Treatment Based Classification Approach to Low Back Pain

Description

Treatment-based classification approach to low back pain describes the model whereby the clinician makes treatment decisions based on the patient's clinical presentation[1].  The primary purpose of the TBC approach is to identify features at baseline that predict responsiveness to four different treatment strategies. This approach is used widely in the USA.

First Level Classification

This step involves determining if the patient is appropriate for physical therapy services, or if a referral to other professionals is necessary.

Second Level Classification

This step involves a determination of the patient's level of severity and degree of disability. 

  1. Stage I is the acute phase where the goal is symptom relief.
  2. Stage II is the subacute phase when symptom relief and quick return to normal function are encouraged.
  3. Stage III is for those who must return to high physical demands but demonstrate poor physical conditioning.

Third Level Classification

This step involves classifying the patient into one of 4 categories to direct your treatment based on signs/symptoms: "manipulation", "stabilization", "specific exercise" or "traction". 

Interpretation of a collection of signs, symptoms and observations derives this decision:

Signs from four primary orthopaedic tests include:

  1. pain centralisation with two or more movements in the same direction, or pain peripheralisation in the opposite direction of centralisation
  2. straight leg raise range of motion
  3. prone instability test
  4. lumbar posterior-to-anterior mobility testing

Signs of nerve root compression are identified by a neurologic examination.
Symptoms of relevance are:

  1. pain duration
  2. pain location
  3. episode frequency
  4. fear avoidance behaviour.

Observation is used to detect presence or absence of aberrant motion or a lateral shift deformity.

Age is considered a predictor for allocation to the "stabilisation" subgroup.

Algorithm

Image:TBC_algorithm-lumbar.jpg

Subgroups

Manipulation

Treatment for this category typically includes mobilization and/or thrust manipulation  as well as ROM exercises. Patients who fall in this category typically meet the following criteria; recent onset of symptoms, symptoms localized to the back only, hypomobility in the lumbar spine, low FABQ scores. Patient who meet the clinical prediction rule for lumbar manipulation should also be included in this category.

Stabilization

Treatment for this category includes exercises that focus on core strengthening and/or motor control exercises. This could include exercises directed at the transverse abdominus and mulitidus musculature as well as generalized trunk strengthening. Patients who fall into this category typically meet the following criteria; younger in age, positive prone instability test, abberant motions, SLR >90 degrees, recurrent episodes.

Specific Exercise

Treatment for this category includes exercises or manual interventions that focus on centralizing and abolishing the patient's symtoms. The most common treatment would include a form of repeat and/or sustained lumbar extension. In some cases repeat/sustained flexion or lateral gliding exercises may be indicated instead. Patients who fall into this category will typically meet the following criteria; symptoms that radiate into the lower extremity, a strong preference for either sitting or walking, centralization and peripheralization with repeated lumbar spine movements.

Traction 

Treatment for this category incldues manual and/or mechanical lumbar traction. Patient's who fall into this catergory typically meet the following criteria; pain radiating into the lower extremity, peripheralization of symptoms with extension, a positive Well (crossed) SLR.


Key Evidence

Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards[2].

Reliability studies

The Reliability of using this approach has been evidenced as good[3] 123 subjects with back pain of less then 90 days duration and 30 therapists within varying levels of experiance. Overall agreement was 75.9% with a kappa coefficiant of .60.

Outcomes studies

For patients with acute, work-related low back pain, the use of a classification-based approach results in improved disability and return to work status after 4 weeks, as compared with therapy based on clinical practice guidelines. [4]78 subjects with work related low back pain randomized to recieve treatment based on the TBC or accepted clinical practice guidelines. At 4 weeks there was a significantly greater change in Oswestry scores for the TBC group. At 1 year median total medical costs were 1003.68 for the guidelines group and 774.00 for the classification group.

[5] suggested that outcomes can be improved when subgrouping for low back pain is used to guide treatment decision-making. 123 subjects recieved care that either matched or did not match their TBC category. Subjects who recieved matched treatment experianced greater long and short term improvements in disability versus those who received unmatched treatment.

Resources

Presentations

http://www.eimqa.com/Fellowship/FellowPresent/RygTBC2012.movTreatment Based Classification Approach to Low Back Pain.png
Treatment Based Classification Approach to Low Back Pain

This presentation, created by Jeff Ryg as part of the Evidence In Motion OMPT Fellowship in 2011, discusses the treatment based classification approach to low back pain and it's implications for research and practice.

View the presentation


Recent Related Research (from Pubmed)

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References

  1. Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995 Jun;75(6):470-85; discussion 485-9.
  2. Scott A. Burns, Edward Foresman, Stephenie J. Kraycsir, William Egan, Paul Glynn, Paul E. Mintken and Joshua A. Cleland. A Treatment-Based Classification Approach to Examination and Intervention of Lumbar Disorders. Sports Health: A Multidisciplinary Approach July/August 2011 vol. 3 no. 4 362-372
  3. Fritz J, Brennan G, Clifford S, et al. [ http://journals.lww.com/spinejournal/Abstract/2006/01010/An_Examination_of_the_Reliability_of_a.18.aspx An examination of the reliability of a classification algorithm for subgrouping patients with low back pain]. Spine. 2006;31:77-82.
  4. Fritz J, Delitto A, Erhard R. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine. 2003;28:1363-1372.
  5. Brennan G, Fritz J, Hunter S, et al. Identifying subgroups of patients with acute/subacute nonspecific low back pain. Spine. 2006;31:623-631