Background
Methods
Search strategy
Study selection
Published studies were included if they fulfilled any of the following criteria: |
• Developed and described an original classification system for back pain that included adult patients with low back related leg pain (LBLP). Leg pain was defined as pain below the gluteal fold. • Adapted an existing classification system that was designed for or included LBLP patients. • Provided approaches to appraising or validating an existing classification system for LBLP. |
Exclusion criteria: |
• Studies looking at specific spinal “red flag” conditions such as cauda equina syndrome, tumours or spinal fractures or a specific disease cohort such as diabetes. • Studies that only used expensive or advanced investigations or technology more likely to be feasible for secondary care settings (e.g. electromyography, surgical findings, imaging or expensive kinematic equipment) for classification of patients. • Case studies and case series design studies. |
Data extraction and quality appraisal
Criteria | Description |
---|---|
Purpose | Is the purpose, population and setting clearly specified? |
Content validity | Is the domain and all specific exclusions from the domain clearly specified? |
Are all relevant categories included? | |
Is the breakdown of categories appropriate, considering the purpose? | |
Are the categories mutually exclusive? | |
Was the method of development appropriate? | |
If multiaxial, are criteria of content validity satisfied for each additional axis? | |
Face validity | Is the nomenclature used to label the categories satisfactory? |
Are the terms used based upon empirical (directly observable) evidence? | |
Are the criteria for determining inclusion into each category clearly specified? | |
If yes do these criteria appear reasonable? | |
Have the criteria been demonstrated to have reliability or validity? | |
Are the definitions of criteria clearly specified? | |
If multiaxial are criteria of face validity satisfied for each additional axis? | |
Feasibility | Is the classification simple to understand? |
Is classification easy to perform? | |
Does it rely on clinical examination alone? | |
Are special skills, tools and/or training required? | |
How long does it take to perform? | |
Construct validity | Does it discriminate between entities that are thought to be different in a way appropriate for the purpose? |
Does it perform satisfactorily when compared to other classification systems which classify the same domain? | |
Reliability | Does the classification system provide consistent results when classifying the same conditions? |
Is the intraobserver and interobserver reliability satisfactory? | |
Generalisability | Has it been used in other studies and/or settings? |
Results
Search results
Data extraction and appraisal of selected studies
Primary author | Purpose | Method of development | Domain of interest | Specific exclusions | Categories | Criteria used | Training/Personnel needed |
---|---|---|---|---|---|---|---|
Barker (1990) [79] | Devise classification meaningful to General Practitioner (GP). | Judgemental approach. GP authorship. | Low Back Pain (LBP). 486 patients attending authors’ GP practice. | Febrile illness, backache accompanied by many other complaints. | 1: Acute lumbago 2: Acute mechanical derangement 3: Acute sciatica 4: Sacro-iliac joint (SIJ) 5: Mild sciatica | Patient history, pain location drawings, clinical examination. | None. |
Ben Debba et al. (2000) [36] | Assign LBP patients into one of four modified Quebec Task Force Classification categories. | Judgemental and statistical approach. Neurosurgeon authorship. | Persistent LBP. 1,997 patients from tertiary care. | Age under 25, ≥1 prior surgical or interdiscal procedure, no pain in the small of the back. | 1: Back pain only 2: Back and above knee pain 3: Back and below knee pain 4: Back and below knee pain with positive straight leg raise (SLR) | Spatial distribution of patient’s pain (from questionnaire). Results of SLR test. | Standardization of SLR performed by clinician or technician. |
Glassman et al. (2011) [37] | Develop simple diagnostic classification for use in clinical practice. | Judgement approach. Orthopaedic spine surgeon authorship. | LBP. Case histories compiled. | None. | Clinical Symptoms (relevant to primary care): 1-6: Dominant location of pain 7: Neurogenic claudication 8: Cauda equine Additional axis: Yes Acute/chronic | Patient history and clinical examination. | Not known. Case histories were compiled and reviewed by orthopaedic spine surgeons. |
