Evaluation Guided Treatment for
Low Back Pain
Tara Jo Manal PT, OCS, SCS
Director of Clinical Services
Orthopedic Residency Director
University of Delaware Physical Therapy
Department
Tarajo@udel.edu
www.udel.edu/PT/clinic
Consensus on the Spine
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No Common Evaluations
No Common Terminology
No Common Classification
No Common Treatment
• ONE COMMON GOAL
The Guru Approach
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Maitland
McKenzie
Paris
Butler
Mulligan
Muscle Energy
Jones Strain Counterstrain
Finding Common Ground
• Classification Systems
– Reliable
– Guide Interventions
• Treatment Techniques
– Effective
– Generalizable
Delitto, Erhard, Bowling, Fritz
• Early Establishment of Classification
Scheme for the Low Back
• Randomized controlled clinical trials
• Case Series
• Better Than Standard Treatment?
LBS Classification
• Appropriate for Treatment?
– Refer for medical, psychological….
• Stage Condition of Severity
– Treatment Goals
• Evaluation Diagnosis Determines Treatment
Strategy
• Creativity of clinician is supported
Issues in Spinal Disorders
• Fear of missing the “bad cases”
• Failure of the pathology based model
– All discs are not created equal
• Potential sources of pain
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Joints
Nerves
Muscles
Ligaments
Issues in Spinal Disorders
• Patient Specific Demands
– Extension problem in line worker
– Time to return to work (independent contractor)
• Confounding Issues
– Emotional component
– Motivation to return (job satisfaction)
First Level of Classification
• Treat by Rehabilitation Specialist
Independently
• Referral to Another Healthcare Practitioner
• Managed by Therapist in Consultation with
Another Health Care Practitioner
When to Refer?
• Constant Pain, Unrelated to Position or
Movement
• Severe Night Pain Unrelated to Movement
• Recent Unexplained Weight Loss of >10lbs
• History of Direct Blunt Trauma
• Appears Acutely Ill (pale, fever, malaise)
• Abdominal Pain/Radiation to Groin (blood
in urine)
When to Refer?
• Sexual Dysfunction
• Recent Menstrual Irregularities
• Bowel or Bladder Dysfunction
– Fecal or Urinary Incontinence/Retention
– Rectal Bleeding
• Temperature >100 F
• Resting Pulse > 100 bpm
Immediate Care of the Injured
Spine
• Physician Evaluation
• Early Care
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Rest/Activity
Ice/Heat
Modalities for Pain Control
X-ray
Medications
1-2 Weeks and No Change
• Life Impact
– ADL’s
– Sport Specific
• Irritability
– Severity of symptoms
– Ease
– Duration
Oswestry Questionnaire
Self Report of Performance Limitation
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Personal Hygiene
Lifting
Walking
Sitting
Standing
Scale: 0
= 50
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5
No
Max
Limitations Limitations
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Sleeping
Social Activity
Traveling
Sex Life
Pain Intensity
Maximum Score
Double Score/100
%Disability
Oswestry Questionnaire
• 5 Minutes to Score
• Initial Classification
• Documentation of Outcome
Importance of History
• Establish a pattern
– What brings on symptoms?
– What relieves symptoms?
• Type of symptoms present
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Sharp, stabbing
Dull, aching
Stretching
Pinching
Importance of History
• Intensity of Symptoms
– Pain levels
• Location of Symptoms
– Rule in/out potential causes
– Add focus to your evaluation
Patient Staging
• Stage I Inability to Perform Stand,
Walk, Sit
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Reduce Oswestry <40%-60%
Enable to Sit > 30 min
Enable to Stand >15 min
Enable to Walk > 1/4 mile
Patient Staging
• Stage II Decreased Activities of Daily
Living
– Reduce Oswestry to <20% - 40%
– Enable to perform ADL’s
Patient Staging
• Stage III Return to High Demand Activity
– Reduce Oswestry to 20% or less
– Enable to Return to Work
Neurological Examination
• Indication - Symptoms Below the Knee
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LE Sensory Testing
Muscle Strength Assessment
Reflex Testing
Nerve Root Testing
Babinski testing
Clonus
Pelvic Assessment I
• PSIS Symmetry in
Sitting
– Unequal heights
– Positive Test
Pelvic Assessment II
• Standing Flexion Test
– Start Position
• Palpate PSIS
– Relative position
Pelvic Assessment II
• Standing Flexion Test
– End Position
– Full Flexion
• Palpate PSIS
– Relative position
compared to standing
• Positive Test
– Change in relationship
– Start to Finish
Pelvic Assessment III
• Prone Knee Flexion
Test
– Start Position
• In prone lying
• Palpate posterior to
lateral malleoli
• Observe leg length
Pelvic Assessment III
• Prone Knee Flexion
Test
– End Position
• Knee flexed to 90
• Positive Test
