Treatment-based Classification System for Low Back Pain: Difference between revisions

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== Introduction ==
Low back pain is the leading cause of disability in most countries,<ref>GBD 2021 Low Back Pain Collaborators. [https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(23)00098-X/fulltext Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021]. Lancet Rheumatol. 2023 May 22;5(6):e316-e329. </ref> with a point prevalence of 11.9%.<ref name=":0">Bastos RM, Moya CR, de Vasconcelos RA, Costa LO. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9344960/ Treatment-based classification for low back pain: systematic review with meta-analysis.] Journal of Manual & Manipulative Therapy. 2022 Jul 4;30(4):207-27.</ref> Several classification / stratification systems have been published to help clinicians select an appropriate intervention, including:<ref name=":0" />
 
# Treatment-based Classification (TBC)
# [[McKenzie Method|Mechanical Diagnosis and Therapy]] (MDT) (also known as the McKenzie Method)
# [[Cognitive Functional Therapy]] (CFT)
# Movement System Impairment (MSI)
This page focuses on Treatment Based Classification. It also provides a brief description of Mechanical Diagnosis and Therapy, Cognitive Functional Therapy and Movement System Impairment.
 
== Description  ==
== Description  ==


Treatment-based classification (TBC) approach to [[Back Pain Functional Scale|low back pain]] describes the model whereby the clinician makes treatment decisions based on the patient's clinical presentation<ref name="Delitto">Delitto A, Erhard RE, Bowling RW. [http://ptjournal.apta.org/content/75/6/470.short?rss=1&amp;ssource=mfc&amp;cited-by=yes&amp;legid=ptjournal;75/6/470 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. </ref>. The primary purpose of the '''TBC''' approach is to identify features at baseline that predict responsiveness to four different treatment strategies. This approach has been validated<ref name=":3" /><ref name=":4" /><ref name=":5" /><ref name=":6" /> and is used widely in the USA.    
The TBC system for low back pain is a model designed to help clinicians make treatment decisions based on a patient's clinical presentation.<ref name="Delitto">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. </ref> The primary purpose of the TBC is to identify features at baseline that predict responsiveness to three different treatment strategies. This approach has been validated.<ref name=":3" /><ref name=":4">Brennan G, Fritz J, Hunter S, et al. [http://journals.lww.com/spinejournal/Abstract/2006/03150/Identifying_Subgroups_of_Patients_With.4.aspx Identifying subgroups of patients with acute/subacute nonspecific low back pain]. Spine. 2006;31:623-631  </ref><ref name=":5">Fritz J, Brennan G, Clifford S, et al. An examination of the reliability of a classification algorithm for subgrouping patients with low back pain. Spine. 2006;31:77-82. </ref><ref name=":6">Fritz J, Delitto A, Erhard R. [http://journals.lww.com/spinejournal/Abstract/2003/07010/Comparison_of_Classification_Based_Physical.3.aspx 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. (Level of evidence 1B)</ref>   


TBC was firstly developed in 1995<ref>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;75:470 – 485; discussion 485– 479.</ref> then updated twice in 2007<ref>Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007; 37:290 –302</ref> and 2015<ref>Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. [https://www.researchgate.net/publication/285728095_The_Treatment-Based_Classification_System_for_Low_Back_Pain_Revision_and_Update Treatment-based classification system for low back pain: revision and update.] Physical therapy. 2016 Jul 1;96(7):1057-66.</ref>. The current TBC has two levels of triage:
The TBC was initially developed in 1995.<ref>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;75:470 – 485; discussion 485– 479.</ref> It was updated in 2007<ref>Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007; 37:290 –302</ref> and then again in 2015.<ref name=":7">Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. [https://academic.oup.com/ptj/article/96/7/1057/2864925 Treatment-based classification system for low back pain: revision and update.] Physical therapy. 2016 Jul 1;96(7):1057-66.</ref> The most recent version of the TBC model has two levels of triage:<ref name=":7" />
# the level of the '''first contact''' health care provider.
# First contact health care provider
# the level of the rehabilitation provider.
# Rehabilitation provider


== First Level of Triage - Determining the Management Approach ==
== First Level of Triage - Determining the Management Approach ==
The triage can be assumed by any practitioner competent in low back pain (LBP)care (ie, primary care physician, nurse practitioner, physical therapist, osteopath). With the responsibility of determining the appropriate approach of management.<ref name=":0">Therapy, P. (2015). The Treatment-Based Classification System for Low Back Pain : Revision and Update, (December). <nowiki>https://doi.org/10.2522/ptj.20150345</nowiki>
At this triage level, "the triage can be assumed by any practitioner competent in [low back pain] care, regardless of his or her professional background (ie, primary care physician, nurse practitioner, physical therapist, chiropractor)."<ref name=":7" /> Practitioners at this level are responsible for determining an appropriate management approach.<ref name=":7" />
</ref>
 
According to the TBC system, at this initial contact, individuals with low back pain should be triaged to one of three management approaches:<ref name=":7" />
 
* medical management
* rehabilitation management
* self-care management


Patients with LBP should be triaged using 1 of 3 approaches:  
Patients who require '''medical management''' will have [[Red Flags in Spinal Conditions|red flags]] that suggest serious pathology (e.g. fracture or cancer) or other significant comorbidities that will not respond to rehabilitation, such as [[Rheumatoid Arthritis|rheumatoid arthritis]] or [[Central Sensitisation|central sensitisation]].<ref name=":7" />


* '''Medical management'''
If red flags or serious pathologies/comorbidities are ruled out, patients can be placed in either the '''rehabilitation''' or '''self-care management''' groups'''.'''
* '''Rehabilitation management'''
* '''or Self-care management'''<ref name=":0" />'''.'''


