䢇

Case Report

Application of the HOAC II:

An Episode of Care for a Patient
With Low Back Pain
Background and Purpose. The HOAC II is a patient management
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algorithm designed, in part, to provide a conceptual framework for

patient management for any type of patient seen by physical therapists.
This case report illustrates how the HOAC II can be used in clinical
practice. Case Description. The patient was a 47-year-old woman with
low back pain. The report describes the patient’s examination, evalu-
ation, diagnosis, prognosis, intervention, and outcomes within the
context of the HOAC II. Outcome. The patient had measurable
improvements in impairments, functional limitation, and disability
following an intervention designed to resolve her impairments and
functional limitations. Discussion. This case report illustrates how the
HOAC II can be used to assist in the management of a patient from
admission to discharge. The report also demonstrates how use of a
disablement model can add clarity to patient care. [Riddle DL,
Rothstein JM, Echternach JL. Application of the HOAC II: an episode
of care for a patient with low back pain. Phys Ther. 2003;83:471– 485.]

Key Words: Neck and trunk, back; Pain; Tests and measurements, general.

Daniel L Riddle, Jules M Rothstein, John L Echternach

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Physical Therapy . Volume 83 . Number 5 . May 2003 471


T
he Hypothesis-Oriented Algorithm for Clini-
cians II (HOAC II)1 is an algorithm designed to
aid clinicians in planning and carrying out the
elements of patient/client management1 for
any type of patient. It is a step-by-step guide that can be
used in total or in part to guide patient care. Part 1 of
HOAC II (Figs. 1 and 2) was designed to address the 5
elements of patient/client management (examination,
evaluation, diagnosis, prognosis, and intervention)
described in the Guide to Physical Therapist Practice1 and to
facilitate the use of evidence in clinical decisions. Part 2
(Figs. 3 and 4) describes a method for monitoring a plan
of care and altering the care when needed. A companion
article (see perspective article by Rothstein et al in this
issue) provides a complete description of the HOAC II,
and the Appendix defines terms commonly used in the
HOAC II.
The primary purpose of this case report is to illustrate
how the HOAC II can be applied to patient manage-
ment. The case report describes all elements of the
management of a patient with low back pain (LBP) who
was referred for physical therapy. A secondary purpose is
to demonstrate how HOAC II can facilitate physical
therapists’ integration of disablement concepts in
patient management.2
Case Description
Initial Data Collection
The patient was a 47-year-old woman with a diagnosis of
LBP who a physician referred to one of the authors
(DLR). She was employed by a large company and for
the 8 years prior to the referral coordinated one of the
company’s departments. She said that the physical
demands of the workplace were primarily desk work,
which required several hours of uninterrupted sitting
daily. She stated that if she slouched in her chair, her
pain would begin or increase, so she sat in a rigid upright
posture to avoid the pain. She also reported that the
emotional demands of the workplace were high because
many people in her department had recently been laid
off. She also said she was “extremely stressed” at work,
not only because of her LBP but also because she
empathized with her recently laid-off colleagues. She
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@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.
All authors provided concept/idea/project design, writing, and project management.
This article was submitted March 12, 2002, and was accepted December 2, 2002.
472 . Riddle et al
This case report illustrates how the
HOAC II can be used to assist in the
management of a patient from
admission to discharge.
reported that her LBP and the psychological distress
adversely affected her productivity at work.
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 prob-
lems, 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
The Patient-Identified Problems (PIPs) List
In the HOAC II, the PIPs are problems reported by the
patient and are almost always descriptions of functional
limitations and disabilities. The patient described several
problems during discussion of her medical history. We
classified these problems, using the system described by
Nagi,2 as functional limitations or disabilities.3 We
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Figure 1.
The initial steps of Part 1 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).

Physical Therapy . Volume 83 . Number 5 . May 2003 Riddle et al . 473

Figure 2.
The final steps of Part 1 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).

474 . Riddle et al Physical Therapy . Volume 83 . Number 5 . May 2003

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Figure 3.
The algorithm for reassessment of existing problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).

