Physical Therapy Reviews 2004; 9: 1730

THE BIOPSYCHOSOCIAL CLASSIFICATION OF NONSPECIFIC LOW BACK PAIN: A SYSTEMATIC REVIEW

CHRISTOPHER J. McCARTHY*, FRANCES A. ARNALL*, NIKOLAOS STRIMPAKOS*, ANTHONY FREEMONT AND JACQUELINE A. OLDHAM*
*The Centre for Rehabilitation Science, University of Manchester, Manchester Royal Infirmary, Manchester, UK Laboratory Medicine Academic Group, University of Manchester, Medical School, Manchester, UK

ABSTRACT Study design: Numerous authors have attempted to sub-classify low back pain in order that valid homogenous subsets of low back pain presentations might be recognised. This review systematically appraises these papers. Methods: Medline, Embase, Cinahl, AMED and PEDro electronic databases were searched with subsequent hand searching of bibliographies. Papers were included between June 1983 and June 2003. Two reviewers independently reviewed 32 papers using a standard scoring criteria for assessment. A third reviewer mediated disagreements. Results: Thirty-two papers were reviewed, with classification systems being grouped by method of classification. Classification has been attempted by implication of patho-anatomical source, by clinical features, by psychological features, by health and work status and in one case by a biopsychosocial weighting system. Scores were generally higher for systems using a statistical cluster analysis approach to classification than a judgemental approach. Both approaches have specific advantages and disadvantages with a synthesis of both methodologies being most likely to generate an optimal classification system. Conclusions: The classification of NSLBP has traditionally involved the use of one paradigm. In the present era of biopsychosocial management of NSLBP, there is a need for an integrated classification system that will allow rational assessment of NSLBP from biomedical, psychological and social constructs. Keywords: Classification, biopsychosocial, low-back pain

INTRODUCTION Non specific low back pain (NSLBP) is a term used synonymously with simple low back pain or mechanical low back pain and is a term derived from an initial diagnostic triage process, classifying patients into one of three categories nerve root problems, serious pathology and NSLBP.13 This process has been recommended in several international guidelines as an important method of classifying low back pain,4 and is a process starting to be adopted clinically.57 The vast majority of
W. S. Maney & Son Ltd 2004

LBP patients fall into the NSLBP category and consequently, as a diagnostic category, NSLBP is only marginally more helpful in characterising patient presentations than LBP. It has long been recognised that the group of patients referred for conservative treatment with the diagnosis of NSLBP form an extremely heterogeneous group and that prognosis and optimal treatment methods vary immensely within this group.8 It is considered that this heterogeneous group consists of several smaller homogenous subsets with each subset
DOI 10.1179/10833190422500395 5

18

McCARTHY, ARNALL, STRIMPAKOS, FREEMONT, OLDHAM

Table 1. Classifications primarily implying patho-anatomical sources of pain

Primary author Purpose Method of development Judgemental (osteopathic authorship) Domain of interest Low back pain Categories Structural anomalies; postural anomalies; misuse; disc; reduced posterior compartment space; nerve root and sleeve; sacroiliac; abnormal function; nociceptor excitation; modulation Dysfunction of spinal motion with 4 subcategories; posterior facet syndrome; combined posterior facet sacroiliac syndromes; myofascial pain syndromes; intervertebral disc disease; repetitive strain injuries; segmental instability; lateral nerve root entrapment; central spinal stenosis; degenerative spondylolisthesis; isthmic spondylolisthesis Fracture; tumour; Scheurmanns disease; spinal stenosis; ankylosing spondylitis; hypomobility dysfunction; nerve root adhesion; nerve root irritation; sacroiliac hypermobility; scoliosis; segmental hypermobility; sacroiliac hypomobility; disk herniation; referred viseral; spinal congenital anomaly; infection; posterolateral disk derangement; postural syndrome 5 common; posterior facet joint; sacroiliac syndrome; myofascial trigger points; radicular syndromes; low back strain; 12 rare; ankylosing spondylitis; arthritis; chronic back pain; coccydynia; disuse; extension dysfunction; low back dysfunction; metastatic disease; piriformis syndrome; myofascial trigger points Symptomatic disc; symptomatic zygapophysial joint; symptomatic sacroiliac joint; nerve root entrapment; adherent nerve root; spinal stenosis; mechanical instability; posture syndrome; dysfunction syndrome; illness behaviour; other diagnoses; inconclusive Disc syndrome: (i) reducible; (ii) irreducible; (iii) non-mechanical disc. Adherent nerve root; nerve root entrapment; nerve root compression; spinal stenosis; symptomatic Z-joint; postural syndrome; sacroilliac joint; dysfunction syndrome; myofascial syndrome; adverse neural tension; abnormal pain; inconclusive Additional axis None Criteria used History and clinical presentation

MacDonald Professional (1990)56 approach

Humphreys (1990)55

Professional approach

Judgemental (chiropractic authorship)

Low back pain

None

History, clinical presentation and radiography

Binkley et al. (1993)53

To identify Judgemental homogeneous (physical sub-sets of therapy patients. Levels authorship) of agreement amongst 30 experts

Low back pain

None

History and clinical presentation

Newton et al. (1997)62

To identify the prevalence of sub-types of low back pain in patients referred to physical therapy

Judgemental (multidisciplinary group)

Acute and sub acute low back pain

None

History and clinical presentation

Laslett & van Wijmen (1999)20

A diagnostic classification for identifying sub-groups for treatment

Judgemental (physiotherapist authorship)

Non-specific low back pain

None

History and clinical presentation

Petersen et al. (2003)19

To classify according to assumed symptomatic structures

Judgemental (physiotherapist authorship)

Non-specific low back pain

None

History and clinical presentation

BIOPSYCHOSOCIAL CLASSIFICATION OF NON-SPECIFIC LOW BACK PAIN

19

Table 2. Systems classifying by clinical features

Primary author McKenzie (1981)15 Purpose Classification to determine treatment Method of development Judgemental (physiotherapy authorship) Domain of Categories interest Low back pain Postural; dysfunction; derangement 17; none Additional axis None Criteria used History and clinical presentation History and clinical presentation History and clinical presentation History, clinical presentation and investigations

Heinrich et al. (1985)63 Sikorski (1985)64

To develop Statistical an empirically (medical defined classi- authorship) fication system Categorisation Judgemental into diagnostic (medical group for authorship) treatment To determine clinical decision making and prognosis Judgemental (multidisciplinary team)

