Application of a Clinical Approach to Diagnosing Primary Pain: Prevalence and Correlates of Primary Back and Neck Pain in a Community Physiatry Clinic

Chronic back and neck pain (CBNP) is the leading cause of disability in the United States, yet its underlying causes remain controversial. While some clinicians attribute CBNP to structural abnormalities found on imaging, research suggests that 80-95% of cases are actually nonspecific or "primary" pain—rooted in central nervous system changes rather than peripheral tissue damage. This study developed a practical, two-step clinical diagnostic approach to identify primary (nociplastic) pain by first ruling out clear structural causes through physical examination and imaging review, and second, identifying primary pain features through detailed patient history.

The research trained a board-certified physiatrist to apply this diagnostic approach to 222 consecutive patients with CBNP seeking care at a Louisiana community physiatry clinic from June 2020 to May 2021. Patients completed standardized questionnaires assessing pain characteristics, psychological factors, and central sensitization symptoms. The sample was predominantly female (73.9%), with an average age of 59.6 years and median pain duration of 3 years. Despite nearly universal imaging findings (97.7% had at least one spinal anomaly), clinicians used the diagnostic approach to classify patients into diagnostic categories.

The study found that 88.3% of patients had primary pain, 5.0% had secondary pain, and 6.8% had mixed pain—findings consistent with prior estimates of nonspecific back pain. Patients with primary pain were more likely to report pain spreading, sensitivity to light touch, pain worsening with stress, and concomitant conditions like migraines and temporomandibular disorder, indicating central sensitization. Surprisingly, depression, anxiety, and pain catastrophizing did not distinguish primary from secondary pain groups, challenging common assumptions about psychological factors in pain diagnosis.

These findings have significant clinical implications. The high prevalence of primary pain suggests that many patients currently receiving expensive, invasive treatments (surgery, injections, opioids) for presumed structural causes may benefit more from brain-focused interventions such as pain neuroscience education and psychological therapies. This diagnostic approach, if validated in future research, could redirect clinical care away from unnecessary structural interventions toward evidence-based treatments targeting central pain mechanisms, potentially improving outcomes and reducing healthcare costs and iatrogenic complications.