Classification and Low Back Pain: Review Literature and Critical Analysis Selected Systems

Classification and Low Back Pain:
A Review of the Literature and

Critical Analysis of Selected Systems
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Classification systems for patients with low back pain have become
more abundant in the literature since the mid-1980s. Some classifica-
tion systems are designed to determine the most appropriate treat-
ment, some are designed to aid in prognosis, and others are designed
to identify pathology. Still other classification systems categorize
patients into homogeneous groups based on selected variables. The
purpose of this review is to describe and critically evaluate low back
pain classification systems. Several classification systems were summa-
rized and examined. Four classification systems that were judged to be
the most commonly cited and most relevant to physical therapists were
critiqued using a more thorough systematic approach. The analysis
suggests that future research should address the usefulness of existing
classification systems as well as the development of new classification
systems designed using commonly accepted measurement principles.
[Riddle DL. Classification and low back pain: a review of the literature
and critical analysis of selected systems. Phys Ther. 1998;78:
708-737.1
Key Words: Classification, Diagnosis, Low back pain.
Daniel L Riddle
708 Physical Therapy . Volume 78 . Number 7 . July 1998

he concept of classification has recently gained myofascial pain syndrome. The usefulness of these types
interest among researchers and clinicians of labels in many cases is limited. Traditional medical
involved in the care of patients with low back diagnostic labels seldom guide physical therapist deci-
pain (LBP). This interest is due, in part, to the sions related to the prognosis or treatment of patients
fact that LBP is most often not attributable to patholo- with LBP.8
gies known to cause pain. Patients with LBP of unknown
origin represent 85% or more of all patients treated for In this article, I examine the usefulness of diagnostic
their LHP by primary care practitioners.'-" Patients with labels and other forms of classification for patients with
LBP of unknown etiology also have been reported to LBP. Many classification systems have been proposed for
represent many heterogeneous s u b g r o ~ p s .Interest
~.~ in patients with LBP, and I will attempt to review most of
classification stems from the notion that this very large these approaches. My primary purpose is to review those
group of patients would likely be treated more effectively classification systems that were designed for the majority
if valid criteria could be established to assign these of patients with LBP. A MEDLINE search for the period
patients to homogeneous subgroups. 1985 to May 1997 was conducted using the key words
"classification and low back pain" in combination. The
In 1995, an international forum was held to discuss the reference lists of the relevant articles found in the
management of patients with LBP by primary care MEDLINE search also were reviewed. Criteria for selec-
practitii~ners.~Among the attendees were 38 LBP tion of classification systems for review were the follow-
researchers. Physicians, chiropractors, and physical ther- ing: (1) the system had to be published in English,
apists were asked to prioritize an agenda for research in (2) the authors had to provide sufficient descriptive
the area of primary care for patients with LBP. The item detail of the structure of the system to allow for a
given the highest priority by the group dealt with the summary description of the system, and (3) the system
concept of classification. The forum summarized this had to have a relatively broad focus that addresses the
priority by posing the question: "Can different varieties, majority of patients with LBP. Systems that dealt only
natural courses, or subgroups of LBP be identified and, with very specifically defined subgroups of patients with
if they can, what criteria can be used to differentiate LBP were not critically reviewed. For example, LBP
among them?" classification systems designed only for patients with
psychosocial disordersg-'"or pathologies such as spinal
Physicians referring patients for physical therapy typi- stenosis or s p o n d y l o l i ~ t h e s i swere
~ ~ ~not
~ reviewed. Sys-
cally assign a diagnosis (a form of classification) to most tems applied to very large groups such as patients with
patients with LBP. Based on historical data, an examina- chronic musculoskeletal pain also were not r e v i e ~ e d . l " ~ ~
tion, and other diagnostic tests, the physician uses some
form of' decision-making process to establish a diagnosis. Following the MEDLINE search, the classification sys-
The diagnostic label may indicate the presence of an tems selected for review were examined to identify those
impairment such as LBP or the presence of a patholog- systems that were most relevant for physical therapists.
ical coildition such as a herniated disk. The diagnosis Four classification systems were judged to be most rele-
may reflect an abnormal physiologic process such as vant to physical therapists and were thoroughly reviewed
Dl, Riddle, PhD, PT, is Associate Professor, Department of Physical Therapy, Virginia Commonwealth University, 1200 East Broad, Richmond, VA
23298-0224 (USA) (driddle@hsc.vcu.edu).
Physical Therapy. Volume 78 . Number 7 . July 1998 Riddle . 709

Table 1.
Description of 4 Common Classification Systems Reviewed in the Critical Appraisal
Bernard and Kirkaldy- Delitto and

Williszz C o l l e a g ~ e s ~ ~ ~ McKenziez5
~~ Quebec Task Forcez6
Professional or Orthopedic surgery Physical therapy Physical therapy Many medical and nonmedical
discipline disciplines
orientation of
system
developer
TY pe Status index Clinical guideline index Clinical guideline index Mixed index
Method of Judgment approach Judgment approach Judgment approach Judgment approach
developmento
Purpose To determine the pathology To determine the To determine the For clinical decision making,

causing the problem appropriate treatment appropriate treatment establishing a prognosis,
quality control, research
Setting Not specified Not specified Not specified Occupational health
Domain of All patients with LBPb All patients with LBP Most patients with LBP All patients with LBP
interest
Patients None None Patients with severe sciatica None
excluded and neurological deficits
and patients whose
symptoms cannot be
reduced or centralized
Categories 23 categories: Three levels of 13 categories: 1 1 categories with 2 axes:
classification:
Group A Postural syndrome Pain without radiation
Herniated nucleus Not all categories
4 dysfunction Pain + radiation proximal
pulposus have been described
syndromes
Pain + radiation distal
Lateral stenosis
For stage 1 : (flexion, extension,
Pain + radiation +
Central stenosis neurological signs
Extension sidegliding,
Spondylolisthesis Flexion (<7, 7-49, >49 days)
adherent nerve root)
Segmental instability (working, idle)
Lateral shift (2)
7 derangement Presumptive root
Group B immobilization (4) syndromes
Sacroiliac joint Traction (5)
compression +image
syndrome ~ ~ b i l (5)i ~ ~ t Hip
i ~ ioint
~ or sacroiliac
Root compression +
image
Spinal stenosis
Posterior ioint joint problem
Postsurgical <6 mo
syndrome
Postsurgical >6 mo
Maigne syndrome
Chronic pain syndrome
Muscle syndromes (6)
Other (W or I)'
Group C
Chronic pain
syndrome
Pseudarthrosis
Nonspecific
Postfusion stenosis
Ankylosing spondylitis
Infection
Tumor
Arachnoiditis
Lateral femoral nerve
entrapment
" A statistical approach t o developir~ga classification systeru relies primaril? on statistical procedures to guide drcisiorls about how t o group patirr~ts.A judgment
approach telies primal-ily on the clinical experience of the developer or on co~l~rnortly arcrpted clinical knowledge to assign patirnr to groups.
"LBP=lo\v back pain.
'Wzuvorking, ]=idle.
using a critical appraisal approach recommended by classification systems were judged to be most appropriate
Buchbinder and colleagues.")," The 4 systems selected for critical evaluation because the systems are thor-
were proposed by Bernard and Kirkaldy-Willis," Delitto oughly described in the literature2"-'hnd in continuing
and ~olleagues,-'!{,~4
McKenzie,'%nd the Quebec Task education courses,2Vhey are reported to be [wed in
Force on Spinal Disorders (QTF)z"Tab. 1 ) . These 4
71 0 . Riddle Physical Therapy . Volume 7 8 . Number 7 . July 1998

-u Table 2.
2. Descriptions of Classification Systems Not Reviewed in the Critical Appraisal
0
I
zr Moffroid et alZa Coste et alZ9 Coste et aI3O Marms et aI3' Binkley et MooneyJ3 SikorskP4
2
3 Professional or Physical therapy Rheumatology Rheumatology Biomechanics, Physical therapy Orthopedic surgery Physical therapy
discipline orthopedic
2 orientation of surgery
5 system
U developer
w
TYpe Status index Status index Status index Status index Status index Status index Clinical guideline
5 index
T
U Method of Statistical approach Statistical approach Statistical approach Statistical Judgment approach Judgment approach Judgment
L developmenta approach approach
C
'<
9 Purpose To identify To identify To identify To identify To identify groups of To identify groups To guide treatment
9
w homogeneous homogeneous homogeneous homogeneous patients with of patients based for groups of
groups of patients groups of patients groups of patients groups based similar signs or on chronicity and patients with
with similar based on diagnosed with a on trunk motion symptoms pain distribution similar signs
physical demographic and psychiatric disorder measures indicating the and symptoms
impairments pain behavior based on DSM Ill presence of
riter ria^^,^^ pathology
Setting Outpatient Outpatient Outpatient Not specified Not specified Not specified Outpatient
Domain of Most patients with Patients with purely Patients with LBP who All patients with All patients with LBP All patients with Most patients with
interest LBP~ organic LBP have a psychiatric LBP LBP without LBP
disorder serious
pathology
Patients Patients with pain Patients with Patients with purely None None None Patients who have
excluded below knee, psychiatric organic disorders, had spinal
neurological disorders, pain pain below the surgery
signs, fracture, below the gluteal gluteal folds,
stenosis, folds, malignancy, malignancy,
infection, infection, fracture, infection, fracture,
pregnancy, neurological signs neurological signs
surgery in past
3 mo, cancer,
psychiatric
disease
" A statistical approach to developing a classification system relies primarily on statistical procedures to guide decisions about how to group patients. A judgment approach relies primarily on the clinical experience of
(he developer or o n cornmonly accepted clinical knowledge to assign patients to groups.
" . 6 ~ = l o u hack pain.
?? ......................,
a
a
b
l!

