Case Report. Classification, Intervention, and Outcomes for a Person With Lumbar Rotation With Flexion Syndrome. Key Words:

Transcription

1 Case Report Key Words: Classification, Intervention, and Outcomes for a Person With Lumbar Rotation With Flexion Syndrome Background and Purpose. The purpose of this case report is to describe the classification, intervention, and outcomes for a patient with lumbar rotation with flexion syndrome. Case Description. The patient was a 22-year-old man with a medical diagnosis of low back strain. Impairments in lumbar flexion and right rotation and lateral bending were identified. Daily activities and positions associated with these actions were associated with increased low back pain (LBP). Instruction focused on modifying lumbar rotation and flexion movements and alignments in daily activities. Exercises to address the direction-specific impairments were prescribed. Outcomes. The patient participated in 4 visits and completed a questionnaire 1 year after intervention. The patient reported a decrease in symptoms, disability, and frequency of recurrences. Discussion. Repetition of specific strategies (alignment and movement) during activities may result in specific impairments that contribute to LBP. Modification of the strategies and exercises to change contributing factors are proposed to help alleviate symptoms, disability, and recurrences. [Van Dillen LR, Sahrmann SA, Wagner JM. Classification, intervention, and outcomes for a person with lumbar rotation with flexion syndrome. Phys Ther. 2005;85: ] Classification, Low back pain, Recurrence. Linda R Van Dillen, Shirley A Sahrmann, Joanne M Wagner 336 Physical Therapy. Volume 85. Number 4. April 2005

2 One system for classifying low back Data suggest that, following an episode of low back pain (LBP), the problem often persists and many people do not fully recover after 12 months. 1 Recurrences of LBP also are common. 2 Despite the high costs associated with such a fluctuating clinical course, no management strategy has been found to be consistently effective in alleviating the symptoms and related disability, and, more importantly, in curtailing the recurrences. Some authors 3,4 have suggested that the lack of evidence to support any one intervention occurs because studies are being conducted on heterogeneous groups of people with LBP and that a system for classifying more homogeneous groups of people with LBP is needed. Some classification systems have been proposed for categorizing LBP problems based on variables relevant to physical rehabilitation. 5,6 The purpose for developing these classification systems is to describe homogeneous subgroups of patients with LBP who may respond better to interventions that are category-specific than to interventions that are not category-specific. To date, no classification system has been found to be applicable to all patients with LBP, 7 and research on the scientific properties of a number of systems continues. One system for classifying LBP is the Movement System, Impairment (MSI) classification system. The MSI system has been described by Sahrmann, 8 and studies examining various aspects of the system are ongoing The MSI consists of 5 general LBP categories that are believed to be most frequently encountered in clinical practice. The categories are named for the specific direction or directions of trunk movements and alignments associated with a person s LBP problem and should be the focus of physical therapy intervention. To date, the overall categories described are: (1) lumbar flexion, (2) lumbar extension, (3) lumbar rotation, pain is the Movement System, Impairment (MSI) classification system. (4) lumbar rotation with flexion, and (5) lumbar rotation with extension. 8 Currently, a patient s LBP problem is classified in the MSI system based on information obtained from a standardized examination that consists of a history and physical examination. 9 The history includes information on demographics and the patient s LBP history and activity level. The physical examination includes: (1) tests in which symptoms are monitored while the person performs movements (trunk and limb) or assumes positions that are believed to impose directionspecific (flexion, extension, rotation) stresses on the lumbar region and (2) judgments of alterations of movements and alignments in various positions. For example, one test requires the patient to perform a forward-bending movement while standing. The patient is asked whether the symptoms were altered during the movement compared with the symptoms during standing. The examiner also judges the relative timing of hip and spine flexion with the movement. The examination is similar to others for LBP because it includes tests of trunk movements and positions in which symptoms are monitored (ie, the patient is asked about any change in LBP with the test relative to LBP with some reference position or movement). Unlike other examinations, however, the MSI examination pays attention to the effect of: (1) limb movements on symptoms and (2) modifying lumbar spine alignment or restricting lumbar spine movement during previously symptomatic tests. 12,13 In addition, examiner judgments focus on the relative timing of movements of the spine and proximal joints during both trunk and limb movements. LR Van Dillen, PT, PhD, is Assistant Professor, Program in Physical Therapy, Washington University School of Medicine, Campus Box 8502, St Louis, MO (USA) (vandillenl@msnotes.wustl.edu). Address all correspondence to Dr Van Dillen. Reprints will not be available from the corresponding author. SA Sahrmann, PT, PhD, FAPTA, is Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington University School of Medicine. JM Wagner, PT, MSPT, ATC, is a doctoral candidate, Movement Sciences, Program in Physical Therapy, Washington University School of Medicine. Dr Van Dillen and Dr Sahrmann provided concept/idea/project design. Dr Van Dillen provided writing, data collection, and fund procurement. Dr Sahrmann and Ms Wagner provided consultation (including review of manuscript before submission). This work was presented, in part, at the Combined Sections Meeting of the American Physical Therapy Association; February 20 24, 2002; Boston, Mass. This work was funded by the National Institutes of Health, National Institute of Child Health and Human Development, National Center for Medical Rehabilitation Research, grant K01 HD This article was received October 9, 2003, and was accepted September 27, Physical Therapy. Volume 85. Number 4. April 2005 Van Dillen et al. 337

