Treatment-Based Classification System for Low Back Pain ...

Treatment-Based ClassificationSystem for Low Back Pain:Revision and UpdateMuhammad Alrwaily, Michael Timko, Michael Schneider, Joel Stevans,Christopher Bise, Karthik Hariharan, Anthony Delitto

The treatment-based classification (TBC) system for the treatment of patients with low backpain (LBP) has been in use by clinicians since 1995. This perspective article describes how theTBC was updated by maintaining its strengths, addressing its limitations, and incorporatingrecent research developments. The current update of the TBC has 2 levels of triage: (1) thelevel of the first-contact health care provider and (2) the level of the rehabilitation provider. Atthe level of first-contact health care provider, the purpose of the triage is to determine whetherthe patient is an appropriate candidate for rehabilitation, either by ruling out serious pathol-ogies and serious comorbidities or by determining whether the patient is appropriate forself-care management. At the level of the rehabilitation provider, the purpose of the triage isto determine the most appropriate rehabilitation approach given the patient’s clinical presen-tation. Three rehabilitation approaches are described. A symptom modulation approach isdescribed for patients with a recent—new or recurrent—LBP episode that has caused signif-icant symptomatic features. A movement control approach is described for patients withmoderate pain and disability status. A function optimization approach is described for patientswith low pain and disability status. This perspective article emphasizes that psychological andcomorbid status should be assessed and addressed in each patient. This updated TBC is linkedto the American Physical Therapy Association’s clinical practice guidelines for low back pain.

M. Alrwaily, PT, MS, PhD, Depart-ment of Physical Therapy, Schoolof Health and Rehabilitation Sci-ences, University of Pittsburgh,Bridgeside Point 1, 100 Technol-ogy Dr, Ste 470, Pittsburgh, PA15219 (USA), and Department ofPhysical Therapy, King Fahad Spe-cialist Hospital, Dammam, SaudiArabia. Address all correspon-dence to Dr Alrwaily at:[email protected].

M. Timko, PT, MS, FAAOMPT,Department of Physical Therapy,School of Health and Rehabilita-tion Sciences, University of Pitts-burgh, and Division of PhysicalTherapy, School of Medicine,West Virginia University, Morgan-town, West Virginia.

M. Schneider, DC, PhD, Depart-ment of Physical Therapy, Schoolof Health and Rehabilitation Sci-ences, University of Pittsburgh.

J. Stevans, DC, Department ofPhysical Therapy, School of Healthand Rehabilitation Sciences, Uni-versity of Pittsburgh.

C. Bise, PT, MS, DPT, OCS,Department of Physical Therapy,School of Health and Rehabilita-tion Sciences, University ofPittsburgh.

K. Hariharan, PT, MS, Departmentof Physical Therapy, School ofHealth and Rehabilitation Sci-ences, University of Pittsburgh.

A. Delitto, PT, PhD, FAPTA,Department of Physical Therapy,School of Health and Rehabilita-tion Sciences, University ofPittsburgh.

[Alrwaily M, Timko M, SchneiderM, et al. Treatment-based classifi-cation system for low back pain:revision and update. Phys Ther.2016;96:1057–1066.]

© 2016 American Physical TherapyAssociation

Published Ahead of Print:December 4, 2015

Accepted: November 22, 2015Submitted: June 18, 2015

Perspective

Post a Rapid Response tothis article at:ptjournal.apta.org

July 2016 Volume 96 Number 7 Physical Therapy f 1057

Dow

nloaded from https://academ

ic.oup.com/ptj/article-abstract/96/7/1057/2864925 by U

NIVER

SITY OF PITTSBU

RG

H user on 19 February 2019

Despite the plethora of researchon low back pain (LBP), clinicaltrials have not provided conclu-

sive evidence supporting the superiorityof any particular intervention.1,2 This gapis often attributed to the fact that thedesign of most clinical trials includesdelivery of a single intervention to a het-erogeneous group of patients with LBP.This heterogeneity, combined with wideinclusion criteria, tends to dilute thetreatment effect. In order to optimize thetreatment effect, patients with LBPshould be classified into homogeneoussubgroups and matched to a specifictreatment. Subgroup-matched treatmentapproaches have been shown to result inimproved outcomes compared withnonmatched alternative methods.3–6

Designing studies that incorporatesubgroup-matched treatments into LBPclassification systems has become aresearch priority.7

In the field of physical therapy, there are4 primary LBP classification systems thatattempt to match treatments to sub-groups of patients using a clinicallydriven decision-making process: (1) themechanical diagnosis and therapy classi-fication model described by McKenzie,8

(2) the movement system impairmentsyndromes model described bySahrmann,9 (3) the mechanism-basedclassification system described byO’Sullivan,10 and (4) the treatment-basedclassification (TBC) system described byDelitto et al.11 All of these systems havemade significant contributions inimproving clinicians’ ability to recognizepatterns of signs and symptoms inpatients with LBP and match them withrespective treatments. Yet, these sys-tems—without exception—have 4 mainshortcomings:

1. No single system is comprehensiveenough in considering the variousclinical presentations of patients withLBP or how to account for changes inthe patient’s status during an episodeof care.

2. Each system has some elements thatare difficult to implement clinicallybecause they require expert under-standing in order to be utilizedefficiently.

