Exercise-Based Management of Lumbar

Spine Pain: An Algorithmic Approach to

Decision-Making

Many types of exercise are utilized in the treatment of lumbar spine disorders. Though, for the non-specific
symptom of low back pain, no single form of physical therapy or exercise has been shown to be superior to
another. There is evidence, however, that some individual subgroups can be reliably identified that could
respond better to specific treatments. To help distinguish these subgroups and understand how different
types of exercise-based treatment are beneficial for different patient characteristics and subsets of lumbar
diagnoses, the NASS Exercise Committee presents this evidence-based algorithmic approach. While this
algorithm has not yet been presented in the literature, there is considerable evidence to support its
pathways and is intended to facilitate patient-centric decision-making as well as guide future research.

#1: Does the Patient’s Pain Generator Have a Directional Preference?

Directional preference (DP) is a single direction of spinal bending that, when
repeatedly performed to end-range, centralizes and/or abolishes radiating,
referred, or axial neck or low back pain (LBP).1 It is first detected in a patient’s
history by inquiring what activities, positions, and movements make the pain
better or worse and listening for a ‘directional theme’. A standardized
mechanical examination then has patients perform various directions of
repeated end-range spinal testing (Figure 1) that typically reveals familiar
patterns of symptom response. Pain centralization (PC) and abolition is by far
the most common pattern of pain response and the most common DP by far is
lumbar extension.

A recently published study showed a prevalence of 74% in acute LBP and 71% in chronic for the DP and PC
clinical findings.2 Other studies show a similarly high prevalence rate for acutes but a lower (50%) prevalence
for chronics.

Inter-examiner reliability is essential to establishing the validity of all patient evaluations including
identifying these patterns and classifying patients into mechanical subgroups. The reliability for DP and PC
is well established with at least 8 studies reporting high kappa values.3 Such high reliability has only been
reported for clinicians who have completed the full curriculum and credentialing examination provided by
The McKenzie Institute, the educational resource for MDT training. To date, clinicians with less training
have generated only fair-to-poor reliability.

When a DP is found, the prognosis for that patient is excellent because a predictably effective, standardized,
self-treatment has been identified. This treatment consists of unidirectional end-range exercises that match
each patient’s DP that predictably generate rapid recoveries. This is documented in more than 10
prospective cohort studies that also report poor outcomes for those who exhibit no DP during their
baseline examination.4

At least eight randomized clinical trials (RCTs) examine the best treatment for DP and PC patients by
randomizing them to matching unidirectional care vs. some other commonly prescribed treatment.5 In all
studies, treatment with directional exercises was superior, often far superior, to all other studied
treatments.
Two systematic reviews of these studies have been published. One concludes: “Without question, the
evidence suggesting inclusion of the centralization phenomenon in a spinal evaluation and as a classification
criterion is quite compelling." It adds: "Using this form of classification has reliably been shown to
differentiate discogenic from non-discogenic symptoms."6

Three studies examined LBP patients considered to be surgical candidates, either with sciatica or
recalcitrant axial LBP. In all three, 50% or more were found to have a previously undiscovered DP because
it was never looked for.7 Given the excellent prognosis for DP patients with appropriate treatment, most,
regardless of pain duration or location, may have otherwise undergone unnecessary surgery.

Examining for a DP and for PC should be top priority in the care of acute or chronic LBP, whether axial or
radiating. With such good outcomes for this very large DP subgroup, it is only those who do not have a DP on
their initial examination that need further evaluation.

