Complejidad Back Pain Peter o Sullivan

[ viewpoint ]

PETER O’SULLIVAN, PT, PhD1,2 • JOAO PAULO CANEIRO, PT, MSc1,2

MARY O’KEEFFE, PT, PhD3 • KIERAN O’SULLIVAN, PT, PhD3,4
Unraveling the Complexity

of Low Back Pain
J Orthop Sports Phys Ther 2016;46(11):932-937. doi:10.2519/jospt.2016.0609
Downloaded from www.jospt.org at on October 30, 2020. For personal use only. No other uses without permission.
L
ow back pain (LBP) is the leading cause of disability world- clinically meaningful long-term effects or
wide.22 Various approaches to diagnose and manage LBP that one form of exercise therapy is supe-
have arisen, leading to an exponential increase in health care rior to another.19,43 Indeed, there is also
growing evidence that nonspecific fac-
costs.12,16 Paradoxically, this trend has been associated with
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tors, such as therapeutic alliance, patient

a concurrent increase in disability and chronicity.12 Biomedical beliefs and expectations, therapist con-
and structural beliefs largely underpin current clinical practice, fidence, pain catastrophizing, and self-
with a focus on providing “magic bullet” supposed biomechanical faults, using spi- efficacy, are more predictive of clinical
treatments directed towards presumed nal manipulation, soft tissue techniques, outcomes than changes to the target of
damaged structures and biomechani- electrotherapy, dry needling, and taping, the therapy (ie, changes in muscle timing,
cal faults and/or on providing symptom to name a few. These therapies, when posture, joint position).17,42,45 Also in this
palliation. Exponential increases in mag- tested, have only demonstrated small and paradigm, the ergonomic industry con-
netic resonance imaging (MRI) scanning at best short-term benefits,2,30 while the tinues to reinforce the belief that backs
Journal of Orthopaedic & Sports Physical Therapy®
to identify these damaged structures mechanisms underlying them have been need to be protected, teaching people to
have led to escalating rates of spinal fu- identified as neurophysiological rather sit upright, avoid bending, and lift with
sions and disc replacements.27,28 This is than biomechanical and structural.5 a braced abdominal wall and a straight
in spite of evidence that abnormal MRI At the same time, a wealth of specific back. This is in spite of a lack of evidence
findings are prevalent in asymptomatic exercise interventions have emerged to that ergonomic interventions reduce the
populations and are poor predictors of address presumed biomechanical and risk of LBP,13 or that the way you bend
future LBP and disability.7,24 Indeed, pro- structural abnormalities. These include increases the risk of LBP.50
viding a patient with a pathoanatomical stabilization, muscle balance, and di- This commonly “threatening” clini-
diagnosis can result in increased fear rectional exercises that target presumed cal climate frequently leaves the patient
and iatrogenic disability.26,41 In terms of impairments such as hypermobilities, with LBP confused and fearful that his
symptom palliation, there has also been subluxations, instabilities, ring shifts, or her spine is frail, vulnerable, and dam-
an exponential increase in spine injec- malalignments, and/or derangements. aged.11 This in turn reinforces protective
tions; pharmacology, including opioid These so-called abnormalities are pre- and avoidant behaviors, leaving people
prescriptions; and implanted spinal cord sumed to be the cause of LBP and com- with few active coping strategies to man-
stimulators. All these interventions have municated as such to patients. This age their pain and maintain quality of
limited long-term efficacy and carry sig- practice persists without evidence that life. This commonly leads to health care
nificant health risks.9,44 the abnormalities it addresses are strong shopping and stepped care, in which pa-
In parallel, there has also been an ex- predictors of LBP and associated dis- tients progress to more invasive and risky
pansion in physical therapies offered for ability. Furthermore, randomized con- treatments. Sadly, this current practice is
LBP. Many of these therapies focus on trolled trials investigating these various often discordant with patient expecta-
symptom palliation and/or correcting interventions have failed to demonstrate tions regarding the importance of clear
1
School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia. 2Body Logic Physiotherapy Clinic, Shenton Park, Australia. 3Department of Clinical Therapies,
University of Limerick, Limerick, Ireland. 4Aspetar Orthopaedic and Sports Hospital, Doha, Qatar. The authors certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Prof Peter O’Sullivan, School of Physiotherapy
and Exercise Science, Curtin University, Kent Street, Bentley, WA 6102 Australia. E-mail: [email protected] t Copyright ©2016 Journal of Orthopaedic & Sports Physical Therapy®
932 | november 2016 | volume 46 | number 11 | journal of orthopaedic & sports physical therapy
46-11 Viewpoint1-O'Sullivan.indd 932 10/19/2016 7:33:11 PM

