Diagnostic clinical prediction rules for specific subtypes of low back pain: a systematic review

Diagnostic models to predict structural spinal osteoarthritis on lumbar radiographs in older adults with back pain: Development and internal validation

Objective

It is difficult for health care providers to diagnose structural spinal osteoarthritis (OA), because current guidelines recommend against imaging in patients with back pain. Therefore, the aim of this study was to develop and internally validate multivariable diagnostic prediction models based on a set of clinical and demographic features to be used for the diagnosis of structural spinal OA on lumbar radiographs in older patients with back pain.

Design

Three diagnostic prediction models, for structural spinal OA on lumbar radiographs (i.e. multilevel osteophytes, multilevel disc space narrowing (DSN), and both combined), were developed and internally validated in the 'Back Complaints in Older Adults' (BACE) cohort (N ​= ​669). Model performance (i.e. overall performance, discrimination and calibration) and clinical utility (i.e. decision curve analysis) were assessed. Internal validation was performed by bootstrapping.

Results

Mean age of the cohort was 66.9 years (±7.6 years) and 59% were female. All three models included age, gender, back pain duration and duration of spinal morning stiffness as predictors. The combined model additionally included restricted lateral flexion and spinal morning stiffness severity, and exhibited the best model performance (optimism adjusted c-statistic 0.661; good calibration with intercept -0.030 and slope of 0.886) and acceptable clinical utility. The other models showed suboptimal discrimination, good calibration and acceptable decision curves.

Conclusion

All three models for structural spinal OA displayed lesuboptimal discrimination and need improvement. However, these internally validated models have potential to inform primary care clinicians about a patient with risk of having structural spinal OA on lumbar radiographs. External validation before implementation in clinical care is recommended.

Diagnostic clinical prediction rules for categorising low back pain: A systematic review

BACKGROUND

Low back pain (LBP) is a common complex condition, where specific diagnoses are hard to identify. Diagnostic clinical prediction rules (CPRs) are known to improve clinical decision-making. A review of LBP diagnostic-CPRs by Haskins et al. (2015) identified six diagnostic-CPRs in derivation phases of development, with one tool ready for implementation. Recent progress on these tools is unknown. Therefore, this review aimed to investigate developments in LBP diagnostic-CPRs and evaluate their readiness for implementation.

METHODS

A systematic review was performed on five databases (Medline, Amed, Cochrane Library, PsycInfo, and CINAHL) combined with hand-searching and citation-tracking to identify eligible studies. Study and tool quality were appraised for risk of bias (Quality Assessment of Diagnostic Accuracy Studies-2), methodological quality (checklist using accepted CPR methodological standards), and CPR tool appraisal (GRade and ASsess Predictive).

RESULTS

Of 5021 studies screened, 11 diagnostic-CPRs were identified. Of the six previously known, three have been externally validated but not yet undergone impact analysis. Five new tools have been identified since Haskin et al. (2015); all are still in derivation stages. The most validated diagnostic-CPRs include the Lumbar-Spinal-Stenosis-Self-Administered-Self-Reported-History-Questionnaire and Diagnosis-Support-Tool-to-Identify-Lumbar-Spinal-Stenosis, and the StEP-tool which differentiates radicular from axial-LBP.

CONCLUSIONS

This updated review of LBP diagnostic CPRs found five new tools, all in the early stages of development. Three previously known tools have now been externally validated but should be used with caution until impact evaluation studies are undertaken. Future funding should focus on externally validating and assessing the impact of existing CPRs on clinical decision-making.

Non-Specific Low Back Pain: An Inductive Exploratory Analysis through Factor Analysis and Deep Learning for Better Clustering

