#1 Cause Of Chronic Pain & A Decreased Lifespan! - Heal Pain Without Medication | Peter O'Sullivan

You have been studying and researching chronic pain for decades now, okay? You're a professor. You are well-respected all over the world for your expertise in musculoskeletal pain. So, at the start of this conversation, I'm really interested if there was one thing that you could impart to the public about pain, what would it be?

Hope. Hope for change. Hope that pain is something that has the ability to be controlled. Hope that if pain limits your ability to function, your ability to do the things in life that you value that you can't do, that there's hope to get it back. I think generally there's a lack of hope, um, around pain and chronic pain, pain that persists, pain that, uh, is distressing and, and disabling. There's this sense that you just have to suck it up and live with it.

How many people these days are suffering with chronic pain? Oh, it's the leading cause of disability of any health condition in the world. Chronic back pain is number one. It's, it's has a devastating effect on people, um, it affects their ability to work, their ability to engage in physical activity, normal activities of daily living, um, it has a pervasive effect. So, we know from population studies up to about 20%, one in five people, uh, suffer from this, and that's for persistent back pain. It emerges early. So, we often think of it as an adult problem, but actually, it begins often in adolescence and then kind of tracks through life.

Yeah, I read a statistic this morning which said that 70% of people in developed countries will get lower back pain at some point in their lives. Yeah, like the flu. It's something you will get. Probably even higher in some cases, but it's, it's incredibly common. The, the thing is, most back pain, well, the majority of cases will get better. And I think that's important to note. But there's a group of people where it becomes persistent or recurrent, uh, and that's the group that really carries the burden.

Yeah, you said it's the leading cause of disability worldwide. This is chronic lower back pain. Yeah. Okay. I think many people will be surprised to hear that. Now, firstly, if you've never suffered from back pain before, right? Let's say you're in that 30% that, that apparently never gets it. Okay, you may not realize the impact of actually having chronic back pain. You might think, "What's the big deal? You know, what, number one cause of disability? You kidding me? Like, what, a bit of back pain?" So, perhaps elaborate in terms of why it is so debilitating for many people.

It's interesting. We have, part of our group has, has asked patients with back pain, like, "Why is this so debilitating for you?" And they go, "It's not like an ankle. You've got another one, you know? You can, you can offload that ankle if, or you can modify. But with the back, it's the center. It's kind of like the center for so many things. It impacts your ability to sit, stand, bend, lift, engage in normal activities." So, it's not like a limb where you can choose another limb. You only have one back. And so, it's this fundamental part of the body that is linked to almost every normal activity of human function. Uh, and so when it becomes painful and debilitating, it just disrupts everything.

Yeah, for me, I, I, I had about 10 years or so in my 20s into my 30s of chronic lower back pain, which had a significant impact on the quality of my life. Yes, it was pain, but it wasn't actually the pain. It was more what it did to my confidence in myself. Y. Like, I had to second-guess everything. Can I do this? Drive? Y. Can I help my friend pick up his sofa that he wants me to help him with? Can I take the shopping up the stairs to the car? Right? Y. Even, I remember this very well. When my son was born, this is back in 2010. I remember days after he was born, we were about, the doorbell went, and I, I twisted and something my back went. I couldn't go and answer the door. I had to call it to my wife, who I think was feeding my baby boy at the time. She needed help and support. And not only did she have to come down and open the door, but I think for four weeks, I wasn't able to help her and lift my baby boy. So, what it does to your self-esteem and how you feel about yourself, I think, is, it's profound.

This must be a story you've heard over and over again, right? Yep, 100%. So, we know from a lot of qualitative research that back pain has such a disruptive impact on just the things you talk about, just normal stuff, like just getting out of a chair, picking up your child, um, the ability to sit, to travel, to do normal stuff. And it kind of starts dominating you. You start becoming hypervigilant. You know, you start, pre, you know, thinking about what your next option is. Um, the other thing that pain does to the body, and it's, it's, you know, it's a whole person experience because when you have pain, your body goes into protective mode. Uh, and when we go into protective mode around the back, we tense up. So, we, we start protecting, guarding those muscles. Muscles subconsciously start contracting and tensing up, which creates secondary processes of pain. And so, you just see this cycle where you become hypervigilant. It's frightening. Uh, we know fear ramps up the nervous system. We overguard and protect. Uh, we start avoiding normal activities and movements. And, and then you start losing your life. And that's deeply, you know, disruptive. Affects your mood.

You mentioned a couple of terms there which I think people may not be familiar with. You said "population research" and you've also just mentioned "qualitative research." Would you want to explain what those, those terms mean?

Yeah, so population research is literally looking at a large group of people, um, and so we've been involved in a study called the RAINE study, which was based in Western Australia, and it looked at people pre-birth, like, so, uh, mothers who were pregnant, and it's tracked the population of babies then into adulthood. We were really lucky in that sense to kind of look at the development of pain in that population, to look at the factors that might be relative to that group of people. It's like about 2,000 young people, babies into adults. So, that's at a population level to go, if we look at a population, what are the factors that are predictive of pain in that group? Qualitative research asks you as an individual, "Tell me about your experience of back pain." And you've given us that already. You know, you've talked about the, the details of your experience, how it's impacted on your life, your ability to lift your child, that sense of "I can't do something I value," that loss of confidence in the body. That's about qualitative research. It's the individual story. Yeah. Both are really important. Yeah.

If we think about back pain, and we think about, I guess, the wider term, chronic pain, yeah. Are there similarities between the two?

Yeah, and they massively coexist. So, we look at, um, chronic back pain, which is pain that lasts more than three months. It's strongly related to neck pain, to headaches, to migraine, to gut pain, to pelvic pain, to widespread body pain. So, there's a "whole body pain" story, and often the back is one of the key elements, and is often one of the most disabling aspects of pain, just because of all the things we described. Yeah. So, it's a, it's a pain story which is linked to sensitization within the system, within the nervous system, which affects all parts of the body. But the back seems to be particularly vulnerable.

You have previously shared in interviews your own story that you were a sufferer, um, and I'd love you to tell us a little bit about your own journey as a patient, yeah, rather than a clinician and an expert. I'm sure, well, I would imagine that your own personal experience has hugely informed your professional expertise. But there was one bit in your story which really struck out to me, which was, I think was it a friend of yours who saw you moving and was like, "What are you doing, Peter? Like, you look rigid. You're not moving normally. You're kind of moving like a..." Can you elaborate?

Yeah, so that was pretty early in my career. So, I'd, um, trained as a young physio in New Zealand, and part of that training was like, you know, focusing on body posture and mechanics and all that kind of stuff. I'd had an injury skiing, actually, where I landed very heavily on my back off a track. I'd misjudged it and landed smack on my back, um, and developed pain. And like, you know, severe back pain. Um, luckily, I hadn't fractured any. And then I tried to get back doing my life again, and it just became, this pain started dominating everything. Um, you know, just going to work became really, like, at the end of the day, I was exhausted. The pain was spreading. It was spreading up my back into my neck and around into my, into my core. And I was starting to worry, you know, I'm like, "I don't know if I can do this job anymore." You know, where I'm using my body and, and I'm, you know, part of my, part of my job. Um, and that, that was scary, actually. And then thinking, "What, what can I do about this?" And there was, probably about three months in, a friend of mine said, "Exactly what you highlighted, Peter, why are you holding yourself so tense or rigid?" And I kind of looked in the mirror and I realized that I'd been overprotecting myself, of trying to hold my posture, all these latent beliefs that we have about backs, of like, you know, "good alignment" and "strong core" and all of these things. Subconsciously, I'd been adopting and holding myself so tense, and it was exhausting. And I had this kind of moment of realization that, actually, this was not helping me. It was hurting me. And started to then relax and realize I was breath-holding and guarding my back. As I started to relax and breathe and start feeling the confidence to get movement back into my back, that was my key to the change. And we've seen this in our research as well. It's like, we know that we have this embodied experience with pain. That when we have pain, we guard and protect our backs. We move slower, we move stiffer, we're more clenched. And that in itself is a mechanism of overprotection, which is not healthy for the back.

And I did it. I experienced that. If that's what the body wants to do, though, can we argue that that's okay in the short term? If you have an injury?

It depends. Okay? So, if you have a spinal fracture, absolutely. It's very normal. Like, that's the body saying, "Protect your back. Don't move that." If you have a big disc prolapse, for example, which is, you know, a, say, a bulge from the disc that's pressing a nerve, your body will go into protective mode. It's completely normal. You want that. So, that's the body saying, "Don't move. Give it a chance to settle down. Let it, let the tissue heal." But a lot of back pain, acute back pain, I think this is where there's a misunderstanding. You can have back pain from an injury like I did, and in the short term, it's normal to guard your back. But lots of back pain is not linked to an injury. Most of back pain is not linked to an injury. Not just a lot, it's, it's most of it. It is. And so, if you, if you look at a population level, back pain often emerges at a time when we're under stress, where we're tired, run down, we're tense, we maybe haven't been as active, um, when we're, you know, got other stresses in our lives, and then it emerges. That's the back pain you don't want to protect, because there's no injury in that case. Do you understand that?

Yeah, but, but it's, but we don't think that these are, these are normal subconscious processes that emerge in our body that even in the absence of injury, with pain, we will protect. I think you, does that make sense?

Yeah, total sense. And I mean, I very much resonate with your story because when I was in the midst of my struggles with my back, and it's so lovely to be able to talk about in the past tense because it literally is in the past. Y. And I've shared on previous podcasts, you know, some of that journey. I'm sure some of it will come up in our conversation. But I remember those days where you'd learn how to lift properly, and you know, you'd, you'd try and sit with, with, with your core on. And if you watch me trying to tie shoelaces or pick one of the kids' toys up, y, it's absolutely ridiculous. On one level, if someone had a video camera on you, you don't look like a natural, connected human. You look like a robot. Yeah. Right? Y. And I understand why people are taught to do certain things, right? They're taught to lift in a certain way. But if you really think about it, people who lift with no pain, they're not thinking about their core, they're not keeping their back straight. 100%. They're just lifting, and their body knows what to do. So, it's kind of nuts, isn't it? That we, we, we have an injury, I shouldn't even use the word injury, we have an episode of back pain, even a pain event, and then we get taught to do a series of movements and actions. And I understand why we're taught that, 'cause people are trying to help, y. But actually, for many of us, it starts to become problematic, massively.

And it's misguided as well. Like, if you look at the evolution of, you know, ergonomics, for example, where we've taught people to lift with a straight back and bend their knees. That there is no evidence that that is protective of the back or that it will prevent an injury or pain event. It's just something that emerged many years ago from some very basic anatomical studies and some studies that looked at pressures and discs, and then we extrapolated this into the workplace.

Okay, so if someone's listening right now, Peter, and they're like, "Okay, you're saying there's no evidence for this as a recommendation, y. But I had back ache, and when I keep my back straight when I'm going up and down and lifting, I don't get flare-ups." What would you say to them?

Great, go for it. But, but the, I suppose the point there is, like, if we look at the evidence to say that if you don't do that, it's dangerous, there is none. Yeah. That's the point. And I'm not saying you shouldn't lift with a straight back and bend your knees, but what you described is what we see in our, in our research, is that people with back pain start lifting like that. People without back pain don't. And so, one of our researchers, it's nuts. It is nuts. It's subtly nuts, 'cause it is the most unnatural thing in the world. When you watch people, you can tell someone's got a history of back ache. And, and I'm so passionate about this topic, Peter, because I've, um, I have suffered and had, you know, the quality, while I've decimated for at least 10 years because of chronic back ache. I've come out the other side by adopting a very holistic approach, by dealing with emotions, psychological issues, yes, mechanics as well. Y. Because it ain't just one thing in my experience. You've got to tackle it from all angles, like many chronic diseases, frankly. But also, I share the belief that I think you have, which is, we as a profession, not just doctors, but also other healthcare professionals, without realizing it, I think we make the problem worse.

