The Empowered Beyond Pain Podcast

Episode 18

Backs don’t wear out with everyday loading and bending. Fact 8 with Dr JP Caneiro, PhD

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, Dr JP Caneiro discusses low back pain fact number 8: back’s don’t wear out with everyday loading and bending.

It’s common to believe that movement, loading and bending causes ‘wear & tear’ of the spine – especially if it’s painful. But that belief hugely undermines our body’s capacity to adapt. Learn more about fact 8 from the 10 facts every person should know about low back pain scientific paper with co-author’s Dr JP Caneiro and Kevin Wernli.

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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
low back pain infographic
Belavý, D., Quittner, M., Ridgers, N. et al. Running exercise strengthens the intervertebral disc. Sci Rep 7, 45975 (2017).
Kevin WernliJay-Shian TanPeter O’SullivanAnne SmithAmity Campbell, and Peter Kent

Journal of Orthopaedic & Sports Physical Therapy 0 0:01-48

Wernli, KO’Sullivan, PSmith, ACampbell, AKent, PMovement, posture and low back pain. How do they relate? A replicated single‐case design in 12 people with persistent, disabling low back painEur J Pain2020241831– 1849



I think this this myth is a is a very strong myth and it’s very undermining of someone’s ability to pursue their recovery to full health you can you can imagine that if the sense that your body is fragile and vulnerable and as you continue to do activity you’re more likely to damage yourself more and have more pain in the future it becomes a bit of a lost battle welcome back to episode 18 of the empowered beyond pain podcast proudly brought to you by body logic physiotherapy in this episode I welcome back dr jp canero jp is a specialist physiotherapist and has a PhD in musculoskeletal physiotherapy where his main topic was investigating high pain related fear in people with low back pain this episode is kind of at the core and that’s a pun intended after our last episode but it’s at the core of our question is there more to pain than damage I think you find that there’s so much to relate to in this episode that will hopefully help you understand more about pain and help empower you on the road to growth thanks again for your value attention if this podcast resonates with you and is helping please consider sharing it with someone else who it may help maybe someone with pain or someone that treats people with pain reach out via ebp podcast on the socials and let us know what you want us to discuss and check out the show notes for this episode at forward slash podcast there you’ll find links to relevant and helpful resources as well as references and a transcript so wherever you’re listening or watching this on YouTube we’re so grateful that we get to bring evidence to your eardrums and help make sense of science for you each fortnight we’ll start today’s episode by hearing fact 8 from the 10 facts about back pain paper presented by patient voice and guest on episode 14 and 16b joe and remember to ask is there more to pain than damage [Music] backs do not wear out with everyday loading and bending the same way lifting weights makes muscles stronger moving and loading make the back stronger and healthier so activities like running twisting bending and lifting are safe if you start gradually and practice regularly welcome back to the podcast everyone we’re welcoming back jp hasn’t appeared on the podcast for a while so huge welcome back to you mates um today we’re discussing episode this eighth episode 18 we’re discussing fact eight from the back facts paper the fact is that backs don’t wear out with everyday loading and bending this comes about from the myth of that repeated spinal loading results in wear and tear and tissue damage and I’m looking forward to discussing where the facts come and the evidence behind that fact I guess it’s a pretty common belief that we see in people with pain and I’m talking probably specifically about back pain but actually applies to knee pain neck pain and most pain really and that belief is that the pain is because of wear and tear of their structure uh and that they should stop moving and loading that specific structure because it will wear out even more and eventually they’ll end up you know crippled old disabled in a wheelchair and if they’re this bad and in this much pain now they’re often worried about what they’re going to be like in 5 10 15 50 years’ time so I guess what are some of the some other examples or stories people come and see us with some common beliefs around this this narrative yeah thanks Kev I think this this myth is a is a very strong myth and it’s very undermining of someone’s ability to pursue their recovery to full health um you can you can imagine that uh if the sense that your body is fragile and vulnerable and as you continue to do activity you’re more likely to damage yourself more and have more pain in the future it becomes a bit of a lost battle because you know we are all aging with time and if we are creating this wear and tear now and what happens if I play more soccer what happens if I continue on going my bush walks and that becomes really undermining of people’s confidence in their body and you know fortunately the evidence doesn’t support that damage you know there’s mounting or growing evidence uh that supports several other factors that influence someone’s paying experience uh and smaller uh amount of um or little evidence to support the only damage is responsible for uh for someone’s pain experience so some of the examples that we see are patients that come up with a history of back pain or with presenting with back pain that their world has reduced because of uh daily activities that they used to do habitually without thinking now become uh became sensitized and every day they need to think about the tasks that they’re doing and they’re thinking about how they posture themselves if they should do it or not uh you know how they should pick up a shoe from the ground how they should empty the dishwasher uh and behind this concern about that task uh is this belief that if they do such tasks that is painful it means that they’re causing more damage to their body and that this is an inherent and um vulnerability that we that we carry in our society or our perception that we carry in our society because it’s a really strong belief that pain equals damage you know if we think back in the day you develop pain you go to see the doctor the doctor sends you free skin that’s the first time you’re getting your skin in any body parts and that body part will very likely demonstrate some age related changes and so in the past we used to be very quick at associating those changes in the scan with the pain experience that you have uh and unfortunately this continues to occur these days but if we if we look at the evidence we are not standing on a very strong ground to make