Originally published in Massage Bodywork magazine, August/September 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.
Your client is a 45-year-old, slightly overweight, office worker. He has a backache that began when he was dressing this morning. While putting on his socks, he felt a twinge in the low back, and since then has become increasingly restricted. He is slightly stooped and tilts a little to the left. When he has been on his feet for more than a few minutes, there is a painful sensation extending from his low back to his right buttock and beyond, as far as the knee.
Movement is awkward, especially getting up and sitting down, as is anything that involves stretching or bending. Coughing, sneezing, and laughing cause a twinge that shoots from the back into his buttock toward the knee.
These symptoms have occurred before, and they usually last a week or so, sometimes longer. But this is the first time there has been pain/discomfort in the leg. In the past, he has received a combination of massage therapy from you and sometimes a chiropractic adjustment or two before the stiffness and pain begin to ease.
He has an appointment with his chiropractor later in the week--the first available appointment.1.
Should you treat him?Answer:
Is his condition one that can be expected to be helped by massage and soft-tissue bodywork methods and exercise?Answer:
Are there any simple ways of knowing which backache clients are most (or least) likely to respond to conservative treatment and simple exercises?Answer:
Yes (see McKenzie Concepts and Directional Preference later in this article, pages 94 and 96, respectively).4.
Should you urge your client to see someone who offers spinal manipulation?Answer:
Spinal-manipulative therapy produces only slightly better outcomes than massage therapy for nonspecific low-back pain of less than three months' duration.3
There is also no evidence that in the first four weeks of treatment, spinal-manipulative therapy is any more effective than McKenzie methods in reducing disability, although according to the Danish Institute of Health Technology Assessment4 there is evidence to support the use of McKenzie-type exercise in the management of acute low-back pain.
I, therefore, urge you to treat this client, both using massage and ideally McKenzie-type, directional-preference exercises, as discussed below.Types of Backache
There is general agreement that low-back pain falls into three broad categories5
Serious spinal pathology, such as a facet syndrome or disc herniation (or non-spinal pathology that refers pain to the spine).2.
Nerve root pain (radicular pain).3.
The third category is the cause of more than 90 percent of cases and is the class of backache that responds well to massage and exercise.6
But how are you to know into which of these groups your client fits?Context
In part one of this article, the importance of understanding the context (the background) of the symptoms presented was stressed.
In that article, we discussed back pain, but the same principle applies to all symptoms. The backache represents a part of a sequence, a snapshot of what's happening now, but the symptoms don't reveal the bigger picture, the background that allowed this to happen. Often the client who presents with common, nonspecific backache is otherwise well. The symptoms usually vary with activity, and this suggests that biomechanical factors are the main aggravating features.7
So, questions to ask include: Why has this person, at this time, developed a backache? Where is this person in the spectrum of compensation, adaptation, vulnerability?
Aspects of the level of adaptation exhaustion/vulnerability can be assessed using a simple sequence described in Assessment of Tissue Preference on page 90. This sequence helps you to evaluate what is known as the common compensatory pattern.
If you had made this assessment during one of your client's previous visits, when he was not in pain, you would have discovered very useful information that might have helped you decide what to do. Now that he is unable to move freely, this assessment, described below, cannot be accurately performed during the acute phase of a backache.8The Common Compensatory Pattern
It is clearly important to have an awareness, as best you can assess this, of the client's current level of vitality and vulnerability, since these features reflect the degree to which the person has adapted to the stresses of life.
G. Defeo and L. Hicks note, "Osteopathic physicians Zink and Lawson have observed clinically that a significant percentage of the population assumes a consistently predictable postural adaptation, arising from nonspecific mechanical forces such as gravity, gross- and micro-trauma, and other physiological stressors. These forces appear to have their greatest impact on the articular facets in the transitional areas of the vertebral column."9
G. Zink and W. Lawson described methods for testing tissue preference in these transitional areas, where fascial and other tensions and restrictions can most easily be noted: occipitoatlantal (OA), cervicothoracic (CT), thoracolumbar (TL), and lumbosacral (LS).10
These sites are tested for rotation preferences (described below).
