Physiotherapy Theory and Practice

An International Journal of Physical Therapy

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

A Movement system impairment approach to

evaluation and treatment of a person with lumbar
radiculopathy: A case report

Eileen Miller PT, DPT, Shirley A. Sahrmann PT, PhD, FAPTA & Dale Avers PT,
DPT, PhD, FAPTA

To cite this article: Eileen Miller PT, DPT, Shirley A. Sahrmann PT, PhD, FAPTA & Dale Avers PT,
DPT, PhD, FAPTA (2017): A Movement system impairment approach to evaluation and treatment
of a person with lumbar radiculopathy: A case report, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2017.1282997

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Published online: 14 Feb 2017.

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PHYSIOTHERAPY THEORY AND PRACTICE
http://dx.doi.org/10.1080/09593985.2017.1282997

CASE REPORT

A Movement system impairment approach to evaluation and treatment of a

person with lumbar radiculopathy: A case report
Eileen Miller, PT, DPTa, Shirley A. Sahrmann, PT, PhD, FAPTAb, and Dale Avers, PT, DPT, PhD, FAPTAc
a
Austin Physical Therapy, Roscoe, NY, USA; bWashington University School of Medicine - Physical Therapy, St Louis, MO, USA; cCollege of
Health Professions SUNY Upstate Medical University - Physical Therapy Education, Syracuse, NY, USA

ABSTRACT ARTICLE HISTORY

Background and Purpose: There are several systems of classification and treatment of patients with Received 12 January 2015
low back pain (LBP) based on assessment of the effect of lumbar postures and movements on Revised 16 November 2015
symptoms. The efficacy of one of these systems, The Movement System Impairment (MSI) method, Accepted 30 January 2016
has not yet been demonstrated in the literature. The purpose of this case report is to describe the KEYWORDS
approach of the MSI method for an individual with lumbar radiculopathy. Case Description: A 79- Lumbar radiculopathy;
year-old woman with a history of chronic LBP was referred to PT with a physician’s diagnosis of low back pain;
sciatica. The patient was classified utilizing a standardized MSI evaluation. She was instructed to movement system
modify her daily postures and movements, as well as perform specific exercises to address these impairment; sciatica
impairments. Outcomes: Her Oswestry LBP disability score improved by over 30% and pain level per
the NPRS improved by 3 out of 10 points. Discussion: Despite the challenges of advanced joint
degeneration and neurological involvement, this approach of identifying and addressing specific
movement impairments appeared helpful for this older individual.

Introduction Particularly successful are the approaches that are geared

toward findings from individual patient assessments that
Lumbar radiculopathy, commonly referred to as sciatica, is
include strengthening and stretching (Hayden, Van
characterized by lower extremity (LE) radiating pain, weak-
Tulder, and Tomlinson, 2005) or that specifically involve
ness, and paresthesias from sciatic nerve irritation. Causes
lumbar stabilization (Ferreira et al., 2007; Rasmussen-Barr,
of radiating pain include disc protrusion (90% of cases),
Nilsson-Wikmar, and Arvidsson, 2003; Van Dillen, Maluf,
lumbar stenosis, and tumors (Luijsterburg et al., 2007).
and Sahrmann, 2009) (Table 1). There is growing evidence
Bedrest has been shown to have no benefits for lumbar
that classification of specific postural, movement, and treat-
radiculopathy (Luijsterburg et al., 2007). Medications, trac-
ment response patterns is more beneficial than a standard
tion, and injections showed no significant benefits com-
PT approach (Fritz and George, 2000; Hoffman et al., 2011;
pared to placebo (Luijsterburg et al., 2007; Pinto et al.,
O’Sullivan, 2012; Sahrmann, 1988).
2012). Spinal manipulative therapy has been shown to
One commonly utilized movement classification system
have similar benefits as motor control exercises, both of
is the Movement System Impairment (MSI) approach. A
which have demonstrated somewhat more effectiveness
primary concept underlining the MSI approach is that the
than general nonspecific exercise (Ferreira et al., 2007;
body takes the “path of least resistance for movement” as
Murphy, Hurwitz, Gregory, and Clary, 2006; Whitman
areas of less passive tissue tension move more readily than
et al., 2006) for low back pain (LBP) and lumbar radiculo-
other areas (Sahrmann, 2005; Sahrmann, 2010). This leads
pathy. An active rehabilitation program, which may
to habitual excessive motion in certain joints during daily
include physical therapy (PT), is usually a treatment of
movements, which creates micro-trauma and eventual
choice for treating radiating lower extremity pain, with
injury, including disc and arthritic changes (Sahrmann,
the exception of surgery, which appears advantageous
2005). By performing the standardized MSI examination,
with lumbar stenosis (Hayden, Van Tulder, and
the therapist determines areas of muscle imbalance which
Tomlinson, 2005; Taylor, Dodd, Shields, and Bruder,
should be addressed in order to stabilize certain joints to
2007; Weinstein et al., 2010) (Table 1). To date, studies
promote healing of injured tissue (Sahrmann, 2005). After
on the benefits of PT for lumbar radiculopathy have shown
identifying symptomatic alignments and movements,
that an intensive, active rehabilitation approach is benefi-
modifying tests are then performed to correct these. If
cial (Hayden, Van Tulder, and Tomlinson, 2005).

