Episode 11: Low back pain fact 1: Scary but rarely dangerous
Low back pain is the worlds 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 (http://dx.doi.org/10.1136/bjsports-2019-101611). The origins and motivations for that paper, as well as patient stories were covered in episode 4 and 5 of the podcast. This episode covers in detail low back pain fact number 1: Persistent back pain can be scary, but it’s rarely dangerous with Professor Peter O’Sullivan and Kevin Wernli.
Listen, subscribe, rate and review on your favourite podcast platforms below.
Share the podcast:
Prefer to read? Scroll down to read the transcript
Prefer to watch? click here to watch the video on youtube
SOCIAL MEDIA LINKS:
FACEBOOK | TWITTER | INSTAGRAM | PETER O’SULLIVAN | JP CANEIRO | KEVIN WERNLI
Episode Show Notes:
Journal of Orthopaedic & Sports Physical Therapy 2020 50:1, 1-4
Body Logic Physiotherapy, empowering people to achieve better health.
JB: ‘Persistent back pain can be scary, but it’s rarely dangerous.’
Persistent back pain can be distressing and disabling, but it’s rarely life threatening and you’re very unlikely to end up in a wheelchair. So, you just heard from Joletta Belton, a prominent patient advocate, presenting the first fact from a scientific paper published in the prestigious British Journal of Sports Medicine earlier this year.
Joletta was one of 10 people with a lived experience of pain, who presented the 10 scientific back pain facts from that paper which we discussed in Episode 4. In Episode 5, we also heard patient stories behind the facts, which many of you have given great feedback on.
But today, look – welcome to Episode 11 of the Empowered Beyond Pain podcast, proudly brought to you by Body Logic Physiotherapy. We’re so grateful to have your ears to bring evidence to and we hope you’re well, wherever you’re listening in from.
Episode 11 corresponds with fact one of the Back Pain Facts Paper and we’ll be diving into the depths of exploring these facts over the next 10 weeks. While the episodes have a particular focus around low back pain, the messages actually apply to pain in all body parts. In today’s episode, Professor Peter O’Sullivan and I talk many things back pain, but one is the slightly backwards funding model in current pain management.
If you’d like to help in the quest to start funding back pain care that has a large evidence base instead of funding care that has a small evidence base, which is what currently happens, the easiest way is to spread the messages you hear in these podcasts. As always, relevant links to research papers, infographics, and websites that Pete and I discuss in today’s episode can be found at www.bodylogic.physio/podcast and remember to ask, is there more to pain than damage?
So, thanks for taking the time out again. We’re going to discuss back pain fact number one today, we’ve just heard Joe Letter talk about the fact which is that – well, the myth is that back pain is usually as a result of something serious, and the fact is that low back pain is usually not a serious or life-threatening condition, I think it’s probably important to just talk about – well first of all, define low back pain.
Back pain – or low back pain – is defined by pain that is from your T12, which is like the lower part of your back – so you’ve got your thorax, which is this bit, and then below that is your back, and then usually between pain between there and your buttock cheeks. So, any pain within that area is defined as back pain and of course back pain can be caused by lots of things, which is partly what that fact is about. Although there’s a general belief, I think, in the community that if you’ve got back pain it’s likely to be something really serious then it could even be life-threatening and certainly, there are some causes of back pain that can be serious and you know any healthcare practitioner has to be alert to those things. So, examples of, like, a serious condition would be a fracture, so it might be some kind of traumatic injury.
And I’ve certainly fractured my back – came off the mountain violated over the back over a log and it crunched and i had severe pain and it was, you know, fractured a couple of bones in my back – it was extraordinarily painful, so there’s a good reason for that like if you’ve broken a bone before you’re going to know about it. So, there’s a trauma that results in tissue damage which causes immediate pain. There are other causes of back pain, which are, you know, again not common, like an infection in the spine. Very uncommon. It’s something that may present for someone who might be, you know, had an intravenous injection or if somehow there’s an infection that’s tracked into your body into your spine.
