Research


Use of Kleiman-Biomechanical Correction Technique to classify and treat a patient with Failed Back Syndrome.
PURPOSE: 
This case report presents the evaluation and treatment of a patient with failed back syndrome using an innovative classification and treatment-based approach, Kleiman-Biomechanical Correction Technique (BCT). BCT classifies according to resultant forces as determined by patterns of joint(s) dysfunction and is not symptom dependent.

CASE DESCRIPTION: 
A 50-year-old female office-worker with 2-year history of low back pain had multiple physical therapy and chiropractic interventions, massage therapy and 2 recent lumbar laminectomies at L4-5. She was referred for treatment of ongoing right lower extremity (RLE) radiculopathy. Symptoms increased with activity, standing, and sitting. Symptoms decreased with slow guarded movement, lying, walking. Patient reported a decreased ability to perform household chores, heavy work, bending/kneeling, stair climbing and distance walking. Clinical examination showed decreased hamstring flexibility on RLE (70°R/90°L) and Straight Leg Raise (SLR) (68° R /85°L), with Manual Muscle Test (MMT) 3+/5 for bilateral Extensor Hallucus Longus (EHL). Clinical observations were correlated with palpation findings, including sacroccygeal, lumbosacral (L-S), lumbar, and sacroiliac rotation. BCT defined patient as an extension mechanism of resultant forces based on ipsilateral rotation of the L-S spine. In addition, musculoskeletal dysfunction(s) were defined as Grade 2 on BCT Classification Additional Axis for grading and prognosis based on soft tissue test findings. Estimated length of stay for Grade 2 Extension is 4 to 8 visits.

INTERVENTION: 
Extension classification dictated a BCT Flexion Correction program. Correction exercises incorporated manual therapy principles into active positional exercises. Seven treatment visits were provided over 4 weeks. Each visit focused on Home Exercise Program (HEP) instruction for specific BCT Check Tests and Flexion Correction exercises for pelvis and spine to address the pattern of joint dysfunctions identified on initial examination. Patient was instructed to keep a daily BCT Check Test Log to monitor recurrence of specific joint dysfunctions as she resumed all Activities of Daily Living (ADLs) with no positional restrictions.

OUTCOMES: 
At discharge, patient had resumed all ADLS except for heavy chores. Hamstring flexibility and SLR measurements were symmetrical at 90° and 100°, respectively. LE MMT was 5/5 for EHL. Roland Morris Disability Questionnaire (RMDQ) improved from 8/24 points pre-treatment to 1/24 post-treatment and Visual Analog Scale (VAS) improved from 4-5/10 pre-treatment to 0/10 at discharge. Outcomes at 2-year follow up completed by mail: RMDQ 0/24 points, VAS 0/10. No outside medical intervention has been needed.

DISCUSSION: 
Due to chronicity of symptoms and lack of improvement with previous interventions, these outcomes suggest the benefit of using a biomechanical classification and treatment approach to address this patient’s decreased function and ongoing pain. Despite previous interventions including two back surgeries, the original mechanism of injury as identified through BCT Biomechanical Evaluation was still present. Outcomes suggest BCT provided the patient with an effective home program to self-assess and treat joint dysfunctions while also providing tools for optimal long-term function. This classification and treatment technique warrants further study by colleagues for validity and reproducibility with varied patient populations.
This study was presented at American Physical Therapy Association Combined Sections Meeting in Tampa, Florida, February 2003.

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Non Operative treatment of Marathon Runner with Herniated Nucleus Pulposus (HNP) using a Biomechanical-Based Classification and treatment program.
Kleiman S, Packard K. Spine & Sport Biomechanical Rehabilitation Center, Grand Rapids, MI
PURPOSE: 
This case report introduces a treatment technique that allowed this patient to continue marathon training despite L4-5 HNP. Biomechanical Correction Technique (BCT) identifies joint dysfunctions, classifies the pattern of dysfunction based on resultant forces and directs correlative treatment. BCT is not symptom dependent.

