Treatment-Based Classification Approach to Low Back Syndrome by zqw77719


									Clinical Perspective

A Treatment-Based Classification Approach to Low
Back Syndrome: Identrfying and Staging Patients for
Conservative Treatment

 We present a treatment-based classzjication approach to the conservative man-                                Anthony Delltto
 agement of low back syndrome. i%e approach has three levels of classzjication                                Richard E Erhard
 based on historical information, behavior of symptoms, and clinical signs. We                                Richard W Bowling
jirst distinguish patients whose conservative care can be managedpredomi-
 nantly and independently by physical therapists versus patients who require
 consultation with other sem'ces (eg, psychology) or who require referral because
 of possible serious nonmusculoskeletalpathology. Once patients who can be
 managed by physical therapists are identzjied, the next level of classzjication is
 to stage their condition with regard to severity. We propose three stages: stage Z
for patients in the acute phase where the therapeutic goal is symptom relieJ
 stage Z forpatients in a subacute phase where symptom relief and quick return
 to normal function are encouraged, and stage Z Zfor selected patients who
 must return to activities requiring high physical demands and who demon-
 strate a lack of physical conditioning necessary to pe$orm the desired activities
 safely. i%e remainder of the article focuses on a third level of classijication for
 stage Z only in which patients are classtjied into distinct categories that are
 treatment-based and that speczjically guide conservative management. i%e
 entire approach is diagnosis based, with specijic algorithms and decision rules
 as well as examplespresented. [Delitto A, Erhard RE, Bowling RW. A treatment-
 based classijication approach to low back syndrome: identifying and staging
patients for conservative treatment. Pbys i%er. 1995;75470- 489.1

Key Words: Backache, Classijication, Decision making, Diagnosis

Low back syndrome (LBS), although                   solve are prone to recurrence at a rate          majority of patients with LBS without a
self-limiting in most cases, leads in a             of up to 90%.3 Contributing to the               specific diagn~sis,~ resulting in a con-
small percentage of patients to chronic             difficulty in managing low back-related          dition that has been described as an
problems that can be very costly to                 disorders is the inability to ident~fy
                                                                                         a           "illness in search of a disease."5
               , ~ ~ ~
m a ~ g eand those cases that re-                   causative agent, thus leaving the vast
                                                                                                     Without a specific diagnosis, the limi-
                                                                                                     tations of the traditional "pathology-
                                                                                                     based model," which implies symp-
A Delitto, PhD, PT, is Chair, Department of Physical Therapy, School of Health and Rehabilitation    toms should be proportional to organ
Sciences, University of Pittsburgh, 101 Pennsylvania Hall, Pittsburgh, PA 15261 (USA). Address all
correspondence to Dr Delitto.
                                                                                                     pathology, become a ~ p a r e n tDeyo7
                                                                                                     suggests that instead of a clinician
RE Erhard, DC, PT, is Assistant Professor, Department of Physical Therapy, School of Health and      searching for the pathological cause of
Rehabilitation Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA 15261.
                                                                                                     LBS, three basic questions should be
RW Bowling, PT, is Assistant Professor, Department of Physical Therapy, School of Health and         answered during the initial clinic visit:
Rehabilitation Sciences, University of Pittsburgh Medical Center, a n d President and Chief Execu-   (1) Is there systemic or visceral disease
tive Officer, Centers for Outpatient Rehabilitation and Evaluation (CORE) Network, Pittsburgh, PA.
                                                                                                     underlying the pain? (2) Is there evi-
This article was submitted April 8, 1994, and was accepted Janua y 12, 1995.

20 / 470                                                                             Physical Therapy / Volume 75, Number 6 /June 1995
dence of neurologic compromise that          causes of low back symptoms; (2)                        of
                                                                                           O v e ~ e w Management
represents a surgical emergency? and         movement tests where the response of          Approach
(3) Are there findings that influence        the patient (in terms of behavior of
the choice of conservative therapies?        signs and symptoms) is noted; and (3)         The structure of our approach is as-
Data from the history and physical           signs that consist of palpatory tests,        sessment of clinical data leading to a
examination presumably lead to an-           measurements, and observations that           series of classifications that specifically
swers to all three questions. Clinicians     focus on alignment of body structures.        direct the management of the patient
facing patients with LBS on a day-to-                                                      with LBS. For the purpose of this text,
day basis, in our opinion, rely primar-      Development and Background                    l w back syndrome is defined as a
ily on patient reports of signs, symp-       of the Examlnatlon Procedure                  clinical entity that is characterized by
toms, and symptom-related behavior.                                                        the occurrence or presence of one or
Although appearing on the surface to         Initially in developing the manage-           more of the following signs or symp-
be "subjective" in nature, the reliability   ment scheme, we relied on input from          toms: (1) pain in the area of the lum-
of data related to signs and symptoms        approximately a dozen practitioners,          bosacral spine, buttock, or referred to
has been demonstrated in a variety of        including physical therapists, chiro-         the thigh area to the knee but thought
clinical ~iluations.~-ll                     practors, and physicians, to arrive at a      to be of spinal origin; (2) pain, pares-
                                             list and description of tests and mea-        thesia, or other changes in cutaneous
How Information related to signs and         sures that would comprise a compre-           sensation located in the leg or foot
symptoms is interpreted and com-             hensive history and physical examina-         area but believed to be of spinal ori-
bined to guide the clinicians in conser-     tion for a patient with LBS.18 Pertinent      gin (radicular symptoms); or (3) alter-
vatively treating patients is unclear.       tests have subsequently been studied          ations in reflexes or loss of motor
Some have argued (without the bene-          in a reliability investigation, and either    function in the lower extremities,
fit of data) that decisions regarding        the tests were shown to have ade-             again from spinal origin (radicular
conservative management can be               quate reliability (reliability coefficients   signs).
made according to clusters or patterns       2.70) or judgments of reliability were
of data obtained during clinical test-       suspended due to inadequate distribu-                          B
                                                                                           The result of L S is usually impaired
ing.12-15When tested, however, others        tion of item scores.19 Subsequent sec-        function in daily activities. Along with
have shown that decisions regarding          ondary analyses of the data have dem-          other^,^^^^^ we recognize that the re-
clinical clustering of data do not show      onstrated adequate internal consist-          ported severity and resultant disability
a consistent pattem.16Such equivocal         ency (reliability coefficients >.80) for      from LBS may often be influenced by
results lend credence to those who           the examination p r o c e s ~ . ~             non-movement-related factors (eg,
describe {hedecision regarding con-                                                        m a m e d illness behavior and other
servative intervention for LBS as "tak-      The initial sources that described the        psychosocial factors). The proposed
ing on the characteristics of a              testing procedures can be traced back         management approach is designed to
lottery."17                                  to writings and teachings of various          help clinicians recognize when these
                                             "authorities" in orthopedic physical          factors may be playing a critical role in
The purpose of this clinical perspec-        therapy, chiropractics, and medicine.18       the patient's symptoms and to direct
tive is to outline an examination ap-        The descriptions of tests and measures        the primary care clinician to refer the
proach for patients with acute LBS that      from virtually all initial sources were       patient to another practitioner or to
leads to a classification that specijcalfy   lacking, however, leading our group           seek consultation of another profes
directs conservative management of           to treat such descriptions as first ap-       sional. Only specific intervention of
LBS. That is, this examination ap-           proximations. We further operational-         movement-related management strate-
proach leads to a classification that        ized the exact procedures for the             gies are included.
will result in a management strategy         specific tests. In addition, when data
that is detailed with regard to the          obtained from testing procedures              First-Lwel Classification
precise type of treatment (ie, mobiliza-     purportedly led to treatment direction,
tion, extension movement, traction) to       we found a void in any clear decision         The first level of classification is deter-
be prescribed to the patient, and not        rules within the writings of "authori-        mining whether the patient's care (1)
relegated to nonspecific terminology         ties." Again, we have attempted to            can be managed independently and
where any number of conservative             operationalize such decision rules            primarily by physical therapy, (2)
strategies can be used for one classifi-     within this article. Although some of         cannot be managed by a physical
cation (ie, "exercise," "active therapy").   the tests and procedures discussed in         therapist and instead requires referral
                                             this article have been subjected to           to another health care practitioner, or
The variables assessed in this clinical      peer-reviewed investigation, we would         (3) may be managed by a physical
examination can be divided into the          remind the reader that much of the            therapist but requires consultation
major categories of symptoms and             decision-making rules that we propose         with another health care practitioner
signs. These categories are (1) histori-     have not been tested through prospec-         (Fig. 1). In making this first-level clas-
cal data related to musculoskeletal as       tive research.                                sification, we recognize that with d-
well as possible nonmusculoskeletal                                                        rect access in many states, patients

