Skip to main content
SpringerLink
Log in

Subclassification of low back pain: a cross-country comparison

  • Review Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Various health professionals have attempted to classify low back pain (LBP) subgroups and have developed several LBP classification systems. Knowing that culture has an effect on LBP symptomatology, assessment findings and clinical decision making, the aim of this review is to perform a cross-country comparative review amongst the published classification systems, addressing each country’s similarities and differences as well as exploring whether cultural factors have been incorporated into the subclassification process. A systematic search of databases limited to human adults was undertaken by Medline, Cinahl, AMED and PEDro databases between January 1980 and October 2005. Classification systems from nine countries were identified. Most studies were classified according to pathoanatomic and/or clinical features, whereas fewer studies utilized a psychosocial and even less, a biopsychosocial approach. Most studies were limited in use to the country of the system’s developer. Very few studies addressed cultural issues, highlighting the lack of information on the impact of specific cultural factors on LBP classification procedures. However, there seem to be certain ‘cultural trends’ in classification systems within each country, which are discussed. Despite the plethora of classification studies, there is still no system which is internationally established, effective, reliable and valid. Future research should aim to develop a LBP classification system within a well identified cultural setting, addressing the multi-dimensional features of the LBP presentation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Aceves-Avila FJ, Ferrari R, Ramos-Remus C (2004) New insights into culture driven disorders. Best Pract Clin Res Rheumatol 18:155–171

    Article  Google Scholar 

  2. Ammendolia C, Bombardier C, Hogg-Johnson S et al (2002) Views on radiography use for patients with acute low back pain among chiropractors in an Ontario community. J Manipulative Physiol Ther 25:511–520

    Article  PubMed  Google Scholar 

  3. Andersson GB (1998) Epidemiology of low back pain. Acta Orthop Scand Suppl 281(69):28–31

    PubMed  CAS  Google Scholar 

  4. Atlas SJ, Deyo RA, Patrick DL, et al (1996) The Quebec Task Force classification for Spinal Disorders and the severity, treatment, and outcomes of sciatica and lumbar spinal stenosis. Spine 21:2885–2892

    Article  PubMed  CAS  Google Scholar 

  5. Barker ME (1990) A practical classification of spinal pains based on a study of patients seen in British general practice over a five-year period. In: Fairbank JCT, Pynsent PB (eds) Back pain: classification of syndromes. Manchester University Press, Manchester, pp 23–36

  6. BenDebba M, Torgerson WS, Long DM (2000) A validated, practical classification procedure for many persistent low back pain patients. Pain 87:89–97

    Article  PubMed  CAS  Google Scholar 

  7. Bergstrom G, Bodin L, Jensen IB et al (2001a) Long-term, non-specific spinal pain: reliable and valid subgroups of patients. Behav Res Ther 27:1783–1789

    Google Scholar 

  8. Bergstrom G, Jensen IB, Bodin L et al (2001b) The impact of psychologically different patient groups on outcome after a vocational rehabilitation program for long-term spinal pain patients. Pain 93:229–237

    Article  PubMed  CAS  Google Scholar 

  9. Billis EV, McCarthy CJ, Stathopoulos I et al (2006) The clinical and cultural factors in classifying low back pain patients within Greece: a qualitative exploration of Greek health professionals. J Eval Clin Pract (in press)

  10. Binkley J, Finch E, Hall J et al (1993) Diagnostic classification of patients with low back pain: report on a survey of physical therapy experts. Phys Ther 73:138–150

    PubMed  CAS  Google Scholar 

  11. Borenstein DG (1999) Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol 11:151–157

    Article  PubMed  CAS  Google Scholar 

  12. Borkan JM, Koes B, Reis S et al (1998) A report from the second international forum for primary care research on low back pain. Spine 23:1992–1996

    Article  PubMed  CAS  Google Scholar 

  13. Borkan J, Van Tulder M, Reis S et al (2002) Advances in the field of low back pain in primary care. A report from the fourth international forum. Spine 27:E128–E132

