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Case Reports |
DL Riddle, PT, PhD, is Professor, Department of Physical Therapy, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Va
JM Rothstein, PT, PhD, FAPTA, is Professor, Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, 1919 W Taylor St, 4th Fl, Room 456, Chicago, IL 60612 (jules-rothstein{at}attbi.com). Address all correspondence to Dr Rothstein
JL Echternach, PT, EdD, ECS, FAPTA, is Professor and Eminent Scholar, School of Physical Therapy, Old Dominion University, Norfolk, Va
Submitted March 12, 2002;
Accepted December 2, 2002
 | Abstract |
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Key Words: Neck and trunk, back • Pain • Tests and measurements, general
| Introduction |
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 TopAbstract Introduction Case DescriptionReported Functional Limitations...The InterventionConclusionAppendixReferences |
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| Case Description |
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TopAbstractIntroductionCase DescriptionReported Functional Limitations...The InterventionConclusionAppendixReferences |
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When asked what other activities were affected by her LBP, she said she was unable to get in and out of her car or to put on her stockings in the morning without pain. She also reported that pain occasionally awakened her at night when she rolled over in bed and that any activity requiring forward bending produced pain. When asked to identify activities that required her to bend forward, she stated that she was unable to do yard work, ride her bicycle, or use the exercise machines at the local fitness center because of LBP.
She said her pain began approximately 3 months prior to the examination. She was unable to attribute the onset of the pain to any incident or activity. She did report, however, that she moved to a new home 2 days prior to the onset of pain and lifted many items during the move.
When asked whether she had any serious medical problems, she said she was healthy except for her LBP. The referring physician took radiographs of her lumbar spine and reported that they were normal. She said that this was her first episode of LBP and that the pain was intermittent, with the intensity and frequency unchanged over the 2 months prior to the referral.
| Reported Functional Limitations and Disabilities |
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To quantify the impact of the functional limitations and disabilities on the patient's health, she completed 2 instruments during the initial data collection: the acute version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)4 and the Roland Morris Questionnaire (RMQ).5 We used 2 instruments because the SF-36 is a multidimensional generic measure designed to assess both physical and mental health status, whereas the RMQ is used primarily to measure physical disability and was designed for patients with LBP. The measurement properties of both instruments, in our opinion, are acceptable for routine clinical use.6,7 Stratford et al6 found that a change of 5 points on the RMQ was necessary to conclude that a real change in a patient's disability occurred. The changes necessary to infer that there is a real change in health status for SF-36 scores8 are larger than those necessary for the RMQ (see the 2 standard error of measurement [2SEM] scores in Tab. 1), but, in our experience, the measures are still meaningful if interpreted correctly.
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The patient had a score of 8 on the RMQ during her initial visit. For patients with chronic LBP, average scores on the RMQ range from approximately 12 to 15.9–11 Our patient scored lower (less disability) than average for patients with chronic LBP, which suggested to us that her disability was somewhat mild compared with that of most people with chronic LBP.
The Examination Strategy and the Examination
The HOAC II requires the therapist to develop a strategy for the examination that is based on initial hypotheses developed from the medical history and other data obtained prior to the examination. We tailored the examination to identify and quantify impairments that we believed (hypothesized) could help to explain why the patient had her problems. Based on the patient's PIPs, it was apparent to us that the functional limitations and disabilities were primarily associated with a flexed lumbar spine. Because she reported she had to sit rigidly upright at work, we suspected limitations and pain would be found during forward bending and accessory motion testing of the lumbar spine. Because she said the pain was intermittent and only in the midline area of the lower lumbar spine, we designed the examination to focus on the soft tissues of the lumbar spine. We did not examine for likely causes of paresthesias or muscle weakness (eg, nerve roots) because the patient did not report symptoms consistent with nerve injury.
Because the patient expressed the desire to return to fairly rigorous recreational activities, we believed that it also was important to measure the lumbar spine motions of side bending and backward bending. Because we believe shortening of the hamstring and hip flexor muscles can affect lumbar spine posture via their attachment to the pelvis, we assessed, indirectly, the length of these muscles by use of the straight leg raise and the Thomas test. Indirect assessment is important, we believe, because there is no way to directly assess muscle length in a clinical examination.