3 Currently, the classification of a patient s LBP is based on identification of a consistent pattern of alignments and movements in a specific direction or directions that increase and decrease the patient s symptoms across tests. Information from examiner judgments of altered alignment and movement also are considered in confirming the specific direction or directions of alignment and movement believed to contribute to the person s LBP. In general, those movements and alignments most consistently identified across the examination become the patient s LBP category. The theory underlying the MSI approach to examination and intervention is that a person s LBP is the result of repetition of: (1) trunk and limb movements that induce movement of the lumbar spine region and (2) assumption of prolonged positions of the spine associated with a specific direction. These repeated movements and alignments of the lumbar spine are believed to result in adoption of movement and alignment strategies that are generalized across the person s daily activities. Repetition is believed to contribute to changes in movement system factors (eg, muscle extensibility, timing and force production of muscle), which then contribute to the continued use of the directionspecific strategies. Like other investigators, we argue that exposure of spinal tissue to loads below the magnitude of failure during prolonged trunk postures and repeated trunk movements contributes to cumulative tissue stress and eventually to LBP. Because the repeated movements and postures are performed in the same direction during several activities, however, we argue that accumulation of tissue stress in the lumbar region is potentially accelerated compared with conditions in which there are a variety of directions of movement and alignments occurring in the lumbar region. 8 We also contend that, until the factors contributing to the use of the directional strategies are modified, the LBP problem will persist or recur. The purposes of this case report are: (1) to describe the use of the MSI classification system for LBP 8 in the examination and classification of a patient with a recurrent LBP problem and (2) to describe the short- and long-term outcomes of a classification-specific management program. In addition, we describe the relationship between the directions of movements and alignments repeated by the patient during his leisure and daily activities and direction-specific impairments identified on examination. Case Description Patient Description The patient was a 22-year-old man referred for physical therapy with a diagnosis of low back strain. Table 1 Table 1. Patient Characteristics Characteristic Value Height (cm) 181 Weight (kg) 76.5 Handedness Right Occupation Full-time student Baecke activity score (3 15) a 8.25 SF-36 b general health score (0% 100%) c 90 a Baecke JA, Burema J, Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr. 1982;36: b SF-36 Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire. c Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection. Med Care. 1992;30: provides patient characteristics. Imaging studies were not performed at the time of diagnosis. The patient s self-reported medical history was unremarkable. He reported no serious spine-related conditions or medical conditions that would limit his prognosis for intervention or would be present as symptoms of LBP. The patient s LBP history consisted of 2.5 years of LBP that occurred in multiple episodes, which he estimated to be present less than half of the days in a year (ie, recurrent LBP 20 ). Although the patient reported that his initial LBP was gradual in onset, he associated the first onset of symptoms 2.5 years previously with an intense bout of racquetball playing. He noted that, since the initial onset of LBP, his symptoms continued to be exacerbated with racquetball play. The patient also described a pattern of recurring symptoms, with a report of 12 flare-ups over the 12 months before his initial clinic visit. Flare-up is defined as a phase of pain superimposed on a recurrent or chronic course, which consists of a period, usually a week or less, when the back pain is markedly more severe than usual for the patient. 20 The patient also reported that the severity and frequency of the flare-ups increased during the previous year, particularly in the last 4 months. He had no history of medical or rehabilitative interventions for LBP. He reported the use of ibuprofen as needed for pain relief. Typically, the patient would take two 200-mg ibuprofen tablets after racquetball play. Although he took ibuprofen regularly after playing, the patient reported that, in the 2 months before his initial physical therapy visit, the ibuprofen was progressively less effective in relieving his symptoms. In particular, the patient said that the medications only took the edge off when he was symptomatic. Table 2 lists the patient s leisure activity history before and after age 18 years (the age often associated with skeletal maturity) to show the extent and duration of his participation in leisure activities Van Dillen et al Physical Therapy. Volume 85. Number 4. April 2005

4 Table 2. Patient s Leisure Activity History Before age 18 y Racquet-specific activity Type Frequency Duration Other activities After age 18 y Racquet-specific activity Type Frequency Duration Estimated frequency of stroke performance Other activities Type Frequency Type Frequency Type Frequency Tennis and racquetball 8-y history; average of 1 /wk 45 min/session None Racquetball 4-y history; average of 4 /wk 75 min/session Forehand backhand overhead serve Rugby 2 3 /wk Soccer 1 /wk Weight training 1 /wk The symptoms for which the patient was seeking intervention included daily, intermittent LBP typically located in the right low back region 21 more than the left low back region. The symptoms occurred after flexion and rotation or lateral bending of the trunk to his right as well as during and after prolonged trunk positions associated with the same alignments. The activities or positions that increased the patient s symptoms included playing racquetball, sitting, and sleeping, with left side lying worse than prone lying and back lying. Standing and side lying on the right tended to relieve the patient s symptoms. The patient reported that the symptoms had increased in severity over the 4 months before his initial visit to our clinic, resulting in regular and frequent sleep interruptions. Table 3 provides the patient s symptoms and other relevant variables at the initial visit. Examination The patient participated in a standardized examination previously described for use in determining a person s LBP classification. 