Original article

Patient characteristics in low back pain subgroups based on an

existing classication system. A descriptive cohort study in
chiropractic practice
Heidi Eirikstoft, Alice Kongsted
*
The Nordic Institute of Chiropractic and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
a r t i c l e i n f o
Article history:
Received 13 February 2013
Received in revised form
4 July 2013
Accepted 15 July 2013
Keywords:
Classication
Cohort studies
Low back pain
Primary health care
a b s t r a c t
Sub-grouping of low back pain (LBP) is believed to improve prediction of prognosis and treatment effects.
The objectives of this study were: (1) to examine whether chiropractic patients could be sub-grouped
according to an existing pathoanatomically-based classication system, (2) to describe patient charac-
teristics within each subgroup, and (3) to determine the proportion of patients in whom clinicians
considered the classication to be unchanged after approximately 10 days. A cohort of 923 LBP patients
was included during their rst consultation. Patients completed an extensive questionnaire and were
examined according to a standardised protocol. Based on the clinical examination, patients were clas-
sied into diagnostic subgroups. After approximately 10 days, chiropractors reported whether they
considered the subgroup had changed. The most frequent subgroups were reducible and partly reducible
disc syndromes followed by facet joint pain, dysfunction and sacroiliac (SI)-joint pain. Classication was
inconclusive in 5% of the patients. Differences in pain, activity limitation, and psychological factors were
small across subgroups. Within 10 days, 82% were reported to belong to the same subgroup as at the rst
visit. In conclusion, LBP patients could be classied according to a standardised protocol, and chiro-
practors considered most patient classications to be unchanged within 10 days. Differences in patient
characteristics between subgroups were very small, and the clinical relevance of the classication system
should be investigated by testing its value as a prognostic factor or a treatment effect modier. It is
recommended that this classication system be combined with psychological and social factors if it is to
be useful.
2013 Elsevier Ltd. All rights reserved.
1. Introduction
Lowback pain (LBP) is the cause of a high number of health care
consultations, but provable treatment effects are modest and
different treatments seem to have more or less the same effects
(van Middelkoop et al., 2010; Rubinstein et al., 2011; Standaert
et al., 2011). This has partly been attributed to the fact that rand-
omised controlled trials often investigate the effect of a one size ts
all approach in which all patients with non-specic LBP have the
same type of care, and it has been suggested that treatment effects
may be improved by classication of non-specic LBP into homo-
geneous subgroups that can guide the choice of treatment
(Leboeuf-Yde and Manniche, 2001; Kent and Keating, 2004; Hill
et al., 2011).
In 1987, the biopsychosocial model was suggested as a theo-
retical framework for the treatment of LBP (Waddell, 1987) and in
the absence of specic diagnoses with consequences for outcome,
proling patients on the basis of biological, psychological and social
prognostic factors appears relevant (Hemingway et al., 2013).
Prognostic research has identied a high number of factors asso-
ciated with outcome in LBP, but no single prognostic factor has been
identied that strongly affects outcome in itself (Kent and Keating,
2008; Chou and Shekelle, 2010). Potentially relevant factors, and
perhaps especially biological factors, are under-investigated in high
quality studies (Kent and Keating, 2008; Hancock et al., 2011).
To enhance the clinical usefulness of prognostic factors and
treatment effect modiers, a number of classication systems have
been developed that combine such factors into predictive models
or classication systems (Fairbank et al., 2011; Karayannis et al.,
* Corresponding author. NIKKB, University of Southern Denmark, Campusvej 55,
5230 Odense M, Denmark. Tel.: 45 65504531.
E-mail address: a.kongsted@nikkb.dk (A. Kongsted).
Contents lists available at ScienceDirect
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1356-689X/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2013.07.007
Manual Therapy 19 (2014) 65e71
2012). A classication system developed by Petersen et al. was
designed to subgroup LBP patients according to the most likely
pathoanatomical diagnosis (Petersen et al., 2003). This system
combines Mechanical Diagnosis and Therapy (MDT) (McKenzie and
May, 2003) with tests for sacroiliac (SI)-joint pain, neurological
signs, adverse neural tension tests, and non-organic signs. In that
way, clinical ndings are combined into classes that are potentially
stronger biological components in a biopsychosocial model than
single tests.
