Our next talk is going to be on exercise for optimal health. This is going to be a virtual lecture by Dr. John Lavelle. And unfortunately, Dr. Lavelle had planned to be here in person, but he had a family emergency. So he had to prerecord his lecture. And unfortunately, he is not going to be available for questions immediately afterwards. So if you do have questions, please email them to Betsy or myself. We'll make sure that Dr. Lavelle gets them. And then he will get back to you within a week. So it's my pleasure to introduce Dr. Lavelle. So he completed his medical school at the College of Osteopathic Medicine at Midwestern University. He went on to do his residency in physical medicine and rehabilitation at the Boston University Medical Center, where he served as chief resident. And then he completed a spine and musculoskeletal fellowship with a focus on spine management and interventional spine procedures at the New England Baptist Hospital in Boston, Massachusetts. So please join me in welcoming Dr. Lavelle. Hello. Thanks for allowing me to come speak at the AOC PM&R mid-year meeting. I wish I could be there in person, or at least presenting to you live virtually. But due to family circumstances, unfortunately, I had to pre-record this. I do hope you enjoy this talk. Again, my name is John Lavelle. I went to medical school at Chicago College of Osteopathic Medicine, Midwestern University in Chicago. Then did my training in Boston, at Boston University Medical Center and fellowship at New England Baptist Hospital in interventional spine and musculoskeletal medicine. Then went on to practice in a pain office in Dallas for two years, and not enjoying that pain environment. Moved to Tennessee, because we did enjoy the South. And I've been at Tennessee Orthopedic Clinics now for almost seven years. And I really enjoy my practice here. So enough about me, but I'd like to get started here. So what I'm talking about today is really something that I've really grown my practice to be very passionate about, which is really focusing on patient's health. And I think, I don't want to exaggerate the benefits from this talk, but I think if we, if in medicine and healthcare, we truly focused on health instead of disease management, I think we could really revolution, revolutionize the way healthcare was provided to patients in our society and make huge changes, not only in what I'm going to focus on today, which is back pain, pain in general, but in overall health, longevity, improvement of patient's functioning as they get older. And I do touch a bit on that towards the end of this talk. But I think, you know, when we really try to focus with our patients and educate them on the importance of movement, movement quality, through exercise and fitness, it can change a whole host of things. And as we're going to touch on here, really their pain and their overall spine health. So we'll move right along here. So kind of touched on this already, but some of the objectives of this talk will be to discuss initially the epidemiology of back pain, review some of the major causes of back pain and how it relates to disability and loss of function for patients. And then to really review some treatment with a focus on what treatments have been beneficial and how exercise or exercise training can really help maximize patient's recovery and return to work and their day-to-day lives that they want to enjoy. So when we look at low back pain, as we all know, there's a whole host of patients out there. It's hard to go a day, no matter what you practice, to really not hear about someone who has had back pain or is having back pain. There's a lifetime prevalence, and I think this is probably underestimated of about 80%. But we do know there's a good percentage, there's about a quarter percent of the population that never really has any significant back pain. So the one-year prevalence is up to about 56% where patients will have it. And then a good percentage of those 24 to 80% wide range there, but will have recurrence in the first year. And in my practice and in some studies, within the first six months of people having an onset of back pain, that's the most common timeframe, those first six months where they may have a recurrence. But as you see from this graph, men, women, pretty much equal in their incidence of back pain, which also, what's also interesting about this study is it affects people, whether you're obese or not obese. We always like to focus with patients, and I hate to say it, but patients feel shamed when they come in overweight and they're always told, oh, just go lose weight, then I can help you. As most of us know, that's not a good way to approach patients. They're just gonna turn off and probably not come back in your door. But we also see that weight may play somewhat of a role, but it's not the only factor. And similar with treatment, just asking someone to go lose weight is not all of a sudden getting rid of your back pain. Actually, studies have shown the opposite. People can lose weight through nutrition or gastrointestinal surgeries, lose 50, 100 pounds, but have the same incidence of back pain. So just the factor of losing the weight, usually the arthritis underlying or the damage that's done in the spine or the nervous system sensitization that's been caused that's developed their back pain, just by losing the weight is not gonna get rid of that. So further, new onset back pain seems to peak in our 30s, though you'll see teenagers with it all the way up through the 50s and 60s where it seems to increase. But then interestingly, when you get to around mid 60s, 70, we do start to see an increase, sorry, a decrease in patients' back pain complaints, which is kind of interesting because as we know, once you hit 65, you don't all of a sudden start reversing and get less degeneration in the spine or less trauma to the spine. But those pain complaints do seem to decrease, which is an interesting finding. And we'll kind of touch on why that may be as we move forward here. But the thing that is interesting with that, which I'll show in a later graph is that though their pain complaints decrease after 65, we know their arthritis or their degeneration in their discs, their spine, their sarcopenia, loss of muscle cells and muscle mass is only worsening. So maybe there isn't that direct correlation with spinal degeneration and pain that some of us once thought. So some common myths with back pain. Pain is an indicator of some sort of inciting incident, damage, or injury. And we know from some studies, less than 4% of the time does that seem to be the case that there's an actual trauma, a car accident, a fall that sets off that back pain. More typically, it's getting up out of bed. The best story I've heard, and you guys will probably appreciate this, is a patient came to me and just told me, he was an attorney. And he said, you know, I was doing fine, never had any back pain. I just reached over to get a check for my staff and my back went out. I said, that must've been a pretty heavy check. But it doesn't always have to be some trauma that caused it, just getting out of bed, picking up your purse, picking up your child. You know, very simple things are the most common things you'll hear that set that pain off or that all of a sudden they got pain down the leg. So maybe it's not some trauma within the tissues of the spine, but something within the nervous system that gets set off. That causes that pain to persist. And as we'll see, as we move on, it's maybe that nervous system sensitivity or hypersensitivity, where you'll hear a lot about central sensitization in the literature within the neurons