Nachemson and Andersson (1982) [80] | Introduce a simple classification system suitable for use in epidemiological screening. | Judgement approach. Orthopaedic spine surgeon authorship. | LBP. | None. | 1: Insufficienta dorsi 2: Lumbago 3: Sciatica 4: Rhizopathy 5: Lumbago sciatica Additional axis: Yes- Duration and recurrence | Patient history and clinical examination. Radiographic results can be used. | Authors report it is simple to use. |
Spitzer et al. (1987) [25] | Compile a diagnostic classification system for: clinical decision making; establishing prognosis; evaluating quality of care; Conducting scientific research. | Judgement approach. Multidisciplinary task force representing wide range of disciplines. | LBP. | None. | 1: Pain without radiation 2: Pain + radiation proximal extremity 3: Pain + radiation distal extremity 4: Pain + radiation to upper limb/lower limb with neurological signs 5: Presumptive root compression, +ve image 6: Root compression, +ve image 7: Spinal stenosis 8: Post surgical < 6 months 9: Post surgical > 6 months 10: Chronic pain syndrome 11: Other diagnoses Additional Axis: Yes Work and duration | Patient history. Clinical examination and paraclinical test results (laboratory tests, radiography, imaging methods, Electromyography (EMG) nerve blocks). | Able to interpret investigative tests. |
Sweetman et al. (1992) [26] | Describe common patterns of LBP and identify clinical tests to help recognize the patterns. | Statistical approach. Rheumatologists authorship. | LBP. 301 patients referred from GP to rheumatology clinic. | Less than 15 or over 75 years old. | 1: Persistent unilateral back pain and sciatica 2: Back pain or sciatic switching sides(sacroiliitis) 3: Central/bilateral back pain 4: Lateral flexion or rotation cause pain on the opposite side(facet joint) 5: Back pain at rest on one side but pain on opposite side with several tests (unstable L4/5 syndrome) 6: Dorso lumbar junction conditions 7. Persistent unilateral back pain and sciatica with loss of lower limb reflex (Disc with nerve root compression) | Questionnaire and clinical examination and x-ray. | Uses a computer algorithm for pattern recognition. |
Primary author | Purpose | Method of development | Domain of interest | Specific exclusions | Categories | Criteria used | Training/Personnel needed |
---|---|---|---|---|---|---|---|
Bernard and Kirkaldy Willis (1987) [41] | Determine pathology causing LBP. | Judgement approach. Orthopaedic surgeon authorship. | LBP. Medical record review of 1293 patients, majority of whom had failed initial treatment by primary care physicians. | None. | Group A:well recognized syndromes 1. Herniated nucleus pulposus 2. Lateral spinal stenosis 3. Central spinal stenosis 4. Spondylolisthesis 5. Segmental instability Group B:less well recognized syndromes 6. Sacroiliac joint 7. Posterior joint 8. Maigne’s syndrome 9. Gluteus maximus 10. Gluteus medius 11. Quadratus lumborum 12. Piriformis 13. Hamstring origin 14. Tensor fascia latae Group C: remaining syndromes 15. Pseudarthrosis 16. Non specific 17. Post fusion stenosis 18. Anklyosing spondylitis 19. Disc space infection 20. Tumour 21. Arachnoiditis 22. Lateral femoral nerve entrapment | Medical records and response to treatment which included: manipulation/stretching; injections; radiofrequency denervation; palpation; joint motion tests, neural tension tests and neurological testing, response to surgery, pain provocation palpation, xray and computed tomography (CT) scans. | None. |
Cassisi et al. (1993) [40] | Explore differences between two groups of chronic LBP patients. | Judgement approach. Neurosurgeon authorship. | Chronic LBP. 151 patients in tertiary care. | Neoplasm, mechanical, toxic-metabolic, inflammatory-infectious, vascular and psycho-physiological conditions. | Myofascial pain. Disc herniation. | Patient history and clinical examination. | None. |
