Physiotherapy for Back Pain: Peter O'Sullivan Interview
Fitness gurus and online influencers seem obsessed with building “the core” to help low back pain. However, it seems the emphasis on core training may be misplaced and cause unnecessary fear around our spines. Moreover, musculoskeletal physiotherapist Professor Peter O’Sullivan says it may actually add to the burden of chronic pain and make our pain experience worse!
Dr O’Sullivan, one of the world’s leading back pain researchers, says people with back pain are already too rigid. Their muscles have tensed up as a protective response to the pain and the last thing we need to be doing is increasing this through core strength exercises.
"The common belief around tensing up a structure that's already tense doesn't really make sense," Prof O'Sullivan said. “The physiotherapy, manual therapy and medical professions have long focused on trying to find the magic ‘technique’, ‘muscle’, ‘injection’ or ‘surgical technique’ required to solve the problem of NSCLBP [non-specific chronic low back pain] and PGP [pelvic girdle pain] disorders. This reductionist approach to dealing with complex disorders in a simplistic manner clearly hasn’t delivered for our patients and contradicts current knowledge that NSCLBP should be considered within a multidimensional bio-psycho-social framework. Relaxing your muscles around your trunk when you have back pain may actually be more helpful."
When asked about imaging, he believes they’re useful for ruling out some red flags, but of limited utility after this, saying,
“Depressed mood predicts future episodes of pain better than abnormal findings on an MRI film. There is a high prevalence of ‘abnormal’ findings on MRI in pain-free populations: disc degeneration (91%), disc bulges (56%), disc protrusion (32%), annular tears (38%). Early MRI imaging for low back pain can result in poorer health outcomes. Although MRI and other imaging has an important role in the triage of people with back pain to identify fractures, cancer and nerve root compression in 1-2% of people, it also puts the spotlight on many patho-anatomical findings that are not related to back pain. In disc prolapse, the natural history is good; the majority of cases recover and the prolapse reduces in size over time. Long term outcomes for surgical intervention are no different to usual care.”
Imaging is not only often unnecessary, but it might actually be harmful as “abnormal” findings on imaging can create fear avoidance, over-protective strategies, reduced independence, increased reliance on pain-killers, increased absenteeism and greater overall disability.
Regarding the best care for chronic low back pain, Dr O’Sullivan cautions an overly anatomical or structural approach.
“Back pain is more complicated than people would like to think. What predicts disability is not necessarily what you see on a scan – it may be your response to what you see on the scan, or how fearful you are about pain, or whether you have a history of depressed mood or anxiety. We also know that there are all kinds of central nervous changes that result from pain over extended periods, and that people suffering from pain change their behaviours in ways that are probably unhelpful and feed into the cycle.”
Dr O’Sullivan, who’s still involved in clinical work, practices what he preaches.
“Best practice management for LBP, once the triage process has been conducted, is guided by screening for psychosocial risk factors and addressing maladaptive beliefs and behaviours to better target care. In the acute phase of LBP, short-term pain management is indicated if the pain is distressing. There is also growing evidence that targeting the beliefs and behaviours that drive disability is more effective than simply treating the symptoms of LBP.”
It’s always recommended that people with back pain be individually assessed by a professional - because everybody has a unique movement signature - to work out exactly what exercises and treatment is needed.