Low Back Pain Treatment-Based Classification

With the lumbar spine comprising 20% of the OCS exam, knowing both Fritz's 2007 treatment-based classification system and Alrwaily's 2016 update is essential to passing the exam. Dr. David Smelser breaks down these systems and includes a case study at the end.

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Transcript

Hello and welcome back to our continuation of our low back pain series. Today we are finally getting into treatment. You will recall that in our last episode, we read a portion of the CPG that stated, “The best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed.” So here’s the situation: as a medical community, we have realized that false positives on MRI and the huge number of potential pain-generating structures in the back make it really hard to identify the specific pain-generating structure in a low back pain case. So we gave up trying to group people based on painful structure. But we can see that not all back pain behaves the same way. And when we treat all back pain the same, our outcomes in research and practice are not great. So the CPG continues: “While many interventions have been dismissed as either ineffective or accompanied with small effect sizes when studied in people with heterogeneous,  nonspecific low back pain, recent reports in the literature suggest that interventions based on subgroup classification have the potential to enhance effect sizes over studies where the identical interventions were administered in a one-size- fits-all approach.”

There are several different types of classification systems. The McKenzie approach is one type. But the CPG authors strongly prefer what is called the treatment-based classification approach, where individuals with back pain are grouped according to similar clinical characteristics that suggest a specific type of treatment might be more effective for them than for a group with different clinical characteristics. The first attempt to do this was by Anthony Delitto in 1995. You will notice that Delitto is also the primary author on the CPG, which partially explains the CPG’s passion for this classification method. But there’s more than just favoritism going on here: several studies have shown improved results when treatments are matched to patients using a treatment-based classification system.

So what does this have to do with the OCS exam? Well, this treatment system is a clear favorite of some of the most prolific researchers in our field right now, including big names like Julie Fritz. And since the CPG relies heavily on it, and since 20% of the OCS exam is material covering the lumbar spine, you are bound to see this material pop up again and again on the exam. So let’s get into what you need to know:

I mentioned that Delitto was the first one to create a treatment-based classification system. His system was helpful but is now fairly outdated, so I’m not going to get into it. The first major revision was done by Fritz, Cleland, and Childs in 2007. You might hear this called, “Treatment-Based Classification 2.0.” You might be pretty familiar with this system already, but because this is so likely to show up on the exam, it’s worth spending a few minutes of this podcast reinforcing what you already know. The 2007 Fritz classification model would go on to be superseded by a third iteration in 2016 by Alrwaily and colleagues. However, the third iteration incorporates a lot of Fritz’s material, so you need to know both.

The 2007 treatment-based classification system by Fritz divides patients into one of four different treatment groups: manipulation, stabilization, specific exercise, and traction. Some of these categories were based on strong evidence, and some were not.

The first group, manipulation, is based on strong evidence, and we’ll cover it first. This group is based on the clinical prediction rule for lumbar manipulation that was developed by Flynn and then validated by Childs and repeated by Cleland. I’d love to take a whole episode to dive into these studies, but I won’t right now. Instead, here’s the gist: Flynn found five characteristics that predicted which individuals with back pain would respond well to lumbar manipulation. These characteristics are: no symptoms distal to the knee, a recent onset of symptoms (meaning <16 days), a Fear-Avoidance Beliefs Questionnaire-Work Subscale score of <19, at least one hypomobile segment in the lumbar spine, and at least 35 degrees of internal rotation in at least one hip. This group had a greater than 50% improvement in their ODI within 1 week of treatment. If an individual met 3/5 criteria, there was a 68% chance of success with manipulation. If an individual met 4/5, there was a 95% chance of success. When subsequent studies validated this rule, people who met the criteria and were manipulated recovered much faster than those who were given exercise or those who just received joint mobilization. So when you get a low back pain case on the OCS exam, and the question asks what kind of treatment you should administer, you should be looking for at least 3 of the following characteristics: no symptoms distal to the knee, onset of symptoms <16 days, FABQ-Work score of <19, at least one hypomobile lumbar segment, and hip internal rotation of at least 35 degrees in at least one hip. I would be shocked if you didn’t see this on the exam. I will also note that in the first two studies, the manipulation that was performed was the supine “Chicago roll” or “million dollar roll” SI joint thrust technique. The third study found the same results with the sidling lumbar thrust technique. And in all three studies, the manipulation was followed by pelvic tilts. So if, on the exam, you had to pick a specific lumbar manipulation technique, this rule was created and validated with the supine SI joint thrust and with the sidling lumbar thrust. And if you have to pick an exercise to do immediately after the manipulation, pick pelvic tilts.

