Application of a diagnosis-based clinical decision guide in patients with low back pain
© Murphy and Hurwitz; licensee BioMed Central Ltd. 2011
Received: 28 January 2011
Accepted: 21 October 2011
Published: 21 October 2011
Low back pain (LBP) is common and costly. Development of accurate and efficacious methods of diagnosis and treatment has been identified as a research priority. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based means to apply the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with LBP.
Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of LBP patients examined by one of three examiners trained in the application of the DBCDG.
Data were gathered on 264 patients. Signs of visceral disease or potentially serious illness were found in 2.7%. Centralization signs were found in 41%, lumbar and sacroiliac segmental signs in 23% and 27%, respectively and radicular signs were found in 24%. Clinically relevant myofascial signs were diagnosed in 10%. Dynamic instability was diagnosed in 63%, fear beliefs in 40%, central pain hypersensitivity in 5%, passive coping in 3% and depression in 3%.
The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability and efficacy of treatment based on the DBCDG.
Keywordslow back pain diagnosis therapeutics practice-based research
Low back pain (LBP) affects approximately 80% of adults at some time in life  and occurs in all ages [2, 3]. Despite billions being spent on various diagnostic and treatment approaches, the prevalence and disability related to LBP has continued to increase . There has been a recent movement toward comparative effectiveness research , i.e., research that determines which treatment approaches are most effective for a given patient population. In addition, there is increased recognition of the importance of practice-based research which generates data in a "real world" environment as a tool for conducting comparative effectiveness research [6, 7]. This movement calls for greater participation of private practice environments in clinical research .
One of the reasons often given for the meager benefits that have been found with various LBP treatments is that these treatments are generally applied generically, without regard for specific characteristics of each patient, whereas the LBP population is a heterogeneous group, requiring individualized care . Developing a strategy by which treatments can be targeted to the specific needs of patients has been identified as a research priority [9, 10].
In recent years there has been a movement away from the biomedical model for understanding the LBP experience toward a biopsychosocial model [11–15]. That is, LBP has increasingly been recognized as involving somatic, neurophysiological and psychological factors that all contribute to the clinical picture clinicians encounter. In addition, it has been recognized in recent years that, while there are several individual treatments for LBP that have evidence of effectiveness, the effects sizes of these treatments are generally small . It was been argued that this is likely because patients with LBP have individual needs and taking an approach that identifies the key features in each case, so that treatment can be tailored to those key features, provides the greatest benefit to the patient . However little information is available on the relative efficacy of any particular systematic approach to applying the biopsychosocial model in clinical practice.
A diagnosis-based clinical decision guide (DBCDG) has been proposed for the purpose of guiding clinicians in applying biopsychosocial concepts to the diagnosis and management of patients with LBP . This has been referred to in previous publications as a diagnosis-based clinical decision rule. The approach evolved from the evidence regarding the somatic, neurophysiological and psychological factors that have been found to contribute to suffering in patients with LBP, along with those treatments that have been found to be effective in patients with LBP . It attempts to respond to the challenge of applying the biopsychosocial model and providing individualized treatment programs based on the particular features of each patient.
Cohort studies documenting the outcome of treatment of subsets of LBP patients have been published and the results appear promising [18–20]. However, more research is needed to determine the generalizability of these findings as well as whether they can be replicated in controlled studies. The primary purpose of this study is to document the types of working diagnoses in patients with LBP that are formed by clinicians trained in the use of the DBCDG. This will serve as the basis for further refining the approach in an attempt to improve diagnostic accuracy.
The study protocol was approved by the Institutional Review Board of New York Chiropractic College (protocol #09-04). It was also reviewed by the Health Insurance Portability and Accountability Act (HIPAA) compliance officer of the facility at which the data were gathered and was deemed to be in compliance with HIPAA regulations. All subjects signed informed consent forms, agreeing to have their data included in the study.
Data were gathered prospectively in consecutive patients seen at the Rhode Island Spine Center between 2/7/08 and 2/26/09.
Patients were included in the study if they 1) had LBP (defined as pain between the thoracolumbar junction and the buttocks, with or without lower extremity pain; 2) were age 18 years or older; 3) provided informed consent; 4) were able to communicate well in English; 5) had a Bournemouth Disability Questionnaire (BDQ) score of 15 or higher.
All examinations were carried out by one of two chiropractic physicians, one with over 20 years experience and the other with over 9 years experience, or by a physical therapist with over 10 years experience. All had a minimum of 50 hours of postgraduate training in the McKenzie method. The physical therapist also had 80 hours of postgraduate training in manual therapy. Several discussions between the examiners took place over the course of five years prior to commencing data gathering on the application of the DBCDG. This occurred in the form of monthly clinical meetings in which the application of the DBCDG in particular patients was discussed as well as recent developments in the literature related to the evaluation and management of patients with LBP. History and examination were performed according to the usual course of patient care at the Rhode Island Spine Center.
