Dr Rupy: If you find yourself struggling with back pain or maybe a loved one and you're spending thousands of pounds on gadgets and interventions that could potentially help, well, this is the episode for you. I'm sitting down with a consultant spinal neurosurgeon, Mr Anthony Ghosh, to dispel some myths and what you can do today.
Dr Rupy: Back pain is still one of the most common health issues worldwide and it's surrounded by confusion, fear and tons of myths. And in this episode, I sit down with Anthony Ghosh. He is a consultant spinal neurosurgeon. He's also an educator and founder of the Spine MDT clinic to separate fact from fiction and give you a practical toolkit for a healthier spine. And it's actually more simple than you think. What I love about Anthony's approach is that he's created Spine MDT, which is a modern multi-disciplinary spine care service that works with physiotherapists, osteopaths and even chiropractors to deliver truly holistic care to patients, many of whom he believes would not benefit from spinal surgery. So today, we're going to cover some myths and bust some of those, like running, lifting weights, posture, mattresses, all those gadgets that I used to think were useful, even standing desks to be honest. We're also going to talk about what's really happening when you get back pain and when to seek help. We talk about effective exercises that I've now started doing every single day, including the McGill Big Three, and this is for strength and recovery. Sleep positions, pillows, shoes and desk-friendly tips to protect your back. And why, as a surgeon, he believes that surgery often isn't the fix people want and expect and when it is and how it can truly change lives. If you've ever wondered whether cracking your back is dangerous or if a herniated disc can heal on its own or what the best daily routine is for back health, this episode has the answers. He's also a strong advocate for educating patients and challenging these outdated views, which he messages very regularly on his growing YouTube channel, Spine MDT, that you can check out on the link in your podcast player.
Dr Rupy: Look, let's, let's dive into what we actually mean by back pain, Anthony. We were talking before we started recording about how complex this is. So when someone comes to see you in, in clinic and they say, I've got back pain, I want surgery for it or whatever it might be, how would you define back pain and how do you explore that with them?
Mr Anthony Ghosh: Well, I break it up into various categories. So you've got acute and chronic. Acute means it started fairly recently, or it's been coming and going or continuous for quite a number of months or even years. And then within those two sort of categories, I think of two models. We've got the pathoanatomical model where there is a true anatomical cause or a problem with the structure, some kind of defect or damage within the structure. And interestingly, that makes up an absolute minority of patients.
Dr Rupy: Really?
Mr Anthony Ghosh: And then, particularly in the more chronic patients who've had it for a long period of time. And then we have what we call the biopsychosocial model, which still incorporates some of the anatomical stuff, but what else is going on in the background. And what I mean by that is, you may have had a real true anatomical cause of your pain at the onset. For example, you've torn a disc at some point and it's caused excruciating back pain. That's the like the cushion between the two vertebral bodies of the spine. Sometimes it tears, releases some inflammatory material, it kicks off a bit of an inflammatory reaction, and then you're in severe pain. But eventually, that that itself heals up. But then we adopt these false protective behaviours and false beliefs. You know, I think I've ruined my back, I've damaged it, it's now really fragile. I have to be really careful with it. And a lot of the research done by a quite a famous Australian researcher, Peter O'Sullivan, has debunked all of that and shown that actually these false behaviours and false beliefs have actually made things worse. And social media today, the internet, the online world is actually full of this stuff that is actually, I believe, making things a lot worse.
Dr Rupy: You know, I really resonate with that because, so when I was younger, in my late teens, I was really into tennis and I think my serve was slightly off and after years of doing a particular serve, I developed an acute instance of back pain. And ever since then, I've sort of identified as someone who has back pain and someone who needs to be really careful about everything from the form of my squats, the form of my deadlifts, or like if I sleep in the wrong position, you know, and and actually, as I've learned a bit more about pain in general, I feel like that's kind of amplified my my my back pain without necessarily an an anatomical issue.
Mr Anthony Ghosh: Well, I think of pain as, or back pain as, imagine a big jigsaw puzzle. One piece of that jigsaw puzzle might be the anatomy. So for example, a disc may have torn, and the pathology, you know, localized inflammation. And then all of the other pieces of the jigsaw puzzle are things like how we adapt our movements as a result of that. Are we doing the wrong things? And then beyond that, you've also got, you know, fear, anxiety, stress. We know these are proven to be potent amplifiers of pain. So we have to address all of those issues.
Dr Rupy: Yeah. And how do you do that in clinic? Because, you know, there's a lot to unpack when someone.
Mr Anthony Ghosh: That's right. So I think I think that's the that's the key thing. I think a clinic consultation has to take, it takes time to unpack these things and you have to spend time drilling into these problems and seeing what else is going on in the background. But equally, you have to be very cautious. This can be misconstrued as you're trying to tell me it's all in my head. That's absolutely not the case. So my approach is, I I first try to find that anatomical cause, make sure I'm not missing anything. So I do all of that with the history, the examination and the scans. And once I'm satisfied in my mind that the imaging hasn't shown anything threatening, then I start educating and explaining all of that stuff and then going into all the other things that might be going on. What do they believe, what does my patient believe is the cause of the pain? What do they believe they're doing that might be aggravating it or protecting it, drilling into all that and unpacking it.
Dr Rupy: Do you think the prevalence of back pain has increased over the last 10, 20 years, would you say? Or would you say it's we've just become a bit more aware of it?
Mr Anthony Ghosh: Certainly over the last few decades, occupations, sedentary occupations have become a bit more prevalent. There's possibly fewer people finishing school going into manual jobs and there are more and more office type jobs. And certainly, I would say 95% of my patients are office workers.
Dr Rupy: Really?
Mr Anthony Ghosh: Yeah. So in that respect, it has gone up. I think the pandemic that we've, you know, came out of a few years ago didn't help with home working and everything. But equally, I think we are going to plateau. You know, millions and millions of people are off work each year with back pain. It's probably one of the commonest causes of time off work and loss of income. But what I've noticed is, I think there's a lot more awareness today and consciousness about good health, you know, thanks to people like you and your podcast and many others. And gym memberships have skyrocketed. People are exercising more, especially younger people. So I'm hopeful, I'm a, you know, I'm an optimist. I'm hopeful that's going to have a positive impact as we go on and things will plateau and improve.
Dr Rupy: It's interesting, isn't it? Because someone new to this area might think people who are in manual jobs, carpenters, labourers, people moving around a lot are probably more at risk of having back problems compared to people in a protected environment perhaps behind a desk. But it's what you're suggesting is it's the exact opposite.
Mr Anthony Ghosh: That's right. Now, don't get me wrong, you have to be careful when you're lifting a certain amount of weight, you know, you can injure yourself. But if you look at statistics overall, the massive majority of people with chronic back pain are office workers.
Dr Rupy: Yeah. And so what is it about that sedentary lifestyle that leads to back pain? Because when I when I said that we were going to get a spinal surgeon in, everyone was like, okay, I better I better like get my posture correct when he walks in because I don't want to be told off. But you know, most people would assume it was it was that. It's like what I'm doing right now, being hunched over.
Mr Anthony Ghosh: Well, this is down to thank, this is down to a lot of work done by Peter O'Sullivan. So I don't want to take credit for his research and he's raised a lot of awareness in this. We've all been indoctrinated in this belief that you have to sit with your back straight, your shoulders back, you know, your your chin down a little bit, as if somehow that's going to help and protect your back. There is no evidence to to prove that. The back, the spine just needs to move. It's not so much the fact that we're slouch. The reason we often slouch is that's our back muscles relaxing, the paraspinal muscles that hold the back upright. They're just relaxing. So the analogy I use is I don't walk around with my biceps flexed all day just to protect my elbows. That's not going to, that's going to ache. So when you're tensing those muscles, any muscle, if you have it under tension for a prolonged period of time, you're actually going to generate more pain. So the secret is to just get up and move every so often.
