Mireille Hamway, SPTCleveland State University

CASE REPORTExamination of a high-level weight lifter with chronic low back pain:

Consideration of complex patient history and comorbidities in diagnosis and treatment efficacy

Abstract:

Background and Purpose

The cause of low back pain can be difficult to determine due to the multifactorial components that contribute to increased pain. Barriers to a successful therapy treatment can often undermine the expected outcome, and psychosocial aspects of the patient’s life can affect the perception of pain. The purpose of this article is to demonstrate the effect of psychosocial barriers on the outcome of a young female body builder with chronic low back pain. Case Description

Presented in this report is a 21-year-old female with chronic low back pain who participated in high-level weight training and has a significant complicated past medical history. The back pain began a year and a half prior to this episode of care, and the mechanism of injury was believed to be improper form during a dead lift. Psychosocial aspects of her life were affecting her ability to cope with stress and manage pain.

Outcomes

The Oswestry Disability Index (ODI) and the Numeric Pain Rating Scale (NPRS) scores did not show improvement at discharge. The patient’s ODI decreased from 29 to 21 indicating a decrease in function. The patient was asked to give a pain rating at the beginning of each session for how she felt at that time and how she felt at her worst since the previous visit. Pain intensity increased as the patient became overwhelmed with managing her physical, mental and social health.

Discussion

The patient did not demonstrate decreased pain and increased function by discharge. Psychosocial barriers, comorbidities and multiple contributing factors interfered with treatment, and the expected outcome was not achieved.

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Background and Purpose:

The identification of the cause of low back pain (LBP) is a subject of much deliberation in many physical

therapy clinics. Physical therapists follow different methods of examination based on their training and

preference. The research shows that the three main systems used, McKenzie, movement impairment,

and treatment-based classification, have good levels of inter-rater reliability and validity, but none is

proven to be superior to the others.1 When looking at a more complicated case, it may be in the best

interest of the patient to look at the information from the viewpoint of each one of these approaches.

Chronic LBP is developed in 62% of people who are experiencing back pain for the first time, and they

will continue to have symptoms that last longer than a year.2 Often, the diagnosis can be difficult to

decipher when there are many comorbidities and an extensive patient history. Many factors can

contribute to LBP, and if all sources are not addressed, treatment directed at only some sources may be

rendered useless. Some common factors include poor coordination and muscle performance of core

musculature, referred pelvic pain, mechanical derangement, and myofascial trigger point referral. 3-8

Performance of core musculature can be especially difficult to ascertain due to the efficiency

of muscle compensation during testing. When there is poor coordination and timing during

athletic activities, this can lead to fatigue in some muscles, which will result in a spine

vulnerable to injury.5 A core stability exercise program is a common treatment and is

designed to retrain muscles to activate appropriately.2 Also, the definition of core muscles

varies in the literature. The pelvic floor is often omitted, and myofascial trigger points found

in musculature can refer to the low back and posterior thigh which mimics radicular

symptoms (pain from a spinal nerve root that refers into the extremities).3,7,9 Radicular

symptoms are a key indicator of a derangement classification in the McKenzie mechanical

diagnosis and therapy method of examination. (This method is discussed in further detail in

the exam portion of this article.) The centralization or peripheralization of these symptoms

(pain coming towards the source at the spine or pain spreading further into the extremities)

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determines the treatment direction for a patient classified with this diagnosis. If the patient

is misdiagnosed, the chronic pain will continue and limitations will hinder participation in

activities for a longer period.

In addition to body, structure and function impairments, the psychosocial background of the

patient will affect treatment efficacy. In a study done by Groeneweg et al, psychosocial

variables were examined as predictors of a positive treatment outcome for people with neck

pain. The researchers concluded that treatment was affected by outcome expectancy,

treatment credibility, fear avoidance and locus of control.10 Also, in particular with veterans,

a comorbidity often accompanying chronic pain is PTSD. Patients who are experiencing both

diagnoses have a greater degree of perceived pain intensity, distress, life interference, and

disability than those who only experience one.11

With all the possible contributions to chronic low back pain, it is easy to see the difficulty in

treating such a multi-faceted condition. The purpose of this case report is to demonstrate

the effect of psychosocial barriers on the outcome of a young female body builder with

chronic low back pain. The secondary purpose is to highlight the importance of a holistic

approach during an episode of care.

