The Empowered Beyond Pain Podcast

Episode 13

Low back pain fact 3:
Rarely associated with serious tissue damage

Low back pain is still the world’s most disabling health condition and costs more than cancer and diabetes combined. A scientific journal article covering 10 facts about low back pain was recently published in the British Journal of Sports Medicine ( The origins and motivations for that paper, as well as patient stories, were covered in episodes 4 and 5 of the podcast. In this episode, Professor Peter O’Sullivan welcomes Professor Rachelle Buchbinder to discuss low back pain. We cover low back pain fact number 3: Persistent back pain is rarely associated with serious tissue damage. We hope you find this podcast as insightful as we did!

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Episode Show Notes:

O’Sullivan PBCaneiro JO’Sullivan K, et al
Back to basics: 10 facts every person should know about back pain
Buchbinder, Rachelle; Underwood, Martin; Hartvigsen, Jan; Maher, Chris G. The Lancet Series call to action to reduce low value care for low back pain: an update, PAIN: September 2020 – Volume 161 – Issue – p S57-S64 doi: 10.1097/j.pain.0000000000001869
Lancet low back pain series:

What low back pain is and why we need to pay attention

Hartvigsen, Jan., Buchbinder, Rachelle et al.
The Lancet, Volume 391, Issue 10137, 2356 – 2367

Prevention and treatment of low back pain: evidence, challenges, and promising directions

Foster, Nadine E., Buchbinder, Rachelle et al.
The Lancet, Volume 391, Issue 10137, 2368 – 2383

Low back pain: a call for action

Buchbinder, Rachelle et al.
The Lancet, Volume 391, Issue 10137, 2384 – 2388

GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016 [published correction appears in Lancet. 2017 Oct 28;390(10106):e38]. Lancet. 2017;390(10100):1211-1259. doi:10.1016/S0140-6736(17)32154-2
Dieleman JL, Cao J, Chapin A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA. 2020;323(9):863-884. doi:10.1001/jama.2020.0734
Lemmers GPG, van Lankveld W, Westert GP, van der Wees PJ, Staal JB. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J. 2019;28(5):937-950. doi:10.1007/s00586-019-05918-1

OxyContin goes global — “We’re only just getting started”

Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872-882. doi:10.1001/jama.2018.0899
Goodman CW, Brett AS. Gabapentin and Pregabalin for Pain – Is Increased Prescribing a Cause for Concern?. N Engl J Med. 2017;377(5):411-414. doi:10.1056/NEJMp1704633
Curtis HJ, Croker R, Walker AJ, Richards GC, Quinlan J, Goldacre B. Opioid prescribing trends and geographical variation in England, 1998-2018: a retrospective database study. Lancet Psychiatry. 2019;6(2):140-150. doi:10.1016/S2215-0366(18)30471-1
Dyer OwenWHO retracts opioid guidelines after accepting that industry had an influence 

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173
Buchbinder, R. (2008), Self‐management education en masse: effectiveness of the Back Pain: Don’t Take It Lying Down mass media campaign. Medical Journal of Australia, 189: S29-S32. doi:10.5694/j.1326-5377.2008.tb02207.x

Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ. 2001;322(7301):1516-1520. doi:10.1136/bmj.322.7301.1516
Buchbinder R, Jolley D, Wyatt M. 2001 Volvo Award Winner in Clinical Studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine (Phila Pa 1976). 2001;26(23):2535-2542. doi:10.1097/00007632-200112010-00005

Buchbinder R, Jolley D. Population based intervention to change back pain beliefs: three year follow up population survey. BMJ. 2004;328(7435):321. doi:10.1136/bmj.328.7435.321
Buchbinder R, Jolley D. Effects of a media campaign on back beliefs is sustained 3 years after its cessation. Spine (Phila Pa 1976). 2005;30(11):1323-1330. doi:10.1097/01.brs.0000164121.77862.4b

Buchbinder R, Jolley D. Improvements in general practitioner beliefs and stated management of back pain persist 4.5 years after the cessation of a public health media campaign. Spine (Phila Pa 1976). 2007;32(5):E156-E162. doi:10.1097/01.brs.0000256885.00681.00



Body Logic Physiotherapy, empowering people to achieve better health.

‘When you talk about persisting symptoms, I try and explain that it’s got much more to do with other factors, not the actual pathology that you might see on an image.

Yeah it’s much more to do with psychosocial factors, yeah, and and that often turns on a light bulb I think, yeah, when when you talk about what what what predicts what are risk factors and what what might reduce your risk and you talk about things like smoking and obesity and catastrophization and fear and beliefs, that that then starts a conversation about ‘oh well, maybe if I think about those things less about the pathology, that might be way through.

Many people with low back pain get the wrong care, causing harm to millions across the world and wasting valuable health care resources.’

