Treatment-based Classification System for Low Back Pain

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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 the most appropriate treatment, including:[2]

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

This page focuses on Treatment Based Classification.

Description[edit | edit source]

The TBC approach to 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 approach is to identify features at baseline that predict responsiveness to three different treatment strategies. This approach has been validated.[4][5][6][7]

TBC was firstly developed in 1995.[8] It has been updated twice, first in 2007[9] and then in 2015.[10] The current TBC 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 level of triage, "the triage can be assumed by any practitioner competent in LBP care, regardless of his or her pro�fessional 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 model, at this initial contact, patients with with low back pain should be triaged using one of three 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 serious co-morbidities that will not respond to rehabilitation, such as rheumatoid arthritis or central sensitisation.[10]

If red flags or serious pathologies/co-morbidities 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 co-morbidities
  • 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 the 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]

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.[10] 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[15].

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)[10]

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 whose pain is described as moderate to low with certain movements/activities, but decreases to baseline once movement ceases. Their pain affects activities of daily living. Interventions are targeted to improve the quality of the patients movement through the use of sensorimotor, stabilisation and flexibility exercises.[10]

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[10].

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.[10]

Clinical Considerations[edit | edit source]

  • 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[10]

** 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[4].

Mechanical Diagnosis and Therapy[edit | edit source]

Mechanical diagnosis and therapy (MDT) also referred to as the McKenzie method is a treatment technique for chronic low back pain based on a comprehensive diagnostic classification system. This diagnostic classification system divides into three 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[17][18]

Cognitive Functional Therapy[edit | edit source]

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.[19] 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[20][19]

Movement System Impairment[edit | edit source]

Movement system impairment (MSI) involves 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. [21]

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 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. ↑ 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.
  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. ↑ 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.
  18. ↑ 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.
  19. ↑ 19.0 19.1 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.
  20. ↑ 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.
  21. ↑ 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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