It’s usually linked to severe pain, night pain fever, so you want to be aware of that – but usually those problems go to emergency department, they don’t come to see people like me in a primary care setting. And then you can have malignancy so you know there are some cancers that can affect the bones or even the structures within the spine, and certainly I have seen patients who have had back pain that has arisen from those, you know, that kind of cause, and that is serious and can be life-threatening, so you definitely want to identify those things. And you know, there are predictors of those around a previous history of cancer, so if you’ve had a melanoma or a breast cancer, for example, then a secondary cancer could present itself in the bone, which could be in the spine.
I’ve seen a young person with intrathecal tumor, so tumor within the spinal cord – very rare, but they do present and we have to be a really alert to identify them, but it’s a very small group of patients. And then you have other causes like inflammatory disorders so Spondyloarthropathy, which could be inflammatory disorder that could affect the structures around the spine and that’s something that a rheumatologist would, you know – a blood test could identify inflammatory markers and link to that. And that’s often linked to a lot of morning stiffness and, you know, response to anti-inflammatories and discomfort of rest etc so there are there are key kind of things that you would be alert to as a clinician that may suggest that there are other causes that are going on in terms of back pain.
The fact is though, that these kind of causes are really real like one percent of the population present with them, and often they don’t present primary care, but they may and we have to be alert to them, and then we’ve got to refer them on for further investigation. The common course of back pain is quite different. I mean, there are other causes like where there may be a structural problem like a disc prolapse, but that’s usually leg pain so people will be saying I’ve got pain right now radiant in my leg. They may have some numbness or some lack of power and that’s because there may be some nerve compression around the nerve, incredibly painful. And of course, in those situations, if you’ve got a loss of bladder function bladder or bowel or sensory loss and around the perineal area, that’s an immediate referral for scanning and potential surgery.
Because that is serious condition that can compromise someone’s continence for example, and I’ve certainly had a case in the last year where that is the case. I reviewed this person, they were operating that night and they’ve had a hard journey since then, where to regain their continence and sensation or apparently your area as well as regain power and sensation in their leg. So, the other kinds of things we have to be alert to as healthcare practitioners to go there are these there’s a checklist of things we’ve got to screen for to make sure it’s not serious, but the great news is the majority of people 95 or even greater percentage of people, it’s not in that category. And that’s a problem for people, because often we think the worse.
I’ve got back pain, oh my God, and yet it’s like a really small group where that is going on. With a natural for the majority of people, the natural cause of back pain is really different to that and it’s a whole different story.
So, that’s for the 95 percent of people, that’s what you’re talking about, so in that group, that 95, what would you say the cause is?
Yeah so what we know is, there are different kinds of pain so all of us have had pain from spraining an ankle before, yeah, and it’s really painful, but we know that your sprained ankle is going to get better. If you, you know, you might have to take it easy for a couple of days, but you keep yourself moving, you get that ankle mobile, you get it strong, and you’ll be back running and jumping and doing all your normal things. And your ankle will be back to normal, should be within a few weeks time, back in to do doing the things you love. So, you can sprain your back and we often hear this with people do a sudden loading event, or they decondition, they lift something, you know, way heavier than they expected or they have been sitting all week and they haven’t been doing much exercise. They get out, they dig a whole lot of holes in the garden, and then they go to bend over and hurt their back.
Acute back pain, incredibly painful, can be incredibly painful, but we would call that a back sprain, so that’s where you sprain or strain your back and that’s like an acute tissue strain with a muscle spasm. It’s really painful, it can be very disabling and limiting, but the natural history is that will get better really quickly. So, within a couple of weeks, the majority of people are significantly better and within, you know, six to eight weeks, they should be really well on the way, a bit like an ankle sprain.
