Perspective

M. Alrwaily, PT, MS, PhD, Depart-

ment of Physical Therapy, School
of Health and Rehabilitation Sci-
ences, University of Pittsburgh,

Treatment-Based Classification Bridgeside Point 1, 100 Technol-

ogy Dr, Ste 470, Pittsburgh, PA

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

15219 (USA), and Department of
System for Low Back Pain: Physical Therapy, King Fahad Spe-
cialist Hospital, Dammam, Saudi
Revision and Update Arabia. Address all correspon-
dence to Dr Alrwaily at:
mza7@pitt.edu.
Muhammad Alrwaily, Michael Timko, Michael Schneider, Joel Stevans,
Christopher Bise, Karthik Hariharan, Anthony Delitto M. Timko, PT, MS, FAAOMPT,
Department of Physical Therapy,
School of Health and Rehabilita-
The treatment-based classification (TBC) system for the treatment of patients with low back tion Sciences, University of Pitts-
pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the burgh, and Division of Physical
TBC was updated by maintaining its strengths, addressing its limitations, and incorporating Therapy, School of Medicine,
recent research developments. The current update of the TBC has 2 levels of triage: (1) the West Virginia University, Morgan-
town, West Virginia.
level of the first-contact health care provider and (2) the level of the rehabilitation provider. At
the level of first-contact health care provider, the purpose of the triage is to determine whether M. Schneider, DC, PhD, Depart-
the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathol- ment of Physical Therapy, School
ogies and serious comorbidities or by determining whether the patient is appropriate for of Health and Rehabilitation Sci-
self-care management. At the level of the rehabilitation provider, the purpose of the triage is ences, University of Pittsburgh.
to determine the most appropriate rehabilitation approach given the patient’s clinical presen- J. Stevans, DC, Department of
tation. Three rehabilitation approaches are described. A symptom modulation approach is Physical Therapy, School of Health
described for patients with a recent—new or recurrent—LBP episode that has caused signif- and Rehabilitation Sciences, Uni-
icant symptomatic features. A movement control approach is described for patients with versity of Pittsburgh.
moderate pain and disability status. A function optimization approach is described for patients C. Bise, PT, MS, DPT, OCS,
with low pain and disability status. This perspective article emphasizes that psychological and Department of Physical Therapy,
comorbid status should be assessed and addressed in each patient. This updated TBC is linked School of Health and Rehabilita-
to the American Physical Therapy Association’s clinical practice guidelines for low back pain. tion Sciences, University of
Pittsburgh.

K. Hariharan, PT, MS, Department

of Physical Therapy, School of
Health and Rehabilitation Sci-
ences, University of Pittsburgh.

A. Delitto, PT, PhD, FAPTA,

Department of Physical Therapy,
School of Health and Rehabilita-
tion Sciences, University of
Pittsburgh.

[Alrwaily M, Timko M, Schneider

M, et al. Treatment-based classifi-
cation system for low back pain:
revision and update. Phys Ther.
2016;96:1057–1066.]

© 2016 American Physical Therapy

Association

Published Ahead of Print:

December 4, 2015
Accepted: November 22, 2015
Submitted: June 18, 2015

Post a Rapid Response to

this article at:
ptjournal.apta.org

July 2016 Volume 96 Number 7 Physical Therapy f 1057

Treatment-Based Classification System for LBP

D espite the plethora of research

on low back pain (LBP), clinical
trials have not provided conclu-
sive evidence supporting the superiority
of any particular intervention.1,2 This gap
3. None of these classification systems
consider the possibility that some
patients with LBP do not require any
medical or rehabilitation intervention
and are amenable for self-care
most appropriate rehabilitation
approach (Table, Fig. 1).
• Linking the components of the TBC
to the APTA clinical practice guide-
lines for LBP.
is often attributed to the fact that the management. • Proposing a course of action
design of most clinical trials includes addressing the limitations of the
delivery of a single intervention to a het- 4. The degree to which the psychosocial previous versions of TBC, including

