Lumbar Differential Diagnosis: Difference between revisions

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Low back pain is a common presenting condition in physiotherapy clinics. The physiotherapy assessment aims to screen for serious spinal conditions and identify impairments that may have contributed to the onset of the pain, or which increase the likelihood of an individual developing persistent pain. These include '''biological factors''' (eg. weakness, stiffness), '''psychological factors''' (eg. depression, fear of movement and catastrophisation) and '''social factors''' (eg. work environment).<ref>M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118.</ref>
Low back pain is a common presenting condition in physiotherapy clinics. The physiotherapy assessment aims to screen for serious spinal conditions and identify impairments that may have contributed to the onset of the pain, or which increase the likelihood of an individual developing persistent pain. These include '''biological factors''' (eg. weakness, stiffness), '''psychological factors''' (eg. depression, fear of movement and catastrophisation) and '''social factors''' (eg. work environment).<ref>M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118.</ref>


Once [[An Introduction to Red Flags in Serious Pathology|serious spinal pathology]] and specific causes of back pain have been ruled out, an individual is classified as having non-specific low back pain. If no serious pathology is suspected, there is no indication for x-rays or MRI diagnostic imaging unless the results of imaging may change / guide the management protocol.<ref>Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. [https://www.bmj.com/content/372/bmj.n291.full Do not routinely offer imaging for uncomplicated low back pain.] bmj. 2021 Feb 12;372.</ref><ref>Almeida M, Saragiotto B, Richards B, Maher C. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275</ref>  
Once [[An Introduction to Red Flags in Serious Pathology|serious spinal pathology]] and specific causes of back pain have been ruled out, an individual is classified as having non-specific low back pain. If no serious pathology is suspected, there is no indication for imaging unless the results may change the management.<ref>Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. [https://www.bmj.com/content/372/bmj.n291.full Do not routinely offer imaging for uncomplicated low back pain.] bmj. 2021 Feb 12;372.</ref><ref>Almeida M, Saragiotto B, Richards B, Maher C. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275</ref>  


90% of patients presenting to primary care with low back pain are classified as having [[Non Specific Low Back Pain|non-specific low back pain]].<ref>Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ. 2017 Nov 13;189(45):E1386-E1395.</ref><ref>Koes BW, Van Tulder M, Thomas S. Diagnosis and treatment of low back pain. Bmj. 2006 Jun 15;332(7555):1430-4.</ref> Non-specific low back pain is defined as "low back pain not attributable to a recognizable, known specific pathology<ref>Otero-Ketterer E, Peñacoba-Puente C, Ferreira Pinheiro-Araujo C, Valera-Calero JA, Ortega-Santiago R. [https://www.mdpi.com/1660-4601/19/16/10145 Biopsychosocial Factors for Chronicity in Individuals with Non-Specific Low Back Pain: An Umbrella Review]. International Journal of Environmental Research and Public Health. 2022 Aug 16;19(16):10145.</ref> (eg, infection, [[Skeletal Metastases|tumor]], [[osteoporosis]], [[Lumbar Spine Fracture|lumbar spine fracture]], [[Congenital Spine Deformities|structural deformity]], inflammatory disorder, [[Lumbar Radiculopathy|radicular syndrome]], or [[Cauda Equina Syndrome|cauda equina syndrome]])."<ref>Balagué, Federico, et al. "Non-specific low back pain." The Lancet 379.9814 (2012): 482-491. Level of evidence 1A</ref> 
90% of patients presenting to primary care with low back pain are classified as having [[Non Specific Low Back Pain|non-specific low back pain]].<ref>Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ. 2017 Nov 13;189(45):E1386-E1395.</ref><ref>Koes BW, Van Tulder M, Thomas S. Diagnosis and treatment of low back pain. Bmj. 2006 Jun 15;332(7555):1430-4.</ref> Non-specific low back pain is defined as "low back pain not attributable to a recognizable, known specific pathology<ref>Otero-Ketterer E, Peñacoba-Puente C, Ferreira Pinheiro-Araujo C, Valera-Calero JA, Ortega-Santiago R. [https://www.mdpi.com/1660-4601/19/16/10145 Biopsychosocial Factors for Chronicity in Individuals with Non-Specific Low Back Pain: An Umbrella Review]. International Journal of Environmental Research and Public Health. 2022 Aug 16;19(16):10145.</ref> (eg, infection, [[Skeletal Metastases|tumor]], [[osteoporosis]], [[Lumbar Spine Fracture|lumbar spine fracture]], [[Congenital Spine Deformities|structural deformity]], inflammatory disorder, [[Lumbar Radiculopathy|radicular syndrome]], or [[Cauda Equina Syndrome|cauda equina syndrome]])"<ref>Balagué, Federico, et al. "Non-specific low back pain." The Lancet 379.9814 (2012): 482-491. Level of evidence 1A</ref> Non-specific does not mean that there is no tissue causing nociception, just that it is not as clear and not as concerning.<ref name=":0" />