    Article  PubMed  Google Scholar 

  14. Bouter LM, Van Tulder MW, Koes BW (1998) Methodologic issues in low back pain research in primary care. Spine 23:2014–2020

    Article  PubMed  CAS  Google Scholar 

  15. Brena SF, Sanders SH, Motoyama H (1990) American and Japanese chronic low back pain patients: cross-cultural similarities and differences. Clin J Pain 6:118–124

    Article  PubMed  CAS  Google Scholar 

  16. Buchbinder R, Goel VK, Bombardier C et al (1996) Classification systems of soft tissue disorders of the neck and upper limb: Do they satisfy methodological guidelines? J Clin Epidemiol 49:141–149

    Article  PubMed  CAS  Google Scholar 

  17. Carron H, DeGood DE, Tait R (1985) A comparison of low back pain patients in the United States and New Zealand: psychosocial and economic factors affecting severity of disability. Pain 21:77–89

    Article  PubMed  CAS  Google Scholar 

  18. Childs MJ, Fritz JM, Flynn TW et al (2004) A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: A validation study. Ann Intern Med 141:920–928

    PubMed  Google Scholar 

  19. Coste J, Paolaggi JB, Spira A (1992) Classification of nonspecific low back pain. I. Psychological involvement in low back pain. A clinical, descriptive approach. Spine 17:1028–1037

    Article  PubMed  CAS  Google Scholar 

  20. Coste J, Paolaggi JB, Spira A (1992) Classification of nonspecific low back pain. II. Clinical diversity of organic forms. Spine 17:1038–1042

    Article  PubMed  CAS  Google Scholar 

  21. Cristiaens T, De Backer D, Burgers J et al (2004) Guidelines, evidence, and cultural factors. Comparison of four European guidelines on uncomplicated cystitis. Scand J Prim Health Care 22:141–145

    Article  Google Scholar 

  22. CSAG. Clinical standards advisory group back pain (1994) HMSO, London

  23. Dankaerts W, O’Sullivan PB, Straker LM et al (2006) The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment. Man Ther 11:28–39

    Article  PubMed  CAS  Google Scholar 

  24. Delaney PM, Hubka MJ (1999) The diagnostic utility of McKenzie clinical assessment for lower back pain. J Manipulative Physiol Ther 22:628–630

    Article  PubMed  CAS  Google Scholar 

  25. Delitto A, Erhard R, Bowling RW (1995) A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther 75:470–489

    PubMed  CAS  Google Scholar 

  26. DeRosa CP, Porterfield JA (1992) A physical therapy model for the treatment of low back pain. Phys Ther 72:261–269

    PubMed  CAS  Google Scholar 

  27. Donahue MS, Riddle DL, Sullivan MS, et al (1996) Intertester reliability of a modified version of McKenzie’s lateral shift assessments obtained on patients with low back pain. Phys Ther 76:706–726

    PubMed  CAS  Google Scholar 

  28. Donelson R (2004) Evidence-based low back pain classification. Improving care at its foundation. Eura Medicophys 40:37–44

    PubMed  CAS  Google Scholar 

  29. Donelson R, Aprill C, Medcalf R et al (1997) A prospective study of centralization of lumbar and referred pain: a predictor of symptomatic discs and annular competence. Spine 22:1115–1122

    Article  PubMed  CAS  Google Scholar 

  30. Dunn KM, Croft PR (2005) Classification of low back pain in primary care: using ‘bothersomeness’ to identify the most severe cases. Spine 30:1887–1892

    Article  PubMed  Google Scholar 

  31. Espeland A, Baerheim A (2003) Factors affecting general practitioners’ decisions about plain radiography for back pain: implications for classification of guideline barriers—a qualitative study. BMC Health Serv Res 8:1–10

