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2000; 80:1097-1111.PHYS THER. DillenKatrina S Maluf, Shirley A Sahrmann and Linda R VanPainManagement of a Patient With Chronic Low Back Use of a Classification System to Guide Nonsurgical
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Use of a Classification System toGuide Nonsurgical Management of aPatient With Chronic Low Back Pain
Background and Purpose. This case report describes the use of aclassification system in the evaluation of a patient with chronic lowback pain (LBP) and illustrates how this system was used to develop amanagement program in which the patient was instructed in symptom-reducing strategies for positioning and functional movement.Case Description. The patient was a 55-year-old woman with a medicaldiagnosis of lumbar degenerative disk and degenerative joint diseasefrom L2 to S1. Rotation with extension of the lumbar spine was foundto be consistently associated with an increase in symptoms during theexamination. Instruction was provided to restrict lumbar rotation andextension during performance of daily activities. Outcomes. Thepatient completed 8 physical therapy sessions over a 3-month period.Pretreatment, posttreatment, and 3-month follow-up modified Os-westry Disability Questionnaire scores were 43%, 16%, and 12%,respectively. Discussion. Daily repetition of similar movements andpostures may result in preferential movement of the lumbar spine in aspecific direction, which then may contribute to the development,persistence, or recurrence of LBP. Research is needed to determinewhether patients with LBP would benefit from training in activitymodifications that are specific to the symptom-provoking movementsand postures of each individual as identified through examination.[Maluf KS, Sahrmann SA, Van Dillen LR. Use of a classification systemto guide nonsurgical management of a patient with chronic low backpain. Phys Ther. 2000;80:1097–1111.]
Key Words: Case report, Classification, Disability, Low back pain, Motor control.
Physical Therapy . Volume 80 . Number 11 . November 2000 1097
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Katrina S Maluf
Shirley A Sahrmann
Linda R Van Dillen
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Despite being one of the most commonlytreated disorders in outpatient physical ther-apy practice,1 the management of low backpain (LBP) continues to be a challenge. We
believe that 2 issues, in particular, contribute to thischallenge. The first issue relates to the lack of anaccepted classification system for LBP that is feasible touse and that is validated through research. The secondissue relates to the conceptual distinction between phys-ical impairment and functional limitation, and thedegree to which each is addressed in the treatment ofpatients with low back–related disorders.
The need to classify patients into homogenous sub-groups to better facilitate the management of LBP hasreceived much attention in recent literature.2–15 Thisneed is reflected by the number of classification systemsthat have been proposed within the past 2 decades.2–12
Riddle13 provided a comprehensive review of the classi-fication systems deemed most relevant to physical ther-apists, along with a discussion of issues related to LBPclassification. There is no consensus regarding the mostappropriate classification scheme to guide the rehabili-tation of patients with LBP.14 In the view of manyauthors, the ability to differentiate among various sub-groups of patients with LBP would enhance both theclinical management and the scientific study of LBP.14,15
Measures of physical impairment such as range ofmotion, muscle force, and endurance are routinelyassessed by physical therapists, with the goal of using thedata obtained with these measures to help direct themanagement of patients with LBP.1,16 However, as notedby Jette,17 several major conceptual models indicate thatphysical impairments reflect only one aspect of thedisablement process. Several authors17–19 have suggested
that rehabilitation pro-fessionals must also con-sider functional limita-tions and disability. Theterms “functional limita-tion” and “disability” willbe considered togetherin this report and referto an inability to performthe basic tasks of daily lifeand to fulfill one’s socialand occupational roles.18
In a recent survey ofpatients with chronic LBP(chronic LBP in this study
was defined as 8 or more episodes of recurrent LBPspaced at least 90 days apart within a 3-year period),difficulty performing everyday activities was the mostfrequently cited reason for seeking medical care.20 How-ever, in a national sample of over 2,300 outpatientphysical therapy records, Jette et al1 found that thera-pists cited independent function as a treatment goal foronly 10.6% of all patients treated for LBP. Functionaltraining was included in only 5.6% of the rehabilitationprograms. A more recent study of physical therapy forLBP similarly revealed that the number of goals relatingto range of motion (65%) and pain reduction (53%)outnumbered those relating to the facilitation offunctional activity (20%).21 Together, these studiessuggest that physical therapists may tend to addressphysical impairments more readily than functionallimitations in the treatment of patients with lowback–related disorders.
Delitto19 observed that clinicians may be more inclinedto document measures of physical impairment com-
There are potential
benefits to using a
classification
approach to guide
identification and
treatment of
symptom-provoking
movements and
postures.
KS Maluf, MSPT, is Graduate Student, Movement Science Program, Program in Physical Therapy, Washington University School of Medicine, StLouis, Mo.
SA Sahrmann, PT, PhD, FAPTA, is Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington UniversitySchool of Medicine, St Louis, Mo.
LR Van Dillen, PT, PhD, is Assistant Professor, Program in Physical Therapy, Washington University School of Medicine, Campus Box 8502, StLouis, MO 63110 (USA) ([email protected]). Address all correspondence to Dr Van Dillen.
All authors provided concept/project design, writing, and data analysis. Ms Maluf and Dr Van Dillen provided project management, and DrSahrmann, Dr Van Dillen, and Kate Crandell, PT, MSPT, provided consultation (including review of manuscript before submission). Ms Malufprovided data collection, and Dr Van Dillen provided subjects and facilities/equipment. The authors acknowledge Jennie Levin for help withphotographs, Kate Crandell for valuable discussions regarding the management of the patient, and Michael Mueller, PT, PhD, for helpfulcomments on a previous draft of the manuscript.
This work was approved by the Human Studies Committee of Washington University School of Medicine.
This work was funded in part by National Institutes of Health-National Institute of Child Health and Human Development, National Center forMedical Rehabilitation Research, Grant No. 2 T32 HD07434-04A1 and Grant No. K01 HD01226-01A1.
This article was submitted July 20, 1999, and was accepted July 13, 2000.
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pared with limitations of function based on the under-lying assumption that correction of impairments willresult in improved treatment outcomes. However, thelink between physical impairment and decline in func-tion in people with LBP remains unclear. Severalresearch groups have failed to find an associationbetween various impairment measures and subsequentdevelopment of LBP.22–28 The absence of an establishedrelationship between physical impairment and functionin individuals with LBP suggests that limitations offunction should be addressed directly in any therapeuticprogram that seeks to improve functional outcomes.
The purpose of this case report is 2-fold. First, we willdescribe the use of a classification system in the evalua-tion of a patient with chronic LBP. Second, we willdemonstrate how this classification system was used toguide development of a treatment plan that includedmodification of symptom-producing motions and align-ments of the lumbar spine during the performance ofdaily work, leisure, and self-care activities. In doing so,we hope to illustrate the potential benefits of using aclassification approach to guide identification and treat-ment of the symptom-provoking movements and pos-tures that are specific to each individual.
