Low Back-related Leg Pain Research Articles

The profile of chiropractors managing patients with low back-related leg pain: analyses of 1907 chiropractors from the ACORN practice-based research network

BackgroundApproximately 60% of people with low back pain also have associated leg pain symptoms. Guidelines for low back pain recommend non-pharmacological approaches, including spinal manipulation - a therapy provided by chiropractors. However, limited empirical data has examined the characteristics of chiropractors managing patients with low back-related leg pain (LBRLP). Our objective is to describe the prevalence, profile and practice characteristics of Australian chiropractors who often treat LBRLP, compared to those who do not often treat LBRLP.MethodsThis is a cross-sectional analysis of a nationally representative sample from the Australian Chiropractic Research Network (ACORN). This study investigated the demographic and practice characteristics as well as clinical management of chiropractors who ‘often’ treated patients with LBRLP compared to those who treated LBRLP ‘never/rarely/sometimes’. Multiple logistic regression models identified independent factors associated with chiropractors who ‘often’ treated patients with LBRLP.ResultsA total of 1907 chiropractors reported treating patients experiencing LBRLP, with 80.9% of them ‘often’ treating LBRLP. Chiropractors who ‘often’ treated LBRLP were more likely to manage patients with multi-site pain including axial low back pain (OR = 21.1), referred/radicular neck pain (OR = 10.8) and referred/radicular thoracic pain (OR = 3.1). While no specific management strategies were identified, chiropractors who ‘often’ treated LBRLP were more likely to discuss medication (OR = 1.8), manage migraine (OR = 1.7) and degenerative spine conditions (OR = 1.5), and treat women during pregnancy (OR = 1.6) and people with work-related injuries (OR = 1.5), compared to those not treating LBRLP frequently.ConclusionsAustralian chiropractors frequently manage LBRLP, although the nature of specific management approaches for this condition remains unclear. Further research on the management of LBRLP can better inform policy makers and educators interested in upskilling chiropractors to deliver safe and effective treatment of LBRLP.

Prevalence, characteristics and clinical course of neuropathic pain in primary care patients consulting with low back-related leg pain

Purpose: Neuropathic pain, thought to be due to nerve damage, is considered challenging to manage. The presence of sciatica in low back-related leg pain (LBLP) is often believed to be neuropathic, similarly the prognosis of patients with neuropathic pain is commonly thought to be worse compared to those without. Currently there is a paucity of evidence on the epidemiology of neuropathic pain in this patient population. The aim of this research was to describe the prevalence, characteristics and clinical course of neuropathic LBLP in primary care.

Local connectivity of the resting brain connectome in patients with low back-related leg pain: A multiscale frequency-related Kendall's coefficient of concordance and coherence-regional homogeneity study.

Increasing evidence has suggested that central plasticity plays a crucial role in the development and maintenance of (chronic) nonspecific low back pain. However, it is unclear how local or short-distance functional interactions contribute to persisting low back-related leg pain (LBLP) due to a specific condition (i.e., lumbar disc herniation). In particular, the multiscale nature of local connectivity properties in various brain regions is still unclear. Here, we used voxelwise Kendall's coefficient of concordance (KCC) and coherence (Cohe) regional homogeneity (ReHo) in the typical (0.01–0.1 Hz) and five specific frequency (slow-6 to slow-2) bands to analyze individual whole-brain resting-state functional magnetic resonance imaging scans in 25 persistent LBLP patients (duration: 36.7 ± 9.6 months) and 26 healthy control subjects. Between-group differences demonstrated significant alterations in the KCC- and Cohe- ReHo of the right cerebellum posterior lobe, brainstem, left medial prefrontal cortex and bilateral precuneus in LBLP patients in the typical and five specific frequency bands, respectively, along with interactions between disease status and the five specific frequency bands in several regions of the pain matrix and the default-mode network (P < .01, Gaussian random field theory correction). The altered ReHo in the five specific frequency bands was correlated with the duration of pain and two-point discrimination, which were assessed using partial correlational analysis. These results linked the course of disease to the local connectivity properties in specific frequency bands in persisting LBLP. In future studies exploring local connectome association in pain conditions, integrated frequency bands and analytical methods should be considered.

