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Journal of Bodywork and Movement Therapies (2004) 8, 199210

Journal of Bodywork and Movement Therapies

www.intl.elsevierhealth.com/journals/jbmt

SELF-HELP: CLINICIAN SECTION

Spinal stabilizationFan update. Part 2Ffunctional assessment$

Craig Liebenson, DC*
10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA

Introduction
Reactivating spine pain patients is a key to early recovery from acute and subacute episodes (Malmivaara et al., 1995; Indahl et al., 1998), prevention of recurrences (Hides et al., 2001), and treatment of chronic pain, disability, and failed surgery syndrome (Fordyce et al., 1986; Lindstrom et al., 1992; Manniche et al., 1991; OSullivan et al., 1997; Timm, 1994). The rst part of this series described the role of instability in low back problems (LBP) as well as specic types of biomechanical advise to prevent low back irritation. This second part will describe the patients functional assessment. Functional assessment is necessary to establish goals, monitor progress towards those goals, and guide the prescription of specic exercises.

Patient evaluation
LBP affects nearly 90% of the population at some time in their lives. Fortunately, its disabling phase typically runs a short-term course (46 weeks) (Hadler, 1986; Spitzer et al., 1987). However, lingering symptoms and activity intolerances are common (Croft et al., 1998). A small minority of individuals develop a chronic, disabling problem
This paper may be photocopied for educational use. *Corresponding author. Tel.: 1-310-470-2909; fax: 1-310470-3286. E-mail address: cldc@ash.net (C. Liebenson). 1360-8592/$ - see front matter & 2004 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2004.03.002
$

and it is these people who absorb the vast majority of all the costs associated with this problem (Hashemi et al., 1998; Spitzer et al., 1987). The problem of patient assessment is that 85% of LBP has no known cause (Deyo and Weinstein, 2001). Fortunately, serious causes of LBP are infrequent. Less than 1% is due to a serious disease such as cancer (Waddell, 1998). Less than 1% involve inammatory rheumatic disease (Waddell, 1998). Approximately 5% involves true sciatica (Waddell, 1998). The remainder are classied as non-specic because modern methods have not been able to pin-point the exact pain generators. 40% of patients with low back pain fear they have a serious problem (Waddell, 1998). A major role of the health care provider (HCP) is to reassure the patient with non-specic LBP that they do not have a serious disease and that the prognosis is generally favorable (Waddell, 1998). A reliable and sensitive process known as diagnostic triage is performed on the initial visit to identify the red ags of serious disease (Deyo and Weinstein, 2001; Waddell, 1998). Those patients without red ags are reassured that their pain is not due to anything serious (Deyo and Weinstein, 2001; Waddell, 1998). Overdiagnosis (e.g. arthritis, herniated disc, etc.) should be avoided because it leads to increased anxiety, treatment dependence and unnecessary testing (e.g. M.R.I.) (Snook, 2004; Deyo and Weinstein, 2001). Unfortunately, it is very common since 20 70% of people with LBP have coincidental herniated or degenerative discs or degenerative arthritis on imaging studies (Jarvik and Deyo, 2000).

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Table 1
* * *

Patient assessment.

Diagnostic triagered ags Psycho-social assessmentyellow ags Functional assessment * Mechanism of injury * Activity intolerances * Mechanical sensitivity * Abnormal motor control (e.g. coordination, endurance, balance) Outcome assessment

month functional assessment (non-provocative) is predictive of 12 month recovery, whereas an earlier assessment is not predictive, probably due to the inuence of acute pain on the tests.

Mechanism of injury
It is important to identify how the pain began and what biomechanical factors are sources of irritation. The MI is often something which the patient does NOT perceive as painful or threatening. For instance, prolonged sitting or bending forward from the waist when performing various activities of daily living (ADLs) (Green et al., 2002; Snook et al., 1998; McGill and Brown, 1992; Scannell and McGill, 2004; Solomonow et al., 2003). Snook has shown that reducing early morning exion accelerates recovery from acute LBP. Solomonow et al. (2003) has shown that creep (stretching) develops in ligaments in 10 min of exposure to end-range static exion. The normal length of the ligaments does not recover after 10 min of rest. Longer periods of prolonged exion such as 2040 min can result in full recovery taking up to 24 h. Dysfunctions such as reduced muscle activity and spasms during static exion periods occurs during a 7 h recovery period. An acute lowgrade inammatory response is also present, and even a 7 or 8 h period of rest does not lead to a full recovery. The dysfunction outlasts the period over which strain occurred by 60 times, resulting in residual creep and chronic inammation. The factors responsible for residual creep include the following: 1. magnitude of load, 2. duration of load, 3. frequency of such loads. A prospective occupational study showed that job rotation, reduced lifting loads and ergonomic redesign reduced days lost from work from 60/ 100,000 h worked to 1/100,000 h worked (Lemestra and Olszynski, 2003). Another prospective study by Marras showed that introduction of lift tables and other lift aids reduced reported LBPs in an occupational setting (Marras et al., 2000).

