1. A Treatment-Based Classification Approach to Low Back Pain Monte Wong PT, DPT, ATC, CSCS Senior Physical Therapist TRIA Orthopaedic Center Minneapolis, MN

2. 2 Evidence Based Practice A Treatment-Based Classification Approach to Low Back Syndrome: Identifying Patients for Conservative Treatment A Treatment-Based Classification Approach to Low Back Syndrome: Identifying Patients for Conservative Treatment Delitto et. al, 1995 Delitto et. al, 1995

3. 3 Low Back Pain Management of low back disorders are difficult Management of low back disorders are difficult Inability to identify a causative agent Inability to identify a causative agent Difficulty getting a specific diagnosis Difficulty getting a specific diagnosis “illness in search of a disease” “illness in search of a disease” Limitation to pathology based model becomes apparent if you do not have a specific diagnosis Limitation to pathology based model becomes apparent if you do not have a specific diagnosis

4. 4 Low Back Pain Agency for Health Care Policy and Research (1994) Developed clinical practice guidelines Developed clinical practice guidelines Recommendations Recommendations Aspirin/NSAIDS, trial of manipulation Aspirin/NSAIDS, trial of manipulation Assure and educate about back problems Assure and educate about back problems Encourage low stress aerobic exercise Encourage low stress aerobic exercise Avoid irritating activities Avoid irritating activities

5. 5 Low Back Pain AHCPR (1994) Options for patients Options for patients Physical agents or modalities (home use) Physical agents or modalities (home use) Shoe insoles Shoe insoles Muscle conditioning exercises after a few weeks Muscle conditioning exercises after a few weeks Epidural steroid injections in the presence of radiculopathy Epidural steroid injections in the presence of radiculopathy

6. 6 Low Back Pain AHCPR (1994) Recommendations against Recommendations against Physical agents provided a healthcare provider Physical agents provided a healthcare provider TENS TENS Lumbar corsets and support belts Lumbar corsets and support belts Traction Traction Bed rest (> 4 days) Bed rest (> 4 days)

7. 7 Low Back Pain United Kingdom (2000) United Kingdom (2000) “on the evidence available at present, it is doubtful that specific back exercises produce significant improvement in acute low back pain, or that it is possible to select which patient’s will respond to which exercises” “on the evidence available at present, it is doubtful that specific back exercises produce significant improvement in acute low back pain, or that it is possible to select which patient’s will respond to which exercises”

8. 8 Low Back Pain Delitto et al, 1995 There is a need for classification There is a need for classification Current systems of grouping patients are inadequate (mostly based on pathology) Current systems of grouping patients are inadequate (mostly based on pathology) The use of clearly described classification systems may enhance the effectiveness of treatment The use of clearly described classification systems may enhance the effectiveness of treatment Without classification, the choice of treatments takes on an appearance of a lottery Without classification, the choice of treatments takes on an appearance of a lottery

9. 9 Low Back Pain Purpose Classification approach specifically directs conservative management of low back pain Classification approach specifically directs conservative management of low back pain Will result in a management strategy that is detailed with regards to the precise type of treatment Will result in a management strategy that is detailed with regards to the precise type of treatment Precise type of treatment is prescribed and not relegated to nonspecific terminology where any number of conservative strategies can be used for one classification Precise type of treatment is prescribed and not relegated to nonspecific terminology where any number of conservative strategies can be used for one classification

10. 10 Low Back Pain 3 levels of classification First Level- appropriate of conservative treatment by the clinician First Level- appropriate of conservative treatment by the clinician Second Level- Staging of the Patient Second Level- Staging of the Patient Third Level- assigning patient to specific treatment classification Third Level- assigning patient to specific treatment classification

11. 11 First Level Classification First level of decision is determining the patient’s care: First level of decision is determining the patient’s care: Can be managed by a clinician solely Can be managed by a clinician solely Can be managed by a clinician in consultation with another specialist Can be managed by a clinician in consultation with another specialist Cannot be managed by a clinician and requires referral to another specialist Cannot be managed by a clinician and requires referral to another specialist

12. 12 First Level Classification 2 things to ponder: 2 things to ponder: Is there a serious pathology that might be referring pain to the low back? (Red Flags) Is there a serious pathology that might be referring pain to the low back? (Red Flags) Is there a psychosocial influence on the symptom behavior (Yellow Flags) Is there a psychosocial influence on the symptom behavior (Yellow Flags)

