Delivered at the 2012 TPTA Annual Conference in San Antonio, TX.

1. Hipsters Unite!
Examining the hip’s influence for patients with back pain.
Eric K. Robertson, PT, DPT, OCS, FAAOMPT
Assistant Professor
Texas State University

2. Hipster Defined
 What is a hipster?
You‘d be surprised. It could very well be YOU.
A hipster is an individual—one that usually fits within a
certain subculture. Which subculture? It doesn‘t
matter. Because the definition for hipster is so very
vague
 In its most simplest terms, a hipster is an individual
who wants to know things.
Source: quotes from a Hipster named Adam
 (http://travelsofadam.com/what-is-a-hipster/)

5. Fact #52
―If you were to lay every hipster in the world
end to end, we don‘t know the length of the
line they would form, but there would be an
Apple store at the end of the line.‖

6. Austin: Epic Hipster Population
*Ranked #2 behind Seattle, WA for hipsterism by designtrends.com

8. Actual Austin Hipsters
A confirmation that a) hipsters do exist in a nearby geographic
locale, and that b) sometimes they gather, and that c)
whatever, I‘m going to just write what I want in the true spirit of
hipsterism.

9. Actually What This Talk is REALLY About:
An examination into the age-old concept that a) yes, the hip bone is
connected to the back bone, that b) when one hurts, the other most
often suffers, and that c) by paying attention to trends in movement
patterns we can flesh out how to direct treatments at the hip that may
assist us in treating patients with low back pain.

10. Actually What This Talk is REALLY About:
An examination into the age-old concept that a) yes, the hip bone is
connected to the back bone, that b) when one hurts, the other most
often suffers, and that c) by paying attention to trends in movement
patterns we can flesh out how to direct treatments at the hip that may
assist us in treating patients with low back pain.

11. Butt First…

12. Oh, the Aching Backs!
Low Back Pain: Eric K. Robertson, PT, DPT, OCS
A Current State of Affairs

13. Relative Healthcare Costs
Cost in Billions
350
Cardiovascular
300 Disease
250
200
Cancer Diabetes LBP All Arthritis
150
100
50
0

14. Relative Healthcare Costs
Cost in Billions
800
700
CHRONIC PAIN!
600
500
Cardiovascular
400 Disease
300
200
100
0

15. Which of the following are predictors of LBP?
• Bulging disc without
herniation or root • History of depression
contact • History of
• Bulging disc without occupational-related
herniation but with LBP
nerve root contact • Fearful beliefs about
• Herniated/Prolapsed work as reported in a
discs survey
• End plate changes /
Shmorl‘s nodes
• Foraminal or canal Psychosocial
stenosis findings
Physical findings
/ Imaging

16. How did you do?
 Physically:
 Only disc contact with nerve root has been shown
to be a WEAK predictor of LBP
 Psychosocial:
 Depression, occupational injuries, and fear-
avoidance are all STRONG predictors of LBP
Implications in terms of pain?

17. Summary of LBP Predictors ?
Physical Psychosocial

18. The Hip – Spine Relationship
It‘s hip to have a high yield!

19. The Hip Bone‘s Connected to the…
 Hip – Spine Syndrome (Offierski and MacNab, 1983)
 Proposed a formal relationship between hip and spine pain
 Three subgroups
 Simple – Primary Dysfunction of one area, but symptoms in
another
 Complex – Dysfunction in both hip and spine
 Secondary – Hip and Spine pain are dependent and inter-related
 This tight hip flexors and increased lumbar lordosis, as example

21. Offierski and MacNab, 1983

22. Hip – Spine Syndrome
 Though frequently cited, few have expanded upon the work of
Offierski and MacNab.
 Ben-Galim et al., 2007 – Effects of THA on LBP
 25 individuals with severe hip OA, received THA
 No radiographic spine changes, but baseline LBP was 5.8 on VAS
 Subjects had PT for ambulation, hip motion, but not for lumbar spine