CONTACT Eileen Miller PT, DPT emiller@sullivanarc.org Austin Physical Therapy, 45 Stewart Ave Roscoe NY 12776, USA
© 2017 Taylor & Francis
2 E. MILLER ET AL.

Table 1. Medical/PT treatments for lumbar spinal stenosis and radiating pain: evidence of efficacy.
Study: Author/date published/type:
randomized controlled trials (RCT),
controlled trials (CT), literature review,
Condition/stage Treatment Vs other systematic Efficacy/findings
Stenosis/all Surgery Nonsurgical Weinstein/2010/randomized cohort Surgery more beneficial for short +
(Weinstein et al., 2010) long term
Stenosis PT including exercise, PT including Whitman/2006/RCT(Whitman et al., 2006) PT beneficial especially if including
manual therapy, body treadmill exercise, manual therapy, body
weight-supported treadmill walking, flexion weight -supported treadmill
walking exercise walking
Stenosis distraction mobilization and None Murphy/2006/prospective case series Distraction + neural mobilization →
neural mobilization (Murphy, Hurwitz, Gregory, & Clary, 2006) ↑function ↓ pain
Lumbar Medications Placebo Pinto 2012/systematic (Pinto et al., 2012) No benefit
radiculopathy
Lumbar Injections, traction Other Luijsterburg 2007/systematic (Luijsterburg No benefit
radiculopathy/all conservative et al., 2007)
stages treatment
LBP + Lumbar MSI: 1° Test: Identify 2° Test: Van Dillen 2009/CT(Van Dillen, Maluf, & Stabilization of Lumbopelvis,
Radiculopathy symptomatic alignment Correcting Sahrmann, 2009) including during LE motions
symptomatic →↓pain
spinal alignment

Table 2. Movement system impairment syndromes of the lumbar spine.

Lumbar flexion Tendency for lumbar spine to move and Symptoms ↑with flexion and ↓with
posture into flexion, including in response to preventing flexion
extremity and spine motions
Lumbar extension Tendency for lumbar spine to posture, move, Symptoms ↑ with extension and ↓with
and induce symptoms in extension, including preventing extension
response to limb motions
Lumbar rotation Tendency for lumbar spine to position or Rotation ↑ symptoms; Symptoms ↓ by
move into rotation or side bending in restriction of rotation
response to limb motions or spine
Lumbar flexion and rotation As above: combination of flexion and rotation Often unilateral symptoms ↑with flexion/
rotation, ↓ with stabilization
Lumbar extension rotation As above but lumbar spine postures + has ↑ {{163 Sahrmann, Shirley 2005}}
in symptoms with rotation with extension

Table 3. Movement system impairment syndromes of the hip.

