Jared Powell:
Today's guests, Chris Neason and Claire Samanna. Chris and Claire are both PhD candidates from Monash University in Melbourne, Australia, who have recently conducted and published a fascinating trial exploring running as a treatment for persistent low back pain. Yes, you heard correctly. Can you outrun persistent low back pain? There is a perception that specific exercise targeting the lumbar spine, which is where the persistent pain is located, is necessary for helping the signs and symptoms of persistent low back pain.
Jared Powell:
But is this really true? Are there other more general exercise approaches that can help people with back pain that don't include planks and bird dogs and whatever else? Mcgill advocates. I've pulled Chris and Claire on the show to give us the brief on the effectiveness of running for persistent low back pain and whether it may be a consideration for suitable patients of yours or even for yourself before we start the podcast. Chris Neason and Claire Samanna. Welcome to the show. Thanks, Jared. Thanks for having us. No, you're welcome. It's, we're gonna have to coordinate, we've got three people here, so it's always hard when three people are trying to talk at the same time. But that's okay. I'll, I'll try and direct as best I can. UChris, let's start with you. Uwho are you mate and what do you do?
Chris Neason:
So I'm an exercise physiologist. I have a clinic in Melbourne outer east. I have a 1-year-old that tends to keep me busy when I can. I'll fit in a bit of running and, and golf read a bit. But yeah, I feel like it's PhD and, and 1-year-old. That's, that's my life at the moment.
Jared Powell:
Yeah, PhD is not hard enough just to add a 1-year-old into the mix. I did the same thing. I've got a 4-year-old and a 1-year-old doing a PhD and don't recommend Chris. Do you, do you, I mean, I do recommend I love my children, but it was challenging. Yeah.
Chris Neason:
Well, and and it took you, you were saying it took you six years to finish off the PhD just the other week. So
Jared Powell:
Yeah, it wasn't my kids' fault. It was 1-year-old, old four year olds. Yeah. That was my fault. Okay.
Chris Neason:
,
Jared Powell:
and Claire, who are you and what do you do?
Claire Samanna:
Hi, I am Claire. I'm credited exercise physiologist and PhD candidate at Monash. I have no children as we've just we're just talking about, so no excuses for delays in PhD there. But my interests are, I'm a race walker who tends to get injured a lot. So I'm also a runner. I also like swimming and I also love to travel, so I find as many opportunities as I as I can to travel both for fun and also to do with the PhD. That's been a big highlight for this year. But yeah, that sums me up.
Jared Powell:
Can I ask about race walking please, Claire? You, you were telling me a moment ago that some of the speeds of these race walkers are probably as fast as I run my 5K speed and they do it for 20 k, which it hurts a little bit, but these are elite athletes. Can you, can you tell me about your sort of dabbling in race walking and how fast these people can actually go
Claire Samanna:
? Well, how fast the Olympian race walker can go is very different to how fast I can go. So they might be at like a four 15 pace for 20 Ks, but my pb was 57 minutes, 40 I think it was for 10 Ks, which is around 5 45 pace for race walking. So I can't run that much faster than that, to be honest. ,
Jared Powell:
That's highly respectable. I wouldn't be diminishing that. And Chris, you're you're a runner.
Chris Neason:
Yeah, I do. I I'm sort of on and off love hate with running. I've ran, yeah, quite a few marathons in the past and then I'll go off it and do two Ks and that's kind of my, my daily run, but it's always a part of what I do just in varying bearing quantities.
Jared Powell:
Good. And yeah. Can, may I ask you your marathon pb?
Chris Neason:
I've got it under four hours once so I'm not a, I'm not a quick marathoner. There's probably race walkers doing it in half that time, but yeah, depending on who you talk to, that's, that's okay. Good.
Jared Powell:
I think four hours. I highly commendable. I don't even think, I honestly, right now, if you made me do a marathon, I don't think I could do it under six. So four hours is massive, so yeah, give yourself a pat in the back mate. All right guys. So you both sort of run Claire walks and runs, she race walks. There's a big difference there. And did these sort of collective interests in, in running slash walking lead to the development of this trial or did you guys just come into a program and this was the trial they had planned, had, what was the genesis of this trial? Yeah,
Chris Neason:
We've kind of gone back and forth a bit with our supervisor and and senior author Dr. Patrick Owen and also one of our collaborators in Germany, Dr. Daniel bvi. And they've been looking at the, the intervertebral disc for a while and, and running sort of popped up as something that seems to be good for it. And a lot of the bias out there is that running is no good for back pain. So I think we both thought when those ideas were flagged that this is a really cool opportunity to maybe challenge these ideas around running, not being safe and, and see what happens to people with, with back pain and, and what happens to their, their diss and, and, and lots of other outcomes. Yeah.
