181: The Relaxback UK Show with Mike Dilke - Episode 181

0:00Hi, I'm Mike Delk and you're listening to the Relax Back UK Show. The show that explores all kinds of health topics relevant to you, your family and your friends. Each week I talk to expert guests from a range of backgrounds to inform and entertain you. So please do join the Relax Back UK family and stay tuned. Hi and thank you for joining me on the Relax Back UK Show. The topic this week is Back Pain. Modern life, you know, prolonged sitting, reduced movements and higher body weights and so on. Just puts loads in the spine that it's not really evolved to handle every day. Dr David McKin gives reasons why you might get back pain, how to help it, getting a diagnosis and one particular method to treat it called Intercept. Emma Fletcher was a back pain sufferer and this treatment helped her greatly. Well, he did say you had to get the bigger habber out because my bones too. Okay. So I didn't feel any pain throughout and I didn't feel a thing afterwards. I was hardly

1:04in any pain after. So please do stay tuned for a great show. Thank you. So my guests today are Dr David McKin, an expert in helping people with back pain and Emma Fletcher, an ex back pain sufferer. My first question to them was just how common is back pain and are we a bad design? Well, back pain is extremely common. So it's one of the most common causes of chronic pain that anyone will have. I think the lifetime prevalence for low back pain in the UK is about 60%. 60% of people will get back pain. Yeah, at some point during their life. Right. And at any one time, about one in six patients or people in the UK will have back pain at any time. Right. So extremely common. And although that said, I wouldn't say that we're necessarily badly designed. It's just

2:07that the human spine is excellent for things like upright walking and load bearing, but some modern life, you know, prolonged sitting, reduced movements and higher body weights and so on. Just puts loads in the spine that it's not really evolved to handle every day. So very common cause of pain, but not necessarily a bad design, but the way that we live nowadays does put a lot of stress on everyone's spine. How about you, Emma? Were you just kind of unlucky in your back health or did you fall off a horse or something? No, I was just slightly unlucky actually. I'm very fit. Always happened. Jim Nassau from a young age, you know, I've been fit all through my life. And I think a lot of mine has come through maybe a bit of wear and tear, maybe overuse. But I think a lot of mine stand from sitting too much. You know, my day job, I sit a lot through it and throw it in my laptop all day. And then in my sort of my other job, the evening's weekend, I'm a personal trader and fitness

3:10instructor. So I've got the benefit of the two, but I found sitting a lot really made my back uncomfortable. Right. And I think that had contributed to a lot of the pain as well that I suffered with. Is that David? Is that something a lot of you? You hear a lot of your patients saying? Yeah, absolutely. I mean, back pains covers a very broad range of different things. So there's lots of different potential causes for back pain. But yes, essentially lifestyle, sitting for a long time, can certainly contribute. You know, Emma's very fit. So it wasn't excess body weight or anything like that in her case. But I think, you know, doing gymnastics and putting all that load through your spine can also cause wear and tear. And that can contribute to patients' risk of back pain as well. Actually, you might have partially addressed this already, but I was thinking like, if it is so common. Yeah. But why is it so hard to treat and so hard to find out what the problem is? Surely you guys have been trying to answer this question for the last 200 years, at least.

4:13Well, part of the issue is that there's so many different causes for back pain. So your spine's a very complicated bit of your body. There's lots of things that can potentially cause pain. Actually, I love me. I did a bit of googling before we chatted. I just put in listed the kind of reasons why you might get a back pain. And there were at least 50 that just came up. So yeah. Exactly. So there's a huge number of different things. And then the vast majority of cases, it's going to be, you know, what are called non-specific and often just some muscle spasms, you know, something that will often settle with time. But there's also going to be subsets of patients who have issues that will go into cause them chronic pain for many, many years. So you can have issues with the muscles and the power spinal muscles around the spine. You can visit issues with your passive joints, the joints at the back of the spine. You can have degeneration within vertebral discs.