Hahne et al. (2011) [38] | Identify patho-anatomical subgroups with subacute LBP. For use in a randomised controlled trial (RCT): the STOPS trial. | Judgement approach including an expert panel of physiotherapists. Physiotherapy authorship. | LBP +/- leg pain. Subacute pain lasting between 6 weeks and 6 months. | Red flags, recent spinal injections, previous spinal surgery, recent regular physiotherapy treatment. | 1: Reducible discogenic pain 2: Non reducible discogenic pain (not responsive to mechanical loading strategies) 3: Disc herniation with associated radiculopathy 4: Facet joint dysfunction 5: Multi-factorial persistent pain | Patient history and clinical examination. | Unclear what specific training is needed for classification. |
Paatelma et al. (2009) [44] | Evaluate the reliability of a patho-anatomical classification system. | Judgement approach. Physiotherapy authorship. | LBP +/- leg pain. 21 patients. | Age > 56, LBP > 3 months. | 1: Discogenic pain 2: Lumbar instability 3: Spinal Stenosis 4: Segmental dysfunction/facet pain 5: SIJ dysfunction/pain | Patient history and clinical examination. | 5 ½ day training sessions to standardise tests. 30 min assessment. |
Petersen et al. (2003) [39] | Develop a classification system with pathoanatomic orientation for use in primary care. | Judgemental approach. Physiotherapist authorship. Slightly modified version of Laslett and van Wijmen (1999) [81] classification system. | Non-specific LBP. | Red flag symptoms, hip disorders, suspected referred pain from viscera. | 1: Disc syndrome (reducible;irreducable and non-mechanical) 2: Adherent nerve root 3: Nerve root entrapment 4: Nerve root compression 5: Spinal stenosis 6: Zygapophysial joint 7: Postural 8: Sacro-iliac joint 9: Myofascial pain 10: Adverse neural tension 11: Abnormal pain 12: Inconclusive | Patient history and clinical examination. | Some training required and experience of the McKenzie assessment. Takes 1 h to complete. |
Vining et al. 2013 [46] | Create a classification system based on available evidence for use in research and clinical setting | Judgement approach. Based on Petersen et al. (2003) [80] model Chiropractic authorship. | LBP. | None | 1. Screening 2. Nociceptive - Discogenic - SIJ - Zygapophyseal joint -Myofascial 3. Neuropathic - Compressive radiculopathy - Non compressive radiculopathy - Neurogenic claudication - Central pain 4. Functional instability 5. Other diagnoses | Patient history and clinical examination. Questions and physical component of the Leeds Assessment for Neuropathic Symptoms and Signs (LANSS). Arterial brachial index test for neurogenic claudication if indicated | None. |
Primary Author | Purpose | Method of Development | Domain of Interest | Specific Exclusions | Categories | Criteria used | Training/Personnel needed |
---|---|---|---|---|---|---|---|
Delitto et al. (2012) [48] | Classify and define musculoskeletal conditions using the World Health Organisation terminology related to International Classification of Functioning, Disability and Health. | Judgement approach. Content experts appointed by Orthopaedic section of the American Physical Therapy Association. | LBP. | Serious medical conditions. | 1: Lumbosacral segmental/somatic dysfunction with mobility deficits 2: Spinal instabilities with movement coordination impairments 3: Flatback syndrome or lumbago due to displacement of disc 4: Of acute low back pain with related (referred) lower extremity pain 5: Lumbago with sciatica 6: Low back pain/strain/lumbago -with related cognitive or affective tendencies 7: Of chronic LBP with related generalized pain Additional axis-Yes-acute, subacute, chronic | Patient history and clinical examination. Questionnaires for category with related cognitive or affective tendencies. | None. |
Hall et al. (1994) [55] | Identify typical patterns of pain and determine treatment direction. | Judgement approach. Spinal surgeon and physical therapist authorship. | LBP. | None. | 1: LBP +/- referred pain aggravated by flexion, slow onset lasting weeks 2: LBP +/- referred pain aggravated by extension, sudden onset lasts 1–2 weeks 3: Leg dominant pain due to nerve involvement, aggravated by flexion, slow onset, lasts weeks 4: Leg dominant pain due to nerve involvement aggravated by activity and extreme sustained extension, relieved by rest. Rapid onset 5: Abnormal pain behaviour, chronic pattern associated work/sleep/psycho/social issues Additional Axis- No | Patient history and clinical presentation. | None. |
