Immediate Effect Of Standing Trunk Extension Postures On Spinal Height And Clinical Outcome Measures In Low Back Pain: A Randomized Clinical Trial
Phase: NA
Conditions: Low Back Pain
Sponsor: Texas Tech University Health Sciences Center

RESEARCH PROPOSAL 
 
 
 
 
 
Title: Immediate Effect Of Standing Trunk Extension Postures On Spinal Height 
And Clinical Outcome Measures In Low Back Pain: A Randomized Clinical Trial 
 
 
Investigators: 
Jean-Michel Brismée, PT, ScD - PI 
Jeremy Harrison, PT, DPT 
Phillip S. Sizer, PT, PhD 
 
 
Clinical Musculoskeletal Research Laboratory, Center for Rehabilitation 
Research, School of Health Professions, TTUHSC, Lubbock, TX, USA 
 
 
 
 
 

 
 
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TABLE OF CONTENTS 
 
ABSTRACT………………………………………………………………………………4 
LIST OF FIGURES……………………………………………………………………...5 
LIST OF ABBREVIATIONS…………………………………………………………….6 
BACKGROUND…………………………………………………………………………7 
PURPOSE, AIMS, VALUES………………………………………………………….12 
RESEARCH QUESTIONS……………………………………………………………13 
HYPOTHESES…………………………………………………………………………13 
COMPARISON VARIABLES…………………………………………………………14 
      Independent Variables……………………………………………………………14 
      Dependent Variables……………………………………………………………..15 
      Relationship Variables……………………………………………………………15 
METHODS……………………………………………………………………………..16 
      Research Design………………………………………………………………….16 
      Pre-Study Approvals………………………………………………………………16 
      Subjects…......................................................................................................16 
      Testing Sequence…………………………………………………………………17 
DATA ANALYSIS………………………………………………………………………22 
RESEARCH PROJECT TIMELINE………………………………………………….25 
REFERENCES…………………………………………………………………………26 
APPENDICES………………………………………………………………………….41 

 
 
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ABSTRACT 
Background: Standing trunk extension postures have been used for many years 
as a mechanical approach to low back pain (LBP), sometimes directed by 
therapeutic intervention, sometimes subconsciously performed by patients to 
relieve LBP. However, no study to date has investigated the effect of standing 
trunk extension postures on spinal height and clinical outcome measures.  
Objective: The purpose of this study will be to evaluate in subjects with LBP 
following a period of trunk loading, how spinal height and/or pain, symptoms’ 
centralization, and function outcome measures respond to: (1) standing repetitive 
trunk extension posture; and (2) standing sustained trunk extension posture. 
Lumbar range of motion (ROM) achieved during these two trunk extension 
postures will be compared to spinal height and outcome measures. 
Methods: A pre-test, post-test comparison group design (randomized clinical 
trial) will be used to determine how spinal height changes in response to 
sustained and repetitive standing trunk extension after a period of spinal loading. 
The study will use a 2 (between subjects – type of trunk extension: sustained vs. 
repetitive) x 3 (within subjects - time: before vs. after vs. 2 weeks after 
intervention) mixed design to evaluate the effects of sustained and repetitive 
trunk extension in standing on spinal height, pain, symptoms’ centralization and 
function. 
Statistical Analysis: A 2(Strategy) X 3(Time) mixed ANOVA will be used to 
statistically identify significant interactions and main effects for spinal height, pain 
and function outcome measures. Post-hoc pairwise comparisons will be used to 
locate significant differences between the different conditions (Time).  
Significance will be set at α = 0.05. Pearson product-moment correlations will be 
used to measure correlations between lumbar ROM in relation to spinal height 
and outcome measures. The Kruskal-Wallis 1-factor ANOVA for difference 
scores will used to determine changes of intensity and location of symptoms 
following sustained versus repetitive standing trunk extension. Spearman Rank 
correlation will be used to evaluate the relationship between spinal height 
changes and changes of pain and location of symptoms for each group. 
Word Count: 326 
Key Words: Standing postures; trunk extension; spinal height change; 
stadiometer  
 
 

 
 
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Lay Summary 
 
Standing back extension postures have been used for many years to treat people 
with low back pain. 
 
No study to date has investigated the effect of standing back extension postures 
on trunk height, pain and function.  
 
The purpose of this study will be to evaluate in subjects with low back pain how 
trunk height, pain and function respond to standing repetitive versus 
sustained trunk extension postures. 
 
Methods: A randomized clinical trial will be used to determine how trunk height, 
low back pain and function change in response to sustained and repetitive 
standing trunk extension after a period of spinal loading.  
 
Statistical Analysis will be used to measure the outcomes. 

