Treatment Based Classification System

Question 1

What are the 5 treatment classifications?

Answer 1

• Directional Preference
• Postural Syndrome
• Stabilization Classification
• Chronic Pain Syndrome
• Decompression

Question 2

What are the clinical prediction rules for “Directional Preference”?

Answer 2

• Discogenic pain with radiculopathy
• Centralization with 2 or more movements in the same direction (flexion/extension)
• Centralization with a movement in one direction and peripheralization with an opposite movement

Question 3

What are the clinical prediction rules for “Postural Syndrome?”

Answer 3

• No symptom radiation distal to elbow or knee
• Hypomobility in thoracic extension and/or rotation, lumbar flexion, or hip extension
• Lumbar hyperlordosis/anterior pelvic tilt or anterior head posture
• Frequent aching pain, worse towards the end of the day without specific trauma or inciting incident, better on the weekends or after physical activity, tension, stiffness and a frequent desire to “pop” their neck or back
• Difficulty recruiting deep neck flexors, lower trapezius, abdominals or gluteal muscles

Question 4

What are the clinical prediction rules for “Stabilization Classification?”

Answer 4

• Average SLR motion >90 degrees
• Positive “Vleemings” active SLR
• Positive “Prone Stability Test”
• Positive aberrent movements
• Age >40

Question 5

What are the clinical prediction rules for “Chronic Pain Syndrome?”

Answer 5

• Consistent pain for >3 months
• High fear avoidance
• Catastrophizing presentation
• Depression or Anxiety

Question 6

What are the clinical prediction rules for “Decompression?”

Answer 6

• Pain with standing or walking
• Positive “Well Leg Raise Test”
• Relief with sitting and lumbar flexion ROM
• Relief with “Cervical Distraction Test”

Question 7

What is the primary treatment modality for a “Directional Preference” classification?

Answer 7

• Treatment is almost entirely active
• Multiple movements in direction of centralization
• Lumbar extension or cervical retraction are common
• Determine correct direction and perform repeated motions or hold static positions in that direction, modify and advance if needed
• Limit certain movements and activities that may be contributing to pain or peripheralization
• Gradually remove restrictions to observe response to load and provide confidence

Question 8

What is the primary treatment modality for a “Postural Syndrome” classification?

Answer 8

• Manual therapy and/or manipulation as well as specific postural exercises is extremely beneficial for persistent mechanical neck and lower back disorders
• Back School
• Ergonomics evaluation
• Micro break strategy
• General exercise recommendations
• XO Fitness referral

Question 9

What are two different types of “Postural Syndrome?”

Answer 9

• Upper Crossed Syndrome: tightness or overactivity of the pectoral muscles, sternocleidomastoid, upper trapezius, and the levator scapula, with elongation or inhibition of the deep neck flexors, serratus anterior, and lower trapezius
• Lower Crossed Syndrome: shortness or hypertonicity of the thoraco-lumbar extensors, rectus femurs, and iliopsoas along with inhibition of the abdominal and gluteal muscles

Question 10

Potential positive ortho’s indicative of “Postural Syndrome?”

Answer 10

• Wall Angel
• Thomas Test
• Jull’s Test (deep neck flexor endurance)
• Lower Trapezius Lift Off Test
• Abdominal Plank Test (patient begins the plank in lumbar extension)
• Hip Bridge (patient initiates movement with lumbar extensors or hamstrings)
• Cat/Cow (inability to demonstrate full ROM)

Question 11

What is the “Wall Angel Test?”

Answer 11

-Head, mid-back and buttocks touching wall with feet away from wall; arms at a 90/90 position with wrists and fingers against the wall; attempt to flatten your lower back against wall
-Perfect (3): Able to achieve the position as shown with eyes horizontal and head not tilting; simultaneously flatten your fingers, hands and spine against the wall.
(will likely gain more benefit from focusing on strength and stabilization training rather than stretching exercises)
Pretty Good (2): Able to flatten head against the wall with your eyes horizontal, able to flatten your fingers and can almost wrists (<1cm form the wall), able to almost flatten your spine to the wall but not quite (time would be better spent working on other areas)
Work Needed (1): Unable to flatten your head against the wall or can flatten head but eyes are no longer horizontal; unable to flatten your fingers against the wall or wrists are way off (> 1cm from the wall); unable to flatten your spine anywhere near the wall (indicates a dysfunction of upright posture)

Question 12

What is the “Thomas Test?”

Answer 12

Patient supine with with knees fully flexed and pulled as close as possible to chest ensuring lumbar spine is flat; lower one leg to table keeping alternate leg fully flexed; negative test results in a flat testing leg, without external rotation, and lumbar spine remains flat; positive test results in flexed hip without knee extension (tight Psoas), extended knee (tight r. femoris), abducted leg (tight IT band), lateral rotated tibia (tight biceps femoris); modified Thomas test patient sitting at end of table

Question 13

What is “Jull’s” test?

Answer 13

Patient supine with head positioned in neutral; drop head piece and instruct patient to hold head position for 10 seconds; repeat with head 3 cm off table and with neck almost fully flexed; positive test is indicated if patient raises head recruiting superficial neck flexors (scalenes/SCM), juts chin and extends head, head begins to wobble/shake and cannot hold for 10 seconds; positive test indicates weak deep neck flexors

Question 14

What is the “lift off test?” (Gerber’s Test)

Answer 14

Patient standing/sitting; internally rotate shoulder and place back of hand on small of back; instruct patient to lift hand off of back with resistance applied if necessary; positive test results if patient is unable to lift off of back, weak in doing so, or has pain; degree of weakness and/or pain is indicate of degree of lesion; complete inability to lift off indicates complete rupture and pain is indicative of partial tear or tendinitis

Question 15

What is the “Single Leg Glute Bridge Test?”