Patients requiring '''medical management''' are those with [[Red Flags in Spinal Conditions|red flags]] of serious pathology (eg, fracture, cancer) or serious co-morbidities that do not respond to standard rehabilitation management (eg, rheumatoid arthritis, central sensitisation).<ref name=":0" />
'''Self-care management''' is for individuals who are unlikely to develop "disabling [low back pain] during the course of the current episode".<ref name=":7" /> We can use risk profiling tools to identify patients for the self-care management group, including the [[STarT Back Screening Tool|STarT Back Tool]]<ref>Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59:632–641.</ref> and [https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/212908/Orebro_musculoskeletal_pain_questionnaire_Final.pdf Orebro Musculoskeletal Pain Questionnaire].<ref>Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the O¨ rebro Musculoskeletal Pain Questionnaire. Clin J Pain. 2003;19:80–86.</ref><ref name=":7" /> Patients triaged to this group will tend to have:<ref name=":7" />
* low levels of psychosocial distress
* no / controlled comorbidities
* normal neurological status
Treatment options for self-care management include:<ref name=":7" />


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 Screening Tool|STarT Back Tool]]<ref>Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59:632–641.</ref>, [https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/212908/Orebro_musculoskeletal_pain_questionnaire_Final.pdf Orebro Musculoskeletal Pain Questionnaire]<ref>Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the O¨ rebro Musculoskeletal Pain Questionnaire. Clin J Pain. 2003;19:80–86.</ref> or similar self-report questionnaires. These patients usually have:
* patient education, including reassurance about the typically "favorable prognosis" for low back pain
* Low levels of psycho-social distress,
* advice about medication, work, and activity
* No or controlled co-morbidities,
* 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.<ref name=":1">Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011; 378:1560–1571.</ref>


The majority of the patients are appropriate for '''rehabilitation management''', as serious pathology is very rare among patients with LBP<ref>Henschke N, Maher CG, Ostelo RW, et al. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev. 2013;2:CD008686.</ref> and patients amenable to self-care management represent a small portion of patients with LBP seen in primary care clinics.<ref name=":1" />
The majority of patients are appropriate for '''rehabilitation management.''' Serious pathology is rare among patients with low back pain - only around 1% of all musculoskeletal presentations in '''primary care''' will be due to serious pathology<ref>Finucane L. An Introduction to Red Flags in Serious Pathology. Plus, 2020.</ref><ref>Melman A, Maher CG, Needs C, Machado GC. [https://link.springer.com/article/10.1007/s10067-022-06054-w Many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause]. Clin Rheumatol. 2022 Jun;41(6):1867-71.</ref> - and only a small number of patients "amenable" to self-care management will be seen in primary care clinics.<ref name=":7" />


== Second Level of Triage - Determining Appropriate Rehabilitation Management ==
== 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.<ref name=":0" /> The three rehabilitation approaches are:
If it is determined that a patient is suitable for rehabilitation management, the rehabilitation provider must determine the appropriate management strategy.<ref name=":7" /> In the TBC, the three rehabilitation approaches are:
 
* symptom modulation
* movement control
*  functional optimization
 
Patients are classified into one of these groups based on their levels of pain and disability and the clinician's perception of their overall clinical presentation.<ref name=":7" />
 
Please note that "patients with a medium-to-high psychological risk profile require psychologically informed rehabilitation"<ref name=":7" /> regardless of the approach selected. Psychosocial status can be assessed using self-report measures, such as the [[Fear Avoidance Belief Questionnaire|Fear-Avoidance Behavior Questionnaire]] or the [[STarT Back Screening Tool|STarT Back Tool]].<ref name=":7" />
 
=== Symptom Modulation Approach ===
A symptom modulation approach is appropriate for individuals who meet the following criteria:<ref name=":7" />
* recent (new or recurrent) episode of low back pain that is "causing significant symptomatic features"<ref name=":7" />
* volatile clinical status, so tend to avoid certain postures
* limited / painful active range of movement
* may have increased sensitivity with neurological examination
Interventions aim to modulate these symptoms. In this group, patients are treated mainly with:
 
* active rest
* [[Lumbar Traction|traction]]
* [[McKenzie Method|directional preference exercises]]
* manipulation
See [https://academic.oup.com/view-large/figure/190920756/ptj1057-fig004.jpeg Figure 4, Treatment-based classification system for low back pain: revision and update].
 
