Post 86: back pain classification

“…it is often not possible to make a specific pathoanatomical diagnosis reliably for patients with low back pain (LBP)…85% to 95% of patients with LBP are diagnosed by their general practitioner as having nonspecific LBP”
 
This is very controversial. We know that back pain exists and exists as an epidemic in terms of how many people. At one point, (again I will try to find the study for a later blog) I read a study that reports at any one point in time there are 5 million Americans with back pain. Put into perspective, this is about the equivalent of the total population of 7 combined states. That’s a massive number of people.
 
RANT: Now for all of these people, we can give a reliable diagnosis to about 500,000 people. OKAY…follow me here. For 4.5 million people, we can not tell them why they are having pain based on population research and prevalence research. The reason why this is controversial is because there is one back specialist in specific, Stu McGill PhD that has said on record many times that there is no such thing as non-specific back pain…only a non-specific assessment. I agree with him partially, there are many patients with a diagnosis of back pain that can be subgrouped into a more specific diagnosis, but I am not willing to say that we can subgroup all patients with back pain into specific diagnoses. Americans should be pissed off. This is an epidemic! Research tells me that I can classify back pain, depending on which classification system I use, in about 75-80% of the cases.
 
Let’s do some math again.
 
Research states that I can classify (doesn’t always mean fixable) about 80% of back pain patients. This correlates to about 4 million of the 5 million people with back pain, we can at least start to give them some answers. This is assuming that they have made it into a clinic that has a physical therapist trained and using (this is another topic for another day) a classification method such as the Treatment-Based Classification System, Movement Impairment System, Mechanical Diagnosis and Therapy, Quebec Task Force system or another system that I may be forgetting off the top of my head, but these are the major systems in the research.
 
Now…research shows that only 7% of patient that have back pain get referred to physical therapy!!! ARE YOU F’NING KIDDING ME! This means that 350,000 patients are seeing a therapist. Continuing with the math that we can classify about 80% of the patients, we can classify 280,000 patients with back pain and 4.6 million are not being assessed by a physical therapist in order to be educated or classified into a syndrome that could be treated.
 
Physical therapists that are well trained can classify patients. This is assuming that there are no other conflicts of interest, such as treating the patient like a bank to simply supply the therapist (more likely the company that the therapist works for) with income. I say to patients many times… “you have the right to choose your therapists. Don’t let your physician tell you that you have to go to a certain therapist.” On the flip side, if you have chosen a physician and have not seen progress in 6 visits, you have to question whether or not that therapist is going to help you. You are not looking for someone that will string you along for 12-30 visits over the course of the year, but instead looking for someone that will give you the guidance and empower you in order to improve. This may or may not include manual therapy, modalities (this will rattle many of my previous students to hear me say that I am okay with using modalities), but will definitely include education and movement. I have heard from many people, including my own personal family, of the stories about going to therapy only to perform all of the exercises on their own and being followed by someone that looks like a high school student. If you are in this type of facility, go seek a therapist that will provide you with personalized care, because that is what you are paying for. I am taking a strong stance on this in this blog because I heard from multiple patients and family members this holiday week about the crappy therapy they are receiving. It upsets me because there are many therapists that are awesome at their job. Unfortunately, these people have only had the experience of the crappy ones, which formulates their opinions of all therapists. It hurts me to the core when I hear a patient say that therapy doesn’t work. It works very well if physical therapy is not seen as a treatment, but an assessment with recommendations either for therapy interventions/treatment or a referral to a specialist outside of therapy. Therapy can’t be seen as treatment, but assessment.
 
END RANT: it’s funny because I’ve already written 2 pages on the blog, but only covered one sentence of the research article.
 
“…most clinicians use pattern recognition and patient profiling in an attempt to optimize treatment outcomes.”
 