– Observe change in heel
position
– Start to Finish
Pelvic Assessment IV
• Supine to Sit Test
– Start Position
• Palpate inferior medial
malleoli
• Note relative lower
extremity length
Pelvic Assessment IV
• Supine to Sit Test
– End Position
• Sitting
• Positive test
– Change in relative leg length
– Start to Finish
Pelvic Assessment Results
• 3 of 4 Tests Composite
– Reliability k=.88
• If (-) Palpate Iliac Crest Heights
– Correct difference with heel lift
• If (+) SIJ Manipulation Indicated
– Manual Techniques
– Manipulation
Specific Manipulation for SIJ
Re-test composite after manipulation
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
Movement Testing
• Assess for a Lumbar Shift
– Pelvic translocations PRN
• Single Motion Testing
• Repeated Motion Testing
• Alternate Positioning (if needed)
Postural Observation
• Presence of a Lumbar
Shift
– Named by the shoulder
Pelvic Translocation
• Performed Bilaterally
– Assess Symptom
response
– Worsen
– Improve
– Status Quo
Lumbar Sidebending
• Determine
Capsular/NonCapuslar
• Perform Movements
– Pelvic Translocation
– Flexion
– Extension
• Status
– Worsen
– Improve
– Status Quo
Pelvic Translocation
• Assess Status
– Worsen
– Improve
– Status Quo
Flexion
• Assess Status
– Worsen
– Improve
– Status Quo
• Note ROM limits
• Quality of Motion
Extension
• Assess Status
– Worsen
– Improve
– Status Quo
• Note ROM limits
• Quality of Motion
Worsen/Improve
Tara J Manal MPT, OCS
Neurological Examination
• Indication - Symptoms Below the Knee
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LE Sensory Testing
Muscle Strength Assessment
Reflex Testing
Nerve Root Testing
Babinski testing
Clonus
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
Peripheralize/Centralize
• Classic Disc
• Stenosis
• Spondylo..
Postural Observation
• Presence of a Lumbar
Shift
– Named by the shoulder
Sidebending/Improve
• Asymmetrical (Non Capsular)
• Do Repeated Motions Improve?
– Lateral Shift Syndrome
• Active Pelvic Translocation
Pelvic Translocation Improves
• What would the treatment look like?
Manual Shift Correction
• Manual Shift
Correction by PT
• Slow Correction
• Slow Ease of Release
Postural Corrections
• Self Correction
• Positioning for
Electrical Stimulation
Self Shift Corrections
• Performed every 30
minutes
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
Flexion Worsens
• Prone Traction
Extension Worsens
• Supine Traction
Sidebending/Worsen
• Asymmetrical Sidebending
– Cyriax Non Capsular Pattern
• Do Repeated Motions Worsen
– Traction Syndrome
Sidebending/Improve
• Symmetrical (Capsular)
• Do Repeated Motions Improve?
– Flexion Syndrome
• ACTIVE FLEXION
– Extension Syndrome
• ACTIVE EXTENSION
Centralization Phenomenon
• Intensity will increase as pain centralizes
• Once no radicular symptoms ~2wks left
• Must re-introduce provocative motion once
radicular symptoms are resolved
Improve with Extension
• What would the treatment look like?
Improve with Extension
• CASH Brace
• Worn 24hrs
• Wean Slowly
Improve with Extension
• Prone Press Ups
Self Correction for Extension
• Repeated Extension in
Standing
• Performed every 30
minutes
Posterior/Anterior Glides
• Assessment
• Symptom Provocation
• Treatment
Flexion Improves
• What would the treatment look like?
Flexion Improves
• Flexion Exercise
Flexion Improves
• Flexion Postures
Flexion Mobilizations
• SNAGs with Belt
Status Quo
Sidebending/Status Quo
• Symmetrical (Capsular)
• Mobilization Syndrome
– Passive Flexion General
– Passive Extension General
Flexion Range is Decreased
• What would a treatment look like?
General Flexion
• Flexion Mobilizations
• Flex LE to desired
levels
• Posterior Glide of LE
on segments
General Flexion for Home
• Slouched sitting
• Flexion stretches
• Flexion activity
– Rower
– Bike
Extension is Limited
• What would the treatment look like?
General Extension
• PA Glides
• Begin in Neutral
• Progress to Extended
Position
General Extension for Home
• Force Movement at
Specific Levels
• Modified Press Up
Exercise
• Extension at L3
• Towel Roll to flex at
L4/5
Sidebending/Status Quo
• Asymmetrical (Non capsular)
• No Pattern
– General Mobilization
• Specific Pattern
– Specific Mobilization
Opening Restriction
• What does the range loss look like?
Opening Restriction
• Forward Flexion
– Deviation to the side of the Restriction
• Sidebending
– Limitation to the contralateral side
• Combined Flexion and Contralateral SB’ing
Opening Mobilization
• Flex to desired level
• Lift Bilateral LE to
ceiling to gap/open
• Opening on side on
table
• Progression - Laterally
flex table
Opening Mobilization
• Joint Glide in Flexion
• Look for deviation
with forward flexion
to determine where in
range to mobilize
Closing Restriction
• What would the pattern look like?