 
 
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LIST OF FIGURES 
Figure 1: Flowchart depicting testing sequence……………………………………31 
Figure 2: Starting position for standing trunk extension (repetitive and 
sustained…………………………………………………………………….34 
Figure 3: Sustained trunk extension position and end position of repetitive trunk 
extension…………………………………………………………………….35 
Figure 4: Position of subject for spinal height measure in stadiometer unit……..36 
Figure 5: Position of subject during spinal loading time in sitting………………...37 
Figure 6: Home exercise program for repetitive trunk extension group……........38 
Figure 7: Home exercise program for sustained trunk extension group…………39 
Figure 8: Home instructions for each subject……………………………………….40 
 
 
 

 
 
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LIST OF ABBREVIATIONS 
Analysis of Variance………………………………………………….…………ANOVA 
Fear Avoidance Belief Questionnaire…..…………………………………….....FABQ 
Intervertebral Disc……………………………………………..……………………. IVD 
Institutional Review Board…………………………………………………………. IRB 
Low Back Pain……………………………………………………………………….LBP 
Numerical Pain Rating Scale……………………………………………….……NPRS 
Range of Motion…………………………………………………………………….ROM 
Standard Deviation……………………………………………………………………SD 
Research Question…………………………………………………………………...RQ 
Research Hypotheses………………………………………………………………..RH 
Independent Variable……………………………………………………………….....IV 
Dependent Variable…………………………………………………………………..DV 
Relationship Variable…………………………………………………………………RV 
 
 
 

 
 
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BACKGROUND 
According to the United States Department of Labor, there were more 
than one million injuries and illnesses requiring days away from work amongst 
private industry, state and local government employees. Among these injuries 
and illnesses, 16.6 % were low back related equating to 191,479 low back 
injuries requiring days away from work (US Department of Labor, Bureau of 
Labor Statistics, 2016). An analysis funded by the National Institute of Health 
found that the cost of pain outweighed the cost of cancer and diabetes by thirty 
percent. The authors further reported that the annual cost of pharmaceuticals for 
pain management was $16.4 billion, and the cost of lumbar surgeries was $2.9 
billion.  Pain indirect costs estimates were $18.9 billion for disability 
compensation and $6.9 billion for productivity loss (Gaskin 2011, The Economic 
Costs of Pain in the United States).  
A joint clinical practice guideline developed by the American College of 
Physicians and the American Pain Society classified low back pain (LBP) into 
three categories: (1) nonspecific LBP; (2) LBP potentially associated with 
radiculopathy or spinal stenosis; and (3) LBP potentially associated with another 
specific spinal cause. Of those three, lumbar intervertebral disc (IVD) herniation 
is one of the most common spinal degenerative disorders leading to LBP 
associated with radiculopathy (Chou 2007, Goupille 1998, McCall 2000). In order 
to better understand the IVD’s role in the development or persistence of LBP and 
spinal stenosis, there have been many stadiometric studies primarily focused on 
lumbar spinal height changes associated with various positions and movements 

 
 
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(Kourtis 2004; Magnusson 1996; Lazzarini 2014; Simmerman 2011). These 
studies stem from IVD height preservation in the aging spine. Natural IVD height 
preservation is so important that the biomedical field has examined the use of 
growth factors for IVD biologic regeneration (Masuda 2004) in order to more 
naturally preserve IVD biomechanical and physiological function as opposed to 
surgical disruption. To further understand IVD functional properties, researchers 
have studied the IVD hydraulic permeability and the influence that age and/or 
degeneration have on fluid movement (Gu 1999). The authors reported that with 
IVD degeneration, the radial permeability of the anulus fibrosus decreased, 
mainly because of reduced water content. However, the axial and circumferential 
permeability coefficients increased, mainly due to structural change, leading to 
greater IVD isotropic permeability behavior (Gu 1999).  
Sixty one percent of time in the work and home environment is spent in 
the standing posture (US Department of Labor, Bureau of Labor Statistics, 2016). 
Although prolonged weight bearing postures, such as standing and walking, have 
been associated with decreased spine height (Tyrrell 1985, Puntumetakul et al 
2009), some studies reported that seated weight bearing postures could result in 
spine height gain (Magnusson 1996a). Sustained and repetitive lumbar extension 
postures frequently occur after periods of prolonged unloading such as sleep. 
These postures are periodically repeated throughout the day during activities 
such as standing and walking (US Department of Labor Bureau of Labor 
Statistics 2016).  
People presenting with directional preferences that include lumbar 

 
 
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extension tend to respond well to exercises geared toward trunk extension 
(Stankovic 1990, Swinkels 2009, Oliveira 2012). Significant and rapid changes in 
central and distal pain intensity and location have resulted from standing end-
range trunk extension in patients with low back and referred pain (Donelson 
1991). Additional studies reported that standing back extension exercises 
resulted in back pain episodes’ prevention and decreased back pain in care 
workers (Matsudaira 2015; Dunsford 2011). Standing exercises have the 
advantage to be functional and easily performed in work and home settings 
(Tonosu 2016).  
 A positive relationship has been found between lumbar extension range 
of motion (ROM) and the centralization process in patients with LBP (Bybee et al 
2009). The centralization phenomenon is part of the clinical examination findings 
used to identify specific treatment-based classification subgroups. Centralization 
is characterized by spinal pain and referred symptoms that are progressively 
abolished in a distal to proximal direction in response to therapeutic interventions 
including unloading or specific movement strategies (Brennan et al 2006, Laslett 
et al 2005). The operational definition and measurement techniques for 
centralization have been laid out in several studies (Aina et al 2004, Werneke et 
al 2008). A decreased spinal ROM is commonly associated with low back 
complications, and functional ROM needs to be restored to allow for the return to 
previous activity levels (Battie 1987, Vaisy 2015). Several methods have been 
used to increase spinal ROM including static, repeated, passive postures, and 
proprioceptive neuromuscular facilitation. Both standing and prone lumbar 

 
 