100%. 100%. Like, I, if I look at my caseload of people who I get to see, the majority of what I see, I believe, would be healthcare-induced disability. Okay. And, and who are these patients you're seeing? These are people with persistent, disabling back pain, right? So, you're seeing the, you're still a, a clinician, you're seeing these people? Yep. Three times a week, I work in the clinic. Okay. And the majority of people I see have beliefs that are not evidence-based, that have been given to them. They've got scans, often they've been told that their backs are worn out, they've got degeneration or disc issues, that they need to protect their back and lift in a certain way and protect their backs, be careful if it hurts. And it creates a massive problem and distress. You know, the distress that goes with that, massive.

Yeah, fundamentally, you, you were going through there, what we are unwittingly doing with our patients, a lot of the time. All of those things you said are, I was going to say subliminally, but not even subliminally, like quite literally giving the patient the message, "There is something wrong with you. You're damaged. You are damaged. You must be careful." Yeah. 100%. And it, it takes years to get rid of that. And for some people, it, we know, we've done studies looking at these people, it can last a lifetime. You know, we've looked at people who had 30 years of back pain who have been told at a young age that they had a, you know, disc of a 60-year-old when they were younger, and it's, it's set a trajectory. So, we know that the things we say and the advice we give can have very long-term impacts on people. And we have to be so careful as clinicians that we don't frighten people unnecessarily. We don't give advice that teaches people to overprotect their bodies, 'cause the health of the back is about movement and activity and engaging in a healthy lifestyle. That is about the health of the back. And we actually teach people to do the opposite.

Over the years, I've learned that movement is healing, right? It is. It's not, it's not your enemy. It's your friend. Although we're sort of honing in on the back at the moment, a lot of these principles also apply, I think, for other chronic pain systems. Any persistent pain. The, it's the same story. Be it knee, shoulder, neck, you know, hip. It's the same story. Yeah.

A few years ago, you and some of your colleagues published, um, this beautiful editorial in the British Medical Journal, "Back to Basics: 10 Facts Every Person Should Know About Back Pain." Now, I wonder, you've mentioned that a lot of the beliefs people have, doctors have, society at large has, around back pain, a lot of those beliefs are not founded on evidence, and you think are downright wrong? Yeah. And harmful. And harmful. Okay. So, in this editorial paper that you guys published, there are 10 myths. Can we go through them one by one and get your commentary on them?

So, I think this will be really useful for people. Okay. Myth number one: Lower back pain is usually a serious medical condition. Yeah. So, what we know is that about 1%, like 1% might be associated with some kind of underlying pathology like a malignancy, cancer. 100%. Yeah. Fracture. Cancer. Um, you know, cauda equina syndrome, where there's compression of the, the nerves that supply the, the, the bladder and, and bowel area. Like, things we can't miss as clinicians. So, we need to screen for them always. That's the minority. And actually, you know, primary care clinicians, like myself, we will see them, but they're not very common. And here's the problem, Peter. If I think about how we're trained, right? We're trained to not miss the serious thing, right? Yeah. Which is really important. It's really important. But if I just think this through logically, okay? So, because the serious things, it's the same thing with headaches, frankly. You know, we're, to headaches, we're, we're always doing what we call our red flags, making sure there are no red flag symptoms which indicates this could be something much worse than a tension headache or much worse than just musculoskeletal back ache, right? So, we're also practicing in a culture where defensive medicine prevails. We're all scared of getting sued. So, therefore, we have to be damn sure we haven't missed the serious thing, which is really important. Which is important, right? Yeah. But because that's where the main focus of our training lies, we're always going to be biased in the consultation to going, "Oh, this is not cancer. This is not a fracture." Okay? But we're not given the same amount of training and attention for the 99% of them which isn't those conditions. We're not given the same level of training around them. Do you get me? So, it's, it's a self-perpetuating cycle. Of course, it is. Because it's not very reassuring for you. Well, if you're frightened that you've got cancer, knowing you don't have it, it's really reassuring. But if you've got debilitating back pain like you had, and you can't pick up your child, you can't do stuff that's important for your life, you can't engage in healthy lifestyle activities, like engaging with movement, and you're told, "Well, at least you don't have cancer." That is not helpful. So, you're kind of left, once, once the serious stuff's excluded, you're either then scanned and given a, like a faulty explanation, actually, which is probably number two, um, around being given a misdiagnosis. But, but this, let's just expand this out of back pain just for a minute, Peter. I think this is one of the, the major problems in medicine today, right? Let's take chest pain. Yeah. Acute chest pain, right? A lot of the time, a patient with chest pain will end up in A&E or the emergency room, depending on which country you live in, right? And it's not uncommon for you to get investigated primarily. They're looking at your heart. Is this a heart attack? Is this angina? Right? Because you need to know that, because if it is, you need quick, immediate treatment. Y. But the amount of patients over the years who I've seen, and any doctor will tell you this, that the patient went in with chest pain to A&E, they weren't told what it was. They were just told, "This is not a heart attack. Go back to your doctor. Go back to your GP." Right? And again, I understand, you know, it's an emergency treatment center, they have to prioritize what they're seeing. But it is not uncommon that people with chest pain go around the houses. They go back to the GP, then they get referred to a gastroenterologist, who says, "Oh, no, this is, this is not gastro. Go back." We, we love to put these things in little boxes as if they're separate, but they're not. It's all related. And so, let's go back to myth one again. Yeah. The, the myth is that lower back pain is usually a serious medical condition. You're saying that's not true? 99% of the time, it's not. And look, you know, there's another group of people who may have a disc prolapse, for example, like a, some disc material that compresses and irritates a nerve. Uh, that's another small group. Is that about 5%? Exactly. But the majority of those get better. The body is amazing, like, you, we can talk about that later. But they, those discs reabsorb for the majority of people. They reabsorb. The body does it itself. So, a lot of people think, "Oh my God, you've got that, that's for life." It's not for life. You know, the studies have scanned people at baseline and six months later and gone, "Disc gone." Like that, that prolapse is gone. The majority of the majority of it. Like you said, it's around 95%. We can't pin the pain on any pathology. And so, we shouldn't. And we need to look way beyond the structure to understand pain. And that's what you're highlighting is not done well. Yeah.

Well, myth two speaks of this: Lower back pain will become persistent and deteriorate in later life. Yeah. You're saying that's completely false?

Yeah. And I think there's a perception of like, doom. Often. And this is why I mentioned hope at the beginning, because we see people who, they go, "If I've got this at 20, what will I be like at 50? I will end up in a wheelchair at 60." Like, there's that perception that if it's this bad now, it can only get worse. And in fact, what we know is that, you know, back pain can be effectively managed at any age, often. And particularly in later, later life, you know, if you scan anyone over the age of 60, you will see an 80% of people, disc degeneration, disc bulges, so-called arthritis. These are normal age-related changes. We call them pathology. We start labeling them as the cause of pain. It's not true.

Well, let's jump to myth four, right? Because it speaks to this, and I, I think this is huge. I think this is a problem that's getting worse. It is. Yep. Whilst initially people might think scans are a good thing, I think for so many people, they cause more problems. The MRI has created a massive issue for people with back pain, right? So, we're going to talk about that. But myth four is: Scans are always needed to detect the cause of lower back pain. Yeah. You're saying that's false?

Yep. So, that's true for the serious group we talked about, malignancy, um, cauda equina syndrome with the compression of the nerves. A scan is helpful in those really important, small minority. Really important. Now, someone, a layperson may be listening, Peter, go, "Okay, but how the hell are we meant to know if it is that unless we do a scan?" Yeah. So, that's why you have trusted healthcare practitioners who can, you know, screen your story, your history. They can look for the key features, because we know there are key features that will be predictive of that. And that's why you need trust in your healthcare practitioners. So, they don't steer you down the wrong path. Now, there's no danger in a scan. Like, an MRI scan, in, in itself, is not dangerous. There's no radiation exposure. But the report is where the problem comes. That it's not only the report, the interpretation, and the language we use as healthcare professionals when we communicate that's a massive issue. So, so let's, let's just make this really straightforward for people, right? Yeah. So, someone's got persistent lower back pain, yep, right? It's not getting better. Y. So, they're going to keep coming back. Let's say to their doctor. "Look, I mean, I, that I went and saw the physio, I've still got it. I can't work. Hey, Doc, I need a scan. I need to know what's going on." That's very, very common. And, and to be fair to doctors as well, yeah, a lot of doctors, particularly in a system like we have in the UK, like the National Health Service, I think it's different in private healthcare systems. Um, but we're very much schooled in British medical schools. We're very much trained to only order tests if they're going to change our management. So, I don't think in this country, historically, we over-order. Whereas in a country like America, which is a private system, Australia's like that too, I think people are, yeah, getting way too many tests, investigations, and scans. Right? But I think sometimes the doctor will think, "Yeah, this is musculoskeletal back ache. This is not cancer. It's not a fracture. I can tell from the history and the examination." But the patient needs some reassurance. So, reluctantly, they order a scan. Y. And that's okay if you interpret the scan properly. Okay? That's the key. Just taking a quick break to give a shout out to Vivo Barefoot shoes. Now, I've been a huge fan of Vivo Barefoot for over 10 years now, well before they started supporting my podcast. They are the only shoes that I wear, and they really have had a huge impact on my own life and the lives of many of my patients. You see, when people start wearing minimalist shoes like Vivos, you can see improvements in things like back pain, hip pain, knee pain, foot pain, even things like plantar fasciitis can often get better. And scientific research shows us that just wearing Vivos for about four months or so improves the strength in your feet by over 60%, which is absolutely incredible. One thing people don't realize about these shoes is just how flexible they are, which allows your feet to do what your feet naturally want to do, rather than the shoe dictating your foot's movement. Vivo Barefoot are giving my audience a 15% off one-time code when you make your first order, and they make it really easy for you to give them a try. They give a 100-day trial for new customers, so if you don't like them, you just send them back for a full refund. I'm a huge fan. I really hope you take advantage of this offer. To get your 15% off code, all you need to do is go to VivoBarefoot.co.nz and use the code [podcast name] at checkout.

...have disc bulges. These are just features that you see on a scan. These are people with no pain. At the age of 40, 80% of people will have degeneration, which is an unfortunate name. It's just the name that's been given to a, a reduction in water content in the disc. 60% have disc bulges. 30% have protrusions. These are in people without back pain.

You, you say "unfortunate name." It is unfortunate. It is not only unfortunate, but you could argue it's downright problematic. 100%. It is. Because it's not... No. If you get told, as I did, as many people do, in your 20s, that you have a degenerative spine, what does that do to your belief system about your body, your spine, your ability to move forward in the world? Massive, massive. I quoted you a statistic earlier on, right? 70% of people in developed countries will get lower back pain at some point in their lives. Developed countries. We know that there are some countries and cultures where they don't get back ache or they get less. There's a, there's a low incidence. I think there's a difference between back ache and disability, and we often, we need to separate those two things out. We don't have what, well, number one, we don't have great data in, you know, some lower, mid, lower-middle income countries. But there was a recent paper that came out of Brazil, for example, that showed that back pain was a really common problem there and also disabling. Um, so, you know, if you, I was in Nepal in November, December, uh, trekking in around the Everest region. Those people are extraordinary, carrying these massive loads on their body. They can't afford, they have no social security. If they don't function, they don't live, they don't eat, they don't, they can't survive. So, in a sense, back pain is a common human experience. Disability is something else. That's interesting, isn't it? Because that really, that also brings in the idea of the brain, right? And beliefs as well. Beliefs. And we were chatting before about my conversation, maybe two years ago now, with Howard Schueler, who also does a lot of great work in chronic pain. And his belief that the brain creates these neural circuits, and if we get scared and, um, we have fear, and I know we're going to talk about that as well, how they can create these self-perpetuating loops in the brain, even if there's nothing physically wrong, like emotionally, that can drive pain. But if we think about what you were saying in Nepal, and we think about belief systems, well, maybe they're not complaining of back ache, but maybe, maybe they're experiencing discomfort. But it's like, "So what? I've got to work. I've got to feed my family. So, I don't have an option of calling it something, labeling it something. I just have to crack on." They do. They do report back pain and back ache. But they don't have, like you said, they have to function. They have to go out to the field. They have to lift the loads. So, you know, they don't have a choice. You know, we've, in a, in a sense, what we've done, I think, in our culture, and that's high-income country society, is we start scanning, like we said, we start scanning people. We tell people they're damaged. We then frighten them. We give them advice that actually makes them overprotect their body. It sets them up for failure. That doesn't happen in, you know, the, the Everest region. No. In Nepal, there isn't an MRI scan up there. Do we know, or do you know, if hunter-gatherer tribes have been studied for back ache, or their backs have been even scanned? I, I don't know. Look, I know there was a, look, I know a little bit about some research in Africa. Um, there was a study done, this is going right off-piece, but, you know, the, the people women who carry these huge loads on their neck, and they looked at whether, you know, the load was actually detrimental for their spine, and it wasn't. No. Like, the spine is designed to load. They had stronger necks, um, if you look at Asian countries and the paddy fields, how do they lift? They stand with this leg straight, fully flexed. And in Africa as well, they don't have ergonomic, you know, advice. In fact, they're, they're unloading their back when they're standing. We've got these long hamstrings, and they unload their backs. It's probably really protective. We've done something else. We've told people to, you know, keep their back straight and bend their knees. They don't do that. Yeah.

