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On today's episode, the myths around low back pain with Dr. Kieran O'Sullivan. Welcome to the Run Smarter podcast. The podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life. But more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers. and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp, I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence and start spreading the right information back into your running community. So let's begin today's lesson. I have been thinking for a long time now, should I do an episode on low back pain because there are a lot of myths out there that need to be busted. I do listen to Empowered Beyond Pain podcast, which essentially does what I'm doing, but dedicates it to low back pain. They debunk a lot of myths and very educational, very insightful, tailored for the everyday layman's person rather than, you know, health professionals or physiotherapists or doctors, that sort of thing. And I just wanted to spread that information, but thought, you know, low back pain isn't common, isn't a common running injury. But from what I know about low back pain, a lot of people suffer from it. And what are the odds are going to be runners? And what are the odds that runners have low back pain? That can be quite common. and it might not necessarily be the running that's caused it, but it's a very, very common condition that a lot of people have. I've suffered from low back pain for a long period of time and managed it very well in the last couple of years, but would be nice if someone does have low back pain to know what to do and make sure they don't get into any traps or any myths. And earlier in the week I did release a post around... low back pain and how that it's shown. Well, there is a study that I posted that shows that running actually does help disc, the fluid within the disc and the height within the disc and definitely doesn't cause disc degeneration and quite similar to what we think about when it comes to knee osteoarthritis or knee wear and tear when the myth was that it's due to wear and tear. contacting the ground and there's over thousands of repetitions that joint will eventually wear out, we know is the opposite. We know that runners actually have a lower prevalence of osteoarthritis because ground reaction force actually stimulates cartilage. The same thing that this study has shown, these are the low back and the discs within the low back are quite similar. So actual ground reaction forces and exercise to the body actually helps the discs adapt and helps the discs actually get stronger and more resilient. So when I did post that I was actually surprised at the amount of reaction that I got, the amount of people that said yes I have low back pain this has helped or I have low back pain this is not helping and just allayed my fears of doing a low back pain episode that no one would listen to. It seems that people are very interested in this and so it helped. my confidence with interviewing Dr. Kieran O'Sullivan, who is our guest today. He is a physio, a clinician, a researcher, and a lecturer. He is the senior lecturer in the School of Applied Health at University of Limerick, so it's nice to see or hear a nice Irish accent on the podcast. And yeah, he's done tons of research and tons of studies around low back pain, so there wouldn't be a better person to have on. constantly reference or used as a template for this episode, a paper that was published called Back to Basics, 10 Facts Every Person Should Know About Back Pain. And it essentially debunks 10 myths around low back pain, which I delve into the important ones or the ones that I thought would be most relevant for this interview. And if you wanted to have a listen or have a read to that whole paper, I'll link that in the show notes. And while you're there, I'll also link a couple of other resources, which I'll name at the end of the interview. But we explore a lot. We talk about having a weak core. We talk about posture. We talk about getting scans, having surgery where manual therapy comes into it. Where is there a place for that? And Kieran was fantastic at having this like unbiased view and It was just a pleasure talking to him. We did have a couple of microphone issues, so his microphone was very faint, but I have done some audio editing, so enhanced his audio. Hopefully that helps you listeners, and hopefully it doesn't disrupt things too much. I think I did an okay job, but we'll wait and see. If you do notice that all of a sudden it's a lot louder than usual, and then a lot softer, that'd be why. But yeah, did my best, and yeah. Let's delve into it. If you like these topics, I think we can talk a lot on low back pain that we haven't covered today. So if you enjoyed it and want to hear more about it, let me know. And yeah, let's get on with the interview. So here is Dr. Kieran O'Sullivan. Okay. So let's get started. Dr. Kieran O'Sullivan. Thank you very much for joining me today. I'm really excited to have you on. I actually posted an article around low back pain on my social media accounts a couple of days ago, and the interest was just, uh, More than I was expecting. So it's great to see that even though this is a running podcast and running injuries, the back injuries aren't that common with runners. A lot of runners have low back pain via other means. So I'm really excited to delve into some myths today. Uh, thanks for joining us on the run smarter podcast. Lovely. Thanks for having me, Brody. Let's start with a bit about you and your background and how you developed this interest in this line of work. Sure. So, um, like you said, I'm a physiotherapist and. when you qualify as a physio, you see a lot of people with back pain. So even if you don't have much interest in it, you're going to have to develop some skills in it. That's one part of the story. So seeing lots of patients, but then of course, like a lot of other people, I had quite a bit of back pain myself. And like some people with back pain, it started to be a big part of kind of, well, it starts to have a big impact on my quality of life. So I used to play a lot of sport. I was somewhat good at it and probably was considered part of my self-esteem and my confidence. And because of that being not allowing me to play sport, it kind of really affected my quality of life. And I did lots of the stuff that I would have been telling patients to do and that others would have told me. And with the benefit of hindsight and all the rest of it, I can now see that was probably making the situation worse because I was, well, we can come back to what I was doing, but I was thinking a little bit too much about what scans are shown on my back, worrying a little bit too much about that. Definitely trying to protect my back, but then some of that stuff I was doing to protect it was provoking it. And so through a mix of those things of seeing lots of people with back pain, but I honestly have to say experiencing it myself that probably is what eventually had a big impact on me changing how I view the spine and back pain. Yeah, we'll definitely explore a lot of that and we're gonna cover a lot of myths. There's a paper that's out there that's is called back to basics 10 facts every person should know about back pain and not necessarily in order. Well, definitely not in order. I want to go through a couple of those myths and we can learn from your personal experience and what you've found in the research. And yeah, so myth number seven that was in that paper is it says that lower back pain is caused by weak core muscles and having a strong core protects us from future low back pain. Let's dive into that myth and how that belief was first created. Sure. So we'll say there's a broad belief, even if we leave apart the core element, that there's a big belief amongst the public and clinicians that back been explained by one of two things, damaged discs and joints and all that kind of stuff, or physical kind of deficiencies or dysfunctions by being weak or stiff. So, you know, the whole area of having, um, your core muscles needing to be strong, it kind of fits that very structural kind of paradigm. And so it was, you know, if you look at back pain as a kind of a biomechanical problem, it makes sense that, you know, having strong muscles would help. Whereas it looks now at this stage that if we look at it in terms of prevention, having strong muscles isn't necessarily preventative. Now, that doesn't mean it's a bad thing either. It just means if you were gonna say, what's the best bang for my buck? If you're taking a bunch of runners who want to prevent themselves getting back pain, working on their core strength isn't what I'd want them