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extension postures are effective for treating low back Dysfunction Syndrome 
(McKenzie 2003). However, which method is best suited for increasing spinal 
ROM remains debated (Sady 1982; Nordez 2017). One author found static prone 
postures to increase ROM more effectively with 30-60 second sustained postures 
as compared to 15-second postures, but no difference between the effectiveness 
of 30-second and 60-second postures (Bandy 1994; Page 2012).  
Repetitive postures are another method used to increase ROM by 
elongating shortened connective tissue. The McKenzie classification of 
Dysfunction Syndrome is defined as the condition in which adaptive shortening of 
soft tissues and resultant loss of mobility cause pain by stretching shortened 
tissues that block full end-range movement (Hefford 2008). Poor postural habits, 
previous trauma and inflammatory or degenerative processes can lead to this 
dysfunction. These patients can develop contraction, scarring, adherence and 
adaptive shortening or imperfect repair and pain is felt when the abnormal tissue 
is stretched.  
Treatment of the Dysfunction Syndrome consists of postural correction, 
along with repeated end-range movements to remodel contracted structures. 
This intermittent stress is reported to provide an adequate stretching effect and is 
most effective in the treatment of extension dysfunction (McKenzie 2003). One 
study found that patients with LBP chose to perform their extension posture for 
home exercise in standing 80.8 % of the time and only 19.2 % of the time in the 
prone position, resulting in similar clinical outcomes where both groups showed 
equal improvements in lumbar extension ROM (Bybee et al 2008).  

 
 
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Previous studies investigated the effects of postures and movements in 
lying (unloaded) or seated positions on spinal height (Owens 2009, Gerke et al 
2010; Pape 2018). These studies primarily focused on spinal height following 
static patient positioning and showed that both the lying and supported seated 
positions resulted in mean spinal height gains of 2 to 5 mm. However, most 
rehabilitation programs focused on LBP prevention and management use both 
repetitive and/or sustained spinal extension exercises to improve patients’ 
outcomes (Peterson 2015, Surkitt 2012).  Such exercises can be performed in 
lying or standing position.  Although patients with acute and recurrent low back 
and referred pain tend to respond well to directionally preferenced postures 
(Machado 2006), subjects with chronic symptoms tend to display greater signs of 
sensitization, biopsychosocial issues (Huysmans 2017), and tend to respond less 
favorably to directional preferences postures and exercises (Garcia 2017). In 
order to assess the biopsychosocial effect on clinical outcomes during this study, 
every subject will complete the Fear Avoidance Belief Questionnaire (FABQ) 
(Cleland et al 2008).  
No study to date has investigated the effects of standing extension 
postures on spinal height, pain, centralization and function. Therefore, the 
purposes of this study will be to evaluate in a sample of LBP patients the effect of 
standing trunk extension, both sustained and repetitive, following a period of 
spinal loading, on (1) spinal height; (2) pain; (3) symptoms centralization and (4) 
functional measures. 
 

 
 
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PURPOSE, AIMS, VALUES 
Purpose(s):  
The purpose of this study is to assess the effect of commonly used 
standing trunk extension postures on spinal height as well as pain, symptoms’ 
centralization, and function in patients with LBP.  
Aim(s):  
Our aim is to better understand the effect of standing sustained and 
repetitive trunk extensions on spinal height and LBP patients’ symptoms 
intensity, centralization and function. With many patients commonly falling into a 
directional preference group and responding positively to mechanical spinal 
input, it is our aim to investigate if such trunk extension postures performed in 
standing affect spinal height in regard to growth or shrinkage and if these 
changes are associated with symptoms intensity, centralization and functional 
alterations. 
Value(s):  
No previous study has examined changes in spinal height following 
standing trunk extension postures and little is known on the effect of such 
standing postures on spinal height.  The results of this study could impact 
rehabilitation programs that include standing trunk extension as a means of 
therapeutic intervention. This is valuable especially in aging population with 
degenerated IVD’s, loss of IVD height and propensities toward spinal stenosis, 
as we do not know if those subjects with directional preferences toward spinal 
extension could use standing trunk extension postures at home or in the work 

 
 
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environment to grow and/or prevent spinal shrinkage. 
RESEARCH QUESTIONS, HYPOTHESES AND VARIABLES 
Research Question(s) (RQs)-This project aims to answer the following research 
questions: 
1. RQ 1: Does sustained and repetitive standing trunk extension following a 
period of spinal loading effect spinal height, pain, centralization and 
function testing outcomes immediately and two weeks following the 
interventions in patients with LBP? 
2. RQ 2: Following a period a spinal loading, is there a difference in spinal 
height, pain, centralization and function testing outcome changes 
immediately and two weeks following sustained and repetitive standing 
trunk extension postures in patients with LBP? 
3.  RQ 3: Is there a correlation between the degree of trunk extension during 
standing lumbar extension posture and spinal height, pain, centralization 
and function testing outcomes changes immediately and two weeks 
following the interventions in patients with LBP?  
 
Research Hypotheses- (RH)This student has devised the following research 
hypotheses: 
1. RH 1: It is expected that following a period of trunk loading, both 
sustained and repetitive trunk extension postures in standing will result in 
increased spinal height, reduced pain, enhanced centralization and 

 
 
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function testing outcomes immediately and two weeks following the 
interventions in patients with LBP. 
2. RH 2: It is expected that following a period of trunk loading, sustained 
standing trunk extension posture in standing will result in greater spinal 
height gain as compared to repetitive standing trunk extension postures, 
while repetitive standing trunk extension postures will result in greater 
improvements in pain, centralization and function testing outcomes as 
compared to sustained standing trunk extension postures immediately 
and two weeks following the interventions. 
3. RH 3: It is expected that following a period of trunk loading, there will be a 
positive correlation between the degree of trunk extension during 
standing trunk extension posture and spinal height, centralization, pain 
and function testing outcomes changes immediately and two weeks 
following the interventions in patients with LBP.  
 
