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Archive for October, 2013

International Chair on Cardiometabolic Risk part 2

Since my last blog was so popular and so many people liked it, I wanted to do a part 2 on it. But this part 2 is going to be a little different. It´s going to be only about facts and statistics. Most people seem to remember the information better when given only numbers. Remember, all this data was given by the International Chair on Cardiometabolic Risk.

  1. 1.5 Billion Adults are overweight – 500 million of them are OBESE. These numbers are projected to reach 2.3 Billion and 700 million, respectively, by 2015.
  2. The childhood prevalence of childhood overweight and obesity increased from 4.2% in 1990 to 6.7% in 2010, with 43 million children estimated as overweight or obese in 2010!!
  3. The International Diabetes Federation estimated that in 2012 there were over 366 million people worldwide with type 2 diabetes. By 2030 this is projected to reach 552 million.
  4. SSBs are sugar-sweetened beverages. They include the full spectrum of soft drinks, fruit drinks, and energy and vitamin water drinks containing added sugars. Beverages that do not contain added sugar, such as 100% fruit juice are not considered SSBs. SSBs offer only ¨empty¨ calories and provide almost no nutritional value. A typical 12-ounce (355mil) soda contains about 35-40g sugar and 140-160Kcal.
  5. Numerous studies have linked consumption of SSBs to weight gain and obesity in children and adults. In one study it was seen that for each additional serving of SSBs consumed each day, the odds of becoming obese increased by 60% after 1.5 years!!
  6. In another study individuals with the highest SSB intake (usually1-2servings/day) had a 26% greater risk of developing diabetes compared to those with the lowest intake (none or less than 1 serving per month).
  7. One serving (12oz) daily increment in SSB consumption was associated with a 22% increased risk of developing type 2 diabetes.
  8. Women who drank more than 2 servings of SSBs had a 40% higher risk of heart attack or death from heart disease than women who rarely drank sugary beverages.

Now I will give stats about different European countries. These stats are from the World Health Organization. According to the WHO, you are overweight if your BMI is equal or greater than 25, and you are obese if your BMI is equal or greater than 30. BMI stands for Body Mass Index. Remember in my last post that, although the BMI is important, it is more important where that fat is distributed.

  Overweight                                                 Obesity

  1. Turkey 63.6%                                         1. Turkey 29.3%
  2. Czech Republic 61.7%                            2. Czech Republic 28.7%
  3. Malta 61.6%                                           3. Malta 26.6%
  4. United Kingdom 61.5%                          4. Israel 25.5%
  5. Ireland 60.9%                                         5. United Kingdom 24.9%
  6. Israel 60.1%                                           5. Russian Federation 24.9%
  7. Spain 58.2%                                          6. Ireland 24.5%
  8. Russian Federation 57.8%                       7. Spain 24.1%
  9. Luxembourg 56.7%                                 8. Luxembourg 23.4%
  10. Poland 55.7%                                         9. Poland 23.2%
  11. Portugal 55.3%                                       10. Portugal 21.6 %
  12. Germany 54.8%                                   11. Germany 21.3%
  13. Finland 53%                                           12. Finland 19.9%
  14. Belgium 51.5%                                     13. Belgium 19.1%
  15. Sweden 50%                                          14. Austria 18.3 %
  16. Austria 49.6%                                         15. Greece 17.5%
  17. Italy 49.2%                                             16. Italy 17.2%
  18. Greece 49.1%                                        17. Sweden 16.6 %
  19. Denmark 48.4%                                     18. Denmark 16.2%
  20. Netherlands 47.8%                                 18. Netherlands 16.2%
  21. France 45.9%                                         19. France 15.6%
  22. Switzerland 44.3%                                  20. Switzerland 14.9%

And the last stats, and probably the most surprising, are the ones that talk about the prevalence of obesity and overweight children among 7 years old. I only have the stats for 12 countries but it is still pretty interesting. This study was done in 2008.


Boys                                                    Girls

  1. Italy- 50% are overweight.                                 42%
  2. Portugal- 41% are overweight                            37%
  3. Malta- 33% are overweight                                29.5%
  4. Ireland-32% are overweight                               28%
  5. Slovenia-32% are overweight                             29%
  6. Belgium-24.7% are overweight                           25.7%
  7. Norway- 22.% are overweight                            22.8%
  8. Sweden-  22.4% are overweight                         21.5%
  9. Czech Republic- 21% are overweight                 20.5%


  1. Italy- 27% boys,                                               17.5% girls
  2. Portugal-17% boys                                           12% girls
  3. Slovenia-16% boys                                           10.3% girls
  4. Malta-14.9% boys                                             12% girls
  5. Ireland-12%boys                                               7% girls
  6. Belgium- 9% boys                                              7.8% girls
  7. Czech Republic- 9% boys                                  6% girls
  8. Norway- 6% boys                                              5.5% girls
  9. Sweden- 6% boys                                              5.2% girls

It is amazing, looking at these stats, that 50% of the population of most European countries are overweight. And that in countries like Spain and Portugal, where the Mediterranean diet comes from, and experts say it´s the best, over 55% of the population are overweight!! But what is more scary and amazing are the stats about the kids. Kids are supposed to be running and playing around all day, but society is changing that. Kids spent more time watching TV, playing video games or at the computer, than actually being outside. They are fed junk food all the time and, what is more worrying, a lot of people consider that normal, they say ¨they are kids, they are supposed to eat those candy’s, chips and donuts¨. I have actually experienced that first hand with family members, where I refused to buy ¨junk food¨ for my nephew and gotten told that ¨I was being mean and that they are just kids¨. The ¨junk food companies¨ have done such a good job on advertisement that it´s ¨normal¨ to give your kid a 12 ounce soda with 35-40 grams of sugar, or candy, or chips, or frozen pizza., and that is exactly what parents are doing, not realizing the impacts that those foods have on kids and on society.

Hopefully by seeing these stats people will start to change the way they think and realize what a huge problem society is facing. So until next time: Eat well, drink better, and move more!

International Chair on Cardiometabolic Risk

This will be a special blog, since it was not programmed. Yesterday, I went to a conference (A Lifestyle Disease) where they talked about the cardiometabolic risk we as a society are facing right now. It was very interesting, thanks in part to all the scientists at the conference, who talked about the latest scientifically research data available related to these diseases. First, let’s clear up what cardiometabolic risks are.

