Episode 4

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Welcome to episode 4 of the Empowered Beyond Pain podcast, proudly brought to you by Body Logic Physiotherapy. I’m Kevin Wernli, a physiotherapist and Ph.D. researcher, and each week I’m joined by world-leading physiotherapy specialists* and clinical researchers Professor Peter O’Sullivan and Dr. JP Caneiro as co-hosts with a simple goal… to help you make sense of science, bring evidence to your eardrums, and empower you to better health, and empower clinicians to provide the best care for people with pain.

In this week’s episode, we start by playing audio from a brand new resource we put together with the help of some prominent global patient advocates to summarise a very popular research article titled: “Back to Basics: 10 facts every person should know about back pain”. This scientific paper was published in the prestigious medical journal: the British Journal of Sports Medicine a few months ago and today we discuss some of the key concepts raised in the paper. 

Professor Peter O’Sullivan led the paper which was also co-authored by Dr. JP Caneiro and myself, as well as Dr. Kieran O’Sullivan, Dr. Ivan Lin, Dr. Sam Bunzli, and Dr. Mary O’Keeffe. Next week we hear the stories behind the patient advocates that presented the facts, as well as talk to Joletta Belton who presented low back pain fact number one and is the patient-partnership lead on the Journal of Orthopaedic and Sports Physical therapy (JOSPT)’s editorial board discussing her journey with persistent pain.

As always, show notes, including resources, references, and transcript, as well as video of the conversation, can be found at www.bodylogic.physio/podcast. We hope you enjoy this episode of the Empowered Beyond Pain podcast and remember to ask, is there more to pain than damage.

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Persistent back pain can be scary, but it’s rarely dangerous. Persistent back pain can be distressing and disabling but it’s rarely life-threatening. You’re very unlikely to end up in a wheelchair and getting older is not a cause of back pain, although that’s a widespread belief. There is concern that getting older causes or worsens back pain, however, research does not support this. Evidence-based treatments can help at any age.

Persistent back pain is rarely associated with any serious tissue damage. If you have had an injury tissue healing occurs within three months. If pain persists past this time it usually means there are other contributing factors. A lot of back pain begins with no injury or with simple everyday movement. These occasions may have contributions with stress tension fatigue during activity or unaccustomed activity which can make the back sensitive to movement. 

Scans are important, but only for a minority of people. Lots of scary-sounding fields can be reported on the skin such as disc bulges, degeneration, protrusions, arthritis, and so on. Unfortunately, the reports don’t say that these findings are very common in people without back pain. And they don’t predict how much pain you feel or how disabled you are. 

Scans also often change with most discs prolapses shrinking over time. Pain with exercise movement doesn’t mean you’re harming when cysts are common that the spine and surrounding muscles become sensitive to touch. With movement, importantly the pain you feel during movement and activities reflects how sensitive your structures are not how damage you are. 

It’s safe and normal to feel some pain when you start to move in exercise. This usually settles down with time as you get more active. Exercise and movement are one of the most effective ways to treat back pain. Having a health professional coach you through the process can be helpful. That pain is not placed before we question how we sit, stand, and bend. 

We know these are not shown to cause back even though these activities may be painful. A variety of postures are healthy for the back and it’s safe to relax during everyday tasks such as sitting, bending, and lifting. It can be more effective. Back pain is not caused by a weak or weak core. Muscles do not cause back pain, in fact, people with back pain often tense their core as a protective response. This is like clenching your fists after you sprained your wrist.

Being strong is important when you need the muscles to switch on, but being tense all the time isn’t healthy. Learning to relax their core muscles during everyday tasks can be helpful. Backs do not wear out with everyday loading and bending, the same way lifting weights makes muscles stronger moving and loading makes the back stronger and healthier. So, activities like running twisting bending, and lifting are safe.

