Commentary
Low back pain: Time to get off the treadmill*

https://doi.org/10.1067/mmt.2001.112009Get rights and content

Introduction

The present conceptual framework pertaining to low back pain (LBP) is useless for the individual practitioner. Granted, LBP is difficult to study and understand. It is often labeled “nonspecific,” “idiopathic,” “mechanical,” or “activity-related,” because it is usually impossible to make a specific diagnosis on the basis of obvious pathologic findings. Clearly, there have been some fundamental changes in the conceptual framework surrounding nonspecific LBP. The pathoanatomical and monocausal explanatory model (eg, spondylolisthesis) has largely given way to the biopsychosocial, and hence multicausal, concept.1

However, the literature in this area is vast and confusing, and though we have some knowledge about the causes of LBP from a public health perspective, we cannot use much of this information on an individual level. For example, it is still not possible to predict who will develop LBP or to determine what the reasons for such development are. Obviously, this renders successful primary prevention impossible.

It is also not known why some people recover fully from an attack of acute LBP and never or rarely experience it again whereas other people have numerous bouts of LBP and may even never recover at all. This renders prediction and secondary prevention impossible.

On the therapeutic side, we have lately seen a paradigm shift toward fitness, exercise therapy, spinal manipulation, and even no treatment at all (merely providing fear-reducing information and patient activation). However, although these methods of approach have been shown to produce positive results in some clinical studies, it is obvious that they do not suit all patients. In other words, we do not know, on an individual level, which patients can be helped, and of those who can be helped we do not know whether the choice of therapy will play any role in the treatment outcome. This renders prescription of treatment uncertain, inasmuch as the process is based on personal experience and intuition.

It is tempting to conclude that to get more streamlined information on the causes and cures of LBP, we simply require more research. However, before embarking on yet another epidemiologic or clinical study on LBP, we must consider the conceptual frame within which we operate. For that reason, it is interesting to look at this issue in some detail.

Section snippets

The 4 basic causal models

The way that we look at LBP, as a disease entity and in relation to its development, will determine our research strategy. Most of the research on LBP can be seen in terms of 4 basic causal models: (1) a single cause, a single disease; (2) a single cause, several diseases; (3) several causes, a single disease; (4) several causes, several diseases. Examples of how these models are used in epidemiologic research are given in Table 1.

. Examples of common causal models in relation to epidemiologic

A proposed fifth causal model: The subgroup concept

It is rare that researchers consider a fifth causal model— namely, that nonspecific LBP is made up of several distinct subentities, each with its own set of causes and thus with its own set of cures, as illustrated in Fig 1.

. Nonspecific low back pain (large circle) may consist of a number of largely unidentified subentities (smaller circles LBP1, LBP2, etc), each having its own set of causal mechanisms (C1, C2, etc).

If this model is correct, then the results of studies would be expected to vary

A strategy for identifying subgroups of LBP

Subgroups could be identified through (1) studies of their association with risk factors, (2) observations of their clinical picture, recovery pattern and natural course, (3) experimental studies, (4) outcome studies, and (5) randomized controlled clinical trials. For some examples, see Table 2.

. Suggested methods of identifying subgroups of LBP

MethodDescription
Identifying subgroups through their association with nonspecific LBP.It might be possible to identify specific subgroups of LBP by

Closing the gap

Ideally, when a number of logical, reproducible, and clinically relevant subgroups of LBP have been identified, they should be tested against suitable treatment methods, such as exercise for the inactivity-induced LBP, rest for the overactivity-induced LBP, ergonomic changes for the posture-induced LBP, spinal manipulation for the mechanical-features LBP, anti-inflammatory treatment for the cyclic LBP, and pain behavior modification for patients who exhibit inappropriate pain behavior. Perhaps

Acknowledgements

A. Jordan, DC, PhD, is gratefully acknowledged for editorial comments.

First page preview

First page preview
Click to open first page preview
View PDF

References (12)

There are more references available in the full text version of this article.

Cited by (38)

  • Predictors of pain intensity and Oswestry Disability Index in prolonged standing service workers with nonspecific chronic low back pain subclassified as active extension pattern

    2019, Musculoskeletal Science and Practice
    Citation Excerpt :

    In previous studies, NSCLBP was tentatively subclassified based on movement and motor control impairments (O'Sullivan, 2005; Sahrmann, 2002). Due to a lack of success in defining subgroups to design effective treatments for NSCLBP, further studies focused on establishing classification systems distinguishing subgroups of LBP (Leboeuf-Yde et al., 1997; Leboeuf-Yde and Manniche, 2001; Borkan et al., 1998). Classification of subgroups is necessary for effective NSCLBP intervention guidelines due to the “wash-out effect”, where the findings for one subgroup are “washed out” by opposite findings in another subgroup (Rose, 1989).

  • Effect of movement control and stabilization exercises in people with extension related non -specific low back pain- a pilot study

    2017, Journal of Bodywork and Movement Therapies

  • Exploring the Definition of Acute Low Back Pain: A Prospective Observational Cohort Study Comparing Outcomes of Chiropractic Patients with 0-2, 2-4, and 4-12 Weeks of Symptoms

    2016, Journal of Manipulative and Physiological Therapeutics

  • Patient characteristics in low back pain subgroups based on an existing classification system. A descriptive cohort study in chiropractic practice

    2014, Manual Therapy
    Citation Excerpt :

    Low back pain (LBP) is the cause of a high number of health care consultations, but provable treatment effects are modest and different treatments seem to have more or less the same effects (van Middelkoop et al., 2010; Rubinstein et al., 2011; Standaert et al., 2011). This has partly been attributed to the fact that randomised controlled trials often investigate the effect of a ‘one size fits all’ approach in which all patients with non-specific LBP have the same type of care, and it has been suggested that treatment effects may be improved by classification of non-specific LBP into homogeneous subgroups that can guide the choice of treatment (Leboeuf-Yde and Manniche, 2001; Kent and Keating, 2004; Hill et al., 2011). In 1987, the biopsychosocial model was suggested as a theoretical framework for the treatment of LBP (Waddell, 1987) and in the absence of specific diagnoses with consequences for outcome, profiling patients on the basis of biological, psychological and social prognostic factors appears relevant (Hemingway et al., 2013).

  • Reliability and measurement error of 3-dimensional regional lumbar motion measures: A systematic review

    2012, Journal of Manipulative and Physiological Therapeutics

  • Musculoskeletal myths

    2012, Journal of Bodywork and Movement Therapies
View all citing articles on Scopus
*

bBack Clinic, Ringe Hospital and University of Southern Denmark.

View full text
Copyright © 2001 JMPT. Published by Mosby, Inc. All rights reserved.