8 The first author (LRV) developed the examination in collaboration with 6 other therapists. The reliability of data for examiners performing physical tests and measures has been reported. 9 Our kappa ( ) values ranged from.21 to.76, and percentage of agreement values ranged from 67% to 90%. Table 4 provides a list of the items included in the examination. At the time of the original reliability testing, the examiners also were able to classify a patient s LBP problem with a fair-to-good level of reliability (.58, percentage of agreement 79%). 16 The first author examined the patient in this report. She was involved in the original reliability testing of the examiners and has continued to use the examination with patients and to train other therapists to perform the tests. Specifically, the examination includes direction-specific tests in which symptoms are assessed with different movements and positions, as well as judgments of alterations of alignments and movements across various positions. Neurological screening and testing for magnified symptom behavior 21 also are performed. The response options were symptoms increased, symptoms remained the same, symptoms decreased, and symptoms were eliminated. For tests in which symptoms were assessed with a postural alignment, the patient reported his symptoms after assuming the alignment for a minimum of 10 seconds. For tests in which symptoms were assessed with movements, the patient reported any change in symptoms. Information regarding the location of the symptoms also was obtained. If the patient reported an increase in symptoms with a primary test of symptoms, the test was immediately followed by a secondary test in which his preferred movement or alignment strategy was modified. 12,13 The modifications of the secondary tests were performed in an attempt to decrease or eliminate the patient s symptoms. The modifications involved either positioning the lumbar spine in as close to a neutral alignment as possible or restricting or eliminating lumbar spine movement during a trunk or limb movement. Modifications were accomplished using verbal cues, trunk muscle activation by the patient, and manual assistance by the examiner. The directions to be modified were determined by the examiner based on visual and tactile information obtained with the primary test. Reports of symptoms and the specific alignments or movements that were modified during the secondary test were recorded. The possible responses for the directions modified were flexion, extension, rotation, lateral bend, and shift, or any combination of these 5 directions. For example, the patient performed a primary test of forward bending from a standing position using his preferred movement strategy. During the movement, the patient reported that his LBP with the primary movement test increased compared with his LBP while standing. The patient then performed a secondary test in which the forward-bending movement was modified to eliminate lumbar spine flexion and rotation and to increase hip flexion. The patient was provided with verbal cues to keep his back straight by easily contracting his trunk muscles while bending forward only at the hips. The patient also was cued to lean into his arms to reduce the load on the trunk during the forwardbending movement. The examiner provided manual assistance by placing her hands and forearms on the anterior and posterior trunk to cue the patient on the Physical Therapy. Volume 85. Number 4. April 2005 Van Dillen et al. 339

5 Table 3. Initial Status and Short- and Long-Term Outcome Measures Measurement Visit 1 (Initial Status) Visit 2 (2 wk After Visit 1) Visit 3 (6 wk After Visit 1) Visit 4 (12 wk After Visit 1) Questionnaire (1 y After Visit 1) Symptom location Left upper lumbar and right and left lower lumbosacral region; right left symptoms Same as previous visit Lumbosacral region; right left symptoms Left L4 L5 region Central L5 S1 region Symptom intensity Current a 4/10 2/10 2/10 1/10 0/10 Average over previous 7 d a 4/10 3/10 3/10 2/10 1/10 Worst over previous 7 d a 6/10 4/10 4/10 3/10 2/10 10-cm visual analog scale of Not available current symptoms 25 Symptom frequency and duration Intermittent; daily persisting most of the day once symptoms were initiated Intermittent; daily persisting only one half of the day if symptoms were initiated Intermittent; daily persisting less than one half of the day if symptoms were initiated Occasional; depending on activity level; gone within 10 min after symptom-provoking activity Occasional; depending on activity level; gone within 5 10 min after symptomprovoking activity Medication use Ibuprofen after play; provided only partial relief No longer needed to control symptoms; discontinued Same as previous visit Same as previous visit Same as previous visit Patient-specific activities Racquetball Increased symptoms after 15 min of play; symptoms persisted for 2 3 d after onset Increased symptoms after 15 min of play; symptoms persisted for 1 d after onset Increased symptoms only if moved to end-range of trunk flexion and lateral bend right; symptoms ceased when returned to upright posture; if continued, flexion and lateral-bending motions with play symptoms may have persisted for 15 min after play Occasional increased symptoms with endrange trunk flexion and lateral bend right; ceased when upright; no symptoms after play Occasional increased symptoms with multiple really low shots and playing for longer than 1.5 hr; ceased when upright; occasional symptoms for 5 10 min after play Sitting (class) Increased symptoms after 30 min Increased symptoms after 30 min if leaned with trunk to the right; no symptoms if avoided leaning with trunk forward and to the right and got up regularly Same as previous visit; sitting a lot due to course load and examinations Sat for 90 min with only occasional increase in symptoms Sat for 100 min with only occasional increase in symptoms; same as previous visit Sitting (driving) Increased symptoms after 30 min Stiffness after 2.5 hr if avoided leaning with trunk to the right Same as previous visit Occasional tightness in lower back region; no symptoms Able to drive 9 hr/d for 3 d with only a little stiffness ; no symptoms Sleeping Awakened 2 times/night due to symptoms Awakened 2 times in past week due to symptoms No more interruptions of sleep Same as previous visit Same as previous visit Oswestry Low Back Pain Disability Questionnaire score (%) 23,b 16% 14% 8% 6% 4% Recurrences 20 in the previous mo c a Verbal estimate of symptom intensity on a scale of 0 (no symptoms present) to 10 (worst imaginable symptoms). 24 b Average behavior over week prior to visit or questionnaire. c Recurrence was defined as a noticeable increase in symptoms, usually lasting for a week and limiting the person functionally Van Dillen et al Physical Therapy. Volume 85. Number 4. April 2005

