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An Interview with Dr. Patrick Roth, MD, author of The End of Back Pain

Dragon Door: In the article you shared earlier, you mentioned your book on back pain is different from anything else out there—how would you describe your approach?

Dr. Patrick Roth: Most of the existing books on back pain say the same things over and over. Every once in a while there’s something a little different, but I wanted to share a totally different perspective. From my experience, when you write a book it takes on a life of its own and The End of Back Pain has been no exception. I started with a very simple premise—just by experimenting when I was a kid, I realized my back problems improved when I strengthened my back muscles. We happened to have a Roman chair in our basement. One day I wandered down to try it, then took it for granted! If my back hurt, I would go work on the Roman chair and through trial and error I would feel better. That was filed away in my memory, and later in life, when I came across a patient who cured his own back problems with kettlebells, I recognized the similarity of his approach. I started to read about back strengthening and kettlebells, then tried it on myself before trying it with my more ambitious patients. The vast majority of the patients who had the nerve to try it, benefitted from the training.

I wanted to share these ideas, because I had never seen them in writing or in the mainstream—even though I think many people who already train with kettlebells know how it can help your back. And while they have personally experienced it, before now it hasn’t really been publicized.

As I researched and wrote the book, two other themes emerged that I wasn't originally planning on writing about. The first was the mind/body relationship and how the body can prime the brain—and the brain can also prime the body. I’ve always known that to be true based on my clinical practice, but found substantiation for it in the psychological disciple of embodied cognition. The example of this interplay in my book is that everyone smiles when they are happy, but tend to forget that they will also be happy simply by smiling. Back strengthening exercises can have a similar effect on your brain—partly in posture, confidence, and in altered mechanics. It’s mediated through the brain, but primed by the body—and vice versa. So, by learning certain concepts and understanding more about the pain, you can actually alter the pain.

The other concept I found was the idea of symmorphosis. We used to wonder why humans have so much excess DNA. We knew that some of it was used to replicate cells, and that some of it was used to create the structure of cell bodies but there was so much more. Now we know that some of that DNA allows the cells to modify themselves when stressed. The stress on a cell is mediated by this DNA. When the cells form an organ—like a liver or a brain—or are part of a muscle, they also work together to mediate the stress. When these organs are together in the body, and the body is stressed, the different parts will react differently, but will be in concert with their reactions. The most obvious example is the body’s reaction to exercise. Weightlifting will cause muscle hypertrophy, while running causes the lungs to be more efficient, and the muscle cell bodies will develop more mitochondria. So, instead of seeing stress as destructive, it can also be seen as a positive source of growth—if you can find the sweet spot of just enough stress.

Dragon Door: How should we find that "sweet spot"?

Dr. Patrick Roth: The sweet spot is different for everyone, but the way to find it is by starting off with a very low level of stress then increasing it if positive results are still happening. If you go too far, you may set yourself back a little bit but that's ok too, it's part of this trial and error process. If the stress stays too low, you’ll never get hurt, but you don’t have the chance to grow either.

Dragon Door: What was your first impression of the patient who helped himself with kettlebells?

Dr. Patrick Roth: When I first met him my first reaction was that this guy was full of it! When I first met him, he told me he was entering the world powerlifting championships. He was about half my size at the time and I didn’t think he could be serious. I’d never seen a kettlebell before, so he took me to his basement and challenged me to do a military press with a 90lb kettlebell—he could do it and I couldn’t! I couldn’t believe it and listened to his story, which reminded me of my experience as a teenager with the Roman chair. Soon after, I found a book by a physical therapist called The Multifidus Back Pain Solution. It’s a great book about the experiences of a physical therapist who only practices very simple back strengthening exercises with his patients.

So, three significant things came together—kettlebells, which significantly strengthen the back muscles, the physical therapist who had great results strengthening his patient’s back muscles, and my own experience as a kid with the Roman chair. I started trying back strengthening exercises with my patients, and learned more about it. Before that time, I didn’t know the difference between back bending and hip hinging. By hip hinging instead of back bending, the back remains straight and unstressed. That information alone was great for patients.

Dragon Door: It seems like most people are afraid to exercise if they’re in pain, but your book goes against that idea. What’s your advice in that area?

Dr. Patrick Roth: I think the instinct to avoid pain is inherent in all humans. There’s a reason for it and obviously certain instances when pain should be avoided. But again, people are more likely to short change themselves by staying "safe" than by taking some risks. If you had a herniated disk that was causing pain, you wouldn't want to do heavy deadlifts, even if it might be relatively safe if your form was impeccable. I advise taking small steps and evaluating what happens. If you take a small step and get in trouble right away, then back off and try again and still experience problems, then it may be prudent to have a doctor investigate the cause of the pain. But what most people don’t realize is that the vast majority of instances of back pain are not diagnosable, in terms of identifying the cause of the pain.