Patient evaluation should include a number of essential components. 1. The rst is diagnostic triage to rule out red ags of serious disease. 2. The second is assessment of psycho-social risk factors of chronicity termed yellow ags. 3. The third is a comprehensive functional assessment of the patients mechanism of injury (MI), activity intolerances (AI) related to pain, mechanical sensitivities (MS), and abnormal motor control (AMC). 4. Fourth is outcome assessment to monitor progress over time. A thorough patient evaluation is necessaryF especially in subacute patients who are slow to recover or in chronic patientsFto reassure the patient that their problem has been addressed, appropriate tests ordered, and management approach individualized to their needs (Linton, 1998) (see Table 1).

Spinal stabilizationFan update. Part 2Ffunctional assessment

Functional assessment
This article focuses on the functional assessment of the patient. While many authors have over-stated the positive early natural history (Hadler, 1986; Spitzer et al., 1987) it is clear that residual pain and activity intolerances persist for up to 1 year in the majority of patients (Croft et al., 1998). Recent research has demonstrated that recovered patients with a past history of low back disability have distinct functional losses not found in individuals without a similar history (McGill et al., 2003). Therefore, functional assessment is an important component in patient care. Some assessments, for example for MS, are necessary early on. While others like functional measures of trunk extensor endurance are most valuable after a month has elapsed (Enthoven et al., 2003). In fact, the 1-

Activity intolerances
Patient reactivation should be goal oriented and outcome based. Most patients want symptomatic relief, but hurt does not always equal harm, so pain relief is not always a good guide. A wiser approach focuses on establishing reduction in activity intolerances associated with pain as a mutually agreed

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Table 2 Minimum clinically important change in outcome score. Revised Oswestry disability questionnaireF8/50 Neck disability indexF5/50 Upper extremity functional indexF9 points Lower extremity functional scaleF9 points

Table 3 Motor control evaluation in low back problems. Endurance: Trunk extensor (Alaranta et al., 1994) Side bridge (McGill et al., 1999) * Trunk exor (Alaranta et al., 1994; McGill et al., 1999) Balance:
* * *

Mechanical sensitivity
Traditional evaluation focuses on impairments such as lumbar range of motion (ROM) decits, however such impairments are poorly correlated with functional ability (Gronblad et al., 1997; Grenier et al., 2004; Parks et al., 2003; Simmonds et al., 1998). Probably the best way to use ROM tests is as an audit of (MS) as employed in the McKenzie system (Kilpikoski et al., 2002). If such testing is used to identify movements which peripheralize symptoms, and those which centralize them, it provides a powerful prognostic and exercise selection guide (Werneke and Hart, 2001). Orthopedic tests and myofascial trigger point evaluation can also be utilized to identify the movements and tissues which reproduce the patients characteristic symptoms. Identifying the patients MS can help in formulation of an exercise strategy which minimizes the patients discomfort. The other value of identifying the patients MS is that it can be used as a quick reference point for auditing the patients status or progress posttreatment and at each follow-up visit. When the patients MS is decreasing it conrms the effec-

Abnormal motor control

New evidence points to the importance of motor control evaluation (coordination, balance, endurance) in contrast to strength or mobility assessment as a more potent guide to treatment selection, prognosis, and outcome (Biering-Sorensen, 1984; Hodges and Richardson, 1998, 1999; McGill et al., 2003; Byl and Sinnot, 1991; Takala and VikariJuntura, 2000). Simple low-tech tests of motor control for which reliability, validity, and/or normative data have been established are shown in Table 3. These tests are most valid if performed after the acute phase has settled and pain-inhibition does not inuence the outcome (Enthoven et al., 2003).

Endurance
Static trunk extensor endurance test (Sorensen test)
Decreased endurance of the trunk extensors has not only been shown to correlate with pain

Spinal stabilizationFan update. Part 2Ffunctional assessment

upon goal (AHCPR, 1994). Examples of AIs, include reducing sitting, standing, bending, or walking intolerances. This can be documented with reliable, valid and responsive outcome tools such as the Revised Oswestry disability questionnaire (Hudson-Cook et al., 1989), neck disability index (Vernon and Mior, 1991), upper extremity functional index (Stratford et al., 2001), or lower extremity functional scale (Binkley et al., 1999). Responsiveness is dened as the accurate detection of change when it has occurred. If a tool is responsive to change, the score on a questionnaire should improve as a persons health status improves. This is clinically signicant change that is not due to a random occurrence. A key dimension of responsiveness is the minimal clinically important change in an outcome in a specic patient population. This is the smallest change in the OA score which the patient perceives as benecial (see Table 2).

