October 23, 2015/Neurosciences/Outcomes

Low Back Pain Care Path Aims to Improve Clinical Outcomes, Reduce Costs

Using subgrouping to match patients with PT interventions


By Ian Stephens, PT, DPT, OCS


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Low back pain (LBP) is one of the most common reasons patients seek healthcare.

The national direct and indirect cost of care for patients with LBP continues to escalate. This increased cost of care has not been shown to correlate with improved outcomes.1 For most patients, expensive imaging, opiate drugs, injections and extended treatment courses are not medically necessary.

Healthcare reform is driving transition from a volume-based reimbursement system to a value-based one. Organizations that are able to standardize care around best-practice patterns are better positioned to maximize clinical outcomes. Currently, significant opportunity exists to improve the management of LBP via standardization of care.

Physical therapists are healthcare providers who are frequently involved in the management of patients with LBP. Early access to physical therapy services for these patients has been reported to result in reduced healthcare utilization and costs.2,3

Recent research on physical therapy management of LBP has focused on classifying patients into subgroups based on clusters of signs and symptoms and providing targeted physical therapy interventions for each subgroup. Studies that emphasize interventions based on subgroup classification have reported improved treatment effect sizes compared with studies that deliver physical therapy interventions using a one-size-fits-all model.4,5


Physical therapy low back pain care path algorithm.

Subgrouping to boost effectiveness

In 2013, Cleveland Clinic developed an evidence-based care path to standardize physical therapist management of patients with LBP. The care path emphasizes the use of subgrouping to match patients with treatment interventions that have the highest probability of effectiveness.

The state of Ohio allows physical therapists to evaluate and treat patients without a physician’s referral. The care path was developed to guide physical therapists’ management of LBP patients in a direct-access model. The care path and direct access system was built with full integration into the physician-based multispecialty spine group, which employs nine PM&R physicians.

The care path initially guides the therapist through a standardized red-flag screening process to identify patients who are at high risk for serious pathology. Physical therapists are instructed to refer to a physician if they identify clusters of red-flag findings that are suggestive of serious pathology, such as fractures, cancer or infection. Once red-flag screening is completed, the care path guides the physical therapist to screen for yellow flags.


Assessment of yellow flags in individuals with LBP is an important part of the examination process. Kendall et al. used the term “yellow flags” to detail how psychological, social and environmental factors could place someone at increased risk for prolonged disability.6 Early identification of yellow flags helps identify patients who may have increased risk for prolonged disability.

Cleveland Clinic’s care path uses the STarT Back Screening Tool (SBST) to assess for psychosocial factors that could impede progress.7,8 The SBST stratifies patients into low, moderate or high risk for prolonged disability. Patients who score high via the SBST are considered to have a high level of psychosocial prognostic risk factors. Physical therapists are expected to manage these patients following principles described in the graded activity/exposure subgroup detailed later in this article and/or refer for medical or psychological management.

The care path also guides physical therapists to use a two-item depression screen to identify patients with elevated risk for depression.9,10 Patients who are positive are referred for further medical and/or psychological management.

Once red- and yellow-flag screening has been completed, the care path guides the physical therapist to complete the objective assessment. The therapist uses the findings to classify the patient in one of five treatment subgroups. Each subgroup is named based on the primary physical therapy treatment intervention that should be emphasized in patient management. The subgroups are:

  • Specific exercise
  • Mobilization/manipulation
  • Stabilization exercise
  • Graded exercise/activity
  • Unweighting

Following are brief descriptions of each subgroup.

Specific exercise

This subgroup uses repeated movement testing to determine whether patients present with a directional preference for exercise. The presence of centralization and/or symptomatic or mechanical response to end-range therapeutic loading strategies is used to determine whether a directional preference is present, and to guide what exercises patients are instructed in for their home exercise program.


Patients in this subgroup often benefit from skilled mobilization or manipulation of their lumbar spine to restore normal mobility and reduce pain. Patients often present with symptoms of stiffness or loss of lumbar motion, sharp pain at end range of motion, no pain below the knee and recent onset of LBP.11

Stabilization exercise

Patients in this subgroup frequently lack strength, endurance and coordination of the muscles that provide support and stability to the lumbar spine. Interventions that improve the patient’s ability to gain motor control of the lumbar spine are emphasized.

Graded exercise/activity

Patients in this subgroup often exhibit signs of psychosocial distress and may show other signs consistent with chronic pain states. Pathoanatomy is de-emphasized in this subgroup, and the focus is on pain neuroscience education and graded exercise.



This subgroup emphasizes unweighting of the lumbar spine via either mechanical lumbar traction or aquatic physical therapy. Unweighting is used to provide relief of symptoms and to allow patients to attempt to progress to functional exercise.

Outcomes assessment is underway

A standardized documentation template has been developed for the care path and is used at Cleveland Clinic to help clinicians effectively classify patients in the appropriate subgroup. Evidence-informed suggestions for duration of plans of care are included in the template to help standardize utilization of physical therapy resources.

Standardized outcome measures are collected during the patient’s initial visit and at predefined intervals during the physical therapy episode of care to track progress. Outcome data currently being collected include:

  • The Modified Oswestry Disability Index
  • The Numeric Pain Rating Scale
  • Boston University’s Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Scale

Data are being collected to assess whether the implementation of the care path’s standardized assessment and treatment method for patients with LBP leads to improved, value-based care.

Dr. Stephens is a clinical team leader in outpatient physical therapy at Cleveland Clinic. His primary areas of practice are with patients with low back pain, headache and chronic pain.


  1. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299(6):656-664.
  2. Fritz JM, Brennan GP, Hunter SJ. Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health Services Res. 2015. Epub ahead of print.
  3. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976). 2012:37(25):2114-2121.
  4. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine (Phila Pa 1976). 2006 Mar 15;31(6):623-631.
  5. Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine (Phila Pa 1976). 2003 Jul 1;28(13):1363-1371; discussion 1372.
  6. Kendall N, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Accident Compensation Corporation and the New Zealand Guidelines Group, Wellington, New Zealand. Oct 2004.
  7. Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008 May 15;59(5):632-641.
  8. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011 Oct 29;378(9802):1560-1571.
  9. Mitchell AJ, Coyne JC. Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and meta-analysis of 22 studies. Br J Gen Pract. 2007 Feb;57(535):144-151.
  10. Lombardo P, Vaucher P, Haftgoli N, et al. The “help” question doesn’t help when screening for major depression: external validation of the three-question screening test for primary care patients managed for physical complaints. BMC Med. 2011;9:114.
  11. Delitto A, George SZ, Van Dillen LR, et al. Low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-A57.
  12. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004 Aug;8(4):283-291.
  13. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther. 2001 Feb;81(2):776-788.
  14. Wang YC, Hart DL, Werneke M, Stratford PW, Mioduski JE. Clinical interpretation of outcome measures generated from a lumbar computerized adaptive test. Phys Ther. 2010 Sep;90(9):1323-1335.

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