Treatment Based Classification of the Lumbar Spine
Finding Common Ground
• Classification Systems– Reliable– Guide Interventions
• Treatment Techniques– Effective– Generalizable
Delitto, Erhard, Bowling, Fritz
• Early Establishment of Classification Scheme for the Low Back
• Case Series
• Randomized controlled clinical trials
• Better Than Standard Treatment?
First Level of Classification
• Treat by Rehabilitation Specialist Independently
• Referral to Another Healthcare Practitioner
• Managed by Therapist in Consultation with Another Health Care Practitioner
Immediate Care of the Injured Spine
• Physician Evaluation
• Early Care– Rest/Activity– Ice/Heat– Modalities for Pain Control– X-ray– Medications
1-2 Weeks and No Change
• Life Impact– ADL’s– Sport Specific
Importance of History
• Establish a pattern– What brings on symptoms?– What relieves symptoms?
• Type of symptoms present– Sharp, stabbing– Dull, aching– Stretching– Pinching
Importance of History
• Intensity of Symptoms– Pain levels
• Location of Symptoms– Rule in/out potential causes– Add focus to your evaluation
Neurological Examination
• Indication - Symptoms Below the Buttock– LE Sensory Testing– Muscle Strength Assessment– Reflex Testing– Nerve Root Testing– Babinski testing– Clonus
Pelvic Assessment Results
• 3 of 4 Tests Composite– Reliability k=.88
• If (+) SIJ Manipulation Indicated– Manual Techniques– Manipulation
• If (-) Palpate Iliac Crest Heights– Correct difference with heel lift
Movement Testing Results• Symptoms worsen: Paresthesia is produced
or the pain moves distally from the spine
– Peripheralizes
• Symptoms improve: Paresthesia or pain is abolished or moves toward the spine– Centralizes
• Status quo: Symptoms may increase or decrease in intensity, but no centralize or peripheralize
Movement Testing
• Assess for a Lumbar Shift– Pelvic translocations PRN
• Single Motion Testing
• Repeated Motion Testing
• Alternate Positioning (if needed)
Postural Observation
• Presence of a Lumbar Shift
– Named by the shoulder
Pelvic Translocation
• Performed Bilaterally– Assess Symptom
response
– Worsen
– Improve
– Status Quo
Lumbar Sidebending• Determine
Capsular/NonCapuslar
• Perform Movements– Pelvic Translocation
– Flexion
– Extension
• Status– Worsen
– Improve
– Status Quo
Pelvic Translocation
• Assess Status– Worsen
– Improve
– Status Quo
Flexion
• Assess Status– Worsen
– Improve
– Status Quo
• Note ROM limits• Quality of Motion
Extension
• Assess Status– Worsen
– Improve
– Status Quo
• Note ROM limits• Quality of Motion
Sidebending/Worsen
• Symmetrical Sidebending– Cyriax Capsular Pattern
• Do Repeated Motions Worsen– Traction Syndrome– If Extension worsens begin in flexion– If Flexion worsens begin in extension
Sidebending/Worsen
• Asymmetrical Sidebending– Cyriax Non Capsular Pattern
• Do Repeated Motions Worsen– Traction Syndrome
Sidebending/Improve
• Symmetrical (Capsular)
• Do Repeated Motions Improve?– Flexion Syndrome
• ACTIVE FLEXION
– Extension Syndrome• ACTIVE EXTENSION
Sidebending/Improve
• Asymmetrical (Non Capsular)
• Do Repeated Motions Improve?– Lateral Shift Syndrome
• Active Pelvic Translocation
Sidebending/Status Quo
• Symmetrical (Capsular)
• Mobilization Syndrome– Passive Flexion General– Passive Extension General
Sidebending/Status Quo
• Asymmetrical (Non capsular)
• No Pattern– General Mobilization
• Specific Pattern– Specific Mobilization
Opening Restriction
• Forward Flexion– Deviation to the side of the Restriction
• Sidebending– Limitation to the contralateral side
• Combined Flexion and Contralateral SB’ing
Maximal Opening
• Flexion Mobilizations
• Flex LE to desired levels
• Posterior Glide of LE on segments
Opening Mobilization
• Flex to desired level
• Lift Bilateral LE to ceiling to gap/open
• Opening on side on table
• Progression - Laterally flex table
Closing Restriction
• Extension– Deviation to contralateral side
• Sidebending– Limitation to the ipsilateral side
• Combined Extension and Ipsilateral SB’ing
Maximal Closing
• PA Glides• Begin in Neutral• Progress to Extended
Position
Self Mobilizations
• Force Movement at Specific Levels
• Modified Press Up Exercise
• Extension at L3• Towel Roll to flex at
L4/5
Opening/Closing Manipulation
• Flex to level of involvement (Gap L4/5 to manipulate L4)
• Stabilize LE
Opening/Closing Manipulation
• Maximally Rotate Upper Body to end range
• Have Patient Exhale and relax abdominals
• Overpress gently with upper body rotation
• Opens side toward ceiling/Closes opp.
Maximize Gains with Home Programs
• Home Exercise of Towel Sitting
• Open- Contralateral
• Close- Ipsilateral
Worsen/Improve
Neurological Examination
• Indication - Symptoms Below the Knee– LE Sensory Testing– Muscle Strength Assessment– Reflex Testing– Nerve Root Testing– Babinski testing– Clonus
Movement Testing Results• Symptoms worsen: Paresthesia is
produced or the pain moves distally from the spine– Peripheralizes
• Symptoms improve: Paresthesia or pain is abolished or moves toward the spine– Centralizes
Peripheralize/Centralize
• Classic Disc
• Stenosis
• Spondylo..
