August 7, 2012

Nutritional biochemistry

What does lower back pain have in common with low carb eating?

Read Time 8 minutes

Strange question, huh? Before you get too excited, I’m not about to tell you that a low carbohydrate diet is a remedy for back pain.  Instead, I am going to explain a remarkably parallel experience I’ve had. I never made the connection until this week when a reader asked an unrelated question about lower back pain.

The best, worst experience of my life

As my third year of medical school was winding down, and I was just about to embark on a bold fourth year curriculum of back-to-back-to-back-to-back surgical sub-internships, I was on top of the world.  I was 27 years old, living in Palo Alto, California with my best friends, I had a wonderful girlfriend, I was working hard to prepare for my application to a surgical residency, and I still found time to work out like a wannabe Olympian.  What more could I ask for?

One sunny, June afternoon I got out of the pool after a good workout and felt a very strange pain in my lower back.  After riding my bike a few hundred yards to the weight room, it wasn’t getting better.  Actually, it was getting worse.  So bad, in fact, I did something I’d never done before – I decided to skip my workout and pedal home.

I iced my back, took some ibuprofen, and went to bed.  The next morning I woke up only to realize I literally could not get out of bed.  After struggling for some time I had to call my roommate to get me out of bed and help me to the bathroom.  I called my chief resident and apologized that I would not be able to come in to the hospital that day, and assured him I’d be fine the next day.  But I wasn’t.  Nor was I fine the day after or the day after.

A few days later I managed to limp my way into the hospital for rounds and with the help of the residents and nurses who were kind enough to give me intramuscular injections of a potent drug called toradol, I was able to survive, just barely.  The pain had gotten worse over the week and I was unable to sleep in any position except lying face down over a counter in an “L” shape.  But the worst was yet to come.

Within a few more days, not only was my back hurting, but I was also experiencing profound sensory pain in my left leg and left foot.  I realize this may sound hyperbolic, but I am not exaggerating at all when I say it felt like the skin was being torn off the bottom of my left foot.  The only way I could sleep was to tie my left foot in a plastic bag of ice to numb it and take 100 mg of Benadryl (enough to put a horse to sleep).  When the ice melted, I would wake up in pain and need to repeat the routine.

Within about 3 weeks of this back and leg pain, I was starting to worry that something very serious was going on.  I’d had a backache or two before, and in one case it even took a week to resolve.  But this was very different.  One night, when the pain was so bad I couldn’t mask it with any cocktail of drugs I finally relented and went to the ER.  After a thorough exam, the physician sent me to the MRI scanner (for those of you reading this outside of the U.S., it must sound crazy to think that a patient could have a MRI scan so quickly).

The MRI showed not only a large herniation of my L5-S1 disk (a bulging of the disk between my L5 and S1 vertebrae), but it also showed a free fragment of broken disk sitting directly on the S1 nerve root.  While the large bulging disk was likely the cause of my back pain, the free fragment pressing one of the largest nerves in my body was undoubtedly the culprit in my leg and foot pain.

The next morning I was taken to surgery by a (supposedly) talented and reputable neurosurgeon.  I was actually very relieved and excited, despite never having undergone surgery or general anesthesia before.  I was told this surgery would fix the problem immediately.  But it didn’t.  In fact, as it turned out, this was the beginning of a long, sordid ordeal, albeit with a positive take-away that is the point of my story.

I woke up from surgery and immediately realized the pain was still there, in my left foot.  Worse yet, I had trouble moving my right foot, which was completely fine before surgery.  Over the next few days it became clear I had developed something called a foot drop on my right side.  I would later learn the surgeon had operated on the wrong side and likely injured the nerve on the right side. Things had gone from bad to worse.

Compounding this, the surgeon who operated on me refused to believe my description of what I was experiencing and was convinced I was just being “soft” for complaining of persistent pain and a new problem.  After 2 weeks of further deterioration — and only when another physician examined me, and herself ordered another MRI — did my surgeon agree I still had a significant surgical lesion.

That night I went back to the operating room and, this time, operating on the correct side, the surgeon removed a 4-centimeter fragment of disc from my spinal canal that was still compressing my S1 nerve root (below).

back pathology specimen

The next three months proved to be what I would later describe as the “best, worst” experience of my life – an assertion I still maintain nearly 15 years later.  For a number of other reasons and complications I suffered that I won’t detail here for sake of time and space, I became completely debilitated after developing another complication called a facet arthropathy.  So much so that my mother flew to California to stay with me, just to feed me and drive me around to endless doctor appointments.

