LOW BACK PAIN
Use of a Classification System to Guide Nonsurgical
Management of a Patient With Chronic Low Back
Pain
+Author Affiliations
Abstract
Background and Purpose. This case report describes the use of a classification system in the evaluation of a patient with chronic low back pain (LBP) and illustrates how this system was used to develop a management program in which the patient was instructed in symptom-reducing strategies for positioning and functional movement. Case Description. The patient was a 55-year-old woman with a medical diagnosis of lumbar degenerative disk and degenerative joint disease from L2 to S1. Rotation with extension of the lumbar spine was found to be consistently associated with an increase in symptoms during the examination. Instruction was provided to restrict lumbar rotation and extension during performance of daily activities. Outcomes. The patient completed 8 physicaltherapy sessions over a 3-month period. Pretreatment, posttreatment, and 3-month follow-up modified Oswestry Disability Questionnaire scores were 43%, 16%, and 12%, respectively. Discussion. Daily repetition of similar movements and postures may result in preferential movement of the lumbar spine in a specific direction, which then may contribute to the development, persistence, or recurrence of LBP. Research is needed to determine whether patients with LBP would benefit from training in activity modifications that are specific to the symptom-provoking movements and postures of each individual as identified through examination.
Despite being one of the most commonly treated disorders in outpatient physicaltherapy practice,1 the management of low back pain (LBP) continues to be a challenge. We believe that 2 issues, in particular, contribute to this challenge. The first issue relates to the lack of an accepted classification system for LBP that is feasible to use and that is validated through research. The second issue relates to the conceptual distinction between physical impairment and functional limitation, and the degree to which each is addressed in the treatment of patients with low back-related disorders.
The need to classify patients into homogenous subgroups to better facilitate the management of LBP has received much attention in recent literature.2–15 This need is reflected by the number of classification systems that have been proposed within the past 2 decades.2–12 Riddle13 provided a comprehensive review of the classification systems deemed most relevant to physical therapists, along with a discussion of issues related to LBP classification. There is no consensus regarding the most appropriate classification scheme to guide the rehabilitation of patients with LBP.14 In the view of many authors, the ability to differentiate among various subgroups of patients with LBP would enhance both the clinical management and the scientific study of LBP.14,15
Measures of physical impairment such as range of motion, muscle force, and endurance are routinely assessed by physical therapists, with the goal of using the data obtained with these measures to help direct the management of patients with LBP.1,16 However, as noted by Jette,17 several major conceptual models indicate that physical impairments reflect only one aspect of the disablement process. Several authors17–19 have suggested that rehabilitation professionals must also consider functional limitations and disability. The terms “functional limitation” and “disability” will be considered together in this report and refer to an inability to perform the basic tasks of daily life and to fulfill one's social and occupational roles.18 In a recent survey of patients with chronic LBP (chronic LBP in this study was defined as 8 or more episodes of recurrent LBP spaced at least 90 days apart within a 3-year period), difficulty performing everyday activities was the most frequently cited reason for seeking medical care.20 However, in a national sample of over 2,300 outpatient physical therapy records, Jette et al1 found that therapists cited independent function as a treatment goal for only 10.6% of all patients treated for LBP. Functional training was included in only 5.6% of the rehabilitation programs. A more recent study of physical therapy for LBP similarly revealed that the number of goals relating to range of motion (65%) and pain reduction (53%) outnumbered those relating to the facilitation of functional activity (20%).21 Together, these studies suggest that physical therapists may tend to address physical impairments more readily than functional limitations in the treatment of patients with low back-related disorders.
Delitto19 observed that clinicians may be more inclined to document measures ofphysical impairment compared with limitations of function based on the underlying assumption that correction of impairments will result in improved treatment outcomes. However, the link between physical impairment and decline in function in people with LBP remains unclear. Several research groups have failed to find an association between various impairment measures and subsequent development of LBP.22–28 The absence of an established relationship betweenphysical impairment and function in individuals with LBP suggests that limitations of function should be addressed directly in any therapeutic program that seeks to improve functional outcomes.
