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Dr Rangan ChatterjeeDr Rangan Chatterjee

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

Did you know that chronic pain affects 1 in 5 people globally and is the leading cause of disability?

Dr. Rangan ChatterjeehostPeter O'Sullivanguest
Sep 4, 20242h 13mWatch on YouTube

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  1. 0:00 – 1:01

    Why the most important message about chronic pain is hope

    1. RC

      You have been studying and researching chronic pain for decades now.

    2. PO

      Yeah.

    3. RC

      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-

    4. PO

      Mm

    5. RC

      ... what would it be?

    6. PO

      Hope. Hope for change. Hope that pain is something that has ab- an 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, just is distressing and, and disabling. There's this sense that you just have to suck it up and live with it.

  2. 1:01 – 3:47

    How common back pain is—and why it becomes so disabling

    1. RC

      How many people these days are suffering with chronic pain?

    2. PO

      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... it has a devastating effect on people. Um, it affects their ability to work, their ability to engage in physical activity, normal activ- activities of daily living. Um, it, 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.

    3. RC

      Yeah. I read a statistic this morning which said that 70% of people in developed countries will get lower back pain at some point-

    4. PO

      Yeah

    5. RC

      ... in their lives.

    6. PO

      Yeah.

    7. RC

      Right.

    8. PO

      It's 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.

    9. RC

      Yeah. You said it's the leading cause of disability worldwide-

    10. PO

      Yeah. Yeah

    11. RC

      ... this is chronic lower back pain.

    12. PO

      Yeah. Yeah.

    13. RC

      Okay. I think many people will be surprised to hear that.

    14. PO

      Yeah. [laughs]

    15. RC

      Now, firstly, if you've never suffered from back pain before, right, let's say you're in that 30%-

    16. PO

      Yeah

    17. RC

      ... that, that apparently never gets it-

    18. PO

      Yeah

    19. RC

      ... okay, you may not realize the impact of actually having chronic back pain.

    20. PO

      Yeah.

    21. RC

      You might think, "Well, what's the big deal? You know-

    22. PO

      Yeah

    23. RC

      ... what? Number one cause of disability? You're kidding me."

    24. PO

      Yeah.

    25. RC

      Like, "What?-

    26. PO

      Yeah

    27. RC

      ... a bit of back pain?"

    28. PO

      Yeah.

    29. RC

      So perhaps elaborate-

    30. PO

      Yeah

  3. 3:47 – 6:28

    The confidence crash: fear, hypervigilance, and the pain-protection cycle

    1. RC

      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.

    2. PO

      Yeah.

    3. RC

      Yes, it was pain, but it wasn't actually the pain, it was more what it did to my confidence in myself.

    4. PO

      Yep.

    5. RC

      Like, I had to second-guess everything.

    6. PO

      Yep.

    7. RC

      Can I do this drive?

    8. PO

      Yep.

    9. RC

      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?

    10. PO

      Yeah. Yep.

    11. RC

      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 back home, the, the doorbell went, and I, I twisted, and suddenly my back went. I couldn't go and answer the door.

    12. PO

      Yeah.

    13. RC

      I had to call out 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-

    14. PO

      Yeah

    15. RC

      ... and-

    16. PO

      Yeah

    17. RC

      ... lift my baby boy.

    18. PO

      Yeah.

    19. RC

      So what it does to your self-esteem-

    20. PO

      Yeah

    21. RC

      ... and how you feel about yourself-

    22. PO

      Yep

    23. RC

      ... I think is-

    24. PO

      Yeah

    25. RC

      ... is profound.

    26. PO

      Yeah.

    27. RC

      This must be a story you've heard over and over again, right?

    28. PO

      100%. 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. Uh, 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 personal experience because when you have pain, your body goes into protector mode. Uh, and when we go into protector mode around the back, we tense up. So we, we start protecting, guarding those muscles, subconsciously start contracting and tensing up, which creates secondary processes of pain.

    29. RC

      Mm-hmm.

    30. PO

      Uh, and so you just see this cycle where you become hypervigilant. It's frightening. Uh, we know fear ramps up the nervous system.

  4. 6:28 – 7:51

    How researchers study pain: population vs qualitative research

    1. RC

      You mentioned a couple of terms there which I think people may not be familiar with. You said population research.

    2. PO

      Yeah.

    3. RC

      And you've also just mentioned qualitative research.

    4. PO

      Yes.