NSLBP

General pain, bilateral high pain scores; pain switching sides; absence of signs; chronic early onset; sciatica with absent reflex; ipsilateral acute Acute low back pain; chronic low back pain; anterior element; posterior element; movement induced; unclassified

No

Low back pain

No

Spitzer et al. (1987)21

Low back pain

Pain without radiation; pain + radiation to Work axis; extremity proximally; pain + radiation to extremity duration distally; pain + radiation to upper/lower limb axis neurological signs; presumptive compression of a spinal nerve root on a simple roentgenogram; compression of a spinal nerve root confirmed by specific imaging; spinal stenosis; postsurgical status 16 months after intervention; postsurgical status > 6 months after intervention; chronic pain syndrome; other diagnoses Acute lumbago; acute mechanical derangement; acute sciatica; mild sciatica; sacro-iliac syndrome; unclassified None

Barker (1990)65

Developed from a survey of primary care cases for GPs

Judgemental (medical authorship)

Low back pain

History, clinical presentation and investigations

Coste et al. (1991, 1992)66,67

Attempt to define clinical subgroups or syndromes

Statistical (medical authorship)

NSLBP without psychiatric disorder

Acute low back pain; chronic condition with insidious onset; chronic condition following acute episodes; older patients and mechanical symptoms; subacute LBP with gradual onset; sudden onset worse with impulsion; chronic low back pain with moderate pain

None

History, clinical presentation and questionnaire

DeRosa & Poterfield (1992)37

To sub-group Judgemental for therapeutic (physical intervention therapy authorship)

Mechanical Back pain without radiation; pain + radiation Acute History and low back to extremity proximally; pain + radiation to injury; clinical pain extremity distally; extremity pain greater than re-injury/ presentation back pain; back pain with radiation and exacerbation; neurological signs; postsurgical status (6 months chronic or > 6 months); chronic pain syndrome pain syndrome

Rezaian et al, (1993)68

To develop a practical aetiological classification of LBP To identify homogenous symptom groups

Judgemental (medical authorship)

Low back pain

Constant pain; intermittent pain; 5 sub-categories LBP aggravated by activity relieved by rest; sudden onset cauda equina syndrome; LBP worse at rest and better with activity; LBP worsened by extension; LBP accompanied by skin lesions Very fit; flexible; mixed; fit; inflexible

None

History and clinical presentation

Moffroid et al. (1994)69

Statistical (physical therapy authorship)

Most low back pain

None

Clinical presentation

Continued on next page

20

McCARTHY, ARNALL, STRIMPAKOS, FREEMONT, OLDHAM

Table 2 (continued) Systems classifying by clinical features

Primary author Delitto et al. (1995)70 Purpose A treatmentbased approach to the management of LBP syndrome Method of development Judgemental (physical therapy authorship) Domain of interest Low back pain Categories Level 1: physical therapy, requiring multidisciplinary treatment, requiring referral for medical/surgical opinion; Level 2: 3 stages (i) recovery of basic function; (ii) recovery of activities of daily living; (iii) work hardening Constant pain; variable pain Additional axis Acute and chronic Criteria used History and clinical presentation

Langwothy To test a Statistical & Breen methodology (chiropractic (1997)71 for the experi- authorship) mental generation of clinical subgroups of LBP patients Van Dillen et al. (1998)23, (2003)40 Wilson et al. (1999)24 To develop a movement impairment system For determining diagnosis and treatment direction Judgemental (physical therapy authorship) Judgemental (physical therapy authorship)

Low back pain

None

History and clinical presentation

NSLBP

Flexion; extension; rotation; rotation with flexion; rotation with extension

None

Physical assessment

Mechanical low back pain

Patterns: (i) back/buttock dominant, worse with flexion; (ii) back/buttock dominant, worse with extension, intermittent; (iii) leg dominant-below buttock; leg pain affected by back movement/ position; constant; (iv) leg dominant-below buttock, intermittent; leg pain increased by walking activity; leg pain decreased with posture change; (v) manipulative behaviour; pain-directed activity; poor sleep pattern; expanding symptom array; constant pain; deterioration instead of anticipated recovery; exaggerated pain response t o standard stimuli Back pain only; back and proximal leg pain; back and distal leg pain; back and distal leg pain and positive straight leg raise

None

History and clinical presentation

Bendebba et al. (2000)59

To develop a simple procedure for assigning persistent low back pain into one of four classes Classification to determine treatment

Judgemental (medical authorship)

Persistent low back pain

None

Clinical presentation and questionnaires

McKenzie and May (2003)22

Judgemental Low back (physiotherapy pain authorship) excluding red flags

Reducible derangement; irreducible derangement; dysfunction; adherent nerve root; postural syndrome; isthmic spondylolythesis; Hip; SIJ; mechanically inconclusive; chronic pain

None

History and clinical presentation

being more likely to respond to a type of treatment unique to that classification.9 Thus, with the recognition that particular conservative treatments may be more efficacious with certain subsets of patients than for the whole heterogeneous group of low back pain sufferers, there has been a strong recommendation to establish a method of classification that will distinguish one subset from another.9,10 The development of a valid classification of homogeneous subsets of NSLBP patients would allow more rational evaluation of the relative effectiveness of conservative treatments with the subgroups of patients most likely to benefit from them.8

In low back pain, as with all musculoskeletal pain, psychological and social factors have been shown to exacerbate the biological component of pain, in part by influencing pain perceptions. 11 Recognition of these important influences has lead to the widespread adoption of a biopsychosocial model of management of acute and chronic low back pain.12 It would seem appropriate that a classification of non-specific low back pain would recognise the biopsychosocial influences on illness presentation and it was with this principle in mind that a review of the literature on the sub-classification of LBP was undertaken.