13. 13 First Level Classification Red Flags Red Flags Fracture Fracture Trauma (major/minor) Trauma (major/minor) Severe muscle spasm on physical examination Severe muscle spasm on physical examination Radiological examination Radiological examination Infection/Osteomyelitis Infection/Osteomyelitis Fever Fever Chills Chills Unexplained weight loss Unexplained weight loss

14. 14 First Level Classification Red flags Continued Red flags Continued Cauda Equina Syndrome Cauda Equina Syndrome Saddle anesthesia Saddle anesthesia Recent onset of bladder dysfunction Recent onset of bladder dysfunction Severe or progressive neurological deficit in the lower extremity Severe or progressive neurological deficit in the lower extremity

15. 15 First Level Classification Red flags Continued Red flags Continued Ankylosing Spondylitis Ankylosing Spondylitis Morning stiffness Morning stiffness Improvement with activity Improvement with activity Onset before 40 Onset before 40 Pain not relieved in supine Pain not relieved in supine Local SI joint tenderness Local SI joint tenderness Paraspinal muscle spasm Paraspinal muscle spasm

16. 16 First Level Classification Red Flags Continued Red Flags Continued Cancer Cancer Age > 50 years or 50 years or < 20 Previous history of cancer Previous history of cancer Unexplained weight loss Unexplained weight loss No relief with complete bed rest No relief with complete bed rest Pain that worsens when supine Pain that worsens when supine Severe night time pain Severe night time pain

17. 17 First Level Classification Yellow Flags Yellow Flags Factors that increase the risk of developing, or perpetuating long-term disability and work loss associated with low back pain (Kendall et al, 1997) Factors that increase the risk of developing, or perpetuating long-term disability and work loss associated with low back pain (Kendall et al, 1997) Factors known to consistently predict poor outcomes: Factors known to consistently predict poor outcomes: Fear-Avoidance Beliefs and Behaviors Fear-Avoidance Beliefs and Behaviors Expectation that passive treatments will help more than active treatments Expectation that passive treatments will help more than active treatments Tendency to low mood and withdrawal from social interaction Tendency to low mood and withdrawal from social interaction

18. 18 First Level Classification Measurement Tools for Yellow Flags Measurement Tools for Yellow Flags Fear Avoidance Belief Questionnaire Fear Avoidance Belief Questionnaire Modified Oswestry Questionnaire Modified Oswestry Questionnaire Numeric Pain Rating Scale Numeric Pain Rating Scale Pain Body Diagram Pain Body Diagram Waddell’s Nonorganic Signs and Symptoms Waddell’s Nonorganic Signs and Symptoms

19. 19FABQ The following statements are about how your physical activity affects or would affect your back pain 1. My pain was caused by physical activity 1. My pain was caused by physical activity 2. Physical activity makes my pain worse 2. Physical activity makes my pain worse 3. Physical activity might harm my back 3. Physical activity might harm my back 4. I should not do physical activities which (might) make my pain worse 4. I should not do physical activities which (might) make my pain worse 5. I cannot do physical activities which (might) make my pain worse 5. I cannot do physical activities which (might) make my pain worse

20. 20 FABQ FABQ The following statements are about how your normal work affects or would affect your back pain 6. My pain was caused by my work or by an accident at work 7. My work aggravated my pain 8. I have a claim for compensation for my pain 9. My work is too heavy for me 10. My work makes or would make my pain worse 11. My work might harm my back 12. I should not do my normal work with my present pain 13. I cannot do my normal work with my present pain 14. I cannot do my normal work until my pain is treated 15. I do not think that I will be back to my normal work within 3 months 16. I do not think that I will ever be able to go back to work

21. 21 First Level Classification FABQ FABQ 16 item questionnaire developed by Waddell et al in 1993 16 item questionnaire developed by Waddell et al in 1993 2 subscales 2 subscales Work (items 6-7, 9-12, 15)- 42 points possible Work (items 6-7, 9-12, 15)- 42 points possible Physical activity (items 2-5)- 24 points possible Physical activity (items 2-5)- 24 points possible >30 for the FABQ-W; >15 for the FABQ- PA >30 for the FABQ-W; >15 for the FABQ- PA

22. 22 Oswestry Pain Questionnaire Pain Intensity Pain Intensity I can tolerate the pain I have without having to use pain medication. I can tolerate the pain I have without having to use pain medication. The pain is bad, but I can manage without having to take pain medication. The pain is bad, but I can manage without having to take pain medication. Pain medication provides me with complete relief from pain. Pain medication provides me with complete relief from pain. Pain medication provides me with moderate relief from pain. Pain medication provides me with moderate relief from pain. Pain medication provides me with little relief from pain. Pain medication provides me with little relief from pain. Pain medication has no effect on my pain. Pain medication has no effect on my pain.

