1. health and fitness
2. disorders

A CASE EXAMPLE
Data Drives Effective Care
in Chronic Conditions
Chronic Low Back Pain
flexibility, and overall
conditioning with the
goal of improving her
functional tolerance
and independence.
Gains were only
modest in six
weeks, and pain had
decreased only two
points.
The office examination findings were as follows:
Dilemma: Initial
treatment focused on
musculoskeletal and
pain management, but did not yield the expected
result. Therefore, other contributing factors were
considered:
• Why was she having so much pain when her musculoskeletal status was stabilized?
• Why was her function not improving?
• What was contributing to her difficulty standing and ambulating on unstable
surfaces and elevations?
• Was there an interaction between her multiple medical problems?
Past medical history: lumbar discectomy
with fusion four years prior, angina, pulmonary
emboli, and deep vein thrombosis
Current medical history: lumbar stenosis,
sacroiliac joint dysfunction, bilateral total knee
replacements, plantar fasciitis, and chronic tibial
tendonitis
Previous work-up: radiographs and MRI were
negative beyond documentation of the mild
stenosis
Clinical examination: all lower quarter tests
were negative or normal. There was limited
range of motion and strength in all trunk motions
and significant paraspinal muscle spasm. Lower
extremity flexibility was poor. Gait was antalgic
and limited to 100 feet with a single point cane.
She was unable to manage stairs or elevations
without assistance.

