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Hipsters Unite!
Examining the hip’s influence for patients with back pain.
                              Eric K. Robertson, PT, DPT, OCS, FAAOMPT
                                                      Assistant Professor
                                                   Texas State University
Hipster Defined
 What is a hipster?
  You‘d be surprised. It could very well be YOU.


  A hipster is an individual—one that usually fits within a
  certain subculture. Which subculture? It doesn‘t
  matter. Because the definition for hipster is so very
  vague

 In its most simplest terms, a hipster is an individual
  who wants to know things.



Source: quotes from a Hipster named Adam
     (http://travelsofadam.com/what-is-a-hipster/)
Fact #52
―If you were to lay every hipster in the world
 end to end, we don‘t know the length of the
 line they would form, but there would be an
 Apple store at the end of the line.‖
Austin: Epic Hipster Population




 *Ranked #2 behind Seattle, WA for hipsterism by designtrends.com
Actual Austin Hipsters
A confirmation that a) hipsters do exist in a nearby geographic
locale, and that b) sometimes they gather, and that c)
whatever, I‘m going to just write what I want in the true spirit of
hipsterism.
Actually What This Talk is REALLY About:
An examination into the age-old concept that a) yes, the hip bone is
connected to the back bone, that b) when one hurts, the other most
often suffers, and that c) by paying attention to trends in movement
patterns we can flesh out how to direct treatments at the hip that may
assist us in treating patients with low back pain.
Actually What This Talk is REALLY About:
An examination into the age-old concept that a) yes, the hip bone is
connected to the back bone, that b) when one hurts, the other most
often suffers, and that c) by paying attention to trends in movement
patterns we can flesh out how to direct treatments at the hip that may
assist us in treating patients with low back pain.
Butt First…
Oh, the Aching Backs!




Low Back Pain: Eric K. Robertson, PT, DPT, OCS
A Current State of Affairs
Relative Healthcare Costs
                Cost in Billions
350
          Cardiovascular
300       Disease

250

200
            Cancer         Diabetes   LBP   All Arthritis
150

100

 50

  0
Relative Healthcare Costs
             Cost in Billions
800

700
                        CHRONIC PAIN!
600

500
                                        Cardiovascular
400                                        Disease

300

200

100

  0
Which of the following are predictors of LBP?
• Bulging disc without
  herniation or root     • History of depression
  contact                • History of
• Bulging disc without     occupational-related
  herniation but with      LBP
  nerve root contact     • Fearful beliefs about
• Herniated/Prolapsed      work as reported in a
  discs                    survey
• End plate changes /
  Shmorl‘s nodes
• Foraminal or canal     Psychosocial
  stenosis               findings
Physical findings
/ Imaging
How did you do?

 Physically:
   Only disc contact with nerve root has been shown
    to be a WEAK predictor of LBP


 Psychosocial:
   Depression, occupational injuries, and fear-
    avoidance are all STRONG predictors of LBP


             Implications in terms of pain?
Summary of LBP Predictors ?




    Physical      Psychosocial
The Hip – Spine Relationship
           It‘s hip to have a high yield!
The Hip Bone‘s Connected to the…
 Hip – Spine Syndrome (Offierski and MacNab, 1983)
  Proposed a formal relationship between hip and spine pain
  Three subgroups
    Simple – Primary Dysfunction of one area, but symptoms in
     another
    Complex – Dysfunction in both hip and spine
    Secondary – Hip and Spine pain are dependent and inter-related
      This tight hip flexors and increased lumbar lordosis, as example
Offierski and MacNab, 1983
Hip – Spine Syndrome
 Though frequently cited, few have expanded upon the work of
  Offierski and MacNab.



 Ben-Galim et al., 2007 – Effects of THA on LBP
  25 individuals with severe hip OA, received THA
    No radiographic spine changes, but baseline LBP was 5.8 on VAS


  Subjects had PT for ambulation, hip motion, but not for lumbar spine
Ben-Galim et al., 2007
      Pain - LBP         Disability - LBP
6                   40
5
                    30
4
3                   20
2
                    10
1
0                    0
     VAS                  ODI
More recently…
                          10                              Saito et al, Spine, May 2012



Case series:
4 patients with leg
pain and confirmed
spinal stenosis and Hip
OA.

                          1
                               Fusion        Helped by            THA        Helped by
                                               Fusion                           TKA



                               ―I‘m sorry we fused your spine…‖
                               ―Conclusions. It is difficult to determine the origin of lower
                               leg pain by spinal nerve block and hip joint block in
                               patients with lumbar spinal stenosis and hip osteoarthritis.
                               We take this into consideration before surgery.‖
So let‘s think about this connection…
How can we evolve as hipsters?
Lumbo-Pelvic
Arthrokinematics
 What is normal lumbopelvic rhythm and how
  does this impact the hip-spine relationship?
Normal Lumbopelvic Rhythm
 Lumbar spine and hips contribute to flexion in equal
  magnitudes.
  Early flexion from the lumbar spine
  Later flexion from the hip contribution
  Extension is the reverse, with muscle activation
   occurring from a caudad to cephalad direction
  Twisting motions are primarily from hip contribution




                                                         Lee & Wang
How about with LBP?
 We move slower, and with less magnitude.



 Hip:Spine Ratio (Shum et al, 4 studies)
  Normal ratio: 0.50
  LBP: 0.38-0.40 (reduced lumbar spine contribution)
    Perhaps even less lumbar motion in those with +SLR


 Peak angular velocity also reduced for individuals with LBP
Shum et al. Contribution
 Examined patients with and without LBP

 Looked at:
  Simple sit-stand
  Sock donning
  Twisting
  Picking up and object from a seated position


 Altered movement strategies may be a strategy to protect
  injured lumbar tissues
  These changes are larger in those with neural tension signs
Lumbopelvic Motion
 Many authors agree that more lumbar motion, earlier in the
  range, especially with rotation is apparent in patients with low
  back pain. (Burnett et al., 2004; Esola et al., 1996; Luomajoki et al., 2008;
  McClure et al., 1997; Roussel et al., 2009)



 Inconclusive overall.
   Heterogeneous populations?



 Can sub-grouping help us?
Low Back Pain Classification
 Systems:
  McKenzie-based
  Treatment-based classification
  Movement System Impairment


  Commonalities?
    Movement
    Symptoms reproduced matters
    Hip motion matters
Low Back Pain Classification
 Systems:
  McKenzie-based
  Treatment-based classification
  Movement System Impairment



  Commonalities?
    Movement
    Symptoms reproduced matters
    Hip motion matters
Treatment-based Classification
 Hip Influence:
  Spinal Manipulation and Exercise Group
    CPR:
      < 16 days
      No pain beyond knee
      Hypomobile lumbar spine accessory motion
      Low Fear-Avoidance Beliefs
      Hip Motion (>35 degrees)


  Also, we see something interesting in the Stability subgroup…
      Important factors: Age, recurrent pain, SLR ROM, etc
Arthrokinematics of a Subgroup
 Teyhen et al, 2007 in PTJ


 Examined subgroup
  indentified to have suspected
  spinal instability per CPR
  Fluroscopic computer analysis


 Found segmental HYPO-mobility in
  this subgroup!
Hip Hypomobility with LBP
 Tafazzoli and Lamontagne, 1996



 With LBP:
  Increased passive elastic moment on the hamstrings
  Increased hip stiffness to oscillatory motions


 A rationale to treat the hips for patients presenting with primary
  LBP
More Hip Trouble from LBP
 Reduced Hip Flexion in patients with LBP
  Wong and Lee, 2004
  3-dimensional analysis of functional motion in patients with LBP



 Increased ER compared to IR in patients with LBP
  Cibulka et al, 1998
  Examined over 100 patients with LBP
Low Back Pain Classification
 Systems:
  McKenzie-based
  Treatment-based classification
  Movement System Impairment



  Commonalities?
    Movement
    Symptoms reproduced matters
    Hip motion matters
Movement System Impairment System
 People with LBP demonstrate earlier and greater lumbopelvic
  rotation during hip lateral rotation compared to people
  without LBP

 5 groups (based on history, symptoms with movement and alignment)
   lumbar extension rotation syndrome
   lumbar extension syndrome
   lumbar flexion rotation syndrome
   lumbar flexion syndrome
   lumbar rotation syndrome

 Important exam items related to the hip:
   Hip Ext, Rot ROM, Hip abduction with lateral rotation in hook-
    lying, relative hip flexibility, hip motion in supine

                                            Van Dillen, Sahrmann, et al. 2003
Hip Musculature
       and LBP
 If we‘re moving differently, we‘re using our
                  muscles differently, right?
Neuromuscular control of walking
with chronic low-back pain
 Vogt et al., 2003, Manual Therapy
  17 male subjects, hip ROM, surface EMG during gait



 Subjects with moderate low back pain had:
  Decreased hip motion and stride time
  Decreased hip extensor and lumbar spine extensor muscle activity
  Persistent firing of the above noted muscle groups compared to
   controls




 Leinonen et al., 2000 – observed similar decreased
  gluteus maximus activation in patients with LBP
Lumbopelvic Stabilization

                  Hungerford et
                   al., 2003, Spine.


