Ben Wand, PhD, is a professor in the Faculty of Medicine, Nursing and Midwifery and Health Sciences at the University of Notre Dame, Australia. He started his career as a physiotherapist and has postgraduate qualifications in sports science and manipulative physiotherapy. He completed a PhD at Brunel University London in physiotherapy management of acute low back pain. His current research interests include the role of central nervous system dysfunction in chronic low back pain and rehabilitation of chronic spinal pain.
Wand spoke recently with PRF Correspondent Aidan Cashin, PhD, a postdoctoral research fellow from Neuroscience Research Australia and the University of New South Wales in Sydney, to discuss contemporary management of low back pain from a neurobiological perspective. Below is an edited transcript of their conversation.
How does a physiotherapist first become interested in addressing low back pain from a neurobiological perspective?
Physiotherapists have always had a significant role in the rehabilitation of people with neurological disorders, and I was very interested in this area early in my career. Although most of my work has been in the musculoskeletal field, as a physiotherapist, you still have a lot of background information on the application of information from the neuroscience world to rehabilitation, particularly from the broad area of applied movement sciences.
When managing musculoskeletal pain, I was always drawn to movement quality and movement problems as the drivers of clinical conditions; I was interested in movement analysis and trying to change the way people moved and used their back. So I think I had probably always tried to integrate a neuroscience perspective into the management of people with musculoskeletal problems like back pain – though early on this was from a pretty strong biomechanical perspective.
What role did your PhD play in inspiring your future research on low back pain treatment through the lens of neurobiology?
My PhD was in low back pain. I emerged from spending five years or so reading everything there was at the time about low back pain and found it a fairly depressing place to be in terms of where the field was and what was known. It was clear that no one really had a good handle on the problem. There weren't many really promising or effective treatments, and a lot of commentary in the literature was about refining or trying to be more targeted with what had already been done, rather than trying to look at alternative ways of approaching the problem.
I thought there was a clear need to look differently at the problem, and to look for different treatment targets. This was also around the time when neuroimaging findings emerged showing that people with low back pain had functional, structural, and chemical changes in their brains, compared to people without low back pain. At the time, this looked like something new and promising, and something worth thinking about – particularly the interaction between what is happening in the back and what is happening in the brain. I happened to arrive at the end of my PhD when this area was really exploding.
There were also people like Lorimer Moseley and Paul Hodges around at the time in Australia who were really looking at pain problems from a novel and neuroscience-informed perspective – really inspiring people who drove my interest as well.
How did these novel neurobiological findings change the way you viewed low back pain diagnosis and management?
Approaching low back pain from a neurobiological perspective enables you to make sense of a lot of things that we were seeing in people with low back pain. It was pretty clear that their beliefs – the way people thought about their back in pain; their sensitivity – the way people’s nervous system attends to and deals with incoming information; and their movement – the way people moved – all seemed to be part of the problem.
A neurobiological framework really united those three things, and provided a coherent model of what might be going on. This framework enables the clinician to bring together a whole lot of things from many different areas and tell a sensible story about the person's low back pain problem – to make sense from what can often seem complex and confusing.
When you look at low back pain through the lens not of peripheral tissue mechanics or peripheral tissue health, but through the way the person views their low back pain problem, deals with information from their body, and uses their body – all those things fit together under a neurobiological framework.
How does a neurobiological perspective contrast to previous perspectives on low back pain diagnosis and management?
There are a number of things that are different, but one issue that resonated strongly with me was how changes in the way the back is represented might have an impact on the problem. There was a time, previously, when low back pain management emphasized getting the person to move despite the pain. You would support people with low back pain by encouraging them that “it'll be fine,” “your back's in good shape,” “you're strong,” and “you can do this; you have just got to move.” These are pretty good messages; however, the lived experience and the things that people with low back pain were saying at the time were very different. They would say, “I know, you're saying it's okay, but it doesn't feel okay to me.”
At the time, this rehabilitation approach felt disconnected from what people were experiencing and saying. This really became apparent when you viewed low back pain through a perspective that appreciates neurobiological processes involved in low back pain. If your body doesn't feel right to you, then no matter what you say to someone about the body being okay, it is not going to be believed, because the body doesn't feel okay, and it doesn't feel in good shape. We make judgments about the capacity of the body based on information from the body, and this is an important component of people buying into the idea that it is okay and safe to move and load the back.
We needed to bring together these ideas of what people think about their back and what their back feels like to them. Information from the body, the beliefs that people have about their body, and how these two interact with each other are really important.
What does a new model of low back pain treatment look like through a neurobiological vantage point?
