Revolutionising back pain treatments: an interview with Dr Kieran O’Sullivan
Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Dr. Kieran O’Sullivan THOUGHT LEADERS SERIES…insight from the world’s leading experts
How common is back pain and who does it usually affect?
Back pain is exceptionally common. In fact, to not experience back pain at some point of your life would be thoroughly abnormal.
Experiencing back pain is like becoming tired or becoming sad; we don’t necessarily like it, but it’s perfectly common.
What isn’t common, however, is that you don’t recover from back pain. A very small proportion of people experience back pain that either never goes away or it comes back so frequently or so commonly that it has a big impact on their life.
For example, sometimes people wonder “How do I prevent getting back pain?” It’s almost something that’s not worth trying to think about because you and I will both get back pain at some point in our lives. I’m fine with that, as long as it’s for a day or two and it still allows me to live a normal life.
The more important question is “How do I prevent my back pain lasting?” That’s a tricky question.
Does back pain affect people of all ages?
It’s very rare for people to get back pain before the age of about 12 or 13. But the rate of back pain increases quite a lot during the teenage years. It increases persistently then through until the midlife.
But then when you get to being beyond 50, back pain actually reduces slightly.
We see the peak onset of back pain being among teenagers and then increasing into adult life. But it is not, for example, a disease or condition of old people exclusively.
Why is back pain one of the most costly conditions to diagnose and treat?
We’ve probably treated back pain for too long as being an injury of tissues. For example, when somebody hurts their back and goes to see their family doctor or physiotherapist, they commonly get asked “How did you injure it?”
When you have persistent back pain, we’re not dealing any longer with a tissue injury – we’re dealing with pain.
An example I would give is you’ve probably had a headache yourself. Would you say that you’ve always injured your head when you’ve gotten those headaches? I would say probably not.
We’re quite comfortable with the idea that I can have abdominal pain or head pain without injury. But we have an assumption that back pain is always caused by and proportional to injury. Of course, that’s common because it often starts as an injury.
But what we know at this stage is that even if you look at things like whiplash or hurting your back while lifting at work, we know that it might be triggered initially by an injury. But the thing that stops you from getting better is not how badly injured the tissues are.
We’ve spent decades becoming obsessed with the idea that “If I just get the right diagnostic test or scan or assessment, I’ll find out which tissue is injured, be it a disk, ligament, or bone. Then I can just cut it out or rub the pain away.”
Unfortunately, what this has led to is more scans, more physiotherapy, more surgery, more medical interventions, and yet our outcomes are very poor.
If we compare ourselves to our colleagues who work in, for example, breast cancer care, we’re not giving the taxpayer the same value for money.
For example, the chances of somebody being disabled because of cardiovascular disease or breast cancer nowadays is thankfully much less. However, the likelihood of being disabled because of something like back pain has increased.
It’s not because back pain has become more common. It looks like it’s more so because we have ways of frightening people that are unhelpful.
For example, when you go for a back MRI, it is very rare for it to not show something. We used to think these things were always important, but it now looks like the things we see on MRI scans are a lot like finding some baldness on the top of your head or some wrinkles on the side of your eyes, that they are themselves not dangerous.
So, the pain is there and the pain is no fun, but it doesn’t look like it’s always very closely related to these scary things we see on MRI scans and so on.
What types of treatment have been used in recent decades to treat chronic back pain and how successful have they been?
If we look at the most common treatments over the last few decades, they tended to be one-dimensional and tried to fix one thing.
For example, there was an injection to numb or reduce inflammation around the nerve, or a physiotherapist might rub or crack something in your back, or a GP would give you drugs, or a psychologist would give you some cognitive behavioral therapy. Most of these things haven’t really been very good.
For example, they might have helped your pain and disability a little bit, and if I look particularly at the medical interventions that physiotherapists and doctors have used, they really have treated the back and not the person. So, we rubbed and stretched it, cracked it, injected it, cut it, but it hasn’t really done an awful lot for people.
In fact, what caused some people like me in my profession to get insecure is that many of the studies are showing that actually more treatment from physiotherapists, chiropractors, and more MRI scans, rather than being helpful, might actually be adding to people’s disability because we can make people more frightened that they have a serious problem.
There are times when more treatment is good, but, in the last few decades, these one-dimensional approaches, where we’ve given everybody exercise or everybody medication and not treated other aspects of their problem, haven’t really been effective. There is evidence that some people are better off without too much treatment.
