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Resources

for clinicians working with people living with pain

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Videos

Interviews, and
stories of recovery

Infographics

Useful infographics for clinicians and people with low back pain

Literature

Clinical guidelines, peer-reviewed journal articles and reports from trusted organisations 

Videos

Separating Fact from Fiction

An interview with Prof. Peter O'Sullivan
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  • What the research says
  • Problems with MRI
  • Things clinicians say that scare patients
  • Unhelpful behaviours and beliefs can drive pain and disability
  • Pain is multidimensional 
  • Fear drives behaviour

Hope for change

Dr Rangan Chatterjee interviews Prof. Peter O'Sullivan
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  • From the Feel Better Live More podcast 
  • Back facts everyone should know
  • Learn about what is healthy for your back
  • Personal pain stories
  • Lets help people develop hope

Stories of Recovery

Hear from people who have had disabling low back pain.

Learn how they restored trust in their back and built confidence to take control of their life.

Joe's journey
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  • Firefighter with active hobbies
  • "My doctor said I have the back of a 60yo"
  • Avoiding activity and good posture didn't help
  • Lost hope
Ann's journey
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  • Retired grandmother
  • Tried many interventions with many clinicians and was told to give up being active
  • MRI - bulging discs and degeneration
  • "I was so stiff, so tense and so frightened...I became less confident with everything, and depressed"
Jon's journey
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  • Australian Aboriginal man and basketballer
  • Couldn't exercise for his mental health
  • "I couldn't contribute at home or work"
  • After side-effects from medication, underwent surgery, but the pain remained
Alison's journey
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  • CFO and triathlete
  • Quit job and stopped training
  • Surgeon couldn't see anything wrong on MRI, infact it was 'better' than most
  • "I was broken and in a dark place"
Sam's journey
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  • Mum and nurse
  • At 20 was told - "you'll be in a wheelchair by 40"
  • Chronic fatigue, disempowered, confused, depressed
  • Avoided playing with kids and living in a state of fear
Jack's journey
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  • Quit manual job and football
  • Was told "you have the back of a 70 year old"
  • Felt that back was "in pieces"
  • Very guarded and protective
Becky's journey
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  • Widespread low back to neck pain after crashing bicycle
  • Post-traumatic stress response
  • Ongoing pain despite going to doctors, physio, Pilates, acupuncture and trying stand up desk and different chairs
  • Was told - "you need to brace your core"

Infographics

Co-designed by researchers and clinicians in partnership with people living with back pain, these infographics summarise the evidence about the most common questions asked by people with low back pain.

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Literature

The Australian Low Back Pain Clinical Care Standard

In 2022, the Australian Low Back Pain Clinical Care Standard was released, providing 8 quality statements describing the standard of care people should receive when presenting with a new acute episode of low back pain. 
The Clinical Care Standard was developed due to growing personal and societal costs of low back pain in Australia and marked variation in the use of medical imaging, opioid prescription and spinal surgery. The 8 quality statements were derived from high-quality research and guideline evidence by expert clinicians, researchers and health care service stakeholders.

International Low Back Pain Clinical Guidelines

  • Screening for serious pathology / red flags
  • Appropriate referral for medical imaging (i.e. eliminating routine referrals)
  • Psychological therapy (e.g. cognitive behavioural therapy)
  • Provide patient education
  • Movement and exercise
National Institute for Health and Care Excellence (UK)
American College of Physicians (USA)
World Health Organisation

Conducting a Patient-Centred Consultation

Patient-centered consultations for persons with musculoskeletal conditions

Joletta Belton, Hollie Birkinshaw & Tamar Pincus
Chiropractic & Manual Therapies, Volume 30, Issue 53, 2022, https://doi.org/10.1186/s12998-022-00466-w
This paper was written by a person with a lived experience of persistent pain and academics for clinicians to help them understand helpful and unhelpful reassurance strategies during a consultation.

Abstract:
Consultations between practitioners and patients are more than a hypothesis-chasing exploration, especially when uncertainty about etiology and prognosis are high. In this article we describe a single individual's account of their lived experience of pain and long journey of consultations. This personal account includes challenges as well as opportunities, and ultimately led to self-awareness, clarity, and living well with pain. We follow each section of this narrative with a short description of the emerging scientific evidence informing on specific aspects of the consultation. Using this novel structure, we portray a framework for understanding consultations for persistent musculoskeletal pain from a position of patient-centered research to inform practice.

Adapted from "Patient‑centered consultations for persons with musculoskeletal conditions. By Belton et al., 2022, Chiropractic & Manual Therapies, 30(53). (https://doi.org/10.1186/s12998-022-00466-w). Copyright 2022 by the authors (Creative Commons).