The reliability of Petersen et al.s systemwas tested in two small
cohorts where the inter-tester agreement was found to be accept-
able for the largest classes (Petersen et al., 2004; Kongsted and
Leboeuf-Yde, 2010), whereas the reliability for the smaller diag-
nostic classes is unknown. Further, preliminary results suggest that
the classication system has some predictive capacity (Kongsted
and Leboeuf-Yde, 2010). However, its ability to categorise patients
with similar proles into the same subgroup, including its value as a
prognostic factor or treatment effect modier, has yet to be proven.
As a basic step to explore the usefulness of the systemdeveloped
by Petersen et al. and to investigate whether classication based on
clinical ndings results in classes that also differ on psychological
and social factors, the objectives of this study were: (1) to examine
whether chiropractic patients could be classied according to the
classication system, (2) to describe patient characteristics within
each subgroup, and (3) to determine the proportion of patients in
whomclinicians considered the classication to be unchanged after
approximately ten days.
2. Methods
Patients with LBP who attended a clinic in the research network
of the Nordic Institute for Chiropractic and Clinical Biomechanics in
Denmark were recruited during their rst visit for the current
episode. Participants completed a questionnaire at baseline and the
chiropractors classied patients based on a standardised exami-
nation protocol. Approximately 10 days after the initial visit, the
clinicians registered whether they considered the diagnostic class
had changed since baseline. The chiropractors were free to plan
treatment that they deemed appropriate. The project was approved
by the Danish Data Protection Agency (J-no. 7840-1011743), and the
local ethics committee declared that the study did not need ethics
approval according to Danish rules (DNcoBR, 2011).
2.1. Setting
Thirty-six chiropractors from 17 clinics geographically spread
across Denmark participated in the study. Prior to data collection,
all clinicians participated in a one-day seminar covering the theory
and practice of the examination protocol for the study. Particular
focus was put on the MDT approach since this was the part of the
protocol with which clinicians were the least familiar. After the
seminar, clinicians were asked to practise the standardised exam-
ination and one of the authors (HE) visited all clinicians to train
them in the execution of the project protocol. If a chiropractor did
not seem conversant with the protocol, another visit was sched-
uled. Three chiropractors in one clinic withdrew from the project
after this introduction because they found that the protocol differed
too much from their usual clinical procedures. The clinical experi-
ence of the participating chiropractors varied from one to more
than 20 years.
2.2. Study sample
The chiropractors were instructed to include patients consecu-
tively in the project as they contacted the clinic. Patients were
potential participants if they sought care because of LBP with or
without leg pain, were aged 18e65 years, had access to a mobile
phone and were able to use text messaging (because of follow-up
procedures unrelated to the objectives of this study), and could
read and understand Danish. Exclusion criteria were pregnancy,
suspicion of inammatory or pathological pain, acute referral to
surgery, and having had more than one health care visit for LBP
within the last three months. Prior to giving consent, oral and
written information about the study procedures was delivered by
the chiropractor or by a secretary.
2.3. Survey data
Patients who gave consent to participate completed a ques-
tionnaire in the reception area before being examined by the
chiropractor. The questionnaire was returned to the secretary in a
sealed envelope and posted to the research unit.
2.3.1. Socio-demographics
Socio-demographic factors were gender, age, physical work load
(mainly sitting, sitting and walking, light physical work, hard
physical work), and sick-leave (proportion reporting any days off
work due to LBP within the previous month).
2.3.2. LBP characteristics
Pain items were duration of the current episode (0e2 weeks, 2e
4 weeks, 1e3 months, >3 months), the number of previous epi-
sodes (0, 1e3, >3), the number of LBP days over the previous year
(30 days, >30 days) (Hestbaek et al., 2003), LBP intensity (typical
pain the previous week on a numeric rating scale (NRS) 0e10
(Dionne et al., 2008)), leg pain intensity (0e10 NRS typical pain last
week), and leg pain (proportion with NRS >0). Activity limitation
was measured using the Danish Roland Morris Disability Ques-
tionnaire (Albert et al., 2003) and summed as a proportional score
(0e100) (Kent and Lauridsen, 2011).
