Whole of Systems Thinking for Those With Persistent Low Back Pain & Allied Health Professionals
Where do we even begin?
Let’s paint a picture: You’re a healthcare professional preparing for a new patient. The case might seem relatively straightforward, at least in your eyes, another case of back pain. You think back (pun intended) to your university training and all the guidelines you’ve studied; the importance of ongoing exercise, screening for red flags, regular check-ins, pain education and some supervised sessions to ensure the treatment plan is working. You’ve got it all lined up, ready to deliver the best care possible.
But then you meet your patient, a single mother who’s struggling to make ends meet. She tells you that this visit might be her last because she can’t afford any more sessions. Private health insurance is a luxury she simply can’t afford. She’s not eligible for any significant disability support, despite facing ADHD, type 2 diabetes and a few other conditions, and she’s too young for aged care assistance. On top of that, she left school early to support her family, so understanding complex medical advice can be a challenge for her. Suddenly, the textbook solutions don’t seem so applicable. You realise that her health isn’t just about the pain in her back; it’s about her financial situation, her education, and the overwhelming stress she faces daily.
This is the reality of health in the real world.
Yet many health professionals are solely focused on the biological, which as we’ll see, can be an issue.
Picture trying to stay healthy while dealing with unstable housing, limited access to nutritious food or the chaotic stress of financial insecurity. It’s like trying to keep your head above water in what may seem to be from onlookers, a calm sea, but below the surface? You’re battling riptides, relentless waves, and occasionally, a hungry shark. Even the strongest swimmer can’t change the conditions alone, and it’ll be a hell of a lot harder to stay afloat than someone who doesn’t experience those issues.
Not quite fair, is it?
You see, health isn’t just about popping pills, that dreaded annual check up or doing your 150 minutes of exercise per week; it’s a complex web woven and intertwined from various social, economic, and environmental threads. These threads, known as the social determinants of health (SDH), create the backdrop for our health journeys, and unfortunately, are not always under our control.
According to the World Health Organization (WHO), social determinants of health are:
“The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.’’
Closely tied to the social determinants of health is the socio-ecological model, which highlights how our health is shaped by interconnected influences, ranging from our personal choices to the societal structures that surround us. Rather than viewing health as solely a matter of individual responsibility, this model recognises that our wellbeing is deeply influenced by the people we interact with, the communities we belong to, and the broader societal forces at play. It shows how everything from our relationships and neighbourhoods to policies and cultural norms intertwine to shape our health outcomes. It paints a comprehensive picture of health, reminding us that to truly improve wellbeing, we must address not only the individual but also the social and environmental contexts that impact health on a broader scale.
‘‘The “socio-ecological model” (the Ecology of Human Development) was developed by psychologist Urie Bronfenbrenner in the late 1970s, as a way to recognize that individuals affect and are affected by a complex range of social influences and nested environmental interactions. This model recognizes that factors can cross between multiple levels. They can also impact people differently, based on cumulative and intersectional experience’’
Over the past twenty years, a substantial and persuasive body of evidence has emerged, highlighting the significant impact of social factors that goes beyond medical care on various health indicators, environments, and populations. In fact, there is research that has evaluated the influence of these social factors on health. One estimated that medical care accounts for only 10%–15% of preventable deaths in the U.S. While this figure might be underestimated, it reinforces the significant impact of social factors on health outcomes. Now, it’s important to remember this evidence does not negate the role of medical care in influencing health; instead, it suggests that medical care is not the sole determinant of health outcomes, and that its effects might be more limited than often assumed, especially in preventing illness or injury.
So, to sum this up simply, the social determinants of health are really important, like really important when it comes to our health and wellbeing.
How does this tie in to people with Persistent Low Back Pain?
Let’s zoom in on one factor that is part of this big puzzle in persistent pain, our mental health. It’s easy to see mental health as just another piece of the puzzle, but in reality, it’s more like the glue that holds everything together. Poor mental health can exacerbate other social determinants, such as employment, social support, and even access to healthcare. For example, someone struggling with anxiety or depression may find it challenging to hold down a job, which in turn affects their income, housing, and overall wellbeing, which in turn, affects their pain, as we’ll see further on in this post. This interconnectedness is why mental health is so critical to consider when discussing the social determinants of health. When AHPs focus on treating just the physical symptoms without acknowleding a mental health component, they risk overlooking a crucial element of the patient’s overall health.
