Low back pain (LBP) is 50% of our current caseload in clinic, and a general PubMed search for low back pain creates almost 2,500 hits. Cost of care is comparable to that of cancer, and diabetes – driving us to evaluate the efficiency of our choices and practice frugal behaviors in our decisions from ordering imaging, to optimizing our care. One would think that due to the frequency of this condition; along with a vast bank of research, it would drive homogeneity of our treatments providing lack of variability among practitioners. Unfortunately, this is not the case.
As we start to veer away from a pathoanatomical model, clinical prediction rules (CPR) seem like a natural next step. Reasoning to venture away from this model was brilliantly discussed by Dr Flynn as he appropriately speculates that we may over treat back pain. The take home points stated were that we are seeing 60% of asymptomatic patients demonstrating a buldging disc on MRI, and 90% of them having some sort of degenerative disc disease.1 Unfortunately, spinal MRI images continue to rise by 309% in the last 5 years, which essentially have harmful effects of health and drive 3 times more surgeries.2 Although there is an appropriate time and place for use of lumbar imaging, physical therapy should not be driven on these results. Furthermore, as stated by Deyo et al, now is the time to cut back on imaging as we continue to see an increase by 629% in use of injections, and 423% increase of opioid use in Medicare patients.2
If we know that MRI findings only correlate to about 10% of patients’ symptoms, and numerous studies state they do not predict who has LBP in acute or chronic situations, nor do they predict rehabilitation success – why are these imaging studies on the rise?10,11,13 How many therapists have seen the patient who right off the bat with a somber tone states they won’t be able to improve as they have 3 budging discs, or they have arthritis in their spine? What a burden to carry, what is our responsibility with a response? How can people switch vantage points to function, recovery, or a treatment based classification (TBC) concept?
Thus, the birth of a structure to drive treatment options and allow practitioners framework for treatment. An understanding that clinical reasoning is of first and of foremost importance, but as stated by a popular book – Checklist Manifesto – aviation, construction, investing, even hand washing in medicine support use of checklists as they reduce error.5Pumping the breaks a bit, for the unfamiliar – TBC approach is a way to gate theory for patients who enter the office based on predicting criteria to hopefully delineate who is appropriate for the following: manipulation, stabilization, centralization, or traction.
As my background began in Colorado, TBC system came ingrained, with little exposure to difference in opinion. Venturing back to the cold tundra of Minnesota is where I started to spot much higher variability in treatment and management of lumbar spine pain. As a developing clinician, I did find some interesting self-reflection with this transition. As apposed to blind acceptance of this method, I was forced to examine a few questions: are we focusing too much on outcomes and not enough on mechanism within literature, does this take away from clinical reasoning, is there such thing as being too research heavy?
Swarming concern drove some fantastic debate, and inevitably, a soft landing back into the arms of TBC. And this is why…
The evolution of my professional growth started with some heavy hitter studies that clearly demonstrated benefit from classification. Brennan et al states this idea that driving studies to subgroup this population to provide more homogenous groups may lend improved outcomes.8 General consensus among most therapists suggests that the following treatments are advantageous for patients with back pain: high thrust manipulation, stabilization of the lumbar spine, centralization, and the occasional use of traction. Variability occurs with use patterns, and selection of the appropriate patient is still essential. For example, manipulation use has been identified to be an extremely valuable tool in treatment of back pain, but for who?
A 2002 study found that patients who met the proposed prediction rule (internal rotation >35 degrees, hypomobility of the lumbar spine, no symptoms distal to the knee, recent onset of symptoms (less than 16 days), and FABQW score <19) increased success probability from 45% to 95%.3 A 2004 study followed this up with again more supportive evidence that manipulation was beneficial in conjunction with this rule and was subsequently validated.6
Continuing with our one classification of manipulation – one could debate that manipulation in low back pain can have such positive affects on attenuation of pain sensitivity and decreased central sensitivity, why not provide this to everyone?7 Also, can life be this black and white?
Although about a quarter of our patients meet more than one classification, overall we see that patients perform better if they are classified vs. if they are treated on clinician opinion.13 Thus stating, treatments are never black and white. A therapist should vary with their patient and when multiple criteria are met, reasoning through the patient’s nuances becomes vital. Again, returning to our theory that a checklist does not replace reasoning, but can enhance it. Thus, the soft landing at the foot of TBC enhances that rules in practice should not be blamed for limiting clinical reasoning – because as previously stated – this population is extremely heterogeneous. Numerous factors play into clinical decision-making. This does not disprove or threaten this framework – because as pilots, investment officers, and construction workers have found – if checklists enhance outcomes why wouldn’t we want to apply this to a condition we are all struggling to appropriately treat?
Original post: January 13, 2014
1) Dr Tim Flynn. (January 2014). Over treating Low Back Pain. Lecture conducted through Evidence In Motion.
2) Deyo RA, Mirza Sk, Turner J, Martin B. Over treating Chronic Back Pain: Time to Back Off? Journal of the American Board of Family; 222: 62-68.
3) Flynn T, Fritz Jm Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement with Spinal Manipulation. Spine. 2002; 24-2835-43.
4) Dr. Tim Flynn . (January 2014). LBP Revolution. Lecture conducted through Evidence In Motion.
5) Gawande Atul. A Check List Manifesto: How to Get Things Right? 2009. Metropolitan Books.
6) Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Maijowski GR, Dellitto A. A Clinical Prediction Rule to Identify Patients with Low Back Pain Most Likely to Benefit from Spinal Manipulation: A Validation Study. Ann Intern Med. 2004 Dec 21;141(12):920-8.
7) Bialosky JE, George SZ, Horn ME, Price DD, Staud R, Robinson ME. Spinal Manipulative Therapy-Specific Changes in Pain Sensitivity in Individuals with Low Back Pain. Journal of Pain. 2013.
8) Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine. 2006;31(6):623-631.
9) Werneke MW, Hart D, Oliver D, McGill T, Grisby D, Ward J, Weinberg J, Oswald W, Cutrone G. Prevalence of Classification Methods for Patients with Lumbar Impairments Using the McKenzie Syndromes, Pain Pattern, Manipulation, and Stabilization Clinical Prediction Rules. Journal of Man Manip Ther. 2010; 18: 197-204.
10) Carragee EJ, Alamin TF, Miller JL, et al. Discographic, MRI and Psychosocial Determinants of Low Back Pain Disability and Remission: A Prospective Study in Subjects with Benign Persistent Back Pain. The Spine Journal 2005; 5: 24-35.
11) Kleinstück F, Dvorak J, and Mannion AF. Are “structural abnormalities” on Magnetic Resonance Imaging a Contraindication to the Successful Conservative Treatment of Chronic Nonspecific Low Back Pain? Spine 2006; 31(19): 2250-2257.
12) Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P, Scott S. The prognostic consequences in the making of the initial medical diagnosis of work-related back injuries. Spine. 1995;20:791-795.
13.Fritz JM, Cleland JA, Childs J. Subgrouping Patients With Back Pain: Evolution of A Classification Approach to Physical Therapy. JOSPT. 2007; 37: 290-310