There is no such thing as a new idea

For my first BIM post I wanted to blog about an article that I read some years ago that had probably the biggest impact on my thinking on low back pain and disability and 15 years later still informs the way that I think about pain and disability.

Around the mid 1990s when I first started research in low back pain a UK-based health psychologist Marie Johnson, wrote an article for monthly publication of the British Psychological Society, the Psychologist (reprinted in Physiotherapy Theory and Practice).  Marie argued that rather than think of disability as a result of some impairment as reflected in the WHO model of impairment, disability and handicap, it might be useful to think of disability as intentional behaviour as this meant that we could apply social psychological theories to help understand why people were disabled.

Marie’s article made quite an impact and the letters pages of the following issues of the Psychologist were full of people arguing strongly, angrily, that thinking about disability in this way was equivalent to blaming disabled people for their own disability.  To many it seemed that Marie was arguing that disabled people were intentionally disabled.  Despite this controversy and although the article barely mentioned pain related disability, the ideas that Marie proposed totally changed the way that I thought about disability related to low back pain.

We know that in low back pain we haven’t had much luck at identifying a structural cause that could result in disability.  In other musculoskeletal conditions this relationship is much clearer for example an ACL injury might cause movement restriction of the knee and make it difficult, if not impossible, to climb stairs due to restricted range of movement.  Although an untreated ACL injury can result in certain movements that are physically impossible, a similar impairment that causes a restriction just doesn’t seem to be identifiable in low back pain.  There may be some local weakness or stiffness (depending on your point of view), but probably nothing to make a particular movement physically impossible.  So if it is not impossible to perform certain movements why are do people with low back pain restrict those movements, reduce their activities and become disabled?  An obvious answer might be pain, but does that fully account for disability?  We know that pain intensity is only moderately related to disability – some people with high levels of pain aren’t disabled at all (and some are) and some with low levels are more severely affected (and some aren’t) so there must be something else going on, what are we missing?

If we take Marie Johnson’s proposal to think of disability as intentional behaviour, does applying socio-cognitive models of behaviour move us any further along?

Since the 1950s the bread and butter of social psychology has been to try to understand attitudes, and particularly their relationship to behaviour.  At first glance, like all psychology, this appears rather simple – your attitude towards something (the attitude object) determines your behaviour towards it i.e. there is consistency between your what you think and what you do.  Well we all know from our own experience that that isn’t fully accurate and unsurprisingly the relationship is often weak as there are other influences, apart from our attitudes, that govern how we behave.  Over the years social psychologists have proposed a range of other factors to describe these influences that, along with attitude, might explain behaviour. These socio-cognitive models have been applied to and successfully used to understand a variety of behaviours, including health behaviours, such as condom use, healthy food choice and dieting, breast cancer screening and exercise.  Can they help to understand low back disability? [to be continued]

James McAuley

James McAuley BiMJames is Manager of the BiM research group at NeuRA. He is a veritable expert at this sort of thing – having been Manager of the Back Pain Research Group at Sydney University and the George Institute. James is possibly the most interesting manager in the world – former club promoter, bar/restaurant and night club operator, underground house music connoisseur, psuedo-vegetarian (for the most interesting of reasons), moped rider and psychologist (yes – that does make him interesting). James has a PhD from Brunel Uni, UK on cultural influences in back pain.

James’ personal research is in identifying and treating risk factors for chronic back pain and developing approaches to improve management of chronic low back pain. Recently he has become interested in novel strategies for managing clinical pain in the real world. More about James here. Link to his published research here.


Johnston, M. (1996). ‘Models of Disability’. The Psychologist, 9, pp. 205-210
Johnston, M (1996). Models of Disability Physiotherapy Theory and Practice, 12 (3), 131-141


  1. Jacqui Clark says:

    Hi Arco, interesting point. But does the diagnosis have to be a pathology? Can it be a diagnosis something like a sensory processing problem for example? And of course there’s all the central sensitisation to explain – it can all be explained to the patient if it is information they need to reduce disability. But isn’t it more complex? I agree with James, behaviours play a huge role in disability and so does some level of personal attitude and responsibility, in combination with a matrix of other factors. How little we really understand about the human condition!

    arco Reply:

    Hi Jacqui

    I meant what I say, and I don’t see anything against the post. I just pointed the need of being systematic with our approach to patients, and being systematic we’ll be able to catch actual disorders or just “central” problems, or may be combinations, and I think it’s difficult to reach such conclusions.

    If we keep in mind only that every pain and/or disability problem is because of the brain perception, we will overlook the underlying problem.

    It’s like yellow flags, they are present very often, but many times as we detect the problem and solve it, they dissapear.

    Anyway, I think I made my point, and didn’t want to argue, but just trying to be sensible!


  2. Pain/disability could be regulated by external factors and internal factors.

    I agree high pain intensity is not always related to high disability, but pain can lead to a disability because of:
    1- illness behaviour (learnt or acquired)- e.g disabled relatives
    2- Reward /punishment -avoidance effect of pain /disability
    3- Coping strategy (individual related with all the yellow flags you can put around)
    4- Compensation
    5- Lack or wrong information about his problem
    6- Reinforcement of “specific labels” like, degenerated disc, OA, muscle weakness, and their catastrophic effects – leading to more avoidance, more disability, creating anxiety and even depression

    But we have never to forget to give the chance to each and every patient of having a good assessment done. And here the question is: Who is so skilled to rule out every single possibility as a cause actual or potential?

    Does the lack of a specific structural abnormality mean there is no pathology?

    Information is always a good way of approaching our patients, but has to be specific to the patient’s problem, and in order to achieve that we really need to assess and have a diagnosis. Without an specific diagnosis, we can play any game we want, but we may be overlooking the true one. And to be sure, that our information doesn’t worsen our patient¡s pain and disability.

    We have a saying in my country: ” My God, leave me like I am” . If we cannot improve a patient, we must try not to make him worse.