23. Ben-Galim et al., 2007
Pain - LBP Disability - LBP
6 40
5
30
4
3 20
2
10
1
0 0
VAS ODI

24. More recently…
10 Saito et al, Spine, May 2012
Case series:
4 patients with leg
pain and confirmed
spinal stenosis and Hip
OA.
1
Fusion Helped by THA Helped by
Fusion TKA
―I‘m sorry we fused your spine…‖
―Conclusions. It is difficult to determine the origin of lower
leg pain by spinal nerve block and hip joint block in
patients with lumbar spinal stenosis and hip osteoarthritis.
We take this into consideration before surgery.‖

25. So let‘s think about this connection…
How can we evolve as hipsters?

31. Lumbo-Pelvic
Arthrokinematics
What is normal lumbopelvic rhythm and how
does this impact the hip-spine relationship?

33. Normal Lumbopelvic Rhythm
 Lumbar spine and hips contribute to flexion in equal
magnitudes.
 Early flexion from the lumbar spine
 Later flexion from the hip contribution
 Extension is the reverse, with muscle activation
occurring from a caudad to cephalad direction
 Twisting motions are primarily from hip contribution
Lee & Wang

34. How about with LBP?
 We move slower, and with less magnitude.
 Hip:Spine Ratio (Shum et al, 4 studies)
 Normal ratio: 0.50
 LBP: 0.38-0.40 (reduced lumbar spine contribution)
 Perhaps even less lumbar motion in those with +SLR
 Peak angular velocity also reduced for individuals with LBP

35. Shum et al. Contribution
 Examined patients with and without LBP
 Looked at:
 Simple sit-stand
 Sock donning
 Twisting
 Picking up and object from a seated position
 Altered movement strategies may be a strategy to protect
injured lumbar tissues
 These changes are larger in those with neural tension signs

36. Lumbopelvic Motion
 Many authors agree that more lumbar motion, earlier in the
range, especially with rotation is apparent in patients with low
back pain. (Burnett et al., 2004; Esola et al., 1996; Luomajoki et al., 2008;
McClure et al., 1997; Roussel et al., 2009)
 Inconclusive overall.
 Heterogeneous populations?
 Can sub-grouping help us?

37. Low Back Pain Classification
 Systems:
 McKenzie-based
 Treatment-based classification
 Movement System Impairment
 Commonalities?
 Movement
 Symptoms reproduced matters
 Hip motion matters

38. Low Back Pain Classification
 Systems:
 McKenzie-based
 Treatment-based classification
 Movement System Impairment
 Commonalities?
 Movement
 Symptoms reproduced matters
 Hip motion matters

39. Treatment-based Classification
 Hip Influence:
 Spinal Manipulation and Exercise Group
 CPR:
 < 16 days
 No pain beyond knee
 Hypomobile lumbar spine accessory motion
 Low Fear-Avoidance Beliefs
 Hip Motion (>35 degrees)
 Also, we see something interesting in the Stability subgroup…
 Important factors: Age, recurrent pain, SLR ROM, etc

40. Arthrokinematics of a Subgroup
 Teyhen et al, 2007 in PTJ
 Examined subgroup
indentified to have suspected
spinal instability per CPR
 Fluroscopic computer analysis
 Found segmental HYPO-mobility in
this subgroup!

41. Hip Hypomobility with LBP
 Tafazzoli and Lamontagne, 1996
 With LBP:
 Increased passive elastic moment on the hamstrings
 Increased hip stiffness to oscillatory motions
 A rationale to treat the hips for patients presenting with primary
LBP

42. More Hip Trouble from LBP
 Reduced Hip Flexion in patients with LBP
 Wong and Lee, 2004
 3-dimensional analysis of functional motion in patients with LBP
 Increased ER compared to IR in patients with LBP
 Cibulka et al, 1998
 Examined over 100 patients with LBP

43. Low Back Pain Classification
 Systems:
 McKenzie-based
 Treatment-based classification
 Movement System Impairment
 Commonalities?
 Movement
 Symptoms reproduced matters
 Hip motion matters

