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Low back pain (LBP) is the second greatest cause of disability in the USA.1 USA data supports that in spite of an enormous increase in the health resources spent on LBP disorders, the disability relating to them continues to increase.2 The management of LBP is underpinned by the exponential increase in the use of physical therapies, opiod medications, spinal injections as well as disc replacement and fusion surgery.2 This is maintained by the underlying belief that LBP is fundamentally a patho-anatomical disorder and should be treated within a biomedical model.1 This is in spite of calls over a number of years to adopt a bio-psycho-social approach, and evidence that only 8–15% of patients with LBP have an identified patho-anatomical diagnosis, resulting in the majority being diagnosed as having non-specific LBP.3 Of this population, a small but significant group becomes chronic and disabled, labelled non-specific chronic low back pain (NSCLBP), consuming a disproportionate amount of healthcare resources.4
Over the past decade, the traditional biomedical view of LBP has been greatly challenged. This is a result of: the failure of simplistic single-dimensional therapies to show large effects in patients with NSCLBP5–8;
the results of clinical trials testing commonly prescribed interventions demonstrating that no management approaches are clearly superior5–7 9;
the stories of NSCLBP patients relating their own ongoing pain experiences of multiple failed treatments, conflicting diagnoses, lost hope and ongoing suffering10;
the indisputable evidence supporting the multidimensional nature of NSCLBP as a disorder, where disability levels are more closely associated with cognitive and behavioural aspects of pain rather than sensory and biomedical ones11 12;
positive outcomes in randomised controlled trials (RCTs) are best predicted by changes in psychological distress, fear avoidance beliefs, self-efficacy in …
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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