Conceptual Overview of LBP ClassificationApproachThe system of classification described in this report wasdesigned in an effort to aid clinicians in identifying theprimary movement problem toward which we believephysical therapy intervention should be directed. There-fore, each category of the classification system is namedfor the specific direction of spinal alignment or motionthat is found to be consistently associated with anincrease in LBP during testing. A summary of the signsand symptoms associated with each of the 5 categoriesproposed in this classification system is presented inTable 1.12,29 The validity of data obtained with thisclassification system has not been demonstrated experi-mentally. The interrater reliability of data obtained forphysical examination items used to classify patientsaccording to this system has been reported previously(kappa$.87 for 100% of items related to symptomproduction; kappa$.42 for 72% of items related toalignment and movement signs).12
An underlying assumption of this approach is that thedaily repetition of similar movements and postures canresult in movement of the lumbar spine in a specificdirection, which then may contribute to the develop-ment, persistence, or recurrence of mechanical LBP.12
We believe that the direction of spinal motion associatedwith an increase in low back–related symptoms reflectsmovement strategies and postures that are repeated by agiven individual throughout each day. For example, an
avid tennis player may be inclined to develop a symptomcausing predisposition for motion of the lumbar spineinto a direction of extension and rotation, whereas acyclist may be more likely to develop symptoms associ-ated with lumbar flexion and rotation. Presumably,individuals may develop habitual movements and pos-tures in response to functional activity demands that maycontribute to LBP and that may be identified andcorrected through the evaluation of alignments andmotions of the lumbar spine.
To classify a patient as being in 1 of the 5 categorieslisted in Table 1, we believe that the clinician shouldattempt to identify a consistent pattern of signs
Table 1.Mechanical Low Back Pain Classification Categories, WithAssociated Signs and Symptoms29
Category Associated Signs and Symptom Behavior
Flexion Tendency for the lumbar spine to move in thedirection of flexion with movements of the spineand extremities. Lumbar spine alignment tends tobe flexed relative to neutrala with the assumptionof postures (ie, standing, sitting, supine,side lying, prone, quadruped).
Symptoms occur or increase with the lumbar spinepositioned or moved into flexion.
Symptoms disappear or decrease with restrictionb
of lumbar flexion.
Extension Signs and symptoms are similar to those describedfor flexion except that they occur with extension.
Rotation Tendency for the lumbar spine to move in thedirection of rotation with movements of the spineand extremities. Lumbar spine alignment tends tobe rotated relative to neutral with the assumptionof postures.
Symptoms (often unilateral) occur or increase withthe lumbar spine positioned or moved intorotation.
Symptoms disappear or decrease with restriction oflumbar rotation.
Rotation withflexion
Tendency for the lumbar spine to move in thedirection of rotation and flexion with movementsof the spine and extremities. Lumbar spinealignment tends to be flexed and rotated relativeto neutral with the assumption of postures.
Symptoms (often unilateral) occur or increase withthe lumbar spine positioned or moved intorotation and flexion.
Symptoms disappear or decrease with restriction oflumbar rotation and flexion
Rotation withextension
Signs and symptoms are similar to those describedfor rotation with flexion except that they occurwith rotation and extension.
a “Neutral” is defined as the position of the lumbar spine at which aninclinometer centered over each lumbar spinous process would result in ameasure of 0 degrees, without rotation or side bending of any of the lumbarvertebrae.12
b Restriction of spinal motions and alignments is accomplished using verbalcues, active stabilization by the patient, and manual stabilization by theexaminer.
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(ie, direction-specific motions and alignments of thelumbar spine) and symptoms (ie, reproduction of lowback–related complaints, including numbness, tingling,or pain in the back or lower extremities) in responseto items performed in several different test positions(eg, standing, sitting). Due to the anatomical relation-ship between the spine and extremities, motions of thespine that occur during limb movement are evaluated inaddition to overt spinal motions that occur duringmovement of the torso (eg, forward bending). Confir-mation that the symptom-provoking spinal motion oralignment has been correctly identified occurs byrestricting that motion or alignment and noting whetherthere is a reduction of symptoms (see Appendix in thefull-text version of this article on the Physical TherapyWeb site at http://www.apta.org/pt_journal).
In this system of classification, the primary direction ofsymptom-provoking spinal motion or alignment identi-fied in the examination as causing symptoms is referredto as the lumbar movement dysfunction. We believe thatonce a patient has been classified according to theprimary movement dysfunction, treatment strategiesdesigned to limit direction-specific motions or align-ments that increase the patient’s low back–related symp-toms can be implemented. We consider identificationand correction of the lumbar movement dysfunctionduring work, leisure, and self-care activities to be apriority due to the presumed frequency with which thesemovements and postures are repeated throughout eachday. We also believe that impairments in muscle forceand joint flexibility should be addressed relative to theirpossible contribution to the lumbar movement dysfunc-tion.
Case Description
PatientThe subject of this case report was a 55-year-old womanreferred for physical therapy with a medical diagnosis ofdegenerative disk disease and degenerative joint diseaseof the lumbar spine. The radiography report describedfindings of decreased intervertebral disk space extend-ing from L2 to S1, as well as decreased joint space andsclerotic changes in the facet joints at L2-3 and L4-5. Thepatient reported a 40-year history of recurrent LBP, withmultiple episodes each year, and symptoms that typicallypersisted less than a week before resolving spontane-ously. Previous management for the patient’s currentepisode of LBP included approximately 12 physicaltherapy sessions at an unrelated facility. The patientreported these sessions to be marginally effective inreducing her low back–related symptoms at the time oftreatment, with an exacerbation of symptoms occurringwithin 2 weeks of her final visit to that facility.
The patient’s self-reported medical history includedbladder neck suspension surgery performed in 1991 forthe treatment of urinary incontinence, along with ahistory of cigarette smoking and high blood pressure.Medications included calcium supplements, Wellbutrin*(prescribed as an antidepressive agent), Premarin† (pre-scribed as a cholesterol-lowering agent), cyclobenza-prine (prescribed as a muscle relaxant), and ibuprofen.The patient reported taking the latter 2 medicationsinfrequently for the relief of severe low back–relatedsymptoms. The patient was self-employed as an insur-ance agent and worked approximately 40 hours perweek from her home office. We were aware of no changein the patient’s medications or employment during thecourse of treatment or during the 3-month follow-upperiod.