Structure of Classification Systems as Described by Buchbinder and C~lleagues*~
Categories Criteria Operational Definitions
Domain of Interest

Figure 1.
An illustration of the structure of classification systems as described by Buchbinder and colleagues.20
clinical practice,Sz5 or they use diagnostic terms that patients with LBP.37This large number of codes would
are familiar to physical therapists.22.26 appear to be excessive and impractical for routine
clinical use.
Prior to examining the 4 classification systems selected
for critical appraisal, I will review some background The use of clearly described classification systems may
material. I will present arguments as to why classification enhance the effectiveness of treatment. Data suggest that
systems should enhance the care of patients with LBP. I patients treated with an approach based on an assigned
will review the terminology proposed by Buchbinder et classification do better than patients whose treatment is
a120 to standardize the descriptions of the classification not based on their pretreatment
systems discussed in this article. Some of the work of Although these studies should be considered to be
Feinstein27 relating to the types of classification systems preliminary, they suggest that patients classified using a
and how they are derived will be reviewed. I will use system designed to guide treatment may be treated more
Feinstein's work to discuss other classification systems effectively than patients treated without regard to
not selected for critical review. Classification systems classification.
described by Moffroid et Coste et a1,29.30Marras et
al,31 Binkley et al," Mooney," and S i k ~ r s k will
i ~ ~ be Some researcher^^^.^^ contend that randomized clinical
discussed and are summarized in Table 2. trials (RCTs) could be better conducted if patients with
idiopathic LBP were placed into homogeneous groups
Why Classify? prior to treatment. Most RCTs have lumped apparently
Perhaps the most compelling argument for developing heterogeneous patients with either acute or chronic LBP
and using classification systems is that our current system into one group prior to randomly assigning the patients
for grouping patients appears to be i n a d e q ~ a t e The
.~ for t r e a t ~ n e n t . ~Because
~ - ~ ~ most RCTs have considered
most common classification used by physicians and patients with LBP as belonging to a homogeneous
physical therapists is the International Classification of group, these studies probably have not measured a
Diseases (ICD)." The ICD is a taxonomy of diagnostic treatment effect that might be expected from a truly
labels used by many practitioners for the purposes of homogeneous sample of patients. Not all researchers,
standardizing the nomenclature for patient diagnoses however, agree that the identification of homogeneous
for statistical and administrative purposes.35Because the subgroups of patients with LBP for RCTs is necessary.
ICD does not describe the procedures used to apply F a a argued,
~ ~ ~ for example, that no evidence exists to
diagnostic labels, the reliability and validity of assigning support the argument for classification prior to ran-
ICD codes are quite low." The ICD, therefore, would domly assigning patients to exercise therapy groups in a
appear to have very limited use for making judgments RCT. Based on the research priorities established by the
about treatment, prognosis, or the presence of pathol- International Forum for Primary Care Research on Low
ogy. The ICD-9, for example, lists 66 codes for use on Back Pain, other researchers7 apparently do not agree
712 . Riddle Physical Therapy . Volume 78 . Number 7 . July 1998

Classification System of the Quebec Task Force on Spinal ~ i s a r d e r s ~ ~
domain describes the type of patients the
classification system is designed to classify.
The QTF classification system, for exam-
ple, was designed to classify patients with
work-related disorders of the spine (Fig.
2 ) . ? T h e domain is subdivided into 2 or
more categories. McKenzie's postural and
flexion dysfi~nctionsyndromes are exam-
ples of categories of patients with LBP in
the McKenzie system (Fig. 3) . ' T h e crite-
ria are the procedures used to make deci-
sions about the categoly to which a patient
should be assigned. For example, the cri-
teria used to place a patient into category

root based on radiographic tests
(eg, spinal instability, fracture) 4 of the QTF system are pain radiating
into a lower limb and neurological signs.
The definitions describe the examination
findings that must be present for each
criterion. For example, the definition of
neurological signs in the QTF system is
For categories 1-4 one or more of the following: focal mus-
cular weakness; asymmetric reflexes; der-
Postsurgical status. ~6 mo matomal senso~yloss; or loss of intestinal,
following surgery
bladder, or sexual function.
Some classification systems further classify

patients based on additional domains. For
For categories 1-4. 10, and 11
example, the QTF system uses 2 additional
domains (time since onset of symptoms
and work status) to further classify
Tp(
Other diagnoses (eg, metastases,
visceral disease, compression
fracture, swnd litis)
patients in categories 1 to 4 and 10 and 11
(Fig. 2).'"he role of these additional
domains is to guide clinical decisions
related to prognosis. Feinstein4# used the
Figure 2.
An illustration of the domain, categories, and criteria for the classification system developed term "axis" describe these additional
by the Quebec Task Force on Spinal Disorders.26 CT=computed tomography, domains within a classification system.
MRI=rnagnetic resonance imaging. Axes are essentially separate and distinct
classification systems within a larger classi-
fication system. Axes have their own
with the assertions of Faas. In my view, the LBP research domain, categories, criteria, and definitions. Figure 2
commurlity appears to be strongly in favor of developing illustrates the use of axes in the QTF system.
classification systems for use in RCTs.
The Different Types of Classification Systems
Terminology for Classification Systems Feinstein, in his book Clinirnetrics," identified the various
The terms proposed by Buchbinder and colleague^^^ uses for what h e described as clinimetric indexes. Clini-
serve to operationally define the different parts of clas- metric indexes are rating scales and other expressions
sificatior~systems and can assist the user in understand- that are used to measure symptoms, physical signs, and
ing the organizational framework of classification sys- other phenomena in clinical medicine. Classificatiori
tems. In this article, therefore, I will use the terms systems are one type of clinimetric index.
defined by Buchbinder and colleagues when describing
the various classification systems designed for patients F e i n ~ t e i n described
~~ 3 major types of clinimetric
with LBP. indexes that are relevant to classification systems used
for patients with LBP. These are the status index, the
Buchbinder et a1O ' proposed a set of terms originally prognostic index, and the clinical guideline index.
described by Fei~~stein'~," to describe the various parts
of a classification system (Fig. 1): (1) domain of interest, Status indexes are likely the most common type of
(2) categories, (3) criteria, and (4) definitions. The classification system used fbr patients with LBP. Classifi-
Physical Therapy . Volume 78 . Number 7 . July 1998 Riddle . 71 3

Classification System of McKenzie 25
No lumbar spine deformity is present, all

test movements are pain-free with no
Postural Syndrome loss of motion, poor sitting and standing
posture are present
\
Flexion Dysfunction
Posture is poor, spinal deformities are

Dysfunction atypical, movement loss is present,
Syndrome

and pain is produced with some test
movements (depending on the type of
syndrome) but subsides when
Side-Gliding returning to start position,
Dysfunction peripheralization occurs only with an
adherent nerve root
Syndrome
Adherent Nerve Root
do not have serious

pathology or constant
severe sciatica with
neurological deficits
Derangement Central or symmetrical LBP is present,

Syndrome 2 may have buttock or thigh pain, will
- have lumbar kyphosis deformity
Unilateral LBP is present, may have

buttock or thigh pain, no spinal
\\\ \ ' ' \ deformity \
\\\1 Derangement
Syndrome 4 Unilateral LBP is present, buttock or
thigh pain may be present, will have a
I\\' \ lateral shift deformity \
\\\
I
Derangement
Unilateral LBP is present, buttock or
Syndrome 5 thigh pain may be present, pain extends
\ \ I I \ be~bwthe knee, n o spinal deformity \
Derangement
Syndrome 6 h/
l
Unilateral LBP is present, pain usually
constant and below the knee, lateral shift
and reduced lordosis deformity are
present, neurologicaldeficits common
I
Derangement
Syndrome 7 Unilateralor bilateral LBP is present,
buttock or thigh pain may be
present, accentuated lumbar lordosis is
present
Figure 3.
An illustration of the domain, categories, and criteria for the classification system developed b y McKenzie.25 LBP=low back pain, SI=sacroiliac.

cation systems that are considered to be status indexes The statistical approach, for example, has
are used to define patient problems. The most common been used extensively in LBP research to identifji homo-
type of status index is the diagnostic index. The ICD-9 geneous groups of patients at varylng risk for a poor
classification system is a form of status index and is the o ~ t c o m e ~and
" ~ ~with varying levels of psychological
most common classification system used by clinicians. inv~lvernent.~~ Other
) - ~ ~ researcher^^^,^" have used a
The pathology-based LBP classification systems of Ber- statistical approach to identify subgroups with similar
nard and Kirkaldy-Willis'" and Kirkaldy-Willis and Hill4" levels of severity for a variety of physical impairments.
also are commonly cited examples of status indexes.
Moffroid and colleague^^^ used a statistical approach to
The second type of index described by F e i n ~ t e i nis~the
~ develop a classification system. They used physical
prognostic index. Classification systems designed to be impairment measures obtained from the National Insti-
prognostic indexes are used to predict the future status tute of Occupational Safety and Health (NIOSH) Low
of the patient. Most prognostic indexes for patients with Back AtlasL"o identify homogeneous groups of patients.
LBP are designed to aid the clinician in making predic- In the study of Moffroid et al, 115 patients with LBP

tions about the likelihood of a poor o u t ~ o m e . l ~ ~ ~ ~undenvent
~~l 53 tests of mobility, alignment, and muscle
force production, as described in the NIOSH Low Back
The third type of classification system is the clinical Atlas. Of these 53 tests, data from a total of 24 tests were
guideline index. This type of index is designed primarily used in the data analysis.
for providing instructions about treatment. Clinical
guideline indexes can be thought of as being designed Moffroid et aIz8 used a cluster analysis to determine
to manage patient problems. Two clinical guideline patient grouping based on the 24 impairment variables.
indexes described in the physical therapy literature are Cluster analysis is used to determine whether individuals
the classification systems described by Delitto and col- are similar enough on various attributes to be divided
leagues2"2hnd M c K e n ~ i e . ~ ~ into groups." Cluster analysis is a multivariate statistical
approach designed to maximize between-group variance
Some indexes are designed for multiple uses and are and minimize within-group variance on the variables of
called "mixed indexes." The QTF system, for example, interest. The system of Moffroid et al is strengthened by
was designed to aid in making clinical decisions, estab- the use of cluster analysis. The authors found that the
lishing a prognosis, and evaluating the quality of care for patients' impairment measurements varied among the 4
patients with LBP.2fiThe QTF system, therefore, can be groups (Fig. 4). The "very unfit" group, for example,
considered a mixed index. tended to have less hip and abdominal muscle force, less
mobility at the hip, and less lumbar spine motion than
Methods Used to Derive Classification Systems the other groups had, whereas the "flexible" group
for Patients With LBP tended to have more hip motion than the other groups
According to F e i n ~ t e i n ,classification
~~ systems have had.
been developed using 2 approaches. These 2 approaches
are the statistical approach and the judgment approach. The data of Moffroid and colleaguesm lend some insight
into the usefulness of physical impairment measures for
The Statistical Approach identifying homogeneous subgroups of patients with
Feinstein*Quggested that a statistical approach may be LBP. Physical impairment measures can be used in
the ideal way to develop a classification system. Accord- isolation to classify patients with LBP into various sub-
ing to Feinstein, if statistical procedures can be used to groups. Other potentially relevant data, however, were
group patients with similar attributes and demonstrate not used. For example, data related to chronicity, pathol-
that patients in different groups do not have overlapping ogy, and pain behavior-factors commonly accounted
attributes, then the classification system has promise for for in other classification systems-were not used by
clinical use. Feinstein contended, however, that the Moffroid and colleagues. Because factors such as chro-
developer of a classification system also must demon- nicity and pain behavior influence o u t ~ o m e , ~ l the
,5~
strate the clinical utility of the classification system. usefulness of this classification system for clinical prac-
According to Feinstein, it must be demonstrated that tice appears to be limited. Moffroid and colleagues did
clinically useful inferences can be made based on the not provide data to indicate how their classification
patient groupings if the classification system is to have system might be used to guide clinical decisions. A
clinical utility. summary description of the system proposed by
Moffroid and colleagues is presented in Table 2.
The statistical approach relies on one or a combination
of statistical procedures designed to identify variables Coste and c o l l e a g ~ e conducted
s ~ ~ ~ ~ a~ series
~ of studies
that can be used to distinguish various subgroups of designed to create a classification system for patients
Physical Therapy . Volume 78 . Number 7 .July 1998 Riddle . 715

