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

Concerns related to the accurate identification of

anterior derangement syndrome in mechanical
diagnosis and therapy for low back pain: A case
report

Hiroshi Takasaki PT, PhD & Stephen May PT, PhD

To cite this article: Hiroshi Takasaki PT, PhD & Stephen May PT, PhD (2018): Concerns
related to the accurate identification of anterior derangement syndrome in mechanical diagnosis
and therapy for low back pain: A case report, Physiotherapy Theory and Practice, DOI:
10.1080/09593985.2018.1488906

To link to this article: https://doi.org/10.1080/09593985.2018.1488906

View supplementary material

Published online: 22 Jun 2018.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=iptp20
PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2018.1488906

Concerns related to the accurate identification of anterior derangement

syndrome in mechanical diagnosis and therapy for low back pain: A case report
Hiroshi Takasaki PT, PhDa,b and Stephen May PT, PhDc
a
Department of Physical Therapy, Saitama Prefectural University, Koshigaya, Japan; bDepartment of Rehabilitation, Aoki Chuo Clinic,
Kawaguchi, Japan; cFaculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK

ABSTRACT ARTICLE HISTORY

Background: In Mechanical Diagnosis and Therapy (MDT), patients with low back pain (LBP) are Received 18 October 2017
classified into subgroups to guide a management strategy. A common subgroup where symptoms Revised 8 May 2018
improve with lumbar extension is labeled posterior derangement syndrome. A less common sub- Accepted 17 May 2018
group where symptoms improve with lumbar flexion is labeled anterior derangement syndrome. KEYWORDS
Case Presentation: The patient was a 23-year-old woman with intermittent LBP and discomfort over Classification; McKenzie;
the left lower extremity was initially diagnosis with posterior derangement syndrome. At the initial resistance training; posture;
and second consultations, postural correction and home exercises with lumbar extension were stratified models
prescribed. However, at the third consultation, sustained lumbar extension revealed worsening of
symptoms and function, which resulted in a revised diagnosis of anterior derangement syndrome.
Complete recovery was achieved using exercises with lumbar flexion over 6 weeks. Outcomes: The
patient wore the LUMOback in daily life, which is a wearable device measuring pelvic angle and
acceleration, for 1 week before the initial MDT consultation and for 6 weeks until discharge. The
posture scores (%) is the proportion of time in a week with neutral pelvic tilt. In this patient, the
posture score decreased greater than a minimum detectable change of 11.7% when MDT classifica-
tion changed to anterior derangement. Conclusions: This case report indicates the importance of
sustained loading to identify the correct derangement syndrome, and follow-up sessions to confirm or
reject the initial diagnosis by monitoring symptom and functional changes carefully. Habitual posture
may be associated with reduction and aggravation of symptoms.

Background A clinical feature of anterior derangement syndrome is

that repeated mechanical loading in the direction of lum-
Mechanical Diagnosis and Therapy (MDT), also known as
bar extension does not always make symptoms and func-
the McKenzie approach, is an evidence-based approach for
tion worse, whereas sustained loading in extension does
management of low back pain (LBP) (Davies et al., 2014;
(McKenzie and May, 2003). However, there has been
Foster, Thompson, Baxter, and Allen, 1999; Takasaki, Saiki,
neither scientific evidence nor case studies to support
and Iwasada, 2014), with an emphasis on patient education
this clinical feature, which may be due to the limited
(Takasaki, 2017b). MDT uses classifications to guide man-
prevalence of anterior derangement of the lumbar spine.
agement strategies through careful evaluation with
The main components of management of derange-
mechanical loading. The derangement syndrome is the
ment syndrome are repeated movements performed by
most common of the MDT classifications, in which rapid
the patient and posture correction. The education of
and sustained improvement in symptoms and/or function
postural correction is included so as not to disturb the
occurs with a specific direction of mechanical loading,
treatment effect achieved with mechanical loadings along
known as the directional preference (DP) (McKenzie and
a DP. Clinically there has been a concern about the
May, 2003). A subgroup of the derangement syndrome has
relationship between LBP and posture. Recent technical
a DP for flexion, and is known as anterior derangement
development of wearable devices has enabled us to under-
(McKenzie and May, 2003), with the proportion of such
stand how patients move in daily life and monitor their
patients with LBP being reported as 4.3% (Hefford, 2008).
habitual posture. One of the wearable devices is the
Common features of anterior derangement are summar-
LUMOback (Lumo Bodytech Inc., Mountain View, CA,
ized in Table 1.

