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[ CLINICAL COMMENTARY ]

JULIE M. FRITZ, PT, PhD, ATC1 • JOSHUA A. CLELAND, PT, PhD, OCS, FAAOMPT2 • JOHN D. CHILDS, PT, PhD, MBA, OCS, FAAOMPT3

Subgrouping Patients With Low


Back Pain: Evolution of a Classification
Approach to Physical Therapy
ow back pain (LBP) is the reason for seeking care in nearly 50% of LBP has traditionally not incorporated a

L all patients presenting to outpatient physical therapy clinics.37,73


As indicated by the Guide to Physical Therapist Practice,5
physical therapists employ a wide range of interventions in the
management of patients with LBP, including manual physical therapy
(ie, spinal manipulation), therapeutic exercise, traction, modalities, and
reality recognized by clinicians: that it is
not reasonable to expect everyone with
nonspecific LBP to benefit from any sin-
gle treatment approach.75 It has been ad-
vocated that researchers can improve the
power of their research by using methods
functional training. Although a variety of interventions are accepted to match subgroups of patients to inter-
ventions from which they are likely to
as standard of care for patients with ture.79 Despite this plenitude of research, benefit.15-17,79
LBP,101 high-quality evidence from ran- the evidence remains contradictory and The lack of conclusive research evi-
domized clinical trials has failed to inconclusive for many interven- dence has provided clinicians with little
offer conclusive support for most tions.62 One explanation offered information to guide decision making in
interventions. Over 1000 random- SUPPLEMENTAL for the lack of evidence for many the selection of interventions for indi-
ized clinical trials investigating the VIDEOS ONLINE common interventions relates vidual patients, resulting in suboptimal
effectiveness of conservative and sur- to study designs with broad inclu- outcomes and wide variations in prac-
gical interventions for the management sion criteria, resulting in heterogeneous tice patterns.82,94 Clinicians agree that
of LBP have been reported in the litera- samples.33 Research on interventions for LBP is a heterogeneous condition, but
there is disagreement as to the most ap-
T SYNOPSIS: The development of valid clas- research evidence available at the time. A substan- propriate methods for classifying these
sification methods to assist the physical therapy tial amount of research has emerged in the years patients to improve clinical outcomes.75
management of patients with low back pain has since the introduction of this classification system, Traditionally the medical model has at-
been recognized as a research priority. There is including the development of clinical prediction
tempted to classify individuals based on
also growing evidence that the use of a classifica- rules, providing new evidence for the examination
tion approach to physical therapy results in better a pathoanatomical source of symptoms;
criteria used to place a patient into a classification
clinical outcomes than the use of alternative and for the optimal intervention strategies for each however, identifying relevant pathology
management approaches. In 1995 Delitto and col- classification. New evidence should continually be in patients with LBP has proved elusive
leagues proposed a classification system intended incorporated into existing classification systems. and is identified in less than 10% of cas-
to inform and direct the physical therapy manage- The purpose of this clinical commentary is to es.2 Therefore, attempting to identify a
ment of patients with low back pain. The system review this classification system, its evolution and
described 4 classifications of patients with low pathoanatomic source will infrequently
current status, and to discuss its implications for
back pain (manipulation, stabilization, specific ex- be useful for guiding decision making,
the classification of patients with low back pain.
ercise, and traction). Each classification could be J Orthop Sports Phys Ther 2007;37(6):290-302. particularly for physical therapists. The
identified by a unique set of examination criteria, doi:10.2519/jospt.2007.2498 Guide to Physical Therapist Practice5
and was associated with an intervention strategy
recognizes that a primary goal of the
believed to result in the best outcomes for the pa- T KEY WORDS: clinical decision making, lumbar
tient. The system was based on expert opinion and spine, manipulation, stabilization, traction diagnostic process is to classify patients
based on clusters of signs and symptoms,

1
Associate Professor, Division of Physical Therapy, University of Utah, Salt Lake City, UT; Clinical Outcomes Research Scientist, Intermountain Health Care, Salt Lake City, UT.
2
Assistant Professor, Department of Physical Therapy, Franklin Pierce College, Concord, NH; Research Coordinator, Rehabilitation Services, Concord Hospital, Concord, NH;
Faculty, Regis University Manual Therapy Fellowship Program, Denver, CO. 3 Assistant Professor and Director of Research, US Army-Baylor University Doctoral Program in
Physical Therapy, San Antonio, TX. Address correspondence to Julie M. Fritz, 520 Wakara Way, Salt Lake City, UT 84108. E-mail: julie.fritz1@comcast.net

290 | june 2007 | volume 37 | number 6 | journal of orthopaedic & sports physical therapy
not presumed pathoanatomical causes. effective.13,91,105,115 One approach to clas- eral studies have been conducted that
The Guide5 and other advocates of evi- sifying patients with LBP based on signs expound on the specific signs and symp-
dence-based practice also promote that and symptoms was described by Delitto toms used to identify patient subgroups
effective subgrouping methods should and colleagues in 1995. 35 Research has and the specific interventions and pro-
ultimately direct decision making to- supported that decision making based tocols that may be most beneficial for
wards the most effective management on this classification structure results patients in a particular subgroup. The
strategies.106,107 in better outcomes for physical therapy purpose of this clinical commentary is to
A good deal of work, both theoretical than decision making based on alterna- describe the evidence published in recent
and experimental, has been performed tive procedures.18,45 No system of patient years that may impact the classification
by Physical Therapists describing sub- management should be considered stat- system originally proposed by Delitto et
groups of patients based on clusters of ic, and it is necessary to incorporate new al,35 and to discuss its implications for
signs and symptoms and proposing a evidence into existing systems. Since the the physical therapy management of pa-
particular intervention strategy as most original proposal by Delitto et al, 35 sev- tients with LBP.

