RHR: Understanding and Addressing Back Pain, with Dr. Stefanie Cohen

In this episode, we discuss:

• Stefi’s personal journey
• The story behind her book Back in Motion
• Common back pain myths
• Neuroplasticity and how the science of understanding pain has evolved
• Where typical treatments for back pain tend to fall short

Show notes:

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Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. Back pain is one of the most common medical complaints today, and it seems to be on the rise. According to Statista, almost 40 percent of the U.S. population experienced lower back problems in the last three months [of] 2019, compared to just 28 percent in 1997. If you’re 65 years and older, that goes up to 46 percent of adults experiencing lower back pain in the last three months. Fifty-four percent of the people who have lower back pain have had it for five years or longer, and almost 75 percent take non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen to manage the pain. This is a huge problem because a growing body of research has linked the use of NSAIDs like ibuprofen over a long period of time to everything from rebound pain to ulcers, [gastrointestinal] disorders, [and] kidney damage. We clearly need a new approach to both understanding and addressing back pain. And that’s what we’re going to cover in today’s episode.

I’m excited to welcome Dr. Stefi Cohen as my guest. In addition to being a doctor of physical therapy, she holds 25 world records in powerlifting and was the first woman in the history of the sport to deadlift 4.4 times her body weight. I can’t even imagine deadlifting almost four and a half times my body weight. She recently took a break from powerlifting and transitioned to professional boxing where she has a record of two wins, zero losses, and one draw. But Stefi didn’t have an easy road to success. At one point, she suffered from such severe lower back pain that she couldn’t tie her shoes without difficulty. Fortunately, through the approaches that we’ll discuss in this episode and that she outlined in her recent book, Back in Motion, she was able to fully recover and go on to break multiple world records in powerlifting, arguably one of the most demanding sports on your lower back.

Dr. Cohen’s an inspiring athlete and a wealth of knowledge in this area. Her method of addressing back pain has empowered thousands of people to achieve a pain-free state and reach higher levels of performance in their sport. I learned a lot myself in this conversation, and I think you will, too. Let’s dive in.

Chris Kresser:  Stefi, it’s a pleasure to have you on the show. Welcome.

Stefi Cohen:  Thank you so much for having me.

Chris Kresser:  I’d love to learn a little bit more about your story. You’ve had an incredible career with 25 world records in powerlifting, and you were the first woman to deadlift almost four and a half times your bodyweight, which I cannot even imagine doing. And now you’ve switched over to boxing and are enjoying a good record there. Two wins, zero losses, [and] one draw. But I know it hasn’t always been easy. You had a period of time where you had pretty intense back pain and couldn’t even tie your shoes without experiencing pain. I’d love to hear about what your journey has been. How did you get started? What was that initial injury? How did that impact you? And what did you do to get through that?

Stefanie’s Personal Journey

Stefi Cohen:  I started my athletic career when I was eight years old playing soccer back home in Venezuela, where I was born and raised. I sucked at the beginning. I was really bad. But I was just doing it, honestly, out of the love for the sport. One thing that we have as kids that we lose as we get older is naiveness of how long it takes to actually get good at something. Because you’re doing it just to play with your friends, to be outdoors, to enjoy the sunshine, maybe to make your dad proud, or your mom, things like that. But you’re not outcome oriented. You’re so much more in the moment, so much more process oriented. That’s something that we definitely lose over time. And there’s a reason why I’m mentioning this, so I’ll get back to that.

I finished my soccer career when I was about 18 [or] 19. I ended up moving to the [United] States [of America] with a potential soccer scholarship that I ended up turning down because moving from South America to the [United] States [of America] wasn’t something easy to do by yourself. There [are] a lot of differences in the way things work that you have to try to figure out on your own and get accustomed to the culture, the education system, [and] the way that the institutions run testing. For example, Scantrons weren’t a thing in South America. So even small things like that can really throw you off and make you have to adjust and get accustomed to simple things like doing your own laundry, or understanding what you have to eat, how much you have to eat, what kind[s] of foods you have to eat. Socially, humor is different [from] South America to the States. So that’s also another adjustment that you have to make. I got to a point where I had to make a decision between really taking my education seriously and really trying hard to get good grades and figuring out my place in a new society or keep playing soccer.