If you start gradually and practice regularly pain flares don’t mean you’re damaging yourself, while painful ups can be very painful and scary, they are not usually related to DC damage. The common triggers are things like poor sleep, stress, tension, worries, low mood inactivity, or unaccustomed activity. Controlling these factors can help prevent exacerbations. 

If you do have a pain flare-up instead of treating it as an injury, try to stay calm, relax, and keep moving. Injections, surgery, and strong drugs are usually not a cure. Spine injections, surgery, and strong drugs like opioids usually aren’t very effective for persistent back pain in the long term. They come with risks and can have unhealthy side effects, so finding low-risk ways to put you in control of your pain is the key. You can read the full paper for free back pain facts and if you’d like to watch the patient stories behind the facts, click the link in the description.

So, we’ve just heard the video and the audio of the video for the back facts that we have published. I wanted to get a bit of an insight into behind the scenes of that paper. That paper has kind of blown up in the journal space. It’s a really popular article, and I think this story behind the article will kind of help explain it or partly explain why it’s been so popular.

It’s also nice to know where all these facts and myths come from. So if you want to take us through it, Pete as you were the lead author of that paper.  

Okay. I’ll give us a bit of a backstory. So, we’ve been involved in a research trial in Australia, and part of that trial we were in involved sitting and watching other clinicians work with people with disabling back pain. Part of our job was to sit there and watch and listen to people’s stories essentially. So, we probably had about 80 to 90 patients who are all profoundly disabled with back pain. They’d be suffering this or a long period. 

Part of this was mentoring by feedback to the physios who were working with them. I was typing up their stories and it became very clear that there were these very clear beliefs these people had that were given to them through societal messages. Given to them through family, given them through messages from health care practitioners which were not evidence-based.

But these facts were things that massively impacted their lives. It influenced the way they care for the back. It influenced their lack of hope. They were sensitive to the levels of the stress and that these facts these kinds of beliefs were not evidence-informed. So, I went through the process of writing this up.

I realised that actually, some consistent themes kept emerging with all these people. I essentially wrote them up and then I remember having this conversation, saying we need to write these facts and myths up to give as a hand out to patients. They need to know this stuff because this is common stuff that if you hand us they believe it. 

It’s the kind of thing you can share with someone. I went through this process of writing them up and then I saw you were involved in the infographic. I flicked it to VGSOM and said look I know you guys are running graphics and we think this would be a great interest to the readers of the British Journal of Sports Medicine. 

We thought we would write it up as an editorial so that was how that whole process began and that’s where it ended up. The cool thing is that then the infographic and that knowledge is now being translated into posters that are running in the National Health Service in the United Kingdom, for example. 

It’s been disseminated and it’s been put into different languages as it’s been rolled out into the world. That’s just gold in my mind. And why it’s been so interesting. I’m thinking because it finally hits our core, that’s what I believe. When something hits your core it’s something you want to know about. So that’s the story behind the paper and that is a fantastic segway to my next question.

Which is around the core. One of the myths that comes from the paper is core strength is important. You have to brace your core. If you want to improve anything you have to brace your core. When you’re sitting down like we’re talking here, you have to brace your core. When you’re washing the dishes, all the time. We see this in not just our profession, but you know personal trainers and occupational therapy.

 What’s the go with the core? 

I suppose a simple way of talking about it might be to use the analogy of the wrist. So, what’s a healthy functioning wrist? Your wrist has this amazing capacity. It’s got an ability to define motor control, writing or playing a musical instrument, where you want your muscles around the wrist to be relatively relaxed. It also has this amazing ability to grip hard so that you can create stiffness to open something up. Or if you’re a boxer to box or whatever. 

What’s not healthy for the wrist would be to walk around clenching it all day, not relaxing it at all. In the same way at the core you’ve got a whole bunch of muscles around the spine that are involved with controlling the spine in three dimensions. Those muscles are not meant to be doing much when you’re sitting and standing and moving in a normal way. And they should allow you to facilitate movement in three dimensions. If you’re doing normal activities of daily living. 

