Treatment-based Classification Research Articles

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 …

Core Stabilization Exercise and Movement System Impairment Approaches for Patients with Movement Control Impairment: A Review Article

Treatment-based and movement system impairment-based classifications have been widely used to identify movement control impairment (MCI) in patients with non-specific low back pain. Clinical observation of aberrant movement patterns is an essential aspect of the examination to identify patients with MCI. The treatment of these patients is a therapeutic exercise that involves static and dynamic stability of core stabilizing muscles. Although exercise prescriptions for these patients are similar, intervention may vary based upon its concept. Interventions include the core stabilization exercise (CSE) approach based upon stabilizing system model, and movement system impairment (MSI) approach based upon kinesiopathologic model. CSE focuses on neuromuscular function to compensate for impairment of intervertebral disc and joints, whereas MSI emphasizes movement correction and enhances movement efficiency to prevent injury and impairment. Both approaches seem equally effective in reducing pain and disability for the MCI group. Therefore, clinicians can utilize either approach for rehabilitating patients with MCI. However, if differences in effectiveness are found when utilizing these different approaches we should explore if the MCI classification needs further definition. In addition, further study needs to investigate the underlying mechanisms in patients with MCI, and the ability of each approach to change those mechanisms.

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.

Movement-based subgrouping in low back pain: synergy and divergence in approaches

BackgroundClassification systems for low back pain (LBP) aim to guide treatment decisions. In physiotherapy, there are five classification schemes for LBP which consider responses to clinical movement examination. Little is known of the relationship between the schemes. ObjectivesTo investigate overlap between subgroups of patients with LBP when classified using different movement-based classification schemes, and to consider how participants classified according to one scheme would be classified by another. DesignCross-sectional cohort study. SettingUniversity clinical laboratory. ParticipantsOne hundred and two participants with LBP were recruited from university, hospital outpatient and private physiotherapy clinics, and community advertisements. InterventionParticipants underwent a standardised examination including questions and movement tests to guide subgrouping. Main outcome measuresParticipants were allocated to a LBP subgroup using each of the five classification schemes: Mechanical Diagnosis and Treatment (MDT), Movement System Impairment (MSI), O'Sullivan Classification (OSC), Pathoanatomic Based Classification (PBC) and Treatment Based Classification (TBC). ResultsThere was concordance in allocation to subgroups that consider pain relief from direction-specific repeated spinal loading in the MDT, PBC and TBC schemes. There was consistency of subgrouping between the MSI and OSC schemes, which consider pain provocation to specific movement directions. Synergies between other subgroups were more variable. Participants from one subgroup could be subdivided using another scheme. ConclusionsThere is overlap and discordance between LBP subgrouping schemes that consider movement. Where overlap is present, schemes recommend different treatment options. Where subgroups from one scheme can be subdivided using another scheme, there is potential to further guide treatment. An integrated assessment model may refine treatment targeting.

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.

Metastatic cancer mimicking mechanical low back pain: a case report

Objective and Importance:The purpose of this report is to describe the clinical course of a patient referred to physiotherapy (PT) for the treatment of low back pain who was subsequently diagnosed with metastatic non-small cell carcinoma of the lung.Clinical Presentation:A 48-year old woman was referred to PT for the evaluation and treatment of an insidious onset of low back pain of 2 month duration. The patient did not have a history of cancer, recent weight changes, or general health concerns. The patient’s history and physical examination were consistent with a mechanical neuromusculoskeletal dysfunction and no red flag findings were present that warranted immediate medical referral.Intervention:Short-term symptomatic improvements were achieved using the treatment-based classification approach. However, despite five PT sessions over the course of 5 weeks, the patient did not experience long-term symptomatic improvement. On the sixth session, the patient reported a 2-day history of left hand weakness and headaches. This prompted the physiotherapist to refer the patient to the emergency department where she was diagnosed with lung cancer.Conclusion:Differential diagnosis is a key component of PT practice. The ability to reproduce symptoms or achieve short-term symptomatic gains is not sufficient to rule out sinister pathology. This case demonstrates how extra caution should be taken in patients who are smokers with thoracolumbar region pain of unknown origin. The need for caution is magnified when one can achieve no more than short-term improvements in the patient’s symptoms.