CONTACT Hiroshi Takasaki, PT, PhD physical.therapy.takasaki@gmail.com Department of Physical Therapy, Saitama Prefectural University,
Sannomiya 820, Koshigaya, Saitama, Japan, 343-8540.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp.
Supplemental data for this article can be accessed here.
© 2018 Taylor & Francis
2 H. TAKASAKI AND S. MAY
Table 1. Common features of the anterior derangement.
Patients commonly present pain over the lower back or back and
anterior thigh or inguinal pain, without any neurological signs or
symptoms.
✓ Slouching often reduces pain after sitting and standing and walking
slowly increase pain.
✓ History may be unclear.
✓ Patients may present a severe loss of flexion, fixing them in lordosis,
but disability is relatively low.
✓ Not pain but stiffness often limits lumbar flexion.
✓ Usually no loss of lumbar extension
✓ Accentuated lordosis
✓ Deviation to one side may be observed in lumbar flexion.
✓ Response to repeated extension may be equivocal, rather than causing
a worsening of symptoms or causing the lordosis to lock in extension.
✓ Sustained end-range extension is likely to provoke pain and cause an
obstruction of lumbar flexion.
✓ Mechanical loading of lumbar flexion must abolish, reduce or
centralize symptoms and may increase flexion range.
USA). A previous study found adequate intersession relia-
bility for the measurement of habitual posture and time
spent sitting during a week using the LUMOback
(Takasaki, 2017a).
A clinical study was undertaken to investigate
whether habitual posture and time spent sitting change
in patients with posterior derangement syndrome (i.e.
patients whose symptoms improve with extension load-
ing to the lumbar spine) through MDT management
over 7 weeks, 1 week before the initial MDT evaluation
and 6 weeks of MDT interventions (UMIN Clinical
Trials Registry – UMIN000024285). In that study, we
subsequently identified a patient with an anterior
derangement syndrome. The patient was initially
involved in the clinical study and LUMOback data
were collected 1 week before the initial MDT. It was
discovered in a follow-up consultation that the patient
had an anterior derangement syndrome and the patient
was excluded from the study. However, data collection
of the LUMOback and other subjective and objective
measures were continued to evaluate changes of habi-
tual posture, time spent sitting and symptoms through-
out the MDT management. Videos captured rapid
aggravation of symptoms and function with sustained
loading in the direction of extension, while no rapid
change was seen with repeated loading in the direction
of extension.
This case report describes the patient identified in
the above study with LBP that was eventually categor-
ized as having an anterior derangement syndrome with
data from the LUMOback as well as symptomatic and
functional data before initiating MDT and through
MDT management. To the authors’ knowledge this is
the first case report to demonstrate different responses
between repeated and sustained extension with video
evidence in a patient with anterior derangement, as well
as changes in habitual posture found during MDT
management. The patient provided written consent to
publish her data, including her videos.
Case description
Patient information and history
The patient was a 23-year-old female university student
with a primary complaint of intermittent LBP radiating
over the left anterior superior iliac spine (ASIS) (Figure 1).
She was routinely dancing once a week and stretching
muscles of the trunk and lower extremities daily. The
symptoms started 2 months ago in the lower back without
any apparent reason.
She had had a history of recurrent LBP since the age
of 15 years, when she had a diagnosis of L3 lumbar
spondylolisthesis. However, detailed information about
the previous diagnosis was not available. Since the first
episode of LBP, her symptoms generally reduced within
a month without doing anything. The last recurrence
was 1 year ago with no apparent cause. She had seen a
physiotherapist, who prescribed exercise involving the
contraction of multifidus and transverse abdominal
muscles. Her symptoms resolved over a month. She
added these exercises for the current episode, after a
month, in addition to her routine stretching exercises,
but did not feel any improvement. After dancing,
3 weeks prior to the initial MDT consultation, she felt
worsening of the LBP, as well as intermittent pain
radiating over the left ASIS, anterior thigh and lower
leg, which led her to seek the MDT consultation in the
Aoki Chuo Clinic in Japan.
Measurement of habitual posture
To measure habitual pelvic posture, she wore the
LUMOback at the level of L5-S1 in daily life, except
when playing water sports, taking a shower or sleeping,
for 1 week before the initial MDT consultation and for
6 weeks during the MDT management. The LUMOback
includes an accelerometer and the algorithms on the
LUMOback sensor calculate angular data of the pelvis
with resolution of one degree and time spent sitting
with resolution of 1 s. The setting was the same as the
previous study (Takasaki, 2017a). Briefly, the posture
score in the LUMOback is a proportion of time in neutral
pelvic posture relative to the time in the pelvic posture
without posterior or anterior tilt above a predetermined
threshold of ‘very slouched’ in the LUMOback setting. In
this setting, minimum detectable changes (MDC) of the
posture score and time spent sitting were 11.7% and
126.7 min (Takasaki, 2017a). The LUMOback has a func-
tion to provide real-time feedback with vibration when a

