A critical review of the biopsychosocial model of low back pain care: time for a new approach?

Figures & data

Figure 1. Visual representation of the biological, psychological, social, and extended aspects of low back pain care presented by the selected articles in this critical review.

Table 1. Overview of the four discourses underpinning the use of the term “biopsychosocial” in physiotherapy literature in the management of people with low back pain (LBP).

Conflating the BPS with the biomedical model	Texts were considered to be underpinned by this discourse if they said they attended to the BPS model, but were predominantly focussed on biological or biomedical elements of LBP (e.g., tissue damage, neurophysiology, physical function)
Cognition, behaviour, yellow flags and rapport	Texts were underpinned by this discourse if they predominantly attended to certain psychological aspects of LBP care (e.g., cognition, behaviour).
Brief and occasional social underpinnings	Texts were considered to be underpinned by this discourse when they mentioned or considered the social context in which people with LBP are situated (e.g., work environment, social network).
Expanded aspects of care	Texts were considered to be underpinned by this discourse if they had elements that did not fit within the previous discourses (e.g., cultural context, power).

*BPS: biopsychosocial.

Table A1. Characteristics of studies included in this critical review that discussed the biopsychosocial model in low back pain in physiotherapy.

Author/year	Design	Title
Alamam et al. 2019	Cross-sectional	Pain Intensity and Fear Avoidance Explain Disability Related to Chronic Low Back Pain in a Saudi Arabian Population
Alrwaily et al. 2017	Perspective	Treatment-based Classification System for Patients With Low Back Pain: The Movement Control Approach
Alshehri et al. 2020	Cross-sectional study	Physiotherapists’ pain attitudes and beliefs towards chronic low back pain and their association with treatment selection: a cross-sectional study
Bath and Grona 2015	Quasi-experimental	Biopsychosocial predictors of short-term success among people with low back pain referred to a physiotherapy spinal triage service
Beales et al. 2016	Cross-sectional study	Disturbed body perception, reduced sleep, and kinesiophobia in subjects with pregnancy-related persistent lumbopelvic pain and moderate levels of disability: An exploratory study
Belache et al. 2018	Trial Protocol	Trial Protocol: Cognitive functional therapy compared with combined manual therapy and motor control exercise for people with non-specific chronic low back pain: protocol for a randomised, controlled trial
Beneciuk and George 2015	Two-phase, preliminary study	Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study
Beneciuk et al. 2019	Trial Protocol	Targeted interventions to prevent transitioning from acute to chronic low back pain in high-risk patients: development and delivery of a pragmatic training course of psychologically informed physical therapy for the TARGET trial
Berger 2007	Perspective study	Perspectives on Physiotherapy Guidelines for Chronic Low Back Pain
Bunzli et al. 2016	Cross-sectional qualitative study	Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain
Cabak et al. 2017	Quasi-experimental	Biopsychosocial Rehabilitation Programme for Patients with Chronic Back Pain. Pilot Study
Caneiro et al. 2013	Case Report	Cognitive functional therapy for the management of low back pain in an adolescent male rower: a case report
Casserley-Feeney et al. 2012	Randomized Clinical Trial	The access randomized clinical trial of public versus private physiotherapy for low back pain
Cowell et al. 2018	Qualitative	Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study
Cowell et al. 2019	Qualitative	How do physiotherapists solicit and explore patients’ concerns in back pain consultations: a conversation analytic approach
Cowell et al. 2019	Qualitative	The perspectives of physiotherapists on managing nonspecific low back pain following a training programme in cognitive functional therapy: A qualitative study
Cuenca-Martinez et al. 2018	Literature Review	Effectiveness of classic physical therapy proposals for chronic non-specific low back pain: a literature review
Ferguson et al. 2008	Delphi Study	A Delphi study investigating consensus among expert physiotherapists in relation to the management of low back pain
Ford et al. 2019	Literature Review	The evolving case supporting individualised physiotherapy for low back pain.
Foster and Delitto 2011	Perspective study	Embedding psychosocial perspectives within clinical management of low back pain: integration of psychosocially informed management principles into physical therapist practice--challenges and opportunities
Franca et al. 2019	Qualitative	‘It’s very complicated’: Perspectives and beliefs of newly graduated physiotherapists about the biopsychosocial model for treating people experiencing non-specific low back pain in Brazil
George 2008	Systematic Review	What is the Effectiveness of a Biopsychosocial Approach to Individual Physiotherapy Care for Chronic Low Back Pain?
Giesbrecht and Battie 2005	Between group design	A comparison of pressure pain detection thresholds in people with chronic low back pain and volunteers without pain
Gomes et al. 2020	Observational cross-sectional	Association between low back pain and biomedical beliefs in academics of physiotherapy
Goudman et al. 2019	Perspective	A Modern Pain Neuroscience Approach in Patients Undergoing Surgery for Lumbar Radiculopathy: A Clinical Perspective
Holopainen et al. 2020	Qualitative	An adventurous learning journey. Physiotherapists’ conceptions of learning and integrating cognitive functional therapy into clinical practice
Hurley et al. 2000	Cross-sectional and longitudinal	Biopsychosocial screening questionnaire for patients with low back pain: preliminary report of utility in physiotherapy practice in Northern Ireland
