Episode 13: Low back pain fact 3: Rarely associated with serious tissue damage

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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 (http://dx.doi.org/10.1136/bjsports-2019-101611). The origins and motivations for that paper, as well as patient stories, were covered in episodes 4 and 5 of the podcast. In this episode, Professor Peter O’Sullivan and Kevin Wernli welcome Professor Rachelle Buchbinder to discuss low back pain. We cover low back pain fact number 3: Persistent back pain is rarely associated with serious tissue damage. We hope you find this podcast as insightful as we did!

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Episode Show Notes:

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

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

Hartvigsen, Jan., Buchbinder, Rachelle et al.
The Lancet, Volume 391, Issue 10137, 2356 – 2367
https://doi.org/10.1016/S0140-6736(18)30480-X

 

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

Foster, Nadine E., Buchbinder, Rachelle et al.
The Lancet, Volume 391, Issue 10137, 2368 – 2383
https://doi.org/10.1016/S0140-6736(18)30489-6

 

Low back pain: a call for action

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

 

 

GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016 [published correction appears in Lancet. 2017 Oct 28;390(10106):e38]. Lancet. 2017;390(10100):1211-1259. doi:10.1016/S0140-6736(17)32154-2

 

Dieleman JL, Cao J, Chapin A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016. JAMA. 2020;323(9):863-884. doi:10.1001/jama.2020.0734

 

Lemmers GPG, van Lankveld W, Westert GP, van der Wees PJ, Staal JB. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J. 2019;28(5):937-950. doi:10.1007/s00586-019-05918-1

 

OxyContin goes global — “We’re only just getting started”
By HARRIET RYAN, LISA GIRION AND SCOTT GLOVER DEC. 18, 2016
https://www.latimes.com/projects/la-me-oxycontin-part3/

Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872-882. doi:10.1001/jama.2018.0899

 

Goodman CW, Brett AS. Gabapentin and Pregabalin for Pain – Is Increased Prescribing a Cause for Concern?. N Engl J Med. 2017;377(5):411-414. doi:10.1056/NEJMp1704633

 

Curtis HJ, Croker R, Walker AJ, Richards GC, Quinlan J, Goldacre B. Opioid prescribing trends and geographical variation in England, 1998-2018: a retrospective database study. Lancet Psychiatry. 2019;6(2):140-150. doi:10.1016/S2215-0366(18)30471-1

 

Dyer OwenWHO retracts opioid guidelines after accepting that industry had an influence 

 

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173

 

Buchbinder, R. (2008), Self‐management education en masse: effectiveness of the Back Pain: Don’t Take It Lying Down mass media campaign. Medical Journal of Australia, 189: S29-S32. doi:10.5694/j.1326-5377.2008.tb02207.x

 

Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ. 2001;322(7301):1516-1520. doi:10.1136/bmj.322.7301.1516

 

Buchbinder R, Jolley D, Wyatt M. 2001 Volvo Award Winner in Clinical Studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine (Phila Pa 1976). 2001;26(23):2535-2542. doi:10.1097/00007632-200112010-00005

 

Buchbinder R, Jolley D. Population based intervention to change back pain beliefs: three year follow up population survey. BMJ. 2004;328(7435):321. doi:10.1136/bmj.328.7435.321

 

Buchbinder R, Jolley D. Effects of a media campaign on back beliefs is sustained 3 years after its cessation. Spine (Phila Pa 1976). 2005;30(11):1323-1330. doi:10.1097/01.brs.0000164121.77862.4b

 

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

 

 

 