Jared Powell:
Cool. Just for the listeners, just for context, so you guys recently published the asteroid trial, well done on the acronym where you have to have a cool acronym these days. Every single clinical trial that gets published, I'm sure you guys met in a dark room and bashed that out over weeks and weeks and weeks published in BJSM, which is no mean feat. So again, congrats on that. And you guys basically the, the premise of the trial was a walk or run walk program versus a sort of usual care control group. Chris, can you please sort of explain in far greater detail and nuance what this trial was and perhaps just run over quickly some of the methods as well? Yeah,
Chris Neason:
So it was a 12 week intervention, running versus wait list control. So people in the control group were able to just continue their usual treatment for low back pain, seeing their doctor taking medications. The only thing we said to them is, don't do any running over the next 12 weeks. Everyone coming into the program hadn't been running in the last three months. That was one of the exclusion criteria, people with non-specific chronic low back pain. So they'd had low back pain for greater than three months, but generally didn't have a a specific diagnosis. Those three to 5% of cases that that do. So these are the other 95% of people we tend to see in the clinic. And that the program tended to follow what you'd kind of see, like a couch to 5K type program where people have intervals of running and then walking as rest periods and they'd go back and forth.
Chris Neason:
This was just a much more regressed program. So as a conservative program, there hasn't really been any research like this before. Couple of studies have done some running in people with low back pain, but there's very little data out there. So we weren't sure how we'd go. So we started very conservative initial week started with 15 to 45 seconds of jogging. So really short jog followed by a couple of minutes of walking. And then they do that between six to 10 times and then each week it just progressed gradually. And you can see all that in the study methods as well. You can see this type of program we used. And then we, we'd tailored a little bit, we'd meet with those participants via Zoom each week and then fortnightly over the top 12 weeks to check in, see how they were going change the program if we needed it.
Chris Neason:
Like if they had an injury, it might be give it a rest for this week and then get back into it next week or instead of progressing to the next stage, let's just hold on for a week. So semi individualizing that way. And then we measured their outcomes at six and 12 weeks. Things like their pain and disability, we had them do MRIs at six 12, baseline six and 12 weeks. We looked at all the feasibility type measures like adherence and adverse events plus things like mental health, sleep beliefs, hyperalgesia via pain sensitivity and inflammation, maybe a couple of others that I'm missing. But we tried to take a real wide breadth of different outcomes because this was fairly novel. We wanted to be able to see yeah, what what is changing and, and maybe we might be able to look at some why, why that's changing at some point, but
Jared Powell:
Fascinating. And so it's interesting and I want to have a broader discussion about this. When we're in musculoskeletal rehabilitation, there's this perception, and I think it's quite widespread no matter if it's for low back pain, shoulder pain, knee pain, hip pain, whatever it may be, that there is sort of a specific remedy for that particular clinical presentation. And, and the specific remedy is often a specific exercise. So in the in low back pain, classically it's been cost stability or what is it the McGill Big three kind of exercises. There's a study that came out recently by Andrew Natoli out of Sydney Uni who did a qualitative study and patients or participants in his study thought that general strength training exercises like deadlifts and squats were good for general health, but they weren't rehab exercises so they weren't good for pain. Whereas like the plank and whatever the other big three exercises of McGill are, they were the
Chris Neason:
Bird dog, surely.
Jared Powell:
Yeah, exactly. They were good for pain versus general health. So there's this perception, and I think it's quite ubiquitous amongst patients that exercise should be specific. So how does running come into that? Because surely there's not, and I dunno how this extrapolates to aerobic exercise, but surely there's a bit of a a credibility problem when you're talking to a patient, they have low back pain and you say, or how about you start running? Is that a hard sell and how do you go about that?
Chris Neason:
Yeah, well it was easy, much easier when running a research study apparently. 'cause People just trust everything you te you say 'cause you're doing research. Yeah, working clinically I think is much more challenging and if I had someone coming in to work on their back pain and reduce it, I probably wouldn't be starting with a running program unless they're coming to me saying, I just saw your study and there's all this great research you guys doing and it looks like running is good. But yeah, you, you really do have to start with where people are. So, and, and, and a lot of this is also, this research is hopefully challenging beliefs amongst clinicians, doctors, surgeons, and also or clients in the general public that yeah, general exercise may be maybe just as effective. We, we don't know that yet, but we seem to be finding that that, for example, high intensity cycling seems pretty good for people with back pain and can go a long way to reducing their pain.
