Evolution of the Treatment-Based Classification for Low Back Pain

The following is an article written for the online, video-based physical therapy continuing education company MedBridge

The prevalence and economic burden of low back pain (LBP) has reached an epidemic level and continues to put a strain on the U.S. healthcare system. According to Hoy et al, the overall incidence of LBP is between 1.5% and 36% with incidence of first-ever LBP ranging between 6.3-15.3%.

This is a HUGE proportion of the general population and typically makes up a large portion of the therapist’s daily caseload. Through the improvement of medical imaging, physicians are better able to see “what’s going on” inside an individual’s spine, but is this information helpful?

Is Medical Imaging the Answer?

The accuracy of the pathoanatomical model in diagnosing and treating LBP is severely overrated. Multiple imaging studies have proven this model is limited by the high rate of false-positives. For example, a study conducted by Savage et al found that 32% of asymptomatic individuals had ‘abnormal’ lumbar spines (as determined by MRI) and 47% of symptomatic individuals had no evidence of abnormality. Additionally, Jarvik and colleagues found no benefit with regards to patient self perceived disability when imaging was conducted early in their course of care. So, if medical imaging isn’t the answer, then how do we diagnose and treat these patients?

Treatment-Based Classification and Its Evolution

According to the Low Back Pain Clinical Guidelines published by Delitto et al, “The best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed.” Within the physical therapy community, there are several unique classification systems, but only one is backed by a substantial bounty of evidence. This Treatment-Based classification (TBC) system distinguishes 4 sub-groups of patients that are treated with specific interventions depending upon their classification. These sub-groups include:

This system was initially proposed by Delitto et al in 1995 and has evolved over the greater part of two decades. Below is a table created by Fritz et al presenting both both the original criteria and the revision proposed in 2007.

FritzTBC2007

Recently, the TBC approach to the management of low back pain underwent another revision in order to address several limitations that have come to light since its revision in 2007. Alrwaily et al recognized that the current system was lacking in addressing the biopsychosocial aspects of low back pain and that the categorization process was not efficient enough. In order to improve this system, the following areas were updated:
  1. Initial triage process includes all healthcare providers who come in first contact with patients with LBP in addition to the level of the rehabilitation provider
  2. Establishing decision-making criteria for the first contact practitioner to triage patients into one of three approaches: medical management, rehabilitation management, self-care management
  3. Utilizing risk stratification and psychosocial tools to determine which patients require psychologically informed rehabilitation
  4. The treatment based classification categories were broadened in order to prevent misclassification of patients

One of the largest issues with the 2007 TBC system proposed by Fritz et al was an inability to match patients to their appropriate treatment group. An evaluation by Stanton et al in 2011 determined that when a patient did not match a specific intervention, they were broadly lumped into the stabilization category or simply remained unclassified. In addition to this flaw, another study conducted by Stanton and colleagues found that close to 25% of patients met the criteria for at least two of the included treatment categories.

In order to address these limitations, Alrwaily and colleagues once again revised the classification system in 2015. This new system breaks the initial triage process into the level of the first healthcare provider contact (direct access) and rehabilitation provider. At the level of the first provider, the patient is directed either toward medical management, rehabilitation management, or self management. This determination is based on the presence/absence of red flags and neurological deficits. Once the patient has been transitioned to rehabilitation management, the classification categories have been broadened in order to direct patients toward the correct treatment approaches. Instead of breaking the categories into specific interventions, they are now broken into logical groups of interventions (symptoms modulation, movement control, and functional optimization). This alteration will prevent patients from being categorized into multiple groups or not being classified what so ever.

TBC2015

Treatment-Based Classification Yields Better Outcomes

In 2000, Fritz et al published a prospective cohort study looking at short-term patient outcomes after matching patient sub-groups to their corresponding treatment strategies. This study evaluated the outcomes of 120 patients receiving physical therapy for acute LBP. While Fritz’s initial evaluation of this treatment strategy did not compare its effects to standard care, it did give some preliminary support to its efficacy.

