 We'll be starting in just a moment. Okay, my name is Jason Moore and it is my pleasure to introduce Matt Smith from Central Florida and Matt, since we're starting a moment late, I'll let you just jump right into it. Okay. You guys hear me alright? So my name is Matt Smith. I am a physiatrist for those of you who don't know what that is. I'm a, it's kind of a combination between sports medicine and neurology a little bit and I did a little extra training in sports and spine. I do a lot of procedures for the spine. My clinic is called the Spine Health Institute. It's in Altamont Springs, Florida, which is just north of Orlando. I hear there's an Altamont around California, but that's not that one. Alright, so the title of my talk is called More Than Bones and the reason it's called that is because as a spine doc, most of my training and focus is on the bony part of the spine. My premise or thesis is that we're missing a lot of the spine when that's all that we concentrate on. So we're going to start off actually with a quote or a couple quotes. So this is one of my favorite authors in the Semtelep. I heard there's a rumor he might be here tomorrow. I don't know if that's true or not. Anyway, he's famously known for saying that you shouldn't quote people, but I'm quoting him and it's from his book of aphorisms, The Bed of Procrustis. Modernity is a double punishment. It's both make us age prematurely and to live longer. And then we're all a bunch of contrarians in Oscar Wilde, I think, shares some of that same spirit and of course he's famous for saying everything popular is wrong. So one of my contrarian viewpoints is the way we look at spine as a medical profession maybe if not wrong and complete. So I'm going to pretend that we're all clinicians here and I'm going to give you a patient presentation. So history of present illness. We had a typical gentleman that I might see in clinic, 45-year-old guy. He's coming in with low back pain around his right butt. Past medical history. He's got insulin-resistant diabetes, melanitis, a little bit of sleep apnea, reflux. He's got some arthritis in other areas, little psoriasis, maybe a little hypercholesterolemic. The social history, fairly clean living guy. He likes to eat the standard American diet. Functional history more or less the same, doesn't exercise quite as much as he should. Review of systems, nothing too scary. When I say scary, I'm thinking infection and cancer, right? So I'm thinking pain that awakens you at night, unintentional weight loss, things like that, nothing too scary. Vitals, he's a little overweight. He's not a weight lifter. This is not because he can squat 500 pounds, he's just a little fat. It's a physical exam, kind of an average build, what you would kind of expect from your everyday guy. So, gets it x-rays, nothing too scary. We think this might be a little bit of sacroiliac joint problem, which we think probably happens maybe up to 15% of the time. How do you treat him? I get him into physical therapy, give him a little bit of ibuprofen, maybe a sacroiliac joint belt, maybe do an injection if he's refracted to all this stuff, you know, your kind of standard stuff. So I've done that, but have I fixed the problem? Let's look at another patient. So a similar 45-year-old guy, this time he doesn't come in with butt pain, he comes in with hand pain. He's got some red, kind of painful nodules on his finger. He's got a history of mitral valve prolapse, tooth decay, he's diabetic too. He's got all those same kind of standard things that we see in almost everybody. This is a picture of his hand. So he's got, I think I'm, I decided not to shave, so this little sticker's not sticking on me. Anyway, so tell me if you can't hear me. So he's got these little nodules. Now these are actually, right here, these are not painful, but he's got ones on his fingertips at R. So what do we say? Well you've got little painful things on your hands, having pains bad, let's give you some things to fix that pain, just don't use your hands so much, right? Fix the problem. Well no, we haven't, because those are, at least these things here are called Janeway lesions, the things on his fingertips are called ozernose. These are septic emboli from what's called bacterial endocarditis, which is where you get an infection in your heart valve, shoots out little bits of bacteria that get lodged in little capillaries in your fingers and you're basically on the, you know, you're on your way to dying really fast. And so if I just treated this guy, I've missed this whole underlying pathophysiology of what's really going on, I've only treated the symptoms. My contention is that treating that guy's sacroiliac pain is very similar to treating this guy's endocarditis with just a little bit of insets. I'm only treating the symptoms of a much deeper pathology. And so for those of you who don't know the