Identifying Subgroups of Patients With Acute/Subacute “Nonspecific” Low Back Pain

Abstract

Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when subgrouping is used to guide treatment decision-making.

Low Back Pain

“…While many interventions have been dismissed as either ineffective or accompanied with small effect sizes, 80 recent reports in the literature suggesting that interventions based on sub-group classification have the potential to enhance effect sizes over studies where the identical interventions administered in a one-size fits-all approach. 34, 49, 105, 118, 199 …”

“…For patients who have had low back pain for > 6 months and/or for patients who have recurring low back pain, this clinical guideline promotes categorizing acute, sub acute, and chronic low back pain based on movement/pain relations rather than solely using time since the patient’s initial onset of low back pain. Movement/pain relations are commonly used in physical therapy for classifying patients into treatment categories that respond best to matched interventions strategies 33, 86, 99, 101, 103, 104 as well to guide dosing of manual therapy, therapeutic exercise, and patient education interventions. 172 The dosing of interventions based upon movement/pain relations is consistent with the concept of tissue irritability and is important for guiding the clinical decisions regarding treatment frequency, intensity, duration, and type with the goal of matching the optimal dosage of treatment to the status of the tissue being treated.…”

“…In the randomized clinical trials suggesting that interventions based on impairment-based classifications are an effective strategy for management of low back pain, 34, 49, 76, 91, 105, 145, 197, 323 the subjects in the impairment-based classification groups were reevaluated continually during the patient’s episode of care, and, if the patient’s examination finding changed resulting in a new classification, the treatment was altered to match the new classification. Thus, it is important for clinicians to reassess and adjust the treatment program on the basis of changes in physical examination findings and that the most relevant impairments of body function, primary intervention strategy, and the associated ICF-based classification may change during the patient’s episode of care.…”

“…1, 190 Several authors have described restricted hip mobility in patients with low back pain as an indicator of positive response to interventions targeting the hip. 33,44, 53,84,184,284,278,289 Some early evidence demonstrates successful incorporation of interventions targeting the hip into a more comprehensive treatment program for patients with lumbar spinal stenosis. 278,279 Though research in this area is developing, clinicians may consider including examination of the hip and interventions targeting identified hip impairments for patients with LBP.…”

Outcomes differ between subgroups of patients with low back and leg pain following neural manual therapy: a prospective cohort study

“…However, these validation studies did not address validity in subjects with leg pain. Brennan et al [9] demonstrated improved outcomes when treatment was matched to subjects' subgroups, defined as manipulation, stabilization and specific exercise according to criteria based on those proposed by Delitto et al [7]. As patients with signs of nerve root compression were excluded from this study, no conclusions can be drawn about this group of patients.…”