communication about their disorder, egorize or subgroup people with LBP in tributing factors that promote pain and
their desire for individualized self-man- order to target treatment.38 It also high- disability.34,48 This enables the patient
agement strategies to control their pain,32 lights why magic bullets and symptom to become a partner in a therapeutic
and goals relating to functional restora- palliation have largely failed, as the ca- journey that aims to lower the threat of
tion and maintaining quality of life.23 Pa- pacity of these approaches to positively pain, develop active coping strategies to
tients with persistent LBP describe this impact this interplay is limited.33 While self-manage the disorder, and engage in
process as having their “life on hold,” in subgrouping within some of these di- value-based activities.34,48 Within this
which they don’t understand their pain mensions has been considered (eg, neu- context, hands-on care can be used as a
problem, have few active coping strate- rophysiological, pain-related movement tool to validate the individual, educate
gies to manage it, and lose their ability behaviors, psychological and lifestyle the patient regarding tissue sensitivity
to do the things in life that they value.8 profiles), randomized controlled tri- and protective muscle guarding, lower
This is often associated with escalating als testing subgroup-targeted care have the threat of the patient’s pain and fear
distress, disability, and depression.8 failed to demonstrate greater benefits.39,47 of movement, provide guidance, and di-
“Boxing” patients into rigid subgroups rect the patient toward behavior change.
CONTEMPORARY may miss the crucial interrelationships This understanding is illustrated in
UNDERSTANDING OF LBP between factors for an individual.38 the following case. A 55-year-old man
In contrast, there is growing evidence This knowledge underpins the need presented with pain in the buttock that
that LBP is a multidimensional disor- for a multidimensional clinical-reason- was referred into the right leg. He re-
der.36 It is increasingly clear that persis- ing approach to patient examination ported an episode of sciatica 9 months
tent and disabling LBP is not an accurate and management in order to identify the earlier, after repeated lifting while mov-
measure of local tissue pathology or dam- various and relevant underlying drivers ing house. Based on an MRI scan, he had
age alone.7,24 Rather, it is best seen as a of pain and disability for each individu- been given a diagnosis of a disc protru-
protective mechanism produced by the al.34,48 This approach enables the clini- sion at L4-5 without nerve compression.
neuro-immune-endocrine systems in cian to recognize the relative weighting He had been nonresponsive to traditional
response to the individual’s perceived and dominance of the various factors that biomedical approaches, including dry
level of danger, threat, or disruption to are unique to each person’s presentation needling, spine manipulation, stabiliza-
homeostasis.29,31,51 These systems con- (FIGURE). The interplay between different tion training, and nerve root sleeve injec-
stantly interact and are influenced by an factors for an individual may vary on a tions. He was taking anti-inflammatory
interplay of physical (loading exposures temporal basis, highlighting the need to medication and strong analgesics. His
and levels of conditioning),35 psychologi- regularly reassess their contribution. For pain was now persistent, distressing, and
cal (cognitions and emotions),37,49 social example, pain and behavioral responses disabling, and he had been advised that
(socioeconomic, cultural, work, home may fluctuate based on a person’s percep- a discectomy was his only management