Because the pain was intermittent, localized to the area of the midline of the lumbar spine and related primarily to trunk flexion movements, we believed the likelihood of serious disease or herniated disk was remote.12 Tests of neurological status such as sensation and reflex testing, therefore, were not conducted.
The patient said that while she was standing just prior to the examination, she had no LBP. We used the methods described by Waddell et al13 to quantify the amount of motion present with forward, backward, and side bending. Waddell et al reported intraclass correlation coefficients (ICCs) for these measures that were on the order of .90 or higher, indicating to us that the data obtained with these measures were highly reliable. We did not estimate the reliability of our measurements. All motions began with the patient standing upright.13 We used an electronic inclinometer to measure all motions.* For the forward- and backward-bending measurements, the inclinometer was positioned on the skin overlying the T12-L1 interspinous space. For the side-bending measurements, the inclinometer was positioned in the frontal plane and on the skin overlying the spinous processes from T10 to T12. Prior to our taking the measurements, the patient did 2 warm-up motions by moving in each direction, followed by a third set of warm-up motions of forward and backward bending.13
While the measurements were being taken, the patient was asked to rate the intensity of her pain using a 0 to 10 verbal pain rating scale, with 0 representing "no pain" and 10 representing "the worst pain imaginable." She reported that when she was forward bending, her pain was level 4, with the pain in the midline region of the lower lumbar spine (pain in the area of the lower lumbar spinous processes). She said the pain occurred at the end of the active range of motion (AROM) and disappeared when she returned to the upright position. She had 62 degrees of forward bending. Waddell et al13 reported the values for AROM measurements of the spine for 70 subjects without LBP between the ages of 20 and 55 years of age using the same methods we used. The mean forward-bending AROM was 100 degrees (SD=14, 95% confidence interval [CI]=96.2–102.8), which indicated to us that our patient had limited forward-bending AROM.
The patient had 10 degrees of backward bending, and she reported a pain level of 2 at the end of the available AROM. Based on data reported by Waddell et al,13 subjects without LBP had a mean of 26.5 degrees (SD=9, 95% CI=24.4–28.6) of backward bending. These data suggest the patient's active backward bending also was limited. The limitations in forward and backward bending are impairments, and we believed they were related to the patient's problems because her LBP occurred at or near the end of AROM for both motions.
Side bending to the right was 26 degrees, and side bending to the left was 24 degrees. She reported having no pain during the 2 side-bending motions. Waddell et al13 reported a mean of 29 degrees (SD=6.5, 95% CI=27.9–31.0) for side bending in people without LBP, which suggested to us the patient's side bending was not limited. The measurements obtained during the AROM assessment are reported in Table 2.
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The examiner palpated the lumbar paravertebral soft tissues to determine whether pain could be elicited in tissues lateral to the midline. Because the P-A pressures caused pain, it appeared to us that inflammatory processes could have been affecting soft tissues along the midline at the L3 to L5 levels (ie, the areas over and near the spinous processes). To palpate, the examiner used the tip of his thumb to apply firm pressure approximately 2 cm and then 4 cm to the left and right of the lumbar spinous processes and to the area of the dorsal surface of the sacrum. No pain was elicited, which suggested to us that any inflammatory processes that might be present were most likely localized to the midline region of the lower lumbar spine.
We used several other procedures in an effort to determine whether any other impairments may have contributed to the patient's functional limitations and disabilities. Because the patient spent most of her working day sitting, we suspected her hamstring muscles were shortened. Prior to assessing hamstring muscle length, the hip joints were assessed so that we could be confident that hip joint structures were not limiting the patient's hip flexion range of motion (ROM). The Patrick test was not painful bilaterally.18 Hip flexion passive range of motion (PROM) with the knees flexed was measured with the patient positioned supine. According to the observations of the examiner (DLR), hip flexion appeared to be approximately 140 degrees on both sides, and we judged this to be normal bilaterally. No pain was reported during hip flexion PROM testing. The Thomas test was negative bilaterally.18 We found no data to support the reliability for the hip measures, and our use of these measurements was based on our opinions and customary practice, not on evidence.
