Low Back Pain With Mobility Deficit

Original Editor -Lieveld Jean Yves, Mostafa Mataichi, Ismael El Habouchi and David Herteleer

Top Contributors - Kelan Krohe, Shannon Petersen, Oyemi Sillo, Evan Thomas and David Herteleer  

Search Strategy

    We started our research by using electronic databases such as: Pubmed, Web Of Knowledge and the Cochrane-library. As keywords we used “Low back pain”, “Lumbar spine”, “mobility deficit” , “spinal movement”, “Range of Motion”, “reduced mobility” or relevant synonyms and related topics. To find more specific information we used targeted terms like “treatment or examination for low back pain with mobility deficit”, “anatomical structures of the lumbar spine”, … To expand our research for each subdivision we used synonyms of the related subject. We went further into advanced options to select what kind of articles we were looking for depending on their relevance such as date of publish, language, time-span, … We tried to keep the search as specific as possible, because the topic “low back pain” itself is very broad.

 

Definition[30]Level of evidence 2A,[29]Level of evidence 2B

A Classification Approach for patients with Low Back Pain has been used as a guide to sub-group patients based on their clinical signs and symptoms[29]Level of evidence 2B. In 2012, Low Back Pain Clinical Practice Guidelines were published.[30]Level of evidence 2A
Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association
• Describes evidence-based physical therapy practice, including diagnosis, prognosis, intervention, and assessment of outcome, for musculoskeletal disorders[30]Level of evidence 2A
• Identifes interventions supported by current best evidence to address impairments of body function and structure, activity limitations, and participation restrictions[30]Level of evidence 2A
• Identifies appropriate outcome measures
• Overall, the purpose of these Low back Pain Guidelines is to describe literature and make recommendations for:
- Treatment for associated subgroups of low back pain

- Treatments that have supported evidence

• Classifies patients into groups based on clinical characteristics and matching these patient subgroups to management strategies likely to benefit them will improve the outcome of physical therapy interventions[30]Level of evidence 2A
o Evolution of Treatment Based Classification: Fritz, Cleland, Childs[29]Level of evidence 2B
o 3 distinct differences from the Treatment Based Classification Approach to Low Back Pain
o Categories incorporate International Classification of Functioning, Disability, and Health (IFC) impairments of body functions terminology
o Addition of the low back pain with “related cognitive or affective tendencies” and “generalized pain”
o Addition of the patients acuity level

• Low Back Pain Clinical Practice Guidelines is divided into 6 categories, upon which this page will focus on Low back pain with mobility deficits

Clinically Relevant Anatomy[25]Level of Evidence 5

The lumbar spine has several distinguishing characteristics:[25]Level of Evidence 5


- The lower the vertebra is in the spinal column, the more weight it must bear. The five vertebrae of the lumbar spine (L1-L5) are the biggest unfused vertebrae in the spinal column, enabling them to support the weight of the entire torso.
- The lumbar spine's lowest two spinal segments, L4-L5 and L5-S1, which include the vertebrae and discs, bear the most weight and are therefore the most prone to degradation and injury.
- The lumbar spine meets the sacrum at the lumbosacral joint (L5-S1). This joint allows for considerable rotation, so that the pelvis and hips may swing when walking and running.


The sacroiliac joint (SI-joint) connects the sacrum (triangular bone at the bottom of the spine) with the pelvis (iliac bone that is part of the hip joint) on each side of the lower spine. It transmits all the forces of the upper body to the pelvis and legs. There is not a lot of motion in the joint and it is very strong and stable.[25]Level of Evidence 5

Epidemiology-Etiology [16]Level of Evidence 1A, [18]Level of Evidence 2C, [19]Level of Evidence 2C,  [15]Level of Evidence 2A, [14]Level of Evidence 2A