themselves that's causing the pain and not trauma within the structure of the spine itself. Also, when we talk about limiting patient's activities, a lot of the things we tell them not to do have never been shown to be harmful. Whether it's running, biking, bending, lifting, twisting, a lot of those things do not seem to induce back pain. Yes, they can cause some pain if you're in discomfort, but most anything will when you're having some back pain. But limiting those activities is only gonna limit their function, their quality of life, and then it'll have a vast downstream effect on what they can do moving forward and just worsen that nervous system sensitivity and put them in chronic pain. So also when you'll hear a lot that, oh, doc, that was amazing. You cured me. You're the one that made a difference. In actuality, it's when people improve from back pain, many, as we'll see, will improve on their own, especially acutely. But patients often wanna relate it just like they wanna relate their back pain to a certain injury. So they also wanna relate their healing to a certain physician that did manipulation injections, gave them a medication or a surgery, when in fact most people will get better just by doing things on their own, through physical activity, improving their stress, their mindset in their own lifestyles through nutrition and activity. So just most of us know what the spine looks like, but this is just a good diagram to show there's a whole host of tissues within the spine and around the spine that can cause pain. So often throughout the spine, especially you'll see in the low back, pain is multifactorial. There's so much there that can cause pain. It's usually not one isolated event, though it can be. It's not typical. Whether it's something within the vertebrae from end plate changes, edema within bone marrow, edema within the end plates or a compression fracture that caused the pain from the disc, from that cascade of disc desiccation to disc herniations, extrusions, possibly hitting the nerve, causing radiculopathy or maybe just causing stenosis, causing that nerve to get irritation based on position. Then as we move posterior, maybe it's the facet joints. Do they have a lot of facet arthropathy or effusion swelling in the joints that could be causing the pain? Or is it more just those inner spinous ligaments, the smaller ligaments that attach throughout the spine that are getting strained, especially in those initial first degrees of movement? With that, the multifidus, the smaller paraspinal muscles, are they atrophied? Are they weaker? Or do they get strained? Or is it a large muscle strain from an overactivity, an overuse injury with the erector spinae musculature? So kind of throughout the spine, there's lots of things that can go on. But within my practice, everyone will develop, especially disc degeneration. We know that that's just like getting gray hairs and wrinkles. It happens with time, but yet not everyone has that persistent pain. So maybe there's more than just what's going on structurally that's causing this pain to come on and persist. I touched upon this briefly, but when we look at low back pain, oftentimes it's not necessary to get initially, but patients will either come into your office with an MRI or they'll have that pain persist. So an MRI will be performed and you'll hear on the MRI report, what's going on with the disc, what's going on with the neuroforamina, the central canal. Sometimes, and I say maybe 50%, maybe a little more now, they'll mention the facet joints, but rarely do they talk about the musculature or soft tissue around the spine. And it's becoming more and more important to evaluate those paraspinal muscles. Part of it's education to the patient, but if you do like to look at your own MRIs, wherever you get your MRIs done, talk to the radiologist and see if they can mention that in the report. If you like to look at the report more, and that's what I've done with a lot of the MRI facilities around us is I've asked them to comment in their reports about the paraspinal musculature because a lot of patients nowadays with the different regulations have to have access to their records. And I want them to be able to know everything that I tell them on the MRI and be able to see that in the report they get, not only my note, but also the MRI radiologist report. But that being said, it's important to look at those paraspinal muscles, posterior to the facet joints there, and look at the quality of those muscles. Is there, as we look at that severe column, a lot of that white fatty infiltrate within that musculature, indicative of a lot of muscle atrophy, whether it's from disuse or age-related changes like sarcopenia, where they've lost a lot of those muscle cells and thus the muscle fibers and muscle mass has decreased and it's been replaced with that fatty infiltrate. So it kind of stages. A lot of patients, as you start to look at this, you'll see those that recover well and pretty quickly have very strong or large muscle mass back there and good preservation of that muscle tissue. And it's definitely harder to get patients that have a lot of fatty infiltrate there. And you'll see that says severe on the right-hand side there, but you'll see a lot of patients with almost no muscle tissue there, especially as they get in their 60s and 70s and extremely sedentary. So it does seem to be important that when we're talking to patients and educating about the spine, especially if you're trying to encourage them to get moving, get active again, to show them their MRI or to explain this picture to them if they do have that going on, that muscle atrophy of why exercise is important to try and build up the muscle tissue that's there and help them stabilize that spine, keep that spine in neutral position, will allow them to get moving better and hopefully have less discomfort with that. And I'll continue to talk about this as we move forward through the treatment process. So when we look at back pain, as I mentioned, that degeneration we see in the spine and in the muscles happens to everyone. It's unavoidable. As we get older, we're gonna get arthritis in the spine, we're gonna get disc degeneration, we're gonna get loss of muscle mass, but not everyone has to have persistent pain because of those structural changes. And so how do we prevent the nervous system from firing that pain signal, from becoming sensitive to those changes? That's how we have to kind of approach it. Is it more of a nervous system problem and less of a structural issue? Again, just kind of highlighting the changes you'll see on MRI, the MRI which looks good on the left here can be seen with someone that has severe low back pain. Maybe they wanna relate it to that L5-S1 mild disc desiccation, minimal disc bulge, but yet they're having diffuse pain throughout the back and radiating down into the buttocks. Or there's that patient on the right, which looks like they should be the ones with severe pain, but they may come into your office and their pain in their left hip is from hip OA. They get that treated, their back MRI will look the same like this, but they have no further pain. So it wasn't the stenosis there at L4-5 causing the issue, it was the hip OA. So many people can have a horrible looking MRI that you would think would be the source of their pain, yet it's coming from elsewhere. So again, just kind of highlighting that point that we all get those structural changes, some more severe than others, but the severity of the pain or the incidence of pain doesn't correlate well to the changes we see on those MRIs. And this graph is another study that just kind of