The purpose of this case report is 2-fold. First, we will describe the use of a classification system in the evaluation of a patient with chronic LBP. Second, we will demonstrate how this classification system was used to guide development of a treatment plan that included modification of symptom-producing motions and alignments of the lumbar spine during the performance of daily work, leisure, and self-care activities. In doing so, we hope to illustrate the potential benefits of using a classification approach to guide identification and treatment of the symptom-provoking movements and postures that are specific to each individual.
Conceptual Overview of LBP Classification Approach
The system of classification described in this report was designed in an effort to aid clinicians in identifying the primary movement problem toward which we believe physical therapy intervention should be directed. Therefore, each category of the classification system is named for the specific direction of spinal alignment or motion that is found to be consistently associated with an increase in LBP during testing. A summary of the signs and symptoms associated with each of the 5 categories proposed in this classification system is presented in Table 1.12,29The validity of data obtained with this classification system has not been demonstrated experimentally. The interrater reliability of data obtained forphysical examination items used to classify patients according to this system has been reported previously (kappa ≥.87 for 100% of items related to symptom production; kappa ≥.42 for 72% of items related to alignment and movement signs).12
An underlying assumption of this approach is that the daily repetition of similar movements and postures can result in movement of the lumbar spine in a specific direction, which then may contribute to the development, persistence, or recurrence of mechanical LBP.12 We believe that the direction of spinal motion associated with an increase in low back-related symptoms reflects movement strategies and postures that are repeated by a given individual throughout each day. For example, an avid tennis player may be inclined to develop a symptom causing predisposition for motion of the lumbar spine into a direction of extension and rotation, whereas a cyclist may be more likely to develop symptoms associated with lumbar flexion and rotation. Presumably, individuals may develop habitual movements and postures in response to functional activity demands that may contribute to LBP and that may be identified and corrected through the evaluation of alignments and motions of the lumbar spine.
To classify a patient as being in 1 of the 5 categories listed in Table 1, we believe that the clinician should attempt to identify a consistent pattern of signs (ie, direction-specific motions and alignments of the lumbar spine) and symptoms (ie, reproduction of low back-related complaints, including numbness, tingling, or pain in the back or lower extremities) in response to items performed in several different test positions (eg, standing, sitting). Due to the anatomical relationship between the spine and extremities, motions of the spine that occur during limb movement are evaluated in addition to overt spinal motions that occur during movement of the torso (eg, forward bending). Confirmation that the symptom-provoking spinal motion or alignment has been correctly identified occurs by restricting that motion or alignment and noting whether there is a reduction of symptoms (see Appendix in the full-text version of this article on the PhysicalTherapy Web site at http://www.apta.org/pt_journal).
In this system of classification, the primary direction of symptom-provoking spinal motion or alignment identified in the examination as causing symptoms is referred to as the lumbar movement dysfunction. We believe that once a patient has been classified according to the primary movement dysfunction, treatment strategies designed to limit direction-specific motions or alignments that increase the patient's low back-related symptoms can be implemented. We consider identification and correction of the lumbar movement dysfunction during work, leisure, and self-care activities to be a priority due to the presumed frequency with which these movements and postures are repeated throughout each day. We also believe that impairments in muscle force and joint flexibility should be addressed relative to their possible contribution to the lumbar movement dysfunction.
Case Description
Patient
The subject of this case report was a 55-year-old woman referred for physicaltherapy with a medical diagnosis of degenerative disk disease and degenerative joint disease of the lumbar spine. The radiography report described findings of decreased intervertebral disk space extending from L2 to S1, as well as decreased joint space and sclerotic changes in the facet joints at L2-3 and L4-5. The patient reported a 40-year history of recurrent LBP, with multiple episodes each year, and symptoms that typically persisted less than a week before resolving spontaneously. Previous management for the patient's current episode of LBP included approximately 12 physical therapy sessions at an unrelated facility. The patient reported these sessions to be marginally effective in reducing her low back-related symptoms at the time of treatment, with an exacerbation of symptoms occurring within 2 weeks of her final visit to that facility.
