
Ben Cormack owns and runs Cor-Kinetic. He is a musculoskeletal therapist with a clinical background in sports therapy, rehabilitation, pain science & exercises stretching back 15 years. Ben specializes in a movement and exercise-based approach with a strong education component and patient-centered focus and runs evidenced-based courses nationally and internationally.
Join us at Practice Human in NYC for Ben’s course September 28-29, 2024. For details and registration CLICK HERE.
Learn more about Ben’s work and follow him via the links below.
Website + blog: cor-kinetic.com
Instagram : @corkinetic
Episode Summary
In this episode, Caitlin and Ben discuss nonspecific low back pain (NSLBP), emphasizing its diagnostic challenges and the importance of understanding pain’s multifactorial nature, including psychological and behavioral influences. They highlight the need for realistic patient conversations about pain recurrence and self-management strategies. Over-medicalization and its detrimental effects on patients are addressed, along with the concept of “movement snacks” as manageable exercises to aid recovery. Ben underscores the importance of understanding pain mechanisms rather than just focusing on exercise. The interview concludes with information about Ben’s course promoting evidence-based approaches for clinicians.
What’s covered in this episode?
- What factors contribute to longer-term or recurrent episodes of low back pain?
- How can over-medicalization negatively impact patients with low back pain?
- What are movement snacks, and how do they help manage low back pain?
- How should clinicians address patients’ expectations regarding the recurrence of low back pain?
- What is the significance of patient beliefs and psychology in the recovery process from low back pain?
Episode Transcript
Caitlin: Welcome back to the Practice Human Podcast. I’m your host, Caitlin Casella. We are diving into summer here in New York City at the time of this recording. It is the first week of June. I just got back from a really fun trip over Memorial Day weekend to visit my friend and yours, Laurel Beversdorf down in Huntsville, Alabama.
I had the pleasure of participating in a 10K race on the morning of Memorial day with Laurel and her husband, Nathan. And it was really great to be down there and reconnect with Laurel. We totally geeked out about all things running and strength training and conditioning and physiological adaptation.
And we had a fun time discussing our running playlists. I made a playlist of music for the 10 K run. I had a goal to run that race in under an hour and I did it. And I decided to put all the music on there that makes me run really fast, which I think if you were listening previously to some of my talk about training for my half marathon, it was really a challenge for me to run slow.
There was a period of time where I had to carefully curate my playlists. So that the music didn’t get too exciting because I can’t, I can’t be trusted to control myself with a slow pace when a good song comes on. But for the 10K race, I really went for it. And it was, it was fun chatting with Laurel about how we use music to drive our training.
And up next, just a little preview up next on the podcast, the next episode I’m going to put out is with Dominique Anne, where we discuss all things. Exercise with music, really interesting conversation. So I’m excited for that. I’m also really excited because as part of that conversation in that interview, we decided to hold ourselves and each other accountable, publicly accountable for creating a couple of Spotify playlists.
That we can share with you all, so stay tuned for that episode And those playlists that we’re going to share along with it should be a really really fun time. The race in huntsville was an awesome course. It was brilliantly Laid out with a giant hill in the middle. So it was pretty flat for the first couple of miles.
Then it had this super, super steep hill, like it was the kind of road where they had to roughen up the street because the road is so steep that cars need, uh, some traction, some tread to get up the road. It was that steep, uh, very, very steep ascent in the middle of the 10K course. And then just a nice gradual downhill that I, I gotta say, I.
Flu on that downhill section. And it felt so awesome. And as Laurel and I discussed together, I think it’s really a testament to the strength training under our belts that we can control those forces when running fast downhill. I had a killer playlist. There was one last little downhill right before the finish line.
sprinted me right, right, right into the finish while I was running to the Muse song Starlight. If you don’t know that song, check it out, put it on when you’re doing some kind of vigorous activity because it will make you move. Starlight by Muse. So it was a fun time. I had a great time down South, a little bit of time in Nashville to hear some music.
And here I am back in New York. I’ve got sort of a mellow June and then we get going with some exciting Programming at practice human in person in July Greg layman’s going to be here if you haven’t signed up for that and plan to attend. It is filling up quickly. We’ve just got a few spots left. Also in July, I am starting a small group strength program on Tuesdays that is called living strength, and it is designed for people 65 and over.
It’s for people who are brand new to strength training and also for people who are finishing up a physical therapy plan of care and looking to continue along the path toward more robust exercise. Uh, my colleague Elizabeth Whip is teaching a shorter version of her True Strength Academy on Wednesday afternoons called Just Train.
It’s for people who’ve already had experience working with Elizabeth, or if you are already experienced with strength training, that will also be starting up in July. And coming up really soon, Elizabeth has an Intro to Strength Training Masterclass. So this is just a one day workshop on Saturday, June 15th.
If you’re curious about strength training, because you’ve heard it’s a powerful way to take an active role in your health, and build a more resilient body, uh, this is a great little session where you can find out about the benefits of strength training, get a little taste of it, and work with master strength coach, uh, Elizabeth with you will love it.
You will not be disappointed. Come and check it out. It’s just a two hour commitment on a Saturday afternoon, Saturday, June 15th. So you can find, uh, all of these in person strength options on our website, practice human. com slash events. And then we’ve got a whole lot more coming in September between Elizabeth and I for in person strength.
Also, I’m really excited to have Ben Cormack here in September, September 28th and 29th. He will be teaching his course, therapeutic movement and exercise, back pain and beyond. We’re going to talk a lot about some of the things that I found most compelling about Ben’s course in the interview. This course helps clinicians confidently navigate the uncertain world of back pain using a practical and evidence based framework.
