[ clinical commentary ]

JULIE A. HIDES, PT, PhD, MPhtySt, BPhty, FACP1-3 • RONALD DONELSON, MD, MS4 • DIANE LEE, PT5
HEIDI PRATHER, DO6 • SHIRLEY A. SAHRMANN, PT, PhD7 • PAUL W. HODGES, PT, PhD, DSc, MedDr, BPhty (Hons)8

Convergence and Divergence of

Exercise-Based Approaches That
Incorporate Motor Control for the
Management of Low Back Pain

M
any physical approaches to managing low back pain movement. Although different
(LBP) include exercise that aims to change motor control. approaches share the underlying
In this context, motor control refers to motor, sensory, assumption that the manner in
which individuals use their body
and central processes involved in control of posture and
and load their tissues is related
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to the development and maintenance of

UUSYNOPSIS: Many approaches for low back pain of the lumbar spine, Mechanical Diagnosis and
their conditions, there are differences in
(LBP) management focus on modifying motor Therapy, motor control training, and the integrated
control, which refers to motor, sensory, and central systems model. These were selected to represent how motor control is assessed and trained,
processes for control of posture and movement. the diversity of applications, including approaches as well as differences in proposed mecha-
A common assumption across approaches is that using motor control as a central or an adjunct fea- nisms for its efficacy. This commentary
the way an individual loads the spine by typical ture, and approaches that are evidence based or aims to describe how motor control is used
postures, movements, and muscle activation evidence informed. This identification of areas of in 4 clinical approaches commonly used in
strategies contributes to LBP symptom onset, convergence and divergence of approaches is de- physical therapy, and to consider areas of
persistence, and recovery. However, there are also signed to clarify the key aspects of each approach
divergent features from one approach to another. convergence and divergence between these
and thereby serve as a guide for the clinician and
approaches and how these approaches in-
J Orthop Sports Phys Ther 2019.49:437-452.

This commentary presents key principles of 4

to provide a platform for considering a hybrid ap-
clinical physical therapy approaches, including terface with nonsurgical medical manage-
proach tailored to the individual patient. J Orthop
how each incorporates motor control in LBP man- ment of patients with LBP.
Sports Phys Ther 2019;49(6):437-452. Epub 15
agement, the convergence and divergence of these
May 2019. doi:10.2519/jospt.2019.8451
approaches, and how they interface with medical
UUKEY WORDS: clinical perspectives, low back
Clinical Approaches That
LBP management. The approaches considered
are movement system impairment syndromes pain, motor control, spinal control Focus on Motor Control
The clinical approaches included in this

1
School of Allied Health Sciences, Griffith University, Nathan, Australia. 2Mater Back Stability Research Clinic, Mater Health Services, South Brisbane, Australia. 3Menzies
Health Institute Queensland, Gold Coast campus Griffith University, Queensland, Australia. 4SelfCare First, LLC, Hanover, NH. 5Diane Lee & Associates, Surrey, Canada.
6
Departments of Orthopaedic Surgery and Neurology, Washington University School of Medicine, St Louis, MO. 7Program in Physical Therapy, Washington University School of
Medicine, St Louis, MO. 8Clinical Centre for Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland,
Brisbane, Australia. Dr Hides receives book royalties from Elsevier. She has been reimbursed by professional scientific bodies and sporting bodies for travel costs related to
presenting research on motor control training and low back pain at meetings, scientific conferences, and symposia, and has received fees for teaching practical courses on
motor control training. She has received industry funding from the Lions Football Club (Brisbane, Australia) and research funding from the Health Innovation, Investment and
Research Office (Office of the Director-General, Department of Health, Queensland Health, Brisbane, Australia). Dr Donelson has received travel expenses and speaker’s fees
for presentations at medical conferences and webinars, and book royalties from SelfCare First, LLC. Ms Lee receives book royalties from Elsevier and Handspring Publishing.
She also receives fees for teaching online and in-class practical classes on the integrated systems model. She has also received travel funding and speaking fees for presenting
at conferences, on the national and international levels, on the integrated systems model as well as diastasis rectus abdominis. She has received funding from the Clinical
Centre for Research Excellence in Spinal Pain, Injury and Health for research into diastasis rectus abdominis. Dr Prather has received travel expenses and speaker’s fees for
presentations at medical conferences, paid directly to Washington University School of Medicine. Dr Sahrmann receives book royalties from Elsevier. She receives honoraria,
and her travel costs are reimbursed for teaching continuing education programs. Dr Hodges receives book royalties from Elsevier. Professional and scientific bodies have
reimbursed him for travel costs related to presentation of research on pain, motor control, and exercise therapy at scientific conferences/symposia. He has received fees for
teaching practical courses on motor control training. He is also supported by a Senior Principal Research Fellowship from the National Health and Medical Research Council
of Australia (APP1102905). 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 Julie A. Hides, School of Allied Health Sciences, Griffith University, Nathan Campus, 170
Kessels Road, Nathan, QLD 4111 Australia. E-mail: [email protected] t Copyright ©2019 Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 437
 [ clinical commentary ]
commentary are movement system im- movements and sustained alignments of cific direction, only a few degrees different
pairment (MSI) syndromes of the lumbar everyday activities. The changes in tis- in patients with LBP than in controls,119,125
spine, Mechanical Diagnosis and Therapy sues associated with repetition of activi- suggests the presence of accessory-motion
(MDT), motor control training (MCT), ties are proposed to induce movement hypermobility that induces microtrauma
and the integrated systems model (ISM). impairments. Studies have demonstrated that becomes macrotrauma over time.
These were selected with the objective of that rotation-related sports induce move- There are several sources of evidence
including approaches with some diversity ment impairments in individuals with for the change in joint flexibility con-
of underlying concepts, that consider mo- LBP.13,38,143,146,148,156 Indirect support for a tributing to a low threshold for motion.
tor control as a central (MSI, MCT, ISM) link between daily activities and the prob- First, patients present with similar types
versus an adjunct feature (MDT), and that lem is provided by evidence that correc- of lumbar motion, for example, rotation,
are evidence based (MSI, MDT, MCT) ver- tion of movement impairments during across different clinical tests involving
sus evidence informed (ISM). Below is an these activities significantly reduces symp- movement of the trunk and lower ex-
overview of the key features of each ap- toms for 1 year.146 The characteristics of tremities in a variety of positions.35,144
proach, including concepts, assessment, specific tissue, movement, and alignment Second, the range of lumbar/lumbopelvic
treatment, and key research evidence. changes are proposed to vary because of motion most often varies with the move-
intrinsic personal characteristics and ex- ment of one lower extremity relative to
MSI Syndromes of the Lumbar Spine trinsic factors, such as the type and inten- the other, supporting variation in the
Underlying Concepts The movement sity of activities. According to the model, flexibility of the joint.144 Third, motion-
system consists of physiological organ the result of these tissue adaptations is a capture studies have shown that patients
systems that interact to produce move- joint that moves more readily in a specific with LBP initiate lumbar/lumbopelvic
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ment of the body and its parts (FIGURE 1). direction (ie, flexion, extension, rotation) movement within a few degrees of initi-
Movement system impairment syndromes than in other directions and more readily ating limb motion and a few seconds ear-
are one set of classifications of patients than another joint with a similar move- lier than individuals without LBP.95,119,125
with musculoskeletal pain and comprise ment direction,82 thus becoming the path Most studies evaluated knee flexion and
the neuromusculoskeletal components of least resistance for movement. hip lateral and medial rotation in the
of the system. The theoretical construct The model proposes that the major de- prone position.68-70 The early onset of
of MSI syndromes is depicted in the ki- terminants of the path of least resistance motion and occurrence with movements
nesiopathologic model,67,116,149 which pro- that cause a joint to move too readily are of the trunk and lower extremities in a
poses how movement induces pathology (1) joint relative flexibility (intrajoint and variety of positions support the concept
(FIGURE 2). interjoint),119,125 (2) relative stiffness (pas- of intrinsic changes in joint flexibility.
J Orthop Sports Phys Ther 2019.49:437-452.

In this model, the main inducers of sive tension of muscle and connective Additional support is derived from
movement impairments are the repeated tissue),35,67,150 and (3) motor performance studies that demonstrate that patients
and learning.95,96,147,151 The predisposition classified as “extension-rotation” have
for a joint to move more readily in a spe- greater lumbopelvic rotation with hip

Nervous Musculoskeletal Nervous Cardiopulmoendocrine

ry En
na
Biomechanics
o

do
Pulm

crine

Repeated movements Personal characteristics: intrinsic

Inducers Sustained alignments Activity demands: extrinsic
rd i
Ca

ov a s c ul a
r
Mu

al

Relative stiffness of
let

Tissue adaptations
ulo e muscle and connective
sc

- Sk tissue
Path of least resistance
I n te g u m e n ta r y Relative flexibility Joint accessory
(intrajoint and interjoint) hypermobility
FIGURE 1. Human movement system. Reproduced
with permission from Washington University in St Motor learning
Louis Program in Physical Therapy, licensed under
a Creative Commons Attribution-NonCommercial- Microtrauma Macrotrauma
NoDerivatives 4.0 International license. Based on a
work at https://pt.wustl.edu/about-us/. FIGURE 2. The kinesiopathologic model, a theoretical construct of movement system impairment syndromes.

438 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
 lateral rotation in prone with one extrem- during sit-to-stand, in a sitting position, tation of both hips; symmetrical; symp-
ity than with the other.144 These patients when going up and down stairs, during tom elimination/reduction: correction/
also demonstrate asymmetrical lateral gait, as well as when bending, returning prevention of lumbar motion).152
trunk flexion.35 This contrasts with pa- to standing, and sidebending.95,96,147,151 All Intervention Outline During the exami-
tients classified as “rotation,” who have these motions are assessed as part of the nation that comprises basic mobility ac-
symmetrical lumbopelvic rotation with examination. tivities, many of which elicit symptoms,
both lower extremities and lateral trunk The reliability of clinicians perform- the patient is immediately instructed to
flexion.35 Studies of lateral trunk flexion ing the examination tests40,134,150 and correct the motion that usually reduces or
have shown that trunk passive elastic the validity of the classifications have eliminates the symptoms. The results of
energy asymmetry is predicted by fac- been examined and are acceptable.152 the examination identify the movement
tors of sex and muscle in LBP, whereas The reliability of examiners to classify direction that most consistently elicits
in controls only sex is predictive.34 Thus, patients has also been established (ap- symptoms and the associated movement
muscle factors in LBP likely contribute to proximately 70% accuracy).39,40,107,134 control impairments. The patient is in-
the greater imbalance in passive elastic Alignment differences between patients formed of the movement direction and
energy. Although muscle and connective with a specific lumbar classification and practices the movement correction. The
tissue can contribute,34 intrinsic flexibil- controls have been documented.107,126 major emphasis is placed on correcting
ity of the spine is also a factor. Other studies have documented that basic daily activities and specifically on
Assessment Procedures Consistent with symptoms are elicited with movements other types of activities that elicit symp-
the model that a specific movement di- of the spine and the extremities and that toms, such as cooking or raking, as well
rection is problematic, the primary ob- preventing lumbar motion during limb as fitness or sports activities.
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jective of the clinical examination is to movements decreased or eliminated the The patient is also instructed in spe-
identify the movement directions that symptoms.96,145,150 Studies using motion cific exercises designed to correct the
elicit symptoms (the path of least resis- capture have demonstrated that lumbo- identified movement impairments. The
tance) and the contributing factors. The pelvic motion occurs more readily during exercises aim to prevent the offending
examination also identifies the associated knee flexion and hip rotation in patients lumbar motion while moving the trunk
movement impairment, such as exces- with LBP than in pain-free individuals.119 and lower extremities. Most often, this
sive early lumbar flexion and limited hip A variety of other details related to varia- involves improved lumbopelvic control
flexion during forward bending. Then, tions in symptom behavior in men versus by contracting the abdominal muscles
the effect of the patient correcting the women and in the different classifications and improved extensibility of the hip
movement impairment on the symptoms have also been examined.33,70 muscles by elongation of the muscles
J Orthop Sports Phys Ther 2019.49:437-452.

