2014 a Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-term Success Following Lumbar Stabilization Exercises; A Randomized Controlled Validation Study

[ research report ]
ALON RABIN, DPT, PhD1 • ANAT SHASHUA, BPT, MS2 • KOBY PIZEM, BPT3
RUTHY DICKSTEIN, PT, DSc4 • GALI DAR, PT, PhD4
A Clinical Prediction Rule to Identify

Patients With Low Back Pain Who Are
Likely to Experience Short-Term Success
Following Lumbar Stabilization Exercises:
A Randomized Controlled Validation Study
Downloaded from www.jospt.org at on February 18, 2018. For personal use only. No other uses without permission.
TTSTUDY DESIGN: Randomized controlled trial. compared with those receiving MT (P = .03). In
TTOBJECTIVE: To determine the validity of a addition, there were main effects for treatment and
previously suggested clinical prediction rule (CPR) CPR status. Patients receiving LSE experienced
Copyright © 2014 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
for identifying patients most likely to experience less disability by the end of treatment compared to
short-term success following lumbar stabilization patients receiving MT (P = .05), and patients with
L
exercise (LSE). a positive CPR status experienced less disability
TTBACKGROUND: Although LSE is commonly by the end of treatment compared to patients with ow back pain (LBP) is
used by physical therapists in the management a negative CPR status, regardless of the treatment
received (P = .04). When a modified version of common among the general
of low back pain, it does not seem to be more
effective than other interventions. A 4-item CPR the CPR (mCPR) containing only the presence of population, with a lifetime
for identifying patients most likely to benefit from aberrant movement and a positive prone instability prevalence and point pre-
LSE has been previously suggested but has yet to test was used, a significant interaction with treat-
be validated. ment was found for final disability (P = .02). Of the valence estimated to be greater
TTMETHODS: One hundred five patients with patients who received LSE, those with a positive than 80% and 28%, respectively.12
Journal of Orthopaedic & Sports Physical Therapy®
low back pain underwent a baseline examination mCPR status experienced less disability by the end
to determine their status on the CPR (positive or of treatment compared to those with a negative Although short-term outcomes are gen-
negative). Patients were stratified by CPR status mCPR status (P = .02), and among patients with erally favorable, some patients go on to
and then randomized to receive an LSE program a positive mCPR status, those who received LSE experience long-term pain and disabil-
or an intervention consisting of manual therapy experienced less disability by the end of treatment
ity,32,40,78 and recurrence rates are high.17,78
(MT) and range-of-motion/flexibility exercises. compared to those who received MT (P = .005).
TTCONCLUSION: The previously suggested CPR
Systematic reviews of various physi-
Both interventions included 11 treatment sessions
delivered over 8 weeks. Low back pain–related for identifying patients likely to benefit from LSE cal therapy interventions for LBP do not
disability was measured by the modified version of could not be validated in this study. However, due provide strong support for any particu-
the Oswestry Disability Index at baseline and upon to its relatively low level of power, this study could lar treatment approach.2,50,51,77 One pos-
completion of treatment. not invalidate the CPR, either. A modified version sible reason is the use of heterogeneous
TTRESULTS: The statistical significance for the of the CPR that contains only 2 items may possess
samples of patients in many clinical trials
2-way interaction between treatment group and a better predictive validity to identify those most
likely to succeed with an LSE program. Because for LBP. Patients with LBP demonstrate
CPR status for the level of disability at the end
of the intervention was P = .17. However, among this modified version was established through post both etiologic and prognostic hetero-
patients receiving LSE, those with a positive CPR hoc testing, an additional study is recommended geneity,7,40,45 which makes it unlikely for
status experienced less disability by the end of to prospectively test its predictive validity. any single intervention to have a signifi-
treatment compared with those with a nega- TTLEVEL OF EVIDENCE: Prognosis, level 1b–. J cant advantage over another in a general
tive CPR status (P = .02). Also, among patients Orthop Sports Phys Ther 2014;44(1):6-18. Epub 21
population with LBP. Classifying patients
with a positive CPR status, those receiving LSE November 2013. doi:10.2519/jospt.2014.4888
experienced less disability by the end of treatment TTKEY WORDS: lumbar spine, manual therapy into more homogeneous subgroups has
been previously identified as a top re-
1
Department of Physiotherapy, Ariel University, Ariel, Israel. 2Bat-Yamon Physical Therapy Clinic, Clalit Health Services, Israel. 3Giora Physical Therapy Clinic, Clalit Health
Services, Israel. 4Department of Physical Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel. This study was approved by the Helsinki
Committee of Clalit Health Services. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest
in the subject matter or materials discussed in the article. Address correspondence to Dr Alon Rabin, Ariel University, Department of Physiotherapy, Kiryat Hamada, PO Box 3,
Ariel, Israel. E-mail: alonrabin@gmail.com t Copyright ©2014 Journal of Orthopaedic & Sports Physical Therapy®
6 | january 2014 | volume 44 | number 1 | journal of orthopaedic & sports physical therapy
44-01 Rabin.indd 6 12/17/2013 5:18:33 PM

search priority,6 and, in fact, more recent first stage in establishing a CPR, the deri- modify, the previously suggested CPR for
research has suggested that matching pa- vation stage.4,14,55 Following derivation, a identifying patients most likely to benefit
tients with interventions based on their CPR must be validated, that is, shown to from LSE. We hypothesized that among
specific clinical presentation may yield consistently predict the outcome of inter- patients receiving LSE, those with a posi-
improved clinical outcomes.8,10,15,27,47 est in a separate and preferably prospective CPR status would exhibit a better
Structural as well as functional tive investigation.26 Given its preliminary outcome compared to those with a nega-
impairments, such as decreased and nature, and because CPRs do not typi- tive CPR status. We also hypothesized
delayed activation of the transversus ab- cally perform as well on new samples of that among patients with a positive CPR
dominis and atrophy of the lumbar mul- patients,21,30,67,68 modification of the CPR status, those who received LSE would ex-
tifidus,25,34,37,48,69,80 have been identified may also be necessary to achieve satisfac- hibit a better outcome compared to those
among patients with LBP. These impair- tory predictive validity. Once validated, who received MT.
ments may result in a reduction in spinal CPRs can move into the final stage of
stiffness82 and possibly render the spine their determination, which includes an METHODS
more vulnerable to excessive deforma- investigation into their impact on clini-

tion and pain. Lumbar stabilization ex- cal practice (impact analysis).4,14,55 Patients
O
ercises (LSE) attempt to address these Validation of the CPR for LSE re- ne hundred five patients diag-
impairments by retraining the proper quires a randomized controlled trial in nosed with LBP and referred to
activation and coordination of trunk which patients with a different status on physical therapy at 1 of 5 outpa-
musculature.58,64 Stabilization exercises the CPR (positive or negative) undergo tient clinics of Clalit Health Services in
are widely used by physical therapists in an LSE program, as well as a comparison the Tel-Aviv metropolitan area, Israel,
the management of LBP.8,11,22,24,35,44,49,50,62,65 intervention.4 The use of a comparison were recruited for this study. Subjects
Although some evidence exists to support intervention is important to determine were included if they were 18 to 60 years
the remediating effects of LSE on some whether the CPR can truly identify pa- of age, had a primary complaint of LBP
of the muscle impairments identified in tients who will benefit specifically from with or without associated leg symptoms
patients with LBP,36,73,74 the clinical ef- LSE, as opposed to patients who have a (pain, paresthesia), and had a minimum
ficacy of this intervention seems to vary. favorable prognosis irrespective of the score of 24% on the Hebrew version of
When compared to sham or no interven- treatment received.66 Finally, to validate the modified Oswestry Disability Index
tion, LSE appears to be advantageous22,65; the CPR in the most clinically meaning- (MODI) outcome measure. Patients
however, when compared to other exer- ful manner, we believe that the compari- were excluded if they presented with a
cise interventions or to manual therapy son intervention should be considered a history suggesting any red flags (eg, ma-
(MT), no definitive advantage has been viable alternative to LSE, rather than a lignancy, infection, spine fracture, cauda
ascertained.11,24,35,44,49,50,62,75 sham or an inert intervention. equina syndrome); 2 or more signs sug-
In light of the variable clinical suc- Manual therapy is an intervention fre- gesting lumbar nerve root compression,
cess of LSE and in accordance with the quently used by physical therapists in the such as decreased deep tendon reflexes,
aforementioned need to classify patients management of patients with LBP39,46,56 myotomal weakness, decreased sensation
who have LBP into more homogeneous and is recommended by several clinical in a dermatomal distribution, or a posi-
subgroups, Hicks et al33 suggested a clini- practice guidelines and systematic reviews tive SLR, crossed SLR, or femoral nerve
cal prediction rule (CPR) to specifically for the management of acute, subacute, stretch test; or a history of corticosteroid
identify patients with LBP who are likely and chronic LBP.1,9,19,76 These factors, com- use, osteoporosis, or rheumatoid arthri-
to exhibit short-term improvement with bined with the fact that LSE programs tis. Patients were also excluded if they
LSE. Four variables were found to pos- have previously demonstrated varied were pregnant, received chiropractic
sess the greatest predictive power for levels of success compared to MT,11,24,50,62 or physical therapy care for LBP in the
treatment success: (1) age less than 40 suggest that MT may be a suitable com- preceding 6 months, could not read or
years, (2) average straight leg raise (SLR) parison intervention for testing the validi- write in the Hebrew language, or had a
of 91° or greater, (3) the presence of aber- ty of the CPR. In contrast to its use among pending legal proceeding associated with
rant lumbar movement, and (4) a positive heterogeneous samples,11,24,50,62 LSE their LBP. Prior to participation, all pa-
prone instability test.33 When at least 3 should demonstrate a clearer advantage tients signed an informed consent form
of the 4 variables were present, the posi- among patients with LBP who also satisfy approved by the Helsinki Committee of
tive likelihood ratio for achieving a suc- the CPR, if the CPR accurately identifies Clalit Health Services.
cessful outcome was 4.0, increasing the the correct target patient population.
probability of success from 33% to 67%.33 The purpose of this investigation was Therapists
The study by Hicks et al33 comprises the to determine the validity of, or to possibly Sixteen physical therapists were involved
journal of orthopaedic & sports physical therapy | volume 44 | number 1 | january 2014 | 7
44-01 Rabin.indd 7 12/17/2013 5:18:35 PM