But if you are lifting monstrously heavy weights then those muscles all get together and they tense up for a very short period to generate power, but you can get stiffness as well. The problem with pain is that we start doing the clinching thing while we are sitting or standing or picking up a chair or that sort of thing. What we’ve done is we’ve taken something that is a good thing that is to be very strong and powerful and controlled in the body, and we translated it to kind of adopting these bizarre guarded protective movements in a way that is not normal for the human body.It’s not helpful.

What we know about clenching your fists is that it creates a lot of compressive load through the structure, in the same way that over contracting the core does for the back.

Is there any danger to that?

No, but if you do it all the time those muscles will fatigue, and you’re putting a compressive load on structures that might be sensitive. You’re not allowing those structures to move in a normal way and we know the human spine needs movement and psychical loading for our health. Fundamentally we’re teaching the people to do things that are not normal and not healthy if they’re engaging those core muscles all the time.

Unfortunately, that principle became almost part of a management approach where we developed this idea of creating control around creating stability around the joint. Because a stable joint is a healthier joint. It was translated to patients as well as personal trainers for their clients, that you have to stabilize your body to be able to do an activity. 

That transformed into people when they were training to get into the habits of tensing up. When you are in pain, naturally your body tenses up. Now, if on top of that you’ve been told to hold your body strong and suck your core in and keep your spine in a neutral position. That creates a lot of stiffness. Unfortunately, we see a lot of patients that come into the practice that has been told that. 

The same message across several clinicians that I’ve seen. They could be medical doctors, they could be surgeons, they could be physios or they could be personal trainers. They reinforce that message. When you get them to sit in a way, for instance, if you’re comfortable when it’s their preference it feels better. But if they say don’t do this, that’s wrong. That’s bad for you, it isn’t allowing your back to relax. Etc. Those messages are strongly put in in society.

If we look at something like the common-sense model, which is something that we use as a framework to understand patients. And also, as part of research where the way you understand the problem comes from messages that are from your family or from your friends that are ingrained in society. That shapes how you understand the problem and is based on how you act to resolve that problem. So it shapes your behaviours. 

If that’s effective your emotional response is positive and it makes sense. It doesn’t make sense for your emotional responses to become frightened and distressed and more worried about that body part. Because you’re following the rules and you’re not getting the benefit that you should be getting. So you kind of get better at following those rules because they are the rules that “should” work for you.

If you want strong back muscles then you want strong muscles to go all over – but you don’t want to have those muscles working all the time because you’ll fatigue rapidly. If you are twisting or if you’re pushing or if you’re tackling or if you’re engaging in some heavily loaded activity you need a strong core, but you don’t need them “on” all the time. 

What we know about motor learning is that as you get better at something, you’ll get more efficient. Often this whole idea of rehabilitation is you need more because it’s better. But actually, most about what we know about motor learning and certainly people have pain as they get better. They use less, not more, and so learning to move better doesn’t engage more motor activity. Often it engages less. 

We see that with some of the studies that have come out that look at people with and without pain. Those with pain young tend to tense their core more and doing it directly. It’s a social thing. There are barriers associated with dancing, they call this you know all their “back wheels” and that probably highlights they’re not protecting their body part as much as they could.  

We’re hearing the word protection with the core and the spine. This idea that maybe you know about the core and that the spine is unstable. It kind of tends to drive this narrative that your back is fragile and you have to be careful with it. And it’s vulnerable. So of course you protect your core. But is that true? Is the spine vulnerable? 

I suppose you could come back with a question and say are human beings vulnerable to back pain? As we know it’s like one of those questions that’s prevalent in society. It can disable you if you think that your human spine is vulnerable to injury. We see there’s a group of people that are vulnerable to disc prolapse or to straining their back. Then what are the factors that leave those people vulnerable? That’s the next question.

