Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=iptp20

Download by: [Laurentian University] Date: 07 April 2016, At: 14:12

Physiotherapy Theory and PracticeAn International Journal of Physiotherapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Clinical diagnosis and treatment of a patient withlow back pain using the patient response model: Acase report

Michael Robinson PT, DPT, OCS

To cite this article: Michael Robinson PT, DPT, OCS (2016): Clinical diagnosis and treatment ofa patient with low back pain using the patient response model: A case report, PhysiotherapyTheory and Practice

To link to this article: http://dx.doi.org/10.3109/09593985.2016.1138175

Published online: 06 Apr 2016.

Submit your article to this journal

View related articles

View Crossmark data

CASE REPORT

Clinical diagnosis and treatment of a patient with low back pain using thepatient response model: A case reportMichael Robinson, PT, DPT, OCS

University of North Carolina – Division of Physical Therapy, Department of Allied Health Sciences, Chapel Hill, NC, USA

ABSTRACTThe medical management of low back pain (LBP) can be approached in a multitude of ways.Classification via subgrouping is increasingly common in orthopedic literature. Clinical diagnosisand treatment of LBP using the patient response model (PRM) can assist clinicians in hypothesiz-ing the origin of pain and providing beneficial interventions unlike the widely used pathoanato-mical model. This case report involved a 52-year-old female with sudden onset of right-sided LBPthat radiated to the foot. These symptoms were accompanied by occasional paresthesias inbilateral lower extremities. Magnetic resonance imaging (MRI) confirmed disc bulges at levelsT11-T12 and T12-L1. On the first of seven visits, she reported 9/10 on the Numeric Pain RatingScale (NPRS), scored a 24/50 on the modified Oswestry disability index (mODI), and demonstratedlumbar flexion range of motion (ROM) of 10°. Using the PRM, the patient was classified as anextension responder and was instructed to perform 10 repetitions of standing lumbar extensionevery 2 waking hours. After 4 weeks of therapy, the patient reported a 1/10 pain localized to thelow back, scored 20/50 on the mODI, and improved flexion ROM to 45°. Classification using thePRM yielded positive outcomes with this patient’s symptoms and daily function.

ARTICLE HISTORYReceived 20 January 2015Revised 16 May 2015Accepted 31 July 2015

KEYWORDSCentralization; directionalpreference; low back pain;McKenzie method; MDT;sciatica

Background

Over the course of a lifetime, 65–85% of adults willexperience low back pain (LBP). In addition, consider-able practice variation exists in the medical managementof this patient population (Gellhorn, Chan, Martin, andFriedly, 2012). LBP is a multifactorial ailment for whichapproximately 45% of cases are discogenic in origin,approximately 13% originate from the sacroiliac joint,and 15–40% arise from facet joint dysfunction(Schwarzer et al, 1994). Each of these anatomic struc-tures is innervated and potentially noxious. Mechanicalor chemical stimulation of these structures can causeLBP (Hancock et al, 2007). The pathoanatomical modelof diagnosing LBP has traditionally been the primarymodel. Even though this model is used widely, it hasprovided a definitive diagnosis in less than 10% of cases(Fritz, Cleland, and Childs, 2007). Other authors havegrouped heterogeneous low back conditions into onesingular group or classified the conditions into time-based categories as follows: acute, 0–7 days; sub-acute,7 days to 7 weeks; and chronic, greater than 7 weeks(Cook, Hegedus, and Ramey, 2005).Physical therapists employ a wide variety of conserva-tive treatments for LBP, which include, but are not

limited to: manual therapy; therapeutic exercise; trac-tion; modalities; and functional training (Delitto et al,2012). Other medical practitioners employ treatmentssuch as non-steroidal anti-inflammatory drugs andmuscle relaxants, both of which may have a positiveeffect on LBP (Koes, Van Tulder, and Thomas, 2006).On the other hand, evidence on more invasive inter-ventions is not as supportive. For example, the use offacet joint, epidural, trigger point, and sclerosant injec-tions has not clearly been effective. For those who failto respond to the aforementioned options, surgical dis-cectomy is typically considered (Koes, Van Tulder, andThomas, 2006). Given the elusiveness of diagnosingLBP, a superior method of treatment has not yet beendetermined. An intervention strategy based on an orga-nized, patient-centered, and evidence-based systemmay be beneficial in the management of LBP.The patient response model (PRM) is an approach thatuses a patient’s response to singular or repetitive move-ments for diagnostic and treatment information.Responses typically include pain provocation, reduc-tion, or both (Cook, Hegedus, and Ramey, 2005). Oneof the goals of this assessment is to determine thedirectional preference (DP) of the patient, if one exists.