That was a direct quote from a research paper published this month, August 2020, in the journal ‘Pain’. The article was led by the voice you just heard which belonged to professor Rachelle Buchbinder.


Welcome to Episode 13 of the Empowered Beyond Pain Podcast, proudly brought to you by Body Logic Physiotherapy.

So, who is Professor Rachelle Buchbinder? Well, for those who aren’t familiar with who she is and what she does, allow me to enlighten you, because she truly is a remarkable voice in the musculoskeletal pain space. Professor Rachelle Buchbinder is a rheumatologist and clinical epidemiologist who also holds a professorship and NHMRC senior principal research fellowship at Monash University in Melbourne. She’s recognized as one of the world’s top experts on low back pain lead that’s right led the highly publicized and highly regarded low back pain series in the prestigious medical journal, the Lancet, in 2018 and is tenacious in the promotion of good high-value care for people with pain.

She recently also added Officer of the Order of Australia to her long list of accomplishments so, in short, she’s kind of a big deal.


That quote I recited at the start of this episode about many people getting the wrong care for back pain causing harm to millions and wasting incredible amounts of health care resources was from an update paper to that Lancet low back pain series. The update highlights that low back pain is still the number one cause of disability in the world; it still costs a lot of money. For example, the US spent an estimated 134.5 billion with a b us dollars on back pain in just the year of 2016.

It highlights that many people are still receiving the wrong care, which causes harm. One of the most disastrous examples of harmful medical care being prescription opioids, which was a problem in most high income countries and now, thanks to aggressive marketing in low and middle income countries, is also becoming a problem there.

By the way, we now have even more evidence that an opioid strategy is not more successful than a non-opioid strategy for persistent low back pain or moderate to severe pain from hip and knee osteoarthritis, thanks to the space trial as well as more evidence that opioids are more likely to cause adverse events. While opioid prescribing does appear to be falling in some high income countries, worryingly it seems they are being substituted with gabapentoids for example gabapentin and pregabalin which the evidence does not support as helpful for those with back pain or sciatica. The vested interest when it comes to pharmaceutical drugs is something Rachelle discusses in this episode and it’s highlighted by the fact that the World Health Organisation recently revoked two guidelines relating to opioid use, conceding they had been influenced by the pharmaceutical industry.

That fact drop you just heard was summarising the update paper that Rachelle led. We are so grateful for all that she has done for people with pain and for the time she gave us to share her incredible knowledge. We’re also super grateful that you’re here with us, listening to the wisdom that she shares as you will hear the incredible power of social sharing and knowledge is what helped the state of Victoria change back pain beliefs and behaviour for the better in the late 1990s, through a huge mass media campaign. Sadly, the funding for this campaign was cut when the government changed, which is a huge shame.

A lot of the fact dropper highlights the negatives, but what should we do instead? Well that’s what we’re aiming to empower you with by doing this podcast. A big part of our mission is to make contemporary pain knowledge go viral and better inform the public people with pain and the people treating those with pain and of course to help empower you beyond pain, so please share this conversation generously with your networks.

Tag us at EBP podcast on the socials and be part of the change that you want to see. This was an absolutely fascinating and insightful chat and I found myself in frequent awe at the quality of conversation between the two profs like a kid listening in on a conversation between two superheroes. I was a happy bystander as beautifully articulated questions and thoughts I found myself having.

If you enjoy the conversation half as much as I did, you’re definitely on to a winner we’ll start by hearing fact three of the back pain facts paper presented by popular patient voice Pete Moore, then we’ll get straight into the conversation with Rachelle.

Show notes with resources discussed in today’s episode, as well as all the others, are available at

And, as you heard last week, we’re moving to fortnightly releases, which will give you more time to digest the conversations and more time to ask.

Is there more to pain than damage? Persistent back pain is rarely associated with any serious tissue damage. Backs are strong – if you have had an injury tissue, healing occurs within three months, so 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 from stress, tension, fatigue, inactivity or unaccustomed activity, which can make the back sensitive to movement and loading.

Welcome everyone, we’re very lucky to have Rachelle Buchbinder to join us on this podcast. Um, first of all, I think Rachelle, could you please just introduce yourself?

Hi, so many thanks for having me, I’m a rheumatologist and a clinical epidemiologist and I work in private practice at Cabrini Hospital and also at Monash University.

Okay and you hold a professorship and you’re also an NHMRC senior research fellow? Yeah, significant positions, can you tell us about those positions?

So, I have a research fellowship from NHMRC for work relating actually to developing the Australian New Zealand musculoskeletal clinical trials network and trying to improve the translation of evidence into practice and that will continue next year with an investigative grant. Along the same lines as well as trying to reduce over-diagnosis and over-treatment.

Fantastic, great, so one of the things that I was particularly interested in, Rachelle, is as a rheumatologist, um you’ve developed quite an interest in back pain and that’s not that common and I’m interested in how that came about.

