A Clinical Model for the Diagnosis and Management
of Patients with Spinal Pain Syndromes

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

Clinical Models for the Diagnosis and Management of Patients with Spinal Pain Syndromes

	Clinical Decision Rule for Primary Care Patient with Acute Low Back Pain at Risk of Developing Chronic Pain Spine J. 2015 (Jul 1); 15 (7): 1577–1586 ~ FULL TEXT Despite these limitations, we conclude that our study provides a clinical decision rule that is urgently needed for one of the most frequent and most costly conditions in primary care. [50] It contains 8 items for the 6-month and 8 items for the 2-year risk classification (5 are common to both) into 3 levels of risk for developing chronic pain in patients presenting in primary care with a new-onset episode of strictly defined acute low back pain. The next step is to prospectively validate this tool in an independent population.
	Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Neck Pain J Manipulative Physiol Ther 2014 (Jan); 37 (1): 42–63 ~ FULL TEXT The studies included in this guideline indicate that cervical manipulation, mobilization, manual therapy, exercise, and massage can be recommended for the chiropractic treatment of nonspecific, mechanical neck pain. The strongest recommendations are typically made for the primary intervention in combination with another intervention, usually exercise and/or patient education. Owing to conflicting findings in the literature, no recommendation could be made for laser, TENS, or thoracic manipulation in the treatment of chronic neck pain or for the use of thoracic manipulation in the treatment of acute neck pain. There is a lack of evidence to support the use of laser, trigger point therapy, or traction for nonspecific, mechanical neck pain in adults.
	An Evidence-based Diagnostic Classification System For Low Back Pain J Canadian Chiropractic Association 2013 (Sep); 57 (3): 189–204 ~ FULL TEXT Health professionals across such disciplines as orthopedics, physical therapy, and chiropractic have shared the goal of categorizing patients with musculoskeletal low back pain (LBP) according to evidence-based classification systems. [1, 2] To this end, several investigators have generated classification systems for LBP diagnosis and treatment. [3–8] Identifying specific pathophysiology causing LBP has the potential to positively impact clinical research and practice by providing opportunities to test, validate or reject treatments targeted at specific diagnoses. [1,2] Clinical prediction rules [4,6] and symptom or treatment-based classification systems [7,8] lack the pathophysiological component(s) clinicians sometimes use to better understand a condition and make clinical decisions. Patho-anatomic diagnoses address pain arising from more specific anatomic structures or pathological processes. However, definitively confirming pain sources for LBP continues to be a challenge.
	Evidence-based Classification Of Low Back Pain In The General Population: One-year Data Collected With SMS Track Chiropractic & Manual Therapies 2013 (Sep 2); 21: 30 ~ FULL TEXT In all, 261 study subjects were included in the analyses, for which 7 distinct LBP subsets could be identified. These could be grouped into three major clusters; those mainly without LBP (35%), those with episodic LBP (30%) and those with persistent LBP (35%). There was a positive association between number of episodes and their duration.
	Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain Topics in Integrative Health Care 2012 (Dec 31); 3 (4) ID: 3.4007 ~ FULL TEXT The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1-3]
	Clinical Decision-making to Facilitate Appropriate Patient Management in Chiropractic Practice: 'The 3-questions Model' Chiropractic & Manual Therapies 2012 (Mar 14); 20: 6 ~ FULL TEXT Clinical decision-making is considered to be a key characteristic of any modern healthcare practitioner. It is, thus, prudent for chiropractors to re-visit the concept of defensible practice with a view to facilitate capable clinical decision-making and competent patient examination skills. In turn, the perception of competence and trustworthiness of chiropractors within the wider healthcare community helps integration of chiropractic services into broader healthcare settings.
	Application of a Diagnosis-Based Clinical Decision Guide in Patients with Low Back Pain Chiropractic & Manual Therapies 2011 (Oct 22); 19: 26 ~ FULL TEXT Low back pain (LBP) affects approximately 80% of adults at some time in life [1] and occurs in all ages [2, 3]. Despite billions being spent on various diagnostic and treatment approaches, the prevalence and disability related to LBP has continued to increase [4]. There has been a recent movement toward comparative effectiveness research [5], i.e., research that determines which treatment approaches are most effective for a given patient population. In addition, there is increased recognition of the importance of practice-based research which generates data in a “real world” environment as a tool for conducting comparative effectiveness research [6, 7]. This movement calls for greater participation of private practice environments in clinical research [7].
	Application of a Diagnosis-Based Clinical Decision Guide in Patients with Neck Pain Chiropractic & Manual Therapies 2011 (Aug 27); 19 (1): 19 ~ FULL TEXT Neck pain (NP) is a common cause of disability. Accurate and efficacious methods of diagnosis and treatment have been elusive. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based guide in applying the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with NP.
	Predictors for Identifying Patients With Mechanical Neck Pain Who Are Likely to Achieve Short-Term Success With Manipulative Interventions Directed at the Cervical and Thoracic Spine J Manipulative Physiol Ther 2011 (Mar); 34 (3): 144–152 ~ FULL TEXT This newly published JMPT study attempted to identify those prognostic clinical factors that may potentially identify, a priori, patients with mechanical neck pain who are likely to experience a rapid and successful response to spinal manipulation of the cervical and thoracic spine. Data from 81 subjects were included in the analysis, of which 50 had experienced a successful outcome (61.7%). Five variables were found to be associated with a positive response.
	Outcome of Pregnancy-Related Lumbopelvic Pain Treated According to a Diagnosis-Based Decision Rule: A Prospective Observational Cohort Study J Manipulative Physiol Ther 2009 (Oct); 32 (8): 616–624 ~ FULL TEXT Fifty-seven patients (73%) reported their improvement as either "excellent" or "good." The mean patient-rated improvement was 61.5%. The mean improvement in BDQ was 17.8 points. The mean percentage of improvement in BDQ was 39% and the median was 48%. Mean improvement in pain was 2.9 points. Fifty-one percent of the patients had experienced clinically significant improvement in disability and 67% patients had experienced clinically significant improvement in pain.
	A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature Chiropractic & Osteopathy 2008 (Aug 11); 16: 7 ~ FULL TEXT Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.
	Predictors For Immediate and Global Responses to Chiropractic Manipulation of the Cervical Spine J Manipulative Physiol Ther 2008 (Mar); 31 (3): 172–183 ~ FULL TEXT Data were collected from 28,807 treatment consultations (in 19,722 patients) and 13,873 follow-up treatments. The presenting symptoms of: “neck pain”, “shoulder, arm pain”, “reduced neck, shoulder, arm movement, stiffness”, “headache”, “upper, mid back pain”, and “none or one presenting symptom” emerged in the final model as significant predictors for an immediate improvement.   The presence of any 4 of these predictors raised the probability for an immediate improvement in presenting symptoms after treatment from 70% to approximately 95%.
	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 (Aug 3); 8: 75 ~ FULL TEXT In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.
	A Clinical Model for the Diagnosis and Management of Patients With Cervical Spine Syndromes Australasian Chiropractic & Osteopathy 2004 (Nov); 12 (2): 57–71 ~ FULL TEXT Neck pain and related disorders are a group of conditions that are common and often disabling. It can be argued that the importance of these disorders is under-appreciated. Because of the prevalence of low back pain and its great cost to society, much clinical attention and research dollars are focused on the low back. But epidemiological research suggests that cervical related disorders are as common and may be more costly to society than low back disorders. [1-4]