1. McKenzie R, May S. Mechanical Diagnosis and Therapy. Second ed. Waikanae, New Zealand: Spinal Publications New
Zealand Ltd.; 2003.
2. Donelson R, Long A, Spratt K, Fung T. Influence of directional preference on two clinical dichotomies: acute versus
chronic pain and axial low back pain versus sciatica. Physical Medicine & Rehabilitation. 2012;In press.
3. Aina S, May S, Clare H. The centralization phenomenon of spinal symptoms - a systematic review. Manual Therapy.
2004;9:134-43.
4. Werneke M, Hart DL, Cook D. A descriptive study of the centralization phenomenon. A prospective analysis. Spine.
1999;24(7):676-83.
5. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized controlled trial of exercise for low back pain.
Spine. 2004;29(23):2593-602.
6. Cook C, Hegedus E, Ramey K. Physical therapy exercise intervention based on classification using the patent response
method: a systematic review of the literature. J Manip Phys'l Ther. 2005;13:152-62.
7. Kopp J, Alexander A, Turocy R, Levrini M, Lichtman D. The use of lumbar extension in the evaluation and treatment of
patients with acute herniated nucleus pulposus, a preliminary report. Clinical Orthopedics. 1986;202:211-8.

#2: Does the Patient Have Clinical Instability ?: Core Stabilization.

Lumbar stabilization exercises are commonly prescribed to patients presenting to a physical therapist with
low back pain. According to McGill, the spine must be stable to protect against tissue injury and overload.
The transverse abdominis and lumbar multifidi contract in an anticipatory manner, prior to distal limb
movement, in order to achieve this. The diaphragm and pelvic floor muscles contribute to this stabilization
function as well. Delayed stabilizing muscle contraction, muscle atrophy and side to side asymmetry have
been demonstrated in subjects with chronic low back pain in multiple studies.

Strengthening or training these muscles has been proposed to be beneficial. In a randomized study by Hides
following patients for 1 year following an acute, first time episode of LBP, the group prescribed specific
stabilization exercises was found to have a 30% rate of recurrence versus 84% in the group given advice on
activities and medical management only. A systematic review by Rackwicz also showed that segmental
stabilizing exercises are more effective than treatment from a general practitioner, however they are no
more effective than other physical therapy interventions for acute and chronic low back pain. As with many
other studies on low back pain, the study populations were those with non-specific acute or chronic low
back pain.

So the next question should be the following: Are there specific subgroups of patients with low back pain
who will respond to a stabilization program? The term “stabilization” implies that instability is present and
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that it is a cause of back pain. Instability, as it is defined by common radiographic criteria, is probably not an
accurate term. Rather, the term “clinical instability” has been coined and is probably more appropriate in
this group of patients thought to benefit from stabilization exercises.

O’Sullivan evaluated specific stabilization exercises in patients with chronic low back pain and spondylolysis
or spondylolisthesis, a classic model for clinical instability. The stabilization exercise group underwent a 10
week treatment program consisting of deep abdominal and lumbar multifidi muscle training. The control
group received medical practitioner directed care, consisting of various regular weekly exercises such as
swimming, walking, gym exercises, and curl ups. Some subjects in the control group also received heat,
massage, and ultrasound. Pain intensity and ODI were unchanged in the control group, whereas the specific
stabilization group had improved pain and ODI scores at the completion of the program and throughout the
30 month follow up period.

Though, in patients without radiographic findings consistent with instability, how does one determine
“instability?” Kumar selected patients based on consensus recommendations for determining instability
published by Cook. These recommendations included subjective and objective factors, including feeling of
the back “giving out”, poor lumbopelvic control of movement, pain and hypermobility with spring testing,
and multiple other findings. Patients found to meet the criteria were randomized to stabilization exercises
versus prone lying. Outcomes measured included VAS, pressure pain threshold, and joint play. The specific
stabilization exercise group was found to be more effective than placebo, however there were no functional
measures and the follow up period was not stated.

Other studies have looked at criteria for determining instability. Hicks found that passive segmental
mobility testing in the prone position had poor test re-test and interrater reliability in diagnosing instability.
The prone instability test, generalized ligamentous laxity, and aberrant motion on trunk ROM testing were
all determined to be reliable measures.

