Low Back Pain Treatment Classification: Let’s Just Flip a Coin

Subgrouping of patients into specific treatments for low back pain is in an advancing era here lately.  I am sure you have heard of this somewhere out there, but maybe even so in a past post of mine here.  In short, this approach is basically taking several signs, symptoms and clinical exam procedures of your low back pain patients to a specific treatment approach based on EBM.

Honestly, I give high credibility to the researchers who have taken the daunting task to create these classifications.  In all reality, how do you base treatments on a diagnosis that is precisely unknown in 80-90% of the time?

– First, the underlying pathophysiology is unknown and multiple structures can be the cause of the pain (we are looking at discs, facets, ligaments, muscles, nerve roots, etc).

– Clinical examination can be somewhat helpful but clinical tests are not greatly useful (+LR are usually low & not conclusive) and asymmetry upon physical palpation does not necessarily mean pathology.

– Also, radiographic evidence does not give us much hope either due to the false positive rates and symptoms do not necessarily correlate with the pathology see on film.

So, as you can imagine, we are working blind in a puddle of mud.

A new study in Physical Therapy discussed an algorithm and gave data on prevalence of patients & reliability for each individual subgroup criteria.

There are currently 4 treatment subgroups with individual criteria present in the literature.

Click on the subgroup below for original research study as it the above is very small.

1.  Manipulation

2.  Stabilization

3.  Specific Exercise

4.  Traction

I am not going to go over each individual one in this post (maybe in future) but the algorithm below is available for your use (again, sorry so small).

As you can see, the classification system is intended to do the 3 things that we normally do in our exam:

1.  Provide a clinical (or physical therapy) diagnosis

2.  Formulate options and consider the possible therapies

3.  Provide the optimal treatment and decide what is best in this particular circumstance

I do think this is a good first step in defining what we do as therapists into more evidenced-based practice.  It is not perfect by any means, but is a start.  The following are several quotes from the article to summarize the results.

“This study showed that approximately 25% of the patients with LBP met the criteria for more than one subgroup when using the individual subgroup criteria”

-Based on this, you will more than likely use more than one individual treatment group, which we all know matches in our clinical setting.

“The most common subgroups that we found to overlap were the specific exercise and manipulation groups (using the individual subgroup criteria), accounting for 68.4% of patients who met 2 subgroups”

Based on this, it would be best to choose both of these groups, rather than just one.  But didn’t past studies show that a non-specific exercise program is just as good as a specific one?

“…25% of the patients with LBP did not meet the criteria for any of the treatment subgroups…”

Based on this, choosing a treatment subgroup would be unclear in 1/4 of patients.  What do we do with these patients?!

“Approximately 50% of patients either meet the criteria for more than one subgroup or none of the subgroups…”

Based on this, we can just flip a coin when deciding to either go with this algorithm.

There are multiple limitations and other discussions in the article.  I would recommend you read it all here as it is honestly too much for this post.

Bottom line, further research is warranted.  This algorithm is a start and there will be more I’m sure.  It is not intended to provide perfection, which is unreasonable in the field of medicine.  Let’s keep in mind that this gives science to the heavily weighted art of physical therapy. But remember, no rules, standards or policies will ever replace the good ol’ practitioner reasoning and clinical judgment.

So for now, continue to manip, tuck your belly buttons and perform repeated motions as I’m sure they all work, individually and together.  If you want evidence, flip a coin but better yet, use common clinical sense.

Spratt KF, Lehmann TR, Weinstein JN, Sayre HA: A new approach to the low-back physical examination.  Spine. 15(2):96-102, 1990.

Stanton TR, Fritz JM, Hancock MJ et al.  Evaluation of a Treatmend-Based Classification Algorithm for Low Back Pain: A Cross-Sectional Study.  Physical Therapy. 91(4): 496-509. 2011.