It’s very interesting. We know that if you look at what predicts an episode of back pain it can be a bunch of factors. If you’re sedentary at your job and your deconditioned and then you go out and start digging ditches. That’s a bit like sitting around all day and then running a half marathon. You are likely to get a sore knee if you run a half marathon if you’re sitting around all day. Because those legs aren’t conditioned to running a half marathon.

So is the back more vulnerable? Yes, it is vulnerable if you don’t keep it healthy. That consistent with lots of things in the human body, especially with your heart. If you smoke and if you don’t eat and if you don’t exercise, then you have got a high-risk factor for cardiovascular disease. 

But you might be at risk as it’s genetic. Then you’re more vulnerable and your heart is vulnerable. But if you keep active, keep healthy, keep moving, and have a good diet and you work on your mental health then your risk for your heart is significantly less.

The way I see it, the back is a bit like the heart. So with what we know about the back, is that it loves to be active. It hates to be sedentary. It loves to be strong. It loves to engage in physical activity. It needs sufficient rest and sleep and benefits from people with social engagement and good mental health for all of those factors, and not too much body fat.

All of those factors influence the health of the back. We have a vulnerability in our backs and having had episodes of back pain in my life, I’ve been certain some events have exposed trauma to forces that are beyond my strength in my body structure. Other issues are having too much tension and stress and other factors that have influenced it when it’s vulnerable.

What it means and what we do about is another question. I’d say it’s more vulnerable than any other body structure. For some reason more vulnerable to pain and vulnerable to damage. We know it’s a really common cause of pain so it is a vulnerable region of the body. When there is this homeostasis in our world environment is threatened for some reason, pain emerges in our body. 

Often it goes through the neck and the back or the pelvis for some reason, that’s probably partly linked to how our whole nervous system has operated. But for some people there would be evidence that they may have to care for their backs more than others, as some are structurally vulnerable. But I don’t see that it’s different, then say, for some people that have to care for their cardiovascular health way more than others. 

I see it with an understanding of where your vulnerabilities are and then optimising the things you can change around that. And then understanding it is also adaptable. I think that’s important.

We have this kind of dichotomous view of when it’s a structure and when it’s not structured. I think the point you raised here is you’re damned to manage that structure to keep it healthy and it’s a bit like the story of the knee arthritis. How do you manage to keep that region as healthy as you can? That’s the question. The other thing too is we talk about the back being vulnerable, but when we listen to patient stories we often find that they had a period of their type of time of their life that they are vulnerable to pain. 

They can be under stress, not exercising, eating crap. A period like Covid-19 isn’t classic for a normal year. We had a lot of people that this situation has significantly impacted and changed their lifestyle. They’ve became highly distressed and they have pain, so it’s an expression of their health system. Looking for a vulnerability around a period in their life may explain this story better, and a lot of those factors may be modifiable.

You’ve kind of mentioned before that a lot of times pain is related to structure, then surely there have been advances with medical technologies? We have seen this historically. We’ve been hunting for a reason to explain the pain, looking for on areas on the skin. 

That’s probably opened up this whole rabbit hole of maybe inefficient care. Can you talk to me about when a scan is important? And what’s the go with scans and the background of scans?

A lot of people think we’re anti scan. I’ve had several scans for other health issues and those scans have been really helpful. They’ve diagnosed issues in my leg and clots in my lungs which has probably saved my life. So, scanning for certain things is essential. Potentially life life-saving.

In terms of the back, I can think of numerous patients in the last year who I’ve referred for scans. One was a young girl with a tumor in her spine. That was important because she could become a paraplegic or even lost her life. Another lady who I saw had a massive disc prolapse and bowel and bladder function and lost neurological deficit. I rang the surgeon so that scan was really important for her. She had surgery that night.

I had other patients recently who have had neurological deficits. So they have power and sensation in their legs. They needed a scan because that was progressive, so not quite a requirement but because it was progressive it was smart to have the scan.  

