Treatment-based Classification System for Low Back Pain

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Description[edit | edit source]

Treatment-based classification (TBC) approach to low back pain describes the model whereby the clinician makes treatment decisions based on the patient's clinical presentation[1]. 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[2][3][4][5] and is used widely in the USA.

TBC was firstly developed in 1995[6] then updated twice in 2007[7] and 2015[8]. The current 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 - Determining the Management Approach[edit | edit source]

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.[9]

Patients with LBP should be triaged using 1 of 3 approaches:

  • Medical management
  • Rehabilitation management
  • or Self-care management[9].

Patients requiring medical management are those with 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).[9]

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[10], Orebro Musculoskeletal Pain Questionnaire[11] or similar self-report questionnaires. These patients usually have:

  • Low levels of psycho-social distress,
  • 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.[12]

The majority of the patients are appropriate for rehabilitation management, as serious pathology is very rare among patients with LBP[13] and patients amenable to self-care management represent a small portion of patients with LBP seen in primary care clinics.[12]

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

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.[9] The three rehabilitation approaches are:

  • Symptom modulation.
  • Movement control.
  • Functional optimisation.

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[14].

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 Behavior Questionnaire, STarT Back Tool)[9]

Symptoms Modulation Approach[edit | edit source]

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

Movement Control Approach[edit | edit source]

The movement control approach is used for LBP patients who are stable, have moderate to low pain and whose disability is considered moderate. Treatment for these individuals include sensorimotor, stabilisation and flexibility exercises.[8]

Functional Optimization Approach[edit | edit source]

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[9].

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, including aerobic, strength and conditioning exercises.[9][8]

Clinical Considerations[edit | edit source]

  • 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[9].
  • The patient can be discharged at any point when rehabilitation goals are attained.[9]
  • 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[9].
  • When 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[15].
  • When medical comorbidities are identified, medical co-management is necessary[9].

Key Evidence[edit | edit source]

Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards[16] and enhances clinical decision making[2].

Presentations[edit | edit source]

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 Treatment Based Classification Approach to Low Back Pain

This presentation, created by Jeff Ryg as part of the 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

References[edit | edit source]

  1. ↑ 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.
  2. ↑ 2.0 2.1 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.
  3. ↑ Brennan G, Fritz J, Hunter S, et al. Identifying subgroups of patients with acute/subacute nonspecific low back pain. Spine. 2006;31:623-631
  4. ↑ 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.
  5. ↑ 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)
  6. ↑ 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.
  7. ↑ 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
  8. ↑ 8.0 8.1 8.2 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.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Therapy, P. (2015). The Treatment-Based Classification System for Low Back Pain : Revision and Update, (December). https://doi.org/10.2522/ptj.20150345
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 12.0 12.1 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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).
  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


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