is noted. Correction of the early lum- The validated classifications are based while preventing lumbopelvic motion.
bar motion has been shown to decrease on the motion or alignment that provokes Evidence of Efficacy A recent random-
symptoms.96,145,151 the patient’s symptoms. The trunk/lower ized controlled trial (RCT) has support-
The systematic movement exam con- extremity movements that cause the of- ed that teaching the patient to keep the
sists of tests performed in different posi- fending movement are then eliminated or spine in neutral during basic mobility
tions: standing, supine, sidelying, prone, reduced to correct or prevent the offend- and fitness activities reduced symptoms
quadruped, and sitting. The tests involve ing spinal movement.151 for 6 months after 6 weekly visits con-
movements of the extremities, primarily The validated classifications are sisting primarily of performance train-
the lower extremity, and the trunk. The “lumbar extension” (greater lumbar ex- ing.146 At 1 year, the symptoms remained
patient moves in the preferred manner tension in standing; symptom provoca- significantly lower than at the initia-
while the symptoms and movement pat- tion: trunk/lower extremity movements tion of treatment. Subsequent RCTs of
terns are noted. Then, the movement is causing lumbar extension; symptom patients with chronic LBP have shown
corrected, primarily by limiting any as- elimination/reduction: alignment cor- greater efficacy for symptom reduction
sociated lumbar motion, and effects on rection or prevention of extension), by correcting movement and alignment
symptoms are noted.145,150-152,156 An impor- “extension-rotation” (symptom provoca- impairments by motor skill training ac-
tant component of the exam and treat- tion: trunk/lower extremity movements cording to the MSI approach than by us-
ment involves instructing the patient in causing extension and rotation; motions ing strength and flexibility exercises.147
correct performance of basic mobility are asymmetrical; symptom elimination/ Research has also demonstrated that
activities, as well as those during work reduction: correction of both movement patients adhere to training of functional
and, if relevant, fitness or sports activi- directions), and “rotation” (symptom activities significantly more often and for
ties. These activities include how to roll, provocation: rotation or sidebending of longer than they do to strength/flexibility
how to come to sitting when recumbent, the trunk/lumbopelvic rotation with ro- exercises.142,146

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 439
 [ clinical commentary ]
Mechanical Diagnosis and Therapy mechanically and systematically loads implement these strategies to restore
Underlying Concepts The MDT para- and tests the tissues considered to be the each individual’s ability to function at
digm is unique in this commentary in patient’s pain source, to determine which home, work, and during recreation. An
that treatment is entirely based on the familiar patterns of pain response occur additional goal is to teach patients suc-
findings of a mechanical examination as a result. cessful prophylactic strategies to avoid
of the behavior of the pain source for If the clinical findings/pain response recurrences and the need for further
each patient. Mechanical Diagnosis and patterns reveal a “directional preference” medical care. Published data support the
Therapy is typically not considered a mo- (a single direction of repeated end-range achievement of those goals for the sub-
tor control approach, yet MDT considers spinal loading that achieves lasting pain group that has a directional preference
posture correction and control to be es- relief ) and “pain centralization” (change and centralization.
sential features of recovery and preven- of pain location toward the spine from Most patients can achieve these recov-
tion for every patient with a directional the periphery), then this is interpreted eries independently after being taught
preference. The type of correction is de- to indicate that the patient’s pain source individualized self-management and
termined by establishing the patient’s is reversible or correctable, as well as preventive strategies.
directional preference associated with reveals the means by which it can be Evidence of Efficacy Numerous observa-
pain relief during the initial assessment. reversed or corrected. This information tional cohort studies,17,19,20,29,77,84,89,90,121,131,155
The performance of matching directional guides the treatment and is unobtainable RCTs,9,10,30,36,82,89,109,118 and systematic re-
exercises is the key component of treat- by other forms of clinical examination or views15,98,132 have reported that patients
ment, along with similar directional imaging technology. Research indicates in whom a directional preference and/
postural modifications. For most, that that these 2 clinical findings (FIGURE 4) or pain centralization is elicited achieved
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involves establishing and maintaining a can be elicited in 70% to 91% of patients better outcomes when treated with ex-
lumbar lordosis and avoiding spinal po- with acute LBP and in 50% of those with ercises that matched their disorder’s
sitions associated with symptom provo- chronic LBP.17,19,20,29,77,84,89,90,121,131,155 directional preference, coupled with ap-
cation, such as prolonged spinal loading Numerous studies31,32,80,81,112,127,155,158 propriate posture modifications, com-
in lumbar flexion.157 Experiencing the re- have reported strong interexaminer pared with other forms of treatment.
lationship between relief of pain and an reliability across clinicians possessing The interexaminer reliability of the
erect sitting posture can be sufficiently the credentialed level of MDT train- MDT assessment findings and patient
motivating for most patients to learn to ing provided by the McKenzie Institute classification—validated by improved
modify their sitting posture to prevent International. patient report of pain reduction and im-
pain from returning.157 In the MDT ap- Intervention Outline The goals of MDT provement in functional outcomes using
J Orthop Sports Phys Ther 2019.49:437-452.

proach, patients perform their assigned are to identify mechanical spinal load- self-management strategies—along with
directional exercise and practice the ing strategies that eliminate pain, then the high prevalence rate for directional
desired pain-relieving/preventative pos-
ture, which then creates a new postural
habit that helps prevent the return of
their pain.
Assessment Procedures Assessment
begins by focusing on mechanical ele-
ments in each patient’s history and with
a dynamic examination (FIGURE 3) that

Centralization

Peripheralization

FIGURE 3. A “press-up” is a prone end-range lumbar FIGURE 4. Pain “centralizes” when it is intentionally caused to retreat back toward the lumbar midline from
extension test that, when done repeatedly, will often its most distal location. It “peripheralizes” when it spreads farther away from the lumbar midline. Reprinted
centralize and/or abolish axial low back pain or any with permission from Donelson R. Is your client’s back pain “rapidly reversible”? Improving low back care at its
variation, such as referred pain or sciatica. foundation. Prof Case Manag. 2008;13:87-96. https://doi.org/10.1097/01.PCAMA.0000314179.09285.5a

440 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
 preference, supports this examination as that not all features will be relevant for common and may be concurrent with
a valuable component of evaluation for the patient and not all individuals with increased activation of other muscles.
patients who seek care for LBP. Mechani- a specific feature will develop symptoms. There is substantial evidence of de-
cal Diagnosis and Therapy is typically not Motor control training includes thera- creased26 or delayed63,93 activation and
considered a motor control approach, yet peutic exercise to modify specific motor reduced ability to voluntarily contract
MDT considers posture correction and control features for a broad, multidimen- muscles.43,154 There are many mecha-
control to be essential features of recov- sional view incorporating psychosocial nisms that could explain compromised
ery and prevention for every patient with aspects of LBP (FIGURE 5). It is important activation. These include reflex inhibi-
a directional preference. In that context, to recognize that MCT considers the po- tion50,60 and other changes at many lev-
motor control could be viewed as an ad- tential relevance of both “upregulation” els of the nervous system.65 Activation of
junct feature of MDT treatment. (ie, increased/augmented activation) and deep muscles such as the multifidus is
“downregulation” (ie, decreased/compro- also compromised by changes in struc-
Motor Control Training mised activation) of muscles. Increased/ ture such as atrophy55 and fat/connective
Underlying Concepts True to the com- augmented activation of muscles, par- tissue accumulation,61,83 which might be
plexity of motor control, MCT encom- ticularly those that are more superficial, secondary to reduced activation or other
passes many aspects. It considers sensory is common. Laboratory studies reported mechanisms such as a local inflammato-
and motor aspects of spine function, and a universal response of increased muscle ry dysregulation.73 If downregulation of
each individual’s management program activity when exposed to a noxious input, muscles such as the multifidus and trans-
is tailored to features considered to be but with a pattern that was unique to versus abdominis is identified, then the
“suboptimal” on assessment. The basic each individual.58 MCT program includes strategies to aug-
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premise of MCT is that, for many individ- There are numerous clinical examples. ment contraction in patients with acute50
uals, inputs from the spine and/or related In response to low-load axial loading and with chronic43,154 LBP. Programs that
tissues (including nociceptive) contribute tasks (25% of body weight), individu- have included this component have de-
to maintenance of symptoms secondary als with LBP have greater activation of creased the recurrence of episodes of
to suboptimal loading by person-specific the obliquus internus abdominis than LBP47 and improved pain/function.117 It
features of alignment, movement, and pain-free controls.46,53,54 This has been is a common misinterpretation that MCT
muscle activation. Motor control train- interpreted as a strategy to enhance aims to “upregulate” or increase muscle
ing aims to identify and modify the sub- protection,65 but could also be related to activity/cocontraction to restrict motion
optimal features of motor control, with features such as habitual postures.16 An via a unidimensional focus on activation
integration into function. MCT program reduced excessive con- of specific muscles. This is not correct.
J Orthop Sports Phys Ther 2019.49:437-452.