Effective Data Collection

  • Let patients tell their narrative
  • Explore impact of pain on life
  • Elicit emotions and beliefs
  • Ask open ended questions
  • Allow patients to tell their story
  • Check if you understand what matters to them
  • Check if you need to know anything else
  • Try to avoid chasing hypotheses while people are talking
  • Explore the whole person. Don't avoid emotions, concerns and problems that are beyond your perceived scope
  • Listen, avoid interrupting 
  • Respond empathetically
  • Show that you are attentive
  • Indicate that it is important
  • Ask open ended questions
  • Allow patients to tell their story
  • Check if you understand what matters to them
  • Recognise suffering and distress
  • Indicate that you believe all aspects of the narrative
  • Indicate that distress is understandable
  • Be clear and explicit about the fact that you believe the patient
  • Acknowledge the pain and suffering
  • Explicitly indicate that distress is completely normal under the circumstances
  • Where possible, describe possible causes
  • Discuss likely prognosis
  • Discuss / agree about possible interventions
  • Discuss prognosis, treatment options and likely obstacles
  • Use simple language and avoid jargon
  • Make sure the conversation flows both ways
  • Discuss prognosis, treatment options and likely obstacles

Avoid Generic Reassurance

Especially with patients who have:
  • Seen many clinicians
  • Trialed many interventions
  • A long history of pain and suffering
  • Avoid telling patients that everything will be alright unless you really know this is the case
  • Recognise that telling patients nothing is wrong is not always reassuring

Cognitive Functional Therapy

Cognitive Functional Therapy:

An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain


Peter O'Sullivan et al. 2018

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain

JP Caneiro et al. 2021

Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain



Samantha Bunzli et al. 2016

Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training:


Aoife Synnott et al. 2016

Physiotherapists’ validating and invalidating communication before and after participating in brief Cognitive Functional Therapy training. Test of concept study



Riikka Holopainen et al. 2021

Cognitive Functional Therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial

Peter Kent et al. 2022

Understanding Pain

A neurobiologist’s attempt to understand persistent pain

Per Brodal
Scandinavian Journal of Pain, Volume 15, 2017, https://doi.org/10.1016/j.sjpain.2017.03.001
This paper was written for pain academics and clinicians to help them understand persistent pain.

Abstract:
This topical review starts with a warning that despite an impressive wealth of neuroscientific data, a reductionist approach can never fully explain persistent pain. One reason is the complexity of clinical pain (in contrast to experimentally induced pain). Another reason is that the “pain system” shows degeneracy, which means that an outcome can have several causes. Problems also arise from lack of conceptual clarity regarding words like nociceptors, pain, and perception. It is, for example, argued that “homeoceptor” would be a more meaningful term than nociceptor.

Pain experience most likely depends on synchronized, oscillatory activity in a distributed neural network regardless of whether the pain is caused by tissue injury, deafferentation, or hypnosis. In experimental pain, the insula, the second somatosensory area, and the anterior cingulate gyrus are consistently activated. 

These regions are not pain-specific, however, and are now regarded by most authors as parts of the so-called salience network, which detects all kinds of salient events (pain being highly salient). The networks related to persistent pain seem to differ from the those identified experimentally, and show a more individually varied pattern of activations. One crucial difference seems to be activation of regions implicated in emotional and body-information processing in persistent pain.

Basic properties of the “pain system” may help to explain why it so often goes awry, leading to persistent pain. Thus, the system must be highly sensitive not to miss important homeostatic threats, it cannot be very specific, and it must be highly plastic to quickly learn important associations. Indeed, learning and memory processes play an important role in persistent pain. Thus, behaviour with the goal of avoiding pain provocation is quickly learned and may persist despite healing of the original insult. Experimental and clinical evidence suggest that the hippocampal formation and neurogenesis (formation of new neurons) in the dentate gyrus are involved in the development and maintenance of persistent pain.

There is evidence that persistent pain in many instances may be understood as the result of an interpretation of the organism’s state of health. Any abnormal pattern of sensory information as well as lack of expected correspondence between motor commands and sensory feedback may be interpreted as bodily threats and evoke pain. This may, for example, be an important mechanism in many cases of neuropathic pain. Accordingly, many patients with persistent pain show evidence of a distorted body image.

Another approach to understanding why the “pain system” so often goes awry comes from knowledge of the dynamic and nonlinear behaviour of neuronal networks. In real life the emergence of persistent pain probably depends on the simultaneous occurrence of numerous challenges, and just one extra (however small) might put the network into a an inflexible state with heightened sensitivity to normally innocuous inputs.

Finally, the importance of seeking the meaning the patient attributes to his/her pain is emphasized. Only then can we understand why a particular person suffers so much more than another with very similar pathology, and subsequently be able to help the person to alter the meaning of the situation.

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Reinforce key messages you provided in the clinic with key information related to their pain story.
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The information provided is general information only.
Clinicians should make their own judgement about the best care for each patient.
People who have pain should discuss information presented here with their healthcare team.


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