L-Spine classification systems Flashcards
What percentage of patients in primary care that have LBP cannot reliably be attributed to specific disease or spinal abnormality?
85 %
What are 7 specific disorders that CAN be a source of back pain?
Cancer = 0.7% Compression fracture = 4% Spinal infection = 0.01% Ankylosing spondylitis = 0.3 – 5% Spinal stenosis = 3% Herniated disc = 4% Cauda equina syndrome = 0.04%
What are 4 non-spinal sources of back pain?
- Pancreatitis
- Nephrolithiasis (kidney stones)
- Aortic aneurysm
- Viral syndromes
What is Level I of an exam?
- Are they appropriate for PT
- Yellow Flags: refer to psycho-social issues
- Red Flags: Refer for medical work-up
What is Level II of the exam?
- Determine the disability stage
What is Stage 1 disability? (4 aspects)
- Acute/ recent onset
- Pain dominates
- Function is significantly affected (mostly by pain)
- ODI > 25 %
What are the 3 factors of Stage 2 disability?
- ODI a little higher than 20 %
- Impairments dominate
- Function moderately affected
What are the 3 factors of Stage 3 disability?
- ODI < 20 %
- Only lacking high level function
- Chronic
What should be kept in mind when assessing stages?
- They are not distinct
What stage is the treatment based classification applied to?
Stage 1
What is the main goal of stage 2?
- Work on impairments and how they affect function
What is the main goal of stage 3?
- Return the patient to a high level of functional activity
What 2 stages are the most likely to blend?
1 and 2
Who were the 3 authors of the KEY article in treatment based classification acute LBP?
- Fritz JM
- Cleland JA
- Childs JD
Who came up with the first treatment based classification system?
- Delitto et al
What is the 3 step process of classification?
- Screen for red flags
- Confirm that the L-spine is the soruces of the problem, and not another musculoskeletal impairment (strain, bursitis, etc…)
- Categorize into: Manip, Spec Exercise, Stabilization, or Traction
What led to the development of the CPR for manipulation?
- Some studies showed it was superior to placebo, while others said it was not
- Wanted to determine what specific patients would benefit from the treatment
What 2 things can be determined by a CPR?
- Determines who is likely to benefit
- Determines who may require a different approach
What is the CPR for spinal manipulation?
4/5 of the following
- No symptoms distal to the knee
- Symptoms < 16 days
- FABQ score < 19
- L-spine hypomobility as determined by PA assessment
- IR of at least one hip > 35 degrees
How was success determined when creating the CPR for manipulation?
Symptoms 50 % better within 2 treatments
What are the 4 contraindications/ strong precautions for manipulation of the L-spine?
- > 60 years old
- Spondylolisthesis
- Osteoporosis or other bony abnormalities/ weakening
- Signs of nerve root compression
Have the lumbar CPR been validated?
Yes
Has non-thrust mobilization been proven be as effective as HVLAs?
No
Should the patient receive a lumbopelvic manip or a lumbar neutral gap manip?
It doesn’t matter.
What 4 exercises made up the HEP following manipulations/ mobilizations in Cleland’s study?
- Cat & Camel
- Crunch in neutral
- Side plank
- Quadriped arm and leg
What exercise typically directly follows a lumbar manipulation?
- Active ROM exercises
What are the 3 effects of a manipulation?
Window for:
- “Safe”, pain free ROM
- Normalize muscle activity, and motor control
- Analgesia, and autonomic effects
According to Dr B, how many sessions are the manipulations typically performed?
< 3 - 4 sessions
What are the 2 most important indicators for lumbar manipulation?
- < 16 days
- No pain below the knee
What are the CPRs for stabilization classification?
3/4 of the following:
- < 40 years old
- R/L average SLR > 91 degrees
- Abberant movement during flexion/ extension
- (+) prone instability test
What are the 2 main deep/ segmental muscles trained for stabilization of the lumbar spine?
- Tranvserse abdominis
- Multidi
What are the 4 main superficial/ regional muscles?
