Now that you know the basics, we can get slightly more specific with classification models. These are classifications used in physiotherapy. Keep in mind that whatever classification you use, it should help you refer when needed. We have to understand that we can not treat everything.
I am biased. I believe that classifying patients leads to better outcome and that it is the future of physiotherapy. Hopefully, I will convince you to think the same way.
In university, I was taught to direct my treatment based on the physiotherapy diagnosis. It felt incredible to believe that I was able to diagnose! It felt incredible to think that I was able to differentiate between a bursitis, a rotator cuff tear, a herniated disc, a hypomobile joint and an instability! Each diagnosis had a slightly different treatment! A herniated disc likes traction. A bursitis benefits from ultrasound. A rotator cuff you check motor control of the scapula and drop some deep tendon friction to realign the fibers. A hypomobile joint you give ROM and throw some massage. It felt great! Too bad a few weeks after my graduation, I realized that physiotherapists weren’t reliable at giving a pathonanatomical diagnostic. This leads to poor evidence regarding effectiveness of physiotherapy. It frustrated me. Take for example low back pain. Even after thousands of randomized control trials, there is still no consensus on the best diagnosis and/or treatment!
Let me explain. The tools we use to diagnose aren’t reliable:
- Palpation: we already know is rarely reliable (here)
- Special tests. (for shoulder: Most of them, just tells you that you have shoulder pain…!)
- For lumbar spine:
- Experimentally induced pain changes ASLR test findings (here) !! So what came first? Pain or “instability”?
- Patho-anatomical diagnosis cannot be given in about 85% of low back pain patients (here)
Let’s push it further. Let us assume that those tests were reliable… Let us assume that somehow we were able to identify that someone has a disc herniation or an instability. How do we even make sure that it is the cause of their pain? To what do we compare them to? MRI? X-Rays? We can’t.
Here is the reason why:
Most asymptomatic people (never even had pain in their life) present with abnormalities! This leads to the question: “Is their pain really due to the herniated disc? Or was the herniated disc already present?”
So… Most of the time, we can’t give a patho-anatomical diagnosis, it does not guide our treatment, and it can even lead to wrong treatment approaches.
This is why many researchers got interested in classification models.
Preliminary researches show that classifying patients leads to better outcome (and yes, I cherry pick my studies and I am biased. Make your own opinion):
Mechanical Diagnosis and Therapy (Low back, knee)
- Lumbar spine RCT
- Knee randomized control trial
- The McKenzie Compared With Manipulation in Low Back Pain
Jeremy Lewis (shoulder)
O’Sullivan classification (low back)
- Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism.
Treatment based classification (neck, low back)
- Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain.
- The cost-effectiveness of a treatment-based classification system for low back pain: design of a randomised controlled trial and economic evaluation
- Exercise Only, Exercise With Mechanical Traction, or Exercise With Over-Door Traction for Patients With Cervical Radiculopathy, With or Without Consideration of Status on a Previously Described Subgrouping Rule: A Randomized Clinical Trial
Mechanism-based classification (just theoretically)
Theory: http://www.manualtherapyjournal.com/article/S1356-689X(12)00081-1/abstract . And theoretical treatment matched to the centrally sensitized subgroup: Pain education helps
I believe that more research is needed but that we have enough evidence to start classifying our patients into homogenous subgroups based on their clinical presentation. Each of them would benefit from a specific treatment…We also have enough evidence to stop worrying as much as before about pathoanatomy.
I believe that classifying patients before we treat them will lead to better outcome. This will then (finally) result in more conclusive researches supporting physiotherapy treatments.
I hope this helps.