3. None of these classification systemsconsider the possibility that somepatients with LBP do not require anymedical or rehabilitation interventionand are amenable for self-caremanagement.

4. The degree to which the psychosocialfactors are considered varies greatlyamong these systems, which runscontrary to the clinical practice guide-lines established by the AmericanPhysical Therapy Association (APTA)that advocate using the bio-psychosocial model as a basis forclassification.12

These shortcomings are likely to be over-come as our understanding of the factorsthat drive LBP improves. We are likely tosee more convergence than divergenceamong the 4 systems.

In this article, we focus on the TBC sys-tem described by Delitto et al.11 The TBCis the most extensively researched clas-sification system in the field of physicaltherapy, with more than 16 articlesinvestigating its usefulness as a guide forclinical decision making.13 Since its pub-lication in 1995, the TBC has passedthrough phases of development thatwere largely based on emerging evi-dence. At each phase, the TBC had dif-ferent strengths and limitations. The pur-pose of this article is to review thosestrengths and limitations and use currentevidence to update the TBC approach.Specifically, the update of the TBC willtake into consideration the followingpoints:

• Recognition that the initial triageprocess includes all health care pro-viders who come in first contactwith patients with LBP.

• Establishing decision-making crite-ria for the first-contact practitionerto triage patients into 1 of 3approaches: medical management,rehabilitation management, andself-care management (Fig. 1).

• Utilizing risk stratification and psy-chosocial tools to determine whichpatients require psychologicallyinformed rehabilitation.

• Updating decision-making criteriafor the triage process by rehabilita-tion providers to determine the

most appropriate rehabilitationapproach (Table, Fig. 1).

• Linking the components of the TBCto the APTA clinical practice guide-lines for LBP.

• Proposing a course of actionaddressing the limitations of theprevious versions of TBC, includingthe development of a novel neuro-muscular assessment, prioritizinginterventions, and identifying aresearch agenda.

TBC System—1995The original TBC system was created in1995 by a panel of experts with the pur-pose of describing a classification systemthat specifically directed conservativemanagement to patients with LBP.11 The1995 TBC system was designed, in part,to be analyzed critically and serve as thebasis for scientific inquiry. This systemrepresented the initial phase ofdevelopment.

The 1995 TBC system had 3 levels ofclassification (Fig. 2). Level 1 classifiedthe patient into 3 groups: (1) patientswho could not be managed by physicaltherapy and needed to be referred formedical management because of greatsuspicion of serious pathology, (2)patients who could be managed by phys-ical therapy but required consultationwith another health care practitionerbecause of presence of chronic comor-bidity or “magnified illness behavior,”and (3) patients who could be indepen-dently managed by physical therapy.

Level 2 was for patients deemed appro-priate for independent physical therapy.Level 2 classified such patients into 3stages, each of which had specific inter-ventions that were appropriate for thepatient’s status. Stage I was for patientswith severe pain and disability status; thegoal of the intervention was symptommodulation. Stage II was for patientswhose pain was not too severe but inter-fered with their activities of daily living;the goals of the treatment were resolu-tion of residual symptoms and improve-ment of physical function to enhance theperformance of activities of daily living.Stage III was for patients who were rel-atively asymptomatic and could performstandard activities of daily living, but

Treatment-Based Classification System for LBP

1058 f Physical Therapy Volume 96 Number 7 July 2016

Dow



NIVER

SITY OF PITTSBU

RG


needed to return to higher levels of phys-ical function; the goal of the treatmentwas to improve the patient’s ability toperform higher levels of physical func-tion without symptoms exacerbation.

Level 3 classified patients into syndromesembedded within each stage. Each syn-drome was named after the interventionthat the patient was going to receive (eg,mobilization syndrome, traction syn-drome). To assign a patient to a particu-lar intervention, a thorough physicalexamination was conducted to identifythe treatment that would be best

matched to the patient’s clinicalpresentation.

Several strengths could be ascribed tothe 1995 TBC system. At level 1, the TBCconsidered a process of patients triagingupon first contact to screen for “redflags” in direct access physical therapyclinics. Also, the 1995 TBC consideredassessment of psychosocial factors usingWaddell’s signs and symptoms of “mag-nified illness behavior,”14 which werethe best available evidence to assesspsychosocial factors at that time.

At level 2, the TBC described the stagingprocess, which was the hallmarkstrength of the system because the TBCdevelopers recognized that using num-ber of days since onset was not useful inguiding treatment matching. Therefore,the TBC developers described the stag-ing process to prescribe interventionsaccording to the patient’s pain intensityand disability status rather than relyingon arbitrary definitions of acute, sub-acute, and chronic LBP based on timeduration alone.

Figure 1.Updated 2015 treatment-based classification system. * Regardless of approach, patients with a medium-to-high psychological risk profilerequire psychologically informed rehabilitation. † The rehabilitation provider also may function as the first-contact health care provider.‡ Rehabilitation must be modified appropriately to account for a patient’s comorbid status.



Dow



NIVER

SITY OF PITTSBU

RG


Level 3 was the level at which thepatient’s signs and symptoms werematched to specific interventions. Inter-ventions at this level targeted a widearray of patients with LBP along the spec-trum of pain and disability status. Theinterventions were not confined to a spe-cific concept; rather, they were open toother schools of thought.