BIOPSYCHOSOCIAL CLASSIFICATION OF NON-SPECIFIC LOW BACK PAIN

21

Table 3. Systems classifying by psychological features

Primary author Keefe et al (1990)72 Purpose Method of development Statistical (psychology authorship) Domain of interest Chronic LBP referred to a pain management programme All low back pain Categories Additional Criteria axis used None Observed behaviour

Classification by observed pain behaviour

(i) Low guarding and pain behaviour; (ii) high guarding and moderate pain behaviour; (iii) high guarding and moderate bracing and rubbing; (iv) high guarding and high rubbing with moderate bracing Purely organic; almost purely organic; mixed; purely psychiatric

Coste et al (1992)57

Development of a clinical and psychological classification of LBP

Statistical (psychology authorship)

None

History, clinical presentation and questionnaires Questionnaires

Main et al. (1992)41

Classification to predict outcome of treatment Evaluation of psychological stress factors differentiate between defined clinical sub groups with low back pain To integrate 6 dimensions of LBP to provide a multidimensional profile of the patient To identify homogeneous groups for treatment A simple classification tool to predict chronic low back pain

Statistical (psychology authorship)

All low back pain

Normal; at risk; distressed somatic; distressed depressed

None

Klapow et al. (1993)42

Statistical (psychology authorship)

Chronic low back pain

Chronic pain syndrome; positive adaptation to pain; good pain control

None

Questionnaires

Strong et al. (1994)44, (1995)45

Statistical (occupational therapy authorship)

Chronic low back pain

In control; depressed and disabled; active copers with high denial

None

Self-report questionnaires

Bergstrom et al. (2001)46

Statistical (psychology authorship)

Chronic low back pain

Dysfunctional; adaptive; interpersonally distressed

None

Questionnaires

Ozguler et al. (2002)60

Statistical (medical authorship)

All low back pain

Workers with minor disability caused by LBP; intermediate group; subjects disabled for some physical activity; subjects with disability for physical activity and disturbance of their emotional capacity

None

Questionnaires

METHODS A review of the literature pertaining to low back pain was undertaken by the following strategy. Initially a systematic search of databases, Medline, Cinahl, AMED, PEDro and Embase was undertaken between January 1983 and February 2003. The search terms used were: low back pain; and classification in combination with reliability, validity and outcome measures. The search was limited to articles in

English and pertaining to human subjects. In all, 1117 papers were identified. From the original 1117 articles, 261 papers were selected on the basis that the title or abstract pertained to the development or use of a classification system for low back pain. The next stage in the review process consisted of two independent reviewers blindly appraising the abstracts of these 261 papers. Articles were chosen for more detailed review if they classified low back pain, regardless of methodology. Thus, studies were included if they

22 Table 4. Work status model

Primary author Krause et al. (1994)48 Purpose

McCARTHY, ARNALL, STRIMPAKOS, FREEMONT, OLDHAM

Method of development

Domain of interest Low back pain of working subjects

Categories

Additional axis None

Criteria used Medical status, working status and insurance policy compensation

A tool to Judgemental communicate (medical and organise authorship) knowledge about risk factors and intervention aimed at reducing work disability

Non-disabling LBP; report of an injury/illness; short-term disability, < 1 week; timely intervention (17 weeks); long-term disability > 712 weeks; late rehabilitation 36 months; chronic disability > 618 months; permanent disability > 18 months

attempted to develop or adapt an existing classification system for use in treatment decision making, as a prognostic indicator, in identifying pathologies and for statistically dividing subjects into clustered groups. Methods utilising expensive or atypical investigations were excluded, thus papers detailing classification by electromyography, imaging, or expensive kinematic equipment were excluded.13,14 Agreement was reached on the need to retrieve 22 papers, after mediation by a third independent reviewer. Independent manual searching, by the same reviewers, of the reference lists of these 22 original articles, identified a further 10 papers, meeting the selection criteria. One classification system, proposed by McKenzie in 198115 was included, although being published before the search period, as there was considerable reference to the system in subsequent work. A further search of the original databases using the primary authors name was undertaken, to ensure subsequent relevant studies were not overlooked; however, no relevant papers were identified by this method. The two independent reviewers then blindly and critically appraised the 32 articles using criteria developed by Buchbinder et al.16 These criteria, designed specifically to facilitate the critical appraisal of classification systems, has been used previously in neck16 and LBP musculoskeletal reviews;10,17 it provides a rigorous framework for reviewing classification systems. Only four incidents of inter-reviewer disagreement occurred and a third reviewer mediated these. The literature retrieved was organised into four themes in order that the literature might be considered in terms of biomedical, psychological and social factors. The classification systems were organised into systems primarily implying patho-anatomical sources of pain (6 papers; Table 1) systems classifying by clinical features (15 papers; Table 2), systems classifying by psychological features (7 papers; Table 3), and finally by work and health status (4 papers; Tables

46). Table 6 summarises the critical appraisal of each paper and details its score for meeting methodological criteria. Each domain was scored as: 1, meeting the criteria; 0.5, partially meeting the criteria; and 0, not meeting criteria or being unable to score due to lack of evidence and a total score produced by summating the score from each domain. As considerable work has been undertaken in this field, it was our intention to detail only the systems with higher methodological scores (Table 6), whilst summarising group scores in the discussion.

RESULTS Classification by implying a patho-anatomical source The classification of LBP by suggestion of pathoanatomical source of pain was undertaken using a judgemental approach. The systems received poor scores predominantly due to lack of evidence of interexaminer reliability and evidence for generalisability (median score, 2.5; interquartile range [IQR], 0.6). Thus, there is little evidence to support the validity of this method of classification, with only two papers reaching even average methodological scores.18,19 Laslett and van Wijmen20 described a judgemental approach classification based on the experience of the two authors, both physiotherapists (Tables 1 and 6). The system took elements of the McKenzie classification,15 which classifies patients by clinical presentation and response to repeated movement and loading with elements of the Quebec Task Force classification21 requiring biomedical investigation. The authors provided a diagnostic algorithm and clear definitions of the criteria for each category but again no data regarding the reliability or validity of the system. Petersen et al.19 proposed a similar system using features of the clinical examination with established evidence of reliability.

BIOPSYCHOSOCIAL CLASSIFICATION OF NON-SPECIFIC LOW BACK PAIN

23

Table 5. Health status taxonomies and biopsychosocial approach

Primary author Harper et al. (1992)49 Purpose Method of development Judgemental with data obtained from patient interview (multidisciplinary team) Domain of interest Chronic low back pain Categories Additional Criteria axis used None Interviews and questionnaires

To provide a taxonomy of the impairments, disabilities & handicaps resulting from LBP

Primary impairments: low back pain/sensory impairment; impairment of lumbosacral movement ;secondary impairments; disability affecting basic movement; work disability; sexual activity disability; recreation disability; home management disability; self-care disability; transportation disability; impairment of general health; impairment of adaptation to disability; impairments of thinking; emotional impairment; impairment in the quality of life; handicaps; economic self-sufficiency handicap; family membership handicap; social integration handicap; service utilisation handicap; occupation handicap 4 domains: biological chronicity, diagnostic uncertainty, severity, complications; psychological: coping treatment resistance, severity, mental health threats; social family disruption, social support, residential instability, social vulnerability; healthcare intensity of prior treatment, appropriateness of referral, care needs. These domains are assessed in the context of time past, current state, prognosis Balancing; standing; sitting; whole body positioning; lying down and getting up; sitting to standing and back; ambulation; climbing; crawling; reaching; lifting and lowering; pushing and pulling; carrying objects; personal presentation; coping with work stress; coping with time pressure; task initiation; task completion; awareness of limitations; multitasking; planning and sequencing organisation; attendance; workplace tolerance; following procedures; using transportation; vehicle operation

