Evaluation of the relative contributions of various structures in chronic low back pain. Correlation of clinical examination characteristics with three sources of chronic low back pain. Diagnostic Accuracy of the Clinical Examination in Identifying the Level of Herniation in Patients with Sciatica Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. An experimental study. Results of Sacroiliac Joint Double Block and Value of Sacroiliac Pain Provocation Tests in 54 Patients With Low Back Pain Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation Symptomatic efficacy of stabilizing treatment versus laser therapy for sub-acute low back pain with positive tests for sacroiliac dysfunction: a randomised clinical controlled trial with 1 year follow-up. Intertester reliability of judgments of the presence of trigger points in patients with low back pain. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. The Reliability of the Low Back Outcome Score for Back Pain Prevalence of lumbar facet joint pain in chronic low back pain. Low Back Pain Rating scale: validation of a tool for assessment of low back pain Low back pain in general practice: reported management and reasons for not adhering to the guidelines in The Netherlands. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. The Relative Contributions of the Disc and Zygapophyseal Joint in Chronic Low Back Pain Intertester reliability of a low back pain classification system.
An attempt was made to determine the relative contribution of various structures to chronic low back pain , including facet joint(s ) , disc(s ) , and sacroiliac joint(s ) in a prospect i ve evaluation . Precision diagnostic blocks , including disc injections , facet joint blocks , and sacroiliac joint injections , are frequently used . In contrast , selective nerve root blocks or transforaminal epidural injections are used occasionally to evaluate persistent or recurrent low back pain in patients without appropriate radiologic or neurophysiologic diagnosis . One hundred and twenty patients with a chief complaint of low back pain were evaluated with precision diagnostic injections , which included medial branch blocks , provocative discography and sacroiliac joint injections . In 40 % ( 95 % CL , 31 % , 49 % ) , of the patients , facet joint pain was diagnosed ; and in 26 % ( 95 % CL , 18 % , 34 % ) of the patients discogenic pain was diagnosed ; and 2 % of the patients were diagnosed with sacroiliac joint pain BACKGROUND CONTEXT Research has demonstrated some progress in using a clinical examination to predict discogenic or sacroiliac ( SI ) joint sources of pain . No clear predictors of symptomatic lumbar zygapophysial joints have yet been demonstrated . PURPOSE To identify significant components of a clinical examination that are associated with symptomatic lumbar discs , zygapophysial joints and SI joints . STUDY DESIGN A prospect i ve , criterion-related concurrent validity study performed at a private radiology practice specializing in spinal diagnostics . PATIENT SAMPLE The sample consisted of 81 patients with chronic lumbopelvic pain referred for diagnostic injections .  OUTCOME MEASURES Contingency tables were constructed for nine features of the clinical evaluation compared with the results of diagnostic injections . Statistical analysis included chi-squared test for independence , phi and odds ratios with confidence intervals . METHOD Patients received blinded clinical examinations by physical therapists , and diagnostic injections were used as the criterion st and ard . RESULTS Significant relationships were found between discogenic pain and central ization of pain during repeated movement testing , and pain when rising from sitting . Lumbar zygapophysial joint pain was associated with absence of pain when rising from sitting . Sacroiliac joint pain was related to three or more positive pain provocation tests , pain when rising from sitting , unilateral pain and absence of lumbar pain . CONCLUSIONS Significant correlations exist between clinical examination findings and symptomatic lumbar discs , zygapophysial and SI joints . The strongest relationships were seen between SI joint pain and three or more positive pain provocation tests , central ization of pain for symptomatic discs and absence of pain when rising from sitting for symptomatic lumbar zygapophysial joints Study Design . Cross sectional Objective . To investigate the ability of the neurological examination to identify the specific level of a disc herniation in patients with sciatica and confirmed disc herniation . Summary of Background Data . Tests included in a neurological examination theoretically provide accurate diagnostic information about the level of the herniated disc . However , there is currently very little evidence about the diagnostic accuracy of