Rethinking Back Pain – Retraining the Brain ABC Radio Health Report
Rethinking what’s best for low back pain
Do you suffer from lower back pain?
Thousands of Australians have a ‘bad back,’ and it’s damaging your lifestyle and your health.
But the evidence shows expensive treatments, sometimes risky, like surgery and cortisone injections, are overused to treat back pain.
Cheap, effective care is under-used.
Then there are new understandings of how best to deal with back pain.
It’s about movement — and retraining the brain.
To bring you the latest, Ann Arnold has been on the road for the Health Report.
Associate Professor of Physiotherapy, Faculty of Medicine and Health Science, Macquarie University
Cathryn Jakobson Ramin
Journalist; Author, ‘Crooked: Outwitting the Back Pain Industry and Getting On the Road to Recovery.’ Published by Harper Collins.
Assistant Professor, Pain Researcher, Bond University
Director, Neuro Orthopaedic Institute, Flinders University
Professor of Clinical Neurosciences, Chair in Physiotherapy, University of South Australia
Dr Norman Swan
Norman Swan: Hello and welcome to the Health Report with me, Norman Swan. Today a special feature on low back pain.
David Butler: And I was looking for examples from the group and someone yelled out, ‘Orgasm!’
Audience: Oh yes! (Laughter)
Norman Swan: Well that might be one antidote for some people, now that codeine’s no longer available off the shelf. But back pain is one of the most disabling conditions in terms of cost, lifestyle and work constraints. But the health system’s response, the evidence is showing, is skewed. Expensive and potentially risky treatments such as surgery and cortisone injections are overused, and cheap and effective care is underused when there are new ways of thinking about dealing with back pain more safely. It’s about movement and retraining the brain.
To bring you the latest, Ann Arnold has been on the road for the Health Report.
Ann Arnold: Those squeals you hear belong to an otherwise sensible physiotherapist who’s being attacked by killer robots in a park beside the North Wollongong Surf Club.
Deirdre McGee: When they fly at you they’re so real!
Ann Arnold: Deirdre McGee is playing a virtual reality game. She’s meant to be shooting the robots; it seems she’s losing.
The robots are flying at you…
Deirdre McGee: Yeah…they shoot you in the face…the robots come at you…
Daniel Harvie: You need to pick up more guns. Drop those ones and pick up the next ones. Yep. And the left one. Good, well done.
Ann Arnold: Deirdre’s holding two remote control devices and pressing their buttons. But in her virtual world she thinks she’s holding guns and pulling triggers.
Deirdre McGee: I can see my hands, but it’s not in my body.
Ann Arnold: She’s getting a glimpse of how the mind can be manipulated to change perceptions of the body, and therefore, potentially, of pain. It was part of a Pain Revolution tour of regional NSW. A bunch of researchers and clinicians educating the public and local health professionals about new approaches to pain.
Cutting edge brain research is just one of the options that might help deal with the perennial problem of lower back pain.
Mark Hancock: What drove this series of papers in the Lancet was primarily the fact that low back pain doesn’t seem to get the attention of a lot of other conditions. But we know it’s actually the number one cause of disability around the world.
Ann Arnold: Associate Professor Mark Hancock was one of 30 international authors of a major Lancet series on lower back pain published recently.
Mark Hancock: We had a feeling from some of the literature that had been published that a lot of people were receiving the wrong types of treatments, the treatments that aren’t recommended in guidelines, and that’s very much one of the strong findings from this series of papers.
Ann Arnold: Australia fits a pattern the researchers found throughout the developed world.
Mark Hancock: The best examples of treatments that seem to be being used excessively and are potentially dangerous include things like spinal surgery, particularly complex fusion surgeries; spinal injections; and also the use of opioids. So these all carried quite significant risks of harm. And again there’s not strong evidence of these being highly effective interventions.
Ann Arnold: Not for any forms of lower back pain?
Mark Hancock: That’s a great question. For some forms of back pain they are appropriate—in very limited cases though. And at the moment they’re being very, very widely used.
