Presentation is loading. Please wait.

Presentation is loading. Please wait.

Treatment Based Classification of the Lumbar Spine.

Similar presentations


Presentation on theme: "Treatment Based Classification of the Lumbar Spine."— Presentation transcript:

1 Treatment Based Classification of the Lumbar Spine

2 Finding Common Ground Classification Systems –Reliable –Guide Interventions Treatment Techniques –Effective –Generalizable

3 Delitto, Erhard, Bowling, Fritz Early Establishment of Classification Scheme for the Low Back Case Series Randomized controlled clinical trials Better Than Standard Treatment?

4 First Level of Classification Treat by Rehabilitation Specialist Independently Referral to Another Healthcare Practitioner Managed by Therapist in Consultation with Another Health Care Practitioner

5 Immediate Care of the Injured Spine Physician Evaluation Early Care –Rest/Activity –Ice/Heat –Modalities for Pain Control –X-ray –Medications

6 1-2 Weeks and No Change Life Impact –ADL’s –Sport Specific

7 Importance of History Establish a pattern –What brings on symptoms? –What relieves symptoms? Type of symptoms present –Sharp, stabbing –Dull, aching –Stretching –Pinching

8 Importance of History Intensity of Symptoms –Pain levels Location of Symptoms –Rule in/out potential causes –Add focus to your evaluation

9 Neurological Examination Indication - Symptoms Below the Buttock –LE Sensory Testing –Muscle Strength Assessment –Reflex Testing –Nerve Root Testing –Babinski testing –Clonus

10 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

11 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

12 Movement Testing Assess for a Lumbar Shift –Pelvic translocations PRN Single Motion Testing Repeated Motion Testing Alternate Positioning (if needed)

13 Postural Observation Presence of a Lumbar Shift –Named by the shoulder

14 Pelvic Translocation Performed Bilaterally –Assess Symptom response –Worsen –Improve –Status Quo

15 Lumbar Sidebending Determine Capsular/NonCapuslar Perform Movements –Pelvic Translocation –Flexion –Extension Status –Worsen –Improve –Status Quo

16 Pelvic Translocation Assess Status –Worsen –Improve –Status Quo

17 Flexion Assess Status –Worsen –Improve –Status Quo Note ROM limits Quality of Motion

18 Extension Assess Status –Worsen –Improve –Status Quo Note ROM limits Quality of Motion

19 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

20 Sidebending/Worsen Asymmetrical Sidebending –Cyriax Non Capsular Pattern Do Repeated Motions Worsen –Traction Syndrome

21 Sidebending/Improve Symmetrical (Capsular) Do Repeated Motions Improve? –Flexion Syndrome ACTIVE FLEXION –Extension Syndrome ACTIVE EXTENSION

22 Sidebending/Improve Asymmetrical (Non Capsular) Do Repeated Motions Improve? –Lateral Shift Syndrome Active Pelvic Translocation

23 Sidebending/Status Quo Symmetrical (Capsular) Mobilization Syndrome –Passive Flexion General –Passive Extension General

24 Sidebending/Status Quo Asymmetrical (Non capsular) No Pattern –General Mobilization Specific Pattern –Specific Mobilization

25 Opening Restriction Forward Flexion –Deviation to the side of the Restriction Sidebending –Limitation to the contralateral side Combined Flexion and Contralateral SB’ing

26 Maximal Opening Flexion Mobilizations Flex LE to desired levels Posterior Glide of LE on segments

27 Opening Mobilization Flex to desired level Lift Bilateral LE to ceiling to gap/open Opening on side on table Progression - Laterally flex table

28 Closing Restriction Extension –Deviation to contralateral side Sidebending –Limitation to the ipsilateral side Combined Extension and Ipsilateral SB’ing

29 Maximal Closing PA Glides Begin in Neutral Progress to Extended Position

30 Self Mobilizations Force Movement at Specific Levels Modified Press Up Exercise Extension at L3 Towel Roll to flex at L4/5

31 Opening/Closing Manipulation Flex to level of involvement (Gap L4/5 to manipulate L4) Stabilize LE

32 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.