individual tests or combinations of tests . Methods . The study included 283 patients with sciatica and confirmed disc herniation from a previous r and omized controlled trial . The reference test for the current study was the MRI scan , reported for level of disc herniation . Index tests investigated were a neurologist 's overall impression of the level of disc herniation , individual neurological tests ( e.g. , sensation testing ) and multiple test findings ( i.e. , the number of positive tests ) . The index tests were performed blinded to the MRI results . The diagnostic accuracy of the index tests in predicting herniations at the lower three lumbar discs was investigated using area under the curve ( AUC ) , sensitivity and specificity . Results . None of the individual neurological tests from the clinical examination were highly accurate for identifying the level of disc herniation ( AUC < 0.75 ) . The outcome of multiple test findings was slightly more accurate but did not produce high sensitivity and specificity . The dermatomal pain location was generally the most informative individual neurological test . The overall suspected level of disc herniation rated by the neurologist after a full examination of the patient was more accurate than individual tests . At L4/5 and L5/S1 herniations the AUC for neurologist ratings was 0.79 and 0.80 respectively . Conclusion . The current study did not find evidence to support the accuracy of individual tests from the neurological examination in identifying the level of disc herniation demonstrated on MRI . A neurologist 's overall impression was moderately accurate in identifying the level of disc herniation Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference st and ards . The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference st and ard . In a blinded concurrent criterion-related validity design study , 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures  were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections . The central isation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process . Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection . Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain . In the primary subset analysis of 34 patients , sensitivity , specificity and positive likelihood ratio ( 95 % confidence intervals ) of the clinical evaluation were 91 % ( 62 to 98 ) , 83 % ( 68 to 96 ) and 6.97(2.70 to 20.27 ) respectively . The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone . A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac The purpose s of this study were to 1 ) propose a method to detect sacroiliac joint dysfunction ( SIJD ) , 2 ) test the interrater reliability of the method on a group of patients with low back pain ( LBP ) , and 3 ) document changes in innominate tilt after manipulation of the sacroiliac joint . Criteria for SIJD were established by the authors . Twenty-six patients with unilateral LBP were examined independently for presence of SIJD by two examiners . Interrater agreement for presence or absence of SIJD was found to be excellent ( Cohen 's Kappa = .88 ) . Twenty of the patients who met the criteria for SIJD were r and omly assigned to an Experimental Group ( n = 10 ) or a Control Group ( n = 10 ) . The left and right innominate bones of these 20 patients were measured for tilt before and after the intervention period . The sacroiliac joint of the patients in the Experimental Group was manipulated during the intervention period , whereas the patients in the Control Group received no treatment . Data were analyzed using a mixed three-factor analysis of variance . The data analysis revealed that the manipulation procedure result ed not only in an altered innominate tilt of the same side but also in an equal and opposite tilt of the opposite side ( F = 67.07 ; df = 1.18 ; p less than .05 ) . The results indicate that SIJD can be identified reliably in patients with LBP and that a manipulative procedure purported to be specific to the sacroiliac joint changes innominate tilt bilaterally and in opposite directions Study Design This prospect i ve study consisted of the evaluation of a double sacroiliac block in patients with low back pain . Objectives To determine the prevalence of sacroiliac pain in a selected population of patients suffering from low back pain , and to assess certain pain provocation tests . Summary of Background Data Previous studies have implicated the sacroiliac joint as a potential etiology of back and leg pain , but none has tested double anesthetic blocks in a prospect i ve fashion . Methods Fifty‐four patients with unilateral low back pain , pain mapping compatible with a sacroiliac origin , tenderness over the sacroiliac joint , and no obvious source of pain in the lumbar spine were selected for a double