Treatment-based Classification System for Low Back Pain

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Description

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Indication

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Clinical Presentation

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Key Evidence

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Description

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.

Manipulation

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.

Stabilization

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.

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

Reliability study:  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:

 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.

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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