Weight loss can reduce back pain

Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

Abdominal fat causes back and spinal nerve pain

• There is a lot of confusion in the medical community regarding the role of obesity and back pain.
• Some researchers say that obesity plays a strong role in increasing back pain, others say obesity has none or little impact.
• More evidence is being published that abdominal obesity does cause mechanical stress on the spine and that abdominal fat is an inflammation making factory attacking spinal nerves.

We know that people do not like to hear that their joint and back pain problems are made worse by abdominal obesity and that they “need to lose weight.” Losing weight is not an easy thing to do and in many cases will lead to greater frustration on the patient’s part. We do see patients who tell us that they have been lectured for years to get rid of that big belly. Clearly lecturing is not motivation. In this article, we will give you the science of how obesity works to give you back pain. We hope that you will see how your back pain is made worse in a different light beyond any gimmicky type article which suggests “8 easy to lose weight and reduce back pain.” If they were that easy you would have lost the weight by now.

The evidence is mounting that when you wake up in the morning with back pain and numbness extending into your feet, that your belly is A if not THE culprit of your problems.

But the evidence is mounting that when you wake up in the morning with that back pain, with that numbness extending into your feet, that your belly is A if not THE culprit in your problems. The goal of this article is to help provide you with reliable information that will make you look down and look at your belly and realize that a big belly is not your friend and for some, will cause you to lose your independence.

Research: There is a link between a big belly and back pain.
Common sense: There is a link between a big belly and back pain

Let’s look at the last ten years of research to understand the debate in the medical community of the role of abdominal obesity and back pain.

Researchers at the Medical University of Graz in Austria conducted a study that lasted over 35 years. (1) They followed patients throughout their lives to determine what impact abdominal obesity had on their back pain and general health. Here is what 35 years of research revealed:

You lose your independence faster if you have a big belly and you will become dependent.

• Compared to people with normal weight, people with obesity more often reported a poor health status
• Compared to people with normal weight, people with obesity reported an earlier loss of mobility and researchers noted a greater earlier death risk.
• Obesity-associated diseases and disorders, such as type 2 diabetes mellitus, cardiovascular diseases, malignant tumors, and back pain are on the rise.

Note: When someone comes into one of our clinics, one of the greatest fears they have is the loss of independence, loss of mobility, and the need to depend on others to help them get around. The evidence is clear, people rid themselves of these fears when they embark on a program to get rid of their big belly.

The evidence presented by the Austrian team:

• Obesity is associated with a higher prevalence of low back pain.
• This problem is more pronounced in women.
• While the researchers observed the highest prevalence of back pain among obese women, the increase of and the greatest risk for back pain were highest among obese men.
• Special emphasis should be placed on obese individuals when planning low back pain prevention strategies. A moderate level of physical activity is recommended to prevent back pain.

For many people, it would seem obvious, a large belly is putting mechanical stress on the spine and that is the cause of back problems.

When there is back pain and there are problems of being sedentary, you have to move or the problems will accelerate.

Big belly causes stress and mechanical load in a bad back – weight loss is very good in many cases

The further your belly sticks out the more back pain

• In the Journal of Back and Musculoskeletal Rehabilitation, doctors at the University Hospital Zürich in Switzerland found that “outer abdominal fat,” fat that is furthest from the spine caused significant pressure to accelerate facet joint osteoarthritis. (2)

L5-S1 problems? A lot of it may be due to weight stress

• Doctors writing in the Journal of Biomechanics found that increased body weight substantially increased the load on the L5-S1 segment of the lower spine, especially in flexed (curved) postures. (3)

The loss of correct spinal curvature – pain, herniated discs, numb and burning sensation into your feet

• The spine is shaped with natural curves that act as springs to lessen the impact of the weight of the upper torso on the lower spine. The natural curvature of the spine acts like a tightly coiled spring or shock absorber. If you straighten the spring out, it does not shock absorb. If it does not shock absorb you get pain, herniated discs, numb and burning sensation into your feet.

What are we seeing in the next image?