Based on this and other work, a set of clinical prediction rules were proposed and tested to select patient
subgroups that will respond to a stabilization program (Hicks). In this study, 54 subjects were screened
then treated with a stabilization exercise program for 8 weeks. At the completion of the study, determinants
of success and failure were assessed. Positive predictors of success included positive prone instability test,
presence of aberrant movement, straight leg raise greater than 91 degrees, and subject age less than 40 years
old. Negative predictors were high FABQ score, negative prone instability test, absence of aberrant
movement, and no hypermobility with lumbar spring testing. As a follow up to this study, more objective
measures were sought. Using diagnostic ultrasound, transversus abdominis and lumbar multifidus
activation were examined to determine whether a relationship exists between their baseline function and
response to a training program based on training of those muscle groups. Decreased lumbar multifidus
activation, but not TrA, predicted clinical success with a stabilization program.

In summary, the literature describing which subgroups benefit from core stabilization exercises is quite
limited in number. However, the above articles provide a framework and reasonable evidence to suggest
that lumbar stabilization exercises are more likely to be beneficial when signs of clinical instability are
present.

Primary References:
1. O'Sullivan PB, Twomey LT, Allison GT. Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back
Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis. Spine 1997;22: 2959-2967.
2. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which
patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-
62.

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 3. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for identification of lumbar
segmental instability. Arch Phys Med Rehabil 2003;84:1858–64.
4. Kumar SP. Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low
back pain: A randomized placebo controlled crossover study. North Am J Med Sci 2011; 3:456-461.
5. Hebert JJ, Koppenhaver SL, Magel JS, Fritz JM. The relationship of transversus abdominis and lumbar multifidus activation
and prognostic factors for clinical success with a stabilization exercise program: a cross-sectional study. Arch Phys Med
Rehabil. 2010 Jan; 91(1):78-85.

Additional supporting references:

1. Rackwitz B, de Bie R, Limm H, von Garnier K, Ewert T, Stucki G. Segmental stabilizing exercises and low back pain. What
is the evidence? A systematic review of randomized controlled trials.Clin Rehabil. 2006 Jul;20(7):553-67.
2. Hides JA , Jull GA , Richardson CA . Long-term effects of specific stabilizing exercises for first-episode low back pain .
Spine . 2001;26:E243–E248
3. Cook C, Brismée JM, Sizer PS Jr. Subjective and objective descriptors of clinical lumbar spine instability: a Delphi study.
Man Ther.2006 Feb:

#3: Radicular pain, neurogenic claudication? : Post- Surgery/ESI.

Post-Op
The utilization of physical therapy after elective spine surgery is variable. Many practitioners believe that
the efficacy of outpatient rehabilitation after spine surgery has not been established. A review of the
literature, however, reveals that this topic has been well studied (1-11).

Manniche examined the effects of active physical therapy on postoperative outcomes and showed that a
high intensity exercise regimen is superior to traditional exercise protocols (3,4). Furthermore, an early
active training program may improve outcome results in patients who undergo lumbar discectomy (2).
Other authors have achieved similar results with an active approach versus passive intervention (1,7).
Additionally, a recent study involving patients undergoing discectomy showed that lifting all restrictions
allowed patients to return to work earlier than the traditional protocol of restrictions and physical therapy
(12). These studies all suggest that an active exercise treatment after surgery may improve outcomes.

Mayer et. al. state that “the major reason why spine surgery has garnered what may be an unjustified
reputation for medical and social complications is the lack of effective postoperative rehabilitation (13). If
the role of surgery is primarily to repair an anatomic lesion, there is no reason that desirable socioeconomic
outcome (e.g., reduced disability, avoidance of health care utilization, or decreased recurrent injury) will
result solely from that surgical intervention.” They conclude by explaining that “discectomy and spine fusion
may have successful socioeconomic outcomes if surgery is accompanied by effective, medically directed
rehabilitation.” This assertion has not been scientifically verified, but warrants further investigation.”

