This article is intended for the general public who is suffering from back, neck, shoulder, or knee pain. If you’ve seen a doctor about your pain, it’s likely that you’ve gotten a confusing recommendation from your doctor about undergoing surgery or getting yourself stronger. It’s especially confusing when you’re highly encouraged to build muscle and get stronger but to avoid doing it with weights.
I have meant to talk about this for a very long time. And trust me, it isn’t because some clients stopped training due to these “poor” recommendations, even though their condition improved with training. Nor it is because the advice confuses some of our clients and they’re worried about whether they should continue training. I want to talk about this because I too, have been on the receiving end of this advice.
At 14 years old, I was diagnosed with a degenerative spine condition – an issue inherited from my mom. At that time, I still dreamed of becoming an NBA player (despite the lack of height and maybe talent). I loved basketball, playing 2-3 hours every day and only went home when it got dark. I wasn’t too bad either; I was on the school team for a while before starting to suffer from a lot of back pain after each basketball session.
We got it checked, and the doctor mentioned that my basketball career must end – no more high-impact activities such as jumping around or even running. Don’t carry any weights! You will make it worse and feel excruciating pain also when you get old if you do so. Practically, don’t do anything.
Let’s set a hypothetical situation where you have been experiencing back pain for the past three months and decided to seek medical advice. As you sit in the waiting room of the doctor’s office, you noticed a lot of other patients also waiting – likely that they’re all anxious about their condition. When you see the doctor, you ask the difficult question “why is my back hurting and what can I do about it? Can we get imaging done to find out what’s causing the pain?”
The doctors will probably do it anyway because there is a super slim chance that your back pain is caused by non-spine-related issues or even life-threatening conditions such as aortic dissection. However, most of the time, they will find out that there’s nothing really “serious” (read: life-threatening), even though it might cause some discomfort in your daily life.
Degeneration of the spine
Almost every time, the imaging will detect some form of degeneration in your spine. A research was published in June 1994 by MC Jensen et al., where 98 asymptomatic people did an MRI scan to understand the correlation between abnormalities in the lumbar spine and back pain. Here’s what they found:
“Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. With the results of the two readings averaged, 52 percent of the subjects had a bulge at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl’s nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women.”
Now hold up! There’s more!
Research published in April 2009 by Kenneth MC Cheung et al. involves participants aged 18-55 years old. The finding summarizes that if you are in your 30s, there’s a 40% chance that you have some amount of disc degeneration; if you are 50-55 years old, the chances increase to over 90%.
In conclusion, these studies show that disc degeneration is a common occurrence that might have some relation with ageing. Some populations might feel some pain in correlation with the degeneration while some don’t.
So what is causing your back pain?
Back to our hypothetical situation. You start feeling some back pain for the past three months. The imaging results are back and show some degeneration. When do you think the degeneration started? 3 months ago, or perhaps for longer than that? Maybe years? Why is it that you started to feel the pain for the last 3 months?
Let me tell you the answer.
I don’t know.
Your doctor doesn’t know either. But they can make an educated guess. “Well, based on your MRI, seems like the degeneration at L5-L6 might be causing the pain. What do you want to do with it? You have two options. Do you want to operate on it? Or do you want to go to the physiotherapist?”
You might think that surgery is not very popular. Well, that’s not really the case – it’s actually more popular than you expect. There’re quite a number of people suffering from back pain who want the pain to stop ASAP and choose surgery. After the surgery, guess what – the pain didn’t go away. We’ve seen this many times when clients who have undergone back surgery tell us their story.
Let’s find other solutions then; maybe something else is causing the pain. So you go for surgery number 2. And…. the pain is still there. This is so common that there’s a name for it – Failed Back Surgery Syndrome. I’m not even kidding, look it up.
So knowing this, you ask your doctor, “How about having surgery as the last option? Tell me more about the physiotherapist.”
The doctor then says, “Well, basically how this works is by strengthening your muscles around the spine, we hope to share the load borne by your spine to the adjacent muscles. It will get your core stronger and should help alleviate your back pain.”
You said, “That makes sense. Can I do it in the gym with some weights?”