This deeper understanding of how various factors, including mental health, intertwine to impact overall wellbeing sets the stage for considering more comprehensive approaches to healthcare. Rather than focusing solely on individual symptoms, we need to consider the broader context of a person’s life.
People with low back pain often experience emotional distress, including feelings of frustration, helplessness, and even depression. The persistent nature of the pain can lead to a sense of despair, as individuals struggle to find relief despite trying various treatments. Over time, this can erode their sense of wellbeing, leading to a vicious cycle where the pain exacerbates mental health issues, and poor mental health, in turn, exacerbates the perception of pain.
Corey Keyes’ Dual Continuum Model of Mental Health can provide a valuable framework for understanding the complexities of mental wellbeing. According to Keyes, mental health and mental illness exist on two separate but related continua. The first continuum represents the presence or absence of mental illness, while the second continuum represents the presence or absence of mental wellbeing:
In this model, mental health is not simply the absence of mental illness. Instead, it encompasses the presence of positive psychological factors, such as life satisfaction, a sense of purpose, and emotional vitality. all which can be greatly impacted by persistent pain. Conversely, mental illness represents a spectrum of psychological conditions, ranging from mild distress to severe disorders. As shown in Keyes’ model, it is possible for individuals to experience mental illness and still have a high level of mental wellbeing, or conversely, to be free of mental illness but have low mental wellbeing.
When applying the Dual Continuum Model to individuals with persistent pain, it becomes evident that managing pain requires more than just addressing the physical symptoms. It requires a holistic approach that also considers the individual’s mental health and overall sense of wellbeing.
For instance, an individual with persistent pain may not necessarily have a diagnosable mental illness, yet there’s a good chance they experience low mental wellbeing. This could manifest as feelings of dissatisfaction with life, low energy, and a lack of motivation or purpose. According to Keyes’ model, this person would be considered “languishing”—a state where they are not experiencing good mental health, even though they might not meet the clinical criteria for depression or anxiety.
Conversely, some individuals with persistent pain may be “flourishing” despite their condition. These individuals might have developed coping mechanisms, social support networks (hello SDH) or a sense of purpose that allows them to maintain a high level of wellbeing, even in the face of pain. The Dual Continuum Model and the socio-ecological model helps to explain why some individuals with pain might report a higher quality of life than others, despite having a similar ‘‘condition’’.
The impact of the social determinants of health on low back pain (LBP) is much larger than most people think, yet many individuals suffering from LBP remain unaware of these influences, largely due to the dominance of a ‘biomedical view’ in healthcare practices. For instance, one qualitative study found that while some physiotherapists are beginning to incorporate broader social and psychological factors into their practice, many still focus predominantly on biological aspects due to ingrained training and institutional pressures. This perspective often focuses narrowly on physical and biological factors, such as spinal structure or muscle function, as the primary causes of LBP, which we now know is not quite accurate. Consequently, healthcare practitioners may overlook the broader socioeconomic conditions that significantly affect pain outcomes, which can leave those suffering from LBP feeling like they’ve ‘failed’ treatment or the health practitioner confused to why people aren’t getting better in a linear fashion.
A systematic review on SDHs and chronic low back pain (CLBP) reveals that factors such as low education, socioeconomic deprivation, and demanding occupations are strongly linked to worse pain severity, increased disability, and more frequent absenteeism from work. However, because the biomedical model emphasises physical treatment; like medications, surgeries, or physiotherapy, patients often do not receive information or interventions that address these underlying social factors. This lack of awareness perpetuates the cycle of pain and disability, particularly in socioeconomically disadvantaged groups, who are more vulnerable to these determinants. Shifting towards a more holistic, biopsychosocial approach that incorporates the SDH is crucial. This approach can empower patients with a deeper understanding of how their social environment influences their health and can guide more effective, comprehensive treatment strategies that address both the physical and social dimensions of LBP.
Take a look at the summary of results on the right hand side, the table highlights key associations between social factors and chronic low back pain (CLBP). People in rural areas, Aboriginal individuals, and those in physically demanding jobs or jobs with overtime are at a higher risk of CLBP. Women are more likely to remain out of work after a year with CLBP than men. Lower education levels are linked to higher pain intensity and greater disability, while lower socioeconomic status (SES) increases the risk of severe CLBP. Socioeconomic deprivation and lack of support at work also contribute to a higher prevalence of CLBP. Additionally, being married, widowed, or divorced is associated with a greater likelihood of experiencing CLBP compared to being single. These findings underscore the significant impact of social and economic factors on CLBP outcomes.
