J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 651–664 ~ FULL TEXT
Robert D. Vining, DC, DHSc, Zacariah K. Shannon, DC, MS, Amy L. Minkalis, DC, MS, and Elissa J. Twist, DC, MS
Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
Thanks to JMPT for permission to reproduce this Open Access article!
OBJECTIVE: The purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use.
METHODS: A systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists.
RESULTS: Of the 3,995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus-level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings.
CONCLUSION: The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.
KEYWORDS: Diagnosis; Evidence-Based Practice; Low Back Pain; Systematic Review
From the FULL TEXT Article:
Low back pain (LBP) is a substantial societal problem
owing to high prevalence and the many problems associated
with cost, chronicity, and disability. [1–3] Despite an intensive
research focus on LBP, definitive diagnostic methods are
largely unavailable and standard terminology is not yet
broadly adopted,4 leading researchers and practitioners to
classify most LBP as nonspecific. 
Nonspecific LBP represents a heterogenous group of
conditions, which may respond differently to available
interventions. Some evidence suggests that treatments
based on subgroupings of patients with LBP may lead to
more effective condition-tailored care. [5, 6] The lack of
standard diagnostic methods for determining a conclusive
diagnosis is due in part to many challenges with definitively
confirming symptom sources and the co-occurrence of
psychological and social factors that contribute to a
person’s lived experience. [7, 8] Although identifying symptom
sources is difficult in many cases, it is necessary to
differentiate benign from ominous conditions and to
meaningfully inform management approaches. [9–11]
Disparate diagnostic terminology creates potential confusion
among both clinicians and researchers. For example,
some clinical studies focused on sciatica, radiculopathy, or
radicular pain instead report they are focused on discogenic
pain. [12, 13] However, discogenic pain is defined as pain
arising from the intervertebral disc, independent of nerve
root involvement.  Spinal stenosis, a radiological finding
describing a narrowed space, is a term synonymously used
for the clinical syndrome of neurogenic claudication. 
However, spinal stenosis is an anatomical characteristic that
may not be associated with symptoms. 
To address some of the diagnostic challenges for LBP,
an evidence-based diagnostic classification system was
published in 2013 ; it defined diagnostic categories for
neuromusculoskeletal LBP and reported evidence-based
criteria supporting a variety of common diagnoses. A novel
and practical diagnostic checklist and corresponding exam
was also proposed to help practitioners interpret examination
evidence to inform evidence-based working diagnoses.
However, this classification system did not involve a
systematic review of the literature or propose standardized
terminology. Furthermore, evidence evolves over time,
requiring periodic reevaluation to remain current.
An evidence-based working diagnosis using standardized
terminology is needed to systematically explain the
most likely biological processes contributing to LBP and to
aid communication among providers, payers, and patients.
The purpose of this study is to review current diagnostic
evidence for office-based (ie, performed in office through
examination, evaluating historical characteristics, or questionnaires)
evaluation of common neuromusculoskeletal
conditions causing LBP and to evaluate the quality and type
of evidence of individual studies and systematic reviews
focused on this topic. We provide recommendations for
terminology use among clinicians and researchers. This
systematic review will inform other studies that will offer a
pragmatic office-based exam and diagnostic checklist, key
aspects of efficient conduct of the exam, practical
considerations for determining the relative strength of
working diagnoses, and an evidence-based chiropractic
treatment decision aid for managing LBP. [18, 19]
This systematic review was conducted according to
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses guidelines and was registered with the
International Prospective Register of Systematic Reviews
A study team member (A.M.) with the assistance of a
research librarian conducted an initial broad electronic
search of literature in the databases PubMed, MEDLINE,
CINAHL, Cochrane, and Index to Chiropractic Literature.
The search dates were 2010 to November 2017. Based on
the information gathered during the initial search, the
authors conducted detailed searches of the same databases
with search dates from inception to May 2018. Subsequently,
searches were updated through December 31,
2018. Reference lists of articles meeting eligibility criteria
were hand-searched, as were author-known articles
included in the previous classification system. 
