Reliability among clinicians diagnosing low back-related leg pain

Stynes, Siobhán; Konstantinou, Kika; Dunn, Kate M.; Lewis, Martyn; Hay, Elaine M

doi:10.1007/s00586-015-4359-2

Cited by 13 publications

(15 citation statements)

References 28 publications

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“…There is no ‘gold standard’ for the diagnosis of sciatica and it is, effectively, a clinical diagnosis where the clinician considers the pain is coming from a lumbar nerve root. As with all clinical diagnoses, the threshold for diagnosing sciatica may vary between clinicians [ 39 ]. An MRI showing nerve root compression should not be taken to confirm the diagnosis of sciatica but is simply one further piece of evidence that a clinician may take into account.…”

Section: Discussionmentioning

confidence: 99%

Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study

Konstantinou

Dunn

Ogollah

et al. 2015

BMC Musculoskelet Disord

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BackgroundPatients with back pain radiating to the leg(s) report worse symptoms and poorer recovery than those with back pain alone. Robust evidence regarding their epidemiological profile is lacking from primary care, the setting where most of these patients will present and be managed. Our objective was to describe the characteristics of patients with back and leg pain, including sciatica, seeking treatment in primary care.MethodsAdults visiting their general practitioner with back and leg pain, of any duration and severity, were invited to participate. Participants completed questionnaires, underwent clinical assessments and received MRI scans. Characteristics of the sample are described, and differences between patients diagnosed with referred leg pain and those with sciatica are analysed.ResultsSix hundred nine patients participated; 62.6 % were female, mean (SD) age 50.2 (13.9). 67.5 % reported pain below the knee, 60.7 % were in paid employment with 39.7 % reporting time off work. Mean disability (RMDQ) was 12.7 (5.7) and mean pain intensity was 5.6 (2.2) and 5.2 (2.4) for back and leg respectively. Mean sciatica bothersomeness index (SBI) was 14.9 (5.1). Three quarters (74.2 %) were clinically diagnosed as having sciatica. In the sciatica group, leg pain intensity, neuropathic pain, pain below the knee, leg pain worse than back pain, SBI and positive MRI findings were significantly higher as compared to patients with referred leg pain.ConclusionsThis primary care cohort reported high levels of disability and pain. This is the first epidemiological study of unselected primary care patients seeking healthcare for back and leg pain. Follow-up of this cohort will investigate the prognostic value of their baseline characteristics. This new information will contribute to our understanding of the characteristics and clinical features of this population, and will underpin future research aimed at defining prognostic subgroups to enable better targeting of health care provision.

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Section: Discussionmentioning

confidence: 99%

Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study

Konstantinou

Dunn

Ogollah

et al. 2015

BMC Musculoskelet Disord

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“…Patients excluded from the analysis were cases where clinicians indicated low diagnostic confidence, irrespective of either a referred leg pain or sciatica diagnosis. A reliability study, nested in this cohort, showed good reliability on diagnosis of LBLP when clinician confidence is high (at least 80%) [ 4 ]. Diagnostic uncertainty is a clinical reality as sometimes a return visit from the patient is needed to further confirm or explore diagnosis.…”

Section: Discussionmentioning

confidence: 99%

“…Diagnosis of sciatica for model (i) reference standard was when the clinician documented the presence of leg pain was due to sciatica and they were ≥ 80% confident in their diagnosis. A cut off point of ≥ 80% diagnostic confidence was used because at this criterion, reliability among clinicians diagnosing LBLP improves considerably [ 4 ].…”

Section: Methodsmentioning

confidence: 99%

“…Once the possibility of serious spinal pathology (‘red flags’) or other non-spinal reasons for the leg pain are ruled out, the differential diagnosis is between leg pain due to nerve root involvement (sciatica) or non-specific referred pain from other structures in the low back. Making this diagnostic decision is recognised as difficult [ 3 ] and clinicians can disagree on diagnosis[ 4 ]. It is not always feasible or necessary to make specific diagnoses in a primary care setting (disc herniation, spinal stenosis) but early identification and differentiation of symptoms of low back-related leg pain (LBLP) (sciatica versus referred leg pain) are important for communicating likely diagnosis and prognosis to patients, formulating treatment plans and guiding the need for timely referrals to specialist services.…”