Later in 2003, Fritz et al conducted a randomized controlled trial of 78 patients comparing their treatment-based classification system to the current clinical guidelines for patients with acute LBP. Patients with work-related LBP of less than 3 weeks duration were admitted after being cleared of “red flags.”

Guideline Group

Subjects assigned to the Guideline Group (GG) were treated with low-stress aerobic exercise (treadmill walking or stationary cycling), general muscle reconditioning exercises, and advice was given to remain as active as possible within the limits of their pain.

Classification Group

Patients in the Classification Group (CG) were evaluated and assigned to the most appropriate sub-group. Following assignment, they were then treated based on the system proposed by Delitto et al.

Results

At 4 weeks, when compared to the GG, the CG had statistically significant mean improvements within group in:

  • Oswestry (22.5 v. 11.6),
  • SF-36 PCS (-13.6 v. -8.0)
  • Improved median satisfaction with treatment

At the one-year follow-up, mean Oswestry scores approached, but did not meet statistical significance (p= 0.063) in favor of the CG.

In terms of healthcare utilization, of the 20 patients who took up 51% of the total medical costs, 13 were from the GG and only 7 were from the CG. This translated into a relative risk of 2.1 for the guideline group and a number needed to treat of 5.5, or an average number of patients who need to be treated to avoid a ‘high cost’ patient when using the classification system compared to the clinical guideline approach.

Why It Works: Superior Interventions or the Matching Principle?

What if the interventions being provided from the previous clinical guideline standards were simply inferior to the techniques used by the classification group? Would proper pairing of presentation to treatment remain an important factor in outcomes when the same interventions were used throughout the patient population?

Brennan et al published a randomized controlled trial that investigated the impact of pairing interventions to the correct sub-group of patients with non-specific LBP. In evaluation of 123 patients, those individuals who were matched to the correct treatment approach demonstrated greater short- and long-term improvements in disability compared to those who were unmatched. Patients in the matched group achieved significantly greater improvements in mean Oswestry scores at 4 weeks (29.9 v. 23.3) and one year from baseline (33.3 v. 26.1).

Additionally, 78% of subjects in the matched group achieved progression to stage II of treatment, while only 60% of the unmatched patients achieved this milestone (p= 0.039). This study gave continued credence to the application of a treatment-based approach in the management of acute LBP.

Do the Outcomes Depend on a Clinician’s Experience?

The above studies give the treatment-based classification system solid evidence-based support, but is it reliable enough for widespread utilization by clinicians?

Fritz et al evaluated the inter-rater reliability of individual examination characteristics related to the treatment-based classification system in clinicians with varying levels of experience.

The evaluation included:

  • 10 ‘novice’ physical therapists (< 5 years of experience, no experience using the classification system)
  • 10 ‘experienced’ physical therapists (5+ years of experience, no experience using the system)
  • 10 ‘expert’ physical therapists (used the system clinically and participated in research involving the system)

Patients were evenly distributed to each clinician category with between 24-25 patients seen by each group. In terms of individual examination characteristics, the inter-rater reliability coefficients were at least moderate for all range of motion measurements, the prone instability test, and judgments of centralization/peripheralization with flexion and extension ROM. However, reliability of centralization/peripheralization with repeated or sustained extension movements and judgments of aberrant movements were fair or poor.

The ultimate agreement among clinicians on patient placement within the classification decision-making algorithm was 75.9%, which correlated to a kappa value of 0.60 (moderate agreement). Additionally, there was no significant difference in kappa value depending on experience of the examining therapist.

Earlier this year, Henry et al conducted a similar study with 12 therapists evaluating 24 total patients. This small cross-sectional reliability study produced total agreement on classification of 80.9% and a kappa value of 0.62 (moderate-good agreement), which agrees with the previous study by Fritz et al.

