a place of love and joy instead of burnout and martyrdom?

One way you can make space for your own heart is by physically changing the shape of your body to encourage more space in the BACK of the heart area.

Interestingly, as we open the back of our hearts physically, our decisions tend to reflect this and become more in support of self nurturing instead of over reaching.

Breathe into your Back

Our bodies are so fascinating. The sympathetic nerve ganglia, which is a fancy way of describing the nerves that make you feel anxious, stressed, worried, angry…generally amped up…live between the vertebrae in your upper back spine. So, if you are always “opening your heart” by pushing your chest up and trying to stand or sit up really straight and never going the other way (rounding your back) you’re going to have a heck of a time getting your brain and body to relax.

Not to worry! You can do a simple exercise to expand the back of your heart. Here’s how to open your upper back:

Re-Establish Physical Boundaries:

Another way to encourage healthy expansion is by re-discovering the boundaries of your physical body, which reminds the mind to keep a little of that loving energy for yourself.

By re-establishing the boundaries of our bodies, we learn to expand. Here are some ways to develop and be aware of the boundaries in your body. This embodiment of where you end and the rest of the world begins teaches your nervous system how to create healthy boundaries in your life.

Here’s how to establish the boundaries of your body:

Are you are needing to create a little (or a lot) more space in your heart for you, so that you can give from a whole and rested place? Or do you need to remind your nervous system what it means to have meaningful boundaries? Or perhaps you’re like me, and you really needed both.

Whatever the case, the fact is that our society drives us to do more, push harder, be better, all the time. And that doesn’t honor the law of nature, it doesn’t honor pendulation.

Try introducing a little more space for you into your life, and see if that allows you to expand a little more. We not only deserve some space for ourselves, we need it to be sustainable.

March 2, 2020August 5, 2020

Balancing Two Sides of One Body

Most of our movements- the way we sit, stand, eat- are happening subconsciously. Furthermore, we all have preferences for doing things on one side or the other, and in one way or another. While handedness plays a role in this, our neurology and the way our brains are wired play a much larger role.

Most of us have heard that we have different functions for the right and left sides of the brain. As far as physical function, the right brain controls the left side of the body, and the left brain controls the right side of the body.

The perception of the two sides of the brain is a bit more nuanced. The right brain manages sustained, broad, and vigilant alertness. Conversely, the left brain has a narrow, sharp, and focused attention to detail. The right brain is more focused on the big picture, the surroundings, what’s going on in the background. The left brain is more alert to what’s right in front of us, the immediate task at hand, what’s next on the agenda, etc.

An example of how the two sides of the brain work together is driving a car. In this situation your left brain has focused attention on the road in front of you. While this is very important, it is also important to be aware of your surroundings. Your right brain is broadly scanning the environment for potential threats such as other cars, pedestrians, hazards, and so on.

sculpture of a head showing different functions of the left brain — Different sides of the brain have different functionality

The left brain contains the centers for speech and language. Since the left brain controls the right side of the body, the right arm becomes prominent in communication, growth, and development. Even in left handed people, there is a tendency for the right shoulder complex to be tipped forward and down as a physical representation of the interactive quality of the right side. This is because even though handedness is a strong driver of pattern, the brain and nervous system are far stronger.

This normal and natural asymmetry can be problematic when it is not balanced with left arm neurological and muscular activity, so in clinic we work on changing movement patterns at the level of the nervous system. My patients often tell me that when they do their exercises at home, they are not sure if they are doing it right and it feels hard to keep track of all the movements in the exercise. I always tell them this is exactly what we want, because we are trying to change a movement pattern, not just get stronger. You can go to the gym by yourself and lift weights if your goal is muscle mass. What you need from physical therapy is to learn how to change the wiring of brain and body, to become better balanced right to left in three dimensions. For this to occur, it will probably feel like your brain is working just as hard, if not harder, than your body when you do your home program.

Learning to change a movement pattern is like learning to drive a car. At your first driving lesson, there was an overwhelming amount to pay attention to: hands on the wheel, gas, brake, checking mirrors, road signs, and if you had a clutch then that’s a whole different animal. But now, you drive somewhere and think, “wow, I don’t even remember driving here, I’m just here!” That’s because the neurological and muscular systems have become automatic through repetition, but you had to start with a very “thinking heavy” process to get there. You had to pay attention in the beginning, and now it just happens naturally.

That is how we bring our body into balance, by literally re-wiring the neurological and muscular patterns in the body. We use conscious effort until it becomes unconscious. Because the reality is that so much of what we do in our day is unconscious; but if those daily patterns are not regulated by transitioning well from right to left and back again, we develop strong patterns that create structural weaknesses, instabilities, and pain syndromes like fibromyalgia.

One simple way to balance the left and right sides of the body is through a breathing technique called “nadi shodhana” in sanskrit, which we can loosely translate as “alternate nostril breathing.” This technique is simple and very soothing to the nervous system as it creates a deep sense of balance in the body at a neural and respiratory level. See the video below to try it out.

Alternate nostril Breathing for Body and Brain Balancing

December 18, 2019June 24, 2021

The Illusion of Symmetry

From the outside we look symmetrical. Left to right, it seems that if you drew a line down our center we would get two equal parts. Most anatomical drawings present the human body in this way.