It is all about the curvature of the spine. 

A. Normal spine:

• We see a normal disc in between two normal vertebrae ready to handle stress and loads. The ligaments of the spine, the posterior ligamentous complex, simply the ligaments that hold the vertebrae in place and the back of the spine.

B. Hyperlordosis:

• If you have hyperlordosis, the obvious sign is that your butt is sticking out in the back and your stomach is sticking out in the front. This is caused by the shape of the spine. This is not a correct postural balance stance. To keep you from falling over, your body makes adjustments. The rib cage will not alter itself to help provide stability but in doing so will cause pressure on the spine in the midback and lumbar region. You can have problems with muscle spasms throughout your spine. You will have lower back pain problems. You may have trouble breathing as your stomach and abdomen, now forced forwards will take up space where the lungs would need to expand. It also makes getting a well-fitting back brace a problem.

C. Kyphosis: The hunchback

• You probably do not need a medical description of what Kyphosis is. It is the hunchback situation. You are bent forward. This condition comes can come with significant back pain or no back pain at all.

The hunchback in women not only caused by osteoporosis but by obesity

Above we discussed a research study that suggested that the problem of big belly and back pain was more frequent in women. We are going to look at another study that helps explain why. Breast size and a big belly are not a good combination for women fearful of hunchback.

Here is a study, reported in March 2020 in the Journal of Sport and Health Science. (4) Look at all the things that happen to obese women and the factors that can lead to the hunchback formation. Yes, it is all about obesity. Here are the learning points of this study:

“This study investigated the effects of obesity on breast size, thoracic spine structure and function, upper torso musculoskeletal pain and physical activity participation in women living independently in the community.”

Learning points:

Breast size:

• Consistent with previous research participants classified as obese in the present study displayed breast volumes, on average, that was 3 times that of the breast volumes displayed by women who were classified as Not Overweight.
• One study reports that breast volume was the strongest predictor of upper torso musculoskeletal pain in a large group of women, whereby women with the greatest upper torso musculoskeletal pain had hypertrophic (big) breasts.
• Because of breast size in obese women, “it is therefore not surprising that the participants classified as obese reported experiencing 1.7 times more upper torso musculoskeletal pain than their counterparts who were classified as Not Overweight.”

Significant structural problems

• Increased thoracic kyphosis is of concern because it can lead to secondary changes in the upper torso musculoskeletal system, including cervical lordosis, increased tension in the neck extensor muscles, reduced thoracic extensor muscle endurance strength, reduced range of motion of the shoulder complex, and increased experience of musculoskeletal pain

You can’t be active and this will increase the risk of the hunchback

• It is imperative that individuals are encouraged to maintain an active lifestyle because participating in physical activity has been shown to be an effective strategy for reducing obesity and the associated higher risk of developing a wide range of negative physical and mental health issues. It is of concern that the participants classified as Obese spent significantly less time each week participating in physical activity compared to the other study participants.

Obesity, back pain, and the workplace

Big Belly? Don’t lift anything heavy

It should be obvious that if you carry a big belly and you have low back pain you are at higher risk for disability. But what if you are the owner of a landscaping company, a building contractor, anything that requires you to be on the worksite? Many of the people that fit this description that we see at our center are stuck in a repetitive cycle of self-managed treatments.

• They wear a back brace which makes it hard for them to breathe because their belly is being pushed into their chest.
• They take pills, a lot of pills some days to get them through.
• Their knees and hips usually hurt.
• There is a constant danger that if they lift something, do something manually, even turn the wrong way they will crumple up in pain.

In the work-place injury-related journal Work, doctors suggest that severely obese individuals are likely at an increased risk of lifting-related low back pain compared with normal-weight individuals. (5)

Most people do not think their big belly is the problem.

