Man’s Search for Pain Science with Professor Peter O’Sullivan, PhD


I have for some time now, been reading articles, pain-science papers and viewing lectures by Professor Peter O’Sullivan, PhD. Some of these quotes are from articles and others are from reviews, lectures and presentations.

Prof. Peter O’Sullivan is professor of Musculoskeletal Physiotherapy at Curtin University, Perth, and is one of the most influential and innovative names in the specialty, that is back pain. Prof. Peter O’Sullivan is recognised as a leading clinician, researcher and educator in the management of musculoskeletal pain. Prof. O’Sullivan has published many excellent papers and is a highly sought-after speaker at conferences world-wide.

Without further ado, here are 36 something quotes from Prof. Peter O’Sullivan:

“The physiotherapy, manual therapy and medical professions have long focused on trying to find the magic ‘technique’, ‘muscle’, ‘injection’ or ‘surgical technique’ required to solve the problem of NSCLBP and PGP disorders. This reductionist approach to dealing with complex disorders in a simplistic manner clearly hasn’t delivered for our patients and contradicts current knowledge that NSCLBP should be considered within a multidimensional bio-psycho-social framework.” Professor Peter O’Sullivan, PhD

“Depressed mood predicts future episodes of pain better than abnormal findings on an MRI film.” Professor Peter O’Sullivan, PhD

“However, when patients are told that the treatment technique ‘puts the pelvis back in’, this can reinforce fear of movement, avoidance behaviours, a loss of confidence in their body and hyper vigilance.These factors can reinforce chronicity. Many patients demonstrate this by statements such as ‘I can’t go for a walk because it will put my pelvis out of place’ or ‘I can’t lift my baby because I have an unstable pelvis and it will cause more damage’. These non-evidence-based beliefs are generally transferred to patients by well-meaning healthcare practitioners; however, they risk leaving patients fearful, avoidant and reliant on passive treatments, or developing muscle-guarding strategies and reliance on pelvic belts in a vain attempt to control their pain.” Professor Peter O’Sullivan, PhD

“There is a high prevalence of ‘abnormal’ findings on MRI in pain-free populations: disc degeneration (91%), disc bulges (56%), disc protrusion (32%), annular tears (38%).” Professor Peter O’Sullivan, PhD

“Currently, there are a lot of systems being used to do this. Physical therapists traditionally look at signs and symptoms, based on the belief that this is all about structure. But systems need to take account of the fact that there are other factors too. You need an integrated approach of sorting through the multiple layers of a personal presentation.” Professor Peter O’Sullivan, PhD

“Best practice management for LBP, once the triage process has been conducted, is guided by screening for psychosocial risk factors and addressing maladaptive beliefs and behaviours to better target care. In the acute phase of LBP, short-term pain management is indi- cated if the pain is distressing. There is also growing evidence that targeting the beliefs and behaviours that drive disability is more effective than simply treating the symptoms of LBP.” Professor Peter O’Sullivan, PhD

“In short, all relevant studies find no difference in pelvic movement or bony alignment between painful and non-painful sides in people with chronic low back or pelvic pain. Many people will of course feel better after undergoing manual therapy of various kinds. However, this improvement is due to reductions in pain, muscle tone and fear rather than realigning of body structures. Unfortunately, being told that you have something out of place can lead to fears about the structural integrity of the body, and increase dependence on others for help. Instead, best practice for such pain disorders should involve a multidimensional approach using a range of physical, lifestyle, cognitive and coping strategies.” Professor Peter O’Sullivan, PhD

“Negative back pain beliefs and fear of pain and movement are more predictive of disability levels, than levels of pain intensity.” Professor Peter O’Sullivan, PhD

“The evidence supports a patient-centred approach to low back pain care that addresses the biopsychosocial influences on the disorder and empowers patients to actively self-manage.” Professor Peter O’Sullivan, PhD

““Working the core” has become a huge focus of rehabilitation of athletes and non athletes in recent years. The belief that the spines stabilising muscles become inhibited with back pain rendering the spine ‘unstable’ and ‘vulnerable’ drives this. Yet  growing evidence tells us that disabling persistent back pain disorders are often associated with increased trunk muscle co-contraction, earlier activation of the transverse abdominal wall and an inability to relax the spines stabilising muscles such as lumbar multifidus” Professor Peter O’Sullivan, PhD

“The biomedical approach to managing persistent back pain over the past 15 years has led to a marked increase in: exercise therapies directed to increasing the ‘stability’ of the spine; MRI imaging; spinal injections; surgical interventions and opioid analgesics use; and health care costs. Ironically, there has been a concurrent increase in disability relating to back pain.” Professor Peter O’Sullivan, PhD

“This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model. This is in spite of calls over a number of years to adopt a bio-psycho-social approach, and evidence that only 8–15% of patients with LBP have an identified patho-anatomical diagnosis, resulting in the majority being diagnosed as having non-specific LBP.” Professor Peter O’Sullivan, PhD

“Early MRI imaging for low back pain can result in poorer health outcomes.” Professor Peter O’Sullivan, PhD

“Chronic low back pain (CLBP) has for many decades been treated as a disorder which primarily reflected damage to the tissues (discs, bones, joints, muscles, ligaments etc.) of the lower back. However, it is now clear that what was previously considered tissue “damage” on scans is actually common among people without pain, as described here recently. In addition, approaches which have tried to relieve pain by focussing treatment almost exclusively on the tissues of the back – including a range of medical, surgical, exercise and manipulative approaches – have failed to significantly reduce the suffering associated with CLBP. “ Professor Peter O’Sullivan, PhD

