Lecture_3(motor control and Radic)_students_2024

Treatment Based Classification
System for LBP: Motor control

impairments and Radicular Syndromes
Integrated Orthopedic Management
PHTH-560
Patrick Ippersiel
Isabelle Pearson
Isabelle Audette 1
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• Assignment
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2
Learning Objectives
The students will be able to:

• Understand and apply assessment and treatment procedures based
on the movement control classification (motor control dysfunction)
of the TBC
• Understand and apply assessment and treatment procedures based
a radicular syndrome classification
• Recall basic anatomy of intervertebral discs
• Understand common pathologies of lumbar disc herniations, spinal
stenosis, and spondylolisthesis
• Recall best practice principles for treatment of LBP.
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What is low back pain?
LOW BACK PAIN

LOW BACK PAIN
NSLBP (90%)
• No clear
pathoanatomical
diagnosis
Movement
Control
*NSLBP = Non-specific low back pain; SLBP = Specific low back pain
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Treatment-based classification
*Physical assessment: Focus on procedures to determine if they are

movement impairments (hypomobility) or motor control impairments
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Movement control
KEY FEATURES
• 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
• Goal: Restore movement quality
Sub-classified as : Movement impairments (hypomobility)

or Motor control impairments
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Alrwaily et al., Phys Ther. 2016;96(7):1057-66
*Movement control
• Sub-Acute / Chronic LBP (>4 weeks)
• Moderate / Low levels of Pain and Disability
• Stable Symptoms
• *Sub-categorizes into movement vs. motor control impairments
Movement impairment 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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What is it and what can I do about it?
MOTOR CONTROL
IMPAIRMENT
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MOTOR CONTROL IMPAIRMENTS
What does a motor control

impairment mean in the
context of LBP?
How does motor control fit in

with exercise?
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Specific approach to motor control

• Aimed at increasing spinal stability
• Classic core stability approach
• Transverse abdominis
General approach to motor control

• Aimed at normalizing dysfunctional
movement patterns
• Classify patients on movement
pattern
• No focus on muscle isolation
10

11
Panjabi, J Electromyogr Kinesiol. 2003 Aug;13(4):371-9.
Spinal instability
• “The inability of the spine under physiologic loads to maintain its pattern of
displacement so that no neurologic damage or irritation, no development of
deformity, and no incapacitating pain occur.”
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Spinal Stability
• Total ROM of a spinal segment = R2
EZ
Neutral zone (NZ) + Elastic zone (EZ)
• NZ = Movement occurring around
neutral spine (minimal passive NZ
resistance)
• EZ = Motion occurring near end
range (increased passive resistance) R1
• Clinical instability = Increased size
of NZ and reduced passive
resistance in EZ
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Control spine in NZ and is pain-free
Painful spine has greater NZ, surpasses

pain-free zone (e.g., injury to capsular
ligament, degenerative changes)
Stabilized spine has decreased NZ

and is pain-free*
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How is stability achieved?
• Spinal stability is achieved

via the interaction of 3 sub-
systems
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Passive subsystem
• Vertebral bodies, facet joints, ligaments, capsule, passive tension from
muscles and tendons
• Stabilizes EZ and limits size of NZ
• Proprioceptive information / feedback provided to control system (where a
spine segment is in space)
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Active subsystem
• Muscles and tendons which generate force to stabilize the spine
• Ensures motion occurs in NZ and helps maintain NZ size
• Proprioceptive information / feedback provided to control system (what
loads are imposed on the spine)
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Control subsystem
• Integrates information from other subsystems and determines requirements
for stability and commands active system to act accordingly.
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SUMMARY OF SPINAL STABILITY
• NZ is a region of ROM where there is minimal resistance to movement,

thus making it vulnerable to injury.
• Clinical instability is a hypothesized condition in which there is an increased
NZ of a vertebral segment, and the stabilizing systems can’t compensate
for this increase.
• This may have resulted from micro-trauma, macro-trauma, prolonged poor
postures and/or dysfunctions of any one of the sub-systems (active,
passive, neural).
• As a result, movement in the NZ becomes poorly coordinated/controlled
and surpasses its physiological limits which can result in abnormal tissue
loading and lead to pain and disability.
• Treatment paradigms are aimed improving stability of the spine to control
vertebral motion within the NZ – effectively decreasing the NZ.
• This forms the overall basis for core stability to treat back pain.
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SUMMARY
“Note that the hypothesis describing the interactions between the

NZ, pain and spinal state (injury and restabilization) is unproven.
These ideas must be tested and validated by future clinical studies.”
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MINI GROUP DISCUSSION
• Did you see any patients who fit this description?
• Did you see use of core stability for back pain?
• What did that look like?
• What were the results?
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AN OVERVIEW OF CORE STABILITY
O’Sullivan 2000, Man Ther. 2000 Feb;5(1):2-12.
1. Isolate local system