CASE DESCRIPTION: 
Patient was a 41-year-old male engineering manager with complaints of low back pain (LBP) and left leg pain for 6 months. Past history included back injury in high school with recurrence 5 years prior to this episode. Previous treatment for current injury consisted of bed rest, chiropractic adjustments, massage therapy and pain medication with temporary relief. Subsequent neurosurgeon assessment and MRI contributed to diagnosis of left posterolateral disc extrusion at L4-5 compromising L5 nerve root. Despite scheduled surgery, patient opted to travel from East Coast to Midwest for treatment. Patient presented with complaints of continuous ache to stabbing pain in left low back with tingling, numbness, and left lower extremity strength loss. Pain increased with twisting, lifting, cough/sneeze, and sitting. Pain decreased with walking, heat, and lying. Patient discontinued running, lifting, and physical chores. Pain rating was 5/10 on Visual Analog Scale (VAS). Initial RMDQ noted 12/24 points and Oswestry Back Pain Disability Questionnaire (ODQ) score was 28%. Observation and palpation showed left ipsilateral rotation of lumbosacral (L-S) spine with left posterior innominate. Trunk AROM was 30° flexion, 20° extension, 40° RSB and 50° LSB and supine SLR 50°R, 45°L measured with inclinometer. MMT for ankle dorsiflexion was 4/5R, 4-/5L and 5-/5 for bilateral EHL. Symptoms were consistent with Practice Pattern F according to American Physical Therapy Association’s Practice Guide. According to BCT, patient was classified as a neutral mechanism based on resultant force patterns of flexion and extension and vertebral posteriority of L1-L4 on L5. BCT also classifies soft tissue test findings on an additional axis for prognosis. Limited ROM classified this patient as Grade 3 per BCT with estimated length of stay 8-16 visits.

INTERVENTION: 
Patient was seen for 2-hour sessions over 3 consecutive days due to travel constraints. This is equivalent to 10 visits for an average patient seen 1 hour for evaluation plus 2 half-hour visits per week. Each visit focused on Home Exercise Program (HEP) instruction for pelvis and L-S spine. HEP included specific BCT Check Test Logs and active positional exercises to address dysfunctional joint patterns. Upon return home, patient resumed a progressive distance running program. OUTCOMES: At discharge, Trunk AROM was 65° flexion, 40° extension, 62° RSB, 60° LSB; SLR was 90°R, 80°L; and MMT 5/5 for bilateral ankle dorsiflexion and EHL. VAS was 0-2/10, RMDQ was 1/24 and ODQ 6%. At 10-month follow-up per e-mail, patient reported twinges of pain that resolved with BCT pelvic exercise. Patient completed the Chicago Marathon 10 minutes faster than preinjury time two years ago.

DISCUSSION: 
Physical therapy treatment focused on biomechanical joint dysfunctions versus disc pathology and symptoms. We believe that BCT provided patient-directed treatment that allowed patient to return to marathon running. Research is needed to determine if a relationship exists between LBP, joint dysfunctions, disc pathology and symptom provocation.

This study was presented at American Physical Therapy Association Combined Sections Meeting, Tampa, Florida, February 2003

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Use of a Biomechanical-Based Classification and Treatment System to diferentiate Chronic Low Back (LBP) from Pelvic Pain.
Packard K, Kleiman S. Spine & Sport Biomechanical Rehabilitation Center, Grand Rapids, MI
PURPOSE: 
This case study presents the evaluation and treatment of a patient using an innovative biomechanical-based classification and treatment-based system, Biomechanical Correction Technique (BCT). BCT has evolved over 12 years from a clinical need for more guidelines to direct treatment.