.Case Description: Patient History and Systems Review

This case report describes a patient who was referred to physical therapy for low back pain. The patient

is a 21-year-old female who served four years in the military and participated in high-level weight

training. She has a significant past medical history involving post-traumatic stress disorder (PTSD), major

depressive disorder, severe headaches, pelvic floor and uterine dysfunction and generalized anxiety.

The patient presented to the clinic with a chief complaint of pain in the lumbar spine and posterior right

lower extremity to the level of the knee. Pain began a year and a half prior to the evaluation and was

believed to be caused by dead lifting, a technique in which a person will bend at the waist and knees to

lift a weight bar from ground level using bilateral upper extremities (see figure 1). She stated that she

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heard a “pop” while performing the lift and

has had difficulty with movement,

prolonged positioning, and pain since this

incident. She was diagnosed by a physician

at the time of injury with a herniated disc

and referred to physical therapy (PT). She

felt that she responded well to mechanical

lumbar traction; however, the effects were

short-lived, lasting only a day or two. Other treatments by multiple providers included epidural steroid

injection, radiofrequency ablation, transcutaneous electrical nerve stimulation (TENS), trigger point

injections, muscle relaxants, NSAIDS, and therapeutic exercise. The patient expressed concern that she

would not be able to return to weight-lifting activity and felt frustrated with many different treatment

options failing to relieve her pain. Her pain was reported as the most limiting factor to her participation

in lifting. She reported a 4-8/10 pain range which she experienced daily. Prior to injury, she was training

as a professional body builder and competed in local events. Since then, she had lost 65lbs and ceased

all weight-lifting activity. Focusing on weight-lifting was therapeutic for the patient and helped to

alleviate symptoms from mental health disorders. The mental health factors contributing to these

symptoms included PTSD that resulted from a sexual assault she experienced while in the military,

suicidal thoughts, unsupportive family and social complications. She had sought out treatment for

mental health symptoms as well, and the patient was being treated by psychiatry during the same

period as this episode of care. In addition to PT and psychiatry, the patient was receiving services from a

neurologist for headaches, a chiropractor for low back pain, a women’s health physician for pelvic floor

and uterine dysfunction, and pain management. The patient was overwhelmed with multiple conditions,

several healthcare providers and constant appointments, and a myriad of symptoms affecting her day to

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Figure 1: Image A demonstrates poor technique when performing deadlift and Image B displays proper form. With incorrect form, the forces distributed through the lumbar spine have potential to cause injury. Image obtained from http://www.precisionnutrition.com/all-about-spinal-health

BA

day life. She felt that the key to get everything under control was to return to her weight-lifting training.

This was the main patient goal: to reduce pain in order to return to training.

Clinical Impression #1

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Physical therapists are specialists when assessing musculoskeletal and movement dysfunction.

According to the APTA Guide to Physical therapist practice, the physical therapy examination involves

tests and measures that determine muscle performance and joint mobility which influences the ability

of the person to perform functional activities.12 The tests and measures used allow for differential

diagnosis of the physical therapy problem and direct treatment. The primary patient identified problem

is back pain caused by a specific mechanism of injury (MOI) which led to decreased activity and

participation. This patient is a good candidate to demonstrate the importance of differential diagnosis as

her medical history and comorbidities are extensive. She has multiple factors that could potentially

contribute to her LBP, and all factors may not have been addressed during her episode of care. She also

presents with typical LBP symptoms which are addressed with conventional exam techniques and

methods. The presentation of back pain with radicular symptoms into the right lower extremity guides