    Google Scholar 

  32. Fardon DF (1997) Differential diagnosis of low back disorders. Principles of classification. In: Frymoyer JW (ed) The adult spine. principles and practice, 2nd edn. Lippincott-Raven Publishers, Philadelphia, vol 2, pp 1745–1768

  33. Flynn T, Fritz J, Whitman J et al (2002) A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 27:2835–2843

    Article  PubMed  Google Scholar 

  34. Freburger JK, Karey TS, Holmes GM (2005) Physician referrals to physical therapists for the treatment of spine disorders. Spine J 5:530–541

    Article  PubMed  Google Scholar 

  35. Free MM (2002) Cross-cultural conceptions of pain and pain control. BUMC Proc 15:143–145

    Google Scholar 

  36. Fritz JM (1998) Use of a classification approach to the treatment of 3 patients with low back syndrome. Phys Ther 78:766–777

    PubMed  CAS  Google Scholar 

  37. Fritz JM, Delitto A, Erhard RE (2003) Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine 28:1363–1372

    Article  PubMed  Google Scholar 

  38. Fritz JM, George S (2000) The use of a classification approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine 25:106–114

    Article  PubMed  CAS  Google Scholar 

  39. George SZ, Delitto A (2005) Clinical examination variables discriminate among treatment-based classification groups: a study of construct validity in patients with acute low back pain. Phys Ther 85:306–314

    PubMed  Google Scholar 

  40. Goubert L, Crombez G, De Bourdeaudhuij I (2004) Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships. Eur J Pain 8:385–394

    Article  PubMed  Google Scholar 

  41. Harper AC, Harper DA, Lambert LJ et al (1992) Symptoms of impairment, disability and handicap in low back pain: a taxonomy. Pain 50:189–195

    Article  PubMed  CAS  Google Scholar 

  42. Hart LG, Deyo RA, Cherkin DC (1995) Physician office visits for low back pain: frequency, clinical evaluation, and treatment patterns from a US national survey. Spine 20:11–19

    Article  PubMed  CAS  Google Scholar 

  43. Heinrich I, O’Hare H, Sweetman B et al (1985) Validation aspects of an empirically derived classification for non-specific low back pain. Statistician 34:215–30

    Article  Google Scholar 

  44. Heiss DG, Fitch DS, Fritz JM et al (2004) The interrater reliability among physical therapists newly trained in a classification system for acute low back pain. J Orthop Sports Phys Ther 34:430–439

    Article  PubMed  Google Scholar 

  45. Helman CG (2000) Cultural factors in epidemiology. In: Helman CG (ed) Culture, health and illness, 4th edn. Gutenberg Press, Malta, pp 218–229

  46. Hicks GE, Fritz JM, Delitto A et al (2005) Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil 86: 1753–1762

    Article  PubMed  Google Scholar 

  47. Hutten MMR, Hermens HJ (2001) Differences in treatment outcome between subgroups of patients with chronic low back pain using lumbar dynamometry and psychological aspects. Clin Rehabil 15:479–488

    Article  PubMed  CAS  Google Scholar 

  48. Huyse FJ, Lyons JS, Stiefel FC et al (1999) “INTERMED”: a method to assess health service needs. I. Development and reliability. Gen Hosp Psychiatry 21:39–48

    Article  PubMed  CAS  Google Scholar 

  49. Karas R, McIntosh G, Hall H, et al (1997) The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain. Phys Ther 77:354–360

    PubMed  CAS  Google Scholar 

  50. Keefe FJ, Bradley LA, Crisson JE (1990) Behavioral assessment of low back pain: identification of pain behavior subgroups. Pain 40:153–160

    Article  PubMed  CAS  Google Scholar 

  51. Kent P, Keating J (2004) Do primary-care clinicians think that nonspecific low back pain is one condition? Spine 29:1022–1031

    Article  PubMed  Google Scholar 

  52. Kent P, Keating JL (2005) Classification in nonspecific low back pain: what methods do primary care clinicians currently use? Spine 30:1433–1440