My dream of becoming a surgeon had quickly vanished along with any athletic aspirations I once had.  I worried whether I’d ever walk again and had begun to accept the fact that I may be addicted to pain killers for the rest of my life. [For anyone familiar with such medications, I was taking about 200 mg of oxycodone per day – about 40 times what a “normal” person would take following a painful dental procedure.]

Things I once took for granted – walking, being able to lean over the sink while brushing my teeth, sneezing without feeling like my kidneys were being ripped out – became distant and fading memories.

Fortunately, with the help of some remarkable doctors (which included several more trips to the operating room), kinesiologists, and physical therapists, I would slowly learn to move again without pain.  I had to train as hard and deliberately for this as I had for every other athletic endeavor I’d ever poured myself into.

I experienced firsthand what narcotic withdrawal is like and the depression that accompanies it.  I experienced firsthand what an arrogant surgeon can do to a patient.  I learned more about medicine in that year than at any other time in my medical training.

As a postscript to this story, I eventually made a remarkable recovery and was able to begin my surgical residency a year later with minimal pain.  Today my back is stronger than it was before this incident. Except for the few people I have shared this story with (until now), no one would ever know what I went through.  I move through the world like someone with a perfectly healthy and strong lower back.

I also gained a profound understanding of pain and addiction, which became one of the most valuable lessons I carried with me through my brief medical career.  It allowed me to understand what a heroin-addicted person goes through, when viewed through the lens of my own experience with the strongest painkillers.

A few years later I would become close friends with Drs. Marty Makary and Peter Pronovost when our paths crossed during my residency at Johns Hopkins.  Marty and Peter have become two of the biggest pioneers of patient safety and the avoidance of medical mistakes.  My story became one of many presented in Marty’s soon-to-be-released book, Unaccountable.

Years later, based on my experience and research I did while overcoming this injury, I gave many talks on the treatment and prevention of lower back injuries and have become a minor expert on the subject.  If anyone is interested, here is a link to one of my presentations (slides only, no video/audio).

What does this have to do with a low carb diet?

Today, when I pick up anything, whether it be a cotton ball or a piece of paper, I do it with my legs, not my back.  When I lean over the sink to brush my teeth, I support the weight of my torso with my arm.  When I get out of a car or out of bed I position myself not to torque my back.  When I need to lift a 265 pound barbeque out of my car, like I did a few months ago, my lower back is never under strain.  How did I learn to do this?  Through a very deliberate and long process of adaptation.  I had to re-learn how to move, how to sit, how to lift, how to sneeze.  Were it not for the long and painful road to recovery I endured, I may have never learned these things.

Many people who suffer back injuries never really recover.  When they do “recover” from one injury, the rate of relapse is very high.  While no two cases are identical, much of the reason for this lies in 2 factors:

  1. The injured person does not learn how to modify their behavior to avoid re-injury.
  2. The injured person does not take the necessary steps to strengthen and rehabilitate their back.

“Curing” a back injury is not a temporary thing or something that just happens because we wish it to be so. It is a very deliberate lifestyle change.  Over time, as we form habits, we can go from consciously thinking through every necessary behavior change – something easy to do when we are in pain – to a place where the behavior is more automatic. But this takes time.

In many ways, transitioning to a low carbohydrate diet is similar.  Consider the figure below.

4 stages

Just like with behaviors that predispose us to lower back injury, most people go through life just eating on autopilot, but eating the wrong things, the “default” things.  They graze in a reactionary manner without any understanding of how what they eat impacts their body.  They are eating in an unconsciously incorrect manner.

Many people learn that what they are eating is actually not ideal and not predisposing them to maximum health.  They move into a place of consciously incorrect behavior.  They realize drinking a Coke with fries and a candy bar is not good for them, despite still eating them.  Some of these people go one step further and actually make corrections – removing sugar and simple carbohydrates from their diet, for example – but doing so requires great effort and deliberate action.  They are now in the realm of consciously correct eating.

This is the place where most people get stuck.  It hurts.  It’s hard to do.  They get frustrated.  Maybe even ridiculed by friends and family.  Most turn back to consciously incorrect eating with brief periods of re-visiting consciously correct eating.  Hence, only a few people make their way into the final stage of unconsciously correct eating, just as only a few people with serious back injuries ever make it into a state of unconsciously correct movement.

Why?