Considerable research has identi- traction,46 along with reducing LBP. This Instead, the target should be the appro-
fied motor control features that dif- can be achieved within a session.135 The priate balance between movement and
fer between pain-free individuals and contrasting observation of decreased/ stiffness, as required by the task and the
those with a variety of presentations of compromised muscle activation is also individual.57
LBP. Most features are highly variable
between individuals. Some examples
Breathing issues
include compromised muscle structure Correction of motor control “faults”
(eg, atrophy, fatty infiltration) and ac- • Posture
• Movement Continence/other pelvic floor issues
tivation or contraction of muscles (eg, • Muscle activation
the multifidus1,55,93,154 or transversus ab- Beliefs and attitudes
dominis26,55), augmented muscle acti-
Optimization of motor Optimization of motor
vation or contraction (eg, the obliquus Adjacent regions
control: static control: dynamic
externus abdominis,58 obliquus internus progression progression
abdominis,44,46,54,72 or erector spinae2,97), Static control of Dynamic control of Sensory function
modified postures,16 and modified move- lumbopelvic lumbopelvic
orientation/alignment orientation/alignment
ment features (eg, augmented trunk Balance issues
and movement
stiffness,56 smaller preparatory trunk
movements101). Muscle strength and endurance
Motor control training aims to iden- Functional re-education
Specific to patient goals
tify candidate features that might be Fitness
relevant for the individual’s pattern of
FIGURE 5. Motor control training approach.
symptom presentation. It is presumed

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 441
 [ clinical commentary ]
Biomechanical/mechanical principles Ultrasound imaging can be used in evaluate these features vary and re-
that are considered in program design in- clinical practice to measure the size quire further refinement.
clude the following. and activation/function of trunk Intervention Outline The following is an
1. A controlled lumbopelvic unit is im- muscles.128,133 Validity and reliability of example of an MCT protocol.53,66
portant for function,100,139 requiring this measurement method have been 1. Optimization of muscle activation:
a balance between movement and established; measures obtained by ul- individualized training targets the
stiffness56,79 achieved through appro- trasound imaging have been validated features identified in the assessment
priately coordinated activation of the against measures obtained from mag- that suggest upregulation and/or
complex array of trunk muscles.58,140 netic resonance imaging45,48,49,55 and downregulation of activity/contrac-
2. Maintenance of a “neutral” lumbar intramuscular electromyography.62 tion as required; that is, the training
spine position (ie, mid-range position 2. Assessment of posture and movement: employs strategies to decrease overac-
with alignment of the trunk relative assessment is based on the identifi- tive muscles and increase recruitment
to gravity, controlled spinal curves, cation of features that deviate from of muscles found to have demonstra-
and frontal/transverse plane align- those considered ideal for a task and ble impairments on clinical muscle
ment) is important for sustained static relevant for the patient’s presentation. testing.43,154 Training can include vol-
positions.14,99 This is based on evidence from a broad untary contraction of deeper trunk
3. For many functions, movement base of research that shows person- muscles to teach the skill of activating
should be initiated from the periphery specific postural attributes related to these muscles138 for later integration
(not the trunk) but should include the symptom profile,16,23 relationships of into function, and reducing “overac-
trunk to achieve full range.119 postures and movements to modified tivity” or increasing “underactivity” of
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4. Adequate mobility and flexibility of muscle activation,14 and that posture more superficial muscles. The MCT
adjacent joints and muscles attach- can be modified with exercise.25 Tests approach to training lumbar paraspi-
ing to the pelvis are required to utilized in MCT are drawn from mul- nal135 and abdominal muscles37 has
maintain spine control during limb tiple sources, including related motor been shown to induce immediate and
movement.143 control approaches (see Hodges et al66 sustained136 changes in coordination
Assessment Procedures Successful ap- for review). Although reliability and of lumbar trunk muscle activation in
plication of MCT principles relies on validity of some tests have been estab- recurrent LBP. Techniques to assist
thorough assessment (including patient lished,21,22 further research in this area this phase include position change,
interview and physical examination); is required. feedback (eg, ultrasound imaging of
good communication skills; rapport with 3. Assessment of functional tasks: as- muscle contraction) (FIGURE 6), relax-
J Orthop Sports Phys Ther 2019.49:437-452.

and an understanding of the patient, in- sessment of more complex functional ation strategies, imagery, and soft tis-
cluding his or her goals and concerns; tasks involves careful observation sue techniques.
and psychosocial context. Although these and relies on principles that are com-
principles are common to several exercise mon across multiple motor control
approaches for LBP, tailoring the MCT approaches (see Hodges et al66 for
treatment to the individual motor control review).
features identified through assessment 4. Assessment of broader dimensions of
contrasts with many generalized exercise LBP: MCT incorporates, as required,
approaches. Multiple elements of assess- consideration of many features that
ment have been shown to have acceptable may determine the relevance of mo-
clinimetric properties.110,128,133 tor control for the patient’s symptoms
1. Assessment of trunk muscle control: (eg, underlying pain mechanism) and
assessment identifies features of mus- features that may interact with the po-
cle activation/contraction considered tential to achieve ideal control. These
suboptimal (more or less activity/ include a range of features that are re-
muscle contraction than expected for lated to motor control of the trunk and
a task). Clinical muscle tests have been LBP psychosocial features,11 breath-
developed for specific trunk muscles ing,74,75 continence124 and pelvic floor
that are commonly involved in LBP. function,111 adjacent joint function,143 FIGURE 6. Ultrasound imaging can be used for
These include deep muscles of the ab- strength and endurance,115 balance,71 detailed assessment and biofeedback of contraction
dominal wall42,43 and the paraspinal sensory function,11 general fitness, of the deep trunk muscles, including the transversus
abdominis and multifidus.
muscles, including the multifidus.42,43 etc.66 Specific assessments used to

442 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
 2. Optimization of posture and move- improvement.28 A systematic review of Individualization of treatment, which is
ment: features of spinal position that 45 exercise trials (all forms of exercise) now generally recommended, appears to
are considered suboptimal in the as- in patients with chronic LBP showed a be important. Several trials have shown
sessment and relevant for symptoms modest benefit of exercise for nonspecif- that specific baseline features of mo-
are corrected/trained. Among many ic LBP, with greater efficacy than other tor control27,137 and features of symptom
options, this can include functional conservative therapies.120 Although effect presentation94 are associated with better
retraining in upright positions, with sizes were modest, this finding should not responses to treatment. These promising
adjustment of spinal alignment; res- be dismissed, because no intervention for findings require further investigation.
toration and maintenance of normal LBP has a large effect when delivered in
patterns of respiration while exercis- an RCT. Exercises classified as “coordi- Integrated Systems Model
ing; dissociation of movement of the nation/stabilization” generally showed a Underlying Concepts The ISM85,86,88
lumbar spine from that of the hip and positive effect. Another systematic review (FIGURE 7) is an evidence-informed (ie,
thorax; practicing functional tasks of 29 trials of MCT showed a clinically founded on research findings, but not yet
such as sit-to-stand, with optimal spi- important effect compared with minimal tested in RCTs), clinical-reasoning ap-
nal alignment and motion; and con- intervention for chronic LBP,117 but no proach to organize knowledge from mul-
trol of alignment and motion when superiority to other forms of exercise. Of tiple fields of science and clinical practice
challenged by unstable support.66,76 note, early trials with large clinical effects for the nonsurgical care of individuals
3. Functional integration and condi- applied MCT to specific patient groups with disability and pain. This approach
tioning: this phase targets the pa- in an individualized manner,47,108,129 is compatible with the “regional interde-
tient’s goals and can include exercises whereas most trials with modest effects pendence model,” a term used to describe
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to achieve increased endurance of have applied nonindividualized treat- clinical observations that regions of the
trunk muscles in functional activi- ments to patients with nonspecific LBP. body appear to be musculoskeletally
ties and positions. Resistance can be
added, with instruction to maintain
spinal alignment when using weights.
Flexible maintenance of spinal align-
ment in daily activities is encouraged,
without causing rigidity or interfering
with normal movement. Application
of MCT according to these principles
J Orthop Sports Phys Ther 2019.49:437-452.

has decreased LBP and the occurrence

of new injuries in several groups, in-
cluding athletes.51-53
4. Broader dimensions of management:
similar to other management ap-
proaches for patients with chronic
LBP, MCT can be combined and inte-
grated with other approaches, such as
those that manage psychological fea-
tures (eg, fear, catastrophizing, etc).
For MCT, as for many other approach-
es, understanding pain processes,
setting appropriate goals, providing
reassurance (minimizing fear avoid-
ance), and restoring pain-free normal
movement are paramount.
Evidence for Efficacy Over the last 3 de-
cades, changes to key recommendations
in clinical practice guidelines for the
management of LBP have placed great-
er emphasis on self-management and
FIGURE 7. The integrated systems model. Reprinted with permission from Diane Lee.
exercise programs targeting functional

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 443
 [ clinical commentary ]
linked, such that dysfunction in one body The patient is asked to report any sen- 3. Correcting alignment, biomechanics,
region could potentially lead to abnormal sations evoked as the task is performed, and/or control with manual examina-
stresses to other body regions and sub- while the clinician observes/palpates each tion and/or words/cues to assess the
sequent development of dysfunction/ region of the body and notes any areas impact of changing performance and
pain in those regions.130 Treating people with alignment, biomechanics, and/or the impact of changes on other body
with complex biopsychosocial problems control considered to be suboptimal. This regions.
requires an understanding of the rela- requires an understanding of what is op- 4. Choosing to first treat the area of the
tionship between, and the contribution timal for each body region for that task. body that has the greatest impact on
of, various body regions and systems that Subsequently, manual or verbal cues are performance of the task, regardless of
ultimately manifest as cognitive, emo- given to change the alignment, biome- the location of pain.
tional, or sensorial dissonance. Collec- chanics, and/or control used for a body Intervention Outline Intervention is
tively, this dissonance can be interpreted region, and the impact of this correction based on the findings of the clinical ex-
by the individual as threatening, and this on the patient’s experience, as well as any amination and a clinical-reasoning ap-
is thought to have the potential to mani- change in performance of other body re- proach.85,87 Intervention using the ISM
fest as pain anywhere in the body, fear gions, is noted. This is called “finding the approach may, therefore, involve a va-
of movement, movement impairments, driver,” which refers to the region of the riety of treatment approaches based on
anxiety, breathing disorders, and/or in- body that, when corrected, results in the different findings from different sys-
continence.3,5,12,64,103,123,141 Individuals with best improvement in both the experience tems, such as treatments based on al-
chronic LBP present with many of these and performance of the task. For an indi- tered active control (including motor
features and have complex histories con- vidual with LBP, it may be the hip, foot, control6,42,53-55,59,64,66), passive mobility or
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taining (1) multiple past high loads or ac- pelvis, thorax, neck, or a combination of passive control of joint structures4 (eg,
cumulative traumas to areas of the body, corrections.102,105,144 The low back is often stress tests) or myofascial tissue, or neu-
many only partly resolved, (2) beliefs and the “victim” of suboptimal strategies for rodynamics of the nervous system.106 The
cognitions that present barriers to recov- transferring loads through the trunk, re- assessment findings direct the initial
ery, and (3) poor lifestyle habits. gardless of whether the pain stage is acute treatment, which is individualized ac-
Ultimately, the ISM considers the im- or chronic.92,93 The driver can change cording to the underlying system impair-
pact that each system and body region both within and between treatment ses- ments impacting the body region.
has on function and performance of the sions when the whole body is evaluated for Each treatment may include the fol-
whole body and person. each task. The driver informs the clinician lowing elements.
Assessment Procedures An ISM assess- where to focus treatment. 1. Education: to address negative
J Orthop Sports Phys Ther 2019.49:437-452.

