What is treatment based classification of lower back pain?

Treatment-based classification approach to low back pain describes the model whereby the clinician makes treatment decisions based on the patient's clinical presentation. It is a clinical prediction rule that groups patients based on their signs and symptoms. The primary goal is to identify features at baseline which will determine success or failure of treatment of the basic treatment strategies.

First level: Determining appropriate management approach (level of first healthcare provider)

At this level, patients are triaged into three categories:

1. Medical management
2. Rehabilitation management
3. Self management

Medical management

This triages those with:

• Red flags (e.g., fracture, cancer)
• Comorbidities that do not respond to standard rehabilitation management (e.g., rheumatoid arthritis, central sensitisation)
• Progressive neurological deficits

Rehabilitation management

For a patient to be put in this category, they should have the following:

• Medium to high psychological risk
• Low psychological risk with predominantly leg pain
• Controlled comorbidities

Self-management

For a patient to belong to this category, they should have:

• Low psychological risk
• Predominantly axial LBP
• Minor or controlled comorbidities

Treatment of patients under self-care management may involve patient education that consists of reassurance about the generally favourable prognosis for acute LBP and advice about medication, work, and activity.

Responsibilities of a physiotherapist

After first level of classification and noted that a patient is appropriate for rehabilitation, the therapist should determine if the patient requires:

• Symptom modulation
• Movement control
• Functional optimization

It should be noted that these classification citeria are based on:

• Pain levels
• Disability
• Clinician’s perception of the overall clinical presentation, not how long the patient has had the symptoms.

Evaluation of psychosocial status of the patient is important in order to determine if psychologically informed physiotherapy is needed. Outcome measures such as Fear Avoidance Behaviour Questionnaire can be used to assess psychosocial status.

Symptom modulation

Symptom modulation is ideal for patients presenting with the following:

• Recent or recurrent episodes of LBP that is currently causing significant symptomatic features
• Posture deviation (avoiding certain postures)
• Limited and painful AROM
• Increased sensitivity with neurological examination

In this group, patients are treated mainly with manual therapy, directional preference exercises (McKenzie), traction and or immobilisation.

Movement control

Movement control is prioritised to patients with new onset of LBP with significant symptomatic features. These patients might be initially treated with symptom modulation to reduce their pain before functional impairments are handled. After treating the pain,

• Address the functional impairments that dominate the clinical picture
• If after the symptom modulating treatment the patient has minimal pain and disability, they may be discharged
• Patient does not have any recent history of a significant LBP episode, but
  • Symptoms started gradually.
  • For no known reason.
• The pain is at a low baseline level but could be aggravated by certain ADLs then returns to baseline level when the activity is stopped.
• For this patient, the impairment of normal activities is more bothersome rather than the pain itself.
• The patient may not benefit from treatments directed only toward symptom modulation.
• Movement control approach should be utilized first without having to pass through the symptom modulation approach.
• Patients may describe recurrent/ repeated episodes of pain that are aggravated with sudden/unexpected movements, but they experience asymptomatic intervals between episodes.
• These patients may shift between symptom modulation and movement control approaches according to their status at the moment of clinical presentation.
• The examination for movement control specifically aims to assess the local mobility and the general stability.

Aims for assessment in movement control are:

To investigate if lumbar movement is hindered by impairment in the following domains:

• Neural mobility: using neural dynamic assessment such as slump test, straight leg raise test, and femoral nerve tension test.
  • Significant nerve root tension signs suggest that the patient may not be appropriate for the movement control approach instead he/she should be classified into the symptom modulation approach
  • Alternatively, a patient with impaired neural mobility may receive neurodynamic techniques
• Joint(s) mobility: to investigate whether the lumbar spine and adjacent regions possess proper joint alignment and ability to move freely within physiologic limits. It involves:
  • Observing spinal curvatures,
  • Observing alignment relationships,
  • Assessing mobility of the joints
• Soft tissue mobility: to determine if soft tissue mobility is impaired which may result in:
  • Faulty movement compensations and in coordination may result and can possibly lead to injury
  • Soft tissue mobility impairments can be addressed with various types of manual therapy interventions.