Dr Rupy: Okay.
Mr Anthony Ghosh: And I suppose it brings us to the earlier quick fire question on standing desks. So there are studies that have shown that standing for a prolonged period of time is equally as bad for the back as sitting. Yeah. It's the fact that we're not moving.
Dr Rupy: Huh.
Mr Anthony Ghosh: I don't mind standing desks. I often advise if you have one, maybe alternate on the hour between standing, raise it up for an hour, sit down for an hour. But more importantly, on the hour, every hour, I have a buzzer on my phone, get up, have a little walk around. You don't have to do anything too strenuous, just walk and move, loosen up, get that blood flowing, and then back to work.
Dr Rupy: Okay. So ditch the standing desk and just move.
Mr Anthony Ghosh: Yeah, don't blow all your, if you have a standing desk, fine, but don't go blowing all your money on one. That's not going to cure your back.
Dr Rupy: Okay. And in terms of the the sort of posture when you're in front of your your computer, my understanding is you're, I mean, our heads are very heavy, aren't they? They're like, I don't think I think we take, yeah, we we take for granted just how heavy our heads are.
Mr Anthony Ghosh: That's right. So, so what we've discussed earlier is more the lower back. Now with the neck part of the spine, it's a bit different. There is a colloquially phrased condition called tech neck. And I used to see this in the start of my career, I'd see it in office workers once they've hit their 50s or 60s. They've spent, you know, hours at a computer with their head looking down at the keyboard. If you're anything like me, I can't type without looking at the keyboard. But now I've started seeing it in much younger patients because of cell phones. They're just sat there with the neck down all day. And after 10 years, they start to develop, you know, neck pain and even impingement of nerves sending pain down the arms. So I think with the neck, it is important to try keep your computer screen, the middle of your computer screen at sort of eye level.
Dr Rupy: Okay.
Mr Anthony Ghosh: I've got a stand for mine that I carry around with me.
Dr Rupy: Yeah, one that you can have a laptop, yeah.
Mr Anthony Ghosh: And I've got a Bluetooth keyboard that I have that's separate to it. So it just makes it easier.
Dr Rupy: Yeah. Are there any other exercises that are useful for folks who are on their phone the whole, I'm actually really trying to reduce my screen time on my phone, but if you're if you're on your laptop, are there are there other things you can do?
Mr Anthony Ghosh: So moving the neck is good, but so moving it in every direction. So we have rotation, flexion, extension, and there's lateral flexion both sides. And then for the deep flexor muscles, a really good one is pulling the neck back and then the chin down. That does the deep. So some people phrase it, some physiotherapists phrase it as, imagine you're just pushing a door shut with the back of your head. So you're just pulling the head back. So you're not extending, you're just pulling it back and looking down, just do a few reps of that at a time.
Dr Rupy: Okay. Okay, great. All right. I'm going to get you to demonstrate that afterwards in the studio for all of us because I think we're all like at risk of that. Um, okay, so we've got standing desks that are potentially useful, but like standing as much as sitting or basically it sounds like being in a prolonged position for any amount of time, whether it's sitting or standing is not going to be great. So you want to move as often as possible. Um, what about chairs? So again, if we move from the neck to the the lower bit of the spine.
Mr Anthony Ghosh: So billions has been have been made on ergonomic chairs and standing desks and and other things. And there is zero evidence to prove they work. So again, you know, if you have one and it's comfortable, find the chair that you feel comfortable sitting in, you know, for for an hour or so. That's my only rule and advice. You know, if you've got an ergonomic chair, fine, don't throw it away. It's not going to harm you. But you know, if you if you have money to spend on fixing your back, don't blow it on desks and chairs. Membership to a gym, a personal trainer, Pilates class, anything that gets you moving.
Dr Rupy: Yeah. That's what I'd spend, that's what I'd spend on primarily.
Mr Anthony Ghosh: So so those little stools that I've, they look quite cool as well, like the ones that move you around and stuff. And they get, you know, you to sort of like tilt your pelvis in a particular way and you know.
Mr Anthony Ghosh: Yeah, because they rock the pelvis forward.
Dr Rupy: Yeah.
Mr Anthony Ghosh: Um, again, there's no evidence that helps. It's the getting up and moving around. And there's good, you know, there's just been researched as well that there's no evidence that that's going to help you.
Dr Rupy: Okay.
Mr Anthony Ghosh: And again, I think it just amplifies this belief that your spine is somehow this really fragile structure. When you think about it, it's the core of your skeleton. Everything comes off the spine. It's probably the most robust part of your body. You have to trust it. You have to learn to trust it.
Dr Rupy: Yeah. When I think of aging individuals, um, and perhaps this is because of lack of movement in its entirety, but back pain does seem to creep up with age. Is it part and parcel of this sarcopenic picture, this sort of muscle wasting that also affects the muscles that keep the spine in a in a neutral erect position that's leading to back pain as well? Or is it just?
Mr Anthony Ghosh: I think I think muscle, you know, as, you know, as you've pointed out previously, you know, as as we age, our muscle mass and strength does does decline. So I think that certainly adds to it. Um, often if we've had a sedentary lifestyle leading up to that or it becomes sedentary, that's also that also adds to it. And yes, there is wear and tear of discs and facet joints, the joints at the back of the spine that that can cause, you know, inflammation and pain every so often and stiffness. Um, but there there are lots of studies done on MRI scans in people of different age groups who have never experienced back pain. And, um, interestingly, you know, when when we age, no or nobody has got a normal spine. So things like worn discs, big facet joints, you know, a whole two pages of A4 sometimes you read on a report. I often spend my time explaining to people this is actually all normal, a lot of this. Um, so I think it kind of oversell that message sometimes that that you've got excessive wear and tear of your spine. It's not it's not really true.
Dr Rupy: And when people have these MRIs, because they're becoming a lot more common now, and even I'm attracted to, you know, getting a full body MRI just seeing what's there, but having a clear management plan if there is going to be a cyst found or, you know, something abnormal, quote unquote abnormal. Um, as people have more MRIs, do you feel like we're going to sort of putting two and two together given that most people's spines are not quote unquote normal?
Mr Anthony Ghosh: Well, you're right, there is a huge abundance now of scanners everywhere and quite a few patients that come and see me have come because they've just been able to walk into an MRI centre, come out with a report, hit the panic button and booked in to see me. Um, I did a video a while ago called the catastrophic effect of an MRI scan. And it's based on, um, a study that was carried out on people with back pain. Um, they were divided into two groups. One group of patients were just given the report of their of the MRI scan, and the other group had the report explained to them by a clinician.
Dr Rupy: Okay.
Mr Anthony Ghosh: They're both the same, you know, they've got the same symptoms, but the group that had it explained to them just did far better.
Dr Rupy: Right.
Mr Anthony Ghosh: And it goes back to my earlier model of that biopsychosocial model, these false beliefs, anxiety and things like that, they are potent amplifiers of pain. I'm not against people having an MRI. I'm, um, the world of preventative medicine and longevity is blowing up. And I think that's a good thing. So I think it's, you know, it's good to to think of prevention in the beginning, but it's important that you have this explained to you properly.
