I’ve tried everything for my back pain – but a robot physio finally cured it

Liz Hoggard
Liz trying the single leg chair squat - Tony Buckingham

“If you improve your upper back flexibility day to day, your lower back should notice a big difference,” Kirsty, my “robot physio”, soothes as I rotate my spine against the kitchen wall. The cat yawns as he sees me throw weird shapes again.

Calm, empathetic Kirsty is my new girl crush. She’s a real person, but she’s not actually present today in my kitchen. Her responses are pre-recorded and delivered to my phone.

But, through the wonders of artificial intelligence, or AI, she can listen to my symptoms, recommend physio exercises and pain management techniques in real-time. It feels strange to engage so personally with someone I’ve never met. But when you’re in pain you’ll try anything. Even advice from a robot.

Since childhood I’ve had mild scoliosis (where the spine twists and curves to the side). As a desk-bound writer, I’ve managed lower back pain by investing in an orthopaedic chair, plus swimming and Pilates. Before the chair – genuinely the ugliest piece of furniture in my flat – I thought I might need morphine.

But then last summer – disaster. I slipped and pulled the abductor muscles in my right thigh, which reignited my back problems. For months it was agony turning over in bed. I saw an excellent physio (£80 a session) who released my lower back and promised me I didn’t need a hip replacement. But a year on, the pain and stiffness in my lower back has spread to my right hip and leg. Getting into the pool, I feel like an old crock.

I’m not alone. Lower back pain is the leading cause of disability worldwide. The knock-on effect of not being able to do regular things – sitting, driving, standing at work – is huge. Over 30 million work days are lost to musculoskeletal conditions (MSK) every year in the UK.

Currently more than 300,000 people are on NHS wait lists for physiotherapy – a quarter have been waiting over three months.

If left untreated, MSK conditions can become more complex and lead to mental health problems, according to the Health Foundation. My partner Mike has been waiting six months for a back scan (he has piriformis syndrome, where the piriformis muscle that runs from lower spine to upper thigh becomes inflamed). And I’ve seen how dejected it has made him.

So when I heard about Flok, the UK’s first AI-powered physio clinic, being rolled out free to NHS patients over the next year, I was keen to try it out. Instead of waiting months for an NHS physio appointment, you start your treatment plan immediately.

Designed by a team of physios and software engineers, Flok is the first tool of its kind to secure approval from the Care Quality Commission. You book in for weekly AI video appointments with a digital physio, via a smartphone app, accessed at any time from your home.

Flok
The exercises are tailored to your symptoms and appear as easy-to-follow videos on your phone or laptop

First I fill in an online profile then I have my first video appointment with ‘robot’ Kirsty. Tall, blonde, super-bendy (she’s been a physio for over a decade), she has a reassuringly normal voice and gestures.

She asks questions about everything from my medical health to the effect pain is having on my wellbeing (can I dress/shower etc) to make sure I don’t have a more serious injury (in which case she would refer me to an urgent care service). No one should do exercises that cause pain. But for 95 per cent of MSK cases, physio is extremely helpful.

Kirsty puts me through movement tests and asks me to log how easy or hard I find them. She spots I have left-sided extension preference, so arching backward and to the left is more comfortable, but my right side is much weaker (studies have found that a directional preference is present in 70 per cent of patients with neck and back pain). And the stiffness I experience in my upper back (or thoracic spine) means my lower back is overworked.

Each week I get a personalised exercise “prescription”. Three bespoke exercises – essentially medical-grade yoga and Pilates-style movements –  appear in my app. Kirsty practises them with me, then I perform them daily on my own in the kitchen. These include standing wall thoracic rotations (to encourage rotation through your spine) and grisly single-leg chair squats for “hip-strengthening”. “You make life easier for your back whenever you can get your hips to do the work,” she explains. Balanced on one leg I can’t even lift my right hip off the chair at first. But despite a small groin strain (last suffered at primary school), it gets far easier.

Kirsty, who appears as an AI physio in the app, demonstrates a yoga pose
Kirsty, who appears as an AI physio in the app, demonstrates a yoga pose

At each assessment, she asks about any pain I’ve experienced (“I’m sorry to hear that”) and if we need to adjust the exercises. Back pain is very rarely just to do with a section of your spine. With additional movement tests, she finds that my leg symptoms are being caused by nerve irritation (or sciatica) in or around my back, likely caused by the strong discs or bones putting pressure on the nerve that runs down to my leg. She sets me nerve slider exercises where you lift your foot and head simultaneously to ease muscular tightness or weakness around the back.

The genius thing is you can do them anywhere. I crunch through series two of Sherwood on my laptop as I flex, and do them at a PJ Harvey gig.

I genuinely feel she is in the room with me, cheering me on. But Kirsty doesn’t even know I exist. It’s a bit like being in love with a replicant in Blade Runner. Her presence is stitched together by computer, which also sends me the exercises (there are a billion combinations devised by Kirsty and the team, but it chooses those specific to your individual symptom pattern).

“We trick your phone into thinking it’s getting a video call by sending it a stream of frames,” says Finn Stevenson, the co-founder of Flok. “But the software is deciding in real time which frames to send, so it can change what the video says and does, based on your responses.”

Stevenson is a medic (he specialised in musculoskeletal medicine) and former professional rower. At one point he ran the spine surgery business unit for a robotics company in Switzerland and witnessed just how much money was being poured into spine surgery around the world. “But only [very few] people with a bad back will benefit from spine surgery. The vast majority should never go anywhere near an operating room.”

