Alex Simotas, MD

Hospital for Special Surgery
Board Certified Physiatrist
Specializing In Spine & Sports Medicine

Home > Learning Center > Anatomy > Taking on the Back Pain Syndrome

Taking on the Back Pain Syndrome

The Back pain “Syndrome”

Most scientists today would agree that back pain in its various forms is best understood as a syndrome rather than a disease. Back problems seem to have a variety of different factors that influence its occurance, severity, and responsiveness to treatment.  This is one reason why making a simple “diagnosis” based on the reading of an XRAY or MRI is difficult and one person might receive a variety of different diagnoses opinions from different physicians.


In the “biopsychosocial” model Biologic, Social, and Psychologic factors overlap. This picture of back pain has 3 domains that overlap to create the whole problem and back pain experience.

back bps
  • Biological refers most of factors we often think of as physical or structural.  Think of alignment, degenerative disease, injury such as fracture or disc herniation, and others that are less obvious: flexibility, muscle and cardiovascular conditioning.  Even more “invisible” are factors that might include tissue inflammation, or sensitivity built into the nervous system.


  • Psychological refers some of the obvious things such as depression, stress, anxiety; and less obvious “cognititive” factors such as pain perceptions (what a person perceives when he/she thinks of pain), fear of pain or injury, panic conditioning, perceptions of self-capacity or activity barriers.


  • Social refers to again some of the more obvious factors such as income and access to medicalcare. Some less obvious factors such as peer group influences:e.g. (are most of your friends tri-athletes who never seem to complain about any pain or physical problems… or are they all mostly sedentary and seem to run from doctor to doctor with a litany of illness complaints?)





Back pain.  What is it?  It can be so debilitating when you have it.  It can hurt a lot. Often nothing very traumatic occurred.  It may have started when you leaned over and picked up something, or reached up to grab something or just started out of the blue.  Maybe it started with something more clear, like a fall, a twist, or sprain. X-rays, and even MRI findings are often of disputable significance.  One physician might be tempted to tell a specific item on your test is the “cause” of your problem while another says it bears no significance at all.


The Common Proposed Causes for Back Pain


So what causes it?  If you suffer or suffered with back pain you’ve heard many different things.  Here is a list of some of the explanations you might hear


Bad posture

Weak stomach muscles (abdominal or back muscles)

Accidents from lifting up a heavy object.

Sudden injury from slight activity such as reach for something

Bulging or herniated discs

Poor spinal alignment

Mental stress and tension

Anxiety and depression


Degenerating discs

Slipped vertebrae


One group says its all physical or some injury, or structural weaknesses and the other says it so mental and psychological.  Which one is it? How could both insist they are right?  Could they all be right or somewhat right?  If that is the case, what should the treatment be?



Some treatments are very physical ranging from surgery to physical exercise and others very holistic sounding such as posture or relaxation training, acupuncture and psychological counseling.   How could such opposite treatments be advised for the same problem?


An “Evidence” based model for back pain



Modern science or “evidence based medicine”[1] supports a model for back pain causation that includes both mental and physical or structural causes.  The biopsychosocial model as it is called allows that all of these assertions may be correct or partially correct in a large landscape of potential influences for low back pain. These causes may coexist for the same person with the same back pain problem


What does the overlap in the diagram mean?  And what does that have to do with my back pain?


Let me draw your attention back to the schematic diagram of back pain causes above.  In this model these domains overlap so that each sphere overlaps and influences the other in a sea of constant change.  This is an overlap model.  What this means is that psychological, social and biologic causes for back troubles not only coexist and but are always constantly influencing one another and therefore also changing one another.


Other examples of the “overlap” in medicine


In reality this “model” is applicable to a lot of disease problems in health care.  Consider for a moment heart disease.  When placed in rigorous exercise, diet and stress reduction programs were noted to have a reduction in the blockage of the coronary arteries over the course of a year study. So that after a year of coaching to adopt lifestyle changes (social and psychological) lead to changing behavior, these individuals have changed the anatomy of their hearts.


Another example is bone health.  Weight bearing exercise has been advised to help maintain and even increase bone density.


In both of these examples a change in behaviors and beliefs about health care lead to helping patients change their health habits and beliefs.  The factors that are really in the psychological and social domains help change the biology of the patient.


Much of this appears to be true in the case of orthopedic problems of back pain.  Some are these ideas will be used in the articles laid out on this web site since they appear to be important in successful treatment.

[1] Evidence based medicine is the major movement of modern medicine in that has made medicine more science that art.  Medical assumptions must be proven through clinical outcome study and not simply hypothesized.