Low back pain (LBP) has a major medical and economic impact in the world. [16]Level of Evidence 1A The impact of severe LBP increases with advancing age and is a strong contributor to mobility disability. [17]Level of Evidence 2C Obese persons with LBP have increased disability, higher pain severity and worse functional capacity than non-obese counterparts. [18]Level of Evidence 2C The causes of low back pain (LBP) appear to be complex and multifactorial, with both biological and psychosocial components associated with chronicity.[14]Level of Evidence 2A There is a significant relationship between reduced hip mobility and low back pain as the reduction in of both passive and active movement (ROM) has been demonstrated in general (Sarah Winter, 2015). Several researchers (Keatan et al.; 2005) described low back pain as the leading cause of activity, limitation and work absence throughout much of the world and is associated with an enormous economic burden. [15]Level of Evidence 2A In spite of the large number of potentially pain generating structures and pathological conditions that can give rise to LBP in most cases approximately eighty-five to ninety percent have no identifiable cause which are defined as non-specific low back pain (NSLBP) (Lethola, 2016). The loss of mobility and functional capacity resulting from back pain are serious threats to public health as they are predictive of chronic disability .[19]Level of Evidence 2C

Characteristics-Clinical Presentation[21]Level of Evidence 2A, [20]Level of Evidence 5

 For acute low back pain with mobility deficits, the dis¬tinguishing movement/pain characteristic is that the pa¬tient demonstrates restricted spinal range of motion and segmental mobility, and that the patient’s low back and low back–related lower extremity symptoms are reproduced with provocation of the involved segments, with intervention strategies focused on reducing pain and improving mobility of the involved spinal segments.[20]Level of Evidence 5


For subacute low back pain with mobility deficits the distinguishing movement/pain characteristic is pain that occurs with mid- to end-ranges of active or passive motions, with intervention strategies focused on movements that in¬crease movement tolerances in the mid- to end-ranges of motions.[20]Level of Evidence 5

According to the ICF (International Classification of Functioning, Disability and Health), codes of low back pain with (sub)acute low back pain with mobility deficits leads tot he following problems on body functions, body structure, and activities and participation:


a) ACUTE LOW BACK PAIN WITH MOBILITY DEFICITS[21]Level of Evidence 2A

'
Body functions:'

- Pain in back
- Pain in body part, specified as pain in buttock, groin, and thigh
- Mobility of several joints
- Mobility of joint functions, specified as mobility in a vertebral segment

Body structure:
- Thoracic vertebral column
- Lumbar vertebral column
- Joints of pelvic region


Activities and participation:
- Bending


b) SUBACUTE LOW BACK PAIN WITH MOBILITY DEFICITS[21]Level of Evidence 2A

'
'
Body functions:
- Pain in back
- Pain in body part, specified as pain in buttock, groin, and thigh
- Mobility of several joints
- Mobility of joint functions, specified as mobility in a vertebral segment


Body structure:
- Thoracic vertebral column
- Lumbar vertebral column
- Joints of pelvic region
- Muscles of pelvic region
- Hip joint
- Muscles of thigh
- Ligaments and fascia of thigh


Activities and participation:
- Bending

The ICD diagnosis of acute low back pain with mobility deficits are made with a reasonable level of certainty when the patient presents with the following clinical findings [20]Level of Evidence 5
- Acute low back, buttock, or thigh pain (duration of 1 month or less)
- Restricted lumbar range of motion and segmental mobility
- Low back and low back–related lower extremity symptoms reproduced with provocation of the involved lower thorac¬ic, lumbar, or sacroiliac segments [21]Level of Evidence 2A

The ICD diagnosis of subacute low back pain with mobility deficits are made with a reasonable level of certainty when the patient presents with the following clinical findings [20]Level of Evidence 5
- Subacute, unilateral, low back, buttock, or thigh pain
- Symptoms reproduced with end-range spinal motions and provocation of the involved lower thoracic, lumbar, or sacroiliac segments
- Presence of thoracic, lumbar, pelvic girdle, or hip active, segmental, or accessory mobility deficits [21]Level of Evidence 2A

Differential Diagnosis[30]Level of Evidence 2A, [13] Level of Evidence 1B

Acute Low back pain with mobility deficits:[30]Level of Evidence 2A

Restricted spinal ROM, segmental mobility, and low back and low back-related lower extremity symptoms are reproduced with provocation of involved segments
Diagnosis:
- Acute low back, buttock or thigh pain for less than 1 month

- Restricted lumbar ROM and segmental mobility

- Low back and related LE pain reproduced with provocation


Subacute low back pain with mobility deficits:[30]Level of Evidence 2A
• Subacute, unilateral, low back pain, or thigh pain
• Symptoms reproduced with end-range spinal motions and provocation of involved lower thoracic, lumbar, or SI segments
• Present with mobility deficits
Chronic low back pain with mobility deficits [13] Level of Evidence 1B
• The symptoms are more than half the time present during a period of 12 month, occurring in a single or in multiple episodes.

