 Welcoming to the stage again here is a man that just got his bachelor's degree last year from Southampton Solent University and is also working on his PhD. He's gonna talk about high intensity exercise, the lower back. Give him a round of applause. James Steele second. James Steele the second. Yeah, here we go. I knew that was gonna happen. There we go. There we go. Got it. Yeah. Bending over too much. Okay guys, right. I'm hoping that this talk isn't gonna bore any of you too much. I was a bit sort of apprehensive about talking about this topic to you guys. It's a big interest of mine obviously. I'm doing my PhD in it. I'm doing a lot of intensive research on it. So for me it's very interesting. So I had to think quite a lot about how to relate it to you guys. And really I kind of thought about how more to talk about how prevalent it is, yet how unpretentious the nature of chronic low back pain is. I mean like who has had back pain, got back pain, know someone with back pain? That's probably about 80% of you which corresponds to the research figures quite interestingly. But anyway yeah just really to kind of give you an introduction of how I kind of got into it because a lot of people ask me that. They say you know how did you get into back pain? It's a bit of a weird topic. Like Peter said I've just finished my bachelor's degree in applied sports science. Before I started that I was very interested in kind of like exercise and how it relates to health and fitness despite their shady definitions and the effect that exercise can have on the body. So I went and did an applied sports science degree with my main focus being on exercise physiology. At that time I was getting introduced to kind of the concepts of high intensity training. I'm sure you guys are aware of like Drew Bay, Doug McGuff, Arthur Jones. And I was reading their works, I was reading my mentors' works at the time. And kind of coincidentally when I then got to Southampton Sirlan to start my degree, one of my lecturers there was involved with some research using the med-ex equipment. We specifically had a med-ex lumber extension machine there. And it was quite interesting that I was just reading all of Arthur Jones' works at the time. And I kind of arrived at the university and was like med-ex, med-ex, where do I know that name from? And I was like, oh yeah, Arthur Jones invented that. And I got involved with the research and it kind of stemmed from there. I really developed my interest in high intensity training, went back, looked at all the research, you know, I was thoroughly convinced by the evidence supporting it and then moved through kind of the same way Arthur progressed from high intensity training involved with nautilus and moving through to strength testing and then rehabilitation for the lower back and other parts of the body as well. And looking through the research, I saw that there are a lot of big holes in our understanding of, you know, predominantly what might be the main causative factor of back pain and potentially how we can try and treat that and try and either prevent it or rehabilitate it for people who suffer from it. So today's talk, I'm going to try and kind of first of all introduce, you know, why care about it? What's it to you guys, whether you've got back pain? I mean, yeah? Exactly. Gentlemen just said, you know, it's really, really annoying like to just have this chronic pain around you like the whole time or recurrently, you know, popping up, popping down. It's really annoying and kind of relating to other themes in the conference as well. If you've got bad back, you know, maybe bad posture, it doesn't look so attractive, doesn't really convey the kind of message you'd want to, to maybe women or other people you're trying to build relationships with. So we're going to talk about, you know, why is it important to care about it? We're then going to discuss maybe, maybe, you know, why is it so prevalent? You know, so many of you've got it, so many people have got it. The figures are really high. But if they're so high, there's got to be something that's causing it, something that's having a real impact on it and something that's meaning that it's going to, you know, that it's kind of permeates our society. So we're going to go through some of my, my ideas based on my reading around the literature of, of what the main sort of like associations with lower back pain are. And what I think has the most influencing factor on why the majority of people suffer from it. But then you're going to kind of cover what you can actually do about it, because it's all well in pain, this is causing it, or this might be causing it, this is the main factor. Great. Now what do I do? It's good to have some information of, you know, how can you tackle it? How can you deal with it? How can you do something about it? How can you improve your situation? Because that's the main reason why all you guys are here, getting information and learning how to apply it and improve, you know, your lives basically. And I'm going to spend a bit of time just just kind of going over what what I'm doing and the impact I kind of envisage that my research is going to have and talking to you a bit about what specific areas I'm looking at and why I'm looking at them and how that kind of like is involved with with lower back pain rehab. And then we're going to conclude and we'll have some time for questions. And just in case any of you aren't aware, although I'm pretty sure most of you are, that's the lower back, the bottom five lumbar vertebrae. And that's where my main area of interest is. So anyone's got questions above there or below there. I don't want to step outside my area of expertise. So I'll give you I can give you an opinion. But if I don't know, I'll tell you I don't know. And I wouldn't be able to answer the question. But anything in between those five vertebrae, I've probably got the knowledge that I can give you give you a good answer on it. So I try and save your questions for something relevant. Okay, so why care about the lower back? Well, first thing to do is to give back pain a definition, you know, what is back pain? If we're going to learn how to tackle something, and why it's even important to care about it, we need to kind of define it and know what it means like Anthony was saying yesterday, you know, some words and some definitions have lost meaning over the years. So to tackle a problem, you need to be able to define it and know what the problem actually is. Well, back pains usually describe as a kind of tension or a soreness or stiffness or all these kind of words that are used to describe what is essentially an overarching kind of condition in the lower back. Like you say, any of these things tension, soreness, stiffness, sharp pains, anything like that, they can be annoying. And they have an impact on our lives. We also kind of categorize lower back pain into into various different sort of like subcategories. Now, acute pain is what we what we consider sort of short term pain. So lasting anywhere up to sort of like 12 weeks. And acute pain would usually be involved with, you know, an injury, maybe a sports injury, maybe you trip down the stairs, or, you know, anything that puts you back out, so to speak, and causes a pain. And usually in the majority of cases, acute pain kind of resolves itself almost kind of naturally. Even the research suggests that it doesn't really matter what you do. The actual pain will tend to go away after about sort of at most, you know, up to that sort of sort of like I'm sorry, I said 12 weeks, two weeks after that sort of like, like initial two week period. The problem is, it's when the pain doesn't go away after those periods. And it turns into what we then categorize as subacute pain, and eventually develops into chronic pain. And chronic pain is anything that any pain that's lasted for a longer period than 12 weeks. And usually in those cases, it's when it develops into, you know, years. I've got some people who are involved in my research, who I do my testing and rehab with, who some of them have had pain for 30 years. You know, they've spent their whole life in pain, basically. And you know, there's no way to lead your life. You know, you want to be happy, you don't want to be suffering. One of the other kind of problems with it, and I was speaking to a gentleman