To provide some perspective, I spent the first 20 years of my career as a neurosurgeon obsessed with finding back pain generators—I wanted to figure out whether the back pain in question was discogenic—coming from a disc herniation—or facetogenic—coming from joints in the back. I was using many tests, asking questions, using MRI information, and putting everything together. At the beginning of my career, I thought I would be able to find the cause of someone's back pain every time. But, that's not the case. Even if you see a herniated disc on an MRI, there’s no assurance it’s the actual cause of the pain. What you want to hear from me right now is the standard disclaimer, "Consult your doctor." But you won’t get that from me—it’s a cop out because the doctor might not know the cause of the pain. And while there are risks to pushing yourself through back pain, in my opinion there’s a bigger risk in not trying—because without trying you may miss a chance to get better. It’s prudent to move forward.

In our culture—particularly Western culture—everyone assumes that back pain is the result of an injury. But, the vast majority of back pain comes and goes like a cold or headache. When someone has a headache, they don’t automatically assume something’s broken, they assume it will be gone by tomorrow. But with back pain, there’s a totally different mindset. When your back hurts, you assume something's broken and you can't move on until it’s fixed, instead of relying on the body’s inherent self-healing abilities. Humans are designed with self-healing capabilities, and while they don’t work all the time, they can work most of the time.

Dragon Door: That comes back to your ideas about the mind/body connection and building back strength and health with both the body and mind. How common is it for patients to have back pain similar to your example in The End Of Back Pain, when the patient’s pain went away as soon as you described his treatment plan?

Dr. Patrick Roth: People often assume the worst. I can't tell you how many times it’s happened, but as soon as people have a plan and proper perspective, the panic subsides. Pain is always interpretive, which is why someone can get their arm blown off in battle without feeling anything until they’re safely in a hospital—then the pain becomes intense. The brain is responsible for the pain going from zero to incredibly intense, and in the example of the patient, from very intense to zero. The brain is very powerful, and I describe the related placebo and nocebo effects later in the book. The placebo effect, which people generally think of kind of bs is actually very strong in all of us—and is put into play every day. If someone is in pain and takes a pain medication, they may think it’s a very scientific. But the truth is, these pills reduce pain by using the body’s existing systems. Pain medication works because it helps the body create endorphins that bind to receptors—this maintains pain homeostasis. One way the placebo effect works is by causing the brain to just release its own natural "pain medications" which bind to the same receptors. It's interesting because with pain medication, science has just imitated what already happens inside us.

Dragon Door: In the article you recently shared with us, you said, "Let your pain be your guide" is not good advice. Considering the interpretive nature of pain, your approach makes a lot more sense.

Dr. Patrick Roth: Another aspect is the medical/legal dynamic. A physical therapist will not tell the patient to push through the pain for fear of being sued or bad-mouthed, because the patient will often find some reason to come back and blame the therapist. So, the common theme with physical therapists, chiropractors and doctors is, "If you feel pain, then take it easy." At that point, the doctor or therapist has cleared themselves of any possible liability—even if they haven't done the patient any service. That advice protects the advisor instead of helping the advisee.

Dragon Door: How do you suggest patients begin a dialog with their doctor if they are willing to try pushing through the pain since there is so much fear of litigation?

Dr. Patrick Roth: That’s difficult. I’ve employed a great physical therapist for over ten years, and the patients love her. I’ve always told her that it’s ok if she sets patients back a little and it’s what I want her to do. It’s a similar concept as when someone doesn’t fall while learning to ski, they probably will never improve at skiing. If we don't set some of our patients back, it means we aren’t pushing them hard enough. But, she won't do it because she’s been trained to not push beyond the point of pain. I think it is really hard for providers to follow that advice. I don't know if it’s only medical-legal related or simply because "let your pain be your guide" sounds like common sense. Sometimes it is prudent advice but usually it isn’t.

Fitness instructors are told the same thing, because if you push through the pain and it gets worse, that client will never come back—and neither will any of their friends. I understand why, but even if you have a torn rotator cuff, the body can often heal itself if stressed properly. If you stress scar tissue it gets stronger, but if it’s overstressed, it won’t heal itself. This gets back into the importance of finding that sweet spot.

Dragon Door: What do kettlebell instructors and fitness professionals need to know or to watch for when working with a client who has back pain?

