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Lumbopelvic Muscle imbalancesLumbopelvic Muscle imbalancesLumbopelvic Muscle imbalancesLumbopelvic Muscle imbalances

Presented by Aaron Rutter PT, BScPT, FCAMPT, CAFCI

www.leadtheway.ca/continuingeducation/

Certificate of Excellence In AssessmentCertificate of Excellence In AssessmentCertificate of Excellence In AssessmentCertificate of Excellence In Assessment

Certificate of Excellence (COE) Program

• Program delivered by the RMTAO

• Certificate of Excellence in Assessment

• CMTO and RMTAO member

• Complete 10 RMTAO run assessment courses over a 5 year period

• Pass each course’s examination with a minimum 70% (multiple choice quiz)

Introduction

• Physiotherapist

• Certified Manual and Manipulative Physiotherapist

• Certified in Acupuncture

• Queen’s University

• RMTAO courses

Course Objectives

• How do you recognize common compensation strategies used by patients with poor lumbopelvic motor control?

• How do you know when a client will benefit from a stabilization program?

• How do you activate the inner unit?

• What is normal endurance of the outer unit?

• Abdominals

• Erector spinae

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Surface Anatomy

� Iliac crest

� Ischial tuberosity

� ASIS

� PSIS (long dorsal SI lig)

� Base of sacrum

� Sacral sulcus (SIJ)

� Apex of sacrum

� Coccyx

� Pubic symphysis

� Xiphoid process

� Lower ribs (10, 11, 12)

� Multifidi

� Quadradus lumborum

� ES

� Spinalis

� Longissimus

� Iliocostalis

� Piriformis

� Rectus abdominus

� Internal oblique

� External oblique

Clinical Instability

• A significant decrease in the capacity of the stabilizing system of the spine to maintain the intervertebral neutral zone within physiological limits, which results in pain and disability (Panjabi 1992)

Neutral Zone

• Range where passive structures (ligaments, capsule) are under minimal stress� similar to the open pack or resting position

� greatest amount of joint glide

• The neutral zone is the position of the joint that is most difficult to achieve effective stabilization, because there is the least contribution from the passive structures in this position

Neutral ZoneBowl Analogy

Normal Joint

Normal neutral zone

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Neutral ZoneBowl Analogy

Stiff Joint

Decreased neutral zone

Neutral ZoneBowl Analogy

Unstable Joint

Increased neutral zone

Instability vs Clinical Instability

Instability• Actually damage to the stabilizing structures

of the spine, usually ligamentous• Increased neutral zone with positive ligamentous

or diagnostic testing eg. Spondylolisthesis

Clinical Instability• Inability to maintain the spine within its

neutral zone

Instability vs Clinical Instability

• Having ligamentous damage does not mean a person is clinically unstable

• Having normal ligaments does not mean a person is clinically stable

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The Concept of Stabilization

Form Closure refers to a stable situation with closely fitting joint surfaces, where no extra forces are needed to maintain the stability of the system

Form Closure

Form ClosureForm ClosureForm ClosureForm Closure(Passive System)

Form closure increased by:

1. Shape of joint surfaces

2. Friction co-efficient of the articular cartilage

3. Integrity of the ligaments which approximate the joint

The Concept of Stabilization

Force closure refers to the muscular forces required to achieve joint compression. The amount of force closure required is dependent on the coefficient of friction of the joint surfaces.

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Force ClosureForce ClosureForce ClosureForce ClosureForce Closure(Active System)

Force closure is increased by:

Inner Unit

– Diaphragm

– Transverse abdominus

– Multifidi

– Pelvic floor muscles

Force ClosureForce ClosureForce ClosureForce Closure(Active System)

Force closure is increased by:

Outer Unit

– Erector Spinae– Spinalis

– Longissimus

– Iliocostalis

– Quadradus Lumborum

– Rectus Abdominus

– Internal and External Abdominal Obliques

– Psoas

– Glutes

Motor ControlMotor ControlMotor ControlMotor Control((((Neural System)

� Made up of the central and peripheral nervous systems

� Receives continuous information from the passive and active systems and causes proper muscular control, strength and patterning

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Integrated Model of Function(Vleeming/Lee/Panjabi)

Form Closure(Passive)

Motor Control(Neural)

Emotions/Awareness

Force Closure(Active)

