Is Your Back Pain All In Your Head? The Surprising Science of Healing Pain - Dr Anisha Joshi

0:00Dr Karan: When you see people, what's the thing that shocks them about their pain and their body? The majority of their pain and discomfort is coming from a place of stress. Really? Yeah. Explain that a bit more to me. So they come in and they're like, obviously presenting with something like neck pain. And then they will be like, it's here, you know, I need treatment here. It's restricted. I when I was younger this happened to me and actually on reflection people get really confused as to why in their medical case history I say okay so what's your stress levels from zero to ten and they just look at me really confused like how is that relevant to my neck pain and actually when I talk through things and I might even say to them so that's really interesting that you've had this over the last 10 years what happened was there something that happened 10 years ago and you know the amount of times I've had people say actually yeah I was in a car accident 10 years ago and and then they'll suddenly have this like realization of actually like I've noticed my neck always gets worse when I drive on the M25 and that's where the car accident was you know and And, you know, there's definitely a connection, what I've seen personally in clinic, but then also kind of what the evidence shows around stress and also mindset and what people are telling themselves and how they perceive pain.

1:40Dr Karan: Yeah, I think a lot of people do underestimate the brain-body connection, specifically as you were talking about stress. Subconsciously, people may be clenching onto their muscles a bit tighter, maybe not sleeping well because of stress, and then that impacts their recovery and fatigue levels. You obviously are an expert in pain, joint problems. You're an osteopath. A lot of people may not have heard of that profession, an osteopath. For people who don't know and who may misconstrue what an osteopath is to the people online who crack backs and so on, chiropractors, what is an osteopath and what would you typically do in your workflow?

2:16I would say an osteopath is essentially a musculoskeletal expert that undergoes a four to five year degree. Essentially, there's a lot of overlap now between chiropractors, physios and osteopaths. I would say that osteopathy is a combination of all those things. So we can offer you exercise rehabilitation like physios do. we might crack your back cracking by the way isn't it sounds so aggressive um and it's definitely something that a lot of therapists use online manipulation yeah and yeah it is used online to get views or more patients through the door but you know um each to their own but we are a lot more than that so we have the ability to when patients come in we take full medical case histories We do orthopedic neurological testing, give diagnosis unless we can't.

3:18So then we'd cross refer or, you know, advise in terms of scans, blood tests, and we treat the, treat the symptoms with our hands. But then also making sure that we're looking at everything else that's going on, like stress, sleep, nutrition, lifestyle stuff.

3:37Dr Karan: So the majority of your patients that you're seeing have pain. That's why they come to see you in the first place. And there's a lot of people live with pain chronically or even acute pain that turns chronic. What are some mistakes that people are making daily, which ends up making their pain worse? I would say that the biggest cause is just lack of movement. You know, we're living in a world or a society where we are on our iPads. No judgment, Karen. and we're on our iPads, we're on our phones, we're on our laptops and it's just how we get, it's how we earn our money a lot of the time, right?

4:19And it's that lack of movement that our bodies are used to that we're not getting anymore. And actually people don't realize that even the smallest things and changes can make a massive impact on how they're feeling.

4:33Dr Karan: Yeah, I think even when I was coming here this morning, I obviously took a train to get into London just under an hour. I drove from my house to this train station and then I got a cab here. So there was a very limited walking done for an hour and a half. And I did feel a bit stiff and I wouldn't say pain, but discomfort of just sitting for about 90 minutes at the start of the day. And this is, you know, stacking that on top of about seven to eight hours of sleep. So there was a long period in the last 12 hours where I've been pretty sedentary. And that's not ideal. It's to some degree inevitable because I needed to do those things to get to where I am at a certain time.