                  EMG analysis of 14 individuals
                   with SIJ pain compared to
                   age-matched controls


                  Reduced activation of
                    Internal oblique
                    Multifidus
                    Gluteus maximus
Where We Stand As Hipsters
 Diagnostic Dilemma

 Patterns of Known Impairments of the hip in patients with low
  back pain

 Presence of hip-based factors in classification systems for
  clinicians to use when treating patients with low back pain.



 Practically Speaking: Education about the role of the hip in low
  back pain is something that people tend to teach in weekend
  courses and at conferences like this. It‘s not something much
  research has supported.
Evidence for
       Interventions
What guidance do we have concerning the
                   hip-spine connection?




                         Image by mpascoe via Flickr
Regional Interdependence Defined
 ―Seemingly unrelated impairments in a remote anatomical
  region may contribute to, or be associated with, the patient‘s
  primary complaint.‖




        Wainner, Whitman, Cleland & Flynn. Regional Interdependence: A Musculoskeletal
        Examination Model Whose Time Has Come. JOSPT, 2007, (37)11.
Spine & Extremity Regions
 Typical referred & radiating pain patterns




 Impairments - often seemingly unrelated
Is this actually happening in clinical practice?
Examples in the Literature:
                       Intervention Studies
Primary LBP
• Cibulka, JOSPT, 1999             Primary Knee Pain
• Boyle & Demske, Physiotherapy     Deyle et al, Ann Int Med, ‗00
   Theory & Practice, ‗09           Deyle et al, PT, ‘05
• Whitman et al, PM&R Clinics of    Cliborne et al, JOSPT ‘04
   North America 2003               Currier et al, Phys Ther, ‘07
• Whitman et al, Spine 2006         Lowry et al, JOSPT, ‘08
                                    Iverson et al, Phys Ther, ‘08
                                    Mascal et al, JOSPT, ‘03
                                    Cibulka & Threlkeld-
                                   Watkins, JOSPT, ‘05
Primary Hip Pain                    Vaughn, JOSPT, ‗08
• Cibulka &
   Delitto, JOSPT, 1993
                                   Primary Foot Pain
• Konczak & Ames, JMPT, 2004
                                   • Cleland et al, JOSPT, 2009
• Wisdo, JMPT, 2004
Treat the Lower
           Quarter for
Primary Low Back Pain
      Classic Examples in the Literature
Lower Quarter Treatment for Primary LBP

          Low Back Pain
          • Cibulka, JOSPT, ’99
          • Boyle & Demske, Physiotherapy Theory &
          Practice, ‗09




           Lumbar Spinal Stenosis
             • Whitman et al, Spine. ‘06
    • Whitman et al, PM&R Clinics of North
                            America, ‘03
Differential Dx for Hip vs. Spine Disease
                           Brown, et al. Clin Orthop. Feb 2004:280-284

 97 pts with LE pain referred to spine specialty clinic
  Age - mean 67.5 ± 11.6 years

 History, physical exam, & diagnostic testing completed
 Imaging studies gold standard for diagnosis
 Findings:
  19% - spinal disorders only
  36% - hip & spine in conjunction
  45% - hip only disorders
  81% - had some hip involvement present

 Limitations
  Diagnostic & test review with spectrum bias
• Limp, groin pain, limited IR at hip
   – More likely to be present in a patient with a hip disorder
• Positive femoral stretch test
   – More likely to have a spine disorder
Hamstring Muscle Strain Treated by
 Mobilizing the Sacroiliac Joint

 Cibulka et al, Phys Ther, 1986
Hamstring Muscle Strain Treated by
Mobilizing the Sacroiliac Joint
 20 patients with a HS       Dependent Measures
  strain                       Hamstring flexibility
                               Hamstring muscle torque
                               Quadriceps muscle torque
 Control- MH and
  stretching
 Experimental-
  MH, stretching and SI
  manip

     Significant difference in hamstring   torque for
      experimental group.
N = 60 patients with LSS
Outcomes:
    • GRC, Disability (OSW)
    • Baseline, 6-weeks, 1-year, long-term (mean 27-29 mo)

Interventions:
    • All subjects: 2x/wk for 6 wks in-clinic, walk at home 3x/week

  Flexion Exercise &                        Manual PT, Exercise, and
  Walking Group (FExWG)                    Walking Group
                                           (MPTExWG)

  • Sub-therapeutic US, SKC/DKC,           •BWS TM walking & SKC/DKC
  TM walking program
                                           • Manual physical therapy -
                                           Impairment-Based,
                                           Comprehensive Lower Quarter
Regions Treated

                                      100
   Patients receiving treatment (%)




                                      90
                                      80
                                      70
                                      60
                                      50
                                      40
                                      30
                                      20
                                      10
                                       0
                                            Thoracic   Lumbo-Pelvic   Hip   Knee   Ankle/Foot
Interventions Utilized: Lower Extremities

                 100
                  90
                  80
                  70
    Percentage




                  60
                  50
                  40
                  30
                  20
                  10
                   0
                           Hip               Knee              Ankle/Foot
                       Manipulation   Mobilization   Stretch    Muscle Energy
Hip Mobilizations

Long-Axis Distraction   Supine P-A




                                     Currier et al, JOSPT, 2008
                                     MacDonald, JOSPT, 2006
Hip Mobilizations

Prone A-P in FABER Position   Prone A-P in FABER Position




                                            Currier et al, JOSPT, 2008
                                            MacDonald, JOSPT, 2006
Related Regional
Interdependence Facts
Other RI Facts:
 Hip-Spine Syndrome / Relationships
Hip ROM & LBP/SIJ
   Ellison et al, Phys Ther, ‘90; Chesworth et al, Physiother Canada, ‘94;
   Cibulka et al, Spine, ‘98; Sjolie , Scand J Med Sci, sports, ‘04;
   Vad et al, Am J Sports Med, ‘04; Coplan, JOSPT, ‘02; Mellin, Spine, ‘88
   Porter & Wilkinson; Spine ‘97; Mellin. Spine ‘88


Hip Region Muscle Performance & LBP
   Nadler et al, Clin J Sport Med, ‘00; Nadler et al, Am J Phys Med Rehabil, ‘01;
   Nadler et al, Med Sci Sports Exerc, ‘02; Kandaanpaa et al, Arch Phys Med Rehabil, ‘98;
   Nourbakhsh & Arab, JOSPT, ‗02


Hip Region Muscle Performance & LBP
   Offierski & McNab, Spine ‘83; Ben-Galim et al, Spine, ‘07; Murata et al, Clin Orthop Surg, ‘02;
   Nakamura et al, Acta Orthop Scand, ‘03; Yoshimoto et al, Spine, ‘05; Takemitsu et al, Spine, ‘88;
   Sato et al, J Musculoskelet Syst, ‘89; Itoi, Spine, ‘91; Watanabe et al, Orthopedics, ‗02

Reiman, Weisbach, and Glynn. The Hip’s Influence on Low Back Pain: A Distal Link to a Proximal
Problem. Journal of Sport Rehab, ‘09
Other RI Facts
   Associations between:
        Hip ROM & response to spinal manipulation
         Flynn et al. Spine ’02.Childs et al, Ann Int Med ’04
        Hip Abd, ER, and Ext Weakness and PFPS
         Robinson, JOSPT, ‘07; Ireland, JOSPT, ‗03
   SIJ manipulation and quadriceps facilitation
        Suter et al. JMPT ‘00
   SIJ manipulation and HS peak torque changes (pts with HS strain)
        Cibulka et al, Phys Ther, ‗85
   LSS source of pain identified after THA
       Bohl et al, Spine, ‘79, Saito et el, Spine 2012
   Concomitant spine and hip disease extremely common
       Brown et al, CORR, ‘04
Primary Hip Interventions for Patients
with Low Back Pain and Hip Impairments:
A Prospective Case Series (Preliminary Results)
Eric K. Robertson1, Cheryl Sparks2, Derek Clewley3
1Faculty,Department of Physical Therapy, Texas State University, San Marcos, TX, USA, 2Faculty, Department of
Physical Therapy, Bradley University, Peoria, IL, USA, 3Benchmark Physical Therapy, Atlanta, GA, USA

*Acknowledgement: Dr. Julie M. Whitman for her review of the study design and report.
Research performed as part of the Evidence in Motion Fellowship Program
Although many clinicians who
are perceived as experts often
describe examination and
interventions at the hip for
patients with low back
pain, very little evidence
describing this exists.




