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    www.intl.elsevierhealth.com/journals/jbmt

    Bodywork and

    Journal of

    Movement Therapies

    SELF-HELP: CLINICIAN SECTION

    Spinal stabilizationFan update. Part 2Ffunctionalassessment$

    Craig Liebenson, DC*

    10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA

    Introduction

    Reactivating spine pain patients is a key to earlyrecovery from acute and subacute episodes (Mal-mivaara et al., 1995; Indahl et al., 1998), preven-tion of recurrences (Hides et al., 2001), andtreatment of chronic pain, disability, and failedsurgery syndrome (Fordyce et al., 1986; Lindstromet al., 1992; Manniche et al., 1991; OSullivan

    et al., 1997; Timm, 1994). The first part of thisseries described the role of instability in low backproblems (LBP) as well as specific types ofbiomechanical advise to prevent low back irrita-tion. This second part will describe the patientsfunctional assessment. Functional assessment isnecessary to establish goals, monitor progresstowards those goals, and guide the prescription ofspecific exercises.

    Patient evaluation

    LBP affects nearly 90% of the population at sometime in their lives. Fortunately, its disabling phasetypically runs a short-term course (46 weeks)(Hadler, 1986; Spitzer et al., 1987). However,lingering symptoms and activity intolerances arecommon (Croft et al., 1998). A small minority ofindividuals develop a chronic, disabling problem

    and it is these people who absorb the vast majorityof all the costs associated with this problem(Hashemi et al., 1998; Spitzer et al., 1987).

    The problem of patient assessment is that 85% ofLBP has no known cause (Deyo and Weinstein,2001). Fortunately, serious causes of LBP areinfrequent. Less than 1% is due to a serious diseasesuch as cancer (Waddell, 1998). Less than 1%involve inflammatory rheumatic disease

    (Waddell, 1998). Approximately 5% involves truesciatica (Waddell, 1998). The remainder are classi-fied as non-specific because modern methodshave not been able to pin-point the exact paingenerators.

    40% of patients with low back pain fear they havea serious problem (Waddell, 1998). A major role ofthe health care provider (HCP) is to reassure thepatient with non-specific LBP that they do not havea serious disease and that the prognosis is generallyfavorable (Waddell, 1998). A reliable and sensitiveprocess known as diagnostic triage is performed onthe initial visit to identify the red flags of seriousdisease (Deyo and Weinstein, 2001; Waddell, 1998).Those patients without red flags are reassuredthat their pain is not due to anything serious (Deyoand Weinstein, 2001; Waddell, 1998). Overdiagnosis(e.g. arthritis, herniated disc, etc.) should beavoided because it leads to increased anxiety,treatment dependence and unnecessary testing(e.g. M.R.I.) (Snook, 2004; Deyo and Weinstein,2001). Unfortunately, it is very common since 2070% of people with LBP have coincidental herniatedor degenerative discs or degenerative arthritis onimaging studies (Jarvik and Deyo, 2000).

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    $This paper may be photocopied for educational use.*Corresponding author. Tel.: 1-310-470-2909; fax: 1-310-

    470-3286.E-mail address: [email protected] (C. Liebenson).

    1360-8592/$ - see front matter & 2004 Published by Elsevier Ltd.doi:10.1016/j.jbmt.2004.03.002

    Journal of Bodywork and Movement Therapies (2004) 8, 199210

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    Patient evaluation should include a number ofessential components.

    1. The first is diagnostic triage to rule out redflags of serious disease.

    2. The second is assessment of psycho-social riskfactors of chronicity termed yellow flags.

    3. The third is a comprehensive functional assess-ment of the patients mechanism of injury (MI),activity intolerances (AI) related to pain, me-chanical sensitivities (MS), and abnormal motorcontrol (AMC).

    4. Fourth is outcome assessment to monitor pro-gress over time.

    A thorough patient evaluation is necessaryFespecially in subacute patients who are slow torecover or in chronic patientsFto reassure thepatient that their problem has been addressed,appropriate tests ordered, and management ap-proach individualized to their needs (Linton, 1998)(see Table 1).

    Functional assessment

    This article focuses on the functional assessment ofthe patient. While many authors have over-statedthe positive early natural history (Hadler, 1986;Spitzer et al., 1987) it is clear that residual painand activity intolerances persist for up to 1 year inthe majority of patients (Croft et al., 1998). Recentresearch has demonstrated that recovered patientswith a past history of low back disability havedistinct functional losses not found in individualswithout a similar history (McGill et al., 2003).Therefore, functional assessment is an importantcomponent in patient care. Some assessments, forexample for MS, are necessary early on. Whileothers like functional measures of trunk extensorendurance are most valuable after a month haselapsed (Enthoven et al., 2003). In fact, the 1-

    month functional assessment (non-provocative) ispredictive of 12 month recovery, whereas an earlierassessment is not predictive, probably due to theinfluence of acute pain on the tests.