to get them to focus on. Like if you wanna get good at planks, do planks. If you wanna get good at deadlifts, do deadlifts. There's nothing bad about any of those. It's just that as a preventative strategy, they're not useful. Now we could have, I suppose, another discussion about whether doing strength training of your core is a useful strategy for anybody or when you have pain. And what I would say is we need to differentiate between doing an exercise that might be considered a core exercise, like if we take a plank as one example. I would say there's still nothing wrong with doing that exercise. It's just an exercise. And I cannot think of any exercise that's bad for you. The problem is people like me and others started to translate that exercise and tell people, now you should move like that all day long. And we don't do that with any other part of the body. If you wanna get big biceps, we tell people to go to the gym, heavy weights, but you do it like your time under tension is a couple of minutes at most. And then we tell them to go away and rest and just don't think about it too much for the rest of the day. And we do the same with your Nordic hamstrings and your calf raises for your Achilles. But for the back, and there's a couple of reasons, but we got into this habit of saying, do the plank, but then go around doing kind of low level planks all day, pulling in your belly button and bracing. And that's unnatural. And now we realize it actually can start to kind of add fuel to the fire and be counterproductive. Okay. Is there any correlation between those who do have weak core muscles and those who have low back pain or will have low back pain in the future? So essentially, no. Like there's been the only studies, especially if you look at in terms of future predictive stuff, no, there's nothing. There's a little bit of a correlation in that. Like if you take people with really bad pain. They tend to be weak and stiff and really everything. So there's a correlation between everything and really bad pain. They're more likely to be fearful, stiff, sore, tender, depressed, you name it. But if we look at it in terms of, if you're going to line up a hundred runners and measured a strength test, um, or anything, it's not really, you're not going to take the bottom 10% and say they're more likely to get back. Okay. Let me, I want to share my experience as a physio, uh, what I learned at into private practice. We did some real-time ultrasound stuff. So, you know, putting a probe on the skin, looking on a screen at those three layers of core muscles. And we were actually taught that people with low back pain have a delay in their activation of their muscles, like their transverse abdominis, which is like the deepest layer, touches onto the spine, helps a lot of, um, control of the spine movement of the spine. And. We were taught that. the, there's a delay in the activation of those core muscles. And therefore we need to start reactivating those. We need to start waking up those core muscles. And once we get that activation, once it's not delayed, then that will help protect you for low back pain. Because as soon as you start moving to pick something up, those core muscles activate milliseconds before you actually start moving to protect the back. And therefore if someone has low back pain and we put them, we do a real time ultrasound session and show that. They can't really activate those muscles very well. And we educate them how to correct them and then educate them to activate those muscles while they're lifting. Then it's going to help them timing, help their movements, help their function. What can you say about that? So I would say you weren't the only one who was first of all, taught that I was taught that, and then I kind of passed on some of those ideas to other people. And I did a lot of that work myself. Now, again, there's I suppose we got to be careful and kind of acknowledge that it's still an area that we don't fully understand. But if you looked at, we'll say where a lot of that work started, it was from very smart people like Paul Hodges and Julie Hydes in Queensland, and my own PhD supervisor, Peter Sullivan, and Perth, although their views would have diverged over time. What we can see is that when we look at those studies showing a delay, and really the delay was only seen on fine wire EMG, the ultrasound studies couldn't pick it up. It's a really, really small delay. And that delay that was there was observed in people who don't have pain at the moment, but who report recurrent intermittent pain. What we know when we look at people who are in pain is we don't see that delay. In fact, we see either no change in the activation or an increased activity. So we'll say, if you were gonna talk about people who have disabling back pain, we don't see that delay. We tend to see in people who've had recurrent intermittent back pain, which is still something, but not the big deal we worry about. There might be some hint that when you use find where EMG, there's a delay. But then let's say that held and everybody had that. We still haven't shown that then any particular exercise is better. Okay, so what they've done, for example, is they've done studies, lots of people have done it, where if you take a group with say back pain and a delay in their activation, and you give half of them what we might call trans abs exercises, they are really good at doing trans abs exercises and their back pain improves a bit. You give people... McGill heavy strength stability exercises, they get really good at that exercise and their back pain improves about the same amount. In other words, most things help a little bit and you've got really good at the thing that you've been practicing but it doesn't necessarily translate over to it. So it's a bit like if you want to get good at touching your toes, practice it by all means. But does it mean it'll change your hamstring injury risk? Probably not so much. Now again, if you looked at my practice 10 to 15 years ago, I would have spent more time looking at those individual muscles. Whereas now I actually don't do any of that. I'm still I'm fine with people doing it, but I just wonder if you look at it in terms of the bang for your buck, how much additional value does it give me? And I think, again, looking at the population you see, but on average, I would see far more people with rigidity, stiffness, caution around their trunk rather than people with what we might call in layman's terms, lax, sloppy core muscles. Yeah, let's, let's explore that a little bit more because I do follow Peter O'Sullivan's work a little bit as well. And he often explains that if you were to teach someone to activate their core muscles with real time ultrasound or feedback of something like draw your belly button in and make sure that's engaged when you lift, when you run, when you do these sorts of things. If someone does have a long history of low back pain or chronic low back pain, it does tend to create hypervigilance and like just attentiveness to that area and constantly focusing on that area. Am I switched on? Uh, is, is my brace switched on when I lift, when I move and tends to be unhelpful because what you're doing is drawing more attention to that area. When what you're explaining is the, like any exercise will be good. Any movement will be good. As long as you're getting stronger, getting fit and active. That's, um, the most bang for your buck recovery strategy. Um, do you see, do you often see a lot of hypervigilance and a lot of people overdoing their core activation and their bracing? Yeah, I do. And I think we'll see a mix of people who are just doing it without even thinking about it. It's just, they're sore, they're tensing, they're protecting, and they become caught up in that cycle. But I see a lot who have been kind of encouraged to do that by physios. And again, I suppose the other thing I would look at in terms of, you know, as a, as somebody who looks at running, there's probably been quite a bit of work done on running. kind of retraining in terms of internal versus external cueing, in terms of how much should I tell you to think about having your foot at a certain angle hitting the ground versus listening to the sounds when you hit the ground and that kind of stuff. And my understanding of that evidence is that they would say the external cues are probably more useful broadly in terms of not getting the person to be too hypervigilant about their body. And I would see the same general principles in terms of if you want to look at. somebody's throwing technique or their golf swing or in this case in terms of changing how you move in your spine that for sure there might be times when we want people to be more