Zink and Lawson's research illustrated that most people display (assessing the occipitoatlantal pattern first) alternating patterns of rotatory preference, with about 80 percent of people showing a common pattern of Left-Right-Left-Right (LRLR) compensation, termed the common compensatory pattern (CCP).
Tissue preference is the sense that the palpating hands derive from the tissues being moved, as to the preferred direction(s) of movement (for example, at its simplest, "This area turns more easily [and further] to the right than the left and, therefore, has a preference to turn right").
Evaluation can be conceived as a series of questions asked of the tissues as they are moved to test whether there is greater freedom turning in one direction compared with the other. (The terms comfort, position of ease, and tissue preference all mean the same thing and are directly opposite to directions that engage barriers, or move toward bind or restriction.)Observed CCP Signs
Defeo and Hicks described the observed signs of CCP as follows: "In CCP, an examiner will note the following observations in the supine patient. The left leg will appear longer than the right. The left iliac crest will appear higher or more cephalad than the right. The pelvis will roll passively easier to the right than to the left, because the lumbar spine is side-flexed left and rotated right. The sternum is displaced to the left as it courses inferiorly. The left infraclavicular parasternal area is more prominent anteriorly, because the thoracic inlet is side-flexed right and rotated right. The upper neck rotates easier to the left. The right arm appears longer than the left when fully extended."11Assessment of Tissue Preference
Note: if a differential assessment is being conducted, the following procedures should be performed both supine and standing. It is suggested you record your findings during the assessment. (Differential assessment is defined on page 91.)Occipitoatlantal (OA) Areaa)
With the client supine, the therapist is seated or standing at the head of the table. Both hands are used to take the neck into maximal unstressed flexion (to lock segments below C2) and the rotational preference is assessed. Is rotation more free left or right?b)
With the client standing, the head/neck is placed in full flexion, and rotation left and right of the head on the neck is evaluated for the preferred direction (range) of movement. Is rotation more free left or right?Cervicothoracic (CT) Areaa)
The client is supine and the therapist places the hands so that they lie, palms upward, beneath the scapulae. The therapist's forearms and elbows should be in touch with the table surface. Leverage can be introduced by one arm at a time, as the therapist's weight is introduced toward the floor, through one elbow, and then the other, so easing the client's scapulae anteriorly. This allows a safe and relatively stress-free assessment to be made of the freedom with which one side, and then the other, moves, producing a rotation at the cervicothoracic junction. Rotational preference can easily be ascertained. Is rotation more free toward the left or the right?b)
The client is seated or standing in a relaxed posture with the therapist behind, with hands placed to cover the medial aspects of the upper trapezius, so that his fingers rest over the clavicles and thumbs rest on the transverse processes of the T1/T2 area. The hands assess the area being palpated for its tightness/looseness preferences as a slight degree of rotation left and then right is introduced at the level of the cervicothoracic junction. Is rotation more free toward the left or the right?
If there was a preference for the OA area to rotate left, then if CCP applies to this person, there should be a preference for right rotation at the CT junction.Thoracolumbar (TL) Areaa)
The client is supine or prone. The therapist stands at waist level facing cephalad and places the hands over the lower thoracic structures, fingers along the lower rib (seven, eight, nine, ten) shafts.
Treating the structure being palpated as a cylinder, the preference for the lower thorax to rotate around its central axis is tested one way and then the other. Is rotation more free toward the left or the right?
The preferred TL rotation direction should be compared with those of OA and CT test results. An alternation in these should be observed if a healthy adaptive process is occurring.b)
With the client standing, the therapist stands behind and with hands over the lower thoracic structures, fingers along the lower rib shafts. The preference for the lower thorax to rotate around its central axis is tested one way and then the other. Is rotation more free toward the left or the right?