Why I think it's really important is that more and more, I can't get away from the idea that our behaviors are massively driven by our beliefs, massively, right? But we don't realize. We're living within our beliefs. So, sometimes we, we can't step outside of to question, "Well, where do we get that belief in the first place, right? And what would happen if I never adopted that belief?" Yeah. Right? So, maybe in Africa, like, 100% they believe that, you know, "We're strong. We can carry big, you know, heavy loads of water and whatever else with a, with a straight spine, and we're going to teach our kids to do it, and there's going to be no problem." And we have to keep doing it, 'cause if I don't do it, no one else is going to be there to do it for me. True. So, there's truth in this. And look, part of our population research looked at this question in Western Australia, and young people. We looked at their beliefs about back pain, uh, and we, we looked at, you know, whether they believed back pain is something that they should be careful with, whether it's going to get better over time. We found there was a general negative belief system in those young people. This is like the age of 15, 16. Um, and when we looked at the likelihood of those kids taking time off school, of avoiding movement, backing out of physical activity, taking medication for their pain, they were more likely to than the kids who had a positive belief about their backs. We then looked at the parents, and we showed that there was a relationship between parental beliefs and the child's beliefs. So, we inherit our beliefs from our parents, and we often model that. So, if the parents are taking time out of school, of work, you know, and, and over, you know, seeking care and avoiding movement activity, the child is more likely to. And that then fast-forwards into their work life. So, if a kid's taking time out of school, the adult is more likely to take time off work. So, and we can't blame people for this. It is normal. Like, it is normal. This is, you know, again, broadening this out, the way that we inherit or learn our beliefs, we learn. We learn. Yeah. Especially as kids, in the environment in which we grow up. So, for many of us, from our parents, like, yes, it can be about back pain behavior. What do you do? Do you take painkillers? Do you not? Do you keep moving or do you stop moving? Do you take time off work? Do you not? Right? You're going to get those. Same thing applies to food, right? Are eating behaviors? 100%. You know, what do you do in times of stress? Physical activity, physical activity. You know, you know, how do you soothe emotional discomfort? Is it with ice cream and sweets, or is it with something else? You will often learn that from your family and how they did it. So, yeah. Yeah. I find it's absolutely fascinating. Interesting. Yeah.

Just going back to these, uh, tribes for a moment. I want to get back to scans, because I think... No, no, it's fine. Um, this idea that, you know, it's normal to have degeneration in your disc, right? Or degeneration in your spine. And I know we probably don't love the term degeneration. What I'm trying to get to is, I wonder what people who live different lifestyles to us, if their backs were scanned, also at the rate our backs were scanned, would we see that sort of degeneration as well? I don't know. Yeah. We... Interesting, isn't it? I don't know. Yeah. It is. Look, you know, those studies haven't been done. But, you know, the thing that amazes me in my work is that I see people with some of the worst-looking scans who can become pain-free relatively and get back to doing all kinds of stuff in their life. That's the hope bit. And that's the bit that we don't share. And I think as clinicians, we become frightened as well. "Oh God, you know, with that back, you really should think of another job." And, actual fact, you know, loading your back makes it stronger. Yeah. Moving your back makes it healthier. And if you do have changes on a disc, it doesn't define your future.

This is a massive point, right? What your work is fighting against is decades of so-called truths that have permeated into culture, where people just say this stuff, health culture and general culture, as if it's real. Right? So, okay, now I would say I was very lucky back in, I think 2003, 2004, because that was sort of three, four years into my journey with back pain, and I was trying everything, going here, going there. I had to take a period of time off as a junior doctor when I was working in Salford Royal Hospital. Um, and I had a scan done, and I think the surgeon's name was Mr. Ross. And I always remember this because what he said, I don't think I realized till this morning how much it may have influenced me. Yeah. But he said to me, "There is a disc bulge at L4-L5, but Rongan, let me tell you, if I was to take 100 people off the street now of your age, Y, and I scanned them, I can't remember the statistic, but essentially over 50% would also have a disc bulge like you. Y. And most of them would not have pain." Yeah. Exactly. And hugely reassuring. H. Reassuring because it made me think, "Oh, it's because had he said, 'Oh yeah, you've got a disc bulge, that's probably the reason you've got this pain.' Y. My belief at that point would have been, 'I have a disc bulge, that's causing my pain. Care, I need to be careful and protect that.'" Right? But because he didn't say that, that just opened the door in my mind to go, "Well, wait a minute. So, I've got a disc bulge, yeah, but he's saying that that may have nothing to do with my pain." And he also said, and this is about 2003, 2004, he said, "Rongan, the problem is that these scans are static as well, right? So, it's just telling me a snapshot at that moment when you're not moving. Ideally, I'd love to see a scan where you're moving, and then I could maybe get a bit more information." So, let's go back to the scans that many people are asking for and getting. Yeah. You're saying, I think, Peter, that many people have been told that a bulge or a bit of degeneration in the disc is the cause of their pain, and you're saying in most cases, it's not?

Well, I'm saying that it doesn't define your future. So, so, you know, you can have a painful disc, but it doesn't mean it's going to define your future. So, there are studies that have looked at this. So, I'll come back to the probably three key studies. Yeah. The first one, um, took this group of people, they scanned them all. One group were told what you were told, "Normal age-related changes. Didn't give them the descriptors, just 'normal for your age.' And people without pain, don't worry about it." The other group were given the detail, "You've got a degenerative disc at L4-L5 and a bulge and some arthrosis and a bit of a fissure." They were given that information. Sound good? Does it? No. It's terrible. They followed them up. They didn't control anything they did. They followed them up six weeks later. The people who were given the scary information, their pain was worse. They were more disabled. Their mental health was worse. Their function was worse. Those who were reassured, their pain was less. Their function was greater. Uh, their, their mental health was better. That, if there was one study that shows the powerful effect of messaging of a scan, it is that. Now, if there is a disc bulge and it's compressing a nerve and you've got neurological deficit, that is relevant. That is relevant. But a disc bulge in the absence of any nerve compression is just a normal feature on your spine.

This is such an interesting study because it really speaks to this idea of beliefs. Yep. For any clinician listening or watching right now, your language matters. What you say to a patient, absolutely matters. Do not give offhand comments, you know, without thinking about it, because people take on those comments, they become their beliefs, and that then influences their behaviors massively. Yeah. And it also starts guiding the clinician as to the advice they give, because if that's the clinician's advice, and look, you know, the sad thing is, is that we're not well-educated. A lot of our professions are not well-educated in this. They've got old thinking, and then they start giving advice and telling people not to do sport and lift things and play with their kids and, you know, lift, go to the gym, or whatever they're into. That in itself has a massive feed-forward negative consequence. And their general...

Okay, so let's say someone's got back ache, and all the red flags are excluded. It's deemed to be, I was going to say "simple," but it seems to, it's non-pathological back pain, let's call it that. Non-pathological back pain that, in most cases, will get better naturally within a few weeks. Within a few weeks, okay? So, that person has got back ache, they've been reassured it's not cancer or a fracture. They're okay, great, I can crack on with my life. But when I try and lift my child or bend down to play with them, I get pain. Mhm. What are you suggesting they do at that point?

Yeah, so if that is an acute presentation, so we would take people through, you know, one, number one is screen them. Um, what does that mean? Oh, make sure we missed, we haven't missed anything. Yeah. That's so sure we haven't missed anything serious. Okay? So, take the history. You know, like, has it injury? No injury. So, what was going on for you at that time? That's so important. History is so important because, you know, I think of a recent case of a lady who I saw, and, you know, her pain, and we know this from the research, as though he said earlier, it's often at a time of stress. That person's not sleeping well, they're run down, they're tired, they're tense, they've got other stuff going on, they haven't been caring for their health. Pain emerges, right? I, we say that's a message from your nervous system to care for your health, to, you know, learn to relax your body, get it moving, get good, healthy sleep, re-engage in physical activity, get... We can do it in a graduated way, so that you're not just forcing people to move. You start in a very graduated way. And that's why practices like yoga, you know, simple, basic, foundational movement, then builds on function. That's where we would take them. So, we kind of, what we call grade, we grade people back up into function with a belief that their body will recover. Um, so, the goal is to get them back to function 100% quickly. So, if someone, a week after their first acute episode, is unable to, um, do certain things like lift their child or bend down and play with them, right? Then you, your approach, and, you know, you publish loads of papers on this, right, which we're going to talk about, you would almost say at the moment, "That's fine." Okay. It is. You recognize it. It's causing you discomfort at the moment. But let's not allow this avoidance to continue for too long. 100%. Because that then becomes your new norm. You've done avoiding. Yeah. So, if you take an example of a sprained ankle, for example, you wouldn't go running on it the next day. So, if the person's had a lifting, twisting incident and, you know, loaded their back and they've sprained their back, you wouldn't say, "Look, just go back to lifting tomorrow." But you would say, "Look, just get yourself moving. Don't do heavy lifting for a couple of days. Get your movement back. Relax your body. Build your confidence back gradually. Build up."

Your ability to lift and then get back into it. But the key thing is what triggered that event. That's what we look for because it's the understanding the factors. Because what we know is that lifting itself may be a trigger. But if you're if you're stressed and tied and run down, that's a much greater chance of it happening. Does that make sense? So it's all these combinations of factors.

100%. I mean, and then if we zoom out, look at the state of society and go, well, wait a minute. Society, it's a cocktail. Back pain is on the rise. Yep. Stress and burnout is on the rise. Yep. Inactivity is on the rise. Activity on the rise. So it's it's almost like the perfect storm where people are going to get pain and discomfort. Yep. But too often, I guess, we just focus on the pain. Yeah, understandably, because it's hurting. Yeah. But we don't look at this holistically and go, would that lifting injury that you may have got when you lifted and twisted an acute back sprain, yeah, would that have happened if you weren't overrunning your life, working too hard, not sleeping? We know the chances are way less. Yeah.

Know more resilience. 100%. You know, it's again, trying to just draw patterns in from other work. It's not quite the same thing, but if you get exposed to a traumatic incident and you have had, you know, a really stable childhood upbringing, you've got support, a community in your life, and you had it as a kid, yeah, that's less likely to become PTSD than if you didn't have that, than if you had early childhood traumas and if you don't have community and support in your life. Right. So the same insult, yep. But the impact of that insult depends on all those other factors massively. And we know that's the case with pain. You know, take an example of like a motor vehicle accident, for example. We know that the key predictor of your response to that injury will be your stress response, how you respond. It's not the, the, it's not the size of the crash, it's not the damage done, it's your body's stress response. So if you, if you freak out and you panic, uh, you, you'd have a potent emotional response, you're more likely to overprotect the body and the nervous system response will be to create this massive sensitization. So we know that those, the same factors are in play. You know, we know, for example, early life trauma is an increased predictor of, as an adult, of you having pain in the body as well. So there is this kind of cross-link between all these factors. And that's why the history is so important because you, what we know is a lot of people are rocking up in A&E with non-traumatic back pain. No one's screened their history. No one's taken their story to understand why they have these terrible episodes of pain in their life that debilitate them and frighten them. No one's done that. We need to do that as healthcare practitioners to help people understand what the meaning of their pain is and then to set them on a path for recovery.

