Treatment-based Classification System Research Articles

The Use of Cluster Analysis by Partitioning around Medoids (PAM) to Examine the Heterogeneity of Patients with Low Back Pain within Subgroups of the Treatment Based Classification System.

Current evidence in low back pain (LBP) focuses on population averages and traditional multivariate analyses to find the significant difference between variables. Such a focus actively obscured the heterogeneity and increased errors. Cluster analysis (CA) addresses the mentioned shortcomings by calculating the degree of similarity among the relevant variables of the different objects. This study aims to evaluate the agreement between the treatment-based classification (TBC) system and the equivalent 3 cluster typology created by partitioning around medoids (PAM) analysis. In this cross-sectional study, a convenient sample of 90 patients with low back pain (50 males and 40 females) aged 20 to 65 years was included in the study. The patients were selected based on the 21 criteria of 2007 TBC system. An equivalent 3 cluster typology (C3) was applied using PAM method. Cohen's Kappa was run to determine if there was agreement between the TBC system and the equivalent C3 typology. PAM analysis revealed the evidence of clustering for a C3 cluster typology with average Silhouette widths of 0.12. Cohen's Kappa revealed fair agreement between the TBC system and C3 cluster typology (Percent of agreement 61%, Kappa=0.36, P<0.001). Selected criteria by PAM analysis were different with original TBC system. Higher probability of chance agreement was observed between two classification methods. Significant inhomogeneity was observed in subgroups of the 2007 TBC system.

Feasibility of using Treatment based Classification System to Plan Management of Patients with Low Back Pain

Background: Low back pain (LBP) is an extremely common symptom and most troublesome of complaints in the general population. Pain can vary from a dull constant ache to a sudden sharp feeling. At any point in time 80% of general population will experience some type of low back pain1. Treatment efficacy for the increasing prevalence of this back pain is a great challenge for both health care providers and individuals coping with this problem3. In order to select an effective and efficient treatment in daily clinical practice, low back pain patients should be classified by symptoms during testing and physical examination. One of the main classification systems which focus individual clinical presentation is treatment based classification system. Treatment based classification system will also have impact on clinical decision-making in the management of low back pain3. Objectives: To educate all therapist working with patients with back pain to categorize each patients using treatment based classification system. To establish the consistency and accuracy of therapists in using treatment based classification system for patients with LBP. To analyze therapists opinion of the feasibility of treatment based classification system to plan the management of LBP. Study design: Observational study Method: A total of 46 patients were recruited in this observational study. Each patients was assessed and allocated to treatment based classification system. Visual analogue scale and Patient-Specific Functional Scale for first and last day of the treatment was taken and number of session also documented by the trained therapist. Results: Results were analysed by the questions obtained from the five therapists. All five agreed for the accuracy in categorization and time, 60% agreed for the consistency in usage and goal setting and only 40% agreement for the usefulness. The total feasibility level was 75%. Conclusion: The study concludes that using TBC system to plan management for low back pain is feasible in terms of categorization, accuracy and time but not cost effectiveness.

Treatment Effect Sizes of Mechanical Diagnosis and Therapy for Pain and Disability in Patients With Low Back Pain: A Systematic Review.

Mechanical Diagnosis and Therapy (MDT) is a treatment-based classification system founded on 3 core principles: classification into diagnostic syndromes, classification-based intervention, and appropriate application of force. Many randomized controlled trials have investigated the efficacy of MDT for low back pain; however, results have varied. The inconsistent delivery of MDT across trials may explain the different findings. To compare treatment effect sizes for pain or disability between trials that delivered MDT consistent with the core principles of the approach and trials that met some or none of these principles. In this systematic review, databases were searched from inception to June 2018 for studies that delivered MDT compared to nonpharmacological, conservative control interventions in patients with low back pain and reported outcomes of pain or disability. Studies were classified as "adherent" (meeting the core principles of MDT) or "nonadherent" (using some or none of the principles of MDT). Data were extracted by 2 independent reviewers. Meta-regression procedures were used to analyze the effect of delivery mode on clinical outcomes, adjusting for covariates of symptom duration (less than or greater than 3 months) and control intervention (minimal or active). Studies classified as adherent to the MDT approach showed greater reductions in pain and disability of 15.0 (95% confidence interval: 7.3, 22.7) and 11.7 (95% confidence interval: 5.4, 18.0) points, respectively, on a 100-point scale compared to nonadherent trials. This review provides preliminary evidence that treatment effects of MDT are greater when the core principles are followed. Therapy, level 1a. J Orthop Sports Phys Ther 2019;49(4):219-229. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8734.