aware of their body but even when we're doing that it's a lot of just being aware of rather than telling them think about it embrace it is think about it where feels stiff where feels tight can you let go of that can you contract it and even if you go back to old school neurological principles we don't learn to roll and sit and walk by activating muscles. We practice the movements and we become more refined with them. And there's a little bit to be said for the old school ideas of being able to, you know, in terms of tone, contract and relax and allow kind of easy reciprocal movement. And if we think about the things in terms of athletes that stand out for me, if I see a lot of them with that being, it's much more around kind of like the behaviors and the personalities, which can be adaptive as well, but we can see in athletes in terms of like, what's been happening to their... Um, their training volume, what's been happening to their recovery. What else is going on in terms of the big picture stressors in their life and how then how they can get caught up in that cycle. Yeah, very well said. And I think this kind of carries over to the next myth that I had written down, which was low back pain is caused by poor posture when sitting, standing, lifting. Uh, I think based on what you said before, we kind of get the gist about this myth, but is there anything we need to add when it comes to posture? I think the only, no, it's, it's this, in many ways, the same story. I often kind of joke that when I go into a talk and I tell people that I did my PhD on how people sit that almost instinctively people feel guilty and dirty and feel the need to kind of sit properly. And I guess the only thing I think it ties in with the core stuff, even though we didn't touch on it is there is an, a whole section here around body posture and what is aesthetically pleasing. I think we see this for everybody, but more so in women, or in terms of expectations of how anybody, if you are to look either handsome or beautiful or sexy enough, how you should carry yourself in terms of the old ideas of being able to carry a book on your head and you're pulling your belly button and chest out. And there's, when people talk about posture, you have to come back to the idea of what's the outcome of interest. So if I was going in for an interview in the morning, to try and get a grant or a new academic position, I probably wouldn't go in there slouched and relaxed, not because I'm afraid of my disk exploding, but you know, societally we assume that means things around how interested and motivated I am. So posture has loads of different meanings. If I was, you know, I'm a middle-aged balding man, so I'm not gonna be dating anybody anytime soon, but you know, if you were going dating somebody, it has a whole series of ways of demonstrating body language and interest and all the rest of it. But if we look at it in the scientific way of like, What's protective in terms of back pain? Look, everybody gets back pain, or almost everybody does at some point, but in terms of the data of preventing back pain, we don't see that at all. What we can see is that when you get sore, your body does some interesting and weird things, and you can get stuck in certain ways. And the best we can see in terms of kind of how do we break that cycle is a lot around, well, what's comfortable? And again, I'm far from an expert on the running and the footwear stuff. But my understanding is with all the biomechanical stuff that's been done on footwear, an awful lot of it will still come back to, well, we've got to play around with comfort and what works for you. And that might mean the same shoe fits everybody, blah, blah. But, you know, so it's that mix. You know, sometimes when you talk about footwear and there's no one good shoe, people say, think you mean, so there's nothing about footwear that's important. And that's not really the evidence as far as I understand it. there might be a role in changing some of these parameters without saying that's a rigid rule for everybody. And so even we'll say, I did a course at the weekend with some physios in the Netherlands. And as part of that, we had a live patient assessment. And a key part of that in terms of her management was changing how she moved. But it wasn't because there was a, I had a perception of a way that every human being should move. But instead it's like, she's moving in a way that she described she never did before. And it's provocative, but she still taught that she shouldn't slouch. And it was interesting because she said, when I do this thing in the chair and she basically slouches it, I do this and it feels good, but I know I shouldn't. And it's like, she only knows she shouldn't because somebody else has given her this little earworm. This is where it kind of overlaps with our first point, because people kind of take, take in the other direction and they brace, they, they overbrace, they get stiff because they think that's the right thing to do when in fact it's. in most cases, making it worse because you're, you're activating a lot of those muscles when in fact, you, like you said, you should be doing what feels nice or what feels good for you, which might mean slouching, which, which might mean just, you know, letting go of those muscles because constantly switching on. Peter I salve and says, says this all the time. It's kind of like clenching your fist for a long extended period of time. And sometimes if you clench your fist for a long time, we'll just get really, really sore and because people really hypervigilant and not sure. how to move or how to sit and they're constantly just like switching on those muscles and bracing, which doesn't allow for recovery at any point. And I think, you know, instinctively, people understand that idea then as long as you give them almost permission to let go and that, you know, it's not that they're a bad person or a lazy person if they start to let go. Probably the most challenging group to get this message across to our people who are involved in terms of work or sport in terms of very heavy activities. So if you're dealing with say front row rugby players and rugby union, for example, they really truly need to be very strong. And there are times in a scrum where they absolutely need to exert kind of core stiffness, but then because, and that's truly the case. And they need to practice that and get good at it. But then it's hard for them to realize that, well, actually when I'm getting up off the ground after the scrum and running across the pitch that I shouldn't be still holding myself stiff in that. Because there is that perception out there that strong means stiff. Whereas when I think of the strongest, you know, most powerful athletes, if I'm talking about Rafa Nadal to Cristiano Ronaldo, I think of them being strong, stiff. When they're playing at the wrist, I never think of them being stiff or rigid, however. Yeah, good point. What can we say about lifting? Because there's a lot of education or a lot of advice that's circulating out there that we should have a good lifting technique. We should keep our back straight. We should brace our core. We should lift with our legs. If you... lift too many times, this will increase your low back pain or increase the risk of low back pain. What can we say about this? So I'll divide it into two parts because there's what the evidence tells us and then there's the stuff I think, but we don't have the data for. So what the evidence tells us is that we spend a fortune on kind of trying to prevent muscular skeletal disorders through manual handling training that's mandatory in lots of cases and, you know, ergonomic design of you know, computers and laptops and all the rest of it. And it looks like whether you're doing this with pain free people or people who have pain, that it's almost all a waste of time. You know, it's just a huge amount of effort going into it. At the same time, legally, if you're an employer, you have to provide some kind of prevention training if you don't want to end up being sued. You know, so there's an obligation on employers to provide some training. It just it looks like we've done a couple of studies, David Nolan in the UK, Dermot Horgan in Ireland, and they've done studies essentially looking at the beliefs of physios and manual handling advisors. And it looks. like you would expect. We are telling people, be careful, be careful. And if you ever bend your back, you're gonna be in big trouble. And that's very old fashioned, outdated, telling people their body's vulnerable. Now, we don't actually know what we should do, but I suppose my sense is that same as anything, if I wanted to get good at running and not get injured running, I