CONTACT Michael Robinson, PT, DPT, OCS m.t.robinson2013@gmail.com Austin Orthopedic Physical Therapy Resident, University of North Carolina– Division of Physical Therapy, Department of Allied Health Sciences, 101 Manning Drive, Chapel Hill, NC 27599, USA.

PHYSIOTHERAPY THEORY AND PRACTICEhttp://dx.doi.org/10.3109/09593985.2016.1138175

© 2016 Taylor & Francis

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

Werneke et al. (2011) defined a DP as, “a mechanicalresponse in which movement in one direction improvespain and limitation of ROM, and movement in theopposite direction causes signs and symptoms to wor-sen.” The phenomenon of centralization, sometimesimproperly used interchangeably with DP, is an emer-ging concept in physical therapy. Fritz, Cleland, andChilds (2007) define centralization as, “when a move-ment or position results in abolishment of pain orparesthesia, or causes migration of symptoms from anarea more distal or lateral in the buttocks and/or lowerextremity to a location more proximal or closer to themidline of the lumbar spine.” Documented as a positiveprognostic indicator (Werneke et al, 2011), centraliza-tion is a desirable finding when utilizing this model.

Delitto, Erhard, and Bowling (1995) presented thetreatment-based classification system for the manage-ment of LBP with the objective of yielding positiveoutcomes faster, more efficiently, and cost-effectively.The algorithm allows practitioners to classify patientsinto categories determined by information gathered viaexamination procedures. The system then matchespatients with evidence-based treatments. This originalclassification system described PRM principles andrecommended direction-specific exercises that decreasepain as the primary therapy intervention (Delitto,Erhard, and Bowling, 1995). Since the formation ofthis system, Fritz, Cleland, and Childs (2007) havepresented a more concise and updated version of theoriginal algorithm as evidence on LBP evolved over theyears. This group termed the PRM portion of the sys-tem, “Specific-Exercise.” The primary differencebetween these models and the widely used pathoanato-mical model is matched intervention. This integralpiece sequentially leads clinicians to potential interven-tions to address their patients’ problems.

The McKenzie method, also known as mechanicaldiagnosis and treatment (MDT), is a more specificclassification approach that enables differentiationbetween discogenic LBP and non-discogenic LBPbased on patient response (Cook, Hegedus, andRamey, 2005). MDT is a heavily researched type ofPRM that is sometimes construed as an extension-based treatment protocol despite evidence demonstrat-ing improvements with flexion-based and lateral flex-ion-based programs (Long, Donelson, and Fung, 2004).Though interexaminer reliability of clinical testing andclassifying LBP patients with this specific approach isgood, this is only when examiners are trained in MDT(Kilpikoski et al, 2002).

The PRM simplifies the diagnostic process bycategorizing the patient based on patient’s responsesto movement rather than categorization based on

tissue pathology. Donelson, Aprill, Medcalf, andGrant (1997) found a strong correlation betweendisc morphology and spinal motions used in clinicalmovement assessments. When considering the effi-cacy of this evidence in practice, clinicians can moreconfidently determine the integrity of a disc byusing patient response as an identifier for abnorm-alities. This model uses direction-specific exerciseswith the goal of centralization to reduce pain andimprove ROM (Southerst et al, 2013). The purposeof this case report, therefore, was to explore thediagnostic utility and treatment efficacy of thePRM for a patient with sub-acute LBP and radicularsymptoms.