So that was a fork in the road, a difficult decision that I had to make, and [I] ended up leaning more into education. [I] come from a Jewish Hispanic family that heavily values traditional, formal education, and that was part of my values growing up, placing a lot of importance on school and making sure that you have a plan B and that you have something to fall [back onto] if things don’t go as planned. We all know how delicate and volatile people’s athletic careers can be. It can all be gone in the blink of an eye. Just one injury. One bad lift, one bad punch, and it’s all over. So I really wanted to make sure that I had a solid educational foundation. I decided to move back to Miami because it was much closer to home. It’s [only] a two-and-a-half-[hour] flight from Miami to Venezuela, and it’s much more central, and the culture was something that I was much more accustomed to, as well. It was just more comfortable for [that] time period of my life, [though] now, looking back, I wish I would have just toughened up and stayed there and tried to figure out how to make it happen for myself. Stay playing soccer and try to figure out multiple things at a time. But, everything’s easier or better in hindsight.

When I gave up my dream of playing soccer, after several months, I felt like there was such a massive void in my heart. I realized that I wasn’t ready to give up that part of my identity, which was being an athlete. I still felt like I had much more to give, and even if it wasn’t through soccer, I wanted to look for another physical or sports outlet to dedicate some time to in trying to climb my way to the top in a different sport. So that started what I consider a discovery period of trying different things out to see not only what sticks, but what most aligns with my skills, my talent, and my passion at the time. I didn’t want to just do a sport because I liked it; I wanted to pick a sport that I had an innate aptitude for [and] that I could objectively and rationally get better at over time. That’s how I landed into CrossFit.

That was my first taste [of] lifting weights. I really wanted to go to the CrossFit Games. That was around 2010, 2011, [when] the CrossFit Games were just getting started and everybody wanted to be a Games athlete. Everybody thought that [by] just doing your regular [workout of the day] (WOD) CrossFit class, once a day, you could make it to the Games. And in that pursuit, I wanted to focus on Olympic weightlifting because it was my weakest link. Strength was my biggest weakness. I started devoting more time to Olympic weightlifting, found myself an amazing coach [named] Camilo Garcia, who coached for the National Cuban team, and he took me under his wing and really, really wanted to make me an Olympic champion. That was his promise to me. So I did that for about six years, and, again, I found myself in a similar situation to undergrad, where I knew that the next logical step professionally for me was to go to graduate school. Just in order to be taken seriously in an industry that’s so male dominated, I knew I was going to have to work hard to gain the respect of the fitness industry in general, especially because of how polluted it is and how male dominated it was. I understood that the logical step for me was to get a degree that gave me a little bit more power of authority to speak on the topics I wanted to [speak] about and to coach and do the things that I wanted to do.

I [went to] grad school to get my doctor[ate] in physical therapy. And again, at the beginning, I was trying really hard to do both. In the back of my mind, I had that story of when I quit playing soccer because I couldn’t do both things, and I just refused to let that happen to me again. So I was trying to do the impossible, [only] this time, [it] was even harder because grad school is not a joke. Grad school is a full-time job no matter how you see it. The first six months of grad school, I traveled with my barbell everywhere that I went so that anytime I had during the day to squeeze in my workout, I would do it. I would pull into an LA Fitness or pull into the university gym with my barbell and do my workout [with] whatever time I had, even if it meant skipping half an hour of a class or skipping half an hour of the 11:30 class to 12:00 and then half an hour from the next one after lunch. I would just try to figure it out like that, while at the same time, obviously, making sure that I’m passing my classes. I never failed a class in my entire life. I was never an A plus student, but I’d never failed a class. So in my mind, that wasn’t even a possibility of something that could happen to me.

It was December, and I went [away] for my winter break. I [came] back home, and there’s a pile of letters underneath my door. And I’m like, “Oh my God, what’s this?” Committee of academic review. Apparently, I had failed a class with a 74. In any class at any given point in time, if you get any less than 75, you get kicked out of the program, and then you have to write an appeal and explain why you got a 74 and then maybe get granted a second chance. But because I had missed all the letters they were sending me, they just, effective immediately, removed me from the program because I wasn’t responding to their letters. They probably just assumed I didn’t want to be part of it anymore. So I got kicked out of grad school, [had] to sit in the committee of academic review, explain my situation, and convince them to give me a second chance. I remember sitting down at this round table, and the professor on my left was like, “Stef, I just don’t think that you’re as strong a student as you think you are. I think you need to pick one thing and focus on that, but I don’t think you have the capability of doing both. And I think you’re going to require extensive psychological counseling to really let go of [the sports] part of your identity. You’ve got to give that up. It’s long gone. You’re 25, 26 [years old]. You better give that up and focus on what really matters.” And that really lit a fire under my ass.

