1. Treatment Based Classification of the Spine- An Evidence Based Journey for the Physical Therapist Tara J. Manal, PT, DPT, OCS, SCS Gregory E. Hicks, PT, PhD

2. Development of a Classification Scheme for the Spine

3. Neck Pain 54% of people have experienced neck pain in the last 6 months 54% of people have experienced neck pain in the last 6 months Economic burden associated with treatment is high Economic burden associated with treatment is high –Second only to LBP in US for worker’s compensation costs Patients with neck pain make up ~25% of all patients in outpatient physical therapy Patients with neck pain make up ~25% of all patients in outpatient physical therapy

4. Low Back Pain Next to the common cold, LBP is the most common reason for people to see physician Next to the common cold, LBP is the most common reason for people to see physician Billions of dollars in expenditures are spent on management of LBP annually Billions of dollars in expenditures are spent on management of LBP annually Nearly 50% of all patients who go to outpatient physical therapy are there because of LBP Nearly 50% of all patients who go to outpatient physical therapy are there because of LBP

5. Classification Schemes Physical Therapists use a wide range of interventions for managing people with spine problems: Physical Therapists use a wide range of interventions for managing people with spine problems: –Manual Therapy (manipulation/mobilization) –Exercise –Traction –Modalities –Functional Training

6. Classification Schemes Although all are accepted as standard of care- Although all are accepted as standard of care- –Very little high quality evidence from randomized clinical trials (RCT) exist –Over 1000 RCTs for LBP (conservative and surgical interventions), but evidence is still conflicting for many interventions

7. Classification Schemes Why is there such a lack of evidence for most interventions used in the conservative care of spine patients? Why is there such a lack of evidence for most interventions used in the conservative care of spine patients? As clinicians we know that…. As clinicians we know that…. –All patients with neck pain are not the same –All patients with LBP are not the same Heterogeneity is the key issue! Heterogeneity is the key issue!

8. What Has Been The Result of Ignoring Classification in Exercise RCTs for Spinal Pain?

9. Faas et al: Spine 1995 363 SUBJECTS Inclusion Criteria: 1) LBP 18 Placebo ultrasound Usual Care group R Flexion Exercise

10. Results and Conclusions The percentage of patients with sickness absence, and number of days of absence in the first year was not different among groups The percentage of patients with sickness absence, and number of days of absence in the first year was not different among groups at 1 yr, no difference in total work days lost among the groups at 1 yr, no difference in total work days lost among the groups exercise therapy for patients with acute LBP does not reduce sickness absences exercise therapy for patients with acute LBP does not reduce sickness absences

11. Cherkin et al: (New Eng J Med 1998) 323 SUBJECTS Inclusion Criteria: LBP persisting more than 7 days after visit to GP McKenzie Approach Educational Booklet R Chiropractic

14. Viljanen et al: BMJ 2003 393 Female Office Workers Inclusion Criteria: 1) Neck pain >12 weeks 2) Age 30-60 Dynamic Muscle Training Ordinary Activity R Relaxation Training

15. Results and Conclusions No significant difference found in neck pain between the groups over a year No significant difference found in neck pain between the groups over a year But, better rotation and lateral flexion ROM in the intervention groups But, better rotation and lateral flexion ROM in the intervention groups

16. Classification Schemes Most likely to be successful if you can match an intervention to the most appropriate sub-group of patients Most likely to be successful if you can match an intervention to the most appropriate sub-group of patients Most can agree upon this idea of “appropriate matching” Most can agree upon this idea of “appropriate matching” –But, there is little agreement about how to classify patients into these sub-groups

17. The Medical Model of Disease Signs/symptoms analyzed Pathology is determined Treatment corrects pathology Signs/symptoms disappear

18. The Medical Model of Disease (Waddell, Spine 1987, Engel, Science 1977) The biomedical model has transformed from a model into cultural dogma. The biomedical model has transformed from a model into cultural dogma. All disease must be explained in terms of derangement of underlying physical mechanisms. All disease must be explained in terms of derangement of underlying physical mechanisms. Not all conditions appear to fit, this is particularly true for LBP and also true for much of musculoskeletal medicine. Not all conditions appear to fit, this is particularly true for LBP and also true for much of musculoskeletal medicine.

19. Traditional Medical Diagnosis Low Back Pain No Low Back Pain Pathology10-20%80-90% No Pathology 20-30%70-80% Classification Using Lumbar Pathology is Unsuccessful

20. The medical model and LBP Use some pathology labels Use some pathology labels –“facet”, “muscle strain”, “disc herniation” Use some syndrome labels Use some syndrome labels –Low back strain –Lumbago –Mechanical low back pain –Backache No direction for treatment No direction for treatment What happens if you can’t find relevant pathology?

21. Diagnosis: “ The process of determining the cause of a patient’s illness or discomfort” Classification: “The process of classifying clinical data into named categories of clinical entities for the purpose of making clinical decisions regarding therapeutic management” (Rose, 1989) Diagnosis vs. Classification

22. How do you develop a classification system?

23. Levels of Evidence

24. No classification system should remain static! Constant evolution should be occurring based on new evidence Systems should be refined and potentially simplified, if possible

25. Finding Common Ground Classification Systems Classification Systems –Reliable –Guide Interventions Treatment Techniques Treatment Techniques –Effective –Generalizable