When Patients Hurt: Understanding Neck and Back Pain in Clinical Practice
Utilization Management Insights
By Kathryn Kolonic, , DO, MPH, CPHQ
AllMed Vice President & Medical Director
“Pain” is itself a subjective concept. What hurts for one person feels differently for others, and our sensations can evolve with changes in brain signaling. But despite its complexity, pain must be measured and managed. So how do you assess something that varies broadly in its definition, causes, and interpretations?
A recent AllMed webinar explored those questions and more in a Q&A between Mercy Udoji, MD, CMQ, FASA (Atlanta Veterans Affairs Medical Center) and Kathryn Kolonic, DO, MPH, CPHQ (AllMed Vice President and Medical Director). Tackling the challenges of modern-day pain management, Drs. Udoji and Kolonic discussed how to make the subjective more objective through pain assessments. Here’s a recap.
Common Causes of Neck and Back Pain
Up to 80% of adults will experience back pain, and up to 70% will have neck pain at some point. But while pain is universal, its symptoms are across the board—from tight or stiff sensations to radiating pain, on-and-off pain, and pain that happens during rest or activity.
These symptoms come from a patchwork of causes and conditions, but the most common causes of pain Dr. Udoji sees are osteoarthritis and disc injury or degeneration. Of course, there are many others as well—from structural problems to infections, tumors, and beyond.
Common Causes of Pain
- Osteoarthritis
- Herniated disc
- Disc degeneration
- Sprains, strains, or broken bones
- Inflammatory arthritis
- Fibromyalgia
- Women’s health concerns, such as pregnancy or endometriosis
- Kidney stones
- Spinal stenosis
- …and much more
Sometimes, a person’s genetics predisposes them to pain, such as when people have so-called “lumbarized” or “sacralized” vertebrae. Affecting fewer than 1 in 5 people, these cases involve abnormal assimilation of either the S1 or L5, creating pressure on facet joints and resultant pain. Abnormal curvature of the spine, known as scoliosis, similarly makes patients more prone to pain.
And then you have behavior and aging. As we live our (often sedentary) lives, slumping and poor posture can raise the risk for future arthritis. And as we get older, our discs get narrower and our bone integrity gets softer, driving pain. Between this mishmash of risk factors, pain rarely happens because of a single reason. Usually, a variety of them come together to create discomfort.
“With the anatomy of the spine, what you find is that there’s not really one particular cause of pain,” Dr. Udoji said. “In most patients, there are at least two things that are combined to cause pain syndromes and you have to figure out which one is the most dominant etiology of their pain.”
For example, say someone has a shift in their lumbar vertebrae. That puts pressure on the joints of the spinal column, which itself causes pain. But because that shift narrows the space through which the spinal cord can move, it then causes traction and further pain.
With the complexity of pain and the significance of its impact on patients’ everyday lives, addressing concerns with modern and evidence-based solutions is key. But first, you have to assess the extent of what hurts—and given the subjectivity of pain overall, that can be just as complicated.
How to Assess, Document, and Measure Pain
Providers have long been challenged to grade people’s pain in a way that makes sense clinically as well as to the patient.
“The measurement of pain is a very complex thing,” Dr. Udoji said. “Pain by its very nature is subjective and personal. The feeling and the intensity of pain that people feel depends on multiple factors—their biology or who they are, and their psychology and how they feel.”
The environment and context surrounding patients can further influence how they sense or express pain, from social factors and day-to-day life to cultural expressions of pain, she added. “All of those things feed together into one’s perception of the severity and intensity and essentially their whole pain experience.”
Still, pain has to be measured and tracked over time. In response to those complexities and the greater clinical needs, experts have created three ways to assess, document, and measure pain. As Dr. Udoji says, each has its pros and cons:
- Verbal Numeric Scale (VNS): This model asks patients to rate their pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. The advantage is that it’s quite familiar to people but can drive variable responses from person to person.
- Visual Analog Scale (VAS): This model takes the VNS to paper form, giving patients a slip of 100 mm paper and asking them to place an X on the line that best correlates with their pain’s severity. With a more comprehensive approach, the VAS is often used for research but isn’t always practical in real life because it requires specialized tools and a hands-on method.
- Mild, Moderate, and Severe: This model consolidates symptoms to a three-part rating, which Dr. Udoji notes makes it more comparable across patients than the VNS model. Even so, it can require education on what each category means.
But as important as it is to track and chart pain, remember that measurement models and scales are just guides. Patient workups, physical assessments, health histories, and other components come together to create a fuller picture for each patient—particularly amid the risk of overprescribing opioids.
“If we’ve learned anything from the opioid epidemic, it’s that we don’t want to overemphasize pain scores as a marker of either pain severity or treatment efficacy,” she said.
In looking at things more comprehensively, clinicians can better understand which treatments best match to which patients—and utilization reviewers can assess care plans accordingly. The next two recap articles explore the latest trends and opportunities in treating neck and low back pain, from spinal cord stimulation to platelet-rich plasma, prolotherapy, and other emerging technologies.
Watch the Webinar
Watch our 45-minute on-demand webinar about modern approaches to pain management and how to assess and document pain from patient to patient. Watch on Demand >