The Effects of Over Exertion for Chronic Low Back Pain Rehabilitation

Emma Vaitkevicius
Abstract
Background and Purpose. The purpose of this retrospective case report is to determine if
overexertion of prescribed home exercises lead to regression throughout the treatment of an adult
female receiving physical therapy treatment for low back pain.
Patient and Setting. The patient was an adult female with low back pain and lumbosacral
radiculopathy secondary to an L5 spondylolisthesis. The patient was being treated at outpatient
physical therapy.
Intervention. The intervention included 5 treatment sessions which included strengthening
exercises for lower extremities and activity modification. Transverse abdominis facilitation,
accompanied with dynamic exercise was performed to improve core stability.
Outcomes. The patient showed improvement in Modified Oswestry Low Back Pain Disability
and Patient Physical FS Primary Measure. The patient reported decreased pain when performing
functional activities. The patient regressed throughout the course of treatment due to increase
activity and poor motor control outside of therapy.
Discussion and Conclusion. The importance of adherence to prescribed home exercise program
was present throughout the case report. The patient showed positive improvements in pain
perception and functional ability. Progression through therapy was limited due to over
willingness to return to prior level of function and not performing activity modification. Provided
education proved to be effective at preventing further regression, by preventing overexertion.

Key Words: Low back pain, Home-exercise program, Regression, Over exertion.
Background and Purpose
The incidence of low back pain (LBP) is one of the most common musculoskeletal
complaints found in clinical practice, with the estimated lifetime prevalence anywhere from 60%
to 90%.1 The term low back pain can be utilized to describe any differential diagnosis causing
compression or irritation of nerve roots in the lumbar spine. This can be caused by a various
number of pathologies, for example, lumbar disc herniation, spinal stenosis, and/or
spondylolisthesis.1 Many of these pathologies, such as spondylolisthesis, can lead to lumbosacral
kyphosis, hamstring contracture, and radiculopathy due to nerve root compression.2 Continuous
lack of treatment can lead to decreased activity, increased pain, and limitations in activities of
daily living. Treatment for many conditions and chief complaints of low back pain consists of
conservative management, specifically physical therapy and pain control.2,3 Exercise with a
combination of education has been shown to be an effective treatment for LBP.3 This includes
two to three times per week of aerobic, strengthening, and stretching exercises to prevent LBP. 3
It is recommended for patients receiving treatment for low back pain to remain physically active;
however, too much physical activity may result in associated LBP.3,4 The second important factor
is incorporating an effective home exercise program to assist with patient treatment. The success
of the patient’s treatment can depend on patient adherence and accuracy of the performance of a
home exercise program (HEP).5 Many factors influence a patient's ability to adhere to an HEP,
including psychological factors, social support, and perceived barriers.6 While the current
literature presents problems with lack of adherence, information regarding the impact of over-
adherence and over-exercising following therapy treatment requires further examination. Periods
of intense or prolonged exercise may lead to higher inflammatory mediators.7 This may lead to
an increased risk of chronic inflammation.7 Presenting the effects and limitations caused by
overexertion, including overperforming HEP and additional exercises received in treatment, can
improve the understanding of requirements for progression and regression of treatment. The
purpose of this retrospective case report is to determine if overexertion of prescribed home
exercises leading to regression throughout the treatment of an adult female receiving physical
therapy treatment for low back pain.

Patient History and Review of Systems

The patient was a 69-year-old retired female nurse who presented with a chief complaint
of upper posterior thigh and buttocks pain. She had begun experiencing symptoms of bilateral
numbness and tingling in her lower extremities 10 years prior. After following a routine walking
program and losing 40 lbs., her symptoms had been alleviated. However, the patient began
experiencing recurring symptoms 3 months prior to the initial evaluation. The patient described
the symptoms as aching pain located in bilateral thighs, extending into the posterior thigh and
buttocks. She stated that the pain increased when climbing stairs, with prolonged sitting and
bending over. Her symptoms gradually worsened throughout the day, especially with increased
activity, severely impacting her daily life and her ability to continue gardening. Symptoms were
alleviated with changing positions, especially when standing up or lying down. She had only
been able to sleep on her stomach due to numbness and tingling experienced in bilateral upper
extremities when sleeping supine. Her past medical history revealed a previous trans ischemic
attack, carpal tunnel syndrome, hypotension, hypothyroidism, latex hypersensitivity, L5
spondylolisthesis, and lumbar degenerative disc disease. Medications include Losartan to treat
hypotension, Levothyroid to treat hypothyroidism, and over-the-counter Tylenol, as well as

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prescribed Aspirin for pain management. Due to her maintaining an active lifestyle, including
many hours spent gardening per day, her goals were based on functional activities. This included
being able to return to her prior exercise routine, garden, bend over at the waist and walk upstairs
without pain.