Despite the strengths of the 1995 TBC, anumber of limitations could be identi-fied. At level 1, when psychosocial fac-tors were identified, there was no spe-cific suggestion of how to address thesefactors other than consultation withanother health care provider.

At level 2, the TBC was somewhat ambig-uous in describing the conceptual terms“levels,” “stages,” and “classification.”This lack of clearly defined terms anddecision-making variables confusedsome readers and led to misinterpreta-tion of stage I, stage II, and stageIII as acute, subacute, and chronic,respectively.

At level 3, one limitation was that thephysical examination was largely basedon findings related to the patient’s staticalignment or response to tissue loadingtests, which could guide the treatmentfor patients in stage I, whose statusrequired symptom modulation, but were

not helpful in guiding the treatment forpatients in stages II and III, whose statuswas related to the movement systemimpairments. As a result, the interven-tions in the 1995 TBC were exclusivelydesigned to be matched with “syn-dromes” for stage I only and never fullydeveloped for stage II or III.

Another limitation at level 3 was confu-sion over the “immobilization” syn-drome. The immobilization syndromewas intended for patients with hyper-acute LBP that was irritable (ie, pain caneasily be provoked with minor lumbarspine movements) and still in the inflam-matory phase. For such patients, immo-bilization meant limiting the patient’smovements until the irritability andinflammation subsided. Unfortunately,“immobilization” was also the same termused to describe patients with signs andsymptoms of “instability” that was aggra-vated with end-range movements. Forpatients with instability, immobilizationmeant limiting their end-range move-ments by the use of stabilization exer-cises. To resolve this confusion, the term“immobilization” for patients with insta-bility was replaced with the term “stabi-lization.” However, the term “stabiliza-tion” erroneously crept in as one of theprimary interventions embedded in stageI, and many clinicians forgot about the

concept of “rest from function” as a strat-egy for managing the hyperacute LBP.

The 1995 TBC was a classification frame-work based largely on clinical observa-tions with minimal research to substan-tiate its theoretical basis. However, the1995 TBC set the stage for a new era ofresearch in the years following itspublication.

TBC System—2007A revision of the TBC was published in2007 by Fritz et al15 with the purpose ofupdating the 1995 TBC with the latestevidence that emerged between 1995and 2007. This revision and update rep-resented the second phase ofdevelopment.

The major strength of the 2007 TBC wasthat it was much more evidence-based.The 2007 TBC incorporated evidencefrom clinical trials that showed thatmatching patients with treatment usingthe TBC principles resulted in improvedclinical outcomes compared with alter-native methods.3,4 The 2007 TBCincluded evidence from a single random-ized controlled trial that showed that theuse of a clinical prediction rule forpatients likely to respond to manipula-tion led to improved clinical outcomes.6

Additionally, the 2007 TBC incorporatedpreliminary criteria for patients likely to

Table.Triage Process and Matching Criteria for the Rehabilitation Provider

Rehabilitation ApproachSymptom

Modulation Movement Control Functional Optimization

Classification Variablesa Pain rating High to moderate Moderate to low Low to absent

Disability ratingb High Medium Low

Clinical statusc Volatile: symptomspredominate

Stable: movementimpairmentspredominate

Well-controlled: performancedeficits predominate

Treatment ModifyingVariables

Psychosocial statusd �/� �/� �/�

Comorbiditiese �/� �/� �/�

a When the classification variables do not agree, we recommend relying on disability rating to match the patient with the treatment approach. Thisjudgment should be aided by the patient’s clinical status.b Disability can be assessed with any outcome measure of disability (eg, Modified Oswestry Disability Questionnaire, Roland-Morris Disability Questionnaire).c “Volatile” means that the patient’s clinical status can easily be aggravated, the patient is highly irritable (ie, minor lumbar spine movements easily provokepain), and occasionally the patient’s presentation does not permit physical examination. “Stable” means that the patient’s clinical status can increase withcertain movements, postures, or tests but return to baseline level relatively quickly. “Well-controlled” means that the patient’s clinical status is asymptomaticmost of the time but can be aggravated when performance demands are increased.d Psychosocial status can be assessed using self-report measures (eg, Fear-Avoidance Behavior Questionnaire, STarT Back Tool). Plus sign (�) means thepatient needs psychologically informed rehabilitation because of higher risk of developing poor treatment outcome. Minus sign (�) means the patient doesnot need psychologically informed rehabilitation because of no concern about developing poor treatment outcome.e Comorbidities (eTab. 3) can be present, along with low back pain. Plus sign (�) means the patient needs to receive medical co-management for existingcomorbidities besides rehabilitation care. Minus sign (�) means the patient does not need medical co-management.



Dow



NIVER

SITY OF PITTSBU

RG


http://ptjournal.apta.org/content/96/7/1057/suppl/DC1

benefit from stabilization exercises16 andupdated the matching criteria forpatients likely to improve with direc-tional preference exercises.15 Further-more, the 2007 TBC replaced Waddell’ssigns and symptoms of magnified illnessbehavior with the use of Fear-AvoidanceBeliefs Questionnaire.14 This question-naire was one of the criteria to considerin matching and predicting a patient’sresponse to an intervention.6,16

However, a number of limitations couldbe noted regarding the 2007 TBC. First,the 2007 TBC did not contain any spe-cific recommendations for how clini-cians could manage patients with highpsychosocial distress.