I’ve had a guy who had an acute injury in the surf and he wasn’t getting better. He had fractured his spine and he needed that scan to know what had happened. Even though he probably would have got better with the passage of time, he was not giving his spine the chance to heal. 

I’ve had other clients who’ve had a scan where they have motor changes or swelling or inflammation around the discs and the bony structures around the disc. We know it can be a source of pain and so we modified the management plan for that person in response to that.

The one thing that’s tricky about a scan is that as we get older our scan results change. We know that it looks like this but what is emerging evidence that at a young age significant changes like this change the scan. They look like they’ve got a higher association with bone, but we know that as you get older ever or all of us have changes on the skin. They are normal age-related changes.

The problem is that it gets all messed up and then the messages we give people about their scans get messed up as well. For example, the public thinks if I’ve had a disprolaxus, it’s there for life. But what we see is it’s an acute event that reabsorbs rapidly usually over months. Those things are not forever. It’s a momentary event and modifiable.

We know that someone can have a degenerated disc and function at a high level. You can have a disc bulge and function at a high level. We know a lot of these things that we think of pathology are present, and a highly active athlete that uses their body every day. We know that certain things are important that we need to identify and that we need to address with the scan. 

But there’s lots of stuff on a scan like moderate degenerative change, for example; fissures, bulges, and prolapses. In the absence of neurological deficits there may be chance findings that are part of your normal picture that we shouldn’t be giving too much attention to. We certainly shouldn’t be protecting it either so it’s a tricky role as a clinician to marry the story of the patient with the picture on the scan. And say is this relevant and important for you in the correct context? Are those things modifiable? Can we manage this differently?

It’s even harder for the patient when they get old these messages around and these are episodes. You’ve raised some really nice examples of when people should get scans, but you know in the broader ecosystem of the health system, the data suggests that it’s not happening.

I’m sending for too many scans and to be fair it’s only about 5% of the population where what you see in the skin is significant in terms of the problem. And all of that can improve. That may be only a momentary thing. Anyway, there’s a modifiable and I think that’s really important to highlight is that people can read the scan incorrectly.

There is a belief they need to protect that body part if you do have some sort of illness that can preclude you from working on things that would facilitate the process. So, if we have a dispro with nerve compression and it is quite inflamed you want to take an anti-inflammatory approach.  

This could include working on your sleep patterns, managing stress, keeping you active, getting you movement in a graduated manner and a nonprovocative manner. That can increase the health and facilitate your body to heal and reabsorb what it needs. So, this idea that you need to protect when there is risk in the pathology is true to an extent. You need to protect yourself from highly provocative activities and the management should facilitate the healing of the body.

That’s kind of paradoxical in a sense, because if you have been told that you’ve got a disc bulge and the common narrative and sort of false belief that when you bend over, you’re gonna shoot pain through the back. While it’s just kind of like a virus soaked with this, so that’s unhelpful. 

With the intention to protect the area the most you’re going to do is not go out and get that healthy movement, and you’re gonna be stressing because you can’t work. That’s going to impact your sleep. So you can really easily see how you ever get down this road. 

There was a lovely paper that just got published looking at active people versus inactive people. It’s been tracking them over some time and showing the active people had healthier-looking spines. We know there are lots of factors around lifestyle and engaging in physical activity etc but it’s also really important for a healthy spine. Unfortunately, we’ve got a growing number of the community who are more and more vulnerable because of their lifestyles to developing problems. 

Final question. Now, this is a controversial one, so controversial that a Ph.D. student is doing a hot topic on it now called Nick Rossini. This is a very often asked question. Should we lift with a straight back?

Let’s talk broadly about lifting. So Nick has a really interesting project in that it looks at the evidence. We have this incredibly common view in society that lifting with your back increases your risk of injury. There is really only studies looking at putting, you know, measuring the pressure within the spine. And looking at different postures. 