    Mechanism of injury

    It is important to identify how the pain began andwhat biomechanical factors are sources of irrita-tion. The MI is often something which the patientdoes NOT perceive as painful or threatening. Forinstance, prolonged sitting or bending forward fromthe waist when performing various activities ofdaily living (ADLs) (Green et al., 2002; Snook et al.,1998; McGill and Brown, 1992; Scannell and McGill,2004; Solomonow et al., 2003). Snook has shownthat reducing early morning flexion acceleratesrecovery from acute LBP.

    Solomonow et al. (2003) has shown that creep(stretching) develops in ligaments in 10 min ofexposure to end-range static flexion. The normallength of the ligaments does not recover after10 min of rest. Longer periods of prolonged flexionsuch as 2040 min can result in full recovery takingup to 24 h. Dysfunctions such as reduced muscleactivity and spasms during static flexion periodsoccurs during a 7 h recovery period. An acute low-grade inflammatory response is also present, andeven a 7 or 8 h period of rest does not lead to a fullrecovery. The dysfunction outlasts the period overwhich strain occurred by 60 times, resulting in

    residual creep and chronic inflammation. Thefactors responsible for residual creep include thefollowing:

    1. magnitude of load,2. duration of load,3. frequency of such loads.

    A prospective occupational study showed thatjob rotation, reduced lifting loads and ergonomicredesign reduced days lost from work from 60/100,000 h worked to 1/100,000h worked (Lemestraand Olszynski, 2003). Another prospective study by

    Marras showed that introduction of lift tables andother lift aids reduced reported LBPs in anoccupational setting (Marras et al., 2000).

    Activity intolerances

    Patient reactivation should be goal oriented andoutcome based. Most patients want symptomaticrelief, but hurt does not always equal harm, so painrelief is not always a good guide. A wiser approachfocuses on establishing reduction in activity intol-erances associated with pain as a mutually agreed

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    Table 1 Patient assessment.

    * Diagnostic triagered flags* Psycho-social assessmentyellow flags* Functional assessment* Mechanism of injury* Activity intolerances* Mechanical sensitivity* Abnormal motor control (e.g. coordination,

    endurance, balance)* Outcome assessment

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    upon goal (AHCPR, 1994). Examples of AIs, includereducing sitting, standing, bending, or walkingintolerances. This can be documented with reli-able, valid and responsive outcome tools such asthe Revised Oswestry disability questionnaire (Hud-son-Cook et al., 1989), neck disability index(Vernon and Mior, 1991), upper extremity func-tional index (Stratford et al., 2001), or lowerextremity functional scale (Binkley et al., 1999).

    Responsiveness is defined as the accurate

    detection of change when it has occurred. If atool is responsive to change, the score on aquestionnaire should improve as a persons healthstatus improves. This is clinically significant changethat is not due to a random occurrence. A keydimension of responsiveness is the minimal clini-cally important change in an outcome in a specificpatient population. This is the smallest change inthe OA score which the patient perceives asbeneficial (see Table 2).

    Mechanical sensitivity

    Traditional evaluation focuses on impairments suchas lumbar range of motion (ROM) deficits, howeversuch impairments are poorly correlated with func-tional ability (Gronblad et al., 1997; Grenier et al.,2004; Parks et al., 2003; Simmonds et al., 1998).Probably the best way to use ROM tests is as anaudit of (MS) as employed in the McKenzie system(Kilpikoski et al., 2002). If such testing is used toidentify movements which peripheralize symptoms,and those which centralize them, it provides apowerful prognostic and exercise selection guide(Werneke and Hart, 2001).

    Orthopedic tests and myofascial trigger pointevaluation can also be utilized to identify themovements and tissues which reproduce the pa-tients characteristic symptoms. Identifying thepatients MS can help in formulation of an exercisestrategy which minimizes the patients discomfort.The other value of identifying the patients MS isthat it can be used as a quick reference point forauditing the patients status or progress post-treatment and at each follow-up visit. When thepatients MS is decreasing it confirms the effec-

    tiveness of the treatment. If the MS is notimproving then it suggests other treatment strate-gies should be employed. Most importantly, if thepatients MS is evaluated immediately after thepatient performs a self-treatment exercise then ifit has improved the patient is likely to be moremotivated to comply with a home exercise pre-scription than if they are just told that theexercises are right for them.

    Abnormal motor control

    New evidence points to the importance of motorcontrol evaluation (coordination, balance, endur-ance) in contrast to strength or mobility assessmentas a more potent guide to treatment selection,prognosis, and outcome (Biering-Sorensen, 1984;Hodges and Richardson, 1998, 1999; McGill et al.,2003; Byl and Sinnot, 1991; Takala and Vikari-Juntura, 2000). Simple low-tech tests of motorcontrol for which reliability, validity, and/or norma-tive data have been established are shown inTable 3. These tests are most valid if performed

    after the acute phase has settled and pain-inhibitiondoes not influence the outcome (Enthoven et al.,2003).

    Endurance

    Static trunk extensor endurance test(Sorensen test)

    Decreased endurance of the trunk extensors hasnot only been shown to correlate with pain

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    Table 2 Minimum clinically important change inoutcome score.

