Treatment Based Classification System and Lumbar Screening

what are the majority of causes of LBP?

it is impossible to identify the source of nociceptive symptoms, therefore its termed non-specific LBP

what are the red flags to look for with LBP?

• malignancy

• vertebral fracture

• spinal infection (discitis)

• inflammatory disorders such as ankylosing spondylitis

• cauda equina

• abdominal aortic aneurysm

what are the potential nociceptive contributors to LBP?

• intervertebral discs

• facet joints

• muscle

• vertebral endplates

what are the neurogenic contributors to LBP?

• lumbar nerve roote compression— sciatica

• narrowing of spinal canal or foramina— stenosis

when is advanced imaging indicated?

most non-specific LBP should begin with conservative care in order to reduce delays in care, cost, and unnecessary imaging. advanced imaging should be reserved for special cases…

• if serious pathology is suspected

• if results are likely to change or direct treatment decisions

• if symptoms persist >4-6 weeks (radicular)

• if severe, neurological compromise (why we do the neruo screen every visit)

dysfuction is based on an imbalance between physical stresses and ________ vulnerabilities and their interaction overtime.

individual

how do we ID yellow flags?

OSPRO-YF

START Back Tool: used to develop the risk of developing chronicity. the higher the score, the greater the risk which affect prognosis

FABQ

most episodes of LBP improve within _____ weeks.

6 weeks

when does LBP peak?

in midlife, between 40s-60s which are considered our working years. it is uncommon in the 1st decade

*while there still can be LBP in the 70’s and 80’s, it just looks different and is more due to age related changes

what is the LBP triage we should consider before treating any patient?

• self care management if pt has a low psychosocial risk status, predominantly axial low back pain, and minor or controlled medical comorbities

• rehab management if pt has median to high psychosocial risk status, low psychosocial risk status with predominantly leg pain, minor or controlled medical comorbidities

• medical management if pt has red flags, medical comorbidities, and leg pain with progressive neurologic deficits

what is our primary PT role when a patient present to the clinic?

recognize concerning patterns and decide whether to continue, modify, or refer

what are the supporting findings of inflammatory diseases, sepcifically ankylosing spondylitis?

• age <45

• chronic LBP >3 months

• morning stiffness

• improves with exercise, not rest

• night pain

• possible systemic inflammatory featrues: heel pain, eye inflammation

what is the PT decision in someone presenting with ankylosing spondylitis?

refer for medical evaluation if undiagnosed or not already medically managed; modify PT based on irritability if already diagnosed

what are the key supporting findings for malignancy?

• history of cancer

• unexplained weight loss

• constant, progressive pain

• pain is not relieved by rest or position change

• unusual fatigue/systemic symptoms

what else would we want to ask in someone presenting with possible malignancy?

• any recent changed in appetite, fever, night sweats, or general health?

• any new neurologic symptoms

• is pain worsening despite conservative care?

• screen vitals and perform a neurologic screen

what are the PT actions we should consider in someone presenting with malignancy?

refer for medical evaluation (urgency depends on severity, progression, neurologic signs, and overall presentation)

what are the key supportive findings for vertebral fractures?

• older age

• osteoporosis

• long term corticosteroid use

• sudden onset after minor loading

• severe pain with movement or weight bearing

• relief when lying still

what else would we want to ask in someone presenting with possible vertebral fractures?

• any recent fall, trauma, or minor loading event?

• history of osteoporosis, steroid use, cancer, or prior fracture?

• pain with coughing, sneezing, transferes, or weight bearing?

• screen neurologic status

• avoid aggressive mobility testing

what are the PT actions we should consider in someone presenting with vertebral fracture?

refer for medical assessment and possible imaging before initiating routine PT

what are the key supportive findings for back related infection?

• fever and chills

• recent infection

• constant, worsening pain

• pain not clearly mechanical

• general feeling of being unwell

• possible recent antibiotic use or unresolved infection

what else would we want to ask in someone presenting with possible back related infection?

• any recent infection, surgery, injection, wound, or hospitalization?

• immunosuppression, diabetes, IV drug use, or other inection risk?

• any new neurologic symptoms?

• check vital signs

• determine wether symptoms are worsening or systemic

what are the PT actions we should consider in someone presenting with back related infection?

emergent medical referral

what are the key supportive findings for cauda equina?

• new bladder dysfunction

• saddle region numbness

• bilateral leg symptoms

• severe low back pain

• new or rapidly changing neurologic symptoms

• symptoms described as different from usual back pain

what else would we want to ask in someone presenting with possible cauda equina?

• any bowel or bladder changes?

• saddle anesthesia or altered sensation in the groin/perineal region?

• bilateral numbness, weakness, or progressive neurologic changes?

• loss of sexual function?

• perform neurologic screen if appropriate, but do not delay referral

what are the PT actions we should consider in someone presenting with cauda equina?

emergent medical referral

what are the key supportive findings for abdominal aortic aneurysm?

• older age

• male

• smoking history

• HTN/high cholesterol

• deep abdominal and LBP

• pain not affected by movement or position

• patient reports it does not feel mechanical

what else would we want to ask in someone presenting with possible abdominal aortic aneurysm?