Physical Therapy / Volume 75, Number
                                                                                             inchcate the possibility of "magmtied
                                                                                             illness behavior," and, if these behav-
                                                                                             iors are confirmed through subsequent
                                                                                             examination, we believe a multidisci-
                                FIRSl-LEVFL CLASSIFICATION
                                                                                             plinary management regimen is
                                              I                                              needed.
                I                                                          I
                                                                                             Modified Oswestry Questionnaire
  Stage I Inflammatory
  Stage I Mechanical                                                                         We use a modified version of the
  Stage Il                                                                                   Oswestry Low Back Disability Ques-
  Stage Ill                                                                                  tionnaire in the initial classification
                                                                                             procedure as well as for the documen-
Figure I. the fin-t-level classification involving a decision of which patients can be                                 The Oswestry
                                                                                             tation of o ~ t c o m e . ~ ~ ? ~ 5
treated primarily and independently by phystcal therapists versus patients who will          questionnaire is a disease-specific (eg,
require multidisciplinary management with physical therapy (consultation) versus             LBS-specific) self-report. In addition to
patients who require referral to another health care practitioner.                           serving as a guide for initial decision
                                                                                             making regarding classifications, we
with serious pathology (eg, metastatic            obtaining further confirmatory data        also find the information from the
cancer) can complain of spinal pain to            within the history and the physical        Oswestry questionnaire to be useful
a physical therapist, and the physical            examination. For example, patients         for indicating patient outcome, espe-
therapist, as a first-contact practitioner,       may check numerous "red flags" as          cially for short-term outcome stud-
must be able to recognize such pa-                present, such as recent weight loss.       ies.26-28 The results from the Oswestry
tients and refer them to appropriate              The clinician does not immediately         questionnaire have been reported to
health care profe~sionals.2~   Second,            refer the patient to a primary care        be highly reliable (Pearson rand intra-
there is good evidence that in addition           physician to rule out metastatic dii-      class correlation coefficients B.90)in
to physical problems, patients with               ease. Instead, the information checked     its original24 as well as modified
L S have psychological distress and
  B                                               on the questionnaire is noted by the       forms.25
socioeconomical concerns that can                 clinician, who then further questions
play a role in their symptoms and                 the patient in the history about the       The Oswestry questionnaire is an
resultant di~ability.~3 contend that
                        We                        nature of the weight loss and makes a      easily administered self-report that
the physical therapist, who is prirnanly          judgment about whether further             results in an index of a patient's per-
trained to address physical dimensions            workup is necessary.                       ceived disability based on 10 areas of
of LBS (eg, the physical impairments),                                                       limitations in performance. The areas
must recognize when the symptoms                  Medical Questionnaire                      covered are pain intensity; personal
related to LBS have a substantial psy-                                                       hygiene; lifting; wallung; sitting; stand-
chosocial or socioeconomic dimension              The medical questionnaire is pre-          ing; sleeping; social activity; traveling;
and refer the patient or consult with             sented in Figure 2. The questionnaire      and, depending on the version used,
another health care professional who              is divided into two components: (1)        sex life, changing status of pain, or
 has training in addressing this                  questions that are intended to unveil      employment/homemakingduties.
 dimension.                                       medical problems that may contraindi-      Each section is scored on a six-point
                                                  cate treatment and 2) questions that       scale (0-5), with 0 representing no
In both the case of severe pathology              are intended to identlfy "nonorganic"      lunitation and 5 representing maximal
and high psychological distress, pa-              pain behavior. The latter questions        limitation. The subscales together add
tients may relate their symptoms in               have been italicized for illustration in   up to a total maximum score of 50.
such a way that the clinician is left             Figure 2. Italics are not used on the      The score is then doubled, and inter-
with an impression that the patient is            actual screening form.                     preted as a percentage of the patient-
experiencing a high degree of illness                                                        perceived disability (the higher the
behavior (abnormally high response of             If an affirmative response to any of the   score, the greater the disability).
the patient to the underlying disease             first group of medical screening ques-
process). We use three forms to assist            tions is given, further information must   Our patients complete the Oswestry
with this level of classification: (1) a          be obtained. We believe our approach       questionnaire while in the waiting
medical screening questionnaire that,             is conservative in that if we have any     room so that it is available when we
in addition to screening for serious              doubt that symptoms are from a seri-       take the history. The questionnaire
pathology, includes "nonorganic"                  ous pathology of musculoskeletal or        takes less than 5 minutes to score, and
descriptions of pain; (2) a modified              nonmusculoskeletal origin, then we         we believe clinicians can use it to
Oswestry questionnaire; and (3) a pain            refer the patient to another health care   approximate the patients' perceived
diagramlpain scale. We do not rely on             professional. Affirmative responses to     functional limitations and overall
any one of the tools listed without               the latter group of questions, however,    disability.

                                                                               Physical Therapy / Volume 75, Number 6 /June 1995
                                                 Law U c PAINMEDICAL S a u m m ~-
                                                      a                        0

         NAME:                                                                                                                      DATE:
          1.             ae                                    Osteopolrsip,a Cancefi
                Do You H v Any Ongdng Msease Process Such as M ,
                IlYes     IlNo
                If Yes. P k Specify
          2.    Have You Had a Recent Physical Eambmkm Including X-Raysand Iabontory Tests'
                IlYes    IlNo
          3.    Have You Recmtly Lost More than 10
                IlYes    IlNo
          4.    If You Answered Yes to the Above Question, Was This Weight Loss Due m Meting!
                IlYes     IlNo
          5.    Are You -Any              Bowel Irre@adties7
                IlYes     IlNo
          6.    k e You Brperiendng Any AWanlnal Pain or Problem?
                []Yes     IlNo
          7.    Are You BrperiendngAny Rectal Bleeding?
                IlYes     []No
          a     Are You m n d n g Any Bladder Irregulatity?
                I ]Yes    I IN0
          9.    Are You Brperlendng Any Menstrual IrregdaritW
                IlYes     IINo
          10.   If You Answered Yes to Any Question Between Numbers 5 and 9, Are You Currently Under a Doctots Care for This or These P r o b W
                IlYes     IlNo
          11.   Do You Brperlence Any Weakness in Your Legs DuringWalking?
                IlYes    []No
          12.   DoYouHaveAnypukvlnePaininYourBack?
                IlYes  IlNo
          13.   DoYouGetP?lninYour~That19CausedbyWalklngandThat~ReUevedby~
                I ]Yes I I N 0
          14.   Do Your Feet Peel Cold a More Painful During Cold Weather!
                IIYes    IlNo
         15.    DoYouGaRahartbe'IlpgfYauTaUtvn&
                []Yes  IlNo
         16.    weSYourEntbl?@bBennnePa~(~,Sldes,dmrdar~Samen&
                []Yes  []No
         17.    aoeSYauEntbl?@bBeconu,M~(Aau,Slda,rmdBaclrar~~Tlme)?
                IlYes  IlNo
         1%     weSYourWbdeLq~Giu?Wap
                IlYes  I1No
         19.                a
                Hat.?? You H d Any fWo& c Tlme in tbe PM Ymr or Durhtg 'Ibis @Isoak wben You Haw Had V i LUrle P l 2
                                        f                                                                       aa
                I ]Yes I I N 0
         20.    Hat.?? You b Had to Repat t a H n I Emergmcy Room BamLce gf Back Pain?
                                          o cpd
                I ]Yes I I N 0
         21.                a
                Hat.?? You H d Any 7 k m n e w m Your AoMem 7lJaI Has H e g d You?
                IlYes      IlNo
         22.    H c Ml 7kmnewfbrYour BathMade You W d
                IlYes     IlNo
         23.    Do You Have Any Numbners a Tingling in Y a y Buttocks or Genltal Region?
                I ]Yes    I IN0

Figure 2.     Medical screening questionnaire, which includes questions related to pain from nonmusculoskeletal origin (1-14)
and questions used to identlfi patients who may be exhibiting magniJied illness behavior (15-23).