Chris Neason:
And and we've had some pretty good results here to say that people with back pain can do a general exercise. We've, my, we've heard from the the walk back trial that I've been doing up in Sydney that they had really good results for prevention of, of low back pain recurrence. So exercises that don't necessarily do a lot to strengthen or or stretch the, the lower back can actually have a, a really good effect on that. Which is why we did measure a bunch of different outcomes like things like mental health and fear avoidance and inflammation to see maybe, yeah, if there's some stronger effects in some of these areas or some stronger improvements that yeah, might relate to their reductions in pain.
Jared Powell:
Yeah, fascinating. So it might not just be due to the delayed onset of the transverses abdominis or, or multifidus. There might be something else going on there. Claire do you have anything else to add to Chris's points?
Claire Samanna:
I did have a point. What was, oh yeah. It was the fact that what I was just thinking of then was when we ran some qualitative interviews right at the end of the study. And this is where we had a chat with participants and we asked them some questions around how they felt their, their their fears and barriers and, and how they like coped with the study. And a few things that stuck out to me was how even though they were a little bit unsure at the start about if they were safe to run and if their back was gonna cope with a run they might even have a sore back that day and and be nervous about running. They did the program anyway and they were so surprised that even doing a single run where their pain came down. And I think that for me was really nice to see. And I think producing research like this and highlighting that is just another, another narrative we can lean on when it comes to sharing, well maybe we don't need these specific exercises 'cause we're just seeing that there's so many different types that actually do work when, when we look at what's actually happening for, for patients. So yeah, that was something that stood out for me. Yeah,
Jared Powell:
That's so true. There's these arbitrary beliefs from people with sort of long-term pain and you know, it's probably well placed. They're, they're suffering and so they're, they're looking to avoid any flare ups in pain and, and running isn't something that leaps out as a, as an effective treatment for, for chronic non-specific low back pain. And so you can re you can understand that, but what you just mentioned then they were surprised, you know, they experienced that sort of expectancy violation that their beliefs were falsified or challenged by actually doing it. And that's, that kind of gets to a lot of Peter Sullivan's cognitive functional therapy and challenging beliefs through movement and behavioral experiments and things like that. So there's a lot of overlap there. So that's, that's quite fascinating. UChris, I'll, I'll go back to you. What were the results mate? What what did we see after, after 12 weeks?
Chris Neason:
So in the paper that I've published, and this is what I've focused on in my PhD, was pain intensity, disability and feasibility. Can, can we actually do this without injuring a bunch of people? And we had pretty good reductions in pain. So their average pain intensity over the last seven days went down about 45% from baseline to 12 weeks compared to our control group. So our control group basically stayed the same for the 12 weeks. Disability was about a reduction of 33% adherence was, was pretty good up around 70% to the program. So able to stick to it pretty well. We had a bunch of adverse events where people had like a bit of an injury or flare up, nothing that stopped them for training for more than about a week. And only one of them was related to an increase in back pain.
Chris Neason:
So when people did have an issue, it wasn't their back, it was more like the, the ankle or the calf having some niggles with. So yeah, some really good relative reductions. When we look at the absolute reductions, these people tended to have mild to moderate pain and disability at the start. So they weren't people with really high levels of pain. I think the average pain across our group was about 40 out of a hundred at baseline and our intervention group they went down by about 15 or 16 points out of a hundred at follow up. So if you look at we predefined our clinically meaningful values, so what is gonna be meaningful to the, to the patient or the, the participant doing the trial is 20 out of a hundred. So we didn't reach those. But then it really all depends how you define clinically meaningful values. Whether you go through absolute changes or percentage changes. Yeah,
Jared Powell:
I mean a point and a half is, might be very significant for someone, you know. So I think there's a lot, there's lots of good research sort of challenging these arbitrary clinically meaningful numbers because who are we to say what's clinically meaningful to someone and, and what isn't, you know, so, but that's quite fascinating. So some, some, some significant changes, although there is some uncertainty about how clinically meaningful it was or wasn't. Cool. And what, what sort of distances did these guys sort of get to in the end on average? Were they running a few ks per session or what was the weekly mileage? How did you measure all that?
