This article has been downloaded from www.educata.

com
and may not be distributed through print or other electronic means.

The Journal of Manual & Manipulative Therapy

jmmtonline.com
Prevalence of classification methods for patients with lumbar impairments using the McKenzie syndromes, pain pattern, manipulation, and stabilization clinical prediction rules. Mark W. Werneke, Dennis Hart, Dave Oliver, Troy McGill, David Grigsby, Jason Ward, Jon Weinberg, William Oswald, Guillermo Cutrone. J Man Manip Ther. 2010;18(4):197-204. The online version of this article can be found at: docserver.ingentaconnect.com/deliver/connect/maney/10669817/v18n4/s5.pdf?expires=1310757997&id= 63587213&titleid=75005573&accname=Guest+User&checksum=C71ACDF23338525E4B14388229BE2382

The Journal of Manual & Manipulative Therapy is the official journal of:
The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) The Australian Association of Orthopaedic Manipulative Therapists (AAOMT) The Canadian Academy of Manipulative Therapy (CAMT)

Additional services and information for The Journal of Manual & Manipulative Therapy can be found at: Subscriptions: jmmtonline.com/subscribe.php Other questions: jmmtonline.com/contact.php

Downloaded from jmmtonline.com on July 15, 2011. 2010 The Journal of Manual and Manipulative Therapy. All rights reserved. Not for commercial use or unauthorized distribution.

Prevalence of classification methods for patients with lumbar impairments using the McKenzie syndromes, pain pattern, manipulation, and stabilization clinical prediction rules
Mark W. Werneke1, Dennis Hart2, Dave Oliver3, Troy McGill4, David Grigsby, Jason Ward4, Jon Weinberg5, William Oswald6, Guillermo Cutrone7
1

Published by Maney Publishing (c) W. S. Maney & Son Limited

CentraState Medical Center, Freehold, NJ, USA, 2Focus On Therapeutic Outcomes, Inc., White Stone, VA, USA, Elmendorf, AK, USA, 4MidSouth Orthopaedic Rehabilitation, Germantown, TN, USA, 5Team Care Physical Therapy, Oxford, NC, USA, 6NYU Hospital for Joint Diseases, USA, 7St Vincents Medical Center Northeast, Fisher, IN, USA

Objectives: Aims were (1) to determine the proportion of patients with lumbar impairments who could be classified at intake by McKenzie syndromes (McK) and pain pattern classification (PPCs) using Mechanical Diagnosis and Therapy (MDT) assessment methods, manipulation, and stabilization clinical prediction rules (CPRs) and (2) for each Man CPR or Stab CPR category, determine classification prevalence rates using McK and PPC. Methods: Eight physical therapists practicing in eight diverse clinical settings classified patients typically referred to rehabilitation by McKenzie syndromes (i.e. derangement, dysfunction, posture, or other), pain pattern classification [i.e. centralization (CEN), not centralization (Non CEN), and not classified (NC)], Manipulation CPR (positive, negative), and stabilization CPR (positive, negative). Prevalence rates with 95% confidence intervals (CI) were calculated for each classification category by McK, PPC, and manipulation and stabilization CPRs. Prevalence rates (95% CIs) for McK and PPC were calculated for each CPR category separately. Results: Data from 628 adults [mean age: 5217 years, 56% female] were analyzed. Prevalence rates were: McK derangement 67%, dysfunction 5%, posture 0%, other 28%; PPC CEN 43%, Non CEN 39%, NC 18%; manipulation CPR positive 13%; Stab CPR positive 7%. For patients positive for manipulation CPR (n579), prevalence rates for derangement were 89% and CEN 68%. For patients positive for stabilization CPR (n541), prevalence rates for derangement were 83% and CEN 80%. Discussion: The majority of patients classified based on initial clinical presentation by manipulation and stabilization CPRs were also classified as derangements whose symptoms centralized. Manipulation and stabilization CPRs may not represent a mutually exclusive treatment subgroup but may include patients who can be initially treated using a different classification method.
Keywords: Clinical prediction rules, Lumbar spine, McKenzie syndromes, Pain pattern classification

Introduction
Low back pain is the second most common reason for patients seeking primary care services and is responsible for substantial economic burden exceeding 10 billion (US dollars) annually.1,2 Because of the high prevalence and economic impact associated with low back pain, classifying patients with nonspecic low back pain into homogeneous treatment

Correspondence to: Mark Werneke, CentraState Medical Center, Freehold, NJ, USA. Email: mwerneke@centrastate.com

subgroups to help direct treatment decisions and improve prognosis, quality of care, and patient outcomes has been recognized as an important research and clinical priority.3,4 Two common classication approaches utilized by physical therapists and researchers are the McKenzie, or Mechanical Diagnosis and Therapy (MDT)5 and the Delitto or Treatment-Based Classication (TBC)6 systems. The MDT method is a standardized assessment including the patients subjective and medical history and a physical examination. One primary

W. S. Maney & Son Ltd 2010 DOI 10.1179/106698110X12804993426965

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .

197

Werneke et al.

Prevalence of classification methods for patients with lumbar impairments

purpose for examining patients following McKenzie assessment is to classify patients into one of three mechanical syndromes, i.e. derangement, dysfunction, or posture based on a series of repeated end-range lumbar movement tests or positioning techniques.5 Repeated movement testing is guided by the patients symptomatic and mechanical responses observed during the examination process. Classication directs an individualized treatment program. The MDT classication system was developed to be inclusive of the majority of patients with mechanical low back pain syndromes who are referred to physical therapy regardless of age and neurological or symptom acuity status. Previous research indicates that a high proportion of patients can be classied into one of the three MDT syndromes.79 A smaller percentage of patients (2.8 32.9%) who do not t into the three mechanical syndromes are classied as Other.8 An important clinical symptom observed during the MDT examination process is centralization. Centralization is characterized by spinal pain and referred spinal symptoms that are progressively abolished in a distal-to-proximal direction in response to therapeutic movement and positioning strategies.5,10 Although the validity for classifying patients into one of the three MDT mechanical subgroups has not been determined, numerous research studies support CEN as an important prognostic factor and classication category for identifying patients who respond favorably from specic CEN-based interventions.1020 Classication by patient response criteria including CEN and directional preference for directing treatment have been frequently recommended by clinicians and researchers.11,1315,2129 Similar to the three McKenzie syndromes, a substantial proportion of patients (estimates range between 31 and 87%) seen in physical therapy clinics for treatment of low back pain can be classied into a CEN category at intake.10 The TBC system is another common approach used by physical therapists for classifying patients based on a standardized physical evaluation process.6 Patients are classied into three stages based on condition severity, i.e., stage 1 or the acute stage where therapy goal is symptomatic relief; stage 2 or the subacute stage where return to normal function is a priority; and stage 3 or the advanced rehabilitation stage for patients requiring high physical demands and conditioning to perform their usual work or activities of daily living.6 Stage 1 of the TBC system, which identies four basic treatment subgroups, i.e. manipulation, exercise, stabilization, and traction, using specic clinical signs and symptoms, has been extensively researched and supported in the

literature.14,30,31 The original TBC classication criteria have been recently updated and evidence supports the application of clinical prediction rules (CPRs) to classify patients into the TBC manipulation and stabilization subgroups.14,3235 CPRs are sophisticated probabilistic and prognostic models where a group of identied patient characteristics and clinical signs and symptoms are statistically associated with meaningful prediction of patient outcomes. Two separate CPRs were developed by researchers for identifying patients who would respond favorably to manipulation.33,34 Flynn et al. developed the original manipulation CPR using ve criteria, i.e. no symptoms below the knee, recent onset of symptoms (,16 days), low fear avoidance belief questionnaire36 score for work (,19), hypomobility of the lumbar spine, and hip internal rotation ROM (.35u for at least one hip).33 Flynns CPR was subsequently modied by Fritz et al. to two criteria, that included no symptoms below the knee and recent onset of symptoms (,16 days), as a pragmatic alternative to reduce clinician burden for identifying patients in primary care most likely to positively respond to thrust manipulation.34 The percentage of patients classied according to the pragmatic manipulation CPR varied between 29 and 48% in the samples studied.21,34,37 The stabilization CPR was developed using four classication criteria, which included younger age ,40 years, positive prone instability test, positive aberrant trunk movements, and average straight leg ROM.91u, and initially derived by Hicks et al.35 The authors reported that the stabilization CPR could be used to determine whether patients with low back pain are likely to favorably benet from stabilization exercises.35 The percentage of patients classied into the stabilization category was reported by Brennan et al. as 24%.21 Preliminary efcacy evidence exists for both MDT and TBC classication systems30,38 as well as classifying patients based on CPR and CEN for treating patients with low back pain.11,16,21,32,35 However, there are no published studies examining outcomes between patients classied according to McKenzie syndromes, PPC, and CPR categories, which may partially explain why there is a lack of agreement between clinicians and researchers on which classication treatment method works best for which patients. Of interest, there are two case studies comparing MDT versus manipulation CPR classication for a patient with low back pain.39,40 Both case studies identied patients who met four out of ve criteria on the CPR for spinal manipulation as proposed by Flynn et al,33 and were successfully treated by specic lumbar exion40 or extension exercises,39 matched to a directional preference or

Published by Maney Publishing (c) W. S. Maney & Son Limited

198

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .

Werneke et al.

Prevalence of classification methods for patients with lumbar impairments

Published by Maney Publishing (c) W. S. Maney & Son Limited

CEN following a standard MDT assessment. Both case studies suggest that the CPR may not identify a unique or mutually exclusive treatment category for thrust manipulation. It appears plausible that some patients classied into one treatment category may also meet criteria for another treatment subgroup and benet from either treatment or a combination of both treatments. At this time, it is unclear what proportions of patients belong to more than one Treatment-Based Classication subgroup. Because of the lack of data comparing patient classication methods, the overall aim was to begin comparisons of common methods currently used to classify patients during the initial examination with non-specic low back pain typically referred to outpatient physical therapy settings. Specic aims were to: (1) determine the proportion of patients who could be classied by McKenzie syndromes and pain pattern classication using MDT assessment methods and clinical prediction rules for manipulation and stabilization; and (2) within each manipulation and stabilization CPR category, determine classication prevalence rates for McKenzie syndromes and pain pattern categories (PPCs). Study results may allow physical therapists to better assess the generalizability of common classication methods currently used for managing a wide range of patients seeking treatment in diverse physical therapy outpatient settings for low back pain complaints.

two military orthopedic outpatient clinic settings. Two therapists worked in the same practice, and one therapist worked in the military and moved from one to another military clinic during data collection. Four clinicians earned masters degree in physical therapy, one PT earned a doctorate degree in science, and one PT earned a doctorate of physical therapy. The average number of years of clinical experience was 15 years (range: 840 years). Not all therapists collected data during the entire study period (July 2007December 2009); three therapists started data collection in the summer of 2009 and four therapists were either transferred between clinics or had other non-patient educational responsibilities which interrupted their data collection. Therapists were experienced with classifying patients into McKenzie syndromes and pain pattern and CPR classication categories. Subjects Of the 725 consecutive patients with lumbar syndromes who were treated, 33 did not start data collection, producing a sample of 692 patients and a participation rate of 95%.43 Reasons for not starting data collection included computer system was down (n59), cognitive decits (n55), language barriers (n58), visual decits (n52), one visit, patient referred for home program only (n53), and no reason given (n56). Of the 692 patients, 64 patients did not have classication data (Table 1).

Methods Design
We conducted a prospective, longitudinal, observational, cohort study. We analyzed data collected from patients with non-specic lumbar syndromes who were classied and treated by eight physical therapists (PTs) working at eight different clinical facilities. All clinicians that participated also used the Focus On Therapeutic Outcomes, Inc. (FOTO) (Knoxville, TN, USA) international medical rehabilitation data management company outcomes system.41,42 The FOTO Institutional Review Board for the Protection of Human Subjects approved the project. The study did not include any change in clinical practice and retrospective data were analyzed; thus patient informed consent was not required for the analyses of data collected during normal clinical practice.

Patient classification methods at intake

McKenzie syndromes Therapists classied patients at intake into one of three McKenzie syndromes (i.e. derangement, dysfunction, or posture) based on symptomatic or mechanical responses observed during repeated endrange lumbar movement testing as demonstrated by McKenzie and May.5 If the patients examination was mechanically inconclusive or did not t the criteria for any of the three syndromes, the patient was classied into Other category. Stenosis, surgery, and chronic pain syndrome are examples of patients classied into Other category. Inter-tester reliability for identifying the three main McKenzie syndromes by qualied examiners attaining credentialed level of MDT training is substantial (K50.60.7).44,45 Pain pattern subgroups Patients were classied into three PPCs at intake: centralization (CEN), non-centralization (Non CEN) and not able to be classied (NC), which have been recommended10,13 and operationally described.20,29 Briey, for PPC, patients were classied into CEN, Non CEN, or NC categories at intake by measuring changes in pain location observed during a standard MDT physical examination without consideration of symptom intensity. A body diagram and overlay

Procedures
Clinicians Eight physical therapists (mean age: 42 years, range: 3159 years; 100% males) participated. All therapists received postgraduate MDT training and achieved either diploma or credentialed educational levels. Practice settings were diverse: three PTs worked in hospital-based orthopedic outpatient clinics, four PTs were in private practice, and one PT worked in

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .

199

Werneke et al.