Lack of Research
Management of a Female with Chronic
Sciatica and LBP: A Case Report
 History
   6 weeks of lumbar stabilization and flexibility intervention did not
    eliminate symptoms



 Intervention
   Treatment plan revised to include impairment-based left hip
    capsule flexibility
   Also included hip strengthening to glut med



 Outcome
   Complete resolution of pain, disability (0 NPRS, 0% on ODI (reduced
    from 41% at baseline))


                          Boyle and Demske, 2009 Physiotherapy Theory and Practice
Management of a Female with Chronic Sciatica and LBP:
A Case Report
• History                           60
  • 6-weeks of lumbar
    stabilization and flexibility   50
    intervention did not
    eliminate symptoms              40

• Intervention                      30                                    41%
                                                                          Reduction.
  • Treatment plan revised to
                                    20
    include impairment-based
    left hip capsule flexibility
                                    10
  • Also included hip
                                              Spine Interventions
    strengthening to glut med
                                     0
                                                                             Hip Interventions
                                                        NPRS        ODI



                            Boyle and Demske, 2009 Physiotherapy Theory and Practice
Purpose
The purpose of this prospective case series was two-fold.

1. Describe the clinical decision making process involved in the
   management of patients with primary complaints of low back
   and hip pain.

2. Provide an evidence-based rationale for directing treatment at
   the hip in a sub-group of patients with low back pain.
Number of Subjects
Six subjects referred to physical therapy with low back pain who
also demonstrated impairments at the hip were recruited to
participate. (Note: Data collection is still in progress, currently
have 11 enrolled.)
About the Subjects
Inclusion Criteria:
• 1. Adults referred to PT with a primary complaint of low back pain (LBP)
• 2. Positive hip impairments as identified in the patient’s initial physical
  examination*




Definition of positive hip impairment:
• Positive special tests, decreased ROM, decreased muscle
  strength, reversed lumbo-pelvic rhythm, decreased mobility or pain with
  accessory motions, or findings consistent with the clinical presentation
  of hip osteoarthritis per the criteria established by Altman et al.
About the Subjects
Exclusion Criteria:
• Any medical red flags
• Spinal or femoral fractures, except for degenerative spondylolisthesis or
  spondylolisis
• Upper motor neural compromise
• Pregnancy
• Lower motor neuron changes suggestive of nerve root irritation and/or
  compression (positive straight leg raise at <45º or diminished lower extremity
  strength, sensation, or reflexes
• High fear-avoidance beliefs (>35 on the Fear Avoidance Belief Questionnaire
  Work [FABQW] subscale)
• Previous history of spine or hip surgery
• Inability to read and understand English
Methods
• Primary outcomes:                             • Secondary outcomes:
  • Oswestry Disability                           • Global Rating of Change
     Index, (ODI)                                    (GROC)
  • Harris Hip Score (HHS)                        • Assessment of hip impairments.
  • Numerical Pain Rating Scale
     (NPRS)




            Initial Examination
                                                                                   Week 4
                Visit #2 (2-3 days after Initial Examination)



 Institutional Review Board approval was obtained from Bradley University for this study.
Important Exam Items
                                              Hip Examination
                                              ROM, all planes
• +/- Hip Impairment                          Special Tests: Scour, FABER, other
• Positive special tests, decreased           Flexibility: Hip flexor, extensor length
  ROM, decreased muscle                       Strength: All planes
  strength, reversed lumbo-pelvic
  rhythm, decreased mobility or pain
  with accessory motions, or findings         Lumbar Spine Examination
  consistent with the clinical
  presentation of hip osteoarthritis per      ROM Screen
  the criteria established by Altman et al.   Accessory Mobility
                                              Core musculature assessment
                                              Special Tests: SLR, PIT, etc
Hip Examination Item                   Results
Hip ROM Impairments                    6/6
Hip Weakness                           4/6
+ Hip Special Test                     5/6


Median age was 50 years (range, 27-61 years)




Examination Results
Interventions
Day 1: Examination and Initial Treatment
If hip impairment was noted, then treatment progressed in the following manner:

• Manual Interventions focused on hip. (thrust/non-thrust)
• Hip-specific therapeutic exercise
• Reinforcing Home Exercise Program

• Re-assess Day 2.
Interventions
Exercises provided to focus on
• gluteus maximus,
• hip abduction and external rotation
• core stabilization progression.

Neuromuscular re-education:
   • Movement re-education
     consisting of patient
     instruction, practice if
     abnormalities noted, i.e. sit to
     stand
   • Squatting and proper lifting
     mechanics
   • Proprioceptive core stability
     exercises
Interventions
Day 2 – Week 4 Treatment
• Treat per impairment-based approach or a pragmatic application
  of the Treatment-based classification approach.
• HEP and TherEx continued to stress hip-focused interventions
Results
Results: At 4 weeks, the average improvement in ODI scores was 39%, and
24% for the HHS. 66% of the patients experienced a significant decrease in the
NPRS. 100% of patients for which data was collected experienced at least a
change of 4 on the GROC (4-7), indicating at least moderate improvement.
Avg. visits = 7.3 (3-10).
                                                     Numeric Pain Rating
   Global Rating of Change*
                                                           Scale*
                     5.3                                          2.8




           Median 5.25, (range, 4-7)                      Median 3, (range, 0-5)

         “Quite a bit better”                               MCID: 1.8

                    *Note: Data on GROC collected for 4/6 patients.
ODI      Avg. Change
                                                                      Day 2          4
                                                                      Week 4        20

                             Oswestry Disability Index
90
80
70
60
50                                                                             Baseline
40                                                                             Day 2
                                                                               Week 4
30
20
10
0
     Patient 1   Patient 2    Patient 3   Patient 4   Patient 5   Patient 6
HHS      Avg. % Change
                                                                      Day 2          18
                                                                      Week 4         24
                                Harris Hip Score
100
 90
 80
 70
 60
                                                                                Baseline
 50
                                                                                Day 2
 40
                                                                                Week 4
 30
 20
 10
  0
      Patient 1   Patient 2   Patient 3   Patient 4   Patient 5   Patient 6
• Small Case Series = No Cause and Effect

• Not consecutive subjects

• Control over interventions limited, especially the
  neuromuscular reeducation to the core




Limitations
Short-term response of hip mobilizations and
exercise in individuals with chronic low back
pain: a case series
    • Subjects:
         • 8 Subjects with CLBP, Avg age 49, with ROM impairments

    • Intervention
         • Impairment-based manual therapy to Bilateral Hips
         • 3 Sessions over 1 week

    • Outcome
         • 5/8 (65%) reports >4 “Moderately Better” on the GROC
         • 24% reduction in ODI scores
 “This case series suggests that an impairment-based approach directed at the hip joints may lead to
improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a
plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to
determine the potential effectiveness of this approach with patients with CLBP.”

                                                           Burns, Mintken, Austin, Cleland. 2010 JMMT
Conclusions
• Significant improvements were observed in all primary outcome measures
  at 4 weeks.

• Secondary outcome measures trended towards significant improvements.

• This case series provides preliminary evidence that some patients with low
  back pain may receive a benefit from interventions directed at the hip.

• Future studies should work to determine the factors that can predict patients
  that may realize this benefit.
HOW TO GET HIP
Yes, you can be a hipster too!
Posterior Pelvic Tilts
 Williams Flexion Exercises
 Hot Packs
 Massage
 Ultrasound




   That‘s so yesterday!
   Once we acknowledge the role of the LE in
   back pain, it frees us from the constraints of
    patients with low back pain. It allows us to
become creative and challenge our patients in
                                     new ways.
ADVANCE EXERCISE CONCEPTS
FOR THE …HIP? LOW BACK?


                            DPTMWG
DPTMWG
• Progression of:
  •   Limb support
  •   Surface
  •   Visual input
  •   Perturbations
  •   Task demands




       Proprioceptive/Balance
       Training
                                DPTMWG
Testing For Strength
                In CKC Positions

•   Sit to Stand
•   Squat
•   Leg Press
•   Lunge
• Used most often with older individuals
• Performance is based on given period of
  time (10-30 seconds) and reps recorded or
  given reps and time recorded in seconds
• Sit to stand performance has direct
  correlation to knee extension force and leg
  press force.



       Sit To Stand Test
Jones et al
                                                DPTMWG
Sit to stand Test
                    DPTMWG
• Sit to Stand Test (Csuka et al, Am J Med 1985)
  • Regression equation for predicting normal performance for
    10 stand ups. Results are in seconds.


     • Women: 7.6 + .17 x age
     • Men: 4.9 +.19 x age




           Sit to Stand Test
                                                                DPTMWG
• Utilized to compare
  uninvolved to involved
  and also to compare to
  norms
• Associated with
  thigh, hip and buttock
  strength
• Takes balance and core
  factors out of strength
  assessment.
• Greater than 90% of
  contra-lateral
  considered acceptable

    Leg Press Test for Strength
                                  DPTMWG
Plisky et al. N Am J Sports Phys Ther. 2009 May; 4(2): 92–99.