hip flexor strength and length
asymmetry, limited passive
mobility of gluteus maximus,
iliopsoas, rectus femoris, tensor
Very Unfit fascia, iliotibial band, limited
forward and lateral bending,
pain with prone press-up
common, weak gluteus medius.
riight hip flexors, upper
abdominal muscles
pelvic height asymmetry,

very limited lateral bending,
Unfit
pain with prone press-up
very common
Patients with
musculoskeletal
limited passive mobility of

tensor fascia lata and
iliotibial band, decreased
Inflexible
lumbar contour standing
and sitting, limited forward
bending
increased single straight leg

raise, increased hip internal
rotation, high ratio of internal to
external rotation, increased
Flexible lumbar contour standing, change
in pain with prone press-up
common, pain location during
prone press-up commonly central
Figure 4.
An illustration of the domain, categories, and criteria for the classification system developed by Moffroid and colleagues.28 LBP=low back pain.
with LBP who either do or d o not have evidence of of the gluteal folds, and patients with neurological
psychological impairment. They used an approach sim- involvement were not admitted to the studies. The
ilar to that used by Moffi-oid and colleague^,^" a statistical DSM-111 criteria were used to identify patients with
approach to divide patients with LBP into homogeneous evidence of psychiatric disease."'J." Of the 330 patients
categories. Coste and colleagues, like Moffroid et al, admitted to the studies, 136 patients were found to have
relied entirely on statistical procedures for group evidence of psychiatric disease. The authors divided the
assignments. sample into those subjects with no evidence of psychiat-
ric disease (purely organic LBP) and those subjects
Coste and c o l l e a g ~ e s 2collected
~ ~ ~ ~ demographic and diagnosed with a psychiatric illness in addition to their
physical examination data on 330 patients referred for LBP.
treatment of LBP. Patients reporting pain below the area
71 6 . Riddle Physical Therapy . Volume 78 . Number 7 . July 1998

ables to perform a cluster analysis. The
Classification System of Coste and ~olleagues
29 cluster analysis revealed 3 categories of
patients (Fig. 6).
Acute (<7 days) LBP, sudden onset.
pain increasedwith impulsion, lifting.
back movement, bending The data by Coste and c0lleagues~~~3~
I forward, pain decreased when lying clearly indicate that patients with LBP
down, limited ROM, paravertebral
muscle shortening, catch, list, can be classified into several different
positive SLR groups with homogeneous characteris-
tics. The authors, however, did not
Chmnic (>3 mo) LBP, insidious present data or theoretical arguments
onset, moderate or mild pain, pain
Chronlc Statlc . increasedwith standing or sitting, for how these homogeneous categories
pain uncommon with SLR, impulsion.
forward bending and walking
might guide clinical decision making.
For example, it is not clear how these
patient categories might be used to

Chronic condition following an acute
episode; morning pain: pain guide decisions related to treatment
increased with climate changes;
Mechanical LBP
limited passive spinal ROM; pain selection or prognosis. More research is
increasedwith spinal ROM, lifting needed to determine how the catego-
impulsion,and SLR
ries proposed by Coste and colleagues
might influence decisions made in clin-
neurologicalsigns increased by standing and sitting. ical practice. Table 2 provides a brief
limitation of passive spinal motion. description of the 2 systems proposed
pain with lumbar flexion and
by Coste and colleagues.
Marras and colleagues31 developed a

Subacute (Iwk to 3 mo) LBP with classification system based on the QTF
gradual onset, mild pain, moderate
mechanical features system and then determined whether
trunk motion measures could be used
to predict the category to which the
patients were assigned (Fig. 7). The
Sudden onset, pain increased by
impulsion or lifting, pain decreased authors used a device designed to mea-
when lying down sure the 3dimensional motion charac-
teristics of the trunk. An electrogoni-
ometer attached to a harness was
strapped to the patients' trunk, and the
Chmnic LBP without morning pain or
pain increased by impulsion speed and acceleration of the trunk in
3 dimensions were q ~ a n t i f i e d .The
~~
authors hypothesized that with pathol-
Figure 5. ogy of the lumbar spine, predictable
An illustration of the domain, categories, and criteria for a classification system developed by asymmetric motions of the lumbar
Coste and colleagues.29 LBP=low back pain, ROM=range of motion, SLR=straight leg raise. spine would be found, especially dur-
ing bending movements requiring pre-
cision (eg, forward bending while in
For the group of patients with purely organic LBP,Coste 15" of rotation to the right). That is, the authors
et a129 collected a large amount of demographic and hypothesized that a patient's movement patterns would
pain behavior data (23 variables) and physical examina- be affected in predictable ways when a patient moved in
tion data (10 variables). They used the data in a cluster precisely defined planes of movement.
analysis to determine whether homogeneous categories
of patients could be identified. Figure 5 summarizes the Marras and colleagues3' tested their hypothesis by deter-
7 different categories of patients identified in the cluster mining whether patterns of limitations would be found
analysis. The authors did not report why they assigned for each of the categories described in their classification
names to only 5 of the 7 categories. system. A total of 171 patients with LBP of greater than
7 weeks' duration were admitted to the study. The
In one study, to classify the patients into categories, patients were approximately equally distributed among
Coste and colleaguesg0 used data obtained on 136 the 10 categories.
patients determined to have a psychiatric disorder. The
authors used the data obtained on 19 variables related to
the patients' pain complaints and 10 examination vari-
Physical Therapy . Volume 7 8 . Number 7 . July 1998 Riddle . 7 17

The Judgment Approach
C l a ~ ~ i f i ~ aSystem
t i ~ n of C0ste and C ~ l l e a g u e ~ ~ ~The second approach to developing a
classification system was described by
Pain increased by psychological F e i n ~ t e i nas~ ~
the judgment approach.
factors (eg, pain avoidance
1 Feinstein asserted that if no statistical
behavior), diffuse spinal pain,
Nonorganlc LBP
dysesthesias, physical examination data exist to guide the development of
findings generally absent
a classification system, the system devel-
oper must rely on 3 forms ofjudgment.
Decisions are made based on (1) tradi-
tional custom, (2) conventional wis-
dom, and (3) personal experience. The
Patients with LBP Nonorganic signs very uncommon, traditional custom method requires the
2 previous history of LBP, back
Almost Purely worse in morning, with movement, system developer to identify the vari-
Organic LBP when standing,and with changing ables in the literature that have been

climate
suggested to be the most important.
For example, most published opinions
by experts suggest that distribution of
pain is an important variable to assess
when examining patients with LBP. It
might be argued, based on traditional
3 Mechanical features and custom, that a classification system
Mixed LBP nonorganic features coexist should include the assessment of pain
distribution.
Figure 6. For the conventional wisdom method,

A n illustration o f the domain, categories, a n d criteria for a classification system developed b ythe system developer would rely on
Coste and colleagues.30 LBP=low back pain. common, but unpublished, beliefs of
the clinical community to guide deci-
sions about what variables should be
Several different statistical approaches were used to included. The system developer might simply survey
determine how accurately the correct category could be local clinicians informally to identify variables. For exam-
predicted for each patient. The statistical approach that ple, if the clinical community believed strongly in the use
gave the best prediction rate was an approach called of screening tests designed to identify patients believed
Modified Classification Using Splines (MCUS)."' The to be malingerers, then a system developer may choose
MCUS approach to classification reportedly allows for to include those screening tests in a classification system.
greater interaction among variables and is similar to the
neural networks a p p r ~ a c h . ~ V sensitivity
he and specific- For the personal experience method, the system devel-
ity of the predictions using the MCUS were generally opers would rely on their past clinical experiences to
high, with sensitivity ranging from 91% to 99% and guide decisions about the structure of a classification
specificity ranging from 55% to 88%. Patients were system. Delitto and colleague^,^^.^^ for example, relied
correctly classified 70% of the time. on their clinical experience to guide decisions related to
the type and number of categories in their classification
The data of Marras and colleaguesg1indicate that trunk system.
motion (primarily speed and acceleration) measure-
ments obtained in different planes show promise for use Several examples of classification systems based on the
in classification systems. The authors suggested that their judgment approach have appeared in the literature.
data support the use of lumbar motion measures for Binkley and colleague^:^' reviewed the literature related
prioritizing requests for diagnostic tests and for diagno- to classification systems and concluded that there was a
sis. They also suggested that the data obtained with their need to determine whether consensus could be devel-
device could be used for making decisions related to oped for a classification system. They stated that a
prognosis and outcomes of care, but no data were classification system should (1) facilitate communication
provided. The authors indicated that their results should among clinicians, ( 2 ) guide clinical decisions, and (3)
be considered preliminary. The method requires further create homogeneous subgroups for effectiveness studies.
refinement and testing on larger numbers of patients.
Table 2 briefly summarizes the system of Marras and Binkley and colleagues"' surveyed physical therapist
colleagues. experts to develop their classification system (Tab. 2).
The authors used a modification of the Delphi tech-
7 1 8 . Riddle Physical Therapy . Volume 78 . Number 7 . July 1998

were developing, 75% of the experts
Classification System of Marras and Colleagues 31 had to rate the item 3 or higher on a
5-point scale, with 1 being "unrelated"
Low back pain with radiation not and 5 being- "essential" for the classifi-
below the knee, negative imaging
test for neural compression, or no cation system. Nineteen categories,
imaging test done each with a varying number of criteria,
were judged by the group of experts to
Low back pain with radiation below
be included in the classification system
(Fig. 8).
The method used by Binkley and col-