Comparison Variables 
Independent Variable(s)-The student plans to use the following Independent 
variable(s) (IV)  
1. IV1: Trunk extension 
a. IV1: sustained 
b. IV2: repetitive 
2. IV2: Time 

 
 
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a. IV1: before 
b. IV2: after (immediately) 
c. IV3: after 2 weeks  
 
Dependent Variable(s)-The Student plans to measure the following dependent 
variable(s) (DV)  
1. DV1: Spinal height using stadiometer (ratio scale).  
2. DV2: Pain rating using numerical pain rating scale (NPRS) (ordinal 
scale). 
3. DV3: Centralization (ordinal) using body diagram. 
4. DV4: Modified Oswestry Pain Disability Questionnaire (ordinal scale) 
 
Relationship Variable(s)- (RV) (if applicable) 
1. RV1: Degree of spinal extension (ratio) 
2. RV2: Spinal height using stadiometer (ratio scale).  
3. RV3: Pain rating using numerical pain rating scale (NPRS) (ordinal 
scale). 
4. RV4: centralization (ordinal).  
5. RV5: Modified Oswestry Pain Disability Questionnaire (ordinal scale) 
 
 

 
 
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METHODS 
Research Design(s) 
A pre-test, post-test comparison group design (randomized clinical trial) 
will be used to determine how spinal height changes in response to sustained 
and repetitive standing trunk extension after a period of spinal loading. The study 
will use a 2 (between subjects – type of trunk extension: sustained vs. repetitive) 
x 3 (within subjects - time: before vs. after vs. 2 weeks after) mixed design to 
evaluate the effects of sustained and repetitive trunk extension in standing on 
spinal height, pain, centralization and function outcome measures. 
Pre-study Approvals 
 
The study will be submitted to the Texas Tech University Health Sciences 
Center Institutional Review Board (IRB) for approval.  The trial will then be 
registered at https://clinicaltrials.gov . 
Subjects / Specimens 
Systematic consecutive sampling of up to 100 subjects with LBP (40 
subjects completing both days of data collection) attending “Sports medicine and 
Physical therapy clinic” in Fredericksburg (Texas) as patients or for the purpose 
of health and wellness will be recruited.  Flyers will also be posted at physician 
offices and the general Fredericksburg community and surrounding areas to 
inform subjects about the study (Appendix A). 
Inclusion Criteria: (1) Ability and willingness to come twice to the clinic for 
approximately 60 minutes each; (2) Subjects with LBP and directional preference 

 
 
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in back extension; (3) Age 18-80 (Yarznbowicz et al 2018); (4) Ability to stand for 
5 minutes; (5) Ability to sit for 10 minutes; and (6) Low back pain on Numerical 
Pain Rating scale (NPRS) of at least 2/10 and less or equal to 9/10 (Ferreira-
Valente 2011).  
Exclusion Criteria: (1) Pregnancy by subject report; (2) history of back surgery or 
spinal fractures within the last six months; (3) history of spinal fusion or 
physician’s diagnosis of spinal instability; (4) current history of acute systemic 
infection, active inflammatory disease, or malignancy; (5) subjects engaged in 
legal/compensation claims for their back symptoms; and (6) subjects unable to 
understand or speak English. 
Testing Sequence 
Subjects will be asked to attend two physical therapy sessions over 
approximately a 60-minute period each to complete the study.  
Session 1 
Participants will complete a pre-screening questionnaire regarding 
inclusion (Appendix B). Each subject will watch an audio-visual power point 
presentation explaining the study, test procedures and describing the 
interventions (standing repetitive trunk extension and standing sustained trunk 
extension). Written informed consent will be obtained. To determine directional 
preference, the investigator (JH) will use the guidelines set forth in the directional 
preference definition (Werneke 2011) and based off of standards set forth in 
randomized clinical trials (May et al 2008). Directional preference has been 

 
 
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defined as either (1) a specific direction of trunk movement or posture noted 
during the physical examination or (2) a specific easing factor reported by the 
patient during the subjective history that alleviates or decreases the patient’s 
pain, with or without the pain having changed location and/or increased the 
patient’s lumbar range of motion (Werneke 2011). A questionnaire including 
pertinent medical history will be completed (Appendix C). Subjects will complete 
(1) a Numerical Pain Rating Scale (NPRS) to rate their current, minimum, 
maximum and average LBP over the last two days (Ferreira-Valente MA 2011) 
as well as paresthesia signs/symptoms intensity (Appendix D); (2) Body Diagram 
for indicating location of symptoms (Appendix E); (3) Modified Oswestry low back 
pain questionnaire (Fritz 2001) (Appendix F); (4) Fear Avoidance Belief 
Questionnaire (Cleland et al 2008) (Appendix G). A researcher will record 
subject’s height and weight. A Flow chart illustrates study sequence in details 
(Figure 1). 
 
