When it comes to LBP, there is “good news and bad news.” The bad news is that in almost all cases, there is not an identifiable cause for the pain and diagnostic tests are not useful. The good news is that in about 90 % of the cases, patients will recover in a few months, with or without the wide variety of treatments currently available (Hazards 1994). Deyo and Weinstein report that 30–60 % of patients recover in 1 week, 60–90 % in 6 weeks, and 95 % recover from LBP in 12 weeks (Deyo and Weinstein 2001).

Clearly, conservative treatment and a “wait and see” attitude toward LBP is appropriate, approaches which are the foundation of multidisciplinary rehabilitation treatment. When Denmark implemented multidisciplinary care which included education, conservative treatment and “watchful waiting,” it succeeded in cutting the rate of lumbar disk surgery in half in just 4 years (Rasmussen et al. 2005). “Between 1992 and 2001, the lumbar surgery rates in North Jutland County were reduced by approximately 50 %, with a steady downward trend,” wrote researchers in Spine. “The reduction was even higher for elective first-time surgery.”

In a Journal of the American Medical Association (JAMA) editorial Hadler et al. submit that LBP is overdiagnosed and overtreated, especially due to its financial relationship to workplace injuries (Hadler et al. 2007). “The back ‘injury’ construct holds that physical demands that render the pain less tolerable are the proximate cause of the back pain and hence the agent of ‘injury,’” they write. Yet, back pain can no more be said to be “caused” by the workplace than the common cold, they contend.

Because of its huge costs to patients and employers in lost work time, researchers have sought predictors of LBP. In a JAMA article titled, “Will This Patient Develop Persistent Disabling Back Pain?,” Chou and Shekelle present the case of a 48-year-old woman who has missed three work days due to LBP, has a history of chronic depression and is avoiding her usual activities and exercise and ask if she can be expected to develop “persistent disabling LBP” (Chou and Shekelle 2010). Not surprisingly, the researchers conclude that a patient’s tendency toward depression and fear and avoidance of regular activities can indeed predict that her LBP will become chronic or disabling. The most helpful predictors, write Chou and Shekelle, are “maladaptive pain coping behaviors, nonorganic signs, functional impairment…and a presence of psychiatric comorbidities.”

Vranceanu et al. have also examined the relationship between psychological states and disability from pain. “Research has established that a patient’s attitudes, beliefs, expectations, and coping resources can increase or diminish pain intensity and pain-related disability,” they write (2009). “Examples include misinterpretation or overinterpretation of pain as tissue damage rather than a temporary problem that will improve or a normal part of daily life, a belief that pain and disability will last forever (which leads to a passive, fatalistic approach to coping), and interpretation of pain as a sign of serious disease or a reminder of our mortality.” The effect of emotional, cognitive, and psychological factors on pain is addressed in Chaps. 1, 2, 3, and 4 of this book.

As noted in those chapters, when we, as clinicians, reinforce patients’ illness behaviors such as groaning, limping, sighing, and abandoning their activities of daily living, their pain can often worsen. Nor does uncoordinated, unimodal pain treatment help, as it still tends to focus on the “pain” and not the “person” say Vranceanu et al. “In spite of the strong support for the biopsychosocial model of illness, many providers persist in a strictly biomedical approach. They may believe that the illness dimensions they are seeing are not within their domain or that any psychosocial issues will resolve after the nociception is addressed. Even providers who do appreciate the psychosocial dimensions of illness may have difficulty addressing them because of the stigmatization of psychological illness in our society as well as an exaggerated belief in their own abilities to heal,” write Vranceanu et al. (2009).

Multidisciplinary care is perceived by insurers and healthcare administrators to be more costly than unimodal care because of the team of medical professionals that may be deployed. But “costs may be offset by few lost wages or days off of work,” write Chou et al. in a comparison of interventional therapies, surgery, and multidisciplinary rehabilitation for LBP in the journal Spine (2009a, b, c). Multidisciplinary care “is moderately superior” to unimodal care, write the researchers, in improving short- and long-term functional status and “the most effective programs generally involve cognitive/behavioral and supervised exercise components with at least several sessions a week, with over 100 total hours of treatment.”

The persistence of unimodal treatments that are not evidence-based can be explained by the “intense competition by pharmaceutical companies, surgical instrument makers, and device manufacturers to convince stakeholders of the benefits of their products,” says Haldeman and Dagenais (2008). “Only rarely do such promotional materials accurately present the scientific evidence underpinning a particular approach, and rarer still are discussions of potential harms.” Haldeman lists 100 available and marketed treatments for LBP in the Spine Journal. Many and perhaps most lack an evidence base.

Epidural injections, for example, may help significantly in a few selected patients with nerve root irritation, but is overutilized, especially in patients with “chronic nonspecific LBP” write Chou et al. (2009a, b, c). The overuse of lumbar fusions and other surgeries despite the lack of evidence for their effectiveness, has produced a cohort of patients with failed back surgery syndrome (FBSS), write the researchers, a term for patients with persistent pain after they had surgeries, a condition rarely seen in countries other than the United States. In radiculopathy, epidural steroids decreased short-term pain compared to placebo; however, results were inconsistent and there were no effects on chronic pain or the need for surgery (Deyo and Chou 2014). Studies of injections for spinal stenosis associated with neurogenic claudication showed no benefits over placebo and the evidence for a benefit of epidural corticosteroids for axial back pain is sparse, say the researchers.

Even though he is a spine surgeon himself, David Hanscom, M.D., sees a broken healthcare system in the phenomenon of FBSS “a significant percentage” of which “could have been avoided with comprehensive rehabilitation” (Hanscom 2012). “In spite of my surgeon’s bent-to-perform surgery, the most satisfying part of my practice is directing patients into a structured rehab program,” he writes. LBP patients who received work hardening/work conditioning but not surgery had five times fewer physician visits than those who had surgery and they were half as likely to go on to have surgery reports Rogers et al. (2013). The diagnosis may be a “catch all” category, suggests the International Association for the Study of Pain’s task force on pain in the workplace, noting that “fewer than 15 % of persons with back pain can be assigned to one of these categories of specific LBP” (Fordyce 1995).

There are many factors that contribute to LBP though few can be pinpointed in diagnostic imagery or laboratory tests. Here are some common causes of this frequent condition which are highlighted in Table 9.1.