So, I did a masters of clinical epidemiology in Toronto, Canada, and when I came back, I had a part-time appointment in the department of epidemiology and preventive medicine where I still work and the work cover authority were planning to set up a mass media campaign for back pain and this was because, for the previous 10 years, their costs for back pain had doubled over – no, had tripled over a decade, and they tried to change clinician behavior. And nothing seemed to work and, at the time, the Back Book had come out in the UK and Australia has a, um, a really good history of mass media campaigns for things like seat belts and skin cancers, so the slip slap slop program, so there they decided they were going to mount this public health campaign. And they actually asked some people in our department who worked with work cover, whether they wanted to be involved and evaluate it and they actually declined, because they didn’t think it would lead anywhere. Then someone just said oh would you like to do it? And I sort of went ‘Me? Well I guess I’m not doing anything else and I wasn’t, you know, I’d just come back.

So I said okay I’ll give it a go and and so that’s really how it started, and I didn’t expect that it would be successful, so I was pretty naive about what they wanted to do. But I decided that if they were going to do it, then they should do it properly and it should be evaluated properly, so so my role was really to develop the evaluation and, you know, to sort of push that they would evaluate patient beliefs as well as doctor beliefs and we’d look at real outcomes. Yeah, and that’s how it started.

So this idea of, um, of targeting beliefs, can you tell us about how that evolved? Yes, so because obviously you’ve got a problem where the costs are going up for a problem tripled and you’re then targeting community beliefs, how does that work, how did that work?

So, basically, the work cover authority looked at the Back Book and pulled out the main messages there and they were very clever, very simple, clear messages, that if you had back pain you didn’t need to worry. Most people didn’t need to stop doing what they were doing, most people didn’t need to see a health care practitioners. They could stay at work and that’s really how the main messages came about and what the work cover authority did was actually to put every all the stakeholders, all the clinical stakeholders, in the room to come up with what the messages were and get everybody to agree on these simple message. They also included employers and and and tried to get everybody on side, to think about the legislation, to think about how everything could be towards the right, the right goals. And so that that’s how it really started and and then they employed a new advertising company to come up with the slogans and the people involved in the messages were involved in the ads.

So, that’s how it all evolved, but my role was really about evaluating it and originally they just wanted to do some focus groups which they did do but we – I wanted to evaluate it quantitatively. And as I said at the beginning, I was really skeptical about it, and so when we saw the first results, we go ‘no, this can’t be right’ although it just seemed too good to be true. But then, when we did, when I sort of then – looked in into public health campaigns, I realized that it was always going to be successful. Like it just was going to work and there are so many benefits of priming the whole population, that not everyone needs to see the ads, everyone will just move better as a result of the ad campaign. If as long as enough people have seen it – so that really started me on a journey about the importance of perceptions and and having the right attitudes and beliefs and how that was so important in the society in the background cultural environment to drive the changes. And then you could add to that more targeted campaigns for high-risk groups as well, but the whole thing was this mass media moving the societal attitudes and beliefs over towards better beliefs.

Yeah, so for people who are not familiar with your study, can you just describe exactly what it was? What the media campaign did and how it worked?

So, the mass media campaign, it was carried out between 1997 to the end of 1999. It was funded by the Victorian workcover authority and it was planned that there’d be subsequent top-up ads every other year, but the government changed at the end of 1999. So, there’s been no ads since then, the campaign was 90, it was television commercials and they were aired during really tv programs that the whole community would watch. So, grand final football cricket and at that point, there was no foxtel or of any of those other streaming services. We basically just had the four or five channels, and so the campaign were these television ads. They were very much shown in these high impact shows, and then there’d be a period of less ads and then there’d be another more intense campaign and it was accompanied by billboards.

Every doctor in the state of Victoria got a booklet about the management of compensable back pain, which we think were just thrown in the bin; no one really looked at that. And the Back Book was translated into many languages and that was given out by caseworkers to people who had compensation claims so that was the the primary part of the campaign. And the evaluation, uh, what we did was we did telephone surveys of the general population before the ads started during the campaign and then, at after the end of the campaign and we compared, we used what’s called a quasi-experimental design, where Victoria was compared with New South Wales and we excluded people who lived on the border who would see Victorian television for example and that was accompanied as well by mailed surveys to GPs in Victoria and New South Wales, again excluding postcodes on the border.

And we also did those surveys before the campaign started, during, and after, and then after the end of the campaign, we were lucky enough to get a couple of additional grants and so we could do follow-up even after the end of the campaign and then the third part of the evaluation was to look at what actually had happened to the work cover claims for back pain compared to non-back pain claims and to try and compare what was happening Victoria to New South Wales and also to South Australia. So we could look at in Victoria we could look at the number of claims to see whether the number had gone down the duration and the costs basically.

And what did you find?

