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. When I saw your TED talk many, many months ago, I cried. Not hard for an old man to do. But to see a doctor who was questioning the standard American diet on a TED talk was truly something to behold. I became an Atkins dieter and advocate in 1995 and have made low carb dieting my way of life ever since. It has been rough. Every doctor I have ever had, has beat me up for it, despite my very good lab numbers with the exception of cholesterol which was 240 when I was first tested in my late 20’s.

    I also ruptured L4-5 at the age of 27 and it took two years to diagnose. I underwent a chemonucleolysis ( a procedure that the do not do anymore – a chymopapain injection dissolves the nucleus of the disc) at the age of 32. It was 4 years of suffering right after I got out of law school. Then at the age of 48 it ruptured again and I had to have surgery this time. My doctor spent an hour and a half pulling disc fragments out of my spinal canal when it shattered. For nine months I was on extreme pain killers. I represented hundreds of people with back injuries over the years (I was a personal injury lawyer for 35 years before I retired) and I could relate.

    So we have experienced some of the same things. My father was a PhD in biochemistry and taught med school and graduate school for about 40 years. I chuckle when you talk about your biochemisty books and courses and the disconnect that biochemists seem to have with other fields of medicine. My brother is also a PhD in BioPhysics but did biochemistry at a number of university for 30+ years till he retired. So biochemistry is something that is hardwired into our family. I enjoy reading about it all the time. And I really enjoy your blog.

    I would like to say a couple things about my 18 plus year experience with low carb that you might appreciate. My father told me when I decided to go Atkins it would work. He understood the biochemisty and explained that Atkins was right about the metabolic advantage of dietary ketoisis, although he was not sure about the safety. But I showed him what Atkins had said about the difference between diabetic ketosis and dietary ketosis and my dad said said it made sense to him. So I tried it. Atkins believed dietary ketosis was a natural state.

    Ironically, I truly became convinced Atkins was right one day while waiting in a doctor’s office (probably one who was going to beat me up over low carb). I picked up a National Geograpic and began to read an article on orangutans. What immediately caught my attention was the the authors noted that these orangutans had ketones in their stools 6 months out of the year! And this was Borneo. Oranutans are vegetarians. If there was any place on earth where a vegetarian ought to be able to get enough carbohydrates all year long to avoid ketosis, Borneo was it. And yet they couldn’t stay out of ketosis half the time.

    I have struggled to stay in ketosis and I now think it has been due to too much protein. I am just beginning to realize after 18 years that has been the problem. I have never struggled to eat low carb. I probably haven’t had 5 days of over a hundred carbs per year in all that time. Normally I am at about 30-50. So I started switching out proteins for fats about a month ago after reading Wheat Belly and Grain Brain.

    There is so much more I could say, particularly on the subject of estrogen excess as the other major cause of obesity. Carbohydrate excess and estrogen excess go hand in hand. Low testosterone is a real problem for older men and progesterone is the Rodney Dangerfield of hormones. I have taken bioidential progesteone topically for two years to block estrogen (mine was bordeline high and now normal) and to increase testosterone level (which was very low and now is in the midrange). You should read Ray Peat, PhD who is the guru of progesterone and who advocates men take it. (raypeat.com). Progesterone also makes insulin and thyroid more efficacious so you need less of them. And it has worked wonders as an anti-inflammatory on my back where I apply it daily (it is the precursor of cortisol/hydrocortisone as well as the precursors of estrogen and testosterone). When your back is bothering you, you would be amazed at the relief! And the side effects are progesterone are zero.

    As you know, pregnenolone, progesterone, cortisol/hydrocortisone, testosterone and estrogen are all produced from LDL the bad cholesterol. Low LDL can really effect these other hormones and Ray Peat believes reducing LDL can be a real problem because of it ( studies show low LDL reduces lifespan — I am sure you know). I began to wonder whether getting levels of pregnenolone, progesterone, DHEA and tesosterone or other hormones to youthful levels might effect LDL. Turns out getting these four hormones to youthful levels lowers LDL and raises HDL.

    http://www.ncbi.nlm.nih.gov/pubmed/21407165

    So I take them all in moderate amounts and do low carb and ketogenic.

