Classification of Lumbar Spine Impairments

Original Editor - Shala Cunningham Top Contributors - Jess Bell and Wanda van Niekerk

Introduction

"The best available evidence supports a classification approach that de-emphasizes the importance of identifying specific anatomical lesions after red flag screening is completed."

Several classification systems have been published to help clinicians select an appropriate intervention for patients with low back pain, including:

• Treatment-based Classification (TBC)
• Mechanical Diagnosis and Therapy (MDT) (also known as the McKenzie Method)
• Cognitive Functional Therapy (CFT)
• Movement System Impairment (MSI)

These classifications are discussed in more detail here: Treatment-based Classification for Low Back Pain.

This page supports the Plus course, Classification of Lumbar Spine Impairments, by Dr. Shala Cunningham. It discusses an updated classification system by Delitto et al. based on the TBC, but with several key differences:

• the categories in Delitto et al.'s 2012 system include specific International Classification of Functioning, Disability and Health (ICF) terminology related to impairments of body function
• additional categories related to cognitive / affective disorders and generalised pain categories have been included
• it considers the patient’s level of acuity

The categories are:

• low back pain with mobility deficits
• low back pain with movement coordination impairments
• low back pain with related lower extremity pain
• low back pain with radiating pain
• low back pain with related cognitive or affective disorders
• low back pain with related generalised pain

To learn more about the ICF, please see: International Classification of Functioning, Disability and Health (ICF).

The following sections describe specific symptoms and impairments to help classify patients into these categories and appropriate interventions based on these presentations. These sections draw on information from Delitto et al.'s 2012 article: Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association, and where relevant, link this system back to the TBC system.

Low Back Pain with Mobility Deficits

The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with mobility deficits.

Table 1. Symptoms, Impairments and Interventions for Low Back Pain with Mobility Deficits

Symptoms	Acute or subacute Usually unilateral symptoms Patients usually report recent unguarded or awkward position or movement Stiffness in the subacute phase
Impairments	Reduced range of motion Reduced segmental mobility Low back and referred pain reproduced with segment provocations (e.g. with posterior-to-anterior (PA) glides or unilateral PA glides)
Interventions	Thrust / non-thrust mobilisations Exercises for spine mobility Patient education for return to activity

Before performing manipulations, you must check for contraindications. See here for more information. Delitto et al. also describe a test-item cluster to determine which patients will likely benefit from spinal manipulation. This cluster has been validated by Childs et al.

• duration of symptoms is less than 16 days
• patient has no symptoms distal to their knee
• patient has lumbar hypomobility
• patient has at least one hip with more than 35 degrees of internal rotation
• the patient's Fear-Avoidance Beliefs Questionnaire (Work) (FABQ-W) is less than 19
• patients with four of these five predictors and no contraindications = manipulate

  Individuals with low back pain with mobility deficits are likely classified into the “symptom modulation” category in the TBC.

Low Back Pain with Movement Coordination Impairments

The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with movement coordination impairments.

Table 2. Symptoms, Impairments and Interventions for Low Back Pain with Movement Coordination Impairments

Symptoms	Acute, subacute or chronic Multiple episodes Referred pain is common
Impairments	Acute: pain with initial and mid-range active or passive range of motion (ROM) Chronic: pain at sustained end-range movements Referred pain reproduced with lumbar motion and / or segment provocations Aberrant movements with trunk motion Hypermobility or hypomobility may be present in the thoracic and lumbar spine Diminished core muscle activation and endurance
Interventions	Neuromuscular re-education for dynamic stability (i.e. muscle stability, with a focus on transversus abdominis and multifidus - see below for information on assessing and strengthening these muscles) Consider temporary external stability as needed (e.g. braces, supports) Self-care home training (e.g. advice to remain active, postures / motions to keep the affected segment in neutral positions or positions that improve symptoms) Exercises to address core muscle activation and endurance Community or work integration training (e.g. education on pain management strategies)

Transversus Abdominis

To assess transversus abdominis:

• position patient in a hook-lying position
• palpate medial to the anterior superior iliac spine (ASIS)
• ask the patient to slowly draw in their lower stomach toward their spine
• palpate for contraction quality, symmetry, and global substitution
• ideal function = holding a contraction for 10 seconds x 10 repetitions with minimal effort

To facilitate transversus abdominis, try the abdominal sling technique:

• patient is in a quadruped position
• therapist places their hand on the patient's stomach and their other hand on the patient's sacrum
• therapist asks the patient to draw in their stomach away from the therapist’s hand
• check that the patient does not round their back to activate their stomach (determined by movement of the sacrum)
• make sure the patient does not hold their breath (can ask them to count to ten out loud to avoid breath-holding)
• can combine with pelvic floor muscle activation (i.e. Kegel exercises)

