Ryan Tauzell, MA, PT, Cert. MDT Slide 2 Disclosures None Slide 3
History 1944 Knuttson: Method of diagnosing segmental instability
by measuring sagittal plane translation and rotation with lateral
flexion/extension radiographs, then compared to normal ranges Slide
4 History 1944 Knuttson: Method of diagnosing segmental instability
by measuring sagittal plane translation and rotation with lateral
flexion/extension radiographs, then compared to normal ranges Slide
5 History 1990 White and Panjabi: Defined criteria for diagnosing
instability -Sagittal translation > 4.5mm, or > 15% vertebral
body width -Sagittal rotation > 15 o at L1-2, L2-3, or L3-4,
> 20 o at L4-5 or 25 o at L5-S1 1944 Slide 6 History 1990 White
and Panjabi: Defined criteria for diagnosing instability -Sagittal
translation > 4.5mm, or > 15% vertebral body width -Sagittal
rotation > 15 o at L1-2, L2-3, or L3-4, > 20 o at L4-5 or 25
o at L5-S1 1944 Slide 7 History 1990 Panjabi: presents a conceptual
model of the spinal stabilization system, the neutral zone and
clinical instability 1944 1992 Slide 8 History 1990 Panjabi:
presents a conceptual model of the spinal stabilization system, the
neutral zone and clinical instability 1944 1992 Slide 9 History
1990 Multiple studies on lumbar clinical instability and its role
in LBP How far have we come in nearly 70 years? 1944 1992Today
Slide 10 Definitions Clinical Instability (Panjabi, 1992) A
significant decrease in the capacity of the stabilizing system of
the spine to maintain the intervertebral neutral zones within the
physiological limits so that there is no neurological dysfunction,
no major deformity, and no incapacitating pain Slide 11 Active
Neural Control Passive Stabilization System (3 Subsystems)
Vertebrae Facets Discs Ligaments Muscles Tendons CNS Nerves
Feedback System Slide 12 Subsystem Dysfunction? Active Neural
Control Passive Compensatory response from other subsystems Slide
13 Response to Subsystem Dysfunction Active Neural Control Passive
Conceptual Response 1.Immediate successful compensation from other
subsystems 2.Long-term compensation from one or more subsystems
3.Injury to one or more subsystems Conceptual Outcome Normal
Function Normal function with altered stabilization system Overall
system dysfunction, LBP Slide 14 Definitions Clinical Instability
(Panjabi, 1992) A significant decrease in the capacity of the
stabilizing system of the spine to maintain the intervertebral
neutral zones within the physiological limits so that there is no
neurological dysfunction, no major deformity, and no incapacitating
pain Slide 15 Neutral Zone That part of the range of the
intervertebral motion, measured from the neutral position, within
which the spinal motion is produced with a minimal internal
resistance. (Panjabi) Zone of high flexibility or laxity Slide 16
Elastic Zone That part of the physiological intervertebral motion,
measured from the end of the neutral zone up to the physiological
limit. Zone of high stiffness/resistance Slide 17 Diagram of IV
movement (Biely et al.) High Laxity High Resistance Neutral Zone +
Elastic Zone = Physiological ROM Zone ROM Weakness or Injury Zone
ROM Strengthening, Osteophytes, Fusion Slide 18 Theoretical
Construct Slide 19 Definitions Radiographic Instability: No
standardized definition Slide 20 Radiographic Limitations Lateral
Flexion/Extension: No standardized procedure False positives
Variation in asymptomatic subjects Variable limits for cutoff
values to diagnose instability Slight variation in patient position
of direction of beam can produce 10%- 15% variation in displacement
measure Provides no information about the active and neural
components Provides no information on what is occurring within
range Can not reliably correlate abnormal image to pain/disability
Clinical instability can exist without radiographic evidence of
instability Slide 21 Are assessment protocols/tools available to
accurately/reliably diagnose clinical instability? Once clinical
instability is diagnosed, is there agreement on an established
treatment? What is the best treatment for lumbar instability?
