Spine Classification Systems PDF Fall 2024

Lumbar Classification Systems: Pathoanatomic Movement Systems Impairments (MSI, ie Sahrmann) Mechanical Diagnosis & Therapy (MDT, ie McKenzie) Treatment Based Classification (TBC) Nick Washmuth Spine...

Lumbar Classification Systems: Pathoanatomic Movement Systems Impairments (MSI, ie Sahrmann) Mechanical Diagnosis & Therapy (MDT, ie McKenzie) Treatment Based Classification (TBC) Nick Washmuth Spine Fall 2024  Pathoanatomic Derived from James Cyriax: “All pain has an anatomic source, and all treatments must reach that anatomic source.” Different tissues require tissue-specific stimuli for healing (intervention). Different tissues heal at different rates (prognosis). Calm “tissue” down, then build “tissue” up. Exam should provoke all the suspected tissues to see if the concordant sign is reproduced. This allows the PT to eliminate normal tissue & identify the pathology. Pathoanatomic classification is discovering the SOURCE of the pain. Pain is very complex. The pathoanatomic approach is more reliable in acute pain. The more chronic the pain, the complex the pain pattern.  Example of Pathoanatomic Classification Every tissue requires specific stimuli for healing and every tissue heals at different rates. Tendon & muscle If it is a muscle or tendon injury, every time the muscle or tendon is stressed during the clinical exam, it should reproduce the patient’s concordant sign. Pathoanatomic approach is used frequently with the extremities, for muscle or tendon sources of pain. Hamstring strain, patellar tendonitis  Example of Pathoanatomic Classification Every tissue requires specific stimuli for healing and every tissue heals at different rates. Joint articular cartilage If it is a facet joint articular cartilage injury, every time the joint is compressed during the clinical exam, it should reproduce the patient’s concordant sign. Pathoanatomic approach is used frequently with the extremities, for joint sources of pain. Knee OA, patellofemoral pain  Pathoanatomic Framework Structure governs function. Inadequacies in anatomic structure will adversely affect function, leading to dysfunction. If the anatomic structure that is the SOURCE of the patient’s pain is discovered, treatment can focus on either calming that tissue down or building that tissue up. Examples: Muscle, IV disc, bone, articular cartilage, facet capsule, skin… Acute = Inflammation = PROM/AAROM/muscle activation/rest/immobilization/modalities = Rest & Protect Sub-Acute = Repair & Healing = strength/endurance/neuromuscular control/power/kinetic chain = On The Fence Chronic = Maturation & Remodeling = activity specific = Push & Build Knowing the SOURCE of the pain is NOT enough. Why did the tissue become painful? There must be a CAUSE. Pathoanatomic Classification: Keys to Success Know how to provoke & relieve all tissues. Know the optimal stimulus to strengthen (repair) all tissues. Specific adaptations to imposed demands.  Pathoanatomic Classification: How do you know what tissue(s) is(are) involved? *you can have more than 1 tissue that is the source of pain Skin: painful to palpate & stretch Ligament & Fascia: painful to palpate & stretch Muscle & Tendon: painful to palpation, stretch, & resist Joint Capsule: painful to palpate & stretch, painful joint play Bursa: painful to palpate & compress Meniscus (knee): + special tests, ROM, & history Articular Cartilage: painful to compress & painful joint play Nerve: + neurological testing Disc: painful to compress, painful to shear, decrease pain with distraction Bone: painful with percussion & palpation; imaging Pathoanatomic Classification: Prognosis Pathoanatomic Classification: How does this guide treatment? Healing = Repair = Every tissue has an optimal stimulus for healing. Strengthening Optimal Stimulus for Healing: Wolff's Law states that Bone – modified compression in the line of stress your bones will adapt Stimulates osteoblasts based on the stress or Collagen – modified tension demands placed on Stimulates fibroblasts them. Nerve – modified tension Articular Cartilage – modified compression & decompression with glide Stimulates chondroblasts Aids in movement & viscosity of synovial fluid Muscle – modified tension Modified = “pain free”; an intensity that does not cause further injury  Movement Systems Impairments Created by