Chronic Neck & Low Back Pain: A Case of Motor Control

1. CHRONIC NECK & LBP, 30 Y/O MALE
A CASE OF MOTOR CONTROL
LAUREN JARMUSZ, PT, DPT
WEDNESDAY, DECEMBER 14TH, 2016

2. BACKGROUND

3. HPI
 Patient: 30 y/o male
 CC: Chronic neck & LB pain. Pt. experiencing weekly left sided neck pain exacerbations and severe
cervicogenic headaches 3-5x/week. “Gets nervous when walks into room and there is no where to sit
because of LBP. ” Non improved LBP for past 8 years.
 MOI (neck): MVA 12/17/15. Pt. was at a complete stop when car was rear ended by another car at 60
mph; airbags were deployed; LOC occurred. Pt Was spine boarded, taken to ER, cleared for CV injury and
was dx with whiplash.
 MOI (LB): Insidious. Pt reports non specific LBP for past 8 years without improvement.
 Prior Treatment: PT (for whiplash) appox. 3 mo [March-May2015], 6 visits, where he reported significant
pain relief before DC.
 Anterior Chain Stretching
 STM & Trigger Point Release
 Low Intensity DNF & Scapular Strengthening
 Pt. education on whiplash injury
• Neural Tension Glides
• Cervical Jt. Mobilizations
• NDI: 9/50
• PSFS: 6.33/10; work at computer; household
chores/wash dishes; sleep

4. PLOF, CLOF & GOALS
PLOF (prior to MVA):
 Moderately active individual with no pain
with driving/ sitting.
 Occasional gym user (1-3x/wk), riding bike
to work, walking, ADLs involving
ambulation
CLOF:
 Unable to comfortably stand for >15min
 Pain with sitting >20-30min
 Stopped going to gym after MVA
Occupation:
 Video Game Programmer,
 Working 40-60 hrs/week.
Pt. Goals:
 Pain free work day when sitting at desk
 Decrease in neck pain exacerbations
 Decrease in cervicogenic HA frequency
 Ability to tolerate >15min of standing

5. EXAMINATION

6. PAIN (NECK)
Aggravating Factors
Neck: (sitting)
computer work and
driving >20min
LB: standing >15min,
lumbar rotation and
extension based ADLs.
Easing Factors
Neck: changing
position, self trigger
point release, heat
LB: sitting, lying
down, stopping
aggravating activity
SINSS (Neck)
Severity: Moderate (3-best; 8-worst)
Irritability: Low if not experiencing neck pain exacerbation,
high if experiencing neck pain exacerbation (6-8/10 pain for 1-
2 days)
Nature: localized, achy
Stage: Chronic (1 yr s/p MVA)
Stability: Stable, known MOI, exacerbated by consistent agg.
factors
SINSS (LB):
Severity: Moderate (3/10-best, 8/10-worst)
Irritability: Low, immediate decrease in sx. upon sitting
Nature: Localized, sharp, achy
Stage: Chronic
Stability: Stable, pain exacerbated and relieved by consistent
factors

7. TOP DIFFERENTIAL DX.
NECK
 Known MOI: MVA with associated whiplash
 Postural Syndrome vs Dysfunction
(McKenzie)
Systems Review:
 CardioPulm (clear)
 Neuro (clear)
 Integumentary (clear)
 GI/Urinary (clear)

8. OBJECTIVE FINDINGS- NECK
Posture:
 Decreased cervical lordosis, thoracic kyphosis, and
lumbar lordosis
 Left scapula protracted and elevated
Cervical AROM/PROM: WNL- Left SB, Left
rotation, extension **pain
Thoracic AROM: WNL except extension = 75%
normal range
Palpation: Hypertonic & tender throughout
bilateral suboccipitals, upper trapezius, scalenes,
levator scap
(L > R)
X-Ray: reduced cervical lumbar lordosis
Jt. Play:
 Cervical- normal mobility C2-7
 Thoracic- Hypomobility T1-T8
Neuro Screen: Pt. denied radiating sx.
Strength:
 DNF endurance test: 10 sec.
 LT, Rhomboids, MT (bilateral): 4-/5
Muscle Length: stiffness of bilateral pec minor/ pec
major noted. Normal Lat length.
MRI: (3/3/16) Left paracentral and foraminal zone disc
extrusion at C6-7 causing severe left neural foraminal
narrowing and likely impingement of the exiting left C7
nerve“- however pt. non symptomatic

