The End Of Back Pain

The End of Back Pain Book by Dr. Patrick Roth

Access Your Hidden Core to Heal Your Body

Book Excerpt / How I Discovered the Hidden Core

When I was just starting to practice neurosurgery, I experienced a month-long episode of severe back pain. A magnetic resonance imaging (MRI) test of my lumbar spine revealed a herniated L5–S1 disc, as well as a chronic condition called spondylolisthesis—the result of a stress fracture that had occurred while I was playing football years before (and that undoubtedly had been the cause of my adolescent back pain). I showed my MRI to my neurosurgical peers, who uniformly recommended surgery. I was just starting my career, however, and couldn’t bear the idea of spending several weeks in recovery.

Although I had always preached the importance of exercise to my patients, I was too frightened to undertake any exertion myself. My pain had improved enough for me to function, but the fear that exercise would bring it back prevented me from following my own advice. Slowly, though, my hypocrisy ate away at me, until I finally got up and, despite the pain, started to exercise. I started slowly, with a few reps, then steadily increased the intensity of my workouts. I felt an immediate difference. My back began to feel a comforting sense of tone and strength. As my back pain slowly receded, I became convinced that I was on the right track.

I didn’t quite know it yet, but I had just backed my way into discovering the importance of strengthening the back muscles and the correlation between these muscles and back pain, both as a cause and as a solution. I also realized that this kind of exercise could be initiated earlier than is traditionally accepted in the course of a patient’s treatment. My search of the literature revealed similar explorations into exercise strategies, but the strategies described had only sporadic success and thus had never become mainstream. That research convinced me that pain-plagued back muscles could be exercised safely, however, and so I began to treat my more ambitious patients with intense back-strengthening. The patients who committed to the program were rewarded with terrific results.

Core Considerations

The muscles of the back—particularly the multifidus muscles—are an integral part of our “core,” but they have too often been overlooked. I like to think of these muscles as the body’s “hidden core.” Our culture has experienced a rich history of strengthening the core to alleviate back pain, a history that peaked in the 1990s when the transversalis muscle (the deep muscle located in the front of your abdomen) was singled out as the essence of the core. This faulty and incomplete definition of “core” suggested that an isolated group of muscles could be developed and used to stabilize the spine and, in turn, reduce back pain. The discipline of Pilates, for example, promotes the strengthening of the transversalis muscle as a means to stabilize the trunk of the body during movement, which limits stress on the spine.

While this movement has met with some success, it hasn’t turned out to be the panacea that was hoped for in its initial stages. Isolating the front of the core is only half the story, and studies have shown that it can cause an asymmetry that may even weaken the back, an outcome that I will explain later in the book. By contrast, the approach outlined in this book focuses on continuing the strengthening program around the entire back—the front, the sides, and the back—like a brace, or the body’s natural weight-lifting belt.

Most of us design our exercise programs after a perusal of our appearance in the mirror. We want better abdominal muscles, better pectorals, and better biceps. Strengthening the abdominal muscles may be the brass ring if you want to be the newest cast member of a reality TV show. The key to back health, however, is to focus on muscles that can’t be seen in the mirror. Through this new paradoxical and effective approach to strengthening your core, the exercises of the Hidden Core Workout will help you treat your back pain once and for all. Oh, and you might even look great in the process!

Over the past twenty-five years, I have seen patients who feel hopeless and helpless because of debilitating, depressing, and disruptive chronic or acute back pain. Perhaps your back pain, too, has led you down a proverbial rabbit hole of inconsistent or contradicting diagnoses, alternative therapies, pain medications, unnecessary surgeries, and even desperation. I understand the physical and emotional effects this particular type of pain can have on a person, especially when the source of the pain is unknown.

Back pain is not the problem. How we deal with back pain is. While a sobering 80 percent of us will suffer from back pain at some point—and nearly 50 percent of us have experienced back pain in the past year!—treatment for back pain has been found largely ineffective when scrutinized by modern, evidence-based medicine.