Ann Arnold: Exceptions that might require major interventions include fractures and tumours. But in Australia, for non-cancer back pain, spinal fusion surgeries rocketed up by nearly 170% in the nine years to 2006, according to a study published in the Australian and New Zealand Journal of Surgery. In the study, the operations were almost entirely in the private sector, and the authors suggested the rise was attributable in part to over-servicing.
Cathryn Ramin: You can never consider surgery as your best option. It is never your best option, because an intact spine is always better than a surgically altered spine. My name is Cathryn Jakobson Ramin, and I am the author of Crooked: Outwitting the back pain industry and getting on the road to recovery, which was published by Harper Collins in May 2017.
Ann Arnold: The very title itself, the back ‘Industry’, why is it an industry?
Cathryn Ramin: Well, you know I didn’t think it was an industry when I got started on this; and I got started on it as a patient, because I had been dealing with back pain since the time I was about 16 years old. And by the time I finished my first book I was in so much agony that I could not envision how I would write a second one without really taking serious steps.
And so as I went through that process, and it took a while, I started to realise that so much of what I was seeing and hearing, there was no good scientific evidence base for. It was an industry because it existed to make money.
Ann Arnold: Cathryn Ramin found herself on the back pain treadmill.
Cathryn Ramin: The first time that I sat myself down in a surgeon’s office, I looked around and I noticed that there were people all over the reception area. Every chair was full. There were people leaning against walls. There were people sitting on the floor. And so I really recognised that money was being made here, big time.
And that was just the beginning. I started to look at what was being done in terms of interventional pain management, i.e. injections, and those are given widely in the US. Injections of cortisone. And there was no evidence base for that. And then I started looking at spinal fusion, and same thing.
Then I started looking at something that I notice is getting rather hot in Australia currently, which is total disc replacement. And there was absolutely no evidence base, and there were a lot of issues in terms of how these devices had been passed by the Food and Drug Administration. There was a lot of crooked activity in fact.
Ann Arnold: Back to those ubiquitous cortisone injections. Well, the Australian picture is not much different to the US. Mark Hancock:
Mark Hancock: The rate of spinal injections has gone up astronomically over the last ten or twenty years, and there’s been a lot of controversy about this. We and other people around the world have looked at this, and the consensus seems to be that spinal injections have very, very small effects that are probably not on average useful or important effects that patients would notice. So again, we’re recommending these not being standard treatments, and being used maybe in very select cases. But the problem is that they’re just becoming very standard and very common. The rates have doubled or tripled over fairly short periods of time.
Ann Arnold: At Sydney’s Convention Centre in Darling Harbour a group of 25 doctors and other clinicians are gathering outside a pain conference. They’re decked out in lycra—black with fluoro polka dots, and are about to cycle to Wollongong.
Karen Jones: I’m Dr Karen Jones. I’m a pain physician from Melbourne, and I’m doing this ride because I grew up in the country and we’re going to stop in lots of country towns and do pain education for GPs and patients along the way. And that’s what I think really makes a difference for people with pain, is to understand what’s going on.
Ann Arnold: Each of these cyclists, nurses and physiotherapists among them, has had to fundraise $3000 to cover the costs of their ride. From Sydney to Albury via Wollongong, Canberra and other stops. They’re also funding the training of a local pain educator in each location.
Simon Macklin: My name’s Simon Macklin. I’m an anaesthetist in Adelaide. So the pain revolution is about empowering local communities to provide that psychological support. Physical, psychological, physiotherapy they need to continue functioning in their local communities.
Ann Arnold: I’m Anne Arnold and this is the Health Report with a special feature on lower back pain.
At Wollongong, the first stop for the cyclists, the Brain Bus, which is also on the tour, has already set up in a park next to the beach. The Brain Bus is manned by researchers demonstrating new developments in brain science. It’s the neuroplasticity road show. And that’s where local physio Deirdre McGee is having her monster robot encounter.
Daniel Harvie: So Deirdre is going to experience some virtual reality. This is something that tells us a bit about how the brain constructs reality from visual information. Okay, let’s get in and do it.
