Monday, June 15, 2009

TBC- Treatment based classification for LBA

Background (Need of TBC):

Similar pathologies presenting with similar clinical features do not respond to similar physiotherapy treatment methods, rather to different physiotherapeutic treatment strategies. Fritz reported 3 patients; each patient had signs and symptoms of compressive nerve root pathology with a similar anatomical distribution of pain. However, basing on TBC (Treatment based classification), each patient was treated with a different approach based on the assigned classification. One patient was classified as needing treatment for a lateral shift, one patient was classified as needing flexion-oriented treatment, and the other patient was classified as needing extension-oriented treatment. The approach used for each patient was successful in reducing patient-reported pain severity and level of functional disability (4).


Classification of patients with low back pain into homogeneous subgroups has been identified (3). Further the development of valid classification methods to assist the physical therapy management of patients with low back pain has been recognized as a research priority. There is also growing evidence that the use of a classification approach to physical therapy results in better clinical outcomes than the use of alternative management approaches (2).

Treatment based on severity of presentation (1):

For LBA entire approach taken by physiotherapists now days is diagnosis based, with specific algorithms and decision rules. Further working in the above said line consistent CPR i.e. clinical prediction rules are also chucked out. However, the causal approach to LBA patients is via historical information, behavior of symptoms, and clinical signs. Most patients can be managed by conservative care are managed predominantly and independently by physical therapists, but still a good deal of patients require other services e.g. psychology or who require referral because of possible serious nonmusculoskeletal pathology.

Physical therapists classify the patients who can be managed by them into 3 stages according to severity of the presentation:

1. Stage I for patients in the acute phase where the therapeutic goal is symptom relief
2. Stage II for patients in a sub-acute phase where symptom relief and quick return to normal function are encouraged and
3. Stage III for selected patients who must return to activities requiring high physical demands and who demonstrate a lack of physical conditioning necessary to perform the desired activities safely.

Further, classification for stage I patients can be further classified into distinct categories that are treatment-based and that specifically guide conservative management.

The treatment based classification (TBC):

Many authorities in past called LBA are a non-specific clinical presentation. However, emerging evidence suggests that there are clearly defined subgroups and respond differently to conservative non-pharmacological treatment, challenging the assertion that LBP is "nonspecific." (5) So, there is emergence of TBC or Treatment-Based Classification. First time Delitto and colleagues, (1995) proposed such 4 level TBC classification system. According to Treatment-Based Classification there are 4 categories of treatment applied to the classified subgroups. These 4 categories of treatments are:

1. Stabilization
2. Mobilization
3. Direction specific exercise or
4. Traction

Each classification could be identified by a unique set of examination criteria, and was associated with an intervention strategy believed to result in the best outcomes for the patient (2). However researchers have found that impairments of the transverse abdominis and lumbar multifidus occur across all subgroups of LBP (5).

Benefits of treatment based classification:

1. Clarification of the unsolved aspects of LBA especially in management aspect.
2. Numerous clinical exploratory researches have emerged to clarify more on this issue.
3. The development of clinical prediction rules regarding the context.
4. Providing new evidence for the examination criteria and optimal intervention strategies for each classification.
5. Incorporation of new clinical into existing classification systems.

Reliability & outcomes of physical therapy treatment when a TBC is used:

Fritz & colleagues concluded in their study analyzing interrater reliability on 120 patients:
1. Reaching a consensus regarding relevant patient subgroups requires data on the reliability and validity of existing classification systems.
2. Further work is required to validate improvement in treatment outcomes using a classification approach.


1. Delitto A et al; Phys Ther. 1995 Jun;75(6):470-85; discussion 485-9.
2. Fritz JM et al; J Orthop Sports Phys Ther. 2007 Jun;37(6):290-302.
3. Fritz JM et al; Spine. 2000 Jan;25(1):106-14.
4. Fritz JM; Phys Ther. 1998 Jul;78(7):766-77.
5. Kiesel KB et al; J Orthop Sports Phys Ther. 2007 Oct;37(10):596-607.

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