And so, uh, we found dramatic improvements in the general population beliefs in Victoria compared to New South Wales, where there was no shift in beliefs.

So what kind of beliefs did you find shifted?

So, the main beliefs that shifted were the main aims of the campaign, so the population in Victoria were much more likely to think that you didn’t need, you could continue usual activity, you didn’t need to rest for back pain, you didn’t need imaging, you could stay at work, you could self-manage. Um, and so and the primary measure that we used was something called the back beliefs questionnaire, and so the back beliefs questionnaire improved on average by about two points compared to no change in New South Wales. And then by the end of the campaign it actually increased by about three points which, at a public health, a public population level, that’s a huge improvement over the whole population.

We also showed that the belief shifted, irrespective of your age, your gender, your work, your socioeconomic status, whether you actually had back pain or not, and whether you’d actually seen the ads or not. So, it actually moved the whole population over, uh, starting with the average and the better beliefs and by the end of the campaign the people, that with the worst beliefs also moved so it was a really dramatic example of how mass media campaigns can shift population beliefs. In terms of GP beliefs we also showed similar things so GPs in New South Wales, there was really not much shift in their beliefs over the three years, but in Victoria the Victorian GPs were much more likely to say you you didn’t need to rest in bed, you could stay at work, you didn’t need imaging, compared to their GPs in New South Wales.

And similarly irrespective of – of many variables, everybody improved in terms of general practitioners but the only group of GPs in Victoria who didn’t shift as a result of the campaign were doctors, who self-reported that they had a special interest in back pain, so we asked them whether they had special interest in occupational health back pain musculoskeletal. And once you allowed for everything else, if they had a special interest in back pain, they’re actually much more likely to think that imaging was necessary, that you did need to stay away from work, and they were also more likely to think that you didn’t need guidelines, and that education would not be helpful to them.

So, they are a really intransigent group and don’t understand who they are, but the bottom line it really is, if you’ve got back pain, to all the patients listening, don’t see it there’s a special interest in back pain because that’s confusing, that’s very confusing for the public though isn’t it? It’s very confusing but I guess you you could you could think about why that might be and you know, we don’t know for sure, but but we think it’s probably because some of these clinicians might have vested interests in that push non-evidence-based care .

Yeah, yeah that’s very interesting, and I think you had other outcomes that were linked to people actually changing their behaviors as well, is that right?

So, it wasn’t just beliefs that changed, so we also were able to – we didn’t think that the the campaign would reduce the number of claims we were hoping that it would reduce the duration that they spent off work, but we actually found that the number of people who put in claims over that period declined significantly as well as the duration, quite a large reduction in the total costs and the medical costs. Yeah right so that was really the the way we could measure behavior, unfortunately we had a very fixed budget. We would obviously like to do lots of other things yeah and I was particularly interested in children, because my kids were young at the time and and they were walking around with that slogan and when I lie down for a headache, they go on, mom, you know, should you take back pain lying down? I just wonder whether that would be really easy for you to study now.

Yeah yeah right, do you think those um uh those changes have sustained in Victoria?

So we were able to do follow-up studies at about, I think, it was about two years after the campaign, and then about four and a half to five years after the campaign, and we demonstrated that both GP beliefs and population beliefs, there was a sustained improvement with some decay, and again in New South Wales, there was absolutely no change. Yeah and so we think that if the – if the government hadn’t changed and we were going to spend some money every second year, topping up those ads, that probably would have – we would have been able to maintain that.

Yeah right so it kind of fascinates me that you’ve got a problem like back pain which is a like, leading cause of disability in the world, it costs governments extraordinary amount of money, why they wouldn’t invest in something like that. What are your thoughts on that?

I really don’t know – I mean, the Victorian work cover authority, when the government changed, all the people with the corporate memory left work cover and they actually went to the wheat board. The reason the first follow-up survey we did was funded by the work cover authority because they came and asked me about doing another media campaign and they really didn’t seem to have any, uh, remember the understanding that they actually funded the first one and then the person that was in charge of public affairs left again. And so then they weren’t interested in doing it again and, then subsequently, another couple of times they’ve contacted me again but there’s just no corporate memory about the value of it and having said that, in Australia, there are campaigns that have that replicated.

What we did in Australia and for example in Alberta Canada, yeah, they continue to have the campaign which is much more local, mainly radio commercials yeah, but they obviously see the value in it.

Yeah right, so interesting, now if we kind of zero back into your role as a clinician, because you would see people who come in to see you with back pain, I presume, yeah, and i’m interested in the common beliefs that you would see typically in those people you see.

Yes so I guess being a rheumatologist, I get people who were referred for back pain so often they’ve already seen a number of other people in primary care and sometimes I might see them more acutely, so they often come with with a whole range of misconceptions about back pain. And I’m sure that pedal, I know you’ve seen them too, that they have beliefs that they can’t move that yeah you know that, and then they’re looking for someone to fix things. Yeah they want some magic medicine, you sure there’s nothing else I can try? And yeah, and so it’s really – it’s really hard to to shift those beliefs and and so i have to spend time explaining what I know about back pain and sometimes I’m not sure that they believe me, but but often they’ve come because I’m the end of the road.