If the subject meets criteria for inclusion in the study, the subject will 
complete a familiarization procedure to determine the consistency to reposition 
themselves in the stadiometer. Subjects able to reposition themselves in the 
stadiometer with a SD of 1.3mm or less for five consecutive measurements 
(Stothart et al 2000; Gerke et al 2011; Owens et al 2009) will be included in the 
study. The digital display will be covered to blind the researcher performing the 
measurements. The data will be automatically recorded by the stadiometer and 
manually downloaded to a laptop computer. 
At the beginning of data collection, a randomization plan generator 

 
 
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(http://www.randomization.com ) will assign each subject to one of two 
interventions: (1) standing repetitive trunk extension at a rate of 10 per 45 
seconds (Figure 2), repeated five times with 15-second rest breaks; or (2) 
standing sustained trunk extension for 5 x 45 seconds with 15-second rest 
breaks (Figure 3). Each subject will complete one intervention. The intervention 
number assigned will be recorded by the subject next to their name to allow 
blinding of the investigator as to which intervention the subject is assigned to. 
The subject will undergo the test sequence after a 10-minute period of trunk 
unloading in a supine posture to ensure spinal height is normalized, head in 
neutral posture, knees supported over a small bolster pillow, hands placed on the 
abdomen (Kourtis et al 2004; Magnusson et al 1996a; Gerke et al 2011; Owens 
et al 2009). The subject will reposition on the stadiometer and spinal height will 
be measured after a relaxed exhalation (Measurement 1) (Figure 4). The subject 
then will undergo a five-minute period of loaded upright sitting with a 4.5kg bag 
secured on each shoulder and spinal height will be measured (Measurement 2) 
(Figure 5) (Kourtis et al 2004; Owens et al 2009; Gerke et al 2011). As continued 
spinal height reduction has been demonstrated following loaded sitting, the 
subject will undergo an additional five minutes sitting without load and spinal 
height will be measured (Measurement 3) (Kourtis et al 2004; Owens et al 2009; 
Gerke et al 2011). Inclinometers will be used to take an initial measure of each 
subject trunk extension prior to intervention. The subject will then undergo one 
intervention for 5 minutes as previously described, according to the 
randomization assignment. In order to determine how sustained and repetitive 

 
 
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interventions related in terms of change in spinal height, the time to perform the 
sustained lumbar posture matches the time necessary to perform the repetitive 
lumbar extension postures.  
The subject will reposition on the stadiometer and spinal height will be 
measured (Measurement 4). Trunk extension will be measured to determine the 
strength of correlations between the degree of trunk extension during standing 
trunk extension posture and spinal height, pain and centralization testing 
outcomes changes (MacDermid et al 2015). The subject will score their low back 
and lower extremity symptoms using NPRS (Ferreira-Valente MA 2011), and 
map their pain on a body pain diagram (Appendix E) prior to intervention, 
immediately after and 2-week following the intervention to determine pain rating 
and centralization of symptoms (Simmerman et al 2011). The principal 
investigator will apply a numeric overlay template to the patient’s body diagrams 
to document the most distal pain location scores between 1 and 6 (Appendix I). 
Higher score will indicate a more distal symptoms’ location.  
Home instructions 
Subjects will be instructed to continue to use their medications, including 
medications aimed at decreasing their pain, as prescribed by their primary 
healthcare provider and not to change them during the follow-up two-week 
period.  A sheet including home exercise instructions will be provided to each 
patient. Instructions will include repetitive or sustained trunk extension based on 
random group assignment, performed approximately 5 times per day. Each 
subject will complete a sheet recording home exercise compliance upon arrival in 

 
 
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session 2 (Appendix I). 
Session 2 
Subjects will complete: (1) a NPRS to rate their current, minimum, 
maximum and average LBP over the last two days as well as paresthesia 
signs/symptoms intensity (Appendix D); (2) Body Diagram for indicating location 
of symptoms (Appendix E) (3) Modified Oswestry low back pain questionnaire 
(Fritz 2001) (Appendix F); (4) Fear Avoidance Belief Questionnaire (Cleland et al 
2008) (Appendix G). Each subject will then complete a familiarization procedure 
to determine the consistency to reposition themselves in the stadiometer as 
described in session 1. The subject will undergo a 10-minute period of trunk 
unloading in a supine posture to ensure spinal height is normalized as described 
in session 1. The subject will reposition on the stadiometer and spinal height will 
be measured after a relaxed exhalation (Measurement 1) (Figure 4). The subject 
then will undergo a five-minute period of loaded upright sitting with a 4.5kg bag 
secured on each shoulder and spinal height will be measured (Measurement 2) 
(Figure 5).  The subject will then undergo an additional five minutes sitting 
without load and spinal height will be measured (Measurement 3). Inclinometers 
will be used to take an initial measure of each subject trunk extension prior to 
intervention. The subject will then undergo the same intervention as in session 1 
for 5 minutes as previously described (standing repetitive trunk extension or 
standing sustained trunk extension). The subject will reposition on the 
stadiometer and spinal height will be measured (Measurement 4). Trunk 
extension will be measured to determine the strength of correlations between the 

 
 