Huyse et al (1999)51 Stiefel et al. (1999)52,58

Classification using of biopsychosocial factors to establish case complexity

Judgemental (medical authorship)

Chronic low back pain

None

Interview

Halpern (2001)50

To provide a taxonomy of functional assessment constructs

Judgemental/ data obtained from clinicians (medical authorship)

Chronic low back pain

None

Expert consensus

Classification by clinical features The classification of LBP by patterns of clinical features was the most undertaken method of sub-classification with widely ranging methodological scores. Again, the median methodological score was low (3.0), with a large central tendency (IQR 2.0). The systems were predominantly judgement systems, based on the impressions of the authors, with the higher scoring systems benefiting from evidence of subsequent investigation for reliability and validity.15,2224 McKenzie15 developed a system of diagnosis and management of LBP to guide the therapist in the choice of treatment, based on the clinical experience of the author (Tables 2 and 6). The system was developed from the authors clinical experience; whilst no data regarding the reliability and validity of the classification was originally detailed, subsequent work has investigated these

issues.2530 It is not the intended scope of this article to evaluate these subsequent investigations; however, whilst earlier work suggested that the classification system possessed low inter-tester reliability,26 more recent work has demonstrated higher reliability.30 The McKenzie approach to treatment is one of the most commonly adopted by physiotherapists in the US,31 UK,32 and Northern Ireland;33 thus, it appears to be an acceptable and usable approach to patient classification and treatment although the efficacy of the approach is still not fully established.17 The system has been recently adapted to increase diagnostic categories and include a diagnostic algorithm involving reassessment after 35 treatment sessions. 22 The system proposed by the Quebec Task Force (QTF)21 was designed to classify all LBP patients and aimed to help with clinical decision making, establishing prognosis and evaluating treatment effectiveness

24

McCARTHY, ARNALL, STRIMPAKOS, FREEMONT, OLDHAM

Table 6. Summary of the critical appraisal of each paper

Classification by pathoanatomy MacDonald (1990)56 Humphreys (1990)55 Binkley et al. (1993)53 Newton et al. (1997)62 Laslett and van Wijmen (1999)20 Petersen et al. (2003)19 Classification by clinical features Purpose stated Content Face validity Feasibility validity Construct validity Reliability Generalisability Total criteria score 2.5 2.5 2.5 2.5 3.0 3.5 Total criteria score 5.5 1.5 1.5 3.5 2.0 2.5 4.0 2.5 2.5 3.5 1.0 4.0 4.0 3.0 5.0

Yes Yes Yes Yes Yes Yes Purpose stated

Partial Partial Partial Partial Partial Partial Content

Partial Partial Partial Partial Partial Partial Face validity

Partial Partial Partial Partial Partial Partial Feasibility validity

Unknown Unknown Unknown Unknown Unknown Unknown Construct

No No No No No Partial Reliability validity

No No No No Partial Partial Generalisability

McKenzie (1981)15 Heinrich (1985)63 Sikorski (1985)64 Spitzer et al. (1987)21 Barker (1990)65 Coste et al. (1991)66,67 DeRosa & Poterfield (1992)37 Rezaian et al. (1993)68 Moffroid (1994)69 Delitto et al. (1995)70 Langwothy & Breen (1997)71 van Dillen et al. (1998)23 Wilson et al (1999)24 Bendebba et al. (2000)59 McKenzie & May (2003)22

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Partial No No Partial No Partial Partial Partial Partial Yes No Partial Partial Partial Partial

Partial Partial No Partial Partial Partial Partial Partial Partial Partial No Partial Partial Partial Partial

Yes No Partial Partial Partial Partial Yes Partial Partial Partial No Partial Yes Yes Yes

Partial Unknown Unknown Partial Unknown Unknown Unknown Unknown Unknown Unknown Unknown Partial Unknown Unknown Partial

Yes No No Partial No No No No No No No Partial Yes No Partial

Yes No No Yes No No Yes No Unknown Partial No Partial No No Yes

Classification by psychosocial methods

Purpose

Content validity

Face validity

Feasibility

Construct validity

Reliability

Generalisability

Total criteria score 5.0 4.0 5.5 6.0 5.5 5.5 4.5

Keefe et al. (1990)72 Coste et al. (1992)57 Main et al. (1992)41 Klapow et al (1993)42 Strong et al. (1994)44 Bergstrom et al. (2001)46 Ozguler (2002)60

Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes

Partial Partial Yes Yes Yes Yes Yes

Partial Unknown Unknown Unknown Unknown Unknown Unknown

Partial Partial Partial Yes Partial Partial Partial

Partial No Yes Yes Yes Yes No

Classification by work or biopsychosocial methods Harper et al. (1992)49 Krause (1994)48 Stiefel et al. (1999)52,58 Halpern et al. (2001)50

Purpose stated

Content validity

Face validity

Feasibility

Construct validity

Reliability

Generalisability

Total criteria score 3.0 3.5 5.5 3.0

Yes Yes Yes Yes

Partial Partial Yes Partial

Yes Yes Yes Yes

Partial Yes Yes Partial

Unknown Unknown Partial Unknown

No No Yes No

No No Partial No

(Tables 2 and 6). The system was designed by a panel of international experts in the field of LBP management and was informed by an extensive review of the literature. The system describes 11 groupings. The system also used two more axes of classification to

place a duration on the symptoms, akin to acute, subacute and chronic LBP terms and also an at work or not at work axis. Thus, this was the first classification system to consider biomedical, psychological and social considerations in the classification process.