    Revised Oswestry disability questionnaireF8/50Neck disability indexF5/50Upper extremity functional indexF9 pointsLower extremity functional scaleF9 points

    Table 3 Motor control evaluation in low backproblems.

    Endurance:

    * Trunk extensor (Alaranta et al., 1994)* Side bridge (McGill et al., 1999)*

    Trunk flexor (Alaranta et al., 1994; McGill et al.,1999)Balance:

    * Single leg stance (Bohannon et al., 1984)Coordination or muscle balance:

    * Active or restricted straight leg raise (Menset al., 2001)

    * Prone hip extension (Vogt and Banzer, 1997;Nadler et al., 2002)

    * Sidelying hip abduction (Nadler et al., 2002)

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    (Biering-Sorensen, 1984; Latimer et al., 1999;Nicolaisen and Joregnesen, 1985), but to predictrecurrences (Biering-Sorensen, 1984; Enthovenet al., 2003), as well as first time onset of episodesin healthy individuals (Luoto et al., 1995). The test,if performed in the manner described by Biering-

    Sorensen, has been shown to be reliable in variouspopulationsFasymptomatic (Latimer et al., 1999),symptomatic (Moffroid, 1994), and those with apast history of LBP (Latimer et al., 1999). TheSorensen test has been reported to be able todiscriminate between subjects with and withoutlow back pain (Moffroid et al., 1994). Normativedata has been established for a variety of healthyasymptomatic populations (Alaranta et al., 1994;McGill et al., 1999). Established mean values rangefrom 62 to 131 s (Alaranta et al., 1994).

    Patient position

    * Prone with the inguinal region/anterior superioriliac spine (ASIS) at the end of the bench.* If using a Roman Chair type device positioned

    with ASIS aligned to the superior edge of thepelvic restraint pad.

    * Arms at sides, ankles fixed (by strap or hands),holding horizontal position.* Plumb-line can be used to ensure horizontal

    position.

    Technique

    * The patient maintains the horizontal position aslong as possible.

    * Timing begins when horizontal and unsupported.* Subjects are verbally encouraged to hold this

    position as long as possible.

    Termination criteria

    * Time the duration the position can be held up toa maximum of 240 s.

    * If patient drops below the horizontal positionthey are given one additional chance to regainit. But, upon dropping below horizontal a secondtime the duration is recorded.

    * If the patient reports low back pain or crampingin their legs the test may be stopped and thetime recorded (Fig. 1).

    Trunk flexor endurance

    Trunk flexor endurance can be reliably measured(Alaranta et al., 1994; Moreland et al., 1997).

    Normative data for different tests has beenestablished (Alaranta et al., 1994; McGill et al.,

    1999; McIntosh et al., 1998). An altered ratio oftrunk flexor to extensor endurance is correlatedwith a past history of disabling LBP, with extensorslosing endurance capacity more than flexors (McGillet al., 2003).

    Trunk curl static endurance test

    McGill et al. (1999) established normative data fora healthy, young group of males and females for asimple curl-up test (see Table 3 above). This testrequires a wedged piece of wood to support the

    patient at a fixed angle of 601.

    Patient position

    * Both knees and hips are flexed 901.* Arms are folded across chest.* Toes are anchored either with a strap or by the

    tester.

    Test

    * The wood is pulled back 10 cm (4 in.).* The subject holds the isometric posture as long

    as possible.

    Termination criteria

    * When any part of the subjects back touches thewood (Fig. 2).

    The mean endurance for young, healthy men andwomen is 134 s. The ratio of trunk flexor toextensor endurance is 0.77 normally (0.84 in youngmales and 0.72 in young females). To highlight the

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    Figure 1 Sorensen trunk extensor endurance test.

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    significance of the balance between antagonistictrunk muscles rather than pure strength Leedemonstrated that the extensor/flexor ratio is amore sensitive index than peak torque in predictingfuture back pain in asymptomatic individuals (Leeet al., 1999). A reduced ratio of trunk extensor toflexor strength/endurance discriminates betweenLBP patients and control subjects. The normal ratiois approximately 1.3:1 with the extensors beingstronger (Mayer et al., 1985).

    Side bridge

    Individuals with histories of disabling LBP haveasymmetry in side bridge endurance as well as adisturbed ratio of trunk extensor to side bridgeendurance (McGill et al., 2003).

    Patient position

    * The subject lies on one side supported by theirpelvis, lower extremity and forearm (elbow bentwith hand facing forward).

    * The top leg is placed in front of the lower legwith both feet on the floor.

    * The upper arm is placed against the chest withthe hand touching the anterior lower shoulder.

    Test

    * The pelvis is raised off the table as high aspossible and held in a line with a long axis of thebody supporting the weight between the feetand elbow.

    * Subject statically maintains this elevatedposition.

    Termination criteria

    * Subject is unable to lift their body up from thefloor.

    * Subjects thigh touches the floor.* Subject drops their pelvis or thigh part way and

    cant raise it up to the start position again.* Significant LBP causes the test to be stopped

    (Fig. 3).

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    Figure 2 Trunk flexor endurance position (a) start position (b) test position.