Effective Stabilization

No Instability

Implications of Clinical Instability(Peter O’Sullivan)

� Pain secondary to recurrent end-range strain or pathological spinal loading

� Pain inhibition of inner unit

� Results in muscle guarding and splinting of outer unit (rigidity strategies)

� Results in a mal-adaptive response to the pain disorder and represents a mechanism for ongoing pain and disability

Stabilization Strategies = Movement Behavior (Diane Lee)

Control Strategy

OPTIMAL FORCE CLOSURE

Rigidity Strategy

EXCESSIVE FORCE CLOSURE

Low High

High Low

Load

Predictability

Control Strategy

�Optimal for low loads with high predictability and in the presence of�A healthy spine and pelvis

�Low real or perceived risk with the activity

�Good awareness of position and demand

�Disrupted by�Pain

�Past experiences, beliefs

�Sensitization of the nervous system (peripheral/central)

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Rigidity Strategy

� Optimal for high loads or low predictability tasks, however often chosen when� Insufficiency of the passive system (decreased form closure) or active

system (decreased force closure)� Increased perceived pain or risk of pain� Poor awareness of position and demand

� Two main rigidity strategies in the lumbar spine1. Chest gripping2. Back gripping

� Poor strategy to use during low load situations

� Increased activity of superficial muscles relative to activity being performed may indicate compensation for poor segmental stability

Rigidity StrategyChest GrippingChest GrippingChest GrippingChest Gripping

� Increased rectus abdominus, external oblique and internal oblique tone/tension

� Do you subconsciously squeeze your chest or upper abdomen in an attempt to flatten your lower back?

� Does your lower abdomen protrude no matter how hard you try to flatten it and when you press on it does it feel really firm (like a balloon filled with pressure)?

� See outline of rectus abdominus in unfit person

� Rib cage is drawn inwards (poor lateral costal expansion) from internal and external oblique tension

� Trigger points in abdominals are usually near attachment to ribcage

� Lumbar spine may be flattened, decreased lordosis

� Apical breathing, instead of diaphragmatic and lateral costal

Chest GrippingRigidity StrategyBack GrippingBack GrippingBack GrippingBack Gripping

� Increased erector spinae and/or quadradus lumborum tone/tension

� Do you subconsciously lift your chest to correct your posture all day?

� Does your back temporarily feel good with forward flexion stretching or massage?

� Lordotic spasm (increased lordosis)

� Trigger points along erector spinae and quadradus lumborum

� Erector spinae tension usually around the thoracolumbar junction

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Back Gripping Clinical Tidbit

�Usually you think of someone who has an instability should have increased range of motion, but patients with increased neutral zones or poorly controlled neutral zones quite often have decreased range of motion (like to stay rigid)

�Giving stretching to someone with clinical instability could make the patient worse

�Sometimes you have to think backwards. If you make them more stable, they will be more willing to move

Signs of Instability

• Congenital abnormalities

• Connective tissue disorders

• Trauma or repeated microtrauma (ligament damage)

• Lumbar or abdominal surgery

• Pregnancy

• Trivial incidents of LBP

• Pain tends to move around

• Reoccurring episodes of severe muscle spasm only relieved temporarily by manipulation or massage

• Poor ability to maintain static postures

• Catch or aberrant movement during lumbar ROM (inconsistent)

• Diminished or unbalanced muscle function

ObservationsDo you see chest or back gripping?

• Posture (standing, sitting)

• Chest gripper• Decreased lordosis

• Increased abdominal tone

• Lower ribs drawn inwards

• Decreased lateral costal expansion (3-7.5cm measured at xiphoid)

• Back gripper• Increased lordosis

• Muscle tension in erector spinae especially around the TL junction

• When squat get increased lordosis

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Lumbar ROM

• Flex 50-70

• Ext 30-35

• SB/rot 15-30

• The hip and pelvis contributes to overall motion to give greater values than above

Observations

During Movement

�Catching pain during motion, rather than end range pain

�Aberrant movement during flexion or extension

�Pivoting of spine (not a smooth curve, skin creases)� Flexion: reversal of lordosis� Extension and side bend: smooth “C” curve� Rotation: smooth “S” curve

�Has to use hands to return from lumbar flexion

� Increased range of motion and decreased pain with activation of erectors and/or abdominals (use rigidity strategy)

No Reversal of Lordosis Pivoting with Side Bend

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Pivoting with ExtensionLumbar AROMFlexion (stabilize T12 and S1)

Lumbar AROMExtension

Lumbar AROMSide Bend

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Lumbar AROMRotation

Lumbar PROMFlexion

� Perform if do not have full and pain free AROM

� Stabilize S1 with inferior hand and T12 with superior hand

Lumbar PROMExtension

Lumbar PROMSide Bend

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Lumbar PROMRotation

Beighton Score

• Grahame, R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol 2000; 27(7): 1777-9.