Clinical Impression #1
Based on the history and system review, the patient appeared to have presented with
lumbar radiculopathy secondary to an L5 spondylolisthesis, worsened with extension-based
movements. Further examination was required to determine strength deficits in the lower
extremities and core muscles that might have limited mobility. Transverse abdominis activation
and core stability were being assessed to determine the need for strengthening to decrease and
centralize symptoms. The patient was attentive and had a comprehensive understanding of health
literacy due to past employment as a nurse. She understood the importance of adhering to the
Home Exercise Program (HEP) to improve symptoms and treatment outcomes. The patient
presented with a good rehabilitation prognosis. After obtaining consent from the patient, tests
and measures, interventions, and education were completed.

Examination Process & Procedures

Several standardized measures were utilized to determine the extent of the patient's
symptoms and develop interventions to treat her impairments. To determine the extent of
postural deviation located in the spine, a standing postural assessment was performed. The inter-
tester reliability is K = 0.64 and intra-tester reliability is K = 0.80 and 0.71.8 She presented with
decreased lumbar lordosis. Palpation assessment indicated a step-off sign in the L4-L5 region
and tenderness to palpation. When palpating the piriformis, the patient expressed pain
accompanied by radiating symptoms into bilateral posterior thighs.
A standing balance assessment, a single leg stance (SLS), was performed to determine
neurological or strength deficits and to determine if lumbar radiculopathy was a contributing
factor. The test-retest reliability is 0.90-0.91 for eyes open and interrater reliability if 0.99 for
eyes open.9 She was able to perform an SLS on both bilateral lower extremities with no noted
sway or requiring support from an external surface to maintain balance.
A dermatome and myotome screen for L2 – S2 was performed to determine the presence
of a lower motor neuron lesion. All dermatomes and myotomes were intact and symmetrical.
Range of motion assessment was performed in a functional setting and standardized
position to determine deficits in patient mobility. Goniometry for range motion intertester
reliability for lower extremities (r = 0.58). 10 She presented with no deficits in range of motion
for bilateral lower extremities.
Strength in the lower extremities was measured using a graded manual muscle scale
scored out of 5. The test has an inter-rater reliability of 0.91 and intra-rater reliability of 0.94. 11
Strength deficits included: right hip flexion 4/5, left hip flexion 3/5, right hip abduction 5/5, left
hip flexion 4/5, left knee flexion 4/5. All other muscle groups/regions tested, including hip
extension, abduction, internal rotation, and external rotation, and knee extension (not listed) were
measured as 5/5. Core strength and Transverse abdominis (TrA) activation were assessed to
determine if impairments in core stability were present. The patient was tested in a supine
position with bilateral knees bent at a 90° angle. She was instructed to contract TrA and lift each
leg separately. She was then instructed, while maintaining TrA activation, to lift the left leg and

2
hold it at a 90° hip flexion, followed by the right leg. Visual examination and palpation of her
core revealed an inability to maintain core stabilization and TrA contraction with double leg lift
due to doming of the abdomen from compensation of rectus abdominis.
Specific special tests were chosen to rule out differential diagnoses. The straight leg raise
(SLR) test, sensitivity 0.91 and specificity of 0.26 and cross straight leg raise, sensitivity 0.29
and specificity 0.8812, were utilized to assess lumbosacral nerve root irritation13.The patient
presented with bilateral positive SLR and crossover SLR for the left side with reported pain in
the posterior thigh and gluteus. The slump test, with a sensitivity of 0.91 and specificity of 0.70,
was used to determine the presence of neuropathic pain correlated with chronic low back pain. 14
The patient experienced pain in bilateral posterior thighs with forward bending. Manual lumbar
traction applied to bilateral lower extremities provided alleviation of distal radiculopathy
symptoms, indicating nerve root irritation.15 She reported alleviation of pain, which returned
when the leg was brought back to the resting position. The Cluster of Laslett is a diagnostic tool
to diagnose sacroiliac joint dysfunction, comprised of 5 tests, including sacroiliac distraction,
compression, thigh thrust, sacral thrust, and Gaenslen's.16,17 A positive result for 3 or more tests,
sensitivity of 0.91, and specificity of 0.78, indicates dysfunction, which was consistent with the
patient's positive results (sacroiliac distraction, sacroiliac compression, and sacral thrust). 16
A Functional Gait Assessment was performed to determine the presence of myotome or
muscular weakness affecting the patient's ability to ambulate. This test has an interrater
reliability of 0.93. 18 She presented with a decreased stance phase on her left leg when
ambulating at her normal walking speed.

