Treatment Based Classification System Flashcards
(26 cards)
What are the 5 treatment classifications?
- Directional Preference
- Postural Syndrome
- Stabilization Classification
- Chronic Pain Syndrome
- Decompression
What are the clinical prediction rules for “Directional Preference”?
- Discogenic pain with radiculopathy
- Centralization with 2 or more movements in the same direction (flexion/extension)
- Centralization with a movement in one direction and peripheralization with an opposite movement
What are the clinical prediction rules for “Postural Syndrome?”
- No symptom radiation distal to elbow or knee
- Hypomobility in thoracic extension and/or rotation, lumbar flexion, or hip extension
- Lumbar hyperlordosis/anterior pelvic tilt or anterior head posture
- Frequent aching pain, worse towards the end of the day without specific trauma or inciting incident, better on the weekends or after physical activity, tension, stiffness and a frequent desire to “pop” their neck or back
- Difficulty recruiting deep neck flexors, lower trapezius, abdominals or gluteal muscles
What are the clinical prediction rules for “Stabilization Classification?”
- Average SLR motion >90 degrees
- Positive “Vleemings” active SLR
- Positive “Prone Stability Test”
- Positive aberrent movements
- Age >40
What are the clinical prediction rules for “Chronic Pain Syndrome?”
- Consistent pain for >3 months
- High fear avoidance
- Catastrophizing presentation
- Depression or Anxiety
What are the clinical prediction rules for “Decompression?”
- Pain with standing or walking
- Positive “Well Leg Raise Test”
- Relief with sitting and lumbar flexion ROM
- Relief with “Cervical Distraction Test”
What is the primary treatment modality for a “Directional Preference” classification?
- Treatment is almost entirely active
- Multiple movements in direction of centralization
- Lumbar extension or cervical retraction are common
- Determine correct direction and perform repeated motions or hold static positions in that direction, modify and advance if needed
- Limit certain movements and activities that may be contributing to pain or peripheralization
- Gradually remove restrictions to observe response to load and provide confidence
What is the primary treatment modality for a “Postural Syndrome” classification?
- Manual therapy and/or manipulation as well as specific postural exercises is extremely beneficial for persistent mechanical neck and lower back disorders
- Back School
- Ergonomics evaluation
- Micro break strategy
- General exercise recommendations
- XO Fitness referral
What are two different types of “Postural Syndrome?”
- Upper Crossed Syndrome: tightness or overactivity of the pectoral muscles, sternocleidomastoid, upper trapezius, and the levator scapula, with elongation or inhibition of the deep neck flexors, serratus anterior, and lower trapezius
- Lower Crossed Syndrome: shortness or hypertonicity of the thoraco-lumbar extensors, rectus femurs, and iliopsoas along with inhibition of the abdominal and gluteal muscles
Potential positive ortho’s indicative of “Postural Syndrome?”
- Wall Angel
- Thomas Test
- Jull’s Test (deep neck flexor endurance)
- Lower Trapezius Lift Off Test
- Abdominal Plank Test (patient begins the plank in lumbar extension)
- Hip Bridge (patient initiates movement with lumbar extensors or hamstrings)
- Cat/Cow (inability to demonstrate full ROM)
What is the “Wall Angel Test?”
-Head, mid-back and buttocks touching wall with feet away from wall; arms at a 90/90 position with wrists and fingers against the wall; attempt to flatten your lower back against wall
-Perfect (3): Able to achieve the position as shown with eyes horizontal and head not tilting; simultaneously flatten your fingers, hands and spine against the wall.
(will likely gain more benefit from focusing on strength and stabilization training rather than stretching exercises)
Pretty Good (2): Able to flatten head against the wall with your eyes horizontal, able to flatten your fingers and can almost wrists (<1cm form the wall), able to almost flatten your spine to the wall but not quite (time would be better spent working on other areas)
Work Needed (1): Unable to flatten your head against the wall or can flatten head but eyes are no longer horizontal; unable to flatten your fingers against the wall or wrists are way off (> 1cm from the wall); unable to flatten your spine anywhere near the wall (indicates a dysfunction of upright posture)
What is the “Thomas Test?”
Patient supine with with knees fully flexed and pulled as close as possible to chest ensuring lumbar spine is flat; lower one leg to table keeping alternate leg fully flexed; negative test results in a flat testing leg, without external rotation, and lumbar spine remains flat; positive test results in flexed hip without knee extension (tight Psoas), extended knee (tight r. femoris), abducted leg (tight IT band), lateral rotated tibia (tight biceps femoris); modified Thomas test patient sitting at end of table
What is “Jull’s” test?