[ research report ]
in the study. Eleven therapists, with be- who screened patients for eligibility to with a few minor changes in the order of
tween 4 and 12 years of experience in participate in the study, were blinded to the exercises and a few additional levels
outpatient physical therapy patient care, the intervention allocation of the patients. of difficulty for some of the exercises. Pa-
provided treatment, and 5 therapists, tients were initially educated about the
with between 13 to 25 years of experi- Reliability structure and function of the trunk mus-
ence, performed baseline and follow- The reliability of the individual physical culature, as well as common impairments
up evaluations. Prior to beginning the examination items comprising the CPR, in these muscles among patients with
study, all participating therapists under- as well as that of the entire CPR, has been LBP. Patients were then taught to per-
went two 4-hour sessions in which the reported previously.60 In that study,60 the form an isolated contraction of the trans-
rationale and protocol of the study were interrater reliability for determining CPR versus abdominis and lumbar multifidus
presented and the examination and treat- status was excellent (κ = 0.86), and the through an abdominal drawing-in ma-
ment procedures were demonstrated and interrater reliability of each of the items neuver (ADIM) in the quadruped, stand-
practiced. Therapists had to pass a writ- comprising the CPR ranged from moder- ing, and supine positions.63,64,69,71,73 Once
ten examination of the study procedures ate to substantial (κ = 0.64-0.73).60 a proper ADIM was achieved (most likely
prior to data collection. Finally, each by the second or third visit), additional
therapist received a manual describing Randomization loads were placed on the spine through
treatment and evaluation procedures, At the conclusion of the physical exami- various upper extremity, lower extremity,
based on the therapist’s role in the study nation, each patient was randomized to and trunk movement patterns. Exercises
(treatment or evaluation). Therapists in- receive LSE or MT. Randomization was were performed in the quadruped, sidely-
volved in treating patients were unaware based on a computer-generated list of ing, supine, and standing positions, with
of the concept of the CPR throughout the random numbers, stratified by CPR status the goal of recruiting a variety of trunk
study, to avoid bias from this knowledge to ensure that adequate numbers of pa- muscles.18,53,54 In each position, exercises
during treatment. All treating therapists tients with a positive and a negative CPR were ordered by their level of difficulty,
provided both treatments of the study status would be included in each interven- and patients progressed from one exer-
(LSE and MT). tion group. The list was kept by a research cise to the next after satisfying specific
assistant who was not involved in patient predetermined criteria. In the seventh
Procedure recruitment, examination, or treatment. treatment session, functional movement
After giving consent, patients completed patterns were incorporated into the
a baseline examination that included de- Intervention training program while performing an
mographic information, an 11-point (0- Patients in both groups received 11 treat- ADIM and maintaining a neutral lumbar
10) numeric pain rating scale (NPRS), ment sessions over an 8-week period. spine. This stage, which was not includ-
on which 0 was “no pain” and 10 was Each patient was seen twice a week dur- ed in the derivation study, was added to
the “worst imaginable pain,” the Hebrew ing the first 4 weeks, then once a week the program because it has been recom-
version of the MODI,3,28 and the Hebrew for 3 additional weeks. A 12th session mended by others.22,58,62 The exercises in
version of the Fear-Avoidance Beliefs (usually on the eighth week) consisted each stage of the LSE program, as well as
Questionnaire.38,79 In addition, the his- of a final evaluation. The total number the specific criteria for progression from
tory of the present and any past LBP of sessions (12) matched the maximum one exercise to the next, are outlined in
was documented, followed by a physical number of physical therapy visits allowed APPENDIX A (available at www.jospt.org).
examination. annually per condition under the policy
The physical examination included a of the Clalit Health Services health main- Manual Therapy
neurological screen to rule out lumbar tenance organization, which covered all The MT intervention included several
nerve root compression; lumbar active patients participating in the study. Pa- thrust and nonthrust manipulative tech-
motion, during which the presence of ab- tients in both groups were prescribed a niques directed at the lumbar spine that
errant movement, as defined by Hicks et home exercise program consistent with have been used previously with some
al,33 was determined; bilateral SLR range their treatment group; however, no at- degree of success in various groups with
of motion; segmental mobility of the lum- tempt was made to monitor patients’ LBP.10,15,20,59 In addition, manual stretch-
bar spine; and the prone instability test. compliance with the home exercise ing of several hip and thigh muscles was
The patients’ status on the CPR (positive program. performed, as flexibility of the lower ex-
or negative) was established based on the tremity is purported to protect the spine
findings of the physical examination. Lumbar Stabilization Exercises from excessive strain.54 Finally, active
Examiners who performed the base- The LSE program was largely based on range-of-motion and stretching exercis-
line examinations, as well as examiners the program described by Hicks et al,33 es were added to the program, as these
44-01 Rabin.indd 8 12/17/2013 5:18:36 PM

are commonly prescribed in combina- be necessary to include 40 patients with positive patients receiving LSE) and
tion with MT to maintain or improve the a positive CPR status; however, 40 such patients receiving an unmatched inter-
mobility gains resulting from the manual patients were included after 105 patients vention (either CPR-negative patients
procedures.10,15,20,47 The exercises included were recruited, and recruitment was receiving LSE or CPR-positive patients
were selected to minimize trunk muscle stopped at that point. receiving MT).
activation and to avoid duplication be- The individual items of the CPR, as
tween the 2 interventions. Statistical Analysis well as different combinations of these
All manual procedures and exercises Descriptive statistics, including frequen- items, were similarly tested to identify
were prescribed based on the clinical cy counts for categorical variables and whether any such combination would
judgment of the treating therapist; how- measures of central tendency and dis- enhance the predictive validity of the
ever, each session could include up to 3 persion for continuous variables, were original version. Finally, the outcome was
manual techniques, 1 of which had to be used to summarize the data. All baseline also dichotomized as successful or unsuc-
a thrust manipulative technique directed variables were assessed for normal distri- cessful based on a previously established
at the lumbar spine, and an additional bution using the Shapiro-Wilk test. Base- cutoff threshold of 50% reduction in the
technique that had to include a manual line variables were compared between baseline score of the MODI.33 The pro-
stretch of a lower extremity muscle. The treatment groups (LSE versus MT), CPR portion of patients achieving a success-
third technique, as well as the comple- status (positive versus negative), and ful outcome was compared among the
mentary range-of-motion/flexibility ex- the resulting 4 subgroups using a 2-way resulting subgroups (LSE CPR+, LSE
ercises, was given at the discretion of the analysis of variance and chi-square tests CPR–, MT CPR+, and MT CPR–) using
treating therapist. The MT techniques, as for continuous and categorical variables, chi-square analysis.
well as all exercises used in the MT proto- respectively. An intention-to-treat approach was
col, are described in APPENDIX B (available The primary aim of the study was performed for all analyses by using mul-
at www.jospt.org). tested using 2 separate analyses of cova- tiple imputations for any missing val-
riance (ANCOVAs), with the final MODI ues of the 2 outcome measures (MODI,
Evaluation score serving as the dependent variable in NPRS). First, Little’s “missing completely
The MODI served as the primary out- 1 model and the final NPRS score serving at random” test was performed to test the
come measure in this investigation. The as the dependent variable in the second hypothesis that missing values were ran-
MODI is scored from 0 to 100 and has a model. In both models, treatment group domly distributed. If this hypothesis could
minimal clinically important difference and CPR status served as independent not be rejected, expectation maximization
(MCID) of 10 points among patients with variables, and the baseline MODI score was used to predict missing values. A per-
LBP.57 The secondary outcome measure (or baseline NPRS score) was used as protocol analysis was performed as well.
was the NPRS, which has an MCID of 2 a covariate. The residuals of all models All statistical analyses were performed us-
points among patients with LBP.16 Both were tested for violations of the ANCOVA ing the JMP Version 10 statistical package
measures were administered before the assumptions and for outliers. The main (SAS Institute Inc, Cary, NC), as well as
beginning of treatment and immediately effects of treatment group and CPR sta- the SPSS Version 19 statistical package
after the last treatment session by an in- tus, as well as the 2-way interaction be- (SPSS Inc, Chicago, IL).
vestigator not involved in patient care. tween these factors on the final MODI
and NPRS scores, were evaluated. The a RESULTS
Sample Size priori level of significance for these analy-
F
Sample size was calculated to detect a be- ses was P≤.05. Two pairwise comparisons ive hundred thirty-one poten-
tween-group difference of 12 points in the were planned following the ANCOVA: (1) tial candidates were screened for
final score of the MODI, based on the in- a comparison of differences between pa- eligibility between March 2010 and
teraction between treatment group (LSE tients with a positive CPR receiving LSE April 2012. Two hundred ninety-seven pa-
versus MT) and CPR status (positive ver- and those with a negative CPR receiving tients did not meet the inclusion criteria,
sus negative), with an alpha level of .05 LSE, and (2) a comparison of differences and another 129 declined participation.
and a power of 70%. Based on a 16-point between patients with a positive CPR The remaining 105 patients were admit-
standard deviation, it was determined receiving LSE and those with a positive ted into the study. Forty patients had a
that 20 patients were needed in each cell. CPR receiving MT. These 2 comparisons positive CPR status, whereas 65 had a
Pilot data suggested that the prevalence were deemed the most relevant for the negative status. Forty-eight patients were
of patients with a positive status on the purpose of validating the CPR, as both randomized to the LSE group, whereas 57
CPR was approximately 33%. Therefore, included a comparison between patients patients were randomized to receive MT.
it was estimated that 120 patients would receiving a matched intervention (CPR- All patients underwent treatment accord-
44-01 Rabin.indd 9 12/17/2013 5:18:37 PM

[ research report ]
pleting the intervention (noncompleters,
Screened for eligibility, n = 531 n = 24) using Wilcoxon and Fisher ex-
act tests for continuous and categorical
Excluded, n = 297: variables, respectively. Noncompleters
• MODI <24%, n = 151 exhibited a higher baseline score on
• Prior physical therapy, n = 28 the Fear-Avoidance Beliefs Question-
• Nerve root compression, n = 26
naire physical activity subscale versus
• Pending legal proceeding, n = 24
• Did not meet other inclusion completers (17.2 versus 15.1, P = .04).
criteria, n = 68 Noncompleters also had a lower level
Declined participation, n = 129 of education compared to completers
(P = .03). No other differences were
Randomized, n = 105 detected between the completers and
noncompleters.
Lumbar stabilization exercises, Manual therapy, n = 57 Analysis by Intention to Treat

n = 48 The baseline and final MODI and NPRS
scores for each treatment group and sub-
group are summarized in TABLE 2. When
8-wk follow-up, n = 32 8-wk follow-up, n = 49 assessing final disability level, the statisti-
16 dropped out 8 dropped out cal level of significance for the 2-way in-
teraction between treatment group and
CPR status was P = .17. A main effect was
detected for treatment (P = .05), which
Analyzed, n = 48 Analyzed, n = 57 indicated that patients receiving LSE
experienced less disability by the end
of treatment compared to the patients
CPR+, n = 18 CPR–, n = 30 CPR+, n = 22 CPR–, n = 35 who received MT. A main effect was also
detected for CPR status (P = .04), indi-
FIGURE 1. Flow diagram of participant recruitment and retention. Abbreviations: CPR, clinical prediction rule; cating that patients with a positive CPR
MODI, modified Oswestry Disability Index. status experienced less disability by the
end of treatment compared to those with
ing to their allocated treatment group. tients with a positive CPR status were a negative CPR status, regardless of the
Sixteen patients did not complete the younger than patients with a negative treatment received. The 2 preplanned
LSE intervention, and 8 patients did not CPR status (P = .0006). This difference pairwise comparisons indicated that (1)
complete the MT intervention (P = .02). was expected, as 1 of the items comprising among patients receiving LSE, those with
FIGURE 1 presents patient recruitment and the CPR is being less than 40 years of age. a positive CPR status experienced less dis-
retention throughout the study. Therefore, we did not correct our model ability at the end of the intervention com-
TABLE 1 presents baseline demographic, to account for this expected difference. pared to those with a negative CPR status
history, and self-reported variables for all Little’s "missing completely at ran- (P = .02); and (2) among patients with a
groups and subgroups. All baseline vari- dom" test indicated that the hypothesis positive CPR status, those receiving LSE
ables were normally distributed, with the that final MODI and NPRS scores were experienced less disability by the end
exception of body mass index and dura- randomly missing could not be rejected of treatment compared to those receiv-
tion of LBP. Log transformations were (P = .76 for the MODI and P = .52 for the ing MT (P = .03). The change in MODI
thus performed on body mass index and NPRS). Therefore, expectation maximi- between baseline and the end of treat-
duration of LBP, resulting in a better dis- zation was used to replace missing values. ment for the 4 subgroups is represented
tribution pattern. As a result, the geomet- in FIGURE 2. No interactions or main ef-
ric mean with 95% confidence interval is Completers Versus Noncompleters fects were noted for pain (P>.26). TABLE 3
reported for these variables, as opposed All baseline demographic, history, and presents the adjusted final disability and
to mean  SD for all other baseline vari- self-reported variables were compared pain scores for all groups and subgroups,
ables (TABLE 1). No baseline differences between patients who completed the and TABLE 4 presents the differences in fi-
were noted between the different groups intervention (completers, n = 81) and nal disability and pain among the differ-
and subgroups other than for age. Pa- patients who dropped out prior to com- ent groups and subgroups.
44-01 Rabin.indd 10 12/17/2013 5:18:38 PM

