Common misconceptions about back pain in sport: Tiger Woods’ case brings 5 fundamental questions into sharp focus

PeteOSBy 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:

  1. “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).

  1. 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.

  1. “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).

  1. “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.

  1. 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.

LISTEN HERE – BJSM PODCAST: Professor Peter O’Sullivan on Tiger Woods’ back and ‘core strength’

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 

 References

Benson, R., S. Tavares, S. Robertson, R. Sharp and R. Marshall (2010). “Conservatively treated massive prolapsed discs: a 7-year follow-up.” Ann R Coll Surg Engl 92: 147–153.

Costa, L., C. Maher, J. Latimer, P. Hodges, R. Herbert, K. Refshauge, J. McAuley and M. Jennings (2009). “Motor Control Exercise for Chronic Low Back Pain: A Randomized Placebo-Controlled Trial.” Physical therapy reviews 89(12): 1275-1286.

Dankaerts, W., P. O’Sullivan, A. Burnett and L. Straker (2009). “Dankaerts W, O’Sullivan P, Burnett A, et al. Discriminating healthy controls and two clinical subgroups of nonspecific chronic low back pain patients using trunk muscle activation and lumbosacral kinematics of postures and movements: a statistical classification model.” Spine 34: 1610-1618.

Deyo, R. (2002). “Diagnostic Evalution of LBP. Reaching a Specific Diagnosis Is Often Impossible.” Archives of Internal Medicine 162: 1444-1447.

Deyo, R., S. Mirza and J. Turner (2009). “Over treating chronic back pain: time to back off? .” J Am Board Fam Med 22: 62 – 68.

Ferreira, M., P. Ferreira, J. Latimer, R. Herbert, P. Hodges, M. Jennings, C. Maher and K. Refshauge (2007). “Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial.” Pain 131(1-2): 31-37.

Ferreira, P., M. Ferreira, C. Maher, R. Herbert and K. Refshauge (2006). “Specific stabilisation exercise for spinal and pelvic pain: a systematic review.” Aust J Physiother. 52(2): 79-88.

Geisser, M., A. Haig, A. Wallbom and E. Wiggert (2004). “Pain related fear, lumbar flexion, and dynamic EMG among persons with chronic musculoskeletal low back pain.” Clin J Pain 20: 61 – 69.

Genevay, S., A. Finckh, M. Payer, F. Mezin, E. Tessitore, C. Gabay and P. Guerne (2008). “Elevated Levels of Tumor Necrosis Factor-Alpha in Periradicular Fat Tissue in Patients With Radiculopathy From Herniated Disc.” Spine 33 (19): 2041–2046.

Gubler, D., A. Mannion, P. Schenk, M. Gorelick, D. Helbling, H. Gerber, V. Toma and H. Sprott (2010). “Ultrasound tissue Doppler imaging reveals no delay in abdominal muscle feed-forward activity during rapid arm movements in patients with chronic low back pain.” Spine 35: 1506 – 1513.

Hill, J., D. Whitehurst, M. Lewis, S. Bryan, K. Dunn, NE, K. Konstantinou, C. Main, E. Mason, S. Somerville, G. Sowden, K. Vohora and E. Hay (2011). “Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial.” Lancet Oct 29(378): 1560-1571.

Jarvik JG, H. W., Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. (2005). “Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors.” Spine 30: 1541-1548.

Kibsgård, T., O. Røise, B. Sturesson, S. Röhrl and B. Stuge (2014). “Radiosteriometric analysis of movement in the sacroiliac joint during a single-leg stance in patients with long-lasting pelvic girdle pain.” Clin Biomech Apr;29(4): 406-411.

Mannion, A., F. Caporaso, N. Pulkovski and H. Sprott (2012 ). “Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function.” Eur Spine J 21: 1301–1310.

McCullough, B., G. Johnson, B. Martin and J. Jarvik (2012). “Lumbar MR imaging and reporting epidemiology: Do epidemiologic data in reports affect clinical management?” Radiology 262: 941-946.

O’Sullivan, P. (2012). “It’s time for change with the management of non-specific chronic low back pain.” British Journal of Sports Medicine 46: 224-227.

O’Sullivan, P. and D. Beales (2007). “Classification of pelvic girdle pain disorders – within a mechanism based bio-psycho-social framework. .” Manual Therapy 12: 86-97.

O’Sullivan, P. and I. Lin (2014). “Acute low back pain: beyond drug therapy.” Pain management Today 1(1): 1-13.

Palsson, T., R. Hirata and T. Graven-Nielsen (2014). “Experimental pelvic pain impairs the performance during the active straight leg raise test and causes excessive muscle stabilization.” The Clinical Journal of Pain in press.

