The ability to take a thorough back pain history is an important skill that is often assessed in OSCEs. This guide provides a structured approach to taking a back pain history in an OSCE setting.
Back pain is a common presenting complaint associated with a wide range of acute and chronic medical conditions. These can vary in severity from simple muscular strain to life-threatening conditions such as a dissecting aortic aneurysm. It is essential that a thorough history is obtained to identify any red flags of serious underlying pathology.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:
Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, can you tell me more about that?”
“Can you explain what that pain was like?”
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.
History of presenting complaint
The SOCRATES acronym (explained below) is a useful tool that can be used to explore a patient’s back pain.
Ask about the location of the back pain:
“Where is the pain?”
“Can you point to where you experience the pain?”
Common back pain locations
Pathology typically associated with different back pain locations:
Pain directly overlying the spine: spinal fracture or arthritis.
Paraspinal: muscle spasm or muscle sprain.
Lateral back pain: renal pain (e.g. pyelonephritis, renal colic), pleuritic pain (e.g. pulmonary embolism or pneumonia) or hip pain (e.g. arthritis).
Pain between the scapula: spinal fracture, dissecting thoracic aortic aneurysm or myocardial infarction.
Clarify how and when the back pain developed:
“Did the pain come on suddenly or gradually?”
“When did the pain first start?”
“What were you doing when the pain first started?”
“How long have you been experiencing the pain?”
Ask about the specificcharacteristics of the back pain:
“How would you describe the pain?” (e.g. dull ache, burning, tearing, sharp)
“Is the pain constant or does it come and go?”
“Is the pain present at rest?”
“Does the pain wake you at night?”
Back pain that is present at rest and wakes the patient at night is typically associated with inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis) and malignancy (e.g. spinal metastases).
Pain that is described as burning in nature is typically neuropathic in origin (e.g. nerve root compression).
Tearing thoracic back pain is typically associated with aortic dissection.
Sharp back pain is less specific but can be associated with spinal fracture, muscular spasms and pulmonary embolism.
Ask if the back pain movesanywhere else:
“Does the pain spread elsewhere?”
Typical areas that back pain can radiate to include:
Head (e.g. cervicogenic headache)
Buttocks or legs (e.g. sciatic nerve compression)
Upper/lower limbs (e.g. radiculopathy secondary to spinal nerve root compression)
Ask if there are other symptoms which are associated with the back pain:
“Are there any other symptoms that seem associated with the pain?”
See the keysymptoms section below for examples.
Clarify how the back pain has changed over time:
“How has the pain changed over time?”
Exacerbating or relieving factors
Ask if anything makes the back pain worse or better:
“Does anything make the pain worse?”
“Does anything make the pain better?”
Triggers for back pain may include walking, coughing and lifting objects.
Relieving factors for back pain may include analgesia (e.g. paracetamol), muscle relaxants (e.g. diazepam) and lying down.
Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:
“On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”
Key symptoms to ask about
Keysymptoms to ask about when taking a back pain history include:
Motor or sensory disturbances: suggestive of nerve root (i.e. radiculopathy) or spinal cord compression (e.g. cauda equina syndrome). Ask specifically about saddle anaesthesia if cauda equina syndrome is a possibility. Causes include prolapsed intervertebral disc, displaced vertebral fracture, haemorrhage and epidural abscess.
Urinary retention or incontinence: typical features of cauda equina syndrome.
Haematuria: may occur secondary to back trauma (due to renal injury), urinary tract infection and renal tract malignancy.
Fever: typically associated with urinary tract infection, pneumonia and discitis.
Malaise: associated with a wide range of pathology but in the context of back pain consider discitis or malignancy.
Weight loss: associated with malignancy.
Early morning stiffness: associated with inflammatory arthritis (e.g. rheumatoid arthritis, ankylosing spondylitis).
Muscular spasms: may be associated with spinal fracture or primary muscular injury.
Red flag presentations ¹
Red flags for caudaequinasyndrome include:
Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)
Red flags for spinalfracture include:
Sudden onset of severe central spinal pain which is relieved by lying down
There may be a history of major trauma (such as a road traffic collision or fall from a height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids
Red flags for cancer include:
Aged 50 or older
Gradual onset of symptoms
Severe unremitting pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining (e.g. opening bowels, coughing or sneezing), and thoracic pain
Localised spinal tenderness
No symptomatic improvement after four to six weeks of conservative lower back pain therapy
Unexplained weight loss
Past history of cancer: breast, lung, gastrointestinal, prostate, renal, and thyroid cancers are more likely to metastasise to the spine
Red flags for spinalinfections (e.g. discitis, epidural abscess) include:
Tuberculosis, or recent urinary tract infection
History of intravenous drug use
HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised
Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Explore the patient’s ideas about the current issue:
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
Explore the patient’s current concerns:
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
Ask what the patient hopes to gain from the consultation:
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”
A systemicenquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:
Neurological: headache (e.g. cervicogenic headache), motor or sensory disturbances (e.g. spinal cord compression)
Dermatological: rashes (e.g. psoriasis)
Past medical history
Ask if the patient has any medicalconditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospitaladmissions.
Ask if the patient has previously had back problems and if so explore what treatments and investigations they received:
“Have you had problems with your back in the past?”
“Have you ever been given a diagnosis for your back problems?”
“Have you previously had any scans or other investigations for your back problem?”
Ask if the patient has previously undergone any surgery or procedures (e.g. spinal surgery):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
Examples of relevant medical conditions
Medicalhistory of particular relevance to back pain includes:
Previous back problems including investigations and treatments