ORIGINAL ARTICLE
A Modified Delphi Survey on the Signs and Symptoms of Low Back Pain: Indicators for an Interventional Management Approach Jose Cid, MD, FIPP*; Jose L. De La Calle, MD, PhD†; Esther L opez, MD, PhD, § §§ † FIPP ; Cristina Del Pozo, MD, FIPP ; Alfredo Perucho, MD ; Marıa Soledad Acedo, MD¶; Dolores Bedmar, MD**; Javier Benito, MD††; Javier De Andres, MD, FIPP*; Susana Dıaz, MD§; Juan Antonio Garcıa, MD, PhD¶¶; Leticia G omez††† Caro, MD*; Adolfo Gracia, MD***; Jose Marıa Hernandez, MD ; Joaquın Insausti, MD, FIPP‡‡‡; Marıa Madariaga, MD§§§; Pedro Mo~ nino, MD¶¶¶; Manuel Ruiz, MD, PhD****; Estrella Uriarte, MD††††; Alfonso Vidal, MD, PhD‡‡‡‡ *Pain Unit, Department of Anesthesiology and Reanimation, “Virgen de la Salud” University on y Hospital, Toledo Hospital Complex, Toledo, Spain; †Pain Study and Treatment Unit, “Ram Cajal” University Hospital, Madrid, Spain; §Pain Unit, Department of Anesthesiology and n University General Hospital, Madrid, Spain; §§Puerta de Reanimation, Gregorio Mara~ no Hierro Majadahonda University Hospital, Madrid, Spain; ¶Pain Unit, 12 October University Hospital, Madrid, Spain; **Pain Unit, Department of Anesthesiology, Fuenlabrada University Hospital, Madrid, Spain; ††Pain Unit, Department of Anesthesiology, “Ruber Internacional” Hospital, Madrid, Spain; ¶¶Pain Unit, Department of Anesthesiology and Reanimation, “Infanta Cristina” University Hospital, Parla, Madrid, Spain; ***Pain Unit, Jimenez-Dıaz Foundation University Hospital, Madrid, Spain; †††Pain Unit, Madrid-Monteprıncipe University Hospital, Madrid, Spain; ‡‡‡Pain Unit, Ciudad Real University Hospital, Ciudad Real, Spain; §§§Pain Unit, Department of Anesthesiology and Reanimation, “Infanta Sofı´a” University Hospital, Madrid, Spain; ¶¶¶Pain Unit, Department of Anesthesiology and Reanimation, “San Carlos” Clı´nical Hospital, Madrid, Spain; ****Department of Anesthesiology and Reanimation, Prince of Asturias University, Hospital, Alcala´ de Henares, Madrid, Spain; ††††Pain Unit, Department of Anesthesiology and Reanimation, “Severo Ochoa” University Hospital, Legane´s, Madrid, Spain; ‡‡‡Pain Unit, Department of Anesthesiology, idcsalud Group Sur Hospital, Alcorco´n, Madrid, Spain Cid MD, FIPP, Address correspondence and reprint requests to: Jose Pain Unit, Department of Anaesthesiology and Reanimation, “Virgen de la Salud” University Hospital, Av de Barber 30, 45071 Toledo, Spain. E-mail: [email protected]. Submitted: April 10, 2013; Revision accepted: September 15, 2013 DOI. 10.1111/papr.12135
© 2013 World Institute of Pain, 1530-7085/15/$15.00 Pain Practice, Volume 15, Issue 1, 2015 12–21
Delphi Survey on Low Back Pain Symptoms and Signs 13
& Abstract Background: Low back pain (LBP) symptoms and signs are nonspecific. If required, diagnostic blocks may find the source of pain, but indicators of suspect diagnosis must be defined to identify anatomical targets. Objective: To reach a consensus from an expert panel on the indicators for the most common causes of LBP. Material and Methods: A 3-round (2 telematic and 1 faceto-face) modified Delphi survey with a questionnaire on 78 evidence-based indicators of 7 LBP etiologies was completed by 23 experts. Results: 98.7% of the questionnaire was consensuated. The most accepted indicators were for zygapophysial joint pain, painful ipsilateral paravertebral palpation, worsening with trunk extension, paravertebral musculature spasm on the affected articulation, and referred pain above the knee, without radicular pattern. For sacroiliac joint pain, unilateral pain when seating, with at least 3 described provoking tests: Approximation; gapping; Patrick’s; Gaenslen’s; thigh thrust; Fortin finger; and Gillet’s tests. For discogenic pain, midline pain that may be provoked by pressure on the spinal processes at the affected level; for quadratus lumborum muscle, painful palpation on both the L1 level paravertebral region, referred to iliac crest, and the iliac crest, referred to greater trochanter. For iliopsoas muscle, pain elicited by thigh flexion, referred to buttock, inguinal region, and anterior thigh. For pyramidal muscle, pain while sitting on the affected side and positive Freiberg’s test. For radicular gue’s test at 60°. pain, paresthesias and positive Lasse Conclusion: Seventy-seven diagnostic suspect indicators of LBP conditions were consensuated. These may facilitate conservative or interventional pain management decisionmaking. & Key Words: low back pain, Delphi, lumbalgia, interventional techniques, diagnostic blocks, panel experts, chronic spinal pain, back pain symptoms, signs, consensus statement
INTRODUCTION Low back pain (LBP) represents a major problem for pain physicians. Despite the paucity of studies in Spain assessing the prevalence of LBP pain in adults, figures of 21% prevalence have been reported when considering neck pain along with LBP1 or of 14.7% when including thoracic and neck pain.2 A recent study reported an annual prevalence of LBP in Spain of 19.9%, growing to 23.7% if considered over the lifetime of the subjects. Moreover, LBP is more common in women (24.5%) than in men (15.1%),3 nearly 2 times higher prevalence in women (14.1%) than in men (7.8%) in the Autonomous Region of Madrid (Spain).4 LBP develops 1.5 times more frequently in individuals between the ages of 31 and 50 years than in those between ages 16 and 30 years.5
Low back pain may originate in several anatomical structures, either alone or in combination: disk annulus; anterior and posterior longitudinal ligaments; dura mater; zygapophysial joints (ZPJ) and articular capsule; nerve roots; dorsal root ganglion; sacroiliac joints (SIJ) and muscles.6–11 One of the most common causes of LBP is discogenic pain (originated in the disk annulus), especially among young people.12 When evaluating a patient with lumbalgia, and once “red flags” (cancer, fractures, infection, etc.) have been discarded, it is first necessary to identify the source of the pain, providing it is not of a clearly radicular origin. Attempts to clarify the anatomical focus of LBP syndromes and the patterns of referred pain have been made by some authors through the painful stimulation of suspected structures, such as the ZPJ13–15 and SIJ,16–18 both in volunteers, or by the retrospective assessment of the anatomical location where the pain is perceived.19 The patterns of pain referral may overlap in different pain conditions, and thus, a definitive diagnosis cannot be made on this basis. In the absence of discal hernia or any neurological deficit, a patient’s history, physical examination and testing results, including imaging studies, neurophysiological and psychological evaluation, identify the cause of low back pain in only 15% of patients.20 Indeed, even when a hernia or neurological deficit is evident, many of the exploratory tests proposed do not provide sufficiently reliable evidence.21,22 In this sense, it is often considered that the positive straight leg raise test (Lasegue’s test) is the only sensitive indicator of herniated-disk sciatica, despite its poor specificity, while other neurological signs and tests are thought to be less reliable in diagnostic terms.23,24 These clinical indicators and provoking maneuvers are used normally in daily practice, yet, there is little consensus on their validity in the literature. For example, a Cochrane review found that most isolated tests had a poor reliability in diagnosing lumbar disk hernia in surgical patients, suggesting that the combination of several tests may have greater validity.25 One way to validate these indicators is to compare them with a standard. Controlled diagnostic blocks can determine the cause of the pain in up to 85% of patients, and they are used to define the pathophysiology of pain, the location of nociception, and the pathway of afferent neural signals.26 The rationale of diagnostic blocks is based on the assumption that if a certain structure represents the source of the pain, pain will disappear if that structure is anesthetized.27 The sensitivity and specificity of this approach varies according to the block type, and there is considerable controversy in the
14
CID ET AL.
literature over its validity, given the high rate of false positives. However, the problem of false positives may be at least partially overcome by refining such techniques.28,29 Despite controversy, the use of diagnostic blocks is indeed considered as the reference standard. To initiate a process of diagnostic confirmation through the use of diagnostic blocks, a reliable suspected diagnosis must initially be available to allow us to diminish the number of different procedures before a diagnosis can be confirmed, thereby improving effectiveness. The difficulties in finding incontrovertible clinical diagnostic indicators for different etiologies of lumbalgia have prompted authors to use consensus techniques, such as the Delphi method.22 This procedure has been used successful in other areas of medicine with similarly complicated diagnoses or problems of classification, such as musculoskeletal pathologies, cervical column instability,30 or carpal tunnel syndrome.31 Given the need to identify LBP patient subgroups in function of the topographical origin of pain, which would permit more focused treatment, we sought the opinion of a panel of experts. The aim of this study is to reach a consensus on the most reliable clinical indicators (symptoms and signs) for the most frequent conditions causing LBP, and if possible, to validate those indicators described in the evidence-based medical literature. Suspected diagnosis provides a rational starting point from which diagnostictherapeutic blocks can be employed.