1. Jackel W, Cziske R, Jacobi E. Intervertebral disk surgery and postoperative rehabilitation treatment: effect on health
status. Rehabilitation (Stuttg) 1987;26:109-14.
2. Kjellby-Wendt G, Styf J. Early active training after lumbar discectomy. A prospective, randomized, and controlled study.
Spine 1998;23:2345-51.
3. Manniche C, Asmussen K, Lauritsen B, et al. Intensive dynamic back exercises with or without hyperextension in chronic
back pain after surgery for lumbar disc protrusion. A clinical trial. Spine 1993;18:560-7.
4. Manniche C, Skall HF, Braendholt L, et al. Clinical trial of postoperative dynamic back exercises after first lumbar
discectomy. Spine 1993;18:92-7.
5. Timm KE. A randomized-control study of active and passive treatments for chronic low back pain following L5
laminectomy. J Orthop Sports Phys Ther 1994;20:276-86.
6. Brennan GP, Shultz BB, Hood RS, Zahniser JC, Johnson SC, Gerber AH. The effects of aerobic exercise after lumbar
microdiscectomy. Spine 1994;19:735-9.
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 7. Johannsen F, Remvig L, Kryger P, et al. Supervised endurance exercise training compared to home training after first
lumbar discectomy: a clinical trial. Clin Exp Rheumatol 1994;12:609-14.
8. Kahanovitz N, Viola K, Gallagher M. Long-term strength assessment of postoperative diskectomy patients. Spine
1989;14:402-3.
9. Long DM. Failed back surgery syndrome. Neurosurgery Clinics of North America 1991;2:899-919.
10. Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction adaptation and enhancement. J Spinal
Disord 1992;5:383-9.
11. Hakkinen A, Ylinen J, Kautiainen H, et al. Pain, trunk muscle strength, spine mobility and disability following lumbar disc
surgery. J Rehabil Med. 2003 Sep;35(5):236-40.
12. Agency for Healthcare Research and Quality.Healthcare Cost and Utilization Project, HCUPnet.
(www.ahrq.gov/data/hcup/.)
13. Mayer T, McMahon MJ, Gatchel RJ, Sparks B, Wright A, Pegues P. Socioeconomic outcomes of combined surgery and
functional restoration in workers’ compensation spinal disorders with matched controls. Spine 1998;23:598-605.

Post-ESI
There is not extensive literature on the utility or exercise treatments after epidural steroid injections.
Though, many practitioners consider it essential to part of a comprehensive treatment plan for lumbar
conditions. One study has shown that ESIs followed by return to mechanical diagnosis and treatment may
improve outcomes. The authors abstract is included below. Further study assessing the outcomes of adding
exercise treatment after ESI may strengthen these findings.

