Classification of Lumbar Spine Impairments
Introduction[edit | edit source]
"The best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed."[1]
Several classification systems have been published to help clinicians select an appropriate intervention for patients with low back pain, including:
- Treatment-based Classification (TBC)[2][3]
- Mechanical Diagnosis and Therapy (MDT) (also known as the McKenzie Method)
- Cognitive Functional Therapy (CFT)[4]
- Movement System Impairment (MSI)[5]
These classifications are discussed in more detail here: Treatment-based Classification for Low Back Pain.
This page supports the Plus course, Classification of Lumbar Spine Impairments, by Dr. Shala Cunningham. It discusses an updated classification system by Delitto et al.[1] based on the TBC, but with several key differences:
- the categories in Delitto et al.'s 2012 system include specific International Classification of Functioning, Disability and Health (ICF) terminology related to impairments of body function[1]
- additional categories related to cognitive / affective disorders and generalised pain categories have been included[1]
- it considers the patient’s level of acuity[1]
The categories are:[1]
- low back pain with mobility deficits
- low back pain with movement coordination impairments
- low back pain with related lower extremity pain
- low back pain with radiating pain
- low back pain with related cognitive or affective disorders
- low back pain with related generalised pain
To learn more about the ICF, please see: International Classification of Functioning, Disability and Health (ICF).
The following sections describe specific symptoms and impairments to help classify patients into these categories and appropriate interventions based on these presentations. These sections draw on information from Delitto et al.'s 2012 article: Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association,[1] and where relevant, link this system back to the TBC system.
Low Back Pain with Mobility Deficits[edit | edit source]
The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with mobility deficits.
Symptoms |
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Impairments |
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Interventions |
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Before performing manipulations, you must check for contraindications. See here for more information. Delitto et al.[1] also describe a test-item cluster to determine which patients will likely benefit from spinal manipulation. This cluster has been validated by Childs et al.[6]
- duration of symptoms is less than 16 days
- patient has no symptoms distal to their knee
- patient has lumbar hypomobility
- patient has at least one hip with more than 35 degrees of internal rotation
- the patient's Fear-Avoidance Beliefs Questionnaire (Work) (FABQ-W) is less than 19
- patients with four of these five predictors and no contraindications = manipulate[1][7]
Individuals with low back pain with mobility deficits are likely classified into the “symptom modulation” category in the TBC.[7]
Low Back Pain with Movement Coordination Impairments[edit | edit source]
The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with movement coordination impairments.
Symptoms |
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Impairments |
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Interventions |
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Transversus Abdominis[edit | edit source]
To assess transversus abdominis:[7]
- position patient in a hook-lying position
- palpate medial to the anterior superior iliac spine (ASIS)
- ask the patient to slowly draw in their lower stomach toward their spine
- palpate for contraction quality, symmetry, and global substitution
- ideal function = holding a contraction for 10 seconds x 10 repetitions with minimal effort
To facilitate transversus abdominis, try the abdominal sling technique:[7]
- patient is in a quadruped position
- therapist places their hand on the patient's stomach and their other hand on the patient's sacrum
- therapist asks the patient to draw in their stomach away from the therapist’s hand
- check that the patient does not round their back to activate their stomach (determined by movement of the sacrum)
- make sure the patient does not hold their breath (can ask them to count to ten out loud to avoid breath-holding)
- can combine with pelvic floor muscle activation (i.e. Kegel exercises)
Lumbar Multifidi[edit | edit source]
To assess lumbar multifidi:[7]
- position the patient in prone
- palpate to assess if the patient can contract their multifidi - this is difficult for many people to achieve
- can also ask the patient to do a contralateral or ipsilateral arm or leg lift and palpate for a contraction
Lumbar multifidi training:[7]
- teach the patient to palpate their multifidi
- try weight shift in a split stance to activate multifidi (can be combined with transversus abdominis contraction)
- add in arm lifts
- add in load as needed
- quadruped contralateral arm lift (can be combined with transversus abdominis activation and pelvic floor activation)
- progress to opposite arm / leg lift
Individuals with low back pain with movement coordination impairments are likely classified into the “movement control approach” category in the TBC.[7]
The following videos demonstrate how to activate transversus abdominis and the lumbar multifidi
Low Back Pain with Referred Lower Extremity Pain[edit | edit source]
The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with referred lower extremity pain.