lingo supertentorial is your cortex and that's kind of medical lingo for saying if your problem's super tentorial, it's all in your brain. So there's a reason probably a lot of our back pain patients come to us and it's not just because they're crazy, right? There's more than just a psychological reason they come with a whole constellation of pain symptoms and other problems. And then a doc I know quoted Bill Davis and he said, just fixing these, these symptoms is like fixing a leaky faucet when your whole house is on fire. So how did I get started? This is actually a picture of me when I was 19. This is Adrian and I said, I'm a cancer survivor at a football size Ewing sarcoma in my belly. And they always say you don't know what you have until you don't have it. I was a mediocre athlete. I was pretty active and whatnot. But I, it wasn't until this happened that I said, you know, I'm gonna start working out. I'm gonna really get into that lifestyle that really values everything that I can do. Of course, this is like late 90s, paleo wasn't around then. This whole kind of thing wasn't around then. But I discovered actually all that when I was in residency. But this is kind of what got me going. So I'm gonna talk about two things in this talk. The first is kind of stuff you guys already know or at least already suspect, at least in regards to low back pain. It's not just due to mechanical pathology but also a manifestation of the metabolic syndrome. And if you don't know what that is, I'll talk about it. The second part is the best way to fix the bulk of low back pain or at least address it, that this chronic low back pain, which is the main thing I'm gonna focus on, is to address the metabolic syndrome in addition to the mechanics, such as what Esther speaks about. And I'm gonna talk about this with seven parts and I'll just get going it now. So some perspective, we all know this is a gigantic problem. And how big of a problem is this? Well, in the world, there's a prevalence of about 70% low back pain. Anywhere, the incidence is thought to be about 5%, probably more. In the United States, we lose about 150 million work days a year because of low back pain. The direct cost is about $70 billion a year, indirect about $130 billion. This is old. So James Steele, I don't know if you guys have seen any of his talks. He goes into this much better than I do. But as far as how this has been prevalent, probably since the beginning of time, we know Otsi, the caveman. He has spondylosis. Spondylosis is arthritis of the spine. But this is also new. There's tons of evidence coming out now that says it's getting worse, and it's getting worse faster than it used to. When studying Sweden in the 80s, saw a four-fold increase. Now there's probably confounding variables such as insurance reimbursement and stuff like that for having low back pain. But it looks like more people are getting it. So it's a big, big bad thing. As a spine doc, some of the common things that I see and that I think about from a bony perspective, at least, are some of these. This is just a schematic of what your bones look like. This is where your belly would be. And this is when you feel those ridges, you're feeling, these are called spinous processes. Your cord comes down here, ends about here, and the rest of that is a string of nerves that look like a horse's tail. We call that the kaudi kwana. Here's your disc, the inner jelly part called the nucleus pulposus. Consistency of toothpaste in the outer part is a tough, fibrous ring. And then each bone individually looks like a tripod where the big front leg is right here is where the disc and the bone is. And then you have these little two back legs called the facets at the end. So the relatively straightforward bony parts. So this is a cross-sectional or axial view of an MRI. And so you can see there's a disc bulge right here, okay? Here's that kaudi kwana or that horse's tail. Here's those facets, and here's the disc bulge. Now, this typically presents with chronic low back pain. If it's pinching on your nerve, you might find it going down your leg. But this can be chronic. I mean, usually it's acute, but it can be chronic, and it can cause focal low back pain in addition to shooting pain. Here's it from a sagittal or a side view. You see that disc coming out. Here's that kaudi kwana right here. Compression fractures usually also present with acute pain. But you can have chronic pain with it. Here's one of my patients, L1 compression fracture. We number our spine bones, yet the low back bones, you typically have five. We start counting below the lowest rib of where the low back bones. And so this is the first one, you see how that's smushed. This is a 3D reconstruction of this CAT scan. You can see how it's smushed a little bit. So this is crazy. Talk about red flags. This is a gentleman I saw probably only about a month