    Article  PubMed  Google Scholar 

  53. Kilpikoski S, Airaksinen O, Kankaanpaa M et al (2002) Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 27:E207–E214

    Article  PubMed  Google Scholar 

  54. Klapow JC, Slater MA, Patterson TL et al (1993) An empirical evaluation of multidimensional clinical outcome in chronic low back pain patients. Pain 55:107–18

    Article  PubMed  CAS  Google Scholar 

  55. Klapow JC, Slater MA, Patterson TL et al (1995) Psychosocial factors discriminate multidimensional clinical groups of chronic low back pain patients. Pain 62:349–55

    Article  PubMed  CAS  Google Scholar 

  56. Krause N, Ragland DR (1994) Occupational disability due to low back pain: a new interdisciplinary classification based on a phase model of disability. Spine 19:1011–1120

    Article  PubMed  CAS  Google Scholar 

  57. Langworthy JM, Breen AC (1997) Rationalizing back pain: the development of a classification system through cluster analysis. J Manipulative Physiol Ther 20:303–310

    PubMed  CAS  Google Scholar 

  58. Laslett M, van Wijmen P (1999) Low back and referred pain: diagnosis and a proposed new system of classification. NZ J Physiother 27:5–14

    Google Scholar 

  59. Leboeuf-Yde C, Lauritsen JM, Lauritzen T (1997) Why has the research for causes of low back pain largely been nonconclusive? Spine 22:877–881

    Article  PubMed  CAS  Google Scholar 

  60. Loisel P, Vachon B, Lemaire J et al (2002) Discriminative and predictive validity assessment of the Quebec Task Force classification. Spine 27:851–857

    Article  PubMed  Google Scholar 

  61. Long A, Donelson R, Fung T (2004) Does it matter which exercise? a randomized control trial of exercise for low back pain. Spine 29:2593–2602

    Article  PubMed  Google Scholar 

  62. Main CJ, Wood PLR, Hollis S et al (1992) The distress and risk assessment method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine 17:42–52

    Article  PubMed  CAS  Google Scholar 

  63. Maluf KS, Sahrmann SA, Van Dillen LR (2000) Use of a classification system to guide nonsurgical management of a patient with chronic low back pain. Phys Ther 80:1097–1111

    PubMed  CAS  Google Scholar 

  64. Maniadakis N, Gray A (2000) The economic burden of back pain in the UK. Pain 84:95–103

    Article  PubMed  CAS  Google Scholar 

  65. Marras WS, Parnianpour M, Ferguson SA et al (1995) The classification of anatomic- and symptom-based low back disorders using motion measure models. Spine 20:2531–2546

    Article  PubMed  CAS  Google Scholar 

  66. McCarthy CJ, Arnall F, Strimpakos N et al (2004) The bio-psycho-social classification of non-specific low back pain: a systematic review. Phys Ther Rev 9:17–30

    Article  Google Scholar 

  67. McKenzie R (1981) Subgroups in non specific spinal disorders. In: McKenzie R (ed) The lumbar spine: mechanical diagnosis and therapy. Spinal Publications Limited, Waikanae, pp 34–37

  68. Moffroid MT, Haugh LD, Henry SM et al (1994) Distinguishable groups of musculoskeletal low back pain patients and asymptomatic control subjects based on physical measures of the NIOSH Low Back Atlas. Spine 19:1350–1358

    Article  PubMed  CAS  Google Scholar 

  69. Mooney V (1989) The classification of low back pain. Ann Med 21:321–325

    PubMed  CAS  Google Scholar 

  70. Newton W, Curtis P, Witt P et al (1997) Prevalence of subtypes of low back pain in a defined population. J Fam Pract 45:331–335

    PubMed  CAS  Google Scholar 

  71. O’Hearn MA (1997) Physical therapy treatment of low back pain: A report of outcomes according to three types of patient classification. J Rehabil Outcomes Meas 1:23–31