Second, the 2007 TBC removed the level2 staging decision from the clinicaldecision-making process,17 whichshifted the focus away from the widearray of interventions listed in the 1995TBC article for improvement in func-tional activities of daily living (stage II)and high physical performance (stageIII). This removal resulted in a categorybroadly defined as “stabilization”exercises.

Third, the 2007 TBC criteria that weresuggested to match a patient with a spe-cific treatment did not always aid inmatching.18 When the criteria could notmatch the patient to manipulation, spe-cific exercises, or traction, the patientwas matched with stabilization exer-cises. As a result, the stabilization exer-cises subgroup became, in and of itself, acomposite of heterogeneous patientswith various signs and symptoms.

Fourth, the criteria did not consider def-icits in muscle performance or motorcontrol when matching patients to treat-ments. When patients with such deficitswere assessed using the 2007 algorithm,they either were erroneously matched tostabilization exercises subgroup orremained unclassified.19

Finally, the 2007 TBC criteria did notensure that patients are matched only toa single intervention, but rather 25% ofthe patients could satisfy the criteria formore than one subgroup.18 This overlappointed to the importance of creating a

hierarchical algorithm that prioritizestreatments based on clinical findings andallows for change within an episode ofcare.

The 2007 TBC produced an algorithmthat was clinically applicable, but thedevelopers were aware that the systemhad its limitations and foresaw that it waslikely going to change. Fritz et al statedthat “the process of developing a classi-fication system is dynamic, and it is likelythat future modification [to the TBC] willinevitably be made.”15(p299) Therefore,the 2007 TBC algorithm should be

revised to incorporate the latest develop-ments, optimize its comprehensiveness,refine current criteria, and explore addi-tional treatments.18

TBC System—2015This update of the 1995 TBC system rep-resents the third phase of development,which we believe is timely because ofmany advances in the way care is deliv-ered to patients with LBP. New researchhas improved our ability to predict therisk of patients with LBP developingpoor treatment outcomes and subse-quently prescribe interventions that bet-

Figure 2.The 1995 treatment-based classification system. Level 1 clinical decision classifies patientsinto 3 groups: (1) patients who cannot be managed by physical therapy and need to bereferred for medical management because of great suspicion of serious pathology, (2)patients who may be managed by physical therapy but require consultation with anotherhealth care practitioner because of presence of chronic comorbidity or magnified illnessbehavior, and patients who can be managed independently by physical therapy. Level 2 is forpatients who are determined appropriate for independent physical therapy. The level 2clinical decision classifies such patients into 3 stages: (1) stage I is for patients with severe painand disability status; the goal of the interventions is symptom modulation; (2) stage II is forpatients whose pain is not too severe but interferes with their activities of daily living; the goalof the treatment is improving muscle impairments to perform activities of daily living; and (3)stage III is for patients who are relatively asymptomatic and can perform standard activitiesof daily living but need to return to higher levels of physical function; the goal of thetreatment is to improve the patient’s ability to perform higher levels of physical functionwithout symptoms exacerbation. The level 3 clinical decision classifies patients into syn-dromes embedded within each stage.



Dow



NIVER

SITY OF PITTSBU

RG


ter match the identified risk level.20 Also,psychosocial factors have beendescribed in the literature, and the reha-bilitation provider’s competency inaddressing them has been reported.21

Additionally, various pain mechanismsthat can underlie LBP have beenhighlighted.22,23

These advancements have beendescribed in the APTA clinical practiceguidelines for LBP.12 These guidelines, inpart, attempt to establish a common diag-nostic language, as well as publishevidence-based principles for cliniciansand researchers. However, the guide-lines’ recommendations have not beenwidely adopted by existing classificationsystems for LBP. Therefore, we are pro-posing a format that allows for the incor-poration of the guidelines’ recommenda-tions into the 2015 TBC, which willprovide a process by which the recom-mendations can be used efficiently in theclinical decision-making process forpatients with LBP. We believe thatlinking these recommendations to the2015 TBC also might guide researchersto new areas of investigation and directclinicians to new patient managementstrategies (eTab. 1, available atptjournal.apta.org).

The improvements on the TBC will bediscussed in detail in a series of upcom-ing articles. In this article, we present anoverview of the most recently updatedTBC algorithm.

Overview of the UpdatedTBC Algorithm—2015The 2015 TBC algorithm proposes 2 lev-els of triage: one at the level of the first-contact health care provider and anotherat the level of the rehabilitation provider(Fig. 1). At the level of the first-contacthealth care provider, the triage can beassumed by any practitioner competentin LBP care, regardless of his or her pro-fessional background (ie, primary carephysician, nurse practitioner, physicaltherapist, chiropractor). This individual’sresponsibility is to determine the appro-priate approach of management. At thelevel of the rehabilitation provider, thepurpose of the triage is to determinewhich rehabilitation approach is appro-

priate for the patient and what factorsmay affect the treatment.

