http://informahealthcare.com/ptp ISSN: 0959-3985 (print), 1532-5040 (electronic) Physiother Theory Pract, Early Online: 1–9 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2014.949393
CASE REPORT
An integrated approach to the examination and treatment of a patient with chronic low back pain Marcia Miller Spoto, PT, DC, OCS1 and Greg Dixon, PT, DPT2 Physical Therapy Department, Nazareth College, Rochester, NY, USA and 2STAR Physical Therapy, Fairport, NY, USA
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Abstract
Keywords
Background and study design: Several physical therapy classification systems exist for low back pain (LBP). Little is known about how these systems could be integrated in clinical practice. This case report describes an episode of care utilizing elements of the mechanical diagnosis and therapy (MDT), movement system impairment (MSI) and treatment-based classification (TBC) systems. Case description: Patient History – the patient was a 40-year-old male presenting to an outpatient musculoskeletal clinic with a complaint of chronic LBP. Examination and diagnosis – there was moderate loss of lumbar extension ROM and joint mobility, and excessive lumbar flexion and rotation with active movement tests. Modified Oswestry Disability Index score ¼ 8%. Worst pain was described as 6/10. Intervention – the patient was treated once per week for seven consecutive weeks. Intervention focused on sitting postural corrections (MSI), functional movement corrections (MSI), lumbar mobilization (TBC) and extension-based exercise (MDT). Outcomes – at discharge, the patient reported a decrease in pain intensity (worst pain 0 to 1 out of 10) and demonstrated an improvement in the quality of lumbar movement and overall function. Discussion: Symptomatic response to active movement, observations of quality of movement and joint mobility assessment were key factors in directing a therapeutic program that was successful in helping the patient meet his treatment goals.
Classification, clinical guidelines, low back pain
Introduction Low back pain (LBP) is a problem that can range from a minor, transient episode of pain, to a serious disabling health condition. Despite advances in health care technology related to diagnosis and intervention, optimal management of LBP remains elusive. Published clinical guidelines help to outline evidence-based assessment procedures and intervention; however, they do not provide comprehensive clinical decision rules that help the clinician select specific treatments based upon patient examination data (Delitto et al, 2012). In addition, the cost associated with diagnosing and treating low back pain in the USA has increased substantially with no corresponding improvement in treatment outcome (Freburger et al, 2009; Martin et al, 2008). Considering the importance of diagnosis in directing appropriate treatments, there have been ongoing efforts among health care providers involved in spine care to develop meaningful diagnostic classification systems for LBP (Fairbank et al, 2011; Waddell, 2005). It has been long recognized that the majority of cases of LBP cannot be attributed to specific pathology and are therefore considered non-specific (Savage, Whitehouse, and Roberts, 1997). It also is accepted that people with LBP can and should be divided into clinical subgroups to better guide treatment (Fritz and George, 2002). In physical therapy practice, several LBP classification systems have evolved. The three models most frequently cited in the literature are: (1) Mechanical Diagnosis and Therapy Address correspondence to Marcia Miller Spoto, Physical Therapy Department, Nazareth College, Rochester, NY, USA. E-mail: mspoto7@ naz.edu
History Received 9 July 2013 Revised 23 May 2014 Accepted 3 June 2014 Published online 25 August 2014
(MDT); (2) Movement System Impairment (MSI) and (3) Treatment-based Classification (TBC) (Appendices A, B and C). All of these systems have named diagnostic categories, explicit inclusion criteria and propose specific interventions based upon the patient subgroup (Delitto, Erhard, and Bowling, 1995; McKenzie and May, 2003; Sahrmann, 2002). The MDT system emphasizes the assessment of symptomatic responses to a variety of static and dynamic lumbar spine motions including both single and repeated movements (McKenzie and May, 2003). The MSI system focuses primarily on identifying and correcting postural and movement impairments in a variety of positions: standing, sitting, supine, prone and quadruped. In contrast to both the MSI and MDT approaches, the TBC system categorizes patients into one of four specific treatment groups based on historical and symptomatic presentation: (1) manipulation; (2) stabilization; (3) specific exercise and (4) traction. Aspects of the TBC system have been tested to predict outcomes for therapeutic intervention following classification (Stanton et al, 2011). All three of these classification systems have been found to have acceptable levels of inter-tester reliability (Fritz and George, 2000; Harris-Hayes and Van-Dillen, 2009; Kilpikoski et al, 2002). There is also some evidence to support the validity of the systems, indicating improved treatment outcomes following systemspecific subgroup classification (Childs et al, 2004; Cook, Hegedus, and Ramey, 2005). Furthermore, no single classification system has been found to be superior to another (Fairbank et al, 2011). Although physical therapists may combine classification systems when making clinical decisions, little is known about how these somewhat disparate approaches to care could be integrated in clinical practice (Spoto and Collins, 2008).
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The purpose of this case report is to describe the management of a patient with chronic LBP utilizing clinical reasoning elements of the MDT, MSI and TBC systems in an integrated manner and to explore the congruency of these systems in directing treatment.
Case description
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History Prior to examination and data collection, patient consent was received and an informed consent was obtained. Approval was granted from the Nazareth College Institutional Review Board for implementation of this case study. The patient was a 40-year-old Caucasian male with a chief complaint of chronic bilateral lumbar paraspinal region pain. He reported an insidious onset of intermittent LBP that developed when working long hours as a truck driver 2 years previously. At the time of the initial examination the back pain was described as a dull ache that developed after either prolonged sitting or following strenuous exercise. The patient rated his LBP level on an 11-point numeric rating pain scale (NRS). He rated pain as 0/10 at rest and 6/10 at worst. Pain intensity levels had been consistent since the time of onset 2 years previously. The patient reported that standing, walking and lying alleviated his pain, whereas sitting and forward bending usually resulted in the production of pain. No clear 24-h pain pattern or pain with sleeping was noted and cough, sneeze or strain did not produce or worsen symptoms. No unexplained weight loss or history of previous trauma was reported. The patient was a full-time graduate teaching student in education and regularly participated in recreational ultimate frisbee and basketball. He additionally reported not taking medications and had no imaging studies. His past medical history as well as general health were otherwise unremarkable. Furthermore, he reported having previously received massage therapy for this condition, which provided temporary relief of symptoms. The patient’s goals were to reduce pain during sitting and following recreational sports. Physical examination Systems review Integument and neurological screen of the upper extremity and lower extremity myotomes and dermatomes were both unremarkable; achilles and patellar reflexes were normal bilaterally (2+). Tests and measures Posture A posterior pelvic tilt and decrease in lumbar lordosis were noted in both sitting and standing.
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Movement impairments (MSI) The primary movement impairments were noted during the following tests: (1) During forward bending and return from forward bending, the rate of lumbar spine movement was greater than hip/pelvic movement within the first 50% of the motion. Excessive lumbar flexion was noted at end-range of forward bend; (2) Lumbar flexion was observed in sitting posture; (3) Lumbar flexion and rotation were noted during active knee extension in short sitting and (4) Lumbopelvic rotation was noted within the first 50% of hip abduction/lateral rotation in supine and side-lying. Table 1 provides other pertinent MSI and MDT examination findings and Appendix A provides definitions regarding other positive MSI tests [i.e. (+) flexion or rotation impairments]. Muscle performance/manual muscle testing Bilateral gluteus maximus and hamstring muscles were noted to be weak and pain free. Muscle length. Impairments were noted in bilateral hamstring extensibility as well as in the rectus femoris, iliopsoas muscle groups and the tensor fascia latae (TFL) muscle groups bilaterally. Range of motion. Deficits were also present in bilateral hip goniometric measurement for both internal and external rotation (Table 2). Special testing/joint mobility. The prone lumbar instability test was negative. Hypomobility without pain was noted for posterior to anterior central vertebral pressures from L1 to L5. Palpation. Mild tenderness was reported just inferior to iliac crest over gluteus maximus and medius muscles bilaterally. Self-report and outcome measures. The Fear Avoidance Belief Questionnaire (FABQ) was used to assess the patient’s perceived fear of movement due to the presence of LBP and the relative likelihood of a positive outcome with conservative therapeutic intervention (Davenport, 2008). The FABQ has demonstrated both adequate internal consistency and validity with regard to predicting disability and work loss in patients with LBP. The Modified Oswestry outcome measure, which has established clinical reliability, validity and responsiveness, was additionally administered to assess patient perceived disability relative to the presence of LBP (Ostelo et al, 2008). Results from both outcome measures were as follows: FABQ scores ¼ physical activity (FABW PA) – 10/24 and work (FABQ W) – 5/42; Modified Oswestry score ¼ 8%.
Single/repeated movements testing (MDT)
Diagnosis, evaluation and clinical assessment
Back pain prior to movement testing was 0/10 NRS. Pain was produced at end-range movement with single flexion in standing (FIS), single/repeated extension in standing (EIS, Rep EIS), single/repeated flexion in lying (FIL, Rep FIL), however was no worse as a result. Pain at onset and during movement was noted with return from forward bending and repeated flexion (Rep FIS). In addition, there was no change in lumbar spine alignment following repeated movement testing (Table 1).
General physical therapy diagnosis The patient presented with chronic, intermittent, central lumbar region pain with associated impairments of muscle performance, muscle length, motor control, ROM and joint mobility. At present, the condition was negatively impacting his quality of life and ability to tolerate work in a sitting position for extended periods of time, therefore skilled intervention was indicated.