=== Movement Control Approach ===
A movement control approach is appropriate for individuals who meet the following criteria:<ref name=":7" />
 
* low-to-moderate levels of pain and disability that affect activities of daily living
* low baseline pain level that increases with certain activities, but returns to a low-level once they stop the activity - may also include individuals who are currently asymptomatic / in remission, but who have recurrent episodes of low back pain where pain is aggravated by sudden / unexpected movement
* typically have full active range of motion but may have altered movement patterns
* may have impaired flexibility, muscle activation, and motor control on examination


* '''Symptom modulation.'''
Interventions aim to improve movement quality and focus on:<ref name=":7" /><ref name=":9">Rainey N. Treatment Based Classification Approach to Low Back Pain Course. Plus, 2023.</ref>


* '''Movement control.'''
* addressing the sensitised neurological structure (e.g. neurodynamic techniques)
*   '''Functional optimisation.'''
* stabilisation exercises
* flexibility exercises (may also include manual therapy to increase range of motion<ref name=":9" />)
* motor control exercises
* endurance exercises


It is important to realise 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<ref>Deyo RA, Dworkin SF, Amtmann D, et al. Report of the NIH task force on research standards for chronic low back pain. Spine. 2014;39(14):1128-1143.</ref>.
See [https://academic.oup.com/view-large/figure/190920757/ptj1057-fig005.jpeg Figure 5, Treatment-based classification system for low back pain: revision and update].


Evaluating the psychosocial status of the patient is important to determine whether a psychologically informed rehabilitation is necessary. Psychosocial status can be assessed using self-report measures (eg,[[Fear Avoidance Model|Fear-Avoidance Behavior Questionnaire]], [[STarT Back Screening Tool|STarT Back Tool]])<ref name=":0" />  
=== Functional Optimization Approach ===
A functional optimization is appropriate for individuals who meet the following criteria:<ref name=":7" />


== Symptoms Modulation Approach ==
* relatively asymptomatic
When patients are presented with the following symptoms/signs, they are best matched to this approach:
* can perform activities of daily living but must be able to perform at a higher level of physical activity, e.g. for sport or work
* Recent or recurrent episodes of LBP that is currently causing significant symptomatic features
* pain is only aggravated only by movement system fatigue
* Patient tend to avoid certain postures
* have impairments in movement system endurance, strength, and power rather than flexibility or motor control deficits
* 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


* [[Spinal Manipulation|manual therapy]]
Interventions aim to maximise physical performance to enable these individuals to participate in high-level activities. Treatments should focus on optimising performance based on the individual's specific work / job requirements. Interventions include:<ref name=":7" />


* [[McKenzie Method|directional preference exercises]]
* aerobic exercises
* strength and conditioning exercises
* work- or sport-specific tasks
* general fitness exercises


* [[Lumbar Traction|traction]], or immobilisation.
See [https://academic.oup.com/view-large/figure/190920703/ptj1057-fig001.jpeg Figure 1, Treatment-based classification system for low back pain: revision and update].


==Movement Control Approach==
==Key Considerations==
The patient with movement control impairment can fit into one of the following clinical scenarios<ref>Dunn KM, Jordan K, Croft PR. Characterizing the course of low back pain: a latent class analysis. Am J Epidemiol. 2006;163(8):754-761.</ref>:  
* '''The first clinical scenario''' involves sudden new onset of LBP with significant symptomatic features. This clinical presentation should be addressed initially with the symptom modulation approach to lessen the symptom intensity.  When the symptoms settle down, some patients continue to experience moderate-to low-level disability that interferes with their activities of daily living (ADLs).  Although they still have lingering pain and symptoms, it is the functional impairment(s) that dominate the clinical picture. This description meets the criteria of '''a movement control approach'''; the patient should be reclassified from symptom modulation into the movement control approach. However, if after the symptom modulating treatment the patient has minimal pain and disability, they may be discharged.<ref name=":2">Alrwaily, M., Schneider, M. J., Bise, C. G., Alrwaily, M., Timko, M., Schneider, M., … Delitto, A. (2017). Treatment-based Classification System for Patients With Low Back Pain : The Movement Perspective Treatment-based Classification System for Patients With Low Back Pain : The Movement Control Approach, (November).
</ref>
* '''The second clinical scenario''' is when the patient does not have any recent history of a significant LBP episode, but rather the symptoms started gradually. For no known reason. The pain is at a low baseline level but could be aggravated by certain ADLs then returns to baseline level when the activity is stopped. For this patient, the impairment of normal activities is more bothersome rather than the pain itself. This type of patient may not benefit from treatments directed only toward symptom modulation. Therefore, the movement control approach should be utilised first without having to pass through the symptom modulation approach. <ref name=":2" />
* '''Finally,''' patients may describe recurrent/ repeated episodes of pain that are aggravated with sudden/unexpected movements, but they experience asymptomatic intervals between episodes. These patients may shift between symptom modulation and movement control approaches according to their status at the moment of clinical presentation.<ref name=":2" />
The examination for movement control specifically aims to assess the '''local mobility''' and the '''general stability'''.