Then, there are different kinds of pain, so you’ve probably had a headache before. Well, I’ve had a headache before. You might have had it from drinking – well, i don’t drink so much – but you might have had a headache also because you’re really tired and run down, and so I had, I had a bit of a virus over the weekend. I had a splitting headache. Now, I knew I hadn’t banged my head, I hadn’t damaged my brain, I didn’t for a moment think I had a brain tumour. I was run down, tired, under pressure, and I had a splitting headache. And what did I do? I went to bed early, you know, chilled out, didn’t push myself so hard, and just gave me some time to recover headache. Resolved now.
Backaches can present like that, so we know that you can develop back pain at a time in your life when you are under stress, where you’re run down, it might be under pressure and that can emerge without any injury at all. So, that’s like a backache, which we would see no differently than a headache, but it might be really painful in the back, just like a headache can be really painful. But you know it’s not. We often don’t think of backache like a headache, we often think of backaches like, oh my god what’s going on? Where, with a headache, we wouldn’t think you’ve broken your mouth, you’d think I’ve had a tough day, I need to, well – hopefully, you don’t think the brain tumour now. If that headache persisted day after day of the day, then you might think hang on a second, what is going on?
And the same with backache. If the natural history isn’t recovering, and it may be because you haven’t addressed other things in your life that are driving that process, and that’s something we see very commonly, and the other thing I think that happens around that is often, when we get pain, we kind of go ‘what do we think it is?’ and we often go into protective mode and so often when we have pain in the body part, we guard that part and, by guarding, we start to start reducing the movement. And it can actually make the pain worse, rather – the thing that you want to do is to relax and move, and get going, and get back to stuff, and get your sleep and your general health and your mental health. And often that kind of pain can subside and I think there’s a hybrid, so you can have, for example, we see this in, say, a work situation where you know – I can think of a case where they strained their back and there was all these other factors, so that there was work-related stuff, there was workers’ compensation stuff. The person was under huge amount of stress. That is not an environment the body, like an injury, can recover in, so you can actually more from an injury pain and when the tissue is healed, it becomes another pain.
And that’s when pain becomes persistent, so it’s a bit like you sprain your ankle and you start over protecting that ankle, and you start guarding that ankle. You start thinking something’s terrible wrong with that. And you start not wanting to use that ankle, and I’ve had a case, I saw yesterday, just like that, or day before, just like that where six weeks later that ankle is not getting better, it’s getting worse and, in the same way, back pain can become like that.
So, the original sprain is well and truly gone. That was the what we call nociceptor pain, that’s like pain from a strain and and the inflammation settled, and then it’s morphed into something else which is where the whole nervous system gets involved, where you start over protecting something and guarding it and start fearing it and worrying about it. That’s when the nervous system starts creating a different kind of pain, which is often called nociplastic pain, which is like pain that emerges where there is no injury and that can morph, that can emerge from a point of stress in your life. But it can also transition from an injury into that kind of pain,, if that makes sense, so there’s lots of reasons why you could have pain and sometimes they’re really really simple and sometimes they’re a little more – a lot more complicated. I saw a lady on Monday who said, you know, if it wasn’t for you to have my back fuse, and all I had to do was relax in my back and I’m so grateful that you helped me work that out. Yeah, so sometimes there are biomechanical drivers that are linked to our beliefs, that make us over protect or guard body parts, that’s really unhelpful and actually can make pain worse.
But it’s not serious, it’s not life-threatening, but it can seriously mess us up in terms of the impact it has in our life and the pain that we feel. That is a really hard thing to realise, but you know, I can think of times in my life where I’ve had back pain, one linked to a fracture, another time linked to a very stressful time in my life, another link to a, like, a major repetitive physical load. Each of them probably were equally as painful, but I know know each one was related to different kind of pain, yeah, and so the way I managed it was really different.
