Minimizing Pain, Normalizing
Movement and Maximizing Function
An Example in Low Back Pain
Linda Van Dillen, PT, PhD
AAOMPT 2015 Annual Conference
Key Note Presentation
Disclosures
Current Funding
• NIH/NICHD-NCMRR R01 HD047709
• NIH/NCATS UL1 TR000448, Washington University,
Institute for Clinical and Translational Sciences CTSA
#705
• NIH/NICHD T32 HD007434
• Orthopaedic Research Section Grant, APTA
• Washington University Olin Women’s Fellowship
• Dr. Hans and Clara Davis Zimmerman Foundation
Program in Physical Therapy
Today
• Discuss the conference theme
• Important and timely topic for profession given APTA vision
statement (2013) for Physical Therapy that emphasizes
• All specialists in treatment of movement system across
lifespan
• As such, interest should be in optimizing treatment based on
patient characteristics with goal of providing best short-term
and long-term outcomes
Program in Physical Therapy
Today
• Relative flexibility impairments
• Describe some of work identifying movement impairments in
people with musculoskeletal pain conditions
• Example today - non-specific LBP
• Describe Kinesiopathologic model
• Studies and relevance
• To provide an understanding of impairment
• Describe clinical relevance of impairment
• Integration and application of information into clinical
practice
Program in Physical Therapy
THEME
Program in Physical Therapy
Theme
• No matter what the clinical specialty/certification, all
therapists are specialists in treating the “movement
system” across the lifespan
•
APTA’s Vision Statement for the Physical Therapy Profession, 2013;
http://www.apta.org/VisionStrategicPlan
• Graphic displaying the major organ
systems that interact to produce
and support movement of the body
and its parts
Program in Physical Therapy
Theme
• As such experts, all of us have the same goals for
management of people with musculoskeletal pain
conditions
• Minimize the person’s pain
• Normalize the person’s movement
• Maximize the person’s performance
• Performance = repetitive everyday functional activities
• Ranging from basic activities (self-care, housekeeping) to
more complex, higher demand activities (work and sportsrelated)
• Associated with physical load
• Similar loading among activities = cumulative effect
HS Picavet et al., 2000, Prev Med; 31: 506-512
Program in Physical Therapy
Theme
• Primary question
• How do we do this, i.e., optimize treatment?
• At global level, evidence for treatment of musculoskeletal
pain conditions supports use of movement-based
approaches to improve outcomes
• Despite the growing evidence, there are still many
unanswered questions about details of the movementbased treatments
• Would like to walk you through what I think are the major
questions that remain
Sogaard K & Jull G, Man Ther, 2015: 20:631-632
Program in Physical Therapy
Theme
• Questions still up for discussion related to movementbased treatment include
• Which movement-based treatment should we provide
for which patient?
• Still not completely answered
• Subgrouping in LBP is good example of efforts to answer ?
• When do we provide treatment?
• So how soon should we see the patient coming into
primary care for a new consultation for a MSK pain
condition?
• Some data suggests early treatment may result in better
outcomes
Program in Physical Therapy
Theme
• Questions still up for discussion related to movementbased treatment include
• How much treatment should we provide?
• What is the appropriate dose of treatment (frequency,
duration, & intensity of treatment)?
• Suggest prescribing a dose that provides not only
immediate improvements but also maintenance of
improvements
• Will provide suggestions for how this might be
accomplished
Program in Physical Therapy
Theme
• Questions still up for discussion related to movementbased treatment include
• How frequently over time should we provide
treatment?
• Should we be seeing people only during acute flare-ups or
should there be a treatment schedule similar to dental
model of care?
• Ongoing study – provide booster sessions at crucial time
points where pain and function appear to worsen
• Can gains in treatment be maintained if have regular
check ups?