Are the symptoms with which the patient is presenting reflective of a visceral disorder or a serious or potentially life-threatening disease?
From where is the patient's pain arising?
What has gone wrong with this person as a whole that would cause the pain experience to develop and persist?
With this question the clinician attempts to identify factors that may serve to perpetuate the ongoing pain experience. These factors may involve somatic, neurophysiologic or psychological processes .
Following each new patient encounter the answers to the three questions of diagnosis were documented on a standardized form (see Additional file 1). These data, along with patient demographic data and data from standardized outcome measurement instruments were then entered on a spreadsheet by a chiropractic intern.
In seeking an answer to the first question of diagnosis (rule out visceral or serious disease) standard history and examination procedures were used. In cases in which it was warranted, special tests such as radiographs, MRI or blood tests were ordered.
Segmental pain provocation signs, detected through historical factors that are associated with lumbar facet or sacroiliac pain  and through the pain provocation tests of Laslett, et al [22, 23, 25, 30]. Evidence suggest that centralization signs must be ruled out prior to consideration of segmental pain provocation signs [22, 30]. Therefore, segmental pain provocation signs were only considered relevant if centralization signs were absent.
Myofascial signs, detected through palpation of myofascial tissues . These signs were only considered relevant if the clinician felt they were separate and distinct from the other signs.
Central pain hypersensitivity, detected through observation of pain behavior in response to stimuli as well as through Waddell's nonorganic signs . A threshold of 3/5 nonorganic signs was used as this is the threshold that has been used in previous studies as being significant for the presence of non-organic pain behavior .
Psychological factors. Fear beliefs were measured using the 11-item Tampa Scale for Kinesiophobia (TSK) . A score of 27 was considered indicative of clinically meaningful fear beliefs. This number was adapted from Vlaeyen, et al  who used a cutoff score 40 using a previous 17-item version of the TSK and Woby (personal communication 3 August, 2009) whose unpublished data suggested a score of 26 to 27 to be associated with clinically meaningful fear beliefs. In addition, two questions from the Coping Strategies Questionnaire  which have previously been found to be predictive of changes in disability in LBP patients  were used to measure patients' perception of their control over the pain. At the time this study was conducted no data were available regarding whether a particular score with these questions constitutes a threshold for clinically meaningful difficulty with coping strategies. The depression subscale of the BDQ  was used to measure depression. As with the coping strategies questions, no data were available at the time of the study by which to determine a threshold for clinical significance with this question.
Each patient completed the full BDQ  and the total score from this questionnaire score was recorded. The initial subscale of the BDQ consists of a Numerical Rating Scale for pain intensity (NRS) , a scale in which the patient is asked to rate the average intensity of the pain over the past week on a 0-10 scale with "0" representing "no pain" and "10" representing "worst possible pain". This score was also recorded.
Treatment was left to the discretion of the primary treating clinician based on the diagnosis, and in general a "team approach" was taken. In the context of the DBCDG, these are the treatments that were applied:
In response to the findings or the second question of diagnosis (source of the pain):
Centralization signs: End range loading maneuvers in the direction that produced centralization . Because centralization signs are believed to reflect disc pain , distraction manipulation  was also used, as this has been found to decrease intradiscal pressure  and has been shown to be helpful in patients with LBP in general .
Segmental pain provocation signs: As joint manipulation has been shown to have both neurological  and biomechanical  segmental effects and has been found to be beneficial in patients with LBP in general , this was applied as the treatment of choice in patients with segmental pain provocation signs.
Neurodynamic signs: In the acute stage, anti-inflammatory measures were pursued via referral. This was in the form of non-steroidal anti-inflammatory medications, oral steroids or epidural steroid injections , depending on the diagnosis. In the subacute or chronic stage, neural mobilization was used .
Myofascial signs: Myofascial therapies such as ischemic compression and post-isometric relaxation  were used if the myofascial signs were deemed clinically relevant by the treating clinician.
In response to the third question of diagnosis (perpetuating factors):
Central pain hypersensitivity: Education was provided regarding the nature of pain for the purpose of helping the patient understand that the intensity of pain was not related to extensive "tissue damage" [63, 64]. In addition, graded exposure  was applied in which patients were exposed to movements, positions and activities that provoked their pain to a level they could handle and the stimulus was continued until habituation occurred . Graded exposure was only applied in the subacute or chronic stage, not in acute patients.
Fear, catastrophizing, passive coping, depression, poor self-efficacy: Education was provided for the purpose of correcting misperceptions regarding the nature of pain . In addition, graded exposure was applied . Occasionally patients were referred for cognitive-behavioral therapy .
The treatment algorithm can be found in Figure 2.
Descriptive statistics were used to characterize the study population. Frequencies, percentages, and 95% confidence intervals were computed for categorical variables; means, standard deviations, medians, and ranges were computed for continuous variables. Data management and statistical analyses were conducted with Microsoft Excel and SAS (version 9.1, Cary, NC).