The patient's self-reported medical history included bladder neck suspension surgery performed in 1991 for the treatment of urinary incontinence, along with a history of cigarette smoking and high blood pressure. Medications included calcium supplements, Wellbutrin* (prescribed as an antidepressive agent), Premarin† (prescribed as a cholesterol-lowering agent), cyclobenzaprine (prescribed as a muscle relaxant), and ibuprofen. The patient reported taking the latter 2 medications infrequently for the relief of severe low back-related symptoms. The patient was self-employed as an insurance agent and worked approximately 40 hours per week from her home office. We were aware of no change in the patient's medications or employment during the course of treatment or during the 3-month follow-up period.
The symptoms for which the patient sought intervention began approximately 10 weeks prior to her first visit to our facility. Symptoms that persist for this duration are considered to be of a chronic nature by the Quebec Task Force for Spinal Disorders.30 The patient reported that she had a constant ache across the central low back that fluctuated throughout the day. The average intensity of her symptoms was 6 on a verbal pain scale ranging from 0 to 10. The 11-point numeric rating scale of average pain intensity has been found to yield reliable measurements31 and to be related to other measures of pain intensity when used by patients with LBP.32 She was told that a rating of 0 should represent the absence of pain and a rating of 10 was the worst pain imaginable. The patient also noted an intermittent stabbing pain along her left posterior thigh and calf, which she said was exacerbated by twisting motions of the trunk. A tingling sensation was occasionally present in the left toes. The patient reported that the onset of her symptoms occurred after walking at a slow pace on a treadmill in her home for several minutes. The patient described herself as inactive, and she said that she had attempted to begin walking to help lose weight. She reported a gradual worsening of symptoms in the first few days after walking on her treadmill, with no notable improvement or decline of symptoms in subsequent weeks. She described having particular difficulty performing the following activities due to increased low back-related symptoms: brushing her teeth, rolling toward her left side, loading the dishwasher, getting into and out of her truck, and walking long distances, such as when grocery shopping.
The patient described in this case report was part of an ongoing clinical study of the effects of modifying symptom-producing movements and postures during aphysical examination being conducted by the third author. The patient was recruited from 1 of 6 outpatient physical therapy clinics participating in a previous study by our group.12 With the exception of a notably higher Oswestry Disability Questionnaire33 score (43% versus 24%), this patient exhibited characteristics similar to the patient population described in a previous report on the interrater reliability of data obtained by examiners administering physical examination items used in the classification of mechanical LBP.12
Examination
To classify the patient's lumbar movement dysfunction according to the system described above, the first author conducted posture and movement testing with the patient in the following positions: standing, sitting, supine, side lying, prone, and quadruped. The first author had limited experience (<6 months) with the proposed system of classification prior to receiving training, which was similar to that received by therapists participating in a previous study.12 Briefly, training consisted of 5 individualized instruction sessions of 45 minutes to 1 hour duration with therapists having documented experience in the proposed classification system12 and completion of a written examination on the content of a reference manual containing operational definitions of terms and standardized clinical examination procedures.
The patient's self-selected movement strategy or posture was assessed for signs of movement dysfunction during performance of each test item. Prior to each test, the patient assumed a reference position in which the intensity and location of the low back-related symptoms were assessed. For tests of alignment, the patient was asked to assume the test position for at least 10 seconds before noting any change in symptoms relative to symptoms in the reference position. For active movement tests, the patient was asked to indicate the point in the range of trunk or limb movement at which a change in symptoms occurred relative to symptoms in the reference position. The patient indicated whether the symptoms increased, decreased, or remained the same with each new position or movement, and descriptions of symptoms were noted. Any test that elicited an increase in the patient's symptoms was repeated, but was modified in an attempt to alleviate the symptoms. Modification of each test item involved restriction of the specific spinal motion or alignment that was observed during performance of the initial, symptom-provoking test. Restriction of symptom-producing spinal motions and alignments was accomplished using verbal cues, active stabilization by the patient, and manual stabilization by the examiner. Following each modified test item, the patient again was asked to indicate the status of her symptoms. Procedures used in the examination of motions and alignments of the lumbar spine are described in further detail in the Appendix (shown in the full-text version of this article on thePhysical Therapy Web site at http://www.apta.org/pt_journal). Findings from the examination of the patient are presented in Table 2.12,30
Active control of the alignment of the lumbar spine was facilitated by verbally and/or manually cueing the patient to contract her abdominal muscles just prior to and throughout the attainment of each modified test position or movement. She had difficulty using her abdominal muscles and often held her breath, which we presumed was to compensate for a lack of muscular control. Successful attempts at using the abdominal muscles, as identified through palpation, frequently resulted in complaints of cramping and pain localized to the pelvic region. The patient indicated that she had been experiencing such symptoms regularly in the 8 years since her bladder neck suspension surgery. The intensity of these symptoms could be reduced or eliminated by instructing the patient to reduce the effort of abdominal muscle contraction.
