Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018.

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5) voting and consensus. Out of 102 articles retrieved, 6 systematic reviews were selected and assessed for quality according to AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Two showed moderate quality. We then updated the most recent review. The updated literature search resulted in 10 additional studies that were included in the qualitative synthesis. The recommendations based on evidence summary and PROMs limitations were presented at the consensus meeting. The group makes the following recommendations: (1) the Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool (iHOT) instruments (long and reduced versions) are the most appropriate PROMs to use in young and middle-aged active adults with hip-related pain; (2) more research is needed into the utility of the HAGOS and the iHOT instruments in a non-surgical treatment context; and (3) generic quality of life measures such as the EuroQoL-5 Dimension Questionnaire and the Short Form Health Survey-36 may add value for researchers and clinicians in this field. We conclude that as none of the instruments shows acceptable quality across various psychometric properties, more methods studies are needed to further evaluate the validity of these PROMS-the HAGOS and iHOT-as well as the other (currently not recommended) PROMS.

Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018.

There is no agreement on how to classify, define or diagnose hip-related pain-a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion-adduction-internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head-neck radiographs are the initial diagnostic imaging of choice-advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.

Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting, Zurich, 2018.

Hip-related pain can significantly impact quality of life, function, work capacity, physical activity and family life. Standardised measurement methods of physical capacity of relevance to young and middle-aged active adults with hip-related pain are currently not established. The aim of this consensus paper was to provide recommendations for clinical practice and research on standardised measurement methods of physical capacity in young and middle-aged active adults with hip-related pain. Four areas of importance were identified: (1) clinical measures (range of motion, muscle strength, functional impairments), (2) laboratory-based measures (biomechanics and muscle function (muscle activity, size and adiposity)), (3) physical activity, and (4) return to sport/performance. The literature was reviewed, and a summary circulated to the working group to inform discussion at the consensus meeting. The working group developed clinical and research recommendations from the literature review, which were further discussed and modified within the working group at the consensus meeting. These recommendations were then presented to all 38 International Hip-related Pain Research Network (IHiPRN) participants for further discussion, refinement and consensus voting. Therefore, the recommendations voted on were based on a combination of current evidence and expert opinion. The consensus meeting voted on 13 recommendations, six of which were clinically orientated, and seven more research specific. We recommended that clinicians working with young and middle-aged active adults with hip-related pain assess strength using objective methods of measurement, and clinically assess performance of functional tasks, including walking and running. Physical activity should be quantified using both self-reported and objective measures, and patient expectations of recovery should be quantified prior to treatment. It was recommended that return to physical activity (including sport and occupation) be quantified, and sport-specific activities should be assessed prior to return to sport. The IHiPRN participants were uncertain regarding recommendations for range of motion assessment. Research recommendations were that the measurement properties of range of motion, strength and functional performance tests be investigated, reported and improved in both clinical and research settings. Reporting of movement-related parameters (biomechanics and muscle function) should be standardised and the relationship among movement-related parameters, symptoms, function, quality of life, and intra-articular and imaging findings should be investigated. Quantification of return to physical activity (including sport and occupational demands) is required in future research, and the return to sport continuum should be used. Future research is required to determine the best criteria for rehabilitation progression and return to physical activity following hip-related pain management.

Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018.

The 1st International Hip-related Pain Research Network meeting discussed four prioritised themes concerning hip-related pain in young to middle-aged adults: (1) diagnosis and classification of hip-related pain; (2) patient-reported outcome measures for hip-related pain; (3) measurement of physical capacity for hip-related pain; (4) physiotherapist-led treatment for hip-related pain. Thirty-eight expert researchers and clinicians working in the field of hip-related pain attended the meeting. This manuscript relates to the theme of physiotherapist-led treatments for hip-related pain. A systematic review on the efficacy of physiotherapist-led interventions for hip-related pain (published separately) was conducted and found that strong evidence for physiotherapist-led treatments was lacking. Prior to the meeting, draft consensus recommendations for consideration in the meeting were also developed based on the systematic review. The draft consensus recommendations were presented to all of the meeting participants via email, at least 1 week prior to the meeting. At the meeting, these recommendations were discussed, revised and voted on. Six recommendations for clinical practice and five recommendations for research were included and all gained consensus. Recommendations for clinical practice were that (i) Exercise-based treatments are recommended for people with hip-related pain. (ii) Exercise-based treatment should be at least 3 months duration. (iii) Physiotherapist-led rehabilitation after hip surgery should be undertaken. (iv) Patient-reported outcome measures, measures of physical impairment and measures of psychosocial factors should be used to monitor response to treatment. (v) Physical activity (that may include sport) is recommended for people with hip-related pain. (vi) Clinicians should discuss patient expectations, use shared-decision making and provide education. Recommendations for research were (i) Reporting of exercise programmes: Exercise descriptors such as load magnitude, number of repetitions and sets, duration of whole programme, duration of contractile element of exercise, duration of one repetition, time under tension, rest between repetitions, range of motion through which the exercise is performed, and rest between exercise sessions should be reported. (ii) Research should investigate the optimal frequency, intensity, time, type, volume and progression of exercise therapy. (iii) Research should examine the effect of patient education in people with hip-related pain. (iv) Research should investigate the effect of other treatments used in people with hip-related pain (for example: manual therapy, medications, injections). (v) Research should examine the impact of comorbidities and social determinants on treatment effectiveness in people with hip-related pain. Clinicians and researchers working with young to middle-aged active adults with hip-related pain may use these consensus recommendations to guide, develop, test and implement individualised, evidence-based physiotherapist-led rehabilitation programmes.

Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision.

The Academy of Orthopaedic Physical Therapy (AOPT), formerly 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). This is an update to the 2014 Clinical Practice Guideline (CPG) for Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain. The goals of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers pathoanatomical features, clinical course, prognosis, diagnosis, examination, and physical therapy interventions in the management of nonarthritic hip joint pain. J Orthop Sports Phys Ther 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302.

Team Approach: Hip Preservation Surgery.

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.

Clinical tests to determine femoral version category in people with chronic hip joint pain and asymptomatic controls.

STUDY DESIGN: Controlled laboratory cross-sectional. OBJECTIVES: To investigate the relationship between femoral version (FV), measured by MRI (FVMRI), Craig's test and hip rotation range of motion (ROM). To determine rotation ROM values associated with FVMRI categories: excessive anteversion, normal version and retroversion. BACKGROUND: Abnormal FV values are associated with hip disorders, such as osteoarthritis, structural instability, acetabular labral tears and femoroacetabular impingement. Clinical assessment of FV may allow clinician to identify the effect of bony abnormalities on hip rotation ROM to guide clinical decisions. METHODS: Thirty-eight participants with chronic hip joint pain (CHJP) and 38 matched controls participated. MRI was used to determine FVMRI. A digital inclinometer was used to assess Craig's test, hip internal rotation (IR) and external rotation (ER) with hip flexed to 90° (90°), and hip IR/ER with hip in neutral flexion/extension (0°). ROM differences (ROMdif) were determined by subtracting ER from IR. Pearson correlation coefficients were used to assess the relationship between FVMRI and clinical variables. One-way analysis of variance (ANOVA) was used to compare rotation ROM among FVMRI categories. RESULTS: There were no differences between CHJP and control groups in demographics, FVMRI, Craig's test or ROM. ROMdif0° showed the highest correlation (r = 0.63) with FVMRI, then IR90° (r = 0.61) and Craig's test (r = 0.61). Differences were noted among FVMRI categories for rotation ROM except hip ER90°. CONCLUSION: Hip rotation ROM and Craig's test may be used for screening when imaging is not indicated. A 20° difference between hip IR and ER ROM would be suggestive of abnormal FV.

Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017.

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 revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to hip pain and mobility deficits. J Orthop Sports Phys Ther. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301.

Gender-Dependent Differences in Hip Range of Motion and Impingement Testing in Asymptomatic College Freshman Athletes.