highlights what we've been talking about. That dark line just showing the elevation of osteoarthritis, the increased incidence and percentage of it just gets higher as we get older. But you'll see that black dotted line after about age 65, which is back problems or back pain starts to decrease. So it's kind of that inverse relationship after 65, we're still getting more degeneration, but not seeing the same amount of pain complaints. So with recovery from back pain, 90% of new onset back pain will resolve in about six weeks. So just encouraging people that this will pass as early as sometimes it's a couple of days, I usually recommend two to six weeks it can take to improve. So just trying to encourage patients to stay active and resume their normal daily activities as tolerated, and hopefully they will see some good improvement. But as we mentioned prior, there is a good amount will have recurrences of their back pain. And as I mentioned, you'll usually see that within the first few months that they may have a second or repeat flare up. And then five to 20% will become chronic. And that's really what we wanna prevent. We wanna prevent these patients who develop that acute pain from becoming chronic. Cause that's where we'll start to see a lot of disability and people not being able to go back to work or just not able to enjoy their life, their life with their family. But then there's that 20, 25% that never really experienced low back pain. So that's the interesting group that kind of spurred a lot of research, first observational studies, and then seeing that some people weren't experiencing pain, but yet had the same amount of degeneration in the back. Maybe they were doing something different in their lives or something going on that wasn't causing them to have pain, or maybe they're just neurons themselves passed on from their families, their genetic makeup, their nervous system didn't fire that pain signal, wasn't as sensitive to developing that nervous system sensitization. And that's kind of where a lot of us have started to focus on back pain treatment is how do we treat that nervous system? In those people that do develop the back pain, how do we get that nervous system to quiet down? So those people that do become chronic, this study was looked at a 15 year period and it was published in 2015, but showing that the huge increase from the late nineties to the, I think it ended in about 2014, 2015, when they stopped looking at patients, but that huge increase in disability due to back pain, way outpacing lots of other causes of disability and a lot of reasons for that. One may be that we started to really focus on patient's pain and how can we treat your pain? And if we can't treat your pain, then patients felt they couldn't return to work because they still had pain. They were scared that they may have a worsening in their pain, but also they may be scared that they had some type of injury causing the pain. So they didn't feel they could return to work. So we need to kind of change our thought process and maybe not focusing so much on treatment based on their pain levels, which is hard with insurance companies to get treatment approved because they always want to know what their pain is and what it decreased to, but trying to move away from that and focus more on how are patients functioning? What can they do despite having some of that discomfort? Again, just looking at disability, a whole host of reasons patients can have disability, one being lack of exercise, lack of movement. Movement quality is a big predictor of people developing disability. So again, with treatment over the years, we've seen since the mid early nineties, a huge increase in different modalities to treat back pain. As you see here, these different graphs, opioids, narcotics, spinal injections, spinal fusions, all dramatically increase in their utilization. But as we've seen, disability keeps going up, back pain incidence keeps going up. We're not improving those outcomes, yet we're utilizing these treatments to a huge degree more and that's healthcare dollars. That's definitely draining the system, but not only that with the way insurance pays, it's also drains patient's bank accounts because co-pays are much higher, they're paying so much more out of pocket. We're recommending these treatments that are not effective. And again, a lot of these treatments increased as we started to focus more on that pain scale, that extra vital sign of pain. Is it truly a vital sign to whether you have pain or not? I don't think it's vital at all. And that's what we got to help educate the patients on is how can we improve you more effectively? You know, a lot of patients come in, they want these procedures done because they think it's going to be that quick, easy fix. And it's also a lot of physicians want to give them that quick, easy fix because it's easier to get a back pain patient out the door when you say, here's this prescription, here's this procedure, let's get it done. But as we're seeing, it's just not effective. So you're not truly helping that patient and their satisfaction will not improve like you want until we can find out how can we effectively treat these patients? It does take more time when you don't have that quick, easy fix, but education is power. So if we start, as we'll show here, educating the patients on what truly is going on in a more effective treatment, I think our outcomes will start to improve. Last thing I mentioned here is orthobiologics. And that's another thing that's, I utilize myself in my practice and it's starting to be over-utilized as well through whether it's physicians that do spine pain or chiropractors utilizing orthobiologics in their office. And why is that? Well, in my opinion, it's because it's cash pay. So it really helps keep those doors open and make a difference in your bank account. But are we seeing a difference in the patient's care by utilizing this another type of modality that's trying to oftentimes market it as regeneration, where I don't know that we can say it truly regenerates tissue. It definitely promotes healing, decreases pain symptoms, decreases inflammation. But when it's marketed as truly regenerating tissue, I don't know that we can say that. But also, I don't know that we can say it's gonna be that quick, easy fix either. So though it does show a lot of promise and it is absolutely effective in the right setting, that's the importance is utilizing these things, which all can be beneficial, but in the right setting and in the right patient with the right indications is what we need to focus on. So again, just another graph adding in MRI here of that increase in modalities, increase in the utilization of things, yet we're not seeing that decrease in pain symptoms that we need to, or sorry, I shouldn't even say pain symptoms, that improvement in patient satisfaction or improvement in patient's function in lives that we wanna see that we're utilizing these things to a greater extent. So all that to be said is what type of treatment can we start doing that's gonna make a difference in our patients' lives? I think we need to kind of take a different direction is how we deliver our treatment to our patients. What are we gonna do differently that'll actually start to improve them? And so maybe exercise or movement and changing their overall lifestyle is gonna be what makes that difference for them. So when we look to treat back pain, initially, the biggest thing is we wanna avoid that bedrest. So a physicist back in the 1960s showed that patients in certain positions have increased discal pressure. And they theorized that because of that pressure on the