METHODS This study was promoted by the Madrid Pain Society (Sociedad Madrile~ na del Dolor: SMD), following a modified Delphi consensus methodology with a panel of experts with broad experience in interventional pain management, including the society’s scientific committee. Two independent experts in this field affiliated to the Cajal Institute, a Neuroscience research centre (Madrid, Spain), executed the method, participated in the face-toface meetings, and analyzed the data. The classical Greek Oracle at Delphi inspired the Delphi method, which was developed in the 1950s by Helmer and Gordon at the RAND Corporation Research Center (USA). The aim was to make predictions on the consequences of a nuclear catastrophe by means of the opinions of anonymous experts. Since then, it has been used in social sciences and medicine, particularly when focusing on new therapies but also in the development of diagnostic criteria.32–35 It is
generally used to reach consensus among professionals in areas where there is poor definition.36 It is a completely anonymous process where participants express judgments freely by answering a questionnaire that is sent to them. The participants’ replies are then collated, analyzed, and presented as part of the second questionnaire. This allows each participant to receive the opinions of the group as a whole, which may influence their responses in the second questionnaire. One of the main advantages of this system is that face-to-face meetings are unnecessary, which is particularly useful and cost-effective when experts are from different cities or countries. Furthermore, it is unnecessary to restrict the number of participants or the group’s composition.31 Although, there are no guidelines about the optimal number of panel experts, estimates vary between 10 and 50.37 Ideally, 20 participants seems to be optimal.38,39 Finally, the anonymous nature of the process prevents individual participants from exerting an excessively strong influence and having a disproportionate impact on the final result.34 Successive questionnaires are completed with the aim of centering opinions within the interquartile range and making the median more precise. However, the lack of face-to-face meetings in the classical Delphi technique is also a limitation when complex problems have to be addressed, and interactions and discussions are desirable. Thus, the modification applied to the Delphi method in this study was to add 1 final step in the process: a face-toface meeting at the end of the study to discuss and finalize by voting the items that on which no consensus had yet been reached. Indeed, this modification has already been successfully employed in other studies.40,41 The phases of the project were (Figure 1): (1) Literature review; design of the questionnaire; (2) Selection of the panelists and invitation to participate; (3) Round 1 survey sent to the panelists, along with the literature review; (4) Reception of the first anonymously completed survey and analysis of the results; (5) Round 2 survey (including all the nonconsensuated items from round 1, all the anonymous responses from Round 1 and the median answer for each item); (6) Round 2 anonymous answers are received, analyzed, and a third questionnaire is prepared with the items for which no consensus was obtained; (7) Round 3 face-to-face meeting (discussion, modification, and/or new redaction of questions for which a consensus was not obtained in previous rounds); (8) Blind, interactive voting on each item; (9) Statistical analysis of the answers and final report; (10) Interpretation of results and consensus determined.
Delphi Survey on Low Back Pain Symptoms and Signs 15
Literature review
Scientific Committee
Questionnaire development Selection of the Expert Panel
Technical Office
Edition of Questionnaire 1
Questionnaire
Round 1: Telematic Survey
Expert Panel
Anonymous response to questionnaire 1
-Round 1 Analysis - Edition of Questionnaire 2 (non consensuated items, with statistical information about group responses to questionnaire 1)
Anonymous response to questionnaire 2
Round 2: Telematic Survey
-Round 2 Analysis - Edition of Questionnaire 3 (non consensuated items, with statistical information about group responses to questionnaire 2)
(after considering round 1 group responses)
-Presentation of results
Round 3: Face to Face meeting
- Discussion of nonconsensuated items and interactive, blind voting process.
Statistical Analysis of Results Technical Report -Analysis of Technical Office's Report
Scientific Committee
-Interpretation of results -CONSENSUS reached
Figure 1. Scheme of the procedure followed for the modified Delphi study.
Literature Review A 6-member Scientific Committee carried out a thorough review of the most relevant literature on LBP to identify diagnostic indicators for the different lumbalgia etiologies, paying special attention to the most recently published evidence-based reviews and clinical guidelines.
Questionnaire Based on the literature review, the scientific committee produced a final questionnaire that contained 78 items, most of them containing assertions based on some degree of evidence from the literature. The options were not mutually exclusive, and where possible, they were intended to address the most recurrent diagnostic signs and symptoms in the literature related to LBP. In each section, the questions addressed the following
syndromes: ZPJ pain; SIJ pain; discogenic pain; myofascial syndrome (quadratus lumborum, iliopsoas and pyramidal muscles) and lumbosacral radicular pain (uni- or bilateral, acute or chronic). The main indicators in the literature related to clinical symptoms, signs, or specific tests were proposed, asking which of them the participant considered to be more reliable to diagnose each disease studied. In the last round, the questionnaire (face-to-face) was presented, so questions could be reformulated or new questions could be raised, depending on the existing consensus and the participants’ suggestions. Expert Panel A total of 30 experts in pain treatment were invited to participate, including 5 of the 6 members of the scientific committee. All participants were members of pain units
16
CID ET AL.
from the most important hospitals in the regions of Madrid and Castilla-La Mancha, with a wealth of experience in interventional pain management. Anesthesiology was the most prominently represented medical specialty on the panel, however, other specialties were involved including rehabilitation and internal medicine. Experts were chosen based on their relevance and professional record, most being part of the faculty at university hospitals in the area. All had participated as professors and speakers in pain management courses, seminars, and symposia. Although other specialists are involved in the management of these pathologies (neurologists, neurosurgeons, orthopedic surgeons, etc.), they are not usually integrated in pain units in these geographic regions, and therefore, they are not so directly involved in the minimally invasive diagnostic-therapeutic procedures usually performed in such units. Panel Activities The Delphi method used involved completing 2 successive telematic rounds of consultation and subsequently a face-to-face meeting. In the first 2 rounds, the panel members replied anonymously to the questionnaire they received by e-mail. The answers were structured according to a 9-level Likert scale used to indicate the degree of agreement (1 = totally disagree, 9 = totally agree) with different statements included in the questionnaire. Each participant recorded their answers in an Excel file devised for this purpose and returned them via e-mail to the technical office. The responses received at the central office were processed, and the questionnaire was again sent to the panel members with additional information related to the distribution and median responses of the entire group of experts’ anonymous opinions. With this information, participants again answered the telematic questionnaire and returned it to the technical office. The process ended with a face-toface meeting of all the panel experts. The results of the telematic rounds were then presented and those items where there was no consensus were discussed. The discussion made it possible (after voting) to reword some of the questions for which a consensus could not be reached due to differing interpretations, and a new round of voting was undertaken to determine whether a final consensus could be reached for each specific item. An interactive electronic voting system was used, which preserved the anonymity of the replies and that enabled the automatic processing of results.
A consensus was defined whenever < 25% of the ratings fell outside the 3-point region (1 to 3), (4 to 6), or (7 to 9) corresponding to the rating median (RAND consensus criterion),42 a criterion used in all the rounds of questionnaire assessment. All the panelists’ answers were processed in Excel, calculating the mean, median, and 95% confidence interval (CI) of the mean for each answer, as well as the rate of answers in the 3-thirds of the Likert scale used to apply the RAND consensus definition (1 to 3, 4 to 6, 7 to 9). In general, the higher the mean rating of a given item, the greater the agreement or the priority it was given, and the lower the mean CI, the closer the unanimity in the group’s opinions.