Recurrent low back pain with mobility deficits [13]Level of Evidence 1B
• The symptoms are less than half the time present during a period of 12 month, occurring in multiple episodes over the year.


Diagnostic Procedures[6]Level of Evidence 2A, [24]Level of Evidence 2C

Objective assessments of lumbar motion can be achieved by a variety of methods:


- Examination of regional motion using an inclinometer ROM,
- Finger-to-floor distance
- Schober Index
- Visualize possible deviations or abnormal structures in the spine of the patient by using radiography, for example: MRI and CT scans.[6]Level of Evidence 2A


However, associations between these ROM measures and the patient rated measures are low [24]Level of Evidence 2C

  Outcome Meausures[22]Level of Evidence 2B

Oswestry Disability Index (ODI): Patient-completed questionnaire which gives a subjective percentage score of level of function (disability) in activities of daily living in those rehabilitating from low back pain.


Roland‐Morris Disability Questionnaire: is designed to assess self-rated physical disability caused by low back pain.


Visual analogue scale (VAS):


ODIs may be more useful than VAS scores in the clinical setting when considering functional movement parameters.[22](Level of Evidence 2B

Examination[2]Level of evidence 5,[1] Level of evidence 5,[6] Level of evidence 2A

There are three important examination-components to examine a patient with low back pain and lumbar mobility deficit. The first one is to visualize possible deviations or abnormal structures in the spine of the patient by using radiography, for example: MRI and CT scans.


There is no imaging indicated if “reduced lumbar spinal movement with low back pain” is described as an acute symptom which lasts 1 month or less and with the absence of red flag signs.[6]Level of Evidence 2A It’s important to know that these investigations do not identify the specific causes of pain( low sensitivity and specificity), but this research is mostly used with serious conditions. The second one is to take a detailed and specific history of the patient. Based on this history we get an overview of possible clues to find the cause of low back pain. And at least there is the last component, the physical examination. This consists of a series of tests which helps to find the causes of pain with which the patient struggles. [2]Level of evidence 5,[1] Level of evidence 5


Objective assesments of the lumbar motion can be achieved by a variety of methods:
- examination of the regional motion using an inclinometer ROM
- Finger-to-floor distance
- Schober-index

However, associations between these ROM measures and the patient rated measures are low [24]Level of Evidence 2C


Low Back Pain RED FLAGS:</u
Patients with back pain for the first time (80%) usually have 1 or more red flags, but it is rarely that they have a serious condition. Overall it is important for a physician to be aware of certain severe signs such as:[1] Level of evidence 5, [2]Level of evidence 5, [6] Level of evidence 2A


- Cauda equina syndrome
- Major intra-abdominal pathology
- Infections
- Malignancy
- Fractures

<u>Physical Impairment Measures examination tests:

I. Lumbar ROM - Quadrant
People with low back pain frequently show movement control impairments of the lumbar spine in the sagittal plane: flexion and extension. The research of C.M. Bauer et Al. noted also a linear effect of Low Back Pain intensity on variability of lumbar movement patterns. It’s therefore we recommend therapists to examine those specific movements in the sagittal plane. [7]Level of Evidence 2C

II. Lumbar spine segmental mobility assessment:
In an article of J.M. Fritz et Al. the mobility of each spinal segment of the lumbar spine was graded as normal, hypomobile, or hypermobile by using PA-techniques (posterior to anterior gentle pressure on the processus spinosus with the hypothenar eminence). Thereafter the patient was categorized in either the presence of hypomobility or the presence of hypermobility. If hypomobility was judged to be present at any level of a subject’s lumbar spine, the subject was categorized as having hypomobility. This examination technique should be interpreted with other information you have obtained. [8]Level of evidence 1B, [9]Level of evidence 2B