that relationship and oftentimes we see patients that go on to have a skin and they have a good looking skin a very healthy looking spine on an image which doesn’t match with the pain experience they have you know I saw a gentleman last week who’s um who has a very distressful uh paying experience over the last seven months and this guy is really struggling and the only finding he’s got on his mri is a minor disc coach at l45 and and he’s a 42 year old man with a long history of playing sports uh and so you look at that at the relationship of his pay experience he’s completely disabled uh he can’t sit for more than five minutes he can’t stand for one and ten minutes he stopped walking uh he struggles to to um to make his kids breakfast in the morning you know you do a vegemite sandwich and then you have to lie down the couch for 10 minutes and then you’ll stand up again to try and complete the other sandwich and there he goes and so it’s a very distressing paying experience that led to significant visibility but when you look at the scan for a 40 for you know any male 42 year old that has a scan of their back it’s very unlikely that you won’t present a minor disappoint and as a matter of fact on examination when you um when you load that segment it was sensitized uh but palpating his spine he wasn’t sensitized palpating the muscles around the spine he was very sensitized so he was sore to touch on the muscles but not sore to touch on the spine but despite that he was bracing and guarding his back because his belief was that in every action that he was taking and every task that he was performing that was painful that that meant that he was further creating damage to his spine and exactly like you said said you know I played football all my life i’m only 42 years old I want to continue uh doing physical activity with my kids but what is it going to be in the future if i’m at that stage you know I only have this small change in my back and my life is ruined what happens if as I get older I have more changes in my in my skin so it kind of it leads people in this in this path that is really hard to uh to shift from and and the tricky thing with pain is that it’s a felt experience in your body so those warning signs they they alert you in every movement that you that you’re doing on a daily basis so this guy he wakes up and he feels pain in his back immediately his body is goes into a protective response and and that protection carries on so initially he developed some pain um in a context that was very stressful a very stressful time in his life and he first felt his pain sitting in his office so sitting was the first task to become painful but very quickly he started avoiding bending he changed the way he picked up his kids he changed the way that he would sit in the car he changed the way that he was going for walks now he avoids walking swimming picking up his kids so you can see this generalization of avoidance which are entirely based on warning signs that he gets from his body so he feels discomfort he feels pain therefore he shouldn’t do it so his his world has reduced and initially was sitting and now he is afraid of twisting he is afraid of lifting his arms above his head because that bends his back backwards you know it’s on google looking at what happens with the disc when you do all these movements and let me tell you the information that you find is not very supportive of movement on the internet unfortunately so this belief can have a significant impact and and this is a patient who I were asked I said what do you think it happens the more you use your back well I have more pain and and what do you think it means what means that i’m causing more damage and you know and i’ve been told by other professionals that usually if one disc is gone uh I would tend to wear out the disc above or the disc below and you know so it just kind of uh um it goes on on a on an avalanche of disabilities yeah his blue box and uh and the interesting thing with him was that he had an epidural to supposedly the source of his pain and he had a day or two of pain reduction and that was it it wasn’t even a significant change and that baffled him because he’s going you know you put this corticosteroid injection in my back right at the source of the pain why am I not better you know why if that’s the source of the pain so you can see this the same person that’s stronger strongly believes that the disc is the source of his pain and that the more that he does creates more weary and tearing is confused by the fact that he had an injection intervention on the source of the pain and he had close to zero effect uh so so this guy is pretty distraught in in in that situation and to change someone’s uh to shift away from that idea that you should protect your body that you should guide your body to towards an idea that actually movement is healthy for your body uh it can be a really tricky tricky transition yeah absolutely and you can kind of see that that’s quite a if that’s his belief in his belief that every time he feels pain he’s making his condition worse he’s making his disc bulge worse then it’s quite a common sense response to start avoiding those things if that’s the meaning that you attribute to what what the pain actually means and I think you sort of I guess it kind of comes down to one of the key messages that we talk about in this podcast around questioning you know um is there more to pain than tissue damage and and that uncoupling of that relationship between pain not necessarily being a direct relationship or a direct reflection of of what’s going on at a tissue level um and and I was hoping we could kind of talk about some maybe some more examples uh around how pain and tissue damage aren’t that well related but before we do that I just wanted to sort of clarify um this person’s you know this case this case that you’re talking about so is it fair to say that his pain that he was feeling perhaps wasn’t coming from his disc and maybe it was coming more from his muscles by the sound of it potentially clenching all the time and that’s probably quite a you know a reductionist approach or a very simple way to look at pain and we know that pain is is a lot more complex than that but I was wondering if you could kind of talk to talk to what was causing his pain or what is causing his pain so so it’s really hard to say um but but I I have no question that his back structures were sensitized and that would be his disc his uh his ligament his joints because the way that he was protecting his body was by bracing his body you know this is a guy that’s sitting across from me and his you know his breathing was really shallow he was bracing his belly while sitting in a chair so the amount of load that he was putting in his back was quite significant for a task like you and I are doing right now which is just sitting here and we are supported by our bodies our chair the chair and our bellies are