I’m like, “No, now, just because he said that, I won’t do that. I have to prove it to myself that I can do both. I can’t be in the same situation twice and make the same decision and, probably 10 years down the line again, regret that I didn’t really, really give it my all.” So that’s how I [landed] into powerlifting. I [said], “All right, the mistake I made before was that I quit entirely instead of doing 20 percent less of the sport and dedicating that 20 percent to my school. So this time, I’m going to do something [like that]. I’m going to keep lifting, [but] I’m going to do Olympic lifting twice a week instead of 12 sessions. Because I was doing double sessions like a crazy person. [I’m going to do] two or three sessions of weightlifting a week, and the rest of the time, I’m still going to go to the gym, [but] for much less time, and I’m just going to get stronger. Because if I get stronger in three basic movements, the squat, the bench, and the deadlift, logically, my snatch and my clean and jerk will eventually go up. They can’t go down from there if my absolute level of strength is going up.

I picked up a barbell at my first sumo deadlift, getting into more powerlifting-type training, and I pulled 315 [pounds], which was so rare at [that] time in powerlifting for a woman. You didn’t see that often. And if you did, it was [in] the much bigger weight classes. I realized that, back to my discovery period when I was 20—what are my skills, my talents, my passions? Does this align with the aptitudes that I was God given? And are there any other skills that I could get better at to climb my way to [the] top in this one sport? It seemed so obvious that I had something special that other people didn’t have, just because of how exponential my growth was in the sport, how fast I was able to progress, how seemingly easy it was for me to pick up on new skills [and] new movements, and how well I was adapting to that style of training. That’s how I landed into powerlifting.

Fast forward into powerlifting two to three years, I progressed so fast and my mindset was such that I was [only] worried about getting strong fast. How fast can I climb to the top? How fast can I get strong? I forgot that I was still human and that there is an adaptation period [where] you’re essentially fighting your biology by putting so much pressure on yourself and such a massive amount of tonnage through your bones, your tendons, your ligaments, your muscles, your entire system. You feel like you’re invincible. You’re young. I didn’t have any injuries. I hadn’t accumulated knee injuries in the past. So I thought that I could demand more and more and more and more from my body. Because I was developing my business in parallel with HYBRID Performance Method, I felt such immense pressure to continuously compete. And because I had so much pressure to continuously compete, I also felt like there was a certain level of expectation from the public every time that I would step onto the platform to continue breaking not only my own records, but world records. Things that people have never seen a woman do before. I was ignoring all the signs and symptoms and signals that my body was sending me about the state of my body, specifically with my back, and started taking more and more ibuprofen, just ignoring it. [I] started having awful anxiety [and] panic attacks from school, taking Adderall, caffeine, and the stress of everything. I was traveling every other weekend, and it was just the perfect environment for an absolute disaster [of] both mind and body. I really did hit rock bottom, but I was so freaking stubborn [that] I refused to quit anything because of my past experiences. I just kept going. And I ended up graduating in spite of my declining mental health and my awful panic attacks and anxiety and debilitating back pain. [I] ended up graduating and continuously competing and continuously breaking world records, but at a massive expense for my physical and mental health.

[I] graduated grad school, a couple of years went by, [and] I was focusing on my business, competing a little bit less, trying to recover from those super stressful, awful three years, and then the pandemic hit. It was the first time in six years that I felt justified in taking time off. Which is insane, because like you said, I could barely tie my shoes. How is it that the only moment where I feel justified to take a step back from my training and not compete is when the entire world shuts down? That’s crazy to me. But it was so eye-opening at that time that I burst my own bubble of reality where I was like, “Man, none of this matters if I don’t have my health. It’s not about how fast I can get strong. It’s about how long I [can] stay injury free and healthy. It’s not about what people think about me; it’s about what I think of myself. I don’t have to do this for anybody other than me, and I can’t do anything if my body doesn’t work.”

That was a reality check [for] me, and I gave myself permission to not train for a powerlifting meet. There weren’t any powerlifting meets because the entire world [had] stopped. But even then, I was always scared of people coming and taking my records, or of my name being erased from the wall and from the history of powerlifting. I always felt like there was another girl working harder than me wanting to take everything that I had worked so hard for. It got to a point where my body was so wrecked that it was the right time. All the pieces fell together, and it made sense for me to take a break from lifting. Naturally, being the person that I am, an athlete and such a goal-centered person, I had to find another outlet to test myself in another way. Because I had ignored my cardiovascular conditioning for so many years, I’m talking about when I was at my peak powerlifting shape, I was in my worst human shape possible. I would go up a flight of stairs and be out of breath. [I’m] not even joking. I couldn’t [even] jump a little bit. My body felt like it was made of aluminum. There was no motion, no movement; it was just really good [at] up and down motion, very slow. Nothing fast. Nothing to the side. Nothing bendy. My body was just this rigid, concrete thing that was really good at down and up, and that was it.