23. 23 Oswestry Continued Personal Care (e.g., Washing, Dressing) Personal Care (e.g., Washing, Dressing) I can take care of myself normally without causing increased pain. I can take care of myself normally without causing increased pain. I can take care of myself normally, but it increases my pain. I can take care of myself normally, but it increases my pain. It is painful to take care of myself, and I am slow and careful. It is painful to take care of myself, and I am slow and careful. I need help, but I am able to manage most of my personal care. I need help, but I am able to manage most of my personal care. I need help every day in most aspects of my care. I need help every day in most aspects of my care. I do not get dressed, I wash with difficulty, and I stay in bed. I do not get dressed, I wash with difficulty, and I stay in bed.

24. 24 Oswestry Continued Lifting Lifting I can lift heavy weights without increased pain. I can lift heavy weights without increased pain. I can lift heavy weights, but it causes increased pain. I can lift heavy weights, but it causes increased pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g., on a table). Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g., on a table). Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can lift only very light weights. I can lift only very light weights. I cannot lift or carry anything at all. I cannot lift or carry anything at all.

25. 25 Oswestry Continued Walking Walking Pain does not prevent me from walking any distance. Pain does not prevent me from walking any distance. Pain prevents me from walking more than 1 mile. (1 mile = 1.6 km). Pain prevents me from walking more than 1 mile. (1 mile = 1.6 km). Pain prevents me from walking more than 1/2 mile. Pain prevents me from walking more than 1/2 mile. Pain prevents me from walking more than 1/4 mile. Pain prevents me from walking more than 1/4 mile. I can walk only with crutches or a cane. I can walk only with crutches or a cane. I am in bed most of the time and have to crawl to the toilet. I am in bed most of the time and have to crawl to the toilet.

26. 26 Oswestry Continued Sitting Sitting I can sit in any chair as long as I like. I can sit in any chair as long as I like. I can only sit in my favorite chair as long as I like. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting for more than 1 hour. Pain prevents me from sitting for more than 1 hour. Pain prevents me from sitting for more than 1/2 hour. Pain prevents me from sitting for more than 1/2 hour. Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting for more than 10 minutes. Pain prevents me from sitting at all. Pain prevents me from sitting at all.

27. 27 Oswestry Continued Standing Standing I can stand as long as I want without increased pain. I can stand as long as I want without increased pain. I can stand as long as I want, but it increases my pain. I can stand as long as I want, but it increases my pain. Pain prevents me from standing for more than 1 hour. Pain prevents me from standing for more than 1 hour. Pain prevents me from standing for more than 1/2 hour. Pain prevents me from standing for more than 1/2 hour. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all. Pain prevents me from standing at all.

28. 28 Oswestry Continued Sleeping Sleeping Pain does not prevent me from sleeping well. Pain does not prevent me from sleeping well. I can sleep well only by using pain medication. I can sleep well only by using pain medication. Even when I take medication, I sleep less than 6 hours. Even when I take medication, I sleep less than 6 hours. Even when I take medication, I sleep less than 4 hours. Even when I take medication, I sleep less than 4 hours. Even when I take medication, I sleep less than 2 hours. Even when I take medication, I sleep less than 2 hours. Pain prevents me from sleeping at all. Pain prevents me from sleeping at all.

29. 29 Oswestry Continued Social Life Social Life My social life is normal and does not increase my pain. My social life is normal and does not increase my pain. My social life is normal, but it increases my level of pain. My social life is normal, but it increases my level of pain. Pain prevents me from participating in more energetic activities (e.g., sports, dancing). Pain prevents me from participating in more energetic activities (e.g., sports, dancing). Pain prevents me form going out very often. Pain prevents me form going out very often. Pain has restricted my social life to my home. Pain has restricted my social life to my home. I have hardly any social life because of my pain. I have hardly any social life because of my pain.