Non-specific low back pain (NSLBP) is a significant and pervasive public health issue in contemporary society. Despite the widespread prevalence of NSLBP, our understanding of its underlying causes, as well as our capacity to provide effective treatments, remains limited due to the high diversity in the population that does not respond to generic treatments. Clustering the NSLBP population based on shared characteristics offers a potential solution for developing personalized interventions. However, the complexity of NSLBP and the reliance on subjective categorical data in previous attempts present challenges in achieving reliable and clinically meaningful clusters. This study aims to explore the influence and importance of objective, continuous variables related to NSLBP and how to use these variables effectively to facilitate the clustering of NSLBP patients into meaningful subgroups. Data were acquired from 46 subjects who performed six simple movement tasks (back extension, back flexion, lateral trunk flexion right, lateral trunk flexion left, trunk rotation right, and trunk rotation left) at two different speeds (maximum and preferred). High-density electromyography (HD EMG) data from the lower back region were acquired, jointly with motion capture data, using passive reflective markers on the subject's body and clusters of markers on the subject's spine. An exploratory analysis was conducted using a deep neural network and factor analysis. Based on selected variables, various models were trained to classify individuals as healthy or having NSLBP in order to assess the importance of different variables. The models were trained using different subsets of data, including all variables, only anthropometric data (e.g., age, BMI, height, weight, and sex), only biomechanical data (e.g., shoulder and lower back movement), only neuromuscular data (e.g., HD EMG activity), or only balance-related data. The models achieved high accuracy in categorizing individuals as healthy or having NSLBP (full model: 93.30%, anthropometric model: 94.40%, biomechanical model: 84.47%, neuromuscular model: 88.07%, and balance model: 74.73%). Factor analysis revealed that individuals with NSLBP exhibited different movement patterns to healthy individuals, characterized by slower and more rigid movements. Anthropometric variables (age, sex, and BMI) were significantly correlated with NSLBP components. In conclusion, different data types, such as body measurements, movement patterns, and neuromuscular activity, can provide valuable information for identifying individuals with NSLBP. To gain a comprehensive understanding of NSLBP, it is crucial to investigate the main domains influencing its prognosis as a cohesive unit rather than studying them in isolation. Simplifying the conditions for acquiring dynamic data is recommended to reduce data complexity, and using back flexion and trunk rotation as effective options should be further explored.

Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews

Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.

Classification Approaches for Treating Low Back Pain Have Small Effects That Are Not Clinically Meaningful: A Systematic Review With Meta-analysis

OBJECTIVE

To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP).

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened.

STUDY SELECTION CRITERIA

We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded.

DATA SYNTHESIS

Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges' g) and 95% confidence interval (CI). Subgroup analyses explored classification system, comparator type, pain type, and pain duration.

RESULTS

Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, -0.31; 95% CI: -0.54, -0.07; P = .014, n = 4416, n = 21 trials) and disability (SMD, -0.27; 95% CI: -0.46, -0.07; P = .011, n = 4809, n = 24 trials), favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful.

CONCLUSION

For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP. J Orthop Sports Phys Ther 2022;52(2):67-84. Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.

Diagnostic tests in the clinical diagnosis of lumbar spinal stenosis: Consensus and Results of an International Delphi Study

PURPOSE

Reach a consensus on which diagnostic tests are most important in confirming the clinical diagnosis of lumbar spinal stenosis (LSS).

METHODS

Phase 1: 22 members of the International Taskforce on the Diagnosis and Management of LSS confirmed 35 diagnostic items. An on-line survey was developed that allows experts to express the logical order in which they consider the diagnostic tests, and the level of certainty ascertained from each test. Phase 2, Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 15 members of Taskforce defined final list of 10 items. Round 3: Survey was distributed internationally, followed by Taskforce consensus.

RESULTS

Totally, 432 clinicians from 28 different countries participated. Certainty of the diagnosis was 60% after selecting the first test and significant change in certainty ceasing after eight items at 90.8% certainty (p < 0.05). The most frequently selected tests included MRI/CT scan, neurological examination and walking test with gait observation. The diagnostic test selected most frequently as the first test was neurological examination.

CONCLUSIONS

This is the first study to reach an international consensus on which diagnostic tests should be used in the clinical diagnosis of LSS. The final recommendation includes three core diagnostic items: neurological examination, MRI/CT and walking test with gait observation. The Taskforce also recommends 3 'rule out' tests: foot pulses/ABI, hip examination and test for cervical myelopathy. If applied, this core set of diagnostic tests can standardize outcomes and improve clinical care of LSS globally.

Diffuse Idiopathic Skeletal Hyperostosis in a Patient With Shoulder Pain

A 74-year-old man was referred to physical therapy by his primary care physician for insidious onset of right shoulder pain. Following examination, spinal radiographs and the human leukocyte antigen (HLA-B27) test, which is used to identify common autoimmune disorders, were completed. The radiographs revealed multilevel changes consistent with diffuse idiopathic skeletal hyperostosis, and the HLA-B27 test was positive. J Orthop Sports Phys Ther 2020;50(4):215. doi:10.2519/jospt.2020.9243.

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.

Systematic Selection of Key Logistic Regression Variables for Risk Prediction Analyses: A Five-Factor Maximum Model

GENERAL AND CRITICAL REVIEW FORMAT

The evolution of clinical practice and medical technology has yielded an increasing number of clinical measures and tests to assess a patient's progression and return to sport readiness after injury. The plethora of available tests may be burdensome to clinicians in the absence of evidence that demonstrates the utility of a given measurement.

OBJECTIVE

Thus, there is a critical need to identify a discrete number of metrics to capture during clinical assessment to effectively and concisely guide patient care.