5:12Dr Karan: But yeah, I think modern life and the environment we've found ourselves in is sort of making us in that way. On the topic of pain and discomfort, just because someone has pain, is that a direct correlate? Or does that mean that someone has got some tissue damage or a problem? Or is it that simple? Definitely not, actually. There's a common misconception about that, that pain equals damage. And actually, a good example of this is, you know how sometimes you might get a bloodshot eye or something and someone will be like, oh, you've got a bloodshot eye and you have no idea, right? You can't feel it.

5:52But technically, that's a burst capillary in your eye, technically damage, but you can't feel it and you know there's also evidence to show i think they took multiple people of differing age groups off the streets and gave them an mri it was obviously more structured than just taking them off the street but anyway and they the results showed that as people got older they the prevalence of them having a disc prolapse or disc herniation was obviously increased right But none of them had symptoms. Absolutely none of them. They had no idea that they had a disc prolapse. So essentially what can happen is pain becomes quite, you know, people fear pain a lot and it can overtake and override the reality of the situation.

6:48And sometimes people can even have an MRI, you know, thinking that it's going to put their mind at ease and actually it can show something completely different. And lo and behold, they end up with other symptoms completely unrelated to what they had before. For instance, someone comes in with lower back pain, you know, they've had multiple treatments, they don't know what to do about it. They go and get an MRI privately. In doing that, they also find out they have a fibroid and, you know, they have inflammation around their lower intestine, let's say. And all of a sudden, a week later, they've got really bad IBS kind of symptoms.

7:29And, you know, just so it's, I'm not saying it's necessarily like psychological, but it's real symptoms.

7:37Dr Karan: Yeah. It's just the brain believes what you tell it. Well, yeah. Perception shapes reality. So if you're told something is a certain way, your experiences will be guided by that information. And I think to go on to say that pain is also, broadly speaking, the thresholds of pain and the amplification of that and the volume of pain is dictated by your perception. I think the simplest analogy I could think about is if you're getting an injection, say you're getting a vaccine into your arm, if you look at the needle going in, the pain will be worse than if you're distracted talking to someone else and then you're like, oh, have you done the vaccine already?

8:16Dr Karan: I think that, you know, because if you look at it, you're putting in more neurological signals and stimuli and input from your eyes that it's going in and you're expecting the pain, the anticipation of that pain drives the pain up, right? Turns the volume up. And I guess what you were talking about is someone's getting all these scans and they find all these incidental findings, these incidentalomas, they're now going to think, oh, I've got to have that symptom now because it's been proven that I've got the inflammation in my intestine. So you're going to start feeling those things. The brain is a very weird thing.

8:48Yeah.

8:49Dr Karan: On the topic of pain, the area which people are mostly blighted by seems to be back pain. It might be because of the sedentary lifestyle, but 80 % of people at some point in their life will have back pain. What are the most common causes of back pain? So again, that tends to go back to the movement element. We just aren't moving as we used to. I mean I've written a book heal your back and and the chapters in that are essentially the the reasons as to why people most commonly have back pain and typically lower back pain and that is mindset so the narrative we tell ourselves you know neuroplasticity is talked about all the time when it comes to things like mental health or confidence but actually quite often people don't understand that if you talk about your body in the same way your brain will believe what you tell it right but for some reason it seems almost acceptable to sort of go oh I'm old now you know just even little things like that I'm sure you are probably like I might have said that last week or you know you just naturally are like oh I've got a week back or I'm not as fit as I used to be or little things like that, you know, your brain will go, okay, yeah, sure.

10:05Like, let's not be as fit as you used to be.

10:07Dr Karan: Yeah. Why not? Or like, oh, you've got bad knees. Let's have bad knees. So the actual problem with the back is not always about the degradation of the actual thing, because there was one study that showed that I think 37 % of people in their 20s with no back pain, who then had an MRI, there were early signs of disc degeneration. And by the time those people hit 80, that number went from 37 % to 96 % of people in their 80s with no back pain had significant disc degeneration. Yeah. That seems a bit at odds because the, you know, the discs are core to the spine and the back, but it's wearing and tearing, but that's not correlating with pain.