Because it takes a lot of time and a lot of effort.  It’s different for everyone, but I know for me it took almost 2 years to get to the point of unconsciously correct eating.  I had spent 36 years mindlessly eating the wrong way, just as I had spent 27 years mindlessly moving the wrong way before injuring my back.

Sixty years ago it was quite easy to default into the correct way of eating because we were mostly surrounded by foods that supported such eating.  But, our food environment has changed dramatically and today’s default eating (e.g., high amounts of sugar, grains, highly refined carbohydrates) puts most of us – about 60 or 70% of us – at serious risk of metabolic disease.  One day, I believe, the work of NuSI and others will fix this problem, and through the elucidation of unambiguous science allow us to create a food environment that supports easier (and more affordable) default eating of the right foods.   However, until then we have to go through these stages.

If you find yourself feeling frustrated at how difficult it is to get from consciously eating well to unconsciously eating well, remember that you are on a journey.  If you are consistent and patient, if you remind yourself that you are embarking on a journey to change your life and not a short-term fix to look good in a bathing suit next month, you will embrace the right mindset to find the ‘sweet’ spot of unconsciously correct eating.

I will be the first to admit that this is not easy.  But, if you’re reading this, you’re already down the path and you’ll be better able to help the next person who struggles through the 4 stages of transition because you’ve experienced it yourself.

Photo by Meta Zahren on Unsplash

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285 Comments

  1. Peter,
    This article is a godsend. Your story moved me almost to tears. As someone who literally just started a low-carb diet, this helped a great deal. It’s also wonderful to see how a trial in your life became a blessing. So often the hardest moments in life become the moments of greatest learning, and we begin to empathize more with others. One of the biggest problems with doctors, it seems, is a lack of empathy. I bet this gives you an age in dealing with obese patients.

    • Susan, your comments move me, also. There’s a big difference between empathy and sympathy, as I can tell you understand. It’s much more important for doctors to have the former, though some lack even the latter.

  2. Peter: It was amazing story and I give you all the credit in the world for making through that period in your life. I’m sure many don’t have your strength.
    I am at a point where it is tough for me to stick to a diet similar to yours. I seem to get bored and also wonder if I really need a diet that extreme. Your wife can handle carbs and I have no reason to believe I can’t since I have not evidence I am prone to insulin resistance.
    Do you have any comment to this short bit of evidence of the downside of a high fat? diet:http://web.mit.edu/press/2012/sirtuins-may-protect-against-diabetes.html

    • The strange thing about this study was the opening sentence, which said ” A protein that slows aging in mice and other animals also protects against the ravages of a high-fat diet, including diabetes, according to a new MIT study”
      I wasn’t aware that one of the ‘ravages of a high-fat diet’ was diabetes.

    • Peter- an enigmatic answer- Do you mean to say that the link between a high fat diet and diabetes is so well established that the link is ‘bulletproof’? I had thought that a high carb diet, rather than a high fat diet, was linked to diabetes.

    • Peter- in looking at another site I saw a reference to a Wikipedia entry called “Poe’s law” which recommended visual clues that a statement is sarcasm. Interesting entry.

  3. Brilliant chart going from unconsciously incorrect to unconsciously correct. So many applications to our daily lives. Great insight Simplifying what can be a long and important process for self improvement/help and life. Thanks

  4. But should we ignore every study that involves mice? Why are they done?
    Regarding the first part of my question, is a ketogenic appropriate for everyone? If not, who should and should not be on that diet.

    • To your first question, no. Some things done in mice make sense. Toxicity studies, for example, if the dosages are reasonably matched and the mechanism of action the same (e.g., cyanide). But for too many things (e.g., aspartame, chemotherapy), the results have little meaning. To your second question, also, no. There are probably many people who do better on a diet other than a ketogenic diet. Furthermore, even a single individual may do well on a KD for some thing and not others. It depends on your genetic make up and your goals.

  5. Hi Peter,

    I added up my gram totals again and averaged it out over the 34 days I have been keeping a record. My Protein total is 3,274gm for a 34 day period, which averages 96g/day. My fat average is 2,160gm for a 34 day period giving me 64gm/day average. Calories averaging (slightly hungry, but satisfied) 1169cal/day.

    As for stages, I am definitely at S3, Consciously Aware. I started this lifestyle change on February 7, 2011. For me it was a medical scare of rising glucose and BP. Even though I have not looked back at the sugar, grains, flour, pasta, I have continued to roller coaster as I try to figure out what percentages work for me. These last 34 days I have given up most dairy (except my heavy cream in my coffee). Believe me, I would live on nuts, heavy cream, cheese, and sopresetta blissfully, but as my brother suggested, perhaps (?) not just yet.