5:13You can have what we're going to talk about. It's supposed first progenic back pain where you're getting changes within the end plates, within the bones, within the spine itself. And then there's all the other causes. So fractures, sometimes infection, sometimes tumor. So a huge range of different things from things that are very benign and will get better by themselves quite quickly, all the way through to things that will cause chronic pain for many years and occasionally things that require urgent treatments. So it's a real minefield for doctors trying to make the diagnosis. I was going to say, is that why patients often seem to take, well, potentially years to get a diagnosis? It's because it's actually, it's very complicated and it's not easy. I think that's important. Absolutely. I think also where we've historically in the UK perhaps not always investigated back pain as quickly as we could. A lot of people will go to their GP and be told, ever gets back pain, do some exercise,

6:19have some physio and vestiflock. And while that works in many cases, there's also patients who actually need more investigations, essentially MRI scans and so on, to help diagnose the underlying cause of pain and accessing that hasn't always been very straightforward. And I think what we need is essentially to find better ways to create the pathways so those patients can access the test that they need to identify the cause of their symptoms. Well, we'll come on to potential cures and et cetera in a moment. But before that, I've got what is essentially really quite an unfair question, but I'm going to ask it anyway. Sure. And it's more of an economic, economic type question. With one in six people having back pain at any one time, 60% of us having at some point in our lifetime, is anyone try to quantify how much this costs, you know, GBUK from days

7:20off for sick from NHS time, all this kind of stuff, because I'm thinking it must be billions. Absolutely. It is going. I mean, the cost of chronic blood back pain, the impact it has is absolutely enormous. So I think that there was a recent report from the Health Foundation that said that the impact of chronic pain, which is very broad, but a lot of those patients will be chronic blood back pain, is up to 50 billion pounds annually to the UK economy. So it has a huge impact. More specifically for back pain, the primary care, healthcare costs are loan are estimated to be between three to three and a half billion pounds annually. And that doesn't count all the other economic costs for loss, point of the sickness, absence, the disability benefits and so on. So tax paid, if people aren't working? Exactly, exactly, exactly. And then there's all the, you know, the costs are very difficult to measure.

8:23People may be at work, but far less productive than they would be normally because of the chronic pain that they're suffering. So yes, you know, chronic back pain has a huge impact on UK economy and productivity generally. Let's bring Emma in for a moment as well, because I'm thinking if you are suffering from, well, any pain, but we're talking about back pain here. And it's going on for months or years and it's difficult to get a diagnosis. I mean, this is just going to weigh you down. It's this is going to be, I'm for most people, not great for mental health and kind of family issues, relationships, it can affect, I imagine, a lot of different parts of your life. I mean, were you lucky or is that your experience? It was, I mean, the pain, the pain I had, I had the pain for about quite a while before I actually got to see David, luckily, see old David. And I suppose for me, it was a fact, I mean, I do work at home a lot from a day job, but it was my work, which was getting noticed.

9:25So people in my, in my, you know, my team, my clients were noticing a difference in me. I did, my self, you know, I was trying to take pain killers and try and do as much as I could to overcome the pain. But it was being noticed by others, you know, and people are actually bringing it to me and asking me if I was okay and because you didn't see yourself. And it was like for the past 18 months before I got the right treatment, you know, I was in chronic pain. I tried not to take as much medication as possible because you tried not to and tried to help myself the best way with physiotherapy and other things. But, you know, it has a massive effect on everything, you know, from your day job to not being able to do the things that you love doing because you just can't move as well. And you're scared to move because you might damage yourself even more so you're kind of right in that way. Yeah, vicious circle. Yeah, exactly. In some ways, if you were suffering for 18 months, it might sound crazy, but you actually might have been relatively lucky because you know, here's stories of people that suffer

10:26for decades. Go ahead, Sharon. Yeah, I mean, I know of people who have suffered a lot longer than me, but, you know, I was lucky enough to get into the system and I was lucky enough for David to spot my MRI at the right time. It was all about timing. So, you know, and it was good to actually get on to some of the treatment that's now available and the trial. All right. But the pain, yeah. Let's move on to talking about treatments a little bit because from my little googling and from what you said, David, yeah, potentially 50 different causes for back pain. I'm quite sure there are hundreds of potential different treatments. Yeah. So, if someone wakes up tomorrow morning or if someone has back pain and it's been around for a number of weeks, what would you first thing suggest they do? Well, the treatment is going to depend on what the rate treatment is going to depend

11:27on identifying the cause of the back pain. And that's the key thing really. In the vast majority of cases, as we were saying, it's going to be some muscle pain which will often resolve by itself. But there are certain red flags you need to look out for. So if the pain is associated with a trauma and you're worried a bit of fracture, then you've got to go in. If you've got symptoms affecting your bladder or your bowel, so if you're losing control of your bladder or bowel, then that's often a sign that those nerves are being compressed and you've got to see somebody urgently. If you've got a fever or you're losing weights and you think that there's some other underlying condition, then again, seek out urgently. But if it's just back pain, then often patients, it can take quite a few months for patients to have try conservative management and then start to potentially look for the, the potential underlying cause.