Localized low back pain and
leaguesx to develop their system
departs from methods used to develop
other LBP classification systems. The

authors reviewed the literature and
lsthmic spondylolisthesis identified the most commonly
described categories and the criteria
associated with each category. They
Herniated nucleus pulposus with
then chose to survey a relatively small,
of the lumbar pain 53 on VAS but well-defined, group of physical
therapist experts. As they suggested,
their classification system appears to be
Herniated nucleus pulposus with incomplete. Another problem the
pain >3 on VAS
authors identified is that the experts
likely varied in the way they defined the
terminology used in the system, and
Spinal stenosis these differences may have contributed
error to the study. More work is needed
to determine whether more categories
are needed for the classification system
Postoperative pain
described by Binkley et al. As Binkley
and colleagues identified, classification
systems must be exhaustive; that is, they
must include all relevant categories to
be clinically useful. The classification
system also must be studied for reliabil-
ity to determine whether other clini-
I 10 Other diagnoses cians interpret the system similarly.
Perhaps most importantly, Binkley et

Figure 7. alx found that experts from around
An illustration of the domain, categories, and criteria for the classification system developed by the world agreed on a large number of
Morras and colleagues.3' VAS=visual analog scale, MMPI=Minnesota Multiphasic Personality
categories and criteria despite potential
Inventory.
differences in practice patterns, termi-
nology, and culture. This study was an
nique, a method designed to develop consensus among important first step in identifying what appear to be
a group of experkb4 Twenty-four physical therapist homogeneous clusters of patients with different patho-
experts who met criteria of proficiency were subjects in logical bases for their L.BP.
the study. The majority of experts (70%) were from
Canada. The experts completed 2 rounds of surveys M ~ o n e y an
, ~ ~orthopedic surgeon, used a judgment
designed to assess the extent of agreement on a group of approach to develop a classification system based on the
25 LBP categories (usually a diagnostic label) and crite- assumption that the majority of cases of LBP are due to
ria (usually a sign, symptom, or diagnostic test result) disk pathology (Tab. 2). The purpose of Mooney's
identified from the literature. The experts rated the system is to guide treatment, although the treatments
degree of importance for each category and criterion. In suggested by Mooney were not fully defined. The system
order for a category or criterion to be judged as relevant has 9 categories (Fig. 9). Mooney did not describe
for the classification system that Binkley and colleagues
.
Physical Therapy Volume 78 . Number 7 . July 1998 Riddle . 719
Classification System of Binkley and Colleagues 32
Positive radiographlbonescan
Positive CT scanlbiopsy
Scheurmann
Positive radiograph
(
Spondylollsthesis Positive radiograph
(
Extension increases painlparesthesia, positive CT
scan, flexion relieves pain

Decreased lumbar flexion and extension; positive
radiograph; increased thoracic, lumbar kyphosis
Decreased accessory motion, flexionlextension ROM

decreased, pain or stiffness, no paresthesia
21 previous LBP episode or pain >2 rno, flexion or side flexion

NeNe Root Adhesion away from pain increases pain, paresthesia, positive SLR
en 30°and 70' of hip flexion, painlparesthesia below knee
All patients with

LBP
NeNe Root Irritation Leg pain increased with lumbar movement,
paresthesia (
Unilateral buttock or posterior thigh pain, SI
joint tests indicate hypermobility (
Spinal curve observed, positive radiograph
(
Sustained positions increase pain, accessory
motion increased or resistance delayed
SI joint tests indicate hypomobility, asymmetrical

pelvic alignment
Neurological signs, SLR positive <70q

Dlsk Herniatlon
positive CT scan (
Examination of relevant viscera positive, lumbar
Referred Visceral
exam negative
Spinal Congenital
Positive radiograph
(
-
Positive bone scan or biopsy
(
Posterolateral Disk Pain increased with repeated flexion or
sustained flexion, onset involved flexion
Pain eased with activity, standing or sitting posture

Postural Syndrome
is abnormal
Figun, 8.
An illustration of the domain, categories, and criteria for the classification system developed by Binkley and colleagues.32 LBP=low back pain,
CT=computed tomography, ROM=range of motion, SLR=straight leg raise, SI=sacroiliac.
720 . Riddle Physical Therapy. Volume 78 . Number 7 .July 1998

Sikorski" proposed a classification sys-
Classification System of Mooney 33 tem designed to guide physical therapy.
There are 8 categories that group
Low back paln for 7 days patients based on similarities in pain
IA or less
duration and pain behavior (Fig. 10).
Sikorski argued that the categories are
- - - 7 based on symptoms, which could then
II A
Low back and th~ghpain for be linked to various pathologies. For
7 days or less
example, patients in the "chronic ante-
J
rior element" categor). were thought to
have disk pathology. Sikorski provided
IllA
Low back and leg paln for 7 no data to support the notion that the
days or less
various categories in the classification
system represented homogenous

pathologies. The medical history and
Low back paln for greater than
IB examination procedures used in Sikor-
1 wk but less than 3 mo
i
ski's system were not adequately
defined. Therapists, therefore, may not
Low back and th~ghpaln for be able to reliably classify patients into
II B greater than 1 wk but less the various categories he proposed.
than 3 mo
--
Low back and leg pain for

Further refinement of the system
111 B greater than 1 wk but less described by SikorskiS4 appears to be
than 3 mo
needed. The history-taking, examina-
tion, and treatment procedures need
clarification. When the system is well-
IC Low back paln for at least 3 mo defined, reliability of the classifications
should be examined. Sikorski's system
is briefly summarized in Table 2.
II C
1
Low back and th~ghpaln for
at least 3 mo Most of the classification systems that
are in clinical use were developed using
Figure 9.
111C Low back and
Ileg
at least 3 mo
pacn for
An illustration of the domain, categories, and criteria for the classification system developed by
the judgment approach and not pri-
marily a statistical approach. Clinicians,
therefore, might be tempted to avoid
using existing classification systems
because they were not developed using
approaches grounded in sound mea-
Mooney.33 surement science. Buchbinder and col-
leaguesa)," and F e i n ~ t e i n "have
~ sug
gested, however, that what ultimately
whether the system he proposed should be used for all determines the usefulness of a classification system is
patients with LBP or only for some patients. how well the classification system functions given the
purpose for which it was designed.
The usefulness of Mooney's system appears to be very
limited for physical therapists because it is based entirely Introduction to Classification Systems Selected
on symptom duration and distribution. All of the other for Critical Appraisal
classification systems described in this article used many
other variables. The domain was not clearly defined, and The Classification System of Bernard and Kirkaldy-Willis
the system does not appear to account for patients with The classification system proposed by Kirkaldy-Willis and
serious pathology or patients with pathology unrelated and later modified by Bernard and Kirkaldy-
to the disk. The assumption that disk pathology is WillisZ2 is a status index and a classic example of a
responsible for almost all cases of LBP appears to restrict pathology-based system (Tab. 1 ). This system is shown in
the use of this system to an unclearly defined and Figure 11. In their original article in 1979, Kirkaldy-Willis
relatively small group of patients. and Hill briefly described what they believed to be the
medical history, physical examination! and radiological
Physical Therapy . Volume 78 . Number 7 .July 1998 Riddle . 72 1

Classification System of ~ikorski
34
Examination findings suggesting the

Nonspinal presence of nonspinal pain
(undefined)
Pain that is not exacerbated by

Nonmechanical
mechanical stress or relieved by rest

Pain of less than 12 wk in
duration that is exacerbated by
Acute Mechanical
mechanical stress and relieved by
rest
Pain >12 wk; increased by

All patients with sustained lumbar spine flexion, not
low back pain who Chronic Anterior
including lifting; pain increased by
Element
have not had spinal sitting and relieved by standing;
hyperlordotic postures relieve pain
Chronic Posterior Pain >12 wk; increased with hyperlordotic

postures, standing, and walking; pain
Element With decreased with flexed postures; evidence of
Obvious spinal stenasis, scoliosis, thoracic kyphosis,
Structural lumbar hyperlordosis, facet arthropathy with
Disease associated changes
\
Pain >12 wk; increased with
Chronic Posterior
hyperlordotic postures, standing, and
Element Without
walking; pain decreased with flexed
Obvious
postures; no evidence of spinal
Structural
pathology other than facet
Disease
arthropathy
Pain >12 wk, relieved by rest,

Chronic
increased with activity, radiographic
Movement
tests indicate the presence of
Related
instability
Chronic Pain relieved by changing positions

and moving, unable to maintain
Mechanical
positions (other than lying) without an
Unclassified
increase in pain
Figure 10.
An illustration of the domain, categories, and criteria for the classification system developed by Sik0rski.3~
722 . Riddle Physical Therapy. Volume 7 8 . Number 7 . July 1998

Classification System of Bernard and Kirkaldy-Willis
Positive SLR, crossed SLR, positive radiologic tests,
symptoms described as sharp with radiation into distribution of
Herniated Nucleus sc~aticnerve, neurological signs common
Positive radiologic tests, LBP often absent, pain may extend

to ankle, minor sensory changes, mild ROM loss and spinal
Lateral Stenosis tenderness, SLR reduced, slight neurological findings common
ain on walking, pain relieved by rest, feeling the legs are goin
to give way, feeling of leg numbness, night pain relieved by
Central Stenosis walking, SLR only slightly limited, slight leg muscle weakness
after walking, positive radiologic tests
Spondylolisthesis Positive radiologic tests

Segmental Instability Positive radiologic tests
May mimic radicular pain, tenderness over PSIS, limited SI

(
SI Joint Syndrome joint motion, pain with Patrick test or Gaenslen maneuver,
pain with SI joint injection, no neurological signs
Ill-defined pain with possible radiation to posterior thigh and
Posterior Joint knee, occasionally below knee; lateral bending in extension
most painful; some sp~naltenderness
Pain referred to area of iliac crests on involved

Maigne Syndrome side, hypersensitivity of skin overlying iliac
crests
All patients with Trigger points in predictable areas resulting in referred pain,
ropy feeling to palpation of trigger point
Chronic Pain
Not described
(
Pseudarthrosis Positive radiologic tests
(
Not described
(
Postfusion Stenosis Positive radiologic tests
(
Positive radiologic tests
(
(
(
Arachnoiditis Positive radiologic tests
i
Not described
Nerve Entrapment
Figure 1 1.
An illustrotion of the domoin, categories, and criteria for the clossification system developed by Bernard and Kirkaldy-Willis.22 LBP=low back pain,
SI=sacroillioc, SLR=straight leg roise, ROM=range of motion, PSIS=posterior superior iliac spine.
Physical Therapy. Volume 78 . Number 7 . July 1998 Riddle . 723

Group A consists of 5 categories
Classification System of Delitto and colleague^^^^^^ described by the authors as "well-recog-
nized syndromes." Group B consists of
Extension 9 categories described as "less-recog-
Referral to another Syndrome nized syndromes." Group C has 9 cate-
practitioner gories described as the "remaining
Flexion syndromes."
Syndrome
One of the most important procedures
2 Lateral Shift used by Kirkaldy-Willis and Hill" for
Syndromes
establishing a diagnosis was the use of the
Stage I
4
results of radiologcal examinations. Clas-
Immobilization sification is particularly dependent on
the results of routine plain films in addi-