44. Movement System Impairment System
 People with LBP demonstrate earlier and greater lumbopelvic
rotation during hip lateral rotation compared to people
without LBP
 5 groups (based on history, symptoms with movement and alignment)
 lumbar extension rotation syndrome
 lumbar extension syndrome
 lumbar flexion rotation syndrome
 lumbar flexion syndrome
 lumbar rotation syndrome
 Important exam items related to the hip:
 Hip Ext, Rot ROM, Hip abduction with lateral rotation in hook-
lying, relative hip flexibility, hip motion in supine
Van Dillen, Sahrmann, et al. 2003

45. Hip Musculature
and LBP
If we‘re moving differently, we‘re using our
muscles differently, right?

46. Neuromuscular control of walking
with chronic low-back pain
 Vogt et al., 2003, Manual Therapy
 17 male subjects, hip ROM, surface EMG during gait
 Subjects with moderate low back pain had:
 Decreased hip motion and stride time
 Decreased hip extensor and lumbar spine extensor muscle activity
 Persistent firing of the above noted muscle groups compared to
controls
 Leinonen et al., 2000 – observed similar decreased
gluteus maximus activation in patients with LBP

47. Lumbopelvic Stabilization
 Hungerford et
al., 2003, Spine.
 EMG analysis of 14 individuals
with SIJ pain compared to
age-matched controls
 Reduced activation of
 Internal oblique
 Multifidus
 Gluteus maximus

48. Where We Stand As Hipsters
 Diagnostic Dilemma
 Patterns of Known Impairments of the hip in patients with low
back pain
 Presence of hip-based factors in classification systems for
clinicians to use when treating patients with low back pain.
 Practically Speaking: Education about the role of the hip in low
back pain is something that people tend to teach in weekend
courses and at conferences like this. It‘s not something much
research has supported.

49. Evidence for
Interventions
What guidance do we have concerning the
hip-spine connection?
Image by mpascoe via Flickr

50. Regional Interdependence Defined
 ―Seemingly unrelated impairments in a remote anatomical
region may contribute to, or be associated with, the patient‘s
primary complaint.‖
Wainner, Whitman, Cleland & Flynn. Regional Interdependence: A Musculoskeletal
Examination Model Whose Time Has Come. JOSPT, 2007, (37)11.

51. Spine & Extremity Regions
 Typical referred & radiating pain patterns
 Impairments - often seemingly unrelated

52. Is this actually happening in clinical practice?

53. Examples in the Literature:
Intervention Studies
Primary LBP
• Cibulka, JOSPT, 1999 Primary Knee Pain
• Boyle & Demske, Physiotherapy  Deyle et al, Ann Int Med, ‗00
Theory & Practice, ‗09  Deyle et al, PT, ‘05
• Whitman et al, PM&R Clinics of  Cliborne et al, JOSPT ‘04
North America 2003  Currier et al, Phys Ther, ‘07
• Whitman et al, Spine 2006  Lowry et al, JOSPT, ‘08
 Iverson et al, Phys Ther, ‘08
 Mascal et al, JOSPT, ‘03
 Cibulka & Threlkeld-
Watkins, JOSPT, ‘05
Primary Hip Pain  Vaughn, JOSPT, ‗08
• Cibulka &
Delitto, JOSPT, 1993
Primary Foot Pain
• Konczak & Ames, JMPT, 2004
• Cleland et al, JOSPT, 2009
• Wisdo, JMPT, 2004

54. Treat the Lower
Quarter for
Primary Low Back Pain
Classic Examples in the Literature

55. Lower Quarter Treatment for Primary LBP
Low Back Pain
• Cibulka, JOSPT, ’99
• Boyle & Demske, Physiotherapy Theory &
Practice, ‗09
Lumbar Spinal Stenosis
• Whitman et al, Spine. ‘06
• Whitman et al, PM&R Clinics of North
America, ‘03

56. Differential Dx for Hip vs. Spine Disease
Brown, et al. Clin Orthop. Feb 2004:280-284
 97 pts with LE pain referred to spine specialty clinic
 Age - mean 67.5 ± 11.6 years
 History, physical exam, & diagnostic testing completed
 Imaging studies gold standard for diagnosis
 Findings:
 19% - spinal disorders only
 36% - hip & spine in conjunction
 45% - hip only disorders
 81% - had some hip involvement present
 Limitations
 Diagnostic & test review with spectrum bias