Shirley Sahrmann & based on concepts proposed by Florence Kendall. Kinesiopathologic Model: Impaired movement causes pain, dysfunction, & pathology Repetitive motion in the presence of biomechanical dysfunction will provoke injury Example: Valgus fault at the knees cause patellofemoral joint injury. Lifting with hyperflexed spine causing lumbar injury (disc injury). Maintaining or restoring ideal movement of specific segments (or body regions) is the key to preventing or correcting neuromusculoskeletal pain. Movement diagnosis is used to describe the CAUSE of the pain or dysfunction. Alternative model is Pathokinesiologic Model: A pathologic condition (health condition) causes a movement dysfunction Example: Stroke with resultant hemiparesis Example of MSI Repetitive motion in the presence of uncoordinated motion or biomechanical dysfunction will provoke injury. Excessive lumbar flexion is required during forward bending in the presence of decreased hamstring extensibility. Case Example: A patient’s job requires them to perform a forward bending movement throughout the day. If this forward bending occurs in the presence of decreased hamstring extensibility, the forward bending mechanics will be impaired, as there will be decreased hip flexion and excessive lumbar flexion during forward bending. This could place excessive compressive stress on the lumbar intervertebral discs. Over the course of days, weeks, or years, this excessive compressive force could provoke a disc injury or herniation.  Example of MSI Impaired movement results in pain, dysfunction, & pathology. During cutting or landing movements, a valgus collapse of the knee puts excessive stress on the MCL & ACL, which can lead to a ligament sprain. Case Example: This patient lands with R knee valgus and tears ACL. The movement fault (valgus) caused the pathology (torn ACL).  Example of MSI Repetitive motion in the presence of biomechanical dysfunction will provoke injury. Lumbar spine instability can lead to osteophyte formation. Case Example: Lumbar spine instability occurs when the static & dynamic stabilizers of the lumbar spine are unable to control a hypermobility (eg. uncontrolled hypermobility). If a hypermobile lumbar spine moves repeatedly without proper stabilization, for example, in the presence of a faulty muscle recruitment pattern, the hypermobile spine will lay down new bone, osteophytes (i.e. bone spurs), to help stabilize the spine. The movement faulty (hypermobility) caused the pathology (osteophyte).  Movement Systems Impairments: Framework In a multisegmental system, movement will take the path of least resistance, a concept referred to as relative flexibility. Areas in the body that are relatively MORE flexible are more likely to experience musculoskeletal impairment through cumulative trauma, since that area likely moves 1st and to a greater degree than adjacent regions. The relative flexibility, or direction of pain, is used to classify the patient’s movement impairment.  Movement System Impairments: Principles of Intervention Segmental hypomobility contributes to compensatory hypermobility at adjacent segments. Classically, the hypermobility is the painful region. The hypermobile regions are compensating for the hypomobilities in neighboring joints. The MSI approach attributes most spine-related symptoms to the regions that have excessive relative flexibility as apposed to segments in which motion is reduced. Hypermobile regions are where the patient will move 1st and are painful Therefore, the focus of intervention is directed toward achieving and maintaining proper spinal alignment and the prevention of unwanted movement. An emphasis is placed on correct exercise performance so that precise movement patterns are adopted. *Dx should guide intervention  Movement Systems Impairments: Lumbar Spine Classification Categories *you can have more than 1 MSI diagnosis Ex. Flexion-rotation syndrome Flexion Syndrome Extension Syndrome Rotation Syndrome  Movement Systems Impairments: Lumbar Flexion Syndrome Symptom Behavior: Increased symptoms with spinal flexion movements and alignments. Symptoms decrease with extension movements What exam findings are expected in a patient with Flexion Syndrome?  