and a half ago. This right here is an abscess. He was parking cars and noted about three months of low back pain. He was parking cars the day before he came into the hospital. Started having low back pain, then he lost control of his bowel and bladder. When it ended up having to do what's called laminectomy, where you take the back part of the bone. My partner did this. I'm not a surgeon, I'm a physiatrist. But my partner took out the back part of his bone here and up top and ran a catheter and had to wash that whole thing out. So those are some of the more straightforward things. You see that MRI, you kind of know what you've got, all right? These are the trickier things. And now we have mechanical low back pain, which is what almost everybody has most of the time, which is your sinews, your tendons, your muscle strains. It's a lot harder to put your finger on what is exactly causing the pain. Now, we talked about a disc herniation causing pain. There's something called interpretable disc disruption. A guy that I actually met last week, Nikolai Bogduk, describes this as not just disc degeneration. You talk about those rings of fibers, you can get tears in those. This is a real hard thing to diagnose. You can put dye inside the disc and then get a CAT scan later and it has a certain characteristic pattern that is suggestive of this. When you look at MRI, it looks real bright on a particular type of way you can look at it. We talked about the back being a three pronged little stool maybe on each level, the facet joints being the back two levels. This is what the facet joint looks like on Axial View. Here's a CAT scan, you can see it a little bit better. See how there's a little arthritis there? I see this all the time. That can definitely be a source of chronic low back pain. I want to touch on idea though, which is, and we'll go into this in a lot more detail in just a second, but there's this idea that there's a progression that goes from a little bit of degeneration to instability to stability and all of these parts of the low back pain kind of complex, the disc and the facets and all these other things might play into that, but then we might eventually at some point come to stability. So let's go and look about how MRIs can be a little misleading. So there's something called spondylosis deformans. Spondylosis means back not looking quite as perfect as it should. That's all it means. Spondylosis means spondy means backbone. Losis means something's up with it. So spondylosis, you get it as you age. Like I said, Otzi the caveman had it, but it seems that something else is going on more than just the normal wear and tear as we age. This is a patient and if you're not used to looking at MRIs, you might not pick this up, but you should even if you're not used to looking at this is not a normal looking back. This is one of my favorite patients. He's a great guy. He only has a little bit of pain. Rating down his leg. He's been oystering. He's been doing all this stuff. Here's his caudy quanta bunched up here. He's got numerous discs that are just getting worn out. This one's almost completely fused on its own. This one, too, looks horrible. His back looks awful, but he doesn't have that much pain. Here's a study that was done in 2013. They looked at about 170 guys in Sweden and they looked at their their two lowest disc levels and they looked at all these different changes. You don't have to know what these mean. But basically, there are a variety of things we might see on MRI. You have to have at least two of these. All right, here's a couple of examples. This is called a modic change. This is at your lowest disc. This is swelling. We see it bright on this kind of MRI, dark on here. Here is that little high intensity zone right here that might indicate a little bit of a tear within the disc. Here's what we call a type two modic change. That's where the bones around the disc get a little fattier. And here's a disc bulge. So I looked at all these all these problems on the MRI. All these things, you know, patients come to me. Oh, my God, I have degenerative disc disease. I mean, you know, it's like some horrible thing. You know, this is degenerative disc disease. This is spondylosis. This is all this. They looked at all this. They put it in this complicated algorithm and they compared it to what's called in a westerly disability, an X, as a measure of function in your visual analog scale, which is a measure of pain. And what did they find as the correlation? Yeah, as my old attending user say, nothing much. So despite a progressive worsening of the people's back, there's not a good correlation with pain. Here's another study. It looked at younger people. They did one MRI on a bunch of guys up to about 55 years of age and then another one 12 months later. There was really no correlation with how bad their MRI looked and how bad their pain