Regional Interdependence in Low Back Pain: Interventions: Difference between revisions

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'''Original Editors&nbsp;'''- [http://www.physio-pedia.com/User:Brandan_Lym Brandan Lym], [http://www.physio-pedia.com/User:Mitch_Blythe Mitchell Blythe],<span style="line-height: 1.5em;">&nbsp;[http://www.physio-pedia.com/User:Cory_Horstmann Cory Horstman], </span>[http://www.physio-pedia.com/User:Nathan_Domino Nathan Domino]<span style="line-height: 1.5em;">, and&nbsp;</span>[http://www.physio-pedia.com/User:Dana_Schmidt Dana Schmidt]<span style="line-height: 1.5em;">&nbsp;part of the </span>[[Des Moines University Student Project]]&nbsp; &nbsp;&nbsp;  
'''<span>&nbsp;</span>''' '''Original Editors&nbsp;'''- [http://www.physio-pedia.com/User:Brandan_Lym Brandan Lym], [http://www.physio-pedia.com/User:Mitch_Blythe Mitchell Blythe],<span style="line-height: 1.5em;">&nbsp;[http://www.physio-pedia.com/User:Cory_Horstmann Cory Horstman], </span>[http://www.physio-pedia.com/User:Nathan_Domino Nathan Domino]<span style="line-height: 1.5em;">,&nbsp; </span>[http://www.physio-pedia.com/User:Dana_Schmidt Dana Schmidt]<span style="line-height: 1.5em;"> and [http://www.physio-pedia.com/User:Shannon_Petersen Shannon Petersen] as part of the </span>[[Des Moines University Student Project]]&nbsp; &nbsp;&nbsp;  
</div>  
</div>  
= &nbsp;Regional Interdependence  =
== Regional Interdependence  ==


*[http://www.physio-pedia.com/Regional_Interdependence Regional interdependence] is the concept that a musculoskeletal treatment targeting a specific area of the body could have effects in another, seemingly unrelated, part of the body<ref name="Wainner et al.">Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther 2007;37(11):658-660. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/18057674 (accessed 26 Oct 2013).</ref>.<br>
*[http://www.physio-pedia.com/Regional_Interdependence Regional interdependence] is the concept that a musculoskeletal treatment targeting a specific area of the body could have effects in another, seemingly unrelated, part of the body<ref name="Wainner et al.">Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther 2007;37(11):658-660. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/18057674 (accessed 26 Oct 2013).</ref>.<br>  
*There is a growing body of evidence to support the treatment of [http://www.physio-pedia.com/Low_Back_Pain Low Back Pain] through interventions aimed at the thoracic spine and the hip joints.&nbsp;


= [http://www.physio-pedia.com/Lumbar_Examination Lumbar&nbsp;Examination] =
== Examination&nbsp;  ==


Screen patient for red flags<ref name="Diletto et al.">Delitto A, George S.Z. et al. Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orhtop Sports Phys Ther. 2012;42(4):A1-A57 Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/22466247 (accessed 26 October 2013).</ref>  
*When treating patients with [http://www.physio-pedia.com/Low_Back_Pain Low Back Pain]&nbsp;be sure to perform&nbsp;[http://www.physio-pedia.com/Lumbar_Examination Lumbar Examination] &nbsp;as well as&nbsp;[http://www.physio-pedia.com/Hip_Examination Hip Examination]&nbsp;and&nbsp;[http://www.physio-pedia.com/Thoracic_Examination <span>T</span>horacic Examination]. This will provide a thorough basis of information on which to base your choice of interventions and ensure safety during those interventions. &nbsp;


Physical Impairment Measures<ref name="Diletto et al." />
== Interventions  ==
Interventions directed at the [http://www.physio-pedia.com/Thoracic Thoracic Spine] and the [http://www.physio-pedia.com/Hip Hip Joints] have been found to be beneficial for patients suffering from&nbsp;[http://www.physio-pedia.com/Low_Back_Pain low back pain].&nbsp;


*Evaluate Thoraco-Lumbar Active and Passive ROM
=== Thoracic Spine<ref name="Oliviera">Oliveira RF, Liebano RE, Costa LCM, Rissato LL, Costa LOP. Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Phys Ther 2013;93(6):748-756. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/23431209 (accessed 28 Oct 2013).</ref><span>&nbsp;</span>  ===