The model that we're proposing – the maladaptive perceptions model – brings together a number of disparate ideas that have been circulating for a while, and tries to bring them into a coherent model that emphasizes the self-reinforcing interactions among a number of different processes.
We are thinking that persistent back pain emerges as people develop the view that the back is not fit for function and is in need of protection, largely through the education they receive about low back pain. This set of beliefs changes the way we move the back, and attend to and interpret information from the back. This has detrimental consequences not only for the back, but also for the central nervous system, which we think reinforces the idea that the back is unfit for function and needs protection – a maladaptive cognitive model about the back in pain continues to be reinforced by information from the back.
The treatment model that emerges from this is embedded in a contemporary understanding of pain as protection, not as a simple reflection of tissue damage. Treatment is then all about trying to shift internal models of an unhealthy self towards the formulation of the back as healthy, strong, and fit for purpose, by providing the system with precise and trustworthy evidence that supports this idea while minimizing information that works against it. This includes information from the body as well as external information.
The first step is to help the person with low back pain understand that it's safe to move and that movement is helpful for their problem – largely through good education – and the “explain pain” education model works really well here.
The next step is to explicitly address how the back feels to the person in pain, so that the back feels safe to move. We think we can do this through various pre-movement strategies like sensory discrimination training and motor imagery, as well as precise and localized movement training that attempts to target body representations and shift attention to non-noxious information streams associated with simple back movements.
The model builds on the idea that both understanding and feeling that everything’s okay is important before next exposing the person progressively and skillfully to more movement, loading, and activity. This component aims to help the person with low back pain experience safety with movement, and then reinforce safety with more complex functional movement and loaded tasks. It is important that this progressive movement and loading continue under a framework where the person stays connected to their body, understands what is going on, and feels confident in knowing where their body is in space as it is being moved and loaded. This reflects a strong movement coaching-based approach to gradual loading of the body.
What are some important considerations for clinicians working with people with low back pain?
We should be careful with what we say to people. Often people with back pain whose problems have been ongoing for long periods of time and who are not managing well are locked into a spiral of pain and disability because of unhelpful information provided by well-meaning healthcare professionals.
The idea that pain is about a system that's overprotecting itself is important and fits with a current conceptualization of ongoing low back pain as a high perceived need to protect the back. If you deliver a treatment program that's really based around an idea of enhancing protection, then you're never going to offer the person the optimal solution. If clinicians are structuring their whole treatment framework around the idea of the back needing protection, of the need to minimize back movement, to move more carefully, and to unload the back, then clinicians are presenting a really unhelpful framework.
You still hear well-meaning healthcare practitioners telling their patients that “you shouldn't do this activity” or “this activity is bad for you.” Modification of loading is sometimes needed, but by withdrawing tasks and activities from patients' repertoire of movement, with no good reason why, clinicians can contribute to further disabling people with low back pain, and reinforce the idea that you need to protect the back and minimize loading.
In contrast, if we want to become load tolerant and return to meaningful daily activities, then people with low back pain need to load their system. It is loading, not avoidance, that makes people load tolerant. Unfortunately, a lot of current treatment models for low back pain still have a strong avoid-and-protect component to them.
What are important considerations for clinical researchers planning future low back pain research?
There is a real need to make sure we keep listening to and learning from clinicians and their ideas about what is important for low back pain management – ideas that develop from observing and interacting with people with low back pain. Researchers should also make sure that the interventions and treatment strategies they develop are realistic and achievable in the clinical environment. This interaction between researchers and clinicians is absolutely vital. It is not just ideas about what should be done, but also ideas about how things can be enacted and rolled out into clinical practice. There is a need for this continual discussion between clinicians and researchers to better appreciate the other's perspective.
What is one important message you have for people with low back pain?
The world really has changed dramatically in terms of our understanding of pain and what contributes to it. It is important to try and immerse yourself, as best you can, in this new understanding of the complexity of pain – for example, that there are multiple contributors to the low back pain experience which can provide a favorable perspective that things can change. Each person’s low back pain problem isn't about a rigid structural issue in the back but is caused instead by many possible, reversible things that can be modified. People with complex, persistent pain problems in the spine, as well as in other areas, can become caught in the fatalistic trap that the cause of their problem is something irreversible and unchangeable. If they can start to appreciate how this is not necessarily the case, it's a really good thing.
The world is changing in terms of basic low back pain guidance. There is a strong shift to de-medicalize treatment and emphasize movement, activity, and rehabilitation to help people understand the enormous value that movement and activity have for pain problems.
PRF Correspondent Aidan G. Cashin, PhD, is a postdoctoral research fellow at the Centre for Pain IMPACT at Neuroscience Research Australia and the University of New South Wales.