Narrowing Down Treatment For Low Back Pain
When it comes to the treatment of mechanical low back pain, physicians and physical therapists have taken a different approach in the last few years. Research has shown that certain subgroups of patients seem to do better with one form of treatment over another. So, efforts are being made to develop a classification system that will help identify which subgroup a patient should be placed in for the best results.

Mechanical low back pain refers to back pain that is related to the way the spine moves. Some movements or positions make it better while other movements or positions make it worse. These patterns are somewhat predictable. The response (pain is better or worse) is the same each time the movement is used or position is assumed. Mechanical pain usually involves the soft tissue structures, joints, discs, cartilage and/or bone. Another term gaining in popularity for this type of pain is nonspecific low back pain (NSLBP). Mechanical or nonspecific low back pain is not caused by tumors, infections, or fractures.

Traditional therapy for mechanical or nonspecific pain has been through a rehab approach. Patients are given reassurance of recovery, an exercise program, and advice to stay active. Bed rest is no longer recommended. Sometimes various forms of heat or cold are used. But this is a one-size-fits-all kind of approach. And many people are left unhappy with the results. They don't really know what is causing their pain and they don't get better.

That's why health care professionals stopped and took a closer look at patients with low back pain and realized there may be subgroups of patients -- patients with certain characteristics, histories, and clinical presentations -- who could be treated in a specific way for a better outcome. Some of those subgroups or classifications are based on clusters of symptoms that seem to occur together. Putting those patterns of symptoms together with a history that always seems to go with them is a way to define what are called syndromes. Once the syndromes are identified, the next step is to study types of treatment that work best for each one.

In this study, physicians and physical therapists from the University of Toronto in Canada defined a patient subgroup based on patterns of pain alone. They did not use specific location of pain or other symptoms to identify a syndrome. They didn't try to identify the soft tissues or anatomic structures involved, or diagnose the underlying pathology as part of the syndrome. Instead, they put patients together who had pain that was constant versus intermittent (comes and goes). They used movement patterns that made the pain better or worse as another way to classify patients.

All together there were four subgroups identified. Patients in group 1 had intermittent or constant back pain that was worse when the spine was flexed or bent forward. Group 2 had intermittent back pain that got worse when the spine was extended. Flexion did not make it worse and sometimes actually improved pain. Group 3 had pain in the buttock and down the leg that fit the diagnostic pattern for sciatica. And group 4 had intermittent leg pain that was predictably worse when walking or in a position of spinal extension and better when resting or in spinal flexion. This pattern is known and recognized as neurogenic claudication.

Almost everyone in the study (over 1,400 patients) easily fit into one of the four classification subgroups. Those who didn't were excluded from this study but entered another (different) study to find an alternate classification for them. The plan with the four subgroups here was to compare treatment and see if patients in the classification subgroups got better results than patients treated all the same using the traditional approach described.

Patients included in the study were being seen for back pain at 15 clinics in a national network of Canadian rehab centers. They were all ages from 18 to 89 and a fairly equal number of men and women (55 per cent men, 45 per cent women). Patients referred to the clinics came from chiropractors, family doctors, and various medical specialists. The authors took a look at patient characteristics between the comparison group and the classification group before treatment to see what kind of differences there might be. They noticed there were more women than men in the classification group. The women saw themselves as having better function than the men even though their scores on function tests weren't any different.

People in the subgroups were given education about posture and exercise that was similar to what patients in the traditional group received. The difference in the classification groups was the way they were told to exercise. Treatment strategies were specifically geared toward finding movement patterns that would reduce pain while at the same time avoiding movements that would bring the pain on or make the pain worse.

The results were measured using a couple of different outcomes. First, subjective pain ratings (better, same, or worse) were provided by the patients at the end of the treatment period. Second, the amount of medication used was compared from before to after treatment. Third, any change in how the patient felt his or her function referred to as perceived function was assessed from before to after treatment. And finally, total number of days in treatment was tallied up for each patient. There wasn't a set number of days in treatment or predetermined period of time for treatment. Each patient received what he or she needed based on the progress made, clinician's satisfaction that the patient had maximized benefit, or third-party payer required discharge.

In all areas measured, the classification group had significantly better results. Their pain resolved faster, they used less medication, and reported greater improved function. Not only that but it took the comparison group longer to benefit from the traditional treatment approach. The authors concluded that classifying and managing patients produces better results.

The authors readily agree with other experts that the idea of subgrouping to formulate a plan of care for low back pain is a good idea. Whether or not their method of basing classification on the clinical picture (movement patterns that make symptoms better or worse) gets the best results remains to be proved.

For the moment, the major advantage of this approach is that almost all of the patients evaluated could fit into one of the four subgroups. There may be other classification schemes with better outcomes. Time will tell as further studies are conducted using this approach. And whether or not it's important to know exactly what's causing the problem in order to treat it remains a point of debate. The authors suggest that's only the case when conservative care has failed and surgery is planned. One other advantage to this classification scheme knows that anyone in groups 1 or 2 is not likely to be a candidate for surgery (i.e., they get better with certain movements and can avoid aggravating movements). That knowledge alone helps speed up the triage process of deciding who can benefit from conservative care.
Hamilton Hall, MD, FRCSC, et al. Effectiveness of a Low Back Pain Classification System. In The Spine Journal. August 2009. Vol. 9. No. 8. Pp. 648-657.