Classification, intervention, and outcomes for a person with lumbar rotation with flexion syndrome.

Background and Purpose. The purpose of this case report is to describe the classification, intervention, and outcomes for a patient with lumbar rotation with flexion syndrome. Case Description. The patient was a 22-year-old man with a medical diagnosis of low back strain. Impairments in lumbar flexion and right rotation and lateral bending were identified. Daily activities and positions associated with these actions were associated with increased low back pain (LBP). Instruction focused on modifying lumbar rotation and flexion movements and alignments in daily activities. Exercises to address the direction-specific impairments were prescribed. Outcomes. The patient participated in 4 visits and completed a questionnaire 1 year after intervention. The patient reported a decrease in symptoms, disability, and frequency of recurrences. Discussion. Repetition of specific strategies (alignment and movement) during activities may result in specific impairments that contribute to LBP. Modification of the strategies and exercises to change contributing factors are proposed to help alleviate symptoms, disability, and recurrences. [Van Dillen LR, Sahrmann SA, Wagner JM. Classification, intervention, and outcomes for a person with lumbar rotation with flexion syndrome. Phys Ther. 2005;85:336-351.]

Key Words: Classification, Low back pain, Recurrence.

Data suggest that, following an episode of low back pain (LBP), the problem often persists and many people do not fully recover after 12 months. (1) Recurrences of LBP also are common. (2) Despite the high costs associated with such a fluctuating clinical course, no management strategy has been found to be consistently effective in alleviating the symptoms and related disability, and, more importantly, in curtailing the recurrences. Some authors (3,4) have suggested that the lack of evidence to support any one intervention occurs because studies are being conducted on heterogeneous groups of people with LBP and that a system for classifying more homogeneous groups of people with LBP is needed. Some classification systems have been proposed for categorizing LBP problems based on variables relevant to physical rehabilitation. (5,6) The purpose for developing these classification systems is to describe homogeneous subgroups of patients with LBP who may respond better to interventions that are category-specific than to interventions that are not category-specific. To date, no classification system has been found to be applicable to all patients with LBP, (7) and research on the scientific properties of a number of systems continues.

One system for classifying LBP is the Movement System, Impairment (MSI) classification system. The MSI system has been described by Sahrmann, (8) and studies examining various aspects of the system are ongoing. (9-17) The MSI consists of 5 general LBP categories that are believed to be most frequently encountered in clinical practice. The categories are named for the specific direction or directions of trunk movements and alignments associated with a person's LBP problem and should be the focus of physical therapy intervention. To date, the overall categories described are: (1) lumbar flexion, (2) lumbar extension, (3) lumbar rotation, (4) lumbar rotation with flexion, and (5) lumbar rotation with extension. (8)

Currently, a patient's LBP problem is classified in the MSI system based on information obtained from a standardized examination that consists of a history and physical examination. (9) The history includes information on demographics and the patient's LBP history and activity level. The physical examination includes: (1) tests in which symptoms are monitored while the person performs movements (trunk and limb) or assumes positions that are believed to impose direction-specific (flexion, extension, rotation) stresses on the lumbar region and (2) judgments of alterations of movements and alignments in various positions. For example, one test requires the patient to perform a forward-bending movement while standing. The patient is asked whether the symptoms were altered during the movement compared with the symptoms during standing. The examiner also judges the relative timing of hip and spine flexion with the movement. The examination is similar to others for LBP because it includes tests of trunk movements and positions in which symptoms are monitored (ie, the patient is asked about any change in LBP with the test relative to LBP with some reference position or movement). Unlike other examinations, however, the MSI examination pays attention to the effect of: (1) limb movements on symptoms and (2) modifying lumbar spine alignment or restricting lumbar spine movement during previously symptomatic tests. (12,13) In addition, examiner judgments focus on the relative timing of movements of the spine and proximal joints during both trunk and limb movements.

Currently, the classification of a patient's LBP is based on identification of a consistent pattern of alignments and movements in a specific direction or directions that increase and decrease the patient's symptoms across tests. Information from examiner judgments of altered alignment and movement also are considered in confirming the specific direction or directions of alignment and movement believed to contribute to the person's LBP. In general, those movements and alignments most consistently identified across the examination become the patient's LBP category.

The theory underlying the MSI approach to examination and intervention is that a person's LBP is the result of repetition of: (1) trunk and limb movements that induce movement of the lumbar spine region and (2) assumption of prolonged positions of the spine associated with a specific direction. These repeated movements and alignments of the lumbar spine are believed to result in adoption of movement and alignment strategies that are generalized across the person's daily activities. Repetition is believed to contribute to changes in movement system factors (eg, muscle extensibility, timing and force production of muscle), which then contribute to the continued use of the direction-specific strategies. Like other investigators, (17-19) we argue that exposure of spinal tissue to loads below the magnitude of failure during prolonged trunk postures and repeated trunk movements contributes to cumulative tissue stress and eventually to LBP. Because the repeated movements and postures are performed in the same direction during several activities, however, we argue that accumulation of tissue stress in the lumbar region is potentially accelerated compared with conditions in which there are a variety of directions of movement and alignments occurring in the lumbar region. (8) We also contend that, until the factors contributing to the use of the directional strategies are modified, the LBP problem will persist or recur.

The purposes of this case report are: (1) to describe the use of the MSI classification system for LBP (8) in the examination and classification of a patient with a recurrent LBP problem and (2) to describe the short- and long-term outcomes of a classification-specific management program. In addition, we describe the relationship between the directions of movements and alignments repeated by the patient during his leisure and daily activities and direction-specific impairments identified on examination.

Case Description

Patient Description

The patient was a 22-year-old man referred for physical therapy with a diagnosis of low back strain. Table 1 provides patient characteristics. Imaging studies were not performed at the time of diagnosis. The patient's self-reported medical history was unremarkable. He reported no serious spine-related conditions or medical conditions that would limit his prognosis for intervention or would be present as symptoms of LBP.

