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Classification of Back and Neck Pain – Research Evidence

There appears to be numerous methods in the attempt at Classification of Back and Neck Pain.

The purpose of this post is to summarise some of the more common classification systems. In addition to this I have also included some references that debate the merits of classifying pain states.

Spine Pain Classification

Shah (2012)

  • Moral questions plague spinal pain classification:
    • “Should we continue to use an inaccurate, imperious classification sys- tem that has a major clinical footprint?” or “Should we aim for a very accurate classification system that is impractical, logistically difficult, and ethically opaque?” The spine community should look for alternative, universal classification systems.
    • Spine pain classification is an ad hoc process, fundamentally guesswork.
    • A patient’s diagnosis may change over time.
    • Similar patients may receive different diagnoses.
    • Spinal diagnoses are not universally transferable from practitioner to practitioner.

Low Back Pain Classification

Fersum et al (2010)

  • Systematic Review
  • A systematic review with a meta-analysis was undertaken to determine the integration of subclassification strategies with matched interventions in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for NSCLBP.
  • Only 5 of 68 studies (7.4%) subclassified patients beyond applying general inclusion and exclusion criteria.
  • In the few studies where classification and matched interventions have been used, our meta-analysis showed a statistical difference in favour of the classification-based intervention for reductions in pain (p=0.004) and disability (p=0.0005), both for short-term and long-term reduction in pain (p=0.001). Effect sizes ranged from moderate (0.43) for short term to minimal (0.14) for long term.
  • Conclusion:
    • A better integration of subclassification strategies in NSCLBP outcome research is needed. We propose the development of explicit recommendations for the use of subclassification strategies and evaluation of targeted interventions in future research evaluating NSCLBP.

Kent et al (2010)

  • Systematic Review
  • This systematic review was undertaken in order to determine the efficacy of such targeted (classification based) treatment in adults with NSLBP.
  • Conclusions:
    • The results of the studies included in this review are too patchy, inconsistent and the samples investigated are too small for any recommendation of any treatment in routine clinical practice to be based on these findings.
    • The research shows that adequately powered controlled trials using designs capable of providing robust information on treatment effect modification are uncommon. Considering how central the notion of targeted treatment is to manual therapy principles, further studies using this research method should be a priority for the clinical and research communities.

Fairbank et al (2011)

  • Systematic Review
  • Aim:
    • To describe the various ways chronic low back pain (CLBP) is classified, to determine if the classificationsystems are reliable and to assess whether classification-specific interventions have been shown to be effective in treating CLBP.
  • Conclusion:
    • There currently are many classification systems for CLBP; some that are descriptive, some prognostic, and some that attempt to direct treatment. We recommend that no one classification system be adopted for all purposes. We further recommend that future efforts in developing a classification system focus on one that helps to direct both surgical and nonsurgical treatments.

Karayannis et al (2012)

LBP Classification Models - Karyannis et al

  • A database search for relevant articles related to LBP and subgrouping or classification was conducted.
  • Five dominant movement-based schemes were identified:
    • Mechanical Diagnosis and Treatment (MDT)
    • Treatment Based Classification (TBC)
    • Pathoanatomic Based Classification (PBC)
    • Movement System Impairment Classification (MSI)
    • O’Sullivan Classification System (OCS)
  • Results:
    • Considerable diversity exists between schemes in how movement informs subgrouping and in the consideration of broader neurosensory, cognitive, emotional, and behavioural dimensions of LBP.
    • Despite differences in assessment philosophy, a common element lies in their objective to identify a movement pattern related to a pain reduction strategy.
      • Two dominant movement paradigms emerge:
        • (i) loading strategies (MDT, TBC, PBC) aimed at eliciting a phenomenon of centralisation of symptoms.
        • (ii) modified movement strategies (MSI, OCS) targeted towards documenting the movement impairments associated with the pain state.
  • Conclusions:
    • A biomechanical assessment predominates in the majority of schemes (MDT, PBC, MSI), certain psychosocial aspects (fear-avoidance) are considered in the TBC scheme, certain neurophysiologic (central versus peripherally mediated pain states) and psychosocial (cognitive and behavioural) aspects are considered in the OCS scheme.
    • The OCS scheme appears to integrate a wider psychological spec- trum of the attention, cognitive, beliefs and behavioural aspect of LBP.
    • MDT and PBC schemes preferentially treat the mechanical dysfunction regard- less of psychological presentation, with the intention that improvement in symptoms may positively affect the psychological domain