The fracture one – I knew I had to let it heal, so I had to just go sensibly, kept working, kept moving, kept exercising, but I didn’t do a lot of stuff that would overload my back. Because I knew the bone needed to heal. Well, the other kind of pain is like, yeah, I know what you are, go to get some rest, get good sleep, care for my health, get active, get moving, relax. Keep going.
And that speaks to that kind of individualised management, based on the specific contributing factors. That person at that moment in time, and that’s where the case, the patient, story, is so important, and unfortunately because you’ve got this diagnostic vacuum, which is called back pain, where like 95, you go what is it? Then we go, we kind of lump everyone in the same category, where clearly there are different drivers and triggers and different pain types that may be present in different people. Then our job is to work that out, yeah, and then target it.
I just want to touch on the idea of non-specific low back pain, we talked about it in last week yeah with Sam Barnsley.
Yeah, the 95 percent that we’re talking about is the non-specific, and that’s a label that researchers probably have used to describe that, and it really annoys patients, and it’s really annoying clinicians. That’s why we don’t talk about that, so briefly I think it’s a really helpful, it’s an exclusion label that’s to say to me, as a clinician: be reassured this is not cancer, it’s not an infection, it’s not an inflammatory disorder, it’s not a fracture. Be reassured. And there’s no specific clear specific pathology, where there’s nerve compromise or neurological deficit, so now that you’ve eliminated, that you’re sitting in this other category where there’s no serious identifiable pathology or tissue damage. So be reassured, like then you go back to basic principles, and you go sprained ankle. What would you say, well, a sprained ankle is a mechanism so you know you sprained your ankle. What were you doing? Oh, you did that, so okay, that’s his brain, so what would you say to someone – you want to go, oh god, you need to rest that up and you shouldn’t go to work. You might say, look mate, you’re probably better off backing off, you first make an estimate. Then you would give simple strategies to say, look, it’s really important we keep that ankle moving, it’s really important we get you – gradually get you strong.
Because there will be an inflammatory tail, you know you’ll get pain secondary to some kind of tissue strain, and then we’re going to get you fit and active and strong to get you back to loading that ankle up and moving it in all directions, so it’s strong and capable of doing that. Back pain is exactly the same in that way, and I think to say that, you just ‘there’s nothing, we don’t know’ there’s nothing wrong with that.
Doesn’t it defy logic?
Yeah in my mind, because the patient’s coming and telling you, I’m telling you I’ve got this problem and that’s what it is. I mean, I saw a guy last week. He came and he said I’ve seen all these people and I know there’s something around my back, but the x-rays, all they show is I’ve got wear and tear. But I presume that’s been there for a while, I want to know what it is and this guy had adopted a strategy of movement that was highly provocative to his back. Simply changing it took his pain away.
Now, so can abnormal or can altered movement or abnormal protective guarding provoke pain?
It probably can. Is it dangerous? No, it’s not dangerous, it’s not dangerous to tense your body when you move, but probably doing it a lot a lot over time could sensitise tissue, make them really tender, which means that you just keep provoking it. It’s a bit like doing that to your finger, you can do that probably for a couple of hours, probably do it for a few days. We get a bit sore and we probably say, you know, what it’s good to bend it the other way so we would see it that way in terms of backs. It’s like, they like movement, they like variability, they like to be strong for tasks. You know, healthy spines are mobile, strong, fit spines.
Yeah absolutely, and you highlighted a nice example before that talked about the, you know, headaches, and people wouldn’t necessarily worry about headaches the same way they do around back pain. I just want to kind of talk through a little bit of a scenario: so let’s say for example, I’ve just hurt my knee and I walked down to some random person in the street and said, look, i’ve hurt my knee. They might say, ‘oh that’s unfortunate, you know, maybe rest it up for a bit if you’ve injured it. But then get it loading, get it moving, and get it strong again.’ If I saw that same person in the street and I said I’ve hurt my back, straight away the alarm bells might go off in their mind and say ‘wow you’re too young to have a back pain, you know this is, it’s going to be a downhill spiral from here. You’ve got to be careful with your back, you’ve only got one. I know a good spinal surgeon or my uncle had back pain and he had to be off work for the rest of the time.’ So there’s a clear difference in terms of the fear that that the label of ‘back pain’ has, what you can talk about?
