The Empowered Beyond Pain Podcast

Episode 14

Low back pain fact 4 with patient voice, Joe: ‘Scans rarely show the cause of pain’

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 Joe, a person with a lived experience of low back pain. Together, they discuss low back pain fact number 4: Scans rarely show the cause of low back pain. 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
Wáng YXJ, Wu AM, Ruiz Santiago F, Nogueira-Barbosa MH. Informed appropriate imaging for low back pain management: A narrative review. J Orthop Translat. 2018;15:21-34. Published 2018 Aug 27. doi:10.1016/
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
Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015;36(12):2394-2399. doi:10.3174/ajnr.A4498
Herzog R, Elgort DR, Flanders AE, Moley PJ. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine J. 2017;17(4):554-561. doi:10.1016/j.spinee.2016.11.009
Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Conservatively treated massive prolapsed discs: a 7-year follow-up. Ann R Coll Surg Engl. 2010;92(2):147-153. doi:10.1308/003588410X12518836438840
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373(9662):463-472. doi:10.1016/S0140-6736(09)60172-0
Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of Magnetic Resonance Imaging. JAMA Intern Med. 2013;173(9):823–825. doi:10.1001/jamainternmed.2013.3804
Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52(9):900-907. doi:10.1097/JOM.0b013e3181ef7e53
Battié MC, Videman T, Kaprio J, et al. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J. 2009;9(1):47-59. doi:10.1016/j.spinee.2008.11.011
Belavý, D. L., Quittner, M. J., Ridgers, N., Ling, Y., Connell, D., & Rantalainen, T. (2017). Running exercise strengthens the intervertebral disc. Scientific reports7, 45975.
Mitchell UH, Bowden JA, Larson RE, Belavy DL, Owen PJ (2020) Long-term running in middle-aged men and intervertebral disc health, a cross-sectional pilot study. PLOS ONE 15(2): e0229457.
Belavy, D. L., Quittner, M., Ridgers, N. D., Ling, Y., Connell, D., Trudel, G., & Rantalainen, T. (2019). Beneficial Intervertebral Disc and Muscle Adaptations in High-Volume Road Cyclists. Medicine and Science in Sports and Exercise, 51 (1), 211-217. doi:10.1249/MSS.0000000000001770



I guess the biggest thing for me was knowing that that that pain wasn’t coming from damage and that the scan wasn’t you know wasn’t telling the truth i mean there’s so many people out there that would have the exact same scan as me that wouldn’t even know welcome to episode 14 of the empowered beyond pain podcast proudly brought to you by body logic physiotherapy today we’re talking imaging mris cts x-rays radiographs we’re talking scans and low back pain this comes from fact 4 of the 10 facts every person should know about back pain paper published in the bjsm that professor peter o’sullivan dr jp canero and myself as well as others co-authored we talked about how that paper was motivated by the rehabilitation stories of almost 100 people who were profoundly disabled by their back pain in episode 4 and then shared some of those stories in episode 5. fact 4 presented by patient voice adrian mcgregor was scans rarely show the cause of back pain [Music] scans are important but only for a minority of people lots of scary sounding things can be reported on scans 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 that they don’t predict how much pain you feel or how disabled you are scans also often change with most disc prolapses shrinking over time pete and i welcome another patient voice joe joe also featured in episode four and five but today we’re particularly talking to him about his imaging findings and the impact they had on him pete and i also discussed some of the research around imaging and back pain the take homes imaging is a fantastic technology but only required for about five to ten percent of people with back pain scans are so detailed these days but this also means they report things we now know maybe more to do with painless aging than pain like disc degeneration bulges and arthritis mri reports don’t appear to be that reliable we talk about a study where the same person with back and leg pain went to 10 different mri centers and practically got 10 different results scan findings change over time with most disc prolapses resorbing by themselves and often irrespective of whether pain or function changes routine imaging does not improve outcomes and can be harmful not to mention costly we highlight a study that showed an eight times greater risk of surgery and five times greater medical cost if people had mris when they shouldn’t have which happens more frequently than not imaging findings appear to be mainly related to genetics and don’t appear to be predicted by heavy manual work either occupational or leisure time in fact there was indications that routine loading may have benefits to the disk we hope you find this episode insightful if you did please share it with a few people you think may benefit or leave a review on itunes the show notes for this episode features three infographics related to imaging and scans for low back pain as well as the references for this episode you can find them at forward slash podcast and remember to ask is there more to pain than damage [Music] so welcome everyone we’re here in episode 14 of the podcast the topic today is how relevant are scans for back pain this is a really common belief and a common thing that we probably see as clinicians that people come in with their scans i think it’s a really important topic to address yeah and we have someone with a lived experience of how scans can influence a person’s life really um joe welcome to the podcast good day kev how are you i’m very well thank you um i’d love to start with just a brief synopsis of your story um and then we’ll get into how your scan findings influenced your life yeah okay well so i mean this is this is quite a long time ago now but um so i guess my story with with back pain started in in 2013-ish so about seven eight years ago and so what happened with me is i had an incident at a job had some really sharp pain go down to my foot um pretty much just saw a couple of physios cairo’s that sort of thing in the meantime it didn’t get better for a fairly long period of time it was about six months and um i i went and got a scan at that point and it showed that i had a couple of disc bulges and some annular tears and i mean there was the word degeneration was used in in it and and uh pretty much after that scan everything just sort of went from being bad to just you know completely crashing i think um at that point in time i was