Static testing (MDT) Pain was produced in the lumbar spine following slouched sitting for 1 min. Decreased LBP was reported following manual correction of sitting posture.
Classification system-specific diagnoses The specific diagnostic classifications based on the unique clinical rationale of each system are presented below.
Integrated approach to diagnose and treat LBP
DOI: 10.3109/09593985.2014.949393
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Table 1. Integrated examination findings (MSI, MDT and TBC). Testa
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Standing Flexion in Standing (MSI, MDT) Return from forward bend (MSI, MDT) Repeated FIS (MDT, TBC) Extension (MSI, MDT) Repeated EIS (MDT, TBC) R side bending (MSI) L side bending (MSI) Sitting R knee extension (MSI) L knee extension (MSI) Static slouched sitting (MSI, MDT) Supine R knee to chest (MSI) L knee to chest (MSI) Passive hip/knee flexion (MSI) FIL (MDT) Repeated FIL (MDT) R hip abd/LR (MSI) L hip abd/LR (MSI)
ROM Mod " lumbar flexion NE Mod # lumbar extension NE
Mod " lumbar flexion/rotation Mod " lumbar flexion/rotation NA
NA NE
Sidelying: (MSI) L hip abd/LR R hip abd/LR L hip abd/Add R hip abd/Add Prone EIL (MDT) Repeated EIL (MDT) R knee flexion (MSI)
NA NE
L knee flexion (MSI) R hip LR (MSI) R hip MR (MSI, TBC) L hip LR (MSI) L hip MR (MSI, TBC) Quadruped (MSI): R arm lift L arm lift Rocking back
Pain (0/10 pretest)
Impairment (MSI)
Correction (MSI)
(+) Flexion
NA
# pain with correction # pain with correction NA
(+) Flexion
NA
NA
NA
() ()
NA NA NA
Prod 4/10 at 1 min, NW;
(+) Flexion; (+) Rotation (+) Flexion; (+) Rotation NA
NC NC NC
() () ()
NA NA NA
Prod (1–2/10), NW Prod (1–2/10), NW NC NC
NA NA (+) Rotation (+) Rotation
NA NA NA NA
NC NC NC NC
(+) (+) (+) (+)
Rotation Rotation Rotation Rotation
NA NA NA NA
NC NC NC
NA NA NA
NC NC NC NC
NA NA (+) Extension, (+) Rotation (+) Extension, (+) Rotation (+) Rotation (+) Rotation (+) Rotation (+) Rotation
NC NC NC
() () (+) Flexion
NA NA NA
Prod at end-range (1–2/10), NW; Prod at onset/during mvt (1–2/10); Prod at onset/during mvt (1–2/10), NW; Prod at end-range (1–2/10), NW Prod at end-range (1–2/10), NW NC NC NC NC
NC 25 35 15 25
Mod " lumbar flexion
(+) Extension
NA # pain with correction
NA NA NA NA NA
Additional tests (TBC) P-A central vertebral pressure (joint mobility): hypomobility L1–L5 Prone instability test: negative NA, not applicable; NC, no change; NE, no effect; NW, no worse; WNL, within normal limits. Tests specific to each system outlined in parentheses.
a
Mechanical diagnosis and therapy According to the diagnostic criteria for the McKenzie system, this patient demonstrated signs and symptoms most consistent with posterior derangement syndrome (‘‘D1 derangement’’) (McKenzie and May, 2003). The patient demonstrated pain at the onset of active return from forward flexion and pain with both single and with repeated forward flexion, indicating pain during movement. Pain during movement is only found in the derangement syndrome of MDT classification. Additional considerations for the diagnosis of derangement syndrome included ruling out flexion dysfunction, as flexion range of
motion was full. Extension ROM was limited but not painful in prone extension (gravity eliminated); therefore extension dysfunction was ruled out. Finally, the patient’s signs and symptoms were not consistent with Posture syndrome because pain was modified with movement and not merely present with static positioning. Movement system impairment Based on clinical findings, the current patient would be classified as having a lumbar rotation with flexion syndrome. The primary dysfunction of this syndrome is that a segment of the lumbar spine
M. M. Spoto & G. Dixon
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This patient’s clinical findings were most consistent with meeting the criteria for the manipulation subgroup (3–4/5). Satisfied criteria include: (1) no lumbar spine-related symptoms below the knee; (2) lumbar spine segmental hypomobility; (3) low FABQ scores and (4) at least one hip with 435 of internal rotation. The last criterion was borderline, as the right hip was measured at 35 (Flynn et al, 2002).
Results from the FABQ indicate low levels of patient-perceived fear avoidance for both the physical activity (10/24) and work (5/42) subscales. Modified Oswestry Disability Index Data from the Oswestry reflect a relatively low level of patientperceived disability (8%) with regard to his LBP. Prognosis
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Treatment-based classification
Fear-avoidance Beliefs Questionnaire
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moves most easily or naturally in the direction of rotation-flexion, and pain is reproduced during flexion-based movements or postures. The specific diagnostic classification is determined based on the patient’s directional susceptibility to movement and corresponding symptomatic responses (Sahrmann, 2002). In this case the patient presented with a directional susceptibility toward flexion and rotation postures and movement. This was based on positive findings in 9 flexion and 12 rotation tests across the exam. In addition, only three tests were positive for extension impairments and the remaining tests were negative for directionspecific impairments.
Findings
Self-stretching for TFL * Supine straight leg hip adduction with belt assist * Lateral shift in quadruped * Standing hip adduction crossover Manual B hamstring stretch Supine piriformis stretch Prone lumbar extensions with grade 1 mobilization Muscle re-education training in quadruped (transverse abdominus and multifidus) * Neutral pelvic cueing Alternating arm/leg extensions in quadruped HEP provided * Self-postural corrections * Hamstring/TFL stretches * Supine, isometric core stabilization exercises * Supine Bridges
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Reassessment performed Manual postural and movement corrections (MSI) – verbal/tactile cueing provided throughout * Forward bend in standing * Return from forward bend * Sitting postural alignment * Semi-hooklying hip LR/abd * SL hip abduction Manual 90/90 hamstring stretch Soft tissue massage B hamstrings in supine Supine bridges (bilateral and alternating LE) Wall squats with yellow Swiss ball
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Manual 90/90 hamstring stretch Supine straight leg TFL stretch with belt assist Soft tissue massage B hamstrings ‘‘Pigeon’’ stretch for piriformis Supine bridges with hip abduction Supine dead bugs Short sitting pelvic tilt awareness training * Unilateral knee extensions * Unilateral hip flexions Prone lumbar extension with grade 1–2 mobilizations * Hips neutral * Hips offset Side-lying planks with knees flexed Alternating straight leg extensions in quadruped * Neutral pelvic cueing
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Completed initial tests and measures for physical examination (MSI) Manual postural and movement corrections (MSI) – verbal/tactile cueing provided throughout * Forward bend in standing * Return from forward bend * Sitting alignment * Semi-hooklying hip LR/abd * SL hip abduction Prone lumbar extensions – verbal cues Manual B hamstring stretch Supine bridges – manual cueing g
Week 2 – Treatment Session 1
Table 2. Visitations and progression of interventions.
Week 3 – Treatment Session 2
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Week 5 – Treatment Session 3
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Week 6 – Treatment Session 4
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Prognosis was determined ‘‘good’’ for stated impairments and functional limitations primarily based on low self-perceived disability and pain. Goals Functional and measureable goals were established based on the patient’s specific exam findings and desired outcomes for therapy. Expected outcomes were established to assess patient progress across a number of domains following the episode of care. The patient’s primary functional and pain-related goals for therapy were integrated into the therapeutic goals. As a result, successful completion of the goals would reflect improvement across both patient-perceived problems and clinically established impairments/functional limitations. Expected outcomes were as follows as the patient will: (1) report 0/10 pain and minimal lumbar spine muscular fatigue when short sitting with proper posture for at least 5 min in 7 weeks; (2) increase lumbar extension ROM to WNL in 7 weeks and (3) decrease pain with Rep FIS to 0/10 in 7 weeks to demonstrate increased tolerance during functional tasks such as athletics and student teaching. The above goals were based on the clinical hypothesis that postural stress and muscle strength/length impairments were the primary contributors to the patient’s LBP. The plan of care was primarily intended to promote core/LE strength/flexibility and improve neutral lumbopelvic positioning. Intervention The patient was seen one visit per week across 7 weeks (six visits total). Initial and final examinations were performed
Integrated approach to diagnose and treat LBP
DOI: 10.3109/09593985.2014.949393
on Weeks 1 and 7, respectively, and the patient did not attend therapy on Week 4 (Table 2). Primary interventions included postural/functional movement retraining, manual and self-lower extremity stretching, therapeutic exercise, soft tissue massage, modalities and joint mobilization. Postural and functional movement retraining was provided for a number of positions (sitting, standing and quadruped) and movements (forward bend, return from forward bend, reaching in quadruped). Manual and active self-stretches were performed on the hamstring, TFL, piriformis and rectus femoris muscle groups bilaterally.