Name
Femoral Syndromes
Anterior glide, with medial rotation (MR), with lateral
rotation (LR); posterior glide with MR; multidirectional
accessory hypermobility with knee movement;
hypomobility
Hip Syndromes:
Hip adduction (add) with medial rotation (MR)
Hip extension with knee extension
Hip extension +MR with knee extension
Hip lateral rotation
Characteristics
Accessory motion impairments
Physiological motion impairments
Exaggerated hip adduction/MR with functional
activities including habit of crossing legs in
sitting, sleeping
Knee hyperextension with functional activities
As above but also with hip MR
Hip LR during standing + activities. Habit of
crossing leg foot on thigh. Shortened LR’s
(including Piriformis) compress sciatic nerve
Effect on Symptoms
Symptoms ↑with faulty joint motions Pain↓
with prevention of faulty joint motion
Pain ↑ with hip add/MR, Pain ↓ with =
weight bearing + contraction of hip lateral
rotators + posterior gluteus medius
↓ Pain with controlled prevention of knee
hyperextension
↓ Pain with less hip MR and prevent knee
hyperextension
↓ Sciatica with gradual ↓ of LR {{163
Sahrmann, Shirley 2005}}

symptoms are decreased, these findings support the initial
impression of a specific alignment or movement impair-
ment (Tables 2 and 3) as a key factor (Van Dillen, Maluf,
and Sahrmann, 2009).
The MSI system identifies and addresses movement-
based risk factors for LBP which have been established in
recent research (Harris-Hayes, Sahrmann, and Van
Dillen, 2009; Hoffman, Harris-Hayes, and Van Dillen,
2010; Hoffman et al., 2011; Scholtes, Norton, Lang, and
Van Dillen, 2010; Van Dillen, Maluf, and Sahrmann,
2009; Van Dillen, McDonnell, Fleming, and Sahrmann,
2000). People with more lumbo pelvic motion during
ADLs, including during lower extremity motions, have
greater pain than those with less motion in this region