Section: Introductionmentioning

confidence: 99%

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Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain

et al. 2018

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BackgroundIdentification of sciatica may assist timely management but can be challenging in clinical practice. Diagnostic models to identify sciatica have mainly been developed in secondary care settings with conflicting reference standard selection. This study explores the challenges of reference standard selection and aims to ascertain which combination of clinical assessment items best identify sciatica in people seeking primary healthcare.MethodsData on 394 low back-related leg pain consulters were analysed. Potential sciatica indicators were seven clinical assessment items. Two reference standards were used: (i) high confidence sciatica clinical diagnosis; (ii) high confidence sciatica clinical diagnosis with confirmatory magnetic resonance imaging findings. Multivariable logistic regression models were produced for both reference standards. A tool predicting sciatica diagnosis in low back-related leg pain was derived. Latent class modelling explored the validity of the reference standard.ResultsModel (i) retained five items; model (ii) retained six items. Four items remained in both models: below knee pain, leg pain worse than back pain, positive neural tension tests and neurological deficit. Model (i) was well calibrated (p = 0.18), discrimination was area under the receiver operating characteristic curve (AUC) 0.95 (95% CI 0.93, 0.98). Model (ii) showed good discrimination (AUC 0.82; 0.78, 0.86) but poor calibration (p = 0.004). Bootstrapping revealed minimal overfitting in both models. Agreement between the two latent classes and clinical diagnosis groups defined by model (i) was substantial, and fair for model (ii).ConclusionFour clinical assessment items were common in both reference standard definitions of sciatica. A simple scoring tool for identifying sciatica was developed. These criteria could be used clinically and in research to improve accuracy of identification of this subgroup of back pain patients.

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“…Patients expressing interest in participating in the trial proceed to have a standardised assessment for sciatica by the physiotherapist, to establish full eligibility and ascertain subgroup allocation. Eligibility for the trial is based on the assessing physiotherapist being ≥70% confident of a diagnosis of sciatica [27]. Patients who have leg pain thought by the assessing physiotherapist to be due to causes other than sciatica are excluded (for example: referred leg pain, hip pathology, peripheral neuropathy, vascular pain), as are patients for whom there is substantial diagnostic uncertainty.…”

Section: Recruitment Proceduresmentioning

confidence: 99%

The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581)

Foster

Konstantinou

Lewis

et al. 2017

BMC Musculoskelet Disord

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BackgroundSciatica has a substantial impact on patients, and is associated with high healthcare and societal costs. Although there is variation in the clinical management of sciatica, the current model of care usually involves an initial period of ‘wait and see’ for most patients, with simple measures of advice and analgesia, followed by conservative and/or more invasive interventions if symptoms fail to resolve. A model of care is needed that does not over-treat those with a good prognosis yet identifies patients who do need more intensive treatment to help with symptoms, and return to everyday function including work. The aim of the SCOPiC trial (SCiatica Outcomes in Primary Care) is to establish whether stratified care based on subgrouping using a combination of prognostic and clinical information, with matched care pathways, is more effective than non-stratified care, for improving time to symptom resolution in patients consulting with sciatica in primary care. We will also assess the impact of stratified care on service delivery and evaluate its cost-effectiveness compared to non-stratified care.Methods/DesignMulticentre, pragmatic, parallel arm randomised trial, with internal pilot, cost-effectiveness analysis and embedded qualitative study. We will recruit 470 adult patients with sciatica from general practices in England and Wales, over 24 months. Patients will be randomised to stratified care or non-stratified care, and treated in physiotherapy and spinal specialist services, in participating NHS services. The primary outcome is time to first resolution of sciatica symptoms, measured on a 6-point ordered categorical scale, collected using text messaging. Secondary outcomes include physical function, pain intensity, quality of life, work loss, healthcare use and satisfaction with treatment, and will be collected using postal questionnaires at 4 and 12-month follow-up. Semi-structured qualitative interviews with a subsample of participants and clinicians will explore the acceptability of stratified care.DiscussionThis paper presents the details of the rationale, design and processes of the SCOPiC trial. Results from this trial will contribute to the evidence base for management of patients with sciatica consulting in primary care.Trial registration ISRCTN75449581, date: 20.11.2014.

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Reliability among clinicians diagnosing low back-related leg pain

Cited by 13 publications

References 28 publications

Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study

Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study

Clinical diagnostic model for sciatica developed in primary care patients with low back-related leg pain

The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581)

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