Signs and Symptoms Originally Proposed as the Criteria


TABLE 1 for Placing a Patient Into a Particular Classification
and Revised Criteria Based on Updated Evidence

Classification Original Classification Criteria Updated Classification Criteria


Manipulation • Asymmetrical lateral flexion ROM (ie, capsular pattern of motion • No symptoms distal to the knee
restriction) • Recent onset of symptoms ( 16 d)
• Unilateral LBP without symptoms into the lower extremities • Low FABQW score ( 19)
• Asymmetrical bony landmarks of the pelvis • Hypomobility of the lumbar spine
• Positive sacroiliac dysfunction tests (ie, supine long sit test, prone • Hip internal rotation ROM (35° for at least 1 hip)
knee bend test, standing flexion test)
Stabilization • Frequent recurrent episodes of LBP with minimal perturbation • Younger age ( 40 y)
• Hypermobility of the lumbar spine • Greater general flexibility (postpartum, average SLR ROM 91°)
• Previous history of lateral-shift deformity with alternating sides • “Instability catch” or aberrant movements during lumbar flexion/
• Frequent prior use of manipulation with dramatic but short-term extension ROM
results • Positive findings for the prone instability test
• Trauma, pregnancy, or use of oral contraceptives • For patients who are postpartum:
• Relief with immobilization (eg, bracing) - Positive posterior pelvic pain provocation (P4), and ASLR and
modified Trendelenburg tests
- Pain provocation with palpation of the long dorsal sacroiliac
ligament or pubic symphysis
Specific exercise
Extension • Symptoms centralize with lumbar extension • Symptoms distal to the buttock
• Symptoms peripheralize with lumbar flexion • Symptoms centralize with lumbar extension
• Symptoms peripheralize with lumbar flexion
• Directional preference for extension
Flexion • Symptoms centralize with lumbar flexion • Older age (50 y)
• Symptoms peripheralize with lumbar extension • Directional preference for flexion
• Diagnosis of lumbar spinal stenosis • Imaging evidence of lumbar spinal stenosis
Lateral shift • Visible frontal plane deviation of the shoulders relative to the pelvis • Visible frontal plane deviation of the shoulders relative to the pelvis
• Asymmetrical side-bending active ROM • Directional preference for lateral translation movements of the pelvis
• Painful and restricted extension active ROM
Traction • Signs and symptoms of nerve root compression • Signs and symptoms of nerve root compression
• No movements centralize symptoms • No movements centralize symptoms
Abbreviations: ASLR, active straight-leg raise; FABQW, Fear-Avoidance Beliefs Questionnaire-Work Subscale; LBP, low back pain; ROM, range of motion;
SLR, straight-leg raise.

journal of orthopaedic & sports physical therapy | volume 37 | number 6 | june 2007 | 291
[ CLINICAL COMMENTARY ]
OVERVIEW OF THE based in biomechanical theories, and the We have pursued the development
CLASSIFICATION SYSTEM examination procedures related to these of a multivariate clinical prediction rule
theories were originally advocated as (CPR) to accurately identify patients who
important classification criteria (TABLE fit a manipulation classification. A CPR is

T
he classification system de-
scribed by Delitto and colleagues35 1). Many of these diagnostic tests have a tool designed to assist the classification
was intended for patients with acute, been found to have poor reliability and process and improve decision making by
or an acute exacerbation of, LBP causing questionable validity38,39,41 and therefore using evidence to determine which pa-
substantial pain and limitations in daily no longer appear to be the preferred tients are likely to benefit from a specific
activities. After screening patients for any method for identifying patients need- treatment strategy.81 The goal of the CPR
medical red flags, the system proposed ing manipulation. Recent research has for the manipulation classification is to
using the information gathered from the focused on identifying baseline exami- identify patients with LBP who are likely
history and physical examination to place nation factors that are associated with to respond to manipulation with rapid
a patient into 1 of 4 basic classification benefiting from manipulation interven- and sustained improvement. Flynn et
categories: manipulation, specific exer- tions without assumptions based on al41 developed a CPR for the manipula-
cise (flexion, extension, and lateral-shift theory or tradition. Studies examining tion classification by examining predic-
patterns), stabilization, and traction. The predictors of response to chiropractic tors of improvement defined as a 50% or
signs and symptoms originally proposed treatment using manipulation have re- greater reduction in self-reported disabil-
as the criteria for placing a patient into ported that patients with shorter dura- ity occurring over 2 treatment sessions in
one of these categories are listed in TABLE tion of symptoms and the absence of leg 71 patients with nonradicular LBP. The
1, and the intervention procedures origi- pain are most likely to benefit.8,110 CPR included 5 factors: current symp-
nally proposed for each category are listed
in TABLE 2. The system was based on clini- Intervention Procedures Originally
cal experience and the evidence available TABLE 2 Proposed for Each Classification and Revised
at the time. In the sections below we will Interventions Based on Updated Evidence
review recent evidence that should inform
the classification criteria and intervention Classification Original Intervention Procedures Updated Intervention Procedures
procedures used for each category. Manipulation • Manipulation or mobilization techniques • Manipulation of the lumbopelvic
targeted to the sacroiliac or lumbar region region
MANIPULATION • Active ROM exercises • Active ROM exercises
CLASSIFICATION Stabilization • Trunk strengthening and stabilization • Promoting isolated contraction and
exercises cocontraction of the deep stabilizing

