Clinical Decision-making

Clinical Examination Findings as Prognostic Factors in Low Back Pain

By Frank M. Painter|November 24, 2017|Clinical Decision-making|

Clinical Examination Findings as Prognostic Factors in Low Back Pain: A Systematic Review of the Literature

SOURCE: Chiropractic & Manual Therapies 2015 (Mar 23); 23: 13

Lisbeth Hartvigsen, Alice Kongsted, and Lise Hestbaek

Department of Sports Science and Clinical Biomechanics,
University of Southern Denmark,
Odense, Denmark.

BACKGROUND: There is a strong tradition of performing a clinical examination of low back pain (LBP) patients and this is generally recommended in guidelines. However, establishing a pathoanatomic diagnosis does not seem possible in most LBP patients and clinical tests may potentially be more relevant as prognostic factors. The aim of this review of the literature was to systematically assess the association between low-tech clinical tests commonly used in adult patients with acute, recurrent or chronic LBP and short- and long-term outcome.

METHODS: MEDLINE, Embase, and MANTIS were searched from inception to June 2012. Prospective clinical studies of adult patients with LBP with or without leg pain and/or signs of nerve root involvement or spinal stenosis, receiving non-surgical or no treatment, which investigated the association between low-tech clinical tests and outcome were included. Study selection, data extraction and appraisal of study quality were performed independently by two reviewers.

RESULTS: A total of 5,332 citations were retrieved and screened for eligibility, 342 articles were assessed as full text and 49 met the inclusion criteria. Due to clinical and statistical heterogeneity, qualitative synthesis rather than meta-analysis was performed. Associations between clinical tests and outcomes were often inconsistent between studies. In more than one third of the tests, there was no evidence of the tests being associated with outcome. Only two clinical tests demonstrated a consistent association with at least one of the outcomes: centralization and non-organic signs.

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Clinical Classification in Low Back Pain

By Frank M. Painter|May 15, 2017|Clinical Decision Rule, Clinical Decision-making|

Clinical Classification in Low Back Pain: Best-evidence Diagnostic Rules Based on Systematic Reviews

The Chiro.Org Blog

SOURCE: BMC Musculoskelet Disord. 2017 (May 12); 18 (1): 188

Tom Petersen, Mark Laslett and
Carsten Juhl

Back Center Copenhagen,
Mimersgade 41, 2200,
Copenhagen N, Denmark.

A clinical decision rule “is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians’ diagnostic and prognostic assessments” [23].This is probably the best and most comprehensive review you will read this year, as it drills down into the findings and treatment of:

Intervertebral disc issues
Facet joint issues
Sacroiliac joint
Nerve root involvement
Spinal stenosis
Spondylolisthesis
Fracture
Myofascial pain
Peripheral nerve issues
Central sensitization

Take the time and enjoy this extensive review

BACKGROUND: Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.

METHODS: A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.

RESULTS: Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.

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Adherence to Clinical Practice Guidelines Among Three Primary Contact Professions

By Frank M. Painter|September 5, 2014|Chiropractic Care, Clinical Decision-making, Evidence-based Medicine, Guidelines|

Adherence to Clinical Practice Guidelines Among Three Primary Contact Professions: A Best Evidence Synthesis of the Literature for the Management of Acute and Subacute Low Back Pain

The Chiro.Org Blog

SOURCE: J Can Chiropr Assoc 2014 (Sept); 58(3): 220–237

Lyndon G. Amorin-Woods, B.App.Sci (Chiropractic)
Randy W. Beck, BSc (Hons), DC, PhD, DACNB, FAAFN, FACFN, Gregory F. Parkin-Smith, MTech(Chiro), MBBS, MSc, DrHC, James Lougheed, BA (Hons), Alexandra P. Bremner, BSc (Hons), DipEd, GradDipAppStats, PhD

Senior Clinical Supervisor, School of Health Professions
Murdoch University
Enrolled student, Master of Public Health
School of Population Health Faculty of Medicine, Dentistry and Health Sciences
The University of Western Australia

Aim: To determine adherence to clinical practice guidelines in the medical, physiotherapy and chiropractic professions for acute and subacute mechanical low back pain through best-evidence synthesis of the healthcare literature.

Methods: A structured best-evidence synthesis of the relevant literature through a literature search of relevant databases for peer-reviewed papers on adherence to clinical practice guidelines from 1995 to 2013. Inclusion of papers was based on selection criteria and appraisal by two reviewers who independently applied a modified Downs & Black appraisal tool. The appraised papers were summarized in tabular form and analysed by the authors.

Results: The literature search retrieved 23 potentially relevant papers that were evaluated for methodological quality, of which 11 studies met the inclusion criteria. The main finding was that no profession in the study consistently attained an overall high concordance rating. Of the three professions examined, 73% of chiropractors adhered to current clinical practice guidelines, followed by physiotherapists (62%) and then medical practitioners (52%).

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A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature

By Frank M. Painter|January 13, 2014|Chiropractic Education, Clinical Decision-making, Diagnosis, Spinal Manipulation|

A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature

The Chiro.Org Blog

SOURCE: Chiropractic & Osteopathy 2008 (Aug 11); 16: 7

Donald R Murphy, Eric L Hurwitz, and Craig F Nelson

Rhode Island Spine Center,
Pawtucket, RI 02860, USA

BACKGROUND: Spinal pain is a common and often disabling problem. The research on various treatments for spinal pain has, for the most part, suggested that while several interventions have demonstrated mild to moderate short-term benefit, no single treatment has a major impact on either pain or disability. There is great need for more accurate diagnosis in patients with spinal pain. In a previous paper, the theoretical model of a diagnosis-based clinical decision rule was presented. The approach is designed to provide the clinician with a strategy for arriving at a specific working diagnosis from which treatment decisions can be made. It is based on three questions of diagnosis. In the current paper, the literature on the reliability and validity of the assessment procedures that are included in the diagnosis-based clinical decision rule is presented.