Syndromes
tion to other radiological testing. (See
5 Traction the article by Beattie and Meyers in this
Syndromes
issue for a discussion of the ralidity of
some radiological tests for making infer-
5 Mobilization ences about pathology.)
Syndromes
The Classification System of Delitto and

Colleagues
Flexibility
Deficit The classification system proposed by
Delitto and is a clinical
guideline index designed to guide
Stage II Strength Deficit treatment for patients with LBP (Tab.
1 ) . The system requires the therapist to
collect historical and disability ques-
Cardiovascular
Deficit tionnaire data to aid in determining
whether the patient's condition is ame-
nable to physical therapy intervention
Coordination
Deficit or requires care of another practitio-
ner. Examination procedures are
Body designed to assess the effect of move-
Mechanics ments on symptom behavior and to
Deficit assess the alignment of various body
structures. Figure 12 illustrates the
structure of the classification system of
Activity
Delitto and colleagues. Figure 12 illus-
Intolerance
Stage Ill trates only the domain and categories
of the classification system of Delitto
Work
Intolerance
and colleagues. The criteria were too
extensive to place in the figure. The
reader is referred to the original work
Figure 12. for a more thorough description of the
An illustration of the domain and categories of the classification system developed by Delitto
and colleagues.23,24 LBP=low back pain.
system.
The classification system of Delitto and

examination findings for each of 5 syndromes.49 No data colleag~es2"2~ has 3 levels involving different types of
were reported to support the descriptions. clinical decisions (Fig. 13). The first level requires the
therapist to use various instruments to decide whether
Based on a retrospective review of 1,293 cases, Bernard the patient (1) can be managed independently by a
and Kirkaldy-Willism revised the diagnostic classification physical therapist, (2) cannot be managed by a physical
originally proposed by Kirkaldy-Willis and Hi11.4"he therapist, or (3) can be managed by a physical therapist
classification developed by Bernard and Kirkaldy-Willis in consultation with another practitioner. The second
has 23 categories divided into 3 groups (Tab.

CWSIFICATION
SCHEME
I
Level 1
CONSULTATION - PHYSICAL
THERAPY
REFERRAL
.......".-..".."."."......"....""--"- ----.- "-".."..--. "-. .-.--.--.-- ".-"...--..----.-

Level 2 I
stage I II stage 11
I
stage ill
.._."....-.......-....... ............."" ....._....-....-.......- ".....".... .""-"-- .-..-"..-..--"".-."-."..-.....---.----."-"...

Extension Flexibility A d v ity
Fldon Deficit Intolerance
Level 3
h-4 Shift s-gh
Deficit Work
Immobilization
Deficit
Mechanics
Detick
Figure 13.
A summary of the 3 levels of classification of Delitto and colleagues. (Reprinted with permission of the American Physical Therapy Association from
Delitto et 01.23)
level of clinical decision making requires the therapist to tinued development. The categories for stage I1 and
stage the patient into 1 of 3 groups (stage I, stage 11, or stage I11 have yet to be described in the peer-reviewed
stage 111) based on the presence and severity of various literature.
functional limitations and disabilities, work status infor-
mation, and scores on a disability scale. When making The Classification System of McKenzie
decisions at the second level, therapists use only histor- The McKenzie system is a clinical guideline index
ical and disability data obtained from the patient. The designed for most, but not all, patients with LBP
examination is not done until the therapist is prepared (Tab. 1).z5 The structure of the McKenzie system is
to make clinical decisions at the third level. shown in Figure 3. The medical history consists of
questions related to symptom onset and symptom behav-
The third level of clinical decision making involves the ior associated with several different postures. The exam-
assignment of the patient, after being assigned to a stage, ination requires the therapist to observe the patient's
to one of the syndromes (categories) described for each posture and the alignment of several bony landmarks.
stage. The examination procedures for stage I were Trunk movements are observed for limitations and
described in a recent article.2" more elaborate descrip- frontal-plane deviations. Movements of the trunk are
tion of the stage I categories and treatments as well as observed, and the patient is questioned about the effect
examination and treatment information for stages I1 and of the movements on symptom location and intensity.
I11 appear in a recently published book chapter.Z4 The The therapist is also required to complete a neurological
categories described in the recently published book examination and to examine the patient's hip and
chapter for stage I syndromes are slightly different from sacroiliacjoints.
those described in the article. For example, the book
chapter described 3 different extension syndrome cate- McKenzie's classification system requires the clinician to
gories, whereas the article described only 1 extension classify the patient's problem into 1 of 13 c a t e g o r i e ~ . ~ ~
syndrome. Apparently, the classification system of The most commonly discussed categories are the pos-
Delitto and colleagues is undergoing a process of con- tural syndrome, the 4 dysfunction syndromes, and the 7
Physical Therapy . Volume 78 . Number 7 . July 1998 Riddle . 725

derangement syndromes. In addition, a category exists to identify pathology), (3) response to treatment (post-
for those patients classified as having a hip o r sacroiliac surgical status and failure to respond to conservative
joint problem. The dysfunction syndrome is further treatment), (4) work status (working, not working), and
subdivided into flexion dysfunction, extension dysf~~nc- (5) symptom duration ( < 7 days, 7 days to 7 weeks, >7
tion, side-gliding dysfunction, and adherent nerve root weeks).
dysfunction. The derangement syndrome is subdivided
into 7 derangement syndromes that are numbered con- The work status and symptom duration data were used lo
secutively from 1 to 7. McKenzie described these various form 2 additional axes of classification. Those patients
syndromes in the way that he did apparently because h e classified into categories 1 through 4 were further clas-
believed each syndrome requires a different treatment. sified based on duration of symptoms a n d work status.
McKenzie also suggested that patients may be classified Patients are classified into different categories depend-
as having a sacroiliac joint problem o r a hip problem, ing on whether their symptoms have been present for
but he did not describe the examination procedures o r less than 7 days, 7 days to 7 weeks, and longer than 7
treatments for these conditions. weeks. For the work status axis, patients are classified as

either working or idle, which the developers of the QTF
McKenzieSVndicated that some patients may have a system defined as being absent from work, unemployed,
more serious problem not amenable to conservative or inactive.'Vor patients classified into category 11, an
treatment, but h e argued that these patients typically are axis of classification based on work status was added.
identified by the referring physician and are not referred These separate axes were added because the developers
for physical therapy. Patients with "constant severe sciat- of the QTF system believed, based o n data collected o n
ica with neurological deficit," patients thought to have a patients by the Quebec Worker's Compensation Board,
serious pathology, and patients whose symptoms cannot that prognosis is influenced by both symptom duration
be centralized during the examination are labeled as and work status." The QTF system does not require the
un~lassifiable.~~ use of other impairment data (eg, spinal flexion or
extension range of motion [ROM]) or the patient's
The Quebec Task Force Classification System report of pain d u e to movement (eg, centralization or
The QTF was a group of experts in various fields brought peripheralization) .
together by the Quebec Worker's Health and Safety
C o m m i s ~ i o n .The
~ ~ QTF report should be of great Combining data on signs and symptoms, radiological
interest to physical therapists. The commission was tests, symptom duration, and work status would appear
formed, in part, because of the large increase in the to result in a rather complex classification system. For
number of physical therapy treatments for LBP in Que- example, a patient in category 4 (pain with radiation to
bec in the years prior to the formation of the QTF. a lower limb and neurological signs) could be essentially
identical, in pathology a n d signs and symptoms, to a
Because the QTF was interested in many aspects of the patient in category 6 (compression of a spinal nerve root
care of patients with LBP, the classification system pro- confirmed by a radiographic test such as magnetic
posed by this group was designed with many different resonance imaging). The developers of the QTF system
purposes in mind (Tab. 1 ) . The classification system apparently believed that the addition of a radiological
designed by the QTF was intended to "help in making test confirming the presence of a compressed nerve root
a clinical decision, establishing a prognosis, evaluating required a separate category. From the perspective of
the quality of care and conducting scientific prognosis a n d physical therapy treatment, patients in
resear~h."~~ The
( ~ QTF
~ ~ " classification system is there- these 2 categories may not differ. From the spine sur-
fore an example of a mixed index." Figure 2 depicts the geon's perspective, the patient with a radiologically
structure of the QTF classification system. confirmed nerve root compression may be considered a
candidate for surgery, whereas the patient with identical
The developers of the QTF classification system argued signs and symptoms but no radiologically confirmed
that because the majority of patients with LBP have a nerve root compression will likely not be a surgical
disorder with an unidentified etiology, a classification candidate. T h e QTF classification system was designed to
system should be designed based primarily o n pain account for those patients who may be candidates for
data.'% They also argued that only in the minority of surgery.
cases can the origin of the pain be identified (ie, the
pathology causing the disability can be determined). Treatments for each category are not defined in the QTF
T h e classification system, therefore, is composed of data system. Instead, the QTF reviewed the literature related
collected from a variety of sources, including (1) a to treatment efficacy a n d made general recommenda-
combination of signs and symptoms (pain and neurolog- tions about treatment appro ache^.^^
ical examination data), (2) radiological data (designed

Table 3.
Critical Appraisal of Classification Systems Described by Buchbinder and C ~ l l e a ~ u e s ~ ~ , ~ '
Purpose
Are the purpose, population, and setting clearly specified?
Content validity
Are the domain and all specific exclusions from this domain clearly specified?
Are all relevant categories included?
Is the breakdown of categories appropriate, considering the purpose?
Are the categories mutually exclusive?
Was the method of development appropriate?
If multiaxial, are criteria of content validity satisfied for each additional axis?
Face validity