Case description

The following case involved a 52-year-old morbidlyobese female bank teller who reported to outpatientphysical therapy with a sudden onset of right-sidedLBP with symptoms radiating distally and posteriorlyto the foot. These symptoms were also felt on the leftside in the same pattern with significantly less fre-quency and intensity. This injury occurred approxi-mately 6 weeks prior to the patient’s initial visit withphysical therapy. While working at the drive-throughstation, the patient reached forward toward the depositchute and instantly felt the aforementioned symptoms.She described her pain as a constant dull ache withintermittent sharp and burning pains that radiatedfrom her low back to her right foot.

She was placed on medical leave for 1 week andprescribed hydrocodone by an urgent care physician.She was instructed to apply ice to her low back andwalk 30 minutes a day. She returned to work after 1week. Upon bending forward to reach below a counter,her symptoms returned with increased intensity. Thatsame week, the patient was evaluated by an orthopedistwho identified two bulging discs at levels T11-T12 andT12-L1 via magnetic resonance imaging (MRI). Hercomplaints included low back and leg pain when shesat longer than 30 minutes, stood longer than 10 min-utes, and with forward bending and lifting activities.She managed her pain by changing positions when:sitting; weight shifting when standing; and use of theprescribed pain medication, ibuprofen, and acetamino-phen. She denied bowel and bladder changes; however,she reported having instances of bilateral lower extre-mity (LE) paresthesias, as well as unusual clumsinesswith gait (i.e., tripping). Her ultimate goal for physicaltherapy was to eliminate her symptoms so that shecould return to work pain-free. The injury was not aworkers’ compensation case.

2 M. ROBINSON

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

Measures

As can be seen in Figure 1, pain was mapped by thepatient using a body diagram. The diagram showed adistribution of pain in the low back and bilateral LEssymbolized by the marked areas. Pain mapping hasbeen reported as a reliable method for recording painlocation and distribution specifically in the acute andchronic LBP population (Southerst et al, 2013). TheNumeric Pain Rating Scale (NPRS) was administeredto gauge the patient’s pain intensity. This scale rangesfrom 0 to 10, where 0 equates no pain and 10 equatesthe worst pain imaginable. An NPRS score wasrecorded on every visit, with her initial score measuredat 9/10 throughout the marked pain distribution. Activerange of motion (ROM) of the lumbar spine in thedirections of flexion and extension was measured witha single inclinometer, and bilateral lateral flexion wasmeasured using a goniometer.

Though the correlation between lumbar ROM andfunction may be weak (Parks, Crichton, Goldford, andMcGill, 2003), this measurement was recorded to deter-mine the effect of treatment on ROM limitations. Repeatedmovements into these planes were also tested to classify thepatient using the PRM (Fritz and Irrgang, 2001). Thepatient demonstrated a reduction in symptom intensityand visual increase in lumbar ROM with 10 repetitions of

repeated standing lumbar extension and an increase insymptom intensity with one repetition of standing lumbarflexion.

A neurological screen consisting of LE dermatomes,myotomes, and deep tendon reflexes was administered.At dermatome levels L2-S1, the patient reported ahypersensitivity of the right LE compared with the leftLE with the application of random light touches by thetherapist. Myotomes for the same levels were normalbilaterally. Deep tendon reflexes of the Achilles andpatellar tendons were 1+ bilaterally. Special testing con-sisted of the straight leg raise (SLR), slump, Patrick’s(FABER), sacroiliac compression, and sacroiliac dis-traction tests. The positive results of these tests were aright-sided SLR test yielding right-sided LBP, a right-sided slump test yielding right-sided buttock pain, anda right-sided Patrick’s test yielding right-sided buttockpain. All other tests administered bilaterally were nega-tive for pain provocation.

The modified Oswestry disability index (mODI) wasthe primary outcome utilized to measure the patient’sperceived level of function in terms of disablement. Theself-rated questionnaire consists of 10 items addressingdifferent aspects of function. These aspects include: (1)pain intensity; (2) personal care; (3) lifting; (4) walking;(5) sitting; (6) standing; (7) sleeping; (8) social life; (9)

Figure 1. Pain mapping by the patient at the initial physical therapy visit using a body diagram. Marked areas reflect the locations ofthe patient’s pain.