It is not just another back pain or exercise course at its core. This is about an active and patient focused approach to rehabilitation. It’s underpinned by the key to great recap, according to Ben, which is clinical reasoning. And I couldn’t help you. agree more. This is truly an evidence based look at low back pain and treatment with exercise and movement.
If you want to join us for Ben’s course here in New York in September, you can find out more at human practice. com slash events. I will also link the course page in the show notes. Sign up soon. If you’re interested in joining us, we do have an early deadline on. Sunday, August 11th. If you sign up by that date, you can save 100 off of the course.
So I hope you enjoy my interview with Ben. Ben Cormack owns and runs CoreKinetic. He’s a musculoskeletal therapist with a clinical background in sports therapy, rehabilitation, pain science, and exercise. Stretching back 15 years, Ben specializes in a movement and exercise based approach with a strong education component and patient centered focus, and runs evidence based courses nationally and internationally.
I hope you enjoy my conversation with Ben Cormack.
Ben, Thank you so much for coming onto the podcast to chat with me today. I’m really looking forward to catching up and hearing your take on a few things related to low back pain and movement and exercise.
Ben: Yeah, no, thank you very much. for inviting me and let’s see if I can adequately answer. Your, uh, deep and searching questions.
Caitlin: Good, good. Thank you. Like, uh, so I, one of the impetus for, uh, having you on to the podcast was I took your course here in New York City last year, a little more than a year ago, and I loved your course, and it’s it’s, uh, Truly evidence based and what you share on social media and on your blog is, is I think really the kind of top shelf of what we know about treatment through exercise.
And there’s a lot we do know and a lot we don’t know about therapeutic treatment. With exercise and with movement and I feel like you are the guy to talk to About movement and exercise when it comes to low back pain, so we’ll delve into that pretty deeply I’d like to start by catching our listeners my listeners up, uh who might not know as much about your work on Where you came from in terms of your clinical practice as a physio in the UK and what has driven you to delve so deeply into the literature on treatment strategies, exercise, pain science, biopsychosocial model, which I think in plain terms is just good.
Patient centered care, right? how’d you get into all of this?
Ben: Yeah, yeah. So firstly, I, I, uh, studied what’s called, uh, sports therapy back in the UK many, many years ago. and I think that. really was the genesis of looking at movement and practicing around a movement based approach. So, that ‘s where I come from, I come from actually a sports background, although I talk about lots of pain science stuff and, you know, and I’ve done lots of manual therapy stuff and all these different things over the years, my love and my passion.
was always, uh, movement and sport and activity. and I think because I went down that road and studied in those areas, that’s always kind of stayed with me. You know, I’ve kind of kept that sports therapy practice, throughout everything that I’ve done over the years. What I love that you mentioned there was that I’m top shelf and I like to think of myself there as, you know, like a 30 year old fine Scotch, maybe that is the true definition of top shelf.
I don’t know. I don’t want to be like a cheap bourbon that makes your mouth burn. So the top shelf sounds good to me.
Caitlin: Yes. Yes.
Ben: So, look, I think, I think that, I think that there’s, there’s a buy actually when it comes to being evidence based. and I’m going to get on to the kind of movement stuff in a minute, but when it comes to being evidence based, I think that there’s actually quite a binary line between being evidence based and not being evidence based, and what that means is you have to take the rough with the smooth.
Does that make sense?
Caitlin: Totally. Totally. Totally. Because I think it’s really easy for practitioners. To maybe even choose to ignore the research that does not align with their point of view or their treatment strategy or just their lens. So absolutely. Yeah. Yeah. And cause like, yeah, you gotta take it as it comes.
Ben: Yeah, and I think that’s, I think, you know, if you’re, I don’t want to say truly evidence based because what the hell does that mean anyway? but I have a little saying on my course. So I don’t know if you remember, I’d say research is not here to make us happy. Right. Right. And I think the point there is to say, it’s not to confirm our biases.
It’s not to make us feel good. It’s not to validate our treatments. What it’s really here to do is to try and explain what actually happens when we take our treatments and we test them and we control them and we take them away from our biases and all these types of things. Yeah. Yeah. So from that sense, I think about what I’m really interested in.
is trying to understand, explain, and work with. Some of the gray areas that evidence throws up, you know, in the fact that evidence is not simply a positive thing or a negative thing. It throws up information that we have to work with in clinical practice. So a great example when it comes to exercise and movement, let’s say, is that we know that strength, you know, getting stronger doesn’t have a great relationship with getting people out of pain.
Right. That would be an evidence based statement. But people still go through strength programs and feel better and get better and really enjoy it and have positive outcomes. It just might not be tied into the getting stronger bit. You know, it might be the process versus the outcome. And what I’m fascinated by is the why.
You know, what really interests me is how we can use that information to work better in clinical practice and say we have all these different options to help people, but what’s really brilliant is it’s not tied into getting longer or stronger or whatever. It’s probably tied into a bit more of the behavioral aspects of I enjoy doing it.
I’m going to do it regularly. I see the value in it. And it might be some of those things that really help us.
Caitlin: Sure. Sure. Yeah. I think a lot of the discourse lately and actually something I just saw you post up on Instagram today is really looking at like, yes, we see positive effects from XYZ type of treatment.
What can we kind of drill down a little deeper and say, what is the mechanism by which? Yeah. That thing is having an effect, right? So like, like you said, just kind of the why, why is it helpful and why could various different treatment methods all be equally helpful, right?