Ann Arnold: Deirdre is wearing a head-mounted display, a screen inside what looks like a snorkelling mask.
Daniel Harvie: I’m Dr Daniel Harvie from Bond University on the Gold Coast.
Ann Arnold: And what do you research, Daniel?
Daniel Harvie: Well generally speaking the role of the brain in chronic pain. And I use virtual reality as one of my tools for that. And I’m also interested in sensory training.
Deirdre McGee: I’m shooting but they’re not dying…
Daniel Harvie: Saving the world from killer robots!
Deirdre McGee: I don’t have a gun in this hand…
Daniel Harvie: Reach down and get it. That’s it. Open your hand and then close it on the gun.
It’s actually quite remarkable that you can put a screen in front of someone, a virtual reality screen, and really transport them to an alternate reality.
Ann Arnold: And there’s potential to apply this to the experience of pain.
Daniel Harvie: There may be some potential use of virtual reality in pain treatment, but for the purpose of today, it’s really about giving people an experience of altered sensory perception. To challenge our normal thoughts about how the brain works and how our feelings of the body work.
Ann Arnold: Because you guys believe that it’s wide open, that we really need to explore different ways of managing our thinking—and therefore, hopefully, our pain.
Daniel Harvie: Yeah, we do. I think for too long we’ve focused too strictly on what’s happening in the body, and in doing that we’ve ignored a lot of other potential contributors that could be helping people who have ongoing pain problems.
Deirdre McGee: Okay, I’ve got both guns.
Daniel Harvie: Okay, you’ve got the hang of it?
Deirdre McGee: Yep.
Cathryn Ramin: What did you think of that?
Deirdre McGee: Well I’ve never played a computer game.
Ann Arnold: Along on the tour is journalist Cathryn Ramin, the author of Crooked, the book about the back pain industry. She’s come from San Francisco to learn more about Australia’s ‘world-leading’ research work on the brain and pain.
Deirdre McGee: … not attached to my body…
Cathryn Ramin: You figured it out. Your brain was quite quick at working out the problem, right?
Deirdre McGee: Yeah. It did really feel like I was somewhere else.
Ann Arnold: Cathryn Ramin is writing about the brain and pain research for the international science magazine, Discover.
Cathryn Ramin: Is there anything that you have learned here so far that you might convey to a patient, or is it too soon to say?
Deirdre McGee: No, no. Definitely the picture of the mountains and the pain buffer is a great analogy to show patients, to help them understand.
Ann Arnold: The picture shows an Activity Mountain. At the peak of the mountain is the injury. Below it is a large chunk of mountain that’s the Protective Pain Zone. It’s often unnecessarily big, and it’s something the brain creates, influenced by fear and other factors. The theory is that you can exercise within that pain buffer. The pain is not necessarily an indicator that further damage will result.
Cathryn Ramin: Do you find that it’s counter-intuitive for most patients that if they’re in pain that they should move?
Deirdre McGee: I think they think that if it hurts when they move, that they think it’s counter-intuitive. So I think there’s a lot of fear involved, so to have that analogy of showing them that there’s a gap between tissue damage and sensation of pain, I think that’s a really good analogy to help patients to understand how their brain works.
Cathryn Ramin: That’s true, because for so long patients have been told that if it hurts don’t do it. I mean every trainer, every physiotherapist, you know: ‘Stop immediately. Let me know if it hurts.’
Well the issue with back pain, which is what I typically write about, is that it hurts, it all hurts, everything hurts, including sitting down at the table and standing back up, it hurts. So you are going to have to deal with it, right?
Mark Hancock: We absolutely need the clinicians that are looking after the people with back pain to rethink about how they’re managing back pain.
Ann Arnold: Associate Professor Mark Hancock, who’s a physio by background and a lower back pain specialist at Macquarie University.
Mark Hancock: But there’s really strong evidence that a lot of clinicians aren’t following the recommendations.
Ann Arnold: Is this GPs?
Mark Hancock: It’s GPS, physios and chiropractors, and arguably anybody that’s treating low back pain.