6 Table 4. Tests and Measures Included in Physical Examination 9 Position Tests a Primary Test b Secondary Test c Alignment or Movement Judgments of Alterations of Standing Standing None Alignment of lumbar spine region in all planes Forward bending Modified forward bending Relative flexibility d of lumbar spine and hips Return from forward bending Modified return from forward bending Relative flexibility of lumbar spine and hips Extension None None Lateral bending Modified lateral bending Asymmetry of lateral bending Sitting Sitting in flexion Modified sitting None Sitting in extension Modified sitting None Sitting in full flexion None None Knee extension Modified knee extension Rotation-related movement in lumbar spine region e Supine Hook lying None None Bilateral hip and knee None None flexion f from hook lying Supine Modified supine None Single knee to chest from supine Modified single knee to chest Rotation-related movement of lumbopelvic region Hip abduction/lateral rotation from partial hook lying Modified hip abduction/lateral rotation Rotation-related movement of lumbopelvic region Side lying Side lying Modified side lying None Prone Prone Modified prone None Knee flexion Modified knee flexion Rotation-related movement of lumbopelvic region Anterior tilt of lumbopelvic region Hip medial rotation Modified hip medial rotation Rotation-related movement of lumbopelvic region Hip lateral rotation Modified hip lateral rotation Rotation-related movement of lumbopelvic region Hip extension Modified hip extension None Quadruped Quadruped Modified quadruped None Arm lift in quadruped Modified arm lift Rotation-related movement of lumbopelvic region Rocking back Modified rocking back Rotation-related movement of lumbopelvic region Rocking back in full flexion None None Rocking forward None None a Includes primary and secondary tests of movements and alignment in several different positions. Symptoms are assessed with each test, and judgments of alterations of movement or alignment also may be assessed. Test movements involving the limbs were performed on the right and left extremities separately. Trunk positions or movements in the horizontal or frontal plane were performed to the left and right separately. b During primary tests of symptoms, the patient performed either a trunk or limb movement or assumed a position using his preferred strategy of movement or alignment, and he reported his symptoms relative to a designated reference movement or position. The movement tests from the examination are active movements unless specified otherwise. c Secondary tests of symptoms were conducted if the patient reported an increase in symptoms with a primary test. Modifications involved either positioning the lumbar spine in as close to a neutral alignment as possible or restricting or eliminating lumbar spine movement during a trunk or limb movement while encouraging movement in other segments (eg, the hips). Modifications were accomplished using verbal cues, trunk muscle activation by the patient, and manual assistance by the examiner. The patient reported his symptoms with each secondary test relative to the symptomatic primary test. d Movement impairment of the lumbopelvic region in which the hips contribute to the overall movement in the last half of the range of trunk movement. e Currently includes movements of lumbopelvic rotation or lumbar lateral bend or shift. f Passive test movement performed by examiner flexing lower extremities toward trunk. Physical Therapy. Volume 85. Number 4. April 2005 Van Dillen et al. 341

7 The examiner s judgments of alterations of alignment and movement across the various test items were based on visual information alone or on visual and tactile information. The judgments of alignment focused on whether or not the lumbar spine region was flexed, extended, laterally bent, rotated, or some combination of these directions of alignment. The judgments for the tests of movements focused on the type, extent, and timing of the pelvis and lumbar movement. The specific directions of movement for which the examiner made a judgment were flexion, extension, rotation, lateral bending, and shift, or some combination of these directions. Table 5 provides the positive responses related to judgments of altered alignment or movement and the specific directions associated with each of the patient s responses. In addition, the patient s neurological status was screened, and tests for magnified symptom behavior, as described by Waddell et al, 22 were performed. The neurological screening consisted of (1) muscle force and sensory testing of both lower extremities for dermatomal, myotomal, or cutaneous dysfunction and (2) questions regarding bowel or bladder or sexual dysfunction. Both were negative. Figure 1. Decision-making process for symptom testing. proper trunk alignment. After successfully completing the secondary test movement, the patient reported that his symptoms with the modified movement were eliminated compared with his symptoms using his preferred movement strategy. Figure 1 illustrates the general decision-making process used with symptom testing. Table 5 provides the positive findings from the symptomatic primary tests and the associated secondary tests as well as the movements or alignments associated with each test. Classification Based on the movement and alignment impairments identified, we believed the patient s MSI diagnosis was lumbar rotation with flexion. 