Treatment-based Classification System for Patients With Low Back Pain: The Movement Control Approach.

We present the movement control approach as part of the treatment-based classification system. This approach proposes a movement control schema that clarifies that movement control is a product of the interplay among multiple biopsychosocial components. The schema illustrates that for movement to occur in a dynamically controlled fashion, the lumbar spine requires both local mobility and global stability. Local mobility means that the lumbar spine and its adjacent regions possess adequate nerve and joint(s) mobility and soft tissue compliance (ie, the malleability of tissue to undergo elastic deformation). Global stability means that the muscles of the lumbar spine and its adjacent regions can generate activation that is coordinated with various joint movements and incorporated into activities of daily living. Local mobility and global stability are housed within the bio-behavioral and socio-occupational factors that should be addressed during movement rehabilitation. This schema is converted into a practical physical examination to help the rehabilitation provider to construct a clinical rationale as to why the movement impairment(s) exist. The examination findings are used to guide treatment. We suggest a treatment prioritization that aims to consecutively address neural sensitivity, joint(s) and soft tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient's needs. We emphasize that treatment for patients with low back pain is not a static process. Rather, the treatment is a fluid process that changes as the clinical status of the patient changes. This movement control approach is based on clinical experience and indirect evidence; further research is needed to support its clinical utility.

On “Treatment-Based Classification System for Low Back Pain: Revision and Update.” Alrwaily M, Timko M, Schneider M, et al. Phys Ther. 2016;96:1057–1066.

We would first like to congratulate the authors on their update of the treatment-based classification (TBC) system.1 As we attempt to move forward in finding the most appropriate path for the clinical management of low back pain (LBP), it's critical to reflect on the systems we utilize and make appropriate adjustments and improvements when and where they are warranted. We are hopeful that the statement regarding “more convergence than divergence” among the systems indicates a scientific readiness to work together in the future for improved patient outcomes. We do feel compelled, however, to correct inaccuracies with several of the statements made. First, the cited reference for the categorical statement that “TBC is the most extensively researched classification system in the field of physical therapy”1(p1058) is the 2012 article by Karayannis et al.2 Examination of this reference reveals no substantiation of …

Treatment-Based Classification System for Low Back Pain: Revision and Update.

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.

Outcomes are not different for patient-matched versus nonmatched treatment in subjects with chronic recurrent low back pain: a randomized clinical trial

Background contextClassification schemas for low back pain (LBP), such as the Treatment-Based Classification and the Movement System Impairment, use common clinical features to subgroup patients with LBP and are purported to improve treatment outcomes. PurposeTo assess if providing matched treatments based on patient-specific clinical features led to superior treatment outcomes compared with an unmatched treatment for subjects with chronic recurrent LBP. Study designThis study is a randomized controlled trial. Patient sampleSubjects (n=124) with LBP (≥12 months) with or without recurrences underwent a standardized clinical examination to group them into one of two strata: ineligible or eligible for stabilization exercises based on the Treatment-Based Classification schema. Subjects underwent additional clinical tests to assign them to one of the five possible Movement System Impairment categories. Outcome measuresQuestionnaires were collected electronically at Week 0 (before treatment), Week 7 (after the 6-week 1-hour treatment sessions), and 12 months. Using the Oswestry disability index (0–100) and the Numeric Pain Rating Scale (0–10), the primary analysis was performed using the intention-to-treat principle. Secondary outcomes included fear-avoidance beliefs and psychosocial work-related and general health status. MethodsAfter subjects were categorized based on their particular clinical features using both the Treatment-Based Classification and Movement System Impairment schemas, they were randomized into one of two treatments using a 3:1 ratio for matched or unmatched treatments. The treatments were trunk stabilization exercise or Movement System Impairment–directed exercises. ResultsOf the patients allocated to treatment for this study, 76 received a matched treatment and 25 received an unmatched treatment. After treatment, both groups showed a statistically significant improvement in the primary outcome measures and almost all the secondary measures; however, the matched treatment group did not demonstrate superior outcomes at Week 7 or 12 months, except on one of the secondary measures (Graded Chronic Pain Scale [Disability Scale]) (p=.01). ConclusionsProviding a matched treatment based on either the Treatment-Based Classification or the Movement System Impairment classification schema did not improve treatment outcomes compared with an unmatched treatment for patients with chronic LBP, except on one secondary disability measure.