    5. RC

      Do you want to explain what those-

    6. PO

      Yeah. So it's-

    7. RC

      ... those terms mean?

    8. PO

      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. Uh, 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-

    9. RC

      Mm

    10. PO

      ... uh, 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.

    11. RC

      Mm.

    12. PO

      That loss of confidence in the body. That's about qualitative research. It's the individual story.

    13. RC

      Yeah.

    14. PO

      Both are really important.

  5. 7:51 – 8:46

    Back pain as part of a broader chronic pain pattern

    1. RC

      Yeah. If we think about back pain, and we think about, I guess, the wider term chronic pain-

    2. PO

      Yeah

    3. RC

      ... are there similarities between the two?

    4. PO

      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.

    5. RC

      Mm.

    6. PO

      So there's a whole pain story, and often the back is one of the key elements, a- and is often one of the most disabling aspects of pain, just because of all the things we described.

    7. RC

      Yeah.

    8. PO

      So it's a pa- 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.

  6. 8:46 – 12:04

    Peter O’Sullivan’s own injury story—and realizing overprotection was fueling pain

    1. RC

      You have previously shared in interviews your own story-

    2. PO

      Mm

    3. RC

      ... that you were a sufferer.

    4. PO

      Mm.

    5. RC

      Um, and I'd love you to tell us a little bit about your own journey as a patient-

    6. PO

      Yeah

    7. RC

      ... rather than a clinician and an expert.

    8. PO

      Yeah.

    9. RC

      I'm sure, well, I would, I would imagine that your own personal experience has hugely informed-

    10. PO

      Yeah

    11. RC

      ... your professional expertise.

    12. PO

      Yeah.

    13. RC

      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-

    14. PO

      Mm

    15. RC

      ... and was like, "What are you doing, Peter?"

    16. PO

      Yeah.

    17. RC

      Like, "You look-

    18. PO

      Yeah

    19. RC

      ... rigid. You're not-

    20. PO

      Yeah

    21. RC

      ... moving normally."

    22. PO

      Yeah.

    23. RC

      "You're kind of moving like a robot."

    24. PO

      Yeah, 100%.

    25. RC

      Can you, can you elaborate?

    26. PO

      Yeah. So that was pretty early in my career. So I'd, um, trained as a young physio in New Zealand, um, 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'd landed very heavily on my back, off a track. I'd misjudged it and landed smack on my back, um, and developed pain, and, uh, like, you know, severe back pain. [laughs] Um, luckily I hadn't fractured anything. Um, and then I tried to get back doing my life again, and it just was-- became-- this pain started dominating everything. Um, uh, you know, just going to work became really-- like, at the end of the day, I was exhausted and the pain was spreading. It was spreading up my back into my neck and around into my, into my core, and I was think- 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, uh, 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 a-- probably about three months in, um, 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 [laughs] and started to then relax and realized 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, I experienced that.

  7. 12:04 – 17:26

    When guarding helps vs harms—and why most back pain isn’t injury-driven

    1. RC

      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?

    2. PO

      It, it depends.

    3. RC

      Okay.

    4. PO

      So if you have a spinal fracture, absolutely. It's very normal. [laughs] Like, that's the body saying, "Protect your back."

    5. RC

      Mm.

    6. PO

      "Don't move that." If you have a big disc prolapse, for example, which is, you know, um, say a, a bulge from the disc that's compressing 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."

    7. RC

      Mm.

    8. PO

      "Let it, let the tissue heal."

    9. RC

      Okay.

    10. PO

      But m- 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.

    11. RC

      Most of back pain-

    12. PO

      Is not linked to an injury

    13. RC

      ... exactly.

    14. PO

      Yeah.

    15. RC

      Not just a lot, it's, it's most of it-

    16. PO

      No, it is

    17. RC

      ... isn't it?

    18. PO

      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, when we're tired, we're 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.

    19. RC

      Yeah.

    20. PO

      Do you understand that?

    21. RC

      Yeah.

    22. PO

      But, but it's ... but we don't think that. These are a nor- these are normal subconscious processes that emerge in our body, that even in the absence of injury, with pain we will protect.

    23. RC

      I think your-

    24. PO

      Does that make sense?

    25. RC

      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 it in the past tense-

    26. PO

      Mm

    27. RC

      ... because it literally-

    28. PO

      Yeah

    29. RC

      ... is in the past.

