VIDEO: Prof Peter O'Sullivan | Back Pain - Separating Fact From Fiction

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Audio Transcript:

​What we know about back pain is that it's only 1% of back pain disorders that have really serious stuff - like it could be caused by a malignancy, a fracture, an inflammatory disorder, - and only around 5% of back pain is linked to a disc prolapse where there’s some kind of nerve compression. 90 - 95% of back pain disorders have no diagnosis based on scans.  

But the problem we've created is that, whereas fifty years ago people would have been called / had what they used to call lumbago, or back pain, or a back sprain, - now we've created another problem because we have highly sensitive imaging techniques like the MRI scanner which picks up so-called “abnormalities” in almost everybody, because if you scan anybody's spine, 90% have got degenerate discs, around 45% have got disc bulges or protrusions, 20-30%: protrusions or annular tears or facet joint arthrosis.  

So in trying to identify the 5%, we've created this massive belief in the majority of back pain patients that back pain is caused by these “findings” on scans which actually are normal findings that are not predictive of back pain.

•  “My MRI scan comes back and it showed herniation in the L5, S1, and I think it was a small herniation or bulge in the L4 / L5. Obviously they mentioned herniations, and at that point my anxieties had probably elevated somewhat and I think my pain had taken off as well.”​

• “I had my MRI scans done back a couple of years after that and got told I had to have an operation. I had to stop everything I was doing.  They said because it’s my lower disc they had to go through the front - might not be able to have kids - all this sort of scary stuff.”

• “People had said it can take you a year to 18 months.  We rang a surgeon. We were going to get a referral to a surgeon.  His PA said people take 10 years.”

• “Another one told me I’d die with back ache. (You what, sorry?) I’d die with back ache.”

• “Kept getting told these horror stories.  I was told they hadn’t seen this in a young man. I had a back of a 70 year old. That’s what I was told.”

• “I went to the GP.  All I really wanted from him was pain killers.  And he said: the last person (my wife will verify this) the last person that come and seem me that had this type of back pain for this long had cancer.  That was a GP.  That was a GP.  (And how did that feel?)  You can imagine can’t you?  I mean, if I’ve got a headache I’ve got a brain tumour.  So someone saying that to me just escalates it a million percent.”

And then what's happened is we then have this belief that back pain’s caused by these damaged structures.  We start treating the spine like it is damaged.  We tell people, ooh you got to protect your back, and keep it straight and watch out when you lift, strengthen your core.  Which are things that we know people with pain already do.

• “And then I went to physio and I was there for a good maybe 8 months doing various - they focused on my core muscles - doing various exercises.”​

• “The physiotherapists started saying that it was muscular imbalances and I needed some core strengthening and prescribed a few exercises to strengthen the back, strengthen the core.”

• “And that lasted for a while.  Never really any improvement.  In actual fact it was getting worse.”

• “(So what kind of things were they doing?)  He was getting me doing things like the crunches, stuff on the ball, good-mornings, where I’m trying to bend my hips and keep a flat back (So in standing?)  Basically, yeah.  And it made it worse.”

• “I’d been doing these core strength exercises. (OK, what kind of things?)  So that when I’m sitting here now I’m tensing my core muscles.  And when I stand up it would be mainly from here and I’d be pushing up with my buttocks.  And every time I move - if I’m going to open the car door I tense my core muscles and things like that. (Is that helpful for you do you think, or not?  For your back pain?)” 

And then we've gone down this other path saying we’ve got to inject the spine, and you know use different kinds of pharmacological approaches, and then end up with fusing the back in an attempt to treat it.

• “I went to see the consultant a couple of weeks ago - back pain still persisted.  I go into his office and he said: Chris, what are you doing? Or, what are the problems? I explained the problem - brings up images, and straight away he sort of said, looking at your scans, he said your not a suitable candidate for any invasive work.  But the only thing that would fix you is a fusion.  So naturally I crapped myself again.”

