Back pain is a common presenting complaint in the emergency department. One study reported that the pooled prevalence of back pain among all patients presenting to the ED was 4.39%. Other studies put that number in the 3-5% range. On certain days, though, it seems that the real number of patients presenting with back pain is significantly greater than what is stated in the literature. Hardly a shift goes by in our fast track that I don't see at least one patient presenting with this complaint.
Among patients with chronic, severe back pain, 75% report disability. This means that these individuals are not able to participate in work, social events or care for themselves or others. However, for patient suffering from acute back pain, the vast majority will recover. It is reported that up to 95% of patients will recover within 12 weeks.
While painful and potentially debilitating, the vast majority of back pain is non-specific and mechanical in nature. Only a small portion of patients have truly life or limb threatening back pain that is caused by something like a fracture, cancer, or compression of the spinal cord. Most patients have some form of muscle strain, nerve impingement or arthritis causing their back pain. Many patients have this form of back pain due to obesity, lack of flexibility, and/or lack of strength in their back and core muscles. Unfortunately, this pernicious triad sets off a negative spiral that leads to chronic pain. Obesity or sedentary lifestyle leads to poor functional ability results in back pain. The combination of pain and poor functional ability leads to further decreased movement and further deconditioning.
The treatment for back pain is varied, ranging from simple non-steroidal anti-inflammatory medications, muscle relaxers, steroids, all the way to surgery. However, one often overlooked and certainly underutilized treatment to back pain is physical therapy in the form of stretching and exercise. In fact, Dr. Marty Makary writes in his book, The Price We Pay, that physical therapy is often a superior treatment for back pain over surgery and argues that PT should be attempted and fail before surgery is performed. For me personally, I have had several episodes of back pain that have responded to targeted stretches and strengthening exercises, namely fitness.
For the past 10 years, I have engaged in various forms of fitness. I started my fitness journey with distance running as a result of seeing a similarly aged patient suffer an acute myocardial infarction. In recent years, I have transitioned to strength training in the form of barbell training. While my programming encompasses a variety of lifts, the core of my routine is built around 4 compound lifts: squats, deadlifts, overhead press, and bench press. I have witnessed the transformation in myself from being deconditioned and doughy to someone who is leaner and stronger.
Simultaneously, I have observed a variety of patients that present to the emergency department. A large number of conditions are the direct result or exacerbated by obesity, poor strength, or poor conditioning. I mentioned the other day to a colleague, I believe that a large number of ED visits could be mitigated or prevented by time spend under a barbell - both for the physical improvements that it creates as well as the mental toughness that it develops.
This brings us to the topic of this particular post: fitness. When we use the word fitness, our minds naturally default to exercise and working out (i.e. physical training). This is understandable as physical exercise is generally the intended use of the word. In fact, the first definition in the dictionary for the word fitness is the condition of being fit and healthy. A brief google search brings up local area gyms and how to articles around exercise and workout routines. While there are a myriad of philosophies and plans, concept of fitness can be boiled down to some combination of strength or conditioning training - applying various stresses to induce cellular hypertrophy or enhance metabolic efficiency.
As we continue in the dictionary to the second of fitness, though, we start to see that fitness can encompass more than just physical conditioning. This definition reads, "The quality of being suitable to fulfill a particular role or task." This helps us see a more holistic understanding of fitness. So, broadly speaking, fitness refers to training ourselves to be capable of handling various situations. It is the context that defines the exact meaning of the word fitness. This idea, being purposeful and intentional to prepare ourselves for all of life, is a vital part of what it means to live with excellence.
Spheres of Fitness
As individuals we are multifaceted creatures. If you stop to break down our existence, you will find that we are a composite of three different spheres. And when we look at each sphere, we can discover ways to apply the concept of fitness.
Physical Fitness
We are physical creatures. We have a visible body. This body is composed of various different organs and organ systems that all work together in a coordinated way. If we dive deeper, our organs are composed of different types and combinations of cells. All of these are held together and function in a coordinated way to maintain proper functioning and homeostasis of the organ system and the body as a whole.