Alternation with previously assessed preferences should be observed if a healthy adaptive process is occurring.Lumbosacral (LS) Areaa)
The client is supine. The therapist stands below waist level facing cephalad and places hands on the anterior pelvic structures. Use the contact as a steering wheel to evaluate tissue preference as the pelvis is rotated around its central axis, seeking information as to its tightness/looseness preferences. Is rotation more free toward the left or the right?
Alternation with previously assessed preferences should be observed if a healthy adaptive process is occurring.b)
The client is standing, and the therapist, standing behind, places his hands on the pelvic crest and rotates the pelvis around its central axis to identify its rotational preference. Is rotation more free toward the left or the right?Questions You Should Ask Yourself Following this Assessment1.
Was there an alternating pattern to the tissue preferences, and was this the same when supine and when standing? See explanation under the Differential Assessment at right.2.
Was there a tendency for the tissue preference to be in the same direction in all, or most of, the four areas assessed?3.
If the latter was the case, was this in an individual whose health is more compromised than average (in line with Zink and Lawson's observations)?4.
What therapeutic methods would produce a more balanced degree of tissue preference?Interpretation
- If there is an alternating pattern (LRLR), the person is demonstrating CCP, and this suggests that adaptation potential remains a feature and that the person will be responsive to appropriate treatment.
- If there is no evidence of CCP--with rotational preferences displayed, for example, as LLLL, RRRR, LLRL, or anything other than the ideal alternation (LRLR or RLRL)--then adaptation potential is compromised or exhausted, and the person is likely to respond inappropriately to treatment. Symptoms may worsen, or new symptoms may appear as adaptation fails and tissues decompensate, and changes induced by treatment fail to be coped with.
- Poorly compensated individuals should be treated with great care, ideally using general, constitutional, whole-body methods (wellness massage, relaxation, breathing exercises, gentle exercise, constitutional hydrotherapy, etc.) and not with specific interventions such as mobilization, manipulation, specific muscle stretches, etc.Differential Assessment12 (based on findings of supine and standing Zink tests)
If the rotational preferences alternate when the client is supine (for example, LRLR), and display a greater tendency to not alternate (i.e., they rotate in the same directions--for example, LLLL) when standing or sitting, a dysfunctional adaptation pattern that is ascending is most likely (i.e., the major dysfunctions that are imposing adaptive demands lie in the lower body, pelvis, or lower extremities).
If the rotational pattern remains the same when supine and standing, this suggests the adaptation pattern is primarily descending (i.e., the major dysfunctional patterns imposing adaptive demands lie in the upper body, cranium, or jaw).Overuse and Misuse
As adaptive changes take place in the musculoskeletal system due to overuse, misuse, trauma, or disuse, and as decompensation progresses toward more compromised degrees of dysfunction, structural modifications appear (muscles may fibrose, shorten, weaken, lengthen, distort, develop trigger points, etc.), as whole-body, regional, and local postural changes evolve.
In that situation, a bending or twisting movement (such as putting on shoes) that would cause no problems at all for supple, well-toned tissues, might result in a twinge, a local irritation, that causes protective guarding by local muscles and a stooped, distorted, painful, and restricted outcome, just like the one your client is displaying.
Or, the slow wear and tear of overuse, misuse, trauma, or disuse may have led to a weakening of spinal disc structures, so that as the client bent to put his socks, the movement resulted in not just a local muscle irritation, but the start of an actual disc herniation. At this stage a herniation causes protective guarding by local muscles and a stooped, distorted, painful, and restricted outcome, just like the one your client is displaying.
The stooping action to put on socks was not the cause, but merely the trigger. The cause was present in the form of the cumulative micro-trauma adaptations that had produced the changes in the client's soft tissues and joints over a period of time.What Associated Features May be Present in Your Client?
There are numerous adaptive changes that can interfere with the ability of muscles to perform their support and movement tasks (motor control), resulting in back pain, including:
- Anxiety and other emotional states.13
- Endocrine disturbances (such as underactive
- Deconditioning/disuse (the opposite of being aerobically conditioned).15
- Disturbed balance.16
- Disturbed information gathering (proprioceptive input, including visual and auditory signals).