Answer 15

• Tests strength of hip abductors and external rotators
• Glute Bridge position: Ask patient what muscle they feel working; should be gluten and not hamstrings/low back muscles; correct if needed
• Have patient raise one leg at a time and then lower and repeat on opposite side; look for hip dipping on unsupported leg

Question 16

What are some exclusion criteria for the Postural Syndrome Classification?

Answer 16

• Red Flag symptoms
• Severe Pain (patient may enter the postural pathway after initial pain is reduced)
• Radicular symptoms or symptoms radiating past the elbow or knee
• Positive Instability tests

Question 17

What are exclusion criteria for the Directional Preference Classification?

Answer 17

• Lack of centralization with repeated motion

- Red flags including gross motor weakness or worsening symptoms

Question 18

What components does a focused history and clinical evaluation include?

Answer 18

• Frequency, duration, severity and location of symptoms
• History of injury, previous injury, and treatment
• Risk factors for potentially serious conditions
• Neurologic deficits: DTRs, dermatomes/myotomes
• Palliative/Provocation
• Quantity and quality of active and passive ranges of motion
• Orthopedic testing

Question 19

What are some red flag conditions?

Answer 19

• Bowel/bladder compromise, saddle anesthesia
• Back or neck pain preceded by trauma
• Fever associated with back or neck pain
• Progressive upper or lower extremity weakness
• Cancer history
• Irregular weight loss
• Rapid and insidious onset
• History of UTI or other infection

Question 20

What are some yellow flag conditions?

Answer 20

• Pain/numbness radiating below the knee or elbow: 4 week trial of conservative care before imaging or specialist care referral
• Conservative therapy plateau or negative responses to treatment: refer to PCP for co-management
• Age > 50 or Previous surgery: consider diagnostic imaging
• Pain management (symptoms effecting sleep, ADLs, work, etc.): consider referral to PCP for co-management
• Psychosocial limitations: Consider behavioral health co-management

Question 21

What are some indications for diagnostic imaging?

Answer 21

• Trauma
• Unexplained weight loss
• Unrelenting pain at rest
• Evolving neurological deficit suggestive of intervertebral disc pathology, stenosis or tumor
• Known history of cancer, corticosteroid use, IV drug use, use of blood thinners, and known endocrine diseases.
• Pinpoint bony tenderness over the vertebral spinous process.
• Patient over age 50
• Suspected spinal instability

Question 22

What are some inclusion criteria for the Spinal Stabilization Classification group?

Answer 22

• Younger in age, positive prone instability test, aberrant motions, SLR >90 degrees, recurrent episodes
• De-conditioned patient or history of sprain strain
• Feeling of the back or neck “giving way” during ADLs
• Hypermobility during AROM
• History of spondylolisthesis or whiplash injuries

Question 23

What are some cervical characteristics for the “Spinal Stabilization” Classifications

Answer 23

• Head feels “heavy” fatigue with sustained positions
• Tense superficial cervical musculature.
• Poor response to cervical/thoracic manipulation
• < 39 seconds on deep neck flexor endurance test
• history of injury/accident to the neck
• Weakness in middle trapezius, serratus anterior, lower trapezius
• Chronic, recurrent episodes of neck pain

Question 24

What is the Deep Neck Flexor Endurance Test?

Answer 24

• Assess the endurance of the deep neck flexors
• Test Position: Supine
• Performing the Test: Tuck patients chin in and lift off table 1 inch. The examiner looks for substitution of the platysma or SCM muscle.
• Normal Values: Men: 38.9 sec, Women: 29.4 sec
• Those with neck pain were found to have significantly decreased deep neck flexor endurance, average of 21.4 sec and tend to over-utilize other muscles for postural maintenance, which leads to forward head postures

Question 25

What are some lumbar characteristics that fit into the “Spinal Stabilization” Classification?

Answer 25

Clinical Prediction Rule: Success of > 67% if tests meet at least 3 out of 4 criteria with stabilization program.
Aberrant Movement (Gower’s sign)     
SLR > 90
Sorensen’s Test 
Vleeming’s /ASLR Test 
Passive Lumbar Extension Test
Age < 40 year old
(+) Prone Instability Test (not specific toward one segment)

Question 26

Describe the “Decompression Classification?”

Answer 26

-Treatment: manual and/or mechanical lumbar traction
-Criteria; pain radiating into the extremity, peripheralization of symptoms with extension, a positive well (crossed) SLR or cervical compression test
-Cervical Traction: avoided when movement can aggravate the condition or result in spinal instability, spinal injury and/or nerve root injury
-Indications are herniated discs, radiculopathy, and any condition in which opening the neural foramen is desired:
Capsulitis of Cervical Spine Joints
Herniated Cervical Disc
Radiculopathy
Facet Joint Dysfunction
Osteoarthritis or Degenerative Disc Disease (DDD)

Lumbar spine pain is there to protect and motivate us to find positions that place less pressure on our back until the symptoms calm down (load intolerance)
-Symptoms include inability to sit and stand for a sustained amount of time; pain while driving