Validity of Clinical Instability Spratt KF, Weinstein JN. Chapter
25: Measuring clinical outcomes. In: Weisel S, ed. The Lumbar
Spine. 2nd ed. v. 2. Philadelphia: W.B. Saunders Co.,
1996:1313-1338 Slide 22 Prevalence Depending on the cutoff limits
and the study 12% of patients manually assessed for lumbar
segmental instability (Abbott JH, McCane B, Herbison P, Moginie G,
Chapple C and Hogarty T. Lumbar segmental instability: a
criterion-related validity study of manual therapy assessment. BMC
Musculoskeletal Disorders. 2005;6:56. http://dx.doi.org/
doi:10.1186/1471-2474-6-56) 57% patients referred for flex/ext
radiographs based on suspicion of instability (Fritz JM, Piva SR,
Childs JD. Accuracy of the clinical examination to predict
radiographic instability of the lumbar spine. Eur Spine J.
2005;14:743-750. http://dx.doi.org/10.1007/s00586-004-0803-4)
http://dx.doi.org/10.1007/s00586-004-0803-4 Slide 23 Is Lumbar
Instability a Valid Subgroup? Abbott et al. (2006) concluded lumbar
segmental mobility disorders are a valid means of defining
sub-groups within NSLBP in a conservative care population of
patients with recurrent CLBP Prospective cohort of 138 consecutive
patients with RCLBP, Roland Morris and VAS scores obtained Sagittal
angular rotation and translation of each lumbar segment was
measured on radiograph then compared to reference range derived
from a study of 30 asymptomatic volunteers Lumbar Segmental
Mobility Disorder (LSMD) defined as 2sd from reference mean Normal
reference intervals developed using 2 models (Gaussian, novel
normalized within-subjects) Rotational Instability: 23%
Translational Instability: 32% Slide 24 Is Lumbar Instability
Associated with pain/disability? LSMDs are a valid means of
defining sub-groups within NSLBP Abbott et al.(2006): Among
patients with RCLBP, presence of any LSMD, regardless of how
defined, does not appear to be strongly associated with greater
levels of pain or disability compared to patients with other forms
of NSLBP without LSMDs Slide 25 Assessment to Diagnosis Abdullah et
al. Clinical Test to Diagnose Lumbar Segmental Instability: A
Systematic Review Hicks et al. Interrater Reliability of Clinical
Examination Measures for Identification of Lumbar Segmental
Instability Hicks et al. Preliminary Development of a Clinical
Prediction Rule for Determining Which Patients With LBP Will
Repsond to a Stabilization Exercise Program Abbott et al. Lumbar
Segemental Mobility Disorders: Comparison of Two Methods of
Defining Abnormal Displacement Kinematics in a Cohort of Patients
with NSLBP Demoulin et al. Lumbar Functional Instability: A
Critical Appraisal of the Literature Fritz et al. Accuracy of the
Clinical Examination to Predict Radiographic Instability of the
Lumbar Spine Abbott et al. Lumbar Segmental Instability: A
Criterion-Related Validity Study of Manual Therapy Assessment Cook
et al. Subjective and Objective Descriptors of Clinical Lumbar
Spine Instability: A Delphi Study Kasai et al. A New Evaluation
Method for Lumbar Spinal Instability: Passive Lumbar Extension Test
Slide 26 Study Mix Prospective Cohorts: 5 Single group repeated
measure interrater reliability study: 1 Critical Appraisal of
Literature: 1 Delphi Study: 1 Systematic Review: 1 Slide 27
Assessment to Diagnosis Tests/Criteria Available
HistoryPassiveActive Age less than 40Beighton Ligamentous Laxity
ScaleProne Instability Test Giving way Giving out Catching Locking
Avg SLR > 91 o Aberrant Motions Temp. Relief with bracingPassive
Lumber Extension TestTotal Flexion > 53 o Self
manipulatorPosterior Shear TestTotal Extension > 26 o Pain with
transitionsPAIVMSit to stand test Pain with sudden movementPPIVM
(flexion)Instability Catch Sign Difficulty sitting unsupportedPPIVM
(extension)Painful Catch Sign Difficulty with static positionsStep
offApprehension Sign Frequent muscle spasmsLack of
hypomobilityGowers Sign Fear with movementSegmental Hinging
Recurrent episodesReversal of Lumbopelvic Rhythm Progressively
worsening Slide 28 Assessment to Diagnosis Tests/Criteria with high