Prevalence of classification methods for patients with lumbar impairments

template were used to quantify changes in pain location.20,29 The patient was instructed by the examiner to shade in all areas on the body diagram where she or he currently was experiencing spinal pains and referred symptoms. Body diagrams were completed in standing before and after end-range repeated trunk movements and or positioning techniques. The overlay template was placed over the body diagram, which allowed quantication of the anatomical location of pain. Inter-rater reliability for documenting CEN and Non CEN identied during the physical examination using body diagrams/ measurement template classication procedure has been reported to be almost perfect (K50.961.0).29 Manipulation subgroup Patients were classied at intake into a manipulation category using two criteria: duration of symptoms ,16 days and no symptoms below the knee.34 The two criteria manipulation CPR was recommended by Fritz et al. as an alternative or pragmatic application of the original Manipulation CPR developed by Flynn et al.33,34 The original CPR was determined by four or ve out of ve positive ndings as
Table 1 Patient characteristics (n5692) Characteristic Age (years) Gender (%)* Male Female Missing Symptom acuity (%) Acute Subacute Chronic Missing Surgical history (%) None One or more Missing Fear of physical activities (%) Not elevated Elevated Missing Number comorbid conditions (%) None One Two or three Four or more Missing Payer (%)* Litigation Medicaid Medicare Part B Patient private pay HMO PPO Workers compensation Other Missing Intake functional status Intake pain

recommended by Flynn et al. (i.e. duration ,16 days, no symptoms below the knee, Fear Avoidance Belief Questionnaire Work subscale36 ,19/42 points, at least one hypomobile lumbar segment, and at least one hip.35u).33 For this study, we applied only the pragmatic manipulation CPR and modied the duration to ,21 days because of our studys standardized procedure for documenting acuity levels.20 The original validation of the Man CPR included patients in the manipulation group with a median duration of symptoms at 22 days.32 The pragmatic manipulation CPR maintains sufcient accuracy compared to the ve criteria CPR for identifying patients who respond favorably to manipulation and has been recommended by others for reliably classifying patients with low back pain.21,34,37,46 Stabilization subgroup Patients were classied at intake into the stabilization subgroup by three or four out of four criteria developed by Hicks et al.: (1) age ,40 years old; (2) average left and right SLR .91u; (3) positive aberrant trunk movement; and (4) positive prone instability test.35 Although inter-rater reliability for each

Published by Maney Publishing (c) W. S. Maney & Son Limited

No classification data (n564) 50 (18), 18, 86 30 70 0 20 25 55 0 80 20 0 55 19 26 13 23 28 36 0 0 5 23 0 19 38 8 3 6 51 (15), 5, 94 6 (2), 2, 10

Complete classification data (n5628) 52 (17), 18, 91 44 56 0 20 25 54 0 83 17 0 71 27 2 12 18 32 38 0 1 1 22 4 25 19 2 16 6 52 (13), 5, 96 6 (2), 0, 10

Note: Continuous data: mean (standard deviation), minimum, maximum. *x2 significant (P,0.05).

200

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .

Werneke et al.

Prevalence of classification methods for patients with lumbar impairments

stabilization CPR criterion was reported to range between poor and substantial (K50.160.87),35,47 inter-rater reliability for classifying patients using a proposed classication algorithm including stabilization CPR category was moderate (K50.60).46

Data analyses
We calculated differences between patients who had missing classication data and those with complete classication data (Table 1) by using chi-square tests of independence (dichotomous and categorical data) or two-sample t-tests (continuous data) using available independent variables. We calculated prevalence rates two ways: rst, prevalence rates were calculated for each classication category (i.e. derangement, dysfunction, posture, other, CEN, Non-CEN, NC, manipulation CPR, and stabilization CPR); second, prevalence rates for McKenzie syndromes and PPCs were calculated for each CPR category separately. Ninety-ve percent condence intervals (CI) were calculated for each prevalence rate.

Results Missing classification data at intake

Characteristics of the 628 patients with complete classication data are displayed in Table 1. Compared to patients with complete classication data (n5628), patients with no classication data (n564) tended to have more females (x255.1, df51, P50.02), tended to receive benets from Preferred Provider Organizations or workers compensation, and tended to receive fewer benets from other methods of payment (x2530.1, df59, P,0.01). The groups were not different by level of symptom acuity (P50.99), number of functional comorbid conditions (P50.79), level of fear (P50.81), number of surgeries (P50.51), age (P51.00), intake functional status (P51.00), and intake pain (P51.00).