57. • Limp, groin pain, limited IR at hip
– More likely to be present in a patient with a hip disorder
• Positive femoral stretch test
– More likely to have a spine disorder

58. Hamstring Muscle Strain Treated by
Mobilizing the Sacroiliac Joint
 Cibulka et al, Phys Ther, 1986

59. Hamstring Muscle Strain Treated by
Mobilizing the Sacroiliac Joint
 20 patients with a HS  Dependent Measures
strain  Hamstring flexibility
 Hamstring muscle torque
 Quadriceps muscle torque
 Control- MH and
stretching
 Experimental-
MH, stretching and SI
manip
 Significant difference in hamstring torque for
experimental group.

61. N = 60 patients with LSS
Outcomes:
• GRC, Disability (OSW)
• Baseline, 6-weeks, 1-year, long-term (mean 27-29 mo)
Interventions:
• All subjects: 2x/wk for 6 wks in-clinic, walk at home 3x/week
Flexion Exercise & Manual PT, Exercise, and
Walking Group (FExWG) Walking Group
(MPTExWG)
• Sub-therapeutic US, SKC/DKC, •BWS TM walking & SKC/DKC
TM walking program
• Manual physical therapy -
Impairment-Based,
Comprehensive Lower Quarter

62. Regions Treated
100
Patients receiving treatment (%)
90
80
70
60
50
40
30
20
10
0
Thoracic Lumbo-Pelvic Hip Knee Ankle/Foot

63. Interventions Utilized: Lower Extremities
100
90
80
70
Percentage
60
50
40
30
20
10
0
Hip Knee Ankle/Foot
Manipulation Mobilization Stretch Muscle Energy

64. Hip Mobilizations
Long-Axis Distraction Supine P-A
Currier et al, JOSPT, 2008
MacDonald, JOSPT, 2006

65. Hip Mobilizations
Prone A-P in FABER Position Prone A-P in FABER Position
Currier et al, JOSPT, 2008
MacDonald, JOSPT, 2006

66. Related Regional
Interdependence Facts

67. Other RI Facts:
Hip-Spine Syndrome / Relationships
Hip ROM & LBP/SIJ
Ellison et al, Phys Ther, ‘90; Chesworth et al, Physiother Canada, ‘94;
Cibulka et al, Spine, ‘98; Sjolie , Scand J Med Sci, sports, ‘04;
Vad et al, Am J Sports Med, ‘04; Coplan, JOSPT, ‘02; Mellin, Spine, ‘88
Porter & Wilkinson; Spine ‘97; Mellin. Spine ‘88
Hip Region Muscle Performance & LBP
Nadler et al, Clin J Sport Med, ‘00; Nadler et al, Am J Phys Med Rehabil, ‘01;
Nadler et al, Med Sci Sports Exerc, ‘02; Kandaanpaa et al, Arch Phys Med Rehabil, ‘98;
Nourbakhsh & Arab, JOSPT, ‗02
Hip Region Muscle Performance & LBP
Offierski & McNab, Spine ‘83; Ben-Galim et al, Spine, ‘07; Murata et al, Clin Orthop Surg, ‘02;
Nakamura et al, Acta Orthop Scand, ‘03; Yoshimoto et al, Spine, ‘05; Takemitsu et al, Spine, ‘88;
Sato et al, J Musculoskelet Syst, ‘89; Itoi, Spine, ‘91; Watanabe et al, Orthopedics, ‗02
Reiman, Weisbach, and Glynn. The Hip’s Influence on Low Back Pain: A Distal Link to a Proximal
Problem. Journal of Sport Rehab, ‘09

68. Other RI Facts
 Associations between:
 Hip ROM & response to spinal manipulation
Flynn et al. Spine ’02.Childs et al, Ann Int Med ’04
 Hip Abd, ER, and Ext Weakness and PFPS
Robinson, JOSPT, ‘07; Ireland, JOSPT, ‗03
 SIJ manipulation and quadriceps facilitation
 Suter et al. JMPT ‘00
 SIJ manipulation and HS peak torque changes (pts with HS strain)
 Cibulka et al, Phys Ther, ‗85
 LSS source of pain identified after THA
 Bohl et al, Spine, ‘79, Saito et el, Spine 2012
 Concomitant spine and hip disease extremely common
 Brown et al, CORR, ‘04