(transverse abdominis /
multifidus)
2. Train local muscle system

control with basic
movements and postures
3. Train local muscle system

functionally
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• Hugely popular amongst health care professionals
• Start by training the local/deep muscle system and

progressively challenge the system more
– Specifically recruit Transverse abdominis and multifidus
• Makes sense intuitively - stabilize my spine, I’ll have less

pain
• Very common in fitness circles, physio clinics, media,

culture
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i t ?
ve is
ct i
ef f e
H o w
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KEY FINDINGS FROM REVIEWS
• “There may be a role for specific stabilisation exercises in some patients with chronic
low back pain, but these are no more effective than other active interventions” (May
2008)
• “Motor control exercise is not more effective than manual therapy or other forms of
exercise” (Macedo 2009)
• “MCE is probably more effective than a minimal intervention for reducing pain, but
probably does not have an important effect on disability, in patients with chronic LBP.
There was no clinically important difference between MCE and other forms of
exercises or manual therapy for acute and chronic LBP” (Saragiotto 2016)
• “In patients with chronic and recurrent low back pain, MCE seem to be superior to
several other treatments. More studies are, however, needed to investigate what
subgroups of patients experiencing LBP respond best to MCE.” (Bystrom 2013)
• “There is strong evidence stabilisation exercises are not more effective than any other
form of active exercise in the long term… further research is unlikely to considerably
alter this conclusion” (Smith 2014)
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WHAT DOES THIS ALL MEAN?
• Multiple SYSTEMATIC REVIEWS show

modest results for core stability for LBP –
often no better than other approaches.
• Core stability can help many people with
LBP, it’s just not the cure-all it is made out
to be
• It may not help people due to the
proposed mechanism of increasing spinal
stability… it’s not that simple!
• Some of these are great exercises and
have a role for the right person in front of
you
• LBP is really heterogenous - should
we think about sub-grouping? Transverse abdominis
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29
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CORE STABILITY SUMMARY
• One ‘blanket’ treatment approach (core stability) for lumbar

hypermobility and instabilities hasn’t shown to be the most effective
means to manage LBP
• This approach will help some people but due to large heterogeneity in
LBP it is not a one size fits all approach
• Sub-grouping helps clinicians tailor a more specific intervention creating

an individualized approach to care
• Sub-groups based on impairments in motor control have been

identified and can help direct treatment for LBP (Dankaerts et al. 2006)
• Including classic core exercises and retraining of the inner unit may be
helpful for some patients but should be integrated within a larger
treatment plan.
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movement patterns
• Classify patients on movement
pattern
32
Spondylolisthesis
(stay tuned..)

movement patterns NSLBP – motor
• Classify patients on movement control impairment
pattern
33

movement patterns NSLBP – motor
• Classify patients on movement control impairment
pattern
34
What is motor
control?
35
Latash 2012, Fundamentals of motor control
”an area of science exploring natural laws that define how the
nervous system interacts with other body parts and the
environment to produce purposeful, coordinated movements”
36
Hodges P. and Tucker K., Pain 2011 Mar;152(3 Suppl):S90-S98.
Motor control is an umbrella term used to refer to all aspects of

control of spinal movement. This includes:
• The decision-making process in the brain (intent to move)

• Sensory inputs to the system (proprioception, location of
segments)
• Nervous system integrating information and planning movement
• Motor output to muscles and how they relate to movement
Motor control can be adaptive

or mal-adaptive
37
THOUGHT EXPERIMENT
You bump into an old friend…
38
ADAPTIVE VS. MAL-ADAPTIVE
• Your friend who was limping initially showed protective (adaptive) motor
control - which is good!
• This temporary strategy helps off-load injured tissues (think ATFL) to
encourage healing.
• This is a normal process that is driven by acute pain – think a loss of DF
following an acute ankle sprain (ie. limping).
• Over time, we expect tissues to heal and a normal motor strategy to return if
the problem has been addressed.
•
•
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• Your friend who is still limping 6 months after an ankle sprain showed a mal-
adaptive (provocative) motor control – which is bad.
• Tissues should heal within 8-12 weeks, why are they still limping?
• Imagine avoiding DF for 6 months when walking, would other structures start
to hurt (ie. Ankle, knee, hip?)
• Mal-adaptive motor control leads to abnormal tissue loading and eventual
becomes a NEW pain issue!
40
O’Sullivan 2005, Man Ther. 2005 Nov;10(4):242-55.
Adaptive changes in motor control are good!

• This is a protective response to pain
– Limping after acute ankle sprain
• Changes to this response should increase/worsen symptoms
– Don’t change a helpful movement strategy!
Mal-adaptive changes in motor control are bad!

• May have been helpful initially
• This is a sub-optimal response to pain that is often provocative
– Still limping 6 months after ankle sprain….
• Helps maintain patient in a painful state
• Correction of this pattern should decrease symptoms
– Change an unhelpful movement strategy
41
Consider two patients with spinal

stenosis…
• One presents with a loss of lumbar lordosis
and inhibition of multifidus
• Another presents with an increase in
lumbar lordosis, with considerable
guarding/bracing in that position
stenosis flexion is good and extension is bad
Both have pain… which one is adaptive?