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Therapeutic exercise was initiated at the second visit with an emphasis on core strengthening in neutral spinal positions and included strengthening of the transversus abdominus, multifidus, internal/external obliques and gluteus maximus. A home exercise program (HEP) was provided emphasizing postural education, LE flexibility, and strength promotion of the aforementioned muscle impairments. Extension-in-lying (EIL) was prescribed and progressed to EIL with manual P to A mobilizations. Specifically, a MDT method of passive overpressure during patient-directed extension was used. Manual deep soft tissue massage was also
Table 3. Post-Treatment Outcomes: Active Movement Tests.
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Testa Standing Flexion in Standing (MSI, MDT) Return from forward bend (MSI, MDT) Repeated FIS (MDT, TBC) Extension (MSI, MDT) Repeated EIS (MDT, TBC)
ROM Mod " lumbar flexion NE Mod # lumbar extension; WNL lumbar extension NE
R side bending (MSI) L side bending (MSI) Sitting (MSI, MDT) R knee extension (MSI) L knee extension (MSI) Static slouched sitting (MSI, MDT) Supine (MSI, MDT) R knee to chest (MSI) L knee to chest (MSI) Passive hip/knee flexion (MSI) FIL (MDT) Repeated FIL (MDT) R hip abd/LR (MSI) L hip abd/LR (MSI)
Mod " lumbar flexion/rotation Mod " lumbar flexion/rotation NA
NA NE
Sidelying (MSI) L hip abd/LR R hip abd/LR L hip abd/add R hip abd/add Prone (MSI, MDT) EIL (MDT) Repeated EIL (MDT) R knee flexion (MSI)
NA NE
L knee Flexion (MSI) R hip LR (MSI) R hip MR (MSI, TBC) L hip LR (MSI) L hip MR (MSI, TBC) Quadruped (MSI): R arm lift L arm lift Rocking back
Pain (0/10 pretest)
26 39 22 31
Mod " lumbar flexion
Correction (MSI)
NA
# pain with correction # pain with correction NA
(+) Flexion
NA
NA
NA
(Negative) (Negative)
NA NA
(+) Flexion; (+) Rotation; (Negative) (+) Flexion; (+) Rotation; (Negative) NA
NA
NC NC NC Prod (1–2/10), NW; NC Prod (1–2/10), NW; NC NC NC
(Negative) (Negative) (Negative) NA NA (+) Rotation; (Negative) (+) Rotation; (Negative)
NA NA NA NA NA NA NA
NC NC NC NC
(+) (+) (+) (+)
(Negative) (Negative) (Negative) (Negative)
NA NA NA NA
NC NC NC
NA NA NA
NC NC NC NC
NA NA (+) Extension, (+) Rotation (+) Extension, (+) Rotation (+) Rotation; (Negative) (+) Rotation; (Negative) (+) Rotation; (Negative) (+) Rotation; (Negative)
NC NC NC
(Negative) (Negative) (+) Flexion; (Negative)
NA NA NA
Prod at end-range (1–2/10), NW; NC Prod at onset/during mvt (1–2/10); NC Prod at onset/during mvt (1–2/10), NW; Prod (1/10 on L side only) Prod at end-range (1–2/10), NW; Prod at end-range (1/10), NW Prod at end-range (1–2/10), NW; Prod at end-range (1/10), NW NC NC NC NC Prod 4/10 at 1 min, NW; NC
NC 25 ; 35 ; 15 ; 25 ;
Impairment (MSI) (+) Flexion; (Negative) (+) Extension; (Negative)
Rotation; Rotation; Rotation; Rotation;
NA # pain with correction
NA NA NA NA NA
Initial exam data ¼ not bold; outcome data and clinically significant differences ¼ bold. NA, not applicable; NC, no change; NE, no effect; NW, no worse; WNL, within normal limits. a Tests specific to each system outlined in parentheses.
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provided to the hamstrings bilaterally. Table 3 provides the specific training provided at each physical therapy session.
Outcomes At the conclusion of therapy, the patient’s LBP had significantly reduced since the onset of skilled intervention and was currently 0/10 when short sitting at rest and was minimal the day after exercise (0–1/10); at worst pain was 1/10 with prolonged bouts of sitting (45 min). The patient had also demonstrated proficiency with the home exercise program indicating the potential for further improvement and maintenance of the patient’s condition following the conclusion of therapeutic intervention.
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Movement system impairment Subjective improvements were observed by the examiner for all static postures and dynamic movement impairments listed in examination (see Table 3). Mechanical diagnosis and therapy Single FIS was no longer painful; RepFIS and RepEIS was 1/10 pain at end-range; FIL and RepFIL reduced to 0/10. Modified Oswestry No change in disability percentage (8%) between initial and final visit. Goals Expected outcomes 1 and 2 were satisfied, however goal 3 was not fully achieved. Although there was no right-sided lumbar spine pain reported with repeated FIS, 1/10 left-sided pain remained at the conclusion of therapy.
Discussion The purpose of this case report was to utilize an integrated approach to the examination, classification and treatment of a patient with LBP. The primary purpose of diagnostic classification is to inform appropriate intervention. Thus, each of the three classification systems would lead to the selection of intervention specific to the diagnosis. Although there is a growing body of evidence within each system to support their validity, little is known about how these systems may be utilized together to inform treatment decisions. Karayannis, Jull and Hodges (2012) studied the prevalence and overlap of movement-based classification systems and suggested that an integrated approach could facilitate clinical decision-making. In this case, the treatment program reflects a synergistic application of clinical decisionmaking tools unique to each system. From a global perspective, this patient presents with chronic, localized LBP. His occupation requires prolonged sitting postures, which may have contributed to movement impairments that include a loss of extension ROM and mobility as well as a directional susceptibility to lumbar flexion and rotation. In addition, he responded well to sitting postural corrections including neutral spine positioning. These findings helped establish general guidelines for treatment. In the MDT system, posterior derangement is treated primarily with extension-based exercise along with postural re-education emphasizing avoidance of flexion positions and postures (McKenzie and May, 2003). These principles were adhered to in treating this case. Similarly, flexion and rotation syndromes in the MSI system are addressed with patient education directed at limiting impairments of lumbar flexion and rotation movements and postures (Sahrmann, 2002). In addition, test
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movements that were found to reproduce symptoms and/or display movement impairments were targeted for corrective exercise. Additionally, a primary emphasis in treating flexion with rotation syndromes in MSI is to facilitate abdominal control of trunk movement. Therefore, core stability exercises were incorporated into the treatment plan. Refer to Table 2 for specific movement re-education interventions used with this patient. The application of the TBC classification system to the patient case is less clear. In a general sense, challenges have been associated with assigning treatment categories to patients with acute and subacute LBP; in one study up to one-half of LBP patients could not be placed into a single category (Stanton et al, 2011). Additionally, this patient had chronic pain and relatively low levels of disability, which may further complicate the diagnostic process given that the treatment-based categories were originally established for patients with higher levels of disability (Delitto, Erhard, and Bowling, 1995). This patient’s clinical findings were most consistent with the manipulation subgroup. Thus, lumbar mobilization was part of the treatment plan. Regardless, when using an impairment-based approach, the finding of lumbar joint hypomobility would have been sufficient to support this treatment choice. A few incongruencies in clinical decision rules for these classification systems were noted when applying them to this case. First, the TBC system would direct treatment of a grade 5 mobilization (manipulation) to the patient. The MDT system, however, includes a ‘‘progression of forces’’ principle whereby the amount of therapist-generated force is informed by patient response and patient-generated forces are given preference (McKenzie and May, 2003). In this case, lower grades of joint mobilization were combined with extension exercise in the context of the MDT system and due to the favorable response, manipulation was not performed. Second, the TBC approach differentiates patients that are treated primarily with manipulation versus lumbar stabilization. Patients meeting the criteria for the lumbar flexion with rotation subgroup in MSI are provided abdominal control exercise interventions, which are part of core stabilization. This patient met the criteria for both the manipulation subgroup (TBC) and flexion with rotation subgroup (MSI). As spinal mobility impairments were coexistent with core strength impairments, both were addressed in the plan of care. Finally, the TBC approach also differentiates patients that are treated with lumbar extension exercise versus manipulation. As this patient met the criteria for the TBC manipulation subgroup and the MDT derangement subgroup, and as derangement is treated with extension-based exercise, both joint mobilization and extension exercise were prescribed. Several outcome measures were used in the diagnosis and care of this patient. Previous studies have reported cutoff scores that predict poor treatment outcomes for the FABQ-PA and FABQ-W scores of 414/24 and 429/42, respectively (Fritz and George, 2002; George, Fritz, Bialosky, and Donald, 2003). Relative to these cutoff scores, this patient had a low level of fear avoidance that may have enhanced the likelihood of a positive outcome with regard to conservative intervention. Previous studies have also demonstrated that changes in the Oswestry Disability Index throughout the episode of care are correlated to a change in patient-perceived disability. According to Ostelo et al. (2008), a higher score on the Oswestry is associated with higher level of perceived disability relative to their LBP. In addition, the minimal clinically important difference (MCID) for a positive outcome with regard to therapy is considered either 10 points (out of 100), or alternatively 30% between pre- and postadministrations of the Oswestry index when scores are relatively low (Ostelo et al, 2008). As this
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DOI: 10.3109/09593985.2014.949393
patient scored quite low on the initial exam (modified Oswestry ¼ 8%), it was determined that the patient had a relatively low level of perceived disability. Accordingly, it was assumed that the patient would demonstrate no clinically significant change in this outcome measure throughout the episode of care. Overall, this patient responded favorably to physical therapy care. A number of improvements were observed across a variety of outcome measures including posture, functional movements and subjective reports of pain and function. Self-report disability measures were low at the onset of treatment; therefore a significant change in the disability score was not expected. The patient was engaging in his usual activities; however, he was experiencing relatively high levels of pain with certain activities. Therefore, the most significant improvement was a decrease of 5–6 points on the numeric pain scale following prolonged sitting and engagement in recreational activity. From a pragmatic standpoint, a variety of benefits and drawbacks of an integrated approach were noted. Generally, a significant advantage was the relative increase in patient data collected, which may ultimately lead to a more thorough clinical picture. There is overlap in the exam process across systems, especially with the subjective history, and the standing active movement and postural assessments. However, the integrated exam took 2 h across two visits indicating the evaluative process was clinically inefficient. In particular, many of the tests utilized in the MSI system are not considered standard elements of the basic orthopedic exam. Further study of measurement qualities of these tests may help to improve efficiency without compromising diagnostic accuracy. The pursuit of the optimal orthopedic exam process is of course an important area for future scientific inquiry. Ultimately this reflects the ongoing challenge for every clinician to perform an exam that is comprehensive and to recognize when sufficient exam data have been collected to implement an effective plan of care.