RESULTS In the first round, the questionnaire was sent to the 26 experts who agreed to participate in the study, from which 24 replies were received. In the second round, 23 experts participated. After these first 2 telematic surveys, a consensus was reached on 75.6% of the questionnaire. At the face-to-face meeting, 19 panelists participated on the first day and 20 on the second. At the end of the meeting, final agreement had been reached on 98.7% of the questionnaire (77 questions, the final results are shown in Appendix S1). The variation in the number of answers reflects the number of panelists that participated in the round where the consensus was reached for each particular item. Consensus was reached on 11 criteria for ZPJ pain, 16 for SIJ pain, 10 for discogenic pain, 9 for myofascial pain of the quadratus lumborum muscle, 7 for iliopsoas muscle pain, 10 for pyramidal muscle pain, and 14 for lumbosacral radicular pain. The indicators with the highest degree of acceptation were: ZPJ, pain provoked by paravertebral ipsilateral palpation on the facet or transverse process, that does not worsen with trunk flexion but that augments with trunk extension (Table 1); SIJ, unilateral pain in a seating position and a positive result in 3 of the 7 tests described (Table 2); discogenic pain, pain provoked by pressure on the spinous process at the affected level (Table 3); pain originated in the quadratus lumborum muscle, pain provoked by palpation in the paravertebral L1 region that is referred to the iliac crest and pain provoked by palpation of the iliac crest that is referred to the greater trochanter; the iliopsoas muscle, pain provoked by thigh flexion that is referred to the buttock, inguinal region, and anterior thigh; for the pyramidal muscle, pain when
Delphi Survey on Low Back Pain Symptoms and Signs 17
Table 1. Lumbar zygapophysial joint pain. Summary of consensuated indicators
Table 5. Lumbosacral radicular pain. Summary of consensus indicators
Pain induced by pressing on the ipsilateral paravertebral zygapophysial joint or transverse process Pain does not get worse with trunk flexion Pain gets worse with trunk extension Unilateral paravertebral muscular spasm on the affected joint If referred to lower limb, the pain is above the knee Absence of radicular pattern
To attribute the pain etiology to a MRI-diagnosed disk hernia, there must be a clinical correlation with the symptoms Patient often reports paresthesias in the affected dermatome The dermatome distribution points to the affected nerve root, although there are anatomical variations. The most consistent dermatome is S1 Canal stenosis pain typically increases when walking and improves immediately with trunk flexion Diagnosis of lumbosacral radicular pain seems to be justified when the patient reports radicular pain in 1 lower limb, combined with 1 or more positive neurological test indicating nerve root irritation or neurological deficit
Table 2. Sacroiliac joint pain. Summary of consensuated indicators Unilateral buttock pain when sitting Pain that is referred to lower limb and (exceptionally) to foot At least 3 positive results in the 7 tests described in the questionnaire (approximation, gapping, Patrick’s, pelvic torsion, axial torsion, Fortin finger and Gillet) Pain gets worse when standing up from a sitting position
Table 3. Discogenic pain. Summary of consensuated indicators Pain induced by pressing on the spinous process at the affected level Persistent nociceptive low back pain Two-phase stretching from flexion Low back pain that radiates to the inguinal region and/or the lower limb, which worsens with axial compression and improves in decubitus MRI is useful to visualize pathological disk changes, but findings often correlate poorly with the clinical developments
sitting on the affected side and a positive Freiberg’s test (Table 4); lumbosacral radicular pain, paresthesias and a positive Lasegue’s test at 60° (Table 5). The discussion that took place at the face-to-face meeting enabled changes to be introduced into some questions, which greatly facilitated the confluence of opinions. In the ZPJ pain section, the wording “central low back pain” was changed to “low back pain at the
midline” (question no. 1), which resulted in the consensus to reject that particular pain location (median 1 [1.2 to 2.6] CI = 95%). In question no. 5 of the same section, there was disagreement about the original wording “zygapophysial joint pain improves with ventral trunk flexion” and after voting, this was changed to “pain does not get worse with ventral trunk flexion.” In the SIJ pain section, question No. 15 referred to pain “that was at times referred to the foot,” and this had to be changed to “pain that was referred to the lower limb and exceptionally, to the foot,” as most of the panelists considered that such a symptom would exclude sacroiliac pain, despite such references in the literature.43 A consensus was finally reached on all explorations, although many participants recognized that they did not usually perform all the tests included in the questionnaire on each patient. The experts did not consider that assisted walking was a sign indicative of myofascial pain of the quadratus lumborum muscle, as published.44 The original wording of question No. 62, related to myofascial syndrome of the pyramidal muscle, was “there may be a shortening of the affected lower limb.” This
Table 4. Myofascial pain. Summary of consensus indicators Quadratus lumborum muscle
Iliopsoas muscle
Piriformis muscle
Painful palpation below the last rib and 5 cm away from the L1 transverse process, with pain referred to the iliac crest Low back pain when walking, sitting, and even laying down Pain increases with postural changes in bed Low back pain during active stretching and lateral tilting Painful palpation of a trigger point at the level of L4 vertebral body, 1 or 2 cm above the iliac crest, with pain referred to greater trochanter Low back pain that is referred to the upper outer quadrant of the buttock, and often to front thigh and inguinal region, getting worse with thigh flexion Painful active leg raise in supine decubitus. Passive raise is not painful Positive Thomas test: in supine decubitus, painful shortening during passive hip extension In thin patients, painful deep palpation of the psoas outside the rectus abdominis muscle Painful deep palpation of the iliopsoas muscle in its insertion into the greater trochanter Trigger point half way between sacral and greater trochanter insertions Low back or buttock pain with symptoms of L5-S1 radiculopathy There may be an impression of shortening in the affected lower limb In the standing position, tendency toward external rotation of the foot of the affected lower limb Positive Freiberg test: forced passive internal rotation of the extended thigh is painful
18
CID ET AL.
was finally changed to “there may be the impression of a shortening of the affected lower limb,” which made it possible to reach a consensus.
DISCUSSION In this study, the clinical signs and symptoms for LBP of the zygapophysial joint, sacroiliac joint, muscular and disk origin were consensuated following a modified Delphi methodology, producing results that match published indicators for each clinical syndrome. The high degree of consensus finally reached was due to the rewording of some questions included in the original questionnaire that generated imprecise interpretations or rejection among the panelists. This could only be achieved in the third (face-to-face) round, which provided an opportunity for the experts to exchange views. Evidence that signs and symptoms per se are not reliable for a firm diagnosis of the origin of LBP justifies occasional seeking the opinion of panels of experts to favor unanimity of criteria. In a postal survey of 651 primary care physicians on the clinical signs and symptoms used to classify LBP patients into distinct etiological groups, little consensus was found among professionals.45 Following a classification based on the mechanism, by which pain was produced in 464 LBP patients through the opinion of investigators’ clinical judgment alone, 3 symptoms and a clinical sign for central sensitization were identified (pain originated by a neurophysiological dysfunction of the central nervous system). Two other signs, a syndrome predicting peripheral neuropathic pain, and 7 clinical criteria predicting nociceptive pain were also identified.46–48 A more rigorous consensus methodology like the Delphi technique has been used occasionally to address the diagnostic process for LBP. This method was used to generate a list of items that must be included by physiotherapists in the exploration of a patient with nonspecific LBP.49 Such an approach was also used to characterize clinical indicators of ZPJ pain,22 the physiotherapeutic treatment of LBP,50 terminological issues on LBP recurrence,51 to characterize lower limb pain,52 to validate the chapter on LBP corresponding to the International Classification of Functioning, Disability, and Health (ICF),53 and to reach a consensus on the clinical signs and symptoms of postsurgical neuropathic pain.35 Few studies have attempted to classify pain according to its anatomic origin.22 Uncertainty regarding the origin
of pain, defined as nonspecific low back pain, may not be determinant in the management of acute or subacute LBP with conservative treatment, which is indeed the recommended approach. However, if we want to carry out an interventional treatment in a patient with LBP with or without associated radicular pain when conservative treatments have failed, it is paramount to identify the pain’s source as closely as possible. For this purpose, we believe the consensus procedure chosen is appropriate. The results prioritized some symptoms and signs according to their reliability as diagnostic indicators of the suspected focus of the pain, thereby allowing the targets for interventional management to be characterized. Furthermore, they highlight the relevance of some clinical findings over others, confirming data published by others and therefore contributing to their validation. One of the disadvantages attributed to the Delphi method is the impossibility of exchanging opinions among panelists to resolve ambiguous issues and to propose changes in the wording of the items. This drawback has been very satisfactorily overcome by adding a face-to-face meeting to the survey rounds. In this meeting, the anonymous nature of the interactive votes after discussing each contentious item meant that the method’s basic advantages were preserved, as was the criteria of independence. We also believe that the number of experts participating and their qualifications reinforce the credibility of the results. Limitations Among the limitations associated to this study is the fact that the questionnaire may have included signs and/or symptoms for other causes of LBP. However, the literature on the topic is usually restricted to the entities listed above. Myofascial pain has been included as a cause of LBP even though it is not usually present in the guidelines and algorithms for LBP interventional treatment.26 The expert panel may be a limitation of the study, as they were selected from a small number of medical specialties. The basic reason for the panel’s composition is that 86% of physicians belonging to pain units in our environment are anesthesiologists, with 3% being neurosurgeons and 3% primary care physicians.54 Nevertheless, other specialties such as Rehabilitation (1 participant) and Internal Medicine (1 participant) were also represented in the panel. The relatively small geographic area in which the panelists operate may constitute a bias, producing a tendency toward a confluence of opinions. However, given the limited
Delphi Survey on Low Back Pain Symptoms and Signs 19
consensus (75.6%) reached after the first 2 rounds, we do not believe that this was an issue. Delphi consensus has limited validity as scientific evidence, and it is no substitute for basic and clinical research, which must be performed to confirm its conclusions. For this reason, the conclusions of the present study are neither absolute truths nor diagnostic standards, yet, they may help facilitate the diagnostic process in the minimal interventional management of LBP.
ACKNOWLEDGEMENTS We acknowledge the support of Medtronic Iberica S.A., Cardiva Centro S.L., and Avances Neurol ogicos Sanitarios (ANS) S.A. for funding the project. The following experts participated in the project but did not participate in all 3 rounds: Gloria Llaurad o, MD. Pain Unit, Department of Anesthesiology and Reanimation, “Gren” University Hospital, Madrid, Spain. gorio Mara~ no Jes us Estrada, MD. Pain Unit, Department of Anesthesiology and Reanimation, Getafe University Hospital, Madrid, Spain. Alfredo Fern andez, MD. Pain Unit, Department of Anesthesiology and Reanimation, “La Paz” University Hospital, Madrid, Spain. Consuelo Nieto, MD. Pain Unit, Department of Anesthesiology and Reanimation, Alcorc on Foundation University Hospital, Madrid, Spain. Concepci on Perez, MD. Pain Unit, Department of Anesthesiology and Reanimation, “La Princesa” University Hospital, Madrid, Spain. Gonzalo del Portillo, from ANS S.A., helped with the English translation of the article. Carlos Goicoechea, PhD (Faculty of Health Sciences, “Rey Juan Carlos” University, Madrid, Spain), collaborated in the methodological aspect of the Project as a scientific committee member.
