Feasibility of a Novel Movement Preference Approach to Classify Case Complexity for Adults with Non-Specific Chronic Low Back Pain

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The study proposes a movement-based classification system to guide low back pain case complexity classification using exercise testing.

Abstract

The non-specific nature of low back pain (LBP) poses challenges in its diagnosis and clinical management. Classifying case complexity with an exercise method may help overcome these challenges. The present study proposed a movement-based classification system based on Dance Medicine Australia (DMA) Clinical Pilates for patients with non-specific chronic LBP. To test the feasibility of the proposed system, 40 adults with non-specific chronic LBP were assessed on their movement preference (i.e., movement directions that can relieve pain or are pain-free) through the DMA Clinical Pilates method. The movement preferences could be a combination of each of the following movement directions: (1) flexion or extension, (2) left or right lateral flexion and/or (3) left or right rotation. For cases that had central or bilateral pain, the number of movement preferences identified was used to guide the classification. Using the proposed system, all 40 (100%) LBP cases were successfully classified into basic (n = 8, 20%), intermediate (n = 17, 42.5%), advanced (n = 8, 20%) or expert (n = 7, 17.5%) levels of complexity. In conclusion, this study has demonstrated that the proposed movement-based classification system was a feasible method for classifying case complexity in adults with non-specific chronic LBP. Future clinical intervention studies are needed to confirm if this classification system can enhance therapeutic outcomes in patients.

1. Introduction

The management of patients with non-specific chronic low back pain (LBP) is a challenging problem to tackle. Even with technological advancements such as the use of diagnostic ultrasound imaging, the findings might not be indicative of effective treatment [1]. An individual with chronic LBP could develop a fear of pain aggravation during activity participation [2]. In addition, the socioeconomic status of an individual can influence the prognosis of LBP [3]. Considering the multi-factorial aspects in LBP management, the trend in pain management has shifted from a biomedical approach towards a biopsychosocial model of care [4]. This change might have lowered the capability of physiotherapists to prescribe exercise treatment for LBP because more emphasis might be placed on psychosocial training [4]. As such, individuals with non-specific LBP are commonly managed with a biopsychosocial approach [5,6]. There exists a psychosocial approach to classifying case complexity [6,7], but patients may bear pain during exercise treatment because the psychosocial approach does not emphasize the physical limitations of the body. Thus, it is important to consider other diagnostic subgroups such as the ‘bio’ component [8], which could be classified into mechanical and non-mechanical pain [9]. Mechanical pain is related to movement disorders, while non-mechanical pain is related to pathological conditions such as inflammation [9]. A recently proposed directional preference classification method based on Dance Medicine Australia (DMA) Clinical Pilates could be useful to guide exercise prescription for non-specific chronic LBP [10]. To administer the treatment, physiotherapists use directional (movement) preference to prescribe exercises that are comfortable for an individual to perform in a specific one-directional movement plane [11,12,13]. This DMA Clinical Pilates approach is theoretically appealing because it allows patients to exercise comfortably without having to bear the pain. The potential of movement preference in LBP management, however, has not been fully explored yet.

Clinically, Pilates is rising as a popular choice to treat people with chronic LBP [14,15]. Among the variations in Pilates methods, the DMA Clinical Pilates method is designed with an exercise testing approach using movement preference [16]. The Clinical Pilates approach uses the history of an individual and exercise testing to identify what is easy for the individual to do [10]. Despite the promising outlook in the use of movement preference, physiotherapists who were newly trained in the Clinical Pilates approach appeared to have gaps in applying the method effectively to elicit efficacy over general exercises [17]. This suggests that not all movement preferences can be identified accurately by a physiotherapist due to the potential case complexity and uniqueness of each person with non-specific chronic LBP.

The multiple factors related to a patient with non-specific chronic LBP could be daunting for novice physiotherapists. Most LBP cases (90%) are non-specific and not associated with structural impairments [18,19], so it can be very hard to pinpoint the cause and prescribe the appropriate intervention. Even if diagnostic ultrasound is a valid and reliable tool to assist in diagnosis [1], it does not provide a pathway for exercise prescription. The difficulty in identifying a cause and matching the appropriate intervention could have led to the perception that LBP cases are complex and even more challenging with increasing chronicity [20]. In addition, the common practice of motor control exercise prescription has been perceived as ambiguous [20]. Exercise methods that can contribute to the development of case complexity classification are scarce. Identifying the problem side and exercising in the preferred movement directions have been shown to improve physical performance, whereas exercising on the wrong side and direction can worsen the performance [16]. This highlights the importance of identifying movement preference early and for the need to objectively classify case complexity. Previously, one study found that movement-based classification is a reliable method to classify LBP [21]. This study, however, did not involve Pilates or consider trunk lateral flexion in its movement preference assessment. To improve the clinical classification of case complexity in patients with LBP, the DMA Clinical Pilates method is potentially useful because this approach is objective and can take into account individual differences [10].

