Treatment Based Classification of Low Back Pain

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  1. Three Levels of Classification
    • First Level: Is the patient appropriate for PT? (3 choices: PT only, consultation and PT, or referral)
    • Second Level: What is the severity of the disability?
    • Third Level: What syndrome is the patient?
  2. First Level Classification: Red Flags
    • Potential Indicators of Serious Pathology:
    • Cauda Equina
    • Tumor
    • Fracture 
    • Infection

    • What to Look For: 
    • Pain precipitated by significant trauma
    • Pain that worsens at night or that is not relieved by any position
    • Bilateral radiculopathy
    • Numbness or paresthesia in the perianal region
    • Change in bladder/bowel function
    • Unexplained significant lower limb weakness
    • Progressive neurological deficit
  3. Cauda Equina Syndrome
    • Requires immediate referral to physician
    • Cauda equina: collection of intramural nerve roots beginning at the end of the SC

    • Patient Presentation: 
    • Saddle paresthesia
    • Severe radicular pain
    • Severe or progressive neurological deficits (LE sensation, reflex, or strength loss)
    • Alteration in bladder or bowel function
  4. Second Level Classification: Stage 1
    • Stage 1: Acute
    • Basic functions limited (i.e. sit, stand, walk)
    • Oswestry range 40-60

    • Treatment:
    • Pain modulation
    • Therex: flex, ext, lat shift
    • Manipulation
    • Traction
    • Immobilization/stabilization
  5. Second Level Classification: Stage 2
    • Stage 2: Sub-Acute
    • Limited IADL's
    • Oswestry 20-40
    • Treatment = improve impairments (flexibility, strengthen, body mechanics, cardiovascular)
  6. Second Level Classification: Stage 3
    • Stage 3: Chronic
    • Limited ability to perform sustained activities 
    • Treatment: simulate work/recreational activity
  7. Stage 1 Syndromes
    • Specific Exercise: Lateral Shift, Extension, Flexion
    • Mobilization
    • Traction
    • Immobilization/Stabilization
  8. Specific Exercise: Lateral Shift
    • History: sudden onset, severe pain
    • Presentation: frontal plane deformity, sidebending asymmetrical, often neurological signs 
    • Treatment: shift correction --> extension syndrome
  9. Specific Exercise: Extension Synrome
    • History: prefer standing and walking
    • Presentation: neurological component, repeated extension --> centralize/improve, repeated flexion --> peripheralize/worsen
    • Treatment: avoid flexion postures, extension exercises (McKenzie)
  10. Specific Exercise: Flexion Syndrome
    • History: preference for sitting, worse w/ walking & standing
    • Presentation: neurological component, repeated flexion --> centralize/improve, repeated extension --> peripheralize/worsen
    • Treatment: flexion exercises, unloading techniques in extension
  11. Mobilization
    • History: mild-moderate pain
    • Presentation: symptoms localized to lumbar region (no radicular symptoms), NO change w/ repeated movement testing
    • Treatment: limited ext --> ext mob, limited flex --> flex mob, SI mob
  12. Traction
    • History: no positional preference
    • Presentation: radicular symptoms, worse w/ repeated movement testing
    • Treatment: 2 types of traction (mechanical and positional)
  13. Immobilization/Stabilization
    • History: frequent episodes, pain w/ sustained posture
    • Presentation: aberrant movement patterns, positive segmental stability test, greater SLR ROM
    • Treatment: stabilization (avoid extreme ROM, stabilization exercises, external support, surgical management)
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Treatment Based Classification of Low Back Pain
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