Most health care practitioners agree that lifestyle influences have a significant role in the onset or alleviation of spinal pain. Incorporating lifestyle changes can have a significant and lasting effect on reducing, eliminating, and preventing recurrent spinal discomfort.

In this section, we address five specific lifestyle factors—fitness level, diet and nutrition, sleep, stress, and smoking—and show you how they affect spinal pain. We provide simple self-help guidelines for each and show you how small changes can have a large and lasting effect. That you can control these factors makes your chances of success all the better.

“Wait a minute,” you say, “What about age? I’m not getting any younger, and my spinal pain is getting worse.” Spinal pain and age are connected to some degree. Several conditions such as spinal stenosis and spondylosis do become more frequent as we age. But the point of this chapter is to discuss the lifestyle choices that we can control, those that undoubtedly affect the onset of or the severity of spinal pain. Aging is not something that we can control. We all age at exactly the same rate, one day at a time. So although aging does lead to a gradual loss of flexibility, strength, and the ability to recuperate, the five lifestyle factors that we can control are the concern of this chapter. If you manage these five factors appropriately, you can significantly diminish spinal pain or prevent it from occurring.

The Science of Health

Before we begin, we need to examine a bit of science to help us understand why these lifestyle factors can benefit or hinder your progress. A basic understanding of cellular biology, tissue strength, and oxygen transport will illuminate why the body reacts as it does to these specific lifestyle choices.

Let’s begin with cellular biology. Picture a classic car that is kept covered in thegarage. As long as the car is kept covered and stored safely in the garage, it poses no concern. If you want to take it for a spin, you need only one thing—fuel for the engine. Without fuel, the car is useless. It will look good regardless, but if you want to use it, you’ve got to gas it up. After the car is filled up, the quality and efficiency of the engine becomes the next key factor in how that car will perform. Are all the cylinders working properly? Is the timing correct? Is the engine putting out the maximal horsepower that it is capable of? Does the engine have enough size and stamina to move the car through town, up a mountainside, across the country?

The car analogy is relevant to your body because similar factors are at play on a cellular level. Your cells also need fuel to perform properly. Whereas gasoline makes the car engine function, oxygen is the required fuel to make the cell motor work. Without enough gas the shiny classic sitting in the garage is not going to get you around town or even down the block. Similarly, without enough oxygen the cells of your body cannot keep you healthy and pain free for a week, month, or year.

Oxygen is to the cell as gas is to the car. Without oxygen, the cell won’t function properly. The engine of the cell is the mitochondria. Mitochondria, the cell’s energy-producing unit, are numerous within each cell. They transform fuel into energy and ultimately make the cell do what it is intended to do. Mitochondria are more numerous and larger in size when the cell gets more oxygen, but they shrivel in number and size when oxygen transport to the cell diminishes. When the mitochondria are plentiful and well fueled, the cell is more resilient and tolerant to daily stress and strain.

The key factor to cellular health is the presence and delivery of oxygen to the cell. Factors that impede the ability of the vascular system to deliver oxygen reduce the ability of the cell to tolerate day-to-day strain. Factors that improve the transport of oxygen to the cell improve cellular resiliency. With cellular resiliency comes greater tissue strength.

When asked to define strength, many say that it is the ability to lift something, produce a force, or exert effort. All are true, but none correct in the context of tissue strength. In this regard, compare tissue wrapping paper to a piece of cardboard, cotton fabric to a burlap bag, or balsa wood to oak. Which is stronger? Which can tolerate repeated stresses, and which is better able to withstand day-to-day wear and tear? If a cup of water is placed on a wet piece of tissue paper, would it keep the cup from falling through as well as a wet piece of cardboard would? Would you feel as secure standing on a ladder made of balsa wood as you would on one made of oak? The analogy of stronger applies to cells as well. Those with superior levels of oxygen and energy production demonstrate greater resiliency to the daily wear and tear that tend to break us down. These stronger cells will be more resistant to breakdown and the subsequent symptoms. Oxygen transport is the key.