anesthetic block . The procedure consisted of a thorough clinical examination with a visual analog scale , testing of sacroiliac pain provocation tests followed by a first screening block with a short‐acting anesthetic . A second examination consisting of the same tests assessed the efficacy of the first block . If results were positive , a confirmatory block was performed . All blocks were performed under fluoroscopic guidance . Results Nineteen patients had a  positive response to the first block . Among them , 10 ( 18.5 % ) were temporarily relieved by the confirmatory block . No pain provocation test reached statistical significance . Conclusion The present study suggests the sacroiliac joint is an uncommon but real source of low back pain . The accuracy of some of the presumed “ sacroiliac pain provocation tests ” is question ed Background Minimal interventional procedures are frequently applied in patients with mechanical low back pain which is defined as pain presumably result ing from single sources : facet , disc , sacroiliac joint or a combination of these . Usually , these minimal interventional procedures are an integral part of a multidisciplinary pain programme . A recent systematic review issued by the Dutch Health Insurance Council showed that the effectiveness of these procedures for the total group of patients with chronic low back pain is yet unclear and cost-effectiveness unknown . The aim of the study is to evaluate whether a multidisciplinary pain programme with minimal interventional procedures is cost-effective compared to the multidisciplinary pain programme alone for patients with chronic mechanical low back pain who did not respond to conservative primary care and were referred to a pain clinic . Methods All patients with chronic low back pain who are referred to one of the 13 participating pain clinics will be asked to participate in an observational study . Patients with a suspected diagnosis of facet , disc or sacroiliac joint problems will receive a diagnostic block to confirm this diagnosis . If confirmed , they will be asked to participate in a R and omized Controlled Trial ( RCT ) . For each single source a separate RCT will be conducted . Patients with a combination of facet , disc or sacroiliac joint problems will be invited for participation in a RCT as well . An economic evaluation from a societal perspective will be performed alongside these four RCTs . Patients will complete question naires at baseline , 3 and 6 weeks , 3 , 6 , 9 and 12 months after start of the treatment . Costs will be collected using self-completed cost question naires . Discussion No trials are yet available which have evaluated the cost-effectiveness of minimal interventional procedures  in patients with chronic mechanical low back pain , which emphasizes the importance of this study .Trial registration numberNational Trial Register : AIM Back pain is a highly frequent condition due to many causes , although most of them can not be established with certainty . It is also the current clinical and scientific belief that sacroiliac joint syndrome can be a specific low back pain cause . Nonetheless the existence of clinical tests aim ed at highlighting the responsibility for lumbar pain secondary to sacroiliac dysfunction , it is not easy to diagnose it with either manual or instrumental means . Moreover , uncertainty is diffuse when facing a correct treatment for patients involved . The aim of this study was to verify , in patients with acute or sub-acute low back pain and positive sacroiliac signs , the efficacy of a stabilising therapy ( orthosis and exercises , with previous mesotherapy ) directly targeted to sacroiliac dysfunction versus a symptomatic usual care such as He-Ne laser therapy . METHODS Over a period of 14 months , we recruited 22 patients ( 10 females , mean age 44+/-11 ) with acute and sub-acute low back pain and symptoms and signs suggesting a sacroiliac dysfunction . They were r and omised in a Group laser ( GL ) , 11 patients treated with He-Ne laser therapy targeting the sacroiliac region , and a Group stabilisation ( GS ) , 11 patients treated with mesotherapy , a specific dynamic sacroiliac support ( ILSA ) and specific exercises . Outcome criteria included VAS , and Mens and Laslett sacroiliac tests . RESULTS Out of 449 acute and sub-acute low back pain out- patients , 22 ( 4.9 % ) had symptoms and signs suggesting a sacroiliac dysfunction . A reduction of pain was achieved only in the GS . All pain-provocation and stability tests were negative both after the end of treatment and at the follow-up only in the GS . CONCLUSIONS A targeted approach based on mesotherapy , a specific sacroiliac belt and specific stabilizing exercises proved its efficacy in acute and sub-acute low back pain patients with symptoms and signs suggesting a