This debate has been going on for ages. And I have respect for both him and Dr. Quintner, although their discussions can often be a bit frustrating to follow.
As we are coming at this topic from the clinical perspective (as opposed to the research perspective), my fundamental question is always: what do I do with the patient in front of me? I am not sure what their proposed method is for "treating the bio component exclusively" , with current medical treatments. I also do not view “BPS” as an explanatory model for pain itself, but rather as a useful approach to better understand a person’s experience with pain, and as a way to identify modifiable variables that may impact it.
I unfortunately do not have time for full discussions of these papers, but will provide a brief response:
cited a study recently which would contradict the the BBM view of imaging(imaging not being effective) for establishing cause of pain.
This is not an accurate representation of our position. Imaging tests cannot “see” pain. They can find changes, which may be incidental, physiologic adaptations, or pathologic abnormalities. We have never argued that imaging has no relevance in the evaluation of pain, nor would we say that imaging findings have no association with pain symptoms. I use diagnostic imaging in the evaluation of pain all the time in medical practice; however, when presented with radiologic findings I have to then determine a few things 1) is this finding relevant to the patient’s presentation, 2) if so, how necessary is it that this imaging finding be intervened upon, in order to improve the patient’s outcome?
So yes, there is an association between a variety of imaging findings and pain. The caveat is that this association is nowhere near 100% for imaging findings relating to musculoskeletal pain. And the critical question is, do we need to intervene specifically on this imaging finding, in order to mediate change/improvement? For many imaging findings, the answer is (fortunately) no – pain can improve on its own with time/natural history, pain can improve with non-specific rehabilitation or other behavioral modification, or with targeting a variety of other factors such as sleep, among others.
Now, what if we were to discover a “purely biological” treatment that eradicates persistent pain? That would be great. If the balance of potential benefits / potential risk were favorable for an individual patient, I’d be ready to use it. But such a thing does not exist at this time, despite a lot of research going into the field of neuroinflammation, voltage-gated sodium channel antagonists, etc. In the meantime, as a clinician working with a patient, I still find an assessment of BPS factors useful to explore a patient’s experience, and to illustrate the ideas that even if we can’t/shouldn’t “fix” your imaging abnormality, there are a lot of other variables that may impact your experience and daily function. The same applies to the catastrophizing paper; there are other papers with conflicting findings in this area, but regardless of whether such psychological factors are causal in the transition from acute to chronic LBP, they are relevant to recognize and address for the person’s experience, regardless.