Non-specific low back pain is usually categorised into three subtypes: acute, sub-acute and chronic low back pain.<ref>Hock M, Járomi M, Prémusz V, Szekeres ZJ, Ács P, Szilágyi B, Wang Z, Makai A. [https://www.mdpi.com/1660-4601/19/19/12024 Disease-Specific Knowledge, Physical Activity, and Physical Functioning Examination among Patients with Chronic Non-Specific Low Back Pain.] International Journal of Environmental Research and Public Health. 2022 Sep 23;19(19):12024.</ref> This subdivision is based on how long the individual has had low back pain. Acute low back pain is an episode of low back pain that has been present for less than 6 weeks, sub-acute low back pain has been present for between 6 and 12 weeks and chronic low back pain has been present for 12 weeks or more.<ref>Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine (Phila Pa 1976). 1995 Mar 15;20(6):722-8.Level of evidence 3C</ref>
Non-specific low back pain is usually categorised into three subtypes: acute, sub-acute and chronic low back pain.<ref>Hock M, Járomi M, Prémusz V, Szekeres ZJ, Ács P, Szilágyi B, Wang Z, Makai A. [https://www.mdpi.com/1660-4601/19/19/12024 Disease-Specific Knowledge, Physical Activity, and Physical Functioning Examination among Patients with Chronic Non-Specific Low Back Pain.] International Journal of Environmental Research and Public Health. 2022 Sep 23;19(19):12024.</ref> This subdivision is based on how long the individual has had low back pain. Acute low back pain is an episode of low back pain that has been present for less than 6 weeks, sub-acute low back pain has been present for between 6 and 12 weeks and chronic low back pain has been present for 12 weeks or more.<ref>Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine (Phila Pa 1976). 1995 Mar 15;20(6):722-8.Level of evidence 3C</ref>
This article discusses red flags and critical features to consider when developing a differential diagnosis for individuals with low back pain.
== Diagnosis versus Classification ==
== Diagnosis versus Classification ==
Diagnosis and classification are defined in more detail [[Practical Decision Making in Physiotherapy Practice#Diagnosis and Classification|here]]. Typically when we discuss diagnoses, we talk about pathoanatomical diagnoses. There are also many classification systems for low back pain, some more commonly used that others. The goal of a classification system is to guide treatment, and ensure that clinicians don't treat all cases of back pain the same.<ref name=":0" />
Diagnosis and classification are defined in more detail [[Practical Decision Making in Physiotherapy Practice#Diagnosis and Classification|here]]. Typically when we discuss diagnoses, we are talking about pathoanatomical diagnoses. There are also many classification systems for low back pain, some more commonly used than others. The goal of a classification system is to guide treatment, and ensure that clinicians don't treat all cases of back pain the same.<ref name=":0" />
 
If a patient does not have a clear cause of their low back pain, this is considered [[Non Specific Low Back Pain|non-specific low back pain.]] Non-specific does not mean that there is no tissue causing nociception, just that it is not as clear and not as concerning.<ref name=":0" />  
== Imaging ==
== Imaging ==
For more information on referring for imaging, please see [[Practical Decision Making in Physiotherapy Practice]], but key points to consider are as follows:<ref name=":0" />  
For more information on referring for imaging, please see [[Practical Decision Making in Physiotherapy Practice]]. Some key points when considering a referral for imaging:<ref name=":0" />  
* imaging is needed if red flags are present or if there is no improvement with conservative care within 6 weeks. If you are unsure about a red flag, you can often treat the patient a little to see if they improve.
* imaging is needed if red flags are present or if there is no improvement with conservative care within 6 weeks - if you are unsure about a red flag, you can often treat the patient a little to see if they improve
* imaging is recommended if it will change the course of treatment.<ref>Al-Hihi E, Gibson C, Lee J, Mount RR, Irani N, McGowan C. [https://bmjopenquality.bmj.com/content/11/1/e001539.abstract Improving appropriate imaging for non-specific low back pain.] BMJ Open Quality. 2022 Feb 1;11(1):e001539.</ref>
* imaging is recommended if it will change the course of treatment<ref>Al-Hihi E, Gibson C, Lee J, Mount RR, Irani N, McGowan C. [https://bmjopenquality.bmj.com/content/11/1/e001539.abstract Improving appropriate imaging for non-specific low back pain.] BMJ Open Quality. 2022 Feb 1;11(1):e001539.</ref>
* a lot of imaging findings correlate with low back pain. This doesn’t mean everyone with imaging findings has pain, but often the more findings there are, the higher the chance the person has pain. We can still help these people though!
* a lot of imaging findings correlate with low back pain. This doesn’t mean that everyone with imaging findings will have pain, but often, the more findings there are on imaging, the higher the chance that the person will have pain. We can still help these people though!


== Differential Diagnosis ==
== Potential Conditions to Consider in a Differential Diagnosis ==
Initially, you should complete a comprehensive [[Lumbar Assessment|lumbar assessment]]. Once this is complete, you then triage the patient, as explained in the Lumbar Assessment page (see figure).   
Differential diagnosis is a key part of the physiotherapy assessment process. After a comprehensive [[Lumbar Assessment|lumbar assessment]], you can triage the patient, as explained in the [[Lumbar Assessment|Lumbar Assessment page]] (see figure below).   


[[File:LBP Triage.png|frameless|600x600px]]
[[File:LBP Triage.png|frameless|600x600px]]


Physiotherapists have valuable assessment and clinical reasoning skills for the differential diagnosis. You will need knowledge of [[Red Flags in Spinal Conditions|Red Flags]] and to consider a range of conditions (see linked pages for more information).
You will need knowledge of [[Red Flags in Spinal Conditions|red flags]] and to consider a range of conditions (see linked pages for more information).<blockquote>"Have a hypothesis. The more thoughtful you are, the better you’ll become." - Nick Rainey</blockquote>
 
