Perspective
Low Back Pain—A Disease or Condition of Impaired Functional
Health? Definition-Inherent Consequences for the
Comprehensive Care of Back Pain Patients
Kurt Ammer 1,2, * , Gerold Ebenbichler 3 and Thomas Bochdansky 4
Citation: Ammer, K.; Ebenbichler, G.;
Bochdansky, T. Low Back Pain—A
Disease or Condition of Impaired
Functional Health?
Definition-Inherent Consequences for
the Comprehensive Care of Back Pain
Patients. BioMed 2022, 2, 270–281.
https://doi.org/10.3390/
biomed2020022
Academic Editor: Wolfgang Graier
Received: 7 April 2022
Accepted: 16 May 2022
Published: 8 June 2022
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4.0/).
BioMed 2022, 2, 270–281. https://doi.org/10.3390/biomed2020022
1 Faculty of Computing, Engineering and Science, University of South Wales, Pontypridd CF37 1DL, UK
2 European Association of Thermology, 1170 Vienna, Austria
3 Department of Physical Medicine, Rehabilitation and Occupational Medicine, Vienna Medical University,
1090 Vienna, Austria; gerold.ebenbichler@meduniwien.ac.at
4 6800 Feldkirch, Austria; t.bochdansky@gmx.at
* Correspondence: kammer1950@aol.com
Abstract: This article provides arguments for and against the classification of low back pain (LBP)
as a disease or health condition. Based on the basic definitions of health, disease, illness, sickness,
infirmity, and pain, little support has been found for the idea that LBP represents a specific disease
entity. Although specified back pains do not signify disease, the pain experienced may be caused by
specific diseases, such as inflammation, neuropathy, fractures, or tumors. Common findings in medi-
cal imaging indicate disk herniation, degenerative joints with or without signs of inflammation in the
facet joints, and spinal stenosis present in a relatively high proportion of pain-free persons. The same
applies to hypomobile segmental dysfunction (joint blockage) and myofascial syndrome. Both func-
tional entities play a core role in manual medicine but are common in asymptomatic subjects, showing
low–moderate reliability and failing to meet the classification requirements of disease. Reducing
disability through interventions targeting a disease’s structural/functional conditions cannot be
achieved since the relationship between pathological changes and activity restrictions/participation
is indirect in most cases. Considering LBP as a condition shifts the goal of treatment from the disease
to the patient’s optimal performance in activities/participation and allows them to be self-determined
and independent.
Keywords: low back pain; health condition; disease; classification; comprehensive individual care
1. Introduction
LBP is the most common medical condition for those living with a disability; in
most countries, it is also the top medical condition requiring rehabilitation [1]. A classical
medical approach is disease-oriented and directs all management efforts of LBP towards
identifying underlying causes of pain in the low back, namely, structural and/or functional
impairments or sensory impairments associated with chronic pain, and treating these
impairments to alleviate the pain and improve a person’s health state. Rehabilitative and
preventive medicine conceive pain in the low back as a medical condition associated with a
person’s impaired functioning and health state. Its efforts are primarily directed towards
interventions that minimize the person’s disability and optimize his/her functioning
level associated with LBP. Disability is defined as an individual’s perceived impaired
functioning and health state, i.e., the perceived impaired functions/structures and limited
activities/participation modulated by personal and contextual factors. As both aspects are
subject to the management of patients with LBP, we aim to discuss the advantages and
disadvantages of disease versus a health approach if a person with low back pain seeks
help in a medical office.
https://www.mdpi.com/journal/biomed
BioMed 2022, 2 271
BioMed 2022, 2, FOR PEER REVIEW