Movement Systems Impairments: Lumbar Extension Syndrome Symptom Behavior: Increased symptoms with spinal extension movements and alignments. Symptoms decrease with flexion movements and positions. What exam findings are expected in a patient with Extension Syndrome?  Movement Systems Impairments: Lumbar Rotation Syndrome Symptom Behavior: Increased symptoms with spinal rotation or side bending movements and alignments. Symptoms decrease when rotation is minimized during provoking activities. Unilateral symptoms. What exam findings are expected in a patient with Rotation Syndrome? Rotation in flexion or extension is painful Mechanical Diagnosis & Therapy: McKenzie Method Robin McKenzie developed classification system based on individual’s symptomatic and mechanical response to movement and position. Exam focuses on having patient performed repeated movements and sustained positions, and monitoring change in symptoms and ROM Emphasis on self-intervention procedures and behavior modifications MDT is a systematic approach to the conservative management of most activity-related spinal disorders. The classification system categorizes patients according to their symptomatic response to movement and position, rather than a system that is based on a pathoanatomical diagnosis. Mechanical Diagnosis & Therapy: Examination The patient’s symptomatic and mechanical response to loading guides the therapist to the appropriate classification and course of intervention. A comprehensive history should include information about the present episode of symptoms, including the MOI, symptom presentation, and functional limitations. This data should help the therapist formulate an initial working hypothesis regarding the patient’s mechanical classification. Then, the physical exam is used to confirm or reject the working hypothesis by testing the patient’s symptomatic response to loading and by observing the quality and quantity of movement.  Mechanical Diagnosis & Therapy: The patient moves as far as possible through a test movement for one repetition and then repeats for 10 reps. During and immediately following these movements, the examiner records the effect on the patient’s symptoms. Repeated movements that produce Test Movements peripheralization of symptoms are immediately stopped. If symptoms improve or centralize during testing, then the patient should continue with the repetitions. 1. Flexion in 2. Extension in Standing Standing During movement – produces, abolishes, increases, decreases, no effect, centralizing, peripheralizing Once the patient returns to the neutral position and rests for a few moments, the effect of movement on symptoms is recorded. After movement – better, worse, no better, no worse, no effect, centralized, peripheralized If there is no conclusive symptomatic or mechanical response to sagittal plane movement (flex/ext), then side gliding can be attempted. 5. Side Glide Although not routinely performed, static tests may be necessary if repeated movement testing is inconclusive. Examples of these positions in Standing are in pictures 3 and 4. 3. Flexion 4. Extension in Lying in Lying  Mechanical Diagnosis & Therapy: Classification Syndromes Derangement syndrome The derangement syndrome is the most frequently observed clinically. May be synonymous with the pathoanatomical model – Discogenic Pain. McKenzie believes derangements typically develop as a result of sustained or repetitive loading (often flexion and/or rotation), chronic postural stresses, or trauma. Signs and symptoms of radiating or radicular pain are very common with derangements Repeated movement testing often reveals centralization/peripheralization May also see motion loss and an obstruction of normal posture (loss of lordosis or a lateral shift/list). The ability to centralize is considered to be a favorable prognostic indicator. Dysfunction syndrome It is thought that these patients have contracted, adhered, or adaptively shortened tissues surrounding one or more of the spinal segments. Movement becomes painful when restricted soft tissues are brought to the end of their available motion. The patient’s motion restriction is observed in same direction in which pain is produced. Symptoms more local and not expected to refer to extremities Pain usually only present when shortened tissues are stretched Postural syndrome Structures (joint capsules, ligaments, muscles) strain in response to prolonged static loading at end range. No reproduction