• Smits-Engelsman B, Klerks M, Kirby A. Beighton Score: A Valid Measure for Generalized Hypermobility in Children. J Pediatr 2011; 158(1): 119-23.

General FlexibilityBeighton Score

• Hands flat on floor with lumbar flexion while keeping knees straight (1 point)

• Knee hyperextension (1 point for each knee)

• Elbow hyperextension (1 point for each elbow)

• Thumb hyperextension to touch forearm (1 point for each thumb)

• Little finger extension beyond 90 degrees (1 point for each 5th digit)

• BRIGHTON CRITERIA• Major criteria

• Beighton score of 4/9 or higher

• Arthragia in 4 or more joints > 3 months

Practical

�Observations� Standing, sitting, functional positions� Is there any chest or back gripping?

� Lumbar active range of motion with overpressure� Flexion, extension, side bend, rotation

�What is their quality of movement�Smooth curves, reversal of lordosis?

� Lumbar PROM� Perform if do not have full and pain free active range of motion

�Beighton Score

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Stork Test

• Hungerford BA et al. Evaluation of the Ability of Physical Therapists to Palpate Intrapelvic Motion With the Stork Test on the Support Side. Physical Therapy 2007; 87(7): 879-887.

Stork Test

• Palpate the PSIS and sacral base of the weight bearing side as patient flexes hip

• Positive test is if sacrum counternutates

• Nutation is the stable position of the SIJ

SquattingSit to Stand

• Does sacrum stay nutated?

• Does the lumbar spine maintain its neutral lordosis?

• Back gripping versus chest gripping

Clinical Prediction Guideline

• How do you know a client needs a stabilization program?

• Hicks GE et al. Preliminary clinical prediction rule for determining response to a lumbar stabilization program. Arch Phys Med Rehabil 2005; 86: 1753-1762.

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Clinical Prediction GuidelineStabilization

1. Age less than 40

2. Greater general flexibility (post partum or average SLR greater than 91 degrees)

3. Instability catch or aberrant movement during active lumbar flexion or extension

4. Positive prone instability test

5. Post-partum patients• Positive posterior pelvic pain provocation (P4)

• Positive active straight leg raise

• Positive trendelenburg

• Painful palpation to pubic symphysis or long dorsal sacroiliac ligament

Straight Leg Raise

Palpate ASIS: monitor for movement

Do they have >91 degrees?

Prone Instability Test

• Have patient extend both of hips and note if any symptom reproduction

Prone Instability Test

• If symptoms were reproduced apply a posterior/anterior pressure to the lower lumbar spine and have the patient extend both hips

• If symptoms decrease or are abolished the test is positive

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Posterior Pelvic Pain Provocation (P4)

Sensitivity 0.81, Specificity 0.80

Active Straight Leg Raise

• Mens J et al. Validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain after pregnancy. Spine. 2002;27:196–200.

Active Straight Leg Raise (ASLR)

• Sensitivity 0.87, Specificity 0.94 (post partum)

• Patient is asked to lift the leg 20 cm off the bed and asked to score the effort from 0 (no difficulty) to 5 (unable to lift) for each leg

• Positive test is any score greater than 0/10

Trendelenburg

• Ask the patient to lift one leg at a time to 90 degrees of hip flexion

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Trendelenburg

• Uncompensated Trendelenburg

• pelvis on non WB side drops

• Compensated Trendelenburg

• trunk leans towards WB side

Palpation of Pubic Symphysis

• Pain must linger at least 5 seconds

Palpation of Long Dorsal Sacroiliac Ligament

• Just inferior to PSIS, part of the sacrotuberous ligament

• Pain must linger at least 5 seconds

Strengthening of the Core

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Management of Clinical Instability(Peter O’Sullivan)