    Google Scholar 

  72. O’Sullivan P (2005) Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Man Ther 10:242–255

    Article  PubMed  Google Scholar 

  73. Ozguler A, Gueguen A, Leclerc A et al. (2002) Using the Dallas Pain Questionnaire to classify individuals with low back pain in a working population. Spine 27:1783–1789

    Article  PubMed  Google Scholar 

  74. Petersen T, Laslett M, Thorsen H, et al (2003) Diagnostic classification of non-specific low back pain. A new system integrating patho-anatomic and clinical categories. Physiother Theory Pract 19:213–237

    Article  Google Scholar 

  75. Petersen T, Olsen S, Laslett M et al (2004) Inter-tester reliability of a new diagnostic classification system for patients with non-specific low back pain. Aust J Physiother 50:85–91

    PubMed  Google Scholar 

  76. Petersen T, Thorsen H, Manniche C et al (1999) Classification of nonspecific low back pain: a review of the literature on classification systems relevant to physiotherapy. Phys Ther Rev 4:265–281

    Google Scholar 

  77. Picavet HJS, Schouten JSAG (2003) Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3 -study. Pain 102:167–178

    Article  PubMed  CAS  Google Scholar 

  78. Pincus T, Burton AK, Vogel S et al (2002) A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 27:E109–E120

    Article  PubMed  Google Scholar 

  79. Rezaian SM, Spector IM, Collins A (1993) A new clinical classification of low back pain: a practical guide for diagnosing etiology by patient history. J Neurol Orthop Med Surg 14:205–209

    Google Scholar 

  80. Riddle DL (1998) Classification and low back pain: a review of the literature and critical analysis of selected systems. Phys Ther 78:708–737

    PubMed  CAS  Google Scholar 

  81. Riddle DL, Rothstein JM (1993) Intertester reliability of McKenzie’s classifications of the syndrome types present in patients with low back pain. Spine 18:1333–1344

    Article  PubMed  CAS  Google Scholar 

  82. Sanders SH, Brena SF, Spier CJ et al (1992) Chronic low back pain patients around the world: cross-cultural similarities and differences. Clin J Pain 8:317–323

    Article  PubMed  CAS  Google Scholar 

  83. Schers H, Braspenning J, Drijver R et al (2000) Low back pain in general practice: reported management and reasons for not adhering to the guidelines in The Netherlands. Br J Gen Pract 50:640–644

    PubMed  CAS  Google Scholar 

  84. Seller RH, Lobley M (1991) Efficient diagnosis of common complaints: a comparative study in the United States and England. J Fam Pract 33:41–46

    PubMed  CAS  Google Scholar 

  85. Sikorski JM (1985) A rationalized approach to physiotherapy for low-back pain. Spine 10(6):571–579

    Article  PubMed  CAS  Google Scholar 

  86. Skovron ML, Szpalski M, Nordin M et al (1994) Sociocultural factors and back pain. A population-based study in Belgian adults. Spine 19:129–137

    Article  PubMed  CAS  Google Scholar 

  87. Spitzer WO, LeBlanc FE, Dupuis M (1987) Scientific approach to the assessment and management of activity related spinal disorders: report of the Quebec Task Force on Spinal Disorders. Spine 12:S16–S21

    Article  Google Scholar 

  88. Stiefel FC, de Jonge P, Huyse FJ et al (1999a) “INTERMED”: a method to assess health service needs. II. Results on its validity and clinical use. Gen Hosp Psychiatry 21:49–56

    Article  PubMed  CAS  Google Scholar 

  89. Stiefel FC, de Jonge P, Huyse FJ et al (1999b) INTERMED—an assessment and classification system for case complexity. Results in patients with low back pain. Spine 24:378–384