Triage at the Level of the First-Contact Health Care ProviderUpon initial contact, patients with LBPshould be triaged using 1 of 3 approach-es: medical management, rehabilitationmanagement, or self-care management.Patients requiring medical managementare those with red flags of serious pathol-ogy (eg, fracture, cancer) or seriouscomorbidities that do not respond tostandard rehabilitation management (eg,rheumatoid arthritis, central sensitiza-tion). Serious pathologies can mimicnonspecific mechanical LBP and shouldbe ruled out upon initial assessment.24

Red flags are best investigated in clustersof signs and symptoms,25 with eachcluster denoting the presence of a par-ticular pathology (eTab. 2, available atptjournal.apta.org).

Central sensitization is a condition thatwill require careful attention (eTab. 2).Central sensitization has been defined asan altered mechanism of pain processingwithin the central nervous system (ie,enhanced synaptic excitability, lowerthreshold of activation, and expansion ofthe receptive fields of nociceptiveinput).26 In this condition, the pain ini-tially may have been caused by a periph-eral pain generator, but now the pain haslasted beyond the normal healing time(ie, chronic pain).23 The pain distribu-tion is widespread and does not followan anatomical pattern. The pain also caneasily be provoked with low-intensitystimuli that would not normally generatepain (eg, light touch). A key feature ofthis pain is the disproportionate mechan-ical provocation patterns in response toclinical examination.27

Central sensitization has a strong associ-ation with psychological factors such asnegative beliefs, pathological anxiety ordepression, and poor coping strategies.When such factors are present with theaforementioned features of central sensi-tization, the patient is unlikely to benefitfrom standard rehabilitation includingthe principles of the TBC. These patientsrequire a multidisciplinary approach topain management, including pharmaco-

logical intervention, psychotherapy, andspecialized rehabilitation.

Comorbidities can be present along withmechanical LBP28 and should be investi-gated upon initial assessment as well(eTab. 3, available at ptjournal.apta.org).24 Comorbidities have beenlinked to increased health care utiliza-tion, higher costs, and poor treatmentoutcome.28–30 Comorbidities, physical orpsychological, can be identified using amedical screening questionnaire pluspatient report. When comorbidities arefound in association with mechanicalLBP, medical co-management (eg, phar-macotherapy) may become necessary inorder to achieve optimal rehabilitationoutcomes.

Patients who do not have serious pathol-ogies are appropriate for either rehabili-tation or self-care management. Patientsamenable to self-care management arethose who are unlikely to develop dis-abling LBP during the course of the cur-rent episode. Such patients can be iden-tified using risk profiling instrumentssuch as the STarT Back Tool,31 OrebroMusculoskeletal Pain Questionnaire,32 orsimilar self-report questionnaires. Thesepatients have low levels of psychosocialdistress, no or controlled comorbidities,and normal neurological status. Theymay be treated with patient educationthat consists of reassurance about thegenerally favorable prognosis for acuteLBP and advice about medication, work,and activity.20

Patients who are appropriate for rehabil-itation management are the remainingmajority, as serious pathology is very rareamong patients with LBP,33 and patientsamenable to self-care management repre-sent a small portion of patients with LBPseen in primary care clinics.20 Webelieve the majority of patients should bereferred quickly to a well-trained rehabil-itation provider. This triaging process ofthe first-contact health care provider isrecapitulated in Figure 3.

Triage at the Level ofRehabilitation ProviderIn some situations, the rehabilitation pro-vider could be the first-contact healthcare provider. In that case, the rehabili-



Dow



NIVER

SITY OF PITTSBU

RG



http://ptjournal.apta.org







tation provider would initially triage thepatient in the same way outlined above.When the triage determines that thepatient is appropriate for rehabilitationmanagement, the rehabilitation providershould continue to match the patientwith 1 of the 3 rehabilitation approachesshown in Figure 1 and described below.

In other situations, the rehabilitation pro-vider may receive patients with LBP via areferral from another health care pro-vider. In that case, we recommend that

rehabilitation providers be watchful forred flags that might have been over-looked by the referring health care pro-vider. Also, the rehabilitation providershould attempt to determine whetherthe patient has any physical or psycho-logical comorbidities that might necessi-tate medical co-management. Also, therehabilitation provider should evaluatethe psychosocial status of the patient todetermine whether a psychologicallyinformed rehabilitation is necessary.

The next step in the triage process of therehabilitation provider is matching thepatient’s clinical status to 1 of 3 rehabil-itation approaches: symptom modula-tion, movement control, or functionaloptimization (Fig. 1). Matching thepatient to each approach relies on theassessment of pain intensity, disabilitystatus, and perception of clinical status.Also, the matching must consider find-ings related to the patient’s comorbidand psychosocial status (Table). Thisapproach is supported by the APTA clin-ical practice guidelines for LBP,12 andconsistent with the research standards ofthe National Institutes of Health taskforce for LBP.34

Depending on the approach to whichthe patient is matched, the rehabilitationprovider should plan the appropriatephysical examination. Patients matchedto the symptom modulation approachshould be assessed using a physicalexamination that elicits symptom modu-lation behavior (eg, centralization,peripheralization). Patients matched tothe movement control approach shouldbe assessed using a physical examinationthat identifies impairments in movementpatterns. Patients matched to the func-tional optimization approach should beassessed using a physical examinationthat accounts for the unique functionaldemands of a specific job or sport.