CONFLICT OF INTEREST The authors have no conflict of interests to declare. The study design, wording of the questionnaire, the survey, analysis and interpretation of results were all performed without the participation of the funding sources. None of these sources influenced the content or composition of this article, or the decision to publish it.
REFERENCES 1. Catala E, Reig E, Artes M, Aliaga L, L opez JS, Seg u JL. Prevalence of pain in the Spanish population: telephone survey in 5000 homes. Eur J Pain. 2002;6:133–140.
2. Pinto-Meza A, Serrano-Blanco A, Miquel Codony M, et al. Prevalencia y comorbilidad fısica y mental del dolor dorsal y cervical cr onicos en Espa~ na: resultados del estudio ESEMeD. Med Clin (Barc). 2006;127:325–330. 3. Fernandez de las Pe~ nas C, Hern andez-Barrera V, Alonso-Blanco C, et al. Prevalence of neck and low back pain in community-dwelling adults in Spain: a population-based national study. Spine. 2011;36:E213–E219. 4. Jimenez-S anchez S, Fern andez de las Pe~ nas C, CarrascoGarrido P, et al. Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain). Gac Sanit. 2012;26: 534–540. 5. La Ruiz P. medici on de la calidad asistencial. Rev Clin Esp. 2001;201:561–562. 6. Cid J, De Andres J, Reig E, Del Pozo C, Cortes A, Garcıa-Cruz JJ. Cervicalgias y lumbalgias mecanicodegenerativas. Tratamiento conservador. Actualizaci on. Rev Soc Esp Dolor. 2001;8:79–100. 7. Bogduk N. The innervation of the lumbar spine. Spine. 1983;8:286–293. 8. Dwyer A, April C, Bogduk N. Cervical zygapophysial joint pain patterns I: a study of normal volunteers. Spine. 1990;15:453–457. 9. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Ortho Clin North Am. 1991;22:181– 187. 10. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine. 1994;19:801– 806. 11. Schwarzer AC, April CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995;20:31–37. 12. De Palma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011;12:224–233. 13. McCall IW, Park WM, O’Brien JP. Induced pain referral from posterior lumbar elements in normal subjects. Spine. 1979;4:441–446. 14. Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain. 1989;39:37–40. 15. Revel M, Poiraudeau S, Auleley GR, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine. 1998;23:1972–1976, discussion 7. 16. Maigne JY, Aivaliklis A, Pfefger F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine. 1996;21:1889– 1892. 17. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10:207–218.
20
CID ET AL.
18. Van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil. 2006;87:10–14. 19. De Palma MJ, Ketchum JM, Trussell BS, Saullo TR, Slipman CW. Does the location of low back pain predict its source? PMR. 2011;3:33–39. 20. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive review of neurophysiologic basis and diagnostic interventions in managing chronic spinal pain. Pain Physician. 2009;12:E71–E121. 21. Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999;246:899–906. 22. Wilde VE, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique. Phys Ther. 2007;87:1348–1361. 23. Rubinstein SM, van Tulder M. A best- evidence review of diagnostic procedures for neck and low-back pain. Best Pract Res Clin Rheumatol. 2008;22:471–482. 24. Deville WL, van der Windt DA, Dzaferagić A, Bezemer PD, Bouter LM. The test of Lasegue: systematic review of the accuracy in diagnosing herniated discs. Spine. 2000;25:1140– 1147. 25. Van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010;17:CD007431. 26. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699–802. 27. Bogduk N. Principles of diagnostic blocks. In: Slipman CW, Derby R, Simeone FA, Mayer TG, eds. Interventional Spine: An Algorithmic Approach. Philadelphia: Saunders Elsevier; 2008:187–191. 28. Manchikanti L, Datta S, Derby R, et al. Critical review of the american pain society clinical practice guidelines for interventional techniques: part 1. diagnostic interventions. Pain Physician. 2010;13:E141–E174. 29. Bogduk N. On diagnostic blocks for lumbar zygapophysial joint pain. Med Rep. 2010;2:57. doi:10.3410/M2-57. 30. Cook C, Brisme ́ e J-M, Fleming R, Sizer PS Jr. Identifiers suggestive of clinical cervical spine instability: a Delphi study of physical therapists. Phys Ther. 2005;85:895–906. 31. Graham B, Regehr G, Wright JG. Delphi as a method to establish consensus for diagnostic criteria. J Clin Epidemiol. 2003;12:1150–1156. 32. Murphy MK, Black NA, Lamping DL, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2:1–88. 33. Brunner F, Lienhardt SB, Kissling RO, Bachmann LM, Weber U. Diagnostic criteria and follow-up parameters in complex regional pain syndrome type I—a Delphi survey. Eur J Pain. 2008;12:48–52.
34. Hunter DJ, Arden N, Conaghan PG, et al. Definition of osteoarthritis on MRI: results of a Delphi exercise. Osteoarthritis Cartilage. 2011;19:963–969. 35. Searle RD, Howell SJ, Bennett MI. Diagnosing postoperative neuropathic pain: a Delphi survey. Br J Anaesth. 2012;109:240–244. 36. Portney L, Watkins M. Foundations of Clinical Research: Applications to Practice. Norwalk, Conn: Appleton & Lange; 1993. 37. Linstone H, Turoff M. The Delphi Method: Techniques and Applications, Reading, Mass: Addison-Wesley Publishing; 1975. Available in http://is.njit.edu/pubs/delphibook/. 38. Jeffery D, Ley A, Bennun I, McLaren S. Delphi survey opinion on interventions, service principles and service organization for severe mental illness and substance misuse problems. J Ment Health. 2000;9:371–384. 39. Mullen PM. Delphi: myths and reality. J Health Organ Manag. 2003;17:37–52. 40. De la Calle JL, Abej on D, Cid J, et al. Est andares de calidad asistencial y cat alogo de procedimientos de las unidades de dolor cr onico. Rev soc Esp Dolor. 2010;17:114– 133. 41. Uphoff EP, Wennekes L, Punt CJ, et al. Development of generic quality indicators for patient-centered cancer care by using a RAND modified Delphi method. Cancer Nurs. 2012;35:29–37. 42. Fitch K, Bernstein SJ, Aguilar MD, et al. The Rand/ UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001. ISBN 0-8330-2918-5. RAND URL: http://www.rand.org. 43. Slipman CW, Jackson HB, Lipertz JS, et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000;81:334–338. 44. Castro M, C anovas L, Garcıa-Rojo B, et al. Tratamiento del Sındrome de Dolor Miofascial con Toxina Botulınica tipo A. Rev Soc Esp Dolor. 2006;2:96–102. 45. Kent P, Keating JL. Classification in nonspecific low back pain: what methods do primary care clinicians currently use? Spine. 2005;30:1433–1440. 46. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitization in patients with low back ( leg) pain. Man Ther. 2012;17:336– 344. 47. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 2 of 3: symptoms and signs of peripheral neuropathic pain in patients with low back ( leg) pain. Man Ther. 2012;17:345–351. 48. Smart KM, Blake C, Staines A, et al. Mechanismsbased classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back ( leg) pain. Man Ther. 2012;17:352–357. 49. McCarthy CJ, Rushton A, Billis V, Arnall F, Oldham JA. Development of a clinical examination in non-specific low
Delphi Survey on Low Back Pain Symptoms and Signs 21
back pain: a Delphi technique. J Rehabil Med. 2006;38:263– 267. 50. Ferguson FC, Brownlee M, Webster V. A Delphi study investigating consensus among expert physiotherapists in relation to the management of low back pain. Musculoskeletal Care. 2008;6:197–210. 51. Stanton TR, Latimer J, Maher CG, Hancock MJ. A modified Delphi approach to standardize low back pain recurrence terminology. Eur Spine J. 2011;20:744–752. 52. Konstantinou K, Hider SL, Vogel S, Beardmore R, Somerville S. Development of an assessment schedule for patients with low back-associated leg pain in primary care: a Delphi consensus study. Eur Spine J. 2012;21: 1241–1249.
53. Glocker C, Kirchberger I, Gla¨ssel A, Finczicki A, Stucki G, Cieza A. Content validity of the comprehensive international classification of functioning, disability and health (ICF) core set for low back pain from the perspective of physicians: a Delphi survey. Chronic Illn. 2013;9:57–72. 54. Barutell C. Unidades de dolor en Espa~ na. Encuesta SED Dıa del Dolor 2007. Rev. Soc. Esp. Dolor. 2009;16:421–428.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article: Appendix S1. Questionnaire and results.