Initial treatment was focused on decreasing
pain, increasing range of motion, strengthening,
Inside
Problems with stairs and elevations could be caused
by poor dynamic balance control as much as pain.
Poor balance and movement control can exacerbate
pain resulting in poor movement control. Additional
information regarding the patient’s sensory and
motor balance control for dynamic movements is
needed before a more effective treatment plan can
be made.
Inside You’ll Find ...
When a patient does not respond to standard protocols, or when multiple problems are interacting,
more information is needed to differentiate the problems contributing to low back pain and to
determine the effects of dynamic mobility stressors upon low back pain.
Model: for illustrative purposes only.
A 66 year-old female complains of a 10+ year
history of chronic low back and lower extremity pain
with frequent recurrence. Her pain is significantly
increased with activities of daily living to an 8/10
rating (10=severe pain), particularly with walking
and standing activities. Management to date has
included multiple episodes of rehabilitation care,
medical management with injections, and corrective
shoe orthotics—all with limited relief. Her goal is to
live life without severe pain.
Measuring Impairments
Chronic pain itself is a problem. Once past the acute phase, individuals with low back injury start to make
adjustments in their control of posture, in their dynamic mobility, and in coping strategies to deal with the problem.
Physiologically, these adjustments are either typical/appropriate or atypical/maladaptive. Coping skills either
help or hurt the recovery process. When multiple medical problems are present, these problems can interact,
making it difficult to ‘tease out’ the cause(s) and to determine specifically where to focus effective intervention.
As one factor improves or declines, others respond and change. Thus, treating the wrong problem can actually
worsen the pain or functional status of an individual with chronic low back pain.
Evaluating Dynamic Mobility and Postural Control: The patient was referred from orthopedics for further
evaluation of her dynamic postural and movement control as it relates to her back pain and mobility limitations.
Computerized Dynamic Posturography (CDP) was used because it isolates and quantifies independent sensory
and motor impairment variables that may be contributing to the postural and movement control problem.
The Sensory Organization Test (SOT) isolates and quantifies abnormalities in the patient’s use of the three
sensory systems that contribute to postural control (somatosensory, visual, and vestibular) as well as the brain’s
central integration of these inputs. It also provides valuable information regarding the location of the center of
gravity (COG) and changes in its position in response to increasing challenges placed by the environment on
the postural control system.
The results in Figure 1 illustrate that the patient has poor balance control under conditions which require use
of vestibular cues. This finding does not necessarily indicate the presence of a vestibular system problem, but
does imply the need to screen that system, ruling it in or out as a contributing factor. The location of her COG
was significantly anterior of normal midline position, resulting in increased spinal extension. This, combined
with an increased use of hip strategy during the more demanding balance testing tasks, increases the demands
upon the paraspinal muscles of the back to prevent a forward fall and impinges on an already narrowed stenotic
(spinal) canal.
An SOT 5, 6 pattern indicates
poor balance when left with
cues from only one balance
system, the vestibular system.
This is a very challenging
balance task. Although this
finding could be indicative of
a vestibular system problem,
a careful review of the
motor test results will help
to determine if poor motor
control is a contributing factor.
Refer to Figures 2 and 3.
B
The COG position (A)
is shifted significantly
anterior of midline
during all test trials,
increasing back
extension. When taken
together with the
overuse of hip strategy
(B) on more difficult test
conditions, the potential
for additional stress on
the low back structures
during ADLs can be
better understood.
A
Figure 1. Results summary for the Sensory Organization Test (SOT).
2
The Motor Control
Test (MCT)
demonstrated
normal timing of
motor responses but
amplitude (strength)
was slightly
increased.
Figure 2. Results summary for the Motor Control
Test (MCT).
The Limits of Stability
(LOS) test identified
significant limitations
in the available
limits of stability in
all directions. Note
the lack of anteriorposterior movement.
Figure 3. Results summary for the Limits of
Stability (LOS) test.
The Rhythmic Weight
Shift (RWS) identified
normal lateral weight
shifting ability to
50% of her available
limits of stability,
but virtually no
ability to generate
and control anteriorposterior movement
as would be required
for effective balance
responses.
Figure 4. Results summary for the Rhythmic Weight
Shift (RWS) test.
The Motor Control Test
(MCT), Adaptation Test
(ADT), Limits of Stability
(LOS), and Rhythmic Weight
Shift (RWS) examine the
integrity of the sensorimotor
pathways (input and output)
linking the lower extremity
musculature and the brain.
Given the patient’s history
of spinal stenosis and lumbar
discectomy, evaluating the
motor pathways and the
potential contribution to
the complaints of back pain
were an essential part of
understanding this problem,
and planning appropriate
treatment.
MCT and ADT results were
within normal limits for
the patient’s age, indicating
intact automatic motor
control responses and
pathway integrity. During
testing, observation of the
patient’s postural control
strategy was consistent with
the SOT findings. The patient
did not use the appropriate
muscles and response timing,
but rather fired and stressed
the paraspinals of the back
first and hyper-extended the
lumbar spine to maintain
balance.
The voluntary motor tests,
Limits of Stability (LOS)
and Rhythmic Weight Shift
(RWS), indicated an inability
to shift weight in the anteriorposterior direction, which is
a critical component for gait
and for effective recovery
from balance challenges. If
the patient cannot generate a
weight shift from the lower
extremities, all balance
responses must then occur in
the trunk.
3
Impression & Recommendation
Rehabilitation focused on the musculoskeletal issues might have a temporary effect, but pain would return with
any functional or vocational activity given this patient’s constant overuse of her low back structures for dynamic
movement control in daily activities.
The CDP data indicated poor postural control and movement strategy selection when the patient was placed in a
challenging dynamic testing environment. The postural responses to these challenges reproduced and increased
the patient’s complaints of pain because her musculoskeletal status was not stabilized in dynamic activity. Her
core stability and choice of balance responses were ineffective for dynamic tasks. Her function was not improving
because every functional activity created excessive structural stress and caused increases in her pain.
The patient’s poor balance on SOT 5 and 6 could be an interaction between her limited motor control (as evidenced
by the LOS and RWS motor testing results) and the motor challenges presented by the SOT. It also could be
related to the disuse of vestibular cues resulting from long periods of inactivity. A screen of the vestibular system
would help determine if further medical evaluation of the vestibular system is warranted.
Based on these data, the treatment plan was changed to focus on core trunk stability training within dynamically
challenging postural control environments with use of visual biofeedback, followed by pain management as
indicated based upon patient performance and tolerance.
Treatment Plan
The first task was to train the patient to relearn center of gravity position while maintaining core stability in order
to relieve the extra stress upon low back structures. Once she was able to achieve and maintain midline with
her eyes open and closed with 100% accuracy, progressive postural challenges were introduced. Progressing
to the use of random surface challenges with exercise difficulties set greater than 100% (where the balance
challenge exceeds the patient’s capabilities) ensured that training matches the demands placed upon the core
trunk structures during daily life activities.
Mobility activities with visual biofeedback were performed, including anterior-posterior weight shifts and lateral
step-ups, in the same challenging environments with increasing speed demand. Throughout treatment, visual
feedback provided the patient with external cues regarding her position and control within the given activity.
Pain intensity was monitored before, during, and after activities.
Impairment: Poor dynamic movement control
Tests: Sensory Organization Test (SOT)
Motor Control Test (MCT)
Adaptation Test (ADT)
Limits of Stability (LOS)
Findings: Inability to effectively use vestibular cues
for balance; poor movement control and strategy
selection (poor core stability) when under these
types of dynamic challenges.
4
Functional Outcome
After one month all objective measures of postural control (Figure 5) and the ability to function without pain
improved to within normal limits, reaching all of the patient and clinical goals. Although improved, the only
remaining impairment of concern was the anterior position of the COG. Given the patient’s current pain-free
state, this information could prove invaluable in patient education, alerting the patient to the risk of recurring back
pain if she returns to her deconditioned, inactive state. A telephone consultation performed every six months for
the next 18 months revealed that the patient was fully functional with no incidence of significant pain.
Normal postural
control on SOT 5, 6.
Appropriate use of all
three sensory system
cues for balance
control.
COG more consistent:
improved but still
anteriorly located at
this point.
Using the right strategy
at the right time—no
overuse of hip strategy.
Figure 5. Results summary for the Sensory Organization
Test (SOT) after one month of focused training
incorporating visual biofeedback on the NeuroCom system.
Figure 6. Normal automatic and voluntary
movement control.
Influence from CDP/computerized tests on patient management:
In this case, medical history and physical examination did not adequately explain the functional limitation,
nor the lack of progress following traditional rehabilitation approaches. CDP results helped to identify and
isolate the contributing factors in this patient’s movement control problems, including:
• A sensory component to her movement control dysfunction. Her ineffective and inappropriate movement control created excessive daily stressors that were consistent with her chronic back pain.
• Inappropriate postural response patterns contributing to and consistent with her pain patterns and
functional limitations.
6
NeuroCom® International, Inc. • 9570 SE Lawnfield Road • Clackamas, Oregon 97015-9611 • Telephone +1-503-653-2144
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M:136
Physical Exam/
History
Diagnostic
Hypotheses
Medical
Evaluation
Diagnosis
Impairment
Evaluation