of symptoms in response to single or repeated movements Low levels of pain in response to maintenance of prolonged positions only  Mechanical Diagnosis & Therapy: How does this guide treatment? Derangement: Goals: centralize symptoms, maintain centralization, restore full ROM Movement into direction that causes centralization or pain reduction. Exercises into the patient’s directional preference are performed 10 times every 1-2 waking hours, or more frequently if symptoms recur. It is important with these exercises that the patient move to their end range. Treatment? Dysfunction: Goals: facilitate remodeling of adaptively shortened tissues, restore full ROM Movement into restricted direction. The treatment approach for this group is progressive movement into the direction of restriction, with the main goal being improvement of motion. Exercises are performed 10 times every 2-3 waking hours. Treatment? Postural: Goals: remove abnormal postural stress that occurs to normal tissue Education is the key to management of those with postural syndrome. The slouch-overcorrect exercise is prescribed to help teach patients how to find good posture in sitting. Treatments? Treatment-Based Classifications The primary purpose of the TBC approach is to identify features at baseline that predict responsiveness to four different treatment strategies. This approach has been validated and is used widely in the USA. In order to classify patients using the TBC, this chart lists the Lumbar Treatment-Based Classifications: data that needs to be collected in either the interview or the physical exam. You should recognize most all of the tests as Key Components of Exam items you have learned in both this and previous semesters. Interview Measures Tests &  Lumbar Treatment-Based Classifications: Treatment SubgroupsThe criteria for the individual subgroups are clearly summarized in this table. At least 1 hip IR ROM GREATER THAN 35deg Tasha R. Stanton et al. PHYS THER 2011;91:496-509  Cervical Treatment-Based Classification System  Treatment Criteria Pain Control MVA or other whiplash mechanism Cervical mobilizations Symptoms < 30 days Cervical ROM exercises Pain >7/10 or NDI >52 Centralization Signs of nerve root compression Cervical traction Symptoms distal to elbow Cervical retraction exercises Symptoms >30 days Cervical Pain 30 days System Mobility Pain 35deg, no symptoms distal to knee c) Diminished patellar DTR, numbness in thigh, + crossed SLR Subjective: Phil, a 67-year-old male retiree, reports a gradual onset of LBP, which began 3 years ago. His pain is focused to his lower lumber region, and he denies numbness or tingling. His pain increases with standing and walking, and his pain decreases with sitting. Phil is otherwise healthy and has the goal to wanting to walk 5 miles without pain. Objective: AROM: Lumbar flexion 25%, no pain Lumbar extension 50%, with pain Repeated lumbar flexion, no pain Repeated lumbar extension, with pain and this increases lumbar extension ROM MMT: LE, abdominals, and paraspinals 5/5, no pain Palpation: TTP lumbar paraspinal musculature and spinous process of L4 & L5 Neuro: Unremarkable Joint Accessory Motion: Central PAs at L4 and L5 are hypomobile and painful Special Tests: + quadrant test to each side, negative lumbar compression, + lumbar distraction, negative passive lumbar extension test, negative active SLR test, negative SIJ special tests Using the lumbar classification systems, what diagnosis(es) can be used for this patient? Defend Your Answer Pathoanatomic: ligament, muscle/tendon, articular cartilage (facet), nerve, disc, bone Mechanical Diagnosis & Treatment (MDT): derangement, dysfunction, postural Movement Systems Impairment (MSI): flexion, extension, or rotation syndrome Treatment Based Classification (TBC): manipulation, stabilization, specific exercise, traction Subjective: Will, a 33-year-old male teacher, reports injuring his low back yesterday while doing a 1-rep maximum attempt on the bench press. His pain is focused to the L side and ranges from 0-8/10. Pain increases with “most movements”, especially when standing up from a sitting position. Pain decreases when he is sitting or lying down or otherwise not moving. FABQ is 10. Will is otherwise healthy and wants to return to working out without pain as quickly as possible. Objective: Posture: Stands with