Lumbar Multifidi

To assess lumbar multifidi:

• position the patient in prone
• palpate to assess if the patient can contract their multifidi - this is difficult for many people to achieve
• can also ask the patient to do a contralateral or ipsilateral arm or leg lift and palpate for a contraction

Lumbar multifidi training:

• teach the patient to palpate their multifidi
• try weight shift in a split stance to activate multifidi (can be combined with transversus abdominis contraction)
• add in arm lifts
• add in load as needed
• quadruped contralateral arm lift (can be combined with transversus abdominis activation and pelvic floor activation)
• progress to opposite arm / leg lift

Individuals with low back pain with movement coordination impairments are likely classified into the “movement control approach” category in the TBC.

The following videos demonstrate how to activate transversus abdominis and the lumbar multifidi

Low Back Pain with Referred Lower Extremity Pain

The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with referred lower extremity pain.

Table 3. Symptoms, Impairments and Interventions for Low Back Pain with Referred Lower Extremity Pain

Symptoms	Acute Associated with buttock, thigh or leg pain Sitting and flexion are usually aggravating factors
Impairments	Symptoms may centralise with specific positions or repeated motions May present with lateral shift Reduced lumbar lordosis and range noted May also present with movement coordination impairments
Interventions	Exercises, manual procedures or traction to centralise symptoms (see direction-specific exercise below) Patient education on positioning Exercises to address core muscle activation and endurance Community or work integration training As referred pain resolves, reassess and, if appropriate, progress to exercises that are consistent with low back pain with movement coordination impairment strategies

Direction-specific Exercises

Flexion category: patients whose symptoms centralise with flexion-based movements:

• mainly older patients with spinal stenosis (but not exclusively)
• lower extremity symptoms come on after standing or walking for a certain amount of time
• sitting improves symptoms
• flexion activities improve symptoms

Exercises for individuals with a flexion preference include:

• single knee to chest
• double knee to chest
• sitting flexion
• standing flexion

Extension category: patients whose symptoms centralise with lumbar extension-based movements and peripheralise with lumbar flexion

• symptoms distal to the buttock

Exercises for individuals with an extension preference include:

• prone positioning (on a pillow)
• prone on elbows
• prone press up
• standing extension
• bridging
• prone leg raise

For patients with a lateral shift, try a slide glide against a wall, as is shown in the video below.

Individuals with low back pain with referred lower extremity pain are likely classified into the “symptom modulation” category in the TBC.

Low Back Pain with Radiating Pain

The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with radiating pain.

Table 4. Symptoms, Impairments and Interventions for Low Back Pain with Radiating Pain

Symptoms	Acute, subacute or chronic Lancinating pain in a narrow band down the leg Associated paraesthesia, numbness and / or weakness may be present Recurring instances
Impairments	Pain with initial or mid-range motions Aggravated by neurodynamic testing May present with lower extremity impairments (i.e. sensory, strength, and reflex deficits)
Interventions	Patient education to reduce stress to nerve root Manual-based treatment to reduce stress to surrounding tissues Manual traction Nerve mobility exercises

Nerve mobility exercises include nerve glides for the sciatic nerve and the femoral nerve. These exercises are demonstrated in the videos below.

Individuals with low back pain with radiating pain are likely classified into the “symptom modulation” category in the TBC.

Low Back Pain with Cognitive or Affective Tendencies

The following table describes symptoms, impairments and potential interventions for patients who are classified as having low back pain with cognitive or affective tendencies.

Table 5. Symptoms, Impairments and Interventions for Low Back Pain with Cognitive or Affective Tendencies

Symptoms	Acute, subacute With or without lower extremity pain
Impairments	One or more of the following: Two positive responses to the “Primary Care Evaluation of Mental Disorders screen and affect consistent with an individual who is depressed” High Fear-Avoidance Beliefs Questionnaire score High Pain Catastrophizing Scale score
Interventions	Patient education and counselling to address specific issues exhibited by the patient Exercise according to pain science research

This is an additional category not included in the TBC system.

Low Back Pain with Related Generalised Pain

The following table describes symptoms and potential interventions for patients who are classified as having low back pain with generalised pain.

Table 6. Symptoms and Interventions for Low Back Pain with Generalised Pain

Symptoms	Has had low back pain for more than three months High fear avoidance Does NOT meet other classifications
Interventions	Education (the acute injury has healed) Movement into fearful positions Fitness

This is an additional category not included in the TBC system.

Please watch the following video if you would like to hear more from Dr. Lorimer Moseley about recent advances in pain science research.