was. Furthermore, 13 of those guys, one year later, developed back pain in that interval on their MRI follow-up, there was no change. So something's going on that we're not seeing on MRI. Here's another study. This is even weirder. So we thought about maybe there's not a one-to-one correlation. There might be a negative correlation. In this study, it showed that with older individuals that the least degenerated disc had the most correlation with low back pain and the most degenerated disc had the least correlation with low back pain. So this brings us to then back to the Krakalli Willis Cascade. Krakalli Willis was actually one guy, William Krakalli Willis. He came up with this in the 70s. So is maybe something going on? Are these guys stabilizing now? They're degenerating even more into where their pain's improving? Maybe. Or are we maybe not looking at all the same stuff or all the right stuff that we should? So we talked about that one study that looked at all these variables. When we look at everything, are we missing the one important thing that we should be looking at, such as, for instance, high-intensity zones? If I look at the setarthropathy and disc degeneration and all this other stuff, and I missed that point that there's a little bit of a T2, a hyperintensity on your disc, am I, by looking at everything else, am I clouding the signal? Or are we not looking at something? Because after all, this talk is called More Than Bones, and I've only talked about bones so far, so I might be alluding to something I'll talk about later. So let's talk real quick about what we tend to do for most low back pain. There's four treatments. Surgery, you can give injections. I'm sure you guys have heard of epidurals and things like that. You can give drugs, and then what we, I'm kind of clumping everything else that we do as far as a physical modality and the physical therapy. This is called dynamic spinal locus thesis. This needs surgery. If you're bending forward and leaning back and your bones are actually shifting a good bit, you really probably need to get that fused. That's not much of a controversy. And there's a variety of things you can do for an injection. This actually comes with a lot of controversy too. A lot of times these are better for acute back pain, like an acute disc herniation, but sometimes you can do a few percutaneous image guided procedures that get people up and going and that can have a useful place, but certainly some of these things, including surgery, might be overdone. And then of course there's drugs. Strangely, the way we dose drugs and the way we choose what to give are based on the World Health Organization's prescription for how we should dose drugs for cancer patients, essentially. But we use that same thing for people with low back pain and one of the results is that we get a lot of people who are taken to lauded and a lot of high dose opioids for low back pain. And there's physical therapy, which is one of those things that can sometimes mean anything to everyone. Could be something like what Esther is prescribing. It could also be you go to the physical therapist and they get you doing an arm cycle or a gometer for low back pain and no one ever gets better. But we're gonna talk more about this later. So I'm gonna have a little bit of a segue now. I'm gonna talk about one of my patients and he, I'm not violating HIPAA because he let me use his, he said I could use his name and his name's Tony. 71 year old guy, he's about 73 now, but he has a pacemaker. He's got a little bit of intermittent low back pain, but no red flags, no neurologic deficit. And this is a picture of him. And he comes to me, I never had anybody say this to him. And he goes, I want you to help me out. I got a little bit of low back pain and I'm going to Ecuador to train my Sherpa because I'm then going to go to Everest. All right, so he's 71 years old. He takes off a shirt for the physical exam. He looks like he's about 35 and a really healthy 35. He's neurologically intact. There's no red flags, a little social history. He's a businessman. He doesn't have any real bad habits. He's completed the Boston Marathon and he's the oldest guy to complete the Antarctic ice marathon with a pacemaker. His CT, I'm not going to read you all this, but basically it's not great. And so here's a picture of it. Here's a disbolge, gigantic disbolge, disbolge, disbolge, disbolge, worn out disc. This is called the vacuum phenomenon. It means the disc is worn out. He's got facet or throat. His back is not good. At least the bony parts aren't. But look at this. These are some muscles around the back. Those are really good. Here's the psoas muscles. These are your muscles that make you do that. Really good. So we ended up doing a little bit of conservative treatment. He hiked for 20 days on Everest. He said he was going over a crevasse. As he was crossing