But equally, there’s evidence that some people, because they have a very complex problem, need an awful lot of support. But that support probably needs to be individualized to what they actually need themselves and it has to cover physical factors as well as some important lifestyle and psychological factors.
Why do you think these treatments have only had marginal success?
It’s not that these treatments are necessarily bad, but they generally tend to look at one thing. So, if you come in with back pain and your back pain is related to being overweight, being stressed, having poor fitness, poor flexibility and those kind of things, doing a one-dimensional thing like strengthening your back muscles or going on a diet on its own isn’t going to fix all the components.
Obviously we do need to look at the back muscles and at all the parts locally in the back, but also we need to look at the health of a person as a whole – their sleep, their stress, their fears, and as well, come back to what they think is wrong with their back; trying to identify what it is for that particular person.
For example, if the person is underweight, asking them to lose weight just plainly doesn’t make any sense. But for some people it might be important. If the person doesn’t have any stress in their life and is sleeping perfectly well, that wouldn’t be where we’d focus our treatment, but for some people that’s critically important.
How important is the way a person thinks about their back problem?
It’s hugely important in terms of how you recover from back pain. Again, there are parallels with most other health conditions.
Take obesity for example. If you wanted to help people lose weight, we know that diet is a huge part of that, but you can’t just tell people “Eat less.” You have to help change their beliefs about what is contributing to obesity and then try and help change their behaviors, because things like obesity are influenced by things like socioeconomic factors, your mood, your motivation and so forth.
Back pain is the same. If a person thinks their back is damaged and that movement and activity is dangerous, I wouldn’t blame them for avoiding things like movement and activity.
So, a lot of the first stage of what we do is we assure people, and this is the case in 99% of the patients that we see, that even though their pain is very sore and no fun for them at all, that movements and activities are generally very safe and actually useful for their back, if they can get some support to try and help them move a little bit better.
The problem here is that sometimes patients might think if I tell them to move, that I’m telling them to just put up with their pain or that I might be casting aspersions on them, and that’s not what it’s about. It’s about identifying why some person with persistent pain might not be healing and recovering.
One thing that very often helps patients, in terms of trying to understand how back pain is a health condition like any other, is talking about cold sores. We’re generally very comfortable with the idea that health conditions like cold sores have a biological trigger, like a virus. But also that that virus is only a problem if you’re a bit run down – maybe stressed or sleep deprived, or maybe drinking too much in Ireland, these kinds of things.
All of those parts are important. You wouldn’t have gotten the cold sore without the virus. But equally, I know myself, I’ve had cold sores in the past, that cold sore is not a problem at the moment because I’m otherwise healthy.
Again, if we look at things like headaches; you might have a previous disposition to headaches, but if you expose yourself to too much alcohol, or stress, or sleep deprivation, if you have a young baby in the house, they could easily come back.
We can look at back pain from that perspective. Yes, you may have some things that sound like wear or tear on an MRI scan, or you may have some muscles that are a little bit weak or a little bit tight, that might be one component of it.
But there are actually millions of people with short, tight back muscles and posture that might look a little bit suboptimal. But as long as their overall health is good, that doesn’t reach a threshold in which it causes endless pain.
Once they’re sleeping well, not under too much stress, their mental health is good, they have good family support structures, they’re not under huge financial pressure, their body can heal from the normal day-to-day stresses and strains of life.
Why does avoiding usual activities and moving too carefully limit the potential for recovery?
First of all, we know the body needs movement to heal. Disks and cartilage etc. need movement to get their blood supply.
Movement in itself is good, but actually moving carefully is a much harder thing to do for your body.
I often say to patients to, for example, lift their hands over their head five times and see how hard it is and how difficult it is, and then compare that to moving very slowly and very carefully. They’ll notice that it’s actually much, much harder moving slowly because you’re fighting against gravity for much longer. Whereas moving at a normal speed, like bending to put on your shoes at a normal speed, is actually much easier.
From a purely physical aspect, movement and activity is good for the tissues of the back, but unfortunately quite painful for people in pain because they tend to move in a way that’s far more careful and cautious, which in itself puts more stress on the back.
That’s one problem. The movement is definitely good, but the way in which people with back pain move tends to be difficult and awkward.
We see this manifested in things like sitting posture. If I told you now to look at your sitting posture, your instinct would probably be to do something like brace your shoulders back and sit up straight. That’s understandable.
