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Care guidelines: Managing non-specific spinal pain

Spinal pain is one of the most common reasons for doctor visits. But it can be a challenge to manage because of its elusiveness and because of patient expectations. You are more likely to be successful with non-specific spinal pain cases if you have a patient who agrees with your philosophy and management approach. It is important to clearly state your views during your patient’s first visit to let the patient decide if he or she agrees with you. Here are some talking points to use with your patient once you have completed the history and physical exam.

Talking points related to your philosophy on non-specific spinal pain

• Explain that your job on the first visit is NOT to say what is wrong, but instead to RULE OUT what isn’t wrong.
  - You need to rule out “bad things” such as a tumor, infection, fracture or dislocation, surgical problem or secondary visceral source for the pain.
  - A true “diagnosis” for spinal pain is rare. If you have some information about your patient’s pain, call it your “theory” instead because:
  • If you diagnose the problem as a sprain, strain or something similar, you cannot substantiate it.
  • If your patient sees another health care provider, chances are he or she will get a different diagnosis. This can be confusing for patients and lead to demands for referrals or imaging tests.
  • There is no one treatment pathway for specific diagnoses that has proven to be more effective than another one.
  
  
• Explain the differences between active and passive management/treatment.  See Philosophical Approaches to Managing Spinal Pain.
  - Active treatment: maintaining function while controlling pain. Experience has shown that immobilizing a body part to heal reduces mobility and function. Patients with other conditions such as joint replacements and uncomplicated heart attacks are mobile as soon as possible with better results. 
  - Passive treatment (heat, ultrasound, massage, etc.): short-term care to reduce symptoms. Passive treatment does not shorten healing times or prevent recurrences. Ideally, passive treatment is combined with some light activity as soon as tolerated. 
  - If you feel a PT visit is warranted, ask the PT to give your patient “theory” rather than diagnosis. 
  
  
• State your guidelines for prescribing medicines as a treatment.
  - Over-the-counter medicines: acetaminophen seems as effective as anything.
  - Prescription medicines: there will be a clear endpoint for the use of mood-altering drugs.
  
  
• State your guidelines for ordering imaging tests.
  - There are very few cases of non-specific spinal pain, even with extremity pain, that need imaging tests. 
  - You will order an imaging test immediately if you suspect any “bad things” may be causing the pain. Otherwise, you have ruled out potentially serious causes for the pain and your patient can be reassured if you don’t order any imaging.
  

Talking points related to your managing non-specific spinal pain

• Reassure your patient that most spinal pain cases are resolved naturally. 
  - Fifty percent of patients will have significant improvement in one week.
  
  
• Explain to your patient that most people with spinal pain who return to their usual activities the soonest do the best. 
  - Patients need to move around as soon as possible to prevent loss of function. Even if bedrest is recommended, the patient needs to be mobile very early. 
  - If mobility hurts, it doesn’t mean it is harmful.
  - Inactivity can lead to loss of function, which results in more pain. This cycle can lead to chronic pain.
  
  
• Discuss activity recommendations for both home and work.
  
  
• Explain that you have an aggressive return-to-work policy if the pain is related to work activities.
  - An early return to daily routines is best for patients with spinal pain.
  - You will not wait until your patient is pain-free to recommend a return to work.
  - Returning to work is safe, even if there is some pain involved.
  

Beyond the First Visit: If Your Approaches Do Not Seem to be Working
If your patient does not improve with your traditional approaches, proceed to the Conservative Treatment Failure Flow Chart.  See Conservative Treatment Failure. 

Primary care can successfully follow the patient for the first six to eight weeks of care when there are no "red flags" present. BEFORE you suggest or imply to your patient that you are considering imaging tests, surgery or a pain clinic visit, obtain a consult from an intensive spine rehabilitation clinic such as the Physicians Neck and Back Clinic. 

There is no perfect pathway for spinal pain. Your patient may not like your approach, especially if you do not routinely consider imaging tests, surgeries or other expensive treatments. But, assisting your patients with early mobility and a long-term self-management plan will result in less chronic pain and improved outcomes that are more cost-effective. To support your approach, you may want to give your patients the education materials on spinal pain treatments and home exercise programs for neck and low back pain.  

First published: 03/05/2002
Last updated: 06/01/2002

Reviewed by: Paul Kleeberg, MD