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Low back pain & why it's more complex than you think


Between the years 1990 and 2010, disability resulting from low back pain increased by 43% internationally, while the overall prevalence did not change significantly [1]. This trend may indicate a need to reevaluate how we address low back pain.


The Biomedical Model


Conventional treatments are bound by the biomedical perspective, which believes that symptoms must come from damaged parts. This model probes for structural issues in the vicinity of symptoms and attempts to correct said issues to eliminate pain. When searching for the source of pain, imaging (x-ray, MRI, etc.) is often utilized as a primary diagnostic tool. If an abnormality is located visually, it is presumed to be the pain generator. Additional analysis strategies include a postural assessment, range of motion measurements, and manual palpation. Treatment is then implemented to specifically correct the structural issues seen on imaging or movement issues detected through other analyses. Corrective methods under the biomedical model include, but are not limited to, surgery, injections, massage, and manipulations [1]. Although this simplistic approach is logical, it often fails to address the intricacies of the individual pain experience. Viewing the human body as a machine with malfunctioning parts may not be the best way to address low back pain. The cornerstone of this model is a reliance on structural and movement disability to explain the pain. Dependence on labeling disability to justify treatment may clarify the increase in rates of disability.

Although this simplistic approach is logical, it often fails to address the intricacies of the individual pain experience.

What happens if pain is present, but no broken parts can be found? Many people are left feeling helpless when imaging is unremarkable, the range of motion is within normal limits and posture cannot explain their symptoms. If pain cannot be explained, treatments may be applied haphazardly. Pain persists, disability ensues and a perpetual reliance on healthcare is created. The healthcare system tends to dispense pain management for nonspecific low back pain in the form of medication, surgery, or perpetual manual therapy.


The Biopsychosocial Model


Based on the prevalence of low back pain and the increase in related disability, there is an evident need for alternatives to the biomedical perspective. Let us now consider the biopsychosocial model as a substitute. This thought process assumes that pain is more complex and multidimensional than structural flaws alone [1]. In order to treat pain effectively, it behooves the clinician to consider structural concerns within the context of the patient’s unique psychological and social relationships to pain and disability. For example, people with similar lumbar disc bulges may experience an array of pain ranging from excruciating to non-existent. How can this spectrum be possible if pain is merely a symptom of broken hardware? Identical structural defects should ideally produce identical symptoms. This model seeks to understand why different patients with the same diagnosis have diverse pain experiences. It attempts to highlight and leverage each patient’s unique needs, personal beliefs, and treatment goals. The objective is to “overcome a linear, reductionist perspective of the human body in which illness is considered to be caused by malfunction of its parts” [1]. Health is a complicated and ever-changing mosaic. Pain and illness are moving targets that need to be continuously reassessed based on contextual factors for each patient.

Health is a complicated and ever-changing mosaic.

Pain management within the biopsychosocial model includes all of the traditional tools used in the biomedical model; however, the use of these tools is not necessarily driven by malfunctioning or abnormal structures. A clinician will consider the patient’s history, beliefs, limitations, future goals, and any other factor that may influence the pain and disability experience. All of these components are incorporated into the management plan. Patients are not simply categorized as low back pain cases; but rather, they are separated, evaluated, and treated based on their own uniqueness.

Patients are not simply categorized as low back pain cases; but rather, they are separated, evaluated, and treated based on their own uniqueness.

In order for the biopsychosocial model to work, it is necessary for the patient to be involved as a codesigner of their own treatment plan [1]. Management must be guided by patient-specific beliefs and goals because clinical outcomes are useless if they do not help patients improve their daily life. The codesign process empowers patients to alter their treatment plans to better meet their needs which increases the likelihood that success in the clinic will translate to success in real life [1].


Biomedical tools such as diagnostic imaging, range of motion measurements, manual palpation, surgery, medication, soft tissue therapy, manipulation, and exercise are important and should not be discarded. The biopsychosocial model seeks to augment these tools with relevant psychological and social drivers of pain and disability. Using biomedical tools in context with patient-specific goals, concerns and beliefs improves treatment outcomes. A patient cares less about increased joint range of motion measured in the clinic and more about whether or not that increased range of motion translates to less painful daily activities. The biopsychosocial model analyzes success from the patient perspective and not from biomedical measurements and test results.

Using biomedical tools in context with patient-specific goals, concerns and beliefs improves treatment outcomes.

Netley Chiropractic acknowledges the need for patients to be active participants in the design and implementation of their own care. We learn as much as we can about our patients and blend that information with our clinical findings to create pain management strategies. Dr. Netley strives to accurately diagnose each patient, but not categorize and treat individuals solely based on their biomedical diagnosis. Netley Chiropractic offers low force and non-force techniques such as the Activator Method, McKenzie (MDT), and Mulligan Mobilization with Movement in addition to a wide variety of therapeutic exercises. Treatment plans are designed to achieve your goals and are structured based on your individual strengths, limitations, and preferences.


Low back pain is complex and multidimensional [1] and Netley Chiropractic is here to help.


Source:

Hush, J. M. (2020). Low back pain: It is time to embrace complexity. Pain,161(10), 2248. doi:10.1097/j.pain.0000000000001933