Chapter 8

The kinesiopathological model and mechanical low back pain

*Program in Physical Therapy and Department of Orthopaedic Surgery, Program in Physical Therapy, Department of Cell Biology and Physiology, Department of Neurology and Neurophysiology and Program in Physical Therapy and Department of Neurology, Washington University School of Medicine at Washington University Medical Center, St Louis, Missouri, USA

Linda R. Van Dillen*, Shirley A. Sahrmann and Barbara J. Norton

CHAPTER CONTENTS The kinesiopathological model The kinesiopathological model and low back pain Low back pain subgroups Studies of select aspects of the kinesiopathological model Movement and alignment patterns Repetition of movements and alignments Contributing factors Summary References 89 90 90 90 91 92 94 96 97

review the ndings from studies that have been conducted to test assumptions of the model in patients with LBP.

THE KINESIOPATHOLOGICAL MODEL

The kinesiopathological model, hereinafter referred to as the Model, describes a process that is proposed to contribute to the development, as well as the course, of many musculoskeletal pain conditions, including mechanical LBP. The process begins with repetition of a daily activity associated with specic movements or specic alignments. The repetitions are proposed to lead to adaptations in the musculoskeletal and neural systems, for example, changes in muscle strength, exibility, stiffness, timing and level of muscle activity, to name just a few. Although such adaptations often may be benecial, continual repetition of specic movements and alignments may be increasingly detrimental because the associated adaptations contribute to imbalances about the joint(s). For example, repeated trunk rotation to the right to reach for the phone (a trunk rotation activity) could cause the muscles that contribute to right trunk rotation to become shorter and stronger while the muscles that contribute to left trunk rotation to become longer and weaker. With continued repetition, the adaptations would result in alterations in the joint motions (accessory and physiological) and in joint alignments. The alterations due to repeated performance of trunk rotation to the right, in turn, lead to alterations in the motions and alignments associated with many other daily activities, i.e. patterns of altered movements and alignments. The repetition of altered patterns of movements and alignments are proposed to result in localized regions of tissue stress, symptoms and, eventually, tissue injury (Adams 2004). According to the Model, the deleterious process can be

Characteristic patterns of movements and alignments can be recognized in many musculoskeletal pain conditions, including mechanical low back pain (LBP). In some instances the patterns displayed by patients can be linked to a specic pathology, disease or injury. There are, however, several musculoskeletal pain conditions in which a specic causal link cannot be identied. A key question in all instances is whether the movements and alignments displayed by the person with musculoskeletal pain are a consequence of the condition or contribute to the development of the condition. One potential answer to this question may be found in the kinesiopathological model (Sahrmann 2002). A basic premise of the kinesiopathological model is that continual repetition of specic movements and alignments which are requisite to performing daily activities can lead to the development of musculoskeletal pain conditions (Fig. 8.1). The purposes of this chapter are to: (i) describe the kinesiopathological model; (ii) describe the application of the model to LBP; and (iii)

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likely because repeated use of the patterns may allow minimal time for normal tissue adaptation to the stresses to occur. The Model further maintains that until the variables contributing to the use of the movement and alignment patterns are modied, the LBP has the potential to persist or recur. Figure 8.2 is a representation of the processes proposed to contribute to the development and course of LBP based on the Model.

Tissue stress, symptoms, injury

Musculoskeletal pain condition

Figure 8.1 Sequence of events proposed for movements and alignments to contribute to development of musculoskeletal pain conditions according to the kinesiopathological model (Sahrmann 2002).

Low back pain subgroups

slowed by maintaining optimal joint mechanics. Optimal joint mechanics can be maintained by minimizing the repetition of the same movements and alignments with daily activities, moving joints throughout the ranges of all available motions, and assuming a variety of positions throughout the day. The assumption that people with LBP display directionspecic movement and alignment patterns that contribute to their LBP suggests that there are different subgroups of people with LBP. The subgroups would differ based on the DT they display with activities. A standardized examination to identify the movement and alignment patterns associated with a DT, as well as related symptoms, has been developed; various measurement properties of the examination have been tested (Van Dillen etal. 1998; Luomajoki etal. 2007). The LBP subgroup labels are based on the lumbar region DT that is: (i) identied most consistently across items in the examination; and (ii) associated with the persons symptoms. The proposed subgroups are lumbar: (i) exion; (ii) extension; (iii) rotation; (iv) rotation with exion; and (v) rotation with extension. Identication of subgroups based on the DT and related symptoms has been pursued in an effort to identify more homogeneous groups of people with LBP to examine in studies of mechanisms contributing to LBP conditions and for the development of treatment programmes.