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - &nbsp;[http://www.physio-pedia.com/Lumbar_Quadrant_Test Quadrant Test]<br>  
==== Thoracic Manipulation ====
*One case study reported improved outcomes in patients with chronic low back pain after utilizing the following intervention aimed at the thoracic spine.&nbsp;  
*Supine Thoracic Posterior to Anterior Thrust Manipulation<ref name="Oliviera" />
{{#ev:youtube|3OpUS_hwakE}}


*[http://www.physio-pedia.com/Manual_Therapy_Techniques_For_The_Lumbar_Spine Segmental Mobility]
=== Hip<ref name="Whitman 1">Whitman JM, Flynn TW, Fritz, JM. Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy. Phys Med Rehabil Clin N Am 2003;14:77-101. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/12622484 (accessed 29 Oct 2013).</ref><ref name="Whitman 2">Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006;31(22):2541-2549. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/17047542 (accessed 29 Oct 2013).</ref><ref name="Cibulka">Cibulka MT. Low Back Pain and its Relation to the Hip and Foot. J Orthop Sports Phys Ther 1999;29(10):595-601. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/10560068 (accessed 26 Oct 2013)</ref><ref name="Lejkowski">Lejkowski PM, Poulsen E. Elimination of intermittent chronic low back pain in a recreational golfer following improvement of hip range of motion impairments. Journal of Bodywork &amp; Movement Therapies 2013;17:448-452. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/24139002 (accessed 29 Oct 2013).</ref><ref name="Burns">Burns SA, Mintken PE, Austin GP, Cleland J. Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series. Journal of Manual and Manipulative Therapy 2011;19(2):100-107. Pub Med Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172945/ (accessed 29 Oct 2013).</ref> ===
*Pain Provocation with Segmental Mobility Testing
*Judgments of Centralization during Movement Testing<br>


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Look for a centralization of pain with repeated motion in a specific direction.
==== Hip Manipulation ====
*One case series found that the use of hip manipulaiton was beneficial for their patients with low back pain.&nbsp;<ref name="Burns" />
*Supine Long Axis Distraction Thrust Manipulation
{{#ev:youtube|EqxxSA9TknY}}


*Prone Instability Test
[http://www.physio-pedia.com/Hip_Mobilizations '''Hip Mobilization''']  
*Judgments of the presence of aberrant movement<br>
 
*Straight Leg Raise
*Slump Test
*Trunk Muscle Power and Endurance<br>
 
*Passive Hip Internal Rotation, External Rotation, Flexion, and Extension
*Mental Impairment Measures
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - &nbsp;[http://www.physio-pedia.com/Depression Depression]
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - &nbsp;[http://www.physio-pedia.com/Yellow_Flags Yellow Flags]
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - [http://www.physio-pedia.com/Fear%E2%80%90Avoidance_Belief_Questionnaire &nbsp;Fear Avoidance Beliefs Questionnaire]
 
'''If using hip or thoracic interventions be sure to perform '''[http://www.physio-pedia.com/Hip_Examination '''hip examination''']'''and/or '''[http://www.physio-pedia.com/Thoracic_Examination '''thoracic examination''']'''.&nbsp;'''
 
<br>
 
<br>
 
= Interventions&nbsp;Directed at&nbsp;Thoracic Spine&nbsp; =
 
In the articles reviewed, the following interventions were found to be beneficial in the treatment of [http://www.physio-pedia.com/Low_Back_Pain low back pain].&nbsp;
 
<br>
 
=== Thoracic Spine<ref name="Oliviera">Oliveira RF, Liebano RE, Costa LCM, Rissato LL, Costa LOP. Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Phys Ther 2013;93(6):748-756. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/23431209 (accessed 28 Oct 2013).</ref>  ===
 