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

erogeneous group of patients with LBP. factors are considered varies greatly the development of a novel neuro-
This heterogeneity, combined with wide among these systems, which runs muscular assessment, prioritizing
inclusion criteria, tends to dilute the contrary to the clinical practice guide- interventions, and identifying a
treatment effect. In order to optimize the lines established by the American research agenda.
treatment effect, patients with LBP Physical Therapy Association (APTA)
should be classified into homogeneous that advocate using the bio- TBC System—1995
subgroups and matched to a specific psychosocial model as a basis for The original TBC system was created in
treatment. Subgroup-matched treatment classification.12 1995 by a panel of experts with the pur-
approaches have been shown to result in pose of describing a classification system
improved outcomes compared with These shortcomings are likely to be over- that specifically directed conservative
nonmatched alternative methods.3– 6 come as our understanding of the factors management to patients with LBP.11 The
Designing studies that incorporate that drive LBP improves. We are likely to 1995 TBC system was designed, in part,
subgroup-matched treatments into LBP see more convergence than divergence to be analyzed critically and serve as the
classification systems has become a among the 4 systems. basis for scientific inquiry. This system
research priority.7 represented the initial phase of
In this article, we focus on the TBC sys- development.
In the field of physical therapy, there are tem described by Delitto et al.11 The TBC
4 primary LBP classification systems that is the most extensively researched clas- The 1995 TBC system had 3 levels of
attempt to match treatments to sub- sification system in the field of physical classification (Fig. 2). Level 1 classified
groups of patients using a clinically therapy, with more than 16 articles the patient into 3 groups: (1) patients
driven decision-making process: (1) the investigating its usefulness as a guide for who could not be managed by physical
mechanical diagnosis and therapy classi- clinical decision making.13 Since its pub- therapy and needed to be referred for
fication model described by McKenzie,8 lication in 1995, the TBC has passed medical management because of great
(2) the movement system impairment through phases of development that suspicion of serious pathology, (2)
syndromes model described by were largely based on emerging evi- patients who could be managed by phys-
Sahrmann,9 (3) the mechanism-based dence. At each phase, the TBC had dif- ical therapy but required consultation
classification system described by ferent strengths and limitations. The pur- with another health care practitioner
O’Sullivan,10 and (4) the treatment-based pose of this article is to review those because of presence of chronic comor-
classification (TBC) system described by strengths and limitations and use current bidity or “magnified illness behavior,”
Delitto et al.11 All of these systems have evidence to update the TBC approach. and (3) patients who could be indepen-
made significant contributions in Specifically, the update of the TBC will dently managed by physical therapy.
improving clinicians’ ability to recognize take into consideration the following
patterns of signs and symptoms in points: Level 2 was for patients deemed appro-
patients with LBP and match them with priate for independent physical therapy.
respective treatments. Yet, these sys- • Recognition that the initial triage
Level 2 classified such patients into 3
tems—without exception— have 4 main process includes all health care pro-
stages, each of which had specific inter-
shortcomings: viders who come in first contact
ventions that were appropriate for the
with patients with LBP.
patient’s status. Stage I was for patients
1. No single system is comprehensive • Establishing decision-making crite-
with severe pain and disability status; the
enough in considering the various ria for the first-contact practitioner
goal of the intervention was symptom
clinical presentations of patients with to triage patients into 1 of 3
modulation. Stage II was for patients
LBP or how to account for changes in approaches: medical management,
whose pain was not too severe but inter-
the patient’s status during an episode rehabilitation management, and
fered with their activities of daily living;
of care. self-care management (Fig. 1).
the goals of the treatment were resolu-
• Utilizing risk stratification and psy-
tion of residual symptoms and improve-
2. Each system has some elements that chosocial tools to determine which
ment of physical function to enhance the
are difficult to implement clinically patients require psychologically
performance of activities of daily living.
because they require expert under- informed rehabilitation.
Stage III was for patients who were rel-
standing in order to be utilized • Updating decision-making criteria
atively asymptomatic and could perform
efficiently. for the triage process by rehabilita-
standard activities of daily living, but
tion providers to determine the

1058 f Physical Therapy Volume 96 Number 7 July 2016

 Treatment-Based Classification System for LBP

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

Figure 1.
Updated 2015 treatment-based classification system. * Regardless of approach, patients with a medium-to-high psychological risk profile
require psychologically informed rehabilitation. † The rehabilitation provider also may function as the first-contact health care provider.
‡
Rehabilitation must be modified appropriately to account for a patient’s comorbid status.

needed to return to higher levels of phys- matched to the patient’s clinical At level 2, the TBC described the staging
ical function; the goal of the treatment presentation. process, which was the hallmark
was to improve the patient’s ability to strength of the system because the TBC
perform higher levels of physical func- Several strengths could be ascribed to developers recognized that using num-
tion without symptoms exacerbation. the 1995 TBC system. At level 1, the TBC ber of days since onset was not useful in
considered a process of patients triaging guiding treatment matching. Therefore,
Level 3 classified patients into syndromes upon first contact to screen for “red the TBC developers described the stag-
embedded within each stage. Each syn- flags” in direct access physical therapy ing process to prescribe interventions
drome was named after the intervention clinics. Also, the 1995 TBC considered according to the patient’s pain intensity
that the patient was going to receive (eg, assessment of psychosocial factors using and disability status rather than relying
mobilization syndrome, traction syn- Waddell’s signs and symptoms of “mag- on arbitrary definitions of acute, sub-
drome). To assign a patient to a particu- nified illness behavior,”14 which were acute, and chronic LBP based on time
lar intervention, a thorough physical the best available evidence to assess duration alone.
examination was conducted to identify psychosocial factors at that time.
the treatment that would be best

July 2016 Volume 96 Number 7 Physical Therapy f 1059

Treatment-Based Classification System for LBP

Table.
Triage Process and Matching Criteria for the Rehabilitation Provider

Symptom
Rehabilitation Approach Modulation Movement Control Functional Optimization
a
Classification Variables Pain rating High to moderate Moderate to low Low to absent

Disability ratingb High Medium Low

c
Clinical status Volatile: symptoms Stable: movement Well-controlled: performance

