Application of a diagnosis-based clinical decision guide in patients with low back pain

Abstract

Background: Low back pain (LBP) is common and costly. Development of accurate and efficacious methods of diagnosis and treatment has been identified as a research priority. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based means to apply the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with LBP.

Methods: Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of LBP patients examined by one of three examiners trained in the application of the DBCDG.

Results: Data were gathered on 264 patients. Signs of visceral disease or potentially serious illness were found in 2.7%. Centralization signs were found in 41%, lumbar and sacroiliac segmental signs in 23% and 27%, respectively and radicular signs were found in 24%. Clinically relevant myofascial signs were diagnosed in 10%. Dynamic instability was diagnosed in 63%, fear beliefs in 40%, central pain hypersensitivity in 5%, passive coping in 3% and depression in 3%.

Conclusion: The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability and efficacy of treatment based on the DBCDG.

Figure 1

Diagnostic algorithm for the application of the DBCDG. Reprinted with permission from: Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision guide for the management of patients with spinal pain. BMC Musculoskelet Disord 2007;8:75. cerv = cervical; thor = thoracic; lumb = lumbar; SI = sacroiliac; TrP = trigger point; CPH = central pain hypersensitivity; dysfx = dysfunction; catastroph = catastrophizing.

Figure 2

Management algorithm for the application of the DBCDG. Reprinted with permission from: Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision guide for the management of patients with spinal pain. BMC Musculoskelet Disord 2007;8:75. ER = end range; NSAID = non-steroidal anti-inflammatory drugs; ESI = epidural steroid injection; mob = mobilization; CPH = central pain hypersensitivity.