33 Maximize Gains with Home Programs Home Exercise of Towel Sitting Open- Contralateral Close- Ipsilateral

34 Worsen/Improve

35 Neurological Examination Indication - Symptoms Below the Knee –LE Sensory Testing –Muscle Strength Assessment –Reflex Testing –Nerve Root Testing –Babinski testing –Clonus

36 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

37 Peripheralize/Centralize Classic Disc Stenosis Spondylo..

38 Postural Observation Presence of a Lumbar Shift –Named by the shoulder

39 Sidebending/Improve Asymmetrical (Non Capsular) Do Repeated Motions Improve? –Lateral Shift Syndrome Active Pelvic Translocation

40 Manual Shift Correction Manual Shift Correction by PT Slow Correction Slow Ease of Release

41 Postural Corrections Self Correction Positioning for Electrical Stimulation

42 Self Shift Corrections Performed every 30 minutes

43 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

44 Flexion Worsens Prone Traction

45 Extension Worsens Supine Traction

46 Sidebending/Worsen Asymmetrical Sidebending –Cyriax Non Capsular Pattern Do Repeated Motions Worsen –Traction Syndrome

47 Sidebending/Improve Symmetrical (Capsular) Do Repeated Motions Improve? –Flexion Syndrome ACTIVE FLEXION –Extension Syndrome ACTIVE EXTENSION

48 Centralization Phenomenon Intensity will increase as pain centralizes Once no radicular symptoms ~2wks left Must re-introduce provocative motion once radicular symptoms are resolved

49 Improve with Extension CASH Brace Worn 24hrs Wean Slowly

50 Improve with Extension Prone Press Ups

51 Self Correction for Extension Repeated Extension in Standing Performed every 30 minutes

52 Posterior/Anterior Glides Assessment Symptom Provocation Treatment

53 Flexion Improves Flexion Exercise

54 Flexion Improves Flexion Postures

55 Flexion Mobilizations SNAGs with Belt

56 Status Quo

57 Sidebending/Status Quo Symmetrical (Capsular) Mobilization Syndrome –Passive Flexion General –Passive Extension General

58 General Flexion Flexion Mobilizations Flex LE to desired levels Posterior Glide of LE on segments

59 General Flexion for Home Slouched sitting Flexion stretches Flexion activity –Rower –Bike

60 General Extension PA Glides Begin in Neutral Progress to Extended Position

61 General Extension for Home Force Movement at Specific Levels Modified Press Up Exercise Extension at L3 Towel Roll to flex at L4/5

62 Sidebending/Status Quo Asymmetrical (Non capsular) No Pattern –General Mobilization Specific Pattern –Specific Mobilization

63 Opening Restriction Forward Flexion –Deviation to the side of the Restriction Sidebending –Limitation to the contralateral side Combined Flexion and Contralateral SB’ing

64 Opening Mobilization Flex to desired level Lift Bilateral LE to ceiling to gap/open Opening on side on table Progression - Laterally flex table

65 Opening Mobilization Joint Glide in Flexion Look for deviation with forward flexion to determine where in range to mobilize

66 Closing Restriction Extension –Deviation to contralateral side Sidebending –Limitation to the ipsilateral side Combined Extension and Ipsilateral SB’ing

67 Closing Mobilizations PA’s with unilateral support SNAG’s in Extension

68 Opening/Closing Manipulation Flex to level of involvement (Gap L4/5 to manipulate L4) Stabilize LE

69 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.

70 Maximize Gains with Home Programs Home Exercise of Towel Sitting Open- Contralateral Close- Ipsilateral

71 General Stabilization Pelvic Neutral with leg lowering

72 General Stabilization Side Lift –Quadratus –Obliques –Minimal LB stress

73 Adhered Nerve Root Status Quo Reproduce Radicular Symptoms with Opening

74 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

75 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

76 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 +

77 Hypothesis What is wrong with this player? What group does he belong in?

78 Hypothesis Status Quo Closing Restriction Specific Mobilization How would you treat him? How long will it take?

79 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

80 Case 1 Soccer Player Outcome Next Treatment 60% improvement in pain and range Continued with closing mobilizations 4 th treatment return to full 100% painfree play

81 Acute Lumbar Treatment Diagnosis Can Lead Intervention Classification Dictates Treatment Maximize Treatment Goals; In Clinic, Home, and Return to Work


Download ppt "Treatment Based Classification of the Lumbar Spine."

Similar presentations


Ads by Google