Evidence-based low back pain classification. Improving care at its foundation.
With the cause of most low back pain unknown, patients are often given an unproven, even inventive, diagnosis or pain theory, followed by treatment targeting the clinician's theories and educational background, rather than the patient's characteristics. When recovery occurs, it is attributed to the treatment, despite the recognized positive natural history. The resulting wide variations in care add substantially to the high costs of low back care. Meanwhile, there is a growing number of studies supporting the benefits of classifying low back patients based on a unique form of clinical assessment. This is a brief description and overview of the scientific literature focusing on a form of clinical evaluation that elicits patients' immediate pain patterns in response to a standardized sequence of lumbar mechanical tests consisting of repeated end-range movements and positions. Multiple studies report good/excellent inter-examiner reliability in performing this type of clinical assessment. Most low back patients can be classified into pain response categories with strong evidence that various categories predict both good and poor outcomes. One recent randomized controlled trial of a large low back subgroup identified with this form of assessment reported highly favorable outcomes when treatment was determined by assessment findings rather than prescribing current ''evidence-based'' care for all. By identifying reliable assessment methods that determine validated low back pain subgroups, multiple studies indicate that outcomes can be accurately predicted for most patients, with new evidence that these same assessment findings likely distinguish efficacious from ineffective, even counter-productive, treatments.
Donelson
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Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. donelson@dartmounth.edu