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

Key points

1. 01Most texts conflated the biopsychosocial model with the biomedical model, using biological primary outcomes like pain intensity and physical disability even when claiming a biopsychosocial approach.
2. 02Psychological aspects were almost exclusively reduced to cognition and behaviour change, with mental health, emotions, and interpersonal dynamics rarely addressed in depth.
3. 03Social factors were the least represented, typically limited to work context and family relationships, while broader determinants such as socioeconomic status, race, culture, and gender were almost entirely absent.
4. 04Pain neurophysiology education approaches, often labelled biopsychosocial, were shown to remain rooted in biological framing by focusing on nervous system processes.
5. 05The authors call for a rethinking or replacement of the biopsychosocial model, suggesting alternative frameworks such as enactive or connectivity-based approaches may better capture complexity.

How it was conducted

Design

Critical review using Foucauldian discourse analysis

Articles analysed

66 articles from PubMed and Web of Science, searched June 2019, updated October 2020

Inclusion criteria

English-language articles explicitly discussing biopsychosocial model implementation in physiotherapy assessment or management of low back pain

Analysis approach

Iterative organisation of article segments into key discourses; independent reading and consensus by three investigators with physiotherapy, social science, and neuroscience backgrounds

Article types

Mixed: systematic reviews, RCTs, case reports, cross-sectional studies, qualitative studies, perspective papers, trial protocols

What they found

• Four key discourses identified: (1) Conflating the BPS with the biomedical model, (2) Cognition, behaviour, yellow flags and rapport, (3) Brief and occasional social underpinnings, (4) Expanded aspects of care.
• Approximately one third of articles focused on treatment, one third on assessment, and one third on physiotherapists' beliefs about the BPS model.
• Biological measures such as pain intensity, disability, range of motion, and posture were the most frequent primary outcomes; psychological outcomes received less attention even when included alongside biological ones.
• The Physiotherapist Attitudes and Beliefs scale was used in ten studies, reflecting the dominant focus on clinician cognition and behaviour rather than social or contextual factors.
• Work-related factors were the most investigated social element; broader social determinants such as class, gender, race, and ethnicity were not discussed at all in the reviewed literature.
• Only five articles mentioned cultural, racial, language, or religious factors, and none explored how these would change clinical management.
• Socioeconomic status was mentioned in several studies but rarely given substantive attention; only one study (Valencia et al.) explicitly investigated mechanisms by which income and education influence pain and disability outcomes.

Limitations

• The review was not exhaustive; a small number of relevant articles may have been missed due to the search terms chosen.
• The analysis focused on physiotherapy research literature, not clinical practice directly, so the discourses identified may not fully reflect what physiotherapists actually do with patients.
• The search was limited to two databases (PubMed and Web of Science) and to articles in English, which may under-represent non-Western perspectives.
• Discourse analysis is an interpretive method; findings reflect the authors' theoretical framework and may not be the only valid reading of the literature.

Why it matters

For patients

Patients with low back pain may not be receiving truly holistic care even from clinicians who claim to use the biopsychosocial model, as social circumstances, culture, and broader life context are often overlooked.

For clinicians

Physiotherapists should critically examine whether their practice and choice of outcome measures genuinely address psychological and social complexity, or whether they default to biological and cognitive-behavioural framing by habit.

For readers

This review highlights a significant gap between the stated ambition of the biopsychosocial model and its actual implementation in physiotherapy research, suggesting the field needs new conceptual frameworks for low back pain care.