Dr Rupy: Yeah, I think, you know, there's a parallel with wearables and trackers. I know that certain people, if they got a poor score on their wearable in the morning, it would derail the rest of their day. You know, I didn't get enough sleep, I didn't hit my deep sleep score, whatever, my HRV is all over the place. Ergo, I'm not going to have a great day. Whereas some people, I would like to say myself included in this bucket, will look at that number and make a pragmatic decision to ignore it if you feel all right, and then just carry on as you would otherwise. And the same thing could be said in a more extreme example with MRI scans because I think you were saying earlier, if you scanned like 100 people, a large proportion of folks would have something abnormal on the report.
Mr Anthony Ghosh: Correct. Above the age of 40, people without back pain, um, at least half of them have one or two dark or worn discs on their scan.
Dr Rupy: Okay.
Mr Anthony Ghosh: And that freaks people out. So the analogy I often tell patients, which makes them laugh is it's the equivalent of me having a few extra grey hairs on my beard or a few wrinkles. I don't run to A&E with it. It's just part of being human. And we've demonstrated that over the years.
Dr Rupy: Uh-huh.
Mr Anthony Ghosh: Um, about 20 odd years ago when MRI scans started popping up everywhere, for spine surgeons and all clinicians, we wrongly made the assumption that these dark discs that we're starting to see are probably the cause of the back pain that people are experiencing. And then spine surgery just exploded. Um, the number of spinal fusions worldwide shot up in a very short period of time and the results were atrocious, were awful. And that's because we we've misconstrued the findings of these scans. We've made false assumptions about these scans. We see those findings in normal adults. But there was a subgroup of patients that did well with surgery. And that's what we've studied over the years. What what is it about those patients and what are those findings on the scan where actually these findings might be the source of pain. Um, and there's there's a few things. Yes, in the acute setting, a torn disc, the the gristle between the two bones can give you acute pain there. That will repair itself in the majority of patients within a few weeks.
Dr Rupy: Okay.
Mr Anthony Ghosh: So, you know, that's that done. Then there are conditions where either through wear and tear or defects in the bones of the spine where one bone of the spine can slip forward over the other. If we think of the spine of a stack of bones, vertebrae, they're they're held together in alignment. Sometimes if the joints and ligaments and muscles that hold them together weaken, one can slip forward over the other, move abnormally. And that's called a spondylolisthesis. And again, you've got to be careful when you find that how you assess the patient to be sure in your mind that that is actually still the cause of the pain. So even then, even when I see something, I'm still cautious in not diving in too quickly with the assumption that this is the root of all their problems. But once I've identified that, then that group may do better by fusing the spine. There are various anatomical conditions where if you fuse or fix the spine and stabilize it, then yes, they will do better in terms of back pain.
Dr Rupy: Okay. So the the majority of the issues around back pain should be treated outside of the the operating theatre.
Mr Anthony Ghosh: That absolutely.
Dr Rupy: Okay.
Mr Anthony Ghosh: Absolutely. Yeah. So I'd say I I in my clinic, I probably operate on one in every 10 patients I see.
Dr Rupy: Really?
Mr Anthony Ghosh: Uh, and I truly believe if you're doing more than that, you're probably overtreating.
Dr Rupy: Gotcha. Yeah, yeah. And in terms of treatment options, just to sort of expand this for the audience, for those who might have hernial, uh, herniated discs or damaged discs, what what would the treatment options look like in in the sort of majority of cases?
Mr Anthony Ghosh: So to start with, I'll say is with, let's just get to to in order to try and get surgery out of the equation for a lot of your viewers, the reason someone might need an operation, the reasons I operate on someone is predominantly, 90% of the time is to protect a nerve that is trapped or the spinal cord and therefore protect your neurological function, your ability to move your arms and legs. So if a disc herniation is pinching a nerve in your lumbar spine, in your lower back, and therefore causing sciatica, pain shooting down your leg, in the majority of people, that will get better within six to eight weeks or so. Actually a lot earlier than that in many, but in most, in about 60 to 80%, it will get better in about six to eight weeks or so. So in that initial period, it's very rare that we need to offer anything invasive.
Dr Rupy: Okay.
Mr Anthony Ghosh: Sometimes an injection of a steroid may help just calm things down. Um, I advise patients to try and walk through it because that walking and moving and wobbling of the the vertebral bodies, um, depending on how much of a herniation you have, if it's a small amount, that movement can actually suck the disc back in. You have this kind of vacuum effect and it gradually sucks it back in.
Dr Rupy: Okay.
Mr Anthony Ghosh: Um, so yeah, generally rest, well not rest a little bit, but it's important to try and move and walk around. As we sit still, all the inflammatory material that's just come out of the disc just sits there and the surrounding tissues, for use of a better word, marinate in it. So when you're moving around, you're kind of pumping it and washing it away and you're more likely to improve sooner. If you've passed that time frame, things haven't got better and got worse, then there are interventions we can do. A microdiscectomy is an operation under a general anaesthetic through a very small incision in the lower back under a microscope where we just simply shave away that small disc fragment that's pinching the nerve and that usually gives a fairly instant result of pain alleviation in the leg. You still have some back pain from the wound, which gets better, you know, as the days and weeks go by. Sometimes an injection can still help at that point. The only indication to to operate early is if you're starting to lose neurological function. Not so much numbness, but weakness in the leg. If you've actually lost some motor function of your, some people present with a foot drop where the ankle just starts going floppy. When they're walking, they notice they're tripping themselves up a bit. Then the earlier we operate, the more likely you are to recover that function because we're protecting the nerve. And then there's the the dreaded, um, syndrome of cauda equina syndrome that, um, I'm sure you've heard of, which is where you've got a large central disc prolapse where a huge fragment of this disc herniates, compressing all of the nerves in the lumbar spine that go to both legs, the sphincters of your bladder and your bowel. That classically gives you back and pain in both legs, numbness in your private area, in your genitals, and then difficulty passing urine, either retention that you're not aware of or eventually incontinence. That is a medical emergency and that needs immediate decompression, diagnosis and immediate decompression to preserve that function.
Dr Rupy: What what are the commonest causes for the herniation in the first place that that you're aware of?
Mr Anthony Ghosh: So think of a disc, if we think of, um, a vertebral body as a cylindrical block, um, the disc is a bit of gristle that sits between those two blocks of bone. And I often describe, well actually the textbooks describe it as, um, crab meat consistency.
Dr Rupy: Right.
Mr Anthony Ghosh: And it's quite accurate when you operate on these, that's what it feels like. It's like a white brown crab meat.
Dr Rupy: Yeah, a white, yeah, a white fleshy sort of.
Mr Anthony Ghosh: Okay, yeah. Fleshy, squishy bit of tissue. So imagine a lump of that, and then it's contained in a in a sort of fabric-like, uh, lining that holds it in place. And those lining fibres, they weaken, they sort of gradually tear and and thin out. That's probably a result of being sedentary, slumped over a desk for eight hours a day. And then it'll be a random movement that causes that final tear and the fragment of disc to pop out. So I've had patients say that they were literally just leaning forward to put a plate in the dishwasher and then suddenly felt that acute pain come on. Um, so yeah, it's weakening of that lining, that lining of the disc material. Again, we've got to be a bit cautious. We see that most of us have got dark discs with some evidence of thinning of the lining by the time we're in our 40s. So we don't want to overinterpret it.
Dr Rupy: Sure.
Mr Anthony Ghosh: And this is where the core strengthening does come into it. One of the mechanisms to help prevent that recurring is to kind of build a bit of a muscular brace around that segment, which can help prevent it in future.
Dr Rupy: So an acute event sounds like the entirety of the the pathological process occurred in that movement, putting plates in the dishwasher or whatever. But actually, from from what you're saying, it sounds like this is actually the accumulation of years or, you know, even longer of sedentary behaviour or, you know, lack of movement of the spine. And it's almost like the straw that breaks the the camel's back.