earlier about it, is it's very difficult, actually it was camera man, it was very difficult to give back pain in a lot of cases, a diagnosis. I mean, we'll go on to it in a second, but there are a lot of different things associated with back pain that may be or may not be causing pain. They may be or may not be affecting the joint's biomechanics and then having a subsequent impact on other structures which may elicit a pain response. You know, they may or may not be affecting function, so how the joint biomechanics actually function. So a lot of the time it's very difficult to say, right, you have back pain and this is causing your back pain or this is causing the pain that you're experiencing. You know, it may be nerve impingement, it may be disc degeneration, disc sensitization, or it could be ligamentous, it could be muscular, it could be actual muscular strain or sprain, but in the majority of cases diagnosis comes up short, so people are labeled as non-specific. You know, you've got back pain but we know for an idea what's causing it. So in those cases it's very difficult to then say, oh if we got no idea what's causing it, how are you supposed to know what to do about it? And this is where the majority of my kind of like research is involved with. It's dealing with, you know, what is probably causing that non-specific category, because it's around 85% of people with chronic low back pain have this non-specific category given to them and it's only that sort of like 15% that you can say, you know, you've got this problem, you've got the specific pathology, the specific condition with your lower back and that's definitely causing you pain. So I'm focusing on kind of like, how can we figure out what's causing that or what may be the predominant cause of those non-specific cases and then how can we address that? So when I talk about, I'll abbreviate as CLBP in the rest of the slides, I'm talking specifically about non-specific chronic lower back pain. So it's back pain without specific diagnosis that's lasting, you know, longer than 12 weeks and it may be recurring or, you know, people's pain perceptions change, but okay. So just a quick diagram for you and this is just to kind of like set the scene for my research and we'll link back to it kind of later. These guys, Lee and Fleming, Lee and Lee and Fleming, they've actually done a lot of research and a lot of reviews on kind of like sacroiliac dysfunction and they put together this kind of integrated model to say like, well in non-specific cases, we often use what's called function as an outcome measure because it's very difficult to say, oh okay, right, something specifically wrong with this structure or that, you know, something that's causing pain, whether it's nervous or whatever. So we use function, like the function of the joint, the joint's biomechanics as an outcome measure and what I've done is I've taken this kind of approach that they've used and the categories they use and adapted it to be applied to the lower back. So what we've got is chronic lower back pain as a kind of like entity, as a kind of concept and function as the outcome measure or function as the perhaps rehabilitation goal. So what I'm looking at is whether or not if we can improve function, we can potentially improve all these other areas that are associated with may not necessarily be causative but certainly associated with chronic lower back pain. So the one thing I am doing is focusing on the physical characteristics involved with it. That section there, psychological and psychosocial instances, my research doesn't tend to focus on that. Like I said, I come from an exercise physiology background and so although there is a psychological impact and a psychosocial impact, a stress impact on pain perception which I'll discuss briefly in a moment as well, the main focus of my research and my efforts are looking at what the actual physical symptoms are because it's difficult also to tell whether or not the psychological stress is causing the pain or whether or not it's the pain causing the psychological distress. You know, it's its whole association doesn't necessarily imply causation. So I'm taking this model and I'm focusing on the physical characteristics and more specifically in my research I'm focusing on things like range of motion, you know, this degeneration, the actual atrophy of the lumbar extensor musculature and also looking a bit at sort of skill-specific biomechanics. When we talk about biomechanics, if you guys are aware of kind of like Bill Desimone's work, most of you are aware of that, seen his videos. Oh, is it not up yet? Okay. Anyone read moment arm exercise? Yeah? Okay, a few of you, cool. Right, well, Bill talks a lot about biomechanics but as an overarching sort of like subject, biomechanics is split into various different things. So we, when Bill talks about biomechanics he's talking specifically about or from what I can gather from his works is joint structure, anatomy, function, you know what some people might call functional kinesiology. But biomechanics also incorporates skill-specific movements as well. So through my applied sport science degree, you know, we when we were looking at biomechanics we look at basically sort of like the physics of how particular movements whether they're elaborate sort of like sports skills work or not. And one of these things is looking at what's called gait which is basically your, you know, form of locomotion. It's a way of describing your locomotion and people with back pain tend to have this kind of like variable gait pattern which doesn't fit the normal pattern which we see people who don't have back pain have. So that's just kind of like set the scene of what I'm looking at and what I think is important to look at. And we're going to link back to this and I'm going to describe in more detail the actual research I'm doing and why it's sort of like important and potentially, you know, the results that I'm hoping to see. Right, so as I was saying, you know, chronic lower back pain really prevalent, really unpretentious though and I've started using this word recently I think I might have used it in the kind of thing about me I put on the 21convention.com. You know, it's this unpretentious condition that is everywhere everyone has it, no one really talks about it, you know, it's not that kind of scary, you know, it doesn't necessarily kill you, although interestingly in some cases I've read case studies and examples of people who have been so sort of distressed by their pain that, you know, they felt suicidal and maybe that goes back to the whole, you know, is the psychological stress causing the pain or is the pain causing the psychological distress? It's an interesting concept. But yeah, because it's kind of unpretentious and no one really kind of like thinks it has a massive impact on society, it doesn't really get a lot of sort of press shall we say, unlike things like cancer and heart disease and all that sort of stuff, obesity. But it is definitely one of the most prevalent medical disorders. In fact, the World Health Organization did a big survey at sort of like end of the 1990s and it actually ranked lower back pain as the second most prevalent disorder in their survey. The only thing that was interestingly and oddly ahead of it was iron deficiency anemia but lower back pain ranked in prevalence higher than almost everything else, including, you know, heart disease, cancer, all these other things. So, you know, it's a real problem and some of the estimates are that 60 to 80 percent of adults will suffer from back pain. So even you guys who haven't necessarily got any pain now or haven't experienced any pain in the past, you know, it may come a point in your life where it's very likely that you're going to suffer from back pain and it's going to really cause you some problems. And also, one of the interesting things is the cost of back pain but it may not have a massive impact, you know, really sort of like severe impact, like death on our lives as some illnesses and conditions do, but in terms of cost, it costs a shit load of money every year. Some of the estimates are it costs about 10,000, one of the most recent estimates for the UK was it cost the economy in direct and indirect costs about 10.6, about 10.6 thousand million, which I think is a billion, I'm not sure, about 