2.3.3. Psychological factors
Depressive symptoms were measured by the Major Depression
Inventory (0e50) (Bech et al., 2001), pain-related fear of movement
by the Fear Avoidance Beliefs Questionnaire (FABQ-work (0e42));
FABQ-physical activity (0e24) (Waddell et al., 1993), and coping by
means of a single item from the Orebro Pain Questionnaire (Linton
and Boersma, 2003) (Based on all the things you do to cope, or
deal with your pain, on an average day, how much are you able to
decrease it? 0 cant decrease it at all; 10 can decrease it
completely). FABQ-workwas onlyaskedof thosewhowereworking.
2.3.4. General health
Self-reported general health was measured by the EQ-5D VAS
(0 worst imaginable health state; 100 best imaginable health
state) (Rabin and de Charro, 2001).
2.4. Subgroup classication
The clinical examination included responses to repeated end-
range movements (MDT testing), ve pain provocation tests for
SI-joint testing (Laslett, 2008), tests for adverse neural tension,
Waddells non-organic signs (Waddell et al., 1980), and a neuro-
logical examination including straight leg raise (SLR) and tests of
muscle strength, sensation and deep tendon reexes. In addition to
the test procedures, the protocol contained questions aimed at
identifying signs of spinal stenosis and facet joint pain (Petersen
et al., 2003).
The examination ndings were translated into diagnostic clas-
ses as suggested by Petersen et al., although in our study, we
H. Eirikstoft, A. Kongsted / Manual Therapy 19 (2014) 65e71 66
allowed clinicians to register both a primary and a secondary
diagnostic class and we added a class named partly reducible disc
that included patients who centralised partly on MDT testing but
who did not meet criteria for a reducible disc. The diagnostic class
referred to by Petersen et al. as nerve root entrapment was
included in the adherent nerve root class as previously suggested
(Petersen et al., 2004). Although the diagnostic classes were named
according to the most likely pathoanatomical pain generator, these
names should be considered labels rather than rm diagnostic
descriptors. An overview of the diagnostic classes is listed in
Appendix 1.
Findings were registered in a web-based examination scheme
and transferred to a central server. When the diagnostic class based
on the predened algorithm for classication was registered, chi-
ropractors were asked whether they agreed with this diagnosis,
based on their clinical judgement.
Prevalence of SLR (classied as positive if radiating pain in the
leg was provoked or aggravated) within the diagnostic classes was
the only nding from the clinical examination that was included in
the current description, since that nding has been shown to be
associated with prognosis (Kent and Keating, 2008) and was not a
nding that would lead to a particular classication on its own.
2.5. Subsequent assessment of the classication
A web-based questionnaire was completed by the chiropractors
approximately 10 days after the rst visit or when the patient was
seen for a second visit. The questions asked were Based on the
patients subsequent visit(s), is there reason to alter the classica-
tion made at the rst visit? (yes, no, not sure, have not seen this
patient again), and If yes, which diagnostic class does the patient
belong to now?. The answers were based on information and
ndings from a routine follow-up consultation and clinicians were
not asked to repeat the entire standardised examination.
2.6. Data analysis
No imputation was made for missing data, and classes with less
than ve patients were not described. This study was purely
descriptive and statistical testing of differences across all diagnostic
groups was not considered relevant. Observed potentially relevant
differences between a diagnostic class and the rest of the cohort
were tested by means of a Chi-squared test (proportions), t-test
(normal distributed continuous variables), or rank sum test
(continuous variables with a non-normal distribution).
Nominal variables were described as proportions with 95%
condence intervals (CI), and continuous variables as means with
standard deviations (SD) or medians with inter-quartile ranges
(IQR). Analyses were performed in STATA/SE 12.1.
3. Results
A total of 951 patients were recruited between September 2010
and January 2012. Both clinician- and patient-reported data were
available for 923 (Fig. 1) of these patients. Each of the 17 clinics
recruited from 14 to 189 patients. Characteristics of the cohort are
summarised in Table 1. The highest proportion of missing items on
patient-reported variables was 5% (FABQ physical activity), and SLR
was missing in 7%.