M
any randomized clinical trials • Advice to avoid end-range movements and muscles (multifidus, transversus
have found spinal manipulation positions abdominus)
to be more effective than pla- • Bracing for more severe cases • Strengthening of large spinal
cebo or other interventions for patients stabilizing muscles (erector spinae,
with LBP.7,25,34,114,125 Conversely, other oblique abdominals)
studies have shown that manipulation
Specific exercise
is not more effective than other treat-
Extension • End-range extension exercises • End-range extension exercises
ments.24,55,56 The incongruous results of
• Avoidance of flexion activities • Mobilization to promote extension
previous trials have led some to suggest
• Avoidance of flexion activities
that manipulation may be effective, but
only for a subgroup of patients with LBP.6 Flexion • End-range flexion exercises • Mobilization or manipulation of the
Further consideration of recent evidence • Mechanical traction performed in flexion spine and/or lower extremities
for examination and intervention proce- • Avoidance of extension activities • Exercise to address impairments of
dures may help to clarify procedures to strength or flexibility
identify and manage patients in a ma- • Body weight-supported treadmill
nipulation subgroup. ambulation
Lateral shift • Exercises to correct lateral shift • Exercises to correct lateral shift
Examination Considerations • Mechanical or autotraction • Mechanical or autotraction
Traditionally, classifying a patient as Traction • Mechanical or autotraction • Mechanical or autotraction
needing manipulation has relied heavily Abbreviation: ROM, range of motion.
on mobility assessments and special tests

292 | june 2007 | volume 37 | number 6 | journal of orthopaedic & sports physical therapy
tom duration of less than 16 days, a score 50 specific dysfunctions.57,86 The importance
on the work subscale of the Fear-Avoid- of the choice of a specific manipulation
40
ance Beliefs Questionnaire (FABQ)119 of technique has recently been challenged

Oswestry Score (%)


less than 19, hypomobility of the lumbar 30 as traditional theories underlying manip-
spine as assessed with posterior-to-ante- ulation are questioned.26,30 Although evi-
20
rior pressure, internal rotation of at least dence is sparse, a few studies have found
1 hip greater than 35°, and symptoms 10 greater benefit from thrust manipulation
not extending distal to the knee. When 4 0
techniques versus nonthrust mobilization
Baseline 1 wk 4 wk 6 mo
of these 5 factors were present, patients for the lumbosacral region.59,92 Although
were highly likely to improve (positive Manipulation group (+rule) Exercise group (+rule) manipulation is generally recommended
Manipulation group (–rule) Exercise group (–rule)
likelihood ratio [LR], 24), while the pres- as superior to mobilization procedures,20
ence of 2 or fewer factors was almost al- FIGURE 1. Oswestry disability scores over time for there is presently no evidence for the su-
ways associated with a failure to improve patients with low back pain who were positive (+rule) periority of one manipulation technique
(negative LR, 0.09). To put these results or negative (–rule) on the manipulation classification over another.29 It is possible that the
clinical prediction rule (CPR), and who received exer-
in perspective, if it is assumed that about choice of a specific manipulation tech-
cise with or without manipulation. The group receiving
50% of all patients with nonradicular manipulation that was positive on the CPR experienced
nique may not be as important as previ-
LBP would improve with manipulation, significantly more change than the other 3 groups. ously thought.76
the likelihood of improvement would Adapted with permission from Childs et al.25 Originally the manipulation classifica-
increase to 97% when at least 4 factors tion proposed by Delitto and colleagues35
were present and decrease to 9% when 2 this area appear to consistently support 2 incorporated traditional biomechanical
or fewer factors were present. factors (short duration of symptoms and approaches to technique selection, dis-
A follow-up study25 was carried out to no leg pain) as important criteria for the tinguishing techniques directed towards
examine the validity of the CPR by ran- manipulation classification,8,41,44,110 and the the sacroiliac or lumbar region (TABLE 2).
domly assigning 131 patients to receive presence of at least 4 of the 5 CPR factors Recent evidence, however, suggests that
a standardized exercise program with or increases accuracy of predicting success the effects of manipulation may not be
without manipulation and by examin- even further. The value of a classification as specific as once believed. For example,
ing the results in subgroups of patients approach is not only the ability to identify Beffa et al9 examined the relationship be-
based on their status on the manipula- the patients likely to benefit from a par- tween manipulation targeted to specific
tion classification CPR. The results dem- ticular intervention, but also the ability spinal levels and the spinal levels actu-
onstrated that patients who were positive to identify patients who need a different ally producing a cavitation during the
on the CPR (ie, 4 or more factors) and re- approach. Patients with 2 or fewer CPR technique. The authors found no correla-
ceived manipulation experienced greater factors appear very unlikely to improve tion between the spinal levels producing
improvement in pain and disability in with manipulation and likely need an al- cavitation sounds and the levels targeted
short-term (at 1 and 4 weeks) and long- ternative intervention. It is also important by the technique. Haas et al58 examined
term (6 months) follow-ups than patients to note that patients over the age of 60 short-term outcomes of patients with
who were negative on the CPR (ie, fewer or with signs of nerve root compression neck pain randomized to receive ma-
than 4 factors) and received manipulation were excluded from consideration in the nipulation targeted to spinal segments
(FIGURE 1). Patients who were positive on studies developing this CPR, as were pa- thought to have increased stiffness based
the CPR and received manipulation also tients with diagnoses of spondylolisthesis, on clinical examination or targeted to
experienced greater short- and long-term osteoporosis, or any concerns of bony ab- randomly selected segments, and found
improvements in pain and disability than normality or weakness. Manipulation is no differences in patient-reported pain
patients who were positive on the CPR but generally considered to be contraindicat- or stiffness. Kent et al76 systematically
received the exercise intervention. These ed in these subgroups,82,102 although some reviewed the evidence on the effect of the
results indicate that the subgroup of pa- believe that manipulation may be appro- discretion given to clinicians to choose
tients identified by the CPR is uniquely re- priate for at least some patients with signs techniques for a particular patient on
sponsive to a manipulation intervention. of nerve root compression.19,108 outcomes in randomized trials examining
The criteria for identifying patients manual therapy and found that although
in the manipulation classification have Management Considerations the evidence was limited, there was no
evolved from factors based largely on Biomechanical theories traditionally used suggestion that allowing clinicians to
biomechanical theory to factors identified to identify patients for the manipulation select techniques for patients improved
through prospective analysis with com- classification have also supported the outcomes compared with studies using
parisons to clinical outcomes. Studies in need for precise techniques to address predefined manipulation protocols.76 Ac-

