Overprotecting your back after a flare: Peter O'Sullivan

On Feel Better, Live More (episode 472, 2024), host Rangan Chatterjee read out a list of common beliefs about back pain to Peter O'Sullivan, a professor at Curtin University in Australia who has researched back pain for decades. Myth five: pain with movement is always a warning that harm has been done, and a signal to stop. The answer was short: not true. Protecting your back is normal and appropriate after a fracture, O'Sullivan said, though not for too long. But after a flare with no trauma behind it, the kind where you roll out of bed and it catches, overprotecting won't help. Then, in that conversation, came the warning about the habit itself:

"Once you get into the pattern of overprotecting, it is bloody hard to get rid of it."

Peter O'Sullivan, Feel Better, Live More, 2024

What overprotecting looks like

A minute later, O'Sullivan used the image of a clenched fist. Clenching makes sense when you pick up something heavy. Nobody walks around clenching a fist all day, and if you did, your arm would ache and stiffen. People with back pain often do the back's version of it: bracing when they roll over in bed, when they get up from a chair, when they bend. In O'Sullivan's description, they move stiffer, more guarded, more tense.

In the first hours of a flare, being careful is normal. The trouble starts when it doesn't switch off. Every careful week teaches your body again that a bend is a risk, and the brace becomes the way you move.

What the research adds

O'Sullivan and colleagues developed cognitive functional therapy, an approach to persistent pain, and O'Sullivan's website offers clinical training in it, so the research is worth reading beside the view.

In one small study that O'Sullivan co-wrote, 44 adults with long-lasting back pain did a reaction-time test that picks up links people don't put into words. Pictures of round-back bending were linked with "danger", even in people who didn't report feeling afraid of it. There was no group without back pain to compare with, so it shows a link, not why it forms (Caneiro et al, 2017).

Where does the habit come from? In interviews with 23 adults with back pain in New Zealand, many had been advised to hold certain postures and strengthen certain muscles, and that advice made them believe their spine was vulnerable (Darlow et al, 2013).

When it's more than a flare

O'Sullivan's point is about flares with no injury behind them. Most flares pass, but a few signs mean more. If any start, get help:

Get medical help straight away

• Trouble peeing, or leaking pee or poo without meaning to
• Numbness around your genitals or bottom, or sex feeling different
• Both legs weak, numb or tingly, or you can't walk because of the pain
• Pain after a serious fall, accident or blow
• Chest pain or trouble breathing with it; or new pain far worse than before, or getting worse fast

See a doctor first

• A fever, or feeling hot, shivery or unwell
• Cancer in the past, or weight lost without trying
• Pain worse at night or unchanged by moving or resting; high between the shoulder blades; one leg weak or numb

If a new flare isn't getting better after a few weeks, keeps getting worse, or worries you, see a doctor.

How this fits the Manage back pain program

In the 1h Protocol to Manage Back Pain, the Brace is one of four back-day patterns: you've stopped things, or do them very carefully. Its first step, in the free part, is one of those things, done small. Chapter 3 works on your pattern, and chapter 4 plans a flare: the first hours, a smaller day you can still keep, and one line in your own words for when your back goes. You leave with fourteen days to try it, with a sheet, reviews on days 7, 14 and 30, and four one-tap check-ins by email if you're signed in.

Source: Feel Better, Live More, episode 472, How to break free from chronic pain, with Peter O'Sullivan, 2024 Research: Caneiro et al, 2017 · Darlow et al, 2013