it, he felt a little twinge. He felt that he could probably go to the top, but he got a little paranoid and so he stopped. But here's a guy with a pacemaker with a really jacked up looking spine climbing Everest. How is that even possible? Is it his genes? Is it his anatomy? Or is there something else going on? And so let's revisit anatomy and physiology a little bit. And this brings us to the perennial question. Why do pigs have less back pain than humans? Well, here's an axial picture of an MRI of around the lumbosacral junction. I flipped it over for comparison purposes. Here's your extensor muscles right here. Here's your psoas muscles. This is one of my patients. And here's a pork chop that I cooked not too long ago and curry and coconut. This is a protein waffle that we made and this is a plantain right here. And so this is gluten-free. Just, I don't want to get crucified. Anyway, so I actually don't know if pigs have less back pain than humans. I'm not a veterinarian, but look at this. One, the anatomy is totally different, but look at the spinous process. It's way unfair. Pigs are also quadruped. There's a lot going on here, but look how big and these muscles are big and delicious. And that's when you compare them to here, you know, the pig has better muscles. And we know from some research in the past that strengthening of certain muscles looks like it can probably help low back pain. So, I talked about the psoas muscles as your hip flexor muscles. It starts kind of like in the front part of your low back and then attaches right over here to your hip. We know that strengthening those tends to help chronic low back pain. Strengthening the multifidus muscles, which are some of the muscles that help the spine extend, also seems to help. And then, of course, having weak ones is then correlated with back pain. But it's a little more subtle than that. So, it looks like muscle asymmetry, almost more than anything, is associated with back pain on that side. And that's what this study showed in 2004 in the journal, Spine. This is a study that was done in Australian football players, which I guess is soccer, where there's this muscle called the transversus abdominisis, one of your corset muscles. You know, if you wear a corset when you're working out, it's that same kind of muscle that helps you hold up your abdomen. And they show that the guys who had low back pain, so even if you have big muscles, you can still get low back pain, but they had a little bit more difficulty activating their corset muscles. And they looked at this on MRI, having them relax and try to activate it. And the guys who didn't have low back pain seemed to do a lot better job. So we know if you're missing muscle or not having the right kind of muscle that could be associated with low back pain. So there's a problem, a deficit, but it looks like there might be a problem of having too much of something too. I don't know if this is a real word, it might be. But this, to me, means having too much fat. And I call it some malignancy. And I'm gonna go into a little bit why later. There's a orthopedic law called Wolf's Law, which states that if you stress any kind of orthopedic structure in a certain way, it's gonna get stronger in that same way. And I mean, that makes sense, right? You stress your bones a certain way, they get stronger in that certain way. So it was always thought that, hey, obesity is not great, but at least it keeps you from being osteoporotic because of that reason. And even though it makes you osteoporotic, though, one of the downsides, it makes your weight-bearing joints worse. And you look at this from a mechanical perspective, it kind of makes sense. However, what Lou at all showed is that that's not true. Yeah, compared to frail people who are malnourished, people with obesity have better bone density, but compared to people who are just normal, obese people are more likely to have osteoporosis than osteopenia. Well, then maybe the reason is, okay, well, they're obese, they're probably not exercising as much as they should, that's why they're osteopenic, but then why are they getting degenerative joints? If it's from a mechanical perspective, their joints should then be preserved if they're not using them so much. And what these guys showed is it's not just they're weight-bearing joints that are bad, but they're wrist bones, they're hand bones, a whole bunch of non-weight-bearing joints. And it's unlikely that they're doing handstands. So what's going on? And it looks like it's not so much just a mechanical problem, but it's a physiological problem. So this is kind of old news to a lot of you guys, but if that is not just a safe haven for triglycerol, it's also an active endocrine organ. Some of the main cytokines we look at for inflammation, TNF alpha, interleukin-6, go up. Leptin goes up, that can lead to some things too. Leptin