On Saturday January 20, 2007, Pilates instructors from around the Bay Area met at Los Gatos Pilates to attend the Physical Therapy of Los Gatos Train-the-Trainer seminar: “Assessment for Pilates Instructors.” The purpose of the seminar was to present key physical assessment tools that Pilates instructors can use to customize exercise programs to meet the specific  needs of individual clients.

“Given the many similarities between Physical Therapy and Pilates, the move to more prescriptive exercise provides greater long term results for clients,” said Rob Naber, founder of Physical Therapy of Los Gatos.   The seminar included an instructional lecture and hands-on practice to assess client’s posture, spinal lumbopelvic range of motion and rhythm, flexibility and core strength.  At the conclusion, case studies were presented with “home work” for the attendees.  Answers to the assignment are provided at the end of the presentation.

Physical Therapy of Los Gatos thanks Nancy Chin and Marcie Ryken at Los Gatos Pilates for hosting the seminar.

Download “Physical Assessment for the Pilates Professional” (7.5 MB pdf)

At the September 2005 Western Occupational Health Conference, Physical Therapy of Los Gatos principal Rob Naber delivered presentations on anterior knee pain and lumbar active range of motion. At the same conference, Rob also gave a somewhat more technical presentation for physicians on the topic of lumbar spine stability. This web site article was adapted from his presentation notes and materials.

Lumbar spine stability is an important concept in orthopedic medicine because its absence is often identified as the cause of lower back pain. When the lumbar spine is insufficiently stable, the motion between the joints of the lower back is exaggerated and abnormal. A patient with lumbar spine instability will experience lower back pain when the joints of the lumbar spine “wobble” in use rather than transferring forces with the smooth, synchronous movements of a healthy spine.

If lumbar spine instability is identified as the cause in a case of lower back pain, lumbar spine stabilization must be the cure. Too often this simplistic view of the relationship between lumbar spine stability and lower back pain is used as the basis for handing out “core strengthening” exercise instructions as a treatment for lower back pain. Few cases of lower back pain caused by lumbar spine instability are relieved by pre-printed handouts of abdominal and paraspinal, or “core,” strengthening exercises.

While we encourage our patients toward any healthy form of exercise, including those forms that address core strength, we are critical of physical therapists and other health care providers who prescribe pre-printed, generic strengthening exercises to patients suffering from lower back pain. In most cases, these exercises will fail to provide any relief. And unfortunately, the most motivated patients receiving these instructions will succeed in strengthening their abdominal and paraspinal muscles. Greater strength will cause untreated lumbar spine joint wobbling to occur with greater force and velocity, and the patient will feel much worse.

In the maintenance of healthy lumbar spine stability, muscle endurance is more important than muscle strength. Furthermore, muscle endurance, the condition of ligaments, and motor control of the structures supporting the spine must be in balance if lumbar spine stability is to be achieved. Generic muscle strengthening regimes that disregard initial measures of paraspinal and abdominal wall muscle endurance, and do not aim to restore correct, specific, balanced, and sustainable force vector ratios around the lumbar spine will fail to produce measurable improvements and will likely increase the patient’s pain and disability.

At Physical Therapy of Los Gatos, our physical therapists are trained to evaluate lumbar spine instability using effective methods and clinical precision. Measurements taken during the evaluation phase of therapy and at key intervals over the course of treatment include timed isometric holding exercises in right and left “side plank” positions, a sixty degree sit-up position, and the Biering-Sorensen position (pictured). The results of these tests are compared with normative time values determined in research studies and are used to design individualized treatment protocols to restore correct force vector ratios around the lumbar spine. These individualized treatment protocols produce complete and rapid recoveries from lower back pain caused by lumbar instability.

Lumbar Spine Stabilization presentation by Rob Naber to the 2005 Western Occupational Health Conference (765 KB .pdf

Conference Program Abstract (76 KB .pdf download)

This entry is adapted from a talk presented by Physical Therapy of Los Gatos principal Rob Naber at the Western Occupational Health Conference 2005, held September, 2005 in Monterey, California:

Active Range of Motion (AROM) refers to the range of motion for a specific movement that a patient can achieve without assistance, such as a measurement of how far the back moves when a patient bends forward to touch his or her toes. The distance or angle between the starting and finishing position is the AROM. A reduction in AROM can impair routine, vocational, and athletic movements and overall functional capability. Restoring AROM following injury, surgery, or the effects of an illness on the musculoskeletal system is often the goal of physical therapy and the principal reason that many patients are referred to physical therapy.

In the past, physical therapists used goniometers to quantify lumbar AROM. Though practical for AROM measurements around knees and shoulders, the goniometer was of of very limited clinical utility as a means of measuring motions of the spine and surrounding joints. Other tools and methods, such as flexible rulers and measuring tapes, suffered from a lack of precision and reference values, and were also of little diagnostic value.

In 1984, Mayer, et al. proposed a method using specific inclinometer measurements to enable quantification of lumbar forward bending AROM and discrimination between the contributions of the hip and spine to the overall motion. In 1986, Keeley, et al. published a follow-up article that validated the reliability of the inclinometer-based technique and presented the reference values needed to make measurements made in the clinic meaningful.

While necessary as components of a complete evaluation, individual inclinometer measurements of lumbar AROM offer little information of clinical value and should not be used to report degrees of impairment. Multiple inclinometer measurements are necessary to determine the effects of the patient’s starting posture and the relative contributions of hip, pelvis, and lumbar joints to forward and backward bending. A patient can present with a normal lumbar AROM but still suffer from a “weak back” and recurring back pain and disability.