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

What Characterizes People Who Have an Unclear Classification Using a Treatment-Based Classification Algorithm for Low Back Pain? A Cross-Sectional Study

A treatment-based classification algorithm for low back pain (LBP) was created to help clinicians select treatments to which people are most likely to respond. To allow the algorithm to classify all people with LBP, additional criteria can help therapists make decisions for people who do not clearly fit into a subgroup (ie, unclear classifications). Recent studies indicated that classifications are unclear for approximately 34% of people with LBP. To guide improvements in the algorithm, it is imperative to determine whether people with unclear classifications are different from those with clear classifications. This study was a secondary analysis of data from 3 previous studies investigating the algorithm. Baseline data from 529 people who had LBP were used (3 discrete cohorts). The primary outcome was type of classification, that is, clear or unclear. Univariate logistic regression was used to determine which participant variables were related to having an unclear classification. People with unclear classifications had greater odds of being older (odds ratio [OR]=1.01, 95% confidence interval [CI]=1.003-1.033), having a longer duration of LBP (OR=1.001, 95% CI=1.000-1.001), having had a previous episode(s) of LBP (OR=1.61, 95% CI=1.04-2.49), having fewer fear-avoidance beliefs related to both work (OR=0.98, 95% CI=0.96-0.99) and physical activity (OR=0.98, 95% CI=0.96-0.996), and having less LBP-related disability (OR=0.98, 95% CI=0.96-0.99) than people with clear classifications. Studies from which participant data were drawn had different inclusion criteria and clinical settings. People with unclear classifications appeared to be less affected by LBP (less disability and fewer fear avoidance beliefs), despite typically having a longer duration of LBP. Future studies should investigate whether modifying the algorithm to exclude such people or provide them with different interventions improves outcomes.

Physical Therapy Management of Low Back Pain: A Case-Based Approach

Upon seeing this book described in its title as “A Case-Based Approach,” a reader might expect a series of different clinical presentations of low back pain (LBP). Editors Julia Chevan and Phyllis Clapis use a different strategy, however, innovatively turning this convention on its head by presenting a single case and making physical therapy “approaches” to managing LBP the variable of analysis. The editors created one hypothetical LBP case, then consulted with nine experts in given approaches to treating LBP. Each expert then wrote a chapter describing his or her approach to evaluating and treating this case. The result is an excellent primer on a series of physical therapy approaches to LBP: Cyriax, Kaltenborn–Evjenth, Maitland, McKenzie, Mulligan, Paris, osteopathic, movement system impairments syndromes (a.k.a. Sahrmann), and treatment-based classification. Chevan and Clapis present their book as an introduction to various models that physical therapists use to make sense of LBP, and in this sense it is very successful. By nature, a design that focuses on breadth will inherently lack depth, and the book does not explore any one approach in sufficient detail to allow a clinician to change his or her practice without additional reading or training. As a result, strict adherents of any of the above-listed approaches may take issue with the superficial coverage of their preferred models of care. Nonetheless, I appreciate the value of this resource, having lived the experience of initial orthopaedics training that was a seamless and undeclared synthesis of multiple approaches—a synthesis that unravelled confusingly in the clinical environment through the clashes and contradictions of different approaches. The book's chapters follow a consistent format: each author offers general background to the chosen approach before describing his or her plans to evaluate and intervene in the case. The number of photographs to demonstrate techniques, and of tables and figures to demonstrate principles, varies by chapter, but in general these additions are clear and complement the text nicely. Chevan and Clapis bookend the approach-specific chapters with their own contributions to contextualize trends in LBP and physical therapy responses to it. Most notable is the final (synthesis) chapter, in which the editors emphasize that rarely is any given physical therapist's practice with respect to LBP confined to any one of the approaches described; practice underpinned by combinations of approaches is far more common. They therefore seek to find commonalities among the multiple approaches to demonstrate a synthesis of philosophies. In this endeavour, they are brief and superficial, which I felt was wise, considering the nearly endless list of possible combinations. Other readers, however, may be disappointed that the editors neither suggest specific evaluation and treatment combinations nor declare preferences among the possibilities. Given contemporary trends in physical therapy, one potential weakness of this book is its limited emphasis on evidence-based practice. Since it is the chapter authors who decide how to use research evidence to describe their approach to LBP and justify its relevance to the case, there is considerable variation in how evidence is integrated and presented. In addition, I question why these nine approaches were chosen for inclusion. The editors, both physical therapy educators in the United States, state in the introduction that “we selected models that were brought to our attention by our students” (p. xx). Although this strategy could be considered a reasonable starting point, I would suggest a more systematic process to identify and delineate physical therapy approaches and select those that are most relevant. That said, I do appreciate the book's intention to link each approach to additional resources, including opportunities for continuing education. Nonetheless, Canadian physical therapists will recognize the influence of some of the approaches in existing continuing education offerings. By identifying and differentiating physical therapy approaches to LBP through their application to a practical case, this book particularly serves students or new clinicians looking to establish the foundations of their own clinical practice and to choose from the array of educational options available. Similarly, it could be helpful to clinical supervisors working with physical therapy students or to experienced clinicians willing to question their own philosophies and explore the different ways in which colleagues make sense of LBP. Canadian physical therapists have at our disposal an exciting but daunting array of approaches to address LBP. These approaches can often be synthesized but will sometimes conflict, creating confusion as to what we actually do or should do. I fully agree with Chevan and Clapis, therefore, in feeling that “it is important that the therapist be able to acknowledge the models from which they are ‘borrowing’” (p. 329). By making these approaches explicit, this book helps physical therapists differentiate and know the origins of various approaches, and thus makes an important contribution to the physical therapy literature.