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the exam towards a McKenzie method of testing.6,13 Due to the MOI, instability in the lumbar spine or a

fracture of the pars interarticularis were considered as well. There were no significant findings in any

imaging reports indicating there may also be involvement of muscle weakness. Muscle activation, timing

and coordination to stabilize the spine during dynamic activity is crucial, and when dysfunction is

present in muscle performance, this may lead to injury. Figure 2 demonstrates the decision-making

process and displays the identification of problems that guided the examination and treatment. Using

the HOAC II model, the patient identified problems lead to inclusion of specific tests and measures in the

objective exam: repeated movement testing to establish directional preference, stork-standing lumbar

extension test to screen for fracture, Prone Knee bend, slump and straight leg raise tests to assess nerve

involvement, prone segmental instability test to test for instability, abdominal and paraspinal stability

testing to establish proper activation of core muscles, and segmental mobility testing to check joint play

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at each segment. In taking a holistic approach to patient care to more accurately provide a prognosis,

additional information was gathered prior to beginning objective measures. This included sleep and

nutrition habits, substance abuse, social support, and stress management. The most significant findings

from additional questioning involved the patient not sleeping, eating or managing stress well. The

patient had difficulty sleeping and positioning to sleep, poor nutritional intake, and no healthy stress

management plan to replace her previous tactic. Her social relationships were also complicated, and

family members were major contributors to stress. There was no admission to substance abuse,

particularly to steroid use which would affect the integrity of soft tissues. Although the patient appeared

motivated at her first visit, these habits affect compliance with a home exercise program (HEP) and may

interfere with the effectiveness of care. Social support is also a good predictor of positive outcomes,

and the lack of support the patient receives may also contribute to a poorer prognosis. The objective

exam will provide additional detail to facilitate the differential diagnosis using all the techniques

considered during the first impression as well as help determine an accurate prognosis.

Examination

The patient received a physical therapy exam which typically includes manual muscle testing (MMT),

range of motion measurements (ROM), and special tests/screening tests. ROM measurements were

completed at bilateral hip, knee and ankle joints using a standard goniometer as described by Reese.14

Muscle testing was completed on major muscle groups of bilateral lower extremities using techniques

outlined and described in McGee.15 Significant findings from these portions of the exam are summarized

in Table 1. Deficits were shown in small stabilizing muscles, such as gluteus medius (GM), transverse

abdominus (TA), and multifidus which indicates a lack of support for the spine during dynamic activities.

The patient presents with normal gross muscle strength due to extensive resistance training; however,

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when body building, smaller stabilizing muscles are typically not the focus of training. This becomes

apparent when these muscles are tested. Screening tests for reflexes, vitals, red flags and sensation

were all normal. The special test portion of the exam will be the focus of discussion in this section and

findings are also summarized in Table 1. The patient’s complaint of pain with prolonged positioning and

pain into the posterior right lower extremity were the symptoms that primarily guided the exam.

Radicular symptoms are key to assessing for derangement using the McKenzie Mechanical Diagnosis and

Therapy theory (MDT). There are three basic diagnoses of the spine that McKenzie describes: postural,

dysfunction and derangement. Derangement is described as a disruption in the

Table 1: Summary of Exam Findings

Muscle Strength Testing • Gross testing of hip adduction, external rotation, internal rotation, abduction, flexion, and extension: 5 bilaterally

• Gross testing of knee flexion and extension: 5 bilaterally

• Gross testing of ankle in all planes of motion: 5 bilaterally

• Specific muscles tested where deficits were demonstrated:

• Right Gluteus Medius: 4• Left Gluteus Medius: 3• Abdominals: moderately

decreased strength in transverse, sagittal and frontal planes; compensatory muscle activation with double straight-leg lowering test and side plank test.

• Multifidus: decreased activation and evident compensatory techniques

Range of Motion • Bilateral lower extremity measurements were all within normal limits

• Gross assessment of lumbar ROM• Flexion: Moderate loss with

increased pain• Extension: Moderate loss with

increased pain

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• Lateral Flexion R/L: no losses• Rotation R/L: minimal losses

Special Tests • Repeated flexion/extension: no change in radicular symptoms after 10 repetitions.

