100% other causes - not a tissue problem
If we are strict about the definition of "chronic lower back pain" being pain in the back greater than 6 months duration WITHOUT any acute exacerbation or flare up (which would be an acute exacerbation of an underlying chronic condition and would equate to a tissue problem) then I believe the problem lies in the central nervous system processing (the brain). The only thing that peripheral tissues can do is relay nociceptive messages TO the brain but this does not equal pain as you can have nociceptive input and not have a pain experience (the same is true in the reverse as well). There are lots of examples of this but a simple one is this: you are working in your garage feverishly on a project only to find out later on that your elbow is bleeding and you must have caught it on a nail... You didn't experience pain at the time because there was a bigger issue at hand, finishing tbe work you started so this little bit of dermal nociceptive bombardment was shut down by central processing and you didn't not experience pain.
These patients often have other chronic pain yellow flags included but not limited to fear avoidance, catastrophization, work/family stressors, financial stressors, etc which all feed into the pain experience via sensitization. To target this, I personally believe (and have had quite good success with) that a pain science educational intervention must take place first to address the yellow flags because we know cognitions change pain, and then we follow that up with an impairment based management program whereby we treat underlying impairments with manipulation/mobilization, exercise, needling, etc. to help them move and engage in exercise as medicine. I have tried to chase tissues earlier in my career until I humbled myself with not knowing it all and looked into this pain science perspective popularized by mosely, butler, and Louw and I have found that within myself I am having better outcomes with chronic pain patients than I was when I was taking a strict pathoanatomical based approach like I was formally trained in.
Looking forward to reading other comments
100% other causes - not a tissue problem
If we are strict about the definition of "chronic lower back pain" being pain in the back greater than 6 months duration WITHOUT any acute exacerbation or flare up (which would be an acute exacerbation of an underlying chronic condition and would equate to a tissue problem) then I believe the problem lies in the central nervous system processing (the brain). The only thing that peripheral tissues can do is relay nociceptive messages TO the brain but this does not equal pain as you can have nociceptive input and not have a pain experience (the same is true in the reverse as well). There are lots of examples of this but a simple one is this: you are working in your garage feverishly on a project only to find out later on that your elbow is bleeding and you must have caught it on a nail... You didn't experience pain at the time because there was a bigger issue at hand, finishing tbe work you started so this little bit of dermal nociceptive bombardment was shut down by central processing and you didn't not experience pain.
These patients often have other chronic pain yellow flags included but not limited to fear avoidance, catastrophization, work/family stressors, financial stressors, etc which all feed into the pain experience via sensitization. To target this, I personally believe (and have had quite good success with) that a pain science educational intervention must take place first to address the yellow flags because we know cognitions change pain, and then we follow that up with an impairment based management program whereby we treat underlying impairments with manipulation/mobilization, exercise, needling, etc. to help them move and engage in exercise as medicine. I have tried to chase tissues earlier in my career until I humbled myself with not knowing it all and looked into this pain science perspective popularized by mosely, butler, and Louw and I have found that within myself I am having better outcomes with chronic pain patients than I was when I was taking a strict pathoanatomical based approach like I was formally trained in.
Looking forward to reading other comments