Before we move on to the other three treatment-based classification categories, I want to point out one more thing that this clinical prediction rule tells us: manipulation appears to be most useful in the acute phase of back pain. If you’re looking at a patient with back pain that started less than 16 days ago and all the symptoms are above the knee, you’ve already met two out of three criteria for manipulation. There’s a good chance you will want to manipulate this patient.

But let’s move on to the second treatment group: stabilization. Fritz and colleagues describe this group as follows: younger age (<40 years old), greater flexibility (either postpartum or with a straight leg raise of >91 degrees), instability catch or aberrant movements during lumbar flexion and extension, and positive prone instability test. They also note that postpartum patients with positive pelvic instability tests, like the active straight leg raise, fit this category as well. So, one more time, here are the criteria: age less than 40, increased flexibility with a straight leg raise of at least 91 degrees, an instability or aberrant movement with lumbar flexion/extension, and a positive prone instability test. If we were to describe common diagnoses in this group using pathoanatomical terms, these are often the spondylolisthesis and postpartum pelvic pain patients. A preliminary clinical-prediction rule indicated at least three of the features we just listed need to be present for an individual to have an 80% chance of improvement with stabilization exercises. One last time, that’s age under 40, increased flexibility, instability catch or aberrant movements, and positive prone instability test.

The third group is specific exercise. If we were to do the thing I said we shouldn’t do and describe this group by pathoanatomical diagnosis, these are your disc derangement and lumbar stenosis patients. The classification criteria are: symptoms distal to buttock, older age, and directional preference for flexion or extension. Keep in mind that a directional preference can include either centralization, where the pain moves proximally and closer to midline, or a decrease in pain with repeated flexion or extension. So an individual can have a directional preference if their pain decreases even if their pain does not centralize. If an individual fits this group, they will be treated based on their directional preference: those with a decrease in pain or centralization with lumbar flexion will be treated with flexion-based exercises, and those with a decrease in pain or centralization with lumbar extension will be treated with extension-based exercises. There’s also a very small “lateral shift” group that fits into this category as well, which is treated by correcting the lateral shift. Easy enough.

Finally, the fourth group is traction. So here’s the deal with lumbar traction: research has failed to consistently identify a subgroup of patients who benefit from lumbar traction. So this is the least evidence-based category. However, both clinicians and researchers still believe there are some patients who probably benefit from traction. So the criteria for the traction category are: signs and symptoms of nerve root compression, and peripheralization of symptoms with flexion and extension. Signs and symptoms of nerve root compression would include symptoms like pain and sensory disturbances in dermatomal patterns, diminished deep tendon reflexes, myotomal weakness, positive nerve tension tests, or a positive crossed straight leg raise. So in other words, if they look like someone who should be in the specific exercise category—meaning they have radiating pain distal to the buttock—but they don’t have any directional preference and AROM in both directions makes them peripheralize, they might benefit from traction.