told that i had a good back for a 50 year old or 60 year old it was it’s a couple of years ago now so i’m struggling to remember the exact terminology that was used but um i i just remember that in my head i was 27 at the time and to hear that you’ve got the back of a 50 year old when you’re 27 and you’re working in a really active job i know just scared the absolute crap out of me and uh from that point i i started you know i started limiting my movements i started avoiding certain things like bending and lifting and twisting and that sort of stuff the the movements that i believed were bad for for me at that point in time and so um i i got really really strong through my core and was always bracing and and made sure that i was tense to lift and that sort of thing that the advice that you sort of hear a lot but um essentially i got the scans and that took me from a a point where i was not great but then it just sent me right off a cliff and that was in my mind that was the beginning of my really long period of uh back pain and that’s where for me i feel like that that’s the sort of period where it all went really really um downhill so after that point in time i i had probably the next two three years where i was i was doing all these core exercises i was always sitting bolt upright and and i was avoiding more and more and more movements and and it was sort of weird as i avoided more and more and more movements i found that everything just got stiffer and stiffer and so instead of getting better my pain sort of got worse uh but at the same time i was i was still going to work i was still doing as much as i could but i was doing it always sort of like a robot and sort of bolt up right um and so it was after about that that so it’s probably three years in that i then had a complete relapse i had another incident where i was i was lifting a heavy object and i had that same pain just shoot down to my foot and um and it just yeah it was it was a really scary time in my life and then that’s fortunately for me at that stage i got some really good advice and uh from that it sort of just got me sort of instead of going slowly backwards and being more and more more pain and avoiding more things that was the period where i got some good advice at the right time thank goodness because who knows what was going to happen and um and then i just started progressing and i i’ve so now i’m i’m back to doing absolutely everything that i love which is which is great i’m back surfing and kite surfing and wing foiling and i’m taking up new sports mountain biking free diving and it’s just yeah i don’t avoid anything anymore i’m back to doing absolutely everything i love so yes it’s uh that’s a hell of a journey oh look well i was sort of trying to get through a um a seven year period in in two or three minutes without taking up too much time but so that is a very abbreviated version i mean the the full story is is a lot longer than that and and i mean everyone that’s sort of going through a similar thing out there i mean you just you just you know you know how much stuff is in between all of that but it’s uh it’s i was just trying to cut it short but yeah so and it hasn’t been smooth either it wasn’t just down then back up i mean i had a down back up and then a little dip again and and so it’s nothing smooth but but i look back on on where i was and where i’ve come from and i’m just so grateful to be back doing the things that i love doing and it was um a really simple uh you know it was a mindset change as much as anything but but i guess the biggest thing for me was knowing that that that pain wasn’t coming from damage and and that the scan wasn’t you know wasn’t telling the truth i mean there’s so many people out there that would have the exact same scan as me that wouldn’t even know and so it’s it’s did you know that at the time joe oh no absolutely not i don’t know that now don’t you i know that now and and i know that looking back and as i said that’s just from the advice i got but you know at the time when i got the scan essentially it gave the pain meaning so in the the pain all of a sudden i was like oh well so the reason why i have pain is because i’ve got these disc bulges which are going to be aggravating nerves and then inflaming stuff and so i’ve got to look after them otherwise it’s just going to get worse um and so that that was sort of the mindset the scan put me into it kind of made sense to you yeah absolutely it gave the it gave the pain meaning it sort of went well oh well there’s pain because there’s damage there so how am i going to prevent more damage and that’s when i went down the track of avoiding things that i thought would damage me further so so can i just ask you joe around the time that you got the scan what were you actually told about it uh so i was i was told that you know that i had bulgers that were close to nerves i don’t know if they were pushing on the nerves but and and then those annular fissures which i i don’t actually truthfully know what that means but it doesn’t sound good what does it sound like for you um well look the the real summary for me was when uh was when i got told i had the back of a 50 year old and i thought well if i’ve got the back of a 50 year old now how much how much time do i have left doing the things that i love yeah and uh so that was that was sort of what the scan meant to me is sort of gave me the impression that my days of being active and fit and healthy and that sort of stuff was sort of limited yeah okay i guess did that create a picture in your head of what your back looked like uh yeah it’s sort of unstable and a bit like compressed down and maybe some you know just damage and old and frail i guess was the the i mean the one big word that um that scared me the most i guess was degenerative or degeneration because that to me sort of said well this is what it’s like now it’s not going to get better it’s only going to get worse yeah yeah so so what does that word degenerative look like in your head oh oh that’s a good question essentially it’s it’s the removal of what i enjoy doing you know if it’s if it’s degenerative and it’s not going to get better then i sort of felt well if this is where i am now and i’m 27 right 30 at the time when i had the second major incident then well i call it a major incident when realistically it was just a pain event but um it sort of put in my head well if this is what i’m like now what what are my options to continue doing what i’m doing and so it does it puts into your head ideas like fusions surgeries yeah all those yeah things that you know absolutely last resort yeah so it’s