The first author also examined muscle force and joint flexibility to determine which physical impairments might contribute to the observed tendency for direction-specific motions and alignments of the lumbar spine. Pretreatment and posttreatment impairment measurements are summarized in Table 3.29,34–38 The patient displayed no signs of neurological deficit, as assessed by light touch sensation and manual muscle testing of L1-S1 myotomes.39 The straight-leg-raising test39 was negative for signs of neural tension. Results of testing for nonorganic signs of magnified illness behavior as described by Waddell et al40also were negative. Neurologic and Waddell tests were used to identify the presence of nerve impairment and to rule out magnified illness behavior. Results were not used in classification of the patient's primary movement dysfunction.
The examiner believed that substitution using the hip flexors occurred during manual muscle testing of several lower-extremity muscle groups (Tab. 3). Hip flexor substitution was thought to be present when the extremity being examined moved from the desired manual muscle test position into a position of increased hip flexion. Excessive use of the hip flexors also was observed throughout the examination as the patient moved in her accustomed manner. For example, the patient's self-selected strategy for moving from a sitting position to a supine position was first to assume a long-sitting position and then to lower her upper body toward the support surface using no upper extremity assistance. This method, which presumably required eccentric contraction of the hip flexor muscles, was associated with an increase in LBP. The patient also exhibited a habit that she referred to as “nervous legs,” characterized by rapid bouncing movements of the lower extremities, apparently initiated at the hip. This habit was observed intermittently throughout the examination, most often when the patient was sitting or lying supine.
Classification and Intervention
Based on the signs and symptoms noted during the examination, we believed that the patient's primary movement dysfunction was lumbar rotation with extension (Tab. 4). We viewed decreased hip flexor length and excessive use of the hip flexor muscles during the performance of routine activities as impairments having the potential to contribute to rotation and extension of the lumbar spine with static postures and active movements of the spine and extremities. Our goal was to improve the patient's ability to perform functional activities, while minimizing the symptoms associated with rotation and extension of the lumbar spine.
Table 4.
Test Items for Which Patient's Symptoms Were Decreased or Eliminated With Restriction of Spinal Alignment or Movementa
During her initial visit, the patient was given instructions for activity modification based on the category to which she was assigned. The recommended strategies for activity modification are summarized in Table 5.12 A feature common to each of these strategies was the specific discouragement of rotation and extension of the lumbar spine during daily activities. Along with addressing the activities that the patient identified as problematic, other tasks commonly associated with rotation and extension of the lumbar spine, such as reaching overhead or across the body, also were addressed (Tab. 5).
During subsequent visits, the patient was instructed in a home exercise program to address both functional limitations and specific physical impairments. The patient was encouraged to practice isolated limb movements while avoiding rotation or extension movements of the lumbar spine. This was accomplished through performance of the modified version of each movement test that resulted in symptoms during examination (Tab. 2), as described in the Appendix (shown in the full-text version of this article on the Physical Therapy Web site athttp://www.apta.org/pt_journal). The importance of activity modification was emphasized by having the patient perform the majority of exercises both in isolation and during functional movement. For example, the patient was instructed to perform 10 to 15 daily repetitions of the forward bend exercise (Tab. 5), with additional instructions to use this same technique each time she bent forward throughout the day, such as when brushing her teeth. A brief description of each exercise and its functional correlate is provided in Table 5. The importance of maintaining a neutral or slightly flexed position of the lumbar spine through active use of abdominal muscles was emphasized. We believed that this position would prevent an increase in low back-related symptoms and facilitate strengthening of the abdominal muscles.
