Treatment-based Classification System for Low Back Pain

Original Editor - Josh McCormack

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Introduction

Low back pain is a common diagnosis with a prevalence of 11.9%. To help clinicians provide the best treatment options, several clinical practice guidelines have been published. The four common models for stratifying LBP include

1. Treatment Based Classification (TBC)
2. Mechanical Diagnosis and Therapy (MDT)
3. Cognitive Functional Therapy (CFT)
4. Movement System Impairment(MSI)

Description

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. 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 and is used widely in the USA.

TBC was firstly developed in 1995 then updated twice in 2007 and 2015. 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

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.

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 co-morbidities that do not respond to standard rehabilitation management (eg, rheumatoid arthritis, central sensitisation).

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, Orebro Musculoskeletal Pain Questionnaire 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.

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. 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.

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)

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 immobilisation
• active rest

Movement Control Approach

The movement control approach is used for LBP patients whose pain is described as moderate to low with certain movements/activities, but decreases to a low level baseline when the movement ceases. Their pain affects activities of daily living. Interventions are targeted to improve the quality of their movement through the use of sensorimotor, stabilisation and flexibility exercises.

Functional Optimization Approach

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.

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.

Clinical Considerations

• The 3 approaches are mutually exclusive
• Reclassification can occur as clinical status changes
• When goals are attained the patient can be discharged
• Prioritisation of treatment occurs when patients fit into 2 or more treatment options
• Psycho-social factors should be discussed with patient when needed including:
  • pain theory
  • muscle relaxation techniques
  • sleep hygiene
  • coping skills
• Co-management is needed when medical co-morbidities are identified

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

Mechanical Diagnosis and Therapy

Mechanical diagnosis and therapy (MDT) also referred to as McKenzie method is a treatment technique for chronic low back pain based on a comprehensive diagnostic classification system. This diagnostic classification system uses four categories:

• derangement:
  • managed with repeated or sustained end-range positions according to directional preference
  • end-range symptom response noted: centralisation, pain intensity and postural correction
• dysfunction
  • treated with repeated end-range movement based on movement loss
  • goal is to gradually increase range and decrease pain intensity over time
  • location of central LBP does not change
• postural
  • treated solely with postural correction techniques

Cognitive Functional Therapy

Cognitive functional therapy (CFT) is a patient-centred approach that targets psychological, lifestyle and physical barriers to recovery. CFT is a physiotherapy-led intervention that facilitates patient self-management of emotions and behaviours contributing to their pain and disability. Therapists explore the mutidimensional nature of LBP through the individuals own experience while focusing on the following three factors:

1. Making sense of the pain
2. Exposure with control
3. Lifestyle change

Movement System Impairment

Movement system impairment (MSI) involved a standardised assessment to identify movement and positions causing impairment. It classifies patients into 1 of 5 subgroups. The main focus of treatment is to minimise specific spine movements, encourage movement in other joints and avoiding extreme lumbar spine postures in specific directions. Interventions using the MSI involve education and exercise prescription to correct impairments of movements and postures linked to LBP symptoms.