TABLE 1 Baseline Demographic, History, and Self-Report Variables for All Groups
LSE CPR+ LSE CPR– MT CPR+ MT CPR–

Characteristic LSE (n = 48) MT (n = 57) CPR+ (n = 40) CPR– (n = 65) (n = 18) (n = 30) (n = 22) (n = 35)
Sex (female), n (%) 25 (52.1) 31 (54.4) 22 (55.0) 34 (52.3) 10 (55.6) 15 (50.0) 12 (54.5) 19 (54.3)
Age, y*† 38.3  10.5 35.5  9.1 32.8  7.5 39.2  10.3 32.7  7.4 41.6  10.7 32.8  7.7 37.2  9.6
BMI, kg/m2‡ 24.4 (22.9, 25.9) 25.8 (24.3, 27.3) 24.2 (22.6, 25.9) 25.9 (24.7, 27.3) 22.9 (20.7, 25.4) 25.9 (24.0, 27.9) 25.6 (23.3, 28.1) 26.0 (24.3, 27.8)
Education, n (%)
Less than high school 2 (4.2) 0 (0) 0 (0) 2 (3.1) 0 (0) 2 (6.7) 0 (0) 0 (0)
High school 21 (43.7) 15 (26.3) 9 (22.5) 27 (41.5) 5 (27.8) 16 (53.3) 4 (18.2) 11 (31.4)
Some postsecondary 8 (16.7) 15 (26.3) 9 (22.5) 14 (21.5) 3 (16.7) 5 (16.7) 6 (27.3) 9 (25.7)
Bachelor 13 (27.1) 17 (29.8) 18 (45.0) 12 (18.5) 8 (44.4) 5 (16.7) 10 (45.5) 7 (20.0)

Master 3 (6.2) 9 (15.8) 4 (10.0) 8 (12.3) 2 (11.1) 1 (3.3) 2 (9.0) 7 (20.0)
Doctorate 1 (2.1) 1 (1.8) 0 (0) 2 (3.1) 0 (0) 1 (3.3) 0 (0) 1 (2.8)
Work status (employed§), 38/43 (88.4) 41/53 (77.4) 28/36 (77.8) 51/60 (85.0) 13/16 (81.3) 25/27 (92.6) 15/20 (75.0) 26/33 (78.8)
n (%)
Smoker, n (%)§ 16/44 (36.4) 11/53 (20.8) 14/36 (38.9) 13/61 (21.3) 8/16 (50.0) 8/28 (28.6) 6/20 (30.0) 5/33 (15.2)
Duration (days since 58.7 (41.8, 82.4) 67.4 (48.9, 92.9) 63.8 (44.2, 92.2) 62.0 (46.5, 82.7) 52.0 (30.5, 88.6) 66.3 (43.6, 101.0) 78.4 (47.3, 130.0) 57.9 (39.1, 85.9)
onset)‡
Use of analgesics, n (%)§ 22/42 (52.4) 32/53 (60.4) 23/36 (63.9) 31/59 (52.5) 9/16 (56.3) 13/26 (50.0) 14/20 (70.0) 18/33 (54.6)
Past LBP, n (%)§ 34/48 (70.8) 35/56 (62.5) 27/39 (69.2) 42/65 (64.6) 13/18 (72.2) 21/30 (70.0) 14/21 (66.7) 21/35 (60.0)
Symptoms below knee, 14 (29.2) 16 (28.1) 8 (20.0) 22 (33.8) 2 (11.1) 12 (40.0) 6 (27.3) 10 (28.6)
n (%)
NPRS (0-10)* 4.9  1.7 5.3  1.7 4.9  1.7 5.3  1.7 4.4  1.7 5.2  1.6 5.2  1.6 5.4  1.8
MODI (0-100)* 37.8  10.6 37.6  12.5 40.0  12.8 36.3  10.6 37.8  9.4 37.7  11.4 41.8  15.0 35.0  9.9
FABQ-PA (0-24)* 16.2  4.4 15.1  4.9 14.9  5.3 16.0  4.3 15.9  4.3 16.3  4.6 14.1  5.8 15.7  4.2
FABQ-W (0-42)* 18.1  9.9 19.4  10.3 19.9  10.5 18.1  9.9 18.9  11.0 17.6  9.4 20.7  10.3 18.6  10.4
Abbreviations: BMI, body mass index; CPR–, patients with a negative status on the clinical prediction rule; CPR+, patients with a positive status on the clini-
cal prediction rule; FABQ-PA, Fear-Avoidance Beliefs Questionnaire physical activity subscale; FABQ-W, Fear-Avoidance Beliefs Questionnaire work subscale;
LBP, low back pain; LSE, patients treated with lumbar stabilization exercises; MODI, modified Oswestry Disability Index; MT, patients treated with manual
therapy; NPRS, numeric pain rating scale.
*Values are mean  SD.
†
CPR– greater than CPR+ (P = .0006).
‡
Values are mean (95% confidence interval).
§
Numbers provided when data not available on all patients.
The proportion of patients who group and the modified version of the CPR nal disability (P = .27). No 2-way interac-
achieved a successful outcome, defined (mCPR) was found for final disability (P tion or main effects were noted for final
as a reduction of at least 50% in disability = .02). When the 2 pairwise comparisons pain level when using the mCPR (P>.09).
as measured by the MODI, did not differ were repeated using the mCPR, findings TABLE 5 presents the adjusted final disabil-
among the 4 subgroups (P = .31) (FIGURE 3). indicated that (1) among patients receiv- ity and pain scores of the different groups
When examining the interaction of ing LSE, those with a positive mCPR sta- and subgroups based on the mCPR, and
treatment group with each of the indi- tus (n = 20) experienced less disability by TABLE 6 presents the differences in final
vidual items comprising the CPR on fi- the end of treatment compared to those disability and pain among the groups and
nal disability, no significant effects were with a negative mCPR status (n = 28, P = subgroups based on the mCPR.
noted (aberrant movement, P = .07; prone .02); and (2) among patients with a posi- Finally, the proportion of patients
instability test, P = .16; age less than 40 tive mCPR status, those receiving LSE (n achieving a successful outcome did not
years, P = .72; SLR of 91° or greater, P = = 20) experienced less disability by the differ between the subgroups based on
.79). However, when combining the pres- end of treatment compared to those re- mCPR status (P = .30) (FIGURE 4).
ence of aberrant movement and a positive ceiving MT (n = 24, P = .005). Unlike the
prone instability test (n = 44), a signifi- original version of the CPR, the mCPR Per-Protocol Analysis
cant 2-way interaction between treatment did not demonstrate a main effect for fi- Similar to analysis by intention to treat,
44-01 Rabin.indd 11 12/17/2013 5:18:39 PM

[ research report ]
45
Baseline and Final Disability (MODI) and Pain
TABLE 2 40
(NPRS) Scores for All Groups and Subgroups* 35 ×
MODI Score, %
30
25
Group Baseline MODI (0-100) Final MODI (0-100) Baseline NPRS (0-10) Final NPRS (0-10) 20 ×
LSE (n = 48) 37.8  10.6 16.1  11.2 4.9  1.7 2.4  1.8 15
MT (n = 57) 37.6  12.5 20.2  16.0 5.3  1.7 3.1  2.5 10
5
CPR+ (n = 40) 40.0  12.8 16.6  17.5 4.9  1.7 2.6  2.4
0
CPR– (n = 65) 36.3  10.6 19.4  11.5 5.3  1.7 2.9  2.2 Baseline Final
LSE CPR+ (n = 18) 37.8  9.4 10.7  9.8 4.4  1.7 1.9  1.6
LSE CPR– (n = 30) 37.7  11.4 19.4  10.8 5.2  1.6 2.7  1.9 LSE CPR+ LSE CPR–
MT CPR+ (n = 22) 41.8  15.0 21.5  20.9 5.2  1.6 3.1  2.8
MT CPR– (n = 35) 35.0  9.9 19.4  12.3 5.4  1.8 3.1  2.4
MT CPR+ × MT CPR–
Abbreviations: CPR–, patients with a negative status on the clinical prediction rule; CPR+, patients FIGURE 2. Change in disability from baseline to the
with a positive status on the clinical prediction rule; LSE, patients treated with lumbar stabilization
end of treatment for the 4 subgroups. Abbreviations:
exercises; MODI, modified Oswestry Disability Index; MT, patients treated with manual therapy;
LSE CPR–, patients with a negative status on
NPRS, numeric pain rating scale.
*Values are mean  SD and are based on intention-to-treat analysis. the clinical prediction rule treated with lumbar
stabilization exercises; LSE CPR+, patients with a
positive status on the clinical prediction rule treated
with lumbar stabilization exercises; MODI, modified
Baseline Adjusted Final Disability Oswestry Disability Index; MT CPR–, patients with a
TABLE 3 (MODI) and Pain (NPRS) Among the negative status on the clinical prediction rule treated
with manual therapy; MT CPR+, patients with a
Different Groups and Subgroups*
positive status on the clinical prediction rule treated
with manual therapy.
Group MODI (0-100) NPRS (0-10)
LSE (n = 48) 15.0 (11.4, 18.6) 2.5 (1.9, 3.1) The 2-way interaction between treat-
MT (n = 57) 20.0 (16.7, 23.3) 3.0 (2.4, 3.5) ment group and the mCPR on final dis-
CPR+ (n = 40) 14.9 (11.0, 18.8) 2.7 (2.1, 3.4) ability was retained in the per-protocol
CPR– (n = 65) 20.1 (17.1, 23.1) 2.8 (2.3, 3.3) analysis (P = .02). The preplanned pair
LSE CPR+ (n = 18) 10.7 (4.9, 16.4) 2.4 (1.4, 3.3) wise comparisons indicated that (1)
LSE CPR– (n = 30) 19.3 (14.9, 23.8) 2.6 (1.9, 3.4) among patients receiving LSE, those
MT CPR+ (n = 22) 19.1 (13.9, 24.4) 3.0 (2.2, 3.9) with a positive mCPR status experienced
MT CPR– (n = 35) 20.9 (16.7, 25.0) 2.9 (2.2, 3.6) less disability at the conclusion of the
Abbreviations: CPR–, patients with a negative status on the clinical prediction rule; CPR+, patients intervention compared to those with a
with a positive status on the clinical prediction rule; LSE, patients treated with lumbar stabilization negative mCPR status (P = .03); and (2)
exercises; MODI, modified Oswestry Disability Index; MT, patients treated with manual therapy;
among patients with a positive mCPR sta-
*Values are mean (95% confidence interval) and are provided based on intention-to-treat analysis. tus, those receiving LSE experienced less
disability at the conclusion of the inter-
vention compared to those receiving MT
there was no 2-way interaction between end of treatment compared to those with (P = .006). No 2-way interaction or main
CPR status and treatment on final disabil- a negative CPR status (P = .02); and (2) effect was noted for pain level when us-
ity (P = .14). In addition, a main effect was among patients with a positive CPR sta- ing the mCPR (P>.13). Finally, although a
retained for CPR status on final disability tus, those receiving LSE experienced less greater proportion of patients with a posi-
(P = .04), indicating that patients with a disability by the end of treatment com- tive mCPR receiving LSE achieved a suc-
positive CPR status experienced less dis- pared to those receiving MT (P = .03). cessful outcome compared to the other 3
ability by the end of treatment compared No 2-way interaction or main effect was subgroups, this difference was not signifi-
to patients with a negative CPR status, noted for pain (P>.21). Chi-square analy- cant (P = .17).
regardless of the treatment received. No sis indicated that the proportion of pa-
main effect was noted for treatment (P = tients achieving a successful outcome was DISCUSSION
.06). The preplanned pairwise compari- greater among patients with a positive
T
sons indicated that (1) among all patients CPR status compared to patients with he previously suggested CPR
receiving LSE, those with a positive CPR a negative CPR status, regardless of the for predicting a successful outcome
status experienced less disability by the treatment received (P = .04). following LSE33 could not be vali-
44-01 Rabin.indd 12 12/17/2013 5:18:41 PM