9. PAIN (LB)
Aggravating Factors
Neck: (sitting)
computer work and
driving >20min
LB: standing >15min,
lumbar rotation and
extension based ADLs.
Easing Factors
Neck: changing
position, self trigger
point release, heat
LB: sitting, lying
down, stopping
aggravating activity
SINSS (Neck)
Severity: Moderate (3-best; 8-worst)
Irritability: Low if not experiencing neck pain exacerbation,
high if experiencing neck pain exacerbation (6-8/10 pain for 1-
2 days)
Nature: localized, achy
Stage: Chronic (1 yr s/p MVA)
Stability: Stable, known MOI, exacerbated by consistent agg.
factors
SINSS (LB):
Severity: Moderate (3/10-best, 8/10-worst)
Irritability: Low, immediate decrease in sx. upon sitting
Nature: Localized, sharp, achy
Stage: Chronic
Stability: Stable, pain exacerbated and relieved by consistent
factors

10. DIFFERENTIAL DX.
LB
 Facet Syndrome
 SI dysfunction
 Syndrome vs Dysfunction (McKenzie)
 Ankylosing spondylitis Systems Review:
 CardioPulm (clear)
 Neuro (clear)
 Integumentary (clear)
 GI/Urinary (clear)

11. OBJECTIVE FINDINGS- LB
Posture:
 Decreased cervical lordosis, thoracic kyphosis,
and lumbar lordosis
 Posterior Pelvic Tilt
Lumbar AROM:
 Pain Left LB (lateral to L5-S1) with Ext, SB right,
Rot right.
 Flat lumbar spine L3-5 with lumbar flexion.
(no reversal of lumbar lordosis)
 Hip dominated lumbopelvic rhythm (1)
Hip PROM: bilateral hip ER, IR, flexion, ext- WNL
Palpation: increased tone Lumbar Paraspinals L3-L5
and bilateral QL (L>R)
Jt. Play:
 Hypomobile L4-L5 (central PA) and L > R (unilateral
PA)
Neuro Screen: Pt. denied radiating sx.
Strength:
 Glutes, HS, Hip Abd, ER (bilateral) 4-/5
 Core:
 Side Plank – 25 seconds (before loss of form)
 Bridge – Unable to maintain level hips with LE lift.
Muscle Length:
 90/90 HS assessment: 50 deg to neutral bilateral
(+)
 SLR HS assessment: 60 deg (bilateral)
 Elys: WNL (bilateral)
 HF (Modified Thomas): WNL (bilateral)

12. OBJECTIVE FINDINGS- LB CONTINUED…
Special Tests:
 (+) stork test on stance leg (bilateral) (2)
 (+) tenderness to palpation of SI ligaments on
left: long dorsal, short SI, iliolumbar
 (+) Fortin's sign on left.
 (+) motor control abnormalities with prone
hip/knee extension: normal muscle firing
pattern on right, abnormal on left: HS ->
Glute ->ipsilateral paraspinal -> contralateral
paraspinal
 (-) thigh thrust test (3)
 (-) distraction SI test (3)
MRI (4/13/16)
 L4-5 mild disc bulge and mild bilateral facet
arthropathy abutting the descending left L5
nerve root in the lateral recess with mild left
foraminal stenosis.
 L5-S1 mild right and mild to moderate left
facet arthropathy.
X-Ray (4/13/16): Normal

13. GAIT ANALYSIS
 Decreased dissociation between lumbar spine
and pelvis in sagittal and transverse planes,
excessive activation of paraspinal musculature.

