Classification of Lumbar Spine Impairments: Difference between revisions
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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.<ref name=":0" /> based on the TBC with several key differences: | 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.<ref name=":0" /> based on the TBC with several key differences: | ||
* the categories include specific International Classification of Functioning, Disability and Health (ICF) terminology related to impairments of body function<ref name=":0" /> | * the categories in this system include specific International Classification of Functioning, Disability and Health (ICF) terminology related to impairments of body function<ref name=":0" /> | ||
* additional categories related to cognitive / affective disorders and generalised pain categories have been included<ref name=":0" /> | * additional categories related to cognitive / affective disorders and generalised pain categories have been included<ref name=":0" /> | ||
* it considers the patient’s level of acuity<ref name=":0" /> | * it considers the patient’s level of acuity<ref name=":0" /> | ||
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* low back pain with mobility deficits | * low back pain with mobility deficits | ||
* low back pain with movement coordination impairments | * low back pain with movement coordination impairments | ||
* low back pain with related lower extremity pain | * low back pain with related lower extremity pain | ||
* low back pain with radiating pain | * low back pain with radiating pain | ||
* low back pain with related cognitive or affective disorders | * low back pain with related cognitive or affective disorders | ||
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* Patient education for return to activity | * Patient education for return to activity | ||
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Before performing any manipulations, you must check for contraindications. See [[Spinal Manipulation#Contra-indications|here]] for more information. <blockquote>Individuals with low back pain | Before performing any manipulations, you must check for contraindications. See [[Spinal Manipulation#Contra-indications|here]] for more information. <blockquote>Individuals with low back pain with mobility deficits are likely classified into the “symptom modulation” category in the TBC.<ref name=":1">Cunningham S. Classification of Lumbar Spine Impairments Course. Plus, 2024.</ref></blockquote> | ||
== Low Back Pain with Movement Coordination Impairments == | == Low Back Pain with Movement Coordination Impairments == | ||
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* progress to opposite arm/leg lift | * progress to opposite arm/leg lift | ||
<blockquote>Individuals with low back pain | <blockquote>Individuals with low back pain with movement coordination impairments are likely classified into the “movement control approach” category in the TBC.<ref name=":1" /></blockquote> | ||
== Low Back Pain with Referred Lower Extremity Pain == | == Low Back Pain with Referred Lower Extremity Pain == |
Revision as of 00:16, 19 February 2024
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 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 with several key differences:
- the categories in this 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 generalized 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 possible 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]
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 any manipulations, you must check for contraindications. See here for more information.
Individuals with low back pain with mobility deficits are likely classified into the “symptom modulation” category in the TBC.[6]
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 |
|
Impairments |
|
Interventions |
|
Transversus Abdominis[edit | edit source]
To assess transversus abdominis:[6]
- position patient in a hooklying 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
Facilitation techniques for transversus abdominis:[6]
- abdominal sling (four point kneeling position)
- therapist places hand on the patient’s stomach and other hand on sacrum
- therapist asks 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 (via hand position on sacrum)
- make sure patient is breathing (can ask them to count to ten)
- can combine with pelvic floor muscle activation (Kegel exercises)
Lumbar Multifidi[edit | edit source]
To assess lumbar multifidi:[6]
- 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 patient to do a contralateral /ipsilateral arm or leg lift and palpate for a contraction
Lumar multifidi training:[6]
- teach patient to palpate their multifidi
- try weight shift in a split stanct to activate multifidi (can be combined with transversus abdominis contraction)
- add in arm lifts
- add in load as needed
- quadraped 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.[6]
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 |
|
Impairments |
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Interventions |
|
Direction-specific Exercises[edit | edit source]
Flexion category: patients whose symptoms centralise with flexion-based movements:[1][6][7]
- 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:[6]
- 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:[6]
- prone positioning (on pillow)
- prone on elbows
- prone press up
- standing extension
- briding
- prone leg raise
For patients with a lateral shift, try a slide glide against wall.
Individuals with low back pain with referred lower extremity pain are likely classified into the “symptom modulation” category in the TBC.[6]
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 |
|
Impairments |
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Interventions |
|
Nerve mobility exercises include nerve glides for the sciatic nerve and the femoral nerve. These exercises are demonstrated in the videos below. ADD
Individuals with low back pain with radiating pain are likely classified into the “symptom modulation” category in the TBC.[6]
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 |
|
Impairments | One or more of the following:
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Interventions |
|
This is an additional category not included in the TBC.[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.[1]
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 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.
- ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 Cunningham S. Classification of Lumbar Spine Impairments Course. Plus, 2024.
- ↑ 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.