Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain.

SYNOPSIS: Many approaches for low back pain (LBP) management focus on modifying motor control, which refers to motor, sensory, and central processes for control of posture and movement. A common assumption across approaches is that the way an individual loads the spine by typical postures, movements, and muscle activation strategies contributes to LBP symptom onset, persistence, and recovery. However, there are also divergent features from one approach to another. This commentary presents key principles of 4 clinical physical therapy approaches, including how each incorporates motor control in LBP management, the convergence and divergence of these approaches, and how they interface with medical LBP management. The approaches considered are movement system impairment syndromes of the lumbar spine, Mechanical Diagnosis and Therapy, motor control training, and the integrated systems model. These were selected to represent the diversity of applications, including approaches using motor control as a central or an adjunct feature, and approaches that are evidence based or evidence informed. This identification of areas of convergence and divergence of approaches is designed to clarify the key aspects of each approach and thereby serve as a guide for the clinician and to provide a platform for considering a hybrid approach tailored to the individual patient. J Orthop Sports Phys Ther 2019;49(6):437-452. Epub 15 May 2019. doi:10.2519/jospt.2019.8451.

Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate.

SYNOPSIS: Although biomechanics plays a role in the development and perhaps the persistent or recurrent nature of low back pain (LBP), whether biomechanics alone can provide the basis for intervention is debated. Biomechanics, which refers to the mechanics of the body, including its neuromuscular control, has been studied extensively in LBP. But, can gains be made in understanding LBP by research focused on this component of biology in the multifactorial biopsychosocial problem of LBP? This commentary considers whether biomechanics research has the potential to advance treatment of LBP, and how likely it is that this research will lead to better treatment strategies. A point-counterpoint format is taken to present both sides of the argument. First, the challenges faced by an approach that considers biomechanics in isolation are presented. Next, we describe 3 models that place substantial emphasis on biomechanical factors. Finally, reactions to each point are presented as a foundation for further research and clinical practice to progress understanding of the place for biomechanics in guiding treatment of LBP. J Orthop Sports Phys Ther 2019;49(6):425-436. Epub 15 May 2019. doi:10.2519/jospt.2019.8825.

Reduced Hip Adduction Is Associated With Improved Function After Movement-Pattern Training in Young People With Chronic Hip Joint Pain.

Study Design Ancillary analysis, time-controlled randomized clinical trial. Background Movement-pattern training (MPT) has been shown to improve function among patients with chronic hip joint pain (CHJP). Objective To determine the association among treatment outcomes and mechanical factors associated with CHJP. Methods Twenty-eight patients with CHJP, 18 to 40 years of age, participated in MPT, either immediately after assessment or after a wait-list period. Movement-pattern training included task-specific training to reduce hip adduction motion during functional tasks and hip muscle strengthening. Hip-specific function was assessed using the Modified Harris Hip Score (MHHS) and Hip disability and Osteoarthritis Outcome Score (HOOS). Three-dimensional kinematic data were used to quantify hip adduction motion, dynamometry to quantify abductor strength, and magnetic resonance imaging to measure femoral head sphericity using the alpha angle. Paired t tests assessed change from pretreatment to posttreatment. Spearman correlations assessed associations. Results There was significant improvement in MHHS and HOOS scores (P≤.02), adduction motion (P = .045), and abductor strength (P = .01) from pretreatment to posttreatment. Reduction in hip adduction motion (r = -0.67, P<.01) and lower body mass index (r = -0.38, P = .049) correlated with MHHS improvement. Alpha angle and abductor strength change were not correlated with change in MHHS or HOOS scores. Conclusion After MPT, patients reported improvements in pain and function that were associated with their ability to reduce hip adduction motion during functional tasks. Level of Evidence Therapy, level 2b. J Orthop Sports Phys Ther 2018;48(4):316-324. doi:10.2519/jospt.2018.7810.

A Movement system impairment approach to evaluation and treatment of a person with lumbar radiculopathy: A case report.