  • Cardiometabolic risks: Primary deal with obesity and type 2 diabetes. So all the problems that are associated with these diseases are related to having a cardiometabolic risk.

Before I start talking about what was said at the conference, I want to show some stats. Numbers are always easier for people to understand and to memorize. So I think this will have a bigger impact than anything else I say.

  1. Europe as of 2009 has 55.4 million people with diabetes.
  2. Half the people who have diabetes don´t even know it.
  3. In 2030 it is predicted that worldwide 430 million will have diabetes!!
  4. In Europe alone we spend 110 billion dollars annually.
  5. 400,000 kids in Europe are obese.
  6. 34.6% of adults are overweight.
  7. There are 5.1 million deaths from smoking, there are 5.3 million deaths related to inactivity!!
  8. Sugar Sweetened Beverages stand for SSB. People who consume 2 servings of SSB increase the risk of getting type 2 diabetes by 25%.
  9. 2 servings of SSB a day and your chances of having a heart attack increase by 40%!!!

I could go on forever but I think these stats have made their point. Obesity is a worldwide epidemic and the consequences of it are horrible. Most people know that the more fat we accumulate the greater the chance of suffering some kind of cardiovascular disease. But what most people don´t know is that where we accumulate that fat is much more important than anything else. Recent studies have shown the importance of body fat distribution as a key determinant of the health risk. Imaging studies have revealed that excess visceral adipose (fat) tissue at undesired sites (such as the liver, the heart, the kidney, the pancreas) may have detrimental effects on the risk of type 2 diabetes and cardiovascular disease. In other words, the fat that is in your organs (visceral obesity), is much more important than the overall body fat.

Now, this is where it gets interesting. They have done studies that have shown that obese or overweight people who engage in physical activity on a regular basis, lose visceral fat and decrease their chance of getting a cardio vascular disease, although their overall weight has NOT gone down. Even more interesting and amazing, people who are overweight or obese and do 30 minutes of physical activity per day have a less chance of getting a cardiovascular disease or cancer, than a ¨normal¨ person who does nothing!!!  These recent studies are amazing and I want everyone really to understand the importance of this, so I will try to clarify it even a little bit more.

  • Your overall weight is not that important!! We have always been obsessed with our scale, but in terms of health, weight is not that important. What is important is the fat you accumulate under and around your organs. And by doing physical activity of at least 30 minutes a day, it has been shown that the fat under and around your organs goes away, although you may still weigh the same!!
  • So for all those people who have ever started in a physical activity and gave up because they never lost weight, these recent studies say DON´T STOP!!! Even if you are not losing weight on the scale, it doesn´t matter. You are doing more good to your body than you can imagine!
  • So if you do exercise and produce weight loss that is GREAT. If you exercise and you don´t lose weight that is also GREAT!!! ¨ We must look beyond weight loss as the only indicator of health.¨- attributed to Dr. Ross.

In conclusion. 5.3 million people will die because of inactivity. Meaning that instead of walking to their job, they will take their car. Instead of going up the stairs, they will take the elevator. Instead of going for a walk, they will sit home and watch a movie.

Throughout this blog I have said physical activity, not sports. They are completely different. You can be poor and do physical activity, you may have the busiest life on the planet and still engage in a physical activity. Physical activity is moving and no one in this world can have an excuse for not doing that.

So until next time, eat healthy, drink healthy and MOVE.

The academic evidence at the conference was giving by:

  1. Jean-Claude Coubard- He is the Directo of Research in Cardiology at Centre de recherche de L´institut universitaire de cardiologie et de pneumologie de Québec.
  2. Ulf Smith- Directo of the Lundberg Laboratory, Vice Chairman of the Departement of Molecular and Clinical Medicien, The Sahlgrenska Academy, Göteborg University, Sweden and Vice President of the European Association for the Study of Diabetes
  3. Luc Van Gaal- A member of the Editorial Board of a series of scientific journals. He is borad member of the Belgian Association for the Study of Obesity (BASO) and Past-President of the Belgian Diabetic Society. He is the running secretary of the Belgian Endocrine Society
  4. Marja-Ritta Taskinen- Professor of Medicine, Department of Medicine, Cardiology Division, University of Helsinki, Finald.
  5. Jean-Pierre Després- Director of Research in Cardiology at Centre de recherche de l´institut universitaire de cardiologie et de pneumologie de Québec. He is also the Scientific Director of the International Chair on Cardiometabolic Risk, Faculty of Medicine, Université Laval, Quebec, Canada.
  6. Frank B. Hu- He is Director of the Harvard Transdisciplinary Research in Energetics and Cancer (TREC) Center, Harvard School of Public Health as well as CO-Director, Program in Obesity Epidemiology and Prevention, Harvard School of Publich Health, Boston, MA, United States.
  7. Robert Ross- Director of the Centre for Obesity Research and Education, Queen´s University, Kingston, Ontario, Canada; Queen´s University Research Chair, and President of the Canadian Society for Exercise Physiology.
  8. Franco Sassi- Senior Health Economist at the Health Division of the OECD and a former lecture at the London School of Economics and Political Science.

Is food addictive part 3?

Last week I did two blogs on how certain foods can be addictive and how we have a hereditary predisposition for wanting to eat foods with lots of calories. I also mentioned how we really don´t have strong instincts to engage in physical activity because, before in the past, physical activity used to occur automatically every time we needed to hunt. No one would just go for a run and waste precious calories, we needed all the calories we had. Now, everything has changed. It´s easy to get food and we barely move, and those are two of the reasons why obesity is a WORLD WIDE EPIDEMIC.

Well, in this third part of ´is food addictive´, I’m just going to mention some facts that most people don´t know and should, and that I consider pretty important. So let´s start off.