Program in Physical Therapy
Theme
• Overall Goal
• Optimize short-term course
• Provide most effective and efficient treatment
• Optimize how much and how quickly recover pain-free
performance of activities that are important to the
patient
As importantly,
• Optimize long-term course
• Provide strategies for maintenance of gains in pain and
function
• Important because course of many pain conditions is
persistent or recurrent symptoms & limitations
Program in Physical Therapy
10
Characteristic course
Pain (0-10)
9
8
7
6
5
4
3
2
1
0
Time
10
Goal
Pain (0-10)
9
8
7
6
5
4
3
2
1
0
Time
Program in Physical Therapy
Theme
• Primary goal today
• Describe work examining a major impairment, relative
flexibility, found to be important in people with mechanical
LBP
• Provide data that suggest that addressing impairment may
• Minimize pain
• Improve quality of movement
• Improve performance
• Effects may be related to improvement of long-term
outcomes
• Break out session – practice in identifying impairment in
people with mechanical LBP
Program in Physical Therapy
Theme
• Secondary goal
• Provide suggestions of how you might integrate information
presented into your clinical practice
• Caveat
• Not the only finding important to treatment
• Clinical presentation = interaction of multiple factors
• Examples = biomechanics, pain processing, psychosocial
• Contributions differ across patients
• Ongoing challenge
• Weigh how much each factor contributes
• Target most important factors per patient
Program in Physical Therapy
Kinesiopathologic Model
Relevant Studies
RELATIVE FLEXIBILITY
IMPAIRMENTS
Program in Physical Therapy
Model for Development and Course of Musculoskeletal Pain
KINESIOPATHOLOGIC
MODEL & LBP
Program in Physical Therapy
Overview
• Pathokinesiologic Model:
Disease/
Pathology/
Injury
Altered
Movements
& Postures
Tissue
Stress
Musculoskeletal
Pain
Tissue Injury
Micro/Macro
• Kinesiopathologic Model:
Repeated
Movements
Postures
Altered
Movements
& Postures
Tissue
Stress
Musculoskeletal
Pain
Tissue Injury
Micro/Macro
Hislop HJ, Phys Ther, 1975;19:1069-1080
Sahrmann SA, Diagnosis and treatment of movement impairment syndromes. 1st ed. Mosby: St. Louis, 2002;
ISBN 0-8016-7205-8
Program in Physical Therapy
Kinesiopathologic Model & LBP
Repetition of Movements and Alignments in Same
Direction with Everyday Activities
Musculoskeletal Changes, e.g.,
Muscle Strength, Joint Flexibility
Neural Changes, e.g., Muscle
Timing and Recruitment Patterns
Individual Characteristics, e.g., Sex, Anthropometrics,
Activity Level
Adoption of Altered Patterns of Movement and Alignment
Generalized Across Activities
Specific Pattern of Altered Joint Movement and Alignment
*Lumbar Region – Moves more readily than other joints
Altered Loading - Accumulation of Localized Areas of
Tissue Stress, Symptoms, Tissue Injury (Micro & Macro)
Program in Physical Therapy
Body Takes the Path of Least Resistance to Produce
Movement
CONCEPT OF RELATIVE
FLEXIBILITY
Program in Physical Therapy
Example of Relative Flexibility
Body takes the path of least resistance to accomplish movement goal
Program in Physical Therapy
Relative Flexibility & Low Back Pain
• During a movement, lack of flexibility of one joint can
cause movement of an adjoining joint – compensatory
movement
• Site of compensatory motion - Lumbar region
• Becomes relatively more flexible than other regions
• Typical compensatory motion
• Early movement of the lumbar spine during trunk and
limb motions or assumption of positions
• In the same direction(s)
• Compensatory movement develops into a pattern of
movement used across multiple everyday activities
Program in Physical Therapy
Lumbopelvic Rotation with
Everyday Activity
kedlewalk.WMV
Program in Physical Therapy
Relative Flexibility Impairments and LBP – Existence and
Importance
STUDY FINDINGS
Program in Physical Therapy
Testing
Overall testing
•
•
•
Clinical measures
Laboratory measures
Participants
•
•
•
•
•
People with recurrent or chronic non-specific LBP
Not in an episode or acute flare-up
Moderate levels of pain and functional limitations
Low levels of fear avoidance behavior
Program in Physical Therapy
Testing
Standardized clinical examination
•
•
•
•
Clinical tests of movements and positions
•
Judgments of relative flexibility
•
Associated symptoms
Classify people into LBP subgroups
•
Subgroups named for directions of movements and
alignments displayed and associated symptoms
•