PHYSIOTHERAPY THEORY AND PRACTICE 3

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

traveling; and (10) employment/homemaking. Eachitem is scored from 0 to 5, with greater values repre-senting greater disability. Despite the minor differencesbetween the modified and original ODI, similar levelsof test–retest reliability and internal consistency existbetween the two (Fritz and Irrgang, 2001). The patient’sinitial score was 24/50, which reflects severe disability.

Differential diagnosis

Given the patient’s subjective report and objectiveexamination, diagnoses of somatic and radicular originsuch as facet joint and nerve root irritation were con-sidered plausible since referred pain can be character-istic of these two sources. When considering adiscogenic diagnosis, the debate of a nociceptive irrita-tion versus radicular irritation can be made. Afferentsfrom a disc share pain referral patterns with irritatednerve roots at the lumbosacral spine (Kallewaard et al,2010). Within the PRM, movement testing of the trunkserves as the most valuable tool, especially in caseswhere a disc lesion is suspected. Donelson, Aprill,Medcalf, and Grant (1997) have suggested that“repeated end-range spinal movement testing in multi-ple directions could identify a lesion-specific directionof asymmetrical disc loading which simultaneously sti-mulates the underlying symptom-producing pathology”Without the need of imaging or diagnostic injection,movement testing allows for a gross assessment ofspinal osteokinematics while assessing the integrity ofthe annulus fibrosus and the ability of a potential discprolapse to reduce itself (Donelson, Aprill, Medcalf,and Grant, 1997).

Collectively, clinical findings such as the dermatomaldiscrepancy, unilateral positive neural tension testing,and negative sacroiliac joint testing increased the like-lihood that the source of pain was radicular. Thepatient denied bowel or bladder changes and deeptendon reflexes were hyporeflexive, decreasing the like-lihood of an upper motor neuron concern. These find-ings were consistent with the reported mechanism ofinjury and suggest that the patient’s pathoanatomicaldiagnosis was lumbar radiculopathy due to the discbulges at T11-T12 and T12-L1 that had been documen-ted on MRI. Based on the patient’s positive response toextension-based movement and negative response toflexion-based movement, the patient would be classi-fied as an extension responder in terms of the PRM.

Treatment

The patient demonstrated a DP of extension at theinitial evaluation, as repetitions of standing lumbar

extension to end-range reduced pain intensity andrepetitions of standing lumbar flexion increased painintensity (Werneke et al, 2011). Therefore, the patientwas prescribed the same pain-reducing movement ofstanding lumbar extension as a home exercise. This soleexercise was provided to allow the process of centrali-zation to continue and to confirm that the selectedmovement was therapeutic. The patient was instructedto perform 10 repetitions of this direction specificexercise every 2 waking hours, based on previousresearch on DP interventions (Long, Donelson, andFung, 2004). Standing extension, as can be seen inFigure 2, was used instead of prone extension, primarilydue to the patient’s size and related difficulty assumingthe prone position. She was also instructed to use astable object, such as a countertop, for balance assis-tance, if needed. The patient was instructed to ceaseexercise if symptoms worsened or migrated distally tothe low back. Recommendations were provided to thepatient regarding workstation modifications to pro-mote a neutral lumbar spine during her work shiftand to avoid pain-provoking movements to supplementher direction specific exercise. She returned for follow-up visits 2 times per week. Her DP was either recon-firmed or reestablished at the start of each visit. Withineach treatment session, the patient was guided throughend-range pain-reducing movements in bouts of 10repetitions. As symptoms and trunk range of motionceased to produce further positive responses, the thera-pist assisted in providing overpressure to ensure max-imum end-range movement with each repetition. Thepatient established a DP of right lateral flexion on thefourth visit only. A plausible explanation for thischange, in terms of the PRM, is that coronal planemovements were the only movements to decreasesymptom intensity and increase trunk ROM upon reas-sessment. On the other hand, a pathoanatomical expla-nation may determine a lateral disc derangement as thereason for change in DP. The home program wasmodified to the single exercise depicted in Figure 3.The sagittal plane exercises were resumed upon reas-sessment at the fifth visit less than a week later.

Outcomes

The patient was treated for seven visits over 4 weeks. Ascan be seen in Figure 4, a body diagram was adminis-tered on the final visit attended by the patient. Thisversion depicts a pain distribution localized to the lowback. This demonstrates the pain was centralized andsupports the idea of direction-specific exercise yieldinga positive effect on an individual with sub-acute LBPand radicular symptoms.