                                                                DPTMWG
• Significant differences associated with chronic ankle
  instability and ACL insufficiency
• Can be predictive of LE injury
• What about LBP?!
  Population       Reach Distance        Implication        P value
  All Players     R:L Difference of   2.5x more likely to   p<.05
                       >4 cm           sustain LE injury
  Females         <94% of LE          6x more likely to     p<.05
                  length              sustain LE injury



   Y Balance Test Utility
                                                                      DPTMWG
Mascal et al. Management of patellofemoral pain targeting hip, pelvis,
and trunk muscle function: 2 case reports. JOSPT 2003




                                           N=2
                                           20, 37 y/o females
Mascal et al. Management of patellofemoral pain targeting hip, pelvis,
and trunk muscle function: 2 case reports. JOSPT 2003


       • 14 week treatment period focused on recruitment and endurance
         training of the hip, pelvis and trunk (including TrA)
       • Patients attended PT 1-2 times per week
       • Hip muscles (particularly glut max, med and external rotators)
         were progressively strengthened, starting in NWB followed by WB
         functional tasks
Hip Abductors and ERs
            • Mini-squats, step-ups/downs and leg presses for
              concentric/eccentric control, BAPS board/lunges for
              proprioceptive training


            Core muscle training




Restore Neuromuscular Control
It‘s Hip to have a high yield!
Before I leave you…
Relative Healthcare Costs
             Cost in Billions
800

700
                        CHRONIC PAIN!
600

500
                                        Cardiovascular
400                                        Disease

300

200

100

  0
Pain…

 It might not be as much of a
  physical thing as we think!




 We need to consider the
  cognitive components!
L E V E L
P A I N




            Injury!
                                  Adapted from Butler & Mosely, 2008, ―Explain Pain‖




            H E A L I N G   R E S P ON SE
―Nociception is neither sufficient
for, or necessary to experience pain.‖




                                Adapted from Butler & Mosely, 2008, ―Explain Pain‖
Identifying Patients at Risk for
Chronic Pain
George & Zepperi, JOSPT, July- 2009



   Fear-avoidance model of musculoskeletal pain
    (FAM) (Measured by FABQ)
      Factors influencing pain perception
         Anxiety
         Fear of re-injury
         Catastrophizing




     Confrontation                                 Avoidance
              Anxiety                              Anxiety
              Fear of re-injury                    Fear of re-injury
              Catastrophizing                      Catastrophizing
FDAQ – A Measurement




                   George & Zepperi, JOSPT, July- 2009
                   George et al., PTJ, July- 2009
Establishing a Baseline

Therapist: ‗How long can you walk before you flare-up?‘
Patient: ‗I can walk for 30 min but I pay for it the next day‘
Therapist: ‗Can you walk for 20 min without flaring up?‘
Patient: ‗No, but I have‘
Therapist: ‗Can you walk for 10 min without flaring up?‘
Patient: ‗Probably not — definitely not up hills‘
Therapist: ‗5 min on a flat surface?‘
Patient: ‗Probably‘
Therapist: ‗3 min on a flat surface?‘
Patient: ‗Definitely‘
Continuous Progression
 ‗Every day you do more than you did
  yesterday, but not much more‘ …at least initially.

 Setting clear measurable goals and objectives!
KEY POINTS

 Pain is not nociception

 The representation of the body in the human brain

 The brain changes as the pain persists

 Body-brain is a 2 way street

 Training the brain for people in Pain

 This is VERY Hip.
References:
•   Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Orthopaedic Physical Therapy
    Clinics of North America, 9:103-118, 2000
•   Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance
    deficits in individuals with functional ankle instability. The Journal of orthopaedic and sports physical therapy.
    2009;39(11):799-806.
•   Kong DH, Yang SJ, Ha JK, et al. Validation of functional performance tests after anterior cruciate ligament reconstruction. Knee
    surgery & related research. 2012;24(1):40-5.
•    Munro AG, Herrington LC. Between-session reliability of the star excursion balance test. Physical therapy in sport     :
    2010;11(4):128-32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21055706. Accessed July 25, 2012.
•   Narducci E, Waltz A, Gorski K, Leppla L, Donaldson M. The clinical utility of functional performance tests within one-year
    post-acl reconstruction: a systematic review. International journal of sports physical therapy. 2011;6(4):333-42. Available at:
    http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3230161&tool=pmcentrez&rendertype=abstract.
•   Pigozzi F, Giombini A, Macaluso A. Do current methods of strength testing for the return to sport after injuries really address
    functional performance? American journal of physical medicine & rehabilitation. 2012;91(5):458-60. Available at:
    http://www.ncbi.nlm.nih.gov/pubmed/22415342. Accessed July 25, 2012.
•    Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure
    during rehabilitation after anterior cruciate ligament reconstruction. Physical therapy. 2007;87(3):337-49
•    Plisky P. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of
    Orthopaedic and Sports Physical Therapy. 2006;36(12):911-919.
•   Hertel J, Braham RA, Hale SA, Olmsted-kramer LC. Simplifying the Star Excursion Balance Test  Chronic Ankle Instability.
                                                                                                          :
    Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12).
•    Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict
    anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine.
    2005;33(4):492-501.
•   Myer GD, Ford KR, Hewett TE. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today.
    2009;13(5):39-44.


                                                                                                                             DPTMWG
References:




              DPTMWG
References:
•   Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Orthopaedic Physical Therapy
    Clinics of North America, 9:103-118, 2000
•   Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance
    deficits in individuals with functional ankle instability. The Journal of orthopaedic and sports physical therapy.
    2009;39(11):799-806.
•   Kong DH, Yang SJ, Ha JK, et al. Validation of functional performance tests after anterior cruciate ligament reconstruction. Knee
    surgery & related research. 2012;24(1):40-5.
•    Munro AG, Herrington LC. Between-session reliability of the star excursion balance test. Physical therapy in sport     :
    2010;11(4):128-32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21055706. Accessed July 25, 2012.
•   Narducci E, Waltz A, Gorski K, Leppla L, Donaldson M. The clinical utility of functional performance tests within one-year
    post-acl reconstruction: a systematic review. International journal of sports physical therapy. 2011;6(4):333-42. Available at:
    http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3230161&tool=pmcentrez&rendertype=abstract.
•   Pigozzi F, Giombini A, Macaluso A. Do current methods of strength testing for the return to sport after injuries really address
    functional performance? American journal of physical medicine & rehabilitation. 2012;91(5):458-60. Available at:
    http://www.ncbi.nlm.nih.gov/pubmed/22415342. Accessed July 25, 2012.
•    Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure
    during rehabilitation after anterior cruciate ligament reconstruction. Physical therapy. 2007;87(3):337-49
•    Plisky P. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of
    Orthopaedic and Sports Physical Therapy. 2006;36(12):911-919.
•   Hertel J, Braham RA, Hale SA, Olmsted-kramer LC. Simplifying the Star Excursion Balance Test  Chronic Ankle Instability.
                                                                                                          :
    Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12).
•    Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict
    anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine.
    2005;33(4):492-501.
•   Myer GD, Ford KR, Hewett TE. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today.
    2009;13(5):39-44.


                                                                                                                             DPTMWG

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Hipsters Unite! Explore the hip's role in patients with low back pain