BACKGROUND: Athletic activity is a proposed factor in the development and progression of intra-articular hip pathology. Early diagnosis and preventive treatments in "at-risk" athletes are needed. OBJECTIVES: Our primary objective was to report hip range of motion (ROM) and prevalence of positive impingement testing in asymptomatic college freshman athletes. Our secondary objective was to determine whether an association exists between hip ROM and a positive flexion-adduction-internal rotation (FADIR) test. DESIGN: Cross-sectional study. SETTING: Collegiate athletic campus. PARTICIPANTS: Four hundred thirty (299 male, 131 female) freshman athletes reporting no current or previous hip pain. METHODS: During the athletes' preseason medical screening, trained examiners performed a hip-specific exam to obtain data for hip ROM and impingement testing. MAIN OUTCOME MEASUREMENTS: Bilateral passive ROM measures included hip flexion, and hip internal and external rotation with the hip flexed 0° and 90°. RESULTS: Mean age of male participants was 18.5 ± 0.8 and female participants was 18.3 ± 0.6 years (P = .003). Male participants demonstrated less hip ROM than female participants in flexion (115.8 ± 11.2° versus 122.0 ± 10.5°, P < .001), internal rotation in 90° flexion (26.9 ± 9.8° versus 34.7 ± 10.7°, P < .001) and 0° flexion (29.0 ± 9.8° versus 38.9 ± 10.1°, P < .001), and external rotation in 90° flexion (44.7 ± 10.9° versus 49.7 ± 10.4°, P < .001) but not for external rotation in 0° flexion (39.8 ± 11.1° versus 37.6 ± 11.5°, P = .06). Pain with FADIR test on the right and left hip were reported in 11.9% and 14.5% of athletes, respectively. Gender and a positive FADIR were not related (male 12.2%, female 15.3%, P = .36). CONCLUSIONS: In asymptomatic college freshman athletes, male athletes generally demonstrated less hip ROM than female athletes. In addition, a positive FADIR was more prevalent than previously reported in healthy young adults. Preseason screenings that use these baseline data in conjunction with other examination findings may allow identification of athletes at future risk for hip pain and/or injury. LEVEL OF EVIDENCE: IV.

Trunk rotation-related impairments in people with low back pain who participated in 2 different types of leisure activities: a secondary analysis.

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 ( < or = .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.

Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: A case report.

Dancers are at risk for developing groin pain that is due to acetabular labral tears. Although surgical management of labral tears has been reported extensively, conservative management has been poorly described. This case report describes the examination, diagnosis, and treatment of groin pain in a professional ballet dancer with a suspected acetabular labral tear. Treatment focused on decreasing anterior hip joint stresses and improving the precision of hip motion through correction of alignment and movement impairments noted during functional activities and dance. Successful outcomes included a reduction in pain and return to professional ballet dancing.

Movement system impairment-based categories for low back pain: stage 1 validation.

STUDY DESIGN: Cross-sectional study of patients with mechanical low back pain (MLBP). OBJECTIVE: To test the construct validity of 3 categories of a movement system impairment-based classification proposed for use with patients with MLBP. BACKGROUND: A pathoanatomic basis for directing treatment has not proven useful in a wide variety of patients with MLBP. In addition, there is a paucity of data describing the movement system impairments that characterize many of the pathoanatomically based MLBP diagnoses. Because of the mechanical nature of MLBP, a system based on groups of signs and symptoms relevant to conservative management needs to be developed. METHODS AND MEASURES: A movement system impairment-based classification was proposed that defined 5 categories of MLBP based on the findings from a standardized examination. Using the examination, 5 physical therapists examined a total of 188 patients with MLBP. A principal components analysis with an oblique rotation was conducted. Eigenvalues were plotted and a scree test was used to determine the number of factors to retain. A split-sample cross-validation procedure was conducted to verify the factor structure. RESULTS: Three factors were identified in both samples: 2 factors related to symptoms with lumbar rotation and lumbar extension alignments or movements, and 1 factor related to signs of lumbar rotation with different alignments and movements. CONCLUSION: Our results provide support for 3 factors related to 3 of the 5 proposed categories: lumbar rotation with extension, lumbar rotation, and lumbar extension. The existence of these 3 factors provides preliminary evidence for specific clusters of tests of alignment and movement impairments that could be used in classifying patients with MLBP into movement-system-related categories.

CASAWORKS for Families. A new treatment model for substance-abusing parenting women on welfare.

This article provides a brief overview of CASAWORKS for Families (CWF), an innovative intervention designed to help substance-abusing parenting women on welfare. CWF was developed in response to the passage of welfare reform legislation in 1996. Factors that provided a background and context for the development of CWF are considered. The rationale, key elements, and the conduct of a pilot demonstration of CWF are described. Evaluation findings that serve to guide the next steps to improve the intervention are reviewed. Finally, new welfare policy priorities emerging around the importance of addressing behavioral health problems among welfare recipients are highlighted.

Hip rotator strength in healthy young adults measured in hip flexion and extension by using a hand-held dynamometer.