10 million pounds a year and that's in a direct and indirect cost. So that's through, you know, the cost of healthcare, cost of, you know, and one of these problems is the treatments that are utilized by people with back pain and also that's the indirect cost of, you know, if people got back pain and they can't get to work, then that's the day's work miss. They're missing out on getting money for working and providing value for their company and their company is also missing out on the work that they're providing for them. So there's all these kind of like costs involved with it and it's this big spiral that just keeps continually costing more and more money and the way the kind of economy is going at the moment with the rates of inflation, that seems to kind of be skyrocketing even more. So big problem, click on. So if back pain is so prevalent, like I said, there's got to be some reasons as to why it's prevalent, you know, what's causing it, what is having an impact on it to make it such prevalent condition in our society. When we look at epidemiological research, which is a study of sort of like epidemics of disease or pathologies or whatever you want to call it, we look at things called risk factors. So we look at the things that are associated with and that we can generate hypotheses about whether or not, you know, maybe is that is that causing it or is it associated with, you know, what link does it have to the actual conditions? So we look at things called risk factors and in back pain, there are kind of mainly sort of free trains of thought and kind of categories of what types of risk factors are responsible for the conditions that we see. Excuse me. So one of these risk factors is these environmental and work-related risk factors. Someone pointed out to me those pictures actually look like they're just farting and I didn't really realize that until after I put them on there, so, but they're supposed to have bad backs and injuring their backs, but you can think they're farting if you want. Something which I remember this morning, which I needed to remember to talk to you about was rice farmers, interestingly. I read a blog post a while back and it's been the kind of interest of mine looking into back pain in like traditional and indigenous sort of cultures. The whole sort of like paleo idea and evolutionary reasoning, you know, is really important, I think, in any kind of like aspect of the human sciences or any kind of like biological sciences and natural sciences. So just as a kind of like example, a lot of people have this idea that working conditions and therefore kind of like postures and that sort of thing that we experience during our work, whether they be, you know, extended seating like in nine to five office jobs, etc. Or the kind of like lifting that we experience and doesn't really look like a manual worker wearing his tie, but, you know, those sorts of things may be linked to high prevalence of back pain. And I'm not going to deny a tool that, you know, you can injure your back lifting something heavily or lifting anything for a matter of fact, if you're lifting it in a stupid way, if you're lifting it in a way that excessively loads perhaps the passive structures rather than the muscles taking the load. So, you know, I'm not denying that you can hurt your back doing stupid stuff at work or in whatever environment you're in. But interestingly, I was looking at some research in Thailand to look at and see whether or not the prevalence of back pain was as high in Thailand as it is in other cultures in the world. And the kind of prevalence that we see is very difficult to kind of like link things together and make draw direct comparisons because methodologies are always different in different studies which is always a problem when you're trying to interpret them. But one interesting thing was, and a lady called Esther Gokli who talks a lot about posture and thinks it's very important, highlighted to me that in a video that I watched that I think they're water chest and our gatherers in a country called Burkina Fasai. Their postures when they're bending lifting is brilliant. They keep a neutral spine, they bend at the hips and they spend hours and hours a day spent in that posture bent down, picking up water chest nuts. And she shows this picture which I kind of regret not putting on it now but of these women with these wonderful posture spending hours a day in that posture and yet they seem to have no back pain. And she kind of uses that as a very sort of like eye catching tool to kind of like highlight her ideas. So I thought oh that's quite interesting. So I had a look around at just some other research and some pictures and I found this interesting picture when I was looking for the Thai prevalence of some rice farmers and you know rice farmers in Thailand in other Asian countries you know they pretty much have the same job. They spend spend their days bent down putting rice in the whatever is the kind of watery fields that they grow in. And interestingly the picture I found showed that about half of the people in the picture you know they have this perfect posture, neutral spine, bending at the hips and you know not overly loading the spine in the manner that these kind of like schools of thought would want you to avoid. But yeah the other half of them had really shit posture you know they were kind of hunched over bending down and you think they're spending hours a day in that position. So I looked at that and thought you know that's quite interesting considering that she's also saying that the rates of back pain in Thailand are quite low as well. So along the lines of my thought my trains of thought of what I think is predominantly the causative factor or maybe the majority or mostly responsible is and we'll move on to it at second is one of the physical characteristics of the lumbar spine was that rice there was actually a study done with rice farmers you found that rice farmers with lower strength levels in their lumbar extensors actually had a higher rate of back pain and that was the factor that was most associated with it. Now that doesn't necessarily imply causation but it's interesting that the actual working conditions didn't really have a big impact on whether or not they have back pain. So what we can usually say is if there is no association it's quite likely that it's probably not causative. So it's very difficult to kind of like say ah you know it's definitely that the majority of people are getting back pain because they're spending time bent over or they're spending time slouching their seats or sat in opposition or whatever because the association is just aren't consistent. They're all over the place and they may be affected by methodologies and the populations we look at but unless they're consistent it's very difficult to say yeah definitely that's it that's what's happening so we need to address that. Coming back as well to the the psychological thing and this links back into the whole work related stuff and work related stresses. As I said my focus isn't predominantly on the psychological stress associated not necessarily causative but associated with back pain and I wouldn't want to step out of my bounds of that. Cognitive behavioural therapy is a very sort of like prevalent treatment option at the moment and the research has shown it to be pretty successful in terms of you know alleviating people's pain perception perhaps but interestingly some of the research that I've looked at looks to has looked at effective disorders which are you know kind of like stress disorders and psychological sensitivity and found that in the majority of cases they're not necessarily associated with the prevalence of lower back pain but they affect the degree of lower back pain so sorry the intensity of the pain they experience so it's another kind of like thought to me that suggests well maybe psychological stress and those sorts of things aren't having you know the direct a direct impact on how much back pain people or how prevalent back pain is so therefore they might not necessarily be the main causative factor but in this whole sort of like holistic approach to it they're going to have an impact on the pain you perceive because pain is obviously a perception you know it's considered it's perceived in the brain stress is going to necessarily