III. Pain Provocation with Segmental Mobility Testing
IV. Judgments of Centralization during Movement Testing
- Patient flex forward multiple times asking about any changes in pain.
- Repeat this with extension and lateral flexion.
- Look for a centralization of pain with repeated motion in a specific direction.
V. Prone Instability Test
VI. Judgments of the presence of aberrant movement
- Measured by painful arc with flexion or return from flexion. If patient complains of pain when returning to standing from flexion or feels a catch, this is a positive test.
VII. Straight Leg Raise
VIII. Slump Test

IX. Trunk Muscle Power and Endurance
- Check Trunk Flexors, Extensors, Lateral Abdominals, Transversus Abdominis, Hip Abductors, and Hip Extensors for strength looking for any muscle imbalances.
X. Passive Hip Internal Rotation, External Rotation, Flexion, and Extension
The article of T. Consmüller et Al. presents the Epionics SPINE, a measurement-instrument to evaluate the lumbar and thoraco-lumbar movement (up to 24h) and is also used for the assessment of the shape of the back. This may provide a clinical and reliable solution for the evaluation of the lower back pain.[10]Level of Evidence 2C, [11]Level of evidence 2C

Mental Impairment Measures:
1) Depression
2) Yellow Flags
3) Fear Avoidance Beliefs Questionnaire


Disability Questionnaire:
- The RDQ (modified Roland Disability Questionnaire, range: 0-23) is a measuring instrument which is also used for detecting back pain related functional limitations. [12]Level of Evidence 1B, [5]Level of evidence 2C


Medical Management[1]Level of Evidence 5, [2]Level of evidence 5, [4]Level of evidence 1B</sup ==

Advise: [1]Level of Evidence 5, [2]Level of evidence 5
o The patients with low back pain need to be stimulated and motivated to remain active and keep doing ADL, instead of resting in bed which has many disadvantages: joint stiffness, muscle wasting, loss of bone mineral density, pressure ulcers, and venous thrombo-embolism.
o To develop coping-strategies through education
o To avoid movements such as: twisting and bending
Another medical treatment is the prescription of certain drugs, such as: [1]Level of Evidence 5, [2]Level of evidence 5
- Analgesics, the research of JM. Williams et Al. shows us that reducing pain by analgesics does not alter the lumbar range of motion in chronic patients with low back pain.[4]Level of evidence 1B
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Muscle relaxants

These drugs can ensure that patients stay active without feeling pain, so that they can function in their daily live. [1] Level of evidence 5,[2]Level of evidence 5

Physical Therapy Management[13]Level of evidence 1B, [30]Level of evidence 2A, [28]Level of Evidence 2B,  [23] Level of Evidence 1A

Acute Low Back Pain with Mobility Deficits[30]Level of evidence 2A

1. Aim and strategy of therapy in this case:

1.1 Manual therapy procedure (thrust or non-thrust) to diminish pain and improve segmental spinal or lumbopelvic motion
1.2 Therapeutic exercise to improve or maintain spinal mobility
1.3 Patient education that encourages the patient to return to or pursue an active lifestyle


2. Example of full therapy:[8]Level of evidence 1B, [9]Level of evidence 2B, [30]Level of evidence 2A</sup

2.1 Manual Therapy:

• Joint mobilizations or manipulations on lumbar spine at the hypomobile segment using either supine or sidelying techniques like the Sidelying Lumbar Thrust Manipulation:
• Joint mobilizations or manipulations on thoracic spine like the Supine Thoracic Thrust Manipulation:


2.2 Therapeutic Exercises:

• Core Stabilization including engaging the transverse abdominus and multifidus. Biofeedback may be useful.