not tensing up so what exact structure was sensitized i’m not sure and perhaps the the l45 minor dispatch could be sensitized and it makes sense you know if you if you have a sore wrist and you’re squishing that wrist all the time you know if both of us continue this conversation for the next 40 minutes doing this you know it’s very likely that that wrist will be a bit uncomfortable and if we repeat that tomorrow and the day after tomorrow and I go and I brush my teeth like this and I start doing other tasks like this it’s very likely that my wrist will be sensitized and so in my understanding of his presentation the behavior that he was adopting right now seven months down the track wasn’t very helpful that was identified through an examination where he was given an option of offloading his back and learning how to relax his back and sitting in a more relaxed manner and then you’re sitting for for nearly 10 minutes without feeling any more discomfort and and that was a was a an experience a felt experience that he wasn’t getting the same warning signs that he usually does and there was a way into his belief system to challenge that where he’s going look I I feel like I should be protecting but actually when i’m not protecting as much it feels better you know how is that possible and that that that’s for the it’s the job that the clinician has uh to challenge that so in you know you look at the uh the mechanism you know he started feeling pain when he was sitting in his office you know he sat on his dead office for a number of years and but what was the context of that and there were significant uh personal stresses in his life that led to changes in his sleep led to changes in his physical activity led to changes in the amount of hours that he was working and he was more sedentary and then his back became sensitized you know i’m not saying that this they are the causes of that but that’s the context in which his back became sensitive and soon after that you know several other activities in his daily daily life became demonized because of that discomfort yeah because you felt like yeah so I think it’s really important for for people to to understand that daily tasks such as bending to tie your shoes or to pick something from the floor lifting your child or picking up the garbage or you know turning back to put your seat belt or to speak to your son on the back uh on the back seat of the car you know things that we do on a daily basis they often are provocative in people that have back pain or I should say that people coming to see us often report those activities as being painful so what does that mean does that mean that those activities cause this pack can they cause pain no it doesn’t mean that it means that your back is sore and when you do those activities those activities can be make your back sensitive right so but you’ve been doing those activities for the majority of your life but now during this period of time they became a bit sensitized so what we need to do is to identify uh you know why you’re sensitized what are the factors that we can actually change uh that can potentially reduce their sensitivity and it’s fair if you develop pain after doing let’s take gardening you develop some backpack and then the next day taking the bin out is a bit sore picking up your kids a bit sore uh going for a run is a bit sore and maybe you take it easy for a couple of days and you let your body settle settle and and then you get back to doing these activities again and oftentimes we get patients that come in to see us that they um gradually stop doing those everyday activities or they continue to do it but they do protecting their bodies and when you ask them many may say that they’re doing that consciously because they know that they shouldn’t ban and they might even tell you that you know I I have these um posters and my work demonstrating how you should bend and lift and how you should sit uh and I never really paid attention to that you know it’s something that you look every day but you don’t pay attention but now now i’m really mindful of it and from now on i’m going to take care of my body and how is that going for you well it’s not better yet but that’s what I should be doing right so people can change their behavior based on the symptoms that they have despite the fact that the new behavior doesn’t really change their experience and and I guess what we need to what we need to understand is that moving your body can help to reduce sensitivity in your body and it can create more health in your body so let’s get an example of osteoarthritis or commonly perceived as knee wear and tear right so your cartilage had enough and you and you ran too much or you play footy too much and that’s the reason why your cartilage doesn’t look very good to that you know that’s a very common belief and the cartilage itself if you rest the knee if you immobilize the knee if you protect the knee what we see is that the the health of the cartilage reduces the cartilage becomes drier becomes less able to um to produce movement with ease on the other hand if you get a sore joint and you gradually uh provide promote movement in that joint in a way that is not highly provocative and you do it regularly and consistently what we see is that cartilage actually looks healthier and responds in a healthier manner what does that mean it means that it’s not as stiff he moves better you have it’s less provocative but to be able to start moving a painful knee joint you have to go past the barrier that the more movement you do with that knee joint will create more wear and tear yeah and that’s why this belief is so undermining and if we look at if we look at um from our clinician perspective right you look at the work that or the the the shift in management of tendon pain indonesians right in the past used to be you know protect the tendon rest the tendon avoid physical activity and over time that changed significantly and today you a large proportion of clinicians and perhaps even the public will start thinking that you actually need to exercise the tendon because the pendant gets healthier and and becomes stronger with movement and load that is provided gradually correct yeah and with the adequate rest as well right yeah exactly so uh it’s it’s like the the the capacity demand uh balance you know the seesaw that we see that we have so if the demands are high and the capacity of the tendon is low you gradually build that up so what does that tell you tell us it tells us that a tendon is stimulated in a consistent graduate manner can become healthier right and we look and and if we go into it we can see tendons that have significant changes on an ultrasound or an mri that can become able to tolerate and produce low such as running jumping playing basketball volleyball and etc so there and then we have an example of a structure that on a scan it could be labeled as damaged but it doesn’t reflect the