Spinal Manipulation Clinical Prediction Rules
- No symptoms distal to knee
- Pain duration less than 16 days
- Score of < 19 on FABQ work sub scale
- Presence of at least 1 hypomobile segment in lumbar spine
- One or both hips with > 35d internal rotation AROM
*presence of 4/5 increases positive likelihood ratio
Alrwaily’s Treatment Based Classification System
Adds initial triage stage for direction to medical management, self care, or rehab
Puts patients in 3 categories on a continuum, based on symptoms:
1. Symptom modulation
2. Movement control
3. Functional optimization
Symptom Modulation
High pain, high disability, irritable symptoms
- directional preference exercises, manipulation or mobilization, traction, active rest (within 24 hours of injury)
Movement Control
Moderate disability, moderate to low pain, stable symptoms
- sensorimotor exercises (nerve glides), flexibility, or stabilization
Functional Optimization
Low disability, low pain, well controlled symptoms
- strength and conditioning, work or sport specific tasks, aerobic exercises, general fitness
A Level Treatment
Manual therapy
- thrust manip for acute
Stabilization exercises
- trunk coordination, strengthening, endurance
- subacute and cLBP with movement coordination impairment
- post lumbar micro-discectomy
Directional preference repeated movement
- promote centralization in aLBP with referred LE pain
- acute, subacute, and chronic with mobility deficits (directional preference)
Progressive endurance and fitness activities
- chronic without generalized pain: mod to high intensity exercise
- chronic with generalized pain: progressive, low intensity, submaximal exercise
B Level Treatment
Education!
- active learning better than passive (such as info pamphlets)
cLBP
- pain neuroscience eduction: teach patients about pain not anatomy
- educate on positive prognosis and resuming normal activities and work
- use in conjunction with exercise and other physical interventions
aLBP
- PNE and pathoanatomical ed not helpful
- focus on reassuring patients of positive prognosis and encouraging return to normal activity
C Level Treatment
flexion based exercises for stenosis
- best when combined with other therapy, including manual
- body weight supported treadmill walking
Nerve mobilization procedures (nerve glides)
- subacute and cLBP with radiating pain
D Level Treatment
Intermittent traction
- preliminary evidence of nerve root compression, peripheralization of symptoms, OR positive crossed SLR may benefit from prone intermittent traction
- moderate evidence to NOT use intermittent or static traction for acute or subacute non-radicular LBP AND cLBP
Stenosis
- bilateral symptoms, start at buttocks, spread to feet
- onset of pain with standing/walking/walking downhill
- pain relieved by flexion or even walking uphill
- treat with manual therapy, flexion exercises, and body weight supported treadmill training
DDx of neurogenic claudication:
- symptoms brought on by exertion (riding a bike, walking uphill) and relieved almost immediately with rest (spinal position has no effect)
- symptoms start distal
Peripheral Nerve Entrapment Testing
All start with SLR:
- sciatic nerve: DF foot + hip adduction or IR
- posterior tibial nerve: ankle DF + eversion + toe extension
- sural nerve: ankle DF + inversion
- common peroneal nerve: hip IR + ankle PF + inversion
Lumbar Instability Test Cluster
Apprehension sign:
- fear of lower back collapse with movement
Instability catch:
- difficulty returning upright from bending without ab engagement
Painful catch sign:
- pain when lowering legs from a lifted position
Prone instability test
SIJ Special Test Cluster (Laslett)
Thigh thrust
SI distraction
Sacral thrust
Compression test
Sometimes Gaenslen’s test
- 2+ positives indicate high likelihood of SIJD
- 4 negatives suggest SIJD is unlikely