Mal-adaptive? Why?
42
RETHINKING MOTOR CONTROL…
Three changes from the ‘core stability’ approaches…
1. Sub-grouping into distinct patterns

- Flexion vs. active extension patterns
2. Less of a focus on ‘isolated exercise’

– Less concerned with transverse abdominis and multifidus work in
isolation
– More focused on pelvis, thorax, general movement concepts
3. Change of language
– Instability is not appropriate for LBP unless they are diagnosed with a
true unstable condition (high grade spondylolisthesis) – we are dealing
with motor control impairments
43
Alrwaily et al., Phys Ther. 2016;96(7):1057-66
*Movement control
• Sub-Acute / Chronic LBP (>4 weeks)
• Moderate / Low levels of Pain and Disability
• Stable Symptoms
• *Sub-categorizes into movement vs. motor control impairments
Movement impairment Motor control impairment
Hebert et al., 2008 Clin

Sports Med.;27(3):463-79.
Burns et al. 2011 Sports Health;3(4):362-72.

44
Motor Control Impairments
What is a motor control impairment (MCI)?
• Loss of functional control of a spinal region (e.g. L5/S1)

resulting in a movement and loading disorder
• Most MCI are mal-adaptive and associated with a loss of

control around the ‘neutral zone’ of a spinal region (e.g. L5/S1)
• Leaves the spine vulnerable to tissue strain, from repetitive

end-range strain and/or abnormal loading (non-physiological
loading)
45
Motor Control Impairments
Pain may as result of…
• Through range movement pain – due to abnormal loading of

spinal region. Think shoulder ‘impingement’
• Loading pain (not end range) – commonly due to excessive

muscle activity and compression of spinal region in specific
positions. Think ‘squeezed fist’ or over-protection
• End-range or overstrain – due to repetitive strain of spinal

motion segment at end range. Think ‘overstretched finger’
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Definition: Loss of functional control of a spinal region (e.g. L5/S1) resulting in

one or more directions
• Motor control impairments impairment: flexion / active extension / passive

extension patterns.
• 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: poor movement quality causing stress/pain
47
ACKNOWLEDGEMENT
Based on the “O’Sullivan Classification System”
• O'Sullivan, P. B. (2000). "Lumbar segmental 'instability': clinical

presentation and specific stabilizing exercise management."
Man Ther 5(1): 2-12.
• O’Sullivan PB 2004 Clinical Instability in the lumbar spine: its
pathological basis, diagnosis and conservative management. In:
Grieve’s Modern Manual Therapy (3rd edn), Ch 22, P311-331.
• O'Sullivan, P. (2005). "Diagnosis and classification of chronic low
back pain disorders: maladaptive movement and motor control
impairments as underlying mechanism." Man Ther 10(4): 242-
255.
• O’Sullivan , P. (2006). “Diagnosis, Classification Management of
Chronic low back pain From a mechanism based bio-psycho-
social perspective” Workshop handbook
• Mitchell, T (2016). “Motor control retraining of athletes with
low back pain: A Revised Context.” Aspetar Sports Medicine
Journal: 144-151.
• The following slides summarize the above-mentioned system

and use images provided in their publications.
48
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
• Catching pain +/- EOR stretch pain (Nociceptive pain)
Pain Pattern
• Pain with movement into direction of impairment (no
loss of ROM)
• Specific activities / posture will aggravate vs. ease pain
• Depends on the pattern you suspect
49
AROM +/- Overpressure

• No loss of AROM, will have pain in the direction of impairment
• End-feel: WFL
P/A (Scan)
• Local pain on Sp of affected segment (e.g., L4) +/- stiffness
Biomechanical Assessment
• Specific functional movement testing (seen in lab) that is consistent with the
hypothesized impairment
–
–
Neurodynamics and Palpation

• May have (+/-) SLR / Slump / PKB
• May have local tenderness of lumbar paraspinals 50
Flexion pattern
Pain resulting from loss of motor control of a segment into flexion
51
Flexion pattern
Definition:
• Pain resulting from loss of motor
control of a segment into flexion
• Common males > females
• Think overstretched finger
• Try dropping into posterior tilt

then bending….
52
Flexion pattern
Observation
• Loss of lumbar lordosis
• Global spinal flexion or lumbar flexion with
extended thoraco-lumbar spine
Pain pattern Ext

• Unilateral vs. bilateral pain
• Pain with flexion related activities (bending,
lifting, sitting)
• Eased with extension-based activities (walking, Flex
supine)
• Arc of pain, catching sensations, sustained
postures in flexion
• Hockey, weightlifting, kayaking, rowing may be
problematic (i.e., flexion)
• Better when some lordosis is introduced
53
Flexion pattern
AROM
• Pain with lumbar flexion (catching and/or end range)
• Greater flexion at symptomatic segment
• Lumbar >> Hip movement (often reduced hip flexion ROM)
– No hip hinge!
• Thoraco-lumbar spine remains extended (maybe)
• Greater posterior pelvic rotation
Functional movements (analyze their complaint!) Ext