would practice running. And I would gradually practice doing more of it and going at faster speeds. And if I'm going into a job where I need to do lifting. let's say I have to lift boxes that are 30 kilos or 60 kilos. The current paradigm is basically telling people, don't lift it, or if you're going to do it, lift it really carefully and worry about your back when you're doing it. Whereas my sense is that what we should be doing is making sure that there's maybe maximum loads that can be shared as much as possible. But other than that, if you have to lift 30 kilos, we should be making sure you can lift 10 kilos and 20 kilos. and 30 kilos and conditioning you to do that job and not talking to you about the vulnerability of discs, but actually talking to you about the importance of having strong legs and moving efficiently and so on. And that's where we'll say, there again, there's that nuance. I really think the manual handling stuff is a mistake and I think it's very overvalued and overemphasized. That doesn't mean we should do nothing for people. We probably have a good role in terms of showing, telling people if you need to lift, you should get strong enough to lift. And again, looking at not just lifting, but whatever the demands are of your job. But unfortunately, because that paradigm of back pain is an injury persists, we end up with situations where, I can think of nurses I've seen, who have nurses get lots of back pain and lots of sick leave. And I've seen nurses where they will shift, switch from a day shift, where there's a bit more manual handling to a night shift, on the basis that might help their back pain. However, That also means that their sleep is never quite the same and they don't see as much of their children by switching to the night shift. And it causes all kinds of chaos and their back pain gets worse. And they don't understand why that's the case when, even if you look at nurses who get lots of back pain, they spend about 3% of their day lifting. So it's not a big part of their job. And there's lots of other things that are much more important like stress and work-life balance and poor job control and all those things we should be looking at. have listened a lot to the Run Smarter podcast episodes. Hopefully they're finding a nice correlation here because this fits exactly with the myths that we go through and the principles that we teach. It's that when it comes to lifting, it seems that it doesn't matter how you're lifting or what form you have, but you need to be strong enough to do the task and the same way that a marathoner can run for four hours where, but as soon as they increase their mileage. too much too soon or too much of a drastic change, then they're increasing their risk of breaking down similar to if someone can run 5Ks, but then they increase their mileage too much. The same thing might be said with, um, with lifting, like if a runner, we don't focus on a lot about running technique and getting that perfect technique, getting that straight kind of posture. We don't really care about that because there's no link to injury, but we need to make sure they're strong enough to do the task. And we want to make sure that if you have to do more, that we allow the body to adapt and we get stronger, we make sure that you're adapting to that task. And not only that, but you're also mentioned around stress and sleep and change in the routine, change in like environments. And we do know for runners, if you do have increased levels of stress and decreased levels of good quality sleep, that can increase your likelihood of injury because you're not recovering, you're not... tolerating the same levels of loads and recovering from the same levels of loads as you once were. So all these principles tie in really well to low back pain and I think that it's really nice to see that kind of uniform principle kind of falling into that. Do you have anything to add to that? No, I think it's a point I raise in that like I appreciate that for example there will be people who will understand shoulder pain much better than me and Achilles pain better than me. I don't see that many of those patients. However, we do make a mistake sometimes just kind of divide people up and say, well, Peter Sullivan, he's good with backs. And Brody, you're good with this. And Jeremy, you're good with shoulders. Whereas I've never seen Peter assess somebody with an elbow pain. I guarantee you he'll be good at it, because he understands pain and understands how these things are connected. And so, for example, if you take Richard Johnson is a Northern Irish physio who is now in Melbourne. He's abandoned us in Ireland to go over there. And he did his PhD looking at endurance athletes. The stuff he found as predictive of injuries are those things you're talking about there that for sure jumps in training load of various parameters, but also sleep and what we label subjective health complaints where you're tired or sad or feeling low in energy. And what we're trying to do is rather than looking at kind of it being vulnerable, just saying like, our bodies can handle quite a bit of stuff, but sometimes if you have a bit too much stuff going on, too much load, too little sleep, other things, your body can have a wobble. And that's not a catastrophe. Like it's very hard to be an elite athlete. Like if I had an elite athlete who said for the last two years they've never had a niggle, I would be suspecting, like that's nice, but I'd be suspecting they weren't training as hard as they could be. You know, like it's just, I'm not saying I want them to be collapsing with stress fractures every three months to prove how tough they are either. But it's almost normal in an active life to get niggles now and again. You learn from it and hopefully they're only niggles and you are not. overreached too much and you can adapt and go on. Whereas if you look at the office worker, there's almost a perspective out there at the moment that if you've got an office worker and she gets a little bit of pain in her shoulder at some point in her time in the office, the employer has failed her and is negligent and there is something seriously wrong with her neck and shoulder. And we've turned what North and Hadler would have described as predicaments of life into like, you know, medical illnesses. Now again, I appreciate for some people, it can become a big thing, but, but so makes and pains is essentially no, let's segue into pain a little bit. Cause there's a myth that's also in that paper that pain related to exercise and movement is always a warning that it's harmful and it's, uh, there's harm being done to the spine and the activity that does cause pain. like the pain should be a signal for you to stop that exercise or modify that activity. That's one of the myths that's in the paper. So could you maybe, uh, enlighten us or give us a bit of insight around that? So I think the key word in that is always. So it's a myth that it always means harm, but because obviously can in Laura Mermozzi is one of his painful yarns books. He starts off the book with an example of how, you know, you don't ignore things cause it could mean something. And so for example, uh, The key issue is to pay attention, don't dismiss things, but just kind of ask yourself as a physio and as a patient, how concerned should I be about an increase in activity? And key markers for me would be whether it's a new activity, is it unexplained or not? So for example, if you're going through, like if you look at, for example, at the moment, in Ireland, the sporting season is restarting after a big layoff. COVID and all the rest of it. I'm sure in Victoria at the moment, there was, even though you're heading into summertime, but there's going to be a lot of people becoming active, especially in team sports in the next while. Now with the best school in the world, even if they've been training on their own, their training load won't be quite what it was. And so you're going to get some people that are going to get a bit sore. The question is, well, how do we interpret that information? And there will be sometimes when it's a warning sign and they should take it seriously, but there's the rest of the time. where there's other time when it's just going to be a reasonably adaptive response of the body. And so the question is how quickly do we panic and escalate? Now there will be certain times when I'll take it more seriously than others without panicking the patient. So for example, if I have a 16, 17 year old who has had intermittent flares of back pain every time they increase their activity, I'd be a little bit more cautious about pushing that activity because at that age, there's a few things they can get like a Paras