Clinicaltrials.gov and the World Health Organization clinic
trials registry databases were searched to identify relevant
unpublished literature.  Search terms for each diagnosis
addressed in this review are available as Appendix A.
Articles were included if they were systematic reviews,
meta-analyses, or individual studies including human
participants focused on evaluating office-based exams or
other diagnostic criteria for a specific diagnosis of
neuromusculoskeletal LBP and published in English
language peer-reviewed journals. Commentaries, narrative
reviews, editorials, letters, conference abstracts, case
reports/series, guidelines, inter-rater or testeretest reliability
studies, and language validation studies were
Two authors (E.T., Z.S.) independently reviewed titles,
abstracts, and full-text articles against predetermined
inclusion/exclusion criteria. Included systematic reviews
and individual studies focused on diagnoses describing
conditions arising from nociceptive signaling within the
intervertebral disc, zygapophyseal (facet) joint(s), sacroiliac
(SI) joint(s), and myofascial tissues, and neuropathic pain
processes including radiculopathy, radicular pain, neurogenic
claudication, and peripheral entrapment (piriformis
and thoracolumbar [Maigne’s] syndrome). Central and
peripheral sensitization were also included. Figure 1
visually displays the major neuromusculoskeletal diagnostic
categories and subcategories included in this review.
Quality Assessment and Data Extraction
Two authors (E.T., Z.S.) independently assessed article
quality using methodology checklists developed by the
Scottish Intercollegiate Guidelines Network (SIGN)
Because the SIGN methodology checklists are tailored to
study design, methodology checklist 1 was used for
systematic reviews and meta-analyses. Systematic reviews
were assigned quality ratings based on 12 internal validity
question scores. Articles were classified as high quality if
the score was 10 or higher, acceptable quality for scores of 6
to 9, low quality for scores less than 6, or unacceptable
quality if the research question and inclusion/exclusion
criteria were not defined or a comprehensive literature
search was not performed. Unacceptable quality systematic
reviews were rejected. Individual studies that were not
included within a systematic review were rated as high, low,
or unclear for 4 risk-of-bias domains (patient selection,
index test, reference standard, flow and timing) and 3
applicability domains (patient selection, index test, reference
standard), using the SIGN methodology checklist 5 for
studies of diagnostic accuracy. Disagreement of article
quality was resolved by a third reviewer (A.M.) who
independently assessed the article and generated a majority
score. Data reporting key elements of all included studies
(study design, performance statistics, study population,
etc.) were abstracted independently by 3 authors (R.V.,
Z.S., A.M.). Each author verified each other’s work.
Disagreement was resolved through consensus discussion
The initial search revealed 3,781 articles. A second updated
search through December 2018 reveled an additional 45 articles.
Hand searching revealed 169 additional articles, resulting in a total
of 3,995. When 1,658 duplicates were removed, 2,337 articles
remained for title and abstract review. After title and abstract
review, 157 articles remained for full-text review. Twenty-five
articles were excluded because they were evaluated in included
systematic reviews (Appendix B). Thirty-six articles (8 systematic
reviews and 28 individual studies) met final eligibility criteria. Of
the 304 trial results displayed from search terms in both clinical
trial registries (clinicaltrials.gov and World Health Organization),
2 studies were identified as potentially eligible with unpublished
results. No response was received from requests for more
information regarding these 2 trials. The search process is
summarized in Figure 2.