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

predominate impairments deficits predominate
predominate

Treatment Modifying Psychosocial statusd ⫹/⫺ ⫹/⫺ ⫹/⫺

Variables
Comorbiditiese ⫹/⫺ ⫹/⫺ ⫹/⫺
a
When the classification variables do not agree, we recommend relying on disability rating to match the patient with the treatment approach. This
judgment should be aided by the patient’s clinical status.
b
Disability can be assessed with any outcome measure of disability (eg, Modified Oswestry Disability Questionnaire, Roland-Morris Disability Questionnaire).
c
“Volatile” means that the patient’s clinical status can easily be aggravated, the patient is highly irritable (ie, minor lumbar spine movements easily provoke
pain), and occasionally the patient’s presentation does not permit physical examination. “Stable” means that the patient’s clinical status can increase with
certain movements, postures, or tests but return to baseline level relatively quickly. “Well-controlled” means that the patient’s clinical status is asymptomatic
most of the time but can be aggravated when performance demands are increased.
d
Psychosocial status can be assessed using self-report measures (eg, Fear-Avoidance Behavior Questionnaire, STarT Back Tool). Plus sign (⫹) means the
patient needs psychologically informed rehabilitation because of higher risk of developing poor treatment outcome. Minus sign (⫺) means the patient does
not need psychologically informed rehabilitation because of no concern about developing poor treatment outcome.
e
Comorbidities (eTab. 3) can be present, along with low back pain. Plus sign (⫹) means the patient needs to receive medical co-management for existing
comorbidities besides rehabilitation care. Minus sign (⫺) means the patient does not need medical co-management.

Level 3 was the level at which the not helpful in guiding the treatment for concept of “rest from function” as a strat-
patient’s signs and symptoms were patients in stages II and III, whose status egy for managing the hyperacute LBP.
matched to specific interventions. Inter- was related to the movement system
ventions at this level targeted a wide impairments. As a result, the interven- The 1995 TBC was a classification frame-
array of patients with LBP along the spec- tions in the 1995 TBC were exclusively work based largely on clinical observa-
trum of pain and disability status. The designed to be matched with “syn- tions with minimal research to substan-
interventions were not confined to a spe- dromes” for stage I only and never fully tiate its theoretical basis. However, the
cific concept; rather, they were open to developed for stage II or III. 1995 TBC set the stage for a new era of
other schools of thought. research in the years following its
Another limitation at level 3 was confu- publication.
Despite the strengths of the 1995 TBC, a sion over the “immobilization” syn-
number of limitations could be identi- drome. The immobilization syndrome TBC System—2007
fied. At level 1, when psychosocial fac- was intended for patients with hyper- A revision of the TBC was published in
tors were identified, there was no spe- acute LBP that was irritable (ie, pain can 2007 by Fritz et al15 with the purpose of
cific suggestion of how to address these easily be provoked with minor lumbar updating the 1995 TBC with the latest
factors other than consultation with spine movements) and still in the inflam- evidence that emerged between 1995
another health care provider. matory phase. For such patients, immo- and 2007. This revision and update rep-
bilization meant limiting the patient’s resented the second phase of
At level 2, the TBC was somewhat ambig- movements until the irritability and development.
uous in describing the conceptual terms inflammation subsided. Unfortunately,
“levels,” “stages,” and “classification.” “immobilization” was also the same term The major strength of the 2007 TBC was
This lack of clearly defined terms and used to describe patients with signs and that it was much more evidence-based.
decision-making variables confused symptoms of “instability” that was aggra- The 2007 TBC incorporated evidence
some readers and led to misinterpreta- vated with end-range movements. For from clinical trials that showed that
tion of stage I, stage II, and stage patients with instability, immobilization matching patients with treatment using
III as acute, subacute, and chronic, meant limiting their end-range move- the TBC principles resulted in improved
respectively. ments by the use of stabilization exer- clinical outcomes compared with alter-
cises. To resolve this confusion, the term native methods.3,4 The 2007 TBC
At level 3, one limitation was that the “immobilization” for patients with insta- included evidence from a single random-
physical examination was largely based bility was replaced with the term “stabi- ized controlled trial that showed that the
on findings related to the patient’s static lization.” However, the term “stabiliza- use of a clinical prediction rule for
alignment or response to tissue loading tion” erroneously crept in as one of the patients likely to respond to manipula-
tests, which could guide the treatment primary interventions embedded in stage tion led to improved clinical outcomes.6
for patients in stage I, whose status I, and many clinicians forgot about the Additionally, the 2007 TBC incorporated
required symptom modulation, but were preliminary criteria for patients likely to

1060 f Physical Therapy Volume 96 Number 7 July 2016

 Treatment-Based Classification System for LBP

benefit from stabilization exercises16 and

updated the matching criteria for
patients likely to improve with direc-
tional preference exercises.15 Further-
more, the 2007 TBC replaced Waddell’s
signs and symptoms of magnified illness
behavior with the use of Fear-Avoidance
Beliefs Questionnaire.14 This question-

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

naire was one of the criteria to consider
in matching and predicting a patient’s
response to an intervention.6,16

However, a number of limitations could

be noted regarding the 2007 TBC. First,
the 2007 TBC did not contain any spe-
cific recommendations for how clini-
cians could manage patients with high
psychosocial distress.