Summary There are various ways physical therapists classify patient conditions. The existing classification systems differ in the type of patient data collected during examination, the clinical reasoning tools utilized in the diagnostic process and the named diagnostic subgroups. Adherence to any one system also impacts both the selection and prioritization of interventions. One advantage of using an established system is that a higher level of efficiency can be achieved in patient management. A disadvantage, however, is that utilizing a single system may limit the physical therapist’s perspective of the patient problem. Drawing information from multiple systems, as was attempted in this current case, can broaden and deepen the practitioner’s understanding of a clinical condition, albeit at the cost of efficiency. However, overall efficiency for the episode of care may be gained with improving initial diagnosis and treatment. Ideally, further attempts to truly integrate these established classification systems could lead to a more streamlined process which is both pragmatic and provides a more comprehensive clinical picture.
Declaration of interest The authors report no declarations of interest.
References Childs JD, Fritz JM, Flynn TW, Irrgang J, Johnson KK, Majkowski GR, Delitto A 2004 A clinical prediction rule to identify patients with low
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back pain most likely to benefit from spinal manipulation: A validation study. Annals of Internal Medicine 141: 920–928. Cook C, Hegedus E, Ramey K 2005 Physical therapy exercise intervention based on classification using the patient response method: A systematic review of the literature. Journal of Manual and Manipulative Therapy 13: 152–162. Davenport TE 2008 How should we interpret measures of patients’ fear of movement, injury, or reinjury in physical therapist practice? Journal of Orthopaedic and Sports Physical Therapy 38: 584–585. Delitto A, Erhard RE, Bowling RW 1995 A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Physical Therapy 75: 470–485. Delitto A, George SZ, VanDillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ 2012 Low back pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy 42: A1–A57. Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hermsmeyer J, Andresson G 2011 The role of classification of chronic low back pain. Spine 36: S19–S42. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S 2002 A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 27: 2835–2843. Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallance AS, Castel LD, Kalsbeek WD, Carey TS 2009 The rising prevalence of chronic low back pain. Archives of Internal Medicine 169: 251–258. Fritz JM, George SZ 2000 The use of a classification approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine 25: 106–114. Fritz JM, George SZ 2002 Identifying psychosocial variables in patients with acute work-related low back pain: The importance of fear avoidance beliefs. Physical Therapy 82: 973–983. George SZ, Fritz JM, Bialosky JE, Donald DA 2003 The effect of a fearavoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine 28: 2551–2560. Harris-Hayes M, Van Dillen LR 2009 The inter-tester reliability of physical therapists classifying low back pain problems based on the Movement System Impairment classification system. PM & R 1: 117–126. Karayannis NV, Jull GA, Hodges PW 2012 Physiotherapy movement based classification approaches to low back pain: Comparison of subgroups through review and developer/expert survey. BMC Musculoskeletal Disorders 13: 24. Kilpikoski S, Airaksinen O, Kankaanpa¨a¨ M, Leminen P, Videman T, Alen M 2002 Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 27: E207–E214. Martin BI, Deyo RA, Marza SK, Turner JA, Comstock BA, Hollingworth W, Sullivan SD 2008 Expenditures and health status among adults with back and neck problems. JAMA 299: 656–664. McKenzie RA, May S 2003 The lumbar spine: Mechanical diagnosis and therapy, 2nd edn. Waikanae, New Zealand, Spinal Publications. Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, Bouter LM, de Vet HC 2008 Interpreting change scores for pain and functional status in low back pain: Towards international consensus regarding minimal important change. Spine 33: 90–94. Sahrmann SA 2002 Diagnosis and treatment of movement impairment syndromes. St. Louis, MO, Mosby, Inc. Savage RA, Whitehouse GH, Roberts N 1997 The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. European Spine Journal 6: 106–114. Spoto MM, Collins J 2008 Physiotherapy diagnosis in clinical practice: A survey of orthopedic certified specialists in the USA. Physiotherapy Research International 13: 31–41. Stanton TR, Fritz JM, Hancock MJ, Latimer J, Maher CG, Wand BM, Parent EC 2011 Evaluation of a treatment-based classification algorithm for low back pain: A cross-sectional study. Physical Therapy 91: 496–509. Waddell G 2005 Subgroups within ‘‘nonspecific’’ low back pain. Journal of Rheumatology 32: 395–396.
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Appendix
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Appendix A. Movement system impairment syndromes and terminology (Sahrmann, 2002). Syndromes
Key test results associated with lumbar rotation/flexion syndrome
Lumbar Lumbar Lumbar Lumbar Lumbar
Forward flexion – symptoms increased Supine hip abd/LR – pelvis and lumbar spine rotate during initial 50% of movement and symptoms are produced Side-lying hip LR – pelvic rotation occurs Side-lying hip adduction – pelvic rotation occurs Prone hip rotation – pelvis and lumbar spine rotate during initial 50% of movement and symptoms are produced Quadruped rock back – lumbar rotation and pelvic tilt or rotation occurs Sitting knee extension – pelvis and lumbar spine rotate and symptoms are produced
flexion syndrome extension syndrome rotation syndrome rotation with flexion syndrome rotation with extension syndrome
Appendix B. Mechanical diagnosis and treatment terminology (McKenzie and May, 2003). Diagnostic criterion Derangement syndrome
Dysfunction syndrome Extension Flexion Side glide Postural syndrome
Definition An acute, subacute or chronic condition of the low back characterized by limitations in ROM, dynamic symptomatic responses including changes in pain presentation with repeated spinal movements and lasting symptomatic changes following movement. See below for specific symptomatic responses associated with movement. A chronic condition of the low back characterized by localized, end-range spine pain, limitations in ROM and intermittent symptoms. Pain will be produced with movement however no worse as a result. In contrast to derangement, the pain response to movement is relatively consistent with limited differences in pain/ROM following testing. A movement criterion is added to the dysfunction diagnosis toward the directional preference to movement (i.e. symptomatic response is reduced with flexion, extension or side-glide) A chronic condition of the low back characterized by localized spinal pain, normal ROM, no pain response with testing movements and pain produced with static positioning, such as slouched sitting/ standing.
Diagnostic terminology (symptomatic responses with movement) Increases (") Symptoms are present and increase in intensity Decreases (#) Symptoms are present and decrease in intensity Produced (P) Symptoms are not present at rest however are elicited with movement Abolished (A) Symptoms are present at rest and are eliminated with movement Worsened (W) Symptoms present at rest or produced increase with movement and remain worse as a result Better (B) Symptoms present at rest or produced decrease with movement and remain reduced as a result No Better (NB) Symptoms present or produced are decreased with movement but remain at baseline following movement Not worsened (NW) Symptoms present or produced are increased with movement but remain at baseline following movement Pain during movement (PDM) Symptoms appear or are increased as movement occurs and disappear or are reduced when movement ceases Pain at end-range (ERP) Pain does not appear until end-range is reached; pain disappears when end-range is released No effect (NE) or No change (NC) Symptomatic presentation is unaffected by movement
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Appendix C. Treatment-based classification system: categories and criteria. Diagnostic criterion
Definition
Mobilization
No symptoms distal to the knee Recent Onset symptoms (516 d) Low ‘‘Fear-Avoidance Belief Questionnaire - Work’’ (score 519) Hypomobility of the lumbar spine Hip IR ROM 435 Age 540 years Greater general flexibility (SLR 491 ) ‘‘Instability catch’’ or aberrant movements during lumbar flexion/extension ROM + Prone Lumbar Instability Test Signs and symptoms of nerve root compression No centralization Extension: Symptoms distal to buttock Symptoms centralize with lumbar extension Symptoms peripheralize with lumbar flexion Directional preference for extension
Stabilization (immobilization)
Traction
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Exercise-specific Flexion Extension Lateral shift
Flexion: Older age (450 years) Directional preference for flexion Imaging evidence of lumbar stenosis Lateral shift: Observation of lateral shift DP of lateral translation
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CASE REPORT
An integrated approach to the examination and treatment of a patient with chronic low back pain Marcia Miller Spoto, PT, DC, OCS1 and Greg Dixon, PT, DPT2 Physical Therapy Department, Nazareth College, Rochester, NY, USA and 2STAR Physical Therapy, Fairport, NY, USA
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Abstract
Keywords
Background and study design: Several physical therapy classification systems exist for low back pain (LBP). Little is known about how these systems could be integrated in clinical practice. This case report describes an episode of care utilizing elements of the mechanical diagnosis and therapy (MDT), movement system impairment (MSI) and treatment-based classification (TBC) systems. Case description: Patient History – the patient was a 40-year-old male presenting to an outpatient musculoskeletal clinic with a complaint of chronic LBP. Examination and diagnosis – there was moderate loss of lumbar extension ROM and joint mobility, and excessive lumbar flexion and rotation with active movement tests. Modified Oswestry Disability Index score ¼ 8%. Worst pain was described as 6/10. Intervention – the patient was treated once per week for seven consecutive weeks. Intervention focused on sitting postural corrections (MSI), functional movement corrections (MSI), lumbar mobilization (TBC) and extension-based exercise (MDT). Outcomes – at discharge, the patient reported a decrease in pain intensity (worst pain 0 to 1 out of 10) and demonstrated an improvement in the quality of lumbar movement and overall function. Discussion: Symptomatic response to active movement, observations of quality of movement and joint mobility assessment were key factors in directing a therapeutic program that was successful in helping the patient meet his treatment goals.