disc with bending or even sitting, you are more likely to have back pain or disc protrusions which would cause that back pain. And that's really when we focused on laying patients down. They need to rest and don't put pressure on it. And we still see that today with a lot of treatment from different clinicians, physical therapists. You don't wanna bend at the waist. You don't wanna do that hip hinge activity such as bending at the waist and picking something up the ground because you're gonna push that disc posteriorly and exacerbate that pain. Unfortunately, or fortunately, clinically, we haven't seen that bear out in the literature. Just because you bend at the waist doesn't show you gonna have increased back pain incidence or any change in your inducing disc herniations or disc protrusions. Actually, the opposite has been starting to be shown when you do do those activities that are things we do every day anyway, that starts to desensitize the back, the nervous system so it doesn't constantly send that pain signal. So that's just kind of where we started to see the limitation, people limiting movement in certain directions. And a lot of it was based off this study showing pressure within the spine. So we wanna kind of move away from that trend. We don't wanna restrict patient's movement because that's gonna then correlate to restricting their functioning from what they do day to day. So we really wanna encourage them to return to early usual activity, return to the normal activities as they can tolerate. And that's definitely been shown to earlier return to work. The more you get back to doing your normal stuff, the quicker you're gonna be able to just continue to do that. And we haven't shown recurrences of back pain just by doing that. Specifically, physical therapy or getting in the gym, exercising in the acute phase is not harmful, but it's also no benefit. People usually get better anyway. So you don't necessarily have to instruct them to go do some certain routine, but just encouraging them at least acutely to get back to their usual activity. Now, long-term, I do think treatment with exercise or training is gonna be beneficial. But initially, if they are kind of really inflamed from a new disc herniation or a muscle strain, if you initially start really pushing them with exercise, that's just gonna irritate it. Think if you have kind of a swollen thumb that you hit with a hammer, if you keep using it right away initially in that first week or so, it's just gonna keep it irritated. So people are gonna be then more withdrawn from doing activities. So you just wanna let them not be bedrest, but slowly return to their activities as possible is usually best. Just using NSAIDs, acetaminophen, can be helpful in that initial phase. Usually you do not need opioids. I don't prescribe opioids at all. But NSAIDs, as we know, and acetaminophen, that combination has been shown to be as effective as five milligrams hydrocodone. And then not necessarily acute phase, but sometimes. But spinal injections can be beneficial, but used as more of an adjuvant to help quiet down that pain or inflammation so they can resume their activities. It shouldn't be the sole and I'll be all type of treatment, but just as a modality you can use to help quiet down those symptoms to allow them to get moving again. So when we saw with certain patients that, why are some doing better, recovering quicker? We started to look more at these observational studies. And people who are physically active, three days a week, seem to have a lower lifetime risk of back pain. Former athletes, interestingly, had less back pain. Was it because they had a higher level of fitness, which was shown in two bullet points ahead, seemed to be related to improve back health, as well as greater amount of exercise did not seem to make pain worse. So we always would kind of educate patients, restrict running, restrict lifting, don't do certain types of exercise, whether it be squats, deadlifts, depending on what was going on, where that didn't seem, when we started to look more in detail, that didn't seem to be the case. Restricting those things or having them continue those things didn't seem to increase back pain, but it did seem to allow them to have improved back health and decrease that incidence of back pain symptoms. Also, we saw that people that had less trunk strength or paraspinal muscle strength, decreased flexibility was associated with increased back pain. So those that may be patients that are less active, don't exercise, more sedentary, sit at a computer eight to 10 hours a day and aren't get up and active at other times, aren't doing the exercises I've mentioned above, those seem to be the ones that are more prone to develop back symptoms or chronic symptoms as well. This study started to look at, take more of an active approach to the studies, is what type of putting people in a physical therapy program, but just focusing on exercise-based physical therapy, having them do strengthening exercise. So that bar that shows strength is low back strength, back extension exercise. The L-pile and C-pile is positive isoinertial lifting exercise, where the L-pile's lumbar, you lift a crate with weight from the ground, hinging at your waist, not bending at your knees, hinging at your waist and lifting it up onto a table that was at waist level. And the cervical pile there is taking that crate then from waist level and lifting it up on a shelf overhead. So things often we wouldn't want patients to do, but doing that with patients, mimicking day-to-day activities and seeing how they improved. And as you can see here, their pain scores did improve pre and post doing that exercise physical therapy program. This graph will show it here as well. When you look at the numbers, as you know, everything was significant with their P-value, but you look at the actual pain scores, it's really, in my opinion, when you're talking to patients, hard for patients to be that specific, whether if their pain drops from a eight to a six, you know, they're still in pain. If we're focusing on that, I don't know that that's really a success, even though it may be statistically significant. But what's interesting here is when you look at the Oswestry disability scores, their flexibility numbers with trunk flexion extension and hip flexion and extension that straight leg raise testing, as well as their strength, their numbers changed significantly. And this was just a six weeks of that exercise physical therapy. And that's what's really interesting to me is looking at those specific numbers and the improvement in their flexibility and strength. That's just gonna correlate to what they do at home, whether it's playing with their grandchildren, their children at home, or being able to go back on the job site to work. If they're stronger and more flexible, they're gonna be able to do those things. And maybe we don't need to focus so much on the pain because if they're starting to do more, the pain will fall off suit, but also that's what life is, being able to function and be active despite still having a little bit of discomfort. So now when we look at these benefits of exercise, when we have people start to do, whether it's through physical therapy or working with a trainer, what type of exercises is the best for them? Is it active physical therapy? When you have them walking, going up and down stairs, squatting, lifting weight versus throwing a TENS unit on them, having them put on ice or heat, we're starting to see that that active exercise is definitely more effective than passive physical therapy or modalities. Modalities still have their plates, but not as