At present, identifying people with a mid-range movement preference using the DMA Clinical Pilates method can be challenging because research and clinical guidelines in this area are limited. Due to insufficient clinical experience, novice practitioners may not be able to evaluate the complexity of the case and to correctly identify a patient’s movement preferences. To overcome this challenge, it is important to design a system to guide clinicians in identifying case complexity. Therefore, this study proposed a comprehensive movement-based classification protocol for adults with non-specific chronic LBP. To test the feasibility of the proposed system, the method was applied to classify 40 non-specific chronic LBP cases.

2. Materials and Methods

2.1. Study Overview

The theoretical consideration and assessment procedures of the proposed DMA Clinical Pilates case complexity classification system were described. A case series approach was carried out to illustrate the feasibility of the proposed system in classifying non-specific chronic LBP.

2.2. Participants

This study is part of a larger study that recruited 40 adults (25 men and 15 women) with non-specific chronic LBP (

Table 1. Characteristics of participants with non-specific chronic LBP (n = 40).

Demographics	Mean (SD)	Range
Age, years	32.1 (7.3)	21 to 40
Body mass index, kg/m2	23.7 (3.5)	16.8 to 33.3
Pain in past 7 days VNS, out of 10	4.6 (0.8)	4 to 7
Patient-specific functional scale, out of 10	5.9 (1.5)	2.5 to 10

VNS: visual numeric scale. SD: standard deviation.

). The inclusion criteria were adults aged 21 to 40 years old who could communicate in English, had had current pain in the lower back for more than 3 months on most days of the week and had average pain in the past week that was ≥4 points rated on the 11-point pain numeric rating scale. Participants were excluded if they had received recent exercise intervention (past 3 months) or surgical intervention (past 6 months) or had ongoing fever or inflammation, known pregnancy, terminal end-stage illness such as cancer, orthopedic or neurological conditions that required medical management or recent unexplained weight loss or loss of appetite. Participants provided written informed consent before the study procedures began. This study was approved by the Nanyang Technological University Institutional Review Board (NTU-IRB-2022-492) and registered prospectively on the Australian New Zealand Clinical Trials Registry (ACTRN12622001195741).

2.3. Identifying Problem Side and Directional Preference

DMA Clinical Pilates assessment was performed by the same assessor (B.C.K.) who is a physiotherapist with more than 15 years of clinical experience and a certified DMA Clinical Pilates instructor. The DMA Clinical Pilates exercise testing method was used to identify the problem side and directional (movement) preference of each participant through a series of movement-based tests and an algorithm (Figure 1) [10,16]. Details of the test movement and algorithm are described in the Supplementary File of a previously published study [10]. This assessment approach determines which directions of movement (e.g., flexion or extension) are the easiest and most comfortable for a person. The problem side might not correspond with the pain side for those with unilateral pain. On the other hand, people with pain on both sides might not be assessed to have problems on both sides. Flexion or extension preference was studied a decade ago [16], while lateral flexion preference to either side was studied recently [22].

As the movement charting of rotation concerning exercise may be confusing, the study provided three scenarios with a diagnostic bullseye in Figure 1 to guide interpretation. Figure 1a is a common rehabilitation exercise, with knees rolling to the right, which results in left trunk rotation, and is a mid-range flexion rotation DMA Clinical Pilates exercise. Figure 1b is the attitude rotation DMA Clinical Pilates exercise used for left trunk rotation and extension (full-range) preference by moving the right leg to the left. Figure 1c is a mid-range extension rotation DMA Clinical Pilates exercise, similarly to the left.