Common to each of the five lifestyle factors discussed in this section is the effect that each has on the delivery of oxygen and nutrients to the cells. By enhancing your fitness, improving your nutrition, promoting restful sleep, controlling stress, and avoiding smoking, you increase blood flow throughout your body, including the joints, bones, muscles, and connective tissues of the back and neck. Also important is the benefit of removing built-up toxins and metabolic wastes from the tissues. The perfusion of oxygen-rich blood to the cells is an important factor in maintaining cellular health and recuperative capacity. If your cells are deprived of the necessary fuels for too long, you will experience symptoms such as pain, aching, stiffness, swelling, or ongoing tightness, among others. As you manage these lifestyle factors in a positive way, the tissues become more resilient to the stresses and strains that you encounter every day. You will achieve an overall benefit to your spinal health.

Lifestyle Factor 1: Fitness Level

You may be thinking, “Here it comes, another doctor telling me I have to go to the gym five days a week, pump some iron, run a 10K, and be as flexible as a gymnast.” Yes, fitness is important, but achieving it does not require as much time and work as you might think. The health care community agrees that overall fitness level directly influences the success of treatment for spinal pain. The North American

Spine Society advocates fitness to enhance the health of your spine, as does nearly every other health care credentialing body. Based on our experience, those who are more fit get better faster and more routinely. Those who become more fit are able to recover better than they did before.

Getting in shape does not require a major time commitment or drain all your energy. To begin, we should first define what we mean by fitness level and then relate it to specific activities for your spine.

For general fitness the American College of Sports Medicine (ACSM) and the American Heart Association recommend 30 minutes a day, 5 days a week, of moderately intense cardiovascular training or 20 minutes of cardiovascular training combined with approximately 20 minutes of strength training 3 days a week. For those over 65, they advocate adding a balance activity to the routine. When training at moderate intensity, you should still be able to carry on a conversation.

General Fitness Guidelines Table

General Fitness Guidelines Table

Myth Exercising at Home Will Help My Neck or Back

This statement may or may not be true, depending on what exercise you are doing. Generally, the more fit you are, the more likely you are to minimize or eliminate your spinal discomfort. That said, you can aggravate your condition in the process of getting or staying in shape. Not all fitness activities are the same.

Exercise programs can take many forms, from traditional weightlifting to jogging and biking, from sports such as basketball and golf to yoga, Pilates, and tai chi. Each has merit for improving your overall health. Some, however, may be counterproductive, worsening your spinal discomfort.

Jim is a young, strong construction worker who has chronic lower back pain. He can’t figure out why his lower back aches. Jim likes to use a leg press machine at the gym. These machines are trouble for those with discogenic problems. After Jim stopped that one activity, his symptoms began to resolve.

Jack is an overweight patient who is trying to get back in shape. He walked mile after mile on his treadmill, only to stop after several months because of severe and increasing leg pain. The walking created so much irritation to his already compressed lower back that the nerve roots became swollen and irritated, hindering rather than helping his progress.

Jane is a middle-aged computer user who has poor posture and unrelenting shoulder pain. She not only worked at a computer all day and often at home at night but also liked to do push-ups, which irritated the problem. Push-ups often irritate an overworked rotator cuff tendon. Temporarily changing her activities enabled Jane to stay active as her shoulders healed.

Ask yourself whether you generally have more spinal discomfort or feel worse the morning after a workout. If so, chances are that your exercise program is contributing to your neck or back issue. Try implementing some of the activities in the book for a while and see how you feel. Often a little foundation building allows you to return to all or part of your prior exercise regime and feel much better for doing it.

Cardiovascular Training

Cardiovascular conditioning includes many forms of activity. Commonly used gym equipment includes stationary bikes, treadmills, elliptical trainers, and arm ergometers or arm bikes. You may include any activity that you find enjoyable and does not seem to worsen your pain. Swimming is an excellent form of exercise for those with spinal pain because of the buoyancy properties of water. Those with extension sensitive conditions such as stenosis, spondylosis, or spondylolisthesis may find flexion-based activities such as biking, rowing, or using a seated ergometer more tolerable, whereas those with flexion-sensitive conditions such as disc prolapse, compression fractures, or postural discomfort may find extension-biased activities such as walking, using an elliptical machine, or swimming especially useful.