*[[Specific Low Back Pain]]  
*[[Specific Low Back Pain]]
**an identified specific cause of back pain such as fracture, disc herniation, infection, tumour<ref name=":1">Casser HR, Seddigh S, Rauschmann M. [https://www.aerzteblatt.de/int/archive/article/175585 Acute lumbar back pain: investigation, differential diagnosis, and treatment]. Deutsches Ärzteblatt International. 2016 Apr;113(13):223.</ref>
*[[Cauda Equina Syndrome]]
*[[Cauda Equina Syndrome]]
**a rare but serious neurological condition which affects the bundle of nerve roots at the lower end of the spinal cord - considered an urgent red flag condition<ref name=":0" />
**symptoms include bladder and bowel changes and saddle anaesthesia<ref name=":1" />
*[[Lumbar Radiculopathy]]
*[[Lumbar Radiculopathy]]
**compression of the nerve roots as they exit the spine
**can result in tingling, radiating pain, numbness, paraesthesia, and shooting pain
*[[Disc Herniation]]
*[[Disc Herniation]]
**the nucleus pulposus is displaced from intervertebral space
**results in low back pain and radicular sciatica, sometimes with sensory and/or motor deficits<ref name=":1" />
*[[Spinal Stenosis]]
*[[Spinal Stenosis]]
**degenerative condition where there is reduced space available for the neural / vascular elements in the lumbar spine<ref>Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, Hwang SW, Mendel RC, Reitman CA. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The Spine Journal. 2013 Jul 1;13(7):734-43.</ref>
**spinal stenosis syndrome is associated with reduced walking distances (neurogenic intermittent claudication), pain which refers to both legs, and possible sensory and motor changes<ref name=":1" />
*[[Spondylolisthesis]]
*[[Spondylolisthesis]]
* [[Piriformis Syndrome]]
**slippage of one vertebral body in relation to the adjacent vertebral body, which results in mechanical or radicular symptoms<ref>Tenny S, Gillis CC. Spondylolisthesis. [Updated 2022 May 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK430767/</nowiki></ref>
* [[Sacroiliac Joint Pain]] (not dysfunction)
*[[Piriformis Syndrome]]
* [[Osteoarthritis]]
** a clinical condition where there is sciatic nerve entrapment at the level of the ischial tuberosity<ref name=":5">Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448172/</ref>
* [[Sciatica]]
** associated with gluteal pain, that may be described as shooting, burning, or aching
* Thoraco-Lumbar Junction Syndrome
** there may also be numbness in the buttocks and tingling along the sciatic nerve distribution<ref name=":5" />
<blockquote>"Have a hypothesis. The more thoughtful you are the better you’ll become." - Nick Rainey</blockquote>A few key factors to consider when looking at a differential diagnosis:<ref name=":0">Rainey N. Differential Diagnosis Course. Physiopedia Plus. 2023.</ref>
*[[Sacroiliac Joint Pain]] (not dysfunction)
** the sacroiliac joint is a potential nociceptive source of back pain<ref>Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005 Aug;10(3):207-18. </ref>
** please listen to this podcast to learn more: The Back Pain Podcast: [https://lnns.co/80bxy2nS1tu Is my pain from my sacroiliac joint?]
*[[Osteoarthritis]]
** a significant cause of chronic low back pain
** likely has a multifactorial pathogenesis<ref>Lindsey T, Dydyk AM. Spinal Osteoarthritis. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553190/</ref>
*[[Sciatica]]
** causes pain and paraesthesias along the sciatic nerve distribution or associated lumbosacral nerve root<ref>Davis D, Maini K, Vasudevan A. Sciatica. [Updated 2022 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK507908/</nowiki></ref>
* Thoraco-Lumbar Junction Syndrome (also called Maigne syndrome)
** an often unrecognised cause of low back pain<ref name=":4">Randhawa S, Garvin G, Roth M, Wozniak A, Miller T. Maigne Syndrome - A potentially treatable yet underdiagnosed cause of low back pain: A review. J Back Musculoskelet Rehabil. 2022;35(1):153-9. </ref>
** underlying mechanisms is poorly understood<ref>Lee H, Chae, Hyocheong C,  Ryu M,  Yang C, Kim S. [https://journals.lww.com/md-journal/fulltext/2023/06090/acupuncture_for_patients_with_maigne_s_syndrome__a.28.aspx Acupuncture for patients with Maigne’s syndrome: A case series.] Medicine 2023; 102(23):p e33999.</ref>
** there are two types:
*** central variant caused by "nerve afferent input secondary to changes of facet joint arthropathy at the thoracolumbar junction"<ref name=":4" />
*** peripheral variant caused by "impingement of the medial branch of the superior cluneal nerve"<ref name=":4" />
For more information on conditions to consider in a lumbar differential diagnosis, please see: [https://www.aerzteblatt.de/int/archive/article/175585 Acute Lumbar Back Pain: Investigation, Differential Diagnosis, and Treatment]. This article includes a number of tables summarising key features / characteristics of different conditions that can cause lumbar pain.


*[[Neurological Assessment|Neurological testing]] isn't exact, but it's close.
== Sources of Pain ==
* When looking at the extremities, there is a higher likelihood the spine is the source of pain if the extremity has full range of motion<ref name=":0" />
When completing a lumbar differential diagnosis, you will need to consider if there is extremity pain or just spinal pain. Then you will need to determine if the spine is contributing to the extremity pain (i.e. spinogenic) or if the extremity is the source.
* A study by Rosedale et al.<ref name=":2" /> found that "current spinal pain" raises the the pre-test probability that extremity pain has a spinal source from 10% to 19% overall. 
* As shown in the table below by Rosedale et al.<ref name=":2" />, a high percentage of people who have pain in their hip, thigh or leg have a spinal source of their pain.
{| class="wikitable"
|+Contingency Table of the Proportions of Spinal or Extremity Source of Symptoms in Each Region. From Rosedale et al.<ref name=":2">Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. [https://www.tandfonline.com/doi/abs/10.1080/10669817.2019.1661706 A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS).] Journal of Manual & Manipulative Therapy. 2020 Aug 7;28(4):222-30.</ref>
!Regions
!Extremity Source Frequency (%)
!Spinal Source Frequency (%)
!Total
|-
|Hip
|9 (29.0%)
|22 (71.0%)
|31
|-
|Thigh/Leg
|5 (27.8%)
|12 (72.2%)
|18
|-
|Knee
|58 (74.4%)
|20 (25.6%)
|78
|-
|Ankle/Foot
|34 (70.8%)
|14 (29.2%)
|48
|-
|Shoulder
|44 (52.4%)
|40 (47.6%)
|84
|-
|Arm/Forearm
|2 (16.7%)
|10 (83.3%)
|12
|-
|Elbow
|14 (56.0%)
|11 (44.0%)
|25
|-
|Wrist/Hand
|16 (61.5%)
|10 (38.5%)
|26
|-
|Total
|182 (56.5%)
|140 (43.5%)
|322
|}