Yeah, it’s a really interesting question, it’s something we have explored because we’ve done quite a few studies looking at back pain beliefs, both in really young people, like in adolescents, and in older people, like baby boomers, and what we’ve seen in the population is there’s a general pessimism around back pain. Ben Darlow and New Zealands done some pretty cool research as well, asking people what they think about backs and the key quote from his paper, which is the lead in his paper, was easy to harm, hard to head. And that view is that, the back’s a really vulnerable structure, and once you’ve got it, might be careful because that could be with you for a long time. Now, where does that come from? Is a really great question and, if you ask people, it’s probably a bit like an urban myth, I think, that has become pervasive in our community. And it’s probably been reinforced through occupational health and safety and through the messages that we give people, like my god, be careful. We don’t say in a workplace, be careful how you bend your knee, be careful how you’ve been chilled out, goodness sake, be careful how you use your shoulder. They might say some of that, but the big message is: be careful how you bend your back, because if you’re in a manual job and your back, well, we know what happens to you. And so we’ve got the firefighter’s back, the farmer’s back, the nurse’s back.
We don’t have the nurse’s knee, nurse’s elbow; we have the nurse’s back. So, there are whole industries that have kind of stigmatised back pain as something really threatening, and look, back pain can be really painful, and it could emerge, and it’s common in those in those in those trades. But it’s probably made worse by the fear that is induced around it and the misinformation that goes with it, and you know, I had, again, a farmer just today who, you know, went some distance to come and review with me. And here’s why I’ll be told I need a fusion and I don’t want it, and and he’s thinking terrible things about his back. And it’s completely ruined his life. But there are very simple things he can do to help his back, no one’s given them but it’s around a belief that is oh my god, my back is this, and it’s, I can identify it on a scan. And my scan shows I’m wearing out and that’s a whole other story around the role of imaging, which is what often happens in our community, now is that you get a scan not to reassure the person. They don’t have the one percent, it frightens them by telling there’s all these things wrong with their back, that actually is normal. Yeah, the whole episode so, we’ve created another monster by using pathology that is normal as a diagnostic label, which frightens a whole group of people which, you know, creates another catastrophe.
And so we we have created this monster in our community around frightening people with back pain, giving them these myths around the natural history is bleak, you know, your pain is going to persist, and we’ve kind of created, it’s like fulfilling a self-fulfilling prophecy. It’s like we’ve set the disaster up and then we’ve over treated it and we’ve over-imaged it and then we’ve told people to be careful with them. We told them to, you know, keep these rules, which are really unhealthy for backs like, guard it, protect it, don’t use it, you know. We don’t tell someone with a knee, god damn don’t bend that knee, but we say ‘I saw a young lady today who hasn’t bent her back in years and she’s in real trouble, someone told her not to bend and she’s done it.’
It’s a really common society societal belief, as well, isn’t it?
It’s nuts and actually, if you think about it, just from a very basic point of view, someone said to you ‘Mate, don’t bend your elbow because you might hurt it.’ Well, you’d have a pretty limited time, you wouldn’t be able to eat much, but actually that’s what we’re doing to people in our population. We give them these crazy rules around what is good and bad for their back, and then they let those rules govern them and it really destroys it, really disrupts their life. Yeah, absolutely I think those rules kind of come from a good place typically, I think originally, but they come from a lack of understanding of the nature of back pain. These are all, these are old thoughts that are not evidence-informed, but they’ve just been self-perpetuated over time. You kind of mentioned the self-fulfilling prophecy, that was one of the points that I sort of had written down, I think. If you know we then create, yeah, like you said, a big vacuum for ourselves, if we think, if our brains getting messages of threat and danger, then ironically we end up producing more. You know, inflammatory cytokines and chemokines.