Clinical Impression #2
The examination confirmed lumbosacral radiculopathy, postural instability of the lumbar
spine, decreased strength in TrA, and sacroiliac joint dysfunction. She continues to be
appropriate for therapy due to her willingness to begin treatment, understanding of the current
impairment complications and potential prognosis, along with her commitment to maintain an
active lifestyle. It was anticipated that through a 6-week intervention, 3 days a week, the patient
would decrease her pain, decrease functional limitations, and correct postural instability to
maintain and improve her current level of function. The projected physical therapy goals for
treatment included enabling the patient to perform the initial and final home exercise program
(HEP) independently, increasing the strength of lumbar stabilizers to be able to stand from a bent
position without complaint of pain, and improving strength in the left knee flexion to be able to
ascend/descend stairs to improve cardiovascular endurance and improve knee flexion and
extension strength to be able to bend down and do yard maintenance.

Intervention
The patient proceeded with interventions to improve the presented impairments, focusing
on core strengthening and stabilization, activity modification, centralization of distal pain,
stretching, and patient education on pain management. The interventions, presented in Figure 1,
spanned over five days of treatment. Each session began with a brief review of patient education,
home exercise program progression, and any questions related to the current pathology. The
patient was pain-oriented and expressed each day which specific activities were increasing
symptoms. She adhered to the prescribed HEP, including Transverse Abdominis (TvA)
facilitation, glute med I, Bent Knee Fall Outs, and Ball Squeeze with TvA activation, performed

3
each day, with 3 sets of 10 repetitions for each exercise. The patient began each treatment
session with a warm-up on the NuStep. The patient performed side steps to improve lower
extremity (LE) strength while maintaining TvA activation. She initially started with Squat taps
with instruction to maintain core stability and a neutral spine, with the goal to progress towards
squats as an activity modification to bending over at the waist. Lunges were incorporated in
“Treatment 1” (Figure 1) as an activity modification to bending in the garden and to assess
stability. Standing core stability exercises were included not only to increase strength and
stability but also to provide active exercise to continue patient adherence and participation. This
included press outs, pull-down, pull-down march, and step outs. To improve core stability and
focus on diaphragmatic breathing for pain modulation, TvA facilitation combined with activity
was included. The patient performed each activity in a supine position, with the goal to
progressively increase the intensity of each exercise while maintaining TvA activation. This
included bent knee fall outs, TvA knee lift, glute med I, ball squeeze with TvA activation,
straight leg raise, isometric knee lift, and ball roll. Intervention began with 2 sets of 15
repetitions performed. Resisted exercises, such as side steps and press outs, were performed
using light resistance, which increased according to equipment. Therabands were utilized,
beginning at yellow, without progression due to fatigue reported by the patient. Standing core-
strengthening exercises utilized sports cords, beginning in red and progressing to green when she
reported a decrease in the occurrence of symptoms or lack of fatigue. Treatment was followed by
manual therapy to correct sacroiliac and pelvic misalignment, which included Muscle Energy
Techniques (MET) to address impairments. Located in Figure 1, the patient progressed through
exercises, with additional ones being included and removed. “Treatment 1” acted as an
intervention and an assessment for the patient, indicating the level of cueing required, ability to
maintain form and TvA activation, and onset of fatigue. The patient required significant cueing
and education to maintain TvA activation, as well as consistent postural cueing. The patient was
unable to perform SLR without substitution of abdominal muscles and trunk, indicating a need
for increased strength. On the second day of treatment, “Treatment 2”, showed improvement
with core stability and strength, adherence to HEP, and reported centralization of pain. The
patient was able to increase repetition of SLR and required less cueing to maintain TvA
activation during exercise. Self-correction was present when performing interventions, with the
patient pausing and continuing exercises to maintain core contraction. The patient was unable to
incorporate pull-down with march, which was utilized as an assessment to increase activity level.
At this time, the patient reported concerns and frustration with low exercise intensity leading to
little improvement. The patient received education on progression and gradual improvement that
would be made as treatment continued. “Treatment 3” required significant regression of
exercises. The patient presented to the treatment session with decreased core activation, poor
motor control with exercise, and increased reports of pain. The patient performed knee lifts and
SLR with substitution from quadriceps and abdominal muscles. When asked about HEP
progression and adherence, she stated performing HEP each day with the inclusion of exercises
performed during therapy. The patient was educated on the importance of adhering to specific
HEP and working on slow and controlled motion to prevent regression. Repetitions of TvA
facilitation exercises were decreased due to the increased requirement of cueing, postural re-
education, and patient education. The patient was unable to progress to standing pull-down
marches but was able to increase the resistance of sports cord while maintaining trunk stability.
She reported pain when ascending and descending stairs, so the patient received gait training for
activity modification. She did not present with motor control, requiring the use of significant
4
trunk flexion to accelerate in a reciprocal pattern when ascending stairs. The patient was
instructed to ascend using a step-to-gait, stepping on one step at a time. This improved patient
pain significantly, and she reported no radiating symptoms into bilateral LE. When descending
stairs, she did not control the descent on the leading foot, leading to a high-impact step causing
aggravating symptoms. As with ascending, the patient was instructed to control movement,
utilize the handrail, and place the entire foot onto the step. The patient was able to progress
during “Treatment 4” due to improved TvA activation and reported decrease in pain with
exercises. Repetitions for TvA-facilitated exercises increased to 15, with incorporation of
reciprocal isometric knee lift as a progression. At the beginning of “treatment 5”, the patient
began showing increased concern for the effectiveness of treatment. The patient reported
consistent pain with certain activities, including stepping onto large steps, sitting for long periods
of time, and feeling sore at the end of the day. The patient received education on pain and causes
due to increased inflammation. Following education, the patient understood the importance of
treatment and presented with increased motivation. The patient was able to progress to full sets
and repetitions of provided exercises (Figure 1), requiring minimal cueing to maintain core
activation and posture, decreased recurrence of symptoms, decreased reports of fatigue. The
patient continued to improve with the ability to self-correct during intervention and explain when
poor form was present. TvA activation accompanied with ball roll was included, using a Swiss
ball under legs, to provide slight distraction in the lumbar spine to decrease radicular symptoms
and improve core stability during dynamic exercise.