Single leg stance (Bohannon et al., 1984) Coordination or muscle balance: Active or restricted straight leg raise (Mens et al., 2001) Prone hip extension (Vogt and Banzer, 1997; Nadler et al., 2002) Sidelying hip abduction (Nadler et al., 2002)

tiveness of the treatment. If the MS is not improving then it suggests other treatment strategies should be employed. Most importantly, if the patients MS is evaluated immediately after the patient performs a self-treatment exercise then if it has improved the patient is likely to be more motivated to comply with a home exercise prescription than if they are just told that the exercises are right for them.

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(Biering-Sorensen, 1984; Latimer et al., 1999; Nicolaisen and Joregnesen, 1985), but to predict recurrences (Biering-Sorensen, 1984; Enthoven et al., 2003), as well as rst time onset of episodes in healthy individuals (Luoto et al., 1995). The test, if performed in the manner described by BieringSorensen, has been shown to be reliable in various populationsFasymptomatic (Latimer et al., 1999), symptomatic (Moffroid, 1994), and those with a past history of LBP (Latimer et al., 1999). The Sorensen test has been reported to be able to discriminate between subjects with and without low back pain (Moffroid et al., 1994). Normative data has been established for a variety of healthy asymptomatic populations (Alaranta et al., 1994; McGill et al., 1999). Established mean values range from 62 to 131 s (Alaranta et al., 1994). Patient position
*

Figure 1 Sorensen trunk extensor endurance test.

Spinal stabilizationFan update. Part 2Ffunctional assessment

Prone with the inguinal region/anterior superior iliac spine (ASIS) at the end of the bench. * If using a Roman Chair type device positioned with ASIS aligned to the superior edge of the pelvic restraint pad. Arms at sides, ankles xed (by strap or hands), holding horizontal position. * Plumb-line can be used to ensure horizontal position.

Normative data for different tests has been established (Alaranta et al., 1994; McGill et al., 1999; McIntosh et al., 1998). An altered ratio of trunk exor to extensor endurance is correlated with a past history of disabling LBP, with extensors losing endurance capacity more than exors (McGill et al., 2003).

Trunk curl static endurance test

McGill et al. (1999) established normative data for a healthy, young group of males and females for a simple curl-up test (see Table 3 above). This test requires a wedged piece of wood to support the patient at a xed angle of 601. Patient position
* * *

Technique
*

* *

The patient maintains the horizontal position as long as possible. Timing begins when horizontal and unsupported. Subjects are verbally encouraged to hold this position as long as possible.

Both knees and hips are exed 901. Arms are folded across chest. Toes are anchored either with a strap or by the tester.

Termination criteria Test

*

Time the duration the position can be held up to a maximum of 240 s. If patient drops below the horizontal position they are given one additional chance to regain it. But, upon dropping below horizontal a second time the duration is recorded. If the patient reports low back pain or cramping in their legs the test may be stopped and the time recorded (Fig. 1).

* *

The wood is pulled back 10 cm (4 in.). The subject holds the isometric posture as long as possible.

Termination criteria
*

When any part of the subjects back touches the wood (Fig. 2).

Trunk exor endurance

Trunk exor endurance can be reliably measured (Alaranta et al., 1994; Moreland et al., 1997).

The mean endurance for young, healthy men and women is 134 s. The ratio of trunk exor to extensor endurance is 0.77 normally (0.84 in young males and 0.72 in young females). To highlight the

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Figure 2 Trunk exor endurance position (a) start position (b) test position.

signicance of the balance between antagonistic trunk muscles rather than pure strength Lee demonstrated that the extensor/exor ratio is a more sensitive index than peak torque in predicting future back pain in asymptomatic individuals (Lee et al., 1999). A reduced ratio of trunk extensor to exor strength/endurance discriminates between LBP patients and control subjects. The normal ratio is approximately 1.3:1 with the extensors being stronger (Mayer et al., 1985).

The top leg is placed in front of the lower leg with both feet on the oor. The upper arm is placed against the chest with the hand touching the anterior lower shoulder.

Test
*

Side bridge
Individuals with histories of disabling LBP have asymmetry in side bridge endurance as well as a disturbed ratio of trunk extensor to side bridge endurance (McGill et al., 2003). Patient position
*

The pelvis is raised off the table as high as possible and held in a line with a long axis of the body supporting the weight between the feet and elbow. Subject statically maintains this elevated position.

