Saturday, February 18, 2017

Peter O'Sullivan, Cognitive Functional Therapy. San Diego Pain Summit 2017 blog series #1

This 2017 pain summit was the the third and best so far. If there was an overall theme, it was that to help people in pain, we as caretakers have to dismantle a lot of our own wrong fears and ideas about pain itself. 

Attendees have been asked to write blogposts reviewing the summit, and I plan to do just that. This is the first of several I plan to write. 

You can obtain videos from the summit, here



I had marvelled at videos online of Peter convincing patients with chronic low back pain that it was perfectly safe for them to bend over and do things they had not done in a long time. Here is a youtube video of Peter explaining what's what, about back pain, to someone who has back pain. 

I attended Peter O'Sullivan's two-day pre-conference workshop and marvelled anew. Not only at the vision he presented, but also his skill at handling two actual people very different from each other who both had chronic low back pain. I learned a new word: "disconfirm."

Such a polite word.
So much more neutral than "challenge" or "refute" or "demolish."
"Deconstruct" has been my favourite word up to now. Now I like "disconfirm" better.


Peter started out by admitting he had had to disconfirm his own beliefs first: he participated in a bunch of research that showed the opposite of what he originally believed; core strength was NOT important for pain, back pain was NOT biomechanical, etc., etc. 

His research has disconfirmed the deep-seated biomedical belief that has propelled the entire profession for a long time that tissue damage -> pain, that nociception -> pain. He showed the usual graphs, references, etc. for geeky people. There are a lot of geeky people in my profession.

Here is a short video (11 minutes) about disconfirming the idea of "core stability."

He is brave enough to rest on this disconfirmation completely, let it be the life raft on which he rides in every oceanic encounter with a new patient. Just by interacting with them, he rules out potential red flags. No type one errors for him. 

He also believes that you must not rush that first encounter. He schedules open-ended sessions that leave him relaxed and free to focus entirely on the patient and their story. He says, sometimes his sessions take a good two hours. 

After presenting his research, he went on to demonstrate how he then disconfirms patients' beliefs about their own back pain. 

First he invites them to tell him their story. He listens very hard to their story. 
Then he starts asking questions and they reveal their fears and beliefs about their pain. (See the first video.)

He gives them lots of positive messages about how strong they are and safe their backs are, about how plenty of studies show that a lot of people with no pain have lots of changes on imaging, so imaging by itself is not a very reliable method of determining pain issues.

He finds out what they would like to do, how they would like to move if they had no pain. What activities they would like to pursue in life or get back to if they weren't afraid of injuring themselves. He talks about the difference between a pain event and an injury,  how pain is protective but how sometimes one's own behaviour can prolong a pain event.

He uses short phone videos to show people how they move their backs. He asks them to bend over, in sitting and standing, takes videos of them moving, does a bit of therapy, communicating to them the entire time, asking them questions, explains how if they contract their abs they actually load their spines more, make their back harder to move, create more anxiety in themselves. He uses the analogy of a tire with too much air in it, which makes it too bouncy. Let a bit of the air out. Soften it a little so that the ride is smoother. He points out that gravity is their friend when they bend over, that they can relax into it, that they don't have to have their abs turned on because gravity can pull them over just fine all by itself. He throws a small object on the floor and asks them to bend over and pick it up. Repeatedly. They do. He asks them how they felt doing it the second time with relaxed abs. They say, better. He takes another video of them doing so, easily. Then he shows them the before and after videos to show them they don't need to protect their backs so much.


In Peter's workshop he worked with two actual back pain patients. 

The first was our internet friend Joletta Belton, @MyCuppaJo, blogger about pain at My Cuppa Jo. She is in her thirties (I think), wonderfully open and gracious, frank and honest about the suffering she endured as her life fell apart after onset of acute low back pain that came on after she stepped off a fire truck. 

Yes, that's all she did. Stepped down from a truck, ended up in rehab. She was fit and healthy and strong, lean, trim (still is). She taught fitness to firefighters and paramedics. She was a strength and conditioning professional. She prided herself on being a warrior. 

Then she was consumed by a pain nightmare, including hip surgery, that changed her whole life, and which she continues to emerge from. She loves being outside, snowboarding, hiking, trekking around, taking photos of natural wonders. Recently she had started organizing groundwork for hosting retreats for people with chronic pain. Also recently she had started feeling pain over her non-operated hip. 

In her interaction with Peter she revealed that her biggest fear was that the other hip had started bothering her and that she feared more surgery. Peter pointed out that it was common for pain to start up in times of increased stress, and asked her if she thought she might have been stressing a bit over getting the new organization up and running. She concurred. 

