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FOTO Rehab Outcomes Blog

Clinical Classification in Low Back Pain

As the FOTO Team has been working on Data Trends in U.S. Healthcare and Patient Rehabilitation, it is quite clear that a substantial amount of patients receive rehabilitative services for low back pain.  I decided to use the data in this report to help fine tune information for blog posts so that maybe what I share is more helpful to the majority of you who use FOTO.

Since I know clinicians treat a lot of patients who have low back pain, I thought this article might have clinical relevance.

When I think of conversations with patients, they are highly focused on what is wrong and why they have back pain. When I think of clinicians, clinicians are focused on determining which treatment philosophy will provide the best outcome for the patient. 

This particular review is a little different than the treatment based classification systems we see in US literature. This review is focused on a diagnostic classification system and reviewing the current research available to weigh in the strength of the evidence in determining the structure involved for the patient's presenting condition. The structures considered include: intervertebral disc, facet joint, sacroiliac joint, disc herniation with nerve root involvement, spinal stenosis, spondylolisthesis, fracture, myofascial pain, peripheral nerve, and central sensitization.  Although the setting is a primary care setting, I believe it still has value due to direct access opportunities available for consumers.

The only problem I have with this particular study has to do with what we know about pain science. We need to somehow merge pain science and biomedical models. The other immediate thought I have: non-specific low back pain. I wonder how many patients do not fit in any particular classification? For low back pain, it seems more often than not that we truly have no clue exactly why a person has low back pain. We need to somehow bridge that and become comfortable with the unknown and help patients also become comfortable with not knowing.

Below you will find a quick view of the abstract. 


Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews.



Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.


A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the QualityAssessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.


Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.


This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

  2017 May 12;18(1):188. doi: 10.1186/s12891-017-1549-6.

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