Classification, clinical guidelines, low back pain
Introduction Low back pain (LBP) is a problem that can range from a minor, transient episode of pain, to a serious disabling health condition. Despite advances in health care technology related to diagnosis and intervention, optimal management of LBP remains elusive. Published clinical guidelines help to outline evidence-based assessment procedures and intervention; however, they do not provide comprehensive clinical decision rules that help the clinician select specific treatments based upon patient examination data (Delitto et al, 2012). In addition, the cost associated with diagnosing and treating low back pain in the USA has increased substantially with no corresponding improvement in treatment outcome (Freburger et al, 2009; Martin et al, 2008). Considering the importance of diagnosis in directing appropriate treatments, there have been ongoing efforts among health care providers involved in spine care to develop meaningful diagnostic classification systems for LBP (Fairbank et al, 2011; Waddell, 2005). It has been long recognized that the majority of cases of LBP cannot be attributed to specific pathology and are therefore considered non-specific (Savage, Whitehouse, and Roberts, 1997). It also is accepted that people with LBP can and should be divided into clinical subgroups to better guide treatment (Fritz and George, 2002). In physical therapy practice, several LBP classification systems have evolved. The three models most frequently cited in the literature are: (1) Mechanical Diagnosis and Therapy Address correspondence to Marcia Miller Spoto, Physical Therapy Department, Nazareth College, Rochester, NY, USA. E-mail: mspoto7@ naz.edu
History Received 9 July 2013 Revised 23 May 2014 Accepted 3 June 2014 Published online 25 August 2014
(MDT); (2) Movement System Impairment (MSI) and (3) Treatment-based Classification (TBC) (Appendices A, B and C). All of these systems have named diagnostic categories, explicit inclusion criteria and propose specific interventions based upon the patient subgroup (Delitto, Erhard, and Bowling, 1995; McKenzie and May, 2003; Sahrmann, 2002). The MDT system emphasizes the assessment of symptomatic responses to a variety of static and dynamic lumbar spine motions including both single and repeated movements (McKenzie and May, 2003). The MSI system focuses primarily on identifying and correcting postural and movement impairments in a variety of positions: standing, sitting, supine, prone and quadruped. In contrast to both the MSI and MDT approaches, the TBC system categorizes patients into one of four specific treatment groups based on historical and symptomatic presentation: (1) manipulation; (2) stabilization; (3) specific exercise and (4) traction. Aspects of the TBC system have been tested to predict outcomes for therapeutic intervention following classification (Stanton et al, 2011). All three of these classification systems have been found to have acceptable levels of inter-tester reliability (Fritz and George, 2000; Harris-Hayes and Van-Dillen, 2009; Kilpikoski et al, 2002). There is also some evidence to support the validity of the systems, indicating improved treatment outcomes following systemspecific subgroup classification (Childs et al, 2004; Cook, Hegedus, and Ramey, 2005). Furthermore, no single classification system has been found to be superior to another (Fairbank et al, 2011). Although physical therapists may combine classification systems when making clinical decisions, little is known about how these somewhat disparate approaches to care could be integrated in clinical practice (Spoto and Collins, 2008).
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The purpose of this case report is to describe the management of a patient with chronic LBP utilizing clinical reasoning elements of the MDT, MSI and TBC systems in an integrated manner and to explore the congruency of these systems in directing treatment.
Case description
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History Prior to examination and data collection, patient consent was received and an informed consent was obtained. Approval was granted from the Nazareth College Institutional Review Board for implementation of this case study. The patient was a 40-year-old Caucasian male with a chief complaint of chronic bilateral lumbar paraspinal region pain. He reported an insidious onset of intermittent LBP that developed when working long hours as a truck driver 2 years previously. At the time of the initial examination the back pain was described as a dull ache that developed after either prolonged sitting or following strenuous exercise. The patient rated his LBP level on an 11-point numeric rating pain scale (NRS). He rated pain as 0/10 at rest and 6/10 at worst. Pain intensity levels had been consistent since the time of onset 2 years previously. The patient reported that standing, walking and lying alleviated his pain, whereas sitting and forward bending usually resulted in the production of pain. No clear 24-h pain pattern or pain with sleeping was noted and cough, sneeze or strain did not produce or worsen symptoms. No unexplained weight loss or history of previous trauma was reported. The patient was a full-time graduate teaching student in education and regularly participated in recreational ultimate frisbee and basketball. He additionally reported not taking medications and had no imaging studies. His past medical history as well as general health were otherwise unremarkable. Furthermore, he reported having previously received massage therapy for this condition, which provided temporary relief of symptoms. The patient’s goals were to reduce pain during sitting and following recreational sports. Physical examination Systems review Integument and neurological screen of the upper extremity and lower extremity myotomes and dermatomes were both unremarkable; achilles and patellar reflexes were normal bilaterally (2+). Tests and measures Posture A posterior pelvic tilt and decrease in lumbar lordosis were noted in both sitting and standing.
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Movement impairments (MSI) The primary movement impairments were noted during the following tests: (1) During forward bending and return from forward bending, the rate of lumbar spine movement was greater than hip/pelvic movement within the first 50% of the motion. Excessive lumbar flexion was noted at end-range of forward bend; (2) Lumbar flexion was observed in sitting posture; (3) Lumbar flexion and rotation were noted during active knee extension in short sitting and (4) Lumbopelvic rotation was noted within the first 50% of hip abduction/lateral rotation in supine and side-lying. Table 1 provides other pertinent MSI and MDT examination findings and Appendix A provides definitions regarding other positive MSI tests [i.e. (+) flexion or rotation impairments]. Muscle performance/manual muscle testing Bilateral gluteus maximus and hamstring muscles were noted to be weak and pain free. Muscle length. Impairments were noted in bilateral hamstring extensibility as well as in the rectus femoris, iliopsoas muscle groups and the tensor fascia latae (TFL) muscle groups bilaterally. Range of motion. Deficits were also present in bilateral hip goniometric measurement for both internal and external rotation (Table 2). Special testing/joint mobility. The prone lumbar instability test was negative. Hypomobility without pain was noted for posterior to anterior central vertebral pressures from L1 to L5. Palpation. Mild tenderness was reported just inferior to iliac crest over gluteus maximus and medius muscles bilaterally. Self-report and outcome measures. The Fear Avoidance Belief Questionnaire (FABQ) was used to assess the patient’s perceived fear of movement due to the presence of LBP and the relative likelihood of a positive outcome with conservative therapeutic intervention (Davenport, 2008). The FABQ has demonstrated both adequate internal consistency and validity with regard to predicting disability and work loss in patients with LBP. The Modified Oswestry outcome measure, which has established clinical reliability, validity and responsiveness, was additionally administered to assess patient perceived disability relative to the presence of LBP (Ostelo et al, 2008). Results from both outcome measures were as follows: FABQ scores ¼ physical activity (FABW PA) – 10/24 and work (FABQ W) – 5/42; Modified Oswestry score ¼ 8%.
Single/repeated movements testing (MDT)
Diagnosis, evaluation and clinical assessment
Back pain prior to movement testing was 0/10 NRS. Pain was produced at end-range movement with single flexion in standing (FIS), single/repeated extension in standing (EIS, Rep EIS), single/repeated flexion in lying (FIL, Rep FIL), however was no worse as a result. Pain at onset and during movement was noted with return from forward bending and repeated flexion (Rep FIS). In addition, there was no change in lumbar spine alignment following repeated movement testing (Table 1).
General physical therapy diagnosis The patient presented with chronic, intermittent, central lumbar region pain with associated impairments of muscle performance, muscle length, motor control, ROM and joint mobility. At present, the condition was negatively impacting his quality of life and ability to tolerate work in a sitting position for extended periods of time, therefore skilled intervention was indicated.