I was like, “Man, I really should do something for my heart.” I started getting into podcasts about breath and started looking into Brian Mackenzie and Andy Galpin and realizing just how bad[ly] I [had] treated my body for so many years, and the contributions that might have had [on] my biology and my physiology and the contributions that probably had for my panic attacks. There’s science that points [to] having poor cardiovascular health and an [increased] concentration of [carbon dioxide] (CO2) and decreased ability to clear that CO2 from your blood that heavily contributes to anxiety and panic attacks. All of that was my motivation to move into a more cardio-based sport. I decided to put a heavy bag on my squat rack in my garage at home during the lockdown, and I had a pair of pink gloves that a friend of mine gave me, and I just started hitting it for cardio. Doing three-minute rounds. That’s as much as I [knew] about boxing at the time, that they did three-minute rounds, and I probably had to look [that] up. I had no idea. I just knew that [Ultimate Fighting Championship] was five-[minute rounds] and that boxing was less. And that’s how I got started in boxing.

I remember when I first started, I had my coach Kareem, who was coaching me on the street. Literally, on the street right here in front of my house. I had to keep telling him, “Kareem, listen, I get intense really fast, and I don’t want this to happen to me with boxing because I’m going back to powerlifting. This is just something I’m doing in the interim. I don’t want to get too intense about it. I just want to have fun doing it.” [But] it’s me, [so that’s] impossible, right? I would get a workout in, and it wouldn’t go as planned, so I would want to repeat the workout the next day, or even in the afternoon, and slowly, I became super obsessed with boxing and turned pro six months later, and I have three fights under my belt and now I train full-time [in] boxing. That’s my story.

Chris Kresser:  Are you thinking you are going to go back to powerlifting? Or you’re not sure? You’re just going to see how boxing goes.

Stefi Cohen:  I don’t know. Part of me feels [like] even if I didn’t go back to powerlifting with the intent of breaking more world records or being the best or beating people at competitions, so much of what I have is thanks to the powerlifting community that I never want to fully let that go, and I want to always try to give back. If my body allows me to participate in a meet in an amateur way, not trying to break records, and that’s if my personality allows me to do that. But in some way, shape, or form, I always want to be involved within that. The one thing in powerlifting that I definitely want to try to do is to get a 600-pound deadlift. I think that just having that one goal in parallel with boxing, that’s something I can do. Obviously, I can’t train full-time powerlifting and full-time boxing, but I think I can incorporate some deadlifting into my routine once every week or once every two weeks for a period of time and try to get that 600-pound [deadlift].

Too often, back pain is misunderstood and ineffectively treated. Tune in to my discussion with Dr. Stefanie Cohen to hear her approach to making better decisions about your movement, your life, and your training. #chriskresser

Chris Kresser:  Well, we’ll be cheering for you. When you look back, that’s quite a story. I really loved hearing it, and there’s a lot there. I think that a lot of people can relate to, not necessarily being the best in the world at something, but just facing all the different challenges and the way that you approached those and overcame those. I think a lot of listeners [of] the podcast, and I have my own version of this story, have had a situation where we were essentially forced into taking care of ourselves for some reason or another. In your case, it was the pandemic that shut down the competitions and really gave you permission to back off [of training] that you weren’t able to give yourself before that happened. For me, it was a chronic illness that made it impossible for me to keep going at the frequency that I was going at before. When you think back on that, how has that changed you? What looks different in your life now, in your training, in how you relate to yourself? What did you take away from that experience?

Stefi Cohen:  I alluded to already about just changing your perspective [and] your mindset from, “How fast can I accomplish a certain task?” to making sure that you’re taking care of yourself in the process and you’re prioritizing your recovery and you’re prioritizing adapting to your workouts and you’re prioritizing your mental health and your heart and your blood and everything that plays a role in that pursuit of the peak level of shape that you’re aspiring to have. Obviously, none of that can happen if those fundamental pyramids or fundamental health markers are not there. When we’re young, we don’t really pay attention to those things. We think nothing’s ever going to happen to us until something does, in the form of an injury or an illness or mental health [issues], whatever it is, and that’s when you realize [it]. It’s funny because I don’t think that anybody listening to this will actually get it until something like that happens to them. Everybody learns in one way or another, sooner or later.