Prevalence
Prevalence rates (95% CI) were: McKenzie syndromes derangement 0.67 (0.63, 0.70), dysfunction 0.05 (0.03, 0.06), posture 0.002 (20.002, 0.005), other 0.28 (0.25, 0.32); PPCs CEN 0.43 (0.39, 0.47), Non CEN 0.39 (0.35, 0.43), Not classied 0.18 (0.15, 0.21); manipulation CPR positive 0.13 (0.10, 0.15); stabilization CPR positive 0.07 (0.05, 0.08). For patients positive for manipulation CPR (n579), the prevalence rates for derangement and CEN were 0.89 (0.82, 0.96) and 0.68 (0.58, 0.79), respectively. For patients positive for stabilization CPR (n541), the prevalence rates for derangement and CEN were 0.83 (0.71, 0.94) and 0.80 (0.68, 0.93).

Discussion
The primary ndings of the study suggest that (1) a greater proportion of patients with non-specic low

back pain syndromes seeking outpatient physical therapy services can be classied based on initial clinical presentation by McKenzie syndromes and by PPCs compared to classifying patients according to TBC manipulation and stabilization categories using clinical prediction rules; and (2) the majority of patients classied by manipulation and stabilization clinical prediction rules were also classied as McKenzie derangements whose symptoms centralized. Classication of these patients is an important research priority,4 and validation of classication systems is a multi-step process including testing for reliability and validity.48 Data support the reliability for classifying patients according to McKenzie syndromes,7,44,45 pain patterns,29,44 and clinical prediction rule criteria.33,46,47 Preliminary efcacy data provide evidence for classifying and treating patients with non-specic low back pain according to the MDT approach,16,38,49,50 CPR,21,32,35 and centralization criteria.11 In addition to reliability and validity, the generalizability of a classication system to guide treatment decision making must also be supported.48 For a classication system to be clinically useful, the system must enhance patient outcomes as well as account for or include a substantial proportion of potential patients referred to rehabilitation.9,51 For example, two recent independent studies found that McKenzie syndromes were frequently diagnosed by physical therapists for diverse and large patient populations referred to multiple clinical settings with non-specic spinal pain complaints.8,9 Hefford reported that of 321 patients, assessed by 34 physical therapists trained in MDT methods, 92% were classied into one of the three McKenzie syndromes.8 Similarly, May found that of 601 patients with spine pain, assessed by 57 therapists trained in MDT in 18 countries, 83% were classied into the three McKenzie syndromes and 17% were considered non-mechanical and classied as Other category.9 Seventy-two percent of the patients in our study were classied into McKenzie syndromes, which is consistent with previous published data. In addition, a large proportion of our patients (43%) were classied into a centralization pain pattern, which is also similar to previous data examining centralization prevalence rates using a standard measurement procedure to document centralization.52 The proportions of patients classied by manipulation and stabilization CPRs in our patient sample were low at 13 and 7%, respectively. The low overall CPR subgroup prevalence rates in our study may be partially explained by differences in our samples patient case-mix and practice settings compared to the CPR derivation studies.33,35 For instance, our sample was older (mean age: 52 years old versus

Published by Maney Publishing (c) W. S. Maney & Son Limited

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .

201

Werneke et al.

Prevalence of classification methods for patients with lumbar impairments

mean age: 37 years old reported by Flynn et al.33 and mean 42 years old in the study by Hicks et al.35) and more chronic, i.e. 54% .3 months (versus primarily acute and subacute patient populations.3335 In addition, our patient sample was recruited from diverse outpatient practice settings compared to military facilities in manipulation CPR studies.32,33 Another reason that may explain the low CPR prevalence rates found in our study was that we calculated the proportion of patients categorized into manipulation and stabilization subgroups based on the total number of patients referred for physical therapy assessment and treatment compared to previously published CPR percentage rates, which were calculated based on eligible and consenting patients.21,32 For example, Brennan et al. reported that a total of 1052 potential patients were referred for treatment to all participating clinics, of which 268 were eligible and of those, 123 subjects provided consent.21 The authors reported that 48 and 24% of eligible and consenting patients were classied into the manipulation and stabilization categories respectively. When these manipulation and stabilization classication percentages reported by Brennan et al.21 were recalculated based on all potential patients referred for physical therapy services, the actual proportions of patients grouped into the Man and Stab categories were 6 and 3%, respectively, which is more consistent with our prevalence data. The patient characteristics in our study appear similar to FOTOs national normative database for lumbar patients53 for age, acuity, number of medical comorbidities, payer type, fear avoidance beliefs of physical activity, and gender (data not shown but available on request) and therefore, our sample appears representative of typical patients seeking physical therapy services in large metropolitan areas. Our results indicate that although CPRs for thrust manipulation and stabilization exercises may be appropriate and effective for young and acute patients with lumbar syndromes identied in randomized trials, these CPRs appear of limited utility for a majority (approximately 90%) of patients with nonspecic low back pain syndromes referred to diverse outpatient therapy clinics. In comparison, diagnosing patients according to McKenzie syndromes and pain patterns appear more generalizable, as assessed using prevalence, in the sample tested. The majority of patients in our study classied by manipulation and stabilization CPR categories were also classied as McKenzie derangements whose symptoms centralized. This contrasts with claims by others that TBC manipulation and stabilization groups will not include patients experiencing centralization of symptoms.14,15,21 For example, Fritz et al. developed a classication treatment algorithm