    Sorry for the long post, but it was fun.

  2. Thank you for sharing your story. Its so frustrating when people dismiss your pain.

    I’m obese and I’ve always suffered from some back pain. Last year, for no obvious reason, I felt like I was being crippled with extreme low back pain. I woke up in so much pain, utterly confused why I was feeling this way. With no insurance from the job i had at the time, i suffered like never before. The pain continued for weeks, turning into months of agony. I would go to work and go straight home to bed. At work, sitting for 8 hours was impossible. I was always so uncomfortable. Actually, uncomfortable is putting it very mildly. I would cry at my desk in pain, I would cry at home in pain. I was miserable. Sometimes Bayer numbed the pain but it was always there.I really didn’t see an end in sight.

    I decided to embark on a low carb journey as a means to decrease my body fat (i was trying any possible solution to feel better). After eliminating bread and eating meat and veggies for 2 weeks… I suddenly realized my back pain was 90% better. I used to rush home and to bed but I finally had energy to cook and even take walks after work. I could stand in line at the grocery store without getting tears in my eyes from the pain. After another 2 weeks, I almost forgot how bad I was prior to low carb. Low carb was the only major thing different i had done. I’ve read that gluten causes a lot of inflammation in people so I theorize that I sustained a minor injury to my back muscles that dramatically worsened from the inflammation; it never allowed my back to heal. LC eating gave my body the chance to heal itself. Mind you, thats a theory from a accountant who likes to read and research, not a scientist.

    After going on vacation a few weeks after that I fell off the LC wagon. Periodically if i have a (minor, in comparison) back ache, I cut out gluten/carbs for a few days to a week. I have yet to suffer that kind of pain again. But now I’m prepping to get back on the wagon. LC gives me great energy and great sleep, a healthy appetite, mental clarify and sharpness, consistent BM, and it eliminates my fluctuating GERD symptoms.

    Thank you for writing about your story and about low carb. Too many of my friends think of LC as just a diet fad but it has been so much more to me.

  3. Thank you for sharing your story!
    Here’s mine…
    I was 30, 6’0″ 210 lbs. (boxers build), running most days and working the heavy-bag every day. I got married that same year. Well, we were happy and comfortable–VERY comfortable. So much so that I gained 73lbs from 2007 – 2012. Needless to say, I was waaaay out of shape. It never really was much of a problem until Halloween, 2012 I picked up a big log and threw it over my shoulder like HE-Man and tossed it onto a campfire. I thought nothing of it, only pausing to beat my chest like a gorilla and went to bed that night. Well, the next morning I immediately noticed a burning sensation running down my left leg. Progressively, daily the pain got worse until January 2013 I went to the doctor. He ordered a MRI which showed a herniated disk. No real option but to have surgery. I managed to make it to March 2013 before the procedure was absolutely a must.
    I had the procedure and immediately felt better but was unable to function normally–walk, sit, stand–it all hurt & recovery was rough but easy compared to some of the horror stories I’ve heard. Unknown before my surgery, I have a nerve configuration known as conjoined-nerve-root. This (I believe) slowed the healing down a bit.
    My doctor was very blunt with me and said if I didn’t lose some (significant)pounds, I had better plan on having he surgery AGAIN! AGAIN!?!? I thought, NO WAY was I going to feel that way again!!
    Well, August 1, 2013 I weighed in at 283 and through diet, slight exercise & a hell of a lot of willpower I am currently down to 221lbs! It wasn’t easy losing over 60lbs in 7-months but I feel it has changed my life! I haven’t felt this good in a long time and I owe it all to hurting my back (as funny as that sounds!).
    My only regret is I let myself get that far out of shape. The great thing is that my wife took the weightloss journey/challenge with me and has lost over 35lbs too!
    My point is, ANYONE can feel better but YOU have to decide that YOU want to feel better.
    Start it, Stick to it and BELIEVE IN YOURSELF!!

