Treatment Based Classification

System for LBP: Movement

impairments
Integrated Orthopedic Management
PHTH-560

Patrick Ippersiel
Isabelle Pearson
Isabelle Audette 1
©
Learning Objectives

• Understand and apply an assessment and treatment approach

based on the TBC system
• Understand assessment and treatment procedures based on the
movement control classification
• Apply these concepts to simple case studies
• Understand the concept of somatic referred pain
• Recall best practice principles for treatment of LBP.

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TREATMENT-BASED CLASSIFICATION FOR LBP

MOVEMENT CONTROL

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What is low back pain?

Adapted from Bardin et al. Med J Aust. 2017 Apr 3;206(6):268-273.doi: 10.5694/mja16.00828.

LOW BACK PAIN

LOW BACK PAIN

NSLBP (90%)
• No clear
pathoanatomical
diagnosis

Movement
Control

*NSLBP = Non-specific low back pain;

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Treatment-based classification
Alrwaily et al., Phys Ther. 2016;96(7):1057-66

*Physical assessment: Focus on procedures to determine if they are

movement impairments (hypomobility) or motor control impairments

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 Movement control
Alrwaily et al., Phys Ther. 2016;96(7):1057-66; O’Sullivan et al. Man Ther. 2005 Nov;10(4):242-55.

KEY FEATURES
• Sub-Acute / Chronic LBP (>4
weeks)
• Low-moderate pain and disability
• Low to moderate irritability
• Stable (worse w/ certain activities
but returns to baseline)
• Aggravated w/ sudden movements
• Back pain > leg pain
Very common presentation
Goal: Restore movement quality

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 Treatment-based classification
Alrwaily et al., Phys Ther. 2016;96(7):1057-66

*Movement control
• *Sub-categorizes into movement vs. motor control impairments

Movement impairment (hypomobility) Motor control impairment

Hebert et al., 2008 Clin

Sports Med.;27(3):463-79.

Burns et al. 2011 Sports Health;3(4):362-72.

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 Treatment-based classification
Alrwaily et al., Phys Ther. 2016;96(7):1057-66

*Movement control
• *Sub-categorizes into movement vs. motor control impairments

Movement impairment/
Motor control impairment
Hypomobility

Hebert et al., 2008 Clin

Sports Med.;27(3):463-79.

Burns et al. 2011 Sports Health;3(4):362-72.

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What is it and what can I do about it?

MOVEMENT IMPAIRMENT
(HYPOMOBILITY)
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Movement impairments (hypomobility)

Mechanism of injury:
Macro-trauma vs. micro-trauma

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Movement impairments (hypomobility)

O’Sullivan et al. Man Ther. 2005 Nov;10(4):242-55.

Definition: Painful loss or impairment of normal (active and passive)

physiological movement in one or more directions

• Movement impairments occur in Flexion / Extension

• Classification is based on: Subjective history (mechanism of injury, pain

site, pain type, pain pattern) and objective examination

• Recall, this is non-specific LBP – meaning we cannot confidently

identify a structure responsible for their pain
– Ligament sprain, muscle strain, joint surface (facet), low-grade
degenerative changes (DDD, OA) could be involved

Think: Stiff and sensitive (painful) spinal segment

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 Patient Assessment Framework

Screen for Mandatory Questions /

Red flag? Referral
complexity Subjective

Acute injury? Proceed to joint specific aspects

of scan/biomechanical ax

Lower quadrant scan

Spinal or Peripheral ?

Lumbar Ax Peripheral joint

biomechanical Ax
Referral?

Lumbar Biomechanical Ax
No
Yes
Treatment Improving? Proceed

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Movement impairments (hypomobility)

O’Sullivan et al. Man Ther. 2005 Nov;10(4):242-55.