Regardless of the type of cardiovascular conditioning that you choose, cardiovascular training promotes both oxygen transport (picking up oxygen from the lungs) and oxygen delivery (dropping off the oxygen molecule to the tissues). The goal is to get your heart rate in the target zone (see figure 5.1) for 20 to 30 consecutive minutes. To find your target zone, use this formula:

(220 − age) × 0.60 to 0.85 / 4 = pulse count per 15 seconds

For example, to achieve a cardiovascular benefit, a 45-year-old would strive for a pulse rate during exercise of 26 to 37 beats per 15 seconds:

220 − 45 = 175

175 × 0.60 = 105

105 / 4 = 26.25 (round down to 26)

175 × 0.85 = 148.75 (round up to 149)

149 / 4 = 37.25 (round down to 37)

Therefore, the 45-year-old would have to work hard enough to get his heart rate above 105 beats per minute but to remain safe not above 149 beats per minute.

Heart Rate Zones Based on Beats per Minute and Age

Heart Rate Zones Based on Beats Per Minute and Age

Heart Rate Zones Based on Beats Per Minute and Age

The easiest place to take your pulse is the inside of your wrist just above the fold. Another easy access site is under the jawbone along the side of your neck just lateral to the Adam’s apple.

Cardiovascular conditioning also promotes the release of endorphins, your body’s natural pain killers. Endorphins work to moderate your perception of pain and are released after bouts of cardiovascular activity. This effect causes the runner’s high, the ability of some athletes to carry on in spite of injury or illness. These natural opiates are important because they provide a good feeling that results from the effort you put in at the gym or at home. They provide a sense of well-being after a day of particularly hard work or exercise. Maintaining a level of endorphins in your blood stream can help diminish the sensation of pain and lessen the anxiety that goes along with it. Cardiovascular conditioning is a great way to naturally ease anxiety and the sensation of pain.

Strength Training

Strength training is necessary for a well-rounded level of fitness. Among the many forms of muscle strength training are weightlifting, Pilates, yoga, and isometrics. In most cases, regardless of the form of strength training used, as long as the parameters are correct and the specific activity that you choose does not elicit a lasting increase in pain, you will experience some gain in muscle strength. By gaining muscle strength, you are on your way toward combating spinal pain.

A properly developed strength program incorporates several factors. First, consider your starting level of fitness. If you’re a novice, you’ll make faster progress if you start slowly. Take your time and spend the first 6 to 10 weeks learning how to work out. The three primary reasons that a fitness program fails and you do not achieve your fitness goals are a lack of time, not having any fun, and getting injured. You can address the last two simply by finding activities that you like and incorporating them into your daily regimen slowly and methodically. If you’ve been on a strengthening or fitness program recently, you may resume a bit more quickly but remember that if it’s no fun and you get hurt, you won’t stick with it. Go slowly and find weight training activities that you enjoy.

Second, assess your current ability and stay within your limits. For a weightlifting program, use the repetition maximum (RM) scale as a guide to workout intensity. Generally, a reasonable starting point is a bout of exercise, called a set, of 15 to 20 repetitions. You should be able to lift the weight 15 to 20 times without a change in technique or posture but not more than that before fatigue. If you can lift a weight more than 20 times, the weight is too light. If you cannot lift the weight 15 times, it is too heavy. When starting a gym weight-training program, work at 15 to 20 RM loads for one set of each exercise. Before adding weight, add a second set. Adjust your program to meet your specific training goals but keep the RM scale in mind and use a 6- to 10-week learning period to avoid injury. After you are comfortable, add weight until you can do at least 12 repetitions but not more than 15. For muscle hypertrophy and enhanced strength, add weight until you can do at least 10 repetitions but no more than 12. This 10- to 12-repetition range will provide a level of safety and enhance strength building. Remember that a weight-training program should not cause spinal discomfort, should be fun, and should not impose a large time drain on your day.

A final consideration in beginning a strength-training program is the type of activity that you’ll do. Although walking, dancing, golf, and yard work are forms of exercise, none offer the benefits of true strengthening that your spine needs to stay healthy and symptom free. Loading, or placing added strain on your muscles and bones, provides the benefits of a strengthening program. You need the added load that weight training, yoga, and Pilates offer to stimulate your body to enlarge your muscles, strengthen your bones, and release endorphins.