You're a physiotherapist, yeah? Right. A lot of people in the UK who have chronic back pain and end up seeing their doctor, certainly within the NHS, will then be referred on to physiotherapists. So in theory, physios have expertise in this area, perhaps more expertise than, let's say, the doctor referring them. Do you think as a profession, physios are more aware of the psychosocial elements that contribute to back ache? They should be, or do you think it still hasn't moved on much and it's still deemed very much a mechanical issue?

Look, I think there's a veneer of understanding. I think in some quarters, there's definitely an understanding. I think there's the understanding is one thing, changing our own practice behaviors is something else. I think that's really hard to shift. And we've, we've seen this in our research as well. Like I could ask you, well, what do you think about back pain? And you go, oh, well, you know, backs need, you know, it's good to move and you shouldn't be fearful and re-engage in healthy lifestyle. And then someone comes in to see you and they've got a disc bulge. You go, well, you better be careful when you've been out for a lift. Like we see this kind of, human beings have got all these kind of mismatches between our own beliefs and behaviors. And so, part, part of what we've been involved with is, um, with our research is actually training clinicians in their own to shift their own beliefs and behaviors so they can support patients. Because if you don't, you know, we know that most of our educational interventions for clinicians don't change their behavior at all.

Amazingly. Well, that's really interesting. Is it? So why is that? Right. So is it because a physio or a doctor is taught how to practice when they're at physio school or medical school, right? Yeah. When they're doing their training and they get used to practicing a certain way, right? So they have a system and how they do things in the time that they have allotted to them. Yeah. And then they might hear something new and novel. They may read some research, they may read some of your research or watch one of your lectures online and go, oh, wow, I didn't realize, you know, what Peter, what Professor O'Sullivan has has published, that's really interesting. Yeah, that would affect my patients. But then, is it too hard sometimes to integrate that into their existing way of practice? Is that what you think it is?

Yeah, I think it's a whole bunch of different things. I think that's one thing. So like, part of the trial, which we'll talk about later, I think we took a group of 18 physiotherapists and we took some who were two years out and some who were 30 years out of training. Yeah. Okay. Yeah. Post, post training. We found the younger ones were able more able to adapt, actually. The older ones found it really tough because of the, you know, they had their confidence was linked to a whole way of working and they felt like we were unraveling them. Um, but over time, they could change. The training program took six months. We would take them in once a month and then we would, we would get them to work with people with back pain, so real-time stuff. And we'd give them feedback around their own, their own way. What we noticed is we'd film it and they would get the clinician to watch themselves and they would go, I didn't know I did that. I didn't know I said that. I didn't know I messaged that in my consult. It just was automated. And so, you know, some of it probably comes down to our own personal pain beliefs about what we're comfortable with. It comes down to distress because, you know, you, with your experience, pain is scary and distressing. And if we don't, if we don't feel comfortable with that distress, or, and often it's deeply emotional, and patients will break down and cry. And if we're not comfortable with someone's emotion, we will shut it down. And we see that as clinicians, we shut it down. And that's a missed opportunity. But also with the body, we have these rules. And so we start telling people to hold themselves this way and do this and do that and be careful and become hypervigilant. We create hypervigilance in our practice. So there's so many elements which we have to untrain and retrain, I think, healthcare practitioners to change the way they think, behave, to support people with pain.

You seem to be someone who quite naturally looks at a patient and their pain and tries to contextualize it. You try and figure out, well, why is this happening at this moment in this person's life?

100% right. Yeah. I've always had that inclination as a clinician as well. It's, it's, why, why now? What's going on? What are all the factors for this many years? Why this lift? Exactly. Yeah. Exactly. And for years, I never thought about how I lifted. But I felt I was pretty strong and able to lift a lot of heavy things. Right. Now, I think I heard you say this in one of your online lectures that did one of your colleagues at one point say, you know, you're delving a bit into psychology now. This is not physiotherapy or something like that. Yeah. Can you just share that a little bit?

Yeah, so we kind of look at, you know, if we think of the person with pain, living with pain, pain is deep. If it's, if you, if it's persistent and it's disabling, it's deeply emotional, right? So if you're a physiotherapist and you don't deal with emotions, you shouldn't be working in that space. It is, it is a fact. So what's happened? You know, our profession is kind of evolved from a very biomechanical exercise-based structural paradigm, but it works very closely with people with pain. So if we're not interested in people's emotional experience, we shouldn't be working with them. Yeah. So, so there's this, there's a gap in health. You know, we have psychologists who are not trained in pain, and we've got physiotherapists who are not trained to deal with people's fears and emotions. And the poor patient is left sitting in the middle. Don't even get me started on this. This is, this is what I fight against my entire career, and particularly in this, in the public facing work that I do. We are these three-dimensional beings, right? You can't just have your psychology dealt with with a psychologist and your biomechanics dealt with with a physiotherapist and your, yeah, I don't know, your annual cardiac checks done by the doctor. It doesn't work. We don't work like that.

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And I don't, I don't understand how you can be a good and effective clinician without delving into psychology. You have to. You can't. Like, I, it doesn't mean you know as much about psychology as a psychologist. It doesn't mean that there isn't a role to refer. No, but it means that we have to be able to cover that side of it. You have to get some confidence at dealing with that, or you're going to be very, very limited. And look, back pain is an embodied experience. What does that mean for people? Understand that. What, what does that mean? It's not just in your head. It's like, you know, for your experience, you felt pain in your back, your back muscles would have clenched up, you would have been super sensitive. If I'd touched the structures in your spine, that's a real local tissue sensitivity, right? So that's your, that's that's real. Like it's not a, something in your head, you didn't make it up. They're local tissues that are super sensitive to touch and to moving and to load. That is a, but you, but fear and overprotection can drive that. Yeah. I, I, 100%. I, I overprotected my back for years. I was scared of it. I felt I was weak and at any point the back could go. So I started to contract my life massively. Y. You wouldn't put yourself in positions where you knew this was even a possibility. I can't do that. I can't go there. Guys, it's too long, too long a drive. Gave up playing squash, all these things.

And just to really highlight that biopsychosocial element of pain, yeah, or or the way I like to frame it for people, and I think this applies to any chronic condition, whether it's a chronic disease or chronic pain, in my experience, is very rarely one thing. We, we never, we know it's not. Yeah. I've never seen back pain, it's not, but back pain, yeah, typical diabetes, autoimmune disease, it ain't one thing. It's a combination of factors. Genetics play a role, lifestyle plays a role, all kinds of things play a role. And that concoction together over time results in the phenotype that you express in the pain symptoms or the disease that you have. Right. So, and, and I know you've got a lot to say on this, but one of my frustrations sometimes with the way we use science to help us or to help educate us to help an individual patient is that there are so many factors going on with any individual patient. But a lot of science, not all science, but a lot of science tries to isolate down to one factor, yeah, and just measure that, which is useful. It doesn't tell you much though. Doesn't tell you that much, right? But you've got to address multiple factors. So exactly. You know, for anyone who didn't hear my conversation with Howard Shuper, let me just give a brief synopsis of my journey with pain, right? Which was, it started when I was about 22, 23. Never had it before, ever. Was helping my flatmate Mary at the time move into our new flat, lifting boxes up three or four flights of stairs all afternoon, out of a car. Y. Suddenly, with one box, it just went. My back just went for the first time in my life. Dropped the box, lay on the floor in agony. And that is when it all started, right? Now, I, I don't remember the exact thing that happened in the hours afterwards. Howard would ask me what happened in those immediate hours, I can't remember. Yeah. But I would have gone to see my doctor. I would have taken painkillers. I would have, and I know I did see a physio and I tried everything, right? Like people do. I spent a lot of money. Y. Physios, chiropractors, osteopaths, and all of them. I'm nothing against those professions. I think there were some fantastic people in all of those professions. But I found that it was only part of the problem. It, it would help me for a few weeks, and then, then it would come back. Now, one of the most significant things that happened was in 20, I don't know, maybe 2011, 2012. I came across a guy called Gary W. A biomechanic specialist. It's phenomenal the way he looks at the human body. And I went to study with him and went on his courses. And again, I don't want to misrepresent Gary's work. But one of the things that I learned was that my right foot wasn't working as well as it could do, right? And Gary wasn't necessarily saying that. He was looking at my entire body going, you know, your right foot, it's flat, but it's stuck in pronation. Pronation is actually normal, but you want to be able to come into it and come out of it. At the moment, you can't. So he did some exercises with me, very simple. Immediately I started doing those, about five minutes a day, I could feel my back starting to loosen. Right. Okay. So I thought, oh, I'm on a winner here, right? And there's no question that significantly helped me. I got back to everything, squash, long drives, everything. But there was still this discomfort there. Yeah. Right. There was an awareness. You know, it sometimes it wasn't there, but it was, I want to say it was fully gone. And I know you've heard my conversation with Howard, so you've heard this story. But one of the most powerful learnings I've ever had about pain was at my dad's funeral. I heard that right. And you know, I was a carer for my dad for many, many years, a huge part of my life. When Dad died in 2013, he got cremated at the end of the service, obviously, you know, moving service, very emotional, right? I was very, very close to my dad. We came out of the crematorium and we were outside at Manchester crematorium, watching Dad's coffin go into the flames, the oven. You could see the orange flames. And I was, it's not as if I was thinking about my back. I was just, I was just present for the experience of my dad's body about to be burnt. Yeah. And I remember Dad's coffin goes inside into those flames, and my back just eased off completely. That happened. I know that happened. And I've reflected on that in the weeks and months afterwards. Yeah. And I got it. I was like, oh, the weight, yeah, of looking after Dad for this many years. That's the embodied. That's the embodied. That's not my conscious mind, that's my subconscious mind. 100%. And it is, although I've told this story once before in the podcast, it is amazing to me to think that is how powerful our mind is. Yeah. Where it saw that my dad's body is about to be burnt to ashes, that gave it the evidence, oh, you don't need to do this anymore. Off. Right. So, so that fits into my model of health, which is very much, there's multiple factors. There was a physical issue, right, which Gary helped improve. And now Helen is helping me improve massively, right? But there was also an emotional issue. It's not one or the other, they were both involved. But a good clinician should be able to tease both of those factors out. And you teach clinicians how to do this. That's what we do.

Tell me about this, um, you've got this kind of social enterprise running, haven't you?

