All posts by andrewstemler

personal trainer, crossfit london uk trainer, Lower back pain researcher

Is Acne bacteria connected to back pain?

The paper by  Hanne B. Albert et al “Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy throws up a fascinating possibility. That some back pain and sciatica is  caused by a pathogen and as such, can be treated by antibiotics .

The pathogen that could be causing this is Propionibacterium acnes.

If you think you recognise the “acne” bit. You’d be correct. The stuff that ruins your teenage years and gives you acne!

As Dr long in his article  “The Murky world of Mordic Changes” . says “there will always be a proportion of our patients who simply don’t respond to our care…….Could there be something far more ‘pathological’ that might perpetuate lower back pain”

To understand this issue you need to  vaguely understand “mordic changes”. These are changes in the bones marrow of the vertebral body either side of a damaged disc. In stage 1 changes these areas have increased levels of pro inflammatory cytokines and increased levels of innervation

“Propionibacterium acnes bacteria secrete propionic acid, which has the capacity to dissolve fatty bone marrow and bone. We hypothesize that diffusion of propionic acid from the disc into the vertebrae causes the Modic changes. Similarly, as increased TNF-alpha and the growth of PGP-5 unmyelinated nerve fibres have been reported in Type 1 Modic changes, with the inherent slowness of these pathological processes perhaps explaining the delayed onset of improvement observed in this study”.(Albert et al)

Needless to say, shooting up clients with lots of antibiotics has drawbacks!

“High-dose long-term antibiotics should not be prescribed without due consideration. Clearly in a condition as chronic lower back pain there is a potential community as well as individual hazard if used indiscriminately. However, as many patients, as in this trial, are on sick leave, at risk of losing their jobs and have a high analgesic intake, we suggest that antibiotics, when applied along the lines of this MAST protocol may be appropriate in this subgroup, i.e. chronic lower back pain with Modic Type 1 changes. We do not support the proposition that all patients with lumbar pain should have a trial course of antibiotics. The criteria in this study were very clear: chronic lower back for more than 6 months, Modic Type 1 changes in the adjacent vertebrae following a previous disc herniation. As we do with other drugs, we rely on our fellow colleagues to use clear evidence-based criteria and to avoid excessive antibiotic use.”

However antibiotic issues to one side, this treatment is mired in controversy .  Lars Bråten authored a report totally failing to find any beneficial effect.

“Efficacy of antibiotic treatment in patients with chronic low back pain and Modic changes (the AIM study): double blind, randomised, placebo controlled, multicentre trial” (click here for report ) tested patients with chronic low back pain and Modic changes at the level of a previous disc herniation. For three months they were treated  with amoxicillin. It  did not provide a clinically important benefit. These  results do not support the use of antibiotic treatment for chronic low back pain and Modic changes

I note though that that Albert experiment (Pro) used amoxicillin–clavulanate and the Braten report (Anti) used Amoxicillin. Im not clever enough to state whether this would have made any difference.

So, keep an eye on that research!

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The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 



Smart phones useage mAy be screwing with your health

Maybe this isn’t the headline , or discovery,  of the century , but smart phones could lead to poor forward head posture, poor rounded shoulders and poor breathing.

Now its not as if the phone jumps out of the package and puts you in a combined head lock  and choke hold,  but it might as well: check out this new report “The effect of smartphone usage time on posture and respiratory function” by Jung et al  smart phones and breathing.

The big take home is this “The result of this study showed that prolonged use of smartphones could negatively affect both, posture and respiratory function”.  Wow.  Modern day scientists  are amazing!

What a lovely phone. I wonder why my neck and back hurts and I cannot breath properly anymore

The truth is this. Using your mobile phone now and then, wont hurt you (unless you walk into a lamp post). You can also  sort of ignore those hippy therapists as  poor posture, as such, wont hurt you. We all know people with disgusting posture who have never had a day of  postural pain in their lives.