Chris Neason:
Yeah, so it was fairly wide range 'cause some people they went from like stage one to 12 and just increased their distance every week without any issues. Other people, they might've went up a stage, stayed at a stage for a few weeks, went back a stage, stayed at that for a few weeks. So the, the average running distance, it started about one kilometer per session at week one and by week 12 it got up to about two and a half kilometers per session. It didn't include that doesn't include the walking distance and, and we treated walking as non effect, but of course walking can be quite effective for reducing people's pain and, and other things. So we can't rule out the, the benefits they got from walking on top of the, the running. But yeah, so it's fairly conservative up to about two and a half Ks. Some people got to about five Ks by the end of the program. Those are the ones that progressed pretty consistently through. And then others, yeah, were, were much lower than that.
Jared Powell:
Did some say in the, in the interviews after that they were keen to continue running and they've fallen in love with it or they keen to end, end the trial as soon as 12 weeks came around.
Chris Neason:
I think most were keen to continue it, whether or not they'd had the motivation to continue it without having us on their back checking in every week or two throughout the intervention. We don't have those long-term follow up, which might be nice to see like can we do a program like this and then people can continue to self-manage going forwards or so with some maybe top up check-ins down the track. But I mean, people are definitely motivated. But yeah, I, I reckon there's a lot to individual, like therapeutic rapport that you build up with a clinician when you check in just to keep them on track. That that can also have an effect on those outcomes of people's pain and, and disability. Because we didn't, we didn't meet with the control group. We only did baseline six and 12 weeks to check in. We didn't, you know, have any other type of relationship building or re weekly check in. So that's also part of that bias towards an intervention or part of the intervention effect perhaps. Yeah,
Jared Powell:
So there was a mismatch in contextual effects, which is not uncommon in this stuff. And it was just an not just, it was an acceptability trial, you know, so in a, in a larger, more robust trial, those things can be matched I'm sure quite easily. And it interesting, when you spoke of adverse events, most of them were tight calf, sore ankle, one low back. Did you say that was, that was a flare up, so that's pretty good.
Chris Neason:
Yep, yep. So these are people who, you know, they're on average are 40 out of a hundred or four outta 10 in terms of pain. So the pains pain's there, it's meaningful to them and it stops them doing things likely and these people outta run without, you know, having back issues with it and able to do the whole intervention. So 20 participants 12 weeks, like yeah, I feel like that's probably a really good takeaway just to say that running seems to be pretty safe. Like whether or not you use it in treatment is another question, but seems to be pretty something that's pretty safe. So avoiding running, if you've got back pain, at least chronic back pain. So you're out of the acute phase, it is probably fine. This
Jared Powell:
Is a bit of a random question. So were these people meeting like World Health Organization sort of recommendations for aerobic exercise like walking per week or, or what have you, did you record any of that or, or measure it?
Chris Neason:
Average met minutes, metabolic equivalent minutes per week using the ipac, which is commonly used to measure habitual physical activity, which I think it had questionable validity and reliability, but average was around 3000 me minutes per week. If you followed the, if you applied those same numbers to the Australian physical Activity guidelines of two and a half hours of moderate physical activity or half of that, if it's vigorous it's about 600 minutes per week. So they, I don't have the number that we're exceeding that, but I imagine quite a lot were exceeding that. But I don't think that's, IPAC is a very good comparator because I think it's, there's so much issues with recall bias and I feel like people tend to overestimate their physical activity using ipac. So can't really say they, they, they weren't running before the intervention. So I feel like a common narrative from participants was that they had been doing physical activity in the past but you know, maybe for the last year or two and we were getting out of covid restrictions and lockdowns in that time that they hadn't been doing as much. So can't give you a concrete answer.
Jared Powell:
That's all right. Claire, do you have anything to add there at all?
Claire Samanna:
No, I think that's summed it up quite well.
Jared Powell:
Awesome. All right. Claire, I'm gonna get to, I'm gonna get to you now. I'm gonna put you on the spot under the microscope. So, so something that I'm really interested in is how and why treatments work, not just do they work, you know, which is what we see in an RCT. We, we get a group of people, we divide them into a couple of groups, we give them something, we don't give the other group that thing and then we see the average difference between the two groups. What's missing in an RCT is understanding often how and why that intervention has worked and I think that's super important because I think an RCT as great as they are, they, they can be superficial in in sort of understanding causal mechanisms and if we don't understand how and why things work then, then we're just sort of throwing at a wall and sort of hoping something sticks. So can you hypothesize, can you conjecture, can you theorize how this running program may have worked? I know you might be working on something at the moment, so give us your spiel please Claire on on all this stuff. Sure.