3.1. Diagnostic classication
The most frequent diagnostic classes were reducible (24%), and
partly reducible (24%), disc syndromes followed by facet joint pain
(14%), dysfunction (11%) and SI-joint pain (8%) (Table 2). The
diagnostic classes of adherent nerve root, non-mechanical disc
syndrome, adverse neural tension, and spinal stenosis included less
than ve patients each and were not included in the description of
patient characteristics. Five percent of patients were classied as
inconclusive.
Chiropractors agreed with the diagnostic classication in 66% of
patients, were unsure or agreed partially in 20%, and did not agree
in 11%. Chiropractors most frequently agreed with the classica-
tions of facet joint pain and SI-joint pain, whereas they most often
disagreed with the classes of non-mechanical disc and inconclu-
sive (Table 3).
3.2. Patient characteristics in the diagnostic classes
Patient characteristics in each diagnostic class appear in Table 2.
Generally, differences were small in size and only some factors are
Fig. 1. Study ow-chart.
H. Eirikstoft, A. Kongsted / Manual Therapy 19 (2014) 65e71 67
commented on below. p-Values refer to a comparison of the
mentioned diagnostic class with the rest of the cohort.
3.2.1. Socio-demographics
A higher proportion of females was observed in SI-joint syn-
drome (p <0.01). Overall, 22% of the cohort reported sick leave due
to LBP or leg pain, whereas 57% of the patients with nerve root
compression had been sick-listed. Patients with myofascial pain
were the least likely to report any sick-listing (p 0.01).
3.2.2. LBP characteristics
Most patients had experienced LBP previously and 49% reported
more than three previous episodes. The majority of the patients had
experienced LBP during this episode for less than two weeks. The
duration of the current episode was longer for patients with
postural syndrome (p <0.05) or dysfunction (p <0.01) when
compared with all other classes (Table 2).
The median LBP intensity was 7 and similar across classes,
although patients with nerve root compression had less intensive
LBP (p <0.01). Leg pain intensity was lower than LBP intensity
except for those patients with nerve root compression, who re-
ported not only more intensive leg pain than LBP, but also more leg
pain than other classes (p <0.001).
Activity limitation was most pronounced in irreducible and
partly reducible disc syndromes, whereas patients with dysfunc-
tion or myofascial pain had the least limitations (all mentioned
differences p <0.001 as compared with the rest of the cohort)
(Table 2).
3.2.3. Psychological factors
Depression scores were low and with small variations between
diagnostic classes (Table 2). Fear-avoidance beliefs concerning
physical activity also did not differ signicantly between groups,
but fear-avoidance beliefs related to work were signicantly more
common with nerve root compression (p <0.05).
3.3. Subsequent assessment of the classication
An assessment of diagnostic class based on a routine follow-up
consultation was completed for 715 (77%) of the participants. In
82%, the chiropractor reported that the diagnostic class had not
changed, 8% that the diagnostic class had changed, 6% that it was
unclear whether the diagnosis had changed, and 4% of the patients
were not seen since the rst consultation.
The diagnostic class in which the largest proportion was
considered to have changed class was irreducible disc syndrome
(19% changed). These 10 patients changed to partly reducible or
reducible disc (n 3), nerve root compression (n 1), SI-joint pain
(n 3), or facet joint pain (n 3).
4. Discussion
Based on a standardised examination protocol, it was possible to
classify the majority of LBP patients seeking care fromchiropractors
according to predened criteria. However, in one third of the pa-
tients, clinicians stated that they did not fully agree with the
diagnostic conclusion reached by the classication system.
Furthermore, patient characteristics were so similar across the
diagnostic classes that it is questionable whether the classication
subgroups were clinically relevant.
