In the last few weeks I’ve had the chance to catch up with some of my old physio mates from university. As much as we try and fight the urge to talk about work when we meet up (enough to bring us to the point creating a forfeit if we mention anything physio-related on a night out), we often can’t seem to help ourselves.
When we, as the super cool group of individuals that we are, finally give in to the urge to talk about physiotherapy, one theme that does repeatedly crop up is the topic of low back pain. As we all like to think of ourselves as physio’s that are moving with the times, the conversation usually goes in the direction of what the current leading experts are telling us.
The New Guru’s?
If you read my last article on why physiotherapy is so important, you would have seen my point on the modern ‘evidence based’ approach to treatment. With this in mind, my friends and I still like to talk about the big names in physiotherapy. Its human nature to be more interested in people and personalities than facts and statistics (just look at America and the rise of Donald Trump). Granted, these days the big names we talk about are people who’ve lead research projects, rather than the ‘guru’s’ that used to be idolised in the decades past, but it’s people that will always catch our attention.
One such personality the caught my attention a few years ago is Professor Peter O’Sullivan. Peter comes across as a laid back New Zealander with, what seems to me, a practical and functional approach to treating low back pain. Peter uses great anecdotes of different people he’s treated with different types of back pain to demonstrate his points of view.
Looking Back… No Pun Intended.
Listening to Peter O’Sullivan has changed my perspective on low back pain, helped progress my understanding and ultimately changed my approach to treatment.
To explain how my thinking has changed, I first need to back-track and show how things were (and sometimes still are) viewed in the medical world. Historically, back pain was thought to be purely down to changes in the structure and anatomy of our backs. People were scanned and x-rayed, and told they had things out of alignment, they had degenerative, bulging or thinning discs, and worn out vertebrae, and this was the cause of their pain.
Things were previously seen from a purely anatomical/ biomechanical perspective, and were treated in line with that thinking. Physio’s spent their time trying to re-align joints, correct slight asymmetries and correct posture. People were told to be careful of bending incase of further damage to their discs, and to avoid certain activities to stop things from getting worse. When things didn’t improve, people were given injections and operated on to remove or correct some of the apparently harmful things shown on the scans they’d had.
In the last few decades our understanding has moved forward quite significantly. We are now more aware of the very complex nature of back pain, factors can increase the risk of sustaining a back problem, and what can influence your recovery from it.
The dogma that has been most difficult to change is this idea that things are purely structural. On a superficial level its easy to think that if things don’t look great on an MRI scan, then that MUST be the cause of your pain. Things aren’t that simple though, as research has shown that even on healthy people who have NO history of back pain, you will often have so called ‘abnormal changes’ on an MRI scan.
“If a computer had a virus, could you tell what was wrong with it just by looking at the circuit board?”
This quote is from another of my favourite current physio personalities, Mike Stewart. This analogy fits in well when it comes to back pain, as mentioned above, looking at a scan of someones back (or ‘the hardware’ if we continue with the computer analogy) is only ever going to give us a small piece of the puzzle. If you wanted to find out more about the computer virus, you’d need to turn the machine on and get it working to see what was going on. With back pain, we need to delve more into how someone uses their body, what makes their pain better or worse, find out about their lifestyle, and even find out how they think about their pain, to get a more complete picture.
When it comes to treatment, the recent work on back pain highlights how we have to approach things differently depending on the individual in front of us. For example, two people may have pain in the same area of their back and a similar problem that causes their pain, but based on the information we gain from them in our assessments, treatment may be completely different for each of them.
A Subtle Difference
An example Peter O’Sullivan used that highlighted this so well, was of two people who both get back pain when sitting down. The first person is an office worker who finds he gets an ache in his back after sitting for 1 hour, has to get up and move around to ease the pain off, and told him that exercise generally helps. On assessment its seen he can move relatively well but is a bit stiff through his hips and back when bending.
The second person also get pain when sitting, but in the waiting room chooses to stand, and seems hesitant to sit when entering the physio clinic. He’s been scanned and told he has a few disc bulges and has the belief that he has to protect his back. He’s developed a habit of tensing his ‘core’, and tells the therapist he’s been avoiding bending. when he is encouraged to sit he is unwilling to relax back into the seat. He’s also tells the therapist that he has avoided his normal hobbies for fear of making things worse, and the stress of what might be going on with his back is giving him trouble sleeping.
The first chap presented with a quite straight forward mechanical pattern of back pain, made better and worse by things he did. Treatment for him might involve some simple advice, exercises to get things moving more freely and possibly some hands on treatment.
The second gentleman presents with seemingly much worse problems. His symptoms were however made much worse by his belief that his back is fragile and something horrible is going on, rather than any serious structural problems. Treatment for this chap would be less physical, and more about encouraging normal movement again, reassurance that appropriate exercise won’t make things worse, strategies to help reduce the guarding around the trunk and possibly even some advice along the lines of slumping back into his seat!
Understanding that pain is different for different people and being able to adapt your approach, is at the core of what Peter O’Sullivan calls ‘Cognitive Functional Therapy’. This much more diverse and practical approach aims to tackle the growing problem of chronic back pain in society today, and improve the poor outcomes from the treatments using the old structural approach mentioned above.
Times are changing. In fact last week saw the launch of the CSP campaign to get more of this new information, out into the public. The campaign on social media with the hashtag #backmyths looks at some of the other common misconceptions around back pain I’ve not discussed in this article. You can read the BBC article on the campaign here, and look at the more detailed CSP article with links to research papers supporting this modern approach to back pain here.
That’s it for this month, I hope you’ve found it interesting, as it’s a topic I’m passionate about. I’m hopeful the we can start to change some of the old views on back pain, and all medical professions sing off the same hymn-sheet, the more we can have a positive impact on people with back pain and prevent so many having such long lasting problems with it.