Rabey, M., D. Beales, H. Slater and P. O’Sullivan (2014). “Multidimensional Pain Profiles in Four Cases of Chronic Non-Specific Axial Low Back Pain: An Examination of the Limitations of Contemporary Classification Systems.” Manual Therapy In press.

Rubinstein, S., M. Middelkoop, W. Assendelft, M. d. Boer and M. v. Tulder (2009). “Spinal manipulative therapy for chronic low-back pain.” The Cochane Library.

Vibe-Fersum, K., P. O’Sullivan, A. Kvale, A. Smith and J. Skouen (2013). “Efficacy of classification based ‘cognitive functional therapy’ in patients with Non Specific Chronic Low Back Pain – A randomized controlled trial.” European Pain Journal 17(6): 916-928.

Webster BS, C. M. (2010). ” Relationship of Early Magnetic Resonance Imaging for Work-Related Acute Low Back Pain With Disability and Medical Utilization Outcomes.” J Occ Environ Med 52: 900 – 907.

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  • Fergus Tilt | Physio

    Thank you Peter.

  • StevenAK

    So what is your strategy when you use the classification system and the patient “fits” into the stabilization classification? What about someone with a history consistent with hyepermobility or instability and positive testing and or positive CPR signs and or symptoms? These are tough. References or thoughts here?

  • chris

    You say magic bullets don’t exist, yet this is incorrect because for some people surgery is a magic bullet. The only problem is that it is hard to know which people will respond to which surgical procedure. For this we need to find ways of accurately identifying the pain source in chronic back pain sufferers. Because of the numerous pain sources treatment that works for one person will not work for all. Many people opt for surgery because they have already tried every conservative option and it doesn’t work so gamble on surgery. Living with chronic pain is almost a fate worse than death so people will always gamble with surgery whilst there is chance, before resigning to a life on painkillers. Yes exercise and healthy living will help some but I don’t think your article offers anything new or changes anything.

  • Tiger woods is a professional Golf player and he is suffering from back pain. It’s good to determine what causes the back pain and when it started. Self-curing is not advisable, only the health practitioner can give an professional advised for long lasting relief. There are many misconceptions about back pain. | Chiropractors in Kansas City.

  • Eddie O Grady

    Physiotherapists in Tralee. A lot of the points raised above are very valid but let me give a little different an angle yet incorporating many of the points raised above. Sometimes an MRI can confirm the back pain is most likely due to a disc issue. It does not necessarily mean an operation. Often if you can centralize say sciatica running down the back of the leg back up to only low back pain there is a good chance the condition may settle. An MRI can save a person going from one practitioner to another and being told stuff like ”your sacrum, pelvis or back is out place” and being brought back again and again. As stated above manual therapy only plays a small part in recovery from disc related low back pain. A lot of cases of back pain we get, possibly over 80 per cent is muscular and after a treatment session there is usually a major change. With disc issues where patients back is in ”S” shape off to one side, prescribed muscle relaxants and NSAIDs over a few days with one or two treatment sessions to get muscles loosened up usually goes a long way(not in very serious cases though). There is big money being made keeping patients returning with their back pain and keeping them in fear. we believe more in the approach by the author of being positive about recovery. We feel core work is overdone as the author states. There is big money being made from pilates classes and keeping people coming. We do however feel that being strong and fit helps the body cope and recover from injury, so we do feel exercise is necessary. Not only for the body but for the mind. In the case of ”Tiger Woods ”, if he has disc issues, the repetitive, rotation, speed and power involved in his sport could make the condition difficult to deal with. Possibly if he gave up golf he would have little discomfort.
    http://www.physiotherapiststralee.ie

  • physiowarzish

    nice post bro

  • dj

    Hi Peter
    great article. I am a neurosurgeon specialising in spine and I’m in busy active clinical practice looking after a massive amount of Low Back Pain in Brisbane through my Practice at the Brisbane Private Hospital.
    2 years ago out of desparation for effective physical therapy I collaborated with experts in FUNCTIONAL MOVEMENT TRAINING and we progressively developed 3 highly effective Functional Movement Training Centres. It is high time that a paradigm shift in Low back pain management guidelines are implemented. Im finding now by focusing on movement proficiency we are converting chronically sick and disabled patients into domestic and industrial athletes. I’d love to collaborate and chew the fat. Feel free to review our service on Face Book at FUNCTIONAL MOVEMENT TRAINING CENTRE.
    Dr David Johnson
    ctcneurosurgery@bigpond.com or joanne@fmtc.com.au

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