ment begins with a patient interview Further tests of the driver (the body thoughts/beliefs about pain12,91 and
to determine the contributions of the region found to have the greatest im- manual therapy to mobilize any joints
individual’s sensations, thoughts, and pact on the function/performance of the thought to be fibrotic or where mobil-
beliefs to the clinical picture. Negative meaningful task), such as active mobil- ity is reduced secondary to overactive
emotions and beliefs, or thoughts, are ity/control and passive mobility/control, muscles6,104,114 or fascia.8
common in patients with complex LBP reveal the contribution of various system 2. Motor control training42,53-55,59,64,66,135,136:
presentations and can be primary bar- impairments (articular, neural, myofas- to teach better recruitment strategies
riers to recovery.113 The patient’s goals cial, and/or visceral) to determine indi- for neuromuscular support of joints
are also determined through the patient vidualized treatment, as no 2 patients for both static loading and movement,
interview, and these goals determine the have identical thoughts, beliefs, and sys- and to restore optimal recruitment of
tasks analyzed in the physical examina- tem impairments culminating in their ex- the transversus abdominis, deep mul-
tion.122 The tasks may not always relate perience. These tests are directed to the tifidus, and pelvic floor muscles.
to the location of pain. For example, driver (thoughts/beliefs, emotions, hip, 3. Movement training: to build strength,
evaluating the squat task and sitting pelvis, low back, thorax, foot, etc). endurance, and capacity for the indi-
posture is meaningful for someone who In summary, assessment using the vidual’s movement goals.24,129
experiences LBP with sitting, but not ISM approach involves the following. Evidence for Efficacy This approach is
relevant for an individual with LBP that 1. Choosing a relevant assessment task evidence informed, and, although aspects
intensifies with walking. An evaluation according to the patient’s movement have been tested in trials, no RCT has yet
of strategies used for stepping forward goals. tested the efficacy of the entire approach.
and thoracic rotation, 2 requisite com- 2. Analyzing how the patient performs The clinician’s challenge is to decide which
ponents of walking, is more meaningful the task, using observation and man- treatment is appropriate for the individual
for the latter individual. ual examination. patient. The ISM aims to help clinicians

444 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
 use both the evidence and their experience 3. All approaches assume that tissue the patient in alignment and move-
to clinically reason the best way forward loading contributes to symptom ment correction; the ISM aims to “re-
for individuals with disability or pain. maintenance. lease and align”; and MCT enhances/
4. Some aspects of treatment aim to op- reduces muscle activity and modifies
Convergence and Divergence of timize tissue loading. alignment and movement as required.
Consideration of Motor Control 5. Correction of posture/alignment is 4. Evidence for assessment and treat-
in the Management of LBP considered in all approaches, particu- ment differs. Although there are vary-
Due to its diversity in presentation, LBP larly with reference to maintenance of ing levels of evidence for assessment
has been identified as a condition that a specific alignment during sustained techniques and the efficacy of MDT,
may be amenable to subgrouping. Clas- postures. the MSI approach, and MCT, the ISM
sification of patients to subgroups has 6. Careful and progressive instruction has not been tested, but some assess-
been highlighted as a research prior- regarding how to appropriately limit ments and treatments included in the
ity for heterogeneous disorders such as lumbar motions and move appropri- ISM approach have been studied.
LBP.7,41 A major aim of subgrouping is to ately at the hips during function is a The wrong question to ask is which
identify groups of individuals who may common theme in most approaches. approach is most effective. Rather, by
be more or less responsive to a specific 7. Attention is placed on the patient- identifying and validating subgroups,
treatment, based on certain presenting therapist alliance: the importance of some patients can be more effectively
characteristics.18 Evidence to support the identifying subgroups, understanding treated with one approach than with
potential benefits of identifying differ- the patient’s goals and expectations, another.78 Further, patients often prefer
ent subgroups of patients with LBP who use of appropriate communication the type of intervention they are willing
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will predictably respond to specific treat- skills, patient education, safety, self- to undertake and adhere to. Clinicians
ments comes from recent trials that show care and patient independence, work- also have differing skill sets, levels and
larger effect sizes for MCT in individuals ing together with the patient and types of training, levels of expertise, and
with specific baseline features27,94,137 and the medical/multidisciplinary team, previous experiences. As LBP can be
from the large clinical effects identified in setting realistic goals, reassurance to multifactorial, ideal management must
early trials that applied MCT to specific minimize fear avoidance, understand- first seek to reliably identify subgroups
groups of patients with LBP.47,108,129 ing pain processes and their relevance, for which there are predictably effective
While no single approach will solve the importance of pain-free move- treatments. Those validated subgroups
the entire LBP problem, identifying sub- ment, and the need to promote LBP will then inform the type of interven-
groups of patients whose condition can be prevention. tion needed to bring about improve-
J Orthop Sports Phys Ther 2019.49:437-452.

resolved by subgroup-specific treatments There are also divergences between ment: mechanical, medication, motor
should be prioritized. Although applica- approaches. control, psychosocial, injection, or even
tion of motor control theory to LBP man- 1. Not all approaches have shown reli- surgery. This may require integrating
agement varies, there is convergence. ability in identifying subgroups that other health professionals who can ad-
The TABLE summarizes key features con- the approach can and cannot treat vise on other forms of treatment (eg,
sidered by each motor control approach. with predictive effectiveness. appropriate medication). Ideally, those
Areas of convergence/similarity between 2. Approaches differ somewhat in their approaches would be complementary
approaches include the following. primary focus, the most obvious be- and enhance the response to physical
1. All approaches incorporate detailed ing that MDT emphasizes evaluation and neuromuscular approaches.
assessment (including patient inter- of patterns of symptom response to a
view and physical examination) to standardized group of repeated end- Interface With Nonsurgical
guide individualized treatment, but range spinal loading tests, whereas Medical Management
the elements addressed differ. the MSI approach, MCT, and the ISM Subgrouping patients via movement
2. All approaches include clinical rea- stress correcting alignment and move- patterns, posture, and provocative and
soning. Although some individual ment patterns, but within different symptom-relieving mechanical testing,
elements of the approaches may help clinical frameworks. such as the methods described above, is
some patients when used in isolation, 3. Initial management differs. Mechani- not only relevant for physical therapists,
effect sizes appear to be larger when cal Diagnosis and Therapy seeks to but also an important concept for health
treatment involves integrated use of identify mechanical subgroups, and care providers of any profession manag-
multiple components in a clinical- patients are taught to perform exer- ing patients with LBP. This consideration
reasoning framework, matched to in- cises based on this assessment; the aids removal of the “non” from “nonspe-
dividual patients.94,153 MSI approach involves instructing cific” LBP.

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 445
 [ clinical commentary ]

TABLE Features of the Approaches

Movement Systems Motor Control Integrated Systems

Medical Approach MDT Approach Training Approach
Evidence
Evidence for effectiveness for patients with acute LBP ? Yes
Evidence for effectiveness for patients with chronic LBP ? Yes Yes Yes
Demonstrated reliability and validity of assessments Yes Yes Yes
Treatment components related to motor control
Treatment based on detailed physical examination Yes Yes Yes Yes Yes
Spinal posture/alignment is assessed and trained Yes Yes Yes Yes Yes
“Neutral spine” is a key feature Yes Yes Yes
Movement is assessed and trained Yes Yes Yes Yes
Movement quality is a key feature Yes Yes Yes Yes
Muscle activation is assessed and trained Yes Yes
Aim for pain-free movement Yes Yes Yes Yes Yes
Focus on importance of mechanical/biomechanical focus Yes Yes Yes
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Body awareness is considered in assessment and treatment Yes Yes Yes

Breathing pattern is assessed and trained Yes Yes Yes
Mobility of adjacent areas is assessed and trained Yes Yes Yes
Includes exercise that aims to integrate into function rehabilitation Yes Yes Yes Yes
Includes exercise to enhance muscle endurance Yes Yes
Includes exercise to enhance muscle strength ? Yes ?
Biofeedback is used to guide motor control training Yes Yes Yes
Additional aspects considered in design of treatment
Patient interview provides information to guide treatment application Yes Yes Yes Yes Yes
Identifies directional preference in response to mechanical loading Yes
J Orthop Sports Phys Ther 2019.49:437-452.

Identification of “pain generators” is important Yes Yes

Whole-person assessment to identify the “driver” of the patient’s Yes Yes
presentation
Approach considers patient’s lifestyle Yes Yes Yes Yes
Self-management is advocated Yes Yes Yes Yes Yes
Aims to enhance prevention of further LBP episodes Yes Yes Yes Yes Yes
Approach can be combined with other treatments Yes Yes Yes Yes Yes
Approach is staged with guidance for progression of training Yes Yes Yes Yes
Adjunct treatments
Considers injection of drugs Yes *
Considers prescription of oral medication Yes *
Psychosocial features are assessed and targeted with management Yes †
Yes Yes
Training
Approach requires specialized training Yes Yes Yes Yes Yes
Credentialed training is available Yes Yes
Abbreviations: LBP, low back pain; MDT, Mechanical Diagnosis and Therapy.
*Studies argue that response to MDT assessment may aid this decision (van Helvoirt H, Apeldoorn AT, Knol DL, et al. Transforaminal epidural steroid injec-
tions influence Mechanical Diagnosis and Therapy (MDT) pain response classification in candidates for lumbar herniated disc surgery. J Back Musculoskelet
Rehabil. 2016;29:351-359. https://doi.org/10.3233/BMR-160662).
†
Studies argue that psychological features may be improved by positive response to treatment (Takasaki H, Saiki T, Iwasada Y. McKenzie therapists adhere
more to evidence-based guidelines and have a more biopsychosocial perspective on the management of patients with low back pain than general physical thera-
pists in Japan. Open J Ther Rehabil. 2014;2:173-181. https://doi.org/10.4236/ojtr.2014.24023).

446 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
 Identification of relevant motor con- Overall, it is critical for health care sion, based on presentation and response.
trol features or a specific response to providers to understand and consider Benefit can be gained by improved com-
a movement test can inform specific the relative importance of factors beyond munication and increased collaboration
movements and corrective exercises, motor control to optimize the treatment between colleagues in multiple disciplines
with a rapid response for some patients. approach and achieve successful long- to manage aspects of the multifaceted pre-
Other patients may have a presentation term patient outcomes.5,139 The impor- sentation of LBP (eg, specialist psycho-
complicated by features such as differ- tance of standardizing the diagnostic/ logical intervention), when needed, and
ences in pain processing, experience of subgrouping process cannot be overem- to facilitate treatment approaches that in-
intense pain, fear avoidance, and previ- phasized, as that will inform treatment clude consideration of motor control (eg,
ous experiences that compromise their decision making in a multidisciplinary appropriate analgesia). t
full participation in physical treatments. framework.
These patients may benefit from coordi- ACKNOWLEDGMENTS: The forum on which this
nating physical and medical treatments CONCLUSION body of research was based, “State-of-the-Art
to fully accomplish recovery from an epi- in Motor Control and Low Back Pain: Inter-

T
sode of LBP and establish a maintenance his commentary reviewed con- national Clinical and Research Expert Fo-
program and future self-management of vergence and divergence in ap- rum,” was supported by the National Health
LBP episodes. A coordinated interprofes- proaches to LBP management that and Medical Research Council of Australia,
sional approach, including medical man- include consideration of motor control. in collaboration with the North American
agement, is required to achieve the best The element common to all approaches Spine Society. The forum was chaired by Dr
outcomes. The TABLE presents some of the is the focus on the need to reliably iden- Paul Hodges.
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interfaces between medical and motor tify membership or nonmembership in

control approaches. validated subgroups of patients who have
At initial presentation, a thorough ex- been shown to respond to treatment that REFERENCES
amination alludes to the potential benefit eliminates pain when possible, optimizes
1. Alaranta H, Tallroth K, Soukka A, Heliövaara M.
of combining medical and motor control alignment, restores and maintains full Fat content of lumbar extensor muscles and low
interventions. The history gives insight lumbar motion, and ensures that adjoin- back disability: a radiographic and clinical com-
regarding medical management that ing body regions demonstrate full and parison. J Spinal Disord. 1993;6:137-140.
2. Arendt-Nielsen L, Graven-Nielsen T, Svarrer
might be necessary as adjunct interven- free movement. This focus is applied
H, Svensson P. The influence of low back
tions to physical treatment. Features that during exercise as well as in activities of pain on muscle activity and coordination
may guide medical management include daily living, fitness, and sports. The major during gait: a clinical and experimental
J Orthop Sports Phys Ther 2019.49:437-452.

