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Abstract
Low back pain and lumbar spinal stenosis (LSS) is an extensive problem in the elderly presenting with pain, disability, fall risk and depression. The incidence of LSS is projected to continue to grow as the population ages. In light of the risks, costs and lack of long-term results associated with surgery, and the positive outcomes in studies utilizing physical therapy interventions for the LSS patient, a non-invasive approach is recommended as a first line of intervention. This Masterclass presents an overview of LSS in terms of clinical examination, diagnosis, and intervention. A focused management approach to the patient with LSS is put forward that emphasizes a defined four-fold approach of patient education, manual physical therapy, mobility and strengthening exercises, and aerobic conditioning.

Abstract
Evidence based practice has been defined as “the explicit, conscientious and judicious attempt to find the best possible available research evidence to assist the health professionals to make the best decision for their individual clients.” (Sackett et al., 1996). In clinical manual therapy practice, this involves integrating research evidence with clinical experience and patient values.

Currently randomised controlled trials are considered the highest level of research design in terms of strength of the evidence provided, due to the methodological control of potential sources of bias. However, the mechanisms that ensure internal validity of an RCT, i.e. randomisation, and intervention standardisation, threaten the generalisibility, and therefore relevance of the evidence to manual therapy.

Manual therapy represents a complex intervention and therapists need to review the notion of ‘research evidence’, in the context of the clinical practice of manual therapy. Reviewing the construct of what constitutes an intervention, increasing post-hoc analysis of subject sub groupings and revisiting ‘lower levels’ of research design are all suggested as possible approaches.

Abstract
Low back pain and lumbar spinal stenosis (LSS) is an extensive problem in the elderly presenting with pain, disability, fall risk and depression. The incidence of LSS is projected to continue to grow as the population ages. In light of the risks, costs and lack of long-term results associated with surgery, and the positive outcomes in studies utilizing physical therapy interventions for the LSS patient, a non-invasive approach is recommended as a first line of intervention. This Masterclass presents an overview of LSS in terms of clinical examination, diagnosis, and intervention. A focused management approach to the patient with LSS is put forward that emphasizes a defined four-fold approach of patient education, manual physical therapy, mobility and strengthening exercises, and aerobic conditioning.

Abstract
Acetabular labral tears are an area of increasing interest to clinicians involved in the diagnosis of musculoskeletal complaints of the hip. This review systematically evaluated the evidence for the diagnostic accuracy and validity of reported symptoms, physical examination and imaging in this complex population. Studies published in English prior to May 2010 were included. One reviewer searched information sources to identify relevant articles. Two reviewers independently assessed studies for inclusion, extracted data and evaluated quality using the Quality Assessment of Diagnostic Studies Tool.

Twenty one studies were included. Meta-analysis was limited owing to heterogeneity between studies. Results showed Magnetic Resonance Arthrography to consistently outperform Magnetic Resonance Imaging. Computerised Tomography also showed high accuracy levels for the few studies identified. Studies investigating physical tests were of poor quality demonstrating a need for further research in this area. Symptoms likely to be present in patients presenting with acetabular labral tears were found to be anterior groin pain and mechanical hip symptoms; however, additional good quality studies are needed to consolidate findings.

Abstract
Sustained postural loading of the cervical spine during work or recreational tasks may contribute to the development of neck pain. The aim of this study was to compare neck muscle endurance and fatigue characteristics during sub-maximal isometric endurance tests in patients with postural neck pain, with asymptomatic subjects. Thirteen female patients with postural neck pain and 12 asymptomatic female control subjects completed timed sub-maximal muscle endurance tests for the neck flexor and extensor muscles. Muscle fatigue, defined as the time-dependent decrease in median frequency electromyography (EMG), was examined using surface EMG analysis during the tests. The median extensor test holding time was lower but not significantly different in the neck pain group (165 s) that the control group (228 s) (p = 0.17). There was no difference between groups in the flexor test holding time (neck pain = 36 s, controls = 38 s) (p = 0.96). The neck pain group was characterised by greater variability in neck flexor (p = 0.03) and extensor (p = 0.006) muscle endurance. For both tests, the rate of decrease in median frequency EMG was highly variable within and between groups with no significant difference between groups for the flexor or extensor test (p = 0.05–0.82). Patients with postural neck pain did not have significant impairment of neck muscle endurance or accelerated fatigue compared to control subjects. However, the greater variability in these indices of muscle function may reflect patient-specific changes in muscle function associated with neck pain disorder.