Interpretation of Scoring for                          ponent to their symptoms, and this is                        is constant and severe, I cannot sit at
First-Level Classification                             usually manifested by emergencies                            all, I cannot stand at all, I must lie
                                                       that require hospitalization or by mag-                      down to travel), indicating the patient
Our interpretation of Oswestry scores                  nfied illness behavior. A score of 75                        perceives his or her low back trouble
greater than 75 is that patients may                   or higher will include near-maximal                          is extremely activity limiting. If the
have a substantial nonmovement com-                    scores in the subsections (ie, the pain                      patient is offering an accurate indica-

Physical 'Therapy / Volume 75, Number 6 /June 1995
                                                                                                                follows: (1) organic, (2) possibly or-
                                                                                                                ganic, (3) possibly nonorganic, and (4)
                            Signs& SymptomsThat Indicate a Need for Medical Referral

                                                                                                                Clarifying Infomation Gatheed
                                                                         I                                      From Questionnaires Through the
  Temperature 1 100D~             Pain Constant, Unrelated to Position or Movement
  BP > 160/95 mm Hg               Severe Night Pain Unrelated to Movement                                       History
  ReStingPulseZlOObpm             Recent Unexplained Weight Loss > 4.5 kg (10 lb)
  Rgting Respiration > 25 bpm     History of Direct Blunt Trauma
                                  Appears Acutely Ill, Generalized Weakness or Malaise                          The questionnaires only serve to give
                                  Abdominal Pain Especially Radiation Into Gmin and Associated With Hematuria   us a first approximation of a patient's
                                  Sexual Dysfunction
                                  Recent Menstrual Irregularities                                               distress level and other issues related
                                  Bowel or Bladder Dysfunction/Aneatheaia Perineum                              to their health status. We use the
                                       Fecal or Urinary Incontinenceor Retention                                questionnaires to help us focus our
                                       Rectal Bleeding
                                       Urethral Discharge                                                       further examination. Any of the data
                                       Hematuria                                                                suggesting serious pathology or mag-
                                                                                                                nified illness behavior are further
Figure 3. A synopsis of possible indicators of serious pathology. (BP= blood                                    scrutinized by acquisition of the pa-
pressure.)                                                                                                      tient's history.

tion of his or her physical limitations                    (or other symptom intensity) on a                    Serious pathology. Indicators of
and disability, then the clinician must                    scale of 0 to 10. Such visual analog                 serious pathology are illustrated in
be attentive to the possibility that                       scales have been shown to be repeat-                 Figure 3. First, the patient is ques-
severe underlying pathology may be                         able in clinical settings.29 The patient             tioned regarding his or her ability to
causing the high degree of discomfort.                     is also asked to rate his or her pain at             sleep without disturbance. Our focus
Bias is a limitation of self-reports,                      its greatest and least intensities over              is on the exact manner in which sleep
however, so the accuracy of the pa-                        the past 24 hours. In interpreting the               is disturbed, and we attempt to distin-
tient's perception must be taken into                      pain scale, we first look for very high              guish whether the patient may be
account, and at times patients may                         ratings (eg, 28/10) on all three judg-               unable to fall asleep because of the
overstate their limitations (eg, the                       ments (present, greatest, and least in               pain or may be awakened by pain
patient whose illness behavior is am-                      past 24 hours), a factor that for us                 during a movement, such as turning
plified). We occasionally see patients                     would be indicative of serious pathol-               over, and fall back to sleep. The most
early after an acute episode of back                       ogy (severe, unremitting pain not                    troubling of these possibilities is awak-
pain (eg, w i t h a few days) who                          affected by change in posture). Our                  ening by pain not related to posture
score greater than 75 and whose sub-                       basis for this statement is that for pa-             or position, especially if the patient
sequent examination confirms the                           tients with mechanical LBS, there is                 also has difficulty falling asleep. If the
severity of the condition. In the re-                      usually at least one posture (eg, lying              patient describes a sleep disturbance
mainder of cases where the initial                         down) that will relieve pain to some                 of this nature, we contend serious
Oswestry questionnaire score is                            degree. Second, we look at the inten-                pathology must be suspected.
greater than 75 but the patient does                       sity of the present pain level and
not demonstrate overt signs of acute                       make a judgment as to whether it                     When a patient has reported any alter-
distress, we begin to question whether                     appears to match our impression of                   ation in bladder or bowel function,
management that totally focuses on                         the patient's distress level. For exam-              particularly due to loss of sphincter
movement-related strategies is                             ple, a person who fills out the pain                 control, or has reported paresthesia in
appropriate.                                               scale indicating that present pain level             the saddle area or fourth sacral der-
                                                           is 28/10 should also, in our opinion,                matome, a surgical consultation
At the other end of the spectrum are                       exhibit obvious distress, especially                 should be sought without delay. These
Oswestry questionnaire scores below                        when the patient is asked to perform                 may be indicators of a central disk
30. We believe these scores indicate                       examination procedures such as for-                  protrusion with compression of the
patients who do not have acute condi-                      ward bending or to remove his or her                 fourth sacral nerve root. Failure to
tions. The focus of further evaluation                     shoes and socks.                                     relieve this compression surgically
will then be directed in a direction                                                                            may lead to permanent neurological
distinct from what occurs for those                        Pain Diagram                                         damage, with resultant loss of control
with acute conditions.                                                                                          of the bowel and bladder sphincters.31
                                                               The patient is asked to complete a
Pain Scale                                                     body chart diagram depicting the area            Questioning is required when any
                                                               of pain and other symptoms. We cate-             change in body weight has recently
We use a pain scale and request that                           gorize the pain diagram using the                occurred. We focus on the extent and
the patient rate his or her present pain                       method reported by Chan et al,30 as              direction of the change, the reason for
                                                                                                                the change, and the time period over