• Pain with sitting – flexed lx
• Pain with squat – buttwink
Flex
• Pain with sit-to-stand – excessive flexion
Movement testing
• Difficulty to anteriorly rotate pelvis and extend lower
lumbar spine
54
Active Extension pattern
Pain resulting from a segment being ‘actively’ held in extension
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Definition
• Pain disorder based on
lumbar spine/segment
being held ACTIVELY in
extension
• Females >> males
• Think squeezed fist

example
• Try standing and moving in

full lordosis…
56
• Observation
– Greater segmental lordosis at ‘symptomatic’ level
– Thorax anterior to pelvis
– Significant co-contraction, bracing of abdominal
wall
• Pain pattern
– Pain with upright sitting and standing postures
– Pain with extension
– Pain with bending (inability to reverse lordosis)
– WORSE with core stability!
– Possible pain with ballet, tennis, swimming, and
running
– Better when movements are performed relaxed
and without lordosis
57
• AROM
– Pain with extension (may be limited)
– Pain with lumbar flexion (inability to reverse
lordosis)
– Hip >>> lumbar movement
• Often stiff hip extension
• Lots of hip hinge!
– Excessive anterior pelvis rotation
• Functional movements (analyze their complaint!)

– Pain with standing
– Sustained forward bending (dishes)
All performed with
excessive anterior tilt /
– Worse with carrying (holding kids)
hyperlordosis
– Walking
• Movement testing
– Difficulty initiating and isolating posterior pelvic
tilt from thorax 58
FLEXION PATTERN - RETRAINING
Retraining dead-lift Retraining rowing
59
Active Extension pattern - retraining
Retraining sitting posture Retraining sit-to-stand
60
Role of PAGs, PPIVMs for motor control
impairments
• For the purposes of this course, the biomechanical assessment for motor
control impairments will focus on specific movement testing.
• Some therapists will “combine” and use other tools to assess. Typical
examples are the inclusion of PAGs and PPIVMs (seen with movement
impairments).
• Some possible findings for motor control impairments:

• PAG on Z-Jt: Pain, Normal NZ, R1, R2, EF at affected segment (e.g.,
L4/5)
• PPIVM may have decreased NZ, R1, R2 at affected segment in
opposite direction of impairment (e.g., L4/5 unilateral flexion for
extension patterns)
• However, it remains that these additional assessments are not hugely

relevant for motor control impairments.
61
Video examples?
62
Break
63
What are they and what can I do about them?
RADICULAR SYNDROMES
64
What is low back pain?
LOW BACK PAIN

LOW BACK PAIN
Radicular
Syndromes (5-10%)
• Radicular pain
• Radiculopathy
• Spinal stenosis
*NSLBP = Non-specific low back pain; SLBP = Specific low back pain
65
Radicular Syndromes
Bardin et al. Med J Aust. 2017 Apr 3;206(6):268-273.doi: 10.5694/mja16.00828.
Radicular syndrome(s) (5-10%)

• An umbrella term that describes three subsets of lumbo-sacral nerve root
pathology/involvement
• Radicular pain (sometimes call sciatica)
• Radiculopathy
• Spinal stenosis (neurogenic claudication)
66
Radicular Syndromes
Bardin et al. Med J Aust. 2017 Apr 3;206(6):268-273.doi: 10.5694/mja16.00828.
Radicular syndromes (5-10%)

• Often LBP of a known pathoanatomical origin
• May occur with back pain, but leg pain is dominant symptom
• Likely accompanied by neurological signs (e.g., loss of S1 reflex)
• Clinical tests / signs and symptoms are helpful to diagnose
• May need to be confirmed by diagnostic imaging (MRI, CT)
Common conditions include:

• Disc prolapse/extrusion with
radiculopathy
• Lateral foraminal stenosis
• Central stenosis
• High grade spondylolisthesis*
67
Radicular Syndromes
Bogduk Pain. 2009 Dec 15;147(1-3):17-9.doi: 10.1016/j.pain.2009.08.020.
Radicular pain (sometimes call sciatica): Pain arising from irritation of a sensory or
dorsal root ganglion of a spinal nerve.
• Sharp, lancinating pain following a dermatomal distribution (E.g., S1)

• Often related to inflammation and disc herniation
68
Radicular Syndromes
Radiculopathy: Conduction is blocked along a spinal nerve or its root

characterized by sensory disturbances, muscle weakness and hypoactive reflexes
• If sensory fibres are blocked = decreased sensation (in dermatome)

• If motor fibres are blocked = decreased muscle strength (in myotome)
• If sensory or motor fibres are blocked = may get diminished reflex
• Not defined by pain! Defined by neurological symptoms
69
Radicular Syndromes
“Although radiculopathy and radicular pain commonly occur

together, radiculopathy can occur in the absence of pain, and
radicular pain can occur in the absence of radiculopathy.”
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Radicular Syndromes
Radicular pain and radiculopathy

are commonly associated with
disc pathology
One big issue with disc pathology is determining

when it is actually pathological or simply normal age
related changes.
71
Discs and age-related changes
Aging
Disc injury/trauma
Symptoms
Disc degeneration
72
Radicular Syndromes
Brinjikji 2015, AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.
73
Normal age-related changes
There’s an inconsistent relationship, between

degenerative findings in the spine (disc degeneration, lx
spine OA, minor disc bulges etc…).
NSLBP (90%) Non-specific

• No clear
pathoanatomical Low Back
diagnosis
Pain!
Symptom Movement Functional
Modulation Control Optimization
74
Normal age-related changes
But there are times when

pathology/structure matters and Radicular
we can reliably (somewhat) syndromes!
identify this clinically!
• Disc herniations causing radicular pain and radiculopathy