30. 30 Oswestry Continued Traveling Traveling I can travel anywhere without increased pain. I can travel anywhere without increased pain. I can travel anywhere, but it increases my pain. I can travel anywhere, but it increases my pain. My pain restricts my travel over 2 hours. My pain restricts my travel over 2 hours. My pain restricts my travel over 1 hour. My pain restricts my travel over 1 hour. My pain restricts my travel to short necessary journeys under 1/2 hour. My pain restricts my travel to short necessary journeys under 1/2 hour. My pain prevents all travel except for visits to the physician / therapist or hospital. My pain prevents all travel except for visits to the physician / therapist or hospital.

31. 31 Oswestry Continued Employment / Homemaking My normal homemaking / job activities do not cause pain. My normal homemaking / job activities do not cause pain. My normal homemaking / job activities increase my pain, but I can still perform all that is required of me. My normal homemaking / job activities increase my pain, but I can still perform all that is required of me. I can perform most of my homemaking / job duties, but pain prevents me from performing more physically stressful activities (e.g., lifting, vacuuming). I can perform most of my homemaking / job duties, but pain prevents me from performing more physically stressful activities (e.g., lifting, vacuuming). Pain prevents me from doing anything but light duties. Pain prevents me from doing anything but light duties. Pain prevents me from doing even light duties. Pain prevents me from doing even light duties. Pain prevents me from performing any job or homemaking chores. Pain prevents me from performing any job or homemaking chores.

32. 32 Oswestry Pain Questionnaire Scoring Scoring Scale: 0 1 2 3 4 5 Scale: 0 1 2 3 4 5 Add Scores / 50 x 100% Add Scores / 50 x 100% Total x 2 (if all 10 questions are answered) Total x 2 (if all 10 questions are answered)

33. 33 Numeric Pain Rating Scale

34. 34 Pain Body Diagram

35. 35 Pain Body Diagram

36. 36 First Level Classification Waddell’s Nonorganic Signs and Symptoms Waddell’s Nonorganic Signs and Symptoms Proposed characteristics Proposed characteristics Able to separate physical and nonorganic elements of examination Able to separate physical and nonorganic elements of examination Able to identify abnormal illness behavior Able to identify abnormal illness behavior Predictive of treatment outcome Predictive of treatment outcome

37. 37 First Level Classification Waddell’s Nonorganic Signs (5 possible) Waddell’s Nonorganic Signs (5 possible) Regional disturbance of sensory changes or weakness that is divergent from accepted neuroanatomy Regional disturbance of sensory changes or weakness that is divergent from accepted neuroanatomy Superficial/Nonanatomic Tenderness Superficial/Nonanatomic Tenderness Simulation Simulation Axial loading Axial loading Rotation Rotation Distraction Distraction Straight leg raise Straight leg raise Overreaction Overreaction

38. 38Rotation

39. 39 Axial Loading (done in standing)

40. 40 Distraction- SLR

41. 41Distraction-SLR

42. 42 First Level Classification Waddell’s Nonorganic Symptoms (7 possible) Waddell’s Nonorganic Symptoms (7 possible) Do you get pain in your tailbone? Do you get pain in your tailbone? Do you have numbness in your entire leg? Do you have numbness in your entire leg? Do you have pain in your entire leg? Do you have pain in your entire leg? Does your whole leg ever give way? Does your whole leg ever give way? Have you had any time during this episode when you have had very little back pain? Have you had any time during this episode when you have had very little back pain? Have you had to go to the emergency room because of your back pain? Have you had to go to the emergency room because of your back pain? Has all treatment for your back made you worse? Has all treatment for your back made you worse?

43. 43 First Level Classification Now that you have some info….what do you do??? Now that you have some info….what do you do??? 1. Red Flags: Refer to Physician 2. Yellow Flags: Consult and treat 3. No red flags/yellow flags: proceed to stage 2

44. 44 First Level Classification Clinician only Clinician only Stage 1 inflammatory Stage 1 inflammatory Stage 1 mechanical Stage 1 mechanical Stage 2 Stage 2 Stage 3 Stage 3 Consultation Consultation Inflammatory process (medical) Inflammatory process (medical) Psychological Psychological Referral Referral Medical Medical Psychological Psychological Surgical Surgical