However, “postural stress” as used in  advanced torture regimes simply takes a bad posture and makes you hold it for hours. The Scavengers Daughter  was device that held you in a stooped posture for hours and was very effective as a torture.

postural stress

As always,  it’s how much “bad”  you take before you start hurting.

Strangely the Backaholic Back Pain management course has a  specific lesson on self  torture techniques. Its sort of bazaar!

If you want more  back pain tips on information on when the Backaholic course will be released, do join our mailing list.

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The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 

Understand your pain

Underpinning every psychological approach to back pain is education.

It’s seen as crucial that you understand the mechanisms of pain within your body. So here is a super simple introduction to the basics of pain. I started teaching in our kitchen:

We have that basic banana approach. We can now build up to a bit more of a technical  overview. You’ll see, I got kicked out of the kitchen, into the bathroom!

now, its up into the brain! We were relocated to the bedroom

Its back to the bathroom to remind ourselves about what switches nociceptive neurons on and off

back into the bedroom to look at “inhibitory interneurons” and “enkephalins”

Helping you understand how pain works  is certainly  the approach used by  Dr Sarno in his TMS (Tension Myositis Syndrome)programme  and  Dr Schubiner in his MBS  ( Mind Body Syndrome) programme. I  just think our educational process is a bit funnier!

The Backaholic course should be ready in late August/early September, so if you want to fix your back pain, do sign up for our newsletter so you know when its available! Obviously we will send out lots of handy hints and tips between then and now.

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The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 

Predict your back pain!

Many have a bout of back pain, then think no more of it. Often you get a second bout! In some cases it turns into chronic long lasting pain that has you demanding pointless MRI’s and screaming for  painkillers like an addict.

This could be your opportunity to  live the rest of your life back pain free. Whilst the isometric flexion tests is only one of many tests, it’s a very useful one. Hook your feet under an object ( or get someone to hold them down) and sit up to 45 degrees with your arms crossed across your chest. Ideally your back is held in a “neutral spinal position”.

Time how long you can hold this position?

The standards are these: men need to be able to hold this position for 136 seconds, women 134 seconds. Less is a substantial  risk factor for future back pain.

If you thought your core was great because you can do lots of  “functional fitness” sit ups and weird crunches, but you fail this test, you need to add soem very specific training to your regime asap.

Incase its news to you,  your core needs to be able to isometrically contract all day long to support your spine! This test  is a very good indicator if you are preparing for that Functional task.

Join the mailing list so I can help you  stay pain free!

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The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 

5 solutions to gaining control of your back pain

AsI discuss here, it’s possible to allow back pain to swamp you. Here are the 5 things that successful back pain managers do.

They carefully return to  exercise.


People who exercise (effectively) are simply  better at managing pain. Ideally you build in things that you like to do, but nothing takes away from the fact that motion is lotion. Your recovery and escape starts and ends with physical activity.

It’s almost a  simple as that. You need to know how to have an effective activity regime that builds in  effective stretching, “smashing”,  education ( careful attention to movement performance) and then Strengthening (SSES for short).

That said, even getting those early short distance walks, sometimes with a helper,  can really make your recovery. Sometimes a bit of gardening can get you moving

Goal setting to avoid the Over activity rest trap.


As discussed here, sometimes you cram lots of work in when you are pain free: you do too much and collapse: each cycle, you get worse. If you can substitute  “going mad”  with modest goal setting, with sensible steps, long term you’ll really improve and conquer pain

They seek out new fun things


If you become bored you will make things awful. If you lock yourself away with your pain it will escalate out of control. Find and remember those enjoyable things: look at new hobbies, learn a language, dance , garden have some fun!

Learn some stress busters


Learn how to relax. As much as it sounds like tree hugging hippy nonsense, some breathing and relaxation exercises, getting outside to suck up some vitamin D, and Earthing yourself can really help.