environment, and stress),20,21 lifestyle tion of threat, levels of attention to pain, option and that he should avoid bending,
(sleep, activity levels),6,25 comorbid health mood, contextual social stressors, sleep, lifting, and exercise.
(mental health, obesity),37,40 and non- and activity levels. Some of these factors Multidimensional screening at his ini-
modifiable (genetics, sex, life stage)3,4,14 may be modifiable (eg, beliefs, mood, tial visit identified high levels of stress,
factors. Interestingly, the emerging evi- behavioral responses, sleep, and activity anxiety, depressed mood, and fear-avoid-
dence reveals that many of these factors levels), whereas others may not be (eg, ance beliefs. He reported that his symp-
are interrelated, rather than being mutu- socioeconomic and social circumstanc- toms developed at a time of high levels of
ally exclusive.10,15,46 The relative contribu- es). The challenge for the clinician is to work and financial stress, which was still
tion from these different factors and their consider the relative contribution of mod- ongoing and which disrupted his sleep.
interactions with each other is variable, ifiable versus nonmodifiable factors as- He reported that he avoided physical ac-
fluctuating, and unique to each individ- sociated with the disorder to target care. tivity and lifting, due to the advice he had
ual with LBP.36 As a result, patients with The dominance of nonmodifiable factors received, for fear of doing further “dam-
LBP can range from low to high levels of may moderate outcomes and require ad- age.” He had a sedentary job.
complexity. This is reflected in their levels ditional targeted multidisciplinary care. On physical examination, he present-
of pain, distress, and coping (behavioral) This contemporary understanding de- ed with high levels of abdominal obesity
responses, all of which, in turn, influence mands a shift away from providing a sim- and had guarding responses to forward
their levels of disability.1,18 plistic structural and/or biomechanical bending (he held his back in lordosis and
This interplay between multiple sys- diagnosis and treatment for LBP. Rather, propped himself up with his hands). A
tems and factors restricts reductionist this process empowers the patient to de- straight leg raise (50°) reproduced his
approaches that attempt to neatly cat- velop a clear understanding of the con- pain, but he had normal neurology. He
journal
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[ viewpoint ]
Impact of LBP
| |
Person’s Valued Goals
Clincal Journey
Understanding pain
Pain controllability
Pain self-efficacy
Return to valued activities
Patient-Therapist Interaction
FIGURE. The multidimensional factors associated with the person with LBP, his or her interaction with the therapist, and the clinical journey. Abbreviation: LBP, low back pain.
was physically deconditioned (sit-to- and gardening. He felt this would im- his spine, coupled with high levels of
stand was difficult without assistance prove his general health. contextual stress, poor sleep, inactiv-
of his hands). He reported his general Multidimensional profiling identified ity, abdominal obesity, and sedentary
health to be poor, being overweight, feel- modifiable risk factors that became tar- lifestyle, had resulted in a vicious cycle
ing run-down, and having high blood gets for care.34,48 of pain and disability.
pressure and high cholesterol. His goals 1. Making sense of his pain: a diagram 2. Graduated exposure (with control) to
were to avoid surgery, reduce his medica- was drawn to show how the combina- feared movements/activities: guided
tion, and develop pain-control strategies tion of avoidance and protective re- behavioral experiments were used in
so he could return to cycling, walking, sponses due to fear of doing damage to a graduated manner (ie, progressed

