Common Spinal Impairment Classifications

Treatment-based classification strategies can help prioritize interventions based on the PT examination findings. Symptoms of spinal pathology can overlap, therefore, the physical therapist will develop a plan of care based on special tests and measures which lead to a movement-based syndrome classification.

In your clinical practice, you will encounter references to several classification systems (e.g., McKenzie, Sahrmann approach, Delitto, Williams flexion). If you can focus your exercise application on a solid rationale of kinesiology, keen observation, patient input, and understanding of pathology, then you can successfully collaborate with your PT partner on treatment planning and modification to reach maximum function.

 

Centralization and Peripheralization

Centralization refers to movements that minimize radicular findings, namely, that isolate symptoms in the spine and remove or reduce symptoms that are lateral to the spine or extend into the extremities. Activities that centralize symptoms generally lead to decreased mechanical strain to the affected spinal unit. Peripheralization is a lateral spreading of symptoms from the spine toward or into the extremity. Activities or positions that result in radiating symptoms away from the spine are avoided.

Click here to see an image of centralization vs. peripheralization

Delitto Impairment-Based Categories

 

 McKenzie Classification System

 

Clinical Decision-Making and Problem-Solving

Before selecting the most appropriate intervention for your patient, it is important to have a firm understanding of involved structures and tissues, healing stages, and risk for recurrence or further injury.

PTAs provide an extensive amount of education to patient's during all stages of healing. By integrating kinesiology and pathological knowledge, the patients you work with will be more likely to understand the why of the exercise. Patients want to get better, and PTAs can help patients build the necessary confidence to believe in the evidence: progressing posture, movements, and performing the selected exercises consistently and as prescribed, is time well spent.

When thinking about your role, plan for data collection, options for modifications, and indications to communicate with the PT. By planning ahead, you can have multiple interventions to choose from based on the patient presentation and response. Most importantly, you can be listening, feeling, and watching for signs and symptoms which indicate the patient is unable to safely participate in physical therapy.

First, do YOU have any questions about the patient's condition and readiness for treatment? Do you have any questions or concerns about your own confidence and skill set to move forward with treatment? Are you uncertain about elements in the plan of care (including precautions and contraindications) or the PTs directions? If you have questions in these areas, consult the supervising PT for clarification and direction.

Decision-Making Strategies

1. Start with subjective data collection

Clinical pearl: let them know you believe movement is valuable and important by asking about it first

Ask the patient about their movement, daily activity, how long they are able to stand/sit/walk, or other relevant functional targets in the physical therapy plan of care.

Then, ask your patient about other signs and symptoms that relate to the complaint, this may include pain, sensory changes, and aggravating positions or movements.

Ask your patient if there are any other general health concerns

2. Make comparisons

Apply your understanding of healing/recovery stages to the subjective data by collecting relevant objective data:

Observe patient movements, positions and postures. Identify position of bias, if any.

Test and measure specific motions, joints, muscles, endurance, or other indicators relevant to the case as needed based on subjective data and observations or as directed by the supervising PT.

Decide if what you hear and what you see matches findings in the physical therapy plan of care and knowledge of healing stages.

Modify and/or progress interventions based on your data and evidence-informed decisions.

Remember, you have the PTA Problem Solving Algorithm process to help guide clinical-decision making. 

Active Learning Exercise

Video approximately 15 minutes

Fill in the table with interventions you have learned so far that would be consistent with managing acute spinal symptoms. Then use a 0-5 scale to rate your understanding and confidence in selecting the intervention and delivering clear and evidence-based instruction

After completing the table above, proceed on through the lecture and refresh interventions from Kinesiology. Consider what you already know when intentionally selecting exercises based on impairment classifications. 

Active Learning Exercise

1. Position yourself in sidelying. Note the amount of side bending in the lumbar spine and weight bearing pressure in the contralateral shoulder and greater trochanter.

2. Repeat with hand towel rolled into a cylinder and placed under waistline

3. Now try this (Look familiar? It comes from PTA 101 Positioning lecture and your Priniciples & Techniques of Patient Care text)

What are the differences in your comfort level? If you needed to be in a sidelying position on a treatment table for greater than 5 minutes, which of the three options would you choose?

Congratulations! This is an example of how you can apply prior knowledge of interventions for soft tissue protection into a therapeutic activity that allows the patient to assume a position of ease in sidelying.