"TREATING LUMBAR RADICULOPATHY WITH TRANSFORAMINAL EPIDURALS

PLUS MECHANICAL DIAGNOSIS & THERAPY"
Introduction/Aim: Although lumbar radiculopathy is regarded as a specific diagnosis, there is considerable variation in its
treatment. Two commonly used treatments include transforaminal epidural steroid injections (TESIs) and McKenzie-exercise
(Mechanical Diagnosis & Therapy, or MDT). The MDT assessment loads the spine repeatedly to end-range in various directions
seeking a centralizing (C) pain response. No studies have assessed the effectiveness of a combination of these two interventions.
Research question: do TESIs in combination with MDT care prevent surgery for patients with non-centralizing (NC) or even
peripheralizing symptoms? Methods & Materials: This was a prospective observational cohort study of patients with lumbar
radiculopathy secondary to an MRI-confirmed disc herniation. After a mechanical assessment performed by MDT Credentialed or
Diplomaed clinicians, patients who had a NC pain response became study subjects and underwent guided TESIs followed by an
MDT re-assessment to again evaluate for a C and NC pain response. Subsequent treatment was guided by those assessment
findings. Primary outcomes were measured at baseline, discharge, and 12 months: Roland-Morris Disability Questionnaire, a
visual analogue scale for leg pain, Global Perceived Effect (GPE), and the occurrence of lumbar disc surgery. Data were analyzed
with linear mixed-models. Results: Seventy-nine patients were studied with mean symptom duration of 8 months and MRI
nerve root involvement found in 96.8%. After a mean of 2.1 TESIs, 80% were scheduled for disc surgery due to no improvement.
Prior to surgery however, all 79 underwent a mean of 2.8 MDT sessions revealing that 14.3% (n =11) had resolved all symptoms
with TESIs, 36.4% remained NC (n = 28), but 49.4% (n =38) had now converted to C. Sixteen NCs underwent surgery but only 1 C.
The other 37 who converted to C soon recovered fully with standard MDT treatment. The mean GPE for all patients right after
treatment was 70% and 86% after 12 months. Only 2 patients were lost to follow-up.
Discussion: Adding MDT re-evaluation after TESIs converted the pain response of 49.4% (N=38) from NC to C with excellent
long-term recoveries in the 37 using MDT treatment. An intriguing interaction influencing the behavior of disc herniations exists
between the anti-inflammatory effect of TESIs and the mechanical effect of loading discs repeatedly at end-range.
Conclusion: For patients who had no apparent benefit from either TESIs or MDT alone, a combination of these two (MDT before
and after TESIs) resulted in a mean GPE of 86% at 12 months. Only 14% responded well to TESIs alone but nearly half of the
remainder converted from being a baseline NC to C. With one exception, all surgical patients were persistent NCs. As reported in
the literature, a C, even after post-TESI conversion, correctly predicted excellent recoveries achieved using directional exercise
MDT treatment.

Presented at: Eleventh International Mechanical Diagnosis & Therapy Conference, Rio de Janeiro, Brazil, 2009. Submitted for
publication. van Helvoirt JNJ1, Apeldoorn AT2, Arts MP3, Knol DL5, Ostelo RW6
1 Medical Back Neck Centre, Gravenhage, Netherlands, 2,5,6EMGO+ Inst. Amsterdam; 3Neurosurgery dept. MCHaaglanden, ‘s-
Gravenhage

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#4: Yellow Flags?

Functional Restoration Programs

Exercise prescription for chronic low back pain (CLBP) is effective, however which exercise application is
best? After intensive diagnostic workup, the anatomic source of pain is unknown in approximately 85% of
cases and is probably multi-factorial. Therefore, treatments have been diverse. Passive treatments have
failed to decrease the incidence of disability, pain, and sick days associated with CLBP. Active treatments
using exercise have been shown to significantly improve disability, pain, and sick days. The optimal type of
exercise is not known however, but exercise that is intensive, is supervised, and contains a cognitive
behavioral component has shown positive influence (2,4,5).

In an effort to address the multifactorial nature of CLBP, functional restoration programs (FRPs) were
developed to address the biopsychosocial model of illness through a multidisciplinary approach. The
functional restoration model incorporates the physical, psychological and social situations of patients
during active participation in treatment. Patients appropriate for functional restoration have not responded
to other treatments and have had LBP for greater than 3 months(1).

FRPs usually consist of greater than 100 hours of treatment over the course of 3-6 weeks, including
intensive exercise sessions (strengthening, stretching, aerobic conditioning). They are often associated with
cognitive and behavioral therapy, and ergonomic or social interventions in the workplace. These programs
are carried out by physicians, psychologists, physical therapists, ergotherapists and social workers. One of
the main themes of these programs is that pain should no longer be the limiting factor. Prescribed exercises
are performed with the intent of successful performance according to the planned progression of resistance
and overall workload(1-5).

Recent randomized controlled trials have compared physical and psychological outcomes produced with
FRPs and a control group. These programs differed in physical intensity and formal psychological
counseling procedures used. All measured physical and psychological parameters significantly improved for
each group. However, FRP is superior to the control intervention in decreasing sick leave days and
improving physical endurance/conditioning in a 1-year follow-up. Prospective clinical trials indicate that
FRPs are effective in treating CLBP and intervention as early as 3 months may improve outcomes (2,5).
According to Bendix, et al. positive predictors of success with a FRP are youth, non-smoking, female, few sick
leave days, job available after rehab, no exposure to vibration, and good isometric trunk muscle endurance.
However, these factors are important not only in those undergoing FR but in identical patients who undergo
shorter outpatient programs or have no treatment(1,2,5). Therefore, FRP is successful in teaching coping
strategies and improving physical conditioning. Yet, if subjects were subgrouped differently, would the
results differ?

