Finding Cancer in Primary Care Outpatients with Low Back Pain A Comparison of Diagnostic Strategies

Joines, Jerry D.; McNutt, Robert A.; Carey, Timothy S.; Deyo, Richard A.; Rouhani, Roya

doi:10.1046/j.1525-1497.2001.00249.x

Cited by 14 publications

(23 citation statements)

References 26 publications

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“…Low back pain remains a common condition among primary care patients with an estimated lifetime prevalence of 13.8 % for chronic pain and 80 % for any episode of pain [1][2][3]. European guidelines for the management of low back pain in primary care define low back pain as ''pain and discomfort'' localized below the costal margin and above the inferior gluteal folds, with or without leg pain.…”

Section: Introductionmentioning

confidence: 99%

Red flags presented in current low back pain guidelines: a review

et al. 2016

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Objective The purpose of this study was to identify and descriptively compare the red flags endorsed in guidelines for the detection of serious pathology in patients presenting with low back pain to primary care. Method We searched databases, the World Wide Web and contacted experts aiming to find the multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We extracted data on the number and type of red flags for identifying patients with higher likelihood of serious pathology. Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.) were presented to support the endorsement of specific red flags. Results We found 21 discrete guidelines all published between 2000 and 2015. One guideline could not be retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain in a primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any specific disease. Overall, we found 46 discrete red flags related to the four main categories of serious pathology: malignancy, fracture, cauda equina syndrome and infection. The majority of guidelines presented two red flags for fracture ('major or significant trauma' and 'use of steroids or immunosuppressors') and two for malignancy ('history of cancer' and 'unintentional weight loss'). Most often pain at night or at rest was also considered as a red flag for various underlying pathologies. Eight guidelines based their choice of red flags on consensus or previous guidelines; five did not provide any reference to support the choice of red flags, three guidelines presented a reference in general, and data on diagnostic accuracy was rarely provided. Conclusion A wide variety of red flags was presented in guidelines for low back pain, with a lack of consensus between guidelines for which red flags to endorse. Evidence for the accuracy of recommended red flags was lacking.

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Section: Introductionmentioning

confidence: 99%

Red flags presented in current low back pain guidelines: a review

et al. 2016

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“…Radiographic findings of lytic or blastic lesions was an excellent discriminator between patients with and without underlying cancer, with reported sensitivity of 0.70 and specificity of 0.95 at a cost of $38. 8,18 None of the patients with cancer in the study had both a negative radiograph and an elevated erythrocyte sedimentation rate.…”

Section: Discussionmentioning

confidence: 94%

“…Other authors reporting cases of hip pain later diagnosed as having pathological origins have also recommended diagnostic imaging in cases involving hip pain that is nonresponsive to conser vative treatment, including physical therapy. 10,31,33 While the decision-making process of when to order imaging in the presence of low back pain has been extensively studied and reported, 8,17,18 there is little available guidance in the literature concerning musculoskeletal complaints of the hip and pelvis.…”

Section: Discussionmentioning

confidence: 99%

“…Alternatively, patients with a previous history of cancer would be imaged with MRI initially due to the high likelihood ratio associated with this finding. 18 It is not uncommon for a patient with hip pain to describe disturbed sleep. When questioned further, this patient described the disturbance as awakening due to pain to the lateral hip when lying on the left side that decreased with position change.…”

Section: Discussionmentioning

confidence: 99%

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Decision Making for a Painful Hip: A Case Requiring Referral

Browder

Erhard²

2005

J Orthop Sports Phys Ther

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Study Design: Resident's case problem. Background: The purpose of this resident's case problem is to describe a 39-year-old female patient with insidious onset of hip pain. This patient had discrete findings on subjective and physical examination that prompted referral for further imaging studies of the left hip and pelvis. Despite having seen multiple providers, no imaging of the involved hip or pelvis had been performed. A prolonged duration of symptoms, severe gait disturbance with an associated Trendelenburg sign, difficulty sleeping, and an empty end feel with passive range of motion increased concern that a pathological process might be present. Diagnosis: Imaging studies revealed a large destructive soft-tissue tumor later found to be non-Hodgkin's lymphoma. Discussion: It is incumbent upon physical therapists to be aware of the potential for severe pathological conditions that mimic musculoskeletal complaints to exist and understand how to identify patients for whom further testing and/or referral may be appropriate. Existing guidelines for low back pain may assist with decision making in the absence of specific guidelines for when to request imaging in patients with nontraumatic hip and pelvis pain. Proficiency in screening for conditions not amenable to physical therapy treatment or that require consultation to other health care professionals is essential to physical therapy practice. J Orthop Sports Phys Ther 2005;11:738-744.

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“…8 The ESR is a laboratory test that measures the distance that erythrocytes have fallen after 1 hour in a vertical column of anticoagulated blood; it is a nonspecific screening test used to detect occult processes and monitor inflammatory conditions. 6 Recently, Joines et al 17 conducted a decision analysis to assess the effectiveness of 11 different plausible diagnostic strategies in diagnosing spinal malignancy in primary care patients with LBP. The diagnostic strategies differed in their use of clinical findings, ESR, and radiographs of the lumbar spine, prior to utilizing advanced diagnostic imaging methods (bone scan and magnetic resonance imaging) and percutaneous vertebral biopsy.…”

mentioning

confidence: 99%

Cancer as a Cause of Low Back Pain in a Patient Seen in a Direct Access Physical Therapy Setting

Ross¹,

Bayer²

2005

J Orthop Sports Phys Ther

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Study Design: Resident's case problem. Background: This paper describes the clinical course of a patient with low back pain (LBP) and left lower extremity pain and tingling, and how the physical therapist used clinical examination findings and a lack of improvement with conservative measures to initiate further medical evaluation, which resulted in a diagnosis of cancer as the primary cause of the patient's low back and hip pain. Diagnosis: A 45-year-old man with chief complaints of left-sided LBP, left posterior thigh pain, and tingling along the anterolateral aspect of his left lower extremity was initially seen by a physical therapist in a direct access setting. Several components of the patient's history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction. However, there were signs and symptoms present that may have been suggestive of more serious underlying disease. Specifically, the patient's most intense pain was in the evening and into the night and an atypical pattern of restricted motion at the left hip was noted. Therefore, the physical therapist recommended that the patient schedule an appointment with his physician for medical evaluation. A short-term course of physical therapy treatment was also undertaken to address neuromusculoskeletal impairments. Despite 5 physical therapy visits over the course of a month, while the patient waited for his scheduled physician appointment, the patient's condition gradually worsened. After medical evaluation, the patient was eventually diagnosed with small cell carcinoma of the lung, with metastases to the spine and pelvis. Despite 2 cycles of chemotherapy, the patient succumbed to the cancer 5 months after he was first seen in physical therapy. Discussion: It is important that physical therapists have an understanding of the clinical findings associated with the presence of serious underlying diseases causing LBP, as this information provides guidance as to when communication with the patient's physician is warranted. J Orthop Sports Phys Ther 2005;35:651-658.

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Finding Cancer in Primary Care Outpatients with Low Back Pain A Comparison of Diagnostic Strategies

Cited by 14 publications

References 26 publications

Red flags presented in current low back pain guidelines: a review

Red flags presented in current low back pain guidelines: a review

Decision Making for a Painful Hip: A Case Requiring Referral

Cancer as a Cause of Low Back Pain in a Patient Seen in a Direct Access Physical Therapy Setting

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