And the doctor replied,” NO! NO! NO! That’s dangerous for you. Don’t do that. You’re going to make it worse if you do that.”
You were then sent to the physiotherapist and made to do some light exercises and 10 types of stretches every day.
Is this the end of your back pain woes?
Well, based on conversations with our clients with this experience, this is very likely not the end of your back pain.
After a few months of physiotherapy, you’re not any stronger and your back still hurts. You’ve done both recommendations from the doctor, surgery and physiotherapy, and your back still hurts. What do you do now? Sounds familiar?
Let me clear up a few things for you.
Why doctors don’t really recommend strength training in the gym, especially when you say that you are going to use barbells
Reason #1: Unfortunately, they are not very familiar with the exercises themselves.
Ask your doctor how to do a proper squat; that might give you an idea why they think it’s dangerous. (Hint: their squat might be dangerously bad, haha. Oh gosh, Marvin, stop being sassy).
Anyways, doctors study the human body, physiology and medicine. And yes, in general, they are pretty smart. However, it is unlikely that they have a deep understanding of how to practically strengthen the human body unless they have a deep interest in it.
A recommendation from fellow Starting Strength Coach and doctor, Dr. Jonathon Sullivan, is to ask your doctor what they know about the exercise and how they know it. Not to challenge their knowledge but to understand how informed they are to the recommendation they give.
Reason #2: Bad exposure of the weight training in the clinic.
A guy limping into their clinic, and the doctor asked what happened. He says, “squat”, “deadlift” or “gym”. It doesn’t help if their exposure to squats/deadlifts/the gym is the small percentage of people getting injured in the gym – it may seem like everyone’s getting hurt.
Reason #3: Liability. Who wants to get sued?
Imagine the doctor replied to you, “OH YASS! Go to the gym, lift some weights! You will be stronger and feel better”. Two weeks later, you are back at the doctor and injured from the gym. Your weak back (or insert the problematic body part) got “even worse” because the doctor gave you the green light to this “super risky”, harmful activity.
Reason #4: It’s not all the doctors’ fault. The fitness industry’s standard can be very low.
I got my first personal training certificate after studying for 40 minutes and taking a 20 minute MCQ exam online. And I’m certified to coach “fitness”. Many personal trainers or coaches have their certificates from a more credible organization than the one I took. Yet, few organisations test the ability to recognise movement patterns and, even more, teach and correct them.
So I wouldn’t blame doctors if they don’t trust their patients to these fools.
My recommendation is to ask your doctor whether strengthening the problematic area’s muscles is a good idea. If yes, ask your doctor if some amount of resistance is necessary to build the strength. Some will think that swimming is a good resistance for your back, some will recommend water therapy, some will recommend whatever the physical therapist does. However, if they can agree that strengthening our body is good for you, most likely you can strength train with barbells.
But hey! Why not go to a physiotherapist first as my doctor recommends? Well, you can. The therapists will most likely give you some meagre resistance accompanied by some stretches on the side. These very low-stress exercises are not sufficient to get you stronger. Make sure that whatever you do, you increase the load progressively.
No, adding more repetitions wouldn’t work as well. Doing higher repetitions train your muscular endurance for that particular muscle group. It will not create stronger, bigger muscles as effectively.
So back to my story about stopping basketball. In hindsight, maybe if I had known about Starting Strength 15 years ago, I would still be playing basketball. Maybe in the NBA, lol. However, because I understand the science behind training and totally ignored my doctor’s advice and chose to train with barbells and get strong, my back feels much better.
Do I still feel pain? I’m not going to lie and say that it’s completely gone. There’s some pain but it occurs very rarely. From constant pain, to very rarely – don’t know about you but I’ll take that any day.
How do you want to manage your pain? Do you choose to admit defeat and keep trying to hide from the pain? Or do you want to try and stabilise those joints by strengthening the muscles around the structure so that you can live your life to the fullest?
1. M C Jensen, M N Brant-Zawadzki, N Obuchowski, et al. Magnetic resonance imaging of the lumber spine in people without back pain. New England Journal of Medicine. 1994.
2. M C Cheung, Karppinen J, Chan D, et al. Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals. Spine. 2009.