  1. Did you know that the last 10,000 years of our history only represents 1% of  human history? The body changes and adapts over time but it usually takes thousands of years for that to happen. Agriculture first arrived 9,000 years ago, if you think about it, in terms of human evolution, that´s not a long time ago.
  2. Before agriculture we were hunter-gatherers. Fossils records show that Paleolithic hunter-gatherers lifespan averaged 26 years, but with the invention of agriculture the lifespan went down to 19!!! (1)
  3. In Greece and Turkey, near the end of the Paleolithic hunter-gatherer era, men averaged 5´9 (175cm) and women 5´5 (166cm). By 3000 BC, with agriculture a way of life, the average height had dropped to 5´3 (161cm) for men and 5´ (152cm) feet for women (1,5). This could be because the Paleolithic hunter-gatherers ate hundreds of plants and animals, supplying lots of complete proteins and vitamins. Farmers ate mainly three crops, wheat, rice and corn, because they were the easiest to cultivate, harvest and store without spoiling.
  4. Human milk matches the exact proportions of amino acids and fats used for brain circuits and contains antibodies to prevent infections. Cows milk contains very different proportions of amino acid and much more fat. Babies fed on breast milk average 8.3IQ points higher by the age of 8 than those fed on milk-based formula.(3)
  5. Predators consistently have larger brains than herbivores. You require more cunning to catch prey than to find the next leaf. Omnivores, who must switch between these tasks, tend to have larger brains yet.
  6. Brains and nervous systems are for mobility; plants don´t have brains, animals do. Exercise especially generates neurons in the hippocampus, an organ associated with memory, and these new neurons have been demonstrated to enhance learning. What I´m basically stating here is: MOVE, it will make you smarter.
  7. Dieting, in the long run, almost never works! Maximal weight loss is typically achieved at around 6 months, followed by weight regain.(2)
  8. Evidence has been building up that if you consume less calories, far below that needed to maintain normal weight, but still consume vitamins, protein and other important nutrients, your lifespan could increased by up to 65 percent.. (8)
  9. They have done studies with a low-calorie diet on different animals such as rats, yeast, worms, flies, spiders, fish and several types of rodents, and have seen the lifespan of the animals increase from 25 to 65 percent.(6-7)
  10. The people who live the longest come from Okinawa, Japan. Their diet consists of a higher percentage of fresh vegetables than in most places, and fish and soy make up virtually all the protein. Okinawans consume 40 percent fewer calories than Americans and 17 percent fewer calories than the average Japanese.  (9)
  11. There have been studies that have demonstrated the effect of larger portions on consumption. Did you know that the standard serving portion size for almost everything is larger than it was a generation ago? We sometimes see this in restaurants, especially in the USA, were the servings are huge. The problem with huge serving sizes is that we eat more than we are supposed to. They did a experiment on people, where people were invited to a lab for a ¨taste test¨of soup. Some of  the participants got a bowl that had a tube connected to the bottom of the bowl, so that it was always full. The other participants ate from a normal bowl. All the participants thought they had a ¨normal¨ bowl. Those with the ¨bottomless¨ bowl ate 40 percent more!!


Certain foods are addictive, we have a hereditary predisposition for storing fat and we don´t have a strong instinct to engage in physical activity. On top of that we have changed drastically the way we eat, especially the last 80 years. Remember, and I know I have stated this a couple of times but it´s quite important, the last 10,000 years only represent 1% of the human evolution. Before agriculture we were hunter-gatherers and ate hundreds of plants and animals. The animals we ate were animals that were in the wild and had a high content of protein. The animals we eat now, are in farms, fed ¨shit¨ food, and given hormones to grow as fat and as quick as possible.  Another problem is that we eat much more than what we are supposed to. Just bear in mind that the people who live the longest on the planet are the Okinawans and they eat quite less than the average American or Japanese. Also, let´s not forget that the bigger the serving the more we eat (compare the dishes you have now with the ones your grandparents have).

So, with all this said, I think I found a solution to the problem. Instead of moving more, eating well and drinking better……… just buy smaller dishes !!! 😉

My next blog will finally be about sports. It will talk abou the myth of high repetitions. I think we have all heard that if you want to lose weight and tonify you have to do more repetitions, but is this true??  We will see in my next blog…. until then .

      1. Deirdre B. Waistland. The Evolutionary Science behind our weight and fitness crisis. W.W. Norton & Company. New York, 2007. pg 11.
      2. Mann T, Tomiyamas J, Westting E, Lew A-M, Chatman J. Medicare´s Search for Effective Obesity Treatments. American Psychologist, 2007;220-30.
      3.Lucas A. Breast Milk and Subsequent Intelligence Quotient in Children Born Preterm. Lancet 339,1992; 261-4.
      4. Reuters, ¨Researcher Links Obesity , Food Portions.
      5. Angel. Paleoecology, Paleodemography and Health.
      6. Lawler F-D. Influence of Lifetime Food Restriction on Causes, TIme and Predictores of Death in Dogs. Journal of the American Veterinary Medical Association 226, 2005; 225-31.
      7. Delaney M, Walford L. The Longevity Diet: Discover Calorie Restriction. Marlowe & CO. New York, 2005.

    9. Wilcox B. How Much Should We Eat? The Association Between Energy Intake and Mortality in a 36 Year Follow-Up Study of Japanese-American Men. Journal of Gerontology: Biological Sciences 59,2004; 789-95.

Is food addictive part 2?

In our last post we talked about how certain foods can be addictive by producing chemical changes in our brain. We also saw that eating refined fatty meals makes us stop producing Leptin. Leptin is a hormone which signals the body to stop eating, but we also saw that the reverse can also happen. Meaning that if you stop eating the junk food and start eating healthy, the levels of those hormones return to normal, so there is hope. But what is eating healthy?

10,000 years ago, which may sound like a long time but it equals to only 1 percent of human history, most humans lived like hunter-gatherers. Back then we used to eat a lot of meat (this meat, contrary to what we eat now, contained much more protein), fish, fruits, leaves and seeds. We ate more than one hundred species of plant- most rich in vitamins, fiber and other nutrients. Fats and sugar were rare but we developed a craving for them because they contain lots of calories, which was important back then to survive. Thanks to our diet, and because we were always on the move, people were lean but whoever could store fat had an advantage. So we developed a predisposition for carrying fat on our bodies as well as wanting it in our foods. The problem is, back then it was difficult to get too much of these foods, now it´s the complete opposite. So not only do we get ¨addicted¨ to these foods when we eat them, we also have hereditary predisposition for wanting to eat them.