    Thanks,

    Chris

  4. Peter- your article on the back pain piece has really lifted my spirits! I’m 34 and had surgery end dec 2013 l4l5 and have had a horrid time with the recovery. I work in belgium and my mom also had to come take care of em and then after I came on my leave to the us in late jan after she had to go back to work…lying flat and all. I’ve been told my positivity and energy is contagious and I can’t tell you how many times I’ve been dejected that I couldn’t will my body to heal itself. I don’t sit for very long after a bit more than 2 m since the surgery. I did have one success- I slowly got myself off narcotics…. I’m amazed at how easily I get prescribed them and am very proud that I forced myself to use them only when absolutely unbearable. The lack of exercise has however not helped my weight and now I need to go back and start all over again, but since I’ve managed to relearn body habits, I hope to do the same with my diet again…. I just ink more light needs to be shed on back pain and post surgery recovery. Not enough people get it!

    • Peter,
      Thank you very much for this article.
      I am 30 years old and suffered a L5-S1 herniated disk just over 6 months ago. Reading your article has been a wonderful encouragement that I can make a full and healthy recovery in time.

      Other than posture correction, what other things do you attribute to your remarkable recovery?
      Also how long after your second surgery would you say it was before you felt completely healed?

      At the moment I am following quite a solid routine of physiotherapy with a focus on core strength. But i’m not yet at the point where I can comfortably squat or dead-lift weights.

      I realize it’s not your main area expertise but any advice or tips you could give would be really wonderful.

      Many Thanks

  5. Peter,
    Thank you for sharing this story. While I transitioned to a ketogenic diet over a month ago after a 3 month long medical ordeal following a “routine” surgery, that wasn’t what I found most valuable. There are so many days I struggle with why I’m doing this, especially since the results (weight loss, etc) have been minimally visible so far. You relating that frustration to the concept of the “relearning” that recovery takes resonates with me. Perhaps those times when I am watching my fiance eat all of the things I do not (but still sometimes miss) I will recall that I am just recovering in a different way now. I have to give my brain the time and effort it takes to relearn and heal just like my body. I’m just beginning this journey and admittedly have always been #1 a results driven individual and #2 impatient, which when combined make this a daunting undertaking indeed. Your site has been my “go to” for so much of this process both for the science (which is sometimes a little over my head but somehow comforting) and for inspiration. Thank you ever so kindly.
    Shanna

  6. After being on my own low carb journey for the last two and a half years, with much success but some pitfalls, your blog re-energises me and makes me think differently about my eating habits. I love the scientific content of your posts – and can appreciate them as a biochemist.

  7. Inspirational sharing Peter! Now, please pray for me who is trying to cure my back pain problem. Thanks for the great post!

  8. There’s a dark side to being consciously incorrect.

    My natural inclination is to eat high fat and moderate carbs ( I particularly dislike things that are too sweet).

    Over time the fake science of high carb low fat got to me in various ways and I tried to consciously “correct” my natural inclination. It never worked well but I tried.

    Now that I’ve consciously re-adopted LCHF, my auto-pilot is kicking back in nicely.

    LESSON: It’s OK to mistrust things that society tries to force on you, where it clashes with your instinct.

  9. Peter,
    Reading your Blog “What does lower back pain have in common with low carb eating?” took me back to the times when I had to experience similar fate as yours. Seven years after surgery ( it happened to me in a more advance age ), recently having been diagnozed with thyroid malfunction, I am now addicted to health and nutrition, not to mention the physical conditioning and am on a path of eating a somewhat similar diet as you are describing in your Blogs (no Sugars, low Carb).
    You are an inspiration and It would be grand to have an opportunity to meet you in person one day.
    Thanking you for all the great Reads that you are providing to your followers.
    Cheers.

  10. Hi there Peter,

    I enjoyed the above blog and am also in CLBP but as a physical therapist, I enjoy the ability to treat myself with Yoga, pilates, self tissue work and lots of running. I work with many companies trying to educate the employees in proper mechanics and home exercise programs to decrease risk of injury and loss of function.

    I hope you are using your back at least a little bit as disuse causes early arthritic changes and future loss of function.

    Adam

  11. Hi Peter,
    I need some clarification on this response you gave wrote some time ago:
    Ellen, that sounds like a lot of protein. What would those ratios work out to if you were, say, 50 gm/d carb, 100 gm/day protein, X gm/day fat (where X = whatever you need to not be starving)?
    I thought I understood but I don’t think I do. Should I calculate these in terms of ounces or caloric terms?
    Am I correct in interpreting it to mean:
    About 4oz. of protein or should I be thinking in terms of calories?
    Thanks for the clarification.