have an impact on what perceptions you have of that pain response so while it's important it's not necessarily my area of focus and I don't necessarily think it's you know the main sort of thing but it's an important thing to consider perhaps in addressing people's pain perceptions and lastly one of the areas of risk factors we look at these physical risk factors so when we talk about physical risk factors we're talking about kind of like demographic characteristics so you know like height, weight blah blah blah all these things are people's physical characteristics and some of these things when we're looking at like joint structures and joint function how the joint actually physically functions like I was saying earlier the actual function of the joint so you know that could be in the lower back the actual strength of the lumbar extensors I don't know if you can see that that well but that's a a little diagram actually from one of Arthur Jones's books just showing a lumbar extension strength curve and just a little diagram looking at things like range of motion as well that does show kind of like gross trunk range of motion not necessarily just specifically lumbar range of motion which we'll talk about a bit in a while as well excuse me okay so like I was saying association doesn't necessarily imply causation though so quite often it's difficult to say also if something's associated with it whether or not it's really causing it or whether or not it's just maybe a symptom you know maybe something else is underlying it and when this thing has an impact on it you know pain is prevalent and something else is prevalent as well with these kind of other conditions we look at so it's very difficult to kind of like discern what's causing what now in the majority of cases and I'm of the same opinion as researchers like Stuart McGill I don't know if any of you have heard of his his name he's quite a big name in sort of like lower back biomechanics and rehabilitation he's of the opinion and I mean in general agreement with him that in the majority cases pain has an organic source you know an injury or some sort of dysfunction of the joint cause it is what initially causes the sequence of events that leads to pain so he focuses a lot on how various different physical characteristics of the lumbar spine have an impact on injury thresholds and the injuries you're going to face and he also distinguishes between whether or not they're you know acute injuries or chronic injuries as well you know whether or not they're you know severe like an acute acute sort of like sprain or a high impact injury or whether or not they're a losing the word right now a repetitive injury for example like marathon runners get repetitive strain injuries people can get repetitive injuries which can develop into chronic back pain in the lumbar spine as well you may not necessarily you know get tackled from behind in rugby or football whatever and suddenly put your back out it may be sustained loading and sustained injury very small small and just builds up into this kind of like chronic response and what tends to happen is after that injury a series of events happens which leads to this final pain response the actual peripheral nervous system so the actual structures and nerves in those structures become sensitized they become really sensitive to pain so any more kind of stimulation to those those structures will elicit even further pain response and some of these things are like you know you can get direct nerve impingement because of all the joint biomechanics and because of the function and the discs and other tissues as well the facet joints which are the actual joints in between the spine the vertebrae and the actual muscular and ligamentous tissue they all have nerve supplies and so they can all feel pain and any kind of like alteration to their biomechanics may be something that's responsible for sensitizing those nerves and then subsequently setting off a series of events to sensitize the rest of the pain response as well so this may be why pain can kind of like develop into a chronic condition as well now one thing I just wanted to point out and it's something that interestingly that I don't know I don't know how many what do you guys follow blogs a lot you kind of bloggy type guys well I'm a big geek and I read a lot of research and I read a lot of blogs as well and I think blogs are a great source of information especially if you can find good blogs run by interesting and you know critically thinking and rational people so I follow a lot of blogs written by various PhDs and doctors etc but one of the guys whose blogs I follow is a guy called Todd Hargrave who writes a blog called Better Movement and he's got a very sort of like brain centered approach on pain and he's quite interested in this whole back pain thing and interestingly he put a couple of studies which I was aware of and I've seen other studies where some people who have abnormalities in the lower back like disc herniations or disc bulging and that sort of thing they show with no pain symptoms so a lot of people have kind of like jumped on that bandwagon to say well you know if if that's not you know if they've got that problem but they've not got pain then maybe that's not responsible for pain in the first place excuse me but as we kind of said like in the majority of cases pain does seem to have an organic kind of like source that kind of stimulates that pain and one of the things that has an impact on that is the severity of the injury as well when you kind of look at these kind of studies which look at abnormalities and symptoms tends to find that the actual degree of injury if for example we're looking at the discs the discs can begin to degenerate they can then start to bulge and they can potentially at that point start pressing on nerves and causing a pain response or they could herniate completely in which case you know they can cause a real sort of like impingement on nervous tissue or they can even move down into the actual vertebrae and you know stimulate this inflammatory cascade of events that can cause a really sort of painful response and it seemed to me that that the majority of links between abnormalities and pain were a lot more associated with the severity of them so the very sort of like low severity injuries and abnormalities weren't necessarily as highly associated with back pain so it seemed to me that it was kind of like almost this dose-response relationship between how badly injured the spine was or how badly deteriorated it was and the extent of pain experienced so it may be that even when we see an abnormality it may not necessarily be sufficient enough to have caused the pain response yet also we've got examples where some people have symptoms some people say they experience pain but the scans show no pain at all or sorry no abnormality at all and this is interesting as well because a lot of people have made a kind of logical error here where they've taken absence of evidence to mean evidence of absence so it's this whole in medicine there's a phrase that they use which is sorry absence of evidence doesn't indicate evidence of absence so it's this whole you can't prove the non-existence of something kind of like going back to what we were talking about yesterday and the objectivism vector it's it's a logical jump that an illogical jump to say say that just because you can't see something on this particular scan that there's nothing there in the first place exactly so you know the scan may have missed it whatever diagnostic tests they're using and I just want to clarify as well now I'm not a diagnostician so this is these are my interpretations of reading the research you know that not not they may have missed something or perhaps the abnormality was there it sensitized and created a pain response and it's potentially alleviated itself the actual abnormality but the pains lingered because of the sensitization it's very difficult to kind of then use these diagnostic tests and say oh you know how how worthwhile actually are they and it's only really through the use of these tests and the kind of clinical wisdom of clinicians like chiropractors and physios that you can actually kind of get this small number of people with an accurate diagnosis in most cases it's not usually that useful so this whole idea of