    Okay, neurotic, but conscious vent/ question here: are not carbs equal to 9cal/1gm? So 50 would mean 450cal. I have fought very hard for these 9lbs. I would be disheartened to give them back. My chart tells me weight loss is happening at the 96gm Protein/68gm Fat and 19gm Carb. Granted, it has been a very hard 34 days.AND I definitely welcome the input. I know, I am relying too much on the calories, old habits die hard, but I am consciously aware, I just want to get out of the double digit 200’s..

    Okay, venting out of the way. I will apply this formula for the next 34 days and see what happens.

    Thank You
    Ellen

    • Hi Ellen –

      I have been working this diet for almost a year, feeling great, lost a lot of weight at the start and then plateaued. I was consuming almost entirely eggs, heavy cream in coffee, some nuts, cheese and meat, along with butter and olive oil.

      I got really annoyed at my plateauing and decided to drop the dairy, as I read at one of the paleo sites (perhaps marksdailyapple) that some people have hormonal-like reactions to dairy. The way I’m eating now, I really don’t care what exactly I eat as long as it fits the program, so dropping cream from my coffee was more a psychological issue than a dietary one. But I figured I had already gone so far on this lifestyle and don’t want to go back, so I said goodbye to dairy. Weight loss has started again. I’m thrilled.

      As a coffee with cream lover for most of my life, I hated to drop dairy from my coffee. I found out that if I drink it iced instead of hot, I really like it a lot. I tried cream in my coffee the other day, thinking I deserved a treat, and found to my surprise I didn’t like it.

      Good luck.

  6. Peter,

    Thanks for this! One of the best things I take away from your blog is looking at month-to-month and year-to-year transitions. Many of the experiences you describe take a long time, and start with just gradual improvement. (“I can brush my teeth without pain! yay!”).

    Sounds like a blinding flash of the obvious, I know, but many of us have spent a long time in the mode of “today I’m going to diet and exercise and do EVERYTHING different!”. It’s good to see that in most cases the process is more like, “Today I’m going to do ONE thing different… and keep it up tomorrow…and the next day…and then maybe add another thing…”

    The other thing that’s particularly helpful is knowing that you’ve been able to overcome the woulda/couldas. By which I mean, going from near-Olympic quality sports performance to being happy to move without pain is hard mentally—you must have caught yourself thinking, many times, “Damn it, if this hadn’t happened, I coulda been…..”

    Learning the ability to focus on improving the future rather than dwelling in the subjunctive tense is very important–and difficult!

    Thanks again!

  7. So how does one determine genetic make up? Is it simply a matter of personal experimentation?
    Can a particular diet work for a period of time and then become less effective? Could you see altering your diet at some point?

  8. “it must sound crazy to think that a patient could have a MRI scan so quickly”

    Ha. Not at all! When I showed up at 10 p.m. in my local ER (having just flown back to Georgia from California lying on the floor ahead of first class (and wasted a first class ticket {sigh}), throwing up and in agony from a kidney stone) — they were VERY happy to throw me right into a scanner — and then charge me TWELVE THOUSAND BUCKS for the privilege!! (Uninsured, so I really get socked with the medical bills! There are no negotiated breaks for the uninsured!) We negotiated it down (later) to a “mere” four thousand bucks! (It’s often the case, if you have a hammer (MRI machine) you want to — and need to ! — hit things with it to pay it off!) {frown}

  9. Darn, I thought you were going to conclude that eating less carb would fix my back!
    I have a 30% slipped L5 and was able to stabilize it with a consistent yoga practice. I’m still running, biking and swimming so I guess it works!
    I loved this article because I know people in all four stages – it does take time to go from one to the next – I think it’s more of being able to emotionally go into the next stage…

  10. I feel very confident with the low carb approach and have followed it for years. It is definitely “unconsciously correct” for me. However, I am plagued by two troubling symptoms when I remain in ketosis. My eyes become dry (very bothersome) and I have episodes where I feel like I’m going to pass out. To me, this seems like dehydration from not enough insulin (can’t hold onto fluid), and I feel better when I eat more carbs. I have tried adding salt but it doesn’t seem to help. Also, I had my insulin checked, and, like yours, it was <2. Any thoughts? Thanks!! Love your blog.