CASE DESCRIPTION: 
This 46 year old female had an 8 year history of low back and pelvic pain post vaginal delivery. She was evaluated and/or treated in multiple facilities in four cities. Evaluators included gynecologists, orthopedists, neurologist, anesthesiologist, physiatrist, pain psychologist, physical therapists, chiropractors, and a massage therapist. Tests included CT scan, MRI, pelvic x-ray, pelvic ultrasound, multiple blood tests, bone scan, bladder reflex tests, and EMG. Diagnoses included LBP, osteitis pubis, Regional Chronic Pain Syndrome, leg length discrepancy, and lipomas. Most prescribed medications failed to provide relief or she was unable to tolerate side effects. Drug-induced menopause and narcotic patches were advised but declined by patient. Patient participated in a comprehensive pain management program with minimal benefit. Proposed surgery included plate fixation, wedge resection and fusion of pubis joint. On examination, patient complained of dull aching to sharp pain in low back with episodic spasms, burning across buttocks and thighs, stabbing pain in lower abdomen, and audible popping in pubis with movement. Symptoms increased with walking, fast movement, prolonged standing, stair climbing and menses. Symptoms decreased with lying, position change and Paxil. Pain rating was 5-8/10 on Visual Analog Scale (VAS). Roland Morris Disability Questionnaire (RMDQ) was 10/24 points. Observation revealed asymmetry in standing posture and gait. MMT of hamstrings were 4-/5. Clinical observations were correlated with palpation findings of sacrococcygeal, sacroiliac, lumbosacral and lumbar ipsilateral rotation. According to BCT, these findings classified patient as an extension mechanism of resultant forces.

INTERVENTION: 
BCT Flexion Correction exercises for pelvis and spine series were given to address extension pattern. BCT incorporates manual therapy principles into active positional exercises. Patient was treated 2 times per week for 4 weeks. Patient received BCT stabilization exercises for recurrent joint dysfunctions as identified on daily BCT Check Log. Patient was encouraged to return to ADLs without positional restrictions using BCT Check Tests as a guide to activity tolerance. At discharge, patient reported feeling 95% better. The only remaining symptom was diffuse soreness across sacrum and pubis that she rated 0-2/10 on VAS. RMDQ listed 2/24 points. MMT of hamstrings was 5/5.

DISCUSSION: 
This patient had sought extensive treatment without success reinforcing the need for a clinically useful classification and treatment based system for non-specific low back/pelvic pain. BCT Check Tests and Logs helped therapist and patient correlate a pattern of symptoms with a given region. Due to chronicity of symptoms, outcomes suggest that identification of dysfunctional movement patterns led patient to improved function and pain reduction. BCT classification and treatment system warrants further study for validity and reproducibility of results.

This study was presented at American Physical Therapy Association’s Combined Sections Meeting in Tampa, Florida, February 2003

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Outcomes of Kleiman-Biomechanical Correction Techniques in the Treatment of Chronic Low Back Pain with Flexion as the Primary Treatment Pattern.
Larissa Robinson, SPT, Tara Tuinstra, SPT, Jennifer Wong, SPT, Joleen Bennett, PT, OCS, ATC, Shirley A. Kleiman, PT, OCS; Grand Valley State University, Allendale, Michigan and Spine & Sport Biomechanical Rehabilitation Center, Grand Rapids, Michigan.

Introduction: 
Low back pain (LBP) is a difficult disorder to diagnose and treat. It has been shown that patients with the same medical diagnoses can show different signs and symptoms requiring different treatment protocols. Researchers agree that patients with LBP should be placed into categories which would help guide treatment. The Kleiman-BCT system classifies patients by identified patterns of joint dysfunctions rather than medical diagnosis. Treatment efficacy is important to consumers and payors who demand decreased costs, shorter treatment duration, and return to functional activities.

Purpose: 
Perform a retrospective study to analyze functional outcomes of patients with chronic LBP who were evaluated, classified and treated with Kleiman-BCT where flexion is the primary treatment pattern. Outcome measures included: Roland-Morris Disability Questionnaire (RMDQ), Visual Analog Scale (VAS), number of treatments, and total length of stay in calendar days.

Subjects: 
Subjects were selected from charts of all patients who qualified for the study based on the inclusion and exclusion criteria. Inclusion was granted to patients who met all the following requirements: 35-55 years of age, mechanical LBP, treated primarily in a flexion pattern, chronic stage of injury (greater that 3 months), treatment received after January 1, 2000 through date of study initiation. Subjects reporting significant co-morbidity or scoring less than or equal to 4 on initial RMDQ were excluded from the study. Ten subjects meeting the criteria were available for analysis. The mean age of the subjects was 47.4 years (± 4.43). Seventy percent of the subjects reported a prior incident of back pain. Forty percent of the subjects had LBP for 3-6 months, while 60% had LBP more than one year. Only one subject reported previous back surgery. None of the subjects were receiving workers compensation.

