It was in Saigon, in June 1999, that I first felt the knot at the base of my lumbar spine. Thirty-one years old, I’d never worried much about taking care of my body. In retrospect, nine months of hunching over my laptop, without a desk in that house Mai and I rented, had done something. I remember, in our last days in Vietnam, hobbling off an escalator and approaching Andrew Steer for a handshake. As head of the World Bank mission there, he was about to keynote a conference at which I would later speak too. I tried to smile and act normal as an invisible hand grabbed my muscles and ligaments from behind and clenched.
But the knot went away after we came back to the States, and I forgot about it. Occasionally it returned… I felt it the year I ported my three-year-old to daycare everyday on the back of my bike. I figured out not to pull so hard on the handlebars when accelerating. That helped. But sometimes I could barely put on my socks.
Then three years ago, my right thigh started cramping whenever I stood up from a chair. This time, ignoring it did not work. I found a chiropractor across the street from CGD. He treated for a pulled hamstring. A week of staying horizontal and getting localized ultrasonic stimulation did no good, so he sent me to his “rock star” colleague, Barrie Pilgrim. Dr. Pilgrim soon diagnosed me with a bulging or herniated lumbar disc. If I recall rightly, the giveaway was Kemp’s test. Sitting on his examination table, I stuck my legs out in front of me and then bent my head forward. My thigh twinged as I did. Yes, the head bone is connected to thigh bone, but not directly. In fact my hamstring was fine, and my abused, displaced disc was pinching a nerve. Bending my head lifted the nerve fiber, increasing the pinch.
I don’t know precisely how my disc is displaced or what movements or muscles displaced it. As a professional digger-for-evidence, I’d like to see what’s going on back there. But Dr. Pilgrim followed best practice, which is not to do an MRI. At best, usually, an MRI would cost an insurance company a bunch of money (and make a hospital or doctor’s office a bunch of money) while providing no information that would improve treatment. At worst, by making my problem more visible, it would put me on the path to unnecessary surgery. At least that’s what Mai says, and she’s studied over-imaging among patients with lower-back pain. I would see the deformed disc and want it fixed. A surgeon would be consulted. A surgeon doesn’t get up and go to work every day to not do surgery (and not earn income thereby), so she’d tend to recommend operating. All the doctors involved might worry about a malpractice suit if a problem so clearly documented went untreated.
The absolute worst case is a vicious cycle, Dr. Pilgrim explained: to compensate for the degradation of my disc, which is the padding between vertebrae, I have the vertebrae fused. This solves the immediate problem. But it leaves unchanged the pattern of forces operating on my back, which my back now has less flexibility to absorb. The fused vertebrae concentrate the bending pressures onto other discs, making the problem worse. Another disc goes and the cycle repeats. Eventually the pain becomes untreatable except with morphine, to which I become addicted.
My job, for the rest of my life, is to arrest that cycle by taking care of my back. It’s your job too.
In the course of learning how do to my new job, I’ve encountered three theories about what I was doing wrong before and how to fix it. They may all be true. As a practical matter, I’ve found that two have really helped and one not so much. I know there are others out there. In reading this list keep in mind that I’m not a chiropractor so I’m probably not getting everything right.
1. The problem is asymmetric muscle use
Until I started working at home a few months ago, I biked daily across DC to get to work. When you bike, you push some muscles hard and others not at all. Your glutei maximi (yes, your butt muscles) and your abdominals shut down. Compared to walking and running, which we are evolved for, the pattern of muscle use becomes asymmetric, as do the stresses they put on the spine, where they attach. Worse, the biking actually trains your brain to favor the same muscles even when you’re not biking. Unconsciously, for example, you learn to go from sitting to standing while making little use of those glutei maximi. The Rx for this Dx is a daily exercise regimen that counter-trains your brain to use the neglected muscles. A lot of the exercises focus on firing abdominal muscles and other muscles in your “core.” Dr. William Booker, who I saw for a while, has posted instructional videos.
Maybe I just wasn’t diligent enough with the exercises—I heard they need to be repeated 10,000 times—but whatever the reason they didn’t seem to do me much good. By improving my posture (see below) I was able to get rid of my pain, and the exercises probably helped with that. But all it took was one hard bike ride to resurrect the pain. I didn’t see how firing my abdominal muscles 1,000 times (I admit I never got to 10,000) would change how my leg muscles yank my spine when I bike.
2. The problem is fascia stuck together
Muscles are encased in white matter called fascia. Fascia is apparently important in giving our bodies their form, and in allowing muscles to slide by each other. However, adjacent fascia can become scarred and adhere to each other, perhaps because of hypoxic events (when acid builds up in the muscles). Then, when one muscle contracts, it yanks adjacent muscles along with it, putting unnecessary pressure on whatever bones those muscles are anchored to, including vertebrae.
