Speaker: Pr Peter O’Sullivan, specialist musculoskeletal physiotherapist, Curtin University, Perth, Australia
Congress: Sport & Exercise Medicine Switzerland and Swiss Sport Physiotherapy Association joint conference: “Structure & Function“, Lausanne, October 30th and 31st 2025
Introduction
Low back pain represents a leading cause of disability worldwide and a common reason for athletic retirement. Traditional management emphasizes structural pathology identification through imaging, activity restriction, and invasive interventions when conservative approaches fail. However, this biomedical paradigm frequently produces suboptimal outcomes, particularly for persistent pain presentations. This article challenges structure-function reductionism in pain management, presenting evidence for biopsychosocial approaches that address the complex ecosystem underlying chronic pain, drawing from research presented by Professor Peter O’Sullivan, physiotherapist and pain researcher from Curtin University.
The Paradigm Problem: Matt’s Story
Matt, a competitive triathlete, developed gradual-onset back and leg pain following training resumption after competition. Over eight months, he progressed from marathon-capable to unable to perform basic activities of daily living—donning socks, tying shoelaces, or rising from seated positions without five-minute procedures. MRI identified L4-L5 and L5-S1 disc bulges with presumed nerve compression, producing “red hot poker” sciatic pain. Surgical intervention provided three days of relief before pain returned to pre-operative levels within two weeks.
Post-surgically, Matt received extensive pharmacological management including neurological medications targeting the “vicious circle of the body thinking it’s in pain,” causing protective guarding that impeded rehabilitation. Despite structural correction, Matt remained disabled, distressed, convinced his back was “screwed,” frightened, hopeless regarding recovery, and profoundly depressed. Multiple specialists uniformly declared his endurance sport career finished: “No more prolonged cycling. Your back is so unstable… Your Ironman career is over. Don’t ever consider running anything more than 10k again.”
Matt’s experience exemplifies a common trajectory where early imaging, structural diagnoses, passive therapies, pharmacological interventions, and surgical procedures—none evidence-based for persistent non-specific back pain—leave athletes disabled, fearful, and career-terminated despite “successful” structural repair.
The Broken Machine Model: Origins and Consequences
Common societal beliefs position back pain as a serious medical condition that deteriorates over time, where pain signifies spinal damage requiring scanning to identify pathology, painful movements warrant avoidance, pain flares indicate tissue damage necessitating rest, and strong drugs or surgery are needed when pain persists. This “broken machine” framework emphasizes protecting vulnerable spinal structures. Critically, most beliefs lack evidence-based support and originate from healthcare practitioners.
Imaging: The Nocebo Effect
Randomized controlled trial evidence demonstrates profound iatrogenic harm from imaging interpretation. Acute low back pain patients without red flags were randomized to either accurate MRI reporting (degenerative discs, facet joint arthrosis, annular fissures) or reassurance that findings represented normal age-related changes. At six weeks, patients told their backs were damaged demonstrated worse pain; reassured patients improved. Imaging interpretation produces measurable detrimental effects on physical health, mental health, and pain outcomes.
Population studies reveal that 76% of asymptomatic individuals demonstrate “abnormal” MRI findings, yet clinical messaging emphasizes catastrophic interpretations: “Be careful with your back… this is a career-ending problem.”This disconnect between evidence and communication produces unnecessary fear and disability.
Movement Beliefs without Evidence
Multiple sacred cows of back pain management lack empirical support:
• Lifting technique: No biomechanically superior method exists; people with back pain demonstrate more squat-like (traditionally “correct”) lifting than pain-free individuals, suggesting protective strategies may perpetuate rather than prevent problems.
• Pain with activity: Systematic review evidence demonstrates no evidence that physical activity, even if painful, is detrimental to people with pain.
• Spinal protection: Interventions teaching people not to protect their backs produce less pain and disability than protection-focused approaches.