(Hoffman, Harris-Hayes, and Van Dillen, 2010; Hoffman
et al., 2011; Scholtes, Norton, Lang, and Van Dillen,
2010). People with LBP often have less hip ROM along
with premature lumbo pelvic motion in response to hip
motion during ambulation (Harris-Hayes, Sahrmann,
and Van Dillen, 2009; Hoffman et al., 2011). In people
with low back pain, stabilization of the lumbo pelvic
region during LE motions leads to a reduction in pain
(Van Dillen, Maluf, and Sahrmann, 2009).
The effectiveness of interventions commonly utilized
as part of the MSI classification system has not been
established. Therefore, until more vigorous randomized
controlled trials are performed, clinical cases employing
this approach continue to be relevant. The purpose of this
case report is to describe a patient with lumbar radiculo-
pathy, who was identified as having a lumbar extension
rotation and a hip adduction with medial rotation MSI
syndrome (Tables 2 and 3), as well as to describe the MSI
examination and specific treatment approach.
Case description
The patient was a 79-year-old woman with a history of
recurring low back and lower extremity pain that began
about 25 years ago after a lifting injury. Last year, she
received physical therapy and an epidural injection for
similar symptoms that according to the patient, “helped a
lot.” This recent episode of pain began about 2 months
prior to her PT evaluation and without a precipitating
incident or cause. She was referred to PT by her physician,
with a diagnosis of sciatica, after his initial advice of bed
rest for an unspecified period of time. The patient’s
description of her medical history was at times unclear
as she was struggling with her memory of events. Her
diagnostic testing, including lumbar MRI, CT scan, and
EMG, showed moderate disc protrusion L5-S1 impinging
the left S-1 nerve root, severe spinal stenosis at L3-L4, and
L5-S1 radiculopathy. She had discussed with her doctor
the option of surgery, which they ruled out due to her risk
factors. She was obese, with a body mass index of 30.5,
and a smoker. Her medical history included diabetes
mellitus (DM) type 2, hypertension, and peripheral neu-
ropathy. She was on the following medications:
Metformin and Liraglutide for DM2; Pramipexole for
Restless Leg Syndrome; Oxybutynin for Overactive
Bladder; Fenofibrate for High Cholesterol; Losartan for
Hypertension combined with DM. She was also taking
Naproxen/Aleve (nonsteroidal anti-inflammatory) and
Oxycodone-Acetaminophen/Percocet (opiod) for pain.
The patient reported that her primary pain began just
below her left buttock and went down to her foot with
occasional LBP. She had chronic numbness in both feet
which recently had become worse in her left foot. She
PHYSIOTHERAPY THEORY AND PRACTICE 3
assumed that the numbness was from diabetic neuropa-
thy. She reported her current pain as 2 and her worst pain
in the last week, while walking, was 5 out of 10 using the
numeric pain rating scale (NPRS). She stated that pain
was aggravated by walking, cleaning her house, and other
activities and was alleviated primarily by lying supine.
Prior to this current episode of pain, the patient
reported being “very active” including working out at
the gym three times a week and enjoying “cleaning a
lot.” Her current functional status was characterized by
difficulty walking more than 4 minutes due to pain. She
also reported being unable to vacuum due to pain. Her
goals for PT were to vacuum and walk around the mall
without pain. The patient was found to have 56% disabil-
ity on the Oswestry Low Back Pain Disability
Questionnaire, which has demonstrated validity as well
as high test-retest reliability (Fritz and Irrgang, 2001).
Initial clinical impression
The patient’s symptoms, including generally more pain
with walking, supported a working diagnosis of lumbar
extension syndrome, most likely with rotation, because her
pain was primarily one sided. A secondary movement
impairment of the hips was also suspected as indicated by
painful ambulation and likely hip muscle dysfunction due
to radiculopathy. Thus, she was also given a working
diagnosis of hip adduction with medial rotation. These
Movement System Impairment diagnoses are consistent
with her radiological findings of spinal stenosis, the chroni-
city of her symptoms, the pattern of pain during and after
walking (ruling out claudication, which is relieved when
resting after walking), (Goodman and Snyder, 2007) and
her age. Since many of her activities tended to exacerbate
her symptoms, an MSI examination including functional
assessment was used to determine exacerbating postures
and movements, muscle impairments, and to continue to
clarify the cause of the impairment.
Examination
The patient’s left calf was severely swollen; the soft
tissue was palpably tender, hard, and cold. After apply-
ing the Well’s Clinical Prediction Rule and determining
a moderate risk for deep vein thrombosis (DVT)
(Scarvelis and Wells, 2006), the patient was asked to
return to her physician as soon as possible prior to
initiating PT treatments. The patient’s physician cleared
her based on his examination. The patient was then
examined using the MSI format for mechanical LBP or
LE pain. Her standing posture was characterized by
prominent erector spinae muscles, increased lumbar
lordosis, right lumbar lateral flexion and rotation, as
4 E. MILLER ET AL.
Figure 1. Standing posture: prominent erector spinae muscles,
right lateral flexion, rotation. Left hip adduction, MR.
well as left hip adduction, and medial rotation
(Figure 1). When unsuccessfully attempting to balance
on either leg, her hips adducted and medially rotated.
The patient was asked about sleeping positions, and she
demonstrated her typical posture of side lying with her
hips in medial rotation, adduction, and spine in lumbar
lateral flexion (Figure 2). She experienced left posterior
thigh pain when lying on either side. A modifying test
was performed in which two pillows were placed
between her lower extremities and a folded towel
under her lumbar spine, placing her hips and lumbar
spine in a more neutral position (Van Dillen, Maluf,
and Sahrmann, 2009) (Figure 3). She reported this side
lying position as being much more comfortable.
The patient presented with the following movement
impairments. Her gait exhibited a severe right and
moderate left hip adduction associated with weak pos-
terior gluteus medius muscles (Kendall, 2005). Donning
her left shoe in sitting by using hip flexion, abduction,
and lateral rotation was painful and much more diffi-
cult than the right, as she appeared to lack the active
range of motion (AROM) to do this. When asked to
bend forward, she had adequate pain-free motion; how-
ever, the extension movement of her lumbar spine
when returning to a fully erect position was painful.
The patient was instructed to alter her movement strat-
egy by activating her gluteus maximus and using her
hands for support to return to standing by hip exten-
sion. The goal was to decrease lumbar extension and
spinal erector activity. This eliminated her pain during
this functional movement. She reported pain with
simulated vacuuming, especially returning to upright
postures using repeated lumbar extension and rotation.
Figure 2. Sleeping posture: hip adduction, medial rotation,
lumbar lateral flexion.
Figure 3. Corrected hips and spine: “feels much better”.
Muscle length, strength, and coordination analysis
were performed to determine contributions to functional
deficits, regional movement impairments, and resultant
pain (Tables 4 and 5). The patient demonstrated domi-
nance of her left tensor fascia latae (TFL) muscle, as
surmised by the observation of hip medial rotation during
seated knee extension (Sahrmann, 2005). Another expla-
nation of this alignment may have been related to a
possible relative difference in stiffness between the medial
and lateral hamstring muscles (Kendall, 2005). Manual
muscle testing (MMT) was performed according to
Kendall (Kendall, 2005) and results (Table 4) revealed
significantly more weakness of the left LE musculature
compared to the right. The two-joint hip flexor length test
was performed and revealed a short left hip flexor muscle,
as demonstrated by −15° of hip extension with knee
flexion with a resultant anterior pelvic tilt, exaggerated
lumbar extension as well as aggravation of symptoms
(Table 5) (Harris-Hayes and Van Dillen, 2009;
Sahrmann, 2005). These findings demonstrate how joints
and soft tissues contribute to the “path of least resistance”
as areas of less passive tension, in this case her abdominal
muscles, are not able to stabilize the lumbar region due to
the stiffer, in this case hip flexor, muscles (Sahrmann,
2005). The two-joint hip flexor length test has been
demonstrated to have reliability ranging from moderate
to substantial agreement for each condition (Cleland,
Koppenhaver, and Netter, 2011; Van Dillen, McDonnell,
Fleming, and Sahrmann, 2000). The secondary test was
performed and was positive, as there was decreased pain
 PHYSIOTHERAPY THEORY AND PRACTICE 5

