Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?
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Over 20 years ago the term non-specific low back pain became popular to convey the limitations of our knowledge of the pathological source of most people’s low back pain. Knowledge of underlying pathology has advanced little since then, despite limited improvements in outcomes for patients with low back pain.
This paper discusses potential misunderstandings related to diagnostic studies in the field of low back pain and argues that future diagnostic studies should include and investigate pathological sources of low back pain.
Six potential misunderstandings are discussed. (1) Until diagnosis is shown to improve outcomes it is not worth investigating; (2) without a gold standard it is not possible to investigate diagnosis of low back pain; (3) the presence of pathology in some people without low back pain means it is not important; (4) dismissal of the ability to diagnose low back pain in clinical guidelines is supported by the same level of evidence as recommendations for therapy; (5) suggesting use of a diagnostic test in research is misinterpreted as endorsing its use in current clinical practice; (6) we seem to have forgotten the ‘bio’ in biopsychosocial low back pain.
We believe the misunderstandings presented in this paper partly explain the lack of investigation into pathology as an important component of the low back pain experience. A better understanding of the biological component of low back pain in relation, and in addition, to psychosocial factors is important for a more rational approach to management of low back pain.
KeywordsLow back pain Diagnosis Back pain
The authors thank Michele Battié for her constructive comments during manuscript preparation.
Conflict of interest
- 3.Anonymous (1987) Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 12:S1–59Google Scholar
- 8.Bogduk N (2005) Low back pain. In: Clinical anatomy of the lumbar spine and sacrum. Elsevier, Sydney, pp. 183–216Google Scholar
- 12.Marshall BJ (1983) Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1:1273–1275Google Scholar
- 13.Rutjes AW, Reitsma JB, Coomarasamy A, Khan KS, Bossuyt PM (2007) Evaluation of diagnostic tests when there is no gold standard. A review of methods. Health Technol Assess 11(50):iii, ix-51Google Scholar
- 21.van Tulder M, Becker A, Bekkering T, Breen A, del Real MTG, Hutchinson A, Koes B, Laerum E, Malmivaara A, On behalf of the Cost B. Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care (2006) Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 15(Suppl 2):S169–S191PubMedCrossRefGoogle Scholar
- 26.Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L (2010) The immediate reduction in low back pain intensity following lumbar joint mobilization and prone press-ups is associated with increased diffusion of water in the L5–S1 intervertebral disc. J Orthop Sports Phys Ther 40:256–264PubMedGoogle Scholar