A passive straight leg raise (SLR) was done bilaterally to indirectly assess the length of the hamstring muscles.13 The inclinometer was positioned on the skin overlying the tibial spine, and the patient was instructed to relax and to inform the examiner if pain or a stretching sensation was perceived during the test. The patient had a straight leg raise of 68 degrees on the right side and 66 degrees on the left side when a stretching sensation was perceived in the area of the hamstring muscles. Waddell et al13 reported reliability coefficients (ICC) on the order of .90 for SLR measures. We judged the patient's SLR to be mildly limited based on data published by Waddell et al13 indicating that for subjects without LBP, the mean SLR was 77 degrees (SD=10, 95% CI=74.4–79.4). The patient reported no LBP during the SLR tests.
The Non–Patient Identified Problems (NPIPs) List
The NPIPs are those problems identified most commonly by the therapist and most typically are risk factors that the therapist believes may increase the patient's risk of recurrence or continuing disability. This patient had 3 problems that appeared to increase her risk for continued or recurrent LBP. First, her risk for future LBP appeared to be high because she routinely sat at her desk for many hours. This prolonged amount of sitting, in our view, can predispose her to hamstring muscle shortening and limitations in lumbar spine ROM. Second, we reasoned that her psychological distress at work increased her risk for future LBP.19 Third, her limited bilateral SLR and limited forward and backward bending also appeared to increase her risk for LBP because, theoretically, limitations in these motions predispose tissues to lumbar spine to excessive forces.
The Hypotheses
In the HOAC II, hypotheses are most commonly the therapist's diagnosis of the relevant impairments that are thought to be causing the problems. Hypotheses, at times, also may identify pathologies or functional limitations. In our opinion, the patient in this case report was unable to achieve her goals because of localized chronic inflammatory processes in the area of the lower 3 vertebrae of the lumbar spine. We also hypothesized that this was a chronic inflammation that appeared to have been precipitated by several impairments. The limited lumbar sagittal-plane motion and lumbar accessory motion appeared to be long-standing and may have predisposed the patient to developing inflammation in the area of the lumbar spine. Because most of the patient's complaints were associated with a flexed lumbar spine, the painful and limited forward bending appeared to be the most important of the 3 impairments associated with movement of the lumbar spine.
Rationale for NPIPs
The HOAC II requires the therapist to develop theoretical arguments or provide evidence to justify why NPIPs warrant intervention. Because our patient's pain began insidiously, we believed it was important to attempt to identify any other risk factors that may have predisposed her to developing her problem. Because her job required sitting for long periods of time, she may have been predisposed to developing lumbar spine ROM limitations. That is, her spinal ROM and hamstring muscle length impairments may have preceded the onset of her pain and subsequent disability. Work by Kelsey20 and Magora21 suggests that prolonged sitting increases the risk for LBP in people with occupations similar to our patient's occupation. We, therefore, considered the prolonged sitting at work to be a risk factor. We also viewed the stress the patient was experiencing—which was a result of many of her fellow employees' job losses—as a risk factor for continued or future LBP. Data exist to suggest that psychological distress increases the risk for long-term LBP.19
We also considered the patient's limited SLR bilaterally to be a risk factor for LBP. The hamstring muscles, when taut, theoretically are in a position to posteriorly tilt the pelvis and to secondarily flex the lumbar spine, a motion that increased the patient's LBP. No direct evidence indicates that shortened hamstring muscles increase a person's risk for LBP, but because it is a commonly held belief, we considered it in our patient management. We thought that this was an especially easy decision because, in our opinion, addressing this impairment is usually not difficult and has little negative consequence.
Merged and Refined Problem List
In the HOAC II, both the PIPs and the NPIPs are reviewed and refined so that a master list of problems can be identified. The refined problem list read as follows. The patient was unable to: (1) roll over in bed without pain, (2) sit in a slouched position without pain, (3) forward bend without pain, (4) sleep through the night without awakening due to pain, (5) be as productive as usual at work, (6) don stockings in the morning, (7) get in and out of a car without pain, and (8) do yard work, bicycle, or exercise in the fitness center without LBP. We considered the prolonged sitting at work and the work-related psychological stress and shortened hamstring muscles to be risk factors for continued LBP. The psychological stress NPIP was kept on the refined problem list even though we believed, based on clinical experience with similar types of patients, that she would be able to appropriately manage her stress. We would consider referring her for psychological counseling at some point in her care if it appeared the stress was not resolving and was continuing to contribute to her LBP or to make future episodes of LBP likely. The limited bilateral SLR was an impairment that we viewed as a risk factor for future LBP.