including specic exercise, manipulation, and stabilization to guide initial treatment delivery based on intake clinical signs and symptoms within each subgroup.14 The algorithm uses a hierarchical decision making process where specic exercise based on centralization is considered rst followed by manipulation criteria and nally stabilization.14,21 If centralization was not observed, then by denition following the algorithms classication decision tree, it would not be possible to detect centralization in the other categories. The reason why centralization was observed in the majority of patients classied by manipulation and stabilization CPR in our study may be partially explained by differences in the physical examination approach to judge centralization. The therapists in our study applied MDT methods and identied centralization by repeated end-range lumbar movements using a variety of positional strategies based on the patients symptomatic and mechanical responses.5 The exact number of repeated movement tests and testing positions were not predetermined, as is the case with other centralization classication methods. For instance in the TBC system, centralization may be judged using a minimum of one or two to a maximum of 10 lumbar movements in predened positions (i.e. lumbar active range of motion and repeated extension in standing, sustained prone extension, and repeated exion with the patient seated),21 which may not accurately assess CEN.54 In addition, for the subject to be classied into CEN in our study, centralizing symptoms had to remain better at the end of the initial evaluation.20,29 Similar to the classication algorithm proposed by Fritz et al. and Brennan et al., setting the priority of centralization also has been recommended by other clinicians and researchers including McKenzie and May,5 Petersen et al.,55 and Laslett.56 Centralization is a key or cornerstone concept to many published and current classication algorithms; therefore, research examining and standardizing testing procedures to judge CEN may be benecial to improve the decision making treatment process and clinical utility of current classication systems. For instance, the clinical interpretation of manipulation and stabilization CPR subgroups in our study may be more relevant for patients whose symptoms do not centralize during the initial examination. Finally, the manipulation and stabilization CPR categories as proposed by Fritz et al., Flynn et al., Hicks et al., and others14,21,3235 may not represent discrete treatment subgroups but may include patients who can be initially treated in alternative ways. It is clear from our data that a substantial proportion of patients belong to more than one of these treatment categories, i.e. 80% of patients who met the criteria for stabilization exercises also met the

Published by Maney Publishing (c) W. S. Maney & Son Limited

202

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .

Werneke et al.

Prevalence of classification methods for patients with lumbar impairments

Published by Maney Publishing (c) W. S. Maney & Son Limited

criteria for prescribing specic exercises based on centralization. It is possible that these patients may benet from just specic exercise or stabilization or from a combination of both treatments. Although our study design cannot answer these questions or recommend one treatment as superior to another, our ndings indicate that current classication categories do not appear to be mutually exclusive when classication methods are applied to diverse patient populations with lumbar impairments seeking treatment in a variety of outpatient settings. Clinicians may be best served by future research that emphasizes collaboration between system developers and clinicians for examining the strengths, weaknesses, limitations, and advantages of current classication algorithms with the ultimate goal of identifying the right treatment for the right patient.

manipulation and stabilization clinical prediction rule criteria. The classication methods using CPR identify a narrow range of subjects resulting in a large proportion of patients remaining unclassied, thereby limiting the generalizability of that classication approach. In addition, the majority of patients classied by manipulation and stabilization CPR criteria were also classied as McKenzie derangements whose symptoms centralized. Manipulation and stabilization CPR may not represent unique treatment categories but include patients who can be initially treated in other ways. Future research efforts should be directed towards nding commonality between classication methods versus head-to-head competitions to judge classication superiority in order to identify best treatment practices designed to enhance patient outcomes and quality of life.