Methods: 
Descriptive statistics were used to summarize the data and describe the sample. Given the small sample size, data could not be assumed to be normal. A non-parametric Wilcoxon signed-rank test was performed using SAS, a statistical computer program. This statistical analysis was used to identify any significant differences between pre and post intervention RMDQ and VAS scores with an alpha level of .05. The VAS distance was measured using a caliper and a standard metric ruler. In this study, the VAS ranged from zero to 100mm. A score of zero represents “no pain” and a score of 100mm represents “pain as bad as it can be”. The number of visits and total length of therapy in calendar days was also collected and analyzed.

Results: 
The mean RMDQ pre, post and difference scores were found to be 9.8 (± 4.9), 1.9 (± 2.2), and 7.9 (±5.2) respectively. The pre-RMDQ scores ranged between five and 19. The post-RMDQ scores ranged between 1 and 15. Using the Wilcoxon signed-rank test, the mean RMDQ score difference was statistically significant at a 95% confidence level with p=.0039. Therefore, there was evidence to conclude that improvement did occur between pre-evaluation and post-evaluation RMDQ scores in this small sample of subjects. The mean VAS pre, post, and difference scores were found to be 48.7mm (± 29.5), 6.4mm (± 10.4), and 42.3mm (±30.3) respectively. The pre-VAS scores ranged between 1mm and 92mm. The post-VAS scores ranged between zero and 30mm. The VAS difference scores showed a change ranging between 3mm and 92mm. The null hypothesis i.e. that use of Kleiman-BCT as an intervention would not result in a change in the status of LBP as measured by the VAS pre- and post- intervention scores, was rejected because the p-value (p= .002), as determined by the Wilcoxon signed-rank test, was less than alpha. The mean VAS difference score was proven to be statistically significant at a 95% confidence level. Therefore, there is evidence to conclude that improvement did occur between pre-evaluation and post-evaluation VAS scores in this sample of subjects. The mean length of treatment in days for this subject sample was 40.5 days (±12.89). The number of calendar days ranged between 23 and 65 days. The mean number of therapy sessions that this subject sample attended was 9.3 visits (±4.19). The number of visits ranged between 4 and 18.

Discussion: 
In examining the RMDQ and VAS scores obtained from this study, it is evident the majority of the subjects showed an improvement in their status of LBP. A positive RMDQ difference score is indicative of an improvement in disability. According to Stratford et al. a four to five point RMDQ difference score is necessary to state that a change in functional status has occurred. All but one subject showed a positive difference score between pre-and post-intervention findings on the RMDQ though this individual did report a one-point decline in his RMDQ score. The mean RMDQ difference score found in this study for Kleiman-BCT was 7.9 (±5.17). Therefore, change in functional status occurred in nine of the ten subjects in this study. Similar results were found in a study by Chok et al. where the mean RMDQ difference score was found to be 6.5 points. All subjects showed a positive difference score between pre- and post-intervention findings on the VAS which indicates an improvement in pain symptoms. In this study the mean VAS difference score was 42.3mm. Chok et al. found a mean VAS difference score of 14.9mm in the treatment of subacute LBP. Ghoname et al. also used the VAS to measure treatment of LBP, and found a mean VAS difference score of 29mm. Kleiman-BCT appears to have a more favorable outcome using the VAS as compared to other studies. Several outcome variables were examined to determine the average duration and number of visits for the sample. It was found that each treatment session lasted approximately thirty minutes. Based on the number of visits and calendar days that subjects were in therapy, it was found that subjects attended a therapy session approximately every three to four days. This averages out to be two to three sessions per week. There was one subject that averaged one session per week. This individual attended four therapy sessions in a 36-calendar day period. According to the APTA Guide to Physical Therapist Practice, the expected number of visits for a patient with LBP ranges between 8 and 24. The mean number of visits found in this study was 9.3 (± 4.19). This falls near the lower end of the expected number of visits, therefore with further research may prove Kleiman-BCT to be more cost-effective than traditional means of treatment for LBP. The mean length of therapy in calendar days for was found to be 40.5 days. This also falls towards the lower end of the one to six month length of therapy that the APTA suggests. The outcomes of BCT for duration of treatment and visits were unable to be compared to other studies secondary to the limited amount of literature available. Modalities were used with four of the subjects. Three of the four subjects received ultrasound and the fourth received vertical functional spinal distraction on the treadmill. It was difficult to conclude if the use of modalities affected the outcomes because those subjects that did not receive modalities showed as much improvement as those who did.