For those interested in firming and toning hard-to-get areas, maintain the cardiovascular conditioning concepts addressed earlier and add 20 to 30 minutes of weight training at loads of 15 to 20 RM. Working in a circuit—doing one set of each exercise followed by a second set of each exercise—will provide the benefit of cardiovascular training while you condition and tone your muscles. Remember that even at a load of 10 to 12 RM, no lasting discomfort or short-term tendon or joint pain should occur after the exercise session. Muscle soreness is acceptable, but tendon and joint pain is not. If you are sore and experience lasting stiffness, stop the weight training and consult your physical therapist or physician. If you choose activities that incorporate body weight as the resistance, such as Pilates or yoga, the same general guidelines apply. These programs offer the advantage that many of the activities are done in gravity-minimized positions. You can adjust the loading on your spine more closely, taking into account pain and other limiting issues. No form of exercise is perfect; each offers merit where some other does not. By balancing your activities over the course of a year, referred to as periodizing the program, you allow your body to benefit from different activities while minimizing the likelihood of musculoskeletal pain and strain common with overuse and overloading.

Contrary to some beliefs, weight training is crucial to maintaining a healthy spine. To increase functional ability, the body must be exposed to greater workloads than normally encountered during typical day-to-day tasks. Because walking, dancing, golf, housework, and the like do not offer greater loads than normally encountered during the course of a day, in and of themselves they cannot be considered strength-gaining activities. Only by placing an added load on the muscles, joints, and spine can an activity offer the benefits of strengthening. Incorporating a 20- to 30-minute strengthening component three days a week, beginning at 15 to 20 RM and slowly progressing to 10 to 12 RM, will enable you to begin promoting the muscle strength and capacity necessary to support your spine.

Resistance training promotes circulatory function and oxygen delivery to the cell’s engine by maintaining an efficient vascular system. Additionally, the pumping action of the muscles during the workout helps to move fluids along the venous system back toward the heart for completion of the circulatory cycle.

Consider Isometrics

For those unable to make it to a gym, isometric exercises provide a great way to accomplish strength-training goals. Isometric exercise, muscle contraction in which no joint movement takes place, aides in promoting circulatory function while working to strengthen muscles. Some argue that isometrics are a poor choice for strengthening. Like everything else, isometrics have limitations. But to accomplish the goals of helping to maintain circulatory, neuromuscular, and muscle performance, isometrics are an excellent choice.


Cardiovascular conditioning and strength training are important components of a fitness program. One often overlooked aspect of fitness is flexibility. Across all ages, flexibility is of particular importance for general health and especially for the spine. Just as we may try to stretch a dollar or perhaps occasionally stretch the truth, we should be mindful of the need to stretch the muscles and supporting myofascia, the sinews that surround the spine and hold us together.

Stretching may be overlooked because it offers no outwardly obvious benefit. Men typically lift weights in an effort to get a big chest or ripped arm and leg muscles, or they may play weekend sports in an attempt to stay young. Women seem to prefer activities that slim their waistlines while toning the muscles. They often choose group activities such as yoga, Pilates, or aerobic classes and tend to avoid the bulk-building activities of the men. Often the time it takes to stretch is viewed as cool-down time, an afterthought, left for the last few minutes of a workout session before the ride home or a quick shower. Yet clinical experience reveals that stretching is the most important part of the program for most people dealing with spinal pain and dysfunction. Degenerative conditions of the spine, stenosis, radiculopathy, overuse and muscle tension issues, athletics-related injuries, adaptive shortening, and many other types of conditions respond well to stretching.

The benefits of stretching are many. Stretching promotes a larger range of motion, reduces muscle tension, enhances circulation, and improves oxygen delivery to the tissues by reducing the mechanical constriction of the vessels from the surrounding connective tissue and muscle tissue tension. The effect is similar to what happens if you stand on the middle of your garden hose and then step off. Clearly, the amount of water flowing out the end increases after you take your foot off the hose. By reducing tissue tension, you improve circulation.

Developing a stretching program needn’t be difficult, although to do it correctly you need to invest some time and perhaps seek the guidance of a qualified professional. Some trained clinicians advocate stretching tight muscles by holding the stretch for 10 seconds and completing three repetitions or so, or holding for 30 seconds before moving to the next stretch, or something of the sort. Although the literature does not specifically state the right amount of time to hold a stretch or recommend a specific frequency for performing stretches, empirically we know that a few bouts of 10-second holds are far too short to gain actual length of shortened myofascia or diminish active muscle tone. Practically, holding a stretch for at least 60 seconds a minimum of two times for each stretch offers some tissue tension relief and a temporary gain of movement ease. Although not validated scientifically, holding the stretch for a minimum of 60 seconds several times is a good starting point. Those with true muscular shortening will need to progress to holding the stretch for several minutes and repeating two or three times as a final ending point. Fortunately, developing a stretching program is not especially difficult and requires less apparatus and time than a gym or swimming workout.