Closing Restriction
• Extension
– Deviation to contralateral side
• Sidebending
– Limitation to the ipsilateral side
• Combined Extension and Ipsilateral SB’ing
Closing Mobilizations
• PA’s with unilateral
support
• SNAG’s in Extension
Opening/Closing Manipulation
• Flex to level of
involvement (Gap
L4/5 to manipulate
L4)
• Stabilize LE
Opening/Closing Manipulation
• Maximally Rotate
Upper Body to end
range
• Have Patient Exhale
and relax abdominals
• Overpress gently with
upper body rotation
• Closes side toward
ceiling/Opens opp.
Maximize Gains with Home
Programs
• Home Exercise of
Towel Sitting
• Open- Contralateral
• Close- Ipsilateral
Lumbar Instability
• Immobilize/Stabilize
• What would the pattern look like?
Instability
• No range Restrictions
• Glitch in forward bending
• Need to support to return from flexed
position
Joint Shear Testing
General Stabilization
• Pelvic Neutral with
leg lowering
General Stabilization
• Side Lift
– Quadratus
– Obliques
– Minimal LB stress
Lumbar Weakness/Instability
• High Intensity Electrical
Stimulation to Lumbar
Paraspinals
• 2500Hz
• Sine wave
• 75 burst/sec
• 15 on/ 50 off
(3sec ramp)
• 15 contractions
Electrical Stimulation for
Strengthening
Classification
Case 1
• 18 year old soccer player
• 6wk history of LBP
• Played until 1 week ago then too painful to
overcome
• Dull aching right sided low back pain
– Denies pain in any other location
Case 1 Soccer Player
• Pain is 0-7/10
• Pain with Activity
– shooting ball
– cutting back and forth
– right sidebending
• Pain improves
– Rest
– Ice
– Relafen
Case 1 Soccer Player
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3 of 4 SIJ tests (-)
50% reduction in Right Sidebending
Good Forward Bending
50% reduction in Left Rotation
Extension is 50% limited
• Quadrant Test or Max ? Test is +
Hypothesis
• What is wrong with this player?
• What group does he belong in?
Hypothesis
• Status Quo
• Closing Restriction
• Specific Mobilization
• How would you treat him?
• How long will it take?
Case 1 Soccer Player Outcome
• Performed manipulation on first treatment
– Greater than 50% improvement in range
– Joint mobilizations for closing
– Home program
• Facet joint closing with towel under right buttock
• Prone press ups at home
Case 1 Soccer Player Outcome
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Next Treatment
60% improvement in pain and range
Continued with closing mobilizations
4th treatment return to full 100% painfree
play
Case 2
• 60 year old with back and leg pain
– Left buttock, anterior knee and big toe
• Symptoms provoked
– Walking < 1 mile
– Standing 10-15 minutes
• Symptoms increase
– Squatting
– Sitting
Case 2 60 year old
• Oswestry 16%
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LQS
Left Quad and HS 4+/5 compared to R
All other = B and Reflexes =B
Sensation- Slight decrease L3 and S1 on
Left
Movement Testing
• Asymmetrical sidebending (decreased L)
– Recreates buttock pain
• Flexion and Extension 75% limited pain-free
– Left deviation with forward flexion
• Repeated L sidebending increases tingling in toe
– symptoms resolve on standing
• L Quadrant closing recreates foot symptoms
– Symptoms resolve when return to standing
Joint Play
• L2 and L3 Hypomobile
• L4, L5 N
• L5/S1 Unilateral
– Recreates buttock pain
• L4/5 Unilateral
– Sore with empty end feel
Special Tests
• SLR (-)
• Slump Test (+) Left
– Recreates Buttock Pain
• Palpation to piriformis
– Recreates buttock c/o
Case 2
• What do you suspect is wrong?
• What category does he fall into?
• What will his treatment program look like?
Case 2
• Asymmetrical Sidebending
• Status Quo or Worsen
• Indication of Radiculopathy
– May argue worsen with extension
• Closing Restriction
Case 2 Treatment
• Joint Mobs to Hypomoblie segments
– Specific mobilizations
• Traction
– Mechanical effects of intervetebral separation
– Parameters to maximize
Treatment and Traction
– 130 lbs first day- progressing to 190 over 4
treatments
– 12th treatment walk greater than 1 mile with no
symptoms and raquetball with no symptoms
– 16th treatment- could stand to lecture today
– 23rd treatment- walked around campus 3x today
• Walking is fun
– 25th treatment- great weekend but has buttock
pain- + SIJ testing
Acute Lumbar Treatment
• Diagnosis Can Lead Intervention
• Classification Dictates Treatment
• Maximize Treatment Goals; In Clinic,
Home, and Return to Work
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Delitto et al Physical Therapy 75:6 1995
Greenwood et al JOSPT 27:4 1998
Fritz Physical Therapy 78:7 1998
McGill Physical Therapy 78:7 1998
Fritz et al Physical Therapy 78:8 1998