The symptoms for which the patient sought interventionbegan approximately 10 weeks prior to her first visit toour facility. Symptoms that persist for this duration areconsidered to be of a chronic nature by the Quebec TaskForce for Spinal Disorders.30 The patient reported thatshe had a constant ache across the central low back thatfluctuated throughout the day. The average intensity ofher symptoms was 6 on a verbal pain scale ranging from0 to 10. The 11-point numeric rating scale of averagepain intensity has been found to yield reliable measure-ments31 and to be related to other measures of painintensity when used by patients with LBP.32 She was toldthat a rating of 0 should represent the absence of painand a rating of 10 was the worst pain imaginable. Thepatient also noted an intermittent stabbing pain alongher left posterior thigh and calf, which she said wasexacerbated by twisting motions of the trunk. A tinglingsensation was occasionally present in the left toes. Thepatient reported that the onset of her symptomsoccurred after walking at a slow pace on a treadmill inher home for several minutes. The patient describedherself as inactive, and she said that she had attemptedto begin walking to help lose weight. She reported agradual worsening of symptoms in the first few days afterwalking on her treadmill, with no notable improvementor decline of symptoms in subsequent weeks. Shedescribed having particular difficulty performing thefollowing activities due to increased low back–relatedsymptoms: brushing her teeth, rolling toward her leftside, loading the dishwasher, getting into and out of hertruck, and walking long distances, such as when groceryshopping.
The patient described in this case report was part ofan ongoing clinical study of the effects of modifying
* Glaxo Wellcome Inc, 5 Moore Dr, Research Triangle Park, NC 27709.† Wyeth-Ayerst Pharmaceuticals, Div of American Home Products Corp, PO Box8299, Philadelphia, PA 19101.
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symptom-producing movements and postures during aphysical examination being conducted by the thirdauthor. The patient was recruited from 1 of 6 outpatientphysical therapy clinics participating in a previous studyby our group.12 With the exception of a notably higherOswestry Disability Questionnaire33 score (43% versus24%), this patient exhibited characteristics similar to thepatient population described in a previous report on theinterrater reliability of data obtained by examinersadministering physical examination items used in theclassification of mechanical LBP.12
ExaminationTo classify the patient’s lumbar movement dysfunctionaccording to the system described above, the first authorconducted posture and movement testing with thepatient in the following positions: standing, sitting,supine, side lying, prone, and quadruped. The firstauthor had limited experience (,6 months) with theproposed system of classification prior to receiving train-ing, which was similar to that received by therapistsparticipating in a previous study.12 Briefly, training con-sisted of 5 individualized instruction sessions of 45minutes to 1 hour duration with therapists having doc-umented experience in the proposed classification sys-tem12 and completion of a written examination on thecontent of a reference manual containing operationaldefinitions of terms and standardized clinical examina-tion procedures.
The patient’s self-selected movement strategy or posturewas assessed for signs of movement dysfunction duringperformance of each test item. Prior to each test, thepatient assumed a reference position in which the inten-sity and location of the low back–related symptoms wereassessed. For tests of alignment, the patient was asked toassume the test position for at least 10 seconds beforenoting any change in symptoms relative to symptoms inthe reference position. For active movement tests, thepatient was asked to indicate the point in the range oftrunk or limb movement at which a change in symptomsoccurred relative to symptoms in the reference position.The patient indicated whether the symptoms increased,decreased, or remained the same with each new positionor movement, and descriptions of symptoms were noted.Any test that elicited an increase in the patient’s symp-toms was repeated, but was modified in an attempt toalleviate the symptoms. Modification of each test iteminvolved restriction of the specific spinal motion oralignment that was observed during performance of theinitial, symptom-provoking test. Restriction of symptom-producing spinal motions and alignments was accom-plished using verbal cues, active stabilization by thepatient, and manual stabilization by the examiner. Fol-lowing each modified test item, the patient again wasasked to indicate the status of her symptoms. Procedures
used in the examination of motions and alignments ofthe lumbar spine are described in further detail in theAppendix (shown in the full-text version of this articleon the Physical Therapy Web site at http://www.apta.org/pt_journal). Findings from the examination of thepatient are presented in Table 2.12,30
Active control of the alignment of the lumbar spine wasfacilitated by verbally and/or manually cueing thepatient to contract her abdominal muscles just prior toand throughout the attainment of each modified testposition or movement. She had difficulty using herabdominal muscles and often held her breath, which wepresumed was to compensate for a lack of muscularcontrol. Successful attempts at using the abdominalmuscles, as identified through palpation, frequentlyresulted in complaints of cramping and pain localized tothe pelvic region. The patient indicated that she hadbeen experiencing such symptoms regularly in the 8years since her bladder neck suspension surgery. Theintensity of these symptoms could be reduced or elimi-nated by instructing the patient to reduce the effort ofabdominal muscle contraction.
The first author also examined muscle force and jointflexibility to determine which physical impairmentsmight contribute to the observed tendency for direction-specific motions and alignments of the lumbar spine.Pretreatment and posttreatment impairment measure-ments are summarized in Table 3.29,34–38 The patientdisplayed no signs of neurological deficit, as assessed bylight touch sensation and manual muscle testing ofL1-S1 myotomes.39 The straight-leg-raising test39 wasnegative for signs of neural tension. Results of testing fornonorganic signs of magnified illness behavior asdescribed by Waddell et al40 also were negative. Neuro-logic and Waddell tests were used to identify the pres-ence of nerve impairment and to rule out magnifiedillness behavior. Results were not used in classification ofthe patient’s primary movement dysfunction.
The examiner believed that substitution using the hipflexors occurred during manual muscle testing of severallower-extremity muscle groups (Tab. 3). Hip flexorsubstitution was thought to be present when the extrem-ity being examined moved from the desired manualmuscle test position into a position of increased hipflexion. Excessive use of the hip flexors also was observedthroughout the examination as the patient moved in heraccustomed manner. For example, the patient’s self-selected strategy for moving from a sitting position to asupine position was first to assume a long-sitting positionand then to lower her upper body toward the supportsurface using no upper extremity assistance. Thismethod, which presumably required eccentric contrac-tion of the hip flexor muscles, was associated with an
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increase in LBP. The patient also exhibited a habit thatshe referred to as “nervous legs,” characterized by rapidbouncing movements of the lower extremities, appar-ently initiated at the hip. This habit was observed inter-mittently throughout the examination, most often whenthe patient was sitting or lying supine.
Classification and InterventionBased on the signs and symptoms noted during theexamination, we believed that the patient’s primarymovement dysfunction was lumbar rotation with exten-sion (Tab. 4). We viewed decreased hip flexor lengthand excessive use of the hip flexor muscles during the
performance of routine activities as impairments havingthe potential to contribute to rotation and extension ofthe lumbar spine with static postures and active move-ments of the spine and extremities. Our goal was toimprove the patient’s ability to perform functional activ-ities, while minimizing the symptoms associated withrotation and extension of the lumbar spine.