We do. Yeah. So, look, the Restore trial was a kind of like a, what you published in The Lancet? That's right. Yeah. So we'd had a number of, of small trials, uh, in different countries, um, one in Ireland, uh, one in Norway, um, that had demonstrated the effectiveness of this intervention, which we call cognitive functional therapy. We had to come up with a name. Um, and the F is so important because it's about the behavior. So CBT, which is cognitive behavioral therapy, is what a lot of psychologists will use around thoughts and behaviors, which are great. The F is about the function, about the body, the whole body. And that's sort of what you're tapping into. And, and that we look to the body, we explore, you know, the confidence in the back, the ability to move, to relax the body, to build safety back in the body. That's one of the key elements of this intervention. So the trial was based in Australia. It was a two-center trial. We took about 500 people with long-term disabling back pain, more disabled than most people in trials. Lots of back pain trials exclude people who are really bad. We included anyone from 18 up to there into the 80s. We had no top, top level. So we wanted to be very inclusive. We had people who had had pain for over four years and who were more disabled than most. Uh, we took a group of physios and we trained them over six months, I mentioned that, um, and then they took the patients through this journey, which essentially was to the first thing is to take, hear this story, you know, and often people were saying, no one's listened to my story. You're the first person through this whole journey to actually listen to my story, to validate me, to help me understand that actually I'm not going crazy, that this is a real experience, that your pain is real, that the impact of pain is huge in your life. But let's build hope back, you know, let's understand the factors that are relevant for you, and they're different for everybody. So, and then let's personalize the program. Let's understand your confidence in your body. Let's have a look at your movement. Let's look at the things you can't do. So, you know, if, if it's picking up your kid, we want to look at that. If it's driving, we want to look at how you hold your body in the car. If you want to get back to running, we want to look at how you're using your body when you load a limb, when you transfer load. So we kind of break all those processes down and then take people on a journey to help them understand that actually pain is modifiable, that to build, you know, like an optimism back around their body through a process of learning to relax the body, re-engage in normal movement. We break all the posture rules and we target the things that people value. So we, you know, it's not prescriptive, it's individualized to say, what are the things you want back in your life? Play tennis, pick up your kids, travel. They are the things we're going to target. And that's a moving target because often when people get them back, they want something else. So that's like a three-month process that we coach people. It's, we're working as a coach to build the confidence back, help them understand the drivers of their pain, be it emotional, be it thought, be it behaviors, which often it's a combination of factors, be other issues around their lifestyle, around their sleep, around their diet, around engaging in physical activity, to realize that actually there's this whole capacity that they have to regain health in all aspects of their health, actually. And that's what the qualitative studies have shown us that people said, look, this was great for my back, but actually I'm sleeping better, I've now lost weight, I've changed my diet, I'm back into work, I'm doing stuff I thought I couldn't do again, and my mental health is better. So it's never just about the back. It's about all of these factors. And I think, you know, people with pain get that. They get it when it's almost like they get lost in the maze of the health system. And a lot of these people had literally given up. They had so much treatment, bit like yourself. They'd been through, they'd been scanned, they'd been given stuff, and they'd literally gone failure, failure, failure until the point they just given up. And that's so sad that we've got people living in our society who have literally given up on healthcare because they think there's nothing left. So that's the journey that we took those people through. And then we followed them up, you know, like 12 months later.

And so getting back to the, to the social enterprise, but what, what did the results show 12 months later?

So, so literally, what we found is that this was compared to usual care, and they could have anything they wanted. Right. A lot of them had given up on care. And about 60%, 58% were on medication, around 28% were seeing a variety of different people. We found significant reductions in their disability. The key thing was it wasn't just after the treatment, this, it actually continued to improve 12 months later. We've got unpublished data showing that the improvements are lasting out three years. That's, that's what we're really looking for, 'cause that's what we're interested in, right? Yeah. 'Cause one of the critiques of a lot of trials is that it only lasted four weeks, last eight weeks. Most back pain trials show that. Yeah. So this, that's, that's the key gold for me, which is, oh, wow, 12 months later, three months later. And I imagine that's what excites us about this. It's an empowerment model around giving people the tools to self-manage their own pain condition. That's the key. It puts them in the driver's seat. And the medical model, it's a disempowerment model, isn't it? It's, let me fix you, let me do something to you. And I got trained in that. I'm a manual therapist by training, where I was training to do stuff to people to make them feel better. And what we know is it doesn't last. I like you, I teach clinicians. I have this training course, prescribing lifestyle medicine, that we run online, clinicians all around the world. And one of the things I'm always keen to teach doctors is, you have to give your patients a sense of agency, massively. They cannot walk out the door feeling that only you have the tools to help them. You know, in manual therapy, it's really stuck on that. It's like, my magic hands can do something to you that makes you feel better, but you have to come back for more. But again, it's not either/or, right? It's like, of course clinicians and experts have lots that they can help patients with, but the patients also have to be massively shown what they can do as well. It's not either/or, it's together. Yeah. Of course, it is. And that's what we, there's a lovely, um, uh, kind of descriptor of the clinicians. They described as this learn driver model. U, but the journey for the patients is a bit like that as well. It's like, you're co-driving at the beginning. You know, just chuck someone in a car and say, look, here's the manual, off you go. You coach them. So you're sitting with them. You, and this is what we saw in the trial, is that we're working very closely with the patient in the first, you know, that person with pain in the first couple of weeks. And then we might see them in the two weeks later, and then it's three weeks later, and then it's four weeks later. And we're chasing up their goals, we're building confidence back in them, we're giving them strategies to re-engage in stuff. We're getting them back to, you know, doing stuff they love, which is very, it's very motivational. You know, when you're getting stuff back, you want more of it. When you're losing stuff, it's very unmotivating. Yeah. And so that, that's a partnership. And, and the qualitative studies have shown talked about the importance of trust in the clinician. That they, they, that trust is so important. It's, it's a bit like, you know, doing something like back pain's scary. So it's a bit like being on a rope with someone on a rock face and knowing that your instructor's got you. They've got you. And it's okay, you're safe with me. And we're going to teach you and coach you and build your skills. We're not going to push you too hard, but we're going to get you back to doing the stuff you love. That's a pro. And that process could be really quick for some and really tough for others.

So you're teaching this model to clinicians around the world?

Well, what we've developed is a social enterprise where we've been literally since the trial came out, we've had inundated with people saying, we want to know about this. And people like healthcare professionals, physios. Well, we also get contacted by patients as well, saying, I've read this, this resonates with me, that's my story. You know, I see those videos on your website, that's my story. I want to know about this. And I, I just want to point people to those videos because those patient videos are very, very powerful. Is it Restore Back Pain? Yeah. So they'll be on our new website, which is Evolve Back Pain Academy. Right. But those people should watch those. They're very, very powerful. They build hope. Yeah. And there's so many different ones with different, we deliberately did that. We, uh, people with different ages, different backgrounds, to to make people realize actually, there's some common themes, but everyone's journey is different. And it goes back to what you said right at the start. The message is one of hope. 100% right. You can get better. You can get back to the activities you want to do. Cure? We're very reluctant to say cure because if we look at the trial, we saw pain reduced significantly, disability reducing. Because some people, they might say, look, it's, you know, pain does not define me anymore. But yeah, I get back pain from some, some time to time, but I know how to handle it. To me, that's the goal. I think this idea of trying to cure something around any chronic health problem, I think can set up a really unhelpful expectation that if I'm not 100%, if it's not pain-free, there's something wrong. Uh, where to me, it's like, you know, if pain, we know that you can have pain in your body, but it doesn't bother you. It doesn't distress you. It doesn't define you. It doesn't stop you from. Maybe it's a reminder to get more sleep, to go for a walk, to go and do yoga, to eat better, to, you know, to integrate your life socially. Use it as a signal, not to think, oh my God, why is it not gone? But to say, what is it? What can it teach me to do today? You can use many symptoms like that, right? What, what signal is my body giving me now? What is this symptom saying? Yeah. About the current state of my life. 100%. Which part of my life might I be able to change on the basis of this? Exactly. It's a different way of looking at the body, of looking at health, but it's a much more helpful way, I think. But it's evidence-based. Yeah. It is. And, and it's this whole thing you talked about before, you know, it's never a single factor. It never is a single factor. And, you know, what we'd like to do is try and upskill patients to go, you know, you can become your own clinician. Yeah. I love it. So, and if you hit a roadblock, and here's a, here's an exacerbation plan. We know that's really important as well. So people can do really well and then they hit a roadblock. You know, they get sick, and you know, we've seen this in our research as well, like the triggers of pain often not injury. I get run down and got sick, a family member got unwell, there's stress in my life, I had a period when I stopped exercising, you know, everything came, and then my pain erupted again. We give them tools to say, if that happens, this is the thing to, these are the things you go through, try first. If that doesn't work, contact us.

The belief you have around pain is so huge, isn't it? Because if we think about it through another lens, for people who work out in a gym, right, and lift weights, they will know that sometimes the day after the strength session, you have discomfort in your muscles, right? Y. DOMS, delayed onset muscle soreness, which could be really painful, be really, especially if you haven't done it for a while or if you're tired and run down. And but a lot of people will frame that pain as, man, I did a good session yesterday. That's a sign that my muscles are, they've been taxed and now they're going to grow back stronger, just as I wanted, right? So that's an uplifting pain. Do you know what I mean? The way we think about it matters. Important. So meaning is critical. And that's why our beliefs are so important. Because if we think pain means I'm damaged, that's got a whole different meaning. So what we know about, like pain when it's scary is it's severe, it's uncontrollable, and it's unpredictable. That's what's frightening. When pain is, you understand it, and it's controllable and predictable, it's not scary. And so what you're describing, you go to a gym, you do a workout, it's controlled, it's predictable, you get the pain you expected. And so that, that's the role of a clinician is to give people an understanding or a meaning of their pain, but also to give them strategies to have more control. We know control is really important. The perception of control, of feeling like, yeah, I've got pain, but you know, I can relax, I can breathe, I can do these movements, I can go for a walk, I can get to bed earlier, I can re-engage my body and it makes me feel better. I'm in control. That's so important.