Physical Therapy . Volume 83 . Number 5 . May 2003 Riddle et al . 475

Figure 4.
The algorithm for reassessment of anticipated problems in Part 2 of the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II).

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Table 1.
Medical Outcome Study 36-Item Short-Form Health Survey (SF-36) Scores Obtained at Admission and Discharge as Compared With Age- and
Sex-Matched Normative Values

Physical Role– Bodily General Social Role– Mental

Function Physical Pain Health Vitality Functioning Emotional Health

Normal
Xa 83 80 72 70 61 83 82 74
SDb 21 35 23 21 21 21 33 18
25th percentilec 75 75 52 62 50 62.5 83 68
2SEMd 12.3 22.6 15 17.6 15.6 25.7 28 14
Admission score 65 75 51 77 40 100 100 56
Discharge score 80 75 72 90 60 100 100 84
a
The mean value for each scale for female subjects without known impairments or pathology between the ages of 45 and 54 years.
b
The standard deviation for each scale for female subjects without known impairments or pathology between the ages of 45 and 54 years.
c
The 25th percentile score for female subjects without known impairments or pathology between the ages of 45 and 54 years.
d
Two standard error of measurement (2SEM) is equivalent to a 95% confidence interval estimate of reliability.

believed that her inability to roll over in bed and her
inability to sit in a slouched position or to forward bend
without pain were functional limitations. A direct link
appeared to exist between the patient’s functional limi-
tations and the disabilities she reported. We considered
her inability to put on stockings and get in and out of a
car without pain as disabilities. The disabilities also
included her diminished level of performance at work,
the intermittent awakening, and her limitations in rec-
reational activities. She identified 3 recreational activi-
ties that were affected by her LBP (yard work, bicycling,
and exercise).
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.
The patient’s initial SF-36 scores are reported in Table 1.
Because the SF-36 is a norm-referenced test, the norma-
tive values for each subscale are provided in Table 1. The
table indicates the mean and 25th percentile scores for
each of the dimensions (variables) measured in a group
of women aged 45 to 54 years from the general US
population.8 The 2SEM scores also are reported for the
sample. We used the normative mean and 25th percen-
tile scores to judge the extent of the patient’s disability,
and we used the 2SEM scores to assess the meaningful-
ness of changes in disability scores following the inter-
vention. From the SF-36 scores, we concluded that the
patient’s health status was diminished in the areas of
Physical Health and Bodily Pain. We expected this
because most of her PIPs involved the performance of
physical activities. Her Vitality and Mental Health scores
also were lower than published norms, and we hypothe-
sized that her psychological distress at work likely led to
these low scores.
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

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Table 2.
Spinal Range-of-Motion and Straight-Leg-Raise Measurements (in Degrees) Taken During the Examination and at Discharge
Forward Backward
Bending Bending
During examination 62 10
At discharge 108 33
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 attach-
ment 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 test-
ing, 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 bend-
ing. Waddell et al reported intraclass correlation coeffi-
cients (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 mea-
surements, the inclinometer was positioned in the fron-
tal 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
* WB Saunders Therapy Products, Bloomington, MN 55439.
478 . Riddle et al
Left Side Right Side Right Straight Left Straight
Bending Bending Leg Raise Leg Raise
24 26 68 66
36 35 93 81
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 disap-
peared 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 bend-
ing 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.
The patient then positioned herself prone, and
posterior-anterior (P-A) accessory motion at each of the
spinous processes of the lumbar spine was assessed using
the P-A central pressure test described by Maitland.14
Physical Therapy . Volume 83 . Number 5 . May 2003

