Back-and-forth on back pain

In the popular cable TV series The Sopranos, a mobster complained of back pain as an excuse to avoid work—hardly a novel concept—so a colleague referred him to a specialist whose diagnostic skills had earned him the unofficial title “the Jonas Salk of backs.”The doctor gave him “the works, MRIs, cat scans, dog scans, you name it” but concluded there was nothing wrong with his back. This finding upset the skeptical colleague, but he acknowledged the difficulty of assessing back pain by noting, “When it comes to backs, nobody knows anything really.”

Clearly the know-it-all colleague had no medical training, but never has the dilemma of low back pain diagnosis been more eloquently stated.

Complaints of back pain—the most common physical condition for which patients see a doctor—result in physician visits of 12% to 15% of the U.S. population in a given year, according to the U.S. Bone and Joint Decade (USBJD). Back pain also is reported more frequently than any other form of musculoskeletal pain, including pain in the arms, shoulders, hips, or knees.

It might be surmised that diagnosis of a condition seen as frequently as back pain would be relatively simple because affected patients would be reporting similar sets of symptoms seen many times before. But that’s hardly the case. Back pain often results from complex conditions that are not easily understood.

Backache traditionally was considered a rheumatologic condition. Now it is recognized that possible causative factors include advanced age, poor fitness,obesity, poor dietary habits, heredity, race, and cigarette smoking.

Many diseases can cause or contribute to back pain, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, and cancer. Mechanical problems maybe responsible, particularly intervertebral disk degeneration but also spasms, muscle tension, and herniated disks. Sports and work injuries can cause acute orchronic back pain. Scoliosis and spondylolisthesis are possible causes.

Even pregnancy, fibromyalgia, and infections may contribute to back pain, and emotional stress can play a role in its severity and duration.

It’s no wonder then that diagnosis of back pain presents practitioners with such a major challenge. But patients face a similar challenge as they try to obtain an accurate diagnosis. Who do they see first when they experience symptoms?

Back pain traditionally was managed by orthopedists and chiropractors. Now many other professionals are involved, including primary care physicians,rheumatologists, pain management specialists, physiatrists, neurologists, physical therapists, trainers, psychologists, and practitioners of complementary and alternative medicine.

It’s generally recommended that persons with back pain see their primary care physician first. But if a patient comes to you with complaints of back pain, are you equipped to manage the problem or make an appropriate referral?

The USBJD used an objective scientific research design to measure the incidence and prevalence of musculoskeletal conditions and to project trends. The goal in reporting the key facts about back pain, as well as other musculoskeletal conditions, was to provide better understanding of the underlying mechanisms and to develop novel approaches to therapy and prevention.

That’s also the goal in this month’s cover story (“Low back pain poses diagnostic challenge to clinicians,” page 20.) This first part of a two-part article by Features Editor Kristen Light provides an overview of basic principles of patient evaluation, including recommendations from the American College of Physicians and the American Pain Society.

We hope this discussion will answer your questions about back pain so you can help patients achieve thebest possible outcome.