Prognosis of low back-related leg pain patients with neuropathic pain: clinical course and prognostic factors

Prognosis of low back-related leg pain patients with neuropathic pain: clinical course and prognostic factors

Noninvasive Measurement of Sciatic Nerve Stiffness in Patients With Chronic Low Back Related Leg Pain Using Shear Wave Elastography.

The purpose of this study was to determine whether sciatic nerve stiffness is altered in people with chronic low back-related leg pain by using shear wave elastography. In this cross-sectional study, the sciatic nerve shear wave velocity (ie, an index of stiffness) was measured in both legs of 16 participants (8 with unilateral low back-related leg pain and 8 healthy controls). Sciatic stiffness was measured during a passive ankle dorsiflexion motion performed at 2°/s in an isokinetic dynamometer. The ankle range of motion and passive torque, as well as muscle activity, were also measured. In people with low back-related leg pain, the affected limb showed higher sciatic nerve stiffness compared to the unaffected limb (+11.3%; P = .05). However, no differences were observed between the unaffected limb of people with low back-related leg pain and the healthy controls (P = .34). People with chronic low back-related leg pain have interlimb differences in sciatic nerve stiffness, as measured by a safe and noninvasive method: shear wave elastography. The changes found may be related to alterations in nerve mechanical properties, which should be confirmed by future investigations.

Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain

BackgroundIdentification of sciatica may assist timely management but can be challenging in clinical practice. Diagnostic models to identify sciatica have mainly been developed in secondary care settings with conflicting reference standard selection. This study explores the challenges of reference standard selection and aims to ascertain which combination of clinical assessment items best identify sciatica in people seeking primary healthcare.MethodsData on 394 low back-related leg pain consulters were analysed. Potential sciatica indicators were seven clinical assessment items. Two reference standards were used: (i) high confidence sciatica clinical diagnosis; (ii) high confidence sciatica clinical diagnosis with confirmatory magnetic resonance imaging findings. Multivariable logistic regression models were produced for both reference standards. A tool predicting sciatica diagnosis in low back-related leg pain was derived. Latent class modelling explored the validity of the reference standard.ResultsModel (i) retained five items; model (ii) retained six items. Four items remained in both models: below knee pain, leg pain worse than back pain, positive neural tension tests and neurological deficit. Model (i) was well calibrated (p = 0.18), discrimination was area under the receiver operating characteristic curve (AUC) 0.95 (95% CI 0.93, 0.98). Model (ii) showed good discrimination (AUC 0.82; 0.78, 0.86) but poor calibration (p = 0.004). Bootstrapping revealed minimal overfitting in both models. Agreement between the two latent classes and clinical diagnosis groups defined by model (i) was substantial, and fair for model (ii).ConclusionFour clinical assessment items were common in both reference standard definitions of sciatica. A simple scoring tool for identifying sciatica was developed. These criteria could be used clinically and in research to improve accuracy of identification of this subgroup of back pain patients.

Assessing neuropathic pain in patients with low back‐related leg pain: Comparing the painDETECT Questionnaire with the 2016 NeuPSIG grading system

Low back-related leg pain with nerve root involvement is conceptually regarded as a neuropathic condition. However, it is uncertain to what extent patients with this condition can be formally classified with neuropathic pain. First, we used the 2016 revision of the IASP Special Interest Group on Neuropathic Pain (NeuPSIG) grading system for neuropathic pain to grade patients suffering from low back-related leg pain and a corresponding disc herniation with either unlikely, possible, probable or definite neuropathic pain. Examination included bedside quantitative sensory testing. Next, we used the clinical classification based on the 2016 NeuPSIG grading system as a reference standard to assess the ability of the painDETECT Questionnaire to identify patients with neuropathic pain. Of the 50 included patients, six (12%) fulfilled the clinical classification criteria for probable and 44 (88%) for definite neuropathic pain, while none were graded unlikely or possible. According to painDETECT, 23 patients (46%) were classified with unlikely neuropathic pain, 18 patients (36%) had an uncertain condition and in nine patients (18%) neuropathic pain was likely. Among the 44 patients graded as having definite neuropathic pain by the clinical classification, eight were classified as likely neuropathic pain by painDETECT, resulting in an agreement of 18%. Of these 44 patients graded with definite neuropathic pain, painDETECT classified 21 patients (48%) as unlikely and 15 (34%) as uncertain. Our results do not support the use of painDETECT as a screening tool to classify or grade neuropathic components in patients with low back-related leg pain. The painDETECT Questionnaire performed poorly at detecting neuropathic pain among patients with low back-related leg pain, compared to clinical examination based on the 2016 NeuPSIG grading system as a reference standard. Our results do not support the use of painDETECT as a screening tool to classify or grade neuropathic components in this population.