journal of orthopaedic & sports physical therapy | volume 37 | number 6 | june 2007 | 293
[ CLINICAL COMMENTARY ]
cumulating evidence suggests that the subgroup that focused on identifying ual variations in spinal motion char-
most important factor to achieve optimal patients presumed to have excessive seg- acteristics in asymptomatic subjects,
outcomes with manipulation may be the mental movements of the spine (TABLE 1), making it difficult to establish thresh-
accurate identification of patients who such as recurrent LBP episodes, frequent olds identifying a spine as unstable. 14,63
are likely to respond rather than the se- manipulation or self-manipulation with Using the amount of segmental motion
lection of specific techniques. short-term relief, trauma, pregnancy, oral as the standard against which examina-
contraceptive use, and positive response tion variables are judged also fails to
STABILIZATION to immobilization of the spine. Recent account for the important role of the
CLASSIFICATION surveys of physical therapists suggest that spinal muscles,48 and it is inconsistent
this perspective on identifying patients with the goal of a classification ap-
for stabilization interventions remains proach. Classification seeks to identify

T
he concept of a subgroup of
patients with LBP related to spinal prevalent.33,75 patients likely to respond to a specific
instability has been described for Most research conducted to iden- treatment approach, not those with a
decades, but was initially discussed as a tify stabilization classification criteria particular imaging finding.
mechanical condition of excessive move- has examined the usefulness of clinical We have sought to identify examina-
ment between adjacent vertebrae that examination findings for identifying tion criteria for the stabilization clas-
required immobilization or surgical sta- radiographic evidence of excessive mo- sification by developing a CPR for this
bilization.52,96,109 The original classifica- tion between vertebrae.1,40,51 However, subgroup. Hicks et al65 provided 8 weeks
tion system proposed in 199535 reflected the validity of this approach has been of stabilization training targeting the
this perspective, labeling this subgroup questioned based on studies showing multifidus/erector spinae, transversus
“immobilization” and recommending ex- wide interindividual and intraindivid- abdominus, and oblique abdominal
amination criteria and interventions de-
signed to manage patients with excessive
segmental movement (TABLES 1 and 2). Re-
Special Tests Suggested to Be Important
cent research has provided a somewhat TABLE 3 Examination Criteria for Identifying
different perspective by emphasizing the
Patients in the Stabilization Classification
importance of spinal muscles in main- Examination Description
taining and restoring spinal stability, 66
Prone instability test The patient lies prone with the body on an examining table and legs over the edge
shifting the focus of rehabilitation from
with feet resting on the floor. While the patient rests in this position, the therapist
immobilization to stabilization.23,32,69,70 In
applies posterior-to-anterior pressure to the lumbar spine. Any provocation of pain
the last few years, this research has greatly
is reported. Then the patient lifts the legs off the floor and posterior compression
increased the popularity of exercise inter-
is applied again to the lumbar spine. If pain is present in the resting position but
ventions designed to enhance the stabi-
subsides in the second position, the test is positive
lizing capacity of spinal muscles.102 There
Posterior pelvic pain The patient is supine. The therapist passively flexes the patient’s hip to 90° and applies
have been several randomized trials pub-
provocation (P4) a posteriorly directed force through the longitudinal axis of the femur. The test is
lished to investigate the effectiveness of
test97 positive if the patient reports a deep pain in the gluteal area during the test
lumbar stabilization exercises for patients
with LBP that have reported inconsistent Active straight-leg raise The patient is supine with straight legs and feet 20 cm apart. The patient is instructed
results.23,56,67,80,99,109 As previously suggest- test93 to lift the legs one after the other approximately 20 cm above the table without
ed, these conflicting results may suggest bending the knee. The patient is asked to score the difficulty of the task on a 6-point
that stabilization exercises are effective scale (0, no difficulty at all; 1, minimally difficult; 2, somewhat difficult; 3, fairly
for some, but not all, patients with LBP. difficult; 4, very difficult; 5, unable to do). Any score greater than 0 is a positive test
Further evaluation of recent evidence on Provocation of the long The patient is supine. The therapist palpates the long dorsal sacroiliac ligament
the examination and intervention proce- dorsal sacroiliac bilaterally. A positive test occurs if at least 1 side is painful, and the pain persists at
dures related to the subgroup of patients ligament118 least 5 seconds after the removal of the therapist’s hand
most likely to benefit from stabilization Provocation of the With the patient in supine the entire front side of the pubic symphysis is palpated
exercise may improve identification and pubic symphysis gently. If the palpation causes pain that persists more than 5 seconds after the
management of these patients. with palpation4 removal of the therapist’s hand, it is recorded as positive
Modified Trendelenburg The therapist is behind the standing patient. The patient is asked to stand on one
Examination Considerations test4 foot while flexing the opposite knee and hip to 90°. The test is positive if the hip
Delitto et al35 originally described the descends on the flexed side
classification criteria for a stabilization