Mr Anthony Ghosh: Yeah. Gotcha. There are other extremes, you know, I think I do occasionally see it happen in people who exercise and and it's happened during sport. Um, and it's very difficult to predict, but it's far, far more in the former group that you've just described.
Dr Rupy: Yeah. Because a typical sort of story that I would have heard, um, during general practice from perhaps another variety of people who are less sedentary and they're active and all the rest of it is they did a heavy session the day or two days before and then the back pain actually came on quite gradually to the point where now they're like, it really like stings and it's and whether or not that's a herniated disc or not, I'm wondering whether that's a.
Mr Anthony Ghosh: That late, yeah, the latency in pain. Yeah. There's various causes of that. Often it is, uh, just muscular. Uh-huh. Um, the the other thing often and often that group of patients with the latency, they usually say it seems to be worse first thing in the morning.
Dr Rupy: Yeah.
Mr Anthony Ghosh: That's because the discs of our spine don't actually have, a healthy disc doesn't actually have a blood supply. All of its nutrition comes from water seeping into the disc with the nutrients. Um, so if you've got a disc that's got a slight bit of wear in it and a bit inflamed, during the night when we're sleeping and sedentary, water's creeping into it, filling it up, expanding that lining a bit and everything feels a little bit stiff. So interestingly, if you measure your height first thing in the morning versus last thing at night, you're actually a bit taller by about a centimetre or so.
Dr Rupy: And that's why?
Mr Anthony Ghosh: Yeah. But when you get up and move around, that water in the disc starts to flow, move a little bit, things loosen up, and patients often say they start to feel a bit better as they move around again.
Dr Rupy: Gotcha. Okay. And so, um, yeah, the the other group of of people having having back pain are fairly active and they that sort of like that pain that comes on later. Would that mainly be in a muscular sort of category rather than something to do with the disc?
Mr Anthony Ghosh: It can be from thinning and localized inflammation in the disc, you know, just described when the lining stretches. But yes, and and combination of muscles and and other structures and things like that. Yeah.
Dr Rupy: And why might somebody have a dehydrated disc? So we were talking earlier about if you MRI a whole bunch of people over the age of 40, a good chunk of people can have a dehydrated dehydrated disc. What's the reason behind that?
Mr Anthony Ghosh: We think again, the the water, so the a disc as I said, it's got that sort of crab meat consistency with water or fluid around it. And that's just leaked out gradually over a prolonged period of time usually. And it is probably thinning of that lining, that sort of fibrous lining of the disc and tearing of it. But the interesting, the good news is that that lining of the disc is made of material called collagen. And guess what, scar tissue that we lay down is collagen. So actually they do repair quite well.
Dr Rupy: Gotcha. Okay. So that brings me to another thing around supplements actually. I was going to ask you about this a bit later, but collagen's a very popular supplement these days. Is there any evidence that it can help with?
Mr Anthony Ghosh: Not that I, you know, I've looked at supplements to improve spine health and things like that. The generic ones to improve bone health are very good, especially as we're aging, especially in female patients, postmenopausal to maintain density. But in terms of discs and things like that, not really. I don't think adding collagen to your diet is has been proven to to benefit.
Dr Rupy: Okay. But what what about the ones for bone health? Is that, uh, calcium supplements, vitamin D3, collagen, protein?
Mr Anthony Ghosh: Yeah. Okay. I mean, there's no just just generic for anything that's for generic bone health, yeah, those sorts of things, yeah.
Dr Rupy: Okay. Um, let's talk about sleeping positions. So we've just been talking about sleeping, uh, and how you you stretch when you when you're sleeping because of the hydration of, um, of of the discs. Is sleeping position important when it comes to protecting your back health?
Mr Anthony Ghosh: I think it gets overplayed personally. So we're again, we're taught to lie in this rigid position completely flat with your arms across your chest like you're in a coffin or.
Dr Rupy: Yeah, yeah. That's how I sleep.
Mr Anthony Ghosh: Completely flat. But, um, there's a there's a a few theories around that. Yes, the spine is in a in a neutral position. But then the spine is part of a whole system. It's part of a a whole body. So we're not there just to protect the spine, we're there to, you know, look after the whole body. Um, and there's neuroscientists have done sleep studies on the sleeping position. Whilst we're drifting away from the spine here, I think this is really important. It is partly related. Um, studies have shown that when you lie on your side, and I think in the majority of people that's on your left side, the cerebral spinal fluid of the brain just drains better and washes the brain better. And this happens, this is why sleep is important. That happens during during your sleep. And when you lie on your side, that's better. And there's probably an evolutionary theory behind that in that, um, when you're lying on your left side, you know, our evolutionary ancestors, your major organs, specifically your heart, are better protected from attack from wild animals in the night. When it comes to the spine, also the posterior chain, that band of muscle from the back of your skull all the way down to your pelvis and then the glute muscles, they're in a slightly more relaxed position when you're on your side. You tend to have your hips a little bit flexed, the knees a little bit flexed, and that just relaxes that posterior chain. So I I believe that's just as good for your back as lying flat on your back. There's no really convincing study to suggest one method of sleeping is better than the other.
Dr Rupy: Okay.
Mr Anthony Ghosh: I'm against front sleeping because you have to have your neck turned to one side for a good few hours and I don't think that's good for you.
Dr Rupy: Ah, that's interesting. So I don't sleep on my front anymore. Yeah. But I do sleep like my my wife thinks I'm like Hannibal Lecter when I'm sleeping. I'm like and a very rigid position. And I don't use a pillow either. Like I.
Mr Anthony Ghosh: That's not bad. I mean, as long as it's if you're comfortable in a position, that's fine. Again, we shouldn't overthink these things about posture and that. Um, pillows is an interesting one. As a habit, we we seem to see a lot of people having two or three pillows under their necks. Now, providing you haven't got any respiratory issues that require you to having your chest up or anything like that, I think forcing your neck into a flexed position for a prolonged period of time, I think it's the parallel of sitting at your desk over a laptop for a prolonged period of time. So I think you only need one pillow just to literally take the back of your head off, you know, off the mattress is plenty.
Dr Rupy: Okay, okay. So one pillow instead of two. Yeah. And what about some of these contraptions where it's literally just like almost like a neck pillow. So you literally just put it underneath your.
Mr Anthony Ghosh: Uh, I think these things get oversold personally. I think, you know, that less is less is more and and they also bring a lot of these contraptions that we have for the spine like collars and braces I see people wearing, they're taking over the job that your muscles should be doing.
Dr Rupy: Right.
Mr Anthony Ghosh: And when we're not using our muscles, what happens to them? They waste. And that's a problem.
Dr Rupy: Okay. Yeah. Um, when I was growing up, uh, I remember the adverts for memory foam, uh, and how, you know, it was like using NASA technology and all this kind of stuff. Yeah. What are your thoughts on memory foam?
Mr Anthony Ghosh: Um, there is a there are studies done on different mattresses, um, that have looked at back pain and sleep quality and things like that. Um, I think the the most important factor is being comfortable.
Dr Rupy: Okay.
Mr Anthony Ghosh: Um, that's it. I think some of the evidence from that particular study was a firm mattress, but the firmest one wasn't the best one for sleep quality and back pain specifically. And again, that probably comes to the side sleeping issue. If you're sleeping on your side, you kind of want the mattress to mold around you a bit. It's more challenging for the mattress to mold around your body than if you're on your back. And therefore a firmer mattress will be even more challenging in in doing so. So firm but not the full end rigid end of the spectrum.
Dr Rupy: Okay.
