DR. ABHAY NENE is a spinal surgeon from Mumbai, India, who has been the recipient of various international awards throughout his career. He is interviewed here by DR. SNEHAL DESHPANDE of the Heartfulness Institute about back pain — why, how, and what to do?
What Causes Back Pain?
Q: Dr. Nene, tell us about back pain. What does it encompass?
AN: The world is made up of three kinds of people: those who are having back pain, those who’ve had back pain, and the rest who will have back pain.
Back pain is one of the top three reasons to consult a doctor worldwide. That’s quite telling. It shows us how common it is.
There is often a misconception that back pain is for the rich, or for the urban, but we’ve done a study where tribal Indians also voted back pain as their biggest problem after infant mortality and malnutrition. Back pain is a huge problem across communities, and across profiles of people.
As a back surgeon, I define two categories of pain: The first comes from the physical structure. The pain comes from bones, joints, muscles, and ligaments. It is physical and mechanical in nature. It is not always urgent, but it is a nuisance.
The second category of pain comes from the neural system, the nervous system. It is more urgent, and so a person often needs to seek medical help.
Q: What are the implications of having bad posture?
AN: Take sitting as an activity. Most people are either leaning toward a computer monitor, looking at their mobile, snoozing at the table, or slouching. You might feel that you’re chilling in your chair, but you’re actually loading your back. Most of us load our backs over days, months, and years on end, without really servicing them. We use our backs for up to eighteen hours a day, and mostly we abuse them.
There’s almost nothing that you do functionally where your back remains straight. That’s where posture comes in. If you load your back in a way that it was not designed to take loads, it’s gonna wear out faster. Posture is a neutral state in which your body takes loads.
Most of us load our backs over days,
months, and years on end,
without really servicing them.
Sitting Versus Standing Desks
Q: Many people have been talking about standing tables while working from home. What are your views on that?
AN: You have probably heard the statement, “Sitting is the new smoking.” The human body was designed to be upright, and the back consists of a central structure which is like the mast of a ship. The muscles around it are the dynamic supporters of the ship. Those two elements together give the back a shape memory. This shape memory loads the back at the disk level. These are the disks that lie between the bones of your back. They are like shape memory pillows. They’re supposed to absorb the load, but over time they degenerate.
It is just like using a sofa for many months; eventually it loses its capacity to maintain shape. Similarly, the discs in the lower back begin to degenerate or dehydrate, so your back loses shape memory. When it’s put in an awkward shape, it doesn’t conform to it but adapts to that shape. If you sit on an old sofa, you sink in. A similar thing happens to your back when it’s loaded beyond its capacity.
Standing: Please stand up with your back against a wall, and your heels dug in. A neutral posture is when the central line of gravity is perfectly aligned to load your back the least. That’s the neutral position of the back.
Sitting: When you sit, instantly the lower back curves forwards, because your pelvis tends to tilt forwards. As soon as that happens, the centerline of gravity moves forward and the load on your back doubles or triples, depending on how you’re sitting.
The right way to sit is in an imitation of standing, where you’re still arching. Your lower back is upright, which is done by engaging your muscles, not sitting passively, but most of us don’t sit like that. So that’s where standing desks, bar stools or high chairs come into play.
When you stand, you get tired, or your legs hurt, but eventually it’s good because it helps you to stand for longer periods. People spend so much money on fancy chairs, but the best chair is your muscles.
Can Shoes Prevent Back Pain?
Q: There are specific kinds of shoes designed for walking, running, and everyday use. Can wearing a particular type of shoe help us avoid backache?
AN: For 95% of the population, there’s no shoe that can remove back pain. I’m gonna to tell you a little story. A company that is a famous sole manufacturer asked someone to jump from ten feet with a very well-padded shoe, and then asked the person to jump without any shoes at all. The load on the knee and spine was less when he was barefoot.
Your foot is not one block. It’s designed with very small hinges. So, when you land barefoot, your feet nicely absorb the shock so almost nothing lands on the torso. Heavy padded shoes actually take away that movement. Even though they give you a lot of shock absorption, they take away the micro movement in your feet, and that can actually be counterproductive.
So, there’s no magic shoe. There are, however, a few things that you may want to remember about shoes. People with flat feet and feet that hurt may do better with shoes that have inner padding which will align their axis together. People who wear tall heels for long hours push their center of gravity forward. They would be well advised to wear them for shorter periods.
Job-related Posture Problems
Q: There are some professions with repeated posture-related problems. What are these professions?
