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) (also known as the McKenzie Method)
  3. Cognitive Functional Therapy (CFT)
  4. Movement System Impairment (MSI)

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

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 TBC 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 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 level of triage, "the triage can be assumed by any practitioner competent in LBP 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 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 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 TBC, the three rehabilitation approaches are:

  • Symptom modulation
  • Movement control
  • Functional optimisation

Patients are classified into one of the three groups based on their levels of pain and disability, and the clinician's perception of the 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]

Symptoms Modulation Approach[edit | edit source]

A symptoms 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 specific activities, but returns to 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 that is aggravated by sudden / unexpected movement
  • typically have full active range of motion but may have altered movement patterns
  • may have reduced flexibility, muscle activation, and motor control on examination

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

  • addressing sensitised neurological structure (e.g. neurodynamic techniques)
  • flexibility exercises (may include manual therapy also 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[edit | edit source]

A functional optimization 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 (i.e. status well controlled)
  • have impairments in movement system endurance, strength, and power rather than flexibility or motor control deficits

Intervnetions aim to maximise physical performance in order to enable these individuals to participate in high-level activities. It is important that treatments focus on optimising performance based on the individual's specific work/job requirements. Interventions include:[10]

  • aerobic exercises
  • strength and conditions 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]

  • These three 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 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
    • catastrophiding about pain and diagnostic reports
  • Co-management is needed when medical co-morbidities are identified[10]

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