Copyright of Pain Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A Modified Delphi Survey on the Signs and Symptoms of Low Back Pain: Indicators for an Interventional Management Approach Jose Cid, MD, FIPP*; Jose L. De La Calle, MD, PhD†; Esther L opez, MD, PhD, § §§ † FIPP ; Cristina Del Pozo, MD, FIPP ; Alfredo Perucho, MD ; Marıa Soledad Acedo, MD¶; Dolores Bedmar, MD**; Javier Benito, MD††; Javier De Andres, MD, FIPP*; Susana Dıaz, MD§; Juan Antonio Garcıa, MD, PhD¶¶; Leticia G omez††† Caro, MD*; Adolfo Gracia, MD***; Jose Marıa Hernandez, MD ; Joaquın Insausti, MD, FIPP‡‡‡; Marıa Madariaga, MD§§§; Pedro Mo~ nino, MD¶¶¶; Manuel Ruiz, MD, PhD****; Estrella Uriarte, MD††††; Alfonso Vidal, MD, PhD‡‡‡‡ *Pain Unit, Department of Anesthesiology and Reanimation, “Virgen de la Salud” University on y Hospital, Toledo Hospital Complex, Toledo, Spain; †Pain Study and Treatment Unit, “Ram Cajal” University Hospital, Madrid, Spain; §Pain Unit, Department of Anesthesiology and n University General Hospital, Madrid, Spain; §§Puerta de Reanimation, Gregorio Mara~ no Hierro Majadahonda University Hospital, Madrid, Spain; ¶Pain Unit, 12 October University Hospital, Madrid, Spain; **Pain Unit, Department of Anesthesiology, Fuenlabrada University Hospital, Madrid, Spain; ††Pain Unit, Department of Anesthesiology, “Ruber Internacional” Hospital, Madrid, Spain; ¶¶Pain Unit, Department of Anesthesiology and Reanimation, “Infanta Cristina” University Hospital, Parla, Madrid, Spain; ***Pain Unit, Jimenez-Dıaz Foundation University Hospital, Madrid, Spain; †††Pain Unit, Madrid-Monteprıncipe University Hospital, Madrid, Spain; ‡‡‡Pain Unit, Ciudad Real University Hospital, Ciudad Real, Spain; §§§Pain Unit, Department of Anesthesiology and Reanimation, “Infanta Sofı´a” University Hospital, Madrid, Spain; ¶¶¶Pain Unit, Department of Anesthesiology and Reanimation, “San Carlos” Clı´nical Hospital, Madrid, Spain; ****Department of Anesthesiology and Reanimation, Prince of Asturias University, Hospital, Alcala´ de Henares, Madrid, Spain; ††††Pain Unit, Department of Anesthesiology and Reanimation, “Severo Ochoa” University Hospital, Legane´s, Madrid, Spain; ‡‡‡Pain Unit, Department of Anesthesiology, idcsalud Group Sur Hospital, Alcorco´n, Madrid, Spain Cid MD, FIPP, Address correspondence and reprint requests to: Jose Pain Unit, Department of Anaesthesiology and Reanimation, “Virgen de la Salud” University Hospital, Av de Barber 30, 45071 Toledo, Spain. E-mail: [email protected]. Submitted: April 10, 2013; Revision accepted: September 15, 2013 DOI. 10.1111/papr.12135
© 2013 World Institute of Pain, 1530-7085/15/$15.00 Pain Practice, Volume 15, Issue 1, 2015 12–21
Delphi Survey on Low Back Pain Symptoms and Signs 13
& Abstract Background: Low back pain (LBP) symptoms and signs are nonspecific. If required, diagnostic blocks may find the source of pain, but indicators of suspect diagnosis must be defined to identify anatomical targets. Objective: To reach a consensus from an expert panel on the indicators for the most common causes of LBP. Material and Methods: A 3-round (2 telematic and 1 faceto-face) modified Delphi survey with a questionnaire on 78 evidence-based indicators of 7 LBP etiologies was completed by 23 experts. Results: 98.7% of the questionnaire was consensuated. The most accepted indicators were for zygapophysial joint pain, painful ipsilateral paravertebral palpation, worsening with trunk extension, paravertebral musculature spasm on the affected articulation, and referred pain above the knee, without radicular pattern. For sacroiliac joint pain, unilateral pain when seating, with at least 3 described provoking tests: Approximation; gapping; Patrick’s; Gaenslen’s; thigh thrust; Fortin finger; and Gillet’s tests. For discogenic pain, midline pain that may be provoked by pressure on the spinal processes at the affected level; for quadratus lumborum muscle, painful palpation on both the L1 level paravertebral region, referred to iliac crest, and the iliac crest, referred to greater trochanter. For iliopsoas muscle, pain elicited by thigh flexion, referred to buttock, inguinal region, and anterior thigh. For pyramidal muscle, pain while sitting on the affected side and positive Freiberg’s test. For radicular gue’s test at 60°. pain, paresthesias and positive Lasse Conclusion: Seventy-seven diagnostic suspect indicators of LBP conditions were consensuated. These may facilitate conservative or interventional pain management decisionmaking. & Key Words: low back pain, Delphi, lumbalgia, interventional techniques, diagnostic blocks, panel experts, chronic spinal pain, back pain symptoms, signs, consensus statement
INTRODUCTION Low back pain (LBP) represents a major problem for pain physicians. Despite the paucity of studies in Spain assessing the prevalence of LBP pain in adults, figures of 21% prevalence have been reported when considering neck pain along with LBP1 or of 14.7% when including thoracic and neck pain.2 A recent study reported an annual prevalence of LBP in Spain of 19.9%, growing to 23.7% if considered over the lifetime of the subjects. Moreover, LBP is more common in women (24.5%) than in men (15.1%),3 nearly 2 times higher prevalence in women (14.1%) than in men (7.8%) in the Autonomous Region of Madrid (Spain).4 LBP develops 1.5 times more frequently in individuals between the ages of 31 and 50 years than in those between ages 16 and 30 years.5
Low back pain may originate in several anatomical structures, either alone or in combination: disk annulus; anterior and posterior longitudinal ligaments; dura mater; zygapophysial joints (ZPJ) and articular capsule; nerve roots; dorsal root ganglion; sacroiliac joints (SIJ) and muscles.6–11 One of the most common causes of LBP is discogenic pain (originated in the disk annulus), especially among young people.12 When evaluating a patient with lumbalgia, and once “red flags” (cancer, fractures, infection, etc.) have been discarded, it is first necessary to identify the source of the pain, providing it is not of a clearly radicular origin. Attempts to clarify the anatomical focus of LBP syndromes and the patterns of referred pain have been made by some authors through the painful stimulation of suspected structures, such as the ZPJ13–15 and SIJ,16–18 both in volunteers, or by the retrospective assessment of the anatomical location where the pain is perceived.19 The patterns of pain referral may overlap in different pain conditions, and thus, a definitive diagnosis cannot be made on this basis. In the absence of discal hernia or any neurological deficit, a patient’s history, physical examination and testing results, including imaging studies, neurophysiological and psychological evaluation, identify the cause of low back pain in only 15% of patients.20 Indeed, even when a hernia or neurological deficit is evident, many of the exploratory tests proposed do not provide sufficiently reliable evidence.21,22 In this sense, it is often considered that the positive straight leg raise test (Lasegue’s test) is the only sensitive indicator of herniated-disk sciatica, despite its poor specificity, while other neurological signs and tests are thought to be less reliable in diagnostic terms.23,24 These clinical indicators and provoking maneuvers are used normally in daily practice, yet, there is little consensus on their validity in the literature. For example, a Cochrane review found that most isolated tests had a poor reliability in diagnosing lumbar disk hernia in surgical patients, suggesting that the combination of several tests may have greater validity.25 One way to validate these indicators is to compare them with a standard. Controlled diagnostic blocks can determine the cause of the pain in up to 85% of patients, and they are used to define the pathophysiology of pain, the location of nociception, and the pathway of afferent neural signals.26 The rationale of diagnostic blocks is based on the assumption that if a certain structure represents the source of the pain, pain will disappear if that structure is anesthetized.27 The sensitivity and specificity of this approach varies according to the block type, and there is considerable controversy in the
14
CID ET AL.
literature over its validity, given the high rate of false positives. However, the problem of false positives may be at least partially overcome by refining such techniques.28,29 Despite controversy, the use of diagnostic blocks is indeed considered as the reference standard. To initiate a process of diagnostic confirmation through the use of diagnostic blocks, a reliable suspected diagnosis must initially be available to allow us to diminish the number of different procedures before a diagnosis can be confirmed, thereby improving effectiveness. The difficulties in finding incontrovertible clinical diagnostic indicators for different etiologies of lumbalgia have prompted authors to use consensus techniques, such as the Delphi method.22 This procedure has been used successful in other areas of medicine with similarly complicated diagnoses or problems of classification, such as musculoskeletal pathologies, cervical column instability,30 or carpal tunnel syndrome.31 Given the need to identify LBP patient subgroups in function of the topographical origin of pain, which would permit more focused treatment, we sought the opinion of a panel of experts. The aim of this study is to reach a consensus on the most reliable clinical indicators (symptoms and signs) for the most frequent conditions causing LBP, and if possible, to validate those indicators described in the evidence-based medical literature. Suspected diagnosis provides a rational starting point from which diagnostictherapeutic blocks can be employed.