• Spinal stenosis causing neurogenic claudication
• High-grade spondylolisthesis (+/- causing radicular pain and
radiculopathy)
75
Radicular Syndromes
• Disc herniations causing radicular pain and radiculopathy
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Disc herniations
Magee D. Orthopedic Physical Assessment, 2021
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Disc Herniation
Disc herniation: When nucleus/annulus material migrates (herniates)

into foramen
Most of the time postero-lateral annular tear

1/ Protrusion = contained herniation (last superficial lamellas still intact)
2/ Prolapse = only outermost fibres of annulus contain the nucleus
3/ Extrusion = non-contained herniation
4/ Sequestration = free fragment
78
Disc herniations
If disc material herniates into:

• Lateral foramen = nerve root compression = radicular pain +/-
radiculopathy
• Central foramen = Cauda equinae compression = red flag
79
Disc herniation
L5/S1 and L4/L5

levels are the
most common!
80
Disc herniation on MRI
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Disc herniation w/ radiculopathy
Mechanism of injury
• Sudden and/or prolonged flexion events (lifting,
lifting and rotation)
• More common in younger populations 35-50 yrs old
Pain Site
• Leg pain >> back pain (radicular pain, goes past knee)
• Likely follows a dermatomal pattern (depends on
what nerve root is affected)
Pain Type
• Lancinating, specific line of pain (radicular pain)
Pain Pattern
• Often worse with bending, sitting, flexion activities
• WB may be a problem (standing)
• Often better supine, side-lying (unloaded positions) 82

• Significant loss of AROM in flexion (pain+, peripheralizes) and possibly extension (blocks)
• May have limited and painful side-flexion on ipsilateral side of leg pain
P/A (Scan) and Traction

• Pain +/- stiffness on Sp of affected segment (e.g., L4)
• Traction might provide some relief
Biomechanical assessment
• SLR (already done) and Crossed SLR (useful for diagnosis)
• To guide
• treatment!
Neurological exam
• Likely a combination of decreased dermatome, decreased myotome, and absent reflexes
corresponding to a nerve root (e.g., L4)

83
• (+) SLR reproducing leg pain
Petersen at al. BMC Musculoskelet Disord. 2017 May 12;18(1):188.doi: 10.1186/s12891-017-1549-6.
“Hancock rule” for disc herniation with nerve root involvement

• (+) SLR reproducing leg pain
• 3 positive out of 4 history or physical
examination findings:
– Dermatomal leg pain location in
“Promising clinical diagnostic
line with a nerve root
rule based on best-evidence”
– Corresponding sensory deficits
– Corresponding reflex loss
– Corresponding motor weakness
• Supplemental physical exam findings:
(+) crossed SLR
84
Petersen at al. BMC Musculoskelet Disord. 2017 May 12;18(1):188.doi: 10.1186/s12891-017-1549-6.
“Hancock rule” for disc herniation with nerve root involvement
SLR (ipsilateral leg) CROSSED SLR (contralateral leg)
85
Disc herniation w/ radiculopathy – Lateral Shift
Thought to relate to disc / nerve root

pathology, still no consensus in the literature.
Most common presentation

86
Disc herniation w/ radiculopathy – Treatment
principles
Stochkendahl et al. Eur Spine J. 2018 Jan;27(1):60-75.doi: 10.1007/s00586-017-5099-2. Epub 2017 Apr 20.
• Education
Current • Stay active and prognosis
• Warning signs (red flag pathology)
guidelines on
conservative • Supervised exercise
• Directional exercises (following principles of
Rx suggest: centralization and peripheralization)
• Motor control exs
• Spinal manual therapy (to promote extension?)
• Patients may also need to be followed by a MD (pain control, imaging)

• May also benefit from lumbar traction (?)
87
principles
GOOD!
BAD!
88
principles
• Protrusion and prolapse= Centralization & peripheralization of pain

more likely to occur
• Extrusion, sequestration = Centralisation/peripheralization less likely

but still possible!
89
principles
• Treatment based on education, extension exercises, and

mobilizations to promote extension over 6 week period
• Significant improvements in pain and disability at 6 weeks
• Adding traction didn’t help
90
principles
Thackeray et al. J Orthop Sports Phys Ther. 2016 Mar;46(3):144-54.doi: 10.2519/jospt.2016.6238. Epub 2016 Jan 26.
91
principles
92
principles
Mobilizations targeting extension for pain control and movement restoration
93
principles
94
principles
Thackeray et al. J Orthop Sports Phys Ther. 2016 Mar;46(3):144-54.doi: 10.2519/jospt.2016.6238. Epub 2016 Jan 26.
Summary of typical conservative treatment approach
• Patient education
• Lx roll when sitting; sleeping position
• Centralization/peripheralization
• Importance of staying active (e.g., walking)
• Prognosis (often months of recovery vs. weeks)
• Exercises targeting extension (and centralization)
• Spinal manual therapy (mobs to increase ext, pain control)
• +/- a form of traction, neurodynamics (?)
95
principles
Chou et al. Spine (Phila Pa 1976). 2009 May 1;34(10):1066-77.
Use of epidural steroid injection?