Mechanism of injury
• Sub-acute / chronic LBP history following traumatic
injury or repetitive strain
• History supports normal movement never fully
recovered following acute pain episode

Pain Site
• Intermittent local low back pain (central or unilateral)
• Back pain >> leg pain (referred NOT radicular pain)

Pain Type
• Stiffness, stretch pain (Nociceptive pain)

Pain Pattern
• Pain and loss of ROM with movement into direction
of impairment
• Better with gentle activity, stretching, heat

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 Movement impairments (hypomobility)

AROM +/- Overpressure

• Loss of AROM (near end-range) in direction of impairment
• End-feel: increased resistance (early capsular?)
• Loss of AROM is consistent with their functional complaints (e.g., it hurts to bend and sit)

P/A (Scan)
• Local pain and stiffness on Sp of affected segment (e.g., L4)

Neurodynamics and Palpation

• May have (+) SLR / PKB
• May have local tenderness of lumbar paraspinals

•
•

•
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Movement impairments (hypomobility)

• What about our PT diagnosis?

There is a movement
impairment (hypomobility)….

? 15
 Movement impairments (hypomobility)

• What about our PT diagnosis?

• Where? Z-jt
There is a movement • Which level? L4/5 vs. L5/S1 etc…
impairment (hypomobility)…. • In which direction? Flexion vs. extension
• On which side? Right vs. left

Typical PT diagnosis will contain all these items

e.g., Movement impairment at L4/5 in flexion on the right side.

How do we go about this? 16

 Patient Assessment Framework

Screen for Mandatory Questions /

Red flag? Referral
complexity Subjective

Acute injury? Proceed to joint specific aspects

of scan/biomechanical ax

Lower quadrant scan

Spinal or Peripheral ?

Lumbar Ax Peripheral joint

biomechanical Ax
Referral?

Lumbar Biomechanical Ax
No
Yes
Treatment Improving? Proceed

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Movement impairments (hypomobility)

Biomechanical assessment for movement impairments

• Combined movement testing (H and I)

• PAGs (Physiological articular glide) on Z-jt

• PPIVMs (Passive Physiological Inter-Vertebral

Movement)

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 Movement impairments (hypomobility)
Olson K. 2016. Manual Therapy of the spine.

Recall joint biomechanics

• Flexion: superior facet glide sup/ant on inferior facet (bilat flex)
• Extension: superior facet glide inf/post on inferior facet (bilat ext)

Neutral Flex (bilat) 19

 Movement impairments (hypomobility)
Olson K. 2016. Manual Therapy of the spine.

Recall joint biomechanics

• Side flexion: Superior facets glide on inferior facets
• Ipsilateral: glide inf/post (unilateral ext)
• Contralateral: glide sup/ant (unilateral flex)
unilateral flexion on right

Left Side flexion

unilateral extension on left 20

 Movement impairments (hypomobility)
Olson K. 2016. Manual Therapy of the spine.

What’s happening at the Z-jts?

Motion: Ext Motion: Flex

Bilateral Z-jt ext Bilateral Z-jt flex
(inf/post) (sup/ant)

Motion: Lt SF
Ext Lt Z-jt
(inf/post) Motion: Rt Rot
…unreliable
Flex Rt Z-jt
(sup/ant)

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 Movement impairments (hypomobility)
Olson K. 2016. Manual Therapy of the spine.

Movement Arthrokinematics (at Z-jt) Clinical terminology

Flexion Superior facets glides sup/ant on inferior Bilateral “flexion”

facets
Extension Superior facets glides inf/post on inferior Bilateral “extension”
facets
Rt Side flex Right: Superior facets glides inf/post on Unilateral “extension” on
inferior facets right

Left: Superior facets glides sup/ant on inferior Unilateral “flexion” on

facets left

Lt Side flex Right: Superior facets glides sup/ant on Unilateral ”flexion” on

inferior facets right

Left: Superior facets glides inf/post on inferior Unilateral ”extension” on

facets left.

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 Movement impairments (hypomobility)

• What about our PT diagnosis?