Second, the 2007 TBC removed the level

2 staging decision from the clinical
decision-making process,17 which
shifted the focus away from the wide
array of interventions listed in the 1995
TBC article for improvement in func-
tional activities of daily living (stage II)
and high physical performance (stage Figure 2.
The 1995 treatment-based classification system. Level 1 clinical decision classifies patients
III). This removal resulted in a category
into 3 groups: (1) patients who cannot be managed by physical therapy and need to be
broadly defined as “stabilization” referred for medical management because of great suspicion of serious pathology, (2)
exercises. patients who may be managed by physical therapy but require consultation with another
health care practitioner because of presence of chronic comorbidity or magnified illness
Third, the 2007 TBC criteria that were behavior, and patients who can be managed independently by physical therapy. Level 2 is for
suggested to match a patient with a spe- patients who are determined appropriate for independent physical therapy. The level 2
cific treatment did not always aid in clinical decision classifies such patients into 3 stages: (1) stage I is for patients with severe pain
matching.18 When the criteria could not and disability status; the goal of the interventions is symptom modulation; (2) stage II is for
match the patient to manipulation, spe- patients whose pain is not too severe but interferes with their activities of daily living; the goal
of the treatment is improving muscle impairments to perform activities of daily living; and (3)
cific exercises, or traction, the patient
stage III is for patients who are relatively asymptomatic and can perform standard activities
was matched with stabilization exer- of daily living but need to return to higher levels of physical function; the goal of the
cises. As a result, the stabilization exer- treatment is to improve the patient’s ability to perform higher levels of physical function
cises subgroup became, in and of itself, a without symptoms exacerbation. The level 3 clinical decision classifies patients into syn-
composite of heterogeneous patients dromes embedded within each stage.
with various signs and symptoms.

Fourth, the criteria did not consider def-

hierarchical algorithm that prioritizes revised to incorporate the latest develop-
icits in muscle performance or motor
treatments based on clinical findings and ments, optimize its comprehensiveness,
control when matching patients to treat-
allows for change within an episode of refine current criteria, and explore addi-
ments. When patients with such deficits
care. tional treatments.18
were assessed using the 2007 algorithm,
they either were erroneously matched to
stabilization exercises subgroup or
The 2007 TBC produced an algorithm TBC System—2015
that was clinically applicable, but the This update of the 1995 TBC system rep-
remained unclassified.19
developers were aware that the system resents the third phase of development,
had its limitations and foresaw that it was which we believe is timely because of
Finally, the 2007 TBC criteria did not
likely going to change. Fritz et al stated many advances in the way care is deliv-
ensure that patients are matched only to
that “the process of developing a classi- ered to patients with LBP. New research
a single intervention, but rather 25% of
fication system is dynamic, and it is likely has improved our ability to predict the
the patients could satisfy the criteria for
that future modification [to the TBC] will risk of patients with LBP developing
more than one subgroup.18 This overlap
inevitably be made.”15(p299) Therefore, poor treatment outcomes and subse-
pointed to the importance of creating a
the 2007 TBC algorithm should be quently prescribe interventions that bet-

July 2016 Volume 96 Number 7 Physical Therapy f 1061

Treatment-Based Classification System for LBP

ter match the identified risk level.20 Also, priate for the patient and what factors logical intervention, psychotherapy, and
psychosocial factors have been may affect the treatment. specialized rehabilitation.
described in the literature, and the reha-
bilitation provider’s competency in Triage at the Level of the First- Comorbidities can be present along with
addressing them has been reported.21 Contact Health Care Provider mechanical LBP28 and should be investi-
Additionally, various pain mechanisms Upon initial contact, patients with LBP gated upon initial assessment as well
that can underlie LBP have been should be triaged using 1 of 3 approach- (eTab. 3, available at ptjournal.
highlighted.22,23 es: medical management, rehabilitation apta.org).24 Comorbidities have been