Recommendation: “In patients with persistent radiculopathy due to
herniated lumbar disc, it is recommended that clinicians discuss risks and
benefits of epidural steroid injection as an option (weak recommendation,
moderate-quality evidence). It is recommended that shared decision-
making regarding epidural steroid injection include a specific discussion
about inconsistent evidence showing moderate short-term benefits, and
lack of long-term benefits.”
96
principles
Chou et al. Spine (Phila Pa 1976). 2009 May 1;34(10):1066-77.
Surgical approaches?
Recommendation: “In patients with persistent and disabling radiculopathy due
to herniated lumbar disc or persistent and disabling leg pain due to spinal
stenosis, it is recommended that clinicians discuss risks and benefits of surgery
as an option (strong recommendation, high-quality evidence). It is
recommended that shared decision-making regarding surgery include a specific
discussion about moderate average benefits, which appear to decrease over
time in patients who undergo surgery.”
“For persistent and disabling radiculopathy due to herniated lumbar disc,

standard open discectomy and microdiscectomy are associated with moderate
short-term (through 6 to 12 weeks) benefits compared to nonsurgical therapy,
though differences in outcomes in some trials are diminished or no longer
present after 1 to 2 years”
97
Radicular Syndromes
• Spinal stenosis causing neurogenic claudication
98
Spinal Stenosis
Bussieres J Pain. 2021 Sep;22(9):1015-1039 .doi: 10.1016/j.jpain.2021.03.147.
Lumbar spinal stenosis:
• Stenosis = a degenerative process

characterized by narrowing of the
central spinal canal, lateral recess, or
intervertebral foramen (or a
combination thereof) causing
compression of neurovascular
structures (not always painful)
• More common in the elderly (65+)
• Lumbar spinal stenosis is often

described in terms of neurogenic
claudication (a clinical feature)
• Stenosis can be central or lateral

99
Spinal stenosis
Bussieres et al. J Pain. 2021 Sep;22(9):1015-1039.doi:10.1016/j.jpain.2021.03.147.
Stenosis can be lateral

• Narrowing of intervertebral
foramen
• Can cause compression of nerve
root
• One sided pain/issue
Stenosis can be central

• Narrowing of spinal canal
• Can compress spinal cord
• Bilateral symptoms
• Red flags?
100
Spinal Stenosis
Bussieres J Pain. 2021 Sep;22(9):1015-1039 .doi: 10.1016/j.jpain.2021.03.147.
Neurogenic claudication:
• Mechanical or ischemic compression of

the nerve roots or spinal cord
• Unilateral/bilateral buttock/thigh/calf
symptoms (aches, cramps, pain,
paresthesias, weakness).
• Worse with standing, walking (lx ext)
• Relieved by sitting, lumbar flexion and

lying down (lx flex)
• LBP may or may not be present (not their

main complaint)
• Pt report major difficult with walking

(pain, need to sit down after a few mins). ,main complaint is leg pain and that they cant walk
old cannot stand or walk si down becomes way better
101
Spinal Stenosis
• True diagnosis requires imaging, clinical tests, and knowledge of

pt’s evolution of symptoms.
• Clinically, it can be classified using the following criteria:

• Pt over age of 60
• Positive 30-second extension test
• (-) SLR
• Pain in both legs* (but also unilateral)
• Leg pain relieved by sitting / leaning
forward or flexing the spine.
102
Spinal Stenosis
Mechanism of injury
• Usually progressive onset
• Older age (> 65 yr old)
Pain Site
• Leg pain >> back pain (past knee, not following clear
dermatome)
• Can be bilateral or asymmetrical
• +/- Intermittent local low back pain (central or unilateral) –
not main complaint!
Pain Type
• Diffuse, cramping, pain, tingling/numbness common
Pain Pattern
• Better with bending, sitting, flexion activities (opens canal)
or supine. Relieved almost immediately.
• Worse in upright positions (standing, walking) , prone lying
103
Spinal Stenosis

• Typically full AROM in flexion (relieving)
• Often lacking AROM lumbar extension (might cause pain)
P/A (Scan)
• No consistent findings / consider age-related stiffness
• 30 second extension test (helpful to diagnose)
•
–
Neurological exam
• Typically negative (neurogenic claudication)

• Often (-) SLR, may have (+) test
104
Spinal Stenosis
Olson K. 2016. Manual Therapy of the spine.
Differential diagnosis
• Vascular claudication: progressive obstruction of

arteries that nourish the extremities – insufficiency
during physical activity
– Causes LE cramping, pain, and weakness with
walking
– Relieved by rest (even in standing, unlike NC)
• May have ischemic changes: pale, reduced pulse,
painful, paresthesias
• (+) bicycle test of van Gelderen
• (+) two-stage treadmill test
– 10 min flat walk / 10 min rest in sit / 10 min
incline walk
– If greater tolerance for walking in inclined
positions: Neurogenic claudication
105
Spinal Stenosis
Olson K. 2016. Manual Therapy of the spine.
Bicycle test of van Gelderen
• Pain in upright position

and relieved in flexion =
neurogenic claudication
• Pain in upright position

and in flexed position =
vascular claudication
(exacerbated by exercise)
106
Spinal Stenosis
Treatment recommendations:
• Patient-centered care plan