So I guess I´m not saying anything new about what is healthy eating. I think most people know what is healthy and what is un-healthy, the problem is people don´t do it. And now we know some reasons why that is. It´s the same thing with physical activity, most people know they have to move more but they don´t do it. They always use excuses like they don´t have enough time or that something hurts, ironically most of these problems are improved by exercise. Biologically we need exercise, but we don´t have strong instincts to engage in it. Before, physical activity used to occur automatically while trying to catch or find out food, now it´s not like that. Back then no one would just go for a run, that would be wasting precious energy and calories, you needed all the energy and calories you could have. Those extra calories could make the difference between life and death.

This blog just gets worse and worse, not only do we have a hereditary predisposition for wanting to eat foods with lots of calories, but once we eat them we get addicted to them – and to top that off I just said that we don´t have strong instincts to engage in sports!!! No wonder we are loosing against obesity and getting fatter and fatter every day. But there is hope, I have seen it, even done it!! You can fight back …… I won´t tell you what you have to do because I want to keep the secret to myself but I´ll give you a hint: It has to do with eating and moving.

In my next blog, we will continue with the third part of ¨is food addictive¨ by mentioning some interesting facts that most people don´t know. Until next time I leave you with the second part of ¨The men who made us fat¨

Is food addictive?

Today in age people are getting fatter and fatter. Obesity is now a world wide epidemic. In the USA in 1995 two-thirds of Americans were overweight and obesity was killing 300,000 people a year, sickening millions and costing $99 billion annually. 10 years later and the Americans (the studies I have are from Americans but I bet in Europe it is the same thing) were eating 50 percent more fast food meals and five more pounds of sugar a year. US obesity related health costs have risen to $117 billion!!!(1) So what´s wrong? Why do we keep eating and getting fatter? We know it´s bad for us but we still don´t do anything about it. Are we just plain stupid? Or is there something more complicated that we still don´t understand? Can food be addictive……..


There is growing evidence that sugary foods can trigger changes in the same brain chemicals affected by addictive drugs. Researchers at Princeton have shown that natural opioids are released when rats eat a large amount of sugar and that they are thrown into a state of anxiety when the sugar is removed. Biologist are also finding that overeating on refined fatty meals triggers similar physiological changes. Leptin is a hormone which signals the body to stop eating after a certain point when consuming natural foods (2). Well, researchers at Albert Einstein Medical College saw that when they fed rats unnaturally fatty meals, the rats would loss all of their ability to respond to leptin. They just kept eating!!! The reverse effect happened when they were taken off the high fat for a while. There was also a study at Rockefeller University that showed that a high fat diet reconfigures the body´s hormonal system to want yet more fat. Galanin, a brain peptide that increases eating and slows energy expenditure, rises in rats on a high fat diet (3). In fact, it only takes 1 high fat meal to stimulate galanin release and the craving for fat. So we are beginning to see that food can actually be addictive, but we can also stop this addiction by eating properly. But what is eating properly? Before I answer this question I want to try to clear some terms that I think are important:

  • Refined: We always hear this word but few people really know what it means. When ¨refining¨ flour, sugar or other foods, it means it is removing the hull and fiber, often even the cell wall of plant structures, leaving only simple carbohydrate or clear oil. Farming refines our food all the time. A recent study of nutrients in food found that, in the second half of the last century (1900-2000), fruits and vegetables suffered significant decreases in protein, calcium, phosphorus, iron, vitamin B2 and vitamin C.
  • Insulin: When we eat simple carbohydrates, glucose levels soar in the bloodstream. In the short term, our bodies release INSULIN to store the glucose as fat. Repeated surges in blood sugar make the pancreas work harder and can contribute to insulin resistance, thereby increasing the risk for type 2 DIABETES, in which blood sugar levels remain elevated, causing damage to our kidneys, eyes and immune system (4).
  • Trans Fats- ¨are produced by heating liquid vegetable oils in the presence of catalysts and hydrogen. This gives them a different shape from the original oil or the natural saturated fats found in meat. They don´t fit properly with cell membranes or with enzyme designed to digest fats. Trans fats cause a significant drop in HDL (good) cholesterol and a significant increase in LDL (bad) cholesterol, they make the veins and arteries more rigid, they cause major clogging of arteries and they contribute to the risk of death from heart disease. Because trans fats contain abundant calories without providing the beneficial fats found in natural vegetable oil, they lead to overeating with under nutrition. Trans fats now make up much of the fat in CANDY, COMMERCIAL COOKIES and cakes, and the oils in which FAST_FOOD CHAINS FRY FOOD¨  (*Taken from Waistland by Deirdre Barrett pg 34)



In my next post I will talk about what eating properly is and how we are doing right now the complete opposite. But in the meantime I would love for you guys to take a look at this link. It´s a series BBC did on obesity and it´s called THE MEN WHO MADE US FAT. It consists of 3 parts and each last 55 minutes but it´s very interesting. Here goes the link:




Barrett D. Waistland, The (R)Evolutionary Science behind Our Weight and Fitness Crisis.Norton & Company.2007


Egan S. Making the Case for Eating Fruit. New York Times. July 2013.


Colantuoni C. Evidence that intermittent, excessive sugar intake causes endogenous opioid dependence.Obesity Research 10,6 (2002):478-88.


Martindale D. Burgers on the Brain:Can you really get addicted to fast food?, ¨New Scientist, February 1,2003.


Wang J. Overfeeding Rapidly Induces Leptin and Insulin Resistance. Diabetes 50(2001):2786-91.

Pain part 3

So we have talked already about how pain is produced in the brain, how posture really doesn´t affect pain and how pain can be divided into acute and chronic pain. Acute pain being pain that last 3 to 6 moths and chronic pain, pain that last more than 6 months. So how do you treat the different kinds of pain?

With acute pain it is usually quite easy, the pain is associated with the tissue injury that has been produced and, in many cases, pain medications do work reasonably well. For example, NSAIDs (Nosteroidal anti-inflammatory drugs) have been shown to be effective for injuries (like ankle sprain), and after surgery. But for chronic pain, medications are only slightly effective and this is due to the fact that pain can change your nervous system (1,2).

It has always been said that the brain and the nervous system couldn´t change. But since a decade ago we know that the brain is plastic and can indeed change, it´s called NEUROPLASTICITY. Scientists have seen from imaging and animal studies that persistent pain or pain which last for months and years can change the pain pathway, in other words we become more sensitive. This hypersensitivity causes the brain to interpret anything related to those tissues to be highly threatening. So basically the nervous system and the brain have become more efficient in producing and maintaining pain (3-5). You could say that in chronic pain, the pain has moved up to the nervous system and now has very little to do with the initial damage to the tissues that caused the pain.