90
Baseline Adjusted Mean Differences in Final 80
TABLE 4 Disability (MODI) and Pain (NPRS) Between
Success Rate, %
70
60
the Different Groups and Subgroups 50
40
30
20
Comparison MODI (0-100)* P Value NPRS (0-10)* P Value 10
LSE versus MT† 5.0 (0.1, 9.9) .05 0.5 (–0.3, 1.3) .26 0
LSE CPR+ LSE CPR– MT CPR+ MT CPR–
CPR+ versus CPR–‡ 5.2 (0.2, 10.2) .04 0.1 (–0.7, 0.9) .88
LSE CPR+ versus LSE CPR–§ 8.7 (1.4, 15.9) .02 0.3 (–0.9, 1.5) .67
FIGURE 3. Rate of success (%) among the 4
LSE CPR+ versus MT CPR+§ 8.5 (0.7, 16.3) .03 0.7 (–0.6, 1.9) .31 subgroups based on the original clinical prediction
Abbreviations: CPR–, patients with a negative status on the clinical prediction rule; CPR+, patients rule and a cutoff threshold of 50% decrease in
with a positive status on the clinical prediction rule; LSE, patients treated with lumbar stabilization baseline modified Oswestry Disability Index score.
exercises; MODI, modified Oswestry Disability Index; MT, patients treated with manual therapy; Abbreviations: LSE CPR–, patients with a negative
status on the clinical prediction rule treated with
*Values are mean difference (95% confidence interval).

lumbar stabilization exercises; LSE CPR+, patients
†
Positive values indicate an advantage to LSE.
‡
Positive values indicate an advantage to CPR+. with a positive status on the clinical prediction rule
§
Positive values indicate an advantage to LSE CPR+. treated with lumbar stabilization exercises; MT
CPR–, patients with a negative status on the clinical
prediction rule treated with manual therapy; MT
CPR+, patients with a positive status on the clinical
dated in our investigation. Nevertheless, patients would have been required to prediction rule treated with manual therapy.
we believe the CPR may hold promise in achieve 80% power for detecting an in-
identifying patients most likely to experi- teraction between treatment group and tween the treatment groups or subgroups.
ence success following LSE. Despite the CPR status, a sample size that was un- As for the application of the CPR it-
absence of a CPR-by-treatment interac- realistic under the circumstances of the self, the sample of the current study in-
tion, the 2 pairwise comparisons most present study. We therefore believe that, cluded a higher proportion of patients
relevant for validating the CPR indicated although our results cannot validate the with a positive CPR status compared to
that, by the end of treatment, patients CPR, they do not invalidate it but, in fact, the derivation study (38% versus 28%). 33
with a positive CPR status who received seem to imply its potential. It is not un- A likely reason for this difference is the
LSE (a matched intervention) experi- reasonable to assume that the CPR in its younger age of our sample (37 versus 42
enced less disability compared to those current form may still be able to indicate years). Another possible reason is the
with a negative CPR status receiving which patients would most likely succeed higher prevalence of a positive prone
LSE or to patients with a positive CPR with LSE. instability test in our study (71% versus
status receiving MT (an unmatched in- Among other potential reasons for 52% in the derivation study33). Because
tervention). Furthermore, effect sizes for the inability to validate a CPR are dif- we used the same testing technique and
both of these comparisons were very close ferences in sample characteristics, in the rating criteria as outlined by Hicks et al,33
to the MCID of the MODI (10 points), application of the CPR itself, in the ad- we cannot explain the difference in prev-
and the lower bounds of the 95% confi- ministration of the intervention, and in alence rates of a positive prone instability
dence intervals were above zero (TABLE 4). the definition of the outcome between the test. In any event, we do not believe that
The extra noise created by the multiple derivation and validation studies. With the higher rate of a positive CPR status in
computations of the ANCOVA might regard to sample characteristics, the in- our study was likely to hinder the ability
have prevented a significant CPR-by- clusion/exclusion criteria in the current to validate the CPR.
treatment interaction effect, despite the study were fairly similar to those of the The LSE program used in the current
consistent advantage for patients with a derivation study,33 which resulted in rela- study was very similar to that used in the
positive CPR treated with LSE. tively similar samples. However, patients derivation study. In addition, the criteria
It seems, therefore, that the inability in the current study demonstrated a high- for dichotomizing the outcomes as suc-
to validate the CPR in this study is most er level of disability at baseline (MODI cess or failure were identical to those
likely related to its level of power. Our score, 37% versus 29% in the derivation used in the derivation study.33 Therefore,
a priori sample-size calculation was de- study33) and a somewhat longer duration we do not believe these factors would
signed to detect a 12-point difference in of symptoms (68 versus 40 days). The likely explain the inability to validate the
the MODI, with α = .05 and a power of longer duration of LBP in the current CPR, either.
70%. Therefore, it could be argued that sample could have had a negative effect Finally, the inability to validate the
our study was somewhat underpowered. on the overall prognosis32,40,72; however, CPR may be related to the comparison
However, based on our findings, 314 this effect was not expected to differ be- intervention used in the current study.
44-01 Rabin.indd 13 12/17/2013 5:18:42 PM

[ research report ]
90
Baseline Adjusted Final Disability (MODI) 80
TABLE 5 and Pain (NPRS) Among the Different Groups
Success Rate, %
70
60
and Subgroups Based on the mCPR* 50
40
30
20
Group MODI (0-100) NPRS (0-10) 10
LSE (n = 48) 15.4 (11.8, 18.9) 2.5 (1.9, 3.0) 0
LSE mCPR+ LSE mCPR– MT mCPR+ MT mCPR–
MT (n = 57) 20.4 (17.2, 23.7) 3.0 (2.5, 3.5)
mCPR+ (n = 44) 16.5 (12.8, 20.3) 2.7 (2.1, 3.3)
FIGURE 4. Rate of success (%) among the 4
mCPR– (n = 61) 19.3 (16.1, 22.4) 2.8 (2.3, 3.3) subgroups based on the mCPR and a cutoff
LSE mCPR+ (n = 20) 11.2 (5.7, 16.6) 2.0 (1.1, 2.9) threshold of 50% decrease in baseline modified
LSE mCPR– (n = 28) 19.6 (15.0, 24.2) 2.9 (2.1, 3.6) Oswestry Disability Index score. Abbreviations:
MT mCPR+ (n = 24) 21.9 (16.9, 26.9) 3.3 (2.5, 4.1) LSE mCPR–, patients with a negative status on the
modified clinical prediction rule treated with lumbar
MT mCPR– (n = 33) 19.0 (14.7, 23.2) 2.8 (2.1, 3.4)

stabilization exercises; LSE mCPR+, patients with
Abbreviations: LSE, patients treated with lumbar stabilization exercises; mCPR–, patients with a a positive status on the modified clinical prediction
negative status on the modified clinical prediction rule; mCPR+, patients with a positive status on the
rule treated with lumbar stabilization exercises;
modified clinical prediction rule; MODI, modified Oswestry Disability Index; MT, patients treated
mCPR, modified clinical prediction rule; MT mCPR–,
with manual therapy; NPRS, numeric pain rating scale.
*Values are mean (95% confidence interval) and are provided based on intention-to-treat analysis. patients with a negative status on the modified
clinical prediction rule treated with manual therapy;
MT mCPR+, patients with a positive status on the
modified clinical prediction rule treated with manual

Baseline Adjusted Mean Differences therapy.
in Final Disability (MODI) and Pain
TABLE 6
(NPRS) Between the Different Groups disability) did not exceed the minimal
and Subgroups Based on the mCPR clinically important threshold.41 Further-
more, another study indicated that none
Comparison MODI (0-100)* P Value NPRS (0-10)* P Value of the variables comprising the stabiliza-
LSE versus MT† 5.0 (0.2, 9.9) .04 0.5 (–0.2, 1.3) .18 tion CPR was associated with increased
mCPR+ versus mCPR–‡ 2.7 (–2.2, 7.7) .27 0.2 (–0.6, 1.0) .67 activation of the lumbar multifidus fol-
LSE mCPR+ versus LSE mCPR–§ 8.4 (1.3, 15.5) .02 0.8 (–0.3, 2.0) .16 lowing spinal manipulation.43 Finally,
LSE mCPR+ versus MT mCPR+§ 10.7 (3.4, 18.1) .005 1.2 (0.0, 2.4) .05 any changes in activation of the lumbar
Abbreviations: LSE, patients treated with lumbar stabilization exercises; mCPR–, patients with a multifidus that were observed immedi-
negative status on the modified clinical prediction rule; mCPR+, patients with a positive status on the ately after manipulation did not seem to
modified clinical prediction rule; MODI, modified Oswestry Disability Index; MT, patients treated
be consistently sustained 3 to 4 days after
with manual therapy; NPRS, numeric pain rating scale.
*Values are mean difference (95% confidence interval) and are provided based on intention-to-treat the application of the technique.42 There-
analysis. fore, we do not believe the manipulation
†
Positive values indicate an advantage to LSE.
techniques in our study were likely to
‡
Positive values indicate an advantage to mCPR+.
§
Positive values indicate an advantage to LSE (mCPR+). produce long-lasting or clinically signifi-
cant changes in recruitment of the spinal
musculature of our patients.
Manual therapy seemed to be a suitable transversus abdominis and lumbar mul- During the process of CPR validation,
comparison intervention because it is fre- tifidi.42,61 It is possible, therefore, that the it is not unusual to attempt to modify
quently used in the management of LBP, manipulation techniques included in the an original version of a CPR by adding,
it is advocated by several clinical practice MT intervention contributed to facilita- omitting, or combining several of its
guidelines,1,19,76 and it has previously been tion of the deep spinal musculature and, items.67,68,81 Our findings indicate that a
shown to have a varied level of success consequently, exerted an effect similar to modified version of the CPR (mCPR),
when compared to LSE in heterogeneous that attributed to LSE. Be that as it may, containing only 2 of the original 4 items,
samples of patients with LBP.11,24,50,62 when spinal manipulation has been pre- yielded a better predictive validity. The
Despite this rationale, recent evidence viously performed specifically on patients mCPR did result in a significant inter-
suggests that spinal manipulation may who meet the stabilization CPR,41 no ef- action effect with treatment, and the 2
result in remediation of some muscle im- fects were observed on the activation of corresponding pairwise comparisons
pairments that are the focus of LSE pro- the transversus abdominis or internal indicated a better outcome for patients
grams, such as increased activation of the oblique, and the clinical effects (pain and with a positive mCPR status treated with
44-01 Rabin.indd 14 12/17/2013 5:18:43 PM