THE KINESIOPATHOLOGICAL MODEL AND LOW BACK PAIN

The specic alteration proposed to contribute to LBP is the tendency for one or more lumbar joints to move more readily than adjacent joints, for example, other lumbar joints, the hip joints or thoracic joints. The tendency to move more readily occurs each time the person performs his or her daily activities. In this context, the denition of more readily is movement that occurs sooner or proceeds farther than is ideal. As the daily activities are performed repeatedly throughout the day and some joints are moving more readily than others, some or all of the lumbar joints become relatively more exible than other joints. Typically, the lumbar joints become more exible in a specic direction(s), for example, exion, extension, rotation or some combination thereof. In such cases, the lumbar joint(s) are said to display a directional tendency (DT). Although the DT is presumed to develop over time primarily as the result of adaptations in the musculoskeletal and neural systems related to repeated movements and sustained postures, personal characteristics, such as, sex, activity level, anthropometrics and genetics, are considered to modify the rate and nature of the adaptations. The DT a person adopts is evidenced in specic patterns of altered movement and alignment used across multiple daily activities. The use of a specic pattern results in decreased variability in the types of lumbar joint movements and alignments used across the day. The reduction in variability then is considered to predispose a person to the development, or persistence and recurrence of LBP. Specically, the exposure of spinal tissue to repeated low magnitude loading in the same direction across a day is proposed to contribute to the accumulation of tissue stress. Stresses on the tissue can contribute to symptoms, microtrauma and, potentially, macrotrauma. This set of events is considered

STUDIES OF SELECT ASPECTS OF THE KINESIOPATHOLOGICAL MODEL

Various studies have been conducted to examine aspects of the Model in people with LBP. One group of studies has used standardized clinical tests (Van Dillen etal. 1998; Luomajoki etal. 2007), designed to identify the pattern of movement, alignment (Henry etal. 2012) and symptoms that characterizes a persons relevant lumbar directional tendency. These studies have focused on whether there are subgroups of people with LBP based on symptoms and the DT identied with clinical tests (Van Dillen etal. 2003b; Trudelle-Jackson etal. 2008; Harris-Hayes etal. 2009), if the subgroups differ from people without LBP (Luomajoki etal. 2008), and the relationship of select test ndings to symptom report (Van Dillen etal. 2001, 2009), sex (Scholtes and Van Dillen 2007), activity type (Van Dillen etal. 2003a, 2006), severity of the LBP condition (De Vito etal. 2007) and injury risk (Roussel etal. 2009). A second group of studies has used laboratory instrumentation to quantify the patterns of movement and alignment with clinical tests to examine

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Repetition of movements and alignments with everyday activities

Musculoskeletal changes, e.g. stiffness, strength, joint flexibilty

Neural changes, e,g. muscle timing, muscle recruitment patterns

Personal characteristics, e.g. activity level, sex, structural variations, generalized hypermobility

Adoption of movement and alignment patterns

Relative flexibility lumbar region

Accumulation of tissue stress, symptoms, tissue injury Figure 8.2 Details of the processes proposed for the development and course of low back pain based on the kinesiopathological model.

differences among LBP subgroups (Gombatto etal. 2007; Van Dillen etal. 2007), differences between people with LBP and people without LBP (Norton etal. 2004; Porter etal. 2009; Scholtes etal. 2009), sex differences (Gombatto etal. 2006) and mechanisms underlying clinical test ndings (Gombatto etal. 2008b, 2009). In the following sections we describe ndings from a subset of these studies that examine some of the major assumptions of the Model as applied to LBP. The studies examine whether: (i) people with LBP can be subgrouped based on movement and alignment patterns that reect a specic DT; (ii) the DT identied with clinical tests is related to the types of repetitive movements that a person participates in regularly; and (iii) the DT a person displays is related to musculoskeletal, neural or personal factors or some interaction of these factors.

