Article

Mechanisms-based classifications of musculoskeletal pain: Part 2 of 3: Symptoms and signs of peripheral neuropathic pain in patients with low back (+/- leg) pain

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Abstract

As a mechanisms-based classification of pain 'peripheral neuropathic pain' (PNP) refers to pain arising from a primary lesion or dysfunction in the peripheral nervous system. Symptoms and signs associated with an assumed dominance of PNP in patients attending for physiotherapy have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of PNP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol. Patients' pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist specifying the presence or absence of various clinical criteria. A binary logistic regression analysis with Bayesian model averaging identified a cluster of two symptoms and one sign predictive of PNP, including: 'Pain referred in a dermatomal or cutaneous distribution', 'History of nerve injury, pathology or mechanical compromise' and 'Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic) that move/load/compress neural tissue'. This cluster was found to have high levels of classification accuracy (sensitivity 86.3%, 95% CI: 78.0-92.3; specificity 96.0%, 95% CI: 93.4-97.8; diagnostic odds ratio 150.9, 95% CI: 69.4-328.1). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of PNP mechanisms in patients with low back pain disorders in a way that might usefully inform subsequent patient management.

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... Neuropathic pain is generally referred in a dermatomal or cutaneous distribution [32]. The most common descriptors used by patients are burning, lancinating, and is accompanied by unusual tingling, crawling, or an electrical shock or shooting in the leg [9,26,27]. ...
... The patient may experience various sensations, such as paresthesia, mechanical or thermal hypersensitivity. Neuropathic pain is also characterized by spontaneous (arise without stimulation), evoked (abnormal responses to stimuli) or paroxysmal (sudden recurrences and intensification) pain [32,34]. ...
... These symptoms contrast with the description of patients suffering from nociceptive (referred) pain. Pain is usually localized to the area of injury/dysfunction (with or without referred pain) [32]. The symptoms are commonly described as intermittent and sharp with movement. ...
Article
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Low back pain (LBP) that radiates to the leg is not always related to a lesion or a disease of the nervous system (neuropathic pain): it might be nociceptive (referred) pain. Unfortunately, patients with low-back related leg pain are often given a variety of diagnoses (e.g. 'sciatica'; 'radicular pain'; pseudoradicular pain"). This terminology causes confusion and challenges clinical reasoning. It is essential for clinicians to understand and recognize predominant pain mechanisms. This paper describes pain mechanisms related to low back-related leg pain and helps differentiate these mechanisms in practice using clinical based scenarios. We illustrate this by using two clinical scenarios including patients with the same symptoms in terms of pain localization (i.e. low-back related leg pain) but with different underlying pain mechanisms (i.e. nociceptive versus neuropathic pain).
... [ case report ] ries. 62,76 One scheme, outlined in TABLE 1, divides pain into central sensitization, 62 peripheral neuropathic pain, 63 and nociceptive pain. 64 Patients may demonstrate a combination of these pain mechanisms. ...
... 64 Patients may demonstrate a combination of these pain mechanisms. [61][62][63][64] Nociceptive pain in musculoskeletal tissue occurs when group III and IV fibers are activated in response to noxious chemical, mechanical, or thermal stimuli. 76 Peripheral neuropathic pain refers to pain arising from trauma, compression, inflammation, or ischemia in a peripheral nerve, dorsal root ganglion, or dorsal root. ...
... The following evidence supported a neuropathic source of pain: the patient's prior history of cerebrovascular accident and diabetes, both of which may lead to neuropathic pain; his score on the LANSS pain scale; and his positive response to gabapentin, a known pharmaceutical treatment for neuropathic pain. 17 In addition, a positive straight leg [ case report ] raise was present, which is a criterion for peripheral neuropathic pain, according to the classification system of Smart et al. 63 However, no deficits in static cutaneous mechanical detection threshold were found during the neurological exam, and the distribution of symptoms was not in a dermatomal pattern, decreasing the likelihood that the patient's symptoms stemmed from the lumbar spine as peripheral neuropathic pain. ...
... Cervical quadrant, distraction, compression, and upper limb neural tension test for the median nerve were all positive, reproducing her familiar pain in the cervical spine and left arm. Smart et al [26] reported that positive neural tension tests and history of neurological tissue compromise are implicated in states of peripheral neurogenic pain. Palpation revealed tenderness and hypertonicity in the left cervical paraspinals, as well as tenderness of the supraspinatus and biceps long head tendons. ...
... The patient presented with subjective reports that indicated fear avoidance, and a disproportional pain rating both described in the literature as related to CS and persistent pain [24]. The objective tests and measures showed positive test results with neural tissue tension techniques, indicating peripheral neuropathic pain as well [26]. The outcome measures indicated the patient had clinically significant levels of fear avoidance behaviors, kinesiophobia, and low knowledge of pain neurophysiology concepts, while also presenting with high levels of perceived disability from cervical and low back regional disability measures. ...
... Hypersensitivity attributes indicate a CS mechanism of pain, which been shown to respond well to PNE [24]. There also appears to be peripheral neurogenic mechanisms of pain indicated with positive upper limb neurological tension test results [26]. The clinical presentation of this patient prompted the student physical therapist to provide a PNE intervention in consultation with the treating physical therapist based on previous literature describing its efficacy [15,21,22,24]. ...
Article
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BACKGROUND Persistent pain is one of the most common reasons individuals seek healthcare in the United States, costing $635 billion annually. At present, the medical literature outlines many treatments for persistent pain. Pain neuroscience education (PNE) is described in the literature as an educational intervention for patients with persistent pain that can be applied by a physical therapist. There is limited research on the application of PNE by a student physical therapist; however, this case report offers a unique opportunity to examine outcomes for this intervention when applied by a student physical therapist in conjunction with manual therapy and therapeutic exercise. CASE REPORT This case report examined the outcomes of PNE for a 65-year-old patient with a long-standing history of low back, cervical, shoulder, knee, and foot pain. Interventions included 7 sessions of PNE over 4 weeks delivered by a student physical therapist, in combination with manual therapy and exercise prescribed by a licensed physical therapist. Outcomes measured were fear avoidance belief questionnaire, visual analog scale, Tampa scale of kinesiophobia, neurophysiology of pain questionnaire, neck disability index, and Oswestry disability index. CONCLUSIONS Outcomes included clinically significant decreases in subjective pain level, and kinesiophobia; however, there was only a minimal decrease in fear avoidance and no decrease in perceived disability. This case report provides preliminary evidence that positive outcomes can be achieved when PNE is delivered by a student physical therapist combined with manual therapy and therapeutic exercise from an expert clinician for patients with persistent musculoskeletal pain.
... A mechanism-based classification approach has been proposed by several different authors [17][18][19][20][21][22][23][24] as an alternative to the traditional temporal-based classification to better inform pain management interventions (see Chapter 96). As the name implies, this approach to classifying pain focuses on identifying the dominant neurophysiological mechanism that is driving the individual's pain experience. ...
... Within this framework, there are three predominant mechanisms: nociception dominant, peripheral neuropathic dominant, and nociplastic dominant (sometimes referred to as central sensitization dominant). [18][19][20]25 ...
... 28 Signs and symptoms of peripheral neuropathic-dominant pain are listed in Box 94.2. 19,27 When considering the common signs and symptoms of peripheral neuropathic-dominant pain, there are a few caveats to keep in mind. Although neuroanatomically logical pain is typically defined as pain being referred in a dermatomal or cutaneous distribution, is important to point out that neuroanatomically logical pain from cervical nerve roots may be outside of traditionally identified dermatomes. ...
... In many occasions, differentiating the various phenotypes clinically is difficult. Smart et al [11][12][13] proposed a mechanism-based classification to differentiate between different types of musculoskeletal LBP (central sensitisation, peripheral neuropathic and nociceptive). ...
... The percentage reduction in NRS pain at week 24 will also be evaluated according to various musculoskeletal CLBP subtypes based on pain mechanism (nociceptive vs peripheral neuropathic vs central sanitisation). [11][12][13] The secondary objectives are to evaluate the effects of PLFMF on (1) pain intensity during treatment and early after treatment completion, (2) level of disability, (3) functional levels, (4) sleep quality, (5) quality of life and (6) fatigue in patients with CLBP. The study will also investigate the long-term side effects of PLFMF. ...
... The 38-item clinical criteria checklist developed by Smart et al [11][12][13] will be used to classify patients into different phenotypes of musculoskeletal CLBP. This method of discriminative validity was established. ...
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Introduction The aim of the present study is to investigate the effectiveness of pulsed low-frequency magnetic field (PLFMF) on the management of chronic low back pain (CLBP). Methods and analysis A randomised double-blinded controlled clinical trial will be conducted, involving 200 patients with CLBP. Participants will be randomised in a 1:1 ratio to receive either active PLFMF (experimental arm) or sham treatment (control arm) using a permuted-block design which will be stratified according to three subtypes of musculoskeletal CLBP (nociceptive, peripheral neuropathic or central sanitisation). The intervention consists of three sessions/week for 6 weeks. The primary outcome is the percentage change in Numerical Rating Scale (NRS) pain at week 24 after treatment completion with respect to the baseline. Secondary outcomes include percentage NRS pain during treatment and early after treatment completion, short form 36 quality of life, Roland and Morris Disability Questionnaire; Depression Anxiety Stress Scale 21, Patient Specific Functional Scale, Global perceived effect of condition change, Pittsburgh Sleep Quality Index and Modified Fatigue Impact Scale. Measures will be taken at baseline, 3 and 6 weeks during the intervention and 6, 12 and 24 weeks after completing the intervention. Adverse events between arms will be evaluated. Data will be analysed on an intention-to-treat basis. Ethics and dissemination The study is funded by Imam Abdulrahman Bin Faisal University (IAU). It has been approved by the institutional review board of IAU (IRB‐ 2017‐03–129). The study will be conducted at King Fahd Hospital of the University and will be monitored by the Hospital monitoring office for research and research ethics. The trial is scheduled to begin in September 2018. Results obtained will be presented in international conferences and will be published in peer-reviewed journals. Trial registration number ACTRN12618000921280, prospectively.
... The use of questionnaires is feasible as they involve self-administered questions and/or simple clinical tests. Three multicomponent systems designed to discriminate between pain mechanisms (Smart,194,(196)(197)(198)175,178 and Kolski 102 classifications) and 3 sets of criteria (Berlin criteria for inflammatory pain, 99,169 RAPIDH criteria for radicular pain [a type of peripheral neuropathic pain], 73 and NeuPSIG neuropathic pain grading system 64,213,220 ) have been tested for validity regarding discrimination between PMCs. Classification systems performed well in most criteria. ...
... Some systems have been developed to discriminate between the 3 main PMCs, their subtypes, or just identify a single PMC. Systems developed by Smart et al. [196][197][198][199] and Nijs et al. 141,144 aim to discriminate between nociceptive, neuropathic, and nociplastic (central sensitisation) pain, whereas the system devised by Schafer et al. 178 aims to discriminate between 3 subgroups of neuropathic pain (denervation, peripheral nerve sensitisation, and neuropathic sensitisation) and nociceptive pain (referred to as musculoskeletal pain). The NeuPSIG neuropathic grading system has been used to identify neuropathic pain. ...
... There is some divergence of opinion regarding the number of categories, terminology, and/or definitions for PMCs and the criteria to discriminate between PMCs ( Table 9). For instance, Smart et al. [196][197][198] described discrimination between 3 PMCs (nociceptive, peripheral neuropathic, central sensitisation pain) and based criteria and validation on a clinical opinion of musculoskeletal physiotherapists. Nijs et al. 141,144 refer to "neuropathic pain" identified by the NeuSPIG criteria (eg, evidence of neural damage) and focus on subjective pain examination and history as evidence of a reasonable explanation for nociceptive pain. ...