“We can massively create health problems” Professor Peter O’Sullivan, PhD

“What we understand from the literature, is that often the fear of pain causes people to make protective movements and as a result people’s movement patterns become really abnormal and act as a mechanism for self harm” Professor Peter O’Sullivan, PhD

“Beliefs such as ‘your sacrum, pelvis or back is out place’ are common among many clinicians. These beliefs can increase fear, anxiety and hypervigilance that the person has something structurally wrong that they have no control over, resulting in dependence on passive therapies for pain relief (possibly good for business, but not for health). These clinical beliefs are often based on highly complex clinical algorithms associated with the use of poorly validated and unreliable clinical tests” Professor Peter O’Sullivan, PhD

“Based on this evidence, there have been calls to adopt a bio-psycho-social understanding and approach to managing back pain. There is growing evidence that targeting the beliefs and behaviours that drive disability is more effective than just treating the symptom of pain alone. “ Professor Peter O’Sullivan, PhD

“”There is strong evidence that NSCLBP disorders are associated with a complex combination of physical behavioural, lifestyle, neuro-physiological (peripheral and central nervous system changes), psychological/cognitive and social factors.” Professor Peter O’Sullivan, PhD

“A number of high quality randomised controlled trials have compared stabilisation training to various forms of exercise, manual therapy and placebo. These studies highlight that this approach is not superior to the other active therapies and only marginally superior to a poor placebo, with only minimal changes in pain and moderate reductions in disability” Professor Peter O’Sullivan, PhD

“Trunk muscles of people with disabling low back pain demonstrate increased co-activation, rather than a lack of stability.” Professor Peter O’Sullivan, PhD

“An approach to low back pain should involve an initial triage to screen for serious pathology, assessment for psychosocial risk, clear explanations to reduce the sense of threat, active rehabilitation and discouragement of unwarranted radiological investigation.” Professor Peter O’Sullivan, PhD

“The burden of low back pain can be reduced if management is more aligned with evidence.” Professor Peter O’Sullivan, PhD

“Radiological imaging for LBP, in the absence of red flags, progressive neurological deficits and traumatic injury, is not warranted and may in fact be detrimental. However, over-imaging for LBP is endemic in primary care.9 Although advanced disc degeneration, spondylolisthesis and modic changes of the vertebral end plate (changes to the bone structure of the vertebral body that may be seen on MRI) are associated with an increased risk of LBP, they do not predict future LBP” Professor Peter O’Sullivan, PhD

“Nonspecific low back pain in which a definitive pathoanatomical diagnosis cannot be made accounts for 90% of people who experience LBP.” Professor Peter O’Sullivan, PhD

“While for some athletes there maybe patho-anatomical and biomechanical explanations to pain, for many others it is far more complex. There is growing evidence that low back pain is associated with a combination of genetic, pathoanatomical, physical, neurophysiological, lifestyle, cognitive and psychosocial factors for each domain. The presence and dominance of these factors varies for each person, leading to a vicious cycle of tissue sensitisation, abnormal movement patterns, distress and disability” Professor Peter O’Sullivan, PhD

“There is growing evidence that factors such as sleep disturbance, sustained high stress levels, depressed mood and anxiety are strong predictors of LBP.” Professor Peter O’Sullivan, PhD

“Commonly in clinical practice, back pain is considered from a purely biomedical perspective, where radiological imaging is the basis for diagnosis. Athough MRI and other imaging has an important role in the triage of people with back pain to identify fractures, cancer and nerve root compression in 1-2% of people, it also puts the spotlight on many patho-anatomical findings that are not related to back pain” Professor Peter O’Sullivan, PhD

“In disc prolapse, the natural history is good; the majority of cases recover and the prolapse reduces in size over time. Long term outcomes for surgical intervention are no different to usual care” Professor Peter O’Sullivan, PhD

“The evidence is quite strong that combining psychological and physical approaches is the most effective way to improve quality of life in chronic lower back pain.” Professor Peter O’Sullivan, PhD

“Abandon old unhelpful biomedical beliefs, and embrace the evidence to change the narrative to help people with pain understand the underlying mechanisms linked to their disorder.” Professor Peter O’Sullivan, PhD

“Back pain is more complicated than people would like to think. What predicts disability is not necessarily what you see on a scan – it may be your response to what you see on the scan, or how fearful you are about pain, or whether you have a history of depressed mood or anxiety. We also know that there are all kinds of central nervous changes that result from pain over extended periods, and that people suffering from pain change their behaviours in ways that are probably unhelpful and feed into the cycle.” Professor Peter O’Sullivan, PhD

“With all this in mind, the challenges for the future in more effectively dealing with NSCLBP disorders are likely to involve primary healthcare providers shifting rig- idly held biomedical beliefs and develop- ing greater skills and knowledge across a number of domains.” Professor Peter O’Sullivan, PhD

“This approach will likely focus less on treating the structure or signs and symptoms of a disorder in NSCLBP disorders and more on targeting the different combinations of beliefs, cognitive, pain, lifestyle and movement behaviours that underlie and drive disorders.” Professor Peter O’Sullivan, PhD

“By retraining people the way people move and changing the way they think about their back, we found much bigger reductions in pain and much less fear of movement” Professor Peter O’Sullivan, PhD

“When reviewing imaging, keep the clinical history and examination at the forefront of your mind. The physical examination seeks to identify the pain sensitive structures and associated pain features. Where pain is mechanically provoked, ask about and observe pain provoking movement patterns specific to the sport (golf swing) and activities of daily life. For example, observe carefully whether the golf swing is associated with increased lumbar flexion or extension, coupled with side bending and rotation, increased trunk muscle co-contraction, breath holding and as well as guarded movement of the hips and thorax, which can increase lumbar spine loading. “ Professor Peter O’Sullivan, PhD