Mr Anthony Ghosh: I am slightly worried I'm I'm probably overselling this to your viewers. I think the key message I wanted to to to drive home is don't overthink the ergonomic stuff like the mattresses, the chairs, the desks and the devices. Um, you know, if you've got money to spend, these are the last things you should be spending it on. It should be looking after your health in general.
Dr Rupy: Yeah, it should be a gym membership.
Mr Anthony Ghosh: Yeah. Yeah.
Dr Rupy: Uh, okay, fine. So, uh, mattresses, not not too firm. We're not talking about like wooden. Yeah. But firm enough and ensuring that you're comfortable. And maybe, you know what, I might try the left position, you know, now that you said that about the uh, the evolutionary benefit. I'm a big fan of thinking through things uh, through the uh, the evolutionary lens. And you know, it's really interesting to think, okay, you've got your, you know, you've got your heart on that side, but I guess you've got your liver, like that's that's exposed. So if you're attacked, you could bleed out.
Mr Anthony Ghosh: I suppose the the spleen is more prone or more hemorrhages a lot more when injured than the liver and the heart.
Dr Rupy: Gotcha. Yeah, yeah.
Mr Anthony Ghosh: It's an evolutionary theory. But you know, I've noticed you're wearing is that an Oura ring?
Dr Rupy: It's a it's an Oura ring. We're not sponsored by them or anything.
Mr Anthony Ghosh: You can do an AB test your sleeping with that.
Dr Rupy: It's a good point. Yeah, yeah. I mean, that's why I mean, I'm a big fan of doing wearables, but if you're someone who is, you know, a bit anxious about health and tracking all the rest of it, just do it for a week or so as a behaviour change tool because one of the biggest things that I've, we're veering a little bit off topic here, but I think it's worth a deviation. One of the biggest insights I got from my ring was actually just how much alcohol impacts my sleep quality. So even a glass of wine, if I have that glass of wine in the evening, it impacts my sleep score. And that's kind of really changed my thinking around alcohol. I did a deep dive into it, um, earlier. But I mean, for for me, it's been revolutionary. And and like eating late at night and what I eat and whether I choose to have dessert or not, like all these different things have impacted my my sleep. And so for me, it's, you know, it's been it's been a real unlock.
Mr Anthony Ghosh: I think with with alcohol and sleep, I mean, you know, getting a good night's sleep for pain, you know, when you when you understand pain science, pain is affected by sleep and sleep affects and also sleep is affected by pain. There is a cycle there. So, you know, when it comes to alcohol, again, I make sure that if if I am having a drink, it's a good couple of hours or at least two to three hours before I actually go to bed. And I time it that way. Not always, I you know, I'm out to socialize once in a blue moon. But, um, yeah, and also excessive excessive alcohol as you know, um, damages your bone integrity and that also causes problems with the spine.
Dr Rupy: These are the conversations that perhaps in the NHS at least, it's hard or difficult to have because they're on the fringes of where you need to get the information across, particularly if you're discussing something as serious as having a procedure. But they often got, they often get left to the side.
Mr Anthony Ghosh: Yeah.
Dr Rupy: And they're so important because, you know, the impact of alcohol across a number of different things, let alone your bone integrity is an important conversation to have. And that's why, you know, I love the medium of podcasting because we can actually inform as many people as possible.
Mr Anthony Ghosh: Yeah, be an educator.
Dr Rupy: Yeah. Um, okay, so ergonomic chairs, standing desks, all that kind of stuff, fringes of what we're really talking about here. Let's talk a little bit about exercises to sort of maintain the strength and the integrity such that, you know, we don't have back pain in the future. I'm 40, I've had back pain in the past. I kind of know what my triggers are. Actually, one of mine is actually a soft mattress, not to bring it back to mattresses. But I feel like when I sleep on a soft mattress when I'm not at home, it does trigger it for me. And I just have to sort of adjust the next day and do some exercises to make sure that I'm moving my spine and that's actually where I get relief.
Mr Anthony Ghosh: Yeah. Yeah. Um, I think I can't undersell, I mean, I can't oversell walking. It's such an important exercise. Just just that alone increases, it has so many other benefits to, you know, to the brain as well, um, to neuroplasticity, um, your heart, your joints, it doesn't overload, you know, any muscles, but that's so important for the spine, improving the blood flow. So that that's really important. There are, you know, I've looked at the research into very focused back exercises versus just generic good health and fitness.
Dr Rupy: Okay.
Mr Anthony Ghosh: And the latter seems to be better for back pain. And we've oversold, um, the concept of the core.
Dr Rupy: Yeah.
Mr Anthony Ghosh: So, um, and it gets really, I get I get really annoyed with this and thankfully again, Peter O'Sullivan has debunked a lot of this. Yes, it has its place. It's important to have a good set of muscles, a brace of muscles that surround your spine. But I'll occasionally see the odd sports person or someone who runs marathons, um, with back pain who've been told they need to work on their core. And they're doing a thousand sit ups a day. And that that's just not, that's just not going to help. So we there's lots of other factors that that come into play. That said, if we've if we've found an anatomical cause for the pain, for example, in acute pain, if you've torn, um, a disc, that little bit of gristle between the bones of your spine, that disc joint when it functions normally is a fairly rigid joint. So each segment of your spine only moves by a few degrees in each direction. If you have a weakness in that segment and then you apply a rotation force, all of that force is going to get transmitted around that disc. So in that scenario, if we've proven both clinically and radiologically that that's the cause of the back pain, then yes, working on the core or a three, I think of it as a 360 degree group of muscles that support that segment as opposed to a set of abs. That's another misconception about the core. And that brings us on to Stuart McGill's work, um, who came up with that, you know, viewers may have heard of the McGill Big Three. Stuart McGill is a therapist in Canada who works with, um, Olympic powerlifters, UFC fighters, and he wrote a book for patients called The Back Mechanic. And I've interviewed him on my, um, YouTube channel. So he describes the McGill Big Three, just three exercises to incorporate in the rest of your workout.
Dr Rupy: Okay.
Mr Anthony Ghosh: Um, so if I go through them, there's the bird dog when you're on all fours.
Dr Rupy: Oh, yeah.
Mr Anthony Ghosh: Left arm out, left leg out.
Dr Rupy: Yeah, yeah, yeah.
Mr Anthony Ghosh: Right leg out, opposite opposite arm, opposite leg, and then cross over and that generally stay builds up some of the paraspinal muscles of the back. Then there are side planks and you do each side. So you rest on your forearm.
Dr Rupy: Okay.
Mr Anthony Ghosh: And your foot. So the only points of contact are your feet and the your forearm with the ground. That does the oblique muscles. You do that both sides. And then there are curl ups when you lie on your back, you bring your, it's a bit like a crunch without actually crunching the abdomen. You're tensing up the muscles there without crunching them. That's what we don't want to do. So you bring your head off the floor, maybe your arm off the floor. There are variants of this and one leg at a time off the floor.
Dr Rupy: Okay.
Mr Anthony Ghosh: Um, so and there are variants of that. I would say if you're in an acute bout of pain, see a physiotherapist once the disc thing has been diagnosed, who can show you those exercises, but also take you through variants of those exercises that you're able to do.
Dr Rupy: And Stuart McGill's got a few of these in his book. He's got all the variants of them. It's the back mechanic is a book I highly recommend.
Mr Anthony Ghosh: Do do the, um, same rules apply around general exercise principles, uh, within the resistance world of like, um, increasing volume and increasing load? So you you do more of the bird dogs or you do them with weights attached to your leg or your arms if you're really trying to build up those, you know, the paraspinal muscles in general.