Article
Mechanism-based classification of pain has been advocated widely to aid tailoring of interventions for individuals experiencing persistent musculoskeletal pain. Three pain mechanism categories are defined by the International Association for the Study of Pain: nociceptive, neuropathic, and nociplastic pain. Discrimination between them remains challenging. This study aimed to: build on a framework developed to converge the diverse literature of pain mechanism categories to systematically review methods purported to discriminate between them; synthesise and thematically analyse these methods to identify convergence and divergence of opinion; and report validation, psychometric properties and strengths/weaknesses of these methods. The search strategy identified papers discussing methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system. Studies that assessed validity of methods to discriminate between categories were assessed for quality. Extraction and thematic analysis were undertaken on 184 papers. Data synthesis identified 200 methods in five themes: clinical examination, quantitative sensory testing, imaging, diagnostic and laboratory testing, and pain-type questionnaires. Few methods have been validated for discrimination between pain mechanism categories. There was general convergence but some disagreement regarding findings that discriminate between pain mechanism categories. A combination of features and methods, rather than a single method, was generally recommended to discriminate between pain mechanism categories. Two major limitations were identified: overlap of findings of methods between categories due to mixed presentations, and many methods considered discrimination between two pain mechanism categories but not others. The results of this review provide a foundation to refine methods to differentiate mechanisms for musculoskeletal pain.
... This research was aimed at identifying NP in musculoskeletal pain and therefore these indicators may not be specific to low back related leg pain. The clinical classification accuracy of these indicators were investigated in low back pain patients with and without leg pain [22], finding that a cluster of two symptoms and one sign demonstrated a high level of classification accuracy. However, this study has been highlighted as being at risk of bias, due to clinicians not being blinded to the results of the reference standard before conducting the index test, therefore the results must be observed with caution [17]. ...
... History of nerve injury, pathology or mechanical compromise was a clinical indicator which remained from Smart et al's [21] original list, demonstrating high agreement (96.7%). This indicator has been demonstrated to have high sensitivity (86.3%) and specificity (96%) diagnosing peripheral NP in low back pain, with or without leg pain, when used as part of a cluster of 3 clinical indicators [22]. However, a low level of evidence supports this cluster of clinical indicators when assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) [17]. ...
... Evidence surrounding positive neurological symptoms/ findings in NP pertains largely to sensory findings [34], with reflex and motor loss suggestive of radiculopathy, which does not necessitate NP [35]. This is further supported by two systematic reviews investigating subjective and objective indicators to identify peripheral NP [22] and lumbosacral nerve root compression [36] respectively, clusters of signs and symptoms were generated in which motor/reflex loss were not featured but a common finding in both studies was sensory symptoms in a dermatomal distribution. Interestingly in this study a clinical indicator removed after round 1 was "Pain referred in a dermatomal or cutaneous distribution." ...
Article
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Background: Neuropathic pain (NP) is common in patients presenting with low back related leg pain. Accurate diagnosis of NP is fundamental to ensure appropriate intervention. In the absence of a clear gold standard, expert opinion provides a useful methodology to progress research and clinical practice. The aim of this study was to achieve expert consensus on a list of clinical indicators to identify NP in low back related leg pain. Methods: A modified Delphi method consisting of three rounds was designed in accordance with the Conducting and Reporting Delphi Studies recommendations. Recruitment involved contacting experts directly and through expressions of interest on social media. Experts were identified using pre-defined eligibility criteria. Priori consensus criteria were defined for each round through descriptive statistics. Following completion of round 3 a list of clinical indicators that achieved consensus were generated. Results: Thirty-eight participants were recruited across 11 countries. Thirty-five participants completed round 1 (92.1%), 32 (84.2%) round 2 and 30 (78.9%) round 3. Round 1 identified consensus (Kendall's W coefficient of concordance 0.456; p < 0.001) for 10 clinical indicators out of the original 14, and 9 additional indicators were added to round 2 following content analysis of qualitative data. Round 2 identified consensus (Kendall's W coefficient of concordance 0.749; p < 0.001) for 10 clinical indicators out of 19, and 1 additional indicator was added to round 3. Round 3 identified consensus for 8 indicators (Kendall's W coefficient of concordance 0.648; p < 0.001). Following completion of the third round, an expert derived consensus list of 8 items was generated. Two indicators; pain variously described a burning, electric shock like and/or shooting into leg and pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness), were found to have complete agreement amongst expert participants. Conclusions: Good agreement was found for the consensus derived list of 8 clinical indicators to identify NP in low back related leg pain. This list of indicators provide some indication of the criteria upon which clinicians can identify a NP component to low back related leg pain; further research is needed for stronger recommendations to be made.
... Similarly, research investigating the use of patient history and clinical examination items to diagnose NP in LBLP is lacking and inconclusive [16,17]. Two separate studies have devised a list of clinical indicators using patient history and clinical examination items to identify peripheral NP in patients with or without leg pain [18] and in lumbosacral nerve root compression [19]. The derived lists share one common item -pain distributed in a dermatomal pattern. ...
... The phenomena of interest varied significantly between studies; two studies investigated lumbosacral nerve root compression [19,34], one study investigated participants with upper/mid lumbar nerve root compression [32] and another looked specifically at L5 lateral stenosis [17]. Two studies investigated peripheral NP and chronic low back pain respectively [18,30] with and without leg pain, whereas Capra et al. [16] investigated sciatica with or without lumbar pain. Poiraudeau et al. [31] investigated participants with sciatica associated with disc herniation and Walsh et al. [35] studied those with LBLP. ...
... Two studies investigated the diagnostic validity of NP screening tools (S-DN4, ID Pain, painDETECT questionnaire, S-LANSS and StEP tool) [12,30]. One study investigated the diagnostic accuracy of patient history data [34], whilst two studies investigated both patient history data and clinical examination data [18,19]. Finally the remaining six studies investigated the use of clinical examination tests; Straight leg raise (SLR) [16], Slump test [33], slump knee bend [32], nerve palpation [35], standardised qualitative sensory testing (SQST) [17], and bell test/hyperextension test [31]. ...
Article
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Background: Low back-related leg pain (LBLP) is a challenge for healthcare providers to manage. Neuropathic pain (NP) is highly prevalent in presentations of LBLP and an accurate diagnosis of NP in LBLP is essential to ensure appropriate intervention. In the absence of a gold standard, the objective of this systematic review was to evaluate the diagnostic utility of patient history, clinical examination and screening tool data for identifying NP in LBLP. Methods: This systematic review is reported in line with PRISMA and followed a pre-defined and published protocol. CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro and PubMed databases, key journals and the grey literature were searched from inception to 31 July 2019. Eligible studies included any study design reporting primary diagnostic data on the diagnostic utility of patient history, clinical examination or screening tool data to identify NP in LBLP, in an adult population. Two independent reviewers searched information sources, assessed risk of bias (QUADAS-2) and used GRADE to assess overall quality of evidence. Results: From 762 studies, 11 studies were included. Nine studies out of the 11 were at risk of bias. Moderate level evidence supports a cluster of eight signs (age, duration of disease, paroxysmal pain, pain worse in leg than back, typical dermatomal distribution, worse on coughing/sneezing/straining, finger to floor distance and paresis) for diagnosing lumbosacral nerve root compression, demonstrating moderate/high sensitivity (72%) and specificity (80%) values. Moderate level evidence supports the use of the StEP tool for diagnosing lumbar radicular pain, demonstrating high sensitivity (92%) and specificity (97%) values. Conclusions: Overall low-moderate level evidence supports the diagnostic utility of patient history, clinical examination and screening tool data to identify NP in LBLP. The weak evidence base is largely due to methodological flaws and indirectness regarding applicability of the included studies. The most promising diagnostic tools include a cluster of 8 patient history/clinical examination signs and the StEP tool. Low risk of bias and high level of evidence diagnostic utility studies are needed, in order for stronger recommendations to be made.
... Lower back pain may be accompanied by leg pain. This may either be referred pain, where pathology in the muscles, joints or ligaments in the lumbar spine or pelvis (including the sacroiliac joint) may produce both pain at the site of nociception and also in the leg, or radicular pain, where there is shooting pain down the leg as a result of lumbar intervertebral disc herniation [44][45][46][47]. Both of these syndromes can have a gradual or sudden onset. ...
... Patients with radicular pain may have motor, sensory or reflexive deficits in their limbs. Imaging, including plain X-ray and MRI scans, nerve conduction studies and electromyography, may be indicated [44][45][46][47]. Treatment of referred pain is directed towards increasing mobility and return to pre-morbid function levels, whereas radicular pain treatment ranges on a spectrum from conservative management with analgesia and physiotherapy to surgery [47]. ...
Article
Popliteal Artery Entrapment Syndrome (PAES) is an uncommon syndrome that predominantly affects young athletes. Functional PAES is a subtype of PAES without anatomic entrapment of the popliteal artery. Patients with functional PAES tend to be younger and more active than typical PAES patients. A number of differential diagnoses exist, the most common of which is chronic exertional compartment syndrome. There is no consensus regarding choice of investigation for these patients. However, exercise ankle-brachial indices and magnetic resonance imaging are less invasive alternatives to digital subtraction angiography. Patients with typical symptoms that are severe and repetitive should be considered for intervention. Surgical intervention consists of release of the popliteal artery, either via a posterior or medial approach. The Turnipseed procedure involves a medial approach with a concomitant release of the medial gastrocnemius and soleal fascia, the medial tibial attachments of the soleus and excision of the proximal third of the plantaris muscle. Injection of botulinum A toxin under electromyographic guidance has recently shown promise as a diagnostic and/or therapeutic intervention in small case series. This review provides relevant information for the clinician investigating and managing patients with functional PAES.
... Knowledge about pain biology and pain mechanisms has increased in recent years, and this has led to a recommendation that the analysis of pain mechanisms be used as one important dimension in diagnostics. It is claimed that this will improve decision making about treatment (47,48,132,136). All of the participants of the study population had had a long duration of pain, and half of them had had back and/or leg pain for longer than 2 years pre-surgery (paper I). ...
... The patients improved in: kinesiophobia (fear of pain measured by the Tampa scale for kinesiophobia), health-related quality of life, depression and self-efficacy postsurgery. Further, function and pain were better at the 3-month and 2-year followups (136). ...
... Standardised clinical interview and examination are used to categorise patients plus a number of additional pain response symptoms (e.g. spontaneous paroxysmal pain and dysesthesia) and physical signs such as allodynic response and painful response to nerve palpation [67]. Supporting the discriminant validity of their system, the authors showed that the CSP group had the most self-report pain, disability, anxiety and depression and poorest health related quality of life compared to the PNP and NP group [68]. ...
... Smart et al. [67] used statistical methods to identify three items from history and physical examination items that were predictive of peripheral neuropathic: history of nerve injury, pathology or compromise; pain in a dermatomal distribution and positive neurodynamic tests. They recognized that these items differ considerably from criteria found in neuropathic pain screening tools and reflect that it may be because their patients were recruited from primary care settings with less severe presentations than the more severe pain populations in studies from which these questionnaires were derived. ...
Article
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Background The identification of clinically relevant subgroups of low back pain (LBP) is considered the number one LBP research priority in primary care. One subgroup of LBP patients are those with back related leg pain. Leg pain frequently accompanies LBP and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back-related leg pain (LBLP) is important for clinical management and research applications, but there is currently no clear agreement on how to define and identify LBLP due to nerve root involvement.The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP, and summarise how leg pain due to nerve root involvement is described and diagnosed in the various systems. Methods The search strategy involved nine electronic databases including Medline and Embase, reference lists of eligible studies and relevant reviews. Selected papers were appraised independently by two reviewers using a standardised scoring tool. ResultsOf 13,358 initial potential eligible citations, 50 relevant papers were identified that reported on 22 classification systems. Papers were grouped according to purpose and criteria of the classification systems. Five themes emerged: (i) clinical features (ii) pathoanatomy (iii) treatment-based approach (iv) screening tools and prediction rules and (v) pain mechanisms. Three of the twenty two systems focused specifically on LBLP populations.Systems that scored highest following quality appraisal were ones where authors generally included statistical methods to develop their classifications, and supporting work had been published on the systems’ validity, reliability and generalisability. There was lack of consistency in how LBLP due to nerve root involvement was described and diagnosed within the systems. Conclusion Numerous classification systems exist that include patients with leg pain, a minority of them focus specifically on distinguishing between different presentations of leg pain. Further work is needed to identify clinically meaningful subgroups of LBLP patients, ideally based on large primary care cohort populations and using recommended methods for classification system development.