Termination criteria
*

* *

The subject lies on one side supported by their pelvis, lower extremity and forearm (elbow bent with hand facing forward).

Subject is unable to lift their body up from the oor. Subjects thigh touches the oor. Subject drops their pelvis or thigh part way and cant raise it up to the start position again. Signicant LBP causes the test to be stopped (Fig. 3).

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Figure 3 Side bridge endurance test.

Spinal stabilizationFan update. Part 2Ffunctional assessment

Quantication The mean endurance for young, healthy men and women is 84.5 s with a SD of 34.5 (McGill et al., 1999). The ratio of right side bridge to left side bridge endurance is normally 0.96 (McGill et al., 1999). According to McGill a side to side difference of greater than 0.05 suggests unbalanced endurance (McGill et al., 1999). The side bridge to extensor endurance ratio is normally 0.49 (McGill et al., 1999).

for 30 s on the rst eyes closed attempt, they may discontinue the test. Termination criteria
* * * *

Reaching out. Hopping. Putting foot down. Touching foot to weight bearing leg (Fig. 4). Quantication:

One leg standing balance test

Balance decits have been demonstrated to be related to LBP (Byl and Sinnot, 1991; Luoto et al., 1998; Takala and Vikari-Juntura, 2000). Byl showed that excessive anterior to posterior body sway on an unstable surface or poor single leg standing balance ability is correlated with LBP (Byl and Sinnot, 1991). Poor balance was correlated with future LBP by Takala (Takala and Vikari-Juntura, 2000). Patient position
* *

The best score with eyes closed for each leg should be recorded. Normative data (Bohannon et al., 1984):

Age (years) 2059 6069 7079

Eyes open (s) 2930 22.5 ave 14.2

Eyes closed (s) 2128.8 (ave. 25) 10 4.3

Standing

The active straight leg raising test (ASLR)

A positive ASLR has been shown to be associated with postpartum sacroiliac (SI) pain (Mens et al., 2001, 2002). It has been shown that altered kinematics of the diaphragm and pelvic oor are present in those with a positive test. Also, that manual compression through the ilia normalizes these altered motor control strategies (OSullivan et al., 2002). The test has been shown to be reliable (Mens et al., 2001). Technique
*

Test
*

The patient stands on one leg with the opposite leg exed at the hip and knee. The patient should be instructed to x their gaze at a point on the wall directly in front of them. The patient should practice with eyes open once for up to 10 s. They should then attempt to balance as long as possible on 1 leg with eyes closed for up to 30 s. The subject may repeat the test up to a maximum of 5 times in an attempt to reach the 30 s target successfully. If the subject can stand

Patient lies supine with feet 20 cm apart

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Spinal stabilizationFan update. Part 2Ffunctional assessment Actively lifts one leg 20 cm up instruction Try to raise your legs, one after the other, above the couch for 20 cm without bending the knee. 205

* *

or, if there is decreased strength (resistance may be added), if there is signicant heaviness of the leg noted, if raising the leg is painful. Recheck:

Test is positive if:

*

the leg cant be raised up,

with manual compression through the ilia and/or with a SI belt, after treatment (e.g. sacro-iliac mobilization, post-isometric relaxation of piriformis, adductors, etc.).

If resistance is offered hip exion strength can be assessed. Grenier et al. (2004) has shown that decreased hip exion strength is strongly correlated with a past history of disabling LBP in asymptomatic workers from 2 different manual material handling occupations (Fig. 5).

Figure 4 One leg standing balance test.

Nadler et al. (2002) demonstrated that hip extension muscle imbalance (weakness of the dominant right leg) is associated both with a past history of LBP and a risk factor for future LBP in female athletes (Nadler et al., 2000, 2001). Those with LBP had a 15% strength imbalance compared with only a 5.3% imbalance in those without LBP. Rehabilitation reduced the imbalance. This same asymmetry was

Figure 5 Active straight leg raise test (a) without resistance and (b) with resistance.

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Hip extension

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not found in male athletes, but it is interesting to note that National Collegiate Athletic Association Injury Surveillance Data from 19971998 showed that female athletes were almost twice as likely as males to develop LBP (National Collegiate Athletic Association, 1998). Other consistent ndings include increased fatigability of the gluteus maximus in individuals with chronic LBP (Kankaapaa et al., 1998; Leinonen et al., 2000). Leinonen demonstrated that the speed of contraction of the gluteus maximus could be improved with rehabilitation (Leinonen et al., 2000). The right leg has been shown to be used as support for kicking and jumping activities (Beling et al., 1998). Janda developed a prone test of hip hyperextension as a simple coordination test related to the terminal-propulsive toe off phase of gait (Vogt and Banzer, 1997; Vogt et al., 2003). Vogt demonstrated the presence of anticipatory activation of contralateral and ipsilateral lumbar erector spinae and hamstring muscles prior to leg lifting (Vogt and Banzer, 1997). This was shown to be a repeatable pattern in normal subjects. Vogt has also shown that in LBP patients there is prolonged activity of the gluteus maximus and lumbar erector spinae during the hip extension phase of gait (Vogt et al., 2003). Test (Janda, 1996):
* *

Figure 6 Hip extension test (after Janda).