defect or bone meridia. that we would like to try and avoid. It's not the end of the world if they get them, but just based on kind of like the susceptibility of the body at that time, you might be more weary. In the same way, if you have a runner where they've had a couple of stress fractions before, if they start reporting some kind of prodromal symptoms, you're going to be a bit more cautious, but it's very much based on their history and their susceptibility, rather than the principle that pain is always bad. So it's, unfortunately then that's a kind of a... where you come back to one of these things around like clinical mileage and going with your index of suspicion as a clinician. But it's all we really want to get across to patients is that always tell me if you have pain and we'll try and figure out if this is something that's, you know, we're not gonna worry about or is this something that we need to take seriously? And again, taking seriously doesn't necessarily mean we scare the hell out of the patient. Taking seriously can mean we're just gonna step back from what we're doing for a couple of days and see what happens. And then we might get back on the horse again. On social media, when I did post that, um, low back pain article, there was a couple of comments around people saying that they do have or had low back pain and they were wondering if running, if they should continue to run with it and found that running actually made their back pain better. And so it was a good, that it's good that they have that trial and error process where sometimes if you were to run and you go, if you do have low back pain, decide to run your trial like really. entry level or really like a conservative speed and pace, and then just see how it feels afterwards. If there's no increased reaction, sometimes it might feel better. If there's a flare up, then we know we've learned from that lesson and take it moving forward, which I think if anyone's listening to this, we do with any lower limb injury anyway, for the runner, we make sure that we're not just completely backing off because then structures become sensitive or become weak and you become more cautious and we're not maintaining that same. level of strength. So if you have knee pain, hip pain, achilles, we want to make sure that we're trialing slow dosages of running and then seeing how you're responding. Not to say you go away and, you know, run your usual long run because that's not really sensible. But if you do manage some sort of injury or symptoms, then making sure we are implementing some low level of running and then to see how you respond. And if there is a flare up, then we know, okay, let's take a step back and let's focus on something else and cross-train for a while, but we're still in the meantime, would you agree with that? Yeah, I think the big thing is that if somebody has pain that we don't as default say, well, we have to stop everything. If we just explore and say, well, let's stop for a little bit or change to a different format or tweak the volume or some of the parameters. And then if it's still sore, we can still reduce it further. But I think, for example, it's a bit of a subject investment. But if you say somebody has got a certain level of activity and they get pain, it's almost a question of, well, how do you know how much to drop it? because we can put them on bed rest, you know, that will certainly reduce the pain. But then the lower you drop it and the longer you keep that activity down, the harder the, they're going to lose the training benefits and the harder it is to get them physically and mentally back to where they were. Yeah. And I think that's what, like I say a lot in this podcast, a lot of it is trial and error, but sometimes it is having the right guidance as well. It's having the right health professional or the running coach who can guide you along that way, because a lot of times people. might not know this, their next step and yeah, trialing from there. And like trial and error, it sounds like a terribly unscientific thing, but it is, that's what it is. But it is based on kind of like the scientific principles that are physiologically sensible. Well, like for example, if you were going to forget about pain, just kind of describe the perfect training program for some to improve their fitness. There's no one recipe that we know and we all agree on is best for a 5k runner or a marathoner. but there are probably some things that you know are more sensible than others. It doesn't mean that it'd be perfect for that person, but there's some things that are broadly sensible. And if we can all agree on that, then that's a good starting point. Well said. The next myth I have written down is a bit of a touchy subject, but I'm happy. I'm really looking forward to exploring this. So treatment, this is the myth. So treatment such as strong medication, injections, surgery are effective and necessary for the treatment of low back pain. What can we say about this? So the reason it's a myth is that basically we look at those almost three different groups, medications, then injections and surgery. The evidence is that they don't have a major effect and then related to that, they can have harms, you know, physiological harms, high costs are just side effects. So we'll say in any treatment applying to exercise or anything else, you've got a way up to some extent, the risks and the benefits. And the Benefits are very small. If we look at most people, there will be certain cases where you would clearly be going for surgery, but that's a very small minority. And then if the benefits are small, then we've got to weigh up the risks. And again, it depends on which medications and how extensive the surgery is. But in each one of the cases, we'll say if you looked at the evidence, what guidelines were saying 20 years ago, and then 10 years ago and now, it's becoming increasingly the pharmacological interventions and the interventional procedures in the surgery are looking more shaky the more we look at them. Now so increasingly then what you see is you see the non-pharmacist stuff like exercise you know becoming more and more prominent in the guidelines. We've got to be honest and say that's not because the exercise interventions are looking amazing. It's just that the evidence of harms and costs with the other stuff keeps kind of accumulating and so that's starting to look less encouraging and impressive. exercise education and all the stuff around that is kind of like to a certain extent Underwhelming but the last man standing in many ways in terms of yeah I have a few follow-up questions, but I think I might break it down into a few segments Uh, you did mention at the start of the episode you had low back pain and got scans in the past That might have been unhelpful. Uh What are the dangers of getting scans and when are scans necessary? Okay. So again, I suppose i'm talking about scans in their the narrow basis of kind of like musculoskeletal care and back pain specifically. So obviously scans can be critical in many cases. I had someone in my own family who had to have an emergency aortic surgery recently after a bleed was diagnosed after trauma and the scans were very useful and critical to that care. So I'm talking only in terms of like, you know, the persistent musculoskeletal aches and pains. And essentially there are two problems with the scans. There's number one, they are overutilized. And that's a really hard thing to change because patients want them and there's money to be made by, you know, hospitals, clinics, doctors, radiologists. There's a whole industry around it. So I would like to have less scans. And if it was up to me in the morning, we would fund less scans. But that's a really hard battle. So my most of my energy is around how we interpret the scans, because essentially, if somebody has a scan, even if I think again of the lady we saw at the weekend, her complaint was the MRI scan showed bone on bone. And there's no way that MRI report says that. There's no way that term appears on it. That's a paraphrasing done by a physio or a doctor who's trying to helpfully, if I use that word, simplify terms. And they've described what is essentially the typical degenerative changes in a catastrophic manner. So when are the scans useful? It's in very specific areas where we have medical, serious medical concerns. And in my area, that's really, really small. And then if we, so we have two options of stopping or limiting the harm, actually banning the procedures or making them really expensive and hard to access is I think long-term necessary, but just really hard to do in your own clinic. So the other thing which I would focus on then is essentially if I've got a patient