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degree of trunk extension during standing trunk extension posture and spinal 
height, pain and centralization testing outcomes changes (MacDermid et al 
2015). The subjects will then score their low back and lower extremity symptoms 
using NPRS (Ferreira-Valente MA 2011), and map their pain on a body pain 
diagram (Appendix H). 
Investigator Blinding 
One investigator will be involved with data collection. The investigator, 
Jeremy Harrison, PT, DPT will carry out inclinometer measurements of lumbar 
and sacral posture, supervised positioning in the stadiometer and stadiometric 
measurements. The investigator will be blinded to the intervention (each subject 
will receive a hidden random number and will perform independently the 
intervention in a treatment room) and the stadiometric measurements during the 
experiment. He will also be responsible for assigning subjects to their initial 
groups, supervising the subjects’ positioning in the different standing postures 
and confirming that a stadiometer reading is recorded on an Excel spreadsheet. 
Subjects Compensation 
Subjects will receive a one-month free membership to Hill Country 
Memorial Wellness Center in Fredericksburg, Texas if they consent to participate 
in the study. 
Subjects Charges 
There will be no charge for the two physical therapy sessions, including 

 
 
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examination and intervention. Following the two intervention sessions, subjects 
referred by primary care providers (physicians, chiropractors, nurse practitioners, 
physician assistants) to physical therapy for LBP will have the choice to receive 
standard care and be charged for physical therapy intervention. 
Confidentiality and data protection 
Electronic Transmission of Personally Identifiable Information (PII) and 
Protected Health Information (PHI) will be followed and computer device has 
been encrypted (password protected). Excel spreadsheet will be used to store 
the data. No Personally Identifiable Information will be retained in the Excel 
spreadsheet where the data will be stored. 
Data Analysis 
Descriptive and inferential statistics will be used utilizing SPSS 23.0 for 
Windows (SPSS, Chicago, IL). 
1. Descriptive analyses: Descriptive statistics including mean, median, 
mode, standard deviation, minimum and maximum values, frequency 
counts will be collected for age, height, weight, body mass index, pain, 
centralization, function (Oswestry Low Back Pain Disability Questionnaire), 
Fear Avoidance Beliefs Questionnaire, spinal height, and spinal height 
changes after repetitive and sustained standing trunk extension after a 
period of spinal loading.  
2. Inferential analyses:  Levene’s test and Shapiro-Wilk test of normality will 
used to test for variance and distribution of measurements of spinal height, 

 
 
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changes in spinal height, degrees of spinal extension, pain, and function 
outcomes.  
For experimental hypothesis 1, a paired-t-test (or Wilcoxon sign-rank test if 
the data do not meet assumptions for parametric inferential statistics) will 
be used to assess differences in spinal height, centralization and pain 
outcomes improvements following sustained and repetitive trunk extension 
postures.  
For experimental hypothesis 2, 2 (between subjects - type of trunk 
extension: sustained vs. repetitive) x 3 (within subjects - time: before, 
immediately after and 2-week after) mixed ANOVA’s will examine 
differences in (1) spinal height; (2) pain; and (3) function outcomes, as a 
result of sustained and repetitive standing trunk extension after a period of 
spinal loading. Post hoc paired t-tests will explore further for significant 
differences in spinal height, pain and function outcomes between the six 
conditions.  
Experimental hypothesis 3 will be tested with Pearson product-moment 
correlations to determine the strength of correlations between the degree 
of trunk extension during standing trunk extension posture and spinal 
height, pain and function, outcomes changes in patients with LBP. 
Spearman's Rank Order correlation will be used to determine the strength 
of the correlation between centralization and the degree of trunk extension 
posture in standing. 

 
 
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Alpha level will be set at 0.05 for significance for all tests and Bonferroni 
corrections performed as needed. 
 
 
 
 

 
 
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Figure 1: Flow chart of test positions and testing sequence 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical Hx, NPRS (pain and paraesthesia), Body diagram, Mod Oswestry, FABQ, Ht/Wt 
If subject is randomized to 
sustained trunk extension group 
If subject is randomized to 
repetitive trunk extension group 
Evaluation – Directional Preference 
Pre-Screening for Inclusion 
Audio/Visual Power Point 
Written Informed Consent Obtained
Familiarization Procedure with Stadiometer 
Measurement 1 
Measurement 1 
Measurement 3 
Supine Lying 10 minutes 
Loaded Upright Sitting 5 minutes 
Supine Lying 10 minutes 
Upright Sitting Without Load 5 minutes 
Loaded Upright Sitting 5 minutes 
Measurement 2 
Upright Sitting Without Load 5 minutes 
Measurement 3 
Randomization of Subjects 
Measurement 2 
45 sec sustained extension, 15 sec rest x 5 
10 trunk extensions in 45 sec, 15 sec rest x 5 
Trunk Ext Measure 1 Using Inclinometers 
Trunk Ext Measure 1 Using Inclinometers 

 
 
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Second Visit 
 
 
 
 
                                                                                    
                                                                                                
 
 
 
 
 
 
 
 
 
Two Weeks of HEP (see HEP form) 
Measurement 4 
NPRS, Body Diagram 
Measurement 4 
Trunk Ext Measure 2 Using Inclinometers 
NPRS (pain and paraesthesia), Body 
diagram, Mod Oswestry 
NPRS, Body Diagram 
NPRS (pain and paraesthesia), Body 
diagram, Mod Oswestry 
Two Weeks of HEP (see HEP form) 
Trunk Ext Measure 2 Using Inclinometers 
Supine Lying 10 minutes 
Supine Lying 10 minutes 
Measurement 1 
Measurement 1 
Loaded Upright Sitting 5 minutes 
Loaded Upright Sitting 5 minutes 
Measurement 2 
Measurement 2 
Upright Sitting Without Load 5 minutes 
Upright Sitting Without Load 5 minutes 
Measurement 3 
Measurement 3 
Trunk Ext Measure 1 Using Inclinometers 
Trunk Ext Measure 1 Using Inclinometers 
10 trunk extensions in 45 sec, 15 sec rest x 5 
10 trunk extensions in 45 sec, 15 sec rest x 5 
Familiarization Procedure with Stadiometer 
Familiarization Procedure with Stadiometer 

 
 
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Measurement 4 
Measurement 4 
Trunk Ext Measure 2 Using Inclinometers 
Trunk Ext Measure 2 Using Inclinometers 

 
 
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Figure 2: Starting position for trunk extensions.  
 
