Journal of Manipulative and Physiological Therapeutics
Original ResearchCurrent Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations
Introduction
Low back pain (LBP) is a substantial societal problem owing to high prevalence and the many problems associated with cost, chronicity, and disability.1, 2, 3 Despite an intensive research focus on LBP, definitive diagnostic methods are largely unavailable and standard terminology is not yet broadly adopted,4 leading researchers and practitioners to classify most LBP as nonspecific.2
Nonspecific LBP represents a heterogenous group of conditions, which may respond differently to available interventions. Some evidence suggests that treatments based on subgroupings of patients with LBP may lead to more effective condition-tailored care.5,6 The lack of standard diagnostic methods for determining a conclusive diagnosis is due in part to many challenges with definitively confirming symptom sources and the co-occurrence of psychological and social factors that contribute to a person’s lived experience.7,8 Although identifying symptom sources is difficult in many cases, it is necessary to differentiate benign from ominous conditions and to meaningfully inform management approaches.9, 10, 11
Disparate diagnostic terminology creates potential confusion among both clinicians and researchers. For example, some clinical studies focused on sciatica, radiculopathy, or radicular pain instead report they are focused on discogenic pain.12,13 However, discogenic pain is defined as pain arising from the intervertebral disc, independent of nerve root involvement.14 Spinal stenosis, a radiological finding describing a narrowed space, is a term synonymously used for the clinical syndrome of neurogenic claudication.15 However, spinal stenosis is an anatomical characteristic that may not be associated with symptoms.16
To address some of the diagnostic challenges for LBP, an evidence-based diagnostic classification system was published in 201317; it defined diagnostic categories for neuromusculoskeletal LBP and reported evidence-based criteria supporting a variety of common diagnoses. A novel and practical diagnostic checklist and corresponding exam was also proposed to help practitioners interpret examination evidence to inform evidence-based working diagnoses. However, this classification system did not involve a systematic review of the literature or propose standardized terminology. Furthermore, evidence evolves over time, requiring periodic reevaluation to remain current.
An evidence-based working diagnosis using standardized terminology is needed to systematically explain the most likely biological processes contributing to LBP and to aid communication among providers, payers, and patients. The purpose of this study is to review current diagnostic evidence for office-based (ie, performed in office through examination, evaluating historical characteristics, or questionnaires) evaluation of common neuromusculoskeletal conditions causing LBP and to evaluate the quality and type of evidence of individual studies and systematic reviews focused on this topic. We provide recommendations for terminology use among clinicians and researchers. This systematic review will inform other studies that will offer a pragmatic office-based exam and diagnostic checklist, key aspects of efficient conduct of the exam, practical considerations for determining the relative strength of working diagnoses, and an evidence-based chiropractic treatment decision aid for managing LBP.18,19
Section snippets
Methods
This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with the International Prospective Register of Systematic Reviews (CRD42018099106).20
Results
The initial search revealed 3781 articles. A second updated search through December 2018 reveled an additional 45 articles. Hand searching revealed 169 additional articles, resulting in a total of 3995. When 1658 duplicates were removed, 2337 articles remained for title and abstract review. After title and abstract review, 157 articles remained for full-text review. Twenty-five articles were excluded because they were evaluated in included systematic reviews (Appendix B). Thirty-six articles (8
Discussion
This systematic review summarizes and assesses studies reporting the diagnostic utility of clinical questionnaires, in-office tests, and patient or symptom characteristics to inform working diagnoses for common causes of LBP.
Conclusion
This review describes evidence-based diagnostic criteria for common conditions contributing to neuromusculoskeletal low back pain. Understanding the accuracy of tests and the evidence basis from which diagnostic criteria are derived can inform management decisions and the amount of confidence placed in a working diagnosis. Adopting IASP-applicable terminology is recommended to improve communication among health professionals, patients, and researchers, and to improve the quality of
Acknowledgments
The authors thank Anna Schmidt, MM, DC, for reviewing manuscript drafts, providing critical feedback, and performing other activities relevant to this project.
Funding Sources and Conflicts of Interest
Drs Vining, Shannon, Minkalis, and Twist report grant support from the National Institutes of Health/National Center for Complementary & Integrative Health 5UG3AT009761-02. Dr Shannon reports support from the NCMIC Foundation. No funding agency was involved in data collection, data analysis, data interpretation, or manuscript writing. No other conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): R.V.
Design (planned the methods to generate the
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Cited by (12)
Best Practices for Chiropractic Management of Adult Patients With Mechanical Low Back Pain: A Clinical Practice Guideline for Chiropractors in the United States
2022, Journal of Manipulative and Physiological TherapeuticsDevelopment of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process
2019, Journal of Manipulative and Physiological TherapeuticsCitation Excerpt :The first was a systematic review of evidence for diagnosing common conditions causing LBP and recommendations for standardized terminology use. The systematic review then informed the development of a practical diagnostic checklist and clinical exam leading to evidence-based and specific working diagnoses.17,18 The purpose of this study was to develop an in-office resource functioning as a treatment decision aid summarizing research evidence to inform VA chiropractic providers caring for US military veterans with LBP.
Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain
2019, Journal of Manipulative and Physiological TherapeuticsCitation Excerpt :The present article proposes a pragmatic office-based exam and diagnostic checklist, describes key elements to efficiently conduct the proposed exam, and addresses practical considerations for how to value the relative strength of working diagnoses. As previously described, a systematic review was conducted to evaluate and summarize current evidence for diagnosis of common conditions causing LBP and to propose standardized terminology use.33 Findings from the systematic review were used to create the evidence-based diagnostic checklist and exam presented in this article.