Uh yeah but it’s –  it’s so hard to talk to them then, compared to if I had them when they first got back pain and what I do with my friends, you know my friend in the next street said I can’t get out of bed and I just go around, I go well, you have to and I just dragged him, and the next day he was much better. So I mean that’s what I really want to do, it’s so interesting, because I mean what you’re tapping here into is that you’re seeing people at the end stage of often of their journey, when they’ve seen lots of healthcare practitioners. And what does that tell us about the health care workforce and the way they care for back pain? Well, it’s just amazing to me that that people, that the clinicians have – I mean, it shouldn’t surprise me, but they have the same misconceptions about back pain as as the patients and, and that’s part of the problem is that clinicians think that they need imaging to find the cause of back pain so that the treatment can be directed to that cause. And they don’t still understand that most – in most cases, that’s not possible, yeah, and so you know a lot of work over the last 30 years trying to reduce imaging from back pain, and we’re now in in a mess where the number of CT scans cost over 100 million dollars a year in Australia.

So we’re actually, even though x-rays have gone down, this more complex imaging has gone up yeah and that finds more sensitive things and then the report, um, makes people very worried, because it mentions all these labels that then they think they’re going to be in a wheelchair, yeah. And so we’re just fighting a losing battle and in lots of vested interests again, unfortunately yeah, trying to justify their specific treatment yeah so that idea of ‘I’m in pain, there’s got to be something on a scan that can make sense of the pain’ and then we’ve got sensitive imaging that shows lots of stuff that then gets dumped as a label on somebody how do we hope to break that process because it’s endemic as you say.

And it’s creating a lot of distress and leading to disability and over treatment, yeah i think it’s a really difficult problem and I’ve spent a long time trying to change clinician behavior and deciding that it’s a waste of time and we have to change public behaviour.

All right um but I’m even wondering now whether we whether we let people have imaging and we change the report and yeah, so we’re working on trying to to simplify the report knowing that more and more people see the report and in some countries they get they get their report you know text it to them immediately often before the clinician yeah but but that will take a lifetime of or maybe a generational change among uh radiologists who think they have to report all the findings in a certain way yeah and the guidelines all say that and and so as until we can try and change that report, to say this norm back is normal for age or there is nothing here that is likely to be the specific cause of this person’s pain, yeah, I think we’re going to be in trouble and we have to stop reports saying suggest injection here or suggest further tests. Because i think that that the right clip the GPs and probably the physios think that they have to follow that advice, because these are specialist radiologists yeah, and I hadn’t realized their influence on things.

So how do you deal with a patient who comes to you and they’ve got a like a typical CT scan and it shows this degeneration facet joint arthrosis disc bulges annular tears, all this scary language on a scan? How do you go about trying to help people understand that that’s not something they should be worried about when they’ve googled on the internet and seen lots of scary stuff and talked to their friends and been told by other healthcare practitioners? It almost seems like you’re sitting on the other side you know on another planet talking a different language.

So I think, I mean without dismissing their worries, I try to explain that these are typical findings in people who don’t have symptoms in their age group, and I quote, studies that have shown you know that, by the time you’re 50, you know 50 of us will have these changes and and they’ll often be present in 25 year olds and it and it doesn’t necessarily mean that that’s the cause of their symptoms. So, that’s how I start, yeah, and then yeah, I, you know, go from there and again, it depends on how much insight or how much they’re prepared to open up in terms of their mis ,you know, how much they’re willing to listen to me. Yeah exactly and you know sometimes if I get them early, I just try and just, oh well, that’s just normal, we don’t even need to go, but but then that might be a bit dismissive. So, try not to try not to be dismissive, but at the same time, let them know that this is normal and and unlikely to be related to your symptoms or we can’t tell you it might be, but but I can’t tell you for sure.

And the treatment is it should be more general anyway in the first instance yeah, and you know I think within medicine, I mean I’m not medically trained, I live with someone who is, but this whole idea of a diagnosis is kind of central to a lot of medical thinking, what kind of diagnostic label do you put on back pain, where it isn’t sitting within a clear pathological process. There is no clear pathological process, what do you think, what are the labels that you think are helpful for clinicians to use and to patients themselves, I’m interested in your thoughts.

So there have been a few studies trying to work out what the, which terms might be the most acceptable, and really it’s got to be something that explains it without being scary, yeah, and the value of having a label is that patients feel more satisfied.