BIOPSYCHOSOCIAL CLASSIFICATION OF NON-SPECIFIC LOW BACK PAIN

25

The QTF system has received considerable interest as a clinically applicable method of identifying homogeneous subsets of NSLBP patients. Several authors have investigated, particularly the clinical categories,14 and evaluated their discriminant and predictive validity. Losiel et al.34 examined the first four categories of the QTF system in 104 long-term absentees from work and found that the categories were correlated with functional status and predictive of return to work. Marras et al.14 reported that the 11 categories were also well discriminated by detailed kinematic information obtained during active physical motion testing, suggesting that the quality of spinal movement was different between the categories. In addition, in a recent hospital-based cross-sectional study, Frank et al.35 examined 657 consecutive referrals with low back pain over 2 years to a district rheumatology service and found that the QTF classification was a useful predictor of both physical and psychological disability and handicap in employment. Another study,36 that used an adapted version of the QTF system suggested by DeRosa and Poterfield,37 found that response to physical therapy was less in the higher, more disabling, QTF categories611 than with the lower, suggesting more evidence for the predictive validity of the system (Tables 2 and 6). This study was undertaken with 263 consecutive patients referred for physical therapy and treatment. It was provided unblinded to classification, thus bias may have unduly influenced results and may explain why in another study much less predictive ability was demonstrated.38 Thus, whilst this system appears to have acceptable face and content validity and begins to integrate biopsychosocial considerations into classification, its reliability and clinical usefulness still require further investigation. Van Dillen et al.23 proposed a classification system focused on movement impairment and based on the physical examination performed in standing, sitting, supine, prone and quadruped kneeling (Tables 2 and 6). The system classified patients into one of five categories flexion, extension, rotation, rotation with flexion and rotation and extension impairment. Individual items used in the classification system were tested for inter-tester reliability in 95 patients, with symptom behaviour in response to movement being more reliable than observational tests such as relative flexibility with forward bending. The authors recognised that assessment of movement impairment is only a component of the diagnostic process and stress that this system could be used in conjunction with systems designed to classify alternative aspects of a patients presentation. Whilst the systems applicability was demonstrated in a single-case study by Maluf in 2000,39 and the validity of three of the five categories

demonstrated in 2003,40 the generalisability and clinical usefulness of the system remains unknown. Classification by psychological features The classification of LBP by psychological features was generally scored highly (median score, 5.5; IQR, 1.0). These systems demonstrated evidence of validity consistent with being derived from patient data post hoc to statistical cluster analysis rather than on an a priori judgemental approach. Main et al.41 adopted a similar statistical approach to establishing a classification to identify distress and evaluate the risk of poor outcome, the distress and risk assessment method (DRAM; Tables 3 and 6). The authors evaluated the clinical examination and psychological features of 567 patients referred to for an orthopaedic consultation. In addition, 172 patients attending a pain clinic were also evaluated. Four clusters were identified normal; at risk; distressed and depressed; and distressed and somatic. Decision rules for allocation into categories were established and the validity of the clusters investigated by comparing the characteristics of the pain clinic and orthopaedic patients. The authors stressed that the system is no more than a first stage screening procedure, but that its use in initial patient assessment may reduce the potential unsatisfactory response to simple physical treatment and identify patients needing multidisciplinary management. Klapow and colleagues42,43 undertook studies aimed at investigating whether differences in three psychosocial dimensions (life adversity, coping and social support) discriminated clinical presentations of chronic LBP (Tables 3 and 6). Following a discriminant function analysis of data obtained from 95 male orthopaedic patients psychological profiles, three clusters were identified. Patients were categorised as: (i) chronic pain syndrome, with high levels of disability, pain and distress; (ii) good pain control, with low levels of disability, pain and distress; and (iii) a positive adaptation to pain, with high levels of pain but low levels of disability and depression. The reliability of the system was supported by several tests of internal consistency and demonstrated good crossvalidity in an independent sample of pain clinic chronic LBP patients (n = 180). In addition, the stability of the clusters over time was tested by re-assessing 36 patients 6 months after they initially were characterised into one of the three outcome groups. Results indicated that the outcome measures and categorisation outcome did not change significantly across time; thus, the system appeared to offer a reliable and valid method of sub-classifying LBP by psychosocial means.

26

McCARTHY, ARNALL, STRIMPAKOS, FREEMONT, OLDHAM

Strong et al.44 investigated chronic LBP patients, aiming to integrate 6 dimensions of chronic low back pain to provide a multidimensional profile of the patient or integrated psychosocial assessment model (IPAM; Tables 3 and 6). These dimensions were: pain intensity; functional disability; attitudes toward pain; pain coping strategies; depression; and illness behaviour. Cluster analysis of the data obtained from 100 patients revealed the presence of three distinct patient groups: (i) patients who were in control; (ii) patients who were depressed and disabled; and (iii) patients who were active copers with high denial. The authors went on to examine the validity of these clusters with significance testing on six external variables and a discriminant function analysis revealing the clusters to be significantly different. The same authors then repeated this methodology in New Zealand45 with 70 patients with chronic LBP. Cluster analyses were performed on the IPAM data resulting in three clusters being again identified. Two of the three clusters correlated highly with clusters in the original Australian study, while the third cluster showed partial resemblance. The authors suggested that support for this cluster model from two (albeit demographically similar) countries, demonstrated its value in providing a multidimensional, psychosocial picture of patients with chronic LBP and recommended that the system be used in prospective trials evaluating its clinical benefits in management. Bergstom et al.46 aimed to identify valid groups of chronic NSLBP patients using data from the Swedish version of the MPI (Tables 3 and 6).47 Cluster analysis was again conducted to detect distinct subgroups, based on data obtained from two patient samples (n = 235 and n = 273). Three clusters were identified: (i) adaptive coper; (ii) dysfunctional; and (iii) interpersonally distressed. The validity of the clusters was investigated using variables not used to generate the clusters (e.g. observed physical functioning). Although the measures were applied in a standardised manner, the inter-tester reliability of all measures and the reliability of classification was not stated; thus, whilst similar clusters were identified in two patient groups, the generalisability of the system must be evaluated further. Classification by work or health status Within this section, the methodologies used to classify LBP varied from a judgement-based classification of patients by duration of work absence48 to taxonomy of LBP based on the International Classification of Impairments Disability and Handicaps (ICIDH) criteria.49,50 One system was specifically designed to rate the complexity of LBP patients in terms of their biomedical,

social and psychological needs, had evidence for reliability, feasibility and validity and received a higher score from the reviewers (5.5; group median score, 3.3; IQR, 2.0). The primary objective of Huyse et al.51 was to develop a classification system that synthesised biopsychosocial information to enable identification of the main disability risk factors in patients with LBP (Tables 5 and 6). The authors used a system developed in the psychiatric field called INTERMED to identify complex patients, with the rationale that complex patients have somatic and psychosocial co-morbidity and require multiple types of care delivery. This system evaluates and weights the biomedical, psychological, social and health care influences on LBP experience and provides information about the complexity of the patients case. The system does not attempt to classify specific impairments, activity and participation problems, but does allow the clinician to identify and weight features of the patient presentation that may influence management decisions. The system has demonstrated reliability and validity in psychiatric and chronic LBP patients.52 The authors assessed 124 patients with LBP, 74 of whom were orthopaedic patients and 50 patients applying for disability compensation at a disability evaluation clinic in the US. Scores were higher for all domains of the INTERMED in patients attending the disability evaluation clinic; following a cluster analysis of all 124 patients data, two clusters emerged. Cluster one represented complex cases with high INTERMED scores and cluster two, less complex cases with low INTERMED scores. In addition, a higher proportion (66%) of the less complex patients returned to work following a rehabilitation programme than the complex patients (20%; P < 0.01). The authors suggested that a comparison between other instruments of assessment, such as the DRAM, 41 and further work assessing the systems impact on clinical decision-making were indicated. However, the system offers a simple method of assessing the biomedical, psychological, social and healthcare needs of patients and allows the identification of patients with multifactorial dysfunction with complex treatment requirements.