• Stork-Standing Lumbar Extension Test: negative

• Prone knee bend: positive• Slump: positive• Straight leg raise: negative• Prone segmental instability: negative• Segmental mobility testing: Hypermobile

through L2-5, hypomobile in lower thoracic region

mechanical alignment of the vertebral segment, possibly caused by disc abnormalities, that can present

as symptoms in myotomal or dermatomal patterns due to irritation of the nerve root.13 This method of

assessment is widely accepted and practiced, but validity and reliability varies between studies.16 MDT

was utilized by asking the patient to flex and extend the lumbar spine repeatedly in standing and in lying

(prone for extension and supine for flexion). The response expected if derangement is present is

peripheralization or centralization of radicular symptoms of the lower extremity. There was no change in

posterior right leg pain when performing the repeated movement test after 10 repetitions.

Due to the mechanism of injury and the age of the patient, ruling out pars interarticularis fracture (PIF)

is necessary. The stork-standing lumbar extension test is used to rule out PIF. The patient stands on one

leg and extends the trunk. A positive sign for fracture is provocation of pain while standing on the leg

ipsilateral to pain. The research available discusses the inability of this test to properly rule out PIF;

however, the gold standard measurements are expensive and not easily accessible during a PT

examination.17 The patient did not have a positive sign with this test and the examining PT ruled out this

diagnosis. The neurological exam findings were more significant. Prone knee bend, slump and straight-

leg raise are all common tests used to provoke pain caused by nerve tension. The patient had positive

slump and prone knee bend results. The prone knee bend test is used to stress the femoral nerve and is

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performed by having the patient lie prone while the PT stabilizes at the pelvis and passively flexes the

knee. A positive sign is reproduction of the patient’s symptoms and indicates L2-4 involvement. The

slump test is indicative of dural tension and is performed by having the patient, in a seated position,

round the back and flex the neck. The therapist will then passively extend the knee and dorsiflex the

foot. Provocation of familiar symptoms is considered a positive test. Research support for these tests is

limited and sensitivity and specificity is poor.18,19 These tests are often used in the clinic due to ease of

administration and lack of alternative screening techniques. The prone segmental instability test is more

statistically supported than the nerve tension test. There are studies that find this test to be more

reliable than other tests used to diagnose instability, but validity is not known. 20 To conduct this test,

the patient lays prone with both lower extremities over the edge, feet resting on the floor. Pressure is

applied in an anterior direction to the segment being tested. The same pressure is applied again while

the patient lifts both legs from the floor. If familiar pain is reproduced when the patient is in resting

position, but not active position, then the test is considered positive. The results in this case were

negative. Lastly, segmental mobility was also examined. The reliability of these judgements made by

clinicians is shown to be fair, but between clinicians there is typically agreement and is shown to be

useful clinically.20 The assessment of the patient, completed by applying a posterior to anterior

compression force through each segment, made evident a hypermobility of L2-L5 vertebrae and a

hypomobility of lower thoracic segments. After evaluation of these findings, a second clinical impression

was formed.

Clinical Impression 2

After careful consideration of the objective exam and patient history, core instability was determined as

the main cause of the patient’s back pain. This instability lead to the hypermobility of the lumbar spine

and eventual nerve compression. With nerve tension tests being poorly supported in the literature, it

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becomes difficult to attribute back pain to a derangement diagnosis when the repeated movement

testing did not reproduce symptoms.18,19 The lifting activity in which the patient participated repeatedly

would put the patient at risk for injury when core muscles are not activating sufficiently.4,5 The plan for

the patient treatment was focused on retraining core muscle timing and coordination through dynamic

activities, such as planks with alternating extremity extension. A full description of therapeutic exercises

will be provided in the treatment section. Reassessment continued throughout the plan of care to gauge

the patient’s response to treatment. The patient’s symptoms appear to be consistent with the typical

presentation of LBP.1,6,13 Prognosis for goal achievement was considered excellent at this stage of the

patient’s evaluation. Her age and fitness level added to the positive prognosis. Later, the poor response

to treatment will be discussed and the difficulty of diagnosing a patient with a complex history will be

displayed.