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    QuantificationThe mean endurance for young, healthy men andwomen is 84.5s with a SD of 34.5 (McGill et al.,1999). The ratio of right side bridge to left sidebridge endurance is normally 0.96 (McGill et al.,

    1999). According to McGill a side to side differenceof greater than 0.05 suggests unbalanced endur-ance (McGill et al., 1999). The side bridge toextensor endurance ratio is normally 0.49 (McGillet al., 1999).

    One leg standing balance test

    Balance deficits have been demonstrated to berelated to LBP (Byl and Sinnot, 1991; Luoto et al.,1998; Takala and Vikari-Juntura, 2000). Byl showedthat excessive anterior to posterior body sway on

    an unstable surface or poor single leg standingbalance ability is correlated with LBP (Byl andSinnot, 1991). Poor balance was correlated withfuture LBP by Takala (Takala and Vikari-Juntura,2000).

    Patient position

    * Standing

    Test

    * The patient stands on one leg with the oppositeleg flexed at the hip and knee.

    * The patient should be instructed to fix their gazeat a point on the wall directly in front of them.

    * The patient should practice with eyes open oncefor up to 10 s.

    * They should then attempt to balance as long aspossible on 1 leg with eyes closed for up to 30 s.

    * The subject may repeat the test up to amaximum of 5 times in an attempt to reach the30 s target successfully. If the subject can stand

    for 30 s on the first eyes closed attempt, theymay discontinue the test.

    Termination criteria

    * Reaching out.* Hopping.* Putting foot down.* Touching foot to weight bearing leg (Fig. 4).

    Quantification:

    * The best score with eyes closed for each legshould be recorded.

    Normative data (Bohannon et al., 1984):

    Age (years) Eyes open (s) Eyes closed (s)

    2059 2930 2128.8 (ave. 25)6069 22.5 ave 107079 14.2 4.3

    The active straight leg raising test (ASLR)

    A positive ASLR has been shown to be associated

    with postpartum sacroiliac (SI) pain (Mens et al.,2001, 2002). It has been shown that alteredkinematics of the diaphragm and pelvic floor arepresent in those with a positive test. Also, thatmanual compression through the ilia normalizesthese altered motor control strategies (OSullivanet al., 2002). The test has been shown to bereliable (Mens et al., 2001).

    Technique

    * Patient lies supine with feet 20 cm apart

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    Figure 3 Side bridge endurance test.

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    * Actively lifts one leg 20 cm up instruction Try toraise your legs, one after the other, above thecouch for 20 cm without bending the knee.

    Test is positive if:

    * the leg cant be raised up,

    * or, if there is decreased strength (resistance maybe added),

    * if there is significant heaviness of the leg noted,* if raising the leg is painful.

    Recheck:

    * with manual compression through the ilia and/orwith a SI belt,

    * after treatment (e.g. sacro-iliac mobilization,post-isometric relaxation of piriformis, adduc-tors, etc.).

    If resistance is offered hip flexion strength can beassessed. Grenier et al. (2004) has shown thatdecreased hip flexion strength is strongly corre-lated with a past history of disabling LBP inasymptomatic workers from 2 different manual

    material handling occupations (Fig. 5).

    Hip extension

    Nadler et al. (2002) demonstrated that hip exten-sion muscle imbalance (weakness of the dominantright leg) is associated both with a past history ofLBP and a risk factor for future LBP in femaleathletes (Nadler et al., 2000, 2001). Those with LBPhad a 15% strength imbalance compared with only a5.3% imbalance in those without LBP. Rehabilitationreduced the imbalance. This same asymmetry was

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    Figure 4 One leg standing balance test.

    Figure 5 Active straight leg raise test (a) without resistance and (b) with resistance.

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    not found in male athletes, but it is interesting tonote that National Collegiate Athletic AssociationInjury Surveillance Data from 19971998 showedthat female athletes were almost twice as likely asmales to develop LBP (National Collegiate AthleticAssociation, 1998). Other consistent findings in-

    clude increased fatigability of the gluteus maximusin individuals with chronic LBP (Kankaapaa et al.,1998; Leinonen et al., 2000). Leinonen demon-strated that the speed of contraction of the gluteusmaximus could be improved with rehabilitation(Leinonen et al., 2000).

    The right leg has been shown to be used assupport for kicking and jumping activities (Belinget al., 1998). Janda developed a prone test of hiphyperextension as a simple coordination testrelated to the terminal-propulsive toe off phaseof gait (Vogt and Banzer, 1997; Vogt et al., 2003).Vogt demonstrated the presence of anticipatory

    activation of contralateral and ipsilateral lumbarerector spinae and hamstring muscles prior to leglifting (Vogt and Banzer, 1997). This was shown tobe a repeatable pattern in normal subjects. Vogthas also shown that in LBP patients there isprolonged activity of the gluteus maximus andlumbar erector spinae during the hip extensionphase of gait (Vogt et al., 2003).

    Test (Janda, 1996):

    * prone,* slowly raise 1 leg straight up to ceiling.