The Most Effective Evidence-Based Tool for Low Back Pain

This classification system has been rigorously evaluated and has come out with moderate to good inter-rater reliability regardless of clinician experience or expertise. This goes along with the improved clinical outcomes and decreased healthcare costs seen in two large randomized controlled trials. Currently, this is the most consistent and effective evidence-based tool to evaluate and treat LBP and should be considered a viable option for any therapist.

Additionally, as new evidence comes to light, the system continues to evolve in order to accommodate the growing body of evidence with regards to the evaluation and treatment of low back pain. During clinical practice, not every patient will fit nicely into a specific subgroup, but having this framework aids clinicians in making more informed, evidence-based treatment decisions.

The Most Important Aspect of Patient Care

The following is an article written for the online, video-based physical therapy continuing education company MedBridge

Helping individuals with a chronic pain and significant functional limitations is a remarkably difficult and delicate task. Numerous treatment philosophies are available to clinicians from the overtly biomechanical (Cyriax, Kaltenborn, Sahrmann, etc.) to more patient-response driven (Maitland, Mckenzie, etc.). Unfortunately, no one approach has been proven superior to others. For instance, in one of the only comparison studies, Powers and colleagues1 investigated the acute effects of a common Maitland intervention (posterior-to-anterior mobilization) to a common McKenzie intervention (prone press-up) on patients with non-specific low back pain. The study concluded that both groups improved significantly in pain level and lumbar extension, but without significant differences between the two interventions.

If the approach isn’t the determining factor, what makes one clinician better than another?

Throughout my clinical education and professional career, I have been exposed to expert clinicians with varying interventions, personalities, and clinical reasoning. However, one aspect holds true for all the clinicians who achieve superior outcomes – they form a positive therapeutic alliance (TA) with their patients.

What is a therapeutic alliance?

Leach et al.2 defines a therapeutic alliance as “a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect”. Moreover, a TA involves working together to define goals and success criteria for the treatment. With trust and mutual understanding, your patients are more confident in the interventions and more positive in their expectations from the treatment, which goes a long way towards achieving positive outcomes3. While every patient and pathology is unique, your patients deserve for a positive TA to be integrated and nurtured within their care.

Is there evidence supporting the importance of a therapeutic alliance?

Quite a bit of literature links a trusting therapeutic relationship to superior patient outcomes. A recent systematic review found that amongst patients with musculoskeletal complaints a positive therapeutic alliance was associated with significant improvements in the patient outcomes, including global perceived effect of treatment and satisfaction with treatment, pain levels, physical function, depression, and general health status4. More recently several randomized controlled trials have found favorable associations between positive alliance and outcomes in patients with chronic low back pain.

Fuentez et al.5 investigated how varying levels of therapeutic alliance impact a single-session treatment of chronic low back pain when combined with interferential electrical stimulation. They found significant improvements when patients received enhanced TA as opposed to limited TA. In a randomized controlled trial, Ferreira and colleagues6 looked into the effect of TA as part of a longer-term treatment with a follow-up at 8 weeks. Once again, therapeutic alliance had a significant influence on patient outcomes. The therapeutic alliance at baseline was a nonspecific predictor for the 4 measures of treatment outcome (global perceived effect, pain, disability, function) regardless of intervention applied by the treating therapist (motor control, general exercise, or spinal manipulative therapy). These two studies give further credence for the importance of forming mutual collaboration and trust with your patients.

Sometimes, techniques or interventions we use play a lesser role than our relationship with the patient. Many therapists downplay one approach in lieu of their chosen technique or approach, however no one approach is effective or ineffective for all patients. Only one aspect of patient care – therapeutic alliance – translates to each and every patient.

References:

1. Powers CM, Beneck GJ, Kulig K, Landel RF, Fredericson M. Effects of a single session of posterior-to-anterior spinal mobilization and press-up exercise on pain response and lumbar spine extension in people with nonspecific low back pain. Phys Ther. 2008; 88(4): 485-93. doi: 10.2522/ptj.20070069.