interesting that um the languaging around the scan is scary and we know that from the research that it can be really scary for people but it sounds like the biggest threat for you was this kind of the sense that it was taking away things you loved yeah and that’s threatened your job but also the the stuff outside your work job hobbies you know it was my my i guess my identity was so tied up in being able to do you know active things because all i’ve ever done is you know activities and stuff outside and sports and so as soon as i sort of saw the scan and heard the way it was described um yeah it scared the absolute hell out of me and then it was funny but you know after the doctor that i now see he sort of said you know to do with this story he said i’ll bring bring the scans in and i’ll have a look at them and he sort of went oh yeah so pretty minor changes i was like well yeah if only that was the advice that i got originally right oh these these are minor changes no you can still do absolutely everything that you love yeah these these findings do not explain your pain yeah i think your pain is because you’re you know you’re always moving like a robot you’re tense you’re not moving yeah if that was the advice i got at the six month mark i wouldn’t i wouldn’t change your journey it would have just been a it would be a six month journey how easy is it do you think to get um to go from having a belief that your back is you know you’ve got these language which is on a scan report like bulges and fishes and degeneration which don’t sound particularly good if you had a if you had a house you’re going to buy and the advertisement was has got just fishes and it’s different generators you probably wouldn’t buy it this this looks like a 50 year old home and really it’s only 20 years old it sounds like it’s crumbling yeah exactly so how easy is it to flip that thought from to then be told actually no this this is not this is normal this is not a big deal how hard is that uh how hard was that figure it was it was extremely hard but it was it was made a lot easier by getting the the right advice the reassurance along it would have been impossible to do on my own right um from from where i was without outside help without intervention and the right intervention i was i was never i was never going to get better right so so it’s it’s unbelievably hard um but when you get the right help and the right advice then i mean as soon as i got the right advice my progress was remarkably quick i would say but you know there was some ups and downs along the way but i mean i i it was funny i said to my my partner that uh when i um after about a year when things were just absolutely humming along i i said to joe’s i said i would have i would have sold the house to feel like this if i if i’m like if someone had told me look this is a a new spine it’s going to cost you 150 grand and it’s going to make you feel this good i would have said oh where do i sign up yeah you know so i mean that the fact that it was only a you know it was all you know in my own hands it was a self-management it was just movements and exercises i was doing i mean it was yeah can i come back to that thought though because um what you’re highlighting is the sense of desperation when you’re in a trap oh yeah and the interesting thing you’re saying is that the languaging around the scan was scary yeah and your the way you then responded to the scan was to kind of protect protect your back even more was that something you were told to do or is that something you kind of worked out for yourself i think i think it was something that i i mean you always there’s stuff in the media all the time about you know you know strong core helps stabilize your back and when you hear stuff like oh i need to when you hear something so you need to stabilize your back you think well my back must be unstable and so it’s like well okay so therefore you know i’ve got pain it must be because of instability and then then on top of that you get the scan that says you know here’s all the damage this is why the pain is there so i guess the the pain was there because essentially i wasn’t moving in a natural way which then prolonged the length of the pain and then that’s were you taught to do that well i just sort of went well i i’ve got a sport science uh background and so i in that degree i mean you know we we did learn you know to protect your back and to have a strong core yeah you know when you’re lifting heavy objects to brace and that sort of stuff and yeah i mean so it’s something that i sort of worked out but i think that there’s a lot of people in the same boat as me and so i guess then when you throw the scan on top then my movements became even more unnatural and even more guarded and then it just sort of spiraled from there okay it’s interesting and so the the the scan the thought of the scan the languaging around it created these kind of responses that for you made you think you needed to protect that back yeah guard it and not move it absolutely hold it rigid yeah right that kind of led you down a path of losing function and make you more vulnerable absolutely i thought that you know if i kept my back nice and straight all the time that you know that would give it a chance to heal when really what it was doing was my back was probably fine but it was just so stiff that it was painful so yeah how did that impact on you emotionally oh well i wasn’t i wasn’t doing anything that was fun i thought that my work was threatened it was it was terrible i mean i i can’t believe the impact that it had on my mental health which then only then fed back in to make my own pain even worse so it’s interesting you say that joe because i know there’s a lot of um there’s a lot of stigma around um you know back pain and people like you know it’s in your head sort of thing but we know that um losing what you what you’re tapping into is that losing your ability to be in control of the things you love to engage at work has a massive effect on someone’s mental health oh absolutely and that’s like a really natural consequence absolutely and just losing stuff and i mean if someone said to me you know this is all in your head to me that would have been better than going on paper oh here’s your scan this is why it’s painful right yeah because yeah but you did have a problem with your back from what you’re saying that’s right but it just stopped you doing the stuff you love yeah absolutely so you said the advice that you got given really helped you this when you saw these new people that um seemed to help you more what was that advice around the scan what was the advice