“Fascial manipulation” is a family of techniques meant to work on fascia. Among these is one developed by the Italian Luigi Stecco, which he confusingly calls Fascial Manipulation in English. Dr. Pilgrim is one of the few practitioners of Stecco’s method in my area. He learned it recently and tried it on me last year. As far as I can tell, it involves the practitioner finding “knots” in the patient’s muscles and then massaging them really hard for about 2 minutes each, delivering pressure and friction. This breaks adhesions and triggers inflammation for a day or so, as well as healing. For the massage to work it has to HURT. To seek this treatment is to volunteer for torture. I was amazed at how many sore spots Dr. Pilgrim found to gouge his thumb or elbow into—in my legs, feet, shoulders, back. Making it tolerable was the knowledge that I was in control. I could ask him to stop at any time. I only did once.
Also amazing was that Stecco’s Fascial Manipulation seemed to help a lot. When I did trigger that familiar knot of pain through careless posture or hard biking, I rebounded more quickly. And the pain recurred less often. I could tell the changes were long-term, because when Dr. Pilgrim tested a spot he had worked months before, it no longer hurt. Also, I gained flexibility. Now I can do backflips with more confidence. (But see this intelligent critique of the “fascia fad.”)
3. The problem is slouching
When a healthy person stands erect, her spine curves inward just above the pelvis as well at the neck. That’s called lordosis (the term also refers to an unhealthily extreme degree of curvature). Again, this posture is what we’re evolved for. But you lose lordosis when you ride a road bike with drop handle bars. And most of us in wealthy nations lose lordosis for most of our waking hours because we sit so much—in the car, at the desk, at the dinner table, on the couch. Some of us manage to maintain good posture through all that. But most of us tire. And not even a fancy ergonomic chair stop you from slumping forward. Here’s an illustration of healthy and unhealthy sitting posture from yogahome.net:
A New Zealander named Robin McKenzie, who died last year, was to my knowledge the leading apostle of the importance of maintaining normal lordosis. He wrote Treat Your Own Back, which is a cheap, succinct read. The book mostly tells you what to do, not why it works. The theory appears to be that prolonged slouching stress the joints between vertebrae and the discs that pad them to a degree for which they are not evolved. McKenzie says it like bending a finger backward: a few minutes is fine, but 8 hours will do damage. In the back, the stress pushes discs out of position, pinching nerves. To prevent that damage, the main thing you need to do, aside from improving posture, is this:
Apparently since we spend so much time bending our backs one way, we need to compensate by bending the other way. This exercise, I can attest, is therapeutic too.
To restore good posture, you must work to change your habits when sitting, standing, and walking. McKenzie says that to find the right position, you should assume extreme lordosis and then relax 10%. You can also buy a McKenzie roll for seats, such as in cars, that provide too little lumbar support. (I’ve got one of those.) You can buy an inflatable one for travel. (Ditto.)
You should be especially careful after exercise, just when the fatigue most tempts you to let go. According to McKenzie, exercise softens the discs, making them more pliable and vulnerable to displacement.
But perhaps most important, you can stand more. Dr. Pilgrim told me that if the choice is between an ergonomic chair and a standing desk, put your money into the desk. You can maintain good posture in a cheap chair and slouch in an expensive one. Wired depicted the standing ideal this way:
But actually that’s not ideal because it’s not adjustable. Standing all day, especially with your knees locked, probably isn’t healthy either. It’s also not what our ancestors did. So the best arrangement is one that allows you to alternate between standing and sitting. And it’s good to move a bit while you stand.
If you use a laptop without an external keyboard or monitor, it is impossible to position it ideally for your hands and eyes at once.
There are lots of options for your set-up, from piles of books to elevate your monitor, to adjustable contraptions that clamp onto a traditional desk (CGD got me one of those), to stand-alone adjustable desks. Before I left the Gates Foundation, they set me up with the all-mechanical Steelcase Airtouch, which was quite fine. I just got an eletrical NextDesk Terra for my home office. This is where I’m writing now:
And this indeed is where I put my money. My chair is a basic metal folder.
(Yes, that’s Mai’s belly on the right, 8-months pregnant with Alexander.)
If you start reading about standing desks, you’ll hit a fourth big idea:
4. Standing is good for more than just your back
Here is a great graphic that says it better than I can—and constitutes as much as I know about the topic. I can’t vouch for its accuracy. But maybe James Levine can.
Nothing I am doing will rewind my body clock. I have not fixed my back. But I am optimistic that the changes I have made will keep me healthier. And with the fervency of the new convert, I believe they can help you too.