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.

Letter to the editor: response.

We would like to thank the authors of the letter to the editor titled “Other Interventions in Approach to Lumbar Disorders” for reading and providing a commentary to stimulate further discussion regarding the treatment-based classification (TBC) approach to individuals with low back disorders. In the letter to the editor, the authors identify the omission of other possible alternative interventions, including acupuncture, for individuals with lumbar disorders. While we believe that alternative interventions do have a place in the management of individuals with low back disorders, further research is required to determine which characteristics identify individuals most likely to respond to these interventions. The main purpose of a TBC is to identify a priori which patients with low back pain are most likely to respond to a particular intervention.2 In 2 randomized clinical trials, individuals matched to the corresponding interventions had superior outcomes with respect to pain and function compared with those receiving standardized or unmatched interventions.1,3 Subgrouping patients who respond to a particular intervention improves clinical decision making and leads to improved clinical outcomes, shorter duration of care, and decreased economic burden to the patient and health care.1 We believe that this is an important distinction. There are numerous interventions that have reported benefits in the management of individuals with low back disorders, including massage therapy, acupuncture, surgery, injections, and cognitive behavioral retraining.4-7 However, when these interventions are applied to a heterogeneous group of patients with low back pain, the clinical effect sizes tend to be modest. Although some research has reported positive benefits for acupuncture in the management of low back pain, there are little data available about patient characteristics that would predict the best response to this intervention. Witt and colleagues attempted to identify predictive criteria to identify patients who responded favorably to routine medical care plus acupuncture treatment.8 In this study, data were pooled from 4 previous randomized controlled trials including individuals with knee/hip pain, low back pain, neck pain, and headache. Four predictor criteria were found that would indicate a favorable response to acupuncture: female sex, living in a multiperson household, failure of other therapies, and previously positive experience with acupuncture.8 While these data do not provide clear decision making regarding patients with low back disorders only, they do provide an initial outline of patients that may be suitable for adding acupuncture treatment to routine medical care. Furlan and colleagues reviewed and reported on the body of literature regarding the use of acupuncture for low back pain and were unable to draw “firm conclusions” regarding its use in acute low back pain, but they did state that it is better than sham treatments for pain relief in the chronic low back pain populations.5 The authors further state, “Acupuncture is not more effective than other conventional or alternative treatments.” We feel that additional research is necessary to clarify which characteristics clearly identify individuals with low back disorders that respond to acupuncture. Until that research is derived and validated, we believe that is appropriate to leave acupuncture and other alternative treatment options outside of the TBC algorithm.