'''The local mobility''' examination aims to investigate if lumbar movement is hindered by impairment in the following domains:
* The three management approaches in the TBC are mutually exclusive
* '''Neural mobility:''' using [[Neurodynamic Assessment|neural dynamic assessment]] such as [[Slump Test|slump test]], [[Straight Leg Raise Test|straight leg raise test]], and [[Femoral Nerve Tension Test|femoral nerve tension test]]. Significant nerve root tension signs suggest that the patient may not be appropriate for the movement control approach instead he/she should be classified into the symptom modulation approach. Alternatively, a patient with impaired neural mobility may receive neurodynamic techniques.
* Reclassification can occur as a patient's clinical status changes
* '''Joint(s) mobility:'''to investigate whether the [[Lumbar Vertebrae|lumbar spine]] and adjacent regions possess proper joint alignment and ability to move freely within physiologic limits. Assessment of joint mechanics involves observing spinal curvatures, alignment relationships, and assessing the mobility of the joints.
* The patient can be discharged when they achieve their goals
* '''Soft tissue mobility:'''when soft tissue mobility is impaired, faulty movement compensations and in coordination may result and can possibly leads to injury<ref>Janda V, Frank C, Liebenson C. Evaluation of muscular imbalance. In: Liebenson C, ed. Rehabilitation of the Spine: A Practitioner’s Manual. Baltimore, MD: Lippincott Williams & Wilkins; 1996:97- 112.</ref>. Soft tissue mobility impairments can be addressed with various types of manual therapy interventions.
* Treatment must be prioritised when a patient fits into two or more treatment options
* The patient's psychosocial status and comorbidities must be considered - when psychosocial factors are high, rehabilitation professionals should provide education on:
** pain theory
** muscle relaxation techniques
** sleep hygiene
** coping skills
** catastrophising about pain and diagnostic reports
* Co-management is needed when medical comorbidities are identified<ref name=":7" />
<blockquote>Managing individuals with low back pain using the TBC has been found to significantly reduce disability and pain compared with current clinical practice guideline standards<ref name="Burns">Scott A. Burns, Edward Foresman, Stephenie J. Kraycsir, William Egan, Paul Glynn, Paul E. Mintken and Joshua A. Cleland. [http://sph.sagepub.com/content/3/4/362.abstract?rss=1 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 </ref> and enhance clinical-decision making.<ref name=":3">Hebert JJ1, Koppenhaver SL, Walker BF. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445227/ Subgrouping patients with low back pain: a treatment-based approach to classification]. Sports Health. 2011 Nov;3(6):534-42.</ref> </blockquote>


'''The''' '''global stability''' :examination aims to investigate if lumbar movement is impaired by one of the following domains:
== Other Classification Systems ==
* '''Activation:''' assesses the ability of an individual muscle to generate isolated contraction and/or a simple movement pattern. Examples of that include [[Exercises for Lumbar Instability|abdominal hollowing]], scapular retraction, [[Core Stability|multifidus activation]], and breathing pattern.<ref name=":2" />
* '''Acquisition''':assesses whether movement is dissociated or coordinated between the lumbar spine and its adjacent regions. Acquisition is tested using basic and advanced [[Lumbar Motor Control Training|motor control abilities]] (eg, active straight leg raise, active hip extension, active hip abduction). When these abilities are compromised, movement appears discordant between regions.<ref name=":2" />
* '''Assimilation''':of movement assesses how newly acquired skills are integrated into ADLs utilising multi-planar movements under dynamic loading conditions. Assimilation is tested by asking the patient to '''''describe activities that aggravate their symptoms. These activities vary with each patient; however, they generally include lifting/lowering, pushing/ pulling, reaching/handling, twisting, and reciprocating. To test how a patient integrates such activities into a daily living function, the rehabilitation provider should simulate these activities in the clinic and plan the rehabilitation strategies accordingly<ref name=":2" />.'''''
Alrwaily et al<ref name=":2" /> stated that the impairments should be addressed in the following prioritisation: neural mobility impairment, joint and soft tissue mobility impairment, motor control impairment, and endurance impairment.


==Functional Optimization Approach==
=== Mechanical Diagnosis and Therapy ===
A functional optimization intervention is for patients who are relatively asymptomatic; they can perform activities of daily living but need to return to higher levels of physical activities (eg, sport, job). The patient’s status is well controlled; that is, the pain is aggravated only by movement system fatigue<ref name=":0" />.
Mechanical Diagnosis and Therapy (MDT), also called the McKenzie method, is a system of diagnosis and treatment for spinal and extremity musculoskeletal disorders. Patients are classified into four groups according to their mechanical and symptomatic response to repeated movements and/or sustained positions.