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

management, or self-care management. linked to increased health care utiliza-
These advancements have been Patients requiring medical management tion, higher costs, and poor treatment
described in the APTA clinical practice are those with red flags of serious pathol- outcome.28 –30 Comorbidities, physical or
guidelines for LBP.12 These guidelines, in ogy (eg, fracture, cancer) or serious psychological, can be identified using a
part, attempt to establish a common diag- comorbidities that do not respond to medical screening questionnaire plus
nostic language, as well as publish standard rehabilitation management (eg, patient report. When comorbidities are
evidence-based principles for clinicians rheumatoid arthritis, central sensitiza- found in association with mechanical
and researchers. However, the guide- tion). Serious pathologies can mimic LBP, medical co-management (eg, phar-
lines’ recommendations have not been nonspecific mechanical LBP and should macotherapy) may become necessary in
widely adopted by existing classification be ruled out upon initial assessment.24 order to achieve optimal rehabilitation
systems for LBP. Therefore, we are pro- Red flags are best investigated in clusters outcomes.
posing a format that allows for the incor- of signs and symptoms,25 with each
poration of the guidelines’ recommenda- cluster denoting the presence of a par- Patients who do not have serious pathol-
tions into the 2015 TBC, which will ticular pathology (eTab. 2, available at ogies are appropriate for either rehabili-
provide a process by which the recom- ptjournal.apta.org). tation or self-care management. Patients
mendations can be used efficiently in the amenable to self-care management are
clinical decision-making process for Central sensitization is a condition that those who are unlikely to develop dis-
patients with LBP. We believe that will require careful attention (eTab. 2). abling LBP during the course of the cur-
linking these recommendations to the Central sensitization has been defined as rent episode. Such patients can be iden-
2015 TBC also might guide researchers an altered mechanism of pain processing tified using risk profiling instruments
to new areas of investigation and direct within the central nervous system (ie, such as the STarT Back Tool,31 Örebro
clinicians to new patient management enhanced synaptic excitability, lower Musculoskeletal Pain Questionnaire,32 or
strategies (eTab. 1, available at threshold of activation, and expansion of similar self-report questionnaires. These
ptjournal.apta.org). the receptive fields of nociceptive patients have low levels of psychosocial
input).26 In this condition, the pain ini- distress, no or controlled comorbidities,
The improvements on the TBC will be tially may have been caused by a periph- and normal neurological status. They
discussed in detail in a series of upcom- eral pain generator, but now the pain has may be treated with patient education
ing articles. In this article, we present an lasted beyond the normal healing time that consists of reassurance about the
overview of the most recently updated (ie, chronic pain).23 The pain distribu- generally favorable prognosis for acute
TBC algorithm. tion is widespread and does not follow LBP and advice about medication, work,
an anatomical pattern. The pain also can and activity.20
Overview of the Updated easily be provoked with low-intensity
stimuli that would not normally generate Patients who are appropriate for rehabil-
TBC Algorithm—2015
pain (eg, light touch). A key feature of itation management are the remaining
The 2015 TBC algorithm proposes 2 lev-
this pain is the disproportionate mechan- majority, as serious pathology is very rare
els of triage: one at the level of the first-
ical provocation patterns in response to among patients with LBP,33 and patients
contact health care provider and another
at the level of the rehabilitation provider clinical examination.27 amenable to self-care management repre-
(Fig. 1). At the level of the first-contact sent a small portion of patients with LBP
health care provider, the triage can be Central sensitization has a strong associ- seen in primary care clinics.20 We
assumed by any practitioner competent ation with psychological factors such as believe the majority of patients should be
in LBP care, regardless of his or her pro- negative beliefs, pathological anxiety or referred quickly to a well-trained rehabil-
fessional background (ie, primary care depression, and poor coping strategies. itation provider. This triaging process of
physician, nurse practitioner, physical When such factors are present with the the first-contact health care provider is
therapist, chiropractor). This individual’s aforementioned features of central sensi- recapitulated in Figure 3.
responsibility is to determine the appro- tization, the patient is unlikely to benefit
priate approach of management. At the from standard rehabilitation including Triage at the Level of
level of the rehabilitation provider, the the principles of the TBC. These patients Rehabilitation Provider
purpose of the triage is to determine require a multidisciplinary approach to In some situations, the rehabilitation pro-
which rehabilitation approach is appro- pain management, including pharmaco- vider could be the first-contact health
care provider. In that case, the rehabili-

1062 f Physical Therapy Volume 96 Number 7 July 2016

 Treatment-Based Classification System for LBP

The next step in the triage process of the

rehabilitation provider is matching the
patient’s clinical status to 1 of 3 rehabil-
itation approaches: symptom modula-
tion, movement control, or functional
optimization (Fig. 1). Matching the
patient to each approach relies on the
assessment of pain intensity, disability

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

status, and perception of clinical status.
Also, the matching must consider find-
ings related to the patient’s comorbid
and psychosocial status (Table). This
approach is supported by the APTA clin-
ical practice guidelines for LBP,12 and
consistent with the research standards of
the National Institutes of Health task
force for LBP.34

Depending on the approach to which

the patient is matched, the rehabilitation
provider should plan the appropriate
physical examination. Patients matched
to the symptom modulation approach
should be assessed using a physical
examination that elicits symptom modu-
lation behavior (eg, centralization,
peripheralization). Patients matched to
the movement control approach should
be assessed using a physical examination
that identifies impairments in movement
patterns. Patients matched to the func-
tional optimization approach should be
assessed using a physical examination
that accounts for the unique functional
demands of a specific job or sport.

Figure 3. Symptoms modulation approach.

Low back pain triage process for the first-contact health care provider. Central sensitization A symptom modulation approach is
is one of the comorbidities associated with widespread pain that is disproportionate to matched to patients with recent—new
provocative mechanical testing (eTab. 2). This condition is strongly associated with elevated or recurrent—LBP episode that is cur-
psychological distress. Patients with central sensitization should receive medical manage- rently causing significant symptomatic
ment that includes pharmacotherapy and psychotherapy, as well as specialized rehabilita- features (Table). Because their clinical
tion. Patients at high psychological risk (eg, pain catastrophizing, fear of movement, anxiety, status is volatile, these patients tend to
and depression) should receive psychologically informed rehabilitation. avoid certain postures; active range of
motion is limited and painful. The neu-
rological examination can reveal
tation provider would initially triage the rehabilitation providers be watchful for increased sensitivity. These patients
patient in the same way outlined above. red flags that might have been over- need interventions that modulate their
When the triage determines that the looked by the referring health care pro- symptoms. In this group, patients are
patient is appropriate for rehabilitation vider. Also, the rehabilitation provider treated mainly with manual therapy,
management, the rehabilitation provider should attempt to determine whether directional preference exercises, trac-
should continue to match the patient the patient has any physical or psycho- tion, or immobilization.
with 1 of the 3 rehabilitation approaches logical comorbidities that might necessi-
shown in Figure 1 and described below. tate medical co-management. Also, the
Movement control approach. A
rehabilitation provider should evaluate
movement control approach is matched
In other situations, the rehabilitation pro- the psychosocial status of the patient to
to patients who have low-to-moderate
vider may receive patients with LBP via a determine whether a psychologically
levels of pain and disability that interfere
referral from another health care pro- informed rehabilitation is necessary.
with their activities of daily living
vider. In that case, we recommend that

