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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

Cas

eRe

port

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.

1098 . Maluf et al Physical Therapy . Volume 80 . Number 11 . November 2000 by guest on January 24, 2013http://ptjournal.apta.org/Downloaded from


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.

Physical Therapy . Volume 80 . Number 11 . November 2000 Maluf et al . 1099

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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.



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


Sitting active kneeextension


Supine hips andknees flexed


Supine passivedouble knees tochest


Supine hips andknees extended


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


Supine active hipabduction andlateral rotation


Side lying Preferred position with hips and knees flexed .90° and lumbar spine aligned inflexion relative to neutral2 in intensity of central LB sxs



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


Quadruped activearm lift


Quadruped rockingbackward


Quadruped rockingbackward in fullflexion


Quadruped rockingforward


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.



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


IIIIII

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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

xing

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

)



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.



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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