  • 1. Hipsters Unite! Examining the hip’s influence for patients with back pain. Eric K. Robertson, PT, DPT, OCS, FAAOMPT Assistant Professor Texas State University
  • 2. Hipster Defined  What is a hipster? You‘d be surprised. It could very well be YOU. A hipster is an individual—one that usually fits within a certain subculture. Which subculture? It doesn‘t matter. Because the definition for hipster is so very vague  In its most simplest terms, a hipster is an individual who wants to know things. Source: quotes from a Hipster named Adam  (http://travelsofadam.com/what-is-a-hipster/)
  • 3.
  • 4.
  • 5. Fact #52 ―If you were to lay every hipster in the world end to end, we don‘t know the length of the line they would form, but there would be an Apple store at the end of the line.‖
  • 6. Austin: Epic Hipster Population *Ranked #2 behind Seattle, WA for hipsterism by designtrends.com
  • 7.
  • 8. Actual Austin Hipsters A confirmation that a) hipsters do exist in a nearby geographic locale, and that b) sometimes they gather, and that c) whatever, I‘m going to just write what I want in the true spirit of hipsterism.
  • 9. Actually What This Talk is REALLY About: An examination into the age-old concept that a) yes, the hip bone is connected to the back bone, that b) when one hurts, the other most often suffers, and that c) by paying attention to trends in movement patterns we can flesh out how to direct treatments at the hip that may assist us in treating patients with low back pain.
  • 10. Actually What This Talk is REALLY About: An examination into the age-old concept that a) yes, the hip bone is connected to the back bone, that b) when one hurts, the other most often suffers, and that c) by paying attention to trends in movement patterns we can flesh out how to direct treatments at the hip that may assist us in treating patients with low back pain.
  • 12. Oh, the Aching Backs! Low Back Pain: Eric K. Robertson, PT, DPT, OCS A Current State of Affairs
  • 13. Relative Healthcare Costs Cost in Billions 350 Cardiovascular 300 Disease 250 200 Cancer Diabetes LBP All Arthritis 150 100 50 0
  • 14. Relative Healthcare Costs Cost in Billions 800 700 CHRONIC PAIN! 600 500 Cardiovascular 400 Disease 300 200 100 0
  • 15. Which of the following are predictors of LBP? • Bulging disc without herniation or root • History of depression contact • History of • Bulging disc without occupational-related herniation but with LBP nerve root contact • Fearful beliefs about • Herniated/Prolapsed work as reported in a discs survey • End plate changes / Shmorl‘s nodes • Foraminal or canal Psychosocial stenosis findings Physical findings / Imaging
  • 16. How did you do?  Physically:  Only disc contact with nerve root has been shown to be a WEAK predictor of LBP  Psychosocial:  Depression, occupational injuries, and fear- avoidance are all STRONG predictors of LBP Implications in terms of pain?
  • 17. Summary of LBP Predictors ? Physical Psychosocial
  • 18. The Hip – Spine Relationship It‘s hip to have a high yield!
  • 19. The Hip Bone‘s Connected to the…  Hip – Spine Syndrome (Offierski and MacNab, 1983)  Proposed a formal relationship between hip and spine pain  Three subgroups  Simple – Primary Dysfunction of one area, but symptoms in another  Complex – Dysfunction in both hip and spine  Secondary – Hip and Spine pain are dependent and inter-related  This tight hip flexors and increased lumbar lordosis, as example
  • 20.
  • 22. Hip – Spine Syndrome  Though frequently cited, few have expanded upon the work of Offierski and MacNab.  Ben-Galim et al., 2007 – Effects of THA on LBP  25 individuals with severe hip OA, received THA  No radiographic spine changes, but baseline LBP was 5.8 on VAS  Subjects had PT for ambulation, hip motion, but not for lumbar spine
  • 23. Ben-Galim et al., 2007 Pain - LBP Disability - LBP 6 40 5 30 4 3 20 2 10 1 0 0 VAS ODI
  • 24. More recently… 10 Saito et al, Spine, May 2012 Case series: 4 patients with leg pain and confirmed spinal stenosis and Hip OA. 1 Fusion Helped by THA Helped by Fusion TKA ―I‘m sorry we fused your spine…‖ ―Conclusions. It is difficult to determine the origin of lower leg pain by spinal nerve block and hip joint block in patients with lumbar spinal stenosis and hip osteoarthritis. We take this into consideration before surgery.‖
  • 25. So let‘s think about this connection… How can we evolve as hipsters?
  • 26.
  • 27.
  • 28.
  • 29.
  • 30.
  • 31. Lumbo-Pelvic Arthrokinematics What is normal lumbopelvic rhythm and how does this impact the hip-spine relationship?
  • 32.
  • 33. Normal Lumbopelvic Rhythm  Lumbar spine and hips contribute to flexion in equal magnitudes.  Early flexion from the lumbar spine  Later flexion from the hip contribution  Extension is the reverse, with muscle activation occurring from a caudad to cephalad direction  Twisting motions are primarily from hip contribution Lee & Wang
  • 34. How about with LBP?  We move slower, and with less magnitude.  Hip:Spine Ratio (Shum et al, 4 studies)  Normal ratio: 0.50  LBP: 0.38-0.40 (reduced lumbar spine contribution)  Perhaps even less lumbar motion in those with +SLR  Peak angular velocity also reduced for individuals with LBP
  • 35. Shum et al. Contribution  Examined patients with and without LBP  Looked at:  Simple sit-stand  Sock donning  Twisting  Picking up and object from a seated position  Altered movement strategies may be a strategy to protect injured lumbar tissues  These changes are larger in those with neural tension signs
  • 36. Lumbopelvic Motion  Many authors agree that more lumbar motion, earlier in the range, especially with rotation is apparent in patients with low back pain. (Burnett et al., 2004; Esola et al., 1996; Luomajoki et al., 2008; McClure et al., 1997; Roussel et al., 2009)  Inconclusive overall.  Heterogeneous populations?  Can sub-grouping help us?
  • 37. Low Back Pain Classification  Systems:  McKenzie-based  Treatment-based classification  Movement System Impairment  Commonalities?  Movement  Symptoms reproduced matters  Hip motion matters
  • 38. Low Back Pain Classification  Systems:  McKenzie-based  Treatment-based classification  Movement System Impairment  Commonalities?  Movement  Symptoms reproduced matters  Hip motion matters
  • 39. Treatment-based Classification  Hip Influence:  Spinal Manipulation and Exercise Group  CPR:  < 16 days  No pain beyond knee  Hypomobile lumbar spine accessory motion  Low Fear-Avoidance Beliefs  Hip Motion (>35 degrees)  Also, we see something interesting in the Stability subgroup…  Important factors: Age, recurrent pain, SLR ROM, etc
  • 40. Arthrokinematics of a Subgroup  Teyhen et al, 2007 in PTJ  Examined subgroup indentified to have suspected spinal instability per CPR  Fluroscopic computer analysis  Found segmental HYPO-mobility in this subgroup!
  • 41. Hip Hypomobility with LBP  Tafazzoli and Lamontagne, 1996  With LBP:  Increased passive elastic moment on the hamstrings  Increased hip stiffness to oscillatory motions  A rationale to treat the hips for patients presenting with primary LBP
  • 42. More Hip Trouble from LBP  Reduced Hip Flexion in patients with LBP  Wong and Lee, 2004  3-dimensional analysis of functional motion in patients with LBP  Increased ER compared to IR in patients with LBP  Cibulka et al, 1998  Examined over 100 patients with LBP
  • 43. Low Back Pain Classification  Systems:  McKenzie-based  Treatment-based classification  Movement System Impairment  Commonalities?  Movement  Symptoms reproduced matters  Hip motion matters
  • 44. Movement System Impairment System  People with LBP demonstrate earlier and greater lumbopelvic rotation during hip lateral rotation compared to people without LBP  5 groups (based on history, symptoms with movement and alignment)  lumbar extension rotation syndrome  lumbar extension syndrome  lumbar flexion rotation syndrome  lumbar flexion syndrome  lumbar rotation syndrome  Important exam items related to the hip:  Hip Ext, Rot ROM, Hip abduction with lateral rotation in hook- lying, relative hip flexibility, hip motion in supine Van Dillen, Sahrmann, et al. 2003
  • 45. Hip Musculature and LBP If we‘re moving differently, we‘re using our muscles differently, right?
  • 46. Neuromuscular control of walking with chronic low-back pain  Vogt et al., 2003, Manual Therapy  17 male subjects, hip ROM, surface EMG during gait  Subjects with moderate low back pain had:  Decreased hip motion and stride time  Decreased hip extensor and lumbar spine extensor muscle activity  Persistent firing of the above noted muscle groups compared to controls  Leinonen et al., 2000 – observed similar decreased gluteus maximus activation in patients with LBP
  • 47. Lumbopelvic Stabilization  Hungerford et al., 2003, Spine.  EMG analysis of 14 individuals with SIJ pain compared to age-matched controls  Reduced activation of  Internal oblique  Multifidus  Gluteus maximus
  • 48. Where We Stand As Hipsters  Diagnostic Dilemma  Patterns of Known Impairments of the hip in patients with low back pain  Presence of hip-based factors in classification systems for clinicians to use when treating patients with low back pain.  Practically Speaking: Education about the role of the hip in low back pain is something that people tend to teach in weekend courses and at conferences like this. It‘s not something much research has supported.
  • 49. Evidence for Interventions What guidance do we have concerning the hip-spine connection? Image by mpascoe via Flickr
  • 50. Regional Interdependence Defined  ―Seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient‘s primary complaint.‖ Wainner, Whitman, Cleland & Flynn. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. JOSPT, 2007, (37)11.
  • 51. Spine & Extremity Regions  Typical referred & radiating pain patterns  Impairments - often seemingly unrelated
  • 52. Is this actually happening in clinical practice?