69. Primary Hip Interventions for Patients
with Low Back Pain and Hip Impairments:
A Prospective Case Series (Preliminary Results)
Eric K. Robertson1, Cheryl Sparks2, Derek Clewley3
1Faculty,Department of Physical Therapy, Texas State University, San Marcos, TX, USA, 2Faculty, Department of
Physical Therapy, Bradley University, Peoria, IL, USA, 3Benchmark Physical Therapy, Atlanta, GA, USA
*Acknowledgement: Dr. Julie M. Whitman for her review of the study design and report.
Research performed as part of the Evidence in Motion Fellowship Program

70. Although many clinicians who
are perceived as experts often
describe examination and
interventions at the hip for
patients with low back
pain, very little evidence
describing this exists.
Lack of Research

71. Management of a Female with Chronic
Sciatica and LBP: A Case Report
 History
 6 weeks of lumbar stabilization and flexibility intervention did not
eliminate symptoms
 Intervention
 Treatment plan revised to include impairment-based left hip
capsule flexibility
 Also included hip strengthening to glut med
 Outcome
 Complete resolution of pain, disability (0 NPRS, 0% on ODI (reduced
from 41% at baseline))
Boyle and Demske, 2009 Physiotherapy Theory and Practice

72. Management of a Female with Chronic Sciatica and LBP:
A Case Report
• History 60
• 6-weeks of lumbar
stabilization and flexibility 50
intervention did not
eliminate symptoms 40
• Intervention 30 41%
Reduction.
• Treatment plan revised to
20
include impairment-based
left hip capsule flexibility
10
• Also included hip
Spine Interventions
strengthening to glut med
0
Hip Interventions
NPRS ODI
Boyle and Demske, 2009 Physiotherapy Theory and Practice

73. Purpose
The purpose of this prospective case series was two-fold.
1. Describe the clinical decision making process involved in the
management of patients with primary complaints of low back
and hip pain.
2. Provide an evidence-based rationale for directing treatment at
the hip in a sub-group of patients with low back pain.

74. Number of Subjects
Six subjects referred to physical therapy with low back pain who
also demonstrated impairments at the hip were recruited to
participate. (Note: Data collection is still in progress, currently
have 11 enrolled.)

75. About the Subjects
Inclusion Criteria:
• 1. Adults referred to PT with a primary complaint of low back pain (LBP)
• 2. Positive hip impairments as identified in the patient’s initial physical
examination*
Definition of positive hip impairment:
• Positive special tests, decreased ROM, decreased muscle
strength, reversed lumbo-pelvic rhythm, decreased mobility or pain with
accessory motions, or findings consistent with the clinical presentation
of hip osteoarthritis per the criteria established by Altman et al.

76. About the Subjects
Exclusion Criteria:
• Any medical red flags
• Spinal or femoral fractures, except for degenerative spondylolisthesis or
spondylolisis
• Upper motor neural compromise
• Pregnancy
• Lower motor neuron changes suggestive of nerve root irritation and/or
compression (positive straight leg raise at <45º or diminished lower extremity
strength, sensation, or reflexes
• High fear-avoidance beliefs (>35 on the Fear Avoidance Belief Questionnaire
Work [FABQW] subscale)
• Previous history of spine or hip surgery
• Inability to read and understand English

77. Methods
• Primary outcomes: • Secondary outcomes:
• Oswestry Disability • Global Rating of Change
Index, (ODI) (GROC)
• Harris Hip Score (HHS) • Assessment of hip impairments.
• Numerical Pain Rating Scale
(NPRS)
Initial Examination
Week 4
Visit #2 (2-3 days after Initial Examination)
Institutional Review Board approval was obtained from Bradley University for this study.