I don’t know if I would say that MOST clinicians use pattern recognition to treat patients. I’ve been assessing back pain for a long time now as a therapist and I still see many therapists that use one-size fits all attempt to treat back pain. For instance, as a clinical instructor there are many students that want to give a “shake and bake” style to treating back pain. This means that every patient gets massage, stretching, bridges, abdominal exercises, bird-dog, hollow-out maneuvers, stability ball work and finishes the session with either a hot pack alone or a hot pack with electrical stimulation. If every patient gets the same treatment, then we must believe that every patient has the same problem. If a thorough assessment is not performed, then every patient does have the same problem…low back pain. This needs to be subgrouped into patterns that will give us better outcomes than we have had in the past from just treating everyone the same way. I am by no means saying that this style of treatment won’t benefit some patients, as there is a category of patient that may benefit from this style of therapy. It won’t benefit ALL patients and at that point, we are no longer treating patients as individuals with individual needs.  
 
All of the above systems of categorizing patients stated in the rant are pattern recognition systems. This means that we take a thorough history and hear certain themes in the history that lead us into a specific subgrouping. We perform tests and measures that either rule in the initial theory or rule out opposing theories and then from that point initiate treatment.
 
The second type of treatment approach is called the HOAC (Hypothesis Oriented Approach for Clinicians: all students, at least my students, should know this approach also). This approach is commonly called the test-retest method of treatment. It is not specifically based on patterns and can be better utilized by novice therapists that have not seen thousands of spines from which to recognize patterns.
 
“One of the attempts is a classification-based treatment approach initially developed by Delitto et al and subsequently updated using more recent research”
 
Delitto…this is one of the “oh great gurus of physical therapy” and I say that seriously. As a therapist, I stand on the backs of the greats, and Tony is one of the greats in our profession. I read an article years ago in which he makes a statement that still holds true for me today. “All therapists classify their patients, but the classification system may not be very sophisticated”. For instance, if someone comes into the clinic and is unkempt, with a low level of education, and is looking to dictate treatment, we can make the assumption that this patient may not do well with therapy. This is great and all because we are at least trying to classify, but this type of patient can do excellent in therapy if a more sophisticated way of classifying is used.
 
“The aim of this study was to determine whether the effectiveness of this classification-based approach was generalized to another health care system, other clinicians, and another population. In this study, we compared classfication-based treatment with usual physical therapy care in patients with subacute (6-12 wk) and chronic (>12 wk) LBP.”
 
FOR THE THOUSANDS IN ATTENDANCE AND THE MILLIONS WATCHING AT HOME…LET’S GET READY TO RUMBLE!!!
 
This is huge. Very rarely are two types of therapy facing off against each other to see which type of therapy is more effective. Typically, the research compares a type of therapy to either no therapy or a placebo type of therapy. Another aspect that is important is this: if I treat a group of patients and they all do well, does that mean that my style of treatment is good for all patients and all other therapists to use? Maybe or maybe not, but the only way to know is to test it.
 
“Participants were recruited by physical therapists from 21 private physical therapy clinics in the city of Amsterdam and the surrounding (rural) areas”
 
This is a large number of clinics that are participating in the research. There is more room for error based on the total number of clinics and difficulty in oversight, but having a large number of clinics allows for better generalization of the results. For instance, a study that demonstrates excellent results with patients in a rural area may not translate well to doing the same type of treatment with patients in an urban area.
 
“On the basis of their clinical presentation, patients could fit 1, more than 1, or none of the classification categories, that is, direction specific exercises, manipulation, or stabilization exercises”
 
Direction specific exercises: when categorizing patients with back pain, there is a high number of patients that respond to one specific exercise in order to either reduce or abolish back pain. This is found through both a thorough history and movement assessment. Typically, the direction is extension, but it is not always the case. Previous research on MDT indicates that of those that are classified into the derangement category.
 
Manipulation: This is a thrust manipulation. Means that the therapist will twist the patient in such a way that a small movement will create a change in the joint position and cause the brain to interpret sensations differently. This may or may not be accompanied with an audible “pop” or cavitation.
 
