The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

J Orthop Sports Phys Ther. 2012;42(4):A1-A57. doi:10.2519/jospt.2012.0301

KEY WORDS: clinical practice guidelines, ICD, ICF, LBP, Orthopaedic Section

STUDY DESIGN: Observational. OBJECTIVE: To assess the effects of spinal decompression procedures performed during a clinical exam on low back pain (LBP) symptoms. BACKGROUND: Not all patients report an immediate or complete improvement in symptoms when the direction of lumbar motion or alignment is corrected according to principles of the movement system impairment (MSI) model. Axial compression of the spine may be responsible for the remaining symptoms. METHODS: Seventy subjects (mean ± SD age, 41.9 ± 11.5 years; 38 females, 32 males) with chronic LBP were evaluated using a standardized MSI exam. Seven tests assessing the effects of spinal decompression on LBP were added to the exam if the subjects’ symptoms were not alleviated with typical standardized corrections of movement and alignment. For each test of decompression, subjects reported their symptoms compared to a reference movement or position. RESULTS: When decompression was performed during lateral bending to the right and left, 21 of 21 (100%) and 16 of 20 (80%) subjects, respectively, reported an improvement. When traction was applied to subjects in right and left sidelying, 6 of 11 (55%) and 7 of 9 (78%), respectively, reported an improvement. When patients performed a push-up in sitting, 36 of 51 (71%) reported an improvement. In subjects who had symptoms in unsupported sitting, 41 of 57 (72%) reported an improvement in supported sitting. In subjects who reported symptoms in standing, 33 of 47 (70%) reported an improvement in hook-lying. CONCLUSION: Patients with chronic LBP consistently reported an improvement in symptoms with tests proposed to decrease the axial load on the spine. These tests are a quick and effective way to assess the contribution of axial decompression to LBP symptoms and potentially could be used as part of the plan of care.

J Orthop Sports Phys Ther 2012;42(2):105-113, Epub 25 October 2011. doi:10.2519/jospt.2012.3724

KEY WORDS: axial loading, distraction, lumbar spine, traction

STUDY DESIGN: Cross-sectional study, quasi-experimental design. OBJECTIVES: To compare the active cervical rotation range of motion (ROM) between healthy young subjects with a neutral vertical scapular alignment and subjects with scapular depression, and to examine the influence of modifying the vertical position of the scapulae on active cervical rotation ROM. BACKGROUND: Altered scapular alignment is proposed to be related to neck dysfunction and pain. Changes in the alignment of either the scapulae or the cervical spine can potentially influence the biomechanics of the other by altering the tension at the cervicoscapular muscles. METHODS AND MEASURES: Fifty-eight college age students with neutral vertical scapular alignment (NS group, n=29) or depressed scapular alignment (DS group, n=29) volunteered to participate in the study. Cervical rotation ROM was assessed using the CROM device in 2 conditions: condition 1, resting scapular position; condition 2, neutral vertical scapular position with forearms supported. RESULTS: The ANOVA revealed no significant group-by-condition interaction (F=0.19, df=1, P=.66). There was a significant main effect of condition (F=47.16, df=1, P<.001).  For both groups, there was an increase in cervical rotation ROM in condition 2 when compared to condition 1 (mean ± SD, 10.2º ± 3.1º, 95% CI= 4.1º to 16.4º). There was no main effect of group (F=.41, df=1, P=.53). CONCLUSION: Our results suggest that in a young healthy population the vertical scapular alignment does not influence cervical rotation ROM. Supporting the upper limbs, however, results in a significant and similar increase in cervical rotation ROM for both groups. LEVEL OF EVIDENCE: Etiology, level 4.