Let's go back to some of these myths, right? There were, there were 10 of them. I think we covered three. So we covered the myth that lower back pain is usually a serious medical condition. As you explain, it's not. Myth two, lower back pain will become persistent and deteriorate in later life. You explain that's a myth. It won't. Most of them will get better and self-resolve. Okay. And even if you have it for a long time, you still have capacity to get better. We saw people in their 80s get better. Okay. That, that is full of hope, right? We went, we then jumped to myth four, scans are always needed to detect the cause of lower back pain. You said that's not true for the majority. Not at all. Okay. And also the way we message those scans can be problematic. Okay. Let's go back to myth three, which we've sort of covered, but I want to go through these 10. They're very useful for people. Yeah. Okay. Myth number three, persistent lower back pain is always related to tissue damage. Yeah, it's not. Majority is not. Like there's nothing, you know, there's nothing on a scan that it comes back to the scan story again. Like for the majority of back pain, there's not an injury. So you can move. And even if you're getting pain, if you can tolerate it, the backs are really strong. Like to actually break it, back is really hard. And unless you're osteoporotic, you know, in which case, that, that's a different story, that's a pathological process that can weaken your bones, but gradually loading those bones can make them stronger and healthier. Yeah. Well, that's not loading anything, right? You put force through it, it gets stronger. Exactly, as long as it's graded in the right way. Yeah. You said our backs are really strong. Let's expand that out. Really strong. But let's expand that out. We are really strong. We are 100%. We are strong, resilient human beings who can put up with a lot. And I think sometimes the belief is for pain and and other conditions that we're weak. No, we're designed to be able to withstand. So we've got strong immune systems that can fight off infections if, yeah, we care for our health. We care for our health. If we're able to, I understand also people have got some people got very challenging lives and it's harder for them. I want to acknowledge that. But if we are able to care for our health, you know, I go back to, you know, my very first book back in 2017 was called The Four Pillar Plan. And I talked about the four pillars of health that I think not only have a huge impact on our health and well-being, but also the four pillars that we have a lot of control over: food, movement, sleep, and relaxation. Well, that's key for back pain. It's key for back pain, which is why many people who bought that book would send me messages saying, oh, this is really helped me with my pain. Totally. For a great. And it makes so much sense. Yeah. Because it's like, yeah, I didn't give you anything to target your back specifically, but if you improve your general well-being, it ain't just your back that's going to get better. Often your mood. Exactly. Your other symptoms start to get better. Exactly. Okay. So that was myth three. Let's now go to, um, okay, so the, the fact alongside that then is that persistent back pain is rarely associated with serious tissue damage. That's a key message, isn't it? And if you do have tissue damage, it heals. The body's ability to heal is amazing. Spinal fractures heal, disc prolapses reabsorb. The body reabsorbs them. So even if you do have pathology, in the majority of cases, the body will do its thing without any serious intervention. Okay. And that's so cool. Let's go to myth five, which I think is related to three. Pain related to exercise and movement is always a warning that harm has been done to the spine and a signal to stop or modify activity. Yeah. So it's a really important one. Look, we have this. Not true. Not true. No. And we have this innate, you know, we talked about this earlier. If you've got a fracture, it's normal to protect your back. If you have pathology, it's normal and appropriate to protect your back, but not for too long. But if you don't have a history of trauma, let's say you have a flare-up, a back pain, you just, you know, roll out of bed and, you know, like you described, protect, overprotecting, that will not be helpful. But the problem is, here's the other thing, which I'm not sure we touched on yet. Once you get into the pattern of overprotecting, it is bloody hard to get rid of it. Well, that's, that's the, that's the trial that we did. 10 years on, you can still be falling into patterns. You heard one of, uh, Howard Shuper's, yeah, literally one of Howard Shuper's in this studio a few weeks before that. This was a couple of years ago now. My mom had fallen. My brother had called me to say, hey mate, I can't get Mom up. Could you come around and help? And I was in a really good place. So instead of going around in a stressed state, yeah, thinking, oh my God, I'm going to do this, I'll help Mom, of course, but it will botch my back up. I went around, chilled, smiled, had a joke with Mom, and with a, with really, uh, uplifting, positive energy, totally relaxed. I got her back up, put her back into bed, made sure she was fine. You know what? That was absolutely fine. Yeah. 100%. But that was years after I'd had any serious backaches. So I had to, I still had to remind myself, you don't have to go and contract your core and keep your back straight, which is quite hard to do with another human being as well. It is. It is. Yeah. We use the analogy of the clenched fist. Like it's normal to clench your fist if you're going to pick up something really heavy. But you don't do it if you're writing. You know, like you don't walk around doing this all day. It's not normal. It's not helpful. We see people with back pain doing it all the time. They do it when they roll in bed, they do it when they get off a chair, they do it when they bend over. So if you did this all the time, how would you? Well, we ask them, how would your arm feel? It'd be painful. Joints get irritated, makes you really stiff. What do we know are the features of back pain? People move stiffer, more guarded, more tense. That's what that's what happens. And of course, asking people to do those things and brace and stiffen and tighten their core, whatever else they're told, for some people can be helpful. Well, it's, it's helpful if you're lifting a really heavy load. It's not normal if you're bending over to do up your shoes. It's not normal if you're picking up your kid. If you've got a little baby, it's not normal. That is not normal. It's not normal to roll over, roll in bed doing it. That's what we see chronic pain do. They brace to roll in bed, they brace to get out of bed, they brace to put on their shoe. They're using something that you and I would do with a very heavy load during normal activities and movement. And they're depriving themselves of movement in the back, which is important for its own health. Yeah. I think there's also an argument that if you do work on your movement mechanics and get them back to optimal, whatever that word optimal means, then your body will naturally kind of know what to do in these situations. Yeah. I think you touched on something really important earlier. You said a healthy back is one you don't think about. It's one you trust. And if you trust it, you're not thinking about how you move, you're not thinking about how you lift. You learn that. Look at a child. Learn to develop. They don't. They're not taught to lift. They learn through play and through activity. That's how we are. That's how we learn to move. They literally, they do not go down with this just straight back. They don't do a perfect deadlift. Yeah. So, so, you know, part of that journey of building trust in the body is to say, you know what, my back is strong. I've got confidence in my body. I don't need to pay it attention anymore. I don't have to prejudge everything I'm doing anymore. I can trust it to relax and move. And I need to be strong to do heavy stuff. I have to be strong. But you also, I think, told in your own personal story, that this overcontraction all the time actually becomes problematic because you don't want this always contracted. It's not healthy for certain muscles. You need this to be relaxed. And for people listening, I'm pointing to my abs and my core, right? You don't want it tight all the time. It needs to relax. I understand. So if you look at the core, it's great for push-ups, sit-ups, planks, um, you know, like that's that's its job. Twisting, you know, you need core muscles to hit a tennis ball, like to, you know, to drive power through the body. But it's not normal to bend over. It's not to be clenching those muscles. It's not normal to be clenching them when you're rolling in bed or, you know, bend over a sink or whatever, do your wash your face. That's what we see people with pain do. Yeah. That reminds me how I used to wash my face or shave when I had back pain. Yeah. Prop off my back. Yeah. Bent my knees. Because I'm very tall, I'm six foot six and a half, almost six foot seven. So you'd, you know, to get into the bathroom mirror, I, because most mirrors aren't high enough for me, so you'd have to bend a little bit, but you'd keep your back straight. And it must have been comical watching me back then. Now, listen, I'm not at all criticizing any healthcare professional. Like I saw some brilliant healthcare professionals. I was teaching this stuff, I was doing this stuff in my early career. I am not judging clinicians. You're just, that's where I came from. You're trying to say there's a better way. There's a more helpful way. And the messaging is so important. Don't frighten your patients unnecessarily. Build hope in the body. You know, be an optimist. Be an optimist. Myth six, lower back pain is caused by poor posture. It's a massive belief when sitting, standing, and lifting. Yeah. Massive belief. So not true. Not true. True. There's not a single study that supports that.

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So why do we think poor posture is a cause? I think it's part of, you know, our, our senses, you know, what we think looks beautiful. I honestly do. I think it's the core thing as well. We have, you know, as a society, we teach, you know, young people to sit in a certain way, hold their bodies in a certain way, lift in a certain way. There's, it, it kind of taps into something deeply human, I think, what social desirability looks like. But, you know, we judge people. I mean, I watch my daughter in her, you know, going through the whole ballet process of like, you know, shoulders back, brace. You go, that's fine for ballet, but don't take that into your life thinking that it's dangerous to relax your back. Or, you know, we often see this as like, oh, if you, you know, tech neck or, you know, if you sit slouch, you're going to get back pain. There is no evidence to support that. Similarly, you know, just bending over and lifting with a round back, there's no evidence that's dangerous. But we teach people it's dangerous. So it's another nocebo thought, like a negative thought that makes you think, oh, you know, better sit like this and hold yourself like this and lift like this. It creates this unhelpful vigilance on the body. So I want to make sure we're not confusing anyone, right? So if someone is listening to this and they have got chronic lower back pain and they have been taught to do those things and they are currently doing those things, if it's working for them, no worries, fine. So you're saying if it's working for you. But don't think of it as a panacea. Because I think there's two issues with it. We know that the human spine needs movement for its health, right? So vary your posture. We would say, look, but, but hold on a minute. Let me just pause you there. Agreed. This is something I've also experienced to myself. The more I can put my spine in different positions, the better. Exactly. Vary it. But you're often told to keep that back straight, keep the core on. Not helpful. You're not moving your spine much there. You're keeping it quite. But not only that, you're you're tensing your body. It's not normal. Like it's literally not normal. So you're saying you could do it temporarily for a big lift. Could you? It's not damaging. But then don't do it when you're just walking as well. No. Exactly. But because that's what we know people with pain do. When we look at people walk with

Pain. They move stiffer. They don't rotate as much. They move stiffer and slower, and they don't rotate as much. Why? 'Cause they're, they're clenched. So, so that's, we know it's a signature for pain. We've done studies looking at people when they improve, they start moving quicker. They move more relaxed. They don't hold such rigid postures. They start to relax their postures. They're less vigilant about their body. They have trust back in it. Yeah, that's a big one, isn't it? Because the, the associated fact alongside that myth is that, you know what you've just said, back pain is not caused by poor posture. Yeah. But if you have back pain, you want to have the confidence to vary your posture, not to. We see people trapped in these rules, and that's what's so constraining. Holding, holding your back up straight for eight hours in a row is really hard. We see it. We see it with people who can't travel in a car, and the seats are bolt upright. They've got a lumbar roll in there, and they're in agony. And it's like, tip the seat back, relax, relax your core, breathe, you know, use your diaphragm.