2. Leach, Matthew J. Rapport: A key to treatment success. Complementary Therapies in Clinical Practice. 2005; 11(4): 262 – 265.

3. Joel E Bialosky, Mark D Bishop, Michael E Robinson, Josh A Barabas and Steven Z George. The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders. 2008; 9-19 doi:10.1186/1471-2474-9-19.

4. Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010; 90(8): 1099-110. doi: 10.2522/ptj.20090245.

5. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross D. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014; 94(4): 477-89. doi: 10.2522/ptj.20130118.

6. Ferreira PH1, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013; 93(4): 470-8. doi: 10.2522/ptj.20120137.

Research Review: Validation of a Clinical Prediction Rule to Identify Patients with LBP Likely to Respond to Stabilization Exercises

Untitled

In the next instalment of my Research Review Series for MedBridge Education, we discuss a recent randomized controlled study investigating the validity of a clinical prediction rule for identifying patients with low back pain likely to respond favoribly to a spinal stabilization program.

Study Design

Randomized Controlled Trial.

Subjects

One hundred five patients diagnosed with LBP and referred to physical therapy at 1 of 5 outpatient clinics of Clalit Health Services in the Tel-Aviv metropolitan area, Israel, were recruited for this study. Of these 105 patients, 40 were positive on the Stabilization CPR and 65 were negative. The most evident difference between baseline differences of groups was age, with those in the stabilization group being significantly younger (one of the items of the CPR is < 40 years old).

Inclusion Criteria: 18 to 60 years of age, primary complaint of LBP with or without associated leg symptoms (pain, paresthesia), and had a minimum score of 24% on the Hebrew version of the modified Oswestry Disability Index (MODI) outcome measure.

Exclusion Criteria: History indicating any red flags (malignancy, infection, spine fracture, cauda equina syndrome), 2 or more signs suggesting lumbar nerve root compression (decreased deep tendon reflexes, myotomal weakness, decreased sensation in a dermatomal distribution, or a positive SLR, crossed SLR, or femoral nerve stretch test), history of corticosteroid use, osteoporosis, or rheumatoid arthritis. Additionally, patients were excluded if they were pregnant, received chiropractic or physical therapy care for LBP in the preceding 6 months, could not read or write in the Hebrew language, or had a pending legal proceeding associated with their LBP.

Methods

Outcome Measures: Hebrew version of the modified Oswestry Disability Index (MODI) and Numerical Pain Rating Scale (NPRS).

Randomization: Based on a computer-generated list of random numbers, which was then stratified by CPR status to ensure that adequate numbers of patients with a positive and a negative CPR status would be included in each intervention group.

Evaluation: A physical examination was conducted that included a neurological screen to rule out lumbar nerve root compression. Next, lumbar active motion was evaluated, during which the presence of aberrant movement, as defined by Hicks et al, was determined. Bilateral SLR range of motion, segmental mobility of the lumbar spine, and the prone instability testing was then also conducted. The patients’ status on the CPR (positive or negative) was established based on the findings of the physical examination.

Interventions: Patients in both the Lumbar Stabilization Exercise group (LSE Group) and Manual Therapy group (MT) received 11 treatments over an 8 week period and a 12 visit, which consisted of solely a re-evaluation. The LSE group was first educated on the function and common impairments related to the lumbar stabilizing musculature, they were then taught to perform an isolated contraction of the transversus abdominis and lumbar multifidus through an abdominal drawing-in maneuver (ADIM) in the quadruped, standing, and supine positions. Once the patient could successfully perform these actions, the demands on the musculature were increased by the addition of various upper and lower extremity movements. Finally, during the seventh session, functional movements were added to their program. Those patients randomized to the MT group received several thrust and non-thrust mobilization techniques to their lumbar spine in addition to manual stretching of several hip and thigh muscle groups. Each treatment session included up to three manual techniques (one of which had to be a thrust technique). With regards to exercise, those in the MT group performed active range of motion and self-stretching exercises, but did not perform isolated spinal stabilization exercises. All variations and progressions of exercises and manual therapy techniques can be seen in the appendix of the research report.