Physical therapy to restore a diminished lumbar AROM is not simply a matter of achieving a specific AROM value. A more nuanced therapeutic goal of restoring ideal ratios between the contributions of involved joints to composite lumbar motions will lead to more rapid and sustained reductions in impairment and more complete and satisfying recoveries.

Lumbar Spine Active Range of Motion: Significance and Relevance in Rehabilitation presentation by Rob Naber to the Western Occupational Health Conference 2005
Western Occupational Health Conference 2005: New Horizons in Occupational Medicine

Low back pain is a vexing medical and personal problem. Almost everyone has to deal with it sooner or later. Low back pain can interfere with almost every aspect of daily living and causes more days lost from work than any other malady except the common cold. Low back pain can make finding a comfortable sleeping or sitting position impossible, and due to the central position of the lower back and its key mechanical role in supporting and enabling movement, resting the painful spine during waking hours is very difficult.

A clear physical evaluation and focused goals are imperative when solving enigmatic health problems such as low back pain. At Physical Therapy of Los Gatos, evaluation for low back pain includes objective measurement of the patient’s function, mobility of the spine, neurological assessment, dynamic strength, flexibility, and gait analysis. In our experience, the outcome of physical therapy that begins with a comprehensive evaluation is more likely to be successful than one that passes over the opportunity to use up-to-date diagnostic instrumentation and methods for precise patient evaluation.

One of many tools and methods we use to evaluate low back pain is the Oswestry Low Back Pain Disability Questionnaire. Originally published in 1980, the Oswestry questionnaire measures how one’s low back pain affects a variety of daily activities. Patients usually complete the questionnaire in less than five minutes. The answers patients select from the multiple-choice questionnaire provide useful information about the behavior, mechanical cause, and severity of the patient’s low back pain. This information, combined with other responses and measures used in our evaluation, help us to design a personalized, effective course of treatment, and prognosticate the duration of treatment.

If you’d like to take the Oswestry Low Back Pain Disability Questionnaire, you can pick up a copy at Physical Therapy of Los Gatos, or call to have us fax or mail it to you, or download the questionnaire. You can find our location and contact information near the top right-hand corner of this web page. Afterwards, we’ll be happy to discuss the results with you and, depending on your score, discuss our recommendations for more precise evaluation of your low back pain.

The role of a physical therapist is to help you regain your function and allow you to return to your life of work, recreation, and other daily activities. A key element of this role is determining whether you have the appropriate range of motion (ROM) available to accomplish your daily activities without pain. Until recently, physical therapists used a device known as a goniometer to measure this range of motion at a joint. Now, physical therapists measure ROM in a different way. This change was brought about by studies showing ROM measurements made using a new tool, known as an inclinometer, are more accurate, precise, and reproducible than measurements made using goniometers. According to the American Medical Association’s Guides to the Evaluation of Permanent Impairment (Third Edition), the inclinometer has been adopted to measure spinal ROM. Physical therapists have also found that inclinometers are easier to use, and provide new and more useful information.

Old School
A goniometer looks a bit like a protractor you may have used to measure angles in geometry class, but with arms, like the type of compass used for drawing circles. The arms of a goniometer intersect at a single axis or pin:

To measure the ROM at a joint with a goniometer, the patient moves his or her body part to the position directed by the therapist (i.e bend your knee). The therapist aligns the arms of the goniometer with the bones surrounding the joint and aligns the pin with the joint axis. Because the therapist cannot hold the goniometer directly against the bones, bone and joint axis positions must be estimated. The angle indicated by the goniometer is recorded. Goniometer measurements typically require the joint to be moved from the beginning of its range to the end of its range of motion. For example in the knee, a measurement is taken when the joint is fully bent and then again when it is fully straightened . Because the positions of the bones and axis points must be estimated, each reading made with a goniometer introduces error into the measurement. Normal joint mechanics introduce another source of error into goniometer measurements: unlike a door hinge rotating around a cylindrical pin, a joint rotates around the ends of the bones, which are not perfectly round. Therefore the joint axis itself moves, making the estimation of the axis position more difficult.

New School
No such estimates or alignments are necessary with an inclinometer. Inclinometers have dials or digital readouts that display the angle at which the inclinometer is situated relative to the line of gravity.



To use an inclinometer, the therapist holds the instrument on the patient, who begins in a standard starting position. The therapist zeroes-out the inclinometer and then instructs the patient to bend the joint through its ROM. The inclinometer’s final reading is the ROM measurement. The inclinometer never leaves contact with the patient and the axis does not need to be identified.

The accuracy of ROM measurements taken using inclinometers can be estimated by comparing their measurements with those taken from X-rays, which allow very direct joint angle measurements. Mayer et al. showed ROM measurements of the spine made using inclinometers are statistically similar to readings determined using X-rays. Keeley et al. showed repeated ROM measurements made using inclinometers yield very reliable values.

Unlike goniometers, inclinometers can be used in pairs to gain even more diagnostic information during patient evaluations. For instance, bending forward to touch the toes is a “composite” motion, that is, some of the motion comes from the hips and some comes from the lower back. When a patient has pain upon bending forward, the physical therapist can use two inclinometers at once to determine whether the lower back and hips are each contributing the proper amount of flexibility to support the movement. The inclinometer readings may indicate that the painful lower back is compensating for the inflexible hips. The therapist can then begin an effective course of physical therapy to relieve the lower back pain by restoring the patient’s hip function and flexibility.

To learn more about inclinometers or see how your spinal range of motion measures up, contact Physical Therapy of Los Gatos at (408) 358-6505.