+LR (Diagnostic Accuracy) HistoryPassiveActive Age less than 40
(3.7)Beighton Ligamentous Laxity Scale (2.5)Prone Instability Test
(1.7) Giving way Giving out Catching Locking Avg SLR > 91 o
(3.3)Aberrant Motions (1.6) Temp. Relief with bracingPassive Lumber
Extension Test (8.8)Total Flexion > 53 o (1.3) Self
manipulatorPosterior Shear Test (1.1)Total Extension > 26 o Pain
with transitionsPAIVM (2.4)Sit to stand test (infinite, selection
bias) Pain with sudden movementPPIVM (flexion) (8.7, 95% CI: 0.6,
134.7)Instability Catch Sign (1.8) Difficulty sitting
unsupportedPPIVM (extension) (7.1, 95% CI: 1.7, 29.2)Painful Catch
Sign (1.4) Difficulty with static positionsStep offApprehension
Sign (1.6) Frequent muscle spasmsLack of hypomobility with PA
(5.0)Gowers Sign Fear with movement (1.4)Segmental Hinging
Recurrent episodesReversal of Lumbopelvic Rhythm Progressively
worsening +LRShift in Probability >10Large 5-10Moderate 2-5Small
1-2Very small Slide 29 Assessment to Diagnosis Tests/Criteria with
high reliability HistoryPassiveActive Age less than 40Beighton
Ligamentous Laxity ScaleProne Instability Test (k=0.69-0.87) Giving
way Giving out Catching LockingAvg SLR > 91 o Aberrant Motion
with Trunk Motion (k=- 0.07,0.60) Temp. Relief with bracingPassive
Lumber Extension Test (high test- retest reliability, however no k
value) Total Flexion > 53 o Self manipulatorPosterior Shear Test
(k=0.27)Total Extension > 26 o Pain with transitionsPAIVM
hypermobile (k=0.48) hypo (k=0.38)Sit to stand test Pain with
sudden movementPPIVM (flexion) (-0.02, 0.26)Instability Catch Sign
Difficulty sitting unsupportedPPIVM (extension) (-0.02,
0.26)Painful Catch Sign Difficulty with static positionsStep
offApprehension Sign Frequent muscle spasmsLack of hypomobility
with PA (k=0.30)Gowers Sign Fear with movementSegmental Hinging
Recurrent episodesReversal of Lumbopelvic Rhythm Progressively
worsening Slide 30 Assessment to Diagnosis Tests/Criteria Available
(Multivariate) Hicks GE, Fritz JM, Delitto A, McGill SM.
Preliminary development of a clinical prediction rule for
determining which patients with low back pain will respond to a
stabilization exercise program. Arch Phys Med Rehabil
2005;86:1753-1762. Variables in the Clinical Prediction Rule (CPR)
for success with stabilization treatment 1. Age less than 40 y/o 2.
(+) Prone Instability Test (k=0.69, 0.87) 3. (+) Aberrant Movements
(k=0.07,0.60) 4. Avg SLR > 91 o (ICC 0.87-0.96) No. of Variables
Present +LR 1 or more1.3 (1.0-1.6) 2 or more1.9 (1.2-2.9) 3 or
more4.0 (1.6-10.0) No reliability score available for 3 or more
tests, however Kappa for PIT, SLR and Aberrant Motions listed
above. If Aberrant Movements are among the 3 tests, reliability
would decrease significantly, along with validity Slide 31
Assessment to Diagnosis Tests/Criteria Available (Multivariate)
Hebert JJ, Koppenhaver SL, Magel JS, Fritz JM. The relationship of
transversus abdominis and lumbar multifidus activation and
prognostic factors for clinical success with a stabilization
exercise program: a cross-sectional study. Arch Phys Med Rehabil
2010;91:78-85. Predictors of clinical success with a spinal
stabilization exercise program 1. (+) Prone Instability Test
(k=0.69, 0.87) 2. (+) Aberrant Movement (k=0.07,0.60) 3. Avg. SLR
> 90 o (ICC 0.87-0.96) 4. (+) Hypermobility with PA (k=0.30) #
of prognostic factors = LM activation No relation between
prognostic factors and TrA No Sn/Sp calculated, No LRs No. +
Prognostic Factors The role of LM in spinal stabilization is
controversial Slide 32 Assessment to Diagnosis Summary The Passive
Lumber Ext Test is not validated, however comes the closest General
consensus of nearly all studies is that diagnosis should not occur
with one clinical test, but rather a cluster of signs/tests Does
using multiple unreliable, inaccurate tests add clarity? Lack of
correlation between radiographic findings and clinical symptoms
increases uncertainty If a diagnosis can not reliably and
accurately be established, can there be agreement on treatment?
