Clinical Prediction Criteria for

Management of LBP
 Purpose
• Next to a cold, LBP is most common reason
individuals visit the doctor
• Estimated $100-$200 billion in health care
expenditures and lost wages annually in the
U.S.
• Importance of matching pts with interventions
they will most likely benefit from
• Improve decision making and outcomes
 Current Evidence
A clinical prediction rule for classifying patients with
low back pain who demonstrate short-term
improvement with spinal manipulation. Flynn T, Fritz
J, Whitman J, et al. Spine. 2002; 27(24): 2835-43

Clinical prediction for success of interventions for

managing low back pain. Herbert J, Koppenhaver S,
Fritz J, Parent E. Clin Sports Medicine 2008; 27: 163-
179
A clinical prediction rule for classifying patients
with low back pain who demonstrate short-
term improvement with spinal manipulation.
Flynn T, Fritz J, Whitman J, et al. Spine. 2002;
27(24): 2835-43
 Background
• Several RCTs shown manipulation to be more
effective than placebo or other interventions.
• Found to be beneficial for a subgroup of pts
with more acute sym or more limited SLR
ROM
• Other studies have not shown any benefits
• Problems? No attempt to id pts most likely to
benefit
Design: Prospective cohort.

Level of Evidence: Level 2

Objective: Develop a clinical prediction rule for

identifying patients with low back pain who
improve with spinal manipulation
 Methods
• 71 Pts age 18-60 referred to PT w/ a chief
complaint of pain and/or numbness in the lumbar
spine, buttock, and or lower extremity
• Pain diagram and rating (0-10)
• Modified Oswestry Disability Questionnaire
(OSW)-assessed disability related to LBP
• Fear Avoidance Belief Questionnaire (FABQ)-assess
pts beliefs about the influence of activity on LBP.
– 2 subscales: general physical activity and work
 Inclusion/Exclusion Criteria
• Baseline Oswestry disability score of at least
30%
• Exclusion
– current pregnancy
– signs consistent with nerve root compression (+
straight leg raise at <45O , or diminished LE
strength, sensation, or reflexes)
– Prior lumbar surgery
– History of osteoporosis or spinal fracture
• Underwent standard exam and history (i.e. M.O.I.,
nature of sym, prior episodes etc.)
• Side to be manipulated was determined by the side +
with standing flexion test, if – side of tenderness
during sacral sulcus palpation, if not, side reported
tby pt to be more symptomatic
• Response to treatment served as a reference
standard, all pts were treated with the same protocol
for 2 sessions
• Success was determined using percent change in
disability scores over 3 sessions
Pt passively side-bent away from therapist. Therapist passively rotated pt
and delivered a quick posterior and inferior thrust through ASIS.
1st Session
Cavitation

YES NO

Reposition and
Proceed to other attempt again
components:
1.) Instruction in
supine pelvic tilt ROM, Cavitation?
10 reps 3-4x daily.
2.) Instruction to
maintain usual activity
level within limits of YES
pain

Attempt opposite NO
side
2nd Session 2-4 days later
OSW questionnaire
- improvement of >50% from intial= success,
participation ended

- <50%, repeat examination and manipulation

procedure

3rd Session 2-4 days later

- improvement <=50% unsuccessful participation
ended
 Results
• 75 entered 71 completed
– 29 females (41%)
– 59 (83%) had prior history of LBP
– Mean age 37.6 +/- 10.6 yrs
– 32 (45%) were classified as treatment successes, 39
nonsuccesses
– 20 successful after 1 session
– Mean OSW improvement in success group was 73.2 +/-
15.8%
– Nonsuccess group was 14.6 +/- 18.2%
 Results
• Out of 11 potential prediction variables, five
were retained in the final model:
– Duration of symptoms <16 days
– At least one hip with >35O internal rotation
– Hypomobility with lumbar spring testing
– FABQ work subscale score <19
– No symptoms distal to the knee
Results
 Results
• The best predictor of success with manipulation
was the duration of sym

• Supports the hypothesis that pts with more acute

sym respond better to manipulation.

• The presence of 4/5 variables increased the

likelihood of success with manipulation from 45%
to 95%
 Why is this important?
• Being able to accurately predict which pts will
have a positive response before hand would
be beneficial for effective and efficient clinical
decision making
Clinical prediction for success of interventions
for managing low back pain. Herbert J,
Koppenhaver S, Fritz J, Parent E. Clin Sports
Medicine 2008; 27: 163-179
Design- Systematic Review

Level of evidence- Level 1

Objective- Review evidence for various interventions

commonly used in the treatment of LBP.
-Identify clusters of findings from the history and
clinical examination that predict a more favorable
outcome with a specific treatment approach.
 Treatment Approaches
• Specific Exercise
– Flexion
– Extension

• Stabilization

• Manipulation

• Traction
• Evidence is inconclusive
• One’s that show some benefits, the magnitude
of observed effects is often small
• One therapy can look as appealing as the next
leading to less effective and efficient
treatment
 Specific Exercise
• First emphasized by McKenzie

• Emphasizes treatment using repeated or

sustained end-range movements of the
lumbar spine in a specific direction to affect
the intensity and location of a pt’s pain.
– Flexion, extension, or lateral translation
• Exam findings identifying pts in this subgroup:
– Presence of sym in the LE
– Signs of nerve root compression (+ SLR, diminished reflex,
sensation, or strength)

Principle finding is the presence of centralization or a

directional preference during examination

*the absence of centralization has been associated with

delayed recovery and the development of chronic LBP and
disablility. (Werneke et al. Spine 2001)*
• Studies that have applied this treatment to pts
fitting this subgrouping have reported
evidence favoring this approach over other
exercise interventions
 Stabilization Exercises
• Lack of trunk control may compromise
function or stability of the lower extremities
• Stabilization exercise programs are typically
designed to address the deficits in strength,
endurance, and function of the trunk muscles
identified in LBP
• Thought to decrease pain and disability by
improving control of spinal segments
 Previous studies
• Been shown to improve trunk muscle function in
individuals with LBP
• Improvements may represent important outcomes of
rehab programs but physiologic changes may not
correspond to patient-centered improvements in
pain and disability.
• Rackwitz and colleagues concluded that stabilization
exercises for LBP is more effective than treatment by
a gen practitioner but not more effective than other
physiotherapy interventions.
 But…..
• Conflicting evidence supports the consideration that
there may be a subgroup of pts with LBP who are
most likely to benefit from this approach.
• Four variables most predictive of success defined as
50% reduction in disability as measured by the OSW.
– Younger than age 40
– Avg SLR >91o
– Aberrant movement present
– Positive prone-instability test
 Spinal manipulation

See previous slides 

 Traction
• Subject of debate and controversery
• Traditional signs of sciatica or nerve root
compression indication for treatment
• These symptoms not enough. . . 2 more
factors
 Traction
1. Peripheralization with extension movement
2. A positive crossed (contralateral) straight-leg
raise test
3. Symptoms below buttock
4. Signs of nerve root compression
 Summary
• Identification of predictive factors in pts with
LBP should allow the pt to be matched with
the most appropriate intervention to
maximize the likelihood of a favorable clinical
outcome
• More information and research is needed