Transcript

*AUTO-GENERATED*

body logic physiotherapy empowering people to achieve better health when you talk about persisting symptoms i try and explain that it’s got much more to do with other factors not the actual pathology that you might see on an image yeah it’s much more to do with psychosocial factors yeah and and that often turns on a light bulb i think yeah when when you talk about what what what predicts what are risk factors and what what might reduce your risk and you talk about things like smoking and obesity and catastrophization and fear and beliefs that that then starts a conversation about oh well maybe if i think about those things less about the pathology that might be way through many people with low back pain get the wrong care causing harm to millions across the world and wasting valuable health care resources that was a direct quote from a research paper published this month august 2020 in the journal pain the article was led by the voice you just heard which belonged to professor rochelle bookbinder [Music] welcome to episode 13 of the empowered beyond pain podcast proudly brought to you by body logic physiotherapy so who is professor rachelle bookbinder well for those who aren’t familiar with who she is and what she does allow me to enlighten you because she truly is a remarkable voice in the musculoskeletal pain space professor rochelle bookbinder is a rheumatologist and clinical epidemiologist who also holds a professorship and nhmrc senior principal research fellowship at monash university in melbourne she’s recognized as one of the world’s top experts on low back pain lead that’s right led the highly publicized and highly regarded low back pain series in the prestigious medical journal the lancet in 2018 and is tenacious in the promotion of good high-value care for people with pain she recently also added officer of the order of australia to her long list of accomplishments so in short she’s kind of a big deal [Music] that quote i recited at the start of this episode about many people getting the wrong care for back pain causing harm to millions and wasting incredible amounts of health care resources was from an update paper to that lancet low back pain series the update highlights that low back pain is still the number one cause of disability in the world it still costs a lot of money for example the us spent an estimated 134.5 billion with a b us dollars on back pain in just the year of 2016 it highlights that many people are still receiving the wrong care which causes harm one of the most disastrous examples of harmful medical care being prescription opioids which was a problem in most high income countries and now thanks to aggressive marketing in low and middle income countries is also becoming a problem there by the way we now have even more evidence that an opioid strategy is not more successful than a non-opioid strategy for persistent low back pain or moderate to severe pain from hip and knee osteoarthritis thanks to the space trial as well as more evidence that opioids are more likely to cause adverse events while opioid prescribing does appear to be falling in some high income countries worryingly it seems they are being substituted with gabapentoids for example gabapentin and pregabalin which the evidence does not support as helpful for those with back pain or sciatica the vested interest when it comes to pharmaceutical drugs is something rachelle discusses in this episode and it’s highlighted by the fact that the world health organization recently revoked two guidelines relating to opioid use conceding they had been influenced by the pharmaceutical industry that fact drop you just heard was summarising the update paper that rochelle led we are so grateful for all that she has done for people with pain and for the time she gave us to share her incredible knowledge we’re also super grateful that you’re here with us listening to the wisdom that she shares as you will hear the incredible power of social sharing and knowledge is what helped the state of victoria change back pain beliefs and behaviour for the better in the late 1990s through a huge mass media campaign sadly the funding for this campaign was cut when the government changed which is a huge shame a lot of the fact dropper highlights the negatives but what should we do instead well that’s what we’re aiming to empower you with by doing this podcast a big part of our mission is to make contemporary pain knowledge go viral and better inform the public people with pain and the people treating those with pain and of course to help empower you beyond pain so please share this conversation generously with your networks tag us at ebp podcast on the socials and be part of the change that you want to see this was an absolutely fascinating and insightful chat and i found myself in frequent awe at the quality of conversation between the two profs like a kid listening in on a conversation between two superheroes i was a happy bystander as beautifully articulated questions and thoughts i found myself having if you enjoy the conversation half as much as i did you’re definitely on to a winner we’ll start by hearing fact three of the back pain facts paper presented by popular patient voice pete moore then we’ll get straight into the conversation with rochelle show notes with resources discussed in today’s episode as well as all the others are available at www.bodylogic.physio forward slash podcast and as you heard last week we’re moving to fortnightly releases which will give you more time to digest the conversations and more time to ask is there more to pain than damage persistent back pain is rarely associated with any serious tissue damage backs are strong if you have had an injury tissue healing occurs within three months so if pain persists past this time it usually means there are other contributing factors a lot of back pain begins with no injury or with simple everyday movement these occasions may have contributions from stress tension fatigue inactivity or unaccustomed activity which can make the back sensitive to movement and loading uh welcome everyone we’re very lucky to have rochelle bookbinder to join us on this podcast um first of all i think rochelle could you please just introduce yourself hi um so many thanks for having me i’m a rheumatologist and a clinical epidemiologist and i work in um in private practice at cabrini hospital uh and also at monash university okay and you hold a professorship and you’re also an hmrc um senior research fellow is that free and your principal reached a