In Assessing Back Pain, Focus on the Patient

With complaints of chronic back pain increasing in frequency, clinicians are being forced to strengthen their examination and assessment skills on a regular basis. A patient-centered approach is often necessary for a practitioner to formulate an appropriate differential diagnosis.

“The idea of a patient-centered approach is based upon taking a step backward and placing greater attention on identifying that particular patient’s pain generator(s) resulting in their clinical presentation of back pain,” said David M. Glick, DC, DAAPM, CPE, FASPE, managing director of Pain Rx/Neural Pain Assessment in Richmond, Virginia. “With a more precise working clinical diagnosis, it is then possible to better target treatment directly toward that presenting pathology.”

Before using a patient-focused method, clinicians may first want to think about discarding back pain misconceptions as not doing so can lead to mishaps later on, such as when establishing a differential diagnosis.

“It is difficult to answer the question concerning why there are misconceptions about back pain,” Dr. Glick said. “Truthfully, there really does not need to be. Several are so well rooted; altering such common misconceptions about back pain seems a more difficult task than treating the underlying pain.”

While there are many misconceptions about back pain, one of the most common false beliefs is that back pain is thought of as pathology.

“Back pain is actually a symptom,” he said. “There are numerous musculoskeletal pathologies that can manifest with back pain as a symptom.  Complicating matters further, in the case of chronic back pain, is that there are often overlapping pathologies or underlying pain generators.”

Other back pain misconceptions are centered around pathologies identified on imaging studies, such the proverbial disk bulge or herniation.

“The prevalence of chronic back pain seems to be increasing, and it is the second most common cause of disability and lost work days in the United States,” Dr. Glick said. “Although it is not a leading cause of mortality, it is clearly a cause of suffering. We already have a variety of clinical tools at our disposal for treating patients with back pain; the key to enhancing clinical outcomes is to know which patient requires which treatment.”

The most important tools used for differential diagnosis are the patient’s history, the clinical examination, and experience of the clinician. During a routine assessment, clinicians should make note of tendon reflexes, conduct a sensory examination, and evaluate motor function.

“Clinical guidelines and algorithms are a double-edged sword,” he said. “While they can be effective in helping to establish a minimal standard of care, clinicians do not always adhere to the guidelines. This is especially true for back pain.”

It is important for the practitioner to look for the underlying cause of a patient’s pain. Remember: pain is a symptom, not a disease. The etiology of back pain can be mechanical/musculoskeletal, inflammatory, infectious, metabolic, or neoplastic.

“Through enhanced, more precise differential diagnosis, one is increasing the likelihood of a favorable clinical outcome with appropriate treatment,” Dr. Glick said. “The idea here is that a little effort goes a long way toward decreasing or eliminating the patient’s pain, not to mention better allocation of resources.”

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