Let´s try to clear this up and make it easier to understand with an example: John, age 45, has had lower back pain for the last 2 years. Everytime he bends down to pick up something he experiences pain, so he stops doing that. We know that tissues or bones usually heal in between 3 to 6 moths, so there is really nothing wrong with him from a anatomical point of view. And everytime he bends down it doesn´t mean that he got hurt again or that he re-injured himself. It is just that Johns brain and nervous system have become so good at constructing pain that the slightest of triggers – even those that don´t cause damage, cause pain. So how do we deal with this?

The most important thing would be to educate John about pain, to teach him the role of the brain in pain, and to explain to him that pain doesn´t always equal to damage. When education about pain physiology is included into physiotherapy treatment of patients with chronic pain, pain and disability are reduced (6,7). After this, the next thing would be to gradually expose John to the feared activity (bending down) without causing pain and thereby lowering the threat level in the brain. So we would teach him first how to bend down correctly and to only bend till the point before the pain starts. This process would start to decentralize his pain and eventually make his pain disappear.

To finish I want to hopefully think that people now understand a little bit more of how pain acts and how to deal with pain. These last 3 articles have been difficult and maybe hard to understand but I would be satisfied if people took at least these 3 points home:

  1. Damage does not equal pain; not all damage leads to pain, and not all pain is caused by damage. Example: a study in the journal Arthritis & Rheumatism looked at the relationship between knee osteoarthritis and pain (8). They found out that some people had little arthritis and high pain, and some people had severe arthritis but low pain. The researchers concluded that the level of knee pain was due to central sensitization, rather than the level of osteoarthritis. In other words, the level of pain had more to do with changes in their nervous system, not changes in their knee structure.
  2. You can have a bulged disc or degenerated spine, maybe even impinging on one of your nerves, and still not have pain. Or you could have none of these problems, and still have persistent pain (9-12).
  3. The International Association for the Study of Pain defines pain as an emotion. That is, pain is a perception rather than a sensation. Unless and until the brain senses danger or threat, nothing can cause pain.

To finish I will post 2 links.

In one of them Lorimer Moseley describes how to explain pain to patients and in the second one, which is quite long (44 minutes), he talks about the whole process of pain. Enjoy

In my next blog we will change the topic drastically and talk about food. Is food a drug?? Can you get addicted to food? We will see and explain in my next blog. See you then.


1. Ekman EF, Ruoff G, Kuehl K, Ralph L, Hombrey P, Fiechtner J, Berger MF. THe COX-2 sècific inhibitor Valdecoxib versus tramadol in acute ankle sprain: a multicenter randomized, controlled trial. Am J Sports Med. 2006 JUn;34(6):945-55. Epub 2006 Feb 13. PubMed PMID: 16476920

2. Buvanendaran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of cuntion after knee replacement a randomized controlled trial. JAMA. 2003 Nov 12,290(18):2411-8. PubMEd PMID: 14612477.

3.Flor H, Nikolajse Li, Stachelin Jensen T. Phantom limb pain: a case of maladaptive CNS plasticity.

Nat Rev Neuroscience 2006 Nov;7(11):873-81.

4. Flor H, Braum C, Elber T, BIlbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience 1997: March 7.224(1)5-8.

5. Ren K, Dubner R. Central nervous system plasticity and persistent pain. J Orofac. Pain.1999.Summer.13(3):155-63.

6.Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J pain 2004. Sept 20(5): 324-30.

7. Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiotherapy 2005: 31(1):49-52.

8.Dallinga JM, Benjaminse A, Lemmink KA. Which screening tools can predict injury to the lower extremities in team sports?: a systematic review. Sports Med. 2012 Sep 1;42(9):791-815.

9. Johnson C. Modernized Chiropractic reconsidered: beyond foot-on-hose and bones-out-of-place. J Manipulative Physiol Ther. 2006 May;29(4):253-4. PubMed PMID:

10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage. 2008 May;35(5):544-62. Epub 2008 Feb 14. Review.

11. Homola S. Chiropractic: history and overview of theories and methods. Clin Orthop Relat Res. 2006 Mar;444:236-42.

12. Good CJ. The great subluxation debate: a centrist’s perspective. J Chiropr Humanit. 2010 Dec;17(1):33-9. Epub 2010 Sep 21.

Pain part 2 – Does bad posture cause pain?

The other day we saw that pain is very complex and that in most cases it´s produced in the brain. So, if it´s really produced in the brain, does posture or movement really matter? We have all gone to the physical therapist or doctor and have heard that ¨your back pain comes because you have too much of a curve in your back¨, or ¨your back pain or shoulder pain comes because of your forward head posture¨ or ¨your knee pain comes because you have too much of a pronation on your foot¨. Hell, I´ve done it, I´ve been saying that to my patients for years because that is what was taught to me.

Up to last year I had a client, XG, who always came to me because he had back pain. I would always tell him that his back pain was coming because of his posture. He had a forward head (still does) and a big lordosis (inward curve) in the lower back .I tried to correct his posture, I gave him exercises to do at home, I stretched him, I did everything you could imagine but his posture hasn´t really changed but guess what, his pain has, it´s gone!!

So what I´m basically trying to say is that there is no consensus on supporting a biomechanical (and posture) model of pain (1-10). Because:

• Postural and structural asymmetries cannot predict back pain and are unlikely to be its cause (1).

• Local and global changes in spinal biomechanics are not demonstrably the cause of back pain (1).

• A postural structural biomechanical model is not suitable for understanding the causes of back pain (1).

This is so because postural structural asymmetries and imperfections are normal!! The body has surplus capacity to tolerate such variation without loss of normal function. That is why there is little scientific evidence to show that posture will cause pain (2-5). If posture was a factor of pain how come you see thousands of people around with bad posture with no pain and thousands more with ideal posture in a lot of pain? That just shows that there is much more to pain than just posture.

This is not meant to deny that there is a correlation between pain and certain postures, but that this association is neither sufficient nor conclusive to justify our efforts to dictate people’s posture and movement. But what we do know for sure is that there is no ‘ideal’ posture, and any posture if maintained for too long will result in dysfunction, and maybe pain. The key is movement.