14. COMPARING LUMBO-PELVIC KINEMATICS IN PEOPLE WITH AND WITHOUT
BACK PAIN: A SYSTEMATIC REVIEW AND META-ANALYSIS (2014)
ROBERT A LAIRD,, JAYCE GILBERT, PETER KENT, AND JENNIFER L KEATING
 43 eligible studies.
 Compared to people without LBP, on average, people with LBP display:
 (i) no difference in lordosis angle (8 studies),
 (ii) reduced lumbar ROM (19 studies),
 (iii) no difference in lumbar relative to hip contribution to end-range flexion (4 studies),
 (iv) no difference in standing pelvic tilt angle (3 studies),
 (v) slower movement (8 studies),
 (vi) reduced proprioception (17 studies).
Conclusion: On average, people with LBP have reduced lumbar ROM and proprioception, and
move more slowly compared to people without LBP.

15. EVALUATION OF THE ABILITY OF PHYSICAL THERAPISTS TO PALPATE INTRAPELVIC MOTION WITH THE
STORK TEST ON THE SUPPORT SIDE
BARBARA A HUNGERFORD, WENDY GILLEARD, MICHAEL MORAN, CATHRYN EMMERSON
 Stork Test is not reliant on a provocation of pain
or a clinical comparison of degrees of joint
mobility between sides of the body. It assesses
the ability of a subject to maintain a stable
alignment of the innominate bone relative to
the sacrum during a functional load transfer task.
 Inter-rater Reliability (Cohen Kappa)
 3 Point Scale: Moderate (left =.59, right =.59)
 2 Point Scale: Good (left = .67, right =.77)
Conclusion: The ability of PTs to reliably
palpate and recognize and altered pattern of
intrapelvic motion during the Stork Test was
substantiated.

16. DIAGNOSIS OF SI JOINT PAIN: VALIDITY OF INDIVIDUAL PROVOCATION
TESTS AND COMPOSITES OF TESTS.
MARK LASLETT, CHARLES APRIL, BARRY MCDONALD, SHARON YOUNG
 Distraction
 Compression
 Thigh Thrust
 Sacral Thrust
 Gaenslen‘s
 Three or more of the six tests produce the
highest likelihood ratio (4.29), but removal of
Gaenslen's test from the examination and
application of the rule “any two positive tests” of
the remaining four tests produces almost as good
a result (likelihood ratio=4.0).
 Because the thigh thrust and distraction tests
have the highest individual sensitivity and
specificity, respectively, performance of these
tests first is suggested. If both tests provoke
familiar pain, no further testing is indicated.

17. EXAMINATION RE-CAP
Dominant Impairment
Patterns:
1. Motor control
2. Mobility
3. Strength
Body Structure/ Function Impairments:
 Thoracic & Lumbar Hypomobility
 SI Hypermobility
 DNF, Scapular, Core, Hip Stabilizer
Weakness
 Impaired Motor Control: DNF
stabilization, LB multifidi, muscle
activation patterns with hip extension &
hip Abduction, “top down extensor
activation pattern”
 Muscle length restrictions: Pec Minor,

18. DIFFERENTIAL DX.
NECK
 (+) Known MOI: MVA with associated
whiplash
 (-) Postural Syndrome vs (+) Dysfunction
(McKenzie)
LB
 (+) Facet Syndrome
 (+) SI dysfunction
 (-) Syndrome vs (+) Dysfunction (McKenzie)
 (-) Ankylosing spondylitis

19. ASSESSMENT & PLAN

20. ASSESSMENT & PLAN
A: Pt. presents with chronic postural
dysfunction secondary to dx whiplash
s/p MVA 12/17/16. Pt. presents with
SI hypermobility dysfunction with
associated hypomobility lumbar facet
syndrome secondary to postural
dysfunction and motor control
abnormalities.
P:
Frequency: 1x week for 12-14weeks
NPV: October 13th, 2016
Visits Seen: 7
Conclusion of Neck Pain Focus & Initiation of LBP
Focus: Nov 21st (Visit #5)

21. TREATMENT (NECK)

22. PHYSIOTHERAPY MANAGEMENT OF WHIPLASH-ASSOCIATED DISORDERS (WAD)
MICHELE STERLING, JOURNAL OF PHYSIOTHERAPY, VOLUME 60, ISSUE 1, MARCH 2014
From a clinical perspective, exercise and activity should
be used in the treatment of both acute and chronic
WAD. However, there is no evidence to indicate that one
form of exercise is superior to another and this is an area
that requires further research.