Symptoms modulation approach.A symptom modulation approach ismatched to patients with recent—newor recurrent—LBP episode that is cur-rently causing significant symptomaticfeatures (Table). Because their clinicalstatus is volatile, these patients tend toavoid certain postures; active range ofmotion is limited and painful. The neu-rological examination can revealincreased sensitivity. These patientsneed interventions that modulate theirsymptoms. In this group, patients aretreated mainly with manual therapy,directional preference exercises, trac-tion, or immobilization.

Movement control approach. Amovement control approach is matchedto patients who have low-to-moderatelevels of pain and disability that interferewith their activities of daily living

Figure 3.Low back pain triage process for the first-contact health care provider. Central sensitizationis one of the comorbidities associated with widespread pain that is disproportionate toprovocative mechanical testing (eTab. 2). This condition is strongly associated with elevatedpsychological distress. Patients with central sensitization should receive medical manage-ment that includes pharmacotherapy and psychotherapy, as well as specialized rehabilita-tion. Patients at high psychological risk (eg, pain catastrophizing, fear of movement, anxiety,and depression) should receive psychologically informed rehabilitation.



Dow



NIVER

SITY OF PITTSBU

RG



(Table). The patient’s status tends to bestable; that is, the patient describes a lowbaseline level of pain that increases bydoing certain daily activities; however,the pain returns to its low-level baselineas soon as the patient ceases the activity.Other patients may describe recurrentattacks of LBP that are aggravated withsudden or unexpected movement, butcurrently they are asymptomatic or inremission. The patient’s active spinalmovements are typically full but may beaccompanied by aberrant movements.The physical examination can revealfindings of impaired flexibility, muscleactivation, and motor control. Thesepatients need interventions to improvethe quality of their movement system.For this group, the treatment in the 2007TBC system mainly relied on stabilizationexercises.16,35 In this updated 2015 TBC,however, we believe that stabilizationexercises must be better defined, andother treatments need to be explored.

Functional optimization approach.A functional optimization intervention isfor patients who are relatively asymp-tomatic; they can perform activities ofdaily living but need to return to higherlevels of physical activities (eg, sport,job). The patient’s status is well con-trolled (Table); that is, the pain is aggra-vated only by movement system fatigue.These patients may not have flexibility orcontrol deficits, but they have impair-ments in movement system endurance,strength, and power that do not meettheir physical demands.36 These patientsneed interventions that maximize theirphysical performance for higher levels ofphysical activities. For this group, thetreatment should optimize the patient’s

performance within the context of a jobor sport.

Considerations Related to theRehabilitation ApproachesThe 3 rehabilitation approaches aremutually exclusive; however, patientscan always be reclassified to receive adifferent rehabilitation approach as theirclinical status changes (Fig. 1). For exam-ple, a patient who initially receives amovement control approach due to mod-erate levels of pain and disability can bereclassified to receive a functional opti-mization approach if his or her statusimproves to low pain and disability sta-tus, or the patient can be reclassified toreceive a symptoms modulationapproach if his or her status suddenlyworsens. Alternatively, a patient can bedischarged at any point when rehabilita-tion goals are attained.

It should be noted that, within each ofthe 3 rehabilitation approaches, a patientmight fit the criteria of 2 or more treat-ment options, which requires prioritiza-tion of treatment. For example, in thesymptom modulation approach, apatient may satisfy the criteria for manip-ulation and extension exercises asshown by Stanton et al.18 In that case,extension exercises take priority overmanipulation. Extension exercisesshould be the treatment of choice untilthe patient’s status plateaus. At thatmoment, manipulation may ensue(Fig. 4). Similarly, in the movement con-trol approach, a patient may have motorcontrol impairment and reduced muscleperformance. In that case, motor controldeficit takes priority over the muscle

reduced performance. When the controldeficit is corrected, muscle performancetraining can ensue (Fig. 5). This methodof prioritization process is largely basedon common clinical sense, warrants fur-ther research, and will be described infuture articles.

To achieve optimal treatment outcomes,it is not enough to only match patientsbased on the above 3 rehabilitationapproaches, but matching also shouldconsider the patient’s psychosocial sta-tus and concurrent comorbiditiesbecause they can weaken the treatmenteffect (Table). When psychosocial fac-tors are high, the rehabilitation providershould educate the patient about paintheory, muscle relaxation techniques,sleep hygiene, and coping skills andaddress catastrophizing about pain anddiagnostic findings. When medicalcomorbidities are identified, medicalco-management is necessary.

Conclusion and FutureDirectionsWe reviewed the phases of developmentof the original 1995 TBC and the subse-quent revisions that were published in2007. We have presented an updatedversion of the TBC, maintaining its pre-viously developed strengths and improv-ing upon its limitations. In this updatedTBC, we recommend a 2-level triage pro-cess: (1) initial triage by a first-contacthealth care provider (regardless of pro-fession) to determine which patients areamenable to rehabilitation and (2) sec-ondary triage by a rehabilitation providerto determine the most appropriate reha-bilitation approach. The initial triage pro-cess now recognizes 2 types of patients

Figure 4.Example of hierarchical exercise progression for patients matched to symptom modulation approach. Patients who need the symptommodulation approach can satisfy the criteria for more than one treatment subgroup. We suggest that the treatment should take theprogression shown in the Figure. For example, if a patient’s status centralizes with extension, the rehabilitation specialist should emphasizeextension exercises until the patient’s status plateaus. At that time, manipulation can ensue. * Irritable means that minor movements of thelumbar spine can easily provoke the symptoms. ** Active rest means limiting the patient’s movement until the inflammation subsides. Suchpatients are usually seen within the first 24 hours of injury. SLR�straight leg raising.



