One of the major problems in rehabilitation is a method of repeatedly testing and classifying patients so as to correctly direct treatment and reassess. A recent push for outcome measures pre and post treatment has been made in most rehabilitative areas however until there is both widespread adoption and widespread data indicating that these measures are valid, this is only the first step towards a solution.
Kent et al 2010 asked does targeted therapy work better than general therapy for non-specific low back pain (NSLB). It worthy of noting that in this review the authors began with 2690 articles and only 4 met inclusion criteria. In this case, the standards for inclusion were very high. The study in its entirety is freely available here and I would encourage therapists to go through it as it is rather eye opening.
In summary, at this time, we have very little evidence indicating that targeted therapy is better than non-targeted therapy over the short-term. The results are patchy, inconclusive and generally inconsistent. What needs to occur is a standardized method of determining sub-groups which physiotherapists then can use to begin targeted vs. non-targeted therapy. Until such screening procedures are developed, physios, chiros, osteos and all the rest in manual and exercise rehabilitation are firing blindly in the dark. The very fact that most countries recognize physiotherapy and chiropractic medicine as the proper routes for rehabilitation and the clinicians have no way to properly classify their patients is very unsettling. The entire system is built upon the idea that a therapist can quickly and correctly take a history, do some tests and diagnose a patient and then begin a specific and appropriate treatment for him or her. If this is not the case, if all the treatments are simply as good as any other- then what is the future of therapy? This requires very serious consideration for all who practice.
Providing hope and in stark contrast is Flynn et al’s 2002 study The idea of the study was to determine if a physiotherapist could determine quickly and accurately who would respond to manual therapy before beginning treatment.
They reported several data points while analyzing spinal manipulative therapy. First, special tests which are supposed to identify who will respond to manual therapy are ineffective. The best predictor was duration of symptoms with t hose having pain less than 16 days in an acute period having the highest chance of recovery. The established Flynn manipulative rules became; duration of symptoms <16 days, FABQ score <19, at least one hip with >35 degrees of int. rot., a hypomobile lumbar spine, and no symptoms distal to the knee. When 4 of the 5 were present, the likelihood of successful manual therapy ranged from 45-95%. This is unfortunately a huge gulf and while a good first step, requires much more analysis before it can be used regularly. Further, as discussed above, once we determine that the patient falls into a category where manual therapy will help them- what does the therapist do- specific or non-specific treatment? It is up to the clinicians at this time to try and do the best they can but this cannot hold forever. Sooner or later, protocols of some sort will be developed.