Before this article’s question can be answered, several basic terms must be defined.
Before this article’s question can be answered, several basic terms must be define
These terms include, among others, definitions of “pain”, “health”, “disease”, “pain”,
These terms include, among others, definitions of “pain”, “health”, “disease”, “pain
“medicine”, and “health care”. This terminology is also the foundation for the following
“medicine”, and “health care”. This terminology is also the foundation for the followi
discussion on whether low back pain should be understood as a disease or condition of
discussion on whether low back pain should be understood as a disease or condition
impaired functional health. Finally, definition-inherent consequences for the comprehensive
impaired functional health. Finally, definition-inherent consequences for the comprehe
care of back pain patients are discussed.
sive care of back pain patients are discussed.
2. Terminology: Health
2. Terminology: Health
The term “health” is elusive in its definition. Health terms, such as “disease” are
understood as aThe term “health”
construct to captureis elusive in its definition.
an important condition Health terms,
of living such as “disease”
organisms. The are u
derstood as a construct to capture an important condition
definition of human health has an enormous impact on the practice of medicine and of living organisms. The defi
interventiontion of human
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to improve the an enormous
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Defining healthand is interve
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the absence of complete
of disease physical,ismental
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not perfect
being, and not merely the absence of disease or infirmity”
but points in the right direction. One problem with this definition is the attempt to is not perfect but points in t
right direction. One problem with this definition is the attempt
define complete health. Keeping that aspect of absolute health counteracts that important to define complete heal
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Classification of merely the absence
Functioning, of disease
Disability or infirmity.”
and Health (ICF) [2] The International
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activity/participation, and an encompassing graded physical
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Figure 1. Modified ICF model
BioMed 2022, 2 272

3. Terminology: Disease
Disease may be defined as a disorder of structure or function in a human, animal, or
plant, especially one that produces specific symptoms or affects a specific location that is not
simply a direct result of physical injury [4]. Thus, the term “disease” refers to a pathological
process identified as a deviation from a biological norm. There is objectivity about disease
that physicians can see, touch, smell, and measure. This approach is predominant in
science-based medicine and textbooks describing disease entities for which patients are
the manifestation field. This definition has served as a basic term in a debate on whether
chronic non-malignant pain (CP) should be regarded as a condition or disease entity [5].
The term “disease” differentiates from other descriptions of unhealth [6], which are illness
and sickness.
Illness refers to a feeling or experience of unhealth in a person’s interior that is entirely
personal. Disease and illness are related, but signs of illness are difficult and almost impos-
sible to measure even when psychological assessment tools objectivate patients’ personal
experiences. On the other hand, subjective health experience relates to the definition of
unhealth for persons afflicted with a disease. Thus, for anyone, it is real, true, and as valid
as any external evaluation of this subjective experience.
The third mode of unhealth is sickness. Sickness is a social role, status, negotiated
position in the world, a bargain struck between the person henceforward called “sick” and
the society prepared to recognize and sustain them. Confirmation of being sick often relies
on a confirmed disease and is accepted on different levels for various diseases and their
affected patients. The whiplash epidemic in Australia declined because health authorities
massively reduced sickness certifications [7].
Illness and sickness would be overlooked if unhealth was reduced to the disease
mode stipulated by a mandatory WHO ICD classification, thus creating the impression
that diseases are strange creatures or small biological agents that attack and modify indi-
viduals’ health. Fighting against these “disease personalities” is mandatory to eradicate
those “demons” forever. “Disease” is defined as a model that describes and explains an
experienced impairment of a person’s state of health or the risk of future health impair-
ments based on structural and functional conditions [3]. In other words, the community
recognizes the personal experience of being unwell or ill as being sick and medically and
causally explained by disease. The quasi-causal position of pathology may lead to the
oversimplification of causal chains stemming from the disease-defining pathological lesion.
In order to define a disease, a diagnosis must be established. The diagnosis distin-
guishes between pathological lesions and is defined as:
• The art or act of identifying a disease, illness, or problem by examining someone or
something;
• A statement or conclusion that describes the reason for a disease, illness, or problem;
• The art or act of identifying a disease from its signs and symptoms;
• The decision reached by the diagnosis [8].
From a quality assurance perspective, diagnosis is understood as a process rather than
a classification label necessary for public health statistics. The core of the diagnostic process
is gathering, integrating, and interpreting information based on a patient’s experiences of a
health problem derived from clinical history, physical examination, referrals, consultation,
and diagnostic tests. The established diagnosis is then communicated to the patient and
serves as the basis for therapeutic interventions. The outcome of treatment serves as
feedback to the core process of diagnostic information processing [9].
Undoubtedly, a person reporting pain in the low back area can be examined, but the
underlying causes of this pain (the “problem”) in the low back are typically complex and
may relate to trauma, a tumor, inflammation, or malformation. The “act of identifying”
causes of low back pain shows that a leading perception impairment, the “symptom pain”,
cannot be classified as a “disease” at the same time. The “decision reached by diagnosis”
would, according to the definitions, be based on diagnostic findings of the disease.
BioMed 2022, 2 273