The Goals
Goals are measurable target levels of function that the patient will achieve in a set period of time. If goals are met, then an episode of care can be considered worthwhile, and most likely the intervention was useful and based on a sound hypothesis. The goals established with this patient were to roll over in bed and to sleep through the night without pain awakening her, to forward bend and slouch while sitting without pain, and to achieve a pre-LBP level of performance at work. In addition, she hoped to be able to get in and out of her car without pain and don her stockings in the morning without pain. She also had a goal of returning to her recreational activities.
When establishing a temporal element for the goals (ie, the time it would take to achieve the goals), the goals were assessed to establish a hierarchy of difficulty. Goals that required demanding activities were given a longer time to achieve than those dependent on easier tasks. Because we could not find data in the literature that could be used to predict when goals might be achieved, our temporal targets were based on our experience. This is an example of how we used our judgments when evidence was not available. By use of the HOAC II, we were able engage in evidence-based practice and to differentiate the types of evidence we used.
We expected that the patient would be able to roll over in bed and sleep through the night within 2 weeks following the start of the intervention). We expected that she would be able to sit without pain and forward bend without pain in 3 weeks. She was expected to get in and out of her car and to don her stockings in the morning without LBP after 4 weeks of the intervention, and we expected her to be able to do yard work, bicycle, and exercise without LBP in 8 weeks. These temporal elements were based on our experience and on our assumption that her ROM limitations were long-standing and that it would take more time to regain the pain-free ROM required for vigorous activities than for less-demanding activities.
The Testing Criteria
Testing criteria are used in HOAC II to test the correctness of the hypotheses. Testing criteria are target levels of performance, typically at the level of impairments, that, if obtained, should result in goal achievement if the hypothesis is correct. The testing criteria were that the patient needed to attain 110 degrees of forward bending without pain and that she needed to attain 25 degrees of backward bending without pain. Based on the patient's goals of returning to relatively vigorous recreational activities, we believed that this amount of sagittal-plane motion was necessary to minimize potentially injurious forces to the lower lumbar spine area. The forward- and backward-bending values that served as the basis for our testing criteria also were equal to or slightly greater than the mean values for subjects without LBP reported by Waddell et al.13
For the accessory motion tests of the lumbar spine, our testing criteria were that the motion had to be judged as "normal" and that the patient would not report any pain during the tests. These criteria were established because the limited accessory motion appeared to be an important factor in the development of this patient's problems. We believed that the accessory motions had to be painless because this, in our opinion, would indicate the absence of a localized inflammatory process. Reliability of measurements of motion during accessory motion tests is highly questionable.16,17 Despite the problems with reliability, the absence of any alternative methods of measuring motion under these conditions led us to create a testing criteria based on the accessory motion testing. This patient's accessory motion limitations appeared to be severe and, in our view, warranted attention. We kept in mind in clinical decision making, however, that this measurement was likely to have considerable error associated with it.
The measures that served as the remaining testing criteria (no pain with accessory motion tests, and pain-free forward and backward bending) have been shown to have what we would consider acceptable amounts of measurement error,13,16,17 and we therefore considered them to be the most crucial criteria related to accessory motion and forward bending to test the hypothesis.
The Predictive Criteria
Predictive criteria are target levels of performance related to anticipated problems that indicate to the therapist that the patient's risk for recurrence has reduced to an acceptable level (eg, acceptable to the therapist, patient, and other members of the health care team). Predictive criteria are determined when treatment begins. True testing of hypotheses related to risk for recurrence cannot be done, because the problem may never actually recur.
To eliminate the risk factor related to prolonged sitting, the patient had to report that she sat for no longer than 1 hour before she took time out to stand and stretch or take a brief walk. To minimize the effect of the psychological stress risk factor, she had to report that her stress level at work approximated her typical stress level prior to her LBP. Although this may appear to be an overly simplistic approach to this factor, we made the determination based on our belief that the problems causing stress were transient and that, if she was unable to experience a reduction in stress, a consultation with a mental health professional would be warranted. A benefit of the HOAC II is illustrated by the manner in which we dealt with this risk factor; that is, we believed it would essentially resolve itself, but, through use of the predictive criteria, we stayed aware of the problem and could determine whether a referral to a mental health professional might be beneficial.