During her initial visit, the patient was given instructionsfor activity modification based on the category to whichshe was assigned. The recommended strategies for activ-ity modification are summarized in Table 5.12 A featurecommon to each of these strategies was the specific
Table 2.Findings From Examination of Alignments and Movements of the Lumbar Spinea
Test Item Test Response With Self-Selected Alignments and Movementsb
Test Response WithModified Alignments andMovements
Standing forwardbending
No change in status of symptoms
Return from forwardbending
Large excursion into spinal extension prior to onset of hip extension (eg, return toupright position accomplished by leading with back rather than hips)1c in intensity of central LBd sxs
No signs of spinal extensionCentral LB sxs eliminatedc
Standing lumbarextension
Lumbar extension1 in intensity of central LB sxs
No modified test
Side bending Rotation of pelvis and lumbar spine in the horizontal plane when side bendingtoward left1 in intensity of central LB sxs
No signs of pelvic or lumbarrotation
Central LB sxs eliminated
Sitting Preferred position with lumbar spine aligned in extension and lateral side bendrelative to neutrale
2c in intensity of central LB sxs (relative to weight-bearing position in whichlumbar spine was similarly aligned in extension)
Sitting with lumbarspine flexed
No change in symptoms
Sitting with lumbarspine extended
No change in symptoms
Sitting active kneeextension
No change in symptoms
Supine hips andknees flexed
No change in symptoms
Supine passivedouble knees tochest
No change in symptoms
Supine hips andknees extended
No change in symptoms
Supine active singleknee to chest
Lumbar extension with initiation of right LE movementCW pelvic rotation with initiation of right LE movement1 in intensity of central LB sxs with initiation of right LE movement2 in intensity of central LB sxs during late phase of right LE movement as knee
moved closer toward chest, reducing amount of lumbar extension
No signs of lumbar extension orpelvic rotation
Central LB sxs eliminated
Supine active hipabduction andlateral rotation
No change in symptoms
Side lying Preferred position with hips and knees flexed .90° and lumbar spine aligned inflexion relative to neutral2 in intensity of central LB sxs
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discouragement of rotation and extension of the lumbarspine during daily activities. Along with addressing theactivities that the patient identified as problematic, othertasks commonly associated with rotation and extensionof the lumbar spine, such as reaching overhead or acrossthe body, also were addressed (Tab. 5).
During subsequent visits, the patient was instructed in ahome exercise program to address both functional lim-itations and specific physical impairments. The patientwas encouraged to practice isolated limb movements
while avoiding rotation or extension movements of thelumbar spine. This was accomplished through perfor-mance of the modified version of each movement testthat resulted in symptoms during examination (Tab. 2),as described in the Appendix (shown in the full-textversion of this article on the Physical Therapy Web site athttp://www.apta.org/pt_ journal). The importance ofactivity modification was emphasized by having thepatient perform the majority of exercises both in isola-tion and during functional movement. For example, thepatient was instructed to perform 10 to 15 daily repeti-
Table 2.Continued
Test Item Test Response With Self-Selected Alignments and Movementsb
Test Response WithModified Alignments andMovements
Prone Lumbar extension1 in intensity of central LB sxs
No signs of lumbar extension2 in intensity of central LB sxs
Prone active kneeflexion
No change in status of symptoms
Prone active hiprotation
Lumbar extension and CCW pelvic rotation during movement of left hip intolateral rotation
Change in location of sxs from central LB, to central LB and left posterior thigh
No signs of lumbar extension orpelvic rotation
Left posterior thigh sxs eliminatedNo change in intensity of central
LB sxsProne active hip
extensionLumbar extension and CCW pelvic rotation during left hip extensionLumbar extension and CW pelvic rotation during right hip extensionChange in location of sxs from central LB in prone, to central LB and left
posterior thigh during extension of each hip
No signs of lumbar extension orpelvic rotation with modifiedtest for left and right hipextension
Left posterior thigh and central LBsxs eliminated with modifiedtest for left and right hipextension
Quadruped Preferred position with lumbar spine aligned in extension and lateral side bendrelative to neutral1 in intensity of central LB sxs
No signs of lumbar extension orlateral side bending
Central LB sxs eliminated
Quadruped activearm lift
No change in symptoms
Quadruped rockingbackward
No change in symptoms
Quadruped rockingbackward in fullflexion
No change in symptoms
Quadruped rockingforward
No change in symptoms
a Signs of direction-specific alignment or movement of the lumbar spine were recorded and modified only when associated with an increase in the patient’ssymptoms. Modification of each test item (third column) was accomplished with verbal cues, active stabilization by the patient, and manual stabilization by theexaminer to specifically restrict the symptom-related alignments or motions (second column) listed for each item. A complete description of each test item isprovided in the Appendix. Abbreviations: 15increase, 25decrease, LB5low back, sxs5symptoms, LE5lower extremity, CCW5counterclockwise (ie, forwardrotation of the right hip with backward rotation of the left hip), CW5clockwise (backward rotation of the right hip with forward rotation of the left hip).b “Self-selected alignments and movements” refers to alignments and movements of the lumbar spine that are observed when the patient initially assumes a testposition (eg, sitting) or performs a test movement (eg, forward bending) using his or her preferred movement strategy with no further instruction from theexaminer.c An “increase” in symptoms is defined as pain or paresthesias that were either produced, increased in intensity, or moved distally from the lumbar spine withassumption of a test position or performance of a test movement. A “decrease” in symptoms is defined as pain or paresthesias that either diminished in intensityor moved proximally toward the lumbar spine with assumption of a test position or performance of a test movement. “Eliminated” is defined as the absence ofsymptoms that were present during assumption of a previous test position or performance of a previous test movement.d “Central LB” refers to the region surrounding the spine extending from T12 to the gluteal fold.29
e “Neutral” is defined as that position of the lumbar spine at which an inclinometer centered over each lumbar spinous process would result in a measure of0 degrees, without rotation or side bending of any of the lumbar vertebrae.12
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tions of the forward bend exercise (Tab. 5), with addi-tional instructions to use this same technique each timeshe bent forward throughout the day, such as whenbrushing her teeth. A brief description of each exerciseand its functional correlate is provided in Table 5. Theimportance of maintaining a neutral or slightly flexedposition of the lumbar spine through active use ofabdominal muscles was emphasized. We believed thatthis position would prevent an increase in low back–related symptoms and facilitate strengthening of theabdominal muscles.
