Treatment-based Classification (TBC) for LBP – APTA CPG

TBC 1995

Triage of Level of First-contact health care provider

1. Determine the patient is an appropriate candidate for rehabilitation by ruling out serious
pathology and serious comorbidities
2. Determine whether patient is appropriate for self-care management

Triage of Level of rehabilitation provider

1. Determine the most appropriate rehabilitation approach given the patient’s clinical presentation

3 rehabilitation approaches – emphasize psychological and comorbid status

1. Symptom modulation approach (pt with recent-new / recurrent LBP episode that cause
symptomatic features)
2. Movement control approach (Pt with moderate ad disability status)
3. Function optimization approach (low pain and disability status)

LBP 4 primary LBP classification systems

1. Mechanical diagnosis and therapy classification model (McKenzie)

2. Movement system impairment syndromes model (Sahrmann)
3. Mechanism-based Classification system (O’Sullivan)
4. Treatment-based Classification (TBC) system (Delitto et. al.)
Waddell’s sign – 8 CLINICAL PHYSICAL SIGNS (non-organic SIGNS) – pain is not real

1. Superficial and non-anatomic tenderness

2. Axial loading and acetabular rotation simulation
3. Distraction
4. Regional sensory disturbance and weakness
5. Overreaction

Superficial tenderness: Tenderness over a wide area of lumbar skin to light touch or pinch.

Non-anatomic tenderness: Deep tenderness over a wide area that crosses the over non-anatomic
boundaries.

Axial loading: In axial loading patient stands and the examiner presses downwards vertically on the
patient’s head, eliciting lumbar pain.

Acetabular rotation: The examiner rotates the shoulder and the pelvis passively in the same plane while
the patient is standing. It is a positive sign if pain is elicited in the first 30 degrees of rotation.

Distracted straight leg raise discrepancy: In distraction test, the same positive physical finding is tested
but while the patient is distracted, which can be achieved by testing a body part of the patient and
observing another. Straight Leg Raising test can be used as a distraction test by using its variations. The
test is positive when the patient reports pain on formal SLR examination such as on supine and the pain
markedly decrease on performing the distracted SLR when the examiner extends the knee with the
patient sitting.

Regional sensory disturbance: The patient’s reports pain that follows a stocking-like disturbance and
doesn’t follow a dermatomal pattern.

Regional weakness: Weakness or cogwheel “giving away” that can’t be explained on neuroanatomical
basis.

Overreaction: Which is exaggerated painful response to a stimulus, that is not reproduced when the
same stimulus is given later.

A score of 3 or more out of the 5 categories is considered significant and the test is positive.
TBC 2007
TBC 2015
Patient psychological status and concurrent comorbidities can weaken the treatment effect

Education on

- Pain theory
- Muscle relaxation techniques
- Sleep hygiene
- Coping skills
- Address catastrophizing about pain and diagnostic findings
TBC // MDT // CFT // MSI

5 LBP Treatment classification System

- Manipulation
- Extension-biased back pain
- Flexion-biased back pain
- Stability
- Traction

Manipulation

Fritz identified five criteria to help determine which LBP patients would benefit most from spinal
manipulation:

1. Pain lasting less than 16 days

2. No symptoms distal to the knee
3. Low fear avoidance beliefs (FABQ score of less than 19)
4. Hip internal rotation greater than 35 degrees
5. Hypomobility of at least one lumbar segment

A JMPT study reported that LBP patients who met the preceding criteria and subsequently underwent
manipulation experienced:

- An average VAS drop from 6.2 to 1.9

- An average of 5.2 treatments at a mean cost of $302
- 95% of respondents rated their care as excellent

Can incorporate with mobility exercise

Stability

A 2020 Musculoskeletal Science and Practice review (3) found that the following test cluster was most
accurate for identifying patients with spinal instability:

- Apprehension sign
- Instability catch sign
- Painful catch sign
- Prone instability test

A clinical prediction rule published in the Archives of Physical Medicine and Rehabilitation (4) reported
the presence of three or more of the following variables predicts a 67% success rate with the
incorporation of a spinal stabilization program.

- Younger age <40

- Average SLR > 91 degrees
- Aberrant lumbar forward flexion (i.e., a “catch or hitch when flexing)
- Positive prone instability test
Exercise

- Deadbug
- Bird dog
- Side bridge

The two following classification sub-groups, extension-biased and flexion-biased, typically (but not
always) include a radicular complaint into the buttock or leg. Classification into one of these two options
requires defining a “directional preference” based upon what happens to the radicular complaint when
the patient repeatedly performs either end-range extension or end-range flexion.

✓ Centralization: repeated end-range lumbar movements rapidly decrease the most distal referred
or radicular symptoms towards the midline.
✓ Peripheralization: repeated end-range lumbar movements rapidly increase the most distal
referred or radicular symptoms.

Determining which direction (extension vs flexion) relieves your patient's symptoms allows you to dial in
the most effective in-office treatments, exercises, and even home care recommendations. And the
results are pretty impressive:

“In patients with low back pain for more than six weeks … we found the directional preference method
to be slightly more effective than manipulation.”

Extension-biased (Radicular symptoms improve with extension)

- Sitting (aka flexion) typically increases pain or distal symptoms

- The most distal symptoms improve with standing or walking (aka extension)
- Repeated end range extension testing improves the most distal complaints

Flexion biased (Radicular symptoms improve with flexion)

- Standing or walking (aka extension) typically increases pain or distal symptoms

- The most distal symptoms improve with sitting (aka flexion)
- Repeated end range flexion testing improves the most distal complaints

Traction

- Symptoms extend distal to the buttock (7)

- Signs of nerve root compression
- Peripheralization with extension
- Positive well leg raise

The presence of three or more of the following predictors more than doubles the likelihood of disc-
related LBP “greatly improving” with lumbar traction (response increases from 23.3% to 48.7%).
- Sudden onset of symptoms
- Short duration of symptoms
- No segmental hypomobility
- Limited lumbar extension
- Low-level fear-avoidance beliefs