In addition to the exercise program, the patient was instructed in techniques that we believed would lengthen the hip flexors and improve gluteus medius muscle force production. While lying prone, the patient used a sheet positioned around her ankle to assist in passively flexing her knee to the point at which she perceived a gentle stretch in the anterior thigh. To avoid an increase in symptoms when positioned prone, the patient initially was instructed to position 2 pillows under her abdomen, but eventually was able to perform this stretch in the absence of pillows without an increase in LBP. In an effort to improve gluteus medius muscle force, the patient was instructed in active hip lateral rotation and abduction performed while side lying. As with all other exercises, rotation and extension movements of the lumbar spine were specifically discouraged during the performance of these 2 exercises. Following instruction in gait modifications that we believed would reduce the magnitude of rotation of the pelvis and lumbar spine (Tab. 5), a walking program was prescribed to improve aerobic fitness. The patient reported that modifying her gait reduced her symptoms immediately following instruction. The patient declined referral to a urogynecologist regarding her symptoms of pelvic pain and cramping.
Outcomes
The patient completed 8 physical therapy sessions over a 3-month period. The first 3 sessions were spaced 1 week apart, with subsequent sessions once every 1 to 4 weeks. Her condition was assessed 3 months after discharge through a telephone interview and a mailed questionnaire. A modified Oswestry Disability Questionnaire33 and a pain diagram were used to document patient-perceived progress once each month, with 1 exception due to an administrative oversight. Patient scores on the Oswestry Disability Questionnaire have been found to be reliable (Pearson r and intraclass correlation coefficients >.90)33,41 as well as related to scores on other accepted measures of disability in patients with LBP,42an indication of construct validity of the questionnaire. Reproducibility of pain diagram responses in patients with chronic LBP has been documented.43Concordance between defined disorders associated with LBP and diagnoses based on pain diagram responses provides evidence of validity of the pain diagram as a clinical tool.44 Physical impairment measurements were obtained by the first author during the patient's final therapy session for comparison with initial values.
During her initial visit, the patient received instruction in activity modification only. In the week following this visit, the patient noted a reduction in both the frequency and intensity of her symptoms. She reported a 75% decrease in the frequency of pain in the central low back region and a 40% reduction in the frequency of symptoms in the left lower extremity. She also reported that the average intensity of her symptoms was reduced from 6/10 to 3.5/10 on a verbal pain scale, with no symptoms present the day of her second session. When asked to describe her activities during the past week, the patient noted a substantial improvement in her ability to perform household chores and in her overall tolerance for physicalactivity. With the exception of sit-to-supine transfers, we observed adherence to all activity modifications taught in the initial therapy session throughout the second treatment session.
By her final therapy session, the patient no longer experienced lower-extremity symptoms. She noted symptoms localized to the central low back as typically being less than 3/10 when present, with approximately 75% to 80% of her week being symptom-free. She noted that the intensity of symptoms in the central low back region generally increased with increasing fatigue. The patient was able to independently demonstrate all prescribed exercises and activity modifications as instructed, without an increase in symptoms. She reported that she typically performed her home exercise program once daily, and was walking 3.5 to 4.5 minutes each day on her treadmill without an increase in low back-related symptoms.
The modified Oswestry Disability Questionnaire33 contains items pertaining to both functional limitation and disability and was used in this case to document functional progress. The patient's pretreatment Oswestry score of 43% dropped to 16% by her final therapy session. As interpreted by Fairbank et al,41 these scores reflect a transition in function from severe disability to minimal disability. In the 3 months following discharge from outpatient physical therapy, the patient did not experience an exacerbation of low back-related symptoms and continued to make functional improvements. Specific examples of functional improvement noted by the patient during the follow-up telephone interview at 3 months included the ability to brush her teeth, get into and out of her truck, and shop for over an hour without an increase in symptoms.
Less consistent changes were observed for measures of muscle force and joint flexibility (Tab. 3). Changes included what we believed to be indicators of increased length of the hip flexors, improved ability to use the abdominal muscles without an increase in pain, and an increase in spinal flexion and extension range of motion. Hamstring muscle flexibility and spinal side-bending range of motion declined over the course of treatment. Estimates of the intrarater reliability of data obtained for these physical impairment measures are provided in Table 3 to the extent that this information is available. However, due to the general lack of documented reliability for many of the physical impairment measures routinely used by clinicians, small changes in the measurements should be interpreted with caution.