Ann Arnold: Because all the evidence is about instead of going into the sickness system, in a sense, it’s about moving and moving away from the pain.
Mark Hancock: Absolutely. So the recommendations for early management of back pain are largely about self-management, and really encouraging people to stay active, which goes against a lot of people’s intuition. In the past there was a strong belief that when people had back pain, the most appropriate thing to do was rest. Unfortunately, it’s still widely recommended as a treatment, despite every international guideline now clearly recommending against bed rest, and clearly recommending that actually staying active, within sensible limits, is the best thing you can do with an acute episode of back pain.
Cathryn Ramin: Here’s the deal: moving is your best option. How you’re going to move? That’s going to depend very much on your preferences.
Ann Arnold: That raises the question of how do you know if the person that you’re seeing—and you went to a whole raft, as a reporting exercise, didn’t you—you went to sports scientists, you tried Feldenkrais, you did structural integration, Alexander technique, etc, etc. So how is a consumer to assess not only the techniques but also the individual practitioners, because that can vary a lot?
Cathryn Ramin: Right. Well, it can be challenging. There’s a lot of smoke and mirrors, there’ are a lot of people claiming to be things they aren’t.
Mark Hancock: The evidence is largely that most of these forms of exercise are reasonably effective for back pain. But things like Pilates, there definitely is evidence from the Cochrane Review that Pilates is effective—maybe marginally more effective than some other types of exercise, but at the moment we don’t have good enough evidence for that.
Good clinicians, despite that lack of evidence, will still try to give people the most appropriate form of exercise for them. So if one person, for example, is clearly very weak in the muscles around their spine, then it makes sense that the exercises would be more focused around strength. If actually they’ve got problems with how they move and the coordination or timing of their movement, then they need quite different type of exercise.
Ann Arnold: But for some, any movement seems impossible.
Cathryn Ramin: People who haven’t moved for years and years; people who are afraid of moving—they can’t just be told that if they stop their guarding and fear avoidant behaviour they’ll be fine. It’s entrenched.
Ann Arnold: And that’s where the mind comes in. It’s about understanding the complexity of pain.
The hall at the North Wollongong Surf Club is fast filling up. They’ve come for a Pain Revolution forum. This one’s for the general public, and later there’ll be another one for health professionals. Both are sold out.
David Butler: Okay. You and I hurt when our brains weigh the world, weigh everything going on, and judge that there’s more danger out there than safety.
Ann Arnold: David Butler himself may well be hurting. He’s just cycled 90 kilometres from Sydney with the other health practitioners and researchers. Some have collapsed in their motel rooms. The cycling is a symbolic gesture about movement and pushing through pain.
David Butler: Equally we will not hurt when our brains weigh the world and judge that there’s more safety out there than danger. Now that’s a bloody hard definition to take on, but it’s a target concept which will open doors for you.
Ann Arnold: David Butler, one of the tour organisers, is a physiotherapist and an adjunct associate professor at the University of South Australia. He’s the director of the Neuro Orthopaedic Institute, an Adelaide based business which organises about 200 seminars around the world every year. David Butler is a showman. Resplendent in green spectacles.
David Butler: Now I’m going to give you a couple of examples here. I’d like you to yell out if you think it’s dangerous or if it’s safe. You ready?
Your doctor reassures you, you’re not alone, there’s hope. Safe? Excellent.
Interest rates on your mortgage go up. Danger! You didn’t know that had an effect on your pain, did you, but now you bloody do.
Ann Arnold: The point is, pain has context, because the brain is influenced by many things.
David Butler: All right. Your partner said yes to joining your yoga class.
Audience: Danger! (laughter, applause).
Ann Arnold: You, in turn, can influence your brain, and that includes seeing your pain more positively.
David Butler: You’ve gone over on your ankle, it’s swelling up fast.
David Butler: Aw, but look at your ankle, swelling up fast…you’ve started the healing already. There’s beautiful stuff in that lovely swollen ankle. Let’s make sure it’s not really damaged badly. If it is we’ll send you somewhere else but, wow, you’re healing already! Well done you old self-healers. Think of that next time you sprain something.