There are no studies comparing directional preference exercises to functional restoration, nor are there any
that rule-out a directional preference before initiation of a functional restoration program. However, there
are multiple studies showing the presence of directional preference in many chronic patients (43-71%) who
then go on to have significant improvement or complete recovery with unidirectional exercises and posture
modification only(see DP references). All patients should therefore be thoroughly screened for directional
preference prior to considering an FRP. Studies are needed to determine the impact of early directional
preference subgrouping/treatment on the FRP patient population and outcomes.

1. Bendix A, Bendix T, Haestrup C. Can it be predicted which patients with chronic low back pain should be offered tertiary
rehabilitation in a functional restoration program? A search for demographic, socioeconomic, and physical predictors. Spine
1998; 23(16):1775-1783; discussion 1783-1784.

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 2. Dufour N, Thamsborg G, Oefledt A, Lundsgaard C, Stender S. Treatment of chronic low back pain: a randomized, clinical
trial comparing group-based multidisciplinary biopsychosocial rehabilitation and intensive individual therapist-assisted
back muscle strengthening exercises. Spine 2010; 35(5):469-476.
3. Moradi B, Hagmann S, Zahlten-Hinguranage A, Caldeira F, Putz C, Rosshirt N, Schonit E, Mesrian A, Schiltenwolf M,
Neubauer E. Efficacy of multidisciplinary treatment for patients with chronic low back pain, a prospective clinical study in
395 patients. Journal of Clinical Rheumatology 2012; 18(2):76-82.
4. Pioraudeau S, Rannou F, Revel M. Functional restoration programs for low back pain: a systematic review. Annales de
Readaptation et de Medicine Physique 2007; 50(6):425-429.
5. Roche G, Ponthieux A, Parot-Shinkel E, Jousset n, Bontoux L, Dubus V, Penneau-Fontbonne D, Roquelaure Y, Legrand E,
Colin D, Richard I, Fanello S. Comparison of a functional restoration program with active individual physical therapy for
patients with chronic low back pain: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2007;
88(10):1229-1235.

Intensive Exercise
The most effective treatment for chronic low back pain is unknown and often debated. The available
evidence suggests that the exercise treatment may not need to be combined with cognitive behavioral
therapy and that the specific type of exercise treatment may not be critical. Patients with chronic low back
pain have shown improvement with an intensive exercise program in which the aim is functional
improvement rather than pain control.

There is some evidence to suggest that intensive physical treatment is just as effective at reducing chronic
low back pain and functional limitation as combining physical treatment with cognitive-behavioral therapy.
In a randomized controlled study by Smeets et al (1), active physical treatment with physical therapist
supervised aggressive, non-pain contingent endurance and strength exercises was compared with cognitive-
behavioral treatment versus a combination of physical treatment and cognitive behavioral therapy. Each of
these three groups was also compared to a waitlist control. All groups improved compared to the waitlist
control. Interestingly, the single component treatment of exercise alone was as effective as cognitive-
behavioral treatment, or combined exercise and cognitive-behavioral treatments, even for the psychological
dimension of pain-catastrophizing (1). Another RCT by Roche et al (2) compared a functional restoration
program to active individual physical therapy. The active individual physical therapy intervention consisted
of stretching, strengthening using isotonic exercises, and endurance training for one hour three times per
week. The functional restoration intervention included group exercise for six hours per day, five days per
week, meetings with a medical supervisor once per week and at least one session with a psychologist. Pain
and disability improved similarly for both groups. The functional restoration group did result in greater
improvements in flexibility, strength and endurance. Though, this group also had 10 times more time
exercising and this did not translate into better outcomes for pain and disability. These studies suggest that
an intensive non-pain contingent exercise program is an effective single treatment for chronic low back pain.