BACKGROUND AND PURPOSE: There are several systems of classification and treatment of patients with low back pain (LBP) based on assessment of the effect of lumbar postures and movements on symptoms. The efficacy of one of these systems, The Movement System Impairment (MSI) method, has not yet been demonstrated in the literature. The purpose of this case report is to describe the approach of the MSI method for an individual with lumbar radiculopathy. CASE DESCRIPTION: A 79-year-old woman with a history of chronic LBP was referred to PT with a physician's diagnosis of sciatica. The patient was classified utilizing a standardized MSI evaluation. She was instructed to modify her daily postures and movements, as well as perform specific exercises to address these impairments. OUTCOMES: Her Oswestry LBP disability score improved by over 30% and pain level per the NPRS improved by 3 out of 10 points. DISCUSSION: Despite the challenges of advanced joint degeneration and neurological involvement, this approach of identifying and addressing specific movement impairments appeared helpful for this older individual.

Efficacy of classification-specific treatment and adherence on outcomes in people with chronic low back pain. A one-year follow-up, prospective, randomized, controlled clinical trial.

BACKGROUND: It is unknown if low back pain (LBP) outcomes are enhanced by classification-specific treatment based on the Movement System Impairment classification system. The moderating effect of adherence to treatment also is unknown. OBJECTIVES: Compare the efficacy of a classification-specific treatment (CS) and a non classification-specific (NCs) treatment and examine the moderating effect of adherence on outcomes. DESIGN: 2 center, 2 parallel group, prospective, randomized, clinical trial. METHOD: Participants with chronic LBP were classified and randomized. Self-report data was obtained at baseline, post-treatment, and 6 and 12 months post-treatment. The primary outcome was the modified Oswestry Disability Index (mODI; 0-100%). Treatment effect modifiers were exercise adherence and performance training adherence. An intention to treat approach and hierarchical linear modeling were used. RESULTS: 47 people received CS treatment, 54 people received NCs treatment. Treatment groups did not differ in mODI scores (p > 0.05). For both groups, scores improved with treatment (p < 0.05), plateaued at 6 months (p > 0.05), and minimally regressed at 12 months (p < 0.05). Performance training adherence had a unique, independent effect on mODI scores above and beyond the effect of exercise adherence (p < 0.05). There were no treatment group effects on the relationship between mODI scores and the two types of adherence (p < 0.05). CONCLUSIONS: There were no differences in function between the two treatment groups (CS and NCs). In both treatment groups, people with chronic LBP displayed clinically important long-term improvements in function. When both forms of adherence were considered, the improvements were uniquely related to adherence to performance training.

What is backward disequilibrium and how do i treat it? A complex patient case study.

BACKGROUND AND PURPOSE: Postural vertical refers to a component of an individual's perception of verticality that is derived from information about the direction of gravitational forces. Backward disequilibrium (BD) is a postural disorder observed in some older adults who have a distortion in their perception of postural vertical. Individuals with BD sustain their center of mass (COM) posterior to their base of support and resist correction of COM alignment. The purposes of this case study are to describe a patient with BD and propose a physical therapy management program for this condition. CASE DESCRIPTION AND INTERVENTION: The patient was an 83-year-old woman admitted for home care services 4 months after falling and sustaining a displaced right femoral neck fracture and subsequent hemiarthroplasty. Details of the clinical examination, diagnosis, and intervention are provided and a treatment protocol for physical therapy management is suggested. OUTCOMES: During the episode of care, the patient (1) decreased her dependence on caregivers, (2) surpassed minimal detectable change or minimal clinically important improvements in gait speed and on the Short Physical Performance Battery and Performance-Oriented Mobility Assessment, and (3) achieved her primary goal of staying in her own apartment at an assisted living facility. DISCUSSION: Knowledge of BD coupled with a thorough clinical examination may assist physical therapists in identifying this condition and employing the specific intervention we have proposed. We believe that failure to recognize and manage our patient's condition appropriately would have led to nursing home placement.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A94).