Prior to testing, the patient reported no pain. When
force was applied to each lumbar spinous process in an
anterior direction, the end-feel was judged by the exam-
iner to be firm, and it was felt almost immediately upon
application of the force. End-feels have been defined in
the literature in a variety of ways. For the purposes of this
case report, a firm end-feel is defined as a rapid increase in
resistance.15 The motion during the P-A accessory
motion test done at each vertebral level of the lumbar
spine was judged by the examiner (DLR) to be hypo-
mobile. Based on the examiner’s experience, a greater
amount of intervertebral movement than what was
found in the patient is typically perceived prior to the
perception of a firm end-feel at the end-range of motion.
The patient reported having pain along the midline of
her lower lumbar spine when the P-A accessory motion
tests were conducted in the area of the L3, L4, and L5
spinous processes. She rated this pain between 2 and 4
on the 0 to 10 scale. She said the pain ceased after the
pressure was released. She reported no pain during P-A
accessory motion tests of the L1 and L2 spinous pro-
cesses. Data suggest that reliability for pain measure-
ments obtained during P-A accessory motion testing of
the lumbar spine is what we would consider acceptable
(ICC⫽.67-.72), whereas other data suggest measure-
ments of the amount of motion are not reliable
(ICC⫽.03-.37).16,17
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 pro-
cesses 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 approxi-
mately 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 deter-
mine whether any other impairments may have contrib-
uted to the patient’s functional limitations and disabili-
ties. Because the patient spent most of her working day
sitting, we suspected her hamstring muscles were short-
ened. 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
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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 com-
monly 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. Sec-
ond, 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 limita-
tions. 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
Riddle et al . 479
the area of the lumbar spine. Because most of the
patient’s complaints were associated with a flexed lum-
bar 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 theoret-
ical 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 Magora 21 suggests that prolonged sitting
increases the risk for LBP in people with occupations
similar to our patient’s occupation. We, therefore, con-
sidered 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 produc-
tive 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
480 . Riddle et al
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 worth-
while, 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 correct-
ness of the hypotheses. Testing criteria are target levels
of performance, typically at the level of impairments,
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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 impor-
tant factor in the development of this patient’s prob-
lems. 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 con-
siderable 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 treat-
ment 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
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take a brief walk. To minimize the effect of the psycho-
logical 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 determi-
nation 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 ben-
efit 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 predic-
tive criteria, we stayed aware of the problem and could
determine whether a referral to a mental health profes-
sional 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.
Planned Reassessments of Testing and Predictive Criteria
In the HOAC II, re-evaluations should be done when
changes in the relevant impairments, functional limita-
tions, or disabilities are expected to occur given the
patient’s condition. The patient was seen once every
week because we hypothesized the impairments related
to lumbar ROM and hamstring muscle length had been
present for a long period of time. A relatively longer
period of time between treatments theoretically allowed
us more time to make gains in ROM than if treatments
were more frequent. Weekly treatments also appeared to
be a more efficient way to plan the limited number of
treatments authorized by the patient’s insurance
company.
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 disabil-
ities 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
Intervention Strategy and Tactics
Intervention strategies are the overall plans for the
intervention, and tactics are the specific interventions
included in the plan of care. The intervention strategy
for this patient consisted of frequent bouts of exercise
Riddle et al . 481
Figure 5.
Summary of selected steps in the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II), critical elements in the case report, and corresponding
disablement terms. PIPs⫽patient-identified problems, NPIPs⫽non–patient-identified problems, LBP⫽low back pain, SLR⫽straight leg raise,
WNL⫽within normal limits.
designed to increase lumbar spine motion and hip ROM
(by presumably increasing hamstring muscle length).
The frequent bouts of exercise also required the patient
to get out of her chair every hour at work. Because we
hypothesized that her prolonged sitting contributed to
her reduced lumbar spine ROM and hip ROM impair-
ments, it was important to avoid prolonged sitting at
work.
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
482 . Riddle et al
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 repeti-
tions of the bilateral knee to chest exercise while posi-
tioned supine, both exercises as described by McKen-
zie.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, suffi-
cient to stretch these shortened tissues. Loading the
shortened tissues often elicited pain until, by the eighth
Physical Therapy . Volume 83 . Number 5 . May 2003