Ben: Yeah, but that’s exactly what we see in the research, right?
So we take all these different things, whether it’s, you know, rubbing your toes or standing on your head or playing tiddlywinks or whatever. and we see all of these things when we test them at a population level, they don’t seem to have great differences to them. Now, if we were to do them individually, they may, if you know, if you were to look at the individual outcomes, you may see something slightly different because you know, that’s part of it.
how research works. It is a lot of individual data that we aggregate. But we often see at a population level, a global level, there isn’t just this one type of treatment or this one exercise or this one type of mobilization or manipulation or, you know, massage type that seems to be superior. And I think what we really have to understand is human beings are all made up of quite similar biology, right?
You know, although we’re, we’re wonderfully different in some ways, we’re also, we do have the same, you know, A lot of the same chemistry and, you know, our DNA is, is quite similar to lots of other DNA, right? But we have, you know, similar mechanisms that work for things like, you know, analgesia or, or pain relief.
Whether that’s, what happens through the immune system, whether it’s what happens descendingly from the brain, whether it’s spinal cord inhibitory mechanisms, whether it’s, you know, You know, various different types of chemicals or, you know, different brain areas that switch on and off with nociceptive stimulus like, you know, the rostral ventromedial medulla and these type of things.
And what it helps us understand is do our treatments or our exercises, do they, stimulate the same system, but in potentially some different ways. And that fascinates me. And it helps us understand why understanding biology and mechanisms helps us understand why we see some of the things that we see potentially in the research base.
Caitlin: Yeah. Yeah. I, one of my biases that I know this is my bias from a background in yoga and meditation and somatic type of practice is that I see so much of it as a sensory motor or neuro, you know, neuromuscular through sense sensory stimulation type of treatment. And that can happen on many levels with many different types of movement or exercise or manual therapy or massage.
And, and so I think, I think it’s really fascinating how. on like a sensory level. It’s, it’s always there. It’s like ever present with any kind of kind of treatment that we have.
Ben: Yeah. And I think that, you know, that may be an area where manual therapy has an edge over exercise, for example, that cutaneous touch.
And we know we have certain, you know, type of nerve endings or afferents in the skin that respond to touch. And actually I remember reading that some of them, some of those afferents are actually Kind of shielded from some of the inflammatories that go on. So you can have a kind of positive touch through the skin that may, you know, not stimulate some of those nasty mechanisms that some of the inflammatories stir up, which I find fascinating.
And I think Zussman, Max Zussman talked about that back in the nineties.
Caitlin: Yeah,
Ben: But you know, you have all of these different types of, you know, mechanisms. You might have a painful massage. and that stimulates our kind of noxious inhibitory controls, which release opioids and you know, and these types of things, yeah.
And then we may have a really light touch that’s a very low level stimulus that might trigger other mechanisms. And I find that, you know, really fascinating. Right.
Caitlin: Right. Kind of like the principle behind using a TENS unit or something for, You know, just a competitive stimulus. That’s a light stimulus for someone with low back pain.
Yeah.
Ben: Yeah. So, noxious inhibitory control would be pain inhibiting pain. So that would be, you know, a big stimulus. Yeah. Whereas, a, uh, attending unit might be a little bit more that classic kind of pain gate type of stimulus, which is obnoxious, but does involve kind of more not noxious information. You know, noxious stimuli are competing with other noxious stimuli.
Whereas with a pain gate, that would be slightly different, but they’re both using inherent biological mechanisms that all human beings pretty much have.
Caitlin: Sure. Sure. Yeah. Yeah. It’s really fascinating. And, what you just posted today about manual therapy was really interesting. And I’ll just say right now, we’re gonna talk about this more at the end, but if you’re not following Ben on Instagram, definitely follow him.
It’s CoreKinetic, C O R. C I N E T I C, Court Kinetic on Instagram. Just so much great information there. Let’s, let’s delve a little deeper into pain science education. And while we’re on, on this topic, you, in your course, you mentioned, and I’m just going to, Kind of paraphrasing, correct me if I’m understanding this incorrectly, but it might not be enough to just have a conversation with patients about their pain or sort of give them a little pain science lecture in a, in a, for example, a PT visit that, that might not be as helpful for the patient.
As, some of the movement and exercise strategies that you teach in your course. One of the things you said in your course that really stuck with me, is you said movement is pain science education.
Ben: Yeah, so I think human beings, look, how many things have you been told in your life That you haven’t acted on or you haven’t really believed or you haven’t done anything with, right?
I have a 12 year old son. I’m constantly telling him stuff that he doesn’t take any notice of. But at one point he is going to learn all of these lessons for himself. And he’ll say, my dad told me so. Right?
Caitlin: And I think
Ben: The same is very, very true when it comes to movement, that we can say to people, it’s okay to bend your spine.
Hurt doesn’t equal harm. You know, Uh, the issue is not in the tissue, blah, blah, blah, blah, but actually without experiencing some of that, without actually bending and saying, well, this isn’t as bad as I thought it was, or, you know, without bending over and maybe not even getting pain or, or bending over and having pain, but I can handle it and I can manage it.
You know, that’s not actually going to update my ideas and my beliefs and my thoughts. Just telling someone it’s okay to do something may have some effect, although we know when we research it, it doesn’t seem to have a big effect. I think it’s really the experiential part of it. Now, if we delve into the psychological literature, they worked this out years ago.