Reference Materials

	Chiropractors as the Spinal Health Care Experts A Chiro.Org article collection Enjoy these articles about chiropractors as first-contact Spinal Health Care Experts.
	Pain Management and Chiropractic A Chiro.Org article collection Explore this collection of articles that discusses the relationship between tissue injury and various pyschosocial factors that may contribute towards developing chronic pain.
	Chronic Neck Pain and Chiropractic A Chiro.Org article collection Review this extensive collection of studies detailing how chiropractic and spinal manipulation are effective for the relief of spinal pain.
	Neck and Back Pain in Children and Chiropractic A Chiro.Org article collection We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for spinal pain in children.
	Radiculopathy and Chiropractic Page A Chiro.Org article collection We hope you will enjoy this extensive collection of articles and studies demonstrating the benefits of chiropractic care for radiculopathy.
	Low Back Pain and Chiropractic A Chiro.Org article collection Ditto.
	The Biopsychosocial Model A Chiro.Org article collection The late George Engel believed that to understand and respond adequately to patients’ suffering — and to give them a sense of being understood — clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness. He offered a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since the mid-20th century. [1] His new model came to be known as the biopsychosocial model.
	Clinical Prediction Rules A Chiro.Org article collection Recently, Flynn and colleagues [17] developed a clinical prediction rule for identifying patients with low back pain who are likely to benefit from manipulation. They examined a series of patients with low back pain who received a manipulation intervention. Five factors formed the most parsimonious set of predictors for identifying patients who achieved at least 50% improvement in disability within 1 week with a maximum of 2 manipulation interventions (Table 1) [17]. The positive likelihood ratio among patients who met at least 4 of 5 of the criteria was 24.4 (95% CI, 4.6 to 139.4).
	Integrated Health Care and Chiropractic A Chiro.Org article collection This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.

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Update 7-02-2022