    30. PO

      Yep.

  8. 17:26 – 21:08

    Healthcare-induced disability: how scans, labels, and advice can make pain worse

    1. RC

      ... 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.

    2. PO

      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.

    3. RC

      Okay, and, and, and who are these patients you're seeing then? Are pe-

    4. PO

      These are people with persistent disabling back pain.

    5. RC

      Right. So you're seeing the ... You're still a, a clinician.

    6. PO

      Yep.

    7. RC

      You're seeing these people.

    8. PO

      Yep, three times a week.

    9. RC

      Three times-

    10. PO

      I work in the clinic.

    11. RC

      Okay.

    12. PO

      And, uh, the majority of people I see have beliefs that are not evidence-based, that have been given the, to them. They've got scans often. They've been told that their backs are worn out, they've got degeneration or disc bulges, that they need to protect their back and lift in a certain way and protect their backs and be careful if it hurts, and it creates a massive problem. And distress. The, you know, the distress that goes with that's massive.

    13. RC

      Yeah. Fundamentally, as 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 gonna say s- subliminally, but not even subliminally, like, quite literally giving the patient the message, "There is something wrong with your back."

    14. PO

      Yeah. You're damaged.

    15. RC

      You are damaged.

    16. PO

      Yep.

    17. RC

      You must be careful.

    18. PO

      Yeah, 100%.

    19. RC

      And it, it takes years to get rid of that.

    20. PO

      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 m- 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.

    21. RC

      Yeah.

    22. PO

      And we have to be so careful as clinicians that we don't frighten people unnecessarily, we don't give advice that teach 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.

    23. RC

      Yeah.

    24. PO

      And we actually teach people to do the opposite.

    25. RC

      Over the years, I've learned that movement is healing, right?

    26. PO

      It is. It's not, it's not your enemy. It's your friend.

    27. RC

      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 syndromes.

    28. PO

      Absolutely. Any persistent pain, the ... It's the same story. Be it knee, shoulder, neck, you know, i-i- hip, it's the same story.

    29. RC

      Yeah. A few years ago, you and some of your colleagues published, um-

    30. PO

      [laughs]

  9. 21:08 – 27:07

    Myths about serious causes and decline: the “red flags” reality and why doom narratives backfire

    1. RC

      Okay. Myth number one, lower back pain is usually a serious medical condition.

    2. PO

      Yeah. So what we know is that about 1%, like 1% might be associated with some kind of underlying pathology.

    3. RC

      Like a malignancy, cancer.

    4. PO

      Yeah, 100%. Yeah. Fracture, cancer, um, you know, cauda equina syndrome, where there's com- compression of the, the nerves that supply the pe- the, the bladder and, and, and bowel area. Like, they are things we can't miss as clinicians, so we need to screen for them always. That's the minority. A- and actually, you know, primary care clinicians like myself, we will see them, but they're not very common.

    5. RC

      And here's the problem, Peter, if I think about how we're trained, right? We're trained to not miss the serious things-

    6. PO

      Yeah

    7. RC

      ... right?

    8. PO

      Yeah, which is really important.

    9. RC

      It's really important, but if I just think this through logically-

    10. PO

      Yeah

    11. RC

      ... okay, so because the serious things ... It's the same thing with headaches, frankly.

    12. PO

      Yeah.

    13. RC

      You know, we're, we're-

    14. PO

      Exactly right

    15. RC

      ... you know, someone comes in with headaches, we're, we're always doing what we call our red flags.

    16. PO

      Yep.

    17. RC

      Making sure there are no red flag symptoms-

    18. PO

      Yeah, yeah

    19. RC

      ... which indicates this could be something much worse than a tension headache or much worse than just musculoskeletal backache, right?

    20. PO

      Yeah.

    21. RC

      So we're also practicing in a culture where defensive medicine prevails.

    22. PO

      Yeah.

    23. RC

      We're all scared of getting sued.

    24. PO

      Yep.

    25. RC

      So therefore, we have to be damn sure we haven't missed-

    26. PO

      Yeah

    27. RC

      ... the serious thing, which I-

    28. PO

      Really important

    29. RC

      ... which is important, right.

    30. PO

      Yeah.

  10. 27:07 – 33:04

    Scans aren’t the answer: how MRI language and interpretation shape outcomes

    1. RC

      Well, let's jump to myth four-

    2. PO

      [laughs] Yeah

    3. RC

      ... right, because it speaks to this, and I-

    4. PO

      Yeah

    5. RC

      ... I think, I think this is huge. I think this is a problem that's getting worse.