When there’s more pressure on the structure, it means it’s a greater risk of injury. We have this view that loading your back with something can increase its risk of injury, where we know that loading something makes it stronger. That mindset is a major problem with that extrapolation straight up. The second thing around that is those studies never actually measured the angle of the spine. Those were measured by an inclination that was followed up with other studies that put pigs on spinal segments in vices. And repetitively bent them and overtime would actually what fraction was the endplate.

It’s not the disc itself. And it kind of makes sense because if you work with any kind of structure. And you do this to it and advise it’s going to break. The question of the thing is that it was never tested well. It’s never been confirmed in real people like me, in living tissue. So, the next study looked at all the evidence available in the literature. To say, is there any evidence to say that it’s bending with around back? Or flexing your spine when you’re engaged in lifting is a risk factor for back pain?

The answer is that actually there were what was there about eleven or twelve studies I think somewhere. At least some were of pretty crappy quality, but there was no evidence at all. So that raises a question. So we have this economic industry or menu handling industry that says lift with a stroke bag because you’ll protect your back. There’s no evidence for it. If you look at the literature that has instituted those recommendations.

What has introduced the episodes of back pain at all so while it hasn’t worked in – it’s not evidence-based so the question then is what is everyone’s back and that’s a tricky thing because actually the evidence is pretty limited at the moment in that space now if you take a broader view ago what’s healthy for the human body what’s healthy for the human body is actually moving in a variety of ways it’s good for us then v beta is good for us so if you’re engaged in a manual job and you’re gonna lift off the ground.

It will be impossible to lift with a straight back so you have to bend to do that job so you want to be fit and strong to bend to do that job so the question then is what’s best to do it and I would say you’re best to learn to get fit for task you’re best to be conditioned for task and to keep all those other factors that are important for your health in check to minimize your risk so there is also some evidence to suggest that you’re more efficient if you’re lifting off the ground with a round back than it with a straight back. That’s not to say you should live in the strike back but it may mean that if you’re repetitively lifting with a round back that you can do it fell longer because it’s more efficient.

You can get away with it for long we’re straight about you know fatigue more so there is the the jury is out actually around what is best but based on current evidence we’ve got to take a sensible view to say actually there’s probably a variety of ways you could lift and having adaptability if you’re engaged in a manual job to do it in a whole bunch of way so that you’re fit and conditioned and confident to do it when you’re caught out, that’s probably smart. but make your job most efficient for you.

That means engage your legs it means that use your body efficiently that to me is where the evidence sits right now and what’s best for you might not be what’s best for me it’s everybody different every body shape is different and and that’s the bit that we don’t really know what we know everyone’s are different yeah and whether some people have more vulnerability than others around different ways, that’s something that will emerge I think in the future when we you know do more research on this space.

But I think what it does tip into some of your words okay that actually we have a lot of fear around bending and lifting that probably tips you into what your work has shown yeah and one of the things that we know is that it’s a fairly commonly reported situation and what people say that was a trigger for their back. I just bent over to pick up my shoe and I had back pain well I went to lift a box and I had back pay and it’s always linked just to that task as opposed to context in which they happen or if you actually fit for the task.

During my PhD we we had a an opportunity of evaluating patients that had high levels of fear around bending and lifting and then you can see the consequence of some of these myths that are in society where people became completely unable to bend and they’re very frightened to bend and they create structures or even using a picker-upper to pick something from the floor because they have this really strong belief that if they’ve been forward something bad will happen with their back and that kind of got us thinking about you know you can ask someone about their beliefs around bending and lifting and they may say to you that no it’s okay to bend your back and it’s safe.

So we kind of designed this we use this this test called an implicit association test which was designed at Harvard University and we adapted to ask the question you know is bending and lifting with a round versus a straight back he’s a safer dangerous and the way that the test is is set up is it kind of depicts your your poor believes you don’t have much time to consciously think about your answers and we looked at people with back pain that had high levels of fear of any and people that had reportedly no fear of bending.