10:51Yeah, it's really difficult because obviously using the words wear and tear, it's something that we know as osteopaths that those words have been created by the medical profession to make it easier for people to understand, right? Which is fair enough. It's, you know, not anyone's fault. But by using the words wear and tear, people are like, I'm wearing and I'm tearing. I am literally. Prepping psychologically for the pain. Yeah. And actually, you're not wearing and tearing. Or, you know, yes, as you age, you have these changes that happen naturally. But like you said, a lot of people don't experience pain and discomfort.

11:36Now, a lot of those people, I'm not sure about this study and if they've looked into their lifestyle, but I'm pretty sure that they are active individuals that eat well, sleep well, have good nutrition as well. So the four kind of pillars are those things, mindset, sleep, stress and movement.

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12:34Dr Karan: If you want your whole health to thrive, start by feeding the ecosystem that runs the show. Head to www.loamscience.com to try Loam. And exclusively for you, just because you're listening to this podcast, get an additional 10 % off with the code POD10. Again, that's POD10 to try Loam and get an additional 10 % off. loam health grows here so you know often i find that when i've had a period of back pain the back pain tends to be worse in the morning than any time of the day and i think a lot of people experience back pain if they do worse in the morning and again you'd think that a night of good rest would improve any pain symptoms you know from having less cortisol spiking and contributing to that and just general, you know, rest.

13:23Dr Karan: But why is that? And why is back pain worse in the morning? It depends really on the cause, but I would say most likely that where you've been stationary, your body stiffens up in the same way that if you're sat in a chair for eight hours, you know, you're going to get up and be a bit like, oh, you know, it's the same. You're, you know, you're in bed for a certain amount of time and then moving first thing, it's going to feel a bit tight or stiff. So I do often recommend people to just do a little stretch. I'm talking literally 20 seconds in the morning before they get out of bed and it can make the world of difference.

14:05Dr Karan: And what's the link between sleep or other, I should say poor sleep and back pain? Because I think the data suggests that people with chronic insomnia are roughly at double the risk of chronic musculoskeletal problems than good sleepers. So what is going on there? It's really interesting actually because the evidence shows that poor sleep is more likely to cause lower back pain than lower back pain cause poor sleep. Quite often people will attribute their back pain to as in they will say I can't sleep though because you know my back hurts and so it does become a bit of a vicious cycle and you know and there's all this stuff around how should I sleep what position should I sleep in what mattress should I get what pillow should I get and actually the reality is the best advice I could give anyone is just sleep you know because that's what evidence shows is that sleep is the biggest healing power for us.

15:10We know that across the board, right? Across any kind of expert opinion, sleep is very, very important to all of us. And it's the same with back pain.

15:22Dr Karan: Back pain obviously is an umbrella term for a number of discrete conditions which affects the back. Now, one of the subcategories under back pain, which includes the back but may go to other there is a sciatica and a lot of people are diagnosed with sciatica, you know, up to 40 % of people might experience it at some point in their lives. What exactly is sciatica? And do you feel given the number of people who are potentially diagnosed with it, is it over diagnosed? Potentially. I mean, if we talk about what it is first, so sciatica is a very large nerve that runs down the back of your leg and there are many things that can cause it.

16:01So quite often people will be like, I have sciatica, but it's about what is causing this referral pain down your leg. You know, is that a disc herniation that's pinching on the nerve at your spinal level? Or is it a nerve impingement through your piriformis? Typically, there's a muscle in your buttock that can get tight and that can also cause sciatic symptoms. And then you've got various areas down the leg which can also impinge the nerve so it's about getting to the root cause of why you have this symptom down the back of your leg you might get numbness you might get weakness and obviously you have it at varying degrees you know some people have mild symptoms others feel like they can barely walk and in terms of it being over diagnosed I would say I would say definitely there are times where I feel like it's a bit of a, I hate to say it, but like a bit of a scapegoat.

