Research Review By Dr. Jeff Muir©

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Date Posted:

May 2020

Study Title:

Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain

Authors:

Vining RD, Minkalis AL, Shannon ZK & Twist EJ

Author's Affiliations:

Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa, USA.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2019; 42(9): 665-676. doi: 10.1016/j.jmpt.2019.08.003.

Background Information:

Diagnosis is the foundation on which all treatment is based, involving the investigation, critical analysis and identification of various causes of disease and distinguishing these conditions by name. Generally speaking, evidence-based diagnosis for low back pain (LBP) should address 3 fundamental questions:
  1. Do the presenting symptoms reflect a visceral disorder or serious/life-threatening disease?
  2. What is the source/location of the pain?
  3. What has gone wrong with this person as a whole that may be causing the experience of pain?
Clinicians may take 3 differing viewpoints when answering these questions:

Viewpoint 1: Seeking a specific diagnosis is largely futile:
LBP is often difficult to definitively diagnose, due to a number of factors, including: the lack of a gold-standard diagnostic test (1); the potential of overlapping symptoms and conditions (2); the influence of psychosocial components (3); and, a limited understanding of causal mechanisms (2, 4). The resulting ambiguity results in nonspecific diagnoses (e.g. mechanical LBP), which do not adequately describe the distinguishing characteristics or help the patient or clinician understand or manage the problem.

Viewpoint 2: Practitioners should identify select conditions:
Current clinical guidelines recommend an approach of limited diagnosis for LBP. The American College of Physicians (5), the US Veterans Affairs/Department of Defence (6) and other authors (7, 8) have all advocated for broad categories for diagnosis, such as mechanical LBP, LBP of radicular origin, LBP of pathological origin, neurogenic claudication and/or LBP of psychosocial origin. The challenge with broad diagnoses is that it leaves open questions, such as:
  1. How should practitioners address conflicting clinical guidelines?
  2. How do clinicians address differentiating conditions when their symptoms may overlap?
  3. How do clinicians decide upon a treatment approach when a firm diagnosis is not available?
Viewpoint 3: Practitioners should seek a working diagnosis:
A working diagnosis is a hypothesis that informs clinical decision-making, largely by balancing the degree of confidence in the diagnosis with the risk associated with treatment and/or the withholding of treatment. Working diagnoses can provide flexibility, allow for the possibility of error, inform initial and follow-up treatment strategies (9) and are less likely to lead to arbitrarily determined care. They also provide an opportunity for patient education and minimize patient isolation, as they provide an opportunity for patients to realize that others suffer from similar conditions (10, 11).

Our current clinical knowledge is lacking in the area of practical tools that can incorporate available evidence to guide clinicians towards a working diagnosis and reasonable treatment plan for LBP. The purpose of this study, therefore, was to develop a practical diagnostic checklist and clinical exam for LBP, using the available scientific evidence. The authors present a pragmatic, office-based exam and diagnostic checklist and address practical considerations for how to value the working diagnoses and their relative strengths.

Summary:

Diagnostic Checklist:

A systematic review was conducted, the results of which were used to create a diagnostic checklist in order to coordinate, summarize, document and display evidence for (or against) a given working diagnosis. Additionally, the checklist can serve as a reference document to ensure a complete interview and examination.

The checklist is modular in design and thus can be reordered based on clinical needs. When completed, the checklist provides a display of what evidence for a working diagnosis is present and what is missing.

The authors recommend an examination ordered by major patient position (e.g. standing, seated, recumbent), although the exam may, in fact, be performed in the order deemed most appropriate by the practitioner.

The checklist summarized below outlines diagnostic criteria and tools (with the corresponding level of current evidence) to help clinicians arrive at a working diagnosis of conditions arising from nociceptive pain.

Nociceptive Pain (expert consensus):
  • Clear proportionate mechanical/anatomical nature to symptoms
  • Pain in proportion to trauma/pathology
  • Pain in area of injury/dysfunction with/without referral
  • Resolving consistent with expected tissue healing time
  • Usually intermittent and sharp with movement/mechanical provocation
  • Pain in association with other symptoms of inflammation (ex. swelling, redness)
Discogenic pain (diagnostic utility studies):
  • Centralization phenomenon (radicular/peripheral pain that is reduced or centralized with certain spinal/body positions)
Myofascial Pain (expert consensus with IASP terminology):
  • Palpable taut region within a muscle with or without referred pain
  • Reproduction of familiar pain upon palpation or muscle use
Sacroiliac Joint Pain (diagnostic utility studies): 3 or more positive provocation tests reproducing familiar pain:
  1. Distraction
  2. Compression
  3. Thigh thrust
  4. Gaenslen’s
  5. Sacral thrust or Patrick’s test
Facet Joint Pain (diagnostic utility study): 3 or more of:
  1. Age > 50
  2. Onset paraspinal
  3. Pain relieved with walking
  4. Pain relieved with sitting
  5. Positive extension-rotation (Kemp’s test)
Nociceptive vs. Neuropathic Pain (validated instruments based on expert consensus):
  • DN4 (Doleur Neuropathique 4)
  • PainDETECT questionnaire
  • LANSS Pain Scale (Leeds Assessment of Neuropathic Symptoms and Signs)
  • Neuropathic Pain Questionnaire
  • ID Pain questionnaire
  • PROMIS PQ-Neuro (Patient-Reported Outcome Measurement Information System Neuropathic Pain Quality Scale)
Checklist page 1 (page 2 below)
 
LBP checklist pg1
 
The checklist summarized below outlines diagnostic criteria and tools (with the corresponding level of current evidence) to help clinicians arrive at a working diagnosis of conditions arising from neuropathic processes.

