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Treatment Based Classification of the Lumbar Spine

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

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Treatment Based Classification of the Lumbar Spine

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  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

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