the primary treatment protocol for these patients. If all they do is every time they come in, they're stretched out, massage, TENS unit on, and then ice until they go home, one, that gets very expensive because as I already mentioned, insurance covers less and less, and the co-pays can be 40, 50, $60 for patients at physical therapy. And if they're just doing the same thing every time, they may leave a little bit better, but within a couple hours, the pain symptoms are right back. And that's what the literature is starting to show, that actually teaching them exercise that they can then go forward and continue and progress with on their own, giving them that education of how to exercise, how to move appropriately, and educating them on a good programming moving forward, that's what is gonna make the benefit long-term for them, decrease that recurrence, decrease that disability. As we see here in that last bullet point, exercising cuts the risk of getting back pain by 50% in this study by Stevens compared to passive treatments. So I would say definitely when you're having patients, if you're seeing them, they've had pain for a while, you wanna start physical therapy. I never just write eval and treat on my note. My note in three different places, a physical therapy script says no modalities. A lot of therapists get pretty put off by that, but most that I send to now throughout the Knoxville area where I live, know my kind of approach to it. And they can use some modalities, but not as the primary source of treatment. It's really an exercise focused. And I'll explain that further as we go. So some more benefits of exercise, you can improve their mobility. So if you can raise your shoulder, raise your arm in that full 180 degrees of motion, you're gonna get less strain on those external musculature. The internal rotator cuff muscles are gonna have less strain. If you can have that full range of motion, I use the shoulder as an example, but if you have a lot of kyphosis, I can't really demonstrate it for you on Zoom here, but if you're in that forward flexion position, it's harder to lift that shoulder overhead. It's harder to lift the plates up into the upper cabinet. You're more likely to get that neck strain or hike your shoulders up to get it up there, clench that neck, develop that tension in the neck. That's gonna lead to some pain symptoms. So if we can improve their overall mobility, it's gonna help them recover, but it's also gonna prevent recurrence. Same thing when we look at the back, spinal mobility, hip mobility. Focusing on, when I talk about mobility, I mean within the joint where flexibility of the muscles. So we're having people stretch, really trying to improve that, elongate those muscles will improve their joint mobility. Decreasing pain under exercise benefits here. So that one study I just mentioned, you can decrease by 50%. This showed up to 54% reduction of pain. Another one showing 40% reduction. So we're definitely seeing pain reduction. And as I said in the beginning, I don't like to focus on pain, but this is just showing that we don't necessarily have to be doing surgery, injections, medication to decrease pain. We can empower patients to move on their own and that naturally is gonna improve their pain system. Resistance exercise and stabilization. So when we look at exercise, it's not just putting their legs side to side or stretching, it's actually using resistance is gonna help decrease those pain symptoms. It's gonna improve their strength, their mobility. And as we see here, reduce their pain, but also improve their function. And it's a lot of questions you'll get is, what type of exercise is good? This last, under decreased pain here, this last bullet point was studied by Gordon, kind of showed that there was no magic one type of exercise, but a combination of aerobic training, flexibility, strengthening, all important to decrease that pain. As I said, it's multifactorial. So you want aerobic conditioning. That's gonna help elongate muscles, stretch muscles, increase blood flow, improve their flexibility, mobility, and also improve their strength. I always tell patients, you wanna have long, flexible, and strong muscles. So you wanna get that joint through its full range of motion and have those muscles strong. A lot of patients are fearful that they're gonna just gain this huge amount of muscle mass. That's very unlikely, unless you're a nutrition, you're eating a calorie surplus to develop that. But even patients that are more prone to muscle strengthening, I mean, to muscle mass, to improving their muscle mass through resistance strengthening, that's why you have them train with someone that's knowledgeable. So they don't get, you don't wanna be too big and bulky because then you lose some of that flexibility or joint mobility. So it's a combination of everything, which I feel is beneficial. And all of this is gonna help decrease that disability by improving patient's functioning, that's gonna improve their ability to work and decrease that sick leave as these couple of last three studies here showed. So it's also with strength training, as we've kinda, I don't mean to keep dwelling on this point, but these slides are just to show that there is so much evidence. And most of these studies are within the last five to six years, showing the importance of exercise, but not just any old exercise, it's strength training and mobility training is really what helps patients improve their pain, improve their function, allow them to work and have improvement in their overall quality of life. So focusing on whole body functional strengthening, this third bullet point looked at the posterior chain strengthening, and I'm gonna show that in more detail in the next slide, but that posterior chain strengthening, those paraspinal muscles is what I'm referring to there, strengthening those back muscles is gonna improve that loss of muscle atrophy we see in that prior MRI showed you of the multifidus and those paraspinal muscles, and that's really gonna help decrease those pain symptoms. So what if we started this early in patients? All these studies are looking at patients that had back pain, but what if we start educating patients in their teenage years? What if we use physical education class to actually educate patients on movement quality instead of just playing games? Now, a lot of this with my patients that are teenagers or even younger that do do some of these exercise classes, you make it fun. They are playing games, but they're also being educated on how to move appropriately through exercise. I think we can make a lot of changes if we focus early, but by minimizing that muscle atrophy they develop, minimizing that loss of mobility by focusing on these exercises throughout people's lives. So this specific study I'm highlighting here, I thought it was a good one because it really talked about that paraspinal posterior chain muscle strength. It looked at the MRIs pre and post to see if there was a change in that quality of muscle tissue or fatty infiltrate. So these patients did a combination of exercise. So they did a combination of strength training plus aerobic training. What they did here was walking. They did a 10-minute dynamic warmup. What that means is they just didn't do a static stretch. They would do walking lunges, walk on their heels, walk on their toes, do air squats, simple things to improve the blood flow to the muscles to get things warmed up. Then they would do a 30-minute strength training. Sorry for the spelling mistake there. Strength training regimen, which included squats, lunges, stair step-ups, planks, back extension exercise, pushups, and