AN: It’s very telling that an athlete who’s running every day, jumping, and doing heavy-duty loaded activities, rarely comes with back pain. But a white-collar professional, who’s sitting on a laptop all day is the most common candidate for back pain. During the pandemic, we all started sitting longer hours. Anyone whose work involves sitting for long hours is likely to suffer from back pain. Of course, athletes and people who engage in heavy lifting can get back pain, especially if they overshoot their capacity.
Also, neck pain is a common postural problem because most people’s jobs involve looking down. That includes surgeons, diamond sorters, secretaries, and dentists; basically, anyone who tilts their neck for long hours will have neck problems.
The most common professions are the most sedentary professions. The more active professions don’t come with back pain. Now, that’s counterintuitive! Something to think about!
Q: There is another group I also look at — gym enthusiasts. Some come to me with pulled muscles and other related injuries. What would you share with this group?
AN: You have to be aware of your capacity, which means knowing your strain versus pain equation: if you do something that gives you strain, the next day you’re okay for another session. The minute you’ve got pain, you’ve overshot it.
The other big problem in gyms is compound exercises. The machines are designed for ergonomic workouts, so the load on your back is not multiplied when you’re exercising your arms or legs. Compound exercise, in other words a free workout, for example, a weighted squat, will load your back, your legs, and your glutes. It’s a multi-muscle workout. If you’re not strong enough, which most of us are not, one of these will give way.
When you’re doing a deadlift, for example, your hamstrings, quads, glutes, back, shoulders, arms, everything is loaded, and if they don’t all work in unison, the back gives way. The back gets the brunt of it.
You have to be aware of your capacity,
which means knowing your strain versus pain equation:
if you do something that gives you strain,
the next day you’re okay for another session.
The minute you’ve got pain, you’ve overshot it.
Lumbar Belts and Cervical Collars
Q: I have seen many people with either a belt around their abdomen or a collar around their neck, while doing everyday activities like going for a walk. What is your viewpoint on the use of collars and belts for neck pain and backache?
AN: A lumbar belt is like a corset, a fake abdominal muscle, which keeps your tummy in. In a way, it gives you the right posture, it keeps your mind on your back, so you’re upright. That’s okay in the early days, but if you keep using it for longer, two or three things happen: your muscles start to forget that it was their job to hold you up, the belt begins to loosen so it’s no longer protecting you, and eventually, you’re not able to survive without it.
Long term, it’s good to create your own belt. That means having really good strong abs so they become your belt. It is a permanent free belt that stays with you. Learn to walk upright, walk tall, and tuck your tummy in.
The same is true for a cervical collar. The neck has a fixed load of ten pounds, but that load can multiply significantly the minute you start tilting your head forward.
A collar allows this distance to remain constant so your head doesn’t drop down. In a way it’s doing you a service, but things can go wrong, so we don’t recommend a collar. First, you get used to it, and without it you’ll stoop. Second, you get a universal-sized collar. Your neck isn’t a one-size-fits-all; you could have a collar that’s too small or too big. It gives you a false sense of security. So, I would also deter you from wearing a collar.
Instead, walk with your chin and vision parallel to the floor, the back of your head in line with your shoulder blades. When you’re upright, your muscles will tire, but they will then learn to adapt to that posture.
So, collars and belts are okay for a short time, but dump them in the long run. Unless you use your muscles, you lose your muscles. Also, if you depend continuously on the belt, you tend to become psychologically dependent.
Q: When is the right time to go for back surgery?
AN: My professional opinion is that many people who have back pain are generally great candidates for rehabilitation, not surgery. Back pain comes from multiple sources, so you can tackle one or two at best. The surgery we do for back pain ends up stiffening the spine. It is going against nature’s principle of mobility. It makes your back stronger but less mobile. It does not necessarily fix your life. Surgery for back pain has a 50% success rate worldwide.
In contrast, people who develop nerve pain are great candidates for surgery, and I would encourage them to have it, because often the pain goes down through the buttock into the leg, and that causes the leg to go numb or weak. It increases leg fatigue, weakness on walking, and so on.
My professional opinion is that
many people who have back pain are generally
great candidates for rehabilitation, not surgery.
Q: Which allied professionals can help with back pain?
AN: First, there are physical therapists, because they know which muscles are weak, and which to strengthen to support the back. A physical therapist knows the physics of back pain, and they start enhancing the muscles without actually damaging the background.
Next are nutritionists. A good nutritionist will help you cut down weight if necessary.
Third, ergonomic experts can see how you place your computers, your workstations, and how you’re driving. They are often the lifestyle experts. Overall, I think these professionals help.