    6. PO

      It is, yep.

    7. RC

      Whilst initially people might think scans are a good thing-

    8. PO

      Mm

    9. RC

      ... I think for so many people, they cause more problems.

    10. PO

      Yeah. The MRI has created a massive issue for people with back pain.

    11. RC

      Right. So we're gonna talk about that.

    12. PO

      [laughs] Yeah.

    13. RC

      But myth four is scans are always needed to detect the cause-

    14. PO

      Yeah

    15. RC

      ... of lower back pain.

    16. PO

      Yeah.

    17. RC

      You're saying that's false.

    18. PO

      Yep. So that's true for the serious group we talked about, malignancy, um, cauda equina syndrome with the compression of the nerves.

    19. RC

      A scan is helpful in those-

    20. PO

      Really important

    21. RC

      ... in that small minority.

    22. PO

      Really important.

    23. RC

      Now, someone, a layperson may be listening, Peter-

    24. PO

      Yeah

    25. RC

      ... and go, "Okay, but how the hell are we meant to know if it is that-

    26. PO

      Yeah

    27. RC

      ... unless we do a scan?"

    28. PO

      Yeah. So that's why you have trusted healthcare practitioners-

    29. RC

      That's right

    30. PO

      ... who can, you know, screen your story, your history. They can look for the key features of... 'Cause we know there are key features that will be predictive of that, and that's why you need trust in your healthcare practitioner, 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.

  11. 33:04 – 52:23

    Beliefs, culture, and learned pain behaviors: why disability differs from backache

    1. RC

      We know that there are some countries and cultures where they don't get backache, or they get less. There's a, there's a lower incidence, or-

    2. PO

      Well, I think there's a difference between backache and disability, and we often-

    3. RC

      Okay

    4. PO

      ... 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 and middle income countries. But there was a recent paper 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, they can't survive. So in a sense-

    5. RC

      Mm

    6. PO

      ... back pain is a common human experience. Disability is something else.

    7. RC

      Mm-hmm. That's interesting, isn't it? Because that really, that also brings in the idea of the brain, right? And-

    8. PO

      Yeah, and beliefs as well.

    9. RC

      And beliefs.

    10. PO

      Yeah.

    11. RC

      And we were chatting before about my conversation maybe two years ago now with Howard Schubiner-

    12. PO

      Yeah

    13. RC

      ... who also does a lot of great work-

    14. PO

      Yeah

    15. RC

      ... in chronic pain-

    16. PO

      Yeah

    17. RC

      ... and his belief that the brain-

    18. PO

      Yeah

    19. RC

      ... creates these neural circuits, and if we get-

    20. PO

      Yeah

    21. RC

      ... scared and-

    22. PO

      Yep

    23. RC

      ... um, we have fear, and I know we're-

    24. PO

      Yep

    25. RC

      ... gonna talk about that as well-

    26. PO

      Yeah

    27. RC

      ... how they can create these self-perpetuating-

    28. PO

      Yeah

    29. RC

      ... loops in the brain.

    30. PO

      Yeah.

  12. 52:23 – 1:07:12

    Why clinicians must address emotions: pain as an embodied experience

    1. RC

      You're a physiotherapist.

    2. PO

      Yep.

    3. RC

      Right? A lot of people in the UK who have chronic back pain and end up seeing their doctor-

    4. PO

      Yeah

    5. RC

      ... certainly within the NHS, will then be referred on to physiotherapists.

    6. PO

      Yep.

    7. RC

      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 biopsychosocial elements that contribute to backache?

    8. PO

      They should be.

    9. RC

      Or do you think it still hasn't moved on much, and it's still deemed very much a mechanical issue?

    10. PO

      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. [laughs]

    11. RC

      Mm.

    12. PO

      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 bend over for a lift." [laughs] Like, we see this kind of ... Human beings have got all these-

    13. RC

      Yeah

    14. PO

      ... kind of, um, mismatches between our own beliefs and behaviors. And so part of-

    15. RC

      They're just-

    16. PO

      [laughs] ... 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. 'Cause if you don't, you know, we know that most of our educational interventions for clinicians don't change their behavior at all, amazingly.

    17. RC

      Well, that's really interesting, isn't it?