July 2016 Volume 96 Number 7 Physical Therapy f 1063

Treatment-Based Classification System for LBP

Figure 4.

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

Example of hierarchical exercise progression for patients matched to symptom modulation approach. Patients who need the symptom
modulation approach can satisfy the criteria for more than one treatment subgroup. We suggest that the treatment should take the
progression shown in the Figure. For example, if a patient’s status centralizes with extension, the rehabilitation specialist should emphasize
extension exercises until the patient’s status plateaus. At that time, manipulation can ensue. * Irritable means that minor movements of the
lumbar spine can easily provoke the symptoms. ** Active rest means limiting the patient’s movement until the inflammation subsides. Such
patients are usually seen within the first 24 hours of injury. SLR⫽straight leg raising.

(Table). The patient’s status tends to be performance within the context of a job reduced performance. When the control
stable; that is, the patient describes a low or sport. deficit is corrected, muscle performance
baseline level of pain that increases by training can ensue (Fig. 5). This method
doing certain daily activities; however, Considerations Related to the of prioritization process is largely based
the pain returns to its low-level baseline Rehabilitation Approaches on common clinical sense, warrants fur-
as soon as the patient ceases the activity. The 3 rehabilitation approaches are ther research, and will be described in
Other patients may describe recurrent mutually exclusive; however, patients future articles.
attacks of LBP that are aggravated with can always be reclassified to receive a
sudden or unexpected movement, but different rehabilitation approach as their To achieve optimal treatment outcomes,
currently they are asymptomatic or in clinical status changes (Fig. 1). For exam- it is not enough to only match patients
remission. The patient’s active spinal ple, a patient who initially receives a based on the above 3 rehabilitation
movements are typically full but may be movement control approach due to mod- approaches, but matching also should
accompanied by aberrant movements. erate levels of pain and disability can be consider the patient’s psychosocial sta-
The physical examination can reveal reclassified to receive a functional opti- tus and concurrent comorbidities
findings of impaired flexibility, muscle mization approach if his or her status because they can weaken the treatment
activation, and motor control. These improves to low pain and disability sta- effect (Table). When psychosocial fac-
patients need interventions to improve tus, or the patient can be reclassified to tors are high, the rehabilitation provider
the quality of their movement system. receive a symptoms modulation should educate the patient about pain
For this group, the treatment in the 2007 approach if his or her status suddenly theory, muscle relaxation techniques,
TBC system mainly relied on stabilization worsens. Alternatively, a patient can be sleep hygiene, and coping skills and
exercises.16,35 In this updated 2015 TBC, discharged at any point when rehabilita- address catastrophizing about pain and
however, we believe that stabilization tion goals are attained. diagnostic findings. When medical
exercises must be better defined, and comorbidities are identified, medical
other treatments need to be explored. It should be noted that, within each of co-management is necessary.
the 3 rehabilitation approaches, a patient
Functional optimization approach. might fit the criteria of 2 or more treat-
Conclusion and Future
A functional optimization intervention is ment options, which requires prioritiza- Directions
for patients who are relatively asymp- tion of treatment. For example, in the We reviewed the phases of development
tomatic; they can perform activities of symptom modulation approach, a of the original 1995 TBC and the subse-
daily living but need to return to higher patient may satisfy the criteria for manip- quent revisions that were published in
levels of physical activities (eg, sport, ulation and extension exercises as 2007. We have presented an updated
job). The patient’s status is well con- shown by Stanton et al.18 In that case, version of the TBC, maintaining its pre-
trolled (Table); that is, the pain is aggra- extension exercises take priority over viously developed strengths and improv-
vated only by movement system fatigue. manipulation. Extension exercises ing upon its limitations. In this updated
These patients may not have flexibility or should be the treatment of choice until TBC, we recommend a 2-level triage pro-
control deficits, but they have impair- the patient’s status plateaus. At that cess: (1) initial triage by a first-contact
ments in movement system endurance, moment, manipulation may ensue health care provider (regardless of pro-
strength, and power that do not meet (Fig. 4). Similarly, in the movement con- fession) to determine which patients are
their physical demands.36 These patients trol approach, a patient may have motor amenable to rehabilitation and (2) sec-
need interventions that maximize their control impairment and reduced muscle ondary triage by a rehabilitation provider
physical performance for higher levels of performance. In that case, motor control to determine the most appropriate reha-
physical activities. For this group, the deficit takes priority over the muscle bilitation approach. The initial triage pro-
treatment should optimize the patient’s cess now recognizes 2 types of patients