Therefore, one may reasonably question whether “low back pain” represents a diagno-
sis and thus be classified as a disease. In the new International Classification of Diseases
(ICD 11), low back pain is classified under “Symptoms, signs or clinical findings of the
musculoskeletal system” Chapter 21—ME84.2, along with other relevant numbers to be
excluded (MG30.02; MG30.3; MG30.5; FA80-FA8.Z)
The detection and treatment of diseases are the core tasks of medicine, whereas health
care expands its aims beyond disease management and comprehensively includes all
determinants of health. Physical activity of various intensities also plays a central role in
health maintenance [10].

4. Terminology: Infirmity/Frailty/Vulnerability
The WHO also defines another antonym to health, i.e., infirmity. This archaic term is a
precursor to the more modern term frailty. In 1949, infirmity was a condition understood
differently than a disease, although with features of personally experienced illness and/or
socially recognized sickness. The medical definition of frailty shares similar features to dis-
ease, including thresholds for normal physical structures and functions, such as body mass,
muscle strength, walking speed, and physical activity [11]. The term frailty was criticized
due to inherent pejorative and exclusionary tendencies [12]. The FRAILOMIC Initiative
promotes the following definition of frailty as “an age-associated syndrome characterized
by a decrease of biological reserve and resistance to stressors due to functional decline of
several physiological systems and placing the individual at enhanced risk of disability,
hospitalization, and death”. In other words, frailty refers to a decline in both robustness
and recovery (resilience). According to the International Classification of Impairments,
Disabilities and Handicaps-ICIDH (WHO, 1980), disability is defined as “any restriction
or lack (resulting from an impairment) of ability to perform an activity in the manner or
within the range considered normal for a human being” ([13]. Thus, the term frailty is
associated with vulnerability, particularly at advanced ages and/or consuming diseases.

5. Terminology: Pain and Definition of LBP

The current IASP definition of pain is “an unpleasant sensory and emotional ex-
perience associated with, or resembling that associated with, actual or potential tissue
damage” [14]. One of their explanatory notes states that “Pain and nociception are different
phenomena as pain cannot be inferred solely from activity in sensory neurons” but this
depends on an individual’s associations with pain and related automatic and voluntary
reactions/responses to pain. This statement is confusing at first glance since the perception
of a noxious stimulus is painful by definition. The second sentence in the note removes
the confusion of nociception being defined as detecting potentially or injurious stimuli
followed by a reflex withdrawal [15].
The person In pain is the only source of explaining and describing the pain experience.
Thus, the pain has features of both illness (“it hurts”) and sickness (“a person in pain”) but
presents few indirect characteristics that are easily captured by medical examination, as
expected in the case of a disease. From a descriptive view, pain is a condition or health
state associated with actual or potential tissue damage. A disease resulting in tissue
damage may cause symptoms of pain. However, the classification of pain as a disease
requires functional and/or structural findings and not just the perception of pain that arises
from actual or threatened damage to non-neural tissue and the activation of nociceptors.
Similarly, “neuropathic pain” is also not a disease and is defined as pain caused by a lesion
or disease of the somatosensory nervous system. The recently promoted term “nociplastic
pain” does not describe a structural and/or functional pathology required for disease
classification. “Nociplastic pain” is defined as pain that arises from altered nociception
despite no clear evidence of actual or threatened tissue damage from the activation of
peripheral nociceptors, which are free nerve endings that transduce harmful information
via A-δ and C fibers to the spinal cord, where this information is relayed to higher centers of
the CNS. Most importantly, the intensity of perceiving the noxious pain stimulus depends
BioMed 2022, 2 274

