Chris J Main, Amanda C de C Williams
Musculoskeletal symptoms of various types (neck pain, limb pain, low back pain, joint pain, chronic widespread pain) are a major reason for consultation in primary care. This article uses the example of low back pain because it is particularly common and there is a substantial evidence base for its management. The principles of management outlined are also applicable to non-specific musculoskeletal symptoms in general.
The increasing prevalence of musculoskeletal pain, including back pain, has been described as an epidemic. Pain complaints are usually self limiting, but if they become chronic the consequences are serious. These include the distress of patients and their families and consequences for employers in terms of sickness absence and for society as a whole in terms of welfare benefits and lost productivity. Many causes for musculoskeletal pain have been identified. Psychological and social factors have been shown to play a major role in exacerbating the biological substrate of pain by influencing pain perception and the development of chronic disability. This new understanding has led to a "biopsychosocial" model of back pain.
Research has also shown that there are many different reasons for patients to consult their doctor with pain—seeking cure or symptomatic relief, diagnostic clarification, reassurance, "legitimisation" of symptoms, or medical certification for work absence or to express distress, frustration, or anger. Doctors need to clarify which of these reasons apply to an individual and to respond appropriately.
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