Prosthetic guidelines for ocular rehabilitation in patients with phthisis bulbi: A treatment-based classification system

Prosthetic rehabilitation of phthisis bulbi defects is the only treatment option for cosmetic rehabilitation of patients with such defects. Currently, there is no treatment-based classification for prosthetic rehabilitation of patients with phthisis bulbi. Phthisical ocular defects and/or prosthetic rehabilitation were evaluated in an attempt to establish prosthetic guidelines that could be organized into a classification system. Fifty patients who received rehabilitation for phthisis bulbi were reviewed. Phthisis bulbi defects were divided into 4 classes. All the patients had rehabilitation, depending upon the class to which they were assigned. The aim of this treatment-oriented classification system was to organize and define the complex nature of the restorative decision-making process for patients with phthisis bulbi.

Is Posterior Delamination in Arthroscopic Rotator Cuff Repair Hidden to the Posterior Viewing Portal?

The purposes of this study were (1) to examine whether posterior delamination is hidden to the most commonly used posterior viewing portal compared with differential rotator cuff portals and (2) to observe posterior delamination patterns so that a treatment-based classification system may be proposed. One-hundred thirty consecutive patients undergoing arthroscopic rotator cuff repair by 4 different surgeons were evaluated for the presence of posterior delamination viewable through the posterior, posterolateral, and lateral portals. Randomized arthroscopic pictures were viewed by 2 independent blinded observers, and the Fleiss κ was used to assess inter-reliability agreement. In addition, patterns of posterior delamination and surgical treatment were assessed. The incidence of posterior delamination was 88%. Only 11% of cases were visualized through the posterior portal, whereas 70% and 100% were visualized through the posterolateral and lateral portals, respectively. The Fleiss κ was 0.78 (95% confidence interval, 0.73 to 0.83), indicating substantial agreement. Three general patterns of posterior delamination with specific surgical repair strategies were identified and subclassified into 5 types: type A1, full-thickness tears with extensive posterior delamination separating the rotator cuff into 2 layers and sometimes with dissociation of the rotator cable; type A2, bursal-sided partial-thickness tears with posterior delamination; type B1, delamination with an L-shaped bursal layer tear and crescent-shaped articular layer tear; type B2, a partial-thickness articular-sided tear with extensive posterior delamination; and type C, extensive degeneration with multiple longitudinal bursal-sided tears. The incidence of posterior delamination is extremely high, and most of these lesions are missed if one is viewing from just the posterior portal. Differential rotator cuff portals are needed to appreciate and treat posterior delamination. Patterns of delamination can be classified according to surgical repair strategy. It is important to recognize that the rotator cable may delaminate from the cuff and not to mistake it for a "retracted" articular layer, as previously described. Level II, prospective comparative study.