    Article  PubMed  CAS  Google Scholar 

  90. Stranjalis G, Tsamandouraki K, Sakas DE et al (2004) Low back pain in a representative sample of Greek population. Analysis according to personal and socioeconomic characteristics. Spine 29:1355–1361

    Article  PubMed  Google Scholar 

  91. Strong J, Ashton R, Stewart A (1994) Chronic low back pain: toward an integrated psychosocial assessment model. J Consult Clin Psychol 62:1058–1063

    Article  PubMed  CAS  Google Scholar 

  92. Strong J, Large RG, Ashton R et al (1995) A New Zealand replication of the IPAM clustering model for low back patients. Clin J Pain 11:296–306

    Article  PubMed  CAS  Google Scholar 

  93. Szpalski M, Nordin M, Skovron ML et al (1995) Health care utilization for low back pain in Belgium. Influence of sociocultural factors and health beliefs. Spine 20:431–442

    Article  PubMed  CAS  Google Scholar 

  94. Tait R, DeGood D, Carron H (1982) A comparison of health locus of control beliefs in low-back patients from the US and New Zealand. Pain 14:53–61

    Article  PubMed  CAS  Google Scholar 

  95. Tenhula JA, Rose SJ, Delitto A (1990) Association between direction of lateral lumbar shift, movement tests, and side of symptoms in patients with low back pain syndrome. Phys Ther 70:480–486

    PubMed  CAS  Google Scholar 

  96. Van Dillen LR, Sahrmann SA, Norton BJ et al (2003) Movement system impairment-based categories for low back pain: stage 1 validation. JOSPT 33:126–142

    PubMed  Google Scholar 

  97. Van Dillen LR, Sahrmann SA, Norton BJ et al (1998) Reliability of physical examination items used for classification of patients with low back pain. Phys Ther 78:979–988

    PubMed  CAS  Google Scholar 

  98. Waddell G (1998) The problem, social interactions, treatment: the scientific evidence. In: Wadell G (ed) The back pain revolution. Churchill Livingstone, Edinburgh, pp 1–8, 204–205, 265–267

  99. Werneke M, Hart DL (2001) Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 26:758–765

    Article  PubMed  CAS  Google Scholar 

  100. Werneke M, Hart DL (2003) Discriminant validity and relative precision for classifying patients with non-specific neck and back pain by anatomic pain patterns. Spine 28:161–166

    Article  PubMed  Google Scholar 

  101. Werneke MW, Hart DL (2004) Categorizing patients with occupational low back pain by use of the Quebec Task Force classification system versus pain pattern classification procedures: discriminant and predictive validity. Phys Ther 84:243–254

    PubMed  Google Scholar 

  102. Werner EL, Ihlebaek C, Skouen JS et al (2005) Beliefs about low back pain in the Norwegian general population: are they related to pain experiences and health professionals? Spine 30:1770–1776

    Article  PubMed  Google Scholar 

  103. Wilson L, Hall H, McIntosh G et al (1999) Intertester reliability of a low back pain classification system. Spine 24:248–254

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Physiotherapy, Technological Educational Institute (TEI) of Lamia, Lamia, Fthiotida, Greece

    Evdokia V. Billis

  2. Centre for Rehabilitation Science, University of Manchester, Manchester, UK

    Evdokia V. Billis

  3. Emergency Care and Rehabilitation, Warwick Medical School, University of Warwick, Warwick, UK

    Christopher J. McCarthy

  4. Wellcome Trust Clinical Research Facility, University of Manchester, Manchester, UK

    Jacqueline A. Oldham

Authors
  1. Evdokia V. Billis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher J. McCarthy
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jacqueline A. Oldham
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Evdokia V. Billis.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Billis, E.V., McCarthy, C.J. & Oldham, J.A. Subclassification of low back pain: a cross-country comparison. Eur Spine J 16, 865–879 (2007). https://doi.org/10.1007/s00586-007-0313-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-007-0313-2

Keywords

Search

Navigation