Low Back Pain -One size doesn’t fit all
Epidemiological studies show that 80% of people will experience low back pain in their lifetime; approximately 25% of people report having had pain in the previous 3 months, and up to 80% of individuals with back pain will have pain that recurs.1 Because of this, the amount of research into appropriate care of nonspecific low back pain is significant; however, it is very inconclusive for the most part as patients included in studies represent a wide cross section of individuals with symptoms likely originating from different sources and patients with differing demographics.
Many years ago patients with low back pain had to traipse from one therapist to another in an attempt to find a treatment that worked for them. A McKenzie therapist, a manipulative therapist, a therapist trained in acupuncture, a Cyraix trained therapist, exercises, traction/decompression, etc. There was little consistency in how back pain was managed. This method of trial and error would quickly eat through extended benefits and put the patient at risk of developing chronic pain.
There cannot be a single approach to the treatment of nonspecific low back pain because in most cases there is no single definitive cause. Less than twenty percent of people with low back pain can be provided with a diagnosis based on pathology of a particular structure in the spine.2 Just as we would not treat all shoulder pain the same way, we should not treat all low back pain the same way. Amongst individuals with nonspecific low back pain we can identify homogenous subgroups of patients with similar characteristics that respond similarly to a method of treatment. We know there are subgroups of patients that will respond to mobilization/manipulation, a group that responds to a McKenzie protocol involving exercises in a specific direction, a subgroup that responds to traction/decompression, and a subgroup that responds particularly well to strengthening/stabilization exercises.
There has been ongoing evolution of this classification system which triages patients into different paths of care and subdivides low back pain sufferers into groups based on the clinical symptoms, behaviour of pain, responses to movement testing, acuity, hypo/hypermobility, age, psychosocial factors, among others.3 Using this algorithm and clinical prediction rules in physiotherapy, we can more accurately determine which patient will benefit from which treatment, which exercise, which manual technique, and which modality. Through a thorough physiotherapy evaluation we can determine in which subgroup(s) a patient may reside, base treatment on this information, and hence optimize outcomes in the shortest time.
For more information on the history of the treatment based classification system refer to the following article: https://academic.oup.com/ptj/article-lookup/doi/10.2522/ptj.20150345
- Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine 2006;31:2724–7.
- Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine 1995;20:11-19.
- M Alrwaily, M Timko, M Schneider, J Stevans, C Bise, K Hariharan, A Delitto; Treatment-Based Classification System for Low Back Pain: Revision and Update, Physical Therapy 2016; 96(7):1057–1066.
Rebecca White | Nov 15, 2017 at 10:23 am
This is a great post that refers to how we have progressed in the treatment of low back pain.
What are your thoughts on the lack of validation for several of the sub classifications of the treatment based classification scheme?
Janice | Nov 15, 2017 at 2:41 pm
Very good point Rebecca. We are trained using a pathoanatomical model: if something hurts, we need to find what’s broken. The TBC approach means we have to think differently because subgrouping patients based on an implied putitive pathology is not valid and very controversial. I think we are on the right road in trying to triage patients that are likely to respond to certain treatments based on their characteristics, we need more research to identify these characteristics. We need the broad initial cohort studies to identify common characteristics; we need studies that validate the existence of these subgroups; and, we need the studies to test the ability of that subgrouping to influence clinical decision making. Treatment can easily be changed if improvements aren’t seen quickly.
Jennifer Lee | Nov 17, 2017 at 12:41 pm
So, where does this leave clinical reasoning?
Janice | Nov 21, 2017 at 2:53 pm
Clinical reasoning comes into play even in stage 1 of LBP as some patients do not respond as predicted.1 A solid evidence-informed PT will recognize this failure to progress, alter course as needed, and rapidly refer to the appropriate provider if failure persists.
1. Chen J, Phillips A, Ramsey M, Schenk R. A Case Study Examining the Effectiveness of Mechanical Diagnosis and Therapy in a Patient who Met the Clinical Prediction Rule for Spinal Manipulation. Manual & Manipulative Thera. 2009;17(4):216–220.
Violetta | Dec 20, 2017 at 6:30 pm
Finally, some solid advice on the internet!
William B. | Sep 22, 2018 at 12:42 pm
Chris | Apr 12, 2020 at 9:28 pm
Absolutely great information for the public to know.