Figure 1: Intervention for Consecutive Treatment Sessions.

Exercise Dosage
Treatment 1: 06/08/2023
Patient education, HEP, Pathology
NuStep 10 minutes, resistance 3
Side steps Yellow TheraBand, 3 laps, 20 ft/lap
Squat taps 2 sets, 15 repetitions
Lunges 2 sets, 15 repetitions
Press out Red Sports Cord, 2 sets, 15 repetitions
TvA facilitation 3 minutes
Bent Knee Fall Outs 2 sets, 15 repetitions
TvA Knee Lift 2 sets, 15 repetitions
Glute med I (clam shells) 2 set, 15 repetitions
Ball Squeeze with TvA activation 2 set, 15 repetitions
TvA Straight Leg Raise 1 set, 5 repetition
MET innominate Rotation
MET Sacroiliac joint
Treatment 2: 06/13/2023
Patient education and postural positioning
NuStep 10 minutes, resistance 3
Side steps Yellow TheraBand, 3 laps, 20 ft/lap
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Squats 2 sets, 15 repetitions
Press out Red Sports Cord, 2 sets, 15 repetitions
Pull down march Red Sports Cord, 1 set, 8 repetitions
Step out Red Sports Cord, 2 sets, 15 repetitions
Bent Knee Fall Outs 2 sets, 15 repetitions
TvA Knee Lift 2 sets, 15 repetitions
Glute med I (clam shells) 2 set, 15 repetitions
Ball Squeeze with TvA activation 2 set, 15 repetitions
TvA Straight Leg Raise 1 set, 8 repetitions
MET innominate Rotation
MET Sacroiliac joint
Treatment 3: 06/15/2023
Patient education, HEP review, and postural positioning
NuStep 10 minutes, resistance 3
Side steps Yellow TheraBand, 3 laps, 20 ft/lap
Squats 2 sets, 15 repetitions
Press out Red Sports Cord, 2 sets, 15 repetitions
Pull down march Red Sports Cord, 1 set, 4 repetitions
Step out Red Sports Cord, 2 sets, 15 repetitions
Gait training (ambulating up and down 5 minutes
stairs)
Bent Knee Fall Outs 2 sets, 10 repetitions
TvA Knee Lift 2 sets, 10 repetitions
Glute Med I (clam shells) 2 set, 10 repetitions
Ball Squeeze with TvA activation 2 set, 15 repetitions
TvA Straight Leg Raise 1 set, 2 repetitions
MET Innominate Rotation
MET Sacroiliac Joint
Treatment 4: 06/20/2023
Patient education, HEP review, and postural positioning
NuStep 10 minutes, resistance 3
Side steps Yellow TheraBand, 3 laps, 20 ft/lap
Squat taps 2 sets, 15 repetitions
Press out Green Sports Cord, 2 sets, 15 repetitions
Pull down Green Sports Cord, 2 set, 15 repetitions
Step out Red Sports Cord, 2 sets, 15 repetitions
TvA facilitation 4 minutes
Bent Knee Fall Out 2 sets, 15 repetitions
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 TvA Knee Lift 2 sets, 15 repetitions
Glute Medius I (clam shells) 2 set, 15 repetitions
Ball Squeeze with TvA activation 2 set, 15 repetitions
TvA Straight Leg Raise 1 set, 10 repetitions
TvA isometric knee lift 2 sets, 15 repetitions
MET Innominate Rotation
MET Sacroiliac Joint
Treatment 5: 06/23/202
Patient education, HEP review, and postural positioning
NuStep 10 minutes, resistance 3
Side steps Yellow TheraBand, 3 laps, 20 ft/lap
Press out Green Sports Cord, 2 sets, 15 repetitions
Pull down with march Green Sports Cord, 2 set, 15 repetitions
TvA facilitation 4 minutes
Bent Knee Fall Out 2 sets, 15 repetitions
Glute Medius I (clam shells) 2 set, 15 repetitions
TvA isometric knee lift 2 set, 15 repetitions
TvA Ball Roll 2 sets, 15 repetitions