294 | june 2007 | volume 37 | number 6 | journal of orthopaedic & sports physical therapy
muscles to 54 patients with nonradicular The variables identified in these stud- exercise programs centered on retraining
LBP. Using a definition of improvement ies are generally consistent with current appropriate activation of the transversus
(50% reduction in self-reported dis- theories emphasizing the importance abdominus and/or multifidus muscles
ability), the authors identified 4 factors of spinal muscles as a component of when compared to no treatment,67,109
that were predictive of improvement: stabilization. Patients in the stabiliza- or multimodal treatment programs
age less than 40 years, average straight- tion classification appear to be those not explicitly focused on strengthening
leg raise (SLR) range of motion (ROM) who are generally flexible (ie, younger, exercises.56,99,113
greater than 91°, aberrant movements excessive SLR ROM) or with increased Two recent studies23,80 have ques-
during sagittal plane lumbar ROM, and flexibility (ie, postpartum), possibly tioned if specific muscle retraining is the
a positive prone instability test (TABLE with increased segmental spinal move-
3).65 A preliminary CPR was defined as ment (ie, hypermobility), whose spinal Cairns et al23 randomized 97 patients
positive when 3 or more of these factors muscles do not provide adequate stabi- with a prior history of LBP to specific
were present; however, the predictive ac- lization (ie, aberrant movements, and muscle retraining or conventional physi-
curacy of the stabilization CPR (positive positive prone instability, ASLR, and cal therapy. Both groups received indi-
LR, 4.0) was not as strong as the ma- modified Trendelenburg tests). Further vidually tailored exercise and manual
nipulation CPR. Assuming that a patient research is necessary to refine and vali- therapy interventions. The specific mus-
has a 50% chance of improving with a date the criteria defining the stabiliza- cle retraining group received additional
stabilization intervention, a positive CPR tion classification. instruction in retraining the multifidus
increases the probability to 80%. Great- and transversus abdominus, supplement-
er accuracy was found for identifying Management Considerations ed with written instructions and real-
patients who were not likely to receive The original classification system35 pro- time ultrasound biofeedback as needed.
even minimal benefit (5 or fewer points posed interventions focused on restrict-
of improvement on the Oswestry) from ing movement that was presumed to be after 12 weeks of treatment or at 1-year
a stabilization intervention. Four factors excessive for patients in a stabilization follow-up.23 Koumantakis et al80 also
predictive of failure included a negative classification. Recommendations in- examined patients with recurrent LBP,
prone instability test, absence of aberrant cluded avoiding end-range positions of randomizing 67 subjects to a specific-re-
movements during sagittal plane lumbar the spine and bracing for more severe training group that focused initially on
ROM, absence of lumbar hypermobility cases, along with spinal muscle strength- retraining the multifidus and transversus
(assessed with posterior-to-anterior pres- ening exercises. Research on the stabi- abdominus or to a general-strengthening
sure), and a score of less than 9 on the lizing role of spinal muscles has shifted group that concentrated on strengthen-
FABQ physical activity subscale. 65 The the focus of treatment for patients in the ing the large muscle groups of the spine
presence of at least 3 of these findings stabilization classification from avoiding (erector spinae, oblique abdominals).
was highly predictive of failure (positive to controlling movement. In particular, The authors found somewhat superior
LR, 18.8), indicating that if a patient was recent research has stressed the impor- outcomes for the general-strengthening
presumed to have a 25% probability of tance of the deep muscles of the spine group following the 8-week treatment
failing, the presence of at least 3 of these for stabilization (ie, transversus abdo-
factors would increase the probability of minus, multifidus).68,69,71 This research week follow-up.80
failure to 86%. has increased attention on stabilization Further research is needed to identify
Stuge and colleagues112,113 have pro- exercise programs that emphasize spe-
posed additional factors to identify some cific retraining of these muscles. 98,103 for patients in the stabilization classifi-
women with posterior pelvic girdle pain Others have focused stabilization exer- cation. Although many experts advocate
who are postpartum as likely to benefit cise regimens on improving the strength the necessity of specifically retraining the
from stabilization treatment. The criteria and endurance of larger spinal muscles deep spinal muscles, 98,104 the evidence
used to define this subgroup are women (ie, erector spinae, oblique abdominals, does not clearly support this approach.
who are postpartum with buttock pain quadratus lumborum),88-90 creating some It appears that specific muscle retraining
and a composite of positive tests: poste- disagreement concerning optimal inter- protocols are superior to treatments that
rior pelvic pain provocation (P4) test, 97 vention strategies for patients in the sta- do not include a well-defined strength-
active straight-leg raise (ASLR) test, 93 bilization classification. ening component, but the superiority of
provocation of the long dorsal sacroiliac Support for the specific-muscle ap- a specific approach to muscle retraining
ligament, provocation of the pubic sym- proach to stabilization comes from ran- over an approach that stresses general
physis with palpation, and the modified domized trials that have found better strengthening of the larger spinal mus-
Trendelenburg test4 (TABLE 3). outcomes resulting from stabilization cles has not been demonstrated.

journal of orthopaedic & sports physical therapy | volume 37 | number 6 | june 2007 | 295
[ CLINICAL COMMENTARY ]
SPECIFIC-EXERCISE most studies have not used centralization Management Considerations
CLASSIFICATION to identify a specific subgroup of patients The basic premise advocated for treating
who preferentially respond to specific- patients in a specific-exercise classification
exercise interventions. A recent study21 is to use repeated end-range movements