===== '''Pathoanatomical Approach Compared to a Signs and Symptoms Approach''' =====
A few key factors to consider when looking for the source of pain:<ref name=":0">Rainey N. Differential Diagnosis Course. Physiopedia Plus. 2023.</ref>  
<blockquote>"A pathoanatomical approach means that you are treating to improve anatomy while a signs and symptoms approach means you test signs and ask for symptoms, treat, and then retest to assess for progress."<ref name=":0" /> - Nick Rainey</blockquote>After our assessment, we should consider the asterisk signs that we have made note of throughout our examination and use these to help decide how to treat using a "signs and symptoms" treatment approach. <blockquote>An asterisk sign is also known as a comparable sign. It is something that you can reproduce/retest that often reflects the primary complaint. It can be functional or movement specific. It is used to measure if symptoms are improving or worsening. </blockquote>


====='''Differentiating between Hip and Lumbar Pain'''=====
* if there are movement restrictions in the spine, there is a higher chance that distal symptoms are from the spine<ref name=":3">Rastogi R, Rosedale R, Kidd J, Lynch G, Supp G, Robbins SM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9255208/ Exploring indicators of extremity pain of spinal source as identified by Mechanical Diagnosis and Therapy (MDT): a secondary analysis of a prospective cohort study]. J Man Manip Ther. 2022 Jun;30(3):172-9.</ref>
In this video you can see a live patient examination differentiating between hip and lumbar pain:  
* there is a higher likelihood that the spine is the source of pain if the extremity has full range of motion<ref name=":3" />
{{#ev:youtube|kVy_FGngB-M}}The following tables detail a range of conditions associated with low back pain.
* "current spinal pain" raises the pre-test probability that extremity pain has a spinal source from 10% to 19% overall<ref name=":2">Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. [https://www.tandfonline.com/doi/abs/10.1080/10669817.2019.1661706 A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS).] Journal of Manual & Manipulative Therapy. 2020 Aug 7;28(4):222-30.</ref> 
{| class="wikitable"
* a high percentage of people who have pain in their hip, thigh or leg have spinogenic pain<ref name=":2" />
|+Types of low back pain associated with physical findings of no clear pathoanatomical significance<ref name=":1">Casser HR, Seddigh S, Rauschmann M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857557/ Acute lumbar back pain: investigation, differential diagnosis, and treatment.] Deutsches Ärzteblatt International. 2016 Apr;113(13):223.</ref>
* if a change in posture affects symptoms, pain is more likely coming from the spine<ref name=":3" />
!Syndrome
For more information, please see these articles:
!Findings
!Assessment/Plan
|-
|Facet syndrome
|History and physical examination:


* local and pseudoradicular symptoms and signs
* [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9255208/ Exploring indicators of extremity pain of spinal source as identified by Mechanical Diagnosis and Therapy (MDT): a secondary analysis of a prospective cohort study]<ref name=":3" />
* pain on movement
* [https://www.tandfonline.com/doi/abs/10.1080/10669817.2019.1661706 A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS)]<ref name=":2" />
* facet tenderness
* pain on reclination
* positive injection test
* joint dysfunction on manual diagnosis


Radiological findings (not indicated on intial evaluation):
During an assessment, it is important to remember that while [[Neurological Assessment|neurological testing]] isn't exact, it is close. "''We just need to figure out where do we need to treat and what gets those distal symptoms better.''"<ref name=":0" /> Also, when considering pain patterns, please note that dermatomal patterns of pain are typically not as well defined as peripheral nerve patterns.<ref name=":0" />


* differentiation from high-grade or activated spondylarthrosis (possibly, juxtaforaminal cyst)
====='''Differentiating between Hip and Lumbar Pain'''=====
* axial spondylarthritis
This video shows a patient examination aiming to differentiate between hip and lumbar pain.
|Differential diagnosis:
{{#ev:youtube|kVy_FGngB-M}}


* major joint dysfunction (blockage)
=='''Pathoanatomical Approach Compared to a Signs and Symptoms Approach'''==
* activated spondylarthrosis
<blockquote>"A pathoanatomical approach means that you are treating to improve anatomy while a signs and symptoms approach means you test signs and ask for symptoms, treat, and then retest to assess for progress."<ref name=":0" /> - Nick Rainey</blockquote>After our assessment, we should consider the asterisk signs that we have made note of throughout our examination and use these to help decide how to treat using a "signs and symptoms" treatment approach. <blockquote>An asterisk sign is also known as a comparable sign. It is something that you can reproduce/retest that often reflects the primary complaint. It can be functional or movement specific. It is used to measure if symptoms are improving or worsening. </blockquote>
 
Treatment:
 
* analgesics (1–3 days)
* muscle stabilization
* manual medicine
* facet injection if indicated
|-
|Sacro-iliac joint syndrome
|History and physical examination:
 
* sactro-iliac joint symptoms, positive provocation test
* functional leg length discrepancy
* injection test
 
Radiological findings (not indicated on intial evaluation):
 
–
 
Differential diagnosis:
 
* inflammation (sacro-iliitis in seronegative spondylarthritis)
|Functional disturbance:
 
* muscular imbalance
 
Treatment:
 
* stabilizing exercises
* analgesics (1–3 days) if needed
* manual medicine
* sacro-iliac joint injection if indicated
|-
|Myofascial pain syndrome
|History and physical examination:
 
* muscle trigger points:
** local pain with peripheral radiation
* peripheral and central sensitization
 
Radiological and histological findings:
 
* not indicated
* no clear evidence from MRI or biopsy
|
* pathogenesis and definitive diagnosis still unclear
* (low intra- and interrater reliability)
 
Local treatment:
 
* active physiotherapy
* manual therapy
* infiltration
* acupuncture
|-
|Functional instability
|History and physical examination:
 