• Motor learning intervention• Prevent repeated stretching of flexible site

• Restore muscle patterning and improve performance of stabilizing muscles in a neutral spine

• Involves both a cognitive and physical process

• Process of changing movement behavior

• Provide patients with the capacity to manage their own disorder

Inner Unit

Inner UnitSegmental Muscles

1. Diaphragm

2. Transverse Abdominus

3. Pelvic Floor Muscles

4. Multifidi

Inner unit activation� No movement of lumbar spine allowed

� Activating these muscles in a neutral spine, where the most force closure required

� Quite often have to use analogies to help patients activate (visualization)

� Submaximal effort (30%) and focus on endurance (minimum 10 sec hold)

Cylinder Analogy

Pelvic Floor

Transverse Abdominus Multifidi

Diaphragm

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Diaphragm

• Origin: central tendon

• Insertion: anterior portion of L1-3 and along lower ribs

• Innervation: phrenic nerve (C3-5)

• Action: breathing and stabilizes L1-3

Diaphragm

Look for…

� Reversed diaphragmatic breathing

� Apically breathing at rest

� Poor lateral costal expansion (<3cm expansion)

� Expiration should be passive

� Expiration should last twice as long as inspiration

Diaphragm: Practical

Diaphragmatic (Belly) Breathing• One hand on upper chest and the other on belly, do not let upper

hand move when breathing in

• When breathe in the lower hand should move away (outwards) from body

• May be performed in any position

• Tactile stimulation:

• Squeezing on inspiration

• Compressing on expiration

• Lift belly to touch hand

Lateral Costal Expansion: Practical

• Overall should have 3-7.5 cm of excursion at level of xiphod process

• Place hands on lateral ribcage and think about breathing into hands

• May be performed in any position

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Lateral Costal Expansion: Practical

Rib Springing

• Compress on expiration

• Suddenly let go after 1 second of inspiration

Transverse Abdominus

� Origin: iliac crest, inguinal lig, ribs 6-12, thoracolumbar fascia

� Insertion: xiphoid process, linea alba, pubis

� Innervation: intercostal nerves T8-12, iliohypogastic and ilioinguinal nerve

� Action: horizontal fiber orientation causes a decrease in abdominal circumference compressing the abdomen

� “Natural brace or corset”

Transverse Abdominus & Diaphragm

Work together to maintain intra-abdominal pressure

Transverse

Abdominus

Diaphragm

Inspiration Decreased

tone

Increased

tone

Expiration Increased tone Decreased

tone

Transverse Abdominus

�Hodges PW, Richardson CA. Delayed postural contraction of transversusabdominis in low back pain associated with movement of the lower limbs. J Spinal Disorders. 1998;11:46-56.

�Hodges PW, Richardson CA. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine. 1996;21:2640-2650.

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Transverse Abdominus

Keys facts regarding normal transverse abdominus function…

1. Works independent from other muscles

2. Non-direction specific

3. Activates prior to movement

4. Increases intra-abdominal pressure

Transverse AbdominusPractical

Analogies…

• Compress ASISs together

• Bring portion of abdomen below belly button up and in

• Bring belly away from waist band of pants

• Movement you do to get top button done up when putting on a tight pair of jeans

• Abdominal hollowing

Remember…

• No activation of superficial abdominal muscles or lumbar movement allowed

• No bulging allowed 1-2 inches medial to ASIS

Transverse Abdominus Pelvic Floor

Coccygeus� Origin: ischial spine,

sacrospinous ligament

� Insertion: coccyx, sacrum

� Innervation: S3-4

� Action: counternutate sacrum, support viscera

Levator ani� Origin: ilium, pubis, obturator

fascia

� Insertion: coccyx, rectum and median fibrous raphe

� Innervation: levator ani nerve, inferior rectal nerve, and coccygeal plexus

� Action: support the viscera and pelvis

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Pelvic Floor

Key facts regarding normal pelvic floor function…

1. Works better in normal to increased lordosis

2. Works synergistically with transverse abdominus

Pelvic FloorPractical

Analogies…

� Stop midflow urination

� Lift testicles up (males)

� Think of pelvis as a ball and try to decrease the circumference or diameter of the ball

� Triangle analogy: compress anteriorly, relax posteriorly (anus)

� Kegel exercise (gentler)

� Elevator (grades of contraction, regain neuromuscular control)

Remember…

� No activation of superficial abdominal muscles or lumbar movement allowed

� No bulging allowed 1-2 inches medial to ASIS

� No glut contraction

� Is the sacrum counternutating?