Letter to the Editor: Other Interventions in Approach to Lumbar Disorders

Dear Editor: With great interest we read the recent article by Burns et al4 titled “A Treatment-Based Classification Approach to Examination and Intervention of Lumbar Disorders.” We would like to commend the authors’ efforts in providing a treatment-based classification approach to low back pain (LBP) in athletes that involves 3 steps. Additionally, this study suggests matching interventions for athletes according to their stage of LBP, which is very informative and robust. However, we think in this article, some therapeutic interventions in approach to athletes with LBP were missed. As it was mentioned in the article, there is an extensive list of differential diagnosis for LBP8; however, most of the causes are infrequently seen in practice.8 It is reported that about 85% of patients with LBP seen in a primary care have no identifiable cause, and so it is termed nonspecific LBP.7 It seems some treatments, such as acetaminophen, nonsteroidal anti-inflammatory drugs, relative rest, coldness, heating, and massage therapy, can also be used to decrease the intensity of pain in patients with nonspecific LBP, while these treatments were missed in the article by Burns et al. In addition, although the effectiveness of alternative medicine for the treatment of chronic nonspecific LBP is not without dispute,13 it currently plays an indispensible role in management of patients with chronic LBP. Acupuncture as a therapeutic intervention is widely used in treatment of patients with nonspecific LBP.13 The superiority of acupuncture to sham acupuncture for pain relief of patients with LBP has not been established in previous studies.15 However, in well-designed randomized controlled studies with a low risk of bias, the effectiveness of this traditional intervention for symptom relief of LBP has been shown.3,10-12 Furthermore, clinical guidelines of societies such as the North American Spine Society,1 the American College of Physicians,5 and the National Institute for Health and Clinical Excellence14 have also recommended acupuncture as a possible treatment option for patients with LBP. On this base, it seems reasonable to consider acupuncture as an effective therapeutic intervention in approach to patients with LBP.2 We agree with the authors that no treatment should be started for patients with LBP before performing a complete diagnostic evaluation and ruling out the major and sometimes life-threatening diagnoses that are called “red flags.” However, considering acupuncture in approach to patients with chronic LBP, which contain the majority of cases of LBP, seems to be useful. The points commonly used for acupuncture of patients with LBP have been listed before,2 although most of the time, supplemental points will also be selected by the physician according to the medical history and pain location of the patients. In use of acupuncture, there is also a list of contraindications, such as bleeding and clotting disorders and warfarin use, that should be considered by the physicians.6 We can suggest that acupuncture might be more effective in a subgroup of LBP patients. In this regard, a review of the literature reveals the following points: Most of published studies that reported the effectiveness of acupuncture in treatment of LBP were carried out on patients with nonspecific LBP in which patients do not have a radicular pain resulting from nerve root compression.9 In some of these studies radiculopathy has been stated as the exclusion criterion for the participants.3,15 In addition, insertion of needles into trigger and painful points has been reported as a part of acupuncture treatment for patients with chronic LBP.9 Therefore, we believe that in Table 4 of the article by Burns et al,4 acupuncture could be added as a therapeutic intervention in patients in stage I. As it is mentioned above, the preferred criteria for doing this intervention on the patients are patients with persistent (> 6 weeks) nonspecific LBP (no radiculopathy pain) who have positive findings of tender or trigger points in their muscles. Sincerely,

Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.

Subgrouping Patients With Low Back Pain

Context:Low back pain (LBP) is a prevalent condition imposing a large socioeconomic burden. Despite intensive research aimed at the efficacy of various therapies for patients with LBP, most evidence has failed to identify a superior treatment approach. One proposed solution to this dilemma is to identify subgroups of patients with LBP and match them with targeted therapies. Among the subgrouping approaches, the system of treatment-based classification (TBC) is promoted as a means of increasing the effectiveness of conservative interventions for patients with LBP.Evidence acquisition:MEDLINE and PubMed databases were searched from 1985 through 2010, along with the references of selected articles.Results:TBC uses a standardized approach to categorize patients into 1 of 4 subgroups: spinal manipulation, stabilization exercise, end-range loading exercise, and traction. Although the TBC subgroups are in various stages of development, recent research lends support to the effectiveness of this approach.Conclusions:While additional research is required to better elucidate this method, the TBC approach enhances clinical decision making, as evidenced by the improved clinical outcomes experienced by patients with LBP.