LSE compared to patients treated with original version seemed to be consistently be as valuable as MT. The manual contact
unmatched interventions. Effect sizes associated with a better outcome, regard- included in the MT intervention could
for these comparisons were either above less of the treatment received. Likewise, have created an attention effect in favor
or slightly below the MCID of the MODI it seems less intuitive why a greater SLR of this intervention, which, in turn, might
(TABLE 6). These findings seem to suggest range of motion would predict a better have contributed to better compliance.
that the mCPR may be a more accurate outcome specifically following LSE. Because this was suspected, the treating
predictor of success following LSE. Finally, our entire sample included 40 clinicians were encouraged to provide
It is acknowledged that because the patients with a positive CPR status ac- patients receiving LSE with continuous
mCPR was derived retrospectively, its cording to the original (4-item) version verbal as well as manual cuing for main-
effect on final disability could have oc- and 44 patients with a positive mCPR taining a neutral lumbar posture and an
curred by chance alone. We believe, how- status. It could therefore be argued that ADIM. It seems, however, that this ap-
ever, that several factors point against the slightly larger number of patients proach still failed to produce a similar
this possibility. First, the mCPR is still with a positive mCPR might have simply level of compliance among the 2 groups.
composed of items that have been previ- increased the power to detect an inter- An intention-to-treat analysis was used
ously linked to success following LSE in action with treatment group. However, in an attempt to minimize the effect of
the derivation study.33 Second, no other as only 31 patients had a positive status the dropout rate on our findings.
combination of items from the original according to both versions of the CPR, it Longer-term outcomes should be as-
CPR produced similar findings. Third, seems that the better predictive power of sessed to determine whether the CPR
we believe this 2-item version may even the mCPR may not simply be a matter of in its original or modified version has
possess a clearer biomechanical plau- sample size but may be inherent in pa- any long-term effects on patients in the
sibility compared to the original CPR. tients presenting with the 2 specific items various subgroups. In addition, the ex-
The mCPR status is considered positive comprising the mCPR. ternal validity of our findings needs to
when both aberrant lumbar movement In summary, we believe that, in addi- be considered, as only 105 patients were
and a positive prone instability test are tion to its stronger statistical association recruited after screening 531 potential
present. Teyhen et al70 demonstrated with success specifically following LSE, participants. Most participants were ex-
that, compared to healthy individuals, the mCPR carries a stronger biomechani- cluded for not meeting the minimal level
patients with LBP, aberrant movements, cal plausibility as a predictor of success of disability required for inclusion (FIGURE
and a positive prone instability test dem- following this intervention. Nevertheless, 1). Therefore, findings are limited to pa-
onstrate decreased control of lumbar due to its retrospective nature, an addi- tients with LBP with at least a moderate
segmental mobility during midrange tional investigation is recommended to level of disability.
lumbar motion. This difference may rep- prospectively establish the predictive va-
resent an altered motor control strategy, lidity of the mCPR. CONCLUSION
which suggests that an LSE program may
T
be most beneficial under those circum- Study Limitations he previously suggested CPR
stances. Furthermore, Hebert et al31 dem- In addition to the aforementioned issues for identifying patients most likely
onstrated that individuals with LBP and of power and the retrospective nature of to succeed following LSE could not
a positive prone instability test displayed some of the findings, the current study be validated in this study. However, be-
decreased automatic activation of their has several additional limitations. First, cause the subgroup comparisons most
lumbar multifidi compared to healthy the dropout rate was fairly high, in par- relevant for the validity of the CPR in-
controls. Given the remediating effects ticular among the LSE group. Overall, dicated an advantage for patients with
of LSE on muscle activation patterns,73,74 24 patients (22.8%) did not complete a positive CPR treated by LSE, and be-
it seems reasonable that LSE would be the study. The dropout rate was greater cause of a relatively low level of power,
most beneficial for patients presenting among patients receiving LSE (33% our findings suggest that the current CPR
with such activation deficits. In contrast, versus 14%). We believe that the overall still has the potential to predict success
it seems much less clear why patients dropout rate of the current study may following LSE. Furthermore, a modified
under the age of 40 would preferentially partly reflect the dropout rate (31%) version of the original CPR that included
benefit from LSE as opposed to MT or among Israeli patients receiving outpa- only 2 of its items (aberrant movement
any other intervention. In fact, a younger tient physical therapy for common mus- and positive prone instability test) was
age has been previously associated with culoskeletal conditions.23 The greater able to predict a successful outcome spe-
a generally favorable prognosis following dropout rate among the LSE group also cifically following LSE and may serve as
an episode of LBP.5,13,29,52,72 This finding suggests that patients receiving this in- a valid alternative. Future study is rec-
may help to explain why the CPR in its tervention may not have perceived it to ommended to prospectively validate the
44-01 Rabin.indd 15 12/17/2013 5:18:44 PM

[ research report ]
mCPR as a predictor of success with LSE Y, Zory H. Modified Oswestry Low Back Pain 17. C
hoi BK, Verbeek JH, Tam WW, Jiang JY.
in individuals with LBP. Alternatively, to Disability Questionnaire: checking reliability and Exercises for prevention of recurrences of
validate the original version of the CPR, a validity of the questionnaire in Hebrew. Gerontol- low-back pain. Cochrane Database Syst
ogy (Israel). 2005;32:147-163. Rev. 2010:CD006555. http://dx.doi.
larger, replication study is recommended
4. Beattie P, Nelson R. Clinical prediction rules: org/10.1002/14651858.CD006555.pub2
in an attempt to overcome the insufficient what are they and what do they tell us? Aust J 18. Cholewicki J, VanVliet JJ, 4th. Relative contri-
power of the current study. The findings Physiother. 2006;52:157-163. bution of trunk muscles to the stability of the
of this study are further limited by a rela- 5. Bekkering GE, Hendriks HJ, van Tulder MW, et al. lumbar spine during isometric exertions. Clin
Prognostic factors for low back pain in patients Biomech (Bristol, Avon). 2002;17:99-105.
tively large dropout rate (22.8%) and lack
of a long-term follow-up. t
referred for physiotherapy: comparing outcomes 19. Chou R, Qaseem A, Snow V, et al. Diagnosis
and varying modeling techniques. Spine (Phila and treatment of low back pain: a joint clinical
Pa 1976). 2005;30:1881-1886. practice guideline from the American College of
KEY POINTS 6. Borkan JM, Koes B, Reis S, Cherkin DC. A Physicians and the American Pain Society. Ann
report from the Second International Forum Intern Med. 2007;147:478-491.
FINDINGS: Although not validated, the
for Primary Care Research on Low Back Pain. 20. Cleland JA, Fritz JM, Kulig K, et al. Comparison
previously suggested CPR for identifying Reexamining priorities. Spine (Phila Pa 1976). of the effectiveness of three manual physical
patients most likely to succeed follow- 1998;23:1992-1996. therapy techniques in a subgroup of patients
ing LSE shows promise. Furthermore, a 7. Bouter LM, van Tulder MW, Koes BW. Methodo- with low back pain who satisfy a clinical pre-
logic issues in low back pain research in primary diction rule: a randomized clinical trial. Spine
modified version of the CPR containing
care. Spine (Phila Pa 1976). 1998;23:2014-2020. (Phila Pa 1976). 2009;34:2720-2729. http://
only 2 of its original 4 items (presence of 8. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, dx.doi.org/10.1097/BRS.0b013e3181b48809
aberrant movement and a positive prone Delitto A, Erhard RE. Identifying subgroups of 21. Cleland JA, Mintken PE, Carpenter K, et al.
instability test) demonstrated a better patients with acute/subacute “nonspecific” low Examination of a clinical prediction rule to
back pain: results of a randomized clinical trial. identify patients with neck pain likely to benefit
predictive validity in identifying those
Spine (Phila Pa 1976). 2006;31:623-631. http:// from thoracic spine thrust manipulation and
most likely to succeed with LSE. dx.doi.org/10.1097/01.brs.0000202807.72292.a8 a general cervical range of motion exercise:
IMPLICATIONS: Patients with LBP present- 9. Bronfort G, Haas M, Evans R, Leininger B, Triano multi-center randomized clinical trial. Phys Ther.
ing with aberrant lumbar movement as J. Effectiveness of manual therapies: the UK 2010;90:1239-1250. http://dx.doi.org/10.2522/
evidence report. Chiropr Osteopat. 2010;18:3. ptj.20100123
well as a positive prone instability test
http://dx.doi.org/10.1186/1746-1340-18-3 22. Costa LO, Maher CG, Latimer J, et al. Motor
may benefit most from an LSE program. 10. Browder DA, Childs JD, Cleland JA, Fritz JM. Ef- control exercise for chronic low back pain: a
CAUTION: Findings are limited by a fectiveness of an extension-oriented treatment randomized placebo-controlled trial. Phys Ther.
relatively small sample size, a relatively approach in a subgroup of subjects with low 2009;89:1275-1286. http://dx.doi.org/10.2522/
back pain: a randomized clinical trial. Phys Ther. ptj.20090218
large dropout rate, and the lack of a
23. Deutscher D, Horn SD, Dickstein R, et al. As-
2007;87:1608-1618. http://dx.doi.org/10.2522/
long-term follow-up. ptj.20060297 sociations between treatment processes, patient
11. Cairns MC, Foster NE, Wright C. Randomized characteristics, and outcomes in outpatient
ACKNOWLEDGEMENTS: The authors thank Dr controlled trial of specific spinal stabilization physical therapy practice. Arch Phys Med
exercises and conventional physiotherapy Rehabil. 2009;90:1349-1363. http://dx.doi.
Gregory Hicks, Arnon Ravid, Ori Firsteter,
for recurrent low back pain. Spine (Phila Pa org/10.1016/j.apmr.2009.02.005
Shai Grinberg, Efrat Laor, Dikla Taif, Alon 1976). 2006;31:E670-E681. http://dx.doi. 24. Ferreira ML, Ferreira PH, Latimer J, et al.
Ben-Moshe, Mossa Hugirat, Meira Lugasi, org/10.1097/01.brs.0000232787.71938.5d Comparison of general exercise, motor control
Lena Oifman, Liron Laposhner, Beni Mazoz, 12. Cassidy JD, Carroll LJ, Côté P. The Saskatch- exercise and spinal manipulative therapy for
ewan Health and Back Pain Survey: the preva- chronic low back pain: a randomized trial. Pain.
Fadi Knuati, Lena Kin, Ruthy Bachar, Chen
lence of low back pain and related disability in 2007;131:31-37. http://dx.doi.org/10.1016/j.
Tel-Avivi, Irit Fridman, Yana Avner, Naomi Saskatchewan adults. Spine (Phila Pa 1976). pain.2006.12.008
Sivan, Rafi Cohen, and Yigal Levran for their 1998;23:1860-1866; discussion 1867. 25. Ferreira PH, Ferreira ML, Hodges PW. Changes
contribution and support of this work. 13. Cassidy JD, Côté P, Carroll LJ, Kristman V. Inci- in recruitment of the abdominal muscles in
dence and course of low back pain episodes in people with low back pain: ultrasound measure-
the general population. Spine (Phila Pa 1976). ment of muscle activity. Spine (Phila Pa 1976).
2005;30:2817-2823. 2004;29:2560-2566.
REFERENCES 14. Childs JD, Cleland JA. Development and applica- 26. Fritz JM. Clinical prediction rules in physi-
tion of clinical prediction rules to improve deci- cal therapy: coming of age? J Orthop Sports
1. A iraksinen O, Brox JI, Cedraschi C, et al. Chapter sion making in physical therapist practice. Phys Phys Ther. 2009;39:159-161. http://dx.doi.
4. European guidelines for the management of Ther. 2006;86:122-131. org/10.2519/jospt.2009.0110
chronic nonspecific low back pain. Eur Spine 15. Childs JD, Fritz JM, Flynn TW, et al. A clinical 27. Fritz JM, Delitto A, Erhard RE. Comparison
J. 2006;15 suppl 2:S192-S300. http://dx.doi. prediction rule to identify patients with low of classification-based physical therapy with
org/10.1007/s00586-006-1072-1 back pain most likely to benefit from spinal ma- therapy based on clinical practice guidelines
2. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, nipulation: a validation study. Ann Intern Med. for patients with acute low back pain: a ran-
Shekelle PG. Spinal manipulative therapy for 2004;141:920-928. domized clinical trial. Spine (Phila Pa 1976).
low back pain. A meta-analysis of effectiveness 16. Childs JD, Piva SR, Fritz JM. Responsiveness 2003;28:1363-1371; discussion 1372. http://
relative to other therapies. Ann Intern Med. of the numeric pain rating scale in patients dx.doi.org/10.1097/01.BRS.0000067115.61673.
2003;138:871-881. with low back pain. Spine (Phila Pa 1976). FF
3. Baron G, Alter R, Halevi-Heitner H, Yasin S, Ofer 2005;30:1331-1334. 28. Fritz JM, Irrgang JJ. A comparison of a modified
44-01 Rabin.indd 16 12/17/2013 5:18:45 PM