Is the nomenclature used to label the categories satisfactory?
Are the criteria for determining inclusion into each category clearly specified? If yes, do these criteria appear reasonable?
Have the criteria been demonstrated to have validity?
Have the criteria been demonstrated to have reliability?
Are the definitions of criteria clearly specified?
If multiaxial, are criteria of face validity satisfied for each additional axis?
Feasibility
Is the classification simple to understand?
Is the classification easy to perform?
Does it rely on clinical examination alone?
Are special skills, tools, or training required?
How long does it take to perform?
Construct validity
Does it discriminate between entities that are thought to be different in a way appropriate for the purpose?
Does it perform satisfactorily when compared with other classification systems that classify the same domain?
Reliability
Does the classification system provide consistent results?
Generalizability
Has it been used in other studies or settings?
An Approach for Critically Appraising Existing Content validity deals with whether the instrument of
Classification Systems interest includes everything needed to describe the
Buchbinder and c 0 l l e a g u e s ~ ~developed
~2~ an approach concept of interest (ie, the thing being measured) .71For
for appraising classification systems. This approach to the concept of content validity, one item poses the
critical appraisal consists of 7 concepts: (1) appropriate- following question: "Was the method of development
ness of purpose, (2) content validity, (3) face validity, appropriate?" Buchbinder and ~olleaguesZ~~2~ suggested
(4) feasibility, (5) construct validity, (6) reliability, and that classification systems should undergo a develop-
(7) generalizability. The authors adapted their approach ment process similar to health status m e a s u r e ~ . ~ ~ . ~ z ~ ~ ~
for examining classification systems from the psycholog- The categories in a classification system, in their view,
ical literature(j7and from work done to construct health should be chosen based on the opinions of a committee
status measure^.^^^^-^" of experts, not on the opinion of an individual. Accord-
ing to their system, a formal group consensus technique
A summary of the approach to critical appraisal devel- should be used to identify the categories. In addition,
oped by Buchbinder et al" is presented in Table 3. The they contended that a review of the literature should be
table lists the items used to judge each of the 7 concepts. used to supplement the classification system and that
Some concepts have only one item (eg, purpose), statistical techniques should be used in the process of
whereas other concepts have several items (eg, content development.
validity) to judge whether the classification system ade-
quately meets the concept. Each item is written in the For the concept of face validity, an item states, "Is the
fo1.111 of a question and is generally self-explanatory, nomenclature used to label the categories satisfactory?"
although some items require elaboration. Some categories in a classification system imply the

Table 4.
Critical Appraisal of Purpose and Content Validity
. Bernard and Delitto and Quebec
Concepts and Items Kirkaldy-Willisz2 Colleaguesz3~" McKenziez5 Task Forcez6
Purpose
Are the purpose, populatian, and setting Yes Yes Yes Yes
clearly specified?
Content validity
Are domain of interest and all specific Yes Yes Yes Yes
exclusions specified?
Are all relevant categories included? Yes Unknown No No
Are the categories mutually exclusive? Yes Unknown Yes No

Are categories appropriate, given the No Unknown Yes Yes
purpose?
Was method of development No Yes No Yes
appropriate?
If multiaxial, are criteria of content N/Aa N/A N/ A Yes
validity satisfied for each axis?
" N/A=not applirablc
presence a specific pathology. For example, in the and the QTF.26A summary description of the 4 classifi-
classification system of Bernard and Kirkaldy-Willis,22 cation systems is presented in Table 1. Readers should
there is a "piriformis syndrome" category. F e i n ~ t e i n , ~ ~note that I was the only person who reviewed the
who is a physician, suggested that diagnostic labels are classification systems. The reliability ofjudgments made
appropriate only for entities that can be verified with using the critical appraisal approach was not assessed for
valid diagnostic tests. Buchbinder and colleaguesz this article. For a more thorough description of the
agreed and suggested that categories implying the pres- critical appraisal, the reader is referred to the article by
ence of unverifiable pathology should not be used in Buchbinder et a1.21
classification systems. Diagnostic tests for piriformis syn-
drome have not been studied for validity. The use of the Purpose
term "piriformis syndrome," therefore, would appear to The purpose is well-defined for the 4 classification
be inappropriate. systems (Tab. 1). Ultimately, each classification must be
judged in the context of the purpose for which it was
An item under the concept of construct validity asks, designed. A summary of judgments related to the pur-
"Does it discriminate between entities that are thought pose of the 4 classification systems is given in Table 4.
to be different in a way appropriate for the purpose?" A
construct is a conceptual idea that might be used to Content Validity
explain a p h e n ~ m e n o nConstruct
.~~ validation may dem-
onstrate that a proposed construct actually exists or that Domain of interest and inclusion of relevant categories.
a new classification system differs from an existing The 4 classification systems differ with respect to the
When determining whether a classification system dis- method of development and inclusivity of the system. All
criminates between entities that are thought to be dif- classification systems clearly defined the domain of inter-
ferent, hypotheses should be tested. To test hypotheses, est, although only the system of Bernard and Kirkaldy-
data need to be collected and examined for relation- Willis" appeared to include all relevant categories based
ships. For example, if a classification system were on the purpose. The QTF system used an additional axis
designed to identify an effective treatment for patients, a to classify patients as either working or not working. The
study demonstrating that the treatment was more effec- QTF did not report why they chose not to use the axis
tive than other treatments would need to be done. This related to work status for all categories, as work status has
would be a study of prescriptive validity.75 been shown to influence Atlas and col-
l e a g u e ~ 'concurred
~ that work status should be assessed
The critical appraisal approach proposed by Buchbinder in other categories of the QTF system.
and colleaguesx is used in this article to critique 4 of the
more commonly discussed classification systems for The systems developed by Bernard and Kirkaldy-Willis"
patients with LBP: the systems proposed by Bernard and and the QTFZ6both include a category that accounts for
Kirkaldy-Willis," Delitto and ~ o l l e a g u e sM
, ~~~K~e ~
n z~i e , ~ ~
patients who d o not meet the criteria of the other

categories in the systems. The system of Bernard and having 2 syndromes, the focus of treatment is initially
Kirkaldy-W'illis has a category called "nonspecific," and directed to the more serious syndrome (eg, a derange-
the QTF system has a category called "other." These ment 3 syndrome would be addressed first in a patient
categories permit the placement of patients into a cate- classified as having both a dysfunction syndrome and a
gory when they do not meet the criteria of any other derangement 3 syndrome).
category in the classification system. For example, in the
QTF system, patients with evidence of cancer, visceral The QTF system was designed to be a hierarchical
disease, compression fractures, or other diseases or scale.26 That is, patients are classified into category 1
conditions requiring non-therapist care are placed in unless they fulfill criteria for category 2 and so on.
categonr 11, the "other diseases" category. Classification systems designed to be hierarchical tend to
have mutually exclusive categories. The QTF system,
When a. classification system accounts for all possible however, was judged to have categories that are not
patient types, the system is said to be exhaustive. The mutually exclusive because patients could potentially fall
McKenzie system2Voes not appear to be exhaustive in into more than one category. For example, patients who

nature. McKenzie's categories do not appear to account are classified as having chronic pain syndrome (cate-
for those patients who stay the same or are worsened by gory 10) and who also report pain radiating to a distal
the examination procedures designed to alter a patient's lower extremity (category 3) could be assigned to either
pain.z3Ilow these types of patients might be classified is category 10 or category 3. The QTF system does not
unclear. Also unclear is how patients with commonly provide the instructions necessary to determine which
accepted pathology-based diagnoses (eg, segmental category a patient should be assigned to when more than
instability, spinal stenosis) might be classified. For exam- one category appears to be applicable.
ple, McKenzie's methods would appear to be of ques-
tionable usefulness for patients with segmental instabil- Again, because the system of Delitto and colleague^^^,^^
ity. Patients with instability would appear to require has not been described completely in the peer-reviewed
treatment designed to restrict motion of the involved literature, I could only rate it as "unknown" for 3 of the
segment..77 In my view, the exercises advocated by items under content validity. Delitto and colleagues
McKenzie would not assist in stabilizing hypermobile appear to have developed categories to address most
segment.s of the spine. known patient groups, including patients with spinal
stenosis and patients with segmental instability. The
McKenzieZVmplied that patients with serious pathology system of Delitto and colleagues can be used to classify
are typically identified by the referring physician and are patients with serious disease or problems not amenable
therefore not referred for treatment. McKenzie and to physical therapy. Whether the categories Delitto and
Donelson stated in a later text that patients with inflam- colleagues have chosen are mutually exclusive and ade-
matory disorders, fractures, and other pathologies not quately capture the critical categories of patients with
amenable to treatment with the McKenzie approach are LBP will have to be determined after the entire system
"quickly recognized when tested appr~priately."~~(p~~~~) has been described in the literature and data are
A clear method for screening patients not suitable for provided.
treatment with the McKenzie approach appears to be
lacking. McKenzie's system does not have a category for Appropriateness of categories. Categories must be
patients suspected of having serious pathology. The judged for appropriateness from the context of the
other systems have such a category. McKenzie's system, purpose of the classification system. The system of
therefore, does not appear to have an exhaustive num- Bernard and Kirkaldy-Miilli~~~ is inappropriate, in my
ber of categories to account for patients with LBP who opinion, because of the extensive use of nonverifiable
might be seen by physical therapists. The system of pathology-based categories. I judged both the McKenzie
Delitto and colleagues2~24 was rated as "unknown" for systemz5and the QTF systemz6to be appropriate for this
the item that asks whether all relevant categories are item.
included because the system has not been thoroughly
described in the peer-reviewed literature. Method of development. I believe the method of devel-
opment was inappropriate for 2 systems: the Bernard
Mutual exc/usiveness. Another item used to judge con- and Kirkaldy-Willis systemz2and the McKenzie system.25
tent validity asks whether the categories are mutually These systems apparently were developed based on the
exclusive. Theoretically, a patient should only be able to clinical experience of the developers. The system of
be classified into one category. If a patient fits more than Delitto and colleagues23~24 and the QTF system2here
one category, the decision rules for the system should developed based on a process of obtaining some form of
indicate how the patient should be classified. McKen- expert consensus and through use of a literature review.
zie2"mplies in his text that if a patient is classified as These 2 systems, therefore, were judged to meet the

Table 5.
Critical Appraisal of Face Validiv and Feasibiliv
Bernard and Delitto and Quebec

I Concepts and Items K i r k a l d y - W i l l i ~ ~ ~ colleague^^^-^^ M ~ K e n z i e ~ ~Task Forcez6
Face validiv
Is nomenclature used to label categories Yes Yes Yes
satisfactory?"
Are criteria for inclusion into categories Unknown Yes Yes
specified?
If yes, are the criteria reasonablezb Yes Yes
Do the criteria have demonstrated No No
validiv?