sacroiliac dysfunction . As soon as it will be possible to identify particular spine syndromes in the universe of non specific low back pain , there will also be the possibility to employ specific therapies The purpose of this study was to determine the intertester reliability of assessment s of the presence of trigger points in the region of the lumbar spine of patients with low back pain ( LBP ) . A total of six trigger points described by Travell and Simons were studied . The trigger point examination procedures described by Travell and Simons were used by 12 physical therapists . R and omly paired therapists examined 50 patients for 197 trigger points . The Kappa coefficient , percent agreement , the observed proportion of positive agreement ( Ppos ) , and the observed proportion of negative agreement ( Pneg ) were used to describe reliability . Kappa values ranged from .29 to .38 . Percent agreement ranged from 76 % to 79 % . Ppos ranged from .43 to .52 . The low Kappa and Ppos values suggest different therapists are unable to reliably determine when a trigger point is present in a patient with LBP . This study suggests the usefulness of examining for the presence of trigger points in patients with LBP should be question ed BACKGROUND Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources , overlapping clinical features , and nonspecific radiologic findings . Diagnostic injection techniques are employed to isolate the source ( s ) of pain . Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply . Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test ( i.e. , accuracy , safety and reproducibility ) . Accuracy must be compared with a " gold " or criterion st and ard that can confirm presence or absence of a disease . There is , however , no available gold st and ard , such as biopsy , to measure presence or absence of pain . Hence , there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections . OBJECTIVES To evaluate accuracy , safety and reproducibility of facet or zygapophysial joint injections in diagnosing chronic spinal pain of facet joint origin . STUDY DESIGN A systematic review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing spinal pain from facet joints . METHODS Relevant literature on diagnostic facet injections was identified through data base search es . Excluded were abstract s , review s , book chapters , case reports and studies based on single blocks or blocks without radiologic control . Prospect i ve studies with placebo control , or controlled comparative local anesthetic blocks , were given priority over retrospective studies . Each study was grade d using AHRQ and QUADAS criteria . The level of evidence was classified as conclusive , strong , moderate , limited , or inconclusive . RESULTS Available literature pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain . There was moderate evidence in the diagnosis of pain arising from thoracic facet joints . CONCLUSION The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves ( medial branch or dorsal ramus ) are reproducible , reasonably accurate , and safe . The sensitivity , specificity , false-positive rates , and predictive values of these diagnostic tests for neck and low back pain have been vali date d and reproduced in multiple studies Study Design . A prospect i ve test-retest study was conducted to investigate both new and follow-up patients with low back pain presenting to an orthopedic surgeon specializing in back pain . Objectives . To further vali date the internal consistency and test – retest reliability of the Low Back Outcome Score , and to compare these results with other condition-specific disability scales . Summary of Background Data . To be useful in clinical practice , health-specific question naires must demonstrate reliability and validity . Several disease-specific question naires for low back pain have been vali date d to different extents . Methods . In this study , 102 new and 42 follow-up patients consecutively attending a consultant clinic completed the Low Back Outcome Score on their visit  , then again after an interval of 1 week in postal form . This instrument also was completed by 230 patients presenting to a physiotherapist . Results . A response rate of 90 % was achieved for the postal question naire . A test of internal consistency conducted with the study sample achieved a Cronbach alpha coefficient of 0.85 . Overall agreement for test – retest reliability was 84 % , and the reliability coefficient ( K ) reached a range of 0.51 to 0.86 ( P < 0.05 ) . A Bl and /Altman plot was calculated , demonstrating that only 5 % of patient scores change by more than 11.6 scale points between test and retest , which is not sufficient to change outcome categories . Conclusion . The Low Back Outcome Score appears to have good internal consistency