Another way in which that whole experience changed me is in the reasoning behind my [pursuit of] certain things. Why [do I want] to be the best powerlifter in the world? Why [do I want] to be a professional boxer? Why do I want my business to grow to six figures plus? What’s the reason behind all of that? Before, it used to be mainly driven by external validation. I don’t know if it’s because of the way that I was brought up, or just constantly having to prove myself to peers and family members and teachers and whatnot, because I was always the black sheep that people never thought was going to be anything. Now, I’m not saying that I’ve accomplished everything that I wanted to accomplish by any means. I still consider myself pretty ambitious, and I’m by no means content with where I am in life. But I think that when you start doing things for yourself, it’s a shift in perspective. It doesn’t change the intensity at which you tackle certain things; it doesn’t change how hard you work, or how long you dedicate to something. It doesn’t change anything. It’s just that slight shift [in] perspective of, “Why am I doing this? Am I doing it for myself?” When doing it for yourself is the answer, it leads to so much more happiness and enjoyment of the process. Again, tying it back to when you’re young, you just do things for yourself because you like it, and it doesn’t matter if it’s going to take you five years to stop being benched and play the first, how do you say [it] in English? The first period?

Chris Kresser:  The first half, in soccer.

Stefi Cohen:  First half, yeah. It doesn’t matter to you because you’re doing exactly what you want to be doing. You’re doing it out of enjoyment [and] for yourself. When I started playing soccer, like I said, I sucked, and it took three, four, five years for me to stop being benched and play 15 minutes of the game. I remember really losing that when I grew up after soccer, especially getting into CrossFit, [and] feeling like I was running out of time. Even [at] 19 and 20 years old, I felt like I was too old because there’s this arbitrary timeline at which everything is supposed to happen. In my head, I only had nine more years because when you’re 30, you’re old. I had this pressure that was manufactured by society that created these beliefs in my head of when things needed to happen for me, [and] that made me not be patient, not enjoy the moment, and not be process-oriented. [I] just [wanted] the results right then and there, [and] that led me to be extremely injured and ultimately ending my career prematurely in powerlifting.

The Story Behind Back in Motion

Chris Kresser:  Let’s talk a little bit about that specifically, back pain injury. You’ve written a book, Back in Motion, and you’ve had your own personal experience with back pain. I imagine you’ve worked a lot with people [who have] back pain as a physical therapist, and your book outlines a really different approach to how to think about back pain from the start, and then what to do about it. Tell us a little bit about some of the biggest myths about back pain. Let’s start there. Then we can talk about how the science of understanding pain has evolved over the recent couple [of] decades, because there [have] been some huge changes that I don’t think have percolated down to mainstream awareness.

Stefi Cohen:  Back in Motion is a book that I started writing at the beginning of my own experience with back pain. I was starting my second year of grad school, and I had access to all of these awesome professors [who] seemingly knew a lot about the topic. And I was so disappointed because the answers were so inconsistent between one another, even in the diagnoses that I would get from one professor to the other. Their rationale for why it happened was different, and their plan of care was different, as well. To me, it was so confusing because when you’re getting a degree that is required in order to get a license, you are forced to think inside the box. Essentially, they’re covering their own ass, where they’re teaching you this very methodical thought process way of doing an examination. You take history, evaluation, exam, and you have all these special tests that they call [for] that you circle yes or no. It’s all these boxes, [a] step-by-step process that essentially prevents you from thinking on your own and thinking based on first principles. You’re forced to think by analogy; you’re forced to think based on what they think is the way to think [and] not what you’re actually observing and what is actually in front of you.

That [quickly] became very obvious to me in [the] pursuit [of] an answer [to] what was going on with my back, and that’s what made me interested in the topic and what made me want to start doing research and writing things down. At the beginning, it was never my intention to write a book. [I] was just going to start a file that [had] all the current best practices about back pain and all the best research, and going to pay attention to neuroscientists and pain specialists that talk about this, and going to try to put everything together for my own understanding. As I gathered a little bit more clarity on the subject, I wanted to find a way to get this information to other people because I found it so helpful in a period of so much uncertainty. Have you ever had an experience with back pain?

Chris Kresser:  I have, yeah.

Stefi Cohen:  It’s so much different than any other injury that you have because the way that most therapists and doctors explain it to you makes it seem like it’s so much more of a bigger deal than it actually is. In your head, you’re already making it seem like it’s this life sentence that you’re going to have [where] your discs are perpetually degenerating and your jelly doughnut is leaking outside everywhere on your nerves, and the pain traveling down your leg [is] going to get to your toes.

Chris Kresser:  And eventually, you have to have surgery, and there’s [only] a 50/50 chance that you’d get better with the surgery. That’s a pretty bleak picture they paint.

