Preliminary evidence for the features of non-reducible discogenic low back pain: survey of an international physiotherapy expert panel with the Delphi technique

Features and methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a Delphi expert consensus study

ABSTRACT

Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

A multivariate prognostic model for pain and activity limitation in people undergoing lumbar discectomy

Purpose: The purpose of this study was to identify a multivariate predictive model for 6-month outcomes on overall pain, leg pain and activity limitation in patients undergoing lumbar discectomy. Identification of predictors of outcome for lumbar discectomy has the potential to assist identifying treatment targets, clinical decision making and disease understanding.Materials and methods: Prospective cohort design. Ninety-seven patients deemed by study surgeons to be suitable for lumbar discectomy completed a comprehensive clinical and radiological baseline assessment. At 6-months post surgery outcome measures of overall and leg pain (visual analogue scale) as well as activity limitation (Oswestry Disability Index) were completed. Univariate and multivariate analyses were conducted to determine the best multivariate predictive model of outcome.Results: In the multivariate model, presence of a compensation claim, longer duration of injury and presence of below knee pain and/or parasthesia were negative prognostic indicators for at least two of the outcomes. Peripheralization in response to mechanical loading strategies was a positive prognostic indicator for overall pain and leg pain. A range of other prognostic indicators for one outcome were also identified. The prognostic model explained up to 32% of the variance in outcome.Conclusions: An 11-factor prognostic model was identified from a range of clinically and radiologically assessed variables in accordance with a biopsychosocial model. The multivariate model has potential implications for researchers and practitioners in the field. Further high quality research is required to externally validate the prognostic model, evaluate effect of the identified prognostic factors on treatment effectiveness and explore potential mechanisms of effect.

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations

OBJECTIVE

The purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use.

METHODS

A systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists.

RESULTS

Of the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus-level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings.

CONCLUSION

The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

Development of a Multivariate Prognostic Model for Pain and Activity Limitation in People With Low Back Disorders Receiving Physiotherapy

OBJECTIVE

To identify predictors for back pain, leg pain, and activity limitation in patients with early persistent low back disorders (LBDs).

DESIGN

Prospective inception cohort study.

SETTING

Primary care private physiotherapy clinics in Melbourne, Australia.

PARTICIPANTS

Individuals (N=300) aged 18-65 years with low back and/or referred leg pain of ≥6 weeks and ≤6 months duration.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Numeric rating scales for back pain and leg pain as well as the Oswestry Disability Scale.

RESULTS

Prognostic factors included sociodemographics, treatment related factors, subjective/physical examination, subgrouping factors, and standardized questionnaires. Univariate analysis followed by generalized estimating equations were used to develop a multivariate prognostic model for back pain, leg pain, and activity limitation. Fifty-eight prognostic factors progressed to the multivariate stage where 15 showed significant (P<.05) associations with at least 1 of the 3 outcomes. There were 5 indicators of positive outcome (2 types of LBD subgroups, paresthesia below waist, walking as an easing factor, and low transversus abdominis tone) and 10 indicators of negative outcome (both parents born overseas, deep leg symptoms, longer sick leave duration, high multifidus tone, clinically determined inflammation, higher back and leg pain severity, lower lifting capacity, lower work capacity, and higher pain drawing percentage coverage). The preliminary model identifying predictors of LBDs explained up to 37% of the variance in outcome.

CONCLUSIONS

This study evaluated a comprehensive range of prognostic factors reflective of both the biomedical and psychosocial domains of LBDs. The preliminary multivariate model requires further validation before being considered for clinical use.

ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study

STUDY DESIGN

Delphi.

OBJECTIVE

The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians.

METHODS

Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting.

RESULTS

A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were "leg or buttock pain while walking," "flex forward to relieve symptoms," "feel relief when using a shopping cart or bicycle," "motor or sensory disturbance while walking," "normal and symmetric foot pulses," "lower extremity weakness," and "low back pain." Significant change in certainty ceased after six questions at 80% (P < .05).

CONCLUSION

This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of "seven history items" that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes.

LEVEL OF EVIDENCE

2.

Effects of individualised directional preference management versus advice for reducible discogenic pain: A pre-planned secondary analysis of a randomised controlled trial

BACKGROUND

Low back disorders are prevalent and directional preference management is a common treatment with mixed evidence for effectiveness.

OBJECTIVES

To determine the effectiveness of individualised directional preference management plus guideline-based advice versus advice alone in participants with reducible discogenic pain of 6-week to 6-month duration.

DESIGN

Pre-planned secondary analysis of a multicentre, parallel group randomised controlled trial.

METHODS

Participants were randomly allocated to receive a 10-week physiotherapy program of 10-sessions of individualised directional preference management plus guideline-based advice (n = 40) or 2-sessions of advice alone (n = 38). Primary outcomes were back pain, leg pain and activity limitation. Outcomes were taken at baseline and 5, 10, 26, and 52-weeks.

