How to treat back pain: Kiwi expert’s new book busts myths, gives solutions

Back pain expert Antony Bush has released a new book, The Back Fix, busting myths about treatment and causes. Photo / George Heard

A new book claims the way we treat back pain is all wrong. Joanna Wane finds out why.

A few days before I talk with spinal pain expert Antony Bush, I ask him to look over a recent article from a UK newspaper titled “Seven daily habits to banish back pain for good”. Practitioners who give their professional advice in the story include a physiotherapist, a chiropractor, an osteopath, a personal trainer and a yoga instructor, so it’s right up his alley.

The next morning, Bush emails back the article covered in digital yellow sticky notes. In his view, more than half of the key claims it makes are myths, part-truths or simply not supported by evidence-based research. But instead of being shocked or outraged at this peddling of misinformation, he’s not surprised in the least.

“This is just classic — it’s all hearsay, handed down by well-meaning practitioners who are repeating what they’ve been taught, and it’s all been proven wrong in controlled clinical trials,” he says.

“Google is rife with old wives’ tales, like it’s dangerous to bend your back, or that if you have persistent back pain, you should image it and if something shows up, definitely do something about it in terms of surgery or injections. Actually, the wrinkles you see on an MRI [scan] are often just normal, age-related changes that have nothing to do with pain. And that starts a trajectory that takes a lot of people down a course of unnecessary treatments.”

Lower back pain is the world’s leading disability, in terms of treatment costs, time off work and related compensation payouts (for example, through New Zealand’s ACC scheme). In the US alone, that accounts for more than $100 billion a year.

However, instead of fixing the problem, it’s getting worse. In his new book, The Back Fix, Bush quotes figures showing the incidence of back pain has increased by more than 50 per cent in the past three decades. “So this is no small thing,” he tells the Herald. “This is a healthcare crisis.”

Staying as mobile as possible is the key to reducing back pain, according to Kiwi physiotherapist Antony Bush, photographed here climbing Aoraki Mt Cook. Photo / Kynan Bazley

Based in Christchurch, where he runs a physiotherapy practice, Bush is a strength and conditioning expert who’s worked with high-performance athletes including Olympic gold medallists and several All Blacks. A former lead physiotherapist with the New Zealand Winter Olympics team, he spent six years at the Sydney Academy of Sport and is a keen multisporter himself.

His “movement is medicine” philosophy applies to everyone, though, shaped by an active, outdoor childhood growing up on a high-country farm. His mother, a rural physiotherapist, had congenital spondylolisthesis and suffered from intermittent back pain for many years but was still an avid gardener and playing tennis in her early 80s. His father, who experienced excruciating episodes of back pain, was “happily ski racing and mountain biking at the age of 91″, Bush writes, in the foreword to his book. “Yet I have seen back pain disable and suck the very life out of people.”

Here’s one of the main takeaways from his book: Medication and hands-on therapies may help with the pain and give you the confidence to get moving again after an injury (like overdoing it at the gym or in the garden), but they aren’t “healing” anything. And, unless you’re in the 1-5 per cent with a structural or medical problem, such as a fracture or cancer, you’ll get better just as quickly with or without treatment.

Here’s another: A negative mindset, poor coping behaviours and fear-induced immobility are more strongly associated with back pain than medical imaging. “We can do psychological testing and find out what people’s ideas about back pain are and [predict] whether they’ll get chronic back pain better than we can from an MRI.”

The vast majority of back pain is not structural, according to this chart, featured in Kiwi physiotherapist Antony Bush's new book, The Back Fix.

Bush thinks it’s no coincidence that the recent “explosion” in the rate of MRI referrals has coincided with a massive increase in reported back pain. He likens the scenario to GPs dishing out antibiotics because patients demand them, even when they won’t be effective (and can be actively harmful, contributing to the rise of antibiotic resistance). “Everybody wants an MRI and then they see stuff that scares them [unnecessarily].”

Our belief that there’s a quick fix for back pain is part of the problem. An ankle sprain might be incredibly painful, notes Bush, but the injured person generally accepts they’ll be on crutches then limping around for six to 12 weeks, giving the damaged tissue time to gradually self-heal.

“As a population, we’ve got all these negative beliefs that pain is bad, that our spines are easily damageable and that as soon as we get pain, we should run off and seek some sort of rectifying treatment,” he says. “In fact, the researchers are saying that our spines are really strong, robust pieces of equipment and if they’re sore, it doesn’t mean they’re badly damaged and you’re going to have back pain for the rest of your life.”

