CF 125: Current Knowledge On A Robust Low Back Pain Diagnosis
Today we’re going to talk about picking apart a Lumbar pain diagnosis. What’s the latest information according to research?
But first, here’s that sweet sweet bumper music
OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around.
We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers.
I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast.
Today, I want to use a current paper from November on low back pain and diagnosing it correctly. I’m going to use the paper as the main source of info here but I’m going to be peppering in my own learning as a Fellow of the International Academy of Neuromusculoskeletal Medicine. I’m a nerd when it comes to the low back for whatever reason. Maybe because its the best researched of the conditions we treat. I don’t know. But I nerd out of this stuff and, if you follow along, by the end of today’s episode, you should be able to raise your low back diagnosis game considerably.
This one is called “Current evidence for the diagnosis of common conditions causing low back pain; systematic review and standardized terminology recommendations” by Robert Vining, et. al(Vining R 2019). and published in Journal of Manipulative and Physiological Therapeutics in November of 2019……hot enough, here we go.
Why They Did It
The purpose of this systematic review was to evaluate and summarize current evidence for the diagnosis of common conditions causing low back pain and to propose standardized terminology use.
How They Did It
What They Found
- 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
- 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.
Let’s dive in a bit, shall we?
- 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
- These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain
, they say provocation discography is the diagnostic reference standard test used to confirm discogenic pain but it costs a lot, it’s not well standardized and there are some pretty significant risks of adverse effects. So the authors are recommending the centralization phenomenon as an office-based test to try to confirm discogenic pain. I’d add a few other signs of the pain being disc in nature. Here are a few off the top of my head:
- The patient locates their pain axially and at L5 or above, not laterally
- You cannot typically provoke the pain when pressing P to A on the segment
- Walking helps
- The Slump Test is highly useful here
- Pain on coughing or sneezing or going from seated to standing
- Pain that is worse sitting and better when lying down
- Pain that can be centralized or peripheralized
- Diminished motor, sensory, or reflexes
- About 40% of low back pain patients under the age of 50 are discs
- And pain that radiates beyond the knee
– They recommend myofascial pain be defined as nociceptive signaling from within muscle or fascial tissues that may or may not include referred pain or the presence of trigger points. Diagnostic criteria consistent with this definition include tenderness within a muscle with or without referred pain and reproduction of familiar pain with palpation or use.
SI Joint Pain
– Despite the existence of numerous provocation tests designed to identify SI joint pain, current scientific evidence does not support the diagnostic utility of individual tests. I can agree with that. Therefore, they say that SI anesthetic injections or blocks are the current diagnostic standard but of course, we don’t do that do we? No, we test the SI joints in several different ways and try to have a consensus.
Facet Joint Pain
- SI joint pain prevalence is about 22.5% of your low back patients
- Fortin’s finger test raises your suspicion considerably
- Walking hurts
- Seated to standing usually hurts
- For a robust diagnosis of SI, you should have 3 of the following 5 positive tests.
- Sacroiliac compression test
- Distraction / gapping test
- FABER test
- Gaenslen’s test
- Thigh thrust
– They point out a study by Laslett et. al. saying a reporting of 3 out of 5 findings is sufficient to make a facet dx. They are:
- Patient over 50
- Paraspinal pain
- Relieved with walking
- Relieved with sitting
- Positive extension/rotation
I will add to that list that facet joints constitute roughly 30% of your low back patients. The extension/rotation test is important. If it’s positive, it can still be something other than facets. But, if it’s negative, it’s almost certainly NOT a facet. Get that again, if extension/rotation is NOT positive, it’s almost certainly NOT facet.
In addition, you can push paraspinal on the patient and provoke the pain whereas, as mentioned, with a disc, you cannot provoke it by palpation.
Typically, long-lever activities are bothersome. Things like vacuuming, doing the dishes, or folding laundry. Anything that involves being slightly bent forward for a period of time.
– They say “Neurogenic claudication occurs when spinal stenosis is severe enough to cause symptoms from intermittent neural compression or ischemia, most commonly from degenerative changes within the spine.”
They say they “recommend diagnostic criteria reported by Nadeau et al. Which are symptoms triggered with standing, relieved by sitting, symptoms above the knees, and positive shopping cart sign.”
For me here in my clinic, I use the protocol Carmen Amendolia created and validated through research. It’s been highly effective for us and our patients.
Current diagnostic criteria are available only through a systematic review of clinical features reported in the scientific literature:
- ipsilateral leg radiation,
- (2) greater sciatic notch tenderness,
- (3) buttock pain,
- (4) positive SLR, and
- (5) pain with sitting
I would add that resisted external rotation could give you a hint. Put your hands on the lateral sides of the patient’s knees bilaterally. Then tell the patient to try to spread their legs while you resist. It’s painful, you have another very simple hint that you may be dealing with a piriformis issue.
So there you have it with my own learning from the neuromusculoskeletal diplomate program salted and peppered in for a good robust discussion. Yes, there are other considerations like lumbar sprain strain and things like that but these are the biggies.
If you weren’t before, you should be well-equipped after this episode to kill it on a low back diagnosis.
Alright, that’s it. Y’all be safe. Continue taking care of yourselves and taking care of your neighbors. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it.
Let’s get to the message. Same as it is every week.
Remember the evidence-informed brochures and posters at chiropracticforward.com
I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots.
When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few.
It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient.
And, if the patient treats preventatively after initial recovery, we can usually keep it that way while raising the overall level of health!
At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints….
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We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
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About the Author & Host
Dr. Jeff Williams – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & VloggerBibliography
Vining R, S. Z., Minkalis A, (2019). “Current evidence for diagnosis of common conditions causing low back pain; systematic review and standardized terminology recommendations.” J Man Manip Ther 42