Unlock Your Hidden Core to Relieve Back Pain

If you suffer from back pain, you might be happy to hear that you can play a central role in facilitating your body’s natural healing abilities to reduce the pain you experience. You can put your time and energy into changing your body, instead of trying multiple quick fixes that won’t work long term. You may have heard that strengthening your core can help your back, but that’s only part of the story. When you think of your core, you are probably picturing your ab muscles. While your abs are an important part of your core, so are the muscles in your back — particularly the multifidus muscles — an integral part of your core that is often overlooked. I call it the hidden core, and strengthening it can significantly reduce your back pain.

Your Hidden Core

Your core has an anterior (front) component, a posterior (back) component and two lateral (side) components. Each of these components has a superficial and deep layer. The anterior, lateral and posterior components are connected to each other by fascia (strong connective tissue) to form a belt. In our society we get too caught up in the muscles of the core we can see — like our oblique muscles for example — and forget about the hidden parts of our core that are equally as important. The core muscle group at your back is referred to as your posterior core. These muscles in combination with your visible core muscles, complete the internal brace you can use to build a stronger core.

Strengthening Your Hidden Core

Even though I am a neurosurgeon, I focus on noninvasive solutions for reducing back pain. In my book, The End of Back Pain, Access Your Hidden Core to Heal Your Body, I write about how we all can build a better back through a series of exercises I call the Hidden Core Workout. The hidden core workout is an exercise program that you can customize to fit your pace and confidence level. To understand why my stackable exercise program works, let’s dive a little deeper into what happens when you strengthen your hidden core.

The hidden core stabilizes the spine and fixes it to the pelvis, thereby reducing motion of the spine. The hidden core strengthens the muscles and the fascia themselves which helps reduce pain in these structures. So, if you remember one thing about your multifidus muscles, let it be this: They provide about 70 percent of the stiffness of the spine during straightening up from a bent position. In other words, if you develop your multifidus muscles, your spine should be able to remain relatively stiff when you move. This will minimize back pain. Strengthening your hidden core muscles leads to a stronger brace that helps you bend and keep a healthy posture, eases tension from your back, and protects the vertebrae of the lumbar spine. As you can see, you can empower yourself to play a starring role in your own healing. Here are eight more takeaways from my book, The End of Back Pain, Access Your Hidden Core to Heal Your Body.

  1. Deciding not to exercise due to back pain can actually make your pain worse.
  2. Exercise is a free and non-invasive solution that can mitigate your back pain.
  3. My Hidden Core Workout incorporates yoga stretches, planks, kettlebell and ab exercises that all work together to build your strongest and best back.
  4. Walking is therapeutic for many ailments, but running offers even more benefits to protect the back.
  5. Become an active participant in your own health care. Education is your best defense against back pain.
  6. Pain medication should not be the first choice and it often can lead to more pain.
  7. Your treatment if often determined by who you see (chiropractor, surgeon, or physical therapist) and not on what’s actually wrong with you. So, be careful of where you start and keep this inherent bias in mind. Listen to your own instincts, and be ready to change direction.
  8. Be open to noninvasive solutions first.

Empower yourself with information and you can strengthen your hidden core. Decrease the intensity, frequency and duration of your back pain and experience lasting relief.

© 2014 Patrick Roth, M.D., author of The End of Back Pain: Access Your Hidden Core to Heal Your Body

The Power of Choosing Exercise to Treat Back Pain

The most significant hurdle to cross in our battle with back pain is accepting that the solution lies in the hands of the sufferer and not the provider. This realization must be accepted by health care providers and sufferers alike.

A recent NPR special featured a back pain boot camp in the Boston area. In this camp, patients with back pain have the opportunity to unlearn their pain. This boot camp is the product of a physiatrist named James Rainville M.D. I recently had the opportunity to speak with him. During our conversation, he kept saying, “We don’t help the back pain, our patients do.”

I couldn’t agree more.

In the boot camp, exercise is the medium through which back pain is mitigated (notice I didn’t say cured).

3 Ways Exercise Helps Back Pain

I thought that this would be an opportunity to mention three positive effects of exercise you might not think about.

Most of us understand exercise as potentiating a classic adaptive response from the body. If our muscles are stressed by exercise, the small damages inflicted will result in repairs that leave our muscles slightly bigger, more energy-filled, and stronger. Yet exercise does so much more.