  12. Hello,
    Very interesting read. I am just now starting to learn about Low Carb and Ketosis and finding it hard to start. I had back surgery almost 3 months ago because my left leg and foot went numb and I could no longer walk. I had to quit working as well. 3 months out my leg is fine, but I am having such a hard time with my lower back. I can barely walk in the morning and I can barely walk after doing anything. (cleaning, mopping, etc.) I am also really heavy which does not make it easy.
    Right now I am feeling so hopeless. Thank you for sharing your story. Makes me believe I can do this and there is something that can be done.
    Angie

  13. Peter, we have a similar story. When I was 18, I developed a back infection that required 2 months to diagnose as an infection then 2 months of antibiotics, and 4 months of rehab for a total of 8 months of mostly lying flat on my back. 25 years later, and I finally found a way to eliminate most of my back pain, because most of the rehab exercises didn’t do the trick. I found isometric stretching, and it worked better with green smoothies. My theory is that the greens that are chelators help remove the heavy metals that can get into the joints and tendons. Well, I finally figured out an exercise that moves the lower back through the full range of motion while under tension. It’s like the light bulb finally went off in my head, and I’m wondering why nobody has ever done this before? See it here: https://www.facebook.com/video.php?v=10152872930974926

    • Jason, an alternative hypothesis to chelation is that the greens increased your omega-3/omega-6 FA balance, thereby reducing inflammation in your back. When I have flare-ups, I consume large quantities of leafy greens and fish oil, and I have also found that it reduces pain as well as blood markers for inflammation.

  14. I do occasionally suffer from lower back pain and when I do, even though it only lasts a few days it can be severe enough that I find it very difficult to move. I think at the moment I am definitely in the category of unconsciously incorrect, as when my back is not giving me any trouble, I do not actively do anything to make sure that the problem does not reoccur. I realize now though that I need to be thinking all of the time about how I can rehabilitate my back until it just becomes something that I do automatically.

  15. Thanks for telling your story! It is always comforting to know that others have had the same experiences that I am struggling with. When I was 21, I am 48 now, I had cancer in my lower back, hip and spinal column, this was brought on by radiation I received 4 years earlier, after removal of a benign tumor on my spinal cord. The entire area that was targeted in that radiation therapy was eventually over run with cancerous tumors. Parts of 7 back muscles, and parts of bone in my vertebrae and hip were removed with the tumors. I was a strong, but naive, 21 year old kid back then, so I did whatever the doctors and my parents told me. It took me three months to get out of the hospital and about a full year to walk with stability, but that was the easy part. I have lived a good life, great wife, great kids, great business, but it has all been under the dark cloud of addiction. I, like you, have taken between 160 & 200mg of different narcotics for the last 27 years. (Never smoked a cigarette, drank alcohol, or did an illegal drug before that, and to this day, that is still the same) I, unlike you, have not been able to beat the addiction. I would say from year 1-2 I took the Medication mostly for the pain, years 2-8 I took the prescribed medication for the pain and feeling of a high, 8-15 to stave off withdrawal, and years 15-25 to stave off withdrawn and as a crutch to help me focus on work, since year 25 I have been trying to cut back, I am down to 20-30mg a day. Also this past year, for the 1st time in my life, I have been trying to change my eating and exercise habits to lose weight. I have found that trying to cut back on the narcotics is very similar to trying to cut back on the calories. I was a 5’10” 280lb man on Jan 1st of this year, and as of today, I am 73lbs lighter. However, this alls seems to be coming with a heavy price. I have not been in this much pain since probably 1991. I don’t know if it is the walking I am doing now for the weight loss or the reduction in the pain meds, that I didn’t think we’re doing anything for my pain anymore, but something is amiss. I am always stressed out now, and I have never been like this my whole life, could those feelings be coming from the lack of calorie intake or the reduction of narcotic intake? Will they pass? Would it be better to a 280lb man, on 100-160mg of narcotics a day but be stress-free and happy again? It is nice to be complimented on how good I look due to the weight loss, but I feel like garbage 90% of my day. I was suppose to be getting healthier so I could enjoy my later years with my kids, but I am not enjoying anything now…

    Thoughts?