The patient's LBP history consisted of 2.5 years of LBP that occurred in multiple episodes, which he estimated to be present less than half of the days in a year (ie, recurrent LBP (20)). Although the patient reported that his initial LBP was gradual in onset, he associated the first onset of symptoms 2.5 years previously with an intense bout of racquetball playing. He noted that, since the initial onset of LBP, his symptoms continued to be exacerbated with racquetball play. The patient also described a pattern of recurring symptoms, with a report of 12 flare-ups over the 12 months before his initial clinic visit. Flare-up is defined as a phase of pain superimposed on a recurrent or chronic course, which consists of a period, usually a week or less, when the back pain is markedly more severe than usual for the patient. (20) The patient also reported that the severity and frequency of the flare-ups increased during the previous year, particularly in the last 4 months. He had no history of medical or rehabilitative interventions for LBP. He reported the use of ibuprofen as needed for pain relief. Typically, the patient would take two 200-mg ibuprofen tablets after racquetball play. Although he took ibuprofen regularly after playing, the patient reported that, in the 2 months before his initial physical therapy visit, the ibuprofen was progressively less effective in relieving his symptoms. In particular, the patient said that "the medications only took the edge off" when he was symptomatic. Table 2 lists the patient's leisure activity history before and after age 18 years (the age often associated with skeletal maturity) to show the extent and duration of his participation in leisure activities.

The symptoms for which the patient was seeking intervention included daily, intermittent LBP typically located in the right low back region (21) more than the left low back region. The symptoms occurred after flexion and rotation or lateral bending of the trunk to his right as well as during and after prolonged trunk positions associated with the same alignments. The activities or positions that increased the patient's symptoms included playing racquetball, sitting, and sleeping, with left side lying worse than prone lying and back lying. Standing and side lying on the right tended to relieve the patient's symptoms. The patient reported that the symptoms had increased in severity over the 4 months before his initial visit to our clinic, resulting in regular and frequent sleep interruptions. Table 3 provides the patient's symptoms and other relevant variables at the initial visit.

Examination

The patient participated in a standardized examination previously described for use in determining a person's LBP classification. (8) The first author (LRV) developed the examination in collaboration with 6 other therapists. The reliability of data for examiners performing physical tests and measures has been reported. (9) Our kappa (K) values ranged from .21 to .76, and percentage of agreement values ranged from 67% to 90%. Table 4 provides a list of the items included in the examination. At the time of the original reliability testing, the examiners also were able to classify a patient's LBP problem with a fair-to-good level of reliability ([kappa] = .58, percentage of agreement = 79%). (16)

The first author examined the patient in this report. She was involved in the original reliability testing of the examiners and has continued to use the examination with patients and to train other therapists to perform the tests. Specifically, the examination includes direction-specific tests in which symptoms are assessed with different movements and positions, as well as judgments of alterations of alignments and movements across various positions. Neurological screening and testing for magnified symptom behavior (21) also are performed. The response options were "symptoms increased," "symptoms remained the same," "symptoms decreased," and "symptoms were eliminated." For tests in which symptoms were assessed with a postural alignment, the patient reported his symptoms after assuming the alignment for a minimum of 10 seconds. For tests in which symptoms were assessed with movements, the patient reported any change in symptoms. Information regarding the location of the symptoms also was obtained. If the patient reported an increase in symptoms with a primary test of symptoms, the test was immediately followed by a secondary test in which his preferred movement or alignment strategy was modified. (12,13)

The modifications of the secondary tests were performed in an attempt to decrease or eliminate the patient's symptoms. The modifications involved either positioning the lumbar spine in as close to a neutral alignment as possible or restricting or eliminating lumbar spine movement during a trunk or limb movement. Modifications were accomplished using verbal cues, trunk muscle activation by the patient, and manual assistance by the examiner. The directions to be modified were determined by the examiner based on visual and tactile information obtained with the primary test. Reports of symptoms and the specific alignments or movements that were modified during the secondary test were recorded. The possible responses for the directions modified were flexion, extension, rotation, lateral bend, and shift, or any combination of these 5 directions. For example, the patient performed a primary test of forward bending from a standing position using his preferred movement strategy. During the movement, the patient reported that his LBP with the primary movement test increased compared with his LBP while standing. The patient then performed a secondary test in which the forward-bending movement was modified to eliminate lumbar spine flexion and rotation and to increase hip flexion. The patient was provided with verbal cues to keep his back straight by easily contracting his trunk muscles while bending forward only at the hips. The patient also was cued to lean into his arms to reduce the load on the trunk during the forward-bending movement. The examiner provided manual assistance by placing her hands and forearms on the anterior and posterior trunk to cue the patient on the proper trunk alignment. After successfully completing the secondary test movement, the patient reported that his symptoms with the modified movement were eliminated compared with his symptoms using his preferred movement strategy.

Figure 1 illustrates the general decision-making process used with symptom testing. Table 5 provides the positive findings from the symptomatic primary tests and the associated secondary tests as well as the movements or alignments associated with each test.

[FIGURE 1 OMITTED]

The examiner's judgments of alterations of alignment and movement across the various test items were based on visual information alone or on visual and tactile information. The judgments of alignment focused on whether or not the lumbar spine region was flexed, extended, laterally bent, rotated, or some combination of these directions of alignment. The judgments for the tests of movements focused on the type, extent, and timing of the pelvis and lumbar movement. The specific directions of movement for which the examiner made a judgment were flexion, extension, rotation, lateral bending, and shift, or some combination of these directions. Table 5 provides the positive responses related to judgments of altered alignment or movement and the specific directions associated with each of the patient's responses. In addition, the patient's neurological status was screened, and tests for magnified symptom behavior, as described by Waddell et al, (22) were performed. The neurological screening consisted of (1) muscle force and sensory testing of both lower extremities for dermatomal, myotomal, or cutaneous dysfunction and (2) questions regarding bowel or bladder or sexual dysfunction. Both were negative.

Classification

Based on the movement and alignment impairments identified, we believed the patient's MSI diagnosis was lumbar rotation with flexion. (8) This classification of his LBP problem was based on the following findings: (1) he reported an increase in symptoms, primarily with alignments and movements associated with trunk flexion and lateral bending or rotation to his right, (2) he reported elimination of symptoms when the trunk flexion and lateral bending or rotation movements and alignments were modified, (3) we identified alignments and movements of trunk rotation and lateral bending or rotation across the various physical tests, and (4) he reported an increase in symptoms with daily activities associated with trunk flexion and right lateral bending or rotation (eg, playing racquetball, sitting in class or in a car, left side lying during sleeping).

Intervention

The patient's intervention had 3 components: (1) education in principles of tissue injury and repair, (2) analysis and instruction in specific modification of daily activities, and (3) exercise directed at specific factors believed to contribute to the development and persistence of his impairments. Table 3 lists the activities and positions the patient reported as symptom-provoking at his initial visit.