The “Antifragile” Back

This book is about changing your back. Before your back can be changed, however, your mind must be changed. The very activities that you imagine will make your back hurt can make your back stronger—and fundamentally different. The transformation of both your back and your mind can be accomplished by leveraging the almost magical synergy that exists between the brain and the body. That transformation also takes advantage of our (and many other creatures’) innate capacity to change in response to stress or any other factor that disrupts our equilibrium. As an example of that capacity, when groups of rats are placed in two different environments, the brains of those in the more varied and challenging environment flourish more. Conventional wisdom views stress (and resulting inflammation) as the foundation of disease and aging. Rather than viewing stress as eroding or weakening, however, we can and should welcome it as a source of growth and health. Stress has a “sweet spot,” however. Too much, and we will be weakened; too little, and we will fail to grow and attain health. Stress also needs to be coupled with adequate “recovery” periods to allow the body to adapt and flourish as a result of that stress.

The Brain-Body Connection

Mens sana in corpore sano is Latin for “A healthy mind in a healthy body.” For the purposes of this book we should perhaps modify this to Mens sana in spina sana, or “A healthy mind in a healthy spine.” The brain and the spine are intertwined—not only developmentally, but functionally. One of the themes of this book is that we can leverage this relationship by applying a biological “bait-and-switch.” If we rewire the brain with regard to the spine, for instance, the spine will follow suit and change. Likewise, by equipping the spine with strength, posture, and technique through exercise, we can effectively rewire the brain.


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Edward Benzel, MD
Chairman of Neurosurgery, Cleveland Clinic

Patrick Roth courageously addresses the chronic pain epidemic/crisis head on. Chronic pain consumes 1/4 of our healthcare expenditures in North America. Why is this so? Well, physicians treat these patients as if they had acute pain. They operate, they do procedures, and they prescribe narcotic medication — all of which are doomed to failure in this patient population. Dr. Roth offers a solution and provides not only a rationale for dealing with chronic back pain, but also provides structure for orchestrated recovery. Bottom line, this is a GREAT BOOK. Must reading for anyone with a back.


Mark Bilsky, MD
Chief of Spine Surgery at Memorial Sloan-Kettering Cancer Center

Pat Roth has done a masterful job describing the complex mechanisms that create back pain, a leading cause of morbidity and disability in the United States. Spine surgeons have developed sophisticated techniques to treat back pain, but Dr, Roth elucidates exercise techniques to strengthen core muscles that will hopefully keep the majority of us off the operating table and out of pain. The book is a phenomenal treatise on the management of back pain by a cutting edge surgeon who sees the bigger picture.


Michael Kelly, MD
Chairman of the Department of Orthopedics, Hackensack University Medical Center

As a busy orthopedic surgeon, my chronic low back pain has been an obstacle to enjoying a pleasant day for many years. I have been treated with a variety of exercise programs, injections and pain medications. The unique approach so clearly presented in Dr Roth’s The End of Back Pain is an outstanding and simple way to conquer your pain and improve your quality of life. Understanding and treating your “hidden core” will assuredly help you as it did me.


Walter Bortz, MD
Clinical Associate Professor of Medicine at Stanford University School of Medicine

Dr. Roth’s book addresses one of the greatest embarrassments of American Medicine, treatment of back pain. The current system rather than helping this epidemic condition actually acts as a co-conspirator through wrong counsel and practice. Dr. Roth’s book is the antidote to this mal-practice.


Carl B. Heilman, MD
Chairman of Neurosurgery at Tufts University School of Medicine

Dr. Roth’s ‘stackable’ exercise program is designed to strengthen the muscles on all sides of the spine, providing an inner support structure to minimize exacerbations of back pain. If patients with chronic back pain are willing to put forth the effort Dr. Roth prescribes, most will be able to take control of their back pain future.


Steven Kirschblum, MD
Medical director at Kessler Institute for Rehabilitation

For those suffering from low back pain, Dr. Roth offers a unique program that combines the body and mind in a clear, thorough, and meaningful way.


Richard D. Guyer, MD
Chairman of Texas Back Institute

I highly recommend this book to any back pain sufferer who is interested in controlling their back pain. In fact I will make this required reading for spine fellow surgeons that train with us every year.


John Du Cane
CEO, Dragon Door Publications

As the co-founder in 2001 of RKC, the world’s first kettlebell instructor certification system—and as the originator of the modern kettlebell movement—I have long championed the skilled use of kettlebells to help reduce or prevent back pain. I therefore applaud Dr. Roth for his compelling, well-reasoned and eminently practical explanation of how the diligent application of this core-strengthening tool can have a profound impact on back health. Accessible medical science vindicates ancient exercise wisdom in Dr. Roth’s impressive contribution to a healthier, safer world.