    18. PO

      [laughs]

    19. RC

      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?

    20. PO

      Yeah.

    21. RC

      When they're doing their training. And they get used to practicing a certain way, right?

    22. PO

      Right.

    23. RC

      So they have a system in-

    24. PO

      Yeah

    25. RC

      ... how they do things in the time that-

    26. PO

      Yeah

    27. RC

      ... they have allotted to them.

    28. PO

      Yeah.

    29. RC

      And then they might hear something new and novel. They may read some research, they may read some of your research or watch-

    30. PO

      Yeah

  13. 1:07:12 – 1:30:12

    Cognitive Functional Therapy and the RESTORE trial: personalized recovery through function, meaning, and self-management

    1. RC

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

    2. PO

      We do, yeah. So look, the RESTORE trial was a kind of like a critical-

    3. RC

      This is what you published in The Lancet

    4. PO

      Yeah, that's right. Yeah. So we'd had a number of small trials, uh, uh, in different countries, um, one in Ireland, uh, one in, uh, Norway, um, that had demonstrated the effectiveness of this intervention, which we call cognitive functional therapy. We j- we had to come up with a name. Um-

    5. RC

      I like it

    6. PO

      ... and the F is so important because it's about the behavior. So CBT, which is cognitive behavioral therapy, is what a lot of, uh, psychologists will use around thoughts and behaviors, which are great. The F bit's about the function, the, about the back, the body, the whole body, and that's sort of what you're tapping into. And, and that we look to the body, we ex- explore, you know, the confidence in, in the back, the ability to move, to relax the body, to, to build safety back in the body. That's one of the key elements of this intervention. So the trial was, uh, based in Australia, and 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, uh, there into their 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, uh, which essentially was to s- the first thing is to take, hear their 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."

    7. RC

      A-

    8. PO

      "To validate me, to help me understand that actually I'm not going crazy, that this is a real experience."

    9. RC

      Mm-hmm.

    10. PO

      "That your pain is real, that the impact of pain i- is huge in your life, but let's build hope back."

    11. RC

      Mm-hmm

    12. PO

      You know, let's understand the factors that, uh, are relevant for you, and they're different for everybody. So, and then let's personalize a program. Let's understand your confidence in your body. Let's have a look at your mood. Let- 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. Uh, if it's driving, we want to look at how you hold your body in a 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.

    13. RC

      Right

    14. PO

      That to build, you know, like an optimism back around their body w- uh, 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 gonna target, and that's a moving target 'cause 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 thoughts, be it behaviors, which often it's a combination of factors, be it 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 have 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."

    15. RC

      Yeah, I love it

    16. PO

      "And my mental health is better." So it's never just about the back.

    17. RC

      Yeah

    18. PO

      It's about all of these factors, and I think, you know, people with pain get that. They get it when w- they, 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'd had so much treatment, bit like yourself. They've been through, they've been scanned, they've been given stuff, and they've literally gone failure, failure, failure until the point and they've just given up. A- and that's so sad that we've got people living in our society who have literally given up on healthcare 'cause 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. A- and so getting back to the, the, to the social enterprise-

    19. RC

      But what, what did the results show 12 months later?

    20. PO

      Yeah, so, so literally what we found is that this is, was compared to usual care, and they could have anything they wanted.

    21. RC

      Right

    22. PO

      A lot of them had given up on care. Then l- about 60%, 58% were on medication. Around 28% were seeing variety of different people. Um, we found significant reductions in their disability The key thing was it wasn't just after the treatment. This l- the, it actually continued to improve 12 months later.

    23. RC

      Yeah.

    24. PO

      We've got unpublished data showing that the improvements are lasting out to three years. So-

    25. RC

      That's, that's what we're really looking for 'cause one of the-

    26. PO

      That's what we're interested in, right?

    27. RC

      Yeah, 'cause one of the critiques of a lot of trials is that, oh, it only lasted four weeks.

    28. PO

      Exactly.

    29. RC

      It only lasted eight weeks.

    30. PO

      Most back pain trials show that.

  14. 1:30:12 – 2:07:30

    The remaining myths: posture, core, ‘wear and tear,’ flare-ups, and overuse of meds/injections/surgery

    1. RC

      Myth six, lower back pain is caused by poor posture-

    2. PO

      It's a massive belief

    3. RC

      ... when sitting, standing, and lifting.

    4. PO

      Yeah, massive belief. So-

    5. RC

      Not true?