These patients need interventions that maximize their physical performance for higher levels of physical activities. For this group, the treatment should optimize the patient’s performance within the context of a job or sport<ref name=":0" />.
* derangement:<ref name=":1">May S, Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method.Spine J. 2008;8(1):134-41.</ref>
**most common syndrome<ref>Sanchis-Sanchez, E., Lluch-Girbes, E., Guillart-Castells, P., Georgieva, S., Garcia-Molina, P. and Blasco, J.M., 2021. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990734/ Effectiveness of mechanical diagnosis and therapy in patients with non-specific chronic low back pain: a literature review with meta-analysis.] ''Brazilian Journal of Physical Therapy'', ''25''(2), pp.117-134.</ref>
**a hallmark of derangement syndrome is a [[Directional Preference|directional preference]]
**treatments focus on specific movements that cause pain to decrease, centralise and/or abolish
* dysfunction syndrome<ref name=":1" />
** pain is intermittent and occurs at the end range of a restricted movement
** treatment focuses on repeated movements in the direction of the dysfunction or in the direction that reproduces the pain
*** the aim is to remodel the tissue that limits the movement through exercises, so that movement becomes pain-free over time
* postural syndrome
** pain occurs with static positioning of the spine (e.g. sustained slouched sitting)
** treatment includes patient education, correction of the posture by restoring lumbar lordosis, avoiding provocative postures and avoiding prolonged tensile stress on normal structures<ref name=":1" /><ref>Halliday, M.H., Garcia, A.N., Amorim, A.B., Machado, G.C., Hayden, J.A., Pappas, E., Ferreira, P.H. and Hancock, M.J., 2019. [https://www.jospt.org/doi/10.2519/jospt.2019.8734 Treatment effect sizes of mechanical diagnosis and therapy for pain and disability in patients with low back pain: a systematic review.] ''journal of orthopaedic & sports physical therapy'', ''49''(4), pp.219-229.</ref>
*other on non-mechanical syndrome
**this group is for individuals who do not fit within one of the three mechanical syndromes but who demonstrate symptoms and signs of other pathologies<ref>Mann SJ, Lam JC, Singh P. McKenzie Back Exercises. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539720/</ref>
For more information on the MDT approach, please see [[McKenzie Method]].


==Clinical Considerations==
=== Cognitive Functional Therapy ===
* The 3 rehabilitation approaches are mutually exclusive; however, patients can always be reclassified to receive a different rehabilitation approach as their clinical status changes. For example, a patient who initially receives a movement control approach due to moderate levels of pain and disability can be reclassified to receive a functional optimization approach if his or her status improves to low pain and disability status, or the patient can be reclassified to receive a symptoms modulation approach if his or her status suddenly worsens<ref name=":0" />.  
Cognitive Functional Therapy (CFT) is a patient-centred approach that enables individuals to manage their pain by targeting "individual pain-related cognitions, emotions, and behaviours that contribute to their pain and disability."<ref name=":2">Kent P, Haines T, O'Sullivan P, Smith A, Campbell A, Schutze R, Attwell S, Caneiro JP, Laird R, O'Sullivan K, McGregor A. [https://www.sciencedirect.com/science/article/abs/pii/S0140673623004415 Cognitive Functional Therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial.] The Lancet. 2023 Jun 3;401(10391):1866-77.</ref> Therapists explore the multidimensional nature of low back pain through the individual's experience while focusing on the following areas:<ref>O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6037069/ Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain]. Phys Ther. 2018 May 1;98(5):408-23.</ref>
* The patient can be discharged at any point when rehabilitation goals are attained.<ref name=":0" />
* Some patient might fit the criteria of 2 or more treatment options, which requires prioritization of treatment. For example, in the symptom modulation approach, a patient may satisfy the criteria for manipulation and extension exercises. In that case, extension exercises take priority over manipulation. Extension exercises should be the treatment of choice until the patient’s status plateaus. At that moment, manipulation may ensue.  Similarly, in the movement control approach, a patient may have motor control impairment and reduced muscle performance. In that case, motor control deficit takes priority over the muscle reduced performance. When the control deficit is corrected, muscle performance training can ensue<ref name=":0" />.
* When '''[[Psychological Approaches to Pain Management|psycho-social factors]]''' are high, the rehabilitation provider should educate the patient about pain theory, muscle relaxation techniques, sleep hygiene, and coping skills and address catastrophizing about pain and diagnostic findings<ref name=":2" />.
* When medical comorbidities are identified, medical co-management is necessary<ref name=":0" />.


== Key Evidence ==
* making sense of pain
Managing individuals with low back pain using '''a treatment-based classification approach''' significantly reduces disability and pain compared with current clinical practice guideline standards<ref name="Burns">Scott A. Burns, Edward Foresman, Stephenie J. Kraycsir, William Egan, Paul Glynn, Paul E. Mintken and Joshua A. Cleland. [http://sph.sagepub.com/content/3/4/362.abstract?rss=1 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 </ref> and enhances clinical decision making<ref name=":3">Hebert JJ1, Koppenhaver SL, Walker BF. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445227/ Subgrouping patients with low back pain: a treatment-based approach to classification]. Sports Health. 2011 Nov;3(6):534-42.</ref>.
* exposure with control
* lifestyle change<ref>Miki T, Kondo Y, Kurakata H, Buzasi E, Takebayashi T, Takasaki H. [https://bpsmedicine.biomedcentral.com/articles/10.1186/s13030-022-00241-6 The effect of cognitive functional therapy for chronic nonspecific low back pain: a systematic review and meta-analysis.] BioPsychoSocial Medicine. 2022 May 21;16(1):12.</ref><ref name=":2" />
For more information, please see [[Cognitive Functional Therapy]] and [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6037069/ Cognitive Functional Therapy: an integrated behavioral approach for the targeted management of disabling low back pain].<ref>O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6037069/ Cognitive Functional Therapy: an integrated behavioral approach for the targeted management of disabling low back pain]. Phys Ther. 2018 May 1;98(5):408-23. </ref>