capacity of the person the person is back doing the activities and what that created for clinicians like ourselves it gives us confidence to get patients to gradually load their tendons right where if you have pain that is acceptable that is tolerable and it doesn’t influence too much of daily activities you continue stimulating the tendon with that load right now when we move to osteoarthritis we are kind of playing catch up now and we see some really good work that is coming out to demonstrate that the same principle applies if you get someone that has significant changes on a on a tibiofemoral joint and they have pain with doing activities such as getting up from a chair or bending down to pick something on the floor and they can barely barely use their leg but you gradually build that tolerance to to load on that knee joint and you do it not completely pain-free you actually accept that having some discomfort is part of the process and and for patients that’s a really tough idea to grapple with but the ones that uh that experience that it’s a winner because you you start realizing that actually I can do a little bit more and my pain doesn’t change and as they keep going you know there’s some data to demonstrate of patients that were on a wait list to get a knee replacement and they embarked on a on a knee rehabilitation program to exercise their knees and and that you know for six weeks and for the first three or four weeks their pain either didn’t change or increased a little and after that the pain reduced and 80 of patients in that group decided against having surgery for one and then two years after the after the program right so that what does that tell us they aged over those two years their joint probably looks a bit different uh you know in a more negative way but their capacity to tolerate their daily activities and the things that they want to do has increased and it’s not sensitized yeah maybe their pain’s decreased as well exactly now what we’re seeing now is seeing clinicians feeling more confident to tell their patients that the skin at times is a big part of the puzzle but at times it’s not a big part of the puzzle but in both situations we have to reduce the sensitivity of the joint and for those who are who are not clinicians listening to us what we mean by that is to make the joint a little less sore make you you know reduce how much discomfort is caused in a body part when you use it and so we have clinicians telling patients that it’s okay to feel a bit of discomfort and that’s part of the process now when it comes to back pain which is probably one of or the most researched body parts or pain experience that there is in musculoskeletal health we don’t see as many clinicians confident to tell their patients to continue to bend despite their discomfort we often see uh and we all been guilty of that of telling someone to bend forward and they experience some discomfort and you say well okay so let’s just back off a little bit so then the message that we are implying in that examination is that if I feel pain with the movement I shouldn’t do it right and that goes directly in line with the belief that if I use my body my body and it’s painful something wrong it’s happening and that maybe may not be conscious on the clinician part and on the patient but it taps into societal beliefs you know if you ask any jp on the street about the what do they think about pain and damage and what do they think about using their back when it’s sore and what do they think about bending and twisting and lifting and twisting you know they are dangerous activities for our backs and so if I have pain with bending and twisting therefore i’m in a in a danger zone right and it’s my beliefs are aligned with my experience therefore I shouldn’t do it and perhaps the way I was doing before put me at risk to that and and that’s been a an assumption that’s been pushed uh in in you know in research and in society uh but luckily we know today that there isn’t a lot of evidence to back that up there is growing evidence to demonstrate the actually the the tasks that you do while can be provocative it can make you feel sore when you do it uh it’s rarely the sole cause of the problem and actually becoming uh more able to do that very task and but doing that in a graduated manner it’s the way out of or the way to recovery and to be able to go back to doing your daily activities with less pain or with no pain so I guess what i’m this this myth is a it’s a really important myth to be um to be argued against because it can really undermine someone’s capacity to move forward with their lives so I um I saw someone yesterday who had a a a terrible car accident you know a young person with a significant car accident that happened just over a year ago and you look at the skins and the skins are not bad at all and so at the most she had but you know this person’s neck became really sensitized uh from that task from that accident and as a consequence there’s a there’s a behavior a defense mechanism that is embodied so it’s like this embodiment of cautious and protective movement in which if i’m going to turn my neck if i’m going to turn my body it should be in a protective way because something happened to my body that hasn’t healed properly yet and we know that you know majority of body parts they would heal after four weeks or six weeks you know broken bone with would you after four weeks but it can continue to be sensitized despite the initial problem that you had now you look at when you dig deep into this person’s uh understanding of their problem that belief that as you use that body part and you get pain means that you’re causing more damage and if the more they use the body part the more pain you get therefore you’re causing more and more damage so that is a it’s like trying to move forward with your life with a handbrake on it doesn’t work very well you know and and we look at the data of uh probably the most common signature of people with pain is that they move less they move slower you know and and as they get better their tendency is to move faster and to not be as tense and guided so that just it kind of reflects this common protective mechanism that can be really useful in an acute stage it can be really useful after a trauma not only useful but necessary yeah protective yeah but at some point at some stage we need to move away from that and rescue back our ability to do the daily activities that we always do yeah absolutely that was really nicely explained and I think um at the heart of that um barrier is like you said that belief that pain must mean you’re you’re wearing out or causing further damage um and what we’re saying really is the what it comes down to is that this relationship between pain and damage just isn’t as clear as what we used to think it was it’s not that strong and I kind of want to talk about a few examples of that so i’m sure everyone’s had a paper cut