research fellow yeah significant positions can you tell us about those positions uh so i have a research fellowship from nhmrc for work relating actually to developing the australian new zealand musculoskeletal clinical trials network and trying to improve the translation of evidence into practice and that will continue next year with an investigative grant um along the same lines as well as trying to reduce over diagnosis and overtreatment fantastic great so one of the things that i was particularly interested in rachelle is as a as a rheumatologist um you’ve developed quite an interest in back pain and that’s not that common and i’m interested in how that came about so i i did a masters of clinical epidemiology in toronto canada and when i came back i had a part-time appointment in the department of epidemiology and preventive medicine where i still work and the work cover authority were planning to set up a mass media campaign for back pain and this was because for the previous 10 years their costs for back pain had doubled over no had tripled over a decade and they tried to change clinician behavior and nothing seemed to work and at the time the back book had come out in the uk and they and australia has a um a really good history of mass media campaigns for things like um seat belts and skin cancers so the slip slap slop program so there they decided they were going to mount this public health campaign and they actually asked some people in our department who worked with workcover whether they wanted to if uh be involved and evaluate it and they actually declined because they didn’t think it would lead anywhere and then someone just said oh would you like to do it and and i sort of went me well i guess i’m not doing anything else and i wasn’t you know i just come back so i said okay i’ll give it a go and and so that’s really how it started and i didn’t expect that it would be successful so i was pretty naive about what they wanted to do but i decided that if they were going to do it then they should do it properly and it should be evaluated properly so so my role was really to develop the evaluation and you know to sort of push that they would evaluate patient beliefs as well as doctor beliefs and we’d look at real outcomes yeah and that’s how it started so this idea of um of targeting beliefs can you tell us about how that evolved yes so because obviously you’ve got a problem where the costs are going up for a problem tripled and you’re then targeting community beliefs how does that work how did that work so basically uh the work cover authority looked at the back book and pulled out the main messages there and they were very clever very simple clear messages that if you had back pain you didn’t need to worry most people didn’t need to stop doing what they were doing most people didn’t need to see a health care practitioners they could stay at work um and and that’s really how the main messages came about and and what the cam what the work cover authority did was actually to put every all the stakeholders all the clinical stakeholders in the room to come up with what the messages were and get everybody to agree on these simple messages and they also included employers and and and tried to get everybody on side um to think about the legislation to think about um how everything could be um towards the right the right goals uh and so that that’s how it really started and and then they employed a really a new um advertising camp um advertising company to come up with the slogans and the people involved in the messages were involved in the ads so that’s how it all evolved but my role was really about evaluating it and originally they just wanted to do some focus groups which they did do but we i wanted to evaluate it quantitatively and as i said at the beginning i was really skeptical about it and and so when we saw the first results we go no this can’t be right although it just seemed too good to be true but then when when we did when i sort of then looked in into public health campaigns i realized that it was always going to be successful like it just was going to work and there are so many benefits of priming the whole population that not everyone needs to see the ads everyone will just move better as a result of the ad campaign if as long as enough people have seen it so that really started me on a journey about the importance of perceptions and and having the right attitudes and beliefs and how that was so important in the society in the background cultural um environment to drive um the changes and then you could add to that more targeted campaigns for high-risk groups as well but the whole thing was this mass media moving the societal attitudes and beliefs over towards better beliefs yeah so for people who are not familiar with your that study can you just describe exactly what it was what the media campaign did on how it worked so the mass media campaign it was it was carried out between 1997 to the end of 1999 it was funded by the victorian workcover authority and it was planned that there’d be subsequent top-up ads every other year but the government changed at the end of 1999 so there’s been no ads since then the campaign was 90 it was television commercials and they were aired during uh um really tv programs that the whole community would watch so grand final football cricket and at that point there was no foxtel or of any of those other streaming services we basically just had the four or five channels and so the campaign were these television ads they were they were very much shown in these high impact shows uh and then there’d be a period of less ads and then there’d be another more intense campaign and it was accompanied by uh billboards every doctor in the state of victoria got a booklet about the management of compensable back pain which we think were just thrown in the bin no one really looked at that and the back book was translated into many languages and that was given out by caseworkers to people who had compensation claims so that was the the primary part of the campaign and the evaluation uh what we did was we did telephone surveys of the general population before the ads started during the campaign and then at after the end of the campaign and we compared we used what’s called a quasi-experimental design where victoria was compared with new south wales and we excluded people who lived on the border who would see victorian television for example and that was accompanied as well by males mailed surveys to gps in victoria and new south wales again excluding