Effect of posture on hip angles and moments during gait.

Anterior hip pain is common in young, active adults. Clinically, we have noted that patients with anterior hip pain often walk in a swayback posture, and that their pain is reduced when the posture is corrected. The purpose of this study was to investigate a potential mechanism for the reduction in pain by testing the effect of posture on movement patterns and internal moments during gait in healthy subjects. Fifteen subjects were instructed to walk while maintaining three postures: 1) natural, 2) swayback, and 3) forward flexed. Kinematic and force data were collected using a motion capture system and a force plate. Walking in the swayback posture resulted in a higher peak hip extension angle, hip flexor moment and hip flexion angular impulse compared to natural posture. In contrast, walking in a forward flexed posture resulted in a decreased hip extension angle and decreased hip flexion angular impulse. Based on these results, walking in a swayback posture may result in increased forces required of the anterior hip structures, potentially contributing to anterior hip pain. This study provides a potential biomechanical mechanism for clinical observations that posture correction in patients with hip pain is beneficial.

Persons with chronic hip joint pain exhibit reduced hip muscle strength.

STUDY DESIGN: Controlled laboratory cross-sectional study. Objectives To assess strength differences of the hip rotator and abductor muscle groups in young adults with chronic hip joint pain (CHJP) and asymptomatic controls. A secondary objective was to determine if strength in the uninvolved hip of those with unilateral CHJP differs from that in asymptomatic controls. BACKGROUND: Little is known about the relationship between hip muscle strength and CHJP in young adults. METHODS: Thirty-five participants with CHJP and 35 matched controls (18 to 40 years of age) participated. Using handheld dynamometry, strength of the hip external rotators and internal rotators was assessed with the hip flexed to 90° and 0°. To assess external rotator and internal rotator strength, the hip was placed at the end range of external rotation and internal rotation, respectively. Strength of the hip abductors was assessed in sidelying, with the hip in 15° of abduction. Break tests were performed to determine maximum muscle force, and the average torque was calculated using the corresponding moment arm. Independent-sample t tests were used to compare strength values between (1) the involved limb in participants with CHJP and the corresponding limb in the matched controls, and (2) the uninvolved limb in participants with unilateral CHJP and the corresponding limb in the matched controls. RESULTS: Compared to controls, participants with CHJP demonstrated weakness of 16% to 28% (P<.01) in all muscle groups tested in the involved hip. The uninvolved hip of 22 subjects with unilateral CHJP demonstrated weakness of 18% and 16% (P<.05) in the external rotators (0°) and abductors, respectively, when compared to the corresponding limb of the matched controls. CONCLUSION: The results of the present study demonstrate that persons with CHJP have weakness in the hip rotator and hip abductor muscles. Weakness also was found in the uninvolved hip of persons with CHJP.

The human movement system: our professional identity.

The 2013 House of Delegates of the American Physical Therapy Association adopted a vision statement that addresses the role of physical therapy in transforming society through optimizing movement. The accompanying guidelines address the movement system as key to achieving this vision. The profession has incorporated movement in position statements and documents since the early 1980s, but movement as a physiological system has not been addressed. Clearly, those health care professions identified with a system of the body are more easily recognized for their expertise and role in preventing, diagnosing, and treating dysfunctions of the system than health professions identified with intervention but not a system. This perspective article provides a brief history of how leaders in the profession have advocated for clear identification of a body of knowledge. The reasons are discussed for why movement can be considered a physiological system, as are the advantages of promoting the system rather than just movement. In many ways, a focus on movement is more restrictive than incorporating the concept of the movement system. Promotion of the movement system also provides a logical context for the diagnoses made by physical therapists. In addition, there is growing evidence, particularly in relation to musculoskeletal conditions, that the focus is enlarging from pathoanatomy to pathokinesiology, further emphasizing the timeliness of promoting the role of movement as a system. Discussion also addresses musculoskeletal conditions as lifestyle issues in the same way that general health has been demonstrated to be clearly related to lifestyle. The suggestion is made that the profession should be addressing kinesiopathologic conditions and not just pathokinesiologic conditions, as would be in keeping with the physical therapist's role in prevention and as a life-span practitioner.