23. Figure 1. Predicted Neck
Disability Index (NDI)
trajectories with 95%
confidence limits and
predicted probability of
membership (%). Suggested
cut-offs for the NDI are: 0 to
8% (no pain and disability);
10–28% (mild pain and
disability), 30–48%
(moderate pain)
Michele Sterling
Physiotherapy management of whiplash-associated disorders (WAD)
Journal of Physiotherapy, Volume 60, Issue 1, 2014, 5–12
http://dx.doi.org/10.1016/j.jphys.2013.12.004
Patient’s Scores:
Prior Treatment NDI: 9%
NPV NDI: 15%

24. NECK
Week 1 (NPV) Week 2
Interventions: Left STM Levator Trap, UT
Outcomes: Dec. TTP and no pain with neck ext, left
left SB, left rot.
HEP:
• Postural Awareness
• Supine DNF strengthening 2x/day 3(20)
• Thoracic Foam Rolling (Daily)
Subjective: Pt. reports that his neck (left sided) has
been extremely sore for the past couple of days. Pt.
was able to complete the DNF exercises without
pain.
Interventions: STM, PA glides T4-T8, Progressed
DNF strengthening (sitting), Prone T, I, Ys
Outcomes: Decreased neck pain and HA.
Independent with completing HEP.
HEP:
• DNF strengthening to sitting: 2-3x/day 3(20)
• Thoracic Foam Rolling (Daily)
• Prone T’s, I’s, Y’s 2x/day 3(10)

25. LB
Week 3 Week 4
Subjective: Pt. reports decreased frequency of
headaches (1x/week). Pt. completing HEP 50%
of time.
Interventions: Left STM Levator Trap, UT; PA
glides grade 3 T4-T8; Resisted Rows (Blue) c
DNF hold
Outcomes: Independent c HEP, Improved
Thoracic Mobility and decreased TTP t/o
neck/UT.
HEP:
• Thoracic Foam Rolling (Daily)
• Prone T’s, I’s, Y’s 2x/day 3(10)
• Resisted rows with DNF hold. 2x/day 3(10)
Subjective: Pt. Reports experiencing no cervicogenic headaches
headaches or neck "flare-ups" this week. Is tolerating sitting at
work for 4-5 hrs w/o pain.
Interventions: PA glides grade 3 T4-T8 pre-positioned in ext.,
Progressed DNF strengthening with scapular stabilization focus
(push-up plus), Standing rows with DNF activation.
Outcomes: Independent with completing HEP.
HEP:
• Thoracic Foam Rolling (Daily)
• Resisted rows with DNF hold. 2x/day 3(10)
• Push-Up Plus with attention to DNF hold 2x/day 3(10)

26. OUTCOMES (NECK)
 NDI: TBD
 Reporting <1 “neck flare-up” every 2+ weeks
 Reporting <1 cervicogenic HA/ week
 Tolerating sitting at desk 5-6hrs/day with neck pain <1/10 pain
 Cervical ROM, all planes, no pain
 Independent with HEP and self pain relief techniques
 Asked to focus PT treatment on LB instead of neck because he thought
that “neck was under control”