1064 f Physical Therapy Volume 96 Number 7 July 2016

 Treatment-Based Classification System for LBP

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

Figure 5.
Example of hierarchical exercise progression for patients matched to movement control approach. These impairments can be present in a
patient all at once or any combination of them. To address these impairments, we suggest that the treatment should take the progression
shown in the Figure. The treatment of a particular impairment does not mean ignoring other impairments; that is, if a patient has flexibility
and motor control impairments, the rehabilitation specialist should emphasize flexibility exercises in the earlier sessions of treatment, with
the possibility of addressing some aspects of the motor impairments. As the flexibility impairment improves, the rehabilitation specialist
should emphasize motor control exercises in the later sessions.

who are not candidates for rehabilitation procedures for that specific approach, 6 Childs JD, Fritz JM, Flynn TW, et al. A clin-
management: those with red flags of suggesting subgroup-matched interven- ical prediction rule to identify patients
with low back pain most likely to benefit
potentially serious medical disease or tions. We hope that the information pro- from spinal manipulation: a validation
central sensitization syndromes and vided in these future articles will stimu- study. Ann Intern Med. 2004;141:920 –
those who are likely to do well with a late thoughts and future research related 928.
self-care management approach. to the concept of matching interventions 7 Henschke N, Maher CG, Refshauge KM,
to appropriate subgroups of patients et al. Low back pain research priorities: a
survey of primary care practitioners. BMC
Additionally, this updated TBC embraces with back pain. Fam Pract. 2007;8:40.
the biopsychosocial model of back pain
8 Hefford C. McKenzie classification of
management, including the importance mechanical spinal pain: profile of syn-
for risk assessment and the need to All authors provided concept/idea/project dromes and directions of preference. Man
address psychological factors, regardless design and consultation (including review of Ther. 2008;13:75– 81.
of the rehabilitation approach. The manuscript before submission). Dr Alrwaily,
9 Sahrmann SA. Diagnosis and Treatment
Mr Timko, and Dr Schneider provided writ- of Movement Impairment Syndromes. St
rehabilitation-level triage establishes
ing. Dr Alrwaily provided project manage- Louis, MO: Mosby Inc; 2002.
decision-making criteria that can be used ment. Dr Schneider provided administrative
by any rehabilitation provider to deter- 10 O’Sullivan P. Diagnosis and classification
support. of chronic low back pain disorders: mal-
mine the most appropriate rehabilitation adaptive movement and motor control
approach for the patient with LBP, using DOI: 10.2522/ptj.20150345 impairments as underlying mechanism.
pain and disability status (Table). We also Man Ther. 2005;10:242–255.
HAVE linked the recommended treat- References 11 Delitto A, Erhard RE, Bowling RW. A
ment approaches in this TBC to APTA’s treatment-based classification approach to
1 Hayden JA, van Tulder MW, Malmivaara low back syndrome: identifying and stag-
clinical practice guidelines for LBP. AV, Koes BW. Meta-analysis: exercise ther- ing patients for conservative treatment.
apy for nonspecific low back pain. Ann Phys Ther. 1995;75:470 – 485; discussion
Intern Med. 2005;142:765–775. 485– 479.
This article has provided a general over-
2 Hayden JA, van Tulder MW, Tomlinson G. 12 Delitto A, George SZ, Van Dillen LR, et al;
view of the major updates and revisions Systematic review: strategies for using Orthopaedic Section of the American
to the TBC, with more detailed informa- exercise therapy to improve outcomes in Physical Therapy Association. Low back
tion to be presented in a series of upcom- chronic low back pain. Ann Intern Med. pain. J Orthop Sports Phys Ther. 2012;42:
2005;142:776 –785. A1–A57.
ing articles. One article will be devoted
to the first-contact provider triage pro- 3 Fritz JM, Delitto A, Erhard RE. Comparison 13 Karayannis NV, Jull GA, Hodges PW. Phys-
of classification-based physical therapy iotherapy movement based classification
cess, with discussions about assessment with therapy based on clinical practice approaches to low back pain: comparison
of red flags, medical and psychosocial guidelines for patients with acute low of subgroups through review and develop-
back pain: a randomized clinical trial. er/expert survey. BMC Musculoskelet Dis-
comorbidities, and the need for a Spine (Phila Pa 1976). 2003;28:1363– ord. 2012;13:24.
psychologically informed rehabilitation 1371; discussion 1372.
approach for patients at high risk of 14 Waddell G, Newton M, Henderson I, et al.
4 Brennan GP, Fritz JM, Hunter SJ, et al. A Fear-Avoidance Beliefs Questionnaire
developing chronic LBP. Another article Identifying subgroups of patients with (FABQ) and the role of fear-avoidance
will include more detailed descriptions acute/subacute “nonspecific” low back beliefs in chronic low back pain and dis-
pain: results of a randomized clinical trial. ability. Pain. 1993;52:157–168.
of the rehabilitation provider triage pro- Spine (Phila Pa 1976). 2006;31:623– 631.
cess that sorts patients into the most 5 Vibe Fersum K, O’Sullivan P, Skouen JS, 15 Fritz JM, Cleland JA, Childs JD. Subgroup-
appropriate rehabilitation approach. ing patients with low back pain: evolution
et al. Efficacy of classification-based cogni- of a classification approach to physical
Each of the 3 rehabilitation approaches tive functional therapy in patients with therapy. J Orthop Sports Phys Ther. 2007;
non-specific chronic low back pain: a ran-
will be the focus of an individual article 37:290 –302.
domized controlled trial. Eur J Pain. 2013;
that discusses the physical examination 17:916 –928.