When we look at their implicit beliefs they had a very clear bias that Romney your back when you’re bending and lifting is dangerous for you and that got us thinking sorry if if regardless of what you saying you have this implicit bias this is something that potentially is spread in society so we looked at and investigated people that had no back pain whatsoever and the same bias is present so despite that they reportedly say that it’s okay it’s ingrained in their memory that is not a cat to bend lift it around back so then we looked at how about we ask people that treat patients with backpack.

So we’ve got a better physiotherapist working with muscle pain and we asked them and the same bias is present interestingly a vast majority of the features were saying that Benjamin around back is okay but when it came to the implicit test they showed the same bias so what that demonstrates to us is that the test is picking up on quick associations you can make in your brain and if we think of the context that we will look at based on that manual handling industry everywhere you go you see a picture of someone they’re nearly feeling around back with a cross and someone lifting with a straight back with postures that maybe you and I cannot achieve with a big tick so it’s ingrained in our society that that’s the way you should do it.

Some people they can achieve that and they struggling they’re trying to achieve it they put it there boy putting their body under stress trying to achieve something that they may not be able to achieve and actually feel much more comfortable doing in a different way so this this kind of reflects the extent to which a myth can be spread in society and the consequences that can have in someone’s in someone’s life you know I saw two patients today that would refuse to bend and pick something on the floor around their back when they’re trying to get by with their life in doing that and the debilitated by it.

That’s basically from the belief that running their back would should destroy the back like I said so I have this boat and therefore I cannot bend forward so it’s really interesting looking back at that seminar any initial work of Alfred mechanism which you know developed this idea of the identified high pressure in the discs and stuff if you follow his work his later work ten twelve years later which not many people know about he was actually saying look. I’ve done all these studies and look at the mechanics of the back but what I’m finding is that some people are not satisfied at work so people more stress some people are not physically conditioned.

It looks like back pain is a little bit beyond what happens with the structure of the disk but those papers didn’t get as much attention and we keep going back to the initial ones because they fit the buyers of training and I think just on from that JP then is the problem with that belief as you highlight is that when people become in pain they revert back to believe and so you know you might be doing your job and getting away with it and very little people work probably most people ignore you know the strike back idea but once I get back pain I like what do I know about back find you that’s when they start straightening out they start doing this and invariably we see this and the clinic always work.

I would say almost invariably we see people squatting to pick up a pen sitting to pick up this shoe doing this stuff completely avoiding a bit in the back and often once we get them relaxing and bending they feel so much better and whether that’s a reduction and fear or whether it’s because they get to relax their body and start to moving painful structures probably lots of reasons why they benefit from it but fundamentally is I think it’s incredibly unhelpful but to change that narrative amongst the ergonomic or menu handling will I think will be a massive massive challenge.

Because it is so embedded and there is so much fear around backpack because it is such a prevalent problem and it’s really easy just to pin it on something simple like your back straight it’s interesting because some of the patients will come back and say yeah look I see all those posters but I never really took care of my back now I know I should and that’s when they start you know protecting me and the other thing too is that when you have pain clerks and as you said you know you may come in to the physio the physical change or narrative change your mindset things are going well and then you have a flare-up and a lot of people get really scared of that flare up and clinicians don’t really like to you know know a patient that was doing one who had a flare-up.

But actually those great opportunities for learning from the patient because they may have had a flare-up those beliefs come back those behaviours come back and they rattled because almost like that fear memory never goes why it just becomes suppressed with a safe stronger memory but once you have a flare of that fear memory emerges and then the clinician has an opportunity to modify that belief in you know shut down their fear memory and strengthen the safe memory and as we see along the journey is that as people continue getting some of these pain flare-ups they learn to manage and this becomes more of a you know safe the safe memories tend to tend to win over time notice the safe memories don’t feed the fear memories exhibit all right the wrong.