Neuropathic Pain (expert consensus-based IASP criteria):
  • History of lesion or disease of nervous system
  • Comorbidities relating to neuropathic pain
  • Pain neuroanatomically distributed
  • Sensory dysfunction neuroanatomically distributed
  • Burning, shooting, or pricking pain description
Neurogenic Claudication (diagnostic study using expert diagnosis, imaging and vascular testing):
  • Symptoms triggered with standing
  • Symptoms relieved when sitting
  • Symptoms primarily located above knees
  • Positive shopping cart sign
Radicular Pain (expert consensus):
  • Burning, shooting, or pricking pain description
  • Lancinating
  • Travels along narrow region
  • Pain beyond the spine
  • May be episodic, recurrent, or paroxysmal
Radiculopathy (expert consensus):
  • Objective findings of nerve root conduction loss in the distribution of a spinal nerve (ex. reduced deep tendon reflex, reduced motor strength, and/or reduced sensation corresponding to a nerve root)
Piriformis Syndrome (common characteristics described in the literature):
  • Radiating pain into an ipsilateral leg
  • Tenderness of the greater sciatic notch
  • Buttock pain
  • Positive SLR test
  • Increased pain with prolonged sitting
Thoracolumbar (Maigne’s) Syndrome (expert description):
  • Pain in cluneal nerve distribution (iliac crest, groin, or greater trochanter)
  • Trigger point over iliac crest approximately 7 cm from midline
  • Sensitivity to iliac crest skin rolling
  • Tenderness of 1 or more thoracolumbar spinous processes or facet joints
Central Sensitization (expert consensus):
  • Low back pain disproportionate to nature or extent of injury/pathology (i.e. there is insufficient evidence for tissue injury, pathology, or other dysfunction to explain self-reported symptoms)
  • Neuroanatomically illogical pattern (ex. pain varying in location, abnormally large painful area, completely symmetrical pain pattern)
  • Hypersensitivity of senses unrelated to the musculoskeletal system (ex. heat, cold, or pressure hypersensitivity; generalized sensitivity remote from low back area; hypersensitivity to light, sound, stress, food, chemical stimuli)
Checklist page 2
 
LBP checklist pg2

Clinical Application & Conclusions:

Using data collected from a systematic review of the literature, the authors present an office-based history and examination leading to a working diagnosis for conditions commonly contributing to low back pain. They suggest that the checklist may provide a method for efficiently demonstrating the evidence for or against a specific working diagnosis.

Download this checklist HERE as a PDF

Study Methods:

A systematic review was conducted, evaluating the current evidence for diagnosis of common causes of LBP, the results of which were used to create an evidence-based diagnostic checklist and examination. The authors utilized an existing checklist/exam (12), updated with the current evidence. Several iterations were developed, prioritized by: incorporating updated exam findings; restructuring categories for a more logical flow; revising questions to add clarity; and organizing in such a way as to allow the checklist to fit within a 2-page document.

The clinical exam was also iteratively developed. The initial exam, which was modular in nature, was modified to incorporate all procedures, ordered by patient position during the exam.

Study Strengths / Weaknesses:

Strengths:
  • Broad and comprehensive evidence source (informed by a systematic review).
  • The use of expert consensus provides an additional source of evidence gleaned from clinical experience.
  • Collaborative, team approach provided opportunities for varied clinical experiences.
Weaknesses:
  • Some relevant articles could have been missed during the initial literature search.
  • The strength of evidence supporting different working hypotheses varies greatly.
  • The limited nature of the evidence suggests that, as new information becomes available, the checklist, and therefore clinician behaviour, will require change.

Additional References:

  1. Lurie JD. What diagnostic tests are useful for low back pain? Best Pract Res Clin Rheumatol 2005; 19(4): 557-575.
  2. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356-2367.
  3. van Erp RMA, Huijnen IPJ, Jakobs MLG, Kleijnen J, Smeets RJEM. Effectiveness of primary care interventions using a biopsychosocial approach in chronic low back pain: a systematic review. Pain Pract 2019; 19(2): 224-241.
  4. Brisby H. Pain origin and mechanisms in low back pain. In: van de Kelft E, ed. Surgery of the Spine and Spinal Cord: A Neurosurgical Approach. Cham: Springer International Publishing; 2016: 399-406.
  5. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147(7): 478-491.
  6. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166(7): 514-530.
  7. Nijs J, Apeldoorn A, Hallegraeff H. Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain Physician 2015; 18(3): E333-E346.
  8. Bussiéres AE, Stewart G, Al-Zoubi F, et al. Spinal manipulative therapy and other conservative treatments for low back pain: a guideline from the Canadian Chiropractic Guideline Initiative. J Manipulative Physiol Ther 2018; 41(4): 265-293.
  9. Ball JR, Balogh E. Improving diagnosis in health care: highlights of a report from the National Academies of Sciences, Engineering, and Medicine. Ann Intern Med 2016; 164(1): 59-61.
  10. Kress VE, Hoffman RM, Eriksen K. Ethical dimensions of diagnosing: considerations for clinical mental health counselors. Couns Values 2010; 55(1): 101-112.
  11. Wong JJ, Côté P, Sutton DA, et al. Clinical practice guidelines for the noninvasive management of low back pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain 2017; 21(2): 201-216.
  12. Vining R, Potocki E, Seidman M, Morgenthal AP. An evidence-based diagnostic classification system for low back pain. J Can Chiropr Assoc 2013; 57(3): 189-204.