The Reliability of using this approach has been evidenced as good<ref name=":5">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. </ref> 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.
=== Movement System Impairment ===
The Movement System Impairment (MSI) classification system "involves a standardized examination with several tests of movements and positions to identify mechanically based impairments."<ref name=":8">Azevedo DC, Ferreira PH, Santos HD, Oliveira DR, de Souza JV, Costa LO. [https://academic.oup.com/ptj/article/98/1/28/4107780 Movement system impairment-based classification treatment versus general exercises for chronic low back pain: randomized controlled trial.] Physical therapy. 2018 Jan;98(1):28-39.</ref>  


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. <ref name=":6">Fritz J, Delitto A, Erhard R. [http://journals.lww.com/spinejournal/Abstract/2003/07010/Comparison_of_Classification_Based_Physical.3.aspx 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. (Level of evidence 1B)</ref> 78 subjects with work-related low back pain randomised 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.
Individuals are classified into one of five subgroups. Treatment focuses on education and exercise to improve classification-specific movement and posture impairments linked to low back pain symptoms. Treatment aims to:<ref name=":8" />


Brennan et al<ref name=":4">Brennan G, Fritz J, Hunter S, et al. [http://journals.lww.com/spinejournal/Abstract/2006/03150/Identifying_Subgroups_of_Patients_With.4.aspx Identifying subgroups of patients with acute/subacute nonspecific low back pain]. Spine. 2006;31:623-631  </ref> suggested that outcomes can be improved when sub-grouping 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.
* minimise certain movements of the lumbar spine
* promote movement in other joints
* avoid extreme postures of the lumbar spine in specific directions


== Presentations  ==
For more information, please see [[Classification Of Low Back Pain Using Shirley Sahrmann’s Movement System Impairments, An Overview Of The Concept]].
<div class="coursebox">
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Image:Treatment_Based_Classification_Approach_to_Low_Back_Pain.png|200px|border|left|
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| [http://www.eimqa.com/Fellowship/FellowPresent/RygTBC2012.mov '''Treatment Based Classification Approach to Low Back Pain''']
This presentation, created by Jeff Ryg as part of the [[EIM Orthopaedic Manual Physical Therapy Fellowship Project|OMPT Fellowship]] in 2011, discusses the treatment based classification approach to low back pain and it's implications for research and practice.  


[http://www.eimqa.com/Fellowship/FellowPresent/RygTBC2012.mov View the presentation]
== Resources ==


|}
* [https://academic.oup.com/ptj/article/96/7/1057/2864925 Treatment-based classification system for low back pain: revision and update]
</div>


== References  ==
== References  ==

Latest revision as of 12:30, 17 October 2023

Original Editor - Josh McCormack

Top Contributors - Admin, Kim Jackson, Jess Bell, Robin Tacchetti, Eric Robertson, Josh McCormack, Rachael Lowe, Shaimaa Eldib, Mariam Hashem, Tarina van der Stockt, WikiSysop, Simisola Ajeyalemi, 127.0.0.1 and Evan Thomas  

Introduction[edit | edit source]

Low back pain is the leading cause of disability in most countries,[1] with a point prevalence of 11.9%.[2] Several classification / stratification systems have been published to help clinicians select an appropriate intervention, including:[2]

  1. Treatment-based Classification (TBC)
  2. Mechanical Diagnosis and Therapy (MDT) (also known as the McKenzie Method)
  3. Cognitive Functional Therapy (CFT)
  4. Movement System Impairment (MSI)

This page focuses on Treatment Based Classification. It also provides a brief description of Mechanical Diagnosis and Therapy, Cognitive Functional Therapy and Movement System Impairment.

Description[edit | edit source]

The TBC system for low back pain is a model designed to help clinicians make treatment decisions based on a patient's clinical presentation.[3] The primary purpose of the TBC is to identify features at baseline that predict responsiveness to three different treatment strategies. This approach has been validated.[4][5][6][7]

The TBC was initially developed in 1995.[8] It was updated in 2007[9] and then again in 2015.[10] The most recent version of the TBC model has two levels of triage:[10]

  1. First contact health care provider
  2. Rehabilitation provider

First Level of Triage - Determining the Management Approach[edit | edit source]

At this triage level, "the triage can be assumed by any practitioner competent in [low back pain] care, regardless of his or her professional background (ie, primary care physician, nurse practitioner, physical therapist, chiropractor)."[10] Practitioners at this level are responsible for determining an appropriate management approach.[10]

According to the TBC system, at this initial contact, individuals with low back pain should be triaged to one of three management approaches:[10]

  • medical management
  • rehabilitation management
  • self-care management

Patients who require medical management will have red flags that suggest serious pathology (e.g. fracture or cancer) or other significant comorbidities that will not respond to rehabilitation, such as rheumatoid arthritis or central sensitisation.[10]

If red flags or serious pathologies/comorbidities are ruled out, patients can be placed in either the rehabilitation or self-care management groups.