Ann Arnold: And, says David Butler, watch your language.
David Butler: Things you say. Repel the invader. Are you saying, ‘It’s like a knife in there, it’s like a knife in there,’ and you’ve said it a million times. ‘There’s something burning inside there, something degenerated inside there.’ The hints of language—that has an effect on brain change. Can you change it, soften it? Can you, your therapist help you with different language? Just know your strategy: active better than passive.
Pain is a defender, not an offender, all right? That’s a really, really critical thing. But can we start to thinking about, ‘Hang on, this is a protector. I can be sore but safe, I can move with some pain.’ It’s a big societal shift. It’ll take us a while, but this is part of the revolution.
Ann Arnold: The leader of the Pain Revolution movement, as many on this tour refer to it, is Professor Lorimer Moseley.
Lorimer Moseley: Pain is an unpleasant feeling in your body that compels you to take protective action, to protect that body part.
Ann Arnold: Lorimer Moseley is Professor of Clinical Neurosciences and Chair in Physiotherapy at the University of South Australia. He’s talking at the Wollongong clinicians’ forum which followed the public forum.
Lorimer Moseley: And if we can appreciate that pain is a protective feeling, and if we can communicate that to people, we change the game. If people can understand that pain is a protective feeling that is urging behaviour, it’s a game-changer.
Ann Arnold: It requires a substantial reset.
Lorimer Moseley: We use, modern pain scientists, use this language of the brain producing pain. And I think this should penetrate our language clinically. The brain makes pain, the brain produces pain. The brain doesn’t detect pain. The brain doesn’t interpret something out there as pain. The brain makes it. If you hear someone say ‘pain detector’ or ‘pain receptor’ or ‘a pain pathway’, it’s nonsense. There’s no such thing as a pain receptor.
In lab studies, the relationship between the noxious stimulus and pain is variable. It’s not just a bit of variability, it’s massive variability. And this is in a highly controlled laboratory with one researcher in the room. The relationship between the message from the tissues and what the brain does is highly variable then. How much more highly variable is it going to be in the real world.
Ann Arnold: One of those variabilities, an important one, is how a clinician responds to a patient.
Lorimer Moseley: The way you guys look at your patients could send a danger message; could send a safety message. The way you look at their x-ray or their scan in front of them, or you look up and you go, ‘Ooooh’. Ever done that? Surgeons, have you ever done, ‘Yours was the worst back I’ve ever seen.’ The next patient comes in: ‘Yours was the worst back I’ve ever seen.’ (laughter)
Ann Arnold: Ah, back imaging. It’s another thing we’re getting wrong.
Mark Hancock: It’s quite logical that people would expect we can look on an image or on a scan and see the problem, and then there should be a logical treatment for that.
Ann Arnold: But, not so. One of the findings of Mark Hancock and colleagues in the Lancet back pain series was the widespread overuse of imaging, which leads, in turn, to cortisone injections or surgery, neither of which have strong evidence in most cases.
Could you explain why it is that looking at an image of what appears to be some damage or a problem within the back, and it might be a bone apparently pressing on a nerve, doesn’t actually explain why you’re getting back pain?
Mark Hancock: There’s a range of reasons why what we see on a scan may not explain an individual person’s pain. We have really good evidence that a lot of these changes are just a normal part of ageing. So round about 90% of people by the time they get to 80 have these signs of degeneration—maybe disc bulges and these types of things—on their scan. So we know that they’re actually a relatively normal part of ageing. The other reason is that pain is just really complex, and we know pain is influenced by our brain, our interpretation of the threat associated with what we feel, and many other things going on.
Ann Arnold: So something not sitting perfectly within the spine doesn’t necessarily cause pain, either.
Mark Hancock: Absolutely. There’s no doubt you can see really quite substantial changes in the spine in people that have never had pain at any point in their life.
Ann Arnold: Mark Hancock is not part of the Pain Revolution group. He welcomes with some caution the new brain science.