that helped you um move on so i i guess the the great advice that i got was that you know there’s lots of people with similar scans to me that wouldn’t even know it walking around the the places and so i was like well you know what’s the difference between me and them how can you know i get from being a symptomatic uh disbulge to being an asymptomatic disposition the fact that people have similar worst much worse scans to me and wouldn’t even know was a sign of was was hope you know it was gave me a bit of hope and then also i mean i just got reassured that the stuff like bending twisting loading was all safe and extremely it’s it’s natural and safe to do those movements and so it it just meant that as soon as i started to unlock movements and be able to move more naturally well it sort of did two things one it reassured me that i wasn’t even close to being as damaged as i thought i was but it also had a massive uh alleviating effect on my pain because you know i’d been held in this brace for so long and of course i was stiff you know of course it was painful to to go you know if i’m bolt upright all the time as soon as i did that you know there was there was pain because that was an un unnatural unnormal movement for me at that point in time and so as soon as i got told no look it’s safe to just go through you know your body is designed to move you you know take your body through its range of motion and as soon as i started to do that it was i guess what really helped is it was such a fast progression that it was it was almost irrefutable that i was on the right track finally so it was the lift experience it was convinced you the most oh absolutely it wasn’t just being told oh that’s it it was i wasn’t only doing all these movements and getting back into activity which i love to do but it was having a drastic impact on the pain levels in the right way which how scary was that for you to start moving again given that you’d gone into that whole protective space it was every single time i got given a new movement by uh by the the physio that i i engaged with it was i thought he must be joking i was like i can’t i can’t do that you you wanted me to pick something up with a bent back and then twist over my shoulder loaded i mean he essentially recreated the movement that that injured my back in the first place so i mean every single time there was this progression i was like no mate what did you think would happen i just thought well i’m gonna i’m gonna do this twist over i’m gonna ex pop the bulge again and then go back to square one i thought you know i thought that that that movement was dangerous and i thought that maybe you know got slipper disc or whatever you should call it but yeah i thought that that it could re-injure it and set me back and i was so worried about going backwards that i was like no no like i’m happy i mean i can bend now like can’t we just leave it there no there was there was it was it was funny that the first session i had i remember getting asked yeah so so what movements don’t you you know don’t you want to do and i was like oh okay thank god you know so i i can’t bend i can’t twist i can’t i don’t want to carry anything heavy one-handed i don’t want to yeah oh yeah okay cool cool i thought you know that would be okay so we won’t go there we’ll try and work around those movements and then i get into the session and i was like all right so let’s start with ben and just not knock them off one after the other and i mean the next day i was i was so like my muscles were all so sore and it was sort of a feeling i hadn’t had in a long time but the actual niggly sharp pain that i was experiencing wasn’t any worse and then from there it was just a whole lot of moving and then and just a whole lot of progressing but yeah do you think that if you had been given the information that you sort of said like loads of people out there are walking around with you know backs that look worse than yours on a scan but have no pain whatsoever would that have changed at all um i i think i had to go through it myself and actually experience it for myself rather than just being told um for it to really sink in about how i don’t know about how eat i guess how simple you know how right it was but i i don’t i don’t think so like yeah something i do want to talk about though because there’s a lot of research out there and we are researchers so i think it’s important we discuss some facts and bring some statistics or some numbers into some percentages into it so one of the most famous studies or i suppose most widely cited studies is a systematic review that looked at about 3 000 people with back pain and also looked at a whole bunch of people without back pain i’ve got the numbers here in terms of when they looked at those without back pain what percentage of those people had these findings on a scan so we’ll kind of quickly rattle through them just briefly now so um 37 of 20 year olds had disc degeneration remember this is in people with no pain yep 80 of 50 year olds had this degeneration and 96 of 80 year olds had disc degeneration and when it comes to disc bulging 30 of 20 year olds had disc bulging 60 of 50 year olds 84 of 80 year olds so you can kind of see there’s this linear relationship between when you get older and the more likely it is that you’re going to have findings on a scan yeah so they’re quite big numbers um and i suppose the other important thing to sort of talk about that was that same author group also did a study where they looked at comparing findings in people that did have pain compared to finding people that didn’t have pain and there was a slight um increased likelihood that those with pain are going to show more findings but the i guess the important take home from that is it’s not a it’s not a death sentence it doesn’t mean that you are likely to be one of those people um and it doesn’t the other thing it doesn’t predict your future in terms of who’s more likely to have back pain as they get older or be um have uh back pain influence their life yeah absolutely i think for me uh when i got told those studies originally and i looked into a bit of stuff myself with the research background i sort of thought well if that’s the case like i fully understand yeah okay if you’ve got findings yeah you’re slightly more likely to have that but then there’s so many people who are asymptomatic with those so how do i become one of those asymptomatic ones and and okay that’s it and i mean it could be largely to do with the the advice that i got and just pretending like you don’t have those findings and just living and then you know it’s just just what