Test (Janda, 1996):

* * *

side lying, lower leg exed at hip and knee, pelvis slightly tucked under patient so body is aligned ankle to shoulder, slowly raise leg up towards ceiling.

Pass/fail criteria: Failure if, before 40 degrees abduction, the following occur:
* * * *

prone, slowly raise 1 leg straight up to ceiling. Pass/fail criteria: Failure if initiation occurs with:

hip exion, hip external rotation, cephalad shift of pelvis (at initiation), pelvic rotation, failure to reach 401 abduction. Clinical relevance:

* * * * *

anterior pelvic tilt (Lumbo-sacral extension), lumbar rotation (or hyperextension), delayed gluteus maximus contraction, muscular contraction above T8, knee exion (Fig. 6). Clinical Relevance:

Altered hip extension typically leads to overstress of the lumbar facet joints during extension and can lead to hamstring strain due to substitution for the gluteus maximus

Hip abduction strength

Nadler demonstrated that female athletes with weaker left hip abductors had a higher probability of requiring treatment for LBP (Nadler 02). The left hip abductors have been shown to be used in stance and posture of right handed individuals (Beling et al., 1998).

Tensor fascia lata substitution for an inhibited gluteus medius is the most common fault. This will result in patello-femoral tracking and iliotibial band friction disorders. Passive insufciency due to shortened psoas or adductors will also inhibit the gluteus medius and lead to hip, sacro-iliac and lumbo-pelvic overstrain. Excessive synergist substitution of the lateral quadratus for an inhibited gluteus medius can result in myofascial pain. Shortening of the piriformis can also alter lower extremity kinetic chain function especially during gait and affect the sacro-iliac by limiting internal hip rotation and blocking normal sacroiliac function (Fig. 7).

Other functional tests Back exibility is inversely related to LBP with greater exibility, not less, being a risk factor (Sorensen, 1984). Hip exibility decreases are related to LBP. Hip internal rotation decreases have been correlated to LBP in a number of studies

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Figure 7 Hip abduction test (after Janda).

Figure 9 Hip internal rotation range of motion test (a) start position and (b) nal position.

Figure 8 Lumbar exion range of motion test (a) start position and (b) nal position.

(less than 401) (Cibulka et al., 1998; Ellison et al., 1990; Grenier et al., 2004). Cibulka reported that bilateral loss of hip internal rotation is associated with LBP while a unilateral restriction is associated with signs of sacro-iliac involvement (Cibulka et al.,

1998). Decreased hip extension mobility has been correlated with a past history of disabling LBP in asymptomatic workers from 2 different manual material handling occupationsFfailure of the thigh to reach horizontal (Grenier et al., 2004). Tafazzoli and Lamontagne (1996) has also correlated decreased hip extension mobility and LBP (Figs. 810). Cardiovascular tness can be measured for baseline purposes. Activity levels correlation with LBP is complex and controversial (Cady et al., 1989; Croft et al., 1999) . However, cardiovascular tness or endurance has not been shown to be correlated with LBP (Battie et al., 1989; Grenier et al., 2004; McQuade et al., 1988; Ready et al., 1993; Van der Velde and Mierau, 2000).

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Figure 10 Hip extension range of motion test.

Spinal stabilizationFan update. Part 2Ffunctional assessment

A comprehensive motor control evaluation would include a number of other tests as well, but most are either high-tech requiring costly equipment or have not met minimum requirements for scientic validation. These include squats, lunges, gait evaluation, etc. The functional assessment of acute patients may be restricted to AIs and MS. While the subacute or chronic patient should also have an evaluation of AMC.

Conclusion
In summary, evaluation should identify the patients AI, MS, and AMC. These will enable the clinician to identify the patients goals as well as the exercises to achieve those goals.