kind of injury severity then kind of puts on this idea of an injury threshold and in most cases when an injury threshold has exceeded and along the lines of kind of Stuart McGill's thinking your joint structure will have a particular level of loading that it can sustain before it breaks basically it's like any kind of like engineering aspect that it will be able to sustain any structure can sustain a particular amount of loading before it then goes boom and breaks when that may be a spectacular failure and it may all collapse or like an acute sort of severe injury an impact injury or it may be a sustained repetitive loading that may cause an injury over a period of time but there's an injury threshold and there are going to be things that impact how well you can alter that or how well you can sustain loading before you actually get injury excuse me I'm just going to grab some more water so if we're talking about injury threshold loading then one of the important things and certainly coming from a from a kind of our exercise Fizz background is the extent of loading a joint can take is usually going to be dependent upon the extent of resistance that the musculature holding the joint together can actually withstand so if you've got weak musculature that's joint structures not going to be able to withstand as much loading it's not going to be able to it may have low low endurance low fatigue characteristics as well and strength and endurance you know they're not separate things they go hand in hand if any of you are familiar with kind of Arthur Jones's like analogies on it you know if for example you implement a strength training program so say any exercise you start off with a with a maximum one rep max of 100 kilos you improve increase that to 200 kilos at the start so you could do one rep max of 100 kilos and you could potentially do eight reps with 80 kilos if you increase that your one rep max to 200 kilos then you're probably going to be able to do about eight reps with 160 kilos now you know roughly eight percent so your actual endurance the amount of reps you can do with a relative load is gone up so strength and endurance is synonymous you know if you improve your strength you improve your endurance your endurance as well so there's no kind of like training for one or the other and that's going to have an impact on how well you can you know withstand impact injuries and also sustained loading as well and we'll have an impact on obviously the injury severity and then the impact that has on the pain response you have so interestingly and one of the most consistent things you find in the literature looking at observational studies in small populations and also larger scale studies looking at these physical characteristics is that a lot of the things associated with the actual lumber extensor musculature you know the multithesis the erector spinae muscle groups show that in people with back pain they're usually very weak and they're very atrophied and they you know compared to a normal population of people without back pain they're probably unable to withstand as much strain and loading as the people who answer from back pain so all of these things like the atrophy the low lumber extension strength lumber extensor activation is usually lower and less coordinated in people with back pain and the atrophy again interestingly as well is that people who have acute injuries tend to have an associated lumber muscle atrophy as well so certainly in the in the multithesis so people come in they with an acute injury a study was done by hydes and colleagues I think and the people who came in with acute injuries found that they had lumber muscle wasting as well and they didn't have a follow-up study as well and also did some studies looking at people coming out of injury as well and found that the degree of the improvement in their back pain was actually related to the degree of improvement in their lumber musculature as well so the amount it actually hypertrophied and the amount of improvement in atrophy that was seen so it's interesting that first time and certainly the impact on whether it becomes chronic or not is also related to how strong and how well developed the actual lumber musculature is kind of aware what time did we start okay I'm going to try and rush through these next kind of bits then and kind of move on to what I'm kind of doing okay so briefly just to touch again on the indigenous populations now I have this kind of idea that well if it's a physical characteristic then it's not necessarily going to be environmental causes it causes all you know the whole sort of like westernization you know we all work in offices and we all lift heavy things or whatever that's having an impact on it so I thought I'm going to go have a look like western price did with indigenous and traditional populations and see what the rates of back pain are and then and see whether you know adhering to a traditional paleo primal lifestyle or whatever you want to call it actually you know reduce the rates of back pain we see and all the kind of like traditional populations that I could find literature on and research on found that you know the rates were just as high and in some cases higher than the back pain we actually get in western populations so interestingly it doesn't really matter whether you kind of adhere to a traditional diet or lifestyle or whatever you seem there seems to be back pain everywhere we go now I put a question mark next to the rural tie just because of the discrepancies in some of the research but on the whole it is very very prevalent regardless of where you go now I've added in a slide here with some of my recent thoughts just to quickly go over now if that's the case I thought that potentially there must be some sort of evolutionary reasoning for why we've got a high prevalence of back pain there must be some sort of structural compromise perhaps is the word to use that that evolution has had to make an evolution have resulted in that means that we've potentially got weaker back muscles then then we really need and I've been writing doing a bit of research into it and writing a few blog posts and I'm working on series at the moment which will get finished at some point just looking at how kind of like the lumbar spine has evolved and how that and I saw links with my research and how strengthening the lumbar extensive muscles actually links back to this and how there is an evolutionary basis for weak lumbar extensors now just as a kind of kind of background high lobates is a macaque you know macaque I believe well it's a type of old world monkey basically old world monkeys are generally anatomically representative of early early myosin apes sort of before the paleolithic era and in the early myosin when we were arboreal quadrupedal forelegged up in the trees locomotive creatures and what we what we had was we used to have very long sort of six or seven lumbar vertebrae what then happened is is we kind of evolved into these short backed terrestrial kind of on the ground and and branched swinging kind of apes and what subsequently happened was that required a shortening of the lumbar vertebrae because using what's called brachiation which is kind of swinging between the trees requires a stable platform from which to brachiate from so this this is actually an image of a chimpanzee's spine and also his pelvis and you can see the lumbar spine has shortened dramatically and what's also happened is the iliac crests have come up elongated and they cause like an entrapment of the lumbar spine so what happens is is we've gone from big long spine to really short spine with a lot of passive rigidity and a lot of passive structural integrity there so what subsequently happens is over that period of time we've gone from having a relatively massive strong erector spinal which was involved in involved heavily in our locomotion to having a relatively small one in terms of cross sectional area and the cross sectional area of a muscle has an impact on the actual amount of force it can generate so smaller muscles generally mean weaker muscles so that kind of sets an evolutionary basis for why potentially a lot of people have got weak back muscles and this is what I see it see when I get people in for testing in the lumbar extension machine which I'll go through in a moment as well so