That’s the point of graded exposure. You can’t tell someone spiders don’t hurt you. You know, and someone says, Oh my God, my phobia of spiders has gone. There has to be an experiential element. So people hold a small spider. They hold a bigger spider. They hold a massive tarantula. I don’t know if
Caitlin: that ever
Ben: happens.
But it’s the experience of having a spider in my hand that updates my beliefs. It’s not just being told that spiders are okay. And I think that is something that we need to realize. I can’t vomit. all over people with my, you know, wonderful knowledge of peripheral magnesium cells and, you know, ion channels and all these things, right?
To, to, to, to people that, you know, firstly, what is all this information? Secondly, do I really care? And then thirdly, Is it actually updating my experiential learning and knowledge? And I think a lot of the time we need movement, we need interaction. And I call it action and interaction. So we give people knowledge.
They understand their problem. They make sense of it. They have experiences that we make sure can be positive and are graded. To, to update, you know, sometimes quickly, sometimes slowly, our, our cognitions of the problem and our, you know, hopefully our level of fear or level of apprehension that just simply telling someone to do something or telling someone it’s okay to do something probably doesn’t do.
Mm
Caitlin: hmm. Mm hmm. What is your take on, movement, doing movement that is painful? As you mentioned before, maybe painful massage can have some mechanism by which that pain becomes desensitized, or there’s a change or modulation in the pain experience when People are in pain and they do movements that are somewhat painful, right?
So, there is some importance, I agree, in moving, having a positive experience with movement, right? Or a successful, pain free, feels good type of movement experience. But I’d like to hear you speak a little bit more on, on like, moving to the edge of discomfort or those edges of, of pain.
Ben: Yeah, so, uh, I’m going to go back there and just say, I don’t always see positive or successful movement as being pain free movement, actually.
Caitlin: Right. Right. Okay.
Ben: Because sometimes it might be saying, well, this hurts, but you know what? It wasn’t as bad as I thought. I can handle it. And the value of what I’m doing outweighs the pain that I’m going to experience. So I think that sometimes we actually make problems worse by looking to be pain free.
Because what are we saying about pain? We’re saying pain is something bad. It’s intolerable. It shouldn’t be there. And actually, sometimes a much better way, can be to have some pain and actually kind of re-update our thoughts around it and say, Do you know what? Actually, this, this pain isn’t leading to terrible damage.
It isn’t going to make my problem dramatically worse. But it is going to enable me to do some of the things that I want to do in the meantime, while this thing gets better. Yeah. Which could be hugely empowering. And. I think that we have this measure called pain self efficacy, which is how well can I do things despite pain.
And people with a very, very low level of self efficacy, so they’re not, you know, they’re not happy with doing things with some pain, often driven by fear, I think, you know, they tend not to do so well. I think that’s what we’ve been told, right? Everything should be pain free, pain is a sign of damage, a sign you’re doing yourself some harm.
And actually, it might be that every injury requires some painful movement. Because, If I’ve hurt my back, there are no treatments out there that magically take all my pain away. So if I want to carry on with a bit of life, I’m probably going to need to have a little bit of pain at some point.
Caitlin: Yeah. Yeah, exactly.
And I, I think you really hit on an important piece there with like, like, like, Is someone afraid of their pain or do they feel like they can experience pain while moving forward and while doing the things they want to do and I think that’s a really key, key piece or at least a key piece in rehab for helping someone kind of walk, walk through the steps to get to that point where they’re like, Oh, yeah, yeah, I feel it, but I’m not worried about it.
It doesn’t make me afraid to move.
Ben: Yeah. And I, I think that we have to find the right level for the person, you know? Uh, yeah. There, I think there’s two ends. Which one would be habitation, which would be you repeatedly stimulate you, you, you get a repeated stimulus such as a movement that causes pain, and over time you desensitize to that.
Mm-Hmm. Or you habituate to it. And on the other end you might. get sensitization. So you do something repeatedly and it makes the problem work. We need to find that balance between habituation and sensitization and that might be the dosage level. It might be the health of the person. There may be lots of factors that determine, you know, the level of someone’s immune system function. They might determine whether they’re more likely to habituate to a stimulus and have a desensitization or the other end of that where they may actually get a sensitization.
Caitlin: Yeah. Yeah. When I took your course, you had some really helpful case studies where we looked at a person’s condition and then we looked at various social, or like the case study included some context around their social and lifestyle factors and you had us come up with exercises that might be meaningful for that person based on social interaction or kind of any, any emotional layers, uh, or general physical health.
Can you speak a little bit more? more about that, about just kind of patient centered care as it relates to finding meaningful activities for people to do?
Ben: Look, so I think that we have to decide for different people with different biopsychosocial profiles, what is going to give them the biggest bang for their buck.
And what I mean by that is for some people, they may do a couple of wiggles on their back and you know, it feels better and that’s great. Or they have a little rub and that’s brilliant for some other people. You know, we know that they’ve got very poor levels of health. They might have poor levels of, you know, movement in terms of, You know, they may be very stiff and very inflexible and not moving a lot and these types of things.
So how can we be a little bit targeted with what we’re trying to do? And that’s kind of a bias. I call it biopsychosocial strength and conditioning because in the physical therapy world, I think we’re looking for what’s the best type of exercise. So is it Pilates? Is it yoga? Is it weightlifting?
Whatever. If you look at S & C, they’re not saying what’s the best exercise for hypertrophy, are they? What’s the best exercise to get strong? Well, there are lots of options that are out there to get you stronger. Right. So sometimes we pigeonhole things a little bit. What we’re trying to identify is, is there an area, a general area that’s going to benefit this patient?