or everyone you know you can imagine pulling the little bit of your skin next to your thumb off and and that’s quite a painful experience i’ve done that before and it’s you know I would rate that as as quite painful um but if you think about how much damage is going on in your thumb when you get a paper cuddle and you’re pulling that little bit of skin off there’s not really that much damage so that’s an example where you can have high levels of pain um and and not really much damage whatsoever on the flip side of that i’m sure most people listening would have these mystery bruises that just seem to appear out of nowhere you know on their legs or just on their knees or somewhere like that and they’re thinking look I don’t know um how that got there I have no idea how I got that I have no recollection of any trauma that has happened that’s caused that internal bleeding but so I don’t feel any pain but there’s clearly been tissue damage there um you know so that’s an example you know opposite ends of the scale um where where these this relationship just isn’t really there and I suppose it speaks to the meaning that we put behind the pain um we sorry you got it now it’s kind of going on on examples like I i’ll give you a personal example as a young child between four and five years old I was diagnosed with what is called perthes disease and for those that don’t know what that is it basically means it’s a a very early onset of degeneration of the cartilage of your hip joint so it’s almost like at a very young age you know your one hip joint grows up to become a little ball and the other one grows up to become a little mushroom you know yeah yeah yeah it becomes a significant change from one side to the other and as you get older or as you grow up the changes become even worse so I uh you know I had some discomfort initially but then growing up I didn’t have much pain at all in my head and going through the university my university degree I remember taking my x-rays to clinicians to surgeons to doctors to lecturers and everyone that looked at my x-ray they were diagnosed as having hip osteoarthritis which would fit the criteria of the skin and that the only way up was surgery but there was playing soccer badly by the way even for brazilian yeah yeah exactly that’s why I moved to australia it’s all clear now yeah exactly but then I was doing several other activities no with no pain experience whatsoever so i’ve been carrying that significant change in my hip with no pain then at times in my life I decided to start new activities that required a little bit more of my hip so I needed a little bit more range uh I was for instance cycling I needed to be sitting in a in a deeper hip flexion or I was doing a rolling agony and initially I didn’t have the mobility in my hip and I didn’t have the capacity so my hip became sore and as I gradually build up because that was something that I wanted to do so there was a demand an activity that I wanted to do and I gradually did that I managed to be able to do it without having discomfort in my head and as time went by times in my life where my hip became painful were times where I was more sedentary sleeping less uh and with higher levels of higher levels of stress in my life for instance when I was doing my PhD and I had my my first son so I was not sleeping much and trying to you know pull out a lot of work working in the clinic sitting my bum on the on the desk for way too long and not exercising enough to counteract them so that just gives us an insight into a couple of elements one is the fact that as you’re nicely described that what your scan shows or the the wear and tear that you have doesn’t always or doesn’t always explain pain uh and that or when it when it’s related to pain it doesn’t explain pain by itself and the second aspect is which is in line with a more uh contemporary understanding of pain is that pain is not related uniquely to how your body looks or how your body is shaped or how you use your body but it’s related to the the beliefs that we have it’s related to the the social aspects of our lives it’s related to um to the emotions that we are uh going through and uh and for patients it’s a really tricky idea to grasp that these factors can how can being stressed and sleeping less cause pain in my body you know and if we um if we simplify it some of the things such as um not sleeping well being sedentary uh high levels of stress and a poor diet uh the one of the significant outputs of those elements is an increase in inflammatory response in your body so there’s a physiological change in the chemistry of your body and structures can become sensitive and sometimes some body parts are a little bit more vulnerable either because of the activities that you do or because of the of the structure of your body or past experiences that you had with that particular body part so for us to you know you you if you look at our our uh paper you know the myth is that repetitive loading can of everyday life can create more wear and tear and damage and pain to the body you know that’s the myth and the fact is that actually using your body uh repetitively in a in a healthy manner in without protection uh is is actually a better way for your body similar to muscles that get stronger as you use them muscles that become less stiff as you use them and you stretch them other body parts are like that the knee joint the tendons the discs the shoulders the neck uh so there’s more and more evidence to demonstrate that and we need to understand that there are several other factors that can affect how one may feel you know and when we talk about a biopsychosocial approach there is uh for some there is a perception that we’re talking about uh you know the pain is in the head and uh it’s the psychology and it’s always about if i’m stressed I mean more pain that that’s not just it grace that’s what we’re talking about here today which is beliefs if I develop pain and I believe that using my body causes more damage and therefore pain that will influence how I behave if their emotions uh or my emotional aspects if I under significant amount of stress which change the chemistry of my body or if I’m naturally anxious or if I have a healthy health anxiety when I develop pain in my body I will pay more attention to it I will protect it more and that will become more bothersome so my emotions will affect how I carry my body and how I use it on daily life social aspects such as developing pain during a time where you are dissatisfied with your job or you’re stressed at work or you’ve been bullied at work right or you are not participating in the social activities that you use to participate or you’re feeling socially isolated so all these factors they play a role around the time of paying on set but also around persistence of pain some of these things may not be modifiable but they can be used for the patient and the clinician to understand that there is