A Treatment-Based Classification Approach to Examination and Intervention of Lumbar Disorders

Context:Low back injuries are a common occurrence in athletes and often result in missed competition and practice time. The examination of athletes with low back pain commonly involves diagnostic imaging, which rarely guides the clinician in selecting the appropriate interventions.Data Acquisition:All years of PubMed, CINAHL, PEDro, and SPORTDiscus were searched in December 2010. Keywords included treatment based classification and lumbar with the following terms: rehabilitation, treatment, athlete, low back pain, sports, and outcomes.Results:A treatment-based classification approach is preferred for the management of the athlete with low back pain. The treatment-based classification approach involves 3 steps. First is to screen the patient for potentially serious conditions that are not appropriate for conservative management. Second is staging the athlete (based on current disability ratings and ability to perform functional activities). Finally, treatment interventions are selected on the basis of the athlete’s signs and symptoms.Conclusion:The treatment-based classification scheme provides the clinician with a reliable algorithm for matching an athlete’s symptom presentation to the optimal intervention, potentially reducing participation loss. Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards.

Evaluation of a Treatment-Based Classification Algorithm for Low Back Pain: A Cross-Sectional Study

Several studies have investigated criteria for classifying patients with low back pain (LBP) into treatment-based subgroups. A comprehensive algorithm was created to translate these criteria into a clinical decision-making guide. This study investigated the translation of the individual subgroup criteria into a comprehensive algorithm by studying the prevalence of patients meeting the criteria for each treatment subgroup and the reliability of the classification. This was a cross-sectional, observational study. Two hundred fifty patients with acute or subacute LBP were recruited from the United States and Australia to participate in the study. Trained physical therapists performed standardized assessments on all participants. The researchers used these findings to classify participants into subgroups. Thirty-one participants were reassessed to determine interrater reliability of the algorithm decision. Based on individual subgroup criteria, 25.2% (95% confidence interval [CI]=19.8%-30.6%) of the participants did not meet the criteria for any subgroup, 49.6% (95% CI=43.4%-55.8%) of the participants met the criteria for only one subgroup, and 25.2% (95% CI=19.8%-30.6%) of the participants met the criteria for more than one subgroup. The most common combination of subgroups was manipulation + specific exercise (68.4% of the participants who met the criteria for 2 subgroups). Reliability of the algorithm decision was moderate (kappa=0.52, 95% CI=0.27-0.77, percentage of agreement=67%). Due to a relatively small patient sample, reliability estimates are somewhat imprecise. These findings provide important clinical data to guide future research and revisions to the algorithm. The finding that 25% of the participants met the criteria for more than one subgroup has important implications for the sequencing of treatments in the algorithm. Likewise, the finding that 25% of the participants did not meet the criteria for any subgroup provides important information regarding potential revisions to the algorithm's bottom table (which guides unclear classifications). Reliability of the algorithm is sufficient for clinical use.

Radiographic Outcomes After Treatment of Pediatric Supracondylar Humerus Fractures Using a Treatment-Based Classification System

To develop a radiographic method to categorize supracondylar fractures into four types that have logical treatment correlations. The new classification is described, illustrated, and then tested to see if it is reproducible, safe, and effective. Clinical follow-up study. Level I trauma center. One hundred forty-one extension-type supracondylar fractures. According to our system, a long arm cast without reduction was indicated for no or little displacement (Type I), closed reduction and long arm casting was indicated for minimal displacement (Type II), closed reduction and lateral pinning was indicated for moderate displacement (Type III), and closed or open reduction and medial-lateral crossed pinning was indicated for complete displacement (Type IV). Baumann's angle (anteroposterior) and the shaft-condylar angle (lateral). : No significant differences were observed among the four types with respect to changes in Baumann's angle or the shaft-condylar angle. No patient experienced a major loss of reduction and no iatrogenic ulnar nerve injury was encountered. The described treatment-based classification of extension-type supracondylar humerus fractures demonstrates promising results.