MET Innominate Rotation
MET Sacroiliac Joint

Outcomes
Due to time constraints in the clinic, a formal progress note was unable to be performed.
Instead, the patient completed a Functional Status Summary, including a Physical Functional
Scale Primary Measure and Modified Oswestry Low Back Pain Disability assessment. The
Patient Physical FS Primary Measure improved from 45 to 56, indicating that the patient is
experiencing little difficulty performing activities of daily living.19 The mean detectable change
for this exam was 6. The Modified Oswestry Low Back Pain Disability has a reliability of 0.78. 20
The patient's score improved from 41.2 at intake to 23.7, indicating a decrease in overall
disability. Throughout the treatment sessions, both subjective and objective information were
collected to assess patient progression. At the end of treatment, the patient reported a decrease in
pain when ascending stairs. Additionally, the patient presented with improved bilateral lower
extremity (LE) strength, with left hip flexion measuring 4/5.

Discussion
This case report outlines the treatment, interventions, and outcomes following five
treatments for low back pain. The patient showed improvement following each course of
treatment but was required to regress the intervention due to overexertion after each treatment
session. Following treatments one and two, the patient began to present with poor form and
lacked muscle recruitment despite continuous instruction and cueing. After discussions and
education with the patient, it was revealed that she was completing her prescribed Home
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Exercise Program (HEP) every day, in addition to exercises performed during treatment. The
presentation of poor motor control and increased fatigue led to extensive education and required
regression in exercise intensity and frequency. The patient was very receptive to education,
which included performing activity modifications to allow a decrease in the inflammatory
response and improve core stabilization strength without unnecessary muscle substitution.
Subsequent treatments showed continuous improvement, as the patient adhered to the prescribed
HEP without overexertion following treatment. She was able to improve and progress exercise
intensity and frequency, resulting in decreased reports of pain during activities such as ascending
stairs. This case report presented limitations due to the limited number of treatment sessions. The
patient was seen for a total of five treatments, which did not allow for documented improvement
and outcomes for complete rehabilitation. A progress note was not able to be completed, leading
to a lack of objective progress measurement. The results of the case report have shown the need
for more evidence regarding outcomes for patients and the necessity for regression following
overexertion in patients with low back pain. This could assist in developing continuing education
strategies for patients to improve their understanding of and adherence to the HEP, as well as
developing specific treatment programs and HEPs for patients with low back pain.