Education

We first educated the patient in general principles of tissue injury and healing because we believe that a primary factor contributing to the development, persistence, and recurrence of LBP is tissue stress induced with repetition of movements and assumption of prolonged alignments in specific directions. We explained how cumulative stress on tissue may contribute to microtrauma, and how it can occur from either loading lumbar region tissue for prolonged periods of time (eg, sitting in class or driving) or repetitively (eg, when performing the same trunk movements during an activity such as racquetball). We also explained that we believed an important component of the patient's LBP was his use of trunk flexion and rotation and lateral-bending strategies during activities that were symptom-provoking as well as other activities. We explained that consistent use of these strategies was likely to accelerate stress accumulation on lumbar region tissues. We then explained the need to decrease the cumulative stresses on tissues to aid tissue healing and resolution of his LBP symptoms, and we explained that the decrease could be achieved by modifying his direction-specific alignment and movement strategies throughout his daily activities.

Analysis and Modification of Daily Activities

The second component of management was the analysis and modification of the performance of daily activities. Activities that were symptom-provoking, as well as those frequently repeated throughout the day, were observed for use of direction-specific strategies that were consistent with those identified in the physical examination. The patient was taught how to modify the alignments and how to restrict or stop the lumbar spine movements in trunk and limb movements that increased his LBP. During modification of movements, we emphasized increasing movement in other segments to achieve the task. The patient also was instructed in ways to modify daily activities that typically were pain-free but incorporated the strategies associated with his LBP. Education was emphasized so that the patient could independently predict any activities that might contribute to his symptoms.

During the initial visit, the patient was observed assuming his preferred alignment during symptom-provoking positions (Tab. 3). The patient then was instructed on how to modify his alignment when he sat in class, drove, and slept. The patient was made aware of his preference: (1) to sit with his trunk unsupported and lean forward and on his right elbow during many of his classes, (2) to sit with his trunk flexed, leaning on his right elbow while driving, and (3) to assume a right lateral bend in his trunk when sleeping on his left side. He was instructed to avoid these alignments and was encouraged to get up every 45 minutes while sitting to change the loading on the tissues in the lumbar spine region. (18) We recommended that the patient avoid sleeping on his left side and to sleep on his back with a pillow under his legs or sleep on his stomach with a pillow under his abdomen. The patient also was given positioning instructions to deal with instances in which he needed to assume left side lying. Table 6 outlines the specific recommendations for modifying the patient's symptomatic alignments. We recommended that the patient attend to other positioning habits throughout his day that could reinforce his preferred strategy. For example, the patient was told to avoid standing with his weight primarily over one leg because this might reinforce his preference to align his trunk in a right lateral bend. Overall, the recommendations discouraged prolonged positioning in trunk flexion and right lateral bending and rotation--the alignments that appeared to contribute to the patient's symptoms.

The only movement reported as symptom-provoking was racquetball. The patient stated that his symptoms increased both during and after play and varied with the intensity and duration of his game. The strokes the patient reported using the most required trunk flexion, rotation, or lateral bending either in isolation or in combination (Tab. 2). The patient was instructed on how these motions might be related to his impairments and, therefore, why racquetball was believed to contribute to his LBP problem. The primary author also discussed other daily activities in which the patient might be reinforcing his preferred movement strategy. For example, the patient noted that he often used a right trunk lateral bend to pick up his backpack. The patient was given suggestions of how to modify performance of movements during activities avoiding his preferred strategy.

Exercise

The exercise component of the patient's management program consisted of practice performing modified versions of movement tests from the physical examination that eliminated his symptoms. In addition, the modifications of some tests in which the patient exhibited his preferred movement strategy also were prescribed as exercises. Six exercises were prescribed on the initial visit and were modified in follow-up visits if the patient was unable to perform the initial exercise correctly or reported an increase in symptoms. The exercises were:

(1) supported right lateral bending while standing,

(2) supported trunk and hip flexion while standing,

(3) knee extension while sitting, (4) knee flexion while in a prone position, (5) hip rotation while in a prone position, and (6) rocking back in a quadruped position. Overall, the goal of the exercises was for the patient to modify his movement by decreasing his preferred movement of the lumbar spine during lower-extremity movements and trunk movements and increasing participation of other joints, such as the hips or other regions of the spine, during various multisegmental movements (eg, rocking back in a quadruped position or lateral bending of the trunk). Table 7 describes the exercises and outlines patient-specific instructions, and Figures 2 through 8 illustrate the initial exercises.

[FIGURES 2-8 OMITTED]

Patient-Specific Exercise Prescription

The patient was instructed to perform his exercises at least once a day. Initially, 6 to 8 repetitions of each exercise were to be performed. Within an exercise session, correct performance of each exercise was emphasized instead of the number of repetitions performed. For example, with the exercise of knee extension while sitting with support, the patient was told to extend his knees only to the point in the movement in which he was no longer able to maintain the correct trunk and pelvic alignment. If the patient could extend the knee only 30 degrees with the correct alignment, then that was the endpoint for each repetition of the exercise. The patient also was instructed to avoid reproducing or increasing his LBP symptoms during or after his exercises. He was told to stop any exercise if it increased his symptoms and to wait to resume the exercise until he could be re-examined. As a prophylactic strategy as well as for relief of symptoms during and after symptom-provoking activities, the patient was encouraged to assume quadruped positioning and perform the rocking back movement regularly throughout his day. Because, as a student, he spent much of his day sitting, the patient was encouraged to frequently extend his knees while sitting. Adherence to his program was assessed at each visit through the patient's verbal report and the first author's assessment of the patient's ability to perform the prescribed exercises. Table 8 provides the patient's reports of adherence.

Outcomes

The patient had 4 physical therapy visits over a 3-month period. The follow-up visits were 2, 6, and 12 weeks after the initial visit. In addition, at 1 year, the patient completed both a mailed questionnaire regarding his progress since the initial visit and the Oswestry Low Back Pain Disability Questionnaire. (23) The data obtained for the primary outcome measures assessed at each visit and at 1 year are provided in Table 3. The overall categories of outcomes were: (1) symptoms (location, intensity, frequency, and duration) at various time points and with symptomatic positions or activities, (2) frequency of medication use, (3) LBP-related disability, and (4) frequency of LBP recurrences (flare-ups) during a 12-month period.