Dr. Patrick Roth: The first thing is to really make sure that the client is instructed and educated on the difference between back bending and hip hinging. Even starting with something simple like standing up from a chair while maintaining a lordotic or straight back when transitioning from sitting to standing is powerful. Similarly, they need to learn how to safely pick up a kettlebell before they ever learn to swing it. It’s also initially important to keep clients working with a weight that's even less than what they can easily handle until they build proper form. Form is paramount with kettlebell training. Once you deviate from proper form, injuries can happen very easily.

When it comes to strengthening the back, we’re actually looking for muscular endurance more than strength. This is a case where the client is better off building strength endurance over time. The overall number of reps is more important in this case than the weight used. This is because the deep muscles of the back are predominantly slow-twitch endurance muscles. A client will get more protection from back pain with strength endurance than overall strength.

The difference is between hypertrophying a muscle with isometrics and increasing the number of mitochondria in a muscle cell with endurance. If someone runs, their muscles don't usually get bigger, but they get stronger in a different way with increased endurance. I think we want the same thing for the back muscles—we want to increase the muscles’ capacity for endurance and the density of mitochondria in the muscle cells.

Dragon Door: What do you think is the best kettlebell exercise to alleviate back pain?

Dr. Patrick Roth: I think once someone’s ready for it, the kettlebell swing, because it helps with endurance. Phil Ross and I are friends, and our story with kettlebells is interesting—I actually got Phil into kettlebells. He is a personal trainer as well, and I used to work out with him. When I was first developing ideas for this book years ago, I told him about kettlebells. He went crazy with them, and took it to a much higher level. Now I send patients to him all the time. He's a stickler for form and an animal himself—he’s as strong as an ox! He taught me a workout called "The Hundreds" which consists of 100 kettlebell squats, then 100 swings, and lastly 100 kettlebell snatches—it’s brutal. Now I start my workouts with 100 snatches. If for some reason I have to quit working out after them, I still feel like I’ve done pretty well.

Dragon Door: Sometimes when people first see a kettlebell swing without knowing how it works, they assume the movement will hurt their back. We know that there's a lot of abdominal engagement required to do the swing...

Dr. Patrick Roth: Yes, and I teach that the core is a circumferential structure. It’s a core inside a core—the deep abdominal muscles attach to deep oblique muscles, which attach to deep multifidus muscles (back muscles). And they are all attached with fascia. There’s a more superficial core as well, but each of these internal cores can constrict like they are squeezing a water balloon. This is a circumferential constriction and necessary for proper spine stability—it’s what we do when we swing a kettlebell. When we hip hinge, we keep our spine stable and have to use all three elements of the core—the front, sides, and back simultaneously. It's not just one muscle group, it’s a team effort.
multifidus psoas

Dragon Door: How long have you been working with kettlebells?

Dr. Patrick Roth: Around 9-10 years, and Phil was only about 6 months behind me—then he went so much further with them.

Dragon Door: How would you describe your own training?

Dr. Patrick Roth: Each week I do a full body workout with traditional weights focused on squats, deadlifts, pull-ups, and clean and jerks. On another day, I do what I call a "core workout"—mostly kettlebells, swings, Roman chair, leg raises, and side planks. One day a week I run intervals, and one day I bicycle. At age 53, I’ve transferred my focus from looking good to living longer.

Dragon Door: That’s important at any age. Since your book came out on April 8th, what’s next for you?

Dr. Patrick Roth: I am writing another book. It’s about the various disadvantages patients face when entering the healthcare arena. The topics are not the obvious issues, but focus more on how decisions are made in healthcare settings. The process is not as logical or reproducible as anyone would like it to be—people have biases and take shortcuts.

In the book I discuss a variety of issues from the surgeon's point of view, including the surgical narrative, one of my favorite topics. Surgeons operate, then speak with the family afterwards. There’s a real burden on the surgeon to communicate the truth, to educate, and to soothe, but many times that doesn’t really happen. In short, I’m writing a patient empowerment book.

At some point I would like to teach. After four years of medical school, seven years of residency and having a practice for twenty years, I’ve honed my surgical talents. I want to slow down when my skills begin to plateau and look forward with a new life plan. What I would love to do is remain a surgeon during the day, but on the nights and weekends, be a surgeon without a scalpel. I want to give advice on the internet, in writing, and through blogs on the subject of promoting health as opposed to disease treatment. That’s kind of my life plan for the near future.

PatrickRothMD thumbnailDr. Patrick Roth, MD is the author of The End of Back Pain.