Oswestry Low Back Pain Disability Question- a clinical prediction rule for lumbar stabilization. for improving exercise regimens. Phys Ther.
naire and theREFERENCES
Quebec Back Pain Disability Scale. J Orthop Sports Phys Ther. 2011;41:666-674. 1998;78:754-765.
Phys Ther. 2001;81:776-788. http://dx.doi.org/10.2519/jospt.2011.3685 55. McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Sti-
29. Grotle M, Brox JI, Veierød MB, Glomsrød B, Lønn 42. Koppenhaver SL, Fritz JM, Hebert JJ, et al. As- ell IG, Richardson WS. Users’ guides to the med-
JH, Vøllestad NK. Clinical course and prognostic sociation between changes in abdominal and ical literature: XXII: how to use articles about
factors in acute low back pain: patients consult- lumbar multifidus muscle thickness and clinical clinical decision rules. Evidence-Based Medicine
ing primary care for the first time. Spine (Phila improvement after spinal manipulation. J Or- Working Group. JAMA. 2000;284:79-84.
Pa 1976). 2005;30:976-982. thop Sports Phys Ther. 2011;41:389-399. http:// 56. Mikhail C, Korner-Bitensky N, Rossignol M,
30. Hancock M, Herbert RD, Maher CG. A guide to dx.doi.org/10.2519/jospt.2011.3632 Dumas JP. Physical therapists’ use of inter-
interpretation of studies investigating subgroups 43. Koppenhaver SL, Fritz JM, Hebert JJ, et al. As- ventions with high evidence of effectiveness
of responders to physical therapy interventions. sociation between history and physical examina- in the management of a hypothetical typical
Phys Ther. 2009;89:698-704. http://dx.doi. tion factors and change in lumbar multifidus patient with acute low back pain. Phys Ther.
org/10.2522/ptj.20080351 muscle thickness after spinal manipulation in 2005;85:1151-1167.
31. Hebert JJ, Koppenhaver SL, Magel JS, Fritz JM. patients with low back pain. J Electromyogr 57. Ostelo RW, Deyo RA, Stratford P, et al. Interpret-
The relationship of transversus abdominis and Kinesiol. 2012;22:724-731. http://dx.doi. ing change scores for pain and functional status
lumbar multifidus activation and prognostic org/10.1016/j.jelekin.2012.03.004 in low back pain: towards international consen-
factors for clinical success with a stabilization 44. Koumantakis GA, Watson PJ, Oldham JA. Trunk sus regarding minimal important change. Spine
exercise program: a cross-sectional study. Arch muscle stabilization training plus general exer- (Phila Pa 1976). 2008;33:90-94. http://dx.doi.
Phys Med Rehabil. 2010;91:78-85. http://dx.doi. cise versus general exercise only: randomized org/10.1097/BRS.0b013e31815e3a10
org/10.1016/j.apmr.2009.08.146 controlled trial of patients with recurrent low 58. O’Sullivan PB. Lumbar segmental ‘instability’:
32. Henschke N, Maher CG, Refshauge KM, et al. back pain. Phys Ther. 2005;85:209-225. clinical presentation and specific stabilizing
Prognosis in patients with recent onset low back 45. Leboeuf-Yde C, Lauritsen JM, Lauritzen T. Why exercise management. Man Ther. 2000;5:2-12.
pain in Australian primary care: inception cohort has the search for causes of low back pain http://dx.doi.org/10.1054/math.1999.0213
study. BMJ. 2008;337:a171. largely been nonconclusive? Spine (Phila Pa 59. Powers CM, Beneck GJ, Kulig K, Landel RF,
33. Hicks GE, Fritz JM, Delitto A, McGill SM. Prelimi- 1976). 1997;22:877-881. Fredericson M. Effects of a single session of
nary development of a clinical prediction rule for 46. Li LC, Bombardier C. Physical therapy man- posterior-to-anterior spinal mobilization and
determining which patients with low back pain agement of low back pain: an exploratory press-up exercise on pain response and lumbar
will respond to a stabilization exercise program. survey of therapist approaches. Phys Ther. spine extension in people with nonspecific low
Arch Phys Med Rehabil. 2005;86:1753-1762. 2001;81:1018-1028. back pain. Phys Ther. 2008;88:485-493. http://
http://dx.doi.org/10.1016/j.apmr.2005.03.033 47. Long A, Donelson R, Fung T. Does it matter dx.doi.org/10.2522/ptj.20070069
34. Hides J, Gilmore C, Stanton W, Bohlscheid E. which exercise? A randomized control trial of ex- 60. Rabin A, Shashua A, Pizem K, Dar G. The inter-
Multifidus size and symmetry among chronic ercise for low back pain. Spine (Phila Pa 1976). rater reliability of physical examination tests
LBP and healthy asymptomatic subjects. 2004;29:2593-2602. that may predict the outcome or suggest the
Man Ther. 2008;13:43-49. http://dx.doi. 48. MacDonald D, Moseley GL, Hodges PW. Why need for lumbar stabilization exercises. J Orthop
org/10.1016/j.math.2006.07.017 Sports Phys Ther. 2013;43:83-90. http://dx.doi.
do some patients keep hurting their back?

35. Hides JA, Jull GA, Richardson CA. Long-term Evidence of ongoing back muscle dysfunction org/10.2519/jospt.2013.4310
effects of specific stabilizing exercises for first- during remission from recurrent back pain. Pain. 61. Raney NH, Teyhen DS, Childs JD. Observed
episode low back pain. Spine (Phila Pa 1976). 2009;142:183-188. http://dx.doi.org/10.1016/j. changes in lateral abdominal muscle thickness
2001;26:E243-E248. pain.2008.12.002 after spinal manipulation: a case series using re-
36. Hides JA, Stanton WR, McMahon S, Sims K, 49. Macedo LG, Latimer J, Maher CG, et al. Effect of habilitative ultrasound imaging. J Orthop Sports
Richardson CA. Effect of stabilization training on motor control exercises versus graded activity Phys Ther. 2007;37:472-479. http://dx.doi.
multifidus muscle cross-sectional area among in patients with chronic nonspecific low back org/10.2519/jospt.2007.2523
young elite cricketers with low back pain. J Or- pain: a randomized controlled trial. Phys Ther. 62. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson
thop Sports Phys Ther. 2008;38:101-108. http:// 2012;92:363-377. http://dx.doi.org/10.2522/ I. Stabilizing training compared with manual
dx.doi.org/10.2519/jospt.2008.2658 ptj.20110290 treatment in sub-acute and chronic low-back
37. Hodges PW, Richardson CA. Altered trunk 50. Macedo LG, Maher CG, Latimer J, McAuley JH. pain. Man Ther. 2003;8:233-241. http://dx.doi.
muscle recruitment in people with low back pain Motor control exercise for persistent, nonspe- org/10.1016/S1356-689X(03)00053-5
with upper limb movement at different speeds. cific low back pain: a systematic review. Phys 63. Richardson C, Hodges P, Hides J. Therapeutic
Arch Phys Med Rehabil. 1999;80:1005-1012. Ther. 2009;89:9-25. http://dx.doi.org/10.2522/ Exercise for Lumbopelvic Stabilization: A Motor
38. Jacob T, Baras M, Zeev A, Epstein L. Low back ptj.20080103 Control Approach for the Treatment and Preven-
pain: reliability of a set of pain measurement 51. Machado LA, de Souza M, Ferreira PH, Fer- tion of Low Back Pain. 2nd ed. Edinburgh, UK:
tools. Arch Phys Med Rehabil. 2001;82:735-742. reira ML. The McKenzie method for low back Churchill Livingstone; 2004.
http://dx.doi.org/10.1053/apmr.2001.22623 pain: a systematic review of the literature 64. Richardson CA, Jull GA. Muscle control–pain
39. Jette DU, Jette AM. Physical therapy and with a meta-analysis approach. Spine (Phila control. What exercises would you pre-
health outcomes in patients with spinal impair- Pa 1976). 2006;31:E254-E262. http://dx.doi. scribe? Man Ther. 1995;1:2-10. http://dx.doi.
ments. Phys Ther. 1996;76:930-941; discussion org/10.1097/01.brs.0000214884.18502.93 org/10.1054/math.1995.0243
942-945. 52. Mallen CD, Peat G, Thomas E, Dunn KM, Croft 65. Shaughnessy M, Caulfield B. A pilot study to
40. Jones GT, Johnson RE, Wiles NJ, et al. Predicting PR. Prognostic factors for musculoskeletal pain investigate the effect of lumbar stabilisation
persistent disabling low back pain in general in primary care: a systematic review. Br J Gen exercise training on functional ability and quality
practice: a prospective cohort study. Br J Gen Pract. 2007;57:655-661. of life in patients with chronic low back pain. Int
Pract. 2006;56:334-341. 53. McGill S. Low Back Disorders: Evidence-based J Rehabil Res. 2004;27:297-301.
@ MORE INFORMATION
41. Konitzer LN, Gill NW, Koppenhaver SL. Investiga- Prevention and Rehabilitation. Champaign, IL: 66. Stanton TR, Hancock MJ, Maher CG, Koes BW.
tion of abdominal muscle thickness changes Human Kinetics; 2002. Critical appraisal of clinical prediction rules that
after spinal manipulation in patients who meet 54. McGill SM. Low back exercises: evidence aim to optimize WWW.JOSPT.ORG
treatment selection for muscu-
44-01 Rabin.indd 17 12/17/2013 5:18:46 PM