Accept you need to help yourself


The faster you can stop obsessing about miracle cures, getting more pain killers, hanging on for that new clinical trial, the faster you will practically take the steps you need to recover:

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The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 

The top 5 things that keep you in pain

Once you have tweaked your back a few times, you stand a good chance of dragging yourself down into a pain cycle. Here are the 5 things people who suffer from pain do.


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If you become sedentary it will start a cascade of bad stuff: your sleep will suffer, you’ll weaken your muscles meaning you’ll slide towards a boring disabled lifestyle, with a loss of control over your daily life. The more you sit and do nothing, the more you focus on your pain. The worse it becomes


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taking advantage of any easing of pain to work yourself to exhaustion, or into pain. This means you need to collapse until you recover. When you have recovered a bit, you slog through loads of work until you are exhausted or in pain. This leads to worse pain and declining physical fitness


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once you have taken time off work, and given up your hobbies, you get bored. Your pain will expand to fill the day


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Stress. is the ultimate multi-tasking sensation: it can make you avoid activity, avoid friends , edge out loved ones: it can make you feel helpless and hopeless. It can lay the foundations for arguments and anger, and given time will deliver you mental health issue such as anxiety and depression


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Rather than simply doing the basic combination of stretches, smashes, movement education and strengthening that I can show you, You start obsessing about a “cure”. You chase your doctor for a magical MRI or a spinal fusion , even if you know that only 1 out of 250 MRI’s show anything remotely useful, and normally leads to a recommendation to stretch and build your core.

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The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 

Needless treatments: spinal fusion surgery for lower back pain is costly and there’s little evidence it’ll work

This article is republished under a Creative Commons license. Read the original article here. It was written by Gustavo Machado, Christine Lin and Ian Harris.

From time to time, we hear or read about medical procedures that can be ineffective and needlessly drive up the nation’s health-care costs. This occasional series explores such needless treatments or procedures individually and explains why they could cause more harm than good in particular circumstances.

Back pain affects one in four Australians. It’s so common, nearly all of us (about 85%) will have at least one episode at some stage of our lives. It’s one of the most common reasons to visit a GP and the main health condition forcing older Australians to retire prematurely from the workforce.

Treatment costs for back pain in Australia total almost A$5 billion every year. A great proportion of this is spent on spinal surgical procedures. Recently, Choosing Wisely, the campaign to educate medical professionals and the public about tests, treatments and procedures that have little benefit, or lead to harm, added spinal fusion for lower back pain to its list.

This is because, despite rates of the procedure being on the rise, current evidence doesn’t support spinal fusion for back pain. Randomised trials (regarded as studies providing the highest-quality evidence) suggest spinal fusion has little advantage over a well-structured rehabilitation program, or psychological interventions, for back pain.
What is spinal fusion?

Spinal surgery is most commonly performed to remove pressure on nerves that causes pain and other nerve symptoms in the legs. This surgery is called decompression. The next most common procedure is spinal fusion, where two or more vertebrae are joined together (using such methods as transplanted bone from the patient, a donor or artificial bone substitutes) to stop them moving on each other and make one solid bone.

Spinal fusion may be performed for fractures, dislocations and tumours, and is commonly performed in conjunction with decompression. For back pain, it’s performed when the origin of the pain is thought to be related to abnormal or painful movement between the vertebrae (from degenerative joints and discs, for example).

Rates of spinal fusions have been rising and continue to increase, outstripping other surgical procedures for back pain. In the United States, rates of spinal fusion more than doubled from 2000 to 2009. In Australia, rates increased by 167% in the private sector between 1997 and 2006, despite almost no increase in the public sector.

Spinal fusion rates differ significantly between regions of Australia, with the highest being in Tasmania and the lowest in South Australia: a seven-fold variation. Significant variations are also seen between countries. For instance, spinal fusion rates in the United States are eight times those in the United Kingdom.

The greatest increase in the use of spinal fusion has been in older Australians, often in conjunction with decompression surgery for spinal stenosis – a condition that causes narrowing of the spinal canal (the cavity that runs through the spinal cord).