behavioral health (occupational health/ differences between approaches relate to study. Pain. 1996;64:231-240. https://doi.
org/10.1016/0304-3959(95)00115-8
psychological interventions), poor sleep the baseline examination methods and
3. Beales D, Lutz A, Thompson J, Wand BM,
(sleep education/medication), quality the patient-specific treatments used to O’Sullivan P. Disturbed body perception, re-
and distribution of pain recognized as eliminate pain while restoring optimal duced sleep, and kinesiophobia in subjects with
neuropathic (medication), and recurrent alignment and movement. pregnancy-related persistent lumbopelvic pain
and moderate levels of disability: an exploratory
soft tissue complaints (interventional No evidence supports one treatment
study. Man Ther. 2016;21:69-75. https://doi.
procedures). approach over another. However, the re- org/10.1016/j.math.2015.04.016
Some patients benefit from medica- liable identification of members of sub- 4. Beazell JR, Mullins M, Grindstaff TL. Lumbar
tion to manage symptoms and to enable groups for which there are predictably instability: an evolving and challenging concept.
J Man Manip Ther. 2010;18:9-14. https://doi.org/
performance of physical treatments to effective subgroup-specific treatments
10.1179/106698110X12595770849443
reach their potential. Decisions about begins the process of identifying stan- 5. Bialosky JE, Bishop MD, Cleland JA. Individual
the need for and type of medications3 dardized treatment for members of each expectation: an overlooked, but pertinent, factor
are influenced by the time course of LBP, subgroup. By identifying areas of conver- in the treatment of individuals experiencing mus-
culoskeletal pain. Phys Ther. 2010;90:1345-1355.
the distribution and quality of pain, the gence/divergence and acknowledging ex-
https://doi.org/10.2522/ptj.20090306
underlying pain mechanism (eg, central, isting literature that validates subgroups, 6. Bialosky JE, Bishop MD, Price DD, Robinson ME,
neuropathic, nociceptive), the nature of we hope these insights can provide guid- George SZ. The mechanisms of manual therapy
provocative activities, sleep interference, ance to clinicians regarding which ap- in the treatment of musculoskeletal pain: a com-
prehensive model. Man Ther. 2009;14:531-538.
and the patient’s beliefs, experiences, and proach will serve their patients best.
https://doi.org/10.1016/j.math.2008.09.001
expectations. A scheduled medication This information can also provide a 7. Borkan JM, Koes B, Reis S, Cherkin DC. A
regime may accomplish adequate pain platform for teams to work together to report from the Second International Forum
control for the patient to participate in consider hybrid approaches tailored to the for Primary Care Research on Low Back Pain.
Reexamining priorities. Spine (Phila Pa 1976).
an active physical therapeutic program. individual patient for a focused progres-

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 447
 [ clinical commentary ]
1998;23:1992-1996. 485; discussion 485-489. https://doi. 2003;28:1363-1371; discussion 1372. https://doi.
8. Branchini M, Lopopolo F, Andreoli E, Loreti I, org/10.1093/ptj/75.6.470 org/10.1097/01.BRS.0000067115.61673.FF
Marchand AM, Stecco A. Fascial Manipulation® 19. D  onelson R, Aprill C, Medcalf R, Grant W. A 31. Fritz JM, Delitto A, Vignovic M, Busse RG. Inter-
for chronic aspecific low back pain: a single prospective study of centralization of lumbar and rater reliability of judgments of the centralization
blinded randomized controlled trial. F1000Res. referred pain. A predictor of symptomatic discs phenomenon and status change during move-
2015;4:1208. https://doi.org/10.12688/ and anular [sic] competence. Spine (Phila Pa ment testing in patients with low back pain. Arch
f1000research.6890.2 1976). 1997;22:1115-1122. Phys Med Rehabil. 2000;81:57-61. https://doi.
9. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, 20. D  onelson R, Silva G, Murphy K. Centralization org/10.1016/S0003-9993(00)90222-3
Delitto A, Erhard RE. Identifying subgroups of phenomenon. Its usefulness in evaluating and 32. Garcia AN, Costa L, de Souza FS, et al. Reliability
patients with acute/subacute “nonspecific” low treating referred pain. Spine (Phila Pa 1976). of the Mechanical Diagnosis and Therapy system
back pain: results of a randomized clinical trial. 1990;15:211-213. in patients with spinal pain: a systematic review.
Spine (Phila Pa 1976). 2006;31:623-631. https:// 21. E lgueta-Cancino E, Schabrun S, Danneels L, J Orthop Sports Phys Ther. 2018;48:923-933.
doi.org/10.1097/01.brs.0000202807.72292.a8 Hodges P. A clinical test of lumbopelvic control: https://doi.org/10.2519/jospt.2018.7876
10. Browder DA, Childs JD, Cleland JA, Fritz JM. Ef- development and reliability of a clinical test of 33. Gombatto SP, Collins DR, Sahrmann SA, Engs-
fectiveness of an extension-oriented treatment dissociation of lumbopelvic and thoracolumbar berg JR, Van Dillen LR. Gender differences in
approach in a subgroup of subjects with low motion. Man Ther. 2014;19:418-424. https://doi. pattern of hip and lumbopelvic rotation in people
back pain: a randomized clinical trial. Phys Ther. org/10.1016/j.math.2014.03.009 with low back pain. Clin Biomech (Bristol, Avon).
2007;87:1608-1618. https://doi.org/10.2522/ 22. E lgueta-Cancino E, Schabrun S, Danneels L, 2006;21:263-271. https://doi.org/10.1016/j.
ptj.20060297 van den Hoorn W, Hodges P. Validation of a clinbiomech.2005.11.002
11. Brumagne S, Cordo P, Lysens R, Verschueren S, clinical test of thoracolumbar dissociation in 34. Gombatto SP, Norton BJ, Sahrmann SA, Strube
Swinnen S. The role of paraspinal muscle spin- chronic low back pain. J Orthop Sports Phys MJ, Van Dillen LR. Factors contributing to lumbar
dles in lumbosacral position sense in individuals Ther. 2015;45:703-712. https://doi.org/10.2519/ region passive tissue characteristics in people
with and without low back pain. Spine (Phila Pa jospt.2015.5590 with and people without low back pain. Clin Bio-
1976). 2000;25:989-994. 23. E lgueta-Cancino E, Schabrun S, Hodges P. Is the mech (Bristol, Avon). 2013;28:255-261. https://
Downloaded from www.jospt.org by 5.189.200.137 on 07/17/19. For personal use only.

12. Campbell CM, Edwards RR. Mind–body interac- organization of the primary motor cortex in low doi.org/10.1016/j.clinbiomech.2013.01.005
tions in pain: the neurophysiology of anxious back pain related to pain, movement, and/or 35. Gombatto SP, Norton BJ, Scholtes SA, Van Dillen
and catastrophic pain-related thoughts. Transl sensation? Clin J Pain. 2018;34:207-216. LR. Differences in symmetry of lumbar region
Res. 2009;153:97-101. https://doi.org/10.1016/j. 24. F alla D, Hodges PW. Individualized exercise passive tissue characteristics between people
trsl.2008.12.002 interventions for spinal pain. Exerc Sport Sci with and people without low back pain. Clin Bio-
13. Chimenti RL, Scholtes SA, Van Dillen LR. Activity Rev. 2017;45:105-115. https://doi.org/10.1249/ mech (Bristol, Avon). 2008;23:986-995. https://
characteristics and movement patterns in people JES.0000000000000103 doi.org/10.1016/j.clinbiomech.2008.05.006
with and people without low back pain who 25. F alla D, Jull G, Russell T, Vicenzino B, Hodges 36. Guzy G, Frańczuk B, Krąkowska A. A clinical trial
participate in rotation-related sports. J Sport Re- P. Effect of neck exercise on sitting posture in comparing the McKenzie method and a complex
habil. 2013;22:161-169. https://doi.org/10.1123/ patients with chronic neck pain. Phys Ther. rehabilitation program in patients with cervical
jsr.22.3.161 2007;87:408-417. https://doi.org/10.2522/ derangement syndrome. J Orthop Trauma Surg
14. Claus AP, Hides JA, Moseley GL, Hodges PW. ptj.20060009 Rel Res. 2011;2:32-38.
Different ways to balance the spine in sitting: 26. F erreira PH, Ferreira ML, Hodges PW. Changes 37. Hall L, Tsao H, MacDonald D, Coppieters M,
J Orthop Sports Phys Ther 2019.49:437-452.

muscle activity in specific postures differs in recruitment of the abdominal muscles in Hodges PW. Immediate effects of co-contraction
between individuals with and without a history people with low back pain: ultrasound measure- training on motor control of the trunk muscles
of back pain in sitting. Clin Biomech (Bristol, ment of muscle activity. Spine (Phila Pa 1976). in people with recurrent low back pain. J Elec-
Avon). 2018;52:25-32. https://doi.org/10.1016/j. 2004;29:2560-2566. https://doi.org/10.1097/01. tromyogr Kinesiol. 2009;19:763-773. https://doi.
clinbiomech.2018.01.003 brs.0000144410.89182.f9 org/10.1016/j.jelekin.2007.09.008
15. Cook C, Hegedus E, Ramey K. Physical 27. F erreira PH, Ferreira ML, Maher CG, Refshauge K, 38. Harris-Hayes M, Sahrmann SA, Van Dillen LR.
therapy exercise intervention based on clas- Herbert RD, Hodges PW. Changes in recruitment Relationship between the hip and low back pain
sification using the patient response method: of transversus abdominis correlate with disability in athletes who participate in rotation-related
a systematic review of the literature. J Man in people with chronic low back pain. Br J Sports sports. J Sport Rehabil. 2009;18:60-75. https://
Manip Ther. 2005;13:152-162. https://doi. Med. 2010;44:1166-1172. https://doi.org/10.1136/ doi.org/10.1123/jsr.18.1.60
org/10.1179/106698105790824950 bjsm.2009.061515 39. Harris-Hayes M, Van Dillen LR. The inter-tester
16. Dankaerts W, O’Sullivan P, Burnett A, Straker 28. F oster NE, Anema JR, Cherkin D, et al. Preven- reliability of physical therapists classifying low
L. Differences in sitting postures are associ- tion and treatment of low back pain: evidence, back pain problems based on the Movement
ated with nonspecific chronic low back pain challenges, and promising directions. Lancet. System Impairment classification system. PM
disorders when patients are subclassified. Spine 2018;391:2368-2383. https://doi.org/10.1016/ R. 2009;1:117-126. https://doi.org/10.1016/j.
(Phila Pa 1976). 2006;31:698-704. https://doi. S0140-6736(18)30489-6 pmrj.2008.08.001
org/10.1097/01.brs.0000202532.76925.d2 29. F ranz A, Lacasse A, Donelson R, Tousignant- 40. Henry SM, Van Dillen LR, Trombley AR, Dee JM,
17. Delitto A, Cibulka MT, Erhard RE, Bowling RW, Laflamme Y. Effectiveness of directional prefer- Bunn JY. Reliability of novice raters in using
Tenhula JA. Evidence for use of an extension-mo- ence to guide management of low back pain in the Movement System Impairment approach
bilization category in acute low back syndrome: Canadian Armed Forces members: a pragmatic to classify people with low back pain. Man
a prescriptive validation pilot study. Phys Ther. study. Mil Med. 2017;182:e1957-e1966. https:// Ther. 2013;18:35-40. https://doi.org/10.1016/j.
1993;73:216-222; discussion 223-228. https://doi. doi.org/10.7205/MILMED-D-17-00032 math.2012.06.008
org/10.1093/ptj/73.4.216 30. F ritz JM, Delitto A, Erhard RE. Comparison 41. Henschke N, Maher CG, Refshauge KM, et al.
18. Delitto A, Erhard RE, Bowling RW. A treatment- of classification-based physical therapy with Prevalence of and screening for serious spinal
based classification approach to low back therapy based on clinical practice guidelines pathology in patients presenting to primary
syndrome: identifying and staging patients for for patients with acute low back pain: a ran- care settings with acute low back pain. Arthri-
conservative treatment. Phys Ther. 1995;75:470- domized clinical trial. Spine (Phila Pa 1976). tis Rheum. 2009;60:3072-3080. https://doi.

