Classification-based physiotherapy is more effective than guidelines-based practice, for acute low back pain.

Classification-based physiotherapy is more effective than guidelines-based practice, for acute low back pain.

Subject:	Low back pain (Physiological aspects) Low back pain (Care and treatment) Low back pain (Research) Physical therapy (Health aspects) Physical therapy (Physiological aspects) Physical therapy (Research) Therapeutics, Physiological (Health aspects) Therapeutics, Physiological (Physiological aspects) Therapeutics, Physiological (Research)
Author:	Abbott, J. Haxby
Pub Date:	03/01/2004
Publication:	Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2004 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue:	Date: March, 2004 Source Volume: 32 Source Issue: 1
Topic:	Event Code: 310 Science & research
Geographic:	Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand

Accession Number:	160542878
Full Text:	Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine. 2003. 28:1363-1372 (Abstract prepared by J. Haxby Abbott) Design: This was a randomised clinical trial with two treatment arms: 1) physiotherapy based on the classification system of Delitto et al. (1995); 2) physiotherapy care based on the clinical practice guidelines (CPG) of the United States Agency for Health Care Policy and Research (1994). Setting: 78 patients (mean age 37 [+ or -] 10 years) with work-related low back pain of less than 3 weeks duration, presented to employee health outpatient clinics of the University of Pittsburgh Medical Centre, USA, and were randomly allocated to one of the above two groups. Intervention: Prior to randomisation, all patients received reassurance and advice to stay active, by a physician. Patients in the classification-based intervention arm were examined by physiotherapists trained in the treatment-based classification system of Delitto et al., and, based on their symptoms and signs, were placed into one of four categories: mobilisation, immobilisation (stabilisation), specific exercise (McKenzie), or traction. Interventions appropriate to the classification were provided. Patients in the CPG group received low-stress aerobic exercise (treadmill walking or stationary cycling) and general conditioning exercises, plus further advice and reassurance. Main Outcome Measures: Follow-up was conducted at one year, and was successful in 65-85% of each group. The principal outcome measures were medical costs, pain intensity Oswestry disability questionnaire, and the SF-36 form for general health status. Return to work during the follow-up period were also compared. Results: Baseline data and attendance were similar between groups. Economic analysis found that (when two non-attendees were discounted) costs of physiotherapy were 25% lower in the classification group, and that the CPG group were 2.1 times more likely to incur high total medical costs. The CPG group were also 2.4 times more likely to have persistent work restrictions. The CPG group were also approximately 2 times more likely than the classification group to miss at least one day of work over the 12 months follow-up period, however this was not statistically significant. Disability outcomes at four weeks were superior in the classification group, however this weakened over time, and, while still better than the CPG group, was not statistically significant at 12 months. Commentary: Many commentators have suggested that sub-classifying "non-specific" low back pain, and directing patients toward the therapy to which their condition is best-suited, is the elusive key to improving outcomes in low back pain. This study attempts to demonstrate that the classification-based approach is superior to the 'across-the-board' approach of current Clinical Practice Guidelines (CPGs) The classification system of Delitto et al. (1) will intuitively appeal to many New Zealand musculoskeletal physiotherapists: if the clinical examination suggests instability (symptomatic hypermobility) prescribe a stabilization approach; if it suggests movement restrictions use a mobilisation/manipulation approach; if the centralisation phenomenon is present use a McKenzie approach; if there are nerve root signs that won't centralise, use traction. Importantly, all of these approaches (apart from traction) have a fair grounding in research evidence behind them. The classification group achieved a 9.0 point greater decrease in the Oswestry disability index, compared to the CPG group, at one year. This is more than twice the suggested minimum clinically significant difference for the Oswestry [index.sup.2], but was not quite statistically significant, suggesting that this study may not have had sufficient power to detect a clinically significant difference, and hence a larger study would have had greater power to detect such a meaningful difference. Importantly, this study found that the costs of health professional services was lower for the classification-based physiotherapy group. Additionally, this group were half as likely be off work with back pain in the year following, and less than half as likely to have persistent work restrictions. Given the costliness of low back pain to both employers and health insurers, this research is an interesting development. 1. Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome. Physical Therapy. 1995;75:470-489. 2. Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine 2000;25:3115-3124. Haxby Abbott Musculoskeletal Research Group Department of Anatomy & Structural Biology University of Otago
Gale Copyright:	Copyright 2004 Gale, Cengage Learning. All rights reserved.

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