on the context/environmental factors under which the pain was perceived [16]. This finding
provides evidence for diseases or lesions within the tissues causing pain [17]. Nociplastic
pain may contribute to the pain experience of common musculoskeletal pain syndromes,
such as low back pain or fibromyalgia.
A variety of techniques and aids for documenting pain experiences transformed this
subjective phenomenon into objective estimates of this unpleasant experience. Simple
visual analog scales (VAS) became the standard to measure the intensity of spontaneous,
recalled, or provoked pain [18]. Sensory testing helps detect allodynia; an acquired misinter-
pretation of non-painful stimuli presented to the skin [19]. Multidimensional questionnaires
capture pain characteristics other than intensity [20] and detect relationships to emotions,
expectations, and pain triggering circumstances [21].
Low back pain is a health condition associated with a higher risk for years of life
living with disability (YLDs) frequently reported worldwide [1]. Low back pain (LBP) is
defined as localized pain and discomfort below the costal margin and above the inferior
gluteal folds, with or without leg pain. Nonspecific (common) low back pain is defined
as pain not attributed to recognizable, known, or specific pathology (e.g., infection, tumor,
osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome,
or cauda equina syndrome) [22].
An important aspect of pain experience is the duration of this unpleasant sensation.
Manifestations lasting up to 6 weeks are commonly classified as “acute”, “subacute” for
manifestations between 6 and 12 weeks, and “chronic” for conditions/diseases lasting
longer than 12 weeks.

5.1. Health: A Condition or Absence of Disease/Infirmity

Functional health is primarily a condition representing the complex interaction of the
physical, mental, and social components in an individual’s life. The basic assumption of
medicine is that all deviations from normal functioning are caused by objectively detected
deficits in physiological functions and/or body structures. This finding leads to a binary
classification of people into “healthy” or “diseased” categories. Therefore, in medicine,
an individual’s health is classified as a disease based on external assessments, evaluation
processes, and the impact on lifetime prevalence. In other words, the older a population, the
smaller the percentage of healthy persons. This model’s subjective perspective of diseased
persons is unfavorable since health is both a rare state and dependent on external judgment.
Considering health and its impairments as a condition has several advantages. Un-
derstanding health as the summary of functioning transforms the categorical classification
of the antonyms “health” and “disease or infirmity, respectively”, into a continuum of
experiences living on different levels of functioning. Functional assessments, personal
activity/participation, and the external environment come first, and investigations into
the physical causes of the observed condition come second. In the condition’s evaluation
process, subjective experience and objective findings equally contribute to the final level
of an individual’s health state. Since an individual’s health state results from subjective
and objective inputs on their functioning, the individual’s perspective on their health may
improve or be maintained at a low level of dysfunction. The condition’s description also
helps compare the health states of different diseases. However, for deciding interventions,
labeling the health condition with a single or collection of ICF codes creates similar prob-
lems to representing disease by a single or a collection of diagnostic codes provided in the
International Classification of Diseases (ICD).

5.2. Non-Specific Low Back Pain as Condition

If LBP is defined as a person’s pain sensations in the low back region of the body, then
this definition should fulfill the requirements of a “condition”. The definition of low back
pain notes that various underlying diseases may cause the pain. The first step in a diagnostic
workup is to recognize the physical condition of any health impairment. In the case of low
back pain, clinicians are advised to check for red flags (or alarm signals) while recording
BioMed 2022, 2 275

