MSK Mod 2 Topic 3 Classification Based Lumbar Treatments

Evidence level A (SHOULD)

Strong evidence from randomized controlled trials with low risk of bias; intervention should be used for patients meeting the criteria

Evidence level B (MAY)

Moderate evidence; intervention may be used for patients meeting the criteria

Evidence level C (CAN)

Weak evidence; intervention can be used but is not strongly supported

Acute LBP with mobility deficits rule in

Unilateral pain up to 6 weeks in low back buttock or thigh; onset related to recent awkward or unbalanced motion; restricted end-range motion on AROM; segmental tests (PA or UPA) show limitation; neuro screen unremarkable

Acute LBP with mobility deficits rule out

Pain-free combined extension with side bend and overpressure; normal PA and UPA segmental testing; patient does not have this category

Acute LBP with mobility deficits interventions (manual therapy)

A level evidence (SHOULD) use thrust or non-thrust joint mobilization to address pain and limited mobility

Acute LBP with mobility deficits interventions (therapeutic exercise)

A level evidence (SHOULD) include direction-specific exercise in preferred direction if patient responsive; B level evidence (MAY) include exercise to increase or retain spinal mobility (stretching and ROM)

Acute LBP with mobility deficits interventions (patient education)

B level evidence (MAY) educate on favorable natural history of recovery; self-management techniques; promote active lifestyle

Acute LBP with movement coordination impairments rule in

Acute exacerbation or recurrent LBP (common presentation); pain in mid-range worsens with end-range movements or positions; aberrant motion (Gowers sign shifting catching); diminished lumbopelvic strength and endurance; PIT or PLET may be positive

Aberrant motion examples

Patient crawls hands up thighs when returning from flexion (Gowers sign); trunk shifts or deviates from sagittal plane during flexion; sudden acceleration hesitation or momentary quiver; reversal of lumbopelvic rhythm

Movement coordination impairments rule out tests

Normal SLR (≥80 degrees); normal thoracic rotation (≥80 degrees); normal trunk flexor strength (double leg lowering test); normal extensor endurance (Sorensen test); normal lateral abdominals and hip abductors (side plank); normal star excursion balance test (SEBT)

Acute LBP with movement coordination impairments interventions (manual therapy)

B level evidence (MAY) use thrust or non-thrust joint mobilization soft tissue mobilization and massage to restore mobility and relieve pain

Acute LBP with movement coordination impairments interventions (neuromuscular reeducation)

B level evidence (MAY) include specific trunk muscle training to promote dynamic (muscle) stability for movement

Acute LBP with movement coordination impairments interventions (therapeutic exercise)

B level evidence (MAY) retrain spinal stability with static and then progressive loaded tasks for strength and endurance

Acute LBP with related LE pain (referred) rule in

LBP with referred buttock thigh or leg pain that worsens with flexion or sitting; pain can be centralized with directional exercise manual techniques or positioning; lateral trunk shift or reduced lordosis; limited extension; neuro screen unremarkable

Acute LBP with related LE pain rule out

Pain location and intensity not changed with positioning lateral shift manual techniques or directional exercise

Acute LBP with related LE pain interventions (manual therapy)

A level evidence (SHOULD) use thrust or non-thrust joint mobilization; SHOULD include lateral shift correction if needed

Acute LBP with related LE pain interventions (therapeutic exercise)

A level evidence (SHOULD) include direction-specific exercise in preferred direction if patient responsive

Acute LBP with radiating pain (radiculopathy) rule in

Acute LBP with associated radiating narrow band lancinating pain in lower extremity; may report paresthesia numbness or weakness; pain in mid-range worsens with end-range movements; positive neuro screen (sensory motor or reflex loss); positive neurodynamic tests (SLR or slump)

Acute LBP with radiating pain rule out

Negative neurodynamic tests (SLR and slump do not provoke familiar lower extremity symptoms)

Acute LBP with radiating pain interventions (manual therapy)

C level evidence (CAN) use thrust or non-thrust joint mobilization; can use soft tissue mobilization or massage

Acute LBP with radiating pain interventions (therapeutic exercise)

B level evidence (MAY) include general exercise training to address identified impairments; may include neurodynamic treatments

Acute LBP with cognitive or affective tendencies rule in

Acute or subacute LBP with or without related LE pain; high scores on psychosocial subscale (STaRT Back); high fear-avoidance (FABQ work >20 or PA >11); high catastrophizing (PCS ≥30); depression (PHQ-2 ≥2 or PHQ-9 ≥10); anxiety (GAD-2 ≥3)

Acute LBP with cognitive or affective tendencies interventions (prognostic risk stratification)