                                                                                                Physical Therapy / Volume 75, Number 6 /June 1995
which the change has occurred. We          physical examination. The nonorganic         indices based on arbitrary durations
are concerned when there is any un-        signs are categorized by Waddell et                                       Consider, for
                                                                                        are not always ~ s e f u l . 3 ~
explained weight loss in individuals       a133 as follows: (1) simulation, which       example, a patient with LBS who
who have probably been more seden-         includes the tests of simulated rotation     complains of severe symptoms but
tary than usual. We strongly believe       and axial loading; (2) distraction,          who has had an onset of greater than
that this change in body weight must       which includes gathering signs of            7 days, the upper limit of the category
be recognized as a warning signal of       inconsistency within the physical ex-        "acute low back pain" imposed by the
serious pathology (eg, a carcinoma).       amination such as noting a disparity         Quebec Study guidelines.35 We con-
In our opinion, a loss of 4.5 kg (10 lb)   between a supine straight-leg-raising        tend that most clinicians would treat
of body weight for no apparent reason      and seated knee extension tests,             this patient as an "acute" patient, a
in a 59-kg (130-lb) patient would have     where the ability of the patient to          decision we propose is based on the
more sinister implications than an         assume a position of a flexed hip with       severity of the patient's symptoms and
18.1-kg (40-lb) loss in a 113.4-kg (250-   an extended knee is presumed to be           not necessarily on the exact number
lb) patient who has been on a diet.        similar; (3) tenderness, which includes      of days since the onset of symptoms.
                                           exaggerated responses to such tests as
The patient is asked about any recent      very light palpation of the spine; (4)       Instead of using days since onset, we
episodes of fever. If fever has oc-        generalized signs of weakness or             base acuteness on a criterion related
curred, the clinician is obligated to      sensory loss that d o not fit a dermato-     to the severity of disability. We have
rule out systemic infection as a possi-    ma1 or myotomal distribution; and (5)        developed three d8erent stages of
ble source of the patient's low back       overreaction, which is a general im-         LBS, with each stage based on the
symptoms (eg, urinary tract infections)    pression of an exagerrated response          severity of disability. For each stage,
through additional questioning during      from all portions of the physical            d8erent patient management strategies
the history and testing during the         examination.                                 are used. An overall perspective of the
physical examination. If infection                                                      staging criteria is included in Figure 4.
cannot be ruled out as a possible          In screening for serious medical condi-
cause of the patient's symptoms, then      tions and magnified illness behavior,        Although we recognize that chronicity
we believe referral to another practi-     the questionnaires that we use are           measured in some time period in and
tioner is indicated.                       designed to detect the possibility of        of itself does not guide treatment
                                           these conditions. Through interactive        management, we do note that pro-
Finally, if the patient has had a trau-    history taking and detailed physical         longed episodes may lead to chronic
matic onset of pain, we contend that       examination, we further evaluate such        pain issues, and it is important to
an adequate radiological examination       issues. If present, referral to or consul-   point out that chronic pain issues are
must be performed. If this has been        tation of another practitioner is indi-      complex in a sense that they encom-
done, as is most often the case, the       cated. In cases that will continue to be     pass more than just a physical dimen-
examiner should at least obtain the        managed by the physical therapist, the       si0n.3~  Chronic pain in LBS should
report of these tests if the radiographs   next level of classification that we         suggest to the physical therapist the
cannot be viewed. If radiological tests    propose is to stage the patient accord-      need for comprehensive (eg, multidis-
have not been performed, the refer-        ing to the acuteness of the injury.          ciplinary) ma1wgement.3~    Therefore,
ring physician should be consulted to                                                   we find it useful to identify patients
determine whether radiological exami-      m n d - O r d e r Classtflcatlon:            who have psychological sequelae of
nation is appropriate.                     Staging the Patlent                          chronic pain so that treatment can be
                                                                                        directed toward those health care
Magnified illness behavior. Wad-           We have found it convenient to clas-         professionals best capable of handling
delP2 has described an illness-based       slfy movement disorders into stages          such problems. Rather than identlfy~ng
clinical model for managing LBS in         based on the acuteness of the injury.        patients as chronic by an arbitrary
which the interaction of a physical        We are not alone in recognizing the          cutoff of symptoms of greater than 6
problem with a patient's high degree       usefulness of assigning patients into        months' duration as per the Quebec
of psychological distress produces         classifications related to acute, "sub-      Study guidelines,35 we instead use
what he has termed "magnified illness      acute," and chronic.35 Most classifica-      accepted tests for "nonrnovement"
behavior." Waddell and colleagues33~3*     tions of acuteness of injury are based       components (eg, magnified illness
have described what they term "non-        on the number of days since the in-          behavior) of LBS as a screening tool
organic" descriptors (symptoms) and        jury. We believe that cutoffs for cate-      for deciding when other disciplines
signs of magnified illness behavior.       gorizations in this manner are arbi-         (eg, behavioral medicine, psychology)
We have included the descriptors in        trarily set and are not always useful in     should be consulted.
the medical questionnaire (Fig. 2;         directing conservative care.
italicized questions). If we find that                                                  Because this article focuses on manag-
more than three of these descriptors       Although we agree that chronicity of         ing "acute" injuries, we will first re-
are used by the patient, we include        the LBS certainly guides treatment, it       view staging criteria that we believe
the tests for nonorganic signs in our      has been demonstrated that most              define acuteness as more related to

Physical Therapy I Volume 75, Number 6 I June 1995
                                                                                                              scores in the range of 20 to 40. Man-
                                                                                                              agement of patient problems in stage
                                                                                                              1 still includes pain modulation but
                                                                                                              broadens to include elimination of

                                                                       I                 I
                                                                                                              signs of physical impairment (eg,
                                                                                                              weakness, flexibility that falls outside
                                                                                                              the ideal range, poor aerobic capacity,
 1             STAGE I                            STAGE U                            STAGE IIl
                                                                                                              faulty body mechanics and posture)
                 Goals                               Goals
                                                                                       Goals                  that may predispose an individual to
  Reduce O w s r to < 40% - 60%
           sety                        Enable to perhrm ADLs               Enable to Work                     recurrence of acute back pain.
  Enable to Sit > 30 min               Reduce Osweshy to < 20% - 40%       Reduce Oswmhy to 20%or Less
  Enable to Stand > 15 min
  Enable to Walk > 0.6 km (1.4 mile)                                                                          Stage 111

Figure 4.     Ovemieu, of staging criteria. Oswestry scores are approximations. Stag-                                 1
                                                                                                              Stage 1 1 is a category for the individ-
ing is based on a clinical judgment of a patient's functional limitations (eg, sitting,                       ual who is returning to an activity that
standing, waking) and not solely on the patient's self-repofl. (ADLs= activities of daily                     places a high physical demand on the
living.)                                                                                                      body, especially the lumbar region.
                                                                                                              Such individuals include workers
the severity of symptoms rather than                     60. If an individual, however, rates his             whose duties include heavy material
days since injury. In addition, data                     or her disability between 60 and 75                  handling, athletes who participate in
from other testing previously men-                       after an acute episode has run its                   sports that place high demand on
tioned (eg, Oswestry questionnaire)                      course, we suggest that he or she may                lumbar structures, and homemakers
will be related to staging criteria.                     still fall in stage I. In such patients,             who must manage household chores
                                                         careful examination is required to                   and numerous small children simulta-
                                                         distinguish those individuals who may                                                    1
                                                                                                              neously. An individual in stage 1 1 is
                                                         be exhibiting signs of symptom mag-                  able to perform instrumental activities
A patient in stage I of the mechanical                   nification from those with a severe                  of daily living and may even be able
low back pain syndrome is character-                     disability resulting from stage I LBS.               to participate in activities involving
ized by an inability to perform the                                                                           high physical demand. Sustained activ-
basic mechanical functions of stand-                     For patients in stage I, we propose                  ities requiring high physical demands
ing, wallung, or sitting. We believe                     that the primary focus of therapeutic                such as those that may be required by
that these activities can best be                        intervention by the physical therapist               occupational duties, however, cannot
thought of as the foundations for other                  is similar to that of other disciplines,             be carried out. Modified Oswestry
purposeful activities, and, if individuals               namely, pain modulation. The primary                 rankings are usually 20 or less. These
are unable to perform these founda-                      treatment methods we propose in                      individuals are often relatively asymp-
tional activities, we cannot expect                      stage I include extension exercises,                 tomatic, but have become generally
them to perform a more complex and                       flexion exercises, lateral-shift regimens,           deconditioned from a lengthy period
stressful activity (eg, material                         manipulation, traction, and, occasion-               of inactivity. The focus of our evalua-
handling).                                               ally, immobilization regimens. Sirni-                tion and treatment in this stage is on
                                                         larly, adjunctive treatment regimens                 the ability or willingness to labor (sirn-
We class* an individual as being in                      may also be prescribed by other disci-               ulated work activity) for prolonged
stage I if he or she is unable to stand                  plines (eg, pharmocological agents),                 periods of time without exacerbation
for 15 minutes or more, to sit for 30                    again with the same goal of pain mod-                of symptorns.
minutes or more, or to walk more                         ulation in mind.
than 0.4 krn (% mile) without worsen-                                                                         Each stage has different goals and
ing of status. This judgment is made                     Stage I1                                             treatment approaches associated with
using the self-report as a first approxi-                                                                     it (Fig. 4). Examination procedures are
mation and subsequently through our                      An individual in stage I1 exceeds the                different for each phase. In the re-
interpretation of the patient's ability to               requirements (time of sitting and                    maining portion of this article, we will
sit, stand, and walk during our hlstory                  standing, distance walked) for stage I,              focus on the clinical data and decision
taking and physical examination. This                    but he or she is unable to perform                   rules used to place patients into stage
individual usually has a modified                        basic functional activities of daily liv-            I classifications.
Oswestry score in excess of 40. In our                   ing. Thus, the patient can sit, stand, or
experience, the majority of patients in                  walk, but pain prevents the patient                  Third-Order Classification:
stage I fall within the range 40 to 60.                  from performing what have been                       Assigning Patients to Stage I
We also find that individuals who are                    described as instrumental activities of              Syndromes
seen shortly after an onset of LBS (eg,                  daily living (eg, vacuuming, lifting,
less than 2 weeks) will often have a                     mowing the grass). Most individuals in               The major components o the exami-
modified Oswestry score greater than                             1
                                                         stage 1 have modified Oswestry                       nation include (1) history taking, (2)