Table 1 [13, 15, 22–29] displays the systematic reviews included in
this review, including the diagnostic foci and quality ratings. Ten
reviews met initial eligibility criteria; 2 were deemed unacceptable
quality, leaving 8 included reviews. Of the remaining 8 systematic
reviews, only 1 was rated as high quality,  and the remaining
were rated as acceptable. [13, 15, 23–27] One review updated evidence
for piriformis syndrome, 1 evaluated a tool for central sensitization,
2 studies evaluated the diagnostic accuracy of orthopedic
tests for SI joint pain, 2 addressed multiple conditions, and 2
assessed studies on lumbar radiculopathy and/or associated
conditions. Supplemental Table 1 displays data abstracted from
included studies. Key characteristics abstracted include study type,
population size, age, symptom duration, diagnostic comparator,
key findings, and key performance statistics.
Table 2 [12, 30–55] displays the risk of bias assessment for
individual studies. One study using Delphi methodology was
unable to be assessed using the SIGN methodology checklist for
diagnostic studies. 
The International Association for the Study of
Pain (IASP) defines nociceptive pain as “pain that arises from actual or threatened damage to non-neural tissue and is due to the
activation of nociceptors.”  Nociceptive pain is caused by neural
signaling in response to chemical (inflammatory), mechanical
(tension or compression), and thermal stress.  In the low back,
nociceptors are located within the major joints, ligaments, and
myofascial tissues. [58, 59] Conditions consistent with nociceptive
signaling (Fig 1) include the following:
(1) discogenic pain: pain
from nociceptive signaling within the intervertebral disc ;
(2) myofascial pain: pain from nociceptive signaling within muscle,
tendon, and/or fascial tissues of the low back region;
(3) SI joint pain: pain from nociceptive signaling within and surrounding a SI
joint ; and
(4) zygapophyseal (facet) joint pain: pain from
nociceptive signaling within and surrounding a zygapophyseal
(facet) joint. 
This review identified 2 individual studies and 1
systematic review of diagnostic tests for discogenic pain. Tonosu
et al reported that a score of 31 or higher on a 5–item differentially
weighted questionnaire provided 1.0 sensitivity and 0.71 specificity
for identifying discogenic pain using discography and
response from decompression or fusion surgery to confirm a
diagnosis.  Chan reported results of a Delphi process consensus
study describing characteristics thought to represent pain from
discal origin.  Petersen et al, in a systematic review, reported that
evidence from several studies is sufficient to conclude that the
centralization phenomenon is useful for identifying likely
discogenic pain. Sensitivity in included studies ranged from
0.40 to 0.64, with specificity ranging from 0.70 to 0.95 with
2 studies reporting moderate to high positive likelihood ratios
(6.9 and 9.4). 
No individual studies assessing common
myofascial pain diagnoses, such as muscle strain, were identified
in this review. Petersen et al, in a systematic review, recommended
that clinicians adopt diagnostic criteria consistent with the IASP
definition of myofascial pain syndrome (palpable taut muscle
region, hypersensitivity within taut muscle region with or without
referred pain, and elicited pain reproduces familiar pain). 
SI Joint Pain. Three systematic reviews and 5 separate articles
assessed tests or studies designed to identify SI joint pain. [15, 22, 25, 37, 39, 44, 52, 55] Szadek et al reported that evidence does not support
the use of individual pain provocation tests to identify probable SI
joint pain.  Three systematic reviews separately concluded that
available evidence supports a composite of 3 or more positive
provocation tests (distraction, compression, thigh thrust, Gaenslen
’s left or right, and either sacral thrust or Patrick’s test) to
suggest SI joint pain. [15, 22, 25]
Zygapophyseal (Facet) Joint Pain.
Five studies and 1 systematic
review assessed findings for facet joint pain. [15, 39, 40, 44, 46, 55]
Diez-Ulloa et al, using anesthetic joint injection as the diagnostic
comparison, reported that the positive and negative predictive
value of the lordosis maneuver was 90% and 61%, respectively. 
The lordosis maneuver begins in the prone position. The head and
chest are actively raised, ending with weight-bearing on elbows
and forearms without raising the pelvis. Mainka et al compared
provocation maneuvers and imaging findings between symptomatic
and asymptomatic age-matched controls with and without
lumbar spine tenderness attributed to facet joint pain.  The
authors concluded that pain provocation testing lacks specificity to
be useful in accurately predicting facet joint pain. Petersen et al
reported on 10 studies assessing diagnostic methods for identifying
facet joint pain. No diagnostic decision rule was recommended.
