Advertisement

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. Hancock
  • Chris G. Maher
  • Mark Laslett
  • Elaine Hay
  • Bart Koes
Review Article

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusions

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.

Keywords

Low back pain Diagnosis Back pain 

Notes

Acknowledgments

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

Conflict of interest

None.

References

  1. 1.
    Mixter WJ, Barr JS (1934) Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 211:210–214CrossRefGoogle Scholar
  2. 2.
    Waddell G (1987) 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine 12:632–644PubMedCrossRefGoogle Scholar
  3. 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
  4. 4.
    Koes BW, van Tulder MW, Ostelo R, Kim Burton A, Waddell G (2001) Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 26:2504–2513PubMedCrossRefGoogle Scholar
  5. 5.
    Deyo RA (2004) Treatments for back pain: can we get past trivial effects? Ann Intern Med 141:957–958PubMedGoogle Scholar
  6. 6.
    Machado LA, Kamper SJ, Herbert RD, Maher CG, McAuley JH (2009) Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology (Oxford) 48:520–527CrossRefGoogle Scholar
  7. 7.
    Deyo RA, Weinstein JN (2001) Low back pain. N Engl J Med 344:363–370PubMedCrossRefGoogle Scholar
  8. 8.
    Bogduk N (2005) Low back pain. In: Clinical anatomy of the lumbar spine and sacrum. Elsevier, Sydney, pp. 183–216Google Scholar
  9. 9.
    Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK (2007) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147:478–491PubMedGoogle Scholar
  10. 10.
    Carragee EJ, Lincoln T, Parmar VS, Alamin T (2006) A gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine 31:2115–2123PubMedCrossRefGoogle Scholar
  11. 11.
    Peng B, Pang X, Wu Y, Zhao C, Song X (2010) A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain. Pain 149:124–129PubMedCrossRefGoogle Scholar
  12. 12.
    Marshall BJ (1983) Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1:1273–1275Google Scholar
  13. 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
  14. 14.
    Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW (1990) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 72:403–408PubMedGoogle Scholar
  15. 15.
    Jarvik JJ, Hollingworth W, Heagerty P, Haynor DR, Deyo RA (2001) The longitudinal assessment of imaging and disability of the back (laidback) study: baseline data. Spine 26:1158–1166PubMedCrossRefGoogle Scholar
  16. 16.
    Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 331:69–73PubMedCrossRefGoogle Scholar
  17. 17.
    Duncan R, Peat G, Thomas E, Hay E, McCall I, Croft P (2007) Symptoms and radiographic osteoarthritis: not as discordant as they are made out to be? Ann Rheum Dis 66:86–91PubMedCrossRefGoogle Scholar
  18. 18.
    Cheung KM, Karppinen J, Chan D, Ho DW, Song YQ, Sham P, Cheah KS, Leong JC, Luk KD (2009) Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals. Spine 34:934–940PubMedCrossRefGoogle Scholar
  19. 19.
    de Schepper EI, Damen J, van Meurs JB, Ginai AZ, Popham M, Hofman A, Koes BW, Bierma-Zeinstra SM (2010) The association between lumbar disc degeneration and low back pain: the influence of age, gender, and individual radiographic features. Spine 35:531–536PubMedCrossRefGoogle Scholar
  20. 20.
    Jensen TS, Karppinen J, Sorensen JS, Niinimaki J, Leboeuf-Yde C (2008) Vertebral endplate signal changes (Modic change): a systematic literature review of prevalence and association with non-specific low back pain. Eur Spine J 17:1407–1422PubMedCrossRefGoogle Scholar
  21. 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
  22. 22.
    Stanton TR, Henschke N, Maher CG, Refshauge KM, Latimer J, McAuley JH (2008) After an episode of acute low back pain, recurrence is unpredictable and not as common as previously thought. Spine 33:2923–2928PubMedCrossRefGoogle Scholar
  23. 23.
    Hayden JA, Chou R, Hogg-Johnson S, Bombardier C (2009) Systematic reviews of low back pain prognosis had variable methods and results: guidance for future prognosis reviews. J Clin Epidemiol 62:781–796PubMedCrossRefGoogle Scholar
  24. 24.
    Kent PM, Keating JL, Kent PM, Keating JL (2008) Can we predict poor recovery from recent-onset nonspecific low back pain? A systematic review. Manual Ther 13:12–28CrossRefGoogle Scholar
  25. 25.
    Henschke N, Maher CG, Refshauge KM, Das A, McAuley JH (2007) Low back pain research priorities: a survey of primary care practitioners. BMC Fam Pract 8:40PubMedCrossRefGoogle Scholar
  26. 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
  27. 27.
    Hides JA, Jull GA, Richardson CA (2001) Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 26:E243–E248PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Mark J. Hancock
    • 1
  • 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

Personalised recommendations