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