Slide 33 Validity of Clinical Instability Are assessment
protocols/tools available to accurately/reliably diagnose clinical
instability? Once clinical instability is diagnosed, is there
agreement on an established treatment? What is the best treatment
for lumbar instability? Slide 34 Diagnosis to Treatment Agreement
on established treatment? Several studies agree Stabilization
exercise Stabilizing Exercise Trunk Muscle Stabilization Training
How this is carried out varies considerably Concentric, Eccentric,
Isometric Muscle Firing, Sequencing, Patterning Position,
Resistance, Reps Progression Feedback: US, EMG, Tactile, Visual
Slide 35 Diagnosis to Treatment Agreement on established treatment?
The most frequently cited study for exercise protocol: Richardson
CA, Jull GA. Muscle control pain control. What exercises would you
prescribe? Manual Therapy 1995;1:2-10. Isometric co-contraction of
the TrA and Multifidus with a static neutral spine Focus on precise
muscle action with re-education of this contraction in: Quadriped
Prone Upright positions Eventual functional training Slide 36
Diagnosis to Treatment Is Stabilization Exercise doing what we
think it is? McGill et al. proposed that no single muscle is the
best stabilizer of the spine. Multiple muscles are required
dependent on the task. This muscle activation produces stability:
Muscles acting as guywires Compression/Loading through antagonistic
activity Stokes et al. : Analytical study of a biomechanical model
Spinal Stability increased with increased intra-abdominal pressure
(IAP) Forced component activation of abdominals decreased lumbar
stability IAP generates an extension moment Can this extension
moment inadvertently have an effect? Slide 37 Diagnosis to
Treatment Summary Spinal Stabilization Specific Muscle
Activation/Recruitment/Firing Gross core activation Intra-Abdominal
Pressure Other / All A general framework of treatment Slide 38
Validity of Clinical Instability Are assessment protocols/tools
available to reliably diagnose clinical instability? Once clinical
instability is diagnosed, is there agreement on an established
treatment? What is the best treatment for lumbar instability? Slide
39 Treatment to Outcome Diagnosed Radiographic Instability
OSullivan (1997): patients with CLBP and radiologic diagnosis of
spondylolysis or spondylolisthesis. Results: A specific exercise
approach decreased pain/disability/pain medication use
significantly more than other commonly prescribed conservative
treatment programs in patients with chronically symptomatic
spondylolysis/spondylolisthesis. Kumar (2011):patients with lumbar
segmental instability. Results: Segmental stabilization exercise
was more effective than placebo intervention in symptomatic lumbar
segmental instability. OSullivan (2011) Editorial:instability
should be reserved solely for unstable fractures and unstable
spondylolisthesis. Slide 40 Koumantakis (2005): patients with RCLBP
and no clinical signs suggesting spinal instability Conclusion:
Stabilization exercises do not appear to provide additional benefit
to patients with subacute or CLBP who have no clinical signs
suggesting the presence of spinal instability Rachwitz
(2006):patients with acute, subacute and CLBP Conclusion: For LBP,
segmental stabilizing exercises are more effective than treatment
by GP (walking, stretching, swimming, education, active rest, out
of work, traction, STM), but they are not more effective than other
physiotherapy interventions. Macedo (2012):patients with CLBP
Conclusion: The results of this study suggest that motor control
exercises and graded activity have similar effects for patients
with chronic nonspecific low back pain. Treatment to Outcome
Absence of Instability Slide 41 Recurrence Hides JA, Jull GA,
Richardson CA. Long-term effects of specific stabilizing exercises
for first-episode low back pain. Spine 2001;26:243-248 1 and 3 year
follow-up of exercise group (Richardson,Jull) vs. control group
after acute, first-episode LBP. 1 year after treatment: specific
exercise recurrence was 30%, control was 84% 2-3 years after
treatment: specific exercise recurrence was 35%, control was 75%
Patients of both groups most commonly reported precipitating
incidents of recurrence related to lifting Lifting is a
flexion-based movement DP was not ruled out initially Prevalence
data shows that up to 90% of patients with acute LBP have a DP
Slide 42 Validity of Clinical Instability Are assessment
protocols/tools available to accurately/reliably diagnose clinical
instability? Once clinical instability is diagnosed, is there
agreement on an established treatment? What is the best treatment
for lumbar instability? Slide 43 Stabilization Exercise may be
effective Cloudy ADTO Linkage Instability may be a valid subgroup
Slide 44 Where do I start? With the suspicion of instability
(history) Cook C, Brismee JM, Sizer PS. Subjective and objective
descriptors of clinical lumbar spine instability: a delphi study.