Pelvic Floor Multifidi

• Origin: mamillary process (spinous

process) at each spinal level R and L

• Insertion: lamina and z-joint capsule

• Innervation: segmental nerve supply (med branch of primary dorsal ramus)

• Action: segmental spinal stiffness/compression

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Multifidi

Key Facts regarding normal multifidifunction….

1. Superficial fibres maintain lumbar lordosis and increases thoracolumbar fascia tension

2. Deep fibres control anterior and posterior shear and don’t change in length throughoutspinal motion

Superficial

Deep

Multifidi

�D'hooge R et al Increased intramuscular fatty infiltration without differences in lumbar muscle cross-sectional area during remission of unilateral recurrent low back pain. Man Ther 2012 Dec; 17(6): 584-8.

�Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine 1996; 21: 2763-2769.

�Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994; 19: 165-172.

Multifidi

What happens to multifidus once a patient has pain

1. Short term: decrease in cross sectional area at level and side of pain, within 24 hours

2. Long term: muscle does not come back automatically, get fatty infiltration instead of loss of cross sectional area

MultifidiPractical

Analogies…

� Fishing hook through belly button on a string, don’t let your skin rip if tension put on string

� Think of doing a slight anterior pelvic tilt or arch of back at desired level

� Gentle isometric hip extension

Remember…

� No erector spinae bulging allowed

� After some practice should be able to activate multifidi without any lumbar motion

� Palpate just lateral to spinous process for bulging of lumbar multifidi

� No bulging allowed 1-2 inches medial to ASIS

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MultifidiActive Straight Leg RaiseCorrect and Retest (Diane Lee)

• Add compression through pelvis and repeat ASLR

• Simulates improved force closure

• Helps you to know which inner unit muscle is the most important to rehab

ASLR: compress ASIS’Transverse Abdominus

ASLR: compress pubic symphysisPelvic Floor Muscles

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ASLR: compress PSIS’Multifidi

Outer Unit

Trunk Endurance

• McGill SM et al. Endurance times for low back stabilization exercises: clinical targets for testing and training from a normal database. Arch Phys Med Rehabil 1999; 80:941-944.

Extensor

� Beiring-Sorensen Test

� Prone with the lower body fixed to the test bed at the ankles, knees, and hips and the upper body extended in a cantilever fashion over the edge of the test bench. The test bench was approximately 25 cm above the surface of the floor. At the beginning of the exertion the upper limbs were held across the chest with the hands resting on the opposite shoulders, and the upper body was lifted off the floor until the upper torso was horizontal to the floor. Subjects were instructed to maintain the horizontal position as long as possible.

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Extensor

• Male: 146 seconds

• Female: 189 seconds

Flexor

• Sitting on the test bed at an angle of 60 degrees. Hips and knees are flexed to 90 degrees. The arms were folded across the chest with the hands placed on opposite shoulders and toes were placed under toe straps. Subjects were instructed to maintain the body position while the supporting wedge was pulled back 10 cm to begin the test. The test ended when the upper body fell below the 60 degree angle.

Flexor

• Male: 144 seconds

• Female: 149 seconds

Side Bridge

� Subjects laid on an exercise mat (2.5 cm thick) on their side with legs extended. The top foot was placed in front of the lower foot on the mat for support. Subjects were instructed to support themselves lifting their hips off the mat to maintain a straight line over their full body length and support themselves on one elbow and their feet. The uninvolved arm was held across the chest with hand placed on the opposite shoulder. The test ended when the hip returned to the exercise mat.

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Side Bridge

• Male: 94 seconds (R), 97 seconds (L)

• Female: 72 seconds (R), 77 seconds (L)

Trunk Endurance

• Arab AM et al. Sensitivity, specificity and predictive value of the clinical trunk muscle endurance tests in low back pain. Clinical Rehabilitation 2007; 21:640-647.

