Doctors and therapists from all different fields treat low back pain in highly variable ways at an associated high cost to insurers, patients and society. It is a standard practice in Medicine today that treatments related to a large degree of arbitrariness, such as back pain or chest pain treatment, suggests the need for a better understanding of the clinical problem being treated and the creation of clinical guidelines. Certainly all doctors who see a patient with chest pain don’t simply send the patient out for chest pain treatment without knowing what kind of chest pain the patient is having, and therefore not properly diagnosing the problem and resulting in treatment that would be ineffective simply as a result of an incorrect diagnosis.
No, what happens is, the primary care doctor has clinical guidelines for chest pain to follow and according to the patient’s history of onset, past medical history and current symptoms allows the clinician to properly classify, diagnose and treat the patient. A basic set of chest pain guidelines is shown below, that helps the physician diagnose the problem from the information derived during the history, and then confirmed with specific tests during the examination.
Back pain is a symptom, just like chest pain. However, most clinical guidelines in today’s research are based off the symptom of low back pain and are void of a classification system that should be the base of the clinical guidelines. Currently, since there is a small following of doctors that know that there are now clinical guidelines for back pain and that there is a classification system that has an abundant amount of clinical research that supports its intertester reliability with positive outcomes. The lack of knowledge and use of a classification system to guide clinical thinking from the history, to the diagnosis to appropriate treatment for, certainly compromises the quality of clinical decision making for low back pain. Just like chest pain, back pain has a classification system to guide physicians in properly diagnosing and treating low back pain patients so that clinicians can properly classify, diagnose and treat back pain. A lot of the information derived during the history allows the primary care doctor to classify back pain into one of four classification groups, each with its own sub-groups, diagnosis and unique treatment. As shown in the inset, the four back pain classifications are Derangement, Dysfunction, Postural Syndrome and Other.
Those cases that do not fit in the first three syndromes are categorized as “Other” and may include severe spinal pathologies shown below.
Using this classification algorithm by Robin McKenzie, information from the history such as onset, location, response to repeated movements and static positions (bending, twisting…), when the pain occurs (constant, intermittent) and whether the pain occurs with Pain During Movement (PDM), End-Range Pain (ERP) or only on static loading provides the information necessary to properly classify back pain. Understanding what movements or positions cause the pain, what movement or position relieve the pain or whether postures and movements don’t have an effect on the pain guides the classification process. This provisional classification is then tested in the physical examination to determine if it is correct or whether there is new information found to divulge information that challenges the it.
“Every patient contains a truth… The clinician must adopt a conscious humility towards the truth concealed within every patient" (Cyriax 1982 p45).
The patient is the only person who knows the history, onset, symptom pattern and symptom behavior, as well as what aggravates and what relieves their pain. The keen clinician can discover the stage and nature of the disorder as well as the prognosis and management required, simply from the history. Understanding the effect that different movements and positions have on symptoms and use it to create an appropriate management strategy is highly reproducible between providers and has been found to be an effective system to classify back pain that results in the proper diagnosis and treatment being done.
To determine what classification of pain you have, or learn more about back pain classification sign-up for one of our low back pain & sciatica workshops or give us a call for your assessment.