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This is a very good question and one that is being reviewed by others as well. After 30 years of following the biopsychosocial model in managing chronic low back pain (LBP), many health care professionals are asking similar questions.
What kind of treatment is best for the patient who is depressed and has poor coping skills? Is it the same as for the worker whose case is in litigation with worker's compensation?
Do the treatment results depend on recognizing and addressing these kinds of factors? And if any of these patients responds well to surgery, what does that suggest?
One must keep in mind there are three parts to this model: bio, psycho, and social. The bio or biologic part still refers to the spine, discs, soft tissues, muscles, and other involved body parts.
It's possible surgery works because there really was a pathologic cause of the back pain. And it's also possible the surgery had a placebo effect. This means the patient thought it would help and it did.
Perhaps some patients (for whatever reasons) respond to treatment directed at the biologic aspects. Others have a good outcome when the social stressors in their lives are dealt with. While others improve when psychologic factors are identified and addressed.
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