  1. Exercise can help us unlearn pain. In my book, The End of Back Pain, I address this through a psychological concept called embodied cognition. Our bodies and our brains are inexorably interwoven. It is true that we smile when we are happy, but we are also happy because we smile. Try it yourself. Simply smile and you will feel slightly happier. Likewise, exercising our back will alter our brain’s concept of what our backs are capable of. It can convince us that we can use our back without pain or with less pain. It is the old “bait and switch” concept. Bend your back without pain during exercise, and you will soon be with less pain in life.
  2. Exercise can help us learn new things. Exercise is now known to cause our brain cells to produce more dendrites and connections to other nerves. It even causes our brain cells to regenerate — something that we thought couldn’t happen. Exercise can even potentiate our children’s learning in school.
  3. Exercise can affect our actual genes. If you subscribe to the calorie in calorie out philosophy of diet, you believe that weight loss comes from either eating less or exercising more. But exercise can bring about actual changes in our genes that have an influence on fat metabolism. One of the ways this occurs is through gene methylation, which is the addition or removal of a cluster of carbon-hydrogen molecules onto the gene. This structural change will change the way the gene operates. A recent study looked at the fat of subjects before and after a six-month exercise block. The genes that controlled the fat metabolism were different after six months. This suggests that exercise contributes more than just logging “calories out.”

Yes, exercise can help your pain. Yes, exercise can make your muscles stronger. But the bigger point is this: You can control your pain with exercise.

© 2014 Patrick Roth, M.D., author of The End of Back Pain: Access Your Hidden Core to Heal Your Body

Don’t Be Misled by Quick Fixes for Your Back Pain

If you suffer from back pain, it likely dominates your life. Naturally, you want to triumph over it. Victory, however, is elusive without struggle. Too often, as I am explaining treatment options to my patients with back pain, I am interrupted by the question, “Is there a pill that I can take?” Media, society and, yes, even physicians, have misled people to believe in, and rely on, the quick fix. Many treatments, including minimally invasive surgery, are promoted as solutions to back pain. Yet these quick fixes often do not withstand the test of time. None of these quick fixes are proven effective in a scientific study.

The promotion of laser surgery epitomizes the quick fix illusion. Painlessly beaming away your pain is extremely enticing, and as a health care provider, an extremely misleading promise of a quick fix. Despite any proven efficacy in its use, patients and physicians embrace this option. Ironically, many patients will also dismiss a suggestion for a steroid injection with the response, “I don’t want a Band-Aid fix.” Obviously patients recognize that the quick fix or Band-Aid approach is not only quick and easy, but also a temporary or incomplete measure. What they don’t seem to recognize is that laser surgery is a masterfully camouflaged Band-Aid.

Here is another problem with back pain: The treatment you receive is often determined by who you decide to see for treatment, and not by what’s actually wrong with your back. If you see a chiropractor, you will likely receive chiropractic treatment. If your first stop is physical therapy, then you will get physical therapy. And most problematic of all, if you start with a surgeon, you are likely to receive surgery.

Embrace the Slow Fix: Education and Exercise 

My book, The End of Back Pain, is based on my 20 years of experience as a neurosurgeon treating back pain. And there’s one thing I know for sure: Educating a patient about their disability is the single most effective way to treat that disability. The more educated patient is the healthier patient. No matter what your health issue is, you will be empowered by learning more about it. It may be easier to let your physician tell you what to do, but you will have more success and better health when you learn about what is wrong in your case and participate in the decision processes.

I am an advocate of an approach of education and progressive exercise. Back pain requires a deliberate, intentional, and plodding fix. This slower fix looks to build back health rather than eliminate pain and this leads to a reduction in back pain. My approach looks to diminish the frequency, duration, and intensity of the invariable episodes of back pain. Building back health requires both a commitment to education and a sustained program of exercise.

Exercise provides a method of fundamentally changing your back. It harnesses your body’s innate capacity to adapt positively to stress.

A combination of aerobic conditioning and core strengthening works best. And not just crunches or planking core work. There is a pervasive idea that doing abdominal work will help back pain. This is partially correct, but abdominal work alone is not sufficient. Our core is comprised of much more than our abdominal muscles. The core is a circumferential group of connected muscles that includes the abdominal muscles, but also includes back muscles called the multifidus muscles. These muscles are essential to core strengthening. In the End of Back Pain, I focus on this part of the core that is usually overlooked. I refer to it as the hidden core. Your hidden core is the most important aspect and least utilized aspect of core strengthening. I have found that prioritizing the back muscles is most effective in promoting back health.

Cardiac disease provides the best analogy to this approach. Consider the following two options as a response to a patient having had a minor heart attack. The first response starts with accepting that you have been dealt a bad heart and then looking for medications or surgery to mitigate your bad fortune. The alternative response is not to accept your fate and to set out to fundamentally change the caliber and function of your coronary arteries through intense and sustained exercise and dietary intervention. Obviously, the second response is a slow fix. As with the heart, the exercises for back health represent the most important part of the slow fix.