Conclusion: 
Literature suggests that there is a need for an assessment-based classification system for the treatment of LBP. Kleiman-BCT is an assessment-based classification system that may help fulfill this need. BCT considers the mechanism of injury and the findings in the evaluation to guide treatment. Results show that the majority of subjects in this study improved in both their RMDQ scores and VAS scores after receiving BCT. This study used outcomes that were meaningful to therapists as well as patients. The RMDQ and VAS scores are meaningful to the patient and consider what the patient is able to do functionally. The mean number of visits and mean length of treatment in calendar days found in this study suggests that Kleiman-BCT may be cost-effective.

Suggestions for Further Research: 
Inter and intra-rater reliability needs to be established for BCT. A follow-up study that looks at the reoccurrence of LBP in the sample used in this study is recommended. There has been one non-published study that examined BCT as a treatment for LBP with extension as the primary treatment pattern. A study needs to be performed which looks at patients with neutral back injuries as classified by the Kleiman-BCT system. A single-subject case design may give practitioners a more in-depth look at how Kleiman-BCT is used. Future research should involve prospective designs using randomized and controlled sample populations. Comparing Kleiman-BCT to other interventions would help determine if BCT is effective or better than other classification systems. Research looking at the effectiveness of BCT as an evaluation and treatment method for extremities needs to be performed.

Key References from 59 listed:
American Physical Therapy Association.
Guide to Physical Therapist Practice. 2nd Edition.
Alexandria, Va: American Physical Therapy Association; 2001.

Chok B, Lee R, Latimer J, Tan SB.
Endurance Training of the Trunk Extensor Muscles
In People with Subacute Low Back Pain.
Phys Ther. 1999; 79:1032-1042.

Ghoname EA, Craig WF, White PF, Ahmed HE, Hamza MA, Henderson BN, Charaj NM, Huber PJ, Gatchel RJ.
Percutaneous Electrical Nerve Stimulation for Low Back Pain:
A randomized Crossover Study.
JAMA. 1999; 281:818-823.

Portney LG, Watkins MP.
Nonparametric Tests of Significance In Foundations of Clinical Research
Applications to Practice. Stamford, CT
Appleton & Lange; 1993:419-428.

Stratford P, Binkley J, Solomon P, Finch E, Gill C, Moreland J, riddle D.
Defining the Minimal Level of Detectable Change for the Roland-Morris Questionnaire.
Phys Ther. 1996; 76:359-365.

Tiplady B, Jackson S, Maskry V, Swift C.
Validity and Sensitivity of Visual Analog Scales in Young and Old Subjects.
Age Aging. 1998; 27:63-72.

Wewers M, Lowe N.
A Critical Review of Visual Analog Scales in the Measurement of Clinical Phenomena.
Res Nurs Health. 1990; 13:227-236.

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Examination of Biomechanical Correction Technique™ in restoring lower trunk kinematics following treatment for chronic low back pain: A Case Report.
S. Kleiman, BS, PT; G. Alderink MS, PT; D. Marchinda, MS; Spine and Sport Biomechanical Rehabilitation Center, Grand Valley State University/Mary Free Bed Hospital, Center for Human Kinetic Studies, Grand Rapids, MI.
Objective: 
To examine the effectiveness of BCT™ in restoring lower trunk kinematics for the resolution of low back pain.