12:28I think in quite a lot of cases, imaging, things like MRI scans are going to be very useful for identifying the, you know, any potential structural causes for the patient's back pain. And again, the treatment then is going to depend on whether it's coming from the facet joints, whether it's coming from things like parse defects where you've got some small defects within the bone. Or whether, as it was in this case, you've got vertebragenic back pain, which is I think a relatively unrecognized cause of back pain. But we think that maybe one and six patients who have chronic back pain actually have this vertebragenic back pain, which we can treat and that's the key thing. It's something that we can potentially try to treat. In the first instance, I'm thinking what, trying things that are not invasive, like a bit of massage, a bit of physio, or go and see a chiropractor or an osteopath, these kind of things. These do, or going for a walk around the block or something like that, it's got to be

13:33the way to go for stuff, isn't it? Absolutely, absolutely. So moving, staying active are going to be really important both for your back pain and for your general health. Keeping the muscles strong around your spine, your core muscles, those parasyphrine muscles, keeping those strong is really important for chronic low back pain because one way to think about it is that with your core muscles are strong, that's actually taking some pressure off the spine. And staying active is actually helping the discs of the spine to stay hydrated, you're keeping the blood flow going and so on. So staying active is really important. In some cases, the pain will persist and sometimes get worse. In those cases, you may want to pursue other investigations to identify what's causing that. So other investigations, we're talking about a scan that you mentioned. Yeah. Yeah. Exactly, things like an MRI scan.

14:34But certainly for the back pain that's M.R.H.D. An MRI is absolutely crucial for identifying those patients. You couldn't pick those patients out without the scan. And with any treatment for back pain, actually getting the diagnosis right, getting to the patient's selection right is crucial. And is a scan like a, you know, a black and white answer of, oh, that's definitely that. Or is it a little bit more, I get the impression actually it's a bit of a black art. Well, yes, I think that's very true. If you scan everybody's spine, when we all get to a certain age, everyone's going to have some wear and tear in there. And in many cases, that's not going to be associated with patient pain. So the art is to correlate the patient's symptoms with the scan findings and then to make a call as to where we think the problem's coming from.

15:38But you're right. You know, in some cases, people can overinterpret the scan and point to a number of different things that aren't, there are just signs of normal wear and tear, which will happen to us all as we get a bit older. That said, getting the diagnosis right is really crucial for the next part of the story, which is you're getting the right treatments. So so yes, so imaging very important. Don't overinterpret the scans and by only other bit of advice is who reports your scan. Can be very important. There's a range of opinions out there and you want a radiologist who knows what they're talking about to report your scan, I suppose, is what I would make. Okay, health radio. This station, I make you feel good. Okay, health radio.

16:46This station, I make you feel good. Okay, are you saying there's like a bit of a postcode lottery or something? Something going on here? Potentially, I mean, I think that for things like first but Janet backpain, which is what Emma had, but it's a diagnosis that's not all radiologists, not all surgeons will even be aware of. Although this is something that we've known about for decades, it's so I think a relatively new concept, particularly in the UK. So so yes, there is a bit of a, there is a bit of a postcode. Okay. We can, there are lots of invasive techniques to deal with different issues. Now, you've mentioned this thing a couple of times. So let's just go into that. Vertogenic back pain. This is something that you can see on the MRI.

17:46What is it? Sure. So it's a vertebral genic back pain is a particular type of back pain where the, the disc between the vertebral bodies is often a bit worn and you get some irregularities and breakdown of the end plates, which are the, the tops and the bottoms of the vertebral bodies. And you get this reaction within the bones and you get these very characteristic findings on the MRI scan, something that we call modic changes. And those are very strongly associated with low back pain. So this deep, exhale back pain often worse when bending forward, worse when doing things like sneezing. And this is a type of back pain that doesn't respond to standard sort of injections or anything that that's, which usually target the, post your column of the spine.

18:49So those are the facet joints at the back of the spine. This is a back pain that's coming from the front of the spine. And up until recently, I think most people would agree was relatively hard to treat. And patients would often suffer with this type of pain for many, many, many years. So with them, Emma, a classic patient did Emma, absolutely, absolutely. Diagnosis and classic. She, yeah. Exactly. So she had, had some wear and tear up the disc, this inflammation within the bones. She had classic symptoms of pain bending forward. And when she was, I think, working as a personal trainer. And her MRI was again, classic modic one reactive and plate changes where there's the spain, flammtry looking appearance to the bones. So when it's all this... So is a specific nerve is it that this particular wear and this modic change and this, in this part of the vertebrae catches on or causes a problem with?

