Professional issue Low back pain misdiagnosis or missed diagnosis: Core principles A.P. Monie * , P.J. Fazey, K.P. Singer Centre for Musculoskeletal Studies, School of Surgery, The University of Western Australia, Perth, Western Australia 6009, Australia article info Article history: Received 22 August 2015 Received in revised form 21 September 2015 Accepted 9 October 2015 Keywords: Lumbar spine Low back pain Assessment Guidelines abstract Consensus guidelines for the management of low back pain recommend that the clinician use contemporary best practice for assessment and treatment, consider biopsychosocial factors and, if chronic, use a multimodal and multi-disciplinary approach. Where guidelines are not followed and basic assessment is inadequate the diagnosis may be compromised and the sequelae of errors compounded. Factors such as a lack of knowledge or recognition of the common structure specific pain referral pat- terns, poor clinical reasoning, inappropriate referral and predilection for popular management ap- proaches also contribute to mis-diagnosis and mis-management. This report describes two cases of chronic low back pain with lengthy histories of multiple failed interventions to highlight the conse- quences of focussing on a singular approach to the exclusion of evidence based pathways and the resulting risk of a missed diagnosis. The eventual management to mitigate these problems is reported with the aid of low back pain outcome measures, computer-aided combined movement examination, disability and pain questionnaires and health quality of life surveys. © 2015 Elsevier Ltd. All rights reserved. 1. Introduction Low back pain (LBP) is a major public health system problem, being one of the five most common reasons for physician consul- tation, with a lifetime prevalence as high as 85% (Joud et al., 2012). Chronic low back pain (CLBP) often includes psychological factors, such as higher than usual levels of stress, depression and/or anxi- ety, with the potential for fear-avoidance and catastrophising be- haviours (Besen et al., 2015; Deyo, 2015). Furthermore, social factors involving relationships, family, work and navigating the medico-legal system, may amplify or prolong pain (Deyo, 2015). Minimum clinical assessment of LBP includes obtaining a medical history and a physical examination (NHMRC, 2004; SAH, 2011). Physical examination incorporates a movement assessment which can include a multi-planar combined movement examina- tion (CME) (Edwards, 1979; Barrett et al., 1999), soft tissue palpa- tion, passive movement examination and neurological screening if implicated. Together, the history and physical assessment should result in a provisional diagnosis (Grieve, 1988). Progressing to treatment without a thorough assessment or without correlating symptoms with examination findings, increases the prospect of misdiagnosis and mismanagement. Where indicated, focussed spine imaging assists with diagnosis and staging interventions (Deyo et al., 2014). Where the condition is complex, not responding to treatment, or where symptoms masquerade as more sinister pathology (Greenhalgh and Selfe, 2015), referral to appropriate health professionals is encouraged. A wide variety of approaches are recommended for treatment of LBP, ranging from passive manual therapy (Maitland, Mulligan, manipulative therapy) to active management (general exercise, Pilates, hydrotherapy, changes to workplace and sleeping habits) and those with a focal psychosocial component (cognitive behav- ioural therapy) (Beck, 2011). Jull and Moore (2012) advocate finding the balance which optimises a multimodal approach and the outcome. In recent years there has been much focus on the psychosocial component of LBP and graded movement rehabilitation (O'Sullivan and Lin, 2014; Deyo, 2015; O'Sullivan et al., 2015). This emphasis risks compromising the importance of assessing fundamental pathoanatomical sources of LBP (Hancock et al., 2011). Additionally, Moore and Jull (2000) remind clinicians to select an appropriate approach based on clinical guidelines. “With our enthusiasm for new trends to seem smart and stylish in our therapeutic practice, we must be careful that we don't fall into the trap of not adhering to recognised and established practices” (Moore and Jull, 2000:197). * Corresponding author. Centre for Musculoskeletal Studies, School of Surgery M424, The University of Western Australia, 35 Stirling Highway, Nedlands, WA 6009, Australia. Tel.: þ61 8 9313 3999. E-mail address: aubrey.monie@research.uwa.edu.au (A.P. Monie). Contents lists available at ScienceDirect Manual Therapy journal homepage: www.elsevier.com/math http://dx.doi.org/10.1016/j.math.2015.10.003 1356-689X/© 2015 Elsevier Ltd. All rights reserved. Manual Therapy xxx (2015) 1e4 Please cite this article in press as: Monie AP, et al., Low back pain misdiagnosis or missed diagnosis: Core principles, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.10.003