The skeletal muscles that move your body can be categorized into two main groups. Postural muscles cross more than one joint and are prone to shortness. Phasic, or movement-oriented, muscles cross just one joint and are prone to weakness. Most often, flexibility loss follows a general pattern, making it easy to predict which areas and muscles to stretch. Your health care provider should be able to identify the pattern and prescribe the proper stretches in a straightforward manner. When done correctly, stretching nearly always has a beneficial effect on the target area. At all times, stretching should feel good. It should never feel noxious or gritty. Usually, stretching is a necessary and beneficial component of a therapeutic program. By targeting the multijoint postural muscles in the area needing greater flexibility, you can achieve a symptomatic and functional benefit in a short time. But when stretching is done wrong or the wrong stretches are used, stretching likely is going to be a source of irritation, compounding the original problem.

Many patients and clinicians believe that stretching the hamstrings, the group of muscles along the back of the upper thigh, is important to ease lower back pain. In some cases, hamstring stretches are useful because the hamstrings are multi-joint muscles that tend to become short. Hamstring flexibility is necessary for resolving some low back pain, and often poor hamstring flexibility is a contributing cause.


Balance training is an important part of any physical fitness routine, especially for those 65 and older. Each year, more than one-third of those 65 and over fall, making falls the leading cause of deaths and most common cause of nonfatal injury in older adults. The American Physical Therapy Association provides materials on the prevention of falls. In it, they note four main aspects to minimize the risk of falling: physical conditioning, yearly vision examinations, home safety assessment, and a medication review with a doctor.

You can perform several self-checks to assess your risk of falling. The easiest is to count the number of medications that you take daily. Taking more than three medications per day has been shown to cause a significant increase in the risk of falling. Narcotics such as vicodan, oxycontin, and methadone are particularly dangerous, especially when taken in combination with tranquilizers, muscle relaxers, or sleep medications. Another self-check is to assess how far you can reach forward. Stand with your feet shoulder-width apart and your arm held out in front of you and then measure how far you can reach forward. If the total distance is 10 inches (25 cm) or more, your risk of falling is small. If it is less than 6 inches (15 cm), you are four times more likely to fall, and if it is less than 4 inches (10 cm), you are six times more likely to fall. A final simple self-check is the single-limb stance test. Studies show that if you are able to stand on one leg without any other support or contact for five seconds or longer, you are less likely to fall than someone who cannot stand on one leg for at least five seconds.

Balance activities are effective and simple and do not require additional equipment. Because balance is a skill, you can improve it by practicing it. Place your feet side by side and reach forward, keeping 10 inches (25 cm) or more as your goal. Stand on one leg for as long as you can or stand in a heel-to-toe position while you reach, bend, or twist. As long as you are safe and have objects nearby for support if you need it, progress in these activities by trying them with your eyes open and then closed.

Lifest yle Factor 2: Diet and Nutrition

The importance of maintaining a healthy diet is something that we’re all aware of, but it seems hard for many of us to do. Public health officials agree that the fattening of the American population is a problem that includes many factors, related not only to the availability of fast food and junk food but also to lifestyle, academic, family, and social pressures. The added girth of the American population has put a strain on the overall health of our nation. Consider these facts:

  • In 1960 the average American male weighed 166 pounds (75 kg). Forty years later he weighed 191 pounds (86 kg). In 1960 the average American female weighed 140 pounds (64 kg). Forty years later she weighed 164 pounds (74 kg).
  • In 1985 eight states reported adult obesity rates greater than 10 percent. By 1994 all states had rates greater than 10 percent and 16 states had rates above 15 percent. By 2004 all but seven states were above 20 percent and nine states were above 25 percent. In 2007 four states were above 30 percent. By the end of 2010 the obesity rate across the United States had reached 31 percent.
  • In the mid-1970s childhood and adolescent obesity rates were 4 percent and 6 percent, respectively. By 2008 they had leveled at 19 percent and 17 percent, respectively.
  • The average American child today eats 780 calories more per day than he or she did in 1967, mostly because of the high-fructose corn syrup in foods and drinks. In 1967 only 3,000 tons of high-fructose corn syrup were produced;  today over 6,000,000 tons are made. Some reports note a one in three likelihood that those born in 2000 or later will develop type 2 diabetes, leading to a lifespan decrease of 17 to 27 years.
  • As reported in the San Francisco Chronicle in June 2009, Illinois remained one of only two states that required mandatory physical education participation for students of all school ages. (Massachusetts was recently added.) Even so, as of 2007 Illinois was one of the states with adult obesity rates above 25 percent.
  • In 2000 the U.S. surgeon general designated obesity as a national epidemic, reaching across all ethnic and economic groups. A war on fat was declared. By 2007 the obesity rate had increased another 7 percent. More than 30 percent of adults (more than 60 million people) were considered overweight or obese (about 30 pounds [14 kg] or more overweight).
  • In 1980 an average box of popcorn contained 270 calories. Today it’s 630 calories. In 1980 an average turkey sandwich had 320 calories. Today’s supersized, overdone turkey sandwich has 820 calories or more.

Studies show that the odds of having an obese child increase considerably when one or more of the adults at home are obese or if the adults themselves were obese as children. The cycle of obesity perpetuates itself, and our health care system is bearing the burden. Costs associated with diabetes and metabolic and cardiac conditions are skyrocketing. In fact, many researchers report that in the 21st century we’re in danger of reversing the steady increase in average lifespan made in the past 100 years simply because we’re eating too much and moving too little. To some degree the increasing prevalence of spinal pain is a result of that weight gain and sedentary lifestyle.

The Problem of Overweight

In a purely mechanical sense, added weight, especially in the abdominal area, places more strain on the musculature and noncontractile elements of the spine. But we are interested in the burgeoning obesity rates for more than just the mechanical factors that affect the spine. The point of this section is not to lament the issue of weight gain itself, but to relate weight gain to spinal pain through a variety of repercussive factors. Like most everything (excluding death and taxes), there are exceptions to the rule. We all know overweight people who have no specific spinal discomfort and people who are thin but have plenty of neck and lower back discomfort. By and large, however, you are more prone to experience spinal pain if you carry excessive weight. If we revert to our initial hypothesis—all things being equal, the greater your level of fitness, the lesser the likelihood of spinal pain—being obese or overweight lessens your level of fitness in every regard. You will exercise less, eat more poorly, get less restful sleep, and be more likely to suffer from ancillary medical problems when you are heavy. Obesity decreases growth hormones, increases levels of the stress hormone cortisol, and increases the risk of sleep apnea. We must be careful to avoid making the connection that only overweight people eat poorly or that they have spinal pain solely because they are heavy. That is obviously not the case. Being overweight itself is not necessarily the issue. Rather, the effects and results of being overweight lead to a greater likelihood of spinal discomfort.

Nutrition and Cell Health

Diet is an important lifestyle choice because it is the primary way that we replenish our fuel stores. In doing so, we provide our bodies the necessary minerals, protein, carbohydrate, and fat to use for tissue health and repair. Along with oxygen, dietary intake enables our cells to recover from one day’s wear and tear and prepare for the next. Without the replenishing process the cells eventually become depleted of the necessary fuel sources. Much like your car when it is low on gas, your cells will cease to work properly. On a cellular level, without the replenishing benefits of a healthy diet the stage that follows is called exhaustion. Exhaustion is the first component of tissue breakdown, eventually leading to discomfort, pain, and, if left unchecked, disability.

This scenario will help you visualize how nutrition plays an important role in your ability to maintain a level of health and recuperate from the strain of the day. A road construction crew was working nearby, building an overpass. The day was very hot, the kind of day that could cause a person to feel drained after a walk of a just few blocks. A tall, thin, and slightly muscled worker had come out of the nearby convenience store carrying a king-sized candy bar, an oversized bag of chips, and a 64-ounce (2 L) soda. Apparently, that was his lunch. His workmate had a homemade sandwich, an apple, and a drink for lunch. Although there is no way to tell exactly what would happen, a little logic will help us predict the result. Although the worker who bought his lunch at the convenience store was thin and obviously not counting calories, he was depriving himself of the necessary benefits of proper refueling by taking on such low-quality fuel. Given the physical nature of his job, we can suspect it was simply a matter of time (or perhaps he already was there) before his cells, running on empty day after day, began to suffer the effects of fuel depletion. Tissue exhaustion and discomfort eventually follow.

