On “Treatment-based classification system for low back pain: revision and update.” Alrwaily M, Timko M, Schneider M, et al. Phys Ther. 2016;96:1057–1066.

The update of the treatment-based classification (TBC) system for low back pain (LBP) published by Alrwaily et al¹ ahead of print in PTJ is an important contribution to the classification literature. The objectives of this commentary are to acknowledge the possible clinical significance of the updated 2015 TBC version and to highlight parallels between this version and the treatment-strategy-based classification system (TREST), presented in 2007² and subsequently evaluated for interexaminer agreement by experienced physical therapists not previously familiar with the approach³ and recently assessed regarding the feasibility of the included subgroup criteria.⁴

To aid decisions concerning appropriate management of LBP, the updated version of TBC has 2 levels of triage: the level of the first-contact health care provider and the level of the rehabilitation provider. Some countries, such as Sweden, implement a system that involves direct access to physical therapy. This practice is patient-centered in that it allows patients themselves to seek health care providers who they consider to be appropriate for their particular disorders, which accordingly makes physical therapists both the first health care contact and the rehabilitation provider in many cases of nonspecific low back pain (NSLBP). This places great responsibility on a physical therapist, not only to decide on appropriate physical therapist interventions (eg, whether the measures should entail self-management or be provided by the physical therapist), but also to recognize serious spinal pathology (“red flags”) and psychological comorbidities (“yellow flags”) and, in some cases, to offer patients advice about suitable care. The manner in which this is done probably varies substantially, and hence the clear guidelines regarding what to identify and evaluate, as outlined in Figures 2 and 3 in the article by Alrwaily et al,¹ are essential for patient safety and proper case management. However, considering time constraints and workloads for clinical physical therapists in primary care settings, it may be unrealistic to expect these professionals to routinely use self-report tools to reveal psychological comorbidities. Hence, in this context, it is necessary to explore other simple strategies for targeting psychosocial factors that may have implications for treatment approach. Another essential aspect is to outline an explicit clinical pathway to determine how patients can be helped to address psychosocial factors in the actual setting, and whether this can be achieved through referral for medical or psychological evaluation or through the qualifications and resources of the physical therapist.

The original TBC⁵ and further development of this system (2007 TBC)^2,6–9 are certainly clinically relevant because of the included well-known physical therapist treatment selections and clinical reasoning processes that are easy to understand. Even so, from a clinical perspective, the TBC has lacked necessary within-subgroup treatment flexibility and has not explicitly included treatment options that can target patients with either neurological deficits or high or low pain/disability/irritability scores. Accordingly, a new classification algorithm was suggested in 2007,² using the original and continued evaluations of the TBC^10–12 as the primary incentive and guiding principle. The objective of this algorithm, like the TBC, is to provide guidance in first-line physical therapist treatment selection by identifying subgroups of patients with NSLBP, and the algorithm is designed to require minimal training and no additional qualifications for physical therapists. To address within-subgroup treatment flexibility, this approach includes treatment strategies rather than specific techniques, and the 4 subgroups are suggested with respect to potential responders to the tailored treatment strategies in each subgroup. Two of the subgroups (stabilization exercise and mobilization) are adapted from the original and 2007 TBCs, whereas the other 2 subgroups (pain modulation and training) are new.

The updated 2015 TBC¹ presents new concepts and classifications that are both similar to and different from those presented in the TREST.^2–4 The similarities indicate convergent validity of the clinical reasoning process among the 2 classification systems. The subgroups' training (TREST) and functional optimization (2015 TBC) include similar clinical findings and have identical treatment options (ie, physical exercise for endurance, strength, and fitness). Similarities between the subgroups' stabilization exercise (TREST) and movement control (2015 TBC) comprise similar clinical findings and a similar suggested treatment option entailing exercises that target impairments of movement coordination. Differences refer to the addition of flexibility exercises and sensorimotor exercises as treatment options in movement control (2015 TBC). In the TREST, flexibility exercises are suggested to match clinical criteria suggested for the mobilization subgroup (ie, patients with signs and symptoms of decreased spinal mobility). The sensorimotor exercises (2015 TBC), considering their purpose and application, have not been clarified to any extent. The clinical findings in the subgroups' pain modulation (TREST) and symptom modulation (2015 TBC) are partly similar (ie, high disability, moderate-to-high pain intensity and neurological deficits/sensitivity), but the proposed treatment options differ. The main disparity is that manipulation/mobilization treatment selection is included in symptom modulation in 2015 TBC, whereas this is a treatment option reserved for the subgroup mobilization in the TREST. The primary reason for this discordance is the clinical reasoning that the mechanical stimuli induced by mobilization techniques may affect sensitized musculoskeletal structures¹³ and thereby increase not only the risk of short-term symptom exacerbation but also the risk of driving further sensitization.¹⁴ Therefore, specific mobilizing treatment has been proposed to match patients with clinical findings suggested in the subgroup mobilization (TREST) (ie, mobility deficits, a normal afferent neural input, and normal pain processing).

Another interesting similarity between the clinical reasoning processes in the TREST and the 2015 TBC is the component of possible reclassification when clinical status changes, which I believe is an important component in any classification system. The TREST even suggests a progressive treatment flow from the subgroups pain modulation, mobilization, and stabilization to the subgroup training in accordance with improved clinical status, with the purpose of increasing fitness and developing a necessary tolerance to spinal loading.

However, it is not yet known whether the clinical reasoning in the TREST can target different subgroups of NSLBP or whether the suggested tailored treatment approaches have a beneficial impact on treatment outcome. Accordingly, further work is needed to evaluate the validity of the TREST. The parallels between the TREST and the 2015 TBC can potentially enhance this evaluation and, by extension, the usefulness of the 2 systems in the management of NSLBP.

Low back pain clinical guidelines based on study-level averages give advice on approaches that apply to populations of patients^15,16 but do not provide guidance regarding individualized quality-driven physical therapist management. The clinical practice guidelines of the American Physical Therapy Association (APTA),¹⁷ therefore, have provided physical therapists and patients with LBP with the first truly clinically relevant recommendations concerning how to provide evidence-based individualized treatment.

It has been suggested that that the ideal classification system should have a limited number of subgroups to ensure the confidence of users with little training.⁶ I agree with this conclusion if the aim is to find a more unanimous clinical reasoning process and thereby facilitate generalizability. Any classification system can only be expected to guide parts of the complex clinical reasoning performed by physical therapists during the patient encounter and can never completely replace clinical judgments based on the full clinical picture of patients' individual circumstances, abilities, needs, and treatment preferences. If uptake of research results in clinical practice is to increase, further work is needed to elucidate how physical therapists in primary care make pretreatment decisions and to explore how treatment options for patients with NSLBP are routinely selected. Some studies^8,10 have shown that, compared with alternative methods, matched treatment can lead to better patient outcomes. However, more recent investigations comparing classified and unclassified¹⁸ or matched and unmatched¹⁹ treatment have not obtained the same results. As a strong advocate of classifying patients into more homogeneous subgroups and targeting treatment to provide “the right treatment, to the right patient, at the right time,” I welcome the updated 2015 TBC and am looking forward to future evaluation of this classification system.

• © 2016 American Physical Therapy Association