I just want to bring it back to a really clinical example as we finish so say for example we’ve got a listener who does have back pain or a hypothetical patient has a back pain and you know we’re hearing this stuff which for us is you know we talk about this stuff a lot but actually for some lots of people hearing it’s like hang on a second I mean that’s completely the opposite to what I’ve been told and what society knows that doesn’t really like sit with me but you know like so I’m gonna go I’m gonna go around my back I mean I’m gonna go Bend in time I shoot and and then they have a pain flare with that so can you kind of talk to why they might still have pain even though their pathology my chances are you know 80% of these prolapses here within the first couple of months.

Why have they still got time in their Bend yep so I suppose the first question is is why did suppose the head pain so it’s a bit like Ward I have pain in my name in a run light of day name a rug she’s a week on that leg I’m so when she’s loading that leg it doesn’t have sufficient support so it starts putting stress than the joint and she’s thinking my knees arthritic.

Well it’s just weak so so there’s lots of reasons why you might have pain and I think that’s the first important thing so I always say to people if it’s not broken don’t protect it that’s number one it’s not broken so how do you know if you get a broken bone well you probably will remember that you’ve had some kind of major trauma if you if you’ve got pain raging down your leg in people go I’ve got none less well grab a needle stick it in your skin if you can’t feel it then you need to go and see some medical care because that means that you’ve lost some of the messages that come through down to your leg you can’t pay that’s important if you’ve got a history of cancer and you’ve developed this onset of pain that’s like.

I’m significant and there’s no real pattern to it then you need to go and see your doctor so there are lots of reasons when you should get sick here all right so it’s not something that but if you’re you know look at the context like JP’s if you’re tired run down estrellas or you done nothing and you’ve gone and you know done crazy stuff in the garden or whatever get back pain don’t freak out because that’s likely that and you often feel your muscles clench when you do it relax your body engage with the moment keep doing normal stuff don’t go straight back and dig your ditch again because that’s just like not very clever and the body will in good chance the majority of back pain over a period of the four weeks will get better.

No matter what you do we do know that 30 percent of people are vulnerable they’re not getting better and they’re the ones who need to seek in so in that first couple weeks if the pain is significant and distressing and is limiting you and it’s not getting better then seek here but seek the right here so sick here where someone’s not gonna just leave you passive and do stuff to you.

I saw a lady this way who went to see a clinician who told them they needed to be said three times a week for 10 weeks they spent all this money and there were no different they were given no soft care strategies so seek here that puts you in charge of your back that gives you an understanding and gives you strategies to put you in control that’s the kind of care you look for empower people right yeah that’s why it’s the name of the podcast.

I’m perhaps asked the question to the clinician is there more to my opinion than just my back yeah are there other things that I can do what else to help and sometimes it’s probably important to also note that sometimes you need some help with that yeah yeah and look there is a role in some cases for just strategies to reduce your pain you know it might be a heat packet when you’re really cutting your muscles are really changed it may be some hands-on work that just gives you a window to get moving although a lot of the time we think it’s important an actual fact you know there are strategies like breathing and movement and gentle exercises I can just do that job beautifully well yeah and it’s cool because we’ve seen that before and we’ve experienced it ourselves yeah yeah so we know that there are other options out there yeah just the tools that we’ve been absolutely us of it in our own way having had lots of back pain of my life I’ve never had treatment it’s because I know how to care for it what’s that option awesome thanks for their chat again guys good thank you pleasure.

So there you have it, episode 4 of the podcast – Jam-packed full of facts. We’ve received lots of great feedback about this resource and with almost all of us knowing someone who’s life is impacted by back pain, why not share this video with them – it may provide some insights or maybe even some hope that they can get back to living. We look forward to having you again as company next time, when we delve into some of the stories behind the patients who presented the back pain facts, including a discussion with Joletta Belton, patient advocate extraordinaire, blogger and just an all round good human, but until then, remember to ask, is there more to pain than damage.