- Overuse and trauma (abuse) associated with poor posture, shortened and/or weakened muscles, unbalanced firing sequences, joint restrictions (physiological "misuse").20
- Poor nutrition.21
- Trigger point activity.22
Stuart McGill 23
summarizes the ideal: "The muscular and motor system must satisfy the requirements to sustain postures, create movements, brace against sudden motion or unexpected forces, build pressure, and assist challenged breathing, all the while ensuring sufficient stability." If these requirements are not met, problems such as backache become inevitable.A Plan
You need to identify what the client wants or needs to do that he cannot now do because of the backache (described either as functional goals or activity intolerances).
You need to identify what the client can do (summarized as capabilities). Ask him: What are your functional-activity goals? What can't you do? What do you find painful to do? What are you avoiding for fear of hurting yourself? What are you concerned you won't be able to do in the future?
Treatment and rehabilitation are designed to close the gap between what clients can do and what they want or need to do. Reassurance is achieved by means of ruling out the presence of serious disease and focusing on improving function. Clients need to know the pain being experienced is part of a functional backache, which makes up around 95 percent of all such problems, and that recovery may take several weeks.
If you have any doubt that this is a simple backache, it is necessary for the client to get a diagnosis from an appropriately licensed healthcare professional to establish it is not one of the 3-5 percent caused by cancer, a herniated disc, arthritic change, or other serious cause of inflammation.
Once pathology has been ruled out, an important message early on should be to help the client understand that hurt doesn't necessarily mean harm. There may be discomfort during treatment, rehabilitation, and exercising, but it is not causing any damage.
Once serious pathology has been ruled out, various modalities may help in treating back pain, including massage, deactivation of local trigger points (these can be responsible for much back pain),24 manipulation, stretching, ultrasound, hydrotherapy, and exercise.
You might advise your client that, in most cases of back pain, there is a great deal of evidence that it is important to not take to bed rest (unless it is absolutely necessary, as in some acute disc herniation situations).
A review of many studies concluded that bed rest has no positive effect for back pain and may have slightly harmful effects.25 General Assessment
Ideally the client should then--using standard tests--be evaluated to discover:
You can employ a wide range of commonly used assessments, depending on the type and degree of training you have. Texts such as Whitney Lowe's Orthopedic Massage (Elsevier, 2004) can greatly help in developing evaluation skills.
The general assessment methods that might be used could include all or any of the following:
-Assessment for soft-tissue texture changes, tenderness, asymmetry, and soft-tissue, range-of-motion changes.26
-Breathing pattern evaluation.28
-Checking key points and aspects of alignment and balance, with the client static, active, standing, walking, sitting, and reclining. What's asymmetrical, out of balance, and distorted?29
-Evaluation incorporating awareness of fascial
-Light touch and deeper palpation. Seeking
evidence of dysfunction.32
-Mechanical interface assessments for nerve involvement (e.g., upper limb tension tests).34
-Neuromuscular technique palpation. Seeking
evidence of active trigger points.35
n Observing postural evaluation, including crossed syndrome patterns, layer syndrome, and core stability. What's loose, what's painful, what's tight/restricted, and why?36
-Off-body scanning for temperature variations.39
-Range-of-motion and functional assessments of joints, including joint-play.40
-Visceral and cranial palpation methodology.43Specialized Assessments for Back Pain
In order to appreciate the value of the approaches outlined below, it is necessary for you to understand the key concepts of centralization and peripheralization.1.
If, when performing an active movement, or during the holding of a static position, the symptoms (back pain and, in this case, referred pain into the buttock and leg) spread further, it is peripheralizing. This is a negative and most undesirable change, and it indicates that the position or movement is contraindicated.2.
