Classification approaches for treating low back pain have small effects that are not clinically meaningful: a systematic review with meta-analysis

Review written by Dr Jarod Hall info

Key Points

  1. Classification approaches for the management of low back pain (LBP) seek to group patients into categories based on examination findings in order to apply a corresponding pre-determined treatment approach.
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Clinical heterogeneity in low back pain (LBP) challenges clinicians who aim to identify and target subgroups of LBP. Most treatments for LBP, such as exercise and spinal manipulative therapy, are often applied in a one-size-fits-all approach and have only modest effects on reducing pain and disability for people with LBP (1,2). An emerging concept over the past several years suggests that tailoring treatment approaches through clinical classification has the potential to improve patient outcomes.

The primary aim of this systematic review was to determine the efficacy of non-surgical classification systems for treating LBP compared to general comparators for patient-reported LBP intensity, leg pain intensity and disability. Additionally, a secondary aim of determining the effectiveness of treating sub-classes of classification systems was explored.

Most treatments for low back pain have only modest effects on reducing pain and disability.
Based on current best evidence, clinicians should avoid the strict implementation of these classification systems until more robust evidence emerges.


MEDLINE, EMBASE, CINAHL, Web of Science Core Collection and CENTRAL were searched from inception to 21 June 2021. The authors included randomized trials comparing a classification system (e.g. McKenzie and STarT Back Tool) to any comparator. Studies evaluating participants with

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