The most frequent diagnostic classes were reducible and partly
reducible disc syndrome (47% of the cohort), which resembles the
46% classied with reducible disc syndrome when Petersen et al.
used this classication system in a secondary care setting (Petersen
et al., 2004). In a study we previously conducted in Danish chiro-
practic practice, only 27% were classied with disc syndromes
(Kongsted and Leboeuf-Yde, 2010), whereas a number of studies
using the MDT system classied around 80% with derangement
syndrome (another term for what we named disc syndromes)
(Kilpikoski et al., 2002; Clare et al., 2005; May, 2006). In the current
cohort, 14% were classied as facet joint syndrome and 11% as
dysfunction, which were high proportions when compared with
Petersen et al.s secondary care cohort, in which only 1e3% of pa-
tients were classied into these categories. In the former chiro-
practic practice study, dysfunction was the most frequent class
(32%) and 6% were classied as facet joint syndrome (Kongsted and
Leboeuf-Yde, 2010). It may be that more patients in primary care t
into these categories, or another explanation could be that tradi-
tionally chiropractors have focused more on the facet joints and
joint dysfunction as sources of back pain and this might inuence
their interpretation of test results.
Differences in sampling between populations do not seem to be
the main reason for these classication differences since our re-
sults were more similar to those from a secondary care setting
than to the results of our previous study from chiropractic prac-
tices. Other possible explanations are differences in performing
the clinical examination or in interpretations of test results. In our
previous study, less emphasis was put on the hierarchy of classes
and on MDT concepts. This meant that chiropractors in that study
may have used end-range loading in a less rigorous manner.
Chiropractors in the current study were taught by an MDT
diploma therapist and a hierarchy of classes was emphasised
more. Whether focus on MDT testing resulted in a more correct
classication or in clinicians being biased towards the disc syn-
dromes is unknown.
Comparing baseline characteristics across diagnostic classes did
not reveal specic patient proles belonging to each class, and
observed differences between classes were small in size, which has
been noted also with other classication approaches (Fritz and
George, 2000; Kongsted et al., 2012). Nevertheless, some clini-
cally meaningful differences were seen. First, it did make sense that
Table 1
Descriptive data and number of missing items.
Total cohort,
n 923
No. of
missing items
Females, % (95% CI) 45 (42e49) 0
Age in years, mean (SD) 43 (12) 0
Physical work load, % (95% CI) 3
a
Sitting 23 (20e26)
Sitting & walking 35 (32e39)
Light physical 20 (17e23)
Heavy physical 22 (19e25)
Sick-listing, % (95% CI) 23 (20e26) 14
a
Duration, % (95% CI) 20
0e2 weeks 63 (60e66)
2e4 weeks 14 (11e16)
1e3 months 10 (8e12)
>3 months 13 (11e16)
LBP 0e10, median (IQR) 7 (5e8) 27
Leg pain 0e10, median (IQR) 2 (0e4) 45
Any leg pain, % (95% CI) 58 (55e61) 45
Previous LBP episodes, % (95% CI) 21
None 16 (14e19)
1e3 35 (32e38)
> 3 49 (46e52)
>30 days LBP last year, % (95% CI) 26 (23e29) 34
Activity limitation, 0e100 median (IQR) 52 (35e70) 16
Depression, 0e50 median (IQR) 6 (3e11) 17
FABQ-W, 0e42 median (IQR) 11 (6e20) 36
a
FABQ-PA, 0e24 median (IQR) 13 (9e16) 48
Coping, 0e10 mean (SD) 5.9 (2.4) 28
Positive SLR, % (95% CI) 11 (9e14) 69
a
Missing values among participants who were working.
H. Eirikstoft, A. Kongsted / Manual Therapy 19 (2014) 65e71 68
more women had SI-joint pain if some pelvic pain can be attributed
to previous pregnancy and childbirth. Also, a more severe prole on
both pain and psychological factors in patients with nerve root
compression was in line with other studies (BenDebba et al., 2000;
Kongsted et al., 2012). Finally, it seems reasonable from a clinical
point of view that patients in the irreducible disc class (that is,
movement tests worsen, not improve pain) tended to be more
severely affected than those with a reducible disc. We could
possibly have introduced clearer differences between classes if the
class denitions had involved the patient history to a higher degree.
We chose to dene classes based almost purely on clinical exami-
nation ndings in order to study the importance of the clinical
examination separately from patient-reported information.
