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,

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