Elsevier

Manual Therapy

Volume 10, Issue 4, November 2005, Pages 242-255
Manual Therapy

Masterclass
Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism

https://doi.org/10.1016/j.math.2005.07.001Get rights and content

Abstract

Low back pain (LBP) is a very common but largely self-limiting condition. The problem arises however, when LBP disorders do not resolve beyond normal expected tissue healing time and become chronic. Eighty five percent of chronic low back pain (CLBP) disorders have no known diagnosis leading to a classification of ‘non-specific CLBP’ that leaves a diagnostic and management vacuum. Even when a specific radiological diagnosis is reached the underlying pain mechanism cannot always be assumed. It is now widely accepted that CLBP disorders are multi-factorial in nature. However the presence and dominance of the patho-anatomical, physical, neuro-physiological, psychological and social factors that can influence the disorder is different for each individual. Classification of CLBP pain disorders into sub-groups, based on the mechanism underlying the disorder, is considered critical to ensure appropriate management. It is proposed that three broad sub-groups of CLBP disorders exist. The first group of disorders present where underlying pathological processes drive the pain, and the patients’ motor responses in the disorder are adaptive. A second group of disorders present where psychological and/or social factors represent the primary mechanism underlying the disorder that centrally drives pain, and where the patient's coping and motor control strategies are mal-adaptive in nature. Finally it is proposed that there is a large group of CLBP disorders where patients present with either movement impairments (characterized by pain avoidance behaviour) or control impairments (characterized by pain provocation behaviour). These pain disorders are predominantly mechanically induced and patients typically present with mal-adaptive primary physical and secondary cognitive compensations for their disorders that become a mechanism for ongoing pain. These subjects present either with an excess or deficit in spinal stability, which underlies their pain disorder. For this group, physiotherapy interventions that are specifically directed and classification based, have the potential to impact on both the physical and cognitive drivers of pain leading to resolution of the disorder. Two case studies highlight the different mechanisms involved in patients with movement and control impairment disorder outlining distinct treatment approaches involved for management. Although growing evidence exists to support this approach, further research is required to fully validate it.

Section snippets

The need to classify CLBP disorders

Low back pain (LBP) is common with up to 80% of people reporting LBP over their life time (Dillingham, 1995). The majority of acute LBP disorders resolve within a 4 week period although recurrence is common (Croft et al., 1998). A small number of disorders (10–40%) become chronic and represent a major cost burden for society (Dillingham, 1995; Croft et al., 1998). In spite of the small number of pathological conditions that can give rise to back pain, most cases (85%) are classified as

Models for the diagnosis and classification of CLBP

Current approaches or models used for the diagnosis and classification of CLBP have tended to only focus on a single dimension of the disorder, limiting their validity (Ford et al., 2003). The following overview is not designed to be exhaustive, but highlights to the clinician the strengths and weaknesses of these different approaches.

Diagnosis and classification of back pain

The Quebec task force classification system provides a logical approach for the diagnosis and classification of LBP disorders within a biopsychosocial framework (Spitzer, 1987; Abenhaim et al., 2000; Waddell, 2004). Under this framework red flags are considered in a diagnostic triage. The patient is screened for yellow flags or non-organic features suggestive of psychological and/or social factors dominating in the disorder. Under this classification system, disorders can be diagnosed as

Validity of the classification system

There is a growing concensus within the literature that current diagnostic and classification approaches for CLBP are limited, and a mechanism based classification of CLBP disorders from a biopsychosocial perspective is required (McCarthy et al., 2004). Although considerable research has documented the biopsychosocial nature of CLBP, further research is required to test the validity of this approach in management of CLBP disorders to determine whether it predicts and indeed improves patient

Summary

CLBP disorders must be considered within a biopsychosocial framework. The presence and dominance of the potential pathoanatomical, physical, neurophysiological, psychological and social factors that may impact on these disorders is different for each individual with CLBP. This highlights the enormous complexity and individual nature of the problem. It is critical that classification of CLBP pain disorders be based on the mechanism (s) underlying and driving the disorder. It is proposed that

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