Movement and alignment patterns

One assumption of the Model is that people with LBP display movement and alignment patterns that reect their DT and the patterns are used across a variety of activities.

In addition, it is assumed that there are different subgroups of people with LBP who differ based on the specic DT that characterizes their LBP condition. We tested this assumption by examining 188 people with LBP (72% chronic (Spitzer etal. 1987)) using a standardized examination that included clinical tests of movement and alignment performed in different positions (Van Dillen etal. 1998, 2003a). Each test is proposed to assess one of the following directional tendencies: exion, extension, rotation, or a combination of rotation with exion or rotation with extension. We predicted that a person would demonstrate positive ndings across tests that assess a specic DT, for example, lumbar exion. We also predicted that a person would demonstrate negative ndings across tests that assess other directional tendencies. Thus, there would be groupings of tests that would represent different DTs that characterize different LBP subgroups. To test the prediction, a statistical technique referred to as factor analysis (Nunally and Bernstein 1994) was applied to two different random samples from the examination data. Factor analysis provides groupings of inter-correlated tests referred to as factors. We predicted that the factors retained from the

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no differences in the amount of lumbar curvature angle (NoLBP: 40.214.8; LBP: 42.515.2). The RotExt subgroup, however, displayed more lumbar extension (46.714.7) than the (i) NoLBP group and (ii) RotFlex subgroup (38.214.1). In addition, the lumbar curvature angle for the RotExt and Ext (43.416.2) subgroups were the same. These data demonstrate that predictable differences in alignment could be identied: (i) between people with and people without LBP when the comparison was made to a specic LBP subgroup; and (ii) among people with LBP when they were subgrouped based on the DT with clinical tests from a standardized examination.

two separate analyses would represent groups of tests consistent with the different proposed LBP subgroups. Three factors were identied in both samples. The factors represented groups of tests that were proposed to capture a DT for lumbar (i) extension, (ii) rotation and (iii) rotation with extension. These ndings provide evidence that clinical test ndings correlate in ways consistent with three of the proposed LBP subgroups, and the subgroups differ based on their DT. To examine whether the clinical test ndings from this data set were relevant to the persons LBP condition we conducted a secondary analysis (Van Dillen etal. 2003a). Typically, each clinical test that results in an increase in symptoms is immediately followed by a second test in which symptoms are monitored while the persons DT is systematically modied. The typical modication involves either (i) positioning the lumbar region in neutral (or as close as possible) or (ii) restricting the timing or amount of lumbar joint(s) movement while movement in other joints is encouraged. An improvement in symptoms with the second test would provide additional support for the importance of the DT observed with the rst test. For each clinical test in which people reported an increase in symptoms, we analyzed symptom responses during the second test. We found that for the majority of tests (86%), the majority of people (76%15%) reported an improvement in symptoms when their DT was modied with the second test. Similar ndings with additional clinical tests have been reported in a sample that included larger proportions of people with acute and subacute LBP (42%) than our original study (Van Dillen etal. 2009). These data suggest that the DT displayed during clinical tests is related to a persons LBP symptoms and systematically changing the DT with performance of the tests improves symptoms. We also tested the assumption that people with LBP display movement and alignment patterns that reect their DT by comparing people in different LBP subgroups (N=100; 72% chronic) to each other, and to people without LBP (NoLBP; N=60) (Norton etal. 2004). The people with LBP were assigned to a subgroup based on their DT identied across clinical tests (Van Dillen etal. 2003b; Trudelle-Jackson etal. 2008). The subgroups examined were rotation with extension (RotExt; N=62), rotation with exion (RotFlex; N=18) and extension (Ext; N=20). Because a persons DT can be reected in his or her alignment we measured lumbar region alignment in standing. We predicted that: (i) the RotExt subgroup would stand in more lumbar extension than the NoLBP group and the RotFlex subgroup; and (ii) the RotExt and Ext subgroup would stand in the same amount of lumbar extension. To test these predictions we used a non-invasive, electromechanical digitizer and trigonometric method (Youdas etal. 1995) to quantify the lumbar curvature angle in the sagittal plane. All people were measured while maintaining a comfortable standing position. When the NoLBP group was compared to all LBP subjects there were

