Background
Aim
Methods
Design
Steering committee
Participants
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≥ 2 peer-reviewed publications in the field of NP in low back related leg pain [25] or
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≥ 10 years experience working in a pain/musculoskeletal outpatient service
Recruitment
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Emailing authors of published systematic reviews relating to NP in low back related leg pain
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Posting social media expressions of interest
Procedure
Round 1
Round 2
Round 3
Data management and analysis
Round 1 | Median value of participants Likert scale data ≥ 3 |
Percentage of agreement 50% | |
Round 2 | Median value of participants Likert scale data ≥ 3.5 |
IQR value of participants Likert scale data ≤ 2 | |
Percentage of agreement 60% | |
Round 3 | Median value of participants Likert scale data ≥ 4 |
IQR value of participants Likert scale data ≤ 1 | |
Percentage of agreement 70% |
Results
Participants
Characteristics of expert participants | Total number |
---|---|
Gender | |
Male | n = 24 |
Female | n = 14 |
Age | |
30–39 | n = 8 |
40–49 | n = 21 |
50–59 | n = 8 |
≥ 60 | n = 1 |
Occupation | |
Physiotherapist | n = 12 |
Extended scope Physiotherapist | n = 9 |
Consultant Physiotherapist | n = 4 |
Lecturer | n = 5 |
Research fellow | n = 1 |
Professor | n = 3 |
PhD student | n = 2 |
Neuroscientist | n = 1 |
Osteopath | n = 1 |
Country of origin | |
UK | n = 20 |
Ireland | n = 2 |
Australia | n = 6 |
India | n = 2 |
Switzerland | n = 2 |
Norway | n = 1 |
Netherlands | n = 1 |
USA | n = 1 |
Italy | n = 1 |
South Africa | n = 1 |
Greece | n = 1 |
Highest academic qualification | |
BSc | n = 1 |
PGDip | n = 2 |
MSc | n = 21 |
MRes | n = 1 |
PhD | n = 13 |
Time period working with NP | |
10–15 years | n = 27 |
16–20 years | n = 3 |
> 20 years | n = 8 |
Peer review journal > 2 | |
0 | n = 28 |
2–5 | n = 4 |
6–10 | n = 0 |
> 10 | n = 6 |
Round 1
Round 1 criteria for consensus: | |||
---|---|---|---|
✓ Median value of participants Likert scale data ≥ 3 | |||
✓ Percentage of agreement 50% (Wiangkham et al., 2016 [25]) | |||
Clinical indicator | Median | Percentage of agreement | Consensus achieved |
Pain variously described as burning, shooting, sharp, aching or electric-shock-like | 4 | 85.7% | Y |
History of nerve injury, pathology or mechanical compromise | 4 | 77.2% | Y |
Pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness) | 4 | 77.2% | Y |
Pain referred in a dermatomal or cutaneous distribution | 3 | 48% | N |
Less responsive to simple analgesia/NSAIDS and/or more responsive to anti-epileptic (e.g. Neurontin, Lyrica)/anti-depression (e.g. Amitriptyline) medication | 3 | 39% | N |
Pain of high severity and irritability (i.e. easily provoked, taking longer to settle) | 4 | 54.3% | Y |
Mechanical pattern to aggravating and easing factors involving activities/postures associated with movements, loading or compression of neural tissue | 3 | 42.9% | N |
Pain in association with other dysesthesias (e.g. crawling, electrical, heaviness) | 4 | 68.6% | Y |
Reports of spontaneous pain (i.e. stimulus independent) and/or paroxysmal pain (i.e. sudden recurrences and intensification of pain) | 4 | 51.4% | Y |
Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic, i.e. SLR, Brachial plexus tension test) that move/load/compress neural tissue | 4 | 65.7% | Y |
Pain/symptom provocation on palpation of relevant neural tissues | 4 | 51.4% | Y |
Positive neurological signs (including altered reflexes, sensation and muscle power in dermatomal/myotomal or cutaneous nerve distribution) | 4 | 63.8% | Y |
Antalgic posturing of the affected limb/body part | 2 | 37.1% | N |
Positive findings of hyperalgesia (primary or secondary) and/or allodynia and/or hyperpathia within the distribution of pain | 4 | 57.2% | Y |
Pain descriptors need to be split into separate indicators
“............too many options in this sentence. Whilst I agree with shooting and electric, many patients describe non-neuropathic low back pain as aching, burning, sharp, and sometimes shooting” (Participant 12)
“some of these descriptors I would associated with neuropathic pain but not all of them” (Participant 10)
“ … …… … aching certainly not neuropathic, so this question is difficult to answer, for burning, shooting, electric shock, I would strongly agree” (Participant 3)
Latency of pain following aggravating factor
“can have a latency affect - which needs to be considered” (Participant 2)
“Latency of pain - nerve pain will often manifest the day after the aggravating activity” (Participant 26)
Positive small fibre testing
“one could also test the small fibres, as NDTs are not enough in order to assess probably a UNT or SLR properly” (Participant 33)
“need to continue to develop clinically feasible methods for assessing function of smaller diameter afferent fibers as part of sensory examination” (Participant 22)
Indicators not exclusive to NP
“Agree that these terms would be used to describe nerve root related leg pain, but not exclusively” (Participant 9)