T
he existence of subgroups of
patients who preferentially respond used centralization as an inclusion cri- in the direction that caused centraliza-
to repeated end-range movements terion and examined the effectiveness of tion. This approach was recommended
was popularized by McKenzie several an extension specific-exercise protocol in the original classification system, 35
decades ago.91 Consistent with principles compared to a stabilization approach. leading to 3 categories based on the cen-
proposed by McKenzie, Delitto and col- The results showed better outcomes in tralizing movement (flexion, extension,
leagues35 identified a classification of pa- the group receiving the extension proto- or a lateral shift). Two recent systematic
tients for whom repeated exercises in a col in this sample of patients who dem- reviews27,85 have pooled data from 6 ran-
specific direction (flexion, extension, or a onstrated centralization with extension domized or quasi-experimental studies
lateral shift) were proposed to be the ap- movements at baseline.21 This is the first investigating the effects of treatment pro-
propriate intervention. The presence of study to provide some evidence of the vided according to principles proposed by
the centralization phenomenon was the usefulness of centralization as a clas- McKenzie, a large component of which is
primary examination criterion proposed sification criterion for specific-exercise repeated end-range movement in the di-
for membership in a specific-exercise classifications. rection of centralization.91 These reviews
classification, and the movement produc- An examination finding related to cen- found greater reductions in pain and dis-
ing centralization determined the specific tralization that has also been studied as a ability for treatments based on McKen-
direction of exercise required for the pa- classification criterion for specific exer- zie principles in the short term, but the
tient. The first generation of randomized cise is the finding of a directional prefer- differences were small in magnitude and
trials examining specific-exercise inter- ence. A directional preference is defined no longer significant at long-term follow-
ventions found no evidence of benefit in as a situation in which movement in one up.27,85 Studies included in these reviews
heterogeneous samples of patients with direction improves pain and limitation used broad inclusion criteria, which may
LBP,24,36,72,87 leading to conclusions that of ROM, and movement in the opposite explain the small treatment effects. The
specific-exercise protocols were no bet- direction causes signs and symptoms to reviews also included only studies with
ter than nonspecific approaches, or no worsen.77 A patient who exhibits central- treatments provided according to McK-
treatment at all.116 Supporting evidence ization with a movement would be con- enzie principles. Examining a broader
is sparse, but is beginning to emerge sidered to have a directional preference group of studies may provide additional
in support of the belief that some pa- for that movement; but centralization is insight into the management of specific-
tients respond best to specific-exercise not required, making directional prefer- exercise classifications.
interventions.21,85 ence a broader category of patients. Long The most common direction used
et al83 studied patients with a directional with patients in a specific-exercise classi-
Examination Considerations preference, randomizing them to receive fication is extension,50 and extension pro-
The centralization phenomenon has a specific-exercise intervention in the tocols have been studied the most. The
traditionally been considered the hall- direction that matched their directional study by Long et al83 included 230 pa-
mark examination criterion identifying preference, a specific-exercise interven- tients with LBP and/or sciatica who had a
a patient for specific-exercise classifica- tion in an unmatched direction, or a con- directional preference, and randomly as-
tion. 91 Although proposed definitions trol group. The results indicated greater signed them to receive exercises matching
vary slightly,3 centralization is defined reductions in disability over a 2-week their preference, exercises opposite the
in the classification system as occurring follow-up period when the specific-exer- identified preference, or a control group.
when a movement or position results in cise regimen was matched to the patient’s For 83% of the patients extension was the
abolishment of pain or paresthesia, or directional preference as compared to direction of preference. The matched-di-
causes migration of symptoms from an the group receiving the unmatched-ex- rection treatment protocol in this study
area more distal or lateral in the buttocks ercise direction.83 Additional research included 2 components: repeated end-
and/or lower extremity to a location is needed to examine the usefulness of range exercises (eg, prone press-ups)
more proximal or closer to the midline centralization and directional preference and patient education. Although patients
of the lumbar spine. Several authors have for identifying patients likely to respond with an extension preference were not
found that patients who exhibit central- to specific-exercise interventions. Future considered separately, the predominance
ization during active movement testing research may also identify additional ex- of an extension preference makes it likely
have a better prognosis than those with- amination criteria for specific-exercise that the matched direction treatment was
out centralization53,74,84,111,120; however, classifications. more effective for the subgroup. Petersen

296 | june 2007 | volume 37 | number 6 | journal of orthopaedic & sports physical therapy
et al109 studied 260 patients with chronic zation or manipulation of the spine and/ TRACTION CLASSIFICATION
LBP with or without sciatica, comparing or lower extremity), exercise to address
an extension-oriented protocol with a impairments of strength or flexibility, and