Figure 1. Body chart of symptoms in the current episode.
certain pelvic position is held for a certain duration, but
this function was switched off for this patient.
Other subjective and objective measures
One week before the initial MDT consultation, the
patient completed subjective measures for (1) pain
intensity; (2) magnitude of disability; (3) self-reporting
functional limitations; and (4) quality of life. The pain
intensity was assessed with the P4 (Spadoni, Stratford,
Solomon, and Wishart, 2004), where a score of 0 indi-
cates no pain and that of 40 indicates the highest
possible pain level. The magnitude of disability was
assessed with the Oswestry Disability Index Japanese
version (Fujiwara et al., 2003), where 0% indicates no
PHYSIOTHERAPY THEORY AND PRACTICE 3
disability and 100% indicates the greatest disability. The
self-reporting functional limitations were assessed with
the Patient Specific Functional scale Japanese version
(Nakamaru, Aizawa, Koyama, and Nitta, 2015;
Stratford, Gill, Westaway, and Binkley, 1995), where a
score of 0 indicates the maximum limitation and that of
10 indicates no limitation. Quality of life was assessed
with the MOS 36-Item Short-Form Health Survey ver-
sion 2 (Fukuhara et al., 1998). The physical component
summary score, indicating quality of life in physical
aspects, and the mental component summary score,
indicating quality of life in mental aspects were calcu-
lated. The value of 50 indicates Japanese average, and
the greater the value is, the better the condition is
(Fukuhara and Suzukamo, 2004).
4 H. TAKASAKI AND S. MAY