17:03Like it's, everyone has heard of the term sciatica, you know, and actually sometimes if, if they're Googling or, you know, like they may go and see a other professional who may not fully know what's going on, they might say, okay, that, that's definitely sciatica. But I have to say that I think that's improved I would say from my clinical practice that used to happen a lot more sort of when I first graduated 18 years ago wow um makes me feel old um and but you know nowadays I am actually quite pleasantly surprised when someone comes in and says I've got sciatica and I saw my GP and they diagnosed me and I'll get their symptoms and I'll be like oh you actually do actually do of sciatica so you know it is it's definitely better diagnosed now

17:56Dr Karan: now i think in medicine people have the tendency to separate all body systems and organs into different discrete buckets but what we're understanding is that there's so many body parts which communicate with each other by different axes and it's a domino effect something higher up the chain can affect something lower vice versa so many other things which can happen And I guess the back is not too dissimilar to all those things where there's so many other components, as we mentioned before, stress and back or pain, MSK pain. Breathing as well can have a significant impact because breathing can affect stress levels, how you breathe.

18:35Dr Karan: Breathing can also affect your posture. So it stands to reason if breathing can affect those two things, stress and posture can also have an impact on your back, but, you know, joint pain in general. So what is the role of breathing in pain, but specifically back pain? Honestly, breath work is, I personally have found it game changing. I first tried breath work two years ago and I was like not convinced at all. I was like, I don't get it. And then I had a one-to-one session, you know, the osteopath in me. i'm there sat there hyperventilating right and i'm going i'm thinking about all the anatomy and my rib cage and like it's not used to doing this surely i'm gonna like get a headache and feel light-headed and anyway did this thing for half an hour got up and felt amazing like it felt so relaxed and i could not believe that i'd just been basically hyperventilating just after one session one session so it was like instant that I felt like relaxed and I walked in going I'm not looking forward to this you know I don't get it you know so I was really impressed and now I recommend it to a lot of people and I think ultimately what breath work is doing is I'll also be honest and say you know I don't know enough about the science behind and in fact you probably know a lot more in terms of what's happening with oxygen levels and all of that but from an anatomical perspective moving your rib cage your diaphragm and being mindful i feel like breath work and breathing instantly makes you present right and it's a form of it is a form of mindfulness and calming yourself down and your nervous system down and i think that that has a big impact on pain yeah i I would concur that perhaps the role of breathwork here is perhaps slightly less mechanical and more neurological in the sense that can it trigger the vagus nerve and improve vagal tone?

20:50Dr Karan: And obviously the vagus nerve is the largest nerve running through your body and can have a role to play in stress relief and just general body relaxation. So maybe it's something to do with that. Yes, there's also a placebo effect component there as well. you know something i want to talk about is just things which people do to drive pain and maybe some misconceptions around that a lot of people these days love running you know it's like a influencer favorite these days you know you start running and then you you become a running influencer a lot of people are running which is great a lot of movement more people running marathons but there's always this tag that running is bad for your knees and your hips and your joints right and i can see you know the sort of evidence there and the validity of that saying where you know you're pounding concrete or you're pounding the treadmill and maybe people don't have the best running technique where there's excessive force being applied to you know their feet or their joints as well have you got any tips for people who are starting to run and who do experience shin pain knee pain or back pain when they start well actually the majority of the evidence shows that running isn't bad for your knees, which is great.

22:03I think where people experience these injuries or, you know, shin splints and all of that is where they just go a bit too hard too soon. You know, our body is incredible. It's incredibly strong and it adapts beautifully. Obviously I'm biased, but it does. And actually if you treat it with respect and, and with patience, it will do what you need it to do right and so when it comes to running i would say just be patient and start a bit slower and i think it's easy to go sort of you know my mom always says don't run before you walk okay she's gonna kill me for doing that exact accent yeah it literally is and and it's almost the same thing it's like you do have to go through those stages i often get loads of parents in around july because they've gone and done the the bloody school race yeah you know sports day and they're suddenly 17 again right and they're and then they're like oh my god I've like pulled this, pulled that, you know, and it's okay, but it's just, it's about being patient with yourself and your body.