  16. Wonderfully informative post, as always! One question: what is your opinion regarding inversion therapy (e.g., inversion tables)? These are touted as releasing gravity-induced pressure on the vertebra, allowing disks to rehydrate, and therefore ideal for preventing and treating lower back pain. I’m a scientist, and therefore have been focusing on the medical literature rather than web testimonials, but there are very few studies that I could find. There are also presumably some potentially dangerous side-effects, such as increased BP in the eyeballs, but I’m not sure how serious this is if one is not doing a full-inversion (65 degrees, rather than 90 degrees) and if it’s only for a few minutes at a time. I know that I started slowly, and did feel pressure in my eyes, but after a couple of weeks I don’t seem to notice it any more.

  17. David,
    What luck to find you this week! Last Wednesday I had a trial spinal cord stimulator implanted (for one week) to treat the chronic pains in my L leg, very similar to yours. I had a spinal cord incident when I was in college (am now in my 50s), but have had a very normal life, physically, with minor pain. Over time, though, the pain has gradually grown. Now I have pain from my low back, groin, knee, calf, down to the tips of my toes. And yes, I have your burning in the sole of my foot.

    In the last five years I’ve seen 20+ docs and have had both hips replaced and an L4/5 fusion. Those things have helped, but the leg pain remained. Hence, the SCS simulator.

    Last Weds. I also decided to switch from a “healthy” vegan diet, which was incredibly carb heavy, to ketogenic. I did this out of vanity–all of these health probs have seen me gain more than 25 lbs. I have no great love of carbs, so the transition has been easy. Most delicious week in years! Oddly, the SCS became disconnected when I rolled over in bed on Saturday night. But today is Monday. You know what? My pain has lessened, rather noticeably, every day. (I’ve also dropped a couple pounds. 🙂

    Tomorrow I get my SCS removed, and the doc and I will decide on whether or not to do the permanent surgery. Now I’m not so sure that’s a great idea. While my pain is reduced with the keto diet, it’s definitely still there. But it’s only been five days. Time will tell.

  18. Hi Peter, thank you for sharing. I have had chronic lumbar pain and have been so lucky to come across a fantastic physio therapist that has helped me to regain painfree movement in my back. My mind feels clear for the first time in a long time! My Pilates journey now begins and the process of relearning how to move correctly.
    Interestingly, I have also started adjusting my diet to low carb in the last year and trying to eat intuitively….your diagram of getting to eating correctly unconsciously is a powerful clear message!
    I think the mind/body connection is overlooked and we need to get back to listening to our inner voice of health. Our bodies know what’s good for us but sometimes we dont hear It!
    Delighted that you have had a positive journey back to health. Thanks for your post. Barbara

  19. I am so glad to hear of your successful journey out of pain and disability. I too am a physician who had a year of my life interrupted by an orthopedic procedure that was not very successful, and had my postoperative complaints treated as malingering, although in fact I continued to work and never considered doing otherwise. Amazing what an arrogant doctor can do to diminish health and well-being. I too have come through it to have my active happy life back again, and am glad to see you talk eloquently and publicly about the harm that an arrogant physician can do and the need for patient self-efficacy.
    I have been eating a ketogenic diet for about 4 years now. With a touch of arrogance myself, I felt that I had reached the stage of unconsciously correct eating until I noticed that my weight had increased by 10 pounds without my being very aware of it until my jeans wouldn’t button. Good warning to get back fully on track. So I would love to see an additional arrow on your flow diagram pointing back up to “unconsciously incorrect” because I think that people with carb addiction problems need to know that “unconsciously correct” can shade back to “unconsciously incorrect” all too easily. But if this happens, it’s a warning to be aware of the cycle and get more on track, not a disaster or an indication that low carb diets “don’t work.” Recovery is a lifelong process and may need to be more conscious at some life phases than at others, however long you have been at it.

  20. If a ketogenic diet has anti inflammatory properties as it relates to diabetes. Does the same hold true for injury rehabilitation? Would a ketogenic diet aid someone who had inflammation problems due to chronic back injury? Potentially?

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