Treatment Based Classification Approach to Low Back Pain
Original Editor - Josh McCormack
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Treatment-based classification (TBC) of low back pain describes the model whereby the clinician makes treatment decisions based on the patient's clinical presentation.
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/or acuity. For patients in need of intensive intervention (those presenting with severe or acute symptoms), the third stage of the classiciation will be undertaken to determine the best treatment to suit the patient.
Third Level Classification
This step involves classifying the patient into one of 4 categories to direct your treatment based on signs/symptoms.
Treatment for this category typically includes mobilization and/or thrus manipulation manual techniques 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.
Treatment for this category includes exercises that focus or 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.
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.
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.
Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards.
The Reliability of using this approach has been evidenced as good 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.
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. 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.
 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.
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| || 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.
Recent Related Research (from Pubmed)
- Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial.
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- A randomized controlled trial on the effectiveness of a classification-based system for subacute and chronic low back pain.
- Classification-based approach for management of an adolescent with LBP, lower extremity pain, and a relevant postural deformity.
- Cost-effectiveness of a classification-based system for sub-acute and chronic low back pain.
- Efficacy of directional preference management for low back pain: a systematic review.
- Ultra-long-term outcome of surgically treated far-lateral, extraforaminal lumbar disc herniations: a single-center series.
- Methodology for the systematic reviews on an evidence-based approach for the management of chronic low back pain.
- Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach.
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- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ Brennan G, Fritz J, Hunter S, et al. Identifying subgroups of patients with acute/subacute nonspecific low back pain. Spine. 2006;31:623-631