Claire Samanna:
So at the start, like when we were proposing the trial the other part that we haven't talked about yet is the integrable disc and how we were measuring the disc at three time points. So baseline six weeks and 12 weeks to see if we could see any meaningful change at the disc level. So in terms of mechanisms we hypothesized that the disc might adapt with the run program and whether this related to pain or not. Well that's another question one I probably can't answer for you today. I am planning to do some secondary analysis that might look at that but not one like I said that I have the answer for today. So to come back to why we think this worked, I honestly don't think it's because of the disc as much as people would probably like to blame the disc when it comes to low back pain a lot of the time, especially if you do have MRI imaging of some kind of pathological disc, whether that be degeneration or a disc bulge.
Claire Samanna:
But I do think we see so many cases where people have this degeneration and no back pain that we the link it's very weak that correlation, even though there is one, it is weak. I think this study worked for back pain just like any other type of exercise study would've. And mechanistically we don't really know why though I hope that touches on part of the answer. I wish, I wish I could give a mechanism answer. I think we all kind of want that but I think we have to keep searching if there is one to be found.
Jared Powell:
Totally. Yeah, I mean I have published like nearly 10 articles on the same thing on shoulder pain and we just don't know why it works and it's pretty crazy when you think about it like here we are physios, exercise physiologists, we're giving movement and exercise to people and we don't really know how it's helping people with pain and I think we should be sort of open, you know, we're not, look, we're a young profession and we'll probably get there with un understanding how and why things work but I think we need to be open and honest about how little we do know about how and why these things are working. And perhaps as we sort of discussed a moment ago, could this all be coming down to contextual effects or you know, the reassurance or finding confidence from the practitioner And that's not to be sneezed at, that's a real mechanism that is helping people reduce their pain. But it might not be all due to the disc in the back pain situation in the shoulder. It's not due to getting stronger or normalizing posture or anything like that. Our favorite sort of theories in physio and n EP are starting to get refuted every other week it seems. So are there any other theories that you might have, Claire or Chris? I'll open it up to both of you that about how running might be helping somebody.
Chris Neason:
Lot, lots of contextual effects we had, we saw people's confidence improve or their self-efficacy, their, their mental health improve. We were working with them at on a regular basis to, to support them and, and guide them possibly some improvements in systemic inflammation with aerobic exercise that we know is certainly possible. I'm not sure if there'd be much of a change in a, a short term period, like 12 weeks doing a fairly conservative program. Maybe some sleep benefits as well. And we've got some, yeah, some of our team looking at the changes in sleep and if you're you're running, you're probably gonna get better sleep and if you're sleeping better your pain's probably gonna come down over time. But yeah, I don't think either of us are specialists in mediation analysis. So maybe that's something we need to talk to you offline about Jared and, 'cause we've got lot, lots of data and not enough answers at this stage. Yeah,
Jared Powell:
It sounds it's super fascinating. It's yeah, mediation analysis is challenging like the both theoretically philosophically and and doing it as well, but the data, the, the information that you get out of it is just so helpful I think. Claire, what about you? What are your, what are your theories? Are you sort of subscribing to this contextual effects narrative? Do you think there is something physiological going on perhaps systemically? Do you think it's physical in terms of building up some sort of robustness or capacity of the spine or something like that? Yeah,
Claire Samanna:
I mean I, two, two paths to that and to answer that question is yes, I, oh I think it's multifactorial and that's why we were having trouble nailing one mechanism working within that biopsychosocial model. There's probably minute changes across many factors and that's why we can't really pinpoint it is my guess. And then two, I think it does depend on the person. Like for some people building up a little bit more muscle, muscle mass might actually be all they need to build a bit more resilience in their back or one other person. Improving their mental health or sleep might be the thing that really works. So I think we can't discount that, although we tend to work in averages and what works for the most, most people I think individual by individual that could potentially change. I don't know how you measure that.
Jared Powell:
Yeah, challenge. It's very hard. So I think, I think what we're getting at there is that general can work, general movement can work, walking, running, moving your body in some systematic way that's sort of deliberate and repeatable and you're doing regularly over weeks and weeks and weeks maybe being supervised by a movement expert like yourselves or physios that seems to do something to a person's bios, psychology and or physiology. And that does something to pain that we're not really aware of. So it's an, it's an open research program and I think the more the merrier that gets involved is a good thing, you know, because there's so many questions that we need to figure out. But I, I do love this trial because running so accessible anyone can do it, although it is, it can be expensive these days with super shoes and you gotta have the right equipment and you gotta have the, the right Garmin watch and you gotta have the right heart rate sensor, blah blah blah blah blah.