Symptom intensity was measured by 2 different methods. The first method was a numeric rating scale (NRS) in which the patient reported his symptoms on a scale ranging from 0 (indicating the absence of symptoms) to 10 (indicating the worst imaginable symptoms). (24.25) The second method was a visual analog scale (25) (VAS) in which the patient marked the intensity of his symptoms at the time of each visit on a 10-cm horizontal line. Initial and final anchor points on the VAS were labeled "no pain" and "worst possible pain." Numeric rating scales have been tested for reliability of patient responses and found to be acceptable (intraclass correlation coefficient [ICC]=.82). (24) Concurrent validity based on a comparison of responses with different pain response scales and NRS responses also has been established (Pearson r=.79, P<.001). (24) The use of a VAS for estimating pain intensity in people with LBP has been examined for both reliability (ICC=.93) (25) and concurrent validity (24) and found to be acceptable (Pearson r=.79, P<.01). Low back pain-related disability was measured with the Oswestry Low Back Pain Disability Questionnaire, (23) a disease-specific, self-report measure. Patient reports using the Oswestry questionnaire have been found to be both reliable (Pearson r=.99, P<.01) (23) and valid (Pearson r=.72, P<.0001) when compared with scores on other accepted measures of LBP-related disability. (26)

At 1 year, the patient reported his outcomes through a mailed questionnaire. The questionnaire included the same questions related to outcomes obtained during each of his prior visits except for the VAS. The patient's responses at 1 year are provided in Table 3. In addition, a series of questions were included to gain more specific information regarding sports participation since his last visit, recurrences (frequency, intensity, duration), and adherence to the prescribed exercises and modifications of strategies during daily activities. The patient also was given the opportunity to provide any general comments about his progress since his initial visit. The patient reported that he was playing racquetball 2 to 3 times per week. As illustrated in Table 3, the frequency of recurrences was reduced. The patient also noted that he was much better at detecting a recurrence of his LBP because he was more aware that any increase in intensity or frequency of his symptoms was a warning that his LBP was worsening. He stated that the frequency and intensity of his symptoms, as well as the overall duration of each recurrence, were much less than before intervention. The patient also reported that, on average, he performed the exercises one time per week and adhered to his daily activity modifications 40% of the time. In instances in which the patient thought that a recurrence of his LBP might be happening, he said he knew that he could better control the symptoms by increasing his activity modifications.

Discussion

The patient in this report had a predisposition to flex, rotate, and laterally bend his lumbar spine when assuming different positions and during various movements of the trunk and limbs. We believe that people with LBP adopt strategies of alignment and movement because they repeat movements or assume prolonged positions in specific directions. We also have proposed that, because these strategies are used repeatedly, some tissues in the lumbar region are exposed to higher levels of localized stress (27) than other tissues. Development of this localized stress may contribute to cumulative microtrauma, and, if not eliminated, may contribute to LBP. In our patient, one factor that may have contributed to the adoption of his directional strategies was the repetition of movements and alignments associated with his participation in racquet sports (Tab. 2). In addition, the patient reported that, prior to developing LBP, he had increased the frequency and intensity of playing racquet sports. Both of these factors could have contributed to the initial onset of symptoms. (18) The patient exhibited the same directional strategies during his symptom-provoking daily activities as those associated with his leisure activity, raising the possibility that he generalized strategies he used repeatedly with racquetball to other activities across his day. If this was the case, then the patient potentially was exposing specific areas of the lumbar region tissues to stress, not only during racquetball play but also during many of the activities he performed on a daily basis. As a result, once the patient developed his LBP symptoms, achieving prolonged relief would be difficult because the contributing stresses would not be removed for a sufficient period of time to allow tissue healing and appropriate adaptation. (28) Instructing the patient in ways to modify, the strategies he used during his daily activities could potentially reduce the cumulative stress contributing to the severity and persistence of his LBP.

Our patient was instructed in methods to change both the duration and direction of movements and positions that could affect the loading on lumbar tissues (Tab. 6). The encouragement to change positions frequently is based on studies linking prolonged loading of tissues to a number of negative consequences. (27) An important part of the intervention for our patient was emphasizing the need to avoid prolonged positions associated with the specific directions of alignment that were most symptomatic both during the examination and with daily activities. Our advice is based on the proposal that sustained positions have the potential to contribute to changes in different tissues. These tissue changes then may serve to reinforce the impairments that appeared to contribute to the patient's LBP problem. For example, assuming an alignment of right lateral bending during a large proportion of the day (sitting and sleeping) could contribute to asymmetries in the length of the lateral trunk muscles. Adams et a1 (27) proposed that such asymmetries may be of clinical significance in LBP because the imbalances could result in changes in side-to-side stresses on the disk and neural arch.

The methods described for assessing symptoms (12,13) during the examination are somewhat unique. We have the patient assume a position or perform a trunk or limb movement using his or her preferred strategy. If symptoms are provoked, the position or movement is modified to restrict the motion in part of the lumbar region or across the entire lumbar region, and symptoms are reassessed. If the patient's symptoms improve with the modifications, then intervention includes: (1) having the patient perform the modified tests as exercises and (2) modifying performance of symptom-provoking daily activities. Other investigators (5,6) used an examination in which symptoms are assessed with single and repeated spine movements within a position. In general, if the patient's symptoms improve with repeated movements of the spine, then intervention includes repetition of the spine movements that were symptom relieving. There is some evidence to support the efficacy of repeated spinal movements in reducing low back-related symptoms in some patients. (29-31) The type of patient with LBP who might benefit from intervention to modify direction-specific lumbar spine movements (as illustrated in our case) versus intervention in which the patient moves the lumbar spine in a specific direction, however, is still not fully understood.

Our patient did not report complete resolution of his LBP symptoms. Considering the continued frequency and intensity of participation in his sports activity, as well as the amount of time the patient spent sitting, this was not unexpected. The patient regularly participated in racquetball at a high intensity level throughout the time of his intervention, as well as across the year after discharge from physical therapy. Some researchers (32,33) have cited the increased risk of injury with combined trunk movements, particularly when flexion and lateral bending are performed together. Although our patient did not report complete resolution of his LBP, he did report relatively large, rapid, and consistent improvements. His intervention, however, did not include specific instructions for modifying his movements during racquetball. We believe that a reasonable explanation for his improvements was, in part, that the changes he reported to have made in his movements and alignments during his daily activities resulted in decreased cumulative stress to the lumbar region.

The exercises we prescribed were the secondary test movements that eliminated the patient's symptoms during the examination. We prescribed these exercises to: (1) make the patient aware of the directions of movements that contributed to an increase in his LBP, (2) teach him to move without symptoms by stabilizing specific regions of the lumbar spine while moving in other spine and limb segments, and (3) increase the extensibility of structures that potentially impeded symptom-free movement. For example, one exercise was to practice trunk bending and return, flexing and extending in his hips while maintaining a neutral spine alignment. The goals of this exercise were: (1) to increase his awareness that flexing and rotating the trunk were related to his symptoms, (2) to learn to stabilize the lumbar region while increasing movement in his hips, and (3) to increase the extensibility of the posterior hip structures that may have contributed to his preferred movement strategy. Because we identified a relationship between strategies used during the examination and those during his symptom-provoking daily activities, the exercises prescribed may have facilitated the use of the modified strategies in which he was instructed during his daily activities. Based on the measures and the case report format that we used, however, it is not known whether the exercises had an effect on the strategies the patient used across his day.

