Classification Approaches for Treating Low Back Pain Have Small Effects That Are Not Clinically Meaningful: A Systematic Review With Meta-analysis

Abstract

Objective To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP). Design Systematic review with meta-analysis. Literature Search The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened. Study Selection Criteria We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded. Data Synthesis Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges' g) and 95% confidence interval (CI). Subgroup analyses explored classification system, comparator type, pain type, and pain duration. Results Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, −0.31; 95% CI: −0.54, −0.07; P = .014, n = 4416, n = 21 trials) and disability (SMD, −0.27; 95% CI: −0.46, −0.07; P = .011, n = 4809, n = 24 trials), favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful. Conclusion For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP. J Orthop Sports Phys Ther 2022;52(2):67–84. Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761

Individualized exercise in chronic non-specific low back pain: a systematic review with meta-analysis on the effects of exercise alone or in combination with psychological interventions on pain and disability

“…In this context, the impact of the results as shown by Tagliaferri et al can be regarded clinically relevant. 56 Summarising our data, the overall low certainty, RoB, MCID, and SMDs, data support the conclusion that individualized exercise interventions versus other active exercise interventions or usual care or passive controls are associated with clinically relevant reduced self-reported pain intensity and disability.…”

“…We will distinguish active and passive controls, and differentiate the type of individualised exercise. This will consolidate previous knowledge and will build a bridge to known effects such as the above mentioned classification systems 18 or classical exercise. 6…”

“…22 Certainty of evidence is low to moderate, and studies did not meet the threshold for minimal clinically important difference. 22 The mean difference between groups as assessed by the meta-analysis on classification-based exercise in low back pain, 56 was presented as the difference to all comparators, suggesting small effects. All above mentioned reviews are principally in line with our results, suggesting effects on very low to moderate certainty, which are at first sight not clinically important.…”

“…However, individualisation as an independent variable defining exercise has not been assessed on a meta-analytical level before. There is one recently published review analysing the effects of classification-based exercise to treat chronic low back pain, 18 showing small and no meaningful effects. However, this study focussed on classification systems and not on exercise that was individualised based on the patient's needs.…”

Scientific Foundations in medicine and Pharmacy

“…Leading position among all pain syndromes is back pain. Acute back pain of varying intensity during life is observed at least once in almost every person, in 15-20% of people it is transformed into prolonged (up to 2 months), and in 8-10% -in chronic pain, which causes long-term disability [281]. Next are pain in the joints, muscles of the shoulder girdle [282].…”