Each patient can present with a different combination of directional preferences: (1) mid-range or end-range; (2) flexion, extension or none; (3) lateral flexion to left, right or none; (4) rotation to left, right or none [10]. The problem side (opposite to directional preference) is first deduced based on the side with flexion or extension preference. If this method is unable to confirm the problem side, the side with lateral flexion preference is taken as the problem side. In cases whereby lateral flexion preference is absent, the side of rotation preference is used to indicate the problem side. Upon completion of the DMA Clinical Pilates assessment, the results are comprehensively mapped on the diagnostic bullseye chart, which provides a quick summary for clinical documentation.

2.4. Classifying Case Complexity

A case complexity classification system was conceptualized through thematic synthesis by three certified DMA Clinical Pilates practitioners (Figure 2). The information from body charting of the pain side was used together with the identified problem side and movement preference to classify case complexity into 4 progressive categories, namely basic, intermediate, advanced and expert levels of case complexity. B.C.K. performed the first round of classification and recorded the rationale and challenges for each case based on the principles illustrated in Figure 2. These classification results were then reviewed by J.X.L.L., a physiotherapist with 9 years of clinical experience and certified in DMA Clinical Pilates, for errors.

Table 2. Examples of movement preferences and case complexity classification.

Movement Preference	Case Complexity	Qualitative Comments
Case (a).	Basic	Pain side = problem side 1 movement preference (right extension)
Case (b).	Intermediate	Pain side = problem side 2 movement preferences (right extension and lateral flexion)
Case (c).	Intermediate	Both sides with same movement preference (central extension)
Case (d).	Advanced	Pain side = problem side 3 movement preferences (right extension, lateral flexion and rotation)
Case (e).	Expert	Problem side (right) opposite to pain side (left)
Case (f).	Expert	Both sides have opposite movement preference

provides examples of how the charted diagnostic bullseyes are interpreted. In basic complexity, the pain and problem sides are on the same side. Case (a) belongs to this ‘basic’ category with the right full-range extension preference. In intermediate complexity, there is an additional movement plane preference as compared to basic complexity, as illustrated by case (b) with right lateral flexion. Intermediate case complexity can also be charted if both sides share the same plane of movement preference, which is explained as a central extension in case (c). In advanced complexity, the assessment will yield all three planes of movement preference, such as in case (d), which includes right rotation as compared to intermediate case complexity. In expert complexity such as in case (e), the pain side is assessed to be different from the problem side despite having a similar movement preference as in a case of basic complexity. Another aspect of expert complexity is the presence of movement preferences on both sides that differ. In case (f), the right side shows a preference for right flexion and lateral flexion, whereas the left side shows a preference for left extension and lateral flexion.

2.5. Data Analyses

The study had no participation drop-out, and there were no missing data. The classification results of each of the 40 participants with LBP were charted. The rate of successful classification that could be classified based on the proposed classification system was calculated using the formula below. We expect a 100% success rate for future clinical and research implementation; otherwise, the system will require further review [23].

$$\mathrm{R}\mathrm{a}\mathrm{t}\mathrm{e} \mathrm{o}\mathrm{f} \mathrm{s}\mathrm{u}\mathrm{c}\mathrm{c}\mathrm{e}\mathrm{s}\mathrm{s}\mathrm{f}\mathrm{u}\mathrm{l} \mathrm{c}\mathrm{l}\mathrm{a}\mathrm{s}\mathrm{s}\mathrm{i}\mathrm{f}\mathrm{i}\mathrm{c}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{o}\mathrm{n}={\displaystyle \frac{\mathrm{P}\mathrm{r}\mathrm{o}\mathrm{p}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{i}\mathrm{o}\mathrm{n} \mathrm{o}\mathrm{f} \mathrm{c}\mathrm{a}\mathrm{s}\mathrm{e}\mathrm{s} \mathrm{c}\mathrm{l}\mathrm{a}\mathrm{s}\mathrm{s}\mathrm{i}\mathrm{f}\mathrm{i}\mathrm{e}\mathrm{d}}{\mathrm{T}\mathrm{o}\mathrm{t}\mathrm{a}\mathrm{l} \mathrm{n}\mathrm{u}\mathrm{m}\mathrm{b}\mathrm{e}\mathrm{r} \mathrm{o}\mathrm{f} \mathrm{c}\mathrm{a}\mathrm{s}\mathrm{e}\mathrm{s}}}$$

3. Results

All participants could be classified with the classification system, with a successful classification rate of 100%. The participant flowchart for the assessment algorithm is presented in Figure 3. Using the proposed classification system, this study identified 10 participants with flexion preference, 21 participants with extension preference and 9 participants with mid-range preference. The variations in the movement preference coupling of this study were summarized with the diagnostic bullseye and presented according to basic (n = 8, 20%), intermediate (n = 17, 42.5%), advanced (n = 8, 20%) and expert (n = 7, 17.5%) case complexity levels in

Table 3. Basic complexity cases for low back pain patients (n = 8).