It was a potential limitation of the study that clinicians were
not formally trained in MDT, since MDT test procedures were a
signicant part of the study protocol. Also, standardisation of the
test protocol was based only on a one-day course and one or two
visits by a research assistant. On the other hand, all participating
chiropractors were experienced in LBP examinations and the
examination protocol resembled to a large extent a standard LBP
examination in Danish chiropractic practice. As mentioned
above, it can also be argued that very strict standardisation could
result in bias. However, it appears from the results that deni-
tions were not always followed. For example, leg pain was pre-
sent in patients classied with postural syndrome, which was
dened as a syndrome with local LBP only. We believe inaccur-
acies like this are an almost inevitable outcome of conducting
research in a real life clinical setting involving a large number of
data collectors.
It is unknown to what extent the study population was repre-
sentative of chiropractic patients. The participating clinicians were
instructed to include new patients consecutively, but this was not
always practically possible because extra time was needed to
conduct the study procedures. Some patients calling for an
appointment were not willing to wait until a project appointment
Table 2
Clinical characteristics of LBP patients in nine diagnostic classes.*
Reducible
disc n 220
Partly
reducible
disc n 224
Irreducible
disc n 60
Dysfunction
n 98
SI-joint
pain n 75
Postural
syndrome
n 8
Facet joint
pain n 127
Nerve root
compression
n 10
Myofascial
pain n 42
Females, % (95% CI) 43 (37;50) 48 (41;54) 52 (39;64) 41 (31;51) 65 (54;76) 38 (2;73) 35 (26;43) 70 (40;100) 45 (30;60)
Age in years, mean (SD) 43 (11) 41 (11) 43 (12) 42 (13) 45 (12) 44 (11) 46 (11) 50 (9) 44 (11)
Physical work load, % (95% CI)
Sitting 20 (14;26) 34 (27;41) 16 (5;27) 14 (6;22) 19 (9;30) 29 (0;65) 24 (16;33) 29 (0;65) 24 (10;37)
Sitting& walking 39 (32;46) 33 (26;39) 48 (33;63) 41 (30;52) 37 (24;49) 14 (0;42) 29 (20;38) 29 (0;65) 29 (14;44)
Light physical 22 (16;28) 16 (11;21) 16 (5;27) 17 (9;26) 21 (10;32) 29 (0;65) 28 (19;36) 21 (8;34)
Heavy physical 19 (13;25) 18 (12;23) 20 (8;33) 28 (17;38) 23 (12;34) 29 (0;65) 19 (12;27) 43 (3;83) 26 (12;41)
Any sick-listing, % (95% CI) 25 (19;32) 29 (23;36) 18 (6;30) 14 (6;22) 24 (12;35) 29 (0;65) 18 (10;26) 57 (17;97) 5 (0;12)
Duration, % (95% CI)
0e2 weeks 67 (61;74) 69 (63;76) 65 (53;77) 46 (36;56) 64 (53;75) 25 (0;57) 67 (59;75) 25 (0;57) 50 (35;65)
2e4 weeks 12 (8;16) 10 (6;14) 15 (6;24) 21 (12;29) 13 (5;20) 13 (0;37) 14 (8;20) 25 (0;57) 17 (5;28)
1e3 months 12 (8;17) 8 (5;12) 8 (1;15) 12 (6;19) 8 (2;15) 13 (0;37) 10 (5;16) 25 (0;57) 14 (4;25)
>3 months 8 (5;12) 13 (8;17) 12 (3;20) 22 (13;30) 15 (7;24) 50 (13;87) 9 (4;14) 25 (0;57) 19 (7;31)
LBP 0e10, median (IQR) 7 (5;8) 7 (6;8) 7 (6;8) 6 (5;7) 7 (5;8) 5 (3;8) 7 (5;8) 3 (2;6) 6 (4;8)