So an example we look at is someone with very low levels of movement, very low levels of health. And for those people, maybe It’s just about engaging in a movement that’s going to help them. And there is no universal best exercise to change behavior. Behavioral change towards a healthier lifestyle that probably includes more movement and exercise and these types of things have to be personalized.
It can never be generic. That’s because people just don’t do generic things, do they? They do things because they value them or they do things because they like them or whatever. So for me, it’s about trying to find an area that’s going to benefit someone such as engagement in, in movement or engagement in health or these types of things, and then filling in the blanks through the patient.
Rather than having all the answers before we have a patient, it’s really important that we say, well, looking at this patient’s characteristics, I think they need to just be engaged in moving more. building their health profile. How do we fill in the blanks about what’s going to work for that patient?
Well, that’s why we need to listen. We need to make sure that we’re understanding them and there is no universal answer. There’s only an answer for this patient. Because if we say, right, you need to do resistance training and they hate resistance training, they can’t get on with it. They don’t like it.
They can’t get to the gym, is that likely to become a behavioral trait? And the answer to that is absolutely not. So, sometimes we need to think about these things as behavior change, not just, do I need to do a couple of pelvic tilts?
Caitlin: Right, right. Yeah, I like that. That’s really helpful. So instead of thinking of specific exercises, thinking more broadly in terms of, like, bigger, broader buckets of qualities, That can improve, right?
Ben: Qualities,
Caitlin: Just kind of general qualities.
Ben: Yeah. And then filling, and then all these blanks are filled in by the patient, you know, filled in by the person because the only place you’re going to, you’re not going to get that information in a, in a randomized control trial. They’re not going to tell you Bob lives in Manhattan.
You know, they’re not going to tell you what he likes and what he wants to do in these types of things. Only Bob is going to tell you that. So how do we identify broad buckets that you know have an effect on musculoskeletal problems and then we fill in those blanks with the patient.
Caitlin: Yeah. And with things that that person will actually want to do, make a habit of doing it, enjoy it.
Ben: There you go. The behavioral, the exercise to be truly powerful. Has to have an element of behavior change.
Caitlin: Yes, that’s so helpful. Yep. Let’s go a little deeper into nonspecific low back pain. This is something that you cover extensively in your work. I’ve read a lot about it on your website, on your blog and in your social media, and it’s a big part of your course.
Before we start talking about back pain, can you define Nonspecific low back pain, and why is it important to understand this diagnosis of nonspecific low back pain?
Ben: Well, yeah, I mean, this causes uproar, doesn’t it? This, you know, this idea of people really, you know, some people love it, some people hate it.
It’s one of the most misunderstood things, I think. And I think the idea of nonspecific back pain was really to say, I think, actually, I can’t remember where I’ve got my back pain. this from, and it might be a complete untruth. I don’t know, but I’m sure I remember someone talking about it being a surgical term, meaning that there is nothing to operate on.
We can’t identify something to operate on. So as I understand it from reading, you know, lots of things over the years, it’s really about our inability to identify a kind of no susceptive driver in the back. So it doesn’t mean that there isn’t one. It doesn’t mean we can’t have an idea about what it is.
What it does mean is we’re not very good at clinically finding that. So there isn’t a test that tells me that your facet joint is firing out nociceptive stuff. There isn’t a test that tells me that you’re not. that it’s your disc. There isn’t a test that tells me it’s your muscle. There isn’t a test that tells me it’s a modic change, you know?
So, we do have things that are, you know, signs and symptoms that are slightly better. We can tell, you know, if something’s likely to be more ridiculous, likely to be radiculopathy, stenotic, inflammatory, uh, you know, serious pathology, but we’re not very good at clinically. differentiating different tissues within the back.
So it’s not that we don’t know. We know all of the tissues in the back, right? That’s called anatomy. We just can’t identify exactly which one is, and if it’s only one that’s contributing to the problem.
Caitlin: Sure, sure. Yeah. And only one is contributing. Like, how could you ever say that? Because really, with anatomy, it’s all pretty continuous, right?
So, like, where anatomy books will break things into pieces. A hundred
Ben: percent. A hundred percent. This has always been the problem with special tests, is that you are unlike Exactly. Let’s take the Kemp’s test. Well, you know, for facet pain and you extend and you rotate and you side flex and what you’re doing is you’re on one side compressing a facet and on the other side you’re distracting it, right?
But is that the only tissue that’s being compressed or distracted?
Caitlin: Yeah, right. Yeah.
Ben: And if it’s not, how do you then say it’s the facet joint? Exactly. What you can say is I’ve got pain with extension and rotation,
Caitlin: right?
Ben: And, and there are lots of different things that might be getting pulled and pushed and compressed and twisted when I do that movement.
That’s why the specificity of these tests is really quite low.
Caitlin: Yeah, so like it can give us a few data points to understand the patient’s experience of their pain, or certain things that might provoke their pain, but we can’t say that it’s all coming down to one little mechanical structure in there that is the source of the pain, right?
Ben: No, if you take, say, the empty can test, they did a study on the, and I know the empty can test is not for the back, don’t worry, my anatomy is not that bad. And what they did is, I think there’s an Australian group and they did a study and they found that they did some MG stuff and they found when they did both the empty can and the four can test, they activated about 15 different muscles with E mg.
Right. So it’s like, well, okay, that’s great. You know, you are not doing a great job at differentiating supinators or any, you know, or any. Any tissue that you’re trying to identify because all of these things are being impacted.