Factors contributing to lumbar region passive tissue characteristics in people with and people without low back pain.

BACKGROUND: Previously, we demonstrated that people in the Rotation with Extension low back pain subgroup display greater asymmetry of passive tissue characteristics during trunk lateral bending than people without low back pain. The purpose of this secondary analysis is to examine factors that explain the group differences. METHODS: Twenty-two people in the Rotation with Extension subgroup, and 19 people without low back pain were examined. Torque, lumbar region kinematics, and trunk muscle activity were measured during passive and isometric resisted trunk lateral bending. The dependent variables were lumbar region passive elastic energy to each side; the independent variables included group, gender, anthropometrics, trunk muscle characteristics, and an interaction factor of group and trunk muscle characteristics. Multiple linear regression was used for the analysis. FINDINGS: Anthropometrics explained passive measures to the left (P=.03). Anthropometrics (P<.01), trunk muscle characteristics (P<.01), and the interaction of group and trunk muscle characteristics (P=.01) explained passive measures to the right. After accounting for gender and anthropometrics, 43.7% of the variance in passive measures to the right was uniquely accounted for by trunk muscle characteristics for the Rotation with Extension subgroup, compared to 0.5% for the group without low back pain. INTERPRETATION: Anthropometrics explained passive measures with trunk lateral bending to both sides, in both groups. For people in the Rotation with Extension subgroup, there was a direct relationship between trunk muscle performance and passive measures to the right. Muscle is an important contributing factor to asymmetry in this subgroup and should be considered in treatment.

Effect of hip angle on anterior hip joint force during gait.

Anterior hip or groin pain is a common complaint for which people are referred for physical therapy. We have observed that people with anterior hip pain often walk in greater hip extension than people without anterior hip pain, and that the pain is reduced when they walk in less hip extension. Therefore, we investigated anterior hip joint forces which may contribute to anterior hip pain and examined the effect of end range hip extension on the anterior hip joint force during gait. To do this, we used a 6 degree of freedom, three-dimensional musculoskeletal model to estimate hip joint forces during gait. Within subjects, the maximum anterior hip joint force for gait trials with the most hip extension was compared to the anterior hip joint force for gait trials with the least hip extension. The musculoskeletal model indicated that increasing the maximum end range hip extension when walking results in an increase in the anterior hip joint force when compared to walking in less hip extension. Walking in greater hip extension may result in an increase in the anterior hip joint force, and thereby contribute to anterior hip pain. The findings of this study provide some evidence supporting the use of gait modification to reduce anterior hip force when treating people with anterior hip pain.

Muscle activation and movement patterns during prone hip extension exercise in women.

CONTEXT: The consistency of muscle activation order during prone hip extension has been debated. OBJECTIVE: To investigate whether women use a consistent and distinguishable muscle activation order when extending the hip while prone and to explore the effects of verbal cues on muscle activation and movement. DESIGN: Single-session, repeated-measures design. SETTING: University laboratory. PATIENTS OR OTHER PARTICIPANTS: Eleven healthy women (age = 27.7 +/- 6.2 years [range, 22-37 years]). INTERVENTION(S): We tested the participants under 3 conditions: no cues, cues to contract the gluteal muscles, and cues to contract the hamstrings muscles. MAIN OUTCOME MEASURE(S): We measured hip and knee angle and electromyographic data from the gluteus maximus, medial hamstrings, and lateral hamstrings while participants performed prone hip extension from 30 degrees of hip flexion to neutral. RESULTS: When not given cues, participants used the consistent and distinguishable muscle activation order of medial hamstrings, followed by lateral hamstrings, then gluteus maximus (195.5 +/- 74.9, 100.2 +/- 70.3, and 11.5 +/- 81.9 milliseconds preceding start of movement, respectively). Compared with the no-cues condition, the gluteal-cues condition resulted in nearly simultaneous onset of medial hamstrings, lateral hamstrings, and gluteus maximus (131.3 +/- 84.0, 38.8 +/- 96.9, and 45.1 +/- 93.4 milliseconds, respectively) (P > .059); decreased activation of the medial hamstrings (P < .03) and lateral hamstrings (P < .024) around the initiation of movement; increased activation of gluteus maximus throughout the movement (P < .001); and decreased knee flexion (P = .002). Compared with the no-cues condition, the hamstrings-cues condition resulted in decreased activation of the medial hamstrings just after the initiation of movement (P = .028) and throughout the movement (P = .034) and resulted in decreased knee flexion (P = .003). CONCLUSIONS: Our results support the contention that the muscle activation order during prone hip extension is consistent in healthy women and demonstrates that muscle timing and activation amplitude and movement can be modified with verbal cues. This information is important for clinicians using prone hip extension as either an evaluation tool or a rehabilitation exercise.

