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LBP: Treatment-based classification approach
Extensive research has allowed physical therapists to identify which patients will benefit from each type of treatment. Click on each treatment to see the key examination findings which are used to determine the most effective form of treatment.
Manipulation
  • No symptoms distal to the knee
  • Recent onset of symptoms
  • Low levels of fear-avoidance beliefs
  • Hypomobility of the lumbar spine
  • Increased hip internal rotation (> 35) or discrepancy in hip internal rotation range of motion between the right and left hip
If these findings are present, treatment should include:
  • Manipulation of the lumbopelvic region
  • Active range of motion exercises
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Stabilization
  • Frequent prior episodes of low back pain
  • Increasing frequency of low back pain
  • Instability catch or painful arcs during lumbar flexion and extension range of motion
  • Hypermobility of the lumbar spine
  • Positive prone segmental instability test
If these findings are present, treatment should include:
  • Promoting isolated contraction and co-contraction of the deep stabilizing muscles (multifidus, transverses abdominus)
  • Strengthening of large spinal stabilizing muscles (erector spinae, oblique abdominals)
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Specific exercise: extension
  • Symptoms distal to the knee
  • Signs and symptoms of nerve root compression
  • Symptoms centralize with lumbar extension
  • Symptoms peripheralize with lumbar flexion
If these findings are present, treatment should include:
  • End-range extension exercises
  • Mobilization to promote extension
  • Avoidance of flexion activities
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Specific exercise: flexion
  • Older age (> 65 year)
  • Symptoms distal to the knee
  • Signs and symptoms of nerve root compression, neurogenic claudication, or both
  • Symptoms peripheralize with lumbar extension
  • Symptoms centralize with lumbar flexion
If these findings are present, treatment should include:
  • Mobilization or manipulation of the spine and/or lower extremities
  • Exercises to address impairment of strength or flexibility
  • Body weight-supported treadmill ambulation
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Specific exercise: lateral shift
  • Visible frontal plane deviation of the shoulders relative to the pelvis
  • Asymmetrical side bending active range of motion
  • Painful and restricted extension active range of motion
If these findings are present, treatment should include:
  • Exercises to correct lateral shift
  • traction
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Traction
  • Signs and symptoms of nerve root compression
  • No movements centralize symptoms
If these findings are present, treatment should include:
  • Mechanical or auto-traction
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References

Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative management. Phys Ther. 1995;75:470-489.

Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: inter-rater reliability and short-term treatment outcomes. Spine. 2000;25:106-114.

Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying sub-groups of patients with "non-specific" low back pain: results of a randomized clinical trial. Spine. 2006;31:623-631.

Fritz JM, Delitto A, Erhard RE. Comparison of a classification-based approach to physical therapy and therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine. 2003;28:1363-1372.

Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843.
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