Subject: 
A twenty-five year old male with a ten-year history of right low back and sacroiliac pain volunteered to participate in this study.

Methods and Materials: 
The subject was assessed structurally and biomechanically in the clinic using the BCT Postural Assessment and Biomechanical Evaluation. Next, the subject was assessed for functional kinematic movement using a four 100 Hz infrared Elite camera system in the Center for Human Kinetic Studies. Clinical examination and three-dimensional kinematic data of the trunk and pelvis were collected prior to and following four weeks of treatment. Treatment incorporated joint biomechanic correction, stabilization and strength exercises per Biomechanical Correction Technique program.

Results: 
Comparison of the initial and final clinical and biomechanical findings after ten treatments revealed increased active range of motion with improved spinal coupling patterns. Improved segmental biomechanics and structural symmetry suggests restoration of normal trunk and pelvic kinematics.

Conclusion: 
Clinical decreases in trunk active range of motion in conjunction with biomechanical and structural asymmetry can be present in patients with chronic low back pain. Trunk kinematics can be restored using Biomechanical Correction Technique exercises correlated to the patient’s specific pattern of dysfunction (treatment group classification). BCT has been found effective in resolving chronic low back pain in a four-week period. Three-dimensional motion analysis was found to be useful in quantifying changes in coupled movement patterns in the spine.

This study was presented at the annual meeting of the American Back Society, San Francisco, California, December 1997.

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Effectiveness of BCT exercises in the treatment of low back pain: A Retrospective Study.
S. Kleiman, BS, PT; G. Alderink, MS, PT; N. Cromer, PTA; Spine and Sport Biomechanical Rehabilitation Center, Grand Valley State University, Grand Rapids, Michigan.
Introduction: 
Biomechanical Correction Technique (BCT) is the transformation of manual therapy into therapeutic exercise to restore biomechanics, allowing for the resolution of a structural dysfunction and symptoms. The corrective exercises are specific to an individual and the pattern of dysfunction (treatment group classification).

Purpose: 
Present outcome data from a retrospective study of treatment using Biomechanical Correction Techniques.

Subjects: 
Twenty males between 25 and 55 years with diagnosis of low back or SI joint pain were randomly selected. Eight of the subjects were classified as acute (< 30 days), six were sub-acute, and six were chronic (>120 days).

Methods: 
20 subjects were evaluated and treated with BCT at Spine and Sport Center between 1991 and 1997. Subjects were evaluated by the same clinician for symmetry of all landmark components of the pelvic girdle. Inclinometric measurements of trunk range of motion, bilateral hip flexion, straight leg raise, and hamstring flexibility at 90º hip flexion were taken. Subjects rated pain on a 0-10 numerical scale. Subjects were classified into a BCT treatment group based on their specific dysfunction. Subjects were instructed in biomechanical correction for their classification with progression into BCT stabilization, strength, and flexibility exercises.

Results: 
Fifteen subjects were classified as extension injury and five were classified as flexion injury. Treatment duration was 1-11 weeks (mean = 4.15 weeks). Total visits ranged from 3-22 (mean 8.7 visits). Subjects demonstrated increased inclinometric measurements of trunk range of motion and supine straight leg raise. Hamstring flexibility was equal to or increased from initial values. All subjects demonstrated a decrease in numerical pain ratings. Overall, 16 of 20 (80%) achieved a painfree state of 0; two (10%) achieved a pain rating of 1-2; 10% achieved a pain rating of 3-5. Nineteen of twenty subjects achieved pelvic symmetry; the one exception had a confirmed diagnosis of structural scoliosis, which was not a primary focus of treatment. Work history upon evaluation revealed 35% of the subjects were off work; 20% were on restricted duty, 5% retired; and 40% were working unrestricted. At completion of the treatment program, 75% were working unrestricted, 10% on restrictions, 5% retired, and 5% pending return to work.