... The biopsychosocial model of pain science has made scientists and PTs aware that in some patients the pain experience is predominately driven by nociceptive information and thus will have a more nociceptive dominant pain mechanism. In other patients, nociception by virtue of tissue healing, becomes less dominant, but biological and physiological processes in the peripheral nervous system becomes a dominant issue in a person's pain experience resulting in a possible peripheral neuropathic pain mechanism (Smart et al, 2012b). In yet another patient, peripheral nociceptive and neuropathic mechanisms are not the key issues associated with the development and maintenance of the pain experience, but more powerfully driven by the central nervous system, resulting in a dominant central pain mechanism (Smart et al, 2012a). ...
... In yet another patient, peripheral nociceptive and neuropathic mechanisms are not the key issues associated with the development and maintenance of the pain experience, but more powerfully driven by the central nervous system, resulting in a dominant central pain mechanism (Smart et al, 2012a). The importance of being able to identify which of these three mechanisms are dominant, are likely more important clinically than "just asking a pain rating" (Smart, Blake, Staines, and Doody, 2010;Smart et al, 2012a;Smart et al, 2012b;Smart et al, 2012c). The aforementioned classification of pain by Smart et al. (2010 and, has demonstrated an accurate preliminary classification of nociceptive, peripheral neuropathic, and central pain mechanisms (Table 2). ...
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The interview of a patient attending physical therapy is the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A thorough, skilled interview drives the objective tests and measures chosen, as well as provides context for the interpretation of those tests and measures, during the physical examination. Information from the interview powerfully influences the treatment modalities chosen by the physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy sessions. Traditional physical therapy focuses heavily on biomedical information to educate people about their pain, and this predominant model focusing on anatomy, biomechanics, and pathoanatomy permeates the interview and physical examination. Although this model may have a significant effect on people with acute, sub-acute or postoperative pain, this type of examination may not only gather insufficient information regarding the pain experience and suffering, but negatively impact a patient’s pain experience. In recent years, physical therapy treatment for pain has increasingly focused on pain science education, with increasing evidence of pain science education positively affecting pain, disability, pain catastrophization, movement limitations, and overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it is time for the examination, both subjective and objective, to embrace a biopsychosocial approach beyond the realm of only a biomedical approach. A patient interview is far more than “just” collecting information. It also is a critical component to establishing an alliance with a patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in pain. This article highlights the interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanism assessment.
... Thereafter, information about the study, an informed-consent form, and questionnaires were sent to their home addresses, and they were scheduled for an appointment with a physical therapist for a final verification of their eligibility. The physical therapist made a full assessment to determine that the pain was predominantly of a nociceptive mechanical nature 38 and that signs and symptoms of other pain mechanisms, such as central sensitization 36 or nerve root signs/peripheral neuropathic pain, 37 were not evident. Yellow-flag inquiries were also made. ...
... Of the 85 individuals referred to the study administrator, 15 were considered ineligible at the verification examination (FIGURE 2), 7 due to dominating signs and symptoms of central sensitization 36 and nerve root signs/peripheral neurogenic pain. 37 Another 7 participants declined to participate after inclusion but before randomization (unknown reasons), and 1 was ineligible due to pain of less than 3 months in duration. ...
... They then used statistical modeling based on patient symptoms to identify predominant sources of a patient's symptoms who have LBP. Through this approach, they identified a mechanisms-based classification for musculoskeletal pain that included: 1) central sensitization; 34 2) peripheral neuropathic (radicular or referred), 35 and 3) nociceptive. 36 The ability to identify the predominant mechanism-based classification is reliable in patients with nonspecific cervical pain (kappa = .84 ...
... This cluster of findings was found to have a sensitivity of 86.3% and a specificity of 96.0%. 35 For patients with potential referred symptoms, hypotheses should be formulated related to the primary mechanism (why) and structure (where) that is responsible for the symptoms. If the primary mechanism and structure are accurate, the clinician should be able to predict how the referred symptoms should change (increase or decrease) with alterations in position, load, and tension through the structure. ...
Article
Background There is considerable overlap between pain referral patterns from the lumbar disc, lumbar facets, the sacroiliac joint (SIJ), and the hip. Additionally, sciatic like symptoms may originate from the lumbar spine or secondary to extra-spinal sources such as deep gluteal syndrome (GPS). Given that there are several overlapping potential anatomic sources of symptoms that may be synchronous in patients that have low back pain (LBP), it may not be realistic that a linear deductive approach can be used to establish a diagnosis and direct treatment in this group of patients. Objective The objective of this theoretical clinical reasoning model is to provide a framework to help clinicians integrate linear and non-linear clinical reasoning approaches to minimize clinical reasoning errors related to logically fallacious thinking and cognitive biases. Methods This masterclass proposes a hypothesis-driven and probabilistic approach that uses clinical reasoning for managing LBP that seeks to eliminate the challenges related to using any single diagnostic paradigm. Conclusions This model integrates the why (mechanism of primary symptoms), where (location of the primary driver of symptoms), and how (impact of mechanical input and how it may or may not modulate the patient's primary complaint). The integration of these components individually, in serial, or simultaneously may help to develop clinical reasoning through reflection on and in action. A better understanding of what these concepts are and how they are related through the proposed model may help to improve the clinical conversation, academic application of clinical reasoning, and clinical outcomes.
... 32 Hence, this domain relates to the nociception arising from dysfunction from the nervous system itself. 29,33,34 These NSDs may take place at the peripheral, spinal, and even supra-spinal levels of the nervous system. 35 This domain is composed of "peripheral or central sources of NSD" (category A) and Table 1 Nociceptive pain drivers ...
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In the past, rehabilitation research initiatives for low back pain (LBP) have targeted outcome enhancement through personalized treatment approaches, namely through classification systems (CS). Although the use of CS has enhanced outcomes, common management practices have not changed, the prevalence of LBP is still high, and only selected patients meet the CS profile, namely those with a nociceptive context. Similarly, although practice guidelines propose some level of organization and occasionally a timeline of care provision, each mainly provides best practice for isolated treatment approaches. Moreover, there is no theoretical framework that has been proposed that guides the rehabilitation management process of mechanical LBP. In this commentary, we propose a model constituted of five domains (nociceptive drivers, nervous system dysfunction drivers, comorbidities drivers, cognitive–emotional drivers, and contextual drivers) grounded as mechanisms driving pain and/or disability in LBP. Each domain is linked to the International Classification of Functioning, Disability and Health, where once a patient is deemed suitable for rehabilitation, the clinician assesses elements of each domain in order to identify where the relative treatment efforts should be focused. This theoretical model is designed to provide a more comprehensive management overview, by appreciating the relative contribution of each domain driving pain and disability. Considering that the multiple domains driving pain and disability, and their interaction, requires a model that is comprehensive enough to identify and address each related issue, we consider that the proposed model has several positive implications for rehabilitation of this painful and highly prevalent musculoskeletal disorder.
... Several instruments have been proposed. 65,66,[74][75][76][77][78] These assessments require further validation and development toward a clinical tool. ...
Article
Synopsis: Motor control exercise has been shown to be effective in the management of low back pain (LBP). However, the effect sizes for motor control exercise are modest, possibly because studies have used a one-size-fits-all approach, while the literature suggests that patients may differ in presence or type of motor control issues. In this commentary, we address the question of whether consideration of such variation in motor control issues might contribute to more personalized motor control exercise for patients with LBP. Such an approach is plausible, because motor control changes may play a role in persistence of pain through effects on tissue loading that may cause nociceptive afference, particularly in the case of peripheral sensitization. Subgrouping systems used in clinical practice, which comprise motor control aspects, allow reliable classification that is, in part, aligned with findings in studies on motor control in patients with LBP. Motor control issues may have heuristic value for treatment allocation, as the different presentations observed suggest different targets for motor control exercise, but this remains to be proven. Finally, clinical assessment of patients with LBP should take into account more aspects than motor control alone, including pain mechanisms, musculoskeletal health, and psychosocial factors, and may need to be embedded in a stratification approach based on prognosis to avoid undue diagnostic procedures. J Orthop Sports Phys Ther 2019;49(6):380-388. Epub 12 Jun 2018. doi:10.2519/jospt.2019.7916.
... In recent studies, people with CLBP are classified in three different subgroups owing to the nature of pain: nociceptive, neuropathic or "central sensitization" [80][81][82][94][95][96][97][98]. Please refer to the clinical guideline proposed by Nijs et al. (2015) for additional details about this classification [80]. ...
Article
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Chronic low back pain (CLBP) is a recurrent debilitating condition that costs billions to society. Refractoriness to conventional treatment, lack of improvement, and associated movement disorders could be related to the extensive brain plasticity present in this condition, especially in the sensorimotor cortices. This narrative review on corticomotor plasticity in CLBP will try to delineate how interventions such as training and neuromodulation can improve the condition. The review recommends subgrouping classification in CLBP owing to brain plasticity markers with a view of better understanding and treating this complex condition.
... Nociceptive pain is primarily localized and clearly related to aggravating and easing factors but not typically associated with dysesthesia, night pain, antalgic postures, or an electric-like quality (Smart, Blake, Staines, and Doody, 2011; Smart et al., 2012c). Peripheral neuropathic pain is primarily dermatomal, associated with nerve pathology, and provoked with movement testing (Smart et al., 2012b). Central pain is primarily nonmechanical, diffuse, unpredictable in response to aggravating/easing factors, disproportionate to pathology, strongly associated with psychological factors, and associated with pain hypersensitivity (Smart et al., 2012a). ...
Article
Patients with cervical radiculopathy (CR) may present with accompanying symptoms of hyperalgesia, allodynia, heaviness in the arm, and non-segmental pain that do not appear to be related to a peripheral spinal nerve. These findings may suggest the presence of central or autonomic nervous system involvement, requiring a modified management approach. The purpose of this case report is to describe the treatment of a patient with signs of CR and upper extremity (UE) hyperalgesia who had a significant decrease in her UE pain and hypersensitivity after a single thoracic spine manipulation (TSM). A 48-year-old female presented to physical therapy with acute neck pain radiating into her left UE that significantly limited her ability to sleep and work. After a single TSM, the patient demonstrated immediate and lasting reduction in hyperalgesia, hypersensitivity to touch, elimination of perceived heaviness and coldness in her left UE, and improved strength in the C6-8 myotome, allowing for improved functional activity capacity and tolerance to a multi-modal PT program. Based on these results, clinicians should consider the early application of TSM in patients with CR who have atypical, widespread, or severe neurological symptoms that limit early mobilization and tolerance to treatment at the painful region.
... Nociceptive pain is pain that is caused by tissue damage and it is usually described as a sharp, aching, or throbbing pain that is proportional to the nociceptive input. 1 Neuropathic pain is defined as pain caused by damage or disease affecting the somatosensory nervous system. 2 Central sensitization is a condition of the nervous system whereby there is an increased neuronal response to stimuli associated with the development and maintenance of chronic pain and reduced pain modulation. 3 There is a significant overlap between these three concepts and specific classification of any pain must be carried out according to the predominant type of pain presented. ...
Article
Recently, more and more studies have found that pain generation, transmission and modulation are under hormonal regulation. Indeed, hormonal dysregulation is a common component of chronic pain syndromes. Studies have attempted to determine whether the relationship between the pain and its perception and hormones is a causative relationship and how these processes interrelate. This review summarizes and analyzes the current experimental data and provides an overview of the studies addressing these questions. The relationship between pain perception and endocrine effects suggests that hormones can be used as important biomarkers of chronic pain syndromes and/or be developed into therapeutic agents in the fight against pain.