1 day - 54 years
Responses to the second question of diagnosis.
Percent (95% CI)
41.1 (35.1 - 47.0)
Segmental pain provocation sign (lumbar)
23.3 (18.2 - 28.4)
Segmental pain provocation sign (sacroiliac)
27.0 (21.6 - 32.4)
23.9 (18.7 - 29.0)
10.3 (6.6 - 13.9)
Responses to the third question of diagnosis
Percent (95% CI)
Dynamic instability (lumbar)
46.6% (95% CI 40.6 - 52.6)
Dynamic instability (pelvic)
16.7 (12.2 - 21.2)
Central pain hypersensitivity
5.3 (2.6 - 8.0)
39.8 (33.9 - 45.7)
3.0 (1.0 - 5.1)
3.0 (1.0 - 5.1)
In recent years, spending on the diagnosis and management of patients with LBP has dramatically increased, yet this has not resulted in improved outcomes in terms of patient suffering and disability rates . As such, there is a great need for improved decision making in the care of patients with LBP. Specifically, there is a need to identify characteristics of each individual's condition that allow clinicians to make treatment decisions. In addition there is a great need for research that documents the clinical processes and outcomes that occur in the "real-world" environment of clinical practice as a contributor to comparative effectiveness research [6, 7]. This study was part of a broad research strategy to respond to the need for practice-based research by investigating and refining the clinical utility of the DBCDG for patients with LBP. The purpose was to document the types of diagnostic features identified and the frequency of the clinical findings.
Centralization signs were found in 41% of patients. This is similar but slightly lower than the 45-50% prevalence of this sign found in other studies of patients with LBP [21, 69, 70]. It is substantially lower than the 61.5% prevalence found by Murphy, et al  in a population of patients with radiculopathy secondary to herniated disc. In the present study data were only gathered at the initial visit. It has been found that when the determination of the centralization response occurs over the course of several visits, the process is more accurate . Thus, the percentage of patients who were centralizers may be underestimated in the present study.
The prevalence of segmental signs involving the SI joint was 27%. This is similar to the 31% reported by DePalma, et al  but substantially higher than the 13% reported by Maigne, et al based on diagnostic injections . This is interesting in that the means of identifying these signs have been found to have high sensitivity and specificity when using injection as a Gold Standard [23, 25]. However, these validity studies used single, rather than double, joint blocks. The prevalence of 23% for segmental signs related to the facet joints was within the range of 15-40% reported previously  and very similar to the 18% reported by DePalma, et al . The prevalence of the diagnosis of muscle palpation signs was low (10%). No prevalence data on myofascial pain is found in the literature, but it is the perception of the clinicians involved in this study, based on discussions over the five years prior to the gathering of these data, that muscle palpation signs are very common but often do not require specific treatment, and that applying treatment based on these signs does not positively impact outcome. This may explain why these signs were deemed clinically relevant in only a small percentage of patients. Further research is needed to investigate this perception. The relatively low prevalence of muscle palpation signs may also reflect the fact that the reliability of palpation to identify myofascial trigger points in the lumbar spine is relatively low [75–77].
There were three factors under the third question of diagnosis (perpetuating factors) for which the prevalence was quite low. Only 5% of patients were identified to have central pain hypersensitivity and only 3% were identified to have each of passive coping and depression. As these factors have been found to be significant in the development of chronic LBP [78–80], it is likely that the low prevalence of the diagnosis of these factors in this study represents under-recognition. However, as the mean duration of pain was only 109 days, it may be that the prevalence would naturally be higher in a cohort of patients with more long-standing pain. Another possibility is that this cohort did not display these features or that a sampling error led to low prevalence. It also may be that the means used in this study to identify these factors were suboptimal. In the case of central pain hypersensitivity, there is no well-established means of identification. Utilizing Waddell's non-organic signs with a threshold of a score of 3/5 may be of insufficient sensitivity to be used as a screening tool for central pain hypersensitivity. In addition, there may be other methods, such as pressure algometry , that may be useful in the detection of central pain hypersensitivity. Criteria have been developed by Smart, et al using a Delphi process , three factors of which have been found to have discriminative validity for the identification of central pain . This may be a more useful approach than the one taken here and further research is required to investigate this. In the case of passive coping and depression, the scales used to identify these factors had no established threshold score that identifies the presence of clinically meaningful problematic coping strategies and depression. The mean score on the coping strategies questions was 5.6 out of a possible 12 and on the depression subscale on the BDQ was 4.3 out of a possible 10. A recent study found that a baseline coping score of less than 8 had the highest sensitivity and score of less than 4 had the greatest specificity in identifying a LBP patient who is not likely to experience clinically meaningful improvement in pain and disability . These data will be used as the basis for further investigation that attempts to establish thresholds for clinical meaningful coping problems. It is expected that this knowledge will increase the validity of these questions when attempting to identify patients with problematic coping
strategies and depression. Other important psychological factors that are of importance in patients with LBP, such as catastrophizing , poor self-efficacy , hypervigilance for symptoms  and cognitive fusion  were not specifically measured. There is some evidence that the various psychological factors interact, rather than occurring in isolation [88–91] and that identification of more than one factor, but not necessarily all factors is adequate . As this was a practice-based research project that is part of the investigation of identification of key elements in the perpetuation of LBP in a "real-world" environment, it was decided that fear, coping and depression would be measured rather than attempting to measure all potentially relevant factors. Further work is needed to determine whether this is a worthwhile approach for clinicians.
