Non-specific Low Back Pain - Classification and Treatment

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.

Abstract (Swedish)

Abstract in Norwegian

Afhandlingens emne er måling af effekt af McKenzie behandlingsmetoden til patienter med uspecifik lænderygbesvær og udvikling af et diagnostisk klassifikationssystem til brug i primærsektoren. McKenzie metoden er en af de mest anvendte af fysioterapeuter i en række vestlige lande til undersøgelse og behandling af patienter med rygbesvær. Delarbejde I er den første publicerede randomiserede kliniske undersøgelse, som tester effekten af McKenzie metoden til undersøgelse og behandling af patienter med længerevarende lænderygbesvær. Resultaterne for de inkluderede 260 patienter viste, at McKenzie-metoden er mindst lige så effektiv til patienter med subakut og kronisk uspecifik lænderygbesvær som intensiv dynamisk udholdenhedstræning, hvilket er den almindeligvis anbefalede behandling. Endvidere understøtter resultaterne behovet for en klassifikation af denne heterogene gruppe af patienter, som ofte er fremført af rygforskere i primærsektoren. I delarbejde II gennemførtes en systematisk litteraturgennemgang af tidligere foreslåede klassifikationssystemer med relevans for fysioterapi. Gennemgangen konkluderede, at flere forskellige systemer konkurrerer om at blive generelt accepterede i fysioterapifaget. I få tilfælde var undersøgelser publiceret, som kunne vise en vis grad af reproducerbarhed. Men ingen af disse systemer var i stand til at dokumentere deres overlegenhed frem for andre med hensyn til validitet (d.v.s. deres evne til at identificere subgrupper af patienter med bedre effekt af en bestemt behandling i sammenligning med andre). Der var således behov for dels fortsat testning af de eksisterende systemer, og dels udvikling af nye alternative systemer. I delarbejde III præsenteredes et nyt diagnostisk klassifikationssystem baseret på patoanatomiske og kliniske kategorier af patienter med uspecifik lænderygbesvær. Valg af kategorier og kriterier for kategorisering byggede på indhold i tidligere klassifikationssystemer, resultatet af en dansk ekspertkonference samt eksisterende evidens vedrørende diagnostisk præcision af kriterier. En systematisk metode blev anvendt til at vurdere kriteriernes reproducerbarhed, validitet, anvendelighed og generaliserbarhed i primærsektoren. Der argumenteredes for, at det nye klassifikationssystem er i stand til at overvinde adskillige af begrænsningerne i tidligere systemer, og at det nye system har potentiel nytteværdi til forskningsformål. Der var dog behov for yderligere undersøgelser af reproducerbarhed og validitet af systemet som helhed. Delarbejde IV testede den nye klassifikation for reproducerbarhed i form af inter-observatør overensstemmelse. Fire undersøgere klassificerede 90 patienter med længerevarende uspecifik lænderygbesvær. Resultaterne viste, at trænede undersøgere var istand til at opnå enighed med en acceptable grad af pålidelighed ved brug af klassifikationen. Dog bevirkede en lav prevalens af positive fund i flere af kategorierne at der er behov for yderligere test af inter-observatør overensstemmelse i en større patientpopulation. Endvidere er fremtidige undersøgelser af validitet og anvendelighed af systemet nødvendig.

• author: Petersen, Tom
• supervisor: [unknown] [unknown]
• opponent: Ass. professor Skouen, Jan Sture, Bergen University, Norway
• organization: Orthopaedics (Lund)
• publishing date: 2003
• type: Thesis
• publication status: published
• subject: Orthopedics
• keywords: revalidation, rehabilitation, Rehabilitering (medicinsk och social), kinesitherapy, Physical medicine, Physical Examination, Diagnosis, Outcome, Validity, Low Back Pain, Reliability, Classification
• pages: 144 pages
• defense location: Kulturen, Lund
• defense date: 2003-12-05 10:15:00
• ISBN: 91-628-5908-0
• language: English
• LU publication?: yes
• additional info: Article: II. Petersen T, Thorsen H, Manniche C, Ekdahl C: Classification of nonspecific low back pain. A review of the literature on classifications systems relevant to physiotherapy. Physical Therapy Reviews, 4, 265-281, 1999. Article: III. Petersen T, Laslett M, Thorsen H, Ekdahl C, Manniche C, Jacobsen S: Diagnostic classification of non specific low back pain. A new system integrating pathoanatomic and clinical categories. Accepted for publication in Physiotherapy Theory and Practice, December issue, 2003. Article: IV. Petersen T, Olsen S, Laslett M, Thorsen H, Ekdahl C, Manniche C, Jacobsen S: Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain. Submitted to Australian Journal of Physiotherapy, 2003.
• id: 0b7baf3e-ad27-4f2a-a09d-2eb752a083af (old id 466374)
• date added to LUP: 2016-04-04 10:04:32
• date last changed: 2018-11-21 20:56:34