postcodes on the border and we also did those surveys before the campaign started during and after and then after the end of the campaign we were lucky enough to get a couple of additional grants and so he could do follow-up even after the end of the campaign and then the third part of the evaluation was to look at what actually had happened to the work cover claims for back pain compared to non-back pain claims and to try and compare what was happening victoria to new south wales and also to south australia so we could look at in victoria we could look at the number of claims to see whether the number had gone down the duration and the costs basically and what did you find and so we found uh dramatic improvements in the general population beliefs in victoria compared to new south wales where there was no shift in beliefs so what kind of beliefs did you find shifted so that the main beliefs that shifted were the main aims of the campaign so the population in victoria were much more likely to think that you didn’t need you could continue usual activity you didn’t need to rest for back pain you didn’t need imaging you could stay at work you could self-manage um and and so and the primary um measure that we used was something called the back beliefs questionnaire and so the back beliefs questionnaire improved on average by about two points compared to no change in new south wales and then by the end of the campaign it actually increased by about three points which at a public health a public population level that’s a huge improvement over the whole population we also showed that the belief shifted irrespective of your age your gender your work your socioeconomic status whether you actually had back pain or not and whether you’d actually seen the ads or not so it actually moved the whole population over uh starting with the average and the better beliefs and by the end of the campaign the people that with the worst beliefs also moved so it was a really dramatic example of how mass media campaigns can shift population beliefs uh in terms of gp beliefs we also showed similar things so gps in new south wales there when there was really not much shift in their beliefs over the three years but in victoria the victorian gps were much more likely to say you you didn’t need to rest in bed you could stay at work you didn’t need imaging compared to their gps in new south wales and similarly irrespective of of many variables everybody improved in terms of general practitioners but the only group of gps in victoria who didn’t shift as a result of the campaign were doctors who self-reported that they had a special interest in back pain so we asked them whether they had special interest in occupational health back pain musculoskeletal and once you allowed for everything else if they had a special interest in back pain they’re actually much more likely to think that imaging was necessary that you did need to stay away from work and they were also more likely to think that you didn’t need guidelines and um and that education would not be helpful to them so they are a really intransigent group and don’t understand who they are but the bottom line it really is if you’ve got back pain to all the patients listening don’t see it there’s a special interest in back pain because that’s confusing that’s very confusing for the public though isn’t it it’s very confusing but it but i guess you you could you could think about why that might be uh and you know we don’t know for sure but but we think it’s probably because they some of these clinicians might have vested interests that that push non-evidence-based care yeah yeah that’s very interesting and i think you had other outcomes that um were linked to people actually changing their behaviors as well is that right so it wasn’t just beliefs that changed so we also were able to we we didn’t think that the the campaign would reduce the number of claims we were hoping that it would reduce the duration that they spent off work but we actually found that the number of people who put in claims over that period declined significantly as well and as well as the duration uh as well as a a quite a large reduction in the total costs and the medical costs yeah right so that was really the the way we could measure behavior unfortunately we had a very fixed budget we would obviously like to do lots of other things yeah and i was particularly interested in children because my kids were young at the time and and they were walking around with that slogan and when i lie down for a headache they go on mom you know should you take back pain lying down i just wonder whether that would be really easy for you to study now yeah yeah right do you think those um uh those changes have sustained in victoria so we we were able to do follow-up studies at about uh i think it was about two years after the campaign and then about four and a half to five years after the campaign and we demonstrated that both um gp beliefs and population beliefs there had there was a sustained um improvement with some decay um and again in new south wales there was absolutely no change yeah and so we think that if the if the government hadn’t changed and we were going to spend some money every second year topping up those ads that probably would have we would have been able to maintain that yeah right so it kind of fascinates me that you’ve got a problem like back pain which is a like leading cause of disability in the world it costs governments extraordinary amount of money why they wouldn’t invest in something like that what are your thoughts on that i i really don’t know i mean the victorian work cover authority when the government changed all the people with the corporate memory left uh work cover and they went actually went to the wheat board um the reason the first follow-up survey we did was funded by the work cover authority because they came and asked me about doing another media campaign and they really didn’t seem to have any uh remember the understanding that they actually funded the first one and then the person that was in charge of public affairs left again and so then they weren’t interested in doing it again and then subsequently another couple of times they’ve contacted me again but there’s there’s just no corporate memory about the value of it and having said that in australia there are campaigns that have that replicated what we did in australia and for example in alberta canada yeah they continue to have the um campaign which is much more locates mainly radio commercials yeah but they obviously see the