If you really teased that out and I asked you “Why aren’t you sitting like that already?” you would probably tell me “Well, that’s because it’s uncomfortable and unnatural.”
If you think about the friends and the people you know or see in a cafe, the people who are sitting relaxed and looking comfortable are the people without pain and the people with the most distressing and disabling pain are sitting upright and fidgeting like crazy.
Movement is good, but particularly, relaxed movement is good. If you look at people with chronic back pain, they’ve almost forgotten how to move easily. They cannot sit easily, they cannot dress easily, they cannot roll in bed easily. Not only are these movements painful but it’s understandable that it causes people to stop moving and to avoid activity. But that leads to further deconditioning.
Our message in terms of usual activities and moving is it’s very good and we would be trying to help people to move with less pain because it makes them more comfortable.
If we don’t change people’s beliefs around the idea that their back is being damaged easily or that their back is vulnerable, I don’t think we can blame them for avoiding activity and exercise.
We spend a huge amount of our time not necessarily cajoling or trying to trick people into moving, but trying to show them that a lot of the time their current strategies for movement are unhelpful.
It’s not that they’re deliberately trying to make themselves worse, it’s just that their body hasn’t understood that there’s a plan B, and that plan B can be moving with confidence and with freedom. But of course, that’s easier said than done when you’ve got a lot of pain.
What are the main misconceptions about back pain and how do you plan to counter this misinformation?
A couple of years ago, we ran a national campaign here in Ireland, I was a chairperson, and it was called “Back Pain Myths.” It was a series of public talks and we focused on five or six of the key misunderstandings we felt that were seen in the evidence, that were seen to be important for the members of the public to get.
In amongst these, we were trying to get across the message that pain is very real and very disabling, but chronic back pain is not an injury anymore. It’s far more like a headache and stomach ache, where there are a whole range of factors involved.
We know that from all the studies that will say the correlation between what we see on scans or what surgeons feel when they go in to operate on people, and pain is very poorly related. The pain is real, but it’s no longer about injury. If people still think injury, they will think it’s like a sprained ankle – “I must rest it and avoid it.”
Another very important misconception related to that is the idea that scans and tests are always useful. For example, when somebody goes for an MRI scan for their back, unless they have cancer or they have a spinal cord compression, which again, would usually be obvious to any GP or physiotherapist or chiropractor, the MRI scan is highly unlikely to be of use.
In fact, what it generally tends to do is increase fear and anxiety amongst people because once you reach the age of 14 or 15, I’m afraid you’re going to find some things. But these things are not damaging.
You can’t see this, but I’m getting balder. Every day I look in the mirror, I’m getting balder. But nobody would ask me if I’m getting terrible headaches because of it, because there’s no suggestion that – you could joke and say I have degenerative scalp disease, but really that’s just genetics and a process of aging.
The stuff we see on scans is very much like that. But people tend to think this disc degeneration is a pathology and it’s not, no more than baldness is a pathology.
Another misconception is that more treatment is always useful. We have a lot of evidence, and again this might sound like a bad business model for me to be saying this, that if you’ve got some back pain but you’re generally healthy and you’re able to cope and keep active, you would be better served by staying away from too many healthcare professionals and continuing to cope.
If you start entering the medical circle, especially if it’s in a privatized healthcare system, you can start getting pushed towards more scans, more tests, more interventions and more treatments. We know, first of all, that it might be a waste of money, but secondly, it might actually start making you paranoid about movement.
So, doctors, physiotherapists and other healthcare professionals are notorious for telling people what not to do. For example, they’ll tell people “Here’s a way you can get fit, but don’t swim, don’t walk, don’t bend, don’t garden, don’t golf, and don’t do this,” and we leave them very few options.
The last few misconceptions — the idea that if it hurts, it’s dangerous. Again, we’re not encouraging people to go out and injure themselves or make themselves very sore. But something can hurt and not be harmful, the reason being is that it looks like when you have chronic back pain, your alarm system has started to misfire.
In my home, intermittently the house alarm goes off if a bird flies into the window, for example. But the alarm system thinks somebody has broken the window because it’s the adjustment isn’t quite done right.
When you have persistent pain, your central nervous system, the nerves that give you the sensation of pain, become hypersensitive. So, even something simple, like stretching a ligament in your back, causes intense pain.
The patient understandably will think “Oh, that’s dangerous,” whereas what’s really happening there is the alarm has become hypersensitive and what we need to do is unwind that sensitivity. That includes activity, stress management, and sleep.
