By Dr Peter O’Sullivan, Curtin University, West Australia @PeteOSullivanPT
The enormous media interest over the demise of Tiger Woods’ golf game because of his back pain disorder highlights that current approaches to management are fuelling rather than reducing the burden of back pain (Deyo, Mirza et al. 2009). (PS: You can listen to the related podcast here).
Tiger’s story demonstrates common underlying beliefs about back pain often reinforced by well meaning health care providers, which in turn leads to the quest for ‘magic bullet’ treatments to ‘fix’ the disorder. Although an isolated case, Tiger’s situation highlights clinicians’ common diagnostic and management dilemma regarding the mechanisms for, and the management of, recurrent and disabling back pain disorders.
Tiger’s quotes and their associated media scrums raise 5 themes for discussion:
- “Tiger has a pinched nerve in his back causing his pain” What is the role of imaging for the diagnosis of back pain?
Commonly in clinical practice, back pain is considered from a purely biomedical perspective, where radiological imaging is the basis for diagnosis. Athough 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 (O’Sullivan and Lin 2014). Disc degeneration, disc bulges, annular tears and prolapses are highly prevalent in pain free populations, are not strongly predictive of future low back pain and correlate poorly with levels of pain and disability (Deyo 2002, Jarvik JG 2005).
The adverse effects of early MRI imaging for LBP, highlight the risk of iatrogenic (caused by the health system) disability if spinal imaging is not communicated carefully and matched to the presenting disorder (Webster BS 2010, McCullough, Johnson et al. 2012). Even when specific pathologies exist, it is crucial to consider all relevant bio-psycho-social domains of the examination, clinical reasoning and management process (O’Sullivan and Lin 2014).
- “Tiger had a micro-discectomy for a pinched nerve which had lasted for several months.” What is the role of microdiscectomy for the management of 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 (Benson, Tavares et al. 2010). For those who don’t recover, levels of pain and disability are not predicted by the size of the prolapse and degree of nerve compression; this suggests other pain mechanisms are involved (Benson, Tavares et al. 2010). The role of decompressive surgery (micro-discectomy) should be limited to nerve root pain associated with progressive neurological loss (e.g., leg weakness) and cauda equina symptoms (O’Sullivan and Lin 2014). Surgery for radiculopathy is unlikely to be useful in the absence of neurological compromise because the pain mechanism is associated with inflammatory mediators in the perineural fat (Genevay, Finckh et al. 2008) rather than nerve compression. Micro-discectomy is not a treatment for back pain.
- “My sacrum was out of place and was put back in by the physio.” What role do manual therapies play to treat back pain?
Passive manual therapies do not prevent nor change the natural history of back pain; they have a limited role in the management of persistent back pain disorders (Rubinstein, Middelkoop et al. 2009). Passive manual therapies can provide short-term pain relief. Beliefs such as ‘your sacrum, pelvis or back is out place’ are common among many clinicians.
These beliefs can increase fear, anxiety and hypervigilance that the person has something structurally wrong that they have no control over, resulting in dependence on passive therapies for pain relief (possibly good for business, but not for health). These clinical beliefs are often based on highly complex clinical algorithms associated with the use of poorly validated and unreliable clinical tests (O’Sullivan and Beales 2007). Apparent ‘asymmetries’ and associated clinical signs relate to motor control changes secondary to sensitised lumbo-pelvic structures, not to bones being out of place (Palsson, Hirata et al. 2014). In contrast, there is strong evidence that movements of the sacroiliac joint is associated with minute movements, which are barely measurable with the best imaging techniques let alone manual palpation (Kibsgård, Røise et al. 2014).
- “I need to strengthen my core to get back to golf pain again.” What is the role of core stability training?
“Working the core” has become a huge focus of rehabilitation of athletes and non athletes in recent years. The belief that the spines stabilising muscles become inhibited with back pain rendering the spine ‘unstable’ and ‘vulnerable’ drives this. Yet growing evidence tells us that disabling persistent back pain disorders are often associated with increased trunk muscle co-contraction, earlier activation of the transverse abdominal wall and an inability to relax the spines stabilising muscles such as lumbar multifidus (Geisser, Haig et al. 2004, Dankaerts, O’Sullivan et al. 2009, Gubler, Mannion et al. 2010). This increase in co-contraction can increase spine stiffness and alter biomechanical loading reinforcing pain.
A number of high quality randomised controlled trials have compared stabilisation training to various forms of exercise, manual therapy and placebo. These studies highlight that this approach is not superior to the other active therapies and only marginally superior to a poor placebo, with only minimal changes in pain and moderate reductions in disability (Ferreira, Ferreira et al. 2006, Ferreira, Ferreira et al. 2007, Costa, Maher et al. 2009). Recent studies have also demonstrated that positive outcomes associated with stabilisation training are best predicted by reductions in catastrophising rather than changes in muscle patterning (Mannion, Caporaso et al. 2012 ), highlighting that non-specific factors such as therapeutic alliance and therapist confidence may be the active ingredient in the treatment – rather than the desired change in muscle.