Mark Hancock: The recent increase in understanding of the brain in our experience of pain is really, really helpful and really important work that all clinicians need to understand. I do, however, think there’s a risk of going too far down that pathway, and I guess, ignoring the local factors that contribute to people’s pain. So I strongly believe in an approach that encompasses all of these, and we definitely need research to investigate this more, and to better understand both elements. We still don’t know enough about the local factors that contribute—and when I say local I mean in your back—that contribute to people’s experience of pain.
Ann Arnold: It’s different strokes for different folks.
Mark Hancock: It’s pretty clear in my mind that for some patients most of their problem is driven from factors in their back. And for other patients the role of the brain is really important. And again, to be clear, that’s not people imagining the pain, that’s just lots of things going on in their brain, changes, physiological changes in the brain, that actually influence the amount of pain that people experience.
David Butler: Don’t you leave, don’t you dare leave this saying that we think it’s all in your head—no, no, no. This pain’s in your body. In your life, right? Get yourself checked out, and get the bits fixed that need to be fixed, if they do. If they do. And there’s a lot of other things to consider. Go out, the spice of life. Plan a meal, a market trip. And go out into the market and smell three different things and taste three different things and touch three different things. Because that creativity provides new pathways, new growth in the brain. It’s powerful.
I was going through this in Victoria last year, just outside Geelong. And I was looking for examples from the group and someone yelled out, ‘Orgasm!’
Audience: Oh, yes!
David Butler: Oh yes! Okay. (Laughter) The front row here could be on for a party tonight.
Ann Arnold: The cyclists and the Brain Bus would push on for another seven days, giving presentations each night in a new town or city. And journalist Cathryn Ramin? Her back is holding up pretty well these days.
Cathryn Ramin: Well, at this point I think I can say that I’m pretty well perfectly fine, because I’ve just been travelling for two weeks in Australia and two weeks in New Zealand, and I have been managing duffle bags and suitcases, hiking up mountains, kayaking across lakes, fording rivers and managing the streets of Sydney—that might be the most dangerous part because I tend to look the wrong way when I’m crossing the street. And I would say that I do not have a back problem at this point. What I did discover was first of all I had a very weak upper body. I really did not have enough muscle to support my own spine. And I had a lot of fear. And fear was really taking its toll. I had had enough pain that I was very afraid to do anything that I thought could cause more.
Ann Arnold: Yours was the classic non-specific lower back pain, was it?
Cathryn Ramin: No, I had a lot of leg pain as well. I had a lot of nerve pain. I had such a numb foot that I had issues with driving for a while.
Ann Arnold: Was sciatica a diagnosis?
Cathryn Ramin: Well, sciatica is always the diagnosis but it’s usually the wrong diagnosis, because it can mean any number of things. Sciatica means a compressed sciatic nerve. Frequently what’s going on has absolutely nothing to do with a sciatic nerve. What I realised is what I had primarily was gluteal amnesia. My butt had fallen asleep. And once I began to do the exercises that recruited those muscles and recruited all of the pelvic muscles, things got better and they got better fast.
Ann Arnold: Cathryn Ramin. To reflect what’s now known about good back care in Australia, Associate Professor Mark Hancock is calling for legislative and funding changes.
Mark Hancock: At the moment many of the treatments that we’re talking about as being ineffective and potentially harmful are covered and funded by health organisations, and that’s problematic. And the reality is that drives poor care.
Ann Arnold: Are you saying it would be a more efficient use of the health dollar if the government subsidised a year’s worth of Pilates classes, for example, or physiotherapy visits, or both, rather than an injection or surgery?
Mark Hancock: Absolutely. To move funding to those interventions which are generally cheaper and safer and more effective, importantly, rather than very complex, expensive interventions, is clearly going to be better for the health budget, but it’s also going to be better for patients. So there’s some really difficult and brave decisions that need to be made about what should be funded and what shouldn’t be funded.
Norman Swan: Anne Arnold with that special feature, and thanks also to producer James Bullen and sound engineer Hamish Camilleri. Join me next time here on the Health Report. I’m Norman Swan.
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