Peter asked her to do single leg squats. Many many many squats. He emphasized repeatedly how strong she was, how competent her body was, how if she had any labrum issues she would never be able to do what she did in front of the class. He disconfirmed her beliefs and fears about her hip in the nicest way I've ever seen anyone disconfirm anything. He praised her for her strength (she snow-boarded!) and bravery. 

He noticed she was in the habit of "checking" her back frequently to see if the pain was still there, by drawing herself erect. He called these pain behaviours "rules" that people employ. He emphasized that behavioural "rules," whether self-imposed or suggested once upon a time by some well-meaning care-giver, generally limited movement variability, and limiting movement variability was counter-productive because that maintained a fear/anxiety/pain cycle. A big one is to bend from the knees, not the back. Every ergonomic class has that idea embedded in it. It is so wrong. 

(I used to teach that myself, doing inservice for hospital employees. I didn't know any better back in those days, in the 70's. Nobody did. Yet apparently that idea still persists.) 

He asked her to let go of her abs long enough to sit in a slumped position. When she did, and he asked her how it felt, she reported feeling less pain. So he gave her that for homework - to slouch instead of check. So simple.


The second patient was a 60-year old man, large, imposing. He had previously had two knee replacements. 

He had gone in for surgery for low back pain a few years ago (I don't remember how many). The aftermath was harrowing: two bouts of MRSA infection that required opening up his entire back and being on IV drip, for months. His low back auto-fused. 

He pulled through. 

He had been an executive, had financial means. He had liked skiing and motorcycling before all this. He couldn't do either activity anymore because of the unpredictability of bounces and bumps and fear of pain or of losing control. He had been on 14 different meds at one point, now he was down to two. He was doing very well, was out and about, engaging in life, but there was a problem. He would get sudden onset pain across his upper back which would stop him in his tracks, and he would have to sit and rest until it passed, about a half-hour to an hour later. 

He wore a back brace when he was out doing things. Peter asked him if he did that because he was worried that perhaps his back was still fragile. Dave answered, yes. Then Peter disconfirmed that his back was fragile by pointing out that his low back was fused, in fact it had auto-fused! So it was protecting itself just fine - he didn't really need the brace, or the belief that his back was fragile.. could it be that the protective behaviour of wearing a brace stemmed from the original issue he had had with his back, more so than any current issue? Dave said that made sense. Peter let that idea hang in the air for awhile. 

Peter asked him about sleeping. It turned out he had to wake up to roll over, about every two hours. And he slept with a pillow between his two replaced knees. 

Peter asked Dave if he would be OK taking off his shirt. He had wide shoulders and a big burley back with a big scar right down the centre, neck to his upper lumbars. I sat there thinking about all those poor severed dorsal cutaneous rami. It turned out his upper back was quite numb, except for when he developed that excruciating pain that would stop him cold. 

Peter examined him for pain behaviour by having him lean forward in sitting, in standing, pick up the water bottle from the floor, etc., made a little video on his phone, then taught him how to let go of his abs to relax his back so he could bend it better, etc., had him pick up several more items using the new strategy, filmed him again, showed him both videos. 

He had him adopt the relaxed slouch posture he would be in if he were on a motorcycle. He asked Dave to go sit on his motorcycle at home, get a picture of it, and send him the picture. 

He had him lie on the plinth at the front of the room and demonstrate how he rolled. He basically log-rolled, protecting his back from any rotation. Peter taught him how to fold his top leg up higher, let it drop so that his pelvis could rotate forward. He taught him how to roll his upper body the other way, leading with his head, let it roll back, follow with the shoulders/ribcage. He had him practice abdominal breathing and relaxing his abs, then perform spinal rotation again. The difference between the first time and the second was astonishing in terms of amount of range he had gained. I could see how it was similar to Feldenkrais' "Spine like a chain" exercise/movement strategy. So effortless. So easy. 

He said he wanted to go skiing with Dave next time he was back in the US.


For both the patients, Peter had not reacted aversely to anything they said. He had stayed in neutral eye contact and had responded empathically, by saying things like, "that must have been hard for you." 

After the session he recapped for them all the ideas, beliefs, fears, anxieties and protective behaviours he had noticed, showed how they were all linked to each other in a positive feedback loop that did nothing but maintain pain. He drew little stick people doing the movements he had suggested, for their homework. He ended each session by reassuring them that they were strong and didn't need to protect their body part anymore, as it was healed completely and doing just fine on its own. 

