Key issues in diagnosis and targeted treatment of low back pain

Abstract

The overall aim of this thesis is to investigate and address key knowledge gaps in the diagnosis of low back pain and the role of a diagnosis in the treatment of LBP. Chapter 2 discusses the origins of the term non-specific LBP, common misconceptions regarding the term, the impact of the term on research and clinical practice, and suggestions for future research to move the field forward. Chapter 3 and 4 assessed the diagnostic accuracy of red flags used to screen for the different types of vertebral fracture in patients presenting with LBP. Most red flags were not useful as screening tools, however the four best red flags found were corticosteroid use, older age, trauma, and a contusion or abrasion. Chapter 5 aimed to determine the diagnostic accuracy of diagnostic tests to identify the disc, sacroiliac joint, or facet joint as the source of LBP. The results of this systematic review provide evidence that some index tests had informative likelihood ratios for the disc, sacroiliac joint, or the facet joint, challenging the current view that a diagnosis is not possible. Chapter 6 then assessed whether MRI can predict future LBP. The results from this systematic review suggest that some MRI findings have weak associations with future LBP; however, most of the MRI findings evaluated was unclear of an association. Chapter 7 investigated targeted treatments for LBP using a classification system (i.e., STarTBack approach) and explored differences in study level factors that may explain differences in results, in studies implementing the STarTBack approach. Reporting of important study level factors in how the STarTBack approach was implemented was often unclear. However, there is some suggestion that key factors may include the individual who implemented the STarTBack tool, whether the recommendations of the tool were followed, the amount of training the clinician delivering the matched treatment received, and whether clinicians actually delivered the matched treatment.