Cases	LBP Duration (years)	Limitation Themes of the ICF Model	Movement Preference	Qualitative Comments
B1	4	Slope/stairs (activity) Lifting load—work (participation)		Pain side = problem side 1 movement preference (extension)
B2	0.33	Sports (participation) Sit to stand (activity)		Pain side = problem side 1 movement preference (flexion)
B3	20	Walking (activity) Lifting load—work (participation)		Pain in both sides; one problem side identified 1 movement preference (extension)
B4	5	Sitting (activity)		Pain side = problem side 1 movement preference (extension)
B5	4.5	Weightlifting—gym (participation)		Pain in both sides; one problem side identified 1 movement preference (flexion)
B6	5	Standing (activity)		Pain side = problem side 1 movement preference (flexion)
B7	3.5	Sitting and running (activity)		Pain side = problem side 1 movement preference (extension)
B8	5.5	Climbing ladder—work (participation)		Pain in both sides; one problem side identified 1 movement preference (flexion)

,

Table 4. Intermediate complexity cases for low back pain patients (n = 17).

Cases	LBP Duration (years)	Limitation Themes of the ICF Model	Movement Preference	Qualitative Comments
I1	4	Sitting, walking and hiking (activity)		Pain side = problem side 2 movement preferences (extension and lateral flexion)
I2	1	Sitting (activity)		Pain side = problem side 2 movement preferences (flexion and lateral flexion)
I3	6	Gym weights training (participation)		Central pain; one problem side identified 2 movement preferences (flexion and lateral flexion)
I4	0.33	Standing (activity) Load lifting—daily activities (participation)		Pain side = problem side 2 movement preferences (flexion and lateral flexion)
I5	0.25	Stairs and forward bending (activity)		Pain side = problem side 2 movement preferences (extension and lateral flexion)
I6	1	Lifting load—work (participation) Standing (activity)		Pain side = problem side 2 movement preferences (flexion and lateral flexion)
I7	8	Walking (activity)		Pain in both sides; one problem side identified 2 movement preferences (lateral flexion and rotation)
I8	4	Sitting (activity) Weightlifting—gym (participation)		Pain in both sides; one problem side identified 2 movement preferences (extension and lateral flexion)
I9	1	Sitting (activity) Weightlifting—gym (participation)		Pain in both sides; one problem side identified 2 movement preferences (flexion and lateral flexion)
I10	3	Load transfer—work (participation)		Pain in both sides; one problem side identified 2 movement preferences (flexion and lateral flexion)
I11	4.5	Sitting and standing (activity)		Pain in both sides; one problem side identified 2 movement preferences (extension and lateral flexion)
I12	7.5	Sitting and squatting (activity)		Pain in both sides; one problem side identified 2 movement preferences (extension and lateral flexion)
I13	6	Squatting (activity)		Pain side = problem side 2 movement preferences (extension and rotation)
I14	8	Sitting (activity)		Pain side = problem side 2 movement preferences (extension and lateral flexion)
I15	7.5	Sitting (activity) Grocery load (participation)		Pain in both sides; one problem side identified 2 movement preferences (extension and lateral flexion)
I16	4	Lifting load—work (participation)		Pain side = problem side 2 movement preferences (flexion and lateral flexion)
I17	7	Sitting (activity)		Pain in both sides; one problem side identified 2 movement preferences (extension and lateral flexion)

,

Table 5. Advanced complexity cases for low back pain patients (n = 8).