This study had several limitations. First, the sample size was only 264 patients. A larger sample would have increased the study's scientific rigor. In addition, all data were gathered at a single clinic and thus it is not known whether the information is generalizable. Also the design was observational and the practitioners were not blinded to the findings on each patient. Finally, because this was a pragmatic study in which data were gathered during the normal course of clinical care detailed information regarding psychological factors was not obtained as this would have required patients to fill out several questionnaires. On the other hand, the fact that this study was carried out in a real-world environment may be a strength, in that it suggests that the information applies to the environment in which patients are most commonly cared for as opposed to the controlled environment of a research center.
Future studies will seek to determine correlations and patterns among the various diagnostic factors, the utility of the coping strategies and depression questions that were used, the inter-examiner reliability of the diagnostic strategy, and ultimately efficacy of the approach. Preliminary data suggests that outcomes in select patients groups may be favorable [18–20, 93], but this is based on observational studies without randomization or control.
The DBCDG can be applied in a private practice setting. It appears that patients with LBP can be distinguished on the basis of the findings of this approach, and treatment plans can be formulated based on the diagnosis by utilizing this strategy. Future research is needed to investigate the validity of the questions used in this study to identify problematic coping strategies and depression and to seek improved means of identifying central pain hypersensitivity. Further research is also needed to investigate correlations between the diagnostic findings, reliability of the diagnoses and efficacy of treatment based on the DBCDG.
This work was originally presented at the Research Agenda Conference, Las Vegas, NV 19 March 2010.
- Deyo RA, Phillips WR: Low back pain a primary care challenge. Spine. 1996, 21 (24): 760-765.Google Scholar
- Hartvigsen J, Christensen K: Pain in the back and neck are with us until the end: a nationwide interview-based survey of Danish 100-year-olds. Spine. 2008, 33 (8): 909-913. 10.1097/BRS.0b013e31816b45f1.View ArticlePubMedGoogle Scholar
- Pellise F, Balague F, Rajmil L, Cedraschi C, Aguirre M, Fontecha CG, Pasarin M, Ferrer M: Prevalence of low back pain and its effect on health-related quality of life in adolescents. Arch Pediatr Adolesc Med. 2009, 163 (1): 65-71. 10.1001/archpediatrics.2008.512.View ArticlePubMedGoogle Scholar
- Deyo RA, Mirza SK, Turner JA, Martin BI: Overtreating chronic back pain: time to back off?. J Am Board Fam Med. 2009, 22 (1): 62-68. 10.3122/jabfm.2009.01.080102.PubMed CentralView ArticlePubMedGoogle Scholar
- Barnett D, Chalkidou K, Rawlins M: Comparative effectiveness research: a useful tool. Health Aff (Millwood). 2009, 28 (2): 600-601. 10.1377/hlthaff.28.2.600. author reply 601View ArticleGoogle Scholar
- Horn SD, Gassaway J: Practice-based evidence study design for comparative effectiveness research. Med Care. 2007, 45 (10 Supl 2): S50-57.View ArticlePubMedGoogle Scholar
- Giffin RB, Woodcock J: Comparative effectiveness research: who will do the studies?. Health Aff (Millwood). 2010, 29 (11): 2075-2081. 10.1377/hlthaff.2010.0669.View ArticleGoogle Scholar
- Leboeuf-Yde C, Manniche C: Low back pain: Time to get off the treadmill. J Manipulative Physiol Ther. 2001, 24 (1): 63-66. 10.1067/mmt.2001.112009.View ArticlePubMedGoogle Scholar
- Borkan JM, Cherkin DC: An agenda for primary care research on low back pain. Spine. 1996, 21 (24): 2880-2884. 10.1097/00007632-199612150-00019.View ArticlePubMedGoogle Scholar
- Bouter LM, van Tulder MW, Koes BW: Methodologic issues in low back pain research in primary care. Spine (Phila Pa 1976). 1998, 23 (18): 2014-2020. 10.1097/00007632-199809150-00019.View ArticleGoogle Scholar
- Jones M, Edwards I, Gifford L: Conceptual models for implementing biopsychosocial theory in clinical practice. Man Ther. 2002, 7 (1): 2-9. 10.1054/math.2001.0426.View ArticlePubMedGoogle Scholar
- Pollard H, Hardy K, Curtin D: Biopsychosocial model of pain and its relevance to chiropractors. Chiropr J Aus. 2006, 36 (3): 92-96.Google Scholar