Results

With regards to MODI, clinical significance could not be determined after 2-way interaction between treatment group and CPR status was calculated (p = 0.17). That being said, individuals who were positive on the CPR did demonstrate less disability at the end of the study compared to those who were negative (p = 0.02). Furthermore, amongst patients who were positive on the CPR, those who received LSE also demonstrated less disability following treatment compared to those who received MT. When the authors introduced a modified CPR, which consisted of positive prone instability test and presence aberrant movement, they did find a significant interaction with treatment for final MODI. Those positive on the modified CPR demonstrated superior outcomes compared to the group as a whole and also showed improved outcomes when receiving LSE compared to MT (p = 0.005).

Limitations

The most prevalent limitations include an inadequate sample size, which resulted in a limited overall power of the findings as well as the retrospective nature of some of the findings (i.e. modified CPR). Additionally, this study had a high drop-out rate for a study of its size with an overall drop-out rate of 22.8% (33% in the LSE group and 14% in the MT group). The lower dropout rate in the MT group could potentially be due to an attention affect due to the manual contact required for the interventions within this group compared to the LSE group. Additionally, while short-term results are important, understanding the long-term implications of either MT or LSE is of greater importance. This study only included an 8 week follow-up and it would be beneficial to see the long-term implications with a 6 or 12 month follow-up to gauge the overall effectiveness of the CPR and associated interventions. Finally, it should be noted that status on CPR was determined prior to group determination, which introduces an additional level of bias. Future studies should look at results with CPR determination post priori or following allocation to groups.

Clinical Implications

Manual therapy and spinal stabilization are two very common interventions utilized by physical therapists when treating low back pain. As manual therapy is common amongst clinicians and generally considered an effective treatment option, it provides an excellent reference value in the validation of the stabilization CPR. Unfortunately, the utility of the CPR as it was constructed could not be validated based on the findings of this study. Several factors could have played into this discrepancy including attention effect by those in the MT group, small sample size, and large dropout percentage. While the original CPR could not be validated, retrospectively an abbreviated CPR was identified and ‘validated’ based on the findings of the 2-way interaction between treatment group and modified CPR status. So, while this study seems like a knock to the current lumbar stabilization CPR, the study design and execution of the study cannot allow the CPR to be disregarded as all of the aforementioned limitations may have played a significant role in the study’s results. Additionally, the creation of an abridged CPR may have more value to clinicians long-term as it provided superior results and requires less factors to be evaluated by the clinician. However, the results must be taken with a grain of salt as a prospective evaluation of the modified CPR must be conducted in order to determine its utility. Clinical prediction rules and the effectiveness of spinal stabilization are polarizing issues within the physical therapy community and this study debatably provides support to the use of spinal stabilization and indicates that future research is needed to clear up the murkiness of the current stabilization CPR. When treating the lumbar spine, no treatment should be provided with every patient and Chad Cook, PT, PhD, FAAOMPT goes into great detail in his course, “Evidence-Based Treatment of the Lumbar Spine”, with regards to the use of spinal stabilization within the Treatment-Based Classification system.

Rabin A, Shashua A, Pizem K, Dickstein R, Dar G. A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(1): 6–18, B1–13. 

Research Review: Validation of a Clinical Prediction Rule to Identify Patients with LBP Likely to Respond to Stabilization Exercises

Untitled

Study Design

Randomized Controlled Trial.

Subjects

One hundred five patients diagnosed with LBP and referred to physical therapy at 1 of 5 outpatient clinics of Clalit Health Services in the Tel-Aviv metropolitan area, Israel, were recruited for this study. Of these 105 patients, 40 were positive on the Stabilization CPR and 65 were negative. The most evident difference between baseline differences of groups was age, with those in the stabilization group being significantly younger (one of the items of the CPR is < 40 years old).