People do recognize weight is a problem and want help in losing the big belly in agricultural/rural communities 

• In the Journal of Neurosciences in Rural Practice (6) neurosurgeons at West Virginia University noted: “The relationship between back pain and obesity is well characterized; therefore, the neurosurgical consultant visit for back pain may be a key interventional opportunity for weight loss. . . Incorporation of patient education regarding the relationship of weight loss to back pain and other weight-related comorbidities is well received in a rural specialist consultation setting. Improved communication with primary care physicians regarding this message and further supportive actions may improve follow-through, and therefore the success of ultimate weight-loss interventions.”

And so and so on, numerous studies on mechanical load as the cause of back pain in obese people.

Neuropathic pain not from musculoskeletal damage was higher in overweight and obese patients. In other words, the weight is causing the pain whether you hurt your back or not

There have been many studies that suggest that it is not the physical load of carrying the extra weight that is causing back pain in obese and overweight patients, but inflammation caused by excess fat changing the body environment to that of chronic inflammation.  Please see our article: Excessive weight and joint pain – the inflammation connection.

Now researchers are suggesting a relationship between neuropathic pain and obesity with an inflammation connection. In a paper from the University of Tokyo, doctors made these observations:

• Being overweight negatively affects musculoskeletal health;
  • obesity is considered a risk factor for osteoarthritis and chronic low back pain.
• Neuropathic pain that did not arise from musculoskeletal damage was higher in overweight and obese patients.
• Paroxysmal pain (sudden acute pain) was more severe, suggesting that neural damage might be aggravated by obesity-associated inflammation. (7)

Pain in your back was clearly made worse by carrying a belly load. Now add to that pain made worse by high blood sugar

A well-cited study in the Journal of the Peripheral Nervous System found that nerve sensory thresholds were metabolically altered which could lead to future clinical neuropathy. (8) What was suspected of metabolically altering the spinal nerves? Hyperinsulinemia and insulin sensitivity. 

This type of research is helping doctors understand metabolic inflammation, obesity, and back pain

This was confirmed by French researchers in Current Opinion in Rheumatology, who suggested that the rising prevalence of hand osteoarthritis is from obesity and since the hand does not bear weight, this suggests that the role of systemic inflammatory mediators in fat cells cause inflammation signaling to be sent out and attack joints. (10)

Please see our article Excessive weight and joint pain – the inflammation connection for more on this subject.

Back surgery and the problems of obesity

A 2016 study published in the Chiropractic & Manual Therapies (11) made these observations:

• There appears to be an association between obesity and disability as well as obesity and the most severe pain.
• Individuals who gained weight (5 or more pounds) were less likely to report improvement in most severe pain.
• The research demonstrated that obese people treated for low back pain will experience better outcomes when they lose weight, particularly in cases of morbid obesity
• An enlarged abdomen (big belly) as a result of obesity has been shown to cause early degeneration of discs, which is associated with low back pain.
• Obesity is associated with disc degeneration because increases in body weight lead to tear and wear on discs and joints, increasing the physical demands on muscles and ligaments.

In a recently published article in the American Journal of Bone and Joint Surgery, researchers examined the effect that obesity has on patients managed for symptomatic lumbar disc herniation. They studied a group of patients who underwent back surgery and a group of patients who had more conservative non-surgical treatments. Both groups showed significantly less improvement as it related to problems of obesity. (12)

The same was found in newer research from St. Olavs University Hospital, in Norway for patients having surgery for lumbar spinal stenosis. The researchers noted: “Obese patients were less likely to achieve a minimal clinically important difference.”(13)

In February 2017, researchers at Cornell, Clemson, the University of Georgia, and Xi’an Jiaotong University in China, completed a study which found that :

• Overweight and obese patients, as compared to normal/underweight respondents, were more likely to develop lower back problems and IDD (Internal disc disruption). (14)

A component of failed spinal surgery is obesity

A study in The Spine Journal said that a component of failed spinal surgery was obesity. This recent research was the first to examine obesity’s role in recurrent disc herniation after spinal surgery.