  11. Thank you for the insightful article! I very much enjoyed it! I have been a physical therapist for 24 years and what I have observed is that when people eat carbs of high inflammatory potential ( sugary drinks, sweets, pastas, refined grains, etc.) there is often a noted increase in pain. I have observed this consistently in low back pain, adhesive capsulitis, neck pain, knee pain and hip pain to name a few. Likewise, when I see clients who do well and ask them about their diets, they often eat low carb….this lead me to go get a Master’s degree in Human Nutrition.

    I hypothesize that refined carbs in any form may actually increase inflammatory cytokines that stimulate pain receptors that are already sensitized by chronic mechanical dysfunction. As physical therapists, we have not yet fully recognized the new definitions of inflammation. Rubor and colar are still the emphasis of PT schools. There is little if any education on inflammatory cytokines. This is a mistake in my opinion.

    There is documented evidence that IL-6 receptors antagonists will help block pain in musculoskeletal issues. Agonist treatment is followed by….you guessed it, low carb eating, sun exposure, exercise and adequate sleep. The outcomes are often successful. This treatment is only available in Germany currently but soon to come to the US.

    So, my point is this…there may be a correlation to low back pain and low carb eating through the avenue of reduced inflammatory cytokines level. And the key is that the systemic reduction in cytokines may decrease the upregulated pain receptors in an area that does indeed have mechanical dysfunction of a chronic nature. Though I have tried many times to interest a university PT program to study this with a medical team, my attempts have not been successful. Maybe the NuSI (? spelling) would be interested some day in the future?

    My thanks again! I was excited to read your experience and glad you are doing well now!

    • Tammy – Two weeks ago I had a high impact fall that resulted in a hip fracture. I have experienced exactly what you report – very little pain. The doctor and nurses and physical therapists were all surprised by how little pain meds I needed after surgery, and they said I had a high pain tolerance, which I don’t believe is true. But after reading your post – I wonder if it’s because I’ve been low carb for two years now. What an interesting theory!

  12. you might want to check out Dr. Sturart McGill who is one of the foremost experts on backs. Pro athletes,etc with back injuries seek him out. He has you tube video’s.
    did you require a fusion? sounds like a large chunk of the disc moved in to the spinal canal.

  13. Peter,

    Very interesting parallel between these two aspects of your life. Not sure I would have thought of it like that, but it really does resonate. Last fall I had the (unpleasant) experience of waking up and not being able to get out of bed due to a spinal problem. My issue was with my neck and turned out to also be facet arthropathy, though at C4-C5, and spondylosis. I was unable to turn or tilt my head at all and it came out of nowhere. After a course of physical therapy, muscle relaxers, anti-inflammatories, (and buying a new bed!), I’ve been able to learn to be cognizant of my posture more often and have greatly alleviated my symptoms, which included severe neck pain, along with radiating pain across the shouler blade out into my left shoulder pretty much whenever I tilted or turned my head.

    However, most of the improvement has come since February, when I really started (reading your blog and) committing to eating better and getting back to the gym on a regular basis. Since that time I’m down from 220 to 195 (I’m 6’4″), have re-strengthened the muscles important to stability in my neck, including my shoulders, which were quite out of shape since my 2004 right rotator cuff surgery, and am generally in much better shape than I was before that time (and I kind of need a new wardrobe that fits my new physique!). All of this is primarily due to the factors that you have described here for both things; not unconciously making the wrong choices (eating and posture) and consciously making the right choices (very little sugar or simple carbs, sitting upright), and even sometimes unconciously making the right choices!

    So for two things that would have seemed so unrelated, the principles are actually quite common and, for me, actually have a lot to do with each other. As an aside, I also happen to be an attorney and practice a lot of medical malpractice defense. Without getting into the quality of the treatment you received initially (and trust me it’s hard for me not to comment on that), the injuries and conditions you describe are certainly very significant and you are quite fortunate that the damage you sustained was able to be overcome through hard work and dedication on your part, as well as with the help of good treating providers (and mother!). Sorry to hear you had to go through that, but glad that you perservered and reflect on it as at least a partially positive experience!

  14. Hi Dr Attia,

    I’d really like your thoughts as to whether you think deadlifts and squats ought to be avoided. Obviously poor form and too much weight are a forumla for injury, but what about moderate weight w/ good form, or even heavy (say, 5 rep) w/ good form?

