Lumbopelvic Pain Treatment Classification

Treatment Based Classification of Lumbopelvic Pain

• Treatment-based classification systems have evolved over the past 30 years
• The goal is to match patients to appropriate treatments
• The aim is to improve patient outcomes
• The aim is to improve research quality
• Studies show that matching interventions to patients' classifications leads to superior outcomes

Objectives

• Demonstrate understanding of the Treatment Based Classification system in the management of lumbopelvic pain.

Treatment Based Classification

• Match patients with appropriate interventions to improve outcomes
• Reduce heterogeneity in research to allow for better comparison of interventions
• Make more powerful recommendations and move away from the pathoanatomical model (Delitto 1995, Fritz 2007, Alrwaily 2016).

TBC - Delitto 1995

• Organized into 3 broad levels (consultation, physical therapy, referral)
• Focused on triage and classifying based on symptom severity (acute, chronic) rather than stage.
• First level classification decides which patients can be treated by physical therapists independently verses those needing multidisciplinary management or referral to another healthcare provider
• Staging criteria uses Oswestry scores to approximate clinical judgment of functional limitations (eg: sitting, standing, walking). Activities of daily living (ADL), not solely on self-reported limitations
• There are three stages of classification (I, II, III) with different intervention focus and goals

TBC - Fritz 2007

• Updated based on research since 1995
• Focus on examination findings, less on triage or symptom severity
• Clinical prediction rules (CPRs) are used in treatment planning
  • Tools to make clinical decision making in treatment and diagnosis
  • Developed by recruiting patients, conducting standardized history and physical exams, giving everyone the treatment, and statistically determining which factors play the largest role in outcome.

Classifications Based on Fritz 2007

• Manipulation:
• Recent onset of symptoms (<16 days)
• No distal symptoms (below the knee)
• Low pain questionnaire (FABQ(W) score <19)
• Hypomobility of lumbar spine (e.g., segmental limitation)
• Hip internal rotation ROM > 35 degrees
• Interventions: HVLAT (thrust) of the lumbopelvic region and AROM exercises.
• Stabilization:
• Age < 40 years
• Greater general flexibility (average SLR >91°)
• Instability "catch" (aberrant motion) during trunk flexion/extension
• Prone instability test (+ results)
• Interventions: Isolated and co-contraction of segmental stabilizing muscles; strengthening large stabilizing muscles; improve function of other stabilizing mechanisms; hydraulic cylinder
• Specific Exercises:
• Extension: Sx distal to buttock, centralizes with lumbar extension, peripheralizes with lumbar flexion, directional preference for extension, Age > 50 years, imaging evidence of lumbar spinal stenosis. Interventions include: end-range extension exercises, manual therapy, flexibility exercises, body-weight support, and avoidance of flexed positions and flexion activities.
• Flexion: Directional preference for flexion, imaging evidence of lumbar spinal stenosis, visible frontal deviation of the shoulders relative to the pelvis, directional preference for lateral translation movements. Interventions include: manual therapy, flexibility exercises, body-weight support, and avoidance of flexed positions and flexion activities.
• Lateral shift: Visible frontal deviation of shoulders relative to pelvis, directional preference for lateral translation movements of the pelvis. Interventions include: exercises to correct lateral shift, mechanical, or autotraction.
• Traction:
• Sx of nerve root compression, no centralization with movements. Interventions include: manual or motorized traction.

TBC - Alrwaily 2016

• Updated terminology to align with APTA guidelines
• Included psychosocial factors in treatment
• Restored triage level and broadened intervention subgroups: symptom modulation, movement control, and functional optimization
• Classification based on symptom severity, like earlier models, but also incorporates clinical findings

Triage

• Medical management
• Rehabilitation management
• Self-care management

STarT Back

• Subgroups for Targeted Treatment (STarT) Back Screening Tool
• Attempts to stratify risk of poor outcomes for patients with persistent disabling pain.

TBC - Alrwaily 2016 - Matching Criteria

• This table describes matching criteria for the rehabilitation provider
• Factors include patient pain and disability rating, clinical status, psychosocial status, and comorbidities. The table also classifies each aspect for symptom modulation, movement control, and functional optimization.

Questions