Rethinking low back pain management with Dr Kevin Wernli

In this episode with Dr Kevin Wernli, we dive into the complexities associated with low back pain. We discuss the importance of clearing red flags, patient beliefs and the role of specific pathology. Kevin also imparts his knowledge about habitual versus exercise programs and talks us through how he delivers these with his patients to encourage patient autonomy and compliance.

This episode is closely tied to Kevin’s Practical he did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Kevin’s Practical here with our 7-day free trial: physio.network/practicals-wernli

Dr Kevin Wernli is a Physiotherapist from Perth, Western Australia. He recently completed his PhD at Curtin University looking at the relationship between movements/postures and low back pain, and the role of psychological factors in this relationship. He also produces and co-hosts the empowered beyond pain podcast and has presented at conferences around the world. He has more recently been exploring how digital health and technology can improve how equitable and effective health care is.

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Our host is @sarah.yule from Physio Network

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Transcript

SPEAKER_02 0:00

Music There's only grey areas in the human system. I mean, yes, complex systems theory will talk about this as well, but yes, it's a complex system. If we had every tool under the sun to measure everything, then maybe we could, but we currently don't. So we live in the grey. I think black and white thinking is probably not that helpful. Fantastic if you're an engineer and you've got a maths problem, but not really so good if you're dealing with complexity in human bodies.

UNKNOWN 0:29

Music

SPEAKER_01 0:30

Education is a dish best served experientially. Today's episode explores the management of lower back pain, including looking at the relationship between pain and posture and embracing movement variety to build capacity. Kevin Wernley has done a practical with Physio Network where you can dive a lot deeper into the topic. So be sure to click the link in the show notes to watch Kevin's practical for free with Physio Network's seven-day trial. I think you're going to love today's episode with so many insights from Kevin that you can implement straight away. I'm Sarah Yule and this is is Physio Explained. Kevin is a repeat guest of Physio Network podcast, and he has also recently done a practical with us on low back pain, which we're going to explore today. So welcome back to the show, Kevin.

SPEAKER_02 1:21

Thanks so much for having me, Sarah. It's good to be back.

SPEAKER_01 1:24

Welcome. So reading your bio, you're a busy man. I'm curious as to what drew you into exploring this topic in particular?

SPEAKER_02 1:33

I've always had a passion for persistent pain. I think as a new grad, I had more questions than answers. I ended up doing a PhD or getting an opportunity to go back and do a PhD with a star-studded supervisory group and project out of Curtin University. So the project was supervised by Professor Peter O'Sullivan, Associate Professor Peter Kant, Professor Anne Smith and Associate Professor Amity Campbell. So some seriously amazing people. So I learned a heap there. And throughout that process, I guess my PhD topic was focused on low back pain and in particular I think as physios and as health professionals and even in society, we have these kind of deep-seated beliefs around movement and posture and low back pain, these ideas that you've got to sit up tall, brace your core, bend with your knees, keep your back straight. And surprisingly, that wasn't that well supported in the literature considering how strong these beliefs were. So I really went in with the lens to try and understand that relationship more, particularly as people recover. So I had a bit of a recovery lens and also the influence of psychological factors because we know these things are really important. So how does that relate to that relationship or influence that relationship? So it was a mixed methods PhD. So really got heavy in the data with some wearable sensors on capturing people's movements and muscle activity, as well as some systematic reviews and then some qualitative interviews, which I think really round the story nicely. So yeah, I still work clinically I love treating more of the complex pain or I certainly love the rewarding side when you do help people. That's something that I really enjoy as well as kind of using technology to sort of facilitate some improvements in symptoms in a number of different areas with an endometriosis platform that we're building and a little bit of lecturing at Curtin on the side as well.

SPEAKER_01 3:12

As clinicians, I suppose we've certainly learned in depth the the pathophysiology and the varying nociceptive drivers of non-specific back pain. So how do you navigate with patients exploring the sort of presence or absence of specific pathology?