    Pass/fail criteria:Failure if initiation occurs with:

    * anterior pelvic tilt (Lumbo-sacral extension),* lumbar rotation (or hyperextension),* delayed gluteus maximus contraction,* muscular contraction above T8,* knee flexion (Fig. 6).

    Clinical Relevance:

    * Altered hip extension typically leads to over-

    stress of the lumbar facet joints during extensionand can lead to hamstring strain due tosubstitution for the gluteus maximus

    Hip abduction strength

    Nadler demonstrated that female athletes withweaker left hip abductors had a higher probabilityof requiring treatment for LBP (Nadler 02). Theleft hip abductors have been shown to be used instance and posture of right handed individuals(Beling et al., 1998).

    Test (Janda, 1996):

    * side lying,* lower leg flexed at hip and knee,* pelvis slightly tucked under patient so body is

    aligned ankle to shoulder,* slowly raise leg up towards ceiling.

    Pass/fail criteria:Failure if, before 40 degrees abduction, the

    following occur:

    * hip flexion,* hip external rotation,* cephalad shift of pelvis (at initiation),* pelvic rotation,* failure to reach 401 abduction.

    Clinical relevance:

    * Tensor fascia lata substitution for an inhibitedgluteus medius is the most common fault. Thiswill result in patello-femoral tracking andiliotibial band friction disorders.

    * Passive insufficiency due to shortened psoas oradductors will also inhibit the gluteus mediusand lead to hip, sacro-iliac and lumbo-pelvicoverstrain.

    * Excessive synergist substitution of the lateralquadratus for an inhibited gluteus medius canresult in myofascial pain.

    * Shortening of the piriformis can also alter lowerextremity kinetic chain function especially dur-ing gait and affect the sacro-iliac by limitinginternal hip rotation and blocking normal sacro-iliac function (Fig. 7).

    Other functional testsBack flexibility is inversely related to LBP withgreater flexibility, not less, being a risk factor(Sorensen, 1984). Hip flexibility decreases arerelated to LBP. Hip internal rotation decreaseshave been correlated to LBP in a number of studies

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    Figure 6 Hip extension test (after Janda).

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    (less than 401) (Cibulka et al., 1998; Ellison et al.,1990; Grenier et al., 2004). Cibulka reported thatbilateral loss of hip internal rotation is associatedwith LBP while a unilateral restriction is associatedwith signs of sacro-iliac involvement (Cibulka et al.,

    1998). Decreased hip extension mobility has beencorrelated with a past history of disabling LBP inasymptomatic workers from 2 different manualmaterial handling occupationsFfailure of the thighto reach horizontal (Grenier et al., 2004). Tafazzoliand Lamontagne (1996) has also correlateddecreased hip extension mobility and LBP(Figs. 810).

    Cardiovascular fitness can be measured for base-line purposes. Activity levels correlation with LBPis complex and controversial (Cady et al., 1989;Croft et al., 1999) . However, cardiovascular fitnessor endurance has not been shown to be correlatedwith LBP (Battie et al., 1989; Grenier et al., 2004;McQuade et al., 1988; Ready et al., 1993; Van derVelde and Mierau, 2000).

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    Figure 7 Hip abduction test (after Janda).

    Figure 8 Lumbar flexion range of motion test (a) startposition and (b) final position.

    Figure 9 Hip internal rotation range of motion test (a)start position and (b) final position.

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    A comprehensive motor control evaluation wouldinclude a number of other tests as well, but mostare either high-tech requiring costly equipment orhave not met minimum requirements for scientificvalidation. These include squats, lunges, gaitevaluation, etc.

    The functional assessment of acute patients maybe restricted to AIs and MS. While the subacute orchronic patient should also have an evaluationof AMC.

    Conclusion

    In summary, evaluation should identify the patientsAI, MS, and AMC. These will enable the clinician toidentify the patients goals as well as the exercisesto achieve those goals.

    References

    Agency for Health Care Policy and Research (AHCPR), 1994.Acute low-back problems in adults. Clinical Practice Guide-line Number 14. US Government Printing, Washington, DC.

    Alaranta, H., Hurri, H., Heliovaara, M., et al., 1994. Non-dynamometric trunk performance tests: reliability andnormative data. Scandinavian Journal of RehabilitationMedicine 26, 211215.

    Battie, M.C., Bigos, S.J., Fisher, L.D., Hansson, T.H., Nachemson,A.L., Spengler, D.M., et al., 1989. A prospective study of therole of cardiovascular risk factors and fitness in industrialback pain complaints. Spine 14 (2), 141147.

    Beling, J., Wolfe, G.A., Allen, K.A., Boyle, J.M., 1998. Lowerextremity preference durine gross and fine motor skillsperformed in sitting and standing postures. Journal ofOrthopedic and Sports Physical Therapy 28, 34003404.

    Biering-Sorensen, F., 1984. Physical measurements as riskindicators for low-back trouble over a one-year period. Spine9, 106119.

    Binkley, J.M., Stratford, P.O.W., Lott, S.A., Riddle, D.L., 1999.The lower extremity functional scale (LEFS): scale develop-ment, measurement properties, and clinical application.Physical Therapy 79, 371383.

