Management of low back pain: A case series illustrating the pragmatic combination of treatment- and mechanism-based classification systems

This case series describes the pragmatic use of a treatment-based classification system for the management of four patients with a chief complaint of low back pain. Patients were initially classified into stabilization, manipulation, or specific exercise subgroups based on history and clinical examination. Each patient was reassessed during the course of clinical care to determine whether to continue treating according to the initially assigned subgroup or to alter management and incorporate a mechanism-based classification addressing identified impairments. Patient #1 was initially classified in the manipulation category. Within three visits, he reported being "a great deal better" on the Global Rating of Change (GROC) and had a 6-point improvement in his Oswestry Disability Index (ODI). Patient #2, classified in the specific exercise/extension category, reported being "moderately better" using the GROC and had a 22-point improvement in her ODI within six visits. Patient #3, classified in the stabilization category, reported being "a very great deal better" on the GROC and had a 30-point improvement in his ODI Index within four visits. Patient #4 was categorized initially in the manipulation category and subsequently in the specific exercise category; after five visits, he noted being "quite a bit better" using the GROC and he reported a 58-point improvement on his ODI. All four patients in this study were managed using a dynamic pragmatic treatment-based classification approach that allowed for the change of subgroup classification and treatment of impairments and all achieved a clinically meaningful improvement in pain and disability.