  • 53. Examples in the Literature: Intervention Studies Primary LBP • Cibulka, JOSPT, 1999 Primary Knee Pain • Boyle & Demske, Physiotherapy  Deyle et al, Ann Int Med, ‗00 Theory & Practice, ‗09  Deyle et al, PT, ‘05 • Whitman et al, PM&R Clinics of  Cliborne et al, JOSPT ‘04 North America 2003  Currier et al, Phys Ther, ‘07 • Whitman et al, Spine 2006  Lowry et al, JOSPT, ‘08  Iverson et al, Phys Ther, ‘08  Mascal et al, JOSPT, ‘03  Cibulka & Threlkeld- Watkins, JOSPT, ‘05 Primary Hip Pain  Vaughn, JOSPT, ‗08 • Cibulka & Delitto, JOSPT, 1993 Primary Foot Pain • Konczak & Ames, JMPT, 2004 • Cleland et al, JOSPT, 2009 • Wisdo, JMPT, 2004
  • 54. Treat the Lower Quarter for Primary Low Back Pain Classic Examples in the Literature
  • 55. Lower Quarter Treatment for Primary LBP Low Back Pain • Cibulka, JOSPT, ’99 • Boyle & Demske, Physiotherapy Theory & Practice, ‗09 Lumbar Spinal Stenosis • Whitman et al, Spine. ‘06 • Whitman et al, PM&R Clinics of North America, ‘03
  • 56. Differential Dx for Hip vs. Spine Disease Brown, et al. Clin Orthop. Feb 2004:280-284  97 pts with LE pain referred to spine specialty clinic  Age - mean 67.5 ± 11.6 years  History, physical exam, & diagnostic testing completed  Imaging studies gold standard for diagnosis  Findings:  19% - spinal disorders only  36% - hip & spine in conjunction  45% - hip only disorders  81% - had some hip involvement present  Limitations  Diagnostic & test review with spectrum bias
  • 57. • Limp, groin pain, limited IR at hip – More likely to be present in a patient with a hip disorder • Positive femoral stretch test – More likely to have a spine disorder
  • 58. Hamstring Muscle Strain Treated by Mobilizing the Sacroiliac Joint  Cibulka et al, Phys Ther, 1986
  • 59. Hamstring Muscle Strain Treated by Mobilizing the Sacroiliac Joint  20 patients with a HS  Dependent Measures strain  Hamstring flexibility  Hamstring muscle torque  Quadriceps muscle torque  Control- MH and stretching  Experimental- MH, stretching and SI manip  Significant difference in hamstring torque for experimental group.
  • 60.
  • 61. N = 60 patients with LSS Outcomes: • GRC, Disability (OSW) • Baseline, 6-weeks, 1-year, long-term (mean 27-29 mo) Interventions: • All subjects: 2x/wk for 6 wks in-clinic, walk at home 3x/week Flexion Exercise & Manual PT, Exercise, and Walking Group (FExWG) Walking Group (MPTExWG) • Sub-therapeutic US, SKC/DKC, •BWS TM walking & SKC/DKC TM walking program • Manual physical therapy - Impairment-Based, Comprehensive Lower Quarter
  • 62. Regions Treated 100 Patients receiving treatment (%) 90 80 70 60 50 40 30 20 10 0 Thoracic Lumbo-Pelvic Hip Knee Ankle/Foot
  • 63. Interventions Utilized: Lower Extremities 100 90 80 70 Percentage 60 50 40 30 20 10 0 Hip Knee Ankle/Foot Manipulation Mobilization Stretch Muscle Energy
  • 64. Hip Mobilizations Long-Axis Distraction Supine P-A Currier et al, JOSPT, 2008 MacDonald, JOSPT, 2006
  • 65. Hip Mobilizations Prone A-P in FABER Position Prone A-P in FABER Position Currier et al, JOSPT, 2008 MacDonald, JOSPT, 2006
  • 67. Other RI Facts: Hip-Spine Syndrome / Relationships Hip ROM & LBP/SIJ Ellison et al, Phys Ther, ‘90; Chesworth et al, Physiother Canada, ‘94; Cibulka et al, Spine, ‘98; Sjolie , Scand J Med Sci, sports, ‘04; Vad et al, Am J Sports Med, ‘04; Coplan, JOSPT, ‘02; Mellin, Spine, ‘88 Porter & Wilkinson; Spine ‘97; Mellin. Spine ‘88 Hip Region Muscle Performance & LBP Nadler et al, Clin J Sport Med, ‘00; Nadler et al, Am J Phys Med Rehabil, ‘01; Nadler et al, Med Sci Sports Exerc, ‘02; Kandaanpaa et al, Arch Phys Med Rehabil, ‘98; Nourbakhsh & Arab, JOSPT, ‗02 Hip Region Muscle Performance & LBP Offierski & McNab, Spine ‘83; Ben-Galim et al, Spine, ‘07; Murata et al, Clin Orthop Surg, ‘02; Nakamura et al, Acta Orthop Scand, ‘03; Yoshimoto et al, Spine, ‘05; Takemitsu et al, Spine, ‘88; Sato et al, J Musculoskelet Syst, ‘89; Itoi, Spine, ‘91; Watanabe et al, Orthopedics, ‗02 Reiman, Weisbach, and Glynn. The Hip’s Influence on Low Back Pain: A Distal Link to a Proximal Problem. Journal of Sport Rehab, ‘09
  • 68. Other RI Facts  Associations between:  Hip ROM & response to spinal manipulation Flynn et al. Spine ’02.Childs et al, Ann Int Med ’04  Hip Abd, ER, and Ext Weakness and PFPS Robinson, JOSPT, ‘07; Ireland, JOSPT, ‗03  SIJ manipulation and quadriceps facilitation  Suter et al. JMPT ‘00  SIJ manipulation and HS peak torque changes (pts with HS strain)  Cibulka et al, Phys Ther, ‗85  LSS source of pain identified after THA  Bohl et al, Spine, ‘79, Saito et el, Spine 2012  Concomitant spine and hip disease extremely common  Brown et al, CORR, ‘04
  • 69. Primary Hip Interventions for Patients with Low Back Pain and Hip Impairments: A Prospective Case Series (Preliminary Results) Eric K. Robertson1, Cheryl Sparks2, Derek Clewley3 1Faculty,Department of Physical Therapy, Texas State University, San Marcos, TX, USA, 2Faculty, Department of Physical Therapy, Bradley University, Peoria, IL, USA, 3Benchmark Physical Therapy, Atlanta, GA, USA *Acknowledgement: Dr. Julie M. Whitman for her review of the study design and report. Research performed as part of the Evidence in Motion Fellowship Program
  • 70. Although many clinicians who are perceived as experts often describe examination and interventions at the hip for patients with low back pain, very little evidence describing this exists. Lack of Research
  • 71. Management of a Female with Chronic Sciatica and LBP: A Case Report  History  6 weeks of lumbar stabilization and flexibility intervention did not eliminate symptoms  Intervention  Treatment plan revised to include impairment-based left hip capsule flexibility  Also included hip strengthening to glut med  Outcome  Complete resolution of pain, disability (0 NPRS, 0% on ODI (reduced from 41% at baseline)) Boyle and Demske, 2009 Physiotherapy Theory and Practice
  • 72. Management of a Female with Chronic Sciatica and LBP: A Case Report • History 60 • 6-weeks of lumbar stabilization and flexibility 50 intervention did not eliminate symptoms 40 • Intervention 30 41% Reduction. • Treatment plan revised to 20 include impairment-based left hip capsule flexibility 10 • Also included hip Spine Interventions strengthening to glut med 0 Hip Interventions NPRS ODI Boyle and Demske, 2009 Physiotherapy Theory and Practice
  • 73. Purpose The purpose of this prospective case series was two-fold. 1. Describe the clinical decision making process involved in the management of patients with primary complaints of low back and hip pain. 2. Provide an evidence-based rationale for directing treatment at the hip in a sub-group of patients with low back pain.
  • 74. Number of Subjects Six subjects referred to physical therapy with low back pain who also demonstrated impairments at the hip were recruited to participate. (Note: Data collection is still in progress, currently have 11 enrolled.)
  • 75. About the Subjects Inclusion Criteria: • 1. Adults referred to PT with a primary complaint of low back pain (LBP) • 2. Positive hip impairments as identified in the patient’s initial physical examination* Definition of positive hip impairment: • Positive special tests, decreased ROM, decreased muscle strength, reversed lumbo-pelvic rhythm, decreased mobility or pain with accessory motions, or findings consistent with the clinical presentation of hip osteoarthritis per the criteria established by Altman et al.
  • 76. About the Subjects Exclusion Criteria: • Any medical red flags • Spinal or femoral fractures, except for degenerative spondylolisthesis or spondylolisis • Upper motor neural compromise • Pregnancy • Lower motor neuron changes suggestive of nerve root irritation and/or compression (positive straight leg raise at <45º or diminished lower extremity strength, sensation, or reflexes • High fear-avoidance beliefs (>35 on the Fear Avoidance Belief Questionnaire Work [FABQW] subscale) • Previous history of spine or hip surgery • Inability to read and understand English
  • 77. Methods • Primary outcomes: • Secondary outcomes: • Oswestry Disability • Global Rating of Change Index, (ODI) (GROC) • Harris Hip Score (HHS) • Assessment of hip impairments. • Numerical Pain Rating Scale (NPRS) Initial Examination Week 4 Visit #2 (2-3 days after Initial Examination) Institutional Review Board approval was obtained from Bradley University for this study.
  • 78. Important Exam Items Hip Examination ROM, all planes • +/- Hip Impairment Special Tests: Scour, FABER, other • Positive special tests, decreased Flexibility: Hip flexor, extensor length ROM, decreased muscle Strength: All planes strength, reversed lumbo-pelvic rhythm, decreased mobility or pain with accessory motions, or findings Lumbar Spine Examination consistent with the clinical presentation of hip osteoarthritis per ROM Screen the criteria established by Altman et al. Accessory Mobility Core musculature assessment Special Tests: SLR, PIT, etc
  • 79. Hip Examination Item Results Hip ROM Impairments 6/6 Hip Weakness 4/6 + Hip Special Test 5/6 Median age was 50 years (range, 27-61 years) Examination Results
  • 80. Interventions Day 1: Examination and Initial Treatment If hip impairment was noted, then treatment progressed in the following manner: • Manual Interventions focused on hip. (thrust/non-thrust) • Hip-specific therapeutic exercise • Reinforcing Home Exercise Program • Re-assess Day 2.
  • 81. Interventions Exercises provided to focus on • gluteus maximus, • hip abduction and external rotation • core stabilization progression. Neuromuscular re-education: • Movement re-education consisting of patient instruction, practice if abnormalities noted, i.e. sit to stand • Squatting and proper lifting mechanics • Proprioceptive core stability exercises
  • 82. Interventions Day 2 – Week 4 Treatment • Treat per impairment-based approach or a pragmatic application of the Treatment-based classification approach. • HEP and TherEx continued to stress hip-focused interventions
  • 83. Results Results: At 4 weeks, the average improvement in ODI scores was 39%, and 24% for the HHS. 66% of the patients experienced a significant decrease in the NPRS. 100% of patients for which data was collected experienced at least a change of 4 on the GROC (4-7), indicating at least moderate improvement. Avg. visits = 7.3 (3-10). Numeric Pain Rating Global Rating of Change* Scale* 5.3 2.8 Median 5.25, (range, 4-7) Median 3, (range, 0-5) “Quite a bit better” MCID: 1.8 *Note: Data on GROC collected for 4/6 patients.