Differences in clinical training, professional opinion, and local practices are likely to play a role in such variations.
Evidence for spinal surgery

There is little high-quality evidence to support the use of spinal fusion for most back-related conditions, including spinal stenosis. And there is disagreement between surgeons on when spinal fusion surgery should be performed, not only for back pain but also for more acute conditions such as tumours and spine fractures.

There have also been no studies comparing spinal fusion to a placebo procedure. Most research to date compares one fusion technique to another technique or to a form of non-surgical treatment, so we still don’t know whether spine fusion is effective against placebo.

We also know that spine fusion surgery is expensive and associated with more complications than decompression surgery. And the surgery often fails. Around one in five patients who undergo spine fusion will have revision surgery within ten years.

Research also shows most patients having spine fusion surgery under workers’ compensation won’t return to the usual job, will still be having physiotherapy and be on opioid medication two years after surgery.

So why are rates going up?

There are several factors, including an ageing population, that may contribute to the rapid increase in spinal fusion despite the lack of evidence supporting its use. Financial incentives might also explain the differences in rates between private and public sectors in Australia and between the United Kingdom and the United States.

We don’t have high-quality evidence on the benefits and harms of spinal fusion. This means there is uncertainty, which allows practitioners to continue doing the procedures they were trained to do unchallenged. This then leads to overtreatment, particularly where reimbursement rates are high, such as in the workers’ compensation setting.

Uncertainty about the appropriateness of spine fusion results in practice variation, wastes scarce health care resources and leads to worse patient outcomes.

We need better research in this area. This means research efforts should shift from studies looking at different ways of performing the surgery and focus on investigating whether or not it works better than non-operative treatments or a placebo, and, if so, whether the benefits outweigh the harms.

In the absence of such evidence, patients can consider other evidence-based and less costly treatments, such as exercise, cognitive behavioural therapy and physiotherapy.


The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 

Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

“Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?: A Longitudinal Case-Crossover Feasibility Study”. Is a useful report as we continue to make the connection between, excessive sitting  and back pain.

The big question was this: whether physical activities trigger flare-ups of pain during the course of acute low back pain (LBP).

The conclusion:

Among participants with acute LBP, prolonged sitting (>6 hours) and stress or depression triggered LBP flare-ups. PT was a deterrent of flare-ups.

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The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here 

But what if your back pain is extension based

Too many of us are obsessed with  flexion driven back disorders. Which  is fair because most cases of back pain  are flexion based.  However, not all of them are. Some are because you are over extended, and frankly, you need some  careful flexion in your life, and back.

Until I produce a good guide, here are some useful thoughts  from

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Piriformis Syndrome

There is a sneaky little muscle in your bum that often makes your back , or legs hurt.

It’s sneaky as, whether or not you have a booty or a skinny ass,  its a muscle that hides underneath the big ( or skinny?) obvious bits.

It creates a lot of mischief. So Voila, the piriformis is the muscle to blame. Its this muscle that I’ll often try and find and “trigger point” if I see you acting  or moving in one of many ways. If you are going to have back pain,  you might as well understand the anatomy

So this is where it lives.

piriformis location

When I’ve found it, here is where I’ll try and press

Piriformis points

I’ll often press or rub each point with my thumb about 10 times. Often I’ll try and teach you how to find these points with a Lacross or massage ball.

Obviously, there are other muscles in this area that I’ll identify and treat, but this is often the cause of a lot of back pain

Well, thats why Ive probably shoved my thumb in your bum!

If you have back pain, do get in contact and I’ll see what I can do to help.

I do a lot of work with the Backaholic programme at Crossfit London in E2 , and I help people cure there back pain. Strangely Im just a massage therapist, but as I teach people to olympic lift,  clamber over objects and do lots of cool  gymnastic stuff, Ive been forced to deal with the bad backs my clients bring to their sessions

The big warning.
Some back pain is really serious: check your RED FLAGS by clicking here