• Where? Z-jt
There is a movement • Which level? L4/5 vs. L5/S1 etc…
impairment (hypomobility)…. • In which direction? Flexion vs. extension
• On which side? Right vs. left

Typical PT diagnosis will contain all these items

e.g., Movement impairment at L4/5 in flexion on the right side.

How do we go about this? 23

Movement impairments (hypomobility)

Biomechanical assessment for movement impairments

• Combined movement testing (H and I)

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Movement impairments (hypomobility)

Combined movement testing (H and I)

• Take lumbar spine to multi-planar end-range position
• Combines different planes of movement (e.g., Flexion and SF)
• Helpful when single plane movements are pain-free or not limited
• Helps classify an impairment in flexion vs. extension

x x

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Combined Movements (H and I)

H = SF then Flex/ext I = Flex/ext then SF

F L SF F R SF

L SF R SF

L SF E R SF
E

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 Combined Movements (H and I)

Clinical example: Your patient has LBP and painful AROM with lx
flexion. You’ve just performed H and I in the flexion quadrant.

I: Combined Flex / RSF is painful and restricted at EOR

• Think: Both z-jt joints are flexed with the first movement (flexion) and then
the left z-jt is getting additional flexion with RSF – this brings on pain!
• Reasoning: Likely a mvt impairment (hypo) in flexion on the left.

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 Combined Movements (H and I)

Clinical example: Your patient has LBP and painful AROM with lx
flexion. You’ve just performed H and I in the flexion quadrant.

H: Combined RSF / Flex is painful and restricted at EOR

• Think: The left z-jt is flexed and the right z-jt is extended with RSF. Adding a
flexion movement adds additional flexion to both sides, but the left is
already in flexion – this brings on pain!
• Reasoning: Likely an impairment (hypo) in flexion on the left.

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 Combined Movements (H and I)

Clinical example: Your patient has LBP and painful AROM with lx
flexion. You’ve just performed H and I in the flexion quadrant.

Therefore, there is evidence for a movement

impairment in flexion on the left side

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Movement impairments (hypomobility)

Consider joint biomechanics for you clinical impression

Flex/RSF and RSF/Flex =

Flex/LSF and LSF/Flex =

Ext/RSF and RSF/Ext =

Ext/LSF and LSF/Ext =

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Movement impairments (hypomobility)

Consider joint biomechanics for you clinical impression

Flex/RSF and RSF/Flex = Movement

impairment in flexion on the (L)
Flex/LSF and LSF/Flex = Movement
impairment in flexion on the (R)

Ext/RSF and RSF/Ext = Movement

impairment in extension on the (R)
Ext/LSF and LSF/Ext = Movement
impairment in extension on the (L)

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 Combined Movements (H and I)

Clinical example: Your patient has LBP and painful AROM with lx
flexion. You’ve just performed H and I in the flexion quadrant.

Therefore, there is evidence for a movement

impairment in flexion on the left side

BUT AT WHAT LEVEL?

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Movement impairments (hypomobility)

Biomechanical assessment for movement impairments

• PAGs (Physiological articular glide) on Z-jt

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 Joint Mobility:
Types of Movement (Review)

REMINDER!
• Accessory motion (Arthrokinematics)
– Motions of articular surfaces relative to one another
– Associated with physiological mvt
– Necessary for full range of physiological motion to occur
– Ligament & joint capsule are stressed during the motion
– Can only be achieved passively (not actively controlled)
• Cannot be voluntary performed
– These mvts are generally an involuntary consequence
of the anatomical constraints of the joint (shape of
articular surfaces, mechanical properties of inert
periarticular soft tissues, etc).

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Lumbar PAGs (Physiological articular glide) on Z-jt

Purpose:
• Test motions of articular surfaces (Z-jt) relative
to one another.
• Assess glides of restricted mvt(s) found during
the scan.
• We note pain and decrease/increase in NZ, R1,
R2, and End-feel
• Not useful as a stand-alone test!

E.g., Limited AROM flexion – check

PAGs at Z-jt to help identify restricted
Anterior direction level (e.g., L4/5) and side (right vs. left)

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How are PAGs different from PA’s on SP?