Physical examinations and interventions at the she had the diagnosis of L3 lumbar spondylolisthesis
initial MDT consultation previously. Mechanical loading of lumbar extension
biomechanically increases anterior sheering force to
At the time of the initial MDT consultation, the patient
the lumbar spine, resulting in a theoretical enhance-
was not taking medication. She had had intermittent
ment of lumbar spondylolisthesis. However, it was
LBP only for the last 3 weeks. Forward and backward
decided that this history only was not enough to deter-
bending, sitting for 10 min, rising at the phase of trunk
mine clinical decision-making about exercise prescrip-
extension and standing for 10 min aggravated her LBP,
tion, but that rather a careful physical examination was
but walking and lying did not. It was observed that her
needed. The prevalence of DP of extension is highest in
sitting posture was slouched but standing posture was
patients with derangement syndrome with unilateral
considered normal. No lateral shift was detected in
symptoms below the knee (56%) (Hefford, 2008). The
standing. Correction of her sitting posture did not
patient was routinely dancing and physical examination
produce any effect. Active full extension of left or
with lumbar extension loading was not considered an
right knee in a sitting posture (AKEiS) produced LBP
absolute contraindication in such an active patient
only momentarily. There were no motor or sensory
without any motor or sensory deficit, despite the pre-
deficits. Straight leg raise on both sides was negative.
vious diagnosis. Therefore, it was decided to explore
Finger Floor Distance (FFD) and active trunk extension
carefully the possibility of a posterior derangement
in standing assessed with a modified Schober method,
syndrome in the following repeated movement testing.
whose validity has been established (Clare, Adams, and
She had no pain in prone lying or by leaning on her
Maher, 2007), were evaluated. Regarding mobility of
forearms in mid-lumbar extension. The patient then
active side-glide, which produces a similar mechanical
put her hands under her shoulders and undertook
effect to the lower lumbar intervertebral disks as side-
extension in lying (EIL) actively by extending her
bend (Takasaki, 2015), there was a negligible loss on
elbows. The active EIL produced LBP (2/10 in the
both sides. However, she experienced LBP on the right
Numerical Rating Scale [NRS]) at her end-range, in
side when she returned to the neutral standing position
which the elbows were slightly flexed. The pain did
from right side-glide.
not remain when she returned to the prone position,
Pain was not provoked with either cough or sneeze.
but there was pain at the mid-range as she returned to
Gait was normal and she did not feel any motor or
prone lying. As the number of repetitions of EIL
sensory deficit. There was no bladder or bowel symp-
increased to 30, she felt less LBP at end-range com-
tom. She did not have any health problem except her
pared to initially and her EIL mobility increased, with
LBP and did not take any medication. There was no
her elbows completely extended. There was no change
history of surgery, cancer or traumatic event. There was
in the mobility of active side-glides, and no symptom
no history of cancer, smoking, night pain, or unex-
responses to active side-glides, and to either side of the
plained weight loss. Therefore, the possibility of serious
AKEiS. There was no motor or sensory deficit, and
pathologies was not considered high.
straight leg raise on both sides remained negative.
The presence of DP is a positive prognostic factor
and interventions using mechanical loading along the
direction of DP is likely to be an effect management Diagnosis/prognosis
strategy (Long, May, and Fung, 2008; Surkitt et al.,
2012). Therefore, it was aimed to explore the presence Based on the examination findings, the patient’s provi-
of the derangement syndrome and the DP first. The sional MDT classification was posterior derangement
patient had had symptoms over the anterior left thigh syndrome and she was enrolled in the previously
and lower leg although these symptoms had not been described study.
felt for the last 3 weeks prior to the initial MDT con-
sultation. The occurrence of symptoms below the knee
is uncommon for the anterior derangement syndrome Intervention
(McKenzie and May, 2003). Pain aggravation in for- At the initial consultation the patient was instructed to
ward and backward bending, sitting, rising at the phase undertake repeated active EIL at least 10 times every 3 h.
of trunk extension and no pain aggravation in walking The patient was also instructed to sit in a neutral sitting
and lying could indicate a DP of extension. However, posture with a McKenzie lumbar roll (The Original
standing for 10 min aggravated her LBP and thus it was McKenzie® Lumbar Roll™, OPTP, Minneapolis, MN,
considered that there was no specific DP suspected USA) and to avoid both slouched sitting and her routine
from the history taking only. She also explained that stretching exercises involving lumbar flexion until the