45. 45 Second Level Classification Easy to classify movement disorders into stages based on acuteness of the injury Easy to classify movement disorders into stages based on acuteness of the injury Studies have shown the usefulness of assigning patients related to acute, sub-acute and chronic Studies have shown the usefulness of assigning patients related to acute, sub-acute and chronic Most classifications of acuteness of injury are based on the number of days since the injury Most classifications of acuteness of injury are based on the number of days since the injury Cutoffs for categorizations in this manner are arbitrarily set and now always useful in directing conservative care Cutoffs for categorizations in this manner are arbitrarily set and now always useful in directing conservative care

46. 46 Second Level Classification Rather than days since injury, define acuteness as more related to the severity of symptoms Rather than days since injury, define acuteness as more related to the severity of symptoms Data from testing in first level classification will be related to staging criteria (ie) Oswestry questionnaire Data from testing in first level classification will be related to staging criteria (ie) Oswestry questionnaire

47. 47 Second Level Classification Stage 1 Stage 1 Characterized as the inability to perform the basic mechanical functions of standing, walking or sitting Characterized as the inability to perform the basic mechanical functions of standing, walking or sitting If people can’t perform these functions, we cannot expect them to perform a more complex and stressful activity If people can’t perform these functions, we cannot expect them to perform a more complex and stressful activity Unable to stand > 15 minutes Unable to stand > 15 minutes Unable to sit > 30 minutes Unable to sit > 30 minutes Unable to walk > ¼ mile Unable to walk > ¼ mile Oswestry within 40%-60% Oswestry within 40%-60%

48. 48 Second Level Classification Stage 1 Stage 1 Proposal of therapeutic intervention Proposal of therapeutic intervention Pain modulation Pain modulation Specific exercises, lateral shift regimens, manipulation, traction, occasional immobilization regimens Specific exercises, lateral shift regimens, manipulation, traction, occasional immobilization regimens Adjunctive pharmacological treatments Adjunctive pharmacological treatments

49. 49 Second Level Classification Stage 2 Stage 2 Exceeds the requirements for stage 1 (sitting, standing, walking) but unable to perform basic functional ADL’s Exceeds the requirements for stage 1 (sitting, standing, walking) but unable to perform basic functional ADL’s Oswestry score between 20-40% Oswestry score between 20-40% Able to sit, stand and walk with little difficulty Able to sit, stand and walk with little difficulty Improve on weakness, flexibility that falls outside the ideal range, poor aerobic capacity, faulty body mechanics and posture Improve on weakness, flexibility that falls outside the ideal range, poor aerobic capacity, faulty body mechanics and posture

50. 50 Second Level Classification Stage 3 Stage 3 About to return to activity About to return to activity Tolerates ADL’s and even activities involving high physical demand Tolerates ADL’s and even activities involving high physical demand Oswestry score < 20% Oswestry score < 20% Usually asymptomatic but deconditioned from inactivity Usually asymptomatic but deconditioned from inactivity Need to tolerate high demands of activity for prolonged periods of time without exacerbation of symptoms Need to tolerate high demands of activity for prolonged periods of time without exacerbation of symptoms

51. 51 Third Level Classification Identification of subgroup to which the patient belongs (Stage 1 patients) Identification of subgroup to which the patient belongs (Stage 1 patients) 4 classifications: 4 classifications: Stabilization Stabilization Manipulation/Mobilization Manipulation/Mobilization Specific Exercise Specific Exercise Extension Extension Flexion Flexion Lateral shift Lateral shift Traction Traction

52. 52 Third Level Classification Examination: Examination: History taking History taking Observation of posture in standing and sitting Observation of posture in standing and sitting Assessment of symmetry of pelvic landmarks in sitting and standing Assessment of symmetry of pelvic landmarks in sitting and standing Examination of trunk movements (forward, backward, side bend, pelvic translocation) Examination of trunk movements (forward, backward, side bend, pelvic translocation) Neurological testing for patients who exhibit symptoms of nerve root involvement (symptoms below the knee) Neurological testing for patients who exhibit symptoms of nerve root involvement (symptoms below the knee)

53. 53 Third Level Classification Stabilization Classification Stabilization Classification Key examination findings Key examination findings Frequent prior episodes of low back pain Frequent prior episodes of low back pain Increasing frequency of episodes of low back pain Increasing frequency of episodes of low back pain Instability catch or painful arcs during ROM Instability catch or painful arcs during ROM Hypermobility of the lumbar spine Hypermobility of the lumbar spine Positive Prone Segmental Instability test Positive Prone Segmental Instability test Treatments Treatments Trunk strengthening stabilization exercises Trunk strengthening stabilization exercises