Static testing (MDT) Pain was produced in the lumbar spine following slouched sitting for 1 min. Decreased LBP was reported following manual correction of sitting posture.
Classification system-specific diagnoses The specific diagnostic classifications based on the unique clinical rationale of each system are presented below.
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DOI: 10.3109/09593985.2014.949393
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Table 1. Integrated examination findings (MSI, MDT and TBC). Testa
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Standing Flexion in Standing (MSI, MDT) Return from forward bend (MSI, MDT) Repeated FIS (MDT, TBC) Extension (MSI, MDT) Repeated EIS (MDT, TBC) R side bending (MSI) L side bending (MSI) Sitting R knee extension (MSI) L knee extension (MSI) Static slouched sitting (MSI, MDT) Supine R knee to chest (MSI) L knee to chest (MSI) Passive hip/knee flexion (MSI) FIL (MDT) Repeated FIL (MDT) R hip abd/LR (MSI) L hip abd/LR (MSI)
ROM Mod " lumbar flexion NE Mod # lumbar extension NE
Mod " lumbar flexion/rotation Mod " lumbar flexion/rotation NA
NA NE
Sidelying: (MSI) L hip abd/LR R hip abd/LR L hip abd/Add R hip abd/Add Prone EIL (MDT) Repeated EIL (MDT) R knee flexion (MSI)
NA NE
L knee flexion (MSI) R hip LR (MSI) R hip MR (MSI, TBC) L hip LR (MSI) L hip MR (MSI, TBC) Quadruped (MSI): R arm lift L arm lift Rocking back
Pain (0/10 pretest)
Impairment (MSI)
Correction (MSI)
(+) Flexion
NA
# pain with correction # pain with correction NA
(+) Flexion
NA
NA
NA
() ()
NA NA NA
Prod 4/10 at 1 min, NW;
(+) Flexion; (+) Rotation (+) Flexion; (+) Rotation NA
NC NC NC
() () ()
NA NA NA
Prod (1–2/10), NW Prod (1–2/10), NW NC NC
NA NA (+) Rotation (+) Rotation
NA NA NA NA
NC NC NC NC
(+) (+) (+) (+)
Rotation Rotation Rotation Rotation
NA NA NA NA
NC NC NC
NA NA NA
NC NC NC NC
NA NA (+) Extension, (+) Rotation (+) Extension, (+) Rotation (+) Rotation (+) Rotation (+) Rotation (+) Rotation
NC NC NC
() () (+) Flexion
NA NA NA
Prod at end-range (1–2/10), NW; Prod at onset/during mvt (1–2/10); Prod at onset/during mvt (1–2/10), NW; Prod at end-range (1–2/10), NW Prod at end-range (1–2/10), NW NC NC NC NC
NC 25 35 15 25
Mod " lumbar flexion
(+) Extension
NA # pain with correction
NA NA NA NA NA
Additional tests (TBC) P-A central vertebral pressure (joint mobility): hypomobility L1–L5 Prone instability test: negative NA, not applicable; NC, no change; NE, no effect; NW, no worse; WNL, within normal limits. Tests specific to each system outlined in parentheses.
a
Mechanical diagnosis and therapy According to the diagnostic criteria for the McKenzie system, this patient demonstrated signs and symptoms most consistent with posterior derangement syndrome (‘‘D1 derangement’’) (McKenzie and May, 2003). The patient demonstrated pain at the onset of active return from forward flexion and pain with both single and with repeated forward flexion, indicating pain during movement. Pain during movement is only found in the derangement syndrome of MDT classification. Additional considerations for the diagnosis of derangement syndrome included ruling out flexion dysfunction, as flexion range of
motion was full. Extension ROM was limited but not painful in prone extension (gravity eliminated); therefore extension dysfunction was ruled out. Finally, the patient’s signs and symptoms were not consistent with Posture syndrome because pain was modified with movement and not merely present with static positioning. Movement system impairment Based on clinical findings, the current patient would be classified as having a lumbar rotation with flexion syndrome. The primary dysfunction of this syndrome is that a segment of the lumbar spine
M. M. Spoto & G. Dixon
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This patient’s clinical findings were most consistent with meeting the criteria for the manipulation subgroup (3–4/5). Satisfied criteria include: (1) no lumbar spine-related symptoms below the knee; (2) lumbar spine segmental hypomobility; (3) low FABQ scores and (4) at least one hip with 435 of internal rotation. The last criterion was borderline, as the right hip was measured at 35 (Flynn et al, 2002).
Results from the FABQ indicate low levels of patient-perceived fear avoidance for both the physical activity (10/24) and work (5/42) subscales. Modified Oswestry Disability Index Data from the Oswestry reflect a relatively low level of patientperceived disability (8%) with regard to his LBP. Prognosis
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Treatment-based classification
Fear-avoidance Beliefs Questionnaire
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moves most easily or naturally in the direction of rotation-flexion, and pain is reproduced during flexion-based movements or postures. The specific diagnostic classification is determined based on the patient’s directional susceptibility to movement and corresponding symptomatic responses (Sahrmann, 2002). In this case the patient presented with a directional susceptibility toward flexion and rotation postures and movement. This was based on positive findings in 9 flexion and 12 rotation tests across the exam. In addition, only three tests were positive for extension impairments and the remaining tests were negative for directionspecific impairments.
Findings
Self-stretching for TFL * Supine straight leg hip adduction with belt assist * Lateral shift in quadruped * Standing hip adduction crossover Manual B hamstring stretch Supine piriformis stretch Prone lumbar extensions with grade 1 mobilization Muscle re-education training in quadruped (transverse abdominus and multifidus) * Neutral pelvic cueing Alternating arm/leg extensions in quadruped HEP provided * Self-postural corrections * Hamstring/TFL stretches * Supine, isometric core stabilization exercises * Supine Bridges
g
Reassessment performed Manual postural and movement corrections (MSI) – verbal/tactile cueing provided throughout * Forward bend in standing * Return from forward bend * Sitting postural alignment * Semi-hooklying hip LR/abd * SL hip abduction Manual 90/90 hamstring stretch Soft tissue massage B hamstrings in supine Supine bridges (bilateral and alternating LE) Wall squats with yellow Swiss ball
g
Manual 90/90 hamstring stretch Supine straight leg TFL stretch with belt assist Soft tissue massage B hamstrings ‘‘Pigeon’’ stretch for piriformis Supine bridges with hip abduction Supine dead bugs Short sitting pelvic tilt awareness training * Unilateral knee extensions * Unilateral hip flexions Prone lumbar extension with grade 1–2 mobilizations * Hips neutral * Hips offset Side-lying planks with knees flexed Alternating straight leg extensions in quadruped * Neutral pelvic cueing
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Completed initial tests and measures for physical examination (MSI) Manual postural and movement corrections (MSI) – verbal/tactile cueing provided throughout * Forward bend in standing * Return from forward bend * Sitting alignment * Semi-hooklying hip LR/abd * SL hip abduction Prone lumbar extensions – verbal cues Manual B hamstring stretch Supine bridges – manual cueing g
Week 2 – Treatment Session 1
Table 2. Visitations and progression of interventions.
Week 3 – Treatment Session 2
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Week 5 – Treatment Session 3
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Week 6 – Treatment Session 4
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Prognosis was determined ‘‘good’’ for stated impairments and functional limitations primarily based on low self-perceived disability and pain. Goals Functional and measureable goals were established based on the patient’s specific exam findings and desired outcomes for therapy. Expected outcomes were established to assess patient progress across a number of domains following the episode of care. The patient’s primary functional and pain-related goals for therapy were integrated into the therapeutic goals. As a result, successful completion of the goals would reflect improvement across both patient-perceived problems and clinically established impairments/functional limitations. Expected outcomes were as follows as the patient will: (1) report 0/10 pain and minimal lumbar spine muscular fatigue when short sitting with proper posture for at least 5 min in 7 weeks; (2) increase lumbar extension ROM to WNL in 7 weeks and (3) decrease pain with Rep FIS to 0/10 in 7 weeks to demonstrate increased tolerance during functional tasks such as athletics and student teaching. The above goals were based on the clinical hypothesis that postural stress and muscle strength/length impairments were the primary contributors to the patient’s LBP. The plan of care was primarily intended to promote core/LE strength/flexibility and improve neutral lumbopelvic positioning. Intervention The patient was seen one visit per week across 7 weeks (six visits total). Initial and final examinations were performed
Integrated approach to diagnose and treat LBP
DOI: 10.3109/09593985.2014.949393
on Weeks 1 and 7, respectively, and the patient did not attend therapy on Week 4 (Table 2). Primary interventions included postural/functional movement retraining, manual and self-lower extremity stretching, therapeutic exercise, soft tissue massage, modalities and joint mobilization. Postural and functional movement retraining was provided for a number of positions (sitting, standing and quadruped) and movements (forward bend, return from forward bend, reaching in quadruped). Manual and active self-stretches were performed on the hamstring, TFL, piriformis and rectus femoris muscle groups bilaterally.
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Therapeutic exercise was initiated at the second visit with an emphasis on core strengthening in neutral spinal positions and included strengthening of the transversus abdominus, multifidus, internal/external obliques and gluteus maximus. A home exercise program (HEP) was provided emphasizing postural education, LE flexibility, and strength promotion of the aforementioned muscle impairments. Extension-in-lying (EIL) was prescribed and progressed to EIL with manual P to A mobilizations. Specifically, a MDT method of passive overpressure during patient-directed extension was used. Manual deep soft tissue massage was also
Table 3. Post-Treatment Outcomes: Active Movement Tests.