Flexion, extension, rotation, rotation with flexion,
rotation with extension
Self-report measures
Van Dillen LR et al., Phys Ther, 1998; 78(9):979-988
Van Dillen LR et al., JOSPT, 2003; 33(3):126-142
Henry SM et al., Man Ther, 2013; 18(1):31-40
Trudelle-Jackson et al., JOSPT, 2008; 38(6(:371-376
Kim MH et al., J Electromyogr Kines, 2013; 23(2):387-393
Program in Physical Therapy
Testing
• Laboratory Instrumentation - motion capture system
• Used to precisely quantify different aspects of movement and
alignment patterns, i.e., relative flexibility
• Variables to “index” relative flexibility
• Overall - Capturing how “readily” the lumbar
region moves relative to other joints or
regions
Program in Physical Therapy
Patterns of Relative Flexibility During Clinical Tests
PEOPLE WITH LBP &
PEOPLE WITHOUT LBP
Scholtes et al, Clin Biomech, 2009;24:7-12
Marich et al, ASB Proc, 2015; 991-992
Program in Physical Therapy
Background
• Rationale
• Examine movement patterns during clinical tests because
assume relationship between clinical test movements and
movements during everyday functional activities
• Repetition across day potentially contributes to LBP condition
• Importance of comparing people with and without LBP
• If different indicates the relative flexibility pattern may be
relevant to the LBP condition
• Purpose
• Examine differences in relative flexibility between people with
LBP and people without LBP during clinical tests
Program in Physical Therapy
Movement Tests
Hip Lateral Rotation (n=91)
Trunk Forward Bend (n=48)
Primary question: Do people with LBP display relative flexibility patterns
during clinical tests to a greater degree than people without LBP?
Program in Physical Therapy
Index of Relative Flexibility:
Hip Lateral Rotation
• Variable: Timing difference
• Start of limb movement - Start of lumbopelvic movement
• Normalized to limb movement time
• Range of values (0 – 1)
• Interpretation of values
0
Small - “Coupled”
1
Large - “Independent’
• Hypothesis: People with LBP move lumbar region earlier
in hip motion than people without LBP
Program in Physical Therapy
Hip Lateral Rotation Test
Small value: Coupled
Large value: Independent
Program in Physical Therapy
Hip Lateral Rotation Test (n=91)
Timing of Lumbopelvic
Rotation
Timing Difference
Active Hip Rotation
0.5
p=0.013
0.4
0.3
*No significant difference
*
0.2
• Pattern not driven by lack
of hip ROM
0.1
0
No LBP
LBP
Program in Physical Therapy
Index of Relative Flexibility:
Forward Bend
• Amount of sagittal plane lumbar motion, particularly in
the early part of the test movement
• Specifically, amount of lumbar motion at increments of
movement time
•
•
•
•
0-25%
25-50%
50-75%
75-100%
• Hypothesis: People with LBP display more sagittal lumbar
motion early in the forward bend compared to people
without LBP
Program in Physical Therapy
Forward Bend Test (n=48)
Sagittal Lumbar ROM (deg) at Quartiles of Movement Time
Movement
Time (%)
BH
(n=16)
LBP-LOW
(n=13)
LBP-HIGH
(n=19)
p-value
0-25#
5.9 ± 2.1*
6.2 ± 2.8
8.6 ± 3.9*
.03
25-50
13.9 ± 3.4
12.7 ± 4.8
13.3 ± 3.6
.73
50-75
9.8 ± 2.8
9.3 ± 3.9
9.5 ± 4.2
.94
75-100
4.1 ± 2.1
4.5 ± 3.3
5.3 ± 3.9
.54
LBP-LOW = mODI score < 20
LBP-HIGH = mODI score ≥ 20
*
LBP HIGH group is significantly different from the BH group
#
Effect size = .26 (eta2; large)
Program in Physical Therapy
Forward Bend Test
Total Sagittal Thoracic, Lumbar, Hip ROM (deg)
BH
(n=16)
LBP-LOW
(n=13)
LBP-HIGH
(n=19)
p-value
Thoracic
28.4 ± 10.7
29.7 ± 8.9
28.8 ± 8.2
.93
Lumbar
33.7 ± 7.1
32.7 ± 10.9
36.8 ± 7.9
.36
62.1 ± 10.5
62.4 ± 11.3
65.6 ± 12.7
.62
59.1 ± 15.3
65.3 ± 12.9
55.2 ± 15.9*
.19#
130.6 ± 9.5
132.0 ± 13.1
125.2 ± 25.0
.52
Spine
Hip
Total
No differences in total end ROM for thoracic, lumbar, hip joints
*Trend for decreased end ROM of hip in LBP-HIGH group
#Effect size = .07 (eta2; medium)
Program in Physical Therapy
Summary
• Compared to people without LBP, people with LBP display
more relative flexibility impairments, i.e., early lumbar
motion, during clinical tests of limb and trunk movements
Program in Physical Therapy
Relevance
• Movements used during clinical tests potentially provide
insight into movements used during everyday activities
• Everyday activities performed in early and mid-ranges of
joint motion
• Based on data from clinical tests, there is potential for
increased frequency of lumbar movement across the day
that could contribute to tissue stress and LBP
Bible JE et al., J Spinal Dis Tech 2010 ;23(2):106-12.