The parable of the tortoise and the hare parallels to my slow fix solution. We have to look beyond obvious concepts that we too easily accept. It is obvious that the faster animal should win the race. In fact, if the hare were to take the race seriously, he would undoubtedly win. With this in mind, we should aspire to be the hare. But this is wrong. We fail to see the real strength of the tortoise, which is not only its dogged perseverance and focus, but its ability to resist being saddled by convictions and assumptions. Slow can win the race.

I tell my patients with back pain that they need to start their exercises while still in some pain. I tell them that letting “pain be your guide” is a potentially limiting, and thus, potentially harmful rule of thumb. I tell them to move even if moving is painful. I realize this advice is unsettling and counterintuitive, but I offer this advice as a physician and back pain sufferer myself. I know it can lead to breakthroughs in pain relief. It is the tortoise, and not the hare that is willing to take that advice and it is the tortoise, and not the hare, that prevails.

Nietzsche once said, “Convictions are more dangerous foes of the truth than lies.” Nowhere is this more evident than in the treatment of back pain. It is dangerous to be saddled by convictions or assumptions. If you are willing to think outside of the box, try something new and focus on what you could be, rather than your current state, then you will have a better chance of triumphing over your back pain.

As a surgeon, of course, I also have an interest in using surgery as a tool to help with back pain. However, surgery rarely fixes back pain. Carefully selected patients can, and often do, benefit from surgery. Surgery has increasingly been subjected to scrutiny, and often appropriately maligned, but this is a result of its misuse and overuse rather than an inherent deficiency. It is essential that, as a surgeon, I overcome the bias of the surgeon to look at all patients as surgical candidates. I want to give patients the longer solution and that’s the slow fix. I must prepare patients for the critical process of exercising for back health.

As we are often our own worse enemies is life, the same is true in confronting our back pain. Accepting conventional wisdom can often lead you down a longer path of suffering with unsatisfactory results. Challenging our assumptions, getting educated and taking charge of our back health is the safest and surest path to a more pain free existence.

I’ve Got Your Back: Tips to Lessen Back Pain

Ergonomics is the design of our environment with the goal of making it more efficient and comfortable. Given that we spend two thirds of our time at the workplace and in bed, it makes sense to discuss how we can improve these environments to lessen back pain. Media outlets run stories on how back pain can be lessened by sitting less, repositioning our computer screens, and changing our office chairs. If our workplace can be the cause of back pain, then surely, we can modify our workplace to prevent back pain, right?

Actually, no. While altering our environments can help, it’s only a part of the story.

Our efforts to alter the workplace to avoid back pain have been scrutinized by evidence-based medicine and found to be largely ineffective. The reason is because the causes of back pain are so varied person to person. And for many people, back pain is just part of life and not preventable — just as you can’t prevent a headache or a common cold. Bottom line: Back pain is a mixed bag — arising from several different underlying pathologies.

The relationship between work and back pain has a long history and when back pain was covered by worker’s compensation insurance, it helped transition back pain from being perceived as part of life to an injury requiring treatment. For anyone who experiences back pain, there are things you can do to lessen your back pain.

Strengthen your core. The optimal intervention is to partake in a regular workout which results in core strengthening and emphasizes the part of your core that is behind you or hidden. This will alter the form with which you sit. It will actually change your back. This will strengthen and shorten the weak gluteal muscles that Czech neurologist Vladimir Janda talks about.

Use kettlebells. Perhaps, the best way to strengthen your hidden core is with the use of kettlebells. These weights with a handle force you to engage your posterior chain of muscles when doing the associated exercises — particularly the gluteal muscles that are often weakened by excessive sitting.

Use good technique. The kettlebell is the proverbial double-edged sword, however. Its tremendous potential is coupled with an inherent risk. Good technique is essential. In my book, The End of Back Pain, I provide a graduated exercise program that culminates in the use of kettlebells. It provides a rational for prioritizing the hidden core over thetraditional core or the abdominal muscles. My exercise program also prioritizes strengthening over stretching, and endurance over power. Learn and then utilize the remarkable kettlebell swing to limit your pain at work.

Still optimize your work environment. This is not to say that we should forget about trying to optimize our work environment. Little changes in computer height or type of chair may pay dividends in terms of comfort.

Don’t sit too long. There is evidence that sitting for long periods of time can be detrimental to our back health. Czech neurologist Vladimir Janda described a lower cross syndrome marked by weak gluteal muscles and tight ileopsoas muscles. This is often the result of too much sitting and can result in repeated episodes of back pain.