Let's go to myth seven, which is about a core. Yeah, okay. Myth seven. And again, to reiterate, these are the 10 myths that you and colleagues published in the British Medical Journal Sports Medicine Journal, yeah, in 2020. Yeah. So not that long ago, right? Myth number seven: Lower back pain is caused by weak core muscles, and having a strong core protects against future lower back pain. Yeah. Again, you're saying that's false. There's no evidence for it. So if we take number one, there's no evidence that a weak core predicts your back pain. Number two is, if you train your core, it's not a panacea to get rid of your back pain. We know physical activity is great. But in actual fact, the evidence would say, do the physical activity that you enjoy the most, that you're likely to keep doing forever. That's the one that's good for you. But if you know, we see lots of people with back pain doing all these core exercises, but they can't do stuff they love in their life. And, and there's nothing wrong with a strong core. There's something not normal about a tense core all the time. And that's two different things. That's an interesting point. Is it two, two different things? So we say, yeah, look, I do core exercises as part of my exercise routine, but I'm not walking around clenching my core. I go for a walk and I bend over and I do stuff. I'm not doing that. But also, I think a lot of people don't realize, and I, I'd love your perspective on this, that when you start to move more efficiently, you're also working your core. 100%. When you breathe efficiently, you do. Yeah. I went for a run this morning, and my running posture is so much improved these days. My, I shouldn't say posture, my running efficiency, my running form through all the work I've done with Helen, like it just feels fantastic at the moment. And if you're really tuned into your body, you can feel your core getting a workout. I'm not doing a specific core exercise, but, you know, proper optimal efficient human movement. And what walking and running are, kind of two core masses that will also strengthen your. And look, you know, there was a, a trial that came out from colleagues last week, I think in the Lancet, showing that walking for people who are not active, walking is highly preventative, like prevents future episodes of back pain. Walking is the best thing. It's gold. Yeah. And also walking, like, again, I'm, I'm sharing this as a case that's useful for people. So because I'm almost 6'7", most chairs are very, very small for me. Yeah. Relative to most adults. And if I'm ever at my children's school, right, in primary school, oh man, the chairs. You know, I said to my wife, if you just imagine you're not kids, yeah, like party chairs, sit on that for three hours. Right? That's kind of what it's like for me when I go and sit on these chairs. Right? And I've realized once that I did go to an event at the school, and my back was really sore afterwards. Again, maybe appropriate because I'd been in a certain position for a period of time that, you know, my long body was struggling to sit. Come, you probably couldn't relax in it. But I went back there a couple of weeks ago for a, um, a musical, and I walked to the school instead of driving. Yeah. No problem. Right? That fits with what you're saying, right? Because I had done something relaxing. I was moving my body, my muscles, they were all warm. Then I could tolerate sitting in an, in inverted commas, poor posture or poor chair without any problems. So it's all related, isn't it? Massively related. Yeah. Yeah. And it's so important that people get that. Okay. All right. Myth number eight. Can I touch on one other thing on the core? Feel free. Diaphragm. So if you brace your core, you can't. Your diaphragm fixes. So it's a pressure cylinder. So you've got your pelvic floor at the base, you've got your core muscles on the side, and the diaphragm is at the top. So if you brace your core, you force yourself to breathe upper chest, which is inefficient. And we know upper chest breathing tends to go rapid. Upper chest breathing tends to drive the stress system. That's like your sympathetic nervous system. You're already stressed in pain. 100%. And then your behaviors start driving it more, reinforcing the pain by your breathing pattern. Exactly. Because you've kept your core tight, because your diaphragm cannot now function as a respiratory muscle. It's, it's creating pressure. Right. Now, the reason I wanted to bring this up is because speaking this idea that nothing in the body works in isolation. Right. So someone has back ache, it affects the quality of their life. They then get told after their scan that they have a degenerative spine. Okay. Even as I say that, it's like, what? Me? G. And then they get told, you have to strengthen your core and keep it tight, hold it tense when you bend, when you move, when you sit, when you stand. And of course, these, this advice has been given with the best of intentions, right? So that person then, and I've seen this loads, and I've been this person, as you have, right? You're always keeping that tight. Yep. So as you just said, that locks your diaphragm, your breathing starts to go up. Tense your neck. Tense your neck. So you're becoming tense. You're activating your stress response system. Yep. But also, something it's important to note, what started with your back now is affecting your diaphragm and your breathing. But that also affects your pelvic floor muscles, does it? Right. And I think this is also, we're bringing in here because so many people, men and women, have pelvic floor muscle problems, particularly women. Yeah. Stress incontinence is huge with women, yeah, especially after they've given birth. And if we just map it all together, back pain's going up, stress is going up in society. We haven't talked about this yet. People have been told, or people are absorbing the message, they should suck their belly in. Massive. These are all problematic, and they're all contributing to pelvic floor issues as well. Yeah. It's true. And like, there's good research to support those interrelationships. Massively. It's a massive issue. And look, you know, we have, as a society, we're so judging of the body, around body form, about body shape, that we see a lot of people trying to hide themselves. Like, you know, young women and men trying, or any age, trying to pull their bellies in to try and hide themselves. That, that creates the same thing. If you suck your stomach in, you create intra-abdominal pressure, you can't use your diaphragm effectively, you start loading up your pelvic floor. That whole system starts overworking. Your abdominal wall attaches to your rib cage. So, you know, the whole system is part of this. Yeah. And a key point, right, is what we said before about a back. It may start off in your back, but depending on what you then do and tighten and stop moving, start spreading. It starts spreading. You get a secondary problem, a tertiary problem, and I don't know what a fourth one of a tertiary is, but, you know, uh, it's true, you get all these knock-on effects. Right. So if we look at sucking your belly in through the same lens. Yeah. And I've done this, right? We all do it. We, we, you know, women have had this for years. And I remember when I was like, a skinny, rib-showing teenager at like 13 or 14, feeling self-conscious about my body. Men's Health came out and suddenly you're seeing all these ripped guys with six-packs and flat abs, and you're thinking, oh God, that's, that's what I need to be like to be a man, right? Yeah. So this is so widespread that I would say more than 50%, most people are probably sucking in their bellies at some point. And I think it's one of the most problematic behaviors. We see it all the time. Let's really hammer home this point. People are doing it. It's not normal. It's not healthy. It's not useful for anything. You know, if you think about any body part, you don't constantly contract any other part of your body, do you? But we teach people to do it for their belly. Yeah. You think about it, there's no other muscle. You don't sit there trying to contract your biceps or your quad or your calf. Maybe the pelvic floor, you know, the people who are, you know, anxious about incontinence or whatever. But the core, massive. But not only that, we teach them to do it. Now, there's a difference between strengthening the core, which I think we talked about earlier, which is important. Consciously contracting a muscle is not normal. It's not normal. We don't do it for any other body part. It's not normal. And, you know, anyone listening to this can sit there, pull in their tummy, and feel what happens to their breath. It has to go up here. And they keep doing that for time. And then feel what happens to your back muscles. They tense up. If you feel your back when you contract your core, you start tensing your back. Now, if your back's sensitive and your muscles are sensitive, and you're contracting them all the time, they're not going to be happy. No. No muscle is going to be happy being contracted all the time. No. It's not. You have to contract, relax. And people forget how painful a muscle spasm is. We often say to people, you had a cramp in your leg, how painful is it? How painful have you had a cramp in your back? Because it's hell painful. Because if there's, they're not that big, the back muscles are not that big. And if you're constantly contracting your core, and you're co-activating, that means because the core are flexors, they pull you forward, the back extensors pull you backwards. You start clenching your core, you start, you're giving work to your back muscles, you start creating this abnormal overprotection or tension. And going back to your model that you've created, I think with colleague's cognitive functional therapy, that you published that wonderful trial, right, in the Lancet. One thing you said to me when you were explaining it is that we give people tools so that even if their back pain comes back, or they have a flare-up, or their pain, per se, comes back, they know what sort of things they can do, including relaxation. Right. So, so diaphragmatic breathing is probably the most important thing at the beginning. Yeah. So this is kind of like the platform around which movement begins. Well, well, I've had multiple conversations about the breath on this show over the years. I've heard them, James Nestor, Patrick McKeown, Brian McKenzie, and many more, right, about how powerful the breath is. Yeah. What I love to try and do for people is to help integrate it all together. So this may, on the face of it, seem like a conversation about back pain and chronic pain, but it's so much more than that. It's about, if you isolate one aspect of your body and overprotect it, there is a knock-on consequence on other parts. But if you start doing the opposite, there's a knock-on positive effect on other parts. So if you do five minutes of diaphragmatic breathing each day where you're really relaxing and breathing fully, yeah, you're training the relaxation response. But then integrate that into movement is the next step. Yeah. And, and funnily enough, I, and I think what yoga does, right, that's what yoga does very well. And I think also, it's funny when I went for my run this morning, right? I was feeling a bit, you know, bit fuzzy-headed this morning. And I thought, oh, peace is coming shortly, right? Let me go for a quick run, see if I can just, you know, blow out the cobwebs of my brain, that sort of thing. Yeah. And maybe because I've been researching your work yesterday, and I'm talking to Helen about it yesterday as well, um, I was really thinking about my breathing. So I went for a 30-minute run, and my only focus was, breathe in a relaxed fashion, make sure when you're breathing in that, um, it's diaphragmatic and it's going all the way. I was just, it was, it was a really relaxed run. My only point of attention for the entire run was my breathing. And, you know, it made, it felt really relaxed because I was focusing on the breath. Well, there's good evidence for it too. You know, breathing is so interesting because it is deeply primal. Like, it's the first thing we do. You know, it's the first muscle we use when we were born. But it's so linked to emotion, to fear, to pain, to body position. It's, it's, it's such a fascinating area. And, you know, when we start working with the body, often we start getting people to relax their core and use their diaphragm, you'll see emotion emerge. You know, and you go, what? Where did that come from? And it's bottled emotion. Like you described this with your dad, like this pressure came off. What was that? Well, something clearly relaxed on your body at that moment when your dad went, you know, went into the fire. But, but also, Peter, you talk a lot about the problem with fear and back pain. It perpetuates the problem, right? We know it's a massive problem. And you, you, you have this, you know, this beautiful thing about the predictors, the things that predict, um, and you shared some of the research on that, you know, whether you're going to have chronic pain or not. One of them is you're scared around it. Whether you're empowered and relaxed about it, right? So training yourself to relax through diaphragmatic breathing, of course, it's going to be beneficial for anyone with pain, right? Because if you're, if you're fearful about your pain, your stress response is on high alert. So that's in your, it's in, it's in fright mode, right? You've got fight, flight, breathing. Going to totally switch that off. Dials it down and dials it right down. So again, as part of your armory to fight back pain, it's one of the key foundations. Yeah. I don't even like using the term fight anymore. Implies that it's you're at war with your body, and you're not. Your body's giving homeostasis again. Yeah. It's just a helpful tool, right? So I, I, I think that's fascinating. And I think the other key thing, which often is missed, so we see a lot of people with back pain do meditation or diaphragmatic breathing, but they do it in a safe place. Where we'd say, you need to do that when you're hurt. You need to do that when you're frightened. You need to integrate that when you're doing the stuff that either hurts you, you avoid, or you fear. Yeah. So take your breath into the movement. So we do a lot of that work because, you know, what you'll realize is they can lie on their back and do diaphragmatic breathing, but when they sit or bend or twist or lift, they brace their, they hold their breath. And what I, what did I say about one of the last times I picked Mum up from the floor? It, I intentionally went in, I had a joke with Mum, she was fine, she just couldn't get up. I said, "Hey Mum, what are you doing here again?" Something like that, right? It was, it was a, it was a light energy. And then, and I'm sure that made a difference because when I go in tense, when I used to go in tense, well, you set yourself up for failure. 100%. Because you're setting off that fear response in your body. It's truly fascinating. It is. Okay, that's myth, uh, seven. We've got to get through these myths. Okay. Myth eight: Repeated spinal loading results in wear and tear and tissue damage. You're saying that's false. Not true. Yeah. Well, I think we touched on that a little bit earlier. Did that actually loading your back makes you stronger? You know, loading bones is important for their bone health. Loading discs makes discs stronger. Loading muscles makes them stronger. So depriving your back from load is terrible. Now, now that's different than this kind of internal compression which is linked to fear or overprotection. We're talking about external load. So say, say running, for example, it's fantastic. It's cyclical loading at the back. It's very good for the human spine. You couldn't tell someone who's not a runner to just start running. You'd want to grade them up to it. But, you know, the body has got this extraordinary ability to adapt. Yeah. To to pretty much anything if you, if that's your goal. And that's the key in my mind to get to build that hope again. To go, you know, don't set limits on your life.