... The neuropathy hypothesis, in contrast, holds that leg pain is a consequence of ectopic impulse discharge (ectopia) generated paraspinally in compressed or irritated ventral ramus afferents that is, in sensory axons of the spinal nerves and roots that innervate the leg, and/or in their cell bodies in the corresponding dorsal root ganglia. Thus, NP in sciatica may be caused by mechanical compression of the nerve root (mechanical neuropathic root pain), or by action of inflammatory mediators (inflammatory neuropathic root pain) originating from the degenerative disc even without any mechanical compression [8,9]. To this hypothesis, sciatica pain may have 2 causes: neuropathic ectopia in injured dorsal ramus afferents or sensitized nociceptor endings in deep back tissues. ...
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Aim: To assess the prevalence of neuropathic pain (NP) in patients with sciatica and to determine the associated factors with increased incidence of neuropathic component in sciatica. Methods: A cross-sectional study enrolled 80 patients with sciatica from a rheumatology outpatient Hospital. Pain severity was measured using the Visual Analogue Scale (VAS). The prevalence of NP was assessed according to the Douleur Neuropathique 4 (DN4). Statistical analysis was performed to find the factors closely related with NP. Results: A total of 70% of the participants were classified as having NP. The DN4 score≥4 was not significantly correlated with VAS, but was significantly associated with gender (sex ratio=0.9; p=0,013), low educational level (p=0,008), illiteracy (p=0,012), chronic disease (p=0,019) and facet joint osteoarthritis (p=0,06). In multivariate logistic regression analysis, only chronicity of the disease remained an independent factor associated with NP in sciatica (OR=5,8). Conclusion: In the present study, NP was a major contributor to sciatica and the DN4 scale was a practical and rapidly administered screening tool for distinguishing the relative contributions of neuropathic component. The knowledge of the associated factors with NP in sciatica may improve the management of NP when these factors can be modified and targeted for treatment.
... The present study showed the LBP patients with neuropathic pain had worse disability scores. Comparable to this finding, in previous studies (9,19), it was showed that the patients who had neuropathic pain had higher-level disability score. Additionally, some previous studies (7,10,20) revealed that the patients with neuropathic pain exploit health resources more than those without neuropathic pain. ...
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Objective:Low back pain (LBP) is the most common chronic pain disorder worldwide. Chronic LBP is a mixed pain syndrome associated with nociceptive and neuropathic pain mechanisms. Investigation and early treatment of neuropathic pain is important in the management of chronic LBP. The aim of this study is to investigate the frequency of neuropathic pain and determine its impact on health-related quality of life and disability in patients with chronic LBP.Materials and Methods:A total of 120 patients with chronic LBP participated in the study. The presence of neuropathic pain was assessed using Leeds Assessment of Neuropathic Symptoms and Signs pain scale. 10-cm visual analogue scale (VAS) pain score, Oswestry Disability index (ODI) and short form-36 (SF-36) measurements were performed. Predictors for the presence of neuropathic pain were also investigated.Results:Neuropathic pain was detected in 49 (40.8%) of the patients with chronic LBP. ODI score and VAS pain score in patients with neuropathic pain were higher than that in those without neuropathic pain (p
... Amended from the available literature. 15,25,54---56 b Amended from Smart et al.17,41,42,57,58Criteria are displayed per category as identified in the Delphi-study of Smart et al.17NOC Indicates the 7 criteria that were retained in the final predictive model for nociceptive pain. 41,57 PNP Indicates the 3 criteria that were retained in the final predictive model for peripheral neuropathic pain. ...
Article
Objective: To examine the interrater reliability and agreement of a pain mechanisms-based classification for patients with nonspecific neck pain (NSNP). Methods: Design - Observational, cross-sectional reliability study with a simultaneous examiner design. Setting: University hospital-based outpatient physical therapy clinic. Participants: A random sample of 48 patients, aged between 18 and 75 years old, with a primary complaint of neck pain was included. Interventions: Subjects underwent a standardized subjective and clinical examination, performed by 1 experienced physical therapist. Two assessors independently classified the participants' NSNP on 3 main outcome measures. Main outcome measures: The Cohen kappa, percent agreement, and 95% confidence intervals (CIs) were calculated to determine the interrater reliability for (1) the predominant pain mechanism; (2) the predominant pain pattern; and (3) the predominant dysfunction pattern (DP). Results: There was almost perfect agreement between the 2 physical therapists' judgements on the predominant pain mechanism, kappa=.84 (95% CI, .65-1.00), p<.001. There was substantial agreement between the raters' judgements on the predominant pain pattern and predominant DP with respectively kappa=.61 (95% CI, .42-.80); and kappa=.62 (95% CI, .44-.79), p<.001. Conclusion(s): The proposed classification exhibits substantial to almost perfect interrater reliability. Further validity testing in larger neck pain populations is required before the information is used in clinical settings. Clinical trial registration number: NCT03147508 (https://clinicaltrials.gov/ct2/show/NCT03147508).
... To this extent, the traditional healers' knowledge and/or understanding of LBP appears to be aligned with its western understanding. However, we also noted that the traditional healers' understanding tended towards the non-use of the classification system that is used by medical practitioners in reference to categorising pain according to its nature (sharp, aching, burning, pins and needles, numbness or tingling, mild, moderate and severe, etc.) and duration (acute, sub-acute and chronic) (Smart, Blake, Staines, Thacker & Doody, 2012). Furthermore, the interpretation and evaluation of some of these symptoms, which may be seen as wholly 'physical' from a western perspective, are either viewed from an entirely 'spiritual' perspective or some 'spiritual' aspect is ascribed to them (e.g. ...
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he treatments, assessment and management strategies related to low back pain (LBP) developed for the western world may have limited relevance for traditional healing. This study explored the management of LBP symptoms by traditional healers at the Warwick Muthi Market in Durban. Using a qualitative method, semi-structured interviews were conducted with ten traditional healers. The gender of participants was equally distributed with the sample comprising 5 males and 5 females. The study found that traditional healers understand LBP in terms of the physical symptoms that a person may present. Traditional belief in LBP takes into account the cultural and biopsychosocial aspects of pain. Traditional healers reported various causes of LBP including ilumbo (a sexually transmitted disease, particularly affecting the youth, mainly males. It is characterised by penile sores, discharge, low sex drive and marked inguinal lymphadenopathy and is difficult to treat), umeqo (a form of witchcraft in which sickness is believed to be caused by walking or stepping over a traditional medicine), ancestors/culture, kidney disease and ageing. In addition, they tended to personalise the causes of LBP and the reason for becoming ill was often sought in the supernatural realm with the only remedy for such diseases being traditional treatment. The traditional healers described various treatments or management strategies for LBP, including plant remedies and certain animal extracts (animal fats). Other substances as well as specific rituals and traditional techniques and methods were also mentioned. These included making incisions in the painful areas (ukugcaba) and bowel cleansing (ukuchatha). Various plants and herbs commonly used for LBP symptoms were mentioned, such as roots and bark which may have certain healing properties and play a role in the treatment of LBP. The study concluded that traditional healers understand LBP in terms of its biopsychosocial nature, while their management and treatment of LBP focus holistically on this complex pain disorder.
... Zusammenfassend wirkt sich der neuropathische Schmerz für das Individuum oft in einem hohen Maß an Einschränkungen sowie einer deutlichen Reduktion der Lebensqualität aus [27,45,63]. Physiotherapeuten befassen sich sowohl aus klinischer als auch aus wissenschaftlicher Sicht mit diesem komplexen klinischen Bild [34,44,59]. Dabei zeigt sich, dass einerseits die Untersuchung und Testung und andererseits die Behandlung und das Management nicht nur die Betroffenen vor Herausforderungen stellt, sondern auch die jeweiligen Behandler. ...
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Zusammenfassung Hintergrund Neuropathische Schmerzsyndrome zeichnen sich durch hohe Chronifizierungsraten sowie lange und intensive Schmerzepisoden aus. Ein treffsicheres Erkennen stellt eine Grundkompetenz von Physiotherapeuten dar, ermöglicht eine ursachengerechte Therapie und kann die Entstehung von Folgeschäden verhindern. Die quantitative sensorische Testung (QST) wird im medizinischen Rahmen als Ergänzung zur klinischen Sensibilitätsprüfung eingesetzt, konnte inzwischen eine beachtliche Stellung in der Forschung einnehmen, wird in der klinischen Praxis jedoch weniger häufig eingesetzt. Fragestellung Welchen Mehrwert hat die QST in der Untersuchung neuropathischer Schmerzen? Was sind die Ursachen für die begrenzte klinische Anwendung der QST? Was sind potenzielle Wege für einen erfolgreichen Übertrag der QST in die physiotherapeutische Praxis? Methode Literaturrecherche im Zuge einer Bachelorarbeit Physiotherapie. Ergebnisse Als valides Untersuchungsinstrument, das zur Evaluierung des gesamten somatosensorischen Profils geeignet ist, bietet die QST vor allem im Bereich der Small-fibre-Neuropathien einen erheblichen Vorteil gegenüber konventionellen Testverfahren. Diese kleinen Fasern scheinen insbesondere in der Frühphase von Neuropathien betroffen zu sein und können über konventionelle Testverfahren nicht evaluiert werden. Das macht den Einsatz von Teilaspekten der QST zu einem nützlichen Instrument für Physiotherapeuten und medizinisches Personal, was besonders in der Früherkennung von Neuropathien von großem Nutzen ist. Diskussion Trotz des bestehenden großen Nutzens existieren bis dato noch Limitationen, die den klinischen Routineeinsatz der QST behindern. Einige davon können durch exakte Testausführungen und Vorkehrungen bis zu einem gewissen Grad überwunden werden, andere, für die Klinik hochrelevante Bereiche wie die hohen Anschaffungskosten der Geräte und der hohe zeitliche Aufwand der Durchführung konnten bislang noch nicht zufriedenstellend gelöst werden. Weniger umfassende Testprotokolle sowie die Entwicklung handlicher und kostengünstiger Testgeräte könnten diesbezüglich erste Lösungsansätze darstellen. Die Ergänzung der konventionellen Bedside-Untersuchung um Testungen zur Wärmesensibilität und Schmerzschwellenbestimmung kann eine weitere Möglichkeit darstellen, um den dargestellten Mehrwert der QST in den klinischen Alltag zu integrieren. Schlussfolgerung Die QST steuert einen wesentlichen Beitrag zur Untersuchung und Diagnose von Neuropathien bei. Physiotherapeuten sind dazu angehalten, Teilaspekte aus der QST in eine standardmäßige Untersuchung zu implementieren, um sowohl in der Früherkennung als auch in der Behandlung positiv einzuwirken.
... These include pain referred in a dermatomal or cutaneous distribution; history of nerve injury, pathology, or mechanical compromise; and pain or symptom provocation with mechanical or movement tests such as neurodynamic tests that move, load, or compress neural tissue. 60 Treatment of peripheral neuropathic pain consists primarily of the application of neurodynamic mobilization both in the form of therapist generated mobilizations as discussed in the previous section on manual therapy and through patient performance of neurodynamic exercises. These exercises are described in more detail in Chapter 102. ...
... [15][16][17] It has been broadly discussed that identification of mechanism and subsequent classification of patients to a pain mechanism category (PMC) may be based on the characteristics of their presentation. [18][19][20][21] On this basis, many different groupings have been proposed with a diversity of terminology and proposed features. 11,15,18 The expansive research on this issue has resulted in considerable confusion. ...