The minimum clinically important difference (MCID), defined as the smallest change or difference in an outcome measure that is perceived as important to patients, has been reported to be an important property to consider in choosing a measure for assessing change in individual patients. (34) Two studies have been conducted to determine the MCID for different versions of the Oswestry questionnaire with patients with LBP of varying acuity. (26,35) Beurksens et al (35) documented the MCID for the original version of the Oswestry questionnaire based on a sample of people with LBP of greater than 6 weeks in duration to be between 4 and 6 points. We also used the original version of the Oswestry questionnaire to document change in our patient. Our patient reported a progressive decrease (16%, 14%, 8%, 6%, 4%) in his Oswestry questionnaire scores across the time of the study. Thus, our patient displayed what would be considered to be important clinical change by his third visit, and, just as importantly, he maintained this improvement up to 1 year after discharge from therapy.

Our case report has limitations. Because of the descriptive nature of a case report, causal inferences regarding the relationship between the patient's direction-specific alignments, movements, and activities and his LBP problem cannot be made. Although the patient reported that the onset of his symptoms was associated with playing racquetball and symptoms were worsened specifically with racquetball, he also performed other leisure activities. Although he did not associate an increase in his symptoms with the other activities, they could have contributed to his LBP. We also do not know whether the direction of his symptom-provoking alignments and movements contributed to his initial and subsequent history of LBP episodes. It could be that the identified movements and alignments developed as a compensation to avoid pain after his initial injury. Over time, repetition of the compensatory positions and movements could have become his symptom-provoking preferred strategy that we identified on examination. Finally, we believe that the exercises and instruction in modifications of daily activities changed the strategies the patient used across his day; however, we did not directly measure his strategies during daily activities.

The case we have described illustrates the need for further research. The intervention used is theory-based, and efficacy or effectiveness of the approach has not been tested experimentally. Clinical trials comparing classification-directed interventions with other standards of care are needed. In addition, studies to begin to examine the contribution of corrective exercise versus modification in daily activities to changes in outcomes would be important. Examination of different aspects of the theory underlying the described classification system also is warranted. For example, we did not directly measure an aspect of the patient's motor control. Such measurement could begin to provide insight into the mechanisms underlying the outcomes we have described. Other studies could focus on whether strategies identified on examination can be generalized to a person's daily activities. For example, researchers could examine whether people with rotation with flexion syndrome actually align themselves in flexion and rotation for the majority of their sitting time.

LR Van Dillen, PT, PhD, is Assistant Professor, Program in Physical Therapy, Washington University School of Medicine, Campus Box 8502, St Louis, MO 63110 (USA) ([e-mail]). Address all correspondence to Dr Van Dillen. Reprints will not be available from the corresponding author.

SA Sahrmann, PT, PhD, FAPTA, is Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington University School of Medicine.

JM Wagner, PT, MSPT, ATC, is a doctoral candidate, Movement Sciences, Program in Physical Therapy, Washington University School of Medicine.

Dr Van Dillen and Dr Sahrmann provided concept/idea/project design. Dr Van Dillen provided writing, data collection, and fund procurement. Dr Sahrmann and Ms Wagner provided consultation (including review of manuscript before submission).

This work was presented, in part, at the Combined Sections Meeting of the American Physical Therapy Association; February 20-24, 2002; Boston, Mass.

This work was funded by the National Institutes of Health, National Institute of Child Health and Human Development, National Center for Medical Rehabilitation Research, grant K01 HD01226-05.

This article was received October 9, 2003, and was accepted September 27, 2004.

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Table 1.
Patient Characteristics

Characteristic                                   Value

Height (cm)                                      181
Weight (kg)                                      76.5
Handedness                                       Right
Occupation                                       Full-time student
Baecke activity score (3-15) (a)                 8.25
SF-36 (b) general health score (0%-100%) (c)     90

(a) Baccke JA, Burema J, Frijters JE. A short questionnaire for the
measurement of habitual physical activity in epidemiological studies.
Am J Clin Nutr. 1982;36: 936-942.

(b) SF-36-Medical Outcomes Study 36-Item Short-Form Health Survey
questionnaire.

(c) Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey
(SF-36), I: conceptual framework and item selection. Med Care. 1992;30:
473-483.

Table 2.
Patient's Leisure Activity History

Before age 18 y

Racquet-specific activity
  Type                        Tennis and racquetball
  Frequency                   8-y history; average of 1 x/wk
  Duration                    45 min/session
Other activities              None

After age 18 y

Racquet-specific activity
  Type                        Racquetball
  Frequency                   4-y history; average of 4x/wk
  Duration                    75 min/session
  Estimated frequency of      Forehand>backhand >overhead
    stroke performance          >serve

Other activities
 Type                         Rugby
 Frequency                    2-3x/wk
 Type                         Soccer
 Frequency                    1 x/wk
 Type                         Weight training
 Frequency                    1 x/wk

Table 3.
Initial Status and Short- and Long-Term Outcome Measures

                                   Visit 1
Measurement                       (Initial Status)

Symptom location                  Left upper lumbar and right and left
                                  lower lumbosacral region; right>left
                                  symptoms

Symptom intensity

* Current (a)                     4/10
* Average over previous 7 d (a)   4/10
* Worst over previous 7 d (a)     6/10
* 10-cm visual analog scale of    4.50
  current symptoms (25)

Symptom frequency and             Intermittent; daily-persisting
duration                          most of the day once symptoms
                                  were initiated

Medication use                    Ibuprofen after play; provided
                                  only partial relief

Patient-specific activities

* Racquetball                     Increased symptoms after 15 min of
                                  play; symptoms persisted for 2-3 d
                                  after onset

* Sitting (class)                 Increased symptoms after 30 min

* Sitting (driving)               Increased symptoms after 30 min

* Sleeping                        Awakened 2 times/night due to
                                  symptoms

Oswestry Low Back Pain            16%
Disability Questionnaire
score (%) (23,b)

Recurrences (20) in the           12
previous 12 mo (c)

                                   Visit 2
Measurement                       (2 wk After Visit 1)