- Burton AK: Back injury and work loss: biomechanical and psychosocial influences. Spine. 1997, 22 (21): 2575-2580. 10.1097/00007632-199711010-00021.View ArticlePubMedGoogle Scholar
- Peters ML, Vlaeyen JWS, Weber WEJ: The joint contribution of physical pathology, pain-related fear and catastophizing to chronic back pain disability. Pain. 2005, 113 (1-2): 45-50. 10.1016/j.pain.2004.09.033.View ArticlePubMedGoogle Scholar
- Waddell G: The Back Pain Revolution. 2004, Edinburgh: Churchill Livingstone, 2Google Scholar
- Murphy DR, Hurwitz EL: A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskeletal Disorders. 2007, 8: 75-10.1186/1471-2474-8-75.PubMed CentralView ArticlePubMedGoogle Scholar
- Murphy DR, Hurwitz EL, Nelson CF: A diagnosis-based clinical decision rule for patients with spinal pain. Part 2: Review of the literature. Chiropr Osteop. 2008, 16: 8-10.1186/1746-1340-16-8.View ArticleGoogle Scholar
- Murphy DR, Hurwitz EL, Gregory AA, Clary R: A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study. BMC Musculoskelet Disord. 2006, 7: 16-10.1186/1471-2474-7-16.PubMed CentralView ArticlePubMedGoogle Scholar
- Murphy DR, Hurwitz EL, McGovern EE: Outcome of pregnancy related lumbopelvic pain treated according to a diagnosis-based clinical decision rule: A prospective observational cohort study. J Manipulative Physiol Ther. 2009,Google Scholar
- Murphy DR, Hurwitz EL, McGovern EE: A non-surgical approach to the management of patients with lumbar radiculopathy secondary to herniated disc: A prospective observational cohort study with follow up. J Manipulative Physiol Ther. 2009, 32 (9): 723-733. 10.1016/j.jmpt.2009.10.007.View ArticlePubMedGoogle Scholar
- Donelson R, Aprill C, Medcalf R, Grant W: A prospective study of centralization of lumbar and referred pain a predictor of symptomatic discs and anular competence. Spine. 1997, 22 (10): 1115-1122. 10.1097/00007632-199705150-00011.View ArticlePubMedGoogle Scholar
- Laslett M, Young SB, Aprill CN, McDonald B: Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aus J Physiother. 2003, 49: 89-97.View ArticleGoogle Scholar
- Young S, Aprill C, Laslett M: Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J. 2003, 3 (6): 460-465. 10.1016/S1529-9430(03)00151-7.View ArticlePubMedGoogle Scholar
- Laslett M, Oberg B, April CN, McDonald B: Zygapophysial joint blocks in chronic low back pain: a test of Revel's model as a screening test. BMC Musculoskel Disord. 2004, 5: 43-10.1186/1471-2474-5-43.View ArticleGoogle Scholar
- Laslett M, Aprill CN, McDonald B, Young SB: Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005, 10: 207-218. 10.1016/j.math.2005.01.003.View ArticlePubMedGoogle Scholar
- Laslett M, Birgitta O, Aprill CN, McDonald B: Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J. 2005, 5 (4): 370-380. 10.1016/j.spinee.2004.11.007.View ArticlePubMedGoogle Scholar
- Laslett M, Aprill CN, McDonald B, Oberg B: Clinical predictors of lumbar provocation discography: a study of clinical predictors of lumbar provocation discography. Eur Spine J. 2006, 15 (10): 1473-1484. 10.1007/s00586-006-0062-7.View ArticlePubMedGoogle Scholar
- Long A, Donelson R, Fung T: Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2004, 29 (23): 2593-2602. 10.1097/01.brs.0000146464.23007.2a.View ArticlePubMedGoogle Scholar
- McKenzie RA, May S: The Lumbar Spine: Mechanical Diagnosis and Therapy. 2003, Waikenae, NZ: Spinal Publications, 2Google Scholar
- Laslett M, McDonald B, Aprill CN, Tropp H, Oberg B: Clinical predictors of screening lumbar zygopophyseal joint blocks: development of clinical prediction rules. Spine J. 2006, 6 (4): 370-379. 10.1016/j.spinee.2006.01.004.View ArticlePubMedGoogle Scholar
- Vroomen PCAJ, de Krom CTFM, Knottnerus JA: Consistency of history taking and physical examination in patients with suspected lumbar nerve root involvement. Spine. 2000, 25 (1): 91-97. 10.1097/00007632-200001010-00016.View ArticlePubMedGoogle Scholar
- Hunt DG, Zuberbier OA, Kozlowski AJ, Robinson J, Berkowitz J, Schultz IZ, Milner RA, Crook JM, Turk DC: Reliability of the lumbar flexion, lumbar extension, and passivve straight leg raise test in normal populations embedded within a complete physical examination. Spine. 2001, 26 (24): 2714-2718. 10.1097/00007632-200112150-00018.View ArticlePubMedGoogle Scholar