For the next decade, this 2007 treatment-based classification system—relying on manipulation, stabilization, specific exercise, and traction subgroups—would be shown to be more effective at treating low back pain than non-matched treatment methods. However, there are a couple problems. First, it didn’t work for everyone. Researchers found that about 50% of individuals with low back pain fit one category well. But 25% fit more than one category, and 25% didn’t fit any category. So when it worked, it worked—but it didn’t always work. The second problem is that it didn’t quite fit what we commonly see and do in clinical practice. In the clinic, we don’t manipulate the same patient every visit and never do stabilization exercises with them. In the clinic, we typically use at least two of these treatment techniques with the same patient over the course of their plan of care. So in 2016, Alrwaily and colleagues published a new treatment-based classification, or TBC 3.0.

This treatment-based classification system changed the game in a couple ways. First, it adds an initial triage stage where a clinician determines if the patient is appropriate for rehab, if they have red flags and need to be referred for more medical management, or if they have such low pain and so few risk factors that they can self-manage. The second way the 2016 classification changed things up is by grouping patients on a continuum based on their symptom severity and irritability. Patients are grouped into one of three rehab approaches: symptom modulation for those with high disability, high pain, and irritable symptoms; or movement control for those with moderate disability, moderate to low pain, and stable symptoms; or functional optimization for those with low disability, low pain, and well-controlled symptoms. As a patient progresses with rehab and their pain decreases, they might move from the symptom modulation category into the movement control category. This might even happen within a single treatment. Or if they have a flare up, they might move back into the symptom modulation category for a couple days. You can see that this approach fits much more nicely with real life in the clinic.

So within each of these three rehab approaches, there are specific matched treatments. Let’s talk about each rehab category in a little more detail.

First, symptom modulation. This is the category for those with high disability (like an Oswestry score greater than 40%), high pain (like a numeric pain rating scale of 7 or higher), and volatile symptoms (or what we might call high irritability—sudden symptom onset and difficult to control). In this category, we have directional preference exercises, manipulation or mobilization, traction, and active rest. You can already see three of Fritz’s categories here, right? Directional preference exercises are for those who fit the “specific exercise” criteria we already mentioned. The manipulation/mobilization category are for those who fit the manipulation CPR. You’ll notice that mobilization is allowed here. Now on the exam, unless the case mentions that the patient has a fear of manipulation, you should always choose to manipulate this group instead of mobilizing them, because all our evidence says manipulation gets patients better weeks faster than mobilization. However, mobilization does help too—it’s just slower. So it’s included here out of a recognition that not every clinician is comfortable manipulating and not every patient is comfortable being manipulated. But anyway, back to treatments. Next we have traction, which is still only for those with signs of nerve root compression who peripheralize with both flexion and extension. And finally, we have a new “active rest” category, which is for patients who are being seen within 24 hours of injury, who are very irritable and very inflamed, and who need to wait for the inflammation to calm down. This needs to be done without giving the patient any instructions that might increase fear, like, “Wear this back brace and don’t move.” These patients need to be encouraged to practice “active rest”: take it easy, rest, but don’t be afraid to move and do things. Then I’ll see you in another day or two.

Let’s move on to the movement control approach. This is for individuals with moderate disability (so think about a 21-40% ODI score), moderate to low pain (so around a 3-6 on the numeric pain rating scale), and stable, predictable symptoms. These patients are matched to sensorimotor exercises (which are typically something like nerve glides), stabilization exercises, and flexibility exercises. As this group’s pain decreases—as their sensitized neural structures are desensitized by sensorimotor exercises, and their motor control improves with stabilization exercises, and their mobility is regained with flexibility exercises—they will progress to the third rehab approach: functional optimization.

The functional optimization group is for those with low disability (think 0-20% on the ODI), low pain (0-3 on the numeric pain rating scale), and well-controlled symptoms. This group receives strength and conditioning exercises, work- or sport-specific tasks, aerobic exercises, and general fitness exercises. Note that this could be the the last stage of rehab, but it could also fit a lot of patients with chronic low back pain. So you could have a case of a patient with a years-long history of 3/10 back pain that is stable and predictable, but it’s giving him more trouble at work. He doesn’t feel limited in his daily life by his pain—it’s just always there—but he wants to regain full work function with less pain and difficulty. This patient might be appropriate to go straight to the functional optimization approach and work on work hardening, aerobic exercises, and general fitness.