J Orthop Sports Phys Ther. 2008; 38(11):668-673, Epub 22 August 2008. doi:10.2519/jospt.2008.2820

KEY WORDS: neck, scapula, support

STUDY DESIGN: Cross-sectional, secondary analysis. OBJECTIVES: To examine potential gender differences in prevalence of lumbopelvic region movement impairments during clinical tests in a sample of people with low back pain (LBP). BACKGROUND: A number of studies have identified factors contributing to differences between men and women in prevalence of lower extremity injuries. Few studies have examined potential gender differences in impairments of people with LBP. METHODS AND MEASURES: Eighty-four males and 86 females (mean ± SD age, 41.5 ± 13.3 years) with LBP participated in a standardized examination. Responses from 7 movement tests that examine early lumbopelvic movement were analyzed using chi-square statistics. RESULTS: A greater proportion of men than women displayed early lumbopelvic movement during the majority of limb movements (3/4) and movements potentially affected by limb tissue stiffness (2/2) (P<.05). There were no differences in the proportions of men and women displaying early lumbopelvic movement during a movement presumed to not be affected by limb tissue stiffness (P>.05). Similar results were obtained when analyzing only the subsets of subjects who reported an increase in symptoms with a specific test. CONCLUSION: Our results provide data to suggest men and women with LBP may move differently in the lumbopelvic region during clinical tests of limb movements and movements potentially affected by limb tissue stiffness. Recognition of gender differences in prevalence of movement impairments is important for improving examination and intervention of people with LBP.

J Orthop Sports Phys Ther 2007;37(12):744-753, published online 29 August 2007. doi:10.2519/jospt.2007.2610

KEY WORDS: limb, lumbar, physical therapy

STUDY DESIGN: Case report. BACKGROUND: Based on our assumption that subtle deviations in the precision of shoulder movement cause tissue injury, we have developed a set of movement-related diagnoses for shoulder problems. The purposes of this case report are to: 1) illustrate the use of a movement system impairment (MSI) diagnosis in a patient with shoulder pain, 2) illustrate how the MSI diagnosis guided treatment prescription, and 3) describe the outcomes of treatment based on a MSI diagnosis for shoulder impingement. CASE DESCRIPTION: The patient was a 46-year-old female with recurrent right shoulder pain of 2 months' duration. Initially she reported her pain was constant but varied in intensity and had increased gradually over time. Shoulder pain limited her ability to bicycle and perform reaching movements. The systematic clinical examination for assessing the patient's preferred alignment and movements included items related to pain, alignment, movement, muscle length, muscle strength, and function. Based on the examination, the MSI diagnosis was humeral anterior glide with scapular downward rotation. The treatment focused on correction of her shoulder alignment, functional movements, and associated impairments of muscle function. The patient was seen 4 times in 6 weeks. OUTCOMES: The patient was pain free with all activities at 1 month and there was no recurrence of symptoms 3 years after the last physical therapy visit. DISCUSSION: A MSI diagnosis of humeral anterior glide with scapular downward rotation guided physical therapy treatment and resulted in positive short- and long-term outcomes.

J Orthop Sports Phys Ther. 2007;37(9):551-553, published online 20 June 2007. doi:10.2519/jospt.2007.2283

KEY WORDS: glenohumeral joint, impingement, scapula, rotator cuff

Study Design: Cross-sectional. Objectives: To test the assumption that postural alignment and gender have a bearing on the specific type of low back pain (LBP) a person manifests. Background: Measurements of static sagittal lumbar curvature are used by clinicians in the management of patients with LBP, but no investigator has reported differences in curvature related to specific categories of LBP. Methods and Measures: We used a computer-interfaced, 3-D, electromechanical digitizer to derive curvature angles for the region of the spine between T12-L1 and S2. Trained clinicians examined the subjects and determined their LBP diagnoses. We used t tests to examine differences in curvature between women and men, those with and those without LBP, and those in 4 different categories of LBP. We used x² to examine the relationship between gender and LBP category. Results: Lumbar curvature angle (lordosis) was 13.2° larger for women than for men (t = 6.74; P<.01). There was no difference in lumbar curvature between people with undifferentiated LBP and people without LBP. There were differences in lumbar curvature between people in various categories of LBP, for example, subjects in the lumbar-rotation-with-extension category had 8.4° more lumbar curvature than subjects in the lumbar-rotation-with-flexion category (t = 2.16; P<.05). Based on the frequency distributions, there was a significant relationship between gender and LBP category (x² = 10.19; P<.01). Conclusions: Measurements of lumbar curvature should be expected to differ between men and women and may be related to different types of low back pain.