 

 
 
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Figure 3: Sustained trunk extension position and end position of repetitive trunk 
extensions. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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Figure 4:  Position of subject for spinal height measure in stadiometer unit.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
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Figure 5: Position of subject during spinal loading time in sitting. 
 
 
 
 
 
 
 
 
 
 
 

 
 
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Figure 6: Home instructions for Repetitive Trunk Extension 
 
 
 
 
 
 
 
 
 
 
STANDING REPETITIVE EXTENSIONS 
 
-Start by standing with your feet shoulder width apart and 
place your hands on your hips. Lean back to arch your back 
then return to starting position. (Lean back as far as you can 
tolerate with each repetition) 
Sets: 1 
Repetitions: 10 (Performed in 45 seconds, rest 15 seconds)  
-Perform sets in succession 
Frequency: 5 times per day 
 
 

 
 
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Figure 7: Home instructions for Sustained Trunk Extension 
 
 
 
 
 
 
 
 
 
 
 
 
STANDING SUSTAINED EXTENSIONS 
 
-Start by standing with your feet shoulder 
width apart and place your hands on your 
hips. Lean back to arch your back, HOLD for 
time listed below, then return to starting 
position. (Lean back as far as you can 
tolerate with each repetition) 
Sets: 1 
Repetitions: 1 (hold extension 45 seconds, 
rest 15 seconds)  
-Perform sets in succession 
Frequency: Five times per day 
 

 
 
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Figure 8: Home instructions 
Continue to use your medications, including medications aimed at 
decreasing your pain, as prescribed by your primary healthcare 
provider/physician.  Please avoid changing them during the follow-up two-week 
period.   
We will ask you to complete a sheet recording home exercise compliance 
when you come to the second treatment session in about two weeks. 
Thank you. 
 
 

 
 
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APPENDIX A  
Volunteers Needed for a Research Study! 
Title of the study:  
“IMMEDIATE EFFECT OF STANDING TRUNK EXTENSION POSTURES ON SPINAL HEIGHT 
AND CLINICAL OUTCOME MEASURES IN LOW BACK PAIN: A RANDOMIZED CLINICAL 
TRIAL” 
The purpose of this research is to help Physical Therapists better treat 
patients with low back pain by understanding the effects of motion on spine 
height.  
 
Volunteers between the ages of 18-80 who currently have low back and/or 
leg pain are needed to participate in a Physical Therapy study conducted 
by the 
Texas Tech University Health Sciences Center 
 
Other requirements for participation in the study:  
• 
Ability to stand for 5 minutes 
• 
Ability to sit for a minimum of 10 minutes, 
• 
Currently have low back pain that rate in the range of 2-9 on 10-point pain rating 
scale 
• 
Subjects MUST NOT: be pregnant, have history of back surgery, spinal fractures, 
spinal fusion or spinal instability, current infection, inflammatory disease, cancer 
or be engaged in legal compensation claims for their back symptoms. 
 
Participation is FREE. You will be asked to attend two, 1- hour sessions in 2-week period. 
 
To compensate you for your time, you will receive free 1-month membership to Hill 
Country Memorial Wellness Center in Fredericksburg, Texas. 
 
Contact Jeremy Harrison, PT, DPT, COMT 
(830)997-2001 jeremy.harrison@ttuhsc.edu 

 
 
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APPENDIX B 
PRE-SCREENING QUESTIONNAIRE LUMBAR PAIN STUDY 
 
Please answer the following questions: 
1. Are you interested to participate in a research project related to low back 
pain and spinal growth in which you will be asked to come twice to our 
clinic and be evaluated and treated twice for a 2-week period? You will be 
evaluated and treated free of charge for two sessions only.      Yes / No 
 
2. Are you between the ages of 18 and 80 years old? 
a. Yes 
b. No 
3. Are you able to stand for 5 minutes? 
a. Yes 
b. No 
4. Are you able to sit for 10 minutes? 
a. Yes 
b. No 
5. Do you experience low back and/or leg pain of at least 2/10 and less or 
equal to 9/10? 
a. Yes 
b. No 
________________________________________________________________ 
 
6. Do you have any history of spinal surgery and/or fractures within the last 6 
months? 
a. Yes 
b. No 
 
7. Do you have a current history of acute systemic infection, active 
inflammatory disease, or malignancy? 
      a. Yes 
      b. No 
 
8. Do you have any history of spinal fusion or diagnosed by a physician with 
spinal instability? 
      a. Yes 
      b. No 

 
 
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9. Are you currently engaged in legal/compensation claims for your back 
symptoms? 
a. Yes 
b. No 
 
10. Is there a possibility that you could be pregnant? 
a. Yes 
b. No 
 
Which, if any of the following positions, helps to relieve your back pain?  
a. Sitting 
b. Sitting with support in your back 
c. Standing 
d. Standing backward bending of your back 
e. Other: _________________________ 
f. No position seems to feel better than the other 
 
FRONT OFFICE USE ONLY 
Diagnosis of Lumbar Pain and/or Radiculopathy:         Yes        No 
Patient referral for Physical Therapy:                            Yes        No 
 
 
 
 
 
 
If you are interested to participate, contact 
Jeremy Harrison, PT, DPT - Investigator 
(830) 997-2001  
jeremy.harrison@ttuhsc.edu 
 
 
 

 
 
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Questionnaire Key 
The purpose of this questionnaire is to take the burden off of participating 
physicians who are assisting with patient recruitment for this study. Simply add 
this questionnaire with your normal intake forms for all patients who are seeing 
the physician for low back pain and leg pain. 
 