• Multi-modal rehabilitation
– Education
– Nutrition/lifestyle advice/Co-morbidity management
– Manual therapy (spine, thorax, lower extremities)
– Individually tailored home exercise program
• Trial of acupuncture / anti-depressants
107
Spinal Stenosis Typical PT treatment
.
Backstrom et al. Man Ther. 2011 Aug;16(4):308-17. doi: 10.1016/j.math.2011.01.010
• Education on pathology, activity, lifestyle

• Flexibility/Mobility
– Flexion protocol in progressive positions (pain relief)
– Hip flexors and RF (increase extension)
– Thoracic mobility (increase extension)
• Aerobic activity
– Cycling / pool exercise/ Incline treadmill
• Strengthening (Based on physical exam)
– Progressive LE strength: Wall squats / Glute bridge / Hip Abd / Heel raises
108
Spinal Stenosis: Sample HEP
.
109
Spinal Stenosis: Sample manual therapy
.
110
Spinal Stenosis – Medical interventions?
Ombregt 2013
Infiltration of a local anaesthetic

• If conservative treatment fails, an infiltration of a local anaesthetic might
be indicated (chemical effect on the C fibres of the dorsal root)
If no relief with an infiltration, surgery might be indicated:

• Excision of an osteophyte by fenestration or Laminectomy with partial
excision of the enlarged facets if necessary
• Interspinous implants (‘spacers’) - de-lordosing the segment & thus
widening the spinal canal in the upright position
Surgical – Lx fusion (more invasive)

• Long term results btw conservative & Sx intervention are often the same
• Multilevel Lx fusion Sx associated with ↑ risk of major life-threatening
complication
111
Radicular Syndromes
• High-grade spondylolisthesis (+/- causing radicular pain

and radiculopathy)
112
Spondylolisthesis
Definition: a forward displacement (slippage)

of one vertebrae relative to another causing
mechanical strain or radicular symptoms.
113
114
Spondylolisthesis
.
Vanti et al. Arch Physiother 2021 Aug 9;11(1):19.doi: 10.1186/s40945-021-00113-2
Definition: a forward displacement of one vertebrae relative to another

causing mechanical strain or radicular symptoms. Can be Lytic or
Degenerative
• Lytic (Isthmic) is the consequence of spondylolysis, which is a

congenital defect or post-traumatic break in the pars interarticularis.
• Degenerative is the consequence of arthritis, disorders of the disc
space
• Regardless of lytic vs. degenerative, it can be graded on a 1 to 4 scale
• Grade I corresponds to less than 25% slippage
• Grade II to 25–50%,
• Grade III to 51–75%,
• Grade IV to 76–100%
115
Spondylolisthesis (Grading)
Source: https://radiopaedia.org/articles/spondylolisthesis-grading-system
Grade 1 Grade 2 116

Spondylolisthesis (Grading)
Source: https://radiopaedia.org/articles/spondylolisthesis-grading-system
Grade 3 Grade 4
117
Spondylolisthesis isn’t always painful…
Brinjikji 2015, AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.
118
Lytic Spondylolisthesis
.
Lytic (Isthmic) Spondylolisthesis: is a forward slippage

of a vertebrae relative the one below (e.g., L5 on S1)
due to a defect in the pars interarticularis.
May be caused by:

• A consequence of spondylolysis (stress fracture of pars),
such as repeated loading (fatigue fracture)
• A congenital defect or post-traumatic break in the pars
interarticularis
• More common in younger and adolescent
people/athletes (gymnasts, football players)
• Foramens aren’t usually compromised w/ lytic

spondylolisthesis
• Nerve root may still be compressed
• Can cause radiculopathy 119
Lytic Spondylolisthesis
Pars interarticularis
= junction of lamina Spondylolisthesis = defect at the pars w/ slippage
w/ pedicle
*Spinal
instability
*Extreme case!!
120
Spondylolysis = defect at the pars, no slippage
Degenerative Spondylolisthesis
.
Degenerative spondylolisthesis is the forward slippage of the

vertebral body caused by degeneration/arthritis of facet joints,
degeneration of the intervertebral disc, +/- ligamentous laxity.
There is no defect at the pars interarticularis.
• Occurs in older patients (esp. women >50)

• Most frequent at L4/5
• Forward slippage can narrow the spinal
foramen/IVF and can compress the nerve
root
• Can cause radiculopathy
• Linked with smaller stabilizer muscle
thickness and multifidus atrophy.
121
Spondylolisthesis (Summary)
.
Degenerative Lytic
• Occurs in older patients (esp. • Break in pars articularis which
women >50) allows forward slippage of
• Most frequent at L4/5 vertebrae
• Caused by degeneration of • Younger, athletic populations
disc and facet joints • Foramens aren’t usually
• Forward slippage can narrow compromised
the spinal foramen/IVF and • Nerve root may still be
can compress the nerve root compressed
• Can cause radiculopathy • Can cause radiculopathy
• Linked with smaller stabilizer
muscle thickness and
multifidus atrophy.
122
Spondylolisthesis
Mechanism of injury
• May be progressive onset in older pts (> 50y,
degenerative)
• May be related to trauma (lytic) – younger pts
Pain Site
• May have lumbar pain and leg pain
• Intermittent leg pain can be bilateral or asymmetrical
Pain Type
• Diffuse pain
Pain Pattern
• Worse with prolonged standing, Lx extension,
bending forward
• Flexion from below is relieving (knees to chest),
crook-lying
123
Spondylolisthesis