* “snapping” feeling
* generalized deconditioning
* pain on movement, possibly accompanied by sensory and motor deficits (reversible)
* impaired proprioception
 
Radiological findings:
 
* no direct evidence
|
* unclear pathogenesis and definition
* treatment with manual medicine
* physiotherapeutic stabilization program
* caveat:
** surgery
** differential diagnosis
** structural instability
|}
{| class="wikitable"
|+Specific causes of low back pain that need immediate treatment (red flags)<ref name=":1" />
!Disease
!Findings
!Further Evaluation
!Treatment
|-
|Fracture
 
* traumatic
* pathological
* osteoporotic
|
* red flags
* acute or acutely exacerbated position-dependent pain
* pain and tenderness over spinous processes
* in some cases, iliocostal syndrome (12th rib)
|Imaging studies:
 
* plain films/MRI/CT
* scintigraphy for pacemaker wearers
* bone densitometry (T score)
 
Laboratory testing:
 
* inflammatory parameters (CBC + CRP)
* osteoporosis parameters
|Conservative:
 
* treatment of pain (strong analgesics if needed)
* basis therapy (osteoporosis)
* physiotherapy
* stabilizing, activating corset
 
Surgical:
 
* vertebro-/kyphoplasty
* pedicle-screw-based instrumentation, possibly with ventral interposition (cage, vertebral body replacement)
 
Prevention:
 
* regular intake of calcium, vitamin D, and biphosphonates
* exercise
|-
|Massive disc herniation
|
* red flags
* mutiple radicular deficits
* bladder/bowel dysfunction
* saddle anesthesia (cauda equina syndrome)
|
* MRI/CT
* electrophysiology:
** EMG
** SSEP
|Surgical:
 
* decompression with:
** sequestrectomy
** nucleotomy
|-
|Bacterial infection (spondylitis/ spondylodiscitis, epidural or paravertebral abscess)
|
* red flags
* pain
* swelling
* signs of instability
* pain on plantar flexion
* bed-shaking test (peritoneal irritation)
* neurologic deficit(s)
|
* inflammatory parameters
* MRI/CT with contrast medium
* plain films in two planes
* biopsy for pathogen identification
* optional:
** scintigraphy
** echocardiography
|The indication for conservative vs. operative treatment (debridement, filling of defects, instrumentation) depends on:
 
* neurologic deficits
* stability
* abscess formation:
** intradiscal epidural paravertebral osseous muscular
* pathogen identification (specific/nonspecific)
|-
|Tumor
|
* red flags
* pain
* swelling
* signs of instability
* pain on plantarflexion
* bed-shaking test (peritoneal irritation)
* neurologic deficit(s)
|Imaging studies: local at first, then staging studies to rule out instability (SINS):
 
* entire spinal axis
* CT of thorax and abdomen
* scintigraphy
 
Laboratory tests:
 
* CBC, ESR, CRP, etc.
* tumor markers, Karnofsky score
* Tissue biopsy (CT- or MRIguided, or open)
|Neurologic deficit present:
 
* decompression and stabilization (dorsal or dorsoventral depending on overall findings)
 
Neurologic deficit absent:
 
* discuss plan in interdisciplinary tumor board
 
Conservative:
 
* treatment of pain (strong analgesics if needed)
* radiotherapy
 
* external stabilization (corset)
|}
{| class="wikitable"
|+Specific types of low back pain that require further diagnostic evaluation<ref name=":1" />
!Disease
!Findings
!Further Evaluation
!Treatment
|-
|Disk herniation
|
* low back pain and radicular sciatica (worse in leg than in back), sometimes with sensory and/or motor deficits
* positive nerve-stretching test
* reflex asymmetry
|Imaging studies: (DD herniation vs. stenosis vs. tumor)
 
* MRI, plain films (CT if MRI is contraindicated)
 
Neurological/electrophysiological testing:
 
* EMG, SSEP, NCS
* in suspected cauda equina syndrome, examination of bladder and rectal function (post-void residual urine volume, sphincter tone)
|Depending on the clinical findings:
 
* Conservative/interventional:
** analgesic and anti-inflammatory drugs
** physiotherapy
** periradicular/epidural injections
* Surgical:
** particularly in case of a motor deficit (strength grade 3 or less)
** sequestrectomy
** nucleotomy
|-
|Spinal canal stenosis /
degenerative instability
|
* spinal stenosis syndrome, limitation of walking distance (neurogenic intermittent claudication), pain radiating into both legs
* possibly, sensory and motor deficits
|Abnormally flexed posture of trunk imaging studies:
 
* plain films
* functional myelography and post-myelographic CT
 
Neurological/electrophysiological testing:
 
* ENG
* SSEP
* EMG
|Depending on the clinical findings:
 
* Conservative:
** pain therapy
** physiotherapy
* Interventional:
** PDA
** sacral block
* Surgical:
** decompression
** decompression and fusion
|-
|Axial spondylitis and
seronegative spondylo -
 
arthropathy
|Inflammatory back pain syndrome
 
* onset before age 45
* back pain for more than 3 months
* morning stiffness >30°
* improvement with movement
* pain at night
* restriction of lateral bending
* sacro-iliac joint syndrome
* enthesitis (heel)
* insertion tendinitis
|Imaging studies:
 
* plain films/MRI (sacro-iliac joint, STIR sequence)
* inflammatory parameters
* HLA-B27
 
 
Rheumatologic consultation
|
* analgesic and anti-inflammatory drugs
* physiotherapy
* maintenance therapy with rheumatologic drugs if indicated
|-
|Deformities
 
* scoliosis: 
** idiopathic
** structural
** neuromyopathic
** other
* idiopathic juvenile kyphosis (Scheuermann's disease)
* spondylolisthesis (dysplastic types)
|Clinical features:
 
* pelvic tilt
* shoulder height discrepancy
* spinal misalignment
* asymmetry of waist
* forward bending test
* hunchback
* lumbar protrusion
* hyperkyphosis
* visible/palpable step in spine
* sacral kyphosis
* lumbar spine fixed in extension
|Early detection in children!
 