Symptom location                  Same as previous visit

Symptom intensity

* Current (a)                     2/10
* Average over previous 7 d (a)   3/10
* Worst over previous 7 d (a)     4/10
* 10-cm visual analog scale of    2.70
  current symptoms (25)

Symptom frequency and             Intermittent; daily-persisting
duration                          only one half of the day if
                                  symptoms were initiated

Medication use                    No longer needed to control
                                  symptoms; discontinued

Patient-specific activities

* Racquetball                     Increased symptoms after 15 min
                                  of play; symptoms persisted for
                                  1 d after onset

* Sitting (class)                 Increased symptoms after 30 min if
                                  leaned with trunk to the right;
                                  no symptoms if avoided leaning with
                                  trunk forward and to the right and
                                  got up regularly

* Sitting (driving)               "Stiffness" after 2.5 hr if avoided
                                  leaning with trunk to the right

* Sleeping                        Awakened 2 times in past week due
                                  to symptoms

Oswestry Low Back Pain            14%
Disability Questionnaire
score (%) (23,b)

Recurrences (20) in the
previous 12 mo (c)

                                   Visit 3
Measurement                       (6 wk After Visit 1)

Symptom location                  Lumbosacral region;
                                  right = left symptoms

Symptom intensity

* Current (a)                     2/10
* Average over previous 7 d (a)   3/10
* Worst over previous 7 d (a)     4/10
* 10-cm visual analog scale of    2.50
  current symptoms (25)

Symptom frequency and             Intermittent; daily--persisting less
duration                          than one half of the day if symptoms
                                  were initiated

Medication use                    Same as previous visit

Patient-specific activities

* Racquetball                     Increased symptoms only if moved
                                  to end-range of trunk flexion
                                  and lateral bend right; symptoms
                                  ceased when returned to upright
                                  posture; if continued, flexion and
                                  lateral-bending motions with play
                                  symptoms may have persisted for
                                  15 min after play

* Sitting (class)                 Same as previous visit; sitting
                                  a lot due to course load and
                                  examinations

* Sitting (driving)               Same as previous visit

* Sleeping                        No more interruptions of sleep

Oswestry Low Back Pain            8%
Disability Questionnaire
score (%) (23,b)

Recurrences (20) in the
previous 12 mo (c)

                                   Visit 4
Measurement                       (12 wk After Visit 1)

Symptom location                  Left L4-L5 region

Symptom intensity

* Current (a)                     1/10
* Average over previous 7 d (a)   2/10
* Worst over previous 7 d (a)     3/10
* 10-cm visual analog scale of    1.20
  current symptoms (25)

Symptom frequency and             Occasional; depending on activity
duration                          level; gone within 10 min offer
                                  symptom-provoking activity

Medication use                    Same as previous visit

Patient-specific activities

* Racquetball                     Occasional increased symptoms
                                  with end-range trunk flexion and
                                  lateral bend right; ceased when
                                  upright; no symptoms after play

* Sitting (class)                 Sat for 90 min with only occasional
                                  increase in symptoms

* Sitting (driving)               Occasional "tightness" in lower
                                  back region; no symptoms

* Sleeping                        Same as previous visit

Oswestry Low Back Pain            6%
Disability Questionnaire
score (%) (23,b)

Recurrences (20) in the
previous 12 mo (c)

                                   Questionnaire
Measurement                       (1 y After Visit 1)

Symptom location                  Central L5-S1 region

Symptom intensity

* Current (a)                     0/10
* Average over previous 7 d (a)   1/10
* Worst over previous 7 d (a)     2/10
* 10-cm visual analog scale of    Not available
  current symptoms (25)

Symptom frequency and             Occasional; depending on activity
duration                          level; gone within  5-10 min after
                                  symptom-provoking activity

Medication use                    Same as previous visit

Patient-specific activities

* Racquetball                     Occasional increased symptoms with
                                  multiple "really low shots" and
                                  playing for longer than 1.5 hr;
                                  ceased when upright; occasional
                                  symptoms for 5-10 min after play

* Sitting (class)                 Sat for 100 min with only
                                  occasional increase in symptoms;
                                  same as previous visit

* Sitting (driving)               Able to drive 9 hr/d for 3 d with
                                  "only a little stiffness"; no symptoms

* Sleeping                        Same as previous visit

Oswestry Low Back Pain            4%
Disability Questionnaire
score (%) (23,b)

Recurrences (20) in the           2
previous 12 mo (c)

(a) Verbal estimate of symptom intensity on a scale of 0 (no symptoms
present) to 10 (worst imaginable symptoms). (24)

(b) Average behavior over week prior to visit or questionnaire.

(c) Recurrence was defined as a noticeable increase in symptoms,
usually lasting for a week and limiting the person fimctionally. (20)

Table 4.
Tests and Measures Included in Physical Examination9

             Tests (a)

Position     Primary Test (b)               Secondary Test (c)

Standing     Standing                       None
             Forward bending                Modified forward bending
             Return from forward bending    Modified return from forward
                                            bending
             Extension                      None
             Lateral bending                Modified lateral bending
Sitting      Sitting in flexion             Modified sitting
             Sitting in extension           Modified sitting
             Sitting in full flexion        None
             Knee extension                 Modified knee extension

Supine       Hook lying                     None
             Bilateral hip and knee         None
             flexion (f) from hook lying
             Supine                         Modified supine
             Single knee to chest from      Modified single knee to
             supine                         chest
             Hip abduction/lateral          Modified hip abduction/
             rotation from partial hook     lateral rotation
             lying
Side lying   Side lying                     Modified side lying
Prone        Prone                          Modified prone
             Knee flexion                   Modified knee flexion

             Hip medial rotation            Modified hip medial
                                            rotation

             Hip lateral rotation           Modified hip lateral
                                            rotation

             Hip extension                  Modified hip extension
Quadruped    Quadruped                      Modified quadruped
             Arm lift in quadruped          Modified arm lift

             Rocking back                   Modified rocking back

             Rocking back in full flexion   None
             Rocking forward                None

             Judgments of Alterations of
Position     Alignment or Movement

Standing     * Alignment of lumbar spine region in all planes
             * Relative flexibility (d) of lumbar spine and hips
             * Relative flexibility of lumbar spine and hips

             * None
             * Asymmetry of lateral bending
Sitting      * None
             * None
             * None
             * Rotation-related movement in lumbar spine
             region (e)
Supine       * None
             * None

             * None
             * Rotation-related movement of lumbopelvic
             region
             * Rotation-related movement of lumbopelvic
             region

Side lying   * None
Prone        * None
             * Rotation-related movement of lumbopelvic
             region
             * Anterior tilt of lumbopelvic region
             * Rotation-related movement of lumbopelvic
             region
             * Rotation-related movement of lumbopelvic
             region
             * None
Quadruped    * None
             * Rotation-related movement of lumbopelvic
             region
             * Rotation-related movement of lumbopelvic
             region
             * None
             * None

(a)Includes primary and secondary tests of movements and alignment
in several different positions. Symptoms are assessed with each test,
and judgments of alterations of movement or alignment also may be
assessed. Test movements involving the limbs were performed on the
right and left extremities separately. Trunk positions or movements
in the horizontal or frontal plane were performed to the left and right
separately.