                                                                                                 Physical Therapy / Volume 75, Number 6 /June 1995
                                                        LUMBAR EXAMINATION

            PERSONAL DATA
                                      1                                         PHYSICAL SIGNS & SYMPTOM BEHAVIOR
     OSWESTRY QUESTIONNAIRE                                                          LOWER-QUARTER SCREEN
     MEDICAL QUESTIONNAIRE                                                                Waddell Teats
                                                               MOVEMENT EXAM                                     LOWER-EXTREMITY EXAM
     PAINSCALE                    1                       1

                                  Right Side-Bending        Standkrg                     Standing
                                                                                                    I           HIP
                                  Left Side-bndmg           SWng                         Siig                   FOOTIANKLE
                                  Backward Bending          Supine                       Suphe
                                  Folward Bending           Prone                        Prone
                                  Right PeMc Translocation  Kneeling                     Kneeling
                                  Left Pelvic Translocation

Figure S.     a e w i e w of allpossible convponents of a lumbar examination.

observatioil of posture in standing and      tion is identified early in the examina-          may occur in the frontal plane and has
sitting, (3) assessment of symmetry of       tion process, and a working hypothe-              been described in the literature as
pelvic landmarks in standing and             sis (classification) is generated. Further        trunk list,40lateral shift,14or sciatic
sitting, and (4) examination of trunk        examination proceeds until the hy-                                 .~~
                                                                                               s c ~ l i o s i sAlternatively, the patient
movements (forward, backward, side           pothesis is confirmed or disconfirmed,            may assume an acute kyphotic posi-
bending, and pelvic translocation) in        the latter leading to a new hypothesis.           tion of the lumbar spine from a major
the standing position. We have out-                                                            loss of lumbar extension.12 The initial
lined the examination in Figure 5.           In addition to history data related to            hypothesis is either lateral shift or an
                                             the first- and second-level classifica-           extension syndrome, depending on
In patients who exhibit symptoms of          tions, we also ask the patient about              the deformity. The hypothesis is con-
nerve root involvement (eg, symptoms         the type and location of symptoms,                firmed with movement testing; other
below the knee), a neurological exam-        mode of onset, most aggravating and               tests may be expected to be positive.
ination is also performed that includes      relieving postures, and number and                For example, patients with relevant
lower-extremity sensory testing, mus-        severity of previous episodes. We                 lateral shifts will usually have asym-
cle strength assessment, reflex testing,     have outlined the pattern of responses            metrical excursions in side bending (a
nerve root tension tests (eg, straight       related to each category. In many                 positive side-bending test) in the as-
leg raise and femoral nerve stretch),        cases, the history can reveal a very              sessment of lateral bending.42 Further
Babinski test, and tests for presence of     compelling picture of certain catego-             confirming information may be gained
clonus.3 From a screening standpoint,        ries, in which case an initial hypothe-           with repeated movement testing,
the neurological examination is a            sis is formulated and the examination             where either lateral pelvic transloca-
traditional and important part of most       proceeds in a fashion in which the                tion or extension movements impose
evaluations of patients with LBS. In         hypothesis is systematically confirmed            a favorable change on the patient's
the treatment scheme that we are             or disconfirmed. With other patients,             status. The hypothesis, however, can
proposing, however, the results of           however, the history is of little help in         be disconfirmed when a movement
such tests ]nay not be useful in direct-     achieving an initial hypothesis, and the          does not improve the patient's status.
ing treatments. For example, a patient       examination proceeds to the lower-                A new hypothesis or treatment cate-
with lowerextremity symptoms con-            quarter screening without an initial              gory is then formulated (eg, traction).
sistent with an L-4 nerve root irritation    hypothesis in mind.
(eg, weak ankle dorsiflexors, positive                                                         Without an obvious hypothesis based
straight leg raise, paresthesia over         A good example of this approach                   on the patient's history, our approach
medial calf and ankle) may fall into         includes the scenario depicted in                 is to proceed with the examination by
any one of four of our different prc-        which a patient has low back pain, leg            first ruling out lower-extremity influ-
posed categories (ie, traction, exten-       paresthesia, and a frontal- or sagittal-          ences (eg, pelvic component, leg-
sion, flexion, or lateral shift).            plane deformity (Fig. 6). The key sign            length discrepancies) and then focus-
                                             in observation of posture in standing             ing on the lumbar spine, specifically
As with most diagnostic processes, a         is the presence of a movement loss so             movement testing. In most cases, a
structured protocol for every patient is     severe that it prevents the patient from          hypothesis (a tentative classification)
not followed.39 Rather, key informa-         assuming an upright posture. This sign            should be generated from these two

