Classification-Guided Versus Generalized Postural Intervention in Subgroups of Nonspecific Chronic Low Back Pain

A Pragmatic Randomized Controlled Study

Liba Sheeran, PhD; Robert van Deursen, PhD; Bruce Caterson, PhD; Valerie Sparkes, PhD


Spine. 2013;38(19):1613-1625. 

In This Article

Abstract and Introduction


Study Design. Pragmatic randomized controlled single-blinded study.

Objective. To compare the effects of the classification system guided postural intervention (CSPI) with generalized postural intervention (GPI) in subgroups of nonspecific chronic low back pain (NSCLBP).

Summary of Background Data. Spinal motor control impairments and the associated alterations in spinal postures adopted by patients with NSCLBP are highly variable. Research evaluating the effect of interventions that target the specific movement/posture impairments in NSCLBP subgroups is therefore warranted.

Methods. A total of 49 patients with NSCLBP with a classification of flexion pattern (n = 29) and active extension pattern (n = 20) control impairment were recruited from a large cohort study and randomly assigned into CSPI and GPI. The primary outcome was change in Roland-Morris Disability Questionnaire, secondary outcomes were change in pain visual analogue scale, spinal repositioning sense including thoracic and lumbar absolute error, variable error, constant error, and trunk muscle activity during sitting and standing. The intervention was evaluated at baseline, immediately post one-to-one intervention and post 4-week home-based training.

Results. The CSPI produced statistically and clinically significant reduction in disability (4.2 [95% CI, 2.9–5.3]) and pain (2, [95% CI, 1.3–2.6]) compared with minimal change in the GPI disability (0.4, [95% CI, −0.8 to 1.6]) and pain (−0.2, [95% CI, −0.5 to 0.9]). Repeated measures analysis of variance revealed that CSPI significantly reduced absolute error in thoracic (sitting) and lumbar spine (standing) and constant error in lumbar spine (standing) post one-to-one phase, although this was no longer significant at 4 weeks. Neither intervention had an effect on trunk muscle activity.

Conclusion. Compared with minimal change in the GPI group, the CSPI produced statistically and clinically significant improvements in disability and pain outcomes and short-term improvements in some parameters of spinal repositioning sense in NSCLBP subgroups.


Low back pain affects up to 84% of people in industrialized countries.[1]

Approximately 23% of cases develop into chronic low back pain (CLBP)[2] using the largest proportion of the overall costs spent on its management.[3] CLBP is frequently nonspecific with different combinations of biological, psychosocial, and lifestyle factors contributing to this extremely complex disorder[4] and presenting a challenge in terms of management.[5]

Altered motor control of the spine and habitual postures that patients adopt during sitting[6–8] and standing[8] have been proposed to perpetuate the pain disorder.[9] The evidence for this is inconclusive with some research indicating that sustained spinal postures increase the risk of back pain[10–13] while others show no link.[14–16] Nevertheless, activities involving sustained sitting and standing postures are clinically reported by patients as the most pain provoking in their daily function.[17,18]

Nonspecific chronic low back pain (NSCLBP) individuals tend to sit nearer the end-range of spinal motion[18–20] and have reduced ability to adopt a midrange position of the spine compared with healthy subjects.[8,21,22] Based on the biomechanical model, continual end-range loading may increase spinal tissue strain, contributing to the development and perpetuation of LBP.[23] Alternatively, posture training to enhance midrange spinal position control may reduce spinal tissue load.[24]

Classifying NSCLBP based on pain provoking postures and movements[9] revealed presence of distinct postural alterations[7,8,25] associated with characteristic trunk muscle activation patterns.[6] Postural training that reflects this variation and is matched to specific posture/movement disorder has therefore been recommended.[6,7,26] The aim of this study was to evaluate the effect of classification-based versus generalized postural intervention (GPI) on pain, disability, and physical motor control outcomes including thoracic and lumbar midrange repositioning sense and trunk muscle activity during sitting and standing in patients with NSCLBP.