B level evidence (MAY) use STaRT Back tool to prioritize interventions addressing biopsychosocial contributors to pain

Acute LBP with cognitive or affective tendencies interventions (therapeutic exercise)

B level evidence (MAY) include general exercise training and aerobic exercises

Acute LBP with cognitive or affective tendencies interventions (patient education)

A level evidence (SHOULD) include pain neuroscience education (PNE); may include active education and advice

Postoperative LBP evidence

No specific examination findings reported in 2021 CPG; limited studies with patients post lumbar discectomy laminotomy hemilaminectomy or laminectomy

Postoperative LBP intervention

C level evidence (CAN) use a general exercise training approach for post-lumbar spine surgery care

LBP in older adults examination

No specific category in CPG; assume any chronic category may apply; sarcopenia (loss of muscle cell size and number) is common

LBP in older adults intervention

C level evidence (CAN) use a fitness model with progressive increase in exercise intensity; exercise over passive treatment

Chronic LBP with movement coordination impairments rule in

Chronic recurring LBP with or without referred LE pain; pain worsens with sustained end-range movements or positions; observable incoordination; variable ROM; thorax or hip mobility deficits; neuro screen normal; PIT or PLET may be positive

Chronic LBP with movement coordination impairments interventions (manual therapy)

A level evidence (SHOULD) use thrust or non-thrust joint mobilization; may include soft tissue mobilization

Chronic LBP with movement coordination impairments interventions (therapeutic exercise)

A level evidence (SHOULD) include trunk muscle strengthening and endurance exercise; SHOULD include specific muscle activation and movement control exercise

Chronic LBP with radiating pain rule in

Unilateral pain; restricted motion; neuro screen unremarkable; strength unremarkable; PA or UPA shows limitation; neurodynamic tests positive (usually)

Chronic LBP with radiating pain interventions (manual therapy)

B level evidence (MAY) include thrust or non-thrust joint mobilization and soft tissue mobilization

Chronic LBP with radiating pain interventions (therapeutic exercise)

B level evidence (MAY) include general exercise and neurodynamic treatment

Chronic LBP with related generalized pain rule in

Chronic LBP with or without related LE pain; high scores on psychosocial subscale fear-avoidance catastrophizing depression or anxiety; can have any chronic LBP presentation

Chronic LBP with related generalized pain interventions (prognostic risk stratification)

B level evidence (MAY) use STaRT Back to prioritize interventions addressing biopsychosocial contributors

Chronic LBP with related generalized pain interventions (therapeutic exercise)

A level evidence (SHOULD) include general exercise training and aerobic exercises

Chronic LBP with related generalized pain interventions (patient education)

B level evidence (MAY) include cognitive functional training (multidisciplinary biopsychosocial approach) to address multiple factors associated with LBP; may include active education and advice

Cognitive functional therapy

Intervention that addresses multiple components associated with low back pain including pathoanatomical physical psychological social lifestyle and health-related risk factors; recommended for chronic LBP with generalized pain

Treatment based classification (TBC) for acute LBP

Classification by history and examination into one of four groups for initial care: stabilization manipulation specific exercise or traction

Mechanical diagnosis and therapy (MDT)

Formerly known as McKenzie system; classification based on response to direction-specific repeated motions or sustained positions; sub-grouped by response and this guides treatment

STaRT Back screening tool

9-item biomedical and psychosocial questionnaire; screens for prognostic indicators for chronic pain and disability; categorizes patients into low medium or high risk; guides psychologically informed physical therapy

Sorensen test

Patient prone with ASIS at edge of table; upper body off table; maintains horizontal position; timed in seconds; poor endurance (males <31 seconds females <33 seconds) predicts low back pain; used to rule out movement coordination impairments

Double leg lowering test

Patient supine; clinician elevates both extended legs until sacrum begins to rise; patient slowly lowers legs; observes when low back loses contact with table; assesses trunk flexor endurance

Side plank test

Patient side-lying with hips in neutral knees flexed 90 degrees; rests on elbow; lifts pelvis off table; timed in seconds; assesses lateral abdominal and hip abductor endurance

Star excursion balance test (SEBT)

Patient stands on one leg and reaches as far as possible in multiple directions; assesses dynamic balance and core control; used to rule out movement coordination impairments

Lumbar extension load test (alternative to PLET)

Prone position; patient actively lifts legs or trunk; assesses ability to maintain extension without pain or aberrant motion; used to predict need for lumbar stabilization exercises

Active straight leg raise test (ASLR)

Supine position; patient actively raises one leg with knee extended while maintaining pelvic control; difficulty or asymmetry may indicate poor lumbopelvic stability; used in instability assessment