Anti-Inflammatory Benefit in Chronic Pain

Diet also affects the body’s response to inflammation and the duration of the inflammatory cycle. In patients with chronic pain, one consideration is the ongoing presence of an inflammatory process that heightens the transmission of pain stimulus by the nervous system. Food that contain antioxidants and other inflammatory-reducing substances can go a long way toward helping turn down the amplification of pain signals, ultimately reducing the perception of discomfort. Common anti-inflammatory foods include nuts, fish, olive oil, complex carbohydrates such as dark blue and dark green fruits and vegetables, and foods rich in omega 3 and omega 9 fatty acids.

Lifestyle Factor 3: Sleep

A third lifestyle choice that directly affects your ability to maintain a strong and pain free spine is your sleep habits. Sleep is the period when the body does the repairs and replenishing that you need to feel rested and rejuvenated for the following day. Without restful sleep, the body is always in a state of catch-up. Quality sleep helps to balance your hormones, increasing the levels of serotonin and dopamine, the feel-good hormones, and decreasing the level of cortisol. Children and adolescents need nine hours and adults need seven to eight hours of restful sleep every day.

Consider the following analogy. We each have a baggage cart that we pull daily. It’s loaded with the various day-to-day strains of life—physical, emotional, and mental—each adding a burden to the baggage cart every day. During sleep, the body repairs, heals, and replenishes, effectively emptying the baggage cart to create a lighter, more manageable load for the next day. Consider what happens if the baggage cart does not fully empty at the end of the day. Gradually it becomes heavier and harder to pull. Because the cart is weighed down with leftover baggage, it becomes harder to steer. The cart may eventually overflow and create a mess to clean up.

How do you feel when you do not get enough sleep? Physically tired, mentally lethargic, sluggish? Do you have difficulty concentrating? Are you moody, short tempered, emotionally more fragile? The weight of the unemptied baggage cart contributes to this feeling. Sleep is not the cure for all problems, but it is a key part of the rejuvenation process. As the cart becomes heavier, it takes a toll on your physical, mental, and emotional health, creating a scenario in which your body begins to break down. Our emotional, mental, and physical baggage can break us down, even kill us. We’ve all heard of people who smoked and drank their way through life yet lived into their 90s, but it’s safe to say we’ve not heard of anyone who’s avoided sleep over a prolonged time and lived that long. Sleep is essential. It is the key to your body’s repair and rejuvenation process and is one of two (stress being the other) sentinel risk factors that lead to a wide range of other medical conditions.

By choosing to manage your day to get enough sleep, you can actively participate in the daily unloading of your baggage cart. Enhance the degree of restful sleep by staying physically active, avoiding stimulants late in the day (no more 5:00 p.m. runs to the coffeehouse), managing stress, and improving your diet. In this way, sleep becomes productive, allowing for blood transportation and oxygen delivery to the tissues, rejuvenating the body, and making it ready to take on the next day.

Lifestyle Factor 4: Smoking

The fourth lifestyle choice for consideration is smoking. Whether or not you smoke plays a significant role in your risk for spinal discomfort. Remember that blood flow and oxygen transport are necessary to maintain healthy tissue. Smoking directly affects the spine on two specific levels. First, smokers are more prone to spinal pain than nonsmokers are because nicotine reduces the flow of blood to the discs, contributing to degenerative changes of the discs. One study showed that blood flow to a lumbar disc was reduced by 50 percent up to one hour after the last cigarette.

Second, smokers have a greater risk for osteoporotic fracture than nonsmokers do because smoking diminishes calcium absorption and prevents new bone growth. Smoking slows recovery after fracture, surgery, or therapy. Nicotine heightens pain perception, so smokers perceive more discomfort than nonsmokers do.

How do your lungs feel when you swim underwater for too long? Your brain gives your muscles a sudden, direct command to get to the surface and take a big breath. When you do, you feel a sense of relief. Without the breath, you feel panic and a sense of urgency. Figuratively, smoking has the same effect on your spinal structures. The tissues become starved for oxygen. A component of spinal pain caused by smoking is the lack of oxygen delivery that leads the tissues to cry out for relief metabolically. They need a big dose of oxygen to feel better.