19:53Exactly. So there's a nerve within the vertebral body called the basivertical nerve that comes in through the posterior wall of the vertebral body. And it goes to the middle of the vertebral body and then it arborizes up and down. So essentially it innervates the end plates. And if we could only find a way to deaden that nerve or essentially, sort of slightly suppress the signals going through that nerve, you can take away a lot of the pain that patients feel. And the team at Boston Scientific and Intercept developed a device that allowed us to do that. And that's what we were able to do just now. Describe that advice a little bit because I must admit I looked at a video on their website and it looked somewhat medieval. So just describe it and what you do with it. So it's actually pretty straightforward procedure. What we do is the patients, as Emma will tell you, hopefully that it wasn't too barbaric,

20:57but the patient would be lying face down on the table in the interventional suite. And we use X-rays to guide a small needle that goes down into the vertebral body. And then we need to curve it round to specific points within the vertebral body where this nerve sits. And was Emma awake at this point or was it a GI general anesthetic? It varies a little bit. Different hospitals will have different pros calls. When we did it, we did it with just some conscious sedation. So Emma was awake and we could talk to her, but she wasn't, I think, in any pain. She was a bit sleepy. Yeah, I'll ask of that later. And we essentially tap this curved needle round to a specific point in the vertebral body. And then when we get to the nerve, we can just go to the other side of the cheek there. Sure, a little bit. The same video I was looking at. You described it as tapping.

21:59Oh, the one I saw, the guy driving the machinery, I would say was whacking. Wacking? Well, there can be a little bit of whacking depending on how dense the patient's bonus. And Emma doesn't mind me saying Emma, Emma's bone was very hard. I think because she's an athlete and a personal trainer and has obviously put lots of load through her spine and she's also young. So no history of osteoporosis, anything like that. So her bone was strong. And so there was a bit of whacking. Was it Emma in the video? I couldn't tell from the shot. I was assuming not. I don't know actually. I don't know. There was a photographer there when we featured Emma. So it might have been. That might be too much info. Sorry. But yes, so you're right. We do have to use a little hammer to tap this device down into the bone. But once it's in the right position, we then put a small probe down into the channel

23:02that we've creased it. And we heat that up something called radio frequency ablation. So we heat up the nerve to release the nerve, which will essentially stop those pain signals coming from the bone. And it can significantly improve patient's pain. All right. How hot is this getting? Pretty hot. Hot enough to kill the nerve. So over 70 degrees. And the over 50 degrees you're going to get the nature of the proteins in the cells in cell death. But about 70 degrees is sufficient to do that. And how is that heat got there? Is that electrical or some fancy gas expanding or? It's it's it's it's something called radio frequency ablation. So it's sort of electrical. I suppose and you're generating this ablation zone, which is maybe about a centimeter or so in science. Okay. And that's sufficient to ablate the nerve within within the bone and take with patients

24:06pain. And my so root into this technique was actually doing something similar but for patients with cancer in the spine. So the pain from cancer in the spine can be very, very severe and very hard to treat. But we knew for many years that essentially if you use this technique, this ablation technique to ablate the cancer in the spine, the patient's pain got significantly better because essentially you're killing the nerve, which was supplying the bone. This is a similar idea, but much more targeted. So rather than ablating the entirety of the bone, you're just ablating a small part with this nerve sitting. All right. So you're stopping the nerve working. Now the nerve is going to be there for a reason doing something fairly special. I would imagine. Yeah. It's always a good idea to turn nerves off because you know, they're there for a reason or has the nerve gone wrong? Is that what's causing the problem? In this case, then the pain that the patients are suffering is disproportionate to the underlying

25:08wear and tear. And that's why we want to try and deaden this nerve. It's not that the patient will become completely insensit at that level. There are other nerves supplying the spine. It's something called the sign of vertical nerve, which is going to be in, it's also supplying the area. So we're not taking away every nerve. We're just taking away the nerve that's carrying the majority of the pain signal. And this has been an available in the US for, but a decade now, and they've had long turnfall up for patients, you know, for seven, ten years in some cases. And it's very well tolerated. Because we haven't seen cases where patients are developing complications from the nerve being ablated. And the fantastic thing about this technique is that one alternative would be to do a spinal fusion where you actually fuse the bones together to stop them moving. And one is not going to like that, I'm assuming. Exactly, exactly.