Self-care management is for individuals who are unlikely to develop "disabling [low back pain] during the course of the current episode".[10] We can use risk profiling tools to identify patients for the self-care management group, including the STarT Back Tool[11] and Orebro Musculoskeletal Pain Questionnaire.[12][10] Patients triaged to this group will tend to have:[10]

  • low levels of psychosocial distress
  • no / controlled comorbidities
  • normal neurological status

Treatment options for self-care management include:[10]

  • patient education, including reassurance about the typically "favorable prognosis" for low back pain
  • advice about medication, work, and activity

The majority of patients are appropriate for rehabilitation management. Serious pathology is rare among patients with low back pain - only around 1% of all musculoskeletal presentations in primary care will be due to serious pathology[13][14] - and only a small number of patients "amenable" to self-care management will be seen in primary care clinics.[10]

Second Level of Triage - Determining Appropriate Rehabilitation Management[edit | edit source]

If it is determined that a patient is suitable for rehabilitation management, the rehabilitation provider must determine the appropriate management strategy.[10] In the TBC, the three rehabilitation approaches are:

  • symptom modulation
  • movement control
  • functional optimization

Patients are classified into one of these groups based on their levels of pain and disability and the clinician's perception of their overall clinical presentation.[10]

Please note that "patients with a medium-to-high psychological risk profile require psychologically informed rehabilitation"[10] regardless of the approach selected. Psychosocial status can be assessed using self-report measures, such as the Fear-Avoidance Behavior Questionnaire or the STarT Back Tool.[10]

Symptom Modulation Approach[edit | edit source]

A symptom modulation approach is appropriate for individuals who meet the following criteria:[10]

  • recent (new or recurrent) episode of low back pain that is "causing significant symptomatic features"[10]
  • volatile clinical status, so tend to avoid certain postures
  • limited / painful active range of movement
  • may have increased sensitivity with neurological examination

Interventions aim to modulate these symptoms. In this group, patients are treated mainly with:

See Figure 4, Treatment-based classification system for low back pain: revision and update.

Movement Control Approach[edit | edit source]

A movement control approach is appropriate for individuals who meet the following criteria:[10]

  • low-to-moderate levels of pain and disability that affect activities of daily living
  • low baseline pain level that increases with certain activities, but returns to a low-level once they stop the activity - may also include individuals who are currently asymptomatic / in remission, but who have recurrent episodes of low back pain where pain is aggravated by sudden / unexpected movement
  • typically have full active range of motion but may have altered movement patterns
  • may have impaired flexibility, muscle activation, and motor control on examination

Interventions aim to improve movement quality and focus on:[10][15]

  • addressing the sensitised neurological structure (e.g. neurodynamic techniques)
  • stabilisation exercises
  • flexibility exercises (may also include manual therapy to increase range of motion[15])
  • motor control exercises
  • endurance exercises

See Figure 5, Treatment-based classification system for low back pain: revision and update.

Functional Optimization Approach[edit | edit source]

A functional optimization is appropriate for individuals who meet the following criteria:[10]

  • relatively asymptomatic
  • can perform activities of daily living but must be able to perform at a higher level of physical activity, e.g. for sport or work
  • pain is only aggravated only by movement system fatigue
  • have impairments in movement system endurance, strength, and power rather than flexibility or motor control deficits

Interventions aim to maximise physical performance to enable these individuals to participate in high-level activities. Treatments should focus on optimising performance based on the individual's specific work / job requirements. Interventions include:[10]

  • aerobic exercises
  • strength and conditioning exercises
  • work- or sport-specific tasks
  • general fitness exercises

See Figure 1, Treatment-based classification system for low back pain: revision and update.

Key Considerations[edit | edit source]

  • The three management approaches in the TBC are mutually exclusive
  • Reclassification can occur as a patient's clinical status changes
  • The patient can be discharged when they achieve their goals
  • Treatment must be prioritised when a patient fits into two or more treatment options
  • The patient's psychosocial status and comorbidities must be considered - when psychosocial factors are high, rehabilitation professionals should provide education on:
    • pain theory
    • muscle relaxation techniques
    • sleep hygiene
    • coping skills
    • catastrophising about pain and diagnostic reports
  • Co-management is needed when medical comorbidities are identified[10]

Managing individuals with low back pain using the TBC has been found to significantly reduce disability and pain compared with current clinical practice guideline standards[16] and enhance clinical-decision making.[4]

Other Classification Systems[edit | edit source]

Mechanical Diagnosis and Therapy[edit | edit source]

Mechanical Diagnosis and Therapy (MDT), also called the McKenzie method, is a system of diagnosis and treatment for spinal and extremity musculoskeletal disorders. Patients are classified into four groups according to their mechanical and symptomatic response to repeated movements and/or sustained positions.

  • derangement:[17]
    • most common syndrome[18]
    • a hallmark of derangement syndrome is a directional preference
    • treatments focus on specific movements that cause pain to decrease, centralise and/or abolish
  • dysfunction syndrome[17]
    • pain is intermittent and occurs at the end range of a restricted movement
    • treatment focuses on repeated movements in the direction of the dysfunction or in the direction that reproduces the pain
      • the aim is to remodel the tissue that limits the movement through exercises, so that movement becomes pain-free over time
  • postural syndrome
    • pain occurs with static positioning of the spine (e.g. sustained slouched sitting)
    • treatment includes patient education, correction of the posture by restoring lumbar lordosis, avoiding provocative postures and avoiding prolonged tensile stress on normal structures[17][19]
  • other on non-mechanical syndrome
    • this group is for individuals who do not fit within one of the three mechanical syndromes but who demonstrate symptoms and signs of other pathologies[20]

For more information on the MDT approach, please see McKenzie Method.