Linguistic Iatrogenesis
Diagnostic terminology profoundly influences patient interpretation and outcomes. Qualitative research reveals patient interpretations: “chronic” means “a couple of steps away from a wheelchair”; “instability” means “liable to pop out”; “wear and tear” means “something’s rotting away”; “degeneration” means “an old person’s spine disintegrating.” Diagnostic labels (bulge, degeneration, herniation) result in greater perceived need for imaging and surgery, greater perceived condition seriousness, and poorer recovery expectations.
The Ecosystem of Pain: Beyond Structure
Once serious pathology is excluded, pain exists within complex biopsychosocial contexts. Evidence demonstrates multiple non-structural determinants:
• Genetic factors: Heritable associations influence pain vulnerability.
• Developmental trajectory: Pain typically emerges during adolescence, increasing through adulthood.
• Emotional responses: Fear, worry, anxiety, and depression potently drive pain through immune-mediated mechanisms.
• Social environment: Relationships, support systems, and cultural contexts influence pain experience.
• Lifestyle factors: Sleep quality, nutrition, stress responses fundamentally affect pain neurobiology.
Large cohort studies of adolescents identify primary pain predictors: female gender, poor mental health, somatic complaints (headaches, fatigue, gastrointestinal symptoms), sleep disruption, and paradoxically, physical activity engagement when other vulnerability factors coexist. Structure and function represent only components of a broader health ecosystem.
Research with Irish dancers revealed that anger, hostility, subjective health complaints, fatigue, sleep deficits, and pain history predicted pain development—not biomechanics or functional testing.
The Vicious Cycle
Healthcare interactions emphasizing structural damage and bodily protection create cascading consequences: disability development, negative pain-related mindsets, distressing emotional responses, and unhelpful coping behaviors. These psychological and behavioral responses drive pain, disability, and sleep disruption, establishing vicious cycles. Systematic reviews demonstrate that people with pain move slower, stiffer, more co-contracted, and more guarded—protective strategies perpetuating rather than resolving pain.
Matt retrospectively recognized profound depression: “Everyone saying don’t do surgery. Essentially, there’s no fix… none of them could fix me… incredibly frustrating… you essentially spend the entire time googling to try and find a cure.” His surgical “success” left him non-active, sleep-deprived, highly guarded, believing his back damaged and untrustworthy, and systemically sensitized despite anatomical “correction.”
Conclusion: Facts About Chronic Low Back Pain
Evidence-based understanding challenges traditional paradigms:
• chronic low back pain rarely represents serious medical pathology
• scans poorly predict pain persistence
• thoughts, emotions, and behavioral responses are critical
• social factors matter; overprotection delays recovery
• pain flares do not usually indicate tissue damage
• strong drugs and surgery are usually unnecessary
• recovery is possible.
Clinical imperative: When assessing back pain, explore the iceberg beneath surface presentation—psychosocial factors, sleep, stress, beliefs, fears, social context—as these drive persistence more powerfully than structural findings. While structure and function assessment remains important, understanding and caring for the whole person within their ecosystem is paramount.
References
1. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-747. doi:10.1016/S0140-6736(16)30970-9.
2. Schofield DJ, Shrestha RN, Cunich M, Tanton R, Kelly S, Passey ME, Veerman LJ. Lost productive life years caused by chronic conditions in Australians aged 45–64 years, 2010–2030. Med J Aust. 2015;203(6):260.e1-6. doi:10.5694/mja15.00132.
3. Wilson F, Thornton JS, Wilkie K, Hartvigsen J, Vinther A, Ackerman KE, Caneiro JP, Trease L, Nugent FJ, Gissane C, McDonnell SJ, McGregor A, Newlands C, Ardern CL. 2021 consensus statement for preventing and managing low back pain in elite and subelite adult rowers. Br J Sports Med. 2021;55(16):893–899. doi:10.1136/bjsports-2020-103385.
4. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P, Lancet Low Back Pain Series Working Group. Low back pain: a call for action. Lancet. 2018 Jun 9;391(10137):2384-2388. doi:10.1016/S0140-6736(18)30488-4.
5. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG, Smeets R; Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018 Jun 9;391(10137):2368-2383. doi:10.1016/S0140-6736(18)30489-6.
6. Rajasekaran S, Dilip Chand Raja S, Pushpa BT, Behera AK, Shetty AP, Mugesh R. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. Eur Spine J. 2021;30(7):2069-2081. doi:10.1007/s00586-021-06809-0.
7. Kasch R, Truthmann J, Hancock MJ, Maher CG, Otto M, Nell C, Reichwein N, Bülow R, Chenot J-F, Hofer A, Wassilew G, Schmidt CO. Association of lumbar MRI findings with current and future back pain in a population-based cohort study. Spine (Phila Pa 1976). 2022 Feb 1;47(3):201-211. doi:10.1097/BRS.0000000000004198. PMID:
34405825.
8. Tran I, Gibbs MT, Yu N, Powell JK, Smith BE, Jones MD. Effectiveness of painful versus nonpainful exercise on pain intensity, disability, and other patient-reported outcomes in adults with chronic musculoskeletal pain: an updated systematic review with meta-analysis. J Orthop Sports Phys Ther. 2025 Aug;55(8):1-11. doi:10.2519/jospt.2025.13253.
9. Kent P, Haines T, O’Sullivan P, Smith A, Campbell A, Schutze R, Attwell S, Caneiro JP, Laird R, O’Sullivan K, McGregor A, Hartvigsen J, Lee DC, Vickery A, Hancock M; RESTORE trial team. 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. Lancet. 2023 Jun 3;401(10391):1866-1877. doi:10.1016/S0140-6736(23)00441-5.
10. Bunzli S, Watkins R, Smith A, Schütze R, O’Sullivan P. Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain. Clin J Pain. 2013 Oct;29(10):907–916. doi:10.1097/AJP.0b013e31827a6dd8.
11. O’Keeffe M, Ferreira GE, Harris IA, Darlow B, Buchbinder R, Traeger AC, Zadro JR, Herbert RD, Thomas R, Belton J, Maher CG. Effect of diagnostic labelling on management intentions for non-specific low back pain: a randomized scenario-based experiment. Eur J Pain. 2022;26(6):1168-1179. doi:10.1002/ejp.1981.
12. O’Sullivan PB, Caneiro JP, O’Keeffe M, Smith A, Dankaerts W, Fersum K, O’Sullivan K. Cognitive Functional Therapy: An integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther. 2018 May 1;98(5):408-423. doi:10.1093/ptj/pzy022.
13. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 9;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X.
14. Cahalan R, O’Sullivan P, Purtill H, Bargary N, O’Ni Bhriain O, O’Sullivan K. Inability to perform because of pain/injury in elite adult Irish dance: a prospective investigation of contributing factors. Scand J Med Sci Sports. 2016 Jun;26(6):694-702. doi:10.1111/sms.12492. PMID:26040202.
15. Prunault C, Vadez G, Descarreaux M, Abboud J. Physical and psychological differences between athletes with and without chronic primary low back pain: a scoping review. Front Sports Act Living. 2025;7:1621796. doi:10.3389/fspor.2025.1621796. PMID:40832556.
16. Wernli K, Smith A, Coll F, Campbell A, Kent P, O’Sullivan P. From protection to non-protection: a mixed methods study investigating movement, posture and recovery from disabling low back pain. Eur J Pain. 2022 Nov;26(10):2097-2119. doi:10.1002/ejp.2022. PMID:35959703; PMCID:PMC9826080.
17. O’Sullivan PB, Caneiro JP, O’Sullivan K, Lin I, Bunzli S, Wernli K, O’Keeffe M. Back to basics: 10 facts every person should know about back pain. Br J Sports Med. 2020 Jun;54(12):698-699. doi:10.1136/bjsports-2019-101611. Epub 2019 Dec 31.
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