- What should clinicians do? The paradigm shift required for managing a complex multidimensional problem like back pain.
So where does this leave us as clinicians – and people like Tiger – when managing persistent and recurrent back pain? Firstly, clinicians need to realise that back pain does not mean that spinal structures are damaged – it means that the structures are sensitised. It the clinician’s job to determine what the mechanisms are that underlie this process. While for some athletes there maybe patho-anatomical and biomechanical explanations to pain, for many others it is far more complex. There is growing evidence that low back pain is associated with a combination of genetic, pathoanatomical, physical, neurophysiological, lifestyle, cognitive and psychosocial factors for each domain. The presence and dominance of these factors varies for each person, leading to a vicious cycle of tissue sensitisation, abnormal movement patterns, distress and disability (O’Sullivan 2012, Rabey, Beales et al. 2014).
The examination of an athlete involves;
- careful history taking,
- understanding the person’s pain experience in relation to their levels of disability and patterns of provocation,
- the level and type of impairments,
- the sport demands,
- the person’s beliefs and expectations
- other lifestyle and relevant psychosocial stressors.
When reviewing imaging, keep the clinical history and examination at the forefront of your mind. The physical examination seeks to identify the pain sensitive structures and associated pain features. Where pain is mechanically provoked, ask about and observe pain provoking movement patterns specific to the sport (golf swing) and activities of daily life. For example, observe carefully whether the golf swing is associated with increased lumbar flexion or extension, coupled with side bending and rotation, increased trunk muscle co-contraction, breath holding and as well as guarded movement of the hips and thorax, which can increase lumbar spine loading. A video analysis of the swing may well assist this process (and help you explain it to the patient). If you identify motor control impairments, then test strategies to normalise these movement patterns to determine if the pain can be reduced, modified and controlled. Also assess levels of conditioning (O’Sullivan 2012, Vibe-Fersum, O’Sullivan et al. 2013).
Based on these findings, consider whether there are likely to be bio-psycho-social drivers for the disorder. Devise a graduated rehabilitation plan in agreement with the coaching staff with clearly defined goals.
For effective management of persistent pain, provide a clear understanding of the factors that drives pain, develop graduated strategies to normalise and optimise movement patterns while controlling pain, and couple these steps by prescribing sports specific conditioning and a graduated return to sport. Addressing psycho-social stressors and unhealthy lifestyle factors is part of this process, especially where ‘central’ pain features are dominant (O’Sullivan 2012, Vibe-Fersum, O’Sullivan et al. 2013). Magic bullets don’t exist, so don’t promise them.
To adopt this new approach clinicians require at least two things:
- Change of mindset: Abandon old unhelpful biomedical beliefs, and embrace the evidence to change the narrative to help people with pain understand the underlying mechanisms linked to their disorder.
- New and broader skills for examining the multiple dimensions known to drive pain, disability and distress. These assessment skills need to be complemented by the skill of developing innovative interventions that enhance self management, allow the patient to engage in relaxed normal movement. The clinician also needs to encourage the patient to adopt healthy lifestyles and positive thinking about backs (O’Sullivan 2012).
There is growing evidence and momentum to support this process (Hill, Whitehurst et al. 2011, Vibe-Fersum, O’Sullivan et al. 2013) but large sections of the health industry have a vested interest in the status quo. For substantial and sustained improvement (as in anti-smorking), all levels of the socioecological framework must contribute/be engaged. Consumers will need to advocate for change by demanding better outcomes. Political will and legislation is needed to prevent expensive ineffective interventions (such as discectomy for back pain). Critically, a large and growing body of clinicians and educators must be committed to evidence based practice with an emphasis on the P for practice. The media reports related to Tiger Woods’ 2014 problems suggest we have some way still to go.
NB: Peter O’Sullivan has 3 BJSM podcasts altogether. (1) The link above relates to Tiger Woods of course. (August 2014)
(2) Prior to that one he discussed managing acute and chronic back pain - click here please (July 2014)
(3) And he also comments on the issue of ‘overdiagnosis’ – ordering too many MRIs, creating fear of pathology in people – ‘pathologising’ and ‘catastrophising’ in this podcast – click here please (also July 2014)
Peter O’Sullivan is a Professor of Musculoskeletal Physiotherapy at Curtin University, Western Australia, and a Specialist Musculoskeletal Physiotherapist. For more info: www.pain-ed.com
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