Another systematic review highlights the significant impact of social determinants of health on the outcomes of lumbar spine surgery, it shows that our experience of pain goes far beyond just the physical aspects. Once again, factors like low education and low-income status are strongly associated with poorer outcomes, such as continued pain, disability, and delayed return to work. Even after surgery, where the physical ailment might be “fixed,” the outcomes can vary widely depending on these socioeconomic factors. It further highlights that pain and recovery are not just about the success of the surgery or ‘‘fixing something’’ but are deeply influenced by the broader social context in which a person lives.
If this is not making sense, maybe an analogy would help. Consider two people with the same back surgery: one is well-educated with a stable job, and the other has limited education and struggles with low income. Despite undergoing the same procedure, the second individual might experience more post-surgical pain, greater disability, and a longer recovery period. Imagine two cars receiving the same repair—one is consistently driven on smooth, well maintained roads (a supportive social environment), while the other is driven on rough, neglected roads (a challenging socioeconomic context). Despite both cars being “fixed,” their performance post-repair differs significantly based on the conditions they face. Unfortunately (or perhaps fortunately) pain is far more complex than we often think, while this may seem overwhelming, it also means there’s lots of paths and avenues one can change in their pain journey, and not all areas have to improve in order to feel better.
The Need For Change in Allied Health Professionals
Now that we better understand the profound impact of the SDH on individual and community well-being, it is clear that the healthcare field, including allied health professionals, must undergo significant changes. But how do we enact this transformation, and where should we begin? The answer lies in rethinking the very foundation of practice, education, and its role within the broader healthcare system. It is no longer sufficient to focus solely on physical rehabilitation; instead, these professions must integrate a deeper understanding of the social contexts that affect health outcomes, ensuring that care is both equitable and comprehensive.
One paper highlights the necessity for a transformational shift in physiotherapy to incorporate social justice principles. The authors argue that while the profession has made strides toward a holistic biopsychosocial approach, it continues to prioritise biological and psychological aspects, often neglecting the critical social factors that shape patient health. This narrow focus is concerning given the growing recognition of how socioeconomic status, cultural background, and systemic inequalities impact health outcomes.
The authors propose adopting a tripartite model of practice, similar to Payne’s typology in social work, which includes therapeutic, social order, and transformational views. This model urges practitioners to move beyond individual-focused treatments and consider how societal structures contribute to health issues:
Therapeutic View
This view focuses on the individual patient, emphasising the role of physiotherapists in helping clients overcome personal suffering through clinical interventions. The approach is centered on the individual’s well-being, often addressing modifiable factors like beliefs, movement behaviors, and coping styles. However, it tends to overlook the broader sociocultural context, treating social determinants of health as external factors rather than integral components of health outcomes.
Social Order View
This perspective sees physiotherapists as part of the larger healthcare system, where their role involves helping patients adapt to societal expectations. In this view, practitioners may provide support that helps individuals navigate their circumstances, such as returning to work after an injury, but this often reinforces existing societal structures without challenging the underlying social inequities. The social order view maintains the status quo by focusing on individual adaptation rather than systemic change.
Transformational View
This view encourages physiotherapists to look beyond the individual and consider how societal structures contribute to health issues. Practitioners adopting this perspective aim to enact broader societal changes to address the root causes of health disparities. The transformational view is less commonly adopted in physiotherapy but is seen as essential for advocating for systemic change and addressing the social injustices that impact health. This view in particular, is emphasised as essential for enacting large-scale change, encouraging physiotherapists to advocate for societal changes that address the root causes of health disparities.
A great quote that embodies these perspectives is from Arthur Kleinman, an American psychiatrist and a professor of medical anthropology who made a point in 1978 writing that ‘Modern physicians diagnose and treat diseases (abnormalities in the structure and function of body organs and systems) whereas patients suffer illnesses (experiences of disvalued changes in states of being and social function)’. Focusing on one view, would be a disservice to health professionals and their patients alike.
At the patient level, healthcare providers are encouraged to be vigilant for “clinical flags” that might indicate underlying social issues, such as signs of stress or frequent missed appointments, going beyond the biomedical. By asking sensitive questions about a patient’s social history and challenges, clinicians can uncover hidden factors that may be contributing to their health problems. Once these issues are identified, “social prescribing” can be employed—referring patients to community resources, support services, or advocacy organisations that can help address their social needs.
