Principles of examining persistent spinal pain

Initial spinal assessment, including general subjective history (history of present complaint, drug history, past medical history, etc.), objective measures of movement and red flags, are appropriate where they have not been done before (see, for example, Koes et al 2006 for further information). Standard assessment tests and questions may become unnecessary if the patient has attended before but a detailed history of the presenting condition is always important. The decision whether or not to repeat physical measures will be made on a case-by-case basis, using the following questions:

The focus here is on the factors to consider in a chronic spinal pain condition where red flags have been ruled out. Sometimes it will be appropriate to repeat a physical examination, not just to confirm the biomedical status of musculoskeletal structures but also for the patient to feel that they are being taken seriously. In such situations a skilful examiner can communicate the purpose of specific tests and findings in a helpful way, e.g. ‘This test tells me that you have some stiffness/reduced movement but it is perfectly safe for you to practise this to make it easier’ rather than ‘You’re very stiff, which could be because of the wear and tear’. The latter may mean to the patient that moving more will cause further deterioration and even damage and should therefore be avoided, even if this was not what the clinician intended.

Clarity and consideration of how a patient may interpret statements are key when delivering messages to a patient with chronic pain. The therapeutic relationship should be viewed in terms of a partnership where the patient’s understanding, opinions and values are heard, respected and incorporated into the management plan whenever possible (Slade et al 2009). The assessment should always include explanations to the patient.

An assessment using closed questions will rarely be helpful for the chronic spinal pain patient. Although time-limited during assessment, it is important to include as many open questions as possible thus allowing the patient to fully explain their situation, interpretations and expectations. Crucial information may be missed by simply not allowing the patient to express themselves appropriately. Encouraging the patient to choose their own descriptions for their pain can reveal psychological and sensory information that might otherwise be lost.

Active listening as part of motivational interviewing techniques can be a valuable skill to develop when examining the chronic spinal patient (Rollnick et al 2010). It may help to establish whether the patient is ready to take action to change or to help them to that point (Miller & Rollnick 1991).

Being able to use language that matches the patient’s can be helpful. This applies to verbal language but also to non-verbal language such as eye contact, intonation and gestures. Offering summaries of what has been said can demonstrate you have been listening as well as consolidate what you have just been told and clarify misunderstandings. There are many helpful texts for those who want to explore communication further (e.g. Main et al 2010; Miller & Rollnick 1991; Moulton 2007).

When assessing chronic spinal pain it is essential to ensure that both the clinician and the patient feel that the assessment is complete. Patients may feel that it is the clinician’s job to know and that their opinion is not important, but when dealing with persistent pain the patient’s view is essential. Skilful questioning can save time and ensure that the patient’s needs are met. A patient who feels they have not been fully investigated will find it very difficult to assimilate key messages that the clinician may want to give them. If they remain unclear regarding their diagnosis and/or more importantly if they feel that something has been missed, this will need to be addressed. A clinician may ask a patient what they feel they need in order to be reassured about their condition. Frequently, patients will ask for an MRI, which may or may not be appropriate (see section on diagnostic tests). If an MRI scan is not appropriate, as is frequently the case, it is important to have a discussion with the patient about why this is and to check with the patient that they understand and agree. It may also be helpful to bring up difficult considerations to ensure the patient is not harbouring secret fears about their condition. For example, patients may be concerned that they may have cancer or that they will end up in a wheelchair. Other patients report thinking that they have a ‘slipped disc’ and the clinician should explore what the patient’s interpretation of this term is. These conversations will allow the clinician to explore with the patient whether their cognitions and expectations are helpful and realistic, and provide an opportunity for explanation, reassurance and further planning.

When delivering a diagnosis it is essential to check the patient’s understanding. Misunderstandings must be clarified. For example, a patient may be told that they have no serious findings on their MRI scans apart from normal age-related changes. They may take this to mean that they have ‘wear and tear’ and that their spine is crumbling. They may also think that they have something so sinister that it does not even show up on a scan. In other words, information that is intended to be helpful may in fact have the opposite effect. Checking how the patient interprets the diagnosis provides an opportunity to explain, reassure and start changing unhelpful behaviours. With skill, underlying fears can be unpicked and addressed in a respectful and constructive manner.

The relevance of a diagnosis

Many patients expect a diagnosis explained in terms of pathology or mechanical problems. It is important that clinicians are familiar with pain physiology so that they can also deliver a ‘pain diagnosis’ or description of the pain mechanisms involved (Main 2009). This is especially important when there is persistent pain despite a paucity of positive medical findings, leading some patients to wonder whether the pain is ‘not real’ and ‘all in their head’. The urge to refer a distressed, demanding patient for more repeat tests or to another speciality rather than delivering a pain diagnosis must be resisted. Adequate time is required to deliver the information in a clear, empathic and constructive manner. The notion that nothing further that can be done must be challenged. Using examples from their values and goals can assist to demonstrate areas in which the patient can make improvements, or reverse the apparent progressive nature of their condition, despite ongoing pain.

Carers too may benefit from improved understanding of the meaning of the diagnosis, especially because over-solicitous behaviour can affect the patient’s pain perception (Flor et al 1995). Conversely, a lack of understanding of family, friends or carers may maintain maladaptive pain behaviours. Involving carers in a patient’s care can improve overall outcomes for the patient (Abbasi et al 2012).

The meaning of a diagnosis of chronic spinal pain can have a major impact on activities such as work or social activity. There are many myths surrounding the condition of low back pain in particular, some instigated by well-meaning healthcare professionals. For example, a patient may be told that they should never bend or lift again. They may be advised to avoid any physical exertion at work. It is not helpful to suggest that a patient is unable to carry out any activities or that certain activities must be avoided indefinitely. Instead, it is more productive to focus on what is manageable and how activities can be adapted. It is helpful to be explicit regarding the patient’s ability to carry out their duties and that it is safe for them to return or continue to work. A graded return programme may be agreed with the patient and their employer, and some patients benefit from a work hardening programme tailored to their specific requirements. Patients also need advice about flare-up management.

Diagnostic tests

X-rays and MRI scans are of limited value when managing chronic spinal pain and frequently make little difference to treatment outcome (Chou et al 2009a, Kleinstück et al 2006). They are generally to be avoided unless a serious pathology such as a fracture or tumour has to be ruled out. There are numerous guidelines on the use of MRI and other diagnostic tests for patients with low back pain (Airaksinen et al 2006; NICE 2009). Evidence shows that routine spinal imaging is not associated with benefits, exposes patients to unnecessary harms and increases healthcare costs (Chou et al 2012). Disc abnormalities occur in asymptomatic people; in one study, bulges were present in 52% of people without a history of back pain, protrusions in 27%, and herniations in 1% (Jensen et al 1994). Even in symptomatic patients it is recognized that the findings on scan do not predict response to treatment (Kleinstück et al 2006). Despite this evidence these changes can be mistaken for the cause of the pain, so careful examination combined with clear clinical reasoning is required. As mentioned, the diagnosis of chronic pain and an explanation of basic pain physiology may give the patient a chance to understand pain without pathology.

When explaining diagnostic findings, clinicians should use language that the patient is familiar with, as long as relevant information is not over-simplified or omitted (Slade et al 2009).

Patient goals

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