Classification of lumbopelvic pain disorders - Why is it essential for management
Curtin University of Technology, School of Physiotherapy, GPO Box U1987, Perth WA 6845, Australia.Manual Therapy (Impact Factor: 1.71). 09/2006; 11(3):169-70. DOI: 10.1016/j.math.2006.01.002
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Classiﬁcation of lumbopelvic pain disorders—Why is it essential for
Curtin University of Technology, School of Physiotherapy, GPO Box U1987, Perth WA 6845, Australia
The majority of lumbopelvic pain disorde rs have no
diagnosis leaving a management vacuum. The classiﬁca-
tion of lumbopelvic pain disorders into subgroups is
considered one of the greatest challenges, so as to enable
the application of speciﬁc and effective interventions. It
is well acknowledged that chronic lumbopelvic pain
disorders are complex and multi-dimensional in nature.
These disorde rs are commonly associated with changes
in neurophysiology, altered motor control, psychologi-
cal factors such as fear and anxiety, faulty coping
strategies, social impact and in some cases pathoanato-
mical factors (Waddell, 2004). There is considerable
debate as to the signiﬁcance of these different factors
and what is cause and effect.
There is a growing focus within physiotherapy to treat
motor control impairments associated with these dis-
orders. Altered motor control in CLBP disorders is
complex, highly variable and individual in nature.
Trunk motor control is inﬂuenced by: spinal–pelvic
posture, movement, stability demand, respiration and
continence demand as well as neurophysiological
factors, pathology and various psycho logical factors.
Altered motor control may be adaptive (protective) or
mal-adaptive (provocative). It can result in excessive
spinal stability and increased spinal loading (due to
muscle guarding and splinting) or reduced spinal
stability (inhibition of spinal stabilizing muscles) leading
to pain (O’Sullivan, 2005).
It is proposed that there are three main groups that
present with chronic disabling lumbopelvic pain with
regard to motor control impairments (O’Sullivan, 2005).
1. The ﬁrst group appears to be represented by subjects
where the movement impairment and motor dys-
function is secondary to an underlying pathological
process such as inﬂammatory pain disorders, neuro-
genic pain, neuropathic or centrally mediated pain
disorders, severe structural disorders.
2. A second group exists where a dominance of
psychological and/or social (non-organic) factors
are the underlying drive behind the disorder. This
results in altered central processing, ampliﬁcation of
pain, and resultant disordered movement and motor
In these two groups, attempts to simply normalize
the motor dysfunction and movem ent impairment
does not result in resolution of the disorder and is
likely to fail.
3. It is proposed that a third group exists where mal-
adaptive movement and motor patterns result in
chronic abnormal tissue loading and ongoing pain
and distress. This group appears to present in two
(a) Pain disorders associated with ‘movement im-
pairment’ classiﬁcation are characterized by
avoidant pain behaviour and are associated with
a loss of normal physiological lumbopevic
mobility in the direction of pain. These disorders
present with abnormally high levels of muscle
guarding and co-contraction of lumbopelvic
muscles. This results in abnormally high levels
of compressive loading across articulations,
excessive stability and hence movement restric-
tion as well as muscle strain and fatique. This is
usually accompanied by fear of moving into the
painful impairment, as well as faulty cognitive
coping strategies and beliefs regarding the pain
disorder. This represents a mal-adaptive re-
sponse to a pain disorder and a mechanism for
ongoing pain and disability.
Management of this group is based on a cognitive
ARTICLE IN PRESS
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YMATH : 687
1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
behavioural model. The aim is to reduce fear of
movement and reduce muscle tone by education
and facilitating graduated movement exposure
into the painful range in a relaxed and normal
(b) Pain disorders associated with ‘control impair-
ment’ classiﬁcation are associated with no
impairment to the mobility of the symptomatic
spinal segment in the direction of pain provoca-
tion. Rather they present with impairments in
the control of the symptomatic spinal segment in
the direction of pain. This is associated with
deﬁcits in motor control with the inability to
effectively control the neutral zone of the motion
segment or ﬁx the spinal segme nt at an end range
provocative positions. This appears to result in
pain secondary to recurrent end range strain an d
non-physiological spinal segment movement and
loading. These patients adopt postures and
movement patterns that are mal-ad aptive, pro-
vocative (not avoidant) and represents a me-
chanism for ongoing pain and disability.