Mr Anthony Ghosh: I think so if the trouble is pain is going to be a limiting factor in both volume and, uh, and load. So, but yes, we know that eventually you have to increase the resistance. There has to be a bit of progressive overload. I don't want to be excessive. Um, and a bit more volume.
Dr Rupy: Gotcha. So, yeah. Okay.
Mr Anthony Ghosh: I don't know the exact, you know, whether we go on the strength side of, you know, low reps, very high weight or or vice versa. But, you know, anecdotally, I kind of stick to that kind of eight to 10 rep range. And if I can go beyond that, then I start adding a bit of weight.
Dr Rupy: Are there any, um, exercises that people should be really wary of when it comes to back pain? Let's say you don't have back pain or, you know, you've never had a history of back pain, but there are there are certain things that may put you at greater risk of it.
Mr Anthony Ghosh: Um, so I often get asked about deadlifts and back squats.
Dr Rupy: Yeah.
Mr Anthony Ghosh: It's like with any exercise, if you do the exercise properly and with the correct form, then actually they can be good for your back. So, you know, doing a deadlift, you're actually arching your back backwards. So you're not pushing, we think about discs when they herniate, they herniate backwards. As we crunch forward and curl forward, like we are slumped at a desk, that's when a disc can get pushed out. Whereas when we're doing deadlifts and things like that, we tend to rotate backwards.
Dr Rupy: Gotcha.
Mr Anthony Ghosh: Um, so deadlifts and back squats at the same time, these are the ones where I have seen the most acute injuries. And again, Stuart McGill has various beliefs around this, particularly with deadlifts. So he he does actually get the Olympic guys back into doing deadlifts when they've injured their backs. But when we overload the spine vertically, when it gets overloaded, sometimes if the load exceeds the counteracting forces that the bones can apply on each other, then discs can rupture into the bone itself.
Dr Rupy: Oh, wow.
Mr Anthony Ghosh: We call that a Schmorl's node. And some people have these incidentally on their MRI scans. It's when you've got a bit of a dip in the top plate of each vertebral body and a bit of disc material lies in it. It's essentially a small fracture of the bone. It's a fracture. It heals up. In that time frame, what McGill was advising in his studies is unilateral loading exercises that can mimic the same movements of a deadlift.
Dr Rupy: Okay.
Mr Anthony Ghosh: So, you know, he does like the some of the reversed, um, step ups and reverse step ups. Um, again, it's still activate the hamstrings and the glutes. But because you're loading one side at a time, the overall load on the spine itself is a lot less.
Dr Rupy: And when someone has a a disc herniation, is there any association between the folks that recover quicker or any sort of like characteristics of those of those people versus those who go on to have prolonged chronic pain, um, that requires, you know, injections or even further intervention?
Mr Anthony Ghosh: That's a good question. The there was a study looking at that actually specifically in sports people.
Dr Rupy: Okay.
Mr Anthony Ghosh: Um, those that just returned early to sport and kind of grit their teeth, bear through it, bear through it, at a year were much more, much closer to their premorbid performance than the group that waited a bit and rested and were cautious. So they they pretty much almost got back to their, you know, pre-injury ability and performance levels.
Dr Rupy: Yeah.
Mr Anthony Ghosh: So the sooner you get moving again, the sooner you physically move, the better. And we see that in all sorts of injuries, even, um, after spine surgery, um, you know, when you cut tissues to get to the area, you have inflammatory material and liquid building up in the muscles. The quicker you move, contract those muscles, you're pumping away all those inflammatory chemicals and things do improve quicker.
Dr Rupy: Yeah, yeah.
Mr Anthony Ghosh: And then you're rebuilding those muscles that support the spine quicker.
Dr Rupy: Yeah, yeah. So it was sort of going back to the olden days, I guess, you know, if you're if you were told that you had back pain, the the early advice was to to rest in bed. You know, that was only like 20, 30 years ago.
Mr Anthony Ghosh: That's right. When I started medical school, that was the advice given and we've shown that that's terrible. That's terrible advice. The best thing you can do. So we often hear this phrase, listen to your body, trust your body. Well, interestingly, in the spine world, it's the opposite. As long as we've proven that there's nothing threatening to your nerves, such as a fracture, for example, to the stability, then actually moving through the pain is far better than not.
Dr Rupy: It sounds counterintuitive, doesn't it? Like moving through the pain, like surely I'm doing more worse.
Mr Anthony Ghosh: Yeah, surely the pain is a warning, but evidently not, no.
Dr Rupy: Yeah. Is that the same in other injuries outside of the back, like the knee pain or, you know, ankle pain?
Mr Anthony Ghosh: Um, I'm not sure, I'm not sure actually about that. Um, that's something we'd have to ask orthopedic, um, specialist. I don't want to dive too outside my my knowledge, but from just anecdotally from colleagues, the advice I've always seen in a lot of injuries is to try and get moving, we encourage them to do physiotherapy. It seems movement is key.
Dr Rupy: Yeah. I mean, exercise is incredible, isn't it? Just as general, like it's the, uh, the a real sort of powerful anti-inflammatory, it's anti-cancer, it's got like so many mental health benefits as well. And it's just the simplest thing, but I think in its simplicity, it it almost gets dismissed. And particularly when you're explaining it, I mean, particularly from your point of view, you know, someone's gone in to see you to have a procedure from, you know, an expert and you're telling them to just go out and have a walk. You know.
Mr Anthony Ghosh: Yeah, it's I mean, it gets under, I think, um, a lot of science has come out now on health and longevity and then, you know, new surgical procedures, new research on the spine. And I think we do get sometimes caught up in the minutia, in the really detailed, terrible stuff. And I think it's important not to go to to not to forget the basics. So, I mean, you'll know, you've mentioned this before, the the biggest thing you can do to live longer, if there's one lifestyle change you can make to be healthy overall, is exercise. That beats everything else hands down. You know, nutrition closely after, but all this other stuff that we see about, um, I don't know, red light therapy and breathing techniques and all this stuff. Yes, it has its place. I'm not dismissing it, but exercise is by far, it's going to have a much bigger impact on your life, not just your back pain, but on your life overall.
Dr Rupy: Yeah, yeah. And, you know, if someone you suspect has stress that is exacerbating their pain, which is almost like catching them in a vicious cycle. I mean, how how do you unpack that to someone in clinic? How how do you approach that subject in a in a sensitive manner?
Mr Anthony Ghosh: Well, I I I start off going in, once I've I start off with a full history and the examination and everything. And and you start off looking for that anatomical cause first and ruling it out. Um, and explaining that to them with scans. That way you gain that patient's trust. Trust is really important in a doctor patient relationship. So that's the first bit in gaining that trust. And then it is really important as if any type of clinician, we're not playing, you know, I'm not I don't pretend to be a psychiatrist or a psychologist, but every clinician, whether you're a doctor, a physiotherapist, you do have to have a bit of an understanding of how behaviour, mood, anxiety and all that can affect your general health and vice versa. So I I I start introducing these questions about what what do they believe is the, what's worrying them? That's a really important question to ask. What's worrying you? And then you can and you can start to unpack things from that. Things start to unfold after a while.
Dr Rupy: Yeah.
Mr Anthony Ghosh: I think the wrong thing to do is dive in with that.
Dr Rupy: Yeah. Yeah, yeah. Um, how often are you doing operations? I know we had to move for today's podcast episode because you had a a last minute surgery last week. But um, yeah.
Mr Anthony Ghosh: Usually once or once or twice a week, once or twice a week.
Dr Rupy: Okay. And these are quite long surgeries. So you're going to be hunched over in a in a particular position, is that?