Abstract
Increased and early lumbopelvic motion during trunk and limb movements is thought to contribute to low back pain (LBP). Therefore, reducing lumbopelvic motion could be an important component of physical therapy treatment. Our purpose was to examine the effects of classification-specific physical therapy treatment (Specific) based on the Movement System Impairment (MSI) model and non-specific treatment (Non-Specific) on lumbopelvic movement patterns during hip rotation in people with chronic LBP. We hypothesized that following treatment people in the Specific group would display decreased lumbopelvic rotation and achieve more hip rotation before lumbopelvic rotation began. We hypothesized that people in the Non-Specific group would display no change in these variables. Kinematic data collected before and after treatment for hip lateral and medial rotation in prone were analyzed. The Specific group (N = 16) demonstrated significantly decreased lumbopelvic rotation and achieved greater hip rotation before the onset of lumbopelvic rotation after treatment with both hip lateral and medial rotation. The Non-Specific group (N = 16) demonstrated significantly increased lumbopelvic rotation and no change in hip rotation achieved before the onset of lumbopelvic rotation. People who received treatment specific to their MSI LBP classification displayed decreased and later lumbopelvic motion with hip rotation, whereas people who received generalized non-specific treatment did not

Abstract
The “Comprehensive ICF Core Set for Low Back Pain (LBP)” is an application of the International Classification of Functioning, Disability and Health (ICF) and represents the typical spectrum of problems in functioning for patients with LBP. The aim of this study was to validate the Comprehensive ICF Core Set for low back pain from the perspective of physical therapists.

Physical therapists experienced in LBP treatment were asked about the patients’ problems, patients’ resources and aspects of environment treated by physical therapists in a three-round survey using the Delphi technique. Responses were linked to the ICF.

Eighty-four physical therapists in 32 countries named 1955 concepts that covered all ICF components. Fourteen ICF categories were not represented in the Comprehensive ICF Core Set for LBP although at least 75% of the participants have rated them as important. Most of them belonged to the ICF component “Body Functions”. Twenty-eight concepts were linked to the not-yet-developed ICF component personal factors. Further, 21 issues were not covered by the ICF.

The validity of the ICF components “Body Structures”, “Activities and Participation” and “Environmental Factors” was largely supported by the physical therapists. However, several body functions were identified which are not covered and need further investigation.

Abstract
The purpose of this study was to investigate the changes in the thickness of the transversus abdominis (TrA) and internal oblique (IO) muscles in three sitting postures with different levels of stability. The technique of ultrasound imaging was used for individuals with and without chronic low back pain (LBP). A sample of 40 people participated in this study. Subjects were categorised into two groups: with LBP (N=20) and without LBP (N=20). Changes in the thickness of tested muscles were normalized under three different sitting postures to actual muscle thickness at rest in the supine lying position and were expressed as a percentage of thickness change. The percentage of thickness change in TrA and IO increased as the stability of the sitting position decreased in both groups. However, the percentages of thickness change in all positions were less in subjects with LBP. There was a significant difference in thickness change in TrA when sitting on a gym ball between subjects with and without LBP but no difference was found when sitting on a chair. There was no significant difference in thickness change in IO in all positions between the two groups.

Our findings indicate that difference in the percentage of thickness change in TrA between subjects with and without LBP increases as the stability of sitting position decreases.

Abstract
Purpose

Despite routine use, clinical tests used to diagnose subacromial impingement often display poor diagnostic accuracy. A lack of anatomical validity may contribute to the poor diagnostic accuracy. The current study aimed to examine the anatomical validity of measuring subacromial pressure in the Hawkins–Kennedy impingement test in a cadaveric shoulder.

Methods

Subacromial pressures were measured using pressure transducers in non-provocative and provocative Hawkins–Kennedy test positions using an ABA research design with 25 repeated measures in one cadaver. Data collected included pressure at four subacromial locations (coracoid process, coraco-acromial ligament, anterior acromion and posterior acromion), and observation of anatomical structures impinging on transducers. The split-middle method of visual analysis and the Reliable Change Index (RCI) were applied to examine any differences between provocative and non-provocative positions.

Results

There was increased pressure in the provocative position at the coraco-acromial ligament, which impinged biceps brachii, and at the anterior acromion, which impinged the rotator interval.

Conclusion

Findings of the current study provide evidence that suggest that structures other than the rotator cuff tendons may be impinged during the Hawkins–Kennedy test.

Abstract
Introduction

Previous research of transversus abdominis (TrA) and multifidus muscle function in the presence of chronic low back pain (LBP) has investigated these muscles in isolation. In clinical practice, it is assumed that a relationship exists between these muscles and so they are often assessed and rehabilitated together. However, no studies have tested or documented this association. This study aimed to examine the relationships between clinical muscle testing and other measures taken in the course of a clinical assessment at a back clinic.

Methods

This retrospective chart audit examined the files of 82 patients (40 Males, 42 Females) for results of clinical tests of TrA and multifidus muscle contraction, multifidus muscle size measurements and other clinical measures such as distribution of pain and pain on manual examination.

Results

The ability to contract multifidus was related to the ability to contract TrA with the odds of a good contraction of multifidus being 4.5 times higher for patients who had a good contraction of TrA. A poor ability to contract multifidus was related to poor TrA contraction. Patients with unilateral LBP had more multifidus muscle asymmetry (11.6%) than those with bilateral/central pain (0.01%) and had a poor multifidus contraction on the affected side (p < 0.01). No other significant relationships were found.

Discussion & conclusion

Current clinical practice of assessment and rehabilitation of both TrA and multifidus muscles in patients with chronic LBP is supported by the findings of this study. Future studies may investigate if a neurophysiological relationship exists between these muscles.