Leg pain 0e10, median (IQR) 2 (0;4) 2 (0;5) 2 (0;6) 1 (0;3) 2 (0;6) 1 (0;3) 0 (0;3) 6 (5;9) 2 (0;5)
Any leg pain, % (95% CI) 62 (55;68) 59 (52;65) 63 (50;75) 64 (52;75) 62 (51;74) 63 (27;98) 44 (35;53) 100 (100;100) 65 (50;80)
Previous LBP episodes, % (95% CI)
None 14 (9;18) 15 (11;20) 10 (2;18) 21 (13;29) 21 (11;30) 13 (0;37) 17 (10;24) 13 (0;37) 14 (3;25)
1e3 36 (30;42) 34 (27;40) 39 (26;52) 33 (24;42) 19 (10;29) 38 (2;73) 40 (34;51) 50 (13;87) 36 (21;50)
>3 50 (44;57) 51 (44;58) 51 (40;64) 46 (36;56) 60 (48;71) 50 (13;87) 40 (32;49) 38 (2;73) 50 (35;65)
>30 days LBP last year, % (95% CI) 24 (18;30) 27 (21;33) 28 (16;39) 29 (19;38) 27 (17;38) 63 (27;98) 18 (11;25) 29 (0;65) 33 (19;49)
Activity limitation, 0e100
median (IQR)
57 (35;70) 61 (39;73) 65 (43;78) 39 (26;59) 53(39;74) 39 (8;50) 52 (30;68) 57 (39;74) 26 (17;61)
Depression, 0e50 median (IQR) 6 (3;11) 6 (3;12) 8 (4;14) 5 (2;9) 6 (3;12) 8 (5;15) 6 (3;12) 8 (4;15) 5 (3;8)
FABQ-W, 0e42 median (IQR) 11 (6;21) 10 (6;18) 12 (5;21) 10 (6;17) 8 (4;19) 18 (7;22) 13 (7;19) 23 (12;28) 15 (6;21)
FABQ-PA, 0e24 median (IQR) 12 (9;16) 13 (9;16) 14 (10;18) 13 (11;17) 13 (9;17) 12 (9;17) 13 (9;17) 14 (8;18) 11 (7;15)
Coping, 0e10 mean (SD) 5.9 (2.4) 5.9 (2.4) 5.8 (2.3) 5.9 (2.4) 5.8 (2.5) 6.7 (2.3) 5.8 (2.4) 5.4 (2.9) 6.5 (2.4)
General Health, 0e100
median (IQR)
75(60;80) 70(60;80) 70(43;80) 70(60;85) 70(50;80) 70(60;85) 75(60;87) 75(48;86) 80(70;88)
Positive SLR, % (95% CI) 14 (10;19) 10 (6;14) 23 (11;35) 2 (0;5) 9 (2;17) 14 (0;49) 2 (0;5) 80 (50;100) 5 (0;14)
*Due to few observations in the classes, non-mechanical disc (n 2), adherent nerve root (n 2), spinal stenosis (n 3), adverse neural tension (n 2) and abnormal pain
syndrome (n 0) are not included in the table. The classication was inconclusive in 50 (5%) cases.
Table 3
Proportion of patients in each diagnostic class for whomclinicians did not agree that
the conclusion reached by the classication system was correct.
Diagnostic class Clinician
agrees
with the
conclusion
Clinician
disagrees
with the
conclusion
Clinician
unsure or
agrees partly
Reducible disc n 220 74% 5% 19%
Partly reducible disc n 224 69% 11% 18%
Irreducible disc n 60 42% 27% 30%
Non-mechanical disc n 2 50% 50% 0%
Nerve root compression n 10 70% 0% 10%
Postural syndrome n 8 38% 25% 38%
SI-joint pain n 75 83% 1% 12%
Dysfunction n 98 64% 9% 23%
Adherent nerve root n 2 50% 0% 50%
Facet joint pain n 127 83% 2% 13%
Spinal stenosis n 3 67% 0% 33%
Myofascial pain n 42 38% 26% 24%
Adverse neural tension n 2 0% 0% 100%
Inconclusive n 50 12% 36% 40%
Because of missing responses regarding agreement not all rows sum to 100%.
H. Eirikstoft, A. Kongsted / Manual Therapy 19 (2014) 65e71 69
was available, and were therefore not included. It is our impression
that lack of time was the main reason for not inviting a potential
participant to become involved in the study, and we do not suspect
that this inuenced the representativeness of the cohort.