SPEAKER_02 3:28

Yeah, I think that's a really important thing that physios as primary care practitioners or any primary care practitioners listening do is exclude serious and sinister pathology. Now, statistically, it's pretty rare at 10% maximum of the patients that we see or the patients with low back pain. A lot of people with pain we probably don't see That's one of the most important things to do. And I would almost preface that everything we're saying in this conversation or even in the practical. In fact, I did preface that that was after these sorts of sinister pathology has been ruled out. So I think that's an important statement. And I think that we're quite well trained to look for things like red flags. Look for signs and symptoms that the way that the patient's describing things, like has there been a large trauma? Have they got a history of malignancy or cancers? Have they got this unremitting night pain? Have they got these sorts of systemic symptoms? high fevers or infections. I had a patient recently who was actually a friend of mine who was up in rural WA and he had this infection under his arm and it kind of got missed and he had some back pain and eventually had an infection in his spine. Those sorts of clues, I think, can tell us these sorts of non-mechanical type pain presentations that, yeah, don't really fit the picture. So that's our job is to make sure that we exclude those things. And in the practicals, I do kind of go through a number of ways and sort of there's lots of false positives with that red herrings in that space. But I think really important that we, that's our first lens, I think, as clinicians, if not that, then maybe building rapport.

SPEAKER_01 4:58

Very true. We're always, always playing the detective. I know certainly for the patients that I treat in clinical practice that present with back pain, moving away from that sort of, you've cleared your red flags and you may be delving into the either specific or non-specific pathology. The conversation invariably leads to a discussion around posture and the contribution of that to their pain. How do you navigate the sort of assessment and discussion around posture that addresses it in a way that's Yeah,

SPEAKER_02 5:28

I think this is something that's, and I'm always learning, I think we're, as clinicians, we should always continue to learn and knowledge evolves, which I think is a good thing. And probably in reflection, I used to be quite, I don't know if gung-ho is the right word, but quite fast in kind of addressing their, what I would deem as maladaptive beliefs. But I think the more that I learn, the more that I kind of just shut up and listen and just get to understand the drivers of that person's worldview and the unique experiences that have led them to where they are now and what their beliefs are. Education is probably a dish that's best served experientially, so I'd like to then explore Well, let's see how these postures and movements actually feel for you. And is there anything that we can do to modify how you do that and what influence does that have on your pain? And the classic kind of example and nothing in clinical practice is black and white, but if I was to try and summarize that. you know, the classic belief is I really look after my posture and I've still got all this pain. And then I might say, well, let's just explore and see what the best posture is for you. You know, the same way that we wouldn't advise everyone to wear size seven shoes because that's terrible advice for anyone that's got bigger or smaller feet than that. We're not going to advise everyone needs to sit in the exact same position. So, we might then say to someone, well, let's explore what feels good for you and give you some individualized advice. And then if I've got good rapport, if they've kind of been referred to me as a second or third opinion. Then I might say, because actually the research around, and this is what my PhD topic was on. So I've kind of, I guess, got an element of support behind that as well. I've got an unfair advantage in that space. I might then say the research, we used to think about all these strong beliefs, but actually the research tells us that people with back pain adopt these postures. They have quote unquote better posture than people without back pain. And as they recover, and this is what my two systematic reviews showed, People actually start moving back towards more normal, less protective and less good, quote unquote, good postures. They start to relax more. They start to move faster and move more. And, you know, I mean, that occurs in the context of lots of changes to multidimensional psychological factors as well. It's not just all about movement and posture. But then, you know, I ask, well, actually, in your story, you told me what feels better. And that's actually like slouching in the couch or sitting down and relaxing. And that's kind of discordant with what you're telling me you're trying to do. So people have these beliefs that are separate to what their experiences are. One of my favorite quotes I'll try to remember is probably not going to be verbatim from one of my PhD subjects, participant six. She said, it feels better to slouch, but I don't because it's bad for me or something like that along the lines of that. So this idea that this experience or belief transcends experience. I think is really interesting. People will adopt and do things that they think are good for them, even though they feel worse. And part of that journey is just helping them explore and learn about their own body and that they can trust certain symptoms.

SPEAKER_00 8:27

Thank you. Thank you.

SPEAKER_01 9:00

As you say, I think knowledge is evolving and certainly it sounds like the more and more evidence that comes out that we're able to translate into clinical practice. Hopefully these are adopted as well. Now, I know you said back in your 2022 paper, you've sort of explored going from protective to non-protective schemas with patients. Can you expand a bit more on that in a practical sense for the clinician?

UNKNOWN 9:26

Yeah.