  • 84. ODI Avg. Change Day 2 4 Week 4 20 Oswestry Disability Index 90 80 70 60 50 Baseline 40 Day 2 Week 4 30 20 10 0 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
  • 85. HHS Avg. % Change Day 2 18 Week 4 24 Harris Hip Score 100 90 80 70 60 Baseline 50 Day 2 40 Week 4 30 20 10 0 Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
  • 86. • Small Case Series = No Cause and Effect • Not consecutive subjects • Control over interventions limited, especially the neuromuscular reeducation to the core Limitations
  • 87. Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series • Subjects: • 8 Subjects with CLBP, Avg age 49, with ROM impairments • Intervention • Impairment-based manual therapy to Bilateral Hips • 3 Sessions over 1 week • Outcome • 5/8 (65%) reports >4 “Moderately Better” on the GROC • 24% reduction in ODI scores “This case series suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to determine the potential effectiveness of this approach with patients with CLBP.” Burns, Mintken, Austin, Cleland. 2010 JMMT
  • 88. Conclusions • Significant improvements were observed in all primary outcome measures at 4 weeks. • Secondary outcome measures trended towards significant improvements. • This case series provides preliminary evidence that some patients with low back pain may receive a benefit from interventions directed at the hip. • Future studies should work to determine the factors that can predict patients that may realize this benefit.
  • 89. HOW TO GET HIP Yes, you can be a hipster too!
  • 90. Posterior Pelvic Tilts Williams Flexion Exercises Hot Packs Massage Ultrasound That‘s so yesterday! Once we acknowledge the role of the LE in back pain, it frees us from the constraints of patients with low back pain. It allows us to become creative and challenge our patients in new ways.
  • 91. ADVANCE EXERCISE CONCEPTS FOR THE …HIP? LOW BACK? DPTMWG
  • 93. • Progression of: • Limb support • Surface • Visual input • Perturbations • Task demands Proprioceptive/Balance Training DPTMWG
  • 94. Testing For Strength In CKC Positions • Sit to Stand • Squat • Leg Press • Lunge
  • 95. • Used most often with older individuals • Performance is based on given period of time (10-30 seconds) and reps recorded or given reps and time recorded in seconds • Sit to stand performance has direct correlation to knee extension force and leg press force. Sit To Stand Test Jones et al DPTMWG
  • 96. Sit to stand Test DPTMWG
  • 97. • Sit to Stand Test (Csuka et al, Am J Med 1985) • Regression equation for predicting normal performance for 10 stand ups. Results are in seconds. • Women: 7.6 + .17 x age • Men: 4.9 +.19 x age Sit to Stand Test DPTMWG
  • 98. • Utilized to compare uninvolved to involved and also to compare to norms • Associated with thigh, hip and buttock strength • Takes balance and core factors out of strength assessment. • Greater than 90% of contra-lateral considered acceptable Leg Press Test for Strength DPTMWG
  • 99. Plisky et al. N Am J Sports Phys Ther. 2009 May; 4(2): 92–99. DPTMWG
  • 100. • Significant differences associated with chronic ankle instability and ACL insufficiency • Can be predictive of LE injury • What about LBP?! Population Reach Distance Implication P value All Players R:L Difference of 2.5x more likely to p<.05 >4 cm sustain LE injury Females <94% of LE 6x more likely to p<.05 length sustain LE injury Y Balance Test Utility DPTMWG
  • 101. Mascal et al. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. JOSPT 2003 N=2 20, 37 y/o females
  • 102. Mascal et al. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. JOSPT 2003 • 14 week treatment period focused on recruitment and endurance training of the hip, pelvis and trunk (including TrA) • Patients attended PT 1-2 times per week • Hip muscles (particularly glut max, med and external rotators) were progressively strengthened, starting in NWB followed by WB functional tasks
  • 103. Hip Abductors and ERs • Mini-squats, step-ups/downs and leg presses for concentric/eccentric control, BAPS board/lunges for proprioceptive training Core muscle training Restore Neuromuscular Control
  • 104. It‘s Hip to have a high yield!
  • 105. Before I leave you…
  • 106. Relative Healthcare Costs Cost in Billions 800 700 CHRONIC PAIN! 600 500 Cardiovascular 400 Disease 300 200 100 0
  • 107. Pain…  It might not be as much of a physical thing as we think!  We need to consider the cognitive components!
  • 108. L E V E L P A I N Injury! Adapted from Butler & Mosely, 2008, ―Explain Pain‖ H E A L I N G R E S P ON SE
  • 109. ―Nociception is neither sufficient for, or necessary to experience pain.‖ Adapted from Butler & Mosely, 2008, ―Explain Pain‖
  • 110. Identifying Patients at Risk for Chronic Pain George & Zepperi, JOSPT, July- 2009  Fear-avoidance model of musculoskeletal pain (FAM) (Measured by FABQ)  Factors influencing pain perception  Anxiety  Fear of re-injury  Catastrophizing Confrontation Avoidance Anxiety Anxiety Fear of re-injury Fear of re-injury Catastrophizing Catastrophizing
  • 111. FDAQ – A Measurement George & Zepperi, JOSPT, July- 2009 George et al., PTJ, July- 2009
  • 112. Establishing a Baseline Therapist: ‗How long can you walk before you flare-up?‘ Patient: ‗I can walk for 30 min but I pay for it the next day‘ Therapist: ‗Can you walk for 20 min without flaring up?‘ Patient: ‗No, but I have‘ Therapist: ‗Can you walk for 10 min without flaring up?‘ Patient: ‗Probably not — definitely not up hills‘ Therapist: ‗5 min on a flat surface?‘ Patient: ‗Probably‘ Therapist: ‗3 min on a flat surface?‘ Patient: ‗Definitely‘
  • 113. Continuous Progression  ‗Every day you do more than you did yesterday, but not much more‘ …at least initially.  Setting clear measurable goals and objectives!
  • 114. KEY POINTS  Pain is not nociception  The representation of the body in the human brain  The brain changes as the pain persists  Body-brain is a 2 way street  Training the brain for people in Pain  This is VERY Hip.
  • 115. References: • Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Orthopaedic Physical Therapy Clinics of North America, 9:103-118, 2000 • Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance deficits in individuals with functional ankle instability. The Journal of orthopaedic and sports physical therapy. 2009;39(11):799-806. • Kong DH, Yang SJ, Ha JK, et al. Validation of functional performance tests after anterior cruciate ligament reconstruction. Knee surgery & related research. 2012;24(1):40-5. • Munro AG, Herrington LC. Between-session reliability of the star excursion balance test. Physical therapy in sport  : 2010;11(4):128-32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21055706. Accessed July 25, 2012. • Narducci E, Waltz A, Gorski K, Leppla L, Donaldson M. The clinical utility of functional performance tests within one-year post-acl reconstruction: a systematic review. International journal of sports physical therapy. 2011;6(4):333-42. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3230161&tool=pmcentrez&rendertype=abstract. • Pigozzi F, Giombini A, Macaluso A. Do current methods of strength testing for the return to sport after injuries really address functional performance? American journal of physical medicine & rehabilitation. 2012;91(5):458-60. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22415342. Accessed July 25, 2012. • Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical therapy. 2007;87(3):337-49 • Plisky P. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12):911-919. • Hertel J, Braham RA, Hale SA, Olmsted-kramer LC. Simplifying the Star Excursion Balance Test  Chronic Ankle Instability. : Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12). • Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine. 2005;33(4):492-501. • Myer GD, Ford KR, Hewett TE. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today. 2009;13(5):39-44. DPTMWG
  • 116. References: DPTMWG
  • 117. References: • Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Orthopaedic Physical Therapy Clinics of North America, 9:103-118, 2000 • Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance deficits in individuals with functional ankle instability. The Journal of orthopaedic and sports physical therapy. 2009;39(11):799-806. • Kong DH, Yang SJ, Ha JK, et al. Validation of functional performance tests after anterior cruciate ligament reconstruction. Knee surgery & related research. 2012;24(1):40-5. • Munro AG, Herrington LC. Between-session reliability of the star excursion balance test. Physical therapy in sport  : 2010;11(4):128-32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21055706. Accessed July 25, 2012. • Narducci E, Waltz A, Gorski K, Leppla L, Donaldson M. The clinical utility of functional performance tests within one-year post-acl reconstruction: a systematic review. International journal of sports physical therapy. 2011;6(4):333-42. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3230161&tool=pmcentrez&rendertype=abstract. • Pigozzi F, Giombini A, Macaluso A. Do current methods of strength testing for the return to sport after injuries really address functional performance? American journal of physical medicine & rehabilitation. 2012;91(5):458-60. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22415342. Accessed July 25, 2012. • Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical therapy. 2007;87(3):337-49 • Plisky P. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12):911-919. • Hertel J, Braham RA, Hale SA, Olmsted-kramer LC. Simplifying the Star Excursion Balance Test  Chronic Ankle Instability. : Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12). • Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine. 2005;33(4):492-501. • Myer GD, Ford KR, Hewett TE. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today. 2009;13(5):39-44. DPTMWG