Do the criteria have demonstrated
reliability?
Are the definitions of the criteria clearly
specified?
If multiaxial, are criteria of face validity
satisfied for each additional axis?
Feasibility
Is classification simple to understand?' Yes Unknown Yes Yes
Is classification easy to Yes Unknown Yes Yes
Does it rely only on clinical examination? No Yes Yes No
Are specials skills, tools, or training Yes Unknown No Yes
required?
How long does it take to perform? Unknown Unknown 45 min 15 min
"This item asks whether the catejioly labels rrqoire the clinician to infer the presence of a spcrific pathology that cannot be verified,
"'l'his item asks wherhrr an) data exist t o sl~pportthe reliability or validitv of the CI-iteria.
' This ite~iiasks whethel- the system is relatively easy to comprehend for a clinician who treats patients with low back pain.
"This item asks whether the steps required when applying the system are I-easonablysimple and clearly described.
" N/A=not applicable.
criteria for development. Delitto and colleagues relied presence of a pathology when using the system. Because
on the input of approximately a dozen clinicians, includ- many of these category labels have not been studied for
ing physical therapists, physicians, and chiropractors, validity, I contend that the terms are unsatisfactory.
when developing the medical history and examination
portions of their classification system. Delitto and col- I believe that all 4 classification systems have unsatisfac-
leagues, however, also relied on personal experience to tory data supporting the reliability and validity of the
develop decision rules for classifying patients into vari- criteria. Some data exist to support the reliability of
ous treatment categories. The McKenzie system and the some of the criteria in the classification systems of
Bernard and Kirkaldy-Willis system appear to be based Delitto and c ~ l l e a g u e and
s ~ ~McKen~ie,~"ut
~~ many
primarily on the clinical experiences of the developers of the criteria in the 4 classification systems have not
and therefore, in my view, have not undergone an been studied for reliability. The definitions for all of the
appropriate method of development. A summary of the criteria are not clearly specified for all 4 classification
content validityjudgments for the 4 classification systems systems. Delitto and c ~ l l e a g u e s , ~ V oexample,
r did
is given in Table 4. not define how to interpret performance on the side-
bending test, a critical examination procedure used in
Face Validity stage I. McIienzieZ5did not clearly define how to differ-
Face validity is judged from a variety of different per- entiate between an accentuated, normal, and reduced
spectives. Most of the items (see Tab. 5) relate to the lumbar lordoses. Bernard and Kirkaldy-UTillis22did not
criteria used to place patients into the various categories. define procedures for the majority of categories in their
One item addresses the category labels. The nomencla- classification system. The developers of the QTF systemz6
ture used to label categories was judged to be unsatisfac- did not define the procedures used to determine when a
tory only for the Bernard and Kirkaldy-U'illis system." patient should be assigned to the "other diagnoses"
Because the Bernard and Kirkaldy-Willis system relies on category. A patient, for example, may have pain in the
pathology-based diagnostic labels, users must deduce the area of the lumbar spine without radiation (category 1)

but may also have a tumor in the lumbar spine (category more effective than treatment that was not matched to a
11). The QTF system does not define the procedures category. Delitto and colleagues conducted 2
used to classify patients who may have characteristics designed to examine the treatment effectiveness of one
consistent with more than one category. A summary of of the many categories they described. They examined
the face validityjudgments for the 4 classification systems the treatment effectiveness of patients classified into the
is given in Table 5 . extension-mobilization category, apparently a stage I
syndrome in their classification system. How this
Feasibility extension-mobilization category relates to the 6 catego-
Three of the 4 classification systems, in my opinion, met ries listed under stage I in Figure 12 is not clear. The
most of the feasibility criteria. I scored the system of 2 studies suggested that patients classified into the
Delitto and colleague^^'^^^^ as "unknown" on 3 of the extension-mobilization category responded better, in
items because the classification system has not been the short term (approximately 1 week), to treatment
described completely. Whether advanced training is designed for these patients than to treatment that was
needed to use the system of Delitto et a1 is not known. not matched to the classification category. No other

Because the Bernard and Kirkaldy-Willis systemw and studies have been conducted on the system described by
the QTF rely on the use of radiological data for Delitto and colleagues.
clascification, I judged them both as requiring special
skills. The system of McKenzie2"oes not appear to As Delitto and colleague^"^:^^' noted, limitations to these
require advanced training, although reliability stud- 2 studies exist. They examined only one category of
iesH2,H3suggest that the system is unreliable for clinicians patients, so the results cannot be generalized to the
who are inexperienced in the use of the McKenzie remainder of the classification system. All examiners
system and for clinicians with some advanced training in received training from one of the authors, so the results
the McKcnzie system. A summary of the feasibility Judg- may not be generalizable to other therapists. The studies
ments for the 4 classification systems is presented in examined small numbers of patients, so the results may
Table 5 . not be generalizable to other patients. In addition, only
the short-term (approximately 1 week) outcomes of care
Construct Validity were measured, so the long-term results of this form of
The items listed under construct validity were assessed by treatment are unknown.
examining the results of published research. The systems
of Delitto and colleague^,^"^^ M c K e n ~ i e , ~ b nthed Most of the treatments for the various categories
QTP-artially met the criteria for the construct validity described by Delitto and c o l l e a g ~ ~ e shave
~ " ~ not
~ been
item tha~:deals with whether a classification system studied for efficacy o r effectiveness. For example, no
discriminates between entities thought to be different in data exist to support the use of autotraction as a treat-
a way appropriate for the purpose. To support the ment for one of the categories in the systern proposed by
notion that the system discriminates among categories, Delitto and colleagues. More work is needed by Delitto
research had to have been done to demonstrate that and colleagues and by other researchers to further
patients assigned to different categories were meaning- determine the usefulness of this system in clinical
fully different from each other. Approaches that have practice.
been studied using a cluster analysis, for example, may
proklde data to suggest that the system is able to discrim- The system of McKenzie. Several studiesM-" have been
inate among patients in different categories. What clus- done to support the centralization phenomenon as a
ter analysis does not do, however, is indicate whether the useful construct for discriminating among patients with
differences anlong categories are clinically meaningful. different conditions using the McKenzie system.Y5
The final item under construct validity deals with studies Although data exist to support the construct of the
that have compared the utility of classification systems. centralization phenomenon, it is not clear how much
No studies were found that made head-to-head compar- impact these studies have on the usefulness of the
isons of classification systems. McKenzie system.
Several studies have examined aspects of the construct Several s t ~ d i e s ~ -have

~ O examined the treatment efficacy
validity of the systems of Delitto et a 1 , 2 3 ~ 2 ~ c K e n z i e , 2 5of the McKenzie approach.Y5 Nwuga and NwugaXHalter-
and the (lTF."j These studies are reviewed in the sec- nately assigned 62 female patients with acute LBP to 1 of
tions that follow. 2 groups: a group treated using the McKenzie
approachY5o r a group treated using an approach pro-
The system of Delitto and colleagues. Delitto and col- posed by Williams.ql WilliamsN advocated the use of
l e a g ~ e s ~ ~provided
.:'~ data to support the notion that exercises designed to decrease lumbar lordosis. McKen-
treatment designed for one category of patients was zieP5advocated the use of exercise and postures based on
Physical Therapy . Volume 78 . Number 7 . July 1998 Riddle . 73 1

examination findings in many cases to increase lordosis. than those receiving education (mean sick leave of 21.6
Nwuga and Nwuga determined which treatment was days), but they provided no data to suggest that both
more effective at decreasing pain and increasing spinal groups were equally disabled prior to the start of the
ROM. They found that the patients treated with the study. All of the subjects in both groups reportedly
McKenzie approach had greater improvements in ROM returned to work by 11 weeks after the start of the study.
and pain intensity as compared with the patients treated 111 a 1-year follow-up, 95 of the 100 patients were
with the Williams approach. Nwuga and Nrvuga did not surveyed, and the 2 groups were found to be no different
have a control group. In addition, only one therapist in their recreational activity levels.
applied the treatments to the patients, limiting the
generalizability of the study. The second study by Stankovic and JohnellW was a
follow-up to their first study. The authors contacted 89 of
Ponte et alx7also compared the efficacy of the McKenzie the 95 patients who completed the first study to deter-
approach2%nd the Williams approach." A group of 22 mine the long-term effects of treatment. Patients treated
patients with acute LBP were admitted to the study. The with the McKenzie approach2"er-e reported to have

physicians referring the patients were responsible for fewer recurrences of LBP during the preceding 4 years,
assigning patients to a group treated with the McKenzie but, as the authors point out, the reliability of recall data
approach or a group treated with the Williams approach. over a 4year period should be questioned. Patients
,4 physical therapist assigned to each group applied all treated with the McKenzie approach also had fewer
treatments for the patients in the group. Dependent episodes of missed work due to LBP compared with the
variables that were assessed were pain intensity, ROM of education group.
the spine, and the straight leg raise. The patients treated
with the McKenzie approach showed greater gains in The 2 studies by Stankovic and J ~ h n e l suggest
l ~ ~ ~that
~
ROM and decreases in pain intensity compared with the the McKenzie treatment a p p r o a c h ' m a y have some
patients treated with the Williams approach. long-term beneficial effects, although the second study
probably contained some bias because the patients were
The usefulness of the study by Ponte et alWis limited by asked to recall events that may have occurred up to
several factors. The method of assigning patients to the 4 years previously. The authors also did not control for
treatment groups was biased. Patients were not assigned many factors that could influence the rate of injury in
randomly to the treatment groups. Instead, the referring the 2 groups. For example, the 2 groups may have
physicians assigned patient? to the treatment groups. differed in their work demands, which could have influ-
The sample size was small, with only 10 patients in one enced the rate of recurrence.
group and 12 patients in the other group, and only one
therapist participated for each group of patients. The QTF system. Atlas and colleagues7fi examined a
variety of issues related to the construct validity of the
Ponte et alx7and Nwuga and Nwuga" used measures of QTF system.2" The authors determined whether there
impairment as the dependent variables, not an unusual were differences between QTF system categories for a
approach for studies published more than a decade ago. variety of patient characteristics, including duration of
Most experts now recommend that measures of disabil- pain and disability level. The QTF implied that, for
ity, health status, and work status be used as the depen- categories 1 through 4 and 6, an ordering effect existed
dent measures of choice in efficacy studies. Impairment such that the disability reported by patients classified
measures may not accurately reflect important changes into category 2 would be higher than that reported by
in a patient's condition. patients in category 1 and so on.2" Atlas and colleagues
also determined whether the category to which a patient
Stankovic and Johnell conducted 2 designed was assigned was associated with the likelihood of surgi-
to examine the long-term effects of McKenzie treatment cal versus nonsurgical treatment. The developers of the
versus a patient education treatment approach for QTF system suggested that patients classified into cate-
patients with acute LBP. In the first study,xgthe authors gories 6 and 7 were most likely to have surgical treatment
randomly assigned 100 patients to either a group treated because of the positive radiological tests. Atlas and
with the McKenzie a p p r ~ a c h 'or
~ a group that received colleagues also assessed the prognoses for patients
education. The patients treated with the McKenzie assigned to different categories to determine whether
approach were treated an average of 5 times (range= category assignment was associated with prognosis. The
2-20) times. The patients in the education group were QTF proposed that the QTF system could be used for
instructed one time for approximately 45 minutes in the making judgments related to prognosis. The QTF
anatomy and function of the spine. The authors found implied that prognosis becomes worse with assignment
that patients treated with the McKenzie approach to higher categories (eg, patients in category 2 have a
returned to work faster (mean sick leave of 11.9 days) worse prognosis than patients in category 1) and that