To end this article and the topic of posture and pain, and to confuse people even more, I will say that there actually is potential harm in  “addressing” the unsubstantiated claims of bad posture. Things just as: focus on “bad” movement or “bad” positioning have the potential to sensitize the individual into believing that a benign (wrong) positioning is in fact something that represents a threat. And as we saw yesterday in the video, pain is the response to threat, either real or perceived, and how we view our environment and ourselves within that environment can positively or negatively affect that threat response. So by addressing things that don’t have evidence to support them (bad posture), we are actually increasing the chance that an individual might have the very real experience of pain. We are creating a self-fulfilling prophecy. That is real harm – and it is evidenced (2-5).

I will finish by quoting some of Lorimer’s famous quotes and with a link to a video that demonstrates the tricks the mind can play on us.

Favorite Lorimer Quotes

  • “Pain is very complex.”
  • “We can’t treat every pain patient with a simple solution.”
  • “The best way to get rid of chronic pain is to chop the person’s head off.”
  • “As soon as you interact with the patient, you are in their brain.”
  • “Always do more today than you did yesterday.”

P.S In my last post I said that you can have an injury without having pain. Some of you didn´t believe me, which is normal, so references 7-12 demonstrate just that.

Also, those that have been following me may be asking themselves why I still  haven´t talked about how to deal with pain. The simple answer is that I first wanted you guys to really understand what pain is and change the way you think about it. With these 2 posts maybe you haven´t really understood it yet, but I probably made you look at pain from a different perspective. Now that we have this different perspective, in my next post I will finally talk about how to ¨deal¨ with it. Hope you liked the article, until next time.


1. Lederman E. The fall of the postural-structural-biomechanical model in

manual and physical therapies: exemplified by lower back pain. J Bodyw Mov

Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011

2. Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May

3.Moseley, G. Lorimer. Reconceptualising pain according to modern pain
science. Physical Therapy Reviews 2007; 12: 169–178.

4.G Lorimer Moseley. Teaching people about pain: why do we keep
beating around the bush? Pain Manage. (2012) 2(1), 1–3.

5.Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.

6. Moseley GL. Pain, brain imaging and physiotherapy–opportunity is
knocking. Man Ther. 2008 Dec;13(6):475-7.
7.Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people
without back pain. N Engl J Med.1994 Jul 14;331(2):69-73.

8. Sher JS et al. Abnormal findings on magnetic resonance images of
asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5.

9.Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset
and descriptor patterns related to different injuries. Pain. 1982

10. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magneticresonance
scans of the lumbar spine in asymptomatic subjects. A prospective
investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.

11. Kleinstück F, Dvorak J, Mannion AF. Are “structural abnormalities” on
magnetic resonance imaging a contraindication to the successful conservative
treatment of chronic nonspecific low back pain? Spine (Phila Pa 1976). 2006
Sep 1;31(19):2250-7.

12. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S,
Einhorn TA, Felson DT. The clinical importance of meniscal tears
demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J
Bone Joint Surg Am. 2003 Jan;85-A(1):4-9.

Pain part 1

It´s a complex and mysterious thing. I always thought that pain came from an injury or damage caused by misaligned joints, weak and tight muscles, ruptured disks, bad posture and so on. But recent studies have shown that to be false. Pain is produced 100% of the time in the brain and depending on the situation, your well being, your emotions and a thousand other things, that pain is going to be more intense or less intense. In some situations you may have an injury and not even feel the pain.!!….surprised? So am I, so let´s try to explain it.

Pain before was often thought of as a reflex mechanism, meaning that when you got hurt, pain receptors would send signals to the brain and we would sense that pain. But it doesn´t really work that way. What we have are called ¨nociceptors¨, and these nociceptors are similar to other receptors that sense pressure and temperature. The only difference being, that you need a bigger stimulus to activate these ¨nociceptors¨.

So when these nociceptors are activated they send warning signals to your brain and it´s up to your brain to decide whether it is a real danger or not. So you will not feel pain unless and until the brain believes that there is a threat to the body.

Pain can be divided into 2 different types of pain:

  1. Acute pain is the one you experience after a broken bone, a cut, a surgery, a burn, and such pain usually goes away when the underlying injury has been treated or healed. It might last for a few seconds, hours, weeks or, at the most, 3-6 months, which is the time it takes to heal and remodel connective tissue.
  2. But in a few people, even after the tissues had enough time to heal, pain persists for years, this is called chronic pain.

This could be a little complicated, so let´s stop here, analyze the information and take a look at a couple of videos that I think will help you understand the concept of pain better.  The second video is about Lorimer Losley. He is the author of ¨Explaining Pain¨, a great book I recommend.

I will stop here for today and continue next time with the second part of pain, where I will talk about how to treat pain. Hope I made you think.


A quick side note before I start talking about acupuncture. I want to say that I did a Postgraduate degree on acupuncture 8 years ago, after finishing my Physical Therapist studies. I never got the hang of it, and I never really understood it, so I never used it with my clients, but during the time of my studies, I inserted needles and people inserted needles onto me.

OK, let´s begin by saying what acupuncture is: Acupuncture is a collection of procedures involving penetration of the skin with needles to stimulate certain points on the body. It is based on the notion that health and well-being relate to the flow of a life force through pathways (meridians) in the human body (1). In its classical form it is a characteristic component of traditional Chinese medicine. There are various schools of acupuncture but the majority support the notion of 12 meridians (there are 12 main rivers in China). Meridians supposedly are associated or connected to one of the mayor organs and there are hundreds of possible acupuncture points along the meridians. Before deciding on the acupuncture points, the acupuncturist must first diagnose the patient by inspection, auscultation, olfaction, palpation and inquiring. (1)

The thing that I always find funny is the way people defend acupuncture. They always say to me ¨it has existed for thousand of years so it has to be true¨, and this makes me believe they don´t know what they just said because right there, in that sentence, is part of the answer of why acupuncture doesn´t really work. First, I´ll start by saying that over 2000 years ago (the first mention of acupuncture was 2,600 BC), we didn´t really know how the human body worked, even now, with all the technology we still can´t explain certain things. So you think 2,000 thousand years ago in a culture that performed no DISSECTIONS, they knew what they were doing or where they were sticking their needles (1,2)? If you believe that, then you have to believe on the principles that a ¨life force¨ called qi flows through bodies along 12 channels or ¨meridians¨, and that illness and pain occur when qi cannot flow freely……….and if that´s the case then acupuncture is the right treatment for you.