[ research report ]
loskeletal conditions. Phys Ther. 2010;90:843- develops chronic low back pain in primary care: 1976). 2000;25:2784-2796.
854. http://dx.doi.org/10.2522/ptj.20090233 a prospective study. BMJ. 1999;318:1662-1667. 78. V on Korff M, Saunders K. The course of back
67. Stiell IG, Greenberg GH, McKnight RD, et al. 73. Tsao H, Druitt TR, Schollum TM, Hodges PW. Mo- pain in primary care. Spine (Phila Pa 1976).
Decision rules for the use of radiography in tor training of the lumbar paraspinal muscles in- 1996;21:2833-2837; discussion 2838-2839.
acute ankle injuries. Refinement and prospective duces immediate changes in motor coordination 79. Waddell G, Newton M, Henderson I, Somerville
validation. JAMA. 1993;269:1127-1132. in patients with recurrent low back pain. J Pain. D, Main CJ. A Fear-Avoidance Beliefs Question-
68. Stiell IG, Greenberg GH, Wells GA, et al. Pro- 2010;11:1120-1128. http://dx.doi.org/10.1016/j. naire (FABQ) and the role of fear-avoidance
spective validation of a decision rule for the use jpain.2010.02.004 beliefs in chronic low back pain and disability.
of radiography in acute knee injuries. JAMA. 74. Tsao H, Hodges PW. Immediate changes in Pain. 1993;52:157-168.
1996;275:611-615. feedforward postural adjustments follow- 80. Wallwork TL, Stanton WR, Freke M, Hides JA.
69. Teyhen DS, Bluemle LN, Dolbeer JA, et al. ing voluntary motor training. Exp Brain Res. The effect of chronic low back pain on size and
Changes in lateral abdominal muscle thickness 2007;181:537-546. http://dx.doi.org/10.1007/ contraction of the lumbar multifidus muscle.
during the abdominal drawing-in maneuver in s00221-007-0950-z Man Ther. 2009;14:496-500. http://dx.doi.
those with lumbopelvic pain. J Orthop Sports 75. Unsgaard-Tøndel M, Fladmark AM, Salvesen org/10.1016/j.math.2008.09.006
Phys Ther. 2009;39:791-798. http://dx.doi. O, Vasseljen O. Motor control exercises, sling 81. Wells PS, Hirsh J, Anderson DR, et al. A simple
org/10.2519/jospt.2009.3128 exercises, and general exercises for patients clinical model for the diagnosis of deep-vein
70. Teyhen DS, Flynn TW, Childs JD, Abraham LD. with chronic low back pain: a randomized thrombosis combined with impedance
Arthrokinematics in a subgroup of patients likely controlled trial with 1-year follow-up. Phys Ther. plethysmography: potential for an improve-
to benefit from a lumbar stabilization exercise 2010;90:1426-1440. http://dx.doi.org/10.2522/ ment in the diagnostic process. J Intern Med.
program. Phys Ther. 2007;87:313-325. http:// ptj.20090421 1998;243:15-23.
dx.doi.org/10.2522/ptj.20060253 76. van Tulder M, Becker A, Bekkering T, et al. Chap- 82. Wilke HJ, Wolf S, Claes LE, Arand M, Wiesend A.
71. Teyhen DS, Miltenberger CE, Deiters HM, ter 3. European guidelines for the management Stability increase of the lumbar spine with dif-
et al. The use of ultrasound imaging of the of acute nonspecific low back pain in primary ferent muscle groups. A biomechanical in vitro
abdominal drawing-in maneuver in subjects care. Eur Spine J. 2006;15 suppl 2:S169-S191. study. Spine (Phila Pa 1976). 1995;20:192-198.
with low back pain. J Orthop Sports Phys Ther. http://dx.doi.org/10.1007/s00586-006-1071-2
2005;35:346-355. http://dx.doi.org/10.2519/ 77. van Tulder M, Malmivaara A, Esmail R, Koes B.
@ MORE INFORMATION
jospt.2005.35.6.346 Exercise therapy for low back pain: a systematic
72. Thomas E, Silman AJ, Croft PR, Papageorgiou review within the framework of the Cochrane
AC, Jayson MI, Macfarlane GJ. Predicting who Collaboration back review group. Spine (Phila Pa WWW.JOSPT.ORG
PUBLISH Your Manuscript in a Journal With International Reach

JOSPT offers authors of accepted papers an international audience. The
Journal is currently distributed to the members of APTA’s Orthopaedic
and Sports Physical Therapy Sections and 31 orthopaedics, manual therapy,
and sports groups in 25 countries who provide online access either as a
member benefit or at a discount. As a result, the Journal is now distrib-
uted monthly to more than 28 500 individuals around the world who special-
ize in musculoskeletal and sports-related rehabilitation, health, and
wellness. In addition, JOSPT reaches students and faculty, physical
therapists and physicians at more than 1,250 institutions in 57 countries.
Please review our Information for and Instructions to Authors at
www.jospt.org in the Info Center for Authors and submit your manuscript for
peer review at http://mc.manuscriptcentral.com/jospt.
44-01 Rabin.indd 18 12/17/2013 5:18:46 PM

APPENDIX A
LUMBAR STABILIZATION EXERCISE PROGRAM

Exercise or Activity/Criteria
for Progression Description
Stage 1
ADIM in quadruped; 30 repetitions Following exhalation, the patient tightens the ab-
dominal muscles and draws the belly button up
toward the spine, while maintaining a neutral
lumbar spine position. The contraction is held for
8 seconds.
ADIM in standing; 30 repetitions Following exhalation, the patient tightens the ab-
dominal muscles and draws the belly button in

8 seconds.
ADIM in supine; 30 repetitions Following exhalation, the patient tightens the ab-
dominal muscles and draws the belly button in
8 seconds.
journal of orthopaedic & sports physical therapy | volume 44 | number 1 | january 2014 | B1
44-01 Rabin.indd 1 12/18/2013 6:15:49 PM

[ research report ]
APPENDIX A
Stage 2 During stage 2, the patient progresses from one
exercise to the next in 4 different positions: supine
lying, sidelying, quadruped, and standing.
Supine ADIM with heel slide; Starting in a hook-lying position, feet flat on the sup-
20 repetitions with each leg porting surface, the patient performs an ADIM and
slides 1 heel on the supporting surface until the
knee is straight. The position is held for 4 seconds,
and the leg is returned to the starting position. The
movement is repeated, alternating between legs.
Supine ADIM with leg lift; The patient performs an ADIM and raises 1 foot 10
20 repetitions with each leg cm off the supporting surface. The position is held
for 4 seconds, and the leg is returned to the start-
ing position.
Supine ADIM with bridging (2 legs); The patient performs an ADIM and raises the but-
30 repetitions tocks off the supporting surface. The position is

held for 8 seconds, and the patient returns to the
starting position.
Supine ADIM with single-leg bridge; Starting in a hook-lying position, the patient per-
30 repetitions with each leg forms an ADIM and straightens 1 knee. The patient
then raises the buttocks off the table using the op-
posite leg. The position is held for 8 seconds, and
the patient returns to the starting position.
B2 | january 2014 | volume 44 | number 1 | journal of orthopaedic & sports physical therapy
44-01 Rabin.indd 2 12/18/2013 6:15:49 PM

APPENDIX A
Stage 2 (continued)
Supine ADIM with curl-up: 1 (elbows The patient assumes a supine position, with one leg
on the table); 30 repetitions straight and the other leg bent at the knee and hip
to maintain a neutral pelvic position (no need to
alternate legs). Patient places both hands under
the lumbar spine (this also helps to maintain a
neutral pelvic and lumbar position). Patient per-
forms an ADIM and raises the head and shoulders
off the table. The position is held for 8 seconds,
and the patient returns to the starting position.
Supine ADIM with curl-up: 2 (elbows The patient assumes a supine position, with one leg
off the table); 30 repetitions straight and the other leg bent at the knee and hip
to maintain a neutral pelvic position (no need to
alternate legs). Patient places both hands under

the lumbar spine (this also helps to maintain a
neutral pelvic and lumbar position). Patient per-
forms an ADIM and raises the head and shoulders
off the table. The position is held for 8 seconds,
and the patient returns to the starting position.
Supine ADIM with curl-up: 3 (hands The patient assumes a supine position, with one leg
over forehead); 30 repetitions straight and the other leg bent at the knee and
hip to maintain a neutral pelvic position (no need
to alternate legs). Patient places both hands over

his/her forehead, performs an ADIM, and raises
the head and shoulders off the table. The position
is held for 8 seconds, and the patient returns to
the starting position.
Horizontal side support, knees bent; The patient performs an ADIM and raises the hips
30 repetitions on each side and trunk off the supporting surface. The position
is held for 8 seconds, and the patient returns to
44-01 Rabin.indd 3 12/18/2013 6:15:50 PM

[ research report ]
APPENDIX A
Stage 2 (continued)
Horizontal side support, knees The patient performs an ADIM and raises the hips
straight; 30 repetitions on each side and trunk off the table. The position is held for
8 seconds, and the patient returns to the starting
position.
Horizontal side support, advanced 1; The patient performs an ADIM and raises the hips
30 repetitions on each side and trunk off the table. The patient then rotates
the trunk backward and forward (4 times in
each direction), and then returns to the starting

position.
Sidelying horizontal side support, The patient performs an ADIM and raises the hips
advanced 2; 30 repetitions and trunk off the table. The patient then rolls
over onto the opposite elbow while maintaining
a neutral spine. The patient then rolls back to the

starting position.
Quadruped with leg raise; The patient performs an ADIM and then straightens
30 repetitions with each leg 1 leg backward, while maintaining a neutral lumbar
spine position. The position is held for 8 seconds
before returning to the starting position.
44-01 Rabin.indd 4 12/18/2013 6:15:50 PM

APPENDIX A
Stage 2 (continued)
Quadruped with contralateral arm and The patient performs an ADIM and then straightens 1
leg raise; 30 repetitions with each leg backward, along with a contralateral arm raise,
arm and leg while maintaining a neutral lumbar position. The
position is held for 8 seconds before returning to
Quadruped, advanced; 30 repetitions The patient performs an ADIM and then straightens
with each arm and leg 1 leg back, along with a contralateral arm raise,
while maintaining a neutral lumbar position. The
position is held for 8 seconds. The patient then

lowers the arm and leg without replacing them
back on the supporting surface and then straight-
ens the arm and leg back to a horizontal position.
Standing rowing; 30 repetitions The patient performs an ADIM and then pulls a 1- to
with each arm 1.5-kg weight in a rowing motion until the weight is
at chest level. The position is held for 6 seconds,
and the patient then returns the weight to the

starting position.
44-01 Rabin.indd 5 12/18/2013 6:15:50 PM

[ research report ]
APPENDIX A
Stage 2 (continued)
Walking; patient progresses The patient alternates between performing an ADIM
to 10 minutes for 8 seconds and relaxing for 10 seconds, while
walking.
Stage 3 The patient continues with the exercises from stage