Stefi Cohen:  Also, I don’t know why [the thought of a back surgery] is so much worse than a knee surgery or shoulder surgery. [People think that] if you have back surgery, you have a big problem there. Those beliefs influence our perception of pain. I was like, “I need to find a way to put all this together in a way that’s easy to digest for most people and then come up with a very general plan of care for most people to be able to follow alongside them improving their understanding of what back pain actually is. So that was the inception of the book. The book does start with the most common back pain myths. I’m not going to be able to [cover them all] (there [are] 10 of them that we write about), but I’ll just cover the number one.

Chris Kresser:  Pick a couple of your favorites.

Common Back Pain Myths

Stefi Cohen:  The first one is that you need [a magnetic resonance imaging] (MRI) [scan] in order to determine the cause of your back pain. Surprisingly, MRIs for the purpose of identifying [the] cause of back pain are only 56 percent sensitive. That means [that] most of the time, they’re [either] giving you confounding findings or false positives. We know that the answers you get from an MRI are not correlated at all with your pain experience. The example that I can give you is [that] I spent three years with awful, awful back pain, and I refused to get an MRI because that was one of the first papers that I ever read. I’m like, “I don’t need the MRI because it doesn’t matter. It doesn’t matter what the MRI says. I still have to be doing the same thing that I’m doing.” But eventually, I was like, “You know what? I’m curious. I’m going to do it for science. I want to see what the MRI says.” Subconsciously, I was really [hoping] something comes up in the MRI. I really hope there’s something so obvious there that I could fuse together, [or] that I could get a surgery, or I could get an injection, or something that would give me much more clarity into this whole thing. [I] go get my MRI, [and it comes] out squeaky clean. [It showed] nothing. Meanwhile, I can’t bend. I’m like, “How does this make any sense?”

Chris Kresser:  I’ve seen those studies and I’ve talked about them, [like] the one at UCLA where they took people with back pain [and] gave them MRIs. Many people who had pain had no issues, and [just] as many people who had no pain had slipped discs or other structural problems that you would expect [to] cause pain. I’ve been treating patients for 15 years. I’ve had so many conversations with them about this, where they come into the clinic, and they say, “I’ve got to get this surgery because I had an MRI and I had a disc issue or this issue.” And it takes a lot of talking people out of that [and convincing them] that [it] is not necessarily even the cause of [their] pain. Correlation is not causation. That’s a fundamental principle in science. But I think it’s really hard for us to get over that. If someone has pain, and then they have an MRI, and they see a structural issue, the doctor and the patient assume that those two things are related, and what you’re saying and what the science says is they’re not often related.

Stefi Cohen:  Also, isn’t it crazy how it immediately becomes part of people’s identity? The second they’re diagnosed with a disc herniation or something more concrete on their back, it’s forever a thing. They’ll come three years later and be like, “Oh no, you know, I have a bad disc.”

Neuroplasticity and the Understanding of Pain

Chris Kresser:  Let’s use that as a segue to talk about the changing understanding of pain and particularly neuroscience and neuroplasticity. You said something earlier that I wanted to highlight. The revelation of neuroplasticity and neuroscience is that our beliefs and our perceptions directly influence our physical body and our experience of ourselves. If you have that belief, “I have a slipped disc, I have a bad back, I have chronic back pain,” while that’s understandable that you might have that belief if you’ve had that situation for a long time, that’s actually, in some ways, solidifying that pattern neurologically. We know that neurons that fire together, wire together. So the more you run that pattern, the more likely that is to persist.

Stefi Cohen:  And what’s most difficult about that is, how can you trick yourself? That was a question that I had for Dr. Greg Lehman. I remember asking him, “I understand what you’re saying right now. But how do I trick myself into not believing what my mind is believing? I get what you’re saying, but I can’t stop believing that my back’s broken and I’m never going to be okay, subconsciously.” I think a big part of that has to do with having a better understanding of what pain actually means in our body. It’s like telling yourself to not think of a pink elephant. The first thing you’re going to do is think of a pink elephant, right? It doesn’t work that way. You can’t trick yourself to not think about something because it [has] the opposite effect. But you can prove [it to] yourself through finding things that you thought you weren’t capable of doing. You can prove it to yourself by doing these things that you were catastrophizing and afraid of, and developing a better understanding of what pain means and the limits that it doesn’t impose on [you].

