Clinical Decision Rule

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

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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Clinical Prediction Rule Page and the:

Low Back Pain and Chiropractic Page

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Leg Pain Location and Neurological Signs Relate to Outcomes in Primary Care Patients with Low Back Pain

By Frank M. Painter|April 6, 2017|Clinical Decision Rule, Sciatica|

Leg Pain Location and Neurological Signs Relate to Outcomes in Primary Care Patients with Low Back Pain

The Chiro.Org Blog

SOURCE: BMC Musculoskelet Disord. 2017 (Mar 31); 18 (1): 133

Lisbeth Hartvigsen, Lise Hestbaek, Charlotte Lebouef-Yde,
Werner Vach and Alice Kongsted

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

BACKGROUND: Low back pain (LBP) patients with related leg pain and signs of nerve root involvement are considered to have a worse prognosis than patients with LBP alone. However, it is unclear whether leg pain location above or below the knee and the presence of neurological signs are important in primary care patients. The objectives of this study were to explore whether the four Quebec Task Force categories (QTFC) based on the location of pain and on neurological signs have different characteristics at the time of care seeking, whether these QTFC are associated with outcome, and if so whether there is an obvious ranking of the four QTFC on the severity of outcomes.

METHOD: Adult patients seeking care for LBP in chiropractic or general practice were classified into the four QTFC based on self-reported information and clinical findings. Analyses were performed to test the associations between the QTFC and baseline characteristics as well as the outcomes global perceived effect and activity limitation after 2 weeks, 3 months, and 1 year and also 1-year trajectories of LBP intensity.

RESULTS: The study comprised 1,271 patients; 947 from chiropractic practice and 324 from general practice. The QTFC at presentation were statistically significantly associated with most of the baseline characteristics, with activity limitation at all follow-up time points, with global perceived effect at 2 weeks but not 3 months and 1 year, and with trajectories of LBP. Severity of outcomes in the QTFC increased from LBP alone, across LBP with leg pain above the knee and below the knee to LBP with nerve root involvement. However, the variation within the categories was considerable.

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Clinical Prediction Rule Page and the:

Low Back Pain and Chiropractic Page

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Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain at Risk of Developing Chronic Pain

By Frank M. Painter|November 1, 2016|Clinical Decision Rule, Low Back Pain|

Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain at Risk of Developing Chronic Pain

The Chiro.Org Blog

SOURCE: Spine J. 2015 (Jul 1); 15 (7): 1577–1586

Wolf E. Mehling, MD, Mark H. Ebell, MD, MS, Andrew L. Avins, MD, MPH, Frederick M. Hecht, MD

Department of Family Medicine,
University of California-San Francisco,
1545 Divisadero St,
San Francisco, CA 94115, USA

BACKGROUND CONTEXT: Primary care clinicians need to identify candidates for early interventions to prevent patients with acute pain from developing chronic pain.

PURPOSE: We conducted a 2-year prospective cohort study of risk factors for the progression to chronic pain and developed and internally validated a clinical decision rule (CDR) that stratifies patients into low-, medium-, and high-risk groups for chronic pain.

STUDY DESIGN/SETTING: This is a prospective cohort study in primary care.

PATIENT SAMPLE: Patients with acute low back pain (LBP, ≤30 days duration) were included.

OUTCOME MEASURES: Outcome measures were self-reported perceived nonrecovery and chronic pain.

METHODS: Patients were surveyed at baseline, 6 months, and 2 years. We conducted bivariate and multivariate regression analyses of demographic, clinical, and psychosocial variables for chronic pain outcomes, developed a CDR, and assessed its performance by calculating the bootstrapped areas under the receiver-operating characteristic curve (AUC) and likelihood ratios.

RESULTS: Six hundred five patients enrolled: 13% had chronic pain at 6 months and 19% at 2 years. An eight-item CDR was most parsimonious for classifying patients into three risk levels. Bootstrapped AUC was 0.76 (0.70-0.82) for the 6-month CDR. Each 10-point score increase (60-point range) was associated with an odds ratio of 11.1 (10.8-11.4) for developing chronic pain. Using a less than 5% probability of chronic pain as the cutoff for low risk and a greater than 40% probability for high risk, likelihood ratios were 0.26 (0.14-0.48) and 4.4 (3.0-6.3) for these groups, respectively.

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Clinical Prediction Rule Page and the:

Low Back Pain and Chiropractic Page

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