Jared Powell:
Like honestly as I've gotten into it, the amount of kit that you can buy and like, anyway it's wild black Friday's coming up so I'm gonna go go to town and get a bunch of different stuff. But anyway, back to my point, it's such an elegant study in that you're testing some something that's available to everybody. They don't need to go and get a gym membership, which sometimes is prohibitive for some people they don't want to be in the gym or let's just face it, some people hate lifting weights, some people hate doing a bridge, some people hate doing a squat. I can, I can relate to that. Whereas getting outta nature going for a walk that might open up some movement for a segment of the population that might not want to do resistance exercise or Pilates or yoga, which are all plausible and valid other treatments, exercises as well. So I wanna get to the clinical implications of this trial Chris, so I'll go back to you. Are there clinical implications? I'm sure this evidence isn't sufficient enough to say to every practitioner go out and start a a walk run program with your people, with patients with non-specific low back pain. But I'm also sure that this evidence could be used to support that intervention as well. So what do you think?
Chris Neason:
I think running is is probably safe for most people with back pain. If the pain is stable, say they're out of that acute phase and they start conservative, they build up up gradually and they're under the supervision of an exercise professional, probably don't even need that. But I think that our research has done, so I'll put that caveat in there. It may help reduce pain and you might be able to throw it in there for and have a treatment effect in people who want to run. If people don't want to run do something they, they enjoy. But I think that the, the limitations particularly of this research and there hasn't been a lot before this, is that this is younger adults. So we were selected people aged 18 to 45 particularly 'cause we didn't trust older people working out the technology and having to deal with like, how do you reset my password and I can't find it. We, we trialed it with both of our parents. So we, we've found out those things early on. I'm
Jared Powell:
Nearly 40 years old. I I resent that comment mate. I
Chris Neason:
We went with a really strict cutoff just to be, just to be safe and we, we ruled out lower limb issues at the start or at least we, we loosely rolled out, ruled out lower limb issues, hip, knee and ankle complaint. So that could definitely complicate if you were getting someone to do a running program mild to moderate low back pain as well. So I dunno if I'd be getting someone with a, a seven outta 10 running maybe, you know, if they can't walk, maybe don't run. But at the same time there's arguments to go the other way as well in certain people who respond. So I think if you take all that into account and we're still working with the individual in front of us to design a program that's appropriate for them, but this sort of program seems to, seems to work pretty well and, and we had very few issues so. Cool.
Jared Powell:
Claire?
Claire Samanna:
Well I guess I can bring in the, the invertible disc side of things in terms of implications. We haven't quite touched on the findings, but what we did see with the, the disc outcomes is that there was no real treatment effect that we could detect over 12 weeks. We had kind of hoped that we might have seen an improvement, but we, what we definitely didn't see is any negative changes at the disc either. So that means that we can say that 12 weeks of conservative run walk based running program seems to be okay for your disc. So, so if you're worried about having degeneration and these people were people with chronic low back pain and on average some of them did have severe degeneration and the average was what we call the lowest level of a degenerated disc. You're looking at lack of fumin grade from one to five, our average is about three and that's considered a like a mild degeneration study shows that seems to be okay for the disc and you don't have to be fearful about progressing that, but that's within the constraints of what we did within our study doesn't mean daring and running a marathon is also gonna be fine.
Claire Samanna:
So I think that's where we can draw our clinical implications is just in line with what we did in our study. Cool.
Jared Powell:
So running is safe and acceptable for people with sort of low-ish level, moderate intensity, specific low back pain, doesn't do any damage to the disc over 12 weeks from what you can see, but it also doesn't sort of lead to positive structural adaptations in that disc either, and so therefore it doesn't really explain the beneficial effect of a, of a running program. Is there anything you wanna add to that little summary? That was good, good Chris?
Chris Neason:
Practical implications. You're talking about talking about technology, we got participants using runkeeper an app that you can get on your phone for free so it doesn't have to be too expensive. They're able to take that along with them and it would start their interval timers, you could set them up. So we found that was, you know, handy for participants just looking to have something to guide them in terms of timing. Cool.
Jared Powell:
Let's just hypothesize for a minute, say if somebody comes in to see any exercise, professional physio osteo, hopefully chiro ep, they've got non-specific low back pain, they're amenable to starting running, but they're also, you know, amenable to any other intervention because they, they think you are the expert. What would be a circumstance in which we could recommend running over and above or above and beyond other exercise approaches such as resistance exercise or yoga or Pilates or stretching, exercise, whatever it may be. Are there people just with a, with a background or an interest in running that you would try or are there people who may benefit more from a running program perhaps if they need to lose weight or they could benefit from losing weight? What would be sort of the ideal candidate for someone who isn't just saying, yeah, I wanna run, give me running. Like if it's, because often it's gray and opaque in what you should do for people.