23:22You can do these things. You a hundred percent can. It's just about letting your body do its thing and adapt.

23:29Dr Karan: Yeah. I think there's something to be said about increasing the load progressively, just like going to the gym. You're not going to be squatting 200 kilograms day one in the gym, right? Your body has to get adapted to that load. It's flexible, but you know, just like a spring, it can break if it's pulled too hard too soon. Yeah. Moving on from back pain, another common area which people complain about is neck pain. I'm particularly interested in the connection between neck pain and head pain and headaches that people get. A lot of people, when they get headaches, they think it's automatically something brain related or blood flow related, but a large proportion of headaches are driven by the neck.

24:05Dr Karan: Can you tell me a little bit more about that? Yeah. I mean, extremely, extremely common. So typically what I see is majority of people have say tight muscles in their neck and you know you've got a group of muscles at the base of your skull called your suboccipital muscles and there's a nerve that runs through them and into your kind of head and face called your greater cervical nerve and if those muscles are tight at the base of your skull for instance it can refer pain into your head and consequently feel like a headache and a tension headache typically but there's just so many muscles and nerves in the area as well and even referral from your jaw for instance and and clenching your teeth at night can impact and you can wake up with a headache but actually you've been clenching your jaw all night and you're just not aware of it unless you become more mindful and see an expert or something that can say, actually, what's going on here.

25:12Dr Karan: With necks as well, I've seen it in myself, particularly when I was doing a lot of surgery. And when I was doing a lot of revision for exams way back when, I'd look at myself in a side profile in a mirror, and I'd notice like this neck hump, you know, poor posture and neck hump is that a consequence of poor ergonomics in your workspace or just kind of like this forward crunch position that we find ourselves in or is there something else and how can we fix that because i think aesthetically as well as well as functionally it's not ideal to have that neck hump this is something that's very popular on social media mainly from an aesthetic perspective and the truth is that that is your spine right like if we could there are so many products that are being sold um where they all say lie on this thing for five minutes a day and you'll get rid of your neck hump you know the reality is is if you were to do that i mean imagine what would happen to your neck or your spine when you squatted 60 kg on a barbell if it was so easy you to manipulate we wouldn't be alive yeah like if it was that malleable um so the reality is is that you're not going to change the shape of your spine typically and actually probably if you look at your parents and you might go oh yeah they had a a neck hump or oh and actually my grandparents have a neck hump and you know because that's just it's the same as going oh i've got my mum's hips, my dad's nose, you know, it's literally a bit like that.

26:52However, what you can do is reduce the appearance of it. There's nothing wrong with a neck hunt, by the way. It's not giving you, it's not predisposing you to any pain or discomfort. But if you want to look better aesthetically, and I get it, I totally get it, then the best thing you can do for yourself is strength training you know strengthening the right muscles and what happens is for instance in your case if you're studying a lot doing surgery and you feel that sort of anterior posture and that anterior head posture by strengthening posteriorly things like your rhomboids your serratus anterior and your trapezius little things i can you know i can give you examples of things you can do at home or even at your desk that can start to strengthen these muscles that will bring your shoulders back naturally without a posture corrector holding it in place and that is going to help reduce

27:51Dr Karan: what that neck hump looks like so if you wanted to neck hump max you'd have to work on your posterior chain so pulling exercises and opening up your shoulders and back to kind of offset the desk heavy forward anterior chain exercises that you're subconsciously doing, you know, passively doing all day. Exactly. And on the topic of necks, a lot of people, and this really irks me when it happens as a bit of a, like a, you know, sending me a shiver down my spine, people always cracking their necks, you know, like little adjustments to their necks, micro adjustments all day. And then you hear a pop as well.