In Memoriam: A Tribute to Robin McKenzie, Musculoskeletal Visionary

Previous article Next article Full AccessEditorialIn Memoriam: A Tribute to Robin McKenzie, Musculoskeletal VisionaryStephen May, PT, PhD, MA, FCSP, Dip MDT, , PT, PhD, MA, FCSP, Dip MDTMark Werneke, PT, MS, Dip MDT, PT, MS, Dip MDTAuthorsStephen May, PT, PhD, MA, FCSP, Dip MDTSearch for more papers by this author, Mark Werneke, PT, MS, Dip MDTSearch for more papers by this authorJournal of Orthopaedic & Sports Physical TherapyPublished Online:August 27, 2013Volume43Issue7Pages442-442https://www.jospt.org/doi/10.2519/jospt.2013.0106SectionsPDFPDF PLUS ToolsAdd to FavoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinkedInRedditEmail AboutAbstractWe are saddened by the passing of Robin Anthony McKenzie on May 13, 2013.J Orthop Sports Phys Ther 2013;43(7):442. doi:10.2519/jospt.2013.0106“My patients taught me all I know.”We are saddened by the passing of Robin Anthony McKenzie on May 13, 2013. Robin was a renowned clinician, international speaker, educator, and author. He started his career in the field of physiotherapy in the 1950s and worked for many years in private practice in Wellington, New Zealand.When Robin began developing his musculoskeletal classification and treatment concepts back in the 1950s and 1960s, there was very little epidemiological evidence to guide him. He was, however, an astute observer of his patients' posture and movements. By chance encounter, he observed that 1 of his patients, while lying in extension on a treatment table, reported his back and leg pain abolished. That fortuitous moment started lifelong clinical observations, experimentations, and the development of a treatment-based classification system now known as the McKenzie classification system, or mechanical diagnosis and therapy.Robin's treatment-based classification system was extraordinarily ahead of its time and transformed the world of physiotherapy and the care of patients with musculoskeletal problems. Robin was the first clinician to recognize the clinical phenomena of centralization and directional preference and the importance of placing his patients at the center of care. The first book he wrote on his self-care patient method, titled Treat Your Own Back, was specifically aimed at educating and empowering individuals to deal independently with their back problems. This always remained a key tenet of his philosophy, and a whole series of Treat Your Own books followed.Download FigureDownload PowerPointRobin initially wrote textbooks for clinicians in 1981 and 1990 on the lumbar and cervical spine; these were thoroughly updated between 2000 and 2006 for the application of his approach to extremity, lumbar, and cervical problems. His work influenced thousands of clinicians. His classification system is one of the most popular methods practiced by physiotherapists worldwide during their everyday clinical practice.Robin's ideas and treatment concepts were developed from his clinical practice; the research to support these ideas came later. But that research is now substantial and growing. As Nikolai Bogduk put it in the introduction to Robin's Lumbar Spine textbook, “Indeed, in many respects, the McKenzie movement has led the way in undertaking research into its precepts, and has implicitly called upon other concepts to catch up. No other system in physical therapy has attracted as much research both from its proponents and its detractors.”Robin McKenzie was not just a physiotherapist. He enjoyed sailing, gardening, and, above all, was a great family man. He will be deeply mourned by the worldwide “McKenzie family,” but especially by his immediate kin. He is gone, but neither he nor his work will be forgotten. While Robin will be greatly missed by the thousands of therapists and the hundreds of thousands of patients whose lives he influenced and improved, his legacy will forever continue for the benefit of our work and those we treat.FiguresReferencesRelatedDetails Volume 43, Issue 7July 2013Pages: 439-514 PDF download

THU0557 Low-Frequency Pulsed Electromagnetic Field Therapy for Non-Specific Neck Pain

BackgroundThere are several types and causes of neck pain. Non-specific neck pain is the most common type. In most of the cases an underlying pathology cannot be definitively determined. It...

Reliability of a Treatment-Based Classification System for Subgrouping People With Low Back Pain

Observational, cross-sectional reliability study. To examine the interrater reliability of novice raters in their use of the treatment-based classification (TBC) system for low back pain and to explore the patterns of disagreement in classification errors. Although the interrater reliability of individual test items in the TBC system is moderate to good, some error persists in classification decision making. Understanding which classification errors are common could direct further refinement of the TBC system. Using previously recorded patient data (n = 24), 12 novice raters classified patients according to the TBC schema. These classification results were combined with those of 7 other raters, allowing examination of the overall agreement using the kappa statistic, as well as agreement/disagreement among pairwise comparisons in classification assignments. A chi-square test examined differences in percent agreement between the novice and more experienced raters and differences in classification distributions between these 2 groups of raters. Among 12 novice raters, there was 80.9% agreement in the pairs of classification (κ = 0.62; 95% confidence interval: 0.59, 0.65) and an overall 75.5% agreement (κ = 0.57; 95% confidence interval: 0.55, 0.69) for the combined data set. Raters were least likely to agree on a classification of stabilization (77.5% agreement). The overall percentage of pairwise classification judgments that disagreed was 24.5%, with the most common disagreement being between manipulation and stabilization (11.0%), followed by a mismatch between stabilization and specific exercise (8.2%). Additional refinement is needed to reduce rater disagreement that persists in the TBC decision-making algorithm, particularly in the stabilization category. J Orthop Sports Phys Ther 2012;42(9):797-805, Epub 7 June 2012. doi:10.2519/jospt.2012.4078.