  15. Great article. Very inspiring.

    For me, low carb diet has a more direct connection to lower back pain. About 4 or 5 years ago I started to consistently injure my lower back every few months. After the 3rd or 4th time this happened I went to a doctor. He examined me and said “You’re basically OK, but for this to stop happening you need to do two things. First, I will show you a few exercises to strengthen your lower back. Second, you’re too fat. Lose some weight.”

    I did both (with the low carb diet helping a lot in the latter) and have had almost no troubles since.

    I wouldn’t be surprised if for many people the easiest thing they can do for their back is to go on a low cab diet, lose some weight, and put less strain on their body. I’m sure you know much more about this than I do. I only mention it because I was surprised you didn’t make the connection between being overweight and having back pain in your article.

  16. Hey Peter,

    I’ve been reading your blog since you launched “War on Insulin,” but this is my first comment. I believe my girlfriend Bianca, med student at MCG in Augusta, has connected with you a couple times.

    I played division 1 football as a linebacker in college. As I’m sure you know, linebackers have the shortest lifespan of any position due to the frequency of high-impact collisions and violence that is required. I herniated my L5-S1 disk my freshman year and thought my career and dreams were over. I tried everything in my power to avoid invasive surgery because one) I knew the success rates were poor and two) surgery would have taken me out of the game for potentially a year and a half. Somehow I got connected to a world class pain specialist and a noninvasive medical treatment called Prolotherapy. Check it out here: http://www.treatingpain.com/diagnosis-and-treatments/prolotherapy.html.

    Have you heard of prolotherapy or platelet rich plasma therapy? Long story short, prolotherapy saved my life and my athletic career. I was able to finish my career playing linebacker at an elite level as well as continue to pursue physical fitness after college: crossfit, triathlons, etc. The pain and discomfort has never come back to where it was before Prolotherapy, and I just feel like the whole world should know about it’s potential

    • I underwent 9 or 10 rounds of 60-70 spinal injections from T12 to S1 over the course of a year to treat my resulting facet arthropathy. Alone, this was not enough, but it made the most important step in reducing my pain enough to do adequate rehab.

    • Blake I am also a former college football player. I hurt my back two years ago lifting weights and hasn’t been the same since. My chiropractor wants me to do the prolozone injections. I was wondering how many injections you went through before you felt relief? Also if you could tell me more about specifics of the injections and treatment and resulting therapy I would really appreciate it
      Thanks!
      Tim
      [email protected]

  17. I’ve been meaning to comment for sometime, as I discovered your site last February, while already well on the path you’ve mapped out (having read Good Calorie, Bad Calorie cover to cover). I have found your site very informative. Your story of the back surgery was the tipping point as I underwent an L5-S1 hemi-laminectomy/discectomy 25 years ago at the age of 20. I have gone on to enjoy a host of physical activities including swimming, tennis, skiing, and weights, but was a “chubby” fit person at 211 pounds two years ago. I was already low carb in February and down to 192, but have been in ketosis now for the last six months and now down to 178 pounds, my BP which was in the range of 148/95 is now averaging 122/72, and everything is right with the world! As a Canadian litigation lawyer, who adopts a critical eye and careful analysis to the things I read, see, and hear, I am well satisfied, based on all my reading and my own self-experimentation, that this is the way to go for someone like me who is very sugar sensitive (with a family history of diabetes, heart disease, obesity, and high BP). Keep up the excellent work (if you can, as the schedule must be grueling) and know that you are truly making a difference in society.

  18. Thank you, Lorraine, for sharing some details of your unique journey. It was most interesting reading about your experience.

  19. I have to second Steve’s recommendation for anyone with lower back problems, especially lumbar disc herniation, check out Dr. Stuart McGill’s work. He is the absolute highest authority on back rehabilitation and has led much of the newest research. Even if you’re an athlete who has never had a back problem I would still recommend his performance book just for the physics of how the torso works in all types of athletic movements and how to maximize efficiency and prevent injury. http://www.backfitpro.com

  20. this happened to me too! ruptured the L5S1 twice, actually… i laughed about the part of you picking up things with your legs/feet and propping your upper body weight on your arms, lol no one seems to be connected to what life is like after back blowouts. your story is almost identical to mine, except what i lost was a nursing career, and it was a lot of work, so i was devastated. but there simply was no bedside care, or 13hr shifts on my feet after those surgeries. thanks for sharing, and i agree, low carb is the best thing a person who is limited with cardio exercise can do for overall health and energy levels.

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