In addition to the exercise program, the patient wasinstructed in techniques that we believed wouldlengthen the hip flexors and improve gluteus mediusmuscle force production. While lying prone, the patientused a sheet positioned around her ankle to assist inpassively flexing her knee to the point at which sheperceived a gentle stretch in the anterior thigh. To avoidan increase in symptoms when positioned prone, thepatient initially was instructed to position 2 pillowsunder her abdomen, but eventually was able to performthis stretch in the absence of pillows without an increasein LBP. In an effort to improve gluteus medius muscle
Table 3.Pretreatment and Posttreatment Physical Impairment Measurementsa
Pretreatment Posttreatment
Lumbar spine excursion range of motion (ROM) (°)b
Flexion 30° 80°Extension 8° 45°Side bend right 34° 31°Side bend left 32° 24°
Muscle length (°) as indicated by ROMc
Hamstrings (R/L) 70/78 76/67Latissimus dorsi (R/L) 151/145 163/145Hip flexors (R/L)d 230/220 0/210
Muscle forcee
Hip medial rotators (R/L)c 41/42 41/4Tensor fascia lata (R/L)c 3/31 3/31Gluteus medius (R/L)c 3/4 31/31Lower abdominalsf NT 2
a Flexibility and force tests performed for all major lower-extremity muscle groups. Measurements listed only for those tests that revealed limitations. Twelve-weektime interval between pretreatment and posttreatment measurements.b Spinal range-of-motion measurements reflect excursion of the lumbar spine from a position of upright standing and were obtained using the 2-inclinometermethod with landmarks over the L1 and S2 spinous processes. Intrarater reliability for 3 examiners measuring 15 patients with low back pain has been reported torange from r5.13 to r5.85.34
c Tests performed as described by Kendall et al.35 R5right, L5left. The average intrarater reliability for 4 examiners performing upper- and lower-extremitygoniometric measurements on 12 male subjects without impairments has been reported to be r5.85.36
d The average intraclass correlation coefficient for indexing intrarater reliability for 2 examiners performing a modified version of the hip flexor length test asdescribed by Kendall et al35 on 10 subjects without impairments has been reported to be .82.37
e Muscle force grades were assigned using a modified Medical Research Council (MRC) grading scale,38 with grades ranging from 0 to 5. Weighted kappa values toindex the intrarater reliability for 4 examiners performing testing of proximal lower-extremity muscle groups according to the MRC scale in 102 patients withDuchenne muscular dystrophy ranged between .71 and .93.38 Substitution of hip flexors noted on testing of hip medial rotator, tensor fascia lata, and gluteusmedius muscles at pretreatment assessment only. (Note: all substitutions were corrected prior to assigning a manual muscle test grade.)f Lower abdominal muscle force test performed as described by Sahrmann.29 NT5not able to test because of pain.
Table 4.Test Items for Which Patient’s Symptoms Were Decreased or Eliminated With Restriction of Spinal Alignment or Movementa
Flexion Extension RotationRotation WithFlexion Rotation With Extension
No lumbar flexion associatedwith an increase insymptoms
Return from forwardbending
Prone
Side bending (left) No lumbar flexion withrotation associatedwith an increase insymptoms
Supine active single knee tochest (right)
Active hip lateral rotation (left)Active hip extension (bilateral)Quadruped
a Test items listed according to the specific direction of spinal alignment or movement that was restricted during performance of the modified test for each item(see Tab. 2). Classification is determined based on the category having the majority of test items in which symptoms are increased. Priority in determining the lowpack pain classification category is given to those tests in which the examiner is able to decrease or eliminate symptoms by restricting the specific direction ofspinal motion or alignment found to be associated with an increase in symptoms during the initial test.
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force, the patient was instructed in active hip lateralrotation and abduction performed while side lying. Aswith all other exercises, rotation and extension move-ments of the lumbar spine were specifically discouragedduring the performance of these 2 exercises. Followinginstruction in gait modifications that we believed wouldreduce the magnitude of rotation of the pelvis andlumbar spine (Tab. 5), a walking program was pre-scribed to improve aerobic fitness. The patient reportedthat modifying her gait reduced her symptoms immedi-ately following instruction. The patient declined referralto a urogynecologist regarding her symptoms of pelvicpain and cramping.
OutcomesThe patient completed 8 physical therapy sessions over a3-month period. The first 3 sessions were spaced 1 weekapart, with subsequent sessions once every 1 to 4 weeks.Her condition was assessed 3 months after dischargethrough a telephone interview and a mailed question-naire. A modified Oswestry Disability Questionnaire33
and a pain diagram were used to document patient-perceived progress once each month, with 1 exceptiondue to an administrative oversight. Patient scores on theOswestry Disability Questionnaire have been found to bereliable (Pearson r and intraclass correlation coefficients..90)33,41 as well as related to scores on other acceptedmeasures of disability in patients with LBP,42 an indica-tion of construct validity of the questionnaire. Reproduc-ibility of pain diagram responses in patients with chronicLBP has been documented.43 Concordance betweendefined disorders associated with LBP and diagnosesbased on pain diagram responses provides evidence ofvalidity of the pain diagram as a clinical tool.44 Physicalimpairment measurements were obtained by the firstauthor during the patient’s final therapy session forcomparison with initial values.
During her initial visit, the patient received instructionin activity modification only. In the week following thisvisit, the patient noted a reduction in both the frequencyand intensity of her symptoms. She reported a 75%decrease in the frequency of pain in the central low backregion and a 40% reduction in the frequency of symp-toms in the left lower extremity. She also reported thatthe average intensity of her symptoms was reduced from6/10 to 3.5/10 on a verbal pain scale, with no symptomspresent the day of her second session. When asked todescribe her activities during the past week, the patientnoted a substantial improvement in her ability to per-form household chores and in her overall tolerance forphysical activity. With the exception of sit-to-supinetransfers, we observed adherence to all activity modifica-tions taught in the initial therapy session throughout thesecond treatment session.
By her final therapy session, the patient no longerexperienced lower-extremity symptoms. She noted symp-toms localized to the central low back as typically beingless than 3/10 when present, with approximately 75% to80% of her week being symptom-free. She noted that theintensity of symptoms in the central low back regiongenerally increased with increasing fatigue. The patientwas able to independently demonstrate all prescribedexercises and activity modifications as instructed, with-out an increase in symptoms. She reported that shetypically performed her home exercise program oncedaily, and was walking 3.5 to 4.5 minutes each day on hertreadmill without an increase in low back–relatedsymptoms.
The modified Oswestry Disability Questionnaire33 con-tains items pertaining to both functional limitation anddisability and was used in this case to document func-tional progress. The patient’s pretreatment Oswestryscore of 43% dropped to 16% by her final therapysession. As interpreted by Fairbank et al,41 these scoresreflect a transition in function from severe disability tominimal disability. In the 3 months following dischargefrom outpatient physical therapy, the patient did notexperience an exacerbation of low back–related symp-toms and continued to make functional improvements.Specific examples of functional improvement noted bythe patient during the follow-up telephone interview at 3months included the ability to brush her teeth, get intoand out of her truck, and shop for over an hour withoutan increase in symptoms.