Let´s just imagine that qi doen´t really exist, since it has never been proven by science (3), this doesn´t mean acupuncture doesn´t work. Maybe acupuncture works through a theory called ¨gate control theory of pain¨. The theory is based on the idea that the spinal cord contains a neural ¨gate¨ that can open and close to reduce or enhance pain messages passing to the brain. This theory seems more logical and maybe that´s why acupuncture does seem to work, or maybe it´s just all a placebo effect.

So to see if acunpuncture is a real treatment or a ¨trick¨, the scientific community has been doing trials, and a lot of trials have been done.

At the beginning these trials compared acupuncture with no treatment. These studies suffered from bias because as I mentioned in my last post ( patients having any procedure tend to feel better than those who have none. So a lot of positive clinical trials came out in the 1970s, 80s and even 90s. Also a lot of positive clinical trials were coming in from China. But if you compared the clinical trials coming from China from the ones coming in from other countries, the Chinese trials were always positive!! (Most people don´t know that during the Daoguang Emperor (1782-1850) acupuncture was in decline and that it only experienced a revival in 1949 as a direct result of Mao Zedong, who promoted Chines traditional medicine during the Cultural Revolution as a way to boost national identity and deliver cheap healthcare (1,2) .

So in 2003 the World Health Organization did a review and analysis of reports on controlled clinical trials and they said that the benefits of acupuncture were either proven or had been shown in the treatment of 91 conditions!!!! (4). But… they had included all those clinical trials that I have mentioned before that were badly conducted and the ones coming in from China.

Cochrane Collaboration is a global network of experts coordinated via its headquarters in Oxford. They adhere to the principles of evidence-based medicine and what they do, is examine clinical trials and other medical research in order to offer clear conclusions about which treatments are genuinely effective for which conditions. It´s basically the  ¨gold standard¨ inside the scientific community. They disregard any clinical trial that is not reliable and only look at those in which their quality is reliable. They published their conclusions and said that there is no significant evidence that acupuncture is an effective treatment for the following conditions:  Smoking addiction, cocaine dependence, induction of labour, Bell´s palsy, chronic asthma, stroke rehabilitation, breech presentation, depression, epilepsy, carpal tunnel syndrome, irritable bowel syndrome, schizophrenia, rheumatoid, arthritis, insomnia, non-specific back pain, lateral elbow pain, shoulder pain, soft tissue shoulder injury, morning sickness, eggcollection, glaucoma,vascular dementia, period pain, whiplash injury and acute stroke (5). They did however say that it ¨could¨ help in the cases of pelvic and back pain during pregnancy, low back pain, headaches, post-operative nausea and vomiting, neck disorders and bed wetting – the important word here is ´could´.

The problem with clinical trials with acupuncture is how do you create a ¨sham¨ group or control group? With pills it´s easy, one group takes the real pill and the ¨control group¨ takes the fake pill, the patients don´t know what they are taking. After that, you just compare results between one group and the other, to see if the real pill does really have an effect or if it´s just a placebo effect. With acupuncture is quite hard because you HAVE to use needles, if not the patient is going to know the difference. So a doctor by name of Edzar Ernst and Jongbae Park created a telescopic needle- that is, an acupuncture needle that looks as if it penetrates the skin, but which instead retracts into the upper handle part (1). The needle offers some resistance as it is retracted into the upper handle. This meant that it would cause some minor sensation during its apparent insertion, so patients would think they were getting real acupuncture but were actually not.

After this new invention came out, new trials started to be conducted and the results of these trial were not that good for acupuncture (6). It showed that acupuncture is just as good as ¨sham acupuncture¨, meaning its benefits are only derived from its placebo effect. A lot of people will say who cares if it´s a placebo effect or something else, if the patient is deriving benefit from the treatment, why not just go ahead with it. I have my opinion regarding to this, which I stated in my last post. Some agree with it, some disagree with it and that´s perfectly fine, as long as you know the real reason why you are doing acupuncture or getting acupuncture.

My next post will be about pain. Do we really know what pain is?  How come people who have arthritis in their knee have no pain and some do have pain? How come people with herniation have pain in their back, and some don´t? Is pain really in the knee, back, arm……… or is it all in the head? If so, then maybe we have to start changing the way we deal with injuries or treat our patients. Until next time enjoy the weekend!

P.S. I have added a video to my last post. I would highly recommend that you take a look at it. Sometimes videos express things more clearly than I do. So far I have posted 2 videos. One in the ¨placebo¨ article and the other one in ¨the myth about fast and slow metabolism¨. Really interesting both of them.


1.Ernst E, Simon S. Trick or Treatment ? Alternative medicine on trial. Transworld Publishers.London,UK.2008.

2. Derbyshire D. Why acupuncture is giving sceptics the needle. The observer 2013.

3. Gorski D. A Trilogy of (Acupuncture) Terror. Science Based medicine 2013.

4. . Word Health Organization.2003.


6. Ingraham P. Does acupuncture work for pain? 2009.

7. Moffet HH. Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials. J Altern Complement Med. 2009 Mar;15(3):213-6.


So now we are going to change topic and start talking about pain. I´m a physical therapist and I treat a lot of patients and I am always surprised by how pain can be so different from one person to the other, even though they may have the same ¨injury¨. Pain is a complex thing and something I will talk more deeply about in one of my next post, but now I want to talk about how to treat pain and the placebo effect.

It´s funny how sometimes using the same technique in 2 different people, I would have different results. In some of my patients the pain would disappear and in other, the pain would just stay there. I know each patient is different and you have to treat every single one individually, but still, wouldn´t you expect to get more or less the same result? I especially remember one time when this patient came by to my clinic. He arrived 30 minutes late, so I didn´t have that much time to treat him, since my next client was already waiting. So I treated him with this new ultrasound that had just arrived to the clinic. I told him how good this ultrasound was and since I didn´t have that much time, I just gave him 5 minutes of ultrasound. After the 5 minutes of ultrasound, the patient felt great, his pain was gone, he had more movement in his shoulder than before he came in!! I couldn´t believe it, especially since the ultrasound was so new that I didn´t even know how to use it properly. I had mistakenly pressed the wrong button, and the 5 minutes that I had thought I had given him ultrasound, I had actually done nothing!!!… but the patient felt better than before, how is that possible?? Well it´s because of the effect of PLACEBO.