OBJECTIVE: To investigate the effect of hip joint position on hip rotator muscle strength of healthy young adults by using a hand-held dynamometer. DESIGN: A cross-sectional cohort study. SETTING: A university medical center. PARTICIPANTS: Thirty-four healthy (19 women, 15 men; mean [standard deviation] age, 25 ± 2.3 years) participated in this study. METHODS: A hand-held dynamometer was used to measure the strength of hip internal rotators and external rotators in 2 positions: hip flexion in sitting and hip extension in supine. The hip was tested in a neutral position with respect to rotation, abduction, and adduction. Isometric force in pounds was measured as the subject pushed against the device. MAIN OUTCOME MEASUREMENTS: For each subject, hip rotator muscle strength measurements were taken during a single session. Hypotheses were developed before data collection. RESULTS: Hip internal rotators were significantly stronger in hip flexion compared with hip extension (P < .01). There was no significant difference found in the hip external rotators between the 2 positions. CONCLUSIONS: Hip internal rotators and external rotators behave differently when comparing strength measurements between the positions of hip flexion and hip extension. A hand-held dynamometer provided an objective measurement of strength that was clinically feasible to use. Both muscle length and moment arms influence force production of the hip rotators as the hip position changes. Understanding these relationships may help clinicians interpret strength findings and direct intervention toward strengthening the appropriate muscles by using the most advantageous position.

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.

Hip rotation range of motion in people with and without low back pain who participate in rotation-related sports.

OBJECTIVE: To examine whether passive hip rotation motion was different between people with and without low back pain (LBP) who regularly participate in sports that require repeated rotation of the trunk and hips. We hypothesized that people with LBP would have less total hip rotation motion and more asymmetry of motion between sides than people without LBP. DESIGN: Two group, case-control. SETTING: University-based musculoskeletal analysis laboratory. PARTICIPANTS: Forty-eight subjects (35 males, 13 females; mean age: 26.56+/-7.44 years) who reported regular participation in a rotation-related sport participated. Two groups were compared; people with LBP (N=24) and people without LBP (N=24; NoLBP). MAIN OUTCOME MEASURES: Data were collected on participant-related, LBP-related, sport-related and activity-related variables. Measures of passive hip rotation range of motion were obtained. The differences between the LBP and NoLBP groups were examined. RESULTS: People with and without a history of LBP were the same with regard to all participant-related, sport-related and activity-related variables. The LBP group had significantly less total rotation (P=.035) and more asymmetry of total rotation, right hip versus left hip, (P=.022) than the NoLBP group. Left total hip rotation was more limited than right total hip rotation in the LBP group (P=.004). There were no significant differences in left and right total hip rotation for the NoLBP group (P=.323). CONCLUSIONS: Among people who participate in rotation-related sports, those with LBP had less overall passive hip rotation motion and more asymmetry of rotation between sides than people without LBP. These findings suggest that the specific directional demands imposed on the hip and trunk during regularly performed activities may be an important consideration in deciding which impairments may be most relevant to test and to consider in prevention and intervention strategies.

The effect of modifying patient-preferred spinal movement and alignment during symptom testing in patients with low back pain: a preliminary report.

OBJECTIVE: To examine the effect on symptoms of modifying patient-preferred movements and alignments of the lumbar spine during patient examination. DESIGN: Repeated-measures study in which patients with low back pain (LBP) participated in a standardized examination that included tests of symptoms with various movements and positions. SETTING: Six university-affiliated outpatient physical therapy clinics and the local community. PARTICIPANTS: Five trained physical therapists examined a total of 185 patients (102 women, 83 men; mean age, 41.89+/-13.29 y) with LBP. The majority of patients had multiepisode, chronic LBP. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The examination included tests of symptoms with various alignments and movements in several different positions. Seven tests were designated as primary tests. Tests that increased symptoms were followed immediately by a secondary test in which (1) patient-preferred lumbar spine movement was modified or (2) the lumbar spine was positioned in a neutral alignment. Patients reported the effect of the secondary test on symptoms relative to their symptoms with the primary test. Three responses were possible: symptoms increased, remained the same, or decreased. RESULTS: Eighty-three percent of the patients reported an increase in symptoms with 1 or more of the 7 primary tests. Ninety-five percent who reported an increase in symptoms with at least 1 of the primary tests reported a decrease in symptoms with 1 or more of the 7 secondary tests. The majority of patients reported a decrease in symptoms when the spinal movement or alignment was modified for 6 of the 7 secondary tests. CONCLUSIONS: Modifying the symptom-provoking movements and alignments of the spine during symptom testing resulted in a decrease in symptoms for the majority of patients. Information about specific modifications that provide relief of LBP symptoms is important because it can be used to design a treatment program that focuses on training a patient to modify the same movements and alignments in their everyday activities.