5 Classifications To Consistently Predict The Best LBP Treatment
Reading time: 5 minutes
Why do many patients respond quickly to spinal manipulation while others don’t?
And why do some improve with mobility, but others benefit from stability?
And why does one love traction while another can’t get back up off the table?
And why do some prefer knee-to-chest exercises while others improve with extension press-ups?
The answer, my friend, is not blowin’ in the wind. Fortunately, you can consistently predict the optimal treatment strategy by employing a simple low back treatment classification system where your history and exam help categorize patients into one of five groups:
Manipulation
Extension-biased back pain
Flexion-biased back pain
Stability
Traction
Let's examine the characteristics of each group, but please recognize that these LBP treatment classification groups are not mutually exclusive, meaning that a patient may benefit from more than one type of concurrent treatment.
Group 1: Manipulation
Fritz (1) identified five criteria to help determine which LBP patients would benefit most from spinal manipulation:
Pain lasting less than 16 days
No symptoms distal to the knee
Low fear avoidance beliefs (FABQ score of less than 19)
Hip internal rotation greater than 35 degrees
Hypomobility of at least one lumbar segment
A JMPT study (2) reported that LBP patients who met the preceding criteria and subsequently underwent manipulation experienced:
An average VAS drop from 6.2 to 1.9
An average of 5.2 treatments at a mean cost of $302
95% of respondents rated their care as excellent
In addition to SMT, your manipulation subgroup may benefit from general mobility exercises, including:
Cat Camel
Group 2: Stability
A 2020 Musculoskeletal Science and Practice review (3) found that the following test cluster was most accurate for identifying patients with spinal instability:
Apprehension sign
Instability catch sign
Painful catch sign
Prone instability test
A clinical prediction rule published in the Archives of Physical Medicine and Rehabilitation (4) reported the presence of three or more of the following variables predicts a 67% success rate with the incorporation of a spinal stabilization program.
Younger age <40
Average SLR > 91 degrees
Aberrant lumbar forward flexion (i.e., a “catch or hitch when flexing)
Positive prone instability test
Your stability subgroup may benefit most from spinal stability exercises, including:
Dead Bug
Bird Dog
Side Bridge
Deeper dive: Check out this previous blog on the Top Tests & Exercises for Spinal Instability.
The two following classification sub-groups, extension-biased and flexion-biased, typically (but not always) include a radicular complaint into the buttock or leg. Classification into one of these two options requires defining a “directional preference” based upon what happens to the radicular complaint when the patient repeatedly performs either end-range extension or end-range flexion.
Centralization: repeated end-range lumbar movements rapidly decrease the most distal referred or radicular symptoms towards the midline. 👍
Peripheralization: repeated end-range lumbar movements rapidly increase the most distal referred or radicular symptoms. 👎
Determining which direction (extension vs flexion) relieves your patient's symptoms allows you to dial in the most effective in-office treatments, exercises, and even home care recommendations. And the results are pretty impressive:
“In patients with low back pain for more than six weeks … we found the directional preference method to be slightly more effective than manipulation.” (5)
Group 3: Extension biased (radicular symptoms improve with extension)
Sitting (aka flexion) typically increases pain or distal symptoms
The most distal symptoms improve with standing or walking (aka extension)
Repeated end range extension testing improves the most distal complaints
Pro tip: Your assessment goal is to determine whether repeated flexion or repeated extension can centralize your patient's complaints. Since there is no need to determine if one will worsen the complaints, your patient will prefer you identify which repeated movement is likely to improve their symptoms, then begin testing in that direction. The question, “would you prefer to walk a mile or sit for 30 minutes?” can help identify the direction to test (and the direction to avoid.)
Your extension-biased subgroup may benefit from using a lumbar support roll when sitting plus exercises including:
Press-Ups
Standing Extension
Group 4: Flexion biased (radicular symptoms improve with flexion)
Standing or walking (aka extension) typically increases pain or distal symptoms
The most distal symptoms improve with sitting (aka flexion)
Repeated end range flexion testing improves the most distal complaints
Your flexion-biased subgroup may benefit most from exercises including:
Knee to Chest
Seated Flexion
Group 5: Traction
“Meta-analyses indicated that supine mechanical traction added to [manual] treatments had significant effects on pain and disability” (6)
Symptoms extend distal to the buttock (7)
Signs of nerve root compression
Peripheralization with extension
Positive well leg raise
The presence of three or more of the following predictors more than doubles the likelihood of disc-related LBP “greatly improving” with lumbar traction (response increases from 23.3% to 48.7%). (8)
Sudden onset of symptoms
Short duration of symptoms
No segmental hypomobility
Limited lumbar extension
Low-level fear-avoidance beliefs
Deeper dive: ChiroUp subscribers can visit their treatment techniques library to review the current recommendations for lumbar traction, including recommended frequency, intensity, duration, and positions.
ABC’s for putting it all together
Access and review our low back pain treatment classification reference card to help you predict the most appropriate category and corresponding treatments.
Beware the LBP classification groups are not mutually exclusive, meaning that a patient may benefit from more than one type of concurrent treatment.
Check out our new Masterclass on treatment-based classification for low back pain. You’ll leave this presentation with new skills to help consistently choose the most appropriate treatment for each LBP patient. Save your spot today.
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1. Fritz, J, Cleland, J, Childs, JD, “Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy,” Journal of Orthop Sports Physical Therapy 37, no. 6 (June 2007): 290-302
2. Paskowski I, Schneider M, Stevans J, Ventura JM, Justice BD. A hospital-based standardized spine care pathway: Report of a multidisciplinary, evidence-based process. JMPT 2011;34(2): 98-106
3. Areeudomwong P, Jirarattanaphochai K, Ruanjai T, Buttagat V. Clinical utility of a cluster of tests as a diagnostic support tool for clinical lumbar instability. Musculoskeletal Science and Practice. 2020 Jul 24:102224.
4. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Archives of physical medicine and rehabilitation. 2005 Sep 1;86(9):1753-62. Link
5. Petersen T, Larsen K, Nordsteen J, Olsen S, Fournier G, Jacobsen S. The McKenzie method compared with manipulation when used adjunctive to information and advice in low back pain patients presenting with centralization or peripheralization: a randomized controlled trial. Spine (Phila Pa 1976). 2011 Nov 15;36(24):1999-2010. doi: 10.1097/BRS.0b013e318201ee8e. PMID: 21358492.
6. Vanti C, Panizzolo A, Turone L, Guccione AA, Violante FS, Pillastrini P, Bertozzi L. Effectiveness of Mechanical Traction for Lumbar Radiculopathy: A Systematic Review and Meta-analysis. Physical Therapy. 2020 Dec 31.
7. Fritz JM, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffit SD, Swalberg A, Rodriquez B. Is there a subgroup of patients with low back pain likely to benefit from mechanical traction?: Results of a randomized clinical trial and subgrouping analysis. Spine. 2007 Dec 15;32(26):E793-800.
8. Hirayama K et al. Developing a clinical prediction rule to identify patients with lumbar disc herniation who demonstrate short-term improvement with mechanical lumbar traction. Phys Ther Res. 2019 Apr 20;22(1):9-16.