J Orthop Sports Phys Ther. 2004;34(9):524-534. doi:10.2519/jospt.2004.1570

Key Words: lordosis, lumbar curvature, posture, spine

Study Design: A descriptive, correlational study of patients with mechanical low back pain (LBP). Objectives: To assess the effect of active limb movements on symptoms in patients with LBP and to examine the relationship between symptoms with limb movements and select patient characteristics. Background: Limb movements result in forces applied to the spine and, thus, may be important in the examination and treatment of patients with LBP. Methods and Measures: A total of 188 people with LBP, 84 men and 104 women, participated in a standardized examination. Six of the items required patients to move their limbs and note LBP symptoms as increased, remained the same, or decreased. The prevalence of various symptom responses with each limb movement test was calculated. Relationships between patient characteristics and reports of increased symptoms were examined with Cochran's linear trend statistic and the Spearman and Pearson correlation coefficients. Differences in characteristics of patients with and without increased symptoms were examined with X2 test, Mann-Whitney U test, or Student's t test for independent groups. Results: An increase in symptoms was reported by 149 patients with at least 1 of the limb movement tests, and 3 of the patients reported a decrease in symptoms. Across the patient sample, the mean number of limb movement tests for which symptoms were reported as increased was 2.30 ± 1.64. Patients with an increase in symptoms reported higher average pain intensity the week prior to the examination (median = 2; range: 1-5) and higher functional disability (mean = 0.25; SD = 0.15) than those without a change in symptoms (pain intensity: median = 1; range: 0-2 and functional disability: mean = 0.16; SD = 0.12). The correlation between the number of increased symptoms and the person's average pain intensity was r = 0.23; the correlation with the functional disability score was r = 0.36. Patients with a history of LBP tended to report an increase in symptoms with more of the limb movement tests (mean = 3.5; SD = 1.40) than those without a previous history of LBP (mean = 2.0; SD = 1.11). Conclusions: Active limb movements performed during the examination primarily resulted in increased LBP symptoms. The presence and number of increased symptoms with the active limb movements was related to the patient's report of average pain intensity and functional disability. Tests of symptoms with active limb movements may provide insight into factors contributing to a LBP problem, as well as information to guide the treatment of patients with LBP.

J Orthop Sports Phys Ther. 2001;31(8):402-418.

Key Words: limb movements, low back pain assessment, motor control, spinal disorders

Study Design: A 2-group, nonrandomized, mixed design with 1 between-subjects factor (group) and 2 within-subjects factors (knee and hip position). Objectives: To determine the amount of passive hip extension during changes in the knee angle in the sagittal plane, and the hip angle in the frontal plane in back-healthy (BH) subjects and subjects with low back pain (LBP). Background: Information regarding the specific contributions of hip flexor muscles to limitations in hip extension range of motion (ROM) is necessary for the prescription of appropriate treatment. Methods and Measures: Thirty-five BH subjects (24 women and 11 men, mean age = 31.37 ± 11.36) and 10 subjects with LBP (6 women and 4 men, mean age = 33.70 ± 9.31) participated in the study. The passive length of the one- and two-joint hip flexor muscles was tested in 4 different conditions in which the positions of the knee and the hip were varied. The knee was positioned passively in full extension or 80° of flexion while the hip was positioned passively in zero abduction or full abduction. Results: Subjects with LBP displayed less passive hip extension than BH subjects (LBP, -5.61° ± 4.30; BH, -2.57° ± 4.18). Both groups had less hip extension when the knee was in flexion of 80° than when the knee was fully extended (flexed, -5.51° ± 4.50; extended, -0.98° ± 4.65), and when the hip was in zero hip abduction than when the hip was fully abducted (zero, -7.55° ± 5.03; full, 1.06° ± 4.31). The contribution of the different hip flexors to a hip extension limitation differed between BH and subjects with LBP. BH subjects demonstrated an effect of knee angle on hip extension when the hip was in zero abduction (flexed, -11.43° ± 5.81; extended, -2.49° ± 5.39), but not when the hip was in full abduction (flexed, 1.74° ± 3.91; extended, 1.89° ± 3.94). Subjects with LBP demonstrated an effect of knee angle on hip extension when the hip was in zero abduction (flexed, -12.60° ± 4.91; extended, -6.65° ± 5.03) and when the hip was in full abduction (flexed, -3.10° ± 5.53; extended, -0.10° ± 5.18). Conclusions: The results of this study provide evidence that changing the knee joint angle in the sagittal plane and the hip joint angle in the frontal plane, during the hip flexor length test, can affect the amount of passive hip extension ROM. The contribution of specific hip flexor muscles to a hip extension limitation may differ depending on the individual's movement dysfunction. Modifying the hip flexor length test, as described, should provide information about the specific muscles contributing to a hip joint extension limitation.