where they're like the desire is there to get a scan, I don't think I can win that debate, then preempt them that look, this is the kind of stuff that you can hear on scans. So if it says this on your scan, You know, that's nothing to worry about. This is what I'm expecting. And I would only change the management plan if we see A, B or C. Just putting myself in the mind of a runner who does have low back pain, if they have severe low back pain, or if they've had long-term low back pain, should they get scans? Um, so again, if it's like, should they, or will they, so they likely will, if they have it for a long time, cause it's like the culture we live in, you know, um, So then my focus will be on like, what are you expecting to see and what for them would constitute a big problem? So if it's, for example, I'll give you a scenario. If it's somebody who's now 30 years of age, they've had back pain intermittently for 10 years, but it's getting more frequent and more troublesome. And, you know, but they don't have any red flags or anything major to worry about. It's just lasting too long. I would try if possible to kind of say, look, do we really need the scan? But if they want then I'll say, fine, now what are you expecting to see in the scan of a third-year-old who's highly active? Are you, what are the chances that they'll show this degeneration? Well, at your age, it's probably 50% at least, and go on and go on. And I would also then, when I get the report afterwards, there's a habit, you know, that it can say on the scan, L1 is fine, L2 is fine, L3 is fine, L4 is fine, L5 is a mild disc bulge. And the only thing that's in the conclusion is L5, mild disc bulge. And we contend to focus on the one kind of positive morphological change and not all the other good stuff. So when we're looking at the report, don't leave out the stuff, but check that they understand the language. And I would start with the real basics. This is good. No fracture, no cancer, no evidence of nerve root compromise. Of all the disc levels they've looked at, it's fantastic. Only the four or the five of them are perfect. And then there's the sort of one that has a bit of what you would expect to see in the backlog of yours. And whether that any of that changes my mind in terms of investigations, the need for search. Does that make sense? Absolutely. And I do have a bit of information that I've written down here when it comes to scans and that, uh, things like, cause people get scans and things pop up. There's, um, like disc degeneration, arthritis, disc bulges. They're like, I guess you can call those kind of common, but When it comes to the accuracy and whether that actually correlates with your current symptoms, that's a whole nother conversation. And just people knowing that a 40 year old that goes and gets a scan, the fact that they've scanned a whole bunch of like people within that age bracket, healthy people, 70% of that population have come back with some sort of disc degeneration. And in that 40 year old kind of population around 50% will have some sort of disc bulge and that's within the healthy population. So who's to say if a runner does start getting back pain and they're in their forties and they go get scans and then it shows disc degeneration or a disc bulge. That can trigger a lot of fear depending on how that message and how those scans are communicated to that runner where I've done a few pain science episodes before, which I hope a lot of people have gone back and listened to can spark a lot of fear and a lot of anxiety and actually. hinder their recovery because they start to think maybe this is really serious. Maybe I should, maybe I shouldn't be running. Maybe this is leading to further damage. Maybe my years and years of running and, um, Contact in the ground, this ground reaction force is actually degenerating a lot of my joints and a lot of my discs and that can like spiral out of control and that fear and worry can actually start to create some long-term problems. And that's what I like when you're talking about the it's whether they should get scans. Yes, they're probably going to get scans via, you know, this, what our culture is like, but how we interpret those scans and how they're communicated to us makes a huge difference. But the fact that people are listening to this episode right now, and they can know that if they go to a doctor and it says that they have disc degeneration, or they do have, um, mild to moderate arthritis, or they do have some sort of disc bulge, that these can be completely normal. And it's very common. than in the healthy population. So if someone were to go to say a surgical option and go see a surgeon and they look at their scans and say, look, the scans aren't looking good. There's a lot of wear and tear and you're probably gonna need surgery, which I see, I hear very often. How much should we trust the doctors and how much should we trust the surgeons if they've looked at scans and come up with those results? I suppose we can to some extent trust any person or any profession as much or as little as any other person in terms of like the surgeons, the physios and all the rest of it. None of them are more or less moral or ethical. And we are all to some extent tied in with our own professional identities. So for example, I hear physiotherapists often criticizing surgeons for saying like these surgeons still want to do surgery when the evidence doesn't propose it like tut tut. yet these same physios if a trial came out showing that manual therapy wasn't useful, they'd say well in that case that study wasn't particularly good and we could put other different spins on this. None of us are free of bias and if you showed me a trial which is kind of inconsistent with what I think, I'm sure I can find a few holes in it and cherry pick a few concerns about it as well. So what I would say about, but your question was answered specifically, I would say that we know about places where there are a conflict of interest, where you are rewarded more for doing more procedures or ordering more scans, you end up ordering more scans. And it turns out that in a lot of those studies, it's been done on radiology clinics and surgeons, especially in the private sector. We also know that if you bring in as a government, we'll say a good policy to reduce the nemenesectomies, it happens much better in the public sector than the private sector, because again, your salary is not gonna be affected by this. All I could say is that I would imagine those same principles apply to most professions. And that what we've got to try and do is, you know, there's lots of complicated reasons, like, you know, if I'm, if I'm going to say to an 18 year old now, look, you're going to qualify in this profession, physio, chiropractor, you know, orthopedic surgeon. But we're going to make you during the course you're training college fees and tuition and expenses in the region of you know fifty thousand dollars to five hundred thousand dollars I shouldn't be surprised that you feel it necessary to make some of that money back and so when we look at some of the places with the most expensive college experiences you end up with some of the most expensive health care in the future as well so we have to kind of control some of those costs and we have to be somewhat skeptical of people offering a treatment just because conveniently that's the treatment I offer. But unfortunately at the moment, I think it's expecting a lot of patients to know how to choose that better, to know that, well, this guy is only offering me that because that's what he do. I think what we really have to do is ask the government. It's not very sexy to say that it's the government's job. We have to have the government and policymakers step in and say, almost divide stuff into there's a difference between kind of an. going to a spa facility because it's nice and getting medical care or rehabilitation. So for example, if you want to go and get a nice massage for your back or some enroma therapy done, I would say good luck to you. But I'm not going to consider that as important as repairing somebody who's got a spinal cord injury surgically or who needs rehabilitation for their hamstring injury because they are things that are evidence-based and we know will improve outcomes. And the other stuff, it's nice and it's pleasant, but I don't see it as being the equivalent. And again, go back to Norton Handler, he would have described the difference between providing really effective care and providing that almost without exception across the board. And then the other stuff, it's almost like an optional extra. Yeah, and I think it's good to dive into this topic as well because I did have written down the