26:09But creating a very stiff segment, a stiff block in your spine often puts increased wear and tear, ill-cruise stress at the levels above and below. Right. Yep. And can actually lead to accelerated degeneration on either side of diffusion. Exactly. So with this technique, we're preserving your anatomy. And we're not damaging anything else. We're just deadening the nerve. And I think long term, that's probably going to be a better option. Right, David, we've had the theory. Let's have the practice. What actually happened? So Emma, how you went in one morning, had the thing go like, look, look, look, look, how you went in one morning, had the thing go like lunchtime and were home by tea time? Or was it, I'm joking, was it a bit more, a, a lot were you in hospital? Really quick. I was literally in for the day. You were for the day. OK. Yeah, in and out, in and out, no time. How long were you on the slab for? Not long, David. Look, I can't quite remember. I was a bit out there, but it was not really in your line. It took us an hour. An hour, it's a lot better. OK.

27:10But it went very smoothly. And as far, I mean, I'm sure it wasn't a joyous hour, but as far as the levels of discomfort, tell us about that, but more about the discomfort when you're recovering from the thing. OK, so drawing, drawing, I did feel a thing. I just, I was about heavily sedated. Every time I kept coming around, I kept just having this kind of, it was a very weird sensation of something pulling, pushing. Not quite sure what was going on. That was David using the hammer. Yeah, it was. Well, he did say you had to get the bigger hammer out because my bones too. OK. It's too strong. So, but I didn't feel any pain throughout, and I didn't feel a thing. Afterwards, I was hardly in any pain after, to be fair. I was literally a couple of paracetamols, and that was about it. I wasn't really, I thought I would be more pain than I was, what I wasn't. And it just got better. There were, you know, I went home, chilled out for a few days,

28:14tried to chill out because I'm, were you, were you walking the next day? Were you walking out of that? I went out of that. You walked out. OK. Yeah, you walked out. Yeah, I walked out just, obviously, was someone walking with me. I didn't drive. Yeah. But yeah, I walked out, not hardly any pain at all. So it was a fantastic procedure. OK. And then, so how long until you, like the, the, OK, the, how long did the after effects of the procedure carry on for? Like a week or two or a couple of months or, you know, how long? Not long at all. I found that within 24 hours, my pain level had dropped completely. OK. Not completely at all, but, you know, it dropped quite dramatically from what it was, because it was chronic. Yeah. And then it just got better and better over the days. I mean, I was, I was out walking a little bit the next day, not too much. And I was most probably walking, you know, a good three or four K.

29:14Maybe I wasn't supposed to do, but I was. So very gently, you know, by the end of the week, you know, just gentle walking with hardly, you know, with a pain level that was up and saying nine down to about three, you know, so it just got better and better. And how long ago did you have this done there, however? A year ago, about a year ago, isn't it? Yeah. And so where are you now? So are you back to your old self or? Yes. Yes, back to my old self. I can back bend. I can forward bend. I really? So you're going to last weeks? Oh, yeah. I'm back. I can do all that now. So, and I can do all the things that I was doing before the pain started, the chronic pain started, which is fabulous. All right. So, I mean, that is a success story, I would say David. Yes. Yeah. But tell me, are there, you know, I like data on this show. Yeah. So I'm assuming there are a pair of you published papers before you're allowed to sort of do it on on patients.

30:15Yes. So give it, give us some statistics. Yes. How many patients have had the procedure done and how many have been followed through successfully for a number of years, that sort of thing? So one of the advantages that we have is that this technique has been around the US for about 10 years. So we've got loads of data and it's very robust data that's come out over the last few years. And the success rates for this treatment are really pretty excellent. About a third of patients will get a 100% reduction in their pain, which is fantastic. About three quarters of patients will get an over 50% reduction in their pain. So that includes 100%. But about a, yeah, let's just start the three quarters. Yeah. So three quarters will get an over 50% reduction in their pain. So about eight to a four or something like that or better.

31:17But that just still does mean that there's about a quarter of patients who get a less than 50% reduction in their pain scoring. So it works very well. It doesn't work for everyone, but it does work well. Now there's a number of other things. If you respond, the pain relief seems to be very long lasting. So they follow patients up to seven years after this treatment. And if you've responded, that response seems to be sustained up to many years post treatment. And we think that that's because if you plate this nerve successfully and it's the cause of your pain, it doesn't come, the nerve doesn't grow back. And so the pain's gone potentially forever. So if it works, it works for a very long time. And now there's always small risk of complications with any procedure. But the complications that have been reported with this technique are really, really pretty minor. So a small number of patients will get a bit of irritation of one of the nerves going down their leg after the procedure.