Intervention

Education was provided to the patient immediately following the evaluation regarding sitting and

standing posture, proper form while performing lifts, and the importance of strengthening core muscles.

The plan of care for this patient was designed to address core strength deficits and neural tension. The

exercises taught and performed included: hip abduction in side-lying, clamshells, planks, prone

multifidus activation and supine neural mobilization. The exercise descriptions are provided in appendix

A. Research shows that core stabilization is found to be beneficial in decreasing pain and disability in

patients with low back pain.2,21 Dry needling was also performed at the start of the session to address

trigger points in the paraspinals that may be causing pain or preventing muscle balance. The piston

method was used and needles were applied bilaterally to lumbar multifidus from L3 through L5. Dry

needling is gaining in popularity and shown to decrease pain in less time than traditional therapies

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alone.22 A moist-heat pack was applied at the end of the treatment session to the lumbar area to

promote relaxation and decrease pain.

Visits 2-3: The patient stated that she did not feel pain was decreasing. Muscle strengthening occurs

over time, so treatment was provided to give immediate relief from pain and support the spine. TENS is

shown to be an effective analgesic by using peripheral and central mechanisms to reduce pain; however,

there are tolerance effects that may impact use with chronic pain.23 This is still unclear in the research.

The patient was issued a TENS unit and posture pal tape was applied to the lumbar spine. The patient

reported compliance at this point in the episode of care. This initial plan and progression is expected to

have good results with a young female who is physically fit.

Visits 4-5: As the treatment sessions continued, additional contributing factors to her back pain became

evident and psychosocial health began to affect treatment and compliance. The patient attempted to

return to her lifting routine as she felt symptoms were starting to decrease. She was asked to take a

video of her dead-lift technique and bring it in for analysis. After reviewing the video with the patient,

she understood that there was a hinging motion occurring at the L3-L4 level of the spine where she

currently was experiencing pain. The patient was educated further on the importance of maintaining

core stability during this activity to protect her back.

Visits 6-8: The patient began to see a chiropractor and a women’s health specialist. A procedure

performed in the women’s health office now added to lumbar pain and created excessive menstrual

symptoms. This affected the patient’s compliance with her home exercise program, and she began to

report exacerbations of her symptoms. Upon reviewing her history, and with the recent procedure

completed, the pelvic floor was considered for trigger point referral. Studies show that obturator

internus can refer pain to the posterior thigh, and pelvic floor pain can result from sexual trauma.7,9 The

obturator internus provocation test and the obturator sign were performed to confirm this was

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occurring with the patient. A stretch for the hip external rotators was added to her home exercise

program; however, compliance was decreasing as the episode of care continued. The stretch was

performed by beginning in supine with both legs bent and both feet on the ground. Then the patient will

cross the foot of the affected side over the thigh of the unaffected side. The patient will rotate the pelvis

toward the unaffected side while making sure both shoulders stay in contact with the supporting

surface. The patient was also referred to a physical therapy pelvic floor specialist.

Visits 9-10: The patient stated that she was having a serious family argument and having difficulty

sleeping. She also reported a return to previous pain levels and expressed being unable to work without

frequent breaks. The patient also had new complaints of migraine headaches for which she sought

treatment from a neurologist. She appeared increasingly emotionally distraught. She was currently

being treated by a psychiatrist for PTSD and family counseling. She was not adhering to the program

designed during the therapy sessions and displayed signs of regression. Progressing therapeutic

exercises was difficult as she was not displaying readiness for the next level of difficulty. The patient was

discharged from care at visit 11 as she stated that she may need to discontinue therapy in order to focus

on her mental and emotional health.