CONCLUSIONS The volume of work accumulated in the last 20 years suggests there is considerable recognition of the need to develop a method of sub-classifying LBP and NSLBP. Overall, the classification systems only moderately met the methodological criteria for critical appraisal. The median methodological score was 3.5 (IQR 2.4), with the highest methodology scores for

BIOPSYCHOSOCIAL CLASSIFICATION OF NON-SPECIFIC LOW BACK PAIN

27

the psychological classifications, median score 5.5 (IQR 1.0) and the lowest for the systems implying a patho-anatomical source 2.5 (IQR 0.6). The greatest variability in methodological score was demonstrated in the classification by clinical features group 3.0 (IQR 2.0), the largest group. The studies retrieved display a wide variety of approaches to the problem of sub-classifying LBP. The approaches can be grouped into three types: (i) a judgement approach derived from the personal experience of the authors; (ii) a statistical approach derived by statistical cluster analysis; and (iii) those based on the consensus of a panel of clinicians. A large number of papers were written by authors wishing to recommend an approach based on their personal experience of the incidence and treatment of subgroups of LBP. This approach often led to systems that possessed face validity, but had often not been evaluated for feasibility or generalisability; all had the potential of being unduly biased by personal opinion. Within this group, a number of systems were considered to have the strongest evidence for methodological rigour, by the reviewers.15,22,24,37,52 Some authors derived systems following statistical cluster analysis approaches, using data obtained from large numbers of patients. These systems provided greater evidence of validity, reliability and, in some cases, generalisability; however, the clusters identified from clinical features were commonly unrecognisable and their clinical usefulness unproven. In addition, the validity of the clusters obtained by this approach was heavily influenced by the choice of the items or tests used in the assessment process. These items were generally derived from the authors personal preferences and had little or no evidence of measurement validity. Within this group, the systems classifying LBP by psychological features were considered to offer the best approaches by the review panel as they generally possessed greater construct and content validity and had some evidence of generalisability and feasibility. Finally, there have been two studies that have developed classification systems using a consensus method. Binkley et al.53 described a professional physical therapy consensus on the classification of LBP, derived from a Delphi procedure. The Quebec Task Force on Spinal Disorders (1987)21 was developed from a consensus of a multidisciplinary committee, informed by a systematic review of the evidence. The Quebec Task Force classification incorporates multiple dimensions of the patients illness presentation; whilst making only rudimentary reference to psychological and social influences, it does provide a system that offers a basic framework for the classification of LBP. Over the last 20 years, the emphasis of LBP management has changed from a biomedical-based

approach to a biopsychosocial approach. 54 It would seem that it is no longer appropriate to try to subclassify LBP solely on a biomedical construct and that a successful classification system must include biomedical, psychological and social assessments. The consequence of using a classification system that assesses more than one construct of presentation is the production of multiple patient characterisations. Thus, in order that future classification systems possess adequate content validity, the establishment of a diagnostic profile of presentation, incorporating important characteristics from biomedical, psychological and social assessments, may be needed. The literature presented here provides some evidence regarding the features considered to be important by previous authors and also the methods of weighting patient characteristics. The majority of classification systems were developed using data obtained from history taking, physical examination and psychosocial questionnaires rather than from laboratory-based investigations. This might suggest that the clinical examination supplemented by psychosocial instruments might provide adequate scope for the sub-classification of most LBP. Pain site, severity, distribution and extent of referral into the leg were commonly used characteristics in classification. In addition, neurological signs of conduction loss were used in conjunction with the straight-leg raise test. The effect of movement on pain presentation was also commonly used in classification. The effect of repeated movements on distribution of pain, the effects of different directions of movement on pain, quality of movement and the presence or absence of effect of movement on pain were considered by previous authors. However, very few systems included the assessment of passive spinal movement in their classification. 19,20,55,56 Psychological features assessed by authors interested in the classification of LBP by psychological characteristics included depression, coping ability, somatisation, fear avoidance, anxiety and distress. The influence of social factors such as absence from work, family support and residential stability were also included as features of some classification systems. In addition, an assessment of the contribution of psychosocial features to overall presentation was made by some authors.52,57,58 This suggests that establishing the relative contribution of biomedical and psychosocial factors in overall presentation may be an important factor in the sub-classification process and is currently a process that is recommended in several clinical guidelines for the management of LBP.13 Whilst a number of systems have suggested a hierarchical order to their categories that imply progressively more serious presentations, 15,41,48,59,60 only one

28

McCARTHY, ARNALL, STRIMPAKOS, FREEMONT, OLDHAM

system has assessed the biomedical, psychological and social presentation of patients and incorporated a mechanism for rating the importance of the characteristics, contained within each domain. The INTERMED system52 requires that a rating of the case complexity of characteristics from each domain are made, allowing an assessment of the relative complexity or challenge to management of each domain of the patients presentation. Thus, this approach to weighting the importance of each domain of presentation may help the clinician in their decisions regarding management strategy. In conclusion, the literature presented above, raises a number of issues regarding the sub-classification of LBP: 1. There is significant multidisciplinary interest in establishing a valid system for sub-classifying this condition. Whilst a great deal of work has been undertaken in this field only a small proportion of the systems proposed have adequate evidence of their methodological rigour. There remains a need for the development of a methodologically valid classification system that is feasible for clinical use and generalisable to all clinical scenarios. 2. Methods of classifying LBP have ranged from an a priori judgemental approach, based on the experience of the authors, to a statistical clustering approach where categories are generated from patient data. Both approaches have specific advantages and disadvantages with a synthesis of both methodologies being likely to generate the most optimal classification system. 3. A clinically useful classification of LBP is unlikely to be achieved by classifying a patient by a single domain of presentation. Categorising patients solely by biomedical characteristics will be insufficiently discriminatory, as will the use of purely psychological or social characteristics. In order to discriminate between clinically meaningful sub-groups of patients with LBP it is likely that assessments of biomedical, psychological and social domains will be needed. Evidence for the important discriminatory characteristics from each domain are beginning to be established, however more evidence is required. 4. The assessment of multiple domains of patient presentation will result in a need to establish a mechanism of weighting the importance of characteristics between domains, in order that the most important characteristic of a patients presentation is identified and subsequently managed. Therefore, it is likely that a clinically useful sub-classification system will need to