There are many pathways that seek to keep the functioning of our body optimized and operating within certain parameters. The insulin/glucagon system is an exquisite example of how counter-regulatory hormones can act on a variety of tissues and organs to shift the body between nutrient storage and nutrient release in order to maintain the blood glucose level within a tight range. Too much glucose and tissues suffer, too little and the body does not have enough energy to function.
Our bodies were made to move and do difficult work. Just like our cars need to be cleaned, given the proper fuel and get preventative maintenance, our bodies need to be cared for, fed the proper nutrients and be given some preventative maintenance of its own. Our bodies function best when simultaneously exposed to physical stressors and given proper fuel. However, technological modernization has removed the effort from existing and has changed the composition of our food from a balanced complement of macronutrients from raw sources to highly enriched, carbohydrate heavy processed foods that are easy to mass produce and store. To make matters worse, urbanization and mechanization have changed our interaction with the world making physical strength and endurance less vital to our daily existence. As a result, in the last 100 years we have seen a rise in obesity and physical deconditioning. To mitigate these as well as downstream effects, physical fitness needs to be a part of our daily routine.
Mental Fitness
In addition to being creatures with a body, we are also creatures with a mind. The brain is the seat of the mind. Neurotransmitters and synapses form the billions of neural connections in our brain bridge the gap between the material and the immaterial. Our minds are the unique aspect of our personhood that allow us to have awareness of the world and our place in it. In colloquial terms, it is our intellect. But in another sense, it is much more. It is our consciousness.
We are all given a mind that can undergo basic functions. Just as we can train our physical bodies to be more effective moving and operating in the physical space, we can also develop our minds to be more effective as we navigate the journey of our life. So, what does it mean to have mental fitness?
Broaden Your Mind
Broadening our minds starts by cultivating a pattern and thirst for lifelong learning. This is done by reading books, listening to podcasts, and learning from others. Our lives can be defined by a dichotomy between the predictable and unpredictable. There are many opportunities that we have that are knowable. And there are opportunities that we cannot anticipate. Broadening our knowledge will allow us to engage adeptly in the predictable opportunities as well as navigate smoothly in the unknown waters. There is a vast canon of knowledge that can be yours if you just seek it. One of the things that I find most sad, is encountering someone who is content to stop learning.
Sharpen Your Reasoning Skills
There is a common phrase which states that knowledge is power. While there is an aspect to which that is true, knowledge alone is not enough. It is not enough just to know a bunch of facts. Most of the time random facts serve little to no purpose unless they are used for a specific purpose. The power that comes from knowledge is our ability to apply that knowledge and use it to create arguments. By arguments, I do not mean emotionally charged squabbles. Rather, an argument is a coherent line of reasoning that is informed by facts and supported through logic with the goal of persuading. As we develop and express our opinions and beliefs, these should be done by developing a premise, analyzing supporting or conflicting data and drawing reasonable conclusions.
Seek Differing Viewpoints
Seek out viewpoints that differ from your own. One of the greatest threats to mental fitness is to surround ourselves with only people who share your viewpoint. It is often easy to convince ourselves that we are right on a particular subject matter until we are exposed to a counter-viewpoint that challenges our thinking. Don't avoid this. Run toward it! Just as muscles are not built without resistance, sharing our opinions and beliefs with others who hold a different viewpoint helps to pull us out of our echo chamber and show us holes in our reasoning or understanding.
Spiritual Fitness
As we build out the various characteristics of our existence, there is one aspect that we have yet to explore - that is the spiritual. It is easy to become seduced by naturalism and think that only that which we can see, feel our touch is real. But our analysis of our personhood would be inadequate without a view toward the spiritual. Though less obvious or tangible, it is certainly no less important than the physical or mental components of our life.