    Bohannon, R.W., Larkin, P.A., Cook, A.C., Gear, J., Singer, J.,1984. Decrease in timed balance test scores with aging.Physical Therapy 64, 10671070.

    Byl, N., Sinnot, P.L., 1991. Variations in balance and body sway inmiddle-aged adults: subjects with healthy backs comparedwith subjects with low-back dysfunction. Spine 16, 325330.

    Cady, L.D., Bischoff, L.P., OConnel, E.R., et al., 1989. Strength

    and fitness and subsequent back injuries in fire fighters.Journal of Occupational Medicine 21, 269.Cibulka, M.T., Sinacore, D.R., Cromer, G.S., Delitto, A., 1998.

    Unilateral hip rotation range of motion asymmetry in patientswith sacroiliac joint regional pain. Spine 23, 10091015.

    Croft, P.R., Macfarlane, G.J., Papageorgiou, A.C., Thomas, E.,Silman, A.J., 1998. Outcome of low back pain in generalpractice: a prospective study. Br. Med. J. 316, 13561359.

    Croft, P.R., Papageorgiou, A.C., Thomas, E., Macfarlane, G.J.,Silman, A.J., 1999. Short-term physical risk factors for newepisodes of low back pain: prospective evidence from theSouth Manchester back pain study. Spine 24 (15), 15561561.

    Deyo, R.A., Weinstein, J.N., 2001. Low back pain. New EnglandJournal of Medicine 344, 363370.

    Ellison, J.B., Rose, S.J., Sahrmann, S.A., 1990. Patterns of

    rotation range of motion: a comparison between healthysubjects and patients with low back pain. Physical Therapy70, 537541.

    Enthoven, P., Skargren, E., Kjellman, G., Oberg, B., 2003.Course of back pain in primary care: a prosepective study ofphysical measures. Journal of Rehabilitation Medicine 35,168173.

    Fordyce, W.E., Brochway, J.A., Bergman, J.A., et al., 1986.Acute back pain: a control-group comparison of behavioralvs. traditional management methods. Journal of BehavioralMedicine 9, 127.

    Green, J., Grenier, S., McGill, S.M., 2002. Low back stiffness isaltered with warmup and bench rest: implications forathletes. Medicine and Science in Sports and Exercise 34(7), 10761081.

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    Figure 10 Hip extension range of motion test.

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    Grenier, S., et al., 2004. Linking a history of work loss due to lowback injury with person al fitness variables such as muscularendurance. Submitted for publication.

    Gronblad, M., Hurri, H., Jouri, J.P., 1997. Relationships betweenspinal mobility, physical performance tests, pain intensityand disability assessments in chronic low back pain patients.Scandinavian Journal of Rehabilitation Medicine 29, 1724.

    Hadler, N.M., 1986. Regional back pain. New England Journal ofMedicine 315, 10901092.

    Hashemi, L., Webster, B.S., Clancy, E.A., Volinn, E., 1998.Length of disability and cost of workers compensation lowback pain claims. Journal of Occupational and EnvironmentalMedicine 40, 261269.

    Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long-termeffects of specific stabilizing exercises for first-episode lowback pain. Spine 26, e243e248.

    Hodges, P.W., Richardson, C.A., 1998. Delayed postural contrac-tion of transversus abdominis in low back pain associatedwith movement of the lower limb. Journal of Spinal Disorders11 (1), 4656.

    Hodges, P.W., Richardson, C.A., 1999. Altered trunk musclerecruitment in people with low back pain with upper limb

    movement at different speeds. Arch Physical Medicine andRehabilitation 80 (9), 10051012.

    Hudson-Cook, N., Tomes-Nicholson, K., Breen, A.C., 1989. Arevised Oswestry disability questionnaire. In: Roland, M.,Jenner, J. (Eds.), Back Pain: New Approaches to Rehabilita-tion and Education. Manchester University Press, Manchester,UK, pp. 187204.

    Indahl, A., Haldorsen, E.H., Holm, S., Reikeras, O., Hursin, H.,1998. Five-year follow-up study of a controlled clinical trialusing light mobilization and an informative approach to lowback pain. Spine 23, 26252630.

    Janda, V., 1996. In: Liebenson, C., (Ed.), Evaluation of MuscleImbalance in Liebenson C. Rehabilitation of the Spine: APractitioners Manual. Williams and Wilkins, Baltimore(Chapters 6).

    Jarvik, J.G., Deyo, R.A., 2000. Imaging of lumbar intervertebraldisc degeneration and aging, excluding disc herniations.Radiology Clinics of North America 38, 12551266.

    Kankaapaa, M., Taimela, S., Laaksonen, D., et al., 1998. Backand hip extensor fatigability in chronic low back pain patientsand controls. Archives of Physical Medicine and Rehabilitation79, 412417.

    Kilpikoski, S., Airaksinen, O., Kankaanpaa, M., Leminen, P.,Videman, T., Alen, M., 2002. Interexaminer reliability of lowback pain assessment using the McKenzie method. Spine 27,E207E214.