8 This classification of his LBP problem was based on the following findings: (1) he reported an increase in symptoms, primarily with alignments and movements associated with trunk flexion and lateral bending or rotation to his right, (2) he reported elimination of symptoms when the trunk flexion and lateral bending or rotation movements and alignments were modified, (3) we identified alignments and movements of trunk rotation and lateral bending or rotation across the various physical tests, and (4) he reported an increase in symptoms with daily activities associated with trunk flexion and right lateral bending or rotation (eg, playing racquetball, sitting in class or in a car, left side lying during sleeping). Intervention The patient s intervention had 3 components: (1) education in principles of tissue injury and repair, (2) analysis and instruction in specific modification of daily activities, and (3) exercise directed at specific factors believed to contribute to the development and persistence of his impairments. Table 3 lists the activities and positions the patient reported as symptom-provoking at his initial visit. Education We first educated the patient in general principles of tissue injury and healing because we believe that a primary factor contributing to the development, persistence, and recurrence of LBP is tissue stress induced with repetition of movements and assumption of prolonged alignments in specific directions. We explained how cumulative stress on tissue may contribute to microtrauma, and how it can occur from either loading lumbar region tissue for prolonged periods of time (eg, sitting in class or driving) or repetitively (eg, when performing the same trunk movements during an activity such as racquetball). We also explained that we believed an important component of the patient s LBP was his use of trunk flexion and rotation and lateral-bending strategies during activities that were symptom-provoking as well as other activities. We explained that consistent use of these strategies was likely to accelerate stress accumulation on lumbar region tissues. We then explained the need to decrease the 342. Van Dillen et al Physical Therapy. Volume 85. Number 4. April 2005

8 Table 5. Positive Findings From Standardized Examination 9 Position Test a Response Associated Directions of Trunk Alignment and Movement With Test Item Standing Alignment Pelvis and trunk rotated clockwise in horizontal plane Rotation/lateral bend Forward bending Lumbar spine flexion greater than hip flexion in first 50% of range of forward bend Flexion Return from forward bending Increased symptoms Extension Trunk rotation to the right with return Rotation/lateral bend Modified b forward bending Increased hip flexion with forward bend Flexion and return Elimination of trunk rotation with return phase Rotation/lateral bend Elimination of symptoms with return phase Rotation/lateral bend Lateral bending Increased symptoms with right lateral bending Rotation/lateral bend Asymmetric lateral bending with pelvic shift to the left Rotation/lateral bend at initiation of the lateral bend to the right and decreased lateral bending motion in the upper and middle lumbar segments compared with the lower lumbar segments with lateral bending to the right Modified lateral bending Elimination of symptoms with right lateral bend Rotation/lateral bend Increased movement across thoracic and lumbar spine segments with lateral bend Sitting Knee extension Lumbar spine flexion and pelvic and lumbar spine Flexion region rotation with right knee extension Rotation/lateral bend Supine Bilateral hip and knee Increased symptoms Flexion flexion (passive) Prone Knee flexion Pelvic rotation with right and left flexion; rotation Rotation/lateral bend greater with right lower extremity than with left lower extremity Hip rotation Increased symptoms with right medial and lateral hip Rotation/lateral bend rotation Pelvic and lumbar spine region rotation with right Rotation/lateral bend medial and lateral hip rotation Modified hip rotation Elimination of symptoms with right medial and lateral hip rotation Rotation/lateral bend Quadruped Alignment Lumbar spine positioned in flexion Flexion Arm lifting Asymmetric trunk rotation with arm lifting; rotation of trunk was greater with left upper extremity lift than with right lower extremity; rotation of trunk to right with left arm lift Rotation/lateral bend Increased symptoms with left arm lift Rotation/lateral bend Modified arm lifting Elimination of symptoms with left arm lift Rotation/lateral bend Rock back Lateral pelvic tilt with rocking back Rotation/lateral bend a The movement tests from the examination are active movements unless specified otherwise. Test movements involving the limbs were performed on the right and left extremities separately. Includes tests of symptoms as well as judgments of alterations of alignment and movement with tests in various positions. Includes responses to tests of symptoms (primary and secondary) as well as signs with various tests. b A modified test indicates a secondary test performed if the patient reported an increase in symptoms with the associated primary test of symptoms. Modifications involved either positioning the lumbar spine in as close to a neutral alignment as possible or restricting or eliminating lumbar spine movement during a trunk or limb movement while encouraging movement in other segments (eg, the hips). Modifications were accomplished using verbal cues, trunk muscle activation by the patient, and manual assistance by the examiner. The patient reported his symptoms with each secondary test relative to the symptomatic primary test. cumulative stresses on tissues to aid tissue healing and resolution of his LBP symptoms, and we explained that the decrease could be achieved by modifying his direction-specific alignment and movement strategies throughout his daily activities. Analysis and Modification of Daily Activities The second component of management was the analysis and modification of the performance of daily activities. Activities that were symptom-provoking, as well as those frequently repeated throughout the day, were observed for use of direction-specific strategies that were consistent with those identified in the physical examination. The patient was taught how to modify the alignments and how to restrict or stop the lumbar spine movements in trunk and limb movements that increased his LBP. During modification of movements, we emphasized increasing movement in other segments to achieve the task. The patient also was instructed in ways to modify daily activities that typically were pain-free but incorpo- Physical Therapy. Volume 85. Number 4. April 2005 Van Dillen et al. 343