Peter's summary for one of the workshop patients

I had an opportunity to self-measure. I've been at this work longer than most who were there, 46 years now. I remember way back when we were taught professional assumptions instead of facts that had been elucidated by science from within our own profession. I remember how wrong many of them were. Yet, clinically, I also remember how we had to make do with the simple things, like empathy, reassurance, encouragement. I remember the whole job was about getting people in pain up from bed and persuading them to do exercises after all sorts of surgery that left them with long rows of very uncomfortable stitches up their abdomens, along their knees, over their backs, or hips, or ribs, teaching them to walk on crutches or to deep breathe and cough to prevent post anesthesia pneumonia (now surgery is much kinder, leaving only small puncture wounds and tiny scars).
In a way, it was revisiting an old skill set I already have, this time with a bunch of deorthopaedicalized science to back it (see Peter's references below).

It had to happen. The science I mean. To disconfirm the old beliefs. 

It's not over yet, though, not by a looooooooooong shot. The orthopaedic mindset in my profession was (and still is) very concrete, biomedical, and overwhelming when it comes to pain - pain must have a cause, and the cause must lie in tissue.

This is still current thinking with orthopaedic surgery. Problems in tissue cause pain, can be visualized on MRI, and must be cut out, or fixed so it can't move, because moving creates more pain.

Sometimes surgery helps people, but much of it is completely unnecessary and it can be a true horror show as well. Here is a sad tale about a young woman who died post-op after spinal fusion. The assumption was that her pains and discomforts stemmed from too loose a spine. I wonder what might have happened if instead, first, she had been lucky enough to have a consult with Peter or someone else with his ease and grace, experience and knowledge, to disconfirm ideas that the biomedical approach and mindset had implanted in her?

I stumbled upon a nice paper describing the various pathways in the brain associated with pain that are hooked up to amygdalar function. I want to study it closely as this is my way of being geeky. 

Here is the link:  Jiang Y, Oathes D, Hush J, Darnall B, Charvat M, Mackey S, Etkin A.; Perturbed connectivity of the amygdala and its subregions with the central executive and default mode networks in chronic pain. Pain. 2016 Sep;157(9):1970-8 (FULL TEXT) All in all, I would sit through a class Peter was teaching any number of times. It's like water to a thirsty camel. A huge bouquet to Rajam for reaching out to him and inviting him to speak and teach at the summit, and to Peter for accepting!


Here is a list of linked references Peter used in his talk. 

  1. O’Sullivan P (2012) It’s time for change in the management of non-specific chronic low back pain, British Journal of Sports Medicine, 46:224-227.
  2. Fersum K, O'Sullivan P, Skouen JS, Smith A, Kv√•le A. (2012), 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. (FULL TEXT)
  3.  O’Keefe, M, Cullinane P, O’Sullivan K, Hurley J, O’Sullivan P, Bunzli S, (2015) What Influences Patient-Therapist Interactions in Musculoskeletal Physiotherapy? A Qualitative Systematic Review and Meta-Synthesis, Physical Therapy Journal, Oct 1. [Epub ahead of print] PMID:26427530
  4.  Paananen M, O'Sullivan P, Straker L, Beales D, Karpinnen J, Pennell C, Smith A, (2015) A low cortisol response to stress is associated with musculoskeletal pain combined with increased pain sensitivity in young adults: a longitudinal cohort study, Arthritis Res Ther. 17: 355. (FULL TEXT)
  5.  Bunzli S, Smith A, Shutze R, O’Sullivan P. (2015) Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear, BMJ open, 5:e008847. (FULL TEXT)
  6.  O’Sullivan P, Dankaerts W, O’Sullivan K, Fersum K (2015) Multidimensional approach for targeted management of low back pain. Modern Manual Therapy, Elsevier. (NOT FOUND)
  7.  Rabey M, Smith A Slater, S; Beales, D, O'Sullivan, P (2016)  Differing psychologically-derived clusters in people with chronic low back pain are associated with different multidimensional profiles, Clin J Pain, accepted 22.1.16.
  8.  Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K, Patient perspectives on participation in Cognitive Functional Therapy for Chronic Low Back Pain: A qualitative study, Physical Therapy Journal, in press 3.2016
  9. Coenen, P; Smith, A; Paananen, M; O'Sullivan, P; Beales, D; Straker, L. (2016) Trajectories of low-back pain from adolescence to young adulthood, Arthritis Care & Research in press 1.6.16.
  10.  O’Sullivan P, Caniero JP, O’Keefe M, O’Sullivan K, (2016) Unravelling the complexity of low back pain, JOSPT, in press
  11. O'Sullivan K, Dankaerts W, O'Sullivan L, O'Sullivan PB; Cognitive Functional Therapy for Disabling Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study. Phys Ther. 2015 Nov;95(11):1478-88 (FULL TEXT)


Back pain - separating fact from fiction - Prof Peter O'Sullivan 15:21

Making Sense of Low Back Pain 1:24:45

Prof Peter O'Sullivan and Core Stability - April 2012