Manipulation
 
*Supine Thoracic Posterior to Anterior HVLA Manipulation<br>
 
&nbsp; &nbsp; {{#ev:youtube|3OpUS_hwakE}}
 
=== Hip<ref name="Whitman 1">Whitman JM, Flynn TW, Fritz, JM. Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy. Phys Med Rehabil Clin N Am 2003;14:77-101. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/12622484 (accessed 29 Oct 2013).</ref><ref name="Whitman 2">Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006;31(22):2541-2549. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/17047542 (accessed 29 Oct 2013).</ref><ref name="Cibulka">Cibulka MT. Low Back Pain and its Relation to the Hip and Foot. J Orthop Sports Phys Ther 1999;29(10):595-601. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/10560068 (accessed 26 Oct 2013)</ref><ref name="Lejkowski">Lejkowski PM, Poulsen E. Elimination of intermittent chronic low back pain in a recreational golfer following improvement of hip range of motion impairments. Journal of Bodywork &amp;amp;amp;amp;amp;amp;amp;amp; Movement Therapies 2013;17:448-452. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/24139002 (accessed 29 Oct 2013).</ref><ref name="Burns">Burns SA, Mintken PE, Austin GP, Cleland J. Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series. Journal of Manual and Manipulative Therapy 2011;19(2):100-107. Pub Med Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172945/ (accessed 29 Oct 2013).</ref>  ===
 
Manipulation
 
*Supine Long Axis Distraction HVLA Manipulation
 
&nbsp;&nbsp; {{#ev:youtube|EqxxSA9TknY}}
 
Mobilizations


*Multiple studies, including randomized controlled trials and case studies, found that mobilization to the hip joints resulted in improved outcomes in their patients with low back pain.&nbsp;<ref name="Whitman 1" /><ref name="Whitman 2" /><ref name="Lejkowski" /><ref name="Burns" />
*Supine Hip Caudal Glide Mobilization
*Supine Hip Caudal Glide Mobilization


&nbsp;&nbsp; [[Image:Supine Hip Caudal Glide.JPG|300px]]<br>  
&nbsp;&nbsp; [[Image:Supine Hip Caudal Glide.JPG|300px]]<br>  
<br>


*Prone Hip Posterior to Anterior Mobilization
*Prone Hip Posterior to Anterior Mobilization


&nbsp;&nbsp; [[Image:Prone Hip Posterior to Anterior Glide.JPG|300px]]  
&nbsp;&nbsp; [[Image:Prone Hip Posterior to Anterior Glide.JPG|300px]]<br>  
 
<br>  


*Hip Posterior to Anterior Mobilization with Flexion, Abduction, and External Rotation
*Hip Posterior to Anterior Mobilization with Flexion, Abduction, and External Rotation
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[[Image:Hip PA with flex, abd, ER.JPG|300px]]<br>  
[[Image:Hip PA with flex, abd, ER.JPG|300px]]<br>  


*Hip Anterior to Posterior Mobilization with Flexion, Adduction, and Internal Rotation &nbsp; &nbsp; &nbsp;
*Hip Anterior to Posterior Mobilization with Flexion, Adduction, and Internal Rotation&nbsp; &nbsp; &nbsp;&nbsp;


[[Image:Hip AP with flex add IR.JPG|300px]]<br>
[[Image:Hip AP with flex add IR.JPG|300px]]  


<br>
&nbsp;&nbsp;


<span>&nbsp;</span>&nbsp; -&nbsp;[http://www.physio-pedia.com/Hip_Mobilizations Hip Mobilization]&nbsp;Physiopedia Page
==== HIp Therapeutic Exercise ====
*&nbsp;''Strengthening''


&nbsp;&nbsp;  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; + One case study found that the following strengthening exercise helped to decrease low back pain.&nbsp;<ref name="Cibulka" />
 
Therapeutic Exercise
 
*&nbsp;Strengthening


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Hip Abduction with slight extension and internal rotation  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Hip Abduction with slight extension and internal rotation  
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&nbsp;&nbsp; [[Image:Hip Abduction with IR.JPG|300px]]  
&nbsp;&nbsp; [[Image:Hip Abduction with IR.JPG|300px]]  


*&nbsp;Flexibility<br>
*&nbsp;''Flexibility''
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; + Two studies found the following stretches to be useful in the treatment of low back pain.<ref name="Whitman 2" /><ref name="Whitman 1" />  