more to play or there’s more to pain than tissue damage yeah yeah absolutely it sort of speaks to how um how wonderfully complex the the pain system is and um some people might find that quite threatening I sort of view it almost as the opposite in terms of that means there’s so many different things that we can do that can influence how much pain we feel and also the meaning maybe there for all the downstream consequences of of um yeah the meaning we put on to on two pain um you talked a little bit before about you know how lifting lifting weights makes your muscles stronger and and that nice example around with the the neoa as well um or the osteoarthritis and knee pain and I want to kind of hone in on that because I think that’s a really central message that that um I want people to try and understand from from this episode of the podcast and and certainly um fact number eight from the the back facts paper um we we have like you we’ve talked about today we have this narrative that our body is is fragile and and you know it’s vulnerable and it’s easy to break and it’s hard to heal um and and that’s quite a rational and quite a normal thought or belief given the messages that exist in the world um but these are just messages their stories they’re maybe not that true but they’re they’re kind of endemic in and um everywhere um so I think it’s helpful to sort of talk a little bit about um this idea that that our bodies you know our structures really aren’t as fragile as what most people think they are and and um you know when we think about okay what’s the opposite of fragile most people would say well that’s robust robust is the opposite of fragile and robust if you define robust it’s like it’s like a block a rock or something that you drop or you drop and you apply force to it and it won’t break you apply a stress book to it and it won’t break but but actually humans are a next step further than robust where you know what um there’s an author called um he’s written a book called anti-fragile nazim nicholas taleb speaks about humans being anti-fragile that actually if we put the appropriate stress on our body with the appropriate recovery then over time we have we add a little bit more stress and then have a more recovery and then a little bit more stress we actually get stronger over time so we’re not just robust in the term that we won’t break when there’s stress on us but we actually adapt to stress and become stronger and more resilient and have more capacity in our structures which is you know this idea of anti-fragility and I think that’s kind of the key key message and we know we have evidence that this is the case in you know spines as well we know that runners have healthier discs than non-runners we know that cyclists have healthier growers and when I say healthier discs I mean you know there’s more more water content uh there’s less disc space narrowing um so yeah I think it kind of starts to question this idea that the more we use our body we wear out in actual fact the complete opposite is true right yeah and I think that’s a wonderful point to uh to make kevin and you know if we think about uh the possibly the origin of this idea for instance for the back bending is uh is dangerous for the back and even to a point where it’s being raised the possibility that we have a set number of bends in our back the original study that came with that was uh looking at human cadaver uh spine so you cut just the section of the lumbar spine of the lower back and you put in a lab and you’ve got a machine to bend it right so it’s a it’s a bad structure that you will have a set number of bins and if you bend anything enough or if you put pressure in any uh structure for enough times you get a point where it it breaks down right and based on that there was a jump to say that human spines have a set number of bands and human spines if they bend too many times they will they will break and fortunately there’s been several studies done in humans that did not reproduce the same results in terms of looking at loads of the spine and etc but what that what we have to remember is that our spines are not moving by themselves our spines are part of a whole organism that is inherently made to respond to stimulus so if we get healthy human beings and you’d send them off the planet to go to mars and come back you know they they feel healthy they’re acting healthy but their bodies became weaker because they didn’t have enough stimulus when they’re out there and now all these these programs they have people uh when they’re away they’re exercising as they can there to come back as healthy as they could if we get a my healthy elbow and we put it in plaster for four weeks I will have a really unhealthy elbow by the end of it but there is really strong evidence to say that if we stop nourishing a body part it becomes unhealthy and nourishment for the body is movement and it’s movement that you’re capable of uh of doing and it’s movement that is done regularly right and so i’ll give you an example of a patient she’s how old is she she’ll be 68. sorry she’s young she’s young yeah she’s between 15 or 72. I I have in my mind that she’s 72 but she looks younger yeah but and she used to practice yoga on a daily basis and then she she had a fall and she hurt her knee and she ended up having surgery on that knee she had a fracture and it was necessary to have surgery in the knee and when she came back from it she felt really fragile which is natural and the process of getting her back on her feet just getting up from a chair and walking it was a lengthy process but you could see that person feeling older with time and behaving as if she was older with time and very quickly going from I practice yoga every day and age is just a number towards you know I feel like I’m getting to my use by debt I feel like there’s not much that I can do with my body anymore I feel like I lost all that I was doing and now I’m gonna have to do you know maybe the seniors class in the gym if I can do if I can go to a gym so this idea that the the body became really fragile and vulnerable and unable to adapt uh became a strong theme in her narrative in our encounters and several emails that we exchanged and as she developed a bit more strengthen the leg and mind you that process wasn’t pain-free all the way that problems had discomfort yeah and she had to wrestle with that idea you know if my leg is healed why am I feeling pain we are kind of pushing your leg is healed but the capacity of your leg to tolerate what you need for it to do is pretty small and we every time we catch up we are pushing it so we are we are making it a little sensitive and anyway she bought the idea because every time she pushed it it was a bit sore but then she was able to push more and it wasn’t a sword so the experience is what made her continue to move forward and we got to a point where she’s doing everyday activities fine and she’s back to