54. 54 Prone instability Test

55. 55 Gower’s Sign

56. 56 Bridging Exercise

57. 57 Core Stability Exercise

58. 58 Prone Plank

59. 59 Side Plank

60. 60 Third Level Classification Manipulation/Mobilization Manipulation/Mobilization No symptoms distal to the knee No symptoms distal to the knee Recent onset of symptoms (<16 days) Recent onset of symptoms (<16 days) Low levels of fear avoidance beliefs Low levels of fear avoidance beliefs Hypomobility of the lumbar spine Hypomobility of the lumbar spine Increased hip internal rotation (>35 degrees) or discrepancy in hip IR ROM between right and leg hip Increased hip internal rotation (>35 degrees) or discrepancy in hip IR ROM between right and leg hip Treatments Treatments Manipulation or mobilization techniques to the SI joint or lumbar region Manipulation or mobilization techniques to the SI joint or lumbar region Range of Motion exercises Range of Motion exercises

61. 61 SI joint Manipulation

62. 62 Muscle Energy Techniques

63. 63 Third Level Classification Specific Exercise Classification Specific Exercise Classification Extension Pattern Extension Pattern Symptoms distal to the knee Symptoms distal to the knee Signs and symptoms of nerve root compression Signs and symptoms of nerve root compression Symptoms centralize with lumbar extension Symptoms centralize with lumbar extension Symptoms peripheralize with lumbar flexion Symptoms peripheralize with lumbar flexion Treatment Treatment Extension exercises Extension exercises Mobilization to promote extension Mobilization to promote extension Avoid flexion activities Avoid flexion activities

64. 64Cat/Camel

65. 65 Prone Press Up

66. 66 Standing Back Extension

67. 67 Third Level Classification Specific Exercises Classification Specific Exercises Classification Flexion Pattern Flexion Pattern Older age (>55 years old) Older age (>55 years old) Symptoms distal to the knee Symptoms distal to the knee Signs and symptoms of nerve root compression Signs and symptoms of nerve root compression Symptoms peripheralize with lumbar extension Symptoms peripheralize with lumbar extension Symptoms centralize with lumbar flexion Symptoms centralize with lumbar flexion Treatment Treatment Flexion exercises Flexion exercises Mobilization to promote flexion Mobilization to promote flexion De-weighted ambulation De-weighted ambulation Avoid extension activities Avoid extension activities

68. 68Cat/Camel

69. 69 Hand Heel Rocks

70. 70 Double Knee to Chest

71. 71 De-weighted exercises

72. 72 Third Level Classification Specific Exercise Classification Specific Exercise Classification Lateral shift pattern Lateral shift pattern Visible frontal plane deviation of the shoulders relative to the pelvis Visible frontal plane deviation of the shoulders relative to the pelvis Asymmetrical side bending active ROM Asymmetrical side bending active ROM Painful and restricted extension active ROM Painful and restricted extension active ROM Treatment Treatment Pelvic translocation exercises Pelvic translocation exercises autotraction autotraction

73. 73 Lateral Shift

74. 74 Lateral Shift Correction

75. 75 Third Level Classification Traction Classification Traction Classification Signs and symptoms of nerve root compression Signs and symptoms of nerve root compression No movements centralization symptoms No movements centralization symptoms Treatment Treatment Mechanical traction Mechanical traction Autotraction Autotraction Goal is for patient to remain status quo with movement, at which time mobilization techniques may be used, or improve with movement at which time patient will move into a self-treatment category Goal is for patient to remain status quo with movement, at which time mobilization techniques may be used, or improve with movement at which time patient will move into a self-treatment category

76. 76 Mechanical Traction

77. 77 Traction with activity

78. 78 Conclusion What does this mean for Athletic Trainers??? What does this mean for Athletic Trainers??? Effectiveness of the classification approach especially in patients with acute low back pain Effectiveness of the classification approach especially in patients with acute low back pain Treatment selection is more directed rather than taking a lottery, and that treatment is specific Treatment selection is more directed rather than taking a lottery, and that treatment is specific Classification systems may improve the power of clinical research as previous research has not identified patients who actually need the treatment Classification systems may improve the power of clinical research as previous research has not identified patients who actually need the treatment

79. 79Questions? monte.wong@tria.com

80. 80 Thank You