    6. PO

      Not true. There's not a single study that supports that.

    7. RC

      To make sure you're taking action after watching this video, I have created a free breathing guide that's gonna help you reduce stress, calm your mind, and boost your energy. In this guide, I share with you six really simple breathing practices that work immediately. Even just one minute a day will start to make a big difference. To receive your free guide, all you have to do is click on the link in the description box below. So why do we think poor posture is a cause?

    8. PO

      I think it's part of, you know, our, our sense as, 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, [laughs] I think-

    9. RC

      Mm

    10. PO

      ... of 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's process of like, you know, shoulders back, brace your core. 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, text neck or, you know, if you sit slouched, you're gonna 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 nos- nocebic thought, uh, like a, 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 in the body.

    11. RC

      So I wanna make sure we're not confusing anyone, right? So if someone is, is listening to this and they have got chronic lower back pain, and they have been taught to do those things-

    12. PO

      Mm

    13. RC

      ... and they are currently doing those things-

    14. PO

      Mm. If it's working for them, no worries.

    15. RC

      Fine. So you're saying if it's working for you-

    16. PO

      Yeah, but don't think of it as a panacea, 'cause I think there's, 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-

    17. RC

      But, but hold on a minute. Let me just pause you there.

    18. PO

      Yeah.

    19. RC

      Agreed. This is something I've also experienced myself. The more I can put my spine in different positions-

    20. PO

      Yeah. Exactly

    21. RC

      ... the better.

    22. PO

      Exactly. Vary it.

    23. RC

      But you're often told to keep that back straight, keep the core on.

    24. PO

      Yeah. Not helpful.

    25. RC

      You're not moving your spine much there, are you?

    26. PO

      No.

    27. RC

      You're keeping it quite locked.

    28. PO

      But, but not only that, you're, you're tensing your body. It's not normal. Like, it's literally not normal. When-

    29. RC

      So you're saying you could do it temporarily for a big lift.

    30. PO

      Yeah, of course you can.

  15. 2:07:30 – 2:13:13

    Closing message: practical hope, clinician-patient partnership, and where to learn more

    1. RC

      You're, 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'll, we'll try and put links to them in the show notes-

    2. PO

      Yeah. Great

    3. RC

      ... for people who wanna check out your papers. Um, where are the websites that people should go and visit, both patients and-

    4. PO

      Yeah

    5. RC

      ... healthcare professionals if they wanna learn more?

    6. PO

      Yeah. So just to highlight that I'm part of a big team of people, so it's not just my work. Um, uh, like, you know, there's a whole group-

    7. RC

      Sure

    8. PO

      ... 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, [laughs] you know, researchers, clinicians. Um, in terms of the, the kind of, um, opportunities for learning, our- the Evolve, uh, Pain Care Academy website, which is this social enterprise, will have a hub for patients, a hub for clinicians.

    9. RC

      Amazing.

    10. PO

      And, uh, what we-- uh, all of that's free. So we want to create, um, uh, a way of empowering... W- 'cause we see it as this partnership. It's not enough to empower the clinician if-

    11. RC

      No

    12. PO

      ... if the patient's uninformed. It's not enough to empower the patients-

    13. RC

      Totally

    14. PO

      ... if the clinicians are giving them completely contradictory advice, and that's, that's something, that's a place that we wanna use to bring patients and clinicians together to work in partnership.

    15. RC

      Yeah.

    16. PO

      Um, so that's a great place. And on that also we have access to, um, any open access, uh, material. We s- we've summarized it. There are patient stories. We- we're, w- it, it... 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.

    17. RC

      Yeah. Love it. Okay. Brilliant. Um, the therapy you talk about, and you've spoken about during this conversation-

    18. PO

      Mm

    19. RC

      ... cognitive functional therapy.

    20. PO

      Yeah.

    21. RC

      A lot of that will be on the website as well.

    22. PO

      Yes. Exactly. Yeah.

    23. RC

      And, and my interpretation of what I read was that there's kind of three components to it. There's, one, making sense of the pain.

    24. PO

      Yeah.

    25. RC

      Two, exposure with control.

    26. PO

      Yeah. Yeah.

    27. RC

      And three, lifestyle changes.

    28. PO

      Yeah.

    29. RC

      Is that a reasonable summary?

    30. PO

      Yeah. It is. Yeah.

Episode duration: 2:13:13

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