9 Table 6. Category-Specific Intervention Instruction in Modification of Daily Activities Visit Instructions Do Do Not 1 (initial) Bend in the hips, not in the lower back when leaning forward. Bend your knees slightly, if needed, to keep from moving in the lower back. Use an arm for support if possible when leaning forward in standing to support your trunk (eg, when brushing your teeth). Sit with your back supported and relaxed, your shoulders aligned over your hips, and your thighs fully supported. Make sure your feet are flat on the support surface so your knees are at the same level as your hips. Do get up from a sitting position every 45 min and try to change your position frequently while sitting. If you sleep on either side, place a towel roll at waist level so that your lower back is straight instead of laterally bent or rotated. Bend your hips and knees to about 30. Place 2 or more pillows between your knees so that the weight of your legs does not pull on your lower back. Do try to assume the quadruped position and perform rocking back in the quadruped position after playing racquetball or during days in which you seem to be more symptomatic than usual to assist with control of symptoms. 3 (6 wk after visit 1) Emphasize importance of adhering to initial instructions for sitting because the patient s primary complaint at this point in time is occasional increased symptoms during sitting. rated the strategies associated with his LBP. Education was emphasized so that the patient could independently predict any activities that might contribute to his symptoms. During the initial visit, the patient was observed assuming his preferred alignment during symptom-provoking positions (Tab. 3). The patient then was instructed on how to modify his alignment when he sat in class, drove, and slept. The patient was made aware of his preference: (1) to sit with his trunk unsupported and lean forward and on his right elbow during many of his classes, (2) to sit with his trunk flexed, leaning on his right elbow while driving, and (3) to assume a right lateral bend in his trunk when sleeping on his left side. He was instructed to avoid these alignments and was encouraged to get up every 45 minutes while sitting to change the loading on the tissues in the lumbar spine region. 18 We recommended that the patient avoid sleeping on his left side and to sleep on his back with a pillow under his legs or sleep on his stomach with a pillow under his abdomen. The patient also was given positioning instructions to deal with instances in which he needed to assume left side lying. Table 6 outlines the specific recommendations for modifying the patient s symptomatic alignments. We recommended that the patient attend to other positioning habits throughout his day that could Do not sit forward and laterally bend or rotate to the right, particularly when sitting in class or driving. Do not lean on your right elbow for support when sitting, particularly when sitting in class or driving. Do not cross your legs when sitting. Do not sleep on your left side. Do not stand on one leg for prolonged periods of time, particularly your right leg. reinforce his preferred strategy. For example, the patient was told to avoid standing with his weight primarily over one leg because this might reinforce his preference to align his trunk in a right lateral bend. Overall, the recommendations discouraged prolonged positioning in trunk flexion and right lateral bending and rotation the alignments that appeared to contribute to the patient s symptoms. The only movement reported as symptom-provoking was racquetball. The patient stated that his symptoms increased both during and after play and varied with the intensity and duration of his game. The strokes the patient reported using the most required trunk flexion, rotation, or lateral bending either in isolation or in combination (Tab. 2). The patient was instructed on how these motions might be related to his impairments and, therefore, why racquetball was believed to contribute to his LBP problem. The primary author also discussed other daily activities in which the patient might be reinforcing his preferred movement strategy. For example, the patient noted that he often used a right trunk lateral bend to pick up his backpack. The patient was given suggestions of how to modify performance of movements during activities avoiding his preferred strategy Van Dillen et al Physical Therapy. Volume 85. Number 4. April 2005

10 Exercise The exercise component of the patient s management program consisted of practice performing modified versions of movement tests from the physical examination that eliminated his symptoms. In addition, the modifications of some tests in which the patient exhibited his preferred movement strategy also were prescribed as exercises. Six exercises were prescribed on the initial visit and were modified in follow-up visits if the patient was unable to perform the initial exercise correctly or reported an increase in symptoms. The exercises were: (1) supported right lateral bending while standing, (2) supported trunk and hip flexion while standing, (3) knee extension while sitting, (4) knee flexion while in a prone position, (5) hip rotation while in a prone position, and (6) rocking back in a quadruped position. Overall, the goal of the exercises was for the patient to modify his movement by decreasing his preferred movement of the lumbar spine during lower-extremity movements and trunk movements and increasing participation of other joints, such as the hips or other regions of the spine, during various multisegmental movements (eg, rocking back in a quadruped position or lateral bending of the trunk). Table 7 describes the exercises and outlines patient-specific instructions, and Figures 2 through 8 illustrate the initial exercises. Patient-Specific Exercise Prescription The patient was instructed to perform his exercises at least once a day. Initially, 6 to 8 repetitions of each exercise were to be performed. Within an exercise session, correct performance of each exercise was emphasized instead of the number of repetitions performed. For example, with the exercise of knee extension while sitting with support, the patient was told to extend his knees only to the point in the movement in which he was no longer able to maintain the correct trunk and pelvic alignment. If the patient could extend the knee only 30 degrees with the correct alignment, then that was the endpoint for each repetition of the exercise. The patient also was instructed to avoid reproducing or increasing his LBP symptoms during or after his exercises. He was told to stop any exercise if it increased his symptoms and to wait to resume the exercise until he could be re-examined. As a prophylactic strategy as well as for relief of symptoms during and after symptom-provoking activities, the patient was encouraged to assume quadruped positioning and perform the rocking back movement regularly throughout his day. Because, as a student, he spent much of his day sitting, the patient was encouraged to frequently extend his knees while sitting. Adherence to his program was assessed at each visit through the patient s verbal report and the first author s assessment of the patient s ability to perform the prescribed exercises. Table 8 provides the patient s reports of adherence. Outcomes The patient had 4 physical therapy visits over a 3-month period. The follow-up visits were 2, 6, and 12 weeks after the initial visit. In addition, at 1 year, the patient completed both a mailed questionnaire regarding his progress since the initial visit and the Oswestry Low Back Pain Disability Questionnaire. 