bridges. Then they would do a 10-minute more static stretching program or cool down. So 50 minutes of some exercise activity, and it did show that they had significantly improved back muscle strength when evaluating their strength pre and post, as well as decreasing their pain levels. So we're gonna decrease their pain, but also improve their back muscle strength. But what I found interesting is, because basically since I've been, last seven years or so, really focused on education of patients on that paraspinal muscle strength. And this study finally was one that was able to show that you can increase patient's muscle mass, their diameter of their muscle tissue, and you can get hypertrophy in those posterior chain musculature, and decrease their fatty infiltrate, the fat mass in those tissues. So this is a nice study, because it kind of shows that you can make changes in those posterior muscles. And as we know, those muscles, especially the multifidus, those are very important to keep that spine in neutral position, especially within the first 10 to 15 degrees of movement. When you bend and twist, those muscles fire, and that's gonna keep the spine in neutral position. So if you have a disc protrusion close to a nerve, maybe that's gonna prevent that disc, in those first degrees, from irritating that nerve. Maybe it's gonna help stabilize those facets if they're arthritic from getting irritated. Now, I don't have a study to show that that's the case, but that's kind of the theory I go off of when I'm educating patients, and why some of these things are effective through exercise. Another study here, similarly, a second study, looking at that paraspinal strength again. This used a free weight-based resistance training in chronic low back patients. This I like because it also looked at patients' quality of life measures. So it looked at their pain scale, their oswestry disability index, and this Euro V2 quality of life measure at baseline and every four weeks throughout the study. Again, exercises were very similar as that last one. You know, very active, functional resistance exercise, glute bridges, overhead squat, deadlift, step-ups, lat pull-downs, and push-ups. So we're looking at core strength with the bridges. We're looking at upper body strength with lat pull-downs, push-ups. That's also strengthening the back. But the overhead squat, you know, we're all bending forward to lift things off the ground. Deadlift, people were very scared to ask patients to do that, and still are. But every time you put something into the lower cabinets, take something out of the dishwasher, they're doing that deadlift activity. There was a study that showed people do that hip hinge where they bend at the waist first before bending at that knees, which is what a deadlift is, over 2,000 times a day. So if we restrict that activity, well, then patients aren't gonna wanna ever do that. So it's gonna really, they're gonna pull back on what they do in their lives, and that's not what we want. We want them to do what they want. And then the step-ups, again, going up and down stairs, things like that. Again, the study showed 72% reduction in pain, 76% reduction in disability, significant improvement in their overall strength, endurance, what they could do exercise-wise for how many reps when we looked at a pre and post study, and then reduction in that fatty infiltrate and increase in that surface area in those musculatures. So again, you can hypertrophy the muscle fibers that are still there, which will take over that space and decrease that fatty infiltration. So we can still make changes. And we knew that when you look at people that go to the gym, their muscles get stronger, their quads get bigger, their biceps get bigger. But we've never been able to really show that until these studies started coming out, specifically looking at the area around the posterior part of the spine, those posterior chain muscles. So interesting studies that show we can induce change and that will induce change that you can see tangibly through their pain levels and their quality of life and their functioning. The one thing, a bold point I forgot to mention is these patients also did have significant improvement in their quality of life. Their satisfaction with what they were able to do, how they were able to function all dramatically improved through that Euro V2 questionnaire. So when we look at, again, at strength training, so when I would approach this with patients, I would say we're gonna start, I usually don't use the word exercise, we're gonna train, because that's what I want patients to do. I want them to be training, and it sounds corny, but training for their game of life. I relate it to athletes. The best athletes are the ones that are able to play later in life into their 40s, early 50s. Look at Tom Brady, he wants to play until he's 50. Some of these great athletes, they take care of themselves. And a lot of that is through what they do with their body, functionally exercising, stretching, mobility training. Also, obviously other lifestyle changes, which I don't touch on in this talk, but nutrition plays a big role. But why are these athletes able to play longer and still be as effective as 20-year-olds? It's because they're doing this type of training. And it's the same thing with our patients. If we want them to be able to keep doing and working when they're 50 and 60, if they're in construction, if they, I see a lot of linemen climbing up telephone poles. If they're able to, if they wanna keep doing these things, building houses, they have to train so they can keep doing that. They can't expect that their body to hold up when they're 45 as it did when they were 25 and still be able to do the same things. The good news is they should be able to, but it takes that training. They have to train their muscles, their body system, their nervous system specifically to not become sensitized to these changes and cause that pain and loss of function. But if they keep training their body and take care of themselves, they're able to, they're gonna be able to keep doing the things later in life that they wanna do. So not only work, but play with their kids, play with their grandkids, go play baseball, hockey, have fun with their grandchildren and not just have to sit on the sidelines. And this study was interesting because it looked at strength training, but also increasing patient's longevity. So improving their quality of life, not only their quality of life, but how long they live just through strength training. And why is that? It seems to increase, not seems to, but it did increase the telomeres. So the ends of your chromosomes, which has been linked to longer telomeres seem to, is linked to increased longevity in life, how long you live and how effectively you live at those later years in life. Higher levels of activity was associated with those longer telomeres. And with one study by Tucker that we're showing here, activity greater than 30 minutes, five days a week had telomeres that appeared nine years younger than those that were sedentary. This other study by Werner showed high intensity interval training lengthens those telomeres. So we can improve our quality of life at the end of life and live longer by staying functionally active, by improving our mobility, becoming less sedentary, you're gonna make changes throughout all your body, even down to the chromosomal level, so you can live longer. And I'm really not trying to dramatize this at all, but this is all just based on studies I've found and analyzed that show that we can truly make this change. Similarly, within our mitochondria, we know people