next appointment. The patient was also warned to stop
the EIL exercises if she felt peripheralization or greater
lasting pain intensity, or motor or sensory deficits
developing.
Second consultation (1 week after the initial
consultation)
The patient reported that she completed at least three
sessions with ≥10 repetitions of EIL every day and
demonstrated appropriate performance of the exercise.
The patient reported less LBP intensity than prior to
the initial MDT consultation. The following were iden-
tified at the second consultation: (1) no motor or sen-
sory deficit, and negative findings to the straight leg
raise on both sides; (2) no LBP in standing for a few
seconds; (3) no LBP in sitting for a few seconds; (4)
LBP at the end-range of active EIL (2/10 in the NRS)
with a position of slight elbow flexion, indicating mini-
mal loss of EIL mobility; (5) LBP at the end-range of
active side-glide on both sides (1/10 in the NRS); and
(6) LBP with both sides of the AKEiS (2/10 in the NRS).
There was no negative response, but no change from
active EIL from the home exercises. Thus, careful
examination with force progression was undertaken.
One active EIL with therapist overpressure was done
and the patient felt less LBP at end-range. As the
number of repetitions for EIL with therapist overpres-
sure increased to 20 repetitions she felt the LBP con-
tinued to decrease at end-range, and her EIL mobility
increased with complete elbow extension. However, no
other baseline measures changed. The patient reported
that further EIL exercises reduced her symptoms and
she desired to continue the exercises at home.
Consequently, the home EIL exercises were progressed
to a self-overpressure of EIL with a towel at least 10
times every 3 h. The patient was again instructed to
stop the EIL exercises if she felt peripheralization or
greater pain intensity, or motor or sensory deficits
developing.
Third consultation (2 weeks after the initial
consultation)
The patient reported that she completed at least three
sessions with ≥10 repetitions of the EIL each day. The
patient reported aggravation of LBP intensity (27/40 in
the P4) and felt reduction of trunk flexion mobility at
the time of the third consultation. The following were
identified at the third consultation: (1) no motor or
sensory deficits, and negative findings on the straight
PHYSIOTHERAPY THEORY AND PRACTICE 5
leg raise on both sides; (2) no LBP in standing for a few
seconds, sitting for a few seconds and the prone posi-
tion; (3) LBP at the end-range of EIL with complete
elbow extension and returning phase from end-range
EIL position to the prone position (2/10 in the NRS);
(4) LBP at the end-range of side-glide in either side (2/
10 in the NRS); and (5) and LBP with either side of the
AKEiS (6/10 in the NRS).
Repeated active EIL 20 times produced LBP (2/10 in
the NRS) but did not remain when she returned to the
prone position. Immediately after the repeated active
EIL, there was a jerky movement during active flexion
in standing (FIS) although FIS mobility did not change
from the baseline (Appendix A). Subsequently, the
patient was instructed to keep the end-range EIL posi-
tion for one minute, which produced LBP (2/10 in the
NRS). Immediately after the sustained EIL, LBP inten-
sity was 1/10 in the NRS in the standing position. FIS
movement was remarkably limited and the mobility
dramatically increased over repetitions of active FIS
(Appendix B). After 12 repetitions of active FIS, FIS
mobility was greater than the baseline and the following
were found: (1) no motor or sensory deficit and nega-
tive finding on the straight leg raise on both sides; (2)
no LBP in the standing and sitting positions for a few
seconds and the prone position; (3) LBP at the end-
range of EIL with complete elbow extension (1/10 in
the NRS); (4) no pain at the returning phase from end-
range EIL position to the prone position; (5) no LBP at
the end-range of side-glide in either side; and (6) and
minimum LBP on either side of the AKEiS (1/10 in
the NRS).
Her MDT classification was changed from the pos-
terior derangement syndrome to the anterior derange-
ment syndrome and she was excluded from the
research study protocol. The patient was instructed to
undertake repeated active FIS at least 10 times every
3 h. The patient was also instructed to sit without the
lumbar roll and to stop her routine stretching exercises
involving lumbar extension until the next appointment.
The patient was also instructed to stop the FIS exercises
if she felt peripheralization or greater pain intensity, or
motor or sensory deficits developing.
Fourth consultation (3 weeks after the initial
consultation)
The patient rated her overall improvement as ‘much
improved’ with a 7-point Global Rating of Change
Scale (worse than ever, much worsened, slightly wor-
sened, no change, slightly improved, much improved,
6 H. TAKASAKI AND S. MAY
completely recovered) (Ostelo and De Vet, 2005). The
patient reported that she completed at least three ses-
sions with ≥10 repetitions of the active FIS each day.
Self-reporting measures assessed before the initial
MDT consultation, FFD and active trunk extension
in standing were assessed (Table 1). The patient
reported a marked reduction of LBP intensity and
frequency. There was no LBP anymore in side-glide
and the AKEiS. Consequently, the home FIS exercises
were progressed to a self-overpressure of flexion in
sitting (FIsit) at least 10 times every 3 h.
Her curvature of the lumbar lordosis from S2 to
Th12 levels was measured in the neutral standing
position using a flexible ruler (Shinwa Rules Co.,
Ltd., Tsubame, Niigata, Japan). For this patient, mini-
mizing loading in the direction of lumbar extension
was considered beneficial and thus reducing lumbar
lordosis was intended. It was considered that increas-
ing stiffness of trunk flexor muscles would result in
reduction of lumbar lordosis and therefore resistance
training of the rectus abdominis muscle was initiated
(Ocarino et al., 2008). The resistance training was
prone-bridge exercise (Comfort, Pearson, and
Mather, 2011), where 5 kg weight was placed over
the back of the patient. Her maximum endurance
was 130 s and therefore its 80% time (104 s) was set
as the target intensity (Rhea, Alvar, Burkett, and Ball,
2003). The patient was instructed to maintain the
prone-bridge for the target intensity per set. She was
asked to perform four sets of the above exercises with
1 min rest in between each set, 3 days a week
(American College of Sports Medicine, 2009; Rhea,
Alvar, Burkett, and Ball, 2003).
Fifth consultation (4 weeks after the initial
consultation)
The patient reported that she completed at least four
sessions with ≥10 repetitions of the active FIsit and
100% compliance of the resistance training. The patient
reported further reduction of LBP intensity and frequency.
Thus, the home exercise menu was maintained and the
target intensity for the prone-bridge endurance was set as
112 s as the maximum prone-bridge endurance increased.
Sixth consultation (6 weeks after the initial
consultation)
The patient reported that she completed at least
four sessions with ≥10 repetitions of the active
FIsit and 100% compliance of the resistance train-
ing. The patient rated her overall improvement as
‘completely recovered’ with the 7-point Global
Rating of Change Scale. The maximum prone-
bridge endurance increased to 182 s. The following
measures were reassessed: (1) self-reporting mea-
sures; (2) FFD and active trunk extension in stand-
ing; and (3) curvature of the lumbar lordosis
assessed in the neutral standing position using the
flexible ruler. The patient had had no symptom for
2 weeks. The patient understood the self-manage-
ment strategy for her LBP and was confident to
manage her symptoms by herself. The patient also
had no anxiety about dancing or any movements
and activities. Thus, the patient was discharged
from physiotherapy and instructed to undertake
active FIS at least 10 times twice a day and more
repetitions when necessary.
Intermediate-term follow-up over the phone
(6 months after the discharge)
The patient reported that she had experienced some
minimal LBP a few times after the discharge.
However, she could abolish the LBP by repeating
active FIS immediately and there had been no further
episode of LBP recurrence lasting ≥24 h with a pain
intensity of >2 on a 0–10 NRS (Stanton, Latimer,
Maher, and Hancock, 2011).
Outcomes
Changes in the LUMOback measures
The posture scores and time spent sitting from 1 week
before the initial MDT consultation to the discharge
6 weeks after the initial consultation were presented in
Figure 2. The posture scores decreased greater than
the MDC after the third consultation 2 weeks after the
initial consultation, which corresponded to the change
of MDT classification and home exercises. In contrast,
there was no change greater than the MDC in time
spent sitting through the MDT management.
Changes in the self-reporting measures and
flexibility measures in standing
Table 2 summarized self-reporting measures and flex-
ibility measures at the initial MDT consultation and 3
and 6 weeks after the initial consultation. In the
patient specific functional scale (0 = the maximum
limitation, 10 = no limitation), she described forward
bending as 7/10, lifting a chair as 7/10, standing for
3 h as 3/10, sitting for 10 min as 8/10, and sitting for
 PHYSIOTHERAPY THEORY AND PRACTICE 7