Placebo can be defined as an ineffective treatment that can nevertheless be consoling, but placebo effect is not restricted only to fake treatments, it also has a role in the impact of real medicine. For example, although a patient will derive benefit from taking aspirin largely due to the pill´s biochemical effects, there can also be an added bonus as a result of the patient´s confidence in the aspirin itself or confidence in the doctor who prescribes it (1). That is why sometimes the doctor´s reputation, the cost of the treatment and its novelty could all increase the placebo effect. Some known cases of placebo:

  1. In the Second World War, there was a lack of morphine at the hospitals so doctors would instead inject saline into the patient saying ¨that it was a powerful painkiller¨. The soldiers would relax immediately and show no signs of pain.(1)
  2. In the 1950´s a new technique came out that could help patients with angina. A cardiologist was not sure about this treatment, so he did a trial. Some of the patients received the new surgery with the new technique, while the other patients did not, the doctor just opened them up so the arteries were exposed, but he performed no further surgery. None of the patients knew what was happening to them, they all thought they were getting the same process. Afterwards, roughly three-quarters of the patients in both groups reported significantly benefits.(1)
  3. 117 patients with chronic low pain, divided into 4 groups. The first group received electrotherapy after limited, five minute interaction with the physical therapist, who avoided eye contact and did not openly engage the patient.The second group received the same electrotherapy with enhanced interaction, meaning the physical therapist talked to him for 30 minutes and was open and nice. The third group limited interaction while hooked to electrotherapy but the device was not connected (patients did not know this). The fourth group enhanced interaction, while hooked to electrotherapy but the device was not connected. The patients who experienced the greatest benefits were the second and fourth group!!(2)

So, as you can see, placebo can be influenced by a lot of things. In example three, just by talking to the patients and being nice and friendly, the patients experienced a better result than when the doctor gave them the real treatment but did not even look at them. It is also know for example, that a drug administered by injection has a bigger placebo effect than the same drug taken in pill form, and that taking two pills provokes a greater placebo response than taking just one. Also, green pills have the strongest placebo effect on relieving anxiety, whereas yellow pills work best for depression.

So now that you know the influence of placebo and how it can influence pain, perception and a thousand other things, do you want to know when the treatment you are receiving is placebo (fake treatment)? I mean does it really matter, as long as you, the patient, is experiencing the real benefit? I have had clients come up to me and say ¨I don´t care what you do to me, just take the pain away¨, and guess what, placebo can do that, but placebo can also be dangerous, as it could hide a serious disease.

I think it´s better to find the true therapy, something that has no doubt, something that has been scientifically proven, but however with the placebo, even test can show up to be false. So how do they really know if something works? Well, the scientifically community does trials to see if the new medicine-treatment works and this is what they do:

  1. They first do a comparison between a control group and a group receiving the treatment being tested (treatment group).
  2. There has to be a sufficiently large number of patients in each group.
  3. Random assignment of patients to each group.
  4. They administer placebo to the control group.
  5. The control group and the treatment group must have identical conditions.
  6. Blinding patients (meaning patients know as little as possible) so that they are unaware to which group they belong.
  7. Blinding doctors so that they are unaware whether they are giving a real or a placebo treatment to each patient.

This is called a randomized placebo controlled, double-blind clinical trial and it is considered to be the highest possible standard of medical testing.

OK, now that we know what placebo is and how it can affect a treatment, we must also be aware that the opposite also exist and this is called Nocebo effect. Nocebo effect is a negative reaction to harmless stimulus, the opposite of placebo. I´ll give a quick example of a nocebo effect: It has been shown that if they did an MRI (magnetic resonance imaging) on us, that about 81% (3) of us could have a disc herniation and be asymptomatic, meaning no pain. But most people think that a disc herniation is a horrible thing. Now, imagine we have back pain and we decide to go to the doctor and the doctor prescribes an MRI. In that MRI the doctor says you have a herniation (which may be producing your pain or may not be producing the pain), this information will most likely cause a very NEGATIVE effect on you and cause you to experience more pain. Instead, if the doctor explains to you that 85-95% of the people that experience back pain is non-specific (meaning they don´t know where it comes from) and that only less than 10% experiences back pain because of a herniation (4-5). And if he also says that most low back conditions have a favorable natural history, that only 5% of the patients with lower back pain will go on to have chronic lower back pain (6), and that the best thing is to try to continue with your daily activity, just maybe that would have a better effect on you.

Here is a nice video that talks about Placebo.

So in my next post I will be talking about acupuncture. A treatment that has existed for thousand of years, there is the Yin and the Yang, it cures morning sickness, strokes, abdominal pain, whooping cough, deafness, chronic asthma, carpal tunnel, rheumatoid arthritis, insomnia, non-specific back pain, shoulder pain, period pains, whiplash……..and the list goes on. Something that can cure so much and has existed for so many years must be true, right …………or is it placebo?? Well, in my next post we will see what the scientific community has to say about that. By the way, if you get treated by acupuncture and get better every time someone sticks a needle on you, you may not want to read my next post. Until then.


1. Ernst E, Simon S. Trick or Treatment ? Alternative medicine on trial. Transworld Publishers.London,UK.2008

2. Medical Xpress: Physiotherapy patient interaction a key ingredient to pain reduction. University Alberta. Profesour Jorge Fuentes.

3. Kim S, Lee T, Lim Soo. Prevalence of Disc Degeneration in Asymptomatic Korean Subjects. Part 1: Lumbar Spine: Journal of Korean Neurosurgical society.2013 January; 53(1):31-38.

4.Agency for Health Care Policy and Research (AHCPR). Acute low back problems in adults. Clinical Practice Guideline Number 14. Wahington DC, US Government Printing, 1994.

5.Danish Health Technology Assessment (DIHTA). Manniche C, et al. Low back pain: Frequency Management and Prevention from an HAD Perspective, 1999.

6. Wiesel SE, Tsourmans N, Fefter HL, et al. A study of computer assisted tomography. The incidence of positive CAT scans in an asymptomatic group of patients. Spine 1984; 9: 549.

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