After leaving the Sydney Academy of Sport in 2017, Bush settled in Christchurch and set up his own physiotherapy practice. As a project on the side, he decided to use his experience working with spinal pain and musculoskeletal sports injuries to update New Zealand physiotherapist Robin McKenzie’s landmark book Treat Your Own Back, which has sold five million copies worldwide since it was first published in 1980 (McKenzie died in 2013).

When Bush started digging into the latest international research, he soon realised it wasn’t going to be a quick job. Evidence emerging from randomised clinical trials had “flipped the script” on the treatment of back pain. One particular editorial, published in the British Journal of Sports Medicine in 2012, caught his eye.

Authored by another New Zealander, Peter O’Sullivan — a Professor of Musculoskeletal Physiotherapy at Curtin University in Perth — it called for a paradigm shift in the management of chronic low back pain. As it happens, O’Sullivan is one of the keynote speakers at a Physiotherapy New Zealand conference in Christchurch this September.

Antony Bush's Christchurch practice includes a gym where patients can build strength and body condition. Photo / George Heard

Much of the approach Bush takes in The Back Fix builds on O’Sullivan’s key principles. Clinical practice is notoriously slow to respond to new research: one study suggests it takes 17 years for the results of controlled clinical trials to filter through to frontline treatment.

Bush advocates for practitioners to take on a greater coaching role, exploring lifestyle factors that might be causing or exacerbating ongoing back pain, such as stress or long hours sitting immobilised in front of a computer screen. It’s been estimated 80 per cent of people will suffer from back pain at some point. For many, it may simply be a symptom of modern life.

“We’ve talked for years about the effect of stress on our hearts, but we’ve never talked about the effect of stress on our musculoskeletal system,” he says. “It’s a bit like treating an asthmatic with drugs and not looking at the damp, mildewed house that’s caused the problem in the first place.

“I’m not saying all back pain is because people are stressed, anxious and depressed. That’s not true. But the researchers are saying it’s much more multidimensional than we think.”

MYTHBUSTERS: The real facts about backs

Back pain rarely signals serious damage. While persistent back pain can be distressing and disabling, only 1-5 per cent has a structural or medical cause, such as a fracture, cancer, infection or compression of the spinal nerve. “The majority of the time, back pain is a normal part of the human highway of life and doesn’t herald significant damage or degeneration,” says Bush, who recommends being “actively patient” and to keep moving within your pain tolerance.

Scanning doesn’t identify or predict pain. Most imaging reveals pre-existing, age-related changes. In a study published by the American Journal of Neuroradiology, scans on 40-year-olds without pain showed disc degeneration (in 68 per cent of cases), disc bulge (50 per cent), annular fissure (22 per cent) and facet degeneration (32 per cent). “The trouble with MRI machines is that they show us our bodies in such fine detail that we see all our splendid imperfections, which most of us don’t realise are present in people suffering no pain at all.”

Back pain is multidimensional. In the vast majority of cases, ongoing back pain is lifestyle or performance-related, triggered by overload, fatigue, inactivity, stress or fear (being over-protective or rigid rather than moving freely). So spine injections, surgery and strong drugs generally aren’t a cure.

Backs don’t wear out. They can’t be “put out” or “put back in”, either. Bush describes the human spine as a highly robust and resilient structure. Moving and loading your back (running, twisting, bending, lifting) makes it stronger and healthier, as long as you start gradually and keep it up regularly. There’s also no research to support the widespread belief that ageing causes or worsens back pain.

Poor posture or a “weak core” doesn’t cause back pain. Staying in any one position for too long is the real problem for many. The next posture is the best posture, is Bush’s advice. To improve mobility and avoid your body getting “stuck”, change position every 20 minutes or so. If you’re in a sedentary job, stand up regularly, move around and try to go for a short walk on your breaks.

There is no quick fix. No modern medical intervention can speed up the healing rate of our tissues, and the initial severity of the pain we feel doesn’t indicate how severe a back injury is or the length of time before it comes right. As a rough guideline, a mild back strain takes about 10 days to recover. A moderate back strain takes 3-6 weeks and a significant injury can take three months. If pain persists for more than three months, Bush advises seeking help from a physiotherapist experienced with chronic back pain who can help weed out the lifestyle factors that may be causing the pain or stopping it from resolving.

• The Back Fix: How to Beat the World’s #1 Disability, by Antony Bush, $44.99, is in bookstores now or can be ordered through thebackfix.com

Joanna Wane is an award-winning senior feature writer in the New Zealand Herald’s Lifestyle Premium team, with a special focus on social issues and the arts.