prognosis worsens as the duration of symptoms becomes more (indicated by larger change scores for the modi-
longer. fied Roland and Morris Scaleg2 and the SF-36"" than
patients who were not working.
In the study by Atlas and colleague^,^^ the patients
(N = 516) reportedly were diagnosed with sciatica or Atlas and colleagues76 collected data to both support
spinal stenosis and had to have had at least 2 weeks of and refute the construct validity of the QTF system. They
unsuccessful conservative treatment (not defined by the found that symptom severity increased from classifica-
authors) within 2 months of their first visit to a surgeon. tion categories 2 to 6, although functional status was
Only patients who were assigned to categories 1 through similar among the categories. Patients classified into
4,6, and 7 of the QTF system were admitted to the study. category 6 were more likely to be treated surgically than
The authors were primarily interested in studying were patients in categories 1 through 4. Approximately
patients who were considered to he candidates for half of the patients in categories 2 through 4 were
surgery. Baseline data on demographic information, treated with surgery, which suggests that the QTF system

symptom characteristics, and disability were collected. does not predict which patients receive surgery. The
Questionnaires were sent to patients 1 year following the QTF system categories do not aid in determining a
initial visit to determine the level of disability, work prognosis for patients treated without surgery as the
status, and type of treatment received. originators have suggested. Patients with higher classifi-
cations (eg, 4 or 6) actually showed more improvement
Atlas et a176found an ordering effect for the likelihood than patients classified into categories 2 or 3. Symptom
of surgical treatment. Patients classified into category 6 duration and work status, however, influenced outcome,
were more likely to have surgical treatment than patients supporting the notion that symptom duration and work
in categories 1 through 4. Approximately the same status are important for classification systems designed
proportion of patients in categories 2 through 4 were for making decisions related to prognosis. Table 6
treated surgically as were treated conservatively, suggest- summarizes the construct validity judgments for the 4
ing the QTF system does not predict treatment decisions systems.
for those patients. The frequency of symptoms was found
to increase from categories 2 to 6, but functional status, Reliability
as measured by a modified Roland and Morris Scaleg2 Reliability is another concept that requires data from the
and the SF-36,93 did not worsen from categories 2 literature for making judgments. No studies were found
through 6. The QTF system did not appear to indicate a that examined the reliability of classifications made
worsening functional status with higher categories. using the systems developed by Bernard and Kirkaldy-
There was no relationship between symptom duration Willis,= Delitto and ~olleagues,~~2* or the QTF.Z6 Errors
and disability level or symptom severity at baseline can be common when using classification ~ y s t e m s . ~ 2 , ~ ~
measurement. The symptom duration axis of the QTF The reliability of classifications made using the systems
system was not a useful discriminator of functional status described by the QTF, Bernard and Kirkaldy-Willis, and
or symptom severity. Delitto and colleagues, therefore, need to be examined.
When examining the issue of prognosis, the patients Two s t ~ d i e shave

~ ~ ,examined
~~ the reliability of classifi-
treated without surgery in the study of Atlas et a17G cations based on use of the McKenzie approach. Kilby
showed a greater change in disability scores as the and colleaguess3 developed an algorithm based on the
categories of the QTF system increased from category 2 McKenzie system and tested the reliability of assessments
to category 6. In addition, the percentage of patients made based on the algorithm. The authors required one
with sciatica who were treated without surgery and who therapist to examine each of 41 patients while a second
were asymptomatic at the end of 1 year increased from therapist observed the examinations of the first thera-
category 2 to category 6. That is, prognosis did not pist. The therapists apparently were able to classify only
appear to become worse with assignment to categories 1 28 of the 41 patients admitted to the study. The thera-
through 4 and 6. These data appear to refute the pists agreed on which syndrome was present in 58% of
developers' claims that the QTF system can be used to the patients.
estimate prognosis, especially for patients treated non-
surgically. For patients treated without surgery, increas- The internal validity of the study by Kilby and col-
ing symptom duration was associated with less improve- leaguesn3 is limited for several reasons. The design
ment in symptoms and disability level, supporting the restricted the patient-therapist interaction to only one
developers' contention that symptom chronicity can be therapist. The other therapist who made judgments
used to predict prognosis. Work status also was shown to about syndrome type only observed the first therapist's
be a predictor of improvements in disability. Patients examinations. Because interaction between the patient
who were working at the time of the study improved and the therapist was restricted for the second examiner,

Table 6.
Critical Appraisal of the Construct Validity, Reliability, and Generalizability
Bernard and Delitto and Quebec

Concepts and Items Kirkaldy-Willisa2 colleague^^^^^" McKenzieaS Task Force2"
Construct validity
Does it discriminate between entities No Partially Partially Partially
thought to be different in a way
appropriate for the purpose?"
Does it perform satisfactorilyb compared Unknown Unknown Unknown Unknown
with other systems with similar
purposes?
Reliability

I Are the intratester and intertester
reliability sati~factory?~
Generalizability
Unknown Unknown Unknown
Has it been used in other studies and No Partially Yes Yes

settings?
"This item asks whether there are any ciala lo suggest the classification aystem ran hc. used for its intended purpose.
"Satistiirtory, in this contcxt, relates to whether data support the llse of a classification system fc)r clinical decisiot~nraking.
the authors artificially controlled for a major source of studied by several groups and appears to have the
error. In addition, the number of patients and therapists strongest evidence for generalizability of the 4 classifica-
participating in the study was small, which further limits tion systems that were reviewed. Table G summarizes the
the usefulness of the study. generalizability judgments for the 4 systems.
Kiddle and Kothsteinx' examined the intertester reliabil- Summary of Critical Appraisal
ity of classifications made o n 363 patients with I,BP The critical appraisal of the 4 classification systems
referred to 1 of 8 clinics. Therapists (N=49) were given demonstrates that each classification system has
written summaries of the McKenzie system that were strengths and weaknesses. The 4 classification systems
based o n McKenzie's b0ok.2~Randomly paired thera- have a clearly defined purpose, and the population of
pists examined each patient independently. The kappa interest and setting are either clearly defined or implied.
coefficient and percentage of agreement were used to In the area of content validity, the system of Delitto and
describe reliability. Therapists agreed 39% of the time colleague^^^^^^ appears to hold promise, hut much is
( ~ = . 2 6 )o n which syndrome was present. Therapists unknown because the system has yet to be fully described
with postgraduate training in the McKen~ie system in the peer-reviewed literature. The McKenzie system25
agreed on the type of syndrome 27% of the time demonstrated some problems in the area of content
( ~ = . 1 5 ) .These data suggest that classifications made validity, primarily because of the issue of exhaustiveness.
using the McKenzie system are unreliable. Modifications The QTF system'" does not have mutually exclusive
of the criteria and definitions appear to be needed to categories, and the work status and synlptom duration
enhance the reliability of classifications. Table 6 summa- axes are missing for some categories.
rizes the reliability judgments for the 4 systems.
The face validity is generally weak for all systems because
Generalizability of the lack of data supporting the reliability and validity
Generalizability is the final concept in the critical of the criteria used to form the categories. Buchbinder
appraisal approach. To assess generalizability, I reviewed et al" reported similar findings for classification systems
the literature to determine whether the classification of the neck and upper limb. The Bernard and Kirkaldy-
systems had been used in other studies and settings. No Willis system22 was especially weak in the area of face
other studies were found that examined the usefulness validity. With the exception of the system of Delitto and
of the Bernard and Kirkaldy-Willis system.22The system c0lleagues,~"~4all systems scored fairly high for the
of Delitto and ~ o l l e a g u e shas ~ ~been
~ ~ ~ examined in concept of feasibility. More description of the system by
other settings, but these studies were conducted by the Delitto et a1 is needed to make judgments related to
system d e v e l ~ p e r s .The
~ ~ : generalizability
~~ of the system feasibility.
of Delitto and colleagues has yet to be demonstrated.
One group of independent investigators has examined Constrrlct validity, reliability, and generalizability are
the QTF ~ y s t e m . ~ V hMcKenzie
e systemP5 has been concepts that require published data for making judg-

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Classification and Low Back Pain: Review Literature and Critical Analysis Selected Systems

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Classification and Low Back Pain:

A Review of the Literature and

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Key Words: Classification, Diagnosis, Low back pain.

708 Physical Therapy . Volume 78 . Number 7 . July 1998

Physical Therapy. Volume 78 . Number 7 . July 1998 Riddle . 709

Bernard and Kirkaldy- Delitto and

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71 0 . Riddle Physical Therapy . Volume 7 8 . Number 7 . July 1998

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Categories Criteria Operational Definitions

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712 . Riddle Physical Therapy . Volume 78 . Number 7 . July 1998

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Some classification systems further classify

Physical Therapy . Volume 78 . Number 7 . July 1998 Riddle . 71 3

No lumbar spine deformity is present, all

Posture is poor, spinal deformities are

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Adherent Nerve Root

do not have serious

Derangement Central or symmetrical LBP is present,

Unilateral LBP is present, may have

714 . Riddle Physical Therapy . Volume 78 . Number 7 . July 1998

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Physical Therapy . Volume 78 . Number 7 .July 1998 Riddle . 715

pelvic height asymmetry,

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limited passive mobility of

increased single straight leg

71 6 . Riddle Physical Therapy . Volume 78 . Number 7 . July 1998

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Marras and colleagues31 developed a

Physical Therapy . Volume 7 8 . Number 7 . July 1998 Riddle . 7 17

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Figure 6. For the conventional wisdom method,

7 1 8 . Riddle Physical Therapy . Volume 78 . Number 7 . July 1998

The method used by Binkley and col-

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Perhaps most importantly, Binkley et

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Decreased accessory motion, flexionlextension ROM

21 previous LBP episode or pain >2 rno, flexion or side flexion

All patients with

SI joint tests indicate hypomobility, asymmetrical

Neurological signs, SLR positive <70q

Pain eased with activity, standing or sitting posture

720 . Riddle Physical Therapy. Volume 78 . Number 7 .July 1998

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Low back and leg pain for

Physical Therapy . Volume 78 . Number 7 .July 1998 Riddle . 72 1

Examination findings suggesting the

Pain that is not exacerbated by

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Pain >12 wk; increased by

Chronic Posterior Pain >12 wk; increased with hyperlordotic

Pain >12 wk, relieved by rest,

Chronic Pain relieved by changing positions

722 . Riddle Physical Therapy. Volume 7 8 . Number 7 . July 1998

Positive radiologic tests, LBP often absent, pain may extend

Spondylolisthesis Positive radiologic tests

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