the patient’s medical history and conducting a physical examination to evaluate severe
underlying pathology [23]. Despite the wide variety of red flags presented in guidelines for
low back pain, there is a lack of consensus on which red flags to endorse. Such a condition-
oriented approach allows the separation of patients with specific low back pain from those
with nonspecific low back pain. Currently, the duration of the back pain episode is used to
assign the most effective treatment for patients with nonspecific low back pain since several
studies have raised evidence that patients with acute, subacute, or chronic nonspecific low
back pain respond differently to the same type of therapeutic intervention [24].
Similar to a diagnosis, a one-dimensional description of a physical condition cannot
capture the complex components associated with pain experienced in the low back region.
Core outcome sets were proposed for back pain trials at the end of the 20th century for
back pain sufferers in acute health care [25]. The three outcome domains in the outcome
set include (1) physical functioning, (2) pain intensity, and (3) health-related quality of life
(HRQoL). The Oswestry Disability Index version 2.1a (ODI 2.1a) or the 24-item Roland
Morris Disability Questionnaire (RMDQ-24) are recommended as assessment tools for
physical functioning. Pain intensity should be recorded using a Numeric Rating Scale
(NRS). For HRQoL, the recommended questionnaires are either the Short Form Health
Survey 12 (SF12) or the 10-item PROMIS Global Health (PROMIS-GH-10) ([25].
Patients with acute conditions may develop ongoing pain for more than 12 weeks,
and treatment results may be biased when derived from populations with back pain
present ≤6 weeks. The transmission from acute to chronic low back pain may be associ-
ated with psychosocial distress [26,27]. Chronicity can also be triggered by the patient’s
emotional experience with pain and their beliefs and expectations about the course of
the pain [28]. Several questionnaires for chronicity screening in patients with acute back
pain have been developed [29,30]. The STarT Back Screening Tool [31] or Orebro Screen-
ing Tool [32] primarily screen for psychosocial risk factors. They were established for
their good discriminative abilities. Matching treatment programs with risk classes de-
tected by the STarT tool results in greater health benefits for back pain patients strati-
fied to risk-matched treatment, than patients receiving physical therapy based on the
physiotherapist’s evaluation [33].

5.3. Non-Specific Low Back Pain as a Disease

As previously mentioned, classifying a health condition as a disease requires that
the confirmed deviation from normal function and/or body structure relates to tissue
lesions, inclusive of nerves and inflammation, due to any cause which establishes a causal
relationship with objectively detected signs of the perceived health impairment and explains
corresponding symptoms. Thus, removing the cause of the illness by eradicating infectious
agents, correction, or compensation for physiological functions and damaged structure
repair appears to be an appropriate way of re-establishing health. However, establishing
causality is more difficult than it appears at first glance. Physiological systems do not
function exclusively in a monocausal relationship, such as stimulus and response. The
physiological system of living beings is a complex network of functions connected by
necessary and/or sufficient and/or contributory causes via multiple pathways. A typical
contributory cause is described as INUS, “an insufficient but necessary part of a condition
which is itself unnecessary but sufficient for the result” [34]. Lesions generated by external
causes, such as physical forces in the case of injuries or biological agents causing infections
are better understood than lesions arising from derangement of structures and/or specific
functions. For the latter lesion, a multifactorial genesis seems to be predominant.
Several common alterations in the structure and motion of the low back region have
been proposed as an underlying disease of non-specific low back pain. However, there is
no evidence that these alterations are the single cause of back pain, which would otherwise
be labeled as specific back pain. Due to gaps in understanding the causal chains initiated
by dysfunction of the lumbar spine vertebral motion segment, this central pathology of
BioMed 2022, 2 276

manual/osteopathic/chiropractic medicine is currently not accepted by scientific/evidence-