The big misconception, which I spend most of my time talking about, is like the cold sore, people think that back pain is either physical or psychological and nothing in between.
Whereas, if you look at, again I mentioned cold sores, but heart disease, we’re quite happy with the idea that heart disease can be linked to a physical thing you have to look at, like cholesterol and diabetes and obesity. But also we’re quite happy with the idea that stress can increase your blood pressure and risk for heart disease.
If you look at cancer, there’s significant evidence out there that genetic risk factors are involved in breast cancer, for example. But we also know that stress and other things lead to cancer.
Back pain isn’t different. Patients almost feel that nobody wants to sign up and say “Oh, I’ve got psychological back pain,” and I don’t ever say that my patients have. But what most patients have, when the pain has lasted a long time, is they have some very clear physical things that are unhelpful about the way they move.
But generally, their overall health. Not just psychological health, but their sleep, stress, mood and the fears and worries they have about their back pain can be a barrier. If we don’t label and identify them, and help people identify how to overcome them, we won’t have a meaningful impact on their pain.
What do you think the future holds for back pain treatments?
The optimist in me, based on recent high quality trials, tells me there’s actually a huge amount we can do for patients if we follow the evidence and we start differentiating pain from injury, and if we start treating the person and not their back.
For example, there’s been some very good studies done recently, showing that we can, compared to the old effects we were having on pain, have a big impact, have people with much less pain, much less disability and have a better quality of life.
It actually doesn’t have to cost a lot because we’ll treat those who don’t need much treatment very scarcely, we’ll stop sending people for unnecessary scans and we’ll start sparing that extra time and attention that we need and spend that on the people that need it most.
However, if I’m being perfectly honest, while I think that is definitely possible, the pessimist in me is telling me that this will be a pointless task if we’re doing one person at a time. For example, only seeing a few patients and changing them one at a time won’t do anything.
If we look at the smoking analogy again, the only way we have raised awareness in terms of preventing lung cancer is through mass media campaigns and every GP, physiotherapist, nurse, consultant singing off the same sheet.
So, if I go down the street tonight and I ask people “What do you think causes lung cancer and what would you do to reduce the effect?” The public knows, even if they’re a smoker, they know “Well, smoking is one of those things.” If you want to look at heart disease, people know “Well, heart disease is linked to things like diabetes and obesity and smoking.”
Whereas if I go down the street and ask “Well, what do you think causes back pain?” They generally come back with “It’s about physical things, like pulling, dragging, and lifting,” which is one part of it, but it’s just one part.
Or they’ll think it’s about damaged tissues in the back, like disks and bones and ligaments. They will have very little awareness of the role of overall health, sleep, stress, mood, fears, anxieties, and worries.
That’s why the pessimist in me thinks that while we can do a lot for people, it’s a huge uphill battle until we really get people thinking about the person and not the pain. That’s why I was involved in the back pain campaign in 2011, the Move For Health campaign, and that’s why we moved to launch our little website, Pain-Ed.com.
Both the campaign and the website are based on trying to get the public, and of course health care professionals, to understand all the little bits and pieces that are involved in their pain.
We know that when you change patient’s beliefs, you can empower them, make them betterconsumers of healthcare, but also help them control their own pain. In summary, I have a lot of hope for individual people and helping their pain but I’m quite pessimistic about where healthcare and society is at the moment.
Where can readers find more information?
I’d always tell patients to trust their own instincts about themselves, or someone close, because when I ask patients about our perspective on pain, this actually makes perfect sense to them.
When they discuss it with their family, the overwhelming majority says “Yeah, you know, I think there is something to this. I hurt my back and I sprained my back, but at this stage I can’t get it off my mind. I know I’m moving too carefully, I know I’m too stiff,” but they’re caught in this vicious circle where they’re in pain, they’re disabled, they’re weak, they’re deconditioned, they’re worried, they’re frustrated and we need to develop that sense of awareness.
People are intuitively able to understand this, but it’s almost as if as a society we haven’t really thought about the importance of it.
Dr. Kieran O’Sullivan is a Chartered Physiotherapist who lectures at the University of Limerick (UL) in Ireland. He completed his PhD in 2012 on low back pain (LBP).
He is currently coordinating several research projects including a multi-centre randomised controlled trial (RCT) on treatment of LBP.
He has been awarded “specialist” physiotherapist status by the national Physiotherapy Society (ISCP).
He has published over fifty peer-reviewed articles, as well as one book and three book chapters.