2 and begins to practice the following functional

activities.
Sit-to-stand transfer; 30 repetitions The patient sits on a standard chair and performs an
ADIM while keeping the spine in a neutral position.
The patient then rises to a standing position and
then sits back down, while maintaining the lumbar
spine in a neutral position.
Rolling from side to side; The patient is in a sidelying position. The patient
30 repetitions performs an ADIM and then rolls from one side to
the other, while maintaining a neutral position of
the lumbar spine. The patient then returns to the
starting position.
Squatting; 30 repetitions The patient leans against a wall and performs an
ADIM. The patient then slides down along the wall
until the knees are at a 45° angle, while maintain-
ing a neutral spine position. The position is held
for 5 seconds, and the patient returns to the start-
ing position.
Lifting; 30 repetitions The patient stands in front of a standard chair. The
patient performs an ADIM and then picks up a 2-
to 3-kg weight placed on the chair and lifts it to a
shelf at shoulder level. The weight is then returned
to the chair, and the patient returns to the starting
position. The patient maintains a neutral position
of the lumbar spine throughout the performance
of the activity.
44-01 Rabin.indd 6 12/18/2013 6:15:50 PM

APPENDIX A
Stage 3 (continued)
Vacuuming, swiping; patient The patient performs a vacuuming/swiping motion
progresses to 3 minutes of while performing an ADIM and maintaining a neu-
continuous activity tral position of the lumbar spine.
Abbreviation: ADIM, abdominal drawing-in maneuver.
APPENDIX B
MANUAL THERAPY PROGRAM

Manual Techniques
Technique or Stretch/Dosage Description
Lumbosacral thrust manipulation; The therapist sidebends the patient toward the
up to 2 thrusts on each side side to be manipulated and rotates the trunk in
an opposite direction until the pelvis lifts off the
table. The therapist then places his/her hand on
the anterior superior iliac spine on the side to be
manipulated, takes up the slack, and applies a
high-velocity, low-amplitude thrust in the direction
of the table.
Lumbar thrust manipulation; The therapist flexes the hip until motion is detected
up to 2 thrusts on each side at the L4-5 segment. The therapist then rotates
the upper trunk backward until motion is detected
at the L4-5 segment. The therapist then rolls the
patient toward him/her and stretches the segment
to its end range. The therapist then applies a high-
velocity, low-amplitude thrust.
44-01 Rabin.indd 7 12/18/2013 6:15:51 PM

[ research report ]
APPENDIX B

Upper lumbar thrust manipulation; The patient places both arms on top of the therapist’s
up to 2 thrusts on each side shoulder. The therapist places the hypothenar
eminence of 1 hand over the transverse process of
the segment to be manipulated. The therapist then
rotates the patient toward him/her and sidebends
away. The therapist then applies a high-velocity,
low-amplitude thrust in a forward direction (rotat-
ing the patient toward him/her).
Posterior/anterior nonthrust mobilization; The therapist places the thenar eminence of 1 hand
40 seconds, 3 repetitions over each (mobilizing hand) over the spinous process of the
segment at the highest grade tolerated segment to be mobilized. The therapist places the
opposite hand over the dorsum of the mobilizing

hand and locks his/her elbows. The therapist then
applies a posterior/anterior force over the segment
in an oscillatory fashion with 1 to 2 oscillations per
second.
Hamstring stretch; 30 seconds, The therapist flexes the hip to 90° and then extends
3 repetitions on each leg the knee until the patient reports a stretching sen-
sation behind his/her knee.
44-01 Rabin.indd 8 12/18/2013 6:15:51 PM

APPENDIX B

Iliopsoas stretch; 30 seconds, The patient maintains 1 knee close to his/her chest.
3 repetitions on each leg The therapist lowers the opposite leg over the
edge of the table into hip extension (while keeping
the knee straight) until a stretching sensation is
reported by the patient.
Quadriceps stretch; 30 seconds, The patient maintains 1 knee close to his/her chest.
3 repetitions on each leg The therapist lowers the opposite leg over the edge
of the table into hip extension and knee flexion
until a stretching sensation is experienced by the
patient.
Tensor fascia lata stretch; 30 seconds, The patient maintains 1 knee close to his/her chest.
3 repetitions on each leg The therapist lowers the opposite leg over the edge
of the table into hip extension and knee flexion.
The therapist then uses his/her leg to externally
rotate and adduct the patient’s hip until a stretch-
ing sensation is reported.
44-01 Rabin.indd 9 12/18/2013 6:15:51 PM

[ research report ]
APPENDIX B

Piriformis stretch; 30 seconds, The therapist flexes the patient’s hip and knee to 90°
3 repetitions on each leg and then fully externally rotates the patient’s hip.
The therapist then stretches the hip into further
flexion and adduction (pointing the knee toward
the opposite shoulder of the patient). The motion
continues until the patient reports a stretching
sensation over the ipsilateral buttock.
Range-of-Motion and Flexibility Exercises

Exercise or Stretch/Dosage Description
Cat horse; 30 repetitions, 4 sets The patient curls his/her back up and down in a
comfortable, pain-free range.
Prone press-up; 10 seconds, The patient presses up on both hands, extending

10 repetitions his/her spine in a pain-free range. The patient
holds this position for 10 seconds and returns to
44-01 Rabin.indd 10 12/18/2013 6:15:52 PM

APPENDIX B

Standing lumbar extension; 3 seconds, The patient leans back and extends the lumbar spine
10 repetitions in a pain-free range. The patient holds the position
for 3 seconds and returns to the starting position.
Quadruped flexion; 10 seconds, From a quadruped position, the patient brings his/
10 repetitions her buttocks toward the heels to create flexion of
the lumbar spine. The patient holds the position
Sidelying trunk rotation; 10 seconds, The patient presses the upper knee down to rotate
10 repetitions on each side the pelvis toward the table, while rotating the
shoulders up (toward the ceiling) to create maxi-
mal trunk rotation. The patient holds the position
44-01 Rabin.indd 11 12/18/2013 6:15:52 PM

[ research report ]
APPENDIX B

Hip flexor stretch; 30 seconds, From a half-kneeling position, the patient performs
3 repetitions on each leg a posterior pelvic tilt and then leans forward until
a stretch is felt in the front of the hip. The patient
holds the position for 30 seconds and returns to
Quadriceps stretch; 30 seconds, The patient uses a towel/belt to pull the foot up to-
3 repetitions on each leg ward his/her buttock (knee flexion) until a stretch
is felt in the anterior thigh. The patient holds the
position for 30 seconds and returns to the starting

position.
44-01 Rabin.indd 12 12/18/2013 6:15:52 PM

APPENDIX B

Hamstring stretch; 30 seconds, The patient extends the knee until a stretch is felt in
3 repetitions on each leg the posterior aspect of the knee/thigh. The patient
holds the position for 30 seconds and returns to
Piriformis stretch; 30 seconds, The patient crosses 1 leg over the opposite flexed
3 repetitions on each leg knee. The patient uses a towel to pull the bottom
knee toward his/her shoulder until a stretch is
felt in the opposite buttock. The patient holds the
position for 30 seconds and returns to the starting
position.
44-01 Rabin.indd 13 12/18/2013 6:15:52 PM

2014 a Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-term Success Following Lumbar Stabilization Exercises; A Randomized Controlled Validation Study

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

2014 a Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-term Success Following Lumbar Stabilization Exercises; A Randomized Controlled Validation Study

Diunggah oleh

Hak Cipta:

Format Tersedia

[ research report ]

A Clinical Prediction Rule to Identify

44-01 Rabin.indd 6 12/17/2013 5:18:33 PM

more vulnerable to excessive deforma- investigation into their impact on clini-

44-01 Rabin.indd 7 12/17/2013 5:18:35 PM

44-01 Rabin.indd 8 12/17/2013 5:18:36 PM

44-01 Rabin.indd 9 12/17/2013 5:18:37 PM

Lumbar stabilization exercises, Manual therapy, n = 57 Analysis by Intention to Treat

44-01 Rabin.indd 10 12/17/2013 5:18:38 PM

LSE CPR+ LSE CPR– MT CPR+ MT CPR–

Bachelor 13 (27.1) 17 (29.8) 18 (45.0) 12 (18.5) 8 (44.4) 5 (16.7) 10 (45.5) 7 (20.0)

44-01 Rabin.indd 11 12/17/2013 5:18:39 PM

44-01 Rabin.indd 12 12/17/2013 5:18:41 PM

*Values are mean difference (95% confidence interval).

44-01 Rabin.indd 13 12/17/2013 5:18:42 PM

MT mCPR– (n = 33) 19.0 (14.7, 23.2) 2.8 (2.1, 3.4)

modified clinical prediction rule treated with manual

44-01 Rabin.indd 14 12/17/2013 5:18:43 PM

44-01 Rabin.indd 15 12/17/2013 5:18:44 PM

44-01 Rabin.indd 16 12/17/2013 5:18:45 PM

do some patients keep hurting their back?

44-01 Rabin.indd 17 12/17/2013 5:18:46 PM

PUBLISH Your Manuscript in a Journal With International Reach

44-01 Rabin.indd 18 12/17/2013 5:18:46 PM

LUMBAR STABILIZATION EXERCISE PROGRAM

dominal muscles and draws the belly button in

44-01 Rabin.indd 1 12/18/2013 6:15:49 PM

30 repetitions tocks off the supporting surface. The position is

44-01 Rabin.indd 2 12/18/2013 6:15:49 PM

and the patient returns to the starting position.

alternate legs). Patient places both hands under

to alternate legs). Patient places both hands over

44-01 Rabin.indd 3 12/18/2013 6:15:50 PM

each direction), and then returns to the starting

a neutral spine. The patient then rolls back to the

44-01 Rabin.indd 4 12/18/2013 6:15:50 PM

position is held for 8 seconds. The patient then

and the patient then returns the weight to the

44-01 Rabin.indd 5 12/18/2013 6:15:50 PM

Stage 3 The patient continues with the exercises from stage

2 and begins to practice the following functional

44-01 Rabin.indd 6 12/18/2013 6:15:50 PM

MANUAL THERAPY PROGRAM

44-01 Rabin.indd 7 12/18/2013 6:15:51 PM

Technique or Stretch/Dosage Description

opposite hand over the dorsum of the mobilizing

44-01 Rabin.indd 8 12/18/2013 6:15:51 PM

Technique or Stretch/Dosage Description

ing sensation is reported.

44-01 Rabin.indd 9 12/18/2013 6:15:51 PM

Technique or Stretch/Dosage Description

Range-of-Motion and Flexibility Exercises

Prone press-up; 10 seconds, The patient presses up on both hands, extending

44-01 Rabin.indd 10 12/18/2013 6:15:52 PM

Exercise or Stretch/Dosage Description

for 10 seconds and returns to the starting position.

44-01 Rabin.indd 11 12/18/2013 6:15:52 PM

Exercise or Stretch/Dosage Description

position for 30 seconds and returns to the starting

44-01 Rabin.indd 12 12/18/2013 6:15:52 PM

Exercise or Stretch/Dosage Description

44-01 Rabin.indd 13 12/18/2013 6:15:52 PM

Anda mungkin juga menyukai