• any sudden, severe, deep, tearing, or pulsing pain?

• any dizziness, fainting, nausea, sweating, or unusual weakness?

• CV risk factors?

• check vital signs and palpate for abdominal mass

• avoid provoking or aggresively examining

what are the PT actions we should consider in someone presenting with abdominal aortic aneurysm?

emergent medical referral

why do we need a classification system?

It helps us decide with information from the LQS and subjective…

1. is there neurological involvement

2. how irritable/sensitive is the presentation?

3. do symptoms match a nerve root pattern?

4. how cautious should I be with my exam and treatment?

5. do findings suggest referral, monitoring, or modifications?

what do we do once we rule out red flags?

Deteremine if the goal is…

• symptoms modulation: for high irritability

• movement control: for moderate irritability

• functional optimization: for low irritability

How does someone who is highly irritable, leading us to a symptoms modulation exam, alter the exam?

• prioritize asking more and testing less

• test in the least provocative positions first; limit repetitions and end range loading

• neuro screen in non-negotiable, but perform it efficiently

• neurodynamic testing: confirm but avoid repeated or sustained sensitizine maneuvers

• judge response, not just findings—how long do symptoms take to settle?

what does a symptom modulation exam mean for treatment?

the goal is to calm symptoms and reduce sensitivity before loading or restraining

what is our clinical priority with a symptom modulation exam?

match the exam intensity to irritability and monitor for worsening neurologic status

what is the primary problem with a patient who has movement control/movement coordination problems?

symptoms are linked to how the patient moves, controls, or loads the spine

what is the patient profile with a patient who has movement control/movement coordination problems?

• symptoms are more predictable

• pain occurs with specific movements, postures, or tasks

• symptoms settle reasonably quickly

• neurologic screen in usually normal or stable

• patient can tolerate mroe of the exam

what are the relevant LQS findings with a patient who has movement control/movement coordination problems?

• myotomes/reflexes/dermatomes are normal

• neurodynamic testing is negataive or only midly sensitive

• hip screen may reveal mobility or strength deficits

• movement testing may reproeduce symptoms more than neuro testing

• functional tasks may reveal poor motor control, coordination, or laoding strategy

what is the clinical priority with a patient who has movement control/movement coordination problems?

identify the movement or task that reproduces symptoms and begin retraining or modifying it

how does a patient presenting with movement control problems alter our exam?

• reproduce the problem on purpose

• use repeated and sustained testing

• neuro screen is still performed but expect it to be normal

• add active movement testing, control, and loading

• screen the hip and adjacent regions as contributors

how does a patient presenting with movement control problems affect our treatment?

retrain or modify the specific movement task that provokes symtpoms and then progress load and control

what is the primary problem in a patient presenting with functional optimization problems?

the patient needs to build capacity for meaningful activities

what is the patient profile in a patient presenting with functional optimization problems?

• symptoms are low irritability

• pain is intermittent or activity specific

• symptoms settle quickly

• neurologic screen is clear or stable

• patient can tolerate more loading and functional testing

what are the relevant LQS findings in a patient presenting with functional optimization problems?

• myotome, dermatomes, and reflexes are normal

• neurodynamic tests are negative or minimally symptomatic

• hip and lower extremity strength may affect function

• functional testing reveals endurance, strength, mobility, or task specific limitations

what is the clinical priority in a patient presenting with functional optimization problems?

progress activity tolerance, strength, endurance, and patient specific functional tasks

how does a patient presenting with functional optimization problems alter our exam?

• test to capacaity: endurance, strength, and task tolerance rather than symptom reproduction

• use functional and higher loading tests tied to the patient goal

• neuro screen to confirm it is negative

• quantify baselines to measure progress

what do our LQS findings tell us in regards to clinical reasoning with LBP?

• is there neurologic involvement?

• are symptoms consistent with a lumbar nerve root pattern?

• is it safe to continue testing?

• how irritable is the patient?

• what region should we examine next?

*so, overall, it helps us determine if the patient symptoms are neurologic, mechanical lumbar, SIJ/hip related, highly irritable, or safe to examine further

what are subjective and exam clues for someone with lumbar/nerve root problems?

subjective: back pain with leg symptoms, numbness/tingling, symptoms below the knee

exam: myotome, dermatome, reflex changes; positive SLR/slump

what are subjective and exam clues for someone with lumbar mechanical problems?

subjective: pain linked to sitting, bending, lifting, or repeated movement

exam: symptoms reproduced with lumbar movement/loading

what are subjective and exam clues for someone with SIJ/pelvic girdle problems?

subjective: pain near PSIS/buttock region, transitional movements, unilateral loading

exam: SIJ provocation cluster may reproduce familiar pain

what are subjective and exam clues for someone with hip problems?

subjective: groin/anterior hip pain, stiffness, pain with walking/shoes/socks

exam: limited hip ROM, painful hip clearing tests, weakness

what are the 4 classifications of LBP?

manipulation

specific exercise

traction

motor control/movement coordination impairments