32:24It's called reticulopathy. And if that were to happen, we would give some a sterile injection to try and calm that down. I thought I've actually never had a case of that. And I think there's been a couple of cases where people have had some bleeding after the procedure. And both of those complications are really related to the technique of getting down into the bone. If you're essentially a little bit too lateral, then you can cause a bleeding. If you're a bit too medial, you can cause irritation of the nerve. But if you're just in the right place, then both of those complications are vanishingly unlikely. How large is the target? The target. So the pedical, it depends which bone you're going down. But the pedical, which is the bit of the bone we're trying to cut the needle through, is going to be maybe six or seven millimeters wide, maybe eight millimeters wide. So it's a narrow little channel. You're trying to direct your needle down. And then the nerve itself is a small nerve. So it's the target's maybe less than a centimeter within the middle of the vertebral body.

33:28And with that's another point I would definitely make, Mike, which is that, as with any target of treatment, the key is to ablate the right bit of the bone. So if you put your ablation probe into the wrong place and somewhere else in the vertebral body, this won't work. You've got to be precise in how you do this. But in the right patients with the right technique, this can work very well. Excellent. So tell me how this is available, because actually this is not approved by a knife, is it, I don't think? Not yet. So myself and some other practitioners have written to nice, asking them to go through the start of the process of considering that's worth a nerve ablation for this particular type of chronic low back pain. I anticipate that they will do that in the next year or so. In the meantime, you're right, it's not straightforward to access, because it's just funding and so on.

34:31In our trust, we've actually been enrolled in a trial called the improved study. Which certainly means that we're able to treat patients through this research project. But it's not available widely in the UK yet, certainly not in the NHS. It is available at some private hospitals. OK. All right. Presumably, from what you've described, it sounds like it's very cost effective. I mean, there's no overnight stay. Yeah. You know, you go in for the day. Yeah. All goes well. You go home and you get better in a couple of days. So for the right person, this does sound like a very cost effective type treatment. So, you know, maybe, maybe nice will approve it. Oh, I hope so. I think I feel pretty confident that they will, because it's a one-off treatment. Kind of a huge impact on patient's pain, court of life, productivity of economic benefits of that down the lane.

35:35It's safe. There's, you know, 10 years plus worth of data to support its use. So I would expect, I would hope that nice would look favorably on this. And I expect that they will approve this in the next few years. So, I mean, if people are currently suffering from back pain, which is proving hard to diagnose and that they'd like to find out a little more about this, because they might be one of the patients that this could help for. How? What's a good source to get a little bit more information just to find out a bit more? I'm not, I don't mean for, yes, I mean for regular, regular people. Yes. Well, actually, there's a really, there's a few good resources out there. There is a page on the internet from Boston Scientific, talking about chronic pain treatment options, and specifically the Intercept Device, which is the name for this treatment for, for password or nerve regulation.

36:42And that's got lots of information on the success rates, the data, the device itself. And so that would, I think, give you a lot of information about this type of back pain and the potential treatment options. And then you might have to search a little bit harder to find radiologists or pain physicians who are able to offer this in the UK at the moment. I think that the normal people offering this will increase over the next few years, certainly. At the minute, there's a relatively small number of people offering this in the UK, but people can probably hunt them down on the internet if they look for buzzword from their regulation. All right. Thank you. Both of you for coming to chat about this. I think this is interesting. It certainly helped Emma greatly. That's obvious. Potentially can help many more people. So many thanks. Sure. Thanks, mate.

37:42Thank you. Thank you very much to my guests on this week's show. They were Dr David McKin and Emma Fletcher, X Back Pain Software. The topic was back pain in particular, the Intercept system of curing back pain. If you are a back pain sufferer and you suffer when sitting at your desk, do take a look at my website, relaxbackuk.com, where you can see the back app chair, which has helped many hundreds of people who suffer pain when sitting at their desk. It can exercise your core muscles very gently when you're sitting down. You can apply to try out a back app chair. The website again is relaxbackuk.com. Many thanks. Okay, health radio. The station I make you feel good. Okay, health radio. The station I make you feel good.

38:52Thanks for listening to the relaxbackuk show. Join me, Mike Dill, to get a next week for more fascinating interviews and chat. If you're listening to the podcast version, please subscribe, like and share it with your family and friends. Have a healthy week. Until next week.