(b) During primary tests of symptoms, the patient performed either a
trunk or limb movement or assumed a position using his preferred
strategy of movement or alignment, and he reported his symptoms
relative to a designated reference movement or position. The movement
tests from the examination are active movements unless specified
otherwise.

(c) Secondary tests of symptoms were conducted if the patient reported
an increase in symptoms with a primary test. Modifications involved
either positioning the lumbar spine in as close to a neutral alignment
as possible or restricting or eliminating lumbar spine movement during a
trunk or limb movement while encouraging movement in other segments
(eg, the hips). Modifications were accomplished using verbal cues,
trunk muscle activation by the patient, and manual assistance by the
examiner. The patient reported his symptoms with each secondary test
relative to the symptomatic primary test.

(d) Movement impairment of the lumbopelvic region in which the hips
contribute to the overall movement in the last half of the range of
trunk movement.

(e) Currently includes movements of lumbopelvic rotation or lumbar
lateral bend or shift.

(f) Passive test movement performed by examiner flexing lower
extremities toward trunk.

Table 5.
Positive Findings From Standardized Examination (9)

Position    Test (a)            Response

Standing    Alignment           * Pelvis and trunk rotated clockwise in
                                  horizontal plane

            Forward             * Lumbar spine flexion greater than hip
            bending               flexion in first 50% of range of
                                  forward bend

            Return from         * Increased symptoms
            forward bending
                                * Trunk rotation to the right with
                                  return

            Modified (b)        * Increased hip flexion with forward
            forward bending       bend
            and return
                                * Elimination of trunk rotation with
                                  return phase

                                * Elimination of symptoms with return
                                  phase

            Lateral bending     * Increased symptoms with right lateral
                                  bending

                                * Asymmetric lateral bending with
                                  pelvic shift to the left at
                                  initiation of the lateral bend to the
                                  right and decreased lateral bending
                                  motion in the upper and middle lumbar
                                  segments compared with the lower
                                  lumbar segments with lateral bending
                                  to the right

            Modified lateral    * Elimination of symptoms with right
            Bending               lateral bend

                                * Increased movement across thoracic
                                  and lumbar spine segments with
                                  lateral bend

Sitting     Knee extension      * Lumbar spine flexion and pelvic and
                                  lumbar spine region rotation with
                                  right knee extension

Supine      Bilateral hip and   * Increased symptoms
            knee flexion
            (passive)

Prone       Knee flexion        * Pelvic rotation with right and left
                                  flexion; rotation greater with right
                                  lower extremity than with left lower
                                  extremity

            Hip rotation        * Increased symptoms with right medial
                                  and lateral hip rotation

                                * Pelvic and lumbar spine region
                                  rotation with right medial and
                                  lateral hip rotation

            Modified hip        * Elimination of symptoms with right
            rotation              medial and lateral hip rotation

Quadruped   Alignment           * Lumbar spine positioned in flexion

            Arm lifting         * Asymmetric trunk rotation with arm
                                  lifting; rotation of trunk was
                                  greater with left upper extremity
                                  lift than with right lower extremity;
                                  rotation of trunk to right with left
                                  arm lift

                                * Increased symptoms with left arm lift

            Modified arm        * Elimination of symptoms with left arm
            lifting               lift

            Rock back           * Lateral pelvic tilt with rocking back

                                Associated Directions of
                                Trunk Alignment and Movement
Position    Test (a)            With Test Item

Standing    Alignment           * Rotation/lateral bend

            Forward             * Flexion
            bending

            Return from         * Extension
            forward bending
                                * Rotation/lateral bend

            Modified (b)        * Flexion
            forward bending
            and return          * Rotation/lateral bend

                                * Rotation/lateral bend

            Lateral bending     * Rotation/lateral bend

                                * Rotation/lateral bend

            Modified lateral    * Rotation/lateral bend
            bending

Sitting     Knee extension      * Flexion

                                * Rotation/lateral bend

Supine      Bilateral hip and   * Flexion
            knee flexion
            (passive)

Prone       Knee flexion        * Rotation/lateral bend

            Hip rotation        * Rotation/lateral bend

                                * Rotation/lateral bend

            Modified hip        * Rotation/lateral bend
            rotation

Quadruped   Alignment           * Flexion

            Arm lifting         * Rotation/lateral bend

                                * Rotation/lateral bend

            Modified arm        * Rotation/lateral bend
            lifting

            Rock back           * Rotation/lateral bend

(a) The movement tests from the examination are active movements unless
specified otherwise. Test movements involving the limbs were performed
on the right and left extremities separately. Includes tests of
symptoms as well as judgments of alterations of alignment and movement
with tests in various positions. Includes responses to tests of
symptoms (primary and secondary) as well as signs with various tests.

(b) A modified test indicates a secondary test performed if the patient
reported an increase in symptoms with the associated primary test of
symptoms. Modifications involved either positioning the lumbar spine in
as close to a neutral alignment as possible or restricting or
eliminating lumbar spine movement during a trunk or limb movement while
encouraging movement in other segments (eg, the hips). Modifications
were accomplished using verbal cues, trunk muscle activation by the
patient, and manual assistance by the examiner. The patient reported
his symptoms with each secondary test relative to the symptomatic
primary test.

Table 6.
Category-Specific Intervention-Instruction in Modification of
Daily Activities

                Instructions
Visit           Do                            Do Not
1 (initial)     Bend in the hips, not in      Do not sit forward and
                the lower back when           laterally bend or rotate
                leaning forward.              to the right, parti-
                Bend your knees slightly,     cularly when sitting in
                if needed, to keep from       class or driving.
                moving in the lower back.
                Use an arm for support if
                possible when leaning
                forward in standing to
                support your trunk leg,
                when brushing your teeth).