Patient supine with head positioned in neutral; drop head piece and instruct patient to hold head position for 10 seconds; repeat with head 3 cm off table and with neck almost fully flexed; positive test is indicated if patient raises head recruiting superficial neck flexors (scalenes/SCM), juts chin and extends head, head begins to wobble/shake and cannot hold for 10 seconds; positive test indicates weak deep neck flexors
What is the “lift off test?” (Gerber’s Test)
Patient standing/sitting; internally rotate shoulder and place back of hand on small of back; instruct patient to lift hand off of back with resistance applied if necessary; positive test results if patient is unable to lift off of back, weak in doing so, or has pain; degree of weakness and/or pain is indicate of degree of lesion; complete inability to lift off indicates complete rupture and pain is indicative of partial tear or tendinitis
What is the “Single Leg Glute Bridge Test?”
- Tests strength of hip abductors and external rotators
- Glute Bridge position: Ask patient what muscle they feel working; should be gluten and not hamstrings/low back muscles; correct if needed
- Have patient raise one leg at a time and then lower and repeat on opposite side; look for hip dipping on unsupported leg
What are some exclusion criteria for the Postural Syndrome Classification?
- Red Flag symptoms
- Severe Pain (patient may enter the postural pathway after initial pain is reduced)
- Radicular symptoms or symptoms radiating past the elbow or knee
- Positive Instability tests
What are exclusion criteria for the Directional Preference Classification?
- Lack of centralization with repeated motion
- Red flags including gross motor weakness or worsening symptoms
What components does a focused history and clinical evaluation include?
- Frequency, duration, severity and location of symptoms
- History of injury, previous injury, and treatment
- Risk factors for potentially serious conditions
- Neurologic deficits: DTRs, dermatomes/myotomes
- Palliative/Provocation
- Quantity and quality of active and passive ranges of motion
- Orthopedic testing
What are some red flag conditions?
- Bowel/bladder compromise, saddle anesthesia
- Back or neck pain preceded by trauma
- Fever associated with back or neck pain
- Progressive upper or lower extremity weakness
- Cancer history
- Irregular weight loss
- Rapid and insidious onset
- History of UTI or other infection
What are some yellow flag conditions?
- Pain/numbness radiating below the knee or elbow: 4 week trial of conservative care before imaging or specialist care referral
- Conservative therapy plateau or negative responses to treatment: refer to PCP for co-management
- Age > 50 or Previous surgery: consider diagnostic imaging
- Pain management (symptoms effecting sleep, ADLs, work, etc.): consider referral to PCP for co-management
- Psychosocial limitations: Consider behavioral health co-management
What are some indications for diagnostic imaging?
- Trauma
- Unexplained weight loss
- Unrelenting pain at rest
- Evolving neurological deficit suggestive of intervertebral disc pathology, stenosis or tumor
- Known history of cancer, corticosteroid use, IV drug use, use of blood thinners, and known endocrine diseases.
- Pinpoint bony tenderness over the vertebral spinous process.
- Patient over age 50
- Suspected spinal instability
What are some inclusion criteria for the Spinal Stabilization Classification group?
- Younger in age, positive prone instability test, aberrant motions, SLR >90 degrees, recurrent episodes
- De-conditioned patient or history of sprain strain
- Feeling of the back or neck “giving way” during ADLs
- Hypermobility during AROM
- History of spondylolisthesis or whiplash injuries
What are some cervical characteristics for the “Spinal Stabilization” Classifications
- Head feels “heavy” fatigue with sustained positions
- Tense superficial cervical musculature.
- Poor response to cervical/thoracic manipulation
- < 39 seconds on deep neck flexor endurance test
- history of injury/accident to the neck
- Weakness in middle trapezius, serratus anterior, lower trapezius
- Chronic, recurrent episodes of neck pain
What is the Deep Neck Flexor Endurance Test?
- Assess the endurance of the deep neck flexors
- Test Position: Supine
- Performing the Test: Tuck patients chin in and lift off table 1 inch. The examiner looks for substitution of the platysma or SCM muscle.
- Normal Values: Men: 38.9 sec, Women: 29.4 sec
- Those with neck pain were found to have significantly decreased deep neck flexor endurance, average of 21.4 sec and tend to over-utilize other muscles for postural maintenance, which leads to forward head postures