78. Important Exam Items
Hip Examination
ROM, all planes
• +/- Hip Impairment Special Tests: Scour, FABER, other
• Positive special tests, decreased Flexibility: Hip flexor, extensor length
ROM, decreased muscle Strength: All planes
strength, reversed lumbo-pelvic
rhythm, decreased mobility or pain
with accessory motions, or findings Lumbar Spine Examination
consistent with the clinical
presentation of hip osteoarthritis per ROM Screen
the criteria established by Altman et al. Accessory Mobility
Core musculature assessment
Special Tests: SLR, PIT, etc

79. Hip Examination Item Results
Hip ROM Impairments 6/6
Hip Weakness 4/6
+ Hip Special Test 5/6
Median age was 50 years (range, 27-61 years)
Examination Results

80. Interventions
Day 1: Examination and Initial Treatment
If hip impairment was noted, then treatment progressed in the following manner:
• Manual Interventions focused on hip. (thrust/non-thrust)
• Hip-specific therapeutic exercise
• Reinforcing Home Exercise Program
• Re-assess Day 2.

81. Interventions
Exercises provided to focus on
• gluteus maximus,
• hip abduction and external rotation
• core stabilization progression.
Neuromuscular re-education:
• Movement re-education
consisting of patient
instruction, practice if
abnormalities noted, i.e. sit to
stand
• Squatting and proper lifting
mechanics
• Proprioceptive core stability
exercises

82. Interventions
Day 2 – Week 4 Treatment
• Treat per impairment-based approach or a pragmatic application
of the Treatment-based classification approach.
• HEP and TherEx continued to stress hip-focused interventions

83. Results
Results: At 4 weeks, the average improvement in ODI scores was 39%, and
24% for the HHS. 66% of the patients experienced a significant decrease in the
NPRS. 100% of patients for which data was collected experienced at least a
change of 4 on the GROC (4-7), indicating at least moderate improvement.
Avg. visits = 7.3 (3-10).
Numeric Pain Rating
Global Rating of Change*
Scale*
5.3 2.8
Median 5.25, (range, 4-7) Median 3, (range, 0-5)
“Quite a bit better” MCID: 1.8
*Note: Data on GROC collected for 4/6 patients.

84. ODI Avg. Change
Day 2 4
Week 4 20
Oswestry Disability Index
90
80
70
60
50 Baseline
40 Day 2
Week 4
30
20
10
0
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

85. HHS Avg. % Change
Day 2 18
Week 4 24
Harris Hip Score
100
90
80
70
60
Baseline
50
Day 2
40
Week 4
30
20
10
0
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

86. • Small Case Series = No Cause and Effect
• Not consecutive subjects
• Control over interventions limited, especially the
neuromuscular reeducation to the core
Limitations

87. Short-term response of hip mobilizations and
exercise in individuals with chronic low back
pain: a case series
• Subjects:
• 8 Subjects with CLBP, Avg age 49, with ROM impairments
• Intervention
• Impairment-based manual therapy to Bilateral Hips
• 3 Sessions over 1 week
• Outcome
• 5/8 (65%) reports >4 “Moderately Better” on the GROC
• 24% reduction in ODI scores
“This case series suggests that an impairment-based approach directed at the hip joints may lead to
improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a
plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to
determine the potential effectiveness of this approach with patients with CLBP.”
Burns, Mintken, Austin, Cleland. 2010 JMMT

88. Conclusions
• Significant improvements were observed in all primary outcome measures
at 4 weeks.
• Secondary outcome measures trended towards significant improvements.
• This case series provides preliminary evidence that some patients with low
back pain may receive a benefit from interventions directed at the hip.
• Future studies should work to determine the factors that can predict patients
that may realize this benefit.

89. HOW TO GET HIP
Yes, you can be a hipster too!

90. Posterior Pelvic Tilts
Williams Flexion Exercises
Hot Packs
Massage
Ultrasound
That‘s so yesterday!
Once we acknowledge the role of the LE in
back pain, it frees us from the constraints of
patients with low back pain. It allows us to
become creative and challenge our patients in
new ways.