Inclusion Criteria: 18 to 60 years of age, primary complaint of LBP with or without associated leg symptoms (pain, paresthesia), and had a minimum score of 24% on the Hebrew version of the modified Oswestry Disability Index (MODI) outcome measure.

Exclusion Criteria: History indicating any red flags (malignancy, infection, spine fracture, cauda equina syndrome), 2 or more signs suggesting lumbar nerve root compression (decreased deep tendon reflexes, myotomal weakness, decreased sensation in a dermatomal distribution, or a positive SLR, crossed SLR, or femoral nerve stretch test), history of corticosteroid use, osteoporosis, or rheumatoid arthritis. Additionally, patients were excluded if they were pregnant, received chiropractic or physical therapy care for LBP in the preceding 6 months, could not read or write in the Hebrew language, or had a pending legal proceeding associated with their LBP.

Methods

Outcome Measures: Hebrew version of the modified Oswestry Disability Index (MODI) and Numerical Pain Rating Scale (NPRS).

Randomization: Based on a computer-generated list of random numbers, which was then stratified by CPR status to ensure that adequate numbers of patients with a positive and a negative CPR status would be included in each intervention group.

Evaluation: A physical examination was conducted that included a neurological screen to rule out lumbar nerve root compression. Next, lumbar active motion was evaluated, during which the presence of aberrant movement, as defined by Hicks et al, was determined. Bilateral SLR range of motion, segmental mobility of the lumbar spine, and the prone instability testing was then also conducted. The patients’ status on the CPR (positive or negative) was established based on the findings of the physical examination.

Interventions: Patients in both the Lumbar Stabilization Exercise group (LSE) and Manual Therapy group (MT) received 11 treatments over an 8 week period and a 12 visit, which consisted of solely a re-evaluation. The SG group was first educated on the function and common impairments related to the lumbar stabilizing musculature, they were then taught to perform an isolated contraction of the transversus abdominis and lumbar multifidus through an abdominal drawing-in maneuver (ADIM) in the quadruped, standing, and supine positions. Once the patient could successfully perform these actions, the demands on the musculature were increased by the addition of various upper and lower extremity movements. Finally, during the seventh session, functional movements were added to their program. Those patients randomized to the MT group received several thrust and non-thrust mobilization techniques to their lumbar spine in addition to manual stretching of several hip and thigh muscle groups. Each treatment session included up to three manual techniques (one of which had to be a thrust technique). With regards to exercise, those in the MT group performed active range of motion and self stretching exercises, but did not perform any exercises that included significant activation of the trunk musculature. All variations and progressions of exercises and manual therapy techniques can be seen in the appendix of the research report.

Results

With regards to MODI, clinical significance could not be determined after 2-way interaction between treatment group and CPR status was calculated (p = 0.17). That being said, individuals who were positive on the CPR did demonstrate less disability at the end of the study compared to those who were negative (p = 0.02). Furthermore, amongst patients who were positive on the CPR, those who received LSE also demonstrated less disability following treatment compared to those who received MT. When the authors introduced a modified CPR, which consisted of positive prone instability test and presence aberrant movement, they did find a significant interaction with treatment for final MODI. Those positive on the modified CPR demonstrated superior outcomes compared to the group as a whole and also showed improved outcomes when receiving LSE compared to MT (p = 0.005).

Limitations

The most prevalent limitations include an inadequate sample size, which resulted in a limited overall power of the findings and the retrospective nature of some of the findings (i.e. modified CPR). Additionally, this study had a high drop-out rate for a study of its size with an overall drop-out rate of 22.8% (33% in the LSE group and 14% in the MT group). The lower dropout rate in the MT group could potentially be due to an attention affect due to the manual contact required for the interventions within this group compared to the LSE group. Finally, while short-term results are important, understanding the long-term implications of either MT or LSE. This study only included an 8 week follow-up and it would be beneficial to see the long-term implications with a 6 or 12 month follow-up to gauge the overall effectiveness of the CPR and associated interventions.