• Anterior and posterior pelvic tilts
• Bridges
• Quadruped for cat/camel stretching

2.3 Patient Education:

• Posture
• Home Exercise Program

Subacute Low Back Pain with Mobility Deficits[30]Level of evidence 2A

<u</u>
1. Aim and strategy of therapy in this case:

1.1 Manual therapy procedures to improve segmental spinal, lumbopelvic, and hip mobility
1.2 Therapeutic exercise to improve or maintain spinal and hip mobility
1.3 Focus on preventing recurring low back pain episodes through use of:
• Therapeutic exercise that address coexisting coordination impairments, strength deficits, and endurance deficit.
• Education that encourages the patient to pursue or maintain an active lifestyle



2. Example of full therapy:

2.1 Manual Therapy:

• Joint mobilizations or manipulations on lumbar spine at the hypomobile segment: See "Sidelying Lumbar Thrust Manipulation" above
• Joint mobilizations or manipulations on thoracic spine: See "Supine Thoracic Thrust Manipulation" above
• Joint mobilizations or manipulations on hip/pelvis:

2.2 Therapeutic Exercises:

• Stretching into limited motion
• Core Stabilization: bicycle kicks, planks
• Wall slides and partial lunges keeping a neutral spine
• Swiss Ball marching, abdominal crunches
• Quadruped with opposite arm and leg reaches
• Bridging on heels (not flat foot)
• Scapular Strengthening in prone

2.3 Patient Education:

• Posture in more functional activities
• Home Exercise Program

Chronic and recurrent low back pain with mobility deficit. Effectiveness [13]Level of evidence 1B, [30]Level of evidence 2A


1. Aim and strategy of therapy in this case:[13]Level of evidence 1B

1.1 To reduce pain and upgrade functions in individuals with non-specific chronic or recurrent LBP with concurrent through exercise therapy (Hip rotation stretching, multi-directional hip stretching and hip strengthening).

2. Example of full therapy:[13]Level of evidence 1B

2.1 Therapeutic Exercises:

2.1.1 HIP Rotation stretching excercice
Frequency; 5 times a week
Duration; each stretch is to be held for 30 seconds
Repeat; 3 times
All stretches most be done on both sides
• Prone hip medial rotation.

• Prone hip lateral rotation – Leg fall in stretch



2.2.2 Multi-directional hip stretching home exercise program

Frequency; 5 times a week
Duration; each stretch is to be held for 30 seconds
Repeat; 3 times
All stretches most be done on both sides
• Crook lying
• Lunge
• Sitting – Hip medial rotation, flexion and abduction stretch
• Standing – Groin stretch
• Sitting – Groin stretch
• Prone hip medial rotation – Leg fall out stretch
• Prone hip lateral rotation – Leg fall in stretch


2.2. 3 Strengthening home exercise programme

Frequency; 5 times a week
All stretches most be done on both sides

Weeks 1 & 2
• Clams
• Prone hip external rotation with theraband
• Side-lying hip abduction
• Quadruped hip extension
• Single leg stand
• Prone hip medial rotation – Leg fall out stretch
• Prone hip lateral rotation – Leg fall in stretch

Weeks 3 & 4
• Quadruped hip extension
• Single leg bridge
• Single leg squats
• Lateral step exercise
• Standing hip rotation exercise
• Prone hip medial rotation – Leg fall out stretch
• Prone hip lateral rotation – Leg fall in stretch

Weeks 5 & 6
• Single leg squats
• Single leg bridge
• Lateral step exercise
• Standing hip rotation exercise with theraband
• Prone hip medial rotation – Leg fall out stretch
• Prone hip lateral rotation – Leg fall in stretch


Stretching program using the Global Postural Reeductaion method showed effective at improving pain, function, some quality of life aspects (emotional, limitations in physical functioning, vitality and mental health) and had no effect on depressive symptoms in patients with chronic low back pain [23] Level of Evidence 1A


The GPR is a therapy which is based on the muscle chains of the muscular system wherein a shortening can occur. Reasons:
- constitutional factors
- Behavioral factors
- Psychological factors
The main goal of this therapy is to stretch the shortened muscles using the creep of viscoelastic tissue and to improve contraction of the antagonist muscles, which leads thus to avoiding postural asymmetry.[28]Level of Evidence 2B