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 perform-
ing 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 down-
ward force while the patient performed her prone-lying
press-up exercise. The patient was taught a home exer-
cise 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
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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 stiff-
ness 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 hypomo-
bile 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 opin-
ions, 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 morn-
ing. 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.
Riddle et al . 483
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 interven-
tion. 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 dis-
charge 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 disabili-
ty.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.
484 . Riddle et al
Conclusion
This case report demonstrates the clinical application of
HOAC II and shows how disablement terms can be
integrated into patient management in a way that we
believe enhances practice. The case is illustrative in that
it demonstrates how all elements of HOAC II can be
addressed for what we consider relatively common types
of patient problems. We believe that by applying the
HOAC II on an individual patient basis, therapists will be
ideally positioned to apply evidence to patient care and
to defend their interventions to colleagues and to third-
party payers.
References
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2 Nagi S. Disability concepts revisited: implications for prevention.
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3 Jette AM. Physical disablement concepts for physical therapy
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4 Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health
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5 Roland M, Morris R. A study of the natural history of back pain, part
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back pain. Spine. 1983;8:141–144.
6 Stratford PW, Binkley JM, Solomon P, et al. Defining the minimum
level of detectable change for the Roland-Morris questionnaire. Phys
Ther. 1996;76:359 –365.
7 Garratt AM, Ruta DA, Abdalla MI, et al. The SF-36 health survey
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Appendix.
Terms Used in the Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)
Anticipated Problems:
These can be identified by the patient, the physical therapist, or any
other person and are statements that describe deficits that the therapist
believes will occur if an intervention is not used for prevention.
Examination Strategy:
This is the plan for examination that a physical therapist uses based on
the therapist’s experience, available data relating to the patient, and
information on similar patients. Because not all possible tests and
measures are used, the choice is considered a hypothesis-driven strat-
egy in the HOAC II.
Existing Problems:
These can be identified by the patient, the physical therapist, or any
other person and are statements that describe deficits in a person’s
function (disability).
Goals:
Functional deficits are problems, whereas goals are descriptions of
function that will be recovered as a result of one or more interventions.
Hypothesis:
The reason that a patient’s problems (which are usually at the disability
level) exist is not necessarily known, but in order for a physical therapist
to carry out an intervention, the therapist must have an idea as to the
underlying causes. In the HOAC II, the therapist’s conjecture as to the
cause is a hypothesis. Often there will be more than one hypothesis, and
usually the hypothesis will involve one or more impairments causing a
deficit in function (ie, a disability).
Intervention Strategy:
These are the overall types of interventions that the physical therapist
believes are needed to alleviate problems (eg, exercises designed to
increase range of motion are a strategy, whereas the specific exercises
are tactics).
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22 McKenzie RA. The Lumbar Spine: Mechanical Diagnosis and Therapy.
Waikanae, New Zealand: Spinal Publications Ltd; 1981.
23 Riddle DL, Stratford PW, Binkley JM. Sensitivity to change of the
Roland-Morris Back Pain Questionnaire: part 2. Phys Ther. 1998;78:
1197–1207.
24 Stratford PW, Binkley JM, Riddle DL, Guyatt GH. Sensitivity to
change of the Roland-Morris Back Pain Questionnaire: part 1. Phys
Ther. 1998;78:1186 –1196.
Non–Patient Identified Problems (NPIPs):
These are problems identified (at least initially) by people other than the
patient, but that are added to the patient’s problem list after consultation
with the patient (these can be existing or anticipated problems).
Patient-Identified Problems (PIPs):
These are problems identified by the patient (these can be existing or
anticipated problems), and because they are generated by the patient,
they cannot be removed from the problem list without the patient’s
consent.
Predictive Criteria:
These are critical values (thresholds) for measurements, which, if met,
would indicate that one or more problems will most likely be avoided
because risk factors were reduced or eliminated. Sometimes the mea-
surement may be how often someone does a task or whether a patient
demonstrates competency in a prevention program (eg, does stretching
or prophylactic back exercises).
Tactics:
These are the elements of an intervention. For instance, the exercises or
techniques used to treat the patient or client are the specific elements of
the intervention, whereas the overall purpose of the interventions is the
strategy.
Testing Criteria:
These represent critical values (thresholds) for measurements, which, if
achieved, would suggest the hypothesis (or hypotheses) is correct if the
associated problem(s) is resolved (these are most often measurements of
impairments).
Riddle et al . 485