It must be practical. When considering whether to attend a seminar or read a research article, I want it to be practical for my everyday practice. When I come across information that is practical in practice, I want to share it. Such is the case with this feature; I would like to share with you two articles from different authors that I believe can have a great impact on your practice when it comes to low back pain.
We know that musculoskeletal pain has an enormous impact on our healthcare system from a pain and suffering standpoint as well as a financial standpoint. According to the “The Burden of Musculoskeletal Disease in the United States,”(1) the annual cost of musculoskeletal disease in the United States is $980 billion. The Burden of Musculoskeletal Disease goes on to say, “Musculoskeletal conditions are among the most debilitating nonfatal health diseases. Persons affected with back pain and arthritis have high rates of chronic pain and disability, reducing the quality of life and limiting ability to participate in many common activities.”
The first article for you to consider is from Vining et al. entitled “Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain.”(2)
Back pain is one of the most common problems that people experience. Despite its high prevalence, doctors face a big challenge when it comes to diagnosing problems that cause low back pain. Rarely can a diagnosis be confirmed with absolute certainty. Because of this problem, doctors and researchers often diagnose back pain as “back pain” or “nonspecific back pain” to acknowledge this diagnostic uncertainty. Unfortunately, such diagnoses simply restate a symptom and fail to adequately identify a suspected cause, distinguish features of a problem, or don’t explain a problem to help people understand a condition to decide about care.
Many scientists recommend certain conditions to be diagnosed specifically because they are thought to require certain types of care. However, to diagnose some conditions causing low back pain, one must be able to distinguish them from others. Practitioners have few tools that use research findings to form examination and diagnosis.
Several diagnostic tests, though not perfect, can help identify reasonable working diagnoses. Now, working diagnoses are not perfect either, but they potentially can be used to identify suspected causes, distinguish conditions by their characteristics, guide care decisions, and improve communication between providers and with patients.
Vining et al. analyzed a large body of research on diagnostic tests for low back pain. This informed the development of an evidence-based exam designed to generate working diagnoses. They also developed a practical checklist designed to guide and streamline examination and coordinate exam data into a single place that serves to document and display evidence for or against working diagnoses.
To summarize the article, Vining et al. proposes three diagnostic categories for common conditions causing or contributing to low back pain. These are:
• Nociceptive (pain from nociceptor activation in response to actual or threatened damage to non-neural tissue)
• Neuropathic (pain caused by a lesion or disease of the somatosensory nervous system)
• Sensitization (increased responsiveness of nociceptive neurons to their normal input and/or recruitment of a response to normally subthreshold inputs)
Each of these categories has a specific diagnosis subtype:
• Nociceptive: Discogenic, facet joint, SI joint, myofascial
• Neuropathic: Neurogenic claudication, radicular pain, radiculopathy, and peripheral entrapment (piriformis syndrome and thoracolumbar syndrome)
• Sensitization: Central, peripheral
Beyond these diagnostic categories and conditions, Vining and his team have identified in-office examination and historical evidence is needed to support a working diagnosis. These in-office exams and historical screens are based upon a systematic review of the literature.
It is beyond the scope and purpose of the article to break down all of this for you, but it is the purpose of this article to point out the evidence-based examination that this piece of research presents. Vining has presented an examination based upon the literature that can provide you, the practitioner, with a solid framework to identify the probable source of the patient’s low back pain. You are encouraged to review this article and the specifics of the examination. You will find that many of the items in the exam are already being done in your examination process or can be easily implemented.
In addition, this research gives you an order and sequencing of an examination based on the patient position during this exam. In my opinion, this is the preferred way to provide an efficient and effective neuromuscular examination. When a patient presents in acute or even chronic low back pain, the provider needs to gather all the information from the examination as possible in a manner that is least cumbersome for the patient. Vining et al. have done a wonderful job of providing practitioners with an evidence-based examination that is extremely practical.
The second article I present to you for consideration is “Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial.”(3) This article presents evidence that the use of three-arch custom orthotics can improve chronic low back pain and functional health status. The objective of this research is “to investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain compared with no treatment.”
Some forms of low back pain were excluded from the Cambron et al. study. If you were to review the exclusion list, the primary category of chronic low back pain patients who were involved in this study would fall under the category that Vining described as nociceptive (discogenic, facet joint, SI joint, myofascial).
The summary results of the Cambron et al. study were:
• Low back pain improved by 34.5% with three-arch custom orthotics alone
• Low back pain improved by 40.4% with three-arch custom orthotics and chiropractic care
• Function improved by 18.5% with three-arch custom orthotics alone
• Function improved by 32.3% with three-arch custom orthotics and chiropractic care
Here is what is significant and practical to me. If a practitioner can improve diagnostic accuracy by applying the evidence-based exam and category principles recommended by Vining and improve treatment outcomes to at least one of those categories of patients through the researched treatments of three-arch custom orthotics and chiropractic care (Cambron study), I have done a great service to patients suffering from low back pain.
The beginning of this article started with the premise that research and seminars need to be practical for the practicing doctor. Summaries of two articles were presented that can improve your efficiency and accuracy of diagnosis and improve your treatment outcomes. Now that is practical!
Dr. Jeff McKinley is a graduate of Lipscomb University in Nashville, TN and Logan College of Chiropractic. He completed post-doctorate training in Sports Injuries and is a Certified Chiropractic Sport Physician (CCSP). As a member of the Foot Levelers Speakers Bureau, he travels the country leading seminars on key chiropractic topics. He is the owner of McKinley Chiropractic in McMinnville, TN. Visit his website at drmckinley.com.
References
1. United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Fourth Edition, 2020. Rosemont, IL. Available at http: www.boneandjointburden.org. Accessed on Jan. 25, 2022.
2. Robert D. Vining, DC, DHSc, Amy L. Minkalis, DC, MS, Zacariah K. Shannon, DC, MS, Elissa J. Twist, DC, MS. Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain. Journal of Manipulative & Physiological Therapeutics . 2019;42(9):665676. (November 2019)
3. Jerrilyn A. Cambron, DC, MPH, PhD, Jennifer M. Dexheimer, BS, LMT, Manuel Duarte, DC, MSAc, DABCO, DAC BSP, Sally Freels, MS, PhD. Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2017;98(9):1752-1762.