Discussion: 
This retrospective study suggests that the majority of low back injuries are related to an extension classification dysfunction, with findings indicating structural and biomechanical asymmetry resulting in decreased active range of motion of the trunk, supine straight leg raise, and hamstring flexibility. BCT was an effective treatment intervention. There was not conclusive evidence to show that flexion classification injuries required a longer recovery period compared to extension classification injuries. It was noted that of the five flexion classification injuries, none had a prior history of low back pain. All fifteen extension classification subjects reported a prior incident of low back pain.

Conclusion: 
Pelvic symmetry and restoration of pelvic girdle biomechanics is attainable through BCT. Restoration of structural symmetry improved function and decreased pain. Results were achieved without manual manipulation, mobilization or other passive means of intervention.

This study was presented at Michigan Physical Therapy Association Fall Conference, 1998.

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Examination of Biomechanical Correction Technique as a Diagnostic and Treatment Classification System for Low Back Pain.
 Ben Asper, SPT; Gordon Alderink, MS, PT; Shirley A. Kleiman, PT, OCS; Grand Valley State University, Allendale, Michigan and Spine & Sport Biomechanical Rehabilitation Center, Grand Rapids, Michigan. Introduction: Given the difficulty in diagnosing and treating low back pain, new treatments must be investigated to determine and compare efficacy. Evaluating studies that report the effectiveness of physical therapy for the treatment of low back pain can be problematic because multiple treatment techniques can be used simultaneously during an episode of care. Methods that classify patients into treatment categories may be more useful in studying treatment outcomes. Biomechanical Correction Technique (BCT) is a classification and treatment based program that identifies a specific pattern of skeletal-muscular dysfunction and dictates specific BCT exercises to restore joint biomechanics. BCT is based on the concept that a change in joint position affects movement and function.

Purpose: 
The purpose of this research in summary is to: 1) conduct a descriptive retrospective study of treatment outcomes for a sample of patients with low back pain secondary to a flexion mechanism of injury who were evaluated, classified and treated with Biomechanical Correction Technique, 2) compare study results with past research.

Subjects: 
Thirty patients selected for inclusion had their initial evaluation and discharge completed within the six-month period (from 1998-1999) chosen for this study. Criteria for inclusion into this study included all patients with: 1) a general, non-scoliosis, low back pain diagnosis, 2) treatment during the period as defined above, 3) a flexion mechanism of injury, as determined by the physical therapist during the initial evaluation. Subjects were selected from those meeting criteria using a reverse chronological search of records starting at time of study initiation until a total of thirty were collected. The sample included seven females and 23 males. Age ranged from 14 to 69 years (mean = 46.3 ± 14.6 years). The onset of symptoms was determined at the initial examination and ranged from two days to 38 years with mean duration of symptoms being 8 years (± 12.1 years). Twenty-seven of the 30 subjects had a prior history of low back pain. Five of the 30 subjects had prior surgical intervention for low back pain. Lower extremity radiculopathy was reported in 26 of the 30 subjects.

Methods: 
Data analysis was based on the changes in patient reported pain using Visual Analog Scale (VAS), straight leg raise (SLR) measurement, lumbar range of motion (ROM), number of therapy sessions and return to work status. These outcome variables were chosen specifically because they had been used in similar past research.

Results: 
Over the course of treatments, pain decreased by an average of four points on the VAS from 4.9 to .8 on a 0-10 scale. Straight leg raise measurements increased on average, nearly 15 degrees. Trunk AROM increased by an average of 17+ degrees.
The average number of visits was 8. Return to work outcome was 100%, however, only 2 of 30 patients were included in this treatment outcome (28 of the 30 subjects were working unrestricted at time of referral). Therefore, return to work outcomes were not included in the following discussion. There was no identifiable trend correlating age, gender, or duration of symptoms to length of stay. Positive changes were seen in all of the outcome variables resulting from classification and treatment with Biomechanical Correction Technique. Although conclusions could not be made from the outcome data using statistics, comparing outcomes to previous research suggests clinical significance.