We kind of have developed this whole belief system around that back pain is all about structure.  And so we've directed our treatments at treating the symptom of pain and we haven't done a very good job of it.

In terms of the cause of the problem what we understand is it's a lot more complex.  Back pain can be caused by a number of factors, both what we call peripheral drivers, things like abnormal muscle tension, or muscle guarding, adopting postures or movement patterns that are rigid and guarded and protective, which can create stress on pain sensitive structures.
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• “So if I ask you to bend down towards you toes, what do you reckon about that?  Would you do that? Not really. Bit nervous with that.”

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• “So that’s it? You wouldn’t bend past that?”

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• “If I just ask you to pick that up? So you don’t bend at all.”

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• “I notice when you sit, you don’t relax in to the chair.  Is that normal for you? (No, I used to be really slothly.)  So why did you change?  Because I’m picking that when you were slothly you didn’t have a back problem.  (No I didn’t.)  So why the change?  (Because I think my GP said that you can always tell people with back problems because they sit upright and then the guy he referred me to talked about core strength.)”

And that interplays with other things around stress-related factors.  People are in high-level of stress.  People who are not sleeping.  People who have suffered from depression or anxiety.  We know that that can influence the amplifier effect of the brain which can sensitise the body's spinal structures.

• “If you don’t mind I’m going to get you to close your eyes again, and if you were to visualise that, you know, that thought you have when you might hit a bump in the road, like when you were in last week, what’s that like for you?  (What, just try and do it now?)  If you do it now. Oh, OK, what happened?  (I just…) What did you notice in your body? Your head starts to move.”

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• “I feel I’m broken.  I feel I’m weak.  I mean my hair’s grey.  My skin’s grey.  I’m just…  (Did that all happen in the last four months?)  No, sadly it didn’t.  (But that’s how you feel?  You feel like you’ve aged?)  I’m in a dark place. (Yeah sure.)”

And we’ve almost created a perfect storm because if your belief is that you've had a scan and your joints are worn out - then when we asked people what that means to them they think that their backs are crumbling or that with time the more they use them they’re going to wear them out.
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• “I had this, perhaps a vision of discs crumbling or collapsing, facet joints sort of being tight together and rubbing, and arthritic conditions developing.  (Horrible thoughts.)  They were horrible thoughts, yes.”

They become very worried about that.  They start protecting their backs and abnormally stress these pain sensitive structures, and they stop doing the things in life that give them meaning.  They’re too frightened to exercise.  That has huge impact on the general health and health co-morbidities.

• “Probably my muscles are probably tight where I’ve not stretched them at all.  (Is that because you’re a bit worried about stretching them?)  Yeah, I’m worried about everything to do with my back, worries me.”

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• “(So are you fearful of your back?)  Constantly.  (Yeah, how fearful?)  Well, as I say, I don’t think the disc is going to go, but I just fear being in a place away from home where I’m suddenly (and you’re feint again) yeah, or I’m in a lot of pain (and you can’t get out?) Yeah. (Yeah.)  So I don’t want to go on the train.  I don’t want to go in the car.”

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• “One day my wife and kids went out and my little girl said, hold a minute, who’s going to dress dad? (Right.)  And that hit me.  I though, I can’t go on like this.  (Yeah, that’s not a good place to be.)  No.”

And then we can create the catastrophe around the fact that their too frightened to do things that help them and the very things that they've been advised to do often feeds the problem that they've created.

• “The physio, that was the fourth one, in occupational health, and they basically got me loads of extension exercises, and that I think just finished me off completely.”

One of our research group, Ivan Lin, published a paper just recently in the British General Medicine Open, proposing that in fact disability around back pain is iatrogenic.  That is, its health care system induced.  Where we hear the stories of people with pain, like we have the last few days, around the pain started with not even, not even an injury.  And then they go through this cascading process of seeking different treatments, given different advice, being told your disc’s damaged, or this is worn out, or you got a pinched nerve, or you’ve got to be careful when you bend, hold your core, and be tense when you move.  And then they describe this process of becoming depressed, highly anxious, fearful, start avoiding stuff, and then their life's trapped.