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Supine Iliopsoas Stretch  
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - Supine Iliopsoas Stretch  
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&nbsp;&nbsp; [[Image:Prone Rectus Femoris Stretch.JPG|300px]]  
&nbsp;&nbsp; [[Image:Prone Rectus Femoris Stretch.JPG|300px]]  


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;
== Outcomes  ==
 
{| cellspacing="1" cellpadding="1" border="2"
= Outcomes  =
<div><br></div>
 
 
{| border="2" cellpadding="1" cellspacing="1"
|-
|-
| Articles  
| Articles  
| Body Region Treated
| Level of Evidence  
| Level of Evidence  
| Improved Oswestry Disability Index Score  
| Improved Oswestry Disability Index Score  
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| Improved Pain Pressure Threshold  
| Improved Pain Pressure Threshold  
| Decreased Pain  
| Decreased Pain  
| Improved Function  
| Improved Function
| <br>
|-
|-
| Burns et al.  
| Burns et al.  
| Hip
| 4  
| 4  
| X  
| X  
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|  
|  
|  
|  
| X  
| X
|
|-
|-
| Cibulka  
| Cibulka  
| Hip
| 4  
| 4  
| X  
| X  
Line 150: Line 104:
|  
|  
| X  
| X  
| X  
| X
| <br>
|-
|-
| Oliviera et al.  
| Oliviera et al.  
| Thoracic Spine
| 2  
| 2  
|  
|  
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| X  
| X  
|  
|  
| <br>
|-
|-
| Whitman et al. 2003  
| Whitman et al. 2003  
| Hip
| 4  
| 4  
| X  
| X  
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|  
|  
| <br>  
| <br>  
| X  
| X
|
|-
|-
| Whitman et al. 2006  
| Whitman et al. 2006  
| Hip
| 2  
| 2  
| X  
| X  
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|  
|  
| X  
| X  
| X  
| X
|
|-
|-
| Lejkowski &amp; Poulsen  
| Lejkowski &amp; Poulsen  
| Hip
| 4  
| 4  
|  
|  
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|  
|  
| X  
| X  
| X  
| X
|
|}
|}
<div>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - An "X" denotes improvement in each specific category regardless of statistical significance.&nbsp;</div>  
<div>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; - An "X" denotes improvement in each specific category regardless of statistical significance.&nbsp;</div>
<br>
== Clinical Implications  ==
Utilizing manual therapy interventions targeted at the hip and thoracic spine along with therapeutic exercise has been shown to provide improved outcomes for patients with low back pain. Clinicians should consider these interventions along with treatments focused on the low back to treat the entire patient and achieve improved results. Additional information can be found in the references listed below.


= &nbsp;Clinical Implications<br> =
== References ==


*Utilizing manual therapy interventions targeted at the hip and thoracic spine along with therapeutic exercise has been shown to provide improved outcomes for patients with low back pain. Clinicians should consider these interventions along with treatments focused on the low back to treat the entire patient and achieve improved results. Additional information can be found in the references listed below.<br>
<references />  


= References  =
<br>


<references />
[[Category:Interventions]]
[[Category:Lumbar Spine]] [[Category:Lumbar Spine - Interventions]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Des Moines University Student Project]]

Latest revision as of 12:03, 2 August 2021

  Original Editors - Brandan Lym, Mitchell Blythe, Cory Horstman, Nathan Domino,  Dana Schmidt and Shannon Petersen as part of the Des Moines University Student Project    

Regional Interdependence[edit | edit source]

  • Regional interdependence is the concept that a musculoskeletal treatment targeting a specific area of the body could have effects in another, seemingly unrelated, part of the body[1].
  • There is a growing body of evidence to support the treatment of Low Back Pain through interventions aimed at the thoracic spine and the hip joints. 

Examination [edit | edit source]

Interventions[edit | edit source]

Interventions directed at the Thoracic Spine and the Hip Joints have been found to be beneficial for patients suffering from low back pain. 

