How is the assessment carried out in low back and neck pain?
In low back and neck pain the first step is screening for warning signs: loss of strength, numbness, a change in bladder or bowel control, fever, unintentional weight loss and a history of trauma. If these are absent, the assessment rests on the examination, and imaging is generally not requested at the first stage.
Low back pain is a common complaint. The World Health Organization (opens in a new tab) reports that in 2020, 619 million people worldwide were affected by low back pain and that this number is expected to reach 843 million in 2050. The same source states that low back pain is the single leading cause of disability worldwide.
The World Health Organization reports that in most cases of acute low back pain the symptoms subside on their own, that most people have a favourable course, and that approximately 90% of cases involve pain that cannot be attributed to a specific structural cause.
Neck pain is also common; the World Health Organization (opens in a new tab) reports that it affects 222 million people.
What is asked about during the examination?
- When and how the pain began; whether there is any history of strain or trauma
- The site of the pain and its radiation (radiation into the leg or arm is assessed separately)
- Whether there is numbness, tingling or loss of strength
- Whether the pain eases with rest at night
- Whether there is fever, unintentional weight loss or a history of cancer
- Whether there is any new change in bladder or bowel control
- Whether there is morning stiffness, and how long it lasts
- Everyday posture, sitting arrangements, screen time, the loads you carry
- Current medication and co-existing conditions
How does the assessment proceed?
- Screening for warning signs. This is the first and most important step.
- Physical and neurological examination. Restriction of movement, tenderness, reflexes, muscle strength and sensation are assessed.
- The decision on imaging. Imaging is generally not requested in the first few days; the examination findings and any warning signs determine whether it is needed.
- Assessment of the accompanying factors. The risk of osteoporosis, vitamin D status and findings suggesting inflammatory disease are reviewed.
- Drawing up the plan. Keeping up movement, adjustments to daily life, medication where necessary and, where considered suitable, procedures performed at the practice are planned.
- Referral. Where a surgical or physical therapy assessment is needed, a referral is made to the relevant specialty.
In which patients is it assessed differently?
- In patients with loss of bladder or bowel control, loss of strength in a leg or numbness around the anus (these symptoms require urgent assessment and must not be delayed)
- In patients with a history of cancer (low back pain is assessed as a priority)
- In patients with a diagnosis of osteoporosis and in patients over 65 years of age (a fracture may develop after minor strains)
- In patients taking cortisone long term (the risk of osteoporosis is also reviewed)
- In patients with fever or weight loss, or who have recently had an infection (spinal infection is considered)
- In patients receiving treatment that suppresses the immune system (the possibility of infection is also considered)
- In pregnant patients (both the cause of the pain and the medicines that may be used are different)
- In patients whose pain began after trauma (priority assessment for fracture is needed)
- In patients taking blood thinners (needle-based procedures are assessed separately)
- In patients under 18 years of age (assessment lies within the field of paediatrics; this page has been prepared for adults)
How long does it take, and how many appointments are needed?
The course varies from person to person and a length of time cannot be given in advance. The World Health Organization reports that in most cases of acute low back pain the symptoms subside on their own, while some turn into long-standing pain lasting longer than 12 weeks.
The number of appointments and the follow-up interval depend on the duration of the pain and the examination findings. Where a procedure is considered suitable and planned, the number of sessions and the interval between them are determined at the end of the examination.
What should you do before and after the consultation?
When you come to your appointment, bring:
- A list of all the medicines and supplements you use
- Your previous imaging reports, if you have them (the films or the reports)
- Your notes on which movements increase the pain
After the appointment, you are given a written plan. Prolonged bed rest is not advised; keep up movement as far as the pain allows. Apply the advice on sitting arrangements and sleeping position in your daily life.
For what to do in the first few days, see our article The First Days of Low Back and Neck Pain: What Should You Be Aware Of?.
Risks and points to be aware of
Do not delay when there are warning signs. Loss of bladder or bowel control, loss of strength in a leg and numbness around the anus require emergency assessment.
Prolonged bed rest does not speed up recovery. The World Health Organization highlights physical approaches that increase muscle strength and the ability to move, rather than medication-first approaches.
Imaging is not needed in every case of pain. Early, unneeded imaging may reveal findings that have nothing to do with the pain and may lead to unnecessary interventions.
Manipulation and massage are not suitable for every patient. They are not used where there is osteoporosis, suspicion of a fracture, spinal infection or findings of nerve compression. Suitability is determined by examination.
Interventional procedures carry risks of their own. Pain at the site of the procedure, bruising, bleeding and, rarely, infection may occur. The suitability criteria for each procedure are set out on its own page.
Do not extend your use of painkillers on your own initiative.
Results vary from person to person.
When should you see a physician without delay?
If you notice these symptoms, consult a physician without delay:
- Low back or neck pain accompanied by fever
- Newly started pain in a person with a history of cancer
- Unintentional weight loss accompanying the pain
- Pain that began after trauma
- Pain that does not ease with rest at night and wakes you from sleep
In the event of loss of bladder or bowel control, loss of strength in a leg or arm or foot drop, or numbness in the inner thighs and around the anus, go directly to the emergency department.
Frequently asked questions
Should I stay in bed when I have low back pain?
Prolonged bed rest is not advised. The World Health Organization reports that in most cases of acute low back pain the symptoms subside on their own, and highlights approaches that maintain mobility. Keeping up daily activity as far as the pain allows is preferred.
Should I have an MRI straight away?
It is generally not needed in the first few days. Imaging is requested according to the examination findings and whether warning signs are present. Unnecessary early imaging may reveal findings that have nothing to do with the pain.
I have a disc herniation; do I need an operation?
A herniation seen on imaging does not on its own show that an operation is needed. The decision rests on the examination findings, the symptoms of nerve compression and the course of the complaint taken together, and it lies within the field of the relevant surgical specialty.
How long does low back pain take to go away?
The course varies from person to person and a length of time cannot be given in advance. In most cases the symptoms subside on their own; in some they may turn into long-standing pain lasting longer than 12 weeks. For this reason follow-up is important.
Should I use a support brace?
A brace is not suitable for every patient, and long-term use may reduce muscle strength. Whether one is needed, for how long and of what type is decided after the examination.
Which procedures may be planned for low back and neck pain?
If considered suitable following the assessment, procedures such as hijama and major ozone therapy may be added to the plan. Each has its own suitability criteria, course and possible side effects; these are described separately on the relevant pages. The decision on suitability is made at the end of the examination.
Sources
- World Health Organization, Low back pain fact sheet, 19 June 2023. https://www.who.int/news-room/fact-sheets/detail/low-back-pain (opens in a new tab)
- World Health Organization, Musculoskeletal health fact sheet, 14 July 2022. https://www.who.int/news-room/fact-sheets/detail/musculoskeletal-conditions (opens in a new tab)