4 M. ROBINSON

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

The NPRS score was assessed at the beginning ofevery visit to determine the current pain status. Overthe course of seven treatment sessions, the patientdemonstrated an improvement in pain intensity from

9/10 to 1/10. As can be seen in Figure 5, a spike in painintensity midway through treatment was attributed tothe patient’s inability to have her workstation modifiedcoupled with a subsequent symptom exacerbation.

Figure 3. Repeated right lateral flexion in standing. Direction-specific exercise used at visit 4.

Figure 2. Repeated extension in standing. Direction-specific exercise used at visits 1–3 and 5–7.

PHYSIOTHERAPY THEORY AND PRACTICE 5

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

Education on body mechanics and avoiding lumbarflexion was emphasized to the patient during this treat-ment to prevent future exacerbations. Childs, Piva andFritz (2005) reported that a 2-point change in NPRSscores was a meaningful improvement in LBP. Thepatient displayed an 8-point improvement in herNPRS score from the initial evaluation to her finalvisit. This result also supports the idea of direction-

specific exercise yielding a positive effect for an indivi-dual with sub-acute LBP and radicular symptoms.

The patient’s lumbar ROM was measured at each visitfor flexion, extension, and bilateral lateral flexion. As can beseen in Figure 6, the most significant improvement was 35more degrees of flexion. Though no strong studies wereidentified regarding the significance of change in lumbarROM values as they relate to function, an overall

Figure 4. Pain mapping by the patient during her final physical therapy visit using a body diagram. The marked area reflects thelocation of the patient’s pain.

Figure 5. The patient’s numeric pain rating over the course of seven visits.

6 M. ROBINSON

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

improvement in lumbar ROM was demonstrated for thispatient from initial evaluation to final visit.

The mODI was assessed on a weekly basis. Thepatient scored 34/50 at week 3 before improving to20/50 at week 4. This spike in mODI score at week3 was also attributed to the aforementioned symp-tom exacerbation. Education on body mechanicsand avoiding lumbar flexion was emphasized to thepatient during treatment to prevent future exacer-bations. The change in scores from initial evaluationto final visit was not large enough to exceed theMCID of the mODI. Although minimal changewas noted on the mODI, the patient’s final surveyexhibited a 2-point improvement in lifting ability. Inaddition, 1-point improvements were noted in thesitting and travel ability sections while all otheraspects of the mODI were unchanged over 4weeks. These specific changes are important to high-light as each of these sections relate to the patient’sultimate goal of returning to work pain-free. Thefinal outcome of 20/50 reflects moderate disabilitydespite decreased pain intensity and location as wellas increased lumbar ROM.

Discussion

Subgrouping patients for diagnostic and treatment pur-poses is becoming the focus of musculoskeletal backpain research (Long, Donelson, and Fung, 2004; Fritz,Cleland, and Childs, 2007). Data from this case reportsupports the use of the PRM. The body diagram is a

clinically useful tool to document the phenomenon ofcentralization when using this model. Similarly, theNPRS and improvements in lumbar ROM are clinicallyuseful tools in the documentation of DP.

According to subjective reports and body diagrams,the patient in this case had complaints indicative oflumbar radiculopathy despite MRIs revealing potentialnerve root involvement at levels T11-T12 and T12-L1.Though rarely reported, lower thoracic disc involve-ment may mimic radicular symptoms, paresthesias,and weakness in the LEs (Benson and Byrnes, 1975;Lyu, Chang, Tang, and Chen, 1999; Tokuhashi,Matsuzaki, Uematsu, and Oda, 2001). Lyu, Chang,Tang, and Chen (1999) proposed that this inconsis-tency exists due to the lumbar enlargement of thespinal cord at lower thoracic levels and subsequentcompression of exiting lumbar spinal nerves.Alternatively, disc bulges are prevalent in asymptomaticpatients and may be unrelated to the patient’s symp-toms in this case (Jensen et al, 1994). Despite an uncer-tain correlation between her MRI findings andsymptoms, this patient achieved a positive outcomewith clinical management based on the PRM.

