title: The addition of manipulation to an extension-oriented intervention for a patient with chronic LBP.
abstract: OBJECTIVE
  There is a paucity of research investigating the combined interventions of direction-specific lumbar exercise and manipulation for individuals with low back pain (LBP) who exhibit centralization or a directional preference. The purpose of this report was to describe the management and outcomes of a patient with chronic LBP who met two categories of the revised treatment based classification (TBC) approach initially described by Delitto and colleagues.
  
  
  METHODS
  A 55-year-old female with a 15-year history of right LBP/leg pain demonstrated centralization of symptoms with repeated extension and met four out of five criteria on the clinical prediction rule for thrust manipulation.
  
  
  METHODS
  The patient was treated for seven physical therapy sessions, once a week for seven weeks. Lumbar thrust manipulation and extension-oriented interventions were combined throughout the course of care. The patient experienced a decrease on the modified Oswestry disability index score from 26 to 8%, an increase in the patient-specific functional scale score from 5.6 to 9.4, and patient-report of full return to pain-free activity at discharge.
  
  
  CONCLUSIONS
  A patient with chronic LBP reported a clinically meaningful improvement after seven visits of manipulation and extension-oriented interventions. Further research should compare the effectiveness of combining interventions for individuals who meet the two TBC groups of manipulation and extension-specific exercise compared with performing either intervention alone.
authors.affiliation: Department of Physical Therapy, College of Health Professions and Social Work, Temple University, Philadelphia, PA, USA ; Regis University Manual Therapy Fellowship Program, Denver, CO, USA.
authors.forename: Heidi
authors.initials: H
authors.lastname: Ojha
authors.affiliation: Department of Physical Therapy, College of Health Professions and Social Work, Temple University, Philadelphia, PA, USA ; Regis University Manual Therapy Fellowship Program, Denver, CO, USA.
authors.forename: William
authors.initials: W
authors.lastname: Egan
authors.affiliation: Regis University Manual Therapy Fellowship Program, Denver, CO, USA ; Moss Rehab, Philadelphia, PA, USA.
authors.forename: Patricia
authors.initials: P
authors.lastname: Crane
keywords: Chronic low back pain; Clinical decision making; Directional preference; Extension specific exercise; Motor control; Thrust manipulation; Treatment based classification