The Use of a Direction Tolerance System for Patients with Low Back Pain: Intra-Rater Reliability and Outcome


Physical Therapy

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Orthopaedic Physical Therapy Practice

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Background and Purpose: In recent years, the approach to treating patients with low back pain (LBP) has evolved to establishing patient diagnosis based upon common clinical characteristics. Several classification systems exist in the current literature; however, the current systems lack examination of tolerance to movement exclusively in the standing position. The Direction Tolerance System (DTS) provides the clinician an examination and treatment tool that observes patient movement through all planes of motion in standing. The purpose of this study was to evaluate the intra-rater reliability of the DTS assessment in patients with LBP, investigate patient success outcomes using the DTS treatment protocol, and determine if an association exists between patient clinical characteristics and outcomes achieved using the DTS. Methods: Five physical therapists (2-26 years of experience) performed the testing and treatment in the study. Sixty subjects, ages 18-80 years (mean = 52 ± 16.0), with LBP were examined and treated using the DTS protocol. The Direction Tolerance Index (DTI), Numeric Pain Rating Scale (NPRS), Oswestry Disability Questionnaire (ODQ), and Fear-Avoidance Beliefs Questionnaire - Physical Activity Sub-scale (FABQ-PA) were collected for inclusion criteria and to evaluate outcomes. Findings: Intra-rater ICC was 0.80 (95% Confidence Interval 0.68-0.88) indicating good reliability (p<0.001). Of the 60 subjects that completed the study, 75% achieved a positive outcome with 62% (37/60) classified as success and 13% (8/60) classified as improved. Clinical Relevance: As treatment classification systems become more prominent in clinical use, the DTS may provide clinicians across all levels of experience a reliable tool that requires minimal training and is easy to administer a way to successfully examine and treat patients with LBP. Conclusion: The results of this study preliminarily suggest that the DTS is a reliable and effective tool for the examination and treatment of patients with LBP using functional testing and treatment positions.