Prone Isometric Chest Raise

• Prone lying with a pad under the abdomen and the arms along the sides. The subject was instructed to lift upper trunk about 30 degrees from the table while flexing the neck and to hold the sternum off the floor as much as possible.

Prone Chest Raise

• Male: 40 seconds

• Female: 52 seconds

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Supine Isometric Chest Raise

� Lying supine on a treatment table with the hands crossed on his or her chest. The knees and hips were in 90 degree flexion. The subject was instructed to lift neck and upper trunk from the table and hold this position.

Supine Isometric Chest Raise

• Males: 43 seconds

• Females: 32 seconds

Prone Double Straight Leg Raise

• Prone with hips extended, the hands underneath the forehead and the arms perpendicular to the body. The subject was then instructed to raise both legs until knee clearance was achieved

Prone Double Straight Leg Raise

• Male: 38 seconds

• Female: 35 seconds

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Supine Double Straight Leg Raise

• Supine lying with hips extended and hands lying beside the trunk. The subject was then instructed to raise both legs from the floor about 20 degrees and hold this position.

Supine Double Straight Leg Raise

• Male: 28 seconds

• Female: 28 seconds

Front Plank

� Chase KA et al. Fitness Norms for the Plank Exercise. International Journal of Exercise Science: Conference Proceedings 2014; 8(2): 14.

� Durall CJ et al. A Comparison of Two Isometric Tests of Trunk Flexor Endurance. J Strength Cond Res 2012; 26(7): 1939-1944.

� Learman K et al. The effect of abdominal strength or endurance exercises on abdominal peak torque and performance field tests of healthy participants: A randomized control trial. Physical Therapy in Sport 2014; 1-8.

� Strand SL et al. Norms for an Isometric Muscle Endurance Test. Journal of Human Kinetics 2014; 40: 93-102.

Front Plank

• Male: 110-126 seconds

• Female: 72-96 seconds

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Treatment

External Oblique Release�Palpate for trigger points along insertion to ribs (must

push underneath ribcage)

�Apply direct pressure to trigger point, with finger tips, while other hand on opposite pelvis

�Wait until trigger point is releasing, then apply a stretch and hold for 30 seconds, then repeat as many times as necessary

External Oblique Release

• Lumbar rotation stretching

• Massage and trigger point release in stretch position

Internal Oblique & Quadradus Lumborum Release

• Massage and trigger point release in stretched position

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Erector Spinae Release

• Active Release

• Have patient flex, side bend and rotate away from the side being treated as you lock or glide the tissue

Points to Remember

� Check ability to activate core with all LBP

� Activation of core in neutral spine

� Diaphragm, TA, PFM, multifidi, psoas

� Slow, controlled, tonic/holding, independent of superficial musculature

� Add outer unit activation once can activate inner unit

� Clinical Prediction Rules for Stabilization

� Sacrum must stay nutated during functional movements

� Release of gripping

� Chest, back

Thank you

• For future courses visit www.leadtheway.ca/continuingeducation/ or email me at aaronjrutter@gmail.com

References

� D'hooge R et al Increased intramuscular fatty infiltration without differences in lumbar muscle cross-sectional area during remission of unilateral recurrent low back pain. Man Ther. 2012 Dec;17(6):584-8.

� Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine.1996;21:2763-2769.

� Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994;19:165-172.

� Hodges PW, Richardson CA. Delayed postural contraction of transversusabdominis in low back pain associated with movement of the lower limbs. J Spinal Disorders. 1998;11:46-56.

� Hodges PW, Richardson CA. Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversusabdominis. Spine. 1996;21:2640-2650.

� O'Sullivan P. Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy 2005;10(4): 242-55

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References

� Hungerford BA et al. Evaluation of the Ability of Physical Therapists to Palpate Intrapelvic Motion With the Stork Test on the Support Side. Physical Therapy 2007; 87(7): 879-887

� Mens J et al. Validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain after pregnancy. Spine. 2002;27:196–200.

� Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbo-pelvic muscle recruitment in the presence of sacroiliac joint pain. Spine. 2003;28:1593–1600.

� Ronchetti I et al. Physical characteristics of women with severe pelvic girdle pain after pregancy. Spine. 2008; 33(5): 145-151.

� Hicks et al. Preliminary clinical prediction rule for determining response to a lumbar stabilization program. JOPST 2004; 34(1): A8.