The vast majority of patients who seek medical attention for lower back pain (LBP) never determine the precise cause of their pain. LBP is one of the most pressing medical issues of our time, with 6-9% of adults consulting a medical professional for the condition annually (1). On a global scale, LBP is the cause of more years of medical disability than any other medical condition (2). Within the large number of individuals seeking care for this condition, 90% of patients walk away with the same diagnosis: non-specific LBP (3). For patients diagnosed with non-specific LBP, no underlying biological condition is identified (4). This pattern is in line with current practice guidelines that encourage medical professionals to diagnose patients’ sources of LBP as non-specific (3). The high percentage of non-specific LBP diagnoses stems in part, from adherence to the biopsychosocial model of LBP first introduced in 1987 (3). This model suggests that LBP arises from a confluence of biological, psychological and social factors and therefore must be analyzed and treated from all three standpoints (5). The use of the biopsychosocial model of LBP and the non-specific LBP diagnosis heavily influence the treatment options available to LBP patients and how medical professionals treat LBP patients.
The biopsychosocial model of LBP is widely used today for a variety of reasons. Traditional medical models involving interactions between the patient and their illness are difficult to use when the precise biological cause of pain is unknown, as is often the case in LBP patients (4). Furthermore, a large body of research has demonstrated that psychological and social factors influence LBP to an equal or greater extent when compared to biological factors (6). Chronic LBP can lead to anxiety, depression and social issues, further highlighting the strong interactions between LBP and an individual’s psychosocial wellbeing (2). The biopsychosocial model was developed as a tool for medical professionals to address the risks and complications that may arise from the psychosocial aspects of LBP. The biopsychosocial model incorporates a wide variety of factors (such as cultural considerations, complex family situations, etc) that are not usually considered in the traditional biomedical model of treatment and that may interfere with recovery (4). Medical professionals then take these factors into consideration when drafting a treatment plan for the patient’s condition (4).
The numerous aspects of LBP that must be considered as part of the biopsychosocial method have led to the development of an equally broad series of treatments for patients diagnosed with non-specific LBP. Many medical professionals recommend multidisciplinary rehabilitation to simultaneously address the biological and psychosocial aspects of an individual’s LBP (2). Multidisciplinary rehabilitation programs are customizable to the patient and may consist of exercise therapy, cognitive behavioral therapy, educational programs and more (4). Although meta-analyses have found multidisciplinary rehabilitation to be effective in certain individuals, it is expensive, time-consuming and often not strictly adhered to by patients (2, 4). For this reason, some professionals recommend multidisciplinary rehabilitation only to patients who are experiencing profound physical and psychosocial symptoms of LBP (2).
Despite widespread adherence to the biopsychosocial model of LBP, some medical professionals are concerned about the effects of not identifying the specific biological source of pain in LBP patients. With a diverse array of treatment options available to LBP patients, it is often difficult for a patient to be matched to the most effective treatment option without knowing the specific cause of their pain (1). The consequences of this difficulty can be seen in the statistics on LBP treatment efficacy: virtually no LBP treatment leads to substantial, long-term improvement (1). Increasing the usage of precise diagnoses could move this trend in a positive direction by allowing patients to be matched to more appropriate treatments, or by leading to the development of new treatments that target specific biological origins of LBP (3).
In addition to creating treatment difficulties for patients, non-specific LBP diagnoses often make it tough for medical professionals to work with individuals suffering from LBP. Physicians and physiotherapists have highly variable conceptions about how long LBP should last and what activities a patient should be doing with LBP (7). An ambiguous diagnosis such as non-specific LBP makes the appropriate treatment less clear and leaves more room for a medical professional’s personal perspective to influence their treatment decisions (7). This theory was confirmed in a study examining the personal beliefs of PT students and how those beliefs impacted their treatment of LBP patients. The study found that PT students with high fear avoidance were more likely to recommend lessening activity in patients with LBP (6). Physiotherapists recognize that LBP is a particularly challenging condition to work with and therefore often do not feel that they have the tools to effectively treat those patients (8). Interviews with physiotherapists reveal that a particularly challenging aspect of treating LBP patients is communicating an unclear diagnosis and the appropriate next steps (8). Furthermore, physiotherapists are encouraged to adhere to the biopsychosocial model of LBP as much as possible, despite the fact that many do not feel comfortable addressing and treating the psychosocial aspects of LBP (7).
The biopsychosocial model allows for a holistic view of LBP and the related multidisciplinary rehabilitation programs ensure that all aspects of an individual’s LBP are addressed. However recent research has demonstrated that relying too heavily on the psychosocial aspects of LBP while not identifying the underlying biological condition can prove challenging for both patients and medical professionals. Esurgi is currently developing the Biostabilizer: a pressure-biofeedback unit that gives immediate feedback to patients completing core strengthening exercises. Innovations such as the Biostabilizer offer concrete data on rehabilitation to patients who may be seeking clarity following an ambiguous diagnosis. Would you find the Biostabilizer helpful for treating patients with non-specific LBP?
2. Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & Van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. Bmj, 350. DOI: 10.1136/bmj.h444
3. Hancock, M. J., Maher, C. G., Laslett, M., Hay, E., & Koes, B. (2011). Discussion paper: what happened to the ‘bio’in the bio-psycho-social model of low back pain?. European Spine Journal, 20(12), 2105-2110. DOI: 10.1007/s00586-011-1886-3
4. Nordin, M., Balague, F., & Cedraschi, C. (2006). Nonspecific lower-back pain: surgical versus nonsurgical treatment. Clinical Orthopaedics and Related Research®, 443, 156-167. DOI: 10.1097/01.blo.0000198721.75976.d9
6. Domenech, J., Sánchez-Zuriaga, D., Segura-Ortí, E., Espejo-Tort, B., & Lisón, J. F. (2011). Impact of biomedical and biopsychosocial training sessions on the attitudes, beliefs, and recommendations of health care providers about low back pain: a randomised clinical trial. Pain, 152(11), 2557-2563. DOI: 10.1016/j.pain.2011.07.023
7. Sanders, T., Foster, N. E., Bishop, A., & Ong, B. N. (2013). Biopsychosocial care and the physiotherapy encounter: Physiotherapists’ accounts of back pain consultations. BMC Musculoskeletal Disorders, 14(1). doi:10.1186/1471-2474-14-65
8. Slade, S. C., Molloy, E., & Keating, J. L. (2011). The dilemma of diagnostic uncertainty when treating people with chronic low back pain: A qualitative study. Clinical Rehabilitation, 26(6), 558-569. doi:10.1177/0269215511420179