Less consistent changes were observed for measures ofmuscle force and joint flexibility (Tab. 3). Changesincluded what we believed to be indicators of increasedlength of the hip flexors, improved ability to use theabdominal muscles without an increase in pain, and anincrease in spinal flexion and extension range ofmotion. Hamstring muscle flexibility and spinal side-bending range of motion declined over the course oftreatment. Estimates of the intrarater reliability of dataobtained for these physical impairment measures areprovided in Table 3 to the extent that this information isavailable. However, due to the general lack of docu-mented reliability for many of the physical impairmentmeasures routinely used by clinicians, small changes inthe measurements should be interpreted with caution.
DiscussionNumerous interventions are available for patients withlow back–related disorders.45 The challenge for physicaltherapists is to identify the most appropriate interven-tion for each patient, based on the findings from astandardized examination. This task is difficult becausethe etiology of LBP is unknown in the majority of cases45
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Table
5.
Cat
egor
y-Sp
ecifi
cTr
eatm
entP
lana
Act
ivity
Funct
ionalI
nst
ruct
ion
bEx
erci
seIn
stru
ctio
nc
Do:
Do
Not:
Initia
l:Pro
gre
ssio
n:
Forw
ard
bend
ing/
retu
rnfro
mfo
rwar
dbe
ndin
g(e
g,br
ushi
ngte
eth,
was
hing
dish
es)
Con
tract
abdo
min
als
tosu
ppor
tspi
nein
neut
rald
orsli
ghtly
flexe
dal
ignm
ent
Flex
athi
pjo
ints
and
mai
ntai
nne
utra
lalig
nmen
tof
lum
bar
spin
ew
hile
bend
ing
forw
ard
Exte
ndat
hip
join
tsan
dm
aint
ain
neut
rala
lignm
ent
oflu
mba
rsp
ine
whi
lere
turn
ing
toth
eup
right
posi
tion
Arc
hLB
whe
nre
turn
ing
toth
eup
right
posi
tion
Sam
eas
mod
ified
forw
ard
bend
ing/
retu
rnfro
mfo
rwar
dbe
ndin
g(s
eeA
ppen
dix
for
patie
ntpo
sitio
nan
din
struc
tions
)(2)
Sam
eas
mod
ified
forw
ard
bend
ing/
retu
rnfro
mfo
rwar
dbe
ndin
gw
ithou
tuse
ofar
ms
tosu
ppor
tw
eigh
tofu
pper
both
(3)
Supi
neN
sitt
rans
fers
and
rolli
ng1.
Bend
knee
sby
slidi
ng1
heel
ata
time
tow
ard
body
.Gen
tlydi
ghe
elin
tosu
ppor
tsur
face
whi
lesli
ding
leg.
Con
tract
abdo
min
als
tosu
ppor
tsp
ine
soth
atLB
mai
ntai
nsco
ntac
twith
supp
ort
surfa
ceth
roug
hout
leg
mov
emen
t.A
void
arch
ing
LBw
ithle
gm
ovem
ent.
2.Ro
llon
tosi
dem
ovin
gth
een
tire
body
asa
sing
leun
it.A
void
twis
ting.
Use
arm
sto
push
toup
right
sitti
ngas
legs
drop
over
side
ofsu
ppor
tsu
rface
atth
esa
me
time.
Reve
rse
the
tech
niqu
eto
perfo
rmsi
tfsu
pine
trans
fers
.
Mov
edi
rect
lyfro
msu
pine
tolo
ng-si
tting
byfle
athi
pjo
ints
Liftb
oth
legs
sim
ulta
neou
slyfro
msu
ppor
tsur
face
Arc
hor
twis
tLB
whe
nm
ovin
gle
gsU
selu
mba
rro
llw
hen
sitti
ng
Sam
eas
step
1fo
rsu
pinef
sit
trans
fers
Perfo
rmw
ith2
pillo
ws
plac
edun
der
knee
ofsta
tiona
rylim
bto
help
mai
ntai
npe
lvic
and
lum
bar
alig
nmen
t(2)
Sam
eas
step
1fo
rsu
pinef
sit
trans
fers
Perfo
rmw
ithou
tpill
ows
(3)
Vehi
cle
trans
fers
Sito
ned
geof
seat
faci
ngdo
oran
dsc
oota
sfa
rba
ckas
poss
ible
,the
npi
vott
ofa
cefo
rwar
dw
hile
usin
gar
ms
tohe
lplif
tleg
sin
tove
hicl
e
Twis
ttru
nkw
hile
getti
ngin
toan
dou
tof
vehi
cle
Wal
king
Keep
hips
asle
vela
spo
ssib
leTa
kesm
alle
rste
psan
dre
duce
ampl
itude
ofar
msw
ing
tohe
lpav
oid
exce
ssiv
etw
istin
gof
pelv
isTa
kefre
quen
tsho
rtbr
eaks
ifw
alki
nglo
ngdi
stanc
esM
ove
feet
totu
rnbo
dyra
ther
than
twis
ting
trunk
Sing
le-li
mb
stanc
e:W
hile
stand
ing
on1
leg,
cont
ract
butto
cks
tom
aint
ain
leve
lpel
vis
and
avoi
dbe
ndin
gtru
nkto
eith
ersi
deH
old
onto
high
coun
ter
orch
air
back
toas
sist
with
bala
nce
Perfo
rmin
front
ofm
irror
tom
onito
rpe
rform
ance
(3)
Sing
le-li
mb
stanc
e:W
hile
stand
ing
on1
leg,
cont
ract
butto
cks
tom
aint
ain
leve
lpel
vis
and
avoi
dbe
ndin
gtru
nkto
eith
ersi
dePe
rform
with
outs
uppo
rtof
arm
s(5
)
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Table
5.
Con
tinue
d
Act
ivity
Funct
ionalI
nst
ruct
ion
bEx
erci
seIn
stru
ctio
nc
Do:
Do
Not:
Initia
l:Pro
gre
ssio
n:
Ove
rhea
dan
dcr
oss-b
ody
reac
hing
(eg,
reac
hing
for
item
slo
cate
din
over
head
cabi
nets,
reac
hing
for
item
sno
tdire
ctly
infro
ntof
body
,rai
sing
arm
sov
erhe
adto
don/
doff
shirt
,ra
isin
gar
ms
tow
ash
orsty
leha
ir)
Con
tract
abdo
min
als
tosu
ppor
tspi
nein
neut
ral
alig
nmen
twhe
nm
ovin
gar
ms
Whe
neve
rpo
ssib
le,s
tand
dire
ctly
infro
ntof
anite
mbe
fore
reac
hing
Arc
hLB
whe
nre
achi
ngov
erhe
adTw
istL
Bw
hen
reac
hing
acro
ssbo
dy
1.W
hile
sitti
ngin
astr
aigh
t-bac
kch
air,
with
LBsu
ppor
ted,
begi
nw
ithsh
ould
ers
and
elbo
ws
bent
to90
°,pa
lms
faci
ngto
war
dyo
uan
del
bow
sfa
cing
forw
ard.