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Testa Standing Flexion in Standing (MSI, MDT) Return from forward bend (MSI, MDT) Repeated FIS (MDT, TBC) Extension (MSI, MDT) Repeated EIS (MDT, TBC)
ROM Mod " lumbar flexion NE Mod # lumbar extension; WNL lumbar extension NE
R side bending (MSI) L side bending (MSI) Sitting (MSI, MDT) R knee extension (MSI) L knee extension (MSI) Static slouched sitting (MSI, MDT) Supine (MSI, MDT) R knee to chest (MSI) L knee to chest (MSI) Passive hip/knee flexion (MSI) FIL (MDT) Repeated FIL (MDT) R hip abd/LR (MSI) L hip abd/LR (MSI)
Mod " lumbar flexion/rotation Mod " lumbar flexion/rotation NA
NA NE
Sidelying (MSI) L hip abd/LR R hip abd/LR L hip abd/add R hip abd/add Prone (MSI, MDT) EIL (MDT) Repeated EIL (MDT) R knee flexion (MSI)
NA NE
L knee Flexion (MSI) R hip LR (MSI) R hip MR (MSI, TBC) L hip LR (MSI) L hip MR (MSI, TBC) Quadruped (MSI): R arm lift L arm lift Rocking back
Pain (0/10 pretest)
26 39 22 31
Mod " lumbar flexion
Correction (MSI)
NA
# pain with correction # pain with correction NA
(+) Flexion
NA
NA
NA
(Negative) (Negative)
NA NA
(+) Flexion; (+) Rotation; (Negative) (+) Flexion; (+) Rotation; (Negative) NA
NA
NC NC NC Prod (1–2/10), NW; NC Prod (1–2/10), NW; NC NC NC
(Negative) (Negative) (Negative) NA NA (+) Rotation; (Negative) (+) Rotation; (Negative)
NA NA NA NA NA NA NA
NC NC NC NC
(+) (+) (+) (+)
(Negative) (Negative) (Negative) (Negative)
NA NA NA NA
NC NC NC
NA NA NA
NC NC NC NC
NA NA (+) Extension, (+) Rotation (+) Extension, (+) Rotation (+) Rotation; (Negative) (+) Rotation; (Negative) (+) Rotation; (Negative) (+) Rotation; (Negative)
NC NC NC
(Negative) (Negative) (+) Flexion; (Negative)
NA NA NA
Prod at end-range (1–2/10), NW; NC Prod at onset/during mvt (1–2/10); NC Prod at onset/during mvt (1–2/10), NW; Prod (1/10 on L side only) Prod at end-range (1–2/10), NW; Prod at end-range (1/10), NW Prod at end-range (1–2/10), NW; Prod at end-range (1/10), NW NC NC NC NC Prod 4/10 at 1 min, NW; NC
NC 25 ; 35 ; 15 ; 25 ;
Impairment (MSI) (+) Flexion; (Negative) (+) Extension; (Negative)
Rotation; Rotation; Rotation; Rotation;
NA # pain with correction
NA NA NA NA NA
Initial exam data ¼ not bold; outcome data and clinically significant differences ¼ bold. NA, not applicable; NC, no change; NE, no effect; NW, no worse; WNL, within normal limits. a Tests specific to each system outlined in parentheses.
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provided to the hamstrings bilaterally. Table 3 provides the specific training provided at each physical therapy session.
Outcomes At the conclusion of therapy, the patient’s LBP had significantly reduced since the onset of skilled intervention and was currently 0/10 when short sitting at rest and was minimal the day after exercise (0–1/10); at worst pain was 1/10 with prolonged bouts of sitting (45 min). The patient had also demonstrated proficiency with the home exercise program indicating the potential for further improvement and maintenance of the patient’s condition following the conclusion of therapeutic intervention.
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Movement system impairment Subjective improvements were observed by the examiner for all static postures and dynamic movement impairments listed in examination (see Table 3). Mechanical diagnosis and therapy Single FIS was no longer painful; RepFIS and RepEIS was 1/10 pain at end-range; FIL and RepFIL reduced to 0/10. Modified Oswestry No change in disability percentage (8%) between initial and final visit. Goals Expected outcomes 1 and 2 were satisfied, however goal 3 was not fully achieved. Although there was no right-sided lumbar spine pain reported with repeated FIS, 1/10 left-sided pain remained at the conclusion of therapy.
Discussion The purpose of this case report was to utilize an integrated approach to the examination, classification and treatment of a patient with LBP. The primary purpose of diagnostic classification is to inform appropriate intervention. Thus, each of the three classification systems would lead to the selection of intervention specific to the diagnosis. Although there is a growing body of evidence within each system to support their validity, little is known about how these systems may be utilized together to inform treatment decisions. Karayannis, Jull and Hodges (2012) studied the prevalence and overlap of movement-based classification systems and suggested that an integrated approach could facilitate clinical decision-making. In this case, the treatment program reflects a synergistic application of clinical decisionmaking tools unique to each system. From a global perspective, this patient presents with chronic, localized LBP. His occupation requires prolonged sitting postures, which may have contributed to movement impairments that include a loss of extension ROM and mobility as well as a directional susceptibility to lumbar flexion and rotation. In addition, he responded well to sitting postural corrections including neutral spine positioning. These findings helped establish general guidelines for treatment. In the MDT system, posterior derangement is treated primarily with extension-based exercise along with postural re-education emphasizing avoidance of flexion positions and postures (McKenzie and May, 2003). These principles were adhered to in treating this case. Similarly, flexion and rotation syndromes in the MSI system are addressed with patient education directed at limiting impairments of lumbar flexion and rotation movements and postures (Sahrmann, 2002). In addition, test
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movements that were found to reproduce symptoms and/or display movement impairments were targeted for corrective exercise. Additionally, a primary emphasis in treating flexion with rotation syndromes in MSI is to facilitate abdominal control of trunk movement. Therefore, core stability exercises were incorporated into the treatment plan. Refer to Table 2 for specific movement re-education interventions used with this patient. The application of the TBC classification system to the patient case is less clear. In a general sense, challenges have been associated with assigning treatment categories to patients with acute and subacute LBP; in one study up to one-half of LBP patients could not be placed into a single category (Stanton et al, 2011). Additionally, this patient had chronic pain and relatively low levels of disability, which may further complicate the diagnostic process given that the treatment-based categories were originally established for patients with higher levels of disability (Delitto, Erhard, and Bowling, 1995). This patient’s clinical findings were most consistent with the manipulation subgroup. Thus, lumbar mobilization was part of the treatment plan. Regardless, when using an impairment-based approach, the finding of lumbar joint hypomobility would have been sufficient to support this treatment choice. A few incongruencies in clinical decision rules for these classification systems were noted when applying them to this case. First, the TBC system would direct treatment of a grade 5 mobilization (manipulation) to the patient. The MDT system, however, includes a ‘‘progression of forces’’ principle whereby the amount of therapist-generated force is informed by patient response and patient-generated forces are given preference (McKenzie and May, 2003). In this case, lower grades of joint mobilization were combined with extension exercise in the context of the MDT system and due to the favorable response, manipulation was not performed. Second, the TBC approach differentiates patients that are treated primarily with manipulation versus lumbar stabilization. Patients meeting the criteria for the lumbar flexion with rotation subgroup in MSI are provided abdominal control exercise interventions, which are part of core stabilization. This patient met the criteria for both the manipulation subgroup (TBC) and flexion with rotation subgroup (MSI). As spinal mobility impairments were coexistent with core strength impairments, both were addressed in the plan of care. Finally, the TBC approach also differentiates patients that are treated with lumbar extension exercise versus manipulation. As this patient met the criteria for the TBC manipulation subgroup and the MDT derangement subgroup, and as derangement is treated with extension-based exercise, both joint mobilization and extension exercise were prescribed. Several outcome measures were used in the diagnosis and care of this patient. Previous studies have reported cutoff scores that predict poor treatment outcomes for the FABQ-PA and FABQ-W scores of 414/24 and 429/42, respectively (Fritz and George, 2002; George, Fritz, Bialosky, and Donald, 2003). Relative to these cutoff scores, this patient had a low level of fear avoidance that may have enhanced the likelihood of a positive outcome with regard to conservative intervention. Previous studies have also demonstrated that changes in the Oswestry Disability Index throughout the episode of care are correlated to a change in patient-perceived disability. According to Ostelo et al. (2008), a higher score on the Oswestry is associated with higher level of perceived disability relative to their LBP. In addition, the minimal clinically important difference (MCID) for a positive outcome with regard to therapy is considered either 10 points (out of 100), or alternatively 30% between pre- and postadministrations of the Oswestry index when scores are relatively low (Ostelo et al, 2008). As this
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DOI: 10.3109/09593985.2014.949393
patient scored quite low on the initial exam (modified Oswestry ¼ 8%), it was determined that the patient had a relatively low level of perceived disability. Accordingly, it was assumed that the patient would demonstrate no clinically significant change in this outcome measure throughout the episode of care. Overall, this patient responded favorably to physical therapy care. A number of improvements were observed across a variety of outcome measures including posture, functional movements and subjective reports of pain and function. Self-report disability measures were low at the onset of treatment; therefore a significant change in the disability score was not expected. The patient was engaging in his usual activities; however, he was experiencing relatively high levels of pain with certain activities. Therefore, the most significant improvement was a decrease of 5–6 points on the numeric pain scale following prolonged sitting and engagement in recreational activity. From a pragmatic standpoint, a variety of benefits and drawbacks of an integrated approach were noted. Generally, a significant advantage was the relative increase in patient data collected, which may ultimately lead to a more thorough clinical picture. There is overlap in the exam process across systems, especially with the subjective history, and the standing active movement and postural assessments. However, the integrated exam took 2 h across two visits indicating the evaluative process was clinically inefficient. In particular, many of the tests utilized in the MSI system are not considered standard elements of the basic orthopedic exam. Further study of measurement qualities of these tests may help to improve efficiency without compromising diagnostic accuracy. The pursuit of the optimal orthopedic exam process is of course an important area for future scientific inquiry. Ultimately this reflects the ongoing challenge for every clinician to perform an exam that is comprehensive and to recognize when sufficient exam data have been collected to implement an effective plan of care.