Table 4. Manual muscle testing: comparison over 2 months.

1 month: 2 month:
Initial: right Left right left right left
Hip Lateral Rotation 4−/5 2+/5 4-/5 3+/5 5−/5 4/5
Hip abduction 4/5 4-/5 4+/5 4/5 5/5 4+/5
Hip extension with knee extn 4/5 3-/5 discomfort 4+/5 2+/5 5/5 3+/5
Hip extension with knee flex 3+/5 3−/5 (strong HS 4−/5 2+/5 4+/5 3+/5 (less HS, more G Max)
activation>GMax)
Hip flexion 4/5 3−/5 4/5 4−/5 (HS cramp) 5−/5 4+/5
Knee flexion 4+/5 4-/5 Cramping 4+/5 4−/5 5−/5 4−/5 no pain
Knee extension 4+/5 4/5 (poor quads, MR) NA 4/5 (poor quads, 5/5 5/5 (good quad, no MR)
MR)
Ankle plantar flexion NA NA NA NA 4+/5 3+/5 Unable to perform in
stance
Ankle plantar flexion ROM from 2 month examination: Right: 0–45 degrees, Left: 0–25 degrees.

Table 5. Other outcome measures.

Measure Initial 1 month 2 months
Lasegue’s SLR Left: positive Left: negative NA
Seated Dural Left: positive Left: negative NA
Calf inspection Circumferential (10 in superior to L: 13.6 in, mildly cooler, still palpably swollen No swelling, soft tissue almost as soft, same
heel) L: 14 in, R: 13.7 in. Left calf but less hard/tight. Tenderness 1/4 as right. Tenderness 0/4
colder, palpable swelling hard, tight.
Tenderness 3/4
Functional mobility Bed mobility—severe pain, slow, Bed mobility (rolling)—less pain, greater Walking 20–30 min. Back ache after 2o min
especially with rolling; Donning left ease. Can don left shoe more easily but of standing—peeling potatoes, washing
shoe—slow, difficult. Walking 5 min ↑ difficulty tying it. “Much more active. . . dishes. Observed standing leaning severely
pain. Not vacuuming. busier.” “Not needing cane as much. . .Can on right hip (Trendelenberg or “baby
shop longer.” Walking 15 minutes while carrying position” (per pt). Vacuumed 2
shopping, pushing cart. Sweeping without rooms without symptoms.
symptoms.
2 joint hip flexor Left short TFL (-15 degrees) hip NL length, but pain lowering left hip actively NL length, feels stretch in left hip flexors,
length test extension from flexion to extension. no pain.