In taking an organized, patient-centered, and evi-dence-based approach to managing LBP like the PRM,this patient was classified and treated, and yieldedfavorable outcomes for multiple measures. On a largerscale, Long, Donelson, and Fung (2004) identified thatthe prevalence of a DP was 74% in a population of 312acute, sub-acute, and chronic LBP patients. In addition,good prognoses have been predicted in individuals

Figure 6. The patient’s lumbar flexion ROM over the course of seven visits.

PHYSIOTHERAPY THEORY AND PRACTICE 7

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

treated with the matching DP exercise (Werneke et al,2011). After determining the patient exhibited a DP forextension, she became part of the significant subpopu-lation of LBP patients who respond favorably whenmanaged with the principles used in the PRM. Thesehigh levels of evidence further validate the effectivenessof the PRM in physical therapy practice. Clusters ofsigns and symptoms have been established for patientswho would benefit from the PRM and patients whowould benefit from other treatments such as manipula-tion, stabilization, and traction (Fritz, Cleland, andChilds, 2007). Examples of criteria that typically havefavorable outcomes with PRM include: DP; symptomsdistal to the buttock; centralization; and age greaterthan 50 years for flexion-based DP (Fritz, Cleland,and Childs, 2007; Long, Donelson, and Fung, 2004).

Limitations to this approach include contradictoryprogress for patients who are not appropriately classi-fied. For example, if a patient’s DP is not correctlyinterpreted, the potential for improvement becomeslimited. Long, Donelson, and Fung (2004) reported asignificant difference in improvement between subjectsprescribed exercise matching their DP versus subjectsprescribed exercise opposite of their DP. In a post-study interview of the first patient randomized to thetreatment group opposite of her extension DP, thesubject reported consistent increases in her pain inten-sity with flexion-based daily activities (Long, Donelson,and Fung, 2004). Second, the absence of determining aDP would limit the application of this approach. If animprovement in symptoms or ROM is not elicited, amatching treatment protocol cannot be assigned.Therefore, awareness of a patient’s subjective andobjective responses to movement testing is essential inutilizing the PRM.

This case report was not without limitations. First,the patient self-discharged due to financial difficulties.Comprehensive data, therefore, could not be collected.Second, the exacerbation of the patient’s symptomsattributed to the patient’s inability to modify her workenvironment was not adequately addressed. From theperspective of the widely used InternationalClassification of Functioning, Disability and Health(ICF) model, contextual factors like the environmentcan affect the status of a health condition (Steiner et al,2002). A more concentrated effort could have beenmade to assist with this matter. Two examples includeinitiating communication with her direct supervisor orhaving the patient bring in photos of her workstation tomake a more comprehensive ergonomic assessment tosupplement the plan of care. Lastly, compliance was notrecorded in this report. Self-management via homeexercise is vital in this model. The frequency of

performing prescribed exercise every 2 walking hoursof the day was adhered to based on patient report.However, documentation of each exercise sessionwould assist in confirming protocol compliance.Accordingly, the PRM is optimal for patients who dis-play the ability to routinely carryout a home exerciseprotocol.

This case study supports the use of patient classifica-tion using the PRM for a patient with sub-acute lowback and radicular symptoms. Such an approach can beimplemented clinically for diagnosis and treatmentpurposes while being cognizant of all environmentalfactors that may affect a patient’s outcome.

Acknowledgments

Special thanks to Michael T. Gross, PT, PhD, FAPTA, andCarla H. Hill, PT, DPT, OCS, Cert. MDT, for their assistancein writing this report. This case study was written by aresident of the Orthopedic Physical Therapy ResidencyProgram at the University of North Carolina, Chapel Hill,in partial fulfillment of the program requirements.

Declaration of interest

The author reports no declaration of interest.

References

Benson MD, Byrnes DP 1975 The clinical syndromes andsurgical treatment of thoracic intervertebral disc prolapse.Journal of Bone and Joint Surgery (Br) 57: 471–477.

Childs JD, Piva SR, Fritz JM 2005 Responsiveness of thenumeric pain rating scale in patients with low back pain.Spine 30: 1331–1334.