Discussion
Numerous interventions are available for patients with low back-related disorders.45 The challenge for physical therapists is to identify the most appropriate intervention for each patient, based on the findings from a standardized examination. This task is difficult because the etiology of LBP is unknown in the majority of cases45 and the relationship between physicalimpairment and disability in this population remains largely undefined.19
Our case report describes an intervention that was chosen based on the evaluation of spinal alignment with postures and spinal motions during active movement of both the spine and extremities. Given the documented lack of association between LBP and various traditional measures of physical impairment,23 we sought to identify a particular pattern of spinal motions and alignments that appeared to be directly associated with a worsening of symptoms across several test positions. We then based intervention on modification of symptom-producing motions and alignments of the lumbar spine during the repetition of daily activities. Despite modest changes in measures of physical impairment (Tab. 3), the patient described in this case report exhibited what we consider a substantial and consistent reduction in low back-related functional limitations and disability (Figure) over the course of treatment. In addition, the most dramatic reduction in low back-related symptoms occurred following the first therapy session, in which the only treatment provided was category-specific instruction in activity modification.
Waddell et al46 found a strong association between low back-related disability and fear-avoidance beliefs, or the extent to which patients avoid activity based on the anticipation of pain. Waddell et al suggested that restricting the activity of patients with LBP might serve only to reinforce fear-avoidance beliefs and increase the chances of subsequent disability. The benefits of maintaining customary activity levels in patients with LBP has been substantiated by the findings of Malmivaara et al.47 These investigators found that subjects with LBP who were advised to continue their usual routine as tolerated recovered more quickly than those who were prescribed either 2 days of complete bed rest or back mobilizing exercises.
Teaching patients specific strategies to reduce the symptoms associated with movements can enable them to perform activities that they might otherwise avoid. We believe that one of the primary advantages of the classification system described in this case report is that it allows physical therapists to make recommendations for activity modification that are specific to the symptom-provoking postures and movements of each patient. We propose that exercise prescription and generic postural instruction may be less effective in addressing restrictions of function in patients with LBP than is individualized instruction in symptom-reducing strategies for positioning and functional movement. The patient described in this report, for example, was instructed in ways to avoid rotation and extension of the lumbar spine during daily activities. The use of a lumbar roll is one example of a generic therapeutic modality that was discouraged in this case because it would have contributed to spinal extension, an alignment found to be associated with an increase in this patient's symptoms. Greater individualization of back care programs may be needed to facilitate patient adherence.21 The patient described in this case report noted the greatest adherence to exercises and activity modifications that could be easily incorporated into her daily routine, such as those related to forward bending, walking, and sitting up in bed (Tab. 5).
The treatment approach described in this case report is founded on the notion that the repetition of direction-specific movements and postures of the lumbar spine can exacerbate low back-related symptoms and prolong recovery. The patient exhibited a consistent tendency toward lumbar rotation and extension, which was observed during examination of movements and postures across several positions as well as during the performance of functional tasks (eg, sit-to-supine transfers) and personal habits (eg, “nervous legs”). We have observed that the propensity for spinal motion to occur in a given direction varies among individuals, and we speculate that this variation may be partly related to individual variations in motor recruitment patterns. This idea is consistent with reports of high intersubject variability in trunk muscle activity patterns during a given movement.48,49 Based on the results of an investigation into the effects of fatigue on trunk motion, Parnianpour et al50 suggested that the loss of muscular coordination associated with fatigue may diminish spinal stability and allow loading of the spine in a more injury-prone pattern. The patient in this case report commented that she found it more difficult to control the position of her spine and pelvis when she was tired, and she associated an increase in her symptoms with fatigue.
We also have observed that variations in occupational and recreational activity demands appear to contribute to individual differences in direction-specific motions and alignments of the lumbar spine. We suggest that this may be related to changes in supportive structures of the spine that occur with repeated stresses in a given direction over time. A relationship between repetitive spinal motion and LBP is suggested by epidemiologic studies that have identified repetition of non-neutral trunk postures as a risk factor for the development of LBP.51 In addition, Gordon et al52 have shown that repetitive loading of spinal segments positioned in a slight amount of flexion and rotation results in pathological changes in the intervertebral disk of the in vitro human spine.
