Evaluation of a Treatment-Based Classification Algorithm for Low Back Pain

eAppendix.
Factors From the Physical Therapist Assessment Required to Classify Patients and Protocol for Assessing Each Factora

Factors From Physical Therapist Assessment Required to Classify Patients

Age

Duration of symptoms (days since onset)

Distribution of symptoms (low back, buttock, thigh, lower leg)

FABQ work subscale score

FABQ physical activity subscale score

Best position for symptoms among sitting, standing, or walking

Worst position for symptoms among sitting, standing, or walking

No. of prior episodes of LBP

Increasing frequency of LBP episodes (yes/no)

Presence of neurological symptoms (myotomal weakness, sensation alteration, hyporeflexive, positive SLR)

SLR ROM (degrees)—average SLR ROM and discrepancy in SLR ROM between sides

Crossed SLR (position or negative)

Any aberrant movements occurring with flexion or extension AROM (present/absent)

Status change with AROM for flexion, extension (pain intensity: no change, increased, decreased; pain location: centralization, peripheralization, no
change)

Status change with repeated flexion in a standing position, repeated extension in a standing position, repeated flexion in a sitting position, sustained
extension in a prone position, and repeated extensions in a prone position (pain intensity: no change, increased, decreased; pain location:
centralization, peripheralization, no change)

Hip medial (internal) rotation ROM

Mobility judgments for each lumbar segment (hypomobile, hypermobile, normal)

Pain reported with mobility testing for lumbar segments (painful, not painful)

Prone instability test (positive/negative)

Operational Definitions/Assessment Protocol

Duration of current episode of symptoms <16 days
Patients are asked to report the number of days since the onset of their current episode of LBP. If there is any
uncertainty, this issue is clarified by asking the patient, “When did the symptoms that have caused you to seek
treatment begin?”

Location of symptoms not extending distal to the knee

A body diagram is used to assess the distribution of symptoms. Location of symptoms categorized as being in the
back, thigh, or leg (distal to knee). The examiner instructs the patient to mark on the body diagram all the areas that
they have symptoms (pain, numbness, tingling).

FABQ work subscale score <19 points

Each item is scored from 0 to 6. Only 7 items (6, 7, 9, 10, 11, 12, and 15) are used for the work subscale. These scores
will be summed (possible range: 0 – 42). Higher scores indicate increased fear-avoidance beliefs.

FABQ physical activity score <9 points

Scores for 4 items (2, 3, 4, and 5) from the FABQ are summed (possible range: 0 –28). Higher scores indicate
increased fear avoidance.
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Continued

Best/worst position for symptoms

Patients are asked which of 3 positions (sitting, standing, or walking) is best for their symptoms. Patients then are
asked which of the 3 positions cause the worst symptoms. This information may be used to help to distinguish a
directional preference (see below).

Signs of nerve root compression

Includes positive SLR (reproduction of symptoms ⬍45°), reflex changes, sensory disruption, or myotomal weakness.
If any one of these signs is present, nerve root compression is deemed to be present.

The nerve roots are tested with the patient in a supine position in the following manner: L1/2—resisted hip flexion,
sensory disturbance to anterosuperior hip and upper medial thigh; L3—resisted knee extension, sensory disturbance
to the medial thigh to the knee; L4 —resisted ankle dorsiflexion and inversion, sensory disturbance to the antero-
medial shin, medial ankle to the big toe, quadriceps muscle reflex; L5—resisted big toe extension, sensory
disturbance to the dorsum of the foot and middle 3 toes; S1—10 unilateral toe raises in a standing position or resisted
ankle eversion, sensory disturbance to the lateral foot, Achilles reflex; S2—resisted flexion of the toes, sensory
disturbance to the posterior thigh and calf.