- Vroomen PCAJ, de Krom MCTFM, Kester ADM, Knottnerus JA: Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002, 72: 630-633. 10.1136/jnnp.72.5.630.PubMed CentralView ArticlePubMedGoogle Scholar
- Lurie J: What diagnostic tests are useful for low back pain?. Best Pract Res Clin Rheumatol. 2005, 19 (4): 557-575. 10.1016/j.berh.2005.03.004.View ArticlePubMedGoogle Scholar
- Simons DG, Travell JG, Simons LS: Myofascial Pain and Dysfunction: The Trigger Point Manual. 1999, Baltimore: Williams and Wilkens, 1:Google Scholar
- Hicks GE, Fritz JM, Delitto A, Mishock J: Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Arch Phys Med Rehabil. 2003, 84: 1858-1864. 10.1016/S0003-9993(03)00365-4.View ArticlePubMedGoogle Scholar
- Murphy D, Byfield D, McCarthy P, Humphreys K, Gregory A, Rochon R: Interexaminer reliability of the hip extension test for suspected impaired motor control of the lumbar spine. J Manipulative Physiol Ther. 2006, 29 (5): 374-377. 10.1016/j.jmpt.2006.04.012.View ArticlePubMedGoogle Scholar
- Mens JMA, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ: The active straight leg raising test and mobility of the pelvic joints. Eur Spine J. 1999, 8:Google Scholar
- Mens JMA, Vleeming A, Snijders CJ, Koes BJ, Stam HJ: Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001, 26 (10): 1167-1171. 10.1097/00007632-200105150-00015.View ArticlePubMedGoogle Scholar
- Mens JMA, Vleeming A, Snijders CJ, Koes BW, Stam HJ: Validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain after pregnancy. Spine. 2002, 27 (2): 196-200. 10.1097/00007632-200201150-00015.View ArticlePubMedGoogle Scholar
- Mens JMA, Vleeming A, Snijders CJ, Stam HJ: Active straight leg raising test: a clinical approach to the load transfer function of the pelvic girdle. Movement, Stability and Low Back Pain The Essential Role of the Pelvis. Edited by: Vleeming A, Mooney V, Snijders CJ, Dorman TA, Stoeckart R. 1997, New York: Churchill Livingstone, 425-431.Google Scholar
- Roussel NA, Nijs J, Truijen S, Smeuninx L, Stassijns G: Low back pain: clinimetric properties of the Trendelenburg test, active straight leg raise test, and breathing pattern during active straight leg raising. J Manipulative Physiol Ther. 2007, 30 (4): 270-278. 10.1016/j.jmpt.2007.03.001.View ArticlePubMedGoogle Scholar
- O'Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB, Tucker B, Avery A: Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine (Phila Pa 1976). 2002, 27 (1): E1-8. 10.1097/00007632-200201010-00015.View ArticleGoogle Scholar
- Fishbain DA, Cole B, Cutler RB, Lewis J, Rosomoff HL, Rosomoff RS: A structured evidence-based review on the meaning of nonorganic physical signs (Waddell Signs). Pain Med. 2003, 4 (2): 141-181. 10.1046/j.1526-4637.2003.03015.x.View ArticlePubMedGoogle Scholar
- Kummell BM: Nonorganic signs of significance in low back pain. Spine. 1996, 21 (9): 1077-1081. 10.1097/00007632-199605010-00017.View ArticleGoogle Scholar
- Woby SR, Roach NK, Urmston M, Watson PJ: Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005, 117 (1-2): 137-144. 10.1016/j.pain.2005.05.029.View ArticlePubMedGoogle Scholar
- Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G: Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behav Res Ther. 2001, 39 (2): 151-166. 10.1016/S0005-7967(99)00174-6.View ArticlePubMedGoogle Scholar
- Koleck M, Mazaux JM, Rascle N, Brichon-Schweitzer M: Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: A prospective study. Eur J Pain. 2006, 10: 1-11. 10.1016/j.ejpain.2005.01.003.View ArticlePubMedGoogle Scholar
- Woby SR, Watson PJ, Roach NK, Urmston M: Are changes in fear-avoidance beliefs, catastrophizing, and appraisals of control, predictive of changes in chronic low back pain and disability?. Eur J Pain. 2004, 8 (3): 201-210. 10.1016/j.ejpain.2003.08.002.View ArticlePubMedGoogle Scholar
- Bolton JE, Breen AC: The Bournemouth Questionnaire. A short-form comprehensive outcome measure I: Psychometric properties in back pain patients. J Manipulative Physiol Ther. 1999, 22 (8): 503-510. 10.1016/S0161-4754(99)70001-1.View ArticlePubMedGoogle Scholar
- Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM: Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001, 94 (2): 149-158. 10.1016/S0304-3959(01)00349-9.View ArticlePubMedGoogle Scholar
- Cox JM: Low back pain: mechanisms, diagnosis and treatment. 1999, Baltimore: Williams and Wilkens, 6Google Scholar