Repetition of movements and alignments

A second assumption of the Model is that a specic DT is, in part, a consequence of repetition of: (i) movements, both trunk and limb, that induce lumbar region movement in the same direction and (ii) sustained positions in the same direction. We examined this assumption by comparing an LBP group (N=50; chronic or recurrent (Von Korff 1994)) that regularly participated in sports that put rotational demands on the trunk and hips and a NoLBP group (N=41) that did not participate in rotation-related sports. Kinematics were captured during two active lower limb movement tests performed in prone, hip lateral rotation and knee exion (Scholtes etal. 2009). We have found in prior work that these limb movement tests are often symptom-provoking in people with LBP (Van Dillen etal. 2001). The limb movements were also thought to be those that were frequently used during the sports activities and, thus, might impact the lumbopelvic region. Because people with LBP are thought to move the lumbar region more readily than people without LBP we predicted that the LBP group would display earlier lumbopelvic motion with each limb movement test than the NoLBP group. We indexed the persons DT by calculating the difference in time between the start of limb movement and the start of lumbopelvic rotation normalized to the limb movement time. We also measured subject characteristics, LBP history, sports participation and activity levels (Baecke etal. 1982). We found that the two groups were the same except for three of the kinematic variables. The groups displayed equal hip rotation (LBP: 44.286.38; NoLBP: 41.596.62), however, the LBP group had slightly less knee exion (114.288.60) than the NoLBP group (119.959.31). As predicted, for both tests the LBP group rotated the lumbopelvic region earlier during the limb movement than the NoLBP group (Fig. 8.3A). Interestingly, the LBP group also had a greater magnitude of end-range lumbopelvic rotation than the NoLBP group with both limb movement tests (Fig. 8.3B). In addition, when the early lumbopelvic rotation was modied during

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No LBP

No LBP 0.50 Normalized time difference between the start of limb movement and lumbopelvic rotation LBP 6.00

LBP

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* *

Maximal pelvic rotation (degrees)

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Hip lateral rotation Group

Knee flexion B

Hip lateral rotation Knee flexion Limb movement test

Figure 8.3 (A) Mean and 95% condence intervals of ratios of the difference in time between the start of lumbopelvic rotation and the start of the limb movement normalized to the limb movement time for people with LBP and people without LBP. The ratios are provided for both groups for lumbopelvic rotation during two tests performed in prone, hip lateral rotation and knee exion. The smaller the ratio the sooner the lumbopelvic region begins to move during the limb movement. The asterisk indicates a signicant difference between the two groups. People with LBP rotate the lumbopelvic region earlier with both lower limb tests. (B) Mean and 95% condence intervals of the maximal lumbopelvic rotation for people with LBP and people without LBP with two limb movement tests performed in prone, hip lateral rotation and knee exion. The asterisk indicates a signicant difference between the two groups. (A) and (B) adapted from Scholtes, S.A., Gombatto, S.P., Van Dillen, L.R.,
2009. Differences in lumbopelvic motion between people with and people without low back pain during two lower limb movement tests. Clinical Biomechanics 24, 7, with permission from Elsevier.

the symptom-provoking limb movement tests, the majority of people reported an improvement in their symptoms with the tests (hip rotation: 93%; knee exion: 88%). These ndings support the idea that the DT displayed by a person with LBP is related to the types of trunk and limb movements the person performs on a regular basis and to the persons LBP symptoms. We identied a similar relationship between types of repetitive movements people participated in and the DT displayed with trunk and limb clinical tests in people with LBP who regularly performed two different types of leisure time activities; symmetrical activities and asymmetrical activities (Van Dillen etal. 2006). An additional comparison was made between two groups who both participated in rotation-related sports; an LBP group (N=50) and a NoLBP group (N=25) (Porter etal. 2013). The same two normalized movement variables were measured as in the previously described study. We found that the kinematic variable to index a persons DT, the time between the start of the limb movement and the start of lumbopelvic rotation, was the same for both groups (hip rotation: LBP: 0.210.18, NoLBP: 0.200.13;