Figure 2. The posture score (A) and time spent sitting (B) measured using the LUMOback device from one week before the initial
consultation to six weeks after the initial consultation.

Table 2. Measures at the initial consultation and three and six weeks after the initial consultation.
Measures Initial consultation 3 weeks after the initial consultation 6 weeks after the initial consultation
P4 (0–40) 14 4 0
Oswestry Disability Index (%) 12 6 0
Patient Specific Functional scale (0–10) 6.8 8.8 10
Physical component summary-SF36 54.2 55.6 65.3
Mental component summary-SF36 47.0 52.7 59.4
Finger Floor Distance (cm)* −15.1 −9.8 −16
Trunk extension in standing using the 10.9 10.1 10.1
modified Schober method (cm)†
7-point Global Rating of Change Scale§ Not Applicable Much improved Completely recovered
Physical component summary-SF36, physical component summary score of the MOS 36-Item Short-Form Health Survey version 2-week; SF-36 mental
component summary-SF36, mental component summary score of the MOS 36-Item Short-Form Health Survey version 2-week.
*A negative value indicates that the finger reaches below the floor and a positive value indicates that the finger reaches above the floor.
†
Max = 15.0 cm, smaller values indicate grater lumbar extension range of motion in standing.
§
0 = worse than ever, 1 = much worsened, 2 = slightly worsened, 3 = no change, 4 = slightly improved, 5 = much improved, 6 = completely recovered.