- Gudavalli MR, Cox JM, Cramer GD, Baker JA, Patwardhan AG: Intervertebral disc pressure changes during low back treatment procedures. BED-Advances in Bioengineering. 1998, 39:Google Scholar
- Gudavalli MR, Cambron JA, McGregor M, Jedlicka J, Keenum M, Ghanayem AJ, Patwardhan AG: A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercise for chronic low back pain. Eur Spine J. 2006, 15 (7): 1070-1082. 10.1007/s00586-005-0021-8.PubMed CentralView ArticlePubMedGoogle Scholar
- Pickar JG: Neurophysiological effects of spinal manipulation. Spine J. 2002, 2 (5): 357-371. 10.1016/S1529-9430(02)00400-X.View ArticlePubMedGoogle Scholar
- Cramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA: The effects of side posture positioning and spinal adjusting on the lumbar Z joints a randomized controlled trial with sixty-four subjects. Spine. 2002, 27 (22): 2459-2466. 10.1097/00007632-200211150-00008.View ArticlePubMedGoogle Scholar
- Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S: Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008, 8 (1): 213-225. 10.1016/j.spinee.2007.10.023.View ArticlePubMedGoogle Scholar
- Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, Smith HS, Manchikanti L: Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician. 2007, 10 (1): 185-212.PubMedGoogle Scholar
- Shacklock M: Clinical Neurodynamics. A New System of Musculoskeletal Treatment. 2005, Edinburgh: ElsevierGoogle Scholar
- Vernon H, Schneider M: Chiropractic management of myofascial trigger points and myofascial pain syndrome: a systematic review of the literature. J Manipulative Physiol Ther. 2009, 32 (1): 14-24. 10.1016/j.jmpt.2008.06.012.View ArticlePubMedGoogle Scholar
- Richardson C, Jull G, Hodges P, Hides J: Therapeutic Exercise For Spinal Segmental Stabilization In Low Back Pain. Scientific Basis and Clinical Approach. 1999, Edinburgh: Churchill LivingstoneGoogle Scholar
- McGill S: Low Back Disorders. Evidence-Based Prevention and Rehabilitation. 2002, Champaign, IL: Human KineticsGoogle Scholar
- Moseley L: Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain. 2003, 4 (4): 184-189. 10.1016/S1526-5900(03)00488-7.View ArticlePubMedGoogle Scholar
- Henrotin Y, Cedraschi C, Duplan B, Bazin T, Duquesnoy B: Information and low back pain management: a systematic review. Spine. 2006, 31 (11): E326-E334. 10.1097/01.brs.0000217620.85893.32.View ArticlePubMedGoogle Scholar
- George SZ, Zeppieri G: Physical therapy utilization of graded exposure for patients with low back pain. The Journal of orthopaedic and sports physical therapy. 2009, 39 (7): 496-505.View ArticlePubMedGoogle Scholar
- Bingel U, Schoell E, Herken W, Buchel C, May A: Habituation to painful stimulation involves the antinociceptive system. Pain. 2007, 131 (1-2): 21-30. 10.1016/j.pain.2006.12.005.View ArticlePubMedGoogle Scholar
- Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G: The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clin J Pain. 2002, 18 (4): 251-261. 10.1097/00002508-200207000-00006.View ArticlePubMedGoogle Scholar
- Hoffman BM, Papas RK, Chatkoff DK, Kerns RD: Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007, 26 (1): 1-9.View ArticlePubMedGoogle Scholar
- Werneke MW, Hart DL: Centralization: association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain. J Rehabil Med. 2005, 37: 286-290. 10.1080/16501970510032901.View ArticlePubMedGoogle Scholar
- Long AL: The centralization phenomenon. Its usefulness as a predictor or outcome in conservative treatment of chronic law back pain (a pilot study). Spine (Phila Pa 1976). 1995, 20 (23): 2513-2520. 10.1097/00007632-199512000-00010. discussion 2521View ArticleGoogle Scholar
- Werneke M, Hart DL: Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns. Spine. 2003, 28 (2): 161-166. 10.1097/00007632-200301150-00012.View ArticlePubMedGoogle Scholar
- Depalma MJ, Ketchum JM, Saullo T: What is the source of chronic low back pain and does age play a role?. Pain Med. 2011, 12 (2): 224-233. 10.1111/j.1526-4637.2010.01045.x.View ArticlePubMedGoogle Scholar
- Maigne JY, Aivaliklis A, Pfefer F: Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine (Phila Pa 1976). 1996, 21 (16): 1889-1892. 10.1097/00007632-199608150-00012.View ArticleGoogle Scholar
- Bogduk N: The anatomical basis for spinal pain syndromes. J Manipulative Physiol Ther. 1995, 18 (9): 603-605.PubMedGoogle Scholar