based medicine as a cause of back pain.
This explanation appears widely endorsed by national and international guide-
lines on non-specific back pain that identify vertebral fractures, infections, radicu-
lopathies/neuropathies, tumors and axial spondylarthritis as the leading causes of
specific back pain. However, they admit that more subtle contributors to LBP cannot
be identified in clinical practice due to the lack of accurate and reliable differential
diagnostic methods for assessing myofascial and joint-related structures’ contribution to
back pain syndrome.
Thus, the German guideline on nine structural entities and two functional entities
as specific causes for back pain, which proposes that all these entities possess an ICD-
code and can be ruled out by objective imaging techniques, is arguable [35]. There is a
striking mismatch between the 2016 English and German ICD codes. The first structural
entity is “the lumbar facet syndrome/spondylarthrosis”, and the Supplementary Table S1
shows the German terminology and English ICD codes side by side. The ICD codes M45–
M49 classify spondylopathies, structural changes of the spinal joints, and vertebral bodies
as “degeneration”, appearing under code M47 as “spondylosis, including arthrosis or
osteoarthritis of spine and degeneration of facet joints”. Code M47.1 combines spondylosis
with myelopathy, whereas code M47.2 is reserved for spondylosis causing radiculopathy.
Code M47.8 describes spondylosis without myelopathy or radiculopathy, and code M47.9
is used for unspecified spondylosis. The differentiation between codes M47.8 and M47.9
remains unclear, but spondylosis without associated clinical symptoms may be the correct
entity for M47.9 (Supplementary Materials Table S1).
The German guideline combines code M47 spondylarthrosis with facet syndrome.
“Syndrome” is defined as a group of symptoms that consistently occur together or a condi-
tion characterized by associated symptoms. The clinical description of a facet syndrome
does not fulfill the classification requirements for a syndrome. In addition, the adjec-
tive scale of acute and chronic pain describes the duration of a disease/condition, not its
signs/symptoms; therefore, it should not be coded as being “associated with radiculopa-
thy”. Another unclear term is “facet irritation—Facettenreizung”, coded by M54.5. The
word “strain” in “low back strain” may have been the reason to code “acute lumbago with
facet irritation” in M54.4. However, if the ligamentous joint structures were damaged by
force, this condition is typically called a “sprain”, whereas the term “strain” is used for
muscle injuries and ligamentous/tendinous attachments to bone. The assumption that
acute or unspecified low back pain is regularly associated with irritated facet joints should
be excluded from codes intended for the objective classification of diseases. However,
Chapter 2 of the structural entities “Discogenic lumbar syndrome/vertebral osteochon-
drosis” relates to adult osteochondrosis of the spine, M43.1, and chronic degenerative
low back pain, falsely coded as M47.26 despite the absence of radiculopathy. M43.1 also
relates to M54.4. with the descriptions “acute „lumbar syndrome”, “chronic-recurrent
lumbar syndrome”, “chronic lumbar syndrome”, “chronic lumbar syndrome with pseudo-
radicular referred pain”, and “lumbar syndrome with pseudo-radicular referred pain”
(Supplementary Materials Table S1).
These definitions of specific LBP widely ignore findings typically observed in clini-
cal imaging or manual medical examinations that may or may not relate to the leading
symptoms of back pain with or without irradiation. Such a view would be strongly sup-
ported by X-ray or MRI findings indicating disk herniation, degenerative joints with or
without signs of inflammation in the facet joints, or spinal stenosis presenting in a relatively
high proportion of pain-free persons [36]; this is particularly the case in middle-aged and
older persons.

5.4. “Joint Blockage”

The “hypomobile segmental dysfunction of the lumbar spine” plays a central role in
Manual Medicine’s pathophysiological back pain models. Minute movements between
BioMed 2022, 2 277

the intervertebral joints are evaluated by manual palpation, and restricted motion towards
one direction is considered reversible hypomobile dysfunction. Specific passive movement
interventions are applied to reinstall the normal, limited “joint play” range. Diagnostic and
therapeutic interventions are based on scientific neurophysiological and biomechanical
principles [37]. Due to a lack of epidemiological data on back pain associated with “ver-
tebral blockages” and fair–moderate results in both the repeatability and reproducibility
studies of palpation [38], “vertebral blockage” is not yet accepted as a specific cause for LBP.