McKenzie (1981) [49] | Develop a classification to determine choice of treatment. | Judgement approach. Physiotherapy authorship. | LBP. | Constant pain, serious pathology, neurological deficit. | 1: Postural 2: Dysfunction 3: Derangement 1–7 | Patient history and clinical examination. | Training in McKenzie assessment desired. |
Albert et al. 2012 [61] | Examine the association between treatment outcome and baseline type of disc lesion. | Judgement approach. Physiotherapy authorship. | Radicular pain with dermatomal distribution to knee or below. 176 patients with sciatica involved in large RCT. | >65 years old, leg pain < 3 on 1–10 scale, duration < 2 weeks or > 1 year, red flags, previous back surgery, serious comorbidities. | 5 groups based on their pain response: 1: Abolition centralization 2: Reduction centralization 3: Unstable centralization 4: Peripheralization 5: No change | Response to repeated moving testing. Lumbar magnetic resonance imaging (MRI). | Training from McKenzie accredited physiotherapist. |
Primary author | Purpose | Method of development | Domain of interest | Specific exclusions | Categories | Criteria used | Training/Personnel needed |
---|---|---|---|---|---|---|---|
Fritz et al. (2007) [64] | To identify if there is a subgroup of patients likely to respond to traction | Judgement and statistical approach. | LBP with signs of nerve root compression Primary care. | >60 years old, red flags, previous spinal surgery in past 6 months, pregnancy, absence of symptoms when sitting. | Patients likely to benefit from traction have: leg symptoms; signs of nerve root compression; symptom peripheralization on extension movement; positive crossed SLR | Patient history and clinical examination | None. |
Roach et al. (1997) [63] | To develop screening tests to place patients into a predetermined structure-based diagnostic classification system. | Judgemental and statistical approach. Physiotherapy authorship. | LBP. 106 tertiary care patients. | Back pain treatment within last year, history of back surgery, unconfirmed diagnosis at end of study. | 1: Disk, 2: Spinal stenosis, 3: Disk disease with spinal stenosis 4: Benign low back pain. | Questionnaire (Pain response to activity and position questionnaire). Additional advanced diagnostic tools such as CT/MRI and lab work. | None. |
Scholz et al. (2009) [62] | Test the utility of a tool (Standardized Evaluation of Pain (StePs)) to differentiate between radicular and axial pain. | Statistical approach. Anesthesiology and Pharmacology authorship. | Chronic LBP. | Pain < 3 months, <18 years old, global pain intensity in week prior to recruitment <6 severe psychiatric or medical illness, another painful or neurological disease or local infection. | Axial low back pain. Radicular low back pain. Most discriminatory items for radicular pain: positive SLR, deficit in detection of cold and reduced response to pinprick Also identified subtypes of radicular and axial LBP based on clusters of signs and symptoms. | Brief structured interview of 6 questions and 10 standardized physical tests. | Training in administering the tests in physical examination to assess cutaneous changes, pressure; pinprick; vibration; thermal sensitivity and proprioception. |
Primary author | Purpose | Method of development | Domain of interest | Specific exclusions | Categories | Criteria used | Training/Personnel needed |
---|---|---|---|---|---|---|---|
Schafer et al. 2009 [65] | Identify the predominant pain mechanisms responsible for patients back and leg pain to guide treatment decisions. | Judgement approach. Physiotherapy authorship. | Low back related leg pain. | Recent surgery or nerve root block, diabetes vascular disease in lower extremities, systematic disease. Inflammatory arthropathies. | 1. Central sensitization 2. Denervation 3. Peripheral nerve sensitization 4. Musculoskeletal | Patient history and clinical examination. Questions and physical component of the Leeds Assessment for Neuropathic Symptoms and Signs (LANSS). | None. |
Smart et al. 2011 [66] | Identify signs and symptoms of patients categorized according to mechanism-based classification of pain. | Judgement and statistical approach. Expert consensus panel to develop clinical criteria list. | LBP +/- leg pain. 464 patients. | History of diabetes, central nervous system injury, pregnancy, non musculo-skeletal LBP. | 1. Centralisation pain 2. Peripheral neuropathic 3. Nociceptive | Patient history and clinical examination. | Practical training with an assessment manual provided. |