Cases	LBP Duration (years)	Limitation Themes of ICF Model	Movement Preference	Qualitative Comments
A1	9	Running (activity) Transferring load—work (participation)		Pain side = problem side 3 movement preferences (extension, lateral flexion and rotation)
A2	1.5	Sports (participation)		Pain in both sides; one problem side identified 3 movement preferences (extension, lateral flexion and rotation)
A3	2.5	Running and squats (activity)		Central pain; one problem side identified 3 movement preferences (extension, lateral flexion and rotation)
A4	8.5	Standing and stretching (activity)		Pain in both sides; one problem side identified 3 movement preferences (extension, lateral flexion and rotation)
A5	5	Walking (activity)		Pain side = problem side 3 movement preferences (extension, lateral flexion and rotation)
A6	6	Standing (activity)		Pain in both sides; one problem side identified 3 movement preferences (extension, lateral flexion and rotation)
A7	0.42	Walking/hiking (activity)		Pain side = problem side 3 movement preferences (extension, lateral flexion and rotation)
A8	3.5	Standing (activity)		Pain side = problem side 3 movement preferences (extension, lateral flexion and rotation)

and

Table 6. Expert complexity cases for low back pain patients (n = 7).

Cases	LBP Duration (years)	Limitation Themes of ICF Model	Movement Preference	Qualitative Comments
E1	2	Grocery load (participation)		Both sides have opposite movement preference
E2	2	Carrying child (participation) Running (activity)		Problem side opposite to the pain side
E3	5	Sitting and stairs (activity)		Problem side opposite to the pain side
E4	1	Sitting and lying prone (activity)		Movement preference (lateral) opposite to problem side
E5	5	Lifting heavy load—gym/work (participation)		Problem side opposite to the pain side
E6	1.5	Gym weights/load (participation)		Problem side opposite to the pain side
E7	1	Carrying child (participation)		Problem side opposite to the pain side

, respectively. Through the thematic synthesis of the patient-specific functional scale inputs by the participants, half (n = 20) of the participants were limited in the activity category of the International Classification of Functioning and Disability (ICF) model by the World Health Organization. Others were limited in the participation category (n = 10) or both the activity and participation categories (n = 10). Among the 40 participants, 24 had unilateral LBP, 2 had central LBP and 14 had bilateral LBP. As the case complexity classification did not describe cases that present with central and bilateral LBP, the assessor (B.C.K.) and reviewer (J.X.L.L.) agreed that these cases would be treated as the problem side being the same as the pain side (basic, intermediate and advanced complexity classification) unless both sides were assessed to have different movement preferences (expert complexity classification). Case E4 had a unique presentation that deviated from routine DMA Clinical Pilates charting about lateral flexion movement preference; thus, this case was recognized as the most complex case among the 40 participants.

4. Discussion

The present study proposed a new classification system based on the DMA Clinical Pilates approach to classify case complexity for non-specific chronic LBP in physiotherapy practice. The study findings showed that the proposed case complexity classification system was successful in classifying all 40 cases studied. Approximately 25% of the participants did not fall into either full flexion or extension preference. Although the pre-conceived classification system did not consider central or bilateral pain, we were able to classify such cases by recognizing the pain and problem side to be on the same side. While rare, we encountered a case that did not fit routine DMA Clinical Pilates charting of movement preference on one side of the diagnostic bullseye, so the extension and lateral flexion preferences had to be charted on different sides of the bullseye. It is possible that multiple unresolved movement traumas led to the unusual movement preferences identified in this complex case. Overall, we demonstrated that it is feasible to use the DMA Clinical Pilates case complexity classification system to complement the clinical assessment of low back pain.

4.1. Movement-Based Classification System for LBP

The use of movement preference to classify case complexity is a novel idea that could facilitate case assignment to novice physiotherapists. Exercise therapy is recognized by newly minted physiotherapists as a key aspect of physiotherapy practice in managing musculoskeletal pain [24]. For instance, cases B7 and E7 have similar movement preferences, but case E7 is of higher complexity than case B7 because the movement preference side (problem side) is opposite to the side with pain. Based on the subjective history of E7, symptoms did not improve with routine physiotherapy management, primarily because exercises were prescribed on the wrong side (side with pain) and in the flexion direction. Exercising on the wrong side is adverse [16], so the careful identification of movement preference is as important. In this study, we showed the possibility of identifying many different movement preference couplings, which can exceed the 20 permutations found among the cases, exceeding what was previously studied [21]. Furthermore, 80% of the cases studied were classified as non-basic. The high variations in movement preference coupling and the high proportion of complex cases highlight the challenges that novice physiotherapists need to overcome in managing non-specific chronic LBP patients. Thus, it is unsurprising that novice physiotherapists lack confidence in prescribing exercises [25].