Article
Objectives: Improvements in pain management might be achieved by matching treatment to underlying mechanisms for pain persistence. Many authors argue for a mechanism-based classification of pain, but the field is challenged by wide variation in proposed terminology, definitions and typical characteristics. This study aimed to: (i) systematically review mechanism-based classifications of pain experienced in the musculoskeletal system; (ii) synthesise and thematically analyse classifications, using the International Association for the Study of Pain categories of nociceptive, neuropathic and nociplastic as an initial foundation; and (iii) identify convergence and divergence between categories, terminology, and descriptions of each mechanism-based pain classification. Methods: Databases were searched for papers that discussed a mechanism-based classification of pain experienced in the musculoskeletal system. Terminology, definitions, underlying neurobiology/pathophysiology, aggravating/easing factors/response to treatment, and pain characteristics were extracted and synthesised based on thematic analysis. Results: From 224 papers, 174 terms referred to pain mechanisms categories. Data synthesis agreed with broad classification based on ongoing nociceptive input, neuropathic mechanisms, and nociplastic mechanisms (e.g. central sensitisation). “Mixed”, “other”, and the disputed categories of “sympathetic” and “psychogenic” pain, were also identified. Thematic analysis revealed convergence and divergence of opinion regarding definitions, underlying neurobiology and characteristics. Discussion: Some pain categories were defined consistently, and despite the extensive efforts to develop global consensus on pain definitions, disagreement still exists regarding how each could be defined, subdivided and their characteristic features that could aid differentiation. These data form a foundation for reaching consensus on classification.
Article
Summary Objective: The mechanisms underlying the effects of neurodynamic techniques are still unknown. Therefore, the aim of this study was to provide a starting point for future research on explaining why neurodynamic techniques affect muscular activities in patients with sciatic pain. Methods: A double-blind trial was conducted in 12 patients with lumbosciatica. Surface elec- tromyography activity was assessed for different muscles during prone hip extension. Pre- and post-intervention values for muscle activity onset and maximal amplitude signals were deter- mined. Results: There was a significant reduction in the surface electromyography activity of maximal amplitude in the erector spinae and contralateral erector spinae (p < 0.05). Additionally, gluteus maximus (p < 0.05) activity onset was delayed post-intervention. Conclusions: Self-neurodynamic sliding techniques modify muscular activity and onset during prone hip extension, possibly reducing unnecessary adaptations for protecting injured compo- nents. Future work will analyze the effects of self-neurodynamic sliding techniques during other physical tasks.
Article
Background Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed. Objective The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making. Design This was an exploratory interview study using inductive content analysis. Method Fifteen semi-structured individual interviews were used to collect data of physiotherapists’ treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. Findings Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity). Conclusion This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.
Article
Background: Explaining pain to patients through pain neuroscience education (PNE) is currently a widespread treatment studied in the musculoskeletal context. Presently, there is sufficient evidence supporting the effectiveness of PNE in patients with chronic musculoskeletal disorders. However, clinicians must pay attention to the actual possibility to transfer research findings in their specific clinical context. Objective: We analysed the applicability of results of studies focused on PNE, which has not been done previously. Methods: A detailed discussion on PNE applicability is provided, starting from published randomized controlled trials that investigated the effectiveness of PNE. Results: This paper markedly points out the awareness of clinicians on the need for an accurate contextualization when choosing PNE as an intervention in clinical practice.
Article
Background: Nonspecific neck pain patients form a heterogeneous group with different musculoskeletal impairments. Classifying nonspecific neck pain patients into subgroups based on clinical characteristics might lead to more comprehensive diagnoses and can guide effective management. Objective: To establish consensus among a group of experts regarding the clinical criteria suggestive of a clinical dominance of 'articular', 'myofascial', 'neural', 'central' and 'sensorimotor control' dysfunction patterns distinguishable in patients with nonspecific neck pain. Study design: Delphi study. Methods: A focus group with 10 academic experts was organized to elaborate on the different dysfunction patterns discernible in neck pain patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 distinct dysfunction patterns resulting from the focus group. Results: A total of 21 musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating neck pain patients completed the 3-round Delphi-survey. Respectively, 33 (response rate, 100.0%), 27 (81.8%) and 21 (63.6%) respondents replied to rounds 1, 2 and 3. Eighteen 'articular', 16 'myofascial', 20 'neural', 18 'central' and 10 'sensorimotor control' clinical indicators reached a predefined ≥80% consensus level. Conclusion: These indicators suggestive of a clinical dominance of 'articular', 'myofascial', 'neural', 'central', and 'sensorimotor control' dysfunction patterns may help clinicians to assess and diagnose patients with nonspecific neck pain. Future validity testing is needed to determine how these criteria may help to improve the outcome of physical therapy interventions in nonspecific neck pain patients.
Article
Introduction This study aimed to elucidate low-back pain (LBP) characteristics, i.e., its qualities, extent, and location, in patients with early-stage spondylolysis (ESS). Methods We recruited patients (≤18 years old) who presented with acute LBP lasting up to 1 month. Patients were divided into ESS and nonspecific LBP (NS-LBP) groups based on their magnetic resonance imaging findings; patients showing no pathological findings that might explain the cause of LBP were classified as NS-LBP. All patients were evaluated using the following tests: hyperextension and hyperflexion (pain provocation tests in a standing position), pain quality (sharp/dull), pain extent (fingertip-sized area/palm-sized area), and pain location (left and/or right pain in side [side]/central pain [center]). We have also compared outcomes between the ESS and NS-LBP groups in terms of gender and physical symptoms. Results Of 101 patients, 53 were determined to have ESS (ESS group: mean age: 14.3 years old; 43 males/10 females), whereas 48 had no pathological findings explaining the LBP origin [NS-LBP group (mean age, 14.4 years old; 31 males/17 females) ]. Chi-squared test has identified gender (male), a negative result on hyperflexion test, pain extent (fingertip-sized area), and pain location (side) to be significantly associated with ESS. Among these, regression analysis revealed that male gender and LBP located on the side were significantly associated with ESS (p < 0.05). Conclusions Although the hyperextension test is generally considered useful for ESS, we demonstrated that its association is not deemed significant. Our results indicate that male gender, a negative result of the hyperflexion test, fingertip-sized pain area, and LBP on the side may be specific characteristics of ESS. Of these physical signs, male gender and LBP located on the side are characteristic factors suggesting ESS presence.
Article
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Playing music is a complex task that requires advanced and exceptional skills. The nature of this wonderful artistic activity makes musicians to be at higher risk of developing musculoskeletal problems. Pain is usually the most common symptom that musicians report when seeking medical help. Patients with persistent pain conditions have been reported to show cortical reorganization in the somatosensory cortex. We assessed Motor Imagery performance (MIP), painDETECT questionnaire and two-point discrimination (TPD) in musicians and non-musicians. There were no differences regarding MIP between both groups. Musicians had significantly higher painDETECT scores compared to non-musicians. Musicians had reduced tactile acuity compared non-musicians. We conclude that the differences in tactile acuity (TPD) in musicians may be related to peripheral or spinal cord mechanisms.
Article
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chronic musculoskeletal pain is a highly prevalent condition that is commonly encountered in both general and special- ist practice. Nonetheless, it still represents a significant challenge to the practitioners because of the lack of substantial evidence-based guidance. this review aimed to summarize the main pathophysiological mechanisms of chronic pain of- fering a mechanism-oriented approach to diagnosis and management. We believe that a basic knowledge of the physical signs and symptoms of these mechanisms could empower the clinician to choose appropriate medication and identify high-risk pain patients. Central sensitization and neuropathic features may arise in previously nociceptive and inflamma- tory pain syndromes. central sensitization is a functional remodeling of the spinal cord, where light touch afferents are recruited by nociceptive second-order neurons. Neuropathic features include both negative signs, such as reduced percep- tion of vibration and touch, and positive symptoms, such as paroxysmal electric shock pain, due to ectopic discharge. These phenomena are the neurobiological basis of the commonly defined refractory chronic pain. early detection and specific treatment of these mechanisms are required in order to restrain the reinforcement of pronociceptive remodeling of the nervous system.
Article
Background: The Czech Manual Physiotherapeutic Correction (MFK) Method® was introduced to Swedish physiotherapists. This study evaluated the inter-tester reliability of the manual muscle testing procedure included in the method. The feasibility of the MFK Method®, when used in Sweden, was also investigated. Methods: Two Czech physiotherapists, experienced in the MFK Method®, rated performance of the 41 tests included in the manual muscle testing procedure for 20 participants. Cohen’s kappa statistics were performed to evaluate agreement between the raters. When investigating the feasibility of the method, two Swedish physiotherapists used the MFK Method® in the rehabilitation of 10 patients. Results: Kappa values varied from −0.06 to 0.84. After adjusting for prevalence of failed tests, 15 of the 41 muscle tests demonstrated values of >0.40. When using the MFK Method® in Sweden, several practical obstacles were found. Conclusion: Most of the tests showed low inter-tester reliability. The testing procedure needs to be further standardized and the practical issues solved before the feasibility of the method, when used in Sweden and/or other countries, can be investigated again.
Chapter
Chronische pijnpatiënten vormen een heterogene populatie. Het mag duidelijk zijn dat niet alle chronische pijnpatiënten per definitie een klinisch beeld hebben dat gedomineerd wordt door centrale sensitisatie. Bij medische diagnosen zoals whiplash, fibromyalgie, prikkelbaredarmsyndroom en het chronischevermoeidheidssyndroom, vertonen patiënten typisch dominante centrale sensitisatiepijn. Bij atraumatische chronische nekpijn is er echter weinig tot geen bewijs voor de aanwezigheid van centrale sensitisatie. Patiënten met artrose, tenniselleboog, schouderpijn en lage rugpijn zijn groepen pijnpatiënten waarvan de minderheid een klinisch beeld vertoont dat gedomineerd wordt door centrale sensitisatie. Daarom is goede differentiaaldiagnostiek noodzakelijk. In dit hoofdstuk reiken we de clinicus praktijkrichtlijnen aan voor de differentiaaldiagnostiek tussen de drie grote pijntypen: dominant nociceptieve, neuropathische en centrale sensitisatiepijn. De klinische werkmethode voor de differentiaaldiagnostiek tussen dominant nociceptieve, neuropathische en centrale sensitisatiepijn bestaat uit twee stappen:1. de diagnostiek of uitsluiting van de aanwezigheid van dominant neuropathische pijn; 2. de differentiaaldiagnostiek tussen dominant nociceptieve en centrale sensitisatiepijn. Stap 2 omvat het screenen van drie criteria aan de hand van een beslisboom. In het laatste deel van het hoofdstuk worden deze criteria toegepast op en gespecificeerd voor (1) de lage rugpijnpopulatie en (2) pijn bij/na kanker.
Article
Context: While as many as 60% of patients with spinal cord injury (SCI) develop chronic pain, limited data currently exists on the prevalence and profile of pain post-SCI in community dwelling populations. Study Design: A cross-sectional population survey. Setting: Primary care. Participants: Community dwelling adults with SCI. Methods: Following ethical approval members registered to a national SCI database (n=1,574) were surveyed. The survey included demographic and SCI characteristics items, the International Spinal Cord Injury Pain Basic Data Set (version 1) the Douleur Neuropathique 4 questionnaire (interview) and questions relating to health care utilisation. Data were entered into the Statistical Package for the Social Sciences (version 20) Significance was set P < 0.05 for between group comparisons. Results: In total 643 (41%) surveys were returned with 458 (71%) respondents experiencing pain in the previous week. Neuropathic pain (NP) was indicated in 236 (37%) of responses and nociceptive pain in 206 (32%) Common treatments for pain included medications n=347 (76%) massage n=133 (29%) and heat n=115 (25%). Respondents with NP reported higher pain intensities and increased healthcare service utilisation (P= < 0.001) when compared to those with nociceptive pain presentations. A higher proportion of females than males reported pain (P = 0.003) and NP (P = 0.001) and those unemployed presented with greater NP profiles compared with those in education or employment (P = 0.006). Conclusion: Pain, in particular NP post SCI interferes with daily life, increases health service utilisation and remains refractory to current management strategies. Increased availability of multi-disciplinary pain management and further research into management strategies is warranted.