Nijs et al. 2015 [75] | Apply a pain classification system to LBP patients | Judgement approach Expert opinion of 18 international pain experts | LBP | n/a | 1. Nociceptive pain 2. Neuropathic pain 3. Central sensitization | Patient history, clinical examination, diagnostic investigations | None |
Clinical features | Pathoanatomy | Treatment based approach | Screening/Prediction tool | Pain mechanisms | |||||
---|---|---|---|---|---|---|---|---|---|
Barker 1990 [79] | 2 | Bernard and Kirkaldy Willis 1987 [41] | 2 | Albert et al. 2012 [61] | 4 | Fritz et al. 2007 [64] | 3 | Schafer et al. 2009 [65] | 5 |
Ben Debba et al. 2000 [36] | 3.5 | Cassisi et al. 1993 [38] | 3 | Hall et al. 1994 [49] | 5 | Roach et al. 1997 [63] | 3 | Smart et al. 2011 [66] | 5 |
Glassman et al. 2011 [37] | 2.5 | Hahne et al. 2011 [38] | 3 | Mckenzie 1981 [49] | 5.5 | Scholz et al. 2009 [62] | 4 | Nijs et al. 2015 [75] | 2.5 |
Nachemson and Andersson 1982 [80] | 3.5 | Paatelma et al. 2009 [44] | 3.5 | Delitto et al. 2012 [48] | 3.5 | ||||
Spitzer et al. 1987 [25] | 4 | Petersen et al. 2003 [39] | 4 | ||||||
Sweetman et al. 1992 [26] | 2.5 | Vining et al. 2013 [46] | 3.5 |
General summary of classification systems organised by themes
Clinical features
Pathoanatomy
Author (first) | Terms to describe nerve root involvement | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Clinical features | ||||||||||||||||
Baker 1990 [79] | Sciatica | x | x | x | x | x | x | |||||||||
Ben Debba et al. 2000 [36] | Back and below knee pain with positive SLR | x | x | |||||||||||||
Glassman et al. 2011 [37] | Leg pain dominant; neurogenic claudication | x | x | |||||||||||||
Nachemson 1982 [80] | Sciatica; Rhizopathy | x | x | x | x | x | x | x | ||||||||
Spitzer et al. 1987 [25] | Pain with lower limb radiation with neurological signs; Spinal stenosis | x | x | x | x | x | ||||||||||
Sweetman et al. 1992 [26] | Sciatica | x | x | x | x | x | ||||||||||
Pathoanatomy | ||||||||||||||||
Bernard 1987 [41] | Herniated nucleus pulposis; Spinal stenosis | x | x | x | x | x | x | x | x | x | x | |||||
Cassisi et al. 1993 [40] | Disc herniation | x | x | x | x | x | x | x | ||||||||
Hahne et al. 2011 [38] | Disc herniation with radiculopathy | x | x | x | x | x | x | |||||||||
Paatelma et al. 2009 [44] | Discogenic pain with nerve root irritation; Spinal stenosis | x | x | |||||||||||||
Petersen et al. 2003 [39] | Disc syndrome:reducible/irreducible | x | x | x | x | x | x | |||||||||
Vining et al. 2013 [46] | Radiculopathy: non/compressive; Neurogenic claudication | x | x | x | x | x | x | x | ||||||||
Treatment approach | ||||||||||||||||
Delitto et al. 2012 [48] | Lumbago with sciatica | x | x | x | x | x | x | |||||||||
Hall et al. 1994 [55] | Leg dominant pain due to nerve root involvement | x | x | x | x | x | x | x | ||||||||
McKenzie 1981 [49] | Derangement; Adherent nerve root | x | x | |||||||||||||
Albert et al. 2012 [61] | Sciatica | x | x | x | x | x | x | |||||||||
Screening tools/CPR | ||||||||||||||||
Fritz et al. 2007 [64] | Low back pain with signs of nerve root involvement | x | x | x | x | |||||||||||
Roach et al. 1997 [63] | Disc; Spinal stenosis | x | ||||||||||||||
Scholz et al. 2009 [62] | Radicular pain | x | x | x | ||||||||||||
Pain mechanisms | ||||||||||||||||
Smart et al. 2011 [66] | Peripheral neuropathic | x | x | x | ||||||||||||
Schafer et al. 2009 [65] | Denervation; Peripheral nerve sensitization | x | x | x | x | x | x | x | ||||||||
Nijs et al. 2015 [75] | Neuropathic/radicular pain | x | x | x | x | x | x | x | ||||||||
Key for history and clinical examination criteria for sciatica | ||||||||||||||||
1 Pain below knee 2 Dermatomal distribution of symptoms 3 Positive cough/sneeze 4 Pins & needles/numbness: subjective reporting 5 Leg pain worse than back pain | 6 Quality descriptor of pain eg “burning” 7 Stenotic aggravating/easing factors 8 Sensory deficit in lower limb (LL) objectively 9 Strength deficit in LL objectively 10 Altered LL reflexes | 11 Positive neural tension tests 12 Positive crossed straight leg raise 13 Aggravated with specific lumbar range of movement 14 Other 15 Positive findings from imaging eg MRI |