Scan done on SP

Biomechanical Ax
done on Z-Jt

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 Passive Accessory Mvts Principles
Concept of Neutral Zone & Elastic Zone

REMINDER!

• Neutral Zone = zone of no

resistance
• Elastic Zone = zone where
you get resistance from the
tissues
Elastic Elastic
• R1 = Resistance 1 = first
zone zone
resistance felt during
passive acc mvt
R1 • R2 = Resistance 2 = end of
R1 the elastic zone, final
R2 R2 resistance felt (if more force
is applied, prox jt will move)

(3)

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 Passive Acc Mvt: Outcome/Types of dysfunction related to
Neutral Zone (NZ) and Elastic Zone (EZ)

PAGs (Physiological Articular Glide) can

also be classified as:
Hypomobility:
q ↓ neutral zone
q Early R1 & R2 (rapid ↑ in resist
btw R1 and R2) = ↓ elastic zone
q Early caps EF

Elastic Elastic
zone zone

R1
R1

R2 R2

(3)

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Lumbar PAGs

Anterior direction Cranial direction Caudal direction

(flex) (ext)

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 Lumbar PAGs (Physiological articular glide) on Z-jt

Clinical example: Your patient has LBP and painful AROM with lx
flexion. You’ve just performed H and I in the flexion quadrant.

• AROM: Decreased and painful lx flexion

• H/I testing: Decreased and painful Flex / RSF and RSF / Flex
• Suspecting movement impairment in flexion on the left side

Therefore let’s assess Z-jt PAG in cranial direction

• L1/2 to L4/5: Normal NZ, R1, R2, capsular end feel

• L5/S1: Decreased NZ, early onset R1 and R2, early caps end-feel (Stiff) on
left side

PT Diagnosis: Movement impairment in flexion on the left side at L5/S1

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Movement impairments (hypomobility)

Biomechanical assessment for movement impairments

• PPIVMs (Passive Physiological Inter-Vertebral

Movement)

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 Movement impairments (hypomobility)

Unilateral extension Unilateral flexion

• Used to assess physiological motion (flexion vs. extension) at a

specific level (e.g., L5/S1)
• We assess NZ, R1, R2, end-feel

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Movement impairments (hypomobility)

PPIVMs (Passive Physiological Inter-Vertebral Movement)

• Assess passive physiological movement of a spinal motion segment
• Eg., flexion at L4/5 segment (Z-joint)
• Assessment based on “feel” – highly subjective*
• Useful when suspecting a movement impairment
• Can help confirm level of hypomobility
• Needs to be consistent with findings of Subjective, AROM, P/A,
PAGs etc…

Not useful as a stand-alone test!

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 Movement impairments (hypomobility)

PPIVMs (Passive Physiological Inter-Vertebral Movement)

• Many different PPIVMs exist:
• Bilateral flexion/extension
Seen again in 623
• Side-flexion
and advanced MT
• Rotation
• Unilateral flexion
• Unilateral extension
• Etc..

We’re focusing on unilateral flexion/extension to line-up with

common movement impairment findings we see clinically!

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Movement impairments (hypomobility)
Stolz et al. Musculoskelet Sci Pract. 2020 Feb;45:102076.

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Movement impairments (hypomobility)
Stolz et al. Musculoskelet Sci Pract. 2020 Feb;45:102076.

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 Movement impairments (hypomobility)

Pain with flexion Pain and Decreased Decreased NZ, R1, R2,
restriction NZ, R1, R2, on Lt L4/5 Z-jt in
in Lt flexion pain, on Lt unilateral flexion
L4/5 Z-jt
cranially

…Good clinical reasoning!

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 Movement impairments (hypomobility)

Pain with flexion Pain and Increased NZ, Decreased NZ, R1, R2,
restriction R1, R2, pain, early caps EF, on Lt
in Rt extension on Lt L4/5 Z-jt L2/3 Z-jt in unilateral
cranially extension

…Flawed clinical reasoning!