And our system becomes more sensitive, as well. In fact, there’s zero biological – there’s a very cool paper from our colleagues in Denmark that giving people scary information before they exercise and looking at their tissue sensitivity response, and the scary information before engaging in activity, made their local tissue more sensitive. So, biologically, it makes complete sense that our nervous system protects us when we’re doing things that potentially could do us harm. So, those diagnostic labels can be really threatening or, like you said, it could be that my parent had a back problem and had a fusion, and my terror, my fear, has become like that.
Totally understandable, yeah, but you know, to make people realise that they’re not their father, and their journey could be a different journey, and that or the same journey, also the opposite is true. As well if you have credible evidence of safety that can reduce your pain as well, and look I think the other thing that’s probably worth pointing out here is that’s this issue with the scan is really contentious, so for example, if i took an MRI scan of your back and it showed this degeneration, now do I know that is or not relevant because we know that there’s a higher prevalence of this degeneration of people with pain. But we also know it’s common with people without pain and I see a little bit like, you know, you’ve got changes like, oh wait, changes in your knee so if those changes emerge really early in life, they’re not so normal. If they are there at the age of 50, they’re pretty normal right. If they’re really advanced though the age 40, that’s not very normal, so when we have a look at a scan result, you’ve got to correlate it against the person. That’s number one.
Does it match the person? So, the guy I saw today, I basically said, look, if I normalise how you move, your pain gets worse. So. that’s telling me there’s nothing serious going on with you. because sorry your pain gets better. So, if we get you to relax and stand up and use your back as it’s designed, it feels better. You can’t do that with damaged backs, you can’t do that with fractures, you can’t do that with prolapse. It doesn’t work like that, when you normalise movement it gets worse right. It’s like, tell someone with a broken leg to just walk normally, it doesn’t feel good. I tried that with the shoulder once, it didn’t work very well.
But you know, so part of our process of reasoning with someone, is to do these experiments with them to go: ‘Okay, let’s just check you out, let’s examine you, let’s look at what happens when we get you relax and move normally. And if it feels better, there’s a really high chance there’s nothing seriously going on with you, your body’s just in protective mode.’
And so rather than judging someone and saying, look, mate, you know you there’s nothing wrong with your back, I think, is never helpful. Because everybody’s back pain is real and back pain can be really destructive to someone’s life and very distressing and hugely disabling. So, it’s not to trivialise it, but it’s to just say that it is a really important problem that has got serious for you, but it is not life-threatening. That probably isn’t very reassuring for someone, when it is threatening their life in terms of the impact of pain in their lifestyle, but then it’s to say ‘Look, there are other factors that we can address, you can’t change what your back looks like, but it can change how you think about it, how you use it. Your confidence is moving at your ability to engage with things and usually that’s a journey that makes people feel better. Yeah absolutely, and you probably don’t have to change what their back looks like. Well, you definitely don’t have to change it, and look, I think the longer I’ve worked as a clinician, I’m forever amazed at what people structures are capable of doing and irrespective of what they look like.
Yeah, I am amazed what they can do, I’ve seen backs that, you know, you would look at and just go oh my goodness, and watching people move with those backs who move normally, and without threat, and without a sense of discomfort. And then I’ve seen people with perfect-looking spines who are profoundly disabled, so you know what your back looks like is, you know, in some cases it’s a great predictor for those specific pathologies, fractures, acute prolapses, progressive stuff one to five percent. But, a lot of the time, they’re just opportunities to frighten people.
Yeah, it kind of reminds me of a time, a case, that, when I was in Nepal, I had an international placement in Nepal, we’re working at a university hospital over there. And we saw this guy who had a really large scoliosis so an S-curve in his spine, and it was phenomenal at how large this curve was, like parts of his upper thoracic spine was touching his lower thoracic spine basically. And I was all right, this is a case that I’m going to go see for pain, and so we started sort of examining and asking questions and he said, ‘Oh no, I’m not here for my pain. I’m here because I’m having trouble breathing.’