Rais
ebo
thar
ms
over
head
whi
leco
ntra
ctin
gab
dom
inal
sso
that
LBm
aint
ains
cont
actw
ithsu
ppor
tsu
rface
durin
gar
mm
otio
n.(3
)2.
Whi
lesi
tting
ina
strai
ght-b
ack
chai
r,w
ithLB
supp
orte
d,be
gin
with
1ar
mov
erhe
ad,h
oldi
nga
0.9-
kg(2
-lb)w
eigh
t.Lo
wer
arm
dow
nac
ross
body
tow
ard
oppo
site
hip.
Con
tract
abdo
min
als
soth
atLB
and
pelv
ism
aint
ain
cont
actw
ithsu
ppor
tsu
rface
.(6)
Perfo
rmex
erci
se1
whi
lesta
ndin
g,w
ithLB
supp
orte
dag
ains
taw
all
and
pelv
istil
ted
poste
riorly
(4)
Perfo
rmex
erci
se2
whi
lesta
ndin
g,w
ithLB
supp
orte
dag
ains
taw
all,
and
pelv
istil
ted
poste
riorly
(7)
Sitti
ngSi
twith
LBei
ther
inne
utra
lor
sligh
tlyfle
xed
alig
nmen
tU
seth
ech
air
back
for
supp
ort
Supp
ortf
eetw
hile
sitti
ng.R
elax
legs
and
letc
hair
supp
ortt
hew
eigh
toft
high
s.C
ross
legs
atan
kles
rath
erth
anat
thig
hsto
avoi
dpe
lvic
rota
tion
Take
frequ
entb
reak
sby
stand
ing
upor
perfo
rmin
ga
“pus
h-up
”fro
mch
air
(ie,p
ush
dow
non
arm
rests
tolif
tbut
tock
sfro
mch
air
seat
)
Sitf
orw
ard
oned
geof
chai
ror
plac
ea
lum
bar
roll
behi
ndLB
Boun
cele
gsre
peat
edly
whi
lesi
tting
orle
tle
gsda
ngle
unsu
ppor
ted
Poste
rior
pelv
ictil
tsw
hile
seat
ed(2
)
aT
he
pati
ent
was
inst
ruct
edto
inco
rpor
ate
tech
niq
ues
for
fun
ctio
nal
acti
vity
mod
ific
atio
nin
tope
rfor
man
ceof
daily
acti
viti
es.
Inad
diti
onto
exer
cise
slis
ted
inta
ble,
the
hom
eex
erci
sepr
ogra
m(H
EP)
incl
uded
perf
orm
ance
ofth
em
odif
ied
vers
ion
ofea
chsy
mpt
om-p
rovo
kin
gm
ovem
ent
test
desc
ribe
din
Tab
le2,
asw
ell
asex
erci
ses
tole
ngt
hen
the
hip
flex
ors
and
impr
ove
glut
eus
med
ius
mus
cle
stre
ngt
h.
Th
epa
tien
tw
asin
itia
llyin
stru
cted
tope
rfor
m6
to8
repe
titi
ons
ofea
chex
erci
se,
2to
3ti
mes
daily
(wit
hth
eex
cept
ion
ofh
ipfl
exor
stre
tch
,w
hic
hw
aspe
rfor
med
twic
eda
ilyfo
r3
to5
repe
titi
ons,
last
ing
30se
con
dsea
ch).
Inte
rmit
ten
tpe
rfor
man
ceof
are
lati
vely
low
num
ber
ofre
peti
tion
sw
asch
osen
inor
der
toav
oid
mus
cle
fati
gue
and
toop
tim
ize
mot
orle
arn
ing
thro
ugh
ran
dom
prac
tice
sess
ion
s.A
sth
epa
tien
t’s
endu
ran
ceim
prov
ed,
the
num
ber
ofre
peti
tion
sfo
rea
chex
erci
sew
asin
crea
sed
to10
to15
repe
titi
ons
per
sess
ion
.A
wal
kin
gpr
ogra
mw
asin
itia
ted
inth
eth
ird
ther
apy
sess
ion
.L
B5
low
back
.b
All
fun
ctio
nal
inst
ruct
ion
sw
ere
prov
ided
duri
ng
init
ial
visi
tan
dw
ere
revi
ewed
peri
odic
ally
acro
ssth
e8
trea
tmen
tse
ssio
ns.
cN
umbe
rin
pare
nth
eses
indi
cate
atw
hic
hvi
sit
the
pati
ent
rece
ived
inst
ruct
ion
inea
chex
erci
se(8
visi
tsto
tal)
.In
gen
eral
,ex
erci
ses
wer
epr
ogre
ssed
wh
enth
epa
tien
tw
asab
leto
perf
orm
atle
ast
10to
15re
peti
tion
sof
init
ial
exer
cise
wit
hou
tve
rbal
orm
anua
lcu
esfr
omth
eth
erap
ist.
Inn
oca
sew
asan
exer
cise
prog
ress
edif
the
pati
ent
was
unab
leto
dem
onst
rate
the
mod
ifie
dex
erci
seas
inst
ruct
edan
dw
ith
out
anin
crea
sein
sym
ptom
s.U
pon
disc
har
ge,
the
pati
ent
was
enco
urag
edto
adh
ere
tofu
nct
ion
alac
tivi
tym
odif
icat
ion
sin
defi
nit
ely
topr
even
ta
recu
rren
ceof
sym
ptom
s.W
eal
sosu
gges
ted
that
she
rem
ain
phys
ical
lyac
tive
byco
nti
nui
ng
her
HE
Pan
dw
alki
ng
prog
ram
atle
ast
once
daily
.d
“Neu
tral
”is
defi
ned
asth
atpo
siti
onof
the
lum
bar
spin
eat
wh
ich
anin
clin
omet
erce
nte
red
over
each
lum
bar
spin
ous
prog
ress
wou
ldre
sult
ina
mea
sure
of0
degr
ees,
wit
hou
tro
tati
onor
side
ben
din
gof
any
ofth
elu
mba
rve
rteb
rae.
12
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and the relationship between physical impairment anddisability in this population remains largely undefined.19
Our case report describes an intervention that waschosen based on the evaluation of spinal alignment withpostures and spinal motions during active movement ofboth the spine and extremities. Given the documentedlack of association between LBP and various traditionalmeasures of physical impairment,23 we sought to identifya particular pattern of spinal motions and alignmentsthat appeared to be directly associated with a worseningof symptoms across several test positions. We then basedintervention on modification of symptom-producingmotions and alignments of the lumbar spine during therepetition of daily activities. Despite modest changes inmeasures of physical impairment (Tab. 3), the patientdescribed in this case report exhibited what we considera substantial and consistent reduction in low back–related functional limitations and disability (Figure)over the course of treatment. In addition, the mostdramatic reduction in low back–related symptomsoccurred following the first therapy session, in which theonly treatment provided was category-specific instruc-tion in activity modification.
