The Bio-psychosocial Model and Multimodal Care for back pain
Low back pain can be confusing for patients and clinicians alike. On the one hand, patients are often told myths about structure, the cause, posture; but best evidence suggests that this is a simplified and often wrong understanding of the condition. (See Hartvigsen et al for a free publication).
You may have been told that there is a single cause of your back pain by a trusted clinician. There are some benefits to having a simple answer. These include a simple narrative and having confidence in your clinician. However, there are some very obvious shortcomings to a simple answer. For example, often times your condition will not respond. Or, worse, you may find yourself with chronic pain which no longer fits the original narrative you were told about your condition. What then? Is it possible that the explanation you originally received is only partially true; or, could it be completely wrong?
Our understanding of low back pain has moved through a variety of models of care. In the past, we used a biomedical and patho-anatomical model. These models attempted to explain low back pain as "caused" by a specific, structural tissue. A disc; a ligament; a posture; a nerve; core muscle weakness.
We now know from quite strong evidence that these narratives are incorrect. How do we know this? Well, the data doesn't seem to fit the old model of explination. While biological structures play a role, there are other components that play an even stronger role in your outcomes for back pain. And they are often counter-intuitive. These include things like stress, the workplace, your daily routine, your sleep, your socioeconomic status.
Management now includes multimodal and multidisciplinary methodologies. While physical therapies, chiropractic, osteopathic techniques may play one role, there are other methodologies that play an even greater role. Exercise is one example. But another example is cognitive behavioural therapy. Or mindfulness based stress reduction. Unfortunately, no single treatment stands out as the unimodal, go-to treatment for chronic low back pain. Taken together, though, there is some evidence to suggest that outcomes improve. For example, chronic low back pain patients who have had poor initial outcomes, but who attend multidisciplinary teams are more likely to end up returning to work in the long run compared to those seeking physical therapy alone (Kamper et al).
What does all of this mean?
There are different structures in your back that cause nociception (pain). Imaging (MRI,CT,Xray etc...) can't locate the specific cause of low back pain in 90% of cases. If your practitioner says they can, well, they might be either misinformed, ignorant or well meaning, but it's just not the case that specific tissues are the cause of your back pain. The newest model of care suggests a diagnosis of non-specific low back pain, a lumbar sprain, or an episode of low back pain are the most useful descriptions of low back pain in most cases.
A variety of treatments work. There is evidence for exercise, chiropractic adjustments/spinal manipulation, dry needling; cognitive behavioural therapy CBT, Mindfulness Based Stress Reduction and psychological therapies also help some patients, but the benefit is small.
Although counter-intuitive, part of the rehabilitation process is to soldier on with normal duties. This includes returning to work early, rather than waiting for your back to get better first, and then returning to work. The return to work is part of your rehabilitation process. While this may seem problematic, the evidence is quite strong in this area. So, if you really want the best possible outcome, try to return to work quickly.
Augeard N, Carroll SP. Core stability and low-back pain: a causal fallacy. J Exerc Rehabil. 2019 Jun 30;15(3):493-495. doi: 10.12965/jer.1938198.099. PMID: 31316947; PMCID: PMC6614774.
Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 9;391(10137):2356-2367. doi: 10.1016/S0140-6736(18)30480-X. Epub 2018 Mar 21. PMID: 29573870.
Kamper S J, Apeldoorn A T, Chiarotto A, Smeets R J E M, Ostelo R W J G, Guzman J et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis BMJ 2015; 350 :h444 doi:10.1136/bmj.h444
O’Keeffe, M., Ferreira, G. E., Harris, I. A., Darlow, B., Buchbinder, R., Traeger, A. C., Zadro, J. R., Herbert, R. D., Thomas, R., Belton, J., & Maher, C. G. (2022). Effect of diagnostic labelling on management intentions for non-specific low back pain: A randomized scenario-based experiment. European Journal of Pain, 00, 1– 14. https://doi.org/10.1002/ejp.1981