Caitlin: Yeah. Yeah. And I think all that can be extrapolated to the area of, you know, blaming pain on a muscle that’s tight or a muscle group that’s weak, you know, and, and of course, that too, we can’t, we can’t just say it’s one specific thing.
Ben: It’s just easy answers to satisfy people’s curiosity, isn’t it?
Caitlin: For sure. Yeah, yeah. Or like easy to write a nice little concise social media or blog blog post about which yes, some of those things are black and white. Or actually, it’s a really good marketing tool. There you go. I think that’s
Ben: probably one of the one of the most prevalent reasons.
Caitlin: Yeah. So nonspecific low back pain. One of the things you cover in your course is natural history, which is just how soon a condition can resolve on its own without any intervention and this difference between acute flare ups of low back pain and the more chronic recurrent type of episodes and I’ve heard described certain conditions that can contribute to a longer, longer term term back pain or recurrent episodes as yellow flags, like some things in the patient’s profile that might indicate that they’re at a greater risk of a chronic condition.
Can you speak a little bit about that?
Ben: Yeah, I don’t, I’m not, so yellow flags are, as I understand them, are a little more psychologically based as I understand them. Yeah. So, so Yeah, but there are lots of things that might be what prognostic is a term that I would use or predict. So look, natural history.
We never really work with natural history because as you said, it’s about things that are untreated, right? So obviously by definition, if you see a patient, They don’t, you know, natural history is out of the window, because they’ve been treated so, and you can only really study that through epidemiology or observational studies anyway.
You can’t do it through an RCT because, because you’re, you’re being treated. So I think what we should really talk about is the average length of symptoms. I think that’s a better, more accurate terminology. Now. What affects accurate length of symptoms? Well, it might be a psychological profile. That’s one. Our health behaviors are another.
Our comorbidity, you know, our associated health conditions are another. So there are a number of different things. So, so some of the, look, there are a couple of things that I don’t see as massively modifiable. So high levels of pain lead to worse outcomes. We know that. Uh, longer pain duration means that you’re likely to have pain for longer.
So the pain gets sticky. We also know people with lower levels of pain and self efficacy. So the people that are not very good at tolerating or having pain tend to do worse. That’s and you may call that A yellow flag, potentially, although I don’t think we were, you know, yellow flags, it goes back to the days of Gifford and Waddell and all those types of things.
And maybe they weren’t talking about things like pain and self efficacy then. Seeking passive care is another one that seems to be, A little bit of a, uh, negative prognostic factor. And then also our expectations of recovery. So if someone doesn’t believe they’re going to recover, it’s likely that they’re not going to recover in the same length of time that someone else will.
And they’re all quite evidence based, uh, prognostic factors as I understand them.
Caitlin: Yeah, and that’s such a big one and such an interesting one. That someone’s belief that they will recover helps them.
Ben: Yeah,
Caitlin: I
Ben: Think about, you know, let’s say we have all these different factors that might be affecting my, you know, my, my positivity levels and engagement with activity, all these different things.
If I don’t think I’m going to get better, then I’m Why would I engage in any of these positive behaviors? And so I think it’s probably that our psychology affects our behaviors. And sometimes, again, that’s why behavioral aspects are really, really important. And they rely not just on our physical behaviors, but also on the state of our psychological psychology to enact those behaviors and be able to enact those behaviors.
Caitlin: Mm hmm. Mm hmm. Yeah, and I think that’s really key too for, uh, the long haul, right? When someone has an episode of low back pain, they see a physical therapist, they get treatment. Like one of my goals with my patients is to give them tools that they can use anytime they have another low back pain episode, because it, it, it’s recurrent.
These things happen sometimes again and again. So that like the next time it happens, they can kind of reduce the impact. of that episode by having understanding and tools and education around how to treat themselves and how to, you know, keep moving as much as possible despite the fact that they’re having some pain and just have more confidence with it in the future.
I think that’s really super important for people that are having recurrent episodes.
Ben: Yeah. And that’s part of understanding the, the, the, let’s say the natural history of low back pain is it is a recurrent condition. 70 percent of people will have a recurrence within one year. If you have had back pain, you are likely to have back pain again.
And in fact, your previous, and this is work, I think by Casper Nim and Alice Kongsted, a pair of Danish researchers. And they found that your previous episodes are prognostic of your future episodes. So if you’ve had a load of future, a load of future, a load of previous episodes,
Caitlin: you are much
Ben: more likely to have recurrent future episodes.
and I do think that that’s important knowledge for people and giving people the tools to deal with that is also an important part. of changing their behavior towards their back pain problem. and so I think sometimes we’re like, Oh my God, back pain gone in two weeks. I’m a magician clinician.
Look at me. I’m amazing. You know, and actually that’s just the natural course of the symptoms. The real skill of great intervention is making, trying to affect That trajectory or those recurring characteristics in the future.
Caitlin: Yeah. Yeah. I kind of, I see this trend, I guess, maybe trend of practitioners, I guess, trying to explain to patients that there are ways to like, mitigate or prevent recurrence of low back pain by doing X, Y, and Z and keeping up with their exercises or strength or whatever.
When really I think, uh, the more realistic conversation is that it will probably happen again. Can we set you up so that the impact is not as severe? Right. It kind of goes along with that more realistic conversation of like, if you’re gonna exercise and move, you’re gonna have some pain here and there.
Right. And it’s not completely avoidable.