If during movement or positioning, central spinal pain that is not radiating into the buttock or limb at the start becomes more intense or starts to radiate or refer into the buttock or limb, it is peripheralization (number one above), i.e., the position or movement is contraindicated.3.
On the other hand, if, when performing an active movement or during the holding of a static position, the symptoms (back pain and, in this case, referred pain into the buttock and leg) retreat or move toward the spine, this is evidence of centralization. This is a positive and desirable change and indicates that the position or movement is strongly indicated as a therapeutic measure.4.
If during movement or positioning, central spinal pain that is not radiating into the buttock or limb at the start decreases or abolishes lumbar midline pain, it is centralization (number three above), i.e., the change indicates the position or movement is strongly indicated as a therapeutic measure.McKenzie Concepts
The highly successful Robin McKenzie assessment and treatment approaches place great emphasis on the client's response to movement and positioning.44
As a client is put through a series of positions and repetitive movements, reactions are assessed. Does pain intensity rise or fall? Does the location of the pain change? Does the range of motion increase or decrease?
These findings are considered more important than any palpatory findings, and in many cases, a successful McKenzie examination can be performed without the therapist actually touching the client.
Note: to use the McKenzie approach successfully as a therapeutic measure, appropriate training is required. The outline of the basic methodology below is not meant as instruction, but has the intention of offering a description of the simplest aspects of McKenzie assessment (see Directional Preference on page 96).Method
Ask the client to stand hands on hips with fingers oriented posteriorly. Request that he register the pain/discomfort that is being experienced by ascribing a value out of ten--where zero is no pain and ten is the worst pain imaginable--and also to register where the pain is being felt. Then, ask the client to slowly introduce a slight backward bend, an arching of the spine, by about 10-15 degrees, and to hold this for some seconds while evaluating whether the pain level has changed (and if he has to report the new pain level out of ten) and also to evaluate whether or not the pain location has altered. If the pain decreases, and/or moves centrally while in this extension position, this indicates that extension exercises are likely to be helpful.
Ask the client to slowly introduce a slight forward bend, a flexing of the spine, by about 10-15 degrees, and to hold this for some seconds while evaluating whether the pain level has changed (and if he has to report the new pain level out of ten) and also to evaluate whether or not the pain location has altered. If the pain decreases and/or moves centrally while in this flexion position, this indicates that flexion exercises are likely to be helpful. These two positions are repeated with the client seated (extension and flexion), and the results are recorded.
The same two positions are repeated with the client lying prone (for extension, introducing a slight--20 degrees--push-up extension) and supine (for flexion, drawing flexed knees toward the chest). Again, changes in pain levels and/or distribution of pain (more widespread, more toward the spine?) are recorded. Those positions that relieve pain or that produce centralization are repeated as homework, and any positions that increase pain, reduce range of movement, or encourage peripheralization, are discouraged.Additional Input
As well as adding overpressure to increase the effects of flexion and extension in the supine and prone positions described above, therapists trained in McKenzie methodology also test lateral translation movements, both exaggerating and reducing any side-flexion that may have occurred, to see whether this causes centralization or peripheralization. A series of active, repetitive movements that have positive effects are commonly suggested, and mobilization and manipulation may also be given.
A study involving directional preference in clients with backache, based on McKenzie principles, is described in Directional Preference on page 96.
Note: none of these measures are recommended unless you have training in the use of McKenzie protocols.Incorporating Findings from Assessment Into Treatment
So your slightly overweight client with a backache has arrived and requests treatment.
If, in the past when he was not in acute pain, you had evaluated him using the Zink-Lawson test, you would now know whether his compensation pattern was common (i.e., alternating) or not. This would inform you as to whether it is safe or unwise to offer anything other than general massage.
If the test then demonstrated the uncompensated pattern (LLLL or RRRR), then only general, nonspecific, massage should be given. If you had established that a compensated pattern was evident (for example, LRLR) you could now usefully treat dysfunctional features you identify, such as stretching shortened muscles or deactivating trigger points, along with therapeutic massage.