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References
1. Alexander CE, Varacallo M. Lumbosacral radiculopathy. Treasure Island, FL: StatPearls
Publishing; 2017. https://europepmc.org/article/nbk/nbk430837#__NBK430837_dtls__.
Accessed August 1, 2023.
2. Gagnet P, Kern K, Andrews K, Elgafy H, Ebraheim N. Spondylolysis and
spondylolisthesis: a review of the literature. J Orthop. 2018; 15(2): 404-407.
doi:10.1016/j.jor.2018.03.008.
3. Shipton, EX. Physical therapy approaches in the treatment of low back pain. Pain Ther.
2018;7(2):127-137. Doi:10.1007/s40122-018-0105-x.
4. Gordon R, Bloxham S. A systematic review of the effects of exercise and physical
activity on non-specific chronic low back pain. Healthcare (Basel). 2016;4(2):22.
doi:10.3390/healthcare4020022.
5. Sevgio OA. The effectiveness of home-based exercise programs for low back pain
patients. J Phys Ther Sci. 2016; 28(10): 2727-2730. doi:10.1589/jpts.28.2727.
6. Argent R, Daly A, Caulfield B, et al. Patient involvement with home-based exercise
programs: can connected health interventions influence adherence? JMIR Mhealth
Uhealth. 2018; 6(3): e47. Doi:10.2196/mhealth.8518.
7. Cerqueria É, Marinho DA, Neiva HP, Lourenço O. Inflammatory effects of high and
moderate intensity exercise – a systematic review. Fron Physiol. 2019; 10: 1550.
Doi:10.3389/fphys.2019.01550.
8. Collins CK, Johnson VS, Godwin EM, Pappas E. The reliability and validity of the saliba
postural classification system. J Man Manip Ther. 2016; 24(3): 171-181.
Doi:10.1080/10669817.2016.1138599.
9. Franchignoni F, Tesio L, Martino MT, Ricupero C. Reliability of four simple,
quantitative tests of balance and mobility in healthy elderly females. Aging (Milano).
1998; 10(1): 26-31. doi:10.1007/BF03339630.
10. Gajdosi RL, Bohannon RW. Clinical measurement of range of motion: revew of
goniometry emphasizing reliability and validity. Physical Therapy. 1987; 67(12): 1867-
1872. Doi:10.1093/ptj/67.12.1867.
11. Pfister PB, de Bruin ED, et al. Manual muscle testing and hand-held dynamometry in
people with inflammatory myopathy: an intra- and interrater reliability and validity study.
PloS one. 2018; 13(3): e0194531. Doi:10.1371/journal.pone.0194531.
12. Devillé WL, van der Windt DA, Dzaferagić A, Bezemer PD, Bouter LM. The test of
Lasègue: systematic review of the accuracy in diagnosing herniated discs. Spine (Phila
Pa 1976). 2000;25(9):1140-1147. doi:10.1097/00007632-200005010-00016
13. Camino Willhuber GO, Piuzzi NS. Straight Leg Raise Test. Treasure Island, FL:
StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/NBK539717/.
Accessed August 1, 2023.
14. Urban LM, MacNeil BJ. Diagnostic accuracy of the slump test for identifying
neuropathic pain in the lower limb. J Orthop Sorts Phys. 2015;45(8):596-603.
15. Pellecchia GL. Lumbar traction: a review of literature. JOSPT. 1994; 20(5) 262-267.
16. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man
Manip Ther 2008;16(3):142-152.
17. Cattley P, Winyard J, Trevaskis J, Eaton S. Validity and reliability of clinical test for the
sacroiliac joint. Australas Chiropr Osteopathy. 2002; 10(2): 73-80.

9
18. Walker M, Austin A, et al. Refernce group data for the functional gait assessment. Phys
Ther. 2007; 87(11): 1468-77. Doi:10.2522/ptj.20060344.
19. Wahl E, Gross A, et al. Validity and responsiveness of a 10-item patient-reported
measure of physical function, PROMIS PF-10a, in a rheumatoid arthritis clinic
population. Arthritis Care Res. 2017; 69(3): 338-346. Doi:10.1002/acr.22956.
20. Dawson AP, Steele EJ, et al. Utility of the oswestry disability index for studies of back
pain related disability in nurses: evaluation of psychometric and measurement properties.
Int J Nurs Stud. 2010; 47(5): 604-607. Doi: 10.1016/j.injnurstu.2009.10.013.

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