July 2016 Volume 96 Number 7 Physical Therapy f 1065

Treatment-Based Classification System for LBP

16 Hicks GE, Fritz JM, Delitto A, McGill SM. 22 Smart KM, Blake C, Staines A, Doody C. 29 Ritzwoller DP, Crounse L, Shetterly S,
Preliminary development of a clinical pre- The discriminative validity of “nocicep- Rublee D. The association of comorbidi-
diction rule for determining which tive,” “peripheral neuropathic,” and “cen- ties, utilization and costs for patients iden-
patients with low back pain will respond tral sensitization” as mechanisms-based tified with low back pain. BMC Musculo-
to a stabilization exercise program. Arch classifications of musculoskeletal pain. skelet Disord. 2006;7:72.
Phys Med Rehabil. 2005;86:1753–1762. Clin K Pain. 2011;27:655– 663. 30 Goode A, Cook C, Brown C, et al. Differ-
17 Fritz JM, Brennan GP, Clifford SN, et al. An 23 Woolf CJ. Central sensitization: implica- ences in comorbidities on low back pain
examination of the reliability of a classifi- tions for the diagnosis and treatment of and low back related leg pain. Pain Pract.
cation algorithm for subgrouping patients pain. Pain. 2011;152(3 suppl):S2–S15. 2011;11:42– 47.
with low back pain. Spine (Phula Pa 31 Hill JC, Dunn KM, Lewis M, et al. A pri-

Downloaded from https://academic.oup.com/ptj/article/96/7/1057/2864925 by Universidad de los Andes user on 13 September 2021

1976). 2006;31:77– 82. 24 Dagenais S, Tricco AC, Haldeman S. Syn- mary care back pain screening tool: iden-
thesis of recommendations for the assess- tifying patient subgroups for initial treat-
18 Stanton TR, Fritz JM, Hancock MJ, et al. ment and management of low back pain ment. Arthritis Rheum. 2008;59:632– 641.
Evaluation of a treatment-based classifica- from recent clinical practice guidelines.
tion algorithm for low back pain: a cross- Spine J. 2010;10:514 –529. 32 Linton SJ, Boersma K. Early identification
sectional study. Phys Ther. 2011;91:496 – of patients at risk of developing a persis-
509. 25 Henschke N, Maher CG, Refshauge KM, tent back problem: the predictive validity
et al. Prevalence of and screening for seri- of the Örebro Musculoskeletal Pain Ques-
19 Stanton TR, Hancock MJ, Apeldoorn AT, ous spinal pathology in patients present- tionnaire. Clin J Pain. 2003;19:80 – 86.
et al. What characterizes people who have ing to primary care settings with acute low
an unclear classification using a treatment- back pain. Arthritis Rheum. 2009;60: 33 Henschke N, Maher CG, Ostelo RW, et al.
based classification algorithm for low back 3072–3080. Red flags to screen for malignancy in
pain? A cross-sectional study. Phys Ther. patients with low-back pain. Cochrane
2013;93:345–355. 26 Latremoliere A, Woolf CJ. Central sensiti- Database Syst Rev. 2013;2:CD008686.
zation: a generator of pain hypersensitivity
20 Hill JC, Whitehurst DG, Lewis M, et al. by central neural plasticity. J Pain. 2009; 34 Deyo RA, Dworkin SF, Amtmann D, et al.
Comparison of stratified primary care 10:895–926. Report of the NIH task force on research
management for low back pain with cur- standards for chronic low back pain. Spine
rent best practice (STarT Back): a ran- 27 Smart KM, Blake C, Staines A, et al. (Phila Pa 1976). 2014;39:1128 –1143.
domised controlled trial. Lancet. 2011; Mechanisms-based classifications of mus- 35 Rabin A, Shashua A, Pizem K, et al. A clin-
378:1560 –1571. culoskeletal pain: part 1 of 3: symptoms ical prediction rule to identify patients
and signs of central sensitisation in with low back pain who are likely to expe-
21 Bryant C, Lewis P, Bennell KL, et al. Can patients with low back (⫹/⫺ leg) pain. rience short-term success following lum-
physical therapists deliver a pain coping Man Ther. 2012;17:336 –344. bar stabilization exercises: a randomized
skills program? An examination of training controlled validation study. J Orthop
processes and outcomes. Phys Ther. 2014; 28 Gore M, Sadosky A, Stacey BR, et al. The
burden of chronic low back pain: clinical Sports Phys Ther. 2014;44:6 –B13.
94:1443–1454.
comorbidities, treatment patterns, and 36 McGill S. Low Back Disorders: Evidence-
health care costs in usual care settings. Based Prevention and Rehabilitation.
Spine (Phila Pa 1976). 2012;37:E668 – 2nd ed. Champaign, IL: Human Kinetics;
E677. 2007.

1066 f Physical Therapy Volume 96 Number 7 July 2016