In fact the tools for managing most MSK pain are simple. Exercise. Better sleep. Breathing exercises. Meditation. The worst thing you can do is rest. “Your musculoskeletal system [made up of bones, muscles, joints] is designed to move. The key to improving symptoms is movement. But obviously, you need  people to do the right sorts of exercises and then, crucially, be able to adjust them.”

Patients stuck on waiting lists deteriorate. “The worst thing you can do for your strength, mobility, and the pain itself, is become more sedentary. This spiral of decline affects lots of people who have MSK pain, turning it from  a minor irritation to a situation where you’re not at work anymore, you’ve stopped exercising, you’re feeling really low. The flip-side is if you can reverse that direction, people see a pattern of recovery.”

Flok Health founder Finn Stevenson with physio therapist Kirsty Henderson
Flok Health founder Finn Stevenson with physio therapist Kirsty Henderson - Tony Buckingham

A strapping 6ft 7in Stevenson had access to round-the-clock physio as an athlete, but when he left rowing and needed to see a physio for back pain, he was shocked at the wait for NHS treatment or the staggering private costs. The backlog was never going to clear, short of retraining half the country as physios.

“About one in three adults a year have at least one serious episode [of musculoskeletal pain]. So you end up with a compromised model  – a four-month waiting list, then a single 10-minute appointment where the clinician barely gets beyond basic safety screening. Or they might send you away with a sheet of exercises. That’s very frustrating for the clinician. It’s also surprisingly expensive and not good for the healthcare system and economy more broadly.”

Stevenson and his team wondered how they could democratise access to world-class physio. They looked at telemedicine – where you speak to a GP live on a video call – but it wouldn’t help the backlog. So they built the software for an AI clinic where patients have access to an autonomous digital physiotherapist for each appointment.

Flok monitors every new symptom. Part of the problem with a photocopied sheet of exercises is they may no longer be suitable in a week’s time. “Two people with the same starting set will progress differently,  see different levels of success with different mixtures of intervention. And if you don’t have the opportunity to monitor and adjust that pathway, you’re shooting in the dark basically,” says Stevenson. True to form, when Mike tries Flok, he’s assigned completely different exercises from me.

What sets the app apart from other digital fitness platforms is the sense of connection. If I forget to exercise, I feel I’m letting Kirsty down personally. Doing it alone, unsupported, would be far harder.

Later when I visit Flok’s headquarters in Cambridge, the real life Kirsty Henderson, 41, greets me warmly and I realise, hurrah, I’m not just interacting with a computer. “When patients feel a connection to ‘AI Kirsty’ it’s a sign we’re on the right track,” she says.

'Real life' Kirsty assisting Liz through some exercises
'Real life' Kirsty assisting Liz through some exercises - Tony Buckingham

In fact Kirsty was screen-tested like a Hollywood actor for the role, and Flok shot their videos in their own film studio. “It’s medical-grade content but we give the experience high production values,” laughs Stevenson.

After successful trials with NHS Trusts, Flok will be rolling out the platform later this year. I genuinely hope more people can try it. A self-confessed technophobe, I found the app easy to use and it’s given me the tools to “reframe” my pain and minimise flare-ups.

I’ve learnt a lot about my body. If I do daily exercises that strengthen hips and activate my glutes, my lower back pain stops. In the past, walking slowly round a blockbuster art exhibition would have given me agonising cramp. Now I simply do my nerve sliders. The chronic nerve pain stops, and no one is any the wiser.

Liz’s exercise prescription for back pain

Here are four of the ”bespoke” exercises Kirsty chose for me over a month  (I did three sets of 10 reps for each). It’s important to build up slowly with time and practice.

Declutch nerve sliders

Declutch nerve sliders
Declutch nerve sliders

This is a gentle massage for the nerves where you move your head and extend your leg at the same time to help the group of nerves that go down your leg to glide back and forth smoothly. “It’s important to do movements that your nerves enjoy rather than pushing through the pain,” says Kirsty. Keeping your whole foot in contact with the ground, slide your left foot forwards (it’s OK to have a bit of a bend in the knee). Keep your heel down but lift your toes towards the ceiling as you look up. Lower both down. Then do the right foot.

Single-leg chair squats

Single leg chair squat
Single leg chair squat

This exercise challenges balance. Feel free to add a cushion or pillow if your chair is low. Stand in front of the chair with arms out to the side, or on your waist etc. Lift your left foot off the ground and squat down as close to the chair as you can (if you need to sit down and then come up into a standing position that’s fine) and rise back up again. Then do the same, lifting the right foot off the ground.

Standing wall thoracic rotations

Standing wall thoracic rotations
Standing wall thoracic rotations

Stand against the wall with your right side touching the wall. Roll your shoulders back and down. Bring your left arm up and take it out in a half-circle to make contact with the wall behind you, following the trajectory with your eyes.  Don’t worry if your hips rotate slightly to allow that rotation through your spine. Return that half-circle, to bring your arm all the way back again. Then do the same thing on the left side. If you want to make it harder, step one leg in front of the other, then start the half-circle.

Jackknives

Jackknives
Jackknives

I built up to this one after three weeks of gentle movement. Lie down on your back on the mat, with arms and legs out straight. Lift your arms, shoulders and legs off the mat and keep them lifted in between the reps. Bring arms towards your legs. Extend your body back to starting position without resting hands or feet on the floor. Take a breath and repeat.