So that, for me, was a really big experience to say Okay, hang on a second, like if this guy can have this sort of scan, but he’s not, he’s not in here for his pain. Because he can’t breathe, because his lungs are getting compressed. That really stuck to me and we get worried about a leg length difference of a centimeter, like hello, like those things don’t really count, and I think it’s a real trap for physiotherapists, people working with back pain, is we often look for things that don’t matter.
You know, we often examine stuff that really doesn’t, it’s not predictive of anything. We look at asymmetry, asymmetry is normal, no superhuman beings are built the same. All of us have got asymmetry somewhere. And that’s a normal part of being human. That’s red herrings in clinical practice. What is it, ninety percent of people have a leg length discrepancy? And then clinicians are always wanting to homogenise it, I get this ridiculous ad that keeps popping up around trying to make people sick with postures look like this. Well, go do that for a day and you’ll see how you don’t feel too good, but these rules that we put on people are just – so it’s, they’re not kind, they come from some archaic part of our past, I think, around prescribing what people, human beings, should do.
I don’t know, that don’t make much sense to me, they’re not supported when you look at when you’re trying to test them, no strong beliefs in clinical practice. But they’re not supported when we try to see whether they’re true or not.
I want to sort of wrap it up for the list now, I also wanted to briefly touch on the burden of back pain while we’re doing 10 episodes. Just on back pain facts. Yeah, so back pain amazingly is the most disabling of all health conditions in the world, yeah it’s a huge problem, amount of money spent on back pain. It’s enormous days lost for work, medications, you know. Opioid crisis, a good chunk of that is spent on back pain, so it is a huge problem in our society. And I think, the more we’ve thrown money at it, the more we treat it, the more we scale it, the more we advise people to do scary stuff. the worse we’re made it. And we know this, that the burden of of disability-related backgrounds actually got worse over time, we know there are people in our population in back pain who never seek help. They’re not disabled. I’m one of them, I get back pain but but it doesn’t worry me, and I engage it, it reminds me to keep active, keep healthy, go to bed on time, do those kinds of things.
So, I’m lucky that, you know, I have an understanding of that, but for other people, it can have a devastating effect on their lives and the problem is, and we know this from research, that if you look at the things that predict someone had, with an acute episode of back pain not getting better, they’re not things like what your scan looks like, they’re things like your beliefs. If you have beliefs that this is a terrible thing and it’s not going to get better and that this is something I have no control over and then I need to take time off work and I need to go out and protect it and rest it, those are the things that make back pain get worse. And that kind of feeds into this negative emotional stuff around fear and worry and distress, which we know fires the nervous system up to become overprotective and linked to that are all the physical components around guarding and protecting and tensing and painful structure.
That’s the mess that we’ve got at the moment, yeah, there’s a lot of that, and so we’ve got a huge job as a profession, I think, and as a society, to try to change the narrative around back pain to de-threaten it and actually reassure people that back pain can be managed well and effectively if you have the right mindset and if you have the right coach and you have the right approach. And it will get better on its own for a number of people, and if it doesn’t, get the right coach. But don’t go and see someone who’s going to front you and tell you ‘Sit straight, don’t bend, brace your core, come and see me three times a week for the next 12 months.’ go to people who are giving you evidence-based care, go find someone and find someone who’s going to become your coach to get you back to doing the stuff in life you value.
That’s the thing that makes the difference, absolutely, and it’s not an equal pathway for each person and, for some, it’s a hard journey and for others, an easier journey. And just in terms of cost, as well, I mean back pain is more costly than diabetes and cancer combined. Yeah, but you know the sad thing around the cost issue is, if you think of around the cost of care, is that we’re spending an enormous amount of money delivering care that has a very poor evidence base and we’re under funding care that has a large evidence base, and that’s a massive issue with the health industry is that there are vested interests. And, you know, industries that are for driving care pathways that are not really helping the problem.