Exactly, you know I try and explain that back pain often people that have back pain will have episodes ongoing, so you’ve just got another episode of back pain non not not worrisome back pain, I try not to use specific, you know, I say I might say non-specific but I have to always qualify that by what that means, U=I’m not even sure that not non-specific is helpful. It’s just another episode of back pain, it’s probably unrelated to what you did, you know, and then I try and explain how it’s really hard to physically hurt your back. Um, but I don’t know that there’s any easy answer I think, I’ve also thought, and there’s a lot of a lot of the way that medicines is evolved, is surgery and a lot of the rationale for surgeries on fixing a problem.

Exactly, you know we’ve seen with arthroscopy of the knee and and decompression of the shoulder, that that what makes sense, um, to sell something is actually may not even be true, so back pain, like shoulder pain and knee pain, they’re just symptoms then. They’re not, they’re not cancer, they’re not being sort of medical diagnoses, and maybe we should just say that you’ve – you’ve just got a symptom, which is back pain, and and not even have a diagnosis.

Yeah, and do you think that’s a bit like people accepting they have a headache but they haven’t got brain tumor? It’s, you know, some headaches don’t have a diagnosis label like back pain, do you think it’s similar to that?

Yeah I mean I often, because I do get migraines, and when I was a medical student I thought I did have a brain tumor, yeah, I did have a scan and and a neurologist that i still see says and how’s your brain tumor going? So I can understand that worry, and people get really worried, and especially the pain’s not getting better, they’re worried, so I think that’s a good analogy and even for people with widespread pain, I actually use the analogy that when I’m stressed I get a migraine and when you’re stressed you might get back pain or generalized pain and I think that’s not a bad analogy, but again you don’t want to dismiss it, because I think people do get severe episodes yeah, but if they try, if you can explain the trajectory that it will come and go, I think that’s more reassuring.

Yeah, yeah, it’s a tough space isn’t it, because you’ve got an expectation that’s placed on a healthcare practitioner to give a label and often you know there are different labels so within the medical world, it’s more around structure and imaging and the physio world, it’s more around, uh, you know, something with the body that’s kind of identified. It’s maybe something wrong and there’s very little evidence that those things are predictive of much, so we’re kind of left with a little bit of a vacuum that is not satisfying for the clinician or the the patient.

Well I think, I mean the only way you can explain it is when you talk about persisting symptoms, I try and explain that it’s got much more to do with other factors, not the actual pathology that you might see on an image, yeah much more to do with psychosocial factors yeah, and and that often turns on a light blue light bulb. I think, yeah, when when you talk about what predicts, what are risk factors and what might reduce your risk, and you talk about things like smoking and obesity and catastrophization and fear and beliefs, that then starts a conversation about ‘oh well maybe if I think about those things yeah and less about the pathology, that might be way through’ yeah, and I think what you’re touching on there is something you can change that potentially is modifiable, that means you’re not under a knife as well and it’s going to have an impact on your pain. It can help you and a lot of time, I mean, we think a lot of pain is genetic and it’s learned and you know, it’s what your brain’s remembering so once we start putting that all into the mix, then it will start to help you if they have the capacity to think about it more deeply.

Yeah, they can then, we can then help them much more I think, exactly, and how I mean if you think about a public health campaign, that sounds like something that would be really important to educate the public about around, what the media paint is, do you think?

Well I think, I mean I think the beauty of the campaign and the reason we, like, we didn’t expect the number of claims to be reduced is that the campaign reached people before they had a problem yeah, and because they’d seen the ads, perhaps, I mean this is all speculation, they go uh oh well I’ve got back pain but I know from that ad campaign that it’ll probably get better and I don’t need to do anything about it.

Yes that’s why we think it reduces the number of claims, so yeah so that’s priming the people before they have a problem, and it’s the same with everything, you know. It’s the same with slip stop slap, you know, having people to know what to do before they get a problem, and then the key thing is if they have a problem that persists then, instead of frightening them with further imaging, making sure they don’t have something serious of course is important, but then instead of frightening with further imaging is give them a broader understanding of the risk factors and then strategies to manage them. So that they can self-care yes and I mean, we didn’t talk about it before, but i mean the primary thing that pushes clinicians to do tests is is the worry that there is something serious and that’s the legitimate concern, yeah, but you know nothing needs to be decided today.

There are not many things that we need to find the answer to that we can’t afford to wait for many many people with that pain, yeah, and so even just thinking about delaying you know further tests, just to see, I think is reasonable as well and and that would be something else that we should encourage like the antibiotics. Yeah you don’t need antibiotics, but if you’re not getting better, we need to reassess it.

I’m kind of interested in, you know, as a rheumatologist, you would look at a lot of scans and obviously screen people’s bloods and things, what are the things that you know that are important, so if we have listeners here who might be going for a scan, one of the things that you see in the scans, there’s lots of stuff reported and there are lots of things that you know are common in people without pain? What are the things that you would say that is important?