Discussion: 
Fritz (1998) studied patients with acute low back pain to determine the effectiveness of using a different classification system on a small subject sample (N=3) compared to 30 in the BCT research. The two subject samples showed similarities in the following areas: same domain of interest (LBP diagnosis), average subject age (within 5 years), and most subjects experiencing prior incidence of LBP. Patients in both studies were given specific treatments after being assigned into a defined treatment group using a classification system . Treatment in this Fritz study included autotraction, repeated flexion, and repeated extension exercises based on treatment classification. With this BCT study, all patients were Flexion classification and received specific BCT extension correction exercises based on their individual joint dysfunctions as determined by evaluation and BCT check tests. The average decrease in pain reports averaged slightly over three points in the Fritz study compared to over 4 points with the use of BCT over the course of treatment, a 25% greater decrease in pain with BCT. The average number of treatment session for the Fritz study was 8.3 compared to 8.0 with BCT. Fritz studied only patients with acute pain while the average duration of symptoms in the BCT study was 8 years.

Giles and Muller (1999) studied the outcomes of treatment for 27 subjects suffering from chronic low back pain. They found a 50% reduction of LBP after 30 days of intervention, which consisted of spinal manipulation. The number of treatments chosen by the clinician was based on severity of symptoms and prognosis. The average decrease in pain in the BCT study was 85%.

Hides, Richardson, and Jull (1996) studied the effectiveness of specific, localized exercise therapy on muscle recovery. The Hides sample contained 39 patients with mean age of 30.7 years. Following four weeks of treatment, the Hides study subjects reported pain reduction of 4.5/10 compared to a mean decrease of 4.1/10 with BCT. Hides also studied SLR and trunk flexion. Subjects in the Hides sample gained 14.0 degrees with SLR compared to 14.9 with subjects treated with BCT. Trunk flexion in the Hides study increased an average of 13.8 degrees compared to increase of 24.7 degrees in the BCT study. Patients treated with BCT gained almost twice the amount of trunk flexion as did patients in the Hides study.

Treatment given by Estlander, Mellin, Vanharanta, and Hupli (1991) involved exercises, cognitive-behavioral group therapy, back school, relaxation training, and socio-economic counseling. Research sample contained 65 LBP patients with a mean age of 41.6 years. The subjects had duration of symptoms ranging from 1-30 years with 22% reporting previous back surgery. Subjects averaged approximately 10 degree increases in trunk flexion, extension, and side bending during the four weeks of treatment. This increase was less than the average trunk AROM increase reported for BCT subjects which was 24.7 degrees trunk flexion, 18.2 degrees extension, 13.1 degrees right side bending, 15.2 degrees in left side bending. The subjects treated with BCT showed a greater increase in all trunk motions compared to the subjects in the Estlander et al. study.

Conclusion: 
Results of this study suggest that BCT classification and treatment based system can be effective for patients with low back pain from a flexion mechanism of injury. All patients demonstrated increased trunk AROM and passive straight leg raise. Every patient experienced a decrease in pain rating by at least 45%, while the patients average decrease in pain levels was 85% over the course of treatment. A decrease in pain appears to be clinically significant. For example, Estlander et al. (1991) stated that pain may be the most important factor in low back pain patients because the anticipation of pain can decrease range of motion, decrease work capacity, and more importantly, negatively affect a patient’s mood. BCT was found to be as effective as treatments including mobilization, traction, specific exercise, strength training, and patient education, based on the outcomes compared in this study. Additional research exploring LBP classification based treatments, and their outcomes will provide a more complete picture of BCT and its effectiveness.

Key References from 56 listed:
Estlander, A.M., Mellin G.,Vanharanta H.,Hupli, M. (1991).
Effects and follow-up of a multimodal treatment program including intensive physical training for low back pain patients. Scand J. Rehab Med, 23, 97-102.

Fritz, J. M. (1998).
Use of classifiction approach to the treatment of 3 patients with low back pain. Physical Therapy, 78(7), 766-777.

Giles, L.G., Muller, R. (1999).
Chronic spinal pain syndromes: a clinical pilot trial comparing acupuncture, a nonsteroidal anti-inflammatory drug, and spinal manipulation. J Manipulative Physiol Ther, 22(6), 376-381.

Hides, J.A., Richardson, C.A., Jull, J.A. (1996).
Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine, 24(23), 2763-2769.