flexed spinal posture. AROM: Lumbar flexion 100%, with pain Lumbar extension 100%, with pain Side bending and rotation 75%, with pain PROM: Hip ER 45° B Hip IR 30° L, 40° R Hip extension 5° B Hip flexion 125° B MMT: Paraspinal strength 4/5 with pain Palpation: TTP L lumbar paraspinal musculature and quadratus lumborum Neuro: Unremarkable Joint Accessory Motion: Hypomobile PAs at L3 & L4, no pain Special Tests: lumbar distraction increase his pain, negative lumbar compression, negative passive lumbar extension test, negative active SLR test, negative SIJ special tests, + Sorenson’s test with pain Using the lumbar classification systems, what diagnosis(es) can be used for this patient? Defend Your Answer Pathoanatomic: ligament, muscle/tendon, articular cartilage (facet), nerve, disc, bone Mechanical Diagnosis & Treatment (MDT): derangement, dysfunction, postural Movement Systems Impairment (MSI): flexion, extension, or rotation syndrome Treatment Based Classification (TBC): manipulation, stabilization, specific exercise, traction  How would we diagnose Kathryn? Subjective: Kathryn presents with ~8 year history of LBP, starting when she was 14 y/o in gymnastics. She points to her beltline as pain location and denies peripheral symptoms or N/T. Pain increases primarily with extension movements, and sometimes with flexion movements. Kathryn’s symptoms improve with lumbar flexion movements and heat. Pain is described as sharp, sometimes dull, and achy after a lot of extension. She did “core stabilization stuff” in high school for this same pain, with questionable success. I am the first provider she has seen for this condition. Objective: Posture: L iliac crest elevated, R shoulder lower than L, forward shoulders, mild swayback AROM: Forward bending: excessive hamstring length, did not reverse lumbar curve (hypomobile), excessive thoracic flex Backward bending: ROM painful, more pain with overpressure SB WNL Rotation painful each side PROM: WNL motion Mild pain with ext and rot Joint Play: Central PAs: pain with L5 Unilateral lumbar PAs: pain at L4 & L5 Grade 3 throughout Palpation: TTP – L4 & 5 SPs Special Tests: Lumbar compression – negative in flexion, positive in extension  Pathoanatomic Classification: How do you know what tissue(s) is(are) involved? Skin: painful to palpate & stretch Ligament & Fascia: painful to palpate & stretch Muscle & Tendon: painful to palpation, stretch, & resist Joint Capsule: painful to palpate & stretch, painful joint play Bursa: painful to palpate & compress Meniscus (knee): + special tests, ROM, & history Articular Cartilage: painful to compress & painful joint play Nerve: + neurological testing Disc: painful to compress, painful to shear, decrease pain with distraction Bone: painful with percussion & palpation; imaging  Movement Systems Impairments: Lumbar Spine Classification Categories Flexion Syndrome Extension Syndrome Rotation Syndrome  Mechanical Diagnosis & Therapy: Classification Syndromes Derangement syndrome The derangement syndrome is the most frequently observed clinically. May be synonymous with the pathoanatomical model – Discogenic Pain. McKenzie believes derangements typically develop as a result of sustained or repetitive loading (often flexion and/or rotation), chronic postural stresses, or trauma. Signs and symptoms of radiating or radicular pain are very common with derangements Repeated movement testing often reveals centralization/peripheralization Dysfunction syndrome It is thought that these patients have contracted, adhered, or adaptively shortened tissues surrounding one or more of the spinal segments. Movement becomes painful when restricted soft tissues are brought to the end of their available motion. The patient’s motion restriction is observed in same direction in which pain is produced. Symptoms more local and not expected to refer to extremities Pain usually only present when shortened tissues are stretched Postural syndrome Structures (joint capsules, ligaments, muscles) strain in response to prolonged static loading at end range. No reproduction of symptoms in response to single or repeated movements Low levels of pain in response to maintenance of prolonged positions only  Lumbar Treatment-Based Classifications: Treatment Subgroups At least 1 hip IR ROM GREATER THAN 35deg Tasha R. Stanton et al. PHYS THER 2011;91:496-509