Dr. Kai Tiltmann is a chiropractor who’s passionate when it comes to returning his patients to an active life. In fact, before it all started he was one (a chiropractic patient) himself!
Since 1999, he’s been practicing in San Francisco and in 2005 opened his practice, Financial District Chiropractic where he specializes in lower back pain.
We got chance to ask Dr. Tiltmann some questions about low back pain and his work as a chiropractor.
Q: Please explain in one sentence what you do?
I provide solutions for patients that have been non-responsive to other low back pain treatments, from chiropractic to surgery.
Q: Can you tell our readers about your career path – what lead you to become a chiropractor and how long have you been practicing?
I studied culinary arts and was a professional chef in Canada and Europe.
After sustaining a low back injury – not uncommon in that industry – I was treated by a chiropractor, which really helped.
The non-pharmaceutical and non-invasive nature of the therapy was intriguing and I decided to become a chiropractor after considering physical therapy, medicine, and orthopedic surgery.
Chiropractic offered both physical and mental stimulation with a holistic health focus. I studied at Palmer College of Chiropractic West in San Jose, California and have been in active practice since 1999.
In 2005, I moved to San Francisco and started Financial District Chiropractic, have been there ever since.
I provide solutions for patients that have been non-responsive to other low back pain treatments, from chiropractic to surgery.
Q: What is the most common complaint you deal with?
Low back pain. My practice has evolved over the years from treating the whole musculoskeletal system to my main focus now which is treating patients that have failed all other interventions (from chiropractic to surgery) for chronic low back pain.
I studied with Prof. Stuart McGill and am a McGill Method Provider, one of only five in the US and 19 worldwide.
Q: What is the most common cause of lower back pain in your patients?
Most back pain develops because of how individuals use their back during activities of daily living, work, and how they exercise.
Do it right and you don’t have back pain, do it wrong, and it will eventually catch up with you. This is the case for most patients I see.
Keep in mind that low back pain is a symptom, not a condition. You can have 20 people, all with low back pain and all with different pain mechanisms.
The real key is finding the pain triggers; which movements, postures, and loads cause the pain, then address those, instead of focusing on symptom relief or pain management.
Q: Are there different classifications for low back pain?
Low back pain can be broken down into 2 major categories:
1) Organic pain:
Like cancer, aortic aneurysm, or kidney infection that refers pain to the low back. These cases require medical intervention and not conservative treatment.
2) Mechanical pain:
Like bulging/herniated discs, radial disc tears, loss of disc height, degenerative disc disease, degenerative joint disease, disc instability, facet syndrome, ligament hypertrophy, nerve root/spinal cord impingement, stable fractures such as end plate or spinous process fractures, sciatica, hip pain, muscle weakness/tightness, etc. These cases can be managed conservatively.
Mechanical pain accounts for the vast majority of low back pain cases. When the pain is not properly addressed and the back does not heal, the pain becomes chronic.
Note: Some mechanical pain, like a posterior arch fracture, requires medical intervention.
Q: How do you work to identify the cause and is it always possible to identify it?
It is possible to identify 95% of low back pain causes. It starts with an in-depth history including:
- Pain or injury onset and cause
- Symptom(s) location and description/fluctuations
- Patient work type
- Activities of daily living
- Exercise history past and present
- Patient movement competency
I observe how patients move, sit, stand, bend, pull, etc., without them knowing. This analysis provides a lot of information.
I then perform an extensive physical evaluation, which loads the spine in various positions, and helps determine which movements, postures, and loads increase patient pain and – more importantly – which ones reduce it.
Professor Stuart McGill has developed these tests and this type of examination is called a McGill Assessment, which takes 2-3 hours to perform.
The McGill Assessment provides a detailed diagnosis often delineating specific tissues and spinal location of the problem.
Few doctors have enough time for this in-depth assessment, instead referring the patient for an MRI, which cannot compare to a comprehensive history and spinal examination.
I observe how patients move, sit, stand, bend, pull, etc., without them knowing. This analysis provides a lot of information.
Q: Isn’t the MRI the “Gold Standard” for imaging the low back? How can a McGill Assessment outperform an MRI?
Yes, MRI imaging is frequently used by doctors to try to determine the patient’s cause of pain. But there are 3 major limitations:
- The MRI shows only anatomy, not function, so there may be a herniated disc on the MRI, but is that really the pain trigger? There are many pain triggers that the MRI can not detect, including lumbar instability, disc hypermobility, sacroiliac instability, shear load intolerances, dynamic disc herniations, spinal nerve root adhesions, hip impingement, etc. A functional exam will be able to determine if any of these hidden triggers are present.
- The MRI cannot show if damage is new or old. There may be a disc herniation, but it has long since healed and no longer causes pain. If the pain trigger is not identified, treatment if often incorrect or ineffective, leading to chronicity and even surgery.
- Frequently, patients have good or bad symptoms days, however, the MRI findings don’t change, so how do you explain that discrepancy if the MRI finding is the claimed cause of pain? For example, a patient may have a disc hernation on MRI (the claimed cause of pain) and on Monday has pain, but not on Wednesday.
Q: How have the causes of low back pain changed over recent years with changes to our lifestyles and the nature of our jobs?