doing her yoga practice but something changed that she’s going I feel like I can do a bit more than what I’m doing now and I feel like I wanna I wanna feel a bit stronger and fast tracking a few months she’s in the gym lifting weights and loving the fact that she’s going under a bar in a squat rack her agent let’s call it 70 to be in the middle and she’s putting big blacks and she’s lifting weights she didn’t start there she started by just getting under the bar and with a very light bar as a matter of fact with a broomstick and then and then some little wipes and and she’s feeling this vitality coming back and feeling younger again and this narrative of you know my friend invited me to go for a bushwalk I haven’t done this but it you know I should be able to do it and this it’s almost like it’s unlocking the the this uh natural human capacity all right it was a slow process but I think her story is it’s quite nice because um it goes from being able to being disabled for a while and resurging again and feeling more able than she was before so you know it goes to to reflect what you’re saying that if you stimulate the body and the body continues to grow and of course we all have our limitations and we all have um our capacities to do that is different and our capacity may be different as well based on our experiences you know I saw another lady who had uh hip pain and she was really struggling to strengthen her legs by doing our traditional exercises of squats and lunges and and she was adopting some postures that she felt really unnatural with and when I asked her about her her past experience you know in the past when did you feel strong oh I used to dance I used to dance a lot and I felt really strong in my legs I felt really strong in my body and I said can you show me some of the things you used to do when you danced and very quickly that tapped into somewhere in her memory where she embodied that memory and she started enacting a few of the drills and the exercise that she used to do that she felt natural and she felt good and very quickly she started developing strength so the pathway to to to feeling anti-fragile uh may not be the same for everyone it may have similar principles which are to do it gradually to do it regularly and be consistent with the belief that as you continue to do your body can strengthen up and of course this is easier said than done and I imagine there’ll be people listening to this and saying look I tried to exercise and every time I exercise I was sore every time I did this I was sore and then there is there is the way in which you do this there is the way in which you perform these activities you know going back to that gentleman that I mentioned at the beginning whose life was very disabled and we managed to you know sit for a while uh I asked him about some of the things that he tried and he said look I I was really keen to get on a bike because I have a bike and I have a stationary bike at home but I tried it several times and I really struggled and I do you mind if I have a look at that and he said said back to me do you mind if we don’t I said why is that because the thought of me sitting on a bike it frightens me because I’m kind of going on a on a good period now and I don’t want to fly and I asked him how fearful he was of trying the bike and he said I’m an 11 out of 10. because I’m dead sure that i’ll be sore afterwards anyway long story short we sat on the bike and the way that he was sitting on the bike was highly provocative he was trying to adopt a posture that wasn’t even his natural you know I put a mirror next to him and said do you recognize this person on the bike he said that’s that’s not how I used to be but that’s what I have to do and I said show me how you used to be and when’s he relaxed into his more natural posture so what was he doing sorry what was he doing um when he was on the bike with high field what did he look like he was trying to sit really straight and keep his back straight and having uh weight on his arms but keeping his chest up just really protective obviously harder than tense yeah yeah got an intense and his old natural posture was something a bit more relaxed just just kind of as he said I used to sit on my bum and now I feel like I’m sitting on the edge of the seat and I’m holding myself with my with my back that was his um his interpretation of that experience and we sat there for 12 minutes and at the end of it he said it actually feels good it feels good that I’m doing this so uh the things that we are talking about here today uh the pathway to get there it’s different for everyone and some people they may need some help along the way they may need medication they may need injections to create a window of opportunity for them to exercise because they’re too sensitive they may need psychological support and others may even need surgery but the important thing is that because you try to exercise and you try to use your body and it doesn’t work for you you gotta probably start looking at someone that can guide you and coach you towards learning how to use your body in a you know perhaps in a different way or someone that challenges your beliefs and enables you to to think in a different way when you are using your body and I think that’s our our greatest challenge as clinicians to guide patients to uh to change their mindset towards uh that you know using the body is good for the body and and creating that regularity and doing it graduate yeah and you can see how um you know for that that gentleman’s experience of being on the bike and actually feeling good that um straightaway kind of updates his system or his understanding of okay well if if this feels good I thought it was you know I was 11 out of 10 out of fear and I was almost certain that I was going to flare up but it actually feels good you can see how that updates his beliefs around what what is what’s happening in his body and maybe his disc bulge isn’t really as the problem that he thought it was and conversely you can see how easy it is for people to get in in a loop of okay I feel pain and when I when I’m on the bike I feel pain so I should never do that and I feel pain now bending as well as not just sitting and twisting as well should never do that and then because you never do it your structures don’t get used to it or they’re not conditioned for it so when you try to do it or something similar it doesn’t take as much for you to flare up and then you get more pain and you can get down this sort of negative sort of spiral as well um and you mentioned sort of before nourishment of of joints and things like that and I think that’s um like highlighted nicely by by an analogy of a sponge cartilage is like sponges if you leave a sponge just by itself it can’t absorb water it can’t absorb you know and nourishment and get rid of waste products but squeezing a sponge and repetitively squeezing it and letting it go helps it absorb um