- Rectus abdominis
- Obliques
- Quadratus Lumborum
- Erector Spinae
Are the manipulation or stabilization CPRs better developed?
Manipulation.
If 3/4 CPRs for stabilization exercise are positive, what is the percentage of patients that will improve 50 % in their disability index scores with treatment?
- 80 %
What are 4 CPRs for FAILURE of stabilization exercises?
- Negative prone instability test
- Lack of aberrant movement during flexion/ extension
- Lack of hypermobility (as determined by PA assessment)
- < 9 on FABQ
If 3/4 CPRs are present for failure of stabilization exercises, what is the percent of patients that will not have successful outcomes?
- 86 %
Should deep or superficial muscles be targeted during stabilization exercises?
- No evidence supporting either
Besides stabilization exercises, how would Dr. B supplement treatment of patients in the stabilization classification?
- Motor control
- Conditioning
What phenomenon is the Specific Exercise classification based on?
The centralization phenomenon
Describe the centralization phenomenon?
- Repeated end-range movements cause a reduction in peripheral symptoms
- Central symptoms may be increased
What is directional preference?
- Movements in one direction decrease symptoms
- Movements in the opposite direction increase symptoms
Are both directional preference and the centralization phenomenon included in the specific exercise classification?
Yes
Describe a general exercise prescription for a patient classified into the specific exercise classification.
- Correct lateral shift
- Position patient into increasing amounts of lumbar extension with prone press ups (Can place belt around pelvis and table) or standing extensions (with hands on the pelvis or glutes)
- Progress ROM and/or force
- Utilize PA mobilizations in extension position to assist the movement
What positions should be avoided? How can the patient be educated?
- Avoid prolonged or end-range flexion activities
- Inform patient about what exacerbates symptoms/ progresses the condition
- Use proprioceptive taping to reinforce positional knowledge
What is a contraindication to the specific exercise classification?
- Spondylolisthesis
What are the CPRs for classification into Specific Exercise?
There is none yet.
Which type of specific exercise has the most evidence?
Extension
When is flexion Specific Exercise typically utilized?
- Spinal Stenosis
Besides the specific exercise its self, what other 2 interventions may be ultilized when the patient is classified into the specific exercise classification?
- Manual therapy of the spine and hips
- Aerobic exercise
What are William’s 1-2-3 flexion exercises?
- Posterior pelvic tilt
- PPT; lift one knee to chest; hold
- PPT; lift both knees to chest; hold
What are the 3-4 indicators for traction classification?
- Symptoms below buttock AND - Signs of nerve root compression AND - Symptoms do not centralize (or peripheralize) with direction specific movements OR - (+) Crossed SLR Test
What patient positioning combined with what exercise were found to be effective by Fritz and Lindsay?
- Prone position
- Extension exercise
How much force is recommended for traction?
30 - 50 % body weight
According Judovich, is static or intermittent traction thought to be more effective?
- Static
If a patient’s symptoms do not centralize or peripheralize with any movement, do not occur distal to the knee, and are recent onset (< 16 days), what is their treatment bsaed classification?
Manipulation
If a patient has:
- An average SLR ROM of 103
- Aberrant movement in active lumbar flexion
- Is 50 years old
What is their treatment based classification?
Stabilization
If a patient’s symptoms peripheralize with flexion, what is the treatment based classification?
Specific exercise
What classification do younger patients typically fit into?
- Stabilization
How does classification into treatment based classification typically affect outcomes?
- Less PT visits
- Less pain and disability (ODI)
- Decrease in medications, injections, and MRI at 1 year follow up
What are the 5 treatments for Stage II LBP?
- Motor control
- Strength
- Endurance
- Flexibility
- Psychosocial education (hurt does not equal harm. We are not damaging tissues)
What are the 3 elements of stage III LBP treatment?
- Psychosocial (Know pain or no gain)
- Gradual exposure to higher level function
- Continue to address impairments
