Treatment Based Treatment Based Classification of the Classification of the Spine-Spine-An Evidence Based Journey An Evidence Based Journey for the Physical Therapistfor the Physical Therapist
Tara J. Manal, PT, DPT, OCS, Tara J. Manal, PT, DPT, OCS, SCSSCS
Gregory E. Hicks, PT, PhDGregory E. Hicks, PT, PhD
Development of a Development of a Classification Scheme for Classification Scheme for the Spinethe Spine
Neck PainNeck Pain
54% of people have experienced neck 54% of people have experienced neck pain in the last 6 monthspain in the last 6 months
Economic burden associated with Economic burden associated with treatment is hightreatment is high– Second only to LBP in US for worker’s Second only to LBP in US for worker’s
compensation costscompensation costs Patients with neck pain make up ~25% Patients with neck pain make up ~25%
of all patients in outpatient physical of all patients in outpatient physical therapytherapy
Low Back PainLow Back Pain
Next to the common cold, LBP is Next to the common cold, LBP is the most common reason for the most common reason for people to see physicianpeople to see physician
Billions of dollars in expenditures Billions of dollars in expenditures are spent on management of LBP are spent on management of LBP annuallyannually
Nearly 50% of all patients who go Nearly 50% of all patients who go to outpatient physical therapy are to outpatient physical therapy are there because of LBPthere because of LBP
Classification SchemesClassification Schemes
Physical Therapists use a wide Physical Therapists use a wide range of interventions for managing range of interventions for managing people with spine problems:people with spine problems:– Manual Therapy Manual Therapy
(manipulation/mobilization)(manipulation/mobilization)– ExerciseExercise– TractionTraction– ModalitiesModalities– Functional TrainingFunctional Training
Classification SchemesClassification Schemes
Although all are accepted as Although all are accepted as standard of care-standard of care-– Very little high quality evidence from Very little high quality evidence from
randomized clinical trials (RCT) existrandomized clinical trials (RCT) exist– Over 1000 RCTs for LBP (conservative Over 1000 RCTs for LBP (conservative
and surgical interventions), but and surgical interventions), but evidence is still conflicting for many evidence is still conflicting for many interventionsinterventions
Classification SchemesClassification Schemes
Why is there such a lack of evidence Why is there such a lack of evidence for most interventions used in the for most interventions used in the conservative care of spine patients?conservative care of spine patients?
As clinicians we know that….As clinicians we know that….– All patients with neck pain are not the All patients with neck pain are not the
samesame– All patients with LBP are not the sameAll patients with LBP are not the same
Heterogeneity is the key issue!Heterogeneity is the key issue!
What Has Been The Result What Has Been The Result of Ignoring Classification of Ignoring Classification in Exercise RCTs for Spinal in Exercise RCTs for Spinal Pain?Pain?
Faas et al:Faas et al: SpineSpine 1995 1995
363 SUBJECTS
Inclusion Criteria: 1) LBP < 3 weeks 2) Age > 18
Placebo ultrasound
Usual Care group
R
Flexion Exercise
Results and Results and ConclusionsConclusions
The percentage of The percentage of patients with sickness patients with sickness absence, and number absence, and number of days of absence in of days of absence in the first year was not the first year was not different among different among groupsgroups
at 1 yr, no difference at 1 yr, no difference in total work days lost in total work days lost among the groupsamong the groups
exercise therapy for exercise therapy for patients with acute patients with acute LBP does not reduce LBP does not reduce sickness absencessickness absences
Cherkin et al:Cherkin et al: ((New Eng J MedNew Eng J Med 1998)1998)
323 SUBJECTS
Inclusion Criteria: LBP persisting more than 7 days after visit to GP
McKenzie Approach
Educational Booklet
R
Chiropractic
Viljanen et al:Viljanen et al: BMJBMJ 2003 2003
393 Female Office Workers
Inclusion Criteria: 1) Neck pain >12 weeks 2) Age 30-60
Dynamic Muscle Training
Ordinary Activity
R
Relaxation Training
Results and Results and ConclusionsConclusions No significant difference found in No significant difference found in
neck pain between the groups neck pain between the groups over a yearover a year
But, better rotation and lateral But, better rotation and lateral flexion ROM in the intervention flexion ROM in the intervention groupsgroups
Classification SchemesClassification Schemes
Most likely to be successful if you can Most likely to be successful if you can match an intervention to the most match an intervention to the most appropriate sub-group of patientsappropriate sub-group of patients
Most can agree upon this idea of Most can agree upon this idea of “appropriate matching”“appropriate matching”– But, there is little agreement about how But, there is little agreement about how
to classify patients into these sub-groupsto classify patients into these sub-groups
The Medical Model of Disease
Signs/symptoms analyzed
Pathology is determined
Treatment corrects pathology
Signs/symptoms disappear
The Medical Model of The Medical Model of DiseaseDisease(Waddell, (Waddell, SpineSpine 1987, Engel, 1987, Engel, ScienceScience 1977) 1977)
The biomedical model has transformed The biomedical model has transformed from a model into cultural dogma.from a model into cultural dogma.
All disease must be explained in terms All disease must be explained in terms of derangement of underlying physical of derangement of underlying physical mechanisms.mechanisms.
Not all conditions appear to fit, this is Not all conditions appear to fit, this is particularly true for LBP and also true particularly true for LBP and also true for much of musculoskeletal medicine. for much of musculoskeletal medicine.
Traditional Medical Traditional Medical Diagnosis Diagnosis
Low Back Low Back Pain Pain
No Low Back No Low Back PainPain
Pathology Pathology 10-20% 10-20% 80-90% 80-90%
No Pathology No Pathology
20-30%20-30% 70-80% 70-80%
Classification Using Lumbar Pathology is Unsuccessful
The medical model and The medical model and LBPLBP
Use some pathology labelsUse some pathology labels– ““facet”, “muscle strain”, “disc herniation”facet”, “muscle strain”, “disc herniation”
Use some syndrome labelsUse some syndrome labels– Low back strainLow back strain– LumbagoLumbago– Mechanical low back painMechanical low back pain– Backache Backache
No direction for treatmentNo direction for treatment
What happens if you can’t find relevant pathology?
Diagnosis:Diagnosis: “ “ The process of determining the The process of determining the causecause of a patient’s illness or discomfortof a patient’s illness or discomfort””
Classification:Classification: “The process of classifying “The process of classifying clinical data into named categories of clinical clinical data into named categories of clinical entities for the purpose of making clinical entities for the purpose of making clinical decisions regarding therapeutic decisions regarding therapeutic management”management”(Rose, 1989)(Rose, 1989)
Diagnosis vs. Classification
How do you develop How do you develop a classification a classification system?system?
Levels of EvidenceLevels of Evidence
I. RCT
II. Lesser Quality RCT
III. Case Control Or
Retrospective Study
IV. Case Series
V. Expert Opinion
No classification No classification system should system should remain static!remain static!•Constant evolution should be occurring based on new evidence
•Systems should be refined and potentially simplified, if possible
Finding Common Finding Common GroundGround Classification SystemsClassification Systems
– ReliableReliable– Guide InterventionsGuide Interventions
Treatment TechniquesTreatment Techniques– EffectiveEffective– GeneralizableGeneralizable
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