Sub-classification by SMARTERehab: Mission accomplished!

The most comprehensive sub-classification model

Background

Sub-classification identifies subgroups based on clinical presentation criteria, physical assessment, specific  questionnaires or other diagnostic investigations. These subgroups then have targeted treatments associated with them. Interventions that use sub-classification are better than ones that do not.   

The goal was to have a reliable and valid sub-classification model that could accurately address all patients that presented to clinicians and provide a rehabilitation directive that would provide significant benefit. The aim of this model (reliability and validity) was to allow it to facilitate a change in the profession and it was designed with that goal. For it to be useful, it needed to be n evidence based model that could be used in the same manner by all therapists.

Mission Accomplished

There are many sub-classification models out there. We have showed quite clearly from our literature review model "what is different between normal subjects and (insert condition)" that all other models fail to adequately address the complexity that patients present with. The completion of The Movement Project, The Learning project, The Body Image Project, The Pain Project and The NISE Syndrome Project has provided the most comprehensive sub-classification model in musculoskeletal medicine. We can now accurately sub-classify and provide a rehabilitation directive to nearly all (>97%) patients with musculoskeletal pain. 

Figure 1: The SMARTErehab Sub-classification Model

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           Sub-classification Categories in Brief:

      NISE Regulation (Neuro-immune-sympathetic-endocrine)

o   assesses symptoms in 18 bodily systems

·         Behavioral Factors

o   using a combined battery of ultra short screens, 14 psychological domains are assessed

·         Pain Mechanisms

o   Nociceptive

o   Central Body Image Pain

o   Central Sensitization spectrum (including neuropathic pain)

·         Neurological Factors & Central Nervous System Coordination (ability to learn)

o   Neurocognitive function

o   Sensory motor deficits

o   Neurological soft signs including Primitive & Postural Reflexes

o   Midline Awareness

·         Movement & Motor Function

o   Movement pattern control

o   Translation control

o   Respiratory function

o   Strength and endurance

o   Directional preference

·         Patho-anatomical

o   Articular

o   Myofascial

o   Neurodynamic

o   Connective tissue

Functional Mechanisms

It is necessary to understand the underlying causes of each sub-classification. Although genetics play a role, rehab can only address those mechanisms that are modifiable therefore the focus is on "functional (modifiable) mechanisms". There are many therapies that are logical and useful, but fail because they do not consider the true underlying functional mechanism. We have organized our sub-classification and interventions to address this.

Reliability & Diagnostic Accuracy

There are many great models out there to address aspects of movement, motor control and chronic pain. Unfortunately many of the assessment strategies have poor reliability or would highly unlikely be found reliable if tested because they do not lend themselves to having reliability if assessed. The mandate of SMARTERehab was to have a reliable sub-classification. In order to change practice and facilitate wide implementation, there is a need to have a reliable sub-classification model. Therefore, questionnaires were chosen as a key component as the assessment since they are much more likely to be reliable than a physical assessment alone. Further, the goal was to have tools with high diagnostic accuracy. It is great of a questionnaire identified two-thirds of a group with a poor outcome for example, but that may be fine for an academic who wants a publication in a peer reviewed journal, but it not helpful for the clinician to miss one - third. We would not accept that for serious medical conditions, so why would we accept it for musculoskeletal pain. The goal of the SMARTERehab model was to get upwards of 90% accuracy (averaging specificity and sensitivity). We have achieved this goal. With an experienced clinician taking a subjective history and utilizing aspects of a physical assessment it even gets higher than this, but even the novice can achieve upwards of 90% accuracy utilizing the existing tools.

Professional issue

I do appreciate that a complex model requires extensive training and adds a financial aspect to learning. A simpler model will likely have more uptake, however do we want to settle for something basic that only sub-classifies psychology and everything else?

A basic model (but albeit slightly better than current practice) will have basic results. It's that simple. If the profession wants to do better, it needs a more comprehensive model.

Given the wide spectrum of deficits that people with chronic pain present with and without addressing the underlying functional mechanisms, a basic model will be have mediocre results.

Some issues

• There is no accepted standard therapy for musculoskeletal pain
• There is no consistent international learning in physiotherapy schools.
• Physiotherapists as new graduates can start practicing without any structured supervision
• Continuing education is not mandatory in many countries. Where it is, the structure or quality of the learning is not addressed. There are only certificates of attendance given, not certificates of competency.

In its current form, it is up to the individual therapist  to better themselves mostly at their own cost. We have a model to facilitate individual learning which can integrate existing knowledge to help significantly improve outcomes. Doing this has secondary benefits of reducing job stress and improving quality of life for the clinician.

A Great Time to Learn - Eliminate Burnout

This is an exciting time for all therapists. Certainly for the newer graduates who have not yet been exposed to the excessive poor outcomes, futility of many therapies, they have a model and learning structure they can follow to have a strategy to provide a rehabilitation directive for almost all patients. They can avoid the frustration, disappointment, and burnout of many others. Extensive research by many individuals has finally come to fruition - MISSION ACCOMPLISHED!