knee exion: LBP: 0.250.21, NoLBP: 0.290.18). The two groups were also the same with regard to all other variables except their activity levels. Sport activity levels from the Baecke Habitual Activity Questionnaire (Baecke etal. 1982) were the same between the two groups (LBP: 3.680.55; NoLBP: 3.550.61). However, people with LBP reported a lower daily activity level (average work + leisure scores; 2.330.30) than people without LBP (2.650.54). These ndings suggest two ideas. First, the activity a person participates in regularly appears to contribute to movement patterns related to the activity. Second, the imbalance between routine daily activities and higher intensity activities may be an important factor that interacts with a persons DT to contribute to an LBP condition. Interestingly, in the same cohort of subjects a preliminary analysis of a different clinical movement test, rocking backward from a quadruped position, demonstrated that the LBP group and the NoLBP group do not display the exact same lumbar region movement pattern across the test movement (Meroni etal. 2009). In the preliminary analysis, the LBP group displayed a greater magnitude of lumbopelvic movement late in the test

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Average passive elastic energy (Nmdeg)

movement compared to the NoLBP group. Thus, compared to people without LBP, the tendency of people with LBP to move the lumbopelvic region more readily was evident as a difference in the magnitude of lumbopelvic region movement rather than a difference in timing of initiation of movement between the lumbopelvic region and the limbs.

200

Side of greater passive elastic energy Side of lesser passive elastic energy

150

Contributing factors
A third assumption is that a persons DT can be related to: (i) musculoskeletal factors; (ii) neural factors; (iii) personal factors; or (iv) any interaction of these factors. We examined the potential relationship of a musculoskeletal factor, passive elastic energy, to a persons DT by comparing a RotExt subgroup (N=22; chronic or recurrent) to a NoLBP group (N=19) (Gombatto etal. 2008b). In prior work we found that people in the RotExt subgroup displayed more asymmetry in their DT than people in the Rot subgroup when they performed the clinical tests of trunk lateral bending and hip lateral rotation (Gombatto etal. 2007; Van Dillen etal. 2007). We reasoned that the asymmetry of lumbar region movement with trunk lateral bending could be, in part, a reection of the passive resistance of structures in the trunk encountered across the trunk movement. Based on our prior study ndings, we predicted that with trunk lateral bending the RotExt subgroup would be more asymmetrical in passive elastic energy of the trunk than a NoLBP group. A passive movement device, a motion capture system and surface electromyography (Gombatto etal. 2008a) were used to capture data to examine our prediction about lumbar region passive elastic energy. The instrumentation provided position and force data during passive trunk lateral bending on a friction-free surface. Trunk muscle activity was monitored during the trunk movement to assure that the movement was passive (Scannell and McGill 2003). The groups were the same with regard to subject characteristics, activity levels and end range of trunk lateral bending motion. The two groups were also no different in their total passive elastic energy (NoLBP: 103.5510.46Nmdeg; RotExt: 103.919.73Nmdeg). The RotExt subgroup, however, displayed a greater difference in passive elastic energy between sides than the NoLBP group (Fig. 8.4). These data suggest that the LBP and NoLBP groups maintain the same overall level of passive tissue characteristics of the trunk in the frontal plane but, as predicted, the RotExt subgroup displays more asymmetry in these characteristics than the NoLBP group. We also have examined the potential relationship between sex and a persons DT. Because men differ from women structurally and physiologically (Chow etal. 2000; Toft etal. 2003), it would follow that men may differ from women in their movement patterns. We have tested this relationship with select clinical movement tests (Scholtes and Van Dillen 2007; Van Dillen etal. 2007) as

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Group of people with no low back pain Group

Rotation with extension low back pain subgroup

Figure 8.4 Mean and 95% condence interval of passive elastic energy with each direction of trunk lateral bending for people in the Rotation with Extension LBP subgroup compared to people with no LBP. The side of greater elastic energy was compared to the side of lesser passive elastic energy for each group. The total passive elastic energy was the same between groups. The asterisk indicates a greater difference in passive elastic energy between sides, i.e. more asymmetry, in the Rotation with Extension subgroup when compared to the people with no LBP. Reproduced from
Gombatto, S.P., Norton, B.J., Scholtes, S.A., Van Dillen, L.R., 2008. Differences in symmetry of lumbar region passive tissue characteristics between people with and people without low back pain. Clinical Biomechanics 23, 986, with permission from Elsevier.