Thoracic Spine[2] [edit | edit source]

Thoracic Manipulation[edit | edit source]

  • One case study reported improved outcomes in patients with chronic low back pain after utilizing the following intervention aimed at the thoracic spine. 
  • Supine Thoracic Posterior to Anterior Thrust Manipulation[2]

Hip[3][4][5][6][7][edit | edit source]

Hip Manipulation[edit | edit source]

  • One case series found that the use of hip manipulaiton was beneficial for their patients with low back pain. [7]
  • Supine Long Axis Distraction Thrust Manipulation

Hip Mobilization

  • Multiple studies, including randomized controlled trials and case studies, found that mobilization to the hip joints resulted in improved outcomes in their patients with low back pain. [3][4][6][7]
  • Supine Hip Caudal Glide Mobilization

   Supine Hip Caudal Glide.JPG

  • Prone Hip Posterior to Anterior Mobilization

   Prone Hip Posterior to Anterior Glide.JPG

  • Hip Posterior to Anterior Mobilization with Flexion, Abduction, and External Rotation

Hip PA with flex, abd, ER.JPG

  • Hip Anterior to Posterior Mobilization with Flexion, Adduction, and Internal Rotation      

Hip AP with flex add IR.JPG

  

HIp Therapeutic Exercise[edit | edit source]

  •  Strengthening

          + One case study found that the following strengthening exercise helped to decrease low back pain. [5]

          - Hip Abduction with slight extension and internal rotation

   Hip Abduction with IR.JPG

  •  Flexibility

          + Two studies found the following stretches to be useful in the treatment of low back pain.[4][3]

          - Supine Iliopsoas Stretch

   Supine Iliopsoas Stretch.JPG

          - Prone Rectus Femoris Stretch

   Prone Rectus Femoris Stretch.JPG

Outcomes[edit | edit source]

Articles Body Region Treated Level of Evidence Improved Oswestry Disability Index Score Improved Fear Avoidance Behavioral Questionairre Score Improved Global Rating of Change Score Improved Modified Spinal Stenosis Scale Score Improved Pain Pressure Threshold Decreased Pain Improved Function
Burns et al. Hip 4 X X X X
Cibulka Hip 4 X X X
Oliviera et al. Thoracic Spine 2 X X
Whitman et al. 2003 Hip 4 X X X
X
Whitman et al. 2006 Hip 2 X X X X X
Lejkowski & Poulsen Hip 4 X X
          - An "X" denotes improvement in each specific category regardless of statistical significance. 

Clinical Implications[edit | edit source]

Utilizing manual therapy interventions targeted at the hip and thoracic spine along with therapeutic exercise has been shown to provide improved outcomes for patients with low back pain. Clinicians should consider these interventions along with treatments focused on the low back to treat the entire patient and achieve improved results. Additional information can be found in the references listed below.

References[edit | edit source]

  1. ↑ Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther 2007;37(11):658-660. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/18057674 (accessed 26 Oct 2013).
  2. ↑ 2.0 2.1 Oliveira RF, Liebano RE, Costa LCM, Rissato LL, Costa LOP. Immediate Effects of Region-Specific and Non-Region-Specific Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Controlled Trial. Phys Ther 2013;93(6):748-756. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/23431209 (accessed 28 Oct 2013).
  3. ↑ 3.0 3.1 3.2 Whitman JM, Flynn TW, Fritz, JM. Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy. Phys Med Rehabil Clin N Am 2003;14:77-101. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/12622484 (accessed 29 Oct 2013).
  4. ↑ 4.0 4.1 4.2 Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006;31(22):2541-2549. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/17047542 (accessed 29 Oct 2013).
  5. ↑ 5.0 5.1 Cibulka MT. Low Back Pain and its Relation to the Hip and Foot. J Orthop Sports Phys Ther 1999;29(10):595-601. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/10560068 (accessed 26 Oct 2013)
  6. ↑ 6.0 6.1 Lejkowski PM, Poulsen E. Elimination of intermittent chronic low back pain in a recreational golfer following improvement of hip range of motion impairments. Journal of Bodywork & Movement Therapies 2013;17:448-452. Pub Med Link: http://www.ncbi.nlm.nih.gov/pubmed/24139002 (accessed 29 Oct 2013).
  7. ↑ 7.0 7.1 7.2 Burns SA, Mintken PE, Austin GP, Cleland J. Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series. Journal of Manual and Manipulative Therapy 2011;19(2):100-107. Pub Med Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172945/ (accessed 29 Oct 2013).


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