1 min as 9/10 at the initial MDT consultation. At the Changes in the lumbar lordosis
discharge, there was no pain, disability or functional
Lumbar lordosis (θ) assessed in the neutral standing
limitations, and quality of life was above the Japanese
position using the flexible ruler at three and six weeks
average of 50.
8 H. TAKASAKI AND S. MAY
after the initial consultation, was calculated using the
following formula;
2H
θ ¼ 4 Arc tan
L
where L was the length between the Th12 and S2
vertebral level and H was the depth to the curvature
at the middle point between the T12 and S2 vertebral
levels.
According to data in a previous study (Seidi et al.,
2009), a MDC of θ was calculated as 6.4° using the
following formulas;
pffiffiffi
MDC ¼ SEM  1:96  2
SEM ¼ ðmean of SDsÞ
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
 ffi
ICC of intersession reliability
1
of the first tester
The reduction of θ from 47.7° before the initiation of
resistance training for the rectus abdominal muscle to
25.8° three weeks after the initiation of resistance train-
ing for the rectus abdominal muscle was greater than
the MDC.
Discussion
This case report described a patient with LBP that was
categorized with the anterior derangement syndrome.
Videos captured rapid changes in symptoms and func-
tion with sustained loading in the direction of exten-
sion and no rapid change with repeated loading in the
direction of extension. This case report indicates the
possible importance of sustained loading to identify the
anterior derangement syndrome.
In this case report, the MDT subgroup was changed
at the third consultation. This clinically indicates the
importance of follow-up to monitor symptoms and
functional changes with loading strategies. When
expected responses have not been achieved at follow-
up, a change may be indicated sequentially in (1) the
amount of force of mechanical loading; (2) the starting
position of mechanical loading (e.g. standing, sitting
and lying); (3) direction of mechanical loading; and
(4) subgroup classifications (McKenzie and May, 2003).
The posture scores measured by the LUMOback
decreased marginally greater than the MDC of 11.7%
(Takasaki, 2017a) after the third consultation, which
corresponded to the change of MDT classification and
home exercises. In contrast, time spent sitting mea-
sured by the LUMOback had no change greater than
the MDC of 126.7 min (Takasaki, 2017a) through the
MDT management. These may indicate that symptom
reduction/aggravation may be associated with habitual
posture, not time spent sitting.
In this case report, resistance training for the rectus
abdominal muscle was included in the loading strate-
gies of lumbar flexion after the subgroup diagnosis was
revised. Stiffness of muscles can be increased by resis-
tance training (Lee and McGill, 2015; Ocarino et al.,
2008), which may result in a change of balance in the
stiffness of muscle (Ocarino et al., 2008), possibly
resulting in a change of posture. Future studies will be
required to determine whether resistance training could
result in postural change and if postural change is a
contributing factor for improving symptoms and pre-
venting recurrence of LBP.
The FFD decreased from −15.1 cm at the initial
consultation to −9.8 cm 3 weeks after the initial con-
sultation. A previous study demonstrated a MDC in the
FFD of 4.5 cm (Ekedahl, Jonsson, and Frobell, 2012).
Therefore, no meaning was considered in the reduction
of the FFD 3 weeks after the initial consultation.
Conclusion
In conclusion, a patient with LBP, who was classified as
having anterior derangement syndrome, demonstrated
rapid aggravation with sustained not repeated mechan-
ical loading in the direction of lumbar extension and
rapid improvement with repeated lumbar flexion. The
habitual posture also changed along with correspond-
ing symptom reduction. This case report provides
hypotheses that habitual posture might change through
the MDT management, and that changing habitual
posture might enhance the treatment effect of MDT.
Declaration of interest
The authors report no conflict of interest.
Funding
This work was supported by the JSPS KAKENHI [15121265].
References
American College of Sports Medicine 2009 American College
of Sports Medicine position stand. Progression Models in
Resistance Training for Healthy Adults. Medicine and
Science in Sports and Exercise 41: 687–708.
Clare HA, Adams R, Maher CG 2007 Construct validity of
lumbar extension measures in McKenzie’s derangement
syndrome. Manual Therapy 12: 328–334.
Comfort P, Pearson SJ, Mather D 2011 An electromyographi-
cal comparison of trunk muscle activity during isometric