The IASP defines neuropathic pain as “pain
caused by a lesion or disease of the somatosensory nervous
system.”  Neuropathic pain may occur separate from, or in
conjunction with, nociceptive pain, potentially complicating the
diagnostic process and demanding methods to differentiate one
from the other.
Neuropathic pain associated with low back pain (Fig 1).
Neurogenic claudication: pain from intermittent compression
and/or ischemia of a single or multiple nerve roots within an
intervertebral foramen or the central spinal canal [61, 62]
Peripheral neuropathic pain: pain from inflammation,
compression, or entrapment of peripheral nerves in the
lumbar region [14, 63]
Radicular pain: pain from ectopic activation of nociceptors in
a spinal nerve or its roots or from other mechanisms (eg,
inflammation, tensile strain) 
Radiculopathy: objective sensory and/or motor function loss
caused by conduction block in axons of a spinal nerve or its
Sensitization: Increased responsiveness of nociceptive neurons
to their normal input, and/or recruitment of a response to
normally subthreshold inputs,  or a process of amplified
peripheral and/or central nervous system pain signaling
processes (central sensitization or peripheral sensitization). [14, 63, 64] Peripheral sensitization refers to reduced activation
threshold among nociceptors in the periphery whereas
central sensitization refers to similar changes among spinal
cord and cerebral cortex neurons that process nociceptive
signals. Central sensitization also involves additional
neuroplastic/neuroadaptive processes. 
Ten studies assessed in-office methods for identifying or
differentiating neuropathic from nociceptive pain. [31–35, 41, 42, 47, 51, 53]
Available instruments include the Leeds Assessment
of Neuropathic Symptoms and Signs (LANSS), S-LANSS
(self-report version of LANSS), painDETECT questionnaire,
McGill Pain Questionnaire, Standardized Evaluation of Pain
tool, Douleur Neuropathique 4, ID Pain questionnaire, and
Patient-Reported Outcome Measurement Information System
Neuropathic Pain Quality Scale.
One systematic review and 1 clinical
study focused on neurogenic claudication were included. 
Petersen et al offered a weak recommendation for using 3 or
more of 5 possible findings to provide evidence for neurogenic
claudication with a sensitivity of 0.29 and specificity of 0.88 (LRþ 2.5, LR– 0.80).
The 5 possible findings are
(1) age more than 48 years,
(2) bilateral symptoms,
(3) leg pain worse than low back pain,
(4) pain with walking/standing, and
(5) sitting relieves.
Nadeau et al assessed symptom characteristics for vascular and
neurogenic claudication in a study using imaging, ankle brachial
index measurements, and expert clinicians to confirm diagnoses
and exclude individuals with both conditions.  Specific symptom
constellations exhibited evidence for neurogenic claudication.
Sensitivity and specificity for the presence of 2 symptoms
(triggered with standing and relieved when sitting) were 0.80
and 0.87, respectively. Sensitivity and specificity for 3 symptoms
(triggered with standing, relieved when sitting, located above
knees) was 0.67 and 0.91, respectively. The addition of a positive
shopping cart sign carried a sensitivity of 0.57 and specificity of
0.96. Positive likelihood ratios were 6.10, 7.70, and 13.00 for each
successive combination (2, 3, and 4 symptoms).
Piriformis and Thoracolumbar Syndromes.
One systematic review
reported features from case studies to describe the frequency with
which specific symptoms were reported by patients suspected to
have piriformis syndrome.  The most frequently reported
symptoms were radiating ipsilateral leg pain, greater sciatic
notch tenderness, buttock pain, positive straight leg raise test
(SLR), and pain while sitting. No data on the diagnostic accuracy
of specific symptoms were identified. No articles reported on
diagnosis for thoracolumbar syndrome, a condition of cluneal
nerve entrapment causing low back and/or lower extremity pain. 