in that case what can you do about it well there are two different kind of like methods of treatment there's a passive treatments which aim at symptom relief and this is one of the reasons why the costs of treating back pain are so high is because a lot of treatment options focus on relieving the symptoms relieving the pain and never focusing on what the actual underlying causative factor is so things like bed rest you know ibuprofen pain killers that sort of thing massage they all focus on pain relief and actually removing the perception of pain removing the experience of pain so they're great on a short term you know you get really a pain for a while but eventually it comes back because they haven't dealt with the cause they haven't dealt with what's actually the mechanism which is actually stimulating the pain response the value of these sorts of treatments and there is some value in them is in terms of the severity of your pain if you've got really bad pain and you need to begin an active treatment program sometimes these sorts of treatments can be very useful in beginning that process if it's hard to overcome the pain and get involved with a program so in that respect they shouldn't be immediately dismissed as being completely disuseful there isn't a role for them but it's knowing what role they should play in a treatment program you know for years and years and years doctors would recommend bed rest for back pain but they're starting to realise now that it doesn't really help so that's a good move the next kind of area is active treatment options which are physical treatment options aimed at trying to address the actual cause of your back pain and the traditional kind of areas are looking at physiotherapy so physical manipulation of the joints and you know there's a really long history of using manipulation techniques such as McKenzie and stuff and they've been very useful in research and in clinical practice in reducing pain outcomes and improving functional outcomes improving the function of the joints of the physiotherapists and manipulating but one of the problems with it is and it's unfortunately just a problem with the technique and no fault with the kind of physiotherapists of their own the technique relies on a subjective the clinical wisdom of the physiotherapists so it's very difficult to provide a very objective and valid measurement of what the joint is actually doing so although it can be useful it's very difficult to then get a baseline measurement that you know is accurate and provide a progressive intervention to try and tackle that and then re-measure again and get accurate results and think I definitely know that that's improved so one of the things we can do instead is actually apply a progressive sort of like exercise program and not necessarily focus on sort of like physical manipulation which to an extent involves a the combination of a subjective sort of like interpretation and also the kind of wisdom of the actual physiotherapist now there are three kind of like areas of exercise that we can look at and which the literature kind of looks at one of them is kind of general activity which is basically this idea of get on with it if you've got back pain get on with it just be active do what you can can you know go for a run go do whatever take part in a class and some areas of research are focused on this and you know they're showing relatively good outcomes in terms of pain response the problem is it's very difficult to say that they're wholly effective because they don't necessarily use in their methodologies objective measures of function so it's very difficult to objectively say you know functional outcomes have improved pain may have reduced for whatever reason maybe because of a kind of just general outcome of the exercise but it's very difficult to objectively validate that the second kind of like school the fort in terms of exercises this whole idea of stability training and motor control training and it's very big in the kind of like sports performance areas and it's also very big in rehab areas as well and there are a number of problems with this approach I feel in terms of the actual control trials done to see it look at its effectiveness again it does show improvements in outcome measures such as pain and disability and that sort of thing but the problem is on a theoretical basis its underlying premise is very very flawed and it seems to be that in general it's probably just a generalized exercise effect from doing the activities that are having an impact on it so as you just put your hand up Anthony oh seen things so for example the whole motor control thing if you guys are familiar with the high intensity training literature and certainly Doug McGuff's but body by science they discuss in quite detail you know the whole fallacy of training a specific skill you know doing a plank or bouncing around at a swiss ball or whatever these specific skills and question the actual transference of that skill and the actual muscle recruitment patterns that are used during that skill to other activities so on that basis doing these motor control and stability exercises it's very tenuous to suggest that it's the actual motor control that's being transferred to then reduce pain and injury rates and improve disability it's probably just a general adaptation in the actual musculature rather than an improvement and a transference of the kind of skills involved on another level as well a lot of recent research has focused on new sort of like techniques of measuring a range of motion and actual joint motion intersegmentally so the lumbar spine like I said earlier is made up of five different vertebrae and what a lot of research recently has focused on is how those individual vertebrae move and how the muscles around those individual vertebrae control that so not only does that fall fallacy to the whole motor control theory and a misinterpretation of skill transference but one of the problems with it is the studies that have looked at people with back pain have suggested that people with chronic lower back pain have a lot of variability in the intersegmental movement of their vertebrae but the problem is so does everyone as soon as you get above the sort of lower vertebrae where the majority of movement actually occurs it seems to be that the movement is very individual you could take a population of healthy individuals and find massive variability between individuals so it makes it quite hard to then say well it's definitely that which is causing an impact on their actual function of their lumbar spine because the majority of movement occurs at the lower levels of the vertebrae and the majority of that movement is produced by the larger musculature externally and the kind of passive rigidity is provided by the internal musculature but again that motor control theory it's not necessarily training that particular or particular skills is going to help there so what we then move on to is this idea of progressive strengthening and in particular high intensity strength training so without going into detail because I'm aware of the time of you know high intensity training principles you know read body by science read all the literature in the area in fact I will quickly mention actually that I'm actually co-offering a paper with Doug at the moment so hopefully that will be published at some point and you guys will be able to read that which would be quite interesting but anyway yeah progressive strengthening so resistance exercise this is going to be one of the question marks though is does do these exercises train the lumbar extensive musculature so we've got a deadlift good morning Roman chair we've got a generic I think this is cybex back extension exercise one of the problems with all these exercises is they involve hip extension as well so there's movement at the hips as well as movement at the at the lumbar spine and when we're looking at any kind of kind of movements any sort of like gross compound movements the body always seems to find a way of making things efficient and making things things efficient in terms of energy expenditure so when we're looking at exercises that involve movement around the hips the larger and stronger muscles of the glutes and hamstrings tend to do the majority of the load bearing now studies have been done to look at activation