Ben: Yeah. Touch on that. So, so making the future less scary, is that likely to have an effect on our outlook for the future? Do you see? Mm-Hmm. . So those behavioral aspects are probably really important. One good thing that we’d know is that people who are more active, and there’s quite a lot of decent research in this, people that are more active or exercise more for whatever reason, and maybe there are lots of confounders with health behaviors and stuff, but we do have data that says that people who are more active, especially more vigorous activity, do have less severe trajectories of their back pain.
So I think there is some good information that we can give you. But to tell someone they’re not going to ever have it again would of course be a dreaded lie that a nefarious clinician may say to get someone to do, you know, their crazy treatment.
Caitlin: Yeah. Yeah. Well, and I think that just kind of that what you’re speaking of, of being more active, doing more vigorous exercise is again, just improving the health of the whole system in such a way that again, it doesn’t matter exactly what you’re doing in terms of specific exercises.
Like there’s no magic pill type of exercises that if you just keep doing those, you’ll prevent the recurrence of your back pain, right?
Ben: No, but I suppose the magic pill would be if you value it. And maybe enjoy it. So you keep doing it.
Caitlin: and
Ben: That, and the only person that has that information about individual values is the person themselves.
There’s no randomized controlled trial to do that. So that’s where we need to be evidence based that we have some data that engaging in doing stuff is important from a social, psychological, and biological standpoint. But the details of that, that broad bucket can only be filled in by the patient in front of you.
Caitlin: Yeah, before we move on from this discussion of low back pain And I wanted to hear a little bit more about this idea of over medicalization, right? And how do you know, we’re talking about all the kinds of positive positive factors and things that can keep people in a place where they can manage their condition of good self efficacy.
What happens when someone has kind of been through the ringer of seeing multiple medical providers who tell them all kinds of things about, like, pathological things about their back pain?
Ben: Well, there’s a great Louis Gifford quote, and I can’t remember whether he says something. Every medical practitioner or every practitioner that your patient has seen before you is a flag.
Oh. I can’t remember whether he called it a yellow flag or he just said a flag, but it was interesting that people build up these layers of misinformation and you know, I’m the best clinician and I’m going to find this secret special thing that’s wrong with you. You just have to do all these tests and you know, sometimes it is more about the ego of the person treating than it is about the welfare of the patient.
But what we know is too many tests, too much intervention, too much treatment is negative. We have a term for it, iatrogenic injury. And I hate saying that word, but it means being harmed by the medical system. And we know that. If you have lots of MRIs or MRIs early in your back pain, that can have a negative influence.
We know that having too much treatment, passive care can be negative. We know that non guideline intervention can be negative. There was a JAMA paper that was in 2022 that listed a bunch of. different things that, you know, were, were negative from, from kind of the medical system. So we, you know, in our pursuit of trying to find the problem and being the clinician that solves the problem, doing every test under the sun, you know, whether it’s invasive or whether it’s not invasive, blah, blah, blah.
We don’t often think, is that actually damaging to us? You know, the person, the patient, their psychology, their behaviors. And then we find the diagnosis and it’s something, you know, Oh my God, your spine is unstable. And then how does that affect the person? Suddenly they’re not moving anymore. They’re not doing the positive things in their lives.
So we have to understand that more treatment is not better.
Caitlin: Let’s talk a bit about movement snacks. You’re an advocate for movement snacks or self, kind of quick self treatment strategies that people can do as maybe a coping strategy for their low back pain or just to be more active. What do movement snacks look like?
Ben: Yeah, so movement snacks, the point of movement snacks is we get a patient in, and actually we also have exercise snacks, right? So exercise snacks, I think are more about health. They’re more about, you know, little bits of exercise that we can fit into our daily lives. Movement snacks are a bit more pain related.
And the idea was that I have this patient come in, their system is set to a bit of sensitivity, you know, their stimulus and response system, you know, when, when, you know, pain essentially in many ways is a stimulus and response system. So we stimulate, The nociceptive system, and it gives us a response, doesn’t it?
And sometimes that response is pain. But it detects stimulus, whether that’s thermal, chemical, or mechanical. But when we have pain, that stimulus and response system is all messed up. It’s sensitized, it’s inaccurate. And the movement snack is one way of saying, if I give an input, Am I less likely to have a negative output?
And that’s always the danger with exercises. We give too much, too much stimulus. And the system says, Oh my God, I, we are being in protective mode and we’re going to give you exactly what you asked for, which is pain, right? So I think that’s what we forget with exercise. The more you exercise, the fitter you get when you have pain, the more mechanical stimulus you get, the more likely your system is to give you pain.
That’s its job,
Caitlin: right?
Ben: So that’s the problem is sometimes we think getting fitter and stronger is likely to have the same effect on pain as it is on hypertrophy or range of movement or cardiovascular. health, right? But it’s not. You’re stimulating a system that’s designed to say no, protect and, and, and flare up.
So the more you stimulate it, actually, the more you’re likely to get pain, not the less pain, right? Again, that’s a really fundamental misunderstanding of pain.
Caitlin: Yeah.
Ben: that it’s, it’s a stim, it’s a stimulus and response system. The more you stimulate it, the more likely you’re likely to get a negative response or not a negative response, the response it’s designed to do.
So my snack is about managing dosage. How can we give a little bit of movement, a little bit of mechanical stimulus that sneaks under the radar? Or is, is, is, is on the threshold and doesn’t cause that response that we don’t want, right? We’re, we’re inputting into a synthesized system. We want it to react in a reasonably favorable way.