METHODS This study was promoted by the Madrid Pain Society (Sociedad Madrile~ na del Dolor: SMD), following a modified Delphi consensus methodology with a panel of experts with broad experience in interventional pain management, including the society’s scientific committee. Two independent experts in this field affiliated to the Cajal Institute, a Neuroscience research centre (Madrid, Spain), executed the method, participated in the face-toface meetings, and analyzed the data. The classical Greek Oracle at Delphi inspired the Delphi method, which was developed in the 1950s by Helmer and Gordon at the RAND Corporation Research Center (USA). The aim was to make predictions on the consequences of a nuclear catastrophe by means of the opinions of anonymous experts. Since then, it has been used in social sciences and medicine, particularly when focusing on new therapies but also in the development of diagnostic criteria.32–35 It is
generally used to reach consensus among professionals in areas where there is poor definition.36 It is a completely anonymous process where participants express judgments freely by answering a questionnaire that is sent to them. The participants’ replies are then collated, analyzed, and presented as part of the second questionnaire. This allows each participant to receive the opinions of the group as a whole, which may influence their responses in the second questionnaire. One of the main advantages of this system is that face-to-face meetings are unnecessary, which is particularly useful and cost-effective when experts are from different cities or countries. Furthermore, it is unnecessary to restrict the number of participants or the group’s composition.31 Although, there are no guidelines about the optimal number of panel experts, estimates vary between 10 and 50.37 Ideally, 20 participants seems to be optimal.38,39 Finally, the anonymous nature of the process prevents individual participants from exerting an excessively strong influence and having a disproportionate impact on the final result.34 Successive questionnaires are completed with the aim of centering opinions within the interquartile range and making the median more precise. However, the lack of face-to-face meetings in the classical Delphi technique is also a limitation when complex problems have to be addressed, and interactions and discussions are desirable. Thus, the modification applied to the Delphi method in this study was to add 1 final step in the process: a face-toface meeting at the end of the study to discuss and finalize by voting the items that on which no consensus had yet been reached. Indeed, this modification has already been successfully employed in other studies.40,41 The phases of the project were (Figure 1): (1) Literature review; design of the questionnaire; (2) Selection of the panelists and invitation to participate; (3) Round 1 survey sent to the panelists, along with the literature review; (4) Reception of the first anonymously completed survey and analysis of the results; (5) Round 2 survey (including all the nonconsensuated items from round 1, all the anonymous responses from Round 1 and the median answer for each item); (6) Round 2 anonymous answers are received, analyzed, and a third questionnaire is prepared with the items for which no consensus was obtained; (7) Round 3 face-to-face meeting (discussion, modification, and/or new redaction of questions for which a consensus was not obtained in previous rounds); (8) Blind, interactive voting on each item; (9) Statistical analysis of the answers and final report; (10) Interpretation of results and consensus determined.
Delphi Survey on Low Back Pain Symptoms and Signs 15
Literature review
Scientific Committee
Questionnaire development Selection of the Expert Panel
Technical Office
Edition of Questionnaire 1
Questionnaire
Round 1: Telematic Survey
Expert Panel
Anonymous response to questionnaire 1
-Round 1 Analysis - Edition of Questionnaire 2 (non consensuated items, with statistical information about group responses to questionnaire 1)
Anonymous response to questionnaire 2
Round 2: Telematic Survey
-Round 2 Analysis - Edition of Questionnaire 3 (non consensuated items, with statistical information about group responses to questionnaire 2)
(after considering round 1 group responses)
-Presentation of results
Round 3: Face to Face meeting
- Discussion of nonconsensuated items and interactive, blind voting process.
Statistical Analysis of Results Technical Report -Analysis of Technical Office's Report
Scientific Committee
-Interpretation of results -CONSENSUS reached
Figure 1. Scheme of the procedure followed for the modified Delphi study.
Literature Review A 6-member Scientific Committee carried out a thorough review of the most relevant literature on LBP to identify diagnostic indicators for the different lumbalgia etiologies, paying special attention to the most recently published evidence-based reviews and clinical guidelines.
Questionnaire Based on the literature review, the scientific committee produced a final questionnaire that contained 78 items, most of them containing assertions based on some degree of evidence from the literature. The options were not mutually exclusive, and where possible, they were intended to address the most recurrent diagnostic signs and symptoms in the literature related to LBP. In each section, the questions addressed the following
syndromes: ZPJ pain; SIJ pain; discogenic pain; myofascial syndrome (quadratus lumborum, iliopsoas and pyramidal muscles) and lumbosacral radicular pain (uni- or bilateral, acute or chronic). The main indicators in the literature related to clinical symptoms, signs, or specific tests were proposed, asking which of them the participant considered to be more reliable to diagnose each disease studied. In the last round, the questionnaire (face-to-face) was presented, so questions could be reformulated or new questions could be raised, depending on the existing consensus and the participants’ suggestions. Expert Panel A total of 30 experts in pain treatment were invited to participate, including 5 of the 6 members of the scientific committee. All participants were members of pain units
16
CID ET AL.
from the most important hospitals in the regions of Madrid and Castilla-La Mancha, with a wealth of experience in interventional pain management. Anesthesiology was the most prominently represented medical specialty on the panel, however, other specialties were involved including rehabilitation and internal medicine. Experts were chosen based on their relevance and professional record, most being part of the faculty at university hospitals in the area. All had participated as professors and speakers in pain management courses, seminars, and symposia. Although other specialists are involved in the management of these pathologies (neurologists, neurosurgeons, orthopedic surgeons, etc.), they are not usually integrated in pain units in these geographic regions, and therefore, they are not so directly involved in the minimally invasive diagnostic-therapeutic procedures usually performed in such units. Panel Activities The Delphi method used involved completing 2 successive telematic rounds of consultation and subsequently a face-to-face meeting. In the first 2 rounds, the panel members replied anonymously to the questionnaire they received by e-mail. The answers were structured according to a 9-level Likert scale used to indicate the degree of agreement (1 = totally disagree, 9 = totally agree) with different statements included in the questionnaire. Each participant recorded their answers in an Excel file devised for this purpose and returned them via e-mail to the technical office. The responses received at the central office were processed, and the questionnaire was again sent to the panel members with additional information related to the distribution and median responses of the entire group of experts’ anonymous opinions. With this information, participants again answered the telematic questionnaire and returned it to the technical office. The process ended with a face-toface meeting of all the panel experts. The results of the telematic rounds were then presented and those items where there was no consensus were discussed. The discussion made it possible (after voting) to reword some of the questions for which a consensus could not be reached due to differing interpretations, and a new round of voting was undertaken to determine whether a final consensus could be reached for each specific item. An interactive electronic voting system was used, which preserved the anonymity of the replies and that enabled the automatic processing of results.
A consensus was defined whenever < 25% of the ratings fell outside the 3-point region (1 to 3), (4 to 6), or (7 to 9) corresponding to the rating median (RAND consensus criterion),42 a criterion used in all the rounds of questionnaire assessment. All the panelists’ answers were processed in Excel, calculating the mean, median, and 95% confidence interval (CI) of the mean for each answer, as well as the rate of answers in the 3-thirds of the Likert scale used to apply the RAND consensus definition (1 to 3, 4 to 6, 7 to 9). In general, the higher the mean rating of a given item, the greater the agreement or the priority it was given, and the lower the mean CI, the closer the unanimity in the group’s opinions.
