Most people suffer back pain at one point or another in their lives.
Back pain is now the leading cause of disability worldwide, yet the way it is often treated makes it worse, according to a team of international health experts and backed by leading Perth physiotherapist Professor Peter O’Sullivan.
“In the western world, what we know is a lot of people with back pain have been offered surgery and opioid injection before they are offered high quality, non-interventional care,” says Professor O’Sullivan, a specialist musculoskeletal physiotherapist.
The Curtin University professor’s views are in line with a series of global studies released earlier this year.
Published in the medical journal The Lancet, the three papers by a group of 31 international authors — led by Monash University’s Professor Rachelle Buchbinder — draw attention to the massive impact of low back pain, and call for the removal of harmful and ineffective practices in treating it.
The authors found there is an over-reliance on scans, surgeries and opioid prescriptions to treat low back pain, which could be more effectively treated through self-management and less-invasive physical and psychological therapies.
Professor O’Sullivan says low-risk, high-value interventions which potentially offer significant benefit are not being offered as a first line.
Instead, expensive and risky intervention procedures without great outcomes are proffered-up instead.
“For someone without private health insurance, it would be cheaper through the public system for someone to have spinal surgery than to see a physiotherapist for a course of education and progressive exercise and that’s just completely crazy,” he says.
A WA Department of Health spokesperson says surgery for back pain is regarded as an option of last resort and in the WA health system is treated as such.
“At Sir Charles Gairdner Hospital, only a quarter of patients referred for back pain go on to have surgery,” the spokesperson says.
Is back pain a damaged back?
Jumping to scans, surgeries and opioids stem from the belief that back pain equals a damaged back and a scan is required to identify a problem, says Professor O’Sullivan.
“The problem is most people have stuff on the scan, so it triggers this ripple effect where the next step is to try and fix the structure. We know there is a strong relationship with having been scanned and going for injections and ending up with surgery. It creates this spiralling effect,” he says.
Professor O’Sullivan is not anti-scanning.
He says scans are required in some cases, say following a major trauma, but he says that is only about one per cent of presenting cases.
While it’s easy to lay the blame on the doorstep of one set of health professionals, Professor O’Sullivan says it is much more complex.
“We know there is a stepped approach that normally happens in clinical care. Even that first step is not well managed and that is a reflection on our profession that we are not adequately dealing with people that are distressed with pain. They rapidly jump to the next step or they just miss the first step completely and I think that is happening quite a lot in the care setting,” he says.
Societal beliefs also play a big part. “If you ask people in the community, ‘what do you think back pain means?’, usually they say ‘God, there is something damaged in your back and it probably means you need a scan, and it probably means you shouldn’t be active, and you should have bed rest and take a day off work’.”
Contradicting this, the Lancet papers state bed rest and not remaining active actually delays recovery.
Do you have the right expectations?
Australian Medical Association (WA) president Dr Omar Khorshid says part of the problem with treating back pain is there is little high-quality evidence to guide treatment.
Are there people that surgery is the right thing for? Yes, there are, but how do you identify those people? I think that is where the research needs to go.
“How we target our interventions, who does benefit from surgery, who doesn’t, because it is clear some people do, but how do we pick them and avoid inappropriate referrals?” explains Dr Khorshid.
He says while doctors have known for decades the best treatment for mechanical back pain is “maintaining activity, minimising rest, keeping the muscles strong and trying to get back to normal life” and of which the majority of presenting patients are advised, patient expectations are a whole different ball game. “We do have a problem in our society where people will be going to doctors expecting an intervention, investigation or treatment and doctors are under a lot of pressure to do that and that is partly behind the rates of investigation that we see,” Dr Khorshid says.
“Like many Western countries we have an over-dependence on opiate medications. Someone presents to the doctor in a lot of pain, the doctor who is a compassionate person feels they need to relieve that pain and offers amongst other things opiate treatment to help the patient get through their acute problem. But what we have realised is in the long-term it makes the pain more difficult to manage as patients become dependent on opiates and their pain overall gets worse.”
A new understanding on backs
A large part of Professor O’Sullivan’s solution to back pain is education, empowering patients with clear, practical strategies to put them “back in charge of their lives”.
Having back pain very rarely means you are damaged or it is something serious, therefore it is really important that we engage with the things that are most likely to be related to your pain … like you are under stress, you are not sleeping well, your mood, or you are not active and that can trigger a pain event. We know those factors are commonly linked to a flare up of back pain.
“And those things are really important to reassure the patient that it is really safe to go to work, it is really safe to get active and it is really important you get moving very quickly and then to map out a plan for that.”
Intervention is the key
Chiropractors Association of Australia WA president Joshua Tymms says not all back pain can be self-managed. He says if treatment is needed to help recovery for back pain, early intervention is key.
“Certainly patients are still not getting the right advice 100 per cent of the time as Professor Buchbinder points out. Research constantly strengthens the case for conservative care of back problems rather than medications and surgery,” Dr Tymms says, adding people should seek out a chiropractor if they are unsure how to manage a back pain problem.
Professor O’Sullivan says what is healthy for the back is movement, loading and physical activity. There is no ideal exercise, just one the person enjoys and will do regularly, and preferably engages movement in all directions.
He also points out it is typical to have aches and pains. “It’s kind of normal but what is not normal is to freak out about your pain and stop working and not engage with activity.
I think it is important to understand that it is not possible to eradicate pain out of people’s lives but it is absolutely possible to provide people with strategies to go about their lives in a very normal way so pain doesn’t disrupt it.
Traditional thinking under fire
It’s a common story told by back pain sufferers — one that starts with an everyday activity.
Three years ago, firefighter Joe Laurence, 30, was hauling a fire hose over a fence. It was something he had done hundreds of times before. The fence shifted and he felt a shooting pain go down his foot.
It pulled up OK, but a week later as he was walking along the beach, he stepped in a hole… and spent the next week and a half immobile in bed.
“I didn’t have a day for the next three years where I didn’t consider my back and it was just a nightmare,” Joe says.
What followed were physiotherapists, chiropractors, rehabilitation and a scan where he was told he had the back of a 60-year-old.
“After the scan, in my head I was thinking there were these bulges and fissures and to me that meant; hold on, you have to take it easy,” explains Joe.
“I was always bracing, always sitting bolt upright with a so-called good posture and now I see, those things are probably what caused it to become the chronic problem it was. If I had just kept moving naturally, not thinking I was damaged, I would have been able to keep moving well.”
Joe’s mental health suffered too. With a physical job, he thought he had a career expiry date. “I really love being a firey, so it really played with my mental health.”
When a second incident put Joe back at square one after three years, he visited physiotherapist Professor Peter O’Sullivan for a different perspective.
“The message I got from everyone else was that you have to protect your back and brace your core. Pete just said your back is designed to bend, so bend it. Your back is designed to twist, so twist it. It’s safe to load your back in a flexed position… within about a month, I went from being worried about tying up my shoelaces or lifting the toilet seat, to this pain-free range of motion which I then strengthened up like you do with any other joint in the body,” he says.
“He literally gave me a licence to move. He said ‘look, pain doesn’t mean damage, if you keep moving, you’ll get better at it and the pain will subside. Your body will realise it is not a threatening action… these actions are perfectly healthy and normal and good for you and not dangerous’… and that was the difference.
“It’s absolutely amazing how effective this way of thinking was and I can’t believe how much resistance there is to it, to be honest.”