A
lthough there was no evidence
general-strengthening program. In this a body weight-supported treadmill-walk- to support the contention, Dellito
study the extension protocol included ing program. The other group received and colleagues35 hypothesized that
repeated end-range extension exercise flexion-oriented exercises, a treadmill- there is a subset of patients with LBP who
along with mobilization performed by a walking program (without body weight would likely benefit from traction. The
physical therapist. Although the sample support), and subtherapeutic ultrasound. examination criteria defining this sub-
was heterogeneous, short-term results Better outcomes were reported by the group was proposed to be the presence
favored the extension protocol group, group receiving manual therapy, exercise, of lower extremity symptoms and signs of
but the treatment effects were small.100 and body weight-supported walking.122 nerve root compression and the absence
Browder et al,21 in a sample of patients The multimodal intervention protocol of centralization with movement testing.
who centralized with extension, also precludes conclusions on any individual There continues to be a lack of evidence
found better results for a group receiv- procedure; however, the results suggest supporting the use of traction for patients
ing mobilization (graded mobilization to that interventions for patients in the flex- with LBP, and the intervention is gener-
promote extension) along with extension ion specific-exercise classification should ally not recommended by systematic re-
exercises and patient education. The op- include several components other than views and practice guidelines.28,78,117
timal intervention strategy for patients flexion-oriented exercise. Studies that have shown no benefit
in the extension specific-exercise classifi- The third movement direction in the from using traction have not sought to
cation may be a combination of exercise specific-exercise classification is a lateral identify the patients who are most likely
and mobilization to promote end-range shift, which is considerably less common to benefit from the intervention, but have
extension. than flexion or extension categories.50,83 instead used nonspecific inclusion crite-
Flexion specific-exercise classification For example, only 7% of the subjects ria, essentially allowing all patients fitting
appears to be less common83 and most with a directional preference studied by a broad definition of acute or chronic LBP
likely occurs in patients who are older, Long et al83 had a preference for a lateral to enter.11,121 Recent systematic reviews on
often with a medical diagnosis of lumbar shift movement. In the original classifi- the effectiveness of traction as an inter-
spinal stenosis.47 Interventions originally cation system, treatment for patients in vention for patients with LBP,54,61 while
advocated for patients in the flexion spe- the lateral shift specific-exercise clas- acknowledging the lack of any evidence
cific-exercise classification were flexion- sification included repeated end-range to support the use of traction, also note
oriented exercises (eg, knee-to-chest, lateral-shifting exercise or traction (me- that this may be related to the fact that
pelvic tilts, etc), and traction with the pa- chanical or autotraction). 35,42 Harrison studies have included “mixed groups” of
tient in a position of spinal flexion if there et al60 reported the results of a nonran- patients rather than homogenous sam-
was a diagnosis of lumbar spinal steno- domized comparison of patients with a ples presumed to be likely to benefit from
sis.35 Little research has been performed visible lateral shift who received a pro- the intervention.
examining the effectiveness of interven- gram of repeated lateral-shift exercises Similar to the recommendations of
tion strategies for these patients, and and mechanical traction, and reported Delitto et al,35 the most common exami-
most research has focused on patients greater pain reductions and correction nation criterion cited by clinicians as an
with stenosis instead of a more general of the shift, compared to a group of pa- indication for traction is the presence
flexion specific-exercise classification. tients receiving no treatment. Gillan et of signs of nerve root compression.61
Case studies of patients with stenosis al54 studied 40 patients with a visible Buerskens et al10 compared the effects
have advocated intervention strategies, lateral shift, randomizing patients to of mechanical traction (maximum force,
including mobilization or manipulation management with repeated end-range 35%-50% of body weight) to sham trac-
for the lumbar spine and/or hip, general lateral-shift exercises or nonspecific ad- tion (maximum force, 20% of body
lower extremity strengthening, neural vice and massage. The group receiving weight) for 12 sessions over 5 weeks in
mobilizations, and a walking program the lateral-shift exercises experienced patients with nonspecific LBP of at least
possibly facilitated with body weight- more rapid resolution of the lateral shift, 6 weeks in duration. Following treat-
supported treadmill ambulation.49,95,123 but no differences were found in disabil- ment, there was no difference between
A recent randomized trial122 examined ity outcomes after 3 months.54 Further groups for perceived recovery. The au-
patients over age 50 with a directional research is required to clarify the most thors performed a secondary analysis
preference for flexion and imaging evi- effective intervention strategies for pa- in an attempt to identify a subgroup of
dence of lumbar spinal stenosis. One tients in the lateral-shift specific-exer- patients responding positively to traction
group received manual therapy (mobili- cise classification. and considered the following variables:

journal of orthopaedic & sports physical therapy | volume 37 | number 6 | june 2007 | 297
[ CLINICAL COMMENTARY ]
age, sex, duration of episode, radiation of specific, reliable criteria for inclusion an area of concern105 that has now been
symptoms below the knee, general health, into each classification. Further research examined in several studies. Heiss et
severity of symptoms, maximum traction identifying examination criteria for the al64 studied the reliability of the classi-
force used, and the physical therapist’s manipulation, stabilization, and spe- fication system among 4 different raters
belief that traction would be beneficial for cific-exercise groups has been conducted who were inexperienced with using the
the patient. None of the aforementioned with distinct criteria identified for each system. Following a 1-day training ses-
subgroups were found to have experi- classification. Interrater reliability of sion, the clinicians classified 45 consecu-
enced a greater benefit with mechanical the individual factors identified for the tive patients with LBP, with each rater
traction as compared to sham traction.10 manipulation,41 stabilization,51,66 and blind to the others’ decisions. Three out
The authors did not investigate all exam- specific-exercise46 subgroups has been of 4 rater pairs achieved a kappa value of
ination criteria proposed in the original published. 0.45 (55% agreement). This kappa value
classification system, and perhaps factors The reliability of classification judg- was slightly lower than that reported by
such as signs of nerve root compression ments made using the system was also Fritz and George50 (65% agreement with
and absence of centralization will prove
to be important examination criteria for Does the patient:
identifying a traction classification. 1. Centralize with 2 or more movements in the
same directions (ie, flexion or extension) Yes Specific Exercise
We believe the available research can OR Classification
be interpreted to indicate that the major- 2. Centralize with a movement in 1 direction
and peripheralize with an opposite movement
ity of patients with LBP are not appro-
priate for a traction intervention and,
No
therefore, traction should not be widely
used for patients with LBP. It does not
Does the patient:
appear that current clinical decision 1. Have a recent onset of symptoms (16 d) Yes Manipulation
making used by physical therapists is AND Classification
2. No symptoms distal to the knee
adequate for identifying which patients
with LBP may respond to a traction in-
No
tervention.10 Future research is needed
to determine if examination criteria exist
Does the patient have at least 3 of the following:
that can identify a patient who is likely to 1. Average SLR ROM 91°
Yes Stabilization
respond to traction. Additional research 2. Positive prone instability test
Classification
3. Positive aberrant movements
is also necessary to define the parameters 4. Age 40 y
that may maximize any treatment effect
(eg, traction force and duration, patient No
position, etc).
Which subgroup does the patient best fit?
FURTHER CONSIDERATIONS Manipulation Stabilization Specific Exercise
Factors Favoring Factors Against Factors Favoring Factors Against Factors Favoring Factors Against
• More recent • Symptoms below • Younger age • Discrepancy in • Strong • LBP only (no
n 1998, Riddle105 provided a review