448 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
 org/10.1002/art.24853 org/10.1249/MSS.0b013e318244a321 to pain. Pain. 2011;152:S90-S98. https://doi.
42. Hides J, Richardson C, Hodges P. Local segmen- 54. H
 ides JA, Stanton WR, Wilson SJ, Freke org/10.1016/j.pain.2010.10.020
tal control. In: Richardson C, Hodges P, Hides M, McMahon S, Sims K. Retraining motor 66. Hodges PW, van Dillen L, McGill S, Brumagne
J, eds. Therapeutic Exercise for Lumbopelvic control of abdominal muscles among elite S, Hides JA, Moseley GL. Integrated clinical ap-
Stabilization: A Motor Control Approach for the cricketers with low back pain. Scand J Med proach to motor control interventions in low back
Treatment and Prevention of Low Back Pain. 2nd Sci Sports. 2010;20:834-842. https://doi. and pelvic pain. In: Hodges PW, Cholewicki J, van
ed. Edinburgh, UK: Elsevier/Churchill LIvingstone; org/10.1111/j.1600-0838.2009.01019.x Dieën JH, eds. Spinal Control: The Rehabilita-
2004:185-219. 55. H
 ides JA, Stokes MJ, Saide M, Jull GA, Cooper tion of Back Pain. State of the Art and Science.
43. Hides J, Stanton W, Mendis MD, Sexton M. DH. Evidence of lumbar multifidus muscle Edinburgh, UK: Elsevier/Churchill Livingstone;
The relationship of transversus abdominis wasting ipsilateral to symptoms in patients with 2013:243-310.
and lumbar multifidus clinical muscle tests in acute/subacute low back pain. Spine (Phila Pa 67. Hoffman SL, Harris-Hayes M, Van Dillen LR. Dif-
patients with chronic low back pain. Man Ther. 1976). 1994;19:165-172. ferences in activity limitation between 2 low back
2011;16:573-577. https://doi.org/10.1016/j. 56. H
 odges P, van den Hoorn W, Dawson A, Chole- pain subgroups based on the Movement System
math.2011.05.007 wicki J. Changes in the mechanical properties Impairment model. PM R. 2010;2:1113-1118.
44. Hides JA, Belavý DL, Cassar L, Williams M, of the trunk in low back pain may be associated https://doi.org/10.1016/j.pmrj.2010.09.003
Wilson SJ, Richardson CA. Altered response of with recurrence. J Biomech. 2009;42:61-66. 68. Hoffman SL, Johnson MB, Zou D, Harris-Hayes
the anterolateral abdominal muscles to simu- https://doi.org/10.1016/j.jbiomech.2008.10.001 M, Van Dillen LR. Effect of classification-specific
lated weight-bearing in subjects with low back 57. H
 odges PW, Cholewicki J. Functional control of treatment on lumbopelvic motion during hip
pain. Eur Spine J. 2009;18:410-418. https://doi. the spine. In: Vleeming A, Mooney V, Stoeckart rotation in people with low back pain. Man Ther.
org/10.1007/s00586-008-0827-2 R, eds. Movement, Stability and Lumbopelvic 2011;16:344-350. https://doi.org/10.1016/j.
45. Hides JA, Cooper DH, Stokes MJ. Diagnostic Pain: Integration of Research and Therapy. 2nd math.2010.12.007
ultrasound imaging for measurement of the lum- ed. Edinburgh, UK: Elsevier/Churchill Livingstone; 69. Hoffman SL, Johnson MB, Zou D, Van Dillen LR.
bar multifidus muscle in normal young adults. 2007:489-512. Gender differences in modifying lumbopelvic mo-
Physiother Theory Pract. 1992;8:19-26. https:// 58. H
 odges PW, Coppieters MW, MacDonald tion during hip medial rotation in people with low
Downloaded from www.jospt.org by 5.189.200.137 on 07/17/19. For personal use only.

doi.org/10.3109/09593989209108076 D, Cholewicki J. New insight into motor back pain. Rehabil Res Pract. 2012;2012:635312.
46. Hides JA, Endicott T, Mendis MD, Stanton WR. adaptation to pain revealed by a combina- https://doi.org/10.1155/2012/635312
The effect of motor control training on ab- tion of modelling and empirical approaches. 70. Hoffman SL, Johnson MB, Zou D, Van Dillen LR.
dominal muscle contraction during simulated Eur J Pain. 2013;17:1138-1146. https://doi. Sex differences in lumbopelvic movement pat-
weight bearing in elite cricketers. Phys Ther org/10.1002/j.1532-2149.2013.00286.x terns during hip medial rotation in people with
Sport. 2016;20:26-31. https://doi.org/10.1016/j. 59. H
 odges PW, Ferreira PH, Ferreira ML. Lumbar chronic low back pain. Arch Phys Med Rehabil.
ptsp.2016.05.003 spine: treatment of motor control disorders. In: 2011;92:1053-1059. https://doi.org/10.1016/j.
47. Hides JA, Jull GA, Richardson CA. Long-term Magee DJ, Zachazewski JE, Quillen WS, Manske apmr.2011.02.015
effects of specific stabilizing exercises for first- RC, eds. Pathology and Intervention in Mus- 71. Hooper TL, James CR, Brismée JM, et al. Dy-
episode low back pain. Spine (Phila Pa 1976). culoskeletal Rehabilitation. 2nd ed. Maryland namic balance as measured by the Y-Balance
2001;26:E243-E248. Heights, MO: Elsevier; 2016:520-560. Test is reduced in individuals with low back pain:
48. Hides JA, Mendis MD, Franettovich Smith MM, 60. H
 odges PW, Galea MP, Holm S, Holm AK. a cross-sectional comparative study. Phys Ther
Miokovic T, Cooper A, Low Choy N. Association Corticomotor excitability of back muscles is af- Sport. 2016;22:29-34. https://doi.org/10.1016/j.
J Orthop Sports Phys Ther 2019.49:437-452.

between altered motor control of trunk muscles fected by intervertebral disc lesion in pigs. Eur ptsp.2016.04.006
and head and neck injuries in elite footballers – J Neurosci. 2009;29:1490-1500. https://doi. 72. Hyde J, Stanton WR, Hides JA. Abdominal muscle
an exploratory study. Man Ther. 2016;24:46-51. org/10.1111/j.1460-9568.2009.06670.x response to a simulated weight-bearing task by
https://doi.org/10.1016/j.math.2016.05.001 61. H
 odges PW, James G, Blomster L, et al. elite Australian Rules football players. Hum Mov
49. Hides JA, Richardson CA, Jull GA. Magnetic Multifidus muscle changes after back injury Sci. 2012;31:129-138. https://doi.org/10.1016/j.
resonance imaging and ultrasonography of are characterized by structural remodeling humov.2011.04.005
the lumbar multifidus muscle. Comparison of of muscle, adipose and connective tissue, 73. James G, Sluka KA, Blomster L, et al. Macro-
two different modalities. Spine (Phila Pa 1976). but not muscle atrophy: molecular and mor- phage polarization contributes to local inflam-
1995;20:54-58. phological evidence. Spine (Phila Pa 1976). mation and structural change in the multifidus
50. Hides JA, Richardson CA, Jull GA. Multifidus 2015;40:1057-1071. https://doi.org/10.1097/ muscle after intervertebral disc injury. Eur Spine
muscle recovery is not automatic after resolution BRS.0000000000000972 J. 2018;27:1744-1756. https://doi.org/10.1007/
of acute, first-episode low back pain. Spine (Phila 62. H
 odges PW, Pengel LH, Herbert RD, Gandevia SC. s00586-018-5652-7
Pa 1976). 1996;21:2763-2769. Measurement of muscle contraction with ultra- 74. Janssens L, Brumagne S, McConnell AK, Her-
51. Hides JA, Stanton WR. Can motor control sound imaging. Muscle Nerve. 2003;27:682-692. mans G, Troosters T, Gayan-Ramirez G. Greater
training lower the risk of injury for profes- https://doi.org/10.1002/mus.10375 diaphragm fatigability in individuals with recur-
sional football players? Med Sci Sports Exerc. 63. H
 odges PW, Richardson CA. Inefficient muscular rent low back pain. Respir Physiol Neurobiol.
2014;46:762-768. https://doi.org/10.1249/ stabilization of the lumbar spine associated with 2013;188:119-123. https://doi.org/10.1016/j.
MSS.0000000000000169 low back pain. A motor control evaluation of resp.2013.05.028
52. Hides JA, Stanton WR, Mendis MD, Franettovich transversus abdominis. Spine (Phila Pa 1976). 75. Janssens L, Pijnenburg M, Claeys K, McConnell
Smith MM, Sexton MJ. Small multifidus muscle 1996;21:2640-2650. AK, Troosters T, Brumagne S. Postural strategy
size predicts football injuries. Orthop J Sports 64. H
 odges PW, Smeets RJ. Interaction between pain, and back muscle oxygenation during inspira-
Med. 2014;2:2325967114537588. https://doi. movement, and physical activity: short-term tory muscle loading. Med Sci Sports Exerc.
org/10.1177/2325967114537588 benefits, long-term consequences, and targets 2013;45:1355-1362. https://doi.org/10.1249/
53. Hides JA, Stanton WR, Mendis MD, Gildea J, Sex- for treatment. Clin J Pain. 2015;31:97-107. https:// MSS.0b013e3182853d27
ton MJ. Effect of motor control training on muscle doi.org/10.1097/AJP.0000000000000098 76. Kang TW, Lee JH, Park DH, Cynn HS. Effect of
size and football games missed from injury. Med 65. H
 odges PW, Tucker K. Moving differently in 6-week lumbar stabilization exercise performed
Sci Sports Exerc. 2012;44:1141-1149. https://doi. pain: a new theory to explain the adaptation on stable versus unstable surfaces in automobile