trunk and dynamic strengthening exercises. Journal of
Strength and Conditioning Research 25: 149–154.
Davies C, Nitz AJ, Mattacola CG, Kitzman P, Howell D, Viele
K, Baxter D, Brockopp D 2014 Practice patterns when
treating patients with low back pain: A survey of physical
therapists. Physiotherapy Theory and Practice 30: 399–408.
Ekedahl H, Jonsson B, Frobell RB 2012 Fingertip-to-floor test
and straight leg raising test: Validity, responsiveness, and
predictive value in patients with acute/subacute low back
pain. Archives of Physical Medicine and Rehabilitation 93:
2210–2215.
Foster NE, Thompson KA, Baxter GD, Allen JM 1999
Management of nonspecific low back pain by physiothera-
pists in Britain and Ireland. A Descriptive Questionnaire of
Current Clinical Practice. Spine 24: 1332–1342.
Fujiwara A, Kobayashi N, Saiki K, Kitagawa T, Tamai K,
Saotome K 2003 Association of the Japanese Orthopaedic
Association score with the Oswestry Disability Index,
Roland-Morris Disability Questionnaire, and short-form
36. Spine 28: 1601–1607.
Fukuhara S, Bito S, Green J, Hsiao A, Kurokawa K 1998
Translation, adaptation, and validation of the SF-36 Health
Survey for use in Japan. Journal of Clinical Epidemiology
51: 1037–1044.
Fukuhara S, Suzukamo Y 2004 Manual of SF-36v2 Japanese
Version. Kyoto: Institute for Health Outcomes & Process
Evaluation Research.
Hefford C 2008 McKenzie classification of mechanical spinal
pain: Profile of syndromes and directions of preference.
Manual Therapy 13: 75–81.
Lee B, McGill S 2015 The effect of long term isometric
training on core/torso stiffness. Journal of Strength and
Conditioning Research 29: 1515–1526.
Long A, May S, Fung T 2008 The comparative prognostic
value of directional preference and centralization: A useful
tool for front-line clinicians? Journal of Manual and
Manipulative Therapy 16: 248–254.
McKenzie R, May S 2003 The Lumbar Spine: mechanical
Diagnosis and Therapy (2nd). Waikenae: Spinal Publications
New Zealand Ltd.
Nakamaru K, Aizawa J, Koyama T, Nitta O 2015 Reliability,
validity, and responsiveness of the Japanese version of the
Patient-Specific Functional Scale in patients with neck
pain. European Spine Journal 24: 2816–2820.
Ocarino JM, Fonseca ST, Silva PL, Mancini MC, Gonçalves
GG 2008 Alterations of stiffness and resting position of the
elbow joint following flexors resistance training. Manual
Therapy 13: 411–418.
Ostelo RW, De Vet HC 2005 Clinically important outcomes
in low back pain. Best Practice and Research. Clinical
Rheumatology 19: 593–607.
PHYSIOTHERAPY THEORY AND PRACTICE 9
Rhea MR, Alvar BA, Burkett LN, Ball SD 2003 A meta-
analysis to determine the dose response for strength devel-
opment. Medicine and Science in Sports and Exercise 35:
456–464.
Seidi F, Rajabi R, Ebrahimi T, Tavanai A, Moussavi S 2009
The Iranian flexible ruler reliability and validity in lumbar
lordosis measurements. World Journal of Sport Sciences 2:
95–99.
Spadoni GF, Stratford PW, Solomon PE, Wishart LR 2004 The
evaluation of change in pain intensity: A comparison of the
P4 and single-item numeric pain rating scales. Journal of
Orthopaedic and Sports Physical Therapy 34: 187–193.
Stanton TR, Latimer J, Maher CG, Hancock MJ 2011 A mod-
ified Delphi approach to standardize low back pain recur-
rence terminology. European Spine Journal 20: 744–752.
Stratford PW, Gill C, Westaway MD, Binkley JM 1995
Assessing disability and change on individual patients: A
report of a patient specific measure. Physiotherrapy
Canada 47: 258–262.
Surkitt LD, Ford JJ, Hahne AJ, Pizzari T, McMeeken JM 2012
Efficacy of directional preference management for low back
pain: A systematic review. Physical Therapy 92: 652–665.
Takasaki H 2015 Comparable effect of simulated side bend-
ing and side gliding positions on the direction and magni-
tude of lumbar disc hydration shift: In-vivo MRI
mechanistic study. Journal of Manual and Manipulative
Therapy 23: 101–108.
Takasaki H 2017a Habitual pelvic posture and time spent
sitting: measurement test-retest reliability for the
LUMOback device and preliminary evidence for slouched
posture in individuals with low back pain. SAGE Open
Medicine 5: 2050312117731251.
Takasaki H 2017b Mechanical diagnosis and therapy
enhances attitude towards self-management in people
with musculoskeletal disorders: A preliminary evidence
with a before-after design. SAGE Open Medicine 5:
2050312117740986.
Takasaki H, Saiki T, Iwasada Y 2014 McKenzie therapists
adhere more to evidence-based guidelines and have a more
biopsychosocial perspective on the management of patients
with low back pain than general physical therapists in Japan.
Open Journal of Therapy and Rehabilitation 2: 173–181.
Appendix A. Video with repeated extension in
lying
Appendix B. Video with sustained extension in
lying and repeated flexion in standing