The effects of smoking on back pain are cumulative. Those who smoke but quit will have to work to rejuvenate the tissues damaged by smoking. The advantage of quitting is that you can begin the process of feeling better without the ongoing negative effects of smoking. You can eat, sleep, and exercise to a healthier spine and happier you.

Lifestyle Factor 5: Stress

The final lifestyle concern related to your ability to manage spinal pain is the way in which you manage stress. Good stress management is paramount to helping control a plethora of medical conditions, especially musculoskeletal pain.

Stress is not a completely negative feeling. Good stress, like that generated from activities such as athletic competition, social interaction, and hard work toward personal goals, is called eustress. Among the positive benefits of eustress is the motivation inspired by this stress. How many times have you put off doing something, finally come to grips with the reality that it has to get done, and then completed the task in record time? Eustress can also be helpful in focusing your concentration or enhancing short-burst muscle strength. It improves the immune system and dulls your perception to pain by increasing levels of serotonin in your brain.

Distress, also called controllable stress, arises from our need to control our lives, work, relationships, and so on. It helps us plan, organize, prepare, and follow through on projects.

Uncontrollable stress is the result of events that are beyond our realm of control, such as world politics, an alcoholic spouse, an adult child’s failing marriage, or a noisy new neighbor.

The key factor with stress management is the balance of hormones. When we are continually anxious, upset, nervous, frustrated, or angry, the emotional system produces an abundance of the chemical cortisol. Cortisol acts on the blood vessels, causing the smooth muscles lining the walls of the blood vessels to narrow. Blood flow and oxygen delivery to the tissues become more difficult, much as standing on your garden hose limits the flow of water needed to nourish your garden.

Additionally, an overabundance of long-term stress leads to a distortion of restful sleep, an increase of muscle tissue tension (you may refer to them as knots), emotional irritability, and a variety of other situations that may produce symptoms. The American Medical Association estimates that stress is a major component in 90 percent of all illnesses.

Managing stress is easy to say but admittedly hard to do. Consider Joan’s story. Joan was experiencing neck pain but could cite no particular incident or trauma that led to the onset of her pain. Her shoulder was beginning to stiffen as well, and she complained of constant headaches. Neck motion was limited, her upper torso muscles were hard, and the discomfort was unremitting. She did not work, instead staying home most of the time with her husband. Treatment led to some relief, but the discomfort gradually returned. Eventually, Joan revealed that she was staying home most of the time to take care of her husband, who had recently become ill. He was no longer working, and Joan was providing care around the clock. She also was dealing with difficult family news from her siblings, and the events had become overwhelming. Joan’s sleep had diminished to bouts of a few hours, and she had stopped going to the gym for her weekly exercise class. The physical strain of moving and turning her husband coupled with the emotional strain of the predicament that they were in and the mental strain of the news from her siblings had congealed and located in the muscles of her neck. In physical therapy we acknowledged these issues and how they contributed to her overall level of discomfort. Joan resumed a gym program that incorporated stretches and massages and began to talk about the strain that she was under. She began to report dramatic changes. As Joan started to feel better, her outlook on the situation grew more optimistic. She was able to see that her husband was getting better, his time off work was not permanent, and her own change in roles was going to be temporary as well. Within a few weeks, she was almost back to her old self—sleeping better, moving better, and noting much less discomfort. The neck discomfort that she was experiencing was a symptom of several other factors, not itself a root cause. Stress was the amplifier to her muscles’ voice of pain.

Cardiovascular exercise is one of the best ways to manage stress independently. As we described earlier, getting your heart rate into the training zone for 20 to 30 minutes a day can do wonders for hormonal balance. Managing cortisol and increasing levels of dopamine and serotonin through exercise, sleep, diet, and professional help when needed can have a beneficial effect on your level of discomfort regardless of the specific source of the problem.

You Have Control

The five lifestyle factors described in this chapter are interrelated, either helping or hindering each other. Each can have a positive or negative influence on your level of pain, depending on how you choose to address it. The good thing about these five lifestyle factors is that we have the capacity to control each of them in a positive way. This is not to say that doing so is always easy, but it can be done. You can exert more influence over your own symptoms than you might have thought. The choice is yours.