“Obesity was a strong and independent predictor of recurrent (disc herniation) after lumbar microdiscectomy. Surgeons should incorporate weight-loss counseling into their preoperative discussions with patients.”(15)

There is even a suggestion from University researchers in Rome, who wrote in the European Spine Journal that elevated cholesterol levels and triglycerides have a role: “patients with symptomatic herniated lumbar disc showed statistically significant higher triglyceride concentration and total cholesterol concentration. Serum lipid levels may be a risk factor for [symptomatic disc herniation]. An enhanced understanding of these factors holds the promise of new approaches to the prevention and management.”(16)

How beneficial is spinal surgery for obese patients?

Any procedure that offers a patient relief of their symptoms is a good procedure. But how much risk should a patient take and for how much relief?

Let’s look at two studies FAVORABLE to spinal surgery for obese patients

The question of how obese patients respond to surgery as compared to non-obese patients was tackled by doctors at the Department of Neurosurgery, the University of Alabama at Birmingham. In this September 2017 study, the doctors looked at obese and non-obese patients treated with lumbar laminectomy for symptomatic lumbar spinal stenosis.

• At baseline, obese patients had significantly more back pain, more leg pain, lower EQ-5D scores (EuroQol 5 dimensions questionnaire is a measurement of general health), and higher Oswestry Disability Index scores (measuring mobility and disability)
• Initially, both none obese and obese patient groups had significant improvement. However, at 3 months postoperatively, obese patients continued to report greater leg pain and higher disability scores relative to non-obese patients. By 12 months leg pain and higher disability scores were equal in both the obese and non-obese groups.

What to make of this?

The researchers concluded: “obese patients with symptomatic lumbar spinal stenosis may require longer to recover after decompression but can expect to reach equivalent outcomes of similarly treated (non-obese) patients”(17)

In the second favorable study, Spanish doctors writing in the medical journal Neurocirugia (Neurosurgery) write off the growing evidence that connects the metabolic processes within the adipose tissue, preferentially abdominal fat, with a low-intensity chronic inflammatory state that causes back pain.

They suggest: Some meta-analyses have confirmed an increase of complications following lumbar spine surgery (mainly infections and venous thrombosis) in obese subjects.

However, functional outcomes after lumbar spine surgery are favorable although inferior to the non-obese population, acknowledging that obese patients present with worse baseline function levels and the prognosis of conservatively treated obese cohorts is much worse. (18)

A 2015 study from doctors at University hospital researchers in the United Kingdom also supported surgery for obese patients.

• They found despite:
  • obese patients having greater intra-operative blood loss,
  • more complications and
  • longer duration of surgery
  • pain and functional outcome are similar to non-obese patients.
  • Based on these results, obesity is not a contraindication to lumbar spinal fusion. (19)

For obese and non-obese patients pain and functional outcome are similar to non-obese patients. So if the surgery failed, it was not the fault of the obesity.

Again, this all comes down to lifestyle choices to accelerate healing or make healing more difficult.

The Spinal ligament repair injection treatment option Prolotherapy

Need help beyond weight loss? Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on research and clinical results, H3 Prolotherapy (H3 is a type of Prolotherapy named after three of its leading physician innovators Hackett-Hemwall-Hauser) is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.

A Prolotherapy treatment into the lumbar spine.

Learning Points

• Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
• Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
• We treat the whole low back area to include the sacroiliac or SI joint. In these images, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
• The black crayon marks all down the midline of this patient’s back give guidance to where the injections should be placed. The horizontal line is drawn where the patient’s pain stops. This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
• After treatment we want the patient to take it easy for about 4 days.
• Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.

Questions about our treatments?

If you have questions about back pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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References:

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This article was updated January 27, 2021

A July 2022 study published in the journal Orthopedic reviews (20) examined what happened to obese patients after they had a spinal surgery. What they found was: “Evidence suggest that obese patients could benefit from spine surgery and (the) outcomes be satisfactory. A higher rate of peri-operative complications is reported among obese patients, especially in posterior (rear incisions) approaches. The use of minimally invasive techniques plays a key role in order to reduce surgical risks.”

But do, as suggested minimally invasive surgeries reduce spinal surgical risks? It may depend on belly fat.

4017

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.