No studies in this review reported diagnostic
methods for distinguishing between radicular pain and
Three systematic reviews and 7 clinical studies
evaluated methods for diagnosing lumbar radiculopathy. [12, 13, 15, 26, 33, 43, 45, 48, 50] Scaia et al synthesized evidence from 7 studies,
reporting that the SLR demonstrated a wide range of sensitivity
from 0.19 to 0.97 and specificity from 0.10 to 0.89, limiting
diagnostic utility.  Tawa synthesized evidence from 12 studies
reporting poor sensitivity of 0.13 to 0.61 for motor tests and
sensitivity ranges of 0.14 to 0.67 and specificity of 0.60 to 0.93 for
deep tendon reflexes.  Savage et al and Inal et al similarly
reported poor relationships among symptom characteristics, exam
findings, and nerve root conduction loss confirmed with
electrodiagnostic testing. [43, 50] Petersen et al, in a review of 20
studies, reported sensitivity (0.28–0.50) and specificity (0.83–0.94)
for a cluster of 3 or more of 4 findings in the presence of a positive
(1) pain in a dermatomal distribution,
(2) corresponding sensory deficit,
(3) diminished reflex, and
(4) motor weakness. 
Two included studies assessed central sensitization. [27, 38] No studies assessed peripheral sensitization. Scerbo et al, in a
systematic review of studies using the Central Sensitization
Inventory (CSI), reported high-quality evidence supporting
psychometric properties and face validity, suggesting the instrument
is useful in measuring central sensitization severity. 
However, the authors note that the central sensitization was
designed as a tool to measure the severity rather than diagnose
central sensitization. Nijs et al, in a guideline for classifying
neuropathic, nociceptive, and central sensitization pain, recommend
practitioners use IASP criteria:
(1) low back pain experience disproportionate to the nature and extent of injury/pathology,
(2) neuroanatomically illogical pain pattern, and
(3) hypersensitivity of senses unrelated to the musculoskeletal system. 
We have provided an instructional video that provides an
overview of this information (see video file online).
This systematic review summarizes and assesses studies
reporting the diagnostic utility of clinical questionnaires,
in-office tests, and patient or symptom characteristics to
inform working diagnoses for common causes of LBP.
Provocation discography is the diagnostic reference
standard test used to confirm discogenic pain.  Discography
as a routine diagnostic procedure is not recommended
owing to high cost; lack of standardized
procedures; and risks such as subarachnoid puncture,
discitis, allergic reaction, and chemical meningitis. 
Similar to prior reviews, we conclude that current evidence
supports the centralization phenomenon as an office-based
test suggesting the presence of discogenic pain.
The term myofascial pain is described as pain arising
from hyperirritable foci within a muscle or related fascia or
as a syndrome of muscle, sensory, motor, and autonomic
symptoms associated with myofascial trigger points. [67, 68]
Both descriptions refer to myofascial pain syndrome.
However, the words myofascial pain simply imply pain
arising from myofascial tissues. We recommend myofascial
pain be defined as nociceptive signaling from within muscle
or fascial tissues that may or may not include referred pain
or the presence of trigger points (Table 3). [14, 15, 22, 31, 32, 35, 36, 41, 47, 51, 57, 60, 69, 70] This broader definition may reduce
confusion caused by current descriptions, which instead
of defining myofascial pain define myofascial pain
syndrome. Diagnostic criteria consistent with this definition
and with those recommended by Petersen et al include
tenderness within a muscle with or without referred pain
and reproduction of familiar pain with palpation or use. 
The presence of hypersensitive areas (trigger points) is a
criterion for myofascial pain syndrome, and thus not
recommended as necessary for identifying the more general
category of myofascial pain, which could include conditions
such as muscle strain.