with lumbo pelvic stabilization during this repeated test symptoms, severely antalgic gait, obesity, smoking, her
(Van Dillen, Maluf, and Sahrmann, 2009). reported dislike of exercise, and signs of limited memory
(Vroomen, De Krom, and Knottnerus, 2002). Her mem-
ory problems were confirmed in subsequent sessions and
Evaluation, classification, and diagnosis did limit her ability to follow up with recommendations.
Short-term PT goals, to be achieved within 4 weeks,
Considering the results of the above findings, her
included reducing the swelling and tenderness of her
Movement System Impairment diagnoses were as follows:
calf by 25% and improving function as seen by a reduc-
lumbar extension rotation and hip adduction with medial
tion in her Oswestry score to 40 or less. Other short-term
rotation (Table 6) (Sahrmann, 2005). The MSI classifica-
goals included walking for 10 minutes and vacuuming
tion system for lumbar spine syndromes has moderate
one room without aggravating symptoms, to address the
reliability as well as partial evidence of validity in several
patient’s goals as previously stated. Long-term goals, to be
studies (Harris-Hayes and Van Dillen, 2009; Van Dillen,
achieved in 10 weeks, were to decrease her pain to 2 out of
Maluf, and Sahrmann, 2009; Van Dillen et al., 2003).
10 while walking for up to 30 minutes on even surfaces
Because the results of the patient’s examination were
and vacuuming two rooms, as well as to return to her
consistent with these MSI syndromes, including the
prior function including working out at the gym three
decrease in symptoms during the secondary tests, the
times per week and cleaning her house three times per
MSI approach was indicated for her treatment.
week for one hour.
Physical therapy was recommended at a frequency of
two times per week for a duration of up to 10 weeks,
supplemented with practice at home, in order to enhance
Intervention
motor learning, muscle activation, and strength to rein-
force the development of desired movement patterns. The The first component of the intervention, which was
patient’s prognosis was believed to be fair due to the repeated during future treatment sessions, was educa-
severity of diagnostic test results, duration of current tion about her MSI diagnoses and underlying spinal
6 E. MILLER ET AL.
Table 6. This patient’s movement and muscle impairments as basis of her MSI diagnosis.
MSI diagnosis Function Posture
Lumbar extension, Overuse extensors +P*with Lumbar
rotation return from forward bend, exaggerated
NP with modification lordosis, lateral
flexion/rot to right
Gait- +P Trendelenberg lordosis
exaggerated,
excessive lateral
trunk flexion
Hip adduction, Antalgic gait with Unilateral stance:
medial rotation Trendelenberg, add, MR^ hips
Sidelying sleeping hip MR, add^
*P=pain NP=no pain
^add = adduction, MR=medial rotation, LR = lateral rotation, ext = extension, rot=rotation, TFL = Tensor Fasciae Latae.
pathology, including the impact of postures and move-
ments on these inflammatory and compressive joint
and nerve conditions. The patient was also encouraged
to quit or reduce cigarette smoking and seek nutritional
counseling for weight loss and diabetes management to
improve conditions for healing (Boulton et al., 2005).
She was then instructed in exercises that were designed
to address specific movement impairments, muscle
weakness, and stiffness identified during the exam
(Table 7). Correction of her performance of functional
activities including basic mobility and household tasks
was included in her treatment program. These modifi-
cations were reviewed during the subsequent PT ses-
sions, and the patient was encouraged to incorporate
them into all her activities (Table 7). During the first 2
weeks of treatment, continuous ultrasound at 1.5 w/
cm2, 1 MHz, was given to the left posterior swollen calf
for a total of two 8-minute treatments, and gentle
myofascial release was also performed for 10 minutes
on the same area for four treatments.
Outcomes
One month reassessment
The patient stated that she had been gradually improving
with generally less pain. She reported that while she was
sweeping she followed the precautions to “not bend or
twist my back.” She stated that she can walk more and
with more focus on “how I walk.” She noticed that her left
leg was less swollen, “I can fit in my shoes better, and I can
put my left shoe on now.” She reported smoking less,
down to five cigarettes per day and her Oswestry Low
Back Pain Disability score was now 24%, down by more
than half of the original disability level. Both of the 4-week
goals were met. The patient’s movements, muscle length
and performance were reexamined and showed signifi-
cant improvements (Tables 4 and 5).
Muscle strength Muscle length Pain
Weak hip ext^, Short L TFL With extension NP*
hypertrophy of spinal with neutral
extensors (especially
multifidus)
Weak bilateral gluteus Greater relative flexibility of NP with passive
medius muscles and abdominals versus hip stabilization with
abdominal muscles flexors and spinal extensors PT’s hands + walker
use
Weak left hip LR, Short L TFL Less P* with
abductors^ stabilization
Short L TFL more comfortable
with 2 pillows-
neutral hips
Two-month reassessment
The patient reported significant improvements. Her
symptoms had improved by 3 out of 10 points on the
NPRS as her current pain level was 0 out of 10, where a
two-point change has been found to be the minimum
detectable change (Childs, Piva, and Fritz, 2005). Her
Oswestry Disability score had considerably (30%)
improved since her initial PT session, as the minimal
clinically important difference for people with chronic
LBP is between 4 and 6% (Fritz and Irrgang, 2001). Her
gait now demonstrated adequate lumbo pelvic stability, as
seen by only minimal hip adduction, representing a dra-
matic improvement. However, significantly less ankle
plantar flexion was observed during the end of stance
phase on the left compared to the right side. The patient’s
movements, muscle length, and performance were reex-
amined (Tables 4 and 5), and there were significant
improvements overall. However, there were several defi-
cits found in left ankle plantar flexion strength. These
examination findings led to a further clinical impression
of left ankle weakness affecting her gait.
The patient’s goals of being able to vacuum and walk
around the mall and the long-term goal of decreasing pain
to 2 out of 10 while walking for up to 30 minutes on even
surfaces were met. The other long-term goal, to return to
prior function including working out at the gym three times
per week and cleaning her house for one hour three times
per week including vacuuming two rooms, was almost fully
met as per the patient. After her HEP was modified to
address the left ankle weakness, the patient was discharged
from PT, after a total of 15 visits over 10 weeks.
Discussion
Despite this patient’s challenges of impaired memory,
reluctance to exercise, and advanced joint degeneration
with neurological involvement, this approach that identi-
fies specific impairments contributing to symptoms and
 PHYSIOTHERAPY THEORY AND PRACTICE 7