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 449
 [ clinical commentary ]
assembly workers with mechanical chronic low 89. L ong A, Donelson R, Fung T. Does it matter org/10.1097/BRS.0b013e3181dfce83
back pain. Work. 2018;60:445-454. https://doi. which exercise? A randomized control trial of 101. Mok NW, Brauer SG, Hodges PW. Failure to
org/10.3233/WOR-182743 exercise for low back pain. Spine (Phila Pa 1976). use movement in postural strategies leads to
77. Karas R, McIntosh G, Hall H, Wilson L, Melles T. 2004;29:2593-2602. https://doi.org/10.1097/01. increased spinal displacement in low back pain.
The relationship between nonorganic signs and brs.0000146464.23007.2a Spine (Phila Pa 1976). 2007;32:E537-E543.
centralization of symptoms in the prediction of 90. L ong AL. The centralization phenomenon: its https://doi.org/10.1097/BRS.0b013e31814541a2
return to work for patients with low back pain. usefulness as a predictor or outcome in con- 102. Moseley GL. Impaired trunk muscle function
Phys Ther. 1997;77:354-360; discussion 361-369. servative treatment of chronic low back pain (a in sub-acute neck pain: etiologic in the sub-
https://doi.org/10.1093/ptj/77.4.354 pilot study). Spine (Phila Pa 1976). 1995;20:2513- sequent development of low back pain? Man
78. Karayannis NV, Jull GA, Hodges PW. Physiother- 2520; discussion 2521. Ther. 2004;9:157-163. https://doi.org/10.1016/j.
apy movement based classification approaches 91. L ouw A, Nijs J, Puentedura EJ. A clinical per- math.2004.03.002
to low back pain: comparison of subgroups spective on a pain neuroscience education 103. Moseley GL, Gallace A, Spence C. Bodily il-
through review and developer/expert survey. BMC approach to manual therapy. J Man Manip Ther. lusions in health and disease: physiological
Musculoskelet Disord. 2012;13:24. https://doi. 2017;25:160-168. https://doi.org/10.1080/10669 and clinical perspectives and the concept of
org/10.1186/1471-2474-13-24 817.2017.1323699 a cortical ‘body matrix’. Neurosci Biobehav
79. Karayannis NV, Smeets RJ, van den Hoorn W, 92. M  acDonald D, Moseley GL, Hodges PW. People Rev. 2012;36:34-46. https://doi.org/10.1016/j.
Hodges PW. Fear of movement is related to with recurrent low back pain respond differently neubiorev.2011.03.013
trunk stiffness in low back pain. PLoS One. to trunk loading despite remission from symp- 104. Moseley L. Combined physiotherapy and educa-
2013;8:e67779. https://doi.org/10.1371/journal. toms. Spine (Phila Pa 1976). 2010;35:818-824. tion is efficacious for chronic low back pain.
pone.0067779 https://doi.org/10.1097/BRS.0b013e3181bc98f1 Aust J Physiother. 2002;48:297-302. https://doi.
80. Kilby J, Stigant M, Roberts A. The reliability of 93. M  acDonald D, Moseley GL, Hodges PW. Why org/10.1016/S0004-9514(14)60169-0
back pain assessment by physiotherapists, do some patients keep hurting their back? 105. Müller R, Ertelt T, Blickhan R. Low back pain
using a ‘McKenzie algorithm’. Physiotherapy. Evidence of ongoing back muscle dysfunction affects trunk as well as lower limb move-
1990;76:579-583. https://doi.org/10.1016/ during remission from recurrent back pain. Pain. ments during walking and running. J Biomech.
Downloaded from www.jospt.org by 5.189.200.137 on 07/17/19. For personal use only.

S0031-9406(10)63053-2 2009;142:183-188. https://doi.org/10.1016/j. 2015;48:1009-1014. https://doi.org/10.1016/j.

81. Kilpikoski S, Airaksinen O, Kankaanpää M, pain.2008.12.002 jbiomech.2015.01.042
Leminen P, Videman T, Alen M. Interexaminer 94. M  acedo LG, Maher CG, Hancock MJ, et al. Pre- 106. Nee RJ, Butler D. Management of peripheral
reliability of low back pain assessment using dicting response to motor control exercises and neuropathic pain: integrating neurobiology,
the McKenzie method. Spine (Phila Pa 1976). graded activity for patients with low back pain: neurodynamics, and clinical evidence. Phys Ther
2002;27:E207-E214. preplanned secondary analysis of a randomized Sport. 2006;7:36-49. https://doi.org/10.1016/j.
82. Kilpikoski S, Alèn M, Paatelma M, Simonen R, controlled trial. Phys Ther. 2014;94:1543-1554. ptsp.2005.10.002
Heinonen A, Videman T. Outcome comparison https://doi.org/10.2522/ptj.20140014 107. Norton BJ, Sahrmann SA, Van Dillen LR. Differ-
among working adults with centralizing low 95. M  arich AV, Hwang CT, Salsich GB, Lang CE, Van ences in measurements of lumbar curvature
back pain: secondary analysis of a random- Dillen LR. Consistency of a lumbar movement related to gender and low back pain. J Orthop
ized controlled trial with 1-year follow-up. pattern across functional activities in people Sports Phys Ther. 2004;34:524-534. https://doi.
Adv Physiother. 2009;11:210-217. https://doi. with low back pain. Clin Biomech (Bristol, org/10.2519/jospt.2004.34.9.524
org/10.3109/14038190902963087 Avon). 2017;44:45-51. https://doi.org/10.1016/j. 108. O’Sullivan PB, Phyty GD, Twomey LT, Allison
J Orthop Sports Phys Ther 2019.49:437-452.

83. Kjaer P, Bendix T, Sorensen JS, Korsholm L, clinbiomech.2017.03.004 GT. Evaluation of specific stabilizing exercise
Leboeuf-Yde C. Are MRI-defined fat infiltrations 96. M  arich AV, Lanier VM, Salsich GB, Lang CE, Van in the treatment of chronic low back pain
in the multifidus muscles associated with low Dillen LR. Immediate effects of a single session with radiologic diagnosis of spondylolysis
back pain? BMC Med. 2007;5:2. https://doi. of motor skill training on the lumbar movement or spondylolisthesis. Spine (Phila Pa 1976).
org/10.1186/1741-7015-5-2 pattern during a functional activity in people with 1997;22:2959-2967.
84. Laslett M, Öberg B, Aprill CN, McDonald B. Cen- low back pain: a repeated-measures study. Phys 109. Petersen T, Larsen K, Nordsteen J, Olsen S,
tralization as a predictor of provocation discog- Ther. 2018;98:605-615. https://doi.org/10.1093/ Fournier G, Jacobsen S. The McKenzie method
raphy results in chronic low back pain, and the ptj/pzy044 compared with manipulation when used adjunc-
influence of disability and distress on diagnostic 97. M asaki M, Tateuchi H, Koyama Y, Sakuma K, tive to information and advice in low back pain
power. Spine J. 2005;5:370-380. https://doi. Otsuka N, Ichihashi N. Back muscle activity and patients presenting with centralization or periph-
org/10.1016/j.spinee.2004.11.007 sagittal spinal alignment during quadruped upper eralization: a randomized controlled trial. Spine
85. Lee D. Highlights from an integrated approach and lower extremity lift in young men with low (Phila Pa 1976). 2011;36:1999-2010. https://doi.
to the treatment of pelvic pain and dysfunc- back pain history. Gait Posture. 2018;66:221-227. org/10.1097/BRS.0b013e318201ee8e
tion. In: Magee DJ, Zachazewski JE, Quillen WS, https://doi.org/10.1016/j.gaitpost.2018.09.002 110. Pinto RZ, Franco HR, Ferreira PH, Ferreira ML,
Manske RC, eds. Pathology and Intervention in 98. M  ay S, Aina A. Centralization and directional Franco MR, Hodges PW. Reliability and discrimi-
Musculoskeletal Rehabilitation. 2nd ed. Maryland preference: a systematic review. Man Ther. natory capacity of a clinical scale for assessing
Heights, MO: Elsevier; 2016:612-650. 2012;17:497-506. https://doi.org/10.1016/j. abdominal muscle coordination. J Manipulative
86. Lee D. The Pelvic Girdle: An Integration of Clinical math.2012.05.003 Physiol Ther. 2011;34:562-569. https://doi.
Expertise and Research. 4th ed. Edinburgh, UK: 99. M  itchell T, O’Sullivan PB, Burnett AF, Straker L, org/10.1016/j.jmpt.2011.08.003
Elsevier/Churchill Livingstone; 2011. Smith A. Regional differences in lumbar spinal 111. Pool-Goudzwaard AL, Slieker ten Hove MC,
87. Lee D. The Thorax: An Integrated Approach. Edin- posture and the influence of low back pain. BMC Vierhout ME, et al. Relations between pregnancy-
burgh, UK: Handspring; 2018. Musculoskelet Disord. 2008;9:152. https://doi. related low back pain, pelvic floor activity and
88. Lee LJ, Lee D. Clinical practice – the reality for org/10.1186/1471-2474-9-152 pelvic floor dysfunction. Int Urogynecol J Pelvic
clinicians. In: Lee D, ed. The Pelvic Girdle: An In- 100. M  ok NW, Brauer SG, Hodges PW. Changes in Floor Dysfunct. 2005;16:468-474. https://doi.
tegration of Clinical Expertise and Research. 4th lumbar movement in people with low back pain org/10.1007/s00192-005-1292-7
ed. Edinburgh, UK: Elsevier/Churchill Livingstone; are related to compromised balance. Spine 112. Razmjou H, Kramer JF, Yamada R. Intertester
2011:147-172. (Phila Pa 1976). 2011;36:E45-E52. https://doi. reliability of the McKenzie evaluation in assess-