that are healthier at an older age have less diseases, that have less systemic diseases, comorbidities, have higher quality of mitochondria, and exercise muscles are the ones that have more mitochondria in them. So if we can exercise more, we can improve our mitochondrial quality and activity that often will decrease with age if we're more sedentary. So I touched on this earlier, but this just looks at patients, exercise and weight loss, and as I said, weight loss alone can make changes. This isn't specifically looking at pain, but it's looking at morbidity and mortality. And when we compare exercise to just weight loss, weight loss was associated with 10 to 15% reduction in mortality, so important. It is good to instruct patients on healthy weight loss activities, but if we also encourage them to increase their exercise activity, they can have a 15 to 60%. Now that's a wide range, I understand, but just showing you that you can have an even further improvement in that reduction in mortality by focusing on exercise, not just weight loss alone. In this last point here, looking at exercise and longevity, middle-aged people who walked at least 7,000 steps a day showed a 50 to 70% decrease in mortality from cardiovascular disease and cancer over the following 10-year period. So obviously we can improve not only our functioning in the short-term, decrease our pain, but we can also improve our quality of life in the long-term. How we're gonna live towards the end of the life is definitely affected to what we do, how we move, and how active we are. So when I see patients, this is kind of my prescription that is on my prescription to the physical therapist, or I've moved often now more towards using more personal training and bypassing physical therapy as I find it much more effective. When you find the right people who are in the fitness realm, who are educated in proper fitness and movement quality to teach patients how to exercise, physical therapy is phenomenal for many things, but when it comes to strength and fitness, training and education, oftentimes they don't have that same education as properly trained personal trainers, but I'll have them do what's called high intensity. So they're not just walking slowly around the block. They're putting in some intensity with it, getting that heart rate up. It's constantly varied. So they're not doing the same five, 10 exercises every time they go to physical therapy or to the gym. They're always doing something different. So you keep changing the activity of the stimulus into those muscles and the nervous system, and that's gonna be what induces change within the muscle tissue. It builds muscle mass more effectively. It also helps desensitize the nervous system by constantly changing and putting in a new stimulus to the nervous system. It doesn't get sensitized. So you're gonna reduce that central sensitization or nervous system sensitization, and I have them do functional movements. So there's no need to go to the gym and do a simple bench press. Very rarely, it doesn't hurt to train that muscle, the chest muscles, the pecs, but it's not a very functional exercise. But doing things like a squat, a deadlift, a push press, lifting up overhead, step-ups, lunges, those are all functional things that patients need to do daily in their day-to-day lives. And so by training those muscles in the gym and patients seeing that they can do it without exacerbations of pain, that's gonna allow them to transition home to be able to do those same exercises at home and not be fearful. So you're eliminating that fear avoidance. They don't wanna do it because they think it's gonna hurt, but if they've already done it in a controlled setting at the gym, then they know they can do it at home or at work. And then non-pain contingent, the second bullet point. It's looking at quarter base, so hitting certain weights, improving their weight, not decreasing their pain. We wanna move away from focusing on, is your pain better? Oh, it's not, then we can't progress. No, let's have them progress based on what they can do, based on their functioning, what their strength is allowing them to do, what their joints are allowing them to move through, that range of motion, not based on whether it's pain. Now, obviously, if they have huge flare-ups, they're getting 10 out of 10 pain with an exercise, maybe something's wrong. We wanna evaluate that. That's not typically the case though. So not focusing on their pain, because if they, again, just like I said, with them doing functional movements at the gym, then they can do it at home. Same if they're having, if we're focusing on their pain, and every time they have a little bit of discomfort or pain with a movement, we tell them to stop, that's gonna transition to their day-to-day lives. They're not gonna wanna work if they have a little bit of pain. They're not gonna wanna get up and do chores around the house or be active with their children, grandchildren, if they feel that pain. So we wanna move away from focusing on that pain vital sign and move more towards maybe function should be that vital sign we use instead. So again, that type of physical therapy that can be beneficial or exercise treatment, no one magic exercise is helpful, but it does seem to be beneficial to do some resistance strength training program. And with some intensity. And that does seem to be more important than every day walking around the house, or maybe a few days doing a more high intensity program where you get that heart rate up and you're really stressing those muscle fibers and that nervous system to a higher degree with a couple of days to recover in between. And also it's important to, obviously, as we've mentioned above, as shown through those MRI studies, including spinal strengthening. And when we tell patients the core, it just doesn't mean your abs in the front, but the core is really from above your knees to above your elbow. That whole trunk is really the core of our body. And that's what we wanna focus on training. And I always tell patients these last two points here, especially if they've never exercised before, but for most everyone, it's gonna cause some flare ups. It will cause some discomfort. The next day you're gonna be sore. That's true for anyone that's going to the gym that's not used to exercising. You will be sore the next day, and that's normal. That means you're making change within those muscle tissues. So that's where another topic would be that nutritional component is important to minimize that and to allow them to recover. But if you warn patients that there will be some discomfort, especially that first week or two with exercise, they're more apt to stick to it, knowing that it's a normal part and they're not doing damage. So last couple of slides here is something I really focus on with patients. And it's really been my treatment modality that I've moved to over the last, I would say three, four years. More than anything else, if I could get all my patients to do a CrossFit type exercise routine, I think we'd have a lot more success. And CrossFit kind of has a scary terminology to some people due to misinformation out there. What CrossFit is, is it really helps, it's educated coaching, focusing on movement dysfunction and abnormal muscle strain patterns. And so that's what you, when I refer patients to CrossFit type exercising, I want them to work with a coach or personal trainer who's really knowledgeable in movement dysfunction and abnormal strain patterns, because I don't want them, as a lot of patients will get with therapy and things like that, a cookie cutter approach. You come in with back pain, you get these