In conclusion, LBP patients could be classied according to a
predened classication system on their rst visit to a chiro-
practor. However, chiropractors often stated that they disagreed
with the classication and this should be considered if future
research suggests that the classication be implemented in
practice. It is questionable whether diagnostic classes with such
small differences in patient characteristics are of any relevance.
Our results imply that this classication system would most
likely not be an adequate description of patients in chiropractic
care, but it is possible that it results in biological entities that
would be relevant in combination with psychological and social
factors.
The next step needed is to investigate the predictive value of the
system, its usefulness in the identication of patients who respond
to certain interventions, and its potential moderating effect on
psychological and social factors.
Acknowledgements
The Danish Chiropractic Fund nanced the data collection and
AKs salary. The McKenzie Institute Denmark and The Danish Phys-
iotherapist Association provided nancial support for HEs salary.
We would like to thank the data collecting chiropractic clinics and
research assistants Jytte Johannesen and Orla Lund Nielsen.
Appendix A. Summary of the denitions of diagnostic classes.
Diagnostic class Denition
Reducible disc* LBP leg pain
Min. 1 painful movement direction, and
Centralisation present (pain can move from one body region to another)
Partly reducible disc LBP leg pain
Pain tends to centralise but
B Does not move from one region to another, or
B Pain relief is not completely sustained, or
B Local back pain is reduced but not abolished
Irreducible disc* LBP leg pain
Min. 1 painful movement direction, and
No centralisation, and
Peripheralisation or increased pain with at least one movement direction
Non-mechanical disc* LBP leg pain
Criteria for other disc types not met, and
pain gets worse after test of all movement directions, and
No centralisation, and
At least one of:
Dominating pain above S1
Acute lateral shift
Symptoms move from one side to the other when testing lateral glide or rotation
Nerve root compression Leg pain worse than LBP
Positive straight leg raise (SLR) test or Reverse SLR, and
Reduced muscle strength or impaired tendon reex
Spinal stenosis Criteria for disc or nerve root not met
Symptoms improved with sitting or walking distance increased with lumbar exion, and
Best position is sitting or worst position is standing/walking
Sacroiliac-joint syndrome LBP leg pain
Does not meet criteria for disc or nerve root, and
Min. any 3 of 5 SI-joint pain provocation tests positive
SI tests: compression, distraction, sacral thrust, Gaenslen test, thigh thrust
Dysfunction syndrome* LBP pain
Does not meet criteria for disc or nerve root, and
Min. one movement direction restricted, and
Pain is ONLY present at end-range of the restricted movement, and
No change in symptoms following testing
Postural syndrome* LBP
Pain only present with static loading, and
Normal range of motion, and
No pain with movement tests, and
Sustained static loading provokes well-known pain
Facet joint syndrome LBP
Does not meet criteria for any of the above mentioned, and
Pain with combined extension/rotation, and
at least two of:
Best position is sitting
Best activity is walking
Pain started in one side (lateral to the midline)
Age >50 years
H. Eirikstoft, A. Kongsted / Manual Therapy 19 (2014) 65e71 70
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(continued)
Diagnostic class Denition
Adverse neural tension (ANT) LBP leg pain
Only used as primary diagnostic class if criteria for the above-mentioned are not met
Positive test for abnormal nerve tension
Pain only present when stretching the painful tissue
Myofascial pain LBP leg pain
Only used as primary diagnostic class if criteria for the above-mentioned other than ANT are not met
Well-known pain is provoked by palpation of a tender muscle spot
Abnormal pain syndrome Only used as primary diagnostic class if criteria for other classes are not met
At least 3 of:
Widespread soreness
LBP with axial compression or simulated rotation
SLR improved when patient is distracted
Reduced muscle strength or sensation in a non-anatomical pattern
Vigorous pain reaction when examined
Inconclusive Non-specic low back pain patients not included in any of the above listed classes
*Reducible disc, irreducible disc and non-mechanical disc were dened the same way as derangement classes in to the Mechanical Diagnosis and Therapy classication
(McKenzie and May, 2003), dysfunction syndrome and postural syndrome were adopted directly from the said classication system.
H. Eirikstoft, A. Kongsted / Manual Therapy 19 (2014) 65e71 71