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