When we dig a little deeper, it turns out that right to left we are quite different, and these differences can have a profound effect on our physical functioning.

Often I have patients ask questions like, “why is it that only my right knee hurts with running?”

Good question! Some may say that this is due to handedness, with most of us being right handed. But have we ever stopped to ask why it is that most of us end up being naturally right handed? I don’t intend to get into a debate about handedness, but it certainly hints that there is something else at play, some asymmetry inherently present in all of us. These asymmetries are normal and natural. However, these asymmetries can become problematic when they become unbalanced.

This can occur due to external or internal circumstances. For example, your life requires that you do repetitive tasks to one side only, like reaching for the phone on the right, or getting in and out of the driver’s side of your car. It may also be something intrinsic to you, such as an injury. If you had an injury to your left leg, you felt more stable on your right leg as you were healing. That is helpful while you heal, but that patterning of preferring the right leg to stand on can remain long after the tissues have healed.

The Postural Restoration Institute has a deep understanding of these asymmetries and how they affect us. This institute is unique in that it addresses these complexities of being a human when creating a treatment plan, which I have not seen in literally any other course or training for physical therapists, even when I was in my doctorate program this was glossed over at best.

Let’s Talk Asymmetries.

The primary source of these asymmetries is the center of our body, the trunk. It is the generator of motion in our limbs and it is our center of stability. At the center of our trunk (the “core of the core,” if you will) lies the diaphragm, which is dramatically impacted by the asymmetries of our organ and lung placement.

The diaphragm on the right tends to be more domed due to:

lower attachments of the diaphragm onto the right side of the spine compared to the left.
The central tendon (which makes the dome of the diaphragm) is thicker and stronger on the right than the left.
The right diaphragm has the support of the liver underneath.
The presence of three lung lobes on the right and only two on the left to make space for the heart.

Radiograph showing the right diaphragm (left side of picture) being higher than the left. This is normal human patterning.

All these things cause the right rib cage to be in an “exhale” position with the ribs dropping down and into the body, and the ribs on the left to be in an “inhale,” an elevated and expanded position. Think of the left lung as a big balloon pushing on the smaller balloon on the right. This causes an orientation of our ribcage to the left. The attachments of the diaphragm on the spine cause the spine to turn right.

The Postural Restoration Institute has recognized this natural asymmetry and incorporates this anatomical variance into their training of physical therapists and therefore the treatment of our patients. When I first heard that everyone is biased one way, it was news to me. When I was in my doctoral physical therapy program, we learned all the asymmetries of the vital organs, however the influence of this asymmetry was not applied to physical function. Furthermore, the asymmetrical structure and pull of the diaphragm was hardly mentioned, if at all. I find this surprising now as the diaphragm is a muscle that we use all day, every day, and it has profound impacts on how we move and interact with our world.

So what’s the big deal about the diaphragm?

The diaphragm is huge! It attaches to our lower back spine and interfaces with our abdominals, low back muscles, and hip flexors. After I took my first postural restoration course, I was pleasantly surprised at the emphasis on diaphragmatic function and it’s role as a driver of human movement. I was also surprised at how “belly breathing,” which I taught and practiced myself, was actually detrimental to harnessing the power of the diaphragm. The inherent asymmetries within our diaphragm drive the initiation of human movement, specifically walking. Essentially, the stability of the right diaphragm supports right stance phase of gait (standing on your right leg and left leg swinging).

walking still shot in Right stance phase with left swing phase

The problem occurs when we go to stand on our left leg, but we are still in right stance with our supporting muscles. The left diaphragm is not able to support our body in this position, and our right leg does not adequately recruit muscles to swing the right leg. This occurs not just in walking but also during day to day tasks. This can create all kinds of issues, knee pain on one side being just one of them. Fortunately, this asymmetry can be addressed with specific exercise that is asymmetrical, and therefore corrective. These exercises incorporate the breath to achieve diaphragm function.

Once again, I want to reiterate that this asymmetry is not a bad thing inherently. It is in fact a wonderful thing as it initiates the walking cycle and allows us to begin rotating through our trunk and pelvis. Asymmetry becomes a problem when we get stuck on one side, and are not able to get over to the other side. Relearning how to transition from right to left, and then back from left to right, is how we get balanced again.

Are you transitioning well from right to left stance?

You may have difficulty transitioning from side to side if you:

Tend to always have tightness in one hip more than the other
Always cross one leg over the other (usually the left one over the right)
One leg feels longer than the other
You notice different wear patterns on your shoes or bike saddle

Try this simple exercise to test your asymmetry:

Stand with toes pointed straight forward (feet not turned in or out). Keep this foot alignment as you transition to standing on one leg. You can touch a counter in front for support. Now, turn your pelvis so that the zipper of your pants comes over your right big toe. Try the same thing standing on the left leg, toes pointed forward, knee slightly bent. This time, try to turn the zipper over your left big toe. Notice if you can do this on one side, but not the other.

If you find one side to be challenging, but not the other, that indicates you may have trouble shifting to one side. Because of our natural human pattern, it is usually harder to do this standing on the left leg. That doesn’t mean you can’t stand on that leg at all, but it means that when you are standing you aren’t using the correct chains of muscles, which results in pain and dysfunction. To address this issue, come see me or a PRI trained therapist near you to get properly screened and the tools to find better ease and balance in your body.