A significant number of patients present to doctors and physiotherapists with back pain. For the majority, the pain is of little consequence and resolves without much hassle. In many instances, reassurance, a positive attitude and a healthy support system is all that is required.

In these situations, a short period of rest, analgesia and reassurance that the pain will settle goes a long way. The pain often does settle but could also recur, revisiting the patient on other occasions.

Moderate to severe back pain is a different kettle of fish. Pain that makes a grown man cry should be taken more seriously and be fully evaluated. In truth, the severity of the pain does not bear much correlation to the presence of an organic or anatomical cause. Patients describe their pain depending on their psychological makeup.

Regardless, moderate or severe and incapacitating pain demands further investigations.

History taking
The questions used to elicit information from the patient aim to discover the seriousness of the pain and its impact on the patient. One of the important aspects of history taking is appreciating the patient. Who is the patient? Age, gender and occupation are important. Why has the patient presented to you at this point in time? What is the driving complaint that needs a solution?

The patient should be allowed time to tell his or her story. Patients will relate in clear terms the origin and location of the pain. They will describe the different characteristics of the pain and its progression. Many will discuss how it affects their life and livelihood with little prompting. Does it affect sleep? Is it associated with other symptoms such as fever?

The medical history especially of trauma, chronic diseases such as diabetes and inflammatory arthritis are important. Is there a history of cancer or even previous surgical intervention?

Clinical examination
The clinical examination gathers more information related to the history from the patient. Further, it confirms the complaints and attempts to determine the physical and neurological aspects related. It looks for signs of cachexia, fever, swelling, tenderness, and evidence of chronic illnesses such as gout and rheumatoid arthritis. What are the physical signs of the problem? Are there signs of movement disorders, restriction of movement, stiffness, scoliosis or kyphosis? Is the patient limping, with a foot drop or bent double by pain?

The neurological examination is very important. A precise anatomical examination will often clarify the level of the pathology. Is it right, left-sided or bilateral? Is it involving the spinal cord or nerves? Which nerve or nerves are affected can often be clarified from the neurological examination. For example, foot drop is due to the affectation of the L5 nerve. It will be associated with numbness of the lateral aspect of the calf.

At this point, two things should be clear. One: Is the patients’ complaint serious and should be taken seriously? Two: Where exactly and what is the likely pathology? For example, a diabetic complaining of fever and severe back pain should be assumed to have discitis (infection of the disc) or some infection until proven otherwise. A patient with a previous history of breast cancer now complaining of severe back pain should be investigated for possible bony metastasis. Similarly, patients with confirmed neurological deficits as described above deserve further evaluation.

There is a huge array of an investigative arsenal at our disposal and the choice depends solely on the initial working diagnosis. The diabetic patient above would have blood tests such a blood sugar level, white cell count, and erythrocyte sedimentation rate. Radiological investigations such as an x-ray of the lumbar spine and an MRI scan are also mandatory.

The patient with a history of trauma could be asked to perform x-rays or a CT scan of the affected area as the evaluation demands.

Action plan
Patients with mild pain can be reassured and plans made to review them regularly. This means that the patient and the doctor or physiotherapist agree that the pain is of little consequence. Also, especially, that there are no important issues termed as ‘red flags’ detected in the complete evaluation of the patient. Such patients do not need any investigations and treatment can proceed as necessary.

Treatment may include reassurance, encouragement to achieve a positive and calm attitude to the pain. The development of a support system at home, work or in the clinic for such patients should be explored. The use of medical therapies such as mild analgesics and physical therapy may be required. All patients with back pain deserve back exercise advice and encouragement to lose any additional weight. Cessation of smoking and reduction of alcohol intake could be additional advice of merit.

Patients with red flags
There are important points to look out for in the evaluation of the patient. These points are the red flags or warning signs related to the patient. Elderly patients, those with severe, unrelenting pain, fever, history of significant trauma, patients on drugs such as Warfarin, history of cancer, HIV AIDS and of course neurological deficits including bowel and bladder problems, should be investigated with the required urgency.

Who does the investigations?
Whoever can interpret the investigations should order the tests. This is critical to understanding the pathology and deciding on the appropriate management. The doctor (general practitioner) or physiotherapist should refer to the appropriate specialist as necessary. This specialist could be a radiologist, rheumatologist, an orthopaedic or a neurosurgeon as may be indicated. Discussing patients with a radiologist has huge merit and should be practised by all.

The final or definitive management depends on the actual final diagnosis and the expert management required. It could range from a referral to the physiotherapist as the definitive care or surgical intervention by the spine surgeon.

The physiotherapist
The role of the physiotherapist is integral to the overall wellbeing of the patient with back pain. Whether the patient is managed conservatively or by surgical intervention, the physiotherapist has an important role to play in the rehabilitation and long term maintenance of the patient.