resistance goes up. Fat cells, when you are lean, your fat tissue is about 20% white blood cells. It's not all fat. As you get more bad fat, it goes up from 20% to 40%, and it's not just increase in quantity, it's a change of kind. So these white blood cells are making more pro-inflammatory cytokines. So if you think about it, if you've got 100 pounds of fat, that's 40 pounds of white blood cells that are pumping out bad cytokines. And this goes down adiponectin, which is a very curious cytokine. And so it makes this vicious feedback loop, and like any kind of cancer, it's self-propagating, right? So you get increased visceral adipose tissue that makes inflammation go up. That inflammation inhibits your body's ability to break down fat, which makes you fatter. You can talk about adiponectin. This makes you more insulin sensitive. It does all the things that protect you from diabetes. It makes you less inflamed, and it's made by fat cells strangely, but as you get more fat cells or more fat, it goes down. And so that makes an even more complicated positive feedback loop. You get more fat, your adiponectin goes down, your inflammation goes up. Now you're hurting more, you're depressed. We know depression is linked with inflammation. That makes you get fatter. We know inflammation in itself directly causes you to get fatter. And this is being seen in a variety of ways. So we know that knee arthritis is associated with decreased adiponectin. We already talked about the white blood cells and the fat, but we're seeing that even more fat around orthopedic areas. Todd Becker posted this article, I thought this was awesome. If you give so many epidural steroid injection for acute or herniated disc, corticosteroids work by inhibiting an enzyme called phospholipase A2. Phospholipase A2 cleaves arachidonic acid from your cell membrane. That then goes and creates all those prostaglandins that cause inflammation. Fat makes your phospholipase A2 activity go up. Fat is like the anti-epidural steroid injection. Now, could this all affect the spine? I've been talking about other joints. Well, we know that the thing that more than arthritis, the thing that causes most back pain is smoking. The second most common thing that is associated with low back pain is obesity. The more obese you are, the more likely you'll have low back pain. And now, we know that osteoarthritis in general deserves a seat at what's called the metabolic syndrome. Now, metabolic syndrome is this pathology that has many faces. Some of the things we think that are causes or manifestations of the metabolic syndrome include hypertension, hyperlipidemia. Obesity is one of them, but not everybody gets obese. Multiple others, increased risk for cancer, numerous others. But what about pain in general? So we know arthritis goes up, pain tends to go up with the metabolic syndrome. And then the spine in particular, this study was just given to me by a friend of mine who's a professor at UCF. And the more manifestations of the metabolic syndrome you have, the more likely you are to have spine arthritis. Now, this is complicated if you haven't already realized. And the devil is in the details. So, we've looked at MRIs. We looked at the level of pain associated with them. There's not a great correlation, right? But you look at muscle mass, you look at these metabolic parameters, and there is a good correlation. And some interesting findings. So, the more pain you have and the more catastrophizing you have, meaning the more you think you're in pain, the less endurance your muscles have when you're trying to do all those good posture things that you're supposed to do to maintain your spine health. Strangely, when you look at how atrophied your muscles are, it's out of proportion to the actual denervation that occurs, meaning you should be stronger than you are. There's not a neurological reason that a lot of people are as weak as they should be. They could be stronger, but they're not. And that then goes to another vicious feedback, Luke. Low back pain, you get depressed, you get inactive. Sarcopenia means, it's like osteopenia, osteopenia is bone thinning. Sarcopenia is muscle wasting. That then leads to the metabolic syndrome, which means more back pain, but it also works the other way, too. So, fortunately, we know that if you work out, if you have more strength, that tends to ameliorate chronic pain of all sorts. And this goes back to Wolf's Law, but again, not just because of the mechanics, but because of the physiology. And fortunately, it's never too late to break the cycle. I used to say, and this is what I was taught, that after 30, no matter what you do, you're gonna lose 10% of your capacity every decade. And then I heard it was about three to 5%. But now, research is showing that we really don't even know what your potential is. And it looks like we've maintained the physiologic