indicators

lumbar spine

What indicates treatment based classification (TBC)?

TBC Indications: - LBP with mobility deficits - LBP with referred LE pain - Directional preference (extension, lateral shift) - Positive within-session & between-session changes in pain/motion - CPR for manipulation (5 factors: pain <16 days, no distal symptoms, FABQ <19, hip IR >35°, hypomobility)

When to use CPA & UPA mobilizations?

Indications: - Hypomobile/painful segments via PAIVM - LBP with mobility deficits or referred LE pain - For flexion deficit: use pillow positioning - For extension deficit: flat positioning if tolerated - Reassess after mobilizations

When is spinal manipulation indicated?

Indications: - Pain <16 days - No symptoms distal to knee - FABQ <19 - Hip IR >35° - Hypomobility at least one level - 4/5 CPR criteria = strong likelihood of benefit

Contraindications of spinal manipulation?

Contraindications: - Bone weakening (osteoporosis, tumors) - Neurological issues (cord/cauda equina compression) - Severe or worsening nerve compression - Vascular issues (aneurysm, bleeding) - Inability to achieve positioning - Pregnancy, RA, Down’s, ligamentous laxity

When to use direction specific exercise (DSE)?

Indications: - Directional preference (extension, flexion, lateral shift) - Symptoms centralize with repeated movement - Subgroups: Extension, Lateral shift - Intervention includes repeated extensions, manual shift correction

When to use neurodynamic glides?

Indications: - Low irritability patients - Positive neurodynamic tests (SLR, Slump) - No contraindications - When MT/exercise does not improve SLR/Slump

When to use traction?

Indications: - LBP with radiating/radicular symptoms - Subgroup within TBC Contraindications: - Spinal infection, tumor, osteoporosis, RA/Down’s - Ligamentous laxity, instability - Pregnancy, steroid use - Fracture suspected, hiatal hernia - Symptoms worsen during traction

When is early PT access indicated?

Indications: Seen <14 days after onset → ↓ imaging, ↓ surgery, ↓ narcotics, ↓ cost. If <4 weeks, associated with improved outcomes. Supports direct access and guideline-adherent PT.

When to consider disc lesion diagnosis?

Indications: Common at L4/5 and L5/S1. Posterolateral > posterior. Causes radicular pain, neuro signs, or cauda equina if central. Presentation: Variable pain, paresthesia, neuro deficits.

When to suspect acute radiculopathy?

Indications: Unilateral LE pain (distal > proximal), dermatomal, paresthesia. Severe constant pain, worse at night. Eases with flexion postures (supine, sidelying). + SLR, Slump. Improvement expected in 7-10 days with conservative care.

When to suspect lumbar spinal stenosis?

Indications: Age >48, bilateral LE symptoms, leg pain > back pain, pain with walking/standing, relief with sitting. Aggravated by extension, eased by flexion. Must differentiate from vascular claudication (treadmill test).

When to suspect cauda equina syndrome?

Indications: Saddle anesthesia, urinary retention, fecal incontinence, bilateral LE weakness, ↓ DTRs. Caused by central disc herniation at L5/S1. Requires immediate surgical referral.

When to suspect ankylosing spondylitis?

Indications: Insidious onset (15-40 yo, M>F). Bilateral/symmetric mobility loss. Loss of lumbar lordosis, ↑ thoracic kyphosis. + HLA-B27. Progressive systemic disease.

Which outcome measures are indicated?

PSFS (MCID ~1.3-2.7) ODI (MCID = 6 points) FABQ (MDC ~5-7) STarT Back tool for risk stratification. GROC for progress monitoring.

When are yellow flags significant?

Indications: High FABQ scores, fear-avoidance, catastrophizing, depression, anxiety. Associated with poor long-term outcomes if unaddressed. Tx: Graded exercise, TNE, CFT.

What red flags suggest serious pathology?

Cancer: Hx of CA, age >50, unexplained weight loss, night pain. Fracture: Age >70, trauma, steroids, female. Infection: Fever, IV drug use, immunosuppression. AAA: Pulsatile back/abdominal pain, vascular risk. Cauda equina: Saddle anesthesia, retention.

What indicates direction specific exercise (DSE)?

Indications: Distal symptoms that centralize with repeated movements. Directional preference noted in history. Centralization with extension/flexion/lateral shift corrections. Peripheralization suggests avoidance.

What are asterisk signs used for?

Indications: Baseline comparable signs noted during T&M. Re-tested post-intervention to measure change. Helps guide classification and treatment effectiveness.

When is palpation indicated?

Indications: Identify bony landmarks, inflammation, tenderness. Differentiate between soft tissue vs joint pathology. Check for anomalies or pain reproduction. Systematic approach (prone, supine).

When is surgery considered for lumbar conditions?

Indications: Severe/progressive neurological deficits, cauda equina, failed conservative management. Discectomy: Best for leg pain. Fusion: Stops motion at painful segment, often for instability. Laminectomy: For decompression. Outcomes: Surgery faster relief, but long-term similar to PT.

When are lumbar surgeries indicated?

Laminectomy: For decompression of nerve root compression. Fusion: For instability, painful motion segments, or stenosis. Discectomy: For radiculopathy from disc herniation. Indicated when conservative care fails or in emergencies (e.g., cauda equina).

What are the risks of lumbar surgery?

Complications: Anesthesia problems, infection (1-8%), nerve damage (1-5%), bleeding, thrombophlebitis, ongoing pain, reoperation (18% decompression, 25% fusion). Poor outcomes: Persistent pain, ↓ function, ↓ ROM, instability.

How do surgical vs conservative outcomes compare?

Discectomy: Provides faster leg pain relief, but long-term outcomes similar to PT. Fusion: 50-70% functional improvement, but risk of poor outcomes (10-40%). Overall: Surgery no better than PT long-term, except for emergencies.