Relationship between the hip and low back pain in athletes who participate in rotation-related sports.

CONTEXT: Hip function has been proposed to be related to low back pain (LBP) because of the anatomical proximity of the hip and lumbopelvic region. To date, findings have been inconclusive, possibly because the samples studied were heterogeneous. Sub-grouping samples based on characteristics such as activity demand, LBP classification, and sex might clarify research findings. OBJECTIVE: To describe and summarize studies that examine 3 factors proposed to be important to the study of the hip-LBP relationship. DESIGN: Review of cross-sectional studies. SETTING: Academic health-care center and research laboratory. SUBJECTS: 3 groups: athletes with a history of LBP who regularly participate in rotation-related sports, athletes without a history of LBP who are active but do not regularly participate in rotation-related sports, and athletes without a history of LBP who participate in rotation-related sports. MAIN OUTCOME: Hip range of motion and hip-lumbopelvic region coordination. MEASURES: Hip range of motion was measured with an inclinometer. Coordination was examined based on kinematics obtained with a 3-dimensional motion-capture system. RESULT: Differences among groups were found based on activity demand, LBP classification, and sex. CONCLUSION: When assessing athletes with and without LBP, characteristics such as activity demand, LBP classification, and sex should be considered.

Further examination of modifying patient-preferred movement and alignment strategies in patients with low back pain during symptomatic tests.

Our purpose was to examine the effect of modifying symptomatic movement and alignment tests in a sample of people with LBP referred to physical therapy. Fifty-one patients (19 males, 32 females; mean age 37+/-10.59 yr) with LBP and a mean Oswestry Disability Index score of 34+/-18% were examined. The examination included 28 primary tests in which patients used their preferred movement or alignment strategy and reported symptoms. Symptomatic tests were followed by a secondary test in which the patient's strategy was standardly modified to correct the spinal alignment or movement that occurred with the primary test. Symptoms and directions of movement or alignment modified were recorded. For 82% of the secondary tests, the majority of the patients' symptoms improved. For 54% of the secondary tests, some patients required modification of more than one direction of movement or alignment to eliminate symptoms. The findings suggest that the modifications described are generalizable across a number of tests with a moderately involved group of patients, and for individual tests there is variability in the numbers and directions of movements or alignments that appear to contribute to symptoms. Information obtained from the modifications is important because it can be used to confirm the patient's LBP classification and, within the context of the examination, immediately be used to teach the patient strategies to change movements and positions that appear to be contributing to his LBP.

Effect of position and alteration in synergist muscle force contribution on hip forces when performing hip strengthening exercises.