Okay, so that there are very few things that are really important, so I would say cancer is important yeah. When you find primary or sick or metastatic disease, that’s obviously really important and that’s something that, you know, you get a good good sense of the likelihood of that from taking a good history, so if they’ve got a history of cancer infection, it is something that you don’t want to miss and. And so people that have got really severe pain and they’ve got a fever, or they’re drug users, I think that’s something that you don’t want to miss. Um, vertical fractures again, that’s something that you need to know about, bu they’re common in older people, and conversation for another day is, a you know, what is a real verbal fracture?

Yeah you’ve done lots of work in that space, haven’t you?

Yeah and you know I think they have to have symptoms, yeah um, and then there’s the sorts of diseases that I do treat, which is the axial spondylitis group, which really are patients that have marked stiffness in the morning that improves with activity rather than gets worse with activity. Young people, males or females, and that’s a diagnosis that’s often delayed because it’s missed, and we have effective treatments for now. So, that’s something important to think about, and then I guess the the only other big group is the people that have true pressure on nerves and pain going down the legs, but again most people can be treated the same as if you didn’t have what we call ‘radiculopathy symptoms’. Things are not getting better, then you want to see that there’s a confirmation of pressure on the nerve, and then there’ll be a lot of other things.

So, if you look at the, you know, take 100 people with back pain, how many fit into those specific groups in primary care?

Yeah, less than one, so that means 99 of people coming in and getting a scan and getting told there’s something arthritis degeneration, all those things are being mislabeled, well again is it a mis label or is it an over label?

Yeah I got it, yeah okay.

I mean that’s something that we struggle with because the changes might be there on an image, but that doesn’t make the diagnosis and I think we have to separate those things and that’s the – that’s the meaning of language right, and the role of a healthcare practitioner, help the patient make sense of what that means for them. Yes that’s a conversation, a conversation that says that these changes are common and often present in people without symptoms, they don’t mean that your – that your pain will not go away, they don’t mean that your outcome, your outlook is terrible, and they don’t mean that you need any specific treatment. And that sounds like, if that was on a radiology report, that sounds like a really easy intervention, it does, and there have been a couple of studies now with conflicting results about the value of putting what we call epidemiologic data, about how common it is in asymptomatic people in your your age and your sex.

But i think that would be relatively easy and even if the reports – we’ve done some work looking at reports – even if the report had a conclusion that said, despite all these changes that I’ve described above, none are specifically likely to have caused the patient’s pain or something like that.

That’s very reassuring I think, would be important, but your confidence of something like that becoming normal is not great from what you’re saying.

Well I mean I don’t know, we’re working with some radiologists, both at our hospital and in Seattle Washington, on trying to improve the way imaging is reported and I, you know, I think that changes will happen but we’ve done a review of the guidelines for imaging reporting and and there’s a lot in there about what machine you use the technical stuff and much less about the comprehensibility to the person that requested the image and nothing at all about the importance of the language for patients who might be reading the report. And some radiologists still think that the report is written for the referring doctor and and the referring doctor, some referring doctors, still think that, but the majority of patients think that the report should be written in a language suitable for them.

Yeah it’s so interesting yeah, I had a scan of my brain a couple, a year ago, for another health complaint, and it came back that my scan of my brain was normal, well the changes were normal for my age, so there is a precedence in radiology to report those things and I’m interested why they would say that for my brain,  which is reassuring, although I was hoping it would be younger for my age. But it seems like it’s not, like it’s not without president, and radiology, and we’ve, I mean, we’ve been looking at reports and some radiologists do say this is normal or this is likely to be of no clinical significance. It’s just, it’s not very consistent yeah, and I think there are differences depending on your vested interest in the report.

So, we know there’s a study done in the USA that found that the the biggest risk factor for getting an x-ray in the us is if the referrer owns the machine. So, those vested interests are really powerful.

I just want to touch on one other thing, I’m really interested in your thoughts on, you were part of the Lancet series on back pain. I think it’s a couple years ago now, and it hit the news, it was like, it was big in Australia, and a lot of the messaging was that we’re over treating people with often risky, not particularly effective treatments and under-treating them with safe ones, we’re not using safer and probably more effective treatments. And, um, there was quite a lot of backfire on some of that messaging in the public, I think and I’m interested. Like, well, we’ve heard a lot of people going, you know – what do you mean? You know, like that that’s quite a conflict to say that actually we’re spending heaps of money on stuff that may be not very helpful and there’s a public demand for that kind of care. How do we try and shift that?

I mean, that’s kind of like bigger than the imaging story, sure, that’s interesting that you say that, so yes we did do the series and there were 15 million people that saw a twitter handle of low back pain, which was the handle we used for the series. We are not aware of negative reports, we’ve actually done a review of the medium and found that 90 plus were accurately reporting our messages and we are really clear on media releases what the main messages were. The only misrepresentation of the Lancet series were people with vested interests who particularly, actually chiropractic organizations and physiotherapy, that use the Lancet series to say that, uh, that people should go to the chiropractor or the physio, that we can yeah – there was some of that misrepresentation of the series.