value in it yeah right so interesting now if we kind of zero back into your role as a clinician um because you would see people who come in to see you with back pain i presume yeah um and i’m interested in the common beliefs that you would see typically in those people you see yes so i guess being a rheumatologist i get people who were referred for back pain so often they’ve already seen a number of other people in primary care and sometimes i might see them more acutely so they often come with with a whole range of mis misconceptions about back pain um and and i’m sure that pedal i know you’ve seen them too that they have beliefs that they can’t move that yeah you know that and then they’re looking for someone to fix things yeah they want some magic medicine you sure there’s nothing else i can try and yeah and and so it’s really it’s really hard to to shift those beliefs and and so i have to spend time explaining what i know about back pain and and sometimes i’m not sure that they believe me but but often they’ve come because i’m the end of the road uh yeah but it’s it’s so hard to talk to them then compared to if i had them when they first got back pain and what i do with my friends you know my friend in the next street said i can’t get out of bed and i just go around they go well you have to and i just dragged him with him and the next day he was much better so i mean that’s what i really want to do it’s so interesting because i mean what you’re tapping here into is that you’re seeing people at the end stage of often of their journey when they’ve seen lots of healthcare practitioners and what does that tell us about the health care workforce and the way they care for back pain well it’s just amazing to me that that people that the clinicians have have almost identi i mean it shouldn’t surprise me but they have the same misconceptions about back pain as as the patients and and that’s part of the problem is that clinicians think that they need imaging to find the cause of back pain so that the treatment can be directed to that cause and they don’t still understand that most in most cases that’s not possible yeah and so you know a lot of work over the last 30 years trying to reduce imaging from back pain and we’re now in in a mess where the number of ct scans cost over 100 million dollars a year in australia so we’re actually even though x-rays have gone down this more complex imaging has gone up yeah and that finds more sensitive things and then the report um makes people very worried because it mentions all these labels that then they think they’re going to be in a wheelchair yeah and so we’re just fighting a losing battle and in lots of vested interests again unfortunately yeah trying to justify their their specific treatment yeah yeah so that idea of um i’m in pain there’s got to be something on a scan that can make sense of the pain and then we’ve got sensitive imaging that shows lots of stuff that then gets dumped as a label on somebody how do we hope to break that process because it’s endemic as you say and it’s creating a lot of distress and leading to disability and over treatment yeah i think it’s a really difficult problem and i’ve spent a long time trying to change clinician behavior and deciding that it’s a waste of time and we have to change public behaviour all right um but i’m even wondering now whether we whether we let people have imaging and we change the report and yeah so we’re working on trying to to simplify the report knowing that more and more people see the report and in some countries they get they get their report you know text it to them immediately often before the clinician yeah but but that will take a lifetime of or maybe a generational change among uh radiologists who think they have to report all the findings in a certain way yeah and the guidelines all say that and and so as until we can try and change that report to say this norm back is normal for age or there is nothing here that is likely to be the specific cause of this person’s pain yeah i think we’re going to be in trouble and we have to stop uh reports saying suggest injection here or suggest further tests because i think that that the right clip the gps and probably the physios think that they have to follow that advice because these are specialist radiologists yeah and and i hadn’t realized their influence on things so how do you deal with a patient who comes to you and they’ve got a like a typical ct scan and it shows this degeneration facet joint arthrosis disc bulges annular tears all this scary language on a scan how do you go about trying to help people understand that that’s not something they should be worried about when they’ve googled on the internet and seen lots of scary stuff and talked to their friends and been told by other healthcare practitioners it almost seems like you’re sitting on the other side you know on another planet talking a different language so i i think i mean without dismissing their worries i try to explain that these are typical findings in people who don’t have symptoms in their age group and i quote studies that have shown you know that by the time you’re 50 you know 50 of us will have these changes and and they’ll often be present in 25 year olds and it and it doesn’t necessarily mean that that’s the cause of their symptoms so that’s how i start yeah and then yeah i you know go from there and again it depends on how much insight or how much they’re prepared to open open up in terms of their mis you know how much they’re willing to listen to me yeah exactly and you know sometimes if i get them early i just try and just oh well that’s just normal we don’t even need to go but but then that might be a bit dismissive so try not to try not to be dismissive but but at the same time let them know that this is normal and and unlikely to be related to your symptoms or we can’t tell you it might be but but i can’t tell you for sure and and and the treatment is it should be more general anyway in the first instance yeah and you know i think within medicine i mean i’m not a medical i’m not medically trained i live with someone who is but um this whole idea of a diagnosis is kind of central to a lot of medical thinking what kind of diagnostic label do you put on back pain where it isn’t sitting within a clear pathological process there is no clear pathological process what do you think what are the labels that you think are helpful for for clinicians to use and to patients themselves i’m interested in your thoughts so there have been a few studies trying to work out