Table 7. Intervention: exercises.

Exercise Instructions Purpose Frequency Repetitions
Supine heel slide 1 knee to chest, pull in Elongate short TFL while 2+ times per day after other 5–10×, hold for 10+
abdominals (abs), slowly slide stabilizing lumbo pelvis exercise or walking seconds at end
out other leg
Quadruped rock back On hands and knees, pull in Reduce spinal rotation, pain, 2× per day or more prn 5–10×
abs, rock back toward heels improve hip flexion
Unilateral stance Hold support, shift your Prepare for controlled LP in 1×/day Start with a few and
weight to the next foot, lifting gait build gradually
the heel of the previous foot.
Contract butt and abs.
Prone knee flexion AROM Keeping your knees out Strengthen hamstrings, 1×/day 10x or as tolerated,
slightly, bend your knees, abdominals, elongate hip gradually increase
tighten abs, not allowing your flexors
pelvis to move
Prone hip extension with Tighten your butt and abs, Strengthen gluteus maximus, 1×/day Start with a few and
knee flexion just lift thigh off surface isolate hip motion with LP build gradually
slightly, without moving your stabilized
pelvis
Sidelying hip LR with knees “Clam ex”: Don’t let your Strengthen deep hip LR’s, 1×/day Start with a few and
+ hips flexed pelvis move, tighten abs, and isolating hip motion with LP build gradually
use the butt muscle to lift the stabilized
knee, keeping foot in place
Sidelying hip abduction Lift the top leg, keeping it in a Strengthen posterior gluteus 1x /day Start with a few and
line with your trunk, and the medius build gradually
knee pointing slightly up,
Stationary bike Keep your knees pointing over Pain free, improve aerobic As available (in PT or gym) Start with 5 min and
your middle toe capacity, circulation, lose build gradually
weight
Revised exercises at 2-month intervention, prioritizing standing over reclining for patient preference. These were all to be performed daily, with as many
repetitions as tolerated, building them gradually.
Exercise Purpose
Bilateral heel raises (ankle plantar flexion in stance) Strengthen gastrocnemius for improved push off in gait
Hold wall and walk sideways Strengthen posterior gluteus medius, holding on for safety
Hold wall, walk backwards:“tighten butt” Strengthen gluteus maximus, avoid hamstring dominance
Seated hip lateral rotation with theraband Strengthen deep lateral rotators to avoid MR postures
Unilateral stance, lifting one knee, holding support lightly, Balance improvement, stabilizing pelvis in preparation for gait, strengthening several muscles
“tighten butt and abdominals” including: hip flexors and posterior gluteus medius
Intervention: Functional activity instructions
Daily Activity Cues Purpose
Rising from sitting and reverse Keep your knees over your middle toe Improve LE alignment, prevent hip MR, adduction
Ambulation Tighten your butt, pull in your belly, use Avoid excessive LP motion, Trendelenberg,+ excessive
shopping cart when able or cane lumbar lordosis
Ambulation endurance Limit the amount of walking + standing you Avoid inflammation and symptom exacerbation due to
do and build it up gradually limited ability + endurance to stabilize LP in gait and stance
Sleeping in sidelying Use 2 pillows between legs Avoid posturing in hip MR + adduction; prevent shortening
+ lengthening of muscles by keeping neutral hip position
Rolling in bed Roll in your bed “like a log” Avoid the lumbopelvic rotation
Sweeping, vacuuming Avoid twisting or bending your back; bend Maintaining a more neutral spine to avoid excessive
your knees instead and pull in your irritating lumbar motions
abdominal muscles
Sweeping, vacuuming endurance Begin with 5 minutes/day and gradually Challenging + irritating activity, with limited ability to
increase control her habit of excessive lumbar motions
1 month- additions:
Vacuum 1 room/day, (same cues as above)
Ambulation endurance Continue to build this gradually
2 months additions:
Standing Avoid “baby carrying position” (shifting most Avoid Trendelenberg position, keep more neutral spine +
of her weight into one hip, adducting). Keep pelvic posture
your weight evenly on both legs, feet under
hips, tighten butt and pull in belly

