Treatment Based Classification of the Lumbar Spine

Finding Common Ground Classification Systems Treatment Techniques 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 Type of symptoms present What brings on symptoms? What relieves symptoms? Type of symptoms present Sharp, stabbing Dull, aching Stretching Pinching

Importance of History Intensity of Symptoms Location 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 Single Motion Testing 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 Note ROM limits Quality of Motion Worsen Improve Status Quo Note ROM limits Quality of Motion

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

Sidebending/Worsen Symmetrical Sidebending Do Repeated Motions Worsen 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 Do Repeated Motions Worsen 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 Sidebending 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 Sidebending 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 Do Repeated Motions Worsen 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 Do Repeated Motions Worsen 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 Sidebending 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 Sidebending 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 Pain improves 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