Cobian DG et al., Spine 2013; 38(20):1754-63.
Program in Physical Therapy
Model: Daily and Sport Activities
REPETITIVE ACTIVITIES &
SPECIFIC TYPES OF
IMPAIRMENTS
Van Dillen LR et al., JOSPT, 2006;36:631-647
Chimenti RL et al., J Sport Rehab, 2013; 22:161-169
Weyrauch SA et al., APMR, 2015; 96:1506-1517
Program in Physical Therapy
Background
• Examined whether the directions of relative flexibility
patterns a person with LBP displays is related to the type of
activity the person participates in regularly
• Rationale
• KPM assumption - People develop specific types relative
flexibility patterns due to repetition of movements and
alignments in the same direction with everyday activities
• Importance
• An association between type of impairment and type of
activity patient participates in provides a point of
intervention, i.e., modify movement impairment during
performance of activity
Program in Physical Therapy
Background
• Model
• Compared relative flexibility patterns in people who played a
sport regularly (2 groups) to people who did not play the
sport regularly (1group)
• Design - Rotation-related sport = tennis, squash, racquetball,
or golf
Rotation-Related Sport
Yes
LBP NoLBP
No
NoLBP
Program in Physical Therapy
Background
• Measures
• Clinical examination to identify rotation-related relative
flexibility impairments (rotation, lateral bending, shift)
• Self-report (demographic, activity-related, LBP-related)
• Purpose
• Examine if (1) people with LBP, and (2) people without LBP
who regularly participate in a rotation-related sport display
more rotation-related relative flexibility patterns than (3)
back-healthy people who do not participate in the sport
Program in Physical Therapy
Background
Hypothesis #1
• People with LBP & people without LBP who play sport vs.
back-healthy people who do not play sport
• Compared to the back-healthy group who do not play the
sport, people with LBP & people without LBP who play the
sport will display
• Greater number of rotation-related relative flexibility
patterns
• More asymmetry of rotation-related relative flexibility
patterns
Program in Physical Therapy
Background
Hypothesis #2
• People with LBP & people without LBP who play sport
• Compared to people without LBP who play the sport, people
with LBP who play the sport would differ in the types of
rotation-related relative flexibility patterns they display
• Compared impairments with trunk movement tests
and limb movement tests
Program in Physical Therapy
Example of Asymmetry of Rotation-Related
Impairment
Program in Physical Therapy
Example of Asymmetry of Rotation-Related
Impairment
Program in Physical Therapy
Rotation-Related Relative Flexibility
Impairments (n= 123)
Program in Physical Therapy
Variability of Activities in People who Play
the Same Sport
• Also interested in comparing the types of activities that
contribute to overall activity level
• What other factors contribute to why some people who play a
sport develop LBP while others do not?
• Related to variability of activities participate in?