For the SLR risk factor, she had to achieve 80 degrees for a SLR before perceiving a stretching sensation in the area of the hamstring muscles. This risk factor, unlike the psychological factor, can be amenable to direct physical therapy intervention. Figure 5 illustrates how several of the steps in Part 1 of the HOAC II interface with the patient data and with terms used to describe the disablement process.
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To assess whether the patient was progressing toward her goals, her ROM and straight leg raise were measured during each visit. Her functional limitations and disabilities were also assessed on each visit. Her self-reported functional status, as measured by the SF-36 and the Roland Morris Questionnaire, was measured at the time she began treatment and again at the time she was discharged from our care.
| The Intervention |
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She was seen in the clinic a total of 10 times during a 3-month period. The intervention tactics were as follows. Each treatment session consisted of 3 to 5 sets of P-A pressures to the spinous processes of L3-L5.14 Each set consisted of a 30-second application of force at each level while the patient was positioned prone. The force was applied gradually until the patient reported pain, and then the force was maintained at the end-range. Usually the patient reported the intensity of pain during this procedure to be a 1or 2 level out of 10. Following each set, the patient did 10 repetitions of the lumbar prone press-up (prone-lying push-up with the abdomen resting on the exercise surface) and a set of 10 repetitions of the bilateral knee to chest exercise while positioned supine, both exercises as described by McKenzie.22 The patient was told she would feel a stretching sensation at the end-range of each motion and to hold the position for a few seconds.
We progressed the intervention (we used greater amounts of force over subsequent treatment sessions) so that the P-A pressures elicited mild pain. Because the patient had lumbar spine impairments, which we believed to be related to shortened tissue, the forces applied during treatment had to be, in our view, sufficient to stretch these shortened tissues. Loading the shortened tissues often elicited pain until, by the eighth treatment session, she had no pain during the P-A pressures. In addition, the therapist applied pressure to the lower lumbar spine during the prone-lying press-up exercise beginning the fifth visit because the patient no longer perceived a stretching sensation while performing a press-up on her own. Overpressure to the lumbar spine was applied by placing the therapist's palms over the patient's lower lumbar spine and applying a downward force while the patient performed her prone-lying press-up exercise. The patient was taught a home exercise program, which was designed to increase forward bending, backward bending, and hamstring muscle length. The home program consisted of a set of 10 repetitions of the bilateral knee-to-chest exercise while positioned supine and 10 repetitions of the prone-lying press-up exercise. The patient was taught to hold each repetition at the end-range for 2 to 3 seconds and to apply force until a stretching sensation was perceived in the midline of the lumbar spine. The patient was also shown how to do hamstring stretching exercises. While standing, the patient placed one foot on her desk with her raised knee straight and gently leaned forward until a stretching sensation was perceived in the area of the stretched hamstring muscles. The position was to be held for 1 minute for each lower extremity. To avoid pain in her low back during the hamstring muscle stretches, she was told to avoid lumbar spine flexion. Two sets were to be done for each lower extremity. She was also told to do the 3 exercises every hour throughout the day at work and while at home during every other waking hour. Based on our clinical experience, this duration and frequency are tolerated well and frequently produce the desired changes.
The patient was told that during the breaks from sitting at work, she should flex, extend, and side bend the trunk while standing and that she should do these movements 2 or 3 times and then walk around the office for approximately 1 minute. She was asked to keep a log of her daily exercise. Because she had a private office at work she was able to exercise in her office and, based on a review of her log, she adhered to her exercise program. For the psychological stress, the patient was encouraged to discuss her concerns with friends, colleagues, and her physician. She reported she had not discussed the stress she was feeling and did not want to "burden" others with her problems. By the fifth week of treatment, she reported that she had many discussions with friends about her work-related stress and that she felt more "in control" at work.
The Reassessment and Outcome
The reassessment, as described in Part 2 of the HOAC II, is a conceptual guide for decision making related to the patient's responses to the intervention. Our patient was discharged from physical therapy after 10 visits (3 months after the first visit). The patient reported that she had achieved all of her goals except she still had some intermittent mild pain when putting on stockings in the morning and when rolling in bed. She rated the intensity of this pain as 1 on the 0 to 10 verbal pain rating scale. She also said that the pain lasted only a few seconds. She stated the pain occurred approximately once every 4 mornings. She appeared to be ready to complete the episode of physical therapy care.