23 The data obtained for the primary outcome measures assessed at each visit and at 1 year are provided in Table 3. The overall categories of outcomes were: (1) symptoms (location, intensity, frequency, and duration) at various time points and with symptomatic positions or activities, (2) frequency of medication use, (3) LBP-related disability, and (4) frequency of LBP recurrences (flare-ups) during a 12-month period. Symptom intensity was measured by 2 different methods. The first method was a numeric rating scale (NRS) in which the patient reported his symptoms on a scale ranging from 0 (indicating the absence of symptoms) to 10 (indicating the worst imaginable symptoms). 24,25 The second method was a visual analog scale 25 (VAS) in which the patient marked the intensity of his symptoms at the time of each visit on a 10-cm horizontal line. Initial and final anchor points on the VAS were labeled no pain and worst possible pain. Numeric rating scales have been tested for reliability of patient responses and found to be acceptable (intraclass correlation coefficient [ICC].82). 24 Concurrent validity based on a comparison of responses with different pain response scales and NRS responses also has been established (Pearson r.79, P.001). 24 The use of a VAS for estimating pain intensity in people with LBP has been examined for both reliability (ICC.93) 25 and concurrent validity 24 and found to be acceptable (Pearson r.79, P.01). Low back painrelated disability was measured with the Oswestry Low Back Pain Disability Questionnaire, 23 a disease-specific, self-report measure. Patient reports using the Oswestry questionnaire have been found to be both reliable (Pearson r.99, P.01) 23 and valid (Pearson r.72, P.0001) when compared with scores on other accepted measures of LBP-related disability. 26 At 1 year, the patient reported his outcomes through a mailed questionnaire. The questionnaire included the same questions related to outcomes obtained during each of his prior visits except for the VAS. The patient s responses at 1 year are provided in Table 3. In addition, a series of questions were included to gain more specific information regarding sports participation since his last visit, recurrences (frequency, intensity, duration), and adherence to the prescribed exercises and modifications of strategies during daily activities. The patient also was given the opportunity to provide any general comments about his progress since his initial visit. The patient reported that he was playing racquetball 2 to 3 times per week. Physical Therapy. Volume 85. Number 4. April 2005 Van Dillen et al. 345

11 Table 7. Category-Specific Intervention Exercise Descriptions 8 and Patient-Specific Instructions Across the Intervention Period Visit Exercise Description Patient-Specific Instructions 1 (initial) Right lateral bending with support (Fig. 2). Stand with your back against a wall, feet positioned comfortably apart, and heels about 2.5 cm (1 in) from the wall. Place your right hand at your waistline, just below the ribs for support. Lateral bend to the right only as far as you can without reproducing symptoms and without lifting your left foot from the floor. Return to a standing position. Hip flexion and extension with flat lumbar spine (Fig. 3). Stand facing a table with feet positioned comfortably apart. Place your hands on the table. While keeping your elbows slightly bent, lean into your arms. Bend forward in the hip joints keeping your back straight. Bend only as far as you can while maintaining your trunk alignment. Return to a standing position by moving in your hips while maintaining your trunk alignment. Knee extension sitting with support (Fig. 4). Sit in a chair with a straight back, thighs fully supported, hips at 90 of flexion, and shoulders over your hips. Your feet should be flat on the floor. Straighten one knee only as far as you can without reproducing symptoms and maintaining your trunk and pelvic alignment. Return the leg to the starting position. Repeat with the opposite leg. Knee flexion in prone position (Fig. 5). Lie on your stomach with your arms positioned at your sides, head positioned comfortably, and legs straight and relatively close together. Bend one knee up toward your buttock and then return it to the starting position. Repeat with the opposite leg. Bend only as far as you can without reproducing symptoms and maintaining your trunk and pelvic alignment. Hip rotation in prone position (Fig. 6). Position yourself as for knee flexion in prone. Bend one knee to 90. Rotate your hip by allowing your foot to move in toward your opposite leg and then away from the opposite leg. Rotate only as far as you can without reproducing symptoms and maintaining your trunk and pelvic alignment. Repeat with the opposite leg. Quadruped position and rocking (Figs. 7 and 8). Assume a hands-and-knees position trying to attain the following alignment: knees about 7.6 cm (3 in) apart, hips centered over knees and at a 90 angle, feet pointing away from body with the front of the feet flat on the support surface, spine straight, shoulders at a 90 angle and directly over hands, and head in line with body. Pushing back with your hands, rock back moving only as far as you can without reproducing symptoms and maintaining your trunk alignment. Return to the initial position. 