Although achieving such transformational change is challenging, particularly due to the lack of social justice training for physiotherapists. The authors advocate for embedding these principles into entry-level training programs and preparing future practitioners to engage in this critical work. By embracing a transformational approach, physiotherapy can evolve into a more holistic, inclusive, and just practice that not only treats physical conditions but also addresses the social injustices that contribute to them.
This paper looks overcoming barriers to adopting a social determinants of health approach in clinical practice
Despite the benefits of operating under a transformational lens, health professionals frequently feel constrained by time, fearing the “Pandora’s box effect” that might arise from opening discussions about these sensitive topics. Yet, research shows that even a modest increase of two or three minutes in consultation time can significantly enhance anticipatory and coordinated care, reduce healthcare workers’ stress, and improve patient outcomes. One of the key facilitators in managing these complex needs is having easy access to local referral resources. Unfortunately, many professionals often lack the necessary knowledge of community specific resources that can address these social challenges effectively. To bridge this gap, access to a well-maintained, user friendly online directory of local community resources is essential. Tools like these empowers healthcare providers to offer more comprehensive care by connecting patients to the appropriate support services.
The CLEAR toolkit can help in providing healthcare workers with practical resources to assess patient vulnerability and identify local referral options:
A Call to Action
The social determinants of health are powerful forces that shape our lives, often in ways we may not immediately recognise. By addressing these underlying factors, we can work toward a future where health equity is not just an ideal but a reality. Allied Health Professionals are uniquely positioned to lead this charge, applying their diverse skills to ensure that every individual has the chance to thrive, no matter the circumstances they face. As we continue to challenge the traditional ways of thinking and embrace a more holistic approach to healthcare, we may be able to move towards a society where the waves of inequality no longer threaten to pull us under but instead become calmer waters where everyone can stay afloat.
It’s time to take action, are you in?
References
Andermann, A & CLEAR Collaboration 2016, ‘Taking action on the social determinants of health in clinical practice: a framework for health professionals’, CMAJ: Canadian Medical Association journal = journal de l’Association medicale canadienne, vol. 188, no. 17–18, pp. E474–E483.
Hnatešen, D et al. 2022, ‘Quality of Life and Mental Distress in Patients with Chronic Low Back Pain: A Cross-Sectional Study’, International Journal of Environmental Research and Public Health, vol. 19, no. 17, p. 10657, viewed 19 August 2024, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9518072/>.
Karran, EL, Grant, AR, & Moseley, GL 2020, ‘Low back pain and the social determinants of health: a systematic review and narrative synthesis’, Pain, vol. 161, no. 11, pp. 2476–2493.
Kleinman, A, Eisenberg, L, & Good, B 1978, ‘Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research’, Annals of Internal Medicine, vol. 88, no. 2, pp. 251–258.
McGinnis, JM, Williams-Russo, P, & Knickman, JR 2002, ‘The case for more active policy attention to health promotion’, Health affairs (Project Hope), vol. 21, no. 2, pp. 78–93, viewed 19 August 2024, <https://doi.org/10.1377/hlthaff.21.2.78>.
McGrath, RL, Shephard, S, & Chen, Y-T 2023, ‘The Need for Transformational Change in Social Justice–Informed Physiotherapy’, Physiotherapy Canada, p. e20220108, viewed 19 August 2024, <https://utpjournals.press/doi/10.3138/ptc-2022-0108>.
Mercer, SW et al. 2007, ‘More time for complex consultations in a high-deprivation practice is associated with increased patient enablement’, The British Journal of General Practice: The Journal of the Royal College of General Practitioners, vol. 57, no. 545, pp. 960–966.
Mescouto, K et al. 2022, ‘Physiotherapists Both Reproduce and Resist Biomedical Dominance when Working With People With Low Back Pain: A Qualitative Study Towards New Praxis’, Qualitative Health Research, vol. 32, no. 6, pp. 902–915.
Westerhof, GJ & Keyes, CLM 2010, ‘Mental Illness and Mental Health: The Two Continua Model Across the Lifespan’, Journal of Adult Development, vol. 17, no. 2, pp. 110–119, viewed 19 August 2024, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866965/>.
Yap, ZL et al. 2022, ‘The role of the social determinants of health in outcomes of surgery for low back pain: a systematic review and narrative synthesis’, The Spine Journal: Official Journal of the North American Spine Society, vol. 22, no. 5, pp. 793–809.