Chapter
The aim of this chapter is to provide an overview of the most common, evidence-based techniques and approaches used by physical therapists to evaluate and treat patients with pain. The first section on evaluation includes examination techniques, prognosis, and patient diagnosis/classification. The second section on treatment presents management strategies linked to a pain mechanism classification scheme of nociceptive, neuropathic, or nociplastic pain. Specific recommendations from clinical practice guidelines are included for the physical therapy management of spinal pain, lower extremity osteoarthritis, radiculopathy, carpal tunnel syndrome, fibromyalgia, and complex regional pain syndrome, type I.
Article
Background: Acupuncture appears to reduce the mechanosensitivity of peripheral nerves in animal models; yet, this possibility has not been demonstrated in humans. Objectives: The main objective of this exploratory trial was to evaluate the immediate effects of acupuncture on the mechanosensitivity of the median nerve, measured by the elbow extension range-of-motion (EE–ROM) at pain onset and maximum tolerance during the upper limb neurodynamic test 1 (ULNT1). Additional objectives were to test the effects of two different points in ULNT1 responses and critically appraise pre-/post-intervention changes for conducting future research. Methods: Thirty-one asymptomatic individuals, randomly assigned to the PC group (n=14) or the LU group (n=17) by the coin ip procedure, underwent acupuncture (leopard spot needling) in PC5 or LU5’’, respectively. Two mixed-model analysis of variance (ANOVA) with time (pre-intervention vs post-intervention) as the within-subject factor and group (PC vs LU) as the between-subject factor, plus time×group interaction, were used to determine the effects of acupuncture therapy on EE–ROM at pain onset and maximum tolerance during ULNT1. Results: At baseline measurements there were no differences between groups (p>0.05). After acupuncture, mean EE–ROM increased 3.1° at pain onset (p=0.029, η2p =0.154) and 5.6° at maximum tolerance (p=0.002, η2p =0.277) with no differences between groups (p>0.05, η2p<0.01). Conclusion: Immediately after acupuncture, the mechanosensitivity of the median nerve appears to be reduced as observed by an increase in EE–ROM during the ULNT1. Further studies are needed to con rm these preliminary ndings.
Article
Background: Nonspecific low back pain (NSLBP) is a common problem. Attempts have been made to classify NSLBP patients into homogenous subgroups. Classification systems based on identifying the underlying mechanism(s) driving the disorder are clinically useful to guide specific interventions. Objective: To establish consensus among experts regarding clinical criteria suggestive of a dominance of 'articular', 'myofascial', 'neural', 'central', and 'sensorimotor control' dysfunction patterns (DPs) in NSLBP patients. Study design: A 2-phase sequential design of a focus group and Delphi-study. Methods: A focus group with 10 academic experts was organized to elaborate on the different DPs discernible in LBP patients. Consecutively, a 3-round online Delphi-survey was designed to obtain consensual symptoms and physical examination findings for the 5 DPs resulting from the focus group. Results: Fifteen musculoskeletal physical therapists from Belgium and the Netherlands experienced in assessing and treating LBP patients completed the Delphi-survey. Respectively, 34 (response rate, 100.0%), 20 (58.8%) and 15 (44.12%) respondents replied to rounds 1, 2 and 3. Twenty-two 'articular', 20 'myofascial', 21 'neural', 18 'central' and 11 'sensorimotor control' criteria reached a predefined ≥80% consensus level. For example, after round 2, 85.0% of the Delphi-experts agreed to identify 'referred pain below the knee' as a subjective examination criterion suggestive for a predominant 'neural DP'. Conclusion: These indicators suggestive of a clinical dominance of the proposed DPs could help clinicians to assess and diagnose NSLBP patients. Future reliability and validity testing is needed to determine how these criteria may help to improve physical therapy outcome for NSLBP patients.
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Introduction Neuropathic low back-related leg pain (LBLP) can be a challenge to healthcare providers to diagnose and treat. Accurate diagnosis of neuropathic pain is fundamental to ensure appropriate intervention is given. However, to date there is no gold standard to diagnose neuropathic LBLP. A Delphi study will therefore be conducted to obtain an expert-derived consensus list of clinical indicators to identify a neuropathic component to LBLP. Methods/analysis Included participants will be considered experts within the field as measured against a predefined eligibility criterion. Through an iterative multistage process, participants will rate their agreement with a list of clinical indicators and suggest any missing clinical indicators during each round. Agreement will be measured using a 5-point Likert scale. Descriptive statistics will be used to measure agreement; median, IQR and percentage of agreement. A priori consensus criteria will be defined for each round. Data analysis at the end of round three will enable a list of clinical indicators to be derived. Ethics and dissemination Ethical approval was gained from the University of Birmingham (ERN_19-1142). On completion of the study, findings will be disseminated in a peer-reviewed journal and presented at relevant conferences.
Thesis
Objectives: The aims of this study were to measure changes in Range of Motion (ROM) using two mobilisation techniques (manual traction and antero-posterior (AP) glide) and to compare the magnitude of changes in cervical ROM with two techniques. Design: Pre- and post-interventional study with crossover design. Setting: The Rehabilitation Research Laboratory (SUPSI-2rLab) at the University of Applied Sciences and Arts of Southern Switzerland (SUPSI Manno Switzerland). Participants: Thirty-six healthy volunteers comprised of lecturers and administrative workers at the university were enrolled in the study. Results: Twelve active ROM measurements were taken for all participants (six directions, before and after using the two mobilisation techniques). All of the measurements taken after the mobilisations showed an increase compared to the baseline; however, in six of the 12 directions, the ROM showed a significant difference (p<0.05): right rotation, left rotation, right side flexion after manual traction and right rotation, left rotation and extension after AP Glide. Both the AP glide technique and manual traction proved to be effective in three directions; the comparison between the two techniques showed that there was no significant difference when the post-treatment Cervical Range of Motion (CROM) results were compared. Extension after AP glide showed the greatest increase in CROM, which supports the use of the technique as originally described. Conclusion: The present study showed that the two studied mobilisation techniques could immediately increase the CROM in healthy volunteers. In a clinical scenario, the AP glide is applied to gain CROM in extension; the study confirmed that the technique could increase the CROM in that direction. Further studies are needed to show the clinical applicability to neck pain in the patient population.
Article
Background: Abdominal aortic aneurysms (AAAs) are found in 1–12% of older males. Low back pain (LBP) is prevalent with incidence increasing with age and can respond to manual therapy (MT). To date, the safety of the application of MT for LBP in the presence of a known AAA has not been reported. This case reports on the short-term effects of MT in a patient with LBP and AAA and pre- and post-therapy imaging. Case Description: A 76-year-old male presented with mechanical LBP, groin pain, and a known 4.2-cm AAA. A lumbar magnetic resonance imaging showed significant multilevel abnormalities. Abdominal screening did not elicit back or groin pain. Lumbar and hip range of motion and accessory motion testing reproduced his complaints. He was treated with lumbar and hip MT. Outcomes: After three visits, he reported that his groin pain resolved, and his back pain could be managed with home exercise. He reported a +6 on the global rating of change. Repeated follow-up imaging of his AAA demonstrated no significant change of his AAA. Discussion: No immediate adverse events were recorded, and repeated follow-up imaging indicated no significant AAA expansion. Considering that mobilization causes similar displacement to active motion, research into the safety of MT in this population is warranted as are guidelines for appropriate initial and ongoing clinical screening during treatment in this population.
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Background: Neuropathic pain in early chronic low back pain is insufficiently recognized and treated. Aim: To establish if there is a difference among chronic low back pain subjects with and without neuropathic pain and healthy subjects, in clinical characteristic and the level of trunk muscle activation. Design: Cross sectional observational study. Setting: Rehabilitation Clinic, inpatient and outpatient. Population: 33 subjects in early chronic phase of low back pain and 26 healthy subjects were included in this research. Methods: . Clinical characteristics and relative thickness change of lumbar multifidus and transversal abdominal muscle, measured by ultrasound, in neuropathic, non-neuropathic chronic low back pain and healthy subjects were analyzed. Results: Chronic low back pain subjects with neuropathic pain reported higher level of pain on visual analog scale (back pain p=0.016, leg pain p=0.006), had higher Oswestry Disability Score (p=0.029), had lower motor (p=0.001) and sensory leg scores (p=0.000), and decreased level of activation of transversal abdominal muscle (p=0.000) comparing to chronic low back pain group without neuropathic pain. Low back pain subjects with leg pain >=5 on visual analog scale were 11.2 times more prone to develop neuropathic pain. Motor leg score = < 47 increases this chance 35 times. Sensory leg score = < 25 increases this chance 14 times. Reduced activation of transversal abdominal muscle for 40-50% increases this chance 7-24 times. Conclusions: Chronic low back pain subjects with neuropathic pain were more painful and disabled, had lower motor and sensory scores, and lower relative thickness change of transversal abdominal muscle comparing to the low back pain group without neuropathic pain. Self -reported leg pain intensity of 5 or more on visual analog scale, motor score of 47 and less, sensory scores of 25 and less and diminished activation of transversal abdominal muscle significantly increase the chance that chronic low back pain subject has neuropathic component of pain. Clinical rehabilitation impact: Neuropathic pain in early chronic low back pain subjects might be more readily recognized if patients with radiculopathy and diminished activation of transversal abdominal muscle were regularly screened for neuropathic pain.
Article
Background: Low back pain (LBP) is a very common pain problem in powerlifters. There is a lack of evidence to guide powerlifters and health-care professionals in understanding the role of powerlifting in the development of LBP and treatment of injuries in powerlifters. This study aimed to describe functional impairments and patho-anatomical findings in eight powerlifters with and without LBP. Methods: First, four powerlifters with LBP were recruited. Each powerlifter was then matched with a pain-free lifter (Control) by age, Body Mass Index and competition weight class. They all performed physical performance tests and were examined with magnetic resonance imaging. Four weeks prior to the examination the powerlifters also recorded training load. Powerlifters with LBP were also examined by a physiotherapist in order to define their pain and impairments. Results: The four male powerlifters with LBP had a nociceptive pain associated with non-ideal squatting technique, higher flexibility in their lumbar spine than in their hips and patho-anatomical findings such as degenerated discs (four), spondylolysis (one) and spinal stenosis (one). However, the controls also showed similar functional impairments and patho- anatomical findings. Conclusions: Powerlifters with and without LBP show similar functional impairments and patho-anatomical findings. However, powerlifters' LBP seems associated with pain during movement and loading of the lumbar spine. The association and causation between specific functional impairments, patho-anatomical findings and LBP in powerlifters has to be further investigated in studies including more participants.
Article
Background The passive straight leg raise (SLR) and crossed SLR are recommended tests for lumbar radicular pain. There are no recent reviews of test reliability. Objectives To summarize SLR and crossed SLR reliability in patients with suspected lumbar radicular pain. Design Systematic review with meta-analysis. Method MEDLINE and CINAHL were searched for studies published before April 2021 that reported SLR or crossed SLR reliability in patients with low back-related leg pain. Supplemental analyses also included patients with low back pain only. Study selection, risk of bias assessment (QAREL), and data extraction were performed in duplicate. Kappa, intraclass correlation coefficients, and smallest detectable difference (SDD95) quantified reliability. Meta-analysis was performed when appropriate. Confidence in the evidence was determined by applying GRADE principles. Results/findings Fifteen studies met selection criteria. One-hundred-eighty-nine participants had low back-related leg pain. Four-hundred-thirty-nine were included in supplemental analyses. Meta-analyses showed at least fair inter-rater reliability when a positive SLR required provocation of lower extremity symptoms or pain. SLR reliability was at least moderate when testing included structural differentiation (e.g., ankle dorsiflexion). A low prevalence of positive crossed SLR tests led to wide-ranging reliability estimates. Confidence in the evidence for identifying a positive SLR or crossed SLR was moderate to very low. SDD95 values for different raters measuring SLR range of motion ranged from 13 to 20°. Conclusions Reliability data support testing SLR with structural differentiation manoeuvres. Crossed SLR reliability data are inconclusive. Measurement error likely prohibits using SLR range of motion for clinical decision-making.