question around manual therapy, mobilizations, massage, those sort of interventions and where you think these this approach fits. And I did have a massage therapist on a couple of weeks ago, uh, Alice San Vito, and we pretty much had the discussion of trigger points, knots, all that sort of thing and how they don't really exist. There's not a lot of evidence around that. And we don't necessarily know why a lot of manual therapy does work. And it is very effective because people, you know, once you have a massage, they feel a lot better. We just don't, not too sure why they feel better. There's not a lot of evidence to support that, but, uh, where do you think manual therapy? mobilizations, massage, where do you think that fits in with the management for low back pain? Okay, so I think if you could put all those kind of hands-on therapies together, and again, physios can get very hot and bothered about the discussions about whether it's hands-on or hands-off, and the whole COVID telehealth thing has kind of brought this kind of back into the discussion again, I would divide it into two things, quite differently in terms of assessment and in terms of treatment. So for example, I think it's critical if at all possible, unless you're confined to telehealth, it is critical with a patient with back pain to put your hands on them, to examine them. Now, my training would have been, because that will help me examine, I'll be able to touch and feel spinal mobility and so on. Whereas I think the big thing I'm trying to do, there's an element to which I'm trying to palpate, sensitivity, tenderness, and how tense they are, but also really important to get across to the patient that I'm taking you seriously. I am. examining you properly and taking you seriously. Because if you look at patient complaints, they're the big things that stand out. He didn't take me seriously. He didn't listen to me. He didn't examine me properly, whatever that means. And so doing a proper physical exam, which almost always includes examining the region and kind of to a certain extent, reproducing their pain within comfort levels, because that almost to a certain extent shows he knows what he's looking for or what he's looking at. And so that's really important in my opinion when possible. As against that then, now that I've examined them and taken a history, how much time, if I've got another 20 minutes left or whatever time is left with them, how much time am I gonna be spending pushing on their back or rubbing their back versus doing other stuff? And for me, it's a very small part. It would be, if at all possible, close to none. But because I would see the evidence saying that the long-term effects of the behavioral stuff is probably better, but. I'm perfectly fine with people doing hands-on therapy. I would, however, be interested in what they're seeing while they're rubbing or stretching the person's back. And so, for example, are you rubbing my neck or my back and saying, this is a bit tense? Did you ever notice that that's tense? Do you notice that when we rub it and your pain is better that it feels less tense? And can you think of any other reasons why it might get tense? And so on, getting them to reflect on their pain and describe anything we're doing around things such as. restoring mobility, increasing relaxation, as opposed to doing the exact same treatment mechanically, but talking about how damaged and stiff and bad and knotted the spine is. So again, not necessarily against it, you'd have to be honest and say like, while you could be critical about the evidence of effect being short-term, with the rare exception of like, strange cervical manipulations having rare but serious effects. The evidence for harm for massage and manual therapy is really, really not there. You know, it looks like it's a fairly safe treatment. It's a very popular treatment with patients, most patients not all. And so we come back to the thing of, well, we've got a basket of options. And what in amongst that, where do we weigh up preference, cost and excess? There is something of an ongoing cost with the hands on therapies. So I would imagine it should be a clearly important part in the examination. a less important part of your treatment and becoming less important all the time. Yeah, I'd have to agree. And like you said, that examination part of it is almost like a bit of reassurance in a way that the client could be like, yes, I've chosen the right therapist here. They really are paying attention to my injury and, um, listening to me and increases their level of confidence in you, which then again, will enhance treatment benefits and maybe placebo and like that, um, that treatment effect. And I like how you. talk about like you're going through what the client beliefs and maybe changing their beliefs or the language that you use. And I think there's a lot of people that have created somewhat unhelpful beliefs because of what a therapist has told them. And I want to touch on this a little bit. Mainly people think that their hips are out or there's misalignment somewhere, or they've got mild form of scoliosis or like my hips always fall out of place and I need an adjustment to, um, to get better. And that's a big belief that people have. And if they run thinking that their hips are out, what's that going to do for their belief? What's that going to do for the brain and producing any signals is can we shed some light on this type of language and how detrimental it can be? Yeah. And again, you see it fits in again with the city. The pain is all explained by patho anatomical or biomechanical forces. No. thing is if we were not in front of a patient, so if we're having this kind of conversation, we can make jokes about how silly these people are because they're all saying one leg is longer than the other, yet you know their pants isn't riding two inches further up their leg you know, so this doesn't add up. But with patients a lot of time when they bring these up these are deeply held beliefs and it's not an opinion, it's a fact because they will say well I went to see Brody the last time, I had back pain, he said my hip position or my spine was out. He manipulated it and I felt better. And that assures night follows day means he was right that the pelvis or the back was out of place. And so if you come along and say, well, that's just silly, you're the one that they'll think is silly and incompetent. So what we've got to try and do is help them make sense of that. Now, my sense is, I'm not saying therefore you just do what they want, but it's a bit of trying to get them to explain, well, why do you think it felt better? Because a lot of the time, you know, they'll hear a little crack or. they'll do something and they will feel more symmetrical. But, you know, this is a hard conversation to have in one session, but if it was me and we're talking about alignment, I'll talk about the fact that if my neck gets sore, I'll use the neck because it's easier usually. But if my neck gets sore, I get a crick and I get all protected and stiff and asymmetrical on one side. And if you took a picture of my spine, at that point you would see I'm asymmetrical, I'm twisted and all the rest of it. But that's not because, you know, I've dislocated my. shoulder blade, it's in response to the pain. And once I do something to help the pain, the asymmetry relaxes and the symmetry is restored. And so we don't want people going around thinking that every time they get a bit of pain, it's out of place because that requires somebody else helping them. We want them to understand that when I get really sore, I carry myself in a funny way and my alignment can look superficially different. But it's not that the bones are out of place, we know that. We know when you manipulate somebody, you're not putting their pelvis back in. But we also know that they can feel a bit better from that. So can we take the fact that, good news, somebody responds well to quickly to having something done to them. That's great. Now, is there a way that we can get them to do some of that stuff at home themselves and ideally not feel their body is so vulnerable? Because it's likely what's happened is they've just done too much or they've had a bit too much stress or not slept as well. And so they need to go back to, well, let's focus on. How am I training? How am I sleeping? How's my stress? And not worry about the vulnerability of their body. When I interviewed Alice, the massage therapist, we kind of finished with a bit of a conclusion, which I want to get your opinion on. So around the topic of manual therapy, it's kind of like, yes, if you have low back pain and you want to resolve that low back pain, there is a place for massage and hands-on