- Njoo KH, Van der Does E: The occurrence and inter-rater reliability of myofascial trigger points in the quadratus lumborum and gluteus medius: a prospective study in non-specific low back pain patients and controls in general practice. Pain. 1994, 58 (3): 317-323. 10.1016/0304-3959(94)90125-2.View ArticlePubMedGoogle Scholar
- Nice DA, Riddle DL, Lamb RL, Mayhew TP, Rucker K: Intertester reliability of judgements of the presence of trigger points in patients with low back pain. Arch Phys Med Rehabil. 1992, 73: 893-898.PubMedGoogle Scholar
- Hsieh CY, Hong CZ, Adams AH, Platt KJ, Danielson CD, Hoehler FK, Tobis JS: Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Arch Phys Med Rehabil. 2000, 81 (3): 258-264. 10.1016/S0003-9993(00)90068-6.View ArticlePubMedGoogle Scholar
- Mercado AC, Carroll LJ, Cassidy D, Cote P: Passive coping is a risk factor for disabling neck or low back pain. Pain. 2005, 117 (1-2): 51-57. 10.1016/j.pain.2005.05.014.View ArticlePubMedGoogle Scholar
- DeLeo JA: Basic science of pain. J Bone Joint Surg. 2006, 88-A (Suppl 2): 58-62.View ArticleGoogle Scholar
- Carroll LJ, Cassidy JD, Cote P: Depression as a risk factor for onset of an episode of troublesome neck and low back pain. Pain. 2004, 107 (1-2): 134-139. 10.1016/j.pain.2003.10.009.View ArticlePubMedGoogle Scholar
- Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P: The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990, 33 (2): 160-172. 10.1002/art.1780330203.View ArticlePubMedGoogle Scholar
- Smart KM, Blake C, Staines A, Doody C: Clinical indicators of 'nociceptive', 'peripheral neuropathic' and 'central' mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Man Ther. 2010, 15 (1): 80-87. 10.1016/j.math.2009.07.005.View ArticlePubMedGoogle Scholar
- Smart KM, Blake C, Staines A, Doody C: The Discriminative Validity of "Nociceptive," "Peripheral Neuropathic," and "Central Sensitization" as Mechanisms-based Classifications of Musculoskeletal Pain. Clin J Pain. 2011, 27 (8): 655-663. 10.1097/AJP.0b013e318215f16a.View ArticlePubMedGoogle Scholar
- Murphy DR, Hurwitz EL: Usefulness of a 2-question coping screening tool in patients with low back pain. American Academy of Pain Management 21st Annual Clinical Meeting, Exploring the Science Practicing The Art. 2010, Las Vegas, NVGoogle Scholar
- Woby SR, Roach NK, Urmston M, Watson PJ: The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy. Eur J Pain. 2007, 11 (8): 869-877. 10.1016/j.ejpain.2007.01.005.View ArticlePubMedGoogle Scholar
- Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW: The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007, 30 (1): 77-94. 10.1007/s10865-006-9085-0.View ArticlePubMedGoogle Scholar
- Wicksell RK, Lekander M, Sorjonen K, Olsson GL: The Psychological Inflexibility in Pain Scale (PIPS)--statistical properties and model fit of an instrument to assess change processes in pain related disability. Eur J Pain. 2010, 14 (7): 771-e771-714View ArticlePubMedGoogle Scholar
- Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H: Fear of movement/reinjury in chronic low back pain and its relation to behavioral performance. Pain. 1995, 62: 363-372. 10.1016/0304-3959(94)00279-N.View ArticlePubMedGoogle Scholar
- Boersma K, Linton S: Psychological processes underlying the development of a chronic pain problem. A prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability. Clin J Pain. 2006, 22: 160-166. 10.1097/01.ajp.0000159582.37750.39.View ArticlePubMedGoogle Scholar
- Woby SR, Urmston M, Watson PJ: Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients. Eur J Pain. 2007, 11 (7): 711-718. 10.1016/j.ejpain.2006.10.009.View ArticlePubMedGoogle Scholar
- Turk DC: Understanding pain sufferers: the role of cognitive processes. Spine J. 2004, 4 (1): 1-7. 10.1016/S1529-9430(03)00068-8.View ArticlePubMedGoogle Scholar
- Murphy DR, Hurwitz EL: The usefulness of clinical measures of psychological factors in patients with spinal pain. J Manipulative Physiol Ther. 2011,Google Scholar
- Murphy DR, Hurwitz EL, Gregory AA, Clary R: A nonsurgical approach to the management of patients with cervical radiculopathy: A prospective observational cohort study. J Manipulative Physiol Ther. 2006, 29 (4): 279-287. 10.1016/j.jmpt.2006.03.005.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.