Irrespective of CCP findings, you can safely ask the client to carefully identify positions that produce centralization, as described above, and to avoid any positions that produce peripheralization. Gentle homework incorporating the centralizing exercises would then be appropriate.Prevention
Once the acute backache has normalized over a period of several weeks, as a rule you should consider a comprehensive reassessment of dysfunctional features (what's weak, what's tight, what's out of balance, etc.) followed by advice on rehabilitation, home stretching, home toning, core stability, better posture and ergonomics, breathing, and use patterns.
In that way, you will be doing what is needed to ensure prevention. That is the best practice.Leon Chaitow, ND, DO, MRO, is a practicing naturopath, osteopath, and acupuncturist in the United Kingdom, with more than forty years of clinical experience. He is a prolific writer and has published more than sixty texts. Chaitow is editor of the Journal of Bodywork and Movement Therapies. He regularly lectures in the United States as well as Europe and was until his retirement in 2004 a senior lecturer at London's University of Westminster, where he remains an honorary fellow. In 1992 he became the first person in the U.K. to be appointed as a consultant naturopath/osteopath to a government-funded National Health Service practice, a position he still holds. Contact him at www.leonchaitow.com.Notes
1. E. Ernst, "Massage therapy for low back pain: A systematic review," J Pain Symptom Management 17 (1999): 65-69.
2. A. Furlan et al., "Massage for low back pain," Cochrane Database Syst Rev 4 (2000): CD001929.
3. M. Ferreira et al., "Efficacy of spinal manipulative therapy for low back pain of less than three months' duration," Journal of Manipulative and Physiological Therapeutics 26, no. 9 (2003): 593-601.
4. Danish Institute of Health Technology Assessment, "Low back pain: Frequency, management and preventions from an HTA prospective," Dan Health Technol Assess 1 (1999): 70.
5. R. Deyo and J. Weinstein, "Low back pain," N England J Medicine 344 (2001): 363-370.
6. M. Pope, R. Phillips, and L. Haugh, "A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain," Spine 19 (1994): 2571-2577.
7. G. Waddell, The Back Pain Revolution (Edinburgh: Churchill Livingstone, 1998).
8. G. Defeo and L. Hicks, "A Description of the Common Compensatory Pattern in Relationship to the Osteopathic Postural Examination," Dynamic Chiropractic 24 (1993): 11.
10. G. Zink and W. Lawson, "An osteopathic structural examination and functional interpretation of the soma," Osteopathic Annals 7, no. 12 (1979): 433-440.
11. Defeo and Hicks, "A Description of the Common Compensatory Pattern."
12. T. Liem, Cranial Osteopathy Principles and Practice (Edinburgh: Churchill Livingstone/Elsevier, 2004), 340-342.
13. J. Vlaeyen and G. Crombez, "Fear of movement: (Re)injury, avoidance and pain disability in chronic low back pain patients," Manual Therapy 4 (1999): 187-195.
14. J. Lowe and G. Honeyman-Lowe, "Facilitating the decrease in fibromyalgic pain during metabolic rehabilitation," Journal of Bodywork and Movement Therapies 2, no. 4 (1998): 208-217.
15. P. Nixon and J. Andrews, "A study of anaerobic threshold in chronic fatigue syndrome," Biological Psychology 43, no. 3 (1996): 264.
16. J. Winters and P. Crago, eds. Biomechanics and Neural Control of Posture and Movement (New York: Springer, 2000).
17. K. Muller et al., "Hypermobility and chronic back pain," Manuelle Medizin 41 (2003): 105-109.
18. L. Lum, "Hyperventilation syndromes in medicine and psychiatry," Journal of the Royal Society of Medicine 80(1987): 229-231.
19. H. Handwerker and P. Reeh, "Pain and Inflammation," in Proceedings of the 6th World Congress on Pain, ed. M. Bond, J. Charlton, and C. Woolf (Amsterdam: Elsevier, 1991), 59-70.
