73
Treatment-Based Classification of Low
Back Pain
Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS
Low back pain (LBP) is the most prevalent of all musculoskel-
etal conditions and one of the primary reasons an individual
visits a primary care physician (Woolf and Pfleger 2003). LBP
affects nearly everyone some time in his or her lifetime and
about 4% to 33% of the population at any given point (Woolf
and Pfleger 2003).
BACKGROUND
Despite extensive research into the assessment and treatment
of LBP, it remains a twentieth-century health care enigma
(Waddell 1996). In the 1990s much of the evidence for effica-
cious treatment remained elusive (van Tulder et al. 1997). The
reason for some treatments failing to demonstrate efficacy in
randomized, controlled trials may be a false assumption that
sufferers of LBP are a homogeneous group (Delitto et al. 1995).
The importance of identifying homogeneous subgroups in ran-
domized, controlled trials has been emphasized to avoid prob-
lems with sample heterogeneity (Binkley et al. 1993, Spratt et al.
1993, Delitto et al. 1995, Fritz and George 2000, Bendebba et al.
2000). The process of developing criteria for the identification of
homogeneous subgroups within the LBP population is classifi-
cation. Different potential types of classification schemes might
include the following:
• Signs and symptoms: LBP classified according to patient pre-
sentation of specific signs and symptoms
• Pathoanatomic: LBP classified according to lumbar structure
pathology
• Psychological: LBP classified according to psychological crite-
ria
• Social: LBP classified according to social criteria
Although there are potentially other types of classification
schemes, and each of those listed has relevance, the literature
currently supports the classification scheme based on signs and
TABLE
73.1 Treatment-Based Classification and Matched Treatment in Patients With Acute Low Back Pain
Classification Key History and Clinical Findings
Manipulation Clinical prediction rule variables (Flynn et al. 2002)
Variables:
1. Duration of symptoms <16 days
2. FABQ work subscale <19
3. At least one hip with a >35 degrees of internal
rotation range of motion
4. Hypomobility of at least one segment in the lumbar
spine
5. No symptoms distal to knee
496
symptoms. Signs and symptom classification and the appropri-
ate subsequent treatment have been termed treatment-based
classification (TBC). 
HISTORY
TBC is based on the premise that subgroups of patients with
LBP can be identified from key history and clinical examina-
tion findings (Delitto et  al. 1995). Delitto et  al. (1995) also
hypothesized that each subgroup would respond favorably to a
specific intervention but only when applied to a matched
subgroup’s clinical presentation. Seven intervention clas-
sification groups were originally described in TBC; how-
ever, recent investigations have collapsed the seven groups
to four: manipulation, specific exercise (flexion, exten-
sion, and lateral shift patterns), stabilization, and traction
(Table 73.1).
The clusters of examination findings and matched inter-
ventions used in the TBC approach were principally derived
from expert opinion, with little evidence. Proper classification
of patients into the appropriate category has proved reliable
(Fritz and George 2000, Heiss et  al. 2004, Fritz et  al. 2006).
However, it is also recognized that refinement is needed, given
only moderate inter-rater reliability for multiple categories
and also because significant numbers of patients met criteria
for either multiple or no (Henry 2012, Stanton 2011) catego-
ries. The manipulation clinical prediction rule (see Table 73.1)
has the best supportive evidence because it has been validated
(Childs et  al. 2004). Perhaps most important to consider
regarding TBC is whether overall outcomes are improved
when it is used in comparison to an alternative approach. Fritz
et al. (2003) and Brennan et al. (2006) both provided support
for the use of a TBC approach and matched intervention for
patients with LBP.
Matched Intervention
Manipulation of the lumbopelvic region with the
technique utilized by Flynn et al. 2002 or Cleland
et al. 2006 (see Figs. 73.1 and 73.2)
 73  Treatment-Based Classification of Low Back Pain 497

TABLE
73.1 Treatment-Based Classification and Matched Treatment in Patients With Acute Low Back Pain—cont’d
Classification Key History and Clinical Findings Matched Intervention

Specific Exercise 1. Symptoms centralize with extension and peripheralize 1. Mobilization and exercise to promote extension;
1. Extension with flexion of lumbar spine avoidance of flexion of lumbar spine
2. Flexion   Symptoms often distal to buttock 2. Mobilization or manipulation of the lumbar spine
3. Lateral    Postural and directional preference for extension to promote flexion; avoidance of extension of
Shift 2. Symptoms improve with flexion and worsen with lumbar spine
extension of lumbar spine   Body-weight–supported treadmill ambulation
  Postural and directional preference for flexion 3. Exercises (either by clinician or patient him or
   Typically older in age (>50 years) herself) to correct lateral shift
   Imaging evidence of lumbar spinal stenosis   Mechanical or autotraction
3. Visible frontal plane deformity, shoulders relative to pelvis
  Directional preference for lateral translation movements of pelvis
Stabilization Clinical prediction rule variables (Hicks et al. 2005) Trunk stabilization training
Variables (in order of importance): Promotion of local stabilizing muscle groups (trans-
1. Age <40 years verse abdominis, multifidus, etc.)
2. Average straight-leg raise >91 degrees Strength training of larger, global muscle groups
3. Positive prone instability test (see Figs. 74.1 and 74.2) (erector spinae, oblique abdominals, etc.)
4. Aberrant movement present Progression of local and global muscle group train-
Postpartum patients: ing in functional positions
1. Positive posterior pelvic pain provocation test
(see Fig. 74.3)
2. Positive active straight-leg raise test
Positive modified
Trendelenburg test
Traction 1. No movement (specifically neither flexion, extension, Mechanical or autotraction
or lateral shift correction) centralizes symptoms
2. Signs and symptoms suggestive of nerve root compression

Fig. 73.2  Side-lying lumbar spine gapping manipulation. Clinician

locks the segment via hip flexion and upper trunk rotation to the in-
volved segment as shown. Clinician maintains this setup and then log
Fig. 73.1  Supine SI regional manipulation. Clinician side bends pa-
rolls the patient to him as a unit. Clinician’s cranial hand blocks the cra-
tient to the involved side (right in this case) and then rotates patient’s
nial spinous process of the segment. Using the left forearm in this case
spine in contralateral direction (left in this case) until slack is taken up.
the clinician provides a thrust in an anterior direction, gapping the right
Thrust to the right side is performed in direction as shown.
facet joint of the involved segment.

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FURTHER READING
George SZ, Delitto A. Clinical examination variables discriminate among
­treatment-based classification groups: a study of construct validity in patients
with acute low back pain. Phys Ther. 2005;85(4):306–314.
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