Part 1 - Introduction to Low Back pain
Most humans will experience low back pain (LBP) at some point in their life. Despite the prevalence of LBP, there remains significant misinformation surrounding why it occurs. In this guide we will bring clarity to the discussion based on current research evidence, while outlining a path forward for management. Let's get started.
What is low back pain?
Low back pain is defined as pain that occurs below the 12th ribs to the inferior gluteal folds and may be associated with leg symptoms. Hartvigsen 2018 Globally, low back pain is the leading cause of disability. In 2017, the global rate of activity limiting low back pain was estimated at 7.5%, which means there were approximately 577 million people dealing with this issue at that time. Wu 2020 In other words, if someone is experiencing low back pain, they are not alone. The question becomes, what should be done about the experience?
What is the meaning of low back pain?
Traditionally, healthcare has examined low back pain as a biological issue which has influenced general population understanding. Ray 2022 Darlow 2013 Setchell 2017 Lutz et al researched our approach to low back pain over the course of the 20th century, and found that clinicians tend to prefer organic, “visible” diagnoses for low back pain. Clinicians also tend to place their trust in technical diagnostic results (e.g., X-rays or MRIs) more than their own clinical judgment. Lutz 2003 Such an approach reflects a “biomedical” model used to assess and understand low back pain. The biomedical model attempts to explain phenomena through a linear cause-and-effect perspective. For example, it operates from the premise that any symptom (e.g., pain) reflects an underlying problem in the tissues (“pathology”). Additionally, the model presupposes that the intensity of pain is directly proportional to the extent of tissue damage, a common belief amongst general population as well. Furthermore, proponents of this model assume once this tissue pathology has been treated, then the patient will be healed, and symptoms will inevitably resolve.
An important consequence of this approach, if a clear pathological source driving the patient's pain cannot be identified, then the patient's experience is doubted, or worse, disbelieved. This approach often leads to dismissive treatment of the patient's pain experience, or applying a psychogenic label suggesting the patient's symptoms are "all in their head". One of the major flaws of the biomedical model is perpetuating a dualistic approach to human experiences. Duality is the idea that the forces governing the body are somehow separate from the forces governing the mind. Dualism can be traced back to Descartes’ era, when the church reigned supreme and classical science was rooted in extreme reductionism, analyzing the parts to understand the whole. Granted, although any model by nature has an element of reductionism to facilitate our understanding, we’ve since expanded beyond merely assessing biological drivers for pain.
The mind-body dualism in healthcare has unfortunately allowed an inaccurate metaphor to permeate the clinician-patient encounter; specifically, the idea of the human “Body as Machine”. Such an analogy makes the assumption that disease is a result of the bodily “machine” breaking down, thus leaving the clinician with the task of performing mechanical repairs to “fix” the patient. Although the biomedical model is popular, the approach has important flaws that often lead to unnecessary investigations in search of a ‘holy grail’ diagnosis to rationalize unhelpful interventions. Toye 2017 In the case of low back pain, radiological imaging like x-rays, CT scans, and MRIs are frequently ordered to find deviations from textbook “norms”. We are obviously not machines and although this approach is appealing, the drawbacks include increasing patient worry, misdirected problem solving, disability, distress, and increased attention to pain. Durnez 2017
Due to the overreliance on imaging, we've seen an expanding biomedical word bank of diagnostic labels to assign patients dealing with low back pain. These labels include things like “degenerative disc disease”, “spinal stenosis”, “spondylolysis”, “spondylolisthesis”, “scoliosis”, “disc herniation”, and “arthritis”, to name a few. These labels not only tend to be overly reductionist, but can have substantial negative effects on the patient. O'Keefe et al recently assessed how 1375 participants' views of diagnostic labels for low back pain influenced expectations for management such as imaging or surgery. The authors found amongst participants with and without low back pain certain diagnostic labels such as episode of back pain, lumbar sprain, and non-specific LBP, reduced participants' perceived need for imaging, surgery, and a second opinion when compared to other labels such as arthritis, degeneration, and disc bulge. Specific diagnostic labels, such as lumbar sprain, non-specific LBP, and episode of back pain, also reduced participants' perceived seriousness of LBP and increased recovery expectations. O'Keefe 2022