Following content analysis nine additional indicators were included in the round 2 survey (Table 4). At the end of each indicator “increases your index of suspicion that there is a NP component to low back related leg pain” was added.“I think this is a multifactorial and multi symptomatic problem. It is an overall picture involving a number of points made above but not exclusively all” (Participant 23)
Round 2 criteria for consensus include: | ||||
---|---|---|---|---|
✓ Median value of participants Likert scale data ≥ 3.5 | ||||
✓ IQR value of participants Likert scale data ≤ 2 | ||||
✓ Percentage of agreement 60% (Wiangkham et al., 2016 [25]) | ||||
Clinical indicator | Median | IQR | Percentage of agreement | Conesus achieved |
Pain described as burning | 4 | 1 | 90.9% | Y |
Pain described as shooting | 4 | 1 | 73.8% | Y |
Pain described as sharp | 3 | 1 | 18.2% | N |
Pain described as aching | 2 | 2 | 12.1% | N |
Pain described as electric-shock-like/electrical | 4 | 1 | 93.9% | Y |
Pain described as cramping | 3 | 2 | 30.3% | N |
Pain described as crawling | 4 | 1 | 66.7% | Y |
Pain described as heaviness | 3 | 2 | 33.3% | N |
History of nerve injury, pathology or mechanical compromise | 5 | 1 | 90.9% | Y |
Pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness) | 5 | 1 | 96.9% | Y |
Pain of high severity and irritability (i.e. easily provoked, taking longer to settle) | 4 | 1 | 72.8% | Y |
Reports of spontaneous pain (i.e. stimulus independent) and/or paroxysmal pain (i.e. sudden recurrences and intensification of pain) | 4 | 2 | 72.7% | Y |
Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic, i.e. SLR, Brachial plexus tension test, prone knee bend) | 4 | 1 | 67.9% | Y |
Pain/symptom provocation on palpation of relevant neural tissues | 4 | 1 | 57.6% | N |
Positive neurological signs (including altered reflexes, sensation and muscle power in dermatomal/myotomal or cutaneous nerve distribution) | 5 | 1 | 94% | Y |
Positive findings of hyperalgesia (primary or secondary) | 3 | 2 | 42.4% | N |
Allodynia and/or hyperpathia within the distribution of pain | 4 | 2 | 66.7% | Y |
Latent pain response to aggravating factor | 4 | 1 | 51.5% | N |
Positive small fibre nerve testing findings (Hot/cold etc....) | 4 | 1 | 84.8% | Y |
Round 2
History of nerve lesion or disease of somatosensory nervous system is difficult to identify/define
“this is of course the IASP definition of NP, that it has to be associated with a lesion or disease of SSNS, tricky bit is that often in clinics it is not so straightforward to demonstrate the lesion/disease” (Participant 29)
“mechanical compromise is difficult to define and will be interpreted differently by various professions / therapists” (Participant 10)
“I'm not sure exactly what mechanical compromise means here” (Participant 31)
As well as a history of nerve injury, pathology or mechanical compromise other factors can contribute to the development of NP in low back related leg pain
“metabolic changes / diabetic or autoimmune diseases” (Participant 8)
“recent or past chemotherapeutic drugs prescription” (Participant 11)
“immune compromise e.g. HIV” (Participant 19)
Round 3 criteria for consensus include: | ||||||
---|---|---|---|---|---|---|
✓ Median value of participants Likert scale data ≥ 4 | ||||||
✓ IQR value of participants Likert scale data ≤ 1 | ||||||
✓ Percentage of agreement 70% (Wiangkham et al., 2016 [25]) | ||||||
Clinical indicator | Median | IQR | Percentage of agreement (%) | Consensus achieved | Ranking patient history indicators | Ranking clinical examination indicators |
Pain variously described as burning, electric shock like and/or shooting into leg | 5 | 1 | 100 | Yes | 2 | |
Pain described as crawling or another unpleasant abnormal sensation (as a common example of dysesthesia) | 4 | 1 | 90.3 | Yes | 4 | |
History of nerve injury, pathology or mechanical compromise at the region of the nerve root/or other nervous tissue around the lumbar spine that can refer into the leg | 5 | 1 | 96.7% | Yes | 3 | |
In a patient with low back related leg pain does the pre-existing knowledge of metabolic (e.g. diabetes, vitamin deficiencies), hormonal (e.g. thyroid), genetic (e.g. channelopathies), pharmacological (antimetabolities), chemical (e.g. chemotherapy) conditions | 3 | 1 | 48.5% | No | 7 | |
Pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness) | 5 | 1 | 100% | Yes | 1 | |
Pain of high severity and irritability (i.e. easily provoked, taking longer to settle) | 4 | 2 | 64.5% | No | 6 | |
Reports of spontaneous pain (i.e. stimulus independent) and/or paroxysmal pain (i.e. sudden recurrences and intensification of pain) | 4 | 1 | 71.1% | Yes | 5 | |
Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic, i.e. SLR, Brachial plexus tension test) | 4 | 1 | 67.8% | No | 3 | |
Positive neurological signs (including altered reflexes, sensation and muscle power in dermatomal/myotomal or cutaneous nerve distribution) | 5 | 1 | 90.4% | Yes | 1 | |
Allodynia and/or hyperpathia within the distribution of pain | 4 | 1 | 74.2% | Yes | 4 | |
A loss of function of small fibre testing | 4 | 1 | 77.4% | Yes | 2 |
Round 3
Other factors such as metabolic, hormonal etc. … contributors are too general and not specific enough when identifying NP in low back related leg pain
“Will be used in the clinical reasoning process, but need other descriptors or indicators. In isolation, not indicative of neuropathic pain” (Participant 3)