450 | june 2019 | volume 49 | number 6 | journal of orthopaedic & sports physical therapy
 ing patients with mechanical low-back pain. J org/10.1016/j.jpain.2009.03.003 pain. J Electromyogr Kinesiol. 2008;18:559-567.
Orthop Sports Phys Ther. 2000;30:368-383; 125. S orensen CJ, Johnson MB, Norton BJ, Callaghan https://doi.org/10.1016/j.jelekin.2006.10.012
discussion 384-389. https://doi.org/10.2519/ JP, Van Dillen LR. Asymmetry of lumbopelvic 137. Unsgaard-Tøndel M, Lund Nilsen TI, Magnussen
jospt.2000.30.7.368 movement patterns during active hip abduction J, Vasseljen O. Is activation of transversus ab-
113. Ross GB, Sheahan PJ, Mahoney B, Gurd BJ, is a risk factor for low back pain development dominis and obliquus internus abdominis associ-
Hodges PW, Graham RB. Pain catastrophizing during standing. Hum Mov Sci. 2016;50:38-46. ated with long-term changes in chronic low back
moderates changes in spinal control in response https://doi.org/10.1016/j.humov.2016.10.003 pain? A prospective study with 1-year follow-up.
to noxiously induced low back pain. J Biomech. 126. S orensen CJ, Norton BJ, Callaghan JP, Hwang Br J Sports Med. 2012;46:729-734. https://doi.
2017;58:64-70. https://doi.org/10.1016/j. CT, Van Dillen LR. Is lumbar lordosis related to org/10.1136/bjsm.2011.085506
jbiomech.2017.04.010 low back pain development during prolonged 138. Van K, Hides JA, Richardson CA. The use of
114. Roy JS, Bouyer LJ, Langevin P, Mercier C. Beyond standing? Man Ther. 2015;20:553-557. https:// real-time ultrasound imaging for biofeedback
the joint: the role of central nervous system reor- doi.org/10.1016/j.math.2015.01.001 of lumbar multifidus muscle contraction in
ganizations in chronic musculoskeletal disorders. 127. S
 pratt KF, Lehmann TR, Weinstein JN, Sayre HA. healthy subjects. J Orthop Sports Phys Ther.
J Orthop Sports Phys Ther. 2017;47:817-821. A new approach to the low-back physical exami- 2006;36:920-925. https://doi.org/10.2519/
https://doi.org/10.2519/jospt.2017.0608 nation. Behavioral assessment of mechanical jospt.2006.2304
115. Roy SH, De Luca CJ, Snyder-Mackler L, Emley signs. Spine (Phila Pa 1976). 1990;15:96-102. 139. van den Hoorn W, Bruijn SM, Meijer OG, Hodges
MS, Crenshaw RL, Lyons JP. Fatigue, recovery, 128. S tokes M, Hides J, Elliott J, Kiesel K, Hodges P. PW, van Dieën JH. Mechanical coupling between
and low back pain in varsity rowers. Med Sci Rehabilitative ultrasound imaging of the poste- transverse plane pelvis and thorax rotations
Sports Exerc. 1990;22:463-469. rior paraspinal muscles. J Orthop Sports Phys during gait is higher in people with low back
116. Sahrmann SA. Diagnosis and Treatment of Move- Ther. 2007;37:581-595. https://doi.org/10.2519/ pain. J Biomech. 2012;45:342-347. https://doi.
ment Impairment Syndromes. St Louis, MO: jospt.2007.2599 org/10.1016/j.jbiomech.2011.10.024
Elsevier Health Sciences/Mosby; 2013. 129. S tuge B, Veierod MB, Lærum E, Vøllestad N. 140. van den Hoorn W, Hodges PW, van Dieën JH,
117. Saragiotto BT, Maher CG, Yamato TP, et The efficacy of a treatment program focusing Hug F. Effect of acute noxious stimulation to the
al. Motor control exercise for chronic non- on specific stabilizing exercises for pelvic girdle leg or back on muscle synergies during walking.
Downloaded from www.jospt.org by 5.189.200.137 on 07/17/19. For personal use only.

specific low-back pain. Cochrane Database pain after pregnancy: a two-year follow-up of a J Neurophysiol. 2015;113:244-254. https://doi.
Syst Rev. 2016:CD012004. https://doi. randomized clinical trial. Spine (Phila Pa 1976). org/10.1152/jn.00557.2014
org/10.1002/14651858.CD012004 2004;29:E197-E203. https://doi.org/10.1097/01. 141. van Dieën JH, Flor H, Hodges PW. Low-back pain
118. Schenk RJ, Jozefczyk C, Kopf A. A random- BRS.0000090827.16926.1D patients learn to adapt motor behavior with ad-
ized trial comparing interventions in patients 130. S ueki DG, Cleland JA, Wainner RS. A regional verse secondary consequences. Exerc Sport Sci
with lumbar posterior derangement. J Man interdependence model of musculoskeletal Rev. 2017;45:223-229. https://doi.org/10.1249/
Manip Ther. 2003;11:95-102. https://doi. dysfunction: research, mechanisms, and clinical JES.0000000000000121
org/10.1179/106698103790826455 implications. J Man Manip Ther. 2013;21:90- 142. van Dillen L. The potential role of adherence to
119. Scholtes SA, Gombatto SP, Van Dillen LR. Differ- 102. https://doi.org/10.1179/204261861 improving low back pain outcomes [abstract].
ences in lumbopelvic motion between people 2Y.0000000027 9th Interdisciplinary World Congress on Low
with and people without low back pain during 131. S
 ufka A, Hauger B, Trenary M, et al. Central- Back and Pelvic Girdle Pain; October 31-Novem-
two lower limb movement tests. Clin Biomech ization of low back pain and perceived func- ber 3, 2016; Singapore.
(Bristol, Avon). 2009;24:7-12. https://doi. tional outcome. J Orthop Sports Phys Ther. 143. Van Dillen LR, Bloom NJ, Gombatto SP, Susco
J Orthop Sports Phys Ther 2019.49:437-452.

org/10.1016/j.clinbiomech.2008.09.008 1998;27:205-212. https://doi.org/10.2519/ TM. Hip rotation range of motion in people

120. Searle A, Spink M, Ho A, Chuter V. Exercise jospt.1998.27.3.205 with and without low back pain who participate
interventions for the treatment of chronic 132. S urkitt LD, Ford JJ, Hahne AJ, Pizzari T, Mc- in rotation-related sports. Phys Ther Sport.
low back pain: a systematic review and Meeken JM. Efficacy of directional preference 2008;9:72-81. https://doi.org/10.1016/j.
meta-analysis of randomised controlled trials. management for low back pain: a systematic ptsp.2008.01.002
Clin Rehabil. 2015;29:1155-1167. https://doi. review. Phys Ther. 2012;92:652-665. https://doi. 144. Van Dillen LR, Gombatto SP, Collins DR, Engs-
org/10.1177/0269215515570379 org/10.2522/ptj.20100251 berg JR, Sahrmann SA. Symmetry of timing
121. Skytte L, May S, Petersen P. Centralization: 133. T eyhen DS, Gill NW, Whittaker JL, Henry SM, of hip and lumbopelvic rotation motion in 2
its prognostic value in patients with referred Hides JA, Hodges P. Rehabilitative ultrasound different subgroups of people with low back
symptoms and sciatica. Spine (Phila Pa 1976). imaging of the abdominal muscles. J Orthop pain. Arch Phys Med Rehabil. 2007;88:351-360.
2005;30:E293-E299. https://doi.org/10.1097/01. Sports Phys Ther. 2007;37:450-466. https://doi. https://doi.org/10.1016/j.apmr.2006.12.021
brs.0000164119.78463.0c org/10.2519/jospt.2007.2558 145. Van Dillen LR, Maluf KS, Sahrmann SA. Further
122. Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus 134. T rudelle-Jackson E, Sarvaiya-Shah SA, Wang SS. examination of modifying patient-preferred
JA. Reduction of pain catastrophizing mediates Interrater reliability of a movement impairment- movement and alignment strategies in pa-
the outcome of both physical and cognitive- based classification system for lumbar spine tients with low back pain during symptomatic
behavioral treatment in chronic low back pain. J syndromes in patients with chronic low back tests. Man Ther. 2009;14:52-60. https://doi.
Pain. 2006;7:261-271. https://doi.org/10.1016/j. pain. J Orthop Sports Phys Ther. 2008;38:371- org/10.1016/j.math.2007.09.012
jpain.2005.10.011 376. https://doi.org/10.2519/jospt.2008.2760 146. Van Dillen LR, Norton BJ, Sahrmann SA, et al.
123. Smith MD, Russell A, Hodges PW. Disorders of 135. T sao H, Druitt TR, Schollum TM, Hodges PW. Mo- Efficacy of classification-specific treatment and
breathing and continence have a stronger as- tor training of the lumbar paraspinal muscles in- adherence on outcomes in people with chronic
sociation with back pain than obesity and physi- duces immediate changes in motor coordination low back pain. A one-year follow-up, prospec-
cal activity. Aust J Physiother. 2006;52:11-16. in patients with recurrent low back pain. J Pain. tive, randomized, controlled clinical trial. Man
https://doi.org/10.1016/S0004-9514(06)70057-5 2010;11:1120-1128. https://doi.org/10.1016/j. Ther. 2016;24:52-64. https://doi.org/10.1016/j.
124. Smith MD, Russell A, Hodges PW. Do inconti- jpain.2010.02.004 math.2016.04.003
nence, breathing difficulties, and gastrointestinal 136. T sao H, Hodges PW. Persistence of improve- 147. Van Dillen LR, Norton BJ, Steger-May K, et al.
symptoms increase the risk of future back ments in postural strategies following motor Effects of skill training versus strength and
pain? J Pain. 2009;10:876-886. https://doi. control training in people with recurrent low back flexibility exercise on functional limitations and

journal of orthopaedic & sports physical therapy | volume 49 | number 6 | june 2019 | 451
 [ clinical commentary ]
pain in people with chronic low back pain over CA, McDonnell MK, Bloom N. The effect of modi- 155. Werneke M, Hart DL, Cook D. A descriptive
a 6-month period [abstract]. The International fying patient-preferred spinal movement and study of the centralization phenomenon. A
Society for the Study of the Lumbar Spine 45th alignment during symptom testing in patients prospective analysis. Spine (Phila Pa 1976).
Annual Meeting; May 14-18, 2018; Banff, Canada. with low back pain: a preliminary report. Arch 1999;24:676-683.
148. Van Dillen LR, Sahrmann SA, Caldwell CA, Phys Med Rehabil. 2003;84:313-322. https://doi. 156. Weyrauch SA, Bohall SC, Sorensen CJ, Van Dil-
McDonnell MK, Bloom N, Norton BJ. Trunk org/10.1053/apmr.2003.50010 len LR. Association between rotation-related
rotation-related impairments in people with low 152. V
 an Dillen LR, Sahrmann SA, Norton BJ, Caldwell impairments and activity type in people with and
back pain who participated in 2 different types of CA, McDonnell MK, Bloom NJ. Movement sys-
without low back pain. Arch Phys Med Rehabil.
leisure activities: a secondary analysis. J Orthop tem impairment-based categories for low back
2015;96:1506-1517. https://doi.org/10.1016/j.
Sports Phys Ther. 2006;36:58-71. https://doi. pain: stage 1 validation. J Orthop Sports Phys
apmr.2015.04.011
org/10.2519/jospt.2006.36.2.58 Ther. 2003;33:126-142. https://doi.org/10.2519/
157. Williams MM, Hawley JA, McKenzie RA, van
149. Van Dillen LR, Sahrmann SA, Norton BJ. The ki- jospt.2003.33.3.126
nesiopathologic model and mechanical low back 153. V
 ibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Wijmen PM. A comparison of the effects of two
pain. In: Hodges PW, Cholewicki J, van Dieën JH, Kvåle A. Efficacy of classification-based cognitive sitting postures on back and referred pain. Spine
eds. Spinal Control: The Rehabilitation of Back functional therapy in patients with non-specific (Phila Pa 1976). 1991;16:1185-1191.
Pain. State of the Art and Science. Edinburgh, chronic low back pain: a randomized controlled 158. Wilson L, Hall H, McIntosh G, Melles T. Intertester
UK: Elsevier/Churchill Livingstone; 2013:ch 8. trial. Eur J Pain. 2013;17:916-928. https://doi. reliability of a low back pain classification sys-
150. Van Dillen LR, Sahrmann SA, Norton BJ, et al. org/10.1002/j.1532-2149.2012.00252.x tem. Spine (Phila Pa 1976). 1999;24:248-254.
Reliability of physical examination items used 154. W allwork TL, Stanton WR, Freke M, Hides JA.
for classification of patients with low back The effect of chronic low back pain on size and

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pain. Phys Ther. 1998;78:979-988. https://doi. contraction of the lumbar multifidus muscle.
org/10.1093/ptj/78.9.979 Man Ther. 2009;14:496-500. https://doi.
151. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell org/10.1016/j.math.2008.09.006 WWW.JOSPT.ORG
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