I work in San Francisco’s Financial District and most of my patients have a sitting or desk job.
Prolonged stationary postures in any position will cause muscle fatigue and pain, so the key is to move often. Sit for three reasons:
- To type
- To write
- To read on the computer
Every opportunity to change position should be taken. Answer the phone – get up. Talk to a co-worker – get up. Read a hard copy document – get up. Check your cell phone – get up. Stuck on the computer for an hour – get up.
We sit more than we have to and choose to sit when we can get up for micro breaks. When sitting, sit correctly, don’t slouch! And stop looking down on your cell phone, which has a greater affect on the neck, but does impact the low back.
Our current workout culture, including CrossFit, HIIT (high intensity interval training), and even yoga, can have negative consequences for the low back.
In a way it’s ironic since we exercise to be strong and stay fit. However, when done incorrectly these activities can cause low back pain and major tissue damage including fractures.
CrossFit and HIIT training focus on sets and reps with insufficient attention to excellent movement form, which can compromise the spine.
Yoga, on the other hand can also damage the spine, through lumbar flexion/extension and twisting movements. Too much yoga and the lumbar discs become hypermobile and unstable, loosing their ability to bear loads.
Keep in mind that many people participate in CrossFit/HIIT/Yoga without issues, and they will defend their particular activity with fervor.
It’s not these individuals I’m talking about, but the ones that started exercising with good intention, get hurt, and are now suffering from the damage inflicted.
Every opportunity to change position should be taken. Answer the phone – get up. Talk to a co-worker – get up… Stuck on the computer for an hour – get up.
Q: Are there exercises that are risky for the low back? What precaution can someone take to minimize their risk while selecting exercises?
How the spine is trained is important. Body building techniques that work well for extremities, hip and shoulders, do not work for the spine.
With bodybuilding or resistance training, the body part being exercised is loaded and then moved through its normal range of motion.
Think of a bicep curl. Hold a weight in your hand and move the elbow through its natural range of motion and repeat, for 3 sets, 10-15 reps.
This concept has been applied to the spine. Place the spine under load and move it through its range of motion. This has disastrous outcomes for the spine and discs, and is a major contributor to back injuries.
Instead, follow this rule: If you move the spine, it cannot be loaded (like dancing) and, if you load the spine, it cannot move, keep it stiff (like a deadlift).
Think of a plank or side plank, farmer carry, or suite case carry. The spine is loaded, but it does not move.
Now think of dancing, the spine is moved, but it is not loaded. This will help reduce the risk of spine injuries.
Follow this rule: If you move the spine, it cannot be loaded (like dancing) and, if you load the spine, it cannot move, keep it stiff (like a deadlift).
Q: Over recent years we’ve increasingly heard sitting being described as the new smoking. When we researched back pain statistics we found that 54% of Americans experiencing low back pain spend most of their workday sitting. Would you say from your experience that sitting for prolonged periods is the single leading cause of back problems?
We touched on sitting above. However, I strongly disagree with the smoking comparison and I think it’s a fear tactic.
When was the last time your heard that sitting causes cancer? I agree that we sit too much, but standing is not the solution either.
We need to move frequently and properly. The rest position for a sitting job is to stand and the rest position for a standing job is to sit.
When sitting, the spine needs to be in a neutral position with the lumbar curve maintained, and head positioned over the hips. Prolonged slouching can cause the lumbar discs to bulge or herniate, and may be painful.
So, sitting is not the leading cause of back problems, but sitting poorly, slouching, or sitting for hours on end, can lead to back problems and will certainly not help someone who already has back issues.
Q: Apart from visiting a chiropractor, such as yourself, what advice would you give to people who are suffering from back pain?
Learn about how the back works. There are many books, but I really like the, “Back Mechanic” by Stuart McGill. It’s written for the patient and is a must read for all back owners.
There are many great providers that can help with low back pain. The hard part is finding them.
The American College of Physicians, non-invasive treatment guidelines for low back pain, include these modalities and providers:
- Exercises
- Rehabilitation (Physical Therapy)
- Acupuncture
- Mindfulness Stress Reduction
- Tai Chi
- Yoga
- Motor Control Exercises
- Biofeedback
- Relaxation
- Laser
- Cognitive Behavioral Therapy
- Spinal Manipulation
- NSAIDS, Tramadol/Duloxetine and Opioids
Back pain is common and usually self-induced.
If it is muscular, it will be very painful at the beginning, but it will resolve within 2-3 weeks.
If pain last longer than 6 weeks, and treatment is considered, the doctors must be able to determine what movements, postures and loads aggravate and alleviate the symptoms.
If they can’t provide that information, success is already compromised so look elsewhere. For cases that are particularly difficulty a McGill assessment is warranted.
Here is a link to the McGill provider network: http://www.backfitpro.com/backpain/provider/
Surgery should always be the very last option as there can be significant complications and the re-surgery rate is high.
We’d like to thank Dr. Tiltmann for taking part in this Q&A session. You can learn more about his practice and work with low back pain at: https://www.fdchiro.com/
This is the latest in a series of question and answer sessions with individuals and companies who are working in the field of pain management that will appear on TheGoodBody.com.
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