Physical Therapy / Volume 75, Number 6 /June 1995
                                            Assessment of Bony Landmarks                 shoes on, the relative leg lengths are
                                            of the Pelvis                                assessed visually. The patient's knees
                                                                                         are then flexed passively to approxi-
                                            An assessment is made of the bony            mately 90 degrees, and the lower-
                                            landmarks of the pelvis in the standing      extremity lengths are again observed.
                                            and sitting positions. Both static (pa-      A change in relative lengths between
                                            tient remaining stationary) and dy-          the two positions is a positive finding.
                                            namic (patient moving) tests are per-        To place a patient in a manipulation
                                            formed. Most of the tests that are           category, three or more of these four
                                            performed are purportedly directed           tests must be positive. Past work has
                                            toward dysfunction of the sacroiliac         shown excellent reliability ( K = .88)of
                                            joints (we prefer to state that a posi-      such a composite.9
                                            tive composite is indicative of need for
                                            a specific manipulation technique) or        If a positive composite is found, a
                                            a leg-length dicrepancy.43                   specific manipulative procedure is
                                                                                         indicated, provided there are no con-
                                            The actual tests used and the decision       traindications.43 The procedure is
                                            rules are outlined in Figures 7 and 8.       illustrated in Figure 9. As an alternative
                                            We use four tests to make the deter-         to manipulation, there are also numer-
                                            mination of whether to intervene with        ous muscle energy procedures that are
                                            manipulation to the pelvis. The four         purportedly indicated in the presence
                                            tests are (1) assessment of the symme-       of such a composite; these procedures
                                            try of posterior superior iliac spine        are described in detail elsewhere.44
                                            (PSIS) heights with the patient in a
                                            seated position, (2) the standing flex-      If the composite is negative, we pal-
                                            ion test, (3) the prone knee flexion         pate iliac crest heights with the patient
                                            test, and (4) the supine to long-sitting     in a standing position and then assess
                                            test. A composite (three of four posi-       symmetry. Any side-teside height
                                            tive) of the four tests is used. Each test   difference is corrected with a heel lift
                                            and subsequent reliability analyses          before movement testing begins. We
                                            have been described elsewhere.19             are aware of the equivocal support for
                                                                                         leg-length inequality being a cause of
                                            The first test conducted is used to          low back prob1ems.l In our experi-
                                            assess heights of the PSISs with the         ence, however, leveling the pelvis
                                            patient in a sitting position. Bilateral     commonly leads to a clearer picture
                                            comparisons are made, and PSISs of           for the movement testing that will be
                                            unequal heights constitute a positive        performed next.
                                            finding. A standing flexion test is con-
                                            ducted next. The patient is in the
                                            standing position, and the examiner          Single-Movement Tests in
Figure 6. A patient with a right            palpates the PSISs bilaterally. The          Standing
lateral shi/t. (Reprinted with permission   patient then bends forward, with the
of the American Physical nerapy Associ-     examiner continuing to palpate the           Selected single-movement tests are
ation from TenhulaJA, Rose SJ, Delitto      PSISs. A positive finding is present if a    examined in the standing position.
A. Association between direction of lat-
eral lumbar shijt, movement tests, and      change in relationship is detected           First, side bending to the right and left
side of symptom in patients with low        between the beginning and end of             is assessed. We prefer to have the
back pain syndrome. Phys Ther.              motion. The third test is a comparison       patient slide his or her hand down the
1990;70:483.)                               of medial malleoli from supine to            lower extremity and note the position
                                            long-sitting positions. With the patient     of the fingertips along the lateral thigh
                                            initially positioned supine, the exam-       and leg. This measure can be quanti-
                                            iner palpates the inferior aspect of the     fied by measuring the fingertips in
examinations and further examination        medial malleoli bilaterally and notes        relationship to a bony landmark (eg,
proceeds, searching out confirmatory        relative lower-extremity length. The         fibular head or lateral malleolus) or,
and discofirmatory data. An overall         patient then sits up, and the lengths        alternatively, to use a vertical ruler, a
structure is presented in Figure 7, and     are again compared. A change in              technique that has demonstrated ex-
an algorithm is presented in Figure 8.      relative lower-extremity length is a         cellent
                                            positive finding. Our fourth test is a
                                            prone knee flexion test. With the            In either case, symmetry of side bend-
                                            patient initially positioned prone with      ing is evaluated. If side bending is

                                                                         Physical The:rapy / Volume 75, Number 6 /June 1995

                                                                          ,     E-ity

                                                                          I                   1
                                                                     Negative              Poritive
                                                                         (-1                 (+I


                          Capsular                                                                   Noncapular
                           Pattern                                                                     Pattern

                              1                                                                           1
                          Movement                                                                    Movement
                           Testing                                                                     fdng

                                                                     Improves                                                 Women0

                                                                    Adive P ~ M C              1                  1          Autotraction

                                                                                        Translocation         Mobiliionl
                     Extension                                                             Mobilization       FRSICldng
                     (General                                                                (SB)             Mobiliinl
                    Mobilization)                                                                             Manipulation

Figure 7 . An organizational outline of the examination process. (ISQ= in status quo; NSR= neutral, side-bending, and rotation
mobilization /eg, pelvic translocationl; ERS= extension, rotation, and side-bending mobilization; FRS=JemX1on,
                                                                                                            rotation, and side-
bending mobilization; SB=side bending.)

judged to be symmetrical, then the           rical and asymmetrical restrictions in                is meaningful and therefore can be
examination will proceed by determin-        side bending correspond with what                     labeled "asymmetrical" as well as other
ing whether repeated movements (eg,          Cyriax12described as "capsular" and                   findings during the testing procedure
flexion or extension) will improve the       "noncapsular" patterns, respectively. In              (eg, change in pain location or elicited
patient's status. If asymmetrical side       some instances, the asymmetty is quite                pain location) that may result in cer-
bending is noted, the examination            profound and the decision rules listed                tain patterns.
proceeds to determine whether pelvic         in Figures 6 and 7 can be followed. In
translocation and extension will im-         other cases, however, the distinction                 We suggest that the examiner note the
prove the patient's status (lateral shift)   between symmetrical and asymmetri-                    range of motion in each direction and
or whether the pain and restriction of       cal is not as clear. Part of our future               any change in symptoms produced by
motion represent a particular pattern        work will entail further study to de-                 the movement. Compiling information
(opening or closing pattern). The            scribe the degree of difference be-                   from the patient's history and from
reader will recognize that the symmet-       tween left and right side bending that

Physical Therapy / Volume 75, Number 6 /June 1995
Flgure 8. Algorithm of examination process. (SB=side bending; NSR= neutral, side-bending, and rotation mobilization.)

evaluation of the results of single-      With symmetrical side bending, the         ment can either worsen or improve a
movement tests is instrumental in         examiner next assesses status change       patient's status. If improvement occurs
formulating the initial working hypoth-   with single extension followed by          with a particular movement, the initial
esis (classification).                    flexion. At times, sagittal-plane move-    hypothesis is to include the patient in

                                                                      Physical Therapy / Volume 75, Number 6 /June 1995
                                                                                         dromes that may exhibit improvement
                                                                                         with active movement: (1) extension,
                                                                                         (2) flexion, and (3) lateral s M
                                                                                         (Figs. 7, 8).

