An Evidence-based Diagnostic Classification System For Low Back Pain
SOURCE: J Can Chiropr Assoc. 2013 (Sep); 57 (3): 189–204
Robert Vining, DC, Eric Potocki, DC, MS, Michael Seidman, MSW, DC, A. Paige Morgenthal, DC, MS
Palmer College of Chiropractic, Palmer Center for Chiropractic Research, 5433 Bryant Ave, South Minneapolis, MS 55419; dr.potocki@yahoo.com
INTRODUCTION: While clinicians generally accept that musculoskeletal low back pain (LBP) can arise from specific tissues, it remains difficult to confirm specific sources.
METHODS: Based on evidence supported by diagnostic utility studies, doctors of chiropractic functioning as members of a research clinic created a diagnostic classification system, corresponding exam and checklist based on strength of evidence, and in-office efficiency.
RESULTS: THE DIAGNOSTIC CLASSIFICATION SYSTEM CONTAINS ONE SCREENING CATEGORY, TWO PAIN CATEGORIES: Nociceptive, Neuropathic, one functional evaluation category, and one category for unknown or poorly defined diagnoses. Nociceptive and neuropathic pain categories are each divided into 4 subcategories.
CONCLUSION: This article describes and discusses the strength of evidence surrounding diagnostic categories for an in-office, clinical exam and checklist tool for LBP diagnosis. The use of a standardized tool for diagnosing low back pain in clinical and research settings is encouraged.
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Introduction
Health professionals across such disciplines as orthopedics, physical therapy, and chiropractic have shared the goal of categorizing patients with musculoskeletal low back pain (LBP) according to evidence-based classification systems. [1, 2] To this end, several investigators have generated classification systems for LBP diagnosis and treatment. [3–8] Identifying specific pathophysiology causing LBP has the potential to positively impact clinical research and practice by providing opportunities to test, validate or reject treatments targeted at specific diagnoses. [1,2] Clinical prediction rules [4,6] and symptom or treatment-based classification systems [7,8] lack the pathophysiological component(s) clinicians sometimes use to better understand a condition and make clinical decisions. Patho-anatomic diagnoses address pain arising from more specific anatomic structures or pathological processes. However, definitively confirming pain sources for LBP continues to be a challenge.
Clinical guidelines recommend evidence-based assessment and suggest classifying LBP patients with substantial neurological involvement, inflammatory arthritis, visceral or metastatic disease, and non-specific pain. [9, 10] Rather than using the label of non-specific pain, an evidence-based diagnostic tool can potentially help identify conditions with similar characteristics, and aid communication with other clinicians, third-party payers, and patients by providing consistent terminology and assessment methods.
It is still largely unknown whether treatment according to various classification systems results in improved clinical outcomes. More research is needed to definitively answer this question. [1, 2, 11, 12] The purpose of this methodological project was to create a diagnostic classification system with an evidence-based diagnostic checklist tool for use in a chiropractic research clinic conducting clinical trials of LBP [13–15] and for use in traditional clinical settings.
Eligibility and treatment decisions for clinical studies of LBP at our research center are in part based on diagnostic information. The authors recognized a need for both a standardized clinical evaluation and diagnostic criteria to facilitate more consistent use of evidence-based diagnostic rationale.
Our goals for this project were to:
(1) identify diagnostic LBP categories supported by the best available evidence, and
(2) create an efficient in-office evidence-based LBP diagnostic checklist and accompanying exam for use in research and clinical practice.
This article outlines the diagnostic categories, accompanying checklist, and discusses the supporting evidence.
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