Apeldoorn et al (2012)

  • Randomised Controlled Trial
  • Objective:
    • To assess the effectiveness of Delitto’s classification-based treatment approach compared with usual physical therapy care in patients with subacute or chronic low back pain.
  • A total of 156 patients were included (classification-based group, n = 74; usual physical therapy group, n = 82).
  • Conclusions:
    • The classification-based system used in this study was not effective for improving physical therapy care outcomes in a population of patients with subacute and chronic low back pain.

Apeldoorn, Bosmans et al (2012)

  • The aim of the present study was to assess the cost-effectiveness of a modified version of Delitto’s classification-based treatment approach compared with usual physical therapy care in patients with sub-acute and chronic LBP with 1 year follow-up.
  • Method:
    • All patients were classified using the modified version of Delitto’s classification-based system and then randomly assigned to receive either classification-based treatment or usual physical therapy care.
  • Conclusion:
    • The classification-based treatment approach as used in this study was not cost-effective in comparison with usual physical therapy care in a population of patients with sub-acute and chronic LBP.

Stanton et al (2013)

  • Cross-sectional study
  • Recent studies indicated that classifications are unclear for approximately 34% of people with LBP.
  • People with unclear classifications had greater odds (compared to people with clear classifications) of:
    • Being older
    • Having a longer duration of LBP
    • Having had a previous episode(s) of LBP
    • Having fewer fear-avoidance beliefs related to both work and physical activity
    • Having less LBP-related disability
  • Conclusions:
    • People with unclear classifications appeared to be less affected by LBP (less disability and fewer fear avoidance beliefs), despite typically having a longer duration of LBP. Future studies should investigate whether modifying the algorithm to exclude such people or provide them with different interventions improves outcomes.

Neck Pain Classification

From my readings it seems that classification of Neck Pain has far fewer systems/approaches than as we can see with low back pain. Having said that, here are a few references.

Childs et al (2004)

  • It is likely that patients with neck pain are not a homogeneous group, but, instead, consist of a variety of subgroups, each of which may benefit from a specific intervention matched to the patient’s signs and symptoms.
  • Studies to date have largely failed to account for this possibility, which may compromise the statistical power of research and ultimately fail to provide guidance for clinical decision making.
  • Classification:
    • Provides a means of breaking down a larger entity into more homogeneous subgroups of patients, based on examination data.
    • Can guide the determination of a patient’s prognosis, and the selection of the most appropriate intervention strategy.
    • Has received considerable attention in the management of patients with low back pain, and evidence is emerging regarding its benefits. There has been considerably less effort made towards examining classification as it pertains to patients with neck pain.
    • The end result of the classification process is to determine the treatment approach believed to be most likely to maximize the clinical outcome for an individual patient with neck pain.

Childs, Cleland et al (2008)

  • Presented the following classification:

Childs et al (2008)

Whiplash Classification

Sterling (2004)

  • The development of chronic symptoms following whiplash injury is common and contributes substantially to costs associated with this condition. The currently used Quebec Task Force classification system of whiplash associated disorders is primarily based on the severity of signs and symptoms following injury and its usefulness has been questioned.
  • Recent evidence is emerging that demonstrates differences in physical and psychological impairments between individuals who recover from the injury and those who develop persistent pain and disability.
    • Motor dysfunction, local cervical mechanical hyperalgesia and psychological distress are present soon after injury in all whiplash injured persons irrespective of recovery.
    • In contrast those individuals who develop persistent moderate/severe pain and disability show a more complex picture, characterized by additional impairments of widespread sensory hypersensitivity indicative of underlying disturbances in central pain processing as well as acute posttraumatic stress reaction, with these changes present from soon after injury.
    • Based on this heterogeneity a new classification system is proposed that takes into account measurable disturbances in motor, sensory and psychological dysfunction. The implications for the management of this condition are discussed.