91. ADVANCE EXERCISE CONCEPTS
FOR THE …HIP? LOW BACK?
DPTMWG

92. DPTMWG

93. • Progression of:
• Limb support
• Surface
• Visual input
• Perturbations
• Task demands
Proprioceptive/Balance
Training
DPTMWG

94. Testing For Strength
In CKC Positions
• Sit to Stand
• Squat
• Leg Press
• Lunge

95. • Used most often with older individuals
• Performance is based on given period of
time (10-30 seconds) and reps recorded or
given reps and time recorded in seconds
• Sit to stand performance has direct
correlation to knee extension force and leg
press force.
Sit To Stand Test
Jones et al
DPTMWG

96. Sit to stand Test
DPTMWG

97. • Sit to Stand Test (Csuka et al, Am J Med 1985)
• Regression equation for predicting normal performance for
10 stand ups. Results are in seconds.
• Women: 7.6 + .17 x age
• Men: 4.9 +.19 x age
Sit to Stand Test
DPTMWG

98. • Utilized to compare
uninvolved to involved
and also to compare to
norms
• Associated with
thigh, hip and buttock
strength
• Takes balance and core
factors out of strength
assessment.
• Greater than 90% of
contra-lateral
considered acceptable
Leg Press Test for Strength
DPTMWG

99. Plisky et al. N Am J Sports Phys Ther. 2009 May; 4(2): 92–99.
DPTMWG

100. • Significant differences associated with chronic ankle
instability and ACL insufficiency
• Can be predictive of LE injury
• What about LBP?!
Population Reach Distance Implication P value
All Players R:L Difference of 2.5x more likely to p<.05
>4 cm sustain LE injury
Females <94% of LE 6x more likely to p<.05
length sustain LE injury
Y Balance Test Utility
DPTMWG

101. Mascal et al. Management of patellofemoral pain targeting hip, pelvis,
and trunk muscle function: 2 case reports. JOSPT 2003
N=2
20, 37 y/o females

102. Mascal et al. Management of patellofemoral pain targeting hip, pelvis,
and trunk muscle function: 2 case reports. JOSPT 2003
• 14 week treatment period focused on recruitment and endurance
training of the hip, pelvis and trunk (including TrA)
• Patients attended PT 1-2 times per week
• Hip muscles (particularly glut max, med and external rotators)
were progressively strengthened, starting in NWB followed by WB
functional tasks

103. Hip Abductors and ERs
• Mini-squats, step-ups/downs and leg presses for
concentric/eccentric control, BAPS board/lunges for
proprioceptive training
Core muscle training
Restore Neuromuscular Control

104. It‘s Hip to have a high yield!

105. Before I leave you…

106. Relative Healthcare Costs
Cost in Billions
800
700
CHRONIC PAIN!
600
500
Cardiovascular
400 Disease
300
200
100
0

107. Pain…
 It might not be as much of a
physical thing as we think!
 We need to consider the
cognitive components!

108. L E V E L
P A I N
Injury!
Adapted from Butler & Mosely, 2008, ―Explain Pain‖
H E A L I N G R E S P ON SE

109. ―Nociception is neither sufficient
for, or necessary to experience pain.‖
Adapted from Butler & Mosely, 2008, ―Explain Pain‖

110. Identifying Patients at Risk for
Chronic Pain
George & Zepperi, JOSPT, July- 2009
 Fear-avoidance model of musculoskeletal pain
(FAM) (Measured by FABQ)
 Factors influencing pain perception
 Anxiety
 Fear of re-injury
 Catastrophizing
Confrontation Avoidance
Anxiety Anxiety
Fear of re-injury Fear of re-injury
Catastrophizing Catastrophizing

111. FDAQ – A Measurement
George & Zepperi, JOSPT, July- 2009
George et al., PTJ, July- 2009

112. Establishing a Baseline
Therapist: ‗How long can you walk before you flare-up?‘
Patient: ‗I can walk for 30 min but I pay for it the next day‘
Therapist: ‗Can you walk for 20 min without flaring up?‘
Patient: ‗No, but I have‘
Therapist: ‗Can you walk for 10 min without flaring up?‘
Patient: ‗Probably not — definitely not up hills‘
Therapist: ‗5 min on a flat surface?‘
Patient: ‗Probably‘
Therapist: ‗3 min on a flat surface?‘
Patient: ‗Definitely‘

113. Continuous Progression
 ‗Every day you do more than you did
yesterday, but not much more‘ …at least initially.
 Setting clear measurable goals and objectives!