Cook C, Hegedus EJ, Ramey K 2005 Physical therapy exerciseintervention based on classification using the patientresponse method: A systematic review of the literature.Journal of Manual and Manipulative Therapy 13: 152–162.

Delitto A, Erhard RE, Bowling RW 1995 A treatment-basedclassification approach to low back syndrome: Identifyingand staging patients for conservative treatment. PhysicalTherapy 75: 470–485.

Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G,Shekelle P, Denninger TR, Godges JJ 2012 Low back pain:Clinical practice guidelines linked to the InternationalClassification of Functioning, Disability, and Health fromthe Orthopaedic Section of the American Physical TherapyAssociation. Journal of Orthopaedic and Sports PhysicalTherapy 42: A1–A57.

Donelson R, Aprill C, Medcalf R, Grant W 1997 A prospec-tive study of centralization of lumbar and referred pain: Apredictor of symptomatic discs and anular competence.Spine 22: 1115–1122.

Fritz JM, Cleland JA, Childs JD 2007 Subgrouping patientswith low back pain: Evolution of a classification approachto physical therapy. Journal of Orthopaedic and SportsPhysical Therapy 37: 290–302.

8 M. ROBINSON

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16

Fritz JM, Irrgang JJ 2001 A comparison of a modifiedOswestry low back pain disability questionnaire and theQuebec back pain disability scale. Physical Therapy 81:776–788.

Gellhorn AC, Chan L, Martin B, Friedly J 2012 Managementpatterns in acute low back pain: The role of physicaltherapy. Spine 37: 775–782.

Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuleyJH, Laslett M, Bogduk N 2007 Systematic review of tests toidentify the disc, SIJ or facet joint as the source of low backpain. European Spine Journal 16: 1539–1550.

Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT,Malkasian D, Ross JS 1994 Magnetic resonance imaging ofthe lumbar spine in people without back pain. NewEngland Journal of Medicine 331: 69–73.

Kallewaard JW, Terheggen MA, Groen GJ, Sluijter ME,Derby R, Kapural L, Van Kleef M 2010 Discogenic lowback pain. Pain Practice 10: 560–579.

Kilpikoski S, Airaksinen O, Kankaanpää M, Leminen P,Videman T, Alen M 2002 Inter-examiner reliability oflow back pain assessment using the McKenzie method.Spine 27: E207–E214.

Koes BW, Van Tulder MW, Thomas S 2006 Diagnosis andtreatment of low back pain. British Medical Journal 332:1430–1434.

Long A, Donelson R, Fung T 2004 Does it matter whichexercise?: A randomized control trial of exercise for lowback pain. Spine 29: 2593–2602.

Lyu RK, Chang HS, Tang LM, Chen ST 1999 Thoracic discherniation mimicking acute lumbar disc disease. Spine 24:416–418.

Parks KA, Crichton KS, Goldford RJ, McGill SM 2003 Acomparison of lumbar range of motion and functionalability scores in patients with low back pain: assessmentfor range of motion validity. Spine 28: 380–384.

Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, BogdukN 1994 The relative contributions of the disc and zygapo-physeal joint in chronic low back pain. Spine 19: 801–806.

Southerst D, Côté P, Stupar M, Stern P, Mior S 2013 Thereliability of body pain diagrams in the quantitativemeasurement of pain distribution and location inpatients with musculoskeletal pain: A systematic review.Journal of Manipulative and Physiological Therapeutics36: 450–459.

Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A,Stucki G 2002 Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medi-cine. Physical Therapy 82: 1098–1107.

Tokuhashi Y, Matsuzaki H, Uematsu Y, Oda H 2001Symptoms of thoracolumbar junction disc herniation.Spine 26: E512–E518.

Werneke MW, Hart DL, Cutrone G, Oliver D, McGill MT,Weinberg J, Ward J 2011 Association between directionalpreference and centralization in patients with low backpain. Journal of Orthopaedic and Sports PhysicalTherapy 41: 22–31.

PHYSIOTHERAPY THEORY AND PRACTICE 9

Dow

nloa

ded

by [

Lau

rent

ian

Uni

vers

ity]

at 1

4:12

07

Apr

il 20

16