Low Back Pain Multidisciplinary Rehabilitation

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King and Bogduk note that the original idea of MDT pain management was to utilise the skills of all potentially relevant health practitioners such as pain physicians, radiologists, surgeons, interventionalists, physiotherapists, psychologists, and occupational therapies. This concept has morphed into one where the biomedical aspects are largely ignored, and so the term "MDT" and "pain clinic" are really misnomers. They may equate a surgeon saying "there is no surgical intervention" with there is "no structural pain generator", and presume the cause is primarily nociplastic in nature without actually testing for nociceptive pain. For example, in the past investigations such as medial branch blocks were offered in some areas of the country, but largely due to the changes in ideology, they are now no longer offered, and furthermore the MDT clinics may refuse to work alongside reductionist clinicians.

The premises that underlie multidisciplinary rehabilitation, as it is currently practiced (a primary focus on psychosocial intervention while ignoring nociceptive drivers), have no support in evidence based medicine.

The first premise that most isolated chronic low back pain is non-specific has repeatedly been proven false - the source of pain can be found in most patients with access to appropriate investigations. The false statement has persisted through a "telephone game of referencing" dating back to the 60s before the advent of modern investigations, while ignoring the copious literature to the contrary. See Non-Specific Chronic Low Back Pain for complete discussion on this topic.

The second premise that chronic nociceptive pain becomes permanently engraved into the central nervous system also has no basis in evidence ("the structure has healed but the CNS still has a memory of the pain"). There is some support for this idea in neuropathic pain, but not nociceptive pain. Otherwise the precision treatments wouldn't have the drastic effect on both pain and function seen in research, hip arthroplasty wouldn't work for chronic hip pain secondary to hip osteoarthritis, microdiscectomy wouldn't work for chronic lumbar radicular pain, omeprazole wouldn't work for chronic dyspepsia, corticosteroids wouldn't work for chronic de quervains tenosynovitis, and percutaneous intervention wouldn't work for chronic angina. Furthermore if the pain was primarily central in origin (like phantom limb pain), the research on diagnostic blocks would have shown that they don't abolish the chronic pain even temporarily, which is of course contrary to what has been found.

With these patently false premises, it is not surprising that MDT is not particularly effective (pain reduction 0.5-1.4 on 0-10 scale, and disability reduction 1.4-2.5 on 0-24 Roland-Morris scale), and is also extremely costly. MDT should be reserved for patients with widespread chronic pain and demonstrable central sensitisation (e.g. as identified through simplified bedside quantitative sensory testing), of which the standard chronic low back pain patient does not fit under. It may also be suitable for patients who are not interested in exploring the biomedical aspect of the biopsychosocial model, or who have a dual diagnosis of chronic low back pain and a mental health disorder or past trauma.