DATA SOURCES

The data sources included Pubmed and PMC Pubmed Central articles on the topic. Therefore, we present a systematic approach to injury risk analyses and how this concept may be used in algorithms for risk analyses for primary anterior cruciate ligament (ACL) injury in healthy athletes and patients after ACL reconstruction.

MAIN RESULTS

In this article, we present the five-factor maximum model, which states that in any predictive model, a maximum of 5 variables will contribute in a meaningful manner to any risk factor analysis.

CONCLUSIONS

We demonstrate how this model already exists for prevention of primary ACL injury, how this model may guide development of the second ACL injury risk analysis, and how the five-factor maximum model may be applied across the injury spectrum for development of the injury risk analysis.

Effectiveness of graded activity versus physiotherapy in patients with chronic nonspecific low back pain: midterm follow up results of a randomized controlled trial

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Graded activity and physiotherapy have similar effects in terms of reducing pain and disability.

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Healthcare professionals may identify inadequate beliefs in patients with low back pain.

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It is important to stimulate patients with LBP return to work.

Background

Low back pain (LBP) is a major health and economic problem worldwide. Graded activity and physiotherapy are commonly used interventions for nonspecific low back pain. However, there is currently little evidence to support the use of one intervention over the other in the medium-term.

Objective

To compare the effectiveness of graded activity exercises to physiotherapy-based exercises at mid-term (three and six months’ post intervention) in patients with chronic nonspecific LBP.

Methods

Sixty-six patients were randomly allocated to two groups: graded activity group (n = 33) and physiotherapy group (n = 33). These patients received individual sessions twice a week for six weeks. Follow-up measurements were taken at three and six months. The main outcome measurements were intensity pain (Pain Numerical Rating Scale) and disability (Rolland Morris Disability Questionnaire).

Results

No significant differences between groups after three and six month-follow ups were observed. Both groups showed similar outcomes for pain intensity at three months [between group differences: −0.1 (95% confidence interval [CI] = −1.5 to 1.2)] and six months [0.1 (95% CI = −1.1 to 1.5)], disability at three months was [-0.6 (95% CI = −3.4 to 2.2)] and six months [0.0 (95% CI = −2.9 to 3.0)].

Conclusion

The results of this study suggest that graded activity and physiotherapy have similar effects in the medium-term for patients with chronic nonspecific low back pain.

Do Muscle Strength Deficits of the Uninvolved Hip and Knee Exist in Young Athletes Before Anterior Cruciate Ligament Reconstruction?

Background:

Muscle strength of the involved limb is known to be decreased after injury. Comparison with the uninvolved limb has become standard of practice to measure progress and for calculation of limb symmetry indices (LSIs) to determine readiness to return to sport. However, some literature suggests strength changes in the uninvolved limb also are present after lower extremity injury.

Purpose:

To examine the uninvolved limb strength in a population of adolescent athletes after an anterior cruciate ligament (ACL) injury and compare strength values with those of the dominant limb in a healthy control group.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 64 athletes were enrolled in this study, including 31with injured ACLs (mean age, 15.6 ± 1.4 years) and 33 healthy controls (mean age, 14.9 ± 1.9 years). The median time from injury to testing was 23 days for the ACL-injured group. Participants underwent Biodex isokinetic strength testing at 60 deg/s to assess quadriceps and hamstring strength. Isometric hip strength (abduction, extension, external rotation) was measured using a handheld dynamometer. The muscle strength of the uninvolved limb of the ACL-injured group was compared with that of the dominant limb of the healthy control group.

Results:

The results showed a significant difference in quadriceps muscle strength between the 2 study groups (P < .001). Isokinetic quadriceps strength of the uninvolved limb in the ACL group was significantly decreased by 25.5% (P < .001) when compared with the dominant limb of the control group.

Conclusion:

The results of this study demonstrate a decreased isokinetic strength of the quadriceps muscle in the uninvolved limb after ACL injury as compared with healthy controls. Consideration should be taken when using the uninvolved limb for comparison when assessing quadriceps strength in a population with an ACL injury.

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.

Evidence base and future research directions in the management of low back pain

Low back pain (LBP) is a prevalent and costly condition. Awareness of valid and reliable patient history taking, physical examination and clinical testing is important for diagnostic accuracy. Stratified care which targets treatment to patient subgroups based on key characteristics is reliant upon accurate diagnostics. Models of stratified care that can potentially improve treatment effects include prognostic risk profiling for persistent LBP, likely response to specific treatment based on clinical prediction models or suspected underlying causal mechanisms. The focus of this editorial is to highlight current research status and future directions for LBP diagnostics and stratified care.

Management of lumbar spinal stenosis

Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.