Limitations
The value of a classication system should be determined by its ability to direct treatment and enhance patient outcomes. The aim of our study was simply to assess the proportion of patients with lumbar impairment who could be classied using common classication methods currently used by clinicians during the initial examination process. Comparative effectiveness between classication systems requires future research. In addition, our high prevalence rates reported for McKenzie syndromes and centralization may not be found among clinicians not specically trained in MDT or clinicians who do not objectively judge patient response classication criteria using precise and standardized operational denitions and physical examination testing methods applied in this study. Finally, the prevalence rates for the manipulation subgroup may have been different if we applied Flynns ve-rule criteria33 versus the pragmatic two-rule CPR recommended by Fritz et al.34 However, the two-factor CPR has accurately predicted the status of the original ve-facctor manipulation CPR developed by Flynn et al.37 In addition, data suggest that the prevalence rate for manipulation CPR decreases as the number of criteria used to judge manipulation CPR increases from 2 to 5.33 Therefore, we believe that the manipulation prevalence rate reported in our study is accurate for the sample investigated. Further research would be benecial.

References
1 Druss BG, Marcus SC, Olfson M, Pincus HA. The most expensive medical conditions in America. Health Aff (Millwood) 2002;21:10511. 2 Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Phys Ther 1994;74:10110; invited commentary 1105. 3 Beaton DE, Bombardier C, Katz JN, Wright JG. A taxonomy for responsiveness. J Clin Epidemiol 2001;54:120417. 4 Borkan JM, Koes B, Reis S, Cherkin DC. A report from the Second International Forum for Primary Care Research on Low Back Pain. Reexamining priorities. Spine 1998;23:19926. 5 McKenzie R, May S. The Lumbar spine: mechanical diagnosis and therapy. 2nd ed. Waikanae: Spinal Publication Ltd; 2003. 6 Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther 1995;75:47085; invited commentary 4858. 7 Clare HA, Adams R, Maher CG. Reliability of McKenzie classification of patients with cervical or lumbar pain. J Manipulative Physiol Ther 2005;28:1227. 8 Hefford C. McKenzie classification of mechanical spinal pain: profile of syndromes and directions of preference. Man Ther 2008;13:7581. 9 May S. Classification by McKenzie mechanical syndromes: a survey of McKenzie-trained faculty. J Manipulative Physiol Ther 2006;29:63742. 10 Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms: a systematic review. Man Ther 2004;9:134 43. 11 Browder DA, Childs JD, Cleland JA, Fritz JM. Effectiveness of an extension-oriented treatment approach in a subgroup of subjects with low back pain: a randomized clinical trial. Phys Ther 2007;87:160818. 12 Bybee RF, Olsen DL, Cantu-Boncser G, Allen HC, Byars A. Centralization of symptoms and lumbar range of motion in patients with low back pain. Physiother Theory Pract 2009;25:25767. 13 Chorti AG, Chortis AG, Strimpakos N, McCarthy CJ, Lamb SE. The prognostic value of symptom responses in the conservative management of spinal pain: a systematic review. Spine 2009;34:268699. 14 Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classification approach to physical therapy. J Orthop Sports Phys Ther 2007;37:290302. 15 George SZ, Bialosky JE, Donald DA. The centralization phenomenon and fear-avoidance beliefs as prognostic factors for acute low back pain: a preliminary investigation involving patients classified for specific exercise. J Orthop Sports Phys Ther 2005;35:5808. 16 Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine 2004;29:2593602.

Conclusions
Our data suggest that the generalizability of different classication approaches for a wide variety of patients with non-specic low back pain syndromes referred to outpatient physical therapy services favors McKenzie syndrome and pain pattern classication based on MDT methods, as assessed using prevalence, compared to categorizing patients based on

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .

203

Werneke et al.