what the which terms might be the most acceptable uh and and really it’s got to be something that’s that that explains it without being scary yeah and the value of having a label is that patients feel more satisfied exactly you know i i try and explain that back pain often people that have back pain will have episodes ongoing so you’ve just got another episode of back pain non not not worrisome back pain um i try not to use specific you know i say i might say non-specific but i have to always qualify that by what that means i’m not even sure that not non-specific is helpful it’s just another episode of back pain it’s probably unrelated to what you did you know and then i try and explain how it’s really hard to physically hurt your back um but i don’t know that there’s any easy answer i think i’ve also thought and there’s a lot of a lot of the way that medicines is evolved is surgery and a lot of the rationale for surgeries on fixing a problem exactly you know we’ve seen with arthroscopy of the knee and and decompression of the shoulder that that what makes sense um to sell something is actually may not even be true so and and so back pain like shoulder pain and knee pain they’re just symptoms then they’re not they’re not cancer they’re not being sort of medical diagnoses and maybe we should just say that you’ve you’ve just got some a symptom which is back pain and and not even have a diagnosis yeah and do you think that’s a bit like people accepting they have a headache but they haven’t got brain tumor it’s you know some headaches don’t have a diagnosis label like back pain doesn’t do you think it’s similar to that yeah i mean i often i often because i i do get migraines and and when i was a medical student i thought i did have a brain tumor yeah i did have a scan and and a neurologist that i still see says and how’s your brain tumor going so i can understand that worry and people get really worried and especially the pain’s not getting better they’re worried so i think that’s a good analogy and and even for people with widespread pain i i actually use the analogy that when i’m stressed i get a migraine and when you’re stressed you might get back pain or generalized pain and i think that’s not a bad analogy but again you don’t want to dismiss it because i think people do get severe episodes yeah but if they try if you can explain the trajectory that it will come and go i think that’s more reassuring yeah yeah it’s a tough space isn’t it because you’ve got an expectation that’s placed on a healthcare practitioner to give a label and often you know there are different labels so within the medical world it’s more around structure and imaging and the physio world it’s more around uh you know something with the body that’s kind of identified it’s maybe something wrong uh and there’s very little evidence that those things are predictive of much so we’re kind of left with a little bit of a vacuum that is not satisfying for the clinician or the the patient well i think i mean the only way you can explain it is is when you talk about persisting symptoms i try and explain that it’s got much more to do with other factors not the actual pathology that you might see on an image yeah much more to do with psychosocial factors yeah and and that often turns on a light blue light bulb i think yeah when when you talk about what what what predicts um what are risk factors and what what might reduce your risk and you talk about things like smoking and obesity and catastrophization and fear and beliefs that that then starts a conversation about oh well maybe if i think about those things yeah and less about the pathology that might be way through yeah and i think what you’re touching on there is something you can change that potentially is modifiable that means you’re not under a knife as well and it’s going to have an impact on your pain it can help you and a lot of time i mean we think a lot of pain is genetic and it’s learned and you know it’s what your brain’s remembering so once we start putting that all into the mix then it will start to if you if they have the capacity to think about it more deeply yeah they can then we can then help them much more i think exactly and how i mean if you think about a public health campaign that sounds like something that would be really important to educate the public about around what the media paint is do you think well i think i mean i think the beauty of the campaign and the reason we like we didn’t expect the number of claims to be reduced is that the campaign reached people before they had a problem yeah and because they they’d seen the ads perhaps i mean this is all speculation they go uh oh well i’ve got back pain but i know from that ad campaign that it’ll probably get better and i don’t need to do anything about it yes that’s why we think it reduce the number of claims so yeah so that’s priming the people before they have a problem and it’s the same with everything you know it’s the same with slip stop slap you know yeah having people to know what to do before they get a problem yeah yeah and then the key thing is if they have a problem that persists then instead of frightening them with further imaging making sure they don’t have something serious of course is important but then instead of frightening with further imaging is give them a broader understanding of the risk factors and then strategies to manage them so that they can self-care yes and i mean we didn’t talk about it before but i mean the primary thing that pushes clinicians to do tests is is the worry that there is something serious and that’s that’s the legitimate concern yeah but you know nothing needs to be decided today there are not many things that we need to find the answer to we can afford to wait for many many people with that pain yeah and so even just thinking about delaying you know further tests just to see i think is reasonable as well and and that would be something else that we should encourage like the antibiotics yeah you don’t need antibiotics but if you not getting better we need to reassess it yeah that sort of idea yeah to go across to yeah got it now i i’m i’m kind of interested in you know as a rheumatologist you would look at a lot of scans and obviously screen people’s bloods and things what are the things that you you know that are important so if you we have listeners here who might be going for a scan one of the things that you see in the scans there’s lots of stuff reported and there are lots of things that you know and are you know common in people without pain what are