incorporate a weighting system or mechanism of identifying the patients greatest barrier(s) to recovery from the biopsychosocial domains. The sub-classification of LBP has been recommended as a priority for future research61 and the establishment of a rigorously developed system that is valid, feasible and generalisable will allow a rational evaluation of the relative effectiveness of conservative treatments with the subgroups of patients most likely to benefit from them. 8 Whilst the task of developing such a system is difficult, the need for this advance in diagnostic practice is undoubted.

ACKNOWLEDGEMENTS This work was funded by an Arthritis Research Campaign ICAC grant and a grant from the UK Department of Health, Research Capacity Development Agency. REFERENCES
Clinical Standards Advisory Group. Back Pain. London: HMSO, 1994 2 ACC and the National Health Committee. New Zealand Acute Low Back Pain Guide. Wellington, NZ: ACC and the National Health Committee, 1997; 113. 3 Materson RS. The AHCPR practice guidelines for low back pain. Bull Rheum Dis 1996;45:68 4 Koes BW, van Tulder MW, Ostelo R, Kim BA, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26:250413 5 Frankel BS, Moffett JK, Keen S, Jackson D. Guidelines for low back pain: changes in GP management. Fam Pract 1999;16:21622 6 McGuirk B, King W, Govind J, Lowry J, Bogduk N. Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine 2001;26:261522 7 Schers H, Braspenning J, Drijver R, Wensing M, Grol R. Low back pain in general practice: reported management and reasons for not adhering to the guidelines in The Netherlands. Br J Gen Pract 2000;50:6404 8 Delitto A, Erhard R, Bowling R. A treatment-based classification approach to low back syndrome: Identifying and staging patients for conservative treatment. Phys Ther 1995;75:47089 9 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 10 Riddle DL. Classification and low back pain: a review of the literature and critical analysis of selected systems. Phys Ther 1998;78:70837 11 Main C, Watson P. Psychological aspects of pain. Manual Ther 1999;4:20315 12 Waddell G. A new clinical model for the treatment of low-back pain. Spine 1987;12:63244 1

BIOPSYCHOSOCIAL CLASSIFICATION OF NON-SPECIFIC LOW BACK PAIN 13 Wiesel S. The reliability of imaging (computed tomography, magnetic resonance imaging, myelography) in documenting the cause of spinal pain. J Manip Physiol Ther 1992;15:513 14 Marras WS, Parnianpour M, Ferguson SA et al. The classification of anatomic- and symptom-based low back disorders using motion measure models. Spine 1995; 20:253146 15 McKenzie RA. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae: Spinal Publications, 1981 16 Buchbinder R, Goel VK, Bombadier C, Hogg-Johnson S. Classification of soft tissue disorders of the neck and upper limb: Do they satisfy methodological guidelines? J Clin Epidemiol 1996;49:1419 17 Petersen T, Thorsen H, Manniche C, Ekdahl C. Classification of non-specific low back pain: A review of the literature on classification systems relevant to physiotherapy. Phys Ther Rev 1999;4:26581 18 Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 1994; 19:12439 19 Petersen T, Laslett M, Manniche C, Ekdahl C, Jacobsen S. Diagnostic classification on non-specific low back pain. A new system integrating patho-anatomic and clinical categories. Physiother Theory Pract 2003;19: 21337 20 Laslett M, van Wijmen P. Low back and referred pain: diagnosis and proposed new system of classification. NZ J Physiother 1999;27:514 21 Spitzer WO, LeBlanc FE, Dupuis M. Scientific approach to the assessment and management of activity related spinal disorders: Report of the Quebec Task Force on Spinal Disorders. Spine 1987;12:S1621 22 McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis & Therapy, 2nd edn. Orthopedic Physical Therapy Products, 2003 23 Van Dillen LR, Sahrmann SA, Norton BJ et al. Reliability of physical examination items used for classification of patients with low back pain. Phys Ther 1998;78:97988 24 Wilson L, Hall H, McIntosh G, Melles T. Intertester reliability of a low back pain classification system. Spine 1999;24:24854 25 Kilby J, Stignant M, Roberts A. The reliability of back pain assessment by physiotherapists, using a McKenzie algorithm. Physiotherapy 1990;76:57983 26 Riddle DL, Rothstein JM. Intertester reliability of McKenzies classifications of the syndrome types present in patients with low back pain. Spine 1993;18:133344 27 Delitto A, Cibulka MT, Erhard RE, Bowling RW, Tenhula JA. Evidence for use of an extension-mobilization category in acute low back syndrome: a prescriptive validation pilot study. Phys Ther 1993;73:21622 28 Donahue MS, Riddle DL, Sullivan MS. Intertester reliability of a modified version of McKenzies lateral shift assessments obtained on patients with low back pain. Phys Ther 1996;76:70616 29 Karas R, McIntosh G, Hall H, Wilson L, Melles T. The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain. Phys Ther 1997;77:35460 30 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:E20714 31 Li LC, Bombadier C. Physical Therapy management of low back pain: An exploratory survey of therapist approaches. Phys Ther 2001;81:101828 32 Foster NE, Thompson KA, Baxter GD, Allen JM. Management of nonspecific low back pain by physiotherapists