Table 2 Oswestry Disability Index Domains and Example Statements

Information obtained directly from the Oswestry Disability index and Rehabmeasures.org

Domains

Pain IntensityPersonal CareLiftingWalkingSittingStandingSleepingSexSocialTravel

Example Statements for Pain Intensity

0-I have no pain at the moment 1-The pain is very mild at the moment 2-The pain is moderate at the moment 3-The pain is fairly severe at the moment

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4-The pain is very severe at the moment 5-The pain is the worst imaginable at the moment

Outcomes

The primary measures of evaluating the patient’s progress were the Oswestry Disability Index (ODI) and

the Numeric Pain Rating Scale (NPRS). The ODI is used to determine the impact low back pain has on

functional abilities. It is a 10-item questionnaire where each item has six statements from which the

patient must choose the one that best applies. Each statement is assigned a numeric value from 0-5, 0

indicating the least disability and 5 indicating the greatest disability. See table 2 for a list of the domains

and example statements. The maximum score is 50 and the results are analyzed using a percentage. (A

score of 45 out of 50 is a 90%.) The minimal detectable change is 12.72 for patients with chronic low

back pain and the minimally clinically important difference is 9.5. Test-retest reliability is excellent,

criterion validity is unclear in the research, and there is an excellent correlation between the ODI and

the visual analog scale as well as with patients’ subjective assessment of improvement pre- and post-

operatively.24

The NPRS is an 11-point scale that allows the patient to choose a rating which best describes the

intensity of pain experienced. The patient verbalizes the score by stating a number between 0 and 10, 0

being no pain at all, and 10 being the most intense pain imaginable. This pain rating scale has been

tested on populations who experience chronic pain and the minimal detectable change is 2 points (95%

confidence interval) with patients who have low back pain. Test-retest reliability is adequate, and

interrater reliability is excellent. Cut-off scores are established as follows: a rating of 1-3 indicates mild

pain, 4-7 is moderate pain, and 8-10 is severe. There is an excellent correlation between NPRS and the

visual analog scale as well as the 21-point Numeric Rating Scale.24 During the episode of care, the patient

was asked to rate her pain using the NPRS at the beginning of every visit. She completed the ODI during

the evaluation and at discharge. Her scores are summarized in Figures 3.

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1 2-3 4-6 7-8 9-10 110

5

10

15

20

25

30

35

Figure 3: Summary of Outcome Measures

Pain Rating Upon Arrival Pain rating at worst since previous visitODI Scores ODI

Visit #

Scor

e

In the graph, there is a fluctuation of symptoms and recovery shown. This demonstrates how other

domains in the patient’s life and concurrent treatment affect the episode of care. At baseline, the

patient was reporting 4/10 pain at best and 7-8/10 pain at worst. At discharge, the patient’s pain score

increased to 6 and 9 respectively. Her ODI scores reflect an increased effect on function as well. It was

expected, given the patient’s age and fitness level, to have a positive outcome. This case displays that

positive outcomes may not occur as expected when the patient has multiple components impacting her

life.

Discussion

Chronic low back pain is a common diagnosis seen in physical therapy clinics with over half of the people

who experience back pain transitioning to a chronic classification.2 Symptoms vary but typically include

an inability to tolerate prolonged positioning, pain that radiates into the lower extremities, and an

inability to participate in activities that were once regularly enjoyed.2,8,21 Core instability is often a cause

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The graph above demonstrates the increase in pain and the decrease in function throughout the episode of care.

of low back pain as the core muscles work to protect the spine during dynamic activities such as

reaching, lifting, playing sports or performing activities of daily living.21,25 Core strengthening programs

are proven to decrease back pain and increase function.2,21 Many factors, however, can contribute to

low back pain. Psychosocial complexities and various providers administering treatment concurrently, as

well as mechanical issues that are more difficult to identify, can be a hindrance to progress as is seen in

this case. PTSD is shown to influence the patient’s perception of pain intensity and ability to cope with

stress or injury.7,11 Emotions are also closely related to activation of pain from myofascial trigger

points.9,22

A 21-year-old fit female presented to the clinic with typical low back symptoms. Upon examination, she

displayed core weakness, segmental hypermobility, and muscle imbalance with presence of myofascial

trigger points. A core strengthening program was designed to address her specific deficits, and various