The best way that I can explain pain, and I think this is from one of Greg’s books, [is] as a smoke alarm. You’re in your kitchen, you’re cooking some bacon, [and] your alarm goes off. Is it a good indicator of the level of threat that you’re under or amount of danger that you’re [in]? Not really. You’re just at home. It’s 9:00 a.m., you’re cooking breakfast, you’re having a sip of coffee [or] orange juice, and the alarm went off. Nothing about that should really alarm you. Anybody in their rational [mind] can be like, “It’s the bacon that set off the alarm.” Our brains are the same way. Our pain sensor alarm can go off, [and] can be highly sensitive, for XYZ reason. Maybe it was a previous experience that was similar to [this] environment that’s triggering your brain to think that you’re having a threat. Understanding that the brain’s sensitivity to external [stimuli] can influence your perception of [the] threat around you, that alone should give you a bigger sense of security [about] what you can and can’t do.

The second thing that he mentioned is using pain like a traffic light. [On] a certain level, you should never try to get rid of pain because pain is a positive thing for survival. It always has been. You don’t want to eliminate pain; you just want to use it to your advantage so you can make informed decisions about your movement, your life, and your training. Once you understand that, you start realizing that you don’t have to be pain free to start doing the things that you enjoy, or that you thought you couldn’t do. Understanding that maybe a 3 out of 10 pain [level] is acceptable for you to try to bend forward and touch your toes. Understanding that maybe a 5 out of 10 pain [level] is acceptable for you to do a farmer’s walk [or] an isometric contraction that doesn’t put any structure at any sort of risk. It’s understanding what that pain means and understanding what it allows you to do and slowly progressing and exposing yourself to the movements that you are once afraid of.

Chris Kresser:  This is such an important perspective, and I talk about it a lot in patients [who] I treat with chronic illness, where sometimes there’s the belief that they have to become completely symptom free in order to live a happy and rewarding life. I really try to invite them to see that differently. Because sometimes symptoms like pain are just a yellow light, to use the traffic signal [analogy], or they’re an artifact of that neural pattern that was created when the situation was more severe. It doesn’t mean that if you have a symptom, you have to never eat that food again or you can’t push yourself a little more with exercise or whatever you’re doing to try to recover your health. I think if you stay in that belief where any kind of symptom, discomfort, or pain is an immediate invitation to stop what you’re doing and contract, then you’re not going to make as much progress.

Stefi Cohen:  Absolutely. You mentioned neuroplasticity. I have such a crazy example of that. I vividly remember at the peak of my back pain, I went into the gym and I said, “Okay, my back’s really bugging me today. I’m just going to have a light deadlift session. I don’t want to miss the session completely. I’m going to work on something else, maybe my timing or my coordination or my position. I want to work on something else that’s not strength.” That day I came in, my back pain was so bad, and it literally felt like the distance that I had to move the bar from floor to lock out was twice as much.

My perception of the amount of work that I needed to do was so exaggerated. I spoke to Greg, and I’m like, “It feels impossible to lift now.” It was two plates [on the bar] and it was 120 percent of my max. It felt like the weight of the world was on that bar. Secondly, it felt like it traveled for two days straight, like it was an impossibly long distance. He explained it to me, and I can’t remember exactly the explanation; I’m not very well versed on the science of neuroplasticity [and] why that happens, but that was his explanation for me.

Chris Kresser:  I’ve talked a lot about [neuroplasticity] on the show, but just for listeners who are new to it, it’s a double-edged sword. It tells us that our beliefs and our experiences can literally change the structure and function of our brain. And that can be in a positive direction, right? But it can also be in a negative direction, which is what we’ve been talking about somewhat [here], where we have limiting beliefs or we had an intense traumatic experience and that creates a trauma loop in the brain that stays stuck even when we’re safely out of whatever those circumstances were that caused that trauma.

One condition that I often use to illustrate this to my patients is CRPS, or complex regional pain syndrome, which you’re probably familiar with as a physical therapist. For those of you who aren’t aware, it’s a broad term that describes excess and prolonged pain that typically follows some kind of injury or inflammation. The normal course of events would be [that] you twist your ankle, you get a lot of swelling and inflammation, which is appropriate in that situation because it’s needed to heal, and then your brain gets the signal that the threat has passed. The inflammation resolves, the pain resolves, and you go about your business. That’s the normal thing that should happen. In CRPS, what happens is, the injury occurs, the inflammation and pain and swelling happen, and for some reason, which we don’t fully understand, the brain continues to believe that the injury just happened and it’s still there. So the inflammation and the pain don’t go away.

I find that’s a fascinating example because objectively speaking, there is no more injury. That’s passed; that’s healed. But the brain is sending signals to that area, as if that injury had just occurred. To me, that’s a really good example of how separate the physical reality of the situation, the actual injury, and the brain signal is. If we understand that separation, like you said, it gives us a little more freedom to explore a different way of being with pain.