Um, we actually – people were silent, the people with vested interests that we really watched in the series were silent from our perspective. That’s interesting and we did highlight that there that a lot of the care is the atrogenic, it’s harmful yeah, and that we’re not really funding or or doing the right care. And there’s a lot of right care that we could do and could be funded, so we pushed for changing the system, changing the pathways that patients have, the education of clinicians and and the public changing policy, so that we can reward the right care and we stop funding the wrong care.

Do you think any of that’s changing?

I think that there are lots of conversations around the world now about some of the messages. We’ve been really pushing in different countries to change things and there are things in Australia like the MBs review that tried to reduce spinal surgery, and and then the AMA got some negative feedback, and the government reversed their decisions. So, I think that again the problem is these major stakeholders that are powerful, trying to stop their progress in terms of addressing the burden of back pain. I mean, it’s not just back pain, it’s others as well, and so we have – that’s why I, you know, some part of me thinks, so I may as well just give up. It’s just disheartening.

Don’t you dare – there are companies, they were pushing opioids and lyrica, and now in developing countries.

Yeah, you know, they have millions of dollars pushing bad care and we know, I mean, one of the things that came out of the series the way we sold it to the so it was, we wanted to try and prevent the same things happening in developing countries, and the disappointing thing is it’s already happening.

Yeah, okay, so we don’t want to end in a really depressing note, so I do share your sentiment, though it does feel like you’re pushing a big a big boulder up a hill and and there’s not many people pushing it. Uh, what do you – where do you see the opportunities to kind of positively impact this area for the future? Because public campaign seems like it’s still something that you really have seen great evidence for, to kind of get the public to drive demands for something different, I think we need to harness the consumer voice and they’re getting much more powerful around the world and they’re, you know, they’re part of NHMRC research grant. I think we have to stop wasting research dollars on rubbish and try and really push evidence-informed practice much more, so I think that there are some positive things that we can push, I think it’s important that we get into positions where we can influence policy makers. We’re still trying to influence the, who I think, we can harness media to work for good and not evil, and try and again get the positive stories out.

So, for example in Croakie, we have a regular series called wise um too much medicine, um, so I’m just struggling to remember the name and we’ve, you know, we’ve got a national collaboration for wiser healthcare and we have a national statement, so the more people that can join this I really think we need a movement. Because we know, I mean, even with covert, we can see that it’s been a lot less medical care and it remains to be seen how much harm there’s been. But I’m sure that some of it’s been positive in unnecessary – imaging, for example, has gone by the wayside yeah. So i think it’s just a matter of getting all the right all the people in the room, and just having the will and the enthusiasm and the drive and the money, to change.

Yeah awesome, and do it together as a social group, right. We can all work together with this, was there anything else you wanted to add? Yeah, I think we’ve done a fantastic job of discussing the landscape around low back pain and we’ve particularly nicely covered our third fact from the paper, which was that persistent back pain is rarely associated with serious tissue damage and you’ve given some fantastic examples of that. Um, before we go Rachelle,  is there anything else that you’d like to add in the in the podcast for the listeners?

Uh no, thank you, hopefully I’ve clarified some issues that people may have had rather than –

Yeah, absolutely, and I think one of the things I’d like to just highlight is to thank you for extra, I mean you probably do the work of four or five people I would imagine, but thank you for the extraordinary work that you have done for, I think, the health professions and also for the public and that you’ve kind of got off slightly, you know, in an area that wouldn’t be traditional for a rheumatologist, but you bring this kind of ability to bring your knowledge and energy and and drive it in all these direction. So, a big thank you to you for the work you do from everyone, thanks.

thank you, awesome Peter.

Thank you, wow, the end of another episode, I’ve got to say I reckon this one could be a game changer. I hope it resonated with you too, my take homes social sharing and mass media campaigns can be pivotal at moving the needle in a positive direction vested and conflicts of interest are rife in the back pain industry, presenting a big barrier for high value care. Back pain due to serious tissue damage is incredibly rare, less than one percent in primary care, but this doesn’t mean people can’t have serious pain for the overwhelming majority, you don’t need imaging, it is safe to stay at work and safe to keep moving, even if you have serious pain which we know can be influenced by lots of different physical emotional and lifestyle factors.

So, let’s not take low back pain, lying down we need to keep this momentum going so please share this across your networks. Check out the show notes at, tag us at #ebpodcast on the socials, and remember to ask: is there more to pain than damage?


Please note what you heard on this episode of Empowered Beyond Pain is strictly for information purposes only and does not substitute individualized care from a trusted and licensed health professional. If you would like individualised high value care for your pain sports or pelvic health problem, head to the body logic website and make an appointment.

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