Prevalence of classification methods for patients with lumbar impairments

17 May S, Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method. Spine J 2008;8:13441. 18 Werneke M, Hart DL. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 2001;26:75864. 19 Werneke MW, Hart DL. Categorizing patients with occupational low back pain by use of the Quebec Task Force Classification system versus pain pattern classification procedures: discriminant and predictive validity. Phys Ther 2004;84:24354. 20 Werneke MW, Hart DL, Resnik L, Stratford PW, Reyes A. Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther 2008;38:11625. 21 Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/ subacute nonspecific low back pain: results of a randomized clinical trial. Spine 2006;31:62331. 22 Cook D, Hegedus EJ, Ramey K. Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature. J Man Manip Ther 2005;13:15262. 23 Donelson R, Aprill C, Medcalf R, Grant W. A prospective study of centralization of lumbar and referred pain. A predictor of symptomatic discs and annular competence. Spine 1997;22:111522. 24 Donelson R, Silva G, Murphy K. Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine 1990;15:2113. 25 Fritz JM, Delitto A, Vignovic M, Busse RG. Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil 2000;81:5761. 26 Laslett M, Oberg B, Aprill CN, McDonald B. Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power. Spine J 2005;5:37080. 27 Long A, May S, Fung T. Specific directional exercises for patients with low back pain: a case series. Physiother Can 2008;60:30717. 28 Long A, May S, Fung T. The comparative prognostic value of directional preference and centralization: a useful tool for frontline clinicians? J Man Manip Ther 2008;16:24854. 29 Werneke M, Hart DL, Cook D. A descriptive study of the centralization phenomenon. A prospective analysis. Spine 1999;24:67683. 30 Fritz JM, Delitto A, Erhard RE. Comparison of classificationbased physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine 2003;28:136371. 31 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine 2000;25:10614. 32 Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141:9208. 33 Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27:283543. 34 Fritz JM, Childs JD, Flynn TW. Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention. BMC Fam Pract 2005;6:29. 35 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. Arch Phys Med Rehabil 2005;86:175362. 36 Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role

37

38

39

40

41

42

43

44

45

46

47

48 49

50

51 52

53

54

55

56

of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:15768. Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation translate into better outcomes in routine clinical care for patients with occupational low back pain? A case control study. Spine J 2006;6:28995. Clare HA, Adams R, Maher CG. A systematic review of efficacy of McKenzie therapy for spinal pain. Aust J Physiother 2004;50:20916. Chen J, Phillips A, Ramsey M, Schenk R. A case study examining the effectiveness of mechanical diagnosis and therapy in a patient who meets the clinical prediction rule for spinal manipulation. J Man Manip Ther 2009;17:21621. May S, Rosedale R. A case of a potential manipulation responder whose back pain resolved with flexion exercises. J Manipulative Physiol Ther 2007;30:53942. Swinkels IC, van den Ende CH, de Bakker D, van der Wees PJ, Hart DL, Deutscher D, et al. Clinical databases in physical therapy. Physiother Theory Pract 2007;23:15367. Swinkels IC, Hart DL, Deutscher D, van den Bosch WJ, Dekker J, de Bakker DH, et al. Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands. Cross sectional analyses of data from three clinical databases. BMC Health Serv Res 2008;8:163. Deutscher D, Hart DL, Dickstein R, Horn SD, Gutvirtz M. Implementing an integrated electronic outcomes and electronic health record process to create a foundation for clinical practice improvement. Phys Ther 2008;88:27085. Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman T, Alen M. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 2002;27:E207 14. Razmjou H, Kramer JF, Yamada R. Intertester reliability of the McKenzie evaluation in assessing patients with mechanical low-back pain. J Orthop Sports Phys Ther 2000;30:36883. Fritz JM, Brennan GP, Clifford SN, Hunter SJ, Thackeray A. An examination of the reliability of a classification algorithm for subgrouping patients with low back pain. Spine 2006;31:77 82. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Arch Phys Med Rehabil 2003;84:185864. Riddle DL. Classification and low back pain: a review of the literature and critical analysis of selected systems. Phys Ther 1998;78:70837. Miller ER, Schenk RJ, Karnes JL, Rousselle JG. A comparison of the McKenzie approach to a specific spine stabilization program for chronic low back pain. J Man Manip Ther 2005;13:10312. Petersen T, Kryger P, Ekdahl C, Olsen S, Jacobsen S. The effect of McKenzie therapy as compared with that of intensive strengthening training for the treatment of patients with subacute or chronic low back pain: a randomized controlled trial. Spine 2002;27:17029. Hall H, McIntosh G, Boyle C. Effectiveness of a low back pain classification system. Spine J 2009;9:64857. Werneke M, Hart DL. Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns. Spine 2003;28:1616. Hart DL, Werneke MW, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with lumbar spine impairments produced valid and sensitive measures of function. Spine (Phila Pa 1976) 2010; to be published. Donelson R, Grant W, Kamps C, Medcalf R. Pain response to sagittal end-range spinal motion. A prospective, randomized, multicentered trial. Spine 1991;16:S20612. Petersen T, Laslett M, Thorsen H, Manniche C, Ekdahl C, Jacobsen S. Diagnostic classifciation of non-specific low back pain. A new system integrating patho-anatomical and clinical categories. Physiother Theory Pract 2003;19:21337. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint J Man Manip Ther 2008;16:14252.

Published by Maney Publishing (c) W. S. Maney & Son Limited

204

Journal of Manual and Manipulative Therapy

2010

VOL .

18

NO .