Yeah. I wanted to finish off with just some, potentially, some advice, you know, so maybe the listeners or the the patients of the listeners are probably more than likely they’re in that 95 category. What sort of advice do we give them, if they’re thinking ‘I think I’ve got something seriously wrong with my back, but he’s now saying that back pain is usually not related.’?
So, I’ve been going, look if you’re really worried about it, first rule of thumb is: have you had significant injury that’s not been picking up a sock? It’s like a trauma, yeah, big fall, you know, sudden loading event, could there be a fracture or maybe that you’ve got a, you know, I can think of people who are osteoporotic where it’s not a major event, but they’ve had an acute, they’ve had acute back pain. But in saying that, those people get better as well, because the bones heal. Bones are wonderful structures, they’re bloody painful but they get better and they get better really well. So number one rule of thumb is that, if you’re worried about something serious, you know, if you’ve got a fever, have you had cancer before? You know, those are the kinds of questions to ask. You know you’ve got pain at night that is not remitting and you’ve got a fever, then you know you’ve got rapid weight loss and you’ve got other, you know, ill health that goes with it? Yeah, go and see your doctor and there’s no harm in getting checked.
Now, that may involve a scan and, if you get a scan, just be aware that as you get older, the more stuff will show up on that scan, so be reassured that you will have stuff on the scan. So, for me, I would expect stuff in the scan. And I had an MRI scan for a different reason and I’ve got disc bulges and, you know, narrowing, and god knows what in my spine, but it’s nowhere near where i might get sore. So, there are a lot of things that are normal, scans are very sensitive, so be reassured again if it’s an acute pain and there’s like, a sprain, then be reassured it will get better within a few, a couple weeks. But do the right thing, keep moving, keep active, use a heat pack, gently move, relax, get mobility back into your spine, keep working, don’t lie, don’t rest, don’t over protect and have a positive mindset.
It will get better. If it doesn’t get better, seek care, but seek care from someone who’s going to provide you an evidence-based approach to managing your pain. And that usually is don’t let someone take over your care, make you the partner in your care, so that you’re given stuff to be in control of your pain and that’s really important in health and I think you have to be demanding of that. The other thing is, you know, there are a number of like, the Pain Health websites, I think it’s a really useful website, give some really cool information around back pain. The Pain Ed website has some wonderful information and patient stories that it really is reassuring, and I think for people who do have persistent disabling back pain, they are the ones who need to seek out care from someone who can take them on a journey, and it takes time, but make sure you’re in the driver’s seat for that journey, that you’re not a passenger out the back waiting for something to happen.
Yeah, yeah, okay, it’s a really good place to leave it. Thanks for your time, Peter. Episode 14 is all about scans so we do have an upcoming episode, all about scans, so make sure you stay tuned for that one. I’d like to thank you again for your time, see you in the next episode, thank you.
Wow, what a cracker that episode was, if I dare to say so myself. If you enjoyed it, consider rating, sharing, or subscribing. My take-home is, although pain is very real and can be debilitating and severe, the chances you have anything serious going on are very low, especially if you’ve had it for some time. Despite its convincing nature, back pain is very unlikely to put you in a wheelchair. Now, I know these may be hard take-homes to swallow for some, so finding a trusted coach to help you along the way, can be vital. Perhaps the silver lining of the Coronavirus pandemic is that, with Telehealth now being so widespread, coaches are far more accessible than they were this time last year.
Show notes for this page are available at www.bodylogic.physio/podcast and, next week, we dive into Fact 2, all about busting the myth that back pain is because you’re getting old. But, until then, remember to ask: is there more to pain than damage?
Please note what you heard on this episode of Empowered Beyond Pain is strictly for information purposes only and does not substitute individualised 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. Music generously provided by Ferven and Cash.