of the lumbar extensive musculature in these various exercises in fact we one of the students has just compared stiff leg deadlifts and traditional deadlifts and you know the lumbar extensors are definitely active in terms of using electromography which measures the electrical activation of the muscles during exercises whilst these exercises are being done but that doesn't tell us anything other than they're active that doesn't tell us the extent of their activation or it can do but there are various flaws involved with the technique all it says is they're active you know standing here now my lumbar extensors are active that doesn't necessarily mean though that they're getting a sufficient stimulus to produce an adaptive response they need to be loaded sufficiently and fatigued sufficiently to actually produce that adaptive response so the problem with all of these exercises is they allow hip extension and they allow the glutes and hamstrings to do the majority of the load bearing studies looking at comparing traditional back extension machines with what we'll move on to in a sec which is the lumbar extension machine produced by med-ex also studies looking at comparing the roman chair exercise to the lumbar extension machine show that as long as hip extensions allowed our isolated lumbar extension strength isn't increased because the lumbar musculature presumably isn't loaded sufficiently and fatigued sufficiently also James Fisher the guy who's going to be coming in on Sunday as well to do the exercise and nutrition Q&A has just finished a study he's been doing comparing the stiff leg deadlift with the lumbar extension machine and interestingly stiff leg deadlifts don't really improve your lumbar extensor strength a couple of people improve their lumbar extension strength but not to a significant degree and on the whole most people didn't so what can we do then so for you guys maybe you're not going to all have access to equipment like this so in those cases how many of you from London actually okay quite a lot of you okay you guys will have access to the equipment Camden I think it is there's a facility called Keezer Training they have a full range of med-ex training equipment and they have a medical version of the lumbar extension machine here and I think they have an exercise version as well the version here is the equipment we've got at the university which has all the testing facilities on it as well and the main principle behind it is these restraint systems so what these restraint systems do is basically lock the pelvis in place by applying force down on the femurs via the thigh restraint which creates this kind of like fulcrum this pivot point the football then applies force up the lower legs which hits the femur restraint which then converts the force backwards to the femur so what it does is essentially it holds the pelvis down and back against this pelvic restraint here and what happens then is no movement forwards and back can actually and upwards can occur from the pelvis so any flexion and extension movement that occurs just occurs at the lumbar at lumbar extensors so what we can do is we can more effectively load them now coming back to the the evolutionary perspective one of the reasons perhaps that we've got stronger glutes and hamstrings is because of the way our gait patterns have evolved when we kind of like our backs shortened we went to sort of like this bent hip bent knee gait when if you think of how like chimpanzees and gorillas move and that involved a heavy influence a heavy involvement of the glutes and hamstrings so potentially there's a pathway there for where the glutes and hamstrings became massively powerful massively strong and now we're in this position where we've got an elongated lumbar lumbar spine again to allow bipedal movement to two-footed two leg walking and we've got this legacy of big strong glutes and hamstrings but weak spine muscles which creates this just recipe for high levels of that or high prevalence of back pain so what we can do is we can isolate it and effectively test in isolation now testing in isolation is important because any of the previous tests that research is used looking at extension generally looks at trunk extension so they've got the participants in a testing machine and not secured the pelvis so it's very difficult for them to say that we're testing the lower back because the hips and the hips extension is involved with glutes and hamstrings are involved so the actual measurements they take are going to be a combination of all of those factors and you can't isolate that one factor but what this machine does is isolates that and allows us to get a very objective and valid picture of lumbar spine function and we can measure for a full range of motion and we can produce and look at what that strength curve looks like in general people with back pain tend to fall even below the kind of like normal range of strength when we look at things we have this kind of like bell curve in the middle is the average some people are really strong some people are relatively weak but most people with back pain tend to have really low levels of lumbar extension strength they tend to fall below the norms or certainly only just make it up into the bottom range so just to finish up then what am I doing so let's bring back this diagram that we looked at the start so what I'm doing is looking at some research using the lumbar extension machine to kind of plug some of the gaps now the lumbar extension machine's rehabilitation and strengthening using high intensity exercise five minutes cool just wrapping up what this allows us what the majority of research and there's been a hell of a lot of research looking at it shows that one yeah it improves lumbar extension strength it improves isolated lumbar spine function great we can objectively measure that the research shows that we know that works two it improves pain outcomes massive studies have been done using the medx machine all of the studies done in people with back pain show improved pain outcomes along with improved function improved lumbar extension strength so as we improve strength and we improve joint function we've got a nice objective measure there we find that pain is reduced and we also find that disability levels measured sort of using more subjective clinical measures are improved as well so great we know that it works in terms of improving function and improving pain and if you guys can get access to the keys of facilities you guys can get access to it as well and if you've got back pain you know you can take part in an intervention then to use that to strengthen your muscles but the thing is coming back to these kind of like associative factors involved with back pain my thoughts on these are that potentially these are more symptoms rather than causes so it would be interesting to see whether or not if we're addressing the potentially ultimate cause I use the word ultimate if any of you are familiar with jarred diamonds but gun germs and steel he uses this idea of proximal causes and ultimate causes the ultimate cause being what causes these things these extra proximal causes which then have an impact on the you know later measures like pain disability and that sort of thing and if we if we consider that potentially weak lumbar extension muscles are what's having an impact and causing these other issues like limited range of motion degenerated discs you know gate variability all these other physical symptoms what we might see is if we address that ultimate cause we might see an impact on these other proximal causes as well or these potential symptoms so what my research is looking at is if we improve lumbar extension strength we improve pain reduce pain improve disability great but can we also look at this idea of improving range of motion as well now some of the some of the research looking at it has improved range of motion but what an interesting thing is is most people with back pain have a limited range of motion to begin with so clinicians employ a limited range of motion intervention now Bill, Bill de Simone talks a lot about a limited range of motion exercise and the theoretical basis of why he suggests avoiding extremes of the range of motion so for lumbar extension it's going to be extremes of flexion extremes of extension is because in those