RESULTS In the first round, the questionnaire was sent to the 26 experts who agreed to participate in the study, from which 24 replies were received. In the second round, 23 experts participated. After these first 2 telematic surveys, a consensus was reached on 75.6% of the questionnaire. At the face-to-face meeting, 19 panelists participated on the first day and 20 on the second. At the end of the meeting, final agreement had been reached on 98.7% of the questionnaire (77 questions, the final results are shown in Appendix S1). The variation in the number of answers reflects the number of panelists that participated in the round where the consensus was reached for each particular item. Consensus was reached on 11 criteria for ZPJ pain, 16 for SIJ pain, 10 for discogenic pain, 9 for myofascial pain of the quadratus lumborum muscle, 7 for iliopsoas muscle pain, 10 for pyramidal muscle pain, and 14 for lumbosacral radicular pain. The indicators with the highest degree of acceptation were: ZPJ, pain provoked by paravertebral ipsilateral palpation on the facet or transverse process, that does not worsen with trunk flexion but that augments with trunk extension (Table 1); SIJ, unilateral pain in a seating position and a positive result in 3 of the 7 tests described (Table 2); discogenic pain, pain provoked by pressure on the spinous process at the affected level (Table 3); pain originated in the quadratus lumborum muscle, pain provoked by palpation in the paravertebral L1 region that is referred to the iliac crest and pain provoked by palpation of the iliac crest that is referred to the greater trochanter; the iliopsoas muscle, pain provoked by thigh flexion that is referred to the buttock, inguinal region, and anterior thigh; for the pyramidal muscle, pain when
Delphi Survey on Low Back Pain Symptoms and Signs 17
Table 1. Lumbar zygapophysial joint pain. Summary of consensuated indicators
Table 5. Lumbosacral radicular pain. Summary of consensus indicators
Pain induced by pressing on the ipsilateral paravertebral zygapophysial joint or transverse process Pain does not get worse with trunk flexion Pain gets worse with trunk extension Unilateral paravertebral muscular spasm on the affected joint If referred to lower limb, the pain is above the knee Absence of radicular pattern
To attribute the pain etiology to a MRI-diagnosed disk hernia, there must be a clinical correlation with the symptoms Patient often reports paresthesias in the affected dermatome The dermatome distribution points to the affected nerve root, although there are anatomical variations. The most consistent dermatome is S1 Canal stenosis pain typically increases when walking and improves immediately with trunk flexion Diagnosis of lumbosacral radicular pain seems to be justified when the patient reports radicular pain in 1 lower limb, combined with 1 or more positive neurological test indicating nerve root irritation or neurological deficit
Table 2. Sacroiliac joint pain. Summary of consensuated indicators Unilateral buttock pain when sitting Pain that is referred to lower limb and (exceptionally) to foot At least 3 positive results in the 7 tests described in the questionnaire (approximation, gapping, Patrick’s, pelvic torsion, axial torsion, Fortin finger and Gillet) Pain gets worse when standing up from a sitting position
Table 3. Discogenic pain. Summary of consensuated indicators Pain induced by pressing on the spinous process at the affected level Persistent nociceptive low back pain Two-phase stretching from flexion Low back pain that radiates to the inguinal region and/or the lower limb, which worsens with axial compression and improves in decubitus MRI is useful to visualize pathological disk changes, but findings often correlate poorly with the clinical developments
sitting on the affected side and a positive Freiberg’s test (Table 4); lumbosacral radicular pain, paresthesias and a positive Lasegue’s test at 60° (Table 5). The discussion that took place at the face-to-face meeting enabled changes to be introduced into some questions, which greatly facilitated the confluence of opinions. In the ZPJ pain section, the wording “central low back pain” was changed to “low back pain at the
midline” (question no. 1), which resulted in the consensus to reject that particular pain location (median 1 [1.2 to 2.6] CI = 95%). In question no. 5 of the same section, there was disagreement about the original wording “zygapophysial joint pain improves with ventral trunk flexion” and after voting, this was changed to “pain does not get worse with ventral trunk flexion.” In the SIJ pain section, question No. 15 referred to pain “that was at times referred to the foot,” and this had to be changed to “pain that was referred to the lower limb and exceptionally, to the foot,” as most of the panelists considered that such a symptom would exclude sacroiliac pain, despite such references in the literature.43 A consensus was finally reached on all explorations, although many participants recognized that they did not usually perform all the tests included in the questionnaire on each patient. The experts did not consider that assisted walking was a sign indicative of myofascial pain of the quadratus lumborum muscle, as published.44 The original wording of question No. 62, related to myofascial syndrome of the pyramidal muscle, was “there may be a shortening of the affected lower limb.” This
Table 4. Myofascial pain. Summary of consensus indicators Quadratus lumborum muscle
Iliopsoas muscle
Piriformis muscle
Painful palpation below the last rib and 5 cm away from the L1 transverse process, with pain referred to the iliac crest Low back pain when walking, sitting, and even laying down Pain increases with postural changes in bed Low back pain during active stretching and lateral tilting Painful palpation of a trigger point at the level of L4 vertebral body, 1 or 2 cm above the iliac crest, with pain referred to greater trochanter Low back pain that is referred to the upper outer quadrant of the buttock, and often to front thigh and inguinal region, getting worse with thigh flexion Painful active leg raise in supine decubitus. Passive raise is not painful Positive Thomas test: in supine decubitus, painful shortening during passive hip extension In thin patients, painful deep palpation of the psoas outside the rectus abdominis muscle Painful deep palpation of the iliopsoas muscle in its insertion into the greater trochanter Trigger point half way between sacral and greater trochanter insertions Low back or buttock pain with symptoms of L5-S1 radiculopathy There may be an impression of shortening in the affected lower limb In the standing position, tendency toward external rotation of the foot of the affected lower limb Positive Freiberg test: forced passive internal rotation of the extended thigh is painful
18
CID ET AL.
was finally changed to “there may be the impression of a shortening of the affected lower limb,” which made it possible to reach a consensus.
DISCUSSION In this study, the clinical signs and symptoms for LBP of the zygapophysial joint, sacroiliac joint, muscular and disk origin were consensuated following a modified Delphi methodology, producing results that match published indicators for each clinical syndrome. The high degree of consensus finally reached was due to the rewording of some questions included in the original questionnaire that generated imprecise interpretations or rejection among the panelists. This could only be achieved in the third (face-to-face) round, which provided an opportunity for the experts to exchange views. Evidence that signs and symptoms per se are not reliable for a firm diagnosis of the origin of LBP justifies occasional seeking the opinion of panels of experts to favor unanimity of criteria. In a postal survey of 651 primary care physicians on the clinical signs and symptoms used to classify LBP patients into distinct etiological groups, little consensus was found among professionals.45 Following a classification based on the mechanism, by which pain was produced in 464 LBP patients through the opinion of investigators’ clinical judgment alone, 3 symptoms and a clinical sign for central sensitization were identified (pain originated by a neurophysiological dysfunction of the central nervous system). Two other signs, a syndrome predicting peripheral neuropathic pain, and 7 clinical criteria predicting nociceptive pain were also identified.46–48 A more rigorous consensus methodology like the Delphi technique has been used occasionally to address the diagnostic process for LBP. This method was used to generate a list of items that must be included by physiotherapists in the exploration of a patient with nonspecific LBP.49 Such an approach was also used to characterize clinical indicators of ZPJ pain,22 the physiotherapeutic treatment of LBP,50 terminological issues on LBP recurrence,51 to characterize lower limb pain,52 to validate the chapter on LBP corresponding to the International Classification of Functioning, Disability, and Health (ICF),53 and to reach a consensus on the clinical signs and symptoms of postsurgical neuropathic pain.35 Few studies have attempted to classify pain according to its anatomic origin.22 Uncertainty regarding the origin
of pain, defined as nonspecific low back pain, may not be determinant in the management of acute or subacute LBP with conservative treatment, which is indeed the recommended approach. However, if we want to carry out an interventional treatment in a patient with LBP with or without associated radicular pain when conservative treatments have failed, it is paramount to identify the pain’s source as closely as possible. For this purpose, we believe the consensus procedure chosen is appropriate. The results prioritized some symptoms and signs according to their reliability as diagnostic indicators of the suspected focus of the pain, thereby allowing the targets for interventional management to be characterized. Furthermore, they highlight the relevance of some clinical findings over others, confirming data published by others and therefore contributing to their validation. One of the disadvantages attributed to the Delphi method is the impossibility of exchanging opinions among panelists to resolve ambiguous issues and to propose changes in the wording of the items. This drawback has been very satisfactorily overcome by adding a face-to-face meeting to the survey rounds. In this meeting, the anonymous nature of the interactive votes after discussing each contentious item meant that the method’s basic advantages were preserved, as was the criteria of independence. We also believe that the number of experts participating and their qualifications reinforce the credibility of the results. Limitations Among the limitations associated to this study is the fact that the questionnaire may have included signs and/or symptoms for other causes of LBP. However, the literature on the topic is usually restricted to the entities listed above. Myofascial pain has been included as a cause of LBP even though it is not usually present in the guidelines and algorithms for LBP interventional treatment.26 The expert panel may be a limitation of the study, as they were selected from a small number of medical specialties. The basic reason for the panel’s composition is that 86% of physicians belonging to pain units in our environment are anesthesiologists, with 3% being neurosurgeons and 3% primary care physicians.54 Nevertheless, other specialties such as Rehabilitation (1 participant) and Internal Medicine (1 participant) were also represented in the panel. The relatively small geographic area in which the panelists operate may constitute a bias, producing a tendency toward a confluence of opinions. However, given the limited
Delphi Survey on Low Back Pain Symptoms and Signs 19
consensus (75.6%) reached after the first 2 rounds, we do not believe that this was an issue. Delphi consensus has limited validity as scientific evidence, and it is no substitute for basic and clinical research, which must be performed to confirm its conclusions. For this reason, the conclusions of the present study are neither absolute truths nor diagnostic standards, yet, they may help facilitate the diagnostic process in the minimal interventional management of LBP.
ACKNOWLEDGEMENTS We acknowledge the support of Medtronic Iberica S.A., Cardiva Centro S.L., and Avances Neurol ogicos Sanitarios (ANS) S.A. for funding the project. The following experts participated in the project but did not participate in all 3 rounds: Gloria Llaurad o, MD. Pain Unit, Department of Anesthesiology and Reanimation, “Gren” University Hospital, Madrid, Spain. gorio Mara~ no Jes us Estrada, MD. Pain Unit, Department of Anesthesiology and Reanimation, Getafe University Hospital, Madrid, Spain. Alfredo Fern andez, MD. Pain Unit, Department of Anesthesiology and Reanimation, “La Paz” University Hospital, Madrid, Spain. Consuelo Nieto, MD. Pain Unit, Department of Anesthesiology and Reanimation, Alcorc on Foundation University Hospital, Madrid, Spain. Concepci on Perez, MD. Pain Unit, Department of Anesthesiology and Reanimation, “La Princesa” University Hospital, Madrid, Spain. Gonzalo del Portillo, from ANS S.A., helped with the English translation of the article. Carlos Goicoechea, PhD (Faculty of Health Sciences, “Rey Juan Carlos” University, Madrid, Spain), collaborated in the methodological aspect of the Project as a scientific committee member.