Article
Study Design Diagnostic accuracy study with non-consecutive enrollment. Objectives Assess diagnostic accuracy of the slump test for neuropathic pain (NeP) in those with low to moderate levels of chronic low back pain (LBP). Determine whether accuracy of the slump test improves by adding anatomical or qualitative pain descriptors. Background NeP has been linked with poor outcomes likely due to inadequate diagnosis which precludes treatment specific for NeP. Current diagnostic approaches are time consuming or lack accuracy. Methods A convenience sample of 21 individuals with LBP with or without radiating leg pain was recruited. A standardized neurosensory examination was used to determine the reference diagnosis for NeP. Afterwards, the slump test was administered to all participants. Reports of pain location and quality produced during the slump test were recorded. Results The neurosensory examination designated 11 of the 21 participants with LBP/sciatica as having NeP. The slump test displayed high sensitivity (0.91), moderate specificity (0.70), a positive likelihood ratio of 3.03, and a negative likelihood ratio of 0.13. Adding the criterion of pain below the knee significantly increased specificity to 1.00 (positive likelihood ratio = 11.9). Pain quality descriptors did not improve diagnostic accuracy. Conclusion The slump test was highly sensitive in identifying NeP within the study sample. Adding a pain location criterion improved specificity. Combining the diagnostic outcomes was very effective in identifying all those without NeP and half of those with NeP. Limitations arising from the small and narrow spectrum of participants with LBP/sciatica sampled within the study prevent application of the findings to a wider population. Level of Evidence Diagnosis, level 3b. J Orthop Sports Phys Ther, Epub 24 Jun 2015. doi:10.2519/jospt.2015.5414.
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CLINICAL SCENARIO You are back where we put you in the previous article1 on diagnostic tests in this series on how to use the medical literature: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans. Using the criteria in Table 1, you have decided that the Prospective Investigation of Pulmonary Diagnosis (PIOPED) study2 will provide you with valid information. Just then, another physician comes looking for an article to help with the interpretation of V/Q scanning. Her patient is a 28-year-old man whose acute onset of shortness of breath and vague chest pain began shortly after completing a 10-hour auto trip. He experienced several episodes of similar discomfort in the past, but none this severe, and is very apprehensive about his symptoms. After a normal physical examination, electrocardiogram and chest radiograph, and blood gas measurements that show a Pco2 of
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Study Design. A systematic review of the literature including statistical meta-analysis. Objectives. To evaluate published methods of the test of Lasègue or straight leg raising test and the cross straight leg raising test by using a recently developed criteria list and to summarize and explore reasons for variation in diagnostic accuracy. Summary of Background Data. Little evidence exists on the diagnostic accuracy of the widely used straight leg raising test and the cross straight leg raising test in diagnosing herniated discs in patients with low back pain. Methods. MEDLINE and EMBASE searches up to 1997 showed 17 diagnostic publications evaluating the straight leg raising test with surgery as reference standard. Quality of methods was assessed with a specific checklist. Eleven studies were selected for statistical pooling. Sources of variation and heterogeneity were studied by meta-regression of the diagnostic odds ratio. Results. All studies were surgical case-series at nonprimary care level. Verification-bias was obvious in one study. Pooled sensitivity for straight leg raising test was 0.91 (95% CI 0.82–0.94), pooled specificity 0.26 (95% CI 0.16–0.38). Pooled diagnostic odds ratio was 3.74 (95% CI 1.2–11.4). Discriminative power was lower in recent studies, in studies with only inclusion of primary hernias, and with blind assessment of both the index-test (straight leg raising test) and the reference (surgery). For the cross straight leg raising test pooled sensitivity was 0.29 (95% CI 0.24–0.34), pooled specificity was 0.88 (95% CI 0.86–0.90), and the pooled diagnostic odds ratio 4.39 (95% CI 0.74–25.9). Conclusions. The diagnostic accuracy of the straight leg raising test is limited by its low specificity. Discriminative power decreased with a more valid design, a more homogenous case-mix, and year of publication. Although the studies may reflect everyday clinical practice, they do not enable a valid evaluation of the diagnostic accuracy of both tests. Diagnostic research should evaluate the validity of the complete diagnostic process and study the evidence of the added value of the different tests used. Although approximately 70% of the adult population experiences low back pain once or more during their life, no specific pathology is identified in up to 85% of the patients. 9 Approximately 1.5% of low back pain patients endure symptoms of sciatica, and only approximately 2% undergo surgery. 9,10 Associations of herniated discs with signs and symptoms and even imaging results remain weak. 45,33 It must be realized that herniated discs can be found by imaging diagnostic tests in 20% to 30% of symptom-free persons. 5,44 Once systemic diseases are excluded as possible causes of low back pain, careful diagnostic neurologic evaluation remains important to avoid unnecessary surgical interventions. 11 The straight leg raising test (SLR), also known as the test of Lasègue, and the cross straight leg raising test (CSLR), are two tests based on stretching of the nerves in the spine. The SLR frequently is used in primary care for making decisions about diagnostic imaging or hospital referral. 19 A few recent reviews have discussed the value of history taking and physical examination for diagnosing herniated discs in patients with low back pain, but only two reviewed the available literature in a systematic manner. 3,11,18,41 Both of the latter two reviews were criteria-based, but only one offered a quantitative summary of the findings. 41 No review tried to study the variability of the diagnostic accuracy of the (C)SLR. The most recent review concluded that the test of Lasègue had a high sensitivity and a low specificity, but that it varied greatly across studies. 41 The present review was conducted as an update for the (C)SLR up to 1997 and to carefully reassess methodologic quality by using a recently developed criteria list. 18,22 It contains a more detailed analysis by summarizing the diagnostic accuracy quantitatively and exploring reasons for its variability in the diagnosis of herniated discs. 40 The methods of this diagnostic meta-analysis closely adhere to recently developed guidelines for conducting diagnostic reviews. 20,21,31,34
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The purpose of this article is to review the case for the inclusion of a mechanisms-based classification for musculoskeletal pain. In response to perceived limitations of the medical/disease model of pain and illness a mechanisms-based classification system for pain has been advocated. The classification of pain according to the underlying neurophysiological mechanisms responsible for its generation and/or maintenance may better explain the variability and complexities of clinical presentations of musculoskeletal pain and facilitate subsequent decision-making associated with the assessment, treatment and prognosis of patients with musculoskeletal disorders. However, current methods of mechanisms-based classification either lack standardised criteria or propose decision rules whose validity has yet to be substantiated empirically. While the case for a mechanisms-based classification for pain has been well made the onus rests with its advocates to (a) establish its validity for use in clinical practice in defined populations with musculoskeletal disorders, and (b) provide evidence that such a system facilitates improved clinical outcomes.
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Empirical evidence of discriminative validity is required to justify the use of mechanisms-based classifications of musculoskeletal pain in clinical practice. The purpose of this study was to evaluate the discriminative validity of mechanisms-based classifications of pain by identifying discriminatory clusters of clinical criteria predictive of "nociceptive," "peripheral neuropathic," and "central sensitization" pain in patients with low back (± leg) pain disorders. This study was a cross-sectional, between-patients design using the extreme-groups method. Four hundred sixty-four patients with low back (± leg) pain were assessed using a standardized assessment protocol. After each assessment, patients' pain was assigned a mechanisms-based classification. Clinicians then completed a clinical criteria checklist indicating the presence/absence of various clinical criteria. Multivariate analyses using binary logistic regression with Bayesian model averaging identified a discriminative cluster of 7, 3, and 4 symptoms and signs predictive of a dominance of "nociceptive," "peripheral neuropathic," and "central sensitization" pain, respectively. Each cluster was found to have high levels of classification accuracy (sensitivity, specificity, positive/negative predictive values, positive/negative likelihood ratios). By identifying a discriminatory cluster of symptoms and signs predictive of "nociceptive," "peripheral neuropathic," and "central" pain, this study provides some preliminary discriminative validity evidence for mechanisms-based classifications of musculoskeletal pain. Classification system validation requires the accumulation of validity evidence before their use in clinical practice can be recommended. Further studies are required to evaluate the construct and criterion validity of mechanisms-based classifications of musculoskeletal pain.
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Low-back pain with leg pain (sciatica) may be caused by a herniated intervertebral disc exerting pressure on the nerve root. Most patients will respond to conservative treatment, but in carefully selected patients, surgical discectomy may provide faster relief of symptoms. Primary care clinicians use patient history and physical examination to evaluate the likelihood of disc herniation and select patients for further imaging and possible surgery. (1) To assess the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica;(2) To assess the influence of sources of heterogeneity on diagnostic performance. We searched electronic databases for primary studies: PubMed (includes MEDLINE), EMBASE, and CINAHL, and (systematic) reviews: PubMed and Medion (all from earliest until 30 April 2008), and checked references of retrieved articles. We considered studies if they compared the results of tests performed during physical examination on patients with back pain with those of diagnostic imaging (MRI, CT, myelography) or findings at surgery. Two review authors assessed the quality of each publication with the QUADAS tool, and extracted details on patient and study design characteristics, index tests and reference standard, and the diagnostic two-by-two table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for all aspects of physical examination. Pooled estimates of sensitivity and specificity were computed for subsets of studies showing sufficient clinical and statistical homogeneity. We included 16 cohort studies (median N = 126, range 71 to 2504) and three case control studies (38 to100 cases). Only one study was carried out in a primary care population. When used in isolation, diagnostic performance of most physical tests (scoliosis, paresis or muscle weakness, muscle wasting, impaired reflexes, sensory deficits) was poor. Some tests (forward flexion, hyper-extension test, and slump test) performed slightly better, but the number of studies was small. In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings.Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35).Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations. When used in isolation, current evidence indicates poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.
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Neuropathic pain can be distressing and difficult to treat, and remains a problem for a significant proportion of palliative care patients. This article considers the identification and assessment of neuropathic pain, and highlights some of the challenges specific to the palliative care population. Further discussion includes definitions, pathophysiology and implications for nursing practice.
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It is commonly stated that nerve root pain should be expected to follow a specific dermatome and that this information is useful to make the diagnosis of radiculopathy. There is little evidence in the literature that confirms or denies this statement. The purpose of this study is to describe and discuss the diagnostic utility of the distribution of pain in patients with cervical and lumbar radicular pain. Pain drawings and descriptions were assessed in consecutive patients diagnosed with cervical or lumbar nerve root pain. These findings were compared with accepted dermatome maps to determine whether they tended to follow along the involved nerve root's dermatome. Two hundred twenty-six nerve roots in 169 patients were assessed. Overall, pain related to cervical nerve roots was non-dermatomal in over two-thirds (69.7%) of cases. In the lumbar spine, the pain was non-dermatomal in just under two-thirds (64.1%) of cases. The majority of nerve root levels involved non-dermatomal pain patterns except C4 (60.0% dermatomal) and S1 (64.9% dermatomal). The sensitivity (SE) and specificity (SP) for dermatomal pattern of pain are low for all nerve root levels with the exception of the C4 level (Se 0.60, Sp 0.72) and S1 level (Se 0.65, Sp 0.80), although in the case of the C4 level, the number of subjects was small (n = 5). In most cases nerve root pain should not be expected to follow along a specific dermatome, and a dermatomal distribution of pain is not a useful historical factor in the diagnosis of radicular pain. The possible exception to this is the S1 nerve root, in which the pain does commonly follow the S1 dermatome.
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Neuropathic pain is triggered by lesions to the somatosensory nervous system that alter its structure and function so that pain occurs spontaneously and responses to noxious and innocuous stimuli are pathologically amplified. The pain is an expression of maladaptive plasticity within the nociceptive system, a series of changes that constitute a neural disease state. Multiple alterations distributed widely across the nervous system contribute to complex pain phenotypes. These alterations include ectopic generation of action potentials, facilitation and disinhibition of synaptic transmission, loss of synaptic connectivity and formation of new synaptic circuits, and neuroimmune interactions. Although neural lesions are necessary, they are not sufficient to generate neuropathic pain; genetic polymorphisms, gender, and age all influence the risk of developing persistent pain. Treatment needs to move from merely suppressing symptoms to a disease-modifying strategy aimed at both preventing maladaptive plasticity and reducing intrinsic risk.