Overview
•Severely limiting chronic low back pain
•Multiple medical problems and previous back fusion
•Previous orthopedic-based management provided
temporary relief
•Course of 6 weeks in rehabilitation was marginally
effective




•Poor dynamic balance control may be contributing to
chronic back pain and limiting recovery
•Confirms mild stenosis with chronic low back pain •Inconsistent with functional/pain complaints
Confirms mild stenosis with chronic low back pain Computerized Dynamic Posturography
• Sensory Organization Test
• Motor Control Test
Voluntary Motor Control testing
• Limits of Stability
• Rhythmic Weight Shift
Impairment
Diagnosis
Functional
Outcome

•Poor movement control and strategy selection when
under dynamic challenge
•Inappropriate movement control stressors
reproduced chronic back pain patterns
•Inability to effectively use vestibular cues for balance

Treatment Phase I (Musculoskeletal and Pain Management)
•All musculoskeletal measures normalized, but pain only
minimally decreased, with no significant improvement in
functional measures
Treatment Phase II (Dynamic Movement/Motor Control)
•All objective measures of both pain, postural control, and
function without pain improved to within normal limits • All patient and clinical goals achieved Long term outcome:
•Follow-up every six months for 18 months indicated full
pain-free function
Summary: How did CDP augment the medical decision-making?
In this case example, the information from computerized testing identified the impairments
most responsible for the pain and functional problems and treatment was redirected to target
those problems. Treatment focused on dynamic movement control produced a favorable
outcome where conventional musculoskeletal approaches had previously yielded only minimal
improvement.