Low back pain: Time to get off the treadmill

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.