SI Joint Pain
Despite the existence of numerous provocation tests
designed to identify SI joint pain, current scientific
evidence does not support the diagnostic utility of
individual tests. Sacroiliac joint anesthetic injections
(blocks) with a placebo or controlled comparative anesthetic
are the current diagnostic standard. [22, 71] Sacroiliac
joint blocks are not recommended for routine use owing to
high cost, invasiveness, and associated risks. The prevalence
of SI joint pain in persons with LBP ranges from
10% to 33%.  Intra-articular injection can only assess
extra-articular pain when injectate leaks from the joint
cavity, leaving potential extra-articular pain sources largely
unstudied. Nevertheless, a composite of 3 or more
maneuvers, which reproduce familiar pain, has diagnostic
value. [15, 22, 25]
Zygapophyseal (Facet) Joint Pain
The prevalence of facet joint pain ranges from 16% to
41% of persons with low back pain reported in studies using
controlled anesthetic injection as the diagnostic standard. 
A study by Laslett et al reported 3 or more of 5 possible
findings (age over 50 years, onset paraspinal, pain relieved
with walking, pain relieved with sitting, positive extension-
rotation test) demonstrated a sensitivity of 0.85, a
specificity of 0.91, a positive likelihood ratio of 9.7, and a
0.17 negative likelihood ratio.  Laslett et al conducted
their study within a secondary/tertiary care setting and
findings are yet to be reproduced. Thus, the evidence base
for these criteria is currently weak, suggesting reported
sensitivity, specificity, and likelihood ratios may be
inflated. We recommend clinicians consider using criteria
reported by Laslett et al, while recognizing the limitations
of evidence obtained from a single study conducted in a
specific setting. Adopting these diagnostic criteria has the
advantage of identifying and describing patients with
similar characteristics, which may have clinical utility.
Nociceptive vs Neuropathic Pain
Distinguishing between nociceptive and neuropathic
pain is important for informing clinical management
strategies as evidenced by the numerous instruments
designed to facilitate this distinction [31, 32, 34, 35, 36, 41, 42, 47, 51]
and clinical guidelines recommending neuropathic pain
identification. [59, 74–76] Research in this area has resulted
in several office-based questionnaires, which exhibit
acceptable psychometric properties, reliability, and face
validity. [77, 78] Such instruments are derived from studies
with a generally high risk of bias owing to the absence of
reference standard diagnostic tests. Some instruments may
not be effective as a screening tool in some subpopulations.
For example, the painDETECT is not considered an
effective screening tool for persons with chronic pain. 
However, when used appropriately, these instruments can
be useful. When neuropathic pain is potentially identified,
further confirmation through neurologic exam, imaging,
electrophysiology, or quantitative sensory testing may be
required. [70, 74]
Neurogenic claudication occurs when spinal stenosis is
severe enough to cause symptoms from intermittent neural
compression or ischemia, most commonly from degenerative
changes within the spine. [79, 80] We recommend
diagnostic criteria reported by Nadeau et al. Constellations
of 2, 3, or 4 symptoms (triggered with standing, relieved by
sitting, symptoms above the knees, and positive shopping
cart sign) exhibit progressively stronger evidence for the
presence of neurogenic claudication with positive likelihood
ratios of 6.10, 7.70, and 13.0, respectively.  The
presence of symptoms occurring primarily above the knees
is more consistent with neurogenic claudication, whereas
symptoms primarily below the knees, when combined with
relief upon standing, more likely identify vascular claudication.  Alternatively, 3 or more of 5 criteria also show
diagnostic utility, though exhibiting lower sensitivity and
(1) age more than 48 years,
(2) bilateral symptoms,
(3) leg pain worse than low back pain,
(4) pain with walking/standing, and
(5) sitting relieves pain. 