28:30Dr Karan: What does that signify when someone's constantly cracking their neck is it a sign of just like immobility and a sedentary heavy lifestyle or something else going on and is there anything first of all is anything dangerous with the actual constant self-popping of the neck um and why does it provide relief yes it also gives me the ick um good and i you know i'm used to that sound so when you firstly when you crack your back or you pop your neck right it is more of a pop crack indicates breaking of bones in my opinion so I call it pop because it's actually air so you get these air pockets and that's what the sound is so what happens is you have these these air pockets and it may or may not reduce your movement now typically when someone has their neck released that air released it's a mixture of goodness I can move my neck much more now and also the sound is like almost like a dopamine kind of right boom like a relief it's a psychological cue that you've done something might help exactly now the problem is when people do it repeatedly right throughout the day so i will say to someone just like to give them perspective how many times do you click your neck a day and actually i can tell by looking at them already that they're a self-manipulator right i call them self-manipulators and they'll say three times or something i'm looking and i I go, if you say three times, it means that you're doing it 30, you know, because you just do like, it's habitual.

30:20You just don't even realize. And then they'll come back the next week and go, yeah, you're right. I do it so many more times than three times a day. I say to them, like, if you're doing it that many times a day, I'm pretty sure that's telling you it's not working. Right. Like you're doing it because you're in pain and in discomfort. I get it. You know, you're just trying to get that moment of relief. But if you're doing it again, 30 minutes later, or an hour later, it means that there's something wrong.

30:50Dr Karan: So it's masking a symptom of something potentially more serious. You know, these self manipulators, I think that's a kind of term than calling them head crackers, maybe. But okay, so actually, yeah, it is kind of self soothing, but in a way that long term is maybe unsustainable and unhelpful, because there may be something, you know, anatomically, or, you know, some issue that maybe they should see someone about. Yeah, 100%. I mean, I think, you know, if you were going to the toilet every half an hour, every day, you'd be like, why? What is going on here? Yeah, I should probably get my bladder checked.

31:27But for some reason, people just think that that's okay. So yeah, and if you're doing that all the time, it's definitely worth getting to the root cause of the problem. Because quite often it's actually very easy to sort out.

31:43Dr Karan: There's a lot of tools available for people, particularly with musculoskeletal problems, to self-medicate and self-heal. I've got a massage gun and foam rollers at home. How effective are they for daily use? They are great at essentially helping you to feel better in order to move more. it's probably the movement that's actually making you better if that makes sense so there is some research to show that for instance a massage gun used prior to working out is good for you because it doesn't reduce your strength but it can increase your movement right so it's like preparing your muscles so you might for instance go into a lower squat with better form And I think there's something to be said about just being actually more connected to your muscles.

32:36So by using the massage gun before you work out, it's bringing, it's drawing your attention out from the work emails and into your body, right? Because you're like, there are my quads and there's my, there are my glutes. so I'd say there's definitely something to be said about it and also foam rolling again it's it's something that I would say prior to working out is great again bringing that mind and body connection so that when you are working out you're in tune with your body but also just as a mobility tool like it's a great way to implement movement you know some people really love the pain that foam rollers give them you know uh feels like a massage but you know what if you're doing a plank and you're massaging your quads at the same time and you're getting movement through your upper

33:26Dr Karan: body and doing some core strengthening go for it and yeah so i don't i don't necessarily recommend it or don't recommend it i just basically say look if it helps you and it means you can go to the gym or you sleep better because you do it before bed go ahead this is something i am ridiculously excited about and i've been using it for a while now myself we've all got wearables for our sleep, steps, heart rate. But the one thing we don't track, the thing that actually tells you more about your health than almost anything else is your bathroom data. And that's why I joined the team at Throne Science.