5.5. Structural and Functional Alterations within the Myofascial System

Objective examinations of musculoskeletal structures are highly limited to imaging
studies by MRI/CT or diagnostic ultrasound. Muscle atrophy and increasing fat content
within the paravertebral muscles are related to LBP. However, these findings have been
either weakly/inconsistently related or unrelated to pain intensity or muscle weakness and
daily activities [39–41]. In addition, manual medical examinations attempt to differentiate
between normal and increased muscle tone or muscle spasms even if the pain widely
depends on the examiner’s palpatory skills and perception. Therefore, a reliable diagnos-
tic examination to objectify impaired muscle tone function is unlikely. Measurements of
muscle function, such as strength, power, and endurance also depend on the cooperation
of the patient. Palpatory findings from myofascial structures are one of the basic diag-
nostic procedures of any manual medical examination. Identifying trigger points, tender
points, myofascial gliding, and muscular hypertonus/spasms are important indicators of
myofascial pain syndromes. However, both trigger points and myofascial tender points
also present themselves in back pain-free individuals. However, they are considered causes
of low back pain when observed in patients with LBP. Trigger points, which are defined as
structural–morphological alterations within a muscle and identified by referring to pain
on palpation [42,43], indicate lesions and malfunction within the neuromuscular struc-
tures. These must be differentiated from “tender points”, which are painful, hyperaesthetic
spots on palpation in typical locations but without structural changes or referred to as
pain on palpation. The presence of tender points may be interpreted as a decreased pain
defense control and/or neuropathic pain (released by provocation) because it presents
where sensory nerves perforate fascial layers.
When tender points are present together with trigger points, indicating a decline in
the central pain defense mechanisms, they are considered morphological manifestations of
neurophysiological and neurovegetative changes within myofascial structures resulting
from back pain and are not the source of pain itself. It is worth mentioning that these
alterations within the myofascial system, which may also be related to inflammatory tissue
processes and reduced blood flow, maintain and thus contribute to processes within the
CNS associated with pain chronification [44].
Likewise, muscle functional changes with weakness, hypertonus, and changes in
the fascial system (densification/fibrosis) impair the neuromuscular output necessary to
induce movement and stability for the spine. Altered neuromuscular control and changes
within the myofascial system change the biomechanic output of muscles contributing to
spine stability, movement, and posture. Depending on yellow and blue flags, i.e., the
psychosocial expectancy and demands of a person in life, the activity’s behavior will likely
change. If the pain is not behaving appropriately, relative overuse can result in myofascial
overload or disuse in atrophy and deconditioning [45]. Both disuse and overuse fuel a
vicious cycle that contributes to the maintenance of pain through stimulating peripheral
and central sensitization processes relevant to enhanced pain perception, pain chronicity,
and disablement [46]. Although myofascial structural and functional changes contribute to
the maintenance of pain and explain flair-ups in LBP, they rarely represent a specific cause
for LBP.
BioMed 2022, 2 278