therapy, but it should mainly be for short-term relief. It should be for short-term relief, unless it feels good for you, unless you want a massage, unless, you know, the, the foam rollers and the massage balls and trigger point releases really feels good and you want to continue with that, that's fine. But it's the language that the therapist uses for what it's actually doing. If they say, you know, your hips are out of line and that, uh, there's wear and tear and there's knots and there's, you know, they can come up with a lot of detrimental language. So B. very cautious of the language that you use and make sure you don't become really dependent on that massage therapy. Like you don't have to continuously go back for relief or you think that you constantly need adjustments and the focus should be on in the short term, yes, focus on the manual therapy, but there needs to be some element of that long-term solution, that being exercise, regular activity, engaging in social like environments and positive like education, positive mind, set of mind, that kind of thing. Would you agree with all of those points? I would agree with the broad principles. Again, I think we have to accept that sometimes, people will have autonomy to make decisions for themselves that might suit their choices. And that doesn't necessarily mean that it's wrong, but it might mean that I shouldn't be paying for it. So for example, I'm gonna say that I like having a nice coffee, I like having a nice beer and a nice glass of wine. And sometimes I get those things and they feel really good. Kind of the way a nice massage would make me feel about those things. The thing is, I don't think the government should necessarily be paying for all of those things. I think they're nice things that I enjoy, but they aren't necessarily all of those things, a form of healthcare that the government should provide. So again, for example, it's not, if somebody feels I'd like a massage, that's great. And if they'd like some aromatherapy or reflexology, or you know, any kind of, there's all kinds of things that people might enjoy. But it comes back to almost that concept of like, what's healthcare that we can say with some, not certainty, but reasonable level of confidence, this is an investment in the person's health and we'll make them less disabled or help them do the stuff that's really important in life and go to work. And then I think as a society, we should spend lots of money in it. And I don't think we do. As in contrast, I think we are still in the public sector providing or in the private sector through insurance subsidizing. Lots of other stuff that we're calling healthcare, but it's really just nice stuff that people like. And again, that's a tricky differentiation to me. But for example, my wife will go off and get her nails done. And there's nothing wrong with that, but I don't consider it healthcare and she doesn't. But I think some of the stuff that people are putting into the healthcare basket, not saying specifically MasterShare, but some of the stuff that people are calling healthcare, a lot of the benefit is often around look, it's a narrow way from the kids or my wife or my husband. But it might be no more or less therapeutic in a medical sense than having a round of golf with my mates. Well said. Yeah. As we wrap up, Kieran, is there any takeaways or any messages that we haven't covered today that you would like to listen to know about? No, I think I think they like I've made. I continue to, but I've made lots of mistakes. talking with too much certainty to patients. So I suppose I've got a bit of a reputation for kind of checking back with people around, look, I've served certain things, what have you heard? And how would you explain that to other people? A really smart physio in the UK, Ian Cowell just finished his PhD and he did a lot of work on conversation analysis, which was looking at the conversations between physios and patients. And it was very interesting looking at these really good physios. looking at the interactions between patients, because a lot of the time they were saying really good stuff, but it was not at all what the patient needed to hear. So in terms of you had patients who would come in with a scan and who was very worried about their ability to go back to work because it involved lifting, but the physios heard scan and just got into a routine talking about, well, disc degeneration isn't the big deal, which is accurate, but that's not where the patient was really interested. So really it's hard when you're tight for time and all the rest of it, but. really focus on what the patient wants to do, what's important to them, and then I suppose spend a bit of time on that. And I suppose if you think about it from a running perspective, the back, you know, will get sore, but that doesn't mean it's vulnerable. In the same way that if you're a runner, at some point your feet and your calf and your shins are going to get a bit sore. It's going to happen. We wish it wouldn't maybe, but it's probably inevitable at some point. We just want to watch that it doesn't become a big deal affecting your training and your quality of life. Yeah. And I'm glad that you mentioned that because I think the, the positive treatments is probably something that we didn't reflect too much on, on this episode. We kind of talked about all the doom and gloom stuff, but I did within that 10 facts paper, they did start covering some facts and one of it is around treatment and treatment can be relatively cheap, can be relatively safe. As long as we focus on education, focus on having a positive attitude, positive mindset about the low back pain. We optimize physical activity. We focus on the mental health components of it as well. We maintain some social activity, make sure we're not isolated from, because of our condition. We focus on nice sleeping habits. We focus on maintaining a healthy weight and just being, just general health can be really, really beneficial for these particular conditions. Anything you wanna quickly add on treatment, if we... No, I would say like, you know, there will always be some things we want to look at specifically at the back. A lot of it comes back to confidence in movement, freedom of movement, but really don't zoom in on the back too much. Step back, think big picture, is the person healthy? And I mean, in terms of, yes, training and rest, recovery, stress, all that kind of stuff, but sleep and diet, nutrition, work-life balance, all that stuff. And if you can, I often say to people that, you know, if I bump into them in three years time. Even if I don't ask about their pain, if I say nothing about pain, but if I find out they're sleeping well, work's okay, family's okay, diet's okay, I won't need to ask them about their pain because their pain will probably be fine too. Okay, nice. And if people want to follow you, learn more about you, I do have your Twitter at Kieran Ocel. Is there any other social medias that I should add into the show notes? No, I'm far too old to be TikToking or doing anything like that. It'll be Twitter and that'll be it for a while. Okay. It would be nice to see you do a tick-tock dance, but I guess, um, that's not an option, but I think there'll be other resources. I'll add in the show notes. One will be the, the 10 facts paper that people should know about low back pain. I found a low back pain communication.com website, which has a quiz, um, done by, um, the Sullivan group and they, I just looked through it the other day. There was fantastic, uh, information provided there. And I will link of mentioned it a couple of times in the podcast before, but, uh, empowered beyond pain podcast, which is mainly around the facts of low back pain, which we'll find Dr. Keelan O'Sullivan on one of those episodes as well, which was fantastic. If people want to listen to that. Um, so all those resources will be there in the show notes. And if you want to learn, I know we just scratched the surface with a lot of these myths and topics, but that podcast as well, we'll cover a lot of that information in more detail. Dr. Kiran, thanks for coming on and sharing all your knowledge. Lovely. Thanks very much, Brody. Thanks for listening to another episode of the Run Smarter podcast. I hope you can see the impact this content has on your future running. If you appreciate the mission this podcast is creating, it would mean a lot to me. If you submit a rating and review, if you want to continue expanding your knowledge, please subscribe to the podcast and get instant notifications when a new episode comes out. If you want to learn quicker, then join our Facebook group by searching the podcast title. 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