METHODS: The databases of Medline, Cinahl, Embase and MANTIS were searched for studies that evaluated the reliability and validity of clinic-based diagnostic procedures for patients with spinal pain that have relevance for questions 2 (which investigates characteristics of the pain source) and 3 (which investigates perpetuating factors of the pain experience). In addition, the reference list of identified papers and authors’ libraries were searched.

RESULTS: A total of 1769 articles were retrieved, of which 138 were deemed relevant. Fifty-one studies related to reliability and 76 related to validity. One study evaluated both reliability and validity.

CONCLUSION: Regarding some aspects of the DBCDR, there are a number of studies that allow the clinician to have a reasonable degree of confidence in his or her findings. This is particularly true for centralization signs, neurodynamic signs and psychological perpetuating factors. There are other aspects of the DBCDR in which a lesser degree of confidence is warranted, and in which further research is needed.

From the FULL TEXT Article:

Introduction

Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.

The Three Essential Questions of Diagnosis

The DBCDR is based on what the authors refer to as the 3 essential questions of diagnosis [2]. The answers to these questions supply the clinician with the most important information that is required to develop an individualized diagnosis from which a management strategy can be derived.

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Clinical Model for the Diagnosis and Management Page

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A Theoretical Model For The Development Of A Diagnosis-based Clinical Decision Rule For The Management Of Patients With Spinal Pain

By Frank M. Painter|January 12, 2014|Chiropractic Care, Clinical Decision-making, Diagnosis, Evidence-based Medicine|

A Theoretical Model For The Development Of A Diagnosis-based Clinical Decision Rule For The Management Of Patients With Spinal Pain

The Chiro.Org Blog

BMC Musculoskelet Disord. 2007 (Aug 3); 8: 75 ~ FULL TEXT

Donald R Murphy and Eric L Hurwitz

Rhode Island Spine Center,
Pawtucket, RI, USA.
rispine@aol.com

BACKGROUND: Spinal pain is a common problem, and disability related to spinal pain has great consequence in terms of human suffering, medical costs and costs to society. The traditional approach to the non-surgical management of patients with spinal pain, as well as to research in spinal pain, has been such that the type of treatment any given patient receives is determined more by what type of practitioner he or she sees, rather than by diagnosis. Furthermore, determination of treatment depends more on the type of practitioner than by the needs of the patient. Much needed is an approach to clinical management and research that allows clinicians to base treatment decisions on a reliable and valid diagnostic strategy leading to treatment choices that result in demonstrable outcomes in terms of pain relief and functional improvement. The challenges of diagnosis in patients with spinal pain, however, are that spinal pain is often multifactorial, the factors involved are wide ranging, and for most of these factors there exist no definitive objective tests.

DISCUSSION: The theoretical model of a diagnosis-based clinical decision rule has been developed that may provide clinicians with an approach to non-surgical spine pain patients that allows for specific treatment decisions based on a specific diagnosis. This is not a classification scheme, but a thought process that attempts to identify most important features present in each individual patient. Presented here is a description of the proposed approach, in which reliable and valid assessment procedures are used to arrive at a working diagnosis which considers the disparate factors contributing to spinal pain. Treatment decisions are based on the diagnosis and the outcome of treatment can be measured.

SUMMARY: In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.

From the FULL TEXT Article:

Introduction

Chronic spinal pain is an increasingly common problem in Western Society [1]. Spinal disorders exact great costs, in terms of both direct medical costs and indirect costs related to disability and lost productivity [1-3]. A number of researchers have attempted to improve our ability to identify the causes of spinal pain as well as to diagnose and treat patients with this problem. In spite of this, accurate diagnosis, leading to specific, targeted treatments, of patients with spinal pain has been elusive.

It has been repeated over the years that only in 15% of patients with spinal pain can a definitive diagnosis be made [4-6]. However, if one surveys the spine literature, one finds a variety of methods for detecting many of the factors that are believed to be of importance, most of which have known reliability and validity, although there are some that do not. Each of these methods may only help the clinician to identify one particular potential contributing factor in the overall clinical picture of the spine pain patient. However, it may be possible that, by utilizing many of the various diagnostic procedures available to the spine clinician, one can develop a specific working diagnosis that encompasses all of the dimensions for which there may be contributing factors and from which a management strategy may be designed that addresses each of the most important factors in each individual patient.

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Clinical Model for the Diagnosis and Management Page

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Stroke Numbers Are Up Worldwide

By Frank M. Painter|October 24, 2013|Clinical Decision-making, Stroke|

Stroke Numbers Are Up Worldwide

The Chiro.Org Blog

SOURCE: MedPage Today ~ Oct 23, 2013

By Todd Neale, Senior Staff Writer

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

The overall burden of stroke in terms of absolute numbers of people affected around the world is growing, especially in younger age groups and in low-to-middle-income countries, a global study showed.

In 2010, there were 16.9 million people who had a first stroke, 33 million stroke survivors, and 5.9 million people who died from a stroke — increases of 68%, 84%, and 26% respectively since 1990, according to Valery Feigin, MD, of the Auckland University of Technology in New Zealand, and colleagues.

Major Points:

Despite declining rates of nonfatal and fatal stroke, the overall burden of stroke in terms of absolute numbers of people affected around the world is growing, especially in low-to-middle-income countries, a study found.

Note that another analysis showed that hemorrhagic — and not ischemic — stroke accounted for the majority of the worldwide burden of deaths and disability-adjusted life years lost due to stroke.

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