Mr Anthony Ghosh: Actually no, the the majority of what I do is a a one, of actual surgical time, most of it's under an hour. So a microdiscectomy is done through a very small, that's probably the commonest operation I do, it's done through a very small wound where we just under the microscope shave away the bit of disc that's pinching the nerve and it gives a fairly instant result. That doesn't take very long. Um, likewise, lumbar decompression for a slightly older patient group who have stenosis of the spine. That's narrowing of the tunnel through which all the nerves run through and the nerves get a bit pinched. They classically have pain that builds up in the back and the legs when they stand for some time and walk and as they sit and rest, it almost disappears. Again, that's mostly done through a very small wound, doesn't take very long. The lumbar fusions I do are, you know, they're not very often. They do take a bit longer, but again, today they can be done through minimally invasive procedures.
Dr Rupy: Yeah. So I was going to ask, so you don't do long operations. That's a good, the majority of them are quite short, relatively speaking. Um, what's your sort of back pain stack look like in terms of how you protecting your your own your own back? Yeah.
Mr Anthony Ghosh: Well, thankfully, using a microscope allows me to just look straight ahead rather than looking down. Um, you know, and my general lifestyle, I I, you know, I take pride in my health. I exercise regularly. I, you know, I do weights at home now three days a week. I run once or twice a week. You know, I eat healthy. That's my focus, actually. I don't do, I don't have a back specific, uh, day. Well, in my workout, that's incorporated in in the other bits and pieces. But and that's the point I was making earlier to not overthink the back. It should be part of your generic fitness and health.
Dr Rupy: Okay. So you do your exercises, you do your resistance training, you move often, you eat well, hydration?
Mr Anthony Ghosh: Yeah, plenty of water on board about two litres of it a day.
Dr Rupy: Okay. Um, and in terms of those McGill exercises, do you incorporate that in your in your weekly routine?
Mr Anthony Ghosh: Well, I probably do, you know, I do planks and side planks. I do an abdominal session with more, you know, with more resistance because I, you know, at the moment I'm not someone that has back pain at the moment, but I have, I do get, like everyone, I do get bouts of back pain. So yes, I do variants of those movements.
Dr Rupy: Okay. And if you could give one or two tips for the audience in terms of designing a routine or designing, uh, habits for for back protection, what what would those involve?
Mr Anthony Ghosh: Well, what I've learned about habits is that it's difficult to maintain them if you overwhelm people and throw in a ton of stuff in in one go. Um, so let's say you're, it depends on on each person's lifestyle. If you if you don't, if you're not someone that exercises, just try and do a little bit each day and then forget about other stuff. You know, so start with exercise, walking, you know, a bit of walking each day. If you can do some running, uh, that's fine. And that's a myth by the way that running damages discs.
Dr Rupy: Yeah, right.
Mr Anthony Ghosh: We know in other joints, um, that it actually helps strengthen the cartilage.
Dr Rupy: Okay.
Mr Anthony Ghosh: I think if you run badly on really firm ground and you fall in potholes all the time, then fine, yes, you can damage the knees. But, you know, that it's good for you to do some exercise with some resistance training. Start off with a small feasible amount each day that fits into your timetable. We all have busy lives. If you if someone doesn't exercise and I go and tell them they need to spend an hour in the gym every day, it's not going to happen. You're going to fail to maintain that habit. So start with a few minutes a day and then gradually build it up.
Dr Rupy: And and out of those exercises, would you say walking is probably the best one?
Mr Anthony Ghosh: Yeah. Definitely. Definitely. Walking's really important. And then if you're already do that, some a mixture of something that gets your heart rate up.
Dr Rupy: Yeah.
Mr Anthony Ghosh: Something that puts your muscles under a bit of strain. That's what you've got to kind of, uh, under a bit of resistance. So a combination of resistance training and cardiovascular training.
Dr Rupy: Barefoot shoes are becoming quite popular at the moment as well. Again, from the perspective of ergonomics and making, you know, um, not putting any undue stress on your ankles and knees and ultimately with the impact on your your back as well. Are you a fan of that or do you think it's like diving in the miners again?
Mr Anthony Ghosh: I've gone into that personally. If you are flat-footed people, um, who can develop back pain because of the way the forces are transmitted to the back. So we have a joint in our spine called the sacroiliac joint, which is where the pelvis joins onto the spine. That joint doesn't move very much, but it's a load attenuator. It kind of shock absorber if you will between the legs and the back. And depending on your foot posture and biomechanics, you can put a lot more shock and force through those joints and actually your your spine. And it has been shown that the right orthotics and exercises to correct that will help with back pain.
Dr Rupy: Okay.
Mr Anthony Ghosh: In terms of, you know, these, um, barefoot, you know, these shoes that you wear now that almost replicate walking around with bare feet, there probably is some benefit in that, but I'm not going to pretend I I'm an expert on that.
Dr Rupy: Okay, fine. I've got I I use barefoot shoe barefoot trainers, um, when I train, particularly when I do weight training. I find the sort of like it just gives me a bit more stability and yeah, my my feet are just a little bit more grounded. Um, but whether or not it's actually having a beneficial or a neutral effect on my back or a worse effect on my back, I'm not too sure actually, but.
Mr Anthony Ghosh: I'm sure I I suspect there is benefit in it. I suspect there is. Yeah.
Dr Rupy: Yeah. Yeah. Um, and another thing about cracking backs. So we didn't we didn't I was one of the first things I asked you. A lot of people go to chiropractors and they get their their back cracked. What is actually happening when you crack your back and.
Mr Anthony Ghosh: So there's a couple of things that make that sound. One is a a tendon, um, a tendon is the tissue that connects a muscle to a bone in a joint and that's what makes it move. And it's when a tendon literally just flicks over, um, either the the facet joint or one of the bony spurs in in the spine, it makes a crack or within the joints of the spine, the the facet joints, and we get this in in our knuckles as well, when you get that sound there. Um, I think that's a a a bubble of vacuum that then that forms from the stretching within the fluid of the joint that then pops.
Dr Rupy: Okay.
Mr Anthony Ghosh: It makes us feel good when it happens, but it's not, and it can help you in, you know, in that acute episode possibly or just make you feel a little bit looser, a bit more comfortable. Um, but it's not, that's not a solution to your back pain by any means. Now, don't get me wrong, my my I believe in a multi-disciplinary team practice. That's why my practice is called the Spine MDT, because I work with a network of physiotherapists, osteopaths and some chiropractors. Um, I think it has its place, but no physiotherapist or chiropractor is going to build muscles that support your spine for you. You have to do that.
Dr Rupy: Yeah.
Mr Anthony Ghosh: So I'm more on I air towards the side of physiotherapy where you're shown how to do these exercises. But what's come into play now is cognitive functional therapy, which is a form of physiotherapy. And it gets misconstrued with or misinterpreted as cognitive behavioral therapy. So it's physiotherapists that actually do this. But they look at your functional movement. They um, so Peter O'Sullivan again, who did a lot of research, I've watched him with a patient, he just watches how they go and pick something up. He had a bottle of water, he just gets them, he throws it on the floor repeatedly getting patients to pick it up just to watch their movements. Are they falsely protecting their movements? And what's been shown is speed of movement, that fast sort of trunk movement, those patients do better than those that are really trying to brace themselves in that false way, bend down with the knees.
Dr Rupy: Yeah.
Mr Anthony Ghosh: That's not how we bend and move things. The analogy he uses is, um, you know, the women in the paddy fields in in in the far east, when you watch them bending all day picking crop up and rice up, they're bending from the hips.
Dr Rupy: Yeah.