Patient can be included in the study if: 
Questions 1-5 
• All answered “YES” 
Questions 6-10 
• All answered “NO” 
 
 
Office Use Only section 
• Qualified for study inclusion  
YES / NO 
• Study Number:____________ 
 
 
 
Referral contact information: 
 
Jeremy Harrison, PT, DPT, COMT 
Texas Tech University HSC 
830-997-2001 
 
 
 

 
 
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APPENDIX C 
 
Intake Questionnaire: 
 
To be filled out by the participant: 
 
Date: _______________________________ Time: _______________am  pm 
 
Last Name:                                                        First Name:  
  
Phone # :(day)______________(evening)____________(cell)______________ 
 
E-mail address: __________________________________________________  
 
Age:_____  
 
Gender:    M / F.   
 
Do you currently have (within the past 24 hours) pain, numbness, tingling 
or burning in any of the of following areas (please circle yes for all that 
apply) 
 
Low back symptoms 
 
                                         Y / N 
 
Buttock symptoms  
 
                                         Y / N 
 
Thigh symptoms                                                                     Y / N 
 
Lower leg symptoms (below the knee)  
                           Y / N 
 
Foot symptoms  
                                                       Y / N 
 
Toe symptoms  
                                                       Y / N 
 
How long ago did your current episode of pain start? ____days ____months 
____years  
 
Do you take pain medications?  Yes / No 
 
   If yes, 
i. Name the pain medications______________________________ 
 
 
ii. How many hours ago did you take your last pain medication? 
 
     _________hours 
 
 
 
 
 
 
 

 
 
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Do you currently have any of the following: (please circle yes for all that 
apply) 
  
Yes/No     Inability to sit for a minimum of 5 consecutive minutes  
Yes/No     Inability to stand upright for a minimum of 5 minutes 
Yes/No     Neurological disorders such as multiple sclerosis, spinal cord    
injury, spinal tumors 
 
Yes/No     History of spinal fusion/surgery 
Yes/No     Pain in shoulders or neck  
Yes/No     Vertebral fractures 
Yes/No      Current vertebral infection 
Yes/No 
Any unhealed bone fracture 
Yes/No 
Diagnosis of cauda equina syndrome 
Yes/No 
Pain level reported above 9/10 on Numerical Pain Scale. 
Yes/No 
Pain level reported at 0/10 at time of testing (no pain)  
Yes/No  Non-English speaking 
 
 
 
For Office use only 
Height: __________inches  
 
 
Weight: ____________lbs 
 
 

 
 
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APPENDIX D 
 
 
Date:         /.       /20   
Time: ____am  ___ pm 
Study #: __________ 
 
Please fill in the following Pain scales regarding the pain in your BACK circling 
the number that correctly describes your pain  
What is the least amount of pain you have experienced in the last 2 days in your back 
(circle the number on the line below)?  
 
 
 
      0         1         2         3         4        5         6         7         8         9        10 
 
 
What is the most amount of pain you have experienced in the last 2 days in your back 
(circle the number on the line below)? 
No Pain  
 
        Moderate Pain 
 
         Unbearable Pain 
 
 
 
      0         1         2         3         4        5         6         7         8         9        10 
 
What is the average amount of pain you have experienced in the last 2 days in your 
back (circle the number on the line below)? 
No Pain  
 
        Moderate Pain 
 
         Unbearable Pain 
 
 
 
      0         1         2         3         4        5         6         7         8         9        10 
 
 
What is the amount of pain you are experiencing in your back right now? 
No Pain  
 
        Moderate Pain 
 
         Unbearable Pain 
 
 
 
      0         1         2         3         4        5         6         7         8         9        10 
 
 

 
 
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APPENDIX E 
Date:         /.       /20   
Time: ____am  ___ pm 
Study #: __________ 
 
 

 
 
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APPENDIX F 
Date:         /.       /20   
Time: ____am  ___ pm 
Study #: __________ 
 

 
 
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APPENDIX G 
Date:         /.       /20   
Time: ____am  ___ pm 
Study #: __________ 
 
 
 
 

 
 
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APPENDIX H 
Body diagram with template for centralization 
Date:         /.       /20   
Time: ____am  ___ pm 
Study #: __________ 
 

 
 
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APPENDIX I 
Date:         /.       /20   
Time: ____am  ___ pm 
Study #: __________ 
 
Please complete the following form regarding compliance with your exercises: 
Standing trunk extension exercises 
 
I did not do the     I did the exercise     I did the exercise     I did the exercise     I did the exercise 
 
   exercise 
    25% of the time       50% of the time       75% of the time       100% of the time  
 
 
Were the exercises of backward bending  
Very helpful  
Helpful  
Neutral 
Not helpful 
     Not helpful at all