When patients want to know the reason and why they have pain, they are often told simple biomechanical and/or structural causes (Darlow et al. 2013, Setchell et al. 2017), such as lumbar lordosis, pelvic tilt, foot arch, leg length difference and so-called degenerative changes, just to name a few. As the reason why they have pain.
This seems like an ill-informed practice, because we have research stating that these structural factors (as a single factor) with high probability do not cause pain (Nourbakhsh et al. 2002, Brinjikji et al. 2014, Jarvik et al. 2005, Lederman 2011). The current clinical guidelines from American Physical Therapy Association go a step further and advice against providing pathoanatomical explanations for the specific cause of the patient’s low back pain (Delitto et al. 2012, Darlow et al. 2013)
A strong and informed argument could be made that we do not want to use patient counseling strategies that increase the perceived threat or fear of any patient, not only with patients who have low back pain.
By reducing the cause of pain to a single event or factor, we make our patients a disfavor, and we are providing them a disadvantage in their road to recovery. When we reduce the cause of pain to one single event, we are in my opinion doing a huge disservice to our patients, and we are ourselves committing the fallacy of the single cause, also known as causal oversimplification (Damer 2009). We are effectively putting our head in the sand to what we have learned from the last 30 years of pain research and science – That pain is a complex personal experience.
“We tend to endorse the complexity of the brain and its fundamental role in what we experience. Unless, of course, we are talking about pain.” Moseley 2012
Research has shown us that there are many factors that influence pain, and that pain is a multi-factorial experience (Melzack et al. 2013). Implying that there is only one single cause, we fail to acknowledge the complexity of the brain and its fundamental role in what we experience. Pain is never straightforward, even when it appears to be.
“Pain can no longer be regarded as merely a physical sensation of noxious stimulus and disease, but conscious experience of pain may be modulated by mental, emotional, and sensory mechanisms and includes both sensory and emotional components” Waddell 1987
“Pain is not simply the end product of a linear sensory transmission system; it is a dynamic process that involves continuous interactions among complex ascending and descending systems. The neuromatrix theory guides us away from the Cartesian concept of pain as a sensation produced by injury, inflammation, or other tissue pathology and toward the concept of pain as a multidimensional experience produced by multiple influences” Melzack et al. 2013
“Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components.” Williams et al. 2016
“Pain is a mutually recognizable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity.” Cohen et al. 2018
The real losers in this event are our clients. Because when we are choosing to only focus on (or search for) one single cause of our clients pain, we are simultaneously choosing to be blind, to all of the multiple other possible contributors of our client’s pain. Thereby drastically reducing, the possible solutions to our clients pain.
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Damer, T. Edward. Attacking faulty reasoning : a practical guide to fallacy-free arguments. Wadsworth, 6 edition (2009).
Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013 Nov-Dec;11(6):527-34.
Delitto A, George SZ, Van Dillen LR, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-57. Epub 2012 Mar 30.
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Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine (Phila Pa 1976). 2005 Jul 1;30(13):1541-8; discussion 1549.
Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. 2011 Apr;15(2):131-8.
Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.
Nourbakhsh MR, Arab AM. Relationship between mechanical factors and incidence of low back pain. J Orthop Sports Phys Ther. 2002 Sep;32(9):447-60.
Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine (Phila Pa 1976). 1987 Sep;12(7):632-44.
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Setchell J, Costa N, Ferreira M, Makovey J, Nielsen M, Hodges PW. Individuals’ explanations for their persistent or recurrent low back pain: a cross-sectional survey. BMC Musculoskelet Disord. 2017 Nov 17;18(1):466.