                                                                                         The reader should note that these are
                                                                                          stage I treatments and that the treat-
                                                                                          ment goal is to modulate symptoms to
                                                                                         the extent that the patient can be
                                                                                         progressed to stage 11. Not all patients
                                                                                         experience such a favorable outcome
                                                                                         with self-treatment, and some patients
                                                                                         change their clinical picture once
                                                                                         treatment is commenced. For example,
                                                                                         some patients who are initially classi-
                                                                                         fied as having extension or lateral-shift
                                                                                         syndrome may successfully use self-
                                                                                         treatment. At a point in time, however,
                                                                                         the status change may plateau or
Figure 9. Illustration of the spec@ manipulative procedure purportedly directed
toward the sacroiliac joint. (Reprinted with permission of the American Physical Ther-
                                                                                         actually reverse direction or worsen.
apy Assochtion from Cibulka MT. The treatment of the sacroiliac joint component to       In our experience, it is not uncommon
low back pain: a case report. Phys Ther. 1992;72917-9223                                 that patients who initially responded
                                                                                         favorably to self-treatment(eg, exten-
the category of self-treatment using the     bilateral side bending, and pelvic          sion movements) may continue to
particular movement in the prescribed        translation with extension) that pro-       exhibit symptoms, but movements that
exercise regimen while concomitantly         duce worsening or improvement in            initally improved status now do not
avoiding the opposite movement. It is        status. When a single movement wors-        change status or may actually worsen
more common to fail to find either           ens status, repeated testing and sus-       status. Such patients are reassessed as
movement actually improving status,          tained testing using the same move-         described later.
in which case the clinician attempts         ment are generally contraindicated, at
additional movements in different            least in the standing position. A move-     We acknowledge McKenzie's contribu-
positions (supine, hand-knee), all in        ment that improves status should be         tion to the body of knowledge
an attempt to elicit improvement in          explored further in both the repeated       through addition of repeated and
status with movement.                        movements and sustained postures to         sustained testing. We believe that
                                             gamer further confirmation that the         McKenzie's work has refined and
Status Change                                movement and direction actually im-         expanded on the descriptions pro-
                                             prove the patient's status.                 vided by Cyriax with regard to
Each movement that is examined is                                                        movement-related symptom behavior
rated according to the operational          The major criterion in determining           and has improved management of
terms useti to describe change in           "worsens" and "improves" in patients         individuals with LBS who demonstrate
status (ie, improve, worsen, status         with back and leg symptoms is the            centralization of symptoms with re-
quo). After the movement, the patient       centralization phenomenon described          peated or sustained movement testing
is asked to compare his or her syrnp-       by Cyriax,45 McKenzie,14and Donel-           (ie, symptoms move in a proximal
toms with the baseline. Possible pa-        son and c0lleagues,~~~7last of
                                                                       the               direction or toward the midline of the
tient responses include (1) wonem,in        whom relate centralization to progno-        body). Studies have demonstrated that
which paresthesia is produced or the        sis. Our first interpretation of McKen-      favorable outcomes accompany cen-
patient's pain or paresthesia moves         zie's description of the movement tests      tralization of symptoms, allowing a
distally from the lumbar spine (periph-     as well as our subsequent work18             clinician a powerful tool for progno-
eralizes); (2) improves, in which pares-    resulted in our adopting the following       sis.&z47McKenzie attributes centraliza-
thesia or pain is abolished or moves        decision rule: For the patient whose         tion and peripheralization to a phe-
from the periphery toward the lumbar        status improves with at least one            nomenon related to the disk, and was
spine (centralizes); and (3) status quo,    movement in any position (eg, exten-         no doubt influenced by a surular ex-
in which the patient's symptoms may         sion in standing), the initial hypothesis    planation provided by Cyriax in an
increase or decrease in intensity but       is formulated (eg, extension syn-            early version of his t e ~ t . ~ 5
do not centralize or peripheralize.         drome). Further repeated or sustained
                                            testing in the same direction either         For those patients in whom centraliza-
Particular attention is given to those      confirms or disconlirms the hypothe-         tion is not complete (pain remains
single movements (forward, backward,        sis. There are three potential syn-          lateral to the midline), it may be rea-
                                                                                         sonable to assume that nondisk struc-

Physical Therapy / Volume 75, Number 6 / June 1995
tures of the spine may be involved                tern of movement restriction that re-              dures have been described else-
(eg, facet joints, sacroiliac joint). More        sembles extension syndrome (lumbar                 where.51 Patients may be assigned to
importantly, however, repeated and                radiculopathy), and (3) noncapsular                this category at the time of initial ex-
sustained exercise may not be the                 pattern of restriction that resembles              amination, or they may progress into
treatment of choice in these individu-            lateral shift with or without distal               this syndrome when status ceases to
als, and in some cases we believe this            symptoms or neurological signs (Figs.              improve with self-treatments consisting
treatment may be contraindicated. We              7, 8). The goal of treatment in traction           of active flexion or extension.
are unable to find a path in McKen-               syndrome is to use mechanical (with
zie's assessment algorithma that ade-             subgroups 1 and 2) or autotraction49               Patients with noncapsular patterns are
quately accounts for all patients whose           types of devices for a short period of             further divided into two subgroups:
status worsens or remains the same                time until on subsequent visits the                those requiring regional mobilization
with testing or subsequent treatment.             patient's status may either (1) remain             and those requiring specific mobiliza-
We propose an alternative treatment               status quo with movement, at which                 tion techniques. Regional techniques
classification system to that of McKen-           time mobilization techniques may be                are used for those patients who re-
zie's postural and dysfunction syn-               used, or (2) improve with movement,                quire passive pelvic translocation
dromes. Patients whose status remains             at which time the patient will move                before they can be successfully man-
the same or worsens with movement                 into a self-treatment category.                    aged with active (self-treatment) pelvic
testing are candidates for this type of                                                              translocation (Figs. 7, 8). In some
classification.                                   Status quo: mobilization. The classi-              cases, regional techniques are not
                                                  fication approach we propose recog-                successful in improving a patient's
Status worsens: traction. One                     nizes and takes advantage of the                   status. In such patients with a visible
shortfall of McKenziels assessment                growing body of evidence supporting                list who are unable to move into lat-
algorithm4 is failure to guide the                the effectiveness of early, judicious use          eral shift (eg, status worsens with
clinician in managing the patient                 of manipulation in managing LBS.50                 self-correction or manual correction),
whose symptoms worsen with move-                  We propose that single, repeated                   the patients may require treatment
ment testing (ie, do not improve with             movements and sustained postures do                with traction as outlined for traction
any movement and commonly worsen                  not cause a change in status in some               syndrome (noncapsular pattern). Re-
with all tests). These patients may or            patients. Our approach is to class^                gional techniques may also be indi-
may not have deformity and may or                 some of these patients whose status                cated in patients with a compensatory
may not exhibit asymmetrical side                 remains unchanged as having lumbar                 scoliosis resulting from leg-length
bending. A prime example of this type             mobilization syndrome. There are two               imbalance or segmental lesions.52
of patient is one with distal symptoms            types of patients with mobilization
that do not improve (do not central-              syndrome: those who have capsular                  Individuals with segmental lesions
ize) during movement testing. We                  patterns and those who have noncap                 require specific manipulation or mobi-
propose that such patients be grouped             sular patterns.                                    lization designed for closing (extend-
into what we have referred to as trac-                                                               ing) or opening (flexing) a lumbar
tion syndmme.                                     Patients with capsular patterns with               segment on one side. Such patients
                                                  limited extension are best managed                 exhibit a characteristic "closing" (pain-
Tracfion syndmme. There are three                 with general mobilization techniques               ful and restricted extension and ipsilat-
subgroups of traction syndrome: (1)               designed to improve extension,                     era1 side bending) or "opening" (pain-
capsular pattern of movement restric-             whereas those with limited flexion                 ful and restricted flexion and
tion that resembles flexion syndrome              receive general mobilization tech-                 contralateral side bending) restriction
(ie, spinal stenosis), (2) capsular pat-          niques to restore flexion; such proce-             during single-movement testing. Un-

                                                        I          Hypermobjliiy
                                                                                             I                                i

 I             Grade I

     Avoid End-?


           Pertinent Histmy
                                    II             Grade II


                                           Omvestry Plateued at 30+
                                                                        I ym
                                                                          z t
                                                                                        Grade 1 1
                                                                                                             II          Grade IV


                                                                                                              Failure of Coneervative Treatment

                                                                              + m - Radiopaphic Evidence
     Pertinent Signs and Symptoms              Pertinent Hietory
                                         Pertinent Simw and Svmutoma    II   Failure of Sta-on      Exache   II   + Radiographic Evidence         I
Figure 10. Proposed spectrum of segmental instability along with proposed indicated treatments.

32 / 482                                                                           Physical Therapy / Volume 75, Number 6 /June 1995

                                                                                              I                                                                                                 I
              Level 1
                                                                           CONSULTATION                           -                  PHYSICAL                                        REFERRAL
                     "                                                                                                                                       "................................................................................................