Postural Observation
• Presence of a Lumbar Shift
– Named by the shoulder
Sidebending/Improve
• Asymmetrical (Non Capsular)
• Do Repeated Motions Improve?– Lateral Shift Syndrome
• Active Pelvic Translocation
Manual Shift Correction
• Manual Shift Correction by PT
• Slow Correction• Slow Ease of Release
Postural Corrections
• Self Correction • Positioning for
Electrical Stimulation
Self Shift Corrections
• Performed every 30 minutes
Sidebending/Worsen
• Symmetrical Sidebending– Cyriax Capsular Pattern
• Do Repeated Motions Worsen– Traction Syndrome– If Extension worsens begin in flexion– If Flexion worsens begin in extension
Flexion Worsens
• Prone Traction
Extension Worsens
• Supine Traction
Sidebending/Worsen
• Asymmetrical Sidebending– Cyriax Non Capsular Pattern
• Do Repeated Motions Worsen– Traction Syndrome
Sidebending/Improve
• Symmetrical (Capsular)
• Do Repeated Motions Improve?– Flexion Syndrome
• ACTIVE FLEXION
– Extension Syndrome• ACTIVE EXTENSION
Centralization Phenomenon
• Intensity will increase as pain centralizes
• Once no radicular symptoms ~2wks left
• Must re-introduce provocative motion once radicular symptoms are resolved
Improve with Extension
• CASH Brace• Worn 24hrs• Wean Slowly
Improve with Extension
• Prone Press Ups
Self Correction for Extension
• Repeated Extension in Standing
• Performed every 30 minutes
Posterior/Anterior Glides
• Assessment• Symptom Provocation• Treatment
Flexion Improves
• Flexion Exercise
Flexion Improves
• Flexion Postures
Flexion Mobilizations
• SNAGs with Belt
Status Quo
Sidebending/Status Quo
• Symmetrical (Capsular)
• Mobilization Syndrome– Passive Flexion General– Passive Extension General
General Flexion
• Flexion Mobilizations
• Flex LE to desired levels
• Posterior Glide of LE on segments
General Flexion for Home
• Slouched sitting
• Flexion stretches
• Flexion activity– Rower– Bike
General Extension
• PA Glides• Begin in Neutral• Progress to Extended
Position
General Extension for Home
• Force Movement at Specific Levels
• Modified Press Up Exercise
• Extension at L3• Towel Roll to flex at
L4/5
Sidebending/Status Quo
• Asymmetrical (Non capsular)
• No Pattern– General Mobilization
• Specific Pattern– Specific Mobilization
Opening Restriction
• Forward Flexion– Deviation to the side of the Restriction
• Sidebending– Limitation to the contralateral side
• Combined Flexion and Contralateral SB’ing
Opening Mobilization
• Flex to desired level
• Lift Bilateral LE to ceiling to gap/open
• Opening on side on table
• Progression - Laterally flex table
Opening Mobilization
• Joint Glide in Flexion
• Look for deviation with forward flexion to determine where in range to mobilize
Closing Restriction
• Extension– Deviation to contralateral side
• Sidebending– Limitation to the ipsilateral side
• Combined Extension and Ipsilateral SB’ing
Closing Mobilizations
• PA’s with unilateral support
• SNAG’s in Extension
Opening/Closing Manipulation
• Flex to level of involvement (Gap L4/5 to manipulate L4)
• Stabilize LE
Opening/Closing Manipulation
• Maximally Rotate Upper Body to end range
• Have Patient Exhale and relax abdominals
• Overpress gently with upper body rotation
• Closes side toward ceiling/Opens opp.
Maximize Gains with Home Programs
• Home Exercise of Towel Sitting
• Open- Contralateral
• Close- Ipsilateral
General Stabilization
• Pelvic Neutral with leg lowering
General Stabilization
• Side Lift– Quadratus
– Obliques
– Minimal LB stress
Adhered Nerve Root
• Status Quo• Reproduce Radicular
Symptoms with Opening
Case 1
• 18 year old soccer player
• 6wk history of LBP
• Played until 1 week ago then too painful to overcome
• Dull aching right sided low back pain– Denies pain in any other location
Case 1 Soccer Player
• Pain is 0-7/10• Pain with Activity
– shooting ball– cutting back and forth – right sidebending
• Pain improves– Rest– Ice– Relafen
Case 1 Soccer Player
• 3 of 4 SIJ tests (-)
• 50% reduction in Right Sidebending
• Good Forward Bending
• 50% reduction in Left Rotation
• Extension is 50% limited
• Quadrant Test or Max ? Test is +
Hypothesis
• What is wrong with this player?
• What group does he belong in?
Hypothesis
• Status Quo
• Closing Restriction
• Specific Mobilization
• How would you treat him?
• How long will it take?
Case 1 Soccer Player Outcome
• Performed manipulation on first treatment– Greater than 50% improvement in range – Joint mobilizations for closing– Home program
• Facet joint closing with towel under right buttock
• Prone press ups at home
Case 1 Soccer Player Outcome
• Next Treatment
• 60% improvement in pain and range
• Continued with closing mobilizations
• 4th treatment return to full 100% painfree play
Acute Lumbar Treatment
• Diagnosis Can Lead Intervention
• Classification Dictates Treatment
• Maximize Treatment Goals; In Clinic, Home, and Return to Work