well as with instrumented measures of alignment (Norton etal. 2004). We rst examined this relationship by comparing men (N=27) and women (N=19) with LBP in our cohort of people who participated in rotation-related sports (Gombatto etal. 2006). Kinematic data and LBP symptoms were recorded during the clinical test of active hip lateral rotation. We examined hip lateral rotation because there are data to suggest that men display more active and passive stiffness of the lower limbs than women (Gajdosik etal. 1990; Granata etal. 2002; Blackburn etal. 2004; Staron etal. 2000). We reasoned that if men have more lower limb stiffness than women, men may move the lumbar region more readily than women. To index the DT with hip lateral rotation we quantied the range of available lumbopelvic rotation used across the

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70 60 Percent lumbopelvic rotation (%) 50 40 30 20 10 0 A

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Men Gender

Women B

Men Gender

Women

Figure 8.5 (A) Mean and standard deviation for the percent of lumbopelvic rotation motion attained at 60% of the maximum hip lateral rotation motion for men and women with LBP. The asterisk indicates that the men used more of their available lumbopelvic rotation than women at the 60% point of the hip lateral rotation motion. (B) Mean and standard deviation for the percent of lumbopelvic rotation motion attained at 60% of the maximum hip lateral rotation motion for men and women who reported an increase in LBP symptoms with the test movement. The asterisk indicates that the men used more of their available lumbopelvic rotation than women at the 60% point of the hip lateral rotation motion. (A) and (B) reproduced from
Gombatto, S.P., Collins, D.R., Sahrmann, S.A., Engsberg, J.R., Van Dillen, L.R., 2006. Gender differences in pattern of hip and lumbopelvic rotation in people with low back pain. Clinical Biomechanics 21, 263, with permission from Elsevier.

range of the hip movement. Specically, we calculated the percentage of maximum lumbopelvic rotation attained at increments of maximum hip lateral rotation. We predicted that the men with LBP would use a greater percentage of their total lumbopelvic motion in the early part of the limb movement than the women with LBP. Men and women were equal with regard to all subject characteristics except weight and LBP history. Compared to women, men were heavier (difference: 18.83.0kg) and had a longer history of LBP (men: 8.16.2 years; women: 3.53.0 years). Men and women displayed the same amount of active hip lateral rotation (men: 44.77.1; women: 42.75.2) and lumbopelvic rotation (men: 6.13.2; women: 4.62.0). Men, however, completed more of their available lumbopelvic rotation in the early part of the hip rotation motion than women (Fig. 8.5A). When we examined only the people who specically reported an increase in symptoms with the hip rotation test, the sex differences were even greater (Fig. 8.5B). Finally, a greater percentage of men (70.4%) reported an increase in symptoms with the hip rotation test than women (36.8%). This was the case even though baseline LBP symptom ratings between men and women were the same (verbal numeric pain

rating scale (010) (Jensen etal. 1986): men: 2.91.4; women: 3.91.7). These data suggest that men with LBP may have more of a tendency to move the lumbopelvic region early in a limb movement than women with LBP, and the lumbopelvic movement with the hip movement may be more likely to be associated with symptoms in men with LBP than women with LBP. A second examination of the relationship between sex and a persons DT was based on a secondary analysis of a subset of clinical test responses obtained from the people with LBP in our factor analysis study described previously (Van Dillen etal. 2003b; Scholtes and Van Dillen 2007). The goal was to examine if the sex differences in kinematics we identied with the hip lateral rotation test would be generalized to other lower limb movement tests in a larger, more heterogeneous sample of people with LBP. The sample included 170 people with LBP (84 men, 86 women) who had participated in our standardized examination. Based on our prior study (Gombatto etal. 2006) we predicted that with each of the tests more men would display early lumbopelvic movement during the lower limb movement test than women. Men and women were the same with regard to all subject characteristics. We

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Table 8.1 Means and standard deviations of sagittal lumbar curvature calculated based on the tangent method, organized by gender and low back pain subgroup. Low back pain subgroup Low back pain (all subgroups) Rotation with extension (N =62) Rotation with exion (N =18) Extension (N =20) Women 48.814.5 50.514.7 47.09.7 46.217.5 Men 35.012.5 39.712.3 34.914.4 35.07.4 Both 42.515.2 46.714.7 38.214.1 43.416.2

