Treatment-based Classification System for Low Back Pain

Original Editor - Josh McCormack

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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(LoE 1A). 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.

TBC was firstly developed in 1995 then developed twice in 2007 and 2015. The current update of the TBC has two levels of triage:

(1) the level of the first-contact health care provider

(2) the level of the rehabilitation provider

First level of triage:

The triage can be assumed by any practitioner competent in LBP care (ie, primary care physician, nurse practitioner, physica therapist, chiropractor). With the responsibility of determining the appropriate approach of management.

Patients with LBP should be triaged using 1 of 3 approaches: medical management, rehabilitation management, or self-care management.

Patients requiring medical management are those with red flags of serious pathology (eg, fracture, cancer) or serious comorbidities that do not respond to standard rehabilitation management (eg, rheumatoid arthritis, central sensitization).

Clearance of serious pathologies places the patient in either rehabilitation or self-care management. Patients who are amenable to self-care management are those who are unlikely to develop disabling LBP during the course of the current episode. Such patients can be identified using risk profiling instruments such as the STarT Back Tool O¨ rebro Musculoskeletal Pain Questionnaire or similar self-report questionnaires. These patients usually have:

• Low levels of psycho-social distress,
• No or controlled comorbidities,
• Normal neurological status.

They may be treated with patient education that consists of reassurance about the generally favorable prognosis for acute LBP and advice about medication, work, and activity.

The majority of the patients are appropriate for rehabilitation management, as serious pathology is very rare among patients with LBP and patients amenable to self-care management represent a small portion of patients with LBP seen in primary care clinics.

Second Level of Triage (Determining appropriate rehabilitation management):

When the triage determines that the patient is appropriate for rehabilitation management, the rehabilitation provider should continue to match the patient with 1 of the 3 rehabilitation approaches.

Evaluating the psycho-social status of the patient is important to determine whether a psychologically informed rehabilitation is necessary.

Psycho-social status can be assessed using self-report measures (eg, Fear-Avoidance Behavior Questionnaire, STarT Back Tool)

The three rehabilitation approaches are:  symptom modulation, movement control, or functional optimization.

It is important to realize that these criteria are based on the levels of pain and disability, and the clinician's perception of the overall clinical presentation rather than the number of days.

The old classification involved classifying the patient into one of four categories of treatment:  "manipulation", "stabilization", "specific exercise" or "traction". 

Symptoms modulation approach:

When patients are presented with the following symptoms/signs, they are best matched to this approach:

• Recent or recurrent episodes of LBP that is currently causing significant symptomatic features
• Patient tend to avoid certain postures
• Active range of movement is limited and painful
• Increased sensitivity with neurological examination

These patients need interventions that modulate their symptoms. In this group, patients are treated mainly with manual therapy, directional preference exercises, traction, or immobilization.

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.
See: Core stability, lumbar instability and Exercises for Lumbar Instability

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.

See: Non-Specific Low Back Pain; Physical Therapy management

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.

See: Lumbar traction

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 (LoE 1B).

Reliability studies

The Reliability of using this approach has been evidenced as good (LoE 1B) 123 subjects with back pain of fewer then 90 days duration and 30 therapists within varying levels of experience. Overall agreement was 75.9% with a kappa coefficient 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. (LoE 1B) 78 subjects with work-related low back pain randomized to receive 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.

(LoE 1B) suggested that outcomes can be improved when subgrouping for low back pain is used to guide treatment decision-making. 123 subjects received care that either matched or did not match their TBC category. Subjects who received matched treatment experienced greater long and short-term improvements in disability versus those who received unmatched treatment.

Resources

• Hebert JJ1, Koppenhaver SL, Walker BF. Subgrouping patients with low back pain: a treatment-based approach to classification. Sports Health. 2011 Nov;3(6):534-42.

Presentations

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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Related pages

- Core stability

- lumbar instability

- Exercises for Lumbar Instability

- Non-Specific Low Back Pain; Physical Therapy management

- Lumbar traction