RESULTS

Between-group differences significantly favoured directional preference management compared with advice for back pain at 5-weeks (1.28; 95% CI 0.34-2.23) and 10-weeks (1.45; 95% CI 0.51-2.40), and leg pain at 10-weeks (1.21; 95% CI 0.04-2.39). These short-term differences were not maintained. There were no significant differences between-groups for activity limitation. Secondary outcomes and responder analyses favoured directional preference management suggesting between-group differences were clinically important.

CONCLUSIONS

In people with reducible discogenic pain, individualised directional preference management plus guideline-based advice resulted in significant and rapid improvement in short-term back and leg pain compared with advice alone. These effects were not maintained at long-term and there were no differences in activity limitation. Individualised directional preference management could be considered for patients with reducible discogenic pain seeking rapid pain relief however further research is indicated.

Diagnostic utility of patient history and physical examination data to detect spondylolysis and spondylolisthesis in athletes with low back pain: A systematic review

BACKGROUND

In adolescent athletes, low back pain has a 1-year prevalence of 57% and causes include spondylolysis and spondylolisthesis. An accurate diagnosis enables healing, prevention of progression and return to sport.

OBJECTIVE

To evaluate the diagnostic utility of patient history and physical examination data to identify spondylolysis and/or spondylolisthesis in athletes.

DESIGN

Systematic review was undertaken according to published guidelines, and reported in line with PRISMA.

METHOD

Key databases were searched up to 13/11/15.

INCLUSION CRITERIA

athletic population with LBP, patient history and/or physical examination accuracy data for spondylolysis and/or spondylolisthesis, any study design including raw data. Two reviewers independently assessed risk of bias (ROB) using QUADAS-2. A data extraction sheet was pre-designed. Pooling of data and investigation for heterogeneity enabled a qualitative synthesis of data across studies.

RESULTS

Of the eight included studies, two were assessed as low ROB, one of which also had no concerns regarding applicability. Age (<20 years) demonstrated 81% sensitivity and 44% specificity and gender (male) 73% sensitivity and 57% specificity for spondylolysis. Difficulty falling asleep, waking up because of pain, pain worse with sitting and walking all have sensitivity >75% for spondylolisthesis. Step-deformity palpation demonstrated 60-88% sensitivity and 87-100% specificity for spondylolisthesis. The one-legged hyperextension test was not supported for spondylolysis (sensitivity 50-73%, specificity 0-87%).

CONCLUSION

No recommendations can be made utilising patient history data. Based on one low ROB study, step deformity palpation may be useful in diagnosing spondylolisthesis. No physical tests demonstrated diagnostic utility for spondylolysis. Further research is required.

Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial

BACKGROUND

Many patients with low-back disorders persisting beyond 6 weeks do not recover. This study investigates whether individualised physiotherapy plus guideline-based advice results in superior outcomes to advice alone in participants with low-back disorders.

METHODS

This prospective parallel group multicentre randomised controlled trial was set in 16 primary care physiotherapy practices in Melbourne, Australia. Random assignment resulted in 156 participants receiving 10 sessions of physiotherapy that was individualised based on pathoanatomical, psychosocial and neurophysiological barriers to recovery combined with guideline-based advice, and 144 participants receiving 2 sessions of physiotherapist-delivered advice alone. Primary outcomes were activity limitation (Oswestry Disability Index) and numerical rating scales for back and leg pain at 5, 10, 26 and 52 weeks postbaseline. Analyses were by intention-to-treat using linear mixed models.

RESULTS

Between-group differences showed significant effects favouring individualised physiotherapy for back and leg pain at 10 weeks (back: 1.3, 95% CI 0.8 to 1.8; leg: 1.1, 95% CI 0.5 to 1.7) and 26 weeks (back: 0.9, 95% CI 0.4 to 1.4; leg: 1.0, 95% CI 0.4 to 1.6). Oswestry favoured individualised physiotherapy at 10 weeks (4.7; 95% CI 2.0 to 7.5), 26 weeks (5.4; 95% CI 2.6 to 8.2) and 52 weeks (4.3; 95% CI 1.4 to 7.1). Responder analysis at 52 weeks showed participants receiving individualised physiotherapy were more likely to improve by a clinically important amount of 50% from baseline for Oswestry (relative risk (RR=1.3) 1.5; 95% CI 1.2 to 1.8) and back pain (RR 1.3; 95% CI 1.2 to 1.8) than participants receiving advice alone.

CONCLUSIONS

10 sessions of individualised physiotherapy was more effective than 2 sessions of advice alone in participants with low-back disorders of ≥6 weeks and ≤6 months duration. Between-group changes were sustained at 12 months for activity limitation and 6 months for back and leg pain and were likely to be clinically significant.

CLINICAL TRIAL REGISTRATION

ACTRN12609000834257.