Efficacy of Caudal Epidural Steroid Injection with Targeted Indwelling Catheter and Manipulation in Managing Patients with Lumbar Disk Herniation and Radiculopathy: A Prospective, Randomized, Single-Blind Controlled Trial.

Lumbar disk herniation (LDH) is considered a common cause of lumbosacral radiculopathy. Epidural steroid injection is a common method to treat inflammation associated with low back-related leg pain. Spinal manipulations are widely used, and systematic reviews have also shown that these manipulations are more effective than placebos. Due to the absence of clinical evidence, we designed a prospective, randomized, single-blind controlled trial in patients with LDH with radiculopathy, aiming to detect the safety and clinical efficacy of targeted indwelling catheter combined with "4-step" manipulative therapy in patients with LDH. Patient visits were performed at baseline and days 1, 3, 7, and 28 after treatment. Clinical outcomes were measured using visual analog scale for back and leg pain, Oswestry Disability Index (ODI), and clinical symptom scores of the Japanese Orthopedic Association (JAO). The study included 85 eligible patients. They were categorized with a randomization schedule into a Catheter Group (N= 43) and No-Catheter Group (N= 42). Between the measurement points, there was a statistically significant difference in the visual analog scale (back) at days 1, 3, and 7 of follow-up after treatment between the 2 groups. The change was statistically different at days 1 and 3, and a higher change was observed in the Catheter Group compared with the No-Catheter Group. There was a statistically significant difference in change of JOA and ODI scores at day 1 of follow-up after treatment between the 2 groups, and a greater change was seen in the Catheter Group at days 1 and 3 compared with the No-Catheter Group. The small sample size was small, and the follow-up time was short. The study also lacked documents of adjuvant therapies, like individual patient exercise routines and analgesic drug therapy. Both methods were effective in reducing pain intensity and functional disability compared with pretreatment. The Catheter Group showed a more significant decrease in visual analog scale and greater changes in JOA and ODI scores of short/term follow-up, compared with the No-Catheter Group. The therapy project was safe.

Novel approach to characterising individuals with low back-related leg pain: cluster identification with latent class analysis and 12-month follow-up.

Traditionally, low back-related leg pain (LBLP) is diagnosed clinically as referred leg pain or sciatica (nerve root involvement). However, within the spectrum of LBLP we hypothesised that there may be other, unrecognised patient subgroups. This study aimed to identify clusters of LBLP patients using latent class analysis (LCA) and describe their clinical course.The study population were 609 LBLP primary care consulters. Variables from clinical assessment were included in the LCA. Characteristics of the statistically identified clusters were compared and their clinical course over one year was described.A five cluster solution was optimal. Cluster 1 (n=104) had mild leg pain severity and was considered to represent a referred leg pain group with no clinical signs suggesting nerve root involvement (sciatica). Cluster 2 (n=122), cluster 3 (n=188) and cluster 4 (n=69) had mild, moderate and severe pain and disability respectively and response to clinical assessment items suggested categories of mild, moderate and severe sciatica. Cluster 5 (n=126) had high pain and disability, longer pain duration, more comorbidities and was difficult to map to a clinical diagnosis.Most improvement for pain and disability was seen in the first four months for all clusters. At 12 months the proportion of patients reporting recovery ranged from 27% for cluster 5 to 45% for cluster 2 (mild sciatica).This is the first study that empirically shows the variability in profile and clinical course of patients with LBLP including sciatica. More homogenous groups were identified which could be considered in future clinical and research settings.