“Although diabetes and radiotherapy can result in NP, this has is not low back-related”, “I suppose it may make you consider that their nervous system is more vulnerable, but whether it means that they have a NP component to their low back pain is unclear” (Participant 11)
High severity and irritability not specific enough to identify NP in low back related leg pain
“it can be part of the picture of neuropathic pain, but not totally discriminatory” (Participant 6)
“ … …… … these components are too non-specific to even increase my index of suspicion of a neuropathic component to low back-related leg pain. While nerve-related problems can often be higher on the severity and irritability scales, non-neural/nociceptive problems can also be high on these scales” (Participant 28)
Neurodynamic testing
“I would not consider a positive lower limb neurodynamic tests to be relevant here. As previously mentioned, a negative SLR/Slump tests etc. does not mean that NP is not present esp. In the presence of nerve function loss, and its presence does not tell you for sure that there is NP component as we know many people with positive. Neurodynamic tests do not have NP. So whilst I agree that its presence may raise my suspicion, it is other factors as well that would confirm its presence” (Participant 14)
“ …………heightened nerve mechanosensitivity is NOT the same as neuropathic pain. Quite often heightened nerve mechanosensitivity is associated with nociceptive pain. This is a huge fallacy in contemporary Physiotherapy, and often misinterpreted...see many studies which show that neurodynamic tests can be negative in patients with properly diagnosed nerve lesions (so by your (IASP) definition have neuropathic pain...)” (Participant 15)
Pain variously described as burning, electric shock like and/or shooting into leg (percentage of agreement 100%) | |
Pain described as crawling or another unpleasant abnormal sensation (as a common example of dysesthesia) (percentage of agreement 90.3%) | |
History of nerve injury, pathology or mechanical compromise at the region of the nerve root/or other nervous tissue around the lumbar spine that can refer into the leg (percentage of agreement 96.7%) | |
Pain in association with other neurological symptoms (e.g. pins and needles, numbness and weakness) (percentage of agreement 100%) | |
Reports of spontaneous pain (i.e. stimulus independent) and/or paroxysmal pain (i.e. sudden recurrences and intensification of pain) (percentage of agreement 71%) | |
Positive neurological signs (including altered reflexes, sensation and muscle power in dermatomal/myotomal or cutaneous nerve distribution) (percentage of agreement 90.4%) | |
Allodynia and/or hyperpathia within the distribution of pain (percentage of agreement 74.2%) | |
Loss of function of small fibre nerve testing (percentage of agreement 77.4%) |
Consensus on ranking
1) Pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness) increases your index of suspicion that there is a NP component to low back related leg pain | |
2) Pain variously described as burning, electric shock like and/or shooting into leg increases your index of suspicion of a NP component to low back related leg pain. | |
3) History of nerve injury, pathology or mechanical compromise at the region of the nerve root/or other nervous tissue around the lumbar spine that can refer into the leg increases your index of suspicion of a NP component to low back related leg pain. | |
4) Pain described as crawling or another unpleasant abnormal sensation (as a common example of dysesthesia) increases your index of suspicion of a NP component to low back related leg pain. | |
5) Reports of spontaneous pain (i.e. stimulus independent) and/or paroxysmal pain (i.e. sudden recurrences and intensification of pain) increases your index of suspicion that there is a NP component to low back related leg pain |
1) Positive neurological signs (including altered reflexes, sensation and muscle power in dermatomal/myotomal or cutaneous nerve distribution) increases your index of suspicion that there is a NP component to low back related leg pain | |
2) A loss of function of small fibre testing increases your index of suspicion that there is a NP component to low back related leg pain | |
3) Allodynia and/or hyperpathia within the distribution of pain increases your index of suspicion that there is a NP component to low back related leg pain |
Discussion
Study findings compared to Smart et al’s (2010) original list
Strengths and limitations
Clinical and research recommendations
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Pain variously described a burning, electric shock like and/or shooting into leg
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Pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness)
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Pain described as crawling or another unpleasant abnormal sensation (as a common example of dysesthesia)
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History of nerve injury, pathology or mechanical compromise at the region of the nerve root/or other nervous tissue around the lumbar spine that can refer into the leg
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Positive neurological signs (including altered reflexes, sensation and muscle power in dermatomal/myotomal or cutaneous nerve distribution)