positions the muscles not aren't necessarily what's being loaded it may be the passive tissues the tendons the ligaments the bones they're going to be what's loaded as well so what what we're looking at doing is seeing whether or not we can actually on the medx take the exercise limited to a very small range of motion avoiding those extremes and see whether or not that still produces full range functional outcomes and see if that still produces improvements in this associated symptom of limited range of motion secondly we're going to look at gait variability as well I showed Anthony it when he came up to the lab we've got what's called a vicon system it's actually a 3d imaging system where if any of you guys have seen how kind of like Lord of the Rings was put together when they did Gollum they stick all these little like ping-pong balls all over him and then he gets does all this stuff the cameras record it it's actually the same system pretty much so what I can do is I can take participants in and I can marker them all up film them using these 10 3d cameras and then reconstruct that and have an animation and see exactly how their lumbar spine is moving relative to their pelvis whilst they're walking so I can see how variable it is to begin with and then look to see what impact strengthening those muscles has on improving the way they walk as well improving this kind of extra symptom that's associated with lower back pain and lastly as well we're going to look at what effect loading has actually on the on the discs as well we know that progressive high intensity strength training loads the muscles it improves increases hypertrophy increases strength we know that it increases bone mineral density in fact studies have looked at what effect the lumbar extension machine has on vertebral bone mineral density the strength and integrity of the actual vertebrae and found that it increases bone mineral density as well one thing that hasn't really looked at and it's the only structure in the lower back that has an impact on back pain doesn't look to see whether it actually has any effect on improving disc health so most people with back pain do to some extent especially as you get older get you know disc degeneration which can turn into herniations and bulging etc and some people have got this idea that the more you move the more it creates variances and pressure across the disc so as you bend forwards and backwards the discs basically get squashed and extend at either side so those kind of extension movements create this suck squeeze mechanism is what it's being termed as to increase hydration to the disc but what I wanted to kind of look at was well maybe that that works in terms of physiotherapy but what about the effect of the actual strength training on it you know does load have an effect on it and it may well do because the study that looked at bone mineral density found that the changes in bone was mainly found on the soft sort of like bone on the interior which is very closely associated with the disc health as well as discs degenerate that tends to degenerate as well so there may be a link there that it could potentially have an effect in addition as well a recent study that was published a big study in Germany found that the heavier the loading of exercise people did so the people who did weightlifting and that sort of thing tended to have better disc health than people who did things like long distance running as well and I kind of alluded in a blog post a while back to the the fact that you know repetitive sports you know marathon running triathlons and things like that aren't very good for your back health so there's a potential link there whereby if we ask that question and we employ this intervention we might be able to see an effect on all these different outcomes and see whether or not in terms of a holistic approach this intervention can have an effect on all the kind of aspects of back pain so that's the whole idea and hopefully that can kind of like provide some benefit you get for anyone who gets back pain but for the meantime you know the research certainly does suggest that anyone who gets back pain should really be employing this kind of an intervention it's really strongly supported and it's a far more objective method of treatment than any other kind of sort of currently existing treatment so to conclude just a summary of kind of what we've gone through there today and we're consciously aware of the time so if there are any questions all right for do you want me to repeat it or yeah so you mentioned that in some cases the actual area of pain may not necessarily be the area in which the symptom is or the actual problem lies has your research come across anything that suggests that a correlation between lower back issues and upper back or shoulder pain? I'll be honest it's not something that I've specifically focused on it's like I made a point of at the beginning it's not I wouldn't want to kind of like step outside my area of expertise and so it's not something that I'm aware of whether or not there is a correlation but I've not looked extensively into the into the research so there may be there may not be but I'm not entirely sure it seems to me like the only way to solve this used a medics machine is the any other way because not I don't think everyone else most people won't have access to it no you're absolutely right and as gloomy as it sounds I think in terms of the way our spine is structured it is certainly the best way to do it but it may not necessarily be the only way some you know the exercises I went through to begin with they do activate and load the lower back and in some cases they'll provide a stimulus for producing adaptation in them Doug McGuff actually went for a few exercises on a few videos of potential exercises which you could use to load the lower back but the only reluctance I have with exercises like that is although they activate it it's very difficult because the research hasn't looked at it to see whether or not they sufficiently load it to produce an adaptation but like what we've seen with other exercises you know general activities this whole motor control course stability training that sort of thing it improves outcome measures such as pain so it's likely that there is some sort of GM rule adaptation so although the loading may not be sufficient to produce the degree of results that you see using something as advanced as the med-ex machine it's probably worth doing as long as you can do them appropriately and safely and you know using following sort of like high intensity principles then you'll likely see an effect from them but if you want best results it's obviously best to kind of like use the best equipment available but yeah if you've not got access to them to it and this is one of the reasons why I'm doing the research as well because it just to draw contrast for it for you med-ex the med-ex website has a facility locator so anyone who buys med-ex equipment tends to load it you know register with the website and anyone can search where a facility is in the UK there are five facilities and that's not including R1 so there are six facilities in the UK which I know have a med-ex lumber extension machine compared to just the Florida area on its own which has about 57 facilities I think so yeah there are loads a lot of them are in kind of like physiotherapy clinics and things like that I don't necessarily always in gym-based facilities but there's a lot more access available and so what I'm kind of hoping is is certainly in this country people aren't aware of it people don't know the options available although it's very sparse I think by doing the research you know presenting academic conferences and making physiotherapists and clinicians more aware of it and showing how effective it potentially could be we'll hopefully make people's eyes open a bit more and go oh fuck you know we need to get a piece of that equipment and we need to make it more available so that we can you know we can get that treatment option going and get sort of you know patients to come in and use that but yeah I think you can get benefit from other exercises but obviously it's not going to be as good as using the MedEx wrap wrap around okay I think that's it guys if any of you have got extra questions just come grab me afterwards thanks for your time