27. TREATMENT (LB)

28. LB
Week 5 Week 6
Subjective: Pt. Reports that neck pain has not been
bothersome this week except for a "neck flare-up" on
Thursday 11/10/16 that lasted a few hours. Pt. Is requesting
that since his neck is feeling better to transition focus of
care to LB. He plans to continue with HEP for scapular and
DNF strengthening while treatment focus is moved to LBP
Objective: Assessment of LBP, see objective previous slide
Intervention & Outcome: Pain in Left LB (lateral to L5)
extension, SB right, rot right (5/10 pain) --> (3/10 pain)
following PA Grade 4++ L3-L5 prone mobilization -->
(1/10 pain) following left localized lumbar rotational
mobilization Grade 4+.
HEP: should have prescribed AAROM for lumbar spine
rotation. (ran out of time).
Subjective: Pt. reports experiencing a cervicogenic
headache which began one day ago. Patient reports that
for 2-3 days, following PT treatment interventions last visit,
he did not experience low back pain. Patient reports that
low back pain has returned. Patient was noncompliant with
neck home exercise program protocol.
Invention & Outcome:
1) cervicogenic headache was relieved following sub
occipital release, cervical distraction
2) decreased pain and increased lumbar extension
following graded 4 localized L4-L5 lumbar mobilization.
3) evaluation of gait
HEP: Emphasized importance of maintenance of HEP for
neck. Plan to provide HEP for LB next visit.

29. EXAMINATION RE-CAP LB
Dominant Impairment
Patterns:
1. Motor control
2. Mobility
3. Strength
Body Structure/ Function Impairments:
 Thoracic & Lumbar Hypomobility
 SI Hypermobility
 Core, Hip Stabilizer Weakness
 Impaired Motor Control: LB multifidi,
muscle activation patterns with hip
extension & hip Abduction, increased
tone throughout paraspinals with activity.
 Muscle length restrictions: Hamstrings

30. ALTERED MUSCLE RECRUITMENT DURING EXTENSION FROM TRUNK
FLEXION IN LOW BACK PAIN DEVELOPERS
ERIKA WONG, BRENDAN ALEX, DAVID CSEPE, DENVER LANCASTER, JACK CALLAGAN * CLINICAL BIOMECHANICS 2012
 Objective: Investigate neuromuscular control differences during the
extension phase from trunk flexion between pain developers and non-pain
developers
 Methods: Continuous electromyography and kinematic data were collected
during standing trunk flexion and extension on 43 participants (22 male) with
an age range of 18–33 years, prior to entering into the prolonged standing
exposure.
 Results: Pain developers demonstrated a ‘top-down’ muscle recruitment
strategy with lumbar extensors activated prior to gluteus maximus, while non-
pain developers demonstrated a typical ‘bottom-up’ muscle recruitment
strategy with gluteus maximus activated prior to lumbar extensors.Conclusion: Individuals predisposed to low back pain development during standing
exhibited altered neuromuscular strategies prior to pain development.

31. EFFECTS OF INCLINED TREADMILL WALKING ON PELVIC ANTERIOR TILT ANGLE, HAMSTRING
MUSCLE LENGTH, AND TRUNK MUSCLE ENDURANCE OF SEATED WORKERS WITH FLAT-BACK
SYNDROME MIN-HEE KIM, WON-GYU YOO * JOURNAL OF PHYSICAL THERAPY SCIENCE * 2014
 Objective: Investigated the effects of inclined treadmill walking on pelvic anterior tilt angle,
hamstring muscle length, and back muscle endurance of seated workers with flat-back
syndrome
 Methods: Eight seated workers with flat-back syndrome who complained of low-back pain in
the L3–5 region participated in this study. The subjects performed a walking exercise on a 30°
inclined treadmill. We measured the pelvic anterior tilt angle, hamstring muscle length, and
back muscle endurance before and after inclined treadmill walking.
 Results: Anterior pelvic tilt angle and active knee extension angle significantly increased after
inclined treadmill walking. Trunk extensor and flexor muscle endurance times were also
significantly increased compared to the baseline.
Conclusion: Inclined treadmill walking stretches the hamstring muscles, continuously co-activities the
trunk muscles, and mobilizes of the pelvis through repetitive trunk and pelvic flexion. Therefore, we
anticipate that inclined treadmill walking may be an effective approach for prevention or treatment of
LBP in flat-back syndrome.