References
Agency for Health Care Policy and Research (AHCPR), 1994. Acute low-back problems in adults. Clinical Practice Guideline Number 14. US Government Printing, Washington, DC. Alaranta, H., Hurri, H., Heliovaara, M., et al., 1994. Nondynamometric trunk performance tests: reliability and normative data. Scandinavian Journal of Rehabilitation Medicine 26, 211215. Battie, M.C., Bigos, S.J., Fisher, L.D., Hansson, T.H., Nachemson, A.L., Spengler, D.M., et al., 1989. A prospective study of the role of cardiovascular risk factors and tness in industrial back pain complaints. Spine 14 (2), 141147. Beling, J., Wolfe, G.A., Allen, K.A., Boyle, J.M., 1998. Lower extremity preference durine gross and ne motor skills performed in sitting and standing postures. Journal of Orthopedic and Sports Physical Therapy 28, 34003404.

Biering-Sorensen, F., 1984. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine 9, 106119. Binkley, J.M., Stratford, P.O.W., Lott, S.A., Riddle, D.L., 1999. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. Physical Therapy 79, 371383. Bohannon, R.W., Larkin, P.A., Cook, A.C., Gear, J., Singer, J., 1984. Decrease in timed balance test scores with aging. Physical Therapy 64, 10671070. Byl, N., Sinnot, P.L., 1991. Variations in balance and body sway in middle-aged adults: subjects with healthy backs compared with subjects with low-back dysfunction. Spine 16, 325330. Cady, L.D., Bischoff, L.P., OConnel, E.R., et al., 1989. Strength and tness and subsequent back injuries in re ghters. Journal of Occupational Medicine 21, 269. Cibulka, M.T., Sinacore, D.R., Cromer, G.S., Delitto, A., 1998. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine 23, 10091015. Croft, P.R., Macfarlane, G.J., Papageorgiou, A.C., Thomas, E., Silman, A.J., 1998. Outcome of low back pain in general practice: a prospective study. Br. Med. J. 316, 13561359. Croft, P.R., Papageorgiou, A.C., Thomas, E., Macfarlane, G.J., Silman, A.J., 1999. Short-term physical risk factors for new episodes of low back pain: prospective evidence from the South Manchester back pain study. Spine 24 (15), 15561561. Deyo, R.A., Weinstein, J.N., 2001. Low back pain. New England Journal of Medicine 344, 363370. Ellison, J.B., Rose, S.J., Sahrmann, S.A., 1990. Patterns of rotation range of motion: a comparison between healthy subjects and patients with low back pain. Physical Therapy 70, 537541. Enthoven, P., Skargren, E., Kjellman, G., Oberg, B., 2003. Course of back pain in primary care: a prosepective study of physical measures. Journal of Rehabilitation Medicine 35, 168173. Fordyce, W.E., Brochway, J.A., Bergman, J.A., et al., 1986. Acute back pain: a control-group comparison of behavioral vs. traditional management methods. Journal of Behavioral Medicine 9, 127. Green, J., Grenier, S., McGill, S.M., 2002. Low back stiffness is altered with warmup and bench rest: implications for athletes. Medicine and Science in Sports and Exercise 34 (7), 10761081.

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Spinal stabilizationFan update. Part 2Ffunctional assessment 209

Grenier, S., et al., 2004. Linking a history of work loss due to low back injury with person al tness variables such as muscular endurance. Submitted for publication. Gronblad, M., Hurri, H., Jouri, J.P., 1997. Relationships between spinal mobility, physical performance tests, pain intensity and disability assessments in chronic low back pain patients. Scandinavian Journal of Rehabilitation Medicine 29, 1724. Hadler, N.M., 1986. Regional back pain. New England Journal of Medicine 315, 10901092. Hashemi, L., Webster, B.S., Clancy, E.A., Volinn, E., 1998. Length of disability and cost of workers compensation low back pain claims. Journal of Occupational and Environmental Medicine 40, 261269. Hides, J.A., Jull, G.A., Richardson, C.A., 2001. Long-term effects of specic stabilizing exercises for rst-episode low back pain. Spine 26, e243e248. Hodges, P.W., Richardson, C.A., 1998. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. Journal of Spinal Disorders 11 (1), 4656. Hodges, P.W., Richardson, C.A., 1999. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch Physical Medicine and Rehabilitation 80 (9), 10051012. Hudson-Cook, N., Tomes-Nicholson, K., Breen, A.C., 1989. A revised Oswestry disability questionnaire. In: Roland, M., Jenner, J. (Eds.), Back Pain: New Approaches to Rehabilitation and Education. Manchester University Press, Manchester, UK, pp. 187204. Indahl, A., Haldorsen, E.H., Holm, S., Reikeras, O., Hursin, H., 1998. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine 23, 26252630. Janda, V., 1996. In: Liebenson, C., (Ed.), Evaluation of Muscle Imbalance in Liebenson C. Rehabilitation of the Spine: A Practitioners Manual. Williams and Wilkins, Baltimore (Chapters 6). Jarvik, J.G., Deyo, R.A., 2000. Imaging of lumbar intervertebral disc degeneration and aging, excluding disc herniations. Radiology Clinics of North America 38, 12551266. Kankaapaa, M., Taimela, S., Laaksonen, D., et al., 1998. Back and hip extensor fatigability in chronic low back pain patients and controls. Archives of Physical Medicine and Rehabilitation 79, 412417. Kilpikoski, S., Airaksinen, O., Kankaanpaa, M., Leminen, P., Videman, T., Alen, M., 2002. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 27, E207E214. Latimer, J., Maher, C.G., Refshauge, K., Colaco, I., 1999. The reliability and validity of the Biering-Sorensen test in asymptomatic subjection and subjects reporting current or previous non-specic low back pain. Spine 24, 20852090. Lee, J.H., Hoshin, O.Y., Nakamura, K., Kariya, Y., Saita, K., Ito, K., 1999. Trunk muscle weakness as a risk factor for low back pain. A 5-year prospective study. Spine 24, 5457. Leinonen, V., Kankaanpaa, M., Airaksinen, O., et al., 2000. Back and hip exion/extension: effects of low back pain and rehabilitation. Archives of Physical Medicine and Rehabilitation 81, 3237. Lemestra, M., Olszynski, W.P., 2003. The effectiveness of standard care, early intervention, and occupational management in workers compensation claims. Spine 28, 226237. Lindstrom, A., Ohlund, C., Eek, C., et al., 1992. Activation of subacute low back patients. Physical Therapy 4, 279293. Linton, S.J., 1998. The socioeconomic impact of chronic back pain: is anyone beneting? Editorial. Pain 75, 63168.