Many philosophers have defined spirituality in different ways. At the root, spirituality is an understanding and a connection with things and ideas that are bigger, more fundamental and more transcendent than ourselves. It is what connects us as individuals to our environment and to one another. The fact that we are spiritual creatures allows us to have meaning and purpose in life. It allows us to engage with one another in deeply meaningful ways. It gives us a moral framework for our dealings with others. And it provides us with perspective on who we are and why we are here on earth. So, how do we develop spiritual fitness?
Seek God
God is the ultimate source of all things and all knowledge. He is the creator (Genesis 1), sustainer (Hebrews 1:3) and supreme ruler of all things (Psalm 103:19). He is the universal sovereign. God is the reason all things exist, and he holds all things together (Colossians 1:15-17).
God is relational. He desires to have a relationship with us as his creatures. As such, God is knowable. He has made himself known to us through his creation (general revelation) and through scripture (special revelation). Paul writes in Romans 1 that "What can be known about God is plain... because God has shown it... For his invisible attributes, namely, his eternal power and divine nature, have been clearly perceived, ever since the creation of the world, in the things that have been made." In 2 Timothy 3, he writes, "All scripture is breathed out by God and profitable for teaching, for reproof, for correction, and for training in righteousness, that the man of God may be competent, equipped for every good work."
Pursuing God requires faith. Hebrews 11 defines faith as the "Assurance of things hoped for, the conviction of things not seen." The author continues, "By faith, we understand that the universe was created by the word of God, so that what is seen was not made out of the things that are visible." And, "Whoever would draw near to God must believe that he exists and that he rewards those who seek him."
As we seek God, we will notice tangible benefits in our lives. In the same way that wearing glasses can improve the visual range of an individual who is myopic, when we seek and understand God, we will begin to have a broader understanding of the world and our purpose and place in it. As we look through the corrective lens that knowing God provides, we begin to see ourselves relative to God, creation, and others. We the overarching reason for the universe, the purpose for which all things exist. We gain a clearer perspective that will inform our purpose and priorities. C.S. Lewis, in the book The Weight of Glory discusses the superiority of theology over naturalism. He writes, "I believe in Christianity (i.e. God) as I believe that the sun has risen, not only because I see it, but because by it I see everything else."
Pursue Meaning & Purpose
Having established the source and sustainer of our existence, the second thing to do is to pursue meaning and purpose. Some say that above all others, this is the chief desire of mankind. There is much equanimity that can be found in knowing our purpose and engaging in activities that provide meaning to ourselves and others.
Meaning comes by understand that we live in a landscape broader than our own. We are a part of something greater. Solomon writes in Ecclesiastes 1, "A generation goes, and a generation comes, but the earth remains forever." While our existence is not insignificant, it is also a small part of the whole. Meaning and purpose therefore is not found in accumulating pleasures for ourselves but in finding the way that God intends for us to live and operate in this world.
Viktor Frankl comes to a similar conclusion as he writes about his experience in a Nazi concentration camp. Of meaning he writes, "It did not really matter what we expected from life, but rather what life expected from us. We needed to stop asking about the meaning of life, and instead to think of ourselves as those who were being questioned by life-daily and hourly. Our answer must consist, not in talk and meditation, but in right action and in right conduct. Life ultimately means taking the responsibility to find the right answer to its problems and to fulfill the tasks which it constantly sets for each individual."
Go seek fitness. Get After It!
Journal References:
Edwards, Jordan; Hayden, Jill; Asbridge, Mark; Gregoire, Bruce; Magee, Kirk. Prevalence of low back pain in emergency settings: a systematic review and meta-analysis.BMC Musculoskeletal Disorders.2017;18(1):143.
Edwards, Jordan; Hayden, Jill; Asbridge, Mark; Magee, Kirk. The prevalence of low back pain in the emergency department: a descriptive study set in the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia, Canada.BMC Musculoskeletal Disorders.2018;19(1):306.
Kinkade, Scott. Evaluation and Treatment of Acute Low Back Pain.American Family Physician.2007;75(8):1181-1188.
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