    Latimer, J., Maher, C.G., Refshauge, K., Colaco, I., 1999. Thereliability and validity of the Biering-Sorensen test inasymptomatic subjection and subjects reporting current orprevious non-specific low back pain. Spine 24, 20852090.

    Lee, J.H., Hoshin, O.Y., Nakamura, K., Kariya, Y., Saita, K., Ito,K., 1999. Trunk muscle weakness as a risk factor for low backpain. A 5-year prospective study. Spine 24, 5457.

    Leinonen, V., Kankaanpaa, M., Airaksinen, O., et al., 2000. Backand hip flexion/extension: effects of low back pain andrehabilitation. Archives of Physical Medicine and Rehabilita-tion 81, 3237.

    Lemestra, M., Olszynski, W.P., 2003. The effectiveness ofstandard care, early intervention, and occupational manage-ment in workers compensation claims. Spine 28, 226237.

    Lindstrom, A., Ohlund, C., Eek, C., et al., 1992. Activation ofsubacute low back patients. Physical Therapy 4, 279293.

    Linton, S.J., 1998. The socioeconomic impact of chronic backpain: is anyone benefiting? Editorial. Pain 75, 63168.

    Luoto, S., Heliovaara, M., Hurri, H., Alaranta, H., 1995. Staticback endurance and the risk of low-back pain. ClinicalBiomechanics 10, 323324.

    Luoto, S., Aalto, H., Taimela, S., et al., 1998. One-footed andexternally disturbed two-footed postural control in chroniclow-back pain patients and healthy controls: a controlledstudy with follow-up. Spine 23, 20812090.

    Malmivaara, A., Hakkinen, U., Aro, T., et al., 1995. Thetreatment of acute low back painFbed rest, exercises, orordinary activity? New England Journal of Medicine 332,351355.

    Manniche, C., Lundberg, E., Christensen, I., Bentzen, L.,Hesselesoe, G., et al., 1991. Intensive dynamic backexercises for chronic low back pain. Pain 47, 5363.

    Marras, W.S., Allread, W.G., Burr, D.L., Fathallah, F.A., 2000.Prospective validation of a low-back disorder risk model andassessment of ergonomic interventions assoicated withmanual materials handling. Ergonomics 11, 18661886.

    Mayer, T.G., Smith, S., Keeley, J., Mooney, V., 1985. Quantifica-tion of lumbar function part 2: sagittal plane trunk strengthin chronic low back patients. Spine 10, 765772.

    McGill, S.M., Brown, S., 1992. Creep response of the lumbar

    spine to prolonged full flexion. Clinical Biomechanics 7,4346.

    McGill, S.M., Childs, A., Liebenson, C., 1999. Endurance timesfor stabilization exercises: clinical targets for testing andtraining from a normal database. Archives of PhysicalMedicine and Rehabilitation 80, 941944.

    McGill, S., Grenier, S., Bluhm, M., Preuss, R., Brown, S., Russell,C., 2003. Previous history of LBP with work loss is related tolingering deficits in biomechanical, physiological, personal,psychosocial and motor control characteristics. Ergonomics46, 731746.

    McIntosh, G., Wilson, L., Affleck, M., Hall, H., 1998. Trunk andlower extremity muscle endurance: normative data foradults. Journal of Rehabilitation Outcomes and Measures 2,2039.

    McQuade, J.J., Turner, J.A., Buchner, D.M., 1988. Physical fitnessand chronic low back pain. Clinical Orthopedics and RelatedResearch 223, 198204.

    Mens, J.M., Vleeming, A., Snijders, C.J., et al., 2001. Reliabilityand validity of the active straight leg raise test in posteriorpelvic pain since pregnancy. Spine 26, 11671171.

    Mens, J.M., Vleeming, A., Snijders, C.J., et al., 2002. Validity ofthe active straight leg raise test to measure disease severityin posterior pelvic pain since pregnancy. Spine 27, 196200.

    Moffroid, M.T., 1994. Distinguishable groups of musculoskeletallow back pain patients and asymptomatic control subjectsbased on physical measures of the NIOSH low back atlas.Spine 19, 13501358.

    Moffroid, M.T., Reid, S., Henry, S., Haugh, L.D., Ricamato, A.,

    1994. Some endurance measures in persons with chronic lowback pain. Journal of Orthopedic and Sports Physical Therapy20, 8187.

    Moreland, J., Finch, E., Stratford, P., Balsor, B., Gill, C., 1997.Interrater reliability of six tests of trunk function andendurance. Journal of Orthopedic and Sports PhysicalTherapy 26, 200208.

    Nadler, S.F., Malanga, G.A., DePrince, M.L., Stitik, T.P.,Feinberg, J.H., 2000. The relationship between lowerextremity injury, low back pain , and hip muscle strength inmale and female collegiate athletes. Clinical Journal ofSports Medicine 10, 8997.