Dow



NIVER

SITY OF PITTSBU

RG


who are not candidates for rehabilitationmanagement: those with red flags ofpotentially serious medical disease orcentral sensitization syndromes andthose who are likely to do well with aself-care management approach.

Additionally, this updated TBC embracesthe biopsychosocial model of back painmanagement, including the importancefor risk assessment and the need toaddress psychological factors, regardlessof the rehabilitation approach. Therehabilitation-level triage establishesdecision-making criteria that can be usedby any rehabilitation provider to deter-mine the most appropriate rehabilitationapproach for the patient with LBP, usingpain and disability status (Table). We alsoHAVE linked the recommended treat-ment approaches in this TBC to APTA’sclinical practice guidelines for LBP.

This article has provided a general over-view of the major updates and revisionsto the TBC, with more detailed informa-tion to be presented in a series of upcom-ing articles. One article will be devotedto the first-contact provider triage pro-cess, with discussions about assessmentof red flags, medical and psychosocialcomorbidities, and the need for apsychologically informed rehabilitationapproach for patients at high risk ofdeveloping chronic LBP. Another articlewill include more detailed descriptionsof the rehabilitation provider triage pro-cess that sorts patients into the mostappropriate rehabilitation approach.Each of the 3 rehabilitation approacheswill be the focus of an individual articlethat discusses the physical examination

procedures for that specific approach,suggesting subgroup-matched interven-tions. We hope that the information pro-vided in these future articles will stimu-late thoughts and future research relatedto the concept of matching interventionsto appropriate subgroups of patientswith back pain.

All authors provided concept/idea/projectdesign and consultation (including review ofmanuscript before submission). Dr Alrwaily,Mr Timko, and Dr Schneider provided writ-ing. Dr Alrwaily provided project manage-ment. Dr Schneider provided administrativesupport.

DOI: 10.2522/ptj.20150345

References1 Hayden JA, van Tulder MW, Malmivaara

AV, Koes BW. Meta-analysis: exercise ther-apy for nonspecific low back pain. AnnIntern Med. 2005;142:765–775.

2 Hayden JA, van Tulder MW, Tomlinson G.Systematic review: strategies for usingexercise therapy to improve outcomes inchronic low back pain. Ann Intern Med.2005;142:776–785.

3 Fritz JM, Delitto A, Erhard RE. Comparisonof classification-based physical therapywith therapy based on clinical practiceguidelines for patients with acute lowback pain: a randomized clinical trial.Spine (Phila Pa 1976). 2003;28:1363–1371; discussion 1372.

4 Brennan GP, Fritz JM, Hunter SJ, et al.Identifying subgroups of patients withacute/subacute “nonspecific” low backpain: results of a randomized clinical trial.Spine (Phila Pa 1976). 2006;31:623–631.

5 Vibe Fersum K, O’Sullivan P, Skouen JS,et al. Efficacy of classification-based cogni-tive functional therapy in patients withnon-specific chronic low back pain: a ran-domized controlled trial. Eur J Pain. 2013;17:916–928.

6 Childs JD, Fritz JM, Flynn TW, et al. A clin-ical prediction rule to identify patientswith low back pain most likely to benefitfrom spinal manipulation: a validationstudy. Ann Intern Med. 2004;141:920–928.

7 Henschke N, Maher CG, Refshauge KM,et al. Low back pain research priorities: asurvey of primary care practitioners. BMCFam Pract. 2007;8:40.

8 Hefford C. McKenzie classification ofmechanical spinal pain: profile of syn-dromes and directions of preference. ManTher. 2008;13:75–81.

9 Sahrmann SA. Diagnosis and Treatmentof Movement Impairment Syndromes. StLouis, MO: Mosby Inc; 2002.

10 O’Sullivan P. Diagnosis and classificationof chronic low back pain disorders: mal-adaptive movement and motor controlimpairments as underlying mechanism.Man Ther. 2005;10:242–255.

11 Delitto A, Erhard RE, Bowling RW. Atreatment-based classification approach tolow back syndrome: identifying and stag-ing patients for conservative treatment.Phys Ther. 1995;75:470–485; discussion485–479.

12 Delitto A, George SZ, Van Dillen LR, et al;Orthopaedic Section of the AmericanPhysical Therapy Association. Low backpain. J Orthop Sports Phys Ther. 2012;42:A1–A57.

13 Karayannis NV, Jull GA, Hodges PW. Phys-iotherapy movement based classificationapproaches to low back pain: comparisonof subgroups through review and develop-er/expert survey. BMC Musculoskelet Dis-ord. 2012;13:24.

14 Waddell G, Newton M, Henderson I, et al.A Fear-Avoidance Beliefs Questionnaire(FABQ) and the role of fear-avoidancebeliefs in chronic low back pain and dis-ability. Pain. 1993;52:157–168.

15 Fritz JM, Cleland JA, Childs JD. Subgroup-ing patients with low back pain: evolutionof a classification approach to physicaltherapy. J Orthop Sports Phys Ther. 2007;37:290–302.