• “The problem about my job as a head teacher is I am sitting a lot.  (Yeah)  I was just aware I was getting increasingly uncomfortable around the top of my (yeah) glutes, and I stood up to try and stretch it and it's just seemed to get worse, and then I just passed out.”

And so we know that if you ask people with pain they say my life is on hold because I can’t, I don't understand it, I can't control it, and I can do the things in life that give me meaning.

• “With the physical journey there’s a sort of spiritual and a psychological journey as well.  And I look back now and I’m almost embarrassed about how low I got, you know what I mean? (What do you mean?)  This sounds ridiculous but I was suicidal.”

I think there's now a general belief that in fact persistent back pain is something that we can't change.  And that the best thing we can do is to really advise people to make the most their lives.  To accept their situation and, and you know, go back to doing things that give their life value so that they’re less disabled.

Now I think that may be the fact for a very small group of people but I think we miss a whole lot of people who have huge opportunity to change.  And I think that's a view that needs to shift among health professionals.  That we stop thinking of backs as back’s been damaged.  That pain does not equal structural injury.  That movement is good for the body.  That backs should be trusted to move in a normal way to give people strategies and confidence - help both healthcare professionals and physiotherapists and other healthcare professionals to give them a different view on pain.  To stop describing backs as being caused by wear and tear, and disc degeneration, and disc bulges.  To tell people that these findings are normal.  And then to build the capacity within themselves, in terms of understanding their pain, in the context of their life, to find ways to break that pain cycle.

And we've seen examples of this, and as we have across a number of years, and we put these up on our Pain-Ed website,  which is a free open-access website that we’re committed to try and change the story around pain.  To make people think of it as something that is modifiable.  That there are ways in which people can take control of their life, to get their life back.

• “(So what’s happened in the last year then? What’s been happening for you?)  I started up my own company and non-stop working, digging holes.  (Did you?  Digging holes!)  Yeah, mains, gas-mains, electrical mains, every day I’m working  I dig every day of my life.  Seven days a week, every month, I don’t stop working. (Not bad for someone with a bad back)”

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• “So just keep your legs straight and bend over.  And up you come.  Bend backwards.”

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• “(What are the key things that allowed you to change, do you think?)  Completely my mindset changed. Learning myself I won’t do myself no damage.  Relaxing and moving.  And yeah that was it.  My mindset was the big thing.”

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• “The big thing for me was the breathing.  It’s just the relaxed breathing.”

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•  “That’s good.  Feel your legs working? (Yeah.)”

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• “I’ve never had to stand up at the desk at work.  I don’t feel it anymore when I’m at work at my desk.  In that, I think largely it’s mind over matter.  I don’t think about it anymore.”

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• “I sort of try and go to the gym at least four times a week.  I try and do, say 40 minutes on a weights session or something and maybe 10 - 20 on a bike.”

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• “Just come… - you’re doing them quite quickly.  You used to do it like this.  (Yeah, yeah, yeah, I know OK).  Just bend side-on. Just bend towards you toes again.  That’s it.  Now we were trying to encourage you to do this a year ago, and it was not easy was it?”

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• “You begin to understand - hold on a minute, this is all normal.  And I don’t have to have these spasms.  And I don’t have to be lying on the floor in meetings at school.  And actually, I can manage my pain, and I can actually get it back to what it should be, and take control of my own destiny.  Suddenly you realise, well hold-on, I’ve not had a day off work for four months and I haven’t felt bad.”

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• “I started doing long walks.  Then I started jogging half of it.  Now I do, I run for 2 miles on a Monday, I run for three on a Wednesday, and I run for five Friday.”

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• “Jogging on the spot.  Show us your squat.  No worries with that?  (No, nothing.)”

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