Mr Anthony Ghosh: You know, they're not bending at the knees, squatting. It's just unnatural. So he kind of restores natural movement, but then gives you a bit of feedback around it and just helps build up that confidence. And the trial data that he's done has shown really promising results from that, far better than the typical, oh, go and build up your core approach.
Dr Rupy: So in in terms of the trial data, what is he getting them to do? Like literally just pick up a bottle or a weight off the floor in a very natural way.
Mr Anthony Ghosh: Yeah, he watches. So it's a long assessment. A lot of it is actually education, sitting down and talking for long enough. Um, and just finding out what they believe and then debunking those beliefs with evidence of what might be on the scan or not. Um, and then watching how asking them what movements they fear, what causes the pain and getting them to do those movements and then correcting them and making them feel more natural again. It takes time. It takes a few sessions. Um, but cognitive functional therapy was trialled with stand, what we call standard treatment where someone's simply told to go and see a physio and they just do whatever they normally do, whether it's exercise therapy, back cracking, um, manual therapy, all of that stuff. The cognitive functional therapy wins hands down.
Dr Rupy: That's for chronic back pain. Yeah.
Mr Anthony Ghosh: Gotcha. It's it's really interesting that you work within an MDT of osteopaths and and chiros and and physios. Where do you butt heads most with with the other professionals? Like because there's always a like healthy tension between these different groups, right?
Mr Anthony Ghosh: Um, I don't, I wouldn't say we butt heads. I think it's important you have a relationship that you realized, not just not just them, but me as a surgeon, look, I've reached my limits here. I can't do anymore.
Dr Rupy: Sure.
Mr Anthony Ghosh: So a classic pathway I see is patients going from one person to the other. A surgeon can only treat a very small number of things. And with most surgeons, and this is not just in the NHS, in the private sector as well, um, once the surgeon realized there isn't a surgical target, they're just told, right, go off and see a physiotherapist.
Dr Rupy: Yeah. And that's the end of it. And then they ask, what's the physiotherapist going to do? I don't know, go and ask them. It's up to them. It's their expertise. Whereas I, what has also been proven to work is if you if you get these people in a room together. So and that's what I try to do with my practice. I you know, I I sit down with the physiotherapist, explain my side of it from the the anatomy and the mechanics and the scan and everything and what I believe is the mechanism causing the pain. Once the physiotherapist has got that, then they have a strategy that's going to be more effective. Uh, sometimes I involve osteopaths because they do, they some of the manual therapy they do, um, is really good. I I work with some chiropractors who do manual therapy. I I broadly call this stuff, the hands-on stuff as manual therapy. Chiropractors call that, you know, adjustment. I sometimes think they overplay the alignment. So I get really annoyed when I see a clinic letter with a photograph in the corner of the patient's x-ray and lines drawn through it and then next to it a normal x-ray of the alignment and trying to tell them that's the whole reason you're in pain.
Dr Rupy: Uh-huh.
Mr Anthony Ghosh: And from the patient's perspective, it is terrifying when you see, yeah, a bit of a curved spine compared to what is supposedly normal. Yeah. Um, and no none of us, no human being on earth has a normal spine on the scan. So, yeah.
Dr Rupy: So so that's really interesting you say that because this this idea of alignment, I think is something that I hear quite a quite a bit as well. Is it possible to have your spine realigned through manual therapy or whatever it might be in the.
Mr Anthony Ghosh: Well, yes, but forcing it into a certain alignment with your muscles, again builds up that unnecessary tension you have in you. And that comes back to my point earlier when you're sat there with you in your chair with your shoulders back all rigid. Um, doing that, you know, to to be able to do that, to hold your spine into alignment for a prolonged period of time is tiring. It fatigues the muscles. Um, you know, there's an excess, you know, an excess curvature like, you know, scoliosis, for example, if it becomes so severe that it starts to cause bad obvious physical deformity, entrapment of nerves and dysfunction of nerves, then yes, we have to do something about that. Um, but otherwise, you know, a bit of a curvature that you can still function with is fine.
Dr Rupy: What what about cupping as well? Cupping's become quite popular online, isn't it?
Mr Anthony Ghosh: Um, I don't know how much of that is is is psychosomatic. There's no harm in it. I you know, I see a few osteopaths, chiropractors, even physios doing that.
Dr Rupy: Yeah, yeah.
Mr Anthony Ghosh: And acupuncture even. There's some there's something in it. It can help, but it's not a long-term solution.
Dr Rupy: Gotcha. Yeah. That was going to ask you about acupuncture as well because that's now offered on the NHS as well.
Mr Anthony Ghosh: Yeah, there are there are studies, you know, whether it's the, we don't quite understand the mechanisms. There's a few theories, um, around that. So, you know, osteopathy, the kind of foundations of osteopathy are about the, you know, the movements of planes and and the fascia, the linings of the muscles in its historic concept. So a lot of the osteopaths I work with, they believe in getting the that dry, you know, that dry needling they call it, getting that needle through the fascia is really important. And whether it releases chemicals that allows the tissues to move better, I don't know. Again, it it's part of a bigger picture. I think it's part of it. But I think understanding just I think our movement, um, and debunking any myths you may have or any false beliefs you have is really important in people who have had chronic pain.
Dr Rupy: Yeah, yeah. I mean, it sounds fascinating around cognitive functional therapy. I need to look into that, um, myself, but, um, is there something or anything that you're excited about in the in the realm of of of back pain and and how we can better improve or reduce our chances of of chronic pain?
Mr Anthony Ghosh: Um, I'm actually going off the spine in general. I'm I'm excited about the world of longevity medicine now. Like it when I was younger, we were always taught prevention is better than a cure, but preventative medicine wasn't really taught at medical school. Um, and now there are a lot of big names in this field, you know, like yourself, Peter Attia, Andrew Huberman, all these guys. And all the research that comes out of it and all of that stuff is going to have a large benefit. And you know, it brings you back to the earlier point I made, you know, research has shown that in terms of chronic back pain, maintaining generic good health, a focus on overall good health beats focusing only on your spine.
Dr Rupy: Yeah, yeah. So, yeah.
Mr Anthony Ghosh: Yeah.
Dr Rupy: I mean, I'm fascinated by this world as well and I I think there's going to be a lot to it as well from not only from a a sort of lifestyle point of view, but a nutraceutical and pharmaceutical perspective as well. There's there's tons of research ongoing around it, so.
Mr Anthony Ghosh: From a surgeon's perspective, you know, I'm excited about any new technology that minimizes the invasiveness of an operation. But equally, something that I think is really important to maintain, when we talk about minimally invasive surgery or keyhole surgery, we're often talking about the wound. So yes, there's a very small wound, but sometimes what goes on beneath that wound is quite, you know, quite extensive. So even lumbar fusion is done through very small incisions where we join two bones that are unstable, when we join them together, it's still in my opinion, a big operation. Now I do a lot of these when it's necessary, but it's very important that there's clear communication with the doctor and patient about these new technologies, um, and explaining the extent and explain what to expect in that recovery period.
Dr Rupy: Yeah. Anthony, this has been super enlightening. Um, really appreciate you, uh, you taking the time to to speak to our audience. And, uh, I will not be investing in a standing desk.
Mr Anthony Ghosh: Good. I'm glad I got that across.
Dr Rupy: Uh, or a special mattress, uh, other than something to cool me down at night because I've heard that definitely does improve, uh, your your sleep quality. But yeah, and I I am going to try the sleeping position, but the main thing is making sure that I'm not in this cramped position for a long period of time and I'm up walking and doing those McGill exercises as well that I'm going to look up too.
Mr Anthony Ghosh: Been an absolute pleasure speaking to you, Rupy. Thank you very much.
Dr Rupy: Oh, great. Thank you, man.