              Level 2
                                                                                           I          Stagel                II          stage II

                                                                                             Extension                           Flexibility                       Activity
                                                                                             Aexion                              Deficit                           Intolerance
              Level 3
                                                                                             Lateral Shik
                                                                                                                                 Deficit                            Work



Figure 11. Summa y of three orden of classification along with specific directed treatments.

like patients in the lateral-shift cate-                                                 Most common symptoms and                                                                    Confirmatory data from the physical
gory, the pain of patients with seg-                                                     signs of immobilkation syndrome.                                                            examination are usually in the form of
mental lesions is not as severe, is                                                      We believe that the most usehl data                                                         key signs, including (1) generalized
usually felt just lateral to the spinous                                                 leading to an initial hypothesis of                                                                                (2)
                                                                                                                                                                                     ligamentous la~ity5~; painful arc of
processes in the lumbar region, and                                                      immobilization syndrome are gener-                                                          motion or "instability catch" on for-
does not radiate distally. Most impor-                                                   ated in the patient's history. Confirma-                                                    ward bending of trunk, which is
tantly, the pain does not improve                                                        tory data include (1) frequent recur-                                                       sometimes accompanied by a devia-
(centralize) with repeated movement                                                      rences precipitated with minimal                                                            tion to the side; (3) painful arc of
testing or regional techniques.                                                          perturbations,55 (2) a previous history                                                     motion on return from forward bend-
                                                                                         of alternating sides of lateral shift, (3)                                                  ing or side bending; (4) during return
ImmobiIizatbn A large percentage of                                                      frequent manipulation (sometimes                                                            from forward bending, a reversal of
patients require some form of motion                                                     performed by the patient) with short-                                                       lumbo-pelvic rhythm (the trunk is first
restriction for excessive motion in a                                                    lived relief, (4) uauma, (5) pregnancy                                                      extended and then the hips and pelvis
segment. Hypermobility or segmental                                                      or use of oral conuaceptives, and (6)                                                       extend to bring the body upright),
instability is an entity with a growing                                                  positive change in status with previous                                                     which is sometimes accompanied with
body of evidence,53.54and we fail to                                                     use of a supportive device (eg, corset).                                                    "thigh climbing" (using the hands
see how any of the treatment proce-                                                      The basis for considering these data                                                        pushing on the thighs to assist the
dures described thus far effectively                                                     confirmatory lies in the literat~re5~155                                                    trunk in attaining an upright posture);
manage this impairment. In our expe-                                                     (for frequent recurrences precipitated                                                      and (5) positive posterior shear test.
rience, this is an area in which move-                                                   with minimal perturbations and for a                                                        Many of these signs have been related
ment testing very often does not pro-                                                    previous history of alternating sides of                                                    to segmental instability in descriptions
vide confirmatory information.                                                           lateral shift) or our own experience.                                                       else~here.5~75~

Physical Therapy / Volume 75, Number 6 /June 1995
Movement testing commonly leads to          in this communication is to propose              back pain: an experimental study. Phys Ther.
a worsening of status with sustained        that in order to improve outcome with            1988;68:1359-1363.
                                                                                             10 Walsh K, Coggon D. Reproducability of
end-range position testing and with         mechanical LBS, we are obligated to              histories of low-back pain obtained by self-
repeated movement when performed            classlfy patients into categories                administered questionnaire. Spine. 1991;16:
over a prolonged time period. The           whereby matching treatments to classi-           1075-1077.
latter is commonly observed when a          fications will result in faster, more            11 McCombe PF, Fairbank JCT, Cockersole
                                                                                             BC, et al. Reproducability of physical signs in
patient's status begins to worsen after     efficient and cost-effective care.               low back pain. Spine. 1989;14:908-918.
an initial successful treatment with                                                         12 Cyriax J. Textbook of Orthopaedic Medi-
active flexion, extension, pelvic trans-    Thus far, we have subjected a portion            cine, Vol I : Diagnosis of Soft Tissue Lesions.
location, manipulation, or tmction.         of this approach to research and peer            7th ed. London, England: Bailli2re Tindall;
                                                                                             1978:1-189, 308-621.
Note in particular the patient with a       review, including reliability of testing         13 Maitland GD. Vertebral Manipulation. 5th
history of recurrent lateml shifts,         procedures and decision analyses,                ed. Oxford, England: Butterworth & Co ( P u b
whose immediate acute incident may          correlational research studying the              lishers) Ltd; 1986.
be manageable in stage 1 with pelvic        relationship among variables necessary           14 McKenzie RA. The Lumbar Spine: Mechan-
                                                                                             ical Diagnosis and Therapy. Waikanae, New
translocation and extension but whose       to classlfy, and predictive validation           Zealand: Spinal Publications Ltd; 1989:85-93.
underlying problem may be more                                              We
                                            pilot testing.8,9,18,19,22,27,28,42 have         15 Kendall HO, Kendall FP, Boynton DA.
related to segmental instability.55.59      also described various activities' pro-          Posture and Pain. Malabar, Fla: Krieger P u b
                                            cesses that have led to the descriptions         lishing Co; 1985.
                                                                                             16 Riddle DL, Rothstein JM. Intertester reli-
Treatment of segmental instability.         provided in this article. We have                ability of McKenzie's classifications of the type
 For purposes of selection of appropri-     tested only a portion of the compo-              of syndrome present in patients with low
ate immobilization treatment strategies,    nents of this approach, and certainly            back pain. Spine. 1%3;18:1333-1344.
we believe it is useful to grade the        we invite others to d o the same. It is          17 Sikorski JM. A rationalized approach to
                                                                                             physiotherapy for low-back pain. Spine. 1985;
degree of disability resulting from the     not only our hope but our expectation            6:571-579.
instability (Fig. 101, with the interven-   that future peer-reviewed contribu-              18 Delitto A, Shulman AD, Rose SJ. On devel-
tions corresponding to the degree of        tions will offer additions, deletions,           oping expert-based decision-support systems
disability. On one end of the spectrum      and modifications to this approach or            in physical therapy: the NIOSH Low Back At-
                                                                                             las. Phys i'ber. 1989;69:554-558.
is a person with minimal disability         offer alternative approaches with the            19 NIOSH Low Back Atlas of Standardized
who responds to avoidance of ex-            goal of treatment efficacy and effec-             Tests and Measurements. Washington, DC: U      S
treme(~)of range of motion. This may        tiveness in the management of LBS.               Dept of Health and Human Services, Public
                                                                                             Health Service, Center for Disease Control,
be in extension, flexion, or combined                                                        National Institute for Occupational Safety and
movements. At the other end of the                                                           Health; December 1988.
spectrum are patients with severe           References                                       20 Tollison CD, Hinnant DW, Kreigel ML.
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27 Erhard RE, Delino A, Cibulka MT. Relative       38 MaGee DJ. Orthopedic Physical Assess-         49 Tesio L, Merlo A. Autotraction versus pas-
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Invited Commentaries

Following are tloo invited commentar-             Delitto and colleagues is timely for the          limitations in examining treatment
ies on '2 Treatment-Based Clasnpca-               profession, and they are to be congrat-           costs for physical therapy management
tion Appmach to Low Back Syndmme:                 ulated for these initial efforts in sug-          of low back pain using tools such as
Identi&ng and Staging Patientsfor                 gesting a system to determine a                   the International Classification of Dis-
Consmtiue Treatment."                             "working classification" for patients             eases, ninth revision, coding system.
                                                  with low back pain and an algorithm-              Although these diagnoses have medi-
For physical therapists to continue to            based treatment approach to ensure                cal relevance, they provide little infor-
play a major role in the management               consistent care based on predeter-                mation regarding the movement dys-
of patients with low back pain, cost-             mined rules rather than care influ-               function and disability associated with
effective analysis (reviewing total costs         enced by examiner bias or emotion.                low back pain. I agree wholeheartedly
for a given syndrome) and the assess-                                                               with the authors' statement that the
ment of patient perception (Did the               The authors present working classifi-             population of patients with low back
intervention succeed in improving the             cations, which can ultimately allow for           pain is not homogenous and to com-
quality of the patient's life?) are clinical      meaningful cost analysis. Physical                pare "treatment approaches" within a
realities. In this regard, this article by        therapists are keenly aware of the                population that is not placed in appro-

Physical Therapy /Volume 75, Number 6 / June 1995

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