Low Back Pain: It's Time for a Different Approach

raise the spectre of an ominous pathology or serious illness.

Second, there is little agreement on the source of pain or the best management for a large number of sufferers of LBP, particularly those who have dominant back pain with minor leg symptoms and no neurological findings.10 The unhelpful and misleading term non-specific low back pain leads to the initial treatment of acute LBP as a homogeneous entity using simple, standardized, "one size fits all" routines that are frequently ineffective.5,10 LBP is a heterogeneous affair, and all current research points to significantly better outcomes with a more specific and stratified clinical approach.11,12 Although there is no uniform agreement as to the best non-surgical management, it is agreed that doing something active is better than adopting a passive, dependent approach.13

This heterogeneity leads to a third problem, the "medicalization" of LBP.4 Medical training and societal expectations dictate that we must establish a cause for the pain and base our therapy on a recognized pathology. This makes sense for diseases for which there are reliable means of diagnosis and an associated remedy. But most patients complaining of LBP experience symptoms from a minor mechanical disturbance, not a disease. The severity of the pain, which can be extreme, does not reflect the seriousness of the underlying problem.

In the majority of cases, the issue is nothing more than the inevitable consequence of "wear and tear," with or without a specific aggravating event. The limited nature of the derangement makes a definitive diagnosis impossible.4,10,14,15 Looking for the source of back pain with computed tomography scans results in a 30% false-positive rate—the identification of genuine findings that are irrelevant to the patient's pain. Magnetic resonance imaging carries a lack of specificity that can exceed 80%.14,16 These imaging "abnormalities" generally do not correlate to the specific symptoms, pain severity or degree of disability. Ultimately, for the majority of low back complaints, obtaining spinal imaging does not improve patient outcomes.4,15 The demand for a test that tells us what is wrong is often driven by the patient and directly or indirectly by third-party payers who require a structural diagnosis even when none is available.4,17 The physical origins of back dominant pain are well recognized, but pinpointing the pain generator in a particular individual may not be possible.

Spinal imaging does, however, substantially increase resource utilization.4,14,18 The direct cost of the investigation is compounded by the subsequent unnecessary expense of a specialist consultation or further investigations. Unfounded concerns produce the indirect costs of lost work time and needless restrictions. It is difficult and time consuming to explain to a patient why a reported abnormality is not necessarily abnormal or in need of treatment or even related to the pain.18

Although current guidelines appropriately recommend a bio-psychosocial approach to LBP, as a result of their training, physicians tend to spend an inordinate amount of time and expense on the "bio" portion, particularly in trying to identify the source of pain.4,19 Yet the psychosocial aspects, the yellow flags of maladaptive behaviour and social dysfunction, are the most predictive factors for chronicity.20 Identifying and addressing the yellow flags is labour intensive. These steps may be outside the comfort zone of the primary care provider or seem unfeasible in a busy primary care practice.5,21 Unfortunately, the necessary services such as cognitive behavioural therapy are generally not covered by health care systems or insurance companies; as a result, many patients requiring these types of therapy do not get them in a timely manner or at all. It is difficult to resolve well-established maladaptive behaviours and easy to question