Clinical Implications

Manual therapy and spinal stabilization are two very common interventions utilized by physical therapists when treating low back pain. As manual therapy is common amongst clinicians and generally considered an effective treatment option, it provides an excellent reference value in the validation of the stabilization CPR. Unfortunately, the utility of the CPR as it was constructed could not be validated based on the findings of this study. Several factors could have played into this discrepancy including attention effect by those in the MT group, small sample size, and large drop-out percentage. While the original CPR could not be validated, retrospectively a abbreviated CPR was identified and ‘validated’ based on the findings of the 2-way interaction between treatment group and modified CPR status. So, while this study seems like a knock to the current lumbar stabilization CPR, the study design and execution of the study cannot allow the CPR to be disregarded as all of the aforementioned limitations may have played a significant role in the study’s results. Additionally, the creation of an abridged CPR may have more value to clinicians long-term as it provided impressive results and requires less factors to be evaluated by the clinician. However, the results must be taken with a grain of salt as a prospective evaluation of the modified CPR must be conducted in order to determine its utility. Clinical prediction rules and the effectiveness of spinal stabilization are polarizing issues within the physical therapy community and this study debatably provides support to the use of spinal stabilization and future direction needed to clear up the murkiness of the current stabilization CPR.

Rabin A, Shashua A, Pizem K, Dickstein R, Dar G. A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(1): 6–18, B1–13. 

Research Review: Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy

de Oliveira et al, 2013

Recently, a randomized controlled trial was published in Physical Therapy by de Oliveira et al that evaluated and brought into question the need for specificity of technique when utilizing spinal manipulation in the treatment of patients presenting with chronic low back pain. This study opposes the predominantly biomechanical explanation associated with the use of manipulative techniques… [Continue Reading]

Research Review: Effectiveness of Physical Therapist Administered Spinal Manipulation for the Treatment of Low Back Pain

In the December issue of the International Journal of Sports Physical Therapy, Chad Cook, PT, PhD, MBA, FAAOMPT and 5 students from Walsh University conducted the first-ever systematic review investigating the effectiveness of spinal manipulation performed by physical therapists on the treatment of low back pain (LBP). In addition to analyzing effectiveness, they also investigated the prevalence of adverse effects following manipulative interventions… [Continue Reading]

Manual Therapy… Why the Apprehension?

According to a survey of 813 british physical therapists conducted by Foster et al, Only 58.9% Physical therapists utilize spinal mobilization (Grade I – IV) and only 2.8% use spinal manipulative therapy (Grade V) when treating patients suffering from low back pain (LBP). Additionally, a survey of 274 canadian physical therapists published by Li et al found that when treating a patient with acute LBP, only 44.4% of therapists utilized spinal mobilization and only 5.0% used spinal manipulation. In the same study, utilization of mobilization and manipulation actually increased when treating a patient in the sub-acute stage at 83.7% and 9.0%, respectively. This finding is especially concerning since one of the variables of the spinal manipulation clinical prediction rule (CPR) is an onset of < 16 days. So, we as a profession are unwilling to perform manual therapy on those individuals that could benefit most. This practice pattern may be because of our apprehension in using such an ‘invasive’ technique on patients that are in such acute distress. However, if the patient is properly screened and is appropriate for manual therapy, the benefits of following through with the treatment will far outweigh the patient’s initial discomfort.

In my experience, this has been the trend that I have seen in the clinic. Honestly, prior to beginning PT school, I had no idea that manual or manipulative therapy was within a physical therapist’s scope of practice. I had the opportunity to work with many talented and experienced therapists throughout my own rehabilitation and during my required ‘observation hours’ and never once did I see anything that resembled manual therapy. So I ask, why are there so many therapists that refuse to utilize such an effective treatment option?

Is it a lack of quality evidence?