the things that you would say that is important okay so that there are very few things that are really important so i would say cancer is important yeah when you find primary or sick or metastatic disease that’s obviously really important and that’s something that you know you get a good good sense of the likelihood of that from taking a good history so they if they’ve got a history of cancer infection is something that you don’t want to miss and and so people that have got really severe pain and they’ve got a fever or their drug users i think that’s something that you don’t want to miss um vertical fractures um again that’s something that that you need to know about but that they’re common in older people um and and and conversation for another day is a you know what is a real verbal fracture yeah you’ve done lots of work in that space haven’t you yeah and you know i think they have to have symptoms yeah um and then there’s the sorts of diseases that i do treat which is the axial spondylitis group we which really are patients that have marked stiffness in the morning that improves with activity rather than gets worse with activity um young people um males or females and that’s a diagnosis um that’s often delayed because it’s missed uh and and we have effective treatments for now so that’s something important to think about and then i guess the the only other big group is the people that have true pressure on nerves and pain going down the legs but again most people can be treated the same as if you didn’t have um what we call radiculopathy symptoms things are not getting better then you want to see that there’s a confirmation of pressure on the nerve yeah and then there’ll be a lot of other things yeah so if you look at the you know take 100 people with back pain how many fit into those specific groups in primary care yeah less than one yeah so that means 99 of people coming in and getting a scan and getting told there’s something arthritis degeneration all those things are being mislabeled miss well again is it a mis label or is it a over label yeah i got it yeah okay i mean that’s something that we struggle with because the the changes might be there on an image but that doesn’t make the diagnosis and i think we have to separate those things yeah yeah and that’s the that’s the meaning of language right and and and the role of a healthcare practitioner help the patient make sense of what that means for them yes that’s a conversation a conversation that that says that these changes are common and often present in people without symptoms they don’t mean that you’re that your pain will not go away they don’t mean uh that your outcome your outlook is terrible um and they don’t mean that you need any specific treatment and that sounds like if that was on a radiology report that sounds like a really easy intervention it does and there have been a couple of studies now with conflicting results about the value of putting what we call epidemiologic data about how common it is in asymptomatic people in your your age and your sex but i think that would be relatively easy and even even if the reports we’ve done some work looking at reports even if the report had a conclusion that said despite all these changes that i’ve described above um none are specifically likely to have caused your the patient’s pain or something like that that’s very reassuring i think would be important yeah but your your confidence of something like that becoming normal is not great from what you’re saying well i mean i don’t know we’re working with some radiologists both at our hospital and in seattle washington um on trying to improve um the way imaging is reported and i you know i think that changes will happen but we’ve done a review of the guidelines for imaging reporting and and there’s a lot in there about what machine you use the technical stuff and much less about the comprehensibility to the um person that ought that requested the image and nothing at all about the importance of the language for for patients who might be reading the report and some radiologists still think that the report is written for the referring uh doctor and and the referring doctor some referring doctors still think that but the majority of patients think that the report is should be written in a language suitable for them yeah it’s so interesting yeah i i had a um a scan of my brain a couple a year ago um for uh another health complaint um and it came back that my um my my scan of my brain was normal well the changes were normal for my age so there is a precedence in uh radiology to report those things and i’m interested why they would say that for my brain which was which is reassuring although i was hoping it would be younger for my age but but it seems like it’s not like it’s not without presidents and radio radiology no and and we’ve i mean we’ve been looking at reports and and some radiologists do say this is normal or yeah this is likely to be of no clinical significance it’s just it’s not very consistent yeah and and i think there are differences depending on your vested interest in the report yeah so we know there’s a study done in the usa that found that the the biggest risk factor for getting an x-ray in the us is if the referrer owns the machine yeah yeah so those vested interests are really powerful yeah i just want to touch on one other thing i’m really interested in your thoughts on you were part of the lancet series on back pain i think it’s a couple years ago now and it hit the news it was like it was big in australia and a lot of the messaging was that we’re over treating people with often risky um not particularly affected treatments and under treating them with um safe we’re not doing using safer and probably more effective treatments and um there was quite a lot of backfire um on some of that messaging in the public i think and i’m interested um like well we we heard a lot of people going you know what do you mean you know like that that’s quite a conflict to say that actually we’re spending heaps of money on stuff that maybe not very helpful as a as a and there’s a public demand for that kind of care how do we try and shift that i mean that’s that’s kind of like bigger than the imaging story sure that’s interesting that you say that so yes we did um do the series and there were 15 million people that saw a twitter handle of low back pain which was the handle we used for the series we are not aware of negative um reports we’ve actually done a review of the medium and found that 90 plus were accurately reporting our