Non-specific Low Back Pain - Classification and Treatment

University dissertation from Department of Physical Therapy, Lund University Hospital, SE-221 85 Lund, Sweden

Abstract: The aims of this thesis were to investigate the effects of the Mc-Kenzie method of mechanical diagnosis and therapy compared with that of intensive dynamic strengthening training for patients with non-specific low back pain (NLBP), and to develop a clinical diagnostic classification system for use in primary care. The McKenzie method is one of the most common methods for examination and treatment of patients with NSLBP used by physiotherapists in the Western World. Study number one is the first published randomised controlled trial testing the efficacy of the McKenzie method for patients with long-term NSLBP. Results from the 260 patients included showed that the McKenzie method was at least equally effective as strengthening training, which is the generally recommended treatment for these patients. Furthermore, the results support the need for a classification system for this heterogeneous patient group. In the second study, a systematic review of the existing classification systems of relevance to physiotherapy was conducted. It was concluded, that several systems compete to be generally accepted within the physiotherapy profession. In a few of these, studies were published demonstrating some level of reliability. However, none were able to document their superiority over others regarding validity, i.e. their ability to identify subgroups of patients with NSLBP that would benefit the most from a particular treatment, compared with other treatments. There appears to be a need for further testing of the existing classification systems as well as for the development of alternative ones. In the third study, a new diagnostic classification system including pathoanatomic and clinical categories, was presented. Selection of categories and criteria for categorisation of patients with NSLBP was based in part on the content of earlier systems, on the existing evidence regarding diagnostic value of criteria, and on the input from a conference of Danish experts. A systematic method was used to critically appraise the reliability, validity, feasibility, and generalizability of criteria for use in primary care. It was concluded that the new system has the potential to overcome some of the fundamental problems inherent in the existing ones, and that the new system may prove itself useful for research purposes. Further studies testing reliability and validity of the new system as a whole is warranted. In the fourth study, the inter-tester reliability of the new classification system was evaluated. Four physiotherapists examined 90 patients with NSLBP. The results showed that trained examiners were able to obtain an acceptable level of agreement when classifying the same patients. However, the low prevalence of positive findings in some categories indicates that there is a need for further testing of inter-tester reliability in a larger patient sample. Future studies investigating the validity and utility of the new classification system are required.

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