Manual Therapy 2006;11:11-21 122 PTs with OCS and/or FAAOMPT
training responded fully to create a consensus on the subjective
and objective symptoms associated with clinical instability of the
spine. Ranked lists of subjective and object reports were created
Fritz (2005):patients with LBP referred for flexion-extension
radiographs due to suspicion of lumbar instability Conclusion:
Prevalence is much higher in this study (57%) compared to other
studies. Slide 45 1. Reports feeling of giving way or back giving
out 2. Self manipulator who feels the need to frequently crack or
pop the back 3. Frequent bouts or episodes of symptoms 4. History
of painful catching or locking during twisting or bending of the
spine 5. Pain during transitional activities (e.g. sit to stand) 6.
Greater pain returning to erect position from flexion 7. Pain
increased with sudden, trivial, or mild movements 8. Difficulty
with unsupported sitting and better with supported backrest 9.
Worse with sustained postures and a decreased likelihood of
reported static position that is not painful 10. Condition is
progressively worsening (e.g. shorter intervals between bouts) Top
10 subjective reports associated with clinical instability Slide 46
What Can I Do Monday? History that suggests instability, +/-
radiographic diagnosis Catching / Locking / Giving out / Pain with
sudden movements Rule out Directional Preference If DP can be ruled
out, history suspicious of instability becomes more relevant
Perform tests, use criteria with the best available evidence
(diagnostic accuracy/reliability) Passive Lumbar Extension Test Age
< 40 y/o Avg SLR > 91 o Perform Lumbar Stabilization Exercise
per Richardson and Jull Progress to patient specific functional
limitations Slide 47 References 1. Nizard RS, Wybler M, Laredo JD.
Radiologic assessment of lumbar intervertebral instability and
degenerative spondylolisthesis. Radiol Clin North Am 2001;39:55-71
2. Cook C, Brismee JM, Sizer PS, Jr. Subjective and objective
descriptors of clinical lumbar spine instability: a Delphi study.
Manual Therapy 2006;11:11-21 3. Hides JA, Richardson CA, Jull G.
Multifidus muscle recovery is not automatic after resolution of
acute, first-episode low back pain. Spine 1996;21:2763-2769 4.
Hides JA, Jull GA, Richardson CA. Long-term effects of specific
stabilizing exercises for first-episode low back pain. Spine
2001;26:E243-E248 5. Fritz JM, Piva SR, Childs JD. Accuracy of the
clinical examination to predict radiographic instability of the
lumbar spine. Eur Spine J 2005;14:743-750.
DOI:10.1007/s00586-004=0803-4 6. OSullivan PB, Twomey LT, Allison
GT. Evaluation of specific stabilizing exercise in the treatment of
chronic low back pain with radiologic diagnosis of spondylolysis or
spondylolisthesis. Spine 1997;22:2959-2967 7. Kumar SP. Efficacy of
segmental stabilization exercises for lumbar segmental instability
in patients with mechanical low back pain: a randomized placebo
controlled crossover study. N Am J Med Sci 2011;3:456-461. doi:
10.4297/najms.2011.3456 8. Koumantakis GA, Watson PJ, Oldham JA.
Trunk muscle stabilization training plus general exercise versus
general exercise only: randomized controlled trial of patients with
recurrent low back pain. Physical Therapy 2005;85:209-225. 9.
OSullivan P. (Editorial) Its time for change wit h the management
of non-specific chronic low back pain. Br J Sports Med 2011.
doi:10.1136/bjsm.2010.081638 10. Hicks GE, Fritz JM, Delitto A,
McGill SM. Preliminary Development of a clinical prediction rule
for determining which patients with low back pain will respond to a
stabilization exercise program. Arch Phys med Rehabil
2005;86:1753-1762 11. McGill SM, Grenier S, Kavcic N, Cholewicki J.
Coordination of muscle activity to assure stability of the lumbar
spine. Journal of Electromyography and Kinesiology 2003;13:353-359
12. Wallwork TL, Stanton WR, Freke M, Hides JA. The effect of
chronic low back pain on size and contraction of the lumbar
multifidus muscle. Manual Therapy 2009;14:496- 500 13. Biely S,
Smith SS, Silfies SP. Clincial instability of the lumbar spine:
diagnosis and intervention. Orthopaedic Practice 2006;18:11-18 14.