Functional Optimisation

For patients who are relatively asymptomatic,

• They can perform activities of daily living but need to return to higher levels of physical activities (e.g., 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.

Clinical Considerations

• The patient can be discharged at any point when rehabilitation goals are attained
• A patient may fit in one or two treatment approaches
• Educate the patient about pain theory, muscle relaxation techniques, sleep hygiene, and coping skills and address catastrophizing about pain and diagnostic findings if psychosocial factors are high
• Rehabilitation goals change with patient status
• Prioritise treatment
• When medical comorbidities are identified, medical co-management is necessary

2nd level: Subgrouping Patients

At the rehabilitation level, patients are grouped based on their clinical presentation in order to decide the best treatment approach. In 1995 Delitto and colleagues proposed a classification system intended to inform and direct the physical therapy management of patients with low back pain. Due to improvement in knowledge via research, this initial classification has undergone modification and refinement. Research has shown that decisions made by physiotherapists in the management of patient based on this classification results in better outcome than using other procedures.
This classification, commonly known as treatment-based classification is a clinical prediction rule that groups patients based on their signs and symptoms. The following are classes in which patients can belong to for optimal treatment of their conditions:

• Manipulation
• Stabilization
• Specific exercise
  • Extension
  • Flexion
  • Lateral shift
• Traction

Manipulation subgroup

To be classified as someone who can benefit from manipulation, there should be:

• No symptoms distal to the knee
• Recent onset of symptoms (< 16 days)
• Low FABQW score (< 19)
• Hypomobility of the lumbar spine
• Hip internal rotation ROM (>35° for at least 1 hip)

Interventions in Manipulation:

• Manipulation of the lumbopelvic region and active range of motion exercises

Stabilisation Subgroup

The following is a criterion to classify a patient into stabilisation group:

• Younger age (< 40 years)
• Greater general flexibility (postpartum, average SLR ROM >91°)
• “Instability catch” or aberrant movements during lumbar flexion/extension ROM
• Positive findings for the prone instability test
• For patients who are postpartum:
  • Positive posterior pelvic pain provocation (P4), and ASLR and modified Trendelenburg tests
  • Pain provocation with palpation of the long dorsal sacroiliac ligament or pubic symphysis

Interventions Under Stabilisation Subgroup Include:

• Promoting isolated contraction and co-contraction of the deep stabilizing muscles (multifidus, transversus abdominus)
• Strengthening of large spinal stabilizing muscles (erector spinae, oblique abdominals)

Specific Exercise Subgroup

Patients in specific exercise subgroup can be subdivided into:

Extension:
1. Symptoms distal to the buttock
2. Symptoms centralize with lumbar extension
3. Symptoms peripheralize with lumbar flexion
4. irectional preference for extension
Flexion:
5. Older age (>50 years)
6. Directional preference for flexion
7. Imaging evidence of lumbar spinal stenosis
Lateral shift:
8. Visible frontal plane deviation of the shoulders relative to the pelvis
9. Directional preference for lateral translation movements of the pelvis

Interventions in the Specific Exercise Subgroup

Extension

• End-range extension exercises
• Mobilization to promote extension
• Avoidance of flexion activities

Flexion

• Mobilization or manipulation of the spine and/or lower extremities
• Exercise to address impairments of strength or flexibility
• Body weight-supported treadmill ambulation

Lateral shift

• Exercises to correct lateral shift
• Mechanical or autotraction

Traction Criteria to be categorised for traction:

• Signs and symptoms of nerve root compression
• No movements centralize symptoms

Intervention in the traction subgroup:

• Mechanical traction or
• Auto traction

Importance of Subgrouping LBP Patients:

• Helps to determine responders and non-responders to a treatment approach
• Cost effective