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Movement impairments (hypomobility)

O’Sullivan et al. Man Ther. 2005 Nov;10(4):242-55.

Mechanism of injury
• Sub-acute / chronic LBP history following traumatic
injury or repetitive strain
• History supports normal movement never fully
recovered following acute pain episode

Pain Site
• Intermittent local low back pain (central or unilateral)
• Back pain >> leg pain (referred NOT radicular pain)

Pain Type
• Stiffness, stretch pain (Nociceptive pain)

Pain Pattern
• Pain and loss of ROM with movement into direction
of impairment
• Better with gentle activity, stretching, heat

49
 Movement impairments (hypomobility)

AROM +/- Overpressure

• Loss of AROM (near end-range) in direction of impairment
• End-feel: increased resistance (early capsular?)
• Loss of AROM is consistent with their functional complaints (e.g., it hurts to bend and sit)

P/A (Scan)
• Local pain and stiffness on Sp of affected segment (e.g., L4)

Neurodynamics and Palpation

• May have (+) SLR / PKB
• May have local tenderness of lumbar paraspinals

PPIVMs and PAGs (Biomechanical assessment)

• PAG on Z-Jt: Pain, Decreased NZ, R1, R2 at affected segment (e.g., L4/5); early caps EF
• PPIVM: Decreased NZ, R1, R2 at affected segment (e.g., L4/5 unilateral flexion); early caps
EF
• H/I testing: consistent with direction of impairment
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 Movement impairments (hypomobility)

Biomechanical ax for movement impairments (Summary)

• Combined movement testing (H and I)

– Develop a hypothesis (e.g., Hypo flexion on rt side)

• PAGs (Physiological articular glide) on Z-jt

– Add to your hypothesis (e.g., Hypo flexion on rt side at L3/4)

• PPIVMs (Passive Physiological Inter-Vertebral Movement)

– Confirm your hypothesis (e.g., Hypo flexion on rt side at L3/4)

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Movement impairments (hypomobility)

Charting your PT diagnosis for the nature of the condition

E.g., Movement impairment at L4/5 in Flexion on the (R)

E.g., Movement impairment at L3/4 in Extension on the (L)

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Movement impairments (hypomobility)

Movement impairments occur in Flexion or Extension

AROM Lx Ax (PA) Biomechanical Ax PT diagnosis

• Movement
impairment in L4/5
Flexion on the Rt
• Movement
impairment in L3/4
Extension on the Rt

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 Movement impairments (hypomobility)

Movement impairments occur in Flexion or Extension

AROM Lx Ax (PA) Biomechanical Ax PT diagnosis

• Decreased • Stiff and • Decreased combined flex/LSF • Movement
and painful painful at and LSF/flex impairment in L4/5
flexion L5 SP • Hypo Rt L4/5 Z-jt PAG in neutral Flexion on the Rt
and cranially
• Hypo Rt Unilat flexion PPIVM at
L4/5
• Decreased • Stiff and • Decreased combined Ext/RSF • Movement
and painful painful at and RSF/ext impairment in L3/4
extension L4 SP • Hypo Rt L3/4 Z-jt PAG in neutral Extension on the Rt
and caudally
• Hypo Rt Unilat ext PPIVM at
L3/4

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Summary of movement impairments

• Movement impairments are one form of “movement control” dysfunction

based on the TBC.
• They are characterized by low back pain +/- some mild irradiation into the
leg (nerve related or somatic referred)
• NOT radicular pain
• Movement impairments can be classified as impairments in: flex/ext; on a
side R/L; at a level (L4/5).
• Biomechanical assessment helps confirm your PT diagnosis and can
identify levels (H and I, PAGs, PPIVMs)
• These tests may be more useful when USED TOGETHER
• There is limited value of these tests in isolation

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Summary

Questions?
Patrick.ippersiel@mcgill.ca

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References

References are in the slides.

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