Chris Neason:
Yeah, that's, yeah, tough question. The weight loss thing, I'm, I'm not sure running is the best way to, to, I'm not sure exercise is the best way to lose weight, but maybe that's certainly a good motivator for people to do the exercise because of the, the promise of weight loss. So that's definitely a, a possibility. The the biggest thing, like you mentioned is people who want to run and are interested in running cost, I guess could come into that decision because, you know, seeing us health professionals regularly isn't always the cheapest thing. Doing your Pilates classes or yoga isn't always the cheapest. Running can be quite affordable as long as you don't need to deck yourself out with the, the top gear. And it also might be ru running sort of limits people to a fairly small range of motions. There might be people who've exacerbated towards end ranges rotation, end range, flexion extension and running. We te we don't go through much of a range of movement in the lumbar spine. We do have more compressive force than what we do with walking or, or some other exercises. But compressive course can actually be really good for the spine over time and it's still very, very low to moderate type of force when we go running. So perhaps for people yeah, who, who don't, who seem to be flaring up with everything else, you might find walking and running can be good options. Yeah,
Claire Samanna:
No I think Chris sums it up really well. Something or wanna add is the, when we say the word running that can mean different things to different people. So depending on people's past experiences. So to some people going for a run means going for a 5K run to others it means going for a 10 K run. And I think something that this study really shows is that even the smallest amount of running can be called going for a run. So 15 second jog and then two minute walk. We call that running. And I think if you've got like a, a patient and they're, they're on the fence about oh I might wanna run or other other exercise options aren't available to me or I wanna be outside but I don't like running, I would ask a, like a follow up question and go what, what is it about the running? Is it because it's you get really hot and it's uncomfortable or perhaps we can do something about that. And I think this interval based program can address some of those barriers that some people face when it comes to running. So yeah, that's, I don't think we can force everyone to run, but I think it definitely makes it a lot more accessible than what some people think.
Jared Powell:
Yeah, totally. When I was looking at the, the interval workout that you guys prescribed just seems really attainable and obviously I don't, I'm not in the cohort of people with non-specific low back pain, but you, you know, like if you're giving resistance exercise and you're like, okay, try this one kilo weight and just do three reps and most people you can find an exercise that someone can enter and often with running as you said, you know, running is not just going for a 10 k run and being really, really good at it. It's running for 15 seconds and then taking a two minute break and as long as you're progressing that sequentially over weeks and weeks and weeks, you can find an entry point for somebody. And I think that's, that's really important. So that's really well said there with that running is not just running, which is not just running, you know, there's different ways of running and interrogating those beliefs is really important because if somebody just fobs off running because they think it's a something and it's 'cause something completely different, then you're sort of missing out on opportunity for that person to get moving there.
Jared Powell:
Chris, you said something important a moment ago about, you know, running perhaps or exercise in general is, is not not good for weight loss and that seems to be what the evidence suggests. Diet is obviously the big ticket item and these days we're getting ozempic in GLP one agonist drugs coming out and we're seeing some benefits for that in people with knee osteoarthritis in terms of losing, losing a lot, a lot of weight and that map mapping pretty well to a reduction in pain. Do you think that something in the future that that may be applied to low back pain where somebody comes in, they've sort of got over 30 BMI, let's go more broadly. Do you think there's a tight association between weight and the experience of non-specific low back pain
Chris Neason:
From the data? It seems to be, yeah, there seems to be an association there and I think this is often argued it's probably due to the systemic inflammatory effects of the weight and how that impacts our metabolism as opposed to the weight on our joints and causing yeah, excess load mechanical loading on the joints, which again may well be a good thing. Yeah, yeah. So yeah, I, again, running or aerobic exercise and it might be walking, it might be cycling or swimming or an option that's suitable may have those inflammatory effects and while, you know, this was a fairly conservative program over 12 weeks, you stick at this for long enough and naturally you're probably gonna start to see even small effects in those areas like reducing inflammation and whether we can fast track that with diet or medications probably yet to be seen. But it's definitely, I think an area for, for research, there's probably gonna be a subgroup of people who do respond really well to targeting inflammation as a, the key part of their treatment.