Waddell et al46 found a strong association between lowback–related disability and fear-avoidance beliefs, or theextent to which patients avoid activity based on theanticipation of pain. Waddell et al suggested that restrict-ing the activity of patients with LBP might serve only toreinforce fear-avoidance beliefs and increase thechances of subsequent disability. The benefits of main-taining customary activity levels in patients with LBP hasbeen substantiated by the findings of Malmivaara et al.47
These investigators found that subjects with LBP whowere advised to continue their usual routine as toleratedrecovered more quickly than those who were prescribedeither 2 days of complete bed rest or back mobilizingexercises.
Teaching patients specific strategies to reduce the symp-toms associated with movements can enable them toperform activities that they might otherwise avoid. We
believe that one of the primary advantages of the classi-fication system described in this case report is that itallows physical therapists to make recommendations foractivity modification that are specific to the symptom-provoking postures and movements of each patient. Wepropose that exercise prescription and generic posturalinstruction may be less effective in addressing restric-tions of function in patients with LBP than is individu-alized instruction in symptom-reducing strategies forpositioning and functional movement. The patientdescribed in this report, for example, was instructed inways to avoid rotation and extension of the lumbar spineduring daily activities. The use of a lumbar roll is oneexample of a generic therapeutic modality that wasdiscouraged in this case because it would have contrib-uted to spinal extension, an alignment found to beassociated with an increase in this patient’s symptoms.Greater individualization of back care programs may beneeded to facilitate patient adherence.21 The patientdescribed in this case report noted the greatest adher-ence to exercises and activity modifications that could beeasily incorporated into her daily routine, such as thoserelated to forward bending, walking, and sitting up inbed (Tab. 5).
The treatment approach described in this case report isfounded on the notion that the repetition of direction-specific movements and postures of the lumbar spinecan exacerbate low back–related symptoms and prolongrecovery. The patient exhibited a consistent tendencytoward lumbar rotation and extension, which wasobserved during examination of movements and pos-tures across several positions as well as during theperformance of functional tasks (eg, sit-to-supine trans-fers) and personal habits (eg, “nervous legs”). We haveobserved that the propensity for spinal motion to occurin a given direction varies among individuals, and wespeculate that this variation may be partly related toindividual variations in motor recruitment patterns. Thisidea is consistent with reports of high intersubject vari-ability in trunk muscle activity patterns during a givenmovement.48,49 Based on the results of an investigationinto the effects of fatigue on trunk motion, Parnianpouret al50 suggested that the loss of muscular coordinationassociated with fatigue may diminish spinal stability andallow loading of the spine in a more injury-pronepattern. The patient in this case report commented thatshe found it more difficult to control the position of herspine and pelvis when she was tired, and she associatedan increase in her symptoms with fatigue.
We also have observed that variations in occupationaland recreational activity demands appear to contributeto individual differences in direction-specific motionsand alignments of the lumbar spine. We suggest that thismay be related to changes in supportive structures of the
Figure.Modified Oswestry Disability Questionnaire33,41 scores reported bypatient across study period.
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spine that occur with repeated stresses in a given direc-tion over time. A relationship between repetitive spinalmotion and LBP is suggested by epidemiologic studiesthat have identified repetition of non-neutral trunkpostures as a risk factor for the development of LBP.51 Inaddition, Gordon et al52 have shown that repetitiveloading of spinal segments positioned in a slight amountof flexion and rotation results in pathological changes inthe intervertebral disk of the in vitro human spine.
Causal relationships cannot be established on the basisof a case report. Symptoms associated with disorders ofthe low back typically resolve within 6 weeks of onset,and only 5% of individuals have symptoms that persistlonger than 3 months.51 The LBP episode described inthis case report began 10 weeks prior to the patient’sinitial therapy visit to our facility, which is beyond thetime frame typically associated with natural resolution ofLBP. Improvement in both functional ability and symp-tom reduction coincided with the initiation of treatmentat our facility. The patient did not experience a recur-rence of low back–related symptoms in the 3 monthsfollowing discharge from our clinic, during which timeshe continued her home exercise program and activitymodifications. Together, these observations suggest thatour approach may have positively influenced thepatient’s recovery. This does not, however, rule out thepossibility that the patient might have recovered sponta-neously, or responded equally well to another therapeu-tic approach.
In any isolated case, there are several factors other thanthe intervention that might account for the observedoutcomes. Aerobic training has been reported to be ofbenefit in the treatment of many disorders, includingthose related to the low back.53 Based on reports of theefficacy of aerobic training, a walking program wasprescribed during the third treatment session. It seemsunlikely that the observed outcomes can be attributed toan improvement in aerobic conditioning, however, giventhat the patient remained unable to ambulate for morethan 5 minutes at one time without becoming short ofbreath. It might be argued that improvements in hipflexor muscle length could be largely responsible forhelping to reduce the patient’s symptoms, as lower-extremity flexibility is a commonly addressed impair-ment in the treatment of LBP. To our knowledge,however, prospective studies have failed to demonstratea consistent correlation between LBP and hip flexortightness.27,54 Because the psoas major muscle is knownto impart substantial compressive forces on the lumbarspine,55 it is conceivable that discouraging the activerecruitment of this muscle may have influenced theobserved outcome.
Further research is needed to determine the validity andclinical feasibility of the system of classification describedin this case report. The theoretical assumptions onwhich the approach was founded should be investigatedto determine construct validity. For instance, is it truethat the lumbar spine can become predisposed to exces-sive movement in a given direction when subjected torepeated stresses in that direction? Examination ofwhether the proposed classification categories are mutu-ally exclusive and appropriate for use in a rehabilitationcontext will be necessary to establish content validity. Forexample, can any patient referred to a physical therapistfor the treatment of LBP be classified into 1 of the 5proposed categories, or does this classification systemdescribe a more limited patient population, such asthose with chronic LBP? If the predictive validity of thissystem could be appropriately demonstrated, then webelieve physical therapists could make a substantialcontribution to preventative health care. Individualscould be screened for patterns of spinal motion andalignment that may increase the risk of developingmechanical LBP, and they could be provided with spe-cific instruction regarding the modification of suchpatterns. Other areas of future research should includecontrolled clinical trials to establish the relative efficacyof individualized versus generic functional instruction,as well as to determine the optimal approach for improv-ing rehabilitation outcomes for patients with LBP.
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2000; 80:1097-1111.PHYS THER. DillenKatrina S Maluf, Shirley A Sahrmann and Linda R VanPainManagement of a Patient With Chronic Low Back Use of a Classification System to Guide Nonsurgical
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