Cognitive Functional Therapy[edit | edit source]

Cognitive Functional Therapy (CFT) is a patient-centred approach that enables individuals to manage their pain by targeting "individual pain-related cognitions, emotions, and behaviours that contribute to their pain and disability."[21] Therapists explore the multidimensional nature of low back pain through the individual's experience while focusing on the following areas:[22]

  • making sense of pain
  • exposure with control
  • lifestyle change[23][21]

For more information, please see Cognitive Functional Therapy and Cognitive Functional Therapy: an integrated behavioral approach for the targeted management of disabling low back pain.[24]

Movement System Impairment[edit | edit source]

The Movement System Impairment (MSI) classification system "involves a standardized examination with several tests of movements and positions to identify mechanically based impairments."[25]

Individuals are classified into one of five subgroups. Treatment focuses on education and exercise to improve classification-specific movement and posture impairments linked to low back pain symptoms. Treatment aims to:[25]

  • minimise certain movements of the lumbar spine
  • promote movement in other joints
  • avoid extreme postures of the lumbar spine in specific directions

For more information, please see Classification Of Low Back Pain Using Shirley Sahrmann’s Movement System Impairments, An Overview Of The Concept.

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ GBD 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023 May 22;5(6):e316-e329.
  2. ↑ 2.0 2.1 Bastos RM, Moya CR, de Vasconcelos RA, Costa LO. Treatment-based classification for low back pain: systematic review with meta-analysis. Journal of Manual & Manipulative Therapy. 2022 Jul 4;30(4):207-27.
  3. ↑ 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.
  4. ↑ 4.0 4.1 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.
  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
  6. ↑ Fritz J, Brennan G, Clifford S, et al. An examination of the reliability of a classification algorithm for subgrouping patients with low back pain. Spine. 2006;31:77-82.
  7. ↑ 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. (Level of evidence 1B)
  8. ↑ 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;75:470 – 485; discussion 485– 479.
  9. ↑ Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther. 2007; 37:290 –302
  10. ↑ 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 10.12 10.13 10.14 10.15 10.16 10.17 10.18 10.19 10.20 10.21 Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. Treatment-based classification system for low back pain: revision and update. Physical therapy. 2016 Jul 1;96(7):1057-66.
  11. ↑ Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59:632–641.
  12. ↑ Linton SJ, Boersma K. Early identification of patients at risk of developing a persistent back problem: the predictive validity of the O¨ rebro Musculoskeletal Pain Questionnaire. Clin J Pain. 2003;19:80–86.
  13. ↑ Finucane L. An Introduction to Red Flags in Serious Pathology. Plus, 2020.
  14. ↑ Melman A, Maher CG, Needs C, Machado GC. Many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause. Clin Rheumatol. 2022 Jun;41(6):1867-71.
  15. ↑ 15.0 15.1 Rainey N. Treatment Based Classification Approach to Low Back Pain Course. Plus, 2023.
  16. ↑ 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
  17. ↑ 17.0 17.1 17.2 May S, Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method.Spine J. 2008;8(1):134-41.
  18. ↑ Sanchis-Sanchez, E., Lluch-Girbes, E., Guillart-Castells, P., Georgieva, S., Garcia-Molina, P. and Blasco, J.M., 2021. Effectiveness of mechanical diagnosis and therapy in patients with non-specific chronic low back pain: a literature review with meta-analysis. Brazilian Journal of Physical Therapy, 25(2), pp.117-134.
  19. ↑ Halliday, M.H., Garcia, A.N., Amorim, A.B., Machado, G.C., Hayden, J.A., Pappas, E., Ferreira, P.H. and Hancock, M.J., 2019. Treatment effect sizes of mechanical diagnosis and therapy for pain and disability in patients with low back pain: a systematic review. journal of orthopaedic & sports physical therapy, 49(4), pp.219-229.
  20. ↑ Mann SJ, Lam JC, Singh P. McKenzie Back Exercises. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539720/
  21. ↑ 21.0 21.1 Kent P, Haines T, O'Sullivan P, Smith A, Campbell A, Schutze R, Attwell S, Caneiro JP, Laird R, O'Sullivan K, McGregor A. Cognitive Functional Therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. The Lancet. 2023 Jun 3;401(10391):1866-77.
  22. ↑ O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther. 2018 May 1;98(5):408-23.
  23. ↑ Miki T, Kondo Y, Kurakata H, Buzasi E, Takebayashi T, Takasaki H. The effect of cognitive functional therapy for chronic nonspecific low back pain: a systematic review and meta-analysis. BioPsychoSocial Medicine. 2022 May 21;16(1):12.
  24. ↑ O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. Cognitive Functional Therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther. 2018 May 1;98(5):408-23.
  25. ↑ 25.0 25.1 Azevedo DC, Ferreira PH, Santos HD, Oliveira DR, de Souza JV, Costa LO. Movement system impairment-based classification treatment versus general exercises for chronic low back pain: randomized controlled trial. Physical therapy. 2018 Jan;98(1):28-39.


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