Method: 

A. Lying on back with the legs extended.
B. Lying on back with the legs flexed.
C. Standing with the body leaning forward’.
D. Sitting with legs extended.
E. Standing in the center


Key Research

• Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil. 2005 Sep;86(9):1745-52.[8]Level of Evidence 1B
• Kulig K, Powers CM, Landel RF, Chen H, Fredericson M, Guillet M, Butts K. Segmental lumbar mobility in individuals with low back pain: in vivo assessment during manual and self-imposed motion using dynamic MRI. BMC Musculoskelet Disord. 2007 Jan 29;8:8. [9]Level of Evidence 2B
• Cherkin DC, Sherman KJ, Balderson BH. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016 Mar 22-29;315(12):1240-9.[12]Level of evidence 1B

Resources

• Cherkin DC, Sherman KJ, Balderson BH. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016 Mar 22-29;315(12):1240-9.[12]Level of evidence 1B

Clinical Bottom Line

Summary:
Clinical Practice Guidelines can be used by clinicians in examination, differential diagnosis, and intervention planning for patients with low back pain. These evidence-based guidelines can be applied to patients with acute and subacute low back pain. This page has summarized the guidelines for patients in the categories of Acute and Subacute Low Back Pain with Mobility Deficits.

Recent Related Research (From Pubmed)

References

1. Casazza B.A. Diagnosis and Treatment of Acute Low Back Pain. American Family Physician.2012;85(4):343-50. [1]Level of Evidence 5
2. David G.B., Andrei C. Diagnosis and Treatment of acute low back pain. Fast Facts: Low Back Pain. Health Press. 2012.[2]Level of evidence 5
3. Garczyński W, Lubkowska A, Dobek A, Andryszczyk M. Ann. The effect of the application of the kinesiology taping technique for muscle range of motion of the lumbar spine, and the subjective perception of pain intensity in patients with back pain. Acad Med Stetin. 2014;60(2):19-24.[3]Level of Evidence 2B
4. Williams JM, Haq I, Lee RY. An experimental study investigating the effect of pain relief from oral analgesia on lumbar range of motion, velocity, acceleration and movement irregularity. BMC Musculoskelet Disord. 2014 Sep 16;15:304.[4]Level of Evidence 1B
5. Caporaso F, Pulkovski N, Sprott H, Mannion AF. How well do observed functional limitations explain the variance in Roland Morris scores in patients with chronic non)specific low back pain undergoing physiotherapy?. Eur Spine J. 2012 May;21 Suppl 2:S187-95.[5]Level of evidence 2C
6. Anthony D., Steven G., Linda V.D. et al. Low Back Pain clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American physical therapy association. Journal of Orthopaedics & Sports Physical Therapy. 2012;42 (4).[6]Level of Evidence 2A
7. Bauer CM, Rast FM, Ernst MJ. et al. Pain intensity attenuates movement control of the lumbar spine in low back pain, M.J Electromyogr Kinesiol. 2015 Dec;25(6):919-27.[7] Level of evidence 2C
8. Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil. 2005 Sep;86(9):1745-52.[8]Level of Evidence 1B
9. Kulig K, Powers CM, Landel RF, Chen H, Fredericson M, Guillet M, Butts K. Segmental lumbar mobility in individuals with low back pain: in vivo assessment during manual and self-imposed motion using dynamic MRI. BMC Musculoskelet Disord. 2007 Jan 29;8:8. [9]Level of Evidence 2B
10. Consmüller T, Rohlmann A, Weinland D, Druschel C, Duda GN, Taylor WR. Comparative evaluation of a novel measurement tool to assess lumbar spine posture and range of motion. Eur Spine J. 2012 Nov;21(11):2170-80.[10] Level of Evidence 2C
11. Vaisy M, Gizzi L, Petzke F, Consmüller T, Pfingsten M, Falla D. Measurement of Lumbar Spine Functional Movement in Low Back Pain. Clin J Pain. 2015 Oct;31(10):876-85.[11] Level of Evidence 2C
12. Cherkin DC, Sherman KJ, Balderson BH. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. JAMA. 2016 Mar 22-29;315(12):1240-9.[12]Level of evidence 1B
13. Sarah Winter et al. Effectiveness of targeted home-based hip exercises in individuals with non-specific chronic or recurrent low back pain with reduced hip mobility. Journal of back and musculoskeletal rehabilitation, 2015.
[13]Level of evidence 1B