Commentary on: Neuropathic pain in low back-related leg pain patients: What is the evidence of prevalence, characteristics, and prognosis in primary care? A systematic review of the literature.

Commentary on: Neuropathic pain in low back-related leg pain patients: What is the evidence of prevalence, characteristics, and prognosis in primary care? A systematic review of the literature.

Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort

Background ContextEvidence is lacking on the prognosis and prognostic factors of back-related leg pain and sciatica in patients seeing their primary care physicians. This evidence could guide timely appropriate treatment and referral decisions. PurposeThe present study aims to describe the prognosis and prognostic factors in primary care patients with low back-related leg pain and sciatica. Study DesignThis is a prospective cohort study. Patient SampleThe present study included adults visiting their family doctor with back-related leg pain in the United Kingdom. Outcome MeasuresInformation about pain, function, psychological, and clinical variables, was collected. Good outcome was defined as 30% or more reduction in disability (Roland-Morris Disability Questionnaire). MethodsParticipants completed the questionnaires, underwent clinical assessments, received a magnetic resonance imaging scan, and were followed-up 12 months later. Mixed-effects logistic regression evaluated the prognostic value of six a priori defined variable sets (leg pain duration, pain intensity, neuropathic pain, psychological factors, clinical examination, and imaging variables). A combined model, including variables from all models, examined independent effects. The National Institute for Health Research funded the study. There are no conflicts of interest. ResultsA total of 609 patients were included. At 12 months, 55% of patients improved in both the total sample and the sciatica group. For the whole cohort, longer leg pain duration (odds ratio [OR] 0.41; confidence interval [CI] 0.19–0.90), higher identity score (OR 0.70; CI 0.53–0.93), and patient's belief that the problem will last a long time (OR 0.27; CI 0.13–0.57) were the strongest independent prognostic factors negatively associated with improvement. These last two factors were similarly negatively associated with improvement in the sciatica subgroup. ConclusionsThe present study provides new evidence on the prognosis and prognostic factors of back-related leg pain and sciatica in primary care. Just over half of patients improved at 12 months. Patient's belief of recovery timescale and number of other symptoms attributed to the pain are independent prognostic factors. These factors can be used to inform and direct decisions about timing and intensity of available therapeutic options.

Neuropathic Pain in Low Back-Related Leg Pain Patients: What Is the Evidence of Prevalence, Characteristics, and Prognosis in Primary Care? A Systematic Review of the Literature.

Patients with LBLP may have neuropathic pain. This systematic review emphasizes the paucity of evidence describing the characteristics and prognosis of neuropathic pain in this patient population. Future research investigating prognosis of these patients with neuropathic pain is likely to contribute to better understanding and management.

Patients' Attitudes Toward Nonphysician Screening of Low Back and Low Back Related Leg Pain Complaints Referred for Surgical Assessment.

A questionnaire survey. The aim of this study was to explore patient attitudes toward screening to assess suitability for low back surgery by nonphysician health care providers. Canadian spine surgeons have shown support for nonphysician screening to assess and triage patients with low back pain and low back related leg pain. However, patients' attitudes toward this proposed model are largely unknown. We administered a 19-item cross-sectional survey to adults with low back and/or low back related leg pain who were referred for elective surgical assessment at one of five spine surgeons' clinics in Hamilton, Ontario, Canada. The survey inquired about demographics, expectations regarding wait time for surgical consultation, as well as willingness to pay, travel, and be screened by nonphysician health care providers. Eighty low back patients completed our survey, for a response rate of 86.0% (80 of 93). Most respondents (72.5%; 58 of 80) expected to be seen by a surgeon within 3 months of referral, and 88.8% (71 of 80) indicated willingness to undergo screening with a nonphysician health care provider to establish whether they were potentially a surgical candidate. Half of respondents (40 of 80) were willing to travel >50 km for assessment by a nonphysician health care provider, and 46.2% were willing to pay out-of-pocket (25.6% were unsure). However, most respondents (70.0%; 56 of 80) would still want to see a surgeon if they were ruled out as a surgical candidate, and written comments from respondents revealed concern regarding agreement between surgeons' and nonphysicians' determination of surgical candidates. Patients referred for surgical consultation for low back or low back related leg pain are largely willing to accept screening by nonphysician health care providers. Future research should explore the concordance of screening results between surgeon and nonphysician health care providers. 3.