Figure 5.Example of hierarchical exercise progression for patients matched to movement control approach. These impairments can be present in apatient all at once or any combination of them. To address these impairments, we suggest that the treatment should take the progressionshown in the Figure. The treatment of a particular impairment does not mean ignoring other impairments; that is, if a patient has flexibilityand motor control impairments, the rehabilitation specialist should emphasize flexibility exercises in the earlier sessions of treatment, withthe possibility of addressing some aspects of the motor impairments. As the flexibility impairment improves, the rehabilitation specialistshould emphasize motor control exercises in the later sessions.



Dow



NIVER

SITY OF PITTSBU

RG


16 Hicks GE, Fritz JM, Delitto A, McGill SM.Preliminary development of a clinical pre-diction rule for determining whichpatients with low back pain will respondto a stabilization exercise program. ArchPhys Med Rehabil. 2005;86:1753–1762.

17 Fritz JM, Brennan GP, Clifford SN, et al. Anexamination of the reliability of a classifi-cation algorithm for subgrouping patientswith low back pain. Spine (Phula Pa1976). 2006;31:77–82.

18 Stanton TR, Fritz JM, Hancock MJ, et al.Evaluation of a treatment-based classifica-tion algorithm for low back pain: a cross-sectional study. Phys Ther. 2011;91:496–509.

19 Stanton TR, Hancock MJ, Apeldoorn AT,et al. What characterizes people who havean unclear classification using a treatment-based classification algorithm for low backpain? A cross-sectional study. Phys Ther.2013;93:345–355.

20 Hill JC, Whitehurst DG, Lewis M, et al.Comparison of stratified primary caremanagement for low back pain with cur-rent best practice (STarT Back): a ran-domised controlled trial. Lancet. 2011;378:1560–1571.

21 Bryant C, Lewis P, Bennell KL, et al. Canphysical therapists deliver a pain copingskills program? An examination of trainingprocesses and outcomes. Phys Ther. 2014;94:1443–1454.

22 Smart KM, Blake C, Staines A, Doody C.The discriminative validity of “nocicep-tive,” “peripheral neuropathic,” and “cen-tral sensitization” as mechanisms-basedclassifications of musculoskeletal pain.Clin K Pain. 2011;27:655–663.

23 Woolf CJ. Central sensitization: implica-tions for the diagnosis and treatment ofpain. Pain. 2011;152(3 suppl):S2–S15.

24 Dagenais S, Tricco AC, Haldeman S. Syn-thesis of recommendations for the assess-ment and management of low back painfrom recent clinical practice guidelines.Spine J. 2010;10:514–529.

25 Henschke N, Maher CG, Refshauge KM,et al. Prevalence of and screening for seri-ous spinal pathology in patients present-ing to primary care settings with acute lowback pain. Arthritis Rheum. 2009;60:3072–3080.

26 Latremoliere A, Woolf CJ. Central sensiti-zation: a generator of pain hypersensitivityby central neural plasticity. J Pain. 2009;10:895–926.

27 Smart KM, Blake C, Staines A, et al.Mechanisms-based classifications of mus-culoskeletal pain: part 1 of 3: symptomsand signs of central sensitisation inpatients with low back (�/� leg) pain.Man Ther. 2012;17:336–344.

28 Gore M, Sadosky A, Stacey BR, et al. Theburden of chronic low back pain: clinicalcomorbidities, treatment patterns, andhealth care costs in usual care settings.Spine (Phila Pa 1976). 2012;37:E668–E677.

29 Ritzwoller DP, Crounse L, Shetterly S,Rublee D. The association of comorbidi-ties, utilization and costs for patients iden-tified with low back pain. BMC Musculo-skelet Disord. 2006;7:72.

30 Goode A, Cook C, Brown C, et al. Differ-ences in comorbidities on low back painand low back related leg pain. Pain Pract.2011;11:42–47.

31 Hill JC, Dunn KM, Lewis M, et al. A pri-mary care back pain screening tool: iden-tifying patient subgroups for initial treat-ment. Arthritis Rheum. 2008;59:632–641.

32 Linton SJ, Boersma K. Early identificationof patients at risk of developing a persis-tent back problem: the predictive validityof the Orebro Musculoskeletal Pain Ques-tionnaire. Clin J Pain. 2003;19:80–86.

33 Henschke N, Maher CG, Ostelo RW, et al.Red flags to screen for malignancy inpatients with low-back pain. CochraneDatabase Syst Rev. 2013;2:CD008686.

34 Deyo RA, Dworkin SF, Amtmann D, et al.Report of the NIH task force on researchstandards for chronic low back pain. Spine(Phila Pa 1976). 2014;39:1128–1143.

35 Rabin A, Shashua A, Pizem K, et al. A clin-ical prediction rule to identify patientswith low back pain who are likely to expe-rience short-term success following lum-bar stabilization exercises: a randomizedcontrolled validation study. J OrthopSports Phys Ther. 2014;44:6–B13.

36 McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation.2nd ed. Champaign, IL: Human Kinetics;2007.



Dow



NIVER

SITY OF PITTSBU

RG


Treatment-Based Classification System for Low Back Pain ...

Documents

Transcript of Treatment-Based Classification System for Low Back Pain ...