Luoto, S., Heliovaara, M., Hurri, H., Alaranta, H., 1995. Static back endurance and the risk of low-back pain. Clinical Biomechanics 10, 323324. Luoto, S., Aalto, H., Taimela, S., et al., 1998. One-footed and externally disturbed two-footed postural control in chronic low-back pain patients and healthy controls: a controlled study with follow-up. Spine 23, 20812090. Malmivaara, A., Hakkinen, U., Aro, T., et al., 1995. The treatment of acute low back painFbed rest, exercises, or ordinary activity? New England Journal of Medicine 332, 351355. Manniche, C., Lundberg, E., Christensen, I., Bentzen, L., Hesselesoe, G., et al., 1991. Intensive dynamic back exercises for chronic low back pain. Pain 47, 5363. Marras, W.S., Allread, W.G., Burr, D.L., Fathallah, F.A., 2000. Prospective validation of a low-back disorder risk model and assessment of ergonomic interventions assoicated with manual materials handling. Ergonomics 11, 18661886. Mayer, T.G., Smith, S., Keeley, J., Mooney, V., 1985. Quantication of lumbar function part 2: sagittal plane trunk strength in chronic low back patients. Spine 10, 765772. McGill, S.M., Brown, S., 1992. Creep response of the lumbar spine to prolonged full exion. Clinical Biomechanics 7, 4346. McGill, S.M., Childs, A., Liebenson, C., 1999. Endurance times for stabilization exercises: clinical targets for testing and training from a normal database. Archives of Physical Medicine and Rehabilitation 80, 941944. McGill, S., Grenier, S., Bluhm, M., Preuss, R., Brown, S., Russell, C., 2003. Previous history of LBP with work loss is related to lingering decits in biomechanical, physiological, personal, psychosocial and motor control characteristics. Ergonomics 46, 731746. McIntosh, G., Wilson, L., Afeck, M., Hall, H., 1998. Trunk and lower extremity muscle endurance: normative data for adults. Journal of Rehabilitation Outcomes and Measures 2, 2039. McQuade, J.J., Turner, J.A., Buchner, D.M., 1988. Physical tness and chronic low back pain. Clinical Orthopedics and Related Research 223, 198204. Mens, J.M., Vleeming, A., Snijders, C.J., et al., 2001. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine 26, 11671171. Mens, J.M., Vleeming, A., Snijders, C.J., et al., 2002. Validity of the active straight leg raise test to measure disease severity in posterior pelvic pain since pregnancy. Spine 27, 196200. Moffroid, M.T., 1994. Distinguishable groups of musculoskeletal low back pain patients and asymptomatic control subjects based on physical measures of the NIOSH low back atlas. Spine 19, 13501358. Moffroid, M.T., Reid, S., Henry, S., Haugh, L.D., Ricamato, A., 1994. Some endurance measures in persons with chronic low back pain. Journal of Orthopedic and Sports Physical Therapy 20, 8187. Moreland, J., Finch, E., Stratford, P., Balsor, B., Gill, C., 1997. Interrater reliability of six tests of trunk function and endurance. Journal of Orthopedic and Sports Physical Therapy 26, 200208. Nadler, S.F., Malanga, G.A., DePrince, M.L., Stitik, T.P., Feinberg, J.H., 2000. The relationship between lower extremity injury, low back pain , and hip muscle strength in male and female collegiate athletes. Clinical Journal of Sports Medicine 10, 8997. Nadler, S.F., Malanga, G.A., Feinberg, J.H., Prybicien, M., Stitik, T.P., DeFrince, M., 2001. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate

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Spinal stabilizationFan update. Part 2Ffunctional assessment

athletes: a prospective study. American Journal of Physical Medicine and Rehabilitation 80, 572577. Nadler, S.F., Malanga, G.A., Bartoli, L.A., Feinberg, J.H., Prybicien, M., DePrince, M., 2002. Hip muscle imbalance and low back pain in athletes: inuence of core strengthening. Medicine and Science in Sports and Exercise 34 (1), 916. National Collegiate Athletic Association, 1998. NCAA Injury Surveillance System (19971998). National Collegiate Athletic Association, Overland Park, Kansas. Nicolaisen, T., Joregnesen, K., 1985. Trunk strength, back muscle endurance and low back trouble. Scandinavian Journal of Rehabilitation Medicine 17, 121127. OSullivan, P., Twomey, L., Allison, G., 1997. Evaluation of specic stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolysthesis. Spine 24, 29592967. OSullivan, P.B., Beales, D.J., Beetham, J.A., Cripps, J., Graf, F., Lin, I.B., Tucker, B., Avery, A., 2002. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine 27, E1E8. Parks, K.A., Crichton, K.S., Godford, R.J., McGill, S.M., 2003. A comparison of lumbar range of motion and functional ability scores in patients with low back pain. Spine 28, 380384. Ready, A.E., Boreskie, S.L., Law, S.A., Russell, R., 1993. Fitness and lifestyle parameters fail to predict back injuries in nurses. Canadian Journal of Applied Physiology 18 (1), 8090. Scannell, J.P., McGill, S.M., 2004. Lumbar postureFshould, and can, it be modied? A study of passive tissue stiffness and lumbar position in activities of daily living. Physical Therapy, accepted for publication. Simmonds, M.J., Olson, S.L., Jones, S., Hussein, T., Lee, C.E., et al., 1998. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine 23 (22), 24122421. Snook, S.H., 2004. Work related low back pain: secondary prevention. Journal of Electromyography and Kinesiology 14, 153160. Snook, S.H., Webster, B.S., McGorry, R.W., Fogleman, M.T., McCann, K.B., 1998. The reduction of chronic nonspecic low

back pain through the control of early morning lumbar exion. Spine 23, 26012607. Solomonow, M., Hatipkarasulu, S., Zhou, B., Baratta, R.V., Aghazadeh, F., 2003. Biomechanics and EMG of a common idiopathic low back disorder. Spine 28, 12351248. Spitzer, W.O., Le Blanc, F.E., Dupuis, M., et al., 1987. Scientic approach to the assessment and management of activityrelated spinal disorders: A monograph for clinicians. Report of the Quebec task force on spinal disorders. Spine 12 (Suppl. 7), S1S59. Stratford, P.W., Binkley, J.M., Stratford, D.M., 2001. Development and initial validation of the upper extremity functional index. Physiotherapy Canada 53, 259266. Tafazzoli, R., Lamontagne, M., 1996. Mechanical behavior of hamstring muscles in lo-back pain patients and control subjects. Clinical Biomechanics 11, 1624. Takala, E.P., Vikari-Juntura, E., 2000. Do functional tests predict low back pain. Spine 25 (16), 21262132. Timm, K.E., 1994. A randomized-control study of active and passive treatments for chronic low back pain following L5 laminectomy. JOSPT 20, 276286. Van der Velde, G., Mierau, D., 2000. The effect of exercise on the percentile rank aerobic capacity, pain, and self-rated disability in patients with chronic low back pain: a retrospective chart review. Archives of Physical Medicine and Rehabilitation 81, 14571463. Vernon, H., Mior, S., 1991. The neck disability index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 14, 409415. Vogt, L., Banzer, W., 1997. Dynamic testing of the motorial stereotype in prone hip extension from the neutral position. Clinical Biomechanics 12, 122127. Vogt, L., Pfeifer, K., Banzer, W., 2003. Neuromuscular control of walking with chronic low-back pain. Manual Therapy 8, 2128. Waddell, G., 1998. The Back Pain Revolution. Churchill Livingstone, Edinburgh. Werneke, M., Hart, D.L., 2001. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 26, 758765.