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

Donald R Murphy,Eric L Hurwitz

doi:10.1186/2045-709x-19-26

Abstract

BackgroundLow 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.MethodsDemographic, 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.ResultsData 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%.ConclusionThe 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.

Highlights

Low back pain (LBP) is common and costly
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 [16]
The diagnosis-based clinical decision guide (DBCDG) can be applied in a private practice setting

Summary

Introduction

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. There has been a recent movement toward comparative effectiveness research [5], i.e., research that determines which treatment approaches are most effective for a given patient population. Developing a strategy by which treatments can be targeted to the specific needs of patients has been identified as a research priority [9,10]. LBP has increasingly been recognized as involving somatic, neurophysiological and psychological factors that all contribute to the clinical picture clinicians encounter. 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 [4]. Little information is available on the relative efficacy of any particular systematic approach to applying the biopsychosocial model in clinical practice

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