SPEAKER_02 9:26

I mean, I feel like I'm promoting my own work. But in that 22 paper, there's a figure that I actually quite like showing to patients, figure two, that sort of talks about this journey in a much more graphical sense. And I think when people see that, they're kind of like, Okay, that makes a lot of sense. I'm here right now and I need to get to here. So maybe have a look at that with reference to what I'm saying. But I guess where this came from was I did interviews, I mentioned qualitative research as well. So the interviews with people with disabling back pain before they had treatment, just to get their ideas and their beliefs around the understanding of their, how did they contextualize that relationship between posture and pain and movement for their own individual experiences. And then I also did interviews with them after my cognitive functional therapy intervention. And I should say, I'm not cognitively function. I'm not trained in CFT, but that was the intervention that we used in the study. And the themes that came out of that pre and post interview just really fit nicely with this sort of model that I'll briefly describe now. But basically, during those interviews at the start, people talked about this sort of feeling of stiffness, this like, I feel tight and restricted and tense and locked up. We kind of deemed that as a sort of the author group sort of deemed that as this, the body is subconsciously trying to protect them. So we called that non-conscious protection. And then we also heard that people not only do this subconsciously, but they actually consciously try to protect. No, no, I am careful with my movements. I avoid bending my spine. I'm really protective and cautious. And I'm bracing my core and I'm making sure my posture is good. And that was usually driven by a belief that they had to do that to protect their kind of damaged or vulnerable structures or perceived vulnerable structures. That was driven usually by imaging or this idea or this belief that, hey, pain means that, you know, it's a really common belief and we can see where it comes from, but that pain means that something's damaged or broken or out of place or injured. So, that was a really strong theme of protection in those initial interviews. And then in the follow-up interviews, we sort of heard these stories of actually learning to relax my back, learning to try and move more normally, understanding more about this kind of multi-dimensionality of pain, but that actually protecting less helped me reduce my pain and helped me get closer to my goals and improve my function. But then people talked about, I actually have to consciously do the opposite of what I've been doing for the last X amount of years. So that helped me with my pain reduction. And some people still had that after about 12 weeks of intervention, that it wasn't automatic yet. They still had to consciously think about, okay, I need to try and relax and move kind of normally and don't be so guarded, be less protective. So we dubbed that conscious non-protection. But most people kind of graduated through that stage into the final stage of what we call non-conscious non-protection. So that kind of less protection in their movement and posture had increased become automatic, habitual and back to normal again. So, that was automatic, habitual, normal, back to living type things that forgotten about their back. But this sort of happened in the context of it wasn't just movement and posture that shifted for these people. I mean, that's what we talk about in the paper, this sort of schema shift from I've got to protect my damaged back or my perceived damage back towards, oh no, it's actually safe to move my body in more normal, less protective ways.

SPEAKER_01 12:43

And where does that idea of building variable capacity sort of integrate into that

SPEAKER_02 12:50

There are so many rules around movement and posture. You know, we have rules around squats that you shouldn't put your knees in front of your toes or crossing midline into this kind of valgus position. We have rules around posture in terms of your neck position, you know, wrist position for desks and keyboards. And I think they all come from well-intentioned places of like we're trying to help people out. I think the reality of life is that it's not just straight lines. And if we train just in quote-unquote the perfect rule-based ways, then we get really good at that. But when inevitably life happens outside of those rules, we're actually not exposed to that. And people develop these very narrow pillars of safety learning or rooms of safety learning. So, they feel very safe in a certain aspect. But as soon as we're out of that aspect, the body freaks out or the mind freaks out or the system freaks out. It's like, well, I haven't been here before. This could potentially be dangerous. And we lack that, I guess, broad safety learning and safety learning is probably the key mechanism that people go through as part of this journey. So I think the idea of bringing variability in comes from this idea of the more evidence we have that our body is not fragile, in fact, our body is safe and it's good to move and I can feel that and I can experience that, the less likely we are to have symptoms or pain with those sorts of movements. So I think we want to encourage people to not just bend with a straight back, maybe bend with a round back and bend to the left and bend to the right and twist and lift and do squats in this way and that way and then on one leg and sit in an upright position, a slouch position. And I think that allows not only just the shift of movement and loading different structures, but it also allows the nervous system to learn that all these different things are safe and they're good and they're tolerable. And I think one of my favourite questions that I'll ask or pieces of homework, I guess, that I'll give to people is, Can you write me a list of all the things, movements, tasks, postures that you are not confident with, that you're frightened to do, that you've been told are bad, that you think are bad, that are painful? Because these are all the things that act as little barriers or little blocks or little spot fires that might potentially ignite a flare if they might go in and examine or engage with those things. I ask them to put in order of least to most frightening and then the rest of your treatment or sort of journey is pretty guided by, well, let's just start ticking these off in a progressive way.