32. INDIVIDUALIZED LOW-LOAD MOTOR CONTROL EXERCISES AND EDUCATION VERSUS A HIGH-LOAD LIFTING EXERCISE
AND EDUCATION TO IMPROVE ACTIVITY, PAIN INTENSITY, AND PHYSICAL PERFORMANCE IN PATIENTS WITH LOW
BACK PAIN: A RANDOMIZED CONTROLLED TRIAL
BJÖRN AASA, LARS BERGLUND, PETER MICHAELSON, RPT, PHD4, ULRIKA AASA* JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY, 2015
 Objective: To compare the effects of low-load motor control (LMC) exercise and those of a high-
load lifting (HLL) exercise.
 Methods: 70 participants with recurrent LBP, Participants offered 12 treatment sessions over an 8-
week period. The primary outcome measures were activity (PSFS) and average pain intensity over the
last 7 days (visual analog scale). The secondary outcome measure was a physical performance test
battery that included 1 strength, 3 endurance, and 7 movement control tests for the lumbopelvic
region.
 Results: Both interventions resulted in significant within-group improvements in pain, intensity,
strength, and endurance. The LMC group showed significantly greater improvement on the Patient-
Specific Functional Scale (4.2 points) compared with the HLL group (2.5 points) (P<.001). There were
no significant between-group differences in pain intensity (P = .505), strength, and 1 of the 3
endurance tests. However, the LMC group showed an increase (from 2.9 to 5.9) on the movement
control test subscale, whereas the HLL group showed no change (from 3.9 to 3.1) (P<.001).
Conclusion: An LMC intervention may result in superior outcomes in activity, movement control, and
muscle endurance compared to an HLL intervention, but not in pain intensity, strength, or endurance

33. LB
Week 7
Subjective: Pt reports that neck pain has been "under control"
and only experienced one flare-up within last 2 weeks. Reports
that LB has continued to be a primary pain generator with daily
function.
Interventions: Localized lumbar rotation at L4-L5 Grade 4;
Posterior Oblique & Lateral Sling Focus therex: side-planks, SLS
with contralateral lat pull, glute bride with emphasis on glute
activation (not paraspinals).
Outcomes: Independent c HEP; decreased LB pain with lumbar
extension and right rot/SB.
HEP:
• Side Planks 1x/day 3(30s)
• Standing hip ext. with contralateral lat pull (blue) 1x/day 3(10)
• Glute Bridge 1x/day 3(10)

34. Impairment Treatment
Hypomobility
Lumbar Facet Hypomobility (Facet Arthropathy) • PA mobilizations (Grade 4)
• Localized Spinal Rotation Mobilization.

35. FUTURE PLANS
Impairment Treatment
Strength
Weakness Glute Med, Glute max, Hip ER, Abdominals,
Multifidi, Back Extensor Endurance (To be assessed)
• Clam Shells, squats, dead-lifts, resisted bridges,
etc.
• Force Closure training Sling Systems: POS and
LS
Lateral PosteriorAnterior Oblique Deep

36. FUTURE PLANS
Impairment Treatment
Motor Control
Over Activation of Lumbar Paraspinals & DLS system.
Utilizing “Top-Down Approach” of spinal stabilization.
LMC exercises to retrain use of multifidi and
abdominal stabilization prior to activation of
superficial lumbar extensor musculature
• Sharman Abs- Level .5/1.0
• Bird Dog
• Maintain neutral lumbopelvic alignments with
dynamic movement (squatting, lifting)
Decreased pelvic sagittal pelvic motion with
ambulation; moderate posterior pelvic tilt at rest
• Teach controlled anterior & posterior pelvic
tilt, independent from lumbar flexion &
extension.
• Incline walking on treadmill
SI Dysfunction Force Closure training Sling Systems: POS and LS