 
Imaging studies:
 
* biplanar imaging of the entire spine
* images on bending
* MRI (secondary scoliosis, intraspinal anomalies)
* CT if indicated
|Depending on the patient’s age and on the cause and severity of the deformity:
 
* physiotherapy
* corset
* surgical correction
|-
|Herpes zoster
|
* mono- or pluriradicular pain syndrome with sensory deficit (much less often, motor deficit)
* dermatomal rash (often arising some time after the pain)
|Lumbar puncture and CSF examination:
 
* CSF pleocytosis
* positive CSF serology
|
* oral or IV virostatic drugs (aciclovir, brivudine, famciclovir)
* analgesic drugs: cf. diabetic radiculopathy
* vaccination of patients at risk
|-
|Diabetic radiculopathy
|
* painful sensory and motor radiculopathy
|
* patient with diabetes mellitus
* other causes ruled out
* no rash
* CSF cell count normal, serology negative
|Pharmacotherapy:
 
* metamizole, NSAIDs + TCA/SSNRI or gabapentin/pregabalin; for lancinating pain, carbamazepine/capsaicin 8% ointment; if necessary, high- or low-potency opioids
|-
|Neuroborreliosis
|
* mono-/pluriradicular pain syndrome with sensory and motor deficits
|Lumbar puncture and CSF examination:
 
* CSF pleocytosis, elevated CSF protein
* intrathecal Borrelia-specific AB
|
* IV antibiotic treatment with ceftriaxone and cefotaxime for 14–21 days, along with steroid (prednisone 100 mg, decreasing dose)
* analgesic drugs: cf. diabetic radiculopathy
|-
|Spinal ischemia
|
* at first, pain in thoracic or lumbar spine, followed by development of spinal cord transection syndrome
|
* MRI / spiral CT / angiography
|
* inhibition of platelet aggregation
* analgesic drugs (NSAIDs, high- or low- potency opioids)
* physiotherapy
|}
Key to abbreviations:
 
* CBC: complete blood count
* CRP: C-reactive protein
* CT: computerized tomography
* EMG: electromyography
* ESR: erythrocyte sedimentation rate
* MRI: magnetic resonance imaging
* SINS: spinal instability in neoplastic disease
* SSEP: somatosensory evoked potentials
* AB: antibodies
* CT: computerized tomography
* CSF: cerebrospinal fluid
* DD: differential diagnosis
* ENG: electroneurography
* EMG: electromyography
* MRI: magnetic resonance imaging
* NCS: nerve conduction study
* NSAID: nonsteroidal anti-inflammatory drug
* PDA: peridural anesthesia
* SSEP: somatosensory evoked potentials
* SSNRI: selective serotonin-norepinephrine reuptake inhibitor
* TCA: tricyclic antidepressant


== Additional Resources ==
== Additional Resources ==
===== '''<u>Physiopedia Pages:</u>''' =====
* [[Low Back Pain]]
* [[Lumbar Assessment]]
* [[Low Back Pain Guidelines]]
* [[Differentiating Inflammatory and Mechanical Back Pain]]
* [[Non Specific Low Back Pain]]
* [[Specific Low Back Pain]]


===== Podcast Links: =====
===== Podcast Links: =====


# The Back Pain Podcast: [https://www.listennotes.com/podcasts/the-back-pain/piriformis-syndrome-JNfz-nLhXdW/ Piriformis syndrome]
* The Back Pain Podcast: [https://www.listennotes.com/podcasts/the-back-pain/piriformis-syndrome-JNfz-nLhXdW/ Piriformis syndrome]
# The Back Pain Podcast: [https://lnns.co/80bxy2nS1tu Is my pain from my sacroiliac joint?]  
* The Back Pain Podcast: [https://lnns.co/80bxy2nS1tu Is my pain from my sacroiliac joint?]
# Modern Pain Podcast: [https://podcasts.apple.com/us/podcast/lumbar-stenosis/id1435013970?i=1000524086734 Lumbar Stenosis]
* Modern Pain Podcast: [https://podcasts.apple.com/us/podcast/lumbar-stenosis/id1435013970?i=1000524086734 Lumbar Stenosis]
# The Back Pain Podcast Episode 82: [https://open.spotify.com/episode/0eDaAPC4DGMklQ87crSzwJ Flexion, Extension, Radicular Pain & Disc Pathology with Adam Meakins and Dr. Mark Laslett]
* The Back Pain Podcast Episode 82: [https://open.spotify.com/episode/0eDaAPC4DGMklQ87crSzwJ Flexion, Extension, Radicular Pain & Disc Pathology with Adam Meakins and Dr. Mark Laslett]


===== Journal Articles and Books: =====
===== Journal Articles and Books: =====
Line 536: Line 98:
* Casser HR, Seddigh S, Rauschmann M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857557/ Acute lumbar back pain: investigation, differential diagnosis, and treatment.] Deutsches Ärzteblatt International. 2016 Apr;113(13):223.
* Casser HR, Seddigh S, Rauschmann M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857557/ Acute lumbar back pain: investigation, differential diagnosis, and treatment.] Deutsches Ärzteblatt International. 2016 Apr;113(13):223.
* Casiano VE, Dydyk AM, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK538173/#:~:text=Inflammatory%20disorders%2C%20malignancy%2C%20pregnancy%2C,all%20part%20of%20the%20differential. Back pain.]
* Casiano VE, Dydyk AM, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK538173/#:~:text=Inflammatory%20disorders%2C%20malignancy%2C%20pregnancy%2C,all%20part%20of%20the%20differential. Back pain.]
===== Physiopedia Pages: =====
*[[Low Back Pain]]
*[[Lumbar Assessment]]
*[[Low Back Pain Guidelines]]
*[[Differentiating Inflammatory and Mechanical Back Pain]]
*[[Non Specific Low Back Pain]]
*[[Specific Low Back Pain]]