J Orthop Sports Phys Ther. 2000;30(6):307-316.

Key Words: flexibility, hip flexor muscles, range of motion

Study Design: Case report. Objective: To describe an intervention approach consisting of a specific active-exercise program and modification of postural alignment for an individual with cervicogenic headache. Background: The patient was a 46-year-old male with a 7-year history of cervicogenic headache. He reported constant symptoms with an average intensity of 5/10 on a visual analogue scale where 0 indicated no pain and 10 the worst pain imaginable. Average pain intensity in the week prior to the initial evaluation was 3/10 secondary to trigger point injections. The patient’s headache symptoms worsened with activities that involved use of his arms and prolonged sitting. Methods and Measures: The patient was treated 7 times over a 3-month period. Impairments of alignment, muscle function, and movement of the cervical, scapulothoracic, and lumbar regions were identified. Outcome measurements included headache frequency, intensity, and the Neck Disability Index (NDI) questionnaire. Intervention included modification of alignment and movement during active cervical and upper extremity movements. The patient also received functional instructions focused on diminishing the effect of the weight of the upper extremities on the cervical spine. Results: The patient reported a decrease in headache frequency and intensity (1 headache in 3 weeks, intensity 1/10) and a decrease in his NDI score from 31 (severe disability) to 11 (mild disability). The patient also demonstrated improvement in upper cervical joint mobility, cervical range of motion, scapular alignment, and scapulothoracic muscle strength. Conclusion: Interventions that included modification of alignment in the cervical, scapulothoracic, and lumbar region, along with instruction in a specific active-exercise program to address movement impairments in these 3 regions, appeared to have been successful in relieving headaches and improving function in this patient.

J Orthop Sports Phys Ther. 2005;35(1):3-15. doi: 10.2519/jospt.2005.1441

Key Words: cervical spine, muscle impairments, posture, scapular alignment

Study Design: Cross-sectional, secondary analysis. Objectives: To examine whether there were differences in the numbers and types of impairments on examination between 2 groups of people with low back pain (LBP), those who participated in symmetric leisure activities and those who participated in asymmetric leisure activities. Background: It has been proposed that people who repeatedly perform an activity that involves trunk movements and alignments in the same direction will develop strategies that are generalized to many activities. The repeated use of these strategies is proposed to contribute to impairments identifiable on examination and to LBP. Methods and Measures: Forty males and 40 females (mean ± SD age, 41.4 ± 13.9 years) with LBP who reported participation in either a symmetric or an asymmetric leisure activity participated in a standardized examination. Responses from 10 trunk-rotation-related impairment tests were analyzed using the Mann-Whitney U and chi-square statistics. Results: Thirty people participated in asymmetric leisure activities and 50 people participated in symmetric leisure activities. The total number of rotation-related impairments was different for the 2 groups (U = 1112, P<.01). The asymmetric group displayed more total rotation-related impairments (median, 4.0; range, 7) than the symmetric group (median, 2.0; range, 6). A greater percentage of the asymmetric group displayed more impairments on 5 out of 10 individual tests, as compared to the symmetric group (P≤.05 for all comparisons). Conclusions: Our results provide preliminary data to suggest that trunk-rotation related impairments, identified on examination, may be related to the general type of movements and alignments used repeatedly by patients with LBP.

 J Orthop Phys Ther. 2006;36(2):58-71. doi:10.2519/jospt.2006.2161

Key Words: examination, lumbar spine, spinal disorders, sports

J Ortho Sports Phys Ther. 2003;33:126-142.

Key Words: classification, impairment, low back pain, principal components analysis, validity