114. KEY POINTS
 Pain is not nociception
 The representation of the body in the human brain
 The brain changes as the pain persists
 Body-brain is a 2 way street
 Training the brain for people in Pain
 This is VERY Hip.

115. References:
• Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Orthopaedic Physical Therapy
Clinics of North America, 9:103-118, 2000
• Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance
deficits in individuals with functional ankle instability. The Journal of orthopaedic and sports physical therapy.
2009;39(11):799-806.
• Kong DH, Yang SJ, Ha JK, et al. Validation of functional performance tests after anterior cruciate ligament reconstruction. Knee
surgery & related research. 2012;24(1):40-5.
• Munro AG, Herrington LC. Between-session reliability of the star excursion balance test. Physical therapy in sport :
2010;11(4):128-32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21055706. Accessed July 25, 2012.
• Narducci E, Waltz A, Gorski K, Leppla L, Donaldson M. The clinical utility of functional performance tests within one-year
post-acl reconstruction: a systematic review. International journal of sports physical therapy. 2011;6(4):333-42. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3230161&tool=pmcentrez&rendertype=abstract.
• Pigozzi F, Giombini A, Macaluso A. Do current methods of strength testing for the return to sport after injuries really address
functional performance? American journal of physical medicine & rehabilitation. 2012;91(5):458-60. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/22415342. Accessed July 25, 2012.
• Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure
during rehabilitation after anterior cruciate ligament reconstruction. Physical therapy. 2007;87(3):337-49
• Plisky P. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of
Orthopaedic and Sports Physical Therapy. 2006;36(12):911-919.
• Hertel J, Braham RA, Hale SA, Olmsted-kramer LC. Simplifying the Star Excursion Balance Test Chronic Ankle Instability.
:
Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12).
• Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict
anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine.
2005;33(4):492-501.
• Myer GD, Ford KR, Hewett TE. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today.
2009;13(5):39-44.
DPTMWG

116. References:
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117. References:
• Davies, GJ, Zillmer, DA. Functional Progression of a Patient Through a Rehabilitation Program. Orthopaedic Physical Therapy
Clinics of North America, 9:103-118, 2000
• Caffrey E, Docherty CL, Schrader J, Klossner J. The ability of 4 single-limb hopping tests to detect functional performance
deficits in individuals with functional ankle instability. The Journal of orthopaedic and sports physical therapy.
2009;39(11):799-806.
• Kong DH, Yang SJ, Ha JK, et al. Validation of functional performance tests after anterior cruciate ligament reconstruction. Knee
surgery & related research. 2012;24(1):40-5.
• Munro AG, Herrington LC. Between-session reliability of the star excursion balance test. Physical therapy in sport :
2010;11(4):128-32. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21055706. Accessed July 25, 2012.
• Narducci E, Waltz A, Gorski K, Leppla L, Donaldson M. The clinical utility of functional performance tests within one-year
post-acl reconstruction: a systematic review. International journal of sports physical therapy. 2011;6(4):333-42. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3230161&tool=pmcentrez&rendertype=abstract.
• Pigozzi F, Giombini A, Macaluso A. Do current methods of strength testing for the return to sport after injuries really address
functional performance? American journal of physical medicine & rehabilitation. 2012;91(5):458-60. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/22415342. Accessed July 25, 2012.
• Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure
during rehabilitation after anterior cruciate ligament reconstruction. Physical therapy. 2007;87(3):337-49
• Plisky P. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of
Orthopaedic and Sports Physical Therapy. 2006;36(12):911-919.
• Hertel J, Braham RA, Hale SA, Olmsted-kramer LC. Simplifying the Star Excursion Balance Test Chronic Ankle Instability.
:
Journal of Orthopaedic and Sports Physical Therapy. 2006;36(12).
• Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict
anterior cruciate ligament injury risk in female athletes: a prospective study. The American journal of sports medicine.
2005;33(4):492-501.
• Myer GD, Ford KR, Hewett TE. Tuck Jump Assessment for Reducing Anterior Cruciate Ligament Injury Risk. Athl Ther Today.
2009;13(5):39-44.
DPTMWG