20. K. Lewit, Manipulation in Rehabilitation of the Motor System, 3rd ed. (London: Butterworths, 1999).
21. J. Brostoff and L. Gamlin, Complete Guide to Food Allergy and Intolerance (London: Bloomsbury, 1992).
22. D. Simons, J. Travell, and L. Simons, Myofascial Pain and Dysfunction: The trigger point manual, Volume 1: Upper Half of Body, 2nd ed. (Baltimore: Williams and Wilkins, 1999).
23. S. McGill, "Functional Anatomy of Lumbar Stability," in Proceedings from the 5th Interdisciplinary World Congress on Low Back and Pelvic Pain (Melbourne, Australia: 2004), 3-9.
24. Simons, Travell, and Simons, "Myofascial pain and dysfunction."
25. K. Hagen, G. Hilde, and G. Jamtvedt, "The Cochrane review of bed rest for acute low back pain and sciatica," Spine 25 (2000): 2932-2939.
26. J. McPartland and J. Goodridge, "Osteopathic examination of the cervical spine," Journal of Bodywork and Movement Therapies 1, no. 3 (1997): 173-178.
27. R. Ward, ed., Foundations of Osteopathic Medicine (Baltimore: Williams and Wilkins, 1997).
28. L. Chaitow, D. Bradley, and C. Gilbert, Multidisciplinary Approaches to Breathing Pattern Disorders (Edinburgh: Churchill Livingston, 2002).
29. Lewit, Manipulation in Rehabilitation of the Motor System.
30. V. Janda, "Evaluation of muscular Imbalance," in Rehabilitation of the Spine, ed. C. Liebenson (Baltimore, Williams and Wilkins, 1996).
31. T. Myers, "Anatomy Trains," Journal of Bodywork and Movement Therapies 1, no. 2 (1997): 91-101 and 1, no. 3 (1997): 134-145.
32. M. Pick, Cranial Sutures (Seattle: Eastland Press, 1999).
33. W. Kuchera and M. Kuchera, Osteopathic Principles in Practice (Columbus, Ohio: Greyden Press, 1994).
34. D. Butler, Mobilisation of the Nervous System (Edinburgh: Churchill Livingstone, 1991).
35. J. DeLany, "American neuromuscular therapy," in Modern Neuromuscular Techniques, ed. L. Chaitow (Edinburgh: Churchill Livingstone, 1996).
36. C. M. Norris, "Spinal stabilisation #4: Muscle imbalance and the low back," Physiotherapy 81, no. 3 (1995): 127-138.
37. C. Liebenson, Rehabilitation of the Spine, 2nd ed. (Baltimore: Williams and Wilkins, 2005).
38. K. Lewit, Manipulation in Rehabilitation of the Motor System.
39. Jean-Pierre Barral, Manual Thermal Diagnosis (Seattle: Eastland Press, 1997).
40. F. Kaltenborn, Mobilization of the Extremity Joints (Bokhandel, Oslo: Olaf Norlis, 1985).
41. A. Vleeming, V. Mooney, T. Dorman, C. Snijders, and R. Stoeckar, eds., Movement, Stability and Low Back Pain (Edinburgh: Churchill Livingstone, 1997).
42. D. Lee, The Pelvic Girdle: An approach to the examination and treatment of the lumbo-pelvic-hip region, 2nd ed. (Edinburgh: Churchill Livingstone, 2000).
43. Jean-Pierre Barral, Visceral Manipulation II (Seattle: Eastland Press, 1989).
44. R. McKenzie, The Lumbar Spine: Mechanical diagnosis and therapy (Waikanae, New Zealand: Spinal Publications, 1981).
45. R. McKenzie and S. May, The Lumbar Spine: Mechanical diagnosis and therapy (Waikanae, New Zealand: Spinal Publications, 2003), 553-563.
46. A. Long, R. Donelson, and T. Fung, "Does it matter which exercise? A randomized control trial of exercise for low back pain," Spine 29 (2004): 2593-2602.