SPEAKER_01 15:11

Fantastic. So sort of translating the whole concept of life is not linear and necessarily black and white right into training and exercise.

SPEAKER_02 15:22

Yeah, absolutely. There's only grey areas in the human system. I mean, yes, it's a complex systems theory. We'll talk about this as well. But yes, it's a complex system. And if we had every tool under the sun to measure everything, then maybe we could, but we currently don't. So we live in the grey. I think black and white thinking is probably not that helpful. Fantastic if you're an engineer and you've got a maths problem, but not really so good if you're dealing with complexity in human bodies.

SPEAKER_01 15:47

Absolutely. Absolutely. Where do you throw in sort of those habit-based programs versus the exercise programs with your patients?

SPEAKER_02 15:56

Yes, I talked about this in the practical as well, I think. This has sort of naturally come out of patients reporting back and also me, I guess, if I put my patient hat on, not in a physio context, in other health encounters that I've had where I'm the patient, I'm pretty bad at doing homework and doing my exercises. And I think most patients can kind of relate to that. Now, obviously, there's things we can do to help improve that, like align it with their values and give them clear instructions. And there's other technologies that we can do to help with that. But I think what it comes down to is if people are really good at their exercises and they do it every day without fail, it might take them half an hour. If they're really good, it might take them an hour. If you're awake for 18 hours, there's still 17 or 17 and a half hours in the day where you might be reinforcing old habits. protective patterns. These are patterns that we see. We sort of see these as protective habitual patterns or actually they're not even protective, they're overprotective because they're usually not helpful. So, I kind of just started shifting towards, well, I'm actually going to start by giving you a habit program before I even give you an exercise program. So, we found out today that, and the classic example is that you're bracing and you're overprotective. So, when you're sitting Oh, and you're bending. So I want your habit to be, first of all, acknowledge that and recognize that you are protective and over-bracing and or over-protective and that's no longer helpful because we found that out in the session. And when you acknowledge that, then celebrate and you can't change anything that you don't acknowledge. So acknowledgement is the first step or awareness. Then is recognition. Change how you respond. Respond with what we found worked better for you. And again, use the cues that you've used in the session with them so that it really resonates with them. And then it's about integrating that into daily life. So here's your Habit program. And then I'll be quite explicit and say, now it's your exercise program. Now, the reason I've put this is in the hierarchy. There's a reason I've put the Habit program in more important because it takes up more of your day and it's more of an opportunity for safety learning again.

SPEAKER_01 17:52

that sounds like you really do take them on the journey with them as well rather than sort of leading them, which we know is so important for behaviour

SPEAKER_02 18:00

change. Yeah, absolutely. And people don't argue with their own data or their own words, I think, and it resonates and it makes sense. And, you know, if there's an engineer or a mechanic or someone that's very mechanical like that, I might use sort of car analogies to try and explain things, you know, and try and tailor the message to them to help them sort of understand education's power or knowledge's power. Fantastic.

SPEAKER_01 18:22

Yeah, absolutely. My goodness. Well, this has been a very insightful conversation today, Kevin. So thank you so much. I think your expertise and your stories has really shed some light on the challenges of dealing with back pain. and have hopefully offered some practical tools for listeners. So thank you so much for sharing your wisdom with us today. Much appreciated.

SPEAKER_02 18:45

My pleasure. I think I stand on the shoulder of giants, so it's not really my wisdom. It's a collective shared wisdom that's evolved and will continue to evolve. But thank you.

SPEAKER_01 18:54

And a reminder for listeners keen to know more, you can click the link in the show notes to have a free seven-day trial of PhysioNetwork and access Kevin's practical. I'm Sarah Yule, and thank you for listening to Physio Explained. it.