We were surprised to find that the 2 PIPs that persisted were the PIPs that were hypothesized to resolve the quickest. Rolling in bed and donning stockings in the morning are 2 activities that are related to being in a recumbent position for several hours. We suspected that the stiffness of the patient's lumbar spine increased after the patient lay down for a night's sleep and that this increased stiffness resulted in some mild pain when rolling in bed or donning stockings. Before the patient was discharged from physical therapy, we instructed her to do 1 set of 10 repetitions each of the prone press-up and the supine knees to chest exercise. She was to do these exercises upon awakening before getting out of bed. The exercises were designed to decrease the stiffness of the spine associated with a night's sleep.
Her impairment measurements at discharge are listed in Table 2. Her range of backward bending achieved the pre-established criteria, and her forward bending was only 2 degrees less than the criteria. Her straight-leg-raise measurements met the testing criteria for both lower extremities. She no longer reported pain during the accessory motion tests of the lower lumbar spine. We judged her accessory motion to continue to be hypomobile at the time of discharge.
This patient was discharged from physical therapy even though she had not achieved all of her goals or met all the testing criteria. We determined that she performed all of her exercises in a manner that was appropriate. Therefore, she implemented the treatment strategy, but problems persisted. We concluded, based on our opinions, that the hypotheses and resultant tactics were not the cause of a less than ideal patient outcome.
We believed that by continuing her exercise program, the patient would eventually have no pain in the morning. In terms of the HOAC II, we had erred in predicting how long it would take for the patient to respond to the intervention and to achieve her goals. The patient was satisfied with her outcome and agreed that discharge from physical therapy was appropriate but that she could continue to improve by doing the exercises in the morning.
We judged the patient to have limited lumbar spine accessory motion, but because of her improved status and the poor reliability of data for the lumbar spine accessory motion tests, the apparently limited accessory motion did not appear to us to warrant further intervention. With the exception of the accessory motion tests, the hypothesis that guided this patient's intervention appeared to be credible. Improvements in disability appeared to follow improvements in the patient's impairments, providing support for our hypothesis. For the anticipated problems, the patient reported she believed her psychological stress was "back to normal." She also reported that she had developed a routine of getting out of her chair hourly and was comfortable with this routine. She demonstrated an understanding of the importance of continuing her exercise program at home. Based on the predictive criteria, she appeared to have minimized or eliminated what we considered risk factors for recurrence of her LBP.
The SF-36 scores listed in Table 1 provide some insights into this patient's apparent recovery. The admission scores indicated that our patient scored below the 25th percentile in the Physical Function, Bodily Pain, Vitality, and Mental Health categories. These categories include activities that correspond to the types of activities reported by our patient in her problem statement. At the time of discharge, our patient showed changes greater than 2SEM in the Physical Function, Bodily Pain, Vitality, and Mental Health scores. Based on the 2SEM values, the changes that occurred between admission and discharge appear to represent real changes in health status following physical therapy care. Based on the normative data, the questionnaire results suggest our patient's perceived functional level at the time of discharge approximated the health status of subjects in her age range from the general US population.
The patient's RMQ scores changed from 8 at the time of admission to 3 at discharge. At the time of discharge, the items from the RMQ that she identified as applying to her related to having trouble with rolling in bed and putting on stockings. The change in RMQ scores also appeared to represent a decrease in disability. Data reported by Stratford and colleagues6 suggest that changes on the order of 5 RMQ points are necessary to infer that a real change in disability has occurred. For patients with relatively mild levels of disability, such as the patient in this report, changes of 3 to 4 RMQ points probably represent important improvements in disability.23,24 We believe the data from the disability measures indicate that the improvement in the patient's disability was important and provide further evidence that the hypothesis was correct. The patient's disability status improved, as did most of her impairments.
| Conclusion |
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TopAbstractIntroductionCase DescriptionReported Functional Limitations...The InterventionConclusionAppendixReferences |
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| Appendix |
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TopAbstractIntroductionCase DescriptionReported Functional Limitations...The InterventionConclusionAppendixReferences |
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| Footnotes |
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* WB Saunders Therapy Products, Bloomington, MN 55439. 
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TopAbstractIntroductionCase DescriptionReported Functional Limitations...The InterventionConclusionAppendixReferences |
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