Treatment-based Classification System for Low Back Pain

Original Editor - Josh McCormack

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Introduction

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

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

The TBC system for low back pain is a model designed to help clinicians make treatment decisions based on a patient's clinical presentation. 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.

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

1. First contact health care provider
2. Rehabilitation provider

First Level of Triage - Determining the Management Approach

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)." Practitioners at this level are responsible for determining an appropriate management approach.

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

• 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.

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". We can use risk profiling tools to identify patients for the self-care management group, including the STarT Back Tool and Orebro Musculoskeletal Pain Questionnaire. Patients triaged to this group will tend to have:

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

Treatment options for self-care management include:

• 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 - and only a small number of patients "amenable" to self-care management will be seen in primary care clinics.

Second Level of Triage - Determining Appropriate Rehabilitation Management

If it is determined that a patient is suitable for rehabilitation management, the rehabilitation provider must determine the appropriate management strategy. 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.

Please note that "patients with a medium-to-high psychological risk profile require psychologically informed rehabilitation" 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.

Symptom Modulation Approach

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

• recent (new or recurrent) episode of low back pain that is "causing significant symptomatic features"
• 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
• traction
• directional preference exercises
• manipulation

See 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:

• 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:

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

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

Functional Optimization Approach

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

• 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:

• 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

• 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

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 and enhance clinical-decision making.

Other Classification Systems

Mechanical Diagnosis and Therapy

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:
  • most common syndrome
  • 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
  • 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
• 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

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

Cognitive Functional Therapy

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." Therapists explore the multidimensional nature of low back pain through the individual's experience while focusing on the following areas:

• making sense of pain
• exposure with control
• lifestyle change

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.

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."

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:

• 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

• Treatment-based classification system for low back pain: revision and update