1. Treatment Based Classification of the Lumbar Spine

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

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

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

19. 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

20. Sidebending/Worsen Asymmetrical Sidebending Do Repeated Motions Worsen
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 Sidebending
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 Sidebending
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 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

44. Flexion Worsens
Prone Traction

45. Extension Worsens
Supine Traction

46. Sidebending/Worsen Asymmetrical Sidebending Do Repeated Motions Worsen
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 Sidebending
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 Sidebending
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 Pain improves
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
4th 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