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Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology. Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%-97%) and specificity (97%; 95% CI 89%-100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs. We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.
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We conducted a systematic review of the literature from 1965-1994 to assess the value of history and physical examination in the diagnosis of sciatica due to disc herniation; we also included population characteristics and features of the study design affecting diagnostic value. Studies on the diagnostic value of history and physical examination in the diagnosis of sciatica due to disc herniation are subject to important biases, and information on numerous signs and symptoms is scarce or absent. Our search revealed 37 studies meeting the selection criteria; these were systematically and independently read by three readers to determine diagnostic test properties using a standard scoring list to determine the methodological quality of the diagnostic information. A meta-analysis was performed when study results allowed statistical pooling. Few studies investigated the value of the history. Pain distribution seemed to be the only useful history item. Of the physical examination signs the straight leg raising test was the only sign consistently reported to be sensitive for sciatica due to disc herniation. However, the sensitivity values varied greatly, the pooled sensitivity and specificity values being 0.85 and 0.52, respectively. The crossed straight leg raising test was the only sign shown to be specific; the pooled sensitivity and specificity values were 0.30 and 0.84, respectively. There was considerable disagreement on the specificity of the other neurological signs (paresis, sensory loss, reflex loss). Several types of bias and other methodological drawbacks were encountered in the studies limiting the validity of the study results. As a result of these drawbacks it is probable that test sensitivity was overestimated and test specificity underestimated.
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A systematic review of the literature including statistical meta-analysis. To evaluate published methods of the test of Lasègue or straight leg raising test and the cross straight leg raising test by using a recently developed criteria list and to summarize and explore reasons for variation in diagnostic accuracy. Little evidence exists on the diagnostic accuracy of the widely used straight leg raising test and the cross straight leg raising test in diagnosing herniated discs in patients with low back pain. MEDLINE and EMBASE searches up to 1997 showed 17 diagnostic publications evaluating the straight leg raising test with surgery as reference standard. Quality of methods was assessed with a specific checklist. Eleven studies were selected for statistical pooling. Sources of variation and heterogeneity were studied by meta-regression of the diagnostic odds ratio. All studies were surgical case-series at nonprimary care level. Verification-bias was obvious in one study. Pooled sensitivity for straight leg raising test was 0. 91 (95% CI 0.82-0.94), pooled specificity 0.26 (95% CI 0.16-0.38). Pooled diagnostic odds ratio was 3.74 (95% CI 1.2-11.4). Discriminative power was lower in recent studies, in studies with only inclusion of primary hernias, and with blind assessment of both the index-test (straight leg raising test) and the reference (surgery). For the cross straight leg raising test pooled sensitivity was 0.29 (95% CI 0.24-0.34), pooled specificity was 0.88 (95% CI 0.86-0.90), and the pooled diagnostic odds ratio 4.39 (95% CI 0.74-25.9). The diagnostic accuracy of the straight leg raising test is limited by its low specificity. Discriminative power decreased with a more valid design, a more homogenous case-mix, and year of publication. Although the studies may reflect everyday clinical practice, they do not enable a valid evaluation of the diagnostic accuracy of both tests. Diagnostic research should evaluate the validity of the complete diagnostic process and study the evidence of the added value of the different tests used. [Key words: sensitivity, specificity, diagnosis, meta-analysis, test of Lasègue, straight leg raising test]
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To evaluate patient characteristics, symptoms, and examination findings in the clinical diagnosis of lumbosacral nerve root compression causing sciatica. The study involved 274 patients with pain radiating into the leg. All had a standardised clinical assessment and magnetic resonance (MR) imaging. The associations between patient characteristics, clinical findings, and lumbosacral nerve root compression on MR imaging were analysed. Nerve root compression was associated with three patient characteristics, three symptoms, and four physical examination findings (paresis, absence of tendon reflexes, a positive straight leg raising test, and increased finger-floor distance). Multivariate analysis, analysing the independent diagnostic value of the tests, showed that nerve root compression was predicted by two patient characteristics, four symptoms, and two signs (increased finger-floor distance and paresis). The straight leg raise test was not predictive. The area under the curve of the receiver-operating characteristic was 0.80 for the history items. It increased to 0.83 when the physical examination items were added. Various clinical findings were found to be associated with nerve root compression on MR imaging. While this set of findings agrees well with those commonly used in daily practice, the tests tended to have lower sensitivity and specificity than previously reported. Stepwise multivariate analysis showed that most of the diagnostic information revealed by physical examination findings had already been revealed by the history items.
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Classification of neuropathic pain according to etiology or localization has clear limitations. The discovery of specific molecular and cellular events following experimental nerve injury has raised the possibility of classifying neuropathic pain on the basis of the underlying neurobiological mechanisms. Application of this approach in the clinic is problematic, however, owing to a lack of precise tools to assess symptoms and signs, and difficulties in correlating symptoms and signs with mechanisms. Development and validation of diagnostic methods to identify mechanisms, together with pharmacological agents that specifically target these mechanisms, seems to be the most logical and rational way of improving neuropathic pain treatment.
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Nociceptive and neuropathic components both contribute to pain. Since these components require different pain management strategies, correct pain diagnosis before and during treatment is highly desirable. As low back pain (LBP) patients constitute an important subgroup of chronic pain patients, we addressed the following issues: (i) to establish a simple, validated screening tool to detect neuropathic pain (NeP) components in chronic LBP patients, (ii) to determine the prevalence of neuropathic pain components in LBP in a large-scale survey, and (iii) to determine whether LBP patients with an NeP component suffer from worse, or different, co-morbidities. In co-operation with the German Research Network on Neuropathic Pain we developed and validated the painDETECT questionnaire (PD-Q) in a prospective, multicentre study and subsequently applied it to approximately 8000 LBP patients. The PD-Q is a reliable screening tool with high sensitivity, specificity and positive predictive accuracy; these were 84% in a palm-top computerised version and 85%, 80% and 83%, respectively, in a corresponding pencil-and-paper questionnaire. In an unselected cohort of chronic LBP patients, 37% were found to have predominantly neuropathic pain. Patients with NeP showed higher ratings of pain intensity, with more (and more severe) co-morbidities such as depression, panic/anxiety and sleep disorders. This also affected functionality and use of health-care resources. On the basis of given prevalence of LBP in the general population, we calculated that 14.5% of all female and 11.4% of all male Germans suffer from LBP with a predominant neuropathic pain component. Simple, patient-based, easy-to-use screening questionnaires can determine the prevalence of neuropathic pain components both in individual LBP patients and in heterogeneous cohorts of such patients. Since NeP correlates with more intense pain, more severe co-morbidity and poorer quality of life, accurate diagnosis is a milestone in choosing appropriate therapy.
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Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits-for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
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Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
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As a mechanisms-based classification of pain 'central sensitisation pain' (CSP) refers to pain arising from a dominance of neurophysiological dysfunction within the central nervous system. Symptoms and signs associated with an assumed dominance of CSP in patients attending for physiotherapy have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of CSP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol. Patients' pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist specifying the presence or absence of various clinical criteria. A binary logistic regression analysis with Bayesian model averaging identified a cluster of three symptoms and one sign predictive of CSP, including: 'Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors', 'Pain disproportionate to the nature and extent of injury or pathology', 'Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours)' and 'Diffuse/non-anatomic areas of pain/tenderness on palpation'. This cluster was found to have high levels of classification accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84.5-96.4; specificity 97.7%, 95% CI: 95.6-99.0). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of CSP in patients with low back pain disorders in a way that might usefully inform their management.
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Evidence of validity is required to support the use of mechanisms-based classifications of pain clinically. The purpose of this study was to evaluate the discriminant validity of 'nociceptive' (NP), 'peripheral neuropathic' (PNP) and 'central sensitisation' (CSP) as mechanisms-based classifications of pain in patients with low back (±leg) pain by evaluating the extent to which patients classified in this way differ from one another according to health measures associated with various dimensions of pain. This study employed a cross-sectional, between-subjects design. Four hundred and sixty-four patients with low back (±leg) pain were assessed using a standardised assessment protocol. Clinicians classified each patient's pain using a mechanisms-based classification approach. Patients completed a number of self-report measures associated with pain severity, health-related quality of life, functional disability, anxiety and depression. Discriminant validity was evaluated using a multivariate analysis of variance. There was a statistically significant difference between pain classifications on the combined self-report measures, (p = .001; Pillai's Trace = .33; partial eta squared = .16). Patients classified with CSP (n = 106) reported significantly more severe pain, poorer general health-related quality of life, and greater levels of back pain-related disability, depression and anxiety compared to those classified with PNP (n = 102) and NP (n = 256). A similar pattern was found in patients with PNP compared to NP. Mechanisms-based pain classifications may reflect meaningful differences in attributes underlying the multidimensionality of pain. Further studies are required to evaluate the construct and criterion validity of mechanisms-based classifications of musculoskeletal pain.
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Neuropathic pain is common in many diseases or injuries of the peripheral or central nervous system, and has a substantial impact on quality of life and mood. Lesions of the nervous system may lead to potentially irreversible changes and imbalance between excitatory and inhibitory systems. Preclinical research provides several promising targets for treatment such as sodium and calcium channels, glutamate receptors, monoamines and neurotrophic factors; however, treatment is often insufficient. A mechanism-based treatment approach is suggested to improve treatment. Valid and reliable tools to assess various symptoms and signs in neuropathic pain and knowledge of drug mechanisms are prerequisites for pursuing this approach. The present review summarizes mechanisms of neuropathic pain, targets of currently used drugs, and measures used in neuropathic pain trials.
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Peripheral neuropathic pain is the term used to describe situations where nerve roots or peripheral nerve trunks have been injured by mechanical and/or chemical stimuli that exceeded the physical capabilities of the nervous system. Clinical manifestations of peripheral neuropathic pain are often discussed in terms of positive and negative symptoms. Positive symptoms reflect an abnormal level of excitability in the nervous system and include pain, paresthesia, dysesthesia, and spasm. Negative symptoms indicate reduced impulse conduction in the neural tissues and include hypoesthesia or anesthesia and weakness. It is proposed that conservative management incorporating neurodynamic and neurobiology education, nonneural tissue interventions, and neurodynamic mobilization techniques can be effective in addressing musculoskeletal presentations of peripheral neuropathic pain. While a small amount of clinical evidence lends some support to this proposal, much more clinical research is necessary to identify those patients with peripheral neuropathic pain that will respond most favorably to neurodynamic mobilization techniques and clarify specific treatment parameters that will be most effective. Regardless of the results of this future research, conservative care will always need to be based on sound clinical reasoning so that interventions can be individualized to address the nuances of each patient’s presentation of peripheral neuropathic pain. q 2005 Elsevier Ltd. All rights reserved.
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We have revised the previous EFNS guidelines on neuropathic pain (NP) assessment, which aimed to provide recommendations for the diagnostic process, screening tools and questionnaires, quantitative sensory testing (QST), microneurography, pain-related reflexes and evoked potentials, functional neuroimaging and skin biopsy. We have checked and rated the literature published in the period 2004-2009, according to the EFNS method of classification for diagnostic procedures. Most of the previous recommendations were reinforced by the new studies. The main revisions relate to: (i) the new definition of NP and a diagnostic grading system; (ii) several new validated clinical screening tools that identify NP components, and questionnaires which assess the different types of NP; (iii) recent high-quality studies on laser-evoked potentials (LEPs) and skin biopsy. History and bedside examination are still fundamental to a correct diagnosis, whilst screening tools and questionnaires are useful in indicating probable NP; QST is also useful for indicating the latter, and to assess provoked pains and treatment response. Amongst laboratory tests, LEPs are the best tool for assessing Adelta pathway dysfunction, and skin biopsy for assessing neuropathies with distal loss of unmyelinated nerve fibres.