you’re tapping into as well is you know it’s it’s you know when you’re in pain and you don’t have strategies to manage it that kind of information may not be helpful yeah you know because it’s like at the end of the day you know hearing something’s one thing but it’s what you do about it is another thing oh but peter i reckon if you scan two people’s backs one person with findings and one person with no findings and you told them the opposite of what they had i from my experience i think that the person who got told that they had a damaged back would be more likely to end up in pain than the guy that got told they had himself start thinking differently because differently differently i i 100 agree i mean i i had a guy that i know who who had a back strain and he had it for about three months he ended up going and getting scanned and he had an absolutely perfect scan and so the doctor said to him he said there’s there’s no reason for your pain it’ll go away and about a month later he was fine all right i i really do wonder if if say that they got his scan mixed up yeah and so he still had the the perfect back but he got his scan mixed up and it showed a whole bunch of damage and the doctor said to him mate your back’s cool well we actually i wonder we know that’s true actually because there are studies that have been done randomizing people to like getting a scan or getting autoget not getting a scan and looking at what happens to people who get scanned and look let’s be clear about the fact that there are some indications where scans are really really important um you know we’ve said this before another podcast but you know if there’s a question of malignancy or fracture or infection or nerve compression and particularly if it’s vetting bladder um function uh it’s an absolute indicator for a scan but those things will show up on the scan as very important that need to be acted on immediately and you know in most cases um you know there is some indication in some situations that you know for example big disc prolapses the majority do resolve in time but if you’ve got progressive loss of power and um bladder control then that’s an indicator that you need that’s significant problem that needs to be dealt with straight away but then that’s sort of like a tiny percentage of people always like one percent of the population the 99 unfortunately so often get scammed and the and the um they get scanned outside the guidelines so the guidelines say if you don’t you know if you’ve not had a trauma like you know there’s not suspicion of a fracture yeah um you don’t there’s no suspicion of a cancer or indication of infection or some inflammatory disease um and you’ve got no raging pain down the leg with a lot of power and sensation and bladder control problems don’t scan it but the majority still end up getting scanned yeah the problem then is what gets it is then they get these labels dumped on you and that can endure for a lifetime um where that person starts living a life like they’ve got to protect their damage back because they might be young and they think their time’s running out yeah yep so there was a study that looked at exactly what you’re talking about at one month they looked at the people that got an early scan that they shouldn’t have um and compared to match controls they were eight times more likely to have surgery and their healthcare costs were five times as high in workers and their general health and their time off work um and their you know their level of function all of those things are impacted just as you’ve described yeah so you are a living example of the um of the of the of the research what we hear a little unusual is that most of the studies suggest that when you get stuck at the point you’re right you don’t get better you are a bit unusual as that account as i said i got the right advice at the right time i i i am almost certain that if i hadn’t had the intervention the positive intervention i had at that three year mark that i would i would be sitting in front of you right now with some form of having gone under surgery for my back which is a very common kind of next step abs absolutely i just want the population i just at that stage i thought this has gone on long enough i’ve gone back to square one this is a three and i just thought well look i’ve i’m probably going to end up needing some sort of intervention here to just because i can’t keep going yes i mean the pain was always there and it was excruciating and horrible situation was terrible the other thing that um the other study that comes to mind is um because we as you said kev we see that there is this relationship between what you see in a scan and someone’s chance having back pain but what we have to understand is there’s a lot of the population who might have back pain who never seek care who are never disabled or minimally impacted they’re not worried about it and they just get on with life and there’s no they’re right there they never seek here so we kind of lose them in the picture it was a really interesting study um that looked at people before they had back surgery yeah and they were either going to get a disc replacement or a fusion to their spine and it rated the severity of their scan from 0 to 10 and then it looked at how much pain those people had and how disabled they had and there was no relationship between the severity of the scan and how much pain and disability they got they had which is pretty scary because if i was going to go and get a surgery on my body i would want to know the thing that the the thing that was the reason for the surgery was to treat my disability and pain if i knew there was no relationship between those two i’d be pretty concerned that might not be the the right thing and i think what it highlights is that pain is complex yeah um and whether we can function or not is also complex and it’s linked to our thoughts our emotions our behaviors and that’s what you’re alluding to yeah is that the things that change for you absolutely and and when i was when i was going well everything was just uh you know going back in it was a feedback loop and so when things were going well i was happier and that would that would have a positive influence i was i was more active which would have a positive influence i was back you know i had distractions and that would have a positive influence and the same thing when i was on the way down um you know i was i was in pain which then led to less activity which then fed back in to make the pain worse and then that made me sad which made the pain worse and so it’s amazing how yeah it’s it’s a downward spiral or an upwards