What’s the only thing that we can do is manage the stimulus or the dosage of that intervention. And that’s why things like yoga or Pilates can be really good for a sensitized system because it’s about managing dosage. Why do we not do plyometrics? Because you’re going to get a big old fat lump of dosage.
And that system that’s already sensitized is likely to say, leave me alone, here’s a big dollop of pain to tell you to go away.
Caitlin: Mm hmm. Mm hmm. So like a little bit, Mm hmm. Low level input a little bit often.
Ben: Yeah, exactly. Yeah, it’s about positively Mechanically stimulating the system. It’s about positive input or not negative input And so, you know, exercise for pain is about understanding pain, not about understanding exercise.
And that’s where we make the mistake of thinking we need to know more about exercise. You don’t, you need to know more about pain because that’s the system you’re stimulating.
Caitlin: Interesting. Yeah. I hadn’t thought of it quite like you, you laid it out in terms of, exercise for progressive overload to train certain qualities that we want to improve in terms of capacity.
And how if we’re taking it to that level for someone in pain, it can push them over that threshold of, you know, flaring things up. So, that’s an interesting way to think about it.
Ben: Pain reduces capacity for mechanical stimulus. Right. That’s what it does. That’s its role. Yeah. You are exactly stimulating it in the way that it’s designed to work.
It’s designed to detect mechanical stimulus or thermal or chemical or mixtures of those and then say, Oh, don’t like that. That’s too high a threshold. Let’s give you some pain to protect or to do whatever.
Caitlin: Yeah. And that’s where I think clinicians get a little mixed up. And you speak about this where someone might have someone walk into the clinic and say, Oh, you have all these dysfunctional movement patterns and weakness.
Oh, we gotta fix that because that’s what puts you in pain when really it’s like they’re moving that way because they are in pain, right?
Ben: It makes sense. If you’ve got a tissue that’s injured or inflamed or whatever, if I put less mechanical stimulus through that, It will hurt less. So that means if I have less strength, I can put less mechanical stimulus through that tissue.
It’s absolutely a no -brainer. So we would regard that as post hoc reasoning. You know, if you are assessing someone in pain, The likelihood is that every change in movement or strength that you are assessing is likely to have more to do with pain than it is to do with their normal function.
Caitlin: Mm hmm. Mm hmm.
Yeah, yeah, yeah. And I think that’s a really helpful thing to understand. so that we’re not sort of pathologizing their movement as like the reason, or the thing that contributed to them being in pain, right? And we don’t, we don’t know that.
Ben: This bugs me is this idea there always is a reason you know, we’re going to find your sex.
Sometimes there are reasons but they may be immune system related. They may be comorbidity related. They may be systemically related. They may be immune. Did I say immune? Maybe I said that already. I don’t know. You know, these, the, the tolerance and capacity of our systems are changed by so many different things.
And, you know, more things than we can ever assess or even understand and imagine. And the problem is we try to boil it down into these things. We can simply assess. Oh, there’s the problem. I fixed that. We’re fine. No problems, you know, and actually natural history probably helps us because it’s going to get better anyway, but it might get worse again.
Caitlin: Right, right, right. Yeah. Thank you so much for this, Ben. We’re almost out of time. I want to leave our listeners with some information on how they can find Out more about you . I’ve been reading your blog for a few years and I find that there’s so much valuable information on your website. So that’s core kinetic.
com c o r k i n e t i c dot com As I mentioned earlier your instagram is at core kinetic or they can just search your name ben cormack uh, and then I wanted to just Let everybody know if you are local here in New York City or want to plan a nice trip to New York City in September. Ben will be here leading his course, uh, Therapeutic Movement and Exercise, Back Pain and Beyond.
This is the one that I attended in New York last spring. Really fantastic weekend for clinicians. Physiotherapists, physical therapists. I think it’s a great course for people who are involved with body work and manual therapy. There were some amazing personal trainers, coaches, strength coaches in the room.
When I took your course last spring, I think it’s really valuable in that area also. So that course. Is coming up in September, September 28th through 29th, and we have an early registration discount, so you can save 100 if you register before August 11th. So I’m looking forward to hosting you here, Ben.
I think, uh, I think it’ll be a really good time and a really nice group of people here in the room in New York.
Ben: Yeah, look, I always like to hope that I make people think and I bring some different perspectives. You know, whether that’s evidence based or mechanistically based or philosophically based or whatever.
And you know, if, if you come along, you’re going to have to get your brain in gear, but you know, I think that’s a positive thing.
Caitlin: I think so too. Yeah. And that’s, that goes to kind of where we started, speaks to where we started this conversation about how research is. We take it all as it comes and just ask, think, think a little more deeply, ask better questions, do, do better.
moving forward with the information that we have. So I think that critical thinking element is so key and definitely something that you bring to your course.
Ben: Absolutely.
Caitlin: Well, thank you, Ben. We’ll put links in the show notes to, uh, to reach you. We’ll put links in the show notes to learn more about Ben’s course here in New York City in September. And, it was great chatting with you.
Ben: Yeah. Thanks for inviting me. I appreciate it.
Caitlin: Thank you so much for listening. I hope you enjoyed my talk with Ben Cormack. Again, if you want to join us here in person for Ben’s course in September, go to practicehuman. com slash events or click the link in the show notes to find out more. If you have any questions for me, you can always email hello@practicehuman.com. Juniper and I respond to all emails and we love to hear from you. And if you enjoy listening to the Practice Human Podcast, if you learn something here, please leave us a reading and a review. It will help the conversation grow.