Are movement-based classification systems more effective than therapeutic exercise or guideline based care in improving outcomes for patients with chronic low back pain? A systematic review

Abstract

Objectives: The purpose of this systematic review was to determine if movement-based classification (MBC) systems are more effective than therapeutic exercise or guideline-based care (GBC) in improving outcomes in patients with low back pain (LBP) based upon randomized clinical trials (RCT) with moderate to high methodological quality and low to moderate risk of bias. Methods: The search strategy was developed by a librarian experienced in systematic review methodology and peer reviewed by a second research librarian. The following databases were searched from their inception to May 17, 2018: PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. The identified RCTs with a PEDro score of ≥6 were screened and assessed for risk of bias by two blinded individual reviewers using Covidence. Results: Seven studies were identified that had moderate-to-high methodological quality. One of the studies was identified as having a high risk of bias. Of the six studies that remained, only one study reported finding a statistically significant difference at the immediate follow-up that was not clinically significant. There was no significance at 6 and 12 months. Discussion: There is a paucity of moderate to high methodological quality RCTs with similar methodology that compare MBC to standard of care treatments for patients with LBP. Studies with moderate to high methodological quality that have a low risk of bias do not support MBCs as being superior to general exercise or GBC in the treatment of nonradicular LBP.

Whole Body Physical Training in the Treatment of Chronic Low Back Pain

“…Strength, personal comfort and muscle contraction shall prevail. 3 The observation group used core strength training based on the treatment of the control group.…”

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

“…However, research investigating the large number of heterogenous approaches for individualising treatment are of variable methodological quality [20,23,24,25,26,27]. Individualising physiotherapy based on movement is recommended in a professional guideline [28] but is not supported by recent clinical trials [29]. The STarT Back approach to individualising physiotherapy has been extensively researched in different contexts [30,31,32,33,34,35,36,37,38,39,40,41,42], and is recommended in clinical guidelines based on cost effectiveness [8,9].…”

“…Identifying subgroups of different types of LBP is one way of individualising physiotherapy, and treatment targeting specific features or causal mechanisms underpinning the nature of the subgroup has the potential of being more effective in RCTs [13,16]. However, developing a LBP subgrouping system is challenging and the review literature shows that a wide array of approaches exist [13,19,20,21,25,26,27,29,69,70,71,72]. Historically, subgrouping systems have been developed by experts combining the best available evidence with their own clinical experience [73,74,75,76,77].…”

Do you really have the only, right, or best evidence-based approach to treat your patients?

“…While on the PEDro website, you discover four different studies that satisfy the external validity criterion on the PEDro score and have PEDro scores of 6 or higher. These studies, with a respectable degree of external and internal validity, provide moderate to high-level evidence that the current system is no better than guideline-based care or advice to stay active [2].…”

“…Any system that does not meet these criteria has significantly limited clinical utility [4]. To date, there are no known classification systems that satisfy these criteria [2,[5][6][7].…”