Evidence-Based Resources for Low Back PainRobert Vining, DC, DHSc

ProfessorAssociate Dean of Clinical Research

September 17, 2021

Case Review

1. Are the patient's symptoms reflective of a visceral disorder or a serious or potentially life-threatening illness?

2. From where is the patient's pain arising?

3. What has gone wrong with this person as a whole that would cause the pain experience to develop and persist?

3 Questions of Diagnosis

• Symptom source

• Psychological• Social• Functional• Environmental

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 Musculoskelet Disord 2007, 8: 75.

The search

•Proposed terms

•Evidence-based exam

•Diagnostic checklist

•Organize•Document•Visualize• Justify

Vining et al., An Evidence-based diagnostic classification system for low back pain. J Can Chiropr Assoc 2013; 57(3)

Unfinished work

•5-years

•Terminology

•Recent research

•Systematic review

1. Responsibility

2. Findings

3. Inform

Vining RD, Minkalis AL, Shannon ZK, Twist EJ. Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain. J Manipulative Physiol Ther. 2019;42(9):665-676. doi:10.1016/j.jmpt.2019.08.003

• Hypotheses: based on evidence• Flexible• Accept possibility of error • Require continual critical analysis• Inform management decisions• Facilitate education, informed

consent, & communication

Vining RD, Minkalis AL, Shannon ZK, Twist EJ. Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain. J Manipulative Physiol Ther. 2019;42(9):665-676.

Systematic Review

4 authors

8 degrees

20+ years

1.5 + 1 years

3995 articles

36 final

Vining R, et al. Current evidence for diagnosis of

common conditions causing low back pain:

Systematic review and standardized terminology

recommendations. J Manipulative Physiol Ther.

Vining RD, Shannon ZK, Minkalis AL, Twist EJ. Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations. J Manipulative Physiol Ther. 2019;42(9):651-664. doi:10.1016/j.jmpt.2019.08.002

Vining RD, Shannon ZK, Minkalis AL, Twist EJ. Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations. J Manipulative Physiol Ther. 2019;42(9):651-664. doi:10.1016/j.jmpt.2019.08.002

Neurogenic Claudication

Radicular Pain vs

Radiculopathy

Thoracolumbar Syndrome

• Pain in cluneal nerve distribution

• Iliac crest trigger point

• Tender Iliac crest skin rolling

• Tender TL spinous process

Dimond M. Rehabilitative principles in the management of thoracolumbar syndrome: A case report. J Chiropr Med 2017;16:331-339

• Allodynia • Hypersensitivity• Migrating pain• Pain long after a stimulus • Ambiguous syndromes (e.g., fibromyalgia)

Wallden M, Nijs J. Before & beyond the pain – Allostatic load, central sensitivity and their role in health and function. Journal of bodywork & Movement Therapies 27 (2021) 338-392

Vining RD, Shannon ZK, Minkalis AL, Twist EJ. Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations. J Manipulative Physiol Ther. 2019;42(9):651-664. doi:10.1016/j.jmpt.2019.08.002

Discogenic Pain

• Centralization

70-75%

Facet Pain

• Age over 50

• Symptoms relieved with sitting

• Onset paraspinal

• Positive extension-rotation test

80%

Methods

• Literature Review

• Seed statements

• Expert review

• Delphi

Delphi

• 113 VA clinicians

• 39 participants

Neurogenic Claudication

• Education

• Neurodynamics

• Muscle stretching

• Mobilization

• Goal setting, graded activity, pacing, relaxation, body positioning techniques

• Home exercise

• Spinal manipulation

0

1

2

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Cognitive-Emotional

Social

Whole-Person Approach

0

1

2

3

4

5

6

7

8

Nociceptive

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Cognitive-Emotional

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Cognitive-Emotional

Social

Facet PainBaseline

0 1 2 3 4 5 6 7 8 9

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Cognitive-Emotional

Social

Facet PainBaseline

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Cognitive-Emotional

Social

Facet PainBaseline

0

12

34

56

78

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Cognitive-Emotional

Social

Follow-upBaseline Follow-up

0

1

2

3

4

5

6

7

8

Nociceptive

Neuropathic

Pathoanatomy

Sensitization

Comorbidity

Mobility

Cognitive-Emotional

Social

Neurogenic ClaudicationBaseline

Nociceptive: SM, therapeuticexercise, myofascial therapy

Neuropathic: Neurodynamics,body positioning

Pathoanatomy:

Sensitization: Pain education,graded activity training,

abdominal breathing

Comorbidity: Co-management

Mobility: Home exercise, gradedactivity training, joint mobilization,muscle stretching, paced activity

Cognitive-Emotional: Goalsetting, Pain education, Co-

management

Social: Connect with socialgroups/resources (chaplain,

marriage counselor, ...)

Neurogenic Claudication

•PMID: 31864769•PMID: 31864770•PMID: 31870637