Sterling et al (2004)

Verhagen et al (2011)

  • We evaluated whether patients with self-reported whiplash differed in perceived pain, functional limitation and prognosis from patients with other painful neck complaints.
  • Overall we found in a population with mild to moderate pain no clinically relevant differences between patients with self-reported whiplash and patients with other painful neck complaints. The findings suggest that whiplash patients with mild to moderate pain should not be considered a specific subgroup of patients with non-specific neck pain.

Stone et al (2012)

  • Systematic Review
  • To synthesise the evidence for central hyperexcitability in Chronic WAD (whiplash associated disorders) with meta-analysis, and review test protocols.
  • Individuals with chronic WAD showed heightened sensitivity to the following tests (p < 0.05):
    • Pressure Pain Thresholds
    • Cold Pain Threshold
    • Heat Pain Threshold
    • Electrocutaneous Stimulation
    • Brachial Plexus Provocation Test

My question…..

Should we or shouldn’t we classify…….does good clinical practice “automatically” classify patients and address the relevant individual impairments?

References:

Apeldoorn AT, Bosmans JE, Ostelo RW, de Vet HC, van Tulder MW. Cost-effectiveness of a classification-based system for sub-acute and chronic low back pain. Eur Spine J. 2012 Jul;21(7):1290-300.

Apeldoorn AT, Ostelo RW, van Helvoirt H, Fritz JM, Knol DL, van Tulder MW, de Vet HC. A randomized controlled trial on the effectiveness of a classification-based system for subacute and chronic low back pain. Spine (Phila Pa 1976). 2012 Jul 15;37(16):1347-56.

Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, Sopky BJ, Godges JJ, Flynn TW; American Physical Therapy Association. Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008 Sep;38(9):A1-A34. Epub 2008 Sep 1.

Childs JD, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. J Orthop Sports Phys Ther. 2004 Nov;34(11):686-96; discussion 697-700.

Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hermsmeyer J, Andersson G. The role of classification of chronic low back pain. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S19-42.

Fersum KV, Dankaerts W, O’Sullivan PB, Maes J, Skouen JS, Bjordal JM, Kvåle A. Integration of subclassification strategies in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review. Br J Sports Med. 2010 Nov;44(14):1054-62.

Karayannis NV, Jull GA, Hodges PW. Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/expert survey. BMC Musculoskelet Disord. 2012 Feb 20;13:24.

Kent P, Mjøsund HL, Petersen DH. Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review. BMC Med. 2010 Apr 8;8:22. doi: 10.1186/1741-7015-8-22.

Shah RV. Spine pain classification: the problem. Spine (Phila Pa 1976). 2012 Oct 15;37(22):1853-5.

Stanton TR, Hancock MJ, Apeldoorn AT, Wand BM, Fritz JM. What characterizes people who have an unclear classification using a treatment-based classification algorithm for low back pain? A cross-sectional study. Phys Ther. 2013 Mar;93(3):345-55.

Sterling M. A proposed new classification system for whiplash associated disorders–implications for assessment and management. Man Ther. 2004 May;9(2):60-70.

Stone AM, Vicenzino B, Lim EC, Sterling M. Measures of central hyperexcitability in chronic whiplash associated disorder – A systematic review and meta-analysis. Man Ther. 2012 Sep 1. [Epub ahead of print]

Verhagen AP, Lewis M, Schellingerhout JM, Heymans MW, Dziedzic K, de Vet HC, Koes BW. Do whiplash patients differ from other patients with non-specific neck pain regarding pain, function or prognosis? Man Ther. 2011 Oct;16(5):456-62.

Posted in: Research Evidence, Spinal and Pelvic Pain

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

2 Comments on "Classification of Back and Neck Pain – Research Evidence"

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  1. Muhammad Irfan says:
    November 11, 2014 at 9:19 am

    Mark.
    I am one of the specialisation candidate and would like to thank you for publishing this material on your website.

    Many thanks for all your dedication.

    Kind regards

    Irfy

    • Mark Gibson says:
      December 1, 2014 at 4:18 am

      Hi Irfy,

      Thanks for the comment, apologies for my delay in responding, it has been a busy few weeks!

      Best of luck with the Specialisation training program. Let me know if I can be of any help.

      Cheers
      Mark