Okay, what’s the point? You are highly, highly likely to get at least a few patient cases on the OCS where you have to pick the best treatment approach for a patient with low back pain. And your treatment options are most likely to be based on these treatment-based classification systems. But even beyond the OCS, treating your patients with these categories in mind will help you identify the most appropriate treatments for your patients. So let’s take a real case from my personal clinical experience with some details changed to protect the patient’s identity. This sort of case is straight from my clinical practice, but it could just as easily be an OCS question.

Jane was a 68-year-old patient in good health and who was generally active before a sudden onset of radiating low back pain that began 1 week ago after bending over and twisting her back to pick something up from the ground. The pain radiated down her anterior thigh, knee, and medial calf down to her ankle. It was 9/10 severe pain, she was unable to walk without a cane, and her gait was very antalgic. The pain would come on suddenly with certain movements, but she couldn’t describe the movements and she didn’t know how to get the pain to calm down. She came to PT as a direct access patient. In the clinic, Jane’s pain peripheralized with flexion and extension. She demonstrated a positive crossed straight leg raise with significant neural tension. She denies bowel or bladder changes and denies saddle anesthesias. She has hypertension, but no other relevant medical history.

First, is this patient appropriate for PT? Let’s practice red flag screening from the last episode. The only red flag mentioned is her age. The pain is severe, but at this point it is clearly connected to a mechanism of injury and clearly connected to lumbar movements. Her age and female sex place her at increased risk for compression fractures, but she has no history of compression fractures, so our determination was that it would be safe to evaluate her but refer out if she failed to progress or if she started showing severe, progressive neurological deficits.

So if she’s appropriate for rehab, what rehab approach does she fit? Is she symptom modulation, movement control, or functional optimization? She’s clearly symptom modulation with severe pain, significant disability, and volatile symptoms. Now what treatment does she receive? Is she directional preference, manipulation/mobilization, traction, or active rest? She has signs of nerve root compression, and her pain peripheralizes with flexion and with extension, so she fits the traction category. So she was treated with intermittent traction and self-traction techniques. 

3 days later, she returned to the clinic feeling significantly better. She still walked with an antalgic gait, but her pain at worst was down to a 7/10, and it was currently a 6/10. Her lumbar ROM now demonstrates peripheralization of pain with extension, but centralization of pain with flexion. She still has a crossed straight leg raise. So now what treatment category does she fit? Now she fits directional preference for flexion-based exercises. So she was treated with a progression of repeated flexion exercises.

10 days later, she returned with her pain at a 4/10. Her symptoms are now more predictable, and she can control them with her home exercises. She continued to centralize with flexion, and at that point her pain was above her knee. Her nerve tension is no longer present, and her straight leg raise is now 92 degrees bilaterally. She demonstrates some aberrant movements when returning to neutral from full flexion and has difficulty maintaining that motion in a single plane. What rehab approach does she fit now? Is she symptom modulation, movement control, or functional optimization? With her reduced pain and stable symptoms, she is now in movement control. And what treatment does she get? Sensorimotor, stabilization, or flexiblity? She fits stabilization the best.

This patient went on to make a full recovery and transition to functional optimization with just about 3 weeks of rehab. And you can see how she happened to fit both Fritz’s 2007 treatment-based classification and Alrwaily’s 2016 update. I happened to work with this patient just a couple months before I took my OCS exam, and applying these classification systems to her really helped me remember the material, and I’m convinced it helped me get her better faster.

So in the coming months, keep a copy of these classification systems in front of you, and apply them to your patients. It’s going to help you pass the exam, and it might make you a better therapist.

That wraps up this podcast, and I hope you found it helpful. I’ve decided that we’re going to put some links on our website to helpful articles like these treatment-based classification systems. This will be a work-in-progress, so keep watching our website for updates.