and test – retest reliability for use in clinical practice This prospect i ve study was design ed to determine the prevalence of lumbar facet joint pain in a consecutive series of patients with chronic low back pain treated at an interventional , multidisciplinary private pain management practice utilizing double diagnostic blocks , to determine the prevalence of false positive rate of uncontrolled facet joint blocks , and to determine the relationship of clinical features of responders and non-responders to double diagnostic blocks . One hundred and twenty patients with low back pain with or without lower extremity pain were selected . The procedure consisted of diagnostic blocks using lidocaine and bupivacaine on separate occasions , usually two weeks apart . Each facet joint nerve was infiltrated with either 0.4 to 0.6 ml of 1 % lidocaine ( Xylocaine(R ) ) or 1 % lidocaine ( Xylocaine(R ) ) and 0.25 % bupivacaine ( Marcaine(R ) ) . A definite response was defined as substantial with at least 75 % relief of pain in the symptomatic area following local anesthetic block . Confirmatory blocks using bupivacaine 0.25 % were performed at the same levels as the first injection if definite relief was obtained . The response to bupivacaine blocks which lasted longer than the lidocaine blocks was accepted as a positive response . All blocks were performed under fluoroscopic guidance . Eighty-one patients ( 67.5 % ) reported a definite response to lidocaine blocks . Confirmatory blocks with bupivacaine were performed in all 81 patients with 54 patients , i.e. 45 % of total sample or 66.6 % of lidocaine positive group reporting definite response with a false positive rate of 41 % . Prevalence and relationship of pain referral pattern in patients with and without facet joint pain confirmed by double blocks showed no significant correlation . We found no relationship between the history , physical findings , age , gender , trauma , duration of pain , and diagnostic blocks . However , history of previous surgery showed a negative correlation as only 29 % of the patients after previous surgery were positive in contrast to 51 % of the nonsurgical population . The results of this study echo previous concerns of reliability of uncontrolled single blocks , history , and clinical features . This study demonstrated that the facet joint is a source of pain in 45 % of the patients suffering with chronic low back pain in an interventional pain management setting in a private practice Low Back Pain Rating scale is an index scale which includes measurements of pain intensity , disability , and physical impairment . The scale was design ed to monitor the outcome of clinical trials of low back pain treatment . It has been vali date d in 58 patients following first-time discectomy .  The scale rating can be rapidly carried out and requires no special aids . With slight modification it can be used in office and telephone interviews , as well as postal question naires . These modifications only slightly reduce the quantity of information gathered . In the study , a high rater agreement ( 97.7 % ) was found without level difference between two observers using the scale . The validation process included : construct validity , criterion-related validity and item bias , relative to Global Assessment s pronounced by the patient and an experienced clinician . Low Back Pain Rating scale hs been shown to be valid and reliable in the assessment of low back pain BACKGROUND Although guidelines for the management of low back pain have been published in the past decade , there is potential for further improvement in back pain care . AIM To document the management of non-specific low back pain by general practitioners ( GPs ) in the Netherl and s , to determine how this management of care is related to patient and physician factors , and to explore possible reasons for not adhering to the guidelines . METHOD A prospect i ve study was set up in which 57 GPs in 30 general practice s completed a computerised question naire after each consultation for low back pain during a four-month period . RESULTS Of 1640 back pain contacts , 1180 referred to non-specific low back pain . Diagnostic tests were ordered in 2 % of first consultations and in 7 % of follow-up consultations within one episode . The advice to  stay active  despite  pain  was given in 76 % and 69 % of these cases respectively . Patients were prescribed an  analgesic  in 53 % and 41 % of cases respectively ( mainly NSAIDs [ 80 % ] ) . Patients were referred to a physiotherapist in 22 % of first and in 50 % of follow-up consultations . Older patients were physically examined less often , prescribed analgesics more often , and were told less often that staying active could benefit them . The advice to remain active was omitted more often when