14. Laird RA, Kent P, Keating JL. Modifying patterns of movement in people with low back pain -does it help? A systematic review. 2012 Sep 7;13:169. doi: 10.1186/1471-2474-13-169.[14]Level of evidence 2A

15. Kent PM, Keating JL. The epidemiology of low back pain in primary care. Chiropr Osteopat. 2005 Jul 26;13:13.[15]Level of evidence 2A

16. Chapman JR, Norvell DC, Hermsmeyer JT, Bransford RJ, DeVine J, McGirt MJ, Lee MJ. Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S54-68. [16]Level of evidence 1A

17. Macfarlane GJ, Beasley M, Jones EA, Prescott GJ, Docking R, Keeley P, McBeth J, Jones GT; MUSICIAN Study Team. The prevalence and management of low back pain across adulthood: results from a population-based cross-sectional study. Pain. 2012 Jan;153(1):27-32.[17]Level of evidence 2C

18. Fanuele JC, Abdu WA, Hanscom B, Weinstein JN. Association between obesity and functional status in patients with spine disease. Spine (Phila Pa 1976). 2002 Feb 1; 27(3):306-12. [18]Level of evidence 2C

19. Nocera J, Buford TW, Manini TM, Naugle K, Leeuwenburgh C, Pahor M, Perri MG, Anton SD. The impact of behavioral intervention on obesity mediated declines in mobility function: implications for longevity. J Aging Res. 2011; 2011():392510. [19]Level of evidence 2C

20. Kenneth A. Olson. Manual Physical Therapy of the Spine. 2008. P. 118[20] Level of Evidence 5

21. Anthony Delitto et al. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2012;42(4):A1-A57. doi:10.2519/jospt.2012.0301[21]Level of evidence 2A


22. Ruiz FK. Bohl DD. Webb ML. Russo GS. MD. Grauer JN. Oswestry Disability Index is a better indicator of lumbar motion than the Visual Analogue Scale. The Spine Journal 14 (2014) 1860–1865. [22]Level of evidence 2B
23. Lawand P. Lombardi IJ. Jones A. Sardim C. Ribeiro LH. Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: A randomized controlled trial. Joint Bone Spine 82 (2015) 272–277[23]Level of evidence 1A 
24. Mieritz PM. Bronfort G. Hartvigsen J. REGIONAL LUMBAR MOTION AND PATIENT-RATED OUTCOMES: A SECONDARY ANALYSIS OF DATA FROM A RANDOMIZED CLINICAL TRIAL. Journal of Manipulative and Physiological Therapeutics (2014) Volume 37, Number 9.[24]Level of evidence 2C
25. Spinal anatomy and backpain. P.F. Ullrich. Spine-health, trusted information for backpain. [25]Level of evidence 5
26. Frank Netter. Atlas of human anatomy: General Spine and Nerve Anatomy: Chapter 1. [26]Level of evidence 5
27. Dr. Aberle. Chiropractorclinic. Lower back pain is extremely common. There are mechanical and nutritional reasons for low back pain, both of which can be treated easily. 277-1975[27]Level of evidence 5
28. Bonetti F, Curti S, Mattioli S et Al. Effectiveness of a 'Global Postural Reeducation' program for persistent low back pain: a non-randomized controlled trial. BMC Musculoskelet Disord. 2010 Dec 16;11:285. [28]Level of evidence 2B

29. Fritz JM, Cleland JA et al. Subgrouping Patients with Low Back Pain: Evolution of a Classification Approach to Physical Therapy. Journal of Orthopadic Sports Physical Therapy. 2007;37(6):290-302.[29]Level of evidence 2B

30.Delitto A, George S.Z. et al, Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orhtop Sports Phys Ther. 2012;42(4):A1-A57[30]Level of evidence 2A