you know yeah all the nourishment that it needs and gets rid of all the sort of waste products and and um the other thing that you sort of talked about that sort of triggered something for me was um you know this idea that we have a number of bends left and you know i’ve heard plenty of stories of patients who come and say yeah look we’ve had a manual handling course at work and they showed us a paper clip and they just kept bending it or gave us all the paper clip and we just kept bending it and bending it benny until we till it broke and then they said that’s our spine so it’s um it’s no wonder that these people come um that’s quite a natural uh responsive then to be frightened of that and and I think it’s really important that we that we squash that belief and and um you know we we adapt with with load with the appropriate load we aren’t like paper clips like I said we don’t wear out with more movement we’re the opposite um we get nourishment and get healthier and get stronger with appropriate load and appropriate recovery there’s two elements as well that it’s really important to to bring through one is that we are not talking about um just pushing through pain we’re not talking about just doing it uh we are talking about uh understand what contributes to your to your to your problem and try to target all these factors because for some people it’s nothing to do with how they move they move fine they’re not guarded and they still have like um so that’s an important aspect the second aspect is that it is also common that some people will present with changes in their scans that are relevant and associated with their pain presentation and so it’s at no point we are ignoring the biology but even then what we know is that if you have changes in your skin and they are a result of either a traumatic incident um or they they appear gradually and they have like a sensitized nerve tissue or or you you know they have back and leg pain that even then movement is helpful in healing for those structures it’s just a matter of the dose in which you’re gonna give that so the dose of the movement so movement kind of it’s never out of the question uh and and also the understanding of all the factors that can create that so we know from research um to date that something like leg pain or like a when your nerve is irritated uh a lot of times that is related to like an inflammatory change in your body rather than something that was damaged and is now pushing on the nerve especially if that pain occurred gradually without a specific incident you know in the past we used to always think that it’s related to something pushing on the nerve and of course your clinician will examine you and determine if that’s the case or not but if it’s there’s nothing pushing on a nerve where your nerve is sensitized then we look at other factors that could be creating an inflammatory context such as your sleep your mood your um your you know if you’re resting too much or if you’re doing too much or if you have high levels of stress or so we look at all those factors and going well these are some of the strategies that we can work on to create an anti-inflammatory environment or context and movement will be part of it and then you gradually build up as the nerve comes down so that’s just to exemplify that at times yes the body has changed or the body is damaged and in those cases we’ll continue to do a gradual return to activities but when we fear and become overprotective of our bodies uh that can become highly unhelpful yeah yeah thanks for clarifying that that was um it’s really important and um yeah highlights that that uh it’s sometimes these things are related um you know things like pathology is certainly an important thing to consider uh as part of the bigger a big picture of a sort of a whole personal understanding of someone’s condition um the the podcast is called empowered beyond pain for a reason we’re hoping that through these podcasts we can give people understanding and update people’s knowledge around the modern research and and you know our experiences both being researchers and clinicians and hopefully people you know I think the the key message here um from from this episode here is that you know that that relationship between pain and damage isn’t that strong as what we thought it was um and that you know your body doesn’t wear out with with more with more movement do you have any final kind of comments to speak to this fact um no I think it’s uh to add to the sentence you just said I think the body craves movement and the body gives signs when it’s not moving enough and when it’s not stimulated enough and the other element as well that I think it’s important to highlight is that this we talked about some patients journeys right and for some that that new experience that positive safe experience can happen quite quickly and for others it takes more time and so the journey is different to everyone uh and it’s not we’re not here saying that it should be easy uh for some it’s easier for others it’s really difficult um and it’s important as well to to understand that probably you know the clinician’s job is to to coach the person so they develop new habits and new strategies that they can self-manage their conditions by themselves and occasions in which your pain flares up uh a lot of these beliefs they tend to come back uh and some of the protective behaviors tend to come back and these are times where it’s really important to reconnect with your clinician and to review uh what’s happening and to make sense of that flare-up and that kind of it’s a nice segue for you for our next myth which talks about pain flare-ups beautifully done jp um i’ll yeah exactly I was going to say the exact same thing next week’s episode is all about um pain flare-ups and and yeah look everyone’s journey is is individual and and that’s why it is so important to get an individualized assessment for for you know whatever health xyz health condition that you’ve got um awesome thanks so much for your time jp it’s lovely to have you back on uh and we look forward to chatting to you again soon thanks kevin so there you have it the end of another episode thanks again for tuning in my take home the inaccurate belief that painful movement loading and bending causes wear and tear is a really imprisoning or limiting belief that can result in unhelpful movement patterns and prevent us from engaging in the very things that help us recover if you’d like to know more you can visit the show notes page at forward slash podcast or contact us via ebpodcast on social media until next time have a fantastic and fun fortnight and 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 personalized high-value care from a licensed and trusted healthcare practitioner we are all individuals and need to be assessed and managed as such theme music generously provided by ferven and cash

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