Piriformis and Thoracolumbar Syndromes
Piriformis and thoracolumbar syndromes are subtypes of
peripheral neuropathic pain. Piriformis syndrome is caused
by compression, entrapment, or inflammation of the sciatic
nerve, from direct piriformis muscular impingement or
other mechanisms. 
Current diagnostic criteria are available
only through a systematic review of clinical features
reported in the scientific literature:
(1) ipsilateral leg radiation,
(2) greater sciatic notch tenderness,
(3) buttock pain,
(4) positive SLR, and
(5) pain with sitting. 
No included articles reported on studies assessing
diagnostic criteria for thoracolumbar syndrome originally
described by Maigne:
(1) pain in nerve distribution (iliac crest, groin, or greater trochanter),
(2) trigger point over iliac crest approximately 7 cm from midline,
(3) sensitivity to iliac crest skin rolling, and
(4) tenderness of 1 or more thoracolumbar spinous processes or facet joints. [65, 82, 83]
Radicular Pain and Radiculopathy
Several studies focused on identifying radiculopathy or
sciatica, reporting wide variations in sensitivity and
specificity of tests such as the SLR. [13, 15, 26] The absence
of convincing evidence for diagnostic accuracy is due to
several methodological limitations shared by many
included studies, most notably by using different methods
to conduct or interpret tests, by considering radicular pain
and radiculopathy as a singular condition, and by presuming
imaging is an adequate reference standard for radiculopathy. [12, 13, 26, 33, 43, 50, 45, 48, 84] Imaging cannot confirm
whether nerve root compression is of sufficient intensity
to cause reduced neural signaling, which is the necessary
element for radiculopathy. Therefore, participants in studies
using imaging confirmation of nerve root compression
probably comprise those with radicular pain and those with
radiculopathy. In the absence of conclusive diagnostic
studies, we recommend practitioners use IASP criteria for
discriminating between radiculopathy or radicular pain
(Table 4). [14, 23, 49, 59, 60, 65, 82]
Research in this area is generally limited by the absence of
an objective standard diagnostic test resulting in questionnaire
instruments that assess neuropathic or nociceptive pain based
on expert consensus criteria or codified into clinical guidelines.  We recommend practitioners adopt the IASP criteria
as recommended in a recent clinical guideline (Table 4). 
Most individual studies included in this review contained
a high risk of bias in the reference standard domain.
This finding is expected because most conditions causing
LBP lack high-quality reference standard tests that can
definitively confirm or rule out their presence. Patient
selection bias was another common domain designated with
a high risk for bias among individual included studies. Both
factors have the potential to bias results toward overestimation
of diagnostic test accuracy (Table 2).
Studies included in this review refer to pain of radicular
origin using disparate and nondescript terms. For example,
Ohnmeiss et al reported examining the relationship between
pain drawings and discogenic pain.  However, radicular
pain, rather than discogenic pain (pain from nociceptive
signaling within the intervertebral disc), was studied. Scaia
et al, in a systematic review of studies evaluating diagnostic
methods for sciatica and disc herniation, concluded that
poor test utility may result from studying separate
conditions that sometimes share similar characteristics,
confounding diagnostic accuracy results. 
Radicular pain occurs with ectopic neural transmission
generated from inflammation or other insult, such as
mechanical stress. In contrast, the hallmark of radiculopathy
is nerve conduction loss.  However, no study
included in this review distinguished these 2 conditions.
Such study designs are likely to report poor diagnostic
utility of studied criteria as observed in this review.
Similarly, neurogenic claudication was commonly referred
to as lumbar stenosis.  Though some included reviews
reported evaluating diagnostic criteria for myofascial pain,
myofascial pain syndrome was the condition of focus. 