machinery to get good muscle mass till basically we die, almost. And there's been studies that show that high-intensity training helps pain of all sorts in elderly people. And like I said, this is really complicated. The mechanisms are so varied, and we don't even understand how all of them work yet, but this just shows, this is a variety of combinations of the physiology and the mechanics that all work to make your bones denser at least, and similar things with muscle. I was always taught that once you lose your brain cells, you can't get them back. Once Alzheimer's hits, once you get a stroke, you can't get them back. Now Todd Backer talks about this. When I was at UAB, we did a lot of research on constrain-induced therapy for stroke, and we showed that you can actually regrow the gray matter in your brain. Well, looks like you can also regrow your disc. And this is done in mice. The conjure sites, these are the cells that make that annulus that we were talking about, are regrowing with exercise. Now unfortunately, or maybe fortunately, we can't make humans exercise and slice up their disc and see how it helps, but we can do it in mice, and it does help. And we have this model. So, and this is the whole hermetic model, right? Stress causes a whole bunch of reactions, causes damage, and then because of those reactions, with adequate rest, we get supercompensation. This is the whole progressive overload type model, right? And we know this forever. Frederick Nietzsche, what does not destroy me makes me stronger. And if you guys don't recognize this, you can move out of America. They never get involved in a land war in Asia. Why did Visini die? Because he didn't have that hermetic response to Iocane powder, and Wesley did, and the Princess Bride. And so that in a way is what we need to be always maintaining in our spine. But again, the devil's in the details. So while we can have stress and then rest and then supercompensation, if we don't stress ourselves, we don't maintain we atrophy. And if we give ourselves too much, then we get tissue degradation. And the parameters of what cause all these things are different for everybody. And going back to the necessity of stress, if we do things that take away that stress response, we don't get adaptation. So colleague, Mark Bamman at UAB, he showed that if you take anti-inflammatories after you exercise, you don't get that adaptive response. One of the ways our muscles grows, the satellite cells around them donate nuclei and that lets our muscle cells grow. They don't do that if we cut off that inflammatory response. Now, just to give you an idea how complicated this is. If we want to make mice lose their disc and get degenerative disc disease, we give them a certain amount of stress. And the mitochondria die and the disc die. And we know how to do this. So not all stress is good stress. And one of the really cool things that we're doing from an interventional perspective is figuring out how to put stem cells in the disc. But we know that every stem cell and every scaffolding that we use has different parameters. What helps one stem cell grow by putting a little bit of stress on it kills another type. So this is very, very varied. And that, I think, is why we get this mediocre meta-analysis from the Cochrane collaboration and from the European Spine Journal and others. When they look at exercise in general and they say, hey, listen, it's kind of a mediocre response. It's because we're looking at everything. You can't look at everything and say what's right for this individual. And here's just two examples. This is a six-month study looking at lumbar extension exercises and some other study and other exercises. And they showed pretty good results. Here's another one. They actually showed good results better than the tonal one indicate, but it's a two-month study. And they did a totally different protocol. But here's another study done in cricketers and they looked with ultrasound at different sizes of their multifit eye, focused on making the multifit eye the same size and they showed statistically significant decreases in pain. And this is just my shameless deadlift plug. Deadlifts, some people love them, some people hate them. Some people think you should do isolated lumbar extension exercises, but in healthy people, deadlifts, when you're looking at EMGs, actually activate the muscles the most, the focused lumbar extensors the most. Now, would I get grandma doing deadlifts on day one when she's never done deadlift before? Probably not. Not if I want to keep my medical license, but it's a good exercise for particular people. Some people though should be doing this. Some people shouldn't even be doing that. They should be doing something totally different. And that then makes us ask, is good enough, good enough? My job as a back doctor is to try to make your pain go away. If you come in