Other modes of exercise treatment have also been shown to decrease pain and disability in patients with
chronic low back pain. In an RCT by Rydeard et al, 39 subjects with chronic low back pain either had 4
weeks of three one-hour sessions per week of a Pilates-based therapeutic exercises or usual physician
directed care (3). The Pilates-based exercise group showed decreased functional disability and low back
pain at treatment completion and the results were maintained at 12 months. It should be noted that most of
the subjects also reported compliance with their home exercise program at 12 month follow-up. General
aerobic training has shown to decrease disability, pain and psychological strain in subjects with chronic low
back pain as well. Chatzitheodorou randomized subjects to either supervised high-intensity aerobic training
or passive modalities without any adjuvant physical exercise for 12 weeks (4). Subjects that received the
passive modalities without exercise showed no changes. Though a small trial of only 20 subjects, the results
suggest that the exercise treatment may not need to be directed toward strengthening and stretching to be

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effective. This hypothesis is corroborated by studies that have shown that physical measures of strength,
flexibility, and motion do not always correlate with improvements in pain and disability (5). Consideration
of patient preferences and resources in order to improve compliance may be equally or more important
than the exact exercise modality in this subgroup of patients with chronic low back pain.

1. Smeets RJ, Vlaeyen JW, Kester AD, et al: Reduction of pain catastrophizing mediates the outcomes of both physical and
cognitive-behavioral treatment in chronic low back pain. J Pain 7:261-71, 2006
2. Roche G, Ponthieux A, Parot-Shinkel E, et al: Comparison of a functional restoration program with active individual
physical therapy for patients with chronic low back pain: A randomized controlled trial. Arch Phys Med Rehabil 88:1229-35,
2007
3. Rydeard R, Leger A, Smith D: Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain
and functional disability: a randomized controlled trial. J Orthop Sports Phys Ther 36:472-84, 2006
4. Chatzitheodorou D, Kabitsis C, Malliou P, et al: A pilot study of the effects of high-intensity aerobic exercise versus passive
interventions on pain, disability, psychological strain, and serum cortisol concentrations in people with chronic low back pain.
Phys Ther 87:304-12, 2007
5. Steiger F, Wirth B, de Bruin ED, Mannion AF. Is a positive clinical outcome after exercise therapy for chronic non-specific
low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review.
Eur Spine J. 2012 Apr;21(4):575-98.

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 Exercise Booth Survey Questions
1. Directional preference has been reported:
a. In at least 70% of acute and 50% of chronic low back pain.
b. Only in patients with sciatica
c. Only in patients with acute low back pain
d. Most commonly when patients are tested with extension testing
e. c and d only
f. b and d only
g. a and d only

2. When a directional preference can be elicited:

a. The patient’s pain can typically be centralized and/or abolished
b. A predictably effective, standardized, self-treatment has been identified
c. The prognosis for that patient is excellent using the proper directional exercises
d. a and b
e. a and c
f. a, b, and c

3. Positive predictors for patients who will respond to a core stability exercise program
include:
a. Positive prone instability test
b. Age > 40
c. High FABQ score
d. Straight leg raise > 91 degrees
e. a and b
f. a, b, and c
g. a and d

4. Which factors are positive predictors for success in FRP, outpatient therapy, AND no
treatment.
a. Youth
b. Non-smoker
c. Female
d. Few sick leave days
e. Employer support
f. No exposure to vibration
g. Good isometric trunk muscle endurance
h. All of the above
 5. True or False: A non-pain contingent intensive exercise program is an effective single
treatment for chronic low back pain.
True False

The following are questions to help the Exercise committee on future projects:

6. On average, how many PT visits do you feel are indicated for an episode of low back
pain?

7. Do you feel that the information at this booth is relevant to your practice? (Circle a
number below)

-5 -4 -3 -2 -1 0 1 2 3 4 5
Not at all Extremely

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