• May have pain with flexion, uses hands to prop self back up.
• Increased AROM in extension with pain (creases)
P/A (Scan)
• Pain at specific level, NO restriction in movement
• (+) prone instability and ASLR test
• Poor recruitment of local muscles (TrA, MF)
– Hypermobile PAG on Z-jt (Inc NZ, R1, R2, soft EF), pain “loose”
– May find adjacent hypomobile segments (Via PAGs, PPIVMS)
Neurological exam
• May have a (+) neuro exam

• Likely (-) SLR, may have a (+) step deformity. 124
Spondylolisthesis
Biomechanical assessment Goal of Treatment
• Active straight leg raise (ASLR) • Improve spinal stability

• Prone instability test (PIT)
• Inner unit muscle recruitment

• Multifidus
125
Prone Instability Test
Purpose: Assess for lumbar instability of L1-L5 segments
126
Active Straight Leg Raise (ASLR)
Purpose: Assess the ability of the lumbopelvic region to accept the load applied
from the lower extremities. Testing for dynamic stabilization of the pelvis
• Three part test which involves observing pt’s ability to perform test, then
adding compressions.
• Anteriorly (TrA), Posteriorly (MF), at greater trochanter (pelvic floor)
127
Transverse Abdominis
INSTRUCTIONS
• Pht and pt palpate TrA 2 cm medial
and inferior to ASIS
• Try to facilitate gentle activation of
TrA using the following cues:
• Visualize a line between your
two ASIS and bring them
together
• Contract your pelvic floor (step
from peeing) COMMON SUBSTITUTIONS
• Draw your belly up and in • Outer unit contraction
• Others… (rotation of pelvis, lx spine
• Need to adapt based on your patient’s flex/ext)
capacity to contract • Bulging of abdomen
• Depression of rib cage
• Breath holding
128
Multifidus
INSTRUCTIONS
• Pt is sidelying or prone
• Pht palpate MF on each side of SP
• Gentle activation of MF using on of
these strategies:
• Ask pt to swell the muscle under
your fingers
• Tell pt to pinch SP with their MF
• Use co-activation of TrA/pelvic
floor muscles to help MF COMMON SUBSTITUTIONS
activation • Outer unit contraction
• Need to adapt based on your patient’s (rotation of pelvis, lx spine
capacity to contract flex/ext)
• ”Butt gripping”
129
Inner unit muscles – treatment
Summary
1. Isolate inner
unit muscles
2. Train inner unit
3. Train inner unit
functionally
130
Inner unit muscles – treatment
131
Vanti et al. Arch Physiother 2021 Aug 9;11(1):19.

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Treatment Based Classification

System for LBP: Motor control

The students will be able to:

LOW BACK PAIN

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

Sub-classified as : Movement impairments (hypomobility)

Movement impairment Motor control impairment

Hebert et al., 2008 Clin

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

What does a motor control

How does motor control fit in

Specific approach to motor control

General approach to motor control

Specific approach to motor control

Control spine in NZ and is pain-free

Painful spine has greater NZ, surpasses

Stabilized spine has decreased NZ

How is stability achieved?

• Spinal stability is achieved

• NZ is a region of ROM where there is minimal resistance to movement,

“Note that the hypothesis describing the interactions between the

• Did you see any patients who fit this description?

• Did you see use of core stability for back pain?

• What did that look like?

• What were the results?

O’Sullivan 2000, Man Ther. 2000 Feb;5(1):2-12.

1. Isolate local system

2. Train local muscle system

3. Train local muscle system

• Hugely popular amongst health care professionals

• Start by training the local/deep muscle system and

• Makes sense intuitively - stabilize my spine, I’ll have less

• Very common in fitness circles, physio clinics, media,

• Multiple SYSTEMATIC REVIEWS show

• One ‘blanket’ treatment approach (core stability) for lumbar

• Sub-grouping helps clinicians tailor a more specific intervention creating

• Sub-groups based on impairments in motor control have been

Specific approach to motor control

General approach to motor control

General approach to motor control

General approach to motor control

Hodges P. and Tucker K., Pain 2011 Mar;152(3 Suppl):S90-S98.

Motor control is an umbrella term used to refer to all aspects of

• The decision-making process in the brain (intent to move)

Motor control can be adaptive

You bump into an old friend…

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

Adaptive changes in motor control are good!

Mal-adaptive changes in motor control are bad!

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

Consider two patients with spinal

Both have pain… which one is adaptive?

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

Three changes from the ‘core stability’ approaches…

1. Sub-grouping into distinct patterns

2. Less of a focus on ‘isolated exercise’

Movement impairment Motor control impairment

Hebert et al., 2008 Clin

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