Development of Physiotherapy Guidance and treatment-based Classifications for People With Huntington’s Disease

SUMMARY Background: Physiotherapy may provide a means of delaying onset or progression of Huntington’s disease (HD), resulting in improved daily functioning and quality of life. Physiotherapy is being more frequently recommended for people with HD, but there have been no specific guidelines published for implementation of a structured physiotherapy program. The Physiotherapy Working Group (PWG) of the European Huntington’s Disease Network (EHDN) set out to develop a comprehensive Guidance Document for physiotherapists to provide best practice guidelines. Methods: A review of the literature was conducted using a systematic approach. There was insufficient literature in support of physiotherapy interventions and approaches to be able to conduct a complete evidenced-based review, therefore, physiotherapy expert subgroups were formed to incorporate consensus as to best practice. A draft document was distributed to the entire membership of the working group, to outside physiotherapists and other healthcare professionals within EHDN to elicit feedback and comments. Results: A Guidance Document covering eight specific areas pertaining to physiotherapy management of HD was developed. In order to facilitate the document’s practical usability among clinicians, a treatment-based classification system is proposed to categorize patients based on presenting signs and symptoms, and provide a foundation for development of a more standardized intervention approach. Discussion: The Physiotherapy Guidance for HD is a comprehensive, consensus- and evidence-based document that can be used by physiotherapists to implement a plan of care that is currently consistent with best practice for individuals at all stages of HD. As evidence becomes available, future systematic reviews will be required in order to inform further development. The use of treatment-based classifications, which aim to better categorize common signs and symptoms and link them to appropriate intervention plans, may be useful in relatively rare diseases, such as HD, to aid clinical reasoning and promote effective outcome evaluation.

Inter-examiner reliability of a proposed decision-making treatment based classification system for low back pain patients

Evolving evidence has shown increased clinical outcomes, when low back pain (LBP) patients are classified and receive matched physical treatment. The present study aimed to examine the inter-examiner reliability of a proposed new decision-making classification system for non-specific LBP patients, using a mixed simultaneous and independent examiner design. With minimal familiarization, two pairs of experienced physiotherapists trained in Orthopedic Manual Therapy (OMT) at two different out-patient clinics in primary care, examined and classified 64 consenting consecutive patients. Further, inter-examiner reliability on five examination items was examined. The agreement between examiners was expressed by percentage of agreement (%) and by the un-weighted (κ) or weighted (κw) kappa coefficient. The overall % agreement, categorizing patients into one of four classifications was 80% and κ = 0.72. For each classification, pain modulation, stabilization exercise, mobilization and training, agreement was 90%, 83%, 58% and 89% (κ = 0.77, 0.67, 0.11 and 0.75), respectively. Agreement on five individual examination items was; irritability 82% (κw = 0.41), specific movement pattern 68% (κ = 0.38), specific segmental signs 67% (κ = 0.28), uni- or bilateral signs 62% (κ = 0.42), and neurological signs and symptoms 92% (κ = 0.84). This study demonstrated that this new classification system had substantial inter-examiner reliability when used by clinically experienced OMT-trained physiotherapists. Agreement within classification was substantial, except for mobilization which was poor. Inter-examiner reliability for the individual examination items varied from fair to almost perfect. Further studies are needed to investigate utility and validity of this new classification system.

The cost-effectiveness of a treatment-based classification system for low back pain: design of a randomised controlled trial and economic evaluation.

BackgroundSystematic reviews have shown that exercise therapy and spinal manipulation are both more effective for low back pain (LBP) than no treatment at all. However, the effects are at best modest. To enhance the clinical outcomes, recommendations are to improve the patient selection process, and to identify relevant subgroups to guide clinical decision-making. One of the systems that has potentials to improve clinical decision-making is a treatment-based classification system that is intended to identify those patients who are most likely to respond to direction-specific exercises, manipulation, or stabilisation exercises.Methods/DesignThe primary aim of this randomised controlled trial will be to assess the effectiveness of a classification-based system. A sample of 150 patients with subacute and chronic LBP who attend a private physical therapy clinic for treatment will be recruited. At baseline, all participants will undergo a standard evaluation by trained research physical therapists and will be classified into one of the following subgroups: direction-specific exercises, manipulation, or stabilisation. The patient will not be informed about the results of the examination. Patients will be randomly assigned to classification-based treatment or usual care according to the Dutch LBP guidelines, and will complete questionnaires at baseline, and 8, 26, and 52 weeks after the start of the treatment. The primary outcomes will be general perceived recovery, functional status, and pain intensity. Alongside this trial, an economic evaluation of cost-effectiveness and cost-utility will be conducted from a societal perspective.DiscussionThe present study will contribute to our knowledge about the effectiveness and cost-effectiveness of classification-based treatment in patients with LBP.Trial registrationTrial registration number: NTR1176

On “Ilial anterior rotation…” Vaughn HT, Nitsch W. Phys Ther. 2008;88:1578–1590.