Make standing up a habit. Getting up from a sitting position every 15 minutes as a habit will certainly help, but it’s not enough.

In addition to back strengthening, there is another intervention that you can make at work that will reduce back pain and it’s not what you would expect. Turns out that job satisfaction is a powerful antidote to back pain at work. If you want to avoid chronic or recurrent back pain, find a way to enjoy your job — or find a job that you enjoy. This is an over-simplification, and easier said than done of course, but the point is that only you can make things better.

Looking for an ergonomic overhaul, to do the job for you, will leave you disappointed.

© 2014 Patrick Roth, M.D., author of The End of Back Pain: Access Your Hidden Core to Heal Your Body

The Great Disconnect

You are going through one of those rare periods in life. You are getting along with everyone, enjoying your job, losing weight and eating better when you suddenly tweak your back — doing something small — like lifting up a chair.

Later that day, your back is worse and the next day there is some leg pain as well. Now you’re worried. Five days later you see your internist or a chiropractor and get a lumbar spine MRI. You are told that you have a herniated disc.

Welcome to the great disconnect. Depending on the professional you see, your course of treatment will be different. At this point, everyone takes a different path. Maybe your internist recommends physical therapy. Another internist may recommend pain management. If you see a chiropractor, you may stick with the chiropractor for treatment.

Let’s follow one path as an example.

You are sent to physical therapy. You meet your therapist and she impresses you with her careful and detailed plan. She has successfully treated many patients with herniated discs. They didn’t need an injection or surgery and returned to their previous lifestyle after several weeks of treatment.

What she didn’t tell you was that she didn’t read your MRI. The internist who sent you to the therapist didn’t read your MRI either. Both of these providers relied on the MRI report.

The MRI was read by a radiologist. The problem is that you have no idea how reliable that radiologist is. Since there is no standardization in terminology, the report of a herniated disc means very little. Besides, herniated discs are common findings on MRIs done on people without any symptoms. What one radiologist would call a herniated disc another may call a degenerative disc or a disc bulge.

Let’s get back to the therapist again. Chances are, the therapist will apply the treatment that she prefers to start with. Is there any scientific literature to support this starting point? Perhaps the therapist decides to use therapy targeted to the herniated disc. Wouldn’t it be nice to have more detail about the disc herniation? For example, an extruded herniated disc should have a different treatment than a bulging herniated disc. But remember, the therapist has not seen the MRI — only the report.

You have failed physical therapy and now you are in pain management. The pain management doctor is recommending an epidural steroid injection. The chances are that she has not read the MRI, but similarly, relies on the report. The injection recommended will vary from provider to provider and is more connected to the preference of the provider than the architecture of the disc herniation.

Back to the chiropractor again. If that’s where you started, you may not be offered therapy or pain management, only chiropractic.

I think you get my point by now.

Here are my concerns:

  1. The treatment you receive depends on whom you see and not on what you actually have.
  2. What you actually have is best represented by either the arbitrary words of a radiologist who has never seen and examined you or by a clinician who cannot read the MRI.
  3. Even if the providers could more coherently put together the history and exam with the MRI findings, there is no scientific evidence to suggest the “best” treatment.
  4. Since we live in a fee-for-service world, the provider who sees you first is often motivated to apply his or her techniques.

This is the great disconnect of you getting the treatment you need. My website is dedicated to both highlighting and providing solutions (primarily non-invasive) to this ugly reality. Once you start your quest for back pain treatment, it’s essential to pursue an understanding of your condition and then, ultimately, to try to link that understanding with the correct treatment. It’s also important to realize that this doesn’t always work, or doesn’t work right away; treatment is often a process rather than a single event. To a large extent, settling on the best treatment is your responsibility.

© 2014 Patrick Roth, M.D., author of The End of Back Pain: Access Your Hidden Core to Heal Your Body

No Tolerance for high pain tolerance

When it comes to providing information during a visit to your doctor, there is a “sweet spot”.

Not contributing enough will undermine the process. For example, it is reasonable to follow the statement “It hurts when I walk” with “and I love to walk” This helps me to decide what is best for you.

On the other hand, contributing too much will also undermine the process. I am more interested in what you are feeling rather than your opinion of why you are feeling something. There will be time later in the visit for you to air your theories.

A recent patient was a middle-aged woman who complained of back pain. As we went through her history, I ask her about the relationship of her pain to various activities. I also tried to understand which activities were most important to her. We were making progress- I understood what she felt and what she needed while she was learning what treatment options she had to choose from. Our progress was suddenly stymied, however. For the third time in ten minutes she told me that she had a “high tolerance” of pain.