five exercises and that's all you need to do. I want my patients to be evaluated, see where their muscle firing pattern is on. Why are they developing that abnormal strain pattern in their low back? What's causing their facet joints, if it is their facet joints, to get irritated? What muscles are and aren't firing? It's tight hamstring. Causing some pull in the low back. Is it causing some hip, pelvis abnormality? Are their glutes, are their hips not internal, external rotating appropriately? Is one side off compared to the other with their hips or their shoulders causing some restrictions and causing that muscle firing pattern in the muscles in their neck or their back to get tight, which is putting strain on the facet joints. So really having someone knowledgeable that can look at the patient, doing that initial evaluation to see what's not firing appropriately, and then developing an exercise program specific for that. And that's where a lot of well-educated CrossFit coaches can come in is they're really adept at developing good exercise programming, but also evaluating what's not firing appropriately and developing that program for that. So helping those patients understand how to train, but with quality movement, which will restore that function, that muscle firing patterns, and that will directly correlate because they're gonna be doing those functional exercises in their day-to-day lives. So, you know, I would get a lot of flack initially, not so much anymore in the Knoxville area, because a lot of people have seen my patients do well with this type of exercise, but it's exactly what I had mentioned above. It's that high intensity, constantly varied functional movement. So there's been 13 studies compared in this 2017 review that showed the same injury rate with CrossFit type exercise as any other exercise program that was looked at in the literature. So a lot of people think you do CrossFit, you're gonna get injured. You do CrossFit, you can get injured if you don't do it appropriately, you're not coached through it. Like anything, if you just jump into it, you know, start playing hockey without being coached or trained how to do it, you're gonna get injury, you're not gonna be very good at it. So you wanna have them work with someone to teach them how to do these movements with good quality, and that's gonna prevent injury. So not only that type of exercise, strength training, aerobic conditioning, and improved mobility, which you're gonna get through these functional CrossFit type exercises, studies have also shown you can have significant improvement in your cardiovascular endurance or VO2 max, you can improve your stamina, your strength, your flexibility, mobility, your power, and your balance. So you'll see significant improvement by doing these types of exercises and these will carry over into your day-to-day lives. You improve your lean body mass, that's improvement for decreasing mortality long-term, 7% lower body fat, greater strength, aerobic capacity compared to traditional recreational exercise. So doing this high intensity, varied functional movements, you can have an improvement over just typical recreational exercise activities, which were mentioned in this study by Manjean. Higher levels, one thing I like about this is this last bullet point is the higher levels of sense of community. When you're in a community with a group of people that are encouraging and doing similar things as you trying to move and be healthy, people feed off of that. As a society, we like to be around people that think like us, that's why there's all these different groups from political parties all over the place. This is one of those similar types of communities, but it's encouraging health. So I don't think there's any negativity to just being around people that wanna be healthy, live longer and live more happy. And that's what this society seems to do. And the reason I came to this type of exercise through CrossFit, and it's not the only thing I use, but finding people that think like-minded with these types of movements is really beneficial for our patients. And the CrossFit community definitely does that. But it doesn't have to be through CrossFit, but finding people around you that can see the evidence that's definitely out there, that this type of exercise using some resistance, functional exercise can be beneficial, gives you someone that can help you through this process. Because if you just tell patients to go exercise, that's not gonna be very effective. But having someone alongside them, coaching them, whether it's a good physical therapist or a good trainer or a good coach, that's gonna help put that positive feedback to the patient so they'll stick with it. Because you want this to be a lifestyle change, not just something they do for four weeks and give in a handout and go home, but something they can have and be educated on how to move appropriately. Doesn't mean they have to keep going to that trainer, but that a good person will help teach them the right type of exercises and teach them how to keep up with this type of programming. It'll make a huge difference for them. And as we've seen here, there's a lot of good evidence to show if patients stick with it, they will make big changes and allow them to live longer and be happier while doing that. Last little piece of encouragement here is I kind of like to have patients focus on what's important. You know, if people look at a jar, you can fill it all with sand and the jar will be full. But if you first fill it with rocks, those big important things, your family, you know, your faith, your job, and then fill it with, you know, little smaller pebbles, things that are a little less important. And then you fill it with the sand. You can fit a lot more in your jar, but you're filling it mostly with those big important things. And that's what we wanna focus on in our life. And as physicians and providers, help patients focus on what's important. What are you gonna fill your life with that makes meaningful change, whether, you know, it's proper fitness, proper nutrition, and then add in those other things that are just for enjoyment that are less important. And I think, you know, proper nutrition, proper fitness specifically can really be one of those important things we can help educate our community on. And that'll really help us deliver better healthcare moving forward. If we start with this type of mentality when people are, you know, in elementary school, in middle school, really teaching nutrition, teaching exercise, that's gonna really help us make a change in our overall health of our community versus waiting till they're 50, 60. They've already developed these bad habits. Now we can still make dramatic change even at that time. But if we start really educating them early on and making that a lifestyle change, I think we'll make a huge difference in healthcare. So let's get people exercising, eating healthy nutrition. And I think we can make a big difference. Now I'm not there in person today. I wish I was. I hope you guys have a wonderful rest of your conference. I am available through email. I'm sure Betsy can get you my information. If you have any questions, further questions, would like any advice of how you can implement this with your patients, meet people in your community that can help you deliver this type of care, I'm more than happy to talk to any of you. So I hope you have a great rest of the weekend. Thank you very much. Have a great time.

exercise

back pain

health promotion

physical medicine

nervous system

strength training

mobility exercises

chronic pain

functional movements

spinal health