I was surprised by the content of the article by Vaughn and Nitsch1 and the inductive and often contradictory logic used throughout the case report. The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm.2,3 This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, transcutaneous electrical nerve stimulation, ice, ultrasound, massage, and taping.4–8 The active treatment provided to the patient appears to be based on inductive reasoning to address the pseudo-diagnostic category arrived at by a series of nonvalid tests, proposed by the authors, and poorly supported by the evidence and anecdotal reference to opinion-based papers. In the introduction, the authors do review the current evidence-based literature and outline that most testing procedures for the sacroiliac (SI) complex have poor validity, yet proceed to ignore this and use the nonvalid tests …

Multimodal Management of Mechanical Neck Pain Using a Treatment Based Classification System

The purpose of this case study was twofold: 1) to illustrate the use of a treatment-based classification (TBC) system to direct the early intervention of a patient with mechanical neck pain, and 2) to show the progression of this patient with multimodal-modal intervention. The patient exhibited axial neck pain with referral into her upper extremity. Her pain peripheralized with cervical range of motion and centralized with joint mobilization placing her primarily in the centralization category. Her poor posture and associated muscle weakness along with the chronicity of symptoms placed her secondarily into the exercise and conditioning group resulting in a multi-modal treatment as the patient progressed. Although the design of this case report prevents wide applicability, this study does illustrate the effective use of the TBC system for the cervical spine as captured by accepted outcomes measures.

March 2008 Erratum

Correction to the name of a co-author of an article originally published in the Journal of Orthopaedic & Sports Physical Therapy in 2007. Kiesel KB, Underwood FB, Mattacola CG, Nitz AJ, Malone TR. A comparison of select trunk muscle thickness change between subjects with low back pain classified in the treatment-based classification system and asymptomatic controls. J Orthop Sports Phys Ther. 2007;37(10):596–607. 2007 Author index. J Orthop Sports Phys Ther. 2007;37(12):770–785. J Orthop Sports Phys Ther 2008;38(3):161. doi:10.2519/jospt.2008.38.3.161

A Comparison of Select Trunk Muscle Thickness Change Between Subjects With Low Back Pain Classified in the Treatment-Based Classification System and Asymptomatic Controls

Cross-sectional descriptive. To investigate if muscle thickness change, as measured with rehabilitative ultrasound imaging (RUSI), is different across subgroups of patients with low back pain (LBP), classified in the Treatment-Based Classification (TBC) system, when compared to controls. Researchers have demonstrated that subgroups of patients with LBP exist and respond differently to treatment, challenging the assertion that LBP is "nonspecific." The TBC system uses 4 categories (stabilization, mobilization, direction specific exercise, or traction) to subgroup patients. Recently, researchers have demonstrated impairments of the transverse abdominis (TrA) and lumbar multifidus (LM) in those with LBP, regardless of classification. Although distinct differences in impairments have been identified between subgroups, TrA and LM impairments have not been studied and may be present across categories of the TBC system. RUSI was utilized to measure percent thickness change from rest to contracted state during a voluntary task of the TrA and during an upper extremity task known to activate the LM in 56 subjects classified in the TBC system and 20 controls. During the prone upper extremity lifting task with a hand weight, there was a significant group difference for the LM at L4-L5 (P = .03) and at L5-S1 (P = .04), and during volitional activation for the TrA (P < .01). Post hoc testing revealed the differences were between controls and both the direction specific and stabilization categories at the L4-L5 level, between control and direction specific category for the L5-S1 level, and between controls and all 3 categories for the TrA. Deficits in the ability to generate muscle thickness changes in the TrA and LM occurred across categories of the TBC system. Intervention studies should be performed to determine if intervention can correct these deficits and if deficit corrections are related to outcomes.

A new treatment based classification system for fractures of the bony orbit

Introduction: Orbital fractures are common and may be isolated or associated with other injuries of the facial skeleton and soft tissues. The floor is often fractured in isolation but orbital fractures can involve all walls. To date there has not been report of a classification system based on treatment algorithm, only on anatomical location of injury.