• Hypothesis
• Two groups would differ in the relative amount & nature of
activities contributing to overall activity level
• Baecke Habitual Activity Questionnaire (3-15)
• Sport activity participation (Leisure Sport subscore)
• Daily activity participation (Average WorkLeisure subscore)
Program in Physical Therapy
Variability of Activities in People who Play
the Same Sport
*
Overall activity
levels were (=)
between people
with LBP and
people without LBP
People with LBP
spent relatively
more time playing
sport and less time
in daily activities
compared to people
without LBP
Program in Physical Therapy
Summary
• People with LBP and back-healthy people that played sport
displayed the same number and asymmetry of rotationrelated impairments, and more impairments than backhealthy people that did not play sport
• The difference between people with LBP and back-healthy
people that played the sport was in the type of
impairments displayed
• People with LBP – more impairments with extremity
movement tests
Program in Physical Therapy
Summary
• People that played the sport also differed in relative
amount and type of activities participated in across their
day
• People without LBP displayed more variability in activities
than people with LBP
• People with LBP are spending more time in activities that
appear to contribute to their relative flexibility impairments
Program in Physical Therapy
Relevance
• Regular participation in an activity may increase the
number of relative flexibility impairments a person
develops
• Supports assumption of KPM - Direction-specific nature of
repetitive activity drives specific adaptations
• Specific relative flexibility impairments may be more
associated with a LBP condition than others
• Example today - impairments with limb movements
Program in Physical Therapy
Relevance
• Balance in type of activities a person participates in may
be an important consideration in treatment of people with
LBP
• Together findings suggest a need to attend to the specific
details of the activities people with LBP participate in
regularly
Program in Physical Therapy
Symptoms with Limb and Trunk Movement Tests and
Trunk Posture Tests
EFFECT OF MODIFYING
RELATIVE FLEXIBILITY
IMPAIRMENTS
Van Dillen LR et al, APMR, 2003;84:313-322
Van Dillen LR et al, Man Ther, 2009; 14:52-60
Program in Physical Therapy
Background
•
Rationale
•
Thus far we have provided data to suggest that relative
flexibility impairments are prevalent in people with LBP
•
Primary question remains - Are relative flexibility
impairments important to a person’s LBP condition?
•
Addressed this question by looking at whether a person’s LBP
symptoms were related to their relative flexibility
impairments
Program in Physical Therapy
Clinical Examination
Clinical tests of movements and positions
•
•
•
Judgments of relative flexibility impairments
Associated symptoms
•
Primary tests: Patient’s preferred strategy
•
Secondary tests: Systematic modification of patient’s
specific relative flexibility impairment
Program in Physical Therapy
Clinical Examination
• Modifications during secondary tests
• Later and less lumbar region movement
• Earlier and more movement of other joints/regions to
accomplish movement/posture goal
• Goal: Redistribute load on lumbar tissue
•
Purpose: Determine effect on symptoms of secondary
tests compared to symptoms with primary tests
•
Hypothesis: Majority of people with LBP will report an
improvement in symptoms with modification
Program in Physical Therapy
Trunk Movement Test
Primary Test:
Patient-preferred strategy
Secondary Test:
Systematically modified
Program in Physical Therapy
Limb Movement Test
Primary Test:
Patient preferred strategy
Secondary Test:
Systematically modified
Program in Physical Therapy
Responses to Modifying Symptom-Provoking
Relative Flexibility Impairments (n=51)
% Symptoms
Test (Trunk)
Decreased
Trunk flexion
90
Return from trunk flexion
90
Trunk lateral bend (mean)
Flexed sitting
Extended sitting
Side lying
Prone
Quadruped
Quadruped: rock back
89
75
88
73(R) 58(L)
78
75
83
Bold = %s significantly different from zero; ps<.05
• 1st PT Visit: 42% acute or subacute; 58% chronic
Program in Physical Therapy
Responses to Modifying Symptom-Provoking
Relative Flexibility Impairments
% Symptoms
Test (Limb)
Decreased
R
L
Hip abduction/lateral rotation
75
100
Knee extension
83
91
Knee flexion
85
100
Hip & knee flexion
81
73
Hip lateral rotation
71
86
Hip medial rotation
93
86
Hip extension
95
89
Shoulder flexion
71
80
Bold = %s significantly different from zero; ps>.05
Program in Physical Therapy
Summary
