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Time to put away the magic bullet theory of back pain – Peter O’Sullivan talks…



The 2023 Global Year aims to raise awareness about integrative pain care and illustrate the knowns and unknowns of this important topic via different initiatives, including a fact sheet series and several webinars.

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Marienke van Middelkoop, and coworkers published a systematic review investigating the benefits of Exercise therapy for chronic nonspecific low-back pain (NSCLBP)[1]. They concluded that no exercise approach is superior to any other (from motor control to conditioning to back school) and that effect sizes for exercise are small in the management of NSCLBP. They proposed that better identification of subgroups and matching treatments might advance the management of these disorders.

While this maybe the case, what they didn’t highlight is maybe we should be doing something different in the management of these disorders. This review asserts the fact that NSCLBP is a complex disorder and highly resistant to change with generic approaches to management. For clinicians who spend the time to listen to the stories of people who suffer from disabling NSCLBP, these results will come as no surprise. The results tell a common story of failed interventions, ongoing pain and disability and a loss of hope in people with this disorder. This is in spite of the promises of well meaning clinicians and the enormous resources being spent on the disorder.

We know that people with NSCLBP disorders do not all present in the same manner. Given this, surely it is time to stop attempting to find the single magic bullet based on a biomedical model for these disorders. It simply hasn’t worked and for good reason. For example common popular beliefs and practice over the past decade that NSCLBP is related to a deficit in spinal stability has not resulted a decline in NSCLBP and associated disability. This belief is also not supported by a growing body of literature that documents that: NSCLBP disorders are commonly associated with excessive trunk muscle motor activity and the inability to relax these muscles (often associated with fear of movement, anxiety and negative beliefs about the spine); and that motor control exercises are no better than general exercise, and only slightly better than detuned shortwave (placebo). Yet stabilizing exercises continue to be prescribed and advocated as best practice for all with NSCLBP, suggesting that clinical practice is driven more by beliefs than by evidence.

It is widely agreed that NSCLBP should be viewed and managed from a bio-psycho-social perspective with physical, lifestlye, neuro-physiological, psychosocial and genetic factors known to be associated with the disorder. Yet few RCT’s reflect this in their interventions. There is also strong emerging evidence that broad subgroups exist in this population based on all these different domains, and that these different factors act together to contribute to a vicious cycle of pain that is unique to each person. Yet very few RCT’s have sub-grouped patients in any way – they instead assume patient homogeneity.

Adopting a flexible, creative and person-centred approach, in order to classify and manage these disorders based on their underlying mechanism/s seems logical. Interventions that target the mal-adaptive cognitive and physical behaviours (commonly reinforced by current biomedical beliefs and practice) that often underlie and drive these disorders, appear to yield greater benefits. This has the potential to reduce both the bottom up and top down drivers of pain. One would hope that no more funding will be given for RCT’s testing single interventions for these complex disorders, in order to tell us and our patients what we already know to be true.

About Peter

Peter O’Sullivan is Professor of Musculoskeletal Physiotherapy at Curtin University in Perth, Australia. Peter has published many excellent papers and is a highly sought-after speaker at conferences world-wide. His team, including his Norwegian collaborators, make an important contribution to our understanding of back pain and its management. He is clever.  His main role is a clinical one so he actually sees a large number of patients. Despite his obvious mass of talent, he remains a really nice bloke.  Clearly, he did not write this bio.
[1] van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, & van Tulder MW (2010). Exercise therapy for chronic nonspecific low-back pain. Best practice & research. Clinical rheumatology, 24 (2), 193-204 PMID: 20227641

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