You may be wondering how such an innocuous assertion could have so derailed us. It turns out that twenty years of practice have taught me that such assertions invariably suggest quite the opposite- she will undoubtedly turn out to have a low tolerance of pain!

Of course we can’t measure tolerance of pain in any meaningful way. We can measure pain thresholds, however. If we do an experiment where we electrically shock the skin of subjects, most subjects will describe the shock as painful around the same amplitude of stimulation. In other words, we all have relatively similar pain thresholds. Tolerance of pain, as opposed to pain threshold, involves more how we interpret our painful sensations. How often do we allow the pain to interrupt our task-at-hand? Do we assume that the pain will go away or that it will persist? Do we presume that something underneath is wrong?

In many ways this interpretive context of pain is more important than the underlying stimulus. Patients who feel the need to boast of their pain tolerance reveal an interpretive process that is already far too developed and biased. The patients with a truly high tolerance of pain have never even considered what their pain tolerance is!

You may actually have a high tolerance of pain. But do me a favor- don’t tell me about it. If you do, it will serve to undermine you. My reaction is like the knee-jerk that I am about to check on you- reflexive and uncontrollable.

When you come to see me, I am, first and foremost, interested in what you are experiencing.  Once this has been vetted, and I have had the chance to ask you questions, I am interested to hear your editorializing and theories. This is the ideal time for a meaningful conversation or teaching opportunity.

Find that “sweet spot” for a productive encounter and tell me how much you hurt and not how much you can handle.



“What would you do if you had this problem?” My patient asked.

This question is problematic for many reasons. Would it surprise you if I recommended something different for my patient and myself? It shouldn’t. The art of medicine often requires applying a treatment to an individual rather than to a disease. The same disease can have different treatments depending on what each individual patient wants or needs. If I am the patient, I may choose to go on a hunch. I may avoid a treatment because the risk is too high for me. I may be a “naturalist” due to my upraising and fundamentally distrust intervention.

You ask me what I would do because you view me as an expert.

Expertise is not a level reached or a degree earned. Expertise is best understood and experienced as a dynamic, rather. It is dynamic not only because information is always being created and disseminated, but because this dynamic body of information has to be interpreted and applied to a unique individual or situation. I, as the physician, may have a good knowledge of the disease, but you, as the patient, have a good knowledge of your own body, your own risk tolerance, and your own expectations. Together — and only together — we are the expert.

Yes, it would be easier for you to hear what I would do and simply rely on that advice. My job is to often avoid what is easiest and try to recommend what is best.

The days of eminence-based medicine have been replaced by evidence-based medicine and will soon be replaced by concurrence-based medicine.

Believe me, I would rather tell you what I would do. It is quicker and easier to be paternalistic than to share in the dynamic of expertise, but by doing you a favor, I am doing you a disfavor.

Blog Zero

It is eight in the morning. I am sitting in the office getting ready for my patients. I have been a neurosurgeon for 20 years, and strangely, I am excited about seeing a number of new patients this morning. I have always come to work with enthusiasm. I learned long ago that satisfaction in my job arises from a deliberate effort — to find something interesting and unique in each patient. It is easy to fall into a habitual sense of boredom and this deliberate effort has paid dividends in terms of satisfaction over the years. In many ways it serves as a paradigm for life. I can trace the roots of this technique back to my days in elementary school where I would stare at the clock in with the hope of speeding up the hands until I realized that the hands would only gain speed when I focused my effort on trying to find something interesting in the lecture.

My patient this morning comes to me with back pain. He wants to know why he has back pain. Although I have dedicated my career to elucidating and pinpointing the pain generator and then recommending the best treatment, he will assuredly be disappointed to learn that I am definitively successful in this endeavor only in the minority of cases.

I explain that I can always make a good and educated guess, however. In this case, we will decide together on a treatment. We will combine my knowledge of back pain with his knowledge of his own body. This will be a dialog — one that may evolve over time — depending on how the initial treatments go. We will focus on creating back health rather than trying to eliminate his back pain.

This is the first of many blogs about back pain. These will hopefully provide meaningful content to you (the back pain sufferer). Some of the blogs will start with “From behind the desk . . . ” and they will describe my perspective (as a surgeon) as I look across my desk at you. I hope that this allows you to learn and consider a different perspective — one that empowers you with knowledge and, as importantly, one that enables you to better navigate the current broken medical system in your quest for better back health and less back pain. Other topics will be about patient empowerment in more general terms or about life itself!

Since I have a daytime job, I want this site to be about what my job isn’t. I can speculate, philosophize, and take risks. Most of all, I want to offer you the unique perspective of a surgeon without a scalpel in hand.