2012 Annual Conference

Greg Propst, PT, DPT, MS; Lindsey Propst, PT, DPT; Matt Malone, PT, DPT; Zane Richardson, PT, DPT

Texas State University - Dept. of Physical Therapy, San Marcos, TX

Low back pain (LBP) is the second most common cause of disability in the United States with the lifetime prevalence for adult and adolescent populations ranging between 54-84% and over 80% of people experiencing some form of LBP in their lifetime. With the high prevalence of LBP being at the forefront of health care issues, further investigation into conservative management of patients with LBP is warranted. Delitto created a treatment-based classification (TBC) approach for managing patients with LBP consisting of classifications that provide a framework for clinicians to screen, stage, and apply appropriately matched interventions to an individual. Clinical prediction rules (CPR’s) have been prospectively developed to assist with this classification process to determine which patients are likely to benefit from a specific treatment strategy. Currently, there are four classification groupings supported by the literature including manipulation, stabilization, specific exercise, and traction with specific exercise and manipulation being the two most common in the literature. However, recent studies have shown that only 66% of patients have a clear classification group leaving 34% of LBP patients without a classification when this framework is applied. The growing body of evidence suggests TBCs are appropriate for use in a clinical setting, but more work is needed to develop a comprehensive classification algorithm. The aim of this case series is to describe the clinical effectiveness of the Delitto TBC system and to evaluate the usefulness of an impairment-based approach on low-back pain patients.

Patients presenting with a chief complaint of LBP, regardless of duration were examined over a 10-month period (July 2011-April 2012). 31 patients (22 females, 9 males) with an average age of 50.8 years (16-80 years) were enrolled in the case series.

Patients completed self-report measures (mODI, VAS, FABQW/PA) at initial and final treatments and were staged based on mODI scores into stage 1 (≥25) or stage 2 (<25). Stage 1 patients were treated using Delitto’s TBC system while stage 2 patients were managed with an impairment-based approach.

Of the 31 subjects, 35% (n=11) were classified as stage 1 and 65% (n=20) were classified as stage 2. Of the 11 participants classified as stage 1, all of them fell into the stabilization category. Furthermore, 73% (n=8) were provided matched initial treatments to their defined classification subgrouping and 27% (n=3) received unmatched initial treatments. No significant differences were found in improvements across time between matched and unmatched stage 1 patients for trunk flexion ROM, VAS, and ODI. The improvements for trunk flexion range of motion and ODI were not significantly different based on staging. As a single group, all outcome measures were significantly improved from evaluation to last session (P<0.0001). Specifically, ODI scores decreased 10.9 points, VAS scores decreased 4.7 points, and trunk flexion ROM improved an average 23.6 degrees per patient from pre to post measurements.

Our findings contrast most previous reports of the TBC with respect to the percentage of LBP patients falling into the stabilization classification, the effectiveness of being matched to a treatment versus being unmatched, as well as the extent of improvement in disability for those stage 1 patients matched on initial treatment. The results did not show statistical significance when comparing stage 1 patients treated with a treatment-based classification versus stage 2 patients treated with an impairment-based treatment approach for the selected outcome measures. Both groups achieved significance from evaluation in all measures regardless of treatment technique chosen. Keeping in mind any limitations, the application of a TBC approach for stage 1 and an impairment-based model for stage 2 in this series were equally effective in improving function of patients in their respective groups.