Jared Powell:
You measured systemic inflammation levels, didn't you, did you see any changes in that over time? Yeah,
Chris Neason:
So we've got a few authors specializing in different areas. We've got sort of a, a team that allows us to do that, which is handy because I don't know anything about the intervertebral dislike, I dunno a lot about inflammation. So those results are still pending. There's nothing off the top of my head that's coming out from those manuscripts. It's gonna be like a game changer, but I don't want to, yeah, I don't want to get ahead of any of those man manuscripts in case I'm, I'm wrong.
Jared Powell:
That's okay. I won't, I won't get you fired. Cool. That's, it's fascinating to know and again, looking at the, the causal mechanisms I think will give us so much more information about just where the benefit from this sort of stuff is coming from rather than just speculating like us here on Zoom, what day is it even? Is it Tuesday, Monday? Is it Monday? What, what day is it guys? Monday. There you go. 4-Year-Old and a 1-year-old. I told you so yeah, it's, it's curious and also the, the physiological effects of running. Like I wonder if you guys measured VO two max at baseline, whether that changed over the 12 week intervention and you know, as people get older, VO two max becomes much very, very important in terms of longevity and health span and things like that. So there's so many general benefits to running and it does seem to reduce pain, although modestly we just dunno how, and it just bugs me, it keeps me up at night about all this or how all this stuff might be working. All right, I'm gonna start to let you guys go. Do you have anything else to add before you depart?
Chris Neason:
I just think we're generally like as physios, exercise physiologists, exercise professionals, we're too cautious with clients with chronic pain. So hopefully research like this helps to challenge some of the beliefs around what people can do when they are in pain and yeah, challenge some of the mindsets to perhaps do a little bit more and, and we might actually see some better results as well when we do challenge people a little bit more and treat them as a robust biological individual and not someone that's broken down that can't do anything. Yeah,
Jared Powell:
Well said. And I, that image of frailty that we often have as clinicians, not, not speaking for you two or myself here, but it widespread, it's not really based on anything is it? When you dig into it, there's no real empirical support for the fragility of humans. Like as you guys have demonstrated running with safe and acceptable for this cohort of patients and I think a lot of people going into it would, would not have thought so, and perhaps even the patients wouldn't have thought so either. So that, that's a really cool finding. What about you Claire?
Claire Samanna:
I'll give the inadvertable disc perspective as I always do. , , I think there's a lot of fear around what if you being, if you have had some imaging and you do have some kind of disc bulge or degeneration, there's fear around progressing that and making that worse. And while I can't say that our trial, like I said, reversed that damage or anything, we can say that you can run and there there wasn't any negative impacts. And then if we zoom further out, we could look to the broader literature. We do see that people who run have healthier discs than people who don't run. And I think there's something to be said for that. The body likes loading. We know that this type of loading seems to be associated with these health benefits at a disc level and I'm talking about more hydration and height, which are how we measure the health of the disc. So I think in the absence of evidence to show the opposite, it's, it's an important narrative that we can bear with patients around. Even the fact that these studies exist in this cross-sectional data can just help change perhaps some of the language you use around discs. And instead of just talking about pathologies all the time, walking about the fact that maybe some exercise is associated with health and I think that can start to chip weight that narrative that's been around for so long.
Jared Powell:
Yeah, that's really clinically applicable. So people come in, they, they have low back pain and they've had an MRI and there's a disc bulge of some description or herniation, whatever it may be. People become really disc centric, don't they? They obsess about it and they will ask you, will this affect my disc, this exercise or running? And so it's good to have data that it may not be definitive, but at least points us in is might be directionally give us some direction and say it's not going to make your disc any worse. And I think that providing a reassurance and safety and confidence at the start really helps someone's psyche to get moving. So I think again, that's another super important takeaway. Okay, thanks guys. Wh where can people find you, you guys on the socials at all? Twitter
Chris Neason:
Or x? At Chris Easton
Claire Samanna:
And I'm on X as well, Claire, Ana and Instagram. Claire, the low back pain ep.
Jared Powell:
Oh, love it. Awesome. Okay guys, this has been a super fun chat. Thank you. Thank you for doing the work. Really great study, really elegant, lovely design and a really clinically important question. And Claire, I'm looking forward to your work coming out. So do let us know and I'll share it when that work is published 'cause that's going to be interesting as well. But I'll let you guys go and thanks so much for coming on. Thanks for
Claire Samanna:
Having us. Yeah,
Jared Powell:
Pleasure. Thank you for listening to this episode of the Shoulder Physio podcast with Chris Neason and Claire Samanna. If you want more information about today's episode, check out our show [email protected] if you'd like to what you heard today. Don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