symptoms lasted longer . Only a small part of the variance in management was accounted for by patient characteristics or by differences between practice s. CONCLUSION The management of low back pain met the guidelines to a large extent . Management decisions were often related to characteristics in which the guidelines lack differentiation . Important reasons for non-adherence were perceived patients ' preferences . Further implementation of guidelines will be difficult unless doctors ' and patients ' views are more explicitly known OBJECTIVE To compare the diagnostic accuracy of a multitest regimen of 5 sacroiliac joint ( SIJ ) pain provocation tests with fluoroscopically controlled double SIJ blocks using a short- and long-acting local anesthetic in order to reduce the exposure of patients to unnecessary invasive SIJ procedures . DESIGN Prospect i ve , observational study . SETTING Hospital setting . PARTICIPANTS Sixty patients with chronic low back pain . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Visual analog scale score and receiver operating characteristic ( ROC ) curve . RESULTS Twenty-seven patients responded positively to the blocks , of whom 23 were found positive after the multitest regimen and 4 were negative . For the nonresponders ( n=33 ) , these figures were 7 positive and 26 negative . The calculated sensitivity and specificity were .85 ( 95 % confidence interval [ CI ] , .72-.99 ) and .79 ( 95 % CI , .65-.93 ) , respectively . Positive and negative predictive values were .77 ( 95 % CI , .62-.92 ) and .87 ( 95 % CI , .74-.99 ) , respectively . The positive likelihood ratio was 4.02 ( 95 % CI , 2.04 - 7.89 ) ; the negative likelihood ratio was .19 ( 95 % CI , .07-.47 ) . The area under the ROC curve was .799 . CONCLUSIONS The test regimen with 3 or more positive tests is indicative of SIJ pain . It can be used in early clinical decision making to reduce the number of unnecessary minimally invasive diagnostic SIJ procedures Study Design . A prospect i ve cross-sectional analytic approach was taken . Objectives . This study sought to determine the relative contribution of the disc and the zygapophyseal Joint as a pain source in patients with chronic low back pain . Summary of Background Data . Previous studies have employed either zygapophyseal joint blocks or discography , but in no studies have both procedures been performed . Methods . Ninety-two consecutive patients with chronic low back pain were studied using both discography and blocks of the zygapophyseal joints . Results . Thirty-six patients ( 39 % ) had at least one positive discogram as defined by exact pain reproduction , an abnormal image , and a negative control . Eight patients responded to both a screening zygapophyseal joint block using lignocaine and confimatory block using bupivacaine . Only three patients had both a positive discogram and a symptomatic zygapophyseal joint . Conclusions . In patients with chronic low back pain , the combination of discogenic pain and zygapophyseal joint pain is uncommon STUDY DESIGN This prospect i ve study of intertester reliability examined pairs of therapists ' ability to agree independently on a patient 's low back pain diagnosis . OBJECTIVE To determine the intertester reliability of a low back pain classification system among experienced and novice clinicians . BACKGROUND Many of the disparate categorization schemes for patients with low back pain are purely nominal , assigning design ations based on the presumptive source of the problem without providing any practical guide for rehabilitation . A useful classification scheme reliably groups patients into treatment-directing categories . METHODS The study included 204 patients with low back pain referred to 10 clinics across Canada . Paired physiotherapists performed separate physical examinations on each patient . Both examiners then completed a simple ballot choosing one of five pain patterns . RESULTS Agreement on patient classification by independent examiners was 78.9 % ( kappa = 0.61 ) . CONCLUSION This clinical ly relevant and clearly defined pain pattern system uses key elements of the history and examination to classify patients with low back pain . The pattern provides a framework for initiating active rehabilitation strategy . Using this approach , clinicians agreed on the categorization of 78.9 % of mechanical low back pain cases
The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ ( but not the facet joint ) as the source of low back pain .
Clinical practice guidelines state that the tissue source of low back pain can not be specified in the majority of patients .
However , there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain .
The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc , facet joint or sacroiliac joint ( SIJ ) as the source of low back pain .