Diagnosis of nerve root involvement in primary care consulters with low back-related leg pain

Diagnosis of nerve root involvement in primary care consulters with low back-related leg pain

Classification of patients with low back-related leg pain: a systematic review.

BackgroundThe 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.MethodsThe 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.ConclusionNumerous 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-016-1074-z) contains supplementary material, which is available to authorized users.

241 Identification of Nerve Root Involvement in Primary Care Consulters with Low Back–Related Leg Pain: Diagnostic Classification Using Alternative Approaches

241 Identification of Nerve Root Involvement in Primary Care Consulters with Low Back–Related Leg Pain: Diagnostic Classification Using Alternative Approaches

050 One-Year Trajectories of Low Back-Related Leg Pain in Primary Care Patients: Analysis Using Growth Mixture Modelling

050 One-Year Trajectories of Low Back-Related Leg Pain in Primary Care Patients: Analysis Using Growth Mixture Modelling

124 Agreement Among Therapists when Diagnosing Low Back-Related Leg Pain

124 Agreement Among Therapists when Diagnosing Low Back-Related Leg Pain

Reliability among clinicians diagnosing low back-related leg pain.

To investigate agreement and reliability among clinicians when diagnosing low back-related leg pain (LBLP) in primary care consulters. Thirty-six patients were assessed by one of six physiotherapists and diagnosed as having either leg pain due to nerve root involvement (sciatica) or referred leg pain. Assessments were video recorded. In part one, the physiotherapists each viewed videos of six patients they had not assessed. In part two, videos were viewed by another six health professionals. All clinicians made an independent differential diagnosis and rated their confidence with diagnosis (range 50-100%). In part one agreement was 72% with fair inter-rater reliability (K=0.35, 95% CI 0.07, 0.63). Results for part two were almost identical (K=0.34, 95% CI 0.02, 0.69). Agreement and reliability indices improved as diagnostic confidence increased. Reliability was fair among clinicians from different backgrounds when diagnosing LBLP but improved substantially with high confidence in clinical diagnosis.

Low back related leg pain: An investigation of construct validity of a new classification system

Leg pain is associated with back pain in 25-65% of all cases and classified as somatic referred pain or radicular pain. However, distinction between the two may be difficult as different pathomechanisms may cause similar patterns of pain. Therefore a pathomechanism based classification system was proposed, with four distinct hierarchical and mutually exclusive categories: Neuropathic Sensitization (NS) comprising major features of neuropathic pain with sensory sensitization; Denervation (D) arising from significant axonal compromise; Peripheral Nerve Sensitization (PNS) with marked nerve trunk mechanosensitivity; and Musculoskeletal (M) with pain referred from musculoskeletal structures. To investigate construct validity of the classification system. Construct validity was investigated by determining the relationship of nerve functioning with subgroups of patients and asymptomatic controls. Thus somatosensory profiles of subgroups of patients with low back related leg pain (LBRLP) and healthy controls were determined by a comprehensive quantitative sensory test (QST) protocol. It was hypothesized that subgroups of patients and healthy controls would show differences in QST profiles relating to underlying pathomechanisms. 77 subjects with LBRLP were recruited and classified in one of the four groups. Additionally, 18 age and gender matched asymptomatic controls were measured. QST revealed signs of pain hypersensitivity in group NS and sensory deficits in group D whereas Groups PNS and M showed no significant differences when compared to the asymptomatic group. These findings support construct validity for two of the categories of the new classification system, however further research is warranted to achieve construct validation of the classification system as a whole.