Stabilization exercises: everyone that has been to a physical therapist is familiar with the term core stabilization. This indicates that the patient will be performing exercises in order to activate the muscles from the mid-thigh to the armpit.
 
One category that is left out of this study is the traction category. I am unsure if it is left out because there are so few patients that would benefit from traction that the authors decided not to use this category.
 
“Baseline characteristics…they were largely similar in both groups”
 
This means that before starting treatment that there were no major differences in the patient population. For instance, if one group has all younger patients and another group has all older patients, this study would not be very telling. The younger patients are expected to respond/heal better than older patients.
 
“The classification procedure classified 54% as direction-specific exercises, 27% as manipulation, and 19% as stabilization exercises…The percentage of patients meeting the criteria of a “clear classification” was 74.4%”
 
Let’s break this down. Using the McKenzie method, we can classify about 80% of the patients. Of these patients, about 70-80% are classified as a derangement, indicating that they may have a directional preference. This would be about 56-64% of the patients that may respond to a directional preference exercise. The statistics from the McKenzie method are very similar to those of this study, so I am not too surprised that about half of the patients that in a study or in the general population would be classified according to a single direction.
About 25% of the patients were classified as manipulation and less than 1/5th were classified according to core stability. Although core stability is traditionally offered in PT, and throughout my career has been the largest intervention issued by many of my colleagues, only 1/5th were categorized into this category.
 
“We hypothesized that patients would benefit most from classification-based treatment; however, we found no support for this hypothesis.”
 
Both the control group and the treatment based classification group improved. This is not to say that the classification group is incorrect, but that it is no better than another system…at least in this study.
 
“We did not include the subgroup traction because the Dutch LBP guidelines discourage traction in patients with LBP”
 
A lot of the studies that I am blogging on I have read over the course of 7 years. I forgot the reason that traction wasn’t included, but having read much research reporting that traction is slowly falling out of favor, it makes sense to take it out of the intervention approach.
 
“Ideally, a classification algorithm should classify patients into 1 subgroup only. In this study, using only the first part of the algorithm, 24% of all patients did not meet any of the subgroups and 16% met more than one subgroup”
 
This is concerning in that this system can’t precisely classify 40% of the patients. This is better than no classification system at all, but it needs to be improved. The authors do a good job of providing ways to improve the system. One way is to change directional specific exercises to centralization.
 
“We attempted to provide optimal training and guidance for our treating physical therapists in the classification-based group; however, this support may have been insufficient for optimal competence and may therefore have caused an underestimation of the effectiveness of the direction-specific exercises and consequently also of the classification-based treatment approach”
 
This is the strongest statement of the entire article. Training a therapist is important and I am glad that the authors make the statement that maybe the therapists weren’t trained well enough to utilize this method, which would then make this method unreliable. Not all researchers are trained in the methods to the highest extend in the subject that they are researching. I can tell you that I treat patients in such a different manner than I did 7 years ago, using the same McKenzie method. I still use the same techniques and principles, but my critical thinking skills and pattern recognition skills have advanced over the years to such an extent that I am faster to make decisions and move on from an intervention that is not giving me the desired effect.
 
This brings forth a previous comment that I read from Tony Delitto in an article regarding physical therapists. It is paraphrased, so don’t judge me. Are you a therapist practicing for 20 years with 20 years of experience or are you a therapist that has been practicing for 20 years with one year of experience repeated 20 times?
I’d like to think that I am the former.
 
As I said, I go back and write these blogs long after having actually read the study. This study has some of the heavy hitters of spine care as the authors. I had the privilege to hear Hans van Helvoirt and Maurits W van Tulder speak at varying conferences and these people are among the greats. Julie Fritz has written many of the articles that I blog on. Essentially, this research was done by the “who’s who” of back pain.
 
Excerpts taken from: Apeldoorn AT, Ostelo RW, Helvoirt H et al. A Randomized Controlled Trial on the Effectiveness of a Classification-Based Syste for Subacute and Chronic Low Back Pain. Spine. 2012;37(16):1347-1356.