J Can Chiropr Assoc 2013; 57(3) 189 ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2013/
J Can Chiropr Assoc 2013; 57(3) 189 ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2013/189–204/$2.00/©JCCA 2013 An evidence-based diagnostic classification system for low back pain Robert Vining, DC* Eric Potocki, DC, MS** Michael Seidman, MSW, DC† A. Paige Morgenthal, DC, MS†† 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 * Corresponding Author, Associate Professor and Senior Research Clinician, Palmer College of Chiropractic, Palmer Center for Chiropractic Research, 741 Brady St, Davenport, IA 52803; Telephone: 563 884-5153 Fax: 1.563.884.5227 robert.vining@palmer.edu ** Palmer College of Chiropractic, Palmer Center for Chiropractic Research, 5433 Bryant Ave, South Minneapolis, MS 55419; dr.potocki@yahoo.com † Research Clinician, Palmer College of Chiropractic, Palmer Center for Chiropractic Research, 741 Brady St, Davenport, IA 52803; michael.seidman@palmer.edu †† Research Clinician, Palmer College of Chiropractic, Palmer Center for Chiropractic Research, 741 Brady St, Davenport, IA 52803; paige.morgenthal@palmer.edu Disclaimers: No conflicts of interest and no disclaimers to declare Funding support: This work was partially funded through a grant from the National Institute of Health’s National Center for Complementary and Alternative Medicine (NCCAM) (1U19AT004137). This project was conducted in a facility constructed with support from Research Facilities Improvement Grant Number C06 RR15433 from the National Center for Research Resources, National Institutes of Health. ©JCCA2013 Introduction : Bien que les cliniciens conviennent généralement que les douleurs lombaires musculosquelettiques peuvent provenir de certains tissus, il reste néanmoins difficile d’en confirmer les sources précises. Méthodologie : Partant de données probantes étayées par des études d’utilité diagnostique, des médecins en chiropratique exerçant en tant que membres d’une clinique de recherche ont créé un système de classification diagnostique, des examens correspondants et une liste de contrôle basés sur la solidité des données probantes et l’efficacité à la clinique. Résultats : Le système de classification diagnostique comporte une catégorie de dépistage et deux catégories de douleurs : une catégorie d’évaluation fonctionnelle, une catégorie nociceptive et neuropathique et une catégorie englobant les diagnostics inconnus ou mal définis. Les catégories de douleurs nociceptives et neuropathiques sont chacune divisées en 4 sous- catégories. Conclusion : Cet article décrit et examine la solidité des données probantes concernant les catégories 190 J Can Chiropr Assoc 2013; 57(3) An evidence-based diagnostic classification system for low back pain 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. ke y wo r d s : low back pain, chiropractic, diagnosis, evidence-based diagnostiques pour des examens cliniques et des outils de liste de contrôle pour le diagnostic de douleurs lombaires musculosquelettiques. L’utilisation d’un outil normalisé pour le diagnostic des douleurs lombaires en milieu clinique et de recherche est encouragée. mots clés : douleurs lombaires, chiropratique, diagnostic, données probantes Introduction Health professionals across such disciplines as ortho- pedics, physical therapy, and chiropractic have shared the goal of categorizing patients with musculoskeletal low back pain (LBP) according to evidence-based clas- sification systems.1,2 To this end, several investigators have generated classification systems for LBP diagno- sis and treatment.3-8 Identifying specific pathophysiol- ogy 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 rules4,6 and symptom or treatment-based classification systems7,8 lack the patho- physiological 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 as- sessment and suggest classifying LBP patients with sub- stantial neurological involvement, inflammatory arthritis, visceral or metastatic disease, and non-specific pain.9,10 Rather than using the label of non-specific pain, an evi- dence-based diagnostic tool can potentially help identify conditions with similar characteristics, and aid com- munication with other clinicians, third-party payers, and patients by providing consistent terminology and assess- ment methods. It is still largely unknown whether treatment accord- ing 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 methodo- logical project was to create a diagnostic classification system with an evidence-based diagnostic checklist tool for use in a chiropractic research clinic conducting clin- ical 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 diagnos- tic information. The authors recognized a need for both a