• Majority of people with LBP who display a symptomprovoking relative flexibility impairment improve when
impairment is systematically modified
• Modification is effective in people with LBP who differ in
LBP acuity level
Program in Physical Therapy
Relevance
• Provides a focus of intervention, particularly if you think
that the same movement patterns are used repeatedly
during everyday functional activities
• Practice the modification of the clinical test
• Practice the modification of the functional activity
Program in Physical Therapy
Relative Flexibility Impairment During a Functional Activity
Test
PEOPLE WITH LBP &
PEOPLE WITHOUT LBP
Marich et al, ASB Proceedings, 2015; 991-992
Program in Physical Therapy
Background
• During clinical tests
• Shown that people with LBP (1) display relative flexibility
patterns and (2) patterns are associated with LBP
symptoms
• Two major assumptions at the clinical level
• Lumbar movement pattern during a clinical test is related to
how a person moves during everyday functional activities
• Lumbar movement pattern during a functional activity is
relevant to the person’s LBP condition
Program in Physical Therapy
Background
• Purpose
• Examine relative flexibility impairments during a functional
activity test in people with LBP and people without LBP
• Examine relationship of relative flexibility impairment to
LBP-related limitation in function (in people with LBP)
Program in Physical Therapy
Movement Test
Picking Up an Object
(PUO)
• Object location scaled to
person’s anthropometrics
• Instructed to pick up
empty plastic container,
and return to standing
• Used preferred movement
speed and strategy
Program in Physical Therapy
Index of Relative Flexibility
• Amount of sagittal plane lumbar motion, particularly in
the early part of the test movement
• Specifically, amount of lumbar motion at increments of
movement time
•
•
•
•
0-25%
25-50%
50-75%
75-100%
Program in Physical Therapy
Pick Up an Object Test
Total Sagittal Thoracic, Lumbar, Hip ROM (degs)
Region
BH
(n=16)
LBP-LOW
(n-13)
LBP-HIGH
(n=19)
p-value
Thoracic
20.9 ± 8.9
19.3 ± 6.0
21.8 ± 5.0
.57
Lumbar#
21.3 ± 4.7
21.5 ± 9.1
28.2 ± 4.4*
.009
42.1 ± 9.5
40.9 ± 11.4
50.1 ± 6.5*
Hip
34.2 ± 12.0
41.4 ± 9.2
35.5 ± 7.6
.13
Total
78.7 ± 10.0
85.4 ± 12.5
87.9 ± 7.0*
.02
Spine
*LBP-HIGH group has significantly more lumbar flexion ROM than
LBP-LOW and BH group
#Effect size = .19 (eta2; large)
Program in Physical Therapy
Pick Up an Object Test
Sagittal Lumbar ROM (degs) at Quartiles of Movement
Time
Movement
Time (%)
BH
LBP-LOW
LBP-HIGH
p-value
0-25#
2.76 ± 1.33
2.39 ± 1.34
5.21 ± 1.47*
0.001
25-50#
6.90 ± 2.07
6.92 ± 3.29
9.26 ± 1.96*
0.008
50-75
7.79 ± 2.33
8.39 ± 3.26
9.17 ± 2.35
0.31
75-100
3.87 ± 1.28
3.78 ± 2.16
4.71 ± 1.87
0.26
*LBP-HIGH group has significantly more sagittal lumbar ROM than
LBP-LOW and BH group (p<.01)
#Effect size = .25 (eta2; large)
Program in Physical Therapy
Correlation – mODI Scores and Lumbar
ROM 0-50% and 50-100% Movement Time
0-50%
50
r = 0.62
r2 = .38
p = .0002
30
20
10
0
r = 0.35
r2 = .12
p = .05
40
mODI (0-100%)
mODI (0-100%)
40
50-100%
50
30
20
10
0
0
10
20
Lumbar ROM (deg)
30
0
10
20
30
Lumbar ROM (deg)
Program in Physical Therapy
Summary
• People with LBP who have high LBP-related functional
limitations move more in the lumbar region early during
a functional activity test compared to
• People with low LBP-related functional limitations
• People without LBP
• In people with LBP the early lumbar region movement
(1st 50% of motion) is moderately associated with the
person’s LBP-related functional limitations
• Even when we account for other variables, e.g., age, duration
of LBP, fear avoidance behavior
Program in Physical Therapy
Relevance
• Data indicates a potential movement-related contribution
to LBP-related limitations
• Increased early lumbar motion is associated with increased
LBP–related functional limitation
• Pattern of movement during functional activity appears to
be a contributing factor to functional limitation
• Provides a point of intervention
• Provide motor skill training to teach the person a different
movement pattern during performance of a functional activity
• Advantage: Functional activity can be practiced frequently
Program in Physical Therapy
INTEGRATION INTO
CLINICAL PRACTICE
Program in Physical Therapy
Integration
Goals today
• Provide information about potentially important impairment
• Provide suggestions of how information could be integrated
into assessment and treatment techniques you already use
in the clinic, i.e., complimentary
Program in Physical Therapy
Which Patient Might you Consider
Assessing this Impairment?