Cook C, Brismee JM, Sizer PS. Subjective and objective descriptors
of clinical lumbar spine instability: a delphi study. Manual
Therapy 2006;11:11-21 15. Richardson CA, Jull GA. Muscle
control-pain control. What exercises would you prescribe? Manual
Therapy 1995;1:2-10 16. Stokes IAF, Gardner-Morse MG, Henry SM.
Abdominal muscle activation increases lumbar spinal stability:
analysis of contributions of different muscle groups. Clin Biomech
2011;26:797-803 17. Alqarni AM, Schneiders AG, Hendrick PA.
Clinical tests to diagnose lumbar segmental instability: a
systematic review. JOSPT 2011;41:130-140 18. Demoulin C, Destree V,
Tomasella M, Crielaard JM, Vanderthommen M. Lumbar functional
instability: a critical appraisal of the literature. Annales de
Readaptation et de Medecine Physique 2007;50:677-684 19. Abbott JH,
Fritz JM, McCane B, Shultz B, Herbison P, Lyons B, Stenfanko, Walsh
RM. Lumbar segmental mobility disorders:comparison of two methods
of defining abnormal displacement kinematics in a cohort of
patients with non-specific mechanical low back pain. BMC
Musculoskeletal Disorders 2006;7:1-11. doi:10.1186/1471- 2474-7-45
20. Kasai Y, Morishita K, Kawakita E, Kondo T, Uchida A. A new
evaluation method for lumbar spinal instability: passive lumbar
extension test. Physical Therapy 2006;86:1661-1667 Slide 48
References 21. Leone A, Guglielmi G, Cassar-Pullicino VN, Bonomo L.
Lumbar intervertebral instability:a review. Radiology
2007;245:62-77. 22. Hayes MA, Howard TC, Gruel CR, Kopta JA.
Roentgenographic evaluation of lumbar spine flexion-extension in
asymptomatic individuals. Spine 1989;14:327-331 23. Danneels LA,
Vanderstraeten GG, Cambier DC, Witvrouw EE, Bourgois J, Dankaerts
W, DeCuyper HJ. Effects of three different training modalities on
the cross sectional area of the lumbar multifidus muscle in
patients with chronic low back pain. J Sports Med 2001;35:186-191
24. Panjabi MM. The stabilizing system of the spine. Part I.
Function, dysfunction, adaptation, and enhancement. J Spinal Disord
1992;5:383-389 25. Panjabi MM. The stabilizing system of the spine.
Part II. Neutral zone and instability hypothesis. J Spinal Disord
1992;5:390-397 26. Abbott JH, McCane B, Herbison P, Moginie G,
Chapple C, Hogarty T. Lumbar segmental instability: a
criterion-related validity study of manual therapy assessment. BMC
Musculoskeletal Disorders 2005;6:1-10. doi:10.1186/1471-2474-6-56
27. Rackwitz B, de Bie R, Limm H, von Garneir K, Ewert T, Stucki G.
Segmental stabilizing exercises and low back pain. What is the
evidence? A systematic review of randomized controlled trials. Clin
Rehabil 2006;20:553-567 28. Hebert JJ, Koppenhaver SL, Magel JS,
Fritz JM. The relationship of transversus abdominis and lumbar
multifidus activation and prognostic factors for clinical success
with a stabilization exercise program: a cross-sectional study.
Arch Phys Med Rehabil 2010;91:78-85 29. Waddell G, Sommerville D,
hendersonI, Newton M. Objective clinical evaluation of physical
impairment in chronic low back pain. Spine 1992;17:617-628 30.
Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of
clinical examination measures for identification of lumbar
segmental instability. Arch Phys Med Rehabil 2003;84:1858-1864 31.
Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility
assessment: an examination of validity for determining intervention
strategies in patients with low back pain. Arch Phys Med Rehabil
2005;86:1745-1752 32. Spratt KF, Weinstein JN. Chapter 25:
Measuring clinical outcomes. In: Weisel S, ed. The Lumbar Spine. 2
nd ed. v. 2. Philadelphia: W.B. Saunders Co., 1996:1313-1338 Slide
49 Thank You