                Sit with your back            Do not lean on your right
                supported and relaxed,        elbow for support
                your shoulders aligned        when sitting, parti-
                over your hips, and your      cularly when sitting in
                thighs fully supported.       class or driving.
                Make sure your feet are
                flat on the support
                surface so your knees are
                at the same level as your
                hips.

                Do get up from a sitting      Do not cross your legs
                position every 45 min and     when sitting.
                try to change your
                position frequently while
                sitting.

                If you sleep on either        Do not sleep on your left
                side, place a towel roll      side.
                at waist level so that
                your lower back is
                straight instead of
                laterally bent or rotated.
                Bend your hips and knees
                to about 30 [degrees].
                Place 2 or more pillows
                between your knees so
                that the weight of your
                legs does not pull on
                your lower back.

                Do try to assume the          Do not stand on one leg
                quadruped position and        for prolonged periods of
                perform rocking back in       time, particularly your
                the quadruped position        right leg.
                after playing racquetball
                or during days in which
                you seem to be more
                symptomatic than usual to
                assist with control of
                symptoms.

3 (6 wk after   Emphasize importance of
visit 1)        adhering to initial
                instructions for sitting
                because the patient's
                primary complaint at this
                point in time is occasional
                increased symptoms during
                sitting.

Table 7.
Category-Specific Intervention-Exercise Descriptions (8) and
Patient-Specific Instructions Across the Intervention Period

                                            Patient-Specific
Visit         Exercise Description          Instructions

1 (initial)   Right lateral bending with    Easily bend to the right,
              support (Fig. 2). Stand       dropping your right
              with your back against a      shoulder over your right
              wall, feet positioned         hand. Do not "shift" your
              comfortably apart, and        pelvis to the left to
              heels about 2.5 cm (1 in)     initiate the right lateral
              from the wall. Place your     bending motion. Try to move
              right hand at your            "throughout the spine"
              waistline, just below the     instead of performing all
              ribs for support. Lateral     of the lateral bending
              bend to the right only as     movement in your lower
              far as you can without        back region.
              reproducing symptoms and
              without lifting your left
              foot from the floor. Return
              to a standing position.

              Hip flexion and extension     Bend both knees and elbows
              with flat lumbar spine        slightly. Do not bend your
              (Fig. 3). Stand facing a      back as you bend forward
              table with feet positioned    in the hips or arch your
              comfortably apart. Place      back as you return to
              your hands on the table.      standing. Move in your
              While keeping your elbows     hips, not your back.
              slightly bent, lean into
              your arms. Bend forward in
              the hip joints keeping your
              back straight. Bend only as
              far as you can while
              maintaining your trunk
              alignment. Return to a
              standing position by moving
              in your hips while
              maintaining your trunk
              alignment.

              Knee extension sitting with   Place your hands on your
              support (Fig. 4). Sit in a    lower back region and
              chair with a straight back,   sacrum. Easily straighten
              thighs fully supported,       your knee. Move only as far
              hips at 90 [degrees] of       as you can without bending
              flexion, and shoulders        or rotating your back to
              over your hips. Your feet     the right.
              should be flat on the
              floor.  Straighten one
              knee only as far as you
              can without reproducing
              symptoms and maintaining
              your trunk and pelvic
              alignment. Return the leg
              to the starting position.
              Repeat with the opposite
              leg.

              Knee flexion in prone         Place your hands on the
              position (Fig. 5). Lie on     front of the pelvis to
              your stomach with your arms   monitor pelvic movement.
              positioned at your sides,     Tighten your abdominal
              head positioned               muscles to hold the pelvis
              comfortably, and legs         steady while bending your
              straight and relatively       knee up and down. Do not
              close together. Bend one      tilt or rotate your pelvis
              knee up toward your buttock   while bending each knee.
              and then return it to the
              starting position. Repeat
              with the opposite leg. Bend
              only as far as you can
              without reproducing
              symptoms and maintaining
              your trunk and pelvic
              alignment.

              Hip rotation in prone         Position your hands as for
              position (Fig. 6). Position   knee flexion. Tighten your
              yourself as for knee          abdominal muscles to hold
              flexion in prone. Bend one    the pelvis steady. Do not
              knee to 90 [degrees].         tilt or rotate your pelvis
              Rotate your hip by allowing   while rotating each hip.
              your foot to move in toward
              your opposite leg and then
              away from the opposite leg.
              Rotate only as far as you
              can without reproducing
              symptoms and maintaining
              your trunk and pelvic
              alignment. Repeat with the
              opposite leg.

              Quadruped position and        Keep your back straight
              rocking (Figs. 7 and 8).      throughout the movement.
              Assume a hands-and-knees      Think about moving in your
              position trying to attain     hips and not your back.
              the following alignment:      Move in the hips equally.
              knees about 7.6 cm (3 in)
              apart, hips centered over
              knees and at a 90
              [degrees] angle, feet
              pointing away from
              body with the front of the
              feet flat on the support
              surface, spine straight,
              shoulders at a 90 [degrees]
              angle and directly over
              hands, and head in line
              with body. Pushing back
              with your hands, rock back
              moving only as far as you
              can without reproducing
              symptoms and maintaining
              your trunk alignment.
              Return to the initial
              position.

2 (2 wk       Hip flexion with flat
after         lumbar spine (modified).
visit 1)      Because of complaints of
              occasional pain during the
              exercise, the patient was
              instructed to flex his
              knees more in standing and
              to put more weight into his
              hands to help him keep his
              trunk stationary with the
              hip flexion (forward bend)
              and extension (return from
              forward bend) phase of the
              exercise.

              Knee flexion (modified).
              Because the patient was
              having difficulty
              controlling his pelvis
              during the exercise, he was
              instructed to position his
              hips in some abduction and
              place a pillow under his
              abdomen to perform the
              exercise.

              Quadruped rocking
              (modified). Because the
              patient was able to control
              left lateral pelvic tilt
              with rocking back through
              one third of the range, he
              was instructed to increase
              the range of rocking back
              as long as he avoided the
              left lateral pelvic tilt
              movement.

Table 8.
Verbal Reports of Average Adherence to Exercises and Daily Activity
Modifications

                                            Adherence to Everyday
                   Adherence to Exercises   Activity Modifications
                     (on Average Since      (Percentage of Time Since
Visit                 Previous Visit)       Previous Visit)

2 (2 wk after               2x/d            100%
  initial visit)
3 (6 wk after              1-2x/d           90%
  initial visit)
4 (12 wk after             1 x/d            60%
  initial visit)
1 y                        1x/wk            40%; increased adherence
                                            when he was developing a
                                            flare-up