37. Week
Interventions (Each wk: Warm-up 20min uphill walk on treadmill & self or AAROM
lumbar mobilization)
8 Progress strengthening from week 7 HEP. Add clam shells. Initiate LMC motor control
exercises: bird dog, sharman abs. Supine education on anterior and posterior pelvic tilt
9 Same strength routine. Re-asses and progress bird dog and Sharman abs. Initiate motor control
therex: maintaining neutral lumbar spine in functional movement patterns: Hip Hinge, Squat
10 Progress strengthening from previous wks. Incorporate dynamic sling strengthening exercises
with focus on motor control with movements. Continue progression of Sharman abs and bird
dog
11 Continuation of dynamic sling strengthening exercises with focus on motor control movements.
12 Progress to combined dynamic strength and motor control exercises, use of HMC (dead lifts)
Note: Progressions pending increase in strength (neural or hypertrophy) & mastery of proper form with
movement

38. END GOAL DYNAMIC STRENGTH & MOTOR CONTROL EXERCISE!

39. TAKE ALWAYS!
Conclusion: On average, people with LBP have reduced lumbar ROM and proprioception, and move
more slowly compared to people without LBP.
Conclusion: The ability of PTs to reliably palpate and recognize and altered pattern of intrapelvic
motion during the Stork Test was substantiated.
Conclusion: Thigh thrust and distraction tests have the highest individual sensitivity and specificity,
respectively, performance of these tests first is suggested.
Conclusion: Individuals predisposed to low back pain development during standing exhibited
altered neuromuscular strategies prior to pain development.
Conclusion: Inclined treadmill walking stretches the hamstring muscles, continuously co-activities the trunk muscles, and
mobilizes of the pelvis through repetitive trunk and pelvic flexion. Therefore, we anticipate that inclined treadmill walking may
be an effective approach for prevention or treatment of LBP in flat-back syndrome
Conclusion: An LMC intervention may result in superior outcomes in activity, movement control,
and muscle endurance compared to an HLL intervention, but not in pain intensity, strength, or
Motor control should be incorporated throughout rehabilitation of entire spine/ all movement patterns

40. REFERENCES
1. Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis Robert A Laird,,
Jayce Gilbert, Peter Kent, and Jennifer L Keating
2. Evaluation of the Ability of Physical Therapists to Palpate Intrapelvic Motion With the Stork Test on the Support Side. Barbara A
Hungerford, Wendy Gilleard, Michael Moran, Cathryn Emmerson
3. Diagnosis of SI Joint Pain: Validity of individual provocation tests and composites of tests. Mark Laslett, Charles April, Barry McDonald,
Sharon Young
4. Guidelines for the Management of Whiplash Associated Disorders. Sydney: Motor Accident Authority (NSW) (2007)
5. A Clinical Pathway for Best Practice Management of Acute and Chronic Whiplash-Associated Disorders. South Australian Centre for
Trauma and Injury Recovery, Adelaide (2008)
6. Michele Sterling, Physiotherapy management of whiplash-associated disorders (WAD), Journal of Physiotherapy, Volume 60, Issue 1,
March 2014
7. R. Teasell, J. McClure, D. Walton, J. Pretty, K. Salter, M. Meyer, et al. A research synthesis of therapeutic interventions for WAD: Part 4—
non invasive interventions for chronic WAD. Pain Res Manag, 15 (2010), pp. 313–322
8. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis
Benjamin E Smith1, Chris Littlewood2 and Stephen May3 BMC Musculoskeletal Disorders2014
9. Individualized Low-Load Motor Control Exercises and Education Versus a High-Load Lifting Exercise and Education to Improve
Activity, Pain Intensity, and Physical Performance in Patients With Low Back Pain: A Randomized Controlled Trial
10. Effects of Inclined Treadmill Walking on Pelvic Anterior Tilt Angle, Hamstring Muscle Length, and Trunk Muscle Endurance of Seated
Workers with Flat-back Syndrome Min-hee KiM, Won-gyu yoo * Journal of physical therapy science * 2014
11. Altered muscle recruitment during extension from trunk flexion in low back pain developers
Erika Wong, Brendan alex, david Csepe, Denver Lancaster, Jack Callagan Clinical Biomechanics 2012