A motor learning intervention based on a cognitive
behavioural treatment model with the aim of changing
faulty movement behaviour that is linked to the pain
disorder is advocated for these disorders.
There is growing evidence to support the presence of
these sub-groups of patients leading to effective targeted
interventions (O’Sullivan, 2000, 2004, 2005; O’Sullivan
et al., 2002, 2003, 2005; Burnett et al., 2004; Elvey and
O’Sullivan, 2004; Dankaerts et al., 2005a, b).
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[Show abstract] [Hide abstract] ABSTRACT: Non-specific low back pain (NSLBP) accounts for over 85% of all low back pain. Homogenous subgroups may exist within this diagnosis. This study derived a clinical examination and evaluated the examination's ability to identify homogenous subgroups in NSLBP. Patients with NSLBP were examined using a standardized clinical examination. Each patient was examined by two physiotherapists. Data were analysed for item reliability and the presence of distinct subgroups using cluster analysis. Cross-validation of the clusters identified was conducted. Three hundred and one patients were examined. The inter-tester reliability of the majority of items was moderate to substantial (52% of items with kappa > 0.40). A K-means cluster analysis of the two data sets revealed agreement on the presence of two subgroups. One group (n = 47, 16%) had higher fear avoidance beliefs, anxiety and disability. They were more likely to be provoked by pain provocative tests. They were also more likely to be judged as having central sensitization and a dominant psychosocial component to their presentation. The identification of a group of hypervigilant NSLBP patients should allow the interventions to be targeted towards this group. A valid, standardized clinical examination does contribute to the diagnostic management of NSLBP.
- "The vast majority of data collected were of physical impairment. Very few data were collected that reflected functional disability, and thus this classification approach has more in common with classification systems using movement and pain response to classify NSLBP (Peterson et al., 1999; Fritz et al., 2003; Van Dillen et al., 2003; Laslett et al., 2005: O'Sullivan, 2006) than those classifying by physical activity and perceptions of pain (Hill et al., 2008; Hill et al., 2010). These differing approaches to classification probably reflect the wide‐ranging requirements of diagnostic classification systems applied to a condition that affects each domain of the biopsychosocial domains. "
- [Show abstract] [Hide abstract] ABSTRACT: Points which should be considered while dealing with heterogeneous clinical problems and presentations are discussed. The process of clinical decision making could be constrained by requiring that the experimental intervention is always administered in a particular way, or by defining precise algorithms for decisions about intervention. A trial might recruit from the diverse populations for whom therapy is usually provided in the course of normal clinical practice. Therapists could be given freedom in exactly how they provide the experimental intervention, and they might be allowed to customize the intervention to particular needs of individual patients. Also, prognostic factors can be identified using cohort studies, but effect modifiers can be identified with controlled clinical trials.
- [Show abstract] [Hide abstract] ABSTRACT: What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the assessment and management of patients with shoulder pain? Qualitative study using a three-round Delphi procedure. Twenty-six experts in the UK consented to be involved and were contactable, of whom 20 contributed, with 12, 15, and 15 contributing to the different rounds. Clinical reasoning was mostly about diagnostic reasoning, but also involved narrative reasoning. Diagnostic reasoning involved both pattern recognition and hypothetico-deductive reasoning. Diagnostic reasoning emphasised general history items, a constellation of signs and symptoms to identify specific diagnostic categories, and standard physical examination procedures. Narrative reasoning was highlighted by the communication involved in expert history taking, seeing patients in their functional and psychological context, and collaborative reasoning with the patient regarding management. These expert clinicians demonstrated the use of diagnostic pattern recognition, and hypothetico-deductive and narrative clinical reasoning processes. The emphasis was on the history and basic physical examination procedures to make clinical decisions.