Where Common Treatments for Back Pain Fall Short

Chris Kresser: So what’s wrong with some of the most common treatments for back pain? You and I probably agree on a lot of this stuff. You were in a graduate program [and] you had access, like you said, to the top professors who had studied this for their whole lives. But you were really disappointed in some of the conventional approaches and modalities. Say more about what you learned in that process, and what you think is lacking with a lot of the typical approaches.

Stefi Cohen: The first one is fear mongering of specific movements. Demonizing specific movements and heavily emphasizing others, for example. When I was at the peak of my back pain, I remember talking to my spine professor, and he was like, “Yeah, you shouldn’t [be] deadlifting. Deadlifting is what’s leading to your back pain. It’s going to eventually break your back.” And he really believed that; he really did.

Chris Kresser:  Deadlifting is what has saved my back, by the way. I will say that when I had back pain, deadlifting is actually what improved and eliminated my back pain, for the record.

Stefi Cohen:  Absolutely. So yeah, fear mongering of movements. I don’t think that does any good to anybody, preventing people from moving in certain ways, limiting their movement options and movement variability. That actually contributes to pain catastrophizing and contributes to pain in the future, as well. I remember I went to see Stuart McGill for my back. Oh my God, this was crazy. Listen to this story. On a Monday, I deadlift[ed] 504 pounds for four reps, and my back was naturally sore after that. Then I was naturally extremely stiff for the following [day]. By the way, I respect [Stu] a lot as an academic, but this was something that I definitely didn’t agree with. [I had my appointment with Stu] on a Saturday, and he’s doing all these provocation tests. Two hours after the [evaluation], everything that he was saying about my back was so bad that toward the end of the session when he [was] going over what I should and shouldn’t do, a lot of his advice was centered around movement avoidance. Even on activities of daily living, it’s like, “Okay, if you’re going to put your socks on, get on one knee, do a lunge, and don’t bend your back. Put your sock on, and then put your foot next to the other one and stand up.” It was all avoiding spinal flexion in any way, shape, or form. And even though I knew that wasn’t the best course of action, the fact that he said [it] made me stop bending completely in my daily life, subconsciously. And that eventually led me to physically not [being] able to bend my spine, which was insane. I completely lost my ability to bend my spine. I think that’s one of them.

And then I think the biggest one is that there is no bridge going from prehab or rehabilitation exercises into the exercises and movements that are actually required to live your life. It includes having a bent spine when you’re picking your grandson off the floor, or when you’re bathing your dog, or when you’re picking up groceries [or] boxes from the ground and taking them up a flight of stairs. There’s no logical progression from a dead bug and a bird dog and a side plank into functional activities or heavy lifting activities or even sport performance activities. There’s no logical bridge there. I think those are the two main things that therapists get wrong, and I think part of it has to do with a little bit of a hidden agenda. This is something that I picked up in grad school, as well, is that while you’re a healer and a clinician, you’re also a salesperson. That was one thing that made me really sad about school and turned me off from the profession was that I felt like a big part of the advice that we were giving people was centered around disempowering them. Making them feel and think that we have the magic touch [and] that without them performing these exercises in front of us, without us starting the session with joint mobilization techniques, and copying in [Active Release Techniques] (ART) and whatever else that they couldn’t progress. [Whereas] I think that the plan of care should always be centered around empowering the human in front of us to be able to make progress on their own. There needs to be, again, that logical progression between the easy bands [and] isometric exercises to whatever is functional for their lifestyle.

Chris Kresser:  [I] love that and love the book and your approach and think it’s so needed in this industry where there’s, frankly, a lot of stuff that’s out of date where the typical recommendations are not in alignment with what the latest scientific research is telling us about pain. That’s something I really appreciate about your approach and your book. Can you tell people where to learn more about your work and pick up a copy of the book?

Stefi Cohen:  You can pick up a copy at HybridPerformanceMethod.com under the tab Back in Motion.

Chris Kresser:  Are you on social media? Where can people follow you and learn more about what’s going on in your world, your boxing career, and what’s next for you?

Stefi Cohen:  I’m on all the social media at Stefi Cohen. That’s where you can find my day-to-day stuff. Also, the educational content that I post on YouTube is longer format, still at Stefi Cohen. And I’m fighting on July 8. So you don’t want to miss that.

Chris Kresser:  Good luck with that. [I] really enjoyed the conversation, and thanks for joining us.

Stefi Cohen:  Likewise. Thank you so much.

Chris Kresser:  All right, everybody. Thanks for listening. Keep sending your questions to ChrisKresser.com/podcastquestion. We’ll see you next time.