29

in Britain and Ireland. Spine 1999;24:133242 33 Gracey JH, McDonough SM, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine 2002;27:40611 34 Loisel P, Vachon B, Lemaire J et al. Discriminative and predictive validity assessment of the Quebec task force classification. Spine 2002;27:8517 35 Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross-sectional survey of the clinical and psychological features of low back pain and consequent work handicap: use of the Quebec Task Force classification. Int J Clin Pract 2000;54:63944 36 OHearn MA. Physical therapy treatment of low back pain: a report of outcomes according to three types of patient classification. J Rehabil Out Meas 1997;1:2331 37 DeRosa CP, Porterfield JA. A physical therapy model for the treatment of low back pain. Phys Ther 1992;72:2619 38 Atlas SJ, Deyo RA, Patrick DL, Convery K, Keller RB, Singer DE. The Quebec Task Force classification for Spinal Disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis. Spine 1996;21:288592 39 Maluf KS, Sahrmann SA, Van Dillen LR. Use of a classification system to guide nonsurgical management of a patient with chronic low back pain. Phys Ther 2000;80:1097111 40 Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, McDonnell MK, Bloom NJ. Movement system impairmentbased categories for low back pain: stage 1 validation. J Orthop Sports Phys Ther 2003;33:12642 41 Main CJ, Wood PL, Hollis S, Spanswick CC, Waddell G. The distress and risk assessment method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine 1992;17:4252 42 Klapow JC, Slater MA, Patterson TL, Doctor JN, Atkinson JH, Garfin SR. An empirical evaluation of multidimensional clinical outcome in chronic low back pain patients. Pain 1993;55:10718 43 Klapow JC, Slater MA, Patterson TL et al. Psychosocial factors discriminate multidimensional clinical groups of chronic low back pain patients. Pain 1995;62:34955 44 Strong J, Ashton R, Stewart A. Chronic low back pain: toward an integrated psychosocial assessment model. J Consult Clin Psychol 1994;62:105863 45 Strong J, Large RG, Ashton R, Stewart A. A New Zealand replication of the IPAM clustering model for low back patients. Clin J Pain 1995;11:296306 46 Bergstrom G, Bodin L, Jensen B, Linton SJ, Nygren AL. Long-tern, non-specific spinal pain: reliable and valid subgroups of patients. Behav Res Ther 2001;39:7587 47 Bergstrom KG, Jensen IB, Linton SJ, Nygren AL. A psychometric evaluation of the Swedish version of the Multidimensional Pain Inventory (MPI-S): a gender differentiated evaluation. Eur J Pain 1999;3:26173 48 Krause N, Ragland DR. Occupational disability due to low back pain: a new interdisciplinary classification based on a phase model of disability. Spine 1994;19:101120 49 Harper AC, Harper DA, Lambert LJ et al. Symptoms of impairment, disability and handicap in low back pain: a taxonomy. Pain 1992;50:18995 50 Halpern M. Functional assessment taxonomy relevant to low back impairments. J Occup Rehabil 2001;11:20115 51 Huyse FJ, Lyons JS, Stiefel FC et al. INTERMED: a method to assess health service needs. I. Development and reliability. Gen Hosp Psychol 1999;21:3948 52 Stiefel FC, de Jonge P, Huyse FJ et al. INTERMED an assessment and classification system for case complexity.

30

McCARTHY, ARNALL, STRIMPAKOS, FREEMONT, OLDHAM low back pain. Statistician 1985;34:21530 64 Sikorski JM. A rationalized approach to physiotherapy for low-back pain. Spine 1985;10:5719 65 Barker ME. A practical classification of spinal pains based on a study of patients seen in British general practice over a fiveyear period. In: Fairbank JCT, Pynsent PB. (eds) Back Pain: Classification of Syndromes. Manchester: Manchester University Press, 1990; 2336 66 Coste J, Spira A, Ducimetiere P, Paolaggi JB. Clinical and psychological diversity of non-specific low-back pain. A new approach towards the classification of clinical subgroups. J Clin Epidemiol 1991;44:123345 67 Coste J, Paolaggi JB, Spira A. Classification of nonspecific low back pain. II. Clinical diversity of organic forms. Spine 1992;17:103842 68 Rezaian SM, Spector IM, Collins A. A new clinical classification of low back pain: a practical guide for diagnosing etiology by patient history. J Neurol Orthop Med Surg 1993;14:2059 69 Moffroid MT, Haugh LD, Henry SM, Short B. Distinguishable groups of musculoskeletal low back pain patients and asymptomatic control subjects based on physical measures of the NIOSH Low Back Atlas. Spine 1994;19:13508 70 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 71 Langworthy JM, Breen AC. Rationalizing back pain: the development of a classification system through cluster analysis. J Manip Physiol Ther 1997;20:30310 72 Keefe FJ, Bradley LA, Crisson JE. Behavioral assessment of low back pain: identification of pain behavior subgroups. Pain 1990;40:15360

Results in patients with low back pain. Spine 1999;24:37884 53 Binkley J, Finch E, Hall J, Black T, Gowland C. Diagnostic classification of patients with low back pain: report on a survey of physical therapy experts. Phys Ther 1993;73:13850 54 Main CJ, de C Williams A. ABC of psychological medicine: musculoskeletal pain. BMJ 2002;325:5347 55 Humphreys K. Back pain syndromes a chiropractic perspective. In: Fairbank JCT, Pynsent PB. (eds) Back Pain: Classification of Syndromes. Manchester: Manchester University Press, 1990; 7381 56 MacDonald RS. An osteopathic view of back pain classification. In: Fairbank JCT, Pynsent PB. (eds) Back Pain: Classification of Syndromes. Manchester: Manchester University Press, 1990; 6272 57 Coste J, Paolaggi JB, Spira A. Classification of nonspecific low back pain. I. Psychological involvement in low back pain. A clinical, descriptive approach. Spine 1992;17:102837 58 Stiefel FC, de Jonge P, Huyse FJ et al. INTERMED: a method to assess health service needs. II. Results on its validity and clinical use. Gen Hosp Psychol 1999;21:4956 59 BenDebba M, Torgerson WS, Long DM. A validated, practical classification procedure for many persistent low back pain patients. Pain 2000;87:8997 60 Ozguler A, Gueguen A, Leclerc A et al. Using the Dallas pain questionnaire to classify individuals with low back pain in a working population. Spine 2002;27:17839 61 Borkan J, Koes B, Reis S, Cherkin D. A report from the second international forum for primary care research on low back pain. Spine 1998;23:19926 62 Newton W, Curtis P, Witt P, Hobler K. Prevalence of subtypes of low back pain in a defined population. J Fam Pract 1997;45:3315 63 Heinrich I, OHare B, Sweetman B, Anderson JAD. Validation aspects of an empirically derived classification for non-specific

CHRISTOPHER J. McCARTHY (for correspondence Tel: +44 161 2766672; Fax: +44 161 2768078; E-mail:christopher.j.mccarthy@man.ac.uk), FRANCES A. ARNALL, NIKOLAOS STRIMPAKOS, JACQUELINE A. OLDHAM, The Centre for Rehabilitation Science, University of Manchester, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK ANTHONY FREEMONT (Tel/Fax: +44 161 275 5268), Laboratory Medicine Academic Group, University of Manchester, Medical School, Stopford Building, Oxford Road, Manchester, UK