Strength testing is conducted by performing an isometric muscle test held for 5 seconds to elicit any myotomal
weakness. Testing is performed bilaterally so a comparison between sides can be made. Sensory testing is completed
using a cotton ball that is lightly brushed over the dermatomes bilaterally. If an alteration in sensation is reported,
pinprick testing using a toothpick is used to more concisely map the area of sensation change or loss. A dermatomal
or widespread sensory loss would constitute a sensory deficit. Reflexes are graded as normal, hypo-reflexive, or
hyper-reflexive. A positive reflex sign is one where there is hypo-reflexia or hyper-reflexia of the lower limbs. In
order to be considered indicative of findings of nerve root compression, there must be a difference between sides
in reflexive testing. Neurological testing is performed for all patients.

Average SLR >91°

Right and left SLR ROM. With the patient positioned supine, an inclinometer is positioned on the tibial crest just
below the tibial tubercle (zeroed on the tibia with the leg extended). The leg is raised passively by the examiner,
whose hand maintains the knee in extension. The leg is raised slowly to the maximum tolerated SLR (not the
onset of pain). The leg opposite to that being tested is placed in neutral hip abduction/adduction, and the opposite
knee is help down by one of the examiner’s hands. Both sides are tested.

Discrepancy in SLR >10° (yes/no)

The SLR ROM of the right and left sides are compared, and any difference between the 2 values is calculated.

Positive/negative SLR
During testing of the SLR, the patient’s pain response is recorded. If reproduction of symptoms is reported, the angle
at which this occurs is documented. Reproduction of symptoms that is reported at an SLR <45° is considered a
positive SLR. A pain response that is reported at an SLR ⬎45° is considered a negative SLR.

Crossed SLR
The crossed SLR is positive if during a unilateral passive SLR, the patient reports reproduction of pain in the
contralateral leg. A test is considered positive when raising the leg <70° reproduces sciatic pain. If during a
unilateral passive SLR, the patient reports reproduction of usual back pain, but not leg pain, the test is considered
negative. Both legs are tested for each patient.

Lumbar ROM
Flexion ROM: While standing with feet a shoulder width apart, the patient is asked to reach down as far as possible
toward the toes while keeping the knees straight.
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eAppendix.
Continued

Extension ROM: While standing with feet a shoulder width apart, the patient is asked to arch backward as far as
possible.

Presence/absence of aberrant motions

Any aberrant motions believed to be associated with lumbar spine instability occurring during lumbar ROM are
noted. In a standing position, the patient is asked to flex the trunk forward as far as possible while the examiner
observes in an effort to identify any of the following abnormalities:

Painful arc in flexion: symptoms felt during the movement at a particular point in the motion (or through a
particular portion of the range) that are not present before or after this point.

Painful arc on return: symptoms occur only during return from the flexed position to the erect position.

Gower sign (“thigh climbing”): pushing on the thighs or another surface with the hands for assistance during
return from the flexed position to the erect position.
Instability catch: any sudden acceleration or deceleration of trunk movement or movement occurring outside the
primary plane of motion (eg, lateral bending or rotation during trunk flexion).
Reversal of lumbopelvic rhythm: on attempting to return from the flexed position, the patient bends the knees
and shifts the pelvis anteriorly before returning to the erect position.

Centralization/peripheralization (ⴙ pain intensity) with active movements

Assessment of centralization or peripheralization is performed with active lumbar movements, including flexion and
extension movements in a standing position, repeated flexion and extension in a standing position, sustained and
repeated extension in a prone position, and repeated flexion in a sitting position. Movements are assessed in the
sagittal plane, that is, with the patient’s spine in a neutral position (correct lateral shifts prior to movement
assessment). Single movements are assessed first to determine whether the patient has an adverse response to the
movement (eg, peripheralization) before moving to repeated movements. If any movement (including a single
movement) produces peripheralization, it does not need to be further tested (no movements in the same
direction need to be tested). However, therapist judgment can be used to determine whether further testing in the
same direction is necessary. If centralization is produced by a movement (eg, extension in standing), further
testing of movements in the same direction is still completed (eg, sustained extension and extension in a prone
position).