== References ==
== References ==
Line 542: Line 112:
[[Category:Lumbar Spine]]
[[Category:Lumbar Spine]]
[[Category:Differential Diagnosis]]
[[Category:Differential Diagnosis]]
<references />
[[Category:Musculoskeletal/Orthopaedics]]

Revision as of 21:56, 28 October 2023

Original Editor - Nick Rainey based on the course by Nick Rainey
Top Contributors - Jess Bell, Carin Hunter, Jorge Rodríguez Palomino and Ewa Jaraczewska

Introduction[edit | edit source]

Low back pain is a common presenting condition in physiotherapy clinics. The physiotherapy assessment aims to screen for serious spinal conditions and identify impairments that may have contributed to the onset of the pain, or which increase the likelihood of an individual developing persistent pain. These include biological factors (eg. weakness, stiffness), psychological factors (eg. depression, fear of movement and catastrophisation) and social factors (eg. work environment).[1]

Once serious spinal pathology and specific causes of back pain have been ruled out, an individual is classified as having non-specific low back pain. If no serious pathology is suspected, there is no indication for imaging unless the results may change the management.[2][3]

90% of patients presenting to primary care with low back pain are classified as having non-specific low back pain.[4][5] Non-specific low back pain is defined as "low back pain not attributable to a recognizable, known specific pathology[6] (eg, infection, tumor, osteoporosis, lumbar spine fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome)"[7] Non-specific does not mean that there is no tissue causing nociception, just that it is not as clear and not as concerning.[8]

Non-specific low back pain is usually categorised into three subtypes: acute, sub-acute and chronic low back pain.[9] This subdivision is based on how long the individual has had low back pain. Acute low back pain is an episode of low back pain that has been present for less than 6 weeks, sub-acute low back pain has been present for between 6 and 12 weeks and chronic low back pain has been present for 12 weeks or more.[10]

This article discusses red flags and critical features to consider when developing a differential diagnosis for individuals with low back pain.

Diagnosis versus Classification[edit | edit source]

Diagnosis and classification are defined in more detail here. Typically when we discuss diagnoses, we are talking about pathoanatomical diagnoses. There are also many classification systems for low back pain, some more commonly used than others. The goal of a classification system is to guide treatment, and ensure that clinicians don't treat all cases of back pain the same.[8]

Imaging[edit | edit source]

For more information on referring for imaging, please see Practical Decision Making in Physiotherapy Practice. Some key points when considering a referral for imaging:[8]

  • imaging is needed if red flags are present or if there is no improvement with conservative care within 6 weeks - if you are unsure about a red flag, you can often treat the patient a little to see if they improve
  • imaging is recommended if it will change the course of treatment[11]
  • a lot of imaging findings correlate with low back pain. This doesn’t mean that everyone with imaging findings will have pain, but often, the more findings there are on imaging, the higher the chance that the person will have pain. We can still help these people though!

Potential Conditions to Consider in a Differential Diagnosis[edit | edit source]

Differential diagnosis is a key part of the physiotherapy assessment process. After a comprehensive lumbar assessment, you can triage the patient, as explained in the Lumbar Assessment page (see figure below).

LBP Triage.png

You will need knowledge of red flags and to consider a range of conditions (see linked pages for more information).

"Have a hypothesis. The more thoughtful you are, the better you’ll become." - Nick Rainey

  • Specific Low Back Pain
    • an identified specific cause of back pain such as fracture, disc herniation, infection, tumour[12]
  • Cauda Equina Syndrome
    • a rare but serious neurological condition which affects the bundle of nerve roots at the lower end of the spinal cord - considered an urgent red flag condition[8]
    • symptoms include bladder and bowel changes and saddle anaesthesia[12]
  • Lumbar Radiculopathy
    • compression of the nerve roots as they exit the spine
    • can result in tingling, radiating pain, numbness, paraesthesia, and shooting pain
  • Disc Herniation
    • the nucleus pulposus is displaced from intervertebral space
    • results in low back pain and radicular sciatica, sometimes with sensory and/or motor deficits[12]
  • Spinal Stenosis
    • degenerative condition where there is reduced space available for the neural / vascular elements in the lumbar spine[13]
    • spinal stenosis syndrome is associated with reduced walking distances (neurogenic intermittent claudication), pain which refers to both legs, and possible sensory and motor changes[12]
  • Spondylolisthesis
    • slippage of one vertebral body in relation to the adjacent vertebral body, which results in mechanical or radicular symptoms[14]
  • Piriformis Syndrome
    • a clinical condition where there is sciatic nerve entrapment at the level of the ischial tuberosity[15]
    • associated with gluteal pain, that may be described as shooting, burning, or aching
    • there may also be numbness in the buttocks and tingling along the sciatic nerve distribution[15]
  • Sacroiliac Joint Pain (not dysfunction)
  • Osteoarthritis
    • a significant cause of chronic low back pain
    • likely has a multifactorial pathogenesis[17]
  • Sciatica
    • causes pain and paraesthesias along the sciatic nerve distribution or associated lumbosacral nerve root[18]
  • Thoraco-Lumbar Junction Syndrome (also called Maigne syndrome)
    • an often unrecognised cause of low back pain[19]
    • underlying mechanisms is poorly understood[20]
    • there are two types:
      • central variant caused by "nerve afferent input secondary to changes of facet joint arthropathy at the thoracolumbar junction"[19]
      • peripheral variant caused by "impingement of the medial branch of the superior cluneal nerve"[19]

For more information on conditions to consider in a lumbar differential diagnosis, please see: Acute Lumbar Back Pain: Investigation, Differential Diagnosis, and Treatment. This article includes a number of tables summarising key features / characteristics of different conditions that can cause lumbar pain.