To avoid the unnecessary complexity and confusion
created by multiple overlapping and nonspecific terms,
adoption of IASP applicable terminology across professions
and within scientific publications is strongly recommended. [14, 60] Standardized terminology adoption fosters clear
communication between and among health professionals,
researchers, and patients, and uses evidence-based terminology
that directly relates to underlying physiology. Diagnoses
with IASP-established definitions included in this
review include radiculopathy, radicular pain, sensitization,
peripheral neuropathic pain, discogenic pain, SI joint pain,
and facet joint pain (Tables 3 and 4). Piriformis syndrome,
thoracolumbar syndrome, neurogenic claudication, and
myofascial pain are not specifically defined by the IASP.
Consistent with IASP terminology, piriformis and thoracolumbar
syndrome represent peripheral neuropathic pain
subtypes as defined by the IASP. Likewise, myofascial pain
describes nociceptive firing from within myofascial tissues,
among which subtypes, such as myofascial pain syndromes
and muscle strain, exist (Table 3). Neurogenic claudication
has been described as a clinical syndrome resulting from
neurologic compression or ischemia caused by spinal
stenosis. [61, 62, 85, 86] However, because persons with spinal
stenosis may not experience neurogenic claudication
symptoms, using the term spinal stenosis to describe
neurogenic claudication is inaccurate and potentially labels
patients with benign conditions, contributing to unnecessary
All systematic reviews are limited by search strategy,
which may not be comprehensive. In this review, multiple
searches using a variety of terms for included diagnoses
were used. Including other systematic reviews with
alternate search strategies was also designed to mitigate
this limitation. We used standardized instruments to
conduct article quality assessment. Although quality
assessment was performed by experienced researchers,
judgment and interpretation are necessary and there exists
no established value separating high-, moderate, and
low-quality studies. Many included studies enrolled
participants in secondary or tertiary care settings, limiting
generalizability to primary spine care settings. The
absence of objective reference standard tests limits
scientific evaluation for several conditions studied in this
review. In such instances, expert recommendations
describing diagnostic criteria represent the best available
evidence. Such diagnostic criteria are supported by current
scientific understanding of physiology, although they lack
stronger validation. As evidence evolves, additional
literature review will be needed to summarize and update
information on this topic. Finally, study heterogeneity
prevented data pooling.
This review describes evidence-based diagnostic criteria
for common conditions contributing to neuromusculoskeletal
low back pain. Understanding the accuracy of tests and
the evidence basis from which diagnostic criteria are
derived can inform management decisions and the amount
of confidence placed in a working diagnosis. Adopting
IASP-applicable terminology is recommended to improve
communication among health professionals, patients, and
researchers, and to improve the quality of diagnosis-related
This systematic review summarizes and
describes the type of scientific evidence
supporting diagnostic criteria for common
causes of LBP.
The review also highlights and describes
problems with current disparate terminology
use and how this practice is hindering
research efforts and causing confusion for
clinicians and researchers.
Formal recommendations for standardizing
terminology are included.
The authors thank Anna Schmidt, MM, DC, for
reviewing manuscript drafts, providing critical feedback,
and performing other activities relevant to this project.
FUNDING SOURCES AND CONFLICTS OF INTEREST
Drs Vining, Shannon, Minkalis, and Twist report grant
support from the National Institutes of Health/National
Center for Complementary & Integrative Health
5UG3AT009761-02. Dr Shannon reports support from
the NCMIC Foundation. No funding agency was involved
in data collection, data analysis, data interpretation, or
manuscript writing. No other conflicts of interest were
reported for this study.
Concept development (provided idea for the research):
Design (planned the methods to generate the results): R.V.,
A.M., Z.S., E.T.
Supervision (provided oversight, responsible for organization
and implementation, writing of the manuscript): R.V.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): Z.S.,
E.T., A.M., R.V.
Analysis/interpretation (responsible for statistical analysis,
evaluation, and presentation of the results): R.V., Z.S.,
Literature search (performed the literature search): A.M.
Writing (responsible for writing a substantive part of the
manuscript): R.V., A.M., E.T.
Critical review (revised manuscript for intellectual content,
this does not relate to spelling and grammar checking):
R.V., A.M., Z.S., E.T.
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