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Low back pain misdiagnosis or missed diagnosis: Core principles

Consensus guidelines for the management of low back pain recommend that the clinician use contemporary best practice for assessment and treatment, consider biopsychosocial factors and, if chronic, use a multimodal and multi-disciplinary approach. Where guidelines are not followed and basic assessment is inadequate the diagnosis may be compromised and the sequelae of errors compounded. Factors such as a lack of knowledge or recognition of the common structure specific pain referral patterns, poor clinical reasoning, inappropriate referral and predilection for popular management approaches also contribute to mis-diagnosis and mis-management. This report describes two cases of chronic low back pain with lengthy histories of multiple failed interventions to highlight the consequences of focussing on a singular approach to the exclusion of evidence based pathways and the resulting risk of a missed diagnosis. The eventual management to mitigate these problems is reported with the aid of low back pain outcome measures, computer-aided combined movement examination, disability and pain questionnaires and health quality of life surveys.

Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for MT

Manual therapy (MT-) is moving beyond its empirical origins and into an era of evidence-based practice. Mechanisms for the appearance of clinically observed symptoms and signs are beng incorporated into its clinical reasoning process. The recent, but well-documented phenomenon, central sensitization, is recognized as being one such mechanism. Anatomical, physiological, behavioural and clinical evidence demonstrate that, in addition to input from the periphery, central sensitization can be enhanced or maintained by supraspinal processes involving cognitions, attention ('focussing') and emotions. These forebrain products may, therefore, make a significant contribution to the symptoms and signs of common musculoskeletal presentations such as 'non-specific' back pain and fibromyalgia. The evidence can also be interpreted to provide MT with an acceptable role in the management of these patients.