that’s right it’s amazing how intertwined everything is but um and it’s not just the scan either it’s it’s it’s also the the language and the the way the scan gets described i mean initially as i said if if that scan came back to me and the doctor and said oh yeah no that’s that’s that’s fine that’s pretty normal and then put that scan away then it wouldn’t have had anywhere near the impact that it ended up having but you know just what would you tell a healthcare practitioner then if they had another joe come to see them oh wow oh there’s there’s so many things that i would love to change about my journey but then also you know i’m grateful that i’ve gone through it because you know it just it just you know so it’s all worked out but i mean at the at the three when i was absolutely at rock bottom and i would just have loved to be able to now be able to go back and say to myself at the start look don’t don’t worry about getting scanned you’re fine you just need to move and you’ll heal your body will heal it’s fine but um you know you’re not as damaged as you think you are don’t worry about that side of things but um even if the so for the health care practitioner i would have said like just reassure this person like words are so powerful it’s amazing like you know you trust in doctors to you know maybe maybe wrongly but you just think that they will have the answers and the the advice that they give you will help so so their words carry so much more weight than um your typical uh person you know like just as standard joe blogs on the street you know says something you just got well that’s but when a doctor says something to you like you know this is this is degenerative or you’ve got the back of a 50 year old or you need to protect your back or your back is on yeah these things they carry a huge amount of weight so i i i would say if there was some advice for a health care practitioner treating me back then i would have said look words carry so much weight so you need to you need to reassure this person and yeah so what’s your picture of your back now then joe because my understanding is that you still get some back pain from time to time it’s not like you’re cured when i really go hard i i mean the truth of the truth of it is pete is i don’t care what my back looks like now because it does what you want because it does what i want i mean to be honest i i don’t want to know what it looks like i don’t care what it looks like all i care is that i’m doing the stuff that i want to be able to do but um look i’ve got no idea i don’t really care maybe that one me and him are friends at the moment so we’re all we’re all good but but look uh you know what uh just i’m not even interested i’m i’m i wouldn’t say that i’m scared to know but i wouldn’t i wouldn’t want to know but but you trust your back now yeah clearly you’ve got a good relationship with it yeah yeah yeah yeah everyone before you feared it absolutely so so now i mean i still get back pain and what do you do if you get a i i just go and do something fun or a bit distracting or you know i just you know most of the time now when i’m i’m getting a bit of pain is after i’ve had a really big day or i’ve done something stupid the day before of lift yeah and and it feels different like now now when i get back pain it feels like it’s just muscle pain you know i’m a bit i’m a bit stiff now from what i did yesterday but this morning i woke up and it was a bit sore and i was like oh god and so i went oh well i know what will help a bit of bit of blood pumping so i went for a run right and and after that i felt absolutely great right and and so it’s it’s very difficult because that’s a really different response oh absolutely your other journey where you would have stopped and parked i would have um you know probably tried to to sit sit upright you know i was here i would have been like this and i would have probably uh you know been uh probably sitting at home on the couch trying not to move too much while letting my back heal while worrying about my back right that’s that’s probably what i would have done previously so quite a different response yeah absolutely absolutely yeah so the the imaging findings if we bring it back to the scans because the topic of the episode they held a lot of power for you obviously an amazing amount yeah i want to quickly talk about so um how reliable those scan findings are so if we took you yeah and you had an mri at ten other or nine other mri centers than the one you had oh yeah what do you reckon the agreement is between those radiologists or between the reports of the mri oh wow look i would have thought pretty i would have thought an mri is pretty accurate i hope so i would have thought so yeah so yeah do you want to talk about when i said oh yeah so they did this study they had a lady who had back pain and raging leg pain or sciatica type synthetic yeah that legs and they they within the space of three weeks they sent her to 10 different 10 different mri scanning places just to see what the commonalities were there was not one common finding across all mris i think um there’s 14 different findings so 14 unique different findings on the on the scan reported and um each radiology each radiologist averaged two errors compared to the two spinal um i think they were neurosurgeons or neuroradiologists that commented on the kind of the gold standard picture so even and that’s i don’t know i should have told you that it’s it’s um it’s past your day yeah yeah i’m not going to go get an mri water for ducks back now but um even you know those findings that the doctors are reporting either correctly or incorrectly they might not even be the same as what if you were to get another mri from a different place i just wanted to pause here for a second because when we recorded the podcast i don’t think i made this point particularly clear i also made an error relating to how many errors each radiologist made the irony anyway that study of a lady with back and leg pain going to 10 different mri centers within three weeks identified 49 different findings 16 were unique and only found once among all 10 reports and not a single finding was common among all 10 reports now each radiologist averaged 12 errors not two as i said in the conversation with joe the take home from that is don’t just rely on the scan or take it as gospel consider this only as part of the bigger clinical picture so now that’s clarified let’s head back to the conversation uh so that’s an important thing to consider and mris are sort of the gold standard you know that and i think the other thing that’s really important to understand is