    Nadler, S.F., Malanga, G.A., Feinberg, J.H., Prybicien, M., Stitik,T.P., DeFrince, M., 2001. Relationship between hip muscleimbalance and occurrence of low back pain in collegiate

    ARTICLE IN PRESS

    Spinal stabilizationFan update. Part 2Ffunctional assessment 209

    S p i n a l s t a b i l i z a t i o n

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  • 7/28/2019 estabilizacion espinal P2

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    athletes: a prospective study. American Journal of PhysicalMedicine and Rehabilitation 80, 572577.

    Nadler, S.F., Malanga, G.A., Bartoli, L.A., Feinberg, J.H.,Prybicien, M., DePrince, M., 2002. Hip muscle imbalanceand low back pain in athletes: influence of core strengthen-ing. Medicine and Science in Sports and Exercise 34 (1), 916.

    National Collegiate Athletic Association, 1998. NCAA InjurySurveillance System (19971998). National Collegiate Ath-letic Association, Overland Park, Kansas.

    Nicolaisen, T., Joregnesen, K., 1985. Trunk strength, backmuscle endurance and low back trouble. ScandinavianJournal of Rehabilitation Medicine 17, 121127.

    OSullivan, P., Twomey, L., Allison, G., 1997. Evaluation ofspecific stabilizing exercise in the treatment of chronic lowback pain with radiologic diagnosis of spondylolysis orspondylolysthesis. Spine 24, 29592967.

    OSullivan, P.B., Beales, D.J., Beetham, J.A., Cripps, J., Graf, F.,Lin, I.B., Tucker, B., Avery, A., 2002. Altered motor controlstrategies in subjects with sacroiliac joint pain during theactive straight-leg-raise test. Spine 27, E1E8.

    Parks, K.A., Crichton, K.S., Godford, R.J., McGill, S.M., 2003. Acomparison of lumbar range of motion and functional ability

    scores in patients with low back pain. Spine 28, 380

    384.Ready, A.E., Boreskie, S.L., Law, S.A., Russell, R., 1993.Fitness and lifestyle parameters fail to predict backinjuries in nurses. Canadian Journal of Applied Physiology18 (1), 8090.

    Scannell, J.P., McGill, S.M., 2004. Lumbar postureFshould, andcan, it be modified? A study of passive tissue stiffness andlumbar position in activities of daily living. Physical Therapy,accepted for publication.

    Simmonds, M.J., Olson, S.L., Jones, S., Hussein, T., Lee, C.E.,et al., 1998. Psychometric characteristics and clinicalusefulness of physical performance tests in patients withlow back pain. Spine 23 (22), 24122421.

    Snook, S.H., 2004. Work related low back pain: secondaryprevention. Journal of Electromyography and Kinesiology 14,

    153

    160.Snook, S.H., Webster, B.S., McGorry, R.W., Fogleman, M.T.,McCann, K.B., 1998. The reduction of chronic nonspecific low

    back pain through the control of early morning lumbarflexion. Spine 23, 26012607.

    Solomonow, M., Hatipkarasulu, S., Zhou, B., Baratta, R.V.,Aghazadeh, F., 2003. Biomechanics and EMG of a commonidiopathic low back disorder. Spine 28, 12351248.

    Spitzer, W.O., Le Blanc, F.E., Dupuis, M., et al., 1987. Scientificapproach to the assessment and management of activity-related spinal disorders: A monograph for clinicians. Reportof the Quebec task force on spinal disorders. Spine 12 (Suppl.7), S1S59.

    Stratford, P.W., Binkley, J.M., Stratford, D.M., 2001. Develop-ment and initial validation of the upper extremity functionalindex. Physiotherapy Canada 53, 259266.

    Tafazzoli, R., Lamontagne, M., 1996. Mechanical behavior ofhamstring muscles in lo-back pain patients and controlsubjects. Clinical Biomechanics 11, 1624.

    Takala, E.P., Vikari-Juntura, E., 2000. Do functional tests predictlow back pain. Spine 25 (16), 21262132.

    Timm, K.E., 1994. A randomized-control study of active andpassive treatments for chronic low back pain following L5laminectomy. JOSPT 20, 276286.

    Van der Velde, G., Mierau, D., 2000. The effect of exercise on

    the percentile rank aerobic capacity, pain, and self-rateddisability in patients with chronic low back pain: a retro-spective chart review. Archives of Physical Medicine andRehabilitation 81, 14571463.

    Vernon, H., Mior, S., 1991. The neck disability index: a study ofreliability and validity. Journal of Manipulative and Physio-logical Therapeutics 14, 409415.

    Vogt, L., Banzer, W., 1997. Dynamic testing of the motorialstereotype in prone hip extension from the neutral position.Clinical Biomechanics 12, 122127.

    Vogt, L., Pfeifer, K., Banzer, W., 2003. Neuromuscular controlof walking with chronic low-back pain. Manual Therapy 8,2128.

    Waddell, G., 1998. The Back Pain Revolution. Churchill Living-stone, Edinburgh.

    Werneke, M., Hart, D.L., 2001. Centralization phenomenon as aprognostic factor for chronic low back pain and disability.Spine 26, 758765.

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