Myth nine: Pain flare-ups are a sign of tissue damage and require rest. Huge one. So this is not true. No. Well, the history is the key. So if you have a flare-up because you've had a heap of stress in your life, you're tired and run down, the last thing you want to do is to avoid movement. Right. It's a sign you need to move to relax, to move to re-engage in physical activity, get good sleep, of course. But this idea of overprotecting, of course, is the issue. Now, if you've had a traumatic injury, that's that's that's tissue damage, right? That's where you do have a period of graduated. But the majority of back pain flare-ups are usually linked to inactivity, high levels of stress, um, uh, you know, poor sleep, rundown and fatigue. And ironically, I say ironically, but a lot of people don't think about this when they're stressed, but one of the best stress relievers is movement. Massively. And breathing and exercise, physical activity. Talking about heavy, intense workouts, walking is one of the best stress relievers. It's gentle on your body. And, and even if it hurts, you're not harming yourself. You're not harming yourself. The key thing. Really, really important point. Okay. Okay. The final myth on your 10-point list of myths, right? And this is a big topic, right? I know it is. Yeah. Okay. Treatments such as strong medications, injections, and surgery are effective and necessary to treat lower back pain. You're saying that's a myth. Yeah. So what's happened is, you know, what, what's really happened the last 20 years is this kind of escalation of what we would call low-value care. Care that's expensive, it comes with risk, and it doesn't do much good, or it's got limited benefits. So if you think of the whole opioid story for chronic pain, we know it doesn't do a good. We know it's not effective. Opioids are not effective for chronic pain. Uh, they come with lots of risks, they have lots of downsides. So they just haven't been a help for drug. I agree. They've not been helpful. They've been downright harmful. Yeah. Right. It's not unhelpful. We, as a profession, knowingly, stroke unknowingly, have have made so many people addicts. Horrible. It is. We've, I've seen it. It's horrible. I've seen it. Yeah. You know, it's not been neutral at all. No. It's not. Right. And more importantly, you're saying that for chronic pain, it's not helpful. We know it's not helpful. I mean, there was a Lumar study last year, published in the Lancet, that looked at, um, opioids for acute back pain versus placebo, showing that the placebo was more effective, right, out to 12 months. So we just don't have good evidence for it. But the risks are significant. So, you know, but what, what I think what happens is in primary care, because we don't effectively manage back pain well, we start escalating. You know, and, and the, the scan is a driver of that. Because if you have someone who's just, you know, you, you got the disc degeneration story, and you've had, you know, various treatments not working, and the patient's getting more distressed, the GP is going, "Well, we better send you to the surgeon." The surgeon goes, "Well, you've got a degenerate disc there, you know, you got this, you know, your surgeon gave you a wonderful advice." But that's not always the case. Then they're like, "Well, the patient's desperate. We'll fuse your disc." And we know the evidence for fusion and disc replacement shows that, you know, there are significant risks that come with that surgery, and the effect, the outcomes are no better than non-surgical treatment. So why are we doing it? And not only that, we know that the things that have been operated on are not predictors of that person's pain and disability. So what are we doing? One of the most important questions I think any patient can ask their doctor is this: What happens if I do nothing? 100%. Right. And, and we need to normalize that more, right? There's an idea that I've got a problem, I'm now going to the healthcare professional to get fixed. Okay. Y. And the healthcare professionals, with all their training, are doing the best that they can in the system in which they're having to work. Yeah. And often that means that there's an ex, there's a kind of unwritten idea out there that you have to do something to validate the fact that this was a consultation, right? Which is about us, right, as healthcare practitioners. Yeah. Yeah. And we, and I've been here before, so I totally get it. You feel like if, if you've given them a prescription, you've given them something, you've done something, right? So you feel satisfied, you've, you've contributed here. And your hope is, and, and I think patients do feel, uh, you know, some patients also will go in with the expectation that going to a doctor means I must come out with a prescription. But we've created that. Yeah. So it's not just, this is not just healthcare professionals, it's also our public perception is that it's only worth it. I took half a day off work, I've waited two weeks for this appointment. If I don't come out with a prescription or a referral or a scan, it was a waste of time. And so the system also is playing into this. It is where people are wanting these quick fixes. But, but they're not neutral. We're not honest. Look, physios are caught in the same cycle. That's this perception. Is if I, if I go and see a physio and I'm not put on the bed and given a rub down or mobilized or whatever, I haven't had treatment. Like good care is giving people a clear understanding of what's going on. Good care is about empowering them to make change in their life, to get back to the stuff they value. That's good care. But we don't value it. This is one of the reasons why I do this podcast, honestly, right? Because let's take it away from pain for a minute. Any GP or doctor knows this scenario. Right. Someone's coming to see them with a cough. Yeah. Right. Yeah. It's, yeah, it's affecting their life. It's bothering them. It's affecting their sleep. They can't work as well as they want to, etcetera, etcetera. Right. So they go in, doctor examines them, looks for the red flags, looks for the signs and symptoms that might indicate a bacterial infection which may need antibiotics. Yeah. More often than not, they're not there. Yeah. Right. There's no fever, there's nothing. You can listen, you know, when you're, um, listening with a stethoscope, you can't find any sort of localized area of infection. Right. And, and, and you just think, yeah, this is, this is a viral infection. It's going to take anywhere from one week to four weeks, or whatever, yeah, to get better. Yeah. Right. So you try your best to reassure the patient, go, "Look, I get that you're worried." And of course, different doctors will do this with different approaches, and some are better than others. But it's always my approach is always to try and explain, said, "Look, I get that you're worried. I get that you think this is serious, but honestly, I don't think it is. This will get better." Yep. Um, it usually takes one to three weeks, but, you know, sometimes it takes a bit longer, sometimes the cough can hang around. Yep. But here's what happens. And I do think society and our, you know, there's a lot of pressure on people at work, they don't want to take time off. Right. Two parents are working, they're struggling. It's people have got difficult lives. So it's really easy. Two weeks later, that patient's like, "Yeah, you know, I listened to the doc, but I just need some antibiotics now. I, I just need to get on with my life." Yeah. Right. No one's at fault here. Yeah. But the system, the medical system, and the state of our culture now is such that people have no time and space to heal. Yeah. So often that patient will end up back in front of the doctor, and the doctor, even if they don't think it's appropriate, they will feel under pressure to that prescription of the antibiotics. And then what happens is that a patient will often take it, and in that week, they got better. But almost certainly, it would have happened anyway. Natural history. Right. I'm not saying that antibiotics aren't sometimes indicated. Yeah. What I'm trying to do is highlight that there is a, there is a systemic issue here for pain, but also for healthcare in general. But the system doesn't help. But also our understanding, our beliefs, also don't help. 100%. Like that's the story of back pain. If you look at most people who have an acute episode of back pain, might go and see someone, but the evidence would say, whether they do or not, the natural history, if they're going to get better, they would have got better anyway. And if they weren't, the things we're doing probably won't prevent it. So, so, so, you know, that's, that's again, why we need to educate people about, hey, you know, for the major. That's why those facts are so important. You know, there are some parts that NHS have have put these into the system, which is super cool because I think they're really helpful for people. Can I just ask, we're talking about medical systems, and I guess how you hear this will depend on which country in which you live and what your experience of doctors has been. But one could argue that in private healthcare systems, people are incentivized massively to do scans that are not needed and to do procedures like injections. Yeah. There is overwhelming evidence of over-treatment, over-investigation, and over-treatment everywhere. Or in private healthcare systems. In private healthcare systems, because people are making money. Yeah. Massively. So, you know, if you look at America, I know, you know, the American system, and Australia is not that different. We have a strong private healthcare system. If you look at the number of surgery, spinal fusions, in the public care system, it's pretty much flatlined, and it's evidence-informed. You know, like it might be an, an unstable fracture or something where a fusion is indicated. If you look at the work comp, so that's our work insurance system, which is a, it's a private system, or our private health system, the number of those procedures is exponentially increasing. The number of spinal injections is exponentially increasing. Hold on. So these things are increasing, but is pain going down? So that's the key, isn't it? These things are increasing. If pain was also going down, you'd be like, okay, we're spending more money, but we're helping. That's why it's low value. That's what. Yeah. I, the, I love these words like low value or unhelpful. They're very kind words. You know, if you think of high-value care, empowers people, it informs people, it gets them back to stuff that, that is important for them. But also cascades into other aspects of their life. That's the healthcare that we should be delivering. People. But, you know, what it takes more time. And that's the other tyranny of our health system is that we have a health system that says, no, you cannot spend time with people. So if you can't spend time, you can't take history. You have no time to explore those different factors that are happening with that individual. You're forced to make quick decisions around treating symptoms, not dealing with underlying causes. So we have a massive issue in the way that we, um, pay healthcare practitioners for time. You know, in the Restore trial, they saw the practitioner seven times. That was it. And then this is the trial you published. And so it was an hour for initial, subsequent were between 30 and 45 minutes. Seven sessions, right? With a follow-up at six months. These people have been through God knows how much treatment before that. There was a cost saving, wasn't there? There was. And, you know, the big cost saving is the people in the trial got back to work. Yeah. So not was it $5,000 per person per year for getting back to work? Some stats which I've learned through your work, which I think really speak to how badly wrong we've got it. In the US, $600 billion per year being spent on back pain. At the same time, back pain is the largest cause for disability out of all health disorders. Those two stats, they don't marry up. Something is feeding the other. Yeah. Okay. It's horrible. And, you know, you know, the saddest part is what we see is that people then had a fusion, and they're not better. What next? You know, what happens next? It's like, well, I've had, you know, the gold standard treatment, and I'm still, fix my back, and I'm not fixed. Yeah. Because if emotions were driving your back pain, if, and they're not in everyone, right, but if they were a significant part of your back pain, and you just deal with the biomechanics, but you don't address the emotions, yeah, of course, it's not going to go. Not only that, you know, once you've had a fusion, you get all these messages to be careful because you might do the next level. So not only that, we infuse people with more fear to overprotect the back. Do you think injections can work? Look, there's limited evidence. It, you know, for, um, for acute radiculopathy, there is some evidence for some short-term relief in terms of reducing radicular pain. For back pain, the evidence is really bad. Some people, some patients will say, "I think I've had an injection." But if you look at the evidence where you compare injection to placebo, injection, they don't stack out well. But, you know, we would say to people, look, you know, it's, it's around benefits and harm, right? So, you know, it does come with some risk. Like, I can, I can think of patients who have had, you know, a spinal, a leak, CSF after an epidural injection, and ended up, you know, hitting the, the dura, which is the coating around the spinal fluid leak, up in hospital for 10 days. I've had others who have had spinal infections. They've had a devastating consequence. Now, they are low risk of getting that, but if you get it, it's a big deal. And why I think understanding risk is so important. We, we've grown up in a culture where medicine is key. What the doctor says is king. Right. Many of us have grown up in a culture where what the doctor says, go and shouldn't be questioned. Right. And shouldn't be questioned. Yeah. And therefore, if the doctor is saying this procedure may help you, yeah, you, you take that on with extra weight. And I don't think we in health have enough of a conversation about risks versus benefits. Yes, there may be a risk of this operation, but there is also a finite risk of these problems. Right. And then, like you say, if we compare it to placebo, is there really a benefit? Now, for some cases, of course, there is, right? But again, if you don't have time in the system, no one's going to have these conversations. And to be fair, good surgeons are having these conversations. I mean, we have them. We have them too. Yeah. Yeah. But I'm sure everyone's trying to do their best. Ex. But, but, you know, we often see it as a failure in primary care that they end up being there in the at the first place, you know, like being where you know, having to see a surgeon, 'cause primary care should manage the majority of people well. So they shouldn't have to go and see a surgeon if we're dealing with back pain. Well, they get, go the other thing, you know, that I think you're tapping into here is that the problem with an injection is you, you're not empowered. You're having someone stick a needle in your back. It gives you short-term pain relief. It, there's no long-term benefit for it. So you just become part of another revolving door. So, you know, I wouldn't deprive anyone of pain relief. I never would. Um, but this idea of, you know, we know it doesn't get them functioning again. It might reduce their pain, but it doesn't get them functioning. So if you have some pain-relieving procedure, marry it with getting your life back. So at least use it as an opportunity to go through a process of getting your life back. Yeah. That's great advice. If that injection gives you relief for a couple of months, use those two months to put in some great work. And all the things we talked about, then means your likelihood of going back for another injection is significantly reduced. Okay. Peter, you're doing incredible work in this field, honestly, and it's much, much needed. I really appreciate all the trials that you've published. We, we'll try and put links to them in the show notes. People who want to check out your papers. Um, where are the websites that people should go and visit, both patients and healthcare professionals, if they want to learn more? So, just to highlight that I'm part of a big team of people. So it's not just my work. Like, you know, there's a whole group of people behind that. So I would want to put that out. That's really important for me. Um, I'm very privileged to work with some amazing, you know, researchers, clinicians. In terms of the, the kind of, um, opportunities for learning, the Evolve Pain Care Academy website, which is this social enterprise, will have a hub for patients, a hub for clinicians. And what we, all of that's free. We want to create, um, uh, a way of empowering, because we see it as this partnership. It's not enough to empower the clinician if, if the patient's uninformed. It's not enough to empower the patients if the clinicians are giving them completely contradictory advice. And that's, that's something that's a place that we want to use to bring patients and clinicians together to work in partnership. Um, so that's a great place. And on that, also, we have access to, um, any open access, uh, material. We, we summarized it. There are patient stories. We, we're, we've got, um, patient advocates who are part of this process as well. So we're using their stories to kind of empower clinicians as well as people with pain. Love it. Okay, brilliant. Um, the therapy you talk about, you've spoken about during this conversation, cognitive functional therapy. A lot of that will be on the website as well. And interpretation of what I read was that there's kind of three components to it. There's one, making sense of the pain. Two, exposure with control. And three, lifestyle changes. Is that a reasonable summary? It is. Yeah. Yeah. Okay. I love it. It's so aligned with my belief around health and giving people agency and empowering them. To finish off this conversation. Okay. There's so many people around the world who are suffering with pain and have done for many years. Yeah. For someone right now who is in pain, who thinks there is no hope. What would you say to them? Well, I would say there is, there is overwhelming evidence that there is hope. And, and that can seem glib or even insincere, but actually, that's what our work has shown is that we, we're not, we're not promising a cure. But if pain is distressing, and it's, it's frightening, and it's taking you away from things in your life that give you meaning, then there's hope for you. And part of that hope is to have a broader understanding of pain, to understand that our thoughts and our emotions and our behaviors and the way we use our body can drive pain in our body. And similarly, to turn that around is to shift the way we think, to acknowledge those emotions, to build confidence back in the body, to address other lifestyle factors around physical activity, our sleep, uh, relaxation practices. They're all part of the pack, the jigsaw puzzle. And for everyone, the, the pieces of the puzzle are a bit different. And so, you know, empowering people to kind of be self-reflective to go, "Hey, what are the key elements of my my pain? What are they?" And then, you know, we've had people contact me saying, "I've looked at your website and I've looked at your videos, and I want to thank you. For the first time in 20 years, I've relaxed my body and I'm starting to move again, and I'm feeling hopeful again." For others, they go, "I've seen it and it resonates with me. Where can I go to to find help?" And one of the things that we're doing is putting up clinicians on the website who are trained in this method. And, you know, we know through telehealth, you can do the stuff through telehealth, and it's not a lot of treatment. You know, it's, it's literally, it's, you know, often for some people, it might be three or four sessions. For some, it may be eight sessions. But it's over a period of time, and it's an empowerment model. And it's, it's around understanding and listening and validating, of building a new understanding of what's happening and building hope for change in the body. Peter, we start this conversation with hope. We're ending the conversation with hope. A huge thank you to you and all of your colleagues for what you're doing and publishing research in this area. Thanks for coming to the studio and good luck for the future. Well, thank you. Because it's people like you that help get our message out. And, you know, it's really hard. I think we touched on this, as researchers, our work gets hidden behind paywalls. It's not often, you know, even decipherable for most people. Um, it's kind of in, it's in medical jargon. Um, and I think what these conversations do is it, it brings the person back in, you know, the people who are out there suffering. They know what it feels like. They know the impact it has. They know the journey they're walking through. And I think building a sense of community and hope is the key for that. And you're doing that. So thank you. Thank you. If you enjoyed that conversation, then I think you are really going to enjoy this one. If at 37, your limit is just being able to run that 30-minute park run, at 75, you're going to have a very difficult time getting around.