Editor's Notes

  1. https://www.biodigitalhuman.com/#/pubkid=29Y
  2. Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis &amp; stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA
  3. Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis &amp; stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA
  4. Flexion-relaxation response – refers to the electromyographic silence of the lumbar spine extensors in end ranges of flexion, thought to be why hip extensors activate first to rise from a flexed position.
  5. Given the findings of Lee and Shum4,8,10-13, these findings do not seem to be in so much contrast to expectations, but perhaps representative of the arthrokinematics of many patients with low back pain.
  6. Image is of control, note early activity of OI, multifidus during gait and early quieting of biceps femoris.
  7. Hip–Spine SyndromeThe concept of a biomechanical link between the hip joint and the lumbar spine has been described as hip–spine syndrome (HSS).40 (offierski and mcnap – hip spine syndrome – spine – ’83) HSS specifically depicts the influence of a pathological hip joint on the alignment of the spine and subsequent muscle length and joint forces.40The most recent documentation of this relationship has been that of severehip osteoarthritis (OA) potentially causing abnormal spinal sagittal alignment andensuing LBP.41 Ben-Galim et al41 evaluated the effects of surgical treatment of hipOA on low back disability in patients preoperative and postoperative total hipreplacement and found significant (P &lt; .01) improvements in both visual analogscores for LBP and Oswestry Disability Index scores after surgery that remainedat the 2-year follow-up.Other specific related interactions of the hip and spine in HSS can include ahip-flexion contracture resulting in compensatory hyperlordosis of the lumbarspine or a posteriorly inclined pelvis with increased kyphotic posture and primaryor rapidly destructive hip OA.40,42–48 In each of these examples, although there isa relationship between the hip and spine, the evidence demonstrating the significanceof its effect on LBP is deficient.Although the biomechanical influences of the hip on LBP are not fully evidentat this time, the current level of evidence does support a regional relationshipbetween the 2 areas. From the preliminary work of Ben-Galim et al,41 one canbegin to appreciate the importance of further investigating hip ROM, as well asregional soft-tissue characteristics, in patients with LBP.Offierski and McNabb published a paper describing a “hip-spine syndrome” in which patients with pain in the lumbo-pelvic-hip region can have concurrent pathologies in both the lumbar spine and hip joints. 1  They stated that the inability to properly determine the primary source of a patient’s pain may lead to inappropriate or incomplete treatments.  Additional studies have been published that support the existence of hip-spine syndrome in patients with the primary complaint of LBP.2-5  .      Offierski CM, MacNabb MB.  Hip-Spine Syndrome.  Spine. 1983;8(3):316-321.2.      Fogel GR, Esses SI.  Hip spine syndrome: management of coexisting radiculopathy and arthritis of the lower extremity. Spine J. 2003;3(3):238-241.3.      Vad VB, Bhat AL, Basrai D, Gebeh A, Aspergren DD, Andrews JR.  Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits. Am J Sports Med. 2004;32(2):494-497.4.      Brown MD, Gomez-Marin O, Brookfield KF, Li PS. Differential diagnosis of hip disease versus spine disease. ClinOrthopRelat Res. 2004;419:280-284. 5.      Lee RYW, Wong TKT.  Relationship between the movements of the lumbar spine and hip. Hum Mov Sci. 2002;21(4):481-494.6.      Ben-Galim P, Ben-Galim T, Rand N, et al. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine. 2007;32(19):2099-2102.
  8. Treatment with hip long axis distraction thrust manipulation if not contraindicated.Hip and low back pain will be re-assessed following treatment.Non-thrust and thrust hip joint mobilization including those to improve flexion,extension, and rotation as indicated by impairments and stretches to theanterior hip musculature to maximize hip joint mobility. Hip and low back painwill be re-assessed following treatment.Perform therapeutic exercises for hip. Prescribe home exercise program (HEP) for hip.
  9. Treatment with hip long axis distraction thrust manipulation if not contraindicated.Hip and low back pain will be re-assessed following treatment.Non-thrust and thrust hip joint mobilization including those to improve flexion,extension, and rotation as indicated by impairments and stretches to theanterior hip musculature to maximize hip joint mobility. Hip and low back painwill be re-assessed following treatment.Perform therapeutic exercises for hip. Prescribe home exercise program (HEP) for hip.
  10. Stabilization progression exercises described by Hicks et alHip extension in prone with knee flexion.Specific exercise to gluteus medius.
  11. Treatment with hip long axis distraction thrust manipulation if not contraindicated.Hip and low back pain will be re-assessed following treatment.Non-thrust and thrust hip joint mobilization including those to improve flexion,extension, and rotation as indicated by impairments and stretches to theanterior hip musculature to maximize hip joint mobility. Hip and low back painwill be re-assessed following treatment.Perform therapeutic exercises for hip. Prescribe home exercise program (HEP) for hip.
  12. NPRS (Childs, Piva 2005, Spine, reported for 1 week)ODI:39%HHS: 24%66% reduced NPRS (1 didn’t report pain)100% at least 4 on GROC= moderate improvement
  13. The intervention for these two patients consisted of an impairment-based approach … Here you can see some of the exercises performed. On the left, basic strength training at 0-6 weeks, In the middle more dynamic training at 6-10weeks, and on the right, functional plyometric exercises at 10-14 weeks. Note that the exercises were steeped in neuromuscular recruitment of the proper muscles and that this trial focused somewhat extensively on hip strengthening. Both patients experienced significant decreases in pain, increased function, muscle strength and endurance.
  14. I do want to talk specifically about the concept of VMO strengthening. Many PT’s hold onto what they were taught back in the 80’s and 90’s about things. The VMO is one example. It’s not possible for us to selective activate any one part of the quad over another, since they all come from the same nerve supply. No evidence exists that consistently supports this concept. However, it’s not uncommon to see this in the clinic, or read articles that includes statements like the one you see here, which are perhaps logical from an embryologic standpoint, but not from a practical application standpoint. The key is to focus on the nm control of the entire lower extremity kinetic chain and leave behind the focus on the VMO.
  15. Low Back Pain: $86 billion/year (2005)• All arthritis: $80 billion (2003)• Cancer: $89 billion (2007)• Diabetes: $98 billion (2002)• Heart dis &amp; stroke: $258 billion (2005)• Costs for LBP rose 65% (inflationadjusted),1997-2005Martin BI, Deyo RA, et al. JAMA