treatment techniques were performed to reduce pain. Positive outcomes and typical progression were

expected; however, minimal improvements, if any, were seen. When looking at the whole person,

psychosocial factors were present and additional mechanical issues were discovered. This patient had

experienced sexual trauma, social support complexities, and multiple medical issues which were being

addressed simultaneously by several health care providers. The patient expressed feelings of being

overwhelmed and became increasingly non-compliant. Also, PTSD most likely affected how she

perceived the intensity of pain. It is more difficult for these types of patients to recover and they

experience pain longer.11

Anecdotally in this clinic, where female patients have often experienced sexual trauma, there appears to

be a connection to pelvic floor dysfunction and referral of pain into the low back and lower extremities.

There is limited research that shows a connection between pelvic floor pain and rape, but a link to

chronic back pain has not been explored.7 Some studies show that emotional stress can initiate

17

excessive muscle activation leading to myofascial trigger points which can increase pain.3,9,22 Further

consideration of the patient’s history lead to testing of the obturator internus where myofascial trigger

points were apparent, and a referral to a pelvic floor specialist was discussed with the patient. The

various sources of stress and health-related problems made it difficult for the patient to address her low

back pain.

A holistic approach is important when looking at all patients regardless of presentation. All domains

should be analyzed for potential barriers to care and strategies should be implemented to address these

barriers and increase quality of life for the patient. Physical therapists should be able to teach stress

coping strategies to patients. Often, the pain or limitation is a source of stress, or, for some, exercise is

the coping strategy they have used up to the point of injury or disability. When this is taken away, the

patient may need additional tactics to address stress and cope with the emotional strain that comes

with chronic pain. Further research is needed to explore how each domain affects the plan of care and

to display how the treatment outcome may differ if these factors are addressed. Also, it would be

beneficial to develop outcome measures that will help clinicians better understand the strength of the

patient’s coping mechanism and social support system to identify a need to provide alternate coping

strategies. There is a lack of research connecting sexual trauma to low back pain and further exploration

into this topic is needed as well.

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Appendix AHome Exercise Program

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Stabilization Plank

Start End

Clamshell

Start End

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Lie on stomach propped up on your hands and toes with your chin tucked-in and your feet together.

Lift up your pelvis creating a straight line with your body.

Hold the position without arching your back.

Hold for 15 seconds, 2 times a day and build time as tolerated

Lie on your side with both legs slightly bent.

Lift your top leg (injured leg), keeping your pelvis stable, your leg slightly bent and your heels together. Rotate your hip so that your foot and your kneecap are pointing upward during the movement.

Return to the initial position and repeat.

10 times per set, 2-3 sets, 1-2 times a day

Stabilization Superman

Start

End

Hip AbductionStart End

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Lie on your stomach with your chin tucked in, your arms by your side and the thumbs in and toward the ceiling.

Activate your lower abdominals (transversus abdomini) by bringing your belly button inward and by activating your pelvic floor muscles 20 to 30% of a maximal contraction.

Maintain a steady abdominal breathing while you pull your shoulder blades down towards your bum and lift one arm, keeping it close to your body as you lift the opposite leg, keeping both hips on the floor.

Return to the initial position and repeat with the other arm and opposite leg.

10 reps per set, 2-3 sets, 1-2 times per day

[Grab your reader’s attention with a great quote from the document or use this space to emphasize a key point. To place this text box anywhere on the page, just drag it.]

Supine Neural MobilizationStart End

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Lie on your back with your leg straight and your back in a neutral position (slightly arched).

Activate your lower abdominals (transversus abdomini) by bringing your belly button inward and by activating your pelvic floor muscles (inner thigh) 20 to 30% of maximal contraction.

Lift one knee towards your chest as far as possible and hold it there with your hands.

Maintain a steady abdominal breathing while you straighten your knee and slowly lower your leg toward the floor, keeping your back and pelvis completely still.

Return slowly to the initial position and repeat beginning with the other leg.

10 reps per set, 1 set, 1 time a day

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