Lower back pain while standing

First … thanks for the great forum. I’ve enjoyed it for a while, particularly Dr. Baraki’s reading lists. I’m a 51 year old physician, and this has been a great resource!

I’m having trouble with back pain and I would like to keep it from interfering with training.

The history goes something like this: I began developing non-radiating lower back pain, only while standing, about 2 years ago. That non-radiating, standing-only pain eventually lessened, until around October 2017 I began having right L5 radicular pain, again worse with standing, and it worsened until August 2018 when I had an MRI showing L5-S1 spondylolisthesis and a right L5-S1 Disc compressing the lateral recess.

I was told by a colleague that a transforaminal epidural shot would help, but in the time it took to set it up, the radicular pain sort of went away on its own, and so I never had that. I saw PT once, but never really followed their suggestions. Instead, I just kept up with CrossFit around 3-4x per week supplemented by some non-programmed squat/deadlift/press days. My strength improved, and I remain able to do about anything I like, and currently have 1RM deadlift at 375#, to give you an idea.

The problem: over the last month, the non-radiating lower back pain has returned. It presents only with prolonged standing (such as when I perform colonoscopies or teach medical students). It seems temporarily improved while exercising – either squats/deadlifts or CrossFit WODs. Sitting and sleeping seem to “help”, too.

The question: I’d like to ignore this and continue to train, letting regression to the mean occur. But the pain is really interfering with things that require prolonged standing. So – Assuming this pain is related to L5-S1 listhesis (I know – it’s an assumption) are there activities/lifts/movements that should either be avoided or, perhaps, encouraged?

For instance, I had a PT tell me to avoid “overhead” activities at CrossFit … Snatches, OH squats. I’m very happy to do that as I don’t really see the point of them, anyway. But is that evidence-based? Is there any evidence based advice for training with L5-S1 listhesis?

To my knowledge, there is no evidence to substantiate this claim. A quick search yielded this SR, which was inconclusive Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review - PubMed.

In 1997 Peter O’sullivan put out this paper. Many held tight to its conclusions. Some still do.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.471.7111&rep=rep1&type=pdf

He has pulled a complete 180 and sometimes even mocks his own work…

Good stuff … I suspected as much (i.e.: no evidence to substantiate claim to avoid overhead activity).

So … any evidence-based advice for training with spondylolisthesis of L5-S1? Are there any firm contraindications?

I’m guessing that the usual advice (avoid catastrophizing, avoid assuming the pain is from the radiologic defect is responsible, limit loading to tolerable limits, etc.) applies.

And, if there is no evidence-based stuff … any anecdotal advice?

Thanks!

Hey @Deertick ,

As others have mentioned, there are no contraindications to training with a spondylolisthesis provided the grade rating isn’t high enough warranting surgical intervention (does not sound like this is the case).

I want to address the assumption the spondy is related to your symptoms - we have strong data against this stance. Also such an approach to LBP would go against what we know about pain at this time. Overall, even once a spondy is identified, progression slows as time goes on and there isn’t cause for concern to avoid activity. Instead such recommendations would likely perpetuate kinesiophobia unnecessarily.

See:

Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis.

The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation.

Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population.

The PT recommending to avoid overhead activity is incorrect. I do not recommend following their advice. You can train normatively based on your goals. Regarding symptomatic development during work activities, we’d be happy to consult with you to give individualistic advice. You’d likely enjoy this blog by @Derek_Miles -
The Problem with a (Entirely) Structural Based Approach to Low Back Pain

Happy to discuss.

Michael … that’s just what I was looking for.

My story is an excellent example of how imaging made pain worse – through the assumption that it showed the “origin” of the pain. Intellectually, I knew the relationship between spondylolisthesis and pain was weak (now I see that it’s practically 0) … but emotionally, looking at the images, it opened the door to magnification of the pain.

In the middle of all this, I saw a colleague who also told me not to “ever lift anything over 30 pounds” because of the “abnormal signal” of “dessication” of my L5-S1 disc. I knew there was nothing evidence-based about this recommendation, but I’ve since learned a lot about what we physicians tell patients and how we can really cause the troubles we say we’re trying to solve.

I’m assuming that similar literature backs up recommendations to avoid considering MRI evidence of “degeneration” of discs as contraindications to strength training.

Thanks for the evidence – this should be the standard of care. You guys are doing a great job.

Yes, your backstory is a great example why we need to be cautious with the language we utilize and ensure appropriate usage of imaging based on case context and future management.

Often, in these scenarios, the added information from imaging isn’t beneficial and has the very real potential of being a nocebo.

To the degeneration point - this is correct. We do not have any data demonstrating people with imaging demonstrating degenerative disc disease (aka aging adaptation) should avoid resistance training (radiculopathy or not). Granted we can have a very nuanced discussion of appropriate exercise prescription alterations while managing symptoms.