standardized clinical evaluation and diagnostic criteria to facilitate more consistent use of evidence-based diagnos- tic 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 out- lines the diagnostic categories, accompanying checklist, and discusses the supporting evidence. Methods Recognizing the need for more specific diagnostic in- formation, the authors sought to create a LBP diagnos- tic classification system based on available evidence for use in both a research and clinical setting. One system was available for use as a model. Therefore, the process began with a diagnostic classification system published by Petersen.3,16 This classification system was chosen be- cause it encapsulated diagnosis from a patho-anatomic/ pathophysiological perspective and it represented the po- tential to categorize LBP patients in a research setting. J Can Chiropr Assoc 2013; 57(3) 191 R Vining, E Potocki Briefly, these diagnostic categories included (1) disc syn- dromes, (2) adherent nerve root, (3) nerve root entrap- ment, (4) nerve root compression, (5) spinal stenosis, (6) zygapophyseal joint, (7) postural, (8) sacroiliac joint, (9) dysfunction, (10) myofascial pain, (11) adverse neural tension, (12) abnormal pain, and (13) inconclusive. Next, references from Petersen’s classification system were reviewed and PubMed searches conducted to iden- tify additional articles supporting each diagnostic category using key words describing the diagnostic category (e.g., facet, zygapophyseal joint, sacroiliac, SI joint, etc.), low back pain, utility, test, diagnosis, diagnostic, and manual therapy. Systematic reviews and clinical guidelines re- garding low back pain diagnosis were also reviewed for conclusions, recommendations and as reference sources. Reference searches of diagnostic utility studies were also conducted. Systematic reviews, clinical guidelines, and publica- tions with higher diagnostic utility values, reference stan- dards for higher quality research were sought and utilized to create the classification system. Criteria utilized for consideration were (1) commonly accepted diagnoses for which there is general agreement regarding pathophysiol- ogy (2) tests performed in an office setting, and (3) articles reporting consistent with evidence-based criteria, such as reporting sample population characteristics, appropriate statistical analysis, use of a gold standard comparison, validation studies performed, and sensitivity/specificity reporting.17 Nine doctors of chiropractic including the authors, functioning as members of the research clinic, utilized the initial diagnostic classification system and checklist for a period of one year while formally reviewing exam- inations of 166 participants with LBP who presented to the clinical research team during an IRB approved clin- ical trial. Formal meetings were held to discuss and in- form clinicians about the classification system prior to its use. Clinicians using the checklist provided verbal and written feedback to the authors regarding clarity of terms, strength of evidence, efficiency, and usefulness as an in-office aid throughout the one-year trial period. The categories contained in the original classification system were (1) Screening, (2) Reducible disc, (3) Irreducible disc, (4) Discogenic pain, (5) Nerve root, (6) Neuro- genic claudication, (7) SI joint, (8) Zygapophyseal joint, (9) Dysfunction/Postural instability, (10) Myofascial, (11) Non-organic, (12) Chronic pain syndrome, and (13) Other diagnoses. Factors observed by clinicians leading to changes in- cluded (1) criteria for some categories were largely simi- lar, (2) the large number of categories created a lengthy exam, (3) the neurogenic claudication category required a checklist item(s) to help rule-out similarly presenting conditions, such as vascular claudication, (4) a single cat- egory entitled central pain better represented the chronic pain syndrome and non-organic pain categories, and (5) separating nociceptive and neuropathic pain diagnoses into subcategories is more aligned with clinical assess- ment. The revised classification system was reorganized into 4 main diagnostic categories. Criteria with positive likeli- hood ratios lower than 2.4 were removed except for the myofascial category. The classification system and check- list presented in this article is currently in use at our re- search center (Appendix A). Results Four diagnostic categories and 8 subcategories in the clas- uploads/Sante/ based-diagnostic-clasification-system-for-low-back-pain.pdf
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- Publié le Jan 24, 2022
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- Langue French
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