Note that there are differences between men and women consistent with other studies of sagittal lumbar curvature using surface measurement devices. Women stand in more extension than men. Men in the rotation with extension subgroup, however, stand in more extension than men in the rotation with exion subgroup. Adapted with permission from Norton, B.J., Sahrmann, S.A., Van Dillen, L.R., 2004. Differences in measurements of lumbar curvature related to gender and low back pain, Journal of Orthopaedic and Sports Physical Therapy 34 (9), 524534. doi: 10.2519/jospt.2004.1570.

found that for three of the four lower limb movement tests, a larger percentage of men displayed early lumbopelvic motion with the limb movement than women (knee extension in sitting: men: 38.1%, women: 18.6%; knee exion in prone: men: 45.2%, women: 19.8%; hip lateral rotation in prone: men: 66.3%, women: 32.6%). To examine the effect of symptoms on responses during a test we also analyzed the data from the subset of people who reported an increase in symptoms with a test. The ndings were the same as for the group as a whole (knee extension in sitting: men: 58.1%, women: 26.9%; knee exion in prone: men: 63.2%, women: 32.0%; hip lateral rotation in prone: men: 76.2%, women: 43.2%). These data provide additional support for the idea that sex may be a factor that contributes to lumbopelvic movement patterns, and that men may be more likely than women to display early lumbopelvic movement with lower limb movements. In addition, these data suggest that the early lumbopelvic movement during a test movement is present even when symptoms are reproduced during the test. The relationship between sex and a persons DT was also examined in our previously described study using the electromechanical device to measure lumbar alignment in standing (Norton etal. 2004). Earlier studies based on non-invasive measures of sagittal plane spinal alignment have documented that women stand in more lumbar extension than men (Bergenudd etal. 1989; Youdas etal. 2000). Given these prior ndings we wanted to know whether the differences in lumbar region alignment we identied among the different LBP subgroups were solely the result of differences in the distribution of men and women in the various subgroups. We predicted that differences in lumbar curvature angle among LBP subgroups would be related to sex. Overall, we found that there was a relationship between sex and LBP subgroup. The percentage of women in the RotExt (65%) and Ext (75%) subgroups was greater than the percentage of men in each

subgroup. Conversely, the percentage of men in the RotFlex (72%) subgroup was greater than the percentage of women in the subgroup. Inspection of the lumbar curvature angles, however, suggested that sex was not the only determinant of LBP subgroup (Table 8.1). We found that men and women in the RotExt subgroup were more extended than their counterparts in the RotFlex subgroup, but that men were not as extended as the women in either subgroup. On the other hand, women in the RotFlex subgroup were not as extended as women in the RotExt subgroup, but were more extended than men in either subgroup. These ndings suggest that sex is not the sole determinant of a persons DT as reected in lumbar region alignment. Sex along with other variables, for example, activity level or occupation, may modify the DT a person displays and, thus, the type of LBP condition he or she presents with.

SUMMARY
The processes described in the kinesiopathological model provide a potential explanation for the role of repetition of movements and alignments during everyday activities in the development and course of an LBP condition. Based on the Model a primary control issue considered to contribute to LBP is the tendency for one or more of the lumbar joints to move more readily than other joints. This tendency to move more readily is typically associated with a specic direction(s) such as exion, extension, rotation or some combination, i.e. a directional tendency. The directional tendency is evidenced by an altered timing or magnitude of movement of one or more lumbar joints with performance of trunk or limb movements or when assuming positions. Recent studies provide initial support for three of the major assumptions of the Model. First,

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people with LBP display a tendency to move one or more of the lumbar joints more readily than other joints across a variety of movements and positions, and the directional tendency displayed assists in identifying subgroups of people with LBP. Second, the types of repetitive movements a person participates in regularly appear to be related to a persons directional tendency. Third, a persons directional tendency is related to select musculoskeletal and personal factors and the interaction of these factors. Additionally, the ndings across studies suggest that the directional tendency a person displays is related to a persons LBP symptoms. Finally, the Model is intended to provide a framework for the role of potential physical and

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personal factors to a LBP condition. The Model does not account for other factors, for example, psychosocial variables, known to inuence the presentation and course of an LBP condition.

ACKNOWLEDGEMENTS
The authors wish to thank Sara P. Gombatto PT, PhD and Sara S. Scholtes, DPT, PhD for their contributions to many of the studies described, and to Kate Baxter for assistance with adapting gures and tables for the text.

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