I and critique of classification systems


for the management of patients with
LBP, including the system proposed by
onset of
symptoms
• Hypomobility
with spring
testing
the knee
• Increasing
episode
frequency
• Peripheralization
• Positive prone

• Aberrant

• Greater SLR
SLR ROM (10°) preference for

(FABQPA score • Centralization


motions present  9) with motion
testing
distal symptoms)
instability test • Low FABQ scores sitting or walking • Status quo with
all movements

Delitto and colleagues22 using defined • LBP only (no with motion ROM • Peripheralization
distal symptoms) testing • Hypermobility in direction
methodological guidelines. At that time, • Low FABQ scores • No pain with with spring opposite
the classification system satisfied only (FABQW score spring testing testing centralization
 19) • Increasing
50% of the methodological criteria re-
episode
lated to feasibility, reliability, generaliz- frequency
ability, and content, face, and construct • 3 or more prior
episodes
validity.105 The system has evolved con-
siderably since 1998, and many deficient
areas have been addressed through ongo- FIGURE 2. Classification decision-making algorithm. Abbreviations: FABQ, Fear-Avoidance Beliefs Questionnaire;
FABQPA, FABQ Physical Activity Subscale; FABQW, FABQ Work Subscale; LBP, low back pain; ROM, range of motion;
ing research.
SLR, straight-leg raise. Adapted with permission from Fritz et al.43
One deficient area105 was the lack of

298 | june 2007 | volume 37 | number 6 | journal of orthopaedic & sports physical therapy
a kappa value of 0.56) in a study using physical therapy sessions. At the 4-week 2. Abenhaim L, Rossignol M, Gobeille D, Bonvalot
more experienced examiners. The clas- follow-up, patients treated with the clas- Y, Fines P, Scott S. The prognostic conse-
sification system has continued to evolve, sification approach exhibited significant- quences in the making of the initial medical
diagnosis of work-related back injuries. Spine.
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algorithm (FIGURE 2), with the traction and increased likelihood of returning to phenomenon of spinal symptoms--a systematic
classification removed and using thera- work than patients treated based on the review. Man Ther. 2004;9:134-143.
4. Albert H, Godskesen M, Westergaard J. Evalua-
pists with varying levels of experience guidelines. More recently Brennan and tion of clinical tests used in classification proce-
with the system.43 The overall agreement colleagues18 randomly assigned 123 pa- dures in pregnancy-related pelvic joint pain. Eur
between therapists was 76%, with a kap- tients to receive treatment according to Spine J. 2000;9:161-166.
pa value of 0.60 (95% CI: 0.56, 0.64). No the stabilization, manipulation, or specif- 5. American Physical Therapy Association. Guide
to Physical Therapist Practice. Second Edition.
differences in agreement existed based ic-exercise classification, then compared Phys Ther. 2001;81:9-746.
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the intervention strategies proposed by
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I a useful classification system for the
management of patients with LBP
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[ CLINICAL COMMENTARY ]
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The efficacy of a treatment program focusing naire (FABQ) and the role of fear-avoidance

@
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MORE INFORMATION
trial. Spine. 2004;29:351-359. 120. Werneke M, Hart DL. Centralization phenome- WWW.JOSPT.ORG

302 | june 2007 | volume 37 | number 6 | journal of orthopaedic & sports physical therapy
ERRATUM

CORRECTION The error occurs in the text on page 295 of evolution of a classification approach to
n 2005, Hicks et al2 published cri- the commentary. The criterion is correctly physical therapy. J Orthop Sports Phys Ther.

I teria related to the prediction of clinical


success or failure for patients with low
back pain, who were undergoing a program
cited in FIGURE 2 on page 298.
We apologize for this error and have
corrected the article by Fritz et al1, which
2007;37:290-302.
2. Hicks GE, Fritz JM, Delitto A, McGill SM.
Preliminary development of a clinical predic-
tion rule for determining which patients with
of trunk strengthening and stabilization is available to members and subscribers low back pain will respond to a stabilization
exercises. One of the criteria related to the for download on the JOSPT web site exercise program. Arch Phys Med Rehabil.
prediction of failure with this treatment ap- (www.jospt.org). T 2005;86:1753-1762.
proach was a low score (<9) on the Physical 3. Waddell G, Newton M, Henderson I,
Activity Subscale of the Fear-Avoidance Somerville D, Main CJ. A Fear-Avoid-
Beliefs Questionnaire (FABQPA).3 This REFERENCES ance Beliefs Questionnaire (FABQ) and
criterion was erroneously published by the the role of fear-avoidance beliefs in
JOSPT as “a score of 9 or higher” in the clin- 1. Fritz JM, Cleland JA, Childs JD. Sub- chronic low back pain and disability. Pain.
grouping patients with low back pain: 1993;52:157-168.
ical commentary from Fritz and colleagues.1

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