2 (2 wk after visit 1) Hip flexion with flat lumbar spine (modified). Because of complaints of occasional pain during the exercise, the patient was instructed to flex his knees more in standing and to put more weight into his hands to help him keep his trunk stationary with the hip flexion (forward bend) and extension (return from forward bend) phase of the exercise. Knee flexion (modified). Because the patient was having difficulty controlling his pelvis during the exercise, he was instructed to position his hips in some abduction and place a pillow under his abdomen to perform the exercise. Quadruped rocking (modified). Because the patient was able to control left lateral pelvic tilt with rocking back through one third of the range, he was instructed to increase the range of rocking back as long as he avoided the left lateral pelvic tilt movement. Easily bend to the right, dropping your right shoulder over your right hand. Do not shift your pelvis to the left to initiate the right lateral bending motion. Try to move throughout the spine instead of performing all of the lateral bending movement in your lower back region. Bend both knees and elbows slightly. Do not bend your back as you bend forward in the hips or arch your back as you return to standing. Move in your hips, not your back. Place your hands on your lower back region and sacrum. Easily straighten your knee. Move only as far as you can without bending or rotating your back to the right. Place your hands on the front of the pelvis to monitor pelvic movement. Tighten your abdominal muscles to hold the pelvis steady while bending your knee up and down. Do not tilt or rotate your pelvis while bending each knee. Position your hands as for knee flexion. Tighten your abdominal muscles to hold the pelvis steady. Do not tilt or rotate your pelvis while rotating each hip. Keep your back straight throughout the movement. Think about moving in your hips and not your back. Move in the hips equally Van Dillen et al Physical Therapy. Volume 85. Number 4. April 2005

12 Figure 2. Right lateral bending with support. As illustrated in Table 3, the frequency of recurrences was reduced. The patient also noted that he was much better at detecting a recurrence of his LBP because he was more aware that any increase in intensity or frequency of his symptoms was a warning that his LBP was worsening. He stated that the frequency and intensity of his symptoms, as well as the overall duration of each recurrence, were much less than before intervention. The patient also reported that, on average, he performed the exercises one time per week and adhered to his daily activity modifications 40% of the time. In instances in which the patient thought that a recurrence of his LBP might be happening, he said he knew that he could better control the symptoms by increasing his activity modifications. Discussion The patient in this report had a predisposition to flex, rotate, and laterally bend his lumbar spine when assuming different positions and during various movements of the trunk and limbs. We believe that people with LBP adopt strategies of alignment and movement because they repeat movements or assume prolonged positions in specific Figure 3. Hip flexion and extension with flat lumbar spine. Figure 4. Knee extension sitting with support. directions. We also have proposed that, because these strategies are used repeatedly, some tissues in the lumbar region are exposed to higher levels of localized stress 27 than other tissues. Development of this localized stress may contribute to cumulative microtrauma, and, if not eliminated, may contribute to LBP. In our patient, one factor that may have contributed to the adoption of his directional strategies was the repetition of movements and alignments associated with his participation in racquet sports (Tab. 2). In addition, the patient reported that, prior to developing LBP, he had increased the frequency and intensity of playing racquet sports. Both of these factors could have contributed to the initial onset of symptoms. 18 The patient exhibited the same directional strategies during his symptom-provoking daily activities as those associated with his leisure activity, raising the possibility that he generalized strategies he used repeatedly with racquetball to other activities across his day. If this was the case, then the patient potentially was exposing specific areas of the lumbar region tissues to stress, not only during racquetball play but also during many of the activities he performed on a daily basis. As a result, once the patient developed his Physical Therapy. Volume 85. Number 4. April 2005 Van Dillen et al. 347

13 Figure 5. Knee flexion in prone position. Figure 7. Quadruped position. LBP symptoms, achieving prolonged relief would be difficult because the contributing stresses would not be removed for a sufficient period of time to allow tissue healing and appropriate adaptation. 28 Instructing the patient in ways to modify the strategies he used during his daily activities could potentially reduce the cumulative stress contributing to the severity and persistence of his LBP. Our patient was instructed in methods to change both the duration and direction of movements and positions that could affect the loading on lumbar tissues (Tab. 6). The encouragement to change positions frequently is based on studies linking prolonged loading of tissues to a number of negative consequences. 27 An important part of the intervention for our patient was emphasizing the need to avoid prolonged positions associated with the specific directions of alignment that were most symptomatic both during the examination and with daily activities. Our advice is based on the proposal that sustained positions have the potential to contribute to changes in Figure 6. Hip rotation in prone position. Figure 8. Quadruped rocking. different tissues. These tissue changes then may serve to reinforce the impairments that appeared to contribute to the patient s LBP problem. For example, assuming an alignment of right lateral bending during a large proportion of the day (sitting and sleeping) could contribute to asymmetries in the length of the lateral trunk muscles. Adams et al 27 proposed that such asymmetries may be of clinical significance in LBP because the imbalances could result in changes in side-to-side stresses on the disk and neural arch. The methods described for assessing symptoms 12,13 during the examination are somewhat unique. We have the patient assume a position or perform a trunk or limb movement using his or her preferred strategy. If symptoms are provoked, the position or movement is modified to restrict the motion in part of the lumbar region or across the entire lumbar region, and symptoms are reassessed. If the patient s symptoms improve with the modifications, then intervention includes: (1) having the patient perform the modified tests as exercises and 348. Van Dillen et al Physical Therapy. Volume 85. Number 4. April 2005