Public health

Reductionism wins over holistic approach to low back pain


Most people who have experienced low back pain adhere to the ‘fear avoidance model’, which they say is driven by the advice they receive mainly from health professionals and the internet.

According to a discourse analysis of patients’ perceptions about low back pain, many view their pain as ‘permanent’ and ‘immutable’ resulting from a biomechanical problem.

They also have a very negative view of low back pain – frequently using words such as ‘damage’ and ‘degeneration’.

The vast majority of participants (89%) in the online survey said their understanding of back pain came from a health professional.

Lead author Dr Jenny Setchell, a Research Fellow in the School of Health and Rehabilitation at the University of Queensland, told the limbic patients and health professionals would do better to embrace a broader biopsychosocial approach.

“Basically our current approach suits our general way of viewing the world which tends to be very reductionist – seeking one or a few simple truths.”

“But most back pain research is saying that it’s more complex than that.”

She said health professionals including doctors and physiotherapists hadn’t really developed their awareness of psychosocial factors beyond perhaps referring a patient with clear psychological issues on to a psychologist.

“It’s a really rich area that we can develop further. We can’t really stick with that Cartesian Divide anymore – where one professional deals with the psychological aspects and one deals with the physical because those things are so interlinked.”

She said there was some evidence from the analysis that patients understood the complexity of low back pain and influences on pain perception such as mood.

However the view that their body was ‘broken’ and needed to be ‘fixed’ was more common.

She said clinicians could start conversations with patients by explaining how complex low back pain could be. It was also reasonable to reassure patients that ‘dysfunction is sometimes okay’ and could be managed.

“We don’t have to be the perfect human or the smoothly working machine,” she said.

“Sometimes we can find a singular cause but it’s really rare and it’s really harmful to keep trying to seek that because people get disappointed, they feel at fault, that they haven’t for example exercised enough or consulted enough specialists.”

“Let’s get all the many possible contributing factors and put them on the table and consider which mix is appropriate for which patient. There’s probably no single, simple causative factor and when that is the case, it’s usually fairly obvious, for example clear radicular symptoms.”

She added that more multimodal approaches to low back pain via pain clinics were a step towards change.

However she and her co-authors acknowledged there was a long way to go to truly integrate the nuances of psychosocial and cultural factors into patient care.

“Changing such deeply held beliefs will not be simple – doing so challenges established institutions of healthcare and the very core of what it means to be a person with low back pain, a health researcher, and a clinician,” they wrote.

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