Symptoms |
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Impairments |
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Interventions |
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Direction-specific Exercises[edit | edit source]
Flexion category: patients whose symptoms centralise with flexion-based movements:[1][7][10]
- mainly older patients with spinal stenosis (but not exclusively)
- lower extremity symptoms come on after standing or walking for a certain amount of time
- sitting improves symptoms
- flexion activities improve symptoms
Exercises for individuals with a flexion preference include:[7]
- single knee to chest
- double knee to chest
- sitting flexion
- standing flexion
Extension category: patients whose symptoms centralise with lumbar extension-based movements and peripheralise with lumbar flexion
- symptoms distal to the buttock
Exercises for individuals with an extension preference include:[7]
- prone positioning (on a pillow)
- prone on elbows
- prone press up
- standing extension
- bridging
- prone leg raise
For patients with a lateral shift, try a slide glide against a wall, as is shown in the video below.
Individuals with low back pain with referred lower extremity pain are likely classified into the “symptom modulation” category in the TBC.[7]
Low Back Pain with Radiating Pain[edit | edit source]
The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with radiating pain.
Symptoms |
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Impairments |
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Interventions |
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Nerve mobility exercises include nerve glides for the sciatic nerve and the femoral nerve. These exercises are demonstrated in the videos below.
Individuals with low back pain with radiating pain are likely classified into the “symptom modulation” category in the TBC.[7]
Low Back Pain with Cognitive or Affective Tendencies[edit | edit source]
The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with cognitive or affective tendencies.
Symptoms |
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Impairments | One or more of the following:
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Interventions |
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This is an additional category not included in the TBC system.[1]
Low Back Pain with Related Generalised Pain[edit | edit source]
The following table describes symptoms and potential interventions for patients who are classified as having low back pain with generalised pain.
Symptoms |
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Interventions |
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This is an additional category not included in the TBC system.[1]
Please watch the following video if you would like to hear more from Dr. Lorimer Moseley about recent advances in pain science research.
References[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ; Orthopaedic Section of the American Physical Therapy Association. Low back pain. J Orthop Sports Phys Ther. 2012 Apr;42(4):A1-57.
- ↑ Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995 Jun;75(6):470-85; discussion 485-9.
- ↑ Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. Treatment-based classification system for low back pain: revision and update. Physical therapy. 2016 Jul 1;96(7):1057-66.Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995 Jun;75(6):470-85; discussion 485-9.
- ↑ O'Sullivan PB, Caneiro JP, O'Keeffe M, Smith A, Dankaerts W, Fersum K, O'Sullivan K. Cognitive Functional Therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther. 2018 May 1;98(5):408-23.
- ↑ Azevedo DC, Ferreira PH, Santos HD, Oliveira DR, de Souza JV, Costa LO. Movement system impairment-based classification treatment versus general exercises for chronic low back pain: randomized controlled trial. Physical therapy. 2018 Jan;98(1):28-39.
- ↑ Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004 Dec 21;141(12):920-8.
- ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 Cunningham S. Classification of Lumbar Spine Impairments Course. Plus, 2024.
- ↑ Physio Fitness | Physio REHAB | Tim Keeley. Correct core activation #2 - switching on multifidus | Feat. Tim Keeley | No.34 | Physio REHAB. Available from: https://www.youtube.com/watch?v=20XBM9ZcnWc [last accessed 20/12/2023]
- ↑ Physio Fitness | Physio REHAB | Tim Keeley. Correct core activation - engage your TA and pelvic floor! | Feat. Tim Keeley | No.18 | PhysioREHAB. Available from: https://www.youtube.com/watch?v=X0HzXm3epAU [last accessed 20/12/2023]
- ↑ Katz JN, Zimmerman ZE, Mass H, Makhni MC. Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022 May 3;327(17):1688-99.
- ↑ joel laing. McKenzie Method: Side-glide self correction of lateral shift to relieve back pain and sciatica. Available from: https://www.youtube.com/watch?v=6qITq7_i6U4 [last accessed 19/2/2024]
- ↑ Northern Lincolnshire and Goole NHS Foundation Trust. MSK Sciatic Nerve Glides. Available from: https://www.youtube.com/watch?v=cZ-kEwWTmus [last accessed 19/2/2024]
- ↑ INSYNC PHYSIO Vancouver. Anterior Hip Pain: Femoral Nerve Glides Sidelye. Available from: https://www.youtube.com/watch?v=wDPjjPkJyEk [last accessed 19/2/2024]
- ↑ Flippin Pain. Available from: The Pain Problem...and how to be a part of the solution! [last accessed 19/2/2024]