5.6. Treatment of a Disease Versus Comprehensive Care of a Health Condition

Understanding LBP as a disease or a condition has important consequences for the
management of LBP patients. Classifying a disease as deficits in either structure and/or
function does not consider pain sensation. In the case of nociceptive pain, the underlying
cause is the noxious stimulus, as neuropathy is the underlying disease of neuropathic pain.
Likewise, inflammatory low back pain disease is an inflammatory process in the lumbar
region, and neuropathic back pain is caused by various affections of the neural structures
located in the spine. Although the separation of back pain cases by the severity of health
impairment is a well-established procedure (“red flags”), reducing the treatment of specific
back pain to the underlying disease may overlook the illness and sickness components of
the patient’s pain condition.
Focusing on specific conditions causing back pain overlooks other important health
components. Gender and age influence the assessment and classification of LBP [47,48], and
context factors of age and gender were implemented into new clinical practice guidelines
was proposed [49].
Epidemiological data, such as prevalence, incidence, prognosis and responsiveness
to therapeutic interventions for LBP are other sources for decision making in the manage-
ment of LBP patients. Many people occasionally report LBP [50,51]. As noticed in daily
practice, many people recover without medical intervention [52]. The lifetime prevalence
of nonspecific LBP is reported to be 84%, and the prevalence of chronic LBP is about 23%,
with 11–12% of the population experiencing disability [53]. LBP incidence in athletes is
between 1 and 30%, and about 90% improve without medical intervention [54]. Therefore,
diagnostic procedures must primarily focus on excluding red and yellow flags, and it may
be reasonable to “wait and see” as part of therapeutic procedures.
Therapeutic procedures should be based on a multidisciplinary biopsychosocial
approach [55,56] because this procedure shows greater cost effectiveness, particularly
in Germany [57].
Key findings in the review article by van Tulder et al. [24] were that bed rest and
exercise therapy is ineffective for patients with acute back pain. Furthermore, manipulation
is not superior to the effects of physiotherapeutic applications, such as massage, shortwave
diathermy, or exercise. Analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) and,
to a lesser degree, muscle relaxants are effective remedies for acute nonspecific low back
pain. The effectiveness of NSAIDs for acute low back pain was recently revised: NSAIDs
are slightly more effective than placebos for short-term pain reduction (moderate certainty),
disability (high certainty), and global improvement (low certainty); however, the magnitude
of these effects is minor and not clinically relevant [58]. A systematic review published
in 2017 on the effects of spinal manipulation reported modest improvements in pain and
function with transient minor musculoskeletal harms. The evidence was moderate for
beneficial effects but greater for transient unwanted effects. These results align with the
outcomes of the 1997 study by van Tulder et al. [24].
Analgesics, NSAIDs and muscle relaxants are less effective for chronic low back pain
than in acute low back pain. Exercise therapy is an effective treatment for chronic low back
pain. At least moderate evidence exists for the benefit of manipulation. A recent review arti-
cle evaluated the effectiveness of commonly used interventions in primary care for chronic
radicular or non-radicular low back pain. The authors reported a moderate certainty of
evidence that exercise, oral NSAIDs, and duloxetine, a serotonin-norepinephrine reuptake
inhibitor, provide clinically meaningful benefits to patients with chronic back pain [59].
These treatments and their varying effectiveness led to different guideline recommen-
dations for managing acute [50] and chronic low back pain [60].

6. Conclusions
We found that LBP is defined as pain in a specified anatomical area and lasting a
certain period. Therefore, can “pain” be defined as a “disease”? Of course, it is “just” a
BioMed 2022, 2 279

symptom affecting an individual’s functional health status for a certain time. Additionally,
not every pain results in disability or affects an individual’s quality of life.
It is doubtful whether primary prevention can be successful since one of the well-
known major risk factors is previous periods of LBP; this health condition has already been
found in younger populations [61]. Other risk factors (modifiable and nonmodifiable) were
not identified for a true first episode of LBP [22] except for exercise programs [62].
Individual management programs of LBP must be based on a “BIO-PSYCHO-
SOCIOECONOMIC-CULTURAL MODEL” [10] that can be classified with the terminol-
ogy of ICF and an assessment by adequate instruments (tests, scores, and questionnaires).
A recent literature review concerning the causality of LBP did not differentiate between
the LBP “disease” and its recurring episodes mainly due to an unclear definition of LBP
absence at baseline. Therefore, the authors could not provide a valid answer on whether
LBP can be defined as a disease or episode [62].
LBP being seen as a condition rather than a disease supports individual compre-
hensive care where interventions are applied for any kind of health component. This
approach does not imply that disease does not have high priority in the management of
health problems, but rather, in absence of disease priority, should be defined based on
the risk of developing restrictions to activity and/or participation. Reducing disability by
targeting the structural/functional conditions defining a disease cannot be achieved since
the relationship between pathological changes and restriction to activity/participation is
indirect in most cases.

Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/biomed2020022/s1, Table S1: English ICD 10 Codes and ICD-codes
used in the Germain guideline “specific back pain”.
Author Contributions: All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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