Causal relationships cannot be established on the basis of a case report. Symptoms associated with disorders of the low back typically resolve within 6 weeks of onset, and only 5% of individuals have symptoms that persist longer than 3 months.51 The LBP episode described in this case report began 10 weeks prior to the patient's initial therapy visit to our facility, which is beyond the time frame typically associated with natural resolution of LBP. Improvement in both functional ability and symptom reduction coincided with the initiation of treatment at our facility. The patient did not experience a recurrence of low back-related symptoms in the 3 months following discharge from our clinic, during which time she continued her home exercise program and activity modifications. Together, these observations suggest that our approach may have positively influenced the patient's recovery. This does not, however, rule out the possibility that the patient might have recovered spontaneously, or responded equally well to another therapeutic approach.
In any isolated case, there are several factors other than the intervention that might account for the observed outcomes. Aerobic training has been reported to be of benefit in the treatment of many disorders, including those related to the low back.53 Based on reports of the efficacy of aerobic training, a walking program was prescribed during the third treatment session. It seems unlikely that the observed outcomes can be attributed to an improvement in aerobic conditioning, however, given that the patient remained unable to ambulate for more than 5 minutes at one time without becoming short of breath. It might be argued that improvements in hip flexor muscle length could be largely responsible for helping to reduce the patient's symptoms, as lower-extremity flexibility is a commonly addressed impairment in the treatment of LBP. To our knowledge, however, prospective studies have failed to demonstrate a consistent correlation between LBP and hip flexor tightness.27,54 Because the psoas major muscle is known to impart substantial compressive forces on the lumbar spine,55 it is conceivable that discouraging the active recruitment of this muscle may have influenced the observed outcome.
Further research is needed to determine the validity and clinical feasibility of the system of classification described in this case report. The theoretical assumptions on which the approach was founded should be investigated to determine construct validity. For instance, is it true that the lumbar spine can become predisposed to excessive movement in a given direction when subjected to repeated stresses in that direction? Examination of whether the proposed classification categories are mutually exclusive and appropriate for use in a rehabilitation context will be necessary to establish content validity. For example, can any patient referred to aphysical therapist for the treatment of LBP be classified into 1 of the 5 proposed categories, or does this classification system describe a more limited patient population, such as those with chronic LBP? If the predictive validity of this system could be appropriately demonstrated, then we believe physical therapists could make a substantial contribution to preventative health care. Individuals could be screened for patterns of spinal motion and alignment that may increase the risk of developing mechanical LBP, and they could be provided with specific instruction regarding the modification of such patterns. Other areas of future research should include controlled clinical trials to establish the relative efficacy of individualized versus generic functional instruction, as well as to determine the optimal approach for improving rehabilitation outcomes for patients with LBP.
Footnotes
- All authors provided concept/project design, writing, and data analysis. Ms Maluf and Dr Van Dillen provided project management, and Dr Sahrmann, Dr Van Dillen, and Kate Crandell, PT, MSPT, provided consultation (including review of manuscript before submission). Ms Maluf provided data collection, and Dr Van Dillen provided subjects and facilities/equipment. The authors acknowledge Jennie Levin for help with photographs, Kate Crandell for valuable discussions regarding the management of the patient, and Michael Mueller, PT, PhD, for helpful comments on a previous draft of the manuscript.This work was approved by the Human Studies Committee of Washington University School of Medicine.This work was funded in part by National Institutes of Health-National Institute of Child Health and Human Development, National Center for Medical Rehabilitation Research, Grant No. 2 T32 HD07434-04A1 and Grant No. K01 HD01226-01A1.Requests for reprints should be directed to the corresponding author of the article. Students and other academic customers may receive permission to reprint copyrighted material from Physical Therapy by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Similar inquiries by all others should be made to the APTA Editorial Office, Attn: Physical Therapy.
- ↵* Glaxo Wellcome Inc, 5 Moore Dr, Research Triangle Park, NC 27709.
- ↵† Wyeth-Ayerst Pharmaceuticals, Div of American Home Products Corp, PO Box 8299, Philadelphia, PA 19101.
- Received July 20, 1999.
- Accepted July 13, 2000.
- Physical Therapy
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