from supine to sitting to standing) sponses to pain, and their social context tions with patient functioning in chronic pain:
to demonstrate to him that when he • Critical thinking and multidimension- a systematic review and meta-analysis. Arch
relaxed his back into flexion without al clinical reasoning Phys Med Rehabil. 2012;93:2109-2121.e7.
http://dx.doi.org/10.1016/j.apmr.2012.05.029
protective guarding and propping • The examination of behavioral re-
2. Assendelft WJ, Morton SC, Yu EI, Sut-
himself up with his hands, he had less sponses to pain (protective guarding torp MJ, Shekelle PG. Spinal manipulative
pain. This was progressed into condi- and avoidance), while considering therapy for low back pain. Cochrane Database
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was used to demonstrate how sensi- ucation regarding their contributing dx.doi.org/10.1093/bja/aet127
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of article (Research Report, Case Report, etc).
Features further curates 3 primary JOSPT article collections:

Musculoskeletal Imaging, Clinical Practice Guidelines, and Perspectives
for Patients, and provides a directory of Special Reports published
by JOSPT.
journal
journal
of orthopaedic
of orthopaedic
& sports
& sports
physical
physical
therapy | volume
therapy | volume
46 | number
40 | number
11 | november 2016 | 937
8 | august 2010 |

This article has been cited by:
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2020. Cognitive Functional Therapy for People with Nonspecific Persistent Low Back Pain in a Secondary Care Setting
—A Propensity Matched, Case–Control Feasibility Study. Pain Medicine 21:10, 2061-2070. [Crossref]
3. David Toomey, Duncan Reid, Steven White. 2020. How manual therapy provided a gateway to a biopsychosocial
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Manipulative Therapy 12, 1-26. [Crossref]
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Marta Buszewicz, Rona Moss-Morris, Peter White. 2020. Behavioural modification interventions for medically unexplained
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[Crossref]
5. Mary O'Keeffe, Peter O'Sullivan, Helen Purtill, Norma Bargary, Kieran O'Sullivan. 2020. Cognitive functional therapy
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controlled trial (RCT). British Journal of Sports Medicine 54:13, 782-789. [Crossref]
6. Richard Thompson, Mårten Prosell, Toomas Timpka. 2020. Elite athletes’ experiences of musculoskeletal pain
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Medicine in Sport . [Crossref]
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Katherine J. Simson, Patrick J. Owen, Daniel L. Belavy. 2020. Randomized Trial of General Strength and Conditioning
versus Motor Control and Manual Therapy for Chronic Low Back Pain on Physical and Self-Report Outcomes. Journal
of Clinical Medicine 9:6, 1726. [Crossref]
8. E.J. de Raaij, R.W.J.G. Ostelo, J.F. Maissan, J. Pool, P. Westers, H. Wittink. 2020. Illness perceptions associated with
patient burden with musculoskeletal pain in outpatient physical therapy practice, a cross-sectional study. Musculoskeletal
Science and Practice 45, 102072. [Crossref]
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Athletes: An Overview Emphasizing Nonoperative Management. Journal of Sports Medicine 2020, 1-15. [Crossref]
10. Alexi Kuhnow, Jason Kuhnow, David Ham, Richard Rosedale. 2020. The McKenzie Method and its association with
psychosocial outcomes in low back pain: a systematic review. Physiotherapy Theory and Practice 1, 1-15. [Crossref]
11. Christian Longtin, Marie-France Coutu, Yannick Tousignant-Laflamme. 2019. Deciphering programs for optimal self-
management of persistent musculoskeletal-related pain and disability – Clinical implications for PTs. Physiotherapy Theory
and Practice 5, 1-9. [Crossref]
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Therapies 27:1. . [Crossref]
13. Jagjit Mankelow, Cormac Ryan, Paul Taylor, Dominic Simpson, Denis Martin. 2019. Effectiveness of pain education to
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protocol. International Journal of Therapy and Rehabilitation 26:8, 1-8. [Crossref]
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Gwendolijne Scholten-Peeters, Pim Cuijpers, Michel W Coppieters. 2019. Identifying psychosocial characteristics that
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BMJ Open 9:8, e028747. [Crossref]
15. Thomas Matheve, Liesbet De Baets, Katleen Bogaerts, Annick Timmermans. 2019. Lumbar range of motion in chronic
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17. Jacek Cholewicki, Pramod K. Pathak, N. Peter Reeves, John M. Popovich, Jr.. 2019. Model Simulations Challenge
Reductionist Research Approaches to Studying Chronic Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy
49:6, 477-481. [Abstract] [Full Text] [PDF] [PDF Plus]
18. J.P. Caneiro, Anne Smith, Steven J. Linton, G. Lorimer Moseley, Peter O'Sullivan. 2019. How does change unfold? an
evaluation of the process of change in four people with chronic low back pain and high pain-related fear managed with
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19. Jacek Cholewicki, John M. Popovich, Payam Aminpour, Steven A. Gray, Angela S. Lee, Paul W. Hodges. 2019.
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Musculoskeletal Science and Practice 39, 107-114. [Crossref]
26. Jeannette Saner, Esther M. Bergman, Rob A. de Bie, Judith M. Sieben. 2018. Low back pain patients' perspectives on
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[Crossref]
27. Giacomo Rossettini, Elisa Carlino, Marco Testa. 2018. Clinical relevance of contextual factors as triggers of placebo and
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28. Monica Unsgaard-Tøndel, Ingunn Gunnes Kregnes, Tom I. L. Nilsen, Gunn Hege Marchand, Torunn Askim. 2018.
Risk classification of patients referred to secondary care for low back pain. BMC Musculoskeletal Disorders 19:1. . [Crossref]
29. Per Kjaer, Alice Kongsted, Inge Ris, Allan Abbott, Charlotte Diana Nørregaard Rasmussen, Ewa M. Roos, Søren T. Skou,
Tonny Elmose Andersen, Jan Hartvigsen. 2018. GLA:D® Back group-based patient education integrated with exercises
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19:1. . [Crossref]
30. Matthew Low. 2018. A Time to Reflect on Motor Control in Musculoskeletal Physical Therapy. Journal of Orthopaedic
& Sports Physical Therapy 48:11, 833-836. [Abstract] [Full Text] [PDF] [PDF Plus]
31. Tristan Paul Eric Delion, Jerry Draper-Rodi. 2018. University College of Osteopathy students' attitudes towards
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29, 41-48. [Crossref]
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International 23:3, e1711. [Crossref]
33. Scott A. Burns, Joshua A. Cleland, Chad E. Cook, Michael Bade, Darren A. Rivett, Suzanne Snodgrass. 2018. Variables
Describing Individuals With Improved Pain and Function With a Primary Complaint of Low Back Pain: A Secondary
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36. Emanuel Brunner, Wim Dankaerts, André Meichtry, Kieran O’Sullivan, Michel Probst. 2018. Physical Therapists’ Ability
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37. Peter B O’Sullivan, J P Caneiro, Mary O’Keeffe, Anne Smith, Wim Dankaerts, Kjartan Fersum, Kieran O’Sullivan. 2018.
Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back
Pain. Physical Therapy 98:5, 408-423. [Crossref]
38. Kieran O’Sullivan, Peter B O’Sullivan, Tim J Gabbett. 2018. Pain and fatigue in sport: are they so different?. British
Journal of Sports Medicine 52:9, 555-556. [Crossref]
39. Ney Meziat-Filho, Arthur Sá Ferreira, Leandro Alberto Calazans Nogueira, Felipe José Jandre Reis. 2018. “Text-neck”:
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Medicine 27, 6-13. [Crossref]
41. David Nolan, Kieran O'Sullivan, John Stephenson, Peter O'Sullivan, Michael Lucock. 2018. What do physiotherapists and
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Science and Practice 33, 35-40. [Crossref]
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What are the similarities and differences between healthy people with and without pain?. Scandinavian Journal of Pain
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49. 2017. March 2017 Letters to the Editor-in-Chief. Journal of Orthopaedic & Sports Physical Therapy 47:3, 219-223.
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51. 2017. February 2017 Letter to the Editor-in-Chief. Journal of Orthopaedic & Sports Physical Therapy 47:2, 126-129.
[Abstract] [Full Text] [PDF] [PDF Plus]

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PETER O’SULLIVAN, PT, PhD1,2 • JOAO PAULO CANEIRO, PT, MSc1,2

Unraveling the Complexity

tors, such as therapeutic alliance, patient

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Person’s Valued Goals

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6. Björck-van Dijken C, Fjellman-Wiklund A, Hild-

O’Sullivan P. Lives on hold: a qualitative syn-

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reira ML. The influence of the therapist-patient 2016;16:588-590. http://dx.doi.org/10.1016/j. math.2015.02.005

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BROWSE Collections of Articles on JOSPT’s Website

Upcoming Issue; a list of available accepted Ahead of Print articles; and

Features further curates 3 primary JOSPT article collections:

46-11 Viewpoint1-O'Sullivan.indd 937 10/19/2016 7:33:12 PM

1. 2020. Schwarzes Brett. physiopraxis 18:10, 48-51. [Crossref]

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