CONFLICT OF INTEREST The authors have no conflict of interests to declare. The study design, wording of the questionnaire, the survey, analysis and interpretation of results were all performed without the participation of the funding sources. None of these sources influenced the content or composition of this article, or the decision to publish it.
REFERENCES 1. Catala E, Reig E, Artes M, Aliaga L, L opez JS, Seg u JL. Prevalence of pain in the Spanish population: telephone survey in 5000 homes. Eur J Pain. 2002;6:133–140.
2. Pinto-Meza A, Serrano-Blanco A, Miquel Codony M, et al. Prevalencia y comorbilidad fısica y mental del dolor dorsal y cervical cr onicos en Espa~ na: resultados del estudio ESEMeD. Med Clin (Barc). 2006;127:325–330. 3. Fernandez de las Pe~ nas C, Hern andez-Barrera V, Alonso-Blanco C, et al. Prevalence of neck and low back pain in community-dwelling adults in Spain: a population-based national study. Spine. 2011;36:E213–E219. 4. Jimenez-S anchez S, Fern andez de las Pe~ nas C, CarrascoGarrido P, et al. Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain). Gac Sanit. 2012;26: 534–540. 5. La Ruiz P. medici on de la calidad asistencial. Rev Clin Esp. 2001;201:561–562. 6. Cid J, De Andres J, Reig E, Del Pozo C, Cortes A, Garcıa-Cruz JJ. Cervicalgias y lumbalgias mecanicodegenerativas. Tratamiento conservador. Actualizaci on. Rev Soc Esp Dolor. 2001;8:79–100. 7. Bogduk N. The innervation of the lumbar spine. Spine. 1983;8:286–293. 8. Dwyer A, April C, Bogduk N. Cervical zygapophysial joint pain patterns I: a study of normal volunteers. Spine. 1990;15:453–457. 9. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Ortho Clin North Am. 1991;22:181– 187. 10. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine. 1994;19:801– 806. 11. Schwarzer AC, April CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine. 1995;20:31–37. 12. De Palma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011;12:224–233. 13. McCall IW, Park WM, O’Brien JP. Induced pain referral from posterior lumbar elements in normal subjects. Spine. 1979;4:441–446. 14. Marks R. Distribution of pain provoked from lumbar facet joints and related structures during diagnostic spinal infiltration. Pain. 1989;39:37–40. 15. Revel M, Poiraudeau S, Auleley GR, et al. Capacity of the clinical picture to characterize low back pain relieved by facet joint anesthesia. Proposed criteria to identify patients with painful facet joints. Spine. 1998;23:1972–1976, discussion 7. 16. Maigne JY, Aivaliklis A, Pfefger F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine. 1996;21:1889– 1892. 17. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. 2005;10:207–218.
20
CID ET AL.
18. Van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil. 2006;87:10–14. 19. De Palma MJ, Ketchum JM, Trussell BS, Saullo TR, Slipman CW. Does the location of low back pain predict its source? PMR. 2011;3:33–39. 20. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive review of neurophysiologic basis and diagnostic interventions in managing chronic spinal pain. Pain Physician. 2009;12:E71–E121. 21. Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999;246:899–906. 22. Wilde VE, Ford JJ, McMeeken JM. Indicators of lumbar zygapophyseal joint pain: survey of an expert panel with the Delphi technique. Phys Ther. 2007;87:1348–1361. 23. Rubinstein SM, van Tulder M. A best- evidence review of diagnostic procedures for neck and low-back pain. Best Pract Res Clin Rheumatol. 2008;22:471–482. 24. Deville WL, van der Windt DA, Dzaferagić A, Bezemer PD, Bouter LM. The test of Lasegue: systematic review of the accuracy in diagnosing herniated discs. Spine. 2000;25:1140– 1147. 25. Van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010;17:CD007431. 26. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699–802. 27. Bogduk N. Principles of diagnostic blocks. In: Slipman CW, Derby R, Simeone FA, Mayer TG, eds. Interventional Spine: An Algorithmic Approach. Philadelphia: Saunders Elsevier; 2008:187–191. 28. Manchikanti L, Datta S, Derby R, et al. Critical review of the american pain society clinical practice guidelines for interventional techniques: part 1. diagnostic interventions. Pain Physician. 2010;13:E141–E174. 29. Bogduk N. On diagnostic blocks for lumbar zygapophysial joint pain. Med Rep. 2010;2:57. doi:10.3410/M2-57. 30. Cook C, Brisme ́ e J-M, Fleming R, Sizer PS Jr. Identifiers suggestive of clinical cervical spine instability: a Delphi study of physical therapists. Phys Ther. 2005;85:895–906. 31. Graham B, Regehr G, Wright JG. Delphi as a method to establish consensus for diagnostic criteria. J Clin Epidemiol. 2003;12:1150–1156. 32. Murphy MK, Black NA, Lamping DL, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2:1–88. 33. Brunner F, Lienhardt SB, Kissling RO, Bachmann LM, Weber U. Diagnostic criteria and follow-up parameters in complex regional pain syndrome type I—a Delphi survey. Eur J Pain. 2008;12:48–52.
34. Hunter DJ, Arden N, Conaghan PG, et al. Definition of osteoarthritis on MRI: results of a Delphi exercise. Osteoarthritis Cartilage. 2011;19:963–969. 35. Searle RD, Howell SJ, Bennett MI. Diagnosing postoperative neuropathic pain: a Delphi survey. Br J Anaesth. 2012;109:240–244. 36. Portney L, Watkins M. Foundations of Clinical Research: Applications to Practice. Norwalk, Conn: Appleton & Lange; 1993. 37. Linstone H, Turoff M. The Delphi Method: Techniques and Applications, Reading, Mass: Addison-Wesley Publishing; 1975. Available in http://is.njit.edu/pubs/delphibook/. 38. Jeffery D, Ley A, Bennun I, McLaren S. Delphi survey opinion on interventions, service principles and service organization for severe mental illness and substance misuse problems. J Ment Health. 2000;9:371–384. 39. Mullen PM. Delphi: myths and reality. J Health Organ Manag. 2003;17:37–52. 40. De la Calle JL, Abej on D, Cid J, et al. Est andares de calidad asistencial y cat alogo de procedimientos de las unidades de dolor cr onico. Rev soc Esp Dolor. 2010;17:114– 133. 41. Uphoff EP, Wennekes L, Punt CJ, et al. Development of generic quality indicators for patient-centered cancer care by using a RAND modified Delphi method. Cancer Nurs. 2012;35:29–37. 42. Fitch K, Bernstein SJ, Aguilar MD, et al. The Rand/ UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corporation; 2001. ISBN 0-8330-2918-5. RAND URL: http://www.rand.org. 43. Slipman CW, Jackson HB, Lipertz JS, et al. Sacroiliac joint pain referral zones. Arch Phys Med Rehabil. 2000;81:334–338. 44. Castro M, C anovas L, Garcıa-Rojo B, et al. Tratamiento del Sındrome de Dolor Miofascial con Toxina Botulınica tipo A. Rev Soc Esp Dolor. 2006;2:96–102. 45. Kent P, Keating JL. Classification in nonspecific low back pain: what methods do primary care clinicians currently use? Spine. 2005;30:1433–1440. 46. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitization in patients with low back ( leg) pain. Man Ther. 2012;17:336– 344. 47. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 2 of 3: symptoms and signs of peripheral neuropathic pain in patients with low back ( leg) pain. Man Ther. 2012;17:345–351. 48. Smart KM, Blake C, Staines A, et al. Mechanismsbased classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back ( leg) pain. Man Ther. 2012;17:352–357. 49. McCarthy CJ, Rushton A, Billis V, Arnall F, Oldham JA. Development of a clinical examination in non-specific low
Delphi Survey on Low Back Pain Symptoms and Signs 21
back pain: a Delphi technique. J Rehabil Med. 2006;38:263– 267. 50. Ferguson FC, Brownlee M, Webster V. A Delphi study investigating consensus among expert physiotherapists in relation to the management of low back pain. Musculoskeletal Care. 2008;6:197–210. 51. Stanton TR, Latimer J, Maher CG, Hancock MJ. A modified Delphi approach to standardize low back pain recurrence terminology. Eur Spine J. 2011;20:744–752. 52. Konstantinou K, Hider SL, Vogel S, Beardmore R, Somerville S. Development of an assessment schedule for patients with low back-associated leg pain in primary care: a Delphi consensus study. Eur Spine J. 2012;21: 1241–1249.
53. Glocker C, Kirchberger I, Gla¨ssel A, Finczicki A, Stucki G, Cieza A. Content validity of the comprehensive international classification of functioning, disability and health (ICF) core set for low back pain from the perspective of physicians: a Delphi survey. Chronic Illn. 2013;9:57–72. 54. Barutell C. Unidades de dolor en Espa~ na. Encuesta SED Dıa del Dolor 2007. Rev. Soc. Esp. Dolor. 2009;16:421–428.
SUPPORTING INFORMATION
Additional Supporting Information may be found in the online version of this article: Appendix S1. Questionnaire and results.
Copyright of Pain Practice is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