that your spine is never static it’s like the garden doesn’t look the same today as it well in a month your spine changes over time we see and we know this from the research that if you look at longitudinal studies at studies over periods of time and you look at active populations versus people who are inactive and that’s the irony is that inactive populations show more progression of those changes negative changes on the scan than active populations so we have this idea that you need to protect your back and have this conversation yesterday with a person going well i’m thinking if it’s um if it’s degenerative now i really don’t want to use it too much because i’ve got these number of years left and that was what you would think yeah for an actual fact is the opposite to protect you and use it and load it because that’s what keeps it healthy which makes sense really i mean you know you go to the gym you do a whole lot of bicep curls yeah what happens your body lays down new tissue exactly you get new tissue you get so i mean degenerating we’re constantly laying down nutrition generally yeah i mean it makes so much sense uh but then for some reason when when the when it’s your back that’s involved you just act completely differently yeah like if it was my if it was my i mean i’ve rolled my ankle uh 50 times and never once did i think to myself well the only way that this ankle is going to get better is if i don’t move it ever again so why the back so differently i i don’t know yeah i think it’s it’s i think it’s because we well we’re always told you know lift with a straight back we’re constantly told that you know keep a good posture keep keep you core tight you know lift with bent knees straight back so i think that we’re sort of conditioned to think that our backs are a fragile structure then on top of that there’s such an important structure that everything that we do yet with a lot of things we can get around certain movements without using our bag i mean you can’t you can’t walk without using your ankle and so at some point you’re just going to have to get up there and walk and your ankles then going to start moving and then it’s going to feel better but it’s amazing the the stuff that you can get done without ever moving your back but it just leads to a whole lot of pain world of pain world of problems so now it’s amazing if we had no choice but to bend our backs if we had no choice but to twist and load then we go i i hate to think how many people are going through what i was going through uh unnecessarily it’s it’s terrible you sort of mentioned before this idea that the more we load our spines actually that’s better for us and that’s sort of highlighted by a study that looked at cyclists that had healthier looking spines than those that didn’t cycle um the other was running same with running yeah this the other side of the coin is that um you know disc prolapses typically the bigger they are the more likely they are to heal and we know that about ribs or you know yeah ribs are pretty better word for that uh we know that about sort of 64 65 of of disk prolapses will reabsorb but the amount of resorption is completely unrelated to whether that person gets better or not so people could get better and their disk looks worse people could not get better and their disc looks better on imaging so there’s this really kind of confusing relationship out there between imaging findings and and scans pain is not simple you know it’s exactly right and that’s why unraveling the complexity of it is kind of like the key job of a good healthcare practitioner or a team of practitioners yeah to kind of support people on that journey yeah joe you kind of mentioned before there was a little bit of a period there where everything was going great you were back to doing everything that you loved and then [ __ ] hit the fan yeah okay so i mean about a year after i i started becoming good and i got some really good advice uh i i ended up having a pain flare and uh i think almost uh the sailing was a little bit too smooth for the 12 months before it because it just it came out of nowhere and it absolutely hit me hit me for six so um essentially i i’d been going good for about 10 12 months and then out of nowhere there was just a tiny little niggle and and then over about an hour it built up built up and then the familiar sensation of my back going into spasm was was um it was was there and i was all bent and i was just in a lot of pain and i couldn’t relax and my mind was going back to you know yeah oh god just try and i was still trying to move as much as i could but my mind was going back to oh what is unfortunately my started conscious because a few more negative thoughts it was a period my brain was anxious i mean the pain probably only lasted about weight at the moment it’s the negative negative possibilities it just made me feel vulnerable in the negative mental side of things yeah yeah i actually recorded a little bit of a video which i want to play for you now yeah yeah absolutely because i think it sort of highlights um certainly how when you have a pain flare lots of your old beliefs come rushing back absolutely so let’s have a quick watch so that was about two years ago one or two years yeah yeah i guess guess probably more than two years ago now yeah yeah so so watching that back now what’s going through you oh yeah just just i remember it like it was yesterday you know like just the the the rapid progression and then all of a sudden i just had these pain flares and and i was right back where i sort of started and i just started being really worried again and i mean it was it was like you know you you’re building a house or a tower or a stack of jenga and you just start taking pieces out every every flair was like just taking pieces out of that that foundation that i’ve you know worked so hard and done you know helped build up and and i guess what happened is the pain flare although the original pain there only lasted a week or two it it got me worried again and then that worry fed back in to not only making the pain worse but also wondering what was behind the pain and then and then when that started happening maybe my movement started being affected i started becoming a bit worried to do certain things again and then you know i stopped stop doing things that were distracting and fun and and i just ended up it was just a downward sort of spiral down and everything sort of fed back into making the pain worse then the pain fed into my mental health and then the mental health just has an impact on everything so what would you say to that joe now don’t worry about it honestly