compromised functional performance appeared success-
ful in facilitating the achievement of many of the goals of
this older individual with significant spinal degeneration.
This supervised exercise program addressing specific
muscle and movement impairments seemed to contribute
to the patient’s improvements. Instruction in more neu-
tral lumbar and hip positioning during functional
activities, particularly those of importance to her such as
walking and vacuuming, did enable her to return to those
activities. Identifying a specific movement direction asso-
ciated with exacerbating the symptoms presumably
increased the efficacy of the treatment program.
Possibly, there are other explanations for her decrease in
symptoms, such as the placebo effect, or just being
8 E. MILLER ET AL.
encouraged to gradually become more active (Weinstein
et al., 2010).
The patient’s lumbo pelvic movement coordination
deficits have been described previously in the literature,
and her response to stabilization was consistent with what
related research suggests. Throughout her examination,
this patient demonstrated excessive lumbo pelvic motion
as well as hip adduction and medial rotation. When
initially asked to control the excessive lumbo pelvic and
hip motions during her ambulation, she was not able to
do so. These findings were consistent with research that
demonstrates that adults with LBP have less ability to
control their lumbo pelvic motion (Scholtes, Norton,
Lang, and Van Dillen, 2010) and that adults with more
lumbo pelvic motion during their daily activities have
more pain (Hoffman, Harris-Hayes, and Van Dillen,
2010; Hoffman et al., 2011). This scenario in which a
woman with severe movement impairments and some
short-term memory limitations learned to stabilize her
lumbo pelvic region during ADLs supports the findings
of previous research which shows that people with LBP
are able to learn to control the lumbo pelvic region
(Hoffman et al., 2011; Scholtes, Norton, Lang, and Van
Dillen, 2010). An association between less hip range of
motion and LBP has been demonstrated (Harris-Hayes,
Sahrmann, and Van Dillen, 2009; Van Dillen, Maluf, and
Sahrmann, 2009; Van Dillen, McDonnell, Fleming, and
Sahrmann, 2000) as was the case with this patient.
Research on this particular classification system, the
MSI approach, has demonstrated adequate reliability and
“partial” validity (Cleland, Koppenhaver, and Netter,
2011; Harris-Hayes and Van Dillen, 2009; Van Dillen
et al., 2003). One suggestion for practitioners using the
MSI approach would be to incorporate the use of video
recordings during the examination for better accuracy in
the visual estimation of postural changes (Xu et al., 2011).
More studies upholding the validity and efficacy of this
system are needed. Randomized controlled studies com-
paring the effects of utilizing the MSI system to a general-
ized physical therapy program might be warranted.
Declaration of interest
The authors have declared that there is no potential conflict
of interests.
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