Evidence-based Diagnosis for Low Back Pain

Author: Robert Vining/Tuesday, March 06, 2018/Categories: Professional Development, Research

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By Robert Vining, DC

Health professionals from different disciplines use diverse diagnostic methods to inform clinical management for patients with low back pain.1 One person may diagnose someone as suffering from sacroiliac joint pain while another might classify the same patient with a movement disorder caused by poor muscle coordination. In a given circumstance, either or both individuals could be right or wrong. However, we can’t realistically discern this until we understand the underlying strength of the diagnostic tests we use.

Part of the problem with diagnosis of spinal conditions in general is terminology. Diagnoses for low back pain are often little more than a repetition of symptoms. For example, common diagnoses include “low back pain,” “lumbalgia,” “mechanical low back pain,” and “non-specific low back pain.”2  These terms are often used because it is difficult to definitively determine a single pain source or cause. The reasons for this problem include:

  • varied and conflicting terminology used to describe identical conditions;
  • few, if any, diagnostic tests that conclusively identify individual diagnoses;
  • multiple conditions that can cause similar or identical symptoms simultaneously; and
  • the challenge of understanding how psychological and social factors influence symptoms.

To inform management decisions and differentiate benign from ominous conditions, we need to consistently identify a symptom source with a reasonable degree of confidence.3;4 However, we are hampered if we don’t understand how much to depend on the information used to reach a diagnosis. To address these issues, I led a team of researchers in developing an evidence-based diagnostic classification system for low back pain.5  The classification system is not original research. Rather, it is a synthesis of a large number of clinical studies on the topic of diagnosis, especially those evaluating office-based examination procedures.

Diagnosis of most non-visceral, non-malignant, and non-infections primary low back pain falls into two broad categories, 1) nociceptive, and 2) neuropathic. Nociceptive pain arises from inflammation and/or damage to tissues where nociceptors are located (intervertebral discs, facet joints, sacroiliac joints, muscles and fascia). Neuropathic pain is caused by dysfunction within the peripheral or central nervous system causing pain to arise from nerve trunks rather than nerve endings (compressive and non-compressive radiculopathy, and neurogenic claudication), or augmented pain through sensitization.

Along with the classification system, we developed a checklist that helps standardize terminology, generate diagnoses based on research evidence, and avoid opinion-based diagnostic reasoning errors. The checklist contains criteria for identifying each diagnostic category. For example, clinical research has generally confirmed that centralization with repeated motion is an in-office test and finding that can identify patients likely suffering from discogenic pain (pain from an intervertebral disc). Other diagnostic criteria, when met, suggest patients likely suffer from other diagnoses. There is enough evidence available now for us to begin moving toward research-based diagnosis, which reduces subjectivity and should improve communication between providers, and with payers and patients.

Dr. Vining is associate professor and senior research clinician at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.

To learn more about the classification system developed by Dr. Vining and his colleagues, register for a special ACA webinar on the subject March 15 from 1 p.m. to 2 p.m. ET at www.acatoday.org/webinarseries. ACA members pay only $10 (1 CEU is available).

References

  1. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med 2017.Deyo RA, Dworkin
  2. SF, Amtmann D et al. Report of the NIH Task Force on research standards for chronic low back pain. Pain Med 2014;15:1249-1267.
  3. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet 2017;389:736-747.
  4. Waddell G. Subgroups within "nonspecific" low back pain. J Rheumatol 2005;32:395-396.
  5. Vining R, Potocki E, Seidman M, Morgenthal AP. An evidence-based diagnostic classification system for low back pain. J Can Chiropr Assoc 2013;57:189-204.

 

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2 comments on article "Evidence-based Diagnosis for Low Back Pain"

Charles Penza

3/8/2018 10:22 AM

Hi Dr. Vining -

Great stuff. You are tackling a difficult topic, and I commend you for your work and contributions to the field. I have two comments:

1. You paraphrased the definitions for nociceptive pain and neuropathic pain. For consistency, I would suggest using the complete definitions, and the updated definition for neuropathic pain which removed dysfunctional In addition IASP recently added a new mechanistic term - nociplastic pain, making three broad categories.

2. The traditional approach of find the problem in the back and fix the problem in the back has been effective in the management of back pain, but there is considerable room for improvement. Should we really expect a considerable improvement if we are only trying to refine our ability to find the problem in the back.

I'll be sure to listen in to your podcast.


Bobby Mozafari

3/31/2018 10:06 AM

This is awesome! Thanks, Dr. Vining!

I'm a better doctor than I otherwise would have been because of your Hot Seat and your clinic meetings. I feel encouraged that you're making these blogs, thereby helping raise the bar in our profession.

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