if i if i saw into the future at that point in time if i if i looked forward into the future and saw where i am now it would have been it would have been a two-week problem i would have taken it a little bit easy while the the pain was bad while it was flared up and then i would have just got on with it because you know if if the worry’s not there about the the loss of function and and identity and physical activity and work and that sort of stuff if the worry’s not there then pain is easy to deal with i mean if you if you think well pain doesn’t if the pain doesn’t mean anything the pain itself isn’t really a problem it’s the it’s what the pain means and so if you look forward and go oh if i if i saw myself in 80 years and i was jogging down the street i wouldn’t have a carrying the world until i probably got to 80 and then i’d start worrying again but so did you get another scan then no why because given that you were worried about it why didn’t you because i had some some really good people in my corner telling me i didn’t need to right and i didn’t didn’t and also even though i was back to sort of i got really bad i spiraled all the way back down to not quite where i was but but pretty close but i still held on to some of the key messages from from all of my time and my experience from from the the progression before and so i knew that like you know i was still telling myself all the right messages you know pain doesn’t mean damage movement’s good for me i still had all these positive messages going through my head which i didn’t have before but they were just getting overwhelmed by the other side of things which which was that but i still had some really good people in my corner telling me you’re going to get through this and and i i ended up you know and it was a while i mean a two-week problem became a six-month problem but you know slowly got back on top of it and then and i’m i’m just i’m away now so it’s all good so if you had another two-week event do you think it would be different oh i i i’ve had a i had a week-long event about six months ago actually and it was it was weird i just thought i think the the more experience that you have dealing with this and the more tools i’d been given and the more i’d been sort of ah you know you you live the experience and once you’ve once you’ve done these things a few times before as i said i think the first time the sailing was a little bit too smooth but now that i’ve had a few few rockier sort of c’s it it just it just helps you know like you so what did you different the last time six months ago i just didn’t worry i just i just distracted myself i just went you know what this will this will get better i i can’t do x y and z for now but as soon as i can do those things i’m going to do them and and i sort of went well i’ve been so much worse than this before why is this why is this going to be any different to the last two three times where you know i got back to being awesome it got back to being fantastic and what if it didn’t get better in a week how would you feel i mean look i still am i’m really really happy that i know when things get really bad i’ve still got some really good people in my corner yeah right oh did you go and see anyone i didn’t i didn’t you did it yourself i did it myself and as you said you know because it only lasted a week maybe maybe that was if it lasted a month or two months yeah i mean it’s it’s some help yeah well absolutely it’s um you know i didn’t seek help maybe a week wasn’t long enough i was able to get navigate that myself but i don’t know if if it had been going for two weeks or a month or two months i i would have started to to call call in some yeah i would have started to mobilize the team yeah so i think that’s really important because um you know what we do know about pain is that it’s strongly linked to memory and like you can have some really negative memories but you can actually build some really positive memories and the old memories which were negative have been superseded by some pretty potent powerful positive memories absolutely that’s what you leaned back on the last time oh and that worked and it kind of circumvented that cycle of negative spiral thinking acting doing that stuff that’s just so consuming oh absolutely and and i think also is whereas i used to just have these flares for for no real reason i mean the last six months or the last year i’ve been hammering myself i mean i should i should have paid i i don’t you know like i mean i’ve i’ve done i’ve done things the last two years 12 months i never thought i’d get to do again so it’s um you know it’s i guess you’re just doing is believing so yeah i don’t know it was um i guess i’ve had enough repeats that i’m getting better and better and better i’m still not i’m i’m not saying that my journey’s over i’m not saying i’m never going to have an issue with pain again because i almost certainly will but i know that you know my experience up to an hour will help me and then i’ve still got a lot of a lot of tools in your toolkit absolutely and i haven’t and it’s probably important to mention that you didn’t have anything serious in terms of signs and symptoms that we’re talking about before changes to your bladder or bowel or things like that but i mean back in the day when i was really really bad if you told me uh not being able to go the toilet is a is a sign of something really bad i wouldn’t have been able to crap for a week i would have just gone oh well i would have stood at the toilet not being out of weight you that’s right but you know it’s it’s amazing yeah it’s your head can do some uh weird and wonderful things when it’s uh when it’s scared in both oh both ways yeah absolutely awesome thanks joe no no worries happy to be here cheers good on you so there you have it the end of another episode a quick recap of the take homes imaging is important but usually only for five to ten percent of people with back pain imaging findings are common in people without pain and don’t predict future pain or function mri reports don’t appear to be that consistent between mri centers and routine imaging is not associated with better outcomes and is often harmful not to mention costly as i mentioned show notes featuring three imaging related infographics and the references discussed today can be found at forward www.bodylogic.physiofords podcast please subscribe share and review and until next time remember to ask is there more to pain than damage [Music] 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 theme music generously provided by ferven and cash

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