CPR for Lumbar Stabilisation

Original Editor - Timothy Richardson

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Purpose

Hicks’ lumbar stabilization rule contains two groups: a “Success” group and an “Improvement” group. The two groups are different in the magnitude of the change in their outcome score and in the variables used to predict group assignment.

The Success group changed by better than 50% on the Oswestry Disablement Scale (ODI). The Improvement group changed from 6% to 49% on the ODI. Any change less than 6% was considered a treatment failure and alternative treatments were suggested.

Clinical Prediction Rule Components

Use this template to test your patient for inclusion in the Success stabilization group.

Yes	No	Success Rule predictor variables
		Age less than 40 years old
		SLR greater than 91 degrees
		Aberrant motion present
		Positive prone instability test

Use this template to test your patient for inclusion in the Improvement stabilization group.

Yes	No	Improvement Rule predictor variables
		FABQ physical activity scale greater than 9 points
		Aberrant movements absent
		No lumbar hypermobility with prone spring testing
		Negative prone instability test

Decision Rule

The decision rules can be considered separately.

Success Rule

Number of variables present	Likelihood ratio	Probability shift	Group assignment
>1	1.3	No shift	Group assignment unlikely
> 2	1.9	Negligible shift	Group assignment unlikely
>3	4.0	34% upward shift	67% chance the patient is in the success group

The “Improvement Rule” defines the amount or improvement each group achieved. The Success Group had better than a 50% improvement in the Oswestry while the Improvement Group had between 6 and 49% improvement in the Oswestry.

Improvement Rule

Number of variables present	Positive likelihood ratio	Negative likelihood ratio	Probability shift	Group assignment
One or more	1.1	0.20	no shift / -50%	Group assignment unlikely
Two or more	6.3	0.18	no shift / -50%	94% likely to be in the improvement group
Three or more	18.8	0.43	+22% / - 50%	97% likely to be in the improvement group
Four	6.0	0.84	+27% / negligible	94% likely to be in the improvement group

Prevalence of the group

Three sub-groups exhibited different responses to lumbar stabilization training.

Number of subjects	Prevalence	Sub-group	Oswestry change score at 8 weeks
18/54	33%	Success group	>50%
21/54	39%	Improvement group	6 – 49%
15/54	28%	Failure group	>6%

Test Description

Historical and self-report findings are the following: 

• Age less than 40 years old
• Fear Avoidance Beliefs Questionnaire physical activity scale greater than nine

Physical exam findings are described as follows:

• SLR greater than 90 degrees: The patient is supine. An inclinometer or a goniometer may be used. The inclinometer is calibrated placed on the tibial tubercle with the patient’s leg resting on the table. The stationary arm of the goniometer is placed alongside the patient’s trunk with the axis centered over the greater trochanter. The therapist raises the leg passively with the knee fully extended.
• Aberrant motion present with trunk forward bending: In standing, the patient is asked to bend forward while keeping the knees straight. Total spine flexion is encouraged although touching the toes is not emphasized. The patient is encouraged to relax in the fully flexed position for 2-5 seconds. Then, the patient is asked to straighten up. A positive test is an “instability catch”, painful arc of motion, thigh climbing (Gowers’ sign)or a reversal of the lumbo-pelvic motion.
• Positive prone instability test, Part 1: The patient lies on the exam table with the trunk, head and arms while the feet are on the floor. The therapist applies posterior-to-anterior pressure (P/A) to the spinous processes of the lumbar spine. Any painful provocation is recorded. Part 2: The therapist then asks the patient to raise one leg up off of the floor and P/A pressure is again applied to the spine. A reduction in pain while the leg is raised is a positive test.
• No lumbar hypermobility with spring testing: In prone, P/A pressure is applied to the lumbar spinous processes with the therapist’s thenar eminence. Segmental spinal mobility at each level is judged hypomobile (stiff), normal or hypermobile (lax).

Evidence

Hicks’ rule is a Level 4 derivation rule.

Hicks examined 54 people with non-radicular lower back pain in three outpatient clinics in Pennsylvania and Mississippi over eight weeks using a prospective, single-arm study design. This study design is capable of deriving prognostic factors but not treatment effect modifiers.

Prognostic factors are patient characteristics that estimate a patients' likely outcome irrespective of the chosen management.²

Treatment effect modifiers are factors measured at baseline that influence the relationship between a specific intervention and an outcome.²

Hicks' subjects were an average of 42.4 years old, had an average NPRS (pain) score of 4.5 and average FABQ physical activities score of 14.6. Baseline Oswestry Disability Index (ODI) score was 30 points.

Change in the ODI score was calculated with this formula: Change score=[(baseline ODI score – 8 week ODI score)/(baseline ODI score)] x 100

Any three variables present for the Improvement group predicted group assignment better than any other combination (97%). Four positive test variables for the Improvement group did not improve the accuracy of the rule for physical therapist decision making (94%).

Hicks checked 26 physical examination variables, six self-report variables and eight demographic/historical variables for association with either success or failure. The association accepted a liberal error rate of 10% to avoid filtering potentially useful predictor variables. Four test variables for success and nine test variables for failure were then entered into a second filter, the logistic regression equation, which resulted in the tests above.

Resources

1. Hicks GE, Fritz JM, Delitto A, McGill SM. (2005) Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-62.
2. Hill JC, Fritz JM. Psychosocial Influences on Low Back Pain, Disability and Response to Treatment. Phys Ther. 2011;91(5):pp.712-721.

Recent Related Research (from Pubmed)

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