Igwesi-Chidobe et al. 2017	Cross-sectional	Biopsychosocial factors associated with chronic low back pain disability in rural Nigeria: a population-based cross-sectional study
King et al. 2018	Qualitative	Pain Reconceptualisation after Pain Neurophysiology Education in Adults with Chronic Low Back Pain: A Qualitative Study
Kirschneck et al. 2011	Delphi	Validation of the comprehensive ICF core set for low back pain: the perspective of physical therapists
Leysen et al. 2020	Observational cross-sectional	Attitudes and beliefs on low back pain in physical therapy education: A cross-sectional study
Lindback et al. 2019	Qualitative	Patients’ experiences of how symptoms are explained and influences on back-related health after pre-surgery physiotherapy: A qualitative study
Magalhães et al. 2012	Cross-sectional study	Attitudes and beliefs of Brazilian physical therapists about chronic low back pain: a cross-sectional study
Mansell et al. 2017	Secondary analysis of a Randomized Controlled Trial	Identification of Indirect Effects in a Cognitive Patient Education (COPE) Intervention for Low Back Pain
Matthews et al. 2015	Validity and feasibility study	A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation
Meziat Filho 2016	Case Report	Changing beliefs for changing movement and pain: Classification-based cognitive functional therapy (CB-CFT) for chronic non-specific low back pain
Miller et al. 1999	Mixed methods	The early stages of low back pain: a pilot study of patient diaries as a source of data
Mitchell et al. 2009	Cross-sectional	Biopsychosocial factors are associated with low back pain in female nursing students: a cross-sectional study
Nagarajan and Nair 2010	Case Report	Importance of fear-avoidance behavior in chronic non-specific low back pain
Nijs et al. 2020	Perspective	Integrating motivational interviewing in pain neuroscience education for people with chronic pain: a practical guide for clinicians
Nordstoga et al. 2019	Prospective observational	Improvement in Work Ability, Psychological Distress and Pain Sites in Relation to Low Back Pain Prognosis: A Longitudinal Observational Study in Primary Care
O’Keeffe et al. 2015	Study protocol	Individualised cognitive functional therapy compared with a combined exercise and pain education class for patients with non-specific chronic low back pain: study protocol for a multicentre randomised controlled trial
O’Neill et al. 2020	Randomized controlled trial	Examining what factors mediate treatment effect in chronic low back pain: a mediation analysis of a Cognitive Functional Therapy clinical trial
Oostendorp et al. 2015	Two-phase cross-sectional study	Manual physical therapists’ use of biopsychosocial history taking in the management of patients with back or neck pain in clinical practice
Ostelo et al. 2003	Cross-sectional	Health care provider’s attitudes and beliefs towards chronic low back pain: the development of a questionnaire
O’Sullivan et al. 2015	Multiple case cohort	Cognitive Functional Therapy for Disabling Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study
O’Sullivan et al. 2019	Case Report	Managing low back pain in active adolescents
Park et al. 2013	Quasi-experimental	The Effects of the Nintendo Wii Exercise Program on Chronic Work-related Low Back Pain in Industrial Workers
Pensri et al. 2010	Cross-sectional survey	Biopsychosocial factors and perceived disability in saleswomen with concurrent low back pain
Petit et al. 2019	Cross-sectional survey	Factors influencing physiotherapists’ attitudes and beliefs toward chronic low back pain: Impact of a care network belonging
Puentedura and Louw 2012	Perspective	A neuroscience approach to managing athletes with low back pain
Roussel et al. 2016	Observational	History taking by physiotherapists with low back pain patients: are illness perceptions addressed properly?
Sanders et al. 2013	Qualitative	Biopsychosocial care and the physiotherapy encounter: physiotherapists’ accounts of back pain consultations
Schröder et al. 2020	Clinical trial and effectiveness-implementation trial	Confidence, attitudes, beliefs and determinants of implementation behaviours among physiotherapists towards clinical management of low back pain before and after implementation of the BetterBack model of care
Simon et al. 2016	Cross-sectional	Comparative Associations of Working Memory and Pain Catastrophizing With Chronic Low Back Pain Intensity
Smeets et al. 2006	Randomized Controlled Trial	Active rehabilitation for chronic low back pain: cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial
Stewart et al. 2011	Perspective	Rethinking yellow flags
Synnott et al. 2016	Qualitative	Physiotherapists report improved understanding of and attitude toward the cognitive, psychological and social dimensions of chronic low back pain after Cognitive Functional Therapy training: a qualitative study
Tagliaferri et al. 2020	Perspective	Domains of chronic low back pain and assessing treatment effectiveness: A clinical perspective
Toomey et al. 2020	Case report	How manual therapy provided a gateway to a biopsychosocial management approach in an adult with chronic post-surgical low back pain: a case report
Valencia et al. 2011	Cohort Study	Socioeconomic status influences the relationship between fear-avoidance beliefs work and disability
Van Erp et al. 2017	Perspective	Development and content of the biopsychosocial primary care intervention “Back on Track“ for a subgroup of people with chronic low back pain
Van Erp et al. 2019	Systematic Review	Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review
Wand et al. 2004	Randomized Controlled Trial	Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise
Wijma et al. 2016	Perspective	Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education
Zangoni and Thomson 2017	Qualitative	“I need to do another course” - Italian physiotherapists’ knowledge and beliefs when assessing psychosocial factors in patients presenting with chronic low back pain