and I give you an epidural and then you come back and you say, hey listen, my pain's gone away, I've done my job. Probably not, because you're gonna come back just a little bit later and your pain's gonna be back. Now, this is a treatment or a program that in 1995 where they did a strength training program in minors, and look, per month, they were giving $14,430 for like a work cop and it went to 380 after they did this strength training program. My specialty journal just published this, which showed that if you make obese people strength trained, they can walk better. If I give you an epidural and you never walk and you never get stronger, you've gotten no better. So, the question is then, how is this ancestral? Well, my feeling is we only have to go back to Otsi the caveman. We can just go back to 1994. So this was the obesity rate, look, 80 to 21% is the worst. This is 2010. That would be the best per state. The way we've gone in treating low back pain, as physicians, has been mainly through passive modalities. You come in, I give you a treatment, you're better, good luck. That's not how it used to be. 50 years ago, it was to get you stronger. It was to do those kind of things that gave you better posture and that gave you tools for the rest of your life. So, in conclusion, Einstein says, make things as simple as possible, but not any simpler. This is really complicated. There's a false dichotomy between posture and strength. That's one of the big things. You see people say, hey, listen, you need to have certain posture, and you see people who say, no, you have to be strong. If you're doing a back squat, you have to have good form, but if you don't have the muscles there, no matter how good your form is, you're not gonna be able to do it right. It's not just the mechanics and the muscle, and it's not just anatomy or physiology. And there's subtleties to everything. Dysdegeneration is normal. Introvertibular dysdegeneration is not normal. And there's variations between how much muscle you have in total and focal loss. Physiology is very complicated. Adiponectin, I talked about how great it is when it goes up. Well, we don't really know exactly what adiponectin does, and with rheumatoid arthritis, it goes up too, and so we're not really sure what it does, so physiology is very complicated. And we also have to be really careful with cause and effect. I talked a lot about correlations, and when future research is done, we need to be really careful with the transversus abdominis thing, it's a big thing. We try to strengthen transversus abdominis a lot, but is that a consequence of back pain or a cause? And lastly, there's no procedure, there's no exercise, there's no one thing that is right for everybody, and this is why, again, those physical therapy studies fail, and most studies fail that try to look at one treatment for everybody. We need to take a multimodal approach and be open to what treatment's the best for the individual. So two quotes, and I'm done. I'm a big Seneca fan, and this is one of my favorite quotes, to live under constraint is misfortune, but there's no constraint to live under constraint. And this is my favorite quote of all time, it's by Mark Ripetow, and most of you guys have probably read this because Starting Strength is such a great book. The weak man is not as happy as that same man would be if he were strong. This reality is offensive to some people who would like the intellectual or spiritual to take precedence. It is instructive to see what happens to these very people as their squat strength goes up. So that's it for me, here's a couple of the studies I quoted, and that's it. So I don't even know if we have any time for, okay, any questions? If there's any questions we have time for one, and then we have about 10 minutes to get over for the closing remarks. Have you're dealt with someone who has a leaky gut and trying to strengthen, like what's the protocol, when to start strength training after their inflammation has calmed down? Yeah, well, that is such a complicated question. So, leaky gut is, I don't have the setup to really test for leaky gut, and from my understanding, leaky gut is such a, the way it presents is so varied as well. I probably have leaky gut for all I know. I mean, I had radiation, so I still do squats and deadlifts and everything like that, and it really depends on, I would say the way I would treat the patient is not so much do you have leaky gut or not, but what can you do when you start out? And of course I'd also have to fully work you up as a patient too, so it's not something that if this, then that, you have to look at the whole picture. I feel like I'm kind of circumventing your question, but it's a really complicated, why you asked is really complicated, yeah. All right guys, Matt Smith. Thank you. We have about 10 minutes until the closing remarks in the Wheeler Hall.