Peter O'Sullivan at the 2017 San Diego Pain Summit: A Paradigm Shift in Understanding and Managing Low Back Pain

Last Sunday, three St. Louis area massage therapists met to watch a video recording of Peter O'Sullivan's keynote address at the 2017 San Diego Pain Summit. The subject of O'Sullivan's address was A Paradigm Shift in Understanding and Managing Low Back Pain.

Peter's assertion is that much of the disability associated with low back pain (LBP) is iatrogenic - that is, created by the health care system itself. Patients are told that they are broken, that they have the spine of a seventy year old man when they are only thirty years old, and that there is no way for them to fix themselves. They are shown images from MRIs that depict discs that they are told are herniated, bulged, and deteriorated. "Managing" their pain often consists of avoiding movement, medication, and time off of work. Patients are led to believe their persistent LBP is the result of injury and tissue damage, even when there was no traumatic event, and that their back is fragile and needs to be protected. As a result, those with low back pain tend to avoid physcial activity, move more slowly and more stiffly, with less variability in their movement.

Yet what does the evidence show? MRIs have increased our ability to detect "abnormalities," yet we've learned that almost everyone has imperfections such as herniated discs. We've learned there is little correlation between herniated discs and back pain. People with LBP are often told they need to "strengthen" their core muscles, but many already hold themselves stiffly, bracing themselves against movement. They do not need to engage their core muscles more but rather need to learn movement that is relaxed.

Peter talked about the importance of listening to the patient's story, not just their history of symptoms. He asked if physical therapists feel prepared to address the psychosocial factors that contribute to chronic pain. He suggests that what is needed is an integrative approach that includes identifying unhelpful ideas and behaviors. He talked about the role of cognitive functional therapy and motivational interviewing, asking the patient questions such as how does their pain impact their life? How important is it to them to reduce their pain? Practitioners can personalize the biopsychosocial model of pain by helping the patient to make sense of the context of their pain.

Peter told a story I found especially interesting in illustrating how changing context can alter experience and help overcome preconceived fears and ideas about our abilities or lack of them. He described a patient with LBP who was unable to bend from the waist and touch his toes. He instructed the patient sit in a chair and asked him if he could bend over and touch his toes while seated. The patient was able to do this without difficulty. Then he asked the patient to straighten his legs. Of course, now the patient was standing and touching his toes. He had the patient look at the mirror on the wall and when the patient saw himself touching his toes while standing, he was amazed to see himself in a position he thought was not possible! Another patient who had worked with Peter said, "Pain used to make me panic. I don't panic any more."

One of the take-away ideas I got from this lecture was the distinction between a tissue being damaged vs. a tissue being sensitized. If we think of ourselves as damaged or broken, we can feel doomed or believe our only way out of pain is for someone else to fix us. If we realize our tissues or nervous system is sensitized, we can see this is a situation that can probably be changed.

Some of the thoughts that came to me as I listened to this presentation for a second time (the first time hearing it live at the San Diego Pain Summit) was that as massage therapists, we're in an excellent position to help the client reduce their fear - whether it is fear of pain or movement or increased tissue damage - and help to increase body awareness, ease of movement, and restore a sense of being comfortable in one's own body. We are not psychotherapists but we have time to listen to clients tell their stories. Massage therapists intuitively understand how psychosocial factors - emotional and social stressors in everyone's lives - can bring on and aggravate pain. Peter pointed out that the onset of LBP often occurs at times of great change. Massage therapists may be more aware of these contributing factors than other healthcare practitioners who see LBP as a biomechanical problem that needs fixing. We're accustomed to hearing our clients tell us, "I just moved," "I just graduated med school, I'm getting married next week, and then I'm moving to Boston to do my residency," or "Things are really crazy at work and it's really getting to me."

We also may help clients feel clearly for themselves that the scary things they have been told about their back may not be an automatic sentence to a life of pain. When a client who has been told they have three herniated discs gets up from the table and has no pain at that moment, they can experience for themselves that they can have less pain in spite of their diagnosis. Their problem does not have to predict their future.

If you are interested in hearing Peter O'Sullivan's keynote address at the 2017 San Diego Pain Summit, videos of the Summit are available for purchase. Peter's website is

Peter gave a workshop prior to the conference and as part of the workshop, did a demonstration of how he works with a patient using Joletta Belton as his model. Joletta lives with chronic pain and blogs about pain science and living with chronic pain. She wrote about her experience working with Peter on her blog. It's a beautiful and moving story.

If you are a massage therapist, physical therapist, occupational therapist, counselor, or any other health care provider, yoga instructor, personal trainer, etc., who is interested in learning more about current pain science and incorporating it into practice, the recently formed St. Louis Area Pain Science FaceBook group will be occasionally hosting gatherings where we can watch videos of the SDPS presentations or discuss pain science and how we can integrate it into practice to help individuals who live with chronic pain. Contact Alice Sanvito on FaceBook to be added to the group. We will post events on the group page. There is also a FaceBook group dedicated to Explaining Pain Science.

Thanks to the other massage therapists who turned out on Sunday. The conversation was fun and interesting. It was great to discuss integrating pain science into practice in a face to face conversation in my own home town!

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