Commonly known practice classifies movement preference into flexion or extension [11,12], but a recent study suggested that the hip flexion angle matters in identifying mid-range and lateral flexion preferences [10,22]. Findings from the present study showed that nine participants did not fall within the classification of full flexion or extension preference. For cases I11 and I12, it is likely that their maximum force exertion will be poorer in 60° and 90° hip flexion angles when performing side-lying clamshell exercises on the problem side [22]. For better motor relearning, exercises should therefore be performed in the easiest position [16]. The current literature suggests that the understanding of directional preference is still limited to guide translation into efficacious treatment [12]. The DMA Clinical Pilates method provides a clear method to comprehensively assess directional preferences [10]. Thus, the DMA Clinical Pilates method can help facilitate structured learning and build the confidence of novice physiotherapists in the management of LBP cases.

It should be noted that the current study only described the theoretical considerations and assessment procedures of the DMA Clinical Pilates classification system. Based on the presented information, we cannot say whether patients undergoing this classification system will have better therapeutic outcomes. To address this research question, a randomized controlled trial is necessary in the future to compare patients whose clinical interventions have been informed by the proposed classification system versus those who have not.

4.2. Practical Implications

Developing skills and gaining essential knowledge are important career growth aspects for physiotherapists [26]. Our findings suggest that some chronic LBP cases might be difficult for novice physiotherapists to handle, but with a structured approach for the assessment of patients, their skills and competency can gradually improve. Furthermore, the Clinical Pilates method uses exercise testing with Pilates exercises, which relates directly to treatment and exercise prescription [10,16]. This could help improve the exercise prescription competency of physiotherapists [25]. Improving the competency of physiotherapists can benefit patients and the healthcare system. Exercise knowledge is essential in motivating patients to adhere to exercise in the longer term [27]. Physiotherapists with specific knowledge to prescribe individualized exercise plans for patients can facilitate faster recovery and reduce appointment lead times [28]. This will translate to improved rehabilitation outcomes and a more efficient healthcare system that is cost-effective for patients and healthcare providers.

Findings from this study can impact the education and capacity development of physiotherapists. For mentors guiding novice physiotherapists, the current case complexity classification is subjective due to a gap in evidence to guide practice. This study proposed an objective system that allows clinicians, physiotherapists and other healthcare professionals, regardless of experience, to identify the complexity of LBP cases using a movement-based classification framework. This classification system provides mentors with an objective approach, helping them know what would be easy or too challenging for the novices and when to progress case exposure. The mentor can then provide the novice physiotherapist with guidance to progressively gain mastery in managing non-specific chronic LBP patients from a movement preference perspective. For students and novice physiotherapists, they can use the proposed framework as a guide and seek help if unsure.

4.3. Limitations

There are a few limitations to the present study. First, this study is limited to adults aged 21 to 40 years old who were suffering from non-specific chronic LBP. Individuals of an older age may present with movement preference coupling with increasing complexity. Second, the 40 cases were evaluated by two experienced physiotherapists who were also certified DMA Clinical Pilates instructors. It remains uncertain whether the same classification results would be retained if the cases were evaluated by assessors with less clinical and Clinical Pilates experience. It will be important for future studies to investigate how the case complexity classification system works for a wider pool of physiotherapists with different levels of clinical experience.

4.4. Future Directions

Extending from the present study, it will be interesting to see if patients treated with clinical interventions chosen based on the DMA Clinical Pilates classification would have better therapeutic outcomes than those who were not. Future studies can also explore if adults aged 40 years and over will present with a similar success rate in classifying case complexity as the young adults in the study. Older adults might present with a myriad of health conditions that could complicate the use of directional preference.

While the study focused on the non-specific chronic LBP population, the proposed system provides a basis for general exercise-based case complexity classification. Future research should explore if such movement-based classification systems can be applied to other health conditions such as knee osteoarthritis and anterior cruciate ligament tears. From the perspective of professional development, the proposed case complexity classification system may help improve career satisfaction and build confidence in exercise prescription among physiotherapists.

5. Conclusions

The present study demonstrated that the DMA Clinical Pilates case complexity classification system is feasible for classifying the complexity of non-specific chronic LBP cases. Guided by a movement-based assessment framework, LBP cases can be classified as having basic, intermediate, advanced and expert levels of complexity. This objective system can potentially allow clinicians, physiotherapists and other healthcare professionals to identify the complexity of an LBP case and seek help if they are unsure. Healthcare systems and clinical practitioners can consider the use of the DMA Clinical Pilates approach for workflow enhancement.