Summary There are various ways physical therapists classify patient conditions. The existing classification systems differ in the type of patient data collected during examination, the clinical reasoning tools utilized in the diagnostic process and the named diagnostic subgroups. Adherence to any one system also impacts both the selection and prioritization of interventions. One advantage of using an established system is that a higher level of efficiency can be achieved in patient management. A disadvantage, however, is that utilizing a single system may limit the physical therapist’s perspective of the patient problem. Drawing information from multiple systems, as was attempted in this current case, can broaden and deepen the practitioner’s understanding of a clinical condition, albeit at the cost of efficiency. However, overall efficiency for the episode of care may be gained with improving initial diagnosis and treatment. Ideally, further attempts to truly integrate these established classification systems could lead to a more streamlined process which is both pragmatic and provides a more comprehensive clinical picture.
Declaration of interest The authors report no declarations of interest.
References Childs JD, Fritz JM, Flynn TW, Irrgang J, Johnson KK, Majkowski GR, Delitto A 2004 A clinical prediction rule to identify patients with low
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back pain most likely to benefit from spinal manipulation: A validation study. Annals of Internal Medicine 141: 920–928. Cook C, Hegedus E, Ramey K 2005 Physical therapy exercise intervention based on classification using the patient response method: A systematic review of the literature. Journal of Manual and Manipulative Therapy 13: 152–162. Davenport TE 2008 How should we interpret measures of patients’ fear of movement, injury, or reinjury in physical therapist practice? Journal of Orthopaedic and Sports Physical Therapy 38: 584–585. Delitto A, Erhard RE, Bowling RW 1995 A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Physical Therapy 75: 470–485. Delitto A, George SZ, VanDillen L, Whitman JM, Sowa G, Shekelle P, Denninger TR, Godges JJ 2012 Low back pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy 42: A1–A57. Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hermsmeyer J, Andresson G 2011 The role of classification of chronic low back pain. Spine 36: S19–S42. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S 2002 A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 27: 2835–2843. Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallance AS, Castel LD, Kalsbeek WD, Carey TS 2009 The rising prevalence of chronic low back pain. Archives of Internal Medicine 169: 251–258. Fritz JM, George SZ 2000 The use of a classification approach to identify subgroups of patients with acute low back pain. Interrater reliability and short-term treatment outcomes. Spine 25: 106–114. Fritz JM, George SZ 2002 Identifying psychosocial variables in patients with acute work-related low back pain: The importance of fear avoidance beliefs. Physical Therapy 82: 973–983. George SZ, Fritz JM, Bialosky JE, Donald DA 2003 The effect of a fearavoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine 28: 2551–2560. Harris-Hayes M, Van Dillen LR 2009 The inter-tester reliability of physical therapists classifying low back pain problems based on the Movement System Impairment classification system. PM & R 1: 117–126. Karayannis NV, Jull GA, Hodges PW 2012 Physiotherapy movement based classification approaches to low back pain: Comparison of subgroups through review and developer/expert survey. BMC Musculoskeletal Disorders 13: 24. Kilpikoski S, Airaksinen O, Kankaanpa¨a¨ M, Leminen P, Videman T, Alen M 2002 Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 27: E207–E214. Martin BI, Deyo RA, Marza SK, Turner JA, Comstock BA, Hollingworth W, Sullivan SD 2008 Expenditures and health status among adults with back and neck problems. JAMA 299: 656–664. McKenzie RA, May S 2003 The lumbar spine: Mechanical diagnosis and therapy, 2nd edn. Waikanae, New Zealand, Spinal Publications. Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, Bouter LM, de Vet HC 2008 Interpreting change scores for pain and functional status in low back pain: Towards international consensus regarding minimal important change. Spine 33: 90–94. Sahrmann SA 2002 Diagnosis and treatment of movement impairment syndromes. St. Louis, MO, Mosby, Inc. Savage RA, Whitehouse GH, Roberts N 1997 The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. European Spine Journal 6: 106–114. Spoto MM, Collins J 2008 Physiotherapy diagnosis in clinical practice: A survey of orthopedic certified specialists in the USA. Physiotherapy Research International 13: 31–41. Stanton TR, Fritz JM, Hancock MJ, Latimer J, Maher CG, Wand BM, Parent EC 2011 Evaluation of a treatment-based classification algorithm for low back pain: A cross-sectional study. Physical Therapy 91: 496–509. Waddell G 2005 Subgroups within ‘‘nonspecific’’ low back pain. Journal of Rheumatology 32: 395–396.
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Appendix
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Appendix A. Movement system impairment syndromes and terminology (Sahrmann, 2002). Syndromes
Key test results associated with lumbar rotation/flexion syndrome
Lumbar Lumbar Lumbar Lumbar Lumbar
Forward flexion – symptoms increased Supine hip abd/LR – pelvis and lumbar spine rotate during initial 50% of movement and symptoms are produced Side-lying hip LR – pelvic rotation occurs Side-lying hip adduction – pelvic rotation occurs Prone hip rotation – pelvis and lumbar spine rotate during initial 50% of movement and symptoms are produced Quadruped rock back – lumbar rotation and pelvic tilt or rotation occurs Sitting knee extension – pelvis and lumbar spine rotate and symptoms are produced
flexion syndrome extension syndrome rotation syndrome rotation with flexion syndrome rotation with extension syndrome
Appendix B. Mechanical diagnosis and treatment terminology (McKenzie and May, 2003). Diagnostic criterion Derangement syndrome
Dysfunction syndrome Extension Flexion Side glide Postural syndrome
Definition An acute, subacute or chronic condition of the low back characterized by limitations in ROM, dynamic symptomatic responses including changes in pain presentation with repeated spinal movements and lasting symptomatic changes following movement. See below for specific symptomatic responses associated with movement. A chronic condition of the low back characterized by localized, end-range spine pain, limitations in ROM and intermittent symptoms. Pain will be produced with movement however no worse as a result. In contrast to derangement, the pain response to movement is relatively consistent with limited differences in pain/ROM following testing. A movement criterion is added to the dysfunction diagnosis toward the directional preference to movement (i.e. symptomatic response is reduced with flexion, extension or side-glide) A chronic condition of the low back characterized by localized spinal pain, normal ROM, no pain response with testing movements and pain produced with static positioning, such as slouched sitting/ standing.
Diagnostic terminology (symptomatic responses with movement) Increases (") Symptoms are present and increase in intensity Decreases (#) Symptoms are present and decrease in intensity Produced (P) Symptoms are not present at rest however are elicited with movement Abolished (A) Symptoms are present at rest and are eliminated with movement Worsened (W) Symptoms present at rest or produced increase with movement and remain worse as a result Better (B) Symptoms present at rest or produced decrease with movement and remain reduced as a result No Better (NB) Symptoms present or produced are decreased with movement but remain at baseline following movement Not worsened (NW) Symptoms present or produced are increased with movement but remain at baseline following movement Pain during movement (PDM) Symptoms appear or are increased as movement occurs and disappear or are reduced when movement ceases Pain at end-range (ERP) Pain does not appear until end-range is reached; pain disappears when end-range is released No effect (NE) or No change (NC) Symptomatic presentation is unaffected by movement
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Appendix C. Treatment-based classification system: categories and criteria. Diagnostic criterion
Definition
Mobilization
No symptoms distal to the knee Recent Onset symptoms (516 d) Low ‘‘Fear-Avoidance Belief Questionnaire - Work’’ (score 519) Hypomobility of the lumbar spine Hip IR ROM 435 Age 540 years Greater general flexibility (SLR 491 ) ‘‘Instability catch’’ or aberrant movements during lumbar flexion/extension ROM + Prone Lumbar Instability Test Signs and symptoms of nerve root compression No centralization Extension: Symptoms distal to buttock Symptoms centralize with lumbar extension Symptoms peripheralize with lumbar flexion Directional preference for extension
Stabilization (immobilization)
Traction
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Exercise-specific Flexion Extension Lateral shift
Flexion: Older age (450 years) Directional preference for flexion Imaging evidence of lumbar stenosis Lateral shift: Observation of lateral shift DP of lateral translation
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