When discussing the application of manual therapy to LBP, I find it hard to believe that a lack of evidence is the problem. Erhard et al conducted a small randomized controlled trial (RCT) investigating the effectivness of exercise based on directional preference versus manual therapy. The treatment group was treated with a supine lumbopelvic roll and the hand-heel rock exercise, while the exercise group was treated with an extension-oriented program similar to that proposed by McKenzie. The results showed that 9/12 patients in the manipulation group were discharged at 1 week, while only 2/12 were discharged from the extension-only group. Discharge from PT was determined by obtaining a score of < 11 on the Oswestry Disability Index (ODI). While this study had a small sample size and lacked adequate follow-up data, it did show an increase in positive outcomes when manual therapy was included in a patient’s treatment plan.

In 2002, Flynn et al developed a CPR for the use of spinal manipulation, which was later validated by Childs et al in 2004. The Flynn prospective cohort study showed that when a patient met the CPR and was subsequently treated with manipulative therapy, their likelihood of success increased from 45% to 95%. According to the Childs randomized controlled trial, when a patient met this CPR and was subsequently treated with the supine lumbopelvic roll and lumbar ROM exercises, 44.3% (31/70) achieved success after 1 week versus only 11.5% (7/61) in the exercise-only group. After 4 weeks, 62.9% (44/70) had achieved success, while only 36.1% (22/61) had achieved this same success in the exercise group. Additionally, at the 6 month follow-up, 27.8% of patients in the matched manipulation group were taking pain medication for their back compared to 43.8% in the exercise group. Even patients that did not meet the CPR and were treated with manual therapy used less pain medication as a group (41.2% v. 70.8%). These studies not only showed the benefit of manual therapy, but also gave clinicians an additional tool in identifying patients who would respond favorably. Also, when comparing ODI scores at 6 months post-treatment, the manipulation groups are still superior to the exercise groups. One of the most common arguments against spinal manipulation is that it is a short-term fix with no long-term effects. This study seems to contradict these beliefs.

Cleland et al also investigated the efficacy of manual therapy when applying the Spinal Manipulation CPR. In this case series, 12 patients who satisfied the CPR were treated with the sidelying lumbar roll. After just 2 treatments, 11/12 (91.7%) patients had at least a 50% reduction in the ODI. This study shows continued support for this treatment approach as well as evidence that more than one manual therapy technique can be applied.

Evidence for the efficacy of manual therapy does not stop at the lumbopelvic region. There is also evidence to support its use for neck pain, tension headaches, shoulder impingement, knee osteoarthritis, hip osteoarthritis, and many other diagnoses.

Is it because manual therapy can cause harm to our patients?

According to a systematic review by Assendelft et al, the incidence of serious complications, such as cauda equina syndrome, due to spinal manipulation is < 1/1,000,000. While complications due to cervical manipulation was found to be slightly more prevalent at ~ 1/1,000,000, it was still minuscule when compared to the complication rates of NSAIDs, spinal surgery, or even vigorous exercise.

So, what is it that stops us from using the best evidence to treat our patients? It could be a lack of emphasis on manual therapy and EBP in many PT programs, especially for those therapists who graduated before this material began to emerge in physical therapy curriculums. Even though this material may not have been taught to some of us, it is our responsibility as healthcare professionals to provide the highest quality of care. To achieve this level of care it is necessary to step outside of our clinical practice patterns and implement new treatments when they are applicable. Also, our profession has such a negative perception of the chiropractic profession that I believe this negativity spills into our understanding of their primary intervention. If you ask the general population where they go to be treated for LBP or neck pain almost every individual would respond, “my chiropractor”. This is in part due to their superior marketing and autonomy, but it also has to do with the interventions they use to treat these patients. While I do not agree with how many DCs market themselves or some of the treatment strategies they employ, this is one aspect that I do agree with (even if it is over utilized). Change is a difficult process when you have been treating patients a certain way your entire career, but if it improves your patient outcomes, why not try?