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34:38Dr Karan: That's thronescience.com. Trust me, it'll be your gut's new best friend. I've seen a lot online these days about people wanting to reconnect with ancestral type movements and flexibility. And I've seen people advocating for the benefits of, you know, things like bear crawls and things like that. How useful is something like that for flexibility and widening your range of movement? Or is it actually harmful? I hadn't heard much of this actually, but I love the sound of it. I really do. Because actually, one of my biggest interests is why is it that when we look at these tribes in the jungles of wherever, right, you see these 80, 90 year olds in a full blown squat, stirring cooking food or whatever, right?

35:36And I'm thinking about my mum and I'm like, she ain't doing that, right? and it's just incredible how these people are living and you know so where's their where's their arthritis like they don't have knee replacements and they're 90 and they're sat in a full squat making food for an hour they don't have pain you know so I do think about this stuff quite often and wonder if we were to implement some of these movements whether that's bear crawls or you know our natural body movement whether it would be really really beneficial but again

36:16Dr Karan: all i'd say is do it slowly yeah i think the the average person listening to this i can say pretty confidently and myself included in this i'm not going to be doing bear crawls but what are some exercises that the average desk dweller can do on a daily basis to improve their mobility and you know reduce pain it honestly doesn't take that much so regarding for instance your commute this morning as described even sort of in the train or the taxi little things like twisting gently and doing say a seated cat cow which i'm doing right now what is that so that is hands across your chest and then you come forward and then back up all the way you know you can do this i know you look like an absolute weirdo on the train but that's fine yeah like who cares yeah i mean everyone's a little weirdo in truth even just literally i'm talking micro movement even just side bending like this just any motion at all is helpful like that with your neck you know it's those things can really help um and in terms of increasing mobility itself dynamic stretching is better for you than static stretching yeah it's got a lot of hate in recent years right stretching in general should you should you not yeah so you know there's not much evidence to show that static stretching does anything physiologically to your muscles and that's why you'll notice as well that if you look at say i mean the world cup is starting soon you'll notice warm-ups with the footballers on the pitch they're not standing there all doing static quad stretches like i did when i was at school you'll notice them running around the england men's football team were playing cricket you know bowling batting and it's not just like a team bonding thing and a bit of fun but actually doing those motions you know bowling stretching your arms and your legs yeah uh so dynamic is definitely the way forward so if you're going to do a run it might be leg swings body weight squats things like that just repeatedly warming up your muscles warming up your body um you know if you're about to lift something in the gym whether that's like just some dumbbells like a chest press you know pick up a few lighter weights first do 10 reps and then go into your working set so it's it's more that that helps.

38:53Dr Karan: Tell me and also the listeners as well, a nice bedtime routine for back health. I would say that it's good to lie on your back. A really simple one is chin tucks. So come off your, your pillow and gently bring your chin into your chest. Give yourself a lovely double chin, very attractive and hold that for a while. And then you can release and do it again. So again, that slight element of dynamic movement but then holding then you can do something like bend your knees and twist them to the side and the other side and again continue more more sort of slow continuous these things quite often people are in a rush or they're just impatient so like really be mindful with what you're doing your movement and take it slowly and you might want to bring your knees to your chest as well.

39:48Get a little stretch through your lower back and actually then just take a minute, you know, because it's that presence and being aware of what you're doing and not like doing it whilst chatting to your partner about what, I don't know, Love Island. You know, it's those things as well that are going to help you sleep better. you know be more present with your body yeah i'd wonder how much of a lever that not watching love

40:18Dr Karan: island before bed is but anisha i think this is fantastic because i think people often tend to worry and be proactive about their back or pain in general once it's a problem but i think you know there's clearly some stuff that we can do day to day you know just even in my day here the 90 minutes that I've spent pretty mobile, immobile, I could have done something about that to offset the risk of injury and pain later in the day because that 90 minutes of me being sedentary, I'm not going to feel it then or I might feel a little bit then but I'm going to feel it towards the end of the day when I've already had the entire burden of the day upon me.

40:55Dr Karan: So thank you so much for joining me today and giving these tips to everyone. My absolute pleasure. Thanks for inviting me on.