BACKGROUND: Understanding the magnitude and direction of joint forces generated by hip strengthening exercises is essential for appropriate prescription and modification of these exercises. The purpose of this study was to evaluate hip joint forces created across a range of hip flexion and extension angles during two hip strengthening exercises: prone hip extension and supine hip flexion. METHODS: A musculoskeletal model was used to estimate hip joint forces during simulated prone hip extension and supine hip flexion under a control condition and two altered synergist muscle force conditions. Decreased strength or activation of specific muscle groups was simulated by decreasing the modeled maximum force values by 50%. For prone hip extension, the gluteal muscle strength was decreased in one condition and the hamstring muscle strength in the second condition. For supine hip flexion, the strength of the iliacus and psoas muscles was decreased in one condition, and the rectus femoris, tensor fascia lata, and sartorius muscles in the second condition. FINDINGS: The hip joint forces were affected by hip joint position and partially by alterations in muscle force contribution. For prone hip extension, the highest net resultant force occurred with the hip in extension and the gluteal muscles weakened. For supine hip flexion, the highest resultant forces occurred with the hip in extension and the iliacus and psoas muscles weakened. INTERPRETATION: Clinicians can use this information to select exercises to provide appropriate prescription and pathology-specific modification of exercise.

Diagnosis and management of a patient with knee pain using the movement system impairment classification system.

STUDY DESIGN: Case report. BACKGROUND: Selecting the most effective conservative treatment for knee pain continues to be a challenge. An understanding of the underlying movement system impairment that is thought to contribute to the knee pain may assist in determining the most effective treatment. Our case report describes the treatment and outcomes of a patient with the proposed movement system impairment (MSI) diagnosis of tibiofemoral rotation. CASE DESCRIPTION: The patient was a 50-year-old female with a 3-month history of left anteromedial knee pain. Her knee pain was aggravated with sitting, standing, and descending stairs. A standardized clinical examination was performed and the MSI diagnosis of tibiofemoral rotation was determined. The patient consistently reported an increase in pain with activities that produced abnormal motions or alignments of the lower extremity in the frontal and transverse planes. The patient was educated to modify symptom-provoking functional activities by restricting the abnormal motions and alignments of the lower extremity. Exercises were prescribed to address impairments of muscle length, muscle strength, and motor control proposed to contribute to the tibiofemoral rotation. Tape also was applied to the knee in an attempt to restrict tibiofemoral rotation. OUTCOMES: The patient reported a cessation of pain and an improvement in her functional activities that occurred with correction of her knee alignment and movement pattern. Pain intensity was 2/10 at 1 week. At 10 weeks, pain intensity was 0/10 and the patient reported no limitations in sitting, standing, or descending stairs. The patient's score on the activities of daily living scale increased from 73% at the initial visit to 86% at 10 weeks and 96% at 1 year after therapy was discontinued. DISCUSSION: This case report presented a patient with knee pain and an MSI diagnosis of tibiofemoral rotation. Diagnosis-specific treatment resulted in a cessation of the patient's pain and an improved ability to perform functional activities.

Does stabilization of the tibiofemoral joint affect passive prone hip rotation range of motion measures in unimpaired individuals? A preliminary report.

Use of the tibia as a lever to produce hip rotation for the purpose of measuring passive hip rotation range of motion (ROM) could result in inaccurate values if motion is allowed at the tibiofemoral joint (TFJ). The purpose of this study was to examine the effect of stabilizing the TFJ during measurement of prone hip rotation ROM in men and women. Passive hip rotation was measured in 20 unimpaired subjects (M = 10, F = 10) in two different stabilization conditions, with the TFJ stabilized and without the TFJ stabilized. A 2 x 2 analysis of variance was used to test for the effects of stabilization condition and gender on hip rotation measures. A significant interaction of gender and stabilization condition was obtained. Women displayed more hip rotation when the TFJ was not stabilized (M = 41.03 degrees , SD = 6.53 degrees ) than when the TFJ was stabilized (M = 35.05 degrees ; SD = 5.12 degrees ). Men displayed no difference in ROM between the two stabilization conditions (not stabilized: M = 39.07 degrees , SD = 4.87 degrees ; stabilized: M = 37.60 degrees , SD = 5.12 degrees ). To avoid measurement error of hip rotation ROM, use of the tibia as a lever to produce passive hip rotation should be used with caution, particularly in women.