First Suggestion
• Patient who improves with manual techniques but returns
next session and has regressed back to baseline
• Suggests other factors may need to be addressed to
sustain improvements
• What are the movements and postures that may contribute to
return of pain and limitation so quickly?
• Does patient demonstrate relative flexibility impairments with
performance of specific activities limited by LBP?
Program in Physical Therapy
Which Patient Might you Consider
Assessing this Impairment?
Second suggestion
• Patient who improves with manual techniques but
plateaus
• If manual technique is targeting a painful, restricted
motion segment and the person’s improvement plateaus
• Are there other joints or segments that appear to have or
early or increased motion?
• If so, these joints or segments need to be held stable to
maintain increased motion gained with manual technique
• Otherwise the body takes the path of least resistance &
the joints that were treated return to their original state
Program in Physical Therapy
Which Patient Might you Consider
Assessing this Impairment?
Third Suggestion
• Patients who have a recurrent or chronic course of LBP
• Think about what factors contribute to acute flare-up and
course of the LBP?
• Primary reason for seeking repeat care in people with
chronic LBP
• Difficulty in performing regular activities (98.1%)
• Important to examine activities that are limited by LBP to
determine potential role of relative flexibility to the
person’s clinical course
McPhillips-Tangum CA et al., J Gen Intern Med, 1998;13:289-295
Program in Physical Therapy
When Should this Impairment be
Treated?
Suggestion
• Data suggests modification of impairment is effective in
improving LBP in people at all levels of acuity (acute,
subacute, chronic)
• Supports early assessment and treatment of relative
flexibility patterns
• Combination of manual therapy and modifying relative
flexibility patterns may improve the rate of recovery from an
acute flare-up
Program in Physical Therapy
How Much Treatment Should be
Given for the Impairment?
• Goal - Modify the relative flexibility patterns
• Requires learning to modify habitual patterns used during
everyday movements and postures
• Requires high levels of challenging practice
• Generalizing principles to multiple activities
• Definitive amount of practice not specifically known
• Large amounts of practice required in animal and human
studies of motor learning
• Suggests that large amounts of practice would be the goal
e.g., Karni et al., Nature. 1995; 377:155-158
Program in Physical Therapy
How Frequently to Treat the
Impairment Over Time?
• Goal – Maintain gains obtained from active treatment
phase
• Frequency of needed check-ups not specifically known
• How frequently to treat is likely affected by many variables
• Severity of LBP condition
• Adherence
• Exposure to challenging situations
• Current study -Providing booster treatments at 6 months
because appears to be a crucial time point for regression
• Not known for many conditions
Program in Physical Therapy
Summary
Relative Flexibility Impairments
• Prevalent in people with LBP compared to people without
LBP
• Differ between people with LBP with low functional
limitation vs. high functional limitation
• Associated with
• Type of activities patients perform regularly
• LBP symptoms during clinical tests
• Functional limitations associated with LBP condition
Program in Physical Therapy
Summary
Integration into Clinical Practice
• Potential to improve short-term and long-term outcomes
by addressing the impairment in patients
• Improve with manual techniques but regress between visits
• Improve with manual techniques but plateaus
• With recurrent or chronic course
• These situations suggest a need to examine and target
impairments with movements/postures that may be
present in addition to the impairments that are frequently
addressed with manual techniques
Program in Physical Therapy
Thank You