European Spine Journal

, Volume 20, Issue 12, pp 2105–2110 | Cite as

Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?

  • Mark J. HancockEmail author
  • Chris G. Maher
  • Mark Laslett
  • Elaine Hay
  • Bart Koes
Review Article



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.


Low back pain Diagnosis Back pain 



The authors thank Michele Battié for her constructive comments during manuscript preparation.

Conflict of interest



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Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Mark J. Hancock
    • 1
    Email author
  • Chris G. Maher
    • 2
  • Mark Laslett
    • 3
  • Elaine Hay
    • 4
  • Bart Koes
    • 5
  1. 1.Faculty of Health SciencesUniversity of SydneyLidcombeAustralia
  2. 2.The George Institute for Global HealthUniversity of SydneySydneyAustralia
  3. 3.School of Rehabilitation and Occupational Studies, Health and Rehabilitation Research CentreAuckland University of TechnologyAucklandNew Zealand
  4. 4.Arthritis Research UK Primary Care CentreKeele UniversityKeeleUK
  5. 5.Department of General PracticeErasmus University Medical CentreRotterdamThe Netherlands

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