messages and we are really clear on media releases what the main messages were yeah right the only the only misrepresentation of the um lancet series were people with vested interests who particularly actually chiropractic organizations and physiotherapy that use the lancet series to say that uh that people should go to the chiropractor or the physio that we can yeah there was a lot of there was some of that miss representation of the series um we we actually people were silent the people with vested interests that we really watched in the series were silent from our perspective that’s interesting um and we we did we did highlight that there that a lot of the care is the atrogenic it’s harmful yeah and that we’re not really funding or or doing the right care and there’s a lot of right care that we could do and could be funded so we pushed for changing the system changing the the pathways that patients have the education of clinicians and and the public changing policy so that we can reward the right care and we stop funding the wrong care do you think any of that’s changing i think that there are lots of conversations around the world now about some of the messages um we’ve been really pushing um in different countries to to change things uh and there are things in australia like the mbs review that that tried to reduce spinal surgery and and then the uh the ama um got some negative feedback and the government um reversed their decisions so so i think that again the problem is these major stakeholders that are powerful trying to uh trying to stop uh their progress in terms of addressing the burden of back pain i mean it’s not just back pain it’s other well and so we have a that that’s why i you know some part of me thinks so i may as well just give up it’s just disheartening don’t you dare there are companies they were pushing opioids and lyrica and now in developing countries yeah you know we it they have millions of dollars pushing bad care and we know i mean one of the things that came out of the series the way we sold it to the so it was we wanted to try and prevent the same things happening in developing countries and the disappointing thing is it’s already happening yeah okay so we don’t want to end in a really depressing note so i do share your sentiment though it does feel like you’re pushing a big a big boulder up a hill and and there’s not many people pushing it um uh what do you where do you see the opportunities to kind of positively impact this area for the future because public campaign seems like it’s still something that you really have seen great evidence for to kind of get the public to drive demands something different i think we have i think we need to harness the consumer voice and they’re getting much more powerful around the world and they’re you know they’re part of nhmic research grants i think we have to stop wasting research dollars on on rubbish and try and really push evidence informed practice much more so i think that there are some positive things that we can push i think it’s important that we get into positions where we can influence policy makers we’re still trying to influence the who i think we can harness um media to uh work for good and not evil and try and again get the positive stories out so for example in croakie we have a regular series called uh wise um um too much medicine um so i’m just struggling to remember the name and we’ve we’ve you know we’ve we’ve got a national collaboration for wiser healthcare and we have a national statement so the more people that can join this i i really think we need a movement because we know i mean even with covert we can see that it’s been a lot less medical care and it remains to be seen how much harm there’s been but i’m sure that some of it’s been positive in in unnecessary imaging for example has gone by the wayside yeah so i think it’s just a matter of getting all the right all the people in the room and just having the will and the enthusiasm and the drive and the money yeah to change yeah awesome and do it together as a social group right we can all work together with this um was there anything else you wanted to add yeah i think we’ve done a fantastic job of um of discussing the the landscape around low back pain and we’ve particularly um nicely covered our third fact from the paper which was that persistent back pain is rarely associated with serious tissue damage and you’ve given some fantastic examples of that um before we go richelle is there anything else that you’d like to add um in the in the podcast for the listeners uh no thank you um hopefully hopefully i’ve i’ve made clarified some issues that people may have had rather than yeah absolutely and i i think one of the things i’d like to just highlight is to thank you for extra i mean you probably do the work of four or five people i would imagine um but um thank you for the extraordinary work that you have done for i think the health professions and also for the public and that you’ve kind of got off slightly you know in an area that wouldn’t be traditional for a rheumatologist but you bring this kind of ability to bring your knowledge and energy and and and drive it in all these directions so i a big thank you to you for the work you do from everyone thanks thank you awesome peter thank you wow the end of another episode i’ve got to say i reckon this one could be a game changer i hope it resonated with you too my take homes social sharing and mass media campaigns can be pivotal at moving the needle in a positive direction vested and conflicts of interest are rife in the back pain industry presenting a big barrier for high value care back pain due to serious tissue damage is incredibly rare less than one percent in primary care but this doesn’t mean people can’t have serious pain for the overwhelming majority you don’t need imaging it is safe to stay at work and safe to keep moving even if you have serious pain which we know can be influenced by lots of different physical emotional and lifestyle factors so let’s not take low back pain lying down we need to keep this momentum going so please share this across your networks check out the show notes at www.bodylogic.physio forward slash podcast tag us at ebpodcast on the socials 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 individualized care from a trusted and licensed health professional if you would like individualised high value care for your pain sports or pelvic health problem head to the body logic website and make an appointment theme music generously provided by ferven and cash