Sources of Pain[edit | edit source]

When completing a lumbar differential diagnosis, you will need to consider if there is extremity pain or just spinal pain. Then you will need to determine if the spine is contributing to the extremity pain (i.e. spinogenic) or if the extremity is the source.

A few key factors to consider when looking for the source of pain:[8]

  • if there are movement restrictions in the spine, there is a higher chance that distal symptoms are from the spine[21]
  • there is a higher likelihood that the spine is the source of pain if the extremity has full range of motion[21]
  • "current spinal pain" raises the pre-test probability that extremity pain has a spinal source from 10% to 19% overall[22] 
  • a high percentage of people who have pain in their hip, thigh or leg have spinogenic pain[22]
  • if a change in posture affects symptoms, pain is more likely coming from the spine[21]

For more information, please see these articles:

During an assessment, it is important to remember that while neurological testing isn't exact, it is close. "We just need to figure out where do we need to treat and what gets those distal symptoms better."[8] Also, when considering pain patterns, please note that dermatomal patterns of pain are typically not as well defined as peripheral nerve patterns.[8]

Differentiating between Hip and Lumbar Pain[edit | edit source]

This video shows a patient examination aiming to differentiate between hip and lumbar pain.

Pathoanatomical Approach Compared to a Signs and Symptoms Approach[edit | edit source]

"A pathoanatomical approach means that you are treating to improve anatomy while a signs and symptoms approach means you test signs and ask for symptoms, treat, and then retest to assess for progress."[8] - Nick Rainey

After our assessment, we should consider the asterisk signs that we have made note of throughout our examination and use these to help decide how to treat using a "signs and symptoms" treatment approach.

An asterisk sign is also known as a comparable sign. It is something that you can reproduce/retest that often reflects the primary complaint. It can be functional or movement specific. It is used to measure if symptoms are improving or worsening.

Additional Resources[edit | edit source]

Podcast Links:[edit | edit source]
Journal Articles and Books:[edit | edit source]
Physiopedia Pages:[edit | edit source]

References[edit | edit source]

  1. ↑ M.Hancock. Approach to low back pain. RACGP, 2014, 43(3):117-118.
  2. ↑ Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. Do not routinely offer imaging for uncomplicated low back pain. bmj. 2021 Feb 12;372.
  3. ↑ Almeida M, Saragiotto B, Richards B, Maher C. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275
  4. ↑ Traeger A, Buchbinder R, Harris I, Maher C. Diagnosis and management of low-back pain in primary care. CMAJ. 2017 Nov 13;189(45):E1386-E1395.
  5. ↑ Koes BW, Van Tulder M, Thomas S. Diagnosis and treatment of low back pain. Bmj. 2006 Jun 15;332(7555):1430-4.
  6. ↑ Otero-Ketterer E, Peñacoba-Puente C, Ferreira Pinheiro-Araujo C, Valera-Calero JA, Ortega-Santiago R. Biopsychosocial Factors for Chronicity in Individuals with Non-Specific Low Back Pain: An Umbrella Review. International Journal of Environmental Research and Public Health. 2022 Aug 16;19(16):10145.
  7. ↑ Balagué, Federico, et al. "Non-specific low back pain." The Lancet 379.9814 (2012): 482-491. Level of evidence 1A
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Rainey N. Differential Diagnosis Course. Physiopedia Plus. 2023.
  9. ↑ Hock M, Járomi M, Prémusz V, Szekeres ZJ, Ács P, Szilágyi B, Wang Z, Makai A. Disease-Specific Knowledge, Physical Activity, and Physical Functioning Examination among Patients with Chronic Non-Specific Low Back Pain. International Journal of Environmental Research and Public Health. 2022 Sep 23;19(19):12024.
  10. ↑ Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine (Phila Pa 1976). 1995 Mar 15;20(6):722-8.Level of evidence 3C
  11. ↑ Al-Hihi E, Gibson C, Lee J, Mount RR, Irani N, McGowan C. Improving appropriate imaging for non-specific low back pain. BMJ Open Quality. 2022 Feb 1;11(1):e001539.
  12. ↑ 12.0 12.1 12.2 12.3 Casser HR, Seddigh S, Rauschmann M. Acute lumbar back pain: investigation, differential diagnosis, and treatment. Deutsches Ärzteblatt International. 2016 Apr;113(13):223.
  13. ↑ Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, Hwang SW, Mendel RC, Reitman CA. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The Spine Journal. 2013 Jul 1;13(7):734-43.
  14. ↑ Tenny S, Gillis CC. Spondylolisthesis. [Updated 2022 May 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430767/
  15. ↑ 15.0 15.1 Hicks BL, Lam JC, Varacallo M. Piriformis Syndrome. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448172/
  16. ↑ Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005 Aug;10(3):207-18.
  17. ↑ Lindsey T, Dydyk AM. Spinal Osteoarthritis. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553190/
  18. ↑ Davis D, Maini K, Vasudevan A. Sciatica. [Updated 2022 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507908/
  19. ↑ 19.0 19.1 19.2 Randhawa S, Garvin G, Roth M, Wozniak A, Miller T. Maigne Syndrome - A potentially treatable yet underdiagnosed cause of low back pain: A review. J Back Musculoskelet Rehabil. 2022;35(1):153-9.
  20. ↑ Lee H, Chae, Hyocheong C, Ryu M, Yang C, Kim S. Acupuncture for patients with Maigne’s syndrome: A case series. Medicine 2023; 102(23):p e33999.
  21. ↑ 21.0 21.1 21.2 21.3 Rastogi R, Rosedale R, Kidd J, Lynch G, Supp G, Robbins SM. Exploring indicators of extremity pain of spinal source as identified by Mechanical Diagnosis and Therapy (MDT): a secondary analysis of a prospective cohort study. J Man Manip Ther. 2022 Jun;30(3):172-9.
  22. ↑ 22.0 22.1 22.2 Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). Journal of Manual & Manipulative Therapy. 2020 Aug 7;28(4):222-30.
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