For extension, a single movement of lumbar extension is assessed first, followed by repeated extension
movements consisting of 10 repetitions performed with the patient in a standing position. Sustained extension (on
elbows) and repeated extension movements also are performed with the patient in a prone position. Similarly for
flexion, a single movement of lumbar flexion is assessed in a standing position, followed by repeated flexion
movements consisting of 10 repetitions performed with the patient in a standing position. This is followed by a single
movement of flexion and then repeated flexion movements (consisting of 10 repetitions) performed with the patient
in a sitting position. Ten repetitions is the maximum number of repetitions to be performed in one position.

The effect of movement on both symptom location and symptom intensity is assessed. In regard to symptom
location, 3 choices exist: centralization, peripheralization, and no effect. Centralization is judged to be present
when a movement abolishes symptoms or causes symptoms to move proximally toward the midline of the lumbar
spine in at least one of these positions. Peripheralization is defined as occurring when a movement causes symptoms
to move distally away from the midline of the spine OR symptoms are produced that were not present prior to the
movement. No effect is defined as no difference in symptoms compared with before the movement began. For
symptom intensity, increased symptom intensity is defined as increased intensity of the symptoms during or after
the movement. Decreased symptom intensity is defined as decreased intensity of symptoms during or after the
movement. No effect is defined as no change in symptoms compared with before the movement began.
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Directional preference
Directional preference is defined as a movement or posture direction that produces centralization OR a
decrease in pain intensity without the pain having changed location. Patients’ answers to the history questions
of best/worst position for LBP may help indicate a directional preference but this information is not required to
determine a directional preference.

At least 1 hip with >35° of medial (internal) rotation ROM

Hip ROM (passive) is tested bilaterally with the patient lying prone and with c-spine at the midline. The leg opposite
to that being measured is placed in a neutral position, in line with the body (0° of hip abduction). The leg of the
side to be tested is kept in line with the body, and the knee is flexed to 90°. A gravity inclinometer is placed on the
distal end of the fibula in line with the bone and is zeroed to a vertical surface. Medial rotation is measured at the
point in which the pelvis first begins to move. Movement of the pelvis is determined either visually and/or
based on end-feel of hip medial ROM.

At least 1 lumbar spine segment judged to be hypomobile with spring testing

Tested with patient in a prone position and head in neutral rotation. The examiner places the hypothenar eminence
of the hand (pisiform bone) over the spinous process of the segment to be tested. With elbow and wrist extended,
the examiner applies a gentle, but firm, anteriorly directed pressure on the spinous process. The stiffness at each
segment is judged as normal, hypomobile, or hypermobile. Assessment begins at L1 and is repeated
through to L5.

No hypermobility present on lumbar spring testing

See procedure above.

At least 1 lumbar spine segment painful with spring testing

During posterior-anterior spinal stiffness testing, if the patient reports pain or discomfort during application of the
anteriorly directed pressure on the spinous processes, the level at which the pressure is being applied is considered
positive for a pain response.

Positive/negative prone instability test

This test is completed only if the patient reports pain with stiffness testing (if no pain is reported with prone
stiffness testing, this test is coded as N/A).

The patient lies prone with the body on the examining table and legs over the edge and feet resting on the floor.
The examining table is positioned specific to the patient, such that when the patient is standing, the table height
is set at the lower one third of the patient’s thigh. The patients’ hips are positioned at the end of the table, so that
their entire legs are off the table. While the patient rests in this position, the examiner applies posterior-anterior
pressure to the lumbar spine. Any provocation of pain is reported. If no pain is reported, the test is coded as negative
and the remainder of the test does not need to be completed. Then the patient lifts the legs